Y HOC V I | T NAM THANG 9 • SO 1/2014
NHAN XET KET QUA KHAU NOI MACH M A U TRONG GHEP THAN
Tir NGirm CHO SONG TAI BENH VIEN NHAN DAN l i s
T6MTAT
£>|it van de: Ky thuat khau noi mach mau la mot khau quan trong trong gliep than. Chung toi trinh bay dac di^m mach mau than ghep, ket qua khau noi mach mau va cac tai bien, bien chuTig ve mach mau trong ghep than tif ngu'di cho song tai benh vien Nhan Dan 115. 067 tu'dng va phu'dng phap nghien cuTu:
64 b§nh nhan (BN) ghep than tu" ngu'di cho song tai benh'vi?n Nhan Dan 115 tu* thanq 2 nam 2004 i3en ttiang 4 nSm 2014. Phat hien cac bien chutig qua kham 13m sang va can l§m san^. Phu'dng |3hap tien cLrtj mo ta tuhg tru'dng hdp. Ket qua va ban lu$n:
Co 7/64 tru'dng hdp (TH) co > 2 (36n9 mach, 2/64 (TH) CO 2 tinh mach. Co 10/64 BN ghep khong theo quy tSc trong do c6 9/64 BN lay than phai ghep vao ho chau phai (chuyen vj mach mau). Bien chutig mach mau gom: hep dong mach than ghep tai v| tri khau noi 3/64 BN {4,68%) xuat hien sau ghep 3 thang, du'dc dat Stent ket qua tot. Khong c6 bien chuhp tSc, huyet khoi sau mo. Ket luan: Ky thugt khau noi mach mau (thong thudng va chuyen vj mach mau trong tru'dng hdp ghep khong theo quy tac) trang ghep than tu"
nqu'di dio song tei benh vien Nhan dan 115 la an toan, ty le bien chuhg thap.
TD'AAos; Khau noi mach mau; Ghep than.
SUMMARY
COMMENT ON THE RESULT OF THE VASCULAR ANASTOMOSIS I N THE RENAL TRANSPLANTATION FROM L I V I N G DONOR
AT 1 1 5 PEOPLE'S HOSPITAL Background: The vascular anastomosis is important technique in the renal transplantation. We report the result of the vascular anastomosis in the renal transplantation from living donor at 115 people's ho^ital. Materials and Methods: 64 patiens underwent renal transplantation at 115 people's hospital from February 2004 to April 2014. Vascular complications were determined by the physical and laboratory examination. Results: 7/64 individuals had multi-artery while 2/64 had 2 renal veins. 10/64 patients (15,62%) get vascular anastomosis irregularly, 9/64 of them (14,06%) had been transferred the vein. Vascular complications were noted in 3/64 patients (4,68%) as arterial stenosis 3 months postoperatively. But good results were obtained by arterial stenting. No complication of
* Benh vi§n Nhan dan 115-Tp.HCM
* * Benh vien 103
Chju trach nhiem chfnh: Pham Quang Vinh Email: [email protected] Ot: 0904.231.596 Phan bien khoa hoc: PGSTS. Nguyen V3n Xuyen Ngay nh$n bai: 30.6.2014
Truotig Hoang Minh*, Pham Quang Vinh**
thrombosis was observed. Conclusions: Vascular anastomosis technique (normal vasculary or transferred vein) in the renal transplantation from living donor at 115 people's hospital was safety. Tlie rate of the vascular stenosis was (4,68%) 3 months postoperatively. All cases were treated successfully by arterial stenting.
Keywords: Anastomosis vasculary; Renal transplantation.
I. OAT V A N OE
Tai Viet Nam, ghep than du'dc thu'c hiSn thanh cong lan dau tien tai Benh Vien i03-Hoc Vien Quan y vao nam 1992. Cho den nay, tren 12 benh vien c6_the thu'c hien du'dc ghep than va da trcf thanh phau thuat thi/cfng quy d mpt so benh vien. Khau noi mach mau bao gom khau noi tinh mach va dpng mach la mpt khau quan trong trong tien trinh gliep ^th$n. Thong thu'dng viec khau noi mach mau dien ra de dang khi co mach mau than ghep va mach mau vung chau binh thu'dng [ 1 ] , [ 2 ] . Tuy nhien, khi co bSt thu'dng mach mau than ghep nhu': tTnh mach than g h ^ ngan, co nhieu dpng mach hoac tTnh mach...[3ij [4] thi viec khau noi se gap ktio khSn va co Uie du'a den bien chu'ng m^ch mau sdm lam mat chu'c nang than ghep. Benh vien Nhan Dan 115 thu'c hien ghep than ti!r thang 2 nam 2004 va cho den nay chung to! da phau thuat difpc 64 tru'dng hdp ghep than tir ngu'di cho song. Chung toi thu'c hien de tai nham muc tieu danh gia dac diem mach mau cua than ghep; danh gia ket qua lam sang va can lam sang sau khau noi mach mau, cac tai bien, bien chil'ng ve mach mau sau ghep.
H. D6\ I V Q N G VA PHLTONG PHAP N G H I E N CUU 2 . 1 . Doi tiTdng nghien c i h j : 64 BN ghep than tif ngu'di cho song tai benh vien Nhan Dan 115 tir 2/ 2004 den 4/2014
2 . 2 . Phu'dng p h a p nghien cili'u; tien cutJ 2.3. Cac bu'dc t i € n hanh
- Viec thyc hien ghep than du'dc thiTc hien theo quy trinh ghep than cua benh vien Nh3n Dan 115 di/a tren quy trinh ghep than cua Bp Y ti.
- Dung dich ru'a: Euro-Collins va HTK-Custbdial d nhiet dp 4 °C
Nieu quan du'dc earn vao bang quang theo phu'dng phap Uch-Gregoir cai bign c6 ho3c khong dat JJ nieu quan tiiy tru'dng hdp.
- Chung toi ghi nhan cac dac diem ve mach mau than ghep sau khi r u ^ than.
y HOC Vr|T NAM THANG 9 - SO 1/2014
- Ghi nhan cac phu'dng phap khau noi tTnh mach - Ghi nhan ket qua khau noi mach mau: tinh va dong mach trang than sau md kep, tu'di mau than ghep, - Tru'dng hdp tTnh mach than ngan, chung toi ap chu'c nang than ngay sau khi md kep, sieu am dung ky thiiat chuyen vi tJhh mach theo 3 mifc Doppler than ghep sau mo ghep.
dp ciia Du' Tlii Ngoc Thu [2]. Z4. Xu* ly so lieu: su' dung f ^ n mem SPSS 11.5 in. Kit QUA
3.1. Oac diem mach mau than gh^p Bang 1. So lu'dng mach mau
Dac di€m lam sang So iL/dng dong
mach than So lu'dng tinh mach
I d m 2 dm 3 dm I t m 2tm
So trUdnq htfp 57 6 1 62 2
Ty le »/o 89,06
9,38 1,56 96,8S
3,12 Nhanxe'frthan ghep phan Idn chi co 1BM (57/64 TH) va 1 TM (62/64 TH)
3.2. Phu'dng phap khau noi mach Bang 2. Khau rioi dpng mach':
So lu'dng PM
lOM
Kieu khau noi OM than ghep-PM chau chung~
DM than ghep-DM chau trong PM than ghep-DM chau ngoai
Cam dm 1 CLTC vao than dm than chinh sau do noi vdi dm chau ngoai
Cam dm 1 ciTc vao than dm than chinh roi noi vdi dm chau chung
DM than chinh noi vdi dm chau ngoai, nhanh dm ci/c noi dm thu'dng vj du'di am cue noi am tnupng vi quo
1 nhanh noi vdi PM chau ngoai 2 nhanh chap Iai kieu ndng sung roi noi vdi PM chau trong
. Tong so
Nhan xet: da so cac tru'dng hdp noi DM than ghep vdi DM chau ngoai
12,50 12,50 64,07 3,12
4,68
Bang 3.Yi:\a\, SS lu'dng TM
ITM 2TM
noi tTnh mach:
Kieu khau noi Cam TM than vdi Tl^l chau chunq Cam Tl^ than vdi Tl^ chau nqoai Cam 2 TM than vao 2 vj tri tren TM chau nqoai rienq biet
Tbnq so
SoBN 5 57 2 64
7,81 %
89,07 3,12
100 3.3. K£t qua khSu nSI mach mau
Bang 4. Phuc hoi chiJc nanq than qhep sau mfl i(ep mach mau Co nu'dc tieu
Nqay sau md kep mach mau a u md kep mach mau 30- 60 phut~
Cham (delayed graft function) 24 qlff
•rong so
So tru'dng hdp 53
Nlt§n xet: 53 TH (82,82%) CO nu'dc tieu ngay sau md kep mach mau Bing 5, Bien cjiutiq mach mau
TYle%
82,82
12,50 4,68Bign ch^ng sdm N=64 Bien chu'ng muon N=64 Chay mau cho khau noi dong mach j Huyet khoi TM Hep PM than tai cho noi
3(4,68%) I 0(0)% _ I 3(4,68%)
Nlt$nxit:Co 3 benh nhan sau khi md kep mach mau, thay ri mau tal mieng n6i OM, chijng toi khau
tSng cu'dng het ri mau.
Y HQC VigT NAM THANG S - s6 1Q014
IV. BAN LUAN
Qua 64 benh nhan du'dc ghep than tiT ngu'di cho song tai benh vien Nhan Dan 115, co 7/64 BN (10,93%) CO > 2 dpng mach^ 2/64 BN (3,12%) cd 2 tTnh mach than phai cam vao 2 vj t n khac nhau tren tTnh mach chau ngoai d ngudi nhan. So lu'dng mach mau nhieu hay it trong ghep than anh hu'dng rat Idn tdi ket qua phau thuat, Mach mau cang nhieu (ca dpng mach va Unh mach) lam cho thdi gian thieii mau non^, thdi gian thieu mau lanh keo dai do phai phau tich lau hdn khi lay than, thdi ^ i a n rira than va khau noi mach mau dai hdn dan den viec phuc hoi chirc nang than kem hdn. Ket qua chung^cua nghiSn ciiu nay chu'c nang than phuc hoi tot va kha la 61/64 TH [95,32%), ngay sau m d kep mach mau thay than hong, cang. 3 BN cdn Iai, thjin hong nhutig mem (4,7%), kiem tra mieng noi thong tot. Chung toi nghi den tanh trang co thcit mach khi md kep, su' dung papaverin t^i cho sau do than c3ng t r d Iai. Sieu am Doppler sau ghep 24 gid: 63/64 tru'dng hdp (98,4%) cd tWdi m^u than ghep tot. Khang iu'c RI trung binh:
0,59 ± 0,06 (0,47-0,74). Khong co s i / khac biet ve khang \\fc RI giij^ nhom chuyen vi va nhdm kliong ciiuyen vj mach mau. So vdi nghien CLTIJ cOa D.Th.N.Thu [2]^ chung toi nhan theiy khong cd St/ khac biet cd y nghTa thong ke ve thdi gian khi phai thi/c hien ky thuat chuyen vi tTnh mach.
Phu'dng phap khau hoi mach ciia chung tdi chii yeu la ghep noi dpng, Snh mach than vdi dpng, tTnh m a d i chau ngoai. Mpt so ky thuat bo xung phai tien hanh nhu* ndi dpng hoac tTnh madi phu cua than vdi mach chinh hoac mach chau khi than cd nhieu hdn 1 dpng hoac tTnh mach J6].
Co 3 truidng hdp c6 hien tu'dng chay mau cho khau deu la cho ndi dpng mach trong do 1 tru'dng h ^ thudc nhdm cam d m 1 cUc vao than dm th$n chi'nh sau dd noi vdi d m chau ngoai, 1 tru'dng hdp thupc nhdm ndi DM than ghep vdi DM cFiau ngoai va 1 tru'dng hdp thupc nhdm 2 nhanh DM chap Iai kieu ndng sung rdi ndi vdi DM ch$u trong, 2 tru'dng hdp dau do Ioi ky thuat cdn trudng hdp cudi ciing nguyen nhan la do dpng mach cua ngu'di nh$n bj x d vij'a. Sau khi khau tSng cu'dng thi ket qua tot.
Khdng cd trudng hdp nao ghi nhan thay tinh trang huyet khoi tTnh mach,
Ngoai ra, cd 3 BN hep ddng mach than ghep tai vi trf khau ndi vao ttidi gian muon, ca 3 TH deu xay ra tren benh nhan du'dc thiTc hien khau ndi ddng mach than ghep vdi dpng mach chau ngoai ( 1 b|nh nhan) va dpng mach c h | u chuiig (2 benli nhSn) kieu tan-ben. Xuat hien sau tfiang thu" 3 sau ghep phat hien vi creatinin/mau tang, sieu am Doppler ghi nhan hep. Cho lam can thiep DSA dat stent sau dd cho ket qua tot. Khdng cd
SI/ khac biSt ty le bien chiitig mach mau giffa 2 nhdm cd va khdng chuyen vi mach mau.
Mpt so bien chutig khac ghi nhan diTdc nhu*:
Bien chutig ve nieu khoa cd 1 benh nhan (1,56
% ) do xi dd d be than, khong cd bien chiitig tai vj t r i trong nieu quan vao bang quang. Co 1 benii nhan nhiem triing vet mo do sii" dung khang sinh d l / phdng (phac dd ciia Bi) nhutig that bai, chung tdi sir dung Iai khang sinh the he 3 (Rocephin) sau dd benh on djnh. Cac bien chti'ng tren khdng lien quan den viec khau noi mach mau [ 5 ] .
V. KET LUAN
Qua 64 benh nhan du'dc ghep than tir ngudI cho sdng tai tienh vien Nhan Dan l i S , cd 7/64 BN (10,93%) CO >2 ddng mach^ 2/64 BN (3,12%) cd 2 tTnh mach than phai cam vao 2 vj t r i khac nhau tren tTnh rnach chau ngoai d ngudi nhan. Da so cd nu'dc tieu ngay sau khi md kep m?ch mau. Chu'c nang than ve binh thu'dng khi ra vien. Cd 3 BN bj hep cho khau noi jnach mau sau 3 thang md ghep, du'dc dat Stent dn dinh, Ky thuat khau ndi mach mau trong ghep than tii nguidi cho sdng tai Benh vien Nhan Dan 115 la an toan, ty le bien chutig thap.
T A I LigU T H A M K H A O
1. T r l n Nggc Sinh & cs. "Ket qua phau th^^t dc tru'dng hdp ghep than tai benh vien Chd Ray", ky yeu cong trinh ghep diah benh vien Chp Ray 1992-2010. NXB y hoc Tp.HCM. 2010; p.81-95.
2. Du" Thj Ngoc T l i u . "Danh gia ky tiiuat diuyen \i mjidi mau trong ghep than tiT ngu'di dio sdng vao hoc chau phai" Luan an tien siy hgc 2012 3. A. Ciudin. A, M. Musquera, J . Huguet , L.
Peri, J.R. Alvarez-Vijander M J . Ribal and A.
Alcaraz. "Transposition of iliac vessels in implantation of right living donor kidneys"
Transplantation proceeding, 2012; 44,2945-2948 4. Ciudin. A , Musquera Felip. M, Peri Cusl. L,
Huguet Perez. 3, Alvarez-Vijande Garcia. J.R, Ribal Caparros. M.J, Alcaraz Asensio. A. "Iliac vein transposition in living donor right kidney transplant-cool trick or the solution?". 26* Annual congress of the European association of urology;
2011.
5. Eduardo Mazzucchi, Auro A. Souza, Willlan C. Nahas, l o a n n i s M. Antonopoulos, Affonso C. Piovesan, Samiarap. "Surgical complications after renal transplantation in grafts with multiple arteries" International Braz J Urol. 2005;
31(2);125-130
6. Haddiva Intissar, Skalli Zoubeir, Benamar Loubna, Fatima Ezzaitouni, Ouzeddoun Naima, Bavahia Rabia et Rhou Hakima. "Les complications diimrgicales de la transplantation renal a partir du donneur vivant : experience du CHU Ibn Sina de Rabat". Pan Afr Med J.2010 ;6 :20
