efla Jr. Gregory Zucearo vd eong su ndm 2005, dp nhay vd dp dde hidu efla SANS trong c h i n d d n giai doan T 3-4 tubng Ung Id 86% (79-92%) va 82% (74- 88%) [8].
Danh gid m i ^ do di cdn hach
Mue dfch ehan doan hach trong SANS bao gdm hach vidm va hach di can 6$ ddnh gia sd bd giai doan bdnh trude khi q u y l t djnh dieu tri. Trong nghidn eUu nay tren 52 trudng hdp SANS danh gia toan bd haeh (trung that va d bung) ed 45 tn/dng hdp phat hidn haeh trong dd 28 tru'dng hpp hach ed ddc diem dl d n (f^l) chiem 53,85%, d n lai 24 tmdng hdp khdng thay haeh di d n (NO) ehiem 46,15%. Khi doi chieu k i t qua chan doan di cdn haeh glOa SANS vdi k i t qua MBHPT sau md eho thay t f fe chan doan dflng cfla SANS d 2 nhdm hach NO va N l tuong Ung la 83,33%
vd 82,14% vd t f Id chung la 82,69%. Trong nghidn edu efla But Vdn Ldnh t f Id ehan doan dflng hach di d n cfla chup CLVT la 73,6%, dd nhay va dp dae hieu lln lupt la 48,3% va 98,4% [1]. Mdt nghidn eUu efla H.J. Dittler va edng sU ndm 1992 cho k i t qua chan doan haeh di d n ehfnii xae d mUc 50% - 60% [9],
K f f L U A N
SANS CO gia tri trong ehan doan giai doan benh UTTQ: Ddi vdi mUc dp xdm lan thdnh (T) thi T3 Id giai doan d tf Id ehan doan dflng, dp nhay va dp dac hidu tdt nhat (>80%); doi vdi di cdn hach thi t f Id xae dinh dflng la 82,69%.
T A I LlgU THAM K H A O
1. Pham DiilC Huan and Dd Mai Lam, Cit thUC quin ndi soi nguc phii vdi tu thi nim sip tmng dieu trj ung thu (/iyc quin. Nghidn cflu Y hpc, 2006. 54(43): p. 30 - 33.
2. Bui Vdn Lenh, D6 Dflc Van, Hoang DUc Kiet, Tridu chimg lam sing vi die diim hinh anh ung thu thuc quin trdn chup dt Idp vi tinh. Y hoc thuc hanh, 2006: p, 39 - 42.
3. F. Campbell, W. V. Bogomolets, and G. T. Williams.
Tumors of the esophagus and stomach. Diagnostic histopathoiogy of tumors, 2000.1: p. 313-328.
4. J. Vickers and D. Anderson, Oesophageal cancer s^ging using endoscopic ultrasonography. Br. J. Surg.
1997.85: p. 994-998.
5. F. K. Binmoeller, H. Seifert, and al.. Ultrasonic esophagoprobe for TNM staging of hightly stenosis esophageal caminome. Gastrointestinal endoscopy, 1995.
41(6): p. 547-552.
6. T.L. Tio. P.P. LO Coene, and al., Endosonography in the clinical staging of esophagogastric carcinoma.
Gasti-ointest. Endosc. 1990. 36: p. 2 -10.
7. Vazquez-Sequeiros, E., Optimal staging of esophageal cancer. ANNALS OF GASTROENTEROLOGY, 2010. 23(4): p. 230-236.
8. Jr. Gregory Zucearo and al. Endoscopic Ultrasound Ermrs in Esophageal Cancer. /American Joumal of Gastroenterology, 2005. 100: p. 601 - 606.
9. Dittler HJ, Pesarini AC, and S. JR.. Endoscopic classification of esophageal cancer: Correlation with the T stage. Gastmitest Endosc, 1992. 38: p. 662-668.
NGHIEN CIAI GAC DANG CHIA NHANH DdNG MACH MAC TREO TRANG DUDI VA l)NG DUNG TRONG PHAU THUAT NOI SOI DAI THUC TRANG
N G U Y I N Hiru THJNH, N G U Y I N HOANG BAC, Lg VAN QUANG, PHAM V A N TA'N, N G U Y I N V A N CHLTNG TOM T A T
Md dau: Trong phau thuit ndi soi (PTNS) dt dai tnjc tring, hiiu ro vi nim vdng giii phiu mach mau va SI/ phin nhanh cda ddng mach mac treo tring dudi (DM MTTD) la diiu rat quan trgng. Muc tidu nghidn cdu Id xic djnh tlld cac dang chia nhanh cda ddng mach mac treo trang dudi Cmg dung trong phau thuit ndi soi cit dai true trang.
Dii tugng va phuang phap nghidn cdu: Bio do hing loat ca dugc PTNS dt dai true trang d ghi hinh cudc phdu thuat vd DM MTTD dUdc bde Id ro tan gic.
ddng thdi phiu tich din chd phin chia c^c nhdnh cda ddng mach.
Kit qui: Cd 32 tn/dng hgp (15 nam, 17 nO), tuii tmng binh 59,2 ± 15,9 tuii. Trong do, cd 13 trudng hop (40,6%) la dang SS (DM DTT va DM DTCH khdng cd thdn chung) chiim tp Id cao nhit, 10 trudng bap (31,3%) Dang V (DM DTT, DM DT CH vi DM TT7" cd Chung 1 diim xuit phat). Dang Y (DM DTT- CH cd 1 thdn chung) cd 7 tn/dng hgp (21,9%). Chiim tp Id thip nhit li Dang Kb (khuyit DM DTT) cd 2 tn/dng hgp (6,2%).
Kit luan: Hiiu biit chi tiit vd suphin chia nhinh mach miu cda ddng mach mac treo trdng dUdi giOp cho phiu thuat ndi soi dt dai true trang an toan vi hidu qui.
Tirkhda: Phau thudt ndi soi, ddng mach mac treo tring dudi, ddng mach dai trdng trai
SUMMARY
BRANCHING PATTERN OF INFERIOR MESENTERIC ARTERY OBSERVED IN LAPAROSCOPIC COLORECTAL SURGERY
Background: Branching pattern of inferior mesenteric artery (IMA) and patterns of vascular supply to the left colon and rectosigmoid areas, though important during colorectal surgery. This study aimed to determine the rate of the branching pattern of IMA observed in laparoscopic colorectal surgery.
Materials and Methods: Thirty - two cases (15 males, 17 females) were studied and determined branching pattern of inferior mesenteric artery (IMA).
Results: IMA frequently branched into left colic artery and a common sigmoid trunk (Type SS) in 13
Y HOC THVC HANH (950) - s 6 2/2015
cases (40.6%), the second rate of branching Pattern of IMA had a common trunk of three branch (Type V) in 10 cases (31.3%), the third rate of branching pattern of IMA branched into surperior rectal artery and a common left colic trunk (Type Y) in 7 cases (21.9%), and the lowest rate was absent the left colonic artery (Type Kh) in 2 cases (6.2%).
Conclusion: A detailed knowledge of the colorectal blood supply and its variations is necessery for performing a safe and efficient laparoscopic colorectal surgery.
Keywords: Laparoscopic surgery, inferior mesenteric artery, left colonic artery.
udDAU
Ti!r khi Jacob gidi thieu p h i u thuat ndi soi eat dai trang dau tien tren the gidi nam 1991, ky thuat ndy ngay d n g phat triln vd da ehfeig td dupe nhiJng uu d i l m so vdi md md [1]. Trong p h i u thuat ndi soi d t dai true trang do ung thu, nguyen tac "no-toueh"
(khdng eham den) vd nao haeh doi hdi bac sT phiu Uiuat phai nam viJmg giai phdu cung nhu su lien quan giO^ d e maeh mau mac treo dai ti^ng [2].
Ngoai ra, nhieu p h i u thuat vien quan tam sau phiu thuat d t ndi dai tnic trang la vj tri that ddng maeh va tinh trang rd, xi mieng ndi. Theo Treneheva K [3], vj tri that eao ddng maeh mac treo trdng dudi cd tl Id xi midng ndi gap 3,8 lan so vdi that thap ddng mach nay. Nghidn cflu d a Bieleeki K [4], Hsu T [5]
eho rang d l h^nh dupe rd, xi mieng ndi sau phiu thudt d t dai true trdng thi phai dam bao dUde nhUng nguyen tae Idm eho mieng ndi lanh tdt. Trong dd, hai nguyen tae dUde chu f nhieu la:
- Mieng ndi khdng d n g (phu thude kha nang bde Id va di ddng tdt dai trang).
- D a m bao day dfl mach mau cung d p eho dau midng ndi.
Chi'nh nhOng d i l u ndy d n g k h i n g djnh dUdc vide hieu rd va nam vQng giai phdu mach mdu vd sU phan nhanh cfla dpng mach vung dai tnJC trang se giflp giam di nhung b i l n chOfng nhu: rd, xi mieng ndi. Mue tieu efla nghien eUu nham xac djnh t l Id eac dang ehia nhanh cfla ddng maeh mac treo trang dudi flng dung bxing phdu thuat ndi soi d t dai true trang.
DOI T U p N G V A PHUONG PHAP NGHIEN CCTU PhUdng phap nghien cUu: Bao d o loat ca.
32 trudng hpp (15 nam. 17 nO) dUde PTNS d t dai true trang ed ghi hinh cudc phdu Uiudt va D M MTTD dupe bde Id ro tan goe. ddng thdi phdu tfeh d i n ehd p h i h chia d e nhanh cfla ddng mach tai Benh vien Dai hpe Y DuOc T P . H d Chf Minh tU thdng 01/2008 den thang 04/2014.
KET QUA
C d 32 trudng hdp dUdc dua vao nghien cflu, tudi t m n g binh 59,2 ± 15,9 tudi.
Cac dang ehia nhanh cfla D M MTTD (Bang 1).
Cd 10 trudng hdp (31.3%) d chia nhanh dang V;
ddng m a d dai ^ n g ^ i v a dpng maeh dai trang ehdu hdng x u l t phdt tai mdt vj t n tren D M MTTD.
7 trudng hdp (21,9%) dang Y : C d thdn chung gitfe dpng maeh dai trang b a i va ddng m a d dai trang ehdu hong.
13 tmdng hop (40.6%) d d i a nhanh dang song song: ddng maeh dai trang trdi v d ddng m a d dai trdng chau hong d xuat phat tU D M MTTD tai hai vj tn rieng bidt nhau.
2 t m d n g hop (6,2%) dpng mach dai h^ng trai khdng xuat phat tatc t i l p tU D M MTTD.
Bang 1. Ti Id d c dang chia nhanh efla D M MTTD Dang
V
Y
SS
Kh
Minh hoa
L4/
[4<
^ _.,...
-k^ , — -"
Sd tn/dng hop
10
7
13
2
(%)
31.3
21,9
40,6
6,2
BAN LUAN
Trong nghien eUu efla ehflng tdi ti Id dang song song ehiem ti le eao nhat 40,6% (13/32 ca) tUdng bS vdi nhiing nghien cUu \rudc day efla Griffiths [6] la 4 1 % (41/100 tnidng hpp). Sinkeet S [7] la 43,9%
(25/57 trudng hpp), Nguyin PhUdc VTnh [8] Id 42,5%
(13/40 tmdng hdp). Mgt sd nghidn eUu khae d tf Id dang nay eao hdn nhii Yada H [9] la 58% (151/260 hudng hdp), Nicolas A [10] la 56% (71/127 ca), Le Van Cudng la 58,06% (36/62 xac). SU khac nhau nay d the do sd lidu trong mdu nghien cC^ efla ehiing tdi d m l u nhd, phuong phdp tiln hdnh khac nhau va nhdn djnh trong Iflc phdu tiiudt cung d nhilu tiiay d l i qua nhiing thdi diem khae nhau giii^ d c tac gia.
Chiem ti le eao thU 2 tmng mdu nghien eUu d a ehflng tdi la dang hinh V 31,25% eflng tuong dUong vdi nghidn cflu cfla nhilu tae gia nhu: Nguyen PhUdc VTnh la 37.5%, Ld Vdn CUcmg la 24,19%, Nicolas A la
Y HOC THUC HANH (950) - S6 2/2015
38%. Nghien cUu cfla Griffiths d dang hinh V thap hdn (23%).
Tl Id dang hinh Y trong m l u nghien cUu cfla ehflng tdi Id 21.9% cao hOn so vdi sd lieu cfla Le Van Cudng la 17,75%, Nguydn Phudc VTnh la 12,5%, thap hdn nghien cCiu cfla Griffiths JD vdi dang hinh Y chiem 30% va ed khac biet Idn trong nhdm dang hinh Y so vdi nghidn eUu da thuc hien efla Nicolas A [10] ehiem tile 6%.
Trong nghien cUu cfla Sinkeet S [7] nam 2012 d dan sd Chdu Phi, tdng ti le 2 dang hinh V va dang hinh Y la 56,1% (32/57 trudng hdp) eung tUdng dUOng vdi ti' le ma ehung tdi ghi nhan dUdc 5 3 , 1 % (17/32 tiudng hdp).
Trong 1 mdu nghidn cUu trdn 260 tn/dng hpp cfla tac gia ngudi Nhdt Yada H [9] dude ehup XQ cd d n quang de quan sat s u phan nhanh efla DM MTTD tnJdc md ghi nhan dang Y ehiem ti le 27% (70 TH), dang V chiem 15% (39 TH), cd khac so vdi nghien d u cfla chung toi la dang V chiem t! Id cao hOn dang Y. Tuy nhidn, tac gia nay eung khdng ghi nhan d tdn tai dang Kh nhu ehung tdi da ghi nhdn.
Nghien cUu khac trdn 40 xdc cfla tdc gia Nguyen Phudc vTnh thuc hien nam 2006 ed 5% khdng d DM DTT, theo Gnftiths JD [6] dang nay cd t f Id 6%.
Nghien cUu cfla ehiing tdi eung ed ti le khdng ed DM DTT Id 6,25%. Ti Id nay khae so vdi nghien cUu efla Sinkeet S [7], Nicolas A [10] va Le Vdn Cudng vdi ghi nhdn khdng cd trudng hpp khdng ed DM DTT.
Trong mdu nghien eUu 40 ca cfla Nguydn Phude VTnh cd 2,5% DM DTT khdng true tiep xuat phat tU DM MTTD ma xuat phat tU dpng mach thdn tang.
Trong bao d o cfla Yoo SJ, Yi S ghi nhdn ed trudng hop DM MTTD xuat phat true tiep tU DM mac treo trang tren. Trong 32 trUdng hpp cfla ehflng tdi nghien cUu khdng ghi nhdn nhung dang nay.
Trong mdt nghidn cflu mdi day cfla Treneheva K vd es [3] vi tri that ddng mach cd anh hudng rat ldn den tinh trang xi mieng ndi sau mo. That eao DM MTTD chilm ti Id xi mieng ndi la 10,2% (13/127 TH) cao g i p 3,8 l l n so vdi vj tri that thap 3,4% (6/167 TH) cfla ddng maeh ndy (p=0,028). Cung trong nghien cUu ndy tae gia eung nhdn djnh ti Id xi mieng noi d nhdm ed ehieu ddi mieng n i l (tfnh tU ria hdu mdn d i n bd midng ndi) £ 10 cm chiem 13,9% (21/151 TH) eao hdn hdn so vdi nhdm ed midng ndi dai > 10 em chilm 3% (14/465 T H ) ( p < 0,01).
Theo Buunen M va cs eho rang, ti Id xi midng ndi phan ldn la do do cang se anh hudng d i n maeh mau cung d p cho midng ndi. De giai quylt van de nay tae gia cd dua ra 3 giai phap: giai phdng DT chau hdng that tdt hoae di ddng gdc Idch hay that cao DM MT7D. Trong dd, 80% (12/15 tmdng hpp) tae gia that thap DM TTT la dfl dam bao mieng ndi khdng edng.
Khi dd, viee that cao ehl Idm eho midng ndi rdi vao tinh trang thieu mau va phSi hoan todn phu thupe vao ddng maeh vien d p mau ti^ nhanh ddng maeh dai bdng giiJa.
Do vdy, vdi bang phan loai cae dang chia nhanh DM MTTD ma trong nghien cUu efla ehflng tdi ghi nhan dUdc, se giflp phdn nao eho bde sT phdu thuat cd nhiJmg nhdn thUe rd hdn ve giai p h i u maeh mau, ddng thdi ed nhUng ap dung dd dang trong thUe hanh lam sang, dae biet trong p h i u thuat npi soi eat d c nhanh mach mau DM MTTD cd chpn Ipc. Vdi nhfltig trudng hpp khdi u dai trang trai hoac dai trang chau hdng ndn bao tdn ddng maeh tnic trdng tren, b^nh that cao tan gdc de dam bao phan xa efla midng ndi ed nguon d p mau tdt n h i t ed the.
K^T LUAN
Nghien cflru nay gdp p h i n vdo giai phdu hpc ung dung trong thUe hanh lam sang ve ddng maeh mach treo trang dUdi va eae dang chia nhanh efla dpng maeh nay. giup eho bac sT p h i u thuat d nhutig nhan djnh rd rang, chinh xae hdn trong viec kiem soat mach mau, flng dung trong PTNS cat dai trUe trang htJTu hieu, giam nguy cd tai bien, b i l n ehflng.
T A I L I $ U THAM K H A O
1. Jacob BP (2005). "Laparoscopic colectomy for colonadenocarcinoma. An 11-year retrospective review with 5-year survival rates". Surg Endosc. 19. p. 643 - 649.
2. Tumbull RB, Kyle K,. Watson FR, et al (1967).
"Cancer of the colon: the influence of the no-toueti isolation technic on survival rates". Annals of Surgery.
166(3), p. 420-427.
3. Treneheva K. Monissey KP, Wells M. et al (2012).
"Identifying Important Predictors for Anastomotic Leak After Colon and Rectal Resection". Ann Surg, 257(1), p.
108-113.
4. Bieleeki K, Gajda A (1999). "The cause and prevention of anastomotic leak after colorectal surgery".
Clin Oncol, p. 25 - 30.
5. Hsu T (2007). "Inferior mesenteric artery stump pressure is an unreliable > predictor of the outcome of colorectal anastomosis". Int J Colorectal Dis. 22, p. 1481 - 1484.
6. Griffiths JD (1956). "Surgical Anatomy Of Ttie Blood Supply Of The Distal Colon". Ann R Coll Surg Eng. p.241-256.
7. Sinkeet S, Muthoka J, and Saidi H (2013).
"Branching Pattem of Inferior Mesenteric Artery in a Black African Population: A Dissection Study". ISRN Anatomy, p. 1-4.
8. Nguyin Phudc VTnh (2006). Dde diem giai phau hpc mach mdu mac treo 6 ngudi Viet Nam. Luan van thae sT Y hoc. Dal hoe Y Dupe TP. Ho Chi Mmh.
9. Yada H, Sawai K, Taniguehi H. et al (1997).
"Analysis of Vascular Anatomy and Lymph Node Metastases Warrants Radical Segmental Bowel Resection for Colon Cancer". Worid J Surg, 21. p. 109 - 115.
10. Nicholas A, Michels MA, Slddharth P, et al (1964). "The variant blood supply to the descending colon, rectosigmoid and rectum based on 400 dissections". Dis Colon Rectum, 8(4), p. 251 - 278.
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