Y HOC VIET NAM THANG 2 - SO 1/2014
V. KET LUAN
Nghien ciru tren 55 benh nhan gay hai xu'dng cSng chan du'dc phau thuat ket hdp xu'dng ONT cd chdt, Chung tdi thay rang:
- Ty le gay 1/3 giij'a va du'di la chu yeu, ehiem 92,7%. Gay kin chiem 45,5%
- Ket qua dieu tri lien vet thu'dng thi dau 89%, lien xu'dng thang true chiem 8 1 , 1 % va ket qua chung la rat tdt 78,9%, tdt 10,6%, trung binh 7,9% va kem 2,6%.
TAI L l | U T H A M KHAO
1. Tran Trung Dung va cpng su" (2006), "Tinh hinh chan thUdng chi do tai nan giao thong tai benh vien Viet Oirc tir 2000 den 2004". Tap chi Ngoai khoa so 5, tr 28 - 38
2. Littenberg B, Weinstein LP, McCarren M, et al (1998). "Closed fractures of the tibial shaft. A meta-analysis of three methods of treatment". 2 Bone Joint Surg Am;80:174-183.
Nguyen Hanh Quang va cpng sir (2000), "Ket qua budc dau ap dung phuong phap dong dmh noi tiiy kin co chot ngang dieu tn gay than xUOng chay". J a p chi Y hpc Viet Nam so 11, tr 17 - 20 Nguyen Hanh Quang, Nguyen Dac NghTa (2003), "Nhan xet ket qua ddng dmh noi tity co chot, khong doa dng tiiy trong dieu tn gay hd mdi hai xu'dng cang chan tai benh vien Xanh Pon". Tap chi Y hoc Viet Nam so dac biet, tr 168 - 171 Bone LB, Sucato D, Stegemann PM, et al (1997) "Displaced isolated fractures of the tibial shaft treated with either a cast or intramedullary nailing. An outcome analysis of matched pairs of patients". J Bone Joint Surg Am; 79:1336-1341.
Hodgkinson AH, Harvey PM (X975).
"Interamedullary nailing in the treatment of open fracture of the tibial and fibula". Bone Joint surgery57: P 909-915
Ji ] . , Zhao Y., He X., Zhou Y.(2009). "Effect of interlocking intramedullar/ nail in treatment of open tibial and fibula fractures",Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhr,:{23):268-70
NHAN XET BiraC DAU AP DUNG PHAU THUAT SUGIURA TRONG DIEU TR| CHAY MAU TINH MACH THUC Q U A N
DO BENH LY TANG AP LU'C TINH MACH CU'A
Tran Huu Vinh*
T 6 M TAT
Myc tieu: Danh gia ket qua budc dau ap dung phSu thuat Sugiura trong chay mau tinh mach thuc quan, Doi tu'png va phu'dng phap dfeu trj: Ddi tu'dng nghien ciru gom 17 benh nhan bi chay mau do v6 tTnh mach thu'c quan tren cd 6\a tSng ap lu'c tinh maeh cira. PhUdng phap nghien ciTu la nghien ciru tien ciru, mo ta cat ngang tir 1/2011 den 12/2013 tai khoa Ngoai benh vien Bach Mai, Ket qua: Ty le bien chu'ng sau mo thap: chay mau trong 6 bung la 11,7%, nhiem triing vet mo la 17,6%, ty le gian TMTQ chay mau Cai phit sau 6 - 5 4 thang chu'a ghi nhan. Ty le tir vong sau m6 1^ 11,7%. Ket luan: Phau thuat Sugiura cai tien ip dung dieu tn vd TMTQ do tang ap luc tinh mach cira cd y nghia thi/c te trong cac trudng hdp cap CIAJ dang chay mau cung nhu' doi vdi cac BN dieu tn bSng cac phuong phap khac khong c6 ket qua, Tiy khda: Chay mau, gian tinh mach thuc quan, tSng ap li/c tinh m^ch cii^.
" Khoa ngo^i Benh vien B^ch Mat
Phan bl^n khoa hgc: PGS. TS Nguyen Quoc Anh
SUMMARY
COMMENTS I N I T I A L APPLICATION OF SURGICAL SUGIURA PROCEDURE I N THE TREATMENT OF BLEEDING ESOPHAGEAL VARICES I N HYPERTENSION PORTAL Objective: To evaluate the initial results of applying Sugiura surgicai bieedmg esophageal veins.
Material and method: Study subjects at 17 patients with bleeding esophageal veins burst on the location of the portal vein pressure. Research methodology is a prospective study from 1/ 2011 to 12/2013 at Bach Mai Hospital. Results: Prevalence of low postoperabve complications: bleeding in the abdominal cavity was 11.7%, wound infection was 17.6%, the proportion of recurrent bleeding follow-up of 6-54 months not recorded. Postoperative mortality rate was 11.7%.
Conclusion: Surgery Sugiura improved treatment applied esophageal varices broken by the portal vein pressure increased significantly m the case of actual emergency bleeding as well as for patients treated with other methods can not results.
Keywords: bleeding, esophageal varices, portal vein pressure.
Y HOC VIET NAM THANG 2 - SO 1/2014
I. DAT VAN DE
Chay mau do vS tinh mach thu'c quan (TMTQ) gian trong benh ly tang ap lu'c tinh mach cira (TALTMC) eho den nay van fa mot bien chirng nang, ty le tir vong cao, nen van eon la mpt van de Icfn doi vdi cac phau thuat vien cung nhu' doi vdi eac nha npi khoa tieu hoa khac.
Trong dieu tri benh ly TALTMC hau het khong the dieu tri nguyen nhan ma chii yeu la dieu tri ngan ngifa hoae kiem soat cac bien chirng, dac biet la chay mau do vd tinh mach thi/c quan.
Den nay van ton tai nhieu phu'dng phap nghien ciru ve van de nay nhu'; dat bong Sengstaken Blackmore, ong Linton, Minnesota nhu'ng cung chi dem lai ket qua tam thcJi nhu'ng thcJi gian lu'u dng khong du'dc qua 6 gid, va cung con rat nhieu tai bien va bien ehirng nhat dinh nhu'hoai tir thanh thi/cquan,,, Cac phu'dng phap khac nhu" npi soi de tiem xd cae bui tinh maeh, that cae bui tTnh mach gian, ty le tai phat rat eao va khong the thi/e hien du'dc trong tru'dng hdp dang ngap mau. Cac phu'dng phap phau thuat khac nhu': Crile-Linton la md thu'c quan khau cam mau eac tinh mach thi/c quan v5 eho ket qua tot nhu'ng ty le tir vong cao khoang 40-50%. Phau thuat noi chii ciTa theo nhieu ky thuat khae nhau cung du'dc cac nha phau thuat du'a ra nhu'ng sau mo lai CO ty le nao chii ci^a cao nen cung it du'dc ap dung [1]. Gan day cac tac gia du'a ra ky thuat TIPS nhu'ng ket qua eung khong du'dc nhu" mong muon va nhieu tai bien va bien ehirng khae.
Nam 1973 tai Nhat Ban Sugiura va Futagawa da bao cao thanh eong phau thuat trong dieu tri chay mau do vd TMTQ trong dieu trj benh ly TALTMC. Sau do co nhieu yeu to cai tien mot phan ky thuat cua phu'dng phap nay, Hien nay tai khoa Ngoai benh vien Bach mai dang phoi hdp vdi khoa Tieu hda ap dung phau thuat nay.
Chung tdi bao cao nghien ciru nay nham gdp
3.1.2, Trieu cJTt/'ng jam sang: {Bang 1)
phan nho danh gia ket qua sdm ciia phau thuat Sugiura cai tien.
II. DOI Tl/QNG VA PHirONG PHAP NGHIEN CUtJ 2.1. Doi tu'dng nghien cu'u: Gom 17 benh nhan du'dc dieu tn tai khoa Tieu hoa va khoa Ngoai benh vien Bach Mai vdi chan doan vd, gian tTnh mach thi/e quan do TALTMC, xd gan mirc do Childs A, va B, Thdi gian nghien ciru tir 1 nam 2011 den 12 nam 2013.
2.2. Phu'ofng phap nghien cu'u: Nghien ciru md ta va tien ciru
Cac dU lieu du'dc ghi nhan theo mot benh an thdng nhat;
- Oac diem chung: Tuoi, gidi. Cac dau hieu lam sang va can lam sang
Oanh gia ehire nang gan theo phan loai Child-Pugh - Cac tai bien va bien chu'ng sau mo
Ket qua kiem tra sau 1-6 thang
- Ky thuat md: Md byng chu' L, Cat lach. Triet mach toan bp phia bd cong Idn da day. Triet maeh 2/3 tren bd cong nhd da day. Triet maeh 2 ben thu'c quan len tdi mirc tinh mach phoi du'di.
Cat ndi thu'c quan bang may Stapler EEA 25mm hoac 27mm each tam vi khoang 3 cm. Cat nhanh than kinh X chpn ipe. Dan lu'u da day.
III. KET QUA NGHIEN CCrU
S.l.Dac diem chung: Gom 17 BN eo tuoi trung binh'la 35,8 ± 5,3 (21-60). Nam la 14 BN, nC la 3 BN. Ty le nam : ntr la 4,66.
3.1.1. Tien st^ benh: Viem gan B, viem gan C la 35,3%, xd gan 64,7%; Chay mau do v6 TMTQ cap tinh 5 BN ap dung tiem xd, that biii tJnh mach thi/c quan that bai. Tai dien chay mau nhieu lan sau dieu trj ndi soi 15 TH, trong do eo 2 TH (^
dieu tri TIPS nhu'ng van chay mau tai phat.
Trieu chu'ng lam sang Non mau
Oau bung vunq thu'dng vi Lach to
Gan to Co dich bang Tuan hoan bang he Vang da vang mat Met moi chan an gay sut
So benh nhan 17 15 17 12 15 17 3 17
Ty le % 100 88,2 100 70,6 88,2 100 17,1 100
NhSn xet: Tren bang 1 cho thay ty le BN non mau ciiiem 100%, ty le lach to d cac mu'c do khSc
nhau la 100%, ty le cd tuan hoan bang he la 100% va ty le met moi chan an gay sut la 100%.
Y HQC VI$T NAM THANG 2 - SO 1/2014
Trieu chu'nq Hong cau (X. 10'^) Tieu cau (X. 10=) Albumin Bilirubin
Chi so
< 2 , 5 2 , 5 - 3 , 5
> 3,5
< 100 100 -140
^ 140 ' 3,5mq/100ml
< 3mq/100ml
< 2mq/100ml ' 3mq/100ml
So BN tru'dc mo 10 4 3 17 0 0 17 17
So BN sau m o 0 2 15 0 3 14 15 2 15 2 Nh$n xet Tren bang 2 cho thay ty le tieu cau thap < 100,10^ chiem 100%, ty le HC < 2,5.10" chiem I
3.2. Banh gia theo phan loai Child - Pugh (Banq 3) Mu'c dp s u y ^ a n
A B C Tong
So BN tru'dc mo 5 12 0 17
Sd BN sau mo 8 7 2 17
NhSn xet: Tren bang 3 cho thay ty le Child A trudc mo la 5BN sau mo la 8BN, Child B trUdc 12BN sau mo la 7BN, Child C tru'dc mo khong sau mo la 2 BN.
3,3, Bien chu'ng sau mo (Bang 4) Bien chu'ng Chay mau trong 6 bung Ro mienq noi thuc quan Nhiem trung vet mo Tran dich manq phoi TLT vong
So benh nhan 2 0 3 5 2
Ty le % 11,7
0 17,6 29,4 11,7 Nh$n xit:lxe.x\ bang 4 cho thay ty le nhiem triing vet md la 17,6%, tran djch mang phoi la 2!
tyle tir vong la 11,7%.
3.4. Ket qud Idem tra sau mo 1-6 thang (Banq 5) Tinh tranq T M T p
0 6 1 B o l l 06 I I I
Sau 1 thang ( n ) 0 15 0
Trong vong 3 - 6 thang ( n ) 10 5 0
Tren 6 thang (r 15 0 0 NhSnxit'Tren bang 5 cho thay ty le mu'c dp gian TMTQ sau mo 6 thang d mirc dd I la 100%.
IV. BAN LUAN
4 . 1 . Oeic diem chung: Ap lu'c t?nh mach cira binh thu'dng vao khoang 3-6 mmHg. Ap li/e ly*c nciy tang nhe khi an, van ddng hay khi lam nghiem phap Valsava. Khi ap lu'c nay tang tren 10 mmHg b5t dau xuat hien thdng ndi cira chu thong qua cac tTnh mach bang he. Khi ap Ii/c nay tSng tren 12 mmHG gay vd eac tTnh maeh bang h§. Vi tr( v9 trong hau het cac tru'dng hdp la cac biil tinh mach thu'c quan, ddi khi co gap d cae vj
trf khac nhu' (phinh vj, hang vj, dai trang trang...). Nguyen nhan phd bien nhat gay ap li/e tinh mach cira la xd gan. Hai nguyen chinh dan den xd gan la nghien ru'du va gan do virus (hepatitis B va C), cac nguyen khae it gap.
BN bj xd gan co the khdng co trieu chi trong nhieu nam. Ty le BN cd tien sir xd ga nhdm nghien cu'u la 64,7%, ty le viem c 35,3%. So vdi ket qua ciia cac t^e gia cd
Y HOC VIET NAM THANG 2 - SO 1/2014 nhau do sir lira chpn phu'dng phap dieu trj. Theo
Haciyanii M dp tudi trung binh ia 46 tudi (18-56) trong do ty le BN cd tien sir xd gan la 60%, Tran Ngpc Thdng cd dp tuoi trung binh la 38±5, trong dd BN cd tien si^ xO gan la 4 0 % . [ 6 ] , [ 3 ] .
4.1.1. Cac dau hieu lam sang: Ty le non ra mau gap d 100%, cd cam giac met mdi, ehan an, gay siit can gap d 100% BN trong nhdm nghien ciru. Gan to du'di bd su'dn ghi nhan trong 10/17 tru'dng hdp ciia nhom nghien ciru, 7 TH khae gan khdng sd va go thay to hdn binh thu'dng. Ty Ie nay so vdi ghi nhan cua cac tac gia khdng cd si/ khac biet, Ty le lach to d nhom nghien ciru la 100%. Theo Vu Duy Thanh ty le lach to gap tren 80-90% d nhdm BN cd TALTMC vdi mirc dp khac nhau. Theo ghi nhan cua Tran Ngpc Ddng ty le BN non mau la 100%, dau viing thu'dng vj la 6 0 % , lach to la 100%, ed dich bang d byng la 50%, tuan hoan bang he la 4 0 % , vang da vang mat la 10% [ 2 ] , [ 3 ] .
4.1.2. Cac dau hieu can lam sang:
- Cac xet nghiem sinh hoa va huyet hpc: Cac xet nghiem nay tuy ed ket qua thay ddi nhu'ng chiing cung khdng dac hieu cho xd gan. Thieu mau thu'dng dang bao, nhu'ng cung cd the nhu'dc sac hong cau nhd, dai bao tren nhu'ng BN ed tien sir nghien ru'du, hay thieu mau huyet tan tren nhu'ng BN cu'dng lach va trong tru'dng hdp nay cung cd the gay nen giam bach cau va giam tieu cau. Cac chi so ve xet nghiem mau ciia nhdm nghien ciru the hien tren bang 2 cho thay ty le hdng eau, tieu cau deu giam d cae BN tru'dc mo, nhu'ng sau mo thi ty le nay thay doi hoan toan tren tat ea eae BN, Chi ed 2 BN do qua trinh hdi sire sdc mat mau tru'dc mo khdng ket qua nen cd ty le Albumin huyet thanh <3mmg/10Qml va ty le Bilirubin huyet thanh > 3mg/100ml,
- Sieu am; Day la phu'dng phap chan doan xd gan re tien, an toan va hieu qua. 100% BN trong nhdm nghien ciru du'dc xu' dung phu'dng phap nay tru'dc mo va sau md. Sieu am Doppler du'dc ap dung tren 100% BN mue dich de danh gia ddng chay tinh maeh cira. Sdng ddng chay tTnh maeh eira bj "ep dep", day la dau hieu dien hinh eiia benh ly xd gan do TALTMC. Phu'dng phap nay du'dc eac tac gia ghi nhan vdi dp nhay va dp chinh xac cao.
- Chup eat Idp vi tmh va chup eong hu'dng tir {CT va MRI) du'dc ehi dinh trong 7/17 BN (41,17%) trong cae tru'dng hdp beo, bung nhieu djch bang lam hinh anh sieu am khdng xac djnh rd rang.
Cac tae gia etjng cho rang eac phu'dng phap nay
ehi can ap dung khi chan doan ban dau chu'a ro rang ve nguyen nhan.
- Ndl soi thu'c quan da day du'dc thi/c hien tren tat ca CSC BN va du'dc thu'c hien nhieu lan tren moi BN. Ndl soi thu'c quan da day la chi djnh dau tien khi nghi ngd cd tang ap lu'c tinh maeh cira.
Tren cac BN ed dau hieu xd gan thi phUdng phap nay cho thay dau hieu dan tinh mach thu'c quan d cac mire dd khac nhau. Ty le gian TMTQ cua nhdm nghien ciru la 100% d mirc dd I I I vi deu da cd hien tu'dng chay mau do vd nhieu lan.
Phu'dng phap nay rat thuan tien trong viec kiem tra sau md, hoac ket hdp ap dung dieu tri nhu"
tiem xd, that vdng,., hoac sinh thiet thu'dng ton neu ed chi dinh nhu' nghi ngd la ung thu' thi/c quan hoac tam vi. .
Anh noi soi da day th&c quan BN Nguyen Van N (57 tuoi) - Cac xet nghiem can lam sang khac nhu' chyp thu'c quan sau udng baryte loang, do ap lu'c TMC, chup TMC chiing tdi khdng thu'c hien tren BN trong nhom nghien ciTu vi 100% BN deu cd hien tu'dng XHTH nhieu lan do v 3 TMTQ.
4 . 2 . D a n h gia chu'c nang gan Cd nhieu phu'dng phap danh gia chiTc nang gan d BN xd gan, nhu'ng theo ghi nhan ciia cac tac gia danh gia ciia Childs-Pugh la du'dc ap dung phd bien hdn ca, Theo ghi nhan tren bang 4, Ty le suy gan mire dp nhe (Child A) ciia nhdm nghien eiTu chiem ty le 70,6 %, ty ie suy gan trung binh (Child B) la 29,4 %, khdng cd tru'dng hdp nao bj suy gan d gia doan cudi (suy nang Child C). Ket qua nay eua nhdm nghien eiTu cd khac so vdi mot 50 tae gia khae vi sy' Ida chpn BN de ap dyng phu'dng phap phau thuat nay, cac tac gia nhu'; co ca BN d nhdm Child C, nen ket qua sau mo ciia cac tae gia ed ty le tir vong va ty le bien ehutig cao hdn. Theo ghi nhan ciia Sugiura-Futagawa (1967-1984) da phau thuat 671 TH trong dd ty le xd gan la 73,7%, trong dd Child A la 36,36%, Child B la 37,4%, Child C la 26,22% va ty le song sdt ciia Child A la 8 6 % , Child B la 7 4 % , Child C la
Y HOC VfET NAM THANG 2 - SO 1/2014 53%. Chiing toi eung quan diem vdi Tran Ngoc
Thdng va mdt sd tae gia khac la khdng ehi dinh ap dung phau liiuat nay doi vdi BN nhdm Child C vi CO nhieu nguy cd cao va ty le tir vong sau mo eao hdn d nhuYig nhdm cdn lai [ 3 ] .
4.3. Ban ve chi djnh p h l u t h u a t Theo quan diem eiia Idezuki Y, Kukudo N, K Sanio, Bandai Y phau thuat Sugiura la giai phap cudi cung ddi vdi benh ty TALTMC [ 7 ] . Theo quan diem ciia Lepner U, Vaasna T, Rebane E, Tamm V vdi ket qua eiia phau thuat: ty le tir vong sau mo la 10,3%, ty le chay mau tai phat la 11,4%
va t / le sdn 84,6% sau 1 nam, 71,8% sau 5 nam va 6 4 , 1 % sau 10 nam, Cac tac gia da ket luan rSng phau thuat Sugiura dem lai ket qua tot trong viec kiem soat chay mau do gian TMTQ ma khdng gay ra rdi loan chirc nang gan va nao va du'dc ehi dmh eho tat ea cac BN bi gian TMTQ chay mau loai trir nhii'ng tru'dng hdp cd suy gan nang. [ 7 ] . Tir ket qua nghien ciru chiing tdi ghi nhan quan diem ciia cae tae gia tren vdi ket qua eiia nhdm nghien cu'u: 5 TH chay mau cap tinh khdng kiem soat du'dc bang eac giai phap ndi soi, chiing tdi da ap dung phau thuat nay co ket qua tot la cam mau du'dc ngay, tuy ed 2 TH tir vong sau dd do khdng hdi sire du'dc sdc mat mau, vi BN den mudn, sd lu'dng mau mat nhieu tru'dc khi vao vien. 3 TH edn lai ket qua tdt, BN du'dc theo doi lau nhat la 30 thang chu'a tai phat, ndi soi tinh mach thy'e quan gian d mirc dp I I , the trang dn dinh, chirc n3ng gan hdi phyc. Ca 5 BN deu d mirc dp Child B, 12 BN du'dc phau thuat ed chuan bi nen ket qua tdt sau kiem tra trung binh la 6 t i l i n g , nhu'ng BN nay van du'dc theo ddi nhu'ng ed 2BN mire dp suy gan tang len tir Child B tru'dc md sau mo 6 thang thi xau di xudng mirc Child C do BN khdng cd dieu kien dieu trj tdt sau md va van cdn udng trdm ru'du. Theo cae tae gia thi ty le that bai d cac tru'dng hdp Child C kha cao.
Theo ghi nhan ciia Haciyanii M 3 0 % BN Child C tir vong do chay mau tai phat,_ suy gan trong vong 4,25 va 28 thang sau mo. Cae BN nhan khae trudc mo chirc nSng gan edn tdt nen ket qua sau md tdt vdi thdi gian theo ddi trung binh la 27 thang [ 6 ] . Tac gia Abouna MG, Baissony H ghi nhan ket qua sau md cd ty le tir vong la 7,7%, chay mau tai phat la 3,4%. So sanh vdi ket qua ciia nhiJng phu'dng phap khae nhu"
Warren cd ty le tir vong la 14,3%, chay mau tai phat la 14,3%, hpi chirng nao ehii cira la 14,3%.
TTieo Belloli G, Campobasso P, Musi L ty le thanh cdng CLia c^c tac gia la 8 0 % va ty le bien chirng
thap [ 5 ] . Theo Haciyanii M ghi nhan ty le chay mau tai phat la 10% trong khoang thdi gian tir 20-28 thang sau mo [ 6 ] . Tir ket qua nghien ciru va ghi nhan ciia cac tac gia chimg tdi eho rang phau thuat Sugiura la giai phap dieu tri tdt ddi vdi cac BN mac chirng benh TALTMC trong giai doan xd gan Child A va B. Can phai cd sd lu'dng BN nghien ciru nhieu hdn va thdi gian theo ddi sau md dai hdn de khang dinh tinh kha thi eua phau thuat nay.
V. KET LU^N
Qua nghien ciTu vdi 17 benh nhan bj chay mau tTnh maeh thu'c quan tren TALTMC du'dc ap dung phau thuat Sugiura cd eai tien chimg tdi riit ra nhu'ng ket luan sau; Ty le bien chirng sau md thap; chay mau trong 6 byng la 11,7%, nhiem trung vet mo la 17,6%, t>' le gian TMTQ chay mau tai phat sau 6 - 5 4 thang chua ghi nhan. Ty le tir vong sau md la 11,7%,
Phau thuat Sugiura cai tien ap dyng dieu trj vd TMTQ do tang ap lu'c tinh mach cira cd y nghia thu'c te trong eae tru'dng hdp cap ciru dang chay mau cung nhu" ddi vdi eae BN dieu trj bang cac phu'dng phap khac khong cd ket qua.
Can du'dc ghi nhan vdi sd BN Idn hdn de cd y nghTa khoa hpc cao.
TAI LIEU T H A M KHAO
1. Vu'dng Hung, Tran Vinh (2002); "Gidi thi^u mot phu'dng phap mdi dieu tn chay mau do gian tinh mach thUc quan"; Thong tin Y hoc Lam sang;
Sd7nSm2002; Tr86-93.
2. Vu Duy Thanh (1993); "Bai giang Benh hpc Ngoai khoa sau dai hoc"; Hoc vien Quan Y; Tap 2, tr: 114-130.
J , Tran Ngpc Thong (2012); "Ket qua budc dau dieu tn chay mau tinh mach trudng thu'c quan do benh ly tang ap cira bang phau thuat Sugiura cai tien"; Ngoai khoa;Tap 61 so 1-2-3, trl7-23.
4. Adnan M, Sibiany A (1995); "Modified Sugiura procedure for nonalcoholicbieeding esophageal varices", Annat of Saudi medicine; Vol 15(4).
5. Belloli G, Campobasso P, Musi L (1992); "
Sugiura procedure in the surgical treatment of bleeding esophageal vances in Children: long-term results"; J Pediatr Surg; 27(11): 1422-6.
^J. Haciyanii M, Gene H, Halici H, Kumkumoglu Y, Gur OS, Ozturk T (2003); "Results of modified Sugiura operation in vanceal bleeding in cirrhotic and noncirrhotic patients";
Hepatogastroenterology; 50(51):784-8.
7. Lepner U, Vaasna T, Rebane E, Tamm V (1999); "Sugiura procedure in the treatment of bleeding esophageal varices"; Ann Chir Gynaecol;
88(2):122-6.
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