• TAP CHl N G H l l N CCKl Y H p C
DANH GIA K^T QUA PHAU THUAT CAT THU'C QUAN KHONG M6' NGyc
DIEU TR! UNG THLF THLfC QUAN
0 6 Mai L d m \ D d T r u d n g San^
^Bdnh vien Vidt Dux:, ^Trwdng Dai hgc YHa Noi Nghidn cOv nham danh gia ket qui eit thwc quan khong md ngwc (phau thudt Oninger) tai khoa Phiu lhu$t tidu hda, bdnh vign Vigt Dwc. Kit qua cho thay 144 bdnh nhan gom 139 nam (96,5%). 5 nir (3.5%), tudi tmng binh 54.3 ± 7,73 tuoi (36- 75). Ung thu biiu md lit cd 106 bdnh nhan (73.6%), bieu mo tuyen 38 bdnh nhin (26,4%). Giai doan bdnh II va III cd 122 bdnh nhan (98,5%). Biin ehwng sau mo 19,4%. tuvong 1,4%. Ty id theo doi xa sau mo dat 93%, thdi gian theo doi tmng binh 19,4 thing (1 - 63). Ty Ip song 1; 3 va 5 nim lin Iwgt li 62,2%, 16,4% vi 1,3%. Ba yiu tS lidn quan den sw xuit hidn cua bien chimg va thdi gian song thdm sau md la tudi (> 60 tuoi), chuc ning hd hip kdm (FEV1% < 70%) va mOc dd xam lin cua u (T4).
Tir kh6a: ung t h u thyc quan, cdt thyc quan khdng m d ngyc, c I t thyc quan qua khe hoanh
I. BAT
V A N©e
Ung thy thuc quan (UTTQ) Id mdt bdnh ndng, ddng hdng thCr 8 trong so cdc loai ung thu trdn todn t h i gidi, ty Id mdi m i c hdng ndm d cdc nude kdm phdt trien cao g i p ddi so vdi cdc nude phdt tnen, dge biet eao n h i t Id d ehdu A [1]. 0" Vidt Nam, ung thy thyc quan dCrng hdng thCr 5 trong ede loai ung t h u dudng tidu hod [2; 3],
D i l u trj ung thu thyc quan chu y l u Id b l n g phdu thudt, mo cdt rpng rai phan thuc quan cd ung thy, k i t hpp xg tn vd hod c h i t tu^jf theo chf djnh cho tdng trydng hpp cy the. Phdu thu^t tndt cdn ung thy t h y c quan can cdc d y d n g mo phoi hap' d u d n g m d byng k i t hpp vdi dudng hid ngyc khi midng ndi d trpng long ngyc; cd khi phai k i t hop ca ba d y d n g mo {ngyc - byng - co) khi mieng ndi d c6 [4]
O/a chi lidn hd' D5 Trutmg Son. Bd mdn Ngoai. tnr&ng Dm hQC YHd Ndi
Email: [email protected] Ngiy nhin-5/5/2014
Ngiy duoc chip thuin 29/8/2014
P h i u thudt ndy cd nhieu nguy c a cho ngudi bdnh vdi ty Id t u vong x i p xi 5% vd ty Id bien ehdng khoang 50%, ddc bidt Id cdc bien ehCrng hd hdp [5]. De khde phyc tinh trang suy hd h i p vd bien chung phoi sau mo, nhieu giai phdp khde nhau da d u a c de x u i t , trong dd phuang phdp c I t thuc quan khdng m d ngyc cua Orringer [6] Id dang d y p e quan tdm nhat, U'u diem eua phyang phdp ndy Id khdng phai m d ngyc, thuc quan vd ede hgch ldn cdn dupe p h i u tieh b l n g tay qua Id hodnh thuc quan, thdi gian phdu tich n g i n , giam d u o c b i l n ChCrng suy hd h i p ndn thudng duae dp dyng eho eae trudng hpp n i u m d nguc se cd nhieu nguy c a [7; 8]
Nhuae diem eua p h l u thudt Ornnger Id bdc tach thuc quan md b l n g tay ndn ed the ed cdc tai bidn nhu chay mdu vl t i n thuong cdc nhdnh mach xuat phdt t u ddng mgeh chu hay ITnh mach don, ddi khi rat khd e l m mdu, rdeh khi - p h i quan, ton thuang t h i n kinh qudt nguoe, ddi hdi phdu thudt vien phai rat quen vd cd kinh nghiem vdi logi phdu thudt ndy.
TCNCYH 89 (4) - 2014
TAP CHi NGHieN^CLFU Y H p C •
Tai khoa Phau thudt tidu hod, bdnh vien Viet Ddc, mdt trung tdm v l p h i u thudt t h u c quan, dd t h y c hidn logi p h i u thudt ndy t d ndm 1998. Qua nghidn edu ndy, ehCing tdi mudn: (1) ddnh gid lai eae k i t qua phdu thugt trdn co s d phdn tieh d d lieu cua 144 bgnh nhdn lidn t i l p dd d u a e mo cdt t h y c quan theo p h y o n g phap khdng m d ngyc, (2) phdn tieh mdt s l yeu to tidn lupng lidn quan den k i t qua d i l u tn.
II. D 6 I TU'ONG VA PHU'aNG PHAP
1. D d i tyo'ng
Bao gom tat ca bdnh nhdn dupe chan dodn Id ung thu thuc quan d vi tri 2/3 d u d i (dudi ngd ba khi phe quan), xdt nghigm md benh hpc Id ung thu bieu md t l bdo vay (squamous cell carcinoma) hoac ung thu bieu md tuyen (adenocarcinoma), dupe mo cdt thyc quan qua khe hodnh tgi khoa Phdu thuat tieu hod, bdnh vidn Vidt €)irc tir thdng 1/2000 - 12/2010. Khdng dua vdo nghidn eCru nhdng benh nhan mo c I t thuc quan ed tao hinh b l n g dgi trang, rudt non hodc mo cd ndi soi h5 trp.
2. P h u a n g phap
Md ta hoi eCru d y a tren he thong d d lieu dupe thu thdp thdng tin tien edu cd sdn tai khoa. Cdc thdng tin theo ddi xa sau mo d y p e thyc hien qua khdm true t i l p , thu, didn thoai vdi benh nhdn ho^e gia dinh
Ky thuat cit thu-c quan khdng m& nguv:
C i t thyc quan qua khe hoanh d u o c thuc hidn theo ky thudt mo m d kinh dien cua Orringer md ta [9] P h l u tich thyc quan vung trung t h I t thap duoc-thue hidn qua Id hodnh dd dup'c m d rdng, giai phdng vd vdt hach quanh thyc quan ldn cap t i i da khi cdn ed t h i nhin thay Thi CO (sau khi dd hodn tat giai phdng da ddy
d thi byng): D u d n g rach dpe theo b d t r u d c co de tJdn bdn trdi. P h i u tich, giai phdng phan cdn Igi cua thyc qudn b l n g cdch phoi hpp cung ICIC ca hai d u d n g e l dl x u I n g vd tCr dudi bung di Idn.Tgo I n g dg ddy d l dua len noi vdi thyc qudn eo qua d u d n g sau x u o n g dc. 0§t I n g d i n luu eo t r u d e khi ddng d u d n g m l co.
3. Phan t i c h t h i n g ke
So sdnh giua cdc bien nhj phdn (dichotonomies) b l n g Fischer exact test, SO dyng hoi qui logistic de xde djnh eac y l u to nguy ca doi vdi bien chCrng sau m l . Xay dung cdc hdm Kaplan - Meier vd k i l m djnh s y khde bigt s6ng cdn bdng test log rank. S u dung md hinh hoi qui Cox de tim m i l lidn quan cua mdt so yeu to tidn lupng d l l vdl k i t qua song thdm So sdnh cd y nghTa thong kd khi p < 0 , 0 5 ,
D^o diPC n g h i e n CCPU
Nghidn cCru nay tudn thu cdc nguydn t i c eua Tuydn ngdn Helsinki ve Dao ddc trong nghien c u u y sinh hpe, dd d u p e c h i p thu§n cua Hdi dong Oao d u e c i p c o s d (IRB) bdnh vidn Viet Ode. Cdc tdc gia bdi bao cam k i t khdng ed xung dot lai Ich trong vide cdng b6 tdi lidu khoa hpc nay.
III. K^T QUA
TCr thdng 1/2000 d i n thdng 12/2010 cd 396 bdnh nhdn d u a c cdt t h y c quan dc ung thu, trong dd cd 144 bdnh nhdn (36,4%) cdt thyc quan qua khe hodnh, bao gom 139 nam (96,5%) vd 5 nO' (3,5%). T u l i trung binh 54,3
± 7.73 tuoi (36 - 75). BMI: 19,0 ± 2,69 (13,7- 25,39), bgnh nhdn cd thdm bdnh man tinh khde kdm theo Id 2 3 % (nhieu n h i t Id bdnh dudng hd hap 21 bgnh nhdn (14,6%).
• tAP CHf NGHIEMIIIJU Y Hpd Bang 1 . Mot s 6 d | c d i l m cua n h d m b^nh nhdn nghien cii'u
Phin loai theo mo hgc:
Ung t h u bieu md t u y i n Ung t h u bieu md Idt
38 106 MOv dp xam lin u:
TO T l T2 T3 T4
1 5 27 91 20
0,7 3,5 18,8 63,2 13,9 Di can hach*:
NO N I N2
57 59 28
39,6 41,0 19,4 Dg bi^t hda:
Bidt hda eao Bidt hda vua Bi$t hda kdm
59 54 31
41,0 37,5 21,5
* NO = khong di cSn hach, NI h^ch t^ng bung duOi ca hoanh.
-• dl cSn hach trung that quanh thi/c quan nguc, N2 = di can
1. Kdt qua s d m sau m d
T i t ea 144 bdnh nhdn deu dwcfc mo md, giai phdng dg ddy, m d rdng Id hodnh bde tach thyc quan tCr d y d i Idn vd t u trdn co x u l n g . Cdt thyc quan d nen eo trudc, sau dd keo .thyc quan xuong bung vd tgo hinh thuc quan mdi b l n g dg ddy ong nhd, dua da ddy Idn c6 noi qua d u d n g trung t h I t sau (mdt so it trydng hap di sau x y o n g ue). Bao g i d cung Idm thdm tao hinh mdn vi vd m d thdng hdng trdng nudi dn,
2. Phan t i c h m p t s d y d u t d tien lu-vng ddi v 6 i bidn c h i r n g vd t u v o n g sau m o
Trong tong s l 144 bdnh nhdn c i t thyc qudn qua khe hodnh, ed t i n g cdng 28 b i l n
ehdng d u p e ghi nhdn (bien ehCrng hd h i p 14 bdnh nhdn, rd midng noi 3 bdnh nhdn, nhidm triing vet mo 11 bdnh nhdn}, Cd 2 bdnh nhan t u vong sau mo vdo ngdy thCr 6 vd t h d 8 sau mo. Ca 2 bdnh nhdn ndy d i u ndm trong nhdm b i l n ehdng hd h i p , Bien chung hd hap gap vdi t;/ Id cao n h i t so vdi cdc bien ehdng khac trong nhdm benh nhan ed b i l n chCrng (bang 2) vd eOng Id nguydn nhdn chinh ddn den tCr vong eua ea 2 bdnh nhdn t u vong dd xay ra trong nhdm nghidn c u u , De tim hieu nhung yeu to nao hen quan mang tinh nhdn qua doi vdi cdc bien chung vd t u vong, ehCing tdi dung phdn tfch hoi qui da b i l n (phuong phdp Back- ward Stepwise (Wald) de phdt hidn cdc bien ed kha ndng gdy nguy c a b i l n chung. K i t qua dupe trinh bdy trong bang 3.
TCNCYH 89 (4) - 2014 85
TAP CHi NGHliN C1>U Y HpC •
Bang 2. Kdt qu^ sdm sau m6 (n = 144) Ket qua
Tai biln trong ml:
Khdng cd tai biSn Rdeh mdng phdi Rdeh d0ng m$ch ph4 quan Rich ca hodnh
Rdeh dng nguc
Tdn thwang thin kinh quat ngug^
Biln ehdng sau mo:
Khong cd biSn chung Biin chirng hd hdp Rd mi$ng ndi Nhiem trimg v4t md
64/144 80 58 3 1 1 1 28/144
116 14 3 11
44,4*
55,6 40,3 2,1 0,7 0,7 0.7 19,4 81,9 9,0 3,5 5,6 TCr vong
Thdl gian m l (phCit) Thdi gian thd mdy (gid) Ngdy nim vien trung vj (min - max)
2/144 1,4 259 90 ±74 69 (120-480)
10,6 ±5,07 (2-25) 12 ngdy (7-50)
Ty Id tai biln rdeh mdng phli eao (40,3%) id do qud trinh bde tdch Idy hgch trung thIt, cdc sy el ndy deu dupe phdt hi0n ngay vd xu tri.
Cd 2 ylu td lidn quan mat thiet vdi sy xuat hi$n cua bien ehdng vd tu vong. Dd Id mCre dd xdm lln u (p = 0,026) vd ehi s l % thi tfch khi thd ra toi da trong 1 phut (FEV1%) (p = 0,000}
trdn dung tich khi thd (VC). Dilu nay cd nghTa nhCrng bgnh nhdn cd dp xdm lan u da xdm lan ra cdc tgng lien ke (T4} vd chuc nang hd hip kdm (do blng ehi so FEV1%i} se cd nguy eo bien chCrng vd tCr vong eao han nhdng ngudi khde khdng ed cdc yeu t l ndy. Cdc bien khde khdng thiy ed moi lien quan ed y nghTa (gidi, tuli, BMI, thdl gian m l kdo ddi hay khdng.,.) (bang 3).
3. Kdt qua theo doi benh nhan xa sau ml
Ngodi 2 bdnh nhdn chit trong vdng 8 ngdy sau nil, so bdnh nhdn trong danh sdeh theo
ddi Id 142. Cd 10 bdnh nhdn (7%) bj mit tin trong qud trinh theo ddi. Tdi thdi dilm kit thuc thu thdp s6 lidu (12/2013), xdc nhdn cd 116 bdnh nhdn dd chet vd 16 bdnh nhan edn dang song. Thdi gian s6ng thdm trung vj (median) Id 15 thdng (95% Cl: 12,32 -17,69), ngdn nhit Id 1 thdng vd ddt nhat Id 63 thdng. Xde suit tieh luy song thdm tgi cdc thdi diem 1 ndm, 3 ndm va 5 ndm lan lupl Id 62,2%, 16,4% vd 1.3% (tinh theo phuong phdp Kaplan Meier),
4. Cdc ylu td lidn quan din thd'i gian sdng thdm sau mo
Kit qua phdn tfch cho thay ehi ed hai ylu t l tuoi (> 60 vs s 60 tuli) vd mde dd xdm lln u (gida T1,T2, T3 vd T4) Id ed moi lidn quan ehdt che (p = 0,01 vd 0.001). Cdc ylu t l khde nhu di cdn hach, giai dogn b$nh. dO bidt hda.
TCNCYH 89 (4) - 2014
• TAP CHl NGHIEN CCPU Y HpC
tinh chat md hpe, khdng thay ed su khde bidt ed y nghTa thong ke (p > 0,05).
Bang 3. Kit qua phan tich hdi qui da bidn (n = 144) Biln phdn tich n Score Do tu> do Giai:
Nam Nu Tuoi:
> 60 tuoi
< 60 tuoi Bdn/j phoi hpp:
Cd Khdng BH/ll:
<18,0
>18,0 DpxSm lan u(pT}:
T0-T3 T4 FEV1%:
< 70%
> 70%
Thai gian mo:
> 240 phiit
< 240 phut
139 5 31 113 33 111
21 123 24 120
IV. BAN LUAN
Ode phuong phdp phiu thudt tridt cdn doi vdi ung thu thuc quan trudc ddy thudng cho kit qua rat kdm vdi ty Id khoi bdnh xip xi 20%
kdm theo ty Id bien chCrng td vong cao hon bit cCr phdu thugt ndo khde eua ong tidu hda [9; 10] Trong nhdng ndm gin ddy, nhilu bdo cdo cua cae trung tdm mo thuc quan ed so luang Idn dd duae cdng b l cd kit qua rit kha quan vdi ty Id sing 5 ndm khoang 40% vd ty l§ tLP vong sau mo dydi 5% [11; 12; 13; 14].
Dd Id nhd, kinh nghidm ky thudt mo ngdy cdng tit hon, cung vdi ung dung nhdng dilu trj da phuang thde mpt cdch hd thdng nhu hda - xa
tn tryde va sau phiu thudt vd vige chu y den nudi dudng benh nhdn ung thu hidu qua. Ket qua cua ehCing tdi qua nghidn cCru ndy cho thay, ty Id bidn chCrng khdng eao (19,4%) vd ty Id tCr vong ehi ed 1,4% nhyng ty Id song 5 ndm edn qud thdp la 1,4% doi vdi todn bp ede giai doan va 3% doi vdi giai dogn I vd II Dd cd the la do sd benh nhan den mo d giai doan mudn (62.1% giai doan II vd 36,4% giai doan 111), kdm theo tinh trang gdy yeu suy dinh dydng tryde mo (39% bdnh nhdn cd chi so BMI <
18,0) vd ehde nang hd hap kdm do nhieu bdnh dudng hd hap phoi hap (16,7% benh
TCNCYH 89 (4) - 2014 87
TAP C H ! NGHIEN ClhJ Y HpC^
nhdn cd FEV 1 % < 70%.) Mdt khde, vide Crng dyng cae phde d l dieu tri da phyong thCrc (khdng phai Id phau thugt) nhu hda - xg trj trude vd sau mo cdn r i t han e h i do tinh hinh.
Ddy chinh Id nhCrng myc tidu mong muon cua Chung tdi trong thdi gian tdi d l khde phue cdc vdn dd tren.
Nhieu y k i l n eho r i n g , p h i u thudt c i t ung thu thyc quan qua khe hoanh, tuy ed uu diem nhu tranh duae nhung b i l n chung ndng ne do phai m d nguc cung nhu thdi gian mo ngdn hon, nhung lai bi hgn e h i vd mdt nao vet hach so vdi e i t thyc quan cd m d ngyc Tuy nhidn mdi day (2013), nhdm nghidn cuu gom F,A.M Fernando (trydng dai hpc South Paolo, Brazil) vd M.G Patti (trudng dgi hoe Y Pritzker.
Chicago USA) [15] cdng bo k i t qua nghidn cuu dieu tra lidn q u i c gia. dd dua ra n h i l u b l n g ehCrng vd Idp ludn t h u y i t phue ve vide vdl hgch tridt de trong mo ung thu thyc quan Id khdng kha thi, dCi mo b l n g phuang phdp ndo (qua khe hodnh hay qua m d ngyc) K i t qua song thdm todn bp (OS) khdng phy thude vdo phuang phdp mo qua dudng ndo ma phu thude vao nhidu y l u to khde Cac tde gia nay di d i n k i t lugn, vige vdt hach rdng rdi vdi y dd triet cdn can phai xem xet lai. Qua ket qua nghien cuu cua chCing tdi d u p e trinh bdy trong bai bdo ndy, chung tdi bj nghidng v l k i t lu^n cua nhdm tdc gia vCra ndu trdn, dde bidt nd phu hpp vdi the trgng vd hodn canh t h y c te cua bdnh nhdn d Vidt nam.
V. K^T LUAN
Phau thudt cdt thyc quan qua khe hodnh (khdng m d ngyc) cd ty Id bien chirng sau mo 19,4%, 10" vong 1,4%i vdi thdi gian s i n g thdm 1. 3 vd 5 ndm lan l y o t Id 62,2%. 16,4% va 1,3% (tinh theo phuang phdp Kaplan Meier).
Ba y l u to lidn quan d i n s y x u i t hidn cua bien ChCrng vd thdi gian song them sau m l Id tuoi
(> 60 tuli). chuc nang hd h i p kem (FEV 1 % <
70%) vd mde dd xam l l n eua u (T4}, Lo'i c a m e n
Xin chdn thdnh cam ede edn bd khoa P h l u thudt tidu hod, bdnh vi§n Vidt Dire dd giup dd trong qud trinh thu thgp ede d d lidu eua nghidn cCru ndy
TAI LIEU THAM K H A O
1. Kamangar Farin, Dores Gracii M., Anderson William F (2006). Patterns of Can- cer Incidence, Mortality, and Prevalence Across Five Continents: Defining Priorities lo Reduce Cancer Disparities in Different Geo- graphic Regions of the World. J Clin Oncol. 24' ( 1 4 ) , 2 1 3 7 - 2 1 5 0 .
2. Pham Hoang Anh (1993). Ung thu trdn ngudi Hd Ndi, Hdi ung t h u Vigt Nam - Bdnh vien K, Hd Ndi
3. Nguydn C h i n Hung, Phd Du'c Man, Cung Thj Tuydt Anh va cong s y (1993).
Dich t l hpc ung t h u hidn nay tgi Ihdnh pho Hd Chi Minh vd cdc tinh phia nam Vidl Nam, Y hoc Thuc h^nh, 1 1 , 31 - 37.
4. Altorki N, Kent M, Ferrara C, Port J (2012). Three-field lymph node dissection for squamous cell and adenocarcinoma nf the esophagus. Ann Surg; 236(2), 177 - 1 8 3 .
5. Donohoe C L , O'Farrell C L , N. Ravi N.J et at (2012). Evidence-Based Selective Application of Transhiatal Esophagectomy in a High-Volume Esophageal Center. World J Surg. 3 6 , 9 8 - 1 0 3 .
6. Orringer M (1978). Esophagectomy without thoracotomy. J. Thorac. Cardiovasc.
Surg, 76, 6 4 3 - 6 5 4
7. Merkow RP, Bilimoria KY, McCarter MD et al (2012). Shortterm outcomes after esophagectomy at 164 American College of Surgeons National Surgical Quality Improve-
•TAP CHf NGHIEN C l J f e S i
menl Program hospitals: effect of operative approach and hospital-level vanation • Arch Surg, 147(11), 1 0 0 9 - 1 0 1 6 .
8. Hulscher JB, Tijssen JG, Obertop H, van Lanschot J J (2001). Transthoracic ver- sus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac SUfg; 72(1), 3 0 6 - 3 1 3 .
9. Orringer MB, Marshall B, Chang AC et al (2007). Two thousand transhiatal esophagectomies, Ann Surg; 246, 363 - 374.
10. Enzinger PC, Mayer RJ (2003). Eso- phageal cancer N Engl J Med; 349, 2241 - 2252,
11. Portale G, Hagen JA, Peters JH et aJ (2006). Modern 5-year sun/ival of resectable esophageal adenocarcinoma, single institution expenenee with 263 patients. J Am Coll Surg;
202, 588 - 596
12. Altorki N, Kent M, Ferrara RN et al (2002). Three-field lymph node dissection for squamous cell and adenocarcinoma of the esophagus. Ann Surg; 2 3 6 , 1 7 7 - 1 8 3 .
13. Yannopoulos P, Theodorldls P, Manes K (2009). Esophagectomy without tho- racotomy 25 years of experience over 750 patients. Langenbecks Arch Surg; 394(4), 611 - 6 1 6 .
14r Vigneswaran WT, Trastek VF, Pai- rolero PC et al (1993). Transhiatal esophagectomy for carcinoma of the esopha- gus. Ann Thorac Surg. 56(4), 838 - 844 dis- cussion 844 - 846.
15. Herbella F.A.M, ^. M. Laurino Neto, M. E. Allaix, M. G. Patti (2013). Extended Lymphadenectomy in Esophageal Cancer Is Debatable. World J Surg; 37,1757 - 1 7 6 7
Summary
OUTCOMES OF ESOPHAGECTOMY WITHOUT THORACOTHOMY FOR THE TREATMENT OF ESOPHAGEAL CANCER
The objective of the study was to evaluate surgical outcomes of esophagectomy without thora- cotomy (op. Orringer) at Viet Due Hospital. The results showed that 144 patients including 139 males (96.5%), 5 females (3,5%), niedian age 54.3 ± 7.73 years (36 - 75). Squamous cell carci- noma encountered in 73 6%, adenocarcinoma in 26.4%), TNM stage II and III occoured in most patients (98.5%). The postoperative complication of the whole study was 19.4%., mortality rate 1,4%. The rate of patient long-term followup achieved 93%, median time of followup was 19.4 nonths(1-63}. The overall 1,3 and 5 years survival rate was 62,2%, 16,4% and 1,3% respectively.
Age (> 60), FEV1%) < 70%) and tumor staging TII.TIII were defined as independent risk fectors for the presence of complication and overall survival time of patients.
Keywords: cancer esophagus, esophagectomy without thoracotomy, transhiatal esophagectomy
TCNCYH 89 (4) - 2014
