NGHIEN CUtJ KHOA HCX
NGHIEN CUtJ SO SANH PHU'DNG PHAP KHAU TOAN CHIEU DAY VQI KHAU GAN TOAN BO CHIEU DAY GIAC MAC TRONG RACH GIAC MAC
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DO CHAN T H U O N G XUYEN
Vii Anh Li', Phgm Thi Thuy Tiin', Phgm Nguyin Huan', Nguyen Vdn Thinh' TOM T A T
Muc tieu: So sdnh ket qud phuong phdp khdu rdch gidc mgc (GM) todn chieu ddy so voi phuang phdp khdu GM gdn todn bp chieu ddy.
Phirffng phap nghien ciru: Nghien cini doc. cd ddi chimg, mil don. 25 benh nhdn (BN) rdch GMdcm thudn dugc chon ngau nhien cho hai nhdm khdu 3 4 den 4/5 chieu ddy vd 100% chieu ddy GM. Cdc bien sd theo doi gdm mirc dp phii GM sau mdi ngdy. thai gian lanh bieu md, chieu ddy GM, dem te bdo npi mo (TBNM). Ghi nhdn cdc bien chimg nhu nhiem trung sau phdu thudt vd sau cdt chi, bieu md xdm ldn tien phdng.
Ket qua: Mirc dp mdt TBNM cua nhdm khdu todn bp chieu ddy 542,7 ± 338,6 (Te bdo (TB)/mm^) cung khdng khde biet hon so vai nhdm khdu GMcd dien 601,3 ±517,6 (TB/mm^). Mirc dp ndng ciia phii GM, phii quanh mep ciia nhdm khdu 100% it han nhdm khdu 3'4 den 4/5 chieu ddy vd su khde biet ndy cd y nghia thdng ke.
Ket luan: Phuong phdp khdu todn bp chieu ddy GM cd uu diem nhu it phit gidc mgc hon, thdi gian het phii ngdn han, nhanh Idnh bieu md. tdn thuang TBNM tuong tu nhu phuong phdp khdu cd dien. Tuy nhien ki thudt thuc hien khdu ndy khd vd thich hap nhdt trong nhimg trudng hop rdch phirc tgp, rdch xeo.
Tir khoa: Chdn thuang xuyen.
I. DAT V A N D E
Tdn thuong rach GM rat pho bien trong chan thuang, chiem tren 50% trong cac chan thuang mat nghiem trgng [1], Khau GM trong chan thuong XU} en. rach GM la viec bat budc phai lam khdng chi thiet lap tinh nguyen ven cua nhan cau ma cdn tai tao dung cac ldp cau tnic giai phau hgc cua giac mac nham han che tdi da qua trinh lanh seo tranh loan thi sau na}.
Trade day ki thuat khau GM kmh dien dugc cac sach md ta khau 3/4 den 4/5 chieu da}' GM bang chi nilon 10/0 giiip giac mac km va khdng ddng cham den ndi md. Tuy nhien, gan day cd mdt nhdm
'Benh vien M£il TP Ho Chi Minh
tac gia [4] dua ra ki thuat khau toan bd chieu day GM giiip GM giam phii va trong nhanh hon, cho phep tien hanh cac can thiep vao ban phan sau scrni hon, giup BN lay lai thi lire sau chan thuang. Nham cap nhat kl thuat khau GM mdi ciing nhu da dang hoa cac phuang phap khau GM trong dieu tri rach GM do chan thuang xuyen, chung tdi tien hanh nghien ciiu so sanh khau toan bp chieu day GM vdi khau gan het chieu day GM cho cac BN bi rach giac mac nhap vien tai khoa Chan thuang, Benh vien Mit TP Hd Chi Minh.
II. PHUONG PHAP NGHIEN CUU
Day la nghien cim doc cd ddi chimg dugc tien hanh ti-ong 2 nam (2008 - 2009). BN nhap \ien d
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khoa Chan tiiuong. Benh \ien Mit TP Ho Chi Minh vdi chan doan rach GM do chan thuang xuyen, rach GM dan tiiuan, khdng kem tiieo bat ki ton tiiuong nao khac nhu rach cung mac, rach bao the thiiy tinh, pha le the tien phdng, ... rach ggn. sach, khdng mat chat, khdng cd diu hieu nhiem trimg ndi nhan. Hai nhdm BN dugc chpn ngau nhien. mii don. Nhdm 1 dugc tien hanh khau GM theo phuang phap cd dien khau gan het chieu day GM. Nhdm 2 ap dung phuong phap khau GM toan phan.
Phuang phap khau GM toan bd chieu day bao gdm: raa sach mep vet rach, dimg que tach dinh day mdng vao tien phdng. tranh ket mdng vao mep vet rach. Tao tien phdng bang chat nhay. Khau GM toan bd chieu day bang chi nilon 10.0, cdt chi 5 vdng, cat va viii chi vao nhu md giac mac hay tien phdng.
Rua sach chat nhav, tai tao tien phdng bang hoi hay nudc muoi sinh li. Bom khang sinh Cefiiroxim vao tien phdng. Trong nhdm ddi chirng, GM dupc khau 3/4 - 4/5 chieu da}, cdt chi 3 vdng. Thude nhd hau phau gdm khang sinh Ofloxacine 0,2g 2vien/nga}'. thuoc nho mat C. Oflovid 0,3% 6 lan/
ngay, C. Atropin 1% 2 lan/ngay, C. Predforte 1% 4 lan/ngay.
Khi cat ehl, BN se dupc cit chi trong phdng md, sat tning mat bang Betadine (nong dp 10% ngoai da va 5%) cho ket mac) trong 1 phut, sir dimg vanh mi. nia sach GM va cac chat tiet bam len not chi, cit chi bing dao hoac keo hoac kim 26, tet Seidel GM kiem tra dd tien phdng sau khi rut chi, va nhd thude khang sinh C.
Oflovid 0,3% 3 nga} sau cat chi.
BN dupe danh gia thi lire trade va sau phau thuat, dp phii GM sau mdi ngay, thdi gian lanh bieu md (nhudm Fluor bieu md khdng bat mau. moi ehi khau ldng leo). do chieu day GM (so sanh mit benh va mat lanh) hau phau 6 thang, dem TBNM (so sanh mat benh va mat lanh). Ghi nhan cac bien chirng nhu nhiem triing sau phau thuat va sau cat chi, bieu md xam lan tien phdng, ...
III. KET QUA
Cd 41 BN tham gia nghien ciiu nhung chi 25 BN dupc ghi nhan tai kham theo ddi tuong ddi day du; 13 benh cho nhdm khau co dien va 12 benh cho nhdm khau 100%. Theo bang 1, BN cua hai nhdm benh thudng den benh vien mudn trang binh la 43,78 ± 43,5 (gid).
Bdng 1. Bdng ddc diem chdn thuong Nhom phau thuat
Sd mat Tudi Dd tudi Nam: Nii
Thdi gian tir luc chan thuang den phau thuat (gid)
TBNM do dupc (TB/mm=) Dp mat TBNM (TB/mm=) Chi sd CV
Thdi gian cat chi (thang)
Nhdm khau giac mac (90%o)
12 30,7 ±7,7
21-49 2:1 39,2 ±36,0
(5-120) 2256,9 ±488,4
601,3 ±517,6 43,4 ± 16,0
3,6±1,1
cua hai nhdm phdu thudt Nhdm khau giac mac
(100%,) 13 33,0 ±10,6
18-46 3:1 48,8 ±51,2
(2-148) 2253,5 ± 6 9 0 542.7 ±338,6 33,6 ± 15,9
3,3 ± 1 , 0
Gia tri p (CI 90%)
- 0,55
- - 0,435 0,991 0,783 0,242 0,506 Binh tiiudng TBNM a nhdm tuoi 30 - 40 tuoi ti-ong khoang 2.400 - 3.100 TB/mm^. So lupng TBNM cua nhdm khau 100% la 2.253.5 ± 690 (TB/mm^) va 2256,9 ± 488,4 (TB/mm-) cua nhdm khau 90% (P=0,991 > 0,1).
Sir khae biet na} khdng cd y nghia tiiong ke. Tuong \\x, miic dp mat TBNM ciia nhdm khau toan bd chieu day 542.7 ± 338,6 (TB/mm-) ciing khdng khac biet hon so vdi nhdm khau GM cd dien 601,3 ± 517,6 (TB/mm-).
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Bdng 2. Bdng kit qud ddnh gid thdi gian phu vd Idnh biiu mo cua hai nhdm
Nhdm p h i u thuat Thdi gian lanh bieu md (ngay) Thdi gian het phii giac mac (ngay)
Nhdm khau giac mac (90%,)
6,58 ± 9,22 6,67 ±6.76
Nhdm khau giac mac (100%>) 1,69 ± 1.18 3.08 ±2.81
Gia tri p (CI 90%)
0.07 0.09 Ngoai ra, khao sat hinh dang T^NM qua chi
sd CV (coefficient of variation - he sd bien thien binh thudng khoang 27-28) cho thay nhdm khau CO dien ed CV la 43,4 ± 16,0 so vdi khau 100% la 33.6 ± 15,9: chiing td cd su thay ddi hinh dang TB, tu}' nhien van khdng ed su khac biet giira hai nhdm (p= 0,242).
Bdng 3. Bdng thong ke mdc dp phu
Thdi gian trung binh cat ehi la tucmg duong cho hai nhdm la 3,6 ± 1.1 (thang), cho nhdm khau cd dien va 3,3 ± 1,0 tiiang cho nhdm khau la 100% (p= 0.506).
Theo bang 2 cho tha}', khau GM toan chieu day cd thdi gian lanh bieu md va mau het phii GM hon nhdm khau cd dien vdi ti le p = 0.07 va p = 0,09
< 0,10. Ket luan nay cd }' nghia thdng ke.
vd kiiu phii theo hai nhdm phdu thudt
Nhdm phau thuat Nhdm cd dien Nhdm 100%
Tdng
Phu giac mac (%>) Nhe
1 (8,3) 5(38.5) 6 (24,0)
Ndng 11 (91,7)
8(61,5) 19(76,0)
Phu quanh mep (%) Nhe
4 (33,3) 10(76,9) 14 (56,0)
Ndng 8 (66,7) 3(23.1) 11 (44,0)
Phil chan chi (%) Khong
5 (41,7) 7(53,8) 12 (48,0)
Cd 7(58.3) 6 (46.2) 13 (52,0)
Phil piac mac nanp Phil ouanh men nan? Phil chan chi nanp
Bieu do 1. Bieu do so sdnh mwc dp ndng ciia phu gidc mac, phu quanh mep rdch vdphii chan chi cua hai nhom khau
0 bang 3. nhdm khau 100% cd mirc dp nang cua phii giac mac it hon nhdm khau cd dien. Su khac biet na} cd y nghia thong ke vdi p = 0.078 < 0.10 (x== 3.105). Tuong tu, cd 8 BN khau cd dien cd phii quanh mep nang. trong khi chi 3 BN a nhdm 100%. su khac biet cd y nghla vdi p = 0.028 < 0.10 (yj = 4.812). Tu}' nhien, phii chan chi xuat hien deu a ca hai nhdm. khdng cd su khac biet vdi p = 0,543 > 0.10 (/-= 0.371).
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IV. BAN LUAN
Vet khau GM tdi uu la lam sao khau chat vet thuang khdng cdn thoat thu}' dich, giam tdi da tinh trang phii sau md. han che dp ldn seo GM. Cd gang tdi da giir dp cong sinh li GM va ban che bien chimg nhu dinh ket mdng vao mep md, hoac loan dudng GM, ...
0 vet thuang mep rach nat mat chat, khdng thang mep, rat khd phan dinh chieu da} ciia mep khau thi miii khau 100% giup phau thuat vien ap sal hai mep GM rach hon, ngan ngira \iec map md vet rach khi khdng la}' du toan bd chieu da} GM (hinh 1).
Ket qua nghien eim cho tha} miii khau toan chieu da}' GM cd the giup cho viec lanh seo tdt. Tuy nhien, theo kinh nghiem lam sang thi kT thuat khau toan bd chieu da} GM khdng de cho phau thuat vien it kinh nghiem. Viec xu}en kim qua mang Descemet va ldp TBNM GM khd, phau thuat vien de bi tragt miii kim khi den mang Descemet nen khdng the khau het toan bd chieu da}'. Khi xuyen kim qua ldp TBNM thi kim de cham vao cac cau tnic trong tien phdng nhu mdng mat, thuy tinh the neu khdng cd chat nha} bao ve.
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4 H Hinh lA. Vit khdu 100% chiiu ddy gidc mgc giup bieu mo phdng trong khi biiu mo gidc mgc
mdp mo d ki thuat khdu 90% (hinh IB) Theo ket qua nghien ciru cung nhu ket luan cua Kuhn [4]. ki thuat khau rach GM tir 3/4 den 4/5 chieu da} GM. Theo kinh dien tiii van cd nhung bat lgi nhu phii giac mac keo dai do ldp ndi md trong cimg cdn ke hd lam thu} dich ngam vao nhu md tang tiidi gian phii GM. Va vi ldp ndi md khdng kin nen dien tich ma ldp TBNM phai bao phu rgng hon lam cham giam phii sau md. Trong khi mui khau toan chieu da} GM. nga} lap tiic ddng kin vet
tiiuong se ngan chan tiiu} dich di vao nhu md GM lam giam phu ne GM gnip GM trong nhanh.
Khi bi chan thuang mang lien ket giira hai TBNM thoai trien lam cho TB ldn hon. tao thanh cac TB khdng Id ma bieu hien tren can lam sang la ehl sd CV cao. Dieu na} phii hgp vdi ket qua chimg tdi thu dugc khi khao sat TBNM o hai nhdm.
Da cd nhieu tranh cai khi cho ring, viec khau GM toan bd chieu da}- se gay ton thuang TBNM nhieu hon do miii kim cham vao TBNM \ a thu}- djch cd the ngam qua miii chi ga} phii quanh chan chi. Ket qua nghien cira cho tha}. ca hai nhdm rach GM cho dii cd khau bang phuong phap gi thi so lugng TBNM deu giam nhu nhau.
LTinh 2. Sdt not chi thudng gap d nhdm khdu 100% khi cdt chi
Hinh 3. Phu chdn chi xdy ra d cd hai nhdm
khdu
Viec mat TBNM do chi de chat vao lam chet TB thi dien tich na}' rat nhd. Hon nira. viec ngan chan nga}' lap tire thiiy dich gay phii GM se giup TBNM khdng bi ehen ep tren mdt dien rpng. Ndi chung viec tdn thuong TBNM d khau 100% se khdng khac gi \'di khau GM cd dien. Tuong tu tha}' ddi chieu da} giac mac ciing khdng khac biet giiia hai nhdm.
Thi luc BN tuy thupc vao nhieu }'eu td nhu thdi gian tir liic BN chan thuang den benh vien. vi tri vet rach. tinh chat vet rach, cac tdn thuang ban phan trade \'a sau di kem, do va}' ban luan den van de thi luc giiia hai nhdm ki thuat khau se khdng chinh xac.
Bupc not chi nhd vira du de vui chi va du manh de tranh long leo, tuy nhien vdi ndt chi nam vdng cua Kuhn [4] qua ldn trong khau GM 100%
thi khdng chi viec viii chi ma khi nit chi ga} khd
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khan khdng nhd, tham chi rat de sdt chi trong nhu md GM (hinh 2). Tuy nhien bien chimg sdt chi gap
1 tradng hgp d khau toan bd chieu day GM.
Vdi lap luan cua Kuhn [4], viec su dung miii khau 100% se cho vet thuang ddng kin tdt hon nhung mat khac nd lai la con dudng cho thuy dich, thoat ra qua miii chan chi va cung la nai de vi khuan va TB bieu md xam nhap vao tien phdng khi nit ehi.
Tu} nhien kha nang nay khd xay ra, vi neu ta la}
ehl dimg each thi bieu md se phu nga} be mat GM ddng thdi TBNM, mang Descemet se phu nga} mat sau vet thuang.
Phil quanh chan chi [3,4] ciing xuat hien a hai nhdm (hinh 3); 6 ca cho nhdm khau cd dien, 4 ea cho nhdm khau 100%, va khdng cd su khac biet
TAI LIEU THAM KHAO
1. KUHN F, MESTER V, BERTA A. MORRIS R. 1998. "Epidemiology of serious ocular trauma:
The United States Eye Injury Registiy (USEIR) and the Hungarian Eye Injury Registratiy (HEIR)", Ophthalmologe, 95:332-343.
2. JAMES Y M, CALVIN H. LITTLE R.
giira hai nhdm ed y nghia thdng ke. Cac bien chimg mudn khac nhu nhiem tning, bieu md tien phdng chua ghi nhan dugc.
Tuy nhien, mau nghien cira na}' nho nen neu dugc tiep tuc nghien ciiu vdi co mau ldn ban thi ket qua se cd tinh thuyet phuc cao.
V. KET LUAN
Phuang phap khau toan bp chieu da} GM cd vai uu diem nhu it phii GM hon. thdi gian het phii nhanh hon, mau lanh bieu md. Tdn thuang TBNM tuang tu nhu phuang phap khau cd dien, nhung kl thuat thuc hien khau nay khd va thich hgp nhat trong nhirng trudng hop rach phirc tap, rach xeo.
1974. "Keratoplasty with use of through and through nilon sutures", ylrc/7 Ophthalmol, 91:381-385.
3. PERRY SB. 1978, 'Evaluation of tiirough and through comeal sutures"'. Arch Ophthalmol. 96:1886-91.
4. KUHN F, PIERAMICI DJ. "Ocular trauma". Principles and Practice. Thieme 2002.
SUMMARY
TECHNIQUE OF FULL THICKNESS CORNEAL SUTURES FOR CORNEAL LACERATION
Purpose: To evaluate the effectiveness offrll thickness corneal sutures for traumatic corneal laceration.
Methods: A prospective, comparative, randomized study. Twenty five patients with simple corneal laceration were randomly recruited into 2 groups: one group was sutured with 3 4 or 4 5 corneal depth and one with 100% depth. Data of stroma edema, time of epithehahzed wound closure, comeal thickness, loss of epithelial cells were recorded. Complications such as infection after suture removal, epithelial downgrowth into anterior chamber were also observed.
Results: The loss of endothelium cells of fill thickness suture with 542.7 ± 338.6 (celTmm^) was similar to that of conventional suture with 601.3 ± 517.6 (cell/mm^). The severity of corneal stromal edema at wound edges offrll thickness suture is statistically significant less than conventional one.
Conclusions: Eull thickness corneal suture brings about some advantages: lesser stroma edema, faster corneal transparency recovery, and better wound closure. Morever, the endo thehal damage is similar
in borth techniques. Full thickness suture is be suitable for complex, obhque wounds.