NGHIEN cOru KHOA HOC
KET QUA DIEU TRI MONG THIT NGUYEN PHAT BANG PHAU THUAT GHEP MANG 01
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[ Nguyin Thanh Hdi', Phgm Nhu Vinh Tuyin', Nguyen Quoc Viet' J TOM T A T
Muc tieu: Ddnh gid kit qud diiu tri mong thit nguyen phdt bdng phdu thudt ghep mdng oi. Phu-ffng phap: Nghien cim tien cim, thic nghiem ldm sdng khong doi chimg. Ket qua: Mong thit nguyen phdt tap trung a dp tuoi lao dpng chiim ti li 69,44%o. Mpng thit dp III chiim 71,15%. Mice dp thi luc tdng khong ddng ki vd mirc dp logn thi gidm ddng ki sau phdu thudt. Kit qud dat tot chiem ti le 93,75%). Ti li tdi phdt sau phdu thudt 3 thdng Id 2,08%. Ket luan: Phdu thudt ghep mdng oi dieu tri mpng thit co nhieu uu diim nhu CO tinh thdm my, ti le benh nhdn hdi long cao, tiit kiim ket mgc. Phdu thudt ndy co ti le tdi phdt tuang duang vdi cdc phuang phdp khdc.
Tir khoa: Mpng thit, mdng oi, tdi phdt, kit mgc, ghep.
I. DAT VAN DE
Mong thjt tuy kh6ng phai la nguyen nhan gay mil 16a quan trgng, song anh huong nhieu den van de tham my, thj lire va gay kich thich kho chju cho nguoi benh. Theo th6ng ke cua Benh vien Mat Tmng uong, nam 1996, mong thjt chiem ti le 5,24% trong t6ng s6 dan dieu tra. Co nhieu phuong phap dieu trj mong thjt da dugc ap dung nhu ghep ket mac tu than -vimg ria co hoac kh6ng ap chat eh6ng chuyen hoa nham ban che m6ng tai phat [2], [3], [5], [6].
Hien nay, mang 6i da dugc sir dung rong rai trong nhan khoa va mgt so tac gia trong nuac da sir dung mang 6i de dieu trj loet Mooren [1], dieu fri thiing giac mac rong [4]. Viec su dung mang 6i dieu trj mong thit ciing da dugc cac tac gia trong va ngoai nuoc tien hanh nghien ciiu vai cae ket qua khac nhau [7], [8]. Xuat phat tir nhiing li do do, chiing t6i tien hanh nghien ciiu de tai: "Kit qud dieu tri mpng thit nguyen phdt bdng phdu thudt ghep mdng oi" nham danh gia hieu qua dieu trj ciia phuong phap nay.
'Khoa Mdt, Benh vien Trung uang Hue
II. DOI TUgfNG VA PHUONG PHAP NGHIEN CUtJ 1. Doi tirong nghien ciru
Cac benh nhan vai chan doan mong thjt nguyen phat co chi djnh phau thuat ghep mang oi dieu trj tai khoa Mat, Benh vien Trung uong Hue tir thang 3/2009 din thang 12/2009.
2. Phu-oTig phap nghien ciru
Thiit ki nghien ciru: nghien ciiu tien ciiu, thii nghiem lam sang kh6ng d6i chimg, danh gia ket qua tren tirng benh nhan.
Mdng oi: sir dung mang l i d6ng kh6 da dugc cat Igc va bao quan theo tieu chuan cua ngan hang M6 Hoa Ky va dugc cung c4p tir ngan hang M6 Thanh ph6 H6 Chi Minh.
Quy trinh phdu thudt:
- Gay te canh nhan ciu bang Lidocain 2%.
- Mong thjt dugc boc tach tir phia dSu mong di ve phia than mong.
- Phau tich bao Tenon, to chiic xa sgi duai than mong ra khoi kit mac.
- Boc tach rong v l phia goc trong (kh6ng den
NGHIEN CUtJ KHOA HOC
cue le), cue tren va cue duoi.
- Tien hanh cat dau m6ng va than m6ng. Cam mau bang dau d6t luong cue.
- Lam sach cac t6 chiic xa sgi a vj tri vira cat bo mong de bgc 16 hoan toan ciing mac. Lam sach cac t6 chirc xa con bam 6 be mat giac mac.
- Tien hanh tao vat mang 6i vai kich thuac rong ban 1 mm a cae phia ciia viing ciing mac -vira bgc 16 trir phia giac mac. Dat vat mang l i vao vj tri voi bo cua vat mang 6i nam duoi ba ket mac.
- Tien hanh khau c6 djnh vat mang 6i, ba ket mac va ciing mac ben duai bang 6 - 8 mui nylon
10.0 mui rai, bang mat.
Theo doi hdu phdu:
Benh nhan dugc sir dung khang sinh, khang viem, ch6ng phii ne sau phau thuat. Sau phau thuat, benh nhan dugc kham danh gia khi ra vien, sau khi ra vien 7 ngay, 1 thang, 3 thang.
Benh nhdn duac theo doi:
- Thj lire, d6 loan thj truoc va sau m6.
- Qua trinh bieu m6 hoa ket mac a viing ghep mang 6i va giac mac viing boc m6ng.
- Cac bien chiing dugc theo doi: u hat ket mac, n6t dellen, kh6 mat.
- Mong thjt dugc cho la tai phat khi mang xo mach phat trien tir m6 ket mac di qua viing ria qua 1,5mm ve phia giac mac.
Ddnh gid kit qud phdu thudt:
- T6t: mang 6i phang bong, bieu m6 hoa hoan toan viing ghep. Mat kh6ng kich thich. Dien ggt giac mac trong phang. Benh nhan hai long.
- Trung binh: mang 6i g6 ghe, bieu m6 hoa vimg Bdng 2. Tinh trgng logn thi cua binh
ghep. Mat kich thich nhe. Dien giac mac ggt m6ng de lai seo xo trang. Benh nhan tuong d6i hai long.
- Kem: ba manh ghep g6 len hoac loai trir manh ghep som, bieu mo hoa kem. Seo xa trang day 6 vi tri ggt giac mac. Mong thjt tai phat, benh nhan kh6ng hai long.
III. KET QUA
1. Dac diem benh nhan tru'dc phau thuat Chung t6i da nghien cim 52 mat bi mong thjt nguyen phat tren 36 benh nhan bao g6m 19 nam (52,78%) va 17 nii (47,22%).
Do tu6i trung binh la 52,64 ± 13,61. Bien do tuoi cao, benh nhan it tu6i nhat la 25 tu6i, cao nhat la 80 tu6i.
Mong thjt tap trung a d6 tu6i lao dgng (tir 20 den 60 tu6i) chiem ti le 69,44%. Co 31 benh nhan (86,11%) CO nghe nghiep hoac tien sir tiep xiic nhieu vai anh nang mat trai, gio, bui.
Mong thjt do 111 chilm ti le 71,15%.
2. Ket qua dieu trj
Bdng J. Thi luc binh nhdn trudc vd sau phdu thudt (n = 52)
Thoi gian Truac phau thuat Ra vien
Sau m6 1 tuan Sau m6 1 thang
Thj luc trung binh 0,50504 ±0,377803 0,52312 ±0,373385 0,53465 ±0,368238 0,54427 ± 0,367453 Qua theo doi sau 1 thang, da s6 benh nhan co thj lire 6n djnh vai thj lire tmng binh la 0,54427 ± 0,367453. Sau m6 1 thang co 3 benh nhan co thj lire tang hon 2 dong.
nhdn trudc md vd sau md (n = 50)
Thoi gian Truoc phau thuat Ra vien
Sau m6 1 tuan Sau mo 1 thang
Do loan thj toi thieu (D) 0,25
0,25 0,50 0,50
Do loan thj toi da (D) 6,50
3,00 3,00 3,00
Do loan thj trung binh (D) 2,3269 ± 1,60158
1,2885 ±0,75632 1,1154 ±0,67784 1,0577 ±0,63712 .
NGHIEN CUtl KHOA HOC
So sanh vl mirc do loan thj truac va sau phau thuat chiing t6i nhan thay rang loan thj sau phau thuat giam dang ke vai p < 0,01.
Bdng 3. Tinh trgng biiu md hda gidc mgc Tac gia
Le Ngoc Lan [3]
Nguyen Thanh Hai
Nam
2005
2009
So mat
56
54 52
Phuong phap PT Cat m6ng don thuan ph6i hgp ap Mitomycin C Cat mong don thuan Ghep mang 6i dieu trj mong thit nguyen phat
Thoi gian bieu mo hoa giac mac Duoi 3 ngay
38 (67,86%)
51 (94,44%)
32 (61,54%)
4 -7 ngay 16 (28,57%)
3 (5,56%)
16 (30,77%)
Tren 7 ngay 2 (3,57%)
0 4 (7,69%) Ket qua nghien ciru ciia chung t6i eho thay, thai gian bieu m6 hoa giac mac lien quan den d6 m6ng va kT thuat ggt mong. Thai gian bieu m6 hoa giac mac tuong duong vai ket qua nghien ciin cat mong don thuan ph6i hgp ap Mitomycin C cua Le Nggc Lan [3] va lau hon so voi cat mong don thuan cung cua tac gia nay.
Co 28 mat (chiem ti le 53,85%) sau phau thuat 7 ngay van con cam giac com x6n va chay nuac mat. Dieu nay dugc giai thich do su kich thich ciia cac miii chi khau. Cac trieu chiing nay giam di va kh6ng con sau khi cat chi 1 thang.
Sau phau thuat 3 thang co 45 mat dat ket qua t6t, chiem ti le 93,75%. Co 2 mat dat ket qua trung binh (4,17%) do mat van con kich thich nhe.
Ket qua theo doi sau phau thuat 6 thang co 1 truang hgp tai phat (ti le 2,08%o) Bdng 4. So sdnh ti li tdi phdt vdi mpt sd phuang phdp khdc
Tac gia David H.K. Ma [7]
Nguyen Van Dam [2]
Le Nggc Lan [3]
Asadollah Katbaab [8]
Nguyen Thanh Hai
Nam
2000 2005 2005 2008 2009
So mat
80 44 56 54 50 52
Phirong phap PT Ghep mang 6i dieu trj mong
thit nguyen phat Ghep ket mac va trugt
chuyen vat ket mac cat mong don thuan ph6i
hgp ap Mitomycin C cat mong don thuan Ghep mang oi dieu trj mong
thjt nguyen phat Ghep mang 6i dieu trj mong
thit nguyen phat
Thoi gian theo doi 13 thang 9 thang 6-12 thang 6-12 thang 12 thang
6 thang
Ti le tai phat
• ( % )
3,8 11,86
4 17,4
2 2,08
IV. BAN LUAN
Day la lan dau tien chiing t6i tien hanh phau thuat dieu trj mong thjt bang phuang phap ghep mang 6i tai Hue. Ve dac diem lam sang, mau nghien cim cua chiing t6i tuong duong vai cac nghien cim trong nuac truac do [2], [3], [5]. Mong thjt d6 III trong nghien ciru cua chimg t6i chilm ti le 71,15%), tuang duang
NGHIEN CCrU KHOA HOC
vai ket qua nghien cim ciia Nguyin Van Dam la 64,41% [2].
Theo bang 1, thi lire trung binh cua benh nhan sau m6 tang ban so vai truac m6, su khac biet vl thj lire truac m6 va sau m6 qua cac thai diem ra vien, sau m6 1 tuan, sau m6 1 thang kh6ng co y nghTa th6ng ke vai p>0,01. So sanh ve miic do loan thj truoc va sau phau thuat cho thay rang, loan thj sau phau thuat giam dang ke vai p < 0,01. Sau m6 1 thang do loan thj trung binh la 1,0577 ± 0,63712, dieu nay dugc giai thich do mong thjt truac do da lam bien d6i do cong ciia giac mac.
Thai gian bieu m6 hoa phu thugc nhieu yeu t6 nhu miic do xam lan cua mong vao giac mac, CO hay kh6ng sir dung cae ch6ng chuyen hoa trong phau thuat va kT thuat ggt giac mac. Da s6 cac truang hgp sau theo doi 3 thang khi bieu m6 hoa hoan toan viing truac day la than mong kh6ng con cuong tu va dugc phu mgt lop bieu m6 mong. Day la mgt uu diem ciia vat ghep mang 6i, vi mang 6i kh6ng chira mach mau, do do kh6ng gay cuong tu dem lai tham my cao cho mat phau thuat.
Sau phau thuat 3 thang co 45 mat dat ket qua tot, chiem ti le 93,75%. Day la nhiing mat co than mong truoc m6 day, sau khi cat bo m6ng va t6 chirc xa ben duai than mong va tien hanh ghep mang 6i van con su chenh lech ve do day giiia hai viing gay kich thich nhe. So sanh ket qua voi Le Nggc Lan la 94,52% [3] va Nguyen Thj Thu la 96,3% [6] ti le dat ket qua t6t cua chiing t6i thap.
Tai phat la mgt trong nhung van de dugc quan tam nhat d6i vai phau thuat m6ng thjt. Mong thjt tai phat gay giam thj lire va gay mat tham my dang ke.
Cac nghien cim ghep mang 6i truoc day cho ti le tai phat cao. Tuy nhien, eae nghien cim ghep mang 6i dieu trj mong thjt gan day lai eho ti le tai phat thap hon. Ti le tai phat sau phau thuat dieu trj m6ng ghep mang 6i la khac nhau qua cac bao cao. Trong nghien
cim ciia chiing t6i vai thai gian theo doi 6 thang, co ti le tai phat la 2,08%, ti le nay tuong duong voi ket qua ghep mang 6i cua Asadollah Katbaab [8] va can dugc theo doi them. So sanh ti le tai phat trong nghien cuu dieu tri mong thjt bang phuang phap ghep ket mac tu than cua Le Nggc Lan [3], co ap Mytomycin C la 4%
thi ti le tai phat ciia chung t6i la thap hon. Tuy nhien, vai nghien cim cua Nguyen Van Lanh [5] la 0% thi ti le tai phat ciia chiing t6i lai cao hon dang ke.
Mang day mang 6i co tinh chat hoan toan gi6ng vai mang day cua ket mac va chu-a cac chat nhu fibronectin, collagen VII laminin-1, laminin-5 va cac chat co ban ngoai bao dong vai tro quan trgng trong sir biet hoa va sir tang sinh ciia cac te bao bieu m6. Tuy nhien, cac nghien ciru ciing cho thay rang cac yeu t6 tang truang ciing chi con 50% tren mang 6i bao quan lanh so vai mang 6i tuoi va tren mang 6i d6ng kho cac yeu t6 nay hau nhu kh6ng con. Co che ngan can sir tai phat cua mang 6i d6ng kh6 sau khi ghep nham tao mang huu ca co tac dung lam rao chan ngan can sir phat trien cua t6 ehiic xa. Viec sii- dung mang 6i d6ng kh6 co san rat thuan tien, la nguyen lieu thay the cho ket mac va co tac dung h6 trg cho qua trinh bieu m6 hoa cua be mat nhan eau.
Ngoai ra, phuang phap nay giiip ehiing t6i tiet kiem dugc dang ke thai gian trong chuan bj phau thuat.
V. KET LUAN
Qua nghien cim ehiing toi thay rang, phau thuat ghep mang 6i dieu trj m6ng thit co nhieu uu diem nhu co tinh tham my cao, ti le benh nhan hai long cao, tiet kiem ket mac d6i vai nhung benh nhan mong kep, mong thjt do IV va nhung benh nhan CO kha nang phai m6 gl6c6m sau nay. Ket qua nghien ciru buac dau cho thay, phau thuat eat mong ghep mang 6i la m6t phuang phap co hieu qua cao trong dieu trj mong thjt nguyen phat, ti le tiii phat tuang duong vai cac phuang phap khac.
NGHIEN CUtJ KHOA HOC
TAI LIEU THAM KHAO
1. H O A N G MINH CHAU (2007): "Nghien cim phuong phap ghep mang 6i dieu trj loet Mooren", Tgp chi nhdn khoa Viet Nam, S6 9, trang 74-81.
2. NGUYEN V A N D A M (2003): "M6 mong ghep ket mac -vung ria tu than va trugt chuyen vat ket mac -viing ria, ket qua buac dau qua 44 truong hgp", Tgp chi nhdn khoa Viet Nam, S6 3, trang
11-16.
3. LE NGOC LAN, PHAM THI K H A N H
VAN (2005): "Hieu qua cua phuong phap cat m6ng ph6i hgp ap Mitomycin C trong dieu trj mong nguyen phaf', Tgp chi nhdn khoa Viet Nam, S6 3, trang 3-10.
4. LE DO THUY LAN (2005): "Kit qua buoc dau ghep mang 6i tuoi nhieu lap dieu trj thiing giac mac rong", Tgp chi nhdn khoa Viet Nam, S6 5, trang 23-28.
5. NGUYEN V A N L A N H (2006): "Cat
mong thjt nguyen phat cai tien, ghep ket mac tu than manh rong", Tgp chi nhdn khoa Viet Nam, So 6, trang 38-47.
6. NGUYEN THI THU (2003): "Ghep kit mac tu than dieu trj mong thjt", Bdo cdo khoa hoc tgi hpi nghi khoa hgc nit trudng dai Hoc Y khoa Hui ndm 2003.
7. DAVID HUI-KANG MA, LAI-CHU SEE, SU-BIN LIAU, RAY JUI-FANG TSAI (2000):
"Amniotic membrane graft for primary pterygium:
comparison with conjunctival autograft and topical mitomycin C treatment", Br J Ophthalmol; 84:
973-978.
8. ASADOLLAH KATBAAB, HAMID- REZA ANVARI ARDEKANI, HAMID KHOSHNIYAT, HAMID-REZA JAHADI HOSSEFNI (208):, "Amniotic Membrane Transplantation for Primary Pterygium Surgery", J Ophthalmic Vis Res; 3(1): 23-27.
SUMMARY
THE OUTCOMES OF PRIMARY PTERYGIUM EXCISION WITH AMNIOTIC MEMBRANE TRANSPLANTATION
The study of primary pterygium excision with amniotic membrane transplantation contribute to the treament of pterygium. Objectives: To evaluate the outcome of primary pterygium excision with amniotic membrane transplantation. Mtt\\oA%: Prospective study, clinical case study with no control. Results: 69.44%
patients with primary pterygia were mainly at the age 20 to 60 years. Pterygia at level III were 71.15%.
After surgery visual acuity was not remarkably increased while astigmation was reduced remarkably. Good result was 93.67%o. Recurrent rate at 3 months after surgery was 2.08%. Conclusion: Pterygium excision with amniotic membrane transplantation has many benefits like highly cosmetic, meet the patient's demand and saving conjuntiva. This method has the same recurrent rate compare wih other methods.
Key words: Pterygium, amniotic membrane, recurrent, conjuntiva, transplantation.
