Nghien oiu Y hoc Y HP"^ TP. Ho Chi Minh • Phn Ban Tap 19 * So 5 * 201^
DIEU TRI RO MAT BANG DAT STENT QUA NOI SOI TAI BENH VIEN CHO RAY
Pham Him Ting', Ho Bang Quy Dung', Tran Dinh Tri', Ngo Phumg Minh Thuan', Tran Vift Tii", Biii Hieu Hoflng*"
TOM TAT
Muc tieu: Noi soi dat stent trong dim tri rd mdt lamotky thuat dieu tri nidi it xdm lan. Chting toi Iwi ciru deddnh gid hieu t^ud va do an todn cita noi soi dat stent trong dieu tri ro mat tai Binh vim Ota Ray.
Dot tU0tg vd phuang phdp: Tat cd henh nhdn (BN) lam sdng chan dodn ro mat hoac nghi ngo ro mat dm chon de thirc hien not soi mat tuy ngieoc dong vd dat stent trin nhimg benh nhdn CO ro mat dmc (Mn dodn tfun noi soi mat tity ngirgc dimg tqi Benh vien Cha My tit 1/2013-10/2014. Cdc BN dirge theo doi deh khi ldm simg cai thien sau do rut stent.
Kei qud: Chung tot thuc hien ngi soi mat tuy ngirgc dong tren 65 BN gom 48 nam vd 17 nie, tuoi trmi binh: 41,3 (16-88) tuoi. Thii thuat thong vdo duimg mat va chup htnh duimg mat thdnh cong Id 62/65 SN (95,38%). Co 3 tnecntg hgp thong vao dtrimg mat that bai, 5 tnrong hop khong ddt stent, 5 tntimg hgp phdi dot stent Un 2, 3 tneimg hap dat stent Imt 3, 6 truong hap khong dugc theo doi sau dat stent, 1 truimg hgp biat chimg phdi phdu thuat (1,6%). Stent di licit vito trong duang mat 1 truimg hgp phdi lap lai ngi soi mat fuj ngugc dong lay stent, stent di Udt ra ngodi ong tieu hoa vd thoat ra ngodi 9 truang hgp. Ty le dieu tri thdnh dig sau dat stent la 50/51 trumg hgp (98,04%).
Kit luan: Ngi soi dat stent dieu tri rd mat Id ky thudt an toan vd hiiu qua. Chirng toi hy vgng trong hroij lai ky thuat ndy se dirge dp dung rgng rdi tai Viit Nam.
Tit khoa: Ro mat, ngi soi mat tuy ngugc dong ABSTRACT
ENDOSCOPIC STENTING IN THE TREATMENT OF BILE LEAKAGE IN CHO RAY HOSPITAL
Pham Huu Tung, Ho Dang Quy Dung, Tran Dinh Tri, Ngo Phuong Minh Thuan, Tran VielTn Bui Huu Hoang * Y Hoc TP. Ho Chi Minh • Supplement of Vol. 19 - No 5 - 2015:28-3!
Background and study aims: Endoscopic stenting in the treatment of bile leakage is a new less imm treatment. We retrospectively reviewed the efficacy and the safety cf endoscopic stenting in the treatment »/i*
leakage in Cho Ray Hospital
Patients and Methods: All selective patients with clinical suspected bile lockage who undenoent endostefl retrograde Aoangicpanrreatograpky and insert stent in patients have bile leakage from Febntary, 2012.
November. 2014 tn Cho Ray Hospital were included in fhe study Patients were followed until clinicd resdui.
for remomng the stents.
.7 f r " " T f ' " ' S ^ w ^ f r * " ""' "^"^" """" "S^-- «-27 ««-«« y - « M. The succe4 bileductcannulattontn62J65(95.38X). There are three patients in biliary cannulation failure, the absence i«.
• FOloa Npi soi - Benh vien Chp Riy " Bo mon Noi Tieu Hoa- Hoc vien Quta Y 103
"* Bpmon Noi-Dai hgc Y Duoc Tp. HoChiMinh
Tdc gii liin lac. ThS.BS Pham Hiiia Tung, DT: 0983121105, Email: huutungbvcrSgmail.com
^* Chuyen D^ Noi Soi Tigu j
Y Hpc T P . H'6 C h i M i n h * P h u Ban T a p 19 * So 5 •^ 2015 N g h i e n c m i Y hpc stent five patients, one patient complication need surgical intervention, five patients qf stenting tlie second times, three patients of stenting the 3rd, missed follow up after stenting in six patients. During follow-up, stent intemal miration in one patient, stent spontaneously disapeared in nine patients. Overall, the rate of treatment success 50/51 patients (98.04%).
Conclusions: Endoscopic Stenting is an effective and safe measure in the treatment of bile leakage. We hope that this technique should be zuidely used in Vietnam in future.
Key word: Bile leak, ERCP
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D A T V A N D E
Ro mat la mpt bien chimg phiic t?p, khong kho ve m^t dian doan xac djnh nhimg kho ve m^it chMi doan vi tri ton thuong, neu xay ra sau phau thuat Igii cang phiic tap. Nguyen nhan ro mat thuong xay ra sau phau thuat can thiep ve gan va duong mat nhu cat ttii mat qua npi soi, cat ttii mat qua mo mo, cat gan va sau ghep gan, chan thuong gan...chiem ty le 0,8%-12% tuy thupc vao timg loai phau thuat^^^. Cac nguyen nhan it gap hon nhu vet thuong do dan bSn'^^, dao dam, sau sinh thiet gan'^^', sau ap-xe gan,...
Theo kinh dieh, phau thu|t la tieu chu&i kmgfe vang trong dieu trj ro mat. Co nhieu phuong phap chon Itja trong dieu tri ro mat nhu noi soi, dan lim qua da, mo npi soi*'*). Tuy nhien, nhiing nam gan day cimg voi su phat trien cua nganh npi soi, npi soi mat ttay ngupc dong khong IGE ngimg phat trieh va da tro thanh phuang phap chpn lua dau tien trong chan doan va dieu tri ro rhmM m^t phau thuat chi th\rc hien khi dieu tri npi soi
«i|- that bai hoac nhiing truong hpp ton thuong duong mat nang that stJ can thiet den phau .^^fcithuaf'^-^i.
jijliftrfflti" Npi soi dieu tri ro mat bao gom cac phuong phap nhu dan luu mui-mat, cat co vong Oddi, J ,^.-.dat Stent vcd cat hoac khong cat co vong Oddi.
, ^ Co che chung la lam giam khang luc duong mat,
" r j j t g i u p n^it ch^y theo duong binh thuong, giam
" lupng mat chay qua duong ro, tao dieu kien cho iuong ro tu lanh''^'. Npi soi mat tuy ngugc dong arsP Jat stent trong dieu tri ro mat dupc ap 6 nhieu tyre, ''"'•^ rung tam tren the gioi, co nhieu nghien ctiu cho
hay ket qua dieu tri dang khich Ie.
d Viet Nam, npi soi dat stent dieu tri ro mat hua dupc ap dtang rpng rai. Do vay, chiing toi
tien hanh nghien cuu danh gia ket qua dieu tri va cac tai bien, bien chumg ciia phuong phap nay tai Benh vien Chp Riy
DOITUtXNG-FHLfC^IGPHAPNGHIENCUtJ D o i t u p n g
Tat ca b|nh nhan lam sang chah doan ro mat ho|c nghi ngo ro mat dupc chpn de thiJc hien npi soi mat tuy ngupc dong va d | t stent tren nhiing benh nhan co co ro m | t dupc chan doan qua npi soi mat tuy ngupc dong tai B^nh vien Chp Ray tir 2/2012- 11/2014. Cac BN dupc theo doi den khi lam sang cai thien, sieu am bung khong con thay dich, sau do nit stent.
Phirong p h a p
Nghien ctiu hoi ctiu, ghi nhan ty le thanh cong ctia thii thuat, ty le tai bien-bien chiing.
Danh gia hi#u qua lam lanh duong ro sau dat stent.
D u n g c u
Stent nhira 7F-10F, dao cat co vong, dao kim {needle knife), ong thong (catheter), day dan.
(guidewdre), ong day stent, may soi ta trang (may soi nhin nghieng), may npi soi da day (may soi nhin thang), may cat dot npi soi, thuoc can quang, thong Ipng(snare) de nit stent.
Q u y trinh Chuan bi benh nhdn
Berth nhan dupc nhin an uong tnroc 8 gio, dieu chinh cac roi loan dong mau (neu co), khang sinh phong ngira thuoc thii thuat, t ^ cam ket dong y lam Ihu thuat.
Trong khi thuc hien thti thuat benh nhan dupc tien me bang Dolargan, Hipnovel va theo doi mach, huyet ap, SpOz
N g h i e n c u u Y hpc Y Hpc TP. Ho Chi M i n h * P h u Ban T a p 19 * So 5 * 2015 Cdc buoc ky thuat
- Dimg dao cat co vong hoac cathter thong vao duong mat
- Bom thuoc can quang vao duong mat xac dinh vi tri va miic dp ro mat
- Dat stent 7-lOFr (khi dat stent co the co hoac khong CO cit co vong Oddi).
Theo dot va ddnh gid
Theo doi bang kham lam sang, sieu am va/hoac c r . Stent dupc luu tai cho it nhat 4 tuan, khi lam sang on dinh (dan luu ngoai khong con ra dich, sieu am khong con dich trong 6 bung), sau do npi soi nit stent bang may soi da day.
KET QUA
Dac diem BN nghien aru
Co 65 BN gom 48 nam va 17 nii. Tuoi trung binh: 41,3 tuoi (16-88). Trong do cac trieu chung thuang gap la dau btang 44 BN, cam gjac cang tlic bung 27 BN, chay dich mat ra ngoai 54 BN, sot 6 BN. Nguyen nhan dan den ro mat chan thucmg gan 15 BN (23,08%), mo npi soi cat ttii m?t 14 BN (21,5%), mo ma di ttii mat 6 BN (9,2%), phau thuat cat gan 4 BN (6,15%), chan thuong gan va co phau thuat gan 22 BN (33,84%), mo npi soi va mo mo cat tiii mat 2 BN (3,07%) ap-xe gan 1 BN (1,5%), nguyen nhan khac IBN (1,5%).
Ket qua
Thti thuat thong vao duong mat va chtjp hinh duong mat thanh cong la 62/65 BN (95,38%). Co 3 truong hpp thong vao duong mat that bai, 5 truong hpp khong dat stent, 5 truong hpp phai dat stent Ian 2, 3 truang hpp dat stent Ian 3,6 tnrong hpp khong dupc theo doi sau dat stent, 1 truong hpp bien chting phai phau thuat (1^%). Stent di l^ch co 10 BN: di lech vao h-ong duong mat 1 truong hpp, 9 truong hop stent di l^ch ra ngoai ong tieu hoa va ttr tiioat ra ngoai theo duong tieu hoa. Ty 1? npi soi dat stent dieu tri ro mat thanh cong la 50/51 tnrang hpp (98%).
BAN LUAN
Nhom nghien ctiu ciia chiing toi co 65 benh nhan, co 3 benh nhan that bai khong thong vao dupc duong mat la do nhti vater nam vi tri kho tiep can, gay kho khan cho Ihao tac thong vao nhii. 5 truong hpp khong dat stent trong do co 2 BN khi chijp duong mat tiiay hinh anh cat ciit hoan toan duong mat doan ong tiii mat thuoc can quang khong vao dupc cac nhanh gan, ca 2 BN nay co cimg nguyen nhan la sau mo npi soi cat tlii mat, co the la do qua trinh thao tac kep dip vao ong ttii mat phau thuat vien kep nham vao ong mat chii gay tinh trang cat ctit ong mat chii. 3 BN khong tha'y hinh anh ro mat tren phim chtjp qua npi soi mat ttiy ngupc dong co 2 BN co nguyen nhan ro mat la do mo npi soi cat ttii mat va IBN ro mat gay ra do c h m thuong. Ro mat khong thay dupc tren phim chup qua npi soi mat tt^y ngupc dong co the do ro mat miic dp thap, ma chiing ta bom thuoc can quang voi ap It^c thap nen vi tri ro chua hien hinh, de khac phtic dupc tinh trang nay chiing ta co the dimg bong chen (balloon) khi bom thuoc can quang vao duong m|it, bong chen se gitip tao dupc ap Ivc cao hon khi bom thuoc can quang vao duong mat. Co the ro mat tir nhihig ong mat khong thong voi duong mat chinh do la nhimg bat thuang nhanh gan phai ma npi soi chyp mat tuy ngupc dong khong phat hifn dupc"*. Do do, voi nhung truang hpp lam sang d i n luu 6 bung ra dich mat ma chi^p duong mat qua npi soi mat hiy ngupc dong khong thay ro mat, tiii nen thtic hien MRCP (Magnetic Resonance Cholangiopancreatography) de xac dinh chan doan. De tang cuong dp tuong phan trong MRCP voi viec tiem Mangafodipir trisodium giiip lam tang kha nang chan doan ro mat, xet nghiem nay co dp nhay 86% va dp dac hi?n la 83% trong c h ^ doan ro mat*'^.
Mpt tnrong hgp bien chiing can phai can thiep phau thuat la do dau trong ctia stent xuyen qua mon ciit ong gan phai tren BN sau phau thuat cat gan phai do u, bien chiing xay ra la do stent dai (12 cm) xuyen qua mon ctjt vao 6 b t ^ g Chuyen De Npi Soi Tieu Hoa
Y Hpc T P . H o C h i M i n h * P h u Ban T a p 19 * So 5 * 2015 N g h i e n c u u Y hoc de tranh dupc bien chirng nay ta nen xac dinh
chieu dai stent can thiet truac khi dat, co the dat stent ngln hon khong can thiet phai dat dau trong stent den vi tri ro.
Trong nhom nghien ciiu co 5 BN phai thay stent ^ 2 va 3BN phai thay stent Ian thti 3. Cac trudng hpp nay sau khi theo doi 2-3 thang thay tinh trang lam sang khong cai thien hoan toan, chiing toi chti dpng cho benh nhan nhap vien va thay stent moi truoc khi stent co nguy co tac; vi thai gian dan luu tnmg binh ctia stent nhua khoang 3 Ihang. Ca 8 BN tiiay stent nay ^ u cho ket qua dieu tri tot
Trong nhom nghien cthi co 6 truong hpp khong dupc tiieo doi sau khi dat stent do nhieu ly do khach quan nhu BN a xa khong co dieu kien tai kham tai Benh vien Chg Riy, chiing toi khong lien lac dupc voi benh nhan... Chinh dieu nay lam kho khan trong viec theo doi benh va lay s6li?u trong nghien ciiu.
Co nhieu ky thuat npi soi dirpc sti dting trong dieu tri ro mat bao gom: Cat vong Oddi don thuan, dat Stent ket hpp voi cat hoac khong cat CO vong Oddi, va dan luu miii-mat ket hpp voi cSt hoac khong cat co vong Oddi. Nhiing phuong phap nay dieu co co che chung la lam giam khang luc duong mat, gitip mat chay theo duong binh thudng, giam luong mat chay qua duong ro, tao dieu kien cho duong ro tu lanhf^t.
So sanh voi ket qua oia mgt so nghien cuu khac
Cac cong ttinh nghien ciiu ve dieu tri ro mat bang npi soi tap trung vao hai phuong phap: c3t CO vong va dat stent (co hay khong cat co v6ng)i^'^.Ca hai phuang phap cat co vong va dat stent deu cho thay co hieu qua cao. Npi soi mat tuy nguoe dong c^t co vong Oddi don tiiuan co hieu qua 88% trong dieu tri ro mat sau phau tiiuatf"'. Thuan lpi ctia cat co vong don thuan trong dieu tri ro mat la benh nhan chi trai qua 1 Ian npi soi. Tuy nhien, mgt nghien ciiu ctia Marks va cgng sir<i'> thuc hien tren mo hinh cho cho thay tiioi gian bit 16 ro ngSn hon co y nghia trong nhom dieu tri voi dat stent so voi nhom dieu tri cat co vong don thuan. Nghien cihi hoi ctiu tren nguoi ciia John Kaffes va cgng su<^
ciing de ngW rang viec dat stent dieu tri ro mat sau phau thuat cat tiii mat tot hon so vai cat co vong don thuan. Do vay, dt co vong don thuan khong duoc xem la phuong phap chgn luu dau tien trong dieu tri ro mat 6 nhiieu trung tam.
Dan luu miii-mat va d|it stent nhua duong mat CO hieu qua tren 85% trong trudng hpp ro mat Dan luu mui mat thuong chi dat mpt lan, khong can lap lai thii tiiUat npi soi khi nit d i n luu. Tuy vay, ong dan luu se lam benh nhan kho duu va de di lech khi benh nhan thay doi tu the.
Dat stent duong mat duong nhu trd thanh phirong phap ngi soi dieu tri tai nhieu trung tam.
tren the gidi:
rac gia Nam S6BN Tiianh c6ng
ttluthu^t Nsailutn thanh cdng Bi^n chu'ng Ttjvong
Naresh Agarwal"'
2006 90 100%
(90/90) 100%
(72/72) 0%
0%
Gurpal S.
Sandha'"' 2004
207 100%
(207/207) 98,04%
(200C04) 1.5% (3/204;
0%
Virendra Singh""
2010 85 100% (86/85) 100% (53^3) 4,7% (4/85)
0%
Shahriyar Ghazanfar"'
2012 97 94.8% (92/97) 87.8% (36/41)
0%
0%
Sammy Saab"»
2000 69 96% (66ffi9) 91.3% (63^9)
1,45% (1/69) 1,45%
Ayman M.
Hassanien'"
2008 31 100% (31/31) 93,5% (29/31) 9,6% (3/31)
0%
Kook Hyun KimI*
2014 32 100%
(32/32) 93,8%
(30/32) 3,25% (2/32)
0%
BVCR 2015 65 96,38%
(62«6) 98,04%
(50/51) 2% (1/51)
0%
Ty le thanh cdng va bien chiing ctia chiing tdi cning tuong duong vcii cac bao cao dupc tiiam khao. Npi soi dat stent la bien phap dupc Itja chpn hang dau trong dieu tri rd mat. Day la mpt thti thuat don gian, hieu qua va an toan. Dau tu
ban dau thap, chi phi thii thuat thap do cac dung CtJ CO the dimg lai dupc nhu day dan, dao cat co vdng, dng day stent... Thii thuat nay cd tiie thirc hien ngay d tuyen tinh, nhung co sir phoi hpp chat che vdi ngoai khoa.
Nghien o h i Y hpc Y Hpc TP. Ho Chi Minh " I'hu Ban I ap 19 * So 5 * 2015
KET LUAN
Vdi mtJC tieu la danh gia ket qua dieu tri va cac tai bien-bien chiing ctia phuong phap npi soi dat stent trong dieu tri rd m a t Qua nghien ciiu tren 65 BN, t)' l^ thanh cong cita tiiii thuat la 95,38%, ty I# bien chiing la 2%, ty le dieu tri thanh cdng la 98,04%. Do vay, noi soi dat stent trong dieu tri rd mat la mpt phuong phap it xam lan, hi?u qua va an toan. Tren co sd cac nghien Cliu da cdng bo va qua mot loat truong hpp rd mat dupc dieu tri thanh cong, chiing toi xin gidi thi?u mpt hudng dieu tri mdi ve ro mat, hy vpng trong tuong lai ky thuat nay se dupc ap dung rgng rai d Vi#t Nam.
TAI LIEU THAM KHAO
1 Agarwal N, Shanna B C Garg S, Kumar R and Sann SK.
(2006). Endoscopic management crf postoperative bile leaks Hepatabiliani Pancratl Dis Int, 5- 273-277.
2 Bndges A, WUcox CM, Varadarajulu S, (2007) Endoscopic management of traumatic bile leaks. Castrointest Eniosc , 65:
1081-1085.
3 Chen XP, Peng SY, Peng CH, Liu YB, Shi LB, Jiang XC, Shen HW. Xu YL, Fang SB, Rui J, Xia XH, Zhao G H (2002). A ten- year study OTi non-surgical treatmenl of poSoperative bile leakage. World ] Gastnxnterol, 8 (5): 937-942.
4. Ghazanfar S, Qureshi S, Leghari A, Taj MA, Niaz SK, Quraishy MS (2012). Endoscopk management of post operative bile duct mjunes / Pat Med/Issue, 62 (3): 257-262 5 Hassamen AM (2003) Endoscopic Management Of biliaiy
leak after cholecystectomy. An initial study. Egyptian Jourfwi of Sur^ny, 22 (4); 336-342
6. H u a n g CS^ Lichtenstem DR (2005). Postcholecystectomy bile leak, what is the optimal treatment? Gastrmnlestijud Endoscopy, 63(2):27fr-278.
7 Kaffes AJ, Houngan 1, De Luca N, Byth K, Williams SJ, Bourke MJ (2005). Impact of endoscopic intervention m 100 patients with suspected postcholecystectomy bile leak.
G(t^fr<>mte(Eddosc,, 61:269-275.
8 KaJavci C, Aisen A, Canal D, Fogel EL, Sherman S, Wiebke E Stockberger S, Lehman G A (2000), Magnetic rescaiance cholangiopancreatography documents bile leak site after cholecystectomy m patients with aberrant nght hepatic dud where ERCP fails. Gaftrain^sthud natosc, 52 (2): 277-281.
9 Kim KH and Kim TN. (2014). £ndoscof»c Management crfBile Leakage alter Cholecystectomy: A Smgle<:enter Expenence for 12 Years. Om Eiithx.. 47 248-253.
10. L ] a c h J , B o r d a s J H E I i z a l d e J L E n r i c o C , G i n e s A , P e l l i s e . M , Mondelo F, Pique JM. (2002). Sfrfuncterotomy m the treatmait of biliary leakage (abstract). Hepatogastroentercios/ , 49 (48):
1496-1498.
11 M a r i s JM, Pcmsky jL. Shillingstad RB, S n ^ J. (1998). Biliaiy stenting is more effective than sphincterotomy in the resolution of bibary leaks. Surg Eiidosc, 12:327-330.
12. H l l a i l F, Billaud Y, Gauber G, Monneuse O, Crombe- Temamian A, Fouque P, Valette P], (2004). Mangafodipi^
enhanced magnetic resonance cholangiography for the diagnoas of bile duct leaks. Gastnrinitsl Eitdosc, 59:818-822.
13, Saab S, Martin P, Soliman GY, Machicado GA, Saab S, Martin P, Soliman GY, Machicado GA, Ghobnal RM, Busuttil RW, and Bedford RA. (2000). Endoscopic Management of Biliaiy Leaks After T-Tube Removal in Liver Transplant Recipients:
Nasobiliary Drainage Versus Biliary Stentmg. Uver Transplantation, 6 (5): 627-632.
11. Sandha GS, Bourke MJ, Haber GB, Kottan PP (2004).
Endoscopic therapy for bile leak based on a n e w classification:
results in 207 patients. Gastrointest Endosc., 60:567-574.
15. Shah JN (2007). Endoscopic treatment of bile leaks: current standards and recent innovations Gastrointestinal fiidosrapi/, 65 (7): 1069-1072.
16. Singh V, S m ^ G, Verma GR and Gupta R (2010). Endoscqjic management of postcholecystectomy biliaiy leakage, Hepatobiban/ Pancreat Dis M , 9- 409-413.
17. Spinn MP, Adler DG. (2006). Successful endoscopic therapy of mtrahepatic bile leaks fallowing hepatic gunshot injury.
Endoscopy, 38: S59.
i c . Zhang JM, Shen W a n d Zheng ZD. (2005). Pathogenesis and treatment postoperative bile leakage: report of 38 cases.
Hepatobiliary Pancreat Disbtl.,4.441-444.
Ngay nhan bai bdo: 30/8/2015 Ngay phdn bien nhan xet bai bdo: 07/9/2015 Ngay bai bdo duac dang- 02/10/2015
Chuyen De Npi Soi Tieu Hoa
