KET QUA LAY SOI DlTONG MAT QUA NQI SOI MAT TUY NGlTOC DONG TRONG 4 NAM TAI BV BINH DAN
(06/2005 - 06/2009)
T^ Vdn Ngoc Due', Nguyen Ngoc Tuan' TOM TAT
D^t van de: Sdi dudng mat la benb ly ngoai khoa rat phd biSn d nude ta, ttong dd da sd la sdi d dng mat chij - dng gan cbung. Nhieu ndm gdn day, tuy ti IS bSnh nhdn cd sdi dudng mgt co gidm, ti IS benh nhan cd sdi tiii mgt dan thudn tang len, nhung sd lupmg benh nhan co sdi dudng mgt van cdn cao, ddi khi nhihig benh nban ndy nhap vien ttong tinh ttang nhilm triing dudng mat nang. Ngi soi mat tuy ngugc ddng (ERCP - Endoscopic Retrograde Cholangiopancreatography) dugc dp dung diu tiSn tai BV Binh Dan vdo nam 1993 va dd dilu tri thanh cdng nhilu benh ly mat Uiy. Ky diuat lay sdi dudng mat qua ndi soi mat tuy ngugc ddng da gdp phdn dilu tri thanh cong benh ly sdi dudng mgt, giiip benh nhan ttdnh dugc cupc phlu thugt dl liy sdi va hdi phuc sue khoe nhanh, trd lai lam viec, sinh hoat binh thudng ttong tiidi gian rit ngdn.
PhiTtfng phap nghign cim: hdi cuu 532 b?nh nhan dugc liy sdi dudng mat qua npi soi mgt tuy ngupc dong tai BV Binh Dan tu thang 6/2005 din didng 6/2009
Ket qua: 532 bSnh nhdn dugc liy sdi dudng mat qua ndi soi mat tuy ngugc ddng (NSMTND) gom 189 nam (35,5%) va 343 nii (64,5%). Chung tdi lay sdi tiianh cdng cho 514 benh nhan (96,9%), trong sd dd. 22/77 benh nhan dugc lay sdi d 2 ong gan doan gan vdi dng gan chung kem theo sdi dng gan chung - dng mgt chii. Ngoai ra, 6 benh nhdn co giun hay xac giun ttong dudng mgt kem vdi sdi va dSu dugc lay hSt.
Chiing toi lay sdi thdt b^i d 18 b^nh nhan do da so trudng hgp sdi dng mat chii qua to (> 2,5cm) va hogc nhieu sdi ket thanh cSy sdi trong dng mgt chu - dng gan chung.
Biln chiing: C6 2 benh nhdn bi viSm tuy cip va 2 b?nh nhan nay deu khdi sau khi dieu ttj npi khoa 3 va 4 ngdy. 1 benh nhan bi chay mdu Oddi vd dupc chfch Adrenahne 0,1 %o cam mdu qua npi soi td ttang.
B^n luan: Nhd ti'ch luy kinh nghiSm tCr ban 10 ndm trudc nen chiing tdi da ddn hodn thien kJ* thugt ldy soi dudng mgt qua NSMTND, lay dugc nhieu sdi to han k fch thuoc tir 2-3cm, nhiSu trudng hpp ldy dugc sdi to > 3cm va tbdi gian lay sdi nhanh hon. Ti IS biSn chung thdp, tuang duang vdi nhimg cdng trinh nghiSn cuu ciia cdc tdc gid ttong vd ngodi nude, khdng bi thung ta trang va khong cd b^nh nhan tu vong.
18 trudng hgp lay sdi that bai do sdi qua to (> 2,5 cm) va hodc nhieu sdi ket hgp thdnh cay sdi ciing nSn chiing tdi khdng thS tdn vd sdi bdng may tan sdi thiiy dien luc. Chung toi cho rdng, can nghiSn cuu them phuang lien tdn sdi laser de tdng hieu qua diSu tri nhung trudng hgp soi to.
Ket luan: Ngay nay, lay sdi dudng mgt qua NSMTND la mot phuong phdp xam Idn tdi thiSu diSu tri hieu qua va an toan cho nhting benh nhdn cd sdi dudng mat.
Tir khod: Ldy soi difdng mat qua nai soi rngt ivy ngircrc ddng ABSTRACT
RESULTS OF BILIARY TRACT STONES EXTRACTION BY ERCP AT BINH DAN HOSPITAL IN 4 YEARS (06/2005 - 06/2009)
Background: Biliary tract stones disease is very common in Vietnam. During many years ago,the ratio of biliary tract stones has gradually decreased; however, there were still many patients which admitted in hospitals because of biliary tract stone and its severe complications. ERCP was firstly applied at Binh Dan Hospital in 1993, and has Ueated many biliary pancreatic diseases. The biUary stones exttaction technique by ERCP has successfully treated biliary stone patients without the help of surgery; and these patient had got recovery, came back lo work very quickly.
Materials: All patients had biliary ttact stones extraction by ERCP from 06/2005 to 06/2009 Methods: Rettospective.
Results: In 4 years, there were 532 patients (189 men and 343 women). We had successfully exttacted
*Benh vifn Binh Dan
Dia chi lien lac: TS.BS.Nguyen Ngpc Tuan DT; 0903838043
388
bihary stones in 514 (96.9%) of all cases with 22/77 cases CBD stones combine with intrahepatic siones, 6 cases had biliary worms and stones.
We failed in 18 cases because of large CBD stones (> 2.5 cm).
Complications: 2/514 patients had acute pancreatitis after stones exttaction by ERCP and they all had been well after 3 and 4 days.
1/514 patients had Oddi bleeding and was stopped die bleeding by endoscopic adrenaline 0.1%6 injection.
Conclusion: Today, die biliary stone exttaction technique by ERCP is an non - invasive, effective, safety procedure for treatment biliary tract stones diseases.
Key words: Biliary stones extraction by ERCP DAT VAN BE
Soi dudng mat la benh ly ngoai khoa rit thudng gdp tai Viet Nam cung nhu cac nuoc Dong Nam A khac, ttong dd da s6 Id sdi d dng mat chii - dng gan chung co hay khdng ket hgp vdi sdi dudng m^t ttong gan. Soi dudng mat d ViSt Nam thudng Id nguyen phdt, hinh tiianh ngay ttong ldng dudng mat do cac loai giun sdn tir dudng rupt den. Nhieu nam gdn ddy, do tinh hinh kinh te xa hpi nude ta ng&y cang phat triln, ddi sdng nhan dan dugc nang cao nSn ti le benh sdi dudng mat co giam, ti I? benh soi tlii mat dcm thuan tdng ISn. Tuy nhiSn, sd lugng benh nhdn mac benh sdi dudng mgt vdn cdn nhilu.
mpt ti IS con cao nhung benh nhan nay nhap vien ttong tinh trang bien chiing ndng do sdi mgt nhir viem mii dudng mgt, soc nhilm Uiing dudng mgt, viSm tuy cip.... Sdi nam Uong dudng mgt lau ddi lam ton thuemg dudno mgt. nhu rad gan thudng dan den teo hep dudng mgt de gay ra soi tdi phat, xo leo gan, suy gan"*'" '"'....
BSnh vien Binh Dan la ca sd dau tien ttong ca nude dp dung ky thuat ngi soi mgt tuy ngupc dong (NSMTND) ttong chan dodn vd dieu tri cac benh ly mgt - tuy tir nam 1993'^^"'"'.Nhd kj? thugt nay, nhiSu benh nhdn ttanh dugc cupc phdu thugt hay ttanh phai phdu thugt md kinh diSn do dugc dieu trj true tiep hay dupc chan doan lopi trii. Hon 15 nam qua, chiing ldi ngdy cang hodn thien ky thugt nay.
lam NSMTND la mpt phucmg tiSn diSu tti true tiSp benh ly mat - tuy, trong do da s6 Id b?nh soi dudng mat, chu khdng chi Id phuong tien chan dodn hinh anh dan thuan'^'""'"'
Muc tilu
Chung tdi thuc hien nghiSn ciiu nay nhdm xdc dinh ti IS thanh cdng, ti le biln chiing, phdn tfch . nguyen nhan thdt b?i ciia ky thuat Idy sdi dudng mat qua NSMTND.
PHITONG PHAP NGHIEN CUt) Thiet ke nghien cuu: hoi ciiu
Doi tugng nghien ciiu; 532 benh nhdn duac Idy sdi dudng mdt qua NSMTND tai BV Binh Dan tir 06/2005 - 06/2009.
Phan U'ch va xu ly s6 li?u: phin mem SPSS 17.0 KET QUA
1. Oac diem cua benb nhan trong nghiSn clhi 1.1 Gioi tinh va tuoi
Co 532 b?nh nhan g6m_189 nam (35,5%) va 343 nu' (64,5%) Tudi: nho nhdt la 16 tudi, ldn nhit 92 ludi, tudi trung binh la 58 ± 17 tudi Bans 1:
Tuoi
< 19 2 0 - 2 9 3 0 - 3 9 4 0 - 4 9 5 0 - 5 9 6 0 - 6 9 7 0 - 7 9 8 0 - 8 9
>90 Ton^ so 1.2 Cir tni
phan bo do tu6i va "idi Nam
1 8 28 30 35 33 35 17 2 189
NO- 4 13 40 52 56 64 81 32 1 343
Tong s6 5 21 68 82 91 97 116 49 3 532
TI1I%
0.94 3,94 12.78 15,4 17,1 18,23 21,8 9,2 0,56 100%
389
TPHCM: 209 benh nhan (39,3%)
Cac tinh mien Dong Nam Bp: 116 benh nhan (21,8%) Cac trail mien Tay Nam Bp: 102 benh nhan (19,2%) Cac tmh mien Trung: 61 benh nhan (11,5%) Cac tinh Tay Nguyen: 36 benh nhan (6,8%) Cac tinh mien B5c: 8 benh nhan (1,5%) 1.3 Tien can pMu thuat duong m§t Bang 2: ti le tien can phlu thuat dugn^ mat
TiSn can phlu thujt S6 tnrimg Ti 1? % Khong CO
cat tlii m|t don thuan Mo OMC ISy soi +/- cat ttii mat
Md OMC lay soi +/- no;
mat mot sau do
L
Mcr OMC lay soi + ERCP liy soi lai phat sau d6 Chi dupc lam ERCP ISv Tdn§ so
Bang 3: bang pi Si Un phlu thu|t dtrimg
0 1 2 3 4 5 Tong so
soi ho^
274 57 128 2 43 28 532 ian bo so benh nhan voi sl
Si lin ERCP UY soi 0
274 145 27 9 4 1 460
1 22 26 8 2 4 0 62
2 6 0 1 1 0 0 8
3 0 0 0 0 2 0 2
51,5%
10,7%
24,1%
0,4%
8,1%
5,3%
100%
) lan phau t Tong so
302 171 36 12 10 1 532
Qua 2 bang ket qua trSn, chdng tdi cd 274 benh nhan chua dugc phau thugt hay NSMTND diSu tri sdi mgt, 57 benh nhan dugc cat liii mat do soi tui mat don thuan; 201 benh nhan cdn lai da dugc phau thugt hay NSMTND lay sdi dudng mat. Nhu vay, ti le benh nhan co sdi dudng mgt tai phat la 201/532
= 37,78%
2. Hnh trang benh nhSn khi NSMTND
Chung tdi da tien hanh lay sdi dudng mat cap ctiu cbo 121 benh nhdn (thdt bai a 6 benh nhdn nhiem triing dudng mdt vd 1 benh nhdn soc nhiem triing dudng mat), ti le NSMTND cdp ciiu la 22.74%
Bang 4: ti 1^ bSnh nhan co bien chiing do sdi dudng mat S6 bSnh nhan
Bien chung Lay sdi Ldy Tong Ti I?
thanh sdi so
Khong Nhiem trung dirong m|t Nhiem triing duong mat va viem tuy cap Viem mu duong mat doa soc
cong 400 102 8
1 that bai 11 6 0
0 411 108 8
1 77,25%
20,3%
1,5%
0,18%
390
Soc nhiem ttiing 3 I 4 0,75%
dudng mat
TongsS 514 18 532 100%
3. Vj tri soi dtrtmg mat lay dirac qua NSMTND
Chung tdi liy duac soi ttong 2 dng gan doan gdn vdi ong gan chung cho 22/77 benh nhan cd sol dudng mat ttong vd ngodi gan, ti IS 28,57%, cdn lai 55 benh nhan cd sdi ttong 2 dng gan do^n cao khong lay dugc.
vj tri sdi dudng mgt va vi tri sdi liy dupc Vi tri soi
lay dirg'c
Soi OMC- OGC Soi OMC- OGC, 2 0 0 Ton;? so
Soi OMC- OGC 411
0
411 Vi tn sol
Soi OMC-
[ dirimg mat Tong SoiTM,S6iTM,s6 OMC- 0GC,2 0GC OG
54 22
76 26
0
26 OMC- OGC, 2 OG
1 492 0 22
1 514 4. Djch mSt va giun trong dirong mat
Trong 121 trudng hgp nhiSm triing vd sdc nhiSm trung dudng mat do sdi dugc lay sdi qua NSMTND, chung tdi nhdn thiy dich mat cd mil due d 45 trudng hgp (3 trudng hpp sdc nhiSm triing dudng mgt deu CO mu trong dich mat)
6 b?nh nhdn cd giun. xdc giun ttong ong mat chii kem theo sdi vd deu dugc chung tdi lay ra het 5. ThM gian lay soi qua NSMTND
Tdng thdi gian lay het sdi cho b?nh nhan ngan nhat la 15 phut, dai nhat la 145 phdt, trung binh 33,96 ± 18,24 phut.
Chiing tdi thudng chia thdi gian lay soi qua NSMTND lam nhieu lan nSu benh nhan cd nhiSu soi hay sdi lo, trung binh mpi lan khoang 15-25 phiit, nhu vgy se gidp bSnh nhan dupc dilng It thuoc me vk mau tinh day ban. ttdnh dupc nhiing bien chiing cua cupc gdy mS keo ddi. Sd lan lay sdi cho b|nh nhan qua NSMTND ma chung toi thuc hien ttong nghien ciiu nay nhu sau
Bang 6: sd ldn Idy sdi cho benh nhan qua NSMTND S6 lap lay soi S6 bSnh nhan Tile
164 31,9%
0.4%
6. Kich thuo'c va so lirong soi lay dugc:
Kich diudc vien sdi lo nhit lay dupc: nhd nhdt la 5mm, to nhit la 40mm, ttung binh 15,37nim d 6.34mm.
Tinh chit sdi dudng mat liy dupc;
soi viSn: 372 irudng hgp (72,4%) soi vien va sdi biin: 139 trudng hgp (27%) soi bun: 3 trudng hgp (0,6%) So lirgng vien soi
lay dime 1 2 3 4
So benh nhan 220 101 73 43
Tile 43,05%
19,76%
14,28%
8,4%
m
5 6 7 8 9 10 12 20 Tong so
36 20 4 4 3 5 1 1 511
7%
3,92%
078%
0,78%
0,58%
0,97%
0,2%
0,2%
100%
7. Bien chdng sau lay soi qua NSMTND
Chung toi cd 2 b?nh nhdn bj viem tuy cap sau khi dugc liy sdi 6ng mat chii Idn kich thudc khoang 20 mm vdi trieu chirng la dau bung viing quanh rdn, khong sdt, kham bung khdng cd diu dS khdng thanh bung. X^t nghiem cho thdy amylase mdu - amylase nude tieu cua 2 bSnh nhan nay la 2350 - 18600 U/1 vd 4024 - 24020 U/1.
2 benh nhdn nay dSu dugc dieu tri npi khoa bang dgt sonde mui - da ddy, nhin dn uong, boi hoan nude - dien giai, khang sinh va octreotide (sandostatin). Ho khdi bSnh sau 3 va 4 ngay, xuit viSn 1 ngdy sau do.
1 benh nhdn khac bi chay mau d ca vdng Oddi vd dugc chung tdi cam mdu bang chi'ch Adrenaline 0,l%c qua npi soi td trang
BAN LUAN
1. D^c diem benh nhan trong nghi§n ciru
Ciing nhu cdc nghien cixu ve benh sdi dudng ragt ciia cac tdc gid ttong va ngodi nudc'^'''^''°"\ so benh nhan nii trong nghiSn ciiu ciia chdng tdi chiem da sd (64.5%). gan gap ddi sd benb nhan nam.
Do tudi cua benh nhan thudng gap nhat ttong nghien ciiu ciia chung tdi Id tu 50 tudi trd len (356 b?nh nhan, ti 1? 66.9%). Ngoai ra, chung tdi cd 1 benh nhdn ldn tuoi nhat la 92 tuoi va 1 b?nh nhan nhd tudi nhdt Id 16 tudi, diSu ndy cho thiy benh sdi dudng mdt thudng gap d nhihig benh nhdn ldn tudi nhung ciing khdng hiSm a nhihig benh nhdn thanh thieu nien'^'^'"''"*
Ti le b?nh nhdn co soi dudng mat tai phat cua chung tdi d miic cao 37,78% nhung cdn ndm ttong khoang ti 1? chung ciia ca nude la 20 -40%, da so cdc trudng hgp nay cd sdi ttong gan hay hep dudng mat di kem"".
Chung tdi cd 57 benh nhan tmdc do da dupc cdt tui mgt ndi soi, mpt thdi gian sau nhiing benh nhdn ndy dSn tdi khdm va dugc phat hiSn cd sdi trong dng mgt chu, mpt sd b^nb nhan nhgp vien ttong tinh trang nhiem triing dudng mgt. Tit cd nhiing benh nhan ndy dSu dugc chdng tdi lay sdi qua NSMTND.
Chung tdi nghT ring da sd nhiing benh nhan nay da cd sdi dng mat chii tmdc do md khdng dugc phdt hien bdng siSu am hay CT scan va ttong ldc mo, bac sT phdu thugt khdng nhan thay do ong mgt chii khdng dan hay chi dan nhe < 10mm. Do vay, chdng ta can phai khao sat dudng mgt ttong ldc md cdt tlii mat npi soi khi thiy dng mgt chii dan ttong khoang lOmm bdng chup hinh dudng mat (Inttaoperative cholangiography) bay siSu dm bdng dau do nhd, cd the dua qua trocar 10 ~ 12nim. Mdt so tac gia tiSn hanh NSMTND ttong tnrdng hgp nay dS khdo sat dudng mgt va ldy sdi nSu co^"'^' 2. Ket qua t b ^ hifn
2.1 Tinh trang benh nhan khi NSMTND
Chung tdi dd tiSn hdnh liy sdi dudng mdt cdp ciiu cho 121 benh nhan (that bai d 6 benh nhan nhiem triing dudng mat va 1 benh nhdn sdc nhiem triing dudng mat), ti IS NSMTND ldy sdi cdp curu Id 22,74%. Nhthig benh nhan nhilm triing dudng mat nhung NSMTND lay sdi thdt bai sau do dugc phdu diuat md dng mgt cbii, liy sdi vd giai dp dudng mat ngay nen khong benh nhan nao tir vong. Ngay nay, nhd vao su tiSn bp cua ky thugt gdy me va hdi sire ttong va sau khi phau thugt kSt hpp vdi diing khang sinh mgnh kjp thdi, viec phau thuat hay NSMTND cho nhiing benb nhdn sdc nhiSm triing dudng mgt c6 thS tiin hanh ngay, khdng cdn dang ngai ma phai tn hoan mpt thdi gian dilu trj hdi siic npi khoa nhu truac ddy niia nSn ti IS ni vong do sdc nhiem triing dudng mgt da giam dl rit nhieu""
Chung tdi da liy sdi dudng mat thanh cong cho 8 benh nhdn nhiem triing dudng mdt kSt hgp vdi viem tuy cip do sdi mat, ca 8 b?nh nhan nay dSu khdng bi viem tuy cap nang hon ma khdi benh nhanh. KSt qud nay cua chiing tdi cung tuang tu nhu nhgn dinh cua tac gia Kevin V Behms vd cpng su*". Sau khi tdng kSt nhiSu nghien cim nglu nhien cd kiem sodt, nghien ciru phan u'ch vS vai trd cua NSMTND ttong bSnh viSm tuy cip do sdi mat, tdc gia Kevin V Behms va cpng sy dd ghi nhan rdng NSMTND 392
khong lam trim ttong them, khdng lam tdng ti le hi vong. cd the ldm giam sd ngdy ndm diSu iri tai benh vien cua benh nhan; ngoai ra nhimg lgi fch ma NSMTND dem lai cho benh nhan bj nhilm tring dudng mat do sdi kem theo la ducmg nhien
2.2 Vi tri soi duong mat ldy dirge
Trong 514 benh nhdn chiing toi liy dugc sdi ong mat chu, sdi dng gan chung didnh cdng, cd 22/?7 benh nhan cd soi d 2 dng gan P vd T doan gin vai dng gan chung dugc chung toi liy hSt, con 55/77 bSnh nhdn con Iai do soi ndm sdu d nhung 6ng gan phan diijy va ha phan tiiuy hay kel ciing ttong long dng gan nen chiing tdi khong liy dupc. Do cung la mdt ttong nhiing dilm cdn ban chS cua kJ diuat liy soi qua NSMTND.
Nhung ttudng hgp sdi ttong gan ndm cao, sau bay ket ciing trong cdc dng gan, tdc gid Peter B Cotton va Joseph Leung'''de nghi cd the lay soi bang:
• Diing bong nong chd hep dudng mgt ben dudi vien sdi trudc, sau d6 dua mpt loai rp ldy soi mdi cd guidewire di kem (Wire - guided basket) vao liy sdi, loai rp nay vln co thS bdp v&
dugc vien sdi tbeo phuong phap tan sdi ca hpc bdng rp (mechanical basket lithotripsy) Diing mpt ong soi mSm con (baby scope) dua qua kenh thao tac 4.2 mm cua dng soi Ion, dieu khiln dl tilp cgn vdi cac dng gan nhd. Qua dng soi con nay, chung ta cd tiie diing rp de Idy soi hay tan soi bdng may tdn soi thiiy - dien. Theo chung tdi, ky thuat nay rat dat tien do ong soi con cd gia thanh cao ma Iai dS hong nen hien tai khdng chi benh vien chiing toi md cdc benh vien khac d nude ta chua cd dugc loai ong soi nay
Lay sdi qua da
Theo kinh nghiSm cua tdc gid Nguyin Cao Cuong va cac tdc gia nude ngoai*'*'''' dieu tti triet dl soi trong gan chi con phucmg phap phdu thugt md ong mat chii - dng gan chung ldy sdi bdng kSm hay qua dng soi mem soi vdo dudng mgt ttong khi mo, co the lay sdi bang rp hay tdn soi thiiy - dien l\rc, vd sau cimg la cit phan gan chiia sdi nSu khong thS ndo ldy hSt dupc sdi
2.3 Nhirng trutmg hop that bai
Chiing tdi that bai d 18 benh nhan da sd do soi qua to >3cm hay vira to >2,5cm vira ciing khdng tdn soi bdng thiiy dien lire va dugc va nhirng trudng hgp sdi to va nhieu ket thanh cay sdi trong dng mgt chil - ong gan chung. Chung tdi ciing da diing loai rg de tan soi co hpc (mechanical basket lithotripsy) kSt hgp vdi tdn sdi thiiy - dien luc nhu ciia cdc tac gid khac tten thS gidi nhimg vln that bai do soi to vk cung''"'''^'. Hien'nay, nhilu trung tam vl NSMTND tten thi gidi da dung mdy tdn sdi laser de tdn nhung vien soi to, ciing va da thanh cdng nen ttong thdi gian sap tdi chung toi se dp dyng phuong phap nay dS dem lai ich lgi cho benh nhdn
1 b^nh nhan ttong nhdm 514 benh nhan dupc chung tdi liy sdi thdnh cdng co sdi rit to, khoang 4cm nhung day la viSn sdi mem, chung tdi da tan va dupc vien sdi nay ra lam nhieu manh nhd vd diing rp lan lugt Idy bet. Theo nghien ciiu cua tac gia Le Vdn Cudng, nhiing vien sdi cd thanh phdn Id sdc t6 mgt (Bilirubinate calcium) nhieu, it cholesterone la nhung vien soi cirng, thudng gdp d nam gidi, it chju tac dung bdi thudc tan sdi hay tan sdi ngoai ca the'''
2.4 Nhung bien chirng
Trong 514 benh nhdn chung tdi ldy soi thanh cong, cd 2 benh nhdn hi viSm tuy cip vd 1 benh nhdn bj chay mdu Oddi. Ti le bien chiing vS NSMTND cua chiing tdi diip tuang duang vdi cac ttung tam NSMTND ttSn till gidi (khoang 2 %)
Bang 8: ti Ie % bien chiing NSMTND tai cac benh vien dai hpc y khoa tten till gidi Thoi Tong So tnrong hgp biSn
gian so chiing - ti IS % ngbie tnrdn
n Cliu g hep Thun Viem Chdy Viem NSM gta tuy mau dudng TND tran° cap mat BV Turku, 1997 - 2555 5 5 5 2 Phdn U n 2005
(cac tnrdng hgp cd bien chimg ndng
393
nguy hiSm)"^'
BV Ajou, 2003 - 2247 20 Suwon, 2007 (0.89 Han Qudc'^' %) BVNam 1 9 9 4 - 9948 13 270 34 32 Carolina, 2004 (0,13 (2,7 (0,32%) Wp*"* %) %) (0.34
Bien chiing d o N S M T N D , dac biet la thiing ta trang, neu xdy ra dii diudng Id b i l n chiing ndng vd phdi diSu tti keo dai. Khi co biSn chimg xdy ra thi da sd cdc tac gid ttSn t h i gidi" "•^•'^' de nghi dieu tri bdo tdn npi khoa vd cac phuong phdp khong xam hai (nhu cac phucmg phdp qua ndi soi) trudc:
• Thung ta trang: cho b^nh nhan nhin dn udng, nuoi dudng qua dudng tinh mach, ddt dng thdng mui - da day, hut dich da ddy qua dng thdng, khdng sinh, thudc lie c h l tilt dich vi. Khi cd d abscess sau phucmac thi chpc hdt, ddn luu qua da, han chS phau thuat vi cd die gdy them tdn t h u a n g vd dien tiln benh ndng hon
Chay mau: chich thuoc cam mdu hay ddt dien cam mdu qua ngi soi
V i e m tuy cap: cho benh nhan nhin an udng, nudi duang qua dudng iTnh mgch, dgt dng thong miii - da day, khang sinh, thudc iic che tiel djch vi. N l u cd d tu dich n h i l m triing khdng ddp ling vdi khdng sinh thi chpc hdt, d i n luu qua da
ViSm d u d n g mat: khang sinh, dan luu mat bdng dng thdng mui - mgt
Tuy nhien, theo chung tdi, dieu quan trpng nhat la chii dpng ttanh de xdy ra biSn chiing bang each tuan thii nghiem ngdt cdc nguyen tdc va ky thuat khi dat dng thdng vao nhii Vater va cdt c a vdng Oddi:
• Nguyen tac dat dng thong vao nhu Vater: ttanh lam tdn thuang nhu, nen dilng phuong phap thdng nhu co chpn lpc, chii dpng thdng vao d u d n g mat d hudng 1 l h . Neu ddt dng thong vdo dng tuy thi can nit ra ngay va hdt hSt thudc cdn quang khi da b o m thudc vao dng tuy NguySn tac cdt c o vdng Oddi: can than ttpng, lien hdnh timg budc mpt, chieu ddi vSt cdt phii hgp vai kich thudc vien sdi vd giai p h l u hpc viing ta trang - nhu Vater cda benh nhan.
Ky thuat cat c o vdng Oddi; chung loi ap dung p h u a n g phap cdt c a vdng kinh diSn, cat cd guidewire dan dudng, vira cdt vira ddt, ludn Iam chii dudng cdt. Trucmg hgp nhd Vater ndm tten b d tdi thira td ttdng, chdng tdi ludn cdt theo bd tiii thira, h u a n g 11 - l h , tuyet d6i khdng dugc cat rpng, sau do chung toi diing dung cu tan sdi de lay sdi. Cd thS tan va lay sdi 2 -3 lan nSu sdi to va nhiSu, giiia cac Idn lay sdi nen ddt dng dan luu miii - mat
KtTLUAN
Ngay nay, liy sdi dudng mgt qua NSMTND la phuang phap dugc chpn ddu tiSn ddi vdi benh sdi dudng mat, day la phuong phap can thiep xdm lan tdi ihiSu, an toan,hieu qua va mang Igi lgi ich Idn cho benh nhan la gidp benh nhdn ttdnh dugc cupc phau thugt, trd lai sinh hoat, ldm viSc binh thudng rat nhanh chdng. Tuy nhien, chung tdi cdn nhiing ban chS nhu that bai d nhung trudng hop sdi ldn. soi tao thdnh cay ttong dng mgt chu, dng gan chung. Do do. chung tdi cho rang can nghiSn cihi ihSm phuang tien tan sdi laser de ldng hiSu qud diSu ttj nhihig trudng hgp soi dudng mat lo
TAI LIEU THAM KHAO
1. B e h m s Kevin E, Ashley Stan W, Hunter John G, Carr - Locke David (2008); Early E R C P for gallstone pancreatitis: for whom and when?, Joumal of Gastrointestinal Surgery, Vol 12, pp 629 - 633.
2. Cotton Peter B, Leung Joseph (2005): Advanced Digestive Endoscopy: ERCP, Blackwell PubHshing Ltd, first pubhshed
3. Dd Kim S a n vd cdng su (1999): Ket qua nghiSn cim va dieu tri sdi mat tai benh vien Viet Diic, tap chi ngoai khoa - hdi nghj ngoai khoa qudc gia Viet Nam Ian thir X, Ha Npi 29 - 30/10/1999, tap 1, trang 51 - 5 5 s
4. Hungness Eric S, Soper Nathaniel F (2006): Management of difficult common bile duct stones, Joumal of Gasttointestinal Surgery, Vol 10, No 4. pp 6 1 2 - 6 1 9
5. Kim Hun Ji, W o o Byung M o o . Kim Jin Hong, Kim Myung Wook, Kim Wook Hwan (2009):
Manaoement of E R C P - Related Perforations: Outcomes of a single institution in Korea, Journal of Gastrointestinal Surgery, vol 13. pp 728 - 734.
394
6. Le Quang Qu6c Anh (2002): Vai tro ciia noi soi mat tuy nguoc dong trong benh ly mat - tuy, up chf y hoc TPHCM, s6 dac biet hpi nghj Idioa hpc ky thuit Benh vien Binh Dan lin thii 11, trang 201-214
7. Le Van Cuong (1998): Nghien cilu thanh phan hda hpc cua soi mat o nguoi Viet Nam, Sinh hoat khoa hpc ky thu|t Benh vien Binh Dan s6 9: trang 90 - 96
8. Lukens Frank J, Howell Douglas A, Upender Sunil, Sheth Sunil G (2009): ERCP in very elderly:
Outcomes among patients older than eighty. Digestive Disease Science, Vol 10, pp 784 - 788 9. Nakajima Masatsugu, Yasuda Kenjiro, Cho Eisai, Mukai Hidekazu (1997): Endoscopic
Sphincterotomy and mechanical basket lithotnpsy for management of difficult common bile duct stones. Journal Hepato- Biliary - Pancreatology Surgery, 4: pp 5 - 10.
10. Nguyen Cao Cuong, Van Tin (1996): Di^u tri soi ong mat chinh t^ B^nh vien Binh Dan 1992 - 1994, Sinh hoat khoa hpc ky thuit Benh vien Binh Dan s6 8 1995 - 1996: trang 104-114 11. Nguyin Dinh Hoi (2002): Nhiing tign b6 trong chan doin vl digu tn benh soi mat, tap chi ngo^i
khoa - hpi nghi ngoai khoa qu6c gia Viet Nam lin thir XII, HuS 9 - 10/5/2002, trang 5-19 12. Pham Xuan Hpi. Nguyin Ngoc Tuin, Nguyen Cao Cuong (1998): Npi soi mil tuy ngupc dong vi
cat CO vong Oddi de liy soi sot duong mat sau m6, Sinh hoat khoa hpc ky diu|t Benh vien Binh Dan s6 9: ttang 130-137
13. Salminen P, Laine S, Gullichsen R (2008): Severe and fatal complications after ERCP: Analysis of 2555 procedures in a single experienced center. Journal of Surgery and Endoscopy, Vol 22, pp 1965 - 1 9 7 0
395
