D A N H GIA K £ T Q U A DIEU TRI N G O ^ I KHOA UNG THU THlTC QUAN TAI B E N H VIEN C H O RAY T R O N G 9 N A M (1999-2007)
Nguyen Cdng Minh TdM TAT
Muc tieu: Ung thu thuc qudn Id benh ly dc tinh tir vong cao. Diiu tri chu yeu hien nay vdn Id phdu thugt. Cong trinh ndy nhdm ddnh gid thuc trgng cua BN un^ thir TQ den viin, khd ndng phdu thudt, cdc logi phau thugt duac tien hdnh tai khoa Ngogi long nguc BVCR vd hieu qud Clia cdc phuang thirc dieu tri kit hop cua nhiing ndm gdn day.
Phirffng phdp nghien ctiu vd kit qud: Trong 9 ndm (1999-2007) chiing toi co 451 BN ung thu TQ: rihieu nhdt Id 50-70, tuoi trung binh Id 51 (tre nhdt 39 vd ldn tudi nhdt Id 94). Nam gdp 10 ldn nir. Hdu hit BN din vien trong giai dogn tre. Da so sang thuang & 1/3 giira, 62%
vd nhieu nhdt la ung thu ti bdo gai, 84%. Phdu thugt 3 dudng md dugc chon (35%), phdu thudt Orringer (5%). Da so deu dugc diiu tri ket hgp hda hogc hoa-xg sau md. Bien chirng sau md la 18% vd tu vong 8,3%. Khdng cd BN ndo sdng 5 ndm. BN sdng lau nhdt Id 2 nam 7 thdng.
Kit lugn: Cho den hien nay, mdc da phau thudt vdn giir vai trd chu lire trong dieu tri cdc ung thu TQ giai dogn sdm, nhung hoa tri hodc hoa-xg trj Mt hgp ludn dugc thuc hien trong diiu tri giai dogn tien triin khu tni. Vi da sd BN cda chung toi den mugn nen chi dinh md khong con J? nghTa triet di nira. Cdc PT chiing toi tien hdnh chi Id PT tgm bg, gidp BN dn uong dugc, do do tf' le sdng 5 ndm khong co, mdc dii tdt cd deu co hoa tri hodc hoa-xg ket hgp.
Ldm sao chdn dodn sam de md triet de Id yeu td thdnh cong trong dieu tri ung thu TQ.
Tir khod: Ung thu thuc qudn, SUMMARY
SURGICAL TREATMENT OF THE ESOPHAGEAL CANCER AT CHORAY HOSPITAL IN 9 YEARS (1999-2007)
Objective: Cancer of th esophagus is a highly lethal malignacy. Until now, the optimal treatmeni is operation. This reseach will focus on the actual situation of the esophagus cancer at the depatment of cardio-thoracic surgery in ChoRay hospital, the surgical for esophagectomy and the results of the combined modality aproaches on these diseases in the recently years.
Methods and Results: During 9 years, between 1/1999 to 12/2007, we are 451 esophagus cancer: the peak from 50-70 years old, the mean age 51 (range 39-94). Male is 10 times more than female. All of them were in the late stage. 62% in the midle third ofthe esophagus and the squamous cell carcinoma was popular, 84%. The triincision esophgectomy technique is prefered, 35% and after that is Orringe's technique, 5%. Most of them were combined chemo or chemoradiotherapy post-operative. The complication was 18% and 8.3% mortality.
The 5 years sunnval rate of 0%, the latest survival person was 2 years and /months.
Conclusion: Although surgery may be consider for selected patients with early stage, radiation conbined with chemotherapy is prefered with locally advanced disease. Because of the late stage disease, the curative treatment was not radical significance. All of our operations were palliatives, the 5 years survival rate was none, though combined chemo or chemoradiotherapy post-opertive. Early stage intramural esophageal cancer for radical en bloc esophagectomy is the optimal condition.
Key words: Esophageal cancer.
PHAN MO DAU
Ung thu thirc quan la mot benh thudng gap nhat ciia thtrc quan (TQ) va la mot trong 10
' Benh vien Trung Virong
Dja chl lien lac: PGS.TS.Nguyln Cong Minh DT: 0903732399 Email: bs.congminh©gmail.com 300
loai ung thir gap hang dau d Viet Nam. Theo 1 thdng ke ciia Vien tam soat ung thu qudc gja M5^ thi moi nim. 6 N^y cd 16.470 ngudi ducrc phat hien ung thu TQ va cd den 14.280 BN chit hang nam vi benh nay'"-^^'. NhiSu gia thiiy6t cho rang loai ung thu nay cd lien quan ddn yeu to nhilm ddc thuc an cua mdi trudng, thi6u dinh dudng, thieu sinh td, thieu mau, ve smh rang mieng kem, an udng do nong. Cdn d cac nude phucmg Tay thi chu ydu la do nrgu ya thudc 11 Di^u tn chu y^u hien nay vin la phau thuat, nhung vi BN den mudn nen phau thuat tam bg chiem da sd, ty le sdng 5 nam cdn thap.
Thuc quan la mot "dng ca", it ngudn mau nudi, nen phau thuat TQ la phau thuat khd, dl buc khi ichSu ndi. Cdng tiinh nay nhSm ddnh gia thuc trang ciia BN ung thu TQ d8n vien, kha nang phau thuat, cac loai phau thuat dugc lien hanh tai BVCR va hieu qua ciia cac phuang thuc dieu trj ket hgp cua nhung nam gan day.
DOI TU'ONG VA PHU'CNG PHAP NGHIEN CtTU
-Tit ca BN bi ung thu thurc quan va tam vj dugc xac dinh ket qua sinh thi^t qua ngi soi v&
chin dodn hinh anh hgc va dugc didu tri phlu thuat tai khoa Ngoai long nguc BVCR trong 9 nam (1/1999-12/2007). Chung tdi khdng nghign ciiu 45 BN cat TQ qua khe hodnh va 49 BN phlu thuat ndi soi dugc md tai khoa Ngoai tdng quat trong cung thdi gian tren.
-Chung tdi chi khao sat tren nhimg BN ma chiing tdi lien hanh phau thuSt cat TQ, ket hgp vdi hda-xa trj ket hgp. Chung tdi khong di sau vao nhimg BN dieu tri phau thuat tam bg hoac dat Stent ma cd hda hoac xa tri.
-Phuang phap nghien ciiu: hdi cuu md ta cat ngang cd ddi chung.
KET QUA NGHIEN CUU
Trong 9 nam (1999-2007) BVCR cd 451 BN ung thu TQ nhap vien phai can thiep phau thuat hoac thti thuat tam bg nudi an. Chung tdi chi khao sat sau 357 BN dugc phlu thuat tai khoa Ngoai long nguc BVCR trong thdi gian tren.
Tudi Tuoi
< 4 0 41-50 51-60 61-70
> 7 0 TS
BN nam 7 91 135 111 63 407
BNnu 3 J 9 14 11 44
Tong so 10 98 144 125 74 451
ryie 2%
22%
32%
28%
16%
100%
Tuoi chiem da so la 50-70 (60%).
Trang binh 51 tuoi. BN nho tu6i nhit la 39, Im nhSt la 94 tu6i Gioi
Nam 407 BN (90%), Nii: 44 BN (10%). Nam gan gap 10 n&.
Ldm sdng Nuotnehen
Nuot nghen la TC dac hieu cua ung thu TQ (s6 bang) Mirc do nu6t nghen
D6 1 Do 2 Do 3 Do 4 Do 5
N=357 D 23 129 196 9
Tyle 0 6%
36%
55%
3%
-Co 6 muc do nuot nghen: do 1 (an uong binh thuemg). Bo 2 (an phai kem theo u6ng nu*c moi nuot du9fc. Do 3 (chi an dugc thiic an nhao nhu chao. Bo 4 (chi nu6t duoc thirc an long).
Do 5 (chl nuot duoc nuoc bot). Dp 5 (khong thS nu6t duoc gi ca).
-Tren 357 BN den vien. Tat ca dju nu6t nghen, trong do nu6t nghen do 3 va 4 c h i t o da s6, 301
91% (P< 0,001). Tat ca d giai doan qua irl.
Ldm sdng cua BN siai doan tri
126/ 357 BN den vien cd lam sang d giai doan mudn, chiem ty Ie 35%.
BN giai doan tr8 U xam lan & hach tren CT
Suy kiet Hach thugng don Khan gigng Vigm phoi tai di tai tai Tong so
S3BN 23/357 56 33 4 10 126/357
Tyle 6%
16%
9%
1%
3%
35%
Ngoai TC nudt nghen, cac dau hieu cua giai doan mudn nhu: suy kiet ( thugng ddn (9%), khan gigng (1%)
Tan sudt va vi tri ung thir thuc quan
)%), da CO hach
vj tri ton thuong 1/3 tren 1/3 giiia 1/3 duoi rhuc quan - tam vi
N=357 13 222 76 46
Pyle 4%
62%
21%
13%
U Ihuc quan d 1/3 tren thi it, chi cd sau do den 1/3 dudi (P< 0,001) Chiiu ddi cua u thuc quan
, trong khi ung thu d 1/3 giiia chiem nhieu nhat, 62%,
Chieu dai cua u
<4 cm
N=325 Ty le 88/325 4-8 cm
> 8 c m
27%
218 19
Tr8n 325 BN dugc danh gia tren CT scan cho thay: da sd BN thudc nhdm cd khdi u dai 4-8 cm, chiem ty le 67% (P< 0,001). Dieu nay chii-ng td sd BN den tri chiem ty le cao, chi dmh md triet de khd khan.
Kk qua GPBL Ton thuong GPBL Ung thu te bao tuyen Ung thu te bao gai Di san te bao gai
N=327 40 274 13
Tyle 12%
84%
4%
-Tr6n 357 BN tai khoa Ngoai ldng nguc, khdng ke nhiing BN nang, suy kiet vdi phim chup TQ cd can quang da r5 tren lam sang, chiinp toi khdng ngi soi sinh thiet niia.
-Tren 327 BN cd xet nghiem GPBL cho thSy: ung thu te bao gai chidm da so, 84%, ung thu th bao tuy6n chi co 12%. (P< 0,001)
Cdc phau thugt thuc hien
357 BN dugc md md tai khoa Ngoai Idng nguc, cho thay:
Phau thuat est TQ tao hinh da day(3 duong m6)
PT Orringer
FT tao hinh TQ bang doan 3^ trang (Colon by pass) PT tam bo: ma da day nuoi In
N=357 126
19 11 147
TylS 35%
5%
3%
4 1 %
Mo hong trang nuoi an Nong cho hep hoac dat Stent TQ
9%
-Tir 1999-2004 tao hinh TQ bang doan dai trang chiem da so (9/11 BN, 82% tren tong so PT dung dai Uang thay the).
-Chung toi chi co 44% (156/ 357) BN con mo cat TQ dugc, trong do phau thuat 3 duong mo (cat TQ-tao hinh da day-n6i a c6) dugc su dung nhiSu nhat, 35%.
Cac thii thuat va phlu thuat tam bg chiSm ty le cao dang ke, 201 BN (57%) so BN den vien.
Dieu nay chung to dai da so BN ung thu TQ ciia chung toi deu trong giai doan mugn. Vi do cung la ly do giai thi'ch ty le s6ng con 5 nam tren BN cua chiing toi khong cd.
Biin chiing vd tii vong sau mo Bien chirng som
Bien chung
Xl mieng noi khu tni a
CO
Xi mieng noi trong bung Xi ch6 khau, gay viem mil trong nguc Khan giong
Do dich du6ng tiap mang phoi
Tong cgng
SoBN 11 2 8 6 2 29/156
Tyle 7%
1%
5%
4%
1%
18%
- Trong sd 8 buc mieng ndi gay viem mu trong nguc:
6 tir cd do xudng nguc: 4 BN xin ve (chiing toi coi nhu BN tii vong).
2 BN cdn lai dugc md lai va md TQ ra da, sdng.
2 xl mep khau da day tao hinh. BN xin ve (tii vong).
- Khao sdt 156 BN dugc phau thuat cat TQ, 18% cd bien chimg, trong dd bi8n chiing do mieng ndi d cd chiem nhieu nhat, nhung da sd lanh tdt sau 7-10 ngay.
- Trong 11 BN cau ndi dai trdng: 2 xi mieng ndi d bung, phai md bung khSu lai, tdt.
- 2 BN bi dd duang trap mdng phdi, 1 tu Idnh va 1 phai can thiep, tdt.
- Liet day TK quae ngugc: chiing tdi cd 6 BN, chiem ty le 4%.
Bien chiing mudn: Trong 156 BN dugc ndi tai cd, cd 13 BN (8%) hi chit hep 1-3 thang sau md. Tdt ca deu dugc nong de duy tri an udng.
Tir vong
Ty le tiir vong sau mo, chiem 8,3% (13/156):
- 6 BN xin ve (da neu tten), ttong do cd 4 BN lam PT 3 dudng md, 2 BN md dudng bung.
- 4 BN tao hinh dai trdng: 2 xi mieng ndi cd gay viem mii nguc, 1 xi mieng ndi ttong bung (ca 3 xin ve). 1 viem phdi.
- 3 BN chet vi benh n6n cua ngudi cao tudi: 2 dot quy (xin vd) va 1 nghi d6n nhdi mau ca tim (trong dd cd 2 BN md nguc).
• 6/126 (4,8%) BN cd md nguc tir vong.
• 2/19 BN PT Orringer hi vong Theo doi
141 BN dugc theo ddi va cd trd lai hda hoac kk hgp hoa-xa tn cho thdy: BN song lau nhdt Id 2 nam 7 thang, BN chet sdm nhit la 8 thdng 12 ngay
PHAN BAN LUAN A. Dac diem benh nhan I. Tuoi, gidi tinh vd yeu to nguy cff
• Trong nghien ciiu nay. tudi nhi^u nhdt la 40-70, nhung BN dudi 60 vdn chiBm han phdn
303
niia. 56%. Dieu nay cho thdy tdn sudt ung thu TQ bdt dau tir tudi trung nien va tang dan theo tudi. Khuynh huong nghieng ve ngudi tre Iai lang len ttong nhiing nam gan day.
Theo cac cdng ttinh ciia cac tac gid tten thS gidi thi tudi 60- 70 chi^m uu thS"^'^'
• Nam gin gap 10 lin nir.
Theo Brugge"^* thi nam glp tu 4-6 ldn nij va tin suit ung thu TQ tang gdp 25-100 lan, tren ngudi nghien nang rugu vd thudc la.
2. Ldm sdng
- Ldm tudi -t- nudt nghen + gidm cdn la trieu chimg thuong oap nhat trong ung thu TQ.
• Nudt nghen cd y nghTa dac hieu, quan ttgng, nhtmg nudt nghen lai la dau hieu mudn ciia benh. Vi thuc quan khdng cd thanh mac n6n de dan to, do do khi BN di kham vi nuot nghen thi ung thu da thdm nhiem ddn ca vdng TQ tren 60% cdc trudng hgp''^'.
Tat ca BN chung tdi den vien vi nudt nghen, ttong do nudt nghen do 3 vd 4 chiem da sd, 91%.
Tat ca deu d giai doan tre.
Theo Peter thi chua day 5% BN tinh cd phat hien qua ndi soi tieu hda, thudng la loai ung thu te bao gai giai doan ngi thanh"^'.
3. Vitri ton thuffng
Trong cdng trinh nay, ung thu d 1/3 giua TQ chiem nhi^u nhdt, 62%, kit do la 1/3 dudi, 21%.
Theo Giusti''^* vd Cs:
-U a thuc qudn co: chiem 8-10% BN, hiu het la K te bao gai, thudng xdm lan vdo mach mau ldn va khi quan, phan lanh con lai khdng du rdng, do do mdt sd ldn phdi chuyen sang di6u tn tam bg. Do dd dii mudn phau thudt cat TQ tam bg nay cung rat khd, ngn BN tien lugng xau*'^'.
•U a 1/3 gitra TQ ngyc chiem da sd, 50%, nam sat vdi khi quan va DM chu, nen chi cat triet de, neu u chua an xuyen khdi thanh TQ va di can hach viing (mdt dieu it gap). Tuy nhien khi md cung phai cd gang lay het hach de tdng ty le sdng cdn (do tai phat tai chd vd chen ep khi quan)<"'.
-[/ a TQ thdp vd tdm vi chi6m 40%, da sd Id loai ung thu te bao tuyen.
• La vi tri ung thu TQ cho nhieu co hoi de md triet de nhat, trCr phi u da xam lan va di can xa.
• Vi u cd khuynh hudng lan rgng lop duoi niem, nen phai cit rdng md lanh (tten dai the). Phai cdt rgng 10 cm tir ranh gidi tten u, d6 ttdnh tdi phai d mieng ndi.
Cu the: *Phia tten phai cdt each u 10cm ho^c cdt ngang TQ d cd; *Phia dudi cit > 50% phan gan ciia da day"^'^ .
4. Chiiu ddi thuong ton ung thu
Danh gia tren CT scan cua chiing tdi, cho thiy: da so BN thudc nhdm cd khoi u ddi 4-8 cm, chiem ty le 67%. Di6u nay chiing td sd BN ddn tti chiem ty le cao, chi dinh mo triet de khd khan, ty le sdng cdn 5 nam rat thap.
• Dau hieu cua giai doan tti: Neu u > 8cm, true TQ bat thudng tten phim can quang hodc cd nhieu hach vimg to (tten CT scan). Cac cdng trinh nghien ciiu gan day cho thay neu chieu dai u < 4 cm thi phdu thuat tdt nhdt. It thuan Igi hon, neu u 4-8 cm va khi u > 8 cm thi khdng cdn CO hgi niia*''' '
• Trong cdng trinh ciia Takagi"^*, vdi carcinom te bdo tuyln: *Chieu dai u < Scm thi 40%
benh cdn khu tni, 25% benh da an lan va 35% dd di cdn hoac khdng cdn cdt dugc. *Vdi u dai
> Scm thi 10% cdn khu tru, 15% xam ldn hach tmng that va 75% da di can.
5. Gidi phdu b^nh vd yeu to tien lugng
Trong nghien ctiu nay cho thay: ung thu te bao gai chiem da sd, 84%.
• Ung thu tB bao gai la loai ac tinh gdp nhieu nhdt ttong ung thu thuc quan (95%), tien luang xlu"^'.
• Ung thu bilu md tuyen < 10%, xuat phdt tir bieu md t l bao tuyln d noi tiep giap tir TQ qua tam vj cua da day hoac ung thu d tam vi an len TQ. La Ioai ung thu xuat hien ngay cang nhilu, tren 50% truong hgp d cdc nude phuong Tay. 10% trong sd do la do benh ly ttdo 304
nougc da day-TQ, phat hien som duoi dang benh Barrett TQ.
•°Chua day 1% la nhihig ung thu TQ hiSm gap nhu sarcom co tron, sarcoma ca van, carcinoma te bao nho
B. Cac phucmg thuc phau thuat
• Phau thuat (PT) la phuong phap dieu tri triet de, nhung da so BN thuong phat hien mupn nen chi 41% BN liic chin doan duong ti'nh la co thS mo dugc, trong do den 87% la phau thuat tam b g " - ' " . (Mo triet de la cSt TQ va nao hach thanh khdi. Mo tam bg: chii yeu la cat TQ, gitip an uong duoc).
• Trong ISn nghien cim nay, co hon phan nira (57%) la dieu tri tam bg va chi co 43% la con cat dugc TQ.
Chpn lua phau thuat
-Dai da s6 cac tnrong hgp, chiing toi chgn PT 3 duong mo 126 BN, 35%; PT Orringer it hon, 5%.
-Theo bio cao cua Giuli"" voi s6 lieu 790 cat TQ tir nhieu trung tam y khoa lon tM 67% lam PT. Ivor-Lewis, 12% lam PT 3 duong m6 va 12% lam PT Onringer.
-Trong lich su, CO 6 phau thuat (PT) de cSt ung thu thuc q u a n " " " ' : 1). Chi mo nguc T (PT Sweet): chi cd ti'nh Ijch sii. 2). Mo nguc bung (trai) chi dung dugc khi u 6 gjn tam vi, ngay nay it dilng. 3). PT 2 dugng m6 (PT. Lewis-Tanner) g6m mg bung de di dgng da day va mc nguc P di cJt TQ roi noi mieng TQ-da day trong nguc (n^u buc mieng noi, tu vong cao). 4).
PT 3 duong m6 gom mo bung, mo nguc P, va rag co. Dung khi u 6 cao, can cat TQ trong nguc roi n6i TQ-da day o c6. Day la PT pho bi jn nhat, tu vong it. LTu thj cua PT nay la K TQ 1/3 giiia hoac 1/3 duoi, qua do co thi nao hach trung thdt va hach bung tr6n, kem theo cit TQ thknh khoi. 5). PT mo bung c5t TQ qua khe hoanh va noi o co (PT Orringer) thuemg dugc sft dung cho cac ung thu TQ thip. 6). PT Colon bypass chi ap dung cho K TQ giai doan som (ngi thanh TQ), hieu qua sinh ly thi'ch hgp. It biin chirng trao ngugc"^"^'
-Th(rc te, nguoi ta da so sanh PT Orringer voi PT 3 duong mo (tm the Men nay). Boi biin chung hau phau va ty le tir vong khong khac nhau dang ke (5% so voi 8%). Tr6n nhieu cong trinh voi so lieu lon cho thay theo doi trung han va song con dai han, khong khac nhau co y n g h i a " " " " ' . '
» Lgi diem ciia PT 3 dudng md la (l)lay sach budu tten TQ tan gdc ban, qua md nguc nMn true tiep, nen han che dugc cac bien chiing nhu: tdn thuong TK quae ngugc, dng nguc, it chay mdu hem nhieu. (2)Neu cd xi mieng ndi co ciing it ttam ttgng. Diem bat lgi ciia PT nay la BC sau md nguc.
-Phlu thuat kit hgp 3 dudng mo cho ty le tii vong thdp, 3,6% (9/250)''*'^*. Nguyen nhan tu vong la viem phdi va suy hd hdp sau md (3/250, chilm 1,2%). Phau thuat 3 dudng md thudng dugc sii dung tai Nhat, tir vong sau md rat thap""'"''.
-Cdng trinh cita chiing tdi, ttr vong sau PT 3 dudng md cao hon, 4,8%.
PT Orringer cd lgi diem la giam dugc bien chirng do md nguc, PT nay dugc chi dinh cho nhiing BN chiic nang phdi kem, benh tim, hodc cac bmh loan than ttim ttgng khde ma ttudc do dugc coi la chdng chi djnh mo cdt TQ. Day la mdt trong nhiing PT phd biln d cac qudc gia Bac My. cd nhilu hiia hen trong dilu tri ung thu t l bao gai TQ. Quan niem cua phlu thuat cat TQ qua khe hoanh da dugc chap nhan hon 10 ndm qua nhu la phuong phap dilu ttj hieu qua cac ung Ihu xam Idn*^''^'.
Gid tri cda phdu thugt triet de
Vi BN din mupn, chung ldi khdng cd co hoi lam PT tan gdc.
Cat rdng va lay tton cac nhdm hach la mang y nghTa quan ttong cua phlu thual triet dl. Tuy nhien, ttong 80% cdc trudng hap tai phdt va hach tdi phat Iai ndm ngoai khdi cdt, nhu d thugng ddn (8Q). hach ttung thdt tren vd ciia sd phe chu (21%), rdn phdi (3%), tru sau co hoanh (5%), sau tuy 18%""'. Do do phai kit hgp vdi hda tri sau md.
Tren thuc le. cd den 30% u cdn trong niem mac, nhung lai da cd di can hach, dii so hach < S.
Theo Akiyama va nhieu tac gia gin day thi ttong dai da sd cac trudng hgp, thi ung thu da di can den nhirng vimg hach xa, bao gdm ca hach cd va hach bung""'^'.
Tgi sao phdi cdt TQ thdnh khdi
Nhieu PTV ung hg cat TQ triet de thanh khdi bdi vi: ttong ung thu bieu md tuyen, sd hach di can ti le thuan voi miic do xam nhap ciia u vdo thanh TQ. Vdi phau thuat triet de nay, tir vong PT cdt TQ thanh khdi cho kit qua sdng S nam la 40-55% ddi vdi ung thu G/d l'^^'^' Tgi sao phdi cdt todn bd TQ trong diiu tri ung thu TQ
Tr6n d^i the, phdi cat cdch u 10cm cho nen phau ti'ch lly hit hach "canh TQ" va "hach khi'-phe quan" ciing vdi "chuoi hach vi (ttai)".
Ung thu TQ lan rdng: *Tgi cho: dn xuyen thanh TQ va xam lan vao md xung quanh.
*Theo bgch mgch: he bach huyet cua TQ ndm d lop duoi niem va cd sd lugng nhieu hon he thdng mach mdu. CJ 2/3 tten, he bach huylt chay theo hudng len tten. 1/3 dudi, bach huyet chay xudng, dd vdo bung. Do mang ludi bach huyet ciia TQ rgng, phiic lap vd khdng cd ranh gidi ro rdng d dudi niem va quanh co TQ, cho nen ll bao ung thu da lan rong mgt khoang xa trong he bach huyet, trudc khi u an xuyen thanh TQ. Do dd nen cdt loan bd thuc qudn va lit ca ciu ttuc xung quanh, nhll la K tl bao gai^'^'"'*.
Bien chiing vd tu vong
Biln chiing sdm The Griffin'^' vd Cs cd din 124/250 (50%) biln chiing sdm (tir nhe din nang), ttong dd BC ndng l£n den 83 TH:
Buc mieng ndi cd cua Griffin la 5,6%'''*. Chung tdi cd 11 BN, 7% bi xi dd mieng noi d co khu tru, tdt cd deu lanh tdt.
Vdn de bi^c mieng noi trong PT cdt TQ tgo hinh -Tan suat xi dd mieng ndi d cd cao hon a nguc,
hiem, trir phi bi dich xi dd lan xudng nguc gay viSm trung thdt.
- Du cdc nghien ciiu gan ddy cho thay ti Ie xi khi ndi trong nguc it ban ndi d cd, nhung da sd phdu thuat vien van thich ndi d cd hon. Dd d cd ft nguy hiem, vi chi can ddn luu thi'ch hgp thi hdu nhu ludn ludn lanh tdt"^''^'.
- Ndi da day TQ trong nguc cho bien chung va tir vong cao ban ndi d cd.
- Nhimg Id dd d cd ndy hdu nhu ludn lanh ttong 7-14 ngay.
Cung ttong nghien ciiu ciia Griffin thi tdn thuang TK quae ngugc la 17% va neu chi md cd (ttai) thdi, thi chi cd 7%''*'''*. Chiing tdi vdn md cd (T), nhimg cd 6 BN bi tdn thuong TK quae nguoc, chiem ty le 4%. Khan giong do TK qudc nguac bi tri keo, thudng khdi trong vdng 4-8 tuln*'^-'^'.
Dd dudng trip mang phdi 22 BN/ 250 (8,8%) 16 dugc m6 khdu lai dng nguc''*'''''. Biln chiing nay chung tdi chi chi cd 2 BN (1%).
Dd duang trap mang phdi: it gap, chi 3%'^'^^''^'thudng ttong cdc trudng hgp nao hach triet de, gay tdn thuang dng nguc*^'. Bien chirng nay khien ni vong tang cao sau PT, gdy xep phdi, de dan den viem phdi. Bdi vi tren BN ung thu TQ da an udng kem trudc ddy, nay lai dd duong trip (mil them dam, sinh td...), khien cac mieng ndi khd lanh. Vi the phai md nguc khau lai cho rdch dng nguc som.
Bign chiing mudn
Chiing tdi cd 13 BN (8%) bi chit hep d mieng ndi cd, tir 1-3 thang sau md, dugc nong va dn udng dugc. Theo Griffin'^^*: 26% (65 BN) bi chit hep mieng ndi, trong do 7 BN phai nong 2 lan.
So vdi cdc tac gia khac Id 50% neu theo ddi lau dai*'^*.
Ung thu TQ la 1 ttong nhimg loai ung thu co ty le tii vong sdm nhat, chi vi phat hien tre. Khi BN cd bilu hien lam sang nhu nudt nghen, tiic la ung thu da tien xa, an xudng dudi lap niem va nhu thi ddng nghTa vdi tinh trang nang, da di cdn hach.
Tii vong
306
• 4.S% BN mo nguc tu vong. Nhu vay s6 tu vong tren cac BN mo nguc ciia chiing toi khong nhiiu so voi cac tac gia khac. Voi Daiko'" 11% vtii cac PT co mo nguc.
C. Dieu tri ho trg sau mo
2. VSn di kit hap da mo thuc trong Xhi tri ung thu TQ
-So sanh voi nliieu cong ninh chi co phSu trj, trong qua khu cho thay ty le song con cai thien hon niu diiu tri kit hgp da mo thirc, dr 2% tang len 36%"". Nhung niu u con khu uii tai thanh TQ thi t\ le s6ng sau 5 nam len din 40%, ngay ca vai mrcmg hgp da co hach ducmg
t f n h " ' " ' • • . . . -Trong 1 cong uinh tai My cua Scott tren 80 BN dugc cit trgn TQ ket hgp cho thaj; ty le song
tren 5 nam len din 51%, neu hach am ti'nh va 33% voi hach duong ti'nh"'"'. Diiu nay cho thiy phai danh gia ui ciia PT co nao hach tan goc.
Dai da so BN ciia chiing toi diu dugc hoa tri sau mo, chiing toi khong co 16 so sanh c6 y nghTa.
-Hach di can d6ng nghia vdi ty le tai phat va tu vong cao. Tuy nhien neu so sSnh voi nhihig BN chi CO PT don thuin thi ty le s6ng con cua cac phuong thirc deu trj ket hgp voi hda va (c6 hoSc khonp) xa cho thay kha quan hon. Xa tri don thuan sau mo ducmg nhu khSng cai thien hieu qua song con"
Trong mgt th6ng ke
-Ket hgp phau tri va xa tri khong Iam tang ty le song con.
-Ket hgp hda ui (cisplatin va 5-FU cd hoac khong epirubicin) va xa tri ti6n phiu c6 cai thi?n cho ca 2 loai ung thu te bao gai va te bao tuyen, nhung bien chung hau phSu tang (nhu nhiem trung, buc mieng noi, ARDS) nhieu hon va thai gian dilng may giiip tho lau hon.
Trong 1 khao sat hda-xa sau mo cho thay: ty le tai phat tai cho thap hon cdc nhdm phau don thuan (13% so yen 35%) va ty Ie song con nhiiu hon (14,1% so voi 47,5%)"^'. Vi le dd khuynh hudng hien nay la ket hgp hoa-xa tri sau PT cat TQ.
Tdm I^i: Cit TQ qua duong nguc, n6i TQ-DD 6 c6 v& nao hach 2 vung triet di (tmng thit- bung U6n), mg hong trang nu6i an la PT an toan va Iy thuan Igi nhit. TrSn nhting BN nay: phau \n don thuin, BN s6ng ttung binh la 13-19 thing. Ty le s6ng 2 nam tir 35-42% vi sdng 5 nam (15-24%)""
D. Ti6n Iugng chung
Thugng 80% BN chit 1 nam sau khi phat hien. Hien nay, plidu tri van la phugng phdp diiu trj chil yeu de BN cho ty le song cdn lau dai"^*.
-Ty le sdng con 5 nam khac ro ret giiia BN chua cd hach di can va BN cd ducri 5 hjch. Tuong tu, khac biet rit nhiiii giira BN cd ducd 5 hach va BN co tir 5 hach txa len. Cach ddnh gid giai doan moi nay cho thiy chi'nh xdc hon vi tien lugng BN va ty le sdng con giam gin 50% khi tang them 1 giai doan cua binh, va s6 hach (+) anh huong ddng ki din tien lugng benh"^'"'.
-Neu cat khong ttiet de thi ty Ie sdng con 5 nam la 0-5% va niu cit triet di trong tit ca mpi giai doan ciia benh, thi ty le iy la 15-40%""'^'.
Chan dodn sdm va mo triet di U yiu to thanh cong ttong diiu tri ung thu TQ.
Theo doi vd thdi gian song con
Tat ca BN chung toi theo doi dugc diu co hoa tti kit hgp. Trong 1 nghien cuu cua Giffin""', 81% hda-xa tri ket hgp thi ty le sdng con 3-4 nam la 44% va 38% va sau 5 nam thi rat it. Vai tro cua PT cat tton TQ va nao hach tan gdc tdt da mang la ty Ie sdng con tren 5 nam cua Swanson la 40% (75% vdi hach am ti'nh va 26% vdi hach duong t i n h ) " ' " . Nhung niu chi phau thuat don thuan thi tten 100 PT cJt TQ ttiet d i khong kit hgp hda-xa tti cua Steup"'"' cho thay: t>- lesdng 5 nam len den 52% ma 1/3 BN cd hach van song 5 nam vi chi cd 1 BN la tai phdt tai cho.
Cho deri hien nay, phlu thuat tan gdc la ly mdmg nhit, khi khdi u con khu mi 6 thanh TQ.
Tren thuc te chi cd 30-40% la con mo dugc"". Trong nghien ciiu ctia chung tdi, cd din 57%
la phau thuat tam bg md da day, hdng trang nuoi an hoac dat Stent TQ. Chi cd 33% la md
3or
dugc nhung tit ca deu cd hach di can, giai doan mugn. Vi le do, ttong cdng tnnh nay, BN sdng lau nhit la 2 nam 7 thang
Ty le sdng cdn 5 nam ciia BN ung thu TQ chi dugc cai thien ttong vong 30 nam gin day, tit 6% 0975-1977) tang 17% (1996- 2 0 0 2 ) " ' " . Tien lugng kit qua lau dai con toi tam, mac dil nhieu trung tam tten thi gidi da tien hanh kit hgp da mo thirc (hda, xa tti kit hgp), nhung KQ chua dugc cai thien. Mac dil hda tti trudc md giup cho PT dugc thuan Igi hon'".
^Ung thu thuc quan la mgt trong sd ung thu cd tu suit cao. Diiu Ui chii yiu hien nay vin la phau thuat, nhtmg vi da sd BN din mugn nen chi dinh md khong con y nghTa ttiet 6^ niia. Cdc PT chung tdi thuc Men chi la PT tam bg, giup BN an udng duoc, do dd ty le sdng 5 nam kh6n§ cd, mac dii tit ca deu cd hda tti hoac hda-xa kit hgp. Chin dodn sdm di md triet di la yiu to thanh cong ttong diiu tti ung thu TQ.
TAI LIEU THAM KHAO
1. ALTORKI, N, KENT, M, FERRARA. C, PORT, J. (2002): 'Three-field lymph node dissection for squamous cell and adenocarcinoma ofthe esophagus". Ann Surg. 236:177.
2. BUSCH R C, OBERTOP H and van LANCHOT I I B (2005): "Incidence and Managemem of Chyle Leakage after esophagectomy". Tire Ann Tliorac Surg.N.2, 80:449-454
3 DAIKO, H, HAYASHI, R, SAIKAWA, M, et al. (2007): "Surgical management ot carcinoma of the cervical esophagus". J Surg Oiicoi ; 96:166.
4 GRIFFIN, SM, LAMB, PI, DRESNER, SM, et al (2001): "Diagnosis and managemenl o f a mediastinal leak followmg radical oesophagectomy". BrJSurg. 88.1346.
5, lEMAL, A, SIEGEL, R, WARD, E, et al. (2008): "Cancer statistics". CA Cancer J Cim. 58:71.
6, KOK, TC, VON LANSCHOT, 1. SIERSEMA. PD. et al. (1997): "Neoadjuvant chemodierapy in operable esophageal squamous cell cancer: Final reporr of a phase HI multieenter randomized comrolled tnal". Proc Am Soc Clin Oncol. 16: 277. LAGARDE S M, OMLOO M T , de lONG K,
7, LE QUANG NGHIA (2001): "Diju tri ung diu Uiuc quan". Ung thu ihuc quan. NXB Y hoc. TP. HCM: 87- 210.
8 NGUYEN MINH HAI, T R A N MINH TRUCiNG, LAM VIET TRUNG, T R A N PHlJNa DUNG TIEN (2008); "Xl do mieng noi thirc quan c6, kinh nghiem qua 92 tnrong hop c§t TQ". Y h(ic TF Hd Chf Mmh.
T5p 12. Phu ban s6 3: 48-54.
9. ORRINGER, MB, MARSHALL, B. lANNETTONI, MD. (1999): "Transhiatal esophagectomy Climcal experience and refinements". Ann Surg. 230: 392.
10. OSUGL H, TAKEMURA, M, TAKADA, N, et al. (2002): "Prognostic factors after oesophagectomy and extended lymphadenecromy for squamous oesophageal cancer". Br J Surg. 89: 909.
11. DTT, K. LORDICK, F, et al. (2007): "Cervical squamous cell carcinoma of the esophagus- a unique series of limited resection and free jejunal graft interpopsiuon after neoadjuvant RCTx in 94 patients". J Clin Oncol. 25:215.
12. PETER I H and DEMEESTER T R. (1999): "Carcinoma of the esophagus". Principles of surgery, 7th Ed.
Ed by S L Schwartz, N.Y.. 1137 - 1153.
13. PHAM H i r u THIEN CHI, VO TAN LONG, LE QUANG NGHiA (2007): "Thay thS thirc quan trong diSu tri ung thir tam vj va 1/3 duoi thirc quan". YIIQC TP. HCM T i p 11, Phy ban 1. 55-60
14. ROUVELAS, 1, LINDBLAD, M, ZENG, W, et al. (2007): 'Impact of hospitai volume on long-term survival after esophageal cancer surgery". Arc/i 5Mrg. 142: 113.
15. SCOTT BOLTON, J, WU, TT, YEO, CJ, et al. (2001): "Esophagectomy for adeno carcinoma in patients 45 years of age and younger". J Goslrointesl Surg. 5: 620.
16. STEUP, WH, DE LEYN, P, DENEFFE, G, et al. (1996): 'Tumors of the esophagogastric junction. Long- term survival in relation to the pattem of lymph node metastasis and a cnucal analysis of the accuracy or inaccuracy of pTNM classification". J Thorac Cardiovasc Surg. 111: 85,
17. SWANSON S, TANABE K. K, SAVARESE D MF. (2008): "Surgical management of locahsed esophageal cancer". Up lo date 16.2
18. URBA, SG, ORRINGER, MB, TURRISL A, et al. (2001): "Randomized Trial of Preoperative Chemoradiation Versus Surgeiy Alone in PaUents With Locoregional Esophageal Carcinoma". J Clin Oncol. 19: 305.
19. ZWISCHENBERGER I B. ALPARD S K, ORRINGER M B. (2001): "Esophageal cancer" T. of surg.
17* Ed. Ed. by Bauchamp Evers Manox, W.B. Saunder Co., Philadelphia: 733-750.
308
