Y HOC VIET NAM THANG 6 - 8 6 2^014
NHAN XET VE DIEU TRI VIEM TUY CAP KHONG
DO NGUYEN NHAN CO" HOC TAI BENH VIEN BACH MAI TIT 2 0 0 8 - 2 0 1 2 TrSn H&u Vinh*
T6M TAT
Oat van de: Hien nay viem tuy cap (VTC) xuat hien ngay cang nhieu dac biet do nguyen nhan khon_p ca hpc. Xu hu'dng hien nay, chu yeu dieu trj I<h6ng mo.
Chi djnh mo trong nhu^g tru'dng hpp nhat djnh.
Phu'tfiig phdp nghien cu'u; mo ta hoi cijtj trong thdi gian tir 1/2008 - 12/2012. Ket qua: Benh gap d nam nhiSu hdn nff (nam/nif = 5,02). Tuoi thu'dng gSp •IO - 49 tu6i, tuoi tnjng binh: 44,9 + 13,5, lien quan den ruWu (48,6%), khdng ro nguyen nhan (33,6%). Dieu tri npi la 85,77%. Chi djnh phlu thuSt la 14,2% tro^ng VTC hoai til CO dau hieu VPM va VTC hoai tiJ' nhiem trOng hay ap xe tuy. Thdi gian nam vien trung binh:
9,3 + 8,3 ngay (dao dpng tiJ' 1 - 73 ngay). Nhdm phau thuat: 21,3 + 15,3 ngay; nhom dieu trj no) idioa: 7,8 + 5,5 ngay. KSt )u^n: Viem tuy cap khong do nguyen nhan cti hoc du'dc dieu tn npi khoa la chii yeu, chi dinh dieu trj phau thuat thu'dng la vieni phuc mac do viem tuy hoai tu" va viem tyy hoai tir nhiem triing.
ri^*l^Aoa/Viem tuy cap S U M M A R Y
E V A L U n O N OF TREATMENT OF ACUTE PANCREATITIS NOT MECHANICAL CAUSED
Background: Currently, acute pancreatitis occurs more espedally because no mechanical cause. The current trend, mainly surgical treatment. Specify surgery in certain cases. Research Methods:
Retrospective descriptive in time from 1/2008- 12/2012. Results; The disease occurs in males than females (male/female = 5,02). Common age 40-49 years, mean age: 44,9-fl3,5, relating to alcohol (48,6
%), unknown causes (33,6 % ) . 85,77% of patients treated. Indications for surgery (14,2% are common signs of peritonitis and pancreatic Infection or abscess.
Average length of hospital stay: 9,3+8,3 days (range 1-73 days). Surgery group: 21,3+15,3 days; medical therapy group: 7,8+5,5 days. Conclusion; Acute pancreatitis not caused by mechanical treatment Is primarily medical, surgical indications for treatment of peritonitis is usually caused by necrotizing pancreatitis and Infected necrotic pancreatitis.
Keywonis: Acute pancreatitis
I.OIJTVXNOI
Viem tuy cap (VTC) la mpt benh !•/ cap tfnh o bung do cac men tuy hoat hoa ngay trong tuyen tuy gay ra hien tu'cfiig tieii hiiy t o chu'c tuy va cac c<) quan lan can. VTC xuat hien ngay caiig nhieu, du'dc chia thanh 2 the cd ban phu thuoc vao
* Klioa Ngo^i - Benh vien Bach Mai Phin bipn khoa hgc: PGS.TS Trjnh Van Tuan
nguyen nhan: VTC do nguyen nhan cd hoc do soi hoac do giun doi hoi phai ran thiep noj^soi du'dng mat ngu'dc dong hoac phau thuat nio m d hoac noi soi de giai quyet nguyen nhan. VTC do nguyen nhan khong cd hoc thi khoang 8 0 % cac tru'dng hdp (TH) dap irng vdi dieu trj noi khoa, so con lai la VTC hoai tii co t h e gay^ nhieu bien chu'ng nang vdi ty le t i f vong cao. Phau thuat chi dat ra khi co cac bien chutig. Theo lam sang VTC tai hoi nghl quoc te Atlanta My 9/1992, nguidi ta phan loai thanh 2 t h e ; The phii va the hoai tii'.
Trong do VTC the phii chiem 8 0 % , la the nhe dap ulng t d t vdi dieu t r i npi khoa trong vong 1-10 ngay, doi vdi the hoai 'tu* chiem 2 0 % thi cd nhD'ng mifc do khac nhau ^cd the cd nhifng tru'dng hdp dien bien xau dan tdi suy da phu tang va co nguy cd t i f vong cao. Van de chinh cua thai do xif t r i doi vdi VTC ia chan doan the benh, danh gia tinh trang nhu mo tuy bi thu'dng ton tir do d u ^ ra quyet dinh phu'dng pliap dieu trj. Ngoai dira tren cac trieu chifng lam sang thi ngay nay nhd iing dung tien bp ciia cac thiet b|
hien dai (sieu a m , chup cat Idp^vi tfnh, chup c§ng hiidng t i f . . . ) khong hhETng chan doan chfnh xSc VTC khong do nguyen nhan c d hpc ma^con co ^ nghla tien lu'dng, gop phan lam thay doi thai dp trong dieu t r i . Tru'dc nam 80 ciia t h § ky t r u & , viem tuy ceip du'dc dieu tri chii yeu bang ghau thuat. Tir n a m l 9 8 0 nhd nhOlig nSu biet ve cd che benh sinh da | 6 viem tuy cap du'dc dieu tri bang hpi khoa, phau thuat chi du'dc chl djnh cho nhu'ng tru'dng hdp viem liuy cap db nguyen nhan cd hpc hoac co bien chu'ng. Tuy nhien cho tdi nay^viec diSu tri phau thuat viem tuy cap con gap nhieu khd khan va chu'a cb sir t h o n g nhat ve thdi diem m d cung nhu" phu'dng phap phau thuat.
Oe tai du'dc thiic hien nham danh gia i<et qua dieu trj viem tuy cap khong do nguyen nhan cd hpc tai khoa Ngoai benh vien Bach mai trong giai doan 2008 - 2012.
II. 061 -njqim vA PHUCNG PHAP NGHIEN du
2 . 1 . D o i tiTclng n g h i e n c i h i : Tieu chuan lu'a chpn chung gom cac benh nhan nam, nu' tuSi
>16 du'dc chan doan va dieu trj VTC khong do nguyen nhan cd hpc. Benh nhan 1:6 day dil h5 sd benh a n , du'dc dieu tri tai khoa Ngoai benh v i | n Bach mai tir i / 2 0 0 8 - 1 2 / 2 0 1 2
2 . 2 . Phu'dng p h d p n g h i e n c i h i : Nghiin ciru mo ta hoi ciru. Ghi nhan cac d5c diem iam sang va can lam sang. Cac gia phap xir iy cd ban
. ..yC VlgT NAM THANG 6 - SO 2/2014 va danh g l a j ^ qua dieu tri theo phan loai: Tdt
(BN ra Vien on djnh, khong co bien chu'ng), trung binh (CO bien chtfng nhu'ng dieu trj khoi), xau (co bien chifng nhutig dieu hi khong khdi xin ve hoac tuf vong). Khong xep vao nghien cihi khi VTC co nguyen nhan cd hpc hoac da du'dc phau thuat tai tuyen tru'dc.
III. KET QUA
3.1. Dac diem chung: Co 253 benh nhan VTC khong'do nguyen nhan cd hpc thupc dol tddng nghien ciru. Ti le nam/nu' = 5,02. Co 2 the VTC chinh vdi ty le tu'dng du'dng (the phu:
44,6%, hoai tir: 53,4%). Tuoi trung binh: 44,9 + 13,5 tuoi. Nguyen nhan lien quan den rddu la 123/253 BN chiem 48,6% va 112/253 BN chiem 44,3% khong ro nguyen nhan. VTC sau phau thuat viing bung hoac sau can thiep npi soi vao viing bong Vater o5 i8 benh nhan (chiem 7,1%).
Trieu chiihg lam sang: chu yeu la dau bung thi/dng vi (100%), diem sddn luhg dau chi gap 47%; 36,8% benh nhan sdt ( > 37,5). benh nhan cd bung trirdng 91,7%. benh nhan cd phan utig thanh bung 52,7%. Bach cau tang > 9000 chiem 84,2% trong dd bach cau tang > 15000 chiem 30,8%. 80,8% sd benh nhan cd amylase mau tang, 66,8% so benh nhan co du'dng mau tang. Sieu am khao sat dddc hinh thai ciia tuy 192/253 chiem 75,88% cac tru'dng hdp. Chup cat Idp vi ti'nh (CLVT) cho 249/253 BN khao sat du'dc hinh thai tuy 100% cac tru'dng hdp, mu'c dp dddc danh gia theo phan ioai Ranson va Balthaza: do E 133/249 BN (53,4%), dd D 57/249 BN (23%), do C 35/249 BN (14%), do B 15/249 BN (6%), dd A 9/249 (3,6%). Mu'c do' hoai tu' xac dinh hen CLVT < 30% chiem 195/249 BN chiem 78,3%, hoai tuf tir 30 - 50% la 40/249 chiem 16,1% va hoai tir > 50% la 14 BN chiem (5,6%).
Hinh anh VTC tren IRM Hinh anh VTC tren CTS Hinh anh VTC hoai td
3.2. C^c phu'dng phdp dieu trj:
3.2.1. Biiu tri npi ichoa: 217/253 benh nhan (85,77%) dddc dieu trj noi khoa: khing sinh, chong bai tiet djch tuy (Stilamin, Sandostatin), nuot du^ng du'dng ttnh mach 24-48 gid dau, hut djch da day lien tuc, thut hau mdn Cho Sn sdm trd iai l(hi binh nhan giam dau bSng nhd^gipt qua sonde da day de han che nhiem khuan tir catheter. Soi vdi cac trdcfng hdp nang chiing toi phoi hdp vdi Oieu W tich cdc hdi sifc h6 hap, hoi sdc tuan hoan...loc mau lien tuc.
Trong so nay cd 24/217 BN du'dc ket hdp dan liru djdi hoai tii bang sonde 12-16F dddi liddng dan cua sieu am, ket qua khong phai mo md.
3.22. Phiu thuit: Trong so 36 BN phai phau thuat cd 29 berih nhan du'dc mo vdi chi dinh 1^ VTC hoai tii nhiem triing (ap xe tuy) 11,46%. BSc bi?t cd 7 benh nhan (2,76%) chi dinh mo vdi chan doan; tic ruot (IBN), VPM do VRT (3 BN), VPM do^thiing tang rong (3 BN). Ton tnuBng hong mo: Ton thu'dng tren toan bd tuyen tay chi&n da sci cac tru'dng hdp 13/29 (44,8%), on thuBng dau va thSn tgy 5/29 BN (17,24%), M tw 11/29 BN (37,96%). 4/29 BN cd OMC
gian khdng cd sdi. Phan Idn BN cd dich d bung, Iddng dich < 500 ml 20/36 BN (55,55%) va lu'dng djch nhieu > 500 ml 16/36 BN (44,45%), nhieu nhat khoang 2000 ml djch.^ Tat ca cac tru'dng hdp djch deu cd mau dd sam hoac nau den. 3 BN hoai tif d dudi tuy vd vao lach gay hoai tir chay mau va vd lach, 3 BN cd hoai tif, ap xe viing dau tuy thay cd tui mat viem ne cd cham hoai td. Oat biet cd mpt tru'dng hdp viem tuy gay huyet khdi dpng mach mac treo dai trang trai, 1 BN hoai tii thiing dai trang phai.
3^2.3. Phwang phip phiu thuft;
Tren tuy: cat ipc to chdc hoai tir va dan tifu rdng rai 6 hoai tir va td chirc xung quanh dddc ap dung d 21/36 BN (58,33%), dan Idu till m|t, md thong hong trang, lau rira 6 bung, dSt dan lull dddi gan, ho lach, hai ho chau va till ciing Douglas. 6/36 BN (16,66%) dddc; md bao tuy, dan Idu HCMN ddn thuan la nhiing tru'dng hdp tuy viem phu ne, cb cham hoai td, 3BN dddc dan Idu ap xe tuy, 1 BN phai cSl: than duoi tuy, cSt lach do khoi ap xe dudi tuy gay hoai td chay mdu lach. 3 BN phai cat lach do chay mau lach, 2 BN phai cat nira dai trang (1 BN hoai tif dai hdng
Y HOC VIET NAM THANG 6 - SO 2/2014 trai do tac mach, 1 BN hoai tu* thung <5ai trang
phai). 27/36 'BN^(75%) dirdc md thong hong trang muc dich de nuoi du9ng sdm.
Xet nghiem vi sinh: BN du'dc lay dich o bung va djch tuy hoai tu" de nuoi cay vi khuan (+) chiem 17/36 (47,2%) nhieu chung vi l<huan), E.coli (9 BN), K.pneumoniae (1 BN), A.baumannii (1 BN), Cfreundii (1 BN), E.faecalis (1 BN), P.aeruginose (1 BN), E.doacae (1 BN), tri/c khuan Gram (-) khong dinh Ioai (4 BN). Kharig
sinh nhay camphalosporin the he ba, amikacin, gentemycin, vancomycin, imipenem. ^
Cac bien chtitig: Trong so 48 benh nhan co nhiJng dien bien sau mo nang len do cac bien chu'ng sau: Suy tuan hoan 30/48 BN (62,5%).
Suy ho hap 14/48 BN (29,1%). Suy than 32/48 BN (66,6%). Suy gan 15/48 BN (31,25%). Suy da tang 13 BN (5,13%) nam^trong nhom tOrvong hoac xin ve. Trong nhom phau thuat: ty le nhilm trung vet mo la 13/24 BN (54,16%). Ch^y mau sau mo 3/24 BN (12,5%).
nil
Phan ioai ket qua Nhdm dieu trj ndi khoa Nhdm phau thuSt
24 (66,66%) 205 (81,l%y Tong Tot
Trun^ binh
181 (83,4%)"
26 (11,98%)
10 (•4,62%) 9 (25,07%) "
3 (8,33%)
35 (13,E 13 (5,1%: P<0,05 253 (100%) . . . - I°."9 . ..I 217(100%) I 36(100°7L.
Khac biet ve ket qua dieu tri ciia 2 nhom co y nghia thong ke, P<0,05.
Thdi gian nam viin tning binh: 9,3 + 8,3 ngiy (dao dong tWl-73 ngiy). Nham phau thuit: 21,3 + 15,3 ngay; nhom dieu tri nil khoa: 7,8 + 5,5 ngay.
IV. BAN LU$N 4.1. Lam sang
Trieu chuhg cd nang dau bung tren ron hpac dddi sddn gap phai d 100% cac trddng hdp, day la trieu chung sdm nhat, la If do chfnh benh nhan den vien. Trong nhdm nghien cull chiihg toi ghi nhan tri^u chdng dau bung d nhdm BN nghien rdiju nang cd biJu hien dau d miTc thap hdn, kiiong^cb nhiihg cdn dau dif dpi, ngoai ra it gap cac trieu chimg lam sang khac. Bu5n non va non 177 TH chiem 69,96%. Bf trung dai tien gap 117 TH chiem 69,96%. Trieu chuhg toan than: 9 BN d trong tinh trang soc khi vao vien, vdi bleu hien mach nhanh nhd > 120 lan/phiit va huyet ap toi da <90 mmHg. Nhiet do d 36,8% trong nhiihg ngay dau d da so BN, khi sot xuat hien vao ngay thd 5 trd di va sot cao > 39 thi thddng la bleu hien ciia tinh trang nhiem triing to chdc tuy hoai td, sot cao lien tuc la mpt trong nhu'ng yeu tot tien Iddng xau vi liguy cd bien chutig va td vong.
Tham kham thay d 232 TH (91,69%) BN cd bung tru'dng d cac mdc dp khac nhau. 133 TH (52,56%) BN cb phan dng thanh bung va dac biet 118 TW (46,64%) so BN cd diem sddn idng'(+) ia nhuhg dau hieu rat guan trpng tren iam sang.
Nhiilig ty; ie ve cac dau hieu iam sang cua nhdm nghien cuu ghi nhan khong cd sd khac biet so vdi cac ket qua cua cac tac gia troiig va ngoai nddc ghi nhan [3J, p j , [6].
4.2. Can lam s^ng: bach cau tang cao la dau hieu thddng gap. Amylase, dddng mau tang giup hddng tdi chan doan VTC. Trong cac BN dujdc xet nghiem lipase mau cd 14 BN cd lipase mau > 3 lan binh thu'dng. Theo Ranson J, dp nhay ciia lipase trong chan doan VTC la 85- 100%, tren lam sang nen chi dinh xet nghiem lipase trong chan doan khi cb nghi ngd VTC.
Nhifng_xet nghiem danh gia tien tddng cung thay thay doi d nhieu BN nhd: tang ure mau ia 40 BN chiem 15,8%, giam canxi mau la 82 BN (32,4%).
Chan doan hinh anh: Rat cb gia trj trong chan doan xac dinh VTC va 1 so bien chuhg. Sieu am;
Khao sat dddc hinh thai tuy 192 BN (75,88%), thu'dng bi han che do vddng hdi, benh nhan bbd.
249 (98,4%)^BN dddc Chup CLVT va dddc phin loai thddng ton day du theo Balthazar va Ranson cai tien. Op A 8i B chiem 98/249 BN (39,35%);
hinh anh tuy binh thddng, cb the tuy tp tpan bo hoac khu tru, dau hieu sdm nhat la bd tuy khong ro do cb sd xam lan cua Idp md quanh tuy.
Nhdm thddng ton nay dddc chan ddan xac dinh bang xet nghiem sinh hba. 06 C,D 8i E la 150/249 chiem 60,2% la nhbm VTC the hoai td.
l/u diem cua CLVT la phat hien khf d trong nhu mo va ngoai nhu mo tuy do hoai td. Mdc do hoai tir nhu mo tuy tren 35% tien Iddng xau. trong qua trinh dieu tn, neu Jinh trang BN khong cai thien hoac nghi ngd nhiem triing tuy hoai td hay ap__xe tuy thi cb the chup kiem tra'danh gia Hen trien va_tien Iddng VTC. Chung tdi cung theo quan diem cua Ranson HG: Ooi vdi hoai td nliu mo tren 50% thi chi dinh phau thuat la bat buoc, trong nhdm nghien cuii ty le nay la 5,6%: Ooi vdi mdc dp hoai td td 30-50% can phai phoi hdp vdi mdc dp ton thddng ngoai tuy, so Iddng va the tich cac 6 djch khac. T'y le nay trang nhdm nghien cdu chiem 16,1%.
4.3. Chi djnh mS; Trong tong s5 36/253 BN (14,22»/o) dddc phau thuat cb 29 benh nhan dddc mo vdi chi djnh la VTC hoai td nhiem hiing hoac ap xe tuy chiem 11,46 %. Cu the frong do 21/36 BN (58,33%) dddc chi dinh mo vi vISm tuy hoai td cb viem phdc mac, 5 BN (13,88%) dddc Chan doan VTCHT nhierfi trung va cd 3 BN chan doan ap xe tuy dda tren CLVT. Tat ca BN
Y HOC V l ^ NAM T H A N G 6 • SO 2/2014 nay deu CO sot > 38,5, co 133/249 BN chiem
53,4% CO hoai tu" dp E theo phan loai cua Ranson- Bathase vdt^ mii'c dp hoai tu" nhu mo >
30%. Theo guan diem^cua W. Harting cho rang khi BN CO bieu hjen nhiem trung phoi hdp vdi suy da tang nen mo sdm [7]. Ket qua sau mo cay dicii 6 bung co 17/36 BN thay vi khuan, dieu nay cho thay dp chi'nh xac trong chan doan tinh trang nhiem tmng tuy hoai tif. ^
^ 4.4. Thdi diem piiau thuat: chon thdi diem de can thiep b-ong^VTC hoai tu" nhiem trung jSt quan trpng vi neu mo gua sdm khi chu^co si/
phan dinh ro rang giu^ to chu'c lanh va to chut hoai tu" thi rat kho co the lay du'dc het to chu'c hoa! tuf va de gay chay mau tu* dien cat tpc va tuy con dep tyc ho?i tu* nen phai^phau thuat nhieu lan. Theo ghi nhan cua Nguyen Thanh Long^thi CO tdi 77,4% CO chi djnh mo tiT 2-14 ngay ke tu"
Wii CO triSu chiing VTC, ty Ie du'di 48 gid chi cd 14j4% va sau 14 ngay la 11,2% [3]. Theo quan diem cua chiing toi doi vdi tru'dng hdp VTC the ho?l tCr con d giai dogn sdm chu^ hinti^ thanh cac 0 khu trii thi nen ap dung bien phap dan lutJ djch hoai tti" bang Jcim nhd du'di hu'dnp dan ciia sieu Sm'vS^chyp cat Idp vi tinh lam gjam du'dc ap life tnsng o^byng, Theo cac tac gia Au, My cho rang ap li/c 6 bung tang ty le thuan vdi dp nang cua VTC va cung la hau qua cua viec tang cac cytokin cSc yeu t^ gay viem trong VTC tao ra vdng xoan b^nh ly dan den benh canh suy da tang nang ne trong VTC nSng [1]. 36 BN co chi dinh nio ciia chiing toi deii nSm trong khoang thdi gian tir 7- 10 ngay, khi to chiTc hoai tir tuy da du'dc dinh hinh nhat djnh thanh tirng o.
4.5. Phu'dng phdp phau thu$t ddi vdi tuy + Liy bo to chu'c tuy hoai tir va cac to chu'c ho?! tir quanh tuy, lam sach nhu'ng o nhiem triing nhSm ngan chjn nhutig Wen chiTng toan thSn (suy da tang, soc) va tai cho (ap xe tuy, rd ri^y, i t tieu hoa^ thiing rupt Theo kinh nghiem cua chiing tpl cac to chu'c hoai tir nen lay bang ngdn tay^de tranh lam dirt cac dai xd lan trong do cd the la mach mau, trong tru'dng hdp co chay mau nen dat meche tam oxy gia va rut sau Veil phut.
+Bao l£n tffl da nhu md tuy lanh vi anh hudng den chirc nang n$i tiet va ngoai tiet cua tuy,
^-Phu'dng phap cat Ipc t6 chu'c hoat tirva dan lutJ rpng rai du'dc ap dung nhieu nhat Dan lull h$u cung m?c noi (HCI^N) ddn thuan 6/36 BN chigm 16,66% ap dyng khi to chu'c hoai tir va to chij'c tanh ciia tyy khong cd ranh gidi ro rang, tuy chi t6 it chSm hogi tiT hoSc tyy viem phii ne. Dan lutj 6 i p xe cd 3 BN. Dac bi?t cd 1 BN du'dc cat than duoi tuy/ lay t6 chirc hoai tir, dan luii. Tat ca b^nh nhSn du^c mo va daii luU theo phu'dng phap dan lu\i kin. NhGtig tnjidng hdp khong the cat lpc dm?c to chlit ho?l ti^ do chu^ cd su' phSn (Jinh KS ring glQ:a to chilt hoai tii" va to chu'c lanh
(thu'dng do mo sdm < 7 ngay) hoac VTC the phii ne, chung tdi dat dan luli du'di sudn trai, ndi Uiap nhat d du'dng nach sau de d i n luXi djch d HCMN.
NhiTng tru'dng^hpp khac, benh nhan thu'dng du'dc dat tCr 4 - 6 dan IUXJ, trong d d ^ d i n iiiu Ithoang HCMN, 1 dan lull ho lach ndi de dpna^djch do li/c hut am ciia khoang mang phoi, i dan lUU di/ctt gan va doi khi nen dat dan luXi ca khoang Douglas. Cac dan IUXJ n^ay can phai dii Idn vi dicii tuy thu'dng ra lan vdi to chiTc hoai tir ciia tyy lam tac dan lulj, va du'dc^rut dan theo timg vi'tri khi lam sang on djnh, danjulj khonp chay djch va sau khi du'dc sieu am kiem tra chac chan khoang dd khong^ddn djch. Quan diem dat nhieu dan lutj to sau mo ngoai myc dich dan liTu chiing toi ket hdp quan diem ciia cac tac gia My chi ra rang tang ap lu'c 6 byng ty le thuan vdi dp nang ciia VTC va cung la hau qua ciia viec tang cac cytokin cac yeu to gay viem trong VTC tao ra vdng xoan benh ly dan den benh canh suy da tang nang ne trong VTC t | ] .
4.6. Dan lu\j du'dng mSt: trong nhdm nghienjjCulj cd 21/36 benh^nhan chiem 58,33%
du'dc dan luu du'dng mat Dan lu'u du'dng mat khi cd gian du'dng mat xet nghiim bilirubin mau tang. Chung tdi cd quan diem khac vdi^ quan diem tru'dc kia ngu'di ta j:ho ring viec dan \\fu du'dng mat la can thiet de tranh trao ngu'dc djch mat gay kfch thfch viem tyy. Nhu'ng qiia cac nghien ciTu thu'c nghiem cuiig nhu* thUc t§ lam sang cho thay kha Qahg nay rat it xay ra^^ Theo ghi nhan ciia Nguyen Thanh Long chi dan lull ogg mat khi cd hien tu'dng chen ep [3]. I^d thdng hong trang: trong nhdm n^hien^ciilJ cd 27/36 BN chiem 75,0% du'dc md thong hong trang de nuoi du@ng sau khi benh nhan cd nhu dpng rupt Ngoai ra cd tac dung dyy tri hang rao bao ve niem mac ruot tranh nhiem khuan. Trong nhdni ngien ciTu cita chung tdl khong cd ty le tai bien vt piiau thuat nay, trong khi dd ty le hoi phyc ciia benh njiah tot iidn, giam du'dc lu'dng djch truyen sau mo de bii trir nu'dc dien giai cung nhu" nudi duQng du'dc thuan tien hdn.
4.7. khang sinh: 36 BN du'dc cay ^jch 6 bung va djch tyy hoai tCr, 17 (47,2%^ mau cho ket qua du'dng tinh.'Vi khuan hay gap nh^t la E.coli^ tiep do la K.pneumoniae xuat hien trong 10 mau. Mpt so loai khac cd tan so xuat hien it hdn la: A.baumannii^ Cfreundii^ E.faecaiis, E.doacae. Trong cac mau nay chi co 9 BN cd ket qua du'dng tinh ddn thuan vdi E.coli ESBL (+), cdn lai thudng cd 2 hoac 3 lo^i vl khuan. So vol ghi nhan ciia Nguyen Thanh Long ket qua: cd vl khuan mpc la 36,4%, ty le E.Coli !^ 66,7% la khdng cd sy khac biet [3].
Viec diir;^ khang sinh cd the lam giam dapg ke ty ie nhiem khuan to chirc hoai tie va nhiem khuan huyet theo Buchler ty le nay giam tii 70%
xuong 43%. Theo nhieu tac gta nu'dc ngoai nen
Y HOC VI$T NAM THANG 6 - SO 2/2014 sir dyng khang sinh diX phong mdt each he
thong, \iu tien lya chpn nliihig kharig sinh pho thong, tinh tham cao vao nhu mo tuy. NhiJhg benh nhan 0 e u trj khi chi/a cd khang sinh do t h i thu'dng phdi hdp lihieu loai khang sinh, trong d d phoi hdp 2 loai cd t ^ le cao nhat (70,1%), tiep den ditng 1 loai khang sinh (25,4%) va diing phoi hdp 3 loai (4,5%). Khang sinh du'dc suf dyng nhieu rihat la cephalosporin the he 3 ket hdp vdi metronidazot hoac aminoglycosid, quinilon.
NhiJtig tru'dng hdp cd bleu hien soc khong hoi phuc hoac suy da phii tang chiing tdi deu chuyen khoa DiBu trj tfch c y t de phoi hdp dieu tri va theo doi, Thu'dng la suy tuan hoan, than^va ho hap ( ^ ty le cao. Theo ghi nhan ciia Nguyen Gia Binh doi vdi the VTC hoai tiT ty le nay la: suy tu3n hoan chi€m 56,5-60%, suy than chiem tu"
40-43,5%, suy hd hap chiem 65^2-68%. Nhiihg tru'dng hdp nay du'dc Ipc mau lien tuc cho thay cd cai thien nhanh ve niirc dp suy taiig, ap t y t o byng va lipase [ 1 ] .
V . KET LUJSlN
- Vidm tuy cap khdng do nguyen nhan cd hpc du'dc dieu tri noi khoa la chu yeu, dieu tri phau thuat thu'dng sau 7 ngay vdi clii dinh m d thu'dng gSp viem phuc^mac do viem tuy hoai tiT va viem tuy hoai tu' nhiem trjing.
- Phu'dng phap phau thuat tren tuy thu'dnq ap dung: lay^to chuTc hoai tir, dan lu'u, dan lu'u o ap xe tuy, dan luU hau cung mac noi, ket hdp m d
thong hong trang va dan \iiu du'dng mat khi co gian du'dng mat. . . . - K a qua sdm'sau dieu t r i : t o t 8 1 , 1 % , trung bmh 13,8%, xau 5 , 1 % . - Thdi gian nam vien t r u n i binh: 9,3 + 8,3 ngay (dao dong tir 1 - 73 ngaya Nhdm phau thuat: 21,3 + 15,3 ngay; nhom d i e i trj npi khoa: 7,8 + 5,5 ngay.
T A I UEU T H A M K H A O
1. Nguyen Gia Binh, Dao X}ian Cxi (2010); "Lo: mau lien tuc ket hdp chpc hut dan luU djdi tiet dutfidan gja sieu am trong dieu tn viem tuy cap nang"; Y hoc lam sang; So 49 (thang 2/2010; tj;22-26.
2. Do Tat Cu'dng, Mai Xuan HiSn (2004);
"Nghien ciJli lam sang, can lam sang cac bien phap hoi sufc tich cut va sieu loc mau tren b^rih nhan viem tuy ceip mu'c dd ning"; YHTH 56 491- Hdl nghi khoa hoc toan quoc; tr: 3(14-117.
3. Nguyeii Thanh Long, Do Tat Thdnh (2004);"Viem tuy cap khong do jiguySn nhan aJ hoc chl dinh va phu'dng phap phau thuat"; YHTH So 491- HOP nghi khoa hgc toan qudc; tr:124-127.
4 . Vu Huy Nung, Nguyen V3n Xuyen (2004);
Nh|n xet tinh nih dieu tri viem tuy cap tai khoa phau thuat bung Quan y vien l03 thdi gian tif 1997-2003"; V H T H SO 491-"Hpi nghj khoa hoc toan qudc; tr:77-80.
5. Balthazar E3, Freeny P.Q Sonnenberg E ( 1 9 9 4 ) ; " Imaging and intervention in acute pancreatitic"; Radiology; 193;pp: 297-306.
6. Farkas G (1998);"Progress in the management and treatment infection pancreatic necrods";
Scand -J_Gastroenterol-suppl. 1998; 228:31-37.
7. Harting W (2002);''Management of infection In acute pancreatitis"; Journal of HPS 2002: 423-428
DANH GIA KET QUA DIEU TRI PHAU THUAT M A U TU D u ' a ! M A N G CiTNG MAN TINH TAI BENH VIEN VIET DlJc
Dirong Bai Ha*, Tran Trung Dung*
T6MTAT
Mau ty dudi m^ng ding man tinh la hien tUtfng t | p hap dich va mau cu co vo bao boc nam d khoang direli mang cijng, xuat hien tir tuan Vail ba sau chan thu'dng. Myc t i e u : danh gia cac dac diem [am sang, c|n iam sang, chan doan hinh anh va k ^ qua dieu tri phau thuat mau tu di/6i mang culig man tinh tai BV Vi|t Du'c. Doi t i r i n g va phu'dng phap nghien citu:
nghien cCru tien cilu mo ta lam sano. Kel qua: 70 b?nh nhan chan doan va dieu tri phau thuat trong 6 thing, tri?u chiihg lam sang th'uSng gSp; dau dau 100%, liet nila ngu'di 61,4%, non 41,4%, roi loan tam th3n 44,3%. Nguyen nhan chu yeu do chan thu'dng 88,6%. Tuoi thudng g i p > 60 tuoi, 30% co cac huyet ap, 14,3% tien silr tieu du'dng, 3% dang dung thuoc
* B$ mon Ngoai, hvdng Oai hoc K Ha noi Phin bifn khoa hgc: PISS. TSHa Kim Trung
chong dong. Hinh anh chijp CLVT co 6 le 81,4%, trong do khoi mau tu giam ty trong 61,4%. Phuang phap dieu tri: phau thuat dan lutJ mau tu 94,3%. Ket qua phyc hoi tot sau dieu trj ph§u thu$t 88,5%. KSt l u | n : Oieu tri mau tu di/di mang cuTig man tinh bSng phau thuat khoan sp 1 lo la phudng phap an toan va hieu qua cho ket qua hoi phyc tot
TCf khoa; mau tu dydi mang ciJng man d'nh, cSt idp vi tinh, giam ty tn?ng,
S U M M A R Y
Subdural chronic hematoma is a miscellaneous liquids capsules located in the epidural cavity, appeared from the third v»eek after injury. Objective:
Evaluate the clinical criteria, the imaging features, diagnosed and surgical treatment. Materials and methods: the prospective descriptive study with subdural chronic hematoma patients at Viet Due hospital from 1/2013 to 6/2013.The critical Steria: