Y HOC VIET NAM THANG 10 - SO DAC BIET/2011
NHAN 5 TRaONG HOP VO TA TRANG DO CHAN THl/ONG BUNG KIN
TAI BENH VIEN VIET TIEP HAI PHONG TRONG NAM 2010
• • • • •
Phan Thj Tuyet Lan, Nguyen Minh Tuan, Nguyen Thai Binh, Pham Van Thuong, Phan Huu Huynh (*)
TOM TAT
NSm 2010, tai benh vien Viet Tiep Hai Phong da CO 5 trUdng hdp v5 ta trang do chan thUOng bung kin du'dc phau thuat. Trong do 4/5 trUdng hdp la nam gidi, dp tuoi trung binh la 28.4 tuoi (tCr 17 den 42 tuoi). Co 1 trudng hdp dUdc chain doan trUdc mo la v3 ta trang. PhUdng phap phau thuat la noi ta hong trang theo phUdng phap Roux en Y mang lai key qua tot. 1 .tru'dng hdp co bien chirng ro ta trang.
SUMMARY
5 CASES OF DUODENAL INJURY I AT VIET TIEP HOSPITAL I N 2010
In 2010, 5 cases of duodenal injury have been operated on at Viet tiep hospital. Average age was 28.4 (range, 17 to 42), 4/5 patients were male.
• Preoperative diagnosis of duodenal ruptures was only one case ( 20% ). The operation method was Roux en Y to the duodenal lesions brings good results. One duodenal fistula was encountered.
I. OAT V X N OE
Vor ta trang la mot t6n thuomg hiem gap, chilm tir 0.5% dhn 15% trong chhn thuong va vet thuang bung [12] [13]. Nam 1896, Herczel bao cao vh ca phau thuat va ta trang ddu tien, tuy nhien benh nhan tu vong sau tn6, dhn nam 1905, benh nhan vor ta trang diu tien s6ng sot sau mo dugc bao cao [1()].
Tai Viet Nam, ty le va ta trang tu 2.6% dhn
5.6"o. CO ,\u huang tang trong thai gian gan day, nguyen nlian chinh la do tai nan giao th6ng [7] [8]. ly le bien chirng sau mo, phai phau thuat lai do bo sot ton thuang hay ro lieu hoa \ a IN lc tu vong con cao [9] [14].
Trong nam 2010, tai benh vien Viet Tiep Hai Phong, da co 5 truang hop dugc chan doan Nli ta trang va deu dugc dieu tn phau thuat thanh c6ng. Phuang phap phau thuat dugc ap dung cho ca 5 truong hop la noi ta hong trang theo phuang phap Roux en Y
Muc tieu: Nhan xet ve chdn dodn vd diiu tri cua 5 truang hgp va td trdng do chdn thuang bung kin tgi benh vien Viet Tiep.
II. D 6 I TUONG VA PHJONG PHAP NGHIEN COU
D6i tugng nghien cuu: 5 benh nhan dugc chdn doan sau mo va ta trang do chan thuang bung kin
Thai gian: Tu thang 01/2010- 12/2010 Dia dilm: Khoa Phau thuat tieu hoa Benh \ ien Viet Tiep - Hai Phong.
Phuang phap nghien curu: Hoi cuu m6 ta.
III. KET QUA VA BAN LUAN 3.1. Tu6i, gioi, nghe nghiep:
Do tu6i trung binh la 28.4 tu6i. Cao nhk la 42 tu6i, thdp nhat la 17 tu6i.
Gidi: Nam/Nu = 4/1
^*) Benh vien Hiru Nghi Viet Tiep Hdi Phdng
Cong nhan Nong dan Hoc sinh
Bang K Phan bo nghc nghiep
N 3 1 1
% 60 20 20
Chung loi ghi nhan lai c;i benh nhan dcu nam trong do luoi lao dong. nam gioi \ a cong nhan chicMii da so. Trong nghicMi cuu ciia 1)6 Trung Dong [2|, do lu6i Irung binh la 28.32 tu6i. nam gicri chicMn da so. Nhung dac dicni nay co lien quan den muc do \an dong ciia benh nhan co lien quan nhieu den C(T che chan thuang.
3.2. Nguyen nhiin chan thuong: Co hai loai nguNLMi nhiin dugc ghi nhiin la lai nan giao th6ng \ a lai nan sinh boat. Trong do lai nan giao th6ng chiem da s6 (4/1).
3.3. Thoi diem phau thuat:
Thai diem phau thual dugc tinh lir luc nhap \ien den khi co chi dinh m6. Truang hgp dugc m6 sam nhat la sau Ih nhap vien. 4
Inrang hgp con lai dirge dugc phau thuat sau 51i. Truang hgp phau ihuat som nhat la benh nhan viio vien vcVi chan doan da chan thuang, CO chan thirang bung do de cp lam va true trang, \d lach. va Dl la trang
Truang h(yp phau thuat muon nhal la hcnh nhan vao \ ien \ai chan doan chan lhu(Tng bung kin. \'ao \ iC-n sau tai nan giao lh6ng. bieu hien dau thugng vi va ha suon phai am i. lien tuc. Trong qua trinh theo doi, CO bieu hien dau lang. s6t. chi dinh mo dugc dua ra sau choc do 6 bung ra dich vang xanh.
Nhu \a>, ca 5 truong hgp trong nghien cuu nay dcu dugc m6 truac 24h. So sanh vdi m6t s6 cac tac uia khac :
Bang 2. T 6 n g ket \ e t h a i d i e m phau i h u a l qua m o t so bao cao [ 9 ] Tac gia
Ta Kim Sdn Van Ngoc Y Ngo Minh NhUt Nguyen Tan CUdng
SoBN 14 14 30 30
Mo trUdc 24h 10(71.4%) 13 (92.6 %) 26 (86.7 %) 23 (76.7 %)
Mo sau 24h 4 (29.6 %)
1 (7.4 %) 4 (13.3 %) 7 (23.3 %)
3.4. Ve chan doiin: 4/5 truang hgp kh6ng chan doan dugc truac m6 co t6n thuang ta trang. Tai ca cac Inrang hgp nay deu nghi nga co l6n thuang lang rung.
So vai mot so nghien ciru khac. ^) 10 truang hgp Irong nghiC'n ciru ciia Ngu}CM-i Xuan Tlung [1] kh6ng dugc chan doan chinh xac truac m6 co t6n thuang la trang. 1 \ lc nay la 83.8% trong nghiC'n cuu cua D6 1 rung D6ng [2].
Nhu \ a>. hau het cac truong hgp khong chan doan truac m6 co t6n thuong ta trang, chi dinh m6 dugc dua ra khi co nghi ngo ton thuang lang r6ng. hoac benh nhan trong tinh Irang da chan thuong. phat hien t6n thuang ta trang hau het la trong phau thuat.
3.5. Dau hieu tren chup CT scanner:
Theo Breen [11]. dhu hieu va ta trang Iren CCLVT g6m : mk lien tuc thanh ta trang, hai tu do sau phuc mac, thuoc can quang thoat ra khoi long ta trang; va nhiing
Y HOC VIET NAM THANG 10 - SO DAC BIET/2011
au hieu kh6ng dac hieu nhu hai tu do trong hue mac, dich tu do trong phuc mac, dich tu 0 sau phuc mac, hai trong thanh ta trang, ay thanh ta trang, thanh ta trang bat thuoc an quang hk thuong. Theo Nguyen Thn
;u6ng [5] tren CT scanner co 5 dhu hieu dh han doan chan thuong ta trang la : hai tu do au phuc mac, mk lien tuc thanh ta trang, hai X do trong phuc mac, dich tu do trong phiic lac, dich tu do sau phiic mac, day thanh ta rang tren 3 mm. hai trong thanli ta trang.
Tong do Dau hieu mat lien tuc thanh la trang a hai tu do sau phuc mac giup chan doan
xac djnh chan thuang va ta trang. Dau hieu hai tu do sau phuc mac la quan trong nhat de chan doan va ta trang tren CCLVT.
Theo Trinh Hong San, chi dinh chup CT Scanner 6 bung la can thiet vai dieu kien tinh trang benh nhan 6n dinh vi con co the phat hien them t6n thuang khac trong 6 bung [6].
Ghi nhan trong 5 truang hgp trong nghien cuu CO 3 truang hgp dugc chup CT scanner 6 bung, trong do co 2 truofng hgp co dau hieu t6n thuang ta trang. Hai truong hgp kh6ng dugc chup vi dugc chi dinh m6 ngay khi vao
\ien.
Bang 3. Ket qua CT scanner 6 bung va t6n thuang trong phau thuat
STT 1 2 3
Ket qua tren hinh anh CT Khf t u do 6 bung va sau phuc mac i t dich xen giij^ cac quai ruot
Khf t u do trong va sau phuc mac, djch trong va sau phuc mac
Ton thUdng thUc the khi phau thuat V9 DII - DIII do I I I
Vd DIII do I I V8 DII, DIII do I I I
3.6. T6n thu-ong ta trang dirffc ghi han :
'^ T6n thuang tai Dili gap nhieu nhat 10%). Trong 4 ca co t6n thuong Dili thi co
" truang hgp co t6n thuang DII kem theo.
"iiong CO truong hgp nao t6n thuang DII
"ctn thuan, co 1 truong hgp ton thuang DI.
"luc do t6n thuong nang nhit la do III va ing chilm da s6 (80%). Co 2 truang hgp li CO ton thuong ta trang don thuan, 3
='uang hgp con lai co ton thuang ph6i hgp
3m.
' Nh t6n thuang ph6i hgp kem theo: co '5 truang hgp t6n thuong cac tang khac.
rong do c6 1 truong hgp da chan thuong, va
^n trang, vo true trang, rach dai trang ngang,
^ch thanh co da day va 1 truong hgp co gay
xuong dui ben phai ph6i hgp. Nghien cuu cua Do Trung D6ng [2] tren 64 truong hgp vo ta trang co 39 ca co ton thuang ph6i hgp.
Ty le nay la 62.5 % trong nghien cuu cua Nguyen Tan Cuong, trong do ton thuang DII gap nhieu nhat chiem ty le 86.39 % [10].
3.7. Phuong phap phau thuat:
Lich su dieu tn va ta trang dugc ghi lai trong y van den nay dugc khoang hon 100 nam [10], nhieu phuang phap dieu tri da dugc dua ra. Quan diem chung ciia cac phuong phap la c6 gang bao toan tren dieu kien t6n thuang cho phep, cat loc va khau kin ta trang di kem voi giam ap toi da cho ta trang, cat khoi ta tuy chi thuc hien voi ton thuong ta trang nang ne kem t6n thuong tuy va duong mat [15]
STT
1
2
3 4
5
B a n ^ 4. T o m l a i chan doan va plurtriig phap phau thuat Chain do^n
V3 DII - D I I I , vd da day
Vd DIII ta trang dp II
Vd DII, DIII do III
V3 DII dp I I , vd hoi trang, v8 trUc trang, v3 lach, r^ch thanh mac dai trang ngang, rach thanh cd da day
V3 DIII dp I I , gay l<im 1/3 giiJa xUdng dui P
PhUdng phap PT
C3t doan ta trang ton thUOng, dong dau dudi, ndi ta hong trang theo PP Roux en Y, dan lUu OMC, md thong hong trang Noi t.i hong trang theo PP Roux en Y, md thong hong trang
Noi ta hong tr^ng theo PP Roux en Y.
CSt lach, c3t 60 cm hoi trang noi hoi - dai trang len, ndi t^ hong trang theo PP Roux en Y, khau thanh cd da day, khau trUc trang, lam HMNT dai trang ngang, md thong hong trang.
Ndi ta - hong trang theo PP Roux en Y, md thong hong trang. Ket hdp xUdng diii phai sau 10 ngay
Thdi gian PT ( g i d )
6 gid
4 gid
4 gid 6.5 gid
3.5 gid
Chiing t6i ap dung phuong phap n6i ta hong trang theo phuang phap Roux en Y va mo thong hong trang trong 4/5 truang hgp. Trong do ,tru6ng hgp thu 3. khi tien hanh phau thuat thay duong \ a keo dai ca a Dll va Dill dut gan roi. Tien hanh mor OMC. luon dan luu so 8 vao qua nhii vater, danh gia thay bong vater kh6ng t6n thuang. Doan ta trang t6n thuong dugfC cat roi. dong kin dau duai. n6i ta h6ng trang tan ben theo PP Roux en.
3.8. Ket qua dieu trj phau thuat:
B a n g 5. T h a i gian nam v i e n Thdi gian
NgSn nhat Trung binh Dai nhat
Ngay 17 23.4
33
Ro tieu hoa xay ra tren 1 benh nhan nam 26 tuoi, vo Dll - Dill ta trang do 111 a ngay thu 15 sau m6. Bieu hien: dich qua dan luu tai mieng n6i tang dan, thay d6i mau .sac khi an qua duong mieng. Co 2 nguyen nhan dugc ghi nhan la: tuot dan luu tai cho o ngay thu 13 va trong lan m6 dau khong dugc mo thong hong trang. Chiing toi da tien hanh phau thuat lan 2, ma th6ng hong trang ket hgp hiit lien tuc, nuoi duong tich cue qua mo
th6ng hong trang. Sau lan m6 thu 2, benh nhan on dinh, ra \ ien sau 36 ngay dieu tri.
Theo Nguyen Minh Hai [3] co nhieu nguN en nhan dan toi buc cho khau ta trang nhu: tinh trang tai cho va ta trang, miic dg viem phiic mac, phuong phap va ky thuat xu tri. Trong do, viec giai quyet tot tinh trang luu thong djch tieu hoa d6ng vai tro quan trong. Tai benh vien Chg Ray (1998 - 2004), CO 9/50 truong hgp vo ta trang dugc phau thuat noi ta - hong trang theo phuong
Y HOC VIET NAM THANG 10 - SO DAC BIET/2011
Roux en Y, kh6ng co benh nhan nao bi ro ta trang [3]. 5/5 truong hgp trong nghien cuu nay deu dugc phat hien t6n thuang ta trang a lan mo dhu, khong bo sot t6n thuang phoi hgp, kh6ng c6 truong hgp nao tu vong, kh6ng CO bien chiing nang sau mo,
T6ng ket 169 ca chdn thuong ta trang tai benh vien Chg Ray cua Nguyin Thn Cuong, 41.42% CO bien chiing sau m6, 16% co ro ta trang [9].
IV. KET LUAN
Trong nam 2010, Khoa phau thuat Tieu hoa Benh vien Viet Tiep Hai Phong da dilu tri phau thuat 5 truong hgp \ a ta trang do chan thuang bung kin. Trong do co 1 truong hgp dut gan het chu vi DIII va 1 truong hgp da ton thuang trong 6 bung. 4/5 truong hgp c6 chi dinh mo kh6ng co chan doan chinh xac CO ton thuong ta trang. Chup CT scanner 6 bung dong vai tro quan trong de chan doan xac dinh, loai trijr va danh gia ton thuang phoi hgp.
Phuong phap phau thuat ap dung cho ca 5 truong hgp nay la noi ta trang hong trang theo phuang phap Roux en Y, giam ap bang ma th6ng hong trang ket hgp nu6i duong tich cue. Kit qua dilu tri : ro tieu hoa 1/5 truang hgp, khong c6 truong hgp nao'm6 lai do bo sot ton thuong.
TAI LIEU THAM K H A O :
T. Nguyen Xuan Hung (2004), "Dilu trj thuong tin ta trang do chan thuang - kinh ' nghiem rieng dilu frj qua 10 truong hgp tai
Benh vien Viet Due ", Hoi nghj Ngoai khoa
; toan qu6c lan thur XI , Tap chi Y hoc thirc ( hanh so 491, t r i 1 7 - 1 2 4 .
;2. D6 Trung Dong, Ha Van Quyet (2004),
"Nhan xet ve chan doan va dieu tri ton J thuang ta trang trong chan thuong bung",
Hpi nghj ngoai khoa loan quoc lan thu XI, Tap chi Y hoc thuc hanh so 491, tr 189 - 194 3. Nguyen Minh Fltii (2007), "Nhung sai lam trong chan doan va dieu trj vo ta trang nhan 50 trudng hgp " , Hoi nghi ngoai khoa toan quoc lan thi'r Xii, lap chi Ngoai khoa so 4/2006. tr 90 - 96.
4. Nguyen Minh Hai (2008), "Mpt so kinh nghiem dieu trj ro ta trang sau mo chan thuong \a vet thiio'iig ta trang". Tap chi Y hoc TP Ho Chi Minh so 12,phu ban 3,nam 2008, tr 5 5 - 6 1
5. Nguyen Tan Cuo'ng (2010), "Gia trj cua chup cat lop vi tinh trong chan doan chan thuong vo ta trang ", Tap chi Y hoc TP Ho Chi Minh so 14, tr 9 2 - 9 7 .
6. Trjnh Hong So'n, Nguyen Thanh Long, Do Tuan Anh, "Chin truong hgp cat khoi ta tuy cap cuu tai benh vien Viet Due", Chuyen de Benh ly & Chan thuong Ta - Tuy,Tap 8 - Phu ban cua So 3 -2004, tr 104 - 112
7. Ngo Minh Nhat (2001), "Nhan xet vl chin doan va dieu trj vo ta trang ", Luan van Thac sy y hoc, Truong Dai hoc Y Dugc Tp. Ho Chi Minh, tr 40 - 84
8. Nguyen Ba Son va cong su- (2000), "Mot so nhan xet ve chan doan, ton thuong va xii tri chan thuong bung kin thai binh". Tap chi y hoc quan sir. Cue quan Y, So chuyen de ky niem 25 nam ngay truyen thong Benh vien
175 (26/05/2000), tr 7 5 - 7 9
9. Nguyen Tan Cu-ffng va cong sy, "Tong ket kinh nghiem xu tri 169 chan thuong va vet thuong ta trang trang 25 nam tai b?nh vi|n Chg Ray", Tap chi Y hoc Tp. Ho Chi Minh, tap 8 nam 2004, U 15-32
10. Michael R Gelding, M.D., Pieter de Jong, M.D., John W Parker,. M.D (1963)
"Intramural Hematoma of the Duodenum", Annals of Surgery
11. Breen DJ., Janzen D L . , Zwirewich CV., et al (1997). "Blunt bowel , mesenteric injury:
diagnostic performance of CT signs" J Comput Assist Tomogr, 21, pp. 706-712.
12. E r r o u g a n i A., A m c u r A . , C h k o f f R. ct all (1997), "l.cs Irauniatisines cluodDno- pancrDatiques: A pmpds dc 30 observations",./. Cliir. 1 Vl( j ) , 9 ! ^.
13. PiVi.s.sat J . , Collet 0 . , A r n o i i v R. et :ill (1991), "IraiinialisMics dn (liiodiniv pniicrhis:
principcs dc Icchniquc ct cic tactiquc chirurgicales" I'dition.s Technicpie.s- Tin vcl.
Mcil Chir, Tec/iiiique.s chirurgicales, .ippureil digestif A0^9i^. 15 p.
14. Synder W , W c i g e l t J , W a t k i n s W , et al, "
The surgical management o f duodenal Irauma " , A r c h Surg 115: 422, 1980.
15. K h o a Ngoai T i c u hoa & K h o a Ngoai Gan- M a t - T u y - B V C h g R a y , "ThiJr dua ra mpt phac (in liii(Viig dan chan doan va dieu trj thuong Ion t.i t^iy", Chuyen d l Benh ly &
Chan thuang l a Tuy,Tap 8 Phu ban ciia So 3 -2004.
OIEU TR! HEP NIEU DAO SAU DO VO Xl/ONG CHAU
B A N G P H A U T H U A T
NO! TAN TAN QUA Dl/ONG TANG SINH MON QUA 18 TRl/ONG HOP TAI BENH VIEN VIET TIEP HAI PHONG
TOM TAT
TCr 1/2008 - 12/2010 tai benh vien Viet Tiep Hai Phong CO 18 trUdng hdp dUdc phau thuat dieu tri hep nieu dao sau do v9 xUdng chau bang phUdng phap noi tan tan qua dUdng tang sinh mon, khong co trUdng hdp nao chay mau sau mo, co 2 trudng hdp nhiem triing vet mo, dieu tri bSng thay b3ng, diing khang sinh theo khang sinh do, co 1 trUdng hdp nieu dao bi hep gay dai kho xu' trf bSng nong nieu dao.
SUMMARY
From 1 / 2008 to 12/2010, in Viet Tiep Hospital in Hai Phong has treated 18 cases of urethral stenosis after due to broken pelvis by connecting the urethra surgery take take students through the floor subjects;
no cases of bleeding after surgery; two cases of wound infection, treatment with dressing changes, antibiotics as Susceptibility Tests; there is a case of urethral narrowing that causes difficult for urination, treatment by urethral dilatation.
* B?nh vi^n Hiru Nghj Viet Tiep Hdi Phong
Pham Van Yen*, Nguyen Cong Binh*
I. OAT VAN o f
Phau thuat noi nieu dao tan tan qua dirang tang sinh mon. 0 nuac ta hoi nghj chu>en de ve chan thirong \ a \ct thucmg nieu dao nam 1988, nhieu bao cao ket qua dieu trj
\ a xiroTig chau dirt nieu dao sau. trong do cac tac gia ap dyng nhieu phuong phap dieu trj khac nhau.
Hi?n na> Yihieu tac gia coi phau thuat noi ni^u dao tan tan la phucmg phap thich hgp nhat de dieu trj hep nieu dao sau do v6 .xuang chau. Tu> nhien da\' van la 1 van de phuc tap, dang dugc cac tac gia nghien cuu
\ ai mong muon dem den cho benh nhan hep nieu dao sau ket qua tot ve ca chuc nang sinh due \ a ticl nieu.
II. S6 LIEU VA PHUONG PHAP
2.1. So U$u: Tu thang 1/2008 - 12/2010;
18 benh nhan hep nieu dao sau do va xuong
