Y HOC Vl&r NAM TAP 449 - THAHG 12 - SO 2 - 2016
NGHIEN Ctru (TNG DUNG D!EU TRI LOET VUNG CUNG CUT MU'C BO NANG BANG VAT DA CAN CO CUONG MACH Nubl
LA NHANH XUYEN CtJA DONG MACH MONG TREN
Nguyin Van Thanh*, Tr4n Van Anh**, Nguyen VSn Huf **
T 6 M T A T reconstruciion. Patients and Method: Thirty seven D|t van de: Wilu ttiuat tao hinh dieu trj ioet Pa^wts with m , IV degree of saaal sore were vung cung cyt do ty de luon gSp nhfeu 1*6 khan. Sy covered vnth 38 superior gluteal artery perforator flap, bien chuyen tif vat can cd mong ldn dgn vat da can including 09 V-Y flaps and 29 propeller flaps (27 vdi cuong nudi la nhinh xuyen cua dong m^di mong unilateral and 02 bilateral). The research was in trfin cho dien tich che phu rpng gtup nang cao hifiu Plastique-ajsm^c surgery-.- department. National qui trong dieu bi loet vung ciing cut €>o3 tu'dng va ^n^Sute af Bum and in Rastique-cosmetic surgery phu'tAig phap nghign cihi: Gom 37 benh nhan loet department of People 115 HospHsl, Ho Chi Minh city vung cCing cut dp m , IV (K du'dc phlu ltiu§t che phu ^^"^ 10/2012 to 09/2016. All patients were used bSng 38 v?t nhanh xuyen cila dpng madi riiong tren, "itrasound to indicate the quatity of pafbraBng trong do: 09 vat kieu V-Y, 29 vat caiih quat (co 01 branches of superior arteries, reconstructed sacral tru'dng hop dung 02 vat canh quat hai ben mong che
phu cho mpt 5 loet vung cCing cyt). Nghien culi du'dc Ben hanh tai khoa Riau thuat tao hinh - tham my Vl|n Bong Quoc Gia Lfi Hffu t r i e ; Ddn vi Phlu thu|t H Q B - tham my, B|nh vien Nhan dan 115, Thanh
pressure sores by the pedide superior gluteal artery perforator flaps, followed and evaluated the results during 38 montiis. Results: TTiirty eight flaps survive completely, two flaps secondary wound healing, no flap necrosis dunng post-operative follow-up period
^ ^ ^ ^ C h i Minh tit thang 10/2012 de'n thang ^^^ months). Conclusion: Superior gluteal artery
^ ^ ^ ^ • c i c bfinh nhan du'pc sieu am xac i^Hnh s6 °^'f°'^*™ f^fw; K afe rffa^+h«. ^^.A i^e* „ i , - i „ ._.
nhinh xuyfin aia d6ng mach mong trfin, t?o vat da cSn c6 cuSng madi nuoi, phau thu|t che phu o lo^t va theo dffl danh gia kfit qua phau thuat trong vdng 38 thing. Ket quS nghten cCfu: 38 v^t song hoan toin, 02 vgt lien vSt thu'dng thi hai, khong co vat nao hoai tu" trong thcfi gian theo doi tii sau mo dSri 38 tiling.
Kfit lu$n: Vat da c3n vi3i cuong mach nuoi la nhanh
xuyfin dpng mgch mong ti^n la giii phip an toan, . . ^ - • • -••
hi^u qua v i lu^ chpn t a cho diSu tri che phii o loet '^^ ° ^ ' - " ' ' ° " thu'dng loet do ty de trong 66 co cdng cyt mCfc dp n^ng do t^ dd. loet vimg cimg cut chiem ty |g cao nhat trong perforator flaps is safe, effective and best choice for severe degree of sacral pressure sore.
Key wort/s: Supenor gluteal artery peri'orator flap, sacral sore treatment.
I . D i ^ T V X l V O l
Loet man tmh la benh ly thu'dng gSp, d$c biet la v6i nhihig benh nhan phai nam dieu tri
Tit khda: Vat da can c6 cuong madi nuoi nhanh xuyfin dpng madi mdng tren, dfeu bi bft vung cung cut SUMMARY
STUDY THE APLICATION OF THE PEDICLE SUPERIOR GLUTEAL ARTERY PERFORATOR
FLAPS FOR SEVERE DEGREE OF SACRAL PRESSURE SORE RECONSTRUCnON Objective: Sacral sore reconsbuction is always a
cac loai ton thu'dng khac nhau cua loet man tfnh.
Neu khong dieu tn, loet co the g i y ra c^c bien chufng nghiem trpng, ke ca tu' vong. Loet vung cung cut dp m , IV gay ^ n thu'dng den c i n , xudng cung cut vi vay ton thu'dng ran dUdc che phu khi 6 khuyet hong da d\ic}c cat loc sach k i t h 0 vcfi hut ap lire am tao nen vat sach, mo hat tot, het cac ngoc ngach va giam dich tiet tSi da w M j « . u « c . j o u a i suic reujnsmJCIIon i s a i w a y s a N a m IQQ^ I f r a h i m a T PS« 5 - « " ' ^ «• ! " • u a . Challenge. There has been a diange from die ^ ^ l ' '^°!^'^? ^' !?" ^ " ^ s " ^ siJ dung musculocutaneous flap to the fasdocutaneous flap ™- " " ? " " ''"V^" ^^ ^png niadi mong tren de with tiie pedide supwior gluteal artery perforator ^'^u tri cho 08 benh nhan loet vimg cung cut cho fesdocutaneous flap adapted for sacral pressure sore ket qua kha quan [4]. Vdi u'u the vat c6 cuong mach nuoi on djnh, cuong vat dal, kfch thu'dc vat ldn, Qoc xoav ror "
*^h Mi^ NhSn din US, TP. Ho Chi Minh
" Bp mdn Bong, Hgc \ri4n Quin Y Chiu bich n h i ^ chinh: Nguyen VSn Thanh Email: drtiianhibcs@igmaiLcom Ngiy nh|n bai: 1/11/2016 Ngiy phin bifin khoa hpc: 30/11/2016 Ngiy duyft bai: 9/12/2016
ldn, goc xoay rpng nen vat nhanh xuyen cCia dgng rnach mong tren du'dc li/a chon cho dieu tri loet mu'c dp nang vung cung cut [3].
a Viet Nam, so lu'dng bilnh nhan bi lo^t vung cung cut xuat hien nh^u d khap cac ai sd y te tir tmng u'dng den dja phu'dng nen r i t can phac do dieu tri thi'ch hdp. Hi§n tai, mot sfi tac
VIETNAM MEDICAL JOURNAL H°2 - DECEMBER - 2016 gia trong nudc da cfiiMapl-not vai trudng hdp
rieng le ve k&. qua dieuM|oet vung cung cut vdi so Iutfng benh nhan n ^ S W i U ft^ co rat ft cac nghien cu\i vg ung dung dieu tri loet viing ciing cyt mirc dp nang b3ng vat da can cd cuong n ^ c ^ n j o i ^ ^ l ^ ^ g i u ^ ^ u a dpng mach mong
^ ^ ^ H i ^ ^ m ^ l ^ ^ ^ ^ l a tien hanh d i u utig dyng dieu t i loet vitng cimg cyt mtit dp nSng t)lng vat da can cd cuong mach nuoi la nlianh xuyen ciia dpng mach mong tren.
ILDdHX/QNGVAPHUUNGPHAPNGHllNCOlJ 2.1. Dfii t u ^ n g nghien c t h i
GSm 37 benh nhan loet vung cung cut dp m , IV di/dc diiu trj tei khoa Phau thuat teo hinh - tham my, Vi^n Bong Quoc Gia tir thing iO/2010 den thang 10/2013 va t^i ddn vj phSu thuit tao hinh - tham my, Benh viin Nhan d i n 115, Tiianh pho Ho Chf Minh tir thing 03/2014 den thang 03/2016.
- Tiiu chuSn chpn b^nh nhin:
+ B?nh nhan loet viing cung cut dp m , IV do ty tf6 ho$c xa trj.
+ DS diSu trj t(Sn vet thudng bing n$i khoa kh6ng cd k& q u i .
+ D5ng y tham gla nghien ciTu.
- Tliu d i u l n to9\ trtf benh nhin:
Bing 1. Loai vat va sUphdJ h0} cac vat
+ B§nh nhan mac cac baih ly n0i Wxa nSng, cd bien chutig nhi/: ti^u dudng, viem t k mach mau...
+ Ton thudng khuyet hfing m6 mem qua rpng gan h ^ vCing mong.
2.2. Phu'dng phdp nghiSn a h i - Xac djnh so l u ^ g c i c nhanh xuyen oja dong mach mong t r i n : Xac djnh so Iutfng nhinh xuySn trong du'dng trdn dudiig kinh 6cm cd iSm la d i ^ 1/3 tren ngoai du&ng noi tir gai ch$u trutic tren d^n mom cimg cut, bSng sleu am Doppter mach mau tan so 8MHz.
- Lam sadi vimg ton thudng: C i t Ipc 6 lo4t, lay bd xuUng ch€t, hut lien tuc ap Igt i m d ^ ^ nen 6 loet s?ch, het ngdc ngach, giam djch ttSt, h i t phil ne, md hat do d i u .
- TTifet ke vat: Thiit ke vat da theo kich thui5c mSi canh dai hdn D,5cni so vcfi kfch thuidc cua o Ioit. Thiit k i cuong vat theo vf trf cua nhinh xuyin ddng m^ich mdng tren trong dudng trdn 6k xie djnh, xie djnh gdc xoay n i u la v^t canh qu?t hay khoing each ciia vj tri nhinh xuyen den bd g i n 6 loet t r i n 4-5 cm dfii vdi v?t V-Y.
III.K^QUANGHIENCI>U 3 . 1 . Lo^l v 9 t vd SM' phfii h ^ cSc v ^ t
Loai V3t Tfing
Cich sii dgng ( n ) V-Y C i n h q u 9 t ~ 02 vgt cung luc
02 vat khic thdi diem "
Tong ' . . . ^ . ' ^ . 1 _ 3 8 Nh$n xdt: Hau het cac tn/dng hffg chi phai sff dyng m^t v^t d^ che phit o khuyit hdng; cd mpt trudng htfp sir dyng cung ttidl diem 2 v?t cinh qu?t ddi di?n de che phCi cho ciing 1 6 Ioit \mng (iing cpt CO di§n tich r^ng.
3.2. SG \\ii}nq n h i n h x u y i n t r i n mfil v ^ t Bing 2. Sdlu^g nhdnh xuyen tren mSi vat
-" ihin" ^ " " ^ Sfi nhanh x u y i n Trung blnlT"
2,9 ± 0.8
p = 0,104>0,05 Sau phau thuat \ 2,6 ± 0.7 ,
N h f n x i t : So Iutfng nhanh xuyin trung binh frudc phiu thuSt l i 2,9 nhinh/v?t, cao hdn phSu thu$t (2,6 nhanh/vat) khdng cd y nghia thong k i (p > 0,05),
3.3. Kfch thu«c V9t Bing 3. l&ch Qjuik vat
ygu t g Dijn tich vat (cm») oiieu d i l vat (an)
•<-i.g.. Jtl-.-,>i'v-Oiieu rong vgt fcnil
Trung b l n h ~
111,6
±27,0 (60
-180)
13.6
±2.2 flO
-IB)
dil l^^!!^'^^ fe^^^/?r,i"^'^-'^' t^J ^^ '^ ^^°*^^^ il"ta°ttilgu \k 60 cm'). Oilk
3.4. TJien gian diSu trj trung binh Bang 4. Thdi gian dieu tn trtjnq binh
r n o t ^ V T t p T H A M T A P 4 4 9 - T H A N G 1 2 - S Q 2 - 2 0 1 6
Loai vat Vat V-Y vat canh qiiaT
Thai qian dieu tri trung binh fnuavT"
25,8 ± 10.5 flO - 10)
3.5. Cac blen chihig trong p h l u thuat _Bang 5. Cac bien chirnn tmnn nhSu i-hnSh Bang 5. Cac bieri chu'ng tronc
Triiu chij^ng ad ludng (n)~
Tyli 7%)
Chay mau
5,3
phau thuat Xoan
vat 2,6
Chen ep
cuong vat Khong
bien diufhq Tong so vat
38
3.6. Ddnh gia Icet ^ua sdm sau p h l u thuat ^ Bang 6. Banh gia sdm tinh trang vat sau phlu thuat
Loai vat Ket qua ^ L
V-Y<n=91 c a n h Q u a t ( n = 2 9 )
26
SS lu'dng ( % )
34 (89,51
4 fl0.51
3.7. DSnh c|ia \A qua xa sau p h l u t h u i t
Bang?. Danh a^lt& aui xa s!,n phlu thuat U thAnn vi ; « ( / ) ^ „ sau 13 Hiann 1 ^ Ket qua
~Tor
Truni^
sa Itfong BN sau 12 thaiin'
j t a 15/17 1/17 -JZJZ
sil itfOnq BN sau 38 t h i i i g T Y l S f / o l
9/9
I " " ^ . ' l y 17/17 o ^^^
IV. B A N LUiJN
V l ^ che phu 0 Ioit man ti'nh bSng vat da co mong Wn da duBc thtfc hiSn trang hOn lial thap nj§n qua vdl uu diem vat c6 do day tao m6 dem tot, kha nSng tuS mau cho vat phong phu nhd nguon m?ch nu6l od mong ldn, theo d6i thdi glan sau mo cho thSy ti l | Ioit t i l ph« thap [51 Tuy nhien, mgt so nhuac diSm cua vat da cd mong Idn cung du'dc nhSu He gla n6u i6n nhu- blen d?ng vung m6ng do ndl nhjn vat go cao va ndl cho v?t bj khuyS ldm, Snh huUiig den chii'c nang dl l?l va dang di ciJa bSnh nhan do phai su' dgng mdt phan co mong ldn, goc xoay vat han chg, de bgc sau mo do vl tn vat IS ndl chiu i p iijc. ldn [1], [4]. Nghien cull cua chung tdi khong su' dgng v?t da od ma s * dung vat da can da khac phuc du^c tat ca cac nhuBc diem tren
trong d6: siJ dgng 29 vat canh quat vS 9 vat V-Y V?t V- Y CO UU diem d i bdc tach va phlu tfch nhanh xuyen cung nhtf dong ndi cho vat Tuv nhien, v^t V - Y doi hdi nhanh xuyen nudi vat phai each xa bd ton khuyet it nhat la 4 - 5cm d l 00 du do dai cuong vat khi chuyen don day vat ve phia ton thi/dng khuyet hong va trong m0t &
truBng h?p khong du dien tich che phii can phai ket hd^ dang vat Pacman ndi dau vat. Vg mSt glal phau hoc, nhanh xuydn ddng mach mdng tan cap mau cho vat da du'qte Koshima (1993);
Tran Van Anh (2011) nghidn cuu cd 2 - 3 nhSnh xwen cho, tnong nghien ciiu cua chiing tdl sau phau ttiuat CO frung binh 2,6 nhanh/vat. Trong S t r h „ ^ " ^ Wp chi.dua tren 1 nhanh xuydn cung cho k a qua nuoi song v?t rat tot [7]. VS hinh I^ 1 5 1 S " S " ? ? * I W ^ ™' V-Y tuy ttiuoc vao kich ttiuHcg toetva h/thSbdnh nhin [2]
. JOURNAL N ' 2 - r ^CEMBER-Z016 Vat nhanh xuy§r! niong tren
thu'dng dudc cac tfe -. --• -LJU t h i a Ite vdi kich thudc ldn ^(f d -^ - / a n cua A. Hurbungs (2012), hay 12 13an dia Yuan- Sheng Tzeng va cpng su" (2u07). Hai Heng-lin va cona su"
(2013) sir dung v?tc6 ta'ch thu'dc trun? •-'-'- ^ f
18,2an, Tran Van Anh (2011; ^ dung vat ro chieu dai ldn nhSt i: -;jeu r6ng ldn nhat la 12cm de che p^ .U,^L hong nio mem vung ciing cut) [1], [2],t f ? ] - Jrong nghien ciili cua chung toi, vst co kicfi thu'dc ldn nhat 1^ ISOcm^ v^ chiSu dar lon nhat cua vat la 18 cm va chieu rong ldn nhat trong cac v?t la 10cm. Theo doi tinh trang vat ngay sau mo co 34/37 vat tot chiem 89,4% va 4/37 vat trung binh khong vat xau. Vat xep ioai trung binh do bj thieu dudng be mat da nong sau do tuan hoan vat tSt nSn vat Ichong bj hoai tu". Ty le nay tu'dng dutfng vdi cac nghien cihi cua Yuan-Sheng Tzeng va cgng su* (2007) vdi ti le 1/12 vat xuat hiSn hoai tO' nhe, A.Hurbungs, H. Ramkalaw/an (2012) vdi ti le i/10 trudng hdp xuat hien mau tu sau phau t h u i t [2], [7].
Theo doi va chim soc h i u phau rat quan trgng dSi vdi vat nhanh xuyin dong m^ch mong tren. Chay mau la bien chuhg thui&ng gap. Trong nghien culi cua chung toi xay ra 3 trudng hdp nhutig nhd theo doi ky va xu" ly Wp thdi nen ft anh hudng den tudi mau cho vat cua nhanh xuy€n.
Cac van dil quan trgng diit ra da du'dc chung t5i giai quyet tren thifc te lam sang trong thiet ke d i i n tfch vat du che phu khuyet hong, dong da ndi cho vat thi dau, hinh thii'c su* dung vat phCi hdp v ^ tu" the nam cua tuYig benh nhan va theo doi ky kjp thdi phat hien v i xuf trf bien chuhg sdm tranh ton.thu'dng vat.
V. K^ LU^N I
Dieu tri phlu thuat che phu ton WiuyS viing i ,- - cyt d mu'c dp I I I , IV bang vat da can c6 r c ,dng mach nuoi la nhanh xuyen cua dgng mach mong tren co do day vCfti du, che phu h i t dien tich khuyet hong, ndi cho vat du^c dong da m6t thi d^u la si/ lu'e chpn hdp iy cho bfnh nhan bi loet vCing cung cut man tfnh mi^c dg n^ng.
TAI LIEU THAM KHAO
1. Tran Vin Anh, VQ Quang Vinh (2011), "Nghien o ^ ling dung vat da nhanh xuyen cua d&ng m^dl mong tren trong dieu tri loet vung cCing cyt do ty de", Tap chf Tham hga va Bdng, trang 20&-214.
2. A. Huriiungs, H. Ramkalawan (2012) "Sacral pressure sore reronstiudion - the pedidett superior gluteal artery peribrator flap", SaJS, vol 50, no.l.
3. Hai Hens-linetal (2013) "QuadrJiobed superior gluteal artery perforator flap for sacrococcygeal defects", Chinese Med«3f Journal •,126{9) 4. Koshima I , Moriguchi T, Soeda Setal (1993),
"The gluteal perforator - base flap for repair of sacral pressure sore", fltesf Reconstr Surg 91, 678-683. ^ r 9. Cillnger Meltem, Cellk Esra, FIndlk Hasan, '^
Duman Ali (2004) 'The gluteal peribrator "^^1 based flap in repair of pressure sores". The British' Association of Plastic Surgeons 57, 342-347. ' | 1 6. Tarek Mahboub (2004) "Superior gluteal artery™
perforator flap for closure of large sacral defectsJ;^
Egypti Jf^a^ReconsirSurg, Vol 28, No 2, i7S-l>^J|
7. Yuan-Sheng Tzeng, et al. (2007) "Modification c ^ superior gluteal artery perforator flap fbr reconstruction of sacral sores", J Med Sd, 27 ( ^ 9
253-258. 'm
D A N H GIA K E T Q U A D I E U T R | TOY RANG H A M L Q N THU" NHAT
HAM DU-ffl CO six DUNG HE THONG PATHFILE VA PROTAPER
T 6 M TAT
Myc tietr. Danh gia k^ quei dieu trj ndi nha d rSng ham I6n thu' nhat ham dudi c6 su" dung h# thong 'Binh M«fJ Rang Ham MSt 71/Ha No!
Chju trach nhiem chfnh: Pham Thj Thu Hien Email: [email protected] Ngay nh$n bai: 30/8/2016 Ngay phan bign khoa hoc: 15/10/2016 Ng^y duyet b^I: 20/11/2016
Ph?m Thi Thu Hi^n*, Lg VSn BSng*
Pathfile va Protaper.0^ t^png vi phtfiing phip nghlSn cihr. Nghien ciru d 36 benh nhSn vdl 36 rdng ham ldn thii- nhSt ham du'di (RHLTIHD), dui?c chSn do^n viem tCiy khong hBi phye (VTXHP). TiSn hSnh mi tuy, sir dyng tram pathfile vS Protaper de siiz so?n Sng tliy. Han kfn 6ng tuy bSng gutta perdia, ThiStki nghiSn cdir. can thi§p lam sSng Wi6ng dSi diiStig- Ket qua: Tai bien gay dyng cu diiem ty le 2,8%.
Ngay sau hhn Sng tuy, k a qu^ tSt chiem ty I? 97,2%, trung binh diigm ty Mf 2,8%, kem 1^ 0%. Sau 1 tuan, tft
