TAP CHf Y DUOC LAIVI SANG 108 Tap 12 - So 1 /2017
Danh gia kgt qua som dilu tri hoi nach bSng phau thuat tai Benh vien Trung uong Quan doi 108
Evaluate the early results of surgical treatment for axillary osmidrosis at 108 Military Central Hospital
Nguyen Hong Hai Benh vien Trung uong Qudn dgi 108 Tran Trpng Kiim
Tom t ^ t
Muc tiiu: Danh gia k^t q u i sdm cCia phUOng phap phau t h u l t dieu tri hdi n i c h tai Khoa Phau t h u l t Long ngiic - Bdnh vien Trung UOng QuIn dpi 108. Doi tugng vd phuang phdp: Gom 152 benh nhan (110 nO va 42 nam) dUpc md loai bd tuyen md hoi dau tiet dUdi da vung nach, trong dd 92 ca md m d n?o bd tuyen v l 60 ca md npi soi sidu am hiit bd tuyen, ti^ t h i n g 5 nam 2010 d^n t h i n g 5 nam 2015, Kit qud: Tudi t m n g binh cCia bdnh n h l n la 24,2 ± 6,7 tudi; bdnh mUc dp 3:82 ca, dd 4:70 ca; thdi gian eude md trung binh: Md m d 40,1 ± 3,0 phiit, md ndi soi 59,7 ± 4,5 phdt; ket qua md md: Tdt 76,1 %, k h i 18,5% v l kdm 5,4%; md ndi soi: T d t 50%, kha 40% va kem 10%); bien ehUng sdm sau md: Md m d 5,5%; md ndi soi 4,4%. Kit lugn: Loai bd cac tuyen md hoi dau tiet dUdi da vung nach bang p h l u thuat m d m d la bien phap dieu tn ed hieu q u i trong didu tri cho hdi nach vdi t j Id bdnh tai p h l t thap (5,5%). Phuong p h I p md npi soi sieu am hUt tuyen cd uu diem la vet seo md nhd nhung t^ Id tai p h l t Idn hon (10%) v l chi phi phau t h u l t cung cao hOn.
Tdkhda: Hdi nach, phau thuat dieu tri hdi nach.
Summary
Objective:To evaluate the early results of surgical treatment for axillary osmidrosis at Depatement of Thoracic Surgery - 1 0 8 Military Central Hospital. Subject and method: Descriptive and retrospective study on 152 patients (110 women and 42 men) underwent surgical treatment of axillary osmidrosis via manual subdermal shavings (92 patients), and endoscopic ultrasonic aspiration (60 patients) from May 2010 to May of 2015. Result: The mean age was 24.2 ± 6.7, the mean operating time was 40.1 ± 3.0 minutes in manual subdermal shavings and 59.7 ± 4.5 minutes in the endoscopic ultrasonic aspiration.
Results of manual subdermal shaving: Good 76.1%, quite good 18.4% and poor 5.5%. Results of endoscopic ultrasonic aspiration: Good 50%, quite good 40% and poor 10%. Post-operative complication in manual subdermal shaving was 5.5% and that in endoscopic ultrasonic aspiration was 4.4%. Conclusion: Removal of subcutaneous axillary apocrine glands by manual subdermal shaving is the treatment of choice for axillary osmidrosis, with a low recurrence rate (5.5%). Ultrasonic aspiration was effective in achieving short scars and a short recuperated period, but there was dissatisfaction in the rate of recurrence and the extra cost of operation.
Keywords: Axillary osmidrosis, surgical treatment for axillary osmidrosis.
Ngdynhgn bai-21/11/2016. ngdy cfiap nhgn ddng: 01/12/2016
NgudiphdnhSi: Trdn TrpngKi&n, Email: [email protected], B$nh vien Trung uang Qudn doi 108
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY yo(-i2-
I.Datvlnde
Hdi nIch II tlnh trang ed miii hdi, ting tiet md hdi va lam ddi mau l o d vi^ng nach. Tinh trang khd chiu nay ed the anh hudng nang den t i m i>? va chat lupng eude sdng. Nguydn nhln cOa tlnh trang nly II do sU tang tiet qua mijfc eOa tuydn md hdi dau tiet [5]. Dly II ket qui eCia qui trinh oxy hda va thOy phin chat e-3-methyi axit 2-hexenoie, dupe thUc hien bdi hd vi khuan sdng ky sinh tren da binh thudng (staphylococcus aureus, trUe khuin gram Im) [6]. Qua trinh trao ddi chat cOa vi khuan dupe gia tang bdi cle yeu td nhU: Van ddng th^ lUc, tiep xiie vdi nhiet va cang thing ve elm xiie. Cle chit nhu axit bdo, protein va carbohydrate la ngudn tao ra £-3-methyl axit 2-hexenoic. Cho den nay nhieu phuong thile didu trj hdi nach da dupe I p dung va phat trien nhU: Tiem Botox dUdi da vung nach, dCing la-de phi hCiy cau trUc tuyen md hdi dau tidt... Phlu thult dieu trj hdi nach d l dupe I p dung dau tien nam 1987 bdi Resbeca et al [9]. Cae phau thult md md nao tuyen, phlu thuat cd hoac khdng co dung cu hd trd d l thu dupe nhUng k^t qui tuong ddi tfch cue va hidn nay bldn phIp phau thuat de loai trCr tuydn md hdi dau tiet duac col la bien phIp triet d^
nhit de dieu tri benh hdi nieh [1], [2], [3], [8], [10], Tuy nhien bien phIp nay eung di kem vdi mdt ti Id bldn chUng phau thult nhat djnh. Tai Vidt Nam dieu tri hdi nach d l dupe thUe hien d nhidu ca sd y te, chi!i yeu vdi 2 phuong thUe phlu thuat phd bien la md md nao tuyen md hdi dau tiet va ndi soi hiit tuyen bIng dao sieu am, tuy nhien cdn ft thay cac nghidn eUu dupc edng bd vd ket qui dieu trj cung nhU danh gil hieu qui eua cac phUdng thUc dieu tri ndi trdn.
Vi vay chiing tdi tien hanh nghien ciifu "Danh gia ket qui sdm dieu tn hdi nlch-blng phau thult tai Bdnh vidn TL/QD 108" nhim: Ddnh gid tinh hiiu qud vd an todn cua 2 phuang thdc phau thuat mo md nao tuyen vd noi soi nao hut tuyin bdng dao siiu dm doi vdi binh l^hoindch.
2. Doi tupng va phuong phap 2.1.D6itU0ig
Gdm 152 bdnh nhln dupe ch^n doan va dieu trj phau thult benh hdi nach tU thang 5/2010 den thing 5/2015 tai Khoa Phau thult Ldng ngUe - Bdnh
vien T U Q B 108., tich so sani
2.2. PhdcdigphdpNghien euli md ta, tien ' cd ddi chUng.
Chan doln benh hdi nIch va rniJc dd hdi nad bang phuong phap cuon gac (The cotton roll method) do Park va Shin cCing nhieu tac g i l trdn thi gidi sd dung v l gidi thidu E5], [4], [7]: Dung mdt cuor bdng hoac gac dat vao 2 bdn nach benh nhln, sai mUdi phut lay ra va dUOc mdt nhdm gdm 2 ble sTv;
1 y ta cung danh gil mii'c dp mOi hdi nach nhUsau:
Dd 1: Hau nhU khdng nhan thay co mCii.
Dp 2: NgOfi thay mui trong khoing each toi thilt 15cm.
Dp 3: NgCfi thay mOI vol khoing eleh xa hon 15cm.
Dp 4; NgCri thay miii vdi khoing each xa hon 30cm.
Chi dinh md khi benh nhln ed phan nan v l khd chju ve hdi nIch ddng thdi dUpc kham xac djnh mtjc
dd hdi nach 6 dp 3 v l 4. ^ f t Ky thudt mo ^ ^ ^ Tu the: Benh nhln nam ngCra, hai tay dUa Idn dau
tao vdi thin ngucrt gde 110 dp, bdc Id rd vung nach 2 ben. Sat trung vung md bang dung djeh Betadin.
V6 cam: Tien me, te tai cho m6i ben bang 100ml lidocain 0,5%, ket hpp epinephrine 1:200000, ddng thdi llm phdng va bdc tach da.
Tiin hdnh ky thudt
Rach da song song vdi nep gap nach: Dli 3cm vdi md md nao tuydn va 1 cm vdi ndi soi hut tuyen.
DCing keo cong bdc tach Idp da va td ehCfc dUcfi da, tao dieu kidn cho vCing da tap trung tuyen mo hdi dau tiet di ddng thuan Ipi. VOng da nay dupcxac djnh 11 mot hlnh elip, ed dudng kfnh khoing 3eni, md rpng cho den hdt viing ed Idng nach. Dung keo phau tfch elt nao toan bp tuyen md hdi dau tidt, lam tuong tu vdi dao sidu am trong phau thult npi soi hiit tuyen.
Kiem tra cam mau. Bam nia loai bd cae tuyen ^ u tiet d l cat ra khdi trudng md bIng nUdc mudi 0,9%, Tien hanh khau xda khoang bIng cle mui rdi chi Vicryl 5/0, trong da hole toan the ngoai da, khong dan iLfu, Ddng da bIng chi Nilon 5/0 mui rdi toan the. Bang dp
nhe sau md 24 gid bIng bang thun. • Sau md cho dung khing sinh dudng udng. N^L
khdng cd bidn chu-ng die biet -y,^^ ^^^^ ^^^^
vien ngay thU 2 sau md.
TAP CHlY DUOC LAM SANG 108 Tap 12-Sd 1/2017
Hinh 2. Phau thuat md md nao tuydn md hdi Hinh 3. Phlu thult ndi soi hUttuyen bang dao sidu am
Theo doi va dinh gia ket qua Khi: Bdnh nhan hai Idng, ehl thay cd mui khi Theo ddi cac bien chUng sdm sau md: Tu mau Hoat dpng eUdng dp cao. Kham xie djnh mUe dp vung md, tu djeh vung md, hoai tOf vat da vCing md, mui do 2.
toaevetmd... Kdm: Benh nhan khdng hii Idng vi van thay cdn Danh gia ket qui sau md 2 tuan: mCii. KhIm xac dinh mUe dp miii dd 3,4.
Tot: Benh nhan hIi Idng, khdng thay mCii. Kham xie dinh mUe dp mui dp 1.
3. Ket qud
Bdng 1. Gidi tfnh va tudi benh nhan
Gidi tinh v^
tuoi trung binli
Gidi tfnil 1 Nam N i l
1 C6ng
Tuoi trung binli Mean ± SD (IVlin - (Wax)PliUtfng pliap m^
iVIomd n 19 73 92
%
20,7 79,3 100 29,1 ±7,2
(16-45)
IVlo noi soi n 23 37 60
%
38,3 61,7 100 32,2 ± 7,1
(17-45)
n 42 110 152
%
27,5 72,4 100 30,3 ±7,3
(16-45)
Nhdn xet: NU gap nhi^u hon nam (72,4% so vdi 27,6%). Tudi trung btnh cua bdnh nhan la 30,3 ± 7,3 (tre
nhat la 16va Idn nh^t la 45).
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY VoL12-N'1/20}7-
Bibng 2 , IVIi]rc d o benh
M i l c d d b f n h
0 6 3
Bo 4
edng
PhiTorng phap m6
K6m6 n
45 47 92
%
48,9 51,1 100
M6 ndi soi
n
35 25 60
%
58,3 41,7 100
n
80 72 152
%
52,6 47,4 100
P
0,319
Nhdn xit: P h i n Idn benh nhan (52,6%) bj benh d mii'c d p 3. Khdng cd sU khac biet giufa 2 phUdng p h I p m d m d v l m d n p i s o i v e m U c d d n a n g e C i a bdnh (vdi p=0,319).
Bdng 3. ThcN gian cudc mS va t h d i gian n a m vien
Thdi gian
Thdi gian cuoc mo (phOt) Mean ± SD (MIn - Max) So ng^y n I m vien Mean ± SD (Min - Max)
PhiTtfng phap mo iVIomd
40,1 ± 3 , 0 (35-60) 2,5 ±1,1 ( 2 - 7 )
IV16 ndi soi 59,7 ± 4 , 5
(50-70) 1,5 ±1,1
( 1 - 7 )
Cong
47,8 ± 1 0 , 3 (35-70) 2,1 ± 1 , 2 ( 1 - 7 )
P
0,0001
0,0001
Nhdn xet: Thdi gian eude m d t r u n g binh d n h d m m d ndi soi (59,7 ± 4,5 phiit) d l i h o n ro ret so vdi nhdm m d m d (40,1 ± 3,0 phut) vdi p=0,0001. Ngupe lai sd n g l y nani vidn t r u n g b i n h eCia n h d m m d ndi soi (1,5 ± 1,1 n g l y ) ngan hon ro ret so vdi n h d m m d m d (2,5 ± 1,1 ngay) vdi p=0,0001.
Bang 4. Bien chUng sdfm sau m d
Bien ehufng sdrm sau mo
Co bien chiJng
Tu mau Toac vet mo Tudich HoaitCrda Tong so co bien chLfng Khong c6 bien chifng
Nhdn xet: 1 (6,7%) n h i m g k 88
Cong
i le CO bien chijng sd hong t h u c s u c o y ng
Phuang phap mo IVIo md
n 2
1 1 1 5 87 92
m sau mo iTa (vdi p=(
2,2
%
1,1 1,1 1,1 5,4 94,6 100
6 n h o m ,740).
Mo noi soi n 1 1 1 1 4 56 60
mo m d (5 1,7
%
1,7 1,7 1,7 6,7 93,3 100
,4%) hoi xt n 3 2 2 2 9 143 152
ap hon so 2,0
%
1,3 1.3 1,3 5,9 94,1 100
vdi n h o m P
0,740
mo npi soi
TAP CH(Y DUOC U M SANG 108 Tap 12-S6 1/2017
B i n g 5 . K £ t q u i k i ^ m t r a s a u m d 2 t u a n
lUlulc d o b e n h
T6t Kha Kem Cong
PhUdng p h a p m6 M o m d
n 70 17 5 9 2
%
76,1 18,5 5,4 100
IMo n o i soi n 30 24 6 60
%
50,0 40,0 10,0 100
n 100 41 11 152
%
65,8 27,0 7,2 100
P
0,004
Nhdn xit: Tl Id ket qua t d t d n h d m m d m d (76,1%) eao hon rd rdt so vdi n h d m m d npi soi (50,0%) vdi p=0,004.
4. Ban l u a n
4.1. Dac diem binh nhdn
Trong 152 bdnh nhan cCia n h d m nghien CIJXJ, sd benh nhan nu" nhieu hdn rd rdt so vdi nam (72,4% so vdi 27,6%, vdi t i Id nU/nam 11 2,6/1). D p t u d i t r u n g binh la 30,3 ± 7,3 tudi, t r d nhat 16 va Idn nhat 45 tudi. Day I I dp t u d i dang ed nhu eau hoat d d n g t h e lUe, ndi ti^t, giao tiep x l hdi...manh me, do d d vide bj hdi nach cd I n h hudng rSt Idn den ch^t lupng cuoc sdng ndi chung va t i m ly ndi rieng eiia benh n h l n , n h i t I I d niJ g i d i
4.2. Mdc do binh vd phuang phdp md
Toan bp s6 benh nhan nghien eiJfu deu cd mUc benh dp 3 va 4 (52,6% la dp 3 va 47,4% la d p 4), nghia ia ed t h e n h l n thay ngay cd mCii hdi d k h o i n g each hon 15cm. Rd r i n g d mUc dp bdnh nhU vay t h i viec chi dinh m d la hoan toan thda d i n g . Qua d l y chung tdi cung n h l n t h a y phUdng phap kham xac t^nh miJc bdnh theo phan d p hdi n I c h eiia Park va Shin (phUdng phap cuon gac) la m d t p h u o n g phap rat thuan tien, kinh t e , de ap d u n g , hieu qua cao va kha chfnh x i e de danh gia mUc dp bdnh eung n h u xac ^ n h chi ^ n h dieu tri p h l u t h u l t . Nhan xet n l y cCia chung t d i cung tUdng t u c l e nghien cUu cCia S h i r o [ 7 ] v l D a e j i n [ l ] .
P h i n tfch m d i lien quan giufa mii'c d p benh v l phuong p h I p m d cho t h i y : Ti Id mUc benh d p 4 d nhdm m d m d (51,1%) hoi cao hon so vdi n h d m m d
ndi soi (41,7%), t u y nhidn su k h I e biet d d k h o n g thUe su cd y nghia ve t h d n g ke (vdi p=0,319). Ket qua nay cho phep ket luan la t r o n g nghien cdu nay viec chi ^ n h phUcmg phap m d khdng lidn quan d d n mUc dp bdnh, ndi each khac vide chi d j n h p h u o n g phap m d m d hay m d ndi soi khdng phu t h u p c vao mdc dp bdnh hdi nach cCta bdnh n h l n .
4.3. Thdi gian cu6c mo vd thdi gian ndm vien Thdi gian eude m d t r u n g binh 6 n h d m m o ndi soi (59,7 ± 4,5 phiit) dai hon r d ret so vdi n h d m m d m d (40,1 ± 3,0 phiit) vdi p=0,0001. Ket q u i n l y eho t h a y viec thUc hien ky t h u l t m d m d ydu eau t h d i gian nhieu hon so vdi ky t h u a t m d m d t h d n g t h u d n g , n g o l i ra viec sii d u n g dau d a o , s i e u a m eung g d p phan l l m cudc m d npi soi cd ehi phf p h u t h d m cao h o n so v d i m d m d t h d n g t h u d n g . Tuy nhien m d ndi soi lai cd uu d i e m v u p t t r d i so vdi m d m d la de lai v ^ t m d nhd h o n , ft anh hUdng d e n t h a m m y hdn [9].
Sd ngay nam vidn t r u n g b i n h eua n h d m m d npi soi (1,5 ± 1,1 ngay) ngan hon rd ret so vdi n h d m m d m d (2,5 ± 1,1 n g l y ) vdi p=0,0001. Tuy nhien, t a t ca benh n h l n sau d d deu dupe theo ddi va ^ e u t r i t h e o che do ngoai t r i i t r o n g 5 ngay t i e p t h e o t r u d c khi t h y c sU ket thiie vide dieu t r i . Khdng cd benh nhan nao phai dan luu sau m d . NhiJng t r u d n g h p p d n d m h , benh nhan cd t h e sinh hoat binh t h u d n g ngay sau m d . Diing k h I n g sinh d y p h o n g (dUdng udng) eho tat e l benh n h l n . Dung giam dau sau m d bang
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N''1/2017
udng paracetamol 0,5 x 2 vidn/ngay, t r o n g 5 ngay ddi vdi ca 2 phUdng phap phau t h u l t .
4.4. liilgt so dac diem veky thudt mo T u the bdnh nhan: Trong qua trinh thUc hidn ehiing tdi tien hanh de tay dang vdi than ngUdl mdt gde 110 dp gidng n h u trong nghien ciJu cCia II Hwan Kim [4] va thay rang t u the n l y thuan I d hon eho thao t i e cua phau thuat vidn. Mot sd tac gia Wile de nghj de tay dang so vdi t h i n ngUdi gde 100 dp nhU Shiro Niiyama [7] h o l e 90 dp n h u Hyung-Sup Shim [2].
X i e djnh v u n g phan b d tuyep mo hdi dau tiet d v u n g n I c h : Chiing tdi ap d u n g vide xac dinh vCing phan b d tuyen mo hoi dau tiet d nach la vung tUdng Ung vdi p h i n b d eua long viing nach 2 bdn n h u t r o n g cac nghidn cUu eiia Hyung-Sup Shim [2] eung n h u Shiro Niiyama [7], Thdng qua viec xac djnh nhU vay de tien hanh gay t d g i l m dau tai eho: SCf d u n g ky thuat gay t d phdng len (tumescent anasthesia) vdi 100 - 500ml d u n g dich lidocain 0,5%, tao dugc sU tach rdi giUa t d ehUe dUdi da va cac tuy^n m d hdi dau tiet [4], [1], [8].
Ky thuat cat hCiy e l e tuyen m d hdi dau tiet:
Trong phau thuat mo m d , tid'n h l n h cat nao tuyen m d hdi dau tiet bang cac dung cu phau t h u l t t h d n g t h u d n g , ket hpp dot huy bang dao dien nen d i m bao hOy dupe eac tuyen mot each tridt de. Trong phau thuat md npi soi sieu I m hiit tuy^n md hdi, viec loai bd eac tuyen m d hdi dau tiet ddi h6i phai cd c l e trang thiet bi ho t r p chuydn biet, do d d ehi phf
p h l u t h u a t se eao hdn m d m d t h d n g t h u d n g , ddi I^i p h u o n g phap nay de lai seo m d n h d , d i m bao t h i m m y t d t h o n m d m d .
4.5. Biin chCdig sau mS
Ti Id cd bien ehiJng sau m d e h u n g eiia n h d m nghidn ciili I I 5,9%, t r o n g d d t l Id cd bien c h i i n g sau m d d n h d m m d m d la 5,4%, t h a p h o n so vdi d nhdm m d ndi soi (6,7%). Tuy nhidn sU k h I e biet d o khdng ed y nghTa t h y c s u (vdi p=0,740). Dieu nay cd nghTa la e l hai phUOng p h a p m d m d va m d npi soi deu ed t i Id bldn chUng sdm sau m d khdng khae nhau.
T i t c l cac t r u d n g h p p ed bien c h i i n g deu la cac bien ehiing nhe (3 ea bj t u m l u d u d i da, 2 ea bj t u dich dudi da, 2 ca bi hoai tCf da va 2 ca toac vet md).
Tat c l deu dupe didu trj b i o t d n , t h a y b I n g ngoai tru h i n g ngay, sau 2 t u a n ddu d n d m h . Khdng cd trudng hpp nao bj c l e bien chUng nang nhU c h l y m a u ^ ^ J I m d , t d n t h u o n g d a m rdi t h a n kinh vCing nach..^^Cd t h e ndi phau t h u a t eat hCiy e l e t u y e n m d hdi dau tiet (md m d hay m d ndi soi) t r o n g n h d m nghien ciiu eua chiing tdi d i m b i o duac tfnh an t o l n v l khdng cd bien chUng nang,
4.6. Ketqu&kiem trasaum62 tudn Ket q u i ki^m tra sau m d 2 t u a n cho thay: 100%
bdnh nhan seo vet m d li^n hoan t o a n , ket qua t d t dat 65,8%, k h i dat 27,0% va 7,2% cd ket q u i kem (benh n h l n v I n thay cd mui, kham xac dinh miie benh van d dp 3 va 4). N h u vay t l Id dat ket qua t o t v l kha
Hinh 4. Seo sau phau thuat md m d nao
tuyen mo hoi (2 tuan sau md) Hinh 5. Seo sau mo p h l u thuat mo m d nao tuyen (sau 6 t h i n g )
TAP CHf Y DUOC LAM SANG 108 T3pl2-S6 1/2017
cOa nhdm bdnh n h l n nghien cUu ia 92,8% (rieng d nhdm m d m d I I 94,6% va 6 n h d m m d npi soi la 90,0%). Ket qua nay cung tUOng d u o n g vdi m o t sd nghidn eiJu khae eua nude ngoai: TI le dat ket q u i tdt v l kha t r o n g nghien ciiu cCia Park va Shin la 923% [5], ciia II Hwan Kim I I 98,8% [4], cCia Liu Q I I 95,8% [3]...
So sanh ket qua kiem tra sau m d giQa 2 p h u o n g phap m d cho t h i y : Tl le dat ket qua t d t d n h d m m d md (76,1%) cao hon rd ret so v& d n h d m m d ndi soi (50,0%), d d n g t h d i ket qua kem d n h d m m d m d (5,4%) cung thap hon rd ret so vdi n h d m m d ndi soi (10,0%). Sy khac biet ndi trdn giiia hai p h u o n g phap md la thyc sy cd y nghTa, vdi p=0,004. Ket q u i tren cho thay t r o n g n h d m benh nhan nghidn cUu ciia chiing t d i , phuong p h I p m d m d ed hidu q u i dieu tri tridt de eao hon so vdi m d npi soi sidu I m hiit t u y e n . 5.Ketiu$n
Ket q u i nghien cUu tren 152 bdnh n h l n eho thay: Phau t h u l t m d m d eat nao loai b d e l e tuyen mo hdi dau tiet dudi da vCing n I e h la phucmg phap dieu tri an toan va hidu qua de dieu trj bdnh hdi nach, vdi kdt q u i t d t v l k h i dat 94,6%, khong cd bien ehUng nang. Phuong p h I p m d npi soi sieu am hiJt tuyen md hdi dau tiet ed Uu didm la seo m d nhd, nhung cd t i l e ket q u i kem (10,0%) eung n h u ehi p h i phau thuat deu eao hon so vdi m d m d . D l y la m o t van di can tiep tuc dupe nghidn ciiu v l h o l n thien.
Tai lieu tham khdo
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