KET QUA DIEU TRI U C0TR0N TlT CUNG BANG KY THUAT NUT DONG MACH TUT CUNG TREN 80 BENH NHAN TAI BENH VIEN BACH MAI
Nguyin Xuan Hien*, Pham IViinh Thdng*
T O M T A T • y-L Ket qua dieu trj u cd trdn tif cung bang phUdng phap nut dong mach tU cung. PhUdng phap: TU thang 1/2004 den thang 12/2007 chung toi da nut mach cho 80 benh nhan bi u cd trdn tir cung tai Khoa Chan doan hinh anh benh vien Bach Mai bang hat nhUa, vdi tudi taing binh la 39,2. Sau khi nut chiing toi theo doi benh nhan bang cac dau hieu lam sang, sieu am tU cung phan phu... va cac thdi diem 1,3,6,12 thang.
Ket qua: Tat ca cac ky thuat deu thanh cong, khong c6 tai biet. Hat nhUa dupc diing de niit mach c6 kich thu6c tU 250 den 700 micromet. Sau 1 thang niit mach CO 92,5% sd benh nhan c6 cai thien rong kinh va 86,7% sd benh nhan co giam dau khi co kinh. Sau 6 thang c6 den 93,3% benh nhan khong con dau bung khi CO kinh va 96,8% benh nhan khong con dau hieu rong kinh. Giam dUdc 77,9% the tich khdi u sau 6 thang (P<0,001). Trong nhon nghien cifu c6 5 benh nhan sinh con sau nut vdi cac con khoe manh va phat trien binh thudng.
Ket luan: Nut dpng mach tif cung la phUdng phap dieu an toan va kiem soat dUdc cac trieu chdng do khdi u gay ra, mang lai nhleu kha nSng c6 thai cho benh nhan sau niit mach.
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ABSTRACT ^ - .
The result of uterine artery embolization for treatment 80 patients with uterine fibroids in Bach
Mai hospital.
Metheod: We analyzed 80 patients(mean ages 39,2 years) with symptomatic uterine fibroids undergoing uterine artery embolization by PVA at the Radiology Department in Bach mai hospital from 1/2004 to 12/2007. After treatment, follow up the symptoms by questionaire, the size and weight of fibroids by ultrasound at 1, 3, 6, 12 monhts.
Results: All procedures were technically successful, no side-effect. PVA size is from 250 to 700micromet. After 1 monhts of procedure, all women reported Improvemnent in their symptoms, with 92,5%
improvement of menorrhgia and 86,7% improvemnent of pain. After 6 months of procedure, 93,3% no pain anf 96,8% no menorrhagia. Bulk symptoms improved 77,9% at 6 months(P<0,001). 5 patients are
prenancies in 5 patients want to have baby and these children are going up normal.
Conclusion: Uterin artery embolization is safe and controls the symptoms caused by leiomyoma in most patients and may be pregnancy after procedure.
I. OAT V A N o l
U CO tron tir cung (UCTTC) la loai khdi u lanh tfnh, phat trien tU cd tu" cung. Day la loai khdi u rat hay gap d dudng sinh due, d nhdm phu nu" tren 35 tudi cd de'n 30% bj benh nay, khoang 50%
phu nu' da den tren 30 tudi bj u co tron tur cung [3]. Cd nhieu phuong phap dieu trj UCTTC trong dd phuang phap nut ddng mach tif cung cd nhieu uu diem, de nghien cifu ky ve van de nay, chiing tdi tien hanh nghien ciru de tai " Ket qua dieu trj u cd trdn td cung bang phUdng phap nut ddng mach tdcung tren 80 benh nhan" dupc tien hanh vdi cac muc tieu sau:
1. Nghien ciiu kei qua dieu trj u cd tron td cung bang phuong phap can thiep ndi mach.
2. Dda ra mdt so chi djnh nut ddng mach tdcung trong dieu trj u cdtrdn tdcung.
II. OOI TUONG VA PHUONG PHAP NGHIEN CQU 2.1. Do'i tuong nghien curu: Bao gdm cac benh nhan dupe dieu trj u co tron tir cung bang nut mach ddng mach tu" cung tai khoa Chan doan hinh anh benh vien Bach Mai trong thdi gian tif thang 01/2004 de'n 12/2007.
2.2. Tieu chuan chon benh nhan
- Benh nhan bj u co tron tuf cung cd trieu chimg lam sang, dUdc kham lam sang, lam sieu am 2D va Doppler trUdc va sau khi nut mach.
- Khdi u cd dudng kfnh dudi 10cm, ne'u nam dudi thanh mac thi khdng cd cudng.
2.3. PhUOng phap nghien culj :
• Chpn phuong phap nghien cifu md ta tien cifu cd dd'i chieu vdi lam sang.
• Cd mau: 80 benh nhan.
Y HOC VIET NAM THANG 12 - SO 1/2010
III. KET QUA NGHIEN COU
3.1. Ly do vao vien
Ty le cae ly do vao vien thudng gSp the hien trong bang 3.1:
Bang 3.1: Ty le ly do vao vien
Ly do vao vien Sdbenh nhan
Ty le%
Rong kinh
44 55
Dau bung
4 5
Dau bung+
rong kinh 29 36,3
Tu so thay u
3 3,7
Tong so
80 100%
Nhan xet:
- Trong nhdm nghien ciru eiia chiing tdi cd 34 benh nhan, ty le vao vien do rong kinh la cao nha't (55%), sau dd de'n dau bung va rong kinh la 36,3%.
- Qua bang 3.1 chung tdi thay trieu chifng chinh de benh nhan bj u co trdn tif eung tdi nut ddng mach tir cung la dau bung, rong kinh. , v, , ;
3.2. Sd ngay nam vien sau nut mach _ .
Bang 3.2: Sd ngay nam vienSo ngay 1-3 4-7 Tren 7 Tong so
So benh nhan 68
8 4 80
Ty le % 85 10 5 100
Nhan xet: Trong nghien cifu, ty le benh nhan phai nam vien sau thCi thuat dudi 3 ngay chiem ty le kha cao (85%). Sd ngay nam vien trung binh la 2,3 ngay.
3.3. Dac diem dau bung sau nut mach 1,3, 6 thang
De nghien ciru trieu chirng dau bung sau niit mach chiing tdi chia lam cac nhdm sau
Bang 3.3: Dac diem dau bung sau niit machDau bung
Khong Giam
Con Tong so
Sau 1 thang 86 BN
9 20
4 33
T^ le%
27 61 12 100
Sau 3thang S6BN
25 5 3 33
Ty le%
76 15 9 100
Sau 6 thang SdBN
30 2 1 33
T'^ 16%
91 6 3 100
Nhan xet: Ty le benh nhan cd cai thien ve trieu chumg dau bung sau 1, 3 thang nut mach la 76%
(25/33BN), sau 6 thang ty le khdng dau bung la 91% (30/33BN).
3.4. Dac diem rong kinh sau nut mach 1, 3, 6 thang ?'i De nghien ciru rong kinh sau nut mach de tai tien hanh chia nhU sau
Bang 3.4: Dac diem rong kinh sau nut mach
Rong kinh
Khong Giam
Con
Tdng sd
1 thang So'BN
21 48 4 73
Ty le%
29 66 5 100
3thang So'BN
69 2 2 73
Ty le%
94 3 3 100
6 thang So'BN
71 1 1 73
T^ le%
97 1,5 1,5 100
Nhan xet: Ty le benh nhan cd cai thien ve trieu chUng rong kinh sau 1, 3 thang sau nut mach la 94% (69/73BN), sau 6 thang nut mach t;^ le khdng rong kinh la 97% (71/73BN).
3.5. Dac diem trgng luang tdcung sau nut mach 1, 3, 6 va 12 thing
Trpng lupng tur cung sau niit mach d tifng thdi diem nghien cifu dUpc chia thanh cac nhdm theo bang sau:
Bang 3.5: Dac diem trong lupng tir cung sau niit mach Trong lupng
tircung(Gram) Kh6ngto(dudi100)
Hoi to (100-199) To vera (200-299) Rat to (>300gram)
Tong so
Sau 1 thang SdBN
13 34 28 5 80
Ty le % 16,25
42,5 35 6,25
100
Sau 3 thang SdBN
35 39 5 1 80
Ty le % 43,75 48,75 6,25 1,25 100
Sau 6 So'BN
65 13 2 0 80
thang Ty le %
81,25 16,25 2,5
0 100
Sau 12 SdBN
72 8 0 0 80
thang Ty le %
90 10 0 0 100 Nhan xet: Trpng lupng tiif cung dudi lOOgram sau 1 thang nut mach ehie'm 16,25% (13/80BN), sau 3 thang chiem 43,75% (35/804BN), sau 6 thang ehie'm 81,25% (65/80BN), sau 12 thang chiem 90% (72/20BN).
3.6. Dac diem trong Iddng u sau nut mach 1, 3, 6 va 12 thing
De nghien cifu ve trpng lupng u sau niit mach d tifng thdi diem nghien cifu, tien hanh chia theo cae nhdm sau:
Bang 3.6: Dac diem trpng lupng u sau nut mach Trong lupng u (gram)
Dudi 25 25-50 51-75
>75 Tong so
Saul So'BN
25 43 7 5 80
thang Ty le %
31,25 53,75 8,75 6,25 100
Sau 3 thang So'BN
58 20 1 1 80
Ty le % 72,5
25 1,25 1,25 100
Sau 6 thang So'BN
74 5 0 1 80
Ty le % 92,5 6,25 0 1,25 100
Sau 12 thang So'BN
78 1 0 1 20
Ty le % 97,5 1,25
1,25 100 Nhan xet: Trpng lupng u dudi 25gram sau niit mach 1 thang chiem 31,25%), sau 3 thang chiem 72,5%, sau 6 thang chiem 92,5%, sau 12 thang chiem 97,5%.
Sau 6 thang khdng cdn cd u cd trpng lupng tU 51-75gram, chi cdn mdt u cd trpng lupng tren 75gram.
U 175 gram trUdc niit mach Hinh chup ddng mach tir cung
Y HOC VIET NAM THANG 12 - SO 1/2010
Sieu am sau 1 thang niit mach Sieu am sau 7 va 12 thang niit mach
IV. BAN LUAN
4.1. Sd ngay nam vien sau nut dpng mach tiircung
Ty le nam vien tU 1-3 ngay chiem 76,5%, sd ngay nam vien trung binh la 3,2 ngay.
Theo Nguyen Hoai Thu, Phan Thanh Hal [1]
thdi gian sau thii thuat benh nhan phai nam vien tu 1 den 1,5 ngay.
Theo Laurent Brunereau va cdng sU [6] thdi gian nam vien sau niit mach tir cung trung binh la 2,3
ngay. Khoang 80%-90% sd benh nhan sau niit mach 4-10 ngay trd lai cudc sdng binh thudng [5].
4.2. Trieu chiirng lam sang sau nut mach 4.2.1. Ngay sau khi nut mach
Sau niit ddng mach tir cung cd den 80,4%
benh nhan cd dau bung vimg ha vi, sdt cd 2 trudng hpp (chiem 2,5%). Mdt sd trudng hpp khac cdn cd them trieu chifng ndn va budn ndn. Theo Laurent Brunereau va cdng sU [6] thay 90% benh nhan sau niit mach tir cung ed dau viing ha vj.
4.2.2. Dau hieu lam sang sau nut mach 1,3,6 thing Bang 4.1. So sanh dau hieu lam sang sau niit mach
Ten tac gia Laurent Brunereau Ravina
Goodwin James B.Spies Nguyin Hoai Thu
Ket qua nghien ciru ciia de tai
SdBN 62 88 60 200 189 80
Ty le cii thien rong kinh 1 thang
29%(-) 66%(±)
3thang 90%
87%
94%(-)
6 thang 92%
89%
81%
89%
-100%
97(-)
Ty le cai thien dau bung 1thang
27%(-) 61%(±)
3 thang 90%
55%
76%
6 thang 92%
93%
-100%
91%
Qua khao sat tren chiing tdi thay ngay sau thang dau tien nut mach da cd tdi 29% benh nhan khdng cdn rong kinh, 66% benh nhan cd giam rong kinh va 88% benh nhan khdng cdn dau hieu dau bung hay cd cai thien dau hieu dau viing ha vj. Sau 3 va 6 thang thi ty le khdng cdn dau hieu lam sang do UCTTC gay ra chiem tren 90%.
Niit ddng mach tir cung la mdt phuong phap rat tdt de cai thien eung nhu lam mat cac dau hieu lam sang gay ra do UCTTC ngay tU nhifng thang dau sau dieu trj.
4.3. Trong luong tijr cung sau nut mach Trpng lupng tir cung sau 1 thang dieu trj giam la 22,4%, sau 3 thang la 39,3%, sau 6 thang la 4 8 , 1 % va sau 12 thang la 54,5% vdi P<0,001. Theo Hutchint [5] thay trpng lupng tir cung sau niit mach giam khoang 50%. Theo Pron et al [7] nghien cifu tren 555 trudng hpp thay trpng lupng tur cung giam 33% sau 3 thang. Spies et al [9] trpng lupng tuf cung giam tU 50% sau 6 thang dieu trj.
Bang 4.2. So sanh ty le giam kfch thudc va trpng lupng tif cung
Ten tac gia Pron et al Spies et al Laurent Brunereau
Nguyin Hoai Thu Chung tdi
Sd BN 555 200 58 189
80
Ty le giam kich thUdc tif cung 1th
7,8%
3th
13%
14,3%
gth
23%
17,4%
12'^
26%
21,4%
Ty le giam trong lUtfng tif cung 1th
22,4%
3th 33%
39,3%
6th
50%
34 -50%
48,1%
12'^
60%
54,5%
Nhu vay, ty le giam ve trpng lupng tir cung la rat Idn. Do vay khi theo ddi ket qua sau dieu trj can chii y den trpng lupng ciia tir cung. Ket qua ciia chiing tdi sau niit mach 6, 12 thang phu hop vdi cac tac gia trong va ngoai nudc.
4.4. Trpng lupng u sau nut mach
Trong nghien cifu 80 benh nhan chung tdi thay cd 9 benh nhan (chiem 11,25%) sau 6 thang dieu trj da khdng thay u tren sieu am do khdi u thoat ra qua dudng am dao hay tuteo nhd.
Trpng lupng u sau 1 thang nut mach giam 37,8%, sau 3 thang giam 62,1%, sau 6 thang giam 74,9% va sau 12 thang giam 85,1%. Ngay
tu thang dau tien sau nut mach trpng lupng ciia u da giam di 37,8%, cang ve sau trpng lupng khdi u cang giam nhieu.
Theo Nguyen Hoai Thu nghien cdu tren 189 trudng hpp thay sau 6 thang ty le trpng lupng khdi u giam khoang 78%, sau 1 nam khdi u nhd gan nhu binh thudng.
Theo Spies et al [9] trpng lupng khdi u giam tu 48-78% sau khi dieu tri tU 3-6 thang. sau Inam trpng lupng khdi u giam tU 50-60%.
Tranquart nhan thay ty le giam trpng lupng khdi u sau 3 thang la 29% va sau 1 nam la 55%.
Bang 4.3. So Ten tac gia
Tranquart Spies et al Laurent Brunereau
Ravina Nguydn Hoai Thu
Chiing tdi
sanh ket qua kich thudc va Sd
BN 61 58 88 189
80
trpng lupng u sau niit mact Ty le giam kich thUdc u
1th
15,9%
3th
23%
26,6%
glh
43%
44,3%
12th
51%
66,1%
1
Ty le giam trpng lUdng 1th
37,8%
3th 29%
48%
62,1%
6th
69%
78%
74,9%
u 12'^
55%
78%
-100%
85,1%
" Qua bang tren thay ket qua nghien ciru ciia ehiing tdi gan vdi eae ket qua nghien cUu trong va ngoai nudc.
Trong niit ddng mach tir cung thi kich thudc va trpng lupng khdi u giam di kha nhanh theo thdi gian. Tham trf cd mdt sd trUdng hpp khdng cdn nhi thay khdi u tren sieu am. Dieu trj UCTTC bang phuong phap niit ddng mach tir cung nham kie'm soat trieu chimg lam sang do u gay ra va la nhd khdi u.
Trong sd 80 benh nhan chiing tdi nghien cifu
cd 3 trudng hpp (chiem 3,75%) khdi u hoai tir va thoat ra ngoai bang dudng am dao, trong dd 2 trudng hpp khdi u tU ra, trudng hop cdn lai phai nhd can thiep cua bac sy san khoa.
Theo Gordon [4] va cdng sU thi ty le u thoat ra ngoai quan dUdng am dao sau niit mach la 5%. Day la mdt ke qua rat tdt cho benh nhan trU khi khdi u rung ra lam bit tac cd tir cung gay dau, nhiem triing cho benh nhan. Chinh vi vay can phai phat hien sdm va sir ly kip thdi.
Y HOC VIET NAM THANG 12 - SO 1/2010 4.5. Kha nang cd thai sau thu thuat nut
dpng mach tir cung
Trong sd 80 benh nhan chiing tdi nghien cifu thi cd 7 benh nhan mudn cd thai sau khi niit mach. Trong 7 benh nhan nay da cd 5 benh nhan cd thai va sinh con khde manh, de'n nay chau Idn nhat la 3 tudi phat trien binh thudng.
Ravina va cdng sUu theo ddi sau 6 nam tren 157 benh nhan nut dpng mach tir cung cd 7 trudng hpp cd thai.
V. KET LUAN
Nghien cUu ciia chiing tdi la mot khao sat budc dau ve ket qua dieu tri UCTTC bang phuong phap nut dpng mach tir cung. TU do chiing toi rut ra mpt sd ket luan sau:
1. Nut ddng mach tiircung la mdt phuong phap dieu trj UCTTC cd hieu qua de giai quyet van de ma ca thay thudc va benh nhan deu quan tam dd la:
9 1 % benh nhan khdng dau bung va 97%
benh nhan khdng rong kinh sau 6 thang niit mach, vdi P<0,001.
- Ty le giam trpng lupng khdi u sau 6 thang dieu tri la 74,9% va 85,1% sau 12 thang vdi P<0,001.
- Sau 6 thang dieu tri ed 9 benh nhan (chiem 11,25%) khdng tim thay u tren sieu am, trong do 4 benh nhan cd u dudi niem mac va 5 benh nhan vdi khdi u cd cau true giam am.
91,6% benh nhan ed kich thudc tir cung trd ve binh thudng sau 6 thang niit mach.
- Thdi gian phai nam vien sau thii thuat ngan, trung binh 2,3 ngay.
- Thdi gian tai nhap cudc sdng thudng ngay Irung binh 7-10 ngay sau thii thuat.
2. Mpt so chi djnh ve nut ddng mach tCr cung trong dieu trj UCTTC
- Khdi u khdng dupc qua to: kich thude dudi 10cm, tdt nhat la 3-5cm, dac biet khdi u cd cau triic giam am tren sieu am, tang sinh mach.
- Khi khdi u gay cac trieu chimg lam sang, dau bung, rong kinh Hay benh nhan UCTTC c6 chi dinh phau thuat nhung benh nhan khdng mudn.
- Nhifng khdi u dudi niem mac cd the rung va lam bft tac budng tir cung cung nhu cd tir cung, vi vay nen chpn u dudi niem mac ed kich thudc dudi 5cm.
- Can cd sU phd'i hpp chat che giuTa cac nha San-phu khoa vdi Chan doan hinh anh.
TAI LIEU THAM KHAO
1. Nguyin Hoai Thu, Phan Thanh Hal(2003), Bao cao hoi nghi Dien quang Phap-Viet, "Nhan 189 tr- dng hap thuyen tac dgng mach tCr cung trong dieu tri nha xa td cung, ung thu te bao nuoi, chay mau san khoa"
2. Glevin K, Palvio P. (1990), "Uterine myomas in pregnancy". Acta obstet gynecol scand; T.69:
P.617-619.
3. Gordin CH. Wong, BA, Suise J Muir, MD, Annie P.W. Lai, MD, and Scott C. Goodwin, MD.
Journal of women's Heath and Gender - Based Medicine. May 2000; 9(4): P. 357-63
4. Hutchins FL, Worthington-Kirsch R, Berkow/itz RP. Selective uterine artery embolization as primary treatment for symtomatic lelomyomata uteri. J Am Assoc Gynecol Laparosc. 1999; 6: 279-84.
5. Laurent Brunereau, Denis Herbreteau, Sophie Gallas, Jeam-philippe Cottier, Jean-Luclebrun, Francois Tranquat, Florence. Fanchier, Gilles Body and Philippe Rouleas. Uterine artery embolizatona in the Primary Treatment of Uterine Leiomyomas. AJR 2000; 175: 1267-1272.
6. Pron G, Banett J, Commen A, Wall J, Asch M, Sniderman K, for the Ontario Fibroid Embolization Collaborative Group. Uterine fibroids reduction and symptom relief after uterine artery embolization for fibroids. Fertil Steril 2003;
79: 120-7.
7. Spies JB, Sclalli AR, Jhan RC, Imaoka I, Ascher SM, Fraga VM et al. Initial results from uterine fibroid embolization for symptomatic lelomyomata.
J Vase Interv Radiol 199; 10: 1149-57.
