can tiiiip khdng edn trudng hpp n i o ehi tra Idi dung <
10 cay thudc.
• TtaiaiaiigS-iattie \
Bleu do 1: Kl^n thdc ve che pham YHCT biidc va sau can ttiiep cua nti6m doi tUUng da) dl^n cdn bo y ts Bieu dd tren cho biet kien thdc ve che pham thudc YHCT cda ddi bJdng dai diin eho c i n 1)6 y t i , va chi sd hiiu qua tai hai tiidi diem trudc can tiiiep va sau can tiiiep. Sau can tiiiep lain thdc v i d i i phim tiiudc YHCT ciia nhdm can tip y te duae cai thiin rd ret vdi chi sd hieu qua ddi vdi viec tra IdidOng t U S d i n 10 che phim l i l i 700% va tra ldi ddng 5 - 7 che pham l i 182,3%, vdi X ± SD chung cua 03 tinh trudc can thiep 3 , 1 ± 1 , 8 v i x ± S D sau can tiiiip 7.6 ±1,4.
Bang 5. Kien Uidc ve huyet vung d i u mat ed tnjdc v i sau can thiep eda nhdm ddi tuang dai dien can bd y
thiin ro ret, trudc can thiep chi cd 01 can bd tra ldi ddng Kf 8 - 1 0 huyet. sau can thiip cd 10 ngufli ba ldi ddng, so ngudi tia Idt dung tU 5 - 7 huyit chiim ty le 35,2%, tmdc can thiip chi chiim ty l i 7,8%. sU khac biit cd y nghTa thdng k i vdi sd huyit tra Idi dung tmng binh tmdc can thiip l i 1,69 ± 1,9 va sau can thiep 5,09
± 2 , 1 .
Bang 6: Thay ddi.diem tmng binh ky n i n g ke dem cda nhdm can t)6 y te trudc va sau can tiiiip trong tticii
te
\ K i *
\ thUc Sfihuyfit IraifilX.
dOng \ 8-10 huyfit 5-7 huyet 3-4 huvfit
<3 huvfit Z±SD
Ha Tinh (n=31)
(%)
T0 6.4 16,1 77,5 1.7±
1,9
(%)
S6,5 38.7 48,4 6.5 4.9±
1.9 TtiOaTtiiSn HuS(n=30)
(%)
T0 10.0 13.3 76.7 1.7±
2.0 S(%)
10,0 33,3 47,7 10,0 5.0±
2,1 Binh Binh
(n=36)
(%)
T3,3 6,7 10.0 80.0 1.7±
1.8
(%)
S16.7 33,3 43,3 26,7 5,3±
2.3 Chung n=91
(%)
T1,1 7,9 13,0 78,0 1,7±
1.9
(%)
S11.0 35,2 46,2 7,7 5,1±
2,1 Chan
h iech
%
9,9 27,3 33,2 -70,3
Sau can tiiiip cda nhdm can bo
gian 1 nam
Tan t'nh ^ — ^
Ha Tinh TtiUa Thian Hua
Binh Binh Chunq
Bi^tmngtllnh( i r ± 5 0 ) TCT 4,0*1,4 3,9 ±1,6 4,0 ±1,7 4,0 ±1.6
SCT 6,3 ±1,1 6,4 ±1.5 6,4 ±1,4 6.4 ±1.3
P1 m
< 0 »
<H0S
<o,os
<0,05
kiin thdt v i huyit vdng d i u mat co y te so vdi tmdc can thiip dUde cai
Sau can thiip ky n i n g ke ddn cda nhdm can bd^y te duac cai thien ro ret so vdi thdi diem trUde can t h i ^ d mdP ed y nghTa thdng k i .
KET L U A N
Cac hoat ddng v e Y H C T tai 03 T Y T can thiep dUOc cai t h i i n rd ret.
Ty le kham chda benh bang YHCT t i n g so vdi budc can thiep vdi c h i s d h i i u qua l i 79,4%.
Sau can thiep kien tiidC va ky n i n g thuc hanh v l YHCT cua nhdm can b d y te dupe cai t h i i n : Kien tiiClt ve huyet vdng dau m i t cS T C T i .7 ±1,9, SCT la 5,1 + 2 , 1 . ky nang ke ddn T C T la 4,0 ± 1,6, SCT 6,4 ± 1,3.
T A I L I E U T H A M K H A O
1. Bp Y te (1999), Dinh hudng chidn lupc kit hop y hpc ci truyin vB y hpc hiin dai tai dja ban xa. Chuang trinh hdp t i c Viet Nam - Thuy Dien.
2. Pham Hung Cdng {1996J, Nghiin cUu Ung dungxa hdi hoa YHCT trong CSSI^D tai cdng ding frorig nin kinh te thi trudng, Luan v i n chuyen khoa cap 2, Dai hoc Y Ha Noi.
3. 8 6 Y te (2001), Cong vSn s d 5123/YT-YH ngiy 03 tiling 7 nSm 2001 v i viec ban h i n h tiiu chi xa tien tien ve YHCT.
4. Bp Y te (2010), Thong tU 12/2010m"-BYT ng^y 29/4/2010 ve danh muc thudc chd yeu ve y hpc cd truyen cho cac cd sd kham chij^ b i n h .
5. Bp Y t e (1998), Hudng din sO dung y dUOc hpc c6 tmyen tal tuyen y te cd sd va cdng ddng, N h i x u i t ban Ha N6i.
6. Bp Y te (1999), Ciy rau eiy thuoc, cBy cinh cay thuoc, cay Bn qua cay thuoc, Nha xuat ban Y hpc.
NHAN XET KET QUA DIEU TRj 52 BENH NHAN UNG THlTDA DAY B A N G P H A U THUAT NOI SOI TAI BENH VIEN TRUNG UONG QUAN DO1108
TOM TAT
Muc tiiu: Nghien eUu nhim md ta kit qua diiu tri phiu thuat ndi sol benh nhin ung thU da day tal Binh viin Quin ddi 108.
Doi tuang va phuang phip: Ddi gdm 52 binh nhin duae chin doin la ung thu da day va dupe phiu thuat ndi soi.
CAO MINH Tt$P, T R I $ U T R i i U DL/ONG
Phuang phap nghiin cUu md ti hii cUu.
Kdt qua vi kit luin:
-Kit qua tdt: 78,8%
- Kit qua tnjng binh: 13,5%
- Kit qui xau (khdng cd td vong): 7,7%.
Nin ip dung phuang phip dieu trj mdi niy tiong
Y HOC THVC HANH (953) - S6 3/2015
phiu diuit diiu tri binh nhan ung thu da diy.
Tir khoa: Ung thu da diy, phau thuat ndi soi d^
day.
SUMMARY
THE EVALUATION OF TREATMENT OF 52 PATIENTS DIAGNOSED GASTRIC CANCER BY GASTRO FIBRO ENDOSCOPY A T ARMY HOSPITAL 108
Objectives: Research was done to evaluate the results of treatment of 52 patients with gastric cancer by gastrt) fibro endoscopy at Army hospital 108 from 2009 to 2011.
Population and method: Population included 52 patients with gastio cancer and treated by gastro ftbro endoscopy operation.
Melhdd was retrospective description. Results and conclusions:
- Good: 78.8%,.
-Fare good: 13.5%).
-Bad(nodeath): 7.7%,.
It needs to apply this method in treatment of patients with gastric cancer.
Keywords: Gastric cancer, gastro fibro endoscopy operation.
DAT VAN DE
Ung thu da day la benh ly hay gap trin the gidi va d nudc ta. Ung thu da d i y ddng dau trong cac loai ung BiUtieu hda, thudng g i p d ngudi tren 40 tudi va chd yiu la ung tiiu biiu md tuyen (chiim tren 95%). D i y l i benh cd ty le td vong cao nhat trong cae loai ung thu.
T9 l i mic d c i c chau luc k h i c nhau: giam d c i c nUdc Chiu Au, chiu My va t i n g d c i c nUde Chau A trong do CO Viit Nam [2]. Phuang phap d i i u tri chd yeu l i phiu thuat cat da d i y . P h i u thuat mo md d i dUdc Pean v i Billroth tien hanh vao n i m (1879-1881) va qua hdn mpt the k j da cd nhieu ky thuit mdi nhung vin chd yeu d i ^ tren 2 phuang phip kinh dien la Billrotii I v i Billroth II [3].
Phiu thuat npi soi duac sd dung de i^eu tri nhieu behh ngoai khoa, ngoai ra p h l u thuat ndi soi d i dude dng dung trong dieu trj ung thu: nhu ung thu dai - trite tr^ng, gan, thuc quan... M i c du v i y ddi vdi ung thu da day do tinh chat cda p h i u thuit, d i e diem eda nao vet hach, tien lUdng xa nen p h i u thuat ung thu da d i y v i n chua duae chip nhin rdng rai t r i n t h i gidi [5].
Sau thinh cdng cat da d i y qua ndi soi cho benh nhan ung thu da d i y duac thuc hiin bdi Kitano S nam 1994, loai phlu thuit nay dd nhanh ehdng phat then d Nhat Ban va cac nUdc chau A. Ngiy cang nhieu phiu thuit viin thich eat da d i y qua npi soi han phiu thuit md md kinh d i i n vdi tinh uu viet cda cua nd: hdi phuc sdm, it dau, tinh t h i m mTcao... [6],
Trong nhdng n i m g i n d i y sd lupng benh n h i n cat da day bang ndi soi cd xu hudng t i n g dan. Phiu thuat nil soi dang dan dUde cdng nhan la mot phuang phap tiiieh h ^ de d i i u trj ung thu da day giai doan sdm [9].
Nhuhg ddi vdi ung thu da d i y giai doan tien tnen tiii vin edn nhieu tranh cai do sU nghi ngai ve han che cOa phuang phip n i y khi nao vet hach. D i e biet d V[et Nam, viec dieu trj tiiit c i i i ung UiU da day bang phau tiiuat ndi soi d i dUdc nhieu tac gia di cap d i n nhung
chua thuc su Uiuyit phuc vi sd luang cdn it, Uidi gian theo ddi edn ngan [1].
X u i t phit td ly do ti-in, chung tdi thuc hiin de tai 'Nhin xit kit qui diiu tri ung thu da day bing phuang phip phau thuit n& soi tai Binh viin Trung uang Quin ddi 108" n i y vdi hai muc t i i u :
Nhin xit kit qui diiu tri sdm ung thu da diy bing phiu thuat ndi soi tai Binh viin Trung uang Quan ddi 108 tu 7/2009 den 11/2011.
D6\ Tl/pNG VA PHUONG P H A P NGHIEN CLfU 1. Do1 tuang nghien cuu
1.1. Tiiu chudn lua chpn
- Cae^binh nhan ung thu da d i y duae phiu thuit npi soi cat da day va vet hach D2 tai Binh vien Tmng uang Quin doi 108 Ha Noi.
- Binh r^hin ung thu bieu md tuyen duae chan doin giai phiu benh ly sau p h i u thuat.
- Ung thu da d i y duac xac djnh chua cd di c i n xa bang c h i n doan hinh anh va noi soi khi md.
- Ung thu da day dUdc mdt nhdm phlu tiiuit vien thuc hien tU thing 7 nam 2009 den thing 5 n i m 2011.
1.2. Tiiu chudn loai trd
^- Cd di c i n xa duac xac iSnh bang hinh anh v i khi md.
- Ket qua md benh hpc khing phai bieu mo tuyin.
- Khong ed k i t qua md binh hoic do that lac.
- Ung thu da d i y thd phat h o i c t i i phat.
- Cd binh iy kem theo ehdng chi dinh phlu thuit n i l soi.
- UTDD ed kem theo cac benh ly khac nhU: soi tui mat, u nang budng trtJTig...
- Khong dd hd sd benh an.
- Loai bo nhdng trudng hdp mat thong tin.
2. Dja diem nghien cihi: Tmng tam phau thuit npi soi Binh viin 108.
3. Thdi gian n g h i i n cUu: Td thing 7/2009 d i n thing 5/2011.
4. PhUdng phap nghien cdu 4.1. Thidt kd nghiin cdu: Md ta hdi cdu.
4.2. Cdmiu: Gdm 52 benh nhin cd dii t i i u chuan ung thu da day trong thdi gian nghiin edu.
4.3. Thu thip thong tin: Thdng tin td hd sd benh i n duae ghi nhin tU 7/2009 d i n 5/2011.
4.4. Thu thip thong tin: Sd liiu dUpe thu thap theo m i u nghien edu thdng nhit, theo trinh tu sau:
4.5. KS thuit n0i soi cat da diy vi n^o vit hach 02
- Chuan bi binh nhin' Thut t h i o phin, an than bude ngay mo. Nhjn i n , sonde da diy, sonde tieu tnJde md.
- Phuang phip vd cam, Ndi khi quan.
- Tu the benh nhin: Nam ngda, 2 chin dang khoang 45 do, dau cao. P h i u thuit v i i n ddhg gida 2 chan binh nhin, ngudi phu 1 cam camera dUng ben phai phlu tiiuat vien, ngUdi phu 2 ddng ben trai benh nhan.
- Trang thiit bj: Dan may NS Olympus, nguon sang lanh Xenon 300W, dng kinh quang hoc 0 dp va 30 dp, m i n hinh chuyin dung cho phlu thuat npi soi, may
fHOr iiUC HANH (953) - S 6 3/2015
bam hdi tu ding, h i thdng may hdt c h i n khong. Bd dung cu dung cho npi soi 6 bung day du, dao dien dan cue, dao siiu am, dung cu ven gan, endostapler, dao ligasure hoic bipolaire, hamoniscapal.
- Ky thuat: P h i u thuat do c i c b i c sy ed trinh do chuyen mdn cao cda Binhvien thuc hien.
4.6. Cac thong sdphau tiiu0t - Thdi gian md: Tinh bang gid.
- Thdi gian theo c i c thi p h i u thuit: npi soi, ndi...
- Vj bl khdi u.
- Ki'di thudc khdi u (cm).
- So luang hadi va vj tn hach vet dUde (vj bi theo phan loai eda Nhat Ban).
- Phuang phip ndi vj tring: Billroth I hoac II, Omega, Roux-en-Y.
- Luang mau mat trong md: Tfnh bang sd luang m i u trong binh hut + M i u tiiam gac (ml).
- Luang mau tmyen frong md (ml).
- Tai biin trong md.
- Chuyen md md va ly do.
4.7. Danh gii kdt qua sdm sau md - Danh gia sau mo trong nhCfng ngay nam vien - Bien chdng sau md.
+ Nhe: Khing de doa b'nh mang benh nhan.
+ Ning: De doa den tinh mang benh nhan.
+ Tdvong, cac tinh trang ning xin ve sau mo cung COI l i td vong.
- Thdi gian cd nhu ddng mot trd lai sau md (ngiy).
- Thdi gian dung thudc giam dau sau md (ngay).
- Thdi gian nam viin sau md (ngiy).
Phan loai k i t qua g i n .
* Tdt: Phiu thuit ndi soi thuin Ipi, phiu thuit triet c i n , khdng phai chuyen md md, khdng cd tai bien trong md, khdng cd biin ehUng, khdng tdvong sau md
* Tmng binh: Phlu thuat triet can. cd bien chdng nhe sau md khdng phai md Iai. khdng tdvong.
" X i u : Khdng triit c i n , chuyen md md, tai biin, biin chdng ning phai mo lai. tdvong sau mo.
5. x d ly so' lieu
- Sd lieu duac quan ly va xd ly theo ehuang trinh SPSS 15.6._^
- Cac bien rdi rac duac trinh bay dudi dang ty le %.
So sanh k i t qua c i c nhdm bang thuat toan x^- - Cae bien liin tuc dUdc trinh bay dudi dang ket qua tmng binh. So sanh k i t qua gida cae nhdm bang thuat toan test T- student.
- Su khae biit gida cae nhdm khi p<0.05.
K l T Q U A NGHIEN Ciiru
Trong thdi gian nghien edu chung toi thu thip dupe 52 benh nhan, nam 61,5%. nd38,5%. Tudi tmng binh 53,44 ± 12,16 tudi. Cd 48,1% l i m mong va 59,6%
benh nhan ed tien sd benh ly da day. Sau day la k i t qua dieu trj loat binh nhin cua chung toi.
1. Nao vet hach trong mo Bang 1. Sd luang hach v i t d u o c
Sdiutmg
< 10 hach 10-15 hadi 16-20 haiii
n e 15 20
15,4
%
28,8 38,4
>20hadi T4iq
9 52
17.4 too Nlian xet. So luong tiacti vet dUDc it ntiat Id 5 hach va nhieu nhat la 35 hach. tnjng binh la 17.65 hach.
Bang 2. S6 benh nhan c6 hach di c3n ung thU S<! benh nhan
Cohadidican KhfinqcohachdicSn
Tfinq
n 11 41 52
%
21i 78.8 Nhin xit: Cd 78,8% benh n h i n khdng cd di c3n
™
hach khi gdf hach l i m sinh thiit giai p h l u benh, cdn 21,2% benh nhan cd di can hach.
2. Phan loai giai doan ung t h u theo TNM Bang 3. Phan loai giai d'oan u theo TNM
Phan ioai
T
N
M Tl T2 T3 T4 N1 N2 N3 MO Ml
n 15 18 12 7 41 8 3 52 0
X 28.8 34.6 23,1 13.5 78.8 15.4 5.8 too 0 N h i n x e t : H a u h e t b e n h n h a n d e u t h u d c v a o T 1 , T2, N I v i M O .
3. Pham vi cat bo da day v i cac phuang phap lap lEii luu thong tieu hoa
Bang 4, Pham vi cat bd da day Phamvicatdaddv Catdadaylfhanqho^ntoSn
CattoSnbft T6ng
n 51
1 52
98.1
%
1.9 100.0 N h a n x e t : C a t d a d i y k h d n g h o i n t o i n (eat 3/4 vS 4 / 5 ) d U d c t h u c h i e n d h a u h e t c a c b e n h n h i n trong n g i i i i n c d u eCia e h d n g t d i c h i e m 9 8 , 1 % .
• Billroth I
• Billralli II I Omega DRouK-En-Y
Hinh 1. Phuong phap lap lai dudng tieu hoi (n=52) Nhin xet' PhUdng phap Omega va Billroth II dUtJc sd dung nhieu nhat de phuc hdi luU thing dudng tiiu hoa chiem tdi 88,5%.
4. C i c ttiong so p h i u thuat khac Bang 5. Sd lUdng trocart
saiuonq 4tR]cart 5 trocart TAwsS
n 45 7 52
90.4
%
9.6 too Nhin xit: H i u h i t cae binh nhan duac dung 4 trocart de tiiut h i i n cac thi b^ong 6 bung chiem tft 90,4%.
Y HOC THUC HANH (953) - SO 3/201S
Bang 6. Sd luang dich tmng binh trong 4 ngiy dau qua d i n luu sau md
Nqay Nqiyl Nqiy2 N«av3 N9ay4
n 52 S2 52 52
Nh6nhat 8 13 29 7
UnnhSt 18 30 45 15
TB 10.96 23.25 34,42 8,59
QJBdi 2,00 3,89 3,28 1,42 1
Thdi qian
<180 181-211 212-242 243-273
>274 T6ngsfi Nhan xet: Thdi gian oh
n 5 18 10 6 11 52
9,6
%
34,6 19,2 15,4 21,2 100
Tai h i ^ tranq m6 Chiiv m^u Thiinq dai trSnq nqanq
n 1 1
%
1,9 1.9 Nhin xit: Tai bien b-ong phau thuat rat hiim, ehi ed 1 ca chay mau va 1 ca thdng dai trang ngang chung toi phSi chuyen md md de xd ly b i i n ehdng.6. Ket qua phuc hdi sau mo va cac bie'n chOmg Bang 9. Thdi gian cd nhu ddng rudt trd lai {ed tmng tiin)
Tiidi qian fnqavl
<2nqav 2-3nqSv 3-4nqSv
>4nqay T6no
n 13 26 8 5 52
25
%
50 15 10 100 Nhan xet: TTidi gian tmng ti^n tnjng binh la 3,65ngay. Nhieu nhat ia 5 ngay, it nhat ia 2 ngay.
Bang 10. Thdi qian dau Thfri qian (nqdy)
<Inqay 2-3nqdv 3-4nqdV
> 4nqdv T«nq
n 15 25 8 4 52
%
28.84 48,07 15,38 7,61 100 Nhan x i t : Thdi gian dau cda b i n h n h i n tmng binh la 2,47 ngay. Nhieu nhat la 5 ngay v i it nhat la Ingay.
Cd benh n h i n dau l i i n tuc phai dung 3 lo giam dau bong ngay, c d benh nhan chi can diJng 1 Ip la het dau.
Thudc hay dung Perfalgan tmyen.
Bang 11. Thdi gian nam v i i r i Thft qian (nqSv)
<7nqav 7-<12nqdy 12-<17nqay
a17 nq^v t Tlinq
n 25 13 9 5 52
48,1
%
25,0 17,3 9,6 100,0
N h i n x i t : Chd yeu benh n h i n duac xuat v i i n sau 1 tuan dieu trj. Thdi gian dieu trj ngan nhat la 5 n g i y va dai nhat 23 ngay. "Ridi gian tmng binh nam vien la 14 ngay.
Bang 12. Bien chdng sau m d
N h i n xet: Lupng djch tmng binh dan luu o bung cao nhat vao n g i y t h d 3 sau md.
Bien chcmq sau nl6 XinXKhSnqmSiai)
Vifim phdi Nhi§m tninq v^tmd
TrSnkhidui^da Apxedixsaumd
n 3 8 5 6 1
5,7
%
15,3 9.6 11.5 1,9 va tran khi dudi da.
v i ngan n h i t la 150 phut. T m n g binh la 220 phiit, H i u h i t b i n h n h i n duac mo trong vdng 181-242 va t r i n 274 phut.
5. Tai bien t r o n g m o Bang 8. Tai bie'n b'ong m d
Hinh2.K£tquidieutn{n=52)
Nhan xet: H i u het s d benh n h i n deu cd ket qua tdt 78,8% tuy n h i i n v i n cdn fian 2 0 % benh nhan c d k i t qua d i u a that tdt.
BAN LUAN
TU k i t qua nghien cdu 52 binh nhan ung thu bieu md tuyen da day dupe phiu thuat npi soi eat da day ed nao vet hach D2 (theo tieu ehu^n Nhit Ban) tai khoa Ngoai nhan d i n (B15) cda Binh viin Tmng uang Quin dpi 108 Chung t i l e d b i n luan nhu sau'
1. Ky thuat phau thuat noi soi cat da day npi soi Lien quan cCia so luang hach vet duae vdi giai phlu benh sau md:
Ung thu da day chd y i u l i di can theo dudng bach huyet vi vay nao vet hach la vd cung quan trpng trong dieu tri binh. Cd t i c gia cdn viit md ung thu da day m i khdng nao vet hach cd nghTa l i khong phai dieu tri binh [7]. Theo k i t qua nghien cdu cda ehUng tdi thi sd ludng hach vet duac chd y i u l i dudi 20 hach va la t i b i o it biit hda chiem tdi 51,9% (bang 1). Oieu nay cang khiing djnh ung thu da day la ung thu ac tfnh vi t i bao sau md ke ca hach vet duae sau md cung cd dp ac tinh cao vi v i y nd d i di can sang cac tang l i n can ban vi di can da day la theo con dudng hach bach huyet v i mite 66 x i m l i n se nhanh hdn va nhiiu han d i t ra cho phlu thuat vien can nao vet hach ti mi hdn va can thin hdn giUp dieu tri sau nay cd hieu qua hdn va tien lUdng sdng sau md tdt hdn
Sau khi l i m giai phau binh c i c nhdm hach chung tdi thiy ed 11 binh nhan ed ket qua giai phlu la di can hach chiim 21,2% (bang 2). So vdi Dd Van Trang va CS [8] tili trong 55 ea ung thU da day vdng hang-mon vj ed 21 ea khdng cd hach di c i n deu l i giai doan sdm chiem 38%, edn lai di c i n hach td 1 den tren 15 hach chiim tJ l i 62%. Dieu nay ehdng to t>' l i phat hien ung thu da day giai doan mudn d nudc ta cdn rit cao, Dieu n i y se lam eho tien luang khd khin ve thdi gian sdng
Y HOCTHV'C HANH (953) - S 6 3/2015
sau phau thuit cung nhu cac bien phit dieu tri hd trd sau phlu tiiuit di keo dai thdi gian sdng.So vdi c i c t i c gia nUdc ngoai thi ty le di can hach trong nhdm nghien cdu cda hp r i t t h i p chi la 4-6% n i n hp tienluang rit tdt sau md va d i i u tn.
2. Phan loai giai doan ung t h u theo TNM Trong nghiin cdu cda chung toi thi thudng nam trong giai doan T2N1M0 chiem ty l i g i n gan 40%
(bang 3). So vdi mot sd t i e gia trong nude tiii g i n tUdng tu nhu cda Hoang Manh An v i CS [1] thi giai doan T2 chiim 18,4% v i T3 chiim 81,6%. Cdn so vdi Dd Van Tring v i CS [8] tiii ung thU da day giai doan sdm chiim 40%, edn lai 60% la giai doan td T2 trd di.
Trong nghien cdu cda chung toi thi giai doan T2 chii'm hau h i t cac tienh n h i n tdc l i ung thu da lan qua Idp thanh mac ciia da day, ChOTig to ung thu da day duac phat hiin d Viet Nam thudng la giai doan muon vi v i y viec dieu tri ung thu da day thudng la khd khin ke ca trong md md vi pham vi x i m l i n cda khdi u Idn han nen viec cat doan da d i y cung nhu nao vet hach se rat khd khan, tien luang trudc v i sau md cijng de dat hdn.
3. Pham vi cat bd da day
Trong nghiin eUu cda ehdng tdi hau het cac benh nhin d i u dUde eat da day khdng hoan toan do la cat 3/4; 4/5 chiem tdi 98,1% (bang 4). Chi ed mdt ea duy nhat duac cat toin bp da d i y do ung thu vdng tam vj viic phiu ti'ch khdng cd gi la dac biet bang npi soi nhung khi ndi da day va thuc quan khd khin hdn va dudng rach b-in rdn dai hdn, thdi gian mo cung cd dai han. So sinh vdi c i c t i c gia khac nhu Trinh Hdng Son trong mo md tiii cat da day khdng hoan la 96,7% [6], cdn eOa Hoang Manh An thi trong md ndi soi thi cat khdng hoan toan la 94,7% [1].
4. PhUdng phap phuc hoi lai luu thong tieu hda Trong nghien cdu cda chdng tdi cd 4 phuang phap lap lai tuu thdng tiiu hda la Billroth I va II, Omega va Roux-en-Y. NhUng chu yeu la Omega chiem 63,5% va Billroth II chiem 13,5% (bieu dd 5). Dieu nay hap ly vdi diiu kiin Viet Nam, do 2 phuong phap nay bao dam miing ndi an toan khi thuc hiin bang tay va d i thiJC hiin khi dudng rach da la 4cm, khdng sd ndi ngude quai. Cdn phUdng phap ndi t i n t i n khd thuc hiin hdn vdi dudng md nhd va can m i y ndi, stapner rit tdn kem.
Theo kinh nghiem cda chung tdi thi thdi gian ndi bang tay ed chim hdn bang may doi ehijt nhung kiem tra dUdc can than hdn va miing ndi cung an t o i n han, tiet kiem duac chi phi. So vdi mdt sd tac gia nudc ngoai ed khac biet han nhU Kinato.S v i cdng su chii y i u la phUdng phip Billrroth I [10] ed le la do Nhit Ban la nude ed dieu kien kinh t i hdn va che dp chim sdc sau md tdt nen mieng ndi tin-tan tdt han. Cdn trong nghien cdu nay ciia chUng tdi tiiUb hien su phuc hdi luu thdng tieu hda l i Omega la chd yeu vi hau het binh nhan ehdng tdi la noi tay. V i kieu ndi nay tdc cd 2 mieng ndi mdt da day-hdng tring kieu t i n b i n va mdt miing ndi njdt mdt kieu ben-bin n i n khdng sa nguac quai, rat d l tiiUC hiin vdi 16 md tren rdn nhd dac biet an t o i n hdn.
5. Thdi gian p h i u thuat
Theo nghiin cdu n i y "thdi gan p h i u thuat ndi soi eat doan da day ^ n g binh la 220 phut (bang 6) tUdng duang vdi lidn 3 gid nd l i u hdn vdi mdt ca p h l u thuit cat da day md nao vet hach (khoang 200phUt) (bang 7). TTidi gian nay bao gdm ea thi mo ndi soi va md bung: l i y benh pham, lap lai luu thdng tieu hda va dat d i n luu, ddng bung. Thdi gian p h l u thuat nd cdn anh hudng ri't Idn bdi vj tifkhdi u v i kich thude khdi u. Khdi u cang nho tiii giai doan ung thu cang sdm lim cho thdi gian phiu thuit cang nhanh vi eac thi giai phdng va nao vet hach duoe rut ngan han. So vdi Triiu Trieu Duang [4] tnidc d i y 1 nam thdi gian didng toi d i nit ngan dUdc thdi gian xudng g i n 30 phUt. TUdng dUUng cQa Dd Van Trang va CS [8] la 221 phut, Hoing Manh An [1] l i 221 phUt, thi thdi gian frung binh cda chCing tfil g i n tuang duang.
Theo nghien cdu cda chUng tdi ty l i tai bien b'ong md khi phlu tich la 2 benh nhan mdt v i o mach mau va mot thiing dai t r i n g ngang (bang 8J, da diuyen md md ngay de xd tri cac thuang tdn, sau dd binh nhan dudc tmyin m i u v i hdi phuc trong vdng 6 ngiy, xuit vien sau 19 ngay. Theo mpt sd t i c gia khac nhu Hoang Manh An [1] va Kiriatp. S [11] thi khdng cd bien chting xay ra trong md. Qua day, chUng tdi nhin tiiay nhOhg tai biin n i y do sU chd quan khi phlu b'ch v i o cac mach mau Idn v i cac ea md nay deu thuc hiin sau 2 di'n 3 ca md khae n i n tinh than, sdc khde phiu thuit vien khdng duOc tdt nhat. Ve so luBng m i u mit trong md noi soi la rat it hau nhu chi dudi 200ml nen khing phai buyin m i u trong va sau mo do sd lUdng v i chit lUdng mau trong cac b i n h nhin eua chung tdi tnJdc md binh thudng, ngoai tri^ 2 ca ed tai bien phai chuyen md md. Luang mau mat eda md md thdng thudng l i cao hdn g i p nhiiu l i n so vdi ndi soi vi vay da phan md md phai tmyen mau.
6. Danh gia ket qua sau p h i u thuat 6.1. Vdsdluang vivi tri trocart
Chdng tdi thudng dung 4 16 l i chd y i u 90, 4%
(bang 9). K i t qua cua-ehung tdi cao hdn so vdi Dd Vin Trang va CS [8] so luang 4 16 l i 78%, Dieu niy chdng to VI tri cung nhu sd luang trocart phu thudc v i o ttShg binh nhan va p h l u thuit v i i n . Neu dat trocart ddng va hdp ly no giup cho cupc p h l u thuit thuin ldi hdn nd anh tiudng rat Idn d i n k i t qua eda phlu thuit. Theo Chung tdi thi'y thi 4 hay 5 Id phu thuoc vao tdn thuang va lam sao de thao t i c thuin lai nhat.
6.2. Thdi gian dau sau md
Theo nghien cUu eda chung tdi tiung binh la 2,47 ngiy (bang 10) nd ngan hdn r i t nhieu so vdi mo mdvi theo kinh nghiem eda chdng tdi khi md md cat 4/6 da day eho mdt b i n h nhan thong thudng phai dung g\am dau trin 5 ngay d i e biit l i dau vet mo c6 the b^n 10 ngay. Nhieu ngudi nhiim triJng vet md thi thdi gian dau cung nhu khd chju cdn keo d i i han nua. Mdc do dau sau md edn phu thu6e v i o tdng binh nhin, ed benh nhan chi dau 1 n g i y ehi can dung i l i n giam dau, c6n cd binh nhan dau nhieu lan phai dung nhieu l i n giSm dau. Thudc giam dau chdng tdi hay dung sau mo la
y HOC THUC HANH (953) - SO 3/2015
Perfalgan I g tiuyin sau mo thudng dung 2 lp/24h, td ngay thd 2 thi neu b i n h nhan de nghj hoac keu dau tiii mdi ddng. Theo Dd Van Tring v i CS [8] thi mdc dp dau ft sau md ehiem 58% v i khong cd benh nhin r i t dau d cac binh nhin p h l u tiiuat npi soi dieu tri UT viJng hang- mdn vj. Nd cung chdng to dau sau md d benh nhan mo n6i soi l i r i t it ehUng td dau sau md chd yiu la dau v i t md.
6.x Thdf gian cd trung tiin
6 nghiin edu cda chung tdi thi tiidi gian c6 tmng tien la 3,65 ngiy (bang 11). Dieu nay cung chdng to nhu ddng mdt trd lai cda md ndi soi ngan hdn so vdi md md. So vdi D6 V i n Trang [8] l i 2,46 ngiy thi ket qua cda ehdng tdi c6 eao hdn. D i i u nay nd cung ehUng minh mdt d i i u sd b i n h n h i n ung thu giai doan sdm tiong nghien cdu cda chdng tdi it hdn rat nhiiu vi v i y thdi gian phlu thuit s i l i u han cung nhu viec tac ddng bong d bung lau hdn va thdi gian dung thudc giam dau cung anh hudng den thdi gan ed nhu ddng trd lai cda rupt.
6.4. Bien chdhg sau md
Theo nghiin cdu cda chdng tdi thi bien chdng sau md hay gap nhat la v i i m phdi chiem 15,3% trong sd 23 binh nhin CO biin chdng, sau dd l i tran khi dudi da 11,5%, nhiim trdng vet md 9,6 % (bang 12). Nhdng biin chdng n i y khdng phai p h l u thuit lai m i ehi c i n dieu tri n i l khoa h o i c nhu xi ro chung toi de d i n luu lau hdn hoac dat them mpt d i n luu qua v i t rach 4em, cho nhjn i n , bdi phu nudc dien giai va ning lUdng tdt la nd tu lien. So vdi mdt sd t i c gia khie h i u nhu khing c6 bien chdng nhUng chiing v i n cd g i p cd the do che 66 chim sde v i tinh trang nhilm trdng b i n h v i i n cung nhu t h i trang cda benh nhan va giai doan binh.
Nhdng bien chdng chd yeu eda c i c t i c gia Nhit Ban la liin quan den ky thuit.
6.5. Thdi gian nim vi$n &ung binh
Trong nghien cdu cda chdng t i i la 14 ngay (bang 13). Qua d i y cd t h i tha'y thdi gian xuat viin phu thudc vio su phuc hdi sdm hay muon d i e biet la han c h i duac cac biin chdng sau md thi s i l i m cho thdi gian xuit vien sdm hdn. So vdi k i t qua nghien cdu cda Dd Vin Tring v i CS [8] Uii ket qua nam d i i u trj la 5.9 ngiy kit qua eda chdng tdi cd eao hdn rat nhieu vi cd tile nhdm nghiin cdu cda chung tdi ed ngudi gia nhieu hdn va rat it benh n h i n phit hien trong nhdm l i giai doan sdm va nhdng bien chdng sau md cda chdng tdi l i liha eao.
6.6. Lupng dfch din luu dbyng
The hiin qua dan luu nd nhieu nhit v i o ngiy tiid 3
^- sau mo va giam dan trong eac ngay tiip theo ed t h i do ngay tiid 3 luang djch tiach huyit duac tiet ra nhieu f han do qua trinh nao v i t hach. Tat ca cac binh nhin ' Chung tdi d i u d i t d i n luu 6 bung de theo ddi va thong ' thudng l i 2 d i n luu. Nd gidp phit hiin cac bien chdng
sau md sdm han,
6.7. Dinh gii kdt qua gdn sau md
I Nghien cdu eua chdng tdi ch! d i n h g i i k i t qua f trong thdi gian b i n h nhan nam vien thi tdt chiim
^ 78.8%. tmng binh 13,5% va xau (khdng cd td vong.
gdm nhiiu b i i n chdng va ca 2 ca md md) chiim 7,7%
(Hinh 2). Q u a d i y ehdng tdi thay ket qua tdt nghTa la p h l u thuat d i i n ra t h u i n Ipi, vet duac h i t hach, thdi gian h i u phau d i i n ra binh thudng, trung binh la p h l u thuat d i i n ra thuin ldi, hau p h l u mac mdt trong cac bien ChCfng va thdi gian nam v j i n keo dai han va xau la phai chuyin md md, h i u p h i u mac t d 2 bien chdng trd l i n .
KET LUAN
Qua ket qua nghien edu va ban luin 52 benh nhin duae phiu thuat npi soi cat da day cd nao vet hach DII tai Khoa B15 Benh v i i n Tmng uang Quan dpi 108 chung t i i dua ra mdt sd k i t luin sau:
- K i t qua tdt: 78,8%.
- K i t qua tmng binh: 13.5%.
- K i t qua x i u (khdng cd t d vong). 7,7%.
KHUYEN NGHj
Qua nghiin cdu tren chdng toi dua ra mpt sd kien nghj sau.
Phiu thuit ndi sol trong dieu bi ung thu da day giai doan tien trien da va dang eho thiy hiiu qua ciia nd nhung do sd lUdng phlu thuat cdn I't, thdi gian theo ddi, kiem ba sau phiu thuit chu^ duae quan t i m . . . n i n ehang chung ta can cd sutheo doi, chpn nhdng m i u nghien cdu thich hpp d^ dua ra k i t luin cho mot phuang phap dieu trj mdi dang l i xu the cua Y hpc t h i gidi.
T A I LIEU THAM K H A O
1. Hoing Manh An va CS (2011), "Nghiin cOU phiu thuat cit da diy, nao vit hach D2 qua ndi soi hd trp diiu tri UTDD tai Binh viin 103", Tap san Ngoai khoa Viet Nam, tap 61^ sd 1, 19 - 24.
2 Nguyen NhU Bing. TrUdng Nam Chi, Pham Kim Binh {1986), 'Nhan xet ve giai phau binh 442 trudng hpp ung thu da diy trong 5 nim", Cong trinh nghien cUu khoa hpc (1981-1985) Benh vien Viet DUc Ha Npi, 254 - 264.
3. Pham Ding Dieu (2003) "Giai phau ngi/c - bun^, Nha xuat ban Y hoc chi nhanh thanh phd Hd Chf Minh, 192-209.
4. Trieu Trieu Dudng (2009), "Ky thuit nil soi trong thuc hanii dieu trf, Nha xuat ban Y hoc.
5. Pham Nhu Hiep va CS (2008), "Phiu thuat dt da day ndi soi tai Binh viin Trung uang Hui", Tap chf Khoa hpc tiiu hda Viet Nam, t i p 3 so 13, 894 - 897.
6. Trinh Hdng Son (2000), "Nghiin cUu nao vet hach trong dieu tri phiu thuat UTDD', Luan an tien sTy hpc.
7. Trinh Hdng Sdn, 06 DUc V i n (1997), "DBc diim di cBn hach bach huyet ung thu da day", Y hoc thuc hanh 11.11-15.'
8. D6 van Tring, Trinh Hdng Sdn, D6 DUc Van (2009), "Ky thuat nao vit hach D2 trong phiu thuit ndi soi diiu tri ung thu da diy viing hang-mdn vl', Y hpc thuc hanh 2, 644-645.'
9. John. R. Breaux, Walter Bringaze, Charies Chappuis and Isidore Cohn (1990), 'Adenocarcinoma of the stomach: a review of 35 years and 1710 cases', Wortd, J, Surg 11,127.
10. Dieh J.T., Hemiann R.E., Cooperman A M., Hoen"
S.O. (1983), "Gastric carcinoma, a ten years reviewf", Ann.
Surg, 198,9.
» YHO( iH^C HANH (953) - Sd 3/2015
