VI$T NAM T H A N G 7 - SO' 1/2011
HIEU QUA DAT STENT CHO BENH
NHANUNG THl/THUC QUAN KHONG CON CHI D|NH
PHAUTHUAT
Vu Vdn Khien*, Trjnh Xuan Hung* va cs T 6 M TAT
Nghien culi 10 benh nhan ung thu' thyc quan du'dc d3t Stent thyc quan qua npi soi tii' 09/2009 den 09/2010 cho thay: Tudi trung binh: 63,7, nam gSp nhieu hdn nff. Trieu chutig nudt nghen khi Sn la trieu chiJtig dien hinh (100%). Tdn thu'dng tren npi soi: 1/3 glu^ (60%), 1/3 dUdi 40%. Tren chup cSt Idp vi tfnh:
Da CO xam lan ra xung quanh (100%). Hieu qua dieu tri: Dat Stent thyc quan thanh cdng: 11/11 (100%).
Sau 03 thang co 1 benh nhan ty vong do ung thu" di can sang phdi, gay suy hd hap va suy klet neing.
ABSTRACT
EFFECT ON STENT INSERT FOR PANTIENTS WITH ESOPHAGEAL CANCER WHO CAN NOT HAVE SUGERY
Study on 10 patients with esophageal cancer lnsert:ed with stent through endoscopy from September 2009 to September 2010 has shown: average age: 63.7, men are more vulnerable to this disease than women.
Unable to swallow Is a significant symptom (100%).
Lesions on endoscopy: 1/3 in the middle (60%) and 1/3 under (40%). On computerized tomography: there are signs of invasion. Treatment effects: successfully insert esophageal stent: 11/11 (100%). After 03 month one patent was dead because of lung cancer, leading to respiratory Allure and serious loss weith.
I.
OAT VAN OEUng thy thyc quan (UTTQ) la mdt benh chi chiem khoang 2% tdng sd cac loai ung thU [1], [5], nhuhg ngay cang cd khuynh hydng gia tang va nhCng nam gan day da cd nhutig bao cao cho biet: UTTQ cd ndi tang tdi 13% [5J. Chan doan UTTQ khdng khd, nhutig da sd van chan doan mudn va cho tdi nay chan doan sdm mdi chi dat difdi 10%. Do phan Idn cac benh nhan khi din vien deu d giai doan mudn, viec dieu trj gap rat nhieu khd khSn, thdi gian sdng trung binh ngSn (khoang 18 thang) va ti le sdng sau 5 nSm chi khoang 7% [5]. Muon cai thien thdi gian sdng va tien lydng bdnh can phai phat hien
benh sdm, khi ma khdi u d thUe quan mdi hinh thanh. Vdi nhu'ng benh nhan cap tudi, khdi u da tp, da ed di can xung quanh thi phau thuat thydng rat han che va hau phiu eye ky phu'c tap. Ngay nay, vdi sy phat trien khdng ngu'ng eda ky thuat ndi soi can thiep, da cho phep dat Stent thyc quan cho benh nhan UTTQ khdng cdn chi djnh phau thuat va ky thuat nay da mang lai tfnh yu viet, dyde nhieu nyde tren the gidi sit dung. Chung tdi da utig dung ky thuat nay tif 09/2009 va de tai nghien culJ nay nham muc dfch: Nghien cu'u ve dae diem lam sang, hinh anh noi soi, hieu qua dat Stent thu'c quan va thdi gian sdng ciia t)enh nhan UTTQ sau dieu trj
II. o 6 l TU0NG • PHUONG PHAP
1. Odi tUdng: 10 benh nhan UTTQ da dyde ndi SPI va xae djnh tren md benh hpc la ung thy thyc quan, khdng cdn ehi dinh phau thuat va dyde dya vao trong nghien culJ nay. Benh nhan nam dieu tri ndi trd tai khoa Ndi tieu hda - Benh vien TU'QD 108 tu' 09/2009 den 09/2010 va chap nhan dat Stent thye quan qua ndi soi
2. PhUdng phap.
* Tat ca benh nhan d\idc kham lam sang, can lam sang diy du va ghi chep theo mdt mau nghien cuTu cu the. Nghien culi: Md ta va theo ddi dpc tif khi chan doan, dat Stent va cho den khi benh nhan tu' vong
* Ndi spi va dat Stent thye quan: Su' dung may ndi soi EVIS 180 (hieu Olympus - Nhat Ban). Dung cu Stent HANORO-STENT eua hang Hano-Han Qude. Thyc hien dat Stent tai phcng Can thiep mach - Benh vien Tl/QO 108
* f a t ca benh nhan trydc khi dat Stent thyc quan deu dyde chup cat Idp vi tfnh Idng ngye de danh gia vj trf, hinh dang, chieu dai va muTe dp xam lan khdi u thye quan ra xung quanh.
* Cae thdng sd can thee ddi: Dae diem lam sang, hinh anh ndi soi, hieu qua dat Stent, cac yeu td lien quan den ky thuat, cac bien chuYig sau dat Stent, thdi gian sdng sau dieu trj...
Khoa N6I tieu hoa - B$nh vi$n Tl/QD 108
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Y HQC VlgT NAM THANG 7 - SO 2/2011
III.
KIT QUABang 1 . Dae diem lam sang va can lam sang UTTQ
Dae diem n (%) 0 | c diem n ( % )
Tuoi trung binh 63,7 (47-87) Ty le: Nam/niy 9/1
Nudt nghen vdi chat dae 10/10 Sut can nhanh 8/10
Nudt nghen vdi chat long 9/10 Da xanh 2/10
Dau nhe sau xu'dng ^c 8/10 Di ngoai phan den 1/10
Noi khan Thieu mau nhe (HST < 120 g/l) 2/10
Nhan xet: Nam gidi bj UTTQ nhieu hdn nu'. Bieu hien lam sang eua UTTQ rat dien hinh: Nuot nghen khi an thu'c an (100%) va gay sut can nhanh (80%)
Bang 2. Hinh anh UTTQ tren ndi soi va chup CLVT
Dae diem n (%) Dae diem tren CT n ( % )
1/3 tren thyc quan Xam lan tai thanh thyc quan 8/10
1/3 qvjta thyc quan 6/10 (60) Xam lan tai thyc quan + hach 1/10 1/3 du'di thyc quan 4/10 (40%) Co di c§n sang phoi 1/10 Nhan xet: Nam gidi bi UTTQ nhieu hdn nff. Bieu hien lam sang eua UTTQ rat dien hinh: Nuot nghen khi an thu'c an (100%) va gay sut can nhanh (80°/o).'
Bang 3. Ket qua dat Stent thyc quan va cac bien chu'ng sau thu thuat
Hi|u qua dat Stent n (%) Cac bien chihig sau dat Stent n (%)
Dau nhe vung ngyc 10/10
Dat Stent thanh cong 10/10 Cam giac kho thd 1/10
Khong thanh cong Sdt 1/10
Ho khan
Nhan xet: Tat ca benh nhan deu dat Stent thanh cong (100%). Dau nhe vung ngye bung a mdt trong nhu'ng bien chu'ng hay gap nhat eua benh nhan UTTQ sau dat Stent.
Bang 4. Hieu qua lau dai sau dat Stent 3 thang
Npi soi sau 3 thang n C%)
Stent van lull thong tdt 9/10
Di can sang tang khac 2/10
Ty l | td* vong sau 3 thang 1/10
Nh$nxet: Sau 3 tliang Stent thyc quan van luU thdng: 9/10. Cd 1/10 benh nhan (10%) bj tu' vong do di c3n sang, suy kiet va khdi u gay tac Stent
Hinh anh npi soi tntdc Ichi can thiep dat Stent
Hinh anh Sten thu'c quan Kit qua sau Ichi dat
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Y HQC VlgT NAM T H A N G 7 • S g 1/2011 IV. BAN LUAN
1 . D | c diem lam sang, hinh anh noi soi yh ket qua chup CT.
* Ve tuoi va gidi m i c UTTQ:
Trong nghien cu'u cua chung tdi (bang 1) sd benh nhan mTQ ed tudi trung binh la 63, trong dd tudi thap nhat la 47 va tudi cao nhat la 87.
Chl cd 01 benh nhan nff mac UTTQ. Tuy nhien, do sd lydng benh nhan nghien eulJ cua chung tdi eon qua ft, vi vay chung tdi khdng the so sanh vdi cae nghien culi khac. Chung tdi chi dya ra cae thdng ke cua cae tae gia khae de hieu sau hdn ve tudi va gidi cua benh nhan UTTQ.
Nguyen Khac Tan va es (3) nghien cu'u d 71 benh nhan UTTQ cho biet: Tudi mIc trung binh cda benh nhan UTTQ IS: 56,6 ± 12,4, trong dd:
Tudi hay gSp nhat trong UTTQ 1^ tudi trung nien (50-59) chidm \^ le 33,8%, tidp den tudi (40-49) chidm t^ Id: 25,4%. Ty le nam/nff 12,6. Nhy vay, phan Idn UTTQ deu gap d tudi trung nien va nam gidi chiem yu the. c i c ket qua nghien cu'u nay cung phu hdp nghien cu'u eua Pham Du'c Huan (1) tai benh vien Viet Du'c.
* Ve lam sang mac UTTQ:
Cac trieu chuYig ed nang ve UTTQ giai doan mudn thydng bieu hien rd rang va cijng song hanh vdi cac trieu chu'ng thye the. Trong bang 2 cho thay tuyet dai da sd (10/10) benh nhan da cc nudt nghen khi an ca chat Idng, chat dae. Benh nhan da bj nudt nghen ca chat Idng thi chuhg td rang khdi u da to, gay bft hep Idng thyc quan va dieu dd the hien giai doan mudn cua benh.
Nghien culi eua Nguyen Khae Tan (3) chp biet: 69/71 UTTQ cd tridu chdng nudt nghen va dyde chia thanh: nudt nghen vdi chdt rIn (18,8%), ch^t dae (53,6%) va chdt Idng (27,5%)
Tridu chOmg thCt 2 hay gdp trong nghidn ciJTU cCia chdng tdi la: Sdt can, cac bdnh nhan UTTQ thirdng cd sdt can d cac mCrc dd khac nhau chidm t^ Id: 90 % (bang 3.6). Nguyen nhan gay sut can ill do benh nhan khdng dn duoc, din ddn tinh trang thieu dinh dirdng, suy kiet. Nghien cdu cda Pham 0(Jc Hudn (1) tren 84 bdnh nhan thi trieu ch(fng co nang cda UTTQ gap nhieu nhdt la:
Nudt nghen (100%), Sdt can (92,9%), dau ngUc (47,6%), mdt mdi (73,8%). Nghien c(tu ciia Nguygn Thj Xuan Huong (2) d 34 bdnh nhan thi tridu chdng co nSng hay gap la nudt nghen 97,1%, sdt can la 97,1%, dau ngUc la 47,1%.
Nghidn cClu ciia chdng tdi gap 01 bdnh nhan di ngoai phdn den. Trong nghidn cdu cda Pham Ode Hudn da gap 4 bdnh nhan chidm t^ Id 4,8%.
2. Hinh anh UTTQ tren npi soi va chup cat Idp vi tinh (CLVT)
* Tren noi soi: Thdng qua ndi soi khdng chi cho biet duoc hinh anh cda tdn thuong, ddng thdi cdn cho bidt vj tri cda tdn thuong. Nhan biet va midu ta vj tri UTTQ ddng vai trd quan trpng va gidp chp BPC sy cd chien luoc dieu trj cu thd.
Bang 2. cho biet: ed 40% UTTQ 1/3 dyd'i va 60%
UTTQ 1/3 giu'a. Chung tdi ehi cd 01 benh nhan ed khdi u nam trong ranh gidi giij'a 1/3 tren vdi 1/3 dydi. Nghien cu'u cda Nguyen Khac Tan cho bidt: UTTQ 1/3 giuTa chiem t^ le cao nhat:
54,9%, tiep den 1/3 dudi (31%) va 1/3 tr§n (14,1%). Nghign cCifu cda Pham Oufc Hudn va cdng su (1) tuong dng nhu sau: (56%, 39,2%, 4,2%). bdi vdi UTTQ 1/3 tren khi dat Stent thi khd khan hdn, vi nd lien quan den vung thanh khf quan va ddng mach chd ngyc.
Cac nghien ctru khac chua difdc thdng nha't ve yeu td tien luong vj tri cda UTTQ. Nghien cifu cda Akiyama va cdng sy [4]. thay r i n g : t^ Id sdng 5 nam cda UTTQ tren la 30%, cda 1/3 giSa la 38,7% va 1/3 dUdi chl cd 27,6%. Nhung ngupc lai, Richelme lai thdy ring UTTQ 1/3 dudi cd tidn luong tdt hon, khdng cd trUdng hdp UTTQ 1/3 tren nao sdng 5 nSm, trong khi dd t9 le sdng 5 nam cda UTTQ 1/3 giOfa la 19,1% va cda 1/3 dudi la: 21,2% (v6l p = 0,05). [6].
* Chup CLVT: Nham de danh gia mu'c dp xam lan eda u tai thye quan, cQng nhy xam lan ra eac td ehu'c xung quanh: trung that va dae biet la ddng mach ehd. Bang 2 chp thay 9/10 benh nhan UTTQ ed xam lan ra td ehu'c xung quanh va cd 01 benh nhan da cc di can phdi.
Trpng nghien cu'u cua Nguyen Khac Tan (3) thi phan Idn benh nhan cd phau thuat, nen mu'c dp xam lan eda UTTQ ra xung quanh khdng nhieu, vdi ket qua cu the: Xam lan tai thyc quan (56,3%), xam Idn ra td chCfc xung quanh Ip (22,6%), cd hach di can (5,5%), di can sang cd quan khac: (5,6%).
3. Hieu qua dat Stent va cac bien chu'ng sau dieu t r j .
Vdi mdt benh nhan UTTQ ed ehi djnh dat stent thi can phai chuan bj that ky, dae biet phai chup eat Idp vi tinh Icng ngyc de biet: Vj trf u, kfch thyde u, mu'c dp xam lan va cae tang xung quanh... Khi cac thdng tin da day dd thi viec dSt Stent thyc quan qua ndi SPI se khdng khd khSn va cd bdnh nhan chung tdi ehl tien hanh xong tryde 15 phut (khdng ke thdi gian gay me).
Trong bang 3 cho biet 10/10 (100%) benh nhan
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Y HQC VigT NAM THANG 7 • s6 2/2011 da 6\tdc dat Stent thyc quan thanh cdng. Tuy
nhien, do sd lydng benh nhan nghien eulJ cua ehdng tdi cdn qua ft, vi vay de khach quan can nghien cu'u tren sd lydng Idn hdn.
Vi ky thuat khdng phu'c tap, do vay cae bien chu'ng sau dat Stent cdng khdng cd gi dae biet.
Trong nghien cu'u eua chdng tdi trinh bay tai bang 3 cho biet: 10/10 (100%) benh nhan cd dau nhe vung ngyc va cd 1/10 benh nhan cd earn giac chen khd thd nhe. Tuy nhien, cae trieu chu'ng nay thi het di sau 1-2 ngay, sau khi da dung thude giam dau. Nguyen nhan gay dau vung ngye la do Stent dat trong Idng thyc quan se gian nd dan ra theo theo thdi gian va se gian het tdi da sau 24 gid dat Stent. Do vay, sau thd thuat chung tdi phai truyen djeh nudi dudng, dung thude giam dau va su' dung khang sinh phdng bdi nhilm trong qua trinh thyc hien thu thuat...
4. Hieu qua lau dai va t y le tu* vong.
Trong nghien cu'u eua chung tdi thi tat ca benh nhan sau dat Stent 01 thang va 03 thang deu phai ndi soi lai de danh gia mu'c dp iyu thdng cua Stent. Bang 4 da cho biet sd benh nhan cd Stent thyc quan van iyu thdng tdt chiem 9/10 (90%). Cd 01 benh nhan Stent bj ban t i e 1 phan va dl can sang phdi, suy kiet cd the va cudi cung benh nhan bj tu' vong do suy hd hap (dl can vao phdi). Nhy vay, vdi ket qua nay da cho thay hieu qua dieu trj bang Stent cd hieu qua tdt, giup cho benh nhan van an udng tdt, tranh dyde cac bien chu'ng suy dinh du8ng do UTTTQ.
Tuy nhien, chung tdi cQng thifa nhan rang dat Stent thyc quan cho benh nhan UTTQ ehi la bien phap dieu trj tam thdi, de giup cho benh nhan cd the an theo dydng t y nhien. Ngay nay, cac Stent thye quan da dyde cai tien rat nhieu va cac Stent hien nay deu dyde phu ngoai bang Idp Silicon (khdng nhiem tif). Do vay, tai eac nydc tien tien thydng ket hdp giu'a dat Stent phdi hdp vdi dieu tri hda chat lioac/va dieu trj bang tia xa....va lieu phap ket hdp nay da lam giam dang
ke kfch thyde khdi u, keo dai thdi gian sdng eua benh nhan- Mdt muc tieu ma Thay thude va benh nhan deu mong ddi. Ky thuat dSt Stent khdng phu'c tap, hau phau ddn gian va dae bjet hOli leh cho nhQ'ng benh nhan cao tudi, khdng cdn chl djnh phau thuat.
V. KET LUAN
Nghien culi 10 benh nhan UTTQ dat Stent thye quan cho thay: Tudi trung binh: 63,7, nam gap nhieu hdn nff. Trieu chu'ng nudt nghen khi an la trieu chu'ng dien hinh (100%). Tdn thydng tren ndi soi: 1/3 givta (60%), 1/3 dydi 40%. Tren chup CLVT: Da cd xam lan ra xung quanh (100%). Hieu qua dat thanh cdng 100%. Sau 03 thang ed 1 benh nhan td' vong do ung thy di can sang phdi, gay suy hd hap va suy kiet nang.
T A I LIEU THAM K H A O
1. Pham Dure Huan (2003). Nghien cdli dieu tri phau thuat ung thu' thyc quan ngyc. Luan an
Tlin sy Yhoc - Ha noi
2. Nguyin Tlij Xuan HUdng (1999). Nghien cuU hinh anh sieu am ndi soi trong chan doan ung thy thyc quan. Luan an thacsy Ykhoa - Ha Ngl 3. Nguyen Khic Tan (2007). D3c diem lam sang,
hinh anh npi soi, md benh hpc va hieu qua dieu tri ung thu' thyc quan. Luan an thacsy Ykhoa - Ha Ngl
4. Akiyama H, Tsurumaru M, Watanabe G, One Y, Udagawa H, Suzuici M (1984):
"Development of surgery for carcinoma of the esophagus", Am.J.Surg, 147, pp. 9 -16
5. Amer American Cancer Society (2007):
"Cancer Facts and Figures 2007", Atlanta, Ga:
American Cancer Sodety, 2007, Also available online. Last accessed July 24, 2007
6. Tabech A Z, Topart P, Vandenbroucke F, Miossec A, Lozac'h P (1997): "Cancer epidermoide T3 de I'oesophage par I'exerese chirurgie exclusive et analyse des facteurs pronostlques':; J. Chir, 134 (9 -10), p. 362 - 367
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