BUOC DAU KHAO S.\T NGUYEN NHAN \.K VI TRI CUA T.A.C >LA.T NGOAI GAN QUA SIEU AM, CT, E R C P
Tran Diic Quang*, Ngd Quang Hung*, Biii Phuang Anh', Vd Thi Minh Trung . E*?n|
Dinh Hoan*, Nguyen Ngpc Tuin TOM TAT
Muc tieu: Tic mat ngoai gan II hdi chiing thudng gap do nhieu nguyen nhan khac nhau. Su tic nghen nay cd thi xay ra bat ky trong 3 mirc; Ong mat chu doan trong tuv. tren tuy, cua gan. Muc dfch nghien cuu nhim khao sit nguyen nhan v l vi tn tic mat ngoli gan qua hinh anh Sieu lm, CT, ERCP.
Doi tupng va phirmig phap nghien cuu: Nghien ciiu tien ciioi cit ngang, tir 01/06/2009 den 09/10/2009 vdi nhimg benh nhan din khim tai khoa CDHA BV Binh Dan thoa man cic dilu kien sau: Hole cd dudng kfnh ong gan cbung >7mm (60 tudi), >10mm (Benh nhan >60 tudi hole sau cit tui mat hoac phlu thuat dng mat trudc do) hole cd nguyen nhan tim thiy 6 cira gan tren kiem tra sieu Sm. Sau dd, ho dugc kiem tra tim kiem nguyen nhSn va vi trf tac mat ngoai gan bing SA hole CT hole ERCP hole phdi hgp.
Ket qua: Trong sd 135 trudng hgp, 98 (72,8%) 11 sdi dng mat chii (trong dd 65 (48%) tai doan trong tuy, 28 (20,7%) tai doan ciia gan, 11 (8,1%) 11 u diu tuy, 3 (2,2%) viem tuy man, 4 (3%) u vung cira gan (U Klatskin hole u gan), 19 cd ngudn gdc tir co vdng Oddi hoac bdng Vater v l nhirng nguyen nhSn khac (5 giun chui dng mat, 2 hpi chirng Mirizzi, 1 hach di can, 9 chft hep dng mat chu v l hep Oddi, 1 nang ldn vung dau tuy)
Ket luan: Chiing tdi chi dua ra vai nhan xet ban diu: Sdi dng mat chii 11 nguyen nhan thudng gap nhat gay tic mat ngoli gan phu hgp vdi y van. Sieu am, CT, ERCP 11 nhung ky thuat hinh anh huu dung trong viec phit hien nguyen nhin va vi trf tic mat ngoai gan, giiip nha ngoai khoa trong viec ehi dinh them phuang thitc hinh anh cGng nhu hoach dinh phau thuat tdi uu.
Can nghien ciiu vdi sd lugng benh nhSn ldn ban de cd danh gia tdt hon Tir khod: Hinh dnh tdc mat ngodi gan.
ABSTRACT
INITIAL STUDY OF THE CAUSES AND LOCATIONS O F EXTRAHEPATIC BILIARY OBSTRUCTION BY US, CT
Purposes: extrahepatic biliary obstruction is a common syndrome resulting firom many various causes. The obstruction may occur at any of three levels: intrapancreatic, suprapancreatic, portal CBD. The aim of the study was to survey of the causes and locations of extirahepatic biliary obstruction by US, CT scanner.
Subjects and methods: Prospective cross section study, from June 01, 2009 to Oct 09, 2009, with the patients who examined at imaging diagnostic department of Binh Dan Hospitai had CHD diameter > 7mm (<60years), > 10mm (>60 years or after previous cholecystectomy or biliary ductal surgery) or had portal obstmctive causes presented on US. After that, they were examined to search the causes and locations of extrahepatic cholestasis by US or CT or both Results: Among 135 cases, 98 accounting for 72.8% were choledocholithiasis (in which 65 (48%) at intrapancreatic CBD, 28 (20.7%) at portal CBD), 11 (8.1%) were pancreatic head tumours, 3 (2.2%) were chronic pancreatitis, 4 (3%) were portal tumours (Klatskin tumours or hepatomas), 19 were Oddi sphincter or ampulla of Vater in origin and others causes (ascarides in CBD (5), Mirizzi syndrome (5), metastatic lymph nodes (1), CBD stricture (1), large cyst of pancreatic head zone (1), stenosis of Oddi's sphincter.
Conclusion: We have only proposed some remarks that choledocholithiasis is the most
Khoa Chan Do5n Hinh Anh, BVBD
"Khoa Xoi soi Tieu h6a. BVBD
Dja chl Hen iac. BS.CKI. Tr4n Due Quang DT: 0937659272
common cause of exuahepatic biliary obstruction as noted in literature. US, CT scanner and ERCP are the useful imaging techniques in detecting the causes and locations of extrahepatic clolestasis to help the surgeon in the further imaging modality indication as well as the optimal surgical planning. It is necessary to study with the sample having the larger number of patients and long time for better evaluation.
Key words: Imaging extrahepatic biliary obstruction D;^T VAN DE
Dan dudng mat ngoli gan do tic mat 11 mpt hdi chiing benh ly thudng gap do nhieu nguyen nhan khac nhau. Su tie nghen cd the xly ra lai bat ky noi nao trong 3 muc: Ong mat chii doan trong tuy, dng mat chii doan tren tuy va cira gan*''^''''''^\ Cac phuong tien ghi hinh hudng den muc dfch phan dinh cic nguyen nhan va vi tri vlng da ma die bi6t II ddi vdi nguyen nhSn tie nghgn ngoai gan bdi le vdi nguySn nhan tic nghen ngoai gan thi viec tai lap luu thdng mat 11 cd the dugc bang cac phuong phip can thiep ngoai khoa . Trong sd nay cd the ke den sieu am nhu 11 phuang phap chpn lua ban dau trong viec nghien ciiu tic nghen dudn^ mat cd the
^^^(6.7,9,12,13.4) ^~,y ^ ^ j ^ phuang tien hinh anh rit tdt vdi dp phan giai cao de kiem chtmg va khac phuc cac gidi ban ciia Sieu Im'^'^'^'"'*. ERCP vdi nhieu thuan lgi trong chSn doin nhu chup tuy ddng thdi, su hinh dung tdt nhll dudng mat doan xa, te bio hpc mit v l tuy, md ca vdng liy sdi, do lp luc mat'^'^'.... Ngoli ra con nhieu phuang phip khic nhu MRCP, chup dudng mat xuyen gan qua da, X quang da day ta trang can quang hole sieu am ndi soi... Ci nude ta chan doin tie mat ngdai gan chu yeu dua vao sieu am, CT v l sd lieu ve nguyen nhan, vi tri chua dugc nhieu. Trong dieu kien phuang tien hinh anh san cd ciia benh vien Binh Dan, chiing tdi chi thu thap so lieu dua chii yeu vao Sieu am, CT va ERCP.
Muc tieu nghien ciru
Diing phuong tien hinh anh Sieu am, CT scanner, ERCP de khao sat tin suat nguyen nhan va vi trf ciia dan dudng mat ngoai gan.
Tdng quan tai li|u 1. Cff sd ly thuylt
-Vi dudng mat dan ly tarn tir cho tic nen dan dudng mat ngoai gan xay ra trudc dan dudng mSt trong gan. Hon nCra, dan dudng mat trong gan khdng the xay ra dl dang d benh nhan xo gan hole gan bi tham nhiem vi nhu md gan mat tfnh dan hdi.*''''*'.
-Hau het cac tac gia xem dudng kfnh dng gan ehung (CHD) 11 diu chi diem nhay cam nhit d l chin doan tic mat'''^-^"'^^'.
- 6 nhieu thuc nghiem sieu am, tic mat dugc ggi y khi ong gan cbung cd dudng kfnh Idn ban 7mm. Mac dii cdn dang nhieu bin cai, nhieu tie gia sieu am cd khuynh hudng ting hg quan diem dng gan cbung, dng mat chu din sau cat tui mat hole phau thuat dudng mat trudc dd hole tang theo tudi, nhung ndi ehung nhieu khao sat ggi y rang sd do 10mm la gidi ban trSn cua cua gii tri binh thudng d nhCmg trudng hgp n^yl^'^'i^i'*-!^)
-Vdi cic ky thuat quet hinh dugc cii tien va thiet bi thdi gian thuc tinh xao, sieu Sm da xlc djnh dugc vi tri dan tren 92% cac trudng hgp va ggi y nguyen nhin chfnh xlc tren 7 1 % cic trudng hop*''''*. Trong chan doan sdi dudng mat ndi ehung dd nhay thay ddi tir 95,7 den 97,3% va do dac hieu thay ddi tir 97 den 98%. Vdi ky thuat quet hinh tdi uu, sdi dng mat chu doan xa cd thi thiy dugc tren 70% benh nhan; 86,6-54,7%*'^*
-Dp chfnh xlc cao tren 90% ciia CT scanner trong phit hien nguyen nhan va vj tri ciia din dudng mat ngoli gan, nhat la sdi dng mat chii doan xa va chan doan phin biet vdi cac nguySn nhan gly tic mat khlc'^"''^"^^*
-ERCP vin dugc xem la tieu chuan vang trong viec danh gii benh ly mat -tuy, dac biet 11 d viing bdng Vater va doan xa dng mat chu'*"'^^'
2. Ky thuat quet hinh
a/6ng gan cbung (CHD) va doan gin dng mat chii (CBD): Khao sat bing cac mat cit 67
hudng theo rdn-vai (P), vi tri diu dd d dudi bd sudn va su phoi hgp hit vio sau kem thay ddi sang tu till chich (P) trudc. Hole thuc hien quet doc ben sau khi nim lai tu thi chich sau fj-. (7,14)
b/Boan xa ciia dng mat chu (CBD): Cd thi sii dung m^t cit ngang qua vung diu tuy, ddi khi can phdi hgp cho benh nhan uong nude va khim tu thi ngdi chech sau (P) hole nim nghieng (P) v l dua v i o cic mat phing quet ngang (T) va cich tiep can dgc bgn.'''^'^'
3. Ky thuat ERCP: Ky tiiuat ndi soi nay lien he din viec dat dung cu quan sat phfa ben, trong ta tring doan xudng; dl quan sat bdng Vater, hudng dan viec dat catheter qua bdng cho viec tiem chpn Igc chat cin quang va dudng mat va dng tuy, rdi tao hinh Inh tren X quang. Ty le thinh cdng cho viec dat canul phu thugc vao kinh nghiem ciia nha ndi soi vl cd the dat din 95% hay hon.*^'^*
DOI TUgfNG VA PHUONG PHAP NGHIEN CUtJ 1. Doi tirgmg
Mlu nghien ciiu la nhung benh nhan den kham tai cac phdng sieu am ciia Benh vien Binh Din, TPHCM tir 01/06/2009 den 09/10/2009 m l lam sang cd trieu ehung vang da hole dau V4 bung tren (P) ho^c qua kiem tra siic khde tinh cd tiida min dieu kien sau:
Hoac dudng kfnh dng gan ehung (thinh ti-ong -trong) dugc thuc hien tai muc ddng mach gan vdi chi sd sau:
•I- > 7mra (benh nhan nhin ddi < 60 tudi).
•I- > 10mm (benh nhan nhjn ddi 60-lOOtudi hole benh nhSn sau cat tiii mat hoac phSu thuat dudng mat tnrdc dd)
• Hoac sieu am fim thay nguyen nhan d ciia gan.
2. Phmmg phap nghien cihi
Phuang phip nghien ciiu la tien ciin, cat ngang, nghien cuu tir 1/06/2009 den 09/10/2009.
Cic benh nhin deu dugc lam sieu am thang xlm, hole cd nhung trudng hgp khd nhan dien can them ky thuat Doppler mau de truy fim nguyen nhin v l vj tri cua dan dudng mat ngoli gan.
Trong nhirng trudng hgp xac dinh chan ddan bing si6u am cd gidi ban hoac theo yeu ciu cua Lam sing, benh nhan dugc chup cat idp vi tinh khdng va cd tiem can quang Xenetic vdi may MSCT Toshiba Quinalion, 4 lit cit de kiem chiing chan doan.
Ky thuat ERCP ed trong mdt sd trudng hgp.
KET QUA VA BAN LUAN Vitn
Nguyen nhan Soi ong mat chu I] dau tuy Viem tuy man Giun chui Dng mat HC Mirizzi Lf vung zita gan Di can duang
Doan trong tuy 65 (48%) 11 (8.1%) 3 (2,2%)
Doan tren tuy 5 (3,7%)
1 (0,8%) Doan cijra gan 28 (20,7%)
5 (3,7%) 2(1,5%) 4 (3%)
Fong so
98 (72,6%) 11 (8,1%) 3 (2,2%) 5 (3,7%) 2 (1,5%) 4 (3,0%) 1 (0,8%)
68
mat Hep duong mat Hep oddi Nang ldn vung dat tuy Tong s6
2(1,5%)
8 (6,0%) 1 (0,8%)
90 (66,7%)
5 (4,4%) 39 (28,9%)
2(1,5%)
8 (6,0%) 1 (0,8%)
135
Ve nguy6n nhan: Trong nghien ciru ciia chiing tdi, sdi dng mat chii diing hang dau vdi 98 benh nhan chiem 72,6%, trong dd sdi doan trong toy cao nhat cd 65 benh nhan chiem 48% va sdi d doan cua gan cd 28 benh nhSn chilm 20,7%. Di8u niy cGng phii hgp vdi y vin. Theo Rumack Carol M. (2002) (14), sdi dng mat chu 11 nguydn nhin don Ie thudng gap nhit d My gay tic mat. Cung cd cung nhan djnh ddi vdi tdng ket ciia cic tic gia khic trong'^' •^•^'^•^^\ Diu ring thinh phin hoi hpc cung nhu ngudn gdc xuat xii tien phat hole thii phat d Viet nam khic vdi vdi cac nude Au- My. Trong nghien ciiu nay cd ba nguyen nhan d doan trong tuy 11 sdi dng mSt chu, u dau tuy va viem tuy man tinh cd 112 benh nhan chiem 84%. Theo Rumac (2002, 2005) va Weissleder R. (1997) chilm khoang 90% tic mat doan xa va theo diing thu tu liet ki trong danh slch nguyen nhan cua doan nay*''*''^'. Ke den nguyen nhan chft hep dugc de cap den nhu la mdt nguyen nhan phd bien dcm le hole kit hgp*^'^'^'*'. Trong nghien cim, nguySn nhan d viing ciia gan ngoai nguyen nhan sdi dng mat chii chiem da sd, cac nguyen nhan khac nhu u viing cira gan vdi 4 (3%) va hdi chiing Mirizzi vdi 2 (1,5%). Nguyen nhan sdi dng mgt chu d doan nay khdng dugc y van de cap den nhieu. Cdn cac nguyen nhan edn lai tuy sd lugng cdn ft nhung cung phan nao phii hgp vdi y van khi cho ring nguyen nhan d doan nay chii yeu la u tan sinh nguyen phat (hepatoma, u tiii mat, cholangiocarcinoma ma ehu yeu la u Klatskin) hoac thii phat*''^*' . 0 day phai ke den nguyen nhan do ky sinh triing la giun chui ong mat vdi giun cdn sdng hay xac giun, vdi benh nhan (3,7%), ndi len nhu la 1 nguyen nhan kha phd bien so vdi cac nguyen nhan cdn lai d dogn nay. Cd the ly giai dugc dieu nay khi hieu ky sinh trung Ascarid lumbricoides 11 benh cdn dugc d^ cap den d Viet Nam ndi neng va cac nude Ddng Nam A ndi ehung. Va dieu nay cung giai thfch phSn nio gia thuyet ciia benh viem dudng mat Phuang Ddng tai phit ma cic tac gii Au My da md tl*^'''^'^'^*.
Nghien ciiu cho thay nguyen nhan d doan tren tuy vdi sdi dng mat chu 4 (3%) va di can dudng mat 1 (0,8%). CJ day ft phii hgp vdi y van nhu cho rang nguySn nhin d dSy 11 u nguySn phat hole thii phat, trong khi sdi la nguyen nhan rat hiem. Cd the do mlu nghiSn ciiu cdn it.
Ve vi tri: Trong ket qua nghien ciiu, vj tn dng mat cbii doan trong tuy chiem uu the vdi 66,7%
va thii den 11 cua gan vdi 28,9%. Giai thfch dugc do nguyen nhSn sdi dng mat chii chiem da KETLUAN
Chiing tdi chi dua ra vai nhan xet ban dau: Sdi dng mat chii la nguyen nhan thudng gap nhat gSy tic mat ngoai gan phii hgp vdi y vin. Vj tri tic mat doan xa dng mat chii chiem uu the.
Sieu am, CT va ERCP la nhOng ky thuat hinh anh biha dung trong viec phat hien nguyen nhSn va vi tri tic mat ngoli gan, deu cd vai trd quan trpng trong viec danh gia bing da phuong thiic hinh anh (Imaging multimodality evaluation); giiip nha ngoai khoa trong viec chi djnh them phuang thiic hinh Inh ciing nhu hoach dinh phau thuat tdi uu. Can nghien ciiu vdi sd lugng benh nhan ldn hem vdi thdi gian dai hon de cd danh gia tdt hon.
*vAi HtNH A N H M I N H H O A :
Thii Thi Anh Tuyet. sdi dng mat chu doan cuoi. sdi tui mat.
Ngu\eii ih] San. soi ong mai chu Doan giiia
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