Banh gii ket qui phiu (hu&t cit thdc qudn ndi soi ngqc bung, nao vet hach r&ng... Nguyin Xudn H&a va c&ng si
Danh gia ket qua phau thuat cat thuc quan noi soi ngiic bung, nao vet hach rong hai vung vdi t u the sap nghieng 30 do
Nguyen Xuan Hoa, Pham Bdc Huan, D 6 Mai L§m
Bgnh vi^n Viet Ddc
Tif kh6a:
CSt thdc quan nfii soi nguc bung, nao v&t h?ch hai viing
Dja chi lien he:
Nguyin XuSn Hoa, Khoa Phau thu&t Ti&u hda Benh vien Vi&l DOc,
4 0 Jrkng ThI, Hokn Kiem, Hk Ndi eien thoai: 0988 110 844 Email: [email protected]
Ngay nhan bai: 01/6/2017, Ngdy duyet: 08/6/2017, Ngay chap nhdn dang:
12/6/2017.
Tom tat
Dat vdn di: Ddnh gid k^t qud phlu thudt cat chtfc qudn ndi soi ngtfc bung nao v6t hach r^ng hai vdng vdi ttf the n'km sdp nghieng 30 dd.
Phucfng phdp nghien ciiu: Nghien cdu mo ta dd'n cflu theo ddi dpc tiJf tfldng 1 nSm 2014 den thang 8 nkm 2016 chung tdi ti^n hdnh phEu thudt 70 trtfdng hdp cat thtfc qudn noi soi ngtfc bung, nao v6t hach r^ng hai viing vdi ttf th^ sd'p nghieng 30 d^.
Ke't qud: Thdi gian md trung binh 350 phut, ltfdng mau mat Irung bmh 2I0mI, thdi gian nam hdi sdc trung binh 65 gid, thdi gian trung tien 3 2 ngdy, thdi gian rut ddn Itfu mang phdi Id 8 ngdy.
Vl tri 1/3 dtfdi CO 37 ngtfdi bSnh, 1/3 giffa 33 ngtfdi b6nh, trong dd cd 5 ngUffi bdnh dieu tri hda chat va xa tri trtfdc md, sd ltfdng hach nao vdt dtfdc 25.6 hach (it nhd't Id 15 hach, nhieu nhS^t la 42 hach). Khdng cd bien chtfng chdy mau, tH vong trong mo, ro migng ndi 6/70 ngtfdi bgnh, suy hd hdp 1/70 ngtfdi benh, ro dtfdng chap: 2/43 ngtfdi benh.
Thdi gian nam vidn trung binh 14 ngdy, hep mieng ndi: 0
Ket luqn: Cat thtfc qudn ndi soi ngtfc bung, nao vdt hach rdng hai viing Id phdu thudt khd, ty le bien chtfng so vdi ky thudt khde khdng cao. Ttf the sdp nghieng 30 dd tao trtfdng md rdng, an todn vd thuan ti$n trong phau tich vi vdy c6 tinh khd thi trong phdu thudt cat thtfc qudn.
Results of thoracoscopic-laparoscopic esophagectomy with two fields lymphadenectomy extend and semi-prone position of thoracoscopy
Nguyen Xuan Hoa, Pham Due Huan, Do Mai Lam
Viet Due hospital
Abstract
Introduction: To evaluate the results of thoracoscopic-laparoscopic esophagectomy with two field extend and semi-
Tap chi phau thugt ndi soi vd ndi soi Vi^t Nam (2017) Sd 2 - Tap 7, 36 - 46
Nguyen Xudn Hoa va c&ng si Bdnh gia kit qud phau thu&t cat thuc qudn n&i soi nguc bung, nao v&t hach r&ng...
prone position of thoracoscopy.
Material and Methods: Prospective observation study enrolled 70 consecutive cases of thoracoscopic-laparoscopic esophagectomy with two field lymphadenectomy extend for cancer and semi-prone position of thoracoscopy performed from 1/2014 to 8/2016 at Vietduc hospital.
Results: Average operative time was 350 minutes, intraoperative blood loss was 210nil, mean of stay times at ICU 65 hours, first flams within 3,2 days, thoracic drainage within 8 days. Location of tumor: lower esophageal cancer.
37 cases, middle esophageal cancer: 33 cases and 5 case underwent neoadjuvant with radiochemolherapy. Average number of lymphonodes harvested were 25.6. We had no mortality, respiratory complication in 1 case, leakage of anastomosis in 6 cases, chylothorax in 2 cases. Average hospital stay were 14 days.
Conclusion: Thoracoscopic-laparoscopic esophagectomy with two field extended lymphadenectomy is safe and feasible..
Keyword: Thoracoscopic-laparoscopic esophagectomy, two f elds extended lymphadenectomy.
I. Oat van de
Ung thtf thtfc qudn (UTTQ) Id bdnh khd thtfdng gdp d Viet Nam, dtfng hdng thtf 5 trong cdc loai ung thtf.
Ddng hdng thtf 9 trong cdc loai benh dc tinh. Nam gap nhieu hdn nS. Tao hinh thtfc qudn (THTQ) Id phdu thuat thay the mdt phan thifc quan hay todn bd thtfc qudn bang mdt doan 6'ng tieu hda. Muc dich THTQ Id gidp cho ngtfdi benh dn udng qua dtfdng mieng md khong phdi an qua d'ng md thdng da ddy hoac md Ihdng hong trang.
Trong phdu thudt UTTQ, sau cat ditfc qudn, vi$c ldp lai Itfu thdng dtfdng tieu hda thtfdng dtfdc ldm trong ciing mot thi. Doan ong tieu hda thtfdng dtfdc chon la da ddy, ngodi ra cd thi chon dai trdng, hong trdng, cdc quai rudt ttf do cd ghep vi mach. Ky thudt thay thd' thtfc qudn bang dng da ddy thudn chi^u thtfdng dtfdc su" dung nhieu nhat. Ngdy nay, p h l u thudt ung thtf thtfc qudn khdng chi ddn thu^n la cat bo thtfc qudn vd ldp Iai Itfu thdng tidu hda. V^n de nao vet hach ngdy cdng dtfdc nhieu phdu thudt vidn thtfc hidn vd trd thdnh thtfdng quy d mdt so' trung tdm ldn.
Tren the gidi, p h l u tiiudt ung thtf thtfc qudn, nao vet hach dtfdc de cdp tH r^t sdm. Tinh trang di cdn hach Id ra't khde nhau phu thudc vd vi tri khdi u nguyen phdt, xu htfdng phdt trien cda khd'i u va stf Itfa chon khu vtfc nao vet hach. Stf phdt trien ciia hach ti-ong ung tiitf tiitfc qudn dtfdc phdt hien d ba
viing: viing co, trung thdt vd vung bung [ I ] , [2]. Phau thudt cat thtfc qudn vd nao vet hach ba vung dtfdc bdo cao ddu tien vdo nam 1981 hdi tdc gid Kmosita vd cdng stf Ngdy nay phau thuat dtfdc phd bie'n d 35 tren tong sd 96 bdnh vien ldn cua Nhdt Bdn vd tren the gidi [3], [4, 5]. Rd't nhieu nghien ctfu chi ra rdng, phdu thudt cat thtfc quan cd nao vet hach rdng rdi cd ty le sdng tren 5 nam cao hdn han so vdi nhtfng ngtfdi benh chl cdt thtfc qudn ddn thuln [1], [6], [7], [4], [8], [1]. Phau thuat cdt thtfc quan ket hdp vdi nao vet hach ba viing (ngtfc, bung, co) phd bien tai Nhdt Bdn, tuy nhidn vdn cdn nhieu tranh cai giffa cdc tdc gia tren the gidi ve viec nao vet hach hai vung (ngtfc, bung) hay nao vet hach ba vdng (ngtfc, bung, co) [9]. Nhieu nghien ctfu chi ra rang phau thudt nao vet hach ba viing cd thdi gian sdng tren ndm ndm khac biet do vdi nao vet hach hai vung [4, 7], [10]. Ben canh dd cung cd nhieu nhffng tdc gid nghien cffu thay rang p h l u thudt cdt thtfc qudn vd nao vdt hach ba vung Idm tdng bien chffng va t;^ 16 ttf vong sau md, ddc biet Id tdn thtfdng ddy than kinh quat ngtfdc, tdng bien chffiig hd hd'p, thieu mdu khi qudn [11-13], khdng cd stf khde biet ve ti Id sd'ng s a u m d [14], [9].
Tai Viet Nam, phdu thudt ndi soi hai vung ngtfc vd bung dd dtfdc dp dung d i l u tri trong UTTQ tff nam 1991. Phdu thudt ndi soi the hien tftf di^m Id gidm dtfdc cdc bien chffng sdm ddc biet Id bien
Tap chi p h l u thuat npi soi va ndi soi Viet Nam (2017) So 2 - Tgp 7; 36 - 46
Bdnh gia kit qui phiu thu&t c&t thuc qudn n&i soi ngi/c bung. n§o vit hach r&ng . Nguyen Xuan Hda va c&ng Si
chffng hd hd^p. Cdc ke't qud cQng btfdc ddu chtfng minh Id ngang bdng vdi phdu thudt md md. Tuy vdy cdn it cdc nghien ctfu v^ phlu thudt ndi soi vet hach vdng (ngtfc-bung).
Xud't phdt tiif nhu cau thtfc te tren chung tdi tie'n hdnh nghien ctfu dd tdi muc tieu:
Ddnh gid ket qud sdm cua phlu thudt noi soi cdt thtfc qudn vd nao vdt hach rdng hai viing (ngtfc-bung) vdi ttf the ndm sap nghieng 30 dd.
II. Doi tadng va phi/ting phap nghien ctfu Dd'i tifdng nghign ctfu
Tieu chudn chqn ngi^ binh.
Tat cd cdc ngtfdi benh UTTQ ngtfc dtfdc di^u tri tai khoa phau thudt tieu hda Benh vidn Viet Dtfc tff thdng 1 ndm 2014 den thdng 8 ndm 2016, cd tieu chuin sau:
Dtfdc md cat thtfc qudn ndi soi ngtfc vd bung.
Nao vdt hach rong hai vung.
Cd ke't qud gidi phlu benh vi the Id UTTQ.
Tieu chudn loqi trU.
UTTQ cd, ung thtf tdm vi.
UTTQ tren ngtfdi benh cd cdc b6nh phdi hdp ndng: suy ho hl^p ndng, lao phdi tidn trien, suy gan, suy than, suy tim, dai thdo dtfdng,... hoac tudi tren 75, suy ki$t.
Nhffng tni'dng hdp phdu thudt cdt thtfc qudn nhtfng khdng tao hinh thtfc qudn bang dng da ddy.
Phtftfng phap nghien cihi.
Loqi hinh nghien ctiu.
Nghidn ctfu md td tid^n ctfu, theo doi dpc (ddnh gid ket qud trtfdc md vd sau md).
Chon mdu nghien ctiu.
Quan thd nghifin cffu: td't cd cdc ngtfdi benh UTTQ den khdm tai khoa phdu thuat tieu hda benh vidn Viet Dtfc ta thdng 1 ndm 2014 thdng 8 ndm 2016,
Mau nghien ctfu; nhffng ngtfdi benh UTTQ ngtfc cd du cdc tidu chuan nhtf da neu d trdn.
PhiTdtag phap phSu thtiSt.
i y a chqn vd chudn bf ngiidi bfnh trud'c md Ngtfdi bdnh dtfdc Idm day dii xet nghiem trtfdc
md bao gdm xdt nghiem chin dodn UTTQ vd cdc xet nghi$m ddnh gid khd ndng phlu thudt. Bdc sy phau thuat vd bdc sy gdy md khdm ky ngtfdi bdnh trtfdc md.
Ngtfdi benh vd ngtfdi nhd dtfdc gidi thich ky ve tinh trang bdnh, khd nang phdu thudt, nguy cd tai bie'n cd the xdy ra trong vd sau khi md.
Quy trinh phdu thu&t Thinguc:[\5\, [16].
Ttf the: ngtfdi benh ndm sdp, kd mdt gdi ddm nhd b ngtfc phdi ldm cho ngtfdi benh nghieng mot gdc khodng 30 do. Tay phdi ngtfdi benh dtfdc ke sao cho khodng khong gian ngtfc phdi vd ndch khong bi can trd.
Gdy md ndi khi qudn vdi ong Carlen dd ldm xep phdi, khdng bdm hdi khoang mdng phdi. Ttf the ngtfdi benh: Ngtfdi benh nam sa'p, nghifing trdi 30".
Vi tri vd sd'ltfdng trocar: 3 trocar 10 mm, trong do 1 ddt d Uen stfdn 5 dtfdng ndch giffa de dat camera, 1 d lien stfdn 9 dtfdng ndch sau vd 1 d lien stfdn 4 dtfdng ndch giffa cho cdc dung cu md, 1 trocar Smm d khoang lifin stfdn 9 dtfdng ndch giffa.
Ky thudt phlu tich thtfc qudn: ddt camera vd dung cu phlu thudt de thdm dd, ddnh gid khd ndng cdt u. Phau thudt bat dau bKng vific phlu tich, that, clip vd cat ddi quai tinh mach ddn vd sau dd Id ddng mach phe qudn phdi de vdo phlu tich thtfc (gidn. Cat ddy Chang tam gidc phdi phdi, md mdng phdi ti-ung thd't bang mdc dien hodc keo theo 2 dtfdng, dtfdng phia sau doc theo bd trtfdc tinh mach ddn va dtfdng phia trtfdc dpc theo mdng tim, phd'quan phdi va doc tiieo khi qudn. Hai dtfdng rach gdp nhau d dinh ldng ngtfc va tren cd hodnh.
Ky thudt bdc tdch thtfc qudn, phau tich vd ddt clip cac mach mdu ciia thtfc qudn, vdt hach trung thd't quanh thtfc qudn vd khd'i hach dtfdi chd chia khi phe qudn thdnh mdt khdi dtfdc thtfc hien vdi ky thudt ndng, d^y thtfc qudn de tao trtfdng mo b^ng 2 dung cu phlu thuat dtfa qua 2 trocar 6 lien sffdn 9 vd 4, ti-ong dd 1 dung cu (dng hdt hodc 1 kep phlu thudt to khoe) nang, diy thufc qudn dd tao ra khoang ldm
Tap chl p h l u ttiuat ngi soi vk npi soi Vi?t Nam (2017) S6 2 - T§p 7; 36 - 46
Nguyen Xudn Hoa vd cong sy Banh gia ket qud phiu thuit cit thqc quin noi soi ngi/c bung, nao vet hach n.
vific vd 1 (keo, mdc difin, hoac dao sieu dm, kep clip) de bdc tdch tiitfc qudn vd clm mdu, Cdc mach mdu cda thtfc qudn dtfdc phlu tich vd dat clip trtfdc khi cdt. Cdc hach trung that dtfdc lay bo ciing vdi thtfc qudn thdnh mpt khdi, Erdnh kep trtfc tie'p vdo hach dd tranh Idm vd hach gdy di cdn ung thtf trong long ngifc. Cdc hach cln nao vet bao gdm hach trung thd't giffa vd dtfdi dtfdc gidi han bdi dtfdng vien di tff nga ba khi phd' quan dd'n khe hodnh, phia trtfdc gidi han bdi rdn phdi vd mdng ngodi tim, phia sau Id dpng mach chii Ien: hach canh thtfc qudn, hach canh khe hodnh, hach nga ba khi phd' qudn, hach canh ddng mach chii, hach rdn phdi hai bfin. Chffng tdi cSng lay thfim nhdm hach d dpc hai ben khi qudn (hach canh thin kinh qudt ngtfdc phdi vd trdi). Vific bdc tdch thtfc qudn tff trdn xudng dffdi hay tff dtfdi ldn trfin Id tuy thudc vi tri u va thtfdng thifc hien tff phan thtfc qudn ldnh den phan thtfc quan cd u. Sau khi bdc tdch hdt thifc quan ngtfc, din Itfu mdng phdi dtfdc dat qua Id trocar lien stfdn 5, nd phdi vd khau cdc Id dat trocar thanh ngtfc
Nqo vet hqch hai viing
i*-9 tAVCEi O x - : - ; , Nao vet hqch ba vitng
Thi bting Chung toi dat 5 trocar I trocar 10: canh rdn.
I trocar 10: d ngay dtfdi mui ffc, cd tdc dung ven gan trong qud trinh phdu tich.
1 trocar 10: giao giffa dtfdng ke ngang qua rdn va dtfdng giffa don trdi.
1 trocar 5: giao giffa dffdng ke ngang qua rdn vd dtfdng giffa ddn phdi.
trocar 5: d dtfdi bd stfdn trdi, dtfdng ndch trtfdc Cat mac nd'i ldn ngodi cung mach vi mac ndi phdi, bdo tdn mach vi mac no'i phdi vd mdn vj, Cdc nhdnh vi ngdn dtfdc cdt bang dao sieu dm. Thdt DM, TM vdnh vi va vi mac ndi trdi.
Cdc nhdm hach bao gdm: 1,2,3,7,8,9,11,12a.
77ii cd trdi
Md dpc bd trtfdc cd ffc ddn chum, phau tich gidi phdng thffc qudn cd. Cdt ddi thtfc qudn cd ngang mtfc bd dtfdi tuyen gidp.
Tqo hinh dng dq ddy
Md nhd 5 cm dtfdi mui ffc, tao hinh dng da ddy
Tap chf phau thu4it ngi soi vk n$i soi Viet Nam (2017) S5 2 - Tap 7; 36 - 46
Banh gii k&( qud phiu thudt c&t thi/c quin n&i so/ ngqc bung, nao vdt hach r&ng... Nguyen Xudn Hoa vd c&ng su
bdng mdy cdt thang LC 75mm, khdu tang ctfdng chi ddn sdi 4.0. Dtfa o'ng da ddy ldn cd qua trung thd't sau vd ldm mieng nd'i thtfc qudn dng da ddy tan bfin mot Idp vat chi ddn sdi 3.0
III. Ket quS nghien cii'u Sd'ngiftdb^nh
Gidl nam T U M
Nghien thudc la Nghien rupu Nuot nghen Dau ngiJc KhdntiSng Benh ly ho hap Ndn mau
Tmng binh 53 tuoi (45-64) 75%
78%
90%
V i t r i u
U1/3dUdi 37(52 8%) U 1/3 giOa. 33 (47,2%) Thdi gian mo
Thdi gian nlm hoi si
TB 350 phdt (240-420) Tmng binh 65 gid Mau mat
Ch^y m^u Suy hd hap Ro mieng nSi Ro dudng chap Hep mi#ng ndi
Tmng binh 210ml 0 2/70 (2.8%) 6/70 (8.5%) 2/70 (2.8%)
Trung ti§n Thdi gian nJt dan luu m^ng phdi
3.2 ngay 8 ngay
Giai phiu b^nh (%}
I: 33.3 Ila. 30 lib; 25.6 ill: 11.1 Sfi tuong hach Thdi gian ndm vien
25.6 14 (8-24)
Tdng sdngtfdi benh chung tdi tie'n hdidi tff thdng 1 ndm 2014 den thdng 8 ndm 2016 cd 70 ngtfdi benh tdt cd deu Id nam gidi. Tudi trung binh Id 53 (45-64), 75% hut tiiuoc Id, 78% nghifin rtfdu vd cd dd'n 90% trtfdng hdp ddn vifin trong tinh trang nudt nghen, khong cd trtfdng hdp nao dau ngtfc, khan tie'ng hay ndn mdu vi nfi'u cd cdc trifiu chtfng ndy thi giai doan mufin, khdng cdn chi dinh phlu tiiudt.
Thdi gian md ti-ung blnh 350 phiit (240-420), ltfdng mau mdt trung blnh 210ml, thdi gian nam hdi stfc 65 gid (2-3 ngdy). Chung tdi nhdn thd'y do'i vdi md thtfc qudn thdi gian ndm hdi stfc cdng lau thi stf hdi phuc cda phdi se td't hdn vi trong qud trinh phlu thudt cd lam xep phdi phdi.
Khdng cd ngtfdi benh bid'n chffng chay mdu, 2 ngtfdi benh rd dtfdng chap trong dd chi cd 1 trtfdng hdp dieu trj nfii khoa khdi bfinh, trtfdng hdp cdn lai chung tdi tifi'n hdnh phdu thudt ndi soi Iai sau 3 tuln dieu tri npi khoa. Ke^t qud phau thudt tdt, kep clip vd khdu vi tri tdn thtfdng d'ng ngtfc ngang mffc D3, ngtfdi benh ra vifin sau 10 ngdy phdu thudt. Hai trtfdng hdp rd mieng nd'i vd dtfdc dieu tri npi khoa bdng an qua md thdng hdng trdng, dat hfi thd'ng hut rtfa vet md cd. Khdng cd trtfdng hdp ndo hep mifing nd'i. Thdi gian trung tifin 3.2 ngdy, thdi gian rut din Itfu mdng phdi 8 ngdy, sd ltfdng hach trung binh 25.6 hach, thdi gian nam vien trung hinh 14 ngay sdm nhd't Id 8 ngdy vd Idu nhat 24 ngdy.
Ttf th€^ md trong noi soi ngtfc phai
Cd rat nhieu nhffng phtfdng phdp cat thtfc quan it xdm la'n, trong dd ndi soi ngtfc phdi va ndi soi bung Id mdt trong nhffng phtfdng phdp cd nhieu tfu diem.
Cd hai ttf the^ trong phlu thudt npi soi ngtfc phdi: ttf thfi'nghieng phdi 90 dp vd ttfthd'sd'p.
Dallemangne et al ndm 1992 Id ngtfdi diu tifin ke't hdp npi soi ngifc phdi vd nfii soi bung trong phau thudt thtfc quan vd ldm mifing nd'i thtfc quan dng da ddy d cd trdi [17]. Ngtfdi hdnh nam 80 tudi
Tap chi phau thu^t npi soi va ndi soi Vipt Nam (2017) SS 2 - TSp 7; 36 - 46
NguySn Xuan Hoa vd cong s(/ Ddnh gia ket qud phiu thudt cat (hqc quin n&i soi nguc bung, nao vet hach r&ng ..
chan dodn ung thtf bidu mo vdy thtfc qudn, dtfdc phau thudt npi soi ngtfc vd ndi soi bung, ngtfdi benh xud't vien sau 9 ngdy. Tdc gid Cuesta vd Nagy nam 1993 md td lln diu tien 12 Qifdng hdp....thdi gian md keo ddi 7-9 gid, trong do thdi gian cho thi ngtfc la 2-3.15 gid. Mpt ti-tfdng hdp ttf vong do nhdi mdu cd tim, ba trtfdng hdp ttf vong trong 30 ngdy sau mo vi bie'n chffng lien quan dfi'n hoai ttf dng da ddy. Cdc tdc gid khdng the gidi thich dtfdc tinh hud'ng ndy vi khdng gdp d ky tiiuat md truyin thdng. Cung trong thdi gian ndy thi cdc tdc gid Azagra et al va Cuschieri et al ndm 1993 cung tien hdnh phlu thudt ndi soi ngtfc phdi, nao vdt hach ttung thd't [18]. Gossot ndm 1993 tien hdnh tren 15 ngtfdi bfinh vd cd 2 ngtfdi bfinh bifi'n chtfng ho hip [19], [20], Ndi chung nhffng bdo cao ban diu ve ndi soi ngtfc phdi cd ty le bien chtfng ho ha'p ltfdng ddi cao. Td't cd nhffng bdo cdo tren deu chung mot diem Id ttf the ndi soi ngtfc phdi Id ttf the' nghifing trai 90 dp.
Nam 1994 chinh tdc gid Cuschieri vd cpng stf (cs) lan diu tien da thay ddi ttf the' rad nfii soi ngtfc phdi tff ttf the nghifing chuydn sang ttf the ndm sd'p vd khong cln ddt Carlen Idm xep phdi vdi bifi'n chtfng ho hd'p giam di nhieu [21]. Ben canh dd ty Ie bien chtfng hd hip cao cdng gap d cdc tdc gid Mcanena et al (9 ngtfdi bfinh), Gossot vd cdng stf (29 ngtfdi benh) vd Dexter (24 ngtfdi henh). Cdc tac gid Robertson, Perachhia, Simon Law cung cho ket qud ttfdng ttf [22], [23-27] vdi ttf the ndm nghifing phdi 90 dd.
Mac du cd nhieu bdo cdo vd ty Ifi bie'n chtfng cua phlu thudt ndi soi ngtfc phai vdi ttf the nghifing trdi 90 dd bfin canh do cd nhieu bdo cdo ciia Luketich vd cdc tdc gid Nhdt bdn vd tinh tfu viet cua phau thudt noi soi ngtfc phdi. Akaishi va cs nghifin ctfu ti-fin 39 ngtfdi benh cat thtfc quan nfii soi nao vet hach thd'y rang: khdng cd stf bie'n chuydn ve thdi gian md (200 phut), ltfdng mdu ma't (270ml), so' ltfdng hach (19.7), khfing cd trtfdng hdp "do ttf vong nhiftig cd stf cdi thien rd
ret ve tinh trang hd hdp sau md vd mffc dfi suy hd hd'p gidm rd rfit so vdi md md [28]. Mot nghifin ctfu khde cua Osugi vd cpng stf ndm 2002 ttfin 149 ngtfdi benh chia ldm hai nhdm: md ngtfc 77 ngtfdi bfinh vd ndi soi ngtfc phdi 72 ngtfdi bfinh. Kdt qud: sd' ltfdng hach tffdng dtfdng 33 vd 32 hach, thdi gian md d nhdm md ngtfc cao hdn 227 vd 186 phiit, stf gidm dung tich sdng d nhdm npi soi ngtfc phdi gidm hdn so vdi md ngtfc 15% va 22%, PO.Ol.
thdi gian sfi'ng thfim 3 vd 5 ndm sau md ttfdng ttf vdi nhdm md ngtfc (70 vd 55% so vdi 60 vd 57%) [29]. Cung cho ke't qua ttfdng ttf vdi nhdm tdc gid Nhat bdn nghien cffu tren 80 ngtfdi benh ttong dd so sdnh ve cdc chi so': ltfdng mdu md't, thdi gian npi soi ngtfc, bie'n chffng ho hdp, so' ltfdng hach [30]. Ke't qua ttfdng ttf vdi nhdm nghifin ctfu cua Teguchi vd tdc gid Smither d Uc vdi 162 ngtfdi benh trong 6 ndm [31, 32].
Rd't nhieu ddng gdp cua cdc tdc gid trfin thfi' gidl nhtfng phai ke dfi'n ddng gdp quan ttpng cua Luketich vd cs, ndm 1998 dng bdo cdo lln dau vdi 8 trtfdng hdp [33] vd ndm 2003 dng bdo cdo 222 trtfdng hdp trong do cd 8 tttfdng hdp cdt thtfc qudn npi soi khe hodnh vd 214 trtfdng hdp ndi SOI ngtfc phai, ndi soi bung. Bdo cdo cho thd'y ty lfi bie'n chffng Id tffdng do'i thd'p: rd mieng ndi 11.7%, rd o'ng ngffc 3.2%, viem phoi 7.7%, ndi khdn 3.6%, ty le ttf vong 1.4%. Ke't qud ndy cung phii hdp vdi tdc gid Nguyen vd cs nghien ctfu trfin 46 ngffdi benh.
Uudiem ciia tff the'sd'p nghieng 30 dp, Hifin nay tren the' gidi da bat ddu cd mdt so' tdc gid tie'n hdnh ndi soi ngtfc phdi vdi ttf the' sd'p nghifing 30 dp. Dac diem ciia ttf thfi ndy gan gid'ng vdi ttf the ndm sdp chi cai tien mdt chiit Id kfi mpt gdi ddn dpc theo bd stfdn phdi de ndng todn bd phan ngtfc vd bung bfin phdi ciia ngtfdi bfinh Ien khodng 30 do. Vi tri cdc Id trocar cdng gifi'ng nhtf ttf the nam sd'p. Thao tdc kT thuat vd phau lich hodn todn gid'ng vdi ttf thfi' nlm sd'p. Ttf thfi' sd'p nghie ng 30 dp cd ta't ca nhffng tfu die m cii a ttf the'
Tap chl phau thu$t ndi soi va ndi soi Viet Nam (2017)86 2 - Tap 7, 36 - 46
Ddnh gia k&( qui phiu (hu$( ca( thi/c quan n&i soi nguc bung, nao vet h^ch rdng... NguySn Xuan Hda vk c&ng si
nam sd'p so vdi ttf the nghieng 90 dfi: dfi rfing ciia phlu trtfdng, gidm bidn chffng hd hd'p, thdi gian phdu tich.. Tuy nhien nd cd tfu diem hdn ttf thfi' ndm sd'p:
Trung thd't sau dtfdc md rpng hdn vi vdy thuan Idi cho phdu tich. 0 ttf the' nam sd'p cpt sdng phin ndo che la'p mdt phin thtfc qudn chinh vl vdy ban che' phau trtfdng phau tich thtfc quan.
Khi ta nghieng mpt chut sang phia ddi didn se ldm cho thtfc qudn dtfdc bfilo nhieu hdn [34], [35], [36]
Vdi ttf thfi' nam sdp khi trong qud trinh phau tich nfi'u cln chuyen md md thi se rat khd khdn. Nhung do'i vdi ttf the' sd'p nghieng 30 dd thi va'n de md md se thudn Idi hdn nhidu
Rd't il nghifin cffu so sdnh giffa ttf the sd'p nghieng vd Itf thfi' sip. Cac nghien cffu chi ra rang hai ttf the sd'p nghifing vd sip khong khde biet ve cdc chi sd: thdi gian, bie'n chtfng hd hd'p, chdy mdu, buc rd mieng ndi, hep mieng ndi, rd dtfdng chd'p, sd ltfdng hach... nhtfng da sd tdc gid thd'y rang ttf
the sdp nghieng thudn Idi hdn trong qud trinh phdu tich [34]
Nao vet hach rong hai vung
Tdi phdt sau md cat thtfc qudn chu yen Id di cdn hach, chie'm mdt ty lfi nhd tdi phdt tai chd hodc mifing nfi'i. Di cdn hach ttong ung thtf thifc qudn phu thupc vdo vi tri khdi u [1], [37]. (Hinh dtfdi)
Phlu thuat cdt thtfc quan nao vdt hach hai hay ba vung cd ty lfi sdng sau ndm ndm cao hdn ban so vdi chi cat thtfc qudn ddn thuan[38] [1], [6], [7], [4], [8]. Rd't nhieu nghifin ctfu d cdc ttung tdm ldn chi ra rang ly le ttf vong sau md thtfc qudn nao vet hach khodng 0-10% vd khdng cd stf khde bifit giffa nao vei hach hai viing hay ba vung [39], [40], [5]. Chung loi khfing cd ngtfdi bfinh ndo tiJ vong sau md, dieu ndy ciing phii hdp vdi cdc tdc gid tren the gidi. Cung cd mpt vdi bdo cdo ndi rang ty le bie'n chffng cua phlu thudt cit thtfc qudn nao vet hach ba viing cao hdn bin so vdi nao vet hach hai vung. Isono vd cpng stf, Udagawa va cpng stf bdo cdo ty le tdn thtfdng ddy thin kinh
1/3 giffa
2,0%O
63ngirmh$nh 7L4%
266 ngifdi b^nh 64.7%
114 ngtfdi bfinh 80.7%
Tgp chi phau thuSt ndi si a ndi soi Vi0l Nam (2017) Sd 2 - Tap 7; 36 -
Nguyin Xuan Hda vd cdng su Bdnh gid kS( qui phau thu$t cat thuc qudn n&i soi ngi/c bung, nao vdt hach r&ng..
qudt ngtfdc d ngtfdi benh nao vet hach ba viing cao hdn hin so vdi nao vdt hach hai viing [39], [12] ddy la mpt trong nhffng nguyen nhdn chinh gay khan tie'ng, dnh htfdng chit ltfdng cupc sdng ve sau ndy. Nghifin ctfu cung chi ra rdng nao vdt hach ba vung Idm tang tf Ie rd mieng ndi, thifi'u mdu khi qudn, hdi chtfng suy hd hip cd'p (ARDS) [12], Mac du nao vet hach ba vdng dtfdc dp dung rpng rai d cdc trung tdm phau thudt ciia Nhdt bdn song khdng dtfdc phd bie'n d cdc ntfdc phtfdng ldy.
Chdng Idi lien hdnh nghifin ctfu ndy vi thiy ring cdt thtfc qudn nao vet hach 3 vdng cd nhieu bidn chffng hdn hin so vdi cit thtfc qudn nao vet hach hai vffng, hdn nffa cung cd nhieu bdo cdo chi ra ring hai phtfdng phdp tten khdng cd stf khde bifit nhieu ve thdi gian sdng sau md [4, 7], [10]. Theo Cheng - Lin Li vd cpng stf nghien ctfu tren 126 ngffdi benh cdt thtfc qudn nao vet hach hai viing nhdn thay rdng 80,2% di cdn hach trung thit khde bipt cd y nghia thd'ng ke vdi ly lfi di cdn hach co (P=0.000).
Phdu thudt cat thifc qudn vd nao vdt hach vung nhdm muc dich keo dai stf sdng cho ngtfdi benh ung thtf thtfc qudn. Phlu thudt cdt thtfc qudn vd nao hach thdnh mpt khd'i "en bloc " dtfdc Itfa chpn d cdc ntfdc phtfdng Tdy vd hoan todn cd the thtfc hien dtfdc. Nao vet hach "tifiu chuan" Id bao gdm phau tich thtfc qudn kem nhffng hach dffdi ngd ba khi phfi' qudn. Phdu tich thffc qudn thanh mot khdi nghia Id phdi Id'y todn bd td chffc mo lifin kfi't xung quanh thtfc qudn ddm bdo difin cat vdng trong gidi han an toan (Ro). Viec phau tich thtfc qudn thanh mot khd'i phan ndo cung dtfa vdo vi tri khd'i u. Vdi vi tri khdi u dtfdi nga ba khi phe qudn thi viec phlu tich rpng hai bfin thtfc qudn cho phdp thtfc hien phau tich thtfc qudn thdnh mdt khfi'i. Bao gdm mdng ngodi tim, td chffc xung quanh dpng mach chli, dng ngtfc, quai linh mach ddn, mach lien stfdn, mdng phdi hai ben [41], [42]. Vdi nhffng ung thtf thtfc qudn doan ttfin gin vdi khi qudn nfin vide phdu tich cdt thtfc qudn chi nen cho
giai doan Tl vd T2.
Phtfdng phdp cdt thtfc qudn thdnh mdt khfi'i "en bloc" dtfdc coi Id vffdt trpi hdn ve viec kiem sodt tffng viing ttong ung thtf thtfc qudn. Trong nghifin cffu chi tifi't vd di cdn hach vd tdi phdt hach sau phau thudt cat thtfc quan ddi vdi ung thtf thtfc qudn doan dtfdi thi ty Ifi tdt phdt hach tai vung phlu tich Id rd't thd'p. Trong 80% tttfdng hdp tdi phdt hach sau md thi vi tri tdi phdt dtfdc tim thiy nlm ngodi vi tri phlu tich trong qud trinh cit thtfc qudn. Trong todn bp ngtfdi bfinh tdi phdt hach ngtfc thi thdy chtf yeu tdi phdt d hach trung tha't trfin dpc theo thin kinh quat ngtfdc thanh qudn hai bfin ddc bifit dfi'i vdi phdu thuat cat thtfc qudn md khdng nao vet hach trung that tten [43]. Dd'i vdi ung thtf thtfc qudn d vi tri doan giffa d Ddng du thi viec phau tich thtfc qudn thdnh mdt khdi khfing dfi thtfc hifin dtfdc. Vific gdp khd khdn dtfdng nhtf nam d vific bdc tdch trung tha't tren. Trong bdo cdo ve tdi phdt d phau thudt cat thtfc qudn nao vet bach ba viing thdy ty lfi tdi phdt hach vdng phlu tich Id rd't thd'p [44]. Trong bdo cdo do thd'y rang chu yeu tdi phat d hach dpc theo thin kinh qudt ngtfdc thanh qudn ddc biet ben ttdi khi qudn vd phd qudn gd'c trdi.
Nhffng nghifin cffu ve phau thudt cit thtfc qudn nao v^t hach ba vung cho tha'y ly Ie tdi phdt hach trung thdt trfin vd dpc thin kinh qudt ngtfdc chiem 30%. Ty Ifi tdi phdt hach cd phu thupc vi tri khd'i u trfin giffa dtfdi Ian Itfdt Id 60, 20, 12.5% [45], [46], [11] . Ne'u xe'p nhdra cd sdu thufic trung tha't tten (hach doc theo than kinh qudt ngtfdc) vdo nhdm hach cd thi ty Ifi tdi phdt hach khd cao vd phu thufic vi tri kho'i u: vdi doan trfin 63,4%, doan giffa Id 45.2%, doan dtfdi Id 42% [4].
Vdi nao vet hach hai vung neu md rdng lay them hach viing trung thit trfin dpc theo than kinh qudt ngtfdc thi cung dtfdc coi Id nao vet hiu he't hach cd [47]. Vdi cdch ndy ldm tang gid tri tifi'p cdn nao vet hach cd mot cdch td'i thieu, it xdm Id'n.
Mpt nghien cffu hdi cffu so sdnh nao vdt hai
Tap chl phSu thuat npi soi va n0i soi V\kt Nam (2017) Sd 2 - TSp 7, 36 - 46
Banh gid kit qui phau thu&t cat thqc qu&n n&i soi ngqc bqng, nao vet hach rang.. Nguyen Xudn Hda vd c&ng su
vung md rdng vdi nao vet h a c h ba viing thd'y r i n g : ty Ifi sd'ng 5 nam sau md lan Itfdt la 54.9% vd 47.6% [48]. Cd hat nhdm d e u cho thay khd ndng vtfdt trpi ve thdi gian sdng sau mo so vdi nhdm nao vet hach hai vung tifiu chuan vdi thdi gian sdng 5 nam 2 8 % . Cung d mpt nghifin ctfu khde so sdnh hdi cffu hai nhdm nao vet hach md rpng vd nao vet hach hai viing chuan thay thdi gian sdng 5 nam sau md cao hdn h i n 41 % vd 10% [49].
Nghien cffu md ra rapt htfdng mdi trong phau tich nao vet hach cd tff dtfdng dtfdi. T a m quan trpng ciia than kinh quat ngtfdc thanh qudn tdi phdt trong p h l u thudt ung thtf thtfc quan dtfdc chffng minh rd rdng. Trong rapt nghifin ctfu tren 55 ngtfdi bfinh ung thtf thtfc quan te bao vdy cho thd'y tdi phdt bach dpc ddy t h i n kinh quat ngtfdc thanh quan Id ye'u td' tifin ltfdng manh nhd't ttong phau thuat nao v e t h a c h [50]
V. Ket luan
Cat thtfc qudn npi soi ngtfc bung vdi ttf the' sap nghifing 30 dd tao trtfdng md rpng rai, thuan Idi cho qua tnnh p h l u tich c i t thtfc qudn vd nao vet hach.
Cat thtfc qudn npi soi ngtfc bung, nao vet bach rpng hai viing cd ty lfi tff vong vd cdc bidn chffng khdng cao so vdi cdc phtfdng phap phau thudt khac.
Cd tinh kha thi cao trong phau thudt dieu tri ung thtf thifc quan tai Vifit Nam.
Tai lieu tham Khiio
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Tap chi phau thual ndi soi vk ngi soi Viet Nam (2017) S6 2 - T^p 7; 36 - 46
Nguyen Xudn Hda va cdng si Ddnh gia kit qui phiu (huat cit thqc qudn noi soi ngqc bung, nao vet hach r&ng ,
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superficial carcinoma of the thoracic esophagus.
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11 phdu thuat nOi soi va ngi soi Vigt Nam (2017) Sd 2 - T i p 7; 36 - 46
