^ H p c T P . H o Chi M i n h * T a p 14 * Phii b a n cua So 4 * 2010 N g h i e n cuu Y hpc
DANH GIA HIEU QUA MO NOI SOI LONG NGlTC KHAU KEN KHI TRONG DIEU TRI TRAN KHI MANG PHOI TlT PHAT NGUYEN PHAT
Vu Quang Viet*, Trinh MinhTranh% NguySn Thi Ngpc Thuy**
r O M TAT
Muc Mch: ddnh gid hieu qua khdu ken khi dem thudn qua noi soi long nguc de xir tn tran khf mang jhoi tuphdt nguyen phdt.
Phmmg phdp nghien cmi: hdi dm mo td. Tit thdng 0I/2(X)8 din thdng 05/2010 co 21 benh nhan gi benh vien Nhdn Ddn Gia Dinh duac chdn dodn tran khi mdng phdi tic phdt nguyen phdt, dd ddn lim ndng phoi nhwig thdt bgi, duac mo noi soi long nguc khdu ken khi. Sau do ghi nhdn bien chimg hdu jhdu vd mire do tdi phdt trdn khi sau 6 thdng, 12 thdng vd 24 thdng. So sdnh vdi phau thugt vira khdu 'ien khi kem ldm dinh mang phdi trong y vdn.
Ket qud: 21/21 benh nhdn khong cobien chung sau nio. Klwng cd tdi phdt trdn khi.
Ket luan: khau kin khi dan thudn cho ket qud tdt. Tuy nhien, cdn so luang nhieu han de khdng iinh.
Tir khoa: trdn khi mdng phoi tuphdt nguyin phdt, cdt mdng phdi thdnh vimg dinh, chd ldm dinh ndng phoi thdnh
\ B S T R A C T
ELEVATING THE RESULTS OF VIDEO-ASSISTED THORACOSCOFIC SUTURING OF APICAL BUUAE FOR PRIMARY SPONTANEOUS PNEUMOTHORAX
Vu Quang Viet, Trinh MinhTranh, Nguyen Thi Ngoc Thuy
* Y Hoc TP. Ho Chi Minh * Vol. 14 - Supplement of No 4 - 2010:33 - 37 Objectives: evaluating the resuhs of video-assisted thoracoscopic suturing of apical bullae for primary spontaneous pneumothorax.
Methods and patients: Retrospective comparative study with medical literature. From January 2(X)8 to May 2010, 21 patients in Nhdn Ddn Gia Dinh with primary spontaneous pneumotliorax treated vith thoracostomy tube. They were indicated with video-assisted thoracoscopic suturing of epical
•jullae for persistent air leak Postoperative complications and pneumothorax recurrence after 6, 12, md 24 montlis have been noticed and compared with medical literature.
Results: No postoperative complications and no pneumotliorax recurrence.
Conclusion: video-assisted thoracoscopic suturing of apical bullae is excellent. However, anotlter luge study is necessary to determine the results.
Key word: primary spontaneous pneumothorax, apical pleurectomy, parietal abrasion DAT VAN DE phoi hoac CT scan nguc va din lim con ra bpt
T i ^ khj mang phdi tir phat nguyen phat la 1^'' * i duac chi dinh m6. Phau thuat thirong lenh ly thirong gap a benh nhan tre cho d^n 40 ^^""8 la **au ken khi qiia npi soi long ngirc kem u6i va khong co benh ph6i n^n. Benh dirac gpi theo lam di'nh mang phoi bSng each lot bo hoac a nguyen phat khi Iran khi xay ra khong do chSn cha nrdm mau la thanh mang phoi'"'. Phuong huong ngirc va thii pham thuang \k nhimg ken phap nay thucmg lam hau phlu nang ne va thai U nho nam duai mat la tang bj vd TSF^\ XU: tri gian nam vien lau. Muc dich nghien ciru ciia huang la dan luu mang ptioi va neu din luu that chung toi la chi phau thuat khau ken khf don ai, ph6i van khong no titin tren phim xquang thuan ma khong lam dinh mang phoi; danh gia
hieu qua ciia phuang phap va so sanh voi y van.
* Khoa Ngoai Ldng Nguc Mach Mau - Benh vien Nhan Dan Gia Djiih
** Bp mon ling ng\rc- Mach mdu DHYD TP HCM
^Mg^fhSti£^U|tQ40ig96ieV.:9lhSW)EUi!&'l@iaDinKw^im^Sa!&59@yaho^ 33
Y Hpc TP. Ho Chi M i n h * T a p 14 * Ph\i ban etia So 4 2010 N g h i e n ciju Y hpc PHI ONG PHAP NGHIEN C l X
Tu thing 01/2008 den thang 05/2010, tat ca benh nhan tai khoa ngoai long nguc mach mau benh vien Nhan Dan Gia Dinh dugc chan doan tran khi m ^ g ph6i tu phat nguyen phat that bai voi dan lim mang phoi, co chup CT scan nguc hoac khong. duac chi dinh mo npi soi long ngirc khau ken khi.
Tran khi mang phoi dugc chin doan dua vao X quang ngirc thang-dung va dtrgc din luu kin xoang mang phoi. Benh nhan dugc theo doi bang X quang phoi/ngay trong 2 ngay dau v^ 2-3 ngay/lan sau do, dugc hiit dan luu mang phoi Uen tuc vcri ap lire am 10cm nuoc neu phoi chua no l6l tren xquang phoi. Sau do, neu xquang phoi cho thay phoi na khong hoan toan va/hoac con xi khi Hen tyc cr btnh dan luu thi chi dinh mo npi soi ngirc khau ken khi. CT scan dupe chup trong mpt so truong hgp gitip xic dinh ken khi truac mo.
Benh nhan dugc gay me mot phoi. Lo vao camera la lo din luu mang ph6i, thucmg a lien suon 5 duong nach giiia. Hai 16 thao tac a phia trgn, tao thanh hinh tam giac, each nhau it nhat 10cm' \ Lo trocar vao cho tay thuan rgng 10mm de diJng dua vao kep kim va 16 kia Smm.
K6n khi dugc xdc dinh thuang a dinh phoi va dtrgc khau bang chi vicryl 2-0. Sau do, kiem tra xi khf bing each cho benh nhan nam dau thap, do nucrc ngap ph6i va b6p bdng.
Hau phau, benh nhan dugc chup xquang phoi sau mo vh rut ong dan Iim m ^ g phoi khi phoi no trpn tren xquang phoi va dan luu khong ra bpt khi. Ghi nhan bien chung tran khi, t r ^ mau, so ngay tuu ong dan lim va thai gian nam vien sau mo. Tiep d6, lien lac benh nhan qua dien thoai de theo doi tran khi tai phat iheo thoi gian 6 thang, 12thang,va24thang'^'^
KET QUA
Tir thang 01/2008 ddn thang 05/2010, tai benh vien Nhan Dan Gia Dinh TPHCM co 21 benh nhan. 19 nam va 2 nir, tuoi tir 18 d6n 36, nhap vien cap ciru voi chan doan tran khi mang phoi ty phat nguyen phat, khong co berth ph6i nen. Tat ca benh nhan dupe dan !im mang ph6i cap cuu bing ong Argyl 28-32 F va dugc hut mkig phoi lien tuc tir ngay thir 2 khi thay ph6i no
chua t6t. 86 benh nhan bi tran khi lan dau la 19 benh nhan va da tran khi han 1 lln la 2 benh nhan. Khi dugc chi djnh mo, co 3 benh nhan duac din Imi chua dugc 7 ngay, va da s6 da hon 7 ngay. Thai gian mo da so la tir 60-90 phiit cd 12 benh nhan, co 7 benh nhan m6 duoi 60 phiit, va chi 2 benh nhan keo dai horn 90 phiit. Hau phlu khong co benh nhan nao bj tran khi hoac tran dich mang ph6i. Co 12 benh nhan dugc rut din luu mang ph6i trong vong 24 gio sau m6 va 9 benh nhan dupe rut vao nghy thu hai sau mo.
Theo doi tai phat cd 5 benh nhSn dupe han 24 thang, 12 benh nhan duoc hem 1 nam, va 4 benh nhan chua dugc 12 thang, tdt ca d8u khong cd tran khi mang phoi tai phat.
Bdng I:
Nam Nir
So benh nhan 19
2 So lan tran khi lan dau hem 1lan 19 benh nhan
2 benh nhan Bdng 2: Tltdi gian ddt ddn lim mdng phdi
Dual 7 ngay 3 benh nhan
Hon 7 ngay 18 benh nhan Thoi gian mo Ducri 60 phiit
7 benh nhan
6 0 - 9 0 phiit 12 benh
nhan
han 90 phiit 2 benh nhan Hau phlu tran khi va tran dich tran khi mang ph6i
tran dich mang ph6i
0/21 0/21 rut dan Imi sau mo nit dan lim trong vong 24 gio
sau mo nit din luu ttong vong 24 - 48
gio sau m6
12/21 benh nhan 9/21 benh
nhan Theo doi tai phat tran khi tai phat sau 24 thang tai phat sau 12 thang tai phat duoi 12 thang
0/5 0/12 benh
nhan 0/4 benh
Hpi Nghi Phau Thuat Npi Soi BV, Nhan Dan Gia Dinh - Nam 2010 34
Y Hgc TP. H o Chi M i n h * T ? p 14 * P h u b a n cua So 4 * 2010 N g h i e n ctju Y hpc
BAN L U ^
Tran khi mang ph6i ty phat nguyen phat van con nhieu ban cai trong each xu tri^~"^*. Mot trong cac ban cai la each xir m' phlu thuat trong tnrcmg hop da cd chi dinh m6 do din luu mang phoi that bai. Hien nay, phan Ian huano din xir In deu nham den mo npi soi long ngyc cat bo ken khf bang stapler va Iam dinh mang ph6i bang cha xat la thanh de gay dinh hoac lot cat bo mang phoi thanh.
Chung toi chi khau ken khi dan thuan qua npi soi long nguc bang chi vicryl 2-0 va khong Iam dinh mang phoi vi thyc su khong thay nguyen nhan nao khac ngoai ken khf hoac chijm ken tim dupe a dinh (thay trong 100%
truang hpp).
Khi so sanh vai cac nghien cuu lam dinh bang cha la thanh hoac c5t bo la thanh, chting toi thay ket qua ciia chung toi nhu sau: ti le bien chung noi chung trong va sau mo la 0%. Khong CO do khf sau mo. Tliuang benh nhan chi cd ra chtit khi do duoi khf chua het trong luc dong ngyc va da s6 nit din luu ttong vong 24 gia sau m6 (12/21 tnrang hpp). Mot s6 ft hon (9/21) dupe nit vao ngay thu hai thuang do ngay le va cham tie trong dpc phim xquang phoi kiem tta ttuac khi riit. Kh6no co tran dich mang phoi sau mo dugc kiem tta bane xquang phoi va dich ra a binh din luu. Chua thay tdi phat tran khi khi theo doi lau nhit la 28 thang.
Khi so sanh voi cac nghien cthi khac Tac gia Gossot (2004) vai 185 benh nhan co bien chung ehung sau m6 la 8,1% (15/185). do khf keo dai c6 8 benh nhan (4.3*7c). hai benh nhan bi tran dich mang ph6i (1,1%), mpt benh nhan tu mau thanh ngyc ngoai mang phoi (0,5%). mot nhiem triing thanh ngyc (0,5%), mpt xep ph6i (0,5%). u ^ mau mang ph6i co 2 benh nhan (1,1%) va phai npi soi tra lai de cam mau; chua ke mgt benh nhan chay mau Iiic mo phai ma nguc. Thai gian a lai benh vien sau mo la tir 2 den 17 ngay (trung binh 5 ngay). Dan luu mang ph6i de 1 d^n 16 ngay (trung binh 3,8 ngay).
Theo doi tai phat tran khf chi dugc 111/185 benh nhan trong tnmg binh la 36,5 thang co 4 benh nhan tai phat tran khi (3,6%) nhung khong can
molai'^'.
Nghien cmi cua Chen (2004) cd 313 benh nhan dugc xii tri cat bo ken khi, cha dfnh la thanh va them lam dmh mang phoi bang minocycline.
Thai gian mo tnmg binh la 90,3 phiit Ti le bien chung chimg la 9,6% (30/313). Do khf keo dai ban 5 ngay la 22 benh nhan (7%) trong do mot benh nhan dupe mo lai ngay thii 10 de cat bo dinh phoi va lot bo mang phoi thanh a dinh phoi (apical pleurectomy), cac benh nhan con lai duoc
&eu tti bao t6n. Tran mau mang phoi sau mo 2 truang hgp (0,6%) trong do mpt phai ma ngyc nho lai de cam mau va trucmg hgp kia sau mo 10 ngay thi chi xu tri dan luu mang phoi. Bon benh nhan bj tran khf sau nit din luu (1,3%). Co 9 benh nhan tai phat tran khi (2,9%) trong dd 1 benh nhan tai phat Irong vong 6 thang), cac benh khac thoi gian tai phat tning binh la 13,3 thang.
Thai gian din luu mang ph6i sau mo la 4.2 ngay va Iim lai benh vien sau mo la 5,8 ngay"'^'^'.
Bao cao ciia Cardilo (2(XX)) cd 432 truong hpp. Ong khong lam cha diiih ma chi cat bo mang phoi thanh hoac lam dinh bang bpt talc.
Mpt truong hpp chay mau trong m6 do pham dgng mach hen suon 4 dupe d6t d m mau don cue (monopolar) npi soi. Co 2 trucmg hgp chuyen mo ho do xi khi khong xir tri dugc a cu6i cupc mo npi soi. Bien chung sau mo noi chung la 4,16% (18/432). B6n trucmg hpp tran khi dudi da. Nam ca ttan dich mang phoi khu tni thi b6n trucmg hop va 1 ca mau ty viing dinh xay ra a benh nhan cat bo mang phoi, ca tran dich con lai la a benh nhan lam dinh bang bpt talc; tat ca dugc xir tri chpe hiit mang phoi. Sau truang hgp do khi hon 5 ngay chi xii tn bao ton on. Mot truang hpp tran khi sau nit dan luu ciing het ty nhien. va 1 bi hgi chung Bernard-Homer thoang qua do d6t dien dan eye cac day dinh a dinh phoi. Thai gian nit dan lim sau mo la 5.4 ngay (tir 4-11 ngay). Thai gian nam vien sau mo trung binh la 6,1 ngay. Tai phat tran khi noi chung la 4,4% vtji thoi gian theo doi trung binh la 38 thang*''^.
Bien chung tran mau sau mo la bien chiing nang. So Ueu ciia chiing toi khong co va cac bao cao so sanh tren cung khong nhieu. Tuy nhien, theo tac gia Cardilo bien chiing chay mau mang
H p i N g h i P h a u T h u a t Npi Soi BV. N h a n D a n G i a D i n h - N a m 2010
Y Hpc TP. Ho Chi Minh * T a p 14 * Phti ban cua So 4 * 2010 N g h i e n ciiai Y hpc ph6i la 2—3% sau cha dmh va cd the den 10%
neu cat bo mang ph6i dugc Iam kem vdi khau ken khf npi soi*"".
Chiing toi theo doi benh nhan nhieu nhat chi 29 thang. Trong do, chi cd 5 benh nhan dugc theo hon 24 thang, 12 benh nhan sau 12 thang, va 4 benh nhan chua dupe 12 thang tW khong cd truang hgp tai phat so vtii 4,4% oia Cardilo (2.000) khong cd cha dfnh, ehi cat bo la thanh hoac lam dfnh bang bpt talc; 3,6% cua Gossot (2.004) va 2,9% Chen (2004) ca hai lac gia sau deu Iam eha dinh.
Do do, cd the thiy khau ken khf npi soi dan thuan trong tran khf mang phoi tu phat cd hieu qua nhat dinh va kh6ng gay bien chiing cho benh nhan. Chiing toi nghT khong can lam cha dinh vi gay bien chiing hau phlu vk thai gian m6 k6o dai khong can thiet, va that su cung thay da giai qu^et dugc nguyen nhan gay ttan khi la k6n khi thay dugc ttong Iiic mo a tat ca dc benh nhan.
Mpt dieu quan ttpng khac cd le la ky thuat khau k6n khf- Chung t6i diing chi vicryl 2-0 khau chii U neu day k6i nho lem, con neu rpng han thi khau mui Finney va liy vira vao mo phoi lanh.
Hpi Nghi P h l u T h u a t Npi Soi BV. Nhan D a n Gia D i n h - N a m 2010
Y Hpc TP. Ho Chi Minh * Tap 14 * Phu ban ciia So 4 * 2010 Nghien cmi Y hpc Bang 3: So sanh mo noi soi tran khi mang phdi tirptiot nguyen phd
Tac gia
Cardilo (2000) Gossot (2004) Chen (2004)
BVGia Dinh
Soca
432
185 313
21 Co ken
khf 78%
88%
95%
100%
Khau may
235
163 313(hoac
citdinh ph6i; + minocyclin
e) 0
Khau tay 104
0 0
21
Cha dinh
Cat la thanh hoac bpt talc 100%
100%
0
Do khi
1,4%
(>5 ngay) 4,3%
7%
0%
Tran mau, dich 1.16%
1,1%
0,6%
0%
Ngay nam vien 6
5 5.8
3 Sd thang
theo doi 38
36,5 39
1-29 Tai phat
(%)
4,4%
3,6%
2,9%
0%
KETLUAN
Khau ken khi dan thuan qua n6i soi nguc co \ai tto nhit dinh trong diSu trj ttan khi mang phdi ty phat. DSy la phuang phap dan gian, de thyc hien, cd hieu qua t6t va budc dau chua thay tai phat. Tuy nhien, do s6 lieu con it va thai gian theo ddi chua du lau, ein th6m dir lieu nijra de khang djnh manh me ban.
TAI LIEU THAM KHAO
1. Ayed AK, Al-Din HJ (2000). The results of thoracoscopic surgery for primary spontaneous pneumothorax. Chest; 118:235-8
2. Baumann MH. Strange C, HefftKr JE, et al (2001): Management of spontaneous pneumothorax.
An American College of Chest Physicians Delphi Consensus Statement. Chest; 119:590-^2 3. Cardillo G (2000): Videothoracoscopic treatment of primary spontaneous pneumothorax: a 6-
year experience. Aim Thorac Surg; 69:357-361.
4. Cardillo G. (2007) Long-term lung function following videothoracoscopic talc poudrage for primary spontaneous recurrent pneumothorax. European Journal of Cardio-thoracic Surgery 31:
802—805
5. Chan P, Clarke P, Daniel FJ, et al. (2001): Efficacy sttidy of video-assisted thoracoscopic sui^ery pleurodesis for spontaneous pneumothorax. Ann Thorac Surg;71:452-4
6. Chen JS, Hsu HH, Kuo SW, et al. (20O4) Effects of additional minocycline pleurodesis after thoracoscopic procedures for primary spontaneous pneumothorax. Chest; 125:50-5.
7. Gossot D, Galena D, Stem JB, et al. (2004): Results of tiioracoscopic pleural abrasion for primary spontaneous pneumothorax. Surg Endosc 2004; 18:466-71
8. loCiero lU J (1996), Glenn's thoracic and cardiovascular surgery. 2nd edition 1996; 540-543 9. Ng CSH, Lee TW, Wan S, Yim APC (2006). Video-assisted thoracic surgery in the management
ofspontaneouspneumotiiorax: the current status. Postgrad Med J;82:179-185
10. Sahn SA, Hefftier JE. Primary care; spontaneous pneumothorax. N Engl J Med: 2000; 342:868- 74
11. WeisbergD, Refaely Y (2000). Pneumothorax: experience with 1,199 patients. Chest;117:1279- 85
Hpi Nghi Phau Thuat Npi Soi BV. Nhan Dan Gia Dinh - Nam 2010
