V HOC VIET NAM THANG 7 - SO 2/2012
KET QUA DIEU TRj SOI NIEU QUAN BANG PHlTONG PHAP TAN SOI HOLMIUM LASER TAI BENH VIEN VIET DUfC
Vu Nguyen Khai Ca*
T O M T A T
Muc tieu nghien cufu: Oanh gia ket qua dieu tn sot nieu quan theo phudng phap tan soi bang laser Holmium qua noi soi nieu quan tai benh vien Viet DiTc.
Phu'dng phap nghien cu'u: Phu'dng phap nghien ciru hoi ciru mo ta tren cac benh an ciia nhiJng benh nhan soi nieu quan diTOc dieu tri theo phu'dng phap tan sdi bang laser Holmium qua noi soi nieu quan tir thang 5 nam 2011 den thang 5 nam 2012. Ket qua nghien cu'u: Tong so 72 benh nhan soi nieu quan doan 1/3 du'di diroc tan s6i bang laser Holmium, trong do co 38 benh nhan nam va 34 benh nhan niJ. Soi nieu quan co the d ben phai, ben trai hoac ca hai ben vdi cac ti le tirong irng la 51,39% (37/72), 47,22% (34/72), va 1,39% (1/72). ThcJi gian nam vien trung binh la 3,15
±0,5 ngay, ket qua tot dat 88,88% (64/72), trung binh dat 8,33% (6/72), xau 2,77% (2/72). Khong cd bien chirng nang. Ket luan: PhUOng phap tan sdi nieu quan bang laser Holmium qua noi soi nieu quan la phu'dng phap CO hieu qua va an toan. Ket qua nghien ciru ciia chiing toi cho thay day la phirong phap it sang chan va nen du'dc lira chon de dieu tri soi nieu quan d tat ca cac v| tn'.
ABSTRACT
OUTCOMES OF OF URETEROSCOPIC HOLMIUM- LASER LITHOTRIPSY FOR URETERIC CALCULI
IN VIET DUC UNIVERSITY HOSPITAL OBJECTIVES: To evaluate the outcomes of ureteroscopic Holmium-laser lithotripsy for ureteric calculi in Viet Due university hospital.
METHODS: We reviewed the records of patients with radiopaque ureteral calculi treated by ureteroscopic Holmium-laser lithotripsy from May 2011 to May 2012. The success rates, complications and the length of hospital stay were evaluated.
RESULTS: A total of 72 patients were treated for ureteral calculi including 38 male patients and 34 female patients. The stone sides were the right, left and bilateral side, accounting for 51,39% (37/72), 47,22%
(34/72) and 1,39% (1/72), respectively. The mean tiospital stay was 3,15 ±0,5 days. The good and moderate results were 88,88% (64/72) and 8,33%
(6/72), respeebvely; treatment failure was in 2,77%
(2/72). No critical complications were seen in our study.
CONCLUSIONS: Ureteroscopic Holmium-laser lithotripsy is safe and effective and associated with low complications. The results of our study showed that this IS an invasive and reasonable treatment option for ureteral calculi.
* Khoa Phau thuat Tiet nieu - Benh vien Viet Du'c Phan bien khoa hoc: PGS.TS. Nguyen Van Huy 28
I. O A T VAN OE
Sdi nieu quan la benh ly thu'dng gap, ehiem 28 - 4 0 % cac benh sdi tiet nieu. Sdi 1/3 du'di nieu quan la loai sdi nam d doan nieu quan tircuoi khe khdp cung chau den thanh bang quang va thu'dng do sdi tir tren than rdi xudng. Cd nhieu each dieu tri sdi nieu quan khac nhau, tir md md truyen thong, mo npi soi frong hoac sau phue mac den lay sdi hoae tan sdi ngoai cd the (TSNCT), trong do phai ke den phu'dng phap tan sdi noi soi ngu'de ddng de dieu tri sdi d vj tri nay. Sdi du'dc tan b^ng eac ky thuat nhu' xung hdi, dien tir tru'dng, sieu am, holmium laser, mdi ky thuat cd nhuVig tinh nang khac nhau. O benh vien Viet Dire, ky thuat holmium laser da du'dc ap dung de dieu trj sdi nieu quan 1/3 du'di va nghien ciru ciia chiing toi nham danh gia hieu qua ciia phu'dng phap trong nam qua.
II. OOI TUONG VA PHUONG P H A P NGHIEN COU 2 . 1 . b o i tu'dng: 72 BN (BN) ed sdi nieu quan 1/3 du'di, cd kich thu'de sdi < 20mm, khdng eo dj dang du'dng tiet nieu, khong hep nieu quan, khdng cd nhiem triing du'dng tiet nieu tren; cung loai khdi doi tu'dng nghien ciTu cac BN dang mang thai, cd roi loan yeu to ddng mau, ung thu"
bieu md du'dng tiet nieu, cd benh tim phd'l nang va eae benh tiet trien. Tat ca BN du'dc dieu tri bang may tan sdi holmium laser cua hang Karl Storz tai Khoa Tiet nieu, Benh vien Viet D(fc, tir thang 5 nam 2011 den thang 5 nam 2012.
2.2. Phu'dng phap nghien cu'u: Hoi culi md ta.
2.2.1 Phu'dng tien: May Karl Storz endoscopy, bao gom: he thong hinh anh: nguon sang, camera ciia hang KarLStorz; ong ndi soi nieu quan cd 2 kenh cd 9,5 Fr; he thong tu'di r i i ^ : guide cac loai, pinee lay sdi, sonde Dormia.
2.2.2 Phu'dng phap tan sol:
- BN du'dc hoan chinh ho sd benh an, cac xet nghiem can lam sang, chup XQ, UIV, sieu am, neu can cho chup CT scanner de xac djnh soi can quang tren phim ehup thu'dng.
- BN nam tu' the san khoa, gay te tiiy song.
- Tan sdi qua ndi soi nieu quan ngu'de ddng
Y HOC VIET NAM THANG 7 - SO 2/2012 2.2.3. Danh gia ket qua
- Chung toi chia ra 3 loai:
+ Tot: tan het sdi, khdng cd tai bien va bien chirng.
+ Trung binh: Tan vyn sdi nhu'ng chu'a lay het sdi kem theo thirdng ton nhe niem mac nieu
quan, chay mau it.
+ Xau: sdi chay len than, cd tai bien va bien chirng nhiichay mau nhieu, thiing nieu quan phai chuyen sang phu'dng phap khac,
- Ngoai ra; tinh thdi gian tan sdi, thdi gian nam vien, cac bien chiTng va tai bien sau tan sdi.
III. KET QUA NGHIEN CCrU
3 . 1 . Tuoi, gidi: 3 8 / 7 2 BN nam (52,78%), 34/72 BN niJ (47,22%). Tudi trung binh: 49,71 ^ 10,59%.
3 . 2 . Chan doan
3.2.1. Tien su'benh tat: 6 BN da md sdi than cimg ben; 16 BN da tan sdi HCT; 22 BN cd tien sir mo sdi du'dng tiet nieu
3.2.2 Vi tri soi
- VI t r i sdi: Nieu quan P; 37 BN (51,39%).
Nieu quan T: 34 BN (47,22%).
Nieu quan 2 ben: 1 BN (1,39%).
3 . 3 . Chan doan hinh a n h
3.3.1 Mu'c dp u'nu'dc than qua sieu am Mu'c d o
Khong is nu'dc (1 nifdc do I a niJcfc do II is ni/dc do III
S o B N I 21 47 3
Ty le "/o 1.39 29.17 65.27 4.17 3.3.2 -Chii'c nang than tren nieu do tinh mach
Than bai t i e t Tot (15-30 phut) Trung binh (sau 30 -60 phut) Kem (>60 phut)
S o B N 64 7 1
Ty le »/o 88.9 9.7 1.39 3.3.3. Kich thu'de, solltting
~ ~ — — — _ _ _ _ ^ ^ K i c h thirdc So lu'dng " "^—
1 vien 2 vien
vien soi du'a tren phim X-quang.
S6BN 69
3
Ty le % 95.83
4.17 3.4. Hinh t h a i nieu q u a n
Hinh thai nieu quan Binh thu'c^ng Viem, phu ne Co polyp
S o B N 66 3 3
Ty le o/o 91.66 4.1 4.2 3 . 5 . Ket qua t a n so
Vi tri Nieu quan (P) Nieu quan (T) Nieu quan 2 ben
Tot 32 31 1
Trung binh 4 2 0
Xau 1 1 0
Y HOC VIET NAM THANG 7 - SO 2/2012 3.6. D a t ong thong nieu quan: thdng J3
eho 62/72 BN (86,11%); thdiig nhi/a eho 10/72 BN (13,89%).
3.7. Thdi gian t a n soi trung binh: 17.8 ± 5.22 phiit.
3 . 8 . Tai bien va bien ehu'ng: 1 BN sdi chay len than; 1 BN tan sdi lam thiing nieu quan phai chuyen mo md.
3.9. Thdi gian n a m vien; 2 - 1 4 ngay, trung binh 3,15 ± 0,5 ngay.
IV. BAN LUAN 4 . 1 . Dac diem BN
6 72 BN du'dc tan sdi, dp tudi 40 - 49 chiem 83.3%; ty le BN nam va BN ntT khdng cd su" khac biet nhieu: 52.78% so vdi 47,22%. Viee tan sdi ngu'de dong eho BN nu' thuan Idi nhieu hdn so vdi nam gidi. Nhan djnh ciia ehiing tdi eijng trimg quan diem vdi Nguyen Minh Quang (2004), 0am Van eu'dng (2002). Trong nghien eiru cd 22 BN CO tien sir md sdi than tru'dc dd. Do vay, nhii'ng sdi nieu quan du'dc tan ed the du'dc hinh_ thanh thir phiat sau eac lan can thiep nay (Nguyen Ky - 1994). Sdi nieu quan gap d nhu'ng BN dirdc tan sdi ngoai cd the la nhii'ng sdi nhd cd the diic khudn d mot doan nieu quan, cd the nam rai rac neu long nieu quan hep. Tinh trang phii ne se gay kho khan eho viec tiep can sdi va tan sdi bang xdng hdi nhu'ng lai thuan Idi neu tan sdi bang laser.
4.2. Dac diem can lam sang Chan doan sdi nieu quan chu yeu diTa vao chan doan hinh anh; sieu am, X-quang, UIV, CT scanner, MSCT 64.
Tren ket qua sieu am danh gia than u' nu'dc mu'c dp I: cd 29 BN (29.17%) than (i nu'dc do 2 cd 47 BN (65,27 % ) . Tuy nhien d chup tJIV cho thay chirc nang than cdn trong gidi han binh thu'dng la 64 BN ( 88.9%). Trong nhii'ng tru'dng hdp sdi khong can quang hoac tinh trang suy than nang khdng the ehup UIV hoae CT scanner cd tiem thuoc can quang thi viec chi djnh chup 64 day khdng bdm thudc cho thay du'dc hinh anh sdi, mire dp dan ciia dai be than mot each toan canh giiip eho viec chan doan de dang hdn
4.3. Nhulig nhan xet ve qua trinh tan soi Tan sdi nieu quan ngu'de ddng bang Holmium laser trong dieu tri sdi 1/3 du'di nieu quan thuan Idi hdn so vdi tan sdi bang cac ky thuat khac. Thu'dng cd hien tu'dng viem phii ne nieu quan d ndi cd sdi nam; soi nieu quan doan nieu quan thanh bang
quang gay viem phii ne d Id nieu quan ciia bang quang va thanh bang quang. Viee tim Id nieu quan va dat day d i n la kho khan vdi phlu thuat vien chu'a quen lam. Cd hai hinh thai viem phii ne trong long doan nieu quan ed sdi: cd cae polyp hinh cau, ddi khi cd nhuYig polyp rii xudng nhu' xuc tu che khuat mot phan sdi hoae toan bd sdi. Tru'dng hdp polyp dang xuc tu hinh cau la thuan Idi eho viec tan sdi bang laser do nang lu'dng laser ed kha nang cat mot each nhanh chdng eae polyp nay de hien rd vien sdi, giup viee tan sdi du'dc de dang.
Tan sdi trdn hoac n h i n la thach thirc vdi phau thuat vien vi sdi trdn nhIn de di ddng va lai cirng, nen neu tan sdi bang xung hdi se rat kho neu vien sdi khdng du'dc ghim lai trong thanh nieu quan hay trong ro Dormia. Ngu'de lai, khi tan bang laser, sir hap thu nang lu'dng eiia song laser lam sdi vd ra mot each nhanh chdng, sdi v3 vun nhd, it tao cac manh sdi Idn nhu' tan sdi bang xung hdi. Tan soi bang laser thi sdi nao cung vd do mire nang lu'dng Idn tao ra tren be mat vien sdi va kha nang dam xuyen eiia sdng laser. Ooi vdi sdi nhd la nhanh nhat cdn doi vdi sdi Idn hdn can ddi hdi sir than trong va kien tri.: tan tir be mat, tan thanh nhieu diem de lam vd vun sdi ket hdp vdi viec lay sdi, gap sdi xudng bang quang.
Ket qua tan sdi tot la 88.9%, trung binh la 8,3%, va 2.8 % xau.
1 BN b| thiing nieu quan do tan sdi da du'dc mo cam lai nieu quan vao bang quang, cd dat ong thdng JJ. Oat ong thdng nieu quan du'dc chi dinh cho tat ca cac BN sau tan, Cd 62 BN dat thdng JJ. Viec danh gia mire anh hu'dng ciia tan sdi lasez len niem mac nieu quan la can thiet vi sau tan sdi thu'dng thay BN cd nu'dc tieu do, chirng td tan sdi cd the lam ton thu'dng niem mac nieu quan. Do vay, de tranh phii ne va tao dieu kien cho nhu'ng manh sdi du'dc dao thai sau tan de dang, viec dat ong thdng JJ cd y nghla quan trong.
V. KET LUAN
Tan sdi ndi soi ngu'de ddng sdi nieu quan 1/3 du'di bang may tan sdi Holmium laser cua hang Karl Storz cho ket qua 88.9%. tot va 8.3% trung binh.
Thdi gian dieu tri ngan. Do da ton trong va tan dung du'dc cae du'dng tir nhien de giai quyet benh ly sdi nieu quan, nd la phu'dng phap du'dc luS chpn trong so nhieu phu'dng phap khac de dieu tri sdi nieu quan cho BN, dem lai ket qua dieu trj kha
Y HOC VIET NAM THANG 7 - SO 2/2012 quan cho eac BN bi sdi nieu quan 1/3 du'di va d l
dang ap dung d dia phu'dng.
TAI LIEU T H A M KHAO
1. A.Hofstetter (1992) "Laser lithotripsy in the treament of ureteral lithiasis" A. E. Euroi 45, 3 pp. 227-9
2. Biii Van Lenh (2004) "Sieu am chuan doan bo may tiet nieu" NXB Y hoc tr 225-237 J. Do Lech Hung va Nguygn Minh Quang
(2010) "Hieu qua ciia npi soi tan soi bang laser trong dieu tn soi nieu quan chau hong", V hoc
TPHCM, 4,1 tr 458-470
Nguyen Ky (1994) Tinh hinh dieu tri soi tiet nieu tai benh vien Viet DiTc trong 10 nam (1982- 1991)'_|_ Tap san ngoai khoa so 1, tr 10-13 N g u y i n Minh Quang (2003) 'Tan soi nieu quan qua npi soi bang laser va xung hdi" Luan van chuyen khoa I I trang 34,40,63 Tran Le Linh^Phu'dng (2008) "Oieu tri soi nieu quan bang phau thuat it xam lan" NXB Y hoc tr 5, 45, 57
Watson (1994)" Pnnciples of laser stone destruction. In: Laser in urologic Surgery" Mosby- Yearbook pp.183.9
SO SANH VIEC SITDUNG THUOC CHONG DONG ACENOCOUMAROl VA WARFARIN or GENH NHAN THAY VAN TIM N H A N TAO CO HOC
TOM TAT
Muc tieu nghien cu'u. l/Mo ta dac diem ciia b/n dang diing thudc chdng dong di/dng udng sau thay van tim nhan tao cd hoc. 2/So sanh sir dung acenocoumarol va warfarin trong dieu tri b/n thay van tim nhan tao cd hoc ve phUdng dien ehinh lieu thudc va hieu qua chdng dong.
Bdi tu'dng va phu'dng phap nghien cij'u: 60 b/n thay van tim nhan tao cP hoc du'dc chia 2 nhdm:
30 b/n nhom warfarin va 30 b/n nhdm chirng hch sir acenocoumarol dieu trj npi trii tai Vien Tim mach Benh vien Bach Mai trong tfidi gian tir thang 1 den thang 7 nam 2011. Thiet ke nghien eiTu: mo ta tien ciru, so sanh vdi nhom chirng hch sir.
Ket qua nghien cu'u. dac diem ciia b/n: Nhom warfarin co 56,7% b/n khi vao vien eo ket qua INR khdng dat muc tieu va d nhom acenocoumarol la 70,0%. Lieu acenocoumarol duy tri TB b/n diing tru'dc khi vao vien d nhom warfarin la 1,4 ± 0,53 (mg), d nhdm aceocoumarol la 1,6 ± 1,06 (mg). Khoang 50%
so b/n d 2 nhdm cd bien ehu'ng khi sir dung thudc chong dong: chay mau nhe 6,7%, chay mau nang 28,3%, huyet khoi tac mach 3,3%. Ve dieu chinh lieu va hieu qua chdng dong ciia hai thudc: sd lan do INR TB/bn khoang 4 lan. Thdi gian TB giO'a cac fan do lien tiep la khoang 3 ngay. So fan thay doi lieu TB /bn khoang 2 lan. Ty le % dieu ehinh lieu so vdi so lan do INR d nhom warfann (36,37%± 24,84) thap hdn nhdm acenocoumarol (47,03 %± 34,15) vdi p>0,05.
Moi tu'dng quan ve lieu duy tri TB: lieu warfarin bang
* Vien Tim mach - Benh vien Bach mai.
Phan bien khoa hoc: PGS.TS. Nguyin Thj Lan
D o Quoc H u n g * lieu acenocoumarol nhan 0,85 cong 1,75 vdi he so tu'dng quan r < 0,3. Sd ngay dieu tn TB hdn 10 ngay.
Khi ra vien cd 80,0% b/n nhom warfarin co ket qua INR dat muc tieu, nhom acenocoumarol chi co 33,3%
b/n. Ty le % so fan do INR trong khoang muc tieu so vdi so lan do INR cua nhom warfarin (50,83% ±28,24) cao hon nhom acenocoumarol (27,3%±25,S6) vdi p<0,05. Ty le % sd ngay cd INR trong khoang muc tieu so vdi tong sd ngay dieu tn cua nhom warfann (47,53%±30) cao hOn nhom acenocoumarol (19,9%
±24,12), (p<0,05).
Kei luan: sir dung wafai-in ty le INR dat muc tieu cao hdn so vdi dijng acenocoumarol. Wafarin it xay ra bien chimg chay mau hay tac mach do huyet khoi hdn so vdi dung acenocoumarol,
SUMMARY
Comparative study of the effect of Wafarin and Acenocoumaro) in patients w i t h mechanical
heart valves.
Obj'ective. description characters of patients with mechanical heart valves use oral anticoagulant after operation. Comparison on Wafarin and Acenocoumarol about correct dosage and efficacy.
Method. cross-sectional, observational retrospective comparative study.
Results', characteriztion of patients: 56,7% of wafarin group and 70% of acenocoumarol group had unoptimal theurapeutic range, averaged dose of warfann group 1,4 ± 0,53(mg) and of aceocoumarol
