ciru ung

Nghien ciru ung dung vat da nhanh xuyen dong mach mong tren trong dieu tri loet vung cung cut do ty de

Application of superior gluteal perforator-base flap for repairing of sacral pressure sore

va Quang Vinh Vien Bdng Le Hihi Trdc

Tom tat

Oat van de: che phui loet do ty de bang vat da la bien phap dieu trj co hieu qua, vat da cP thudng hay dupc sddung. SU phat trien c u i vat da nhanh xuyen giup cac phau thuat vien tao hlnh thu dupc nhdng vat da ma khong can p h i i lay kem theo cP. Do do, vat dupc phan lap ma khong can phai hy sinh than cua dpng mach chfnh va han che sU bien dang cua vung cho vat. Vat da nhanh xuyen dpng mach mong tren thudng dupc sd dung de dieu tri ton thUPng loet do ty de vung cung cut. Ooi tupng va phUPng phap nghien cdu: 15 benh nhan loet vung cung cut do ty de dupc dng dung vat da nhanh xuyen dpng mach mong tren de che phCi vdi 4 vat V-Y va 11 vat dang canh quat. Vj tri cCia cac nhanh xuyen dupc xac djnh trong vong tron dudng kinh 5cm tai diem noi 1/3 gida va 1/3 dUdi cua dudng thing noi t d gai chau trUdc tren den u ngoi. So lupng cac nhanh xuyen xac djnh b i n g Doppler cam tay trUdc mo va khi phau tich trong mo se dupc ban luan trong bai bao nay. Ket q u i : 12 vat song hoan toan, vet mo lien ky dau, 2 vat vet mo cham lien va 1 vat hoai t d toan bp. So lupng cac nhanh xuyen xac dinh bing Doppler cam tay trudc mo va phau tfch dupc trong khi mo gan tuong dUPng, sU khac biet kh6ng dang ke. Ket luan: viec che phu ton khuyet loet do ty de la viec kho khan trong phau thuat tao hlnh. Tac g i i cho ring, vat da nhanh xuyen dpng mach mong tren an toan,'dang tin cay va la lUa chpn an toan nhat trong viec che phu loet vijng cCing cut.

TCf khoa: nhanh xuyen, dpng mach mong tren, vat da, loet ty de.

Summary

Background: flap coverage is essential for successful treatment of pressure sore, and musculocutaneous flap have been preferred. Development of peri^orator flaps has allowed reconstructive surgeons to harvest flap without including muscle. Thus, flap was elevated but not necessary sacrifice main trunk artery and reduced morbidity donor site. The superior gluteal perforator base flap was used popular for repair of sacral pressure sore.Patient and Method: 15 patients with sacral pressure sore were applied superior gluteal- base flap for coverage including 4 V-Y flaps and 11 propeller flap. Position of peri'orators has been determined in circle 5cm at point junction of the third and second one third of line is drawn connecting of superior anterior spine and edge of sacrum. Relation between number of perforators pre-operation (Determined by hand dopper) and number perforators dissected in-operation will be discussed in our paper. Results: twelve flap sun/ival completely; two flap secondary wound healing and one flap total necrosis. Number of perforators determined by hand Doppler pre-opreation and number of perforators dissected in-operation different no significantly. Conclusion: pressure sore management is a difficult issue in plastic surgery. We confirmed that superior gluteal perforator base flap is safety, reliable, and best choice for coverage sacral pressure sore.

Keyword; superior gluteal artery, perforator, flap, pressure sore.

PhSn bifn khoa hgc: PGS.TS. N G U Y I N TAI SON

JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 6 - N 3/2011 1. Oat van de

Loet do ty de vung cung cut thddng gap tren nhdng benh nhan nam l i u do dot quy, chan thdong cot song, suy mdn bdng...Vat co hoac vat da c i n cP thddng la sd Ida chpn toi du do dp day cua vat cung nhd sd cap m i u tot eua nd da g i i m thieu toi da loet t i i phat sau mo. Kroll va Rosenfield [1] n i m 1998 gidi thieu khii niem vat nhinh xuyen trong dieu trj ton khuyet vung mong. Sd linh dpng trong thiet ke va ban che toi thieu tdn thdPng nPi cho vat giup vat nhanh xuyen nay ngay cang ddpc sd dung nhieu hPn trong che phCi ton khuyet phdc tap do ty de.

Vat da nhanh xuyen dpng mach mong tren d i ddpc sd dung dddi dang vat ed cuong hoac vat t d do trong tao hinh cac ton khuyet khac nhau. Nim 1993 Koshima [2] lan dau tien da sd dung vat da nhinh xuyen cCia dpng mach mong tren che phu cho 8 benh nhan loet cung cut dem lai ket qua rat k h i quan. Vat ed dp day d i m b i o , it g i y ton thdong vung cho vat, cung xoay Idn va d i e biet sd linh boat trong thiet ke nhd dang V-Y, vat cinh quat lam cho hinh dang mong khong bj bien doi ma van d i m b i o muc dich che phu.

Tuy nhien, do dpng mach mong tren ed nhieu nhinh xuyen, de xic djnh chinh xic vj tri va tao thuan Ipi cho phau thuat vien trong phau thuat, t d t h i n g 8/2009 den t h i n g 2 nam 2011, tai khoa phau thuat tao hinh Vien Bdng Le Hdu Trie, chung toi d i tien hanh i p dung vat da nhanh xuyen dpng mach mong tren dieu trj cho 15 benh nhin loet cung cut do ty de. Lfu va nhdpc diem, tim va xac djnh vj tri nhinh xuyen de thiet ke vat se ddpc ban luan trong nghien cdu cua chung toi.

2. Doi ti/prng va phUdng phap nghien cufu 2.7. Doi tuang nghien cdu

15 benh n h i n ddpc dda vao dieu trj npi tru tai khoa phau thuat tao hinh, Vien Bdng Le Hdu Trie t d t h i n g 8/2009 den t h i n g 2/2011. Tuoi: 22-71 tuoi.

Gidi: nam: 13/15. Nd: 2/15.

Tieu chuan Ida chpn benh nhan:

+• Khong phan biet dp tuoi, gidi tfnh.

+ Benh nhan cd ton thdong loet vung cung cut.

+ Dieu trj lien vet thdPng b i n g phdong phip npi khoa khong ket qua.

Tieu chuan loai trd:

+ Benh nhan ed cac benh ly npi khoa ning nhd viem t i e mach mau, benh tieu dddng d i bien chdng...

-I- Benh n h i n tam than khong hpp t i e dieu trj.

-I- Benh nhan ton khuyet phan mem q u i rpng toan bp vung mong.

2.2. PhUcfng phip nghien cdu

2.2.1. Nghien cdu xdc dinh chon lUa nhdnh xuyen ddng mach mdng tren

Cac t i c gia tren the gidi Koshima, Shaw deu dda ra vj trf xac djnh nhinh xuyen eua dpng mach mdng tren la: diem noi 1/3 tren va 1/3 gida dddng noi gai chau sau tren va mau chuyen Idn. Nhdng trong nghien cdu nay chung toi xac djnh vi tri nhinh xuyen theo dddng landmark mdi nhdsau:

+ Vj tri tren da cua nhanh xuyen dpng mach mong tren ddpc xac djnh trong vdng trdn bin kinh 2,5 cm vdi tam la tai diem noi 1/3 dddi va 1/3 gida eCia dddng thang noi t d gai chiu trddc tren den u ngoi.

+ Sieu i m Doppler mach m i u cam tay tan so 5MHZ ddpc sd dung x i c djnh so Idpng nhinh xuyen trong vdng trdn nay.

2.2.2. Nghien cdu Idm sdng

Ton khuyet ddpc eat bo toan bp to chdc viem va bd mep xung quanh ton khuyet. Cam mau ky, lay bd xdong chet neu ed.

Thiet ke vat: Vat da ddpc thiet ke theo kich thddc tdn khuyet. Diem xoay cua vat chinh la vj trf nhanh xuyen ddpc x i c djnh trong vdng trdn ban kinh 2,5cm. T i m cCia dddng trdn la diem 1/3 dddi cda dddng thang noi gai chau trddc tren va u ngoi.

- Cic bddc phau thuat:

-H Vat da ddpc phau tfch t d ngoai vi den trung tam. Toan bp Idp can sau ddpc lay kem theo vat. Khi den vj tri dddng tron thiet ke, qua trinh phau tich ddpc tien hanh can trpng de xac djnh nhinh xuyen theo vj tri ddpc xac djnh trddc dd b i n g sieu i m Doppler. Cac nhinh xuyen se ddpc xac djnh sd phu

hpp ve vj tri gida phau tich lam sang va sieu am Doppler trddc mo. Cac nhinh xuyen ddpc phau tich sau xuong dddi co theo hanh trinh eua nd de lam ting chieu dai cua cuong mach, giup cho khi ning di dpng cua vat tot hdn. Cac nhanh xuyen se ddpc xic djnh dddng kinh ngoai bang thddc Palmer, sau do phau thuat vien se quet djnh Ida chpn nhinh xuyen chfnh cap mau cho vat. Cac nhanh nhd hon

khong phu hpp se ddpc t h i t bupe.

-I- Vat da ddpc xoay de che phu ton khuyet.

-I- Vung cho vat khiu ddng kin mot thi.

+ Dan Idu i p Idc am ddpc sd dung trong 3 ngay dau sau mo.

Co sd d i n h g i i ket q u i : Tmh trang song cda vat; sd lien seo sau mo; mdc dp phue hoi chdc ning va tham my.

- Ket q u i gan:

Tot: Vat song hoan toan, vet mo lien seo tot, khong viem rd, eit chi sau 10-14 ngay, khdng phii can thiep phau thuat gi khic. Chdc ning va tham my vung mo tot.

Vda: Vat thieu dddng, xuat hien phdng nddc tren be mat hoac hoai t d mot phan vat, cd hoac khdng phii ghep da bo xung. Hoac vat bj hoai t d Idp da nhung edn Idp cin, luc niy vat ed dang cin md, phii ghep da len Idp cin cua vat, vet mo bj nhiem khuan g i y toac.

. Xau: Vat bj hoai t d tren 1/3 dien tfch den hoai hoai t d toan bp, phii eit bd va thay the bang phdong phip dieu trj khic.

3. Ket qui nghien cufu

Bang 1. Nguyen nhin g i y ton thdong

Nguyen nhan So lupng (n)

Tyle

Chan thuong cot song 9

60%

Opt quj 3 20%

Khac 3 20%

Tong 15 100%

So benh nhan loet do ty de vung cung cut do chan thdong cot song chiem 60% sd benh nhin nghien cdu.

BSng 2. Hinh thdc sddung vat

Hlnh thdc sddung Vat V-Y Vat Propeller

Tong so

Solupng 4 11 15

Ti/le 26,67%

73,33%

100%

Vat Propeller ddpc sd dung chinh trong phau thuat chiem 73,33%.

Bdng 3. Tdong quan gida so Idpng nhinh xuyen trong dddng trdn b i n kinh 2,5cm va so Idpng vat sd dung

So nhinh xuyen So lupng vat T^le

1 nhanh 2 13,33%

2 nhanh 5 33,33%

3 nhanh 7 46,67%

4nhanh 1 6,67%

Trong dddng tron ban kinh 2,5em ed 3 nhinh xuyen ddpc xac djnh tren 6 vat chiem ty le 40%. 1 nhinh xuydn chi cd tren 3 vat chiem ty le 30%.

JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 6 - N 3/2011

Bang 4; Kich thddc vat va sd tddng quan ve so Idpng nhanh xuyen trong dddng trdn bin kfnh 2,5cm trddc va trong mo (n=15)

Benh nhan

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

Gidi/ tuoi

Nam/44 Nd/39 Nam/ 29

Nd/26 Nam/71 Nam/22 Nam/58 Nam/57 Nam/47 Nam/34 Nam/47 Nam/50 Nam/43 Nam/28 Nam/68

Kich thudc

1 0 x 7 1 2 x 8 1 4 x 9 17x11 15x10 1 8 x 9

16x9 17x10 13x12 18x11 1 7 x 8 16x10

1 5 x 9 15x11

1 4 x 7

So lupng nhanh xuyen trudc mo

3 2 2 3 2 2 3 3 4 2 4 3 3 2 3

So lupng nhanh xuyen trong md

3 2 1 3 2 2 1 3 3 2 4 3 3 2 3 Nhd viy:

- Chieu dai cCia vat: Idn nhat: 18 cm; nhd nhat: 10 em; trung binh: 15,2 em.

- Chieu rpng eua vat: Idn nhat: 12 em; nhd nhat: 7 em; trung binh: 9,4 em.

- So Idpng nhinh xuyen ddpc xie djnh bang Doppler tdong dng trddc mo va trong mo: 12/15 = 80%.

So Idpng nhinh xuyen ddpc xie djnh b i n g Doppler khong tdOng dng trddc mo va trong mo:

3/15 = 20%.

Bdng 5. Tinh trang vat

—-...^^^ Ket qua

Vat ^^~~~~~~---...^

Vat Propeller Vat V-Y Tong so Tyle

Tot

8 4 12 80%

Vda

2

2 13,33%

Xau

1

1 6,67%

Tmh trang vung cho vat: 100% ddpc khiu ddng kin 1 thi va lien ky dau.

Hinh 1: Vung xdc dinh nhdnh xuyen- vong trdn dudng kfnh 5cm, tdm Id diem noi 1/3 tren vd 1/3 gida dUdng noi tdgai chau sau

tren vdi mau chuyen Idn.

Hinh 2: Vung xdc dinh nhdnh xuyen-vong tron dudng kfnh 5cm,

tdm Id diem noi 1/3 tren vd 1/3 gida dudng noi tdgai chdu

trudc tren vdi u ngoL

Hinh 3: Cdc nhdnh xuyen duac phau tich.

Hinh 4: Vat duac phdn lap vdi cung xoay Idn.

4. Ban luan

Loet do ty de vung cung cut thddng gap tren nhdng b§nh n h i n n i m l i u do dot quy, chan thdong cdt sdng, suy mdn bdng (bing 1)... Vat co hoac vat da can co thddng la sd Ida chpn tdi du de che phCi, do dp day cua vat cung nhd sd c i p m i u t6t d i m b i o ddpc chdc nang ty de cda vung nay trong eupc song thddng ngay cCia ngddi benh, do dd l i m g i i m tinh trang loet t i i p h i t sau m6. Vat da CO mdng Idn da ddpc cong bo bdi Shaw n i m 1983 [3] v i Boustred [4]. Sau hdn hai t h i p ky' i p

Hinh 5: Vat che phu ton khuyet, vung cho vat khdu kin.

dung vat niy, du v i nhupe diem eCia vat cung d i ddpc nhieu t i e g i i b i n luan. Nhdng bat Ipi chinh cua vat da co nay la i n h hddng ket q u i tham my do vat q u i day, viJng mdng bj bien dang nhieu sau khi lay di mot vung da eo rpng va siu. Khi n i n g xoay vat bj han che do cuong mach n g i n , nhieu bien chdng d i x i y ra. N i m 1993 Allen va Tucker [5] d i c i i tien hinh thdc sd dung vat nay vdi viec ehi lay da v i md ma khdng can hy sinh eo mdng to. Sd cap m i u cho vat da c i n nay dda tren n h i n h xuyen xuat p h i t t d dpng mach mdng tren.

JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY V0I6-N 3/2011 cuong mach cap mau cho vat cd the phau tich s i u

den dpng mach mong tren thong qua viec tach qua Cd mong. Ky thuat nay cho phep phan lap ddpc cuong mach dai hon va hinh thdc sd dung cua vat cung phong phu hon. Vat ed the sd dung nhd vat cuong mach lien hoac sd dung dddi dang vat t d do. Giii phau eua vat cung ddpc nhieu t i e g i i nghien edu va cdng bo nhd Koshima 1993 [2], Boustred n i m 1998 [4]... Nhdng nhin chung cic t i e g i i deu thdng nhat dpng mach mong tren chia thanh 4 n h i n h : Nhinh len, n h i n h xuong, n h i n h ngang va n h i n h xuyen vuong gde. Trong hanh trinh cua nd cic n h i n h n i y deu cho cic nhanh nuoi CO va nhanh xuyen nuoi da. Va vat n h i n h xuyen dpng mach mdng tren deu dda tren cac n h i n h xuyen nay.

Hau het cic t i c g i i deu lay diem noi 1/3 tren va 1/3 gida eua dddng t h i n g noi gai chau sau tren va mau chuyen Idn lam tam de khu tru vj tri eCia cac nhinh xuyen dpng mach mong tren [2, 3, 4]. Tuy nhien, trong dieu trj loet vung cung cut, vijng n i y lai cich k h i xa ton khuyet, nen thddng phii lay kem theo vung da lanh lan can vdi ton khuyet khi thiet ke vat da (hinh 1). Nhd viy, vat can phii phau tich rpng hPn, mdc dp sang chan se ldn hpn. Trong nghien edu, chung toi nhin thay cd mot so Idpng nhinh xuyen nam xung quanh diem noi 1/3 dUdi va 1/3 gida di/dng noi gai chau trddc tren v i u ngoi, thddng la 2,3 nhinh (hinh 2, 3), tham chi cd trddng hpp cd tdi 4 nhinh xuyen (bing 3), tdong ddong vdi so Idpng nhinh xuyen d vung ma cic t i e g i i khic d i ap dung [1,2,3,4]. Cac nhanh xuyen nay lan can ton khuyet hon va giup cung xoay ciia vat trd nen linh dpng hon nhieu so vdi cic nhanh xuyen ma cac t i e g i i nddc ngoai da sddung.

Trong phau tich vat n h i n h xuyen, viec xac djnh chinh xie vj tri nhanh xuyen la van de het sdc quan trpng. Tai eae cP sd tuyen chuyen khoa, may Doppler thddng ddpc sd dung de giup cac phau thuat vien xie djnh vj tri n h i n h xuyen trddc mo.

Tuy nhien, trong mot so trddng hpp, sd dan cheo dddng di cua cic mach mau tao nen sd nham lan cho cac phau thuat vien ve vj tri nhinh xuyen do chong lap i m thanh khi dd mach bang may

Doppler. De tao thuan Ipi cho eae phau thuat vien cd the djnh hinh khu vdc tap trung nhanh xuyen cung nhd cic phau thuat vien tuyen co sd noi khong cd Doppler de xac djnh chinh xac vj tri nhanh xuyen trddc mo, nghien edu eua chung tdi khao s i t sd tdong quan gida so Idpng nhanh xuyen trddc mo bang sieu i m Doppler tan so 5MHZ trong b i n kinh 2,5cm vdi t i m la diem 1/3 dddi va 1/3 gida eua dddng noi gai chau trddc tren va u ngoi va so Idpng n h i n h xuyen phau tich ddpc trong khi mo. Ket qua cho thay gan nhd khong ed sd chenh lech ve so Idpng n h i n h xuyen trddc va trong mo, vdi ty le tdong ddpng la 80% (bing 4). Trong dddng trdn ban kinh 2,5em so Idpng 2 den 3 nhinh xuyen chiem da so trong vat nghien edu, dieu nay d i m b i o cho sd tin cay khi n i n g vat. Chung tdi cung cho r i n g khi khdng cd Doppler cam tay de xie djnh mach m i u , vdi cac phau thuat vien ed kinh nghiem thi ed the phau tich vat cd cuong can md vdi dddng kinh 5cm tai diem noi 1/3 dddi v i 1/3 gida eua dddng noi gai c h i u trddc tren va u ngoi, nhd vay se d i m b i o cho sd an toan cua vat.

Trong nghien edu cua chung tdi, vat nhinh xuyen ddpc sd dung dddi hai dang: vat cinh quat cuong ngoai vi (Propeller) v i vat V-Y. Chung tdi da thfeh sd dung hinh thdc thd nhat (11/15 vat) bdi vat ed che phu ddpc ton khuyet rpng, dp di dpng etia cuong mach lam cho vat cd cung xoay Idn, ed the xoay vat vdi gde 180° (hinh 4, 5), kich thddc eua vat dat tdi 18 cm X 12 cm, cd the che phu ddpc nhdng ton khuyet rpng. Dang vat V-Y ddpc sd dung cho 4 benh nhin, vat ed dp an toan cao, tuy nhien nhdpc diem la khong che phu ddpc ton khuyet rpng, trong trddng hpp do can phai sddung hai vat V-Y, nhd vay dddng khau tai dau xa hai vat nam tai vj tri khe mong nPi d i y 6 loet ma xdong cung hay bj Id. Do viy, neu qua trinh lien seo cham hoac nhiem khuan, vet mo de bj toac va k h i n i n g che phu xdOng cung se trd nen khd khin. Cd 1 trddng hpp vat dang each quat true ngoai vi bj hoai t d nguyen nhan do chiy m i u sau mo gay chen ep cuong mach, chung toi phai eit bo phan hoai t d va sd dung vat dang V-Y ben doi dien de che phu ton thdong. Do viy, chiy mau la mot bien chdng sdm, hay gap va nguy hiem.

can ddpc phat hien sdm va x d ly kjp t h d i , t r i n h chen ep cuong mach nuoi vat.

5. Ket luan

Loet do ty de v u n g cung cut can ddpc phau thuat b i n g vat cd d p day phu h p p de d i m b i o chdc n i n g dem d d , han che t i i p h i t . Vat n h i n h xuyen dpng mach m o n g tren la sd Ida chpn t o t cho c i c phau thuat vien tao hlnh t r o n g dieu trj t o n t h u o n g nay. Vat cd the phau tich nhanh xuyen hoac sd d u n g cuong can m d d d d n g kinh 5 cm vdi t a m la diem noi 1/3 dddi va 1/3 gida cija d d d n g noi gai c h i u trude tren v i u ngoi kha n i n g song eua vat ddpc d i m bao an t o i n .

Tai lieu t h a m khao

1. Kroll, S. S., and Rosenfield, L Perforator-based flaps for low posterior midline defects. Plast. Reconstr.

Surg. 81:561,1988.

2. Koshima I, Moriguchi T, Soeda S et al. The gluteal peri'orator-base flap for repair of sacaral pressure sore. Plast Reconstr Surg 91:678-683,1998.

3. Shaw WW. Breast reconstruction by superior gluteal microvascular free flaps without silicon implant. Plast Reconstr Surg 72:490-501,1983.

4. Boustred AM, Nahai F. Inferior gluteal free flap breast reconstruction. Clin Plast Surg 25:275-282,1998.

5. Allen RJ, Tucker C Jr. Superior gluteal artery peri'orator free flap for breast reconstruction. Plast Reconstr Surg 95:1207-1212,1995.