TAP CHl Y HOC VigT NAM TAP 452 - THANG 3 - SO 2 - 2017
KET QUA SO^M C O A P H A U THUAT NOI SOI DIEU TRI TRIET CAN U N G T H I T D A I T R A N G
T6MTAT
D§t van de: Phau thuat noi soi cat dai trang dtfiSc thut hien ^ u tien tren the gi6i nam 1991 bdi Jacob.
Oiung toi thi/c tilen nghien culi nay nham (Janh gia k ^ qua sdm oia phau thuat noi soi dieu tri triet can ung thu* dai trang. Dm tii'dng va phu'tfng phap nghien cOii: Nghien culi tien CLTU gom cac benh nhan tren 15 tuoi du'cfc chan doan la ung thif bi^u mo tuyen nguygn phat cOa dai trang va du'dc phlu thuat noi soi cat dai trang tif 11/2011- 12/2015 tai_^Binh vien Nguyen Tri Phuting. Ket qua: Thdi gian mo ttiing binh 136.5 phut, CO 1 tru'dng^hcfp (0.97%) radi nieu quan trai, 8 tn/c(ng hijp nhiem trUing v a mo (7.8%), 1 tni'dng hdp t i e rupt sdm sau mo (0.97%). KhSng co trUdng hdp nao xi, ro mieng noi, thdi gian co Iai trung tien va tlidi gian nam vien trung binii lan lu*dt la 1.54 ngay va 7.45 ngay. Ket l u | n : Phau thuat noi soi cSt dai trang do ung thu' la an toan, Wia tiii va hieu qua.
Td" khda: Ung thu* dai trang, phau thuat noi soi cat d^i trang, ket qua sdm.
SUMMARY
SHORT-TERM OUTCOME OF LAPAROSCOPIC COLECTOMIE FOR COLON CANCER Background: Laparoscopic Colectomie was first performed in 1991. The aim of this study was to investigate the feasibility and safety of Laparoscopic Colectomie for Colon cancer. Metiiod: Prospective study, we reviewed colon cancer patients who underwent laparoscopic coledomie at Nguyen Tri Piiuong Hospital from 11/2011 tol2/2015. Results:
The mean operating time was 136.5 minutes. There were 1 case of ureter injury (0.97%), 8 cases of wound Infection (7.8%), "one case of early bowel obstruction, no lealoge or fistula, the median time for passage of flatus and hospitalization were 1.54 and 7.45 days respectively. Conclusion:
Lympfiadenectomie in Laparoscopic Colectomie for Colon cancer is safe, feasible and effective.
Keywords: Colon cancer, Laparoscopic Colectomie, short-term outcome.
I.OATVXNBE
UTOT la benh ly thu'dng gap d cac nu'dc Au My, hang dau trong cac ung thu" du'dng tieu hoa, rt hdn c( cac nu'dc chau A, chau Phi. Theo thong
Huynh Thanh Long*, Vu Huy Nung**, Nguyen Hoang Bac***
ke cua Hiep hoi Ung thu" Hoa Ky (American Cancer Society - ACS) nam 2009, t^ le ttr vong dtrtig hang thu" 2 6 nam gidi, thu" 3 cf nff gidi. a Viet Nam, UTDT dutig hang thu" hai sau ung thu*
da day trong cac ung thu" du'dng tieu hda.
iJng dung phau thuat noi soi (PTNS) dieu t n LTTDT du'dc thi/c hien tren the gidi t i i ' nam 1991.
Gan day, nhieu nghien CUXJ y hoc chiing CLT mu'c dp n i da cong nhan \d\ fch ciia PTNS trong dieu trj UT€»T ngoai Uu the giam chcTn thu'dng phau thuat, giam bien chuYig hau phau, thdi gian hoi phuc nhanh, seo mo nho [ 4 ] , ma t y le song con tu'dng tu* nhu' cac phau thuat mo m d kinh dien dong thdi dat du'dc nhi^ng ket qua tot ve mat ung thu" hoc, bao dam du'dc cac nguyen tac trong dieu trj ung thu* nhu" la phau thuat each ly khong cham, buoc mach mau tan goc va nao vet hach tiieu qua an toan.
Chung t6i thi/c hien nghien cu'u nay nham danh gia ket qua sdm sau mo cua p h l u thuat npl soi dieu trj triet can ung thu" dai trang.
*Benh vien Nguyen Tri PhUOng
** Hoc vien Quin Y,
*** Benfi vien Dai hoc YDifdc TPHCM Oiiu trach nhiem chinh; Huynh Thanh Long Email: [email protected] Ngay nhan bai: 17/12/2016 Ngay piian bien khoa tioc: 18/1/2017 Ngay duyet bii: 27/1/2017
II. £X3I TUONG VA P H y O N G PHAP NGHIEN CUU S o l tu'dng n g h i e n c u t i : gom cac benh nhan tren 15 tuoi vao benh vien Nguyen Tri Phu'dng du'dc chan doan la ung thu" bieu mo tuyen nguyen phat cua dai trang va du'dc dieu tri bang phau thuat noi soi cat dai trang t i r 11/2011- 12/2015.
Phu'dng p h a p n g h i e n cu'u: nghien culj tien cull, cat ngang mo t a .
Tieu chuan loai tru': Chyen mo md. Cd di can xa tru'dc phau t h u a t Benh nhan du'dc phau thuat tCr benh vien khac chuyen td\. Benh nhan bj ung thu' tijr cd quan khac di can t d i dai trang.
Benh nhan khong du cac chi tieu nghien cu'u, khong lien lac du'dc benh nhan. Sau phau thuat.
Benh nhan thda cac tieu chuan chgn benh nhu^ig tong trang Item, nguy cd phau thuat cao, benh ly noi khoa nang khong chju du'dc phau thuat.
Trong phau thuat noi soi cat dai trang tai BV Nguyen Tri Phu'dng, chung toi ap dung ky thuat phau tich tCr trong ra va nao hach mu'c D3, ap dung ky thuat cat toan bg mac treo dai trang (CME: complete mesocolic excision).
So l i e u du'dc t h u t h | i p tu* ho sd benh an t i f luc mo den sau phau thuat 1 thang, ggi dien thoai cho benh nhan. So lieu du'dc \Uu tru' va thong ke bang phan mem IBM SPSS 20.0.
VIETNAM MEDICAL JOURNAL N°2 - MARCH - 2017
III. Kn* QUA
Chung toi theo doi du'dc 103 benh nhan thoa tieu chuan chon benh, trong do ty le nam la 54.4%. Tuoi trung t3inh 59.61 ± 14.373 (18-85).
U d dai trang phai co 29 tru-dng hdp (28.2%), dai trang ngang 7 tru*dng hdp (6.8%), dai trang trai 18 tru'dng hdp (17.5%), dai trang sigma 49 tru-dng hdp (47.6%). Co 16 tnidng hdp u d giai
Bang 3.1._ Phu'dng phap phau thuat
doan T4 (15.5%), 32 tru'dng hdp u d giai doan T3 (31.1%), T2 cd 47 tru'dng lidp (45.6%), T l ^ cd 8 tru'dng hdp (7.8%). Trong nghien ciiru cua ,- chung toi khong cd tru'dng hdp nao dien cat xa con te bao ung thu* ve dai the cung nhu' vi the,' dieu nay cho thay phau thuat noi soi dat du'd'' tinh triet can dieu trj ung thu' dai trang.
3.1 PhuVng phap phau thuat
Phu'dng phap Ty le (%)
Cat 1/2 dai trang phai Cat 1/2 dai trang trai Cat dai trang ngang Cat d^i trang sigma
30 19 6 48
29.1 18.4 5.8 46.6
Tong c6ng
100ThUi gian phau ttiuat: thdi gian mo ngan nhat 80 phut, lau nhat 220 phut, trung binh 136.5 ± 33.92 phut Bang 3.2. DJn \Uw xoang bung
So benh nhan
Ty le (%)76.7
Kh6ng 24 23,3
Tong cong
103BiSn chu^g: Tai bien: cd 1 tru'dng hdp rach
nieu quan trai khi boc tach dai trang sigma phai xu" tri dat sonde JJ va khau Iai nieu quan chiem ty le 0.97%.
^Bien chuYig: cd 8 tru'dng hdp nhiem trung vet mo (7.8%), 1 tru'dng hdp tac rugt sdm sau mo (0,97%), tru'dng hdp nay mo cap cu'u gd dinh.
Khong CO tru'dng hdp nao xi, ro mieng noi trong nghien ciTu cua chung toi.
/>i^n tien hau phau: Thdi gian hoi sifc sau
mo: chung toi khong co tru'dng hdp nao thd may lau dai va nam theo doi tai khoa hoi su'c tich ci/c, benh nhan sau mo den khi tinh han chuyen ra khdi phong hoi su'c sdm nhat ia 2 gid, cham nhat 48 gid.
100,0
Thdi gian phuc hoi chu'e nang du'dng tieU' hda; thdi gian tu" luc cd trung tien va an Iai du'dng mieng sdm nhat 1 ngay, cham nhat 5 ngay, trung binh thdi gian cd Iai trung Hen 1.54±
0.638 ngay
Thdi gian van dgng trd Iai: sdm nhat 1 ngay, cham nhat 2 ngay
Thdi gian rut ong dan lUu 3.77 ± 0.8 ngay.
Jhdi gian nam dieu tri I't nhat la 4 ngay, nhieu' nhat la 16 ngay, trung binh 7.45 ngay, co 1 tru'dng hdp nam vien keo dai la do benh nhan bj nhiem trung vet mo va viem phoi).
Chat Mdng cuoc song sau mo: chung tdi co 103 benh nhan, chet 8 benh nhan, cdn Iai 95 benh nhan.
Bang 3.3. Theo doi til kham sau mo
Can nang
Tinh trang an uong
Tinh trang di cau
Kha n^ng lao dong
Chl tieu theo doi Tang can Khong tang
Sut can Nqon mienq
An l<em Chan an De B6n Roi loan Lao dong nhe TU cham soc Khong tu cham soc
Benh nhan .
46 34 15 54 28 13 51 31 13 42 46 7
48 %
36 16 57 29 14 54 33 14 44 48 8 _ Nhanxetna bang 3.37 nhan thay sau mo co 46 benh nhan tang can(48%), An uong nqon mienq CO 54 benh nhan (57%). 01 cau de co 51 benh nhan (5'4%), lao d6ng txd Iai co 42 benh nhan (44%
'• 1
T»P CHl Y HOC VIET NAM TAP 452 - "mANG 3 • SO 2 - 2017
IV. BAN LUAN
4.1 Thdi gian hdi phuc sau md: Chung toi danh gia hoi phuc sau mo di/a vao thcfi gian hot tinh sau mo, mu'c do dau, van dgng sdm, thdi gian trung tieriL thdi gian an uong iai, thdi gian dieu tri sau mo. Trong 16 nghien cuYi cua chung toi, khdng co tru'dng hdp nao phai thd may va nam theo doi tai khoa hoi su'c ti'ch ciTc lau, thdi gian tu" sau mo den Idil chuyen ve khoa lau nhat 48 gid, sdm nhat 2 gid.
De danh gia mu'c do dau sau mo chung toi difa vao ttiang diem EVA, tuy nhien co mot s5 benh nhan du'dc dieu tri giam dau bang te ngoai manacQtiava khong co 16 doi chutig. Tuy nhien, da so phau thuat vien deu nhan thay PTNS la phau thuat it xam, ft gay sang^chan thanh bung, du'dng mo Iai nho, nen sau mo benh nhan ft dau hdn mo md. Van dong sdm sau mo duWc tfnh tu*
khi benh nhan du'dc chuyen tiT phdng cham soc dac biet sang phong thu'dng, sdm nhat 1 ngay, ctiam nhat 4 ngay.
Thdi gian trung tien: Nghien ciTu cua chiing toi, benh nhan trung tien du'dc sau 1.54 ngay (1-3), xuat vien sau 7.45 ngay (4-16). Theo Nguyen Hoang Bac [1], thdi gian trung tien:
trung binh 3 ngay (2-5 ngay).
Trang phau thuat vung bung, nhat la khau noi du'dng ong tieu hda ndi rieng, viec cho benh nhan an Iai du'dng mieng la van de rat quan trgng, tru'dc day quan niem sai lam la an sdm de bi xi ro mieng noi. Tuy nhien, qua theo doi chung toi thay clio benh nhan an sdm la an toan, giup cho he tieu hoa hoat dgng sdm, nhu dgng rugt trd Iai sdm hdn, mieng noi de lien hdn. Trong 16 nghien cu'u thdi gian an Iai sdm nhat la 2 ngay, cham nhat la 4 ngay. Viec an uong sdm du'dng mieng khong lam tang bien chuYig xi mieng noi ma giup cho siT lien vet thLTcJng nhanh hdn.
Thdi gian nam vien; trung binh 6 ngay (2-12 ngay). Nghien cifli COST [3] du^ ra thdi gian nam vien la 5 ngay (4-6).
Dan IUu xoang bung: Nham muc di'ch dan lulJ dich u" dong sau phau thuat, ngoai ra cxin giup cho phau thuat vien phat hien cac bien chutig sdm sau mo nhu' chay mau, xi buc mieng noi. Chi djnh dat dan lull xoang bung tuy theo phau thuat vien, theo mot so tac gia cho rang dan lu\j khong cd 1^ khi cugc mo khong co tai bien. Trong 16 nghien cu'u cua chung toi cd 71 tru'dng hdp chiem 84%, khdng cd moi lien quan giu^ yeu to dan lull xoang bung va bien chiJng sdm sau mo.
Tha^ gian phau fftuat: Thdi gian mo trung binh trong 16 nghien cull cua chung toi la 136.5
phut, trong do thdi gian mo dai trang phai la 143.64 phut, thdi gian mo dai trang trai la 133.14 phut; trong do thdi gian mo nhanh nhat la 80 phut, thdi gian mo dai nhat la 220 phut.
Khong CO su* khac biet ve thdi gian mo glu^ cac loai phau thuat. Sieu hien nhien la thdi gian mo se rut ngan khi phau thuat vien thiTc hanh nhieu va cd kinh nghiem. So vdi mot so tsc gia trong nu'dc, Nguyen Hoang Bac [1] thdi gian mo tmng binh la 155 phut (110-240), cung theo tac gia nay trong 1 nghien cu'u khac [2] siT khac biet ve thdi gian mo cung nhu" thdi gian nam vien giup cac loai phau thuat khong co '^ nghta ttiong ke, thdi gian mo trung binh cho tat ca cac loai phau thuat 142±31 phut. TTidi gian nam vien trung binli la 7.5 ngay. Tat ca benh nhan nam vien hdn 8 ngay deu do cd bien chiitig sau mo [2].
Bien chuftg: Cac yeu to nguy cd cua isi bien va bien chu'ng sau mo: t^oi, gidi tinh nam, suy dinh du©ng, kinh nghiem cua phau thuat vien, mau mat, truyen mau Irong mo, thcfi gian mo, beo phi, tien can nhoi mau cd tim, suy tim [6].
Tai bien trong md: Chung tdi cd 1 tru'dng hdp tai bien trong mo chiem ty le 0,97%,benh nlian nam 42 tuoi u dai trang sigma to di'nh vao thanh bung, bang'quang trong qua trinh bdc tach fam rach nieu quan, khau Iai nieu quan qua ngl sol, dat dan lull JJ, dien bien hau phlu on dinh. Theo Sarii L [7], 100 ca dan so Y, du'dc PTWS cat nifa dai trang trai cd 12% (12/100 ca) phai chuyen mo md, trong do cd 4% (4/100 ra) cd bien chutig chay mau trong mo (2 ca khong cam du'dc mau trdng PTNS, 2 ra mat mau nhieu khong thuan Idi tiep tuc noi soi phai mo md ram mau), trong luc phau tich cd iam ton thu'dng cac cd quan khac nhu' thung rugt non 2 ca, cac tru'dng hdp cdn Iai la do khd Wian trong phau*
thuat, 3 ca dfnh vung gdc gan kho bdc tach, 1 ra khd khan khi phau tfch vung tn/c trang, 2 ra con Iai do tang CO2 mau qua muTc. Nghien culi nay ghi nhan kha nang xay ra tai bien trrong mo cung nhu' ty le chuyen mo md phu tiiugc vao 2 yeu to: Trgng lu'dng cua l)enh nhan (p=0.049) va do xam lan cua khoi u (p=0.046).
Chiing tdi thay rang ty le tai bien trong mo nay phu hdp vdi cac nghien cu'u khac [6]. Tham chf CO nghien cCrtj du'a ra ty le tai bien trong mo la 4% va ty le bien chuYig sau mo la 19% [3].
Bien eJii^ng sau md: Ngh[en cuti cua chung
tdi cd CO 8 tru'dng hdp nhiem trung vet mo
(7.8%), 1 tru'dng hdp tac ruot sdm sau mo
(0,97%) da du'dc mo gd dinh, bien chu'ng
thu'dng gap la nhiem trung vet mo so vdi mot so
tac gia Wiac la 10-20%. Vdi nhQng ket qua dat
VIETNAM MEDICAL JOURNAL N*^ - MARCH - 2017 du'dc nhu" tai bien trong mo thap, khong cd
tru'dng hdp nao can truyen mau trong mo do phau tfch ti mi, dung Idp du'di sir phong dai cua kinh soi, ty le bien chu'ng thap (14,5%) cho thay ra the thUc hien cat dai trang ndi soi thu'dng qui trong UTDT. Hdn n u ^ , vdi FTNS, benh nhan ft dau hdn, tticfi gian hoi phuc cung nhu' nam vien ngan, ty le nhiem trung vet mo thap. Vdi ky thuat phau tfch tu" trong ra ngoai, chung tdi nhan thay cd the nao vet hach den tan goc cac bd mach chfnh d l dang, giam thieu lu'dng mo b|
cam nam trong qua trinh phau tfch tim cuong mach, dat du'dc yeu cau cua nguyen tac "cat rach ly khdng cham u". Phau tfch tiT trong ra cang thuan Idi hdn cho viec quan sat vdi kfnh soi dat d trocar ron. ViSc bdc tach va cat mac treo thuan Idi va rut ngan thdi gian hdn neu s ^ dung dao cat dot sieu am. Nhd sU chuan hoa ve dung cu va ky thuat, chiing toi nhan thay viec bdc t^ch dai trang va cat mac treo khdng qua khd, cd the ha dai trang gdc gan hay gdc lach nham di dgng dai trang dij de d u ^ ra ngoai thu*c hien cat noi.
V. K f r LUAN
Qua bu*dc dau nghien ciili, chiing tdi nhan thay phau thuat noi soi cat dai trang do ung thu' 1^ an toan va kha t h i , vdi kinh nghiem va ky nang ngay cang du'dc cai thien, hoan thien cac
quy trinh chan doan tru'dc mo (chup CT Scan bung de danh gia di can hach), k j thuat mo (ky thuat cat toan bo mac treo dai trang: CME).
TAI LIEU T H A M KHAO
1 Nguyen Hoang Bac, D 3 Minh Oai, Le Quan AnhTuan, et al. ( 2 0 0 3 ) . Cat dai trang noi soi. V hpc TPHo Chl Minh, ^l), tr. 127-132.
2 Nguyin Hoang Bac, Nguyen HChi Thinh.
(2008). Phlu thuat noi soi cat dai trang do ung thu': Kinh nghiem m o t p h l u ' thuat vien. Y.hoc TP Hd Chi Minh, Tip Ji(phu ban so 1), tr. 186T189.*
3 COST Study Group. (2004). A comparison of laparoscopically assisted and opencolectomy for colon cancer. N EnglJ Med^ 350), p. 2050-2059.
4 Nana Alhomoud & Oscar Falcon. (2012).
Laparoscopic asasted Vs Open Surgery for Cblon Cancer.
V\^xld Joumal of l^parosa^ Surgery, i[3), p. 128-130.
5 Masayuki Kojima., Fumio Konishi & Masaki Okada. (2004). Laparoscopic Colectomy Versus.;
Open Colectomy for Colorectal Cardnoma: A Retrospective Analysis of Patients Followed Up for at Least 4 Years. Surg Today, 34, pp. 1020-1024.
6 Philipp Kirchhoff., Pierre-Alain Clavien., Dieter Hahnloser. (2010). Complications in colorectal surgery: risk factors and preventive strategies. Patient Safety in Surgery \ip. 4-5 <
7 SarIi L, Lusco DR & Regina G. (2006).
Predicting Conversion to Open Surgery in Laparoscopic Left Hemicolectomy. Surg iaparosc Endosc Percutan Tech, /6(4), pp. 212-216.
NGHIEN CU'U MOI LIEN QUAN GIITA MU'C DO TON THU'ONG TREN PHIM CAT LOP VI TINH VA TINH TRANG ROI LOAN CHU-C NANG HO HAP (y BENH N H A N CHAN THU'ffNG SO NAO
T O M TAT
Myc tieu nghien cCfu: Xac dinh mS lien quan gjife rniJc do ton thu'ong trgn phim cSt Idp vi tinh sp nao va tinh trang roi loan chiJc nang ho hap 6 benli nhan chan thu'dng sp nao. Doi ttf^ng va phiAJng phjip nghiSn cfru: Nghien cijli tren 65 b|nh nhan dian thu'dng sp nao co chi dinh phau thuat tai khoa hoi Slit cap cull va khoa phau thuat thankinh benh vien 103 tCr 12/2014 den 5/2016. Phu'dng phap nghien cu^: tien cult mo ta theo doi doc. Tai thdi diem tru'dc phau thuat chula co can thiep ho hap, ghi nhan Sn so
* BSnh vien Quin y 103
**BSnh viin Tl/QD 108
Oiiu trach nhiem chfnh: Pham Thai Dung Email: [email protected] Ngay nh?n bai: 28/11/2016 Ngay phan bien khoa hpc: 26/12/2106 Ngay duyet bai: 16/1/2016
Ph^m Thai Dung*, Nguyin Tai Thu**
thd, SpO;, roi loan*nhip Wid, co keo cd ho hap, tim moi dau chi, va mo hoi, khi mau dong mach. Oiup phim cat Idp vi tinh sp nao tru'dc phau thuat. K€t qua: Roi loan ho hap glip d nhom mau tu ngoai mafig^^
cijtig (89,66%), nhdm mau tu du'di' mang cutig (73,9%), va trong nao (46,15%). Chii yeu g?p ti l§
cao d nhom co mau tu d vtjng cham (100%), mau t j ^ ^ vCing dinh (86,66%), viing tran (71,42%), vung t h a i l l duyng (69,7%). The tfch khoi mau tu>60ml co roS lo?n ho hap (100%), mau tu 30-60ml co roi loan ho hSp 70%, mau tu <30mi co roi loan ho hap 56,25%. '•\
K§t luSn: Qua nghien cu'u 65 benh nhan chan thu'dng sp nao c6j:hi djnh phlu thuat, chung toi nhan thay hmh anh ton thu'dng tren phim cat Idp vi tinh'co lien quan mSt thiet vdi tinh trang roi loan chiTc nang ho hap d binh nhan chan thu'dng so nao. Mu'c dp roi loan chCfc ning ho hap phu thuoc vao hinh thai, vj trf va the tfch khoi mautu.
Tif Ithoa: RSi loan chufc nang ho hap, chup cat Idp vi tfnh, ch^n thu'dng so nao.
