T C N C Y H PhM trUdng 80 (3B) - 2012
Amniotic bands in paternal half-siblings. 9. Salem SBA, Asaad HS, and David TN Clinical Dysmorphology 2010, 19:62 - 64 (2006). Threatened Lower Extremity in a Neonate 7. Pillay V K and Hesketh KT (1965). From a Severely Constricting Amniotic Band. A Intra-Uterine Amputations and Annular Limb ' ' ^ ^ ^ ^°' '-''^'' Salvage After a 6-Year Functional Defects in Singapore. Journal of Bone & Joint FoUow-u . Ann Plast Surg; 57: 569 - 572 Surgery; 4 7 ( 3 ) : 6 0 6 - 6 1 2 lO.Stevenson TW (1946). Release of
8. Samia AT, Mona SA, Adel MA and "™'^' constricting scars by z flaps. Plast Tarek HE (2010) Limb malformations with Reconstr Surg ; 1:39 - 42
associated congenital constriction rings in 11. Weinzweig N (1995). Constriction two unrelated Egyptian males, one with a band - induced vascular compromise of the disorganization-like spectrum and the other foot: classification and management of the with a probable distinct type of septo-optic "intermediate" stage constriction nng syndrome, dysplasia. Clinical Dysmorphology; 19:14 - 22 Plast Reconstr Surg; 96: 972 - 977.
Summary
SURGICAL T R E A T M E N T OF CONGENITAL CONSTRICTION RING IN CHILDREN Objective of study was to evaluate the clinical and functional results of a technical procedure in the surgical treatment of congenital constriction nng in children The results show that there were 86 patients (121 constnction nng), whom the average age at surgery was 1 years 2 months. There were three types of congenital constriction ring: Type 1 in 5 (4.1%), Type 2 in 107 (88.5%), and Type 3 in 9 (7.4%). Of the patients, 73.6% had good and 26.4% fair results All patients were operated on without complications, without skin necrosis or wound healing problem. In conclusion, this method is a simple and safe technique for surgicai treatment of congenitei constriction ring in children.
Keywords: Congenital constriction band syndrome, dermofat flap. Amniotic bands, Direct closure, Z-plasty
KiT QUA OIEU TR! PHAU THUAT NOI SOI SAU PHUC MAC C A T THAN BENH LY M A T CHiPC NANG
Chu Van Lam, Hoang Long Truxyng Dai hoc Y Ha Noi
Phau thuit cit thin npi soi (CTNS) sau phuc mac (SPMj duvc Gaur thuc hien dau tien vao nam 1993.
Nghien ciu dinh gii tinh hiiu qua, muc dp an toin vi rut ra nhang kinh nghiem de cd thi phat then ky thu ft niy tmng diiu tn cic benh If thin mit chirc ning. Kit qui cho thiy chi dinh cit thin u nuic mit chirc nang chiim 55,754 (do sol than - NQ 25,7%, hepBT- NQ 20%, hep NQ 20%) vi do than teo li 11,4%, thin da nang chiem 2,9% vi unuac thin - NQ phij la 20%. Chiing tdi sirdijng3 trocars trong 34,3% va 4 trocar trong 65,7%. Thai gian mi trung binh la 124,6 ± 36 phut, iuvng miu mit trung binh ii 73,9 ± 39.1ml. Cat
TCNCYH Phg trUdng 80 (3B) - 2012
th$n khd chiim 25.7%, liin quan din tinh tr^ng vidm quanh th$n vi m& diy quanh thin v&i 1 trw&ng h^
chiy miu phii chuyin md m&. 88.6%, cSt thin binh ly mit chOv ning d$t kit qui tdt Tl 1$ tai biin (ronj mi 2,86%, vi biin Chung sau md 5.72%,. Th&l gian nim vlin trung binh li 5,3 ± 1,7 ngiy
TLH khoa: Thgn mat chuc nang, cat thgn, phau thugt npi sol sau phuc mgc I. OAT V A N Dt
BOnh ly sbl dudng t i l l nlOu rit phi biln d Vigl Nam v i da phin bOnh nhin din khim khi soi d i giy biln chung u nude, u mu lim giam hay m i t chifc ning thOn dua din ty 10 cit thgn 28,99% - 34,29% [2,4]. Ty 10 cit thOn trong bOnh ly hgp b l thOn - niOu quin d ngudi Idn la 23,5%, cic nghiOn cuu trOn t h l gidi vO dj dgng bim sinh niy lim mit chuc ning thOn cd ty 10 o i l thOn eung khi eao tu 25% - 40%
[4]. Ti 10 cit thgn thay d l l tuy thupc vao giai dogn phit hign bOnh va mdc db suy giim chuc nang thgn.
Nhu'ng can thiOp tilt niOu i p dyng phiu thugt npi soi (PTNS) I bgng da chung tb dup'C nhilu uu diem ca dii vdi ngudi bOnh cung nhu kinh t l y te. Nam 1990, dayman R.V ap dyng ndi soi qua phiic mge (QPM) de c i t u thgn lin dau tiOn tren t h l gidi. Nam 1993 tgi An DO Gaur D. thye hiOn cit IhOn nOi soi (CTNS) qua dudng sau phuc mgc (SPM). Hign nay, PTNS da dupe triln khai rOng rai trong viOc dieu trj eae bOnh linh tinh v i i c tinh eua dudng tilt nigu [2]. Tgi ViOt Nam, tu nim 2000. PTNS d i dupe i p dyng dilu trj pic bOnh ly tiet niOu tgi nhieu bgnh viOn v i c i t thgn npi soi da dupe thyc hign tu nam 2004. ViOc then khai CTNS SPM d i dgt dup'C kit qua v i kinh nghiOm budc diu lim ca sd cho chiing tbi tilp eOn phiu thuOt niy v i tiln hanh d l tai nghiOn cuu vdi myc tieu: Dinh gii kit qua phlu thuOt nOi soi sau phiic mgc c i t thgn bgnh ly m i t chdc ning tgi BOnh viOn ViOt Due.
II. D 6 I TU'ANG VA PHU'aNG P H A P
1. Doi lu'p'ng
35 BN mo CTNS SPM tgi khoa Tilt ni#u,
bOnh viOn ViOl Due t u 1/2006 din 9/2011 co cic bOnh Iy sau; ThOn u nude mit chuc ning do sbl BT NQ, do bOnh ly bim sinh, do h?p NQ sau m l , thOn xa teo g i y ting huyet ap, IhOn da nang m i t chuc ning va u nude mit chdc ning thOn - NQ phy. NghiOn cuu khOng bao gIm' Cic bOnh Iy i c tinh ciia thOn, th§n if nude dp IV cb suy thgn, thOn u mu, tien sir mo cQ khoang SPM cung bOn, nhiem khuin thinh byng, nhiem khuin t i l l niOu chua dieu tn
2. Phuang phap nghien cuu Nghien cuu mb ta tiln cuu theo mb hlnii djnh sin bOnh nhan cd cac triOu chimg t^c nghen dudng tilt nigu tren: Dau thit lung, 6a\
bull, d i i rit hoOc d i i miu, khim thiy thgn to. Tiln su dilu trj soi, bgnh ly tilt nigu ho|c eb ting huylt i p d i p ung kOm hay khOng dip ung vdi dilu trj. Bgnh nhin dupe lam sieu am, chyp Xquang v i CTScanner hO tiet niOu, Doppler mgch thOn d l xac djnh nguyfin nhin. Chyp dong vj phbng xg xie ^nh chiic ning thOn. Xet nghiOm chuc nang ttiOn: Ure, creatinin.
Cit thOn nbi soi sau phuc mgc dupe dii djnh cho thOn bOnh Iy m i t chdc nSng: Chyp DVPX chue nang th^n <10%, th$n u nudcd$
IV hoOc thOn teo giy tOng huylt i p . Dinh gia trong m l : Thay dii huylt flOng.
ning db O2 va COj mau qua SpOj v i PetCO;
gay mO hli sue. Luang m i u mit va m^u truyin. Cic bien ehung trong mo; Chay m^u do t i n thuang mgch, t i n thuang tgng kh^cdo phau tich. chuyin m l md.
Dinh g i i cic y l u to liOn quan din kit qu^
phiu thugt: NhOn djnh t i n thuang va phin ticli cic y l u tl-nguy ca g i y khb khin cho pM"
138
TCNCYH Phy trUdng 80 (3B) - 2012 thuOt va gay biln chicng trong, sau m l : BN
bOo phi, khoang each bd sudn - mao chOu ngin, tien su mo cu, tan soi ngoai ea thl, tin soi npi soi nguac ddng, viem thgn - b l thgn cu, thgn to ie nude, thgn xa teo, bit thudng mgeh mau, rich phiic mac, ton thuang tgng, chay mau trong m l ,
Dinh gia sau mo: Huyet dpng, dau sau ml, so lup'ng nude tilu, Igp igi luu thong lieu hoa, Iran khi dudi da v i so lupng djch qua 2. Chan doan thgn bgnh ly mat chuc nang
Bang 1. Thai gian bieu hign cac trigu chung lam sang
din luu. Thdi gian nim vign, kit qua giii phiu bOnh. Theo ddi xa sau mo: Danh gia chuc nang thgn va phit hien bien ehung xa.
III.
K E T Q U A1. Tuli va gidi
Op tuoi trung binh la 46.8 ± 17.77 tuoi (17 - 78 tuoi). Tuoi thudng gap nhit la 41 - 50 tuoi va trOn 60 tuoi chiem ti Ig 25.7% cho moi nhbm, Ti Ig nam/nu l i 1/4.
Thoi gian Dau thilt lung Dai buot - rit Dai mau Tg'soth^ythanto Kham thay th|n to Tang huylt ap Tan suat
<
16 6 thang
9 4 0 3 0
(45,71%) 12thang
4 1 1 2 1
(tai th&i diem9(25,71%)
18thang 1 0 0 1 0
vao vien) 2 (5,71%)>2 nam 18 4 0 1 2
25(71,43%)
Tong - % 32(91,4%) 9 (25,7%) 1 (2,9%) 7 (20%) 19(54,3%) 5(14,3%)
51.4% BN phat hien benh mupn tren 2 nam. 2 BN phat hien tinh cc/. Dau thit lu'ng chl4m 91.4%. Thgn to chiem 54.3%. Than phai gap 54.3%. 3 BN hep NQ phai sau mo sol NQ 1/3 duoi (each 5 - 6 nam) va 1 BN teo than THAsau mo hep NQ 9 nam.
Sieu am danh gia
3 than u nude dQ 111 (8.6%) gom 1 hepNQ, 2 hep BT - NQ. 28 th$n u nuoc dp IV (80%) g6m 6 do sol thgn, 3 do soi NQ, 6 do hep BT - NQ, 6 do hep NQ, 7 it nude thgn - NQ phg v^ 1 th§n da nang. 4 thgn teo (11,4%) gom 3 do soi va 1 hep BIVIT Co 8/35 BN (22,86%) I<h6ng thiy ro hlnh OBT (7 sau 90 phut va 1 sau 120 phut), Co 27/35 (77,14%) thgn khong ngam thuac (23 sau 90 phut, 4 sau 120 phut).
26/30 BN chup phim CLVT co than to, 19 than khong nglm thu6c, 11 thgn con ngSm thuoc rat It sau tiem, 13/15 BN chgp BVPX CO chuc nang than con rlt it <10%. 2/15 benh nhan chup OVPX co chuc nang thgn >10% la 2 thgn teo gay THA(13% va 12%).
Chan doan nguyen nhan truvx: mo gdm
9 u nuoc thgn do sol (25,7%), 7 Hep BT - NQ (20%), 4 teo thgn (11,4%), 7 than i> nude do hep NQ (20%), 7 iy nude than - NQ phg (20%) va 1 trudng hpp than da nang (2.9%)
3. K i t qua phau thuat
65,7% su dgng 3 trocar, 34,3% su dgng 4 trocar. 65,7% rad quanh than mong, 34,3%
md quanh thgn day. Tit ca than teo dlu c6 md
quanh thjn day Than in nu-dc do sol, hgp BT -
TCNCYH Phg truong 80 (3B) - 2012
NQ, i! nude th^n - NQ phg d4u c6 md quanh v4 TMT. 8 BN khdng quan s4t rS cu6ng mgcli thgn mdng (78,26%) khSc bigt c6 y nghTa th^n g6m 2 th$n teo, 6 u nu-dc thgn - NQ ptui th6ng ke (p = 0,03). 77,1% cuing mgch th|n khdng thiy r6 DM - TM cho th^n phg ci/c trSn, dupe bpc 10 riSng bi$t vi cjp clip riSng DMT
Bang 2. Diln biln trong m6 Chi tl&u Nguyen nhan t h g n m i t chirc nang
d4nh gia l> nu'dc Hpp U' nude Teo th$n Thjn da ti nude Kit qua do sdl BT - NQ Hep NQ nang thgn NQ phg chung (n = 9) (n = 7) (n = 7) (n = 4) (n = 1) (n = 7) (n = 35)
Bpc 10 thjn khd 2 1 2 2
Chiy mau 1 0 0 0
M4u mit (ml) 88,9 ± 42,3 94,3 ± 51,3 68,6 ± 29,1 63,8 ± 29,3
Chuyin m l md 1 0 0 0
0 0 60
0
2 9 0 1 57,1 ±20,6 73,9±39,1
0 1 9 BN bpc 10 thOn khb chiem tl 10 25,7%. Cd 1 chay miu trong m l (2,9%) tu diOn tuyln thupng thgn phai chuyin md cim miu. Khbng g$p tin thuang tgng. Miu mit trung binh cao nhit d nhdm hgp trung binh - NQ, khbng ggp roi logn khi mau trong mo. Thdi gian mo trung binh 124,6 ± 36 phiit. Thgn u nude do sbi va hgp BT - NQ m l dai nhit (133,3 ± 31.2 phut).
Bang 3. Dien bien sau mo Chi tieu danh gia
Chay mau sau mo Ngay dung giam dau Ngay mt dan luu
Ngay nim vien U" nude
do sdi 0 2 - 5 3 - 5 4,8(3-6)
Nguyen nhan gay thgn mat chi>c nang Hep
BT-NQ 1 3 - 4 3 - 5 4,9(2-7)
Ij' nude Teo th^n HepNQ
0 0 3 - 4 3 - 5 3 - 6 2 - 5 4,7(3-6) 5,3(3-7)
Th^n da nang
0 3 3 5
Kit qua
\y nude chung
th^nNQphg
0 1 2-3 3,2±0,7 3-11 3,9 ±1,6 7,3(6-12) 5,3 ±1,7 Bien Chung sau 'mo ggp 1 chay mSu tCr thanh bgng ch5 d§t trocar va 1 bpnh nhan njt din lifu sdm sau 2 ngiy xult hign s6t, chay dich qua chan din luu. Cac bgnh nh§n c l t th|ln - NQ phii it phii dung gl4m dau nhat, ngup'c Igi la nhdm b^nh nhSn teo thgn. khSc bi$t khdng cd ^ nghia thong kd (p > 0,05). Cd 1 b^nh nhSn c l t thjn - NQ phg phii d l din luu sau 11 ngSy ra vldn muS"
sau 12 ngay Thdi gian nim vi$n tmng binh 5,3 ngSy sg' kh4c bl$t giu'a cic nhdm khdng c6}
nghfa thong ke (p > 0,05). Kit qua GPB deu la viem thgn ke mgn tinh.
Danh gia kit qua gin: 88,57% dgt kit qua t6t. Khdng g i p m l Igi hay biln chimg, tif vong.
4 BN cd kit qua trung binh (11,43%) d l u IS clt th^n khd g6m: 1 chuyin mo md do chSy mSu til
T C N C Y H Phy trUdng 80 (3B) - 2012
dign boc tach tuyen thup'ng thgn, 1 chay m i u sau mo tLF c h i n trocar, 1 nhiem triing sau m l , 1 bOnh nhan eat thgn - NQ phy cb d i n luu ra djch keo dai.
Theo ddi xa sau m l : 30/35 BN d u p e k h i m Igi dgt ty 10 85,7% v d i t h d i gian trung binh sau mo: 18,9 ± 6,4 t h i n g (1 - 45 t h i n g ) . T i t ca BN deu khbng dau t h i t l u n g v i khdng cb roi logn lieu tiOn, khbng x u i t hiOn tSng h u y l t ap m d i . Sieu am, chyp XQ hO t i l t nigu khbng t h i y b i t thu'dng. XOt nghiOm ure, creatinin m i u trong gidi hgn binh t h u d n g .
IV. BAN LUAN
BOnh ly sbi thgn - niOu quan va di tgt b i m sinh t i l t nigu gay i n h h u d n g r i t idn d i n hlnh t h l va chipc n i n g thOn. BOnh n h i n t h u a n g den vien mupn d giai dogn thOn ir n u d e ngng, thgn xa teo nOn khdng cdn kha nang bao ton.
51,4% bOnh nhan phat hign bgnh 2 nam sau trigu chung d i u tien. Theo Le NguyOn Vu (2006), 54,28% bgnh nhan phat hign bgnh mupn trOn 2 nam [4]. Ob tuoi trung binh I i 46.8 tuoi, gap nhieu n h i t l i 41 - 50 t u l i va trOn 60 l u l l . S l bgnh nhan tren 40 tuoi chiem ti 10 tdi 65,7%. NghiOn c u u da cho thay ti 10 nO' n h i l u han nam mpt c i c h ro rgt g i p 4 l i n . Dieu nay do bgnh nhan nu" d i n k h i m , can thiOp y t l mupn h a n .
Chi dinh phau thugt CTNS. C i c tac g i i nhuAbbou, RassweilerdOu n h i n mgnh nhdng uu diem han h i n cua p h l u thugt nbi sol so vdi mo m d d l eat thgn n h u hgu phau d a n gian, giam dau sau m l v i t h i m m j tot han eho bOnh nhan. ViOc i p dyng PTNS c i t thgn d u p e chi djnh rpng han trong h i u h i t cac benh thgn l i n h tinh mat chue nang: Thgn d n u d e do t i c nghen, do trao ngup'c, teo than do hep mach thgn g i y tang h u y l t ap, thOn da nang cd triOu chifng hay trong mot so e h i n t h u a n g thgn d l dan luu mau ty, c i t than ban p h i n hay t o i n
bp [5,10,12]. Trong nghiOn c d u nay 35 bgnh nhan d l u ed e h i n d o i n n i m trong eae ehi djnh m l nOu tren. 23 bgnh n h i n khbng thay hinh anh sbi can quang tren chyp Xquang thl sieu i m v i chyp CTScanner phat hiOn d u p e 7 hgp BT - NQ, 7 hgp NQ sau mo, 1 thgn da nang, 7 u n u d e thOn - NQ phy v i 1 hgp DM thgn. Xg hinh thOn t h y c hign d 15/35 bOnh nhan vdi k i t qua thu d u p e rat co y nghTa: 13 thgn bgnh ly cb chirc n i n g tif 0% den d u d i 10% va 2 thgn teo cd ehuc nang tren 10% (12 va 13%).
L y a chpn d u d n g m l CTNS. Nhieu nghien c d u cho thay khbng cd s y k h i c biet ve higu qua ciia p h i u thugt CTNS trong va sau phuc mgc n h u eiia Gupta NP (2004), Bishoff Jl (2007) [7,12], D u d n g mo SPM cb han che la khd t h y c hign d BN mo cu SPM, trudng mo hep han do khoang SPM hep bi gidi hgn bdi t l chii'c m d gay khd khan cho tiep can, bpc Ip cuong thgn, giai phdng than va l i y bgnh p h i m . Tuy nhien, d u d n g mo SPM quen thupc vdi phau thuat viOn tiet nigu v i t r i n h 6\jac c i c tai bien trong mo qua phiic mgc [1,9]. Viec lya chpn d u d n g m l n i o la tuy thudc v i o loai bgnh ly va t i l n s u mo cu. Ddi vdi cae bgnh ly u thgn, nhung b i t t h u d n g mat t r u d c than hay BN cb t i l n s u mo cu SPM thi d u d n g qua phiic mgc ed lai the h a n . V d i bat t h u d n g d mat sau thgn, bgnh nhan da p h i u thuat byng hay viem phuc mge thi d u d n g mo SPM d u p e lya chpn [2,3].
Giai phbng than va x u ly cuong thgn. Dpng mach than d u p e cap Clip v i c i t dau tiOn, sau 36 d i n ITnh mach than. S u dung Clip Titanium d l kgp dpng mgch thgn I i du an toan. S u dyng it n h i t 3 clip cho mpt D M : 2 clip d dau trung tam, 1 d dau ngogi vi. Khong e h l dpng mach thgn t r u d c giup lam giam l u p n g mau tdi thgn, tgo d i l u kiOn thugn lai eho viec c i t tTnh mgch.
V d i tTnh mgeh thgn ed t h l bupc tang c u d n g b i n g chi Vicryl 2/0 hay 3/0 de thu nhb d u d n g kinh tTnh mgch t r u d c khi cgp clip. Trong nghiOn
T C N C Y H P h y trUdng 80 (SB) - 2 0 1 2
c u u n i y cd 27/35 t r u d n g h p p quan s i t dup'e rd cuong mgch thOn chinh c h i l m ti 10 7 7 , 1 % ; 2 thgn teo khdng quan sat I h i y rd cuong mgch IhOn chinh; 6/7 c i t thOn - NQ phy d n u d e khdng I h i y rd c u i n g mgch cho thOn phy. MOt s6 l i e g i i n h u Bishoff J l , Chan DY, Doublet JD t h u d n g s u dyng kgp Endovascular G I A d I cOp o i l ITnh mgch thOn. Kavoussi cho r i n g vigc su' dyng Endovascular GIA de xii- tri cuong mgch cd t h l bj tuOt g i y c h i y m i u hoOc eb b i l n chung thdng dbng - ITnh mgch. Both v i Chan (2005) d i b i o c i o viOc su' dyng Endovascular GIA tgi My gOp t i i vdi ti Ig 0,3% v i 0,2% [7,10]. MOI s l t i e g i i k h i c Igi s u dgng Hemo-lock d l kgp DM thOn vl cb dp an t o i n cao, g i i t h i n h Igi rO h a n nhieu so vdi Endovascular GIA N g u y i n Minh Tuan (2010) cung s u dyng Hemo-lock d l x u ly cuong thgn cho 42bOnh nhan, m i l bOnh n h i n diing 5 - 6 c h i l e [3],
D i n h g i i k i t qua c i t thgn bOnh ly m i t chue nang qua nOi soi S P M . T r u d n g mo hgp bi gidi hgn bdi t l c h u c m d can t r d vigc t i l p can thgn. bpc Ip cuong thgn g i y khd k h i n h a n eho viOc giai phdng t h i n . Phau thugt CTNS SPM I h u d n g cd nguy c a chay m i u eao h a n d u d n g mo qua phiic mge. Trong m l m d , chay mau it khbng gay anh h u d n g den q u i trinh phau thuOt. Ngup'c Igi trong mo nbi soi, mOt l u p n g it mau chay eung da g i y nhieu c i n t r d n h u che lap nguon g i y ch^y mau, h i p thy i n h sang lam giam dp chieu sang, viOc s u dyng may hiit lam giam ap lye hai vung mo, mau d l b i n dinh v i o camera va l i m m d camera. Ben cgnh dd, c i t than npi soi SPM cung cb nguy c a lam ton t h u a n g tgng, ton t h u a n g mgeh m a u , r i c h thung phiie mgc, r i c h c a h o i n h v i thung mang phoi khi dgt trocar [3], Bien c h u n g toan m i u trong mo CTNS SPM cb nguy c a gOp phai n h i l u han CTNS Q P M do khoang S P M I i 1 khoang ao khbng cb gidi hgn rb r i n g , giau mgch m i u , n h i l u t l e h u c Ibng leo, m d rpng
d i n theo lup'ng h a i b a m vao, do 66 se h i p thu CO2 n h i l u h a n d l g i y toan mau v i trin khi d u d i da [4]. C h i i n g tbi khbng ggp r l i logn khi m i u trong v i sau m l . C i c BN trong m l va d giai dogn h l i tinh d l u cb S p O j v i PetCOj duy tri trong gidi hgn binh t h u d n g (SpOj 99%
- 1 0 0 % , P e t C 0 2 £ 35mmHg).
T h d i gian m l trung binh l i 124,6 ± 36 phOt v i k h i c nhau giu'a c i e n h b m nguyOn nhan n h u n g khbng cb y nghia t h i n g ke (p > 0,05).
T h d i gian m l phy thuOc m d c db p h u c tgp cua t i n t h u a n g , dO khb eua p h l u thugt v i kinh nghigm eua n g u d i mo. So v d i CTNS QPM, thdi gian m l d i i h a n mOt c i c h cb y nghTa t h i n g kO d nhbm thgn iy n u d e do sbi (133 ± 31,23 so vdi 90 ± 21.25) [2,4] So s i n h v6i cac t i e g i i k h i c tien h i n h CTNS SPM. th^i gian m l cua nghien c d u n i y n i m d p h i n muc trung gian n h u theo Nguyen Minh Tuan (2010) 10 99,6 phiil, Nguyen Phuc C a m Hoang (2006) I i 144 p h u t c b n theo Rassweiler (1998) I i 160 phiit [1,3,10].
M u c dp khd eua p h i u thuat Vigc phiu tich v i o ron thgn l i khd nhat trong ky thu?t nbi soi. T h u a n g t i n mgeh m i u t h u d n g xay ra trong q u i trinh p h i u lich v i o r l n thOn l i m tang t h d i gian mo, nguy c a m i t m i u va lam tang nguy e a that bgi cua nbi soi. P h i u tich vao c u i n g thOn e i n c i n phgn, tach bigt D M vaTM thgn, dOc biOt l i khi cb hiOn t u p n g viOm dinh quanh thOn. Bijan d i n h g i i k i t q u i 12/21 cit thOn viem t h i y r i n g r i t khb nhOn dgng diing Idp bdc t i c h khiOn cho p h l u tich vb thgn va Idp mb' quanh thgn khbng thugn Ip-i v i chay m i u n h i l u . Khi cuong thOn dinh n h i l u , can giai phbng c i c phan k h i c nhau eua thOn bgnh ly, sau db vigc t i l p c | n vao cuong thgn se d l d i n g h a n . T h a y doi t u t h l B N , dOt them cac trocar cQng l i cac bign p h i p du(?c dgt ra.
N l u van cbn q u i khd d l t h y c hiOn, can can n h i c chuyen mo m d an toan cho BN [12]. M6t
T C N C Y H Phu trUdng 80 (3B) - 2012
y l u t l lam tang nguy c a chay m i u trong mo, tang muc dp khd cua phau thugt l i BN beo phi hay dai thao d u d n g . L d p m a quanh thgn day khb phau tich tim dup'e thgn. Mgt k h i c , s y tang sinh mgch m a u va mgng bgeh h u y l t trong Idp m a lam giam tac dyng cua cat va dot trong q u i trinh phau tich. Gill l.S. da n h i n mgnh vai trd eua n h i n h mgch b i t t h u d n g di vao eye trOn thgn la nguon goc g i y chay mau.
Vl vgy khi bbe t i c h quanh e y e trOn thgn p h i i r i t c i n thgn v i phai k i l m tra c i m m i u ky mgt dudi t u y l n thup'ng thgn [7,9]. N g o i i ra, c i c bgnh nhan eb b i t t h u d n g ve cOt s i n g , khoang each s u d n lung hgp cung la mpt yeu to cang l i m tang m i f c dp khd cCia d u d n g m l nbi soi SPM. Chung tbi gOp 9 t r u d n g hp'p c i t thgn khb chiem tl 10 25,7%. Bpc Ip thgn khd do m b quanh thgn day va viem dinh chiem 7 5 % c i c bgnh n h i n cd m a quanh thgn day bao gom: 2
•BN thgn d n u d e do sbi, 1 hgp BT - NQ, 2 hgp NQ, 2 than teo va 2 u n u d e than - NQ phu.
Nguyen Minh T u i n (2010) cung ggp 11/42 bgnh nhan (26,19%) mo khb. So sanh vdi tac gia Le NguyOn V u (2006) cb 11/35 CTNS QPM phau thugt khb c h l l m 31,4%.
Luang mau mat trong m l . Nghien c d u cua c i c t i c gia khi so sanh giua npi soi va m l m d thi deu t h i y khbng cb s y k h i c bigt v l lupng mau m i t trong mo trung binh l i 100ml [2]. Lupng m i u mat trung binh cua CTNS SPM thay doi t u a n g doi rpng tir 42 - 260ml, con trong nghiOn c d u n i y la 73,9 ± 39,1ml.
Khong cd bgnh nhan nao truyen m i u trong m l . Lupng mau mat thay d i i giua c i e nhbm nguyOn n h i n tuy thupc m u c dp khb cua p h i u thugt, k h i c biOt khbng cb y nghTa thong kO (p >
0,05). So vdi CTNS Q P M theo Le Nguyen V u
• la 66,25 ± 18,6 ml thi s y k h i c nhau n i y khbng cO •y nghTa t h i n g kO (p = 0.3).
B i l n chu-ng trong m o . Phau t(ch d n h u n g tnj'dng hpp c u i n g than viem dinh n h i l u r i t de
lam r i c h DM hay TM thgn gay chay m i u . Tai bien mgch mau trong npi soi n l u khong kip thdi x u tri se phai chuyen m l m d . Chung tbi gOp 1 t r u d n g h a p chay mau trong m l t u dign bbc t i c h vdi tuyen t h u p n g than d u p e ehuyen m d d l c i m m i u c h i l m 2,9%. NguyOn Minh T u i n cung ggp 1 r i c h TM thgn trong 42 CTNS SPM (2,3%) d u p e x u trl kip thdi [3]. Theo Ramakumar, ton t h u a n g mgch trong PTNS t i l t niOu xay ra b i t ky luc nao trong m l v i e h i l m 1 - 3%, trong dd 0,5 - 1 % la khbng kiem s o i t d u p e Meraney ggp 7 tai bien mach m i u trong 404 CTNS SPM c h i l m 1,7% gom 2 r i c h TM t h u p n g thgn, 3 ton t h u a n g TM than, 1 ton t h u a n g D M thgn va 1 ton t h u a n g TMCD [6].
R i c h phiic mgc la 1 tai b i l n hay gap.
Nguyen nhan chu y l u cung la do viem dinh quanh than nhieu gay khd khan khi phau tich, bpc Ip thgn. Nguyen Minh Tuan (2010) gap tai bien nay d 21,4% [3J. Giai phap dat ra la e i n dat thOm 1 trocar de ven phiic mgc. NOu khdng dup'C thi can n h i c mo m d . Nguyen Phiic Cam H o i n g (2006) cb 3/24 t r u d n g hpp r i c h phuc mac vdi 1 gay ton t h u a n g dai trang gde laeh phai chuyen mo m d [1].
R i c h c a hoanh cd t h l xay ra khi dgt trocar s i t b d s u d n , h u d n g trocar khdng dung. N l u phat hien kip thdi khau c a hoanh qua ndi soi sau khi da hut h i t khi trong khoang mang p h i i , phau t h u i t cat than van cd the t i l n hanh binh t h u d n g . Delpizzo (2003) long k i t 10 t r u d n g h p p thung c a h o i n h , trong db 2 do dgt trocar va 8 BN ggp trong qua trinh p h i u tich thgn [11]. N g o i i ra, eb the ggp ton t h u a n g ta trang dup'c Meraney ghi nhan hay rb tyy theo Rassweiler. Ti le tai b i l n trong m l nbi chung l i 1,27 - 26,2% v i ehuyen mo m d t u 0 - 14,3%
[6,10].
D i l n b i l n sau m l . Cd 1 tm-dng hpp-chay m i u ngay sau mo t d c h i n trocar da d u p e p h i t hign v i x u tri kip thdi. Tren t h y c t l , b i l n ehung
TCNCYH Phy trUdng 80 (3B) - 2012 chay miu sau m l do tin thuang mgch miu d nhu'ng viing hay gOp l i tuyln thup'ng thOn, TM sinh dye. mbm cit NQ. Vdi viOc giim i p lye bam hai v i quan sit ky trudc khi kit Ihiic phiu thuOt ed thl phit hiOn dup'e nhO'ng dilm chay miu tu' eic nguOn khic nhau nOu tren, DM eye, ldp md quanh thgn, dOc biOt l i cic TM toi'dc dd b| dd bp do bam hai i p lye eao. Theo Henry M.R (2006), cat thgn nOi soi SPM cb ti Ig biln chung chiy miu sau mo l i 3,3% [8]. Cdn theo nghiOn cuu cua Rassvweller (1998) l i 4,6%
vdi ti 10 phii mo Igi sau CTNS l i 3,4%, trong db 50% do chiy miu, 25% do i p xe sau mO [12].
Ti Ig m l Igi vi chiy miu trong nghien ciru cua Nguyin Phiic Cim Hoing (2006) l i 4,2% [1].
V. KET LUAN
Phiu thuOt npi soi dupe thye hiOn qua dudng sau phuc mgc d 35 BN cit thgn bgnh ly mit chue ning vdi 3 hoOc 4 trocars. Chi djnh cit thgn do thgn u nude mat chue nang chiem 55,7% (do sbi thgn - NQ 25,7%, hgp BT - NQ 20%, hgp NQ 20%) v i do thOn teo l i 11,4%.
Thgn da nang ehilm 2,9% v i u nude thOn - NQ phy la 20%.
Phau thugt cit thgn thugn Ip^i trong 74,3%
trudng hop. Cit thgn khd ehilm 25,7% bOnh nhin liOn quan din tinh trgng viem quanh thOn va t l chiPC ma day quanh thgn. 88,6% cit thOn bgnh ly mit chuc ning dgt kit qui tit. Ti 10 tai biln trong mo l i 2,86% va bien chdng sau m l gOp 5,72%. Phiu thugt d i riit ngin thdi gian nim viOn v i dam bao an toan, khbng cd tu vong, khdng bgnh nhin phii m l Igi hoOc eb di ehifng sau mo.
TAI LIEU THAM K H A O 1. Nguyen Phiic Cam Hoang, Vu Le
Chuyen, va CS (2006). Cit thOn qua npi soi sau phiic mgc trong thgn mit chuc nSng do bOnh ly lanh tinh: Kinh nghiOm ban dau qua 24 trudng hp'p. Y hpe ViOt Nam. 319. 269 - 279.
2. Hoang Long, Trin Binh Giang, VQ Nguyin K h i i Ca, va CS (2006). Cit thOn npi soi qua phiic mgc nhin 35 trudng hpp phiu thuOt tgi bOnh viOn ViOt Due. Y hpc ViOt Nam.
319:292-300.
3. Nguyen Minh Tuin, Nguyen Ngpc Bich (2010). Kit qui cit thOn nOi soi sau phuc mgc tgi BOnh viOn Bgch Mai nim 2008-2010.
Ngogi khoa. s l dOe biOt 4-5-6. 269 - 275.
4. Le Nguyen Vu (2006). NghiOn cuu ap dyng phiu thuOt nbi soi qua phuc mge cit thOn do bOnh ly linh tinh. LuOn vin tot nghiOp B^c s? nOi trii, Dgi hpc Y H i Npi.
5. Abbou CC, Cissco A, Gasman D (1999). Retroperitoneal laparoscopic versus open radical nephrectomy. The Joumal of Urology 161: 1776-1780.
u. Anoop M. Meraney, Inderbir S. Gill (2002). Vascular and bowel complications during retroperitoneal laparoscopic surgery.
The Journal of Urology168; 1941 -1944.
7. Bishoff Jay I, Louis R. Kavoussi (2007). Laparoscopic surgery of the kidney.
Campbell's Urology sect 12, chap 51: 1759- 1809.
8. Henry M. Rosevear, Jeffrey S.
Montgomery, William W. Roberts (2006).
Characterization and management of postoperative hemorrhage following upper retroperitoneal laparoscopic surgery. The Joumal of Urology 176: 1458 -1462.
9. Jason W. Anast, Marshall L. Stoller, Maxwell V. Meng (2004). Differences in complications and outcomes for obese patients undergoing laparoscopic radical, partial or simple nephrectomy The Joumal of Urology.
172:2287-2291.
10. Jens J. Rassweiler, Otmar Seemann, Thomas Frede (1998). Retroperitoneoscopy:
144
T C N C Y H Phg trUdng 80 (3B) - 2012
experience viiith 200 cases. T h e Journal of 12, Narmada P. Gupta, Rajiv Goel, Ashok Urology 160: 1265 - 1 2 6 9 , K, Hemal (2004). Should retroperitoneoscopic 11, Joseph J . Delpizzo, Stephen S. nephrectomy be the standard of care for Jacobs, Bishoff Jl (2003). Pleural Injury ' " = " ' 9 " nonfunctioning kidneys? An outcome During Laparoscopic Renal Surgery: Early analysis based on experience with 449 cases Recognition and Management. The Joumal of ' " ^ ^'l^"' ^''"°^- ^ h e Jounial of Urology Urology 1 6 9 : 4 1 - 4 4 . 172: 1411 -1 413.
summary
O U T C O M E S OF RETROPERITONEOSCOPIC NEPHRECTOMY FOR NON FUNCTIONING KIDNEYS
The first retroperitoneoscopic nephrectomy (RPN) was done by Gaur in 1993 for treatment the nonfunctioning kidney The study evaluate the safety efficacy and our experiences to expand the use of this technique surgical for the treatment of nonfunctioning diseases of the kidney 35 patients underwent RPN between January 2006 and September 2011 at Viet Due Hospital including 7 males and 23 females who had age ranged from 17 to 78 years (mean 46.8 ± 17.77). RPN indication included: 55.7% non functioning hydronephrosis, 11.4% hypertensive atrophy kidney. 2.9% renal polycystic disease and 20%
duplex kidney and ureter anomalies. We used 4 trocars lor 65.7% cases and 3 trocars for 34.3%. Average time of operation was 124.6 ± 36 minutes. Mean volume blood loss occupies 73.9 ± 39.1 ml. The RPN was difficult in 25.7% relating to the inflammatory renal conditions and obese patients with one converted case. 88.6% RPN was successful. The rate of per and post operative complications was 2.86% and 5,72%
respectively. The mean duration of hospitalization was 5.3 ± 1.7 days (range 2 - 12 days).
Key words: Nonfunctioning kidney, nephrectomy, retroperitoneoscopic surgery
PHAU THUAT NOI SOI OAT CATHETER b BUNG
Di. THAM PHAN PHilC MAC
Pham Viet H a ' , Nguyen Ngoc Bich^, Tran Hu'u V i n h ' , Tran H i l u Hoc^
I" Binh vien B^ch Mai, « Tnriing Dai hpc YHa Npi
Tham phin phuc mac li mpt phuang phip diiu tri nhung benh nhin suy than giai doan cuoi cd hiiu qui. Phiu thuit mo nil sol dat catheter thim phin phuc mac ti mpt phuang phip an toin, dit dupe chinh xic vi tri cua catheter vi It biin chung. Nghien ciyu dupe thuc hien nhim md ta ky thuit vi kit qui cua phau thuit. Kit qui nghiin cim cho thay dd tuii trung binh ciia doi tuxyng nghien cuv ii 44 tuoi: thdi gian mo tmng binh khoing 37 phCif Khong c6 biin chimg ngay vi sau 24 gia sau mi. Cd 02 benh nhin N tic vi di chuyin diu catheter sau 01 thing va 03 benh nhin bi nhiem trung cho duang ra ciia catheter. Phau thuit dat catheter i bpng ndi soi li mpt phuang phip dat catheter chinh xic vao till cung viing tiiu khung
