TCNCYH PhLi trWdng 62 (3) - 2009
DAT GlA DOf CHO KHI QUAN (STENT)
CAP CI/U NGAT T H d DO KHO! UNG THU KHI QUAN KHOA HO HAP BENH VIEN BACH MAI
Hoang Hong Thai Bg mdn Ndi Dai hoc Y Ha Ngi
Ky thuiit loai ho khdi u bing dien ddng c.'io tin vi gid cho dudng thd thdng thoing d benh nhin ung thtf khi quan bing each dat mdt gii dd (stent) di dtfgc ip dung td lau d nhieu nUdc tren thi gidi. Muc tieu: Mo ta ket qua dieu trj dien ddng loai bd khd'i u khi quan vi ket qua budc dau thuc hien dat gii dd khi quan (stent ndi khi quan) d mgt tnfdng hgp ung thtf khi quan giy chit hep khi quan khdng cdn chl djnh ngoai khoa. Boi tUeing va pbsiang phap nghien cdu: giai phdng Idng khi quan bing ky thuat dien ddng cao tin vdi hai loai xdng dien cue ciia hang ERBE mgt trudng hgp li nam gidi 59 tudi bj ung thu khi quan loai ti bao viy. Khdi u d 1/3 gida khi quin, lap gin bet Idng khi quan gay ngat thd cap tinh. Tiip theo li dat Stent Dumon ciia Hang NOVATEC (Phip) sau khi khdi u da duac loai bd. Kit qua: ddt dien ddng cao tin loai bo gin hoin loan khdi u, gia dd (stent) duge dat diing vj tri, tU the tdt, Idng stent thdng thoing. NgUdi benh sau 5 thing dat stent: khdng khd thd, khdng cd tieng thd rit, khdng ho mau, ndi duac binh thudng. Soi kiem tra:
thay stent van on djnh. Kei luan: mdi trtfdng hgp ung thU khi quan hiem gap gay ngat thd dp khdng cdn chl djnh ngoai khoa. Nhd 2 ky thuat dien ddng cao tan loai bd u va ky thuit dit stent benh nhan da dugc cdu sdng. Day li mot ky thuit mdi ddi vdi tntdng hgp u khi quan d tha'p, lin dau tien thuc hien tai khoa Hd ha'p ciia benh vien Bach Mai cung nhU d Viet Nam.
Td khda: ung thif khi quaiv, khi quan
L e,AT VAN DE
U khi quan la mot trong nhCfng khd'i u nguy hiem, nguy ca co the gay tif vong cho ngudi benh trong thdi gian ngan do ngat thd ca'p neu khdng dupc phai iiien va xuf tri kip thdi. Trong mpt so tinh hudng phifc tap, can thiep bang md khi quan hay dat npi khi quan ddi vdi mpt sd trifdng hpp cung khd g i i i quyet. Tai benh vien Bach Mai vifa qua chung tdi cd tiep nhan mpt trddng hop ung thu khi Cjuan, khdi u lap gan he't Idng khi quan da difdc loai bd bang ky thuat dien ddng cao tan va difdc dai mdt stent noi khi quan. Thanh cdng bifdc d i u cua ky thuat da md ra mpt hifdng mdi day trien vpng cho nhCfng trifdng hpp ton thUong tifong tu, gdp pUan cifu sdng benh nhan trong hoan canh ngat tno d p .
Chung tdi xin trinh b l y trifdng hpp nay de quy ddng nghiep tham k h i o vdi muc dfch phat hien sdm benh d giai doan cdn cd the can thiep difdc.
Muc tieu:
Md ta kit qua loai bo can trd trong long khi quan bang ky thuat dien dong cao tin va ky tbuat dat gia da khi quan (stents) d benb nhan cd ung thu gay chit bep khi quan CO ngat thd cap.
If. OOI TUgfNG VA PHU'ONG PHAP NGHJENCCU
1. Do'i tu'dng nghien cu'u
Benh nhan Cao Van S. 59. Que quan: Chifdng My (Ha Tay cQ).
Benh an: thang 6 - 2008 benh nhan xuat hien khan tieng, da dUdc kham tai benh vien tinh vdi
chan doan viem thanh quan. Sau dd, benh nhan den kham tai benh vien K vdi chan d o l n liet hdi quy trai chifa rd nguyen nhan cung chda soi phe q u i n de xac djnh tdn thifdng. Benh n h i n dUpc d i i u trj thud'c gi khdng rd nhUng cd bieu hien ngat thd, cd sdt. Benh nhan den kham va difoc tiep nhan vao khoa cap cifu benh vien Bach M a i .
- T i i n sif cd hut thudc la, thud'c l l o da l l u (40 bao/nam).
- Sau khi d i i u tri ban dau cho bdt khd thd, benh nhan difpc chuyen vao khoa Ho ha'p benh vien Bach Mai trong tinh trang;
- Sdt 38 dp, tinh nhifng cd bieu hien ngat thd, ho nhieu, khac ddm trang due.
- Khan tieng, khdng ndi difdc.
- Tim nhjp nhanh 90 chu ky /phut. Huyet ap 120/70 mmHg.
- Tie'ng thd rft nghe rd d vung cd ngay chfnh benh nhan cung nhan tha'y.
- Kham phdi: thd rft lan xudng phia dUdi khf quan.
- Rieng vung nen cd tieng rft va ngay rd.
- Benh nhan dUdc chup phim X quang ngifc;
Hinh anh chi cho thl'y trung that tren rpng hdn binh thifdng.
- Cac xet nghiem mau khong cd gi dac biet.
- Chup MSCT ngifc dp phan g i i i cao cd t i i tao 3 c h i i u . Ket q u i cho thl'y cd hinh anh mpt khdi u ii 1/3 difdi, s i t bd trai khf q u i n . Khdi tdn thifdng cd c h i i u dai gan 3cm. Ldng khf quan chi cdn la mpt khe nhd. Tdn thifdng ngoai khf quan chiem gan het n i n cd vung bd trai khf quan.
- Npi soi phe q u i n n g l y 18/12/2008 dng soi m i m Olympus, cd d'ng 5,6 m m ghi nhan cd mpt khd'i u sui vao trong long khf q u i n d 1/3 giifa khf q u i n , be mat khd'i u hoai tiif, cd n b i l u mach mau tang sinh, d l c h a y m a u . Ldng khf quan c h i cdn mdt khe hep, khdng difa dupc d'ng soi xudng difdi. s • : " K ' = ; •>!;:.::.
- Sinh thie't tdn thifdng; ke't q u i g i i i p b l u benh I I ung thif bieu mo vay kem biet h o i . Hpi chan vdi mot so' b i c sy phau thuat long ngifc, Tai - M u i - Hpng khang djnh; Ung thif khf q u i n x l m nhap vao thanh khi q u i n , trung that, khdng cdn chi djnh ngoai khoa. Tien trien cua benh cang ngay c l n g nang vdi khd thd do ngat, can p h i i npi soi can thiep cl'p cifu bang ddt dien dong cao tan vdi hd trd cua gay me npi khf q u i n v l dat stent khf q u i n , dudng kfnh cua stent 16 m m , chi't lieu silicon. C I c dung cu dat stent cua hang NOVATEC.
- Ca p b l u thuat npi soi khf phe quan dupc tien hanh ngay 27/12 nam 2008 tai phdng md benh vien Bach M a i . Sau 3 gid dd't, d t bang dien ddng cao tan da g i i i phdng long khi q u i n . Cdng doan dat stent khf q u i n difdc tien hanh l i k dau vdi dung cu day stent va stent cua Hpi phdi Phap Viet. Nhung vi stent nho nen bj Ipt vao phe q u i n gd'c t r i i , thay bang loai stent cd du'dng kinh Idn hdn (kfch thu'dc stent mdi dai 4 cm, t h i n h day 1 m m , difdng kfnh 15 mm).
- Stent difpc difa vao khf q u i n , sau ft phut chinh trang bang kim chuyen dung dat stent, stent dUdc difa vao vi tri da djnh.
- Ngay hom sau, qua soi dng m i m kiem tra, khdng cd gi dac biet. Benh nhan difpc d i i u trj bd sung bang khf dung huyet thanh man 0,9% 4 lan/
ngay, mdi lan 5ml, thud'c lam loang ddm va khang sinh phdi hop chdng bdi n h i i m .
Din nay, sau gin 5 thang luu stent, benh nhin duac soi phe quan kiem tra:
Lan 1: sau 1 tuan d i i u trj (ngay 5/1/2009) cho thl'y Idng stent t h o i n g , cd dpng ldp dich phe q u i n loang va mpt m i n g hoai tif 6 cifc difdi ciia stent, ll'y ra d l d i n g bang kim sinh thiet mem. Ldng phe q u i n phfa dddi thdng t h o i n g , khdng if dpng.
Benh nhan difdc chuyen den trung t i m Ung budu benh vien Bach Mai dieu trj xa trj quanh tdn thifdng d khi q u i n .
TCNCYH PhtJ trWdng 62 (3) - 2009
Sau 5 thing mang stents ' •'••
- Benh khong khd thd, khong cd tie'ng rft b khf quin.
- Khac ddm tdt sau khf dung huyet thanh man hang ngay.
- Phdi khdng ran. Tim nhjp d i u , tieng tim binh thifdng tan sd 90 chu ky/ phut. Huyet ap
120/80 m m H g .
- Chup phdi va CT ngUc kiem tra; stent van d vi tri binh thudng. Khdi u khf q u I n sau xa trj da nhd hon nhieu so vdi tru'dc khi d i i u trj.
III. BAN LUAN
Unng thu khf q u i n loai te bao bieu md vay la mpt tdn thUdng ung thif kha hiem d khi q u i n qua y van the gidi cung nhif trong nUdc. Giai doan dau u khf quan thudng chi gay ho khan tham chf cd ho m l u . Dan dan ngifdi benh cd khd thd khi khdi u chiem gan 50 % khl'u kfnh khf q u i n . Giai doan nay, ve lam sang thifdng hay lam vdi benh canh ciia hen phe q u i n hay ddt cap cua benh phdi man tfnh. Chfnh vi v l y , n b i l u trUdng hdp khi den difpc cac cd sd chuyen sau thudng mupn vdi chft hep dudng thd nguy kich.Trong sd nhifng trifdng hdp dd, cd mpt sd ft d c trifdng hop may m i n vi dat dddc ndi khf quan hoac md khf quan do vj trf khdi u d tren chd md khf q u i n va thUdng d 1/3 tren cua khf q u i n . Khi khdi u d vj trf thi'p hdn, npi khf quan, md khf q u i n cung chi g i i i quyet dUdc khd thd mpt phan rat nho. Noi soi phe q u I n cha'n d o l n , chup MSCT d i n h gia tdng the tdn thifdng, khi da cd lan rpng, chi djnh p h i u thuat cat ndi khf quan rat ban che.
Benh nhan cua chiing tdi cd u trong Idng khf q u i n , da mat 6 t h i n g vi bi bd qua, cho tdi khi kho thd nang mdi dUdc dUa den cd sd chuyen khoa.
D l y cung la d i i u m l nhieu cd sd y te cd the nham. Khi khd'i u da ldn chiem gan het long khf q u i n , x l m la'n ra ldng ngUc khdng cdn chi dinh p h i u t h u | t
Bgnh nhan trong tinh trang ngat thd nguy kjch can p h i i xuf tri khan trifdng. Chiing toi da xif dung 2 ky thuat can thiep tren cung mpt bgnh n h i n . 1 . Ky thuat d i f n dong cao tan de loai bo u trong long khi quan
Qua d c cong trinh nghien cifu cho thl'y chi djnh cua chiing tdi hoan t o l n phu hop vi khdi u khf quan ldn la'p gan he't khau kfnh khf q u i n . Hdn nOa vj trf ciia khd'i u lai d 1/3 difdi khf q u i n va nam trong Idng ngifc, khdi u lan t r i n ra khdi thanh khi quan, v i o trung that nen chi djnh cua ky thuat dien dong cao tan h o l n t o l n hpp ly.
Theo s i c h v d , khi dot dien ddng cao tan vdi nhifng khd'i u khf quan, d ngoai Idng ngifc thifdng p h i i md khi q u i n neu khdi u d tren chd md khf q u i n . Neu khdi u cl trong khf quan doan trong ldng ngifc thi phai thao tac thdng qua npi khf quan kich thifdc ldn va tien hanh qua ong soi m i m . PhufPng thifc tien hanh ky thuat dien ddng cua chiing tdi phu hdp vdi nhifng khuyen c l o ciia n b i l u nghien cifu cua nhieu t i c gia. Chung tdi thifc hien da t u l n thu nhiing quy djnh cua quy tnnh cua n b i l u nghien cifu. Chfnh vl vay, khdi u bi loai bo nhifng v l n bao d i m an toan cho benh n h i n .
2. Ky thuat ddt gia d d cho vung khi quan sau khi khdi u da dUoc loai bo
Cung nhif n h i i u cdng trinh dat stent tren the gidi, chiing tdi da thifc hien quy trinh, chpn stent v l thao t i e cung nhif duy tn khf dung huyet thanh man hang n g l y nen b i o d i m cho stent khdng bj di lech, khdng tac. Qua n b i l u lan soi phe quan kiem tra cung nhU ghi nhan qua 5 t h i n g Idu stent trong khf q u i n ngUdi benh. Benh nhan difpc dat stent, dung nap td't. Khdng tha'y stents di chuyen sau khi dat mac du benh nhan cd ho n h i i u .
Dieu trj bd sung d c thud'c Idng ddm, k h l n g sinh hd trd nhd nhieu tac g i l khuyen cao trong nhieu cdng trinh nghien cifu tren the gidi.
Hinb anh tdn thuang tren phim cbup phdi chuan va tren phim cbup cat Idp vi tinb ngUc
Hinh anh MSCT ngUc
Khdi u trUdc khi ddt Khd\ u dang dUdc ddt
IV. KET LUAN
Dat g i l dd khi q u i n (stent) la mpt ky thuat mdi do'i vdi Viet Nam trong d i i u tri cac c l n trd d difdng thd l d n . NhCfng trUdng hdp nhU vay trUdc day, ty le tif vong do u khf quan chiem ty le gan 1 0 0 % . Ngay nay do tie'n bp cua khoa hpc, viec ap dung ky thuat nay md ra mpt
Stent da duac dat trong khi quan
hifdng d i i u trj mdi cho benh nhan thupc chuyen n g l n h hd h i p . Benh nhan cd tdn thUPng g l y chit hep k h i q u i n sd'ng sdt dddc I I mdt phan nhd vao ky thuat nay.
Day I I mpt ky thuat cd trien vpng p h l t trien trong tuong lai ddi vdi d c tdn thifdng g l y chit hep khf q u i n du lanh hay I c tfnh.
TCNCYH PhLi trWdng 62 (3) - 2009
T A I L I E U T H A M K H A O 3 - John F Beamis, Jr Praveen N, Mathur, Atul 1 - D u m o n JF (1990) A dedicated tracheobron- ^ ^ ^ ' ' * ^ <2004). Intervetional pulmonary chial stents.Chest 97. pp. 328 - 332. medicine.Marcel Dekker.Inc.
2 - Eric M.Walser (2005) Stents placement for "* " Steven H. Felsilver, Alan M Fein tracheobronchial disease. European Journal of (1995). Texbook of bronchoscopy Williams - Radiology 55, pp: 321 - 3 3 0 . Wilkins 1995.
Summary
UGENT STENT PLACEMENT FOR ASPHYXIA DUE TO ENDOTRACHEAL CANCER IN THE RESPIRATORY DEPARTMENT OF BACHMAI HOSPITAL
Tracheobronchial stenting for palliative restoration of airway narrowing after treated by electrocautery in the patient w i t h neoplastic airway obstruction is widelly application in many country of the World.
Objective: to descibe the result of electrocautery treatment in patient w i t h tracheal stenosis by tumor endo luminal and initial result with the Dumon silicon stent for the treatment of tracheal stenosis by malignant tumor. Method: 59 years old man with the signs of tracheal stenosis tridor coughing and hemoptisy, lost weight for 6 months).This patient was admited in Respiratory Department of Bach Mai Hospital.
Desobtrution of the tumor by electrocautery was done by ERBER machine (Germany). Dumon silicon Stent by Novatec (French), was placed in operation room with general anesthesis .The stent was put in to the traceal luminal by rigid tube of bronchoscopy. Result: the tracheal tumor was destruited totally and Dumon silicon stent was stable in the lumen of the tracheal. Conclusion: that is the firt case of tracheal obstruction by malignant tumor unoperable was treated by electrocautery and stenting w i t h good result in our Respiratory Department of Bach Mai Hospital and the firt case of our country .
Keyword: stent placement, electrocautery, tracheobronchial cancer
DANH GIA TAC DUNG CUA ENOXAPARIN TRONG DIEU TRI DLf PHONG VIEM TAC TINH MACH LEN CAc YEU TO DONG M A U 6
BENH N H A N CHAN THU'ONG SO N A O
Trjnh Van Dong Tritdng Dai hoc Y Ha Ngi
Muc tieu: dinh gia su thay ddi ve ddng miu trong khi sd dung enoxaparin de dieu trj dit phdng viem tic Hnh mach tren benh nhin chan thuang sg nao. Bdi tuang va phuang phap nghien cdu: chdng tdi tien hanh nghien cifu tren 55 benh nhan sau md chan thuang sg nao duac sd dung enoxapann 40 mg tiem dUdi da.
Danh gia hang ngiy siJ thay ddi ve Heu ciu, thdi gian prothrombin, INR, aPTT, Hbnnogen vi D - dimer. Djnh lUdng yeu td khing Xa trong niau cua bdnh nhin vio thdi diem sau 4 gid Hem de dieu chinh lieu enoxaparin. Kit qua: benh nhin ed Glasgow 4-5 chiem 36,4%o va 6 - 8 li 63,6%o. Mau tu ngoai ming cdng chiem 23,6%, dudi ming cdng li 76,4% va phdi hap li 60%o. Nong do yeu td khing Xa li
