TAI TAO THI/C QUAN BANG VAT OA CANG TAY QUAY KET QUA BUtfC DAU
Vu Quang Vinh*, Tran Van Anh*
Hoang Manh An**, Nguyin Van Thanh", Mai Van Vien"
Vien Bong Le Hdu Trac' Benh vien 103**
TOM TAT
Tai tao thi/c quan vin la mpt kho khan doi vdi cac phiu thuat vien tao hinh. Khdi -phuc chdc
nang nudt, noi va han che toi thieu ton thdOng kem theo la muc tieu quan trpng cho viec Ida chpn ky thuat. Tuy nhien, sd thieu mau hoac chiy mau cua cud'ng vat cua da day, rupt non, hoac rudt gia sau cit bd thdc quin luon tao ra cac bien chdng sau phiu thuat. Ky thuat vi phiu dng dung trong tao hinh thdc quan nhd ghep rudt non td do va vat da can cing cing tay quay da ddng gop mpt vai tro quan trpng. Trong bai bao nay tac gii xin gidi thieu ket qui bddc dau trong sd dung vat da can cing tay quay trong tao hinh thdc quin.
Title: Pharyngoesophageal reconstruction using the radial forearm fasciocutaneous free flap:
preliminary results ABSTRACT
Pharyngoesophageal reconstruction remains a challenge to the head and neck surgeon. The
goals of pharyngoesophageal reconstruction include restoration, with minimal morbidity, of a person's ability to swallow and to speak. However, ischemia or hemostasis in the gastric, jejunal, and colonic pedicle after esophagectomy is believed to contribute significantly to postoperative complications. Microsurgical free tissue transfer represented by the free jejunum and forearm flap also plays an important role in esophageal reconstruction. In this paper, the authors introduce the technical points important for successful utilizing the radial forearm fasciocutaneous free flap for pharyngoesophageal reconstruction.
I. OAT VAN OE
Phiu thuat tai tao vung hau hgng-thuc quan sau phau thuat dieu tri ung thu hoac do tai nan mac phai vin la mdt trong nhCrng khd khan cua cac phau thuat vien. Nhieu phuong phap phau thuat da dugc sir dung, nhung tieu tri dat ra trong tai tao vung hau hgng-thuc quan ddi hdi can phai dat dugc yeu cau nhu han che cac tdn thuang kem theo, dat dugc chdc nang
Phan bien khoa hpc: PGS. TS. Nguydn Gia Tidn.
ndi va nud't, giam thieu cac bien chdng va rUt ngan thdi gian dieu tri. Do vay, ngay nay phiu thuat tai tao hau hgng - thuc quan da dat dugc mdt so tien bd dang ke so vdi cac phiu thuat kinh dien trudc kia khi sd dung cac vat vat tru Philatop dugc ap dung the ky 19 Vat tai chd nhu vat Delta-nguc 2), vat ca nguc Idn 3), trong tao hinh thuc quan, va phd bien nha't la keo da day len thay the doan thuc quan mat, hoac dai trang len thay the. Tiep theo dudi su phai trien cda ky thuat vi phau cac vat tu do nhu vat rudt non, vat dai trang da dugc sd dung vdi ket qua td't. Nam 1985 Harii va cdng sir lan dau tien md
64 TCYHTH&B so 4 - 2009 ta sd dung vat da can tu do clng tay quay
trong tao hinh hau hgng - thuc quan 4). TU dd den nay, vat da can tu do da dugc uhg dung rdng rai tren lam sang bdi vi nd giam thie'u nhung bien chdng vung cho vat so vdi nguy co tiem tang khi lay vat trong d bung. Sau dd, nhieu vat da can tu do da dugc ap dung trong tao hinh tdn khuyet chu vi thuc quan nhu vat trUdc ngoai dui, vat cSng tay tru, vat da cang can dui, vat canh tay ngoai... 58>.
Vat da can sd dung trong tao hinh hau hgng thuc quan vin cdn cd nhung bien chdng gap sau phiu thuat nhu rd, hep thuc quan. Tuy nhien, nhdng cai tien trong phau thuat da gdp phan giam thieu cac bien chdng nay. Mdt so nghien cdu cho thay vat da can trong tao hinh thuc quan cd nhieu uu diem hon vat rudt non tu do, dSc biet kha nang phat am cua benh nhan sau md. Dua tren cac y van cdng bd chung tdi cung manh dan ap dung ky thuat nay trong tao hinh thuc quan, tuy so lugng chua nhieu nhung chung tdi nhan thay rang phuong phap nay can dugc ap dung rdng rai tren lam sang.
II. BENH NHAN VA PHUCSNG PHAP NGHIEN CL/ll 1. Benh nhan
La benh nhan mat doan hau hgng thUc quan sau phiu thuat ung thu hoac tai nan trong dieu tri.
2. Phuong phap 2.1. Ky thuat phdu thuat:
- Benh nhan sau khi dugc phiu thuat cat doan thuc quan dugc tien hanh do dudng kinh va chieu dai doan mat.
- Mach mau vung nhan dugc lua chgn.
Thdng thudng 4 mach nhan cd the dugc lua chgn bao gdm: Bd mach mat, bd mach giap trang tren, bd mach cd ngang, bd mach vu trong. Su lua chgn bd mach nhan se dua tren vi tri thuc quan bi cit doan.
- Vat da can cing tay quay se dugc lua chgn (Vat nay phu hgp tren ngUdi Chau a do khdng cd nhieu long vung cing tay). Chieu dai vat dugc thiet ke dai hon chieu dai mat doan thuc quan khoang 1cm. Chieu rdng vat da dugc tinh toan nhu sau: Oudng kinh thuc quan x 3,14+1cm (1cm dugc them vao cho mdi chieu de' tranh co hien tugng co hep manh ghep sau khi nang vat).
- Vat dugc nang len td ngoai vi vao trung tam dgc theo dudng di cua ddng mach quay.
- Vat dugc khau cudn lai thanh hinh d'ng vdi mat da ben trong va can, td chdc dudi da d ben ngoai.
- Vat da hinh d'ng duoc dua den vung nhan. Bd mach quay se dugc ndi vdi mach mau nhan, kiem tra mau luu thdng. Hai dau d'ng vat da se dugc khau ndi vdi mom cut thuc quan.
- Benh nhan dugc an udng thdng qua Sonde md thdng da day
2.2. Danh gia ket qua:
2.2.1 Theo doi tinh trang vat da Thudng chung tdi cd hai each theo ddi tinh trang sd'ng cua vat da nhu sau:
- Cach 1: Vat da dugc kiem tra tinh trang luu thdng mach mau bing sieu am Doppler cim tay tai vi tri ndi mach. Ngay thU 5 sau md cd the tham dd danh gia bang ky thuat ndi soi.
- Cach thd 2: Trong khi nang vat chung tdi lay kem them mpt vat da nhd vdi su cap mau cua nhanh xuyen nhd cua ddng mach quay.
Vat da nay se dupe khau ra ngoai de theo ddi tinh trang vat da bang mat thudng.
2.2.2. Theo doi tinh trang luu thong dddng tieu hoa:
- Ngay thd 5 vat da kiem tra bing ndi soi tieu hda danh gia tinh trang vat da, va mieng md'i ndi. Kiem tra sUxi rd.
- Ngay th CY 21 benh nhan dugc chup can quang tieu hda danh gia su luu thdng va tinh trang hep cua thuc quan.
III. CA THONG BAO
Benh nhan MVN 47 tuoi vao vien 8/2008 vdi chan doan mat doan thuc quan sau phau thuat rd xoang le. Benh nhan da dugc phau thuat tao hinh thu'c quan 9/2007 bing ky thuat chuyen quai rudt non va mac ndi Idn. Ca mo khdng thanh cdng mieng ndi bi tac ca hai dau tren va dudk.va dugc phau thuat nong chd tic nhung khdng cd ket qua thdi gian nam vien keo dai 4 thang. Benh nhan den vdi chung tdi trong tinh trang gay yeu, phai an, udng qua Sonde md thdng da day. Chung tdi quyet dinh sd dung vat da can cing tay quay tranh gay them tdn thuang trong d bung. Sau khi phiu thuat xac dinh vi tri hai dau mom cut, dudng kinh thUc quan 2cm, chieu dai thuc quan mat 5cm.
Bd mach mat dugc chgn lam nguon cho dugc Hin
Phau thuat xac dinh hai dau mom cut thuc quan
Vat dude tao thanh hinh ong vdi cudng bd mach quay
tien hanh phiu tich. Vat da cing tay quay phai duac thiet ke vdi kich thudc 6,5 X 6cm dugc bdc tach va tao thanh hinh dng (Hinh 1) bang ky thuat khau 2 Idp sole nhau de' han che rd sau md. Bd mach quay duac khau ndi vdi bd mach mat dudi kinh hien vi phiu thuat. Hai diu mom cut dugc khau ndi vdi hai diu vat da hinh d'ng bang ky thuat khau 3 Idp. Sau md vat da dugc kiem tra bang sieu am Doppler cim tay tai vj tri ndi mach. Sau 1 tuan benh nhan cd cam giac nud't, cd the' udng nudc sau 10 ngay, chup tieu hda can quang va ndi soi tieu hda thay thuc quan thdng tot, khdng xi rd va hep nhe mieng ndi. Benh nhan ra vien sau 28 ngay dieu tri trong tinh trang an thdc an long binh thudng.
1
Benh nhan mat doan thu'c quan
Vat cang tay quay dUdc thiet ke va phau tich nang vat
66 TCYHTH&B so 4 - 2009
Hai dau mom cut dUdc khau noi vdi vat da
IV. BAN LUAN
Sd dung quai rudt non trong tai tao mat doan thyc quan lan dau tien dugc cdng bd nSm 1959 9). Dau thap nien 70 khi ky thuat vi phiu bit dau dugc ap dung tren lam sang 1 1 0 "i nhung phai den giua nam 1980 vat ty do rudt non cd ndi mach vi phiu trong tao hinh thuc quan mdi dugc cdng bd. Cung thdi diem nay Harii va cdng sU cung cdng bd ap dung thanh cdng lan diu tien vat da can ty do cing tay quay trong tao hinh mat doan thUc quan 4). NhCrng Igi the cua vat da can so vdi vat rudt non da dugc nhieu tac gia de cap den nhu vat sd dung linh ddng hon, cd the thiet ke dUa tren hinh thai cua khuyet thieu, vat mem mai vdi cudng mach dai cho phep vat cd do di dgng cao. Dac biet, vat da can cing tay cd thdi gian chiu dung thieu mau tot hon vat rudt non, do vay dam bao sy thanh cdng cho cac phiu thuat vien chua cd nhieu kinh nghiem trong phiu thuat tao hinh thyc quin. Them nua, vat da can tranh dugc su can thiep vao trong d bung nen thdi gian phuc hdi cua benh nhan nhanh hon. Tranh dugc cac bien chUng nhu tic rudt, sd bung sau md. Tuy nhien, vat da can cd nhuoc diem nhu vat day, khdng sinh ly, cd nhieu long. Do vay, vat cin dugc lam mong va triet long sau phiu thuat12'.
Hinh anh luu thong cua Bariumsulphat trong chup can quang tieu hoa
Mac du cd nhCrng Uu diem trong tao hinh nhung cd nhieu thdng bao cho thay ty le co hep va rd cua vat da can cdn cao hon vat rupt non. Ty le nay theo cac thdng bao chiem khoang td 13-16,3% 1 3 1 va tap trung chu yeu tai mieng ndi. Mot so tac gia da dua ra cac giai phap giam thieu rd cua vat da. Murray cho rang nen sd dung Idp can nhu mdt Idp dem do, cai thien tuin hoan tai chd giup cho gua trinh lien vet thuong tai md'i ndi va lam giam su co keo tai chd ndi da- niem mac "M 5 ). Reece va cdng sy cho rang nen gid lai Idp md bao bpc xung quanh mom cut thyc quan khoang 2cm de bao dam tuan hoan cua hai mieng ndi gdp phan cho qua trinh lien vet thuong , 6 ). Trong ca phiu thuat cua minh, chung tdi da cd mdt vai cai tien nhu vat dugc lay dai va rdng hon so vdi kich thudc tdn khuyet 1cm lam cho vat trung hon mem mai hon gdp phan cho lien mieng ndi de dang hon. Va khi vat co hep lai thi chu vi cua nd se tuong ddng vdi mieng ndi thuc quan.
Phin md bao bpc xung quanh thuc quan duoc gid lai khoang 2cm va dupe khau phu trum len Idp can cua vat da nhu mpt Idp thd 3 sau khi khau hai Idp tai mieng ndi (Ldp khau da- niem mac, Idp khau can sau- thanh mac co). Ca md cho thay sau mdt thang benh nhan an udng binh thudng khdng rd va co hep thyc quan.
NhCrng nghien cunj gan day cung cho thay sir dung vat da can trong tai tao hau hgng-thuc quan cho thay benh nhan sau md' cd chdc nSng phat am td't hon so vdi tao hinh bing vat rudt non. Ty le hoai tCr vat da chi chie'm 2%
thap hon so vdi tao hinh bang vat rudt non cd le do thdi gian chiu thie'u mau cua vat da can td't hon , 3 ). Thdi gian nam vien cung giam dang ke khi tao hinh bing vat da can.
VI. KET LUAN
Vat da can cang tay quay la mdt trong chat lieu td't cho tao hinh mat doan thuc quan.
Vat duoc cung cap mau dn dinh, cud'ng dai, dd di ddng td't, thdi gian chiu thie'u mau cao thi'ch hgp trong nhCrng trudng hgp tao hinh thUc quan phUc tap.
TAI LIEU THAM KHAO:
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3. Ariyan S. Further experiences with the pectoralis major myocutaneous flap for the immediate repair of defects from excisions of head and neck cancers.
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Pharyngoesophageal reconstruction using a fabricated forearm free flap. Plast Reconstr Surg 1985;75:463-76.
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Pharyngoesophageal reconstruction with the ulnar forearm flap Arch Otolaryngol Head Neck Surg 1998;124:1146-51.
7 Endo T, Nakayama Y. Pharyngoesophageal reconstruction: a clinical comparison between free
tensor fasciae latae and radial forearm flaps J Reconstr Microsurg 1997;13:93-7.
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Lateral upper arm free flap for primary reconstruction of pharyngeal defects in ablative oncological surgery. Report of six consecutive cases. Ann Otol Rhinol Laryngol 2003;112:611-6.
9. Seidenberg B, Rosenak SS, Hurwitt ES, et al.
Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 1959;149:162-71.
10. Huguier M, Gordin F, Maillard JN, et al. Results of 117 esophageal replacements. Surg Gynecol Obstet 1970;130:1054-8.
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pharyngolaryngoesophagectomy. Surg Gynecol Obstet 1979:149:858- 62.
12 Ohjimi H, Taniguchi Y, Kawano K, et al. A comparison of thinning and conventional free-flap transfers to the lower extremity. Plast Reconstr Surg 2000;105:558-66.
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14. Murray DJ, Gilbert RW, Vesely MJJ, et ai.
Functional outcomes and donor site morbidity following circumferential pharyngoesophagea reconstruction using an anterolateral thigh flap and salivary bypass tube. Head Neck 2007;29:147-54.
15. Yu P, Lewin JS, Reece GP, et al. Comparison of clinical and functional outcomes and hospital costs following pharyngoesophageal reconstruction with the anterolateral thigh free flapversus the jejunal flap. Plast Reconstr Surg 2006;117:968-74.
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Morbidity and functional outcome of free jejunal transfer reconstruction for circumferential defects of the pharynx and cervical esophagus. Plast Reconstr Surg 1995;96:1307e16.
