Y HOC VIET NAM THANG 7 - SO 2/2012 Eyal G, Ahron A (2002): Reconstruction of the
Mandible by Fibula free flap. IMAJ
Flood J (2000): Head and neck I I : Reconstruction. Selected Reading in Plastic surgery.
Hidalgo DA (2005): Mandible reconstruction.
Plastic surgery
Lee 3 H, Kim MJ, Choi WS (2004):
Concomitant reconstruction of mandibular basal and alveolar bone with a free fibular flap. Int 3 Ora! Maxillofac.
KET QUA DIEU TR! PHAU THUAT VIEM TUY CAP DO SDI MAT TAI BENH VIEN VIET DUTC, GIAI DOAN 2007-2010
Tran Bao Long * , Nguyen Tien Quyet * * , D o Manh Hung * * , Nguyen Vu Hai *
T O M T A T
Myc dich: Mo ta dac diem lam sang, can lam sang va ket qua phau thuat ciia 93 benh nhan (BN) viem tyy cap do soi mat dUdc phau thuat tai benh vien Viet Dire giai doan 2007-2010, Do/ td&ng va phudng phap nghien cdu. nghien ciru hoi ciru mo ta cac BN mo vi viem tuy cap do soi mat, tiT 2007- 2010 tai benh vien Viet DiTc. ket qua va ban luan: Tuoi trung binh: 54,42 ± 17,57 tuoi {dao dong 19-89). ND':
63 BN(67,7%). Lam ruong: 44 BN (56,4%). Tien si^
mo soi mat: 38 BN (40,9%). Oau viing gan: 93 BN (100%), sot: 53 BN (57%), vang da:56 BN(60.2%).
Phan img thanh bung: 60 BN ( 64,5%). Oiem sudn lUng dau: 33 BN ( 35,5%).Amyla5e mau tang hcfn 6 lan binh thUdng: 62,4 %. Billirubin tang chiem 87,8%.
Sieu am: phu tuy: 26 BN ( 28%), sdi mat: 93 BN (100%). L'/^tojhhaygap nhat la £CD//(59,3%). Ton thu'dng trong mo: Sdi dUdng mat chinh: 78 BN (83,9%). Hoai tir tuy: 12 BN (17,4%). Phau thuat: 78 BN (83,9%) md OMC lay sdi + dan lUu Kehr (± cat tiii mat). Md bao tyy + dan luu hau cung mac noi: 10 BN (10,8%). Ket qua: Thdi gian nam vien: 11,5 ± 4,61 ngay (dao dong tir 3 -29 ngay). Bien chiTng sau mo 5 BN (dieu tn ngi khoa). Khong co BN nao bi tir vong hay nang xin ve. Ket iuam Viem tuy cap do soi mat hay gap d tuoi 41-60 (39,8%). Oau thUOng vj va ha su'dn phai (100%), sot (57%), vang da (60.2%), phan img thanh bung (64,5%), diem sUdn lUng dau (35,5%). 62,4% Amylase mau gap 6 lan binh thUdng.
Hoai tir tuy chiem 17,4%. Md OMC lay soi + dan lUu Kehr (+ cat tui mat) chiem 83,87%, 10,8% md bao tuy + dan lUu HCMN. Ti le bien chirng thap, khong co tru'dng hpp nao phai mo lai va cung khong co tu" vong hay nang xin ve. Thdi gian nam vien: 11,35 ± 4,51 ngay (3-29).
Tiychia khoa: viem t j y cap, soi mat, phau thuat.
SUMMARY
Objectives: describing of the clinical,paradinical features and surgical outcomes of 93 patients with acute pancreatitis due to gallstones at Viet-Duc Hospital 2007-2010. Patients and Methods.
Retrospective descriptive study on the patients with gallstones pancreatitis being operated from 2007-2010 in Viet-Duc Hospital. Results and discussion: The average age: 54.42 ± 17.67 years (range 19-89).
Female: 63 patients (67.7%). Farmers: 44 patients (56.4%). Prehistory of gallstone surgery: 38 patients (40.9%). Pain in the right upper quadrant and epigastric region: 93 patients (100%), fever: 53 patients (57%), jaundice: 56 patients (60.2%), The abdominal tenderness: 60 patients (64.5%). Mayo Robson' sign (+): 33 patients (35.5%). High serum amylase (more 6 times normal): 62.4%. High serum total billirubin: 87.8% . Ultrasound: oedematous pancreatitis, 26 pabents (28%), gallstones: 93 patients (100%). Ecoii IS the most common (59.3%). Per operative lesions: CBD stones: 78 patients (83.9%).
Pancreatic necrosis: 12 patients (17.4%). Operations:
78 patients (83.9%) were performed choledochotomy for removing biliary stones with T tube (±
cholecystectomy); Opened capsule and drainage; 10 patients (10.8%). Results: The length of hospitalization: 11.5 ± 4.61 days (range 3 -29 days).
Complications: 5 patients (no patients had re- inten/ention). No cases were fatal or serious about applying. Conclusion: gallstones pancreatitis were common in the age 41-60 (39.8%). Common symptoms were right upper quadrant and epigastric pain (100%), fever (57%), jaundice (60.2%), abdominal wall defence (64.5%), Mayo Robson'sign (+): 35.5%. Amylase were higher 6 times (62.4%);
17.4% had pancreatic necrosis. Choledochotomy accounted for 83.87%; 10.8% opened capsule and drainage. Low complication rate, no case was Bo mon Ngoai-Dai hoc Y Ha Noi; ** Khoa phau thuat Gan mat-BV Viet Out
Y HOC VIET NAM THANG 7 - SO 2/2012 reopened and no deaths or serious about applying.
Length of hospitallzabon after surgery: 11.35 ± 4.61 days (3-29).
/fey wo/ris; pancreatitis, gallstone, surgery I. OjBkT V A N D I
Viem tyy cap la mot cap ciru thu'dng gap d Viet Nam cung nhU tren the gidi, ty le mo cap ciru vi viem tuy cap la 6-15% [ 2 ] , [ 7 ] . Benh cd the gay nhieu bien chirng nguy hiem va ty le tir vong eao. Nguyen nhan hay gap la sdi dudng mat, ru'du [ 2 ] , [ 7 ] . Gan day, nhd tien bg trong chan doan hinh anh nhu' sieu am, chyp cat Idp vi tinh da day... eOng nhir eac tien bo trong dieu trj, gay me hoi sire... da lam giam ti le bien chirng va tir vong. Tuy nhien, chan doan va chien thuat xif tri, ket gua phau thuat luon !a van de du'dc cac nha phau thuat tieu hoa quan tam. -De tai du'dc tien hanh nham muc dich: Mo ta dae diem lam sang, can lam sang cua viem tyy cap do sdi mat du'dc phau thuat tai benh vien Viet Diic giai doan 2007- 2010 va nhan xet ket qua sdm eiia phau thuat trong (Jeu trj viem tuy cap do sdi mat.
II. OOI T U ^ N G VA PHUONG PHAP NGHIEN COU Nghien ciru mo t a , hoi eiru du'dc thi/e hien tai khoa Phau thuat Gan Mat Benh vien Viet Diic giai doan 2007-2010. Benh nhan (BN) du'dc lya chpn vao nghien eij'u khi thoa man eac dieu kien sau: du'dc chan doan trong mo la viem tyy cap do soi du&ng mat. Khong gidi han tuoi, gidi.
III. KET Q u A
93 BN thuoc doi tu'dng nghien ciru, tuoi trung binh : 54,42 ± 17,67 (dao dong 19-89 tuoi). Nu': 63 BN (67,7%), Nam:30 BN (32,3%).
Nghe lam rugng: 44 BN (56,4%). 38 BN (40,9%) eo tien sir mo sdi mat. Benh tim mach, ho hap phoi hdp ehiem 12,9o/o (12 BN). Trieu ehu'ng lam sang luc vao vien: dau viing gan: 93 BN (100%), buon non: 58 BN (62,4%), non: 51 BN (54,8%), bf trung dai tien: 11 BN (11,8%), sot: 53 BN (57%), vang da: 56 BN (60.2%). Sdc: 2 BN (2,2
%).Gan t o : 11 BN, Tui mat t o : 12 BN. Phan iTng thanh bung: 60 BN (64,5%). Oiem su'dn lu'ng dau: 33 BN (35,5%). Bach eau tang > 15000 d 39 BN (chiem 41,9%) Amylase mau: 62,4 % tang hdn 6 lan binh thu'dng. 8/9 BN thir lipase mau tang. Glucose mau tang ehiem 53,3%
(49BN). 79BN cd billirubin toan phan tang (87,8%). SGOT t§ng chiem 95,6% (87 BN),
SGPT tang chiem 9 0 , 1 % (82 BN). Canxi mau giam ehiem 23,3% (20 BN).
Sieu a m : tyy to phii ne: 26 BN (28%), ed 6 hoai tir tyy: 4 BN (4,3%), djeh quanh tuy: 18 BN (19,4%), djch 6 byng: 24 BN (25,8%). Sdi mat: 93 BN (100%). Giun chui ong mat; IBN.
Chup c l t Idp vi tinh (54 BN): Tyy kich thudc to: 37 BN (68,5%), bd tyy khong deu: 31 BN (57,4%), nhu md tuy khong dong nhat: 24 BN (44,4%), dich quanh tuy co 31 BN (57,4%), dich 6 byng cd 26 BN (48,1%).Du'dng mat cd soi, gian dUdng mat: 53 BN (98,1%). Hoai tu' tuy: 15 BN (27,8%).
V i s i n h : Tren 59 BN ed ket qua vi khuan trong djch mat: 23 BN thay 1 chiing vl khuan (29,9%), CO 32 BN thay 2 chiing vi khuan (45,7%), ed 4 BN thay 3 chiing vi khuan (5,7%).
Vi khuan thu'dng gap nhat la Eco//ehiem 59,3%
(35 BN), Enterococcus faecali's chiem 32,2 % (19 BN) va Klebsiella pneumoniae ch\Qm 23,7%
(14 BN). Khang sinh nhay cam: nhdm earbapenem: 98,6%; amlnosid(gentamycin):
75,4%; cephalosporin the he thir ba (Ceftriaxone): 72,3% nhdm quinolon (ciprofloxacin): 6 9 , 1 % ; nhdm Amoxieillin+
a.elavulanic 67,9%. 53 BN (56,9%) du'dc phau thuat trong 24 gid sau vao vien. 7 BN (8,7%) du'dc phau thuat t d 24-48 gid va 33 BN (35,5%) du'dc phau thuat sau 48 gid.
Ton thu'dng trong mo: 41 BN (44,1%) 6 bung dinh, 49 BN (52,7%) cd djeh 6 bung. 36 BN (54,5%) ed sdi/ biin mat, ed 33 BN (50%) tui mat viem day, ed 8 BN (12,1%) tiii mat hoai tir.
24 BN (25,8%) gan xd. 7 BN bj ap xe gan du'dng mat. 82 BN (88,2%) co OMC gian (>10mm), 78 BN (83,87%) ed sdi du'dng mat, 1 BN bj san la gan. Hoai tir tuy: 12 BN (12,9%).
e a c h thu'e p h i u t h u a t : 83,870/0 ( 7 8 B N ) md OMC lay soi + dan lu'u Kehr ( + cat tiii mat).
8 BN eat tiii mat ddn thuan va 7 BN cat till mat kem tham dd du'dng mat. Trong dd ed 4 BN eat thiiy gan trai. 6 BN eo noi soi du'dng mat va tan soi dien thuy lu'c trong mo.
Can thiep t r e n tuy: tham do tyy va dan lu'u hau eung'mac noi (HCMN): 76 BN (81,7 % ) . Md bao tuy + dan lu'u HCMN: 10 BN (10,8%).
Nao vet to chu'e hoai \\S + dan lu'u HCMN: 7 BN.
Cd 5 BN du'dc m d thong hong trang de nuoi du'dng sau mo. 5 8 , 1 % (54 BN) sir dyng thuoe chdng bai tiet dich tyy (Sandostatin, somatosan).
89,2% (83 BN) sir dyng thuoc iSc che bdm proton (Losee, Nexium...).
81
Y HOC VigT NAM THANG 7 - SO 2/2012 Ket qua: khoi ra vien 93 BN (100%). Thdl
gian nam vien: 11,5 ± 4,61 ngay (dao dong 3- 29). 19 BN sdt sdi trong gan (24,4%), IBN sdt sdi OMC. Bien chdng sau mo: 2 BN bi rdi loan dong mau, 1 BN bi suy da tang du'dc hoi sire npi khoa, tinh trang cai thien eho ra vien, 1 BN bi nhiem triing vet mo, 1 BN bi ap xe ton du'. Khdng cd BN nao phai mo lai.
IV. BAN LUAN
Oac diem chung: tuoi trung binh; 54,42 ± 17,67 (19-89). Gap d nir 63 TH (67,7%) nhieu hdn nam 30 TH (32,3), ket qua tu'dng tu' vdi y van [ 1 ] , [3] ...
Nghe nghiep: nghe lam rupng ehiem 56,4%. (cd the do ti le nghe ndng trong dan sd nu'dc ta chiem ti le cao nen ti le benh cung eao hdn). 9 BN eo tien sir viem tuy cap. 25 BN (26,9%) cd tien sir phat hien sdi mat, 38 BN (40,9%) CO tien su' mo sdi melt, 3 BN co tien sir giun chui ong mat. Benh ly tim mach thu'dng phoi hdp (8,6 % ) . Nhu" vay, sd BN cd tien sir mo sol mat nay phai can thiep lai vi bien chirng vien tuy cap la kha Idn, tu'dng ty" nhu' 1 so thong bao tru'dc [2], [ 4 ] , [5]... Nghien ciTu cho thay, day la van de can du'dc quan tam trong quan ly sau mo BN bi sol mat.
Lam sang: chan doan viem tuy cap do sdi thu'dng du'dc hu'dng tdi khi BN cd trieu ehirng sol mat va ed edn dau dC doi tren ron, xuyen ra sau luTig. Tat ea eac BN deu dau d ha su'dn phai hay thu'dng vj (100%) kem theo buon non va non (62,4% va 54,8%)... Oae diem lam sang ciia cae BN bj viem tuy cap do sol mat tu'dng ty' nhu' y van trong nUde [ 2 ] , [ 4 ] , [5]... va 1 sd thong bao cua tac gia nu'dc ngoai [7],... Gan to (11,8%), tiii mat to (12,9%). Phan iTng thanh byng (64,5%), ti ie nay thap hdn ket qua eiia 1 so thong bao (73-91,4%). Oiem su'dn lu'ng dau la dau hieu lam sang rat ed gia trj ehan doan viem tyy cap ehi gap 6 33 BN (35,5%). Khong BN nao ed dau hieu bam ti'm da viing quanh ron.
Can lam sang: 39 BN (41,9%) co baeh eau
> 15 000/mm^. Xet nghiem sinh hoa giiip khang dinh viem tuy eap; Amylase mau; tang hdn 6 lan binh thu'dng (62,4%) va 8/9 BN thir cd lipase mau tang. Ket qua nghien ciru tu'dng ty' y van da thong bao tir 67-92% [ 1 ] , [ 2 ] , [ 5 ] . Glucose mau tang la dau hieu kha thu'dng gap (53,3%).
Billirubin toan phan mau tang ehiem 87,8%.
Canxi mau giam chiem 23,3%, la dau hieu dang quan tam trong dieu tri va tien lu'dng benh.
Chan doan hinh a n h : Sieu am: tuy to phii ne: 26 BN(28%), 11 BN (11,8%) khong khao sat dUde tyy do vudng hoi, hoai tir tyy: 4 BN. Cac BN deu bi soi mat. IBN (1,1%) bi giun chui ong mat. Cd le do tien bp trong chan doan hinh anh nen ty le khong khao sat du'dc tyy trong nghien ciru nay thap hdn giai doan trUdc day [1], [2], [3], [ 7 ] , [8] ... Chup cat Idp vi tinh (54 BN): tuy to (68,5%), bd tyy khong deu (57,4%). Nhu mo tyy khong dong nhat ( 4 4 , 4 % ) . . . ; chyp cat Idp vi tinh cho biet chinh xac du'dc mire dp ton thu'dng tyy, khdng bi han che do vUdng hdi nhir sieu am.
Xet nghiem vi khuan djch mat: Thirdng gap 1 ehiing vi khuan (29,9%) va 2 ehiing vl khuan. Vi khuan thu'dng gap nhat la Eco//chiem 59,3% (35 BN), Enterococcus faecalis ehiem 32,2 % (19 BN) va Klebsiella pneumoniae c\\\t^
23,7% (14 BN). Khang sinh nhay theo thir tiT giam dan la: earbapenem (98,6%), aminosid (75,4%), quinolon (69,1%), beta lactam (67,9%). Ket qua nghien eiru gop phan eung eap thong tin trong lira ehpn khang sinh khi chu'a co ket qua khang sinh do.
P h l u t h u a t : Oa sd BN (57%) du'dc phau thuat tru'dc 24 gid (tir khi vao vien). 7 BN dUdc phlu thuSt 24-48 gid va 33 BN (35.5%) diTde phau thuat sau 48 gid. Thai do xii tn phii hdp quan i^em cua nhieu nghien eim khuyen cao [2], [7] ...
Ton thu'dng t r o n g mo; 41 BN (44,1%) 6 bung dinh, 49 BN (52,7 cd djch % ) 6 bung, chu yeu la dich vang trong (83,7%), ed 5 BN djch nau dd. 8 BN bi till mat hoai tif, 24 BN bj gan xd. Da so eae tru'dng hdp OMC gian (88,2%)) va chiTa sol (83,87%). Cac hinh thai ton thu'dng do sdi mat tu'dng t i / nhir thong bao eua 1 so y van trong nu'dc [ 2 ] , [4] ... Hinh thai tyy hoai tir ehi ehiem 12,9% nhu'ng lam thay thuoe quan tam nhieu do tinh chat benh ly phu'c tap va ti le tir vong cao 10-47% [4]i [6]...
e a c h thu'e p h l u t h u a t : 83,87% (78BN) md OMC lay sdi + dan lu'u Kehr ( + cat tiii mat).
Trong do co 4 BN cat thiiy gan trai. 6 BN ed soi trong gan du'dc noi soi tan sdi dien thuy liTc trong mo nhd no ly'c rat Idn ciia tap the benh vien trong trien khai cac phu'dng phap dieu trj ap dung edng nghe cao trong dieu trj cap ciTu ma giai doan tru'dc day khong trien khai du'dc. So vdi giai doan 1999 thi^ti le eac phUdng phap mo tu'dng tu", do dae diem sdi mat d nu'dc ta thu'dng la sdi trong va ngoai gan phdi hdp ke ca soi mat
82
Y HQC VIET NAM THANG 7 - SO 2/2012 mo lai nhieu lan, nen mo m d la can thiet. Day la
dae diem benh ly eua nu'dc ta khac vdi cae mrdc Au-My la sdi tiii mat di ehuyen tir tiii mat gay viem tuy cap, thu'dng nhd va di chuyen theo du'dng t y nhien tdi 7 0 % sau 72 gid [ 7 ] . Cd 8 BN cat till mat ddn thuan va 7 BN eat tui mat kem md OMC tham dd ed dan lu'u du'dng mat, eho thay ben canh eae bien chiing sdi mat nhu' tru'dc day thi benh ly viem tuy cap d nu'dc ta da cd xu hu'dng gidng cae nu'dc phat tnen: sdi tiii mat va bien chirng viem tuy cap la van de can quan tam hien nay. Nhu vay, trien khai ky thuat md noi soi hay noi soi can thiep nhOng BN nay va ehup du'dng mat trong mo hay sieu am ngi soi trong mo la can thiet. Oay la yeu cau thy'c te dat ra cho ca eae nha quan ly y te va cac phau thuat vien.
Can t h i e p t r e n t u y tham do tuy va dan luu hau cung mac noi (HCMN); 76 BN (81,7 % ) . Md bao tyy + dan lu'u HCMN: 10 BN (10,8%). Nao vet to ehire hoai tir -i- dan lu'u HCMN: 7 BN. Cd 5 BN du'dc md thong hong trang de nuoi du'dng sau mo do ton thu'dng tuy nang da giup cho viec nuoi du9ng sau mo thuan Idi hdn. 5 8 , 1 % (54 BN) sir dung thudc chong bai tiet djch tuy (Saldostatin. Somatosan). 89,2% (83 BN) sir dyng thuoc ire che bdm proton(losec, nexium, pantoloe...). Theo doi sau mo, tinh trang lam sang va sinh hoa eiia BN xu hu'dng nhanh chong trd ve gidi han binh thu'dng. Khong eo tru'dng hdp nao tir vong/ nang ve.
T h 6 i g i a n n a m v i e n s a u m o : 11,35 ± 4,61 ngay (3 - 29 ngay).
V. K i r LUAN
- Viem tuy Ccip do sdi mat hay gap d lira tuoi 41-60 (39,8%), hay gap d nu' (67,7%), hay gap d nghe nong (56,4%). Trieu ehu'ng hay gap la;
dau thu'dng vi va ha su'dn (100%), buon non (62,4%),' non' (54,8%). sot ( 5 7 % ) , vang da (60.2%), phan u'ng thanh bung (64,5%), diem su'dn lu'ng dau (35,5%). 6 2 , 4 % Amylase mau gap 6 lan binh thu'dng, billirubin mau toan phan tang (87,8%). Sieu am eo gia tri chan doan sdi
mat eao (100%) nhuTig han ehe hdn ehup cat Idp vi tinh trong danh gia ton thUdng tuy. Hinh thai hoai tir tuy chiem 17,4%.
- Ket qua dieu tr;: phUdng phap phau thuat du'dc ap dung pho bien la md OMC lay sdi -i- dan iUu Kehr ( + cat tiii mat) ehiem 83,87%. 81,7 % tham dd tuy va dan lu'u hau eung mae ndi, 10,8% md bao tyy + dan lUu HCMN. Ti le bien ehirng thap (5/93 BN), khong ed tru'dng hdp nao phai mo lai va eung khdng cd tir vong hay nang xin ve. Thdi gian nam vien sau m 6 : l l , 3 5 ± 4,61 ngay (3-29).
T A I U E U T H A M K H A O
1. Ton That Bach, Nguyen Thanh Long, Kim Van Vu (2001), "Mot sd nhan xet ve ket qua dieu tri viem tuy cap hoai td khong do nguyen nhan cO hoc tai khoa phau thuat cap cuU bung Benh vien Viet Ddd. Ky yeu cong trinh nghien ciru khoa hoc ( Ky niem 95 nam Benh Vien Viet DLTC 1906-2001), tap 2, tr. 16-21.
2. Nguyen Khac Du'c (2000), "Nghien cdu die diem iam sang, can lam sang va thai dd xd tri ngoai khoa viem tuy cap do soi mat', Luan van thac sy Y hpc. Hoc vien Quan Y.
3. Nguyen Thj Hang (2002), "Nghien cuV dac diem lam sang, can lam sang va hinh anh sieu am cua viem tuy ca'ff'. Luan van tot nghiep bac sy chuyen khoa cap 2.
4. Tran Bao Long (2005), "Nghien cuU dac diem benh ly va danh gia kit qua phau thuat tong soi mat mo lai", Luan an Tien sT Y hoc, Oai hpc Y Ha Noi.
.J. Nguyen Tien Quyet, Do Kim Sdn, Tran Gia Khanh va CS (1995), ''^Nhan xet ve chad doan va kit qua dieu tn 228 tru'dng hdp viem tuy cap td 1991-1993 tai benh vien VletD&c", Ngoai khoa, 9, 168-176.
6. Trjnh Van Thao (2002), "Nghien cuXi d$c diem lam sang, can lam sang va thai do xd tri ngoai khoa viem tuy cap hoai tiT. Luan van thac sy Y hoc. Hoc vien Quan Y
7 Chirica.M, Paye.F (2011), "traitement de la iithiase biliaire responsible d'une pancreabte aigue", La Revue du practicien, Vo! 61, 224-225.
