NGOAI KHOA S 6 4/2011
KET QUA DIEU TRj PHAU THUAT NOI SOI VIEM TUI MAT CAP DO SOI
TAI BENH VIEN DA KHOA THANH PHO CAN THO
Nguyen Van Nghia*
T O M TAT
Bat van de: Viem tui mat cap do soi la mot benh kha thi/dng gap trong cap cutJ ngoai khoa gan mat. Dieu trj ngoai khoa thay doi tiT mo md qua mo npi soi ke tu" khi Philippe Mouret (Phap) mo ca cat TMNS dau tien n3m 1987. Trong viem tui mat cap do soi, PTNS co nhieu kho khan, tai bien, thdi diem mo cung con ban cai. Vung dong bang song CLTU long nghien cilTu de tai nay chu'a nhieu PhuVng phap nghien cu'u: Hoi ciTu tat ca cac benh nhan di/dc cat tui mat noi soi dieu trj VTMC do soi trong thdi gian tir 1/2009 den thang 10/2010 tai Benh vien Da khoa TP Can thd. Chan doan xac dinh d u ^ vao cac dau hieu khi mo va ket qua giai phau benh. Ket qua: Co 139 tru'dng hdp gom 97 (69,8%) nff va 42 (30,2%) nam, tuoi trung binh la 55,8(19-93 tuoi). Benh npi khoa di kem: 54,38%, tien siS phau thuat bung:
6,43%. Cac trieu chCfng lam sang thi/dng g§p:
Oau (100%), Sot (56,87%), Phan u^ng HSP (47,48%), Tui mat t o (30,21%). Trieu chu'ng can lam sang thu'dng gap: Bach cau tang>
10000/mm3 chiem 57,5%. Sieu am thanh tui mat day> 5mm 5 9 , 7 1 % . Su" dung 3 trocar chiem 95,7%. Thdi gian phau thuat TB: 106,9 phut. Cat TM thanh cong d 95,68%, ehuyen mo hd 6 ca (4,32%). Bien chuing sau mo: 2 0 , 1 % . Khong tru'dng hdp nao X.\i vong hoac phai md lai. Kit tuan: PTNS la an Ixjan, hieu qua, la phu'dng phap du'dc chpn d da so benh nhan VTIMC do soi.
S U M M A R Y
Background. Acute gall bladder infection by cholecystolithiasis is quite common in
* B4nh viin da Ichoa thdnh phd Cdn Tha
hepatobiliary interventional emergency. An era of laparoscopic cholecystectomy has been blossomed since Philippe Mouret (France) firstly implemented in 1987. Technics of laparoscopic cholecystectomy due to acute calculous cholecystitis is difficult, complicated, and highly transferred to open surgery... Methods. AH laparoscopic cholecystectomies of acute gall bladder infection by cholecystolithiasis done from 1/2009 to March 10/2010 at Can tho general hospital. Diagnosis based on figures of symptoms and signs, subclinics and results of pathology.
Results: 139 cases including 97 (69.8%) female and 42 (30.2%) male, mean age 55.8 (19-93 years). Medical conditions included: 54.38%, a history of abdominal surgery: 6.43%. The common clinical symptoms: pain (100%), fever (56.87%), right upper quadrant guard (47.48%), gallbladder tenderness (30.21%). Clinical symptoms common: White blood cells over 10000/mm^ up at 57.5%. Gallbladder thickness on ultrasound > 5 mm at 5 9 . 7 1 % . Three trocar approach applied 95.7%. Average surgical time:
106.9 minutes. Successful cholecystectomies in 95.68%, open surgery transfer to 6 cases (4.32%). Postoperative complications: 2 0 . 1 % . Neither death nor re-operation confronted.
Conclusions: Laparoscopic cholecystectomy is safe, effective, and firstly choiced for acute calculous cholecystitis in well - equipped centers
I. O^TVANOE
Viem tiii m£it edp do soi la mgt benh kha thuang gap trong cap ciiu ngoai khoa gan
NGOAI KHOA S6'4/2011
mat. Dieu trj ngoai khoa thay doi tCr mo m6 da CO tir tren 100 nSm qua sang mo npi soi ke tir khi Philippe Mouret (Phdp) mo ca cdt TMNS ddu tien nSm 1987. Trong tinh trang VTMC do soi, cat TMNS c6 nhieu kh6 khdn, tai bi^n, thdi diem mo cap cthi hay tri ho3n?
thoi gian mo k6o ddi, li 1^ ehuyen mo hd eao hoTi khi ttii m$t khong viem. Ci trong nucVc vd viing dong bang song Cthi Long, nghien cihi van de nay chua nhieu. Vi v^y chiing toi thuc hipn nghien cthi ndy
M. PHUONG P H A P N G H I E N CCTU
Hoi cihi ede tnrong hpp viSm ttii mat cap do soi du^c dieu tii bdng phau thuat npi soi cat ttii mat, t^ b?nh vipn Da khoa thdnh pho Cdn Tha tii 1/2009 d6n 10/2010. Chdn dodn VTMC do soi dua vdo ede dau hieu lam sdng, x^t nghiSm, sieu am bung, thuang ton khi mo vd ket qud GPBL
So lieu thu thap chii yeu ve khdo sat cdc trieu chtjmg lam sang, can lam sdng, thai gian mo ke tir khi nhap vi^n, thai gian mo trung binh, ti le thanh cong, ehuyen mo ho, thoi gian nam vi?n trung binh, tai bien trong mo, biln ehiing sam sau mo...
Ddnh gid ket qud( Tu khi m6 den khi ra vi?n), chia ldm 4 logi:
Tot; Dien biln trong mo thuan lai, lam sdng vd cdn sdng trd vl g4n binh thudng, hit dau. Sieu am binh thudng,
- K.hd: C6 biln chting nhe, xu ly kjp thdi trong mo ho^c bang ngi khoa
- Trung binh: Biln chiing cin m6 lai - Kdm: B?nh ti> vong hode xin vl Xij ly so li?u theo phuang phap thing ke y hpc, sii dyng phan mem SPSS 17.0. Sir dyng ede test thong ke y hpc. Tinh tri so P tim sy lien quan ciia cac bien so khdo sat.
Trinh bdy qua cae bdng, bieu.
III. KET QUA
Vdi 139 b?nh nhan viem tiii mat edp do soi dupc phau thuat noi soi cat tiii mat tir thang 1/2009 din thdng 10/2010 tai Benh vien Da khoa thdnh phd Can Tho. Chiing toi thu dupc eac ket qua nhu sau: Tuoi tmng binh Id 55,8 (19- 93 tudi), gdm 97( 69,8%) n& va 42 (30,2%) nam. Ti le Nam/N& la 1/2,3. B?nh npi khoa di kem: 54,38%, tiln sii phlu thudt byng: 6,43%.
M$t so dac diem ISm sang va can lam sang:
Bang 1: Trieu chiing ldm sang Trl«u chu^q LS
Oau diTdl su'dn P Sot > 37,5°C Phan iJnq HSP Tui mat to Soc
n=139 139
79 66 42 0
Ti le »/o 100%
56,83 47,48 30,21 0
Cac diu hi^u lam sang thuang gap luc nhap vien 14: Dau, Sot, Phan ling HSP, Tiii mat to.
Khong CO benh nhan nhSp vien trong tinh trang s6c
NGOAI KHOA s o 4/2011 Bang 2. Ket qua sieu am gan mat.
Dau hieu sieu am Soi tui mat
Tui mat to
Thanh tui mat day > 5mm Soi ket CO tui mat Dau Murphy tren sieu am Dich quanh tui mat Dich du'di qan
n=139 125
52 83 37 67 48 11
Ty le % 89,92%
37,41 59,71 26,61 48,20 34,53 7,91 Ket qua sieu am thanh tiii mat day > 5 mm chiem 59,71%, dieh quanh tiii mdt 34,52%
Bang 3: Phdn loai ASA trudc md
ASA I II III Tong c6ng
n=139 36 94 9 139
Ty le »/o 25,9 67,6 6,5 100
Bang 4. Thai diem mo.
Thdl diem mo Mo tru'dc 72 qid Mo sau 72 qid Tonq conq
n=139 79 60 139
Ty IS »/o 56,8 43,2 100
Bang 5. Tinh trang tui mSt quan sat khi Tinh treng tui mSt Tui mat phu ne, yiem mu Tui mat hoai ttt Tonq conq
mo n=139
97 42 139
Ti le ( % ) 69,78 30,22 100
Bang 6. Xix ly ong tiii mat Xu* ly ong tiii mat Dunq clip
Cot chi Tonq conq
n=139 127
12 139
TV le % 91,37
8,63 100
NGOAI KHOA S6«2011 cat TM thinh cong 6 (95,7%), ehuyen
m6 hd 6 ca (4,32%). Bien chimg sau m6:
20,14%. 6 trudng hgp ehuyen mo md gom 3 trudng h(7p ch4y mdu khd cam. 3 trudng hcjp dinh nhi^u viing c6 tui mjt. C6 4 trudng hgp cat tiii m&t bin ph^n chira Igi c6 tOi m§t, do cau true viing c6 tui mSt thay d6i, dinh nhieu.
Thdi gian mo trung binh 14 106 phut.
95,7% c4c trudng hgp mo vdi 3 trocar. S6 trudng hgp din luu dudi gan 102 trudng hgp, chi^m 77%. Khong c6 trudng hgp n4o bi t6n thugng dudng m^t
Tai bi^n tromg mo chu yeu 14 ch4y mdu, thiing tiii mgt dugc xir tri trong md (cd 3 ca chuydn mo hd).
B4ng 7. Bi^n chimg sau md Loai bien chu'ng Tu dich VLinq dudi qan Nhiem triinq io trocar Rd mat sau mo Tonq conq
n=139 15
9 3 27
Ty IS »/o 10,79
6,47 2,88 20,1%
Cdc trudng hpp bien chiing sau mo dieu tri npi khoa, khdng phdi md iai.
Thdi gian ndm vipn trung btnh 5,1 ngay (2-16 ngdy) Khdng c6 trudng h ^ ndo tii vong
Kit qud sau md: Tdt 117 trudng hpp (84,17%). khd 15,83%.
IV. BAN LUiBiN
Viem hii mat c^p do sdi ehilm tren 90%.
PTNS da ehiing minh s\r an toan vd hieu qua [1]. Tuy nhien vdi VTMC cd cd mdt sd y kien: Thdi diem md cap cim hay tri hoan, cac khd khan khi bde tdeh, dinh, biln ddi gidi phau khi tiii mat viem, nguy co tai biln, biln chiing cao hon m6 md. Vdi viem tiii mat hosii tii vi^c phau thuat npi soi edn khd khdn hem [2], [8].
Ve thdi dilm m6 sau khi nhap vi$n nghiSn ciru ciia chiing tdi khdng thiy sir khde bi?t giila mo trudc v4 sau 72 gid, nhieu tdc gid Cling ung hg mo s6m sau khi nhap vi^n trong vdng 48 gid de gi4m ti le chuySn mo.
hd[6],[ll].
Cac trifu chiimg lam sang va can lam sang cho thiy tri$u chung cua viem tui mat cip do sdi kha ro: Dau b\ing, phan irng thdnh
bving HSP, tui mat to. Bach cau tang, sieu am th4nh ttii mdt d4y, cd dich quanh tiii mdt. Mot sd tac gi4 khac cung cd nhdn xet tuong ty [3].
Sieu dm rit hiJu ich trong chan dodn, theo doi v4 dilu tri. KSt qua sieu am thanh tiii mat day
> 5 mm 14 59,71%, sdi k?t c6 tui mdt Id 26,61%.
Tui mat ho^ tii quan sdt khi mo 14 30,22%. Tat ca 6 trudng hgp ehuyen mo hd cua chiing tdi dSu la VIM hoai til. DiSu ndy cho thdy viSm tiii mat ho^ tu Id ySu td du bdo kho klian vd nguy co cua cudc md [9], [10].
Da s6 cdc trudng hgp chiing tdi sil diing 3 trocar (95,7%), cd 6 trudng hgp su dung 4 trocar. Cdc tde gid khde ciing thudng sii dung 3 trocar [4], [12].
Xir ly 6ng tiii m^t da sd ehiing tdi diing kep clip (91,37%), cd 12 trudng hgp cgt chi
NGOAI KHOA SO 4/2011
tan cham, nhi§u tac gia cho rdng cpt chi cd nhieu imdi8m [5], [13].
Din luu sau md 107 trudng hop (76,9%) vd thudng nit sau 48 gid. Dan luu giup trdnh tu dich, mau sau md, phat hien rd mat [14].
Benh npi khoa kem theo cung Id van de khi chpn mo npi soi. Can ddnli gid trudc mo theo ASA. Chiing tdi klidng cd trudng hop nao ASA >IV, ehii ylu ASA IMII
Cac tai bien thudng gap khi md Id thiing tiii mat, chay mau, rai sdi ra d bung. Do thdnh tui mdt bi viem day, khd cam nam bang dung cu nen de bi rdch. Phan ling viem cung lam cho mau de chdy ri rd, khd cam han [15]. Chung ldi gSp thiing tiii mat trong 17,9%, chay mau 18,7%. Tat ca cdc tai bien nay deu xu tri bang ndi soi khdng phai ehuyen mo md, khdng phai truyen mdu. Tdn thuong dudng mdt la tai bien cao hon mo hd, nguy hiem. Chiing toi cd 4 trudng hop rd mat, cd thi do tdn thuong nhanh mat phu viing giudng tui mat dd vao gan, dieu tri npi khoa dn khdng can md lai. Can bde tach viing tam giac gan mat, thay duoc dng mat chii, dng gan chung trudc khi k?p Ing tiii mat, cdn cdn than khi cam mdu bang dot vimg ed tiii mat, bde Id viing tiii Harmann de tim dng tui mat, hoac cdt tiii mat tir day, cat tiii mgt ban phdn chua lai viing ed, cd 4 trudng hpp chiing tdi cat chira lai viing cd tiii mat
Cac biln chiing sau md: Tu dich dudi gan: 10,7%, nhiim trung Id trocar 6,4%, rd mat sau md 2,28%. Cdc bien chung nay cung duoc dilu tri bdng npi khoa, ldm keo ddi thdi gian ndm vien vd gay lo lai^ cho ngudi benh [7].
Thdi gian md trung binh: 106,94 phiit, tuang tu cac tac gid khac [3], [8]. Trudng hop md keo dai nhdt Id 240 phiit, trudng hpp ndy dinh nhilu. Ca md keo ddi nhdt trong
nghien ciiu ciia Nguyen Van Hdi Id 295 phiit [4]. Thdi gian md k^o ddi ndi len kho khdn ciia cat TMNS khi tiii m | t viem cap: Chay mdu, dinh, thay ddi, mat cau true viing cd tiii mat, mdt thdi gian edm mdu, hiit rua... Theo chung tdi khdng nen ddt mdc cho thdi gian md, phdi ndm vung gidi phau viing cd tiii mdt de trdnh tai bien.
Thdi gian nam vien trung binh 5,1 ngay, lau nhat Id 16 ngdy do cd bien chiing rd mat.
Thdi gian md cua ehiing tdi cung tuong tu ede tdc gia kliac
V. KET LUij^N
Cac trieu chiing LS vd CLS tuang ddi ro trong VTMC do sdi, kit qud PT cho thdy md sdm s6 giam thdi gian nam vien, bdt dau, mau hdi phuc.
Kit qud dilu tri tdt 84,2%, khd 15,8%, khdng cd trudng hop nao phai md lai, khdng cd tai bien nang hoac tu vong.
PTNS dilu tri VTMC do sdi Id khd thi, an todn, hieu qud.
TAI LIEU THAM KHAO.
1. LS Trirfrng Chien, Nguyen Tan C i r ^ g , Pham Hftu Thien Chi va cs (2010) "Phlu thuat noi soi dieu tri viem tiii mat cap: Danh gia l^i kit qua qua 686 ca", Ngogi khoa sd dac bi^t 4-5-6, trang 61-67
2. NguySn TSn Cu-ffng, Ph^m Huii Thien Chi, Biii An Tho va cs (2008) "Ro mat sau phlu thuat gan mat". Y hQC thdnh pho Ho Chi Minh tap 12, phu ban ciia so 3, trang 81- 86.
3. D^ng Thanh Dong (2010) "Mo ta dac dilm lam sang, ciin lam sang va ket qua phau thuSt npi soi cat tui mat cap ciiu do viem tiii mat
NGOAI KHOA s d 4/2011
edp", Lugn van tot nghidp bdc sT ehuyen khoa cap 2, Dgi hoc Y Hd npi.
4. Nguyen Vdn Hdi, Nguyin Tu^n (2005) Ket qua cua cdt tui mat npi soi trong viem tiii mat c^p do s6i", Y hoc thdnh pho H6 Chi Minh tgp 9. so 2. trang 109-114.
5. Trkn Bdo Long, Doikn Thanh Tung (2006)
" Nghien ciiu phdu thuat cdt tiii mgt npi soi khong dirng clip", Y hgc Vi?t Nam .so 9, trang 25-31.
6. Le Quang Minh, Nguyen Cu6'ng Thinh (2009) "L^a chpn thdi gian cdt tiii mat npi soi dieu trj viem tiii mgt cap" Tgp chi ngogi khoa. Tgp 59, so 3. NXB Yhgc, trang 31-37.
7. Tran Vin Phoi, Nguyin Hoang BSc (2003)
"Thiing tiii mgt trong cdt tiii mat npi soi", Y hgc thdnh phd Ho Chi Minh, Tgp 7, ph^i bdn sd I. trang 39-47.
8. Hd van Quyet, Hoang Viet Dung (2007) "
Nghien ciru d^c di^m b?nh ly va ket qua dieu trj phau thugt viem tiii mgt d ngudi cao tuoi", Ngogi khoa so 4, trang 40-44.
9. Atta H Soomro, Ajaz A Memon (2005)
"Role of Laparoscopic Cholecysectomy in the Management of Acute Cholecystitis", Jlumhs May- August, p 68-71
10. L.H. Blumgart, Y Fong (2000) "Surgical and radiologic anatomy of the liver and
biliary tract", Surgery of the liver and biliary trad. W.B. Sounder, U.K. p 3-34.
n . Chung-Mau Lo, Chi-Leung Liu (1998)
"Propective Randomized Study of Early Versus Deleyed Laparoscopic Cholecystectomy for Acute Cholecystitis", Annals of Surgery. Lippincott- Raven Publishers. Vol 227. No 4. p 461-467.
12. U Giger, J M Michel, R Vonlanthen (200S)
"Laparoscopic Cholecystectomy in Acute Cholecystitis: Indication, Technique, risk and outcome" , Langenbecks Arch Surg ,390, p 373-380
13. Margret Oddsdottir and John G. Hunter (2006) Gallbladder and Extrahepatic Biliary System" Schwartz's Manual of Surgery, The Graw-Hill Companies, p 821- 834.
14. W. K. Peng, Z. Sheikh, S. J. Nixon (200S)
"Role of laparoscopic cholecystectomy in the early management of acute gallbladder disease", British Journal of Surgery: 95:
586-591.
15. Steven M Straberg (2008) Acute Calculuos Cholecystitis", The New England Journal ofMedecine. 358. p2804-2811
