VIETHAM MEDICAL JOURHAL H''1 - FEBRUARY-2017
T A I U f U T H A M KHAO
1 . Collin C, Wade DT, Davies S, Home V (1988).
The Barthel ADL Indec: a reliability study. Int DisabllStud. 10{2), 61-63.
2. Tr^n Ng^c An (2002). Benh thap khdp, NXB Y hoe, 118.
3. Nordenskiold U (1997). Daily activities in women rheumatoid arthritis. Aspects of patient education, asa'tive devices and metiiods fiar disability and impairment assessment. Scand J.Rehabil Med Suppi, 37-42.
4. KauppI M, Haitikainen S, e t al (2005).
Capability for daiiy activities in old people wijlj rheumatoid arthritis: a populayion based study.J^
5. Lg Quang Hong ( 2 0 0 7 ) . Hoi dap cac benli'w xu'dng kh6p. NXB Yhgc, 123-135.
6. Vu Oinh Hung ( 2 0 0 6 ) . Benh hoc mot so benli ly cd xu'dng khdp thu'dng g i p . NXB Yhoc, 123- 266.
7. Dunlop D, Song J , e t al (2011). Objech^
physical acb'\flty measurement in the osteoarthtM initiative: Are guidelines being met? Arthnti^
Rheumadsm. 6 3 , 1 1 , 3372-82.
THU'C TRANG PHAU THUAT NOI SOI TRONG DIEU TRI CHU'A NGOAi Tiy CUNG TAI BENH VIEN S A N NHI NINH BINH
TIT T H A N G 0 1 N A M 2 0 1 4 DEN T H A N G 6 N A M 2 0 1 5
T6MTAT
De tai du^c thut hi$n theo phudng phap nghiin cuTu mo ta cat ngang ket hi?p nghien a i l i hoi ciili, ti§n cufu tren 297 binh nlian du'dc ch^n doan la d i u ^ ngoai tif cung, trong do co 218 benh nhan du'dc dieu trj bang phau thuit ngi soi tai Benh vien San Nhi tinh Ninh Binii td thang 01 nam 20i4 den thang 6 n i m 2015. Ket qua nghien culr cho thay nhu* sau: thdi gian phSu tiiuat trung binh 49,38 ± 13,94 phut (l§u nhat:
120 phut, nhanh nhat: 20 phiit); khong co tru'dng h^p tlf vong; khong co cac tai bien nhu' diay m^u, ton thudng cac tang, tr^n khi du'di da, c^c tai bien aSy me; ty te tran khi txddc phiic mac 0,48%; ty l i nhiem triing vet mo 0,48%; hau het l3?nh nhan van dg'ng sdm trtmg 12 gid diu, trung ti|n sdm trong 24 gid dau sau mo; thdi gian dfeu trj hau phau 6,29 ± 1,01 ngay.
TCf khoa: phau tiiuSt noi soi, chda ngoai tii" cung.
SUMMARY
REAL S I T U A T I O N LAPAROSCOPIC SURGERY I N TREATMENT OF ECTOPIC PREGNENCYIN N I N H B I N H CHILDREN'S HOSPITAL FROM JANUARY TO JUNE - 2 0 1 5
This study was perfiDrmed according to the method described cross-sectional study combined retrospective study with over 297 patients who were diagnosed as ectopic pregnancy, in which 218 patients were treated with endoscopic surgery in rilnh Binh Children's Hospital from 01/2014 to 6/2015. The results of the study on 218 patients showed that: the average surgical time 49.38 ± 13.94 minutes (the longest: 120 minutes, the festest: 20 minuiss); no
'Benh viin San Nhi b'nh Ninh Binh
^LiSn hiep c^c Hdi Idioa hocvaky thuat tinh Ninh Binh Chju trach nhiem chi'nh: €)5 V3n Dung
Email: [email protected] Ng^ynh$n bai: 5.12.2016 NgSy phan bien khoa hoc: 6.01.2017 Ngay duy$t b^i: 17.01.2017
Pham Ngoc Ha', D 6 Van Dung^
deaths; no complications such as bleeding, organ damage, subcutaneous emphysema, anestheaa complkations; the rate of emphysema previous is 0.48%
peritoneal; the rate of wound infection is 0.48%; moa patients with early mobilization in the first 12 iioifls, flatus eariy in the first 24 hours after surgery; treatment duration 6.29±1.01 days postoperatively.
Key word: Endoscopic surgery, ectopwc pregnancy.
I. DjQhT V A N o l
Chu^ ngoai t i f cung (CrTTC) la b^nh ly cap ciill thu'dng gap trong San Phu khoa. Ty le chiila ngoai tuT cung co xu hu'dng ngay cang tang. Vao thap nien 80 ciia t h § ky 20, t ^ le nay khoang 0,5% so phu nd co thai; gan dSy, ty le nay la khoang 1,9 - 2 % [ 4 ] .
Dieu trj chiJa ngoai tuT cung kinh di^n la mo mcf du'dc ap dung cho tat ca cac txddng hdp chij^ ngoai tii' cung. Hien nay, phau thu$t noi soi (PpiS) dieu t r ] chifa ngoai tu" cung la mot buSc tien ldn, co tiie giiip dat du'dc cac muc dich dieu trj nhu": ciili song tinh mang ngu'di benh, baolSn kha nang sinh de, han che chifa ngoai tif cung tai phat. Phau thuat npi soi co nhutig chi dinh va chong chi djnh nhat djnh, nhu'ng co rat nhieu i ^ diem nhu': thdi gian nam vien ngan, hoi phuc sau md nhanh, giam du'cfc lu'dng tiiuoc giam dau, khang sinh phai ^d dung..., dac biet, seo mo noi sol rat nho nen con mang ti'nh t h i m my.
Ooi vcti chil^ ngoai tu" cung, phau thuat noi soi CO the giiip chan doan va dieu trj bang each cSt bo khoi thai hoac rach m d vol t i f cung iay khS tiiai de bao tSn vol t i f cung hoac tiSm methotrexate vao vj t r i khoi thai de heu hiiy kliS tfiai. 6 nhieu cd sd san phu khoa tren the gidi, ptrau tiiuat npi soi dieu trj chii^ ngoai t i f cung da gan nhu' thay th€ hoan toan cho phau tiiuat md o bung, ^m
116
Tiflf CHl Y HQC VigT NAM TAP 451 - THANG 2 - S 6 1 - 2017 Tai Ninh Binh, phau thuat noi soi dieu tii chu^
tgoai tlf cung bat dau du'dc thi/c hien tif nam
!D06. Den nay, tai B$nh vien San Nhi, phau ht4t noi soi dilu trj chd^ ngoai td cung gan nhu' la tiiay the cho phau thuat md o bung. Tuy ihien, nhutig nghien cuXi ve phau tiiuat npi sol raig dieu tri chda ngoai tif cung con han che.
i^ CO tiie nit ra du'dc nhiJng kinh nghiem trong
^ * a S g dung phau thuat npi soi dieu tri chtfei
^baltiJCcung tai Benh vien San Nhi Ninti Binh, Mng t£i tien hanh de tai "Thu'c tiang phiu thuat in SCH trong dieu tii diu^ ngoai txi cung tai B^h rien San Nhi Ninh Binh tOr tiiang 01 nam 2014 den Mng 6 nam 2015" vdi 2 muc tieu:
1. Mota cae ehi djnh va i^ut^ f^p f^u thiat noi soi kha ch^ tnjng cht^ ngoai tu'cung talB&ih vien San Nhi Ninh Snh tif 01/2014 deh 6/2015.
2. Nhan xet k& qua dieu trf va cac tai bien cua ky diuat nay.
II. {)6i TUONG VA PHU'CYNG PHAP NGHIEN CUU - Boi tu'dng nghien cihi: Tctt ca benh nhan du'dc dian doan la chda ngoai tiir cung va difdc dieu tri bang phau thuat noi sol tai Benh vien San Nhi Ninh Binh ti^ 01/01/2014 den 31/6/2015.
- Phudng phap nghiSn dhi: Nghi^ ciiU mo ta cat ngang hoi ciilt ket hdp vdi tien cii'u.
Mau nghien caS^i: (mau toan bo) Trong nghien ciiU diiing toi c6 218 benh nhan thoa man cac ti§u chuan lifa chpn.
PhiAiitg phap xd' ly so lieu: Thu thap so lieu qua mau benh an nghien cu'u xay dtfng san.
Quan ly tiiong tin va xif ly so iieu bing phan mem Epi-Info 6.04
II. KET QUA NGHIEN CU'U VA BAN LU^N
3.1. Ty le ngtfcfi b$nh chijfa ngoai tuf cung du'dc dieu trj bang phau thuat noi soi
Bieudd3.1. Ty le ngWcff benh CNTC dddc PTNS
Nhanxet^Txong cac phu'dng phap dieu trj chda ngoai tu" cung tai Benh wen San Nhi Ninh Binh, phau tiiuat npi soi chi«n t^ le cao nhat: 73,40%.
3.2. Dac diem cua d6i tu'dng nghien cii'u 3.2.1.'7iioi
Bang 3.1. Phan bo w6i cua doi tif dng nghien cui/ (n=218) Tuoi
<20 20-24 25-29 30-34 35-39
>40
SoIUdng 9 37 57 52 40 23
rudi trunq binh = 30,90 ± 6,5z
Ty le Vo 4,13 16,97 26,15 23,85 18,35 10,55 tuoi
Nhan jrefcTuoi hay gap nhat la tir 25 den 39 (68,35%); tuoi trung binh: 30,90 ± 6,52 tuoi.
3.2.2. Tien sd sin phu Idioa
Bing 3.2. Tien su'sill phu khoa Cn=2tS)
Oade Ngo hut bu6ng tir cung
Solan So lu'dng (nl T Y l e ( % ) So lu'dng" Ty le (°/ol
53 24,31
38 69,73
61 17,43
87 39,91 7,34
£ 3 1 17 I 7,80 I 12 I 5,50 Nhfn xeb 1^ le CNTC <S nhiJhg benh nhan da de la 75,69%; <J benh nhan chua de lan nao la 24,31%; ty le chiia ngoai tur cung d nhifng benh nhan da nao hiit thai la 30,27%; is benh nhan chua nao hiit thai fan nao la 69,73%.
VIETNAM MEDICAL JOURHAL N l • FEBRUARY - 2017
3.2.3. TiSn sdrphau thuit Sbyng
Bang 3.3. Tien su'phau thuat o bung (n=218) TiBn stf phau thuat o bung
Mo lay thai 1^0 chila nqoai tli' cung
SS lu'dng 18
T» le % 8,25
3,21
3
Nhin xet: Co 12,84% tru'dng help co tien sOTphau thuat obung; i y l§ c6 tien sftmo dp cTiiem ^ le cao nhat trong so cac tru'cfng hdp CO tien siJ phau thuat o bung. ^
• 33. Bac diem lam sing, can lam sing cda cac benh nhin duvc phau thuat ngi soi CNTC 33.1, Trieu chdng at nang
Bieu di 3.2. Cic trieu chiifng cdnSng
Nhin xeb Cac dau hieu cham Idnh (165 ca = 75,69%), dau ha vj (131 ca = 60,09%), ra mau (127 ca = 58,26%) deu chiem ty le cao so vdi so benh nhan co trieu chiitig am ti'nh. Trong do, 73 benh nhan (33,48%) co dii ca 3 tneu chijng cham kinh, dau ha v| va ra mau.
3.3.2. Trieu truitg thu'c the
Bing 3.4. Toin trang benh nhin (n-218}
Dau hieu Mach (lan/p) Huyet ap (mmHg)
< 100
>100
< 90/60 mmHg
> 90/60 mmHq Binh thu'dnq
So Iifdng 212
212
_2JS_
2,75 97,25
Mau sac da, niem mac 204 93,58
Nhdt I 14" 1 6,42 ^ Nh$n xeb Co 6 truBng hdp khi nhap vien da co bieu hien truy mach (mach > 100 Ian/phut, Huylt ap; < 90/60 mmHg), chiem 2,75%.
3.33. Trigu chdtig c$n lim sing Bing 3.5. Cic diu hiiu siiu im (n=218)
Dau hieu So lu'dng Ty 16 %
Kich thu'dc khoi chiia (cm)
12,39
106 48,62
38,99
Djch cling do (mm) 37,62
Nhin xeb Co 12,39% khoi chiia co kich thu'dc < 1 cm; 48,62% co kich thu'dc 1-3 cm tuy nhien trong do co 8 tru'dng hdp tim thai du'dng tinh; trong 85 tru'dng hi?p (38,99%) kich thu'dc > 3cm co 6 tru'dng hdp tim thai du'dng b'nh; dich cung do > 15 mm chlem 86,24%.
Bing3.6. Testhce(n=2l'8) KSt aua
DuSnq tinh Am tinh Khonq ro rang
TSng
SoliTtfng 90
1 127 218
TV le »/o 41,28
0,46 58,26
100
«ft3njfefr03 58,26% 00 ka qua khong ro rang khi Bm test nhanh; 41,28% dutJng Hnh vdi test nhanh.
TAP CHi Y HCK VigT NAM TAP 451 - THANG 2 - S 6 1 - 2017 3.4. CSc dli d|nh phau tiiuat noi soi
Bang 3.7. Cac chi dinh phau thuat noi soi (n=218) Chan doan
ChiJfa ngoai tor cunq v3 Chu^ ngoai txi cung chu^ v3 nhuYig khong
con chi dinh dieu tri noi khoa Dieu tri noi khoa khonq ket qua Ngu'cfi benh co chi djnh dieu trj ngi khoa
nhutig khong chap nhan Nhanxet:Qo 66,97% tru'dng hdp dii dinh p
So lu'cfng 146
37 35 8
hau thuat la chda ngoai tu' c
Ty le o/o 66,97 16,97 16,06 3,67 ung vd; ty le mo vi die tri noi khoa Idiong ket qua la 16,06%; co 16,97% md vi khong con chi djnh dieu trj npl khoa mac du ciiuS CO bieu hien vd khoi chu^, gom nhiJng tru'cfng hdp: tim thai du'dng ti'nh; kicii tiiu'dc khoi chij^
idn; nong dp p-liCG trong mau > 5000 mlU/ml.
3.5. fiac diem ichdi diura 3.5.1. yi tri khoi chu'a
vitri Boan ke VT"C Ooan eo VTC Boan bdnq VTC
Loa VTC Sav qua loa VTC Chiia d buonq trimq
SS IUdng 3 26 169 1 17 2
Ty le Vo 1,38 11,92 77,52 0,46 7,80 0,92 nhat (77,5%).
3.5.2. "hnh trang khoi chu^
Bang3^. Titih trangkhm chu'a (n=218) Tinh trang khoi chu'a
Chu^vS
So itftfng Ty ie p/o
"vg~
74
Huyet tu 2,75
Say qua loa VTC 17
Tong
Nhan xet: chu yeu la khoi chda da vd hoac ri mau: 82,11%.
3.6. Phifdng phap xu' tri trong PTNS
Bang 3.10. Cack^tftuStxu'tnkftd/chu^ (n=218)
Chan doan So lu'dng Ty le %
Cat vol fe" cung 194 88,99
Bao ton VTC
Xu* In' khSi chira cf vj tri khac voi tu* cung~
22 10,09
0,92 Nh$n xet: Cat VTC chiem ty le cao 88,99%; ty !e bao ton VTC la 10,09%.
3.7. Van de truyen mau
- C6 14 tru'dng hdp phai truyen mau, chiem 6,42%, trong do co 7 tru'dng hdp du'dc truyen mau hoan hoi bang 3,21% tong so ca PTNS CNTC.
- Trong 7 tnji&ng hdp truyen mau hoan hoi: trudng hdp truyen nhlSu mau hoan hoi nheit la 6 ddn vj; budng hdp ft nhat la 1 ddn vj.
3.8. Bien chulig cua phau thuat
Tran khf trul5c phuc mac: 01 tru'dng hdp (0,48%); nhilm trijng vet mo: 01 trutfrig hdp nhiem bring vBi mo boca in tri ron (0,48%) (benh nhan beo, thanh bung day). Cac bien chutig khac Idiong c6.
3.9. S^ dung ichang sinh
Bang 3.13. Su'dung khang^nh (n=218) Khang sinh
Du* phonq tn/dc mo Sau mo
Sd iu'dng 55 163
Tv le (o/ol 25,23 74,77
VIETHAM MEPICAL JOURMAL N'M - FEBRUARY - 2017
Nhan xet; 100% cac tru'dng hdp phlu thuat dtfdc siJ dung khang sinh; ty le du'dc siJ dung khang sinh id phong truSc mo la 25,23%, thap hdn nhiilig benh nhan khong du'dc dilng khang sinh dir phong (74,77%). ^
3.10. Su' dvng thuoc giam dau sau phau thuSt Bing 3.14. SUdung thuS^giim dau (n=218)
Thuoc giam dau So lu'dng TV le (%)
Co dung 159 72,94
Khonq dung 59
Nhin xit; Ty le benh nhan co diing thuoc giam dau sau mo la 72,94%, thuoc giam dau sau phau thuat npi soi thu'dng duUc dilng la diclofenac ioOmg dat h?u mon.
3.11. Thdi gian dieu tri hau p h l u - Thdi gian dieu tri hau phau trung binh: 6,29
± 1,01 ngay
- Ca 01 truSng hdp dl§u tr\ h$u phau lau nhat do nhilm triing vfi: mo lo tnxa \rf tri ron: 10 ngay IV. KET LU$N
1. Nghien cii'u ve chi djnh phau t h u | t ndi soi trong dieu trj CNTC
- PTNS hien nay du'dc u\i tien chi dinh doi vdi ca cac tru'dng hdp: oi tien sii phau thuat o bung tru'dc do (CO 2,84% s3 benh nhan FTNS); truy mach dap iJng vdi hoi siic {co 2,75% so beiih nhan PTNS)
^ - Chi djnh PTNS dieu trj CNTC phu thuoc vao cac trieu chiitig lam sang va can lam sang chinh sau; phan litig cCing d3; djch cCing do > 15 mm;
xet nghiem anh lu'dng ^-h'CG > 5000 mlU/ml - Cac chi djnh phau thuat noi soi dieu tri CNTC: chiJa ngoai tiJ cung v8; 66,97%; chiis ngoai tiJ cung chua v3 nhuiig khong con chi dinh dieu tri noi khoa: 15,97%; dieu tri noi khoa khdng ka qua: 16,06%; nguSi tienh co dii dinh dieu tri noi khoa nhung khong chap nhan: 3,67%.
2. Cac phifdng phap xu' t r i khoi chii'a trong phau thuat n6i soi
C§t voi til cung: 88,99%; bao ton vol tiJ cung: 10,09%; lay khoi thai, dot cam mau khoi thai d buong triing: 0,92%.
3. KSt qua va tinh an to^n cua p h i u thu$t n6i soi trong dieu trj CNTC
- TIKS gian phau thuat tnjng binh: 49,38 ± 13,94 pha (lau nhat 120 phiili nhanh nhat: 20 phiit).
- Khong CO tru'dng hdp t i l vong; khong co cac tai bien nhtf: chay mau, ton thu'dng cac tang, tran khi dudi da, cac tai bien gay me.
- Jy le tran khi tru'dc phuc mac; 0,48% (01 tru'dnghdp).
- Ty le nhiem triing vet mo: 0,48% (01 tru'dng hdp).
- Hau het benh nhan van dong sdm trong 12 gid dau, bung ti$n sdm bung 24 gid ^ u sau mo - Thdi gian dieu W hau phau; 6,29 ± 1,01 ngay
27,06 KHUYEN NGH!
1. Ooi vdi cong d3ng: Can ting cuSng truyen thong, giao due sii'c khde cho phu nff nham nang cao hieu biet ve chiJa ngoai tii cung: nhiitig nguy cd, cac bien phap tranh thai, nhan biet sdm trieu chiitig, cac phu'dng phap dieu trj CNTC.
2. Phau thuat n6i soi digu trj chis ngoJi til cung la mdt phau thuat ngi soi pliu khoa cd ban, khSng ddi hdi ky thuat qua cao, cac benh vien tuyen huyen can dau tU trang thiet bj phau thuat no^ so| cung nhtf dao tao phau thuat vien de oj the tien hanh phau thuat noi soi cap ciiij diTdc nhiitig ca chiis ngoai ttf cung ngay tai benh vi§n huyen, tranh nhffng nguy cd chay mau trong qiia trinh chuyen vien.
3. Odi vdli phau thuat vien: CSn can nhac trong Itfa chon phuBng phap xtf tri doi vdi khoi chda ngoai til cung (bao ton hay khong bao iBn vol ttf cung); can xem xet, ap dung thtfdng quy vi&: stf dung khang sinh dtf phong de rat ngan thdi gian dieu trj, dem lai ldi fch ve kinh te cho ngtfdi benh cung nhtf cd sc( icham chuS b|nh. ;<
T A I U E U THAIVI KHAO
1. Phan TnTSng DuySt (1998). Pliau thu$tllQist dieu tri bio ton voi tivng tren binh nllSn CMC gua noi soi Phau thuat san phu khoa. NXB YiEI
Ha Noi, tri74-775 «'—' 2. Vu'dn; Tien Hod (2001). Ttiong iao tum
ngiiien ciiv fi-iiCG dong CNTC, Y hoc thut M
so3,ir. 52. 1 3. Nguyen Thj Nggc PhuUng (2002). Tmil « ]
Chan doan va dieu tri tiiai ngoai td cung ^^^^^
nam 2001 tai BV phu san TO'DO thanh piio Npi san phu khoa s5 dac bi§t, tr. 67.
4. Tran Thj Anh (2003). Nghiin cuV uhg dimg.
thuat noi soi trong dieu tri chiia ngoai ttf- Luan an tien OT y hoc. Hoc vien Quan y.
5. Mai Thanh Hang (2004). Hnh hinh chuS . tdcung ian 2 dieu tri tai Benh vien Phu San Tr udng dong 3 nSth '2001-2003. Luan vSn — nghiep bdc sy chuyin khoa cap II, Tn/flng Bai
hocYHaN6i. a 6. Nguyen Thj Thuy Ha (2014). NghiSn ahi m
Chan doan va xiy tri chua tai voi td cung til ^ n | tai Benh vien Phu San Truiig u'dng. Luan v3n tf^
sy y hoc. Tru'dng Dai hoc Y Ha N6I. fl 7. Tay JI; Moore J et al (2000). Regular rem,
ectopic pregnancy, BMI. Vo! 320. April, pp 917-919J
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