I NGHIEN c i r u KHOA HOC
KET QUA Bl/aC DAU SCf DUNG TAM BIEU MO CUONG RON NUOI CAY DIEU TRI LOET GIAC MAC
KHO HAN GAN
Nguyin Dinh Ngdn*, Hodng Thi Minh Chdu**, Phan Todn Thdng***
TOM T A T
Loet gidc mgc khd ftdn gdn Id hgu qud cua nhicu h^nh ly khdc nhau. vi^c dieu tri den nay vdn ggp nhieu khd khan Sird{ing tam bieu md nudi cay dieu trj loet gidc mgc khd hdn gdn la hudng mdi trong dieu tri b^nh ly ndy
Muc tieu: danh gid hi(-u qud cua ghep tdm hieu md cuong ran nghien ciru dieu trj loet gidc mgc khd hdn gdn.
Doi tu-ong va phurottg phap: thiet ke nghien cuv can thi^p lam sdng. tien cuu.
Nghien ciru da tien hdnh ghep tdm bieu md cudng rdn nudi cdy dieu trj cho 16 mdt (16 b^nh nhdn) loet gidc mac khd han gdn tir 1/2011 den 1/2012 tgi khoa Ket Gidc mgc. B?nh vien .Mat Trung Vang. Cdc mdt ndy deu cd tinh trgng loet gidc mac keo ddi. thdi gian loet gidc mgc trung binh 8.8 ±3.2 tuan vd thaigiat) cd bieu hien kho han gdn trung binh 4,3 ± 7,5 tudn.
Ket qua: phdu thuat thdnh cong 15/16 mdt (93,7%). trong do cd 14 mdt d lien bieu md trong vdng 2 tudnsaughep. (jf 15 trudng h(rp thdnh cdng. vdi thai gian theo doi tir 6 den 19 thdng (11.5 ± 4 thdng.) di^n gidc mgc ghep lien seo. nhdn bdng. khong cd khdi tdn tgo. Danh gid tgi di^n ghep bdng test dp (impression cytology) thdy cdc te bdo cd hinh thdi cua te bdo bleu mo gidc mgc binh thirdng.
Ket luan: ghep Idm bieu md cudng rdn nudi cdy la phuang phdp khd hi^u qud trong dieu tri loet gidc mgc khd hdn gdn.
I. DAT VAN DE
Loet giac mgc khd hdn gdn la tinh trang d loet khdng bieu md hda sau khi dd dieu trj tich cue loai trir nguyen nhan gay benh. 6 lo^t tdn tgi keo ddi, tdn thuong sdu ddn trong nhu md ed the gay loet thiing, la benh ly nan gidi doi vdi cdc thdy thuoc nhan khoa. Cdc bien phdp dieu tri nhu ehdng viem, tdng dinh dudng be mat nhan cau, tang sy ben vung ciia phim nude mat (nhdm thuoc nude mdt nhdn tgo, huyet thanh tu than) [9] dgt kinh tiep xiic mem, khau cd mi da dugc dp dung, tuy nhien trong nhieu
* HQC vien Quan Y
** B?nh vien Mdt Trung irang
*** Dgi hoc Qudc gia Singapo
trudng hgrp qua trinh bieu md hoa giac mgc vdn khd khdn vd de dga den chiic ndng thj gidc. Trong giai dogn ndy ghep gidc mge cho kel qua han che do tinh trgng viem nhilmcuad loet, khd nang thai loai mdnh ghep m^nh, ddi khi loet khd hdn gdn xuat hien tai phdt tren mdnh ghep, hon niia khdng phai liic ndo ciing cd sdn nguyen lieu de thuc hien ghep.
Ghep mang o\ Id phuang phap mdi dugc ling dgng trong dieu trj loet giac mgc khd han gan trong 10 nam gan day, dii dugc chiing minh cd hieu qua, tuy nhien cac tac gia deu thdng nhat rang khdng
16 I Nhan khoa Viet Nam {So 29 - 2012)
NGHIEN CUtJ KHOA HOC I
nen sii dyng nhu Id bien phap dau tien d6 dieu tri vd ti 1? thdnh cdng khdng ddng nhat d cac nghien ciiu khdc nhau (31,4% -91,7%) [I],[4],[5]. Ngoai ra vif e sir dyng mdng 6i dS phyc hoi mgt phan nhu md giac mgc mac dii giiip lien biSu md nhung se Idm giam nhieu sy trong suot ciia gidc mgc, dnh hudng den chiic nang thi giac, dgc biet la cdc trudng hop ghep mdng di d trung tain qua tryc thj giac.
Bieu mo cudng rdn ban chat la bieu md mdng di bgc quanh cuong rdn lien tiep vdi da ciia thai nhi. Cac nghien cuu gdn day da chung minh cdc te bdo nay co tinh chat ciia te bdo gdc bieu md, cd kha nang bi?t hda thanh mgt sd logi te bdo bieu md khac nhau trong mdi trudng thich hgp [2], So sdnh vdi bieu md hk mat nhan cdu, Zhou Y, MacAry RA. vd cdng sy da phat hien te bdo bieu md cuong rdn nudi cay ed cdc marker gidng vdi te bdo nguon viing ria va bieu md gidc mgc, ddng thdi ed do an todn cao, khdng gay ung thu, ed kha nang su dyng de ghep tren ngudi [8],[10]. Reza va cgng su (2011) cung da cdng bd ket qud thuc nghiem su dung tdm bieu md cudng rdn nudi cay ghep tren mat thd dugc ggt sach bieu md gidc mgc va te bdo ngudn vung ria [7]. Ket qud cho thdy gidc mac thd vdn trong sau 10 tudn dugc ghep tdm bieu md, khdng cd tdn mgch.
Viec sii dung cac tam te bdo bieu md ung dung trong dieu trj loet gidc mac khd hdn gan ciing dugc nhieu tdc gid quan tam nghien ciiu. Gdn ddy, Parmar D.N, Alizadeh H va cdng sy (2006) da Idn dau tien cdng bd ket qua su dung tdm bieu md mdng di nudi cdy dieu tri thdnh cdng 3 trudng hgp loet gidc mge khd han gdn miic do nang [6].
Xuat phdt tir cac kk qud tren chung tdi da budc ddu sir dung vd danh gid hieu qud ciia tam bieu md cudng rdn nudi cdy trong dieu trj loet giac mac khd hdn.
ILDOITU'gfNGVAPHU'OfNGPHAPNGHIENCUtJ I. Doi tuffng nghien cihi
16 benh nhan loet gidc mac khd han gdn dugc dieu trj tai khoa K8t giac mgc - Benh vien mdt Trung uong tir 1/2011 dgn 1/2012.
Tat cd cdc b?nh nhdn deu dugc thdng bao ve quy trinh phdu thuat vd tinh nguyen tham gia nghien eiru.
Ti^u chuan lira ctwn
Nudi cay chat ngo 6 loet cho ket qua dm tinh vdi vi khuan, nam (vdi cdc trudng hgp loet nhiem triing).
Da dugc dieu tri ngi khoa het cdc dau hieu viem cap tren be mat nhan cau nhung d loet cd dau hi?u khd hdn gan vdi gd cugn bifiu md bd d lo^t va khdng cd bieu hien bieu md hda trong vdng 2 tuan.
Tieu chuan logi trie
Loet gidc mgc dga thiing hoac thiing.
6 loet cdn phan irng viem manh vdi bieu hien lam sdng: mu tien phdng, hoai tu, mat kich thich nhieu.
Benh nhdn cd quam hoac bien dgng, hd mi nang kern theo.
Cdc trudng hgp loet khd han gan do suy giam te bdo ngudn viing ria giac mac todn bd.
2. Phuong phap nghien ciru
Thiet ke nghien ciru: can thiep 1dm sang, tien ciiu, khdng ddi chiing, so sanh dge trudc vd sau dieu trj.
Phuang tien nghien cuu
+ Phuong tien, dung cy cho tham khdm va phdu thuat.
+ Tdm bieu md cudng rdn nudi cay: dugc nudi cay tgi phdng thi nghiem ciia bd mdn Ngogi, Dgi hgc qudc gia Singapore. Cdc tam bieu md trudc khi sir dung dugc danh gid vi the dudi kinh hien vi dien tir vd xac dinh cd cac marker ciia te bdo bieu mo be mgt nhan cau K3 (AE-5), KI2, MUC5AC va p63, ABCG2, Connexin 43
Quy trinh phau thuat
+ Dung dao ludi trdn (cresent knife) ggt Idy bd hogi tir, lam sach day d loet, tgo nen cho dien ghep.
Ddi vdi bd d loet, lam sach het phan bieu md benh ly phii, lien ket kem vdi nhu md phia dudi.
I NGHIEN CLfU KHOA HOC
+ Ddt tam bi6u md cuong r6n nudi c^y len tren 6 loet dd dugc lam sgch, eat tam bieu md khdng c6 mdng ddy ciing mdng gid dd ciia gJeng nudi cdy diing theo hinh dgng vd kich thudc 6 lodt. D^t up tam bieu md len diijn loel dd 1dm sgch. D^I kinh tidp xiic mem dudng kinh 11 mm che phu di?n dd ddt tam biSu md. Khau c6 dinh bdt chdo qua kinh tiep xiic bdng chi Vicryl 8/0 Ilico hinh dau cgng vdi diem co djnh sat ria.
+ Cac phdu thugt phoi hgp: trong mgt so trudng hgp cd iiiii lien phdng hogc xuat tiet bdm mgt sau gidc mgc, phau thugt nia mii tien phdng dugc tien hdnh dong thdi vdi vdi phau thudt ghdp tam bieu md.
Cham sdc sau md
+ Cat chi CO dinh kinh ticp xiic. kiem Ira tinh trang bieu md cua d loet sau phdu thuat 7 ngay.
Cac b?nh nhan da lien bieu md thudng dugc tiep tuc dat kinh tiep xuc mem tiep 1 tudn de dam bdo cho bieu md ben v&ng. Cac trudng hgp chua bieu md hda hoan todn cung dugc tiep tyc dgt kinh tiep xiic phdi hgp vdi dieu trj ngi khoa eho den khi lien ton thuang hoac sii dung phuong phap dieu tri khdc.
+ TTiudc sau md dung djch khdng sinh dugc sii dung den khi be mat nhan cau dugc bieu mo hod hoan toan. Dinh dudng be mgt nhdn cau bdng nude mat nhdn tgo khdng cd chit bao quan, huyet thanh ty thdn. Corticoid tra tgi chd dugc can nhdc sii dyng khi gidc m^c bieu md hda hodn todn. Thudc uong khdng sinh diing 7 ngdy sau phau thugt.
+ Cdc mdt sau m6 dugc ddnh gid tinh trgng te bdo tgi dipn ghdp bdng test ap (impression cytology) tgi thdi diem 1 thdng, 3 thdng, 6 thdng,
Ddnh gid ket qud
+ Thdnh cdng: 6 lo6t bieu md hda hoan toan sau mgl hay nhieu phdu thugt gh^p tam bieu md cu6ng r6n nudi c^y.
+ That bgi: o lo6t khong bieu mo hda hodn todn sau dieu trj ho^c loct Idi phdt trong vdng 1 thdng sau gh^p, c^n sii dyng phuang phdp dieu trj khdc (ghep gidc mge, ghep mdng 6i).
Ket qud phSu thu^t duftc chia thdnh cdc muc theo n-ubota (1999)/9/
+ Tot: gidc mgc bieu md hda hodn todn trong 2 tuan sau phau thugt.
+ Trung binh: 6 khuyet bleu md thu ggn sau 2 tuan phau thuat vd gidc mge bieu md hda hoan hodn todn sau 1 thang dieu trj.
+ Kem: tinh trgng khuyel bieu md keo ddi tren 4 tuan sau khi phau thuat, can ghep Ian hai.
i n . KET QUA NGHIEN CUtJ
Nghien cii'u tien hanh tren 16 benh nhan (10 nam, 6 nQ-) cd dp tuoi tir 26 den 76 (trung binh 59,1
± 11 tudi). Tat cd cdc trudng hgp deu chi loet giac mgc 1 mdt, cd 7 mdt phdi, 9 mdt trai.
Nguyen nhan gay b^nh dugc chia thdnh hai nhdm chinh: loet giac mgc do nhiem triing vd loet do logn dudng. So Ii?u cy the dugc trinh bay d bang I.
Bdng 1. Nguyen nhan gdy b^nh Nguyen nhan
Nhiem trung
Loan du'&ng
Nhiem virus Herpes Nhiem Idluan Nam Sau plilu thu^t Sau tia xa
Solu^ng 6 5 1 3 1
%
37,5 31,2 6,3 18,7 6,3
18 I Nhan khoa Viet Nam (So 29 - 2012)
J NGHIEN CUtJ K i
Trong nghien cii'u nhdm lo^t khd hdn gdn do Herpes chiem ti le cao nhat (37,5%), tuang dong vdi ket qud nghi6n ciiu ciia Nguyen Hiru Le (2002) [1] la 36,l%i (13/36 mdt). Nhdm logn dudng sau phdu thuat ed 2 mdt Id loet khd hdn gdn sau mo mdng va 1 mdt xuat hien loet sau phdu thuat thay th^ thuy tinh.
Cac mdt trong nghien ciru deu cd tinh trang lo6t gidc mac k^o dai, thdi gian lo6t gidc mge trung binh 8,8 ± 3,2 tuan va thdi gian cd bieu hi?n khd hdn gdn trung binh 4,3 ± 1,5 tuan (bieu do 1,2).
1
< 4 tudn 5 - Studn V - 12 tudn > 12 tudn BiL'ii dd 1. Thi'i'i i;iiin \tiiii hien hcnli
2 -<4 tudn 4 -< 6 tudn 6 - < N tudn > 8 tudn
Bieu do 2. Thai gian loet khd hdn gdn Qua bieu do 1 ta thdy trong nghien cihi da sd
mat (12/16 trudng hgp) cd loet keo ddi tren 1 thdng (> 5 tudn), trong do cd 8 mdt loet keo ddi tren 2 thdng (> 9 tuan), cd biet ed 1 mat loet gidc mac keo ddi gdn 4 thdng (16 tuan). Danh gia thdi gian loet khd hdn gdn, cd 12/17 mat cd bi6u hien khd han gan tren 1 thdng (tren 4 tuan) vd dac biet cd 1 mat loet khd hdn gdn keo ddi tdi 8 tudn.
Cac benh nhan tren deu da dugc di6u trj ngi khoa loet khd hdn gdn (dirng thudc gay dgc vdi gidc mac, tra mdt nude mdt nhdn tao, dung djch hyaluronate) nhung khdng cd bieu hien hdn gan ton thuong. Cd 1 benh nhdn da dugc ghep mdng o\
nhung sau mo van khuy6t bieu md keo dai (3 tuan) nen dugc phau thudt ghep tdm bieu md cudng ron nudi cay.
Trong 16 mat ghep tdm bieu md cudng rdn nudi cay cd 14 mdt cd tinh trgng thieu nude mat (test Shirmer I < 5mm) vd 7/16 mdt cd viem tac tuyen sun mi. Cac benh 1^ ndy cd the xudt hien trudc khi cd viem loet gidc mgc hoac Id hdu qud ciia tinh trgng viem be mat nhdn eau vd sii dung cde thudc keo ddi, nhung deu la yeu td quan trgng anh hudng den sy liSn ciia bieu md giac mac.
Cd 7/16 mat ed mu tien phdng, dugc phau thugt nia mu tien phdng phdi hgp ciing mdt thi vdi phdu thugt ghep tam bieu md.
Ket qua sau phdu thugt cd 16/16 mdt lien bieu md sau 1 -2 Ian ghep tam bieu md cudng rdn nudJ cay (bdng 2).
I N G H I I N ciru KHOA HQC
Biing 2. Kel qua sau phihi lhu(tl ghifp liim liieu mil cui'mg ri'm nudi c&y
Ket qu>^
So lirong Ti It (%)
TiSl 14 87,4
Trung binh 1 6,3
K£m 1 6,3
Trudng hgp mdt cd ket qua k<im dugc ghep Igi tdm bieu mo Ian 2 sau phau lhu§t liin Ihii nhat 4 tuan va cho ket qud lot, gidc mgc bieu md hda hodn todn sau phau thugt 1 tuan.
Tu;' nhien trong thdi gian Iheo doi. cd I mdi xuat hien loci lai phat sau phau thugl 3 luan. Day Id trudng hgp loet gidc mgc khd hdn gdn, Idc livt trong 60" sau tia xg (dieu trj ung thu vdm hgng).
Ca che loet giac mgc ciia trudng hgp ndy do Ion thuong than kinh, mat cam giac gidc mgc, ddng thdi do vi tri giac mgc bj day vdo trong nen mdng phim nude mat tren be mat nhdn cdu khdng dugc ddn trdi deu cung nhu sy bdo ve cua mi vdi gidc mgc ciing kem, do dd benh nhan dugc ti^p tuc dat kinh tiep xuc de bdo ve mac dii gidc mac da bieu md hda hodn todn sau phdu thugt 1 tuan. Tuy nhien su bdt thudng tuong quan giira vj tri ciia Bdng 3. Ket qud thi
gidc mgc vdm i do Idc li?l 1dm cho mdt nay rat kho luu gid' dugc kfnh tiep xiic vd thyc te b?nh nhdn lien lye bj roi kfnh sau khi cdt chi co djnh, B?nh nhdn xuat hi?n loiSt gidc mgc tdi phdt sau khi tudt kinh tiep xiic Ian cuoi 1 luan. Mac dii sau do, mdt ndy da dugc dieu trj bdng khdu cd ml 3 thang, nhung sau khi Ihdo cd mi, gidc mgc Igi loet tai phdt vd thung. Hi?n lai. b?nh nhdn dd tgm on djnh sau phau thugt gh^p mdng 6i dieu trj lo6t Ihung phoi hgp vdi khdu cd mi. Nhu vgy ti le thdnh cdng ciia nghien ciru Id 15 /16 mdt (93,7%).
Trong 15 mdt cdn Igi vdi thdi gian theo ddi trung binh 11,5 ± 4 thdng (tir 6 dSn I9thdng)chicd 1 mdt loet tdi phat sau phau thugt 2 thdng do nhiem nam va da dugc dieu trj khdi. Cdc trudng hgp khdc deu on djnh, khdng cd loet tai phdt, dien ghep cd xu hudng trong ddn theo thdi gian.
lire d cdc thai diem
~~~~~—^^__^ Thj luc ThM diem ^ ^ ^ ^ Tnroc phau thu|t (n= 16)
SauPTl thing (n=15) Sau PT3 thing(n-15) Sau PT 6 thing (n-15)
'•;<BNT3m
15 4 4 4
DNT 3m -
<20/200 1 5 5 5
20/200 - <20/60
0 4 3 3
> 20/60
0 2 4 4
Cde mat loet gidc mgc trong nghien ciiu deu cd thdi gian viem loet keo ddi nen thi lye trudc md rdt thap, da sd mat (15/16 mat) cd thj lye d miic mil Ida, dac biet cd 1 trudng hgp thj lye chi ST (+).
Sau phdu thuat 1 thang thi luc ed sy thay ddi rd r?t, cd 6/15 mdt thj luc tir 20/200 trd len, trong dd co 2 mat thj luc 20/50. Tinh trgng cdi thien thj lye ro ret trong 3 thdng ddu sau phdu thugt va cd xu hucoig
dn djnh tir thdi di6m 3 thang. Tuy vdy do tinh trgng logn thj khdng deu vd s?o md trong giac mgc nen sau 6 thdng ciing chi cd 4 trudng hgp thj lyc 20/60 - 20/50, khdng cd trudng hgp ndo thj lyc tot, tir 20/25 trd len.
Ket qud test dp t^ bdo be mat tgi dien gidc mac dugc ghep tam bleu mo so sdnh vdi vung giac mac lanh ciia ciing mdt, ciing b?nh nhdn d cdc thdi diem
20 1 Nhan khoa Viet Nam (So 29 - 2012)
NGHIEN CU*U KHOA HOC
1 thdng, 3 thdng, 6 thdng cho thay le bdo cd hinh thdi te bdo bieu md gidc mgc, hinh da dien, kich thudc tuang ddi ddng d6u, diing sdt nhau vd cd nhdn trdn deu. Khdng cd hinh dnh te bdo bieu md bat thudng, nhan qudi, nhdn chia.
IV. BAN LUAN
Loet gidc mgc khd hdn gdn Id tinh trgng d loet khdng bilu md hda sau khi dd dieu trj tich eye logi tru nguyen nhan gdy benh. Tinh trgng khd bieu md hda d loet tren giac mac cd the do cac te bao biSu md bj ton thuong mat sy tang sinh, d6i mdi li§n tuc hoac do Idp bi§u md mdi hinh thdnh khdng tao dugc lien ket vdi Idp nhu md phia dudi va bj bong di. Vi vgy cdc phuong phdp dieu tri loet khd han gdn tu trudc den nay chii ylu tap trung vdo hai nhdm chinh:
Tgo ra mgt dien nen phii hgp tren d loet de bieu md tdng sinh, vi dy nhu ggt giac mgc, ghep mangdi...
Kich thieh, tao dieu kien cho cac te bdo bieu md xung quanh phdt trien ehe phu d tdn thuong, vi du nhu tra huyet thanh ty than, dat kinh tiep xiic, khau cdmi...
Tuy nhien, mdi mgt phuong phap deu cd uu nhugc diem khac nhau, va qua trinh nghien ciiu, tim kiem cac phuong phap mdi dieu tri loet giac mgc khd hdn gdn vdn ludn dugc ti6p tuc. Gdn ddy, Parmar D.N., Alizadeh H. vd cdng sy (2006) da Ian dau tien cdng bd thii nghiem sir dung thanh cdng tdm bieu md mdng di nudi cay tren tam collagen (corneal collagen shield) cho 3 benh nhan loet gidc mac khd hdn gdn that bgi vdi cdc bien phdp dieu tri ngi khoa [6]. Sau khi nudi cay bieu md mdng 6i tren mat trong tam collagen, tdm nay dugc dat len be mdt giac mgc cd d loet khd hdn gan vd phu ngodi bdng kinh tiep xiic mem. Tdm collagen se bi phan hiiy sau 3 ngdy vd kinh ti6p xuc dugc thao ra sau mgt tudn de ddnh gid tdn thuang. Phan tich co che lien bieu md, Parmar D.N vd cdng sy cho rang cd dugc sy lien d loet la do tac dgng sinh hgc ciia
bieu md mdng di vdi ede yeu to tang trudng (EGF, KGF, HGF. ,), khd ndng uc che viem vatang sinh tan mgch dd edi tgo vi mdi trudng cua 6 tdn thuong tren gidc mgc, giiip cdc te bao bieu mo gidc mac xung quanh tang sinh che phii lo^t, Ngodi ra tam bieu md nudi cay cung ddng vai trd nhu mgt khung dd te bao (scaffold) de cho cdc te bdo gidc mgc xung quanh di vdo 6 ton thuong. Mdt gid thuy€t cung dugc cdc tdc gid luu y Id bieu md mang 6i cd the lien ket tam thdi nhu md phia dudi de che phii o loet, tgo dieu ki|n cho bieu md giac mgc xung quanh phat trien. Dieu ndy xuat phat tir nghien ciiu thyc nghiem cua He Y.G, McCulley J.R (1999) [3]
khi ghep tdm bieu md mdng di nudi cdy tren giac mgc thd tdn thuong. Cde tdc gid thdy rang sau ghep 24h, cdc te bao bieu md mdng di da tdi phan cue, gdn chat vdi nhu md gidc mgc phia dudi bang cac the ban lien (hemidesmosomes) gidng nhu te bfo bieu md giac mac nudi cay, sau 10 ngdy phdu thuat 4/12 trudng hgp van phdt hien su tdn tgi cua cac te bao nay tren giac mac thd.
Bieu md cudng rdn hay bieu mo mang di cudng rdn Id phan bieu md ciia mang di bao bgc quanh cudng rdn, cd tinh chat sinh hgc va cau true hoan loan gidng nhu bieu md mdng di, nhung khd nang thu nhan, phan lap vd nudi cay thudn tien hon.
T6 bao biSu md cudng rdn nudi cdy dd dugc chiing minh hau nhu khdng cd khd ndng gay ung thu vd gdy thdi ghep khi tien hdnh cdy ghep [8], [10]. Gan ddy mdt sd nghien ciiu da phat hien te bdo bieu md cudng rdn nudi cdy cd cdc marker gidng vdi marker ciia t% bdo ngudn viing ria nhu p63, ABCG2, Connexin, Mucin vd CK3 (cytokeratin dgc hieu cho biSu md giac mac) [7],[10]. Reza va cgng sy (2011) da nghien euu thyc nghiem so sdnh hieu qua ghep tam bieu md cudng rdn nudi cdy, mang di don thudn vd khdng ghep gi vdi mat thd da dugc got sgch bieu md giac mgc vd 16 bdo ngudn viing ria [7]. K6t qud cho thdy d nhdm thd dugc ghep tam bieu md cudng rdn nudi cay cd 100% gidc mgc vdn
I NGHIEN cCrU KHOA HOC
trong sau phdu thugt 4 tuan vd sau 10 tuan Id 50%, trong khi dd cdc nhdm cdn Igi deu cd bieu hi?n suy gidm te bao nguon viing ria d cdc thdi diem thdm khdm. Ket qud md b^nh hgc cho thay 7-8 Idp le bdo bieu md rat ddy tren be m§t gidc mgc nhdm thd khdng ed gh^p, trong khi d nhdm gh^p mdng 6i Id Idp bieu md khd mdng nhung cd nhieu t^ bdo viem ndm dudi Idp mdng ddy. Ngugc Igi tren mfit nhdm thd gh^p tam bieu md nudi cay Id cdc Idp te bdo bieu mo Idt tang khdng simg hda vdi be mdt khd nhdn (gidng vdi bi^u md thd binh thudng trudc khi thyc nghiem).
Trong nghien cdu ciia chiing tdi lam bieu md cuong ron khdng cd mdng ddy dugc dat lip vdo di?n ton thuong vd co dinh bdng kinh tiep xiic mem vdi chi Vicryl 8/0 d ben tren. Ket qud sau cdt chi co djnh kinh tiep xiic (I tuan sau phdu thugt) cd 12/16 mdt d loet bieu md hda hodn toan, 2 mSt lien bieu md trong tuan thii 2, mgt mdt lien bieu md d tuan thii 3 sau phau thugt. Trong thdi gian theo doi tir 6 - 1 9 thdng, chi cd 1 mdt loet tai phdt phai chuyen phuang phdp dieu trj khdc (that bgi) vd 1 mat loet sau phau thugt 2 thdng do nhiem ndm, da dugc
di^u trj khdi. Ddnh gid di?n gh6p bdng hien vi den khe thay gidc mgc li^n s?o, nhdn bdng, khdng cd khoi tdn tgo. Ddnh gid tgi di?n ghdp bdng test dp (impression cytology) th^y cdc te bdo c6 hinh thdi cua te bdo bieu md gidc mgc, hinh da di?n, nhan trdn deu, Ii6n ket sdt vdi nhau.
Co ch^ lien bieu m6 trong lo6t gidc mac kh6 hdn gdn ciia phuong phdp ndy den nay van chua r5 rdng, nhung chiing tdi cho rdng hi$u qua ndy chu yeu Id do tdc dgng sinh hgc cua bieu md cuong ron nudi cay vdi cdc yeu to tdng trudng, lie che phan irng viem cdi thi^n vi moi trudng ciia o loet gidc mgc vd kich thich te bdo bieu md xung quanh phdt trien che phii ton thuong.
V. K ^ T LUAN
Gh6p tam bieu md cuong ron nudi cay Id mgt phuang phap khd hi?u qua trong dieu trj loet giac mgc khd ban gan, md ra mgt phuang phdp mdi, sii dyng tam te bao trong dieu tri b?nh ly khd khan ndy.
Tuy nhien can cd thdi gian theo ddi danh gia ddi hon cung nhu nhiing nghien ciiu sdu hon de danh gid ca che lien bieu md cua phuong phap nay.
TAI LIEU THAM KHAO
1. NGUYEN HCTU LE (2002). " Nghien ciiu phuong phdp ghep mang di dieu tri loet gidc mgc khd han gan", Lugn vdn Thgc sy Y hgc, Tnrdng Dgi hgc Y Ha Ngi.
2. DO D.V., MASILAMANI J., LIM I.J., PHAN T.T. (2009). "Derivation of Heptocytes from Human Umbilical Cord Lining Epithelial Stem Cells", chapter 26, in Stem Cells: From Bench to Bedside (BongsoA and Lee E.H editors.), 2nd edition. World Scientific Publishing Group, Singapore.
3. HE Y.G, ALIZADEH H., KINOSHITA K., MCCULLEY J.R (1999). "Experimental Transplantation of Cultured Human Limbal
and Amniotic Epithelial Cells onto the Corneal Surface", Cornea. 18(5). pp 570-579.
4. LEE S.H.,TSENGS.C.G.(I997). "Amniotic membrane transplantation for persistent epithelial defects with ulceration". Am J Ophthalmol, 123, pp 303-312.
5. LETKO E., FOSTE C.S. ET AL (2001).
"Amniotic Membrane Inlay and Overiay Grafting for Corneal Epithelial Defects and Stromal Ulcers", Arvh Ophthalmol, 119, pp 659-663.
6. PARMAR D N, ALIZADEH H, EL AL (2006). "Ocular surface restoration using non-surgical transplantation of tissue cultured human amniotic epithelial cells", Am J Ophthalmol, 141, pp 299-307.
22 I Nhan khoa Viet Nam (So 29 - 2012)
NGHIEN CUti KHOA HOC I
7. REZA HM, NG BY, GIMENO FL, PHAN TT, ANG LR {2011). "Umbilical Cord Lining Stem Cells as a Novel and Promising Source for Ocular Surface Regeneration", Stem Cell Rev. 7(4):935-47.
8. SIVALINGAM J., KRISHNAN S., PHAN T.T. ET AL (2010). "Biosafety Assessment of Site-directed Transgene Integration in Human Umbilical Cord-lining Cells", Moi Ther. 18(7), pp 1346 -1356.
9. TSUBOTA K., GOTO E., SHIMMURA S., SHIMAZAKI J. (1999). "Treatment of persistent corneal epithealial defect by autologous serum application". Ophthalmology, 106, pp 1984 -1989.
10. ZHOU Y, MACARY P A, ET AL (2011).
"Characterization of Human Umbilical Cord Lining Derived Epithelial Cells and Transplantation Potential", Cell Transplant. 2011 Mar 24. doi:
10.3727/096368910X564085. [Epub ahead of print]
SUMMARY
Persistent corneal epithelial defect (PED) is a consequence of many ocular surface disorders. The treatment of this disease have faced a lot of difficulties up to now. The transplatation of epithelial cells sheets is the new promised method for PED.
Purpose: to evaluate the outcome of the transplatation of epithelial cells sheets in treatment of eye with PED.
Methods: Our study of tissue-cultured human cord lining epithelial cells transplantation was carried out in 16 eyes of PED (16 patients) fi-om January 2011 to January 2012 in Department of Cornea and External diseases, Vietnam National Institute of Ophthalmology.
Results: All of these eyes were sufferdfrom long time corneal ulcer with average time 8.8 ± 3.2 weeks, and average time of PED 4.3± 1.5 weeks. Fifteen of 16 eyes were healed with the cells transplantation and 14 eyes of them healed within 2 weeks postoperatively. There are normal corneal scars and normal corneal epithelial cell (by impression cytology detection) on transplantation site in all 15 successful cases with 6 — 19 months follow-up.
Conclusion: tissue-cultured human cord lining epithelial cells transplantation is a quite effective treatment for persistent corneal epithelial defect.