Chiou Grace, Crowe Christopher, Suarez Paola, Chung Lorinda, Curtin Catherine, Chang James
From the *Division of Plastic and Reconstructive Surgery, Department of Surgery and †Division of Immunology and Rheumatology, Department of Medicine, Stanford University Medical Center, Stanford, CA.
Ann Plast Surg. 2015 Dec;75(6):637-43. doi: 10.1097/SAP.0000000000000614.
Periarterial sympathectomy is a treatment option for patients with systemic sclerosis (SSc) suffering from digital vasculopathy. Despite potential benefits of ulcer healing, pain improvement, and amputation prevention, this operation appears to be infrequently performed. The aims of our study are as follows: (1) to assess national digital sympathectomy rates in patients with SSc and (2) to improve our understanding of referring physicians' perceptions of operative management and access to hand surgeons. Our hypothesis is that rheumatologists' practices largely influence their referral patterns for digital sympathectomy.
To determine the rates and demographics of hospitalized patients with SSc who had undergone digital sympathectomy, we queried the Nationwide Inpatient Sample from 2006 to 2010. Additionally, we mailed a self-administered survey to a national sample of 500 board-certified rheumatologists to elicit their practice patterns and perceptions of digital sympathectomy. Using logistic regression, we analyzed potential predictor variables associated with rheumatologists performing the following: (1) routinely counseling patients about digital sympathectomy and (2) expressing the desire to refer these patients for operative evaluation.
Of 348,539 hospitalizations associated with a diagnosis of SSc, only 0.2% were for digital sympathectomy. Our questionnaire revealed that only 50% of rheumatologists routinely counseled, whereas 67% expressed the desire to refer. Factors associated with increased rheumatologists' interest in surgical management for patients with SSc included positive perception of the operation's efficacy, comfort with postoperative management, and interdisciplinary relationship with a hand surgeon.
Critical components to increasing appropriate utilization of digital sympathectomy include enhancing rheumatologists' understanding of the operation, comfort with postoperative management, and promoting strong, interdisciplinary relationships with hand surgeons. Increasing education and awareness, as well as establishing a solid referral network of hand surgeons may thereby improve patient access to digital sympathectomy.
动脉周围交感神经切除术是系统性硬化症（SSc）合并指端血管病变患者的一种治疗选择。尽管该手术在促进溃疡愈合、缓解疼痛和预防截肢方面具有潜在益处，但似乎很少实施。我们研究的目的如下：（1）评估SSc患者的全国性指端交感神经切除术发生率；（2）增进我们对转诊医生对手术治疗的看法以及他们与手外科医生联系情况的了解。我们的假设是，风湿病学家的诊疗习惯在很大程度上影响他们对指端交感神经切除术的转诊模式。
为确定接受指端交感神经切除术的住院SSc患者的发生率和人口统计学特征，我们查询了2006年至2010年的全国住院患者样本。此外，我们向全国500名获得委员会认证的风湿病学家发送了一份自填式调查问卷，以了解他们的诊疗习惯以及对指端交感神经切除术的看法。我们使用逻辑回归分析与风湿病学家进行以下行为相关的潜在预测变量：（1）定期为患者提供指端交感神经切除术咨询；（2）表示希望将这些患者转诊进行手术评估。
在348,539例诊断为SSc的住院病例中，仅0.2%是因指端交感神经切除术。我们的调查问卷显示，只有50%的风湿病学家会定期提供咨询，而67%表示希望转诊。与风湿病学家对SSc患者手术治疗兴趣增加相关的因素包括对手术疗效的积极看法、对术后管理的熟悉程度以及与手外科医生的跨学科关系。
提高指端交感神经切除术合理使用率的关键因素包括增强风湿病学家对该手术的了解、对术后管理的熟悉程度，以及促进与手外科医生建立紧密的跨学科关系。增加教育和提高认识，以及建立稳固的手外科医生转诊网络，可能会改善患者接受指端交感神经切除术的机会。
