Y HOC VigT NAM THANG 11 - SO CHUYEN DE - 2D15
PHAU THUAT CAT PHAN THUY PHOI THEO GlAl P H A U KET QUA BU-aC DAU TAI BENH VIEN PHOI TRUNG U-CNG
Nguyen SI Khanh*, Dinh Van Tuan*, Nguyin Le Vinh*.
Pham Thi Thanh Dua*, Khieu Manh Cirffng*, Nguyin Thanh Long*.
Dinh Van Lupng*, Le Ngpc Thanh**
TOM TAT
Muc tieu: Nhan xet bu'dc dau ve tinh kha thi va gia trj ciia phau thuat cat phan thuy dien hinh trong dieu trj cac benh ly phoi. Phu'dng phdp: Nghien cihj hoi cuXi 23 benh nhan tir 5/2013 tdi 5/2015, phan tich cac thong so tru'dc mo, trong mo, sau mo va ket qua giai phau benh ly. Ket qua: 23 benh nhan vdi 08 nam va 15 niJ, dp tuoi trung binh 45,2 (28 - 78). Cac phan thuy dUdc phau thuat bao gom: day (7), Nelson (4), Oilmen (6), Lingula (3), dinh sau phai (1), dinh sau trai (1) va 5 trai (1). Thu'dng ton benh ly bao gom: 2 tru'dng hdp viem lao, 2 tru'dng hpp phoi biet lap trong thuy, 3 tru'dng hdp ung thu"
phoi nguyen phat va 16 tru'dng hdp cac nhiem trijng khac cua phoi. Thdi gian rut dan lull trung binh 3 ngay (2- 7), khong co bien chiing n§ng hay tai phat sau mo. Ket luan: Phau thuat cat phan thuy theo giai phau trong dieu trj cac benh ly cua phoi la phuUng phap an toan, kha thi va ket qua tot sau mo.
Td"khoa: Cst phan thuy phoi, benh ly phoi
SUMMARY
AN ANATOMICAL SEGMENTECTOMY APPROACH:
THE INITIAL RESULTS AT NATIONAL LUNG HOSPITAL Purpose: To assess the therapeutic feasibility of typical segmentectomy and
* B?nh vi4n Phdi Trung irang
* * B?nh vi?n E Trung uang Chju trach nhi?m chinh: Nguyen ST Khanh Email: [email protected] Ngay nh^n bai: I5/9/20I5 Ngay phan bi?n khoa hoc: 15/10/2015 Ngay duyet bai: 22/10/2015
efFlciency to lung pathology. Materials and methods: Retrospective study of 23 consecutive patients who are operared between May 2013 to May 2015 was reviewed: pre- operation, operation, post-operation and pathological characteristics of patients analysed.
Results: 23 patients underwent anatomical segmentectomy with 8 males and 15 females, the mean age was 45,2 (28 - 78).The following segmentectomies were performed: basilar (7), Nelson (4), Culmen (6), Lingula (3), right apicoposterlor (1), left apicoposterior (1) and left 55 (1). Pathology: Tuberculosis in 2 cases, intralobar sequestration in 2 cases, lung cancer in 3 cases and non- TB inflamation in 16 cases.
The average time of chest tube was 3 days (2- 7), there were no major postoperative complications or recurrences to date.
Conclusions: an anatomical segmentectomy approach to lung pathology is a safe and technically feasible procedure.
Keywords: segmentectomy; pulmonary diseases
I.DATVANDE
Phan thiiy la mpt dcm vi giai phau ciia phoi, moi phan thuy co mpt cuong phe quan- dpng mach. mang luai tinh mach quanh phan thiiy phan bo trong cac vach lien phan thuy.
lien ha phan thiiy va lop dudi mang phoi lang a tnmg that va cac khe. Do cd cac vach mo lien ket do ma ta co the mo cat rdi phan thuy phoi. Nhu vay. phan thuy phoi khong nhiing la mot dcm vj giai phlu ma con la mpt don vi benh ly va phau thuat [1].
Cat phan thuy phdi theo giai phau (sau day gpi tat la cat phan thuy phoi) bao gdm cat mpt hay nhieu phan thuy vdi su bpc 16 va
CHAO MLTNG HQI NGHj KHOA HQC THUONG NIEN HQI HO HAP VIET NAM
kiSm soat rieng re timg thanh phan cua cuong phdi: dpng mach, ttnh mach va phe quan. Cat phan thuy phdi quy udc bao gdm:
phkn dinh cua thuy tren phdi trai (Culmen- cach goi ten rieng cua Jackson Ruber se dugc dung sau day), phan ludi ciia thuy tren phdi trai (Lingula), phan dinh ciia thuy dudi (Nelson) va cac phan thuy day (Basilar). Cac phan thuy dcm Ie (tu 1- 10 theo each danh s6 ciia Boyden) cd thi thyc hien duac song tinh ung dung khong cao vi phijrc tap trong xac dinh vj tri cung nhu ky thuat md [1]. [8].
U'u diem cua loai hinh phau thuat nay bao gdm: bao tdn tdi da nhu md phdi lanh giiip cai thien chiic nkng hd h^p sau mo, nit ngan thdi gian hdi phuc, giam ty le bidn chiing ya di chiing, tang kha nang chiu dung vdi diiu tri bd trp trong ung thu va kha nSng chiu dung phau thuat phdi sau nay neu cd [8]. Chiing tdi thuc hien ky thuat cat phan thuy phdi theo giai phau tu nSm 2013; tong kit va danh gia tinh kha thi, ket qua budc dau cua phau thuat la muc tieu cua bai viet nay.
II. 06\ TUQMG VA PHirONG PHAP NGHIIN CCTU 2.LDdi tu'png v^ p h u o n g p h a p -Nghien ciiu hdi ciiu 23 trudng hpp dupe phau thu^t cit phan thuy phdi t^i benh vien Phdi trung uong tir 5/2013- 5/2015.
- Cac thdng sd trudc, trong va sau md dupe thu thap theo mpt mau benh an thdng nhat - Xu ly sd Ii?u bang phan mem toan thdng ke SPSS 16.0
2.2. Quy trinh ky thuat
- B?nh nhkn dagc gay me bang dng ndi khi quan 2 ndng. cd lap phdi ben phau thuat - B?nh nhan nim nghieng 90° vk phia ddi di^n
- Dudng md nguc nhd dudi nach trong tam' giac an toan, khong cat ca
- P h a u tich bdc Id, that va cit timg thanh phan ciia cudng phdi theo treit ty: dong mach, tinh mach va phe quan. Khau mdm phe quan bing chi Pds 3/0- 4/0 2 idp
- T a c h dien gian phan thu^* theo phuang phap CO hpc phdi hpp vdi dao dien dan cue, khau tang cudng nhiing cho ro khi bing chi Pds 4/0, khau vit 2 ldp.
- T r o n g trudmg hop K phe quan phdi ho§c nghi ngd, sau khi c i t phan thuy phdi chiing tdi md mang phdi trung thit kiem tra, niu c6 hach trung that va/ hoac hach gian phan thuy (nhdm 13) thi se bdc hach giii di lam ti bao nhanh va giai phau benh ly.
- Ket thiic phau thuat, chiing tdi d§t I sonde dan luu mang phdi co 32F (mpt sd trudng hap cd nguy ca chay mau sau md dugc dat 2 dan luu) va ddng nguc
- S o n d e dan luu dugc rut thudng quy vdi tieu chuan: khdng rd khi va lugng dich
<l50ml/24h, Xquang phdi nd.
III.K^TQUA
Bang 1 cho thay nghien ciiu thyc hi^n tren 23 trudng hgp gdm 8 nam va 15 nit, tu6i trung binh 45,2 (28- 78). Chin doan trudc md: 18 trudng hop lanh tinh- hiu hit diu co chan doan xac djnh sau md tuang dong ngo^i trir mpt trudng hgp thay ddi chan do^n tir ken phe quan bgi nhiem sang K phe quan phdi loai bieu md te bao vay; 4 trudng hgp ndt dan dpc phdi khdng rd ban chat gdm 2 trudng hgp u lao. 1 trudng hpp viem m ^ tinh va 1 trudng hgp ung thu phdi nguySn phat; chin doan trudc md cd mdt trudng hgp K phi quan phdi nguyen phat giai dogn IA.
Bang 1. Dac diem lam sang va can lam sang
DSc diem n = 23
Tudi (trung binh) Nam/NG
28- 78 (45,2) 8/15
Y HQC VIET NAM THANG 11 - S 6 CHUYEN BE - 2015
Chan doan lam sang Lanh tinh trudc md
Lanh tinh sau md K phe quan phdi sau md Ndt dan dpc khdng ro ban chat
Lanh tinh sau md K phe quan phdi sau md K phe quan phdi
duac trinh bdy trong Bane 2 v&i cdc loa
18 17 1 4 3 1 1
hinh cdt phdn thuv phdi au
nhu eat I hogc 2 phdn thuy rieng le tuy theo ddc linh thuang tdn. Dde biet eo hai trudng hgp gidn phe qudn ed hai thuy tren vd duoi ben frdi da dugc cat chgn lgc: J trudng hgp cdt phdn thuy ludi vdi thuy dudi. I trudng hgp cat phdn thuy ddy vdi phdn thuy ludi khong dien hinh.
Bang 2. Phan thuy phdi dugc cat bd Phai
Dinh sau: 1 Nelson: 2 Day: 4
Trai Dinh sau: I Culmen: 6 Lingula: 2
Lingula + thuy dudi: 1 Phan thuy 5: I Nelson: 2 Day: 2
Day + lingula khdng dien hinh: 1
Vi kit qud phdu thudt sam: thai gian mo trung binh cua ehiing toi Id 177 phiit (90- 300), thdi gian ddn lim trung binh 3 ngdy (2- 7). Bien chieng trong vd sau md bao gdm: ehay mdu trong mi yeu cdu phdi truyin mdu, rd khi keo ddi. nhiem triing vet md. eon ho ra ddy mdu keo ddi sau mo (benh nhdn ho ra mdu so lugng nhieu tnrde md). dong dde phdi: mdi logi ed mgt h$nh nhdn (Bdng 3).
Bdng 3. Ket qua phau thuat Bien so Thoi gian m6 (phut)
Bien do Trung binh
Thoi gian dan lu^ trung binh (ngay) Bien do
Trung binh Biin chijmg
Chay mau trong m5 (phai truyen mau) Ro Ichi Iceo dai
Nhiem trimg vjt m6 Ho ra mau Dong dac phoi
N=23
90-300
177
2-7
CHAO MiTNG HQl NGHj KHOA HOC THUdNG NIEN Hdi HO H ^ * VlfT NAM
IV. BAN LUAN
Phlu thuat cat phan thuy phdi theo giai phSu ian diu tien dupe Churchill va Belsey md ta vao nam 1939 trong dieu tri gian phe quan d 86 trudng hgp. Mac dii cd nhieu uu diim song do tinh chit phirc tap ciia ky thuat nen chi dupe thuc hien d nhirng trung tam phlu thuat ldn, ngudi ta udc tinh rang cat phan thuy chl chiim 4,4% trong tdng sd phlu thuat phdi [8]. Theo sd lugng mat phing gian phan thuy, cit phan thuy phdi dugc chia lam hai lo^i: (a) dan gian niu chi cd mot mat phing va (b) phiic tap niu cd tir hai mat phing trd len [4]. Kit hgp vdi giai phdu mach mau. miic dp khd ciia phau thugt giam dan nhu sau: cit phan thuy 2 phdi phai, culmen. basilar, lingula va Nelson [7].
Trong khi giai phau mach mau cua phan thuy 2 phdi phai va phan thuy culmen hay cd nhftng bien the va khd ludng thi dieu nay lai de nhgn biet han va kiem soat tdt han d nhiing phan thuy thupc thuy ludi va thuy dudi (Nelson va Basilar). Mpt sd tac gia da sir dyng chup cit ldp vi ti'nh (CLVT) da day dung hinh mach mau ddi vdi nhung thuang tdn thuy tren de danh gia sd lugng, kich cd, hudng di cua nhung mach mau nay giup viec phiu tich an toan ban va dieu nay dac biet diing trong phau thugt ndi soi. Theo Fukuhara va cdng sy, CLVT da dSy giiip nhgn dien dugc cac nhanh ciia ddng mach phdi trong 95% cac trudng hgp [3]. Trong nghien ciiu ciia chiing tdi. tit ca cac trudng hpp diu dugc phau thugt md ngyc khiin viec nhgn dinh va phau tich tuang doi thuan lpi;
do vay vi?c dyng hinh mgch mau chua dupe thuc hien mdt each thudng quy.
Mdt khd khan khac phai ddi mat ia nhan dien va phan chia mat phing gian phan thuy, chiing tdi thyc hi^n theo each kinh diin: cd lap phi quan phan thuy can cit bd va cho nd phdi, luc nay se Id ra ranh gidi giiia phdi xep (phan cat bd) va phdi nd (phin d i lgi). Tuy nhien trong mot sd trudng hgp cd thdng khi
bang he thi phan phdi cit bd van cd thdng' khi, luc nay chiing tdi nhgn dien ranh gidi bing tinh mach gian phan thuy. D i khic phuc tinh trang thdng khi bang he anh hudng den viec nhan dinh ranh gidi gian phan thuy, nam 2007 Okada da de xuit quy trinh thdng khi ngugc Igi: cho nd phan phdi cit bd va lam xep phan phdi de Iai, do ddng mgch v^
ttnh mach cua phan phdi b^nh da dugc cit nen phdi khdng t h i xep lgi trong khi phin phdi de lai xep mpt each de dang. Ngoai ra cdn cd the diing chit chi thj mau vdi sy ho trp nhan dien qua ndi soi phe quan hdng ngogi [2], [6]. Tiip theo, chiing tdi phan chia mat phang gian thuy theo each dupe khuyen cao hien nay: bdc tach ca hpc ket hpp vdi dao dien, sau dd kiem tra va khau tang cudng nhiing vi tri cd rd khi. Mac dii cd thi diing may cat hoac kpp nhu md cit va sau dd khau tay nhung day deu la nhiing each it nhiiu gay ra sy bd phdi lam ban che sy gian nd cua phdi [6].
Thach thiic tiep theo la vin d i vi chi djnh. trong khi nhung benh ly lanh tinh, ndt don ddc phdi va nhan di can da dupe chip nhan rgng rSi thi ung thu phdi nguyen phat vin dang gay nhiiu tranh cai. Ap dung ban dau doi vdi ung thu phdi nguyen phat cho nhihig benh nhSn cd nguy ca cao: gia, yeu, chtie nang tim phdi ban che va cd nhiJng benh ddng m i c ; tuy nhien theo doi xa sau md tren nhieu nghien ciiu cho thay ty le sdng cdn va tai phat la ngang bang so vdi phau thuat cat thuy phdi d nhung benh nhan cd kich thude khdi u nhd. Han niia vdi sy phat trien ciia chuyen nghanh chan doan hinh anh ciing vdi ehuang trinh sang lgc ung thu phoi tdt, ngay cang nhiiu tdn thuong ung thir dugc phat hien sdm. Ben cgch dd, xu the ngay nay la diiu tri it xam lin: tir md nguc rgng rai din md nguc nhd khdng cat ca va ngay nay la phau thugt ndi soi, tir diiu tri chuin trong ung thu phdi la cit ca la phoi trudc nhung nam 50 ctia thi ky trudc din cit
Y HQC VIET NAM THANG 11 . SO CHUYEN DJ • 2015
thuy phdi sau nhiing nam 95 va bay gid ngudi ta dang quan tam din phau thuat cit phan thuy phdi theo giai phiu. Chi dinh dugc nhieu tac gia ung hd khi khdi u thoa man dupe cac tieu chi: (a) d giai doan IA (ly tudng la Tia); (b) each mat phing gian phan thuy tdi thieu bang kich thude u va (c) d ngoai vi cua phdi (1/3 ngoai) [2].Nhu chiing ta da biet, cd sy thay ddi dang ki vk kich thude phan thuy phdi, nhd nhit la phan thuy cgnh tim phdi phai va ldn nhit la phan thuy dinh sau trai. Nhu vay, chi djnh cit phan thuy phdi phu thugc vao kich thude phan thuy, vi tri va kich thude khoi u. Ca hdi cho nhiing khdi u cd kich thude 1, 2. 3cm lin lugt la: 33, 24 va 18%, cit hai phan thuy cd ca hpi cao han; 49% voi nhiJng khdi u cd kich cd < 2cm [5]. Nghien ciiu ciia chiing tdi cd 3 tnrdng hgp ung thu phdi nguyen phat; 1 tnrdng hgp cd tdn thucmg dang ken vdi vd mdng, nhSn, cd miic dich khi chiia dich mu ben trong dupe chan doan trudc md la ken phe quan bdi nhiem, sau md giai phau benh tra ldi la K phe quan iogi bieu md vay giai doan IIA, trudng hgp nay chiing tdi nghl den kha nang mdt benh ly nhiem triing man tinh dan den thoai hoa ac tinh, hien tugng nay da dugc nhic den trong y van- sau md benh nhan dugc dieu tri hoa chat bd trg: trudng hgp tiep theo la mgt ndt dcm dpc phdi. xet nghidm te bao nhanh trong md tra ldi la tdn thuang viem song md benh hpc xac dinh K phe quan loai ti bao to; trudng hop cudi cung cd chan doan trudc md la K phe quan logi biiu md tuyin. Hai trudng hpp sau nay d giai doan IA (Tla/b, NOMO). Nhu da ndi d tren viec cit nhiiu hon mdt phan thuy dam bao ban nhQng nguyen tic trong phau thuat ung thu, d 3 benh nhan nay lin lugt chung tdi cit cac phan thuy day phai, dinh sau trai va Lingula. Thdi gian theo ddi cua 3 benh nhan din nay lin lugt la 3, 19 va 22 thang, hipn tai chua ghi nhgn hien tugng tai phat tai cho hay di can.
Thyc te cho thay nhiing uu diim cua phau thuat cat phan thuy trong dieu tri cac benh ly cua phdi ke ca ung thu phdi nguyen phat. Mac dii kinh nghiem trong loai hinh phiu thuat nay cua chiing tdi la chua nhiiu song vdi ket qua budc diu thu dupe, chung tdi tin rang ky thugt nay la kha thi va an toan.
TAI u f u THAM KHAO
L Nguyen Dinh Kim (1994), "Giai phlu phdi", Benh lige lao vd benh phdi, Nha xuat ban Y hpc. Ha Npi; 1: 12-33.
2. Chi- Fu Jeffrey Yang, and Thomas A.
D'Amico (2012). "Review: Thoracoscopic Segmentectomy for Lung Cancer". Ann Thorac Surg, 94: 66S-i\
3. Fukuhara K, Akashi A, Nakane S et al (2008). "Preoperative assessment of the pulmonary artery by three- dimensional computed tomography before video- assisted thoracic surgery lobectomy", Eur I Cardiothorac Surg: 34: 875- 7.
4. Hisashi Iwata, Koyo Shirahasbi, Yoshimasa iVlizuno et al (2013), "Surgical technique of lung segmental resection with two intersegmental plane". Interact CardioVasc ThoracSurg: 16: 423- 5.
5. Kazubiro Ueda, Toshiki Tanaka, Masataro Hayashi et al (2012). "What proportion of lung cancers can be operated by segmentectomy ? A computed- tomography- based simulation". Eur I Cardiothorac Surg: 41: 341 - 5.
6. Okada M, Mimura T, Ikcgaki J et al (2007), "A novel VATS anatomic segmentectomy technique". / Thorac Cardiovaxc Surg. 133: 753- 8.
7. Scott J. Swanson (2010), "Video- Assisted Thoracic Surgery Segmentectomy: The Future of Surgery for Lung Cancer", Ann Thorac Surg: 89: S2096- 7.
8. Thomas A. D'Amico (2008),
"Thoracoscopic Segmentectomy: Technical Considerations and Outcomes", Ann Thorac
Surg.i5:Sl\6-i.
CHAO MiTNG HQI NGHj KHOA HOC THUONG HIEN HOI HO HAP VIET NAM
BIEN D O I NONG D O CORTISOL H U Y E T T H A N H TRONG VIEM P H O I TRE EM TIC 2 T H A N G D E N 5 TUOI
T O M TAT
Muc tieu va phu'dng phap; Nghien ciTu mo ta cat ngang tren 8 1 tre viem phoi tu' 2 thang den 5 tuoi tai i<hoa Nhi, Benh vien Trung trdng Hue tir 3/2012 den 5/2013 nham l<hao sat nong dp Cortisol huyet thanh va xac dinh moi lien quan giu^ nong dp Cortisol huyet thanh vdi mpt so bleu hien lam sang, can lam sang va gia trj tien doan mu'c dp nang viem phoi ciia Cortisol huyet thanh S tre tir 2 thang den 5 tuoi. Kgt qua; 51,9% tre viem phoi nhap vien co nong dp Cortisol huyet thanh trong khpang 171-536 nmol/L Nong dp Cortisol huyet thanh tang dan CO y nghTa theo mirc dp nSng ciia viem phoi.
Nong dp Cprtlspl huyet thanh co tu'ong quan thuan mu'c dp y l u vdi tan so thd, so ItfOng bach cau mau ngoai vi va ty le % bach cau Neutrophile mau ngoai vi. Ty le tre co dau hieu rut lom long ngiTc va phap phong canh mOi, hinh anh tham nhiem phe nang tren X-quang ngiTc gia tang co y nghia theo nong dp Cortispl huyet thanh. Nong dp Cprtlsol huyet thanh co dien ti'ch du'dl duSng cong AUC cao nhat (0,79; iihoang tin cay 95%: 0,685-0,872), vdi diem cat > 449 nmol/L CO dp nhay va dp dac hieu toi mi (69,44% va 82,22%) trong tien doan mu'c do nSng cua viem phoi. Ket luan; Nong dp Cortispl huyet thanh gia tang co y nghia theo mirc dp nSng viem phoi, va tang cap d nhung tre co rut 16m long^ngirc, phap phong canh mui, hinh anh tham nhiem phe nang tren X- quang ngi/c. NSng
* Bfnh vifn Trung uang Hue
• • Bfnh vifn Ba khau Trung uang Qudng Nam Chiu trach nhi?ra chinh: Biii Binh Bao Son Email: [email protected] Ngay nhjn bai: 18/9/2015 Ngay phan bifn khoa hoc: 12/10/2015 Ngay duyft bai: 19/10/2015
Bui Binh Bao Son*, Nguyen Thi Dieu Linh**
dp Cortisol huyet thanh c6 gia tri Idia tot trong trong tien doan mu'c dp nang cua viem phoi va cao hdn nhiiTig xet nghiem l<hac.
TO" khda: Cortisol huyet thanh, viem phoi, tre tir 2 thang den 5 tuoi.
SUIVIMARY
SERUIM CORTISOL LEVELS IN CHILDREN AGED 2 MONTHS TO
5 YEARS WITH PNEUMONIA Objective and methods: A descriptive cross-sectional study in 8 1 children aged 2 months-5 years with pneumonia at the Pediatric Department, Hue Central Hospital from March 2012 to May 2013 was conducted to evaluate the serum Cortisol levels; to determine the correlation between serum Cortisol levels and some clinical features, tests; and to identify the predictive values of serum cprtlsol levels In assessing the severity of pneumonia. Result:
51.9% children with pneumonia had serum Cortisol levels In the range of 170-536 nmol/L.
Serum Cortisol levels increased in ccrrelation with the severities of pneumpnia. Serum ccrtisol levels correlated positively weal!ly with respiratory rates, WBC and peripheral neutrophil percentage. High cortispl levels were seen in children with chest indrawing, nasal flaring and alveolar Infiltrates on chest X-ray. Serum Cortisol levels had the highest AUC (0.79; 95% a , 0.685-0.872); and cut-off > 449 nmpl/L had pptimal sensitivity and specificity in predicting the severity of pneumonia (69.44% and 82.22%, respectively). Conclusion: Serum Cortisol levels increased in correlation with the severities of pneumpnia and high cortispl levels were seen in children with chest indrawing, nasal flaring and alveplar infiltrates on chest X-ray. Serum Cortisol
