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Ket qua dieu tri lay soi ong mat chu qua npi soi mat tuy ngirpc dong
The results of ERCP in treatment of common bile duct stone
I • ' ' • '
Mai Hong Bang, Duong Minh Thang, Nguyin Tien Thinh, Benh vien Trung uang Quan dgi 108 Tran Van Riep, Thai Doan Ky, Trjnh Xuan Hung,
Nguyin Thanh Tu va cong su - G
Tom tat
Soi dng mat chu la mot benh rat pho' bien tren the gidi cung nhu d Viet Nam. PhUdng phap dieu trj soi mat trudc day chii ye'u la phlu thuat, nhung day la phlu thuat Idn vdi nhieu bien chffng nang ne va hau phau phffc tap. Npi soi mat tuy ngUpc dong chan doan va dieu trj soi dng mat chu da dupc ap dung rpng rai tren the gidi tff nhieu nam nay, tuy nhien d Viet Nam mdi chi dupc ap dung tai mot sd benh vien Idn. Npi soi mat tuy ngUpc dong dUpc ap dung tai Benh vien TL/QD 108 tff nam 2002 da thu dUpc ke't qua dang khich le. Trong pham vi nghien cffu nay cac tac gia danh gia hieu qua dieu trj lay soi d'ng mat chii d 104 benh nhan dieu trj npi tru tai Benh vien TLTOD 108 trong 4 nam, tff 2005-2008. Ket qua cho tha'y cd tdi 92,2% trUdng hdp lay soi thanh cong, thdi gian thUc hien ky thuat nhanh (trung binh la 38 ± 8,5 phut) va thdi gian nam dieu trj npi trii ngan (3,5 ngay). T^ le bie'n chffng thap (6,7%) va deu d'n djnh sau dieu trj. Npi soi mat tuy ngUpc ddng la phUdng phap cd hieu qua cao va an toan trong dieu trj benh ly sdi d'ng mat chu, nen dupc then khai ap dung rpng rai tai cac benh vien trong ca nUdc.
Summary
Common bile duct stone (CBD) is very common. In the past, operation was the dominant option for CBD but it had many severe complications and complicated postoperation. Endoscopic Retrograde Cholangiopanceatography (ERCP) has been now applied to diagnose and treat CBD for years in the world but just only in some hospital in Viet Nam. ERCP was used in the 108 military Hospital since 2002 and it has been shown very promising. This study accessed the effect of ERCP for treatment of 104 inpatiens with CBD at 108 hospital for 4 years, from 2005 to 2008. The results showed that 92.2% of cases were successful, the time of this technique (38 ± 8.5 minutes) and hospitalization (3.5 days) were short. The percentage of complications was low (6.7%) and all of these were stable after treatment. It indicated that ERCP is a value and safe method for treatment of CBD and should be applied widely in our country.
1. Dat van de the gidi tff nhieu nam nay, nhung d Viet Nam mdi ehi Sdi d'ng mat chO la mot benh rat phd bie'n d Viet dupe ap dung tai mdt sd benh vien Idn. Ndi soi mat tuy Nam cung nhu tren the gidi. Trudc day phUPng phap ngUpe ddng da dupe ap dung tai Benh vien TLTQD 108 dieu tri chCi ye'u la p h l u thuat, tuy nhien day la mot tff n§m 2002, budc dau thu dupe ke't qua td't nhUng phlu thuat Idn vdi nhieu bie'n ehffng nSng ne va hau nhuTig nghien effu ve van de nay edn ehUa dupe day phau phffc tap [1,2,3,6,8]. Hien nay, npi soi mat tuy du [1,2,5]. Muc tieu eua nghien effu nham danh gia ngupe ddng (NSMTND) da dupc ap dung rpng rai tren hieu qua dieu trj va eac bie'n chimg ciia ky thuat npi Phan bien khoa hgc: PGS.TS. vO VAN KHIEN
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soi mat tuy ngUpe ddng trong dieu trj benh ly sdi d'ng mat ehil.
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2. Doi tupng va phUdng phap 2.1. Ddi tugng nghien ciiu
Gdm 104 benh nhan dupe tie'n hanh NSMTND tai Benh vien TWQD 108 trong thdi gian tff 2005-2008.
- Tieu chuan chpn benh nhan nghien effu; Benh nhan dupc ehan doan ve lam sang, can lam sang va sieu am nghi ngd ed sdi hoae/va giun trong d'ng mat chii:
+ Lam sang; dau ha sudn phai, sdt, vang da...
+ Sieu am; gian dudng mat ngoai gan va/hoac trong gan, ed hinh anh nghi sdi, giun CMC.
+ Prothrombin >70%, mau chay va mau ddng binh thudng.
+ Kieh thudc cOa sdi do tren sieu am < 25mm.
- Tieu ehuan loai trff; .•
+ Kieh thudc sdi (do tren sieu am) > 25mm. <. i + Rdi loan ddng mau. :'. •
+ Suy gan, suy than nang. cQ.";
+ Cd benh ly ac tinh dudng mat tuy. , , :' + Suy tim, suy hd hap, qua gia ye'u. _, .;-' + Benh nhan tff ehd'i lam NSMTND.
2.2. Phuang phap nghien ciiU Tie'n cffu, md ta cat ngang.
HJI
- Quy trinh nghien ciru;
+ Lua chpn benh nhan. .,, , ,
+ Chuan bj benh nhan. ^ -^ ^ -^' '"•'' P + Thuc hien ky thuat NSMTND. | ; ,;s + Theo ddi sau NSMTND.
+ Thu thap va phan tich so lieu. ^* • ^'••'' - Phuang tien nghien effu; ' ' + May sieu am Sonos 7500 va 5500 (My) + May ehijp mach hieu Philips (My)
+ May npi soi ta trang cffa ben Olympus-EVIS 240(Nhat Ban)
+ Catheter telfon ciia hang Wilson- Cook, day dan (Guidewires), rp lay sdi, dung cu tan sdi.
+ Ngudn eat dot.
+ Cae thude nhU thud'c can quang, thud'c tien me (Seduxen), thude me, thude giam nhu ddng rupt va eac thudc cap cffu khac. u; ~r, i/ur; ./•If'.^i 's. luig
- Cae budc eOa ky thuat NSMTND; •.•&>4jfl i + Oua may xud'ng ta trang.
+ Tim Papilla va ludn catheter vao Papilla.
+ BPm thud'c can quang chup dUdng mat tuy.
+ Cat CO Oddi, ludn rp vao lay sdi/giun.
+ Chup dudng mat kiem tra lai. =fio nji<>Vi(ft' + Bdm rffa dudng mat.
- Xff ly sd lieu bang phan mem SPSS.
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3. Ket qua nghien curu " i i :M ' - ^',;> ^-.M!^;. ; r,n . rr5r>n
104 benh nhan dMc tie'n hanh NSMTND tai Benh vien TWQD 108 tff 2005-2008. Ty le nam/nff 38,5%/61,5% (-1/1,6); tren 40 tudi gSp 84,6%. Trong sd 104 trudng hpp ed 2 trudng hpp chup mat tuy ngUpc
ddng nhUng khdng tha'y cd sdi . . .
Bang 1; Ke't qua lay sdi qua npi soi mat tuy ngUpc ddng
Ke't qua Lay het sdi . i Khdng lay he't
Khdng lay dupc sdi
Khdng ehup dupe dudng mat Tdng sd
SdBN
8 1 .•»:' - - ' ^ i ' . -
13 3 5 102
Tl le (%)
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Nguyen nhan Sdi to
Sdi ddng chac trong CMC Sdi ket Cd Oddi
Hep OMC Sdi d vj tri khae
Khdng lam dupc NSMTND
Sd lUdng (n) 0 3 0 0 13
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Tl le (%) 0 2,9
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iKifl,,'.;v'';)'. '^^ ,v,' Bang 3; Bie'n ddi lam sang sau dieu trj
Bien ddi lam sang Tdt Kha NhUcu
Xau di Tdng sd
Sd lUdng (n) 79 12 9 4 104
Tl le (%) 76 11,5
8,7 3,8 100
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Bieu do 1; Ty le gian dudng mat tren sieu am trude va sau dieu trj
'• -. ifi' Bang 4; Bien ehffng sau lam ERCP Bien chffng
Viem tuy cap Xua't huyet tieu hoa Thiing ta trang
ThDng ta tranq + XHTH Tdng sd
Sd benh nhan 4 1 1 1 7
Tl le (%) 3,8 0,96 0,96 0,96 6,7
Bang 5; Thdi gian thuc hien ky thuat va thdi gian nam vien
Thdi gian ngan nha't Thdi qian dai nha't
Trunq binh
Thdi qian thUe hien ky thuat 20 phiit 90 phiit 35,3 ± 8,2 phiit
Thdi gian nam vien 1 nqay 17 nqay 3,5 ngay
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4. Ban luan
4.1. Thanh cong ky thuat
Tien hanh NMSTND 104 benh nhan, chimg tdi ehi chup duac dudng mat 99 trudng hpp (95,2%).
Trong dd ed 2 trudng hpp sieu am phat hien cd sdi mat nhung chup mat tuy khdng thay sdi. Tuy nhien dudng mat gian, hdi ehffng vang da tac mat rd chiing tdi chuyen benh nhan phau thuat lay dugc sdi OMC.
Nghien cffu 97 trudng hpp ed sdi chung tdi thu dupe ket qua; ty le lay dupc sdi d OMC la 94/102 trUdng hpp (chiem ty le 92,2%), cd 3 ea (2,9%) khdng lay dupc sdi, 13 trudng hpp khdng lay het dupc sdi do sdi d vj tri khae (12,8%) nhU sdi tren cao, nam trong d'ng gan, sdi till mat ket hpp. Trong khi lay sdi cd 15 (15,5%) trudng hpp sdi to chiing tdi phai dung may tan sdi nghien nat vien sdi sau dd diing rp va bdng mdi lay het dupe sdi.
La Van PhUdng nghien ciaj 80 trUdng hpp cd sdi dudng mat, ty le thanh cdng la 87,5%, cd 17/80 trudng hdp sdi to >20mm, phai diing dung cu tan sdi, Uwe Seitz tdng hpp hPn 8204 trudng hpp tha'y ty le thanh edng ciia lay sdi la 86% - 9 1 % [5].
Le Quang Qudc Anh khi nghien cffu ffng dung cOa NSMTND trong ehan doan va dieu trj benh ly dudng mat tuy da tha'y; lay sdi OMC sau md thanh cdng 100%, sdi OMC ddn thuan 89,9%, sdi OMC phdi hpp vdi sdi trong gan 16,6%. Lay giun trong dudng mat dat ty le 100%. Ty le thanh edng chung la 7 1 % . PhUdng phap dieu trj lay sdi qua ndi soi an toan va it xam lan hon nhieu so vdi dieu trj ngoai khoa. Ddi vdi viem tuy cap do sdi ket cd Oddi, neu lay dupc sdi se lam giam tinh trang viem tuy va khdng can phau thuat [1].
Ket qua ciia ehiing tdi tUPng tU nhU cae tac gia trong nude, thap hdn so vdi mdt sd tac gia nUde ngoai do eac tac gia nay lay sdi cd kich thudc rat nhd (trung binh <8mm) [6,7,8]. 6 Viet Nam, do dieu kien kinh te edn ngheo, eae trUdng hpp cd sdi nhd thudng dupe dieu trj npi khoa, khi sdi to hoae ed bie'n ehffng mdi dupe dieu trj npi soi hoSe phau thuat, dieu nay anh hudng nhieu tdi ty le thanh edng ciia dieu trj.
Cd 3 trudng hpp sdi to (>20mm) va ddng chac chiing tdi khdng the lay sdi dupc mae dii da sff dung dung cu tan sdi, nen chimg tdi phai chuyen p h l u thuat. C.-K Hui da nghien cuu diing may tan sdi thuy
dien luc khi lay sdi cd kich thudc Idn va thu dupc ket qua cao. Nhieu tac gia da nghien cffu va dat stent dudng mat d nhffng trUdng hpp sdi qua to ma khdng tan sdi dupc, stent nay lam mat luu thdng d§ dang qua dd cd tac dung lam sdi nhd lai, sau mot thdi gian tien hanh lay sdi lan thff 2 va deu thanh cdng [6,8,9].
4.2. Bien ddi lam sang va sieu am sau lay soi Trieu chffng lam sang cd lien quan vdi tinh trang tac nghen dudng mat do sdi gay ra. Sau lay sdi mat qua NSMTND phan ldn cac trieu chffng lam sang dupe cai thien, tdt len chiem ty le 76%, nhU eu cd 9 trudng hpp chiem ty le 8,7% va xau di cd 4 trUdng hpp chiem ty le 3,8% (day la cae trudng hpp bie'n chifng).
Ket qua lam sang cung phu hdp vdi sieu am, ed 87,5% benh nhan hinh anh dudng mat trd ve binh thudng sau lay sdi OMC.
4.3. Cac bien chiing ciia NSMJND
La mot thii thuat can thiep cd chay mau nen NSMTND ed the gap mot sd bien chimg. Theo cac bao cao trong nude eung nhu d nude ngoai, eae bien chffng cd the gap sau NSMTND bao gdm viem tuy cap, ehay mau tieu hoa, thiing ta trang, suy gan than, nhiem triing huyet... ty le tff vong tff 0,5 den 1,7% [6, 8]. Trong nghien effu ciia chimg tdi gap 7 trUdng hpp cd bien chimg sau lay sdi qua NSMTND chiem ty le 6,7%. Trong dd viem tuy cap ed 4 trUdng hdp ehiem 3,8%; ehay mau tieu hoa 1 trudng hdp; thiing ta trang 1 trudng hdp; dac biet ehiing tdi gap 1 trUdng hpp ed 2 bien chffng ket hpp (Chay mau tieu hoa- Thiing nhd ta trang). Cac BN cd bien chimg viem tuy cap thudng nhe ho§c vUa, dieu trj ndi khoa it ngay dn dinh.
Mot trudng hpp chay mau dudng tieu hda nhe dleu tri npi khoa 3 ngay dn djnh. Rieng 2 trudng hpp bj thiing nhd ta trang chimg tdi ehuyen dieu trj ngoai khoa khau Id thung benh nhan ra vien dn djnh. Chiing tdi khdng gap benh nhan nao tff vong do NSMTND.
Nguyen nhan gay viem tuy cap sau NSMTND la do eac dung cu lay sdi gay tdn thuong dudng mat, dudng tuy hoac do bdm thudc can quang va eae dung djeh bdm rffa nhieu cung kich thich viem tuy. Mot sdtac gia khae lai cho rang ndng dp thude can quang qua cao eung la nguyen nhan gay phan ffng tuy hoae viem tuy [2, 3, 5]. Bien ehffng thiing ta trang thudng do dien eat
CO Oddi qua rpng hoac khdng dung hudng. Vi tri cat cd Oddi an toan thudng d hudng 11 - 12 gid va bae sT lam thii thuat phai Udc lupng tUdng ddi chinh xac dien cat cd Oddi cho vUa du khdng nen eat rpng qua.
Trong trUdng hpp cat khdng an toan cd the sff dung bdng nong gian. Van de nay ngoai kinh nghiem eiia thay thude cdn phu thupe vao trang bj ky thuat [8,9].
So sanh ty le bien ehffng eiia NSMTND vdi phau thuat lay sdi OMC, eac bao eao deu eho tha'y bien chimg ciia NSMTND thudng it va nhe nhang hdn nhieu so vdi p h l u thuat [4, 5, 6]. Do Kim Sdn va edng SI/ nghien cffu 5773 trUdng hpp p h l u thuat lay sdi OMC tai benh vien Viet Dffe tha'y cd rat nhieu loai bien chimg; suy than cap (2,08%), chay mau dUdng mat (2,63%), ap xe dUdi hoanh (0,99%), sdc nhiem trimg (1,42%), vet md nhiem trung rpng (0,42%), tran djch mang phdi (0,40%), rd da day (0,40%), rd ta trang (0,64%), rd dai trang (0,08%), tac rupt sau md (0,3%), ap xe gan vd len mang tim (0,15%), dirt nganh ngang Kehr (0,08%).
4.4. Thdi gian lam ky thuat va ngay nam dieu tri ngi trii cua benh nhan sau NSMTN
Cd nhieu nguyen nhan lien quan den thdi gian lam thO thuat nhu; kinh nghiem ngudi lam thCi thuat, ca'u triic dudng mat va tinh chat eiia sdi OMC. Neu benh nhan dupc gay me (tmh mach hoSc ndi khi quan) se thuan Ipi eho tien hanh ky thuat va rut ngan dupc thdi gian [2, 3, 5]. Trong nghien ciru eiia ehiing toi, thdi gian lam thii thuat trung binh la 35,3 ± 8,2 phiit, thdi gian ngan nha't la 20 phut, dai nhat la 90 phut. Trong dd 78,6% eae trUdng hpp ed thdi gian lam thii thuat tff 30 - 45 phiit. Ket qua nay phii hpp vdi bao cao eiia eac tac gia khac.
Thdi gian nam dieu trj ndi tru trung binh ciia benh nhan sau khi lam NSMTND trong nghien cffu nay la 3,5 ngay; ngan nha't la 1 ngay; dai nha't la 17 ngay.
Phan Idn khoang thdi gian dieu trj npi tru chi tff 2 den 6 ngay (84,3%). Benh nhan dupe ra vien khi eac trieu chffng nhu dau va sdt het h l n , cam giac ngUdi dd chju, an ngff dupc. Cae benh nhan lay giun dPn thuan sau khi lam thii thuat benh nhan ehi can nghi ngpi tai chd 1 - 2 gid cd the xua't vien.
Sau p h l u thuat md d bung lay sdi va dan luu Kehr, thdi gian chd cat chi da la 7 - 10 ngay, thdi gian theo ddi d i n lUu Kehr trung binh tff 7 -15 ngay. Ngoai cae dau hieu phai theo ddi sau khi phau thuat nhU dau, sdt, danh hPi, theo ddi d bijng... cdn phai theo ddi djch mat ehay qua Kehr trong vdng 14-30 ngay, bdm rffa Kehr thudng xuyen. Neu vet md td't thi sau 7- 10 ngay cat ehi, edn neu vet md bi nhilm trimg thi phai cat chi dirt quang, cham sdc vet md trong 1 thdi gian dai ve sau; neu tac dan luu Kehr cd the phai md lai. Nhu vay, theo ddi benh nhan sau NSMTND ddn gian hdn sau phau thuat nhieu, khdng phai theo ddi ve nhu dpng rupt, khdng phai theo ddi Kehr, khdng phai cat ehi... Xet ve mat hieu qua kinh te thi NSMTND cung dd tdn kem hdn phau thuat [5,6,8,9].
5. Ket luan
Qua nghien cffu 104 benh nhan dupe dieu tri lay sdi dng mat chii qua NSMTND tai Benh vien TLTQO 108 trong 4 nam tff 2005-2008, ket qua cho tha'y;
1. NSMTND la mot phuong phap rat cd hieu qua va an toan trong dieu trj benh ly sdi dng mat chii; Ty le lay sdi thanh edng eao 92,2%. Thdi gian thUe hien thii thuat nhanh, trung binh la 35,3 ± 8,2 phiit. Thdi gian dieu trj ndi trii ngan, trung binh la 3,5 ngay.
2. NSMTND la phUPng phap dieu trj kha an toan, ty' le bien chffng thap; 6,7%, trong do; viem tuy cap: 4 BN (3,8%), xua't huyet tieu hoa 1 BN (0,96%); thiing ta trang 1 BN (0,96%), ehay mau ket hpp thiing 1 BN (0,96%). Cae trudng hpp nay deu dupe xff tri dn djnh, khdng ed benh nhan tff vong do NSMTND.
Tai lieu tham khao
1. Le Quang Qud'c Anh (2003), Ndi soi mat tuy, Nha xua't ban Y hpe, tr 42-44.
2. Pham Thj Binh, Nguyen Khanh Trach, Kieu Van Tuan (2000), Danh gia ket qua ehup mat ngUoc ddng qua npi soi trong chan doan va dieu trj hdi chffng tac mat cho 132 trUdng hpp. Tap ehi thdng tin Y Dupe, sd ehuyen de tieu hoa.
3. Pham Quang Cff (2006), Nghien effu gia trj ciia ndi soi mat tuy ngupe ddng trong ehan doan va
117
dieu trj sdi dng mat ehii. Oe tai nghien cffu khoa hpe cap bd.
Nguyen Dinh Hdi va cdng sU (2002), Nhffng tien bp trong ehan doan va dieu trj benh sdi mat, Tap chi ngoai khoa, sd 2, tr 1-17.
La van PhUdng (2001), Oanh gia ket qua ciia phUdng phap ndi soi mat tuy ngUpe ddng trong ehan doan va dieu trj hdi chimg tac mat cho 139 trudng hpp. Tap chi ngoai khoa, sd 3/2001.
Tze-Zen Ong, Jen-Lock Khor, Dede-Sutedja Selamat, Khay - Guan Yeoh, Khek - Yu Ho (2005), Complications of endoscopic retrograde cholangiography in the post - MRCP era; A tertiary center experience. World J Gastroenterol September 7, 2005 Vol. 11 No. 33.
7. Uwe Seitz, MD, Amol Bapaye, MD, Sabine
•: Bohnacker, M.D, Claudio Navarrete, M.D (2003), Advances in Therapeutic Endoscopic Treatment of the Common Bile Duct Stones, Asia pacific digestive week 2003.
8. E J Williams, J Green, 1 Beekingham, et al (2008), Guideline on the management of common bile duct stones (CBDS), Gut 2008 57; 1004-1021 originally published online March 5, 2008.
9. Shadi Kolandoozan, et al (2010), Long-term follow-up of common bile duct diameter after endoscopic sphincterotomy in patients with common bile duet stones, Indian J Gastroenterol 2010 (January-February); 29(1); 22-25.
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