Summary
PRIMARY LAPAROSCOPIC - ASSISTED ENDORECTAL COLON PULL - THROUGH FOR HIRSCHSPRUNG'S DISEASE: MEDIUM TERM RESULTS
Objective: To evaluate the feasibility and medium term results of primary laparoscopic endorectal colon pull - through for Hirschsprung's disease in infants. Method: Prospective review of the infants with Hirschsprung's disease treated by primary laparoscopic endorectal colon pull - through proceduee from January 2008 to August 2009 was carried out according to Georgeson's technique. These patients were evaluated with regard to age, position and length of the aganglionic segmenL intraoperative details, postoperative functional results or complications and medium term functional outcomes. Results: Sixty four patients (55 boys and 9 grirls) underwent a curative surgery with average age 5.5 ± 0.8 months (range, 16 days to 24 months). Mean postoperative stay was 5.9 ± 0.9 days (range, 4 to 9 days). Thirty one patients had temporary perianal excoriation (20 patients were < 3 months of age), no death. Spontaneous defecation was achieved in all patients before discharge. Anatomotic leakage occurred in one patient (three weeks after operated) requiring redo pull - through after enterostomy. 54 patients were followed - up at 17 ± 7.8 months of mean age. Mean follow - up period was 1T± 5.3 months (range, 2 to 20 months), mean time of defecation was 1.9 ± 1 (range,1 to 5), normal defecation was noted in 44 of 54 (81.4%), 45/54 (83.3%) patients had normal stool consistency. Oceasionnal spiling occurred in 18 (33.3%).
Recurrent episodes of enterocolitis occurred in 5 of those patients, three of w h i c h improved without hospitalization. Recurrent constipation, anatomotic stricture, tight sphincter, adhesive bowel obstruction Vi/as not noted in any patient. Conclusion: Spontaneous defication was achieved in all patients after primary laparoscopic - assisted endorectal colon pull - through for Hirschsprung's disease. Low rate posoperative complication. These patients need continuing follow - up.
Keyword: Laparoscopic, Hirschsprung's disease
HIEU QUA CUA VI VIEM SO I TREN MO HINH THL/C NGHIEM VIEM TEO NIEM MAC DA DAY MAN TINH
• • •
Nguyin Thj Thu Ha Trifdng Dai hoc Y Ha Ndi Viem teo niem mac da diy man tinh (Chronic Atropic Gastritis, CAG) la mot benh thddng gap, khd diiu tri trong dudng tieu hda, cd nguy cd cao din tdi ung thd da day. Muc tieu: md ta sd thay doi hinh anh md binh hoc da day, dinh gia sd thay ddi yeu td viem trong huydt thanh tren chudt cdng bj bdnh CAG ddac dieu trj bang Vi viem sd I. Doi tugng va phuang phap nghien cdu: 60 con chudt cdng chuan SD, tao md hinh CAC trong 20 tuin, ngiu nhien chia 6 nhdm: md hinh, chdng, Vi viem so I lieu cao, trung binh, tha'p vi Weimeisu. Sau qui trlnh diiu trj lay mau chudt, ly tim lay huyet thanh, dung phuang phip phdng xa miin dich do luang Interleukin - 10 (IL - Ifi) va yeu td hoai td khdi u - a (TNF - a) trong huyet thanh, dong thdi tien hanh quan sit hinh thii hoc da day. Ket luan: vj viem sd I cai thien hinh anh ton thdang md benh hoc cua viim teo niem mac da day man tinh trdn chudt. So vdi nhdm md hinh thi cic nhdm diiu trj bang Vj viem sd I Hiu trung binh, thi'p vi dieu tri bang Weimeisu deu cd him luang TNF - a trong hdyet thanh giam thi'p, qua dd giup lim giam mde dd ton thdang cua niem mac da day.
TO khoa: Vj viem sd I, viem teo nigm mac da day, TNF - a
L D A T V A N D E
Viem teo niem mac da day man tfnh (Chronic Atropic Gastritis, CAG) la mpt benh thudng gap va khd d i l u tri trong dUdng tieu hda, bieu hien la t l bao bieu md eua da day va d e t u y i n teo nhd, Idp niem mac bac mau, t l bao t u y i n eua niem mac da day bj thay t h i bang d c t l bao b i l u md dang niem mac rupt, tang sinh khdng dien hinh [1]. CAG cd nguy cd cao dan tdi ung thfl da day, la mdt trong nhflng benh ung thU thUdng gap nhat eua dudng tieu hda, vdi ty le tfl vong eao d nflde ta. Viee sdm dfldc phat hien, ehan d o l n va d i l u trj ed the nang cao ty le sdng. Thfldng cd mpt thdi gian dai tien ung thU trUdc khi te bao bieu md cua niem mac da day binh thfldng bi l e tinh hda thanh te bao ung thfl, nen viee phat hien va dieU trj giai doan tien ung thfl la mpt d c h td't de phdng t r l n h ung thU da day. C I c chuyen gia eua Td chdc Y te The gidi cho rang Viem teo niem mac da day map tinh cd tang sinh khdng dien hinh ehinh la giai doan t i l n ung thU [2]. Y hpe cd t r u y i n cd hieu qua d i l u trj td't trong giai doan nay.
Chfnh vi vay, chdng tdi t i l n h i n h nghien cflu de tai nay vdi muc tieu:
1. Mo ta stf thay ddi hinh anh mo benh hoc da day tren chugt cdng bi benh viem teo niem mac da day man tinh dugc diiu tri bang Vi viem sd I.
2. Danh gia stf thay ddi cua ye'u td viim trong huyit thanh cua chugt cdng bi benh viem teo niem mac da day man tinh dtfgc diiu tri bang Vi viem sd I.
II. DOI TUONG VA PHUONG
P H A PNGHIEN CL/U
1. Chat lieu nghien cOu
Thanh phan bai thud'c Vj viem sd I gdm: D i n g sam 16g, Nga truat 1 Og, bpt Tran chau m l u 1 Og, That diep nhat chi hoa 12g, Bo edng anh 12g,
Bach hoa xa thiet t h i o 12g, Dfldng quy 12g, Ke cdt hUdng 16g, Cam thao 6g, do khoa DUdc cda benh vien phu thupe sd 1, Hpe vien Trung Y Dupc Quang Chau, Trung Qudc che dUdi dang djch thudc sac san.
Weimeisu la: vitaccemzym chiet suit tfl hat dau tUdng len men.
2. Ddi tOdng nghien cdu: 60 ecn chuot cdng chuan SD, n g l u nhien phan thanh 6 nhdm: nhdm chflng (ehudt binh thudng), nhdm md hinh (gay viem teo da day, khdng dung thude), nhdm Vi viem sd I lieu cao, trung binh, thap (gay viem teo da d i y , dung Vj viem sd I l i l u eao, trung binh, thap) va nhdm Weimeisu (gay viem teo da day, dung thudc Weimeisu). Mdi nhdm 10 con.
Nghien eflu dUpe tien hanh tai phdng thf nghiem eua Trung tam thflc nghiem dpng vat, Hpe vien trung y dUpe Quang Chau, Trung Qudc.
3. PhOdng phap nghien cOu
TrO nhdm chflng cho udng nUde mudi sinh ly hang ngay, d c nhdm khac cho udng N - Methy - N' - Nitro - N - nitrosoguanidine (MNNG lieu Ig/L) cung vdi eho ud'ng Ranitidin (0,03g/kg) de , tao md hinh viem teo nigm mac da day trong 20 tuan. Sau khi tao dUde md hinh eho d c nhpm chuot ud'ng Vi viem so' I vdi d e l i l u 2,16 g/kg/d;
1,08 g/kg/d, 0,54 g/kg/d v l Weimeisu vdi lieu 0,85 g/kg/d trong 90 ngay [5]. Sau q u i trinh dieu trj la'y mau ehudt, li tam lay huyet thanh, dung phUdng phap phdng xa mien djeh do lUdng Inter- leukin - I p (IL - 1|3) va Ye'u t d hoai tfl khdi u - a (TNF - a) trong huyet thanh, ddng thdi t i l n hanh quan sat hinh thai hpe eua da day.
4. XO ly sd lieu: theo ehUdng trinh xfl ly thdng ke SPSS 13.0.
i n . K E T Q U A
1. SO thay ddi cua hinh thai hoc da day chugt trong nghien cOu
Niem mac da day cua nhdm chdng dp day binh thfldng, te bao thflpng bi va cac tuyen sap xep t h i n g hang, ngay ngan. Nhdm md hinh xuat hien rd ret chflng viem d niem mac da day, d e tuyen teo nhd cd hien tUdng hda sinh nhUng chUa
cd hien tUdng tang sinh ba't thUdng. Nhdm dieu trj bang Vi viem so' I va Weimeisu so vdi nhdm md hinh cd sfl khac biet Idn, trong dd e l c nhdm d i l u trj bang Vj viem sd I ed t i c dung d i thien hinh thai benh ly cua CAG.
Hinh 1. Nhom chdng HE x 200 Hinh 2. Nhom chdng HE x 400 O hinh 1 va 2 ta thiy do day niem mac binh thudng, sd kfdng tuyen phong phu, xep chinh ti.
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Hinh 3. Nhom mo hinh HE x 200 O hinh 3 va 4 ta thiy niem mac teo nhd, viem xim lin, te bao tuyen cua niem mac mac rudt.
Hinh 4. Nhom mo hinh HE x 400
bac mau, cac tuyen sd luang it, gian chit cd nhiiu te bao da day bj thay the bang cac te bao bleu md dang niem
Hinh 5. Nhom thudc liiu cao HE x 200 Hinh 6. Nhom thudc lieu cao HE x 400
0 hinh 5 va 6 ta thiy cic tuyen sip xep khdng thing hang, trong gian chit xuit hien cac te bao viem.
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Hinh 7. /V/idm thudc liiu TB HE x 200 Hinh 8. Nhom thudc liiu TB HE x 400 0 hinh 7 va 8 ta thiy Idp niem mac va cac dng tuyen da day xep hang chinh ti, gian chat it ti bao viem xam lan, khdng cd te bao hoai td.
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H;n/i 9. iV/idm thudc liiu thap HE x 200 Hinh 10. Nhom thudc liiu thap HE x 400 O hinh 9 va 10 ta thiy cie dng tuyen da day sd Iddng kha nhiiu, sd bj teo nhd cd kfdng it.
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Hinh 11. Nhom Weimeisu HE x 200 Hinh 12. Nhom Weimeisu HE x 400 O hinh 11 va 12 ta tha'y Idp niem mac day, gian chit it te bao viem xam lin, cac dng tuyen da day xip hang chinh ti, sd tuyen bj^ teo nho it.
2. SO thay ddi cua ham lOdng IL - 1 p, TNF - a trong huyet thanh
So sanh vdi nhdm ehdng thi nhdm md hinh ed ham Ifldng IL - i p trong huyet thanh ed xu hfldng tang nhflng khdng cd y nghia thdng ke (p > 0,05). So s i n h vdi nhdm md hinh thi d c nhdm d i l u trj deu cd xu
hudng giam nhflng khdng cd y nghTa thdng ke (p > 0,05). So s i n h vdi nhdm chflng, d e nhdm ehudt d i u ed ham lUdng TNF - a trong huyet thanh tang cao d d c mde dp khac nhau, trong dd nhdm md hinh cd mfle tang rd ret nha't (p < 0,05). So sanh vdi nhdm md hinh thi d e nhdm d i l u trj bang Vj viem sd I l i l u trung binh, thap va d i l u tri bang Weimeisu d i u cd ham lUpng TNF - a trong'huyet thanh giam tha'p, rieng nhdm dieu tri bang Vi viem so' I l i l u cao thi sU g i l m tha'p khdng rd ret.
Bang 1. Su thay ddi cua ham Itfgng IL - Ifi, TNF - a trong huyet thanh Cac nhom NC
Nhdm chflng Nhdm md hinh Vj viem so' 1 lilu cao Vj viem sd 1 lilu TB Vj viem sd 1 lilu tha'p Nhdm Weimeisu
So lOdng (n)
10 10 10 10 10 10
I L - i p (pg/ml)
0,20 ± 0,06 0,24 ± 0,09 0,23 ± 0,05 0,20 ± 0,05 0,20 ± 0,07 0,20 ± 0,09
T N F - a (pg/ml)
1,31 ±0,19*
1,79 ±0,36*
1,51 ±0,46 1,42 ±0,25*
1,35 ± 0 , 3 1 * 1,45 ±0,19*
Cliu thich: so sanh vdi nhdm md hinh: 'p < 0,05; 'p < 0,01; so sanh vdi nhdm chdng: "p < 0,05, '"p<0,01.
IV R A M 11 I A N t h i bang d c t l bao bieu md dang niem mac rupt.
Thdng qua viec nhudm mau cd t h i phan thanh t l So thay doi cua hinh t h a i hoc da dav chuot trong • - u—' - L.- J ^-^ » ^ u - u - '
• ' ^ ° v^ . r '- . 6 bao bieu mo hoa dang tieu trang hoac bieu mo nghien cOu y^^^ ^^^^ l^g-^ ^^^^^ Q-^^^ ^Q ^^^^ ^^^^ ^-^^^ ^^^^^
Thay ddi b§nh ly cua CAG ehu yeu tap trung d la sfl phan hda td't, la mpt tdn thflpng thfldng thay phan CP niem, d i u tien la cd sfl xam nhap eua t l trong sfl bien ddi benh ly cua ed niem kem theo bao viem vao trong ldp cd niem, tiep thee la teo ed tfnh chat phan I n h mde dp nang d i n cua viem nhd d c tuyen d ldp thUdng b i , sau dd Idp thUdng nhiem. Bieu md hda dang k i t trang la sU phan bi va gian chat xua't hien d c mde dp k h I e nhau hda kem, thfldng dfldc eho rang la giai doan t i l n eua tang sinh va bieu md hda dang niem mac rudt ung thfl da d i y . Sfl tang sinh hoac tang sinh di [3]. Cae te bao viem xam nhap ehu yeu la te bao thfldng la do viem nhiem man tinh keo dai kfch lympho, ed mpt it la bach c l u Ua axit va dai thUe thich t l bao bieu md p h l t trien tang sinh. Sfl tang bao, d s l u trong tang cd niem ed hinh thanh d c sinh cua ldp bieu md va bieu md hda dang rudt cd hach lympho. N l u ke't hpp d nhiem HP thi cung the p h l t trien mpt d c h dj thudng, xuat hien d c cd the xay ra tdn thUdng cua viem nhiem va Icet. t l bao bieu md khdng dien hinh, nhan to hoac Cae tuyen teo nhd man tfnh keo dai v l viem mat nhan, k i t ca'u cd niem rd'i loan, mde dp trung n h i l m mde dp nang ed t h i dan tdi sfl thoai hda, binh cua tang sinh khdng dien hinh dUdc coi la tieu huy va tham c h i bien mat eua cac tuyen, ehu t i l n ung thU da day.
yeu bieu hien la d e t u y i n thu nhd va g i l m sd TO k i t q u i nghien eflu eho thay sfl khac biet Iflpng. Mfle dp teo nang d phan ed niem la ldp rd ret giOa nhdm ehdng va nhdm md hinh. Nhdm niem mac bae mau va b i t dau xuat hi§n tang md hinh xua't hien rd viem n h i l m d Idp cd niem, sinh. T l bao t u y i n cua niem mac da day bi thay eae t u y i n teo nhd va b i l u md hda niem mac rupt,
nhung ehua thay tang sinh dj thudng. Cac nhdm d i l u tri bang Vj viem sd I va nhdm md hinh cd sfl khae biet kha ro ret, eho thay Vi viem sd 1 cd hieu q u i trong viec d i thien hinh thai bSnh ly cua viem teo niem mac da day man t i n h .
SO thay ddi cua ham lOdng IL - i p , TNF - a trong huyet thanh
Cytokines la mpt protein ed trpng Ifldng phan tfl tha'p, ed tac dpng quan trpng trong viee d i l u hda he thdng m i l n djch cua ed the. Hien nay, ehdng ta b i l t rang Interleukin va y l u t d hoai tfl khdi u (TNF - a) la cytokines do te bao mien djch s i n sinh. Y l u t d hoai td khdi u cd vai trd la mpt y l u t d d i l u tiet mien djch quan trpng," ed tac dgng tieu diet d c te bao ung thU rat manh, k h i l n t l bao ung thU hoai tfl. Tac dung sinh vat bpc bao gdm: dc che va diet te bao n h i l m virut hoac te bao ung thfl; kich boat tinh nang eua te b i o bach c l u da nhan trung tfnh, kfch thich tang t i l t IL - 1, IL - 5, IL - 8 thue day phan dng viem; tang cUdng san sinh te bao T va B de kfch hoat p h i n flng vdi k h i n g nguyen. Trong nhOng nam gan day, tac dung eua TNF - a va IL - 1 p cung nhU cae cy- tokines trong qua trinh p h l t sinh benh tat da dUde n h i l u t i e g i l quan tam [5].
B i n g 1 eho tha'y nhdm md hinh cd TNF - a va I L - i p d i u cd xu hudng tang hdn so vdi eae nhdm khae, nhUng ehi cd TNF - a thay ddi ed y nghTa thd'ng ke vdi p < 0 , 0 1 . K i t qua eho tha'y TNF - a cd the da tham gia qua trinh viem va tdn thUdng cua td chdc da day bi viem teo. TNF - a cdn cd tac dung thdc day d e phan flng viem trong qua trinh m i l n dich. Trong dieu kien binh thfldng, Ifldng TNF - a tham gia phan dng bao ve cua cd the la e i n thieL nhflng khi cd the bj tdn thflpng thi nd lai tang len kha rd ret. TNF - a ed the gay bien ddi t d bac bieu md cua h u y l t q u I n , gay ddng mau trong vi quan khie'n eho niem mac dinh dfldng khdng d i y du [4]. Ddng thdi thdc day thuc day qua trinh viem lam tang JDhIn flng viem tai niem
mac. Do dd nhflng bie'n ddi trong viem teo niem mac da day mde dp nang cd the dc vai tro TNF - a kieh flng qua trinh m i l n djeh trong cd the gay ra. Nghien cflu nay cho thay Vi viem sd I eo kha nang thong qua viee lam giam thap TNF - a ma giup lam g i l m mfle dp tdn thfldng cua niem mac da day.
V . K E T L U A N
Vj viem sd I d i thien tdn thfldng ve md benh hpe cua td ehfle trong viem teo niem mac da day man tinh tren chuot.
Vj viem sd I lam g i l m h i m Iflpng y l u td viem TNF - a trong h u y l t thanh, qua dd giup lam giam mde dp tdn thUPng eua niem mac da day.
TAI LIEU
THAM
KHAO1. ^ f | g . (2003),'"ftttS^'[4l5^" J t a : * H U S f ^ S t i i M t t • (8) : 42.
2. 5Kig.WM. (aoo4)-mximW)hn'mm
^t4ffi^36#l][J]",iI=?^M^|5^^fB . 6(5) : 381.
3. mMm. mUXm.. (2003),"±>g1bl!l^5S9910
iM, 11 (3) : 167 - 168.
4. ^ ^ . (2004),"^ 1^5f *F.5Ei^|?-S, ffiU
21 (6): 334.
5. SI J, Zhou W , W u J, Cao Q , XIang Z, Jiang L, Lu W, Huang H. (2001), "Establishment of an animal model of chronic atrophic gastritis and a study on the factors inducing atrophy". Chin Med J (Engl), Dec; 114 (12): 1323 - 5 .
6. Won Chang Y, Oh HC, Young Jang J, Hwangbo V, Won Lee J, Jung Lee H, Ro Joo K, Ho Dong S, Soo Kim S, Jong Kim H, Ho Kim B, Chang R. (2008), "IL - Ibeta and IL - 8, matrix metalloproteinase 3, and pepsinogen secretion before and after H. pylori eradication in g a s t r o d u o d e n a l p h e n o t y p e s " , S c a n d J Gastroenterol, May 19: 1 - l o .
Summary
E F F E C T OF W E I Y A N Y I H A O O N C H R O N I C A T R O P I C G A S T R I T I S
Chronic atrophic gastritis (CAG) is one of the most common and difficult diseases in the tumors. It easy to change into gastric carcinoma. Objectives: To describe histopathological changes of gastric tissue and to evaluate changes in serum inflammatory factors in chronic atrophic gastritis rats treated by Weiyanyihao formula. Method: 50 SD rats were modeling CAG in 20 weeks, radomisely devided into 6 grpups: model group, control group, Weiyanyihao with high - dose, medium - dose and low - dose group and Weimeisu group. By the end of treatment, isolating the serum, using of radioimmunoassay to measure serum IL - i p , TNF - a content; morphological observation at the same time. Results: The model group has significant stomach membrane inflammation, gland atrophy and metaplasia. There is no significant dysplasia. There are significant differences between Weiyanyihao groups and model group. It indicated that Weiyanyihao formula has improvement effect on the histopathological changes in CAG. Compared with control group . serum TNF - a content in treatment groups were increased,but only the model group had significantly dif- ferent. Compared with model group, serum TNF - a in Weiyanyihao with middle and low - dose groups and Weimeisu group were significantly lower, and in Weiyanyihao. Conclusion: Weiyanyihao can improve histopathological changes of of experimental CAG in rats . Weiyanyihao can reduce the inflammatory cytokines TNF - a content.
Keywords: Weiyanyihao, Chronic atrophic gastritis, TNF - a
DANH GIA NHANH TY LE MAT HOT HOAT TINH VA
QUAM DO MAT H O T , TY LE MU vA CAC NGUYEN NHAN CHINH GAY MU 6 C O N G DONG 3 TINH
NAM D j N H , THAI BINH, HAI D U O N G NAM 2009
Nguyen Chi Dung Benh vien Mit Trung uang Danh gii ty Id mit hdt boat tinh d tre em dddi 16 tdoi va ty le qdSm do mit hot d ngddi td 40 tuoi trd l&n di lip kd hoach thanh toin mit hdt d 3 tinh. Muc tieu: (1) Xic djnh ty le mit hot boat tinh d tre em dddi 16 tuoi va t'y le quim do mit hot d ngddi td 40 tuoi trd len (2) Dinh gia ty le mu va cic nguyen nhin chinh gay mu d ngddi td 40 tudi trd len. Doi tugng va phuang phap nghien cdu: nghien cdu cit ngang tren 5201 tre em dddi 16 tuoi vi 9554 ngddi td 40 tdoi trd len. Ket qua: ty le mit hot hoat tinh d tre em dddi 16 tudi tai 3 tinh li 0%o. Ty le quam do mit hot d ngddi td 40 tudi trd len li 4,48%o d Thai Binh, l,44%o d Nam Djnh va 1,28%, d Hai Ddang, chu yeu d nhdm ngddi tren 70 tudi. Ty le mu 2 mit d ngddi td 40 tddi trd len li 4,17%o d Thii Binh, 2,62%o d Nam Djnh va 7,24% d Hai Ddang. Nguyen nhan giy mu chu yeu vin la due the thuy tinh (DTTT): 3,3%, d Thii Binh, 2,3%o d Nam Dinh, 0,9%o d Hai Ddang. Ty le md do mit hot cao 0,1 %o d Thii Binh, thi'p 0,03%o d Nam Djnh va 0%o d Hai Ddang. Kit luan: de kiem soat benh mit hot giy mil phai day manh mo quam, die biet d Ida tuoi dudi 70 la muc tieu cd the dat duac.
TO khoa: danh gia mat hot va quam