CVv339S302014034.pdf

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34 Tap chi GAN MAT VIET NAM so 30-2014

iTng dung phau thuat noi soi trong c4p cihi chin thuorng va vet thuong thau bung

Laparoscopic approach for acute abdominal trauma and penetrating wound

B^t v&n di: phau thuat noi soi (PTNS) 6 bung CO the duoc sii dung an toan va hieu qua d6 chdn doan va di6u tri cac chSn thucmg - vet thuong byng, tranh phai ma bung.

Phu-angphdp: tCr 05/2001 din 01/2012, 316 b?nh nhan chin thuong bung huy^t dong 6n dinh nghi ngd ton thuong tang trong 6 bung duQfc phlu thuat npi soi chan doan va dieu tri.

Tu6i b?nh nhan tir 7 d§n 78 (trung binh 28t). Co chS chin thuong: 176 chan thucmg bung kin, 137 vk thuong b\mg va 3 vet thuong dan bin.

Tit ca phiu thuat ngi soi duoc thuc hien trong phong m6, bSnh nhan dugc gay me. 6 bung dugc tham sat co he thong, ghi nhan cac ton thuomg tang, xu tri thuong ton a miic do cho phep.

Kit qua: Qua tham sat, 110 ca chi can PTNS chan doan, PTNS dieu tri dugc thuc hien cho 186 bSnh nhan (58.8%) gom dot - khau cim mau gan [34], dot - khau cam mau lach, cat lach [22], khau cam mau tuy va din luu hau cung mac noi [4], khau nipt non [21], cat - n6i rugt non (PTNS h6 trg) [3], khau rugt gia [7], khau

Nguyen Phuac Hung'*. Nguyen Tdn Cuong*.

- cim mau thanh mac va mac treo rugt [44], khau thanh da day [12], cit dii mat [3], khau bang quang [59], khau co hoanh [15]. PTNS di§u tri toan bg dugc thuc hien cho 179 b?nh nhan, PTNS h6 trg cho 7 b?nh nhan. PTNS khong bo sot t6n thuomg 1dm nao cua tang, va khong trucmg hgp nao phai ma byng tham sat.

Thofi gian phlu thuat trung binh 90 ± 70 phiit, thai gian nam vien trung binh 4.8 ngay. Ba trucmg hgp (0.9%) biSn chiing sau PTNS gom 1 ty djch trong gan, 1 tu dich hau cung m^c noi, va 1 xi vet khau bang quang, chi mgt thung dai trang bi bo sot tren b?nh nhSn bi t6n thuang ca hoanh - da day - lach, khong co tii vong do PTNS.

Kit luan: Phau thuat ngi soi la bi?n phap kha thi, an toan va hieu qua de danh gia v^ di^u tri cac benh nhan chan thuang bung co huySt dgng on dinh, lam giam ti le ma biing khong dieu trj.

Tu khoa: Chin thuang biing, ngi soi 6 bung, ma bung khong dieu tri, phSu thuat ngi soi, ngi soi chan doan - dieu tri.

Abstract:

Backround: Instead of open laparotomy, laparoscopy can be used safely and effectively for the diagnosis and treatment of traumatic abdominal injuries.

Methods: Between May 2001 and Jan 2012, 316 with suspicious abdominal injiuies under- went diagnostic or therapeutic laparoscopy. The patients ranged m age from 7 to 78 years (me- dian, 28 years). Of these patients, 176 were eval- uated for blunt trauma, 137 had sustained a stab wound and 3 had a missile wound. All of the la-

paroscopic procedures were performed in the operating room with the patient under general anesthesia. The abdominal cavity was systemi- cally examined, the hemoperitoneum aspirated, and the lesion causing the bleeding or spillage located.

Results: On the basis of the laparoscopic findings, diagnostic laparoscopy was enough for 110 patients, and therapeutic laparoscopy was performed in 186 patients (58.8%) for hemostasis of liver [34], hemostasis of spleen [22], hemostasis of pancreas and drainage of collected

* Khoa Gan-mdt-tuy - Benh vien ChaRay Tp. Ho Chi Minh.

Phan bien khoa hoc: PGS. TSLeLoc

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Tap chi GAN MAT VIET NAM so 30-2014 35 fluid in omental sac [4], small bowel repair [21],

small bowel resection-anastomosis [3], colon repair [7], ligation of bleeders or repair of the mesentery and serous membrane [44], gastric wall repair [12], cholecystectomy [3], bladder wall repair [59], diaphragm repair [15]. Purely laparoscopic procedures were performed in 179 patients, and hand-assisted laparoscopic surgery in 7 patients. No significant abdominal injuries were missed as a result of laparoscopy, and no conversion to exploratory laparotomy was noted. The mean operation time was 90 ± 70 min, and the mean hospital stay was 4.8 days.

There were three cases (0.9%) of postoperative complications (1 collected fluid in liver, 1 collected fluid in omental sac, and 1 leakage of bladder), and only one large bowel wound was missed (patient had diagphram - gastric - spleen injuries, as well) and no mortality.

Conclusions: Lapm-oscopy is safe, feasible, effective for evaluation and treatment of hemodynamically stable patients with abdominal trauma, and it can reduce the number of nontherapeutic laparotomies performed.

Tii khoa: abdominal h^uma, laparotomy, nontherapeutic laparotomy, laparoscopic surgery.

1, Dgt van de

Trong chan thuang va vet thuang bung, mac dii CO nhieu phuong phap chSn doan khac nhau dugc s^ dung nhu choc rua 6 bung, sieu am bung, chup dien toan cat lop; viec danh gia su hien dien va do nang cua cac sang thuong trong 6 byng van kho khan. Mo bung tham sat la phuong phap an toan va ro rang de xac djnh, danh gia. Tuy nhien, ti le lai bien, bien chiing co the cao den 40%, bao gom 20% bien chiing som do phiu thuat, 0 - 5% hi vong va 3% nguy co tac rugt non sau nay [23], [24].

Nghien ciiu nay nhim chiing minh PTNS 6 bung CO hieu qua de danh gia thucmg ton cua vet thuang va chin thuang bung. Thanh cong ciia phau thuat ngi soi 6 bung (1) giiip giam ti le mo bung tring tir 23 - 54% s6 benh nhan [2], [[10]], [25]. Ivatury va cs. [11] khao sat kha nang phau thuat ngi soi 6 byng de dieu tri cac vet thuang byng CO quy dao khong ro rang, chi 30 - 40%

cac vet thuang bung can phau thuat dieu tri; (2) PTNS giiip can thiep som va giam ti le bo sot thuang ton trong 6 byng.

Z Boi tuang vd phucmg phap nghien cmt Tir 5/2001 den 1/2012, 316 benh nhan chin thuang bung co huyet dgng on dinh c6 nghi ngo CO thuong ton tang dugc phau thuat ngi soi chan doan va dieu tri tai Khoa Cap ciiu BV Chg Ray.

Trong suot thai gian nghien ciiu, khoang 9400 benh nhan dugc chan doan chan thucmg byng, trong do hon 5400 co chi dinh phau thuat, chung toi chgn 316 benh nhan (176 chan thuang byng kin va 140 vlt thuong bung) co huyet dgng on dinh (huyet ap toi da fren lOOmmHg, HA toi thieu tren 60mmHg, nhip tim duoi 1001/p) de thuc hien phau thuat ngi soi 6 byng danh gia.

Danh gia lam sang; cong thiic mau, sinh hoa mau; sieu am bung toan bg, Xquang bung, nguc CO dien; CT Scan bung cho truong hgp chan thuong bung kin (CTBK); chgc do 6 byng trong mgt so truong hgp. Khong c6 truong hgp nao chgc nia 6 bung. Chup he nieu c6 can quang dugc thuc hien cho cac trugng hgp nghi nga va bang quang. Mgt so vet thuang bung dugc tham sat vet thuang thanh bung trudc khi phiu thuat ngi soi. Loai trir cac chan thuang sg nao nang, huyet dgng khong on dinh, co benh ly ngi khoa chong chi dinh bom hoi 6 bung, ti6n can mo byng, viem phiic mac nang, c6 vit thuong byng CO dau hieu ton thucmg tang ro rang nhu non ra mau, tieu - tieu man tuoi. Kip mo phlu thuat npi soi c6 ky nang va trinh do quy^t dinh chi dinh phau thuat.

Benh nhan dugc giai thich va d6ng y lam phiu thuat ngi soi 6 byng va co thi bi mo byng.

Phiu thuat dugc thuc hien tai phong mo lan, gay me ngi khi quan.

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36 Tap chi GAN MAT VIET NAM 5^30-2014 Bom hoi 6 bung bang CO2 qua 16 trocar duoi r6n, vao bvng bing ky thuat Hasson, quan sat 6 bung bang kinh soi 30°. Haihocar5 - lOmmdua vao o ngang r6n, ba ngoai co thang bung. Ap luc bom hoi 6 bung di6u chmh duoi ISmmHg.

Sau khi khao sat khoang bung c4n than, hut sach mau, dich tieu hoa, danh gia cac thuong t6n thjy duoc. N8u cin, trocar phu duoc them vao, phy thugc vi tri thuong ton. Chuyen mo bung khi tham sat 6 bung khong hoan toan diy du, thucmg t6n qua Ion, qua kha nang phau thuat npi soi. Nhimg tniong hcjp dang chay mau phai duoc kijm scat dau tien bang dot dien, kep clip, cpt - khau cot... DS danh gia mot non va dai hing, dung kep rapt khong gay sang chan, kijm tra raot qua trocar hai ben thanh byng;

ki8m tra rapt non bit diu tir goc h5i manh trang, tiln vi phia tren din goc Treitz moi 4-8 cm cho din hit chiiu dai ruot. Cac tin thuong rapt non va m£ic treo dupe xijr tri bang khau don gian bang vicryl 3.0.

- C6 thuang tin tang dac: chay mau, lupng it -vita khong anh huong huyet dong, dot - khau cim mau. Niu thanh cong, ket thuc phau thuat va dat din luu 15 Fr qua 16 trocar hong phai.

Neu chay mau nhieu, thay doi huyet dong trong mi, chen tam mot bac dan luu, ngung npi soi va chuySn sang mo ho kinh dien. Cac ton thuong khac sij d\mg phiu thuat noi soi ho trp; khi can cat doan rapt ton thuong nang, chiing toi dua thuong ton ra ngoai 6 bung qua vet rach thanh bung 3-4cm, cat bo - khau n6i rapt nhu trong ma b\ing, sau d6 dua trof lai vao 6 bung.

- Vdi cac vit thuong thiu bung (VTTB), dong vet thuong trade khi bam hai 6 bung va PTNS. Neu khong c6 diu hieu ton thuong tang, lam sach vet thuong va khong can mo bung.

- Trong vo co hoanh, ngay khi dat trocar rin va bom hoi ducfi ap luc thap (SmmHg), dat them 1 ttocar 10mm khong co van a gian sucm 5 trung don cua ben ling nguc bi ton thuang, mot trocar 5mm a thuong vi ben hai day chjng liim va I trocar 10mm d hong trai; khau co hoanh qua npi soi bang chi Prolene 1.0 mui cha U hoac khau

hen tuc. Kiim tra cac tang trong bung. Neu co vo t ^ g ring, tiip tuc soi ling nguc kiem tra, d^t them 2 trocar 5mm va 10mm tudi nla khoang mang phii, dat din luu khoang mang phoi qua 16 trocar 10mm 6 gian suon 5 tnmg don.

Hau phau ghi nhan sinh hieu, vit mo, 6 byng, ngay trang ti^n, thdi gian nam vien. Lsim thSm cac xet nghiem sinh hoa, chan doan hinh anh, tray tim cac biin chiing hau phau ciing nhu tinh hang bo sot thuong tin trong 6 bvmg.

• Tieu chuin vang di dii chung:

- Kit qua tin thuang cac tang duac khjng dinh Iji khi chuyin sang mi hd vi mot ly do nao do nhu: qua kha nang can thiep qua ngi soi hay phau thuat npi soi ho tro xil tri thuong ton.

- Kit qua con dupe khang dinh qua theo doi hSu phau trong nhimg hTidng hop khdng chuyin mi hd: dupe gpi la kh6ng tin thuong tang khi diin tiin lam stog khdng xuit hien cac trifn chiing cua hpi chiing viem phiic mac, xuat huyet n§i, ap-xe tdn lira hay ro tieu hoa.

3. Ket qua

Tit 05/2001-01/2012, trong 5400 bpnh nhan duac phau thuat vl chan thuang bung, 316 benh nhan (5.9%) co huyit dpng in dinh dugc chpn.

3.1. Dac dilm dSn s6 nghiSn cihi:

- Tuii trung binh 28 ± 9t, cao nhit 78, nho nhat 7. Da so con trong tudi lao dgng (21-40 tuii), chiem 58.7%.

- Gidi: ti le Nam: Nii = 5:1 (262 nam: 54 nS).

- Co chi chin thuang: 176 CTBK (55.6%);

137 VTB (43.3%), 3 vit thuang hoa khi (1.1%).

Bang 1. Thuang ton phoi hap ngoai 6 biing

Chin thucmg diu Chin thucmg cot sing Chan thuang nguc Gay khung chau Gay xuong dai Chin thuong than

CTBK 45

5 26 48 57 28

VTB 0 0 32 0 0 0

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3.2. Cac chi so can lam sang

3.2.L Sieu dm bung-' Trong 176 ca CTBK, 158 ca (89.7%) phat hign co dich va 18 ca (10.3%) khong phat hien dich. Trong 140 ca VTB, 96 ca (68.5%) CO dich va 44 ca (31.5%) khong phat hi?n dich. Ti le phat hi?n dich la 85%.

3.2.2. CTScan bung (CT):

Bang 2. Chup dien todn cat lap by.ng/chdn thuang bung kin

Tap chi GAN MAT V I £ T NAM so 30-2014 37

3.4. Trong mo:

Bang 5. Thucmg ton tgng qua ngi soi CTBK

So lugng Ti le %

CTbung 141 80%

Khdng CT bung

35 20%

* Trong 140 ca VTB, chi 10 ca co chi dinh CT Scan.

Bfing 3. Ca quan thucmg ton qua CTbung

T\i mau sau phuc mac Gan

Lach Tvy Than Tang r6ng Vd CO hoanh Vd bang quang Khong phat hien thuang tdn

Sd lugng 27 11 14 3 20 18 2 33 22 3.3. Chi djnh phau thu^t n^i soi 6 byng:

Bang 4. Chi dinh soi 6 bung chan doan:

Chi dinh Nghi XH ngi dang tien trien Nghi tin thuong tang ring Nghi vo tang rdng/vd bang quang

Nghi ton thuong co hoanh Nghi vet thuang thau bung Nghi tin thuang t$ng/VTTB

CTBK 42 76 56 2

VTB

29 30 81

Thuong ton Ty mau sau phiic mac Lach

Gan Tyy Rugt non Thanh mac rugt non Mac treo rugt non Dai trang Thanh mac dai trang Mac treo dai trang Va CO hoanh Va bang quang

Bang 6. Thuang ton tang qua

Thuong ton Vet thuong thanh bung VTTB khong ton thuang tang Thiing gan

Thiing lach Rach tuy Thiing mot non

Rach thanh mac, mac treo RN Thung dai trang

Rach thanh mac dai trang Thung da day Thung tui mat

Rach mach mau mac n6i lan Thiing co hoanh

CTBK 60 19 12 3 12 14 15 3 7 3 2 61 noi soi VTB

So lugng 28 39 28 7 2 12 4 5 7 15 4 3 18

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38 Tap chi GAN MAT VIET NAM so 30-2014

3.5. Chan doan sau mo:

Bang 7. Nhom "nghi XH noi dang tien trien ": 43 ca

Thuong tdn Tu mau sau phiic mac Vdgan

Vd lach Votuy Chin thucmg than

Rach thanh mac rapt non Rach mac treo rapt non Vd bang quang

Khdng thuong ton

Theo PTNS 25

8 13 2 10

3 7 5 2

KQ sau ciing 25

8 13 2 10 3 7 5 2

Ti le dung 100%

100%

Bang 8. Nhom "nghi nga va tang rang "vd "nghi nga va tang rong/bao ton chan thuang tang dac": 132 ca

Thuong tdn Tu mau sau phiic mac Vdgan

Va lach Votuy Vd rapt non Rach thanh mac rapt non Rach/vd mac treo rugt non Va dai trang

Rach thanh mac dai trang Rach mac noi Ion Vd bang quang

Theo PTNS 44

5 6 1 12 11 6 4 6 2 56

KQ sau cimg 44

5 6 1 12 11 6 4 6 2 56

Ti 1| dung 100%

100%

Bang 9. Nhom "nghi vet thuang thdu bung ": 32 c

Thuong tdn Vet thuang thanh bung VTTB kh6ng tdn thuong tang VTTB Rach gan

VTTB Thiing rapt non VTTB cd rach mac noi VTTB thung gan-i-tiii mat VTTB thiing da day VTTB rach day chang

Theo PT NS 15 9 2 1 1 1 2 1

KQ sau cimg 15 9 2 1 1 1 2 1

Ti i§ diing 100%

100%

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Tap chi GAN MAT VIET NAM so 30-2014

Bang 10, Nhom "nghi ton thucmg tang/ VTTB": 79 ca Thuong tdn

Vet thuong thanh bung Vet thuong thau bung Thiing gan Thiing lach Rich tuy Thung rapt non Rich thanh mgc rapt npn Thung dai trang Rach thanh mac dai trang Thiing da day Thiing hii mat Rach mac noi Thung hoanh

Bang 11. Nhom "Vet thuang nguc - bung

Thuang ton Khdng ton thuang Thiing co hoanh Vet thuong gan Vet thuong lach Thiing da day Rich tuy

Rach thanh mac mgt non

Bang 12. Cac thuang ton tang qua phau bang PTNS

Thuang tdn Tu mau sau phiic mac Tdn thucmg gan Ton thuang lach Tdn thuong tuy Tdn thuong rapt non Tdn thuang mac treo rapt non Tdn thuong thanh mac rapt non Tdn thuong dai trang Tdn thuang thanh mac dai trang Ton thuong da day

Tdn thuong tiii m^t Tdn thuang co hoanh Tdn thuang bang quang

Theo npi soi 5 29 17 4 1 11 2 3 5 7 3 2 3 '.• 29 ca

Theo ngi soi 14 15 7 3 6 1 1

KQ sau cung 5 29 17 4 1 11 2 4 5 7 3 2 3

KQ sau cimg 14 15 7 3 6 1 1

Ti le dung 100%

100%

75%

100%

Ti Ip dung 100%

100%

thuat noi soi tru&c ma bung dieu tri vd dupe xit tri

SL 60 40 26 5 24 15 18 8 14 15 4 20 61

Xu hi qua PTNS 60

34 22 4 21 13 17 7 14 12 3 15 59

100.0%

85.5%

84.6%

80.0%

87,5%

86.6%

94.4%

87.5%

100%

80.0%

75.0%

98.3%

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40 Tap CM GAN M A T VIET NAM s6' 30-2014 3.6. Mire do can thiep:

Muc dp can thiep PTNS tham sat chin doan

PTNS diiu tri PTNS hd trg Md byng dieu tri

Si lugng (%) 110

179 7 20

34.8%

56.9%

2.0%

6.3%

93.7%

*Li do ma bung nho (Ngi soi h6 trg): 3 vo rugt non D4-5, 3 vo dai trang (HMNT), 1 rach mac treo rugt phiic tgp.

3.7. Thoi gian mS: Ngin nhit 20 phiit. Dai nhit la 180 phut. Trung binh la 90 ± 70 phiit.

3.8. Thod gian nSm vien va dien tiin sau mh:

Bang 13. Thai gian nam vi^n vd dien tien sau

* Ly do mo byng Ion: 20 ca - 3 ca vo gan do 4, chay mau 6 at.

- 2 xuat huyet ngi do vo lach do 3-4 dang chay mdu, qua kha nang xu tri qua ngi soi (!).

-1 vo nhieu tang: gan va d6 3 + rach ndt mac treo va thanh mac rugt non.

-1 thung rugt non nhieu noi, dich tieu hoa va gia mac nhieu.

- 1 ca va rugt non gan sat goc Treitz.

- 1 ca VPM nang do va RN 2/3 khiu kinh, rdch nat mac treo can rua byng va cit n6i rugt.

- 2 ca va hoanh phiic tap.

- 1 ca vk thucmg gan sau, thung tiii mat.

- 1 ca thiing da day rgng, thung mat sau va rach tuy.

- 1 ca thiing co hoanh, d^ day, vo lach.

- 1 ca thung ca hoanh, da day, vo lach va thiing dai trang.

~ 1 ca v6t thuong gan ha phan thuy 7 - 8 , sau, thiing CO hoanh khong xir tri cim mau dugc bing PTNS.

- 1 ca va rugt non, dai trang goc gan va lach va do 1.

-1 ca thung da day Ion, chay nhi^u mau, kem CO vet mo cii, kho thao tac va tham sat mat sau da day.

- 2 ca va bang quang phiic t^p trong va ngoai phiic mac.

Ngay Trung binh

Trung tien 1,91

An lai 2,44

Namvi?n 4,8 3.9. Bien chii-ng sau mo (0.9%): 1 tu dich trong gan sau ddt cam mau nhu md gan qua npi soi. 1 ca ap xe tdn luu d hau cung mac ndi (do tuy) phai md bung lai de din lira d tuy bang din luu c6 gid (sump drain). 1 ca xi chd khku bang quang do phau thuat ngi soi c§n md bung.

4. Ban lu^n

Du chan thuang hay vet thuong bung, cac chi dinh kinh dien md bung la chay man i bung i at lam thay ddi huyet dgng, cd cac bing chiing khach quan cho thiy cd thung/vo tang ring [27].

Chiing toi khdng dua nhiing trudng hpp xuit huyit ngi cd huyit dpng khdng i n dinh hoac viem phuc mac nang vao Id nghien ciiu vi han che cua PTNS trong kiem soat chay mdu ciing nhu kha nang sua chiia tin thuang Ion tang ring, vi keo dai thdi gian phiu thuat. NgoM nhung tinh huing ro rang fren, thuc te lam stog cd rat nhiiu trudng hop sau mot thdi gian theo ddi kit hpp cac phuong tien chin doan nhu Xquang bung khdng siia soan, sieu am bung, CT Scan bung, dung tich hdng ciu..., nhiiu frudng hgp vin chua tim ra hudng diiu fri thich hop.

Trong cac tinh huing nay, ludn cd su can nhac giua tiep tuc theo doi, dgi khi cdc trieu chiing that to rang rdi mi hay md bimg tham sat niu nghi nga cd tin thuang tang. Ca hai each giai quyit diu cd nhiing tru-khuyit diim nhu: ti le bien chiing sau mi cao hay ti le md bung khdng diiu fri cao [3], [4], Di lam giiim ti le bien chiing sau mi cung nhu giam tl le md bung khdng diiu tri, hi 1995 din nay cd nhiiu tac gia

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Tap chi GAN MAT VIET NAM s^ 30-2014 41 ap dyng phau thuat ngi soi 6 bung vao b$nh canh

chan thuang - vet thuong bung. Cung theo xu hudmg chimg, chiing toi thuc hien nghien ciiu nay trong hoan canh Viet Nam vai cac chi dinh dugc ban luan sau:

4.1. Chin thmrag bung:

4. LI. Nghi nga tinh trang mdt mdu cap tren Idm sdng la do thuang ton tang 6 bung: Benh nhan da thuong co dong thoi nhi8u thuang t6n CO the gay ra tinh trang mat mau tren lam sang, chiing toi chgn nhung truong hgp phlu thuat vien nghi ngof chinh thuong t6n trong 6 bung gay ra cac thay doi theo chieu huong xau dan trong qua trinh theo doi (Hct giam, raach-huy^t ap xau di...). Chiing toi co 42 truong hgp (Bang 4) roi vao chi dinh nay, co 32 trucmg hgp kem thuong t6n ngoai 6 byng, 3 benh nhSn c6 thai 8 - 32 tuan. Tat c^ deu dugc theo doi lam sang, can lam sang, hoi siic ban dau trong thai gian trung binh li 12.1 ± 4.1 gio. 42 truong hgp nay dugc chi dinh PTNS 6 bung chin doan thay thi cho ma bung tham sat. K8t qua 40 truong co dich va mau trong 6 bung.

Cac thuang ton dugc mo ta trong Bang 7:37 truong hgp (88.0%) tranh dugc ma bung.

Nhiing ca ma bung do vo gan do 3-4 (3 ca) tren benh nhan c6 thai hay kem thuong ton khac, vo lach (2 ca) chay mau nhieu.

4.1.LI. Cac uu diem cua noi soi:

- Phucmg dien chan doan: tot ve miic do ton thuang tang dac va xac djnh tinh chat va miic do chay mau. Sieu am khong danh gia dugc muc do thuong ton (Bernard Boulanger). CT tot hon sieu am trong vi6c danh gia miic do thuang ton tang dac, nhimg khong danh gia bet dugc tinh chat chay mau cua thuang ton du co dung can quang tinh mach [26], [13], [15]]. PTNS giiip chan doan cac thuong ton khong gay chay mau nhung de dga tinh mang benh nhan neu khong dugc chan doan kip thai nhu vo bang quang trong phiic mac (5 ca) cung nhu lo^i trir cac ton thuong khac. Khong co thuang ton bi bo sot trong chi dinh nay.

- Phuong di?n di^u tri: thuc hien xii tri mgt so thucmg ton tir nh§ den viia: dot - khau cim mau tang dac, cat bo tang, khau ong tieu hoa

neu dugc trang bi du cac dyng cy hien dai [6].[8].

4.1.1.2. Cac nhuac diim cua noi soi:

- Van la mgt phuong phap xam lan.

- Phai gay me, mac du mgt so tac gia [5] [1]

thuc hien te tai cho, nhung chi ap dyng cho nhiing benh nhan hgp tac tot. Hien chua sii dyng dugc gay te tai cho do nhiing ban che cua gay me h6i siic.

- Co the gap bien chiing do ap luc CO2 nSu khong tuan thu cac nguyen tic cai dat ap luc.

Nhu vay hoan toan co the ap dung PTNS 6 bung cho cac trudng hop nghi nga co tinh trang mat mau cap tren lam sang la do thuong t6n tang trong 6 byng. Tuy nhien, can lua chgn va tan dung bet kha nang cua cac phuong tien chan doan khac truoc khi de nghi PTNS dl tranh lam dung ngi soi qua raiic nhu trong truong hgp vo gan CO chay man tren CT scan bung, co th^ dung DSA de lam TAB vi rat c6 hieu qua.

4.1.2. Nghi nga CO ton thuang tang rong hay mot tinh trang VPM dang dien ra: 132 ca (Bang 8).

Hien chua co phuong ti?n nao c6 do nhay va dac hieu cao de loai trir vo tang rong, nhat la cac truomg hgp dang dieu tri t6n thuang tang dac bao ton. Che do tham kham co he thdng, nhic lai nhieu lan la chia khod d6 chin doan trong tru6mg hgp vo tang rong don thuin [1]. Dilu kien tien quyet trong dieu tri bao t6n khong m6 cho tang dac la khong co vof tang r6ng kem theo [13]. Khi lam sang kho khan, Xquang khong chuan bi, sieu am bung, CT scan bung la cac phuong tien da va dang dugc ap dyng nhim h6 trg chan doan. Nhieu cong trinh nghien cuu gia tri cac phuong tien nay trong vo tang r6ng.

Chung toi nhan thiy khong co phuong tien nao noi tren c6 gia tri cao de chan doan loai tru vo tang rong, nhit la rugt non [3], [6], [14], [20].

Ngi soi 6 bung ciing tung dugc xem la phuong tien CO gia hi kem trong loai \xii thuong t6n tang r6ng [16], [17], [22]. Nha su tiln bg ciia ITnh vuc ngi soi va trinh do phau thuat vien dugc nang cao trong nhiing nam gin day, chung toi manh dan ap dung ngi soi cho nhiing benh nhan

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42 Tap chi GAN MAT VlfeT NAM so 30-2014 nay. Tit ca 85 trucmg hgp tren diu co dich hren sieu am, qua theo doi, trung binh la 14 ± 8 gio, kl tu liic nhap vien. Tuy khong co nhiing bang chiing khing dinh va tang rong nhung cac dau hieu lam sang va can lam sang phan anh tinh trang nhilm tning trong 6 bung. Mpt nguyen nhan nua lam cho tinh trang 6 byng trong nhom nay kho danh gia la cac thuong t6n ph6i hgp ngoai 6 byng (40%). Kit qua thu dugc rit kha quan, cac thuang ton gan (5 ca), lach (6 ca) deu xu tri dugc bing PTNS. 1 ca vo gan do 3 kem rach nat mac treo va thanh mac mgt non nhieu nen chuyen md byng, 1 ca vo rugt non kem vd dai trang goc gan phai md bung, 2 ca vo bang quang phiic tap md byng. Cac trudng hgp tu mau sau phiic mac (44 ca) khong co dau hieu ton thuong cac co quan sau phiic mac, chiing toi khong thuc hien tham sat thudng quy. 4 trudng hgp vd dai trang dp 1,2 dugc khau don gian (3 trudng hgp) va khau dieu tri va lam hau mon tam (1 trudng hgp) bang PTNS ho trg. 12 ca vd rugt non dugc khau don gian 9 ca vd do 1-3; 3 ca phai md bung do vd rugt non dp 3-4 co nhilu gia mac va thiic an trong 6 byng,va 1 ca co kem va dai trEing. 56 ca vo bang quang trong phiic mac CO 54 ca dugc khau hai lop bing chi tan kem tham sat 6 byng; 2 ca vd bang quang phiic tap phai md byng khau. Phat hien theml7 ca rach, vd thanh mac rugt non va rugt gia, 6 ca rach vd mac treo rugt; cac thuong ton nay ciing xii tri dugc bing PTNS. Khong ^uong t6n nao bi bo sot theo tieu chuan vang da neu. Nhu vay, trong chi dinh nay, chiing toi da thuc hien PTNS chan doan va dilu tri 128 trudng hgp, tranh dugc md bung khong cin thilt (97.0%). Chi dinh PTNS cho cac trudng hgp nay la co Igi vi ngoai viec mang nhirag uu dilm chung cua phlu thuat it xam pham, quan trong la giiip phat hien som nhiing thuong ton trong 6 bung, lam giam ti 1? md bung khong dilu tri va nhiing biln chiing cua nhiing phlu thuat tudng chung nhu vo hai nay [3], [4],

4.1.3. Nghi nga hay xac dinh va ca hoanh bang cac phuang tien chan doan khac: khi co hoanh vd, cac tang trong 6 byng thoat vi qua ch6 vd; Xquang byng-nguc khong sua soan, hinh anh vung nguc-bung dudi man huynh quang, Xquang can quang u6ng, CT scan nguc-bung c6

the phat hifn cac tang thoat vi len long nguc.

Day la cac phucmg tien chin doan hinh anh kinh dien ma benh vi6n Chg Rly thuc hien. Trong chi dinh nay, chiing toi co 2 trudng hgp dugc PTNS xac dinh vd hoanh ben trai, cac tang bi keo len long nguc qua chd vd; keo nhe cac tang ve 6 byng se thay ro duong vd. Qua cho vd, thSy dugc khoang mang phdi va nhu m6 phdi. Ca 2 trudng hgp nay r^t kho khan de khau dugc ch§

vd hoanh vi kich thudt co hoanh bi vd qua 16n (> 15 cm), vi tri vo sat cho bam ciia co hoanh len thanh nguc khien cho tam nhin bi khuit, goc thao tac bi han che; ca hai deu phai md bung dl xii tri thuong ton co hoanh. Chiing toi chua c6 nhieu kinh nghiem khau tai tao vd co hoanh Ion bing PTNS.

4.2. V^t thmmg bung

Chi dinh md bung tham sat thudng quy cho vet thuang thau bung hay nghi ngd thau byng khong con dugc ung ho tren IhS gidi [4], [25], [27]. Theo Mitsuhide [18], vdi chS do theo doi lam sang thich hgp, ti le md bung tring co the dugc ha thap xuong con 11%. Tai BV Chg ray, con s6 nay con d miic 35% (2008-2009). Vi thi chiing toi lua chgn benh nhan theo cac tieu chuin tren nhim giam s6 ca md bung khong dieu tri,

4.2 J. Nghi nga vet thucmg thdu bung:

Ddi vdi vit thuang thanh bung trudc, tham sat tinh chit thiu bung tuong d6i dl dang. D6i vdi vit thuong tilp tuyin, viec tham sat lai rit kho khan do dudng di ciia vit thuang xuySn thanh bung mgt doan dai. Vi thi chi dinh ngi soi nhiing trudng hgp nay nhim xac dinh la phuc mac CO bi t6n thuong hay khong va tim tang thuong ton.

Trong 32 ca (Bang 9), PTNS cho thay 15 ca khong tdn thuong la phiic mac. Chiing toi chi can 1 ttrocar d rdn va 6ng soi 30° dii cho phep tham sat toan bd la phuc mac v^ tinh tr^ng chung d byng. HSu phlu nhe nhang, b$nh nhan c6 the xuat vien sau 1 ngay. Thilt nghi cin trien khai rgng rai ngi soi d bung cho chi dinh nay.

Con lai 17 ca c6 thiing phiic mac, th8m 2 troc^

niia dl danh gia cbi tilt thuong tdn; kit qu^ 9 ca khdng tdn thuong tang, 2 ca rach gan, 2 ca thung

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Tap cM GAN MAT V I 6 T NAM so 30-2014 43 da day, 1 ca thiing rugt non, 1 ca rach gan kem

thung tiii mat, 2 ca rach dgng mach vi mac ndi phai; va day chan tron dang chay mau, tat ca deu xu tri dugc bang PTNS ngo^i trii ca rach gan sau c6 thung tiii mat phai chuyin md byng. Ti le xii tri bing PTNS la 31/32 ca (96.9%)!

4.2.2. Nghi nga ton thuang tang a benh nhan CO bang chung vet thucmg thdu bung:

Co 79 ca dugc chgn (Bang 10). Vlt thuang dugc ggi la thau byng khi co tdn thuong phiic mac thanh, bieu hi?n lam sang bing cac trieu chiing nhu loi tang ra ngoai vlt thuang,tham sat tai chd thay thiing la phiic mac thanh hay cac dau hieu tdn thuang tang trong d bung nhu non ra man, tieu - tieu ra mau, tyt huylt ap hoac cd cac bieu thau bung tren chin doan hinh anh nhu hoi ty do tren Xquang byng hay CT scan, dich ty do trong d bung tren sieu am hay CT scan.

Tuy nhien, vet thuong thau bung khdng co nghia la c6 ton thuong tang. Chiing tdi khdng chgn vao Id nghien ciiu nhung trudng hgp chic chin CO thuong ton Idn can sua chiia, chi chgn nhimg ca thau bung co kha nang tdn thuong tang byng hay thuong tdn tuong doi on dinh theo tieu chuan chgn benh va loai trii. Kit qua co 5 ca chi rach phuc mac rat nho, chu ylu la ty mau sau phiic mac; 29 ca thung phiic mac nhung tgng d bung khdng bi ton thuong, nghia la 34 ca (43%) trong chi dinh nay la dan thuan la PTNS chan doan. 45 ca cd tdn thuong tang theo Bang 10, tat ca deu xu tri dugc bing PTNS tni 4 trudng hgp phai md byng: 1 ca thiing da day rgng va r^ch tuy, thiic an do vao d byng nhieu; 1 thiing da day Ion chay mau nhieu kem co vet md cu, 1 thiing rugt non nhieu noi, dich tieu hoa va gia mac nhieu; 1 ca thiing co hoanh, da day, vd lach.

Dac biet 1 ca thung co hoanh, thung da day, vd lach; md bung phat hien them thiing dai trang.

Ngodi ra cd 2 ca thung rugt non va 2 ca thung dai trang cin PTNS hd trg. Do do ti le PTNS dieu tri va chan doan hoan toan cho chi dinh nay la 71/79 ca (89.9%). Thdi gian nim vien trung binh 4 ngay, chi mgt trudng hgp ty dich trong gan sau PTNS dugc dieu tri ndi khoa dn dinh.

Khong cd bien chiing phau thuat va tu vong. Ro rang tmh an toan va chat lugng dieu tri dugc dam bao. Khdng chi thi, kit qua 89.9% xii tri hoan toan bang PTNS nit ngan thdi gian nim

vien, giam sd lugng md bung khdng dieu tri.

Seo md rat nhd ciing la mgt uu diem ndi bat cua PTNS trong chi dinh nay.

4.2.3. Vet thuang nguc - bung nghi nga ton thuang ca hoanh.

Trudc day, nhieu tac gia khuyen cao khdng nen su dyng PTNS bom CO2 vi lo ngai bien chiing tran khi mang phdi ap luc. Nghien ciiu thuc nghiem ciia James E Wiederman [12] cho thay neu ta luu y den van de nay, bien chiing nay cd the tranh dugc. Sau tham khao thanh cdng cua cac tac gia khac [11], [19], chiing tdi ap dung PTNS cho cac trudng hgp vlt thuang nguc - byng. 29 ca trong Bang 11 trong chi dinh nay, trong do cd 2 ca PTNS Idng nguc. Kit qua, 14 ca khdng thiing hoanh, PTNS chi tham sat; con lai 15 ca thiing hoanh dugc tiln hanh tham sat toan the d bung. Chiing ta cd the hoan toan tin tudng vao ket qua loai tni qua PTNS ddi vdi thuang tdn co hoanh [11], [19]. Cac thuang tdn kem theo dugc phat hien gdm 7 vet thuong gan (thung hoanh phai), 3 vlt thuong lach, 5 thiing da day, 1 vet thuong tyy, I rach thanh mac rugt non. Tat ca diu xu tri dugc bing PTNS. 2 trudng hgp cin phdi hgp PTNS Idng nguc bSn tdn thuang de nia dich tieu hoa va cim mau khoang nguc. Chi duy nhat ca thiing hoanh phai kem vet thuang gan ha phan thuy 7 -8 sau phai md bung xu tri. Ti le PTNS chin doan va dilu tti trong chi dinh nay la 28/29 ca (96.5%). Qua phan tich, chiing tdi nhan thiy chi dinh soi d bung cho vet thuang nguc byng, hay vlt thuang nghi ngd thiing co hoanh la hgp li cung nhu khuyen cao ciia nhiSu tac gia (?) bdi 3 U do sau:

(1) Ty le bd sot thuang tdn ca hoanh cao khoang 33% trong vlt thuang nguc bung (?); (2) Khdng cd phuong tien nao khac c6 do nhay cao trong chan doan thuong tdn co hoanh do dao dam; (3) Kha nang can thiSp cua PTNS trong viec sira chua cac thuang tdn co hoanh.

Soi Idng nguc phdi hgp duoc thuc hien d mgt vai trung tam chin thuong tren thi gidi.

Chiing tdi ap dung vao cdng trinh nay cho thiy no vira dam bao dugc muc tieu dilu tri vira thua hudng nhiing uai dilm ciia phlu thuat xam nhap tdi thieu. Chiing tdi thiet nghT chi dinh nay cin dugc pho bien rgng rai.

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44 Tap chi GAN MAT VIET NAM so 30-2014 4.3. Gla tri xir tri thu-ffng tdn tang bang PTNS

4.3.1. Doi vai tgng dac:

4.3.1. L Gan: co 40 tdn thuang gan, hong do 13 vo gan do 1- 3,27 vlt thuang gan.

- Theo Leniot, Pilgrim, Usatoflf [21], 50% vd gan dg 4 va 70% vd gan do 5 c6 kha nang dilu trj bao tdn thit bai cin can thiep lai, 10% bi md lai do do dich mat vao trong d bung, dan luu cac d ty dich khong du (40% thit bai) nen cin md bung din luu. PTNS riia byng va din luu se hieu qua, trdnh dugc md byng Idn. 80% cac trudng hgp vd gan do 1 - 3 tu cam. Trong nghien cihi CO 7 trudng hgp vo gan dg 1 - 2, dang chay mau it, chiing tdi cam mau bang dung dao dien ddt diem; 2 trudng hgp vd gan dg 3 dugc cam mau bang khau chi tan cham 1.0. Theo chung tdi, cac trudng hgp vd gan dg 1 -3 cd the ty cam, chi can can thi?p cam mau khi tdn thuong van dang chay mau khi PTNS. Cac thuong ton phan bd khip cac thuy gan nhung hau nhu cac vi tri va tinh chat chay man deu cd the quan sat qua ndi soi ro rang. 4 trudng hgp vd gan dp 3-4 chay mau nhieu cd hay khdng dang kem rach thanh mac rugt non phiic tap, khdng cam mau qua ndi soi dugc phai chuyen sang md kinh diln.

- Tat ca vet thuong gan deu can dugc xu tri vi vet thuang thudng sau, rach ngang mach mau, chay mau hiem khi tu cam. Trong nghien ciiu 27 vlt thuang gan, qua PTNS chiing tdi ddt cam mau va khau vlt thucmg gan thanh cdng cho 25 ca (92.6%).

4.3.1.2. Lach: lach kho quan sat hon gan, dac bi$t bd sau tren va mat sau rdn nhung cac diu hieu gian tilp nhu mau eye dudi hoanh trai la chi diem tot thucmg tdn lach.

Dac diem ciia tdn thuang lach trong nghien ciiu cua chiing tdi thudng tir do 1-3, chay mau thudng da tu cam hay ri ra nen kha nang can thiep dugc bang PTNS cao.

- 19 ca vd lach trong nghien ciiu: 7 ca vd do 1 -2 cim mau dugc bang ddt dien; 4 ca vo dp 2- 3 cim mau bing khau bang chi PDS 3.0 qua PTNS. 5 ca vd lach do 1-2 dugc thiy da tu cim, chiing tdi dat them 1 manh Surgicell dl "dan"

len ton thuong giiip tranh chay mau lai, 2 ca vd lach do 3 ch^y mau nhilu phai md bung cat lach, PTNS cat lach hoan toan lea vd lach do 4.

- 7 ca vlt thuang lach, 5 vlt thuong lach dugc khau cam mau bing chi PDS 3.0 qua PTNS. 2 vlt thuong lach con lai cd chi dinh md byng do tdn thuong khac (co hoanh, da day).

- PTNS cat lach cin nhilu thilt bi hien dai nhu dao sieu am, dao cat va khau ndi soi, kep Bulldog khdng chi bd mach lach, dao Argon de cim mau bl mat cat lach, may loc mau ho^n h6i...Vi vSy du cit lach chgn Igc (md chuong trinh), chiing tdi da dung PTNS cit lach thanh thao nhung chua sOr dyng nhilu cho cip ciiu.

4.3.1.3. Tuy: tyy nam sau phiic mac cung khdng nim ngoai tim kiem soat ciia ngi soi. Vao hau cung mac ndi qua day chang vi dai tr^g, tao ciia sd d viing vd mach cua day chang, sau do dung hai k?p khdng sang chin dl nang bd cong Idn cua da day va cho dng soi vao h^u cung mac ndi qua cua sd nay la cd the quan sat dugc toan bd mat trudc tuy. Chi kiem tra hau cung mac ndi khi nghi ngd thuang tdn tuy vdi cac dau hi^u gian tiep d phia trudc nhu da day bi dgi len cao ra phia trudc (tu the nim), vay nen hay cd dich mau trong bung ma khdng phat hi?n thuong tdn nao khac. Nhu vay hoan toan cd the chin doan thuang tdn tyy qua ndi soi. Tuy vay, do sd lugng it, chua dam ket luan vl do nhay va chuyen biet trong chan doan. Thudng nhiing chin thuang tyy do 1-2 thudng it gay biln chiing nang, cd the gay viem tuy cap hay nang gia vl sau. Trong nghien ciiu, cd 3 trudng hgp d^p tyy dp 1 -2 dugc riia din Ivm hau cung mac ndi va 1 vlt thuang tyy khau cim mau va phong ngua ro tuy. 1 vet thuang tyy phai md bung vi kem vlt thuang Idn da day gay viem phiic mac.

Tuy nhien sau PTNS tyy, 1 ca phai md byng do tu dich tyy trong hau cimg mac ndi. Chiing tdi khong gap tdn thuang tuy do 3-4 cin cit tyy trong nghien ciiu.

4.3.2. Doi vai tgng rong: Vi van dl nay con mdi, chi chgn cac Id thung vd dng tieu hoa c6 mep ggn va nhd hem Y2 khau kinh. Ddi vdi cac thuong tdn can cat doan hay ndi ong tieu hoa, chgn vi tri gin thanh bung, tao mgt dudng md nhd de dua thuang tdn ra ngoai xir ly; sau dd

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Tap chi GAN M A T VIET NAM s6' 30-2014 45 dua lai vao trong d byng ciing mang mgt y nghia

nhat dinh ciia ndi soi. Dac biet, tat ca cac va bang quang trong phiic mac diu cd thi xir tri tot bang ndi soi.

4.3.2.1. Ruot non: 24 ca thuong tdn nipt non (12 vd, 12 thung). lOcavdva 11 thung nipt non (83.3%) xii tri dugc bing PTNS hay PTNS hd trg. Xir tri bao gdm khau don gian mgt Idp bang vicryl 3.0 qua PTNS (18 ca) va dua rugt non tdn thuong ra ngoM qua vet rach thanh bung 3 - 4 cm bd ngoai co thang bung, cat ndi rugt bang vicryl 3.0 hoac PDS 4.0, rdi dua lai vao d byng bang PTNS cd ho trg (3 ca).

- 30/33 ca (91%) tdn thuong thanh mac hay mac treo rugt non trong nghien ciiu dugc xii tri hoan toan bang PTNS khau bang chi vicryl 3.0.

Trong 30 ca nay, cd 1 ca sau khi Idiau mac treo, nghi ngd thieu mau nudi thanh nipt, PTNS dugc thuc hien lan 2 (sau 12 gid) de kiem tra, khdng ghi nh3n bSt thudng cua viing rugt c6 lien quan.

4.3.2.2. Ruot gid: 7/8 (87,5%) thuong tdn rudt gia xii hi dugc bing PTNS hoac PTNS ho trg. PTNS (4 ca) thiing nhd (<2cm) sach, dugc khau rapt 1 Idp chi PDS 4.0. PTNS h5 trg cho 3 ca thimg Idn (>2cm), khdng sach dugc lam hau mdn tam.

- Tit ca tdn thuong thanh mac radt gia (14 ca) ngan 2cm den dai 10 cm deu khau dugc bing PDS 4.0 qua PTNS.

4.3.2.3. Dg day: 12/15 ca ton thuong da day mat trade hay sau khau dugc qua PTNS. Ky thuat khau mat trade don gian 2 Idp bang vicryl 3.0; mat sau phai vao dugc hau cung mac ndi qua nga bd cong Idn da day tham sat va khau 2 lap bing vicryl 3.0. Tdn thuang da day thudng xu tri dugc bang PTNS tni khi tdn thuong dai tren 3 cm, ban, hay nam d mat sau gan tam vi, hoac vimg hang vi sat dau tuy khien kho tiep can de xu tri, chung tdi cd 3 ca thiing da day phai md byng do tdn thuong phdi hgp nhieu co quan va chay mau nhieu, kho thao tac.

4.3.2.4. Tui mat: nhd kmh nghiem cit tiii mat bing PTNS, chiing tdi dl dang cit hii mat bi tdn thuang cho 3/4 ca tdn thuang tiii mat.

4.3.2.5. Bang quang: 59/61 (96.7%) ca vd bang quang trong phiic mac dugc phau thuat vien nieu khoa khau 2 lop, chi vicryl 2.0 dugc bang PTNS. Khdng can md bang quang ra da, chi dat thdng tieu, 2 ca phai md byng khau do vd phiic tap trong va ngoai phiic mac.

4.3.3. Can thiep dieu tri thuang ton ca hoanh:

Trong 316 ca nghien ciiu, chiing tdi deu thuc hien kiem tra co hoanh trudc khi kiem tra cac tang khac. Ket qua 20 thuong tdn ca hoanh dugc phat hien, khdng thuong tdn hoanh nao bi bd sot, dp nhay la 100%.

- Vet thuong hoanh thudng ngan, ggn nen cd the xir tri bang PTNS. 15/18 vet thuong hoanh dugc khau tot bang Prolene 1.0, miii chii X hoac U. 3 vet thuang hoanh con lai vIn cd the xir tri bang PTNS, nhung phai md bung do tdn thuong da day, lach, gan. Nhung theo Ivatury, Murray [11], [19] gia tri tuyet vdi ciia no dupe khang dinh nen chiing tdi khdng ban den van de nay niia.

- Va CO hoanh (2 ca) toac rong, sat th^nh nguc khdng the xir tri bang PTNS.

4.4. Bien chung: neu tinh theo bien chiing hen quan PTNS, cd 3 trudng hgp (0.9%),

-1 ty dich trong gan sau md ddt cam mau nhu md gan qua npi soi.

-1 tradng hgp chu dgng PTNS lan 2 dl kilm tra thuang tdn radt sau khau mac treo.

-1 tradng hgp md bung sira chiia xi vet khau bang quang sau PTNS, tuy nhidn xi vet khau la do dng thdng tieu bi tac.

4.5. ThM gian nam vien:

Nhom ngi soi khdng cd thucmg tdn tang la 2.00 ± 1.25 ngay, ngin nhit lai, dai nhit la 3 ngay. Neu so sanh vdi thdi gian nam vien trang binh 7 ngay trong 256 ca md bung khdng dilu tri cua Feliciano thi khac biet cd y nghia thdng ke (do tin cay 95%).

4.6. Tu- vong: Tii vong trong Id nghien ciiu khdng do tai biln hay biln chiing cua ndi soi ma do tinh trang chan thuang ngoai d bung gay ra.

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46 Tap clll GAN MAT VIET NAM so 30-2014

S.Kit luan

5.1. Phau thuat n?i soi la bien phap an toan hi§u qua:

- Khdng tai biin - biin chiing trong md:

khdng biin chiing tac mach - hoi, khdng bien chiing tang ap luc npi so, khdng bien chung ve hd hap.

- Khdng cd chay mau Idn can truyen man.

- lOidng cd xi buc cho khau nil, khdng cd viem phuc mac sau md.

- Giam md bung Idn cho 179 benh nhan cd tin thuang cin xit tri (56,9%).

- Thdi gian md trung bmh khdng qua dai.

- Giam chi phi dieu tri.

5.2. Nhirng thuong ton co thi dieu tri bang phau thuat n$i soi cap ciiu chin thinmg bung:

- Tin thuong ndng tang dac miic do nhe den trung binh.

- Vd tang ring chua gay viem phiic mac nang.

- Tdn thuong ca hoanh khdng phiic tap.

5.3. Cac thumig ton hien chira xir tri hang phiu thuat n9i soi cap ciiu:

- Vd Idn tang dac cd chay mau nhieu (vd gan tren dp 3, vd lach tren dp 2, tdn thuong tiiy tren do 2).

- Vd tang rdng phiic tap, vd ta trang.

- Rach mac treo phiic tap, chay mau nhiiu.

- O bung ban.

- Nhieu thuang tdn tang d bung cd kha nang keo dai thdi gian PTNS.

Tai lif u tham khao

1. Biii Van Ninh (2003). Chan thuong va vit thuang bvmg, Benh hpc Ngoai Khoa, Nha Xuat ban Y hpc TPHCM. 27-35.

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bung. Luan van tit nghiep BS npi tni. DHYD TPHCM.

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