14 Tap chi GAN MAT VIET NAM so 31-2015
Chi dinh va ky thuat d§n liru tui mat trong viem tui mat cap
Ho Vdn Linh, Nguyen Cuang Thinh
Summary
Percutaneous tranhepatic gallbladder drainage (PTGBB) is considered a safe alter- native to early cholecystectomy, especially in surgically high - risk patients with acute chole- cystitis. Although randomized prospective con- trolled trial are lacking, data from most retrospective studies demonstrate that PTGB is the most common gallbladder drainage method.
There are several alternatives to PTGBD. Per- cutaneous tranhepatic gallbladder aspiration is simple alternative drainage method with fewer complications: however, in clinical usefulness has been shown only by case - series studies.
Endoscopic naso - gallbladder drainage and
Tom tat:
Ddn luu tiii mat xuyen gan qua da (PTGBD) duac xem Id mot gidi phdp an todn thay the cho phau thudt cdt tiii mat sdm, ddc bi$t nhitng truang hap viem tiii mat cdp tren benh nhdn co nguy caphdu thugt cao. Mgc dii chua co kit qud cua nhirng thu nghiem ldm sdng tiin cim ngdu nhien, cdc kit qud nghien cuu hoi cim cho thdy rdng PTGBD Id phuang phdp ddn luu tui mat hay duac dp dung nhdt. Cdc phuang phdp ddn luu till mat khde hien nay duac dp dung gom:
hilt tui mat xuyen gan qua da, day Id phuang phdp dan gidn, it bien chimg, tuy nhien chi co mQt so it cdc nghien cim de cap den: dan luu tiii mat qua mUl hogc dgt stent tiii mat td ti-dng qua bong Vater theo duang npi soi dg ddy td trdng cUng duac xem Id gidi phdp ddn luu tui mat trong viem hii mat cdp, nhung cd 2 phuang phdp tren ky thudt kho khdn, ty le thdnh cong thdp han PTGBD. Hien nay ddn luu tui mat xuyen thdnh duai huong ddn cua sieu dm noi soi duac xem Id mot ky thudt ddc biet ddn luu tui mat, tuy
gallbladder stenting via a transpapillary endo- scopic approach are also alternative methods in acute cholecystitis, but both of them have tech- nical difficulties resulting in lower success rates than that of PTGBD. Recentlyendoscopic untra- sonography - guided transmusal gallbladder drainage has been reported as a special tech- nique for gallbladder drainage . However, it is not yet an established technique. Therefore, it should be perfomed in high - volume institutes by skilled endoscopists. Further prospective evaluations of the feasibility, satety, and efficacy of these various approaches are needed. This ar- ticledecribes indications and techniques of drainage for acute cholecystitis.
vgy no chua duac chung minh bang nghien cm ndo, do do chi nen thuc Men a nhiing trung tdm lan, bai nhirng chuyen gia ngi soi co kinh nghiem. Tinh khd thi, mite do an todn vd hieu qud ciia cdc ky thudt neu tren vdn cdn tiip luc duac ddnh gid. Bdi viet ndy chd yiu di sdu vdo chi dinh vd cdc ky thugt ddn luu tiii mgt.
Dat van de
Huong din Tokyo thang 1-2007 (TG07) da dua ra tieu chuan chan doan va danh gia miic do viem tui mat cap. Trong Huang dan nay din luu tiii m^t xuyen gan qua da (PTGBD) dugc chi dinh cho viem tiii mat d p miic do trung binh (grade II), va viem tiii mat c^p nang (grade HI), Trong mgt nghien ciiu so sanh giua dan luu tiii mat xuyen gan qua da vdi dilu tri ngi khoa dan thuan thay ring d i n liru tui mat xuyen gan qua da khong lam giam ty le tir vong a nhimg b?nh nhan viem dii mat c4p. Tuy nhien, nghien ciiu nay bpc Ip nhieu giai han nghiem trgng; (1) trong lya chgn mau (nhom b?nh nhan dan Imi tui miit xuyen gan qua da rat nhieu truang hgp
Tap chi GAN MAT VIET NAM so 31-2015 15 nam tai khoa hoi siic tich cyc); (2) phuong phap
dan luu dugc thay doi sau mpt truang hop biln chiing tir vong; (3) chpn mau thuan tien, khong sii dung phuang phap lam "mii". Do do, din luu tui mat xuyen gan qua da dugc de cap a nhilu nghien ciiu truang hgp benh, nhung chua dugc chiing minh bang nhirng thu nghiem lam sang ngau nhien chi dugc xem la phuang phap dSn luu tui mat pho bien nhat cho nhiJng benh nhan cao tuoi, CO benh ket hgp nang. Mgt so giai phap thay the cho PTGBD: choc hiit tiii mat xuyen gan qua da (PTGBA); ngi soi dat din luu tiii mat qua mui (ENGBD); ngi soi dat stent tiii mat - ta trang (EGBS); dac biet voi su phat trien cua sieu am ngi soi, din luu tiii mat xuyen thanh duoi huong dan cua sieu am ngi soi qua hang vi hoac
ta trang ciing dugc ap dung. Mac dii vay hieu qua cua nhirng phuang phap tren chua dugc nghien ciiu, kiem chimg day du, nen dan luu tui mat xuyen gan qua da van dugc xem la ky thuat chuan.
Trong bai viet nay chiing toi chu yeu mo ta chi dinh, ky thuat dan luu tiii mat trong viem tiii mat cap, va neu nhiing khuyen cao trong Huang din Tokyo 2013 (TG13).
Cau hoi 1: Ky thuSt dan lini tui mat nao la tieu chuan cho nhung trtrong hffp viem tiii mat cap khong "phii hop" ph3u thuat?
Nhieu tac gia khuyen cao PTGBD la ky thuat tieu chuan trong dan luu tiii mat. Dieu nay dupe the hien a bang 1 (duai day):
KTdIn luu
PTGBD PTGBA ENGBD/ EGBS
Phau thuat dan luu TM
Cac yeu to anh huong den khuyen cao Tinh chiing minh
B (tnmg binh) C (thap) C (thdp) C (thap)
Sy can d6i giua lgi va hai
RSt tit Tot (hieu qua DL
thip) Tot (Ty le thanh
c6ng thap) Tot (nguy ca
phlu thuat)
Kho khan ky thuat KJiong
Co Khong Khong
Gia tti vai nguai benh
Co Khong Co / Khong
Co
Gia thanh Th4p R4t thap
Thap Cao Chi dinh v^ y nghia ciia PTGBD
Mac dii mo cat tiii mat sdm trong viem tiii mat cap dupc coi la phuang phap chuan trong dieu hi viem tiii mat cap, nhung ty le tii vong trong mo o nhom benh nhan cao tuoi, benh ket hgp nang kha cao (19%). Do do, PTGBD dugc xem la giai phap thay the an toan 6 nhung benh nhan nguy ca phau thuat cao. Khong co gi phai nghi nga ve hieu qud ciia PTGBD kit hgp khang sinh toan than nham giai quyet tinh trang nhiem khuan frong viem tiii mat cip. Ky thuat thi PTGBD khong phiic tap, ty I? tai biln, bien chimg thap ( 0 -
13%). Theo mgt nghien cuu hoi ciiu cho thdy ty le tir vong ttong vong 30 ngay hoac tu vong trong benh vien sau dan luu tiii mat xuyen gan qua da la 15.4%. Trong do tir vong lien quan din ky thuat chi 0.36%. Benh nhan tii vong phan Ion la do cac benh ket hgp nang chii khong phai do tinh trang nhiem khuan ciia tiii mat.
Mat khac, cac nghien ciiu cho thay ty Ie tu vong sau mo cat tui mat sam da giam dang kl so vai nhiing nam truac : 4.0% (truac nam 1995:12.0 %). Ket qua dat dugc nhu vay nha sy tien bp cua gay me, hoi siic trong mo tren nhiing
16 Tap chi GAN MAT VIET NAM so 31-2015 b?nh nhan benh nang. Nhung cho den nay cung chua CO nghien ciiu kiem can thiep nao so sanh giira PTGBD va cit nii mat som. Co mpt s6 it bao cao vl chii dl nay: Melloul va CS nghien ciiu 42 benh nhan viem tiii mat cap tren nhung b?nh nhan nang tai mot trung tam hii siic cap cim trong 7 nam, tac gia nhan thay a nhom phau thuat ty le biln chung cao han nhom PTGBD (47% & 8,7%), khong co su khac nhau vl ty le tii vong. Mpt nghien ciiu o Tay Ban Nha qua 62 trucmg hgp viem tiii mat cap co benh ket hgp nang, cac benh nhan dugc chia Iam 2 nhom la nhom PTGBD vh nhom ml cit tiii mat. Tac gia nhan thiy ty le tu vong o nhdm PTGBD cao han nhom phlu thuat ( 17,2% vs 0%). Tuy nhien nghien ciiu nay co nhieu diem han che: thiet ke nghien ciru khong phai tien ciiu, trong chia nhom tac gia chgn nhom PTGBD la nhimg benh nhan nang hon. Do do khong dii tinh khoa hgc de dua ra khuyen cao ve dieu tri viem hii mat cap fren nhirng b^nh nhan tuoi cao b$nh ket hgp nang la nen din luu hii mat xuyen gan qua da hay mo cat tiii mat. Can c6 nhung nghien ciiu lam sang ngau nhien, da trung tam de co so lugng b?nh nhan nhieu han nham giai quyet van de nay..
Thcri diem dan luu tiii mat
Benh nhan viem tiii mat cap miic do nang (grade III) co chi dinh dan luu nii mat, viem tiii mat cap miic do vira (grade II) din luu tui mat chi dat ra khi khong dap iing voi dilu hi bao tin.
Trong mgt nghien ciiu hoi ciiu dua ra cac yiu tl tien lupng dieu tii bao ton khong hieu qua la tuii tren 70, dai thao duang, nhip tim nhanh, tiii mat cang to tai thai diem vao vien, ciing gilng nhu vay: mii >70, BC> 15 G/L, nhiet do tang len la yiu tl tien iugng bao tin thit bai sau 24-48h dieu tri.
Cac ky thu^t dan luu tiii mat
Ddn luu hii mat xuyen gan qua da (PTGBD):
PTGBD dupc xem la ky thuat chuan trong dan luu tiii mat khong phlu thuat. Duai huong din cua sieu am chgc kim 18-G xuyen gan vao tui mat qua giuong tiii mat, sau do 1 catheter co 1 diu u6n cong co hi 6 - 10 Fr dugc dat vao tui mat duoi din duang cua guidewire (phuong phap Seldinger). Ky thuat khong co gi kho khan va CO thi thyc hien a tit ca cac eg so Y te. Tuy nhien ky thuat nay co 1 s6 nhugc diem: catheter chi dugc nit sau khi da hinh thanh 1 duong him quanh dan luu; co nguy co tugt dan luu khoi tui mat; benh nhan cam thay kho chiu va co the ti;
nit dan luu.
Ninh I Dan Itai tui mat .xuyen gan qua d
Hinh I. Dan luu hii mat xuyen gan qua da
Chpc hut tui mat xuyen gan qua da (PTGBA): PTGBA la ky thuat chpc hiit djch tiii mat bang I kim nho duai huong din sieu am.
Day la phuang phap dan gian, chi phi thap, de thuc hien, dong thai Ichong gay cam giac kho chiu cho nguoi benh. Theo ly thuyit thi tac dyng dieu tri cua phuong phap nay khong bang PTGBD, tuy nhien viec chgc hiit nhieu Ifin co the dem lai hieu qua thyc su, va phuang phdp nay chua dugc so sanh vai PTGBD. Mac dii chgc bing kim nho (21G) lam giam nguy co i6 mat, nhung khi hiit dich mat nhieu can bin se kho khan, dieu nay co thi khic phyc bing viec nia bang dung dich pha khang sinh.
Tap chi GAN MAT VIET NAM so 31-2015 17
Hinh 2. Chgc hiit tiii mat xuyen gan qua da
Noi soi dan lini tiii mat qua bong Vater Npi soi ddn lim tui mat - mui (ENGBD - en- doscopic naso-biliary gallblader drainage):
ENGBD la phuang phap dan luu c6 the ap dung cho nhiing benh nhan toan than nang, dac biet vai benh nhan benh gan giai doan cuoi, 6 nhiing b?nh nhan nay cac can thi§p qua da kh6 co the thyc hien. Tuy nhien ky thuat nay kha phirc tap (ty le thanh cong tu 64-100%), va chi co the thyc hien a mgt so trung tam nhat dinh. ENGBD khong duac xem la ky thuat chuan trong dan luu tiii mat, va chi nen thyc hien o nhung trung tam CO ky thuat npi soi thanh thao.
Ky thuat ENGBD: dat 1 catheter tir mui vao tui mat khong can cat co Oddi: sau khi tiep can dugc duang mat, mgt guidewue 0.035-in dugc luon va tiii mat qua ong co tiii mat. Cuoi cung 1 catheter 5-8.5 Fr co 1 dau cong dugc luon vao tiii mat qua miii.
Bdt stent tiii mat td trdng qua bong Vater EGBS (Endoscope transpapillary gallbladder stening}la mgt ky thuat phirc tap va chi thuc hien duoc d 1 so it trung tam npi soi, va no ciing khong dugc xem la ky thuat dan luu tiii mat chuan. Ky thuat cung gan tuong tu ENGBD, 1 stent 2 dau cong co 6-10 Fr dugc dat vao tiii mat va ta trang. Ky thuat nay c6 the ket hgp dan luu duang mat chinh trong hgi chiing Mirizzi's, khi nay can thiet ma ca oddi de dy phong viem tuy cap sau ERCP.
Hinh 3. Ngi soi din luu tiii mat - miii
Hinh 4. Dat stent tiii mat ta trang qua bong Vater
Cau hoi 2: Ky thuat nao duroc xem la ky thuat dac biet trong dan lun tiii m^t?
[Ky thuat npi soi dan luu tiii mat xuyen thanh duai huong dan cua sieu am ngi soi (EUS-GBD endoscopic ultrasonography - guided gallblad- der drainage) ]
EUS-GBD dugc thuc hien qua hang vi hoac ta trang, dan luu co the dua ra m{ii(EUS- guided naso-gallbladder drainage) hoac dat stent tiii mat da day hoac ta trang (EUS-guided gallbladder stenting). Mpt nghien cim chi ra tinh kha thi va hieu qua cua EUS-GBD c6 the so sanh voi PTGBD. tuy vay day van khong dupc xem la ky thuat dan luu chuan, va chi dugc thyc hien a mgt so it trung tam bai nhiing chuyen gia npi soi CO kinh nghiem.
18 Tap chi GAN MAT VIET NAM so 31-2015 Ky thuat ngi soi dan liru tui mat xuyen tlianli duoi huomg dan cua sieu am noi soi (EUS-GBD)
Theo ly thuyfe, tui mat khong dinh vao duong tieu hoa, do do co the co nguy co ro mat trong qua trinh thuc lilen ky thuat, tren thuc te niu ky thuat thjt bai co Ihi xu4t hien viem phiic mac mat. Viec xac dinh vi tri dat stent la r4t quan trgng dam bao viec thuc hien ky thuat an toan.
Tui mat dugc quan sat r5 nhat tvr hang vi hoac ta trang qua mgt dSu do sieu am ngi soi tai dau ngoai vi cua 6ng soi. Duoi huong dan cua sieu am ngi soi (dJu do huong sang phai), mot catheter c6 dau dao dot dien (Zimmon, hoac Cystotome, Wilson-Cook, Winston-Salem, NC, USA) hoac kim s5 19-G (Echo Tip, Wilson-
Cook) dugc chgc huong vS phia tui m»t, sieu am ngi soi giiip duong di cua kim tranh cac mjch mau, ch6ngchay mau. Sau khi cam kim vao tiii mat, dich mat dugc rut ra, sau do bom thu6c can quang vao tiSn hanh chup hii mSt; mpt guidewire 0.025 hoac 0.035-in dugc dua vao qua vo ngoai ciia kim, nSu cSn thiet co the nong rpng duong ham giua da day- tui m$t, hoac ta trang - tui mat. Sau cung, mgt catheter 5-10 Fr dugc dua tir mui vag tui mat theo duong ham da dugc nong. Ky thuat dat stent tui mat - ta trang, tiii mat da day ciing tuong tu nhu vay, chi khac la khong dua catheter qua mtii ma dua vao duong him 1 stent 2 dSu cong hojc stent lu dgng gian rpng vao duong ham da day - tui mat hoac ta trang - tiii mat.
Hinh 5. Dan luu hii mat xuyen thanh duoi huong din cua sieu am npi soi
Co 9 nghien cuu hoi cuu, 1 nghien cuu tien cuu, trong do co 3 nghien cuu ve sieu am ngi soi huong dan dan luu tui mat - mui (EUS-guide naso-gallbladder drainages) va 7 nghien ciru ve ngi soi sieu am huong dan dat stent tiii mat(
EUS-guide gallbladder stentings) (Bang 2). Ty Ip thanh cong va hieu qua dieu tri deu khoang 100%, nhimg ty le tai bien, bien chiing kha cao
(khoang 11-33%). C k co nhiSu nghien ciiu hon vi tinh an toan ciing nhu gia ni cua phuong phap nay.Duoi day la mgt s6 tai bijn, biSn chiing som cd thi gap sau ky thuat EUS-GBD: rg mat, stent tugt vao trong 6 bung, vao hii mat hoac tugt khoi hii mat, chay man.. Cac bien chiing muon c6 the gap: viem TM cip tai phat do tac dan luu, hiP' dan iuu...
Tap chi GAN MAT VIET NAM so 31-2015 19 Bang 2: Kit qud ddn luu tui mat duai hu&ng ddn sieu dm npi soi
T.gia
Baron Kwan Lee Takasawa Kamata Song Itoi Jang Itoi Jang
Sobn
1 3 9 1 I 8 2 15 5 30
Loai dan luu /stent
Stent chat dec DL mui - tui mat DL miii - tiii mat Stent chSt deo Stent tir nong kim loai Stent chat deo Stent chat deo Stent ty nong kim loai Stent ty nong kim loai DL mui - tOi mat
Duong din lim
Qua ta trang Qua ta trang Qua ta trang Qua da day Qua ta trang 1 Qua da day/
7 Qua ta Uang 10 Qua da day/
5 Qua ta frang ] Qua da day/
4 Qua ta trang Khong xac dinh
Thanh congky thuat (%)
100 100 100 100 100 100 100 IOO 100 97
Thanh cong di6utn
(%)
100 100 100 100 100 100 100 100 100 IOO
Bien chiing (so bn)
Khong Ro mat (I)*
Tran khi phiic mac (1) Khong
Khong Ro mat (1), Tran khi phiic mac (1), Stent di chuyen (1) Ro m|t (1) Khong Khong
Tran khi phiic mac (2)
* Nhung truang hgp do mat nhe, di&u tri ngi khoa het.
Tai lieu tham kh&o
1. Itoi T et al. Endoscopic gallbladder drainage for management of acute cholecystitis.Gas- yointestEndosc, 2010;71: 1038-45.
2. Itoi T et al.Clinical evaluation of a novel lumen - apposmg metal stent for endosonog- raphy - guided pancreatic pseudocyst and gallbladder drainage. Gastrointest Endosc.
2011;75:870-6.
3. Jang JW et d\. Endoscopic untrasound - guided transmusal and percutaneous tran- shepatic gallbladder drainage are comparable for acute cholecystitis. Gastroenterology.
2012;142:805-11.
4. Masamichi Yokoe et al. TGI 3 diagnostic cri- teria and severity grading of acute cholecys- titis. J Hepatobiliary Pacreat Sci. 2013; 20: 35 - 4 6 .
5. Melloul E et al. Percutaneous drainage ver- sus emergency cholecystectomy for freat-
ment of acute cholecystitis in critically il pa- tients does it matter ? World J Surg, 2011;
35:826-33.
6. Rodriguer Sanjuan JC et al. Acute cholecys- titis in high surgical risk patents percutaneous cholecystectomy or emergency cholecystec- tomy ? AM J Surg.2012; 204: 54 - 9.
7. Toshio Tsuyuguchi et al. TG13 indications and techniques for gallbladder drainage in acute cholecystitis. J Hepatobiliary Pacreat Sci. 2013; 20: 81-88.
8. Yuichi Yamashita et al. Updated Tokyo guide- lines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Surg.2013;20: 1-7.
9. Yuichi Yamashita et al.TG 13 surgical man- agement of acute cholangitis. J Hepatobiliary Pancreat Surg. 2013; 20: 89 - 96.