56
Bd tuc sau dai hoc:
Dieu tri ngoai khoa viem tui mat cap Surgical management of acute cholecystitis
NcuvfiN CudNG THINH, VU VAN QUANG
Summary
Laparoscopy cholecystectomy is now accepted as a surgical procedure for acute cholecystitis. There are several lines of strong evidence, such as radomized controlled trials (RCTs) and meta - analyses, supporting the introduction of laparoscopic cholecystectomy for patients with acute cholecystitis. This article describe the surgical treartmentfor acute chole- cystitis accoding to the grade of severity, the timing and theprodure used for acute cholecys- titis in question and answer format using the evi-
Tom tat
Hien nay, cat hii mat ndi soi dugc chdp nhdn Id mgt phuang phap dieu tri ngoai khoa viem hii mat cdp ( VTMC). Nhimg nghien cuu thiic nghiem lam sang ngdu nhien cd ddi chung vd nghien cim tdng hgp tir nhieu thong ke khdc nhau dua ra cdc bang chiing rd rdng ve uu the cua cat hii mat ngi soi frong didu tri viem tiii mat cdp. Bai bdo ndy frinh bdy \h didu fri ngoai khoa viem hii mat cap dya theo mire do viem, thdi didm vd phucmg phdp phau thuat dieu hi Gioi thieu
Cat hii mat da dugc sir dung rgng rai trong dieu tri viem tiii mat cdp (VTMC). Nhidu nghien cuu v6 lua chgn thdi didm cdt hii mat da dugc thyc hien trong giai dogn cdt hii mat md tmydn thdng ciing nhu hien nay thdi ky phat trien ciia phau thudt ngi soi. Nhiing nghien cuu ndy cho thay nen tien hdnh phau thuat cdt hii mat sdm trong vdng 72-96 h tir khi khdi phdt tripu chimg dau tien do nhimg uu viet: gidm tai bien, bien chung, thdi gian ndm vien ngdn, giam chi phi dieu tri....
Liic dau, viem hii mat cdp dugc coi Id chong chi dinh ciia cdt hii mat ngi soi. Sau ndy, Sfras- berg vd cdng sy dua ra nhiing di6m quan trgng
Benh vipn TWQD 108 ^
dence concerning surgical management of acute cholecystitis. They are base on the following: Updated Tokyo Cruidelines-for surgi-
cal management of acute cholecystitis 2013;
Updated Tokyo Guidelines for diagnostic crite- ria and severity grading of acute cholecystitis 2013.
Keywords Acute cholecystitis - Diagnostic criteria - Severity grading - Guidelines - Laparoscopic cholecystectomy.
viem tiii mat cdp theo mgt dinh dgng cau hdi va cdu trd Idi. Nhirng vdn de nay dua vdo: Cap nhdt Hudng dan Tokyo ve: Dieu tri ngogi khoa viem hii mat cap (2013): Cap nhat Hudng ddn Tokyo ve: Tieu chuan chan dodn vd phdn logi mire do viem ciia viem hii mat cap ( 2013).
Tu" khoa: Viem hii mat cap -Tieu chudn chdn dodn - Miic do nang - Hudng ddn - Cdt tui mat ngi soi.
de phdu tich tam giac Calot, ciing su phdt fridn ciia ky thud cat hii mat ngi soi, nhiing cdi tiln dung cu sir dung cho phdu thuat ndi soi, cdt hii mat ngi soi didu trj VTMC ngdy cdng dugc dp dung rdng rai[l][2][6][8]]. Nhimg nghien ciiu thir nghiem lam sang ngau nhien cd ddi chiing vd nghien cim tdng hop hi nhiSu nghien cim khac nhau so sdnh cdt hii mat ngi soi vd cdt hii mat md didu fri VTMC cho thdy cdt hii mat ndi soi uu viet hon cdt tiii mat md[8].
Huong ddn Tokyo ndm 2007 va d i k fri viem dudng mat vd viem hii mat cdp dugc cdng bd tren Tap chi Phau thuat gan- mat- hay, Idn ddu tien da frinh bdy phdn loii mire do cua
Tap chi GAN MAT VIET NAM s6 24-2013 57 viem hii mdt cdp[3][6]. Tmdc do, chua cd tdi
lipu ndo ve phdn logi miic dg viem ddi vdi viem hii mat cap. Vi vay, cung khdng cd bdo cao ndo ve nhung vai frd ciia dieu tri phdu thuat hogc dan luu hii mat theo miic dg viem cua hii mat. Do do, cac phuong phap dieu tri dugc xdc dinh dya fren y kien chung ciia cdc chuyen gia.
Tir khi cdng bd Hudng ddn Tokyo ndm 2007, van chua cd bao cdo ddng tin cay ndo ve
phuang phdp digu hi ngogi khoa tdi uu ddi vdi viem tiii mat cdp theo timg miic do viem.
Chien luge dieu tri viem hii mat cdp dugc trinh bdy d ddy theo cdc dinh dang cdu hdi vd cdu trdldi[7][8].
QI. Phumtgphdp dieu trj ngo^i khoa ndo toi mi doi vdi viim tui m^t cdp theo tUitg mire dg viem ?
Chiing toi khuyin cko phuong phdp dieu tri ngo^i khoa t6i iru theo tung mirc do viem nhu sau:
Muc dp I (vi£m tui mat cap muc dg nta^) cSt tui m^t ngi soi %(fm la phucmg phap toi uu nhSt
Mux d$ II (vi€m tiii m^t c4p muc d$ vira) nen cdt tui m|it s(hn tai nhung trung tdm ngoai khoa cd kinh nghiem. l^y nhi€n, nlu b^nh nh^n c6 tinh trang viem ti^i mki tai cho nang, nen dan luu tui mat sthn (b^ng mo ho^c dan luu qua da). Do cdt tui mat sthn co the kh6 khan, b^nh nhSn can dieu tri noi khoa, sau d6 cat tiii m|it tri hoan.
Muc d$ i n (vi@m tui m$t c4p muc dd n^ng) tich cue dilu tri roi loan chuc nang cac CO quan \k tinh tr^ng viem tai cho cua tui m|lt bang din luu tiii mdt. C^t tiii mat tri hoan khi c6 chi djnh.
Phan logi muc do viem ciia hii mat theo Hudng ddn'Tokyo(26l3>[3]:
+ Mac do nhe (mirc do 1): Tiii mat viem nhe, chi cd phdn img viem tgi chd, khdng cd rdi loan chirc nang cac co quan.
+ Mice do trung binh (mirc do 2): Tiii mat viem cd mdt hodc nhieu tieu chudn sau: Bgch cau > 18 G/l, sd thdy mass d hg sudn phai, thdi gian mac benh > 72h, xuat hien cac tdn thuong:
viem phiic mgc mat, dp xe hii mat, dp xe gan, tiii mat hogi tir, hogi thu tiii mat.
+ Muc dQ nang (muc do 3): Tiii mat viem phdi hgp mgt hodc nhieu cdc tieu chuan sau:
• Rdi logn chiic ndng tim mach (tut huyet ap phai dieu tri bang Dopamine)
• Rdi logn chiic ndng thdn kinh.
• Rdi logn chuc ndng hd hdp.
• Rdi logn chiic ndng than.
• Rdi logn chiic ndng gan.
• Rdi logn huyet hgc (tieu cdu gidm dudi 100.000/ml)
Dieu fri tdi uu viem hii mgt cap Id cat bd hii mat sdm, vd cdn thiet phdi lua chgn mdt phuang phdp thich hgp cho timg miic do viem cda hii mat. Cat bd tui mat ngi soi sdm dugc chi duih cho cdc benh nhdn viem hii mat cdp
miic do 1 (nhe), nhimg benh nhdn ndy thyc hien cdt hii mat ndi soi thdnh cdng d hdu het cdc trudng hgp. Tai cdc tmng tdm ngoai khoa cd kinh nghiem, nhiing benh nhan viem hii mat cdp miic do ll(vua), tien hanh cat hii mat ndi soi hoac cdt hii mat md sdm (frong vdng 72 gid sau khi xudt hien trieu chung viem hii mat cap). Mdt sd benh nhdn viem tiii mat cdp miic do II cd the khd khan khi cdt hii mat do tinh trang viem nhiem tai chd ciia hii mat nang.
Tmdc nhiing tmdng hgp ndy cdn can nhdc lya chgn tiep tuc dieu tri ndi khoa hodc ddn luu tiii mat xuyen gan qua da hodc phau thudt cat hii mat. Nhijng tmdng hgp dan luu hii mat hodc didu tri ngi khoa, tidn hdnh cat hii mat fri hoan khi tinh frgng viem cua hii mat dugc cdi thipn.
Tmdng hgp VTMC mirc do II cd bien chimg :viem phiic mac mat, ap xe quanh hii mat, dp- xe gan hodc xodn tiii mat, viem tiii mat khi, viem hii mat hoai hi, vd viem hii mat mu, phdu thuat cdp ciiu dugc tien hdnh (md hoac ndi soi phu thudc vdo kinh nghiem) cung vdi sy chdm sdc hd trg toan thdn.
Viem tiii mat cdp miic do III (ndng) phdi tich eye dieu tri ngay nhiing rdi loan chirc nang cua cdc CO quan, va cdn phdi ddn luu hii mat
nhdm gidi quylt tinh trgng viem nhiem ndng cua hii mat. Cdt tui mat tri hodn 2 din 3 thang sau, khi tinh trgng chung ciia bpnh nhan cdi thien[5][7][8].
Q2. Lua chgn phuong phdp phau thu^t nao, cdt tiii mat ngi soi hay cdt tui mat md?
trong dieu tri viem hii mat cap[4].
Q3. Thdi diim tdi mt cua ch tui m^t diiu tri •''^'W '«' "*?' ^^P^
Chung toi khuyen cdo: cdt tui mgt npi soi tot han cdt tiii mgt m&.
Sdi mat Id mdt trong nhung nguyen nhan chinh ciia viem tiii mat cdp, vd cdt tiii mat Id phuang phdp dieu trj dugc lya chgn cho bpnh nhdn viem tiii mat do sdi. Cho den niia ddu nhijng nam 1990, nhieu y kien cho rang phau thudt ngi soi khdng nen chi djnh d nhijng benh nhan viem tiii mat cdp. Thdi ky ndy, cdt tiii mat md dugc coi Id phuang phap dieu tri chudn ddi vdi VTMC. Tuy nhien, gdn ddy, phau thuat ngi soi ngdy cdng dugc dp dung rdng rai dieu tri viem tiii mat cdp va hien nay dugc coi Id phuong phdp dieu tri ngoai khoa lua chgn hang dau ddi vdi VTMC.
Ket qud cdc nghien ciiu thii nghiem Idm sang ngdu nhien cd ddi chiing (RCT) so sdnh cat hii mat npi soi vd cat tiii mat md dieu tri VTMC cho thdy cat tiii mat ngi soi td ro nhidu uu viet hon so vdi md md: thdi gian ndm vien ngan, giam ty le cdc bien chiing sau md.
Nghien ciiu tap hgp tir nhilu thdng ke khdc nhau cho thdy cdt tiii mat ngi soi khdng chi dem Igi kit qud hjong hJ nhu cdt tiii mat md, md cdn Id phuang phap dieu tri hieu qua do ty le tir vong vd bien chimg thdp. Tuy nhien, cac bdo cao fren da khdng phdn chia viem tiii mat cdp theo mirc do. Vi vay, cdt hii mat ndi soi khdng dugc khuyin cdo cho tdt ca mgi frudng hgp viem tiii mat cdp do nhilu benh nhdn VTMC ndng thi cdt tui mat gap rdt nhilu khd khan.
Mdt nghien cim dugc thyc hien tren 30.000 benh nhan tir 66 tudi trd len hi viem tiii mat cdp dieu tri theo cdc phuang phdp phdu thudt khdc nhau, 75% benh nhan cdt hii mat ngay sau khi nhap vien, trong dd 71% cdt hii mat ndi soi vd 29% cat hii mat md. Ket qud nghien ciiu cho thay cdt hii mat ndi soi la lua chgn hdng ddu
Chiinf; tdi khuyen cao nen cdt tiii mat noi soi ngay sau khi nhap vien la tdt nhat, ddc hitt tning \nng 72 gid tu khi xuat hien Irieu chirng ddu tien.
Mdt sd nghien ciiu RCT ve lya chgn thdi diem cdt tiii mat md dieu tn viem hii mat cdp dugc tien hanh trong nhimg nam 1970 vd 1980, so sanh giira nhdm dugc phdu thudt sdm vd nhdm bpnh nhan mo tri hoan cd ke hoach (trong vdng 4 thdng tir khi khdi phat trieu chiing ddu tien). Cdc thu nghipm khdng tim thay sy khac bipt giira hai nhdm ve lugng mdu mdt, thdi gian phau thudt, vd ty Ip bien chimg.
Tuy nhien, nhdm phdu thudt sdm td rd nhieu uu diem hem so vdi md tri hoan do thdi gian ndm vien ngan vd bpnh nhdn het dau sdm[l][2].
Nhijng ndm gdn ddy, cdt tiii mat ngi soi ngdy cang dugc dp dung rdng rai trong dieu fri viem tiii mat cdp, ty le cdt hii mat ndi soi dieu tri VTMC tang len theo thdi gian. Lgi ich cua phdu thudt sdm da dugc chi ra trong cdc RCT va nghien ciiu tdng hgp tir nhieu thong ke khdc nhau d nhimg bpnh nhdn viem hii mat cdp. Tuy nhien, dinh nghTa phau thudt sdm khac nhau trong timg bdo cdo, bdi vi thdi diem bdt ddu phau thudt khdc nhau. Phau thudt sdm chii yeu dugc tien hdnh trong vdng 72-96 h tir khi khdi phdt cdc trieu chimg.
Nhieu nghien ciiu so sdnh cdt hii mat ndi soi sdm vd tri hoan dilu hi VTMC cho thdy cdt till mat ndi soi sdm giup thdi gian nam vien ngan hon, phuc hdi nhanh hon, chi phi \\ hon so vdi cdt tiii mat md.
Sau khi ddnh gid tinh trgng chung ciia bpnh nhdn, khdng dinh chdn dodn bdng sieu dm, chup cdt Idp vi tinh (CT) hodc cdng hudng tir gan mat, thdi diem phdu thuat cdn dugc quylt dinh bdi cdc phdu thudt vien co kmh nghipm.
Ddng tiec la, phdu thuat sdm dugc thuc hipn it hon so vdi khuyin cdo hien nay vi thilu cdc bdc sT phdu thudt.
Tap chi GAN MAT VIET NAM s6 24-2013
Q4. Khi nao la thoi diem toi uu de chuyen ta cdt tui m^t ngi soi sang cat tiii mat md?
Chiing toi khuyen cao cac phau t h u a t vien khdng nen do d y khi chuyen tir cat tui mat noi soi sang mo m d neu cat tin mat noi soi de gap kho khan do ngdn ngira cac tdn t h u o n g .
Ty le chuyen tir cat hii mat ngi soi sang cdt hii mat md frong dieu fri viem tiii mat cdp cdn tuong ddi cao do nhiJng khd khan ve ky thuat, biln chimg khi md. Mac du cdc yeu td lien quan din chuyen tir cat hii mat ndi soi sang cat tiii mat md da dugc dy doan tmdc phau thudt chSng hgn nhu nam gidi, tien sir cd md viing bung, frudc khi vdo vien hoac khi chdn doan
VTMC CO vdng da, viem hii mat tien friln va bien chiing nhiem khuan. Bac sT phdu thudt danh gia benh nhan bdng each su dung cdc yeu td khdc nhau khi quyet dinh chuyen tir cdt hii mat ndi soi sang cdt hii mat md hay khdng ? ddc biet gap kho khdn khi dang thyc hipn cat tiii mat ndi soi. Vi vay, ddi hdi kinh nghiem khdng chi ciia ca nhan phau thudt vien, md cdn cd ciia CO sd noi thuc hien cat hii mat ndi soi.
Nam 1995, Strasberg vd cdng su da mo td nhiing diem quan trgng nhat nham dam bao su an toan trong cdt tiii mat ndi soi (Hinh 1). Hipn nay, day la nguyen tac tdi quan trgng de ngdn ngira tdn thuong dudng mat chinh (BDI) trong cat tiii mat ngi soi vd phdu tich tam giac Calot's.
Hinh 1 Tam gidc Calot duac phdu tich vd tiii mdt duac gidi phong khoi giuang tin mat.
Khong cdn thiet phdi boc lo ong mat chu Truang mo an todn bdy gia la tieu chuan toi thuong de ngdn chdn BDI trong qud trinh noi soi cat tui mat. That bai trong viec tao ra truang mo an todn ndy la mot ddu hiiu cho viec chuyen cdt tiii mat ma
Tmdng hgp chuyen tir cat tiii mat ndi soi sang cat hii mat md de franh tai bien phdu thudt va cac bien chung sau phau thudt khdng phdi la dieu bat Igi cho bpnh nhan, cac phdu thudt vien khdng nen ngdn ngai de thuc hien su chuyen ddi nhu vay neu gap khd khan frong khi thuc hien cat hii mat ndi soi.
Q5. Khi ndo Id thai gian toi wu de cdt bo tiii maty sau ddn lun mat xuyen gan qua da ? Van con la van de tranh cai do thilu nhung bang chung ro rang.
Khdng cd thii nghiem 1dm sdng ngdu nhien
cd ddi chimg ddnh gid phdu thuat viem hii mat cdp d nhiing benh nhdn ddn luu mat xuyen gan qua da. Tuy nhien, ddn luu mat xuyen gan qua da la mdt phuong phdp dugc lua chgn dem lai hieu qua tot d nhimg benh nhan nang, dac biet d nhiing benh nhdn cao tudi, viem tiii mat co biln chirng. Cdt tin mat cd thi thuc hien sau ddn luu mat xuyen gan qua da vai ngay. Tuy nhien, thdng thudng sau 2 tudn . Nhin chung, cdt hii mat sdm sau ddn luu mat xuyen gan qua da tdt hon khi tinh trang benh nhan dugc cdi thien, va khdng co biln chiing. Cac biln chimg cua ddn luu mat xuyen gan qua da co the xay ra
nhu ty mdu trong gan, dp-xc quanh tiii mgt,, tran dich mang phdi, viem phiic mgc mgt, gdy ra do tdn thuong gan vd sy di chuyen ciia catheter.
Q6. Trong cdt tiii mgt npi soi can phdng trdnh cdc bien chiimg gi?
T6n thuomg dujmg mSt, chfty mdu yk ihn thuong cAc CC quan khAc.
Cac bien chiing ciia phdu thuat cat hii mat ngi soi da dugc bdo cdo ngay sau khi phuang phdp nay dugc gidi thipu, bao gdm ton thuong dudng mat, chay mdu, tdn thuong mgt, tdn thuong gan, cung nhu nhirng bien chirng thudng thdy nhu cdt hii mat md tmyen thdng nhu nhiem khudn vet md, tdc mdt, xpp phdi,
huylt khdi tinh mach sau, nhiem khudn tiet nipu. Ton thuong dudng mat dugc coi Id mgt bien chiing ngng nl.Ton thuong rugt gan la bien chiing nghiem trgng ciing can phdng trdnh. Cdc ton thuong do han che cua phau thuat ngi soi nhu trudng md hpp vd thao tdc khdng xiic gidc. Mac dii cd nhieu cai tien frong ky thudt vd trang thiet hi, cung nhu hgc tap ciia phau thugt vien, ty Ip tdn thuong dudng mat (BDI) trong cdt hii mat ngi soi van cdn cao so vdi cdt tui mat md. Bang 1 cho thdy ty Ip BDI tai Nhdt Ban thu dugc qua cac cugc khao sat djnh ky sdu thang thyc hipn bdi Hipp hgi Phdu thuat ngi soi Nhdt Bdn (JSES). Ty Ip BDI frong cdt hii mat ngi soi cao hon so vdi cat hii mat md: khoang 0,6%.
Bang I. Cdc biin chimg cdt tui mat noi soi a Nhdt Bdn
TI le ton thucmg duong mat (%) Ton thuong cac CO quan (%) Chay mau (%) So BN cat tui mat noi soi
1990- 2001
0.66 0.25 0.65 176,294
2002
0.79 0.43 0.72 19,557
2003
0.77 0.17 0.72 19,084
2003
0.77 0.17 0.72 19,084
2005 0.77 0.22 0 69 20,203
2006
0.65 0.14 0.56 21,550
2006
0.65 014 0.56 21,550
2008
0.54 0.20 0.52 25,174
2009
0.62 0.20 0.55 26,140 Khi tinh trang viem tui mat nang thi t6n
thucmg inach mau, duang mat nhiSu kha nang xay ra nju co gSng phau tich co tiii mat. Tdn thucmg CO the do phau tich phia sau ong co vao cu6ng ciia phai. DS ngan chan t6n thuooig nay, cac phau thuat vien nen xac dinh tinh trang viem dinh, khong nen sii dung ky thuat phlu tich giai phong tiii mat tu co xudng day khi co nhung biSu hi^n nay.
Q7. Khi ndo Id Ihdi diem tdi tru cho cdi tui mat sau liy soi 6ng mat chu qua nfi soi mat tuy nguffc dong d nhirng bfnh nhdn sdi lui mat kem sdi du&ng mat?
KhSng dira ra fliryc kit lu^n chic chan do thieu bang chirng
Cat tui mat noi soi sau lay soi qua noi soi mat tuy nguac dong ( ERCP) duac cho la mot
phucmg phap dieu tri hieu qua a benh nhan soi tiii mat ket hgrp soi ducmg mat. Tuy nhien, thai diem toi im cat bo tiii mat npi soi sau ERCP van con la van de tranh cai a nhirng benh nhan viem tui mat dp. Da co mot s6 bao cao cho rang thai gian cat hii mat npi soi sau ERCP la mpt vai ngay, tuy nhien, vin con lam theo quan diem ca nhan ciia timg phlu thuat vien.
Hien nay, hiu hjt cac tac gia Sh nghi cit tui mat npi soi som sau ERCP trong thai gian nim vien[5].
Thdng ke cua Rial] TS va cpng su (2010) tren 30.000 benh nhan vap khoa d p ciru duac chan doan la viem hii mat d p da cho thiy 38%
b?nh nhan quay tro lai vien 2 nam sau diSu tri niu khong d t tiii mat [12].Vi vay, phai thong bao nguy ca quay tra lai vien ddi vai nhung b$nh nhan khdng cat dii mat trong thai gian nam vi$n dau tien.
Tap chi GAN MAT VIET NAM s6 24-2013
Tai liSu tham khao
1. Chandler CF, Lane JS, Ferguson P, Thonpson JE. Prospective evaluation of early versus delayed laparoscopic cholecys- tectomy for the treatment of acute cholecysti- tis. Am Surg. 2000;66(9):896-900.PubMed 2. Gurusamy K, Samraj K, Glund C, Wilson
E, Davidson R. Meta-analysis of randomized control trials on the safety and effectiveness of early versus delayed laparoscopic chole- cystectomy for acute cholecystitis. Br J Surg.
2010;97:141-50.PubMedCrossRef3.
3. Masamichi Yokoe et al. TG 13 diagnostic criteria and severity grading of acute chole- cystitis. J Hepatobiliary Pancreat Surg. 2013;
3 5 ^ 6 .
4. Riall TS, Zhang D, Townsend CM Jr, Young-Fang K, Goodwin JS. Failure to per- form cholecystectomy for acute cholecystitis in elderly patients is associated wilh increased
morbidity, mortality, and cost. J Am Coll Surg. 2010; 210:668-79.PubMedCrossRef 5. Sarli L, lusco DR, Roncoroni L. Preopera-
tive endoscopic sphincterotomy and laparo- scopic cholecystectomy for the management of cholecystocholedocholithiasis: 10-year experience. World J Surg. 2003;27:180- 6.PubMed
6. Yuichi Yamashita et ai. Tokyo guidelines for the management of acute cholangitis and cholecystitis. J Hepatobiliary Pancreat Surg.
2007;14:1-121.
7. Yuichi Yamashita et al. Updated Tokyo guidelines for the management of acute cholangitis and cholecystitis. J Hepatobibary Pancreat Surg. 2013; 1 - 7.
8. Yuichi Yamashita et al.TG 13 surgical man- agement of acute cholangitis. J Hepatobiliary Pancreat Surg. 2013; 89 - 96.
