Y HOC VIET NAM THANG 8 - SO 1/2011
KET QUA PHAU THUAT NOI SOI CAT THAN MAT CHlTC NANG TAI BENH VIEN VIET - DLTC GIAI DOAN 2005-2010: NHAN 86 TRl/ONG HOP
• • • "
Do Tru'dng Thanh*, Le Nguyen Vu*
TOM TAT:
Muc tieu: Trong giai doan 2005-2010 khoa phau thuat tiet nieu benh vien Viet OiJc da thUc'hien 86 trUdng hpp cat than mat chufc nang bang phau thuat npi soi.
Nghien diu aia chung toi nham danh gia tfnh hieu qua, miTc dp an toan va nhuhg kinh nghiem tir 86 benh nhan nay, de co the phat trien ky thuat cat than npi soi trong dieu tri cac benh ly ciia than. Sd lieu va phu'dng phap: Tir thang 1/2005 den thang 6/2010, 86 benh nhan (BN) dUpc chan doan va dieu tri phau thuat than benh ly lanh tfnh mat chufc nang do cac nguyen nhan : 63 Bn sol tiet nieu soi than, be than nieu quan gay than iT nUdc mat chu'c nang, 6 BN hep khue noi be than nieu quan than mat chufc nang, 25 BN teo than, 2 BN hep nieu quan 1/3 dUdi sau md. Ket qua: Trong 86 tru'dng hpp cat than npi soi qua phuc mac (61), va sau phuc mac (25) chiing toi khong co bien chifng nao trong va sau md. Thdi gian md trung binh la 83 phut (ddi vdi phau thuat sau phuc mac) va 95 phut vdi phau thuat trong d bung. Thdi gian nam vien tir 3 den 6 ngay, trung binh la 3,9 ngay. Ket luan: Phau thuat cat than npi soi la phUPng phap an toan, hieu qua, giup benh nhan hoi phuc sdm sau md.
TCr khoa: Phau thuat npi soi cat than mat chiTc nang.
SUMMARY:
RESULTS OF LAPAROSCOPIC NEPHRECTOMY IN KEDNEY NONFUNCTION: 86 CASES.
Objective: During the period 2005 - 2010, the univercity urology department of Viet Due Hospital has carried out 86 cases of simple laparoscopic nephrectomy. Our study aims at evaluating the efficiency, the safe degree and with drawing first results in order on the treatment of kidney diseases.
Material and method: From fanuary 2005 to fune 2010, 86 patients are selected and surgically treated with diagnosis: benign nonfunction kidney disease due to: urologic calculus, renal and ureteral calculus causing hydronephrosis 63 cases. Nonfunction kidney due to obstruction of the pelvi-ureteric junction: 6 cases. Atrophic, kidney: 25 cases. Postoperatire restriction of ureter at 1/3 lower section: 2 cases.
Results: Among 86 cases of laparoscopic nephrectomy transperitoneal (61) and retroperitoneal (25). There were no peroperative and postoperative complications. Arerage operating time is 83 minutes (with extraperitoneal operation) and 95 minuter (with Intra abdominal operation). Hospitalizing time is from 3 to 6 days; 3,9 days on average. Conclusion: The
laparoscopic nephrectomy is a safe efflective method, helping patient to restore soon in post operative time.
Keyword: Simple laparoscopic nepherectomy.
I. OAT V A N OE
Gat than la mot trong nhiTng phau thuat nieu khoa dUde ap dung phUdng phap ndi soi dau tien. Nam 1991, dayman [4] la ngUdi dau tien thiTc hien cat than phai ndi soi bang dUdng qua d bung. Ciing nam dd Ferry thUe hien cat than trai ndi soi qua d bung. Hai nam sau 1993, Gaur thiTc hien eat than bang dUdnci sau phiic mac [5]. Cung tiT thdi diem nay, phau thuat npi soi qua thanh bung dUdc phat trien mot each vUdt bac.
' Nam 2002 Hdi nieu khoa chau Au (EAU)[5]
sau khi danh gia ket qua ciia gan 1500 trUdng hdp cat than npi soi, da chap nhan ufhg dung phau thuat ndi soi trong nhii'ng trUdng hdp cit than benh ly lanh tfnh mat chu'c nang.
Tai Viet Nam, nhieu phau thuat md md trong nieu khoa dUde thUe hien bang phau thuat ndi soi d bung. TiT thang 1/2005 den thang 6/2010 tai klioa phau thuat tiet nieu benh vien Viet Du'e da thUe hien cat than bang phau thuat npi soi cho 86 BN. Vdi ket qua thu dUdc tiT 86 trUdng hdp nay, chung tdi xin d\idc ddng gdp mdt phan kinh nghiem, de han che nhiitig bien chiTng cung nhU tang them dUdc nhii'ng Idi diem ciia phUdng phap phau thuat nay.
I I . DOI TU'gNG VA PhUOiyiG PHAP NGHIEN CUU Nghien cufu hoi cifu nhuYig trUdng hdp phau thuat cat than mat chufc nang bang phUdng phap npi soi sau phiic mac va trong phiic mac tiT thang 1/2005 den thang 6/2010 tai khoa phau thuat tiet nieu benh vien Viet Du'e Ha Ndi.
2.1. Dac diem chung
Tudi va g i d i : Dd tudi trung binh: 49,74±
11,18 (20 - 75) tudi.
Nam cd 17 BN, nii' cd 69 chiem, ty le nff/
nam la 4/1
2.2. C$n lam sdng
2.2.1 Sd lUdng hong cau, bach cau deu trong gidi han binh thUdng
* Khoa Phau thuat tiet nieu - Benh vien Viet Ddc 48
2.2.2 Nong dp ure va creatinin mau trUdc md trong gidi han binh thudng
Y HQC VlfeT NAM THANG 8 - SO 1/2011
2.2.3 Cac phUdng phap tham kham chan doan hinh anh
* Chup he tiet nieu khdng chuan bj Bang 2 . 1 : Vi tri ciia sdi he tiet nieu qua chup he tiet
Vj tri cua sdi Sdi NQ ciing ben Sdi be than Khdng thay sdi Tdng sd
Sdlupng 61 15 10 86
nieu khdng chuan bi Ty le o/o
70,930/0 17,440/0 11,630/0 1000/0 Sdi nieu quan chiem ty le eao 70,93o/o.
* Ket qua chup UIV (Ghup nieu do tTnh mach)
16/86( 18,60o/o) than bai tiet rat kem hinh anh OBT khdng rd.
74,410/0 than khdng bai tiet khdng thay hinh OBT.
6 benh nhan hep khue ndi be than- nieu quan, chup tiep UIV thdi diem 120' van khdng thay hinh OBT (thSn khdng ngam thuoc).
* Ket qua chan doan hinh anh than ii' nUde CLVT (chup eSt Idp vi tfnh) - DVPX (chiip dong vj phdng xa). Chup CLVT chi djnh bd sung trong cac trudng hdp benh nhan cd tien sir benh than da ran thiep ngoai khoa va sieu am chan doan than ii' nUde do hep khue ndi BT-NQ va chup OVPX de xae djnh cliufc nang hai than.
2.3. Chan doan nguyen nhan gay benh ly than mat chuTc nang
63 benh nhan sdi tiet nieu, be than nieu quan gay than uf nUde mat chu'c nang. 6 Hep khue ndi be than nieu quan than mat chiTc nang.
15 Teo than. 2 trUdng hdp hep nieu quan sau md viing tieu khung.
I I I . KET QUA NGHIEN CUU 3.1 Ket qua trong md
- Tat ca benh nhan deu diidc thiTc hien gay me toan than (86/86)
21 benh nhan dUde eat than bang dUdng sau phiic mac, 65 benh nhan d\idc cat than bSng dudng trong d bung.
- 25 benh nhan cat than phai, 61 benh nhan cat than trai.
Thdi gian phau thuat va dien bien trong md E
Thdi gian md Rdi loan HA Truyen mau Ghuyen md md
tang 3 . 1 : thdi gian phau thuat c§t than ndi soi Cat than sau phuc mac
83 phut (70'-90') 0
0 1
cSt than qua phuc mac 95 phut (70'-130')
0 0 0
3.2. Giai phau bpnh: Cac benh pham dUde xet nghiem vi the deu ket luan viem dai be than, viem than ke man tfnh khdng thay cd hinh anh ac tfnh.
3.3. Ket qua sau md
Bang 3.2: ket qua sau md cat than ndi soi DIffn bi§n sau md
Chay mau sau md
Phuc hdi luU thdng tieu hoa NKvetmd
Ng^y nSm vien TB
Cat th$n sau phuc mac 0
1 ngay 0 4 ngay
C i t than qua phuc mac 0
1 ngay 0 5 ngay
49
Y HQC VIET NAM THANG 8 - SO 1/2011 IV. BAN LUAN
Chi djnh phau thuat ndi soi cat than, la nhti'ng trUdng hdp than mat nang va than teo.
Nguyen nhan ciia nhii'ng trUdng hdp nay la: viem than be than man tfnh, tac nghen, benh ly sdi, chan thUdng than, xd hoa than nieu quan, trao ngUde bang quang than, teo than l3am sinli. Gat than ddn thuan cung chi djnh eho nhu'ng trUdng hdp rao huyet ap nguyen nhan mach mau than va than da nang cd bien chirng. C^c benh nhan trong nghien ciTu ciia chung tdi deu nam trong nhu'ng ehi djnh nay.
Trong nghien cufu nay da sd cac trUdng hdp thUe hien bang dUdng trong phuc mac (70,9o/o).
Sd di chung tdi sir dung dUdng trong d bung la vi da sd benh nhan than ii nUde d mufc dp nang.
Than gian rat to. Vdi dUdng md trong d bung cd trUdng md rpng, giiip quan sat va bdc tach than de dang hdn. Theo kinh nghiem cua chiing tdi, vdi nhu'ng trUdng than ii nUde gian to neu siT dung dudng vao sau phiic mac thUc hien phau thuat se rat khd khan vi than to da choan het viing md. Neu chpc hiit cho than nhd lai thi gd dinh than cung gap khd khan vi khi dd nhu md than rat miin, khd bdc tach ra khdi td chufc xung quanli, kill'phau tfch rat de lam rach nhu md than, gay chay mau (mac dii khdng nhieu) nhUng se lam trUdng md tdi, khdng quan sat dddc ro rang. Va dac biet tdi thi phau tfch vao cudng than cang khd khan, de gay bien chufng.
OUdng sau phiic mac cd Uu diem la tiep can nhanh va triTc tiep vao cudng than. Cung la dudng md thdng thudng ciia phau thuat md md.
Tuy nhien dUdng md nay ed khoang phau thuat hep, hap thu anh sang nen quan sat trong md han che hdn so vdi dUdng trong phiic mac.
Chiing tdi suf dung chii yeu de eat than teo va than ii' nUde mat chu'c nang, than ii' nUdc dp 2,3.
Theo Keeley ty le phai ehuyen md md la 3-9,4o/o [6}: DUdng nhU dUdng sau phiic mac thdi gian phau thuat nhanh hdn. Ket qua cua chung tdi thdi gian md trung binh 83 phut vdi dUdng sau phiic mac va 95 phut vdi dUdng trong d bung.
Keeley [6] cung cd ket qua tUdng tiT vdi 100 benh nhan cat than bang dUdng qua phiic mac, d 20 benh nhan sau ciing thdi gian md giam tiT 204 phiit xudng cdn 108 phut. Bien chiiYig phau thuat dudng nhU hay gap d 20 trUdng hdp dau tien.
Bien chufng phau thuat cat than npi soi theo thdng ke vdi sd lUdng Idn benh nhan la: 2,8- 370/0, ty le ehuyen md md la 2,8-10,3o/o [6].
Trong nhdm benh nhan ciia chiing tdi cd 1 benh nhan phai ehuyen md md, dd la trUdng hdp teo than do viem than be than. Khi phau tfch than chay mau lam tdi trUdng md, phai ehuyen md md de cat than.
Gill [4] va edng sU thdng ke tren nhieu trung tam thay ty le bien chiing la: I60/0 va ty le ehuyen md md la 60/0. Phau thuat cat than npi soi 6\idc coi la mot phau thuat khd vdi nguy cd Idn ve chay mau, ddi hdi ky nang phau thuat phai thanh thao. Thdi gian de hpc va lam quen vdi phau thuat nay ddi hdi phai keo dai hdn.
Theo Wendy Tabor [7] phau thuat cat than ndi soi mang lai nhieu Uu diem cho lienh nhan: ft mat mau, ft dau sau md, giam thdi gian nam vien va ehi phf cupc md. Sau md benh nhan hoi phuc sdm va trd lai sdm cac hoat dpng xa hdi. Cac benh nhan ciia chiing tdi deu cd thdi gian nam vien ngan (4-5 ngay), thdi gian binh phuc sau md nhanh va khdng ed biln chiitig gl dang ke trong va sau md.
V. K§t LUAN
Qua kinh nghiem 86 trUdng hdp phau thuat cat than npi soi, chiing tdi nhan thay day la mdt phUdng tien dieu trj hieu qua va an toan trong nhu'ng trUdng hdp than mat chu'c nang. Vdi nhuYig trUdng hdp than H nUdc gian to thi dUdng qua d phiic mac se de thUc hien phau thuat hdn.
DUdng sau phiic mac tiep can than nhanh hdn nhUng trUdng md hep khd phau thuat cho nhutig trUdng hdp than to nhieu, nhUng lai rat hieu qua vdi than teo nhd.
TAI LIEU THAM KHAO
1. Vu Le Chuyen va edng su* (2005): NhuYig kinh nghiem qua 40 trUdng hdp cat than benh ly qua ndi sol d bung, Y hoc Viet Nam 8-2005, pp 33-38.
2. Nguyen Phuc Cam Hoang, Vu Ld Chuyen, Nguyen Van An, Nguyen Te Kha, Ngd D^i Hai, Tran Thu'dng Phong, Tran Quang Phuc (2005): Cat than noi soi sau phiic mac trong than mat chu'c nang do benh ly than lanh tfnh: kinh nghiem ban dau qua 24 truSng hdp, Y hoc Viet Nam 8-2005, pp 39^7.
3. Hoang Long, Tran Blnh Giang, Vu Nguyen Khai Ca, Nguyen Du'e Tien, Le Viet Khanh, Nguyen Quang (2005): CSt than ndi soi qua phiic mac nhan 15 trUdng
50
Y HQC VigT NAM THANG 8 - S6' 1/2011
5.
hdp md tai benh vien Viet Du'e, Y hoc Viet Nam 8-2005, pp 25-30.
Gill I . S, dayman R. V, Retroperitoneal and pelvic extraperitoneal laparoscopy: an international perspective. Urology, 1998; 52:
566-571.
Keeley FX, Tolley DA: A review of our first 100 rases of laparoscopic nephrectomy:
Defining risk factors for complirations. Br J Urol 1998, 82:615-618.
Kevin C. Zorn and Arieh L. Shalhav (2009), Laparoscopic Simple Nephrectomy:
Transperitoneal and Retroperitoneal Approach, Essential Urologic Laparoscopy, pp 79-113.
D A C D I E M
LAM SANG, CHAN DOAN HINH ANH VA KET QUA PHAU
THUAT CCiA U MANG NAO VUNG XOANG
T I N HMACH DOC TREN
Nguyen The Hao*, Pham Quynh Trang*
TOM TAT
Muc dich: Danh gia cac dac diem lam sang, chan doan hinh anh va ket qua phau thuat u mang nao viing xoang tTnh mach dpc tren. Phu'dng phap.
Nghien ciili hoi ciru d|c diem lam sang, chan doan hinh anh va ket qua phau thuat 41 trUdng hpp u mang nao vung xoang tinh mach doc tren tai Benh vien Viet- Oifc tir 4/2004-4/2010. Ket qua: 4 i bgnh nlian (17 nam/24 nff), tuoi trung binh 48,4(21-67). Trieu chuYig lam sSng thudng g5p la dau dau (80,5%), yeu/liet nira ngu'di (73,2o/o) va dpng kinh (22%). 61% khoi u co kfch thudc tir 2-4cm, 36% khdi u co kfch thu'dc tren 6cm. 70,70/0 CO khdi u khu tai d 1/3 giu^a xoang tinh mach dpc tren, 19,5% d 1/3 sau va 9,8% d 1/3 trUdc.
100% benh nhan dUpc md lay u, ty le bien chuYig sau md la 9,8%. Ket qua xa sau md: tot 82,9%, trung binh 14,6%, xau 2,5%. Ket luan: oac diem lam sang thu'dng gcip ciia u mang nao viing xoang tTnh mach dpc tren la dau dau, yeu/liet 1/2 ngUdi va dpng kinh.
ChKn doan diTa vao chup cpng hUdng tiT sp nao va chup mach mau nao. Phau thuat la phUPng phap dieu trj cho ket qua tot.
SUMMARY
The cllnlco-radiological findings and surgical results of Parasagittal meningiomas Objective: Analyzing the dinico-radiological findings and surgical results of parasagittal meningiomas. Methods. Retrospective reviews of dinical presentations, imaging and surgical results of 41 parasagittal meningiomas in the Departement of Neurosurgery-Viet Due Hospital from April 2004 to April 2011. Results. 41 patients (17 males/24 females) with mean age 48,4 (21-67). Significant dinical findings: Headache (80,5%), hemiparesis/paralysis (73,2%) and seizures(22%).
* Khoa Phau thuat Than Kinh- Benh vien Viet Ddc Phan bl$n khoa hgc: PGS.TS. Ha Kim Trung
Size 2-4cm (61%), >6cm (36%). 70,7% tumors invading the middle third of SSS, 19,5% the posterior third and 9,8% the anterior third. 100% underwent surgery with 9,8% morbility. Long-term outcome:
Good 82,9%, moderate 14,6%, disablity/death 2,5%.
Conclusion: The most significant signs of parasagittal meningiomas are headache, hemiparesis/paralysis and seizures. Diagnosis based on MRI and DSA. Surgical outcomes are good.
I . DAT VAN DE
U mang nao chiem ty le tiT 15-18o/o cac khdi u ndi sp [8]. Trong dd, u mang nao viing xoang tTnh mach dpc tren chiem 17-20o/o tdng sd u mang nao. U mang nao viing xoang tTnh mach dpc tren la nhCJYig khdi u nam d mdt hoac ca hai ben, ngay canh xoang tTnh mach dpc tren va cd xam lan vao xoang tTnh mach nay [3]. Trieu chu'ng lam sang ciia u mang nao viing xoang tTnh mach dpc tren khdng dien hinh va chi xuat hien khi khdi u Idn, gay chen ep nao nhieu. Chan doan u mang nao loai nay dUa vao chup eat Idp vi tfnh, va cpng hUdng tiT sp nao. Tuy nhien, mudn xac djnh khdi u cd xam lan vao xoang tTnh mach dpc tren, ran phai chup mach nao. Cac khdi u mang nao viing xoang tTnh mach dpc tren thudng lanh tfnh va cd the dieu trj khdi hoan toan bang phau thuat. Tuy nhien, phau thuat u mang nao viing xoang tTnh mach dpc tren la mdt thach thu'c ddi vdi phau thuat vien, khdng phai luc nao cung ed the bao toan td chu'c nao, xoang tTnh mach dpc tren va he thdng tTnh mach dd ve xoang, dac biet khi khdi u khu trii d viing van ddng, vi vay lay.bd hoan toan khdi u, ddi khi
51
