外傷性斷指再植之進階研究--克服血管問題及簡化手術麻醉過程

Abstract

人類萬能而靈巧的雙手，創造了先進科技與高度文明的社會，幫助我們改善日常生活。 絕大多數生活上的工作，都需要倚賴雙手，尤其在視覺不良的情況下，往往更需要手部觸覺來輔助視覺，完成各式各樣的任務。 因此，我們的雙手是最常受傷的部位之一，也是醫院急診部門常見的求診原因。 這些手部的意外傷害，傷勢非常急迫而且十分疼痛，需要立即處理。 另一方面，手部的構造精細且複雜，修復手部外傷需要高超的顯微手術技巧，以及高度細心與耐心。 在手部外傷當中，以外傷性斷指或斷肢為最嚴重。 若沒有即時有效的處置，將會導致肢體永久缺損，嚴重影響手部的功能及外觀，進一步降低勞動力與生產力，對於家庭及社會的影響甚鉅。 回顧文獻報告，外傷性斷指嘗試手術接合率約略是20%至30%。 意即大多數的斷指傷害，都放棄再植接回治療，進而喪失復原的機會。 探討放棄斷指再植的原因，包括：就醫可近性不足，醫療費用昂貴，手術過程困難且複雜，恢復期漫長，專科醫師人力缺乏與設備不足，醫療給付太低，醫師缺乏熱忱。 這些因素都是負面影響病患和外科醫師的接合斷指意願。 即使病患接受斷指再植接回，文獻報告的手指再植存活率差異頗大，約略是30%至90%。 差異如此大的原因，是斷指本質上的隨機性與高度不可預測性之傷害，再加上這類手術需要憑藉繁瑣的顯微縫合技巧與勞力密集的術後照顧。 因此，大多數的外科醫師不願投入這個領域，對於斷指再植手術避之唯恐不及。 身為整形外科醫師，我投入於醫治手部外傷已經累積二十年的經驗，專精於斷指再植手術。 這份論文的主軸，包含四個核心主題，循序漸進克服指尖的血管問題以及簡化手術麻醉過程，目標以增進斷指手術的嘗試接合率和手指存活率。 第一部分是探討外傷性指尖的再植手術。 由於遠端指節的解剖構造很精細，末梢血管分支的管徑非常細小，接合血管的顯微手術十分困難。 甚至在甲床附近缺乏合適的靜脈，因此，大多數的外科醫生顯然已經放棄了試圖指尖再植的所有努力。 我嘗試只有動脈吻合的指尖再植，其手指的存活率為81.8%，並不遜於兼具動脈吻合和靜脈吻合的斷指再植之存活率。 然而，另一組無法接合動脈及靜脈之指尖再植，其手指的存活率為0 %。 因此我得一個重要結論，末端指節的斷指再植存活率，並不必然需要靜脈的吻合，但是指尖動脈的吻合具有決定性的重要角色。 這部分的研究成果，鼓舞外科醫師盡量去嘗試遠端指節的斷指再植手術，即使是缺乏手指靜脈的吻合，也有不錯的手指存活率。 第二部分的研究是延續上一階段。 一般而言，常規的斷指再植手術通常兼具動脈吻合和靜脈吻合，重建斷指的血液循環。 然而，手術後偶而出現靜脈阻塞，導致手指充血腫脹的併發症，此時需要立即處置，否則該手指就會逐漸壞死。 傳統上，斷指再植術後出現靜脈阻塞，需要緊急安排再次手術，再一次重建靜脈管路，疏解充血現象。 根據前一段成果，既然遠端指節的斷指再植，不需要依賴靜脈吻合，於是我採用放血治療挽救靜脈阻塞的方法。 臨床觀察比較這二組處置的手指存活率，竟發現放血治療效果優於再次手術效果的趨勢。 但是值得注意，放血治療承受較高的失血風險，需要接受較多的輸血量。 面對斷指再植術後發生靜脈不良的突發情況，我建立了一套治療策略，幫助臨床醫師篩選合適的病人接受合適的治療，以提升手指的存活率。 這部分的研究成果，幫助外科醫師有效處理再植術後靜脈阻塞，有效避免不必要的二次手術，減輕術後照顧的負擔，增進斷指挽救的成功率。 斷指的意外傷害，我們無法預測傷害發生的時間點和嚴重程度，病患和外科醫師常常需要緊急應變，以應付這個突發其來的意外狀況。 由於斷指再植的手術，必須要修補細小血管和神經的精密步驟，而且手術過程非常耗時，傳統上都是安排病患接受全身麻醉，以方便進行顯微手術的技術。 因此，為了全身麻醉的準備，病患在急診處等候的期間長久，增加傷口的疼痛與失血，也延長斷指的缺血時間。 為了克服上述的狀況，本論文第三部分的研究方向是採用局部麻醉來進行斷指再植手術，以減少等候時間和傷痛折磨。 在充分清醒的局部麻醉下，執行斷指再植的成功率是81.25%，其不遜於全身麻醉下的斷指再植之存活率，並且有效縮短等候麻醉的準備時間。 根據我的經驗，為了順利完成充分清醒局部麻醉之斷指再植手術，篩選合適的病患是最重要的關鍵步驟。 我建議適合本術式的病患條件如下：1.斷面切口整齊的單支斷指，組織沒有粉碎壓砸傷害、2.預估手術時間小於三小時、3.病患心智成熟穩定，配合度良好可遵從醫囑，並且沒有危及生命之傷害。 這部分的研究成果，證明斷指再植手術可以在充分清醒局部麻醉之下順利進行，並縮短等待時間及等候焦慮，減少醫療依賴與需求，降低醫療花費。 這個簡化手術麻醉過程，可以幫助外科醫師和病患更容易更方便進行斷指再植手術，甚至進一步增進斷指結合的意願和嘗試接合率。 第四部分的內容是設立一個評估斷指傷害嚴重程度的分級標準。 回顧文獻報導，斷指傷害並沒有一個客觀的分級準則，傳統上只有大略區分成截斷傷、壓砸傷、或是撕脫傷。 然而，大多數的斷指傷害都是混和型外傷，嚴重性程度也參差不齊。 因此，我根據斷指修復的構造順序，依照外傷嚴重程度給予分級，愈嚴重的損傷相對應愈高的分數。 一個好的外傷分級系統，明確訂定各個組織損傷的嚴重程度，可以幫助醫師完整評估傷勢，詳細的醫療紀錄，並且作為互相比較治療成果的基礎。 這部分的研究成果，更可以合理化斷指再植的嘗試接合率以及存活率。 挽救受傷的手，不單單只是醫治一位傷患，更救治了一個家庭，重建社會勞動力與生產力。 這是顯微外科醫師的任務與使命，非常具有意義。 這本論文紀錄了我的工作與研究成果，期待這些工作成果，可以幫助未來的外科醫師，成功救治更多複雜的手部外傷。

The dexterous hands of human beings have created advanced technology and a highly civilized society, helping us to improve our daily lives. The vast majority of work relies on the hands, especially in the case of poor vision, and often requires hand touch to assist vision and complete various tasks. Therefore, our hands are one of the most frequently injured parts and a common reason for hospital emergency department visits. These accidental injuries to the hands are very urgent, painful, and require immediate treatment. On the other hand, the structures of the hand are delicate and complex, and repairing hand trauma requires superb microsurgical skills, as well as a high degree of care and patience. Among the hand injuries, traumatic amputation is the most dangerous form. Reviewing the literature, most of the severed finger injuries were not replanted for treatment, thus losing the chance of recovery. Even though patients undergo replantation, the reported survival rates for finger replantation vary widely. The reason for such a large difference is the inherently random and highly unpredictable injury of severed digits, combined with the need for cumbersome microsurgical techniques and labor-intensive post-operative care. The main theme of this dissertation, which contains four core themes, is a step-by-step approach to overcoming vascular problems and simplifying the surgical anesthesia process, to increase the attempted rate and the survival rate in amputated fingers surgery. The first part is distal digit replantation which the small caliber of vessels makes this surgery very difficult. There are no suitable veins beyond the nail bed, so most surgeons have given up on all attempts to replant it. I treated artery-only replantation in the fingertips, and the survival rate of the replant was 81.8%. The result is not inferior to the survival rate of replantation with both arterial and venous anastomosis. However, in the other group, where the artery and vein were not repaired, the survival rate of the fingers was 0 %. Therefore, the distal digit replantation relies on digit artery repair, not venous anastomosis. The results of this part encourage surgeons to try to replant the severed fingertips as much as possible. Generally speaking, a standard digit replantation involves both arterial and venous anastomosis to rebuild the circulation of severed fingers. Traditionally, venous occlusion occurs after digit replantation, and it is necessary for urgent reoperation, to rebuild the vein once again. Since the replantation of the severed fingertip does not rely on venous anastomosis, I adopted the method of bloodletting to save the venous occlusion. The result of this part shows the trend of bloodletting is better than the effect of reoperation. However, bloodletting has a higher risk of blood loss and requires more blood transfusions. Faced with the sudden occurrence of venous insufficiency after digit replantation, I have established a treatment strategy to help clinicians select suitable patients to receive appropriate treatment. The research results in this part help surgeons to effectively deal with venous occlusion after replantation, avoid unnecessary secondary operations, reduce the burden of postoperative care, and improve the success rate of salvage. Traditionally, patients receive general anesthesia to facilitate microsurgery of digit replantation. Preparing for general anesthesia, the patient waits for a long time in the emergency department. The third part of this dissertation is to use wide-awake local anesthesia for the digit replantation. The success rate of replantation under wide-awake local anesthesia is 81.25%, which is not inferior to that under general anesthesia. The indications for wide-awake local anesthesia include single-digit amputation, absence of severe crush injury, estimated operation time of fewer than 3 hours, and a psychologically stable and cooperative patient with no associated life-threatening injury. This simplified anesthesia process can help surgeons and patients to replant severed fingers more conveniently, and even further increase the willingness and attempt rate of replantation. The fourth part of this dissertation is to establish a grading score for assessing the injury severity of traumatic digit amputations. Reviewing the literature, it is roughly divided into sharp injuries, crush injuries, or avulsion injuries. However, most traumatically amputated injuries are mixed and vary in severity. I give grades according to the injury severity, and the more serious the damage, the higher the score. A good trauma grading system, which clearly defines the severity of damage to each tissue, can help physicians to assess the injury and scientific records, and serve as a reference basis for comparing treatment outcomes. The results of this part can further rationalize the attempt rate and survival rate of digit replantation. Saving an injured hand is not only to heal a patient but also to save a family and restore the labor force and productivity of society. This is the responsibility and privilege of microsurgeons. This dissertation records my work and research results, and I hope these results can help future surgeons successfully treat more complex hand injuries.