56 Tap ciit I ^N MAT VIET NAM s6 22-2012
Soi trong gan: c^t gan, x^ gan lay s6i; d^c dilm l^m sang va ket qua dieu trj
Hepatolithiasis: Hepatectomy, removing stones by liver incision; clinical characteristics and surgical results
VAN TAN, LUONO THANH Ttnoo, Vd THI$N LAI, PI IAM VAN VifiN vA CS
S u m m a r y
Hepatolithia.sis is frequently meet in Asian especially in Viet Nam. The cause ofdevelop- ping of intrahepatic stones is usually primary.
Aim of study: We study the characteristics oJ hepatolithiasis and the results of hepatectomy and extraction of stones by hepatotomy. Patients and Methods: It is a retrospective study of all oJ patients who came to Binh Dan hospital to treat the intrahepatic stones from 2006 to 2010.
Results: There are 157 patients, 55 males and 102 females that the middle age is 46.66. 90% oJ intrahepatic and 86% of extrahepatic stones.
Stones in the left intrahepatic bile duct is 90%, in the right. 31%. bilateral. 16%.
Patient characteristics: Almost of them have had cholangitis due to bile duct stones. All have RUQ and epigastic pain. A half have fever andjaundice.
- Hepatectomy is practiced in 150 cases.
Hepatotomy for extration of stones in 7 cases.
The primary results are abstained in 71 patients (45%), the stones are cleared. The retained
stones are secondary extraction through dilata- tion off tube during 2 to 6 months, so the final results are 88,54%.
- Follow-up: with midlle time 12 months, the stones are retained and recurrent are 19 patients (12,7%), II patients have had extracted stones through the T tube during this time.
Discussion: Almost came to us have had cholangitis with bile duct stones.
Because the stones are localized almost in the left lobe with the liver, fibrosed and advanced inflammation, removing of the lobe is essential. The extraction of retained stones through T tube are of choice. The final results are abstained with 88,54 %. In the follow-up average 12 months, the retained and recurrent stones are 12,7%. Conclusion: When stones are localized in the duct of left liver, the surounding tissue are fibrosed and marked inflammation, removing of the left lobe is procedure of choice, though, it is necessary to break and removing of stones through dilatation of big Ttube.
T o m t a t
Sdi trong gan Ii benh thudng gap d cic nude chiu A, nhat Ii d Vipt Nam. Nguyen nhan hinh thanh sdi trong gan h i u h i t l i tien phit. M^c tieu: Chiing tdi nghien ciiu d i e diem Iim sing va kit qui cit gan, xe gan liy sdi. B^nh nhan vd phuang phdp: L i nghien ciiu hdi eiiu t i t c i
nhihig benh nhan din dilu tri tii thing 1,2006 d i n thing 12,2010.
Tit c i cd 157 b?nh nhin, nam 55, nft 102, tudi hung binh l i 46,66. Sieu i m cho thiy 90%
b^nh nhan cd sdi trong gan v i 86% cd sdi ngoii gan. Sdi trong gan cd 150 I i sdi gan trii, 31 la sdi gan phii 16 l i sdi c i 2 gan. Ket qua diiu trj:
- B^c dilm ISm sing: Da so bj viem dudng mgt do sdi dudng m i t ngoii gan. H i u hit cd diu hi?u dau ha sudn phii hay thugng vi. Gin phan niia cd sot v i so k h i e cd ving da.
- Ket q u i dilu trj: C i t gan trii 150, xe gan phii l i y sdi 7 benh nhan. 71 (45%) benh nhan BY Binh Dan 371 DBP, Q3, TP Hd Chi Mmh
Phin bien khoa hgc: PGS TS Pham Duy Hiln
T?ip chi GAN MAT VI$T NAM s6 22-2012 57
hoan toin sgch sdi. Tai bien vi bien chiing li 48 (31%). 86 b?nh nhin cdn sdt sdi dugc lay qua nong dudng him 6ng T trong vdng 6 thing tir 2 thang sau md. Ket qui sau cdng Ii 88,54% b$nh nhan dugc liy sgch sdi.
- Theo doi trung binh 12 thing, sdi sdt hay tai phit li 19 b?nh nhin vdi ti I§ li 12,7%. Thdi gian niy cd liy sdi qua dudng him Ing T dugc 11 benh nhin. Bdn ludn: Hau hit b^nh nhin den vdi chiing tdi deu cd diu hi$u vi€m dudng mat nhilu hay it do sdi. Vi sdi khu tni trong gan L Dat van d^
Soi frong gan li b?nh thudng gap d Viet Nam vi cic nude Ddng Nam A.
La tien phit, sdi tao ra tCr dudng mit trong gan. Da so trudng hgp sdi nam trong gan trii, CO thi vi d gan trii dudng m^t gip khiic de Iim cho mat li dpng vi nhilm triing.
Khic vdi ngudi phuang Tay, sdi trong gan hiu hit li thii phit, tu tiii mat [ 10]. Cd sy khie biet ve cau tnic dudng mat trong gan trii d ngirdi chiu A vi ngudi chau Au chang ? Vin decinphii nghien ciiu [8,10,11,15,26,32].
Dieu tri phiic tap vj liy sdi thudng khdng het. Ngay ei khi lay hit', thi sdi tii phit nhanh vai mOt ti 1? ding kl [18,25,28].
Xic dinh vi tri sdi, dudng mat ehua sdi vi mo gan quanh sdi la can thiet.
Vi dudng mat dan, md gan bi xa teo do nhiem triing kinh nien, gan mit mgt phin churc nang. Liu ngiy, gan cd the bi suy khi md nhieu Ik [16,24,31].
Phit hien sdm, gan cdn tuang ddi tdt, cd gang xe gan vao dudng mat liy sdi rdi tao hinh 2. Dii tuwng v^ Phuomg phdp nghien cuu:
Ddi tugng Ii hdi ciiu, cat dge, md ti hing loat tnrdng hgp nhiing benh nhin cd cat gan hay xe gan dl liy sdi tir 2006 din 2010.
1- Phin tich dac dilm lam sing vi can lam sang
2- Phan tich kit qua dieu trj
Trong thdi gian tii 2006 din 2010 (5 nam), tgi benh vien Binh Din cd 157 benh nhin cit gan, xe gan hay viia cit gan vira xe gan liy sdi.
So tren g6ra cd nam 55, nu ed 102. Tudi trung binh 46,66 (12-75). 76% d cic tinh, 24% d
trii, cd md gan xo hoi vi viem nang, cit bo gan trii li cin thilt. Liy sdi cdn lai qua dng T Idn, nong rgng la chu yen. 88,54 % dudng mat trong, ngoii gan dugc sgch sdi. Trong theo doi hung binh 12 thing, sdi Idn len hogc tii phit Ii 12,7%.
Kit lu^n: Khi sdi nim trong gan h-ii, md gan bi xo hoi vi viem ngng, cit bd gan li can thilt, my nhien can cd tin sdi, liy sdi bing each nong dudng mat qua 6ng T dl hh tiic cho nhihig thilu sdt frong lin cit gan.
dudng mgt, hay lay sdi tii dudng mit ngoii gan (mo md), lay sgch sdi, siic rua rhi dat stent vio cho du^ig mat bj hep [7,25,26]. (type II, theo Furukawa, 1993)
Da s6 trudng hgp sdi gan khu tni d gan trii, md gan bi nhiem nang, cat bd gan trii Ii phiu thuat dugc nhieu ngudi chip nhin (type III, IV, V, theo Furukawa, 1993). [4, 6, 8,11, 18, 20, 21,22,24,26,28,30,31].
De phdng ngiia sdi sdt hoac sdi tii phit trong gan, ndi Roux Y dudng mit vi hdng tring, mdt quai nam dudi da de liy sdi nhiSu lan, khdi phii md bung nhieu Ian theo Fang K viChouTC[3,13].
Ti le biln chiing chung li 17-33,3%, do nhilm tning vet md, apxe trong bung, dd mat vi tii vong chung li 0-9% do nhilm tning huyet.
M\fC tiiu nghien cuu:
1- Nghien curu vl die diem Iim sing 2- Nghien cihi vl kit qui dieu tri
thinh phd. Da sd li ngudi ngheo, lam nghe ndng-ngu hay thg thil cdng vdi ddi s6ng tuong doi thip.
Nhdm miu: 0 = 38% (60), A = 20% (32), B
= 20%(31),AB=4%(6) Nhdm miu A co ti le mac benh cao Tilu dudng: 09 bpnh nhan (5,8%) Cd tien cin md mat md md hay^ ndi soi (cat tui mgt, md OMC gip sdi, ml liy sdi trong gan, ERCP): 59 benh nhan (37,57%).
5 8 TjipchiGANMA, r NAM s6 22-2012
3. Ket q u i -D^c diem tdm sdng:
Hau het nh?p vien vi dau HSP, dau HST hay thugmg vj (TV) Tri^u chiing
Dau TV, HSP, HST Sot, dn Ignh Ving da 6i
s6c nhiem triing
Da so 14 tri?u chiijig sdi dudng mjt ngodi gan.
Xit nghiim
Biich can cao > 8.000 H^ng cku th4p Mdt trong mdu cao > 2,5 ALT cao > 40
Amylase trong mdu cao > 250 HBsAg (+)
CA 19.9 cao
BN 154 93 25 16 02
BN 67 03 53 41 11 11 12 Gdn 1/2 cd nhiem triing dudng mjt, 1/3 cd dnh hudng den chiic Vjtri:
Sdi dudng mat trong gan T Sdi dudng mat trong gan P Sdi dudng mdt ngodi gan ket h^rp OMC, OGC
Sdi tui mat ket h(7p
BN 150 31 135 11
Ti 1$ % 98 59 16 10 1,27
Ti 1^ % 43 02 33,75 26,11 7,00 7,00 7.35
; nang gar Til^%
96 20 86 7
Sdi trong gan trii Ii 150, sdi gan phii 31 ket hgp vdi sdt gan trii. Sdi dudng mgt ngoii gan ket hgp cd 146. Nhu vgy sdi trong gan dan thuan chi cd 14%.vi v$y, da sd d$c dilm lam sing la viem dudng mat ngoii gan vi sdi blnh thinh trong dudng mgt ngoii gan r6i di len hay sdi hinh thinh trong dudng mgt trong gan roi di xuong ?.
Sdi trong gan trii, nim trong nhung dudng nhung tiii sdi !i 57 (36,30%).
mat dan Idn, cd djch mat nhiem triing li 30 1 trudng hgp cd nang OMC, 1 tnidng hgp (19,10%), cd khi li mu thgt sy mi chiing tdi cd khoi u ic tinh dudng mgt trong gan trii, 1 xem nhu nhihig apxe, nhdm nay chilm 14 trudng hgp li polip tui mgt va t n i ^ g hgp Ii (9,17%) trudng hgp. Md gan bj ton thuang khoi u tdi m§t. Viem tuy cap Ii 7,35, tilu ning, xa hda vi Iim thuy gan co rum quanh dudng Ii 5,88, suy thgn Ii 2.
T^p chi GAN MAT VIET NAM s6 22-2012 6 9
.Ph&uthu$t:
cit gan v4 xe gan idy sdi:
- e s t hpt gan 150(95,54%) cat hpt II+ 111 144(91,71%)
est hpt I + II liy sdi qua ong mat 1 Cat II lay soi qua 6ng mdt 1 cit III +1 liy sdi qua ong mdt 1 Cit II,III,IV liy sdi 1 cit gan III 2 - Xe dudng mdt trong gan liy sdi: 16
Xe ong gan hpt II liy sdi 3(1,91 %) Xe 6ng gan hpt III lay sdi 3 (1,91 %) X4 OMC len 2 ben liy sdi 2 gan 1 X6 ong gan phdi lay sdi 1 Xd dng gan hpt V liy sdi 1 Xi 6ng gan chimg lay sdi ong gan giua 7 (4,45%) - Phau thudt phdng ngira: 6 (2,82%)
cit gan trdi liy sdi, md hii mat thong vdi ong gan ra da 4 (2,55%) Md ong gan chung liy sdi, noi 6ng gan chung-HT Roux Y 1 cit mi?ng ndi cii, md dng gan liy sdi, ndi 2 ong gan-HT 1
Co 144 Idn cat gan 2 vd 3, 6 lan md cat gan khdc, 16 Idn xe gan liy sdi vd 6 Idn ndi dudng mdt vdi hdng trdng hay tui mat mpt ddu dua ra da.
Lay sdi OMC v4 dan lim cd 146 benh nhdn. 0 nhimg benh nhdn niy 96 dat dng T Idn vd cd 63 benh nhan phdi lay sdi qua dudng hdm dng T, 102 lan sau khi chi^p hinh kiem tra thdy sot sdi d trong hoac ngodi gan.
-Ket qud phdu thufft:
- Tai bien 3 benh nhan:
1 BN cat Idch do vd, nam vien sau md 18 ngay, 1 BN thiing dgi trdng, nam vien sau md 9 ngdy.
i BN chay mau d mat gan phai md lai, ndm vi?n sau md 13 ng4y (tmyen 2000 ml mdu) - BiSn chiing phdi ndm vien Idu: 45 benh nhdn (28,66%), ndm vien sau md > 14 ngdy (14-36 ngdy):
Bien chiing nim vi?n > 14 ngay Nhiem trimg tb4nh byng
Viem phiic mjc Xuat huydt vira Ddmdt Apxe dudi gan Suy kiet Dd vet md Tdng
BN 31 6 2 2 2 1 I 45
Ti le % 19,74 3,82 1,27 1,27 1,27 0.63 0,63 28,66 Tdng sd tai bidn, bidn chdng sau md 14 48 benh nhan, ti le 14 30,57%
60 TspchiGANMATVl$TNAMs622-2012
- Vi nilng (Nhung apxe gan v4 nhilm hTing njng) BN Ti If % Ecoli 15 9,6 Pseudomonas 4 2,5 Cifrobacter 1 ".6 Enterobacter 1 0,6 Proteus 1 ".6 Staphyloccocus 2 1,2 Vi triing khdc 3 1,9 T6ng 27 17,2 - Tir vong 1 BN (0,64%): 2 ngdy sau m6 do hit thirc dn vdo ph6i gdy suy hd hip trong tinh tr?ng nliiem mlng. B$nh nhdn niy da m6 1 lin do sdi OMC v4 sdi trong gan 2 bdn 2 nSm trudc. Tien cdn cd dieu tri lao ^hoi.
Thdi gian ndm vi?n sau mi: trung blnh Id 11,62 ngdy (8-35 ngdy), (1801/155) - Gi4i phiu b^nh:
Md gan sinh Ihiit BN Ti I? % Viem gan mgn tinh 19 12,1 Xagan 23 14,6 Tang s4n tuy^n ong mgt 1 0,6 Apxe dudng mgt 14 9,2 Ung thu dudng mgt trong gan 1 0,6 Xdc giun 1 0,6 Tdng 59 37,7 - Theo doi, tdi nh$p vifn:
- Trong vdng 1 thdng, trifu chung 1dm sdng: tdi nhap vi$n
Dau HSP 14 Sot 10 Vdng da 7 Sieu am: sdi OMC v4 trong gan giiia 2, sdi gan phdi 3, sdi OMC: 7.
- Trong vdng 6 thdng: nhirng b?nh nhan nay tdi nhdp vi?n trong vdng 2 den 4 thdng, hdu het cd trieu chdng dau HSP, thu(?ng vi.
Vjtri BN Til?%
d gan phdi (HPT 5, HPT 8): 22 11,76 C) gan trdi (HPT 3, HPT 4): 29 16,17 6ng gan chung (cho hijp luu) 12 7,35 Ong mgt chu (OMC, Oddi) 23 14,70 Tdng 86 54.43 Lay sdi qtia dudng ham ong T, 68 b?nh nhdn, 96 Idn, sach sdi dugc 40/68 b?nh nhdn, cd 13 b?nh nhan sdi cdn lai nhd, nam sdu trong cdc nhdnh, 3 benh nhan chua mo vd 2 bfnh nhdn tir choi md.
Theo ddi 12 thdng sau md, sdi nhd hay sdi tdi phdt nhu sau:
Vi tri BN Ti 1? % C) gan phdi: 3 1,9 Cigantr4i: 10 6,3 Sdi gan 2 ben 5 3,2 Sdi d hgp luu dudng mgt 1 0,6 Sdi OMC 2 1,3 Tong 19 12,7
Tap chi GAN MAT VIET NAM so 22-2012 6 1
4. Bin lu|n
- Sdi trong gan thudng kit hgp vdi sdi ngoii gan, do dd thudng cd h^i chiing viem dudng mat ma tam chiing Charcot la dien hinh hay ngii chiing Raynaud, sle nhiem tning (rit hilm)..
- Phin tich sdi; da so Ii sdi sic to nau cd nhan la xic vi tning, do nhilm triing mi hinh thanh, nhu vgy sdi niy li tien phit trong dudng mgt ngoii gan hogc trong gan.
- NIU sdi trong gan thi thudng hinh thinh trong HPT III, d day ed ylu td dudng mit udn khiic, lim li dpng mgt, li b?nh thudng xay ra d cac nude A Ddng. 6 Trung Qu6c, Dii Loan khoing 20%, d Vipt Nam, khoing 15%, d Hin Quoc 10%, Hong Kdng khoing 3%, d Nhat 2%. Ci 2 phii diu bj gin giong nhau, d d$ tuoi 30-40. 6 nude ta, tudi thudng eao han. Vi tning thudng gip Ii E coli, Klebsiella, Pseudomonas, Enteroeoecus, Bacterioides...
Enzyme ciia vi triing, phin tich mat, Iim ket tik biin mat. Biin mgt vi xic vi triing lim thinh sdi sic to niu [10]. Sdi lim nghpt mat giy viem duong mat. Yiem dudng m^t chiia sdi lau ngiy lam dan dudng mat dogn diu vi teo dudng mat doan cuoi [17].
- Sdi tii phit cd the do md nhieu lan Iim xa teo dudng mat them, khu tni trong dudng mat a HPT gan b; viem, xa hoi, nhiem triing, cd khi la apxe. Nhiing HPT niy cd thi Ian rOng din den suy gan [32].
- Ngudi benh bi dau thugng vj vi hg sudn phai, s6t Ignh vi ed khi bi ving da. Cho khing sinh thi bdt nhung se tii phit neu khdng can thi?p.
- Sieu im tdt se dinh v\ dugc sdi, da sd d gan h-ai. CT scan vi MRCP, PTC se cho kit qui ro vl dudng mgt (hpp, dan, ung thu) nhung ton kem.
- Trudc tinh trang viem dudng mat cap, ta phai din luu cip eihi, dgc bipt li cd apxe gan.
Tat nhien khi tinh trang cho phep se mo liy sgch sdi vi lim cho dudng mat thdng. NIU md gan cdn tuang doi tot, mo Ian dau, xe md gan ket hgp vdi xe dudng mgt ngoii gan dl liy sdi [12,15,23,27,30,31.34], roi tao hinh dudng mat [7,10,17,19,25,27]. Nlu mo gan bi nhilm n^ng, cit HPT, dl dng T Idn, liy sdi qua dudng
him eua nd [7,11,30}. Neu dudng mgt chinh khdng dan, liy sdi xuyen gan qua da [13,19]....
- Phau thuat: cit gan HPT II, III khdng khd, nhung khi bj viem nhilm, dl xuit huyet [ 1,6,8,11,18,20,21,22,24,26,28,30,31]. Thudng thi eat gan trii roi md hay nong rpng dudng m^t liy sdi HPT 4, kit hpp vdi md dudng mat chinh.
- Phau thuit cit gan phai, da so ha phin thuy cd nhilu sdi, bj viem xo [10,18,20,24]
- Tai bien thinh thoing xiy ra do dinh chat gan vi dudng mgt vio dgi tring (gay thing), than tuy (giy xuit huylt), lich (gay vd lich), thinh byng, ca hoinh (giy rich ca hoinh)...
Bien chiing thudng xay ra do nhiem triing, nhieu hon li cit gan trong ung thu, die biet la nhiem triing vlt md vi d bung do vi tning tim thiy trong dudng mat [28]. Ngoii ra, cdn dd mat [4,6,18,21,22,33] vi khau mgt cit khdng ky, dge biet trong tin sdi Idn, trong nong dudng mat [7], cd the gay thiing dudng mat.
Chiy miu khi cat gan khau khong ky hay khi bi rdi logn ddng miu, khi tin sdi trong gan.
Viem phiic mgc [28] xiy ra khi dudng mat hi nhilm trimg ngng, vi tning de khing vdi khang sinh. Suy gan [16] it xiy ra, trir khi bi nhiem triing lau ngiy.
- Ung thu dudng mat trong gan [2,9,23], khoing 5-10%, cd lien h6 vdi sdi vi sdi lau ngiy giy tdn thuang niem mgc dudng mat.
Benh Caroli [5,14], dl lau cd thi b; ung thu hoa, eho nen khi gap thi phii hoac cat gan hoac nong dudng mat.
- Sdi cdn trong gan udc tinh khoang 70%.
thudng xiy ra khi lim ERCP cip ciiu liy sdi Idn ong mat chu, dat dng thdng miii-mat xuyen sdi hay md cip cdu khi ERCP thit bai,
Sdi cdn sau cit gan hay xe gan liy sdi trong ml kl hoach khoing 15%.
- Sdi sdt vi sdi tii phat giy tri?u chiing (dau, ving da hay viem dudng mat) khi cit gan khdng hit, die biet d gan trai, hg phan thuy 4.
[25,28] vi d dng gan phii. Sdi cdn hay tii phit se liy qua dudng him dng T nong rpng hay xuyen gan qua da (kit hgp vdi tan sdi). Cu6i cung it khi sdi Idn edn trong gan.
62 Tap chi CAN MAT V11 I NAM s6 22-2012
Ket luan
6 mien Nam Vift Nam, soi trong gan khd nhiSu. Da sd ket hpp vdi sdi ngodi gan hay ngugc Igi. Ddc didm lam sdng gom trifu chimg viem dudng mgt hogc ngng hojc nhf, ngudi bfnh vdi trifu chiing v4ng da vita, dau hg sudn phdi, sot nhf. SA cho thiy sdi trong gan ket hgp vdi sdi ngodi gan hay ngugc Igi, nhu vdy, trifu chiing phin Idn Id do sdi ngodi gan tit trong gan roi xuong hay do sdi ngo4i gan.
Dieu tri sdi trong gan phiic tgp, thudng 14 Tdi li{'u tham khdc
1. Azuma T (1999): The significance of hepatectomy for primary intrahepatic stones. Surg Today; 29(10): 1004-10.
2. Bae JY, Park YN, Nakanuma Y et al (2002): Intestinal type cholangiocarci- noma in intrahepatic large BD associated with hepatolithiasis, a new histologic sub- type for fiirther investigation. Hepatogas- troenterology, May-Jun; 49(45): 628-30.
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5. Carol! Bosc FX, Demarquay JF, Conic M et al (1998): The role of endoscopy associated with extracorporeal shock- wave litotripsy and bile acid treatment in the management of Caroli's disease.
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9. Chijiiwa K, Ohtani K, Noshiro H et al (2002): Cholangiocellular carcinoma
dilu tri sdi cd sdi ngodi gan. Mgt trong nhung phuong phdp dieu tri 1^ cdt gan hay xd gan 14y sdi, tdn, liy sdi ngodi gan. Sdi cdn Igi tuoiig d6i nhilu v4 sdt sdi d phan gan cdt khdng het.
Vi vjy, liy sdi qua dudng him dng T 14 cin thilt, ed trong lan ngo4i gan. Ngo4i ra, mgt sd phiu thudt ndi rudt hode tdi mdt vdi dudng mdt dl mOt diu sdt da dl sdi tdi phdt xu6ng rudt hay liy sdi Idn khi sdi tdi phdt trong v4 ngo4i gan.
depending on the kind of intrahepatic calculi in patients with hepatolithiasis.
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Hepatectomy in intrahepatic lithiasis.
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12. Do trong Hai (2005): KQ dilu tri sdi trong gan, PT NS so sanh vdi md md cd kit hgp k^ thudt tdn sdi difn thuy luc, Y hgc TPHCM; 9(0,62-66.
13. Fan ST (1993): Appraisal of hepaticocu- taneous jejunostomy in management of hepatolidiiasis. Am J siirg; 165: 332-5.
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World J Gastroenterol;16(7),3423-3426 17. Kim KH, Sung CK, Park BG et al
(1998): Clinical significance of intrahep- atic biliary stricture in efficacy of hepatic resction for intrahepatic stones. J Hepato- biliary Pancreat Surg, 5:3,303-8.
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19 Maetani I, Ishiguro J, Ogawa S et al (1999): Peteutaneous choledoscopic treat- ment of intrahepatic stones, including management of associated biliary steno- sis. Endoscopy, Aug, 31:6,456-9 20. Napolitano L (1996): Resection therapy
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