LlTA CHON THOI GIAN CAT TUI MAT NOI SOI DIEU TRI VIEM TUI MAT CAP
TOM TAT
Muc dich: Vai trd ciia cat tiii mat ndi soi dieu tri viem tiii mat cap chUa dUdc khang dinh ro. Chiing tdi trinh bay kinh nghiem cat tiii mat noi soi cap ciTu dieu trj viem tiii mat cap va xac dinh sU an toan ciia phau thuat.
Benh nhan va phUOng phap: TiT thang 1/2003 den thang 6/2009, 104 benh nhan viem tui mat cap dUdc mo cap ciTu cat tiii mat noi soi tai Benh vien Tl/QD 108, gdm 41 nii, 63 nam, tuoi trung binh 57.
Ket qua: Thdi gian phau thuat 93 ± 42 phut (42 - 211 phut), ty le chuyen md md 18,9%, giam dan d nhiing nam sau. Bien chirng sau md 12,2% benh nhan, bien chu'ng trong d bung 6,8%. Thdi gian nam vien trung binh 6, 7 ngay.
Ket luan: Phau thuat cat tiii mat ndi soi cap CLJ'u dieu trj viem tui mat cap an toan va trd thanh thUdng quy. A..;
SUMMARY
Background: The role of laparoscopic cholecystectomy for acute cholecystitis is not yet clearly established. We reviewed our experience with immediate laparoscopic cholecystectomy for acute cholecystitis to determine whether this also was safe
Patients and methods: From January 2003 to Jun 2009, 104 patients with acute cholecystitis were operated on laparoscopic cholecystectomy in 108 hospital. There were 41 women and 63 men, mean age: 57 years.
Results: The mean duration of surgery was
Le Quang Minh * Nguyen Cudng Thjnh **
93 ± 42 minutes (42 - 211). The conversion rate was 18,9% and decreased through the years. The postoperative complication rate was 12,2%, 6,8%) had an abdominal complication.
The mean postoperative hospital stay was 6,7 days only.
Conclusion: Immediate Laparoscope cholecystectomy for acute cholecystitis is safe and has become our standard of practice. '-"
1. OAT V A N OE
Phau thuat cat tiii mat ndi soi (Laparoscopic cholcystectomy) (LC) trd thanh tieu chuan vang trong dieu tri viem tui mat, nhd giam dau sau md, thdi gian nam vien ngan...[7,8]. Tuy nhien, vai trd cua LC trong dieu tri viem tiii mat cap van cdn la van de ban cai. Mdt sd tac gia chu truong cat tui mat ndi soi cap ciiu de dieu tri viem tiii mat cap [l,2,3,4,5,6,7];trong khi mot sd tac gia khac cho rang viem tiii mat cap la mot chong chi dinh cua LC vi tinh trang tiii mat viem phii ne, cang to, nhieu khi mac ndi ldn bao boc, tham chi dinh nhieu vao cac tang lan can, gay khd khan cho phau thuat dt bd tiii mat, lam keo dai thdi gian phau thuat, tang nguy CO cac bien chiing sau md, thdi gian nam vien lau hon...[14]. Chting tdi tiln hanh de tai nay nham tim hieu k6t qua cua dt ttii mat ndi soi cap ciiu trong didu tri viem tiii mat cap.
2. BENH NHAN VA PHUONG PHAP:
Benh nhan: Tir thang 1/2003 din thang
* Benh vien 199 -Bg Cong an
** Benh vien TW Quan dgi 108
f i f i U
II 2009, tai Khoa Phlu thuat Tieu hoa,
BVTLTQD 108 cd 104 trudng hgp cat tiii mat ndi soi cap ciiu dieu tri viem tiii mat cap, gdm 21 nii, 53 nam, tudi trung binh 57 (dao ddng tir 16 - 90). Tat ca cac benh nhan (BN) dugc chan doan viem tui mat cap bang lam sang va sieu am.
Phuong phap md: Cat tiii mat ndi soi cap ciiu dugc thuc hien theo ky thuat thudng quy, BN nam ngira dang 2 chan, phau thuat vien diing giiia 2 chan. Sir dung 4 trdca (1 trdca d rdn 10 mm dugc sir dung bom khi va he thdng camera, 1 troca 10mm dudi sudn
trai cho keo hoac dung cu de giai phdng tiii mat, 2 trdca 5mm; 1 dudi sudn phai, 1 thugng vi). Sau khi quan sat tham dd d bung, tiii mat , tien hanh giai phdng viem dinh quanh tui mat, bdc tach bdc Id vung tam giac Calot, tim dng cd tiii mat, kep dng cd tiii mat, kep hoac ddt cam mau ddng mach tiii mat.
Trudng hgp tiii mat cang to, khd kep tiii mat, tien hanh choc hiit dich mat. Giai phdng giudng tiii mat, tiii mat dugc cat bd, cho vao tui va lay ra ngoa qua Id troca 10mm dudi sudn trai. Lau nia va dan luu d bung neu can.
3. KET QUA
Tat ca cac benh nhan trong nghien ciiu dugc md cap cim trong vdng 72 gid sau khi vao vien.
Bang 1 : Mdt sd dac diem lam sang va xet nghiem
Dac diem lam sang Dau ha sUdn phai hoac thUOng vj Dau hieu Murphy dUOng tfnh Sot (T > 37 )
Bach cau tang (BC > 10.000) Men gan tang
Bilirubin toan phan tang Sieu am thay viem tiii mat cap Giai phau benh VTMC
N 87 79 61 72 26 21 97 104
o/o
83,6 75,9 58,6 69,2 25 20,1 93,2 100
Bang 1 cho thay sieu am phat hien VTMC 97 (93,2%)BN, cac trieu chiing thudng gap nhat ciia VTMC la dau ha sudn phai hoac thugng vi 87 (83,6%)BN, dau hieu Murphy duong tinh 79 (83,6%) BN.
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Hinh 1. Sieu am cho thdy hinh anh thanh tiii mat day cd dich xung quanh.
1. Ket qua chung
Ket qua chung • , •.
Thdi gian md trung binh 93 ± 42 phiit •) Chuyin mo md 18 (17,3%)
Biln chiing 9(8,6%) " • : '..
Thdi gian nam vien 6,7 ngay
3. Ty le va nguyen nhan chuyen md md: Phau thuat cat tui mat ndi soi thuc hien thanh cdng d 86 (82%)) BN, 18 (17,3%) BN phai chuyin md md; trong dd, nam 2003 la 50%, nam 2006 la 10%). Nguyen nhan chuyen md md dugc trinh bay d bang 3.
Bang 2. Nguyen nhan chuyen md md (n= 18)(17,3%))
Nguyen nhan Khd khan ve ky thuat
Chay mau Sdi OMC Rach dng cd till mat
N (O/o)
7 (6,7) 4(3,8) 2(1,9) 1(0,9)
Nguyen nhan chinh phai chuyen md md la khd khan ve ky thuat 7 (6,7%)) BN.
4. Bien chung: Bien chiing xuat hien sau md gap 9 ( 12,2%) BN, 5 (6,8%)) BN cd bien chiing trong d bung.
Bang 3. Bien chung trong d bung Bien chu'ng
DUdng mat Rd dng mat chii Rd dnq co tui mat Ap xe dudi hoanh Chay mau dUdnq mat
So BN (O/o) 3(4,1%)
1 2 1 (1,4%) 1 (1,4%) Biln chiing rd mat hay gap nhat 3 (4,l%o) benh nhan.
4. BAN LUAN
Lira chgn thdi gian va phuong phap cat tiii mat dilu tri viem ttii mat cap van la van dl gay tranh cai. Trudc day, viem tiii mat cap dugc coi nhu mdt chdng chi dinh ciia cat tui mat ndi soi [11]. Mot so tac gia cho rang khdng nen md cdt tiii mat ndi soi cap ciiu trong dilu tri VTMC do ty le phai chuyin md md cao ( 30 - 35%), tai biln, biln chiing nhilu...cac tac gia chu truong md cat tiii mat ndi soi sau khi BN dugc dilu tri khang sinh.
luc nay cat tiii mat ndi soi de dang hon, ty le chuyen md md thap [15].
Trudc mdi trudng hgp VTMC, khi nao thi md cat tui mat ndi soi? Da cd nhieu nghien ciiu va thao luan ve lira chgn thdi gian md LC trong dieu tri VTMC. Nhiing nghien cim gan day phan ra 2 nhdm: cat tiii mat ndi soi sdm trong vdng 72 gid tir khi cd trieu chiing ban dau, neu sau 72 gid ggi la md cham (de ngudi). Ket qua nhieu nghien ctiu so sanh md cat tiii mat ngi soi sdm va dt tiii mat ndi soi ngudi dieu tn VTMC cho thky
phau thuat cat tiii mat ndi soi cap ciiu dem lai nhieu ket qua tdt va dugc coi la phuong phap dieu tri chuan trong VTMC vi sir an toan tuong duong md ngudi vdi thdi gian nam vien ngan hon, ty le chuyen md md va gia thanh dieu tri thap hon [9, 12, 15].
Kent A Stevens va cdng sir (2006) chii truong md cat tiii mat ndi soi cap cim ngay nhiing BN VTMC trong vdng 24 gid tir khi BN vao vien. Tac gia chia BN VTMC thanh cac nhdm md vdi thdi gian khac nhau va d nhdm md ngay LC cd the thuc hien thanh cdng d hau het cac trudng hgp viem tiii mat ckp 86(82%) BN, chi 18 (17,3%) benh nhan phai chuyen md md. Tac gia ket luan: khdng cd su khac biet ve ket qua giiia md cat tiii mat ndi soi cap ciiu va mudn trong dieu tri viem tui mat cap vi thay khdng cd sir khac biet giiia hai nhdm ve ty le chuyen md md, ty
le bien chiing sau mo va thdi gian nam vien...
[11].
Mdt sd nghien ctiu nhan xet khdng cd su khac biet ve ket qua giira md cat tiii mat noi soi sdm va mudn trong dieu tri viem tiii mat cap do khdng thay sir khac biet giiia hai nhdm ve ty le chuyen md md, ty le biln chiing sau md va thdi gian nam vien...
[3,10,11,12,15]
KoUa SB va cdng su (2004) cho rang dt tiii mat ndi soi dieu tri viem tiii mat cap la phucmg phap an toan va hieu qua do thdi gian nam vien dugc nit ngan, cac tac gia chii truong thuc hien cat tiii mat ngi soi cho nhung benh nhan viem tiii mat cap trong vdng 72 - 96 gid sau khi cd nhimg bieu hien cua viem tiii mat cap, cac tac gia nhan xet nhieu trudng hgp dng cd tiii mat van de dang nhan ra sau khi bdc tach vao viing tam giac Calot [9}.
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Hinh 2. Viem tiii mat cap, mac ndi ldn dinh quanh tiii mat.
BN.NguyIn Hoang V, mo ngay 1/8/2008
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Trong thuc te lam sang, chiing tdi cQng cd nhimg thay ddi ve chien thuat dieu tri VTMC. Trudc dky, thudng chi djnh md cat tiii mat md sau khi dung mot dgt khang sinh cho BN VTMC. Sau dd, cat ttii mat ndi soi dugc chi dinh trong mot sd trudng hgp VTMC. Hien nay, chiing tdi mo cap ciiu cho
hau hit BN VTMC ngay sau khi vao vien va hoan thanh dii cac xet nghiem ckp cuu.
Bang 1 cho thay nhirng trieu chiing thudng gap la dau ha sudn phai hoac thugng vi 87 (83,6%))BN, dau hieu Murphy duong tinh 79 (83,6%) BN, sieu am phat hien VTMC 97 (93,2%)BN. Kit qua nghien cim tuong tu ciia Salam F Zakko (2008). {13].
Trong chan doan VTMC, chan doan sieu am dugc danh ^ a cao va thudng dugc thuc hien d4u tien. Salam F Zakko (2008) nhan xet 2 trieu chimg quan trgng tren sieu am chan doan VTMC la thanh tiii mat day (tren 4 mmm) hoac phii ne (dau hieu 2 thanh) (hinh
1) va dau hieu Murphy (BN dau khi diing dau dd kiem tra viing tui mat [13]
Ky thuat md tuong tu md LC dieu tri VTM man, sau khi quan sat tham dd d bung, tiii mat, danh gia tdn thucmg (hinh 2), tien hanh choc hiit mu va dich lam cho tiii mat do cang ne neu can thiet ( hinh 2,3), giai phdng tiii mat, tim ddng mach tiii mat va dng cd tiii mat de kep clip va cat. Trong trudng hgp tiii mat cang to chira dich mil nen tien hanh choc hut lam xep tiii mat de de kep tiii mat •' od-)
Hinh 3. Chgc hiit mil trong d bung.BNTran Thi T, md ngay 21/11/2006
Hinh 4. Choc hut dich mil qua thanli bung BN.NguyIn Hoang V, md ngay 1/8/200
/sri Jc/fi ('
Thdng ke cho thly: Thdi gian mo trung binh 93 + 42 phiit. Ty le chuyin md md: 18 (17,3%)BN, biln chimg gap 9 (8,6%) BN, thdi gian nam vien 6,7 ngay (bang 2). Ket qua nghien ciiu thu dugc tuong tu thdng ke
ciia Chris N Deniak va CS (2008) va mdt so tac gia khac [3, 4, 5,6,7,8,9, 10 ].
Phau thuat cat tiii mat ngi soi ckp ciiu dilu tri VTMC thuc hien thanh cdng d 86 (82%) BN, 18 (17,3%) BN phai chuyin md
md; trong dd, nam 2003 la 50%o, nam 2006 la 10%). Nguyen nhan chuyen md md dugc trinh bay d bang 2. Ket qua nghien ciiu thu dugc tuong tu thdng ke ciia Chris N Deniak va CS (2008) va mdt sd tac gia khac [3].
Hobbs MS va cdng su (2006) nhan xet: Ty le chuyen md md giam khi chi dinh hgp ly, kinh nghiem ciia phau thuat vien tdt ; tac gia cho rang: Tinh trang viem phii ne ciia tiii mat, dinh cua cac tang xung quanh, thdi gian tir khi cd trieu chirng den khi md ... la nhiing yeu td quan trong anh hudng tdi thanh cdng cua phau thuat [7]
Braghetto L va cdng sir (1997) danh gia cao vai trd ciia sieu am chan doan viem tiii mat cap trudc md, Tac gia nhan xet : Sieu am cd the cho phep nhan dinh nhiing khd khan ciia phau thuat va tir dd xac dinh dugc nguy CO phai md md [2]. Ngugc lai, Satambrogio R va cdng su (1996) khang dinh: Sieu am khdng quan sat dugc viing tam giac Calot, vi vay khdng danh gia dugc kha nang bdc lo tim dng cd tiii mat va ddng mach tiii mat [14]. Quyet dinh chuyen tir md ndi soi sang md md trong viem tui mat cap phu thudc vao kinh nghiem ciia phau thuat vien, nham tranh keo dai thdi gian md, de phdng cac bien chiing va keo dai thdi gian dieu tri sau md tai benh vien [6,10,11,12, 14,15].
Nghien ciiu cho thay bien chimg sau md trong cat tiii mat ndi soi dieu tri viem tiii mat cap gap 9 (12,2%)) BN, nhiing biln chiing trong d bung gap 5 (6,8%o) BN, Bien chiing rd mat hay gap nhat 3 (4,1%)) BN, cac bien chung apxe dudi hoanh va chay mau dudng mat dIu gap 1 (1,4%)) BN. Phan tich nguyen nhan rd mat cd the do cap clip khi dng cd tiii mat dang viem, sau dilu tri tinh trang viem nhiem giam hoac hit lam long clip cap dng CO tui mat. Giai doan sau chiing toi sir dung clip nhua, cd mdc khdp vao nhau chat nen
khdng gap lai biln chiing rd mat. Cac trudng hgp rd mat dugc dilu tri bang chgc hiit, dat dan luu dudi gan nhd sieu am, md co that oddi qua ngi soi, khdng cd trudng hgp nao phai md lai. Ket qua ciia nghien cim thu dugc tuong tu nhu cua Kent A Stevens va cdng sir (2006), ciing nhu mdt sd tac gia khac [1,8,9,10, 11]. Nhilu tac gia nhan xet : Tdn thuong dudng mat trong cat tiii mat noi soi tang hon so vdi cat tiii mat md [8, 11]; tuy nhien, mdt sd nghien ciiu gan day, ngudi ta khdng thay sir khac nhau ve ty le tdn thuong dudng mat trong cat tiii mat ndi soi so vdi md md [6,12, 15].
Nghien cim cua mdt sd tac gia cho thay:
Thdi gian nam vien sau cat tiii mat noi soi dieu tri viem tiii mat cap dai hon cat tiii mat md, do cac bien chimg sau md xuat hien nhieu hon [9,10, 11]. Ket qua nghien cim cho thay thdi gian nam vien 6,7 ngay la ket qua tuong ddi tdt.
Lgi ich ciia phau thuat cat tui mat noi soi trong dieu tri viem tiii mat cap la thdi gian nam vien ngan, benh nhan giam dau sau mo va ngudi benh nhnh chdng trd ve boat dong binh thudng [1,2,3,6,6]. Ket qua nghien ciru cho thay cd 66%o BN ra vien trong vdng 6 ngay. Phan ldn sd BN khac phai nam vien lau hon do ldn tudi, khd khan trong viec cham sdc d nha hoac do cac bien chiing sau mo.
Thdi gian nam vien sau md ciia nghien ciiu thu dugc Cling tuong tu kit qua nghien ciru ciia cac tac gia khac [1,2,3,4,5,8].
5. KET LUAN
Ket qua nghien ciiu cho thay cat tiii mat ndi soi caaps ciiu trong dilu tri viem tiii mat cap an toan va hieu qua tdt, day la phuong phap nen dugc lira chgn trong dilu tri viem tui mat cap.
TAI LIEU THAM KHAO
1. Bickti A et al. Laparoscopic cholecystectomy for acute cholecystitis.
Surg Endosc 1996,10: 1045- 9. »^5 2. Bragetto I et al. Correlation among
untrasonographic and vidioscopic fidings of the gallbladder: Surgical difficulties and reasons for convention during laparoscopic surgery. Surg Laparosc Endosc 1997; 7:310 - 5 .
3. Chris N Daniak et al . Factor associate with time to laparoscopic cholecystectomy for acute cholecystitis. World Journal Of iv: gastroenterology, 2008, 1 0 8 0 - 1 0 9 4 .
4. Eldar S et al. Laparoscopic cholecystectomy for acute cholecystitis:
Prospective trial. World J Surg 1996,10:
1045-9.
5. Estes NC et al. Acute cholecystitis treated urgently by non selective Laparoscopic cholecystectomy. Am Surg 1996; 62: 598 - 602.
6. Garber SM et al. Early Laparoscopic cholecystectomy for acute cholecystitis.
Surg Endosc 1997, 1 1 : 3 4 7 - 5 0 .
7. Hobbs MS et al. Surgeon experience and trends in intraoperative complications in laparoscopic cholecystectomy. British Journal of Surgery 2006; 93: 8 4 4 - 8 5 3 . •,
(,a l i i ; j
8. James Y Lau et al. Laparoscopic cholecystectomy after endoscopic sphincterostomy. Gastroenterology; 2006;
1 2 0 : 2 2 4 7 - 2 2 5 1 .
9. Kolla S. B et al. Early vs delayed laparoscopic cholecystectomy for acute cholecystitis. Surg Endosc; 2004,18: 1323-1327.
10. Koo XP et al. Laparoscopic cholecystectomy in acute cholecystitis. Arch Surg 1996, 131:540- 5.
11. Kent A Stevens et al. Immediate laparoscopic cholecystectomy for acute cholecystitis: no need to wait. The American Journal of Surgery, 2996, 736 - 731.
12. Lo CM et al. Early versus delayved Laparoscopic cholecystectomy for treatment of acute cholecystitis. Ann Surg 1996, 223:
3 7 - 42.
13. Salam F zakko et al. Clinical features and diagnosis of acute cholecystitis Up To Date, 2008.
14. Santambrogio R et al. Technical difficulties and complications during laparoscopic cholecystectomy : Predictive use of preoperative ultrasonography. World J Surg 1996; 20: 9 7 8 - 8 1 .
15. Shikata S et al. . Early versus delayved Laparoscopic cholecystectomy for treatment of acute cholecystitis. Surg Today 2006, 35:
5 5 3 - 560. . r,..;. ,. . i
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