Tap chi GAN MAT VIET NAM sd 29-2014 61
Danh gia ket qua bvo'c dau ndi soi m§t tuy ngirgc dong kit hgrp cit tui mat noi soi trong dieu tri ong mat chu kem soi tiii mat
Evaluation initial results endoscopy retrograde cholagiography com- bined laparoscopic cholecystectomy in treatment of gallstones associ- ated common bile duct stones
Duong Xudn Loc, Ho Vdn Linh, Hodng Trpng Nhat Phuang. Le Manh Hd, Trdn Nhu Nguyen Phucmg, H6 Ngpc Sang, Pham Nhu Hiep. Le Lp
Tdm tat
B^vandi:¥hoding 10-15% benh nhan sdi tiii mat kem sdi dudng mat chinh dugc phat hien khi nhip vi§n. Ngay nay, cat tiii mat ndi soi da ttd thinh phuang phap dugc lya chpn dh dilu tri sdi tui mit. Ndi soi mat tyy ngugc ddng giiip tao diem nhieu sy lya chgn ttong cich dilu tri sdi tui mat kem sdi dudng mat chinh. Ki thuat thuc hien ddng thdi dd l i ket hgp ca 2 d l dieu tri sdi tiii mat kem sdi dudng mat. Dinh gia phuang phap dieu tri s6i tui mat kem sdi dudng mat chinh bang ndi soi m^t tyy ngugc ddng va cit tiii mat npi soi.
Boi tupvig vd phuong phdp nghiin cuu:
nghien ciiu tien ciiu md t i dua tten 25 b?nh nhin bi sdi tiii mat kem sdi dudng mat chinh dugc chuan doin bang sieu am tai Benh vien Trung uong Hue. Benh nhan dugc Iiy sdi dudng mat chinh bang ndi soi mit tuy ngugc ddng trudc khi dugc cat tiii mat ndi soi, ttong 1 lin m d .
Ket qud: cd 16 nir v i 9 nam. Tudi trung binh 61,64 +10,18 ttidi (hi 38 din 81 tudi). Tit c i benh nhan dugc chdn doan sdi tui mat kem sdi dudng mat chinh trudc md bang 2 lin sieu im. Tit c i
benh nhan deu dugc chuan hi lay sdi dudng mat chinh bang ndi soi mat tyy ngugc ddng v i cat tiii mat npi soi frong cung 1 lan md. Ndi soi mat tuy ngugc ddng lay sdi thanh cdng d c i 25 benh nhan.
Khdng cd benh nhan cat TMNS n i o chuyen sang md md. Thdi gian trung binh ciia npi soi mat tuy ngugc ddng lay sdi l i 36,15 ± 12,20 phiit. Thdi gian trung binh cua cat tiii mat ndi sol la 42,10 ± 22 phiit. Khdng cd bien chiing ttong md hen quan den ndi soi mat tuy ngugc ddng lay sdi va cit tiii mat ndi soi. Thdi gian ndm vien trung bmh 5,75 ± 2,5 ngay. Theo doi trung bmh sau md 12 thing ( 2- 18): 2 benh nhin h?p doan cuoi ong mat chu, 3 trudng hop viem tyy cip.
Kit luqin: Nghien ciiu niy cho thay ndi soi mat tiiy ngugc ddng lay sdi ket hgp cat tiii mat npi soi frong dieu tri sdi tiii mit kem sdi dudng mat chinh budc d i u mang tinh an toan v i hieu qui. Tuy nhien, can phii nghien ciiu vdi sd lugng benh nhin nhieu hon nua de tim ra dugc nhiing han chi ciia ndi soi mat tuy ngugc ddng khi ket hgp vdi cat tui mat ndi soi de dieu tri benh ly niy.
Abstract
Introduction: Common bile duct stones oc- curs in 10% to 15% of patients with gallstone admitted to hospital. Laparoscopic cholecystec- tomy (LC) is today the tteatment of choice for gallstone. The advent of endoscopic techniques changed surgery in the regard of management gallstone associated with common bile duct stones. This has created a dilemma in the man- agement of common bile duct stones. Today a
number of options exist, including endoscopic sphincterotomy (ES) before LC in patients with common bile duct (CBD) stones.
Objectives: The aim of this study was to as- sess initial results of the treatment of gallstone associated with common bile duct stones (CBDS) by endoscopic refrograde cholagiopan- creatography (ERCP+ES) and laparoscopic cholecystectomy (LC).
1. B$nh vi?n Trung ucmg Hue va Dai hpc Y - Dugc Hue.
Phin bi?n Khoa hpc: GS Van Tan.
62 Tap chi CAN MAT VIET NAM s« 29-2014 Materials and methods: This prospective study was carried out on 25 patients with gall- stones associated with common bile duct stones diagnosed by ultrasound at Hue central Hospital.
They were treated by ERCP+ES prior to LC im- mediately.
Results: There were 16 females and 9 males.
Then mean age was 61,64 + 10,18 years (ranging from 38 to 81 years). All of patients and confimed gallstones and CBDS by preoperative ultrasound (US). All patients were prepared for ERCP and LC in one session. Cholecystectomy was com- pleted laparoscopically in 25 patients (100%). The mean time of ERCP was 36,15 ± 12,20 min. The
mean time of LC was 42,10 ± 22 minutes. Patients were dischanged after a mean post operative hos- pital stay of 5,75 ± 2,5 days. None of the patients presented on the postoperative follow-up with symptoms, signs, laboratory or radiological evi- dence of retained CBDS.
Conclusion: The current study suggests that ERCP combmed LC for the management of cholecysto-choledocholithiasis is a safe and an ef- fective technique. However, additional studies with larger patient populations are needed keeping in mind that the luniting characteristic is the prox- unity and availability of the endoscopic settings.
1. B^ vdn de
Khoang 10-15% benh nhan soi tuy mat kem soi duong mat chinh duoc phat hien khi nhap vien [7], [8]. Ngay nay, cat tui mat noi soi da tro thanh phuong phap duac lira chpn de dieu tri soi tuy mat.Do do, vol su xuat hien cua noi soi mat tuy nguoc dong, soi tui mat kem soi duong mat chinh CO nhiSu sir lua chpn trong each dieu tri.
Hien nay, hai phuong phap cung t6n tai do la lay soi duong mat chinh bang npi soi mat tuy ngupc dong (NSMTND) ket hop cSt tui mat npi soi (cat TMNS). Muc tieu: Danh gia ket qua ban dau phuang phap dieu tri soi tiii mat kem soi duong mat chinh bang npi soi mat tuy nguac dong ket hpp c4t tui mat npi soi.
2. Doi tirang vd phirffng phdp nghien cmi Doi turnig nghien cmi:
Tir 2012 dSn 2014 co 25 benh nhan bi soi tiii Bdng 1: Cdc yeu to nguy ca
mat kem soi duang mat chinh duac lay soi bang NS-MTND va c5t TMNS, trong do 16 nti va 9 nam. Tu6i trung binh 61,64 + 10,18 tu6i (tvr 38 dfa 81 tu6i ). SiSu am it nhit 2 Ito cho kSt qua giong nhau.
Cac b$nh nhan co soi duang mat trong gan, hoac nhiju soi (>3 vien) dupc loai khoi nghien cuu nay. Benh nhan co nhiem trung duang m^t dugc &ih\x tri on dinh truac khi phau thuat.
Phirong phap nghien cihi: nghien ctoi tien ciiu, mo ta, khong so sanh dua tren tat ca b?nh nhan dirpc lAy soi duong mat chinh bang npi soi mat tuy nguac dong truoc khi dupc cat tui mat npi soi. Tit ca benh nhan dSu dupc chuin bi de cit TMNS ngay sau khi l4y soi duang mat chmh bing NSMTND.
3. Ket qud Dac diem ldm sdng
Yeu to nguy co Cao HA Dai duong Chuc nang tim giam Chirc nang ho hap giam
n 16 12 5 6
%
64 48 20 24
Tap chi GAN MAT VIET NAM so 29-2014 Bang 2: Cdc trieu chung ldm sdng
Tri^u chung lam sang Vang mat
Tang Bilirubin true tiep Men gan tang Photphatase kiem tang S A c6 sdi OMC + OMC dan
n 12 18 9 14 25
%
48 72 36 56 100
Npi soi mat tyy ngugc ddng lay sdi thinh cdng d ci 25 benh nhin. Thdi gian trung binh eua npi soi mat tuy ngugc ddng Iiy sdi la 36,15 ± 12,20 phiit. "Khdng cd bien chiing xay ra frong Iiy sdi bing NSMTND.
Cat tiii m^t ndi soi tiianh cdng tien 25 b?nh nhin (100%). Thdi gian trung binh cua cit tiii mat npi soi li 42,10 ± 22 phiit, Khdng cd biin chiing frong mdCTMNS.
Thdi gian nim vi$n frung bhih 5,75 ± 2,5 ngiy.
Khdng ed bien chiing sau md.
Theo ddi trung binh sau md 12 thing (2-18):
2 b?nh nhin h?p do?in cudi dng mat chu dugc nong thinh cdng, 3 trudng hgp viem tuy cip dieu tri npi khoa
4. Bdn luffn
Hi?n nay, cat TMNS da thay thi phiu thuit cat hii m$t hd vdi ty le fren 95% vi ERCP dugc su dyng de lay sdi dudng mat chinh da frd nen ngay cang phd bien. Do dd, frong trudng hgp sdi tiii mat, lay sdi dudng mat chinh bang md OMC ndi soi hay bing ERCP dang la van de dugc nhieu phau thuat vien quan tim. Cit TM va md OMC lay sdi ndi soi cd uu diem la cudc md dugc tien hinh frong 1 lan, chi can 1 kip phiu thuit. Tuy nhien, md OMC Iiy sdi NS ddi hdi nhilu ylu td nhu phiu thuat vien cd kinh nghiem, phdng md phii dugc trang hi nhieu dyng cy, d^c biet la he thdng NS dudng mat, may tan sdi... Do dd khdng phii trung tim ngogi khoa nao cung thuc hien dugc. Ngoai ra, cupc md thudng keo dai, b^nh nhin nim vi?n liu hon vi chi phi phau thu^t cao hon. Nghien ciiu nay cho thiy 5,75 ± 2,5 ngiy.
ngan hon thdi gian nam vien so vdi md OMC ket hgp cat TMNS li 6,5 ngay [3],
Mdt van dl niia la lam cho phuang phip cat TM kit hgp vdi md OMC NS khdng thyc hien dugc la cac yeu td lien quan din benh nhan. Tudi TB tiong nghien ciiu niy la 61,64 + 10,18 tudi, frong dd 20 benh nhan fren 60 tudi chiem 80%.
Tren 50% b6nh nhin cd cao HA vi gin 50% benh nhin cd kem theo b$nh dii dudng (bing 2).
Nghien ciiu ciia Himal H.S cung nhan thiy vin de ngan cin md OMC ket hgp cat TMNS chinh la da sd bpnh nhin frong nhdm niy cd tudi ldn vi cd nhieu b^nh ly kem theo [5].
Trudc cic vin de fren, chiing tdi da chpn lay sdi dudng mat chinh bing ERCP kit hgp cit TMNS de trien khai. Tit ci cic PTV tieu hda tai cac benh vien ciia chiing tdi deu cd the ket hgp vdi cac bic si ndi soi thyc hien phuang phap nay.
Day li thuin Igi dau tien mi chiing tdi nhan thiy khi trien khai ky thuat nay.
Cac nghien ciiu trudc day ciia chiing tdi ve lay sdi dudng mat chinh bang ERCP cho thiy phuang phip niy cd ty le thinh cdng khi cao fren 85%.
Ty le bien chiing la 3,5% [2], Nghien ciiu ciia cic tic gia khac cung cho ket qua tuong ty [1]. Ty 1?
thanh cdng cua phuong phap niy frong nghien ciiu ciia chung tdi li 100%. Vdi ty le bien chiing frong md la 0%. Ket qui nay cd le do chiing tdi da chpn nhiing benh nhin cd sdi it vi cd kich thudc dudi 2cm de tien hanh nghien ciiu.
Ty le cit TMNS phii chuyen md md li 0%. Ty 1? chuyen md md frong nghien ciiu cua chiing tdi nim 1999 la 12%, nguyen nhan chu yeu la do viem
64 Tap cM GAN MAT VIET NAM s« 29-2014 dmh 6 tam giac Calot Cac nghien ciiu khac CO ty le chuySn m6 mcr la 9,8% [9]. So vdi cac tac gia tren ty le chuy&l mfl ma cua chiing toi thlp han.
Mpt vin dS Uen quan d6n ky thuat ma chung toi mu6n d8 cap dSn do la nen tien hanh cat TMNS trong mpt lin mi voi ERCP, hay la cat hii mat sau ERCP 2-3 ngay Trong nghieii ciiu cua chiing toi co 100% benh nhan duac cit hii mat trong mpt lin m6 sau khi lam ERCP vcri ty le chuySn sang m5 ma la 0%. Khong co bign chiing ttong va sau md nao dupc ghi nhan. Mpt so tac gia tren thS gioi cho ring: khong nen cit tui mat ngay sau ERCP n8u co tinh trang chuang bung va nlu tri hoan thi nen cit som sau 2-3 ngay de tranh tinh trang viem nhilm cua tui mat. Ronnie TPP.
hi hoan cat TMNS sau 6-12 tuin voi ty le chuyen m6 mo la 9,8%, ma theo Lo CM. tinh trang viem tiii mat se gia tang neu tri hoan tren 72 gia. Mpt s6 tac gia khac lai chii truang th\rc liien cimg mpt liic di tranh cho benh nhan 2 lan phau thuat ma vin mang lai kit qua kha quan (2, 4, 5). Mpt so nghien ciiu cho thiy trong trucmg hpp viem tiii mat niu cit tiii m$t sau 72 gicf, tmh trang viem tiii mat se tang len nliieu lam cho viec phau tich TM a tam giac Calot kho khan hon di gay bien chiing.
Chiing toi cho rang tinh trang chuang bung sau khi lam ERCP khong lam cho cit TMNS tra nen qua kho khan.
Theo chiing toi: khong nen cimg nliic chi dinh cit TMNS ngay sau khi lam ERCP hoac cit tiii mat tri hoan sau 2-3 ngay. Ma chiing ta nen bo tri san mpt kip phau thuat ngoai tieu hoa cimg tham gia lam ERCP vci bac sT npi soi. Dieu nay co 2 lpi ich la: phau thuat cap cim ngay niu ERCP co tai bien nhu chay mau, thung hanh ta trang... hoac CO the cat TMNS ngay neu tmh trang benh nhan cho phep nhu: bung khong chuang, hinh anh X- quang chac chan khong con soi. Neu diiu kien benh nhan khong cho phep co thi len lich phiu thuat cho benh nhan sau 2-3 ngay.
Ket luan
Nghien ciiu nay cho thay npi soi mat tuy ngupc dong lay soi ket hpp cat tiii mat npi spi trong diiu tri soi tiii mat kem soi duong mat chinh buac diu mang lai hipu qua va an toan.
c i n phai nghien cim vdi si luang benh nhan nhiiu ban niia di tun ra nhirng bm ehi cua npi soi mat tuy nguac dong khi kit hop vdi cat hii mat npi soi di diiu tri benh ly nay.
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2. TVin Nhu Nguyen Phuwng, Hi Ngoc Sang, Lam Thj Vmh, Pham Nhu Hi?p, (2008).
" Diiu tri soi dudmg m|t chinh bing noi soi mjt tuy ngupc dong tai BVTW Hui". Y hpc TP Hi Chi Minh, Hpi nghi ngoai khoa va phiu thuat npi soi toan quoc, tt: 329-332.
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