TAPCHIYDaOCLAMSANGlOS Tap 10-So4/2015
Danh gia ket qua dieu tri benh nhuac co* sau mo c3t tuyen uc qua dirotig co co noi soi h6 tru
Evaluating the results of video-assisted transcervical thymectomy for the treatment of myasthenia gravis
Nguyen Hong Hien*, Ngo Van Hoang Linh** * Trung tdm gidm dinh Y khoa Hd Ndi, Nguyen Van Nam**, Mai Van Vien*** **Benh vien 103
*** Benh vien Trung uang Qudn dgi 108.
Muc tieu: Oanh gia ket qua dieu tri benh nhUpe cO bang phau thuat cat bd tuyen Ue qua dUdng cd cd ngi soi h d t r g . Ddi (Uongvap/juongp/idp: Nghien cUu 52 benh nhan(BN)nhUOeeodUOC dieu trj ngoai khoa bang phau thuat cat tuyen Uc qua dudng co cd npi soi ho tro trong thdi gian ti^ 6/2009 den thang 9/2013 tai Benh vien Quan y 103 (Hpe vien Quan y). Kit qud: 18 nam (34,6%), 34 nU(65,4%), t y le nU/nam - 1 3 9 / 1 . Tudi trung binh tCr38,3 ±14,2 (1 -72 tuoi).Theo ddi sau md: 50/52BN - 96,2%, thdi gian theo ddi sau m d trung binh (thang) tU 35,6 ±14,1 (3-62). Ket quS sau mo: Theo ddi sau md < 1 nam, cd hieu qua 78,0%, Ididng cd hieu qua 22,0%. Sau m d > l - 3 nam ed hieu qua 84,4%, khdng cd hi^u quS 15,6%. Sau mo > 3-5 nam; cd hieu qua 88,0%, khong cd hieu quA 12,0%. Gicfl' tfnh: NQ cd hieu qu3 sau mo la 87,5%
so vdi nam la 76,9%. Nhdm tuoi < 50 tudi ed hieu q u i sau m d 89,2% so vdi 62,5 % eua nhdm>50 tudi.
Tinh trang nhuoc ccf: Nhuoc co nhdm I cd hieu qu3 sau mo la 100% so vdi nhuqc CO nhdm HA la 89,6%, nhugc co nhdm 116 la 55,5%. Thdi gian mac benh 5 12 thang cd hieu qua sau mo 90,5% so vdi 79,2% cua nhdm mac benh >12 thang. Md benh h o c Nhdm tang san tuyen Uc va u tuyen Uc cd hieu qua sau md la 88,9% (24/27) so vdi 773% (14/18) cua nhdm ton tai tuyen ufc Kit lugn: Phau thuat c5t tuyen Uc qua dudng cd cd ngi soi ho t r g dieu tri benh nhugc co la mgt ky thuat mdi dang dugc Ung dung dau tien d Viet Nam, phau thuat khdng phUe tap, an toan, thdi gian phau thuat ngan, gay t d n thuong Idng ngiie d mUe dp toi thieu, nhung cd t y le BN cd hieu qua sau m d {thuyen gidm hodn todn vd benh cdi thiin) tUOng ducmg vdi ky thuat md c^t tuyen Uc qua dudng m d xuong Uc hoac cat tuyen Uc bang phau thuSt ndi soi long nguc.
Tdkhod: Phau thu3t eSt tuyen Uc, cat tuyen Ue qua dUdng co cd ngi soi hd trg.
S u m m a r y
Objective: To evaluate the r « u l t s o f video - assisted transcervical t h y m e a o m y for the treatment of myasthenia gravis. Su6/ect and mef/iod:The study was condutted on 52 patients with myasthenia gravis, underwent video - assisted transcervical thymectomy at 103 Hospital (Military Medical University), from June 2009 t o September 2013. Result Male 18 (34.6%), female: 34 (65.4%), the ratio of female / male
=1.89/1. Mean age (years): 3 8 3 ± 14.2 (15-72). Postoperative follow-up: 50/52 patients = 96.2%. Mean time of follow-up: 35.6 ± 14.1 months (3-62). Follow- up < 1 yean Effectiveness 78.0%, > l - 3 years:
Effectiveness 84.4% and > 3-5 years: Effectiveness 88.0%; sex: The effectiveness was 87.5% in female and 76.9% in male patients. Age: The results o f patients under 50 years were better than those >50 years.
Phan bien khoa hpc: TS. TRAN TRQNG KIEM
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY VoLlO-N''4/2015
Condition of myasthenia gravis: The effectiveness in myasthenia I group was 100%, in myasthenia IIA group was 89.6% and in myasthenia KB group was 55.5%. Disease duration 12 months or iess 90.5%, upper 12 months: 79.2%. Histopathology: Thymic hyperplasia and thymoma are higher than persistance of thymus. Conclusion: Video - assisted transeen/ical thymectomy is a new technique which is being applied for the first time in Vietnam, the surgery was not complicated, safety, the time of surgery was short, minimum invasion, but the rate effective resylt (recover and remission) comparable equivalent effectiveness to the method of transsternal thymectomy or thoraeoseopie thymectomy.
Keywords: Thymectomy, Video - assisted transcervical thymectomy.
1 . D a t v a n de
Phau t h u a t cat b d tuyen dc dieu tri benh nhugc CO dugc sU chap nhan rdng rai tren The gidi t d nam 1939 sau khi Alfred Blalock m d ta cu t h e ky t h u a t m d c$X tuyen Uc qua d u d n g m d xUong de va sau d d da ed nhieu nghien edu tiep theo chu'ng m i n h hieu q u i sau m d cat b d tuyen de da eai t h i e n d u g c t i n h trang benh ly benh nhugc cd, d o n g t h d i xac d j n h cac yeu t d cd lien quan anh hudng den ket q u i sau f n o [8], [10].
Cho tdi nay da cd nhieu dudng mo tiep can t r u n g that de e3t bd tuyen Uc va to chdc m d xung quanh, tuy nhien moi mdt phUdng phap deu ed nhCfng Uu diem va han che rieng. Phau thuat c^t tuyen dc qua dUdng ed ed ngi soi ho trg ia m d t ky thuat mdi dang dugc dng dung dau tien d Viet Nam, ket q u i budc dau eho thay day la mgt phuong phap cd nhieu uu diem va dang trong giai doan tiep tue dugc hoan thien. Vi vay, muc dfch cua nghien cufu nham danh gia ket q u i sau phau thuat va xac djnh m g t so yeu t o lien quan tdi ket q u i dieu tri benh nhugc ca sau m d cSt tuyen de qua dudng cd cd ndi soi ho trd.
2 . D o i t u m i g v a p h U d n g p h a p 2.1. Ddi tugng
Gdm 52 BN nhuge cd dugc phau thuat cat tuyen dc qua d u d n g cd cd ngi soi ho t r g tai Khoa phau thuat Ldng ngue Benh vien Quan y 103 - Hoc vien Quan ytCr 6/2009 den 9/2013.
2.2. PhUa^g phdp Nghiin cdu mo td c6 phdn tich.
Quy trinh phau thuat: Tat c l cac BN duge phau t h u a t eSt tuyen u'c qua dUdng eo ed ndi soi ho t r g dieu trj benh nhUde cd theo mot quy trinh t h o n g nhat da dUdc t h d n g qua Hdi d d n g khoa hgc Benh vien 103.
Cac mau benh p h a m tuyen Uc dugc gCfi xet n g h i e m m d benh hge tai Bg m d n Giai phau benh - Hgc vien Quan y.
Oanh gia ket qua BN sau mo vao cac thdi gian: s 1 nam, > 1 - 3 nam va > 3 -5 nam.
Ket q u i BN sau m o dUde danh gia, phan loai mde d d theo tieu chuan danh gia cua Hiep hgi nhUde ed Hoa Ky [7] g d m cd:
Thuyen g i l m hoan t o a n d n dinh (CSR: Complete Stable Remission): Khdng cd yeu cd hoae trieu chiing nao cua benh nhUdc cd ft nhat trong 1 nam va khong p h l i sCr d u n g bien phap dieu trj benh nhUde cfl t r o n g t h d i gian nay.
C i i thien (I: Improved): Giam thUc sd cac bieu hien lam sang so vdi trudc dieu trj hoac g i l m c\\k chan keo dai cac t h u d c dieu trj nhugc ed trong lieu trinh dieu trj benh.
Khdng thay doi (U: Unchanged): Khdng co thay doi chac ch^n ve cac bieu hien lam sang so v ^ trirdc dieu trj hoac khdng g i l m duge thue su cac thuoc dieu trj nhUdc c d t r o n g lieu trinh dieu trj benh.
Nang h a n (W: Wofse): Tang nang cac bieu hien lam sang so vdi t r u d c dieu trj hoac phai tang lieu t h u d c d i e u trj b e n h n h u g e cd t r o n g lieu trinh dieu trj b e n h .
Tai dien nang hdn (E: Exacerbation): BN da co t i n h trang g i l m benh d n d j n h hoan toan hoac giam benh do t h u d c nhUng sau d d lai cd eae bieu hien lam sang nang h o n .
T d v o n g (D: Death): Cac BN bi chet do nhUdc cfl, do cac bien ehdng cCia cac bien phap dieu trj benh nhugc cd h o l e bj ti!r v o n g t r o n g v d n g 30 ngay sau m o cat b d t u y e n ufc.
De t h u a n ldi cho viec nghien CUXJ, danh gia ket q u i sau m o vdi eae yeu t d lien quan, dua vao sU ch\
t h i e n cae trieu chdng lam sang va mde do giam lieu t h u d c dieu tri so vdi trUde m d , chung t d i tien hanh
TAP CHl YDJOC LAM SANG 108 Tap10-Sd4/2015
gop n h o m p h a n loai ket qua Sieu tri sau m o t h a n h 2 nhom t h e o m o t so tac gia: Mack M J [ 9 ] , Medany Y . E . L [ l l ] . . . . g 6 m c 6 :
Nhom CO hieu qua {cd cdi thien) sau phau t h u a t Gom cac BN thuyen giam hoan toan va benh cai thien.
Nhom khong co hieu qua {khong cai thiin) sau phau thuat: Gom cac BN sau mo khong thay doi, nang len, tai phat hoac til v o n g do benh nhuoc ca.
3. Ket q u a
3.1. Ket qua chung
Tuoi t r u n g b i n h : 38,3 ± 1 4 , 2 Uil IS den 72 tudn Gidi: 18 nam (34,6%), 34 nCr (65,4%). Ty le nij/nam:
1,89/1
Tmh trang nhuoc CO: N h o m I: 8 BN (15,4%), n h o m IIA: 32 BN (61,5%), n h o m IIB: 12 BN (23,1%)
Thdi gian mac benh t r u n g b i n h (thang): 29,9 ± 33,5(1-196).
Giai phau benh tuyen ufc: 55,8% t a n g s5n, 42,3 % t o n tai va 1,9% u tuyen u'c.
Thcligianm6:58,3±12,0 phut(tu'40ifen nOp/luf).
Thdi gian t h e o doi sau m o t r u n g binh {thdng):
35,6 ± 1 4 , 1 ( 3 - 6 2 ) .
Ket qua theo doi BN sau m o > 1-3 nam (n = 45):
t h u y e n giam hoan t o a n : 18/45 = 40,0%, b e n h c i i thien: 20/45 = 44,4%, khong thay d o i : 7/45 =15,6%.
N h u vay, BN co hieu qua sau mo la: 84,4%, khong co hieu qua: 15,6%.
3.2. Mgtsoyeu to lien quan vdi ket qua phau thudt
Bang 1 , T h d i g i a n t h e o d o i va Icet qui sau m o
Ket qUti b e n h n h a n sau m o
Thuyen g i l m hoan toan CSi thien
Khong thay ddi Nang hon TCf vong
Cong
T h d i gian t h e o d o i sau mo
£ 1 nam (n = 50) SoBN
6 33 8 0 3 50
T y l e % 12,0 66,0 16,0
6,0 100,0
>^-3nam(n=4S}
SoBN 18 20 7 0 0 45
T y l e % 40,0 44,4 15,6
100,0
> 3 - 5 namfn =25}
SoBN 12 10 3 0 0 25
T y l e % 48,0 40,0 12,0
lOO.O Nhdn xet Thdi gian theo ddi sau mo cang dai ed X)f le BN thuyen giam hoan toan cang cao, sU khac biet cd y nghia t h d n g ke (p<0,05).
Thdi gian theo ddi sau m o < 1 nam cd 3 t r u d n g h g p t d v o n g do benh nhuge eo (3/50 = 6,0%).
B a n g 2 . Ket q u a d i e u t r i sau m o v a thori g i a n m a c b e n h
Ket q u i BN sau mo (sau mo 3 n a m , n = 45)
Cd hieu q u i sau md Khdng cd hieu q u i
Cpng
T h d i g i a n
£ 1 2 t h a n g SoBN
19 2 21
T y l e % 90,5
9,5 roo,o
m a c b e n h
> 1 2 t h a n g SoBN
19 5 24
T y l e % 79,2 20,8 100,0
S o B N 38
7 45
TJIe%
84,4 15,6 100,0 Nhdn xit Ty' le BN ed hieu q u i sau phau thuat: N h d m t h d i gian mac benh s 12 t h i n g la 90,5%, n h d m thdi gian m i c benh > 12 t h i n g la 79,2%, sU khac biet khdng cd y nghia t h d n g ke (p>0,05).
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
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Vol. 10-NM/201S
Bang 3. Ket qua dieu trj sau m d va n h o m tuoi
Ket q u i BN sau mo (sau mo 3 nam, n = 45) Co hieu qua sau md Khdng cd hieu qua
Cgng
< 20 tuoi SoBN
5 0 5
Ty le % 100,0
700,0
Nhom tuoi
> 20 - 50 tuoi SoBN
28 4 32
TJIe%
87,6 12,4 700,0
> 50 tudi SoBN
5 3 8
T y l e % 62,5 37,5 700,0 Nhgn xet BN cd hieu q u i sau m d cao nhat d n h d m <20 t u o i (100%), n h d m >20-50 tudi chiem t^ le 87,6%, thap nhat d nhdm > 50 tudi (62,5%). BN d n h d m <50 t u o i ed t^ le hieu q u i sau mo cao hgn nhom
>50tudi(p<0,05).
Bang 4. Ket qua dieu trj sau m d va gidi tinh
Ket qua BN sau md (sau md 3 nam, n = 45) Cd hieu q u i sau md Khdng cd hieu qua
Cgng
Nam SdBN
10 3 13
TJIe%
76,9 23,1 100,0
NO SoBN
28 4 32
T y l S % 87,5 12,5 100,0 Nhdn xet BN cd hieu q u i sau phau thuat: NU gidi chiem ty ie 87,5%, nam gidi chiem ty le 76,9%, sU khac biet khdng cd y nghia thong ke {p>0,05).
B l n g 5. Ket qua dieu trj sau m d v a tinh trang nhUdcctftrUdcmd
Ket qua BN sau md (sau md 3 nam, n = 45) Cd hieu q u i sau md Khdng cd hieu q u i
Cgng
Tmh trang nhUtfc cdtrUdc m d Nhdm 1
SdBN 7 0 7
Ty le % 100,0
100,0
N h d m IIA S d B N
26 3 29
Ty le % 89,6 10,4 100,0
Nhdm IIB SdBN
5 4 9
T y l e % 55,5 44,5 700,0 Nhdn « f Ket q u i dieu tri sau phau thuat cd lien quan den tinh trang nhugc co trade m d (p < 0,05). TJ le BN c6 hieu qua sau phau thuat Nhuqc CO nhdm I la 100%, nhuoc co nhdm IIA la 89,6%, nhuoc co nhdm IIB la 55,5%
Bang 6. Ket qua dieu trj sau md va t d n t h u o n g mo benh hoc tuyen (Ic
Ket qua BN saumd (sau md 3 nam, n = 45)
Cd hieu q u i sau md Khdng cd hieu q u i
Cgng
Tdn thUdnq md benh hoc tuyen He U
SdBN 1 0 7
T y l e % 100,0
700,0
Tang s i n SdBN
23 3 26
T ^ l e % 88,5 11,5 700,0
Tdn tai SdBN
14 4 78
T y l e % 77,8 22,2 700,0 Nhdn xit: BN cd hieu q u i sau m d : Nhdm u tuyen iJc chiem ty le 100%, n h d m t a n g s i n tuyen ufc chiem tJ le 88,5%, nhdm ton tai tuyen dc chiem ty le 77,8%, sU khac biet khong cd y nghia t h d n g ke (p>0,05).
TAP CHi Y Daoc U M SANG 108 Tapl0-S64/2015
4. Ban l u a n
Benh n h u o c co lien quan den su bien doi bat thudng cua t u y e n Uc (u hay tdng sdn tuyen dc) da dugc nhieu c o n g t r i n h nghien cdu t r o n g ITnh vUc y hpe tren The gidi ket luan Xd nhCfng nam dau t h e ky 20. Phau t h u a t eat b d t u y e n de da ap d u n g rdng rai va dugc d a n h gia la m g t p h u d n g phap dieu trj cd hieu q u i , d d n g vai t r d quan t r g n g t r o n g cac bien phap dieu trj benh nhuge eo. Hau het eae nghien cuu deu nhan thay ket q u i sau m d cat tuyen dc dieu trj benh nhUde eo p h u t h u d c vao nhieu yeu t d nhU:
Tudi, gidi, t l n h trang nhugc c d trude m o , m d benh hge tuyen Ue, kha nang can thiep phau t h u a t t h d i gian theo ddi sau m d [5] [8]...; t u y nhien, sU lien quan eua cac yeu t o nay ed I n h h u d n g t h e nao tdi ket qua dieu trj ngoai khoa benh nhuge cd van cdn chUa thdng nhat, t h a m ehi edn ed ket luan trai ngugc nhau, cd nhieu y kien ban luan va can dUdc tiep tue nghien cdu danh gia.
Tbcd gian theo doi vd ket qua sau mo Ket q u i nghien CL^J t r i n h bay d b l n g l eho thay ty le benh t h u y e n g i l m hoan toan o n d i n h n h u sau:
S a u m 6 < l nam la 12,0%; s a u m d >1-3 nam 1140,0%, sau m o > 3-5 nam la 48,0%. Ket qua tren eho thay . thdi gian t h e o ddi sau m d cang dai thi t:^ le benh [ thuyen giam hoan t o a n d n d j n h cang eao, sU khac : biet ed y nghia t h d n g ke (p<0,05). Ket q u i d a n h gia I s l nam: BN cd hieu q u i sau m d ehiem ty- le 78,0%, I khdng cd hieu q u i sau m o ehiem t J le 22,0%, t r o n g do cd 3 BN (6,0%) t d v o n g d o benh nhuge co t r o n g nam dau tien sau m d . Ket q u i sau m d > l - 3 n a m : Ty le BN cd hieu q u i sau m o la 84,4%, tUdng dUdng vdi ket q u i danh gia sau m o eat tuyen dc qua d u d n g ed - mui de - NSLN hoac bang PTNS long nguc cua m d t sd t i e gia nhu: IVlack IWJ (1996)[9], Nguyen Cdng ' Minh (2011)[1] Ket qua sau m d t h d i gian>3-5 nam:
; Ty le BN ed hieu q u i sau m o la 88,0%, tUdng dUdng
• vdi ket q u i d a n h g i l sau m o cat tuyen dc qua m d 1 xUdng Lfc, m d rdng qua dUdng eo hoae b l n g PTNS
; long ngue eua: Mai Van Vien (2004)[3], Shrager J.B - {20O6)[12],.... Day la m d t ket q u i p h u hdp, vl d a n h '• gia ket q u i sau m d d t h d i gian sau m d cang dai t h i t y . le BN CO hieu qua sau phau t h u a t cang cao va t a n g dan t h e o t h d i gian theo d d i . Kha nang phuc hdi eda
BN tang dan theo t h d i gian sau m o vi t r o n g qua t r i n h mac b e n h nhUde co cae t h u e l m t h e t i e p nhan acetylcholin d mang sau xinap t h a n kinh - ed g i a m ve sd l u o n g va kem ve chat lucmg, do vay sau phau t h u a t eat b d tuyen u'c phai cd t h d i gian de cac t h u d m t h e phuc hoi.
Ket q u i tren cho thay tai e i e t h d i d i e m khac nhau, ty le BN cd hieu qua sau phau t h u a t {ttinh thuyen gidm hodn todn dn dinh vd benh cai thien) t a n g dan t h e o t h d i gian t h e o d d i . NhU vay, t h d i gian sau m o cd lien quan den ket q u i dieu trj: Thcri gian sau mo cdng ddi thi ty le BN thuyen gidm hodn todn Sn dinh hay ty le BN co hieu qud sau phau thudt cdng cao, nhan xet nay cua chung t d i cung phu h c ^ vdi nhan xet eCia m g t so t i e gia nhU: Nguyen Cdng M i n h ( 2 0 n ) [ l ] , Mai Van Vien (2004)[3], Budde J.M (2001)[5], Kiriakos A (2007)[8]. Medany Y.E.L (2003)[n]... Do vgy deddnh gid kit qua sau cdt tuyen dc qua dudng co cd Video trg giup cung nhu ddnh gid kit qud sau phdu thudt cdt bo tuyin dc cua cdc phuang phdp phdu thudt khde (mo md hay phau thudt NSLN) cdn phai cd thcri gian theo doi.
Tbdi gian mac binb va ket qua sau mo Nhan xet ve sU lien quan giUa t h d i gian mac b e n h trude m d va ket q u i sau m o eua cac nghien cdu tren The gicfl" va t r o n g nude edn chua t h o n g n h a t Cd nhieu nghien edu xac nhan thcfi gian m l e benh trUde khi phau t h u a t eat b d tuyen ufc khdng phai la m g t yeu to quan t r g n g I n h hUdng t d i ket qua dieu trj sau m o , nhUng cung ed nhOng bao cao cho rang t h d i gian mac benh trudc m o ngan se cd I n h h u d n g t d t tdi ket qua sau m o , nhat la khi t h d i gian mac benh trUde m o t i / < 12 t h i n g [1] [21 [6] [8] [10].
Trong nghien cdu cua chung t d i {bdng 2) cho thay: Ty le BN cd hieu qua sau phau t h u a t 3 nam d n h d m t h d i gian mac benh < 12 t h a n g la 90,5%, d n h d m ed t h d i gian mac benh >12 t h a n g la 79,2%, khdng ed su khac biet ket qua sau mo d 2 n h d m BN cd t h d i gian mac b e n h khac nhau vdi p>0,05. NhU vay, t h d i gian mae benh trudc m o khdng I n h h u d n g t d i ket q u i sau m d . Nhan xet nay cua chung t d i cung p h l i h g p vdi ket luan cua m d t sd t i e gia [4] [5].
Tuoi vd ket qud sau mo
Tuoi la m d t yeu t d tien lUdng cho ket qua sau m o eSt tuyen de dieu trj benh nhUdc cd, t u y nhien
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol. 10 - N° 4/2015
gidi han tudi BN cd hieu q u i sau phau thuat eat tuyen dc d cac cdng trinh nghien cdu van edn khae nhau, ed nhdng nghien edu de xuat ket qua sau mo t d t dudi 40 tuoi, cd nhUng de xuat cho rang t u d i sau mo ket q u i t d t dUdi 50 tuoi [1], [5], [8], [10].
De t i m hieu moi lien quan gida ket qua dieu tri sau m d vdi tuoi, chung tdi tien hanh so sanh ket q u i dieu trj sau mo 3 nam d cac nhdm tudi. Tudi eua BN t r o n g nghien cdu dugc phan chia thanh 3 n h d m theo nhdng giai doan cd sU thay doi ve yeu to ndi tiet t d cCia ed the la: 5 20 tuoi, > 20 den 50 tuoi va >
50 t u o i . Ket q u i t h d n g ke b l n g 3 cho thay: Nhdm BN s 50 tuoi ed ty le hieu q u i sau phau thuat eao hdn (100% va 87,6%) 50 vdi nhdm > 50 tuoi (62,5%), sU khac biet nay cd y nghTa t h d n g ke vdi p < 0,05. TJ- le BN cd hieu q u i sau phau thuat cao nhat d n h d m tudi < 20, thap nhat d nhdm tuoi > 50. Nhu vay, t u o i ed lien quan den ket q u i dieu tri sau md, t u o i cang tr^ thi ket qua dieu trj sau mo cang ed hieu q u i . TJ le BN cd hieu qua sau m d cd xu hUdng giam dan theo SU tang len cua tuoi, dieu d d cho thay nhOng ngudi tr^ dap dng ket q u i phau thuat t o t hon. Ket qua tren eho thay t u o i la m g t yeu t d ed the duoc sd d u n g de tien lugng ket q u i dieu tri sau mo cat tuyen de, nhan xet nay rat ed y nghTa ddi vdi cac nha ngoai khoa sd d u n g lam can cd lua chgn BN, chi dinh mo de dat dUde ket q u i t d t n h a t Nhan xet nay cua chung tdi cung phu hop vdi nhan xet t r o n g nghien edu danh gia ket q u i sau md cat tuyen Uc dieu tri benh nhugc cd cCia mdt so tae gia: Nguyen Van Thanh (1988}[2], Mai Van Vien (2004) [3], Budde J.M (2001 )[5], Kiriakos A (2007)[8], Masaoka A (1996)[10].
Tuy nhien, mgt sd tac g i l cho rang tudi la yeu t d khdng lien quan den ket q u i dieu trj sau md [6],[9].
Gidi tinh vd ket qua sau mo
Anh hudng cua gidi tinh den ket q u i sau m d ed nhieu ket luan khae nhau, nhieu nghien cdu cho rSng ket qua sau m d t d t hon vdi cae BN nU. Trong nghien cufu [bang 4) thay r i n g Xy le BN ed hieu qua sau m d cua nU gidi la 87,5%, nam gidi la 76,9%, n h u n g su khac biet khdng cd y nghTa thong ke (p >
0,05), cd nghTa la gidi tinh khdng lien quan vdi ket q u i sau m d . Nhan xet nay eCia ehung tdi cung phu hop vdi eie ket q u i nghien cdu sau mo cat tuyen dc
cCia: Nguyen Cdng Minh {2011)[1], DeFilippi v j (1994)[6]....Tuy nhien, nghien cdu cua cic tac q\i.
Nguyen Van Thanh (1988)[1], Mai Van Vien (2004)[3], Budde J.M {2001 )[5], Kiriakos A (2007)[8]... da cd nhari xet gidi tfnh ed lien quan den ket q u i phau thuat NiJ gidi sau m o cd ket q u i t d t hon so vdi nam gidi.
Tinh trgng nhugc catrUc/cmo vd kit qua sau mo Tinh trang nhUde c d cua BN trude mo la mot yeu t d dUdc nhieu tac g i l sd d u n g de tien lugng ket q u i sau m o . Ket q u i m g t sd nghien cdu cd nhOtig nhan xet khac nhau, m g t sd t i e g i l nhan thay khong I n h h u d n g hay khdng ed lien quan giUa tinh trang nhugc CO trudc m d vdi ket q u i sau md nhU: IVlai Van Vien (2004)[3], Budde J.M (2001)[5], Defilippi VJ (1994)[6].
Trong ket qua nghien cufu cua chung tdi (bdng 5) thay rang ty le BN cd h i f u q u i sau phau thuat 6 nhuoc ed n h d m I la 100%, nhugc cd nhdm IIA la 89,6%, nhUde cd n h d m IIB la 55,5%, sU k h i c biet c6y nghTa t h d n g ke vdi p<0,05, tde la tinh trang nhifdc ed trude mo ed hen quan den ket q u i sau md. Nhan xet nay cda chung tdi p h u hgp vdi nhan xet eCia mot sd tac g i l cho r i n g BN e d t i n h trang nhugc co trudc m o nhe thi k h l nang phuc hdi sau m o nhanh hdn,ty le BN cd hieu q u i sau phau t h u a t cao hgn [10].
Md benb hgc tuyen dc va ket qud sau mo Tuy cac ket luan edn chua t h d n g n h a t nhutig m d t sd edng t r i n h nghien edu nhan thay ket q u i sau m d BN tang s i n tuyen de ed t y le dat hieu q u i cao hon[1],[4],[5],[8].
Ket q u i tai b l n g 6 cho thay: Sd lUdng BN mo u tuyen dc thap (1/52=1,9%) do chi djnh phau thuat chi dugc thUc hien vdi cac khdi u nhd kich thifdc
<2cm va khdng dfnh vdi t d chdc xung quanh. Ket q u i BN cd hieu qua sau m d t a n g s i n tuyen dc la 88,5%, sau m o t o n tai t u y e n dc la 77,8%, sU khde biet khdng cd y nghTa t h d n g ke vdi p>0,05. NhU vay, ton t h u o n g m o benh hgc d n h d m tang s i n va ton tai tuyen dc khdng lien quan den ket q u i sau md. Nhan xet nay cua c h u n g tdi eung phu hgp vdi ket qu3 nghien edu cua m d t so tac gia: Defilippi V J (1994)[6], Mai Van Vien (2004)[3].
Vdi sd lUdng BN ehUa nhieu, t h d i gian theo doi chua dugc lau dai, can dddc tiep tue theo ddi va
TAPCHlYDUOCLAM SANG 108 Tap 10-So 4/2015
danh gia; nhUng vdi ket q u a . n g h i e n cdu ban dau eho thay: Phau t h u a t cat tuyen dc qua dUdng co ed ndi soi ho t r g la m d t p h u o n g phap phau t h u a t cd ty le ket q u i BN cd hieu q u i sau m d t u o n g d u o n g vdi cae phUdng phap phau t h u a t k h I c ; t y Ie ket q u i t o t tang dan t h e o t h d i gian theo ddi sau m o , eae ket q u i danh gia sau m o p h u h g p vdi nhieu nghien cdu trudc day.
5. Ket luan
Nghien edu 52 BN nhugc co d u g c phau t h u a t e l t tuyen ufc qua d u d n g eo ed ndi soi ho t r g , budc dau t h u dugc m d t sd ket q u i n h u sau:
Phau t h u a t ndi soi ho t r g cat tuyen ufc qua dudng cd dUde chl d j n h d cae BN nhugc cd Xd n h d m I den n h d m IIB, cd hoae khong cd u tuyen ufc, d ca 2 gidi nam va nCf, cd d o t u d i t d 15 den 72.
Thdi gian m o ngan, t h d i gian m o t r u n g binh (phut): 58,3 ± 1 2 , 0 ( 4 0 - 1 1 0 )
Theo ddi sau m d thdi gian > 1-3 nam cd ket qua (n = 45): Benh t h u y e n g i l m hoan toan: 40,0%, benh eli thien: 44,4%, khdng thay d d i : 15,6%. BN cd hieu q u i sau m o {benh thuyen gidm hodn todn vd benh cdi thiin) chiem x^ le cao (84,4%). Ty le BN t h u y e n giam hoan toan sau m o t a n g dan theo t h d i gian theo d d i : sau 5 1 n a m : 12,0%, > 1 - 3 nam: 40,0%, > 3 - 5 nam:
48,0%. Ket q u i tUdng dUdng vdi ket qua cac phUdng phap e l t tuyen dc qua d u d n g m d xuong ufc hoac PTNS Idng ngUc cix tuyen ufc.
Cic yeu to: Tuoi, tinh trang nhugc eg trude mo, thdi gian theo ddi sau md la eie yeu t d dUdc xem x e t d i n h gia va tien lugng eho ket q u i sau phau t h u a t
Tai lieu t h a m khSo
1 Nguyen Cdng Minh (201 l)W/iur)gt/en6dmd( trong diiu trj binh nhugc ca. Nha xuat b i n Y hge - Chi n h i n h Thanh phd Hd Chi Minh.
2. Nguyen Van Thanh (1988) Gdp phdn nghien cdu chdn dodn vd dieu tn ngogi khoa binh nhuac ca.
Luan an Phd tien sT khoa hge Y d u g c Hgc vien Quany
3. Mai Van Vien (2004) Nghien cdu mgt sd ddc diem Idm sdng, X guang vd md tjenh hgc tuyai dc lien quan den kit qud dieu tri ngogi khoa benh nhdOc ca. Luan an Tien sy y hgc. Hge vien Quan y.
4. Mai Van Vien (2010) Ddnh gid kit qud cdt tuyen Uc diiu tri benh nhugc ca. Tap chi Y hgc Viet Nam (2) tr. 140-146
5. Budde J.M, Morris C D , Gal A.A et al. (2001) Predictors of outcome in thymectomy for myasthenia gravis. AnnThorac Surg 72:197-202.
6. DeRlippi V J , Richman D.P, Ferguson M.K (1994) Transcervical thymectomy for myasthenia gravis.
Ann Thorac Surg 57 (1): 194 -197.
7. Jaretzki ill Alfred, Barohn Richard J, Emstoff Raina M at al Task Force o f t h e Medical Scientific Advisory Board of the Myasthenia Gravis Foundation of America (2000) Myasthenia gravis:
recommendations for clinical research standards.
Ann Thorac Surg 70: 327 - 334.
8. Kyriakos Anastasiadis and Chandi Ratnatunga (2007) Thymectomy. The Thymus Gland - Diagnosis and Surgical Management 9 : 6 3 - 8 4 . 9. Mack Michael J, Landreneau Rodney J, Yim A.P.C,
Hazelrigg Steven R, Scruggs Granger R (1996) Results of video - assisted diymectomy in patients with myasthenia gravis. J Thorac Cardiovasc Surg 112:1352-1360.
10. Masaoka A, Yamakawa Y, Niwa H, et al (1996) Extended thymectomy for myasthenia gravis patients:
A 20year review. Ann Thorac Surg 62:853 - 859.
11. Medany Yasser E.L, Hajjar Waseenr, Essa Mohamed, Kattan Khaled A l , Hariri Zohair, Ashour Mahmoud (2003), Predictor of outcome for Myasthenia gravis after Thymectomy. Asian Cardiovasc Thorae Ann 11:323-327.
12. Shrager J.B, Nathan D, Brinster CJ, Yousuf O, Spenee A. Chen Z, Kaise LJ^ (2006) Outa>mes after 151 extended transcerwca! thymectomies for myasthenia gravis. Ann Thorac Surg 82:1863 -1869.
