T « P CHl KHOA HOC TlEU H d A Vl&T NAM 2012 • TAP v u - s d 29
TSng quan /Review article
Xac dinh bfnh nh§n nguy ctf cao bi ung thtf da day trdn n^i soi: Ai c i n sinh thigt hf thd'ng va n§n sinh thi§'t d vf tri nao?
Endoscopically identifying patients at high risk of gastric cancer: Who need systematic biopsies and which location to take biopsies?
QUACH TRQNG OOC', Lfe MINH HUY'. NGUYEN THUY OANH', NGUYEN SAO TRUNG' 'Dai hpc Y Dupc TP. H 6 Chi Minh
Abstract
Gastric cancer (GC) is one ofthe leading cancers in Vietnam. About one third of patients with advanced GC have undergone gastroscopy within the last 6 years, partly because the present diagnostic system fails to identify subjects at high risk. In addition, the lack of official recommendations for the surveillance of gastric precancerous conditions (i.e. atrophy and intestinal metaplasia) makes the issue fiirther confusing.
There have been remarkable advances in this issue over the past 5 years, especially with the development of European guidelines on the management of gastric precancerous conditions and lesions (MAPS). Studies in Vietnamese population have shown that the assessment of endoscopic gastric atrophy (EGA) according to Kimura - Takemoto classification could help to identify patients who are at high risk, guide endoscopists on whom to peiform systematic biopsy, is appropriate and take full advantage of the low-cost, widespread gastroscopy network in Vietnam. Pathologically, the Operative Link on Gastritis Assessment (OLGA system) has also been proved to be a useful tool to identify patients at high risk in several populations including Vietnamese. Formal training for the assessment of EGA and OLGA gastritis is, therefore, crucial to solve this issue. In clinical practice when OLGA gastritis assessment is not yet available, taking 3 specimens along the lesser curvature according to the updated Sydney system (carried in different vials) has been shown to be enough for assessing the extension of gastric atrophy and intestinal metaplasia so that to make an individiuil surveillance according to MAPS. Future studies in Vietnam should focus on this issue in order to develop a guidelines which is most appropriate for our population.
Tom t^t
Ung thir da dfiy (UTDD) lfi mdt trong nhiTng ung thd thtfdng gfip nhat 5 Vifit Nam. Mfit phan ba s^
tnrdng hdp UTDD phfit hifin t r i da tiTng nOi soi da dfiy trong vdng 6 nfim tnfdc dd, m^t phin ifi do he thd'ng chin dofin hien lai chda gitip nhfin difin cfic trddng hdp nguy ccf cao d^ cd kfi' hoach Iheo doi.
Thfim vfio dd, su" thifi'u vfing cua mdt hddng d i n chlnh lhti"c v^ cfich theo doi cfic tinh trang ti^n ung thtf da dfiy (teo nifim mac vfi di sfin rudt) gdp phdn lfim pht?c tap thfim vfi'n di. Da cd nhu'ng tifi'n bO v l hi^u bifi't ve vific nhfin difin dd'i tUdng nguy cd cao trong vdng 5 nfim qua vfi dfic bifit lfi khuyfi'n cfio chlnh thti'c v l cfich theo doi cfic tinh trang liln ung thu" cfia chfiu Au trong nfim 2012 (dUdc goi ifii lfi MAPS).
Cfic nghifin cd'u 6 Vi^t Nam cho Ihfi^y he thoang dfinh gifi teo nifim mac trfin nfii soi (TNMNS) theo phfin loai Kimura - Takemoto gitip nhfin difin d6i titdng nguy cd cao, hddng dfin vific ra quyfi't dinh khi nfio nfin sinh thi^t h | th^ng, thich hdp vfi tfin dung drfdc du the" cua hfi thdng ndi soi da dfiy chi phi thfi^p vfi
T ^ P C H I KHOA Hpc TlEU HdA VlfiT NAM 2012 • T^P VII- Sd29
phfil tri^n rOng khfip cfi nirdc. Trfin md b$nh hpc, dfinh gifi giai doan vifim d^ dfiy theo h§ thdng phfin loai OLGA cflng chti'ng minh diT^c gifi trj lifin liTdng UTDD d nhi^u chiing t0c khfic nhau bao g6m cfi ngu'di Vi$t. Do vfiy, cfich dfinh gifi TNMNS vfi leo nifim mac trfin md b$nh hpc Iheo phfin loai OLGA nfin dtrdc dtfa vfio cfic chifdng trinh dfio t^o chinh ihtic. Trfin ihi/c tfi' khi chira th^ dfinh gifi md b$nh hpc theo phfin loai OLGA. lfi'y mfiu sinh thifi't d 3 vi tri dpc theo phia bd cong nhd Iheo khuyfi'n cfio cia phfin loai Sydney cfii tifi'n (chti'a trong tp rifing) dfi dir^c chti'ng minh lfi di) d^ dfinh gifi mti'c dd lan rdng ctia tinh tr^ng teo nifim mac vfi dj sfin ruOt, trfin cd sd dd cd th^ ra chifi^n lir^c theo ddi theo hirdng din MAPS. Tuy nhifin, cSn tfip trung ddu lu" nghifin cti'u ve ITnh vUc nfiy di phfit tri^n mOl chifi'n lupc iheo ddi rifing phii hpp cho Vi$t Nam trong tifdng lai.
l . D $ t v g ' n d l
Ung thir da dfiy (UTDD) hi$n dting hfing thti"
3 trong cfic ung thu" thirdng gfip d Vi^i Nam theo thd'ng kfi ctia T6 chtic Nghifin ctilj Ung thiT Qud'c Tfi' (lARC). Mfic dii hi$n nay npi soi da. dfiy (NSDD) dfi phfit tri^n khfi manh me vfi tUdng dd'i d i u khfip dfi'n tfin cfic cd sd y tfi' tuyfi^n qufin huy^n, cfic nghifin ctili trong nUdc gdn dfiy vin cho thfi'y dfi'n hdn 90% cfic tru'dng hpp UTDD dti^c phfil hi^n d giai doan Irl [6], [27]. Dfing liru tfim hdn nffa lfi cd dfi'n m0t phdn ba cfic tru'dng hdp UTDD phfit hifin d giai doan t r i nfiy dfi tirng diTdc NSDD trong vdng 6 nfim tnrdc dd [5]. Cfic sd' Ii$u k^
trfin cho thfi'y hai vfi^n d l cdn dirpc dfit ra nhfim gifii quyfi't thiTc trang hifin tai: (1) Cdn nhfin di$n cfic dd'i tiTdng chira bi UTDD nhimg cd nguy cao se tifi'n trien thfinh UTDD di cd kfi' hoach theo ddi thich hpp; (2) cdn phfil tri^n ky thufit ndi soi ch^n dofin de nhfin dien, trfinh bd sdt tdn thirdng UTDD, dfic bi^t lfi nhffng tnrdng hpp cdn d giai doan sdm.
Trong pham vi cua bfii trlnh bfiy, chting tdi xin bfin lufin d^n vfi'n de ddu lifin, diTa trfin nhffng bfing chti'ng y khoa cfip nhat ctia thfi' gidi, cd kfi't hdp vdi k^t qufi nghifin ctiti trong nirdc vfi vfin dung cfic dfic thiJ rifing cua h$ th^ng chfim sdc tai Vi^t Nam.
2. N$i soi da d^y d Vi^t Nam: thi/c t r ^ n g & yfiu cdu nhSn di^n b^nh nhdn nguy cd UTDD cao
Phdn ldn cfic ddn vi nOi soi vfi gifii phlu b?nh tifiu hda d Vi$t Nam hi$n nay d i u dfinh gifi kfi't qufi dtfa Iheo hirdng d i n cua hfi th^ng phfin loai Sydney cfii tie'n (hinh I) [4], d i l u nfiy gdn lirdng lif nhu: cfic nirdc PhiTdng Tfiy. K^ tiT khi ra ddi nfim
1990 vfi dffdc hofin thi^n vfio nfim 1994. h§ thtfng Sydney cfii tifi'n dfi ddng vai trd nhiT m^t ngdn ngff nghifin ctiu chung vfi diTdc sti* dyng h^l stic r0ng rfii trfin tofin th^gidi vdi hdn 1.000 Idn dupc trich d i n trfin PubMed. Tuy nhifin. cho d^n nay h$ thd'ng nfiy dfi bOc 10 khfi nhieu di^m bfi't cfip:
v l nOi soi: Cfic dang md tfi vifim trfin ngi soi tuy cd khfic nhau nhffng irfin thifc lfi" dilu nfiy khdng cho thfi^y di^m khfic bi$l trong quy^l dinh dieu tri cho bfic sT lfim sfing. Dilm thu'c stf khfic bi^t quyfi't dinh chifi'n Iffpc dieu tri ctia bfic sT lfim sfing tfi than phien chinh ctia ngtfdi bfinh (kilu khd lifiu hay ki^u lofit) vfi tinh trang nhilm Helicobacter pylori. Hdn ihfi' nffa. h§ thdng nfiy khdng gidp nhfin ra nhffng dd'i tffdng cd nguy cd UTDD cao cdn phfii cd chfi' dd theo ddi sfit sao hdn di phfit hi§n UTDD khi cdn d giai doan sdm.
Rd'i loan tifiu hda khdng lodi (non-ulcer dyspepsia) hay cdn gpi lfi r^i loan tieu hda chti'c nfing (functional dyspepsia) thtfdng di k6m vdi ch^n dofin vifim da dfiy trfin npi soi vfi md b§nh hpc lfi mdt tinh Irang thtfdng gfip nhfi't tai cfic phdng khfim tieu hda. Tuy tfin gpi cd khuynh htfdng gdi S ^^^ uiOt tinh trang tfinh tinh. nghifin cti'u dofin h^ tai Nhfit thtfc sff cho Ihfi'y cd dfi'n 2.5% trtfdng hdp rdi loan tifiu hda khdng lodt cd nhiSm Helicobacter pylori bi UTDD sau 8 nfim Iheo ddi [28]. Nghifin cffu tai Vi$t Nam cung cho Ihfi'y ti 1? bi Vifim da dfiy man teo (VDDMT) mtfc dO vffa-nfing. DSR vfi loan sfin d cfic trtfdng hpp trfin iln Itfdt lfi 34.6%, 24.5% vfi 4,9% [24]. Nghifin ctiti dtfa trfin h$ thdng qufin I^
gifii phdu b$nh tofin qutfc vdi cd m l u ldn tai Hfi Lan cho th^y nguy cd hda ung thtf hfing nfim c6a cfic trtfdng hdp bi VDDMT, DSR vfi LS iln Itfdt lfi 0,1%, 0,25% vfi 0.6-6% [2]. D i l u nfiy gdi ^ rfing
TAP CHf KHOA HQC TifiU H d A VI^T NAM 2012 - T ^ P Vll - s d 29
khfi nfing chuyin thfinh UTDD ctia cfic trtfdng hdp rtfi loan tifiu hda khdng do lodt rfi't dfing dtf^c quan tfim.
- V l md b$nh hpc: H0 thtfng Sydney cfii tifi'n cdng k i n h nfin khd tfng dyng trfin thyc tfi'. Quan trpng hdn cfi lfi phdn md b^nh hpc kdm cung cfi'p gifi tri lifin dofin nguy cd UTDD. Vi$c chtfa cd mdt bfin htfdng d i n cy t h i cfich theo doi VDDMT vfi DSR sutft hdn 20 nfim k l tir khi phfin loai Sydney ra ddi cfing lfi mtft I^ do quan trpng khitfn cho cfic bfic si lfim sfing Iting tting khi dtfa ra ldi khuyfin cho cfic b^nh nhfin dtfa trfin kfi't qufi md bfinh hoc. Chinh vi nhffng 1^ do trfin. ngofii cfic cdng tiinh nghifin clhi khoa hpc, trfin th\fc tfi' vi$c sinh thifi't h$ thd'ng Iheo phfin loai Sydney cfii titfn hdu nhtf r^t it dtfdc thtfc hifin do khdng mang lai mOt ldi ich cu th^ cho thtfc hfinh Ifim sfing. Rifing dtfi vdi Vifit Nam cdn cd mOt didm dfic Ihti rifing lfi tfu diem ctia NSDD chi phi thfi'p, ddng thdi kfio theo mpt ditfm han chfi' quan trpng lfi tinh Irang qufi tfii, khdng the tifi'n ^finh sinh thifi't h$ thtfng thtfdng qui cho tfi't cfi cfic trtfdng hdp dtfdc ch^n dofin vifim da dfiy trfin ndi soi d i n dfi'n bd sdt cfic trtfdng hdp cd ttfn thtfdng t i l n UTDD c i n phfii dtfdc theo ddi.
Ttfdng ttf nhtf cfic nhfi nOi soi phtfdng Tfiy, NSDD d ntfdc ta cfing chti yeu tfip trung vfio viec dm kifi'm nhttng ton thtfdng tren nOi soi cd thtf gifii thicfa dtfdc trifiu chtfng ctia ngtfdi b^nh nhtfng khdng dfinh gifi khfi nfing bi UTDD ctia ngtfdi b$nh. Diem khfic biet d dfiy lfi tdn su^t UTDD d cfic ntfdc phtfdng Tfiy ttfdng dd'i th^p trong khi ntfdc ta thuOc khu vtfc cd nguy cd UTDD trung binh - cao so vdi thtf gidi [12].
Do dd. dfinh gifi nguy cd UTDD ctia bfinh nhfin trfin n0i soi nfin dtfdc xem vfi dtfa vfio m0l trong nhffng yfiu cdu thtfdng qui trong mOt ttfdng trinh ktfl qufi ndi soi vfi md bfinh hpc da dfiy S ntfdc ta. V l v^n d l nfiy, trfin thtfc ttf vific dfinh gifi ktft qufi NSDD hi$n nay ctia chting ta chi mdi dffng lai d mtfc nhfin dinh benh nhfin dtfdc nOi soi cd bi hay khdng hi UTDD. Vi^c sinh thifi't lfim xdt nghiem md bfinh hpc trfin thtfc ttf chu yfi'u chl dtfdc thtfc hi^n trong cfic trtfdng hqfp nghi ngd ung thtf trfin ndi soi. Ro rfing rfing
trong tinh hinh thtfc ttf cfi'p bfich vdi UTDD lfi mOt trong nhffng ung thtf thtfdng gfip hfing ddu tai Vi^t Nam, chting ta cdn cd nhffng cdng cy dfinh gifi trfin nOi soi, md b$nh hpc phti hdp dtf tifin dofin nguy cd bi UTDD, mfi 15^ ttfdng lfi cfic cdng cu ddn gifin, d l sti* dyng, chi phi thfi'p vfi cd thtf tfin dyng dtfdc tfu Ihtf ctia NSDD chi phi thfi'p vfi phd bifi'n d Vi0i Nam.
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mnh 1: H^ thtfng phfin loai Sydney cfii titfn [4]
3. Nhflng tifi'n b$ trong vi^c nh$n di$n va theo d5i b^nh nhdn co nguy cd UTDD cao
3.1. Titfn bQ trong nh^n di$n b^nh uMn nguy cd cao
Tifi'n trinh hinh thfinh UTDD thtfdng di qua cfic giai doan VDDMT, DSR, LS vfi cutfi cfing lfi hinh thfinh UTDD [1]. Trong cfic giai doan tren, VDDMT vfi DSR dtfdc xem lfi cfic linh trang lien img thtf cdn LS dtfdc xem lfi ton thtfdng tiln ung thtf [3], Trong khofing 5 nfim qua, vific nhfin dien vfi len kfi'hoach theo ddi cfic b$nh nhfin cd nguy cd UTDD cao da dat dtfdc nhilu tifi'n bO dfing k l :
PhtiOng phdp huyit thanh hgc: Do n6ng dO Pepsinogen (PG) I, II vfi tinh ti stf PGI/PGII thu htit nhilu stf quan tfim do dfiy lfi phtfdng phfip khdng xfim Ifi'n gitip nhfin difin ra cfic trtfdng hdp nguy cd UTDD cao. PGI dtfdc bfii tifi't tff cfic ttf bfio chinh vfi tfi' bfio cd tuytfn vting thfin vi trong khi PGII cdn dtfdc bfii tifi't bdi cfic ttf bfio cila tuytfn mdn vi. Do dd Irong trtfdng hdp vifim teo a thfin vi, dinh Itf^ng PGI vfi ti lfi PGI/PGH trong huyfi't thanh gifim. Cfic gifi tri ngtfdng thtfdng dtfdc
TAPCHi KHOA HpCTieU HdA VIETNAM 20l2-TAPVn-Sd29
stf dung nhfi't Irong cfic nghifin ctfu trfin thtf gidi lfi PGI S 70ng/ml vfi PGI/PGII <. 3. Mdt nghifin ctfu tdng hdp dtfa trfin 42 nghifin ctfu gtfc trfin 300,000 b$nh nhfin cho thfl'y dO nh(iy trong chin dofin UTDD ctia phtfdng phfip nfiy chl d(il 77% nhtfng gifi trj tifin dofin fim dat dfi'n 99% [14]. Do dd. tfic gifi d l mit phudng phfip nfiy nfin dtf^c dUng vfio myc dich xfic dinh cfic trtfdng hdp cd nguy cd cao cSn dtfdc chi djnh NSDD kilm tra hdn lfi mtft phtfdng phfip chdn dofin UTDD. Nghifin ctili t^i Vi$t Nam cho thify phtfi hdp tifiu chudn PGI < 70 ng/ml vfi PGI/PGII S 4 cd dd nh^y vfi dO dfic hi$u trong c h ^ dofin VDDMT Iln luyt lfi 81,8% vfi 96,7% 19]. Ti stf PGI/PGII < 9,95 cd dd nhay vfi dd dfic hi^u trong chdn dofin DSR lfi 81,8% vfi 65%; vfi chdn dofin LS lfi 83,3% vfi 66,1 % [26]. Dfiy lfi mtft htfdng tifi'p c^n ttft cd tilm nfing lpi ich tdm sofit rOng trong ctfng ddng vfi gifim tfii cho h^ thtfng n0i soi vfi gifii phlu btfnh, dfing dtfdc quan tfim nghien cti\i kp hdn d Vi^t Nam.
Mo b^nh hoc:
Trfin cd s6 nln lfing lfi dfinh gifi md btfnh hpc theo phfin loai Sydney cfii tifi'n. m^t nhdm cfic chuyfin gia v l Imh vtfc gifii phlu btfnh tifiu hda vfi cung ihu0c nhdm ndng ctfl dfi phfit triln hfi thtfng Sydney dfi nhdm hpp vfi de xud^t ra cfich dfinh gifi giai doan vifim da dfiy man leo theo mtft he thtfng mdi lfi Operative Link for Gastritis Assessment (vifi't tfit lfi he thtfng OLGA). H$
thtfng nfiy chia VDDMT thfinh 4 giai doan 0 - IV dv^
tren stf lich hdp dilm dfinh gifi mtfc dO teo niem mac cua vfing hang vi vfi thfin vi [20J. Theo cfich dfinh gifi nfiy, cfic nhfi md bfinh hpc stf dung dinh nghla m0t dinh nghla teo nifim mac mdi lfi Qnh trang mfit cfic tuyfi'n thich hdp (appropriate glands). Nhtf vfiy. DSR cung dtfpc xem lfi m0t tinh trang mfi't tuytfn thich hdp vfi dtfdc xtfp vfio nhdm teo niem mac cd kfem di sfin (metaplastic atrophy) [21]. Lfu dilm vtfdt trpi ctia h^
thtfng phfin loai nfiy lfi dat d0 thtfng nhfit cao hdn so vdi dfinh gifi teo nifim mac Iheo Sydney cfii tifi'n, quan trpng nhfi't lfi gitip tifin Itfdng dtfgfc nguy cd bi UTDD.
Cfic nghifin ctiti trfin thtf gidi cho thdy c6 stf tfip trung cfic midng hdp UTDD sdm vfi LS d cfic trtfdng hdp vifim da dfiy d giai doan OLGA m - IV [22], [23].
Nghien ctfu lai Vi$t Nam trfin btfnh nhfin rtfi loan tifiu hda khong lodt cho thfiy btfnh nhfin d giai doan OLGA m - IV cd nguy cd bi LS gSfp 39 Iln so vdi
giai dopn 0 - II [15]. Cfic kfi't qufi nghifin ctiu irfin cfic dfin stf khfic nhau cfing cho thfiy gifi tr; tifin Itfpng ctia h$ thtfng OLGA md ra mtft triln vpng ttft d ^ dfiy GS lfi m0t cdng cy md b$nh hpc ttft gitip dfinh gifi mlit d0 nguy cd UTDD ctia b^nh nhfin. Dilm khd khfin khi tihg dyng vfio thyt ttf Vi^t Nam lfi dtf dfinh gifi m6 b^nh hpc iheo h^ thtfng nfiy. cdn phfii ctf djnh 5 mlu md sinh thitft trong 5 Ip rifing bi^t cd dfinh stf vi tri Idy mlu; vi^c dfinh gifi ktft qufi md btfnh hpc cfing phfii dpc d tffhg v) trf mtft sau dd mdi tiinh mtit dd teo nifim mac trung binh cho ttfng vfing thfin vfi hang vi (hinh 2).
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Hinh 2: DSnh gi4 giai doan VDDMT tlieo ph4n loai OLGA [20]
N^i soi dg dhy:
Cdc ddng nghiep d Nhat Id nhifng ngirdi cd nhilu kinh nghiem trong vi^c nh^n di#n dd'i tiring nguy cd cao. phSt hi^n vJl can thi^p nOi soi UTDD giai doan sdm hi^u qu5 nha't trSn th^gidi.
TCr nam 1969 tai Nh$t da Sp dung vi$c dSnh giS nulc dO teo niSm mac tr6n nOi soi (TNMNS) theo h§ thd'ng phan loai Kimura - Takemoto (hinh 3.
4). Tuy nhifin m5i cho dfi'n gJn day h^ thfi'ng niy mdi khSng djnh dU(?c ch6 diJng ciia minh trong vi$c tifin doSn nguy cd UTDD trfin cic y v5n qufi'c t^: nghifin cti'u ciia Uemura va cs (2001) trfin cac dfi'i tlTtJng b^nh nhan r^i loan tifiu h6a khdng lofit c6 nhifim Helicobacter pylori cho th^y miJc dp TNMNS c6 lien quan d^n nguy cd hinh thanh UTDD sau 8 nam theo doi [28]. G^n day hdn. Take va cs (2007) tim hi^u v l cac y^u t^tifin doan nguy cd bi UTDD trfin nhifng bfinh nhan lo6t da day - td trang da diTiJc tiet trir Helicobacter pylori [25], Sau 10 nam theo doi, nghien ctfu niy
T A P C H ! KHOA H p c TLfeU H 6 A V I ^ T NAM 2012 - T A P Vll • Sd 29
cung cho thfi'y mtfc dtf TNMNS d thdi ditfm ban ddu cung lfi ytfu ttf tifin dofin nguy cd UTDD. Hai nghifin ctfu dofin h$ vdi c3 m l u nghifin ctiM ldn hdn 1000 benh nhfin dtfdc Iheo ddi trong mtft thdi gian dfii nfiu trfin cho ihiy phfin loai Kimura - Takemoto lfi m0t hfi thd'ng thtfc stf cd khfi nfing gitip nh^n di0n cfic trtfdng hdp nguy cd UTDD cao trfin n0i soi.
Dilu nfiy dtfdc 1^ gifii bdi cfic nghifin cOu gdn dfiy ctia chting tdi cho thfi'y cd md'i ttfdng quan thufin gitfa mtfc d0 TNMNS theo htf thtfng phfin loai Kimura - Takemoto vdi giai doan VDDMT dtfdc dfinh gifi theo tifiu chudn cfip nhfit ctia h^ thtfng OLGA vfi cd stf tfip trung cfic trtfdng hpp DSR vfi LS d nhffng b#nh nhfin cd mtfc d0 TNMNS vffa-nfing. [15], [18]
Vi$c tfng dyng dfinh gifi TNMNS theo h$ thtfng phfin loai Kimura-Takemoto yfin thtfc tfi' Vi0t Nam lfi rfi't tilm nfing vfi cd tinh khfi thi cao do cd thi tfin dyng dtfgfc tfU ditfm ctia he thtfng NSDD chi phi thfi'p vfi phd bitfn. Tuy nhifin. mtft trong n h ^ g ditfm quan trpng thtfdng bi cfic nhfi n0i soi phtfdng Tfiy dfit dfi'u hdi lfi Ufiu cfich dfinh gifi nfiy cd qufi phtfc tap hay khdng? Kinh nghiem chting tdi cho tha'y dfiy khdng phfii lfi mtft hfi thd'ng phan loai khd. hofin tofin cd thd thtfc hifin dtfdc vdi cfic mfiy NSDD tifiu chudn hifin tai d Viet Nam. Thtfc ttf lfi cfic tfic gifi Kimura vfi Takemoto cd thd phfit tritfn ra h0 thtfng phan loai nfiy ngay tff Ihfip nifin 1960 dtfa trfin hfi thtfng d'ng NSDD bfing sdi quang [11]. Dilm quan trpng nhfi't ve mfit ky thufit ndi soi lfi chting ta cdn chudn bi da dfiy sach vdi thuo'c lan bpt simethicone [10] cd mtft tfng ntfi soi cd cdn Up/Down dfi manh vfi bdm du hdi dtf lfim mfi^t cfic ntfp niem mac 6 vfing thfin vi phia bd cong nhd khi quan sfit thfin vi d ttf the' qufit ngtfdc. Do titfn trinh teo niem mac da dfiy thtfdng d i l n tifi'n tff hang vi lan ddn lfin thfin vi vdi td'c dp nhanh hdn d phia bd cong nhd, vfing teo nifim mac Ian ddn Ifin thfin vj theo trinh ttf tff cfic dang C1-C2-C3; sau khi dfi Ian dfi'n tfim vi thi vfing teo nifim mac se Ian ddn ra phia mfit trtfdc, mfit sau vfi phia bd cong Idn tao ra cfic dang cfic dang 0 1 - 0 2 - 0 3 . Mtfc d0 TNMNS dtfdc chia Ifim 3 mtfc nhe (C1,C2), vffa (C3, 0 1 ) vfi nfing ( 0 2 , 0 3 ) . Cfich dfinh gifi TNMNS dtfa trfin hfi thtfng Kimura -Takemoto
dfi dtfpc chting tdi trlnh bfiy chi tifi't vfi cd thtf tham khfio trfin T^p chi Khoa hpc Tifiu hda stf trtfdc dfiy [18], do dd chdng tdi xin khdng trlnh bfiy ky trong pham vi bfii bfio nfiy.
Ding C-2 Dang C-3
I • n
Dang 0-3
Hinh 3: Cfic mtfc do TNMNS theo phan loai Kimura - Takemoto (ve lai theo tfii lieu tham khfio [11]). Mfiu xfim nhat Itfdng tfng niem mac bi teo vfi mfiu cam dfim ttfdng tfng lfi vfing nifim mac
binh thtfdng.
3.2. Tifi'n b0 trong chitfn ltf</c theo doi b^nh nhfin nguy cd cao
Cfic tdn thtfdng tiln ung Ihtf da dfiy vtfn khdng gfiy khd khfin trong vific dtfa ra thfii dO theo ddi do da cd khuyfi'n cfio ctia H0i N0i soi Tifiu hda My ttf 2006. Theo khuyfi'n cfio nfiy, LS d0 cao cdn phfii dtfdc dilu tri ngay bfing nOi soi hofic phlu thufit;
LS dtf thfi'p cdn dtfdc theo doi b^ng ntfi soi vfi sinh thifi't mtfi 3 thfing cho dfi'n khi 2 Idn lifin tifi'p khdng cdn thfi'y tdn thtfdng LS [8]. Mai cho dfi'n gdn dfiy, vfi'n d l gay khd khfin vfi Iting tting nhfi't cho cfic nhfi tifiu hda lfim sfing lfi tinh trang tiln ung tiitf da dfiy (VDDMT vfi DSR) khfi thtfdng gfip trfin Ifim sfing. da dtfdc bifi't ro lfi cd nguy cd cao bi UTDD nhUlig lai chtfa cd khuyfi'n cfio chinh thtfc ve ktf hoach theo ddi ngtfdi b$nh. Nfim 2012 thtfc stf dfi
TAP CHf KHOA HOC TifiU H O A V l ^ NAM 2012 - T A P Vll- Stf 29
danh da'u mOt mfi'c quan trpng trong Hnh vt;c nay:
D i n g thujln Maastricht IV cOa chau Au v l vafn d l xiJ tri nhilm Helicobacter pylori da dtra ra khuyfi'n cdo d mtic A (miic dO khuyfi'n cao cao nha't) r^ng flnh trang tiln ung thu d? day (VDDMT va DSR) cirt phSi dupc theo d6i bSng nOi soi [13]. Day la mOt dilm rft quan trpng do djlc thd NSDD la mOt phudng phap ch^n dodn xam ISfn va chi phi cho NSDD A chau Au kha cao cho tht^y vai trb ciia nOi soi tSm soat la khfing t h i thay thif diTpc bSng cac phudng phap khfing xam ISh. Kfi'dfi, HOi NOi soi Tifiu h6a chau Au va HOi Nghifin ciiu Helicobacter pylori cOa chau Au cQng da cfing bCi chinh thflc bin hfldng dSn da dflpc chd dpi tfl rft lau v l each thflc theo dfii VDDMT va DSR dflpc gpi t i t la hfldng d3n MAPS (Management pf precancerous conditions and lesions in the stomach) [3]. Theo dfi, cdc tru?Jng hpp VDDMT mflc dO nhp - vfla, cfi / khfing cd DSR nhflng chi t§p trung d vflng hang vi chi cin dflpc ti^t trfl Helicobacter pylori va khfing cSn theo doi thfim; cac trudng hpp VDDMT va / hoac DSR lan rOng d cS hang va than vi c i n dflpc theo doi 3 nam mOt Iln bSng nOi soi sinh thifi't ngay ci sau khi da d i l u tri tiOt trfl Helicobacter pylori (khi sinh thilt ll'y it nhft 2 m l u sinh thifi't tfl than vi \h 2 m l u tfl hang vi).
Hinh 4: Cac d?ng va mflc dfi TNMNS Mui tfin chi ranh gidi giifa vflng teo va vflng khfing
leo. Khdng thSfy mui lfin chl ranh gidi d dang Cl (do loan bO nifim mac than v} khfing bi teo) va dang
0 3 (do toan bO nifim mac than vi diu da bi teo)
4. Nh$n di^n v i theo d5i b#iih nhSn nguy ctf UTDD cao trfin thifc t l ' t « i Vi$t Nam
D?c thfl cfl a h | thfing y t^ a Vi^t Nam la NSDD cfi gia tfldng d^i r l so vdi cdc nfldc va dflpc trang bi rOng khIp do dfi ngfldi b$nh d l t i l p cjn, tuy nhiln ITnh vflc giSi phlu b$nh tilu hfia chfl ylu vSn cdn t^p trung d cdc vi$n trfldng va cdc b|nh v i | n ldn, Trong khi v i n c i n phli t i l p tuc phdt triln vd hoan thi^n h$ th^ng, vi^c flng dung cdc khuyin cdo vd bing chd'ng y hpc vao u-ong thflc t l tai Vi$t Nam cin phdi ddm bdo d i l m md'u chfi't Id tinh khd thi va t$n dMng dflpc sflc manh, flu dilm cfla h$ th6ng y t l h i l n tai.
• Ai \i ngUitl c6 nguy ctf UTDD cao vk cin diT^c sinh thil't h$ thlTng: Ddnh gid mflc dp TNMNS theo phdn loai Kimura - Takemoto cho th^y cfi khd nang nhan d i | n dflpc cdc dfii tflpng nguy cd UTDD cao, k l cd sau khi da ti|t trfl Helicobacter pylori [15], [25], [28]. ijng dung h^ thtfng ddnh gid TNMNS cfi flu dilm Id tdn dijng dflpc t h i manh cila h$ thtfng NSDD chi ph! thip va dflpc trang bi phd b i l n d tuyln qudn huy^n: cdc cd sd y t l dflpc trang bi NSDD nhUBg khfing t h i thflc h i | n xfit nghi#m gidi phlu b^nh vin cfi t h i ddnh gia ntfi spi, trdnh bd sfit nhdm b$nh nhdn cfi nguy cd cao vd chuyin d i n bfinh vi^n tuyln trfin d l ddnh gid ky bdn v l mfi bfinh hpc. Nghifin cflu cfla chflng tfii cho thd'y tft cd cdc trfldng hpp VDDMT giai doan OLGA III - IV vd h i u h i t cdc trfldng hpp LS, DSR lan rOng d cJ thdn vd hang vi d i u tdp trung d cdc b^nh nhdn cd dac d i l m TNMNS mtfc dO vfla - nang [15], [19].
Do v9y, thay vl xem xfit vi^c sinh thifi't h$ thtfng thfldng qui trfin ta't cd b$nh nhdn dflpc chin dodn VDDMT (ma hodn todn khfing t h i khd thi), chflng ta cfi t h i t?p mmg sinh thilt chpn Ipc 5 nhflng trfldng hpp dflpc ddnh gid Id TNMNS mflc dO vira - n?ng. MOt nghifin ctfu mrdc ddy cfla chflng t6i cflng cho thify fl-fin 1109 bOnh nhdn lifin tilp din NSDD tai BV DHYD TP. HCM, chflng tfii gbi nhdn ti 1| TMNNS mflc dtf vfla - ndng khodng 15,8% [16], Nhflvjy, ngay cd d nhflng flung tdm y t l ldn, vi$c fliig dung cdch thtfc sinh thilt hi thtfng mOt cdch cfi chpn chpn Ipc trfin cdc b$nh nhdn cfi bilu hi$n TNMNS mflc dO vfla - nang Id
Tftp CHl KHOA H p c JlfeU H P A V I ^ T NAM 2012 - T ^ P Vll • s d 29
hofin tofin khfi thi vi khdng gfiy qufi tfii.
- Sinh thifi't h$ thd'ng nfin dU^c thiXc hi$n d nhffng vi trf nao: ti-ong d i l u ki0n I^ ttfdng, nfin thtfc hi§n sinh thifi't lai 5 vi tii iheo khuytfn cfio ctia h§ thtfng Sydney cfii titfn vfi dfinh gifi kfi't qufi theo h$ thtfng phfin loai OLGA. Chlnh vl v^y, vi$c tfng dung h$ thtfng nfiy vfio thtfc tfi' cin cd thdi gian dtf hu^n luyfin, bfin canh dd v i n se ttfn khfi nhilu cdng stfc cho cfic ddn v] ntfi soi, gifii phlu b0nh vfi lfing gfinh nfing chi phi cho ngtfdi b$nh. Trong trtfdng hdp chtfa thtf lfim dtfdc dilu nfiy, dilu quan trpng ctia gifii phlu b^nh lfi phfii cin dfinh gifi dtfpc tinh tiang LS, mtfc dO lan r0ng vfi tinh ir^ng tiln ung tiitf (VDDMT. LSR) dtf cd ktf hoach tiieo ddi thich hdp theo MAPS. Nghifin ctfu trtfdc ctia chting tdi cho thfi'y so vdi sinh thifi't 5 mlu md theo phfin loai Sydney cfii tifi'n. chi c i n sinh thitft 3 m i u md dpc theo phia bd cong nhd cfing d vi tri theo khuytfn cfio ctia h0 thtfng nfiy gitip phfit hitfn dtfdc 100% cfic bfinh nhfin cd LS, 97.7% VDDMT (100% lan rtfng d tiifin - hang vi) vfi CSR lan rtfng [17]. Do dd, chdng tdi cho rfing dtf Ifip ktf hoach theo ddi theo htfdng d i n MAPS, chdng ta cd tiitf chi cdn sinh thifi't d 3 vi tri ke trfin cho vfio hai lo rifing biet: m l u thfin vi bd vfio m0t Ip, mlu l^y d gdc bd cong nh6 vfi hang vi bd vfio Ip cdn lai (theo phan loai OLGA tiii m l u sinh thifi't d vfing gdc bd cong nhd dtfdc dpc chung trong phdn dfinh gifi mtfc dd teo nifim mac ctia vfing hang vi.) [20]
- Vi0c nhfin difin dtfdc cfic dd'i ttfdng nguy cd cao bi UTDD lfi cd sd n l n tfing cho vific xfiy drfng cfic chtfdng trinh tdm sofit rifing cho Viet Nam. 6 thdi ditfm hifin tai, vi$c tfng dung MAPS vfio thtfc ttf Vifit Nam chfic chfin se cd nhffng didm khfic bi0t so vdi 6 chfiu Au, tuy nhifin it nhfi't dfiy v i n lfi m0t tin mtfng ldn dtfi vdi cfic nhfi tifiu hda lfim sfing vi chting ta da cd htfdng d i n btfdc ddu dtf ti-fin cd sd dd titfp tyc xfiy dtfng vfi phfit tiitfn mpt chitfn Itfdc tiieo ddi phfi hdp hdn vdi b§nh nhfin Vifit Nam.
5. Ktft lu^n
Do Vitft Nam lfi vfing cd nguy cd UTDD tiung binh - cao ctia thtf gidi vfi UTDD hitfn xfi'p hfing
thtf 2 trong cfic loai ung thtf thtfdng gfip tai Vi0t Nam, vi0c dfinh gifi mtfc d0 nguy cd titfn tritfn thfinh UTDD dtfa U-fin n0i soi nfin dtfdc xem lfi thtfdng qui bfin canh vi$c nhfin dinh cfic tdn thtfdng cd thtf gifii thich tri0u chtfng lfim sfing d cfic b0nh nhfin dtfdc chi djnh NSDD.
TNMNS mtfc d0 vtfa - nfing lfi dfi'u hi0u gitip nhfin di§n cfic titfdng hpp cd nguy cd UTDD cao, cdn dtfdc sinh thifi't h0 tiitfng dtf Ifip ktf hoach theo ddi dfii ban ngay cfi sau khi ti§i tiir H. pylori (ntfu cd nhilm Helicobacter pylori). H$ thtfng dfinh gifi mtfc d0 TNMNS nfin dtfpc dtfa vfio chtfdng tiinh hufi'n Iuy0n NSDD vfi dfinh gifi m0t cfich thtfdng qui khi thtfc hien NSDD chdn dofin. .
Trong trtfdng hpp chtfa thd dfinh gifi md bfinh hpc giai doan vifim da dfiy theo hfi thtfng phfin loai OLGA, sinh thitft 3 vi tri dpc Iheo phia bd cong nhd Iheo khuyfi'n cfio ctia phfin loai Sydney cfii tifi'n vfi cho vfio hai Ip rifing bifit gitip xfic dinh kfi' hoach theo doi bfinh nhfin nguy cd cao Iheo htfdng din MAPS. Trong ttfdng lai cdn titfn hfinh nghifin cdn dtf xfic dinh ktf hoach theo ddi rieng phfi hdp hdn vdi ngtfdi Vi0t Nam.
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