BAI HQI HQI NGOAI KHOA VN LAN THCT XII VA HOI NGHj KHOA HOC NGOAI KHOA TOAN QUOC LAN THiJ XIV
KET QUA B a d e DAU PHAU THUAT NOI SOI CAT TRL/C TRANG THAP Vdi MIENG NO! DAI TRANG - HAU MON KHAU TAY QUA
DUdNG HAU MON CO BAO TON CO THAT TRONG UNG THl/TRliC TRANG THAP
Trhn Thien Hda, Dd Minh Hung, Nguyen Hai Dang, Van Tan (*)
T O M TAT
Muc di'ch: Oanh gia tinh kha thi va ket qua sdm cua phau thuat cat doan tri/c trang thap qua ndi soi cd bao tdn cP that vdi ky thuat cat gian cd that, noi dai trang - ong hau mon khau tay qua dudng hau mon, cat toan bd mac treo tru'c trang, bao tdn than kinh t i / ddng vimg chau cho ung thu'tri/c trang thap.
Ddi t&dng va ph&dng phap nghien c&u:
Nghien ciru hoi ciiu tren 28 benh nhan ung t h u tru'c trang thap 1/3 du'di khoang tir < 5cm each ria hau mon, khdng cd xam lan cd that va cd nang hau mon dUpc thUc hien ndi dai trang dng hau mon tir thang 09/2009 tdi thang 03/2011 tai Benh vien Binh Dan TPHCM.
Kit qua: Khdng cd tru'dng hdp nao t i i vong p h l u thuat. Tat ca cac tru'dng hPp cd bd cat an toan. Cac benh nhan deu cam thay it dau sau md, trung tien sdm. Ti le bien chu'ng sau sdm sau mo: 5/28 tru'dng hdp (17,9%), trong do cd 2 tru'dng hdp rd mieng ndi (7,1%), 1 tru'dng hdp (3,5%) nhiem trimg vet mo, 1 tru'dng hpp (3,6%) thoat vj vet md va 1 tru'dng hpp (3,6%) hep mieng noi sau 2 thang. Ve bien chii'ng mudn:
cd 4/28 tru'dng hpp tai phat tai cho (14,3%), 1 tru'dng hdp phat hien di can gan (3,6%) sau 2 nam. Ve chirc nang hau mon triic trang: cd 26/28 benh nhan (92,9%) sau md di cau tren 3 lan / ngay trong thang dau. Sau 6 thang ti le nay giam cdn 5 7 , 1 % (16/28).
(*) Benh vien Binh Dan - TP.H'6 Chi Minh
Kit luan: Phau thuat cat doan triTc trang thap qua ndi soi vdi mieng noi dai trang - ong hau mon khau tay qua dUdng hau mon vdi ky thuat cat gran cP that kha thi, cd ket qua tdt ve ung t h u hpc va bao tdn diTpc ong hau mon cho ung thu' trUc trang thap neu dupe lUa chpn diing chi dinh. Phau thuat cd Uu diem la tranh di/dc du'dng md bung de lay benh pham, benh nhan it dau sau md", phuc hoi nhanh, ngoai ra con that bao ton chu'c nang cP that. C3n cd thdi gian theo ddi lau dai va vdi sd lu'dng benh nhan Idn hdn de danh gia chinh xac hdn ve ket qua ciia phau thuat nay.
Tut khoa: ndi dai trang - ong hau mon, khau tay, phau thuat ndi soi, ung thU tri/c trang.
S U M M A R Y
THE PRIMARY RESULTS OF LAPAROSCOPE - ASSISTED TRANSANAL INTERSPHINCTERIC
RESECTION VtfnH HANDSEWN COLOANAL ANASTOMOSIS FOR LOW RECTAL CANCER Objectives: Jo evaluate the applicability and early resuits of laparoscope assisted anal sphincter - preserving operation with transanal intersphincteric resection, handsewn coloanal anastomosis, total mesorectal excision and preservation of the pelvic autonomic nerves for low rectal cancer.
Material and method: Retrospective study.
Bebween 09/2009 and 03/2011 at Binh Dan
NGOAI KHOA S6 DAC BIET 1, 2,3/2012 Hospital, we performed laparoscope - assisted
transanal intersphincteric resection for 28 patients with low rectal cancer about 5cm from anal verge, with no sphincter involvement.
Results: There was no surgical mortality. All of patients had safe margin. Patients felt less pain and had early bowel movement. Early complications were 17.9% (5/28 cases) include:
2 patients had anastomotic leak (7.1%), 1 patient had wound sepsis, 1 patient had incisional hernia and 1 patient had anastomotic stenosis 2 months later. Late complications: 4 cases (14.3%) had local relapse. There was 1 case with liver metastasis in 2 years follow-up (3.6%). In anorectal function: 26/28 patients (92.9%) defecated more than 3 times / day in 1 month follow-up. 6 months later, this rate decreased gradually to 5 7 . 1 % (16/28).
Conclusion: Laparoscope - assisted transanal intersphincteric resection with handsewn coloanal anastomosis for low rectal cancer is feasible and had showed the good results of oncology and preserves the anorectum if patients had been selected correctly. It prevents an abdominal incision for specimen extraction, so that patients have less pain, early recovery, otherwise it preserves sphincteric function. There will be a need for a larger scale study with longer follow- up time to further evaluate this procedure.
Key words: handsewn coloanal anastomosis, laparoscopic surgery, rectal cancer.
I. OAT VAN OE
Phau thuat chuSn didu trj ung thu true trang 1/3 gitra la cat toan bd mac treo true trang vdi bao tdn ca that hau mdn va than kinh ty dpng vimg chau. Tuy nhien, benh nhan bj ung thu true trang 1/3 dudi ludn phai chpn lua giiia ca hdi duac chiia lanh va nguy ca suy giam chat luong cupc sdng. Vdi nhthig benh nhan nay, phau thuat cat toan bd
true trang qua nga bung va tang sinh mdn (phau thuat Miles) da dugc chi dinh hem 100 nam nay, va sir nang ne ciia nd da gay ra nhieu rdi loan nieu - sinh due. Hon nira, nd ddi hdi mot ducmg md bung rdng va dua den nhimg bien chu:ng sau md nang nd nhu dau, nhiem triing vet md va tac ruot non. Benh nhan ludn bi am anh phai mang hau mdn nhan tao sudt ddi nen nhieu ngudi da tir chdi phau thuat.
Trong nhung nam gan day, phucmg phap cat gian ca that qua nga hau mdn da dupe ra ddi va timg budc trd tranh phuang phap dieu tri phau thuat tdi uu cho ung thu true trang thap, tranh dupe hau mdn nhan tao sudt ddi' " '' '. Phau thuat nay ra ddi dua tren ca sd nhirng hieu biet ve ung thu true trang:
xam lan xudng theo thanh true trang thucmg khdng vugt qua 1- 1,5cm, di can ra xung quanh vao trong mac treo true trang; va nhijng hieu biet ve giai phau va chuc nang ca that hau mdn: phan cao ciia ca that trong khdng ddng vai trd quan trpng trong ca che tu chu cua hau mdn [3,9]. Dii phau thuat ndi soi giiip lam giam cac bien chung va da dupe ap dung vao cat true trang [2,4,6], tuy nhien nd ddi hdi ky thuat phuc tap do phai thao tac trong viing khung chau hep, dac biet la d nam gidi [4]. Qua dd, chung tdi nghT rang mdt cupc phau thuat cd hieu qua cao va xam lan tdi thidu cd the dat dupe khi phdi hap 2 ky thuat cit gian ca that qua nga hau mdn va phau thuat ndi soi.
Muc dinh cua nghien cim nay la danh gia tinh kha thi va hieu qua cua phau thuat cat doan true trang thap qua ndi soi vcri mieng ndi dai trang - dng hau mdn khau tay qua dudng hau mdn, cd bao tdn ca that vdi ky thuat cat gian ca that.
DAI HOI HQI NGOAI KHOA VN LAN THCTXII VA HQI NGHI KHOA HOC NGOAI KHOA TOAN Q U ( 5 C L A N T H I J X I V II. DOI TUONG VA PHUONG PHAP NGHIEN COU
Doi tirpug nghien cihi: Tir 09/2009 den 03/2011, chiing tdi da tien hanh phau thuat cat doan true trang thap qua ndi soi vdi mieng ndi dai trang - dng hau mdn khau tay qua dudng hau mdn tren 28 benh nhan bi ung thu true trang thap tai benh vien Binh Dan.
Tat ca benh nhan deu duac danh gia bao gdm kham lam sang, ndi soi sinh thiet, sieu am long true hang qua nga hau mdn, CT Scan hoac MRI vimg chau trudc md; tinh trang trong khi md; kham lam sang va ket qua giai phSu benh sau md.
Phu'OTig phap nghien ciiu: Nghien cuu hdi cuu.
Tieu chuan chon benh: Benh nhan phai thoa tat ca cac dieu kien sau:
Dupe chan doan xac dinh ung thu true trang.
Khdi u each ria hau mdn < 5cm.
' Khdi u khdng cd xam lan ca that, ca nang hau mdn.
• Loai trir cac trudng hpp khdng ndi duac dai trang - dng hau mdn.
Phu-oTig phap phau thuat: Qua nga bung va nga hau mdn.
Nga bung duac thuc hien qua ndi soi.
Benh nhan nam tu the Trendenlenburg, dang 2 chan. Vao bung bang 4 trocars. That bd mach mac treo trang dudi tan gdc. Cat toan bp mac treo true trang va bao tdn thin kinh
ha vi. Giai phdng dai trang sigma, d^i trang trai va di ddng toan bd true trang din sang chau mire tliSp nhit cd thd duoc (qua ca nang hau mdn va thay co that hau mdn).
Nga hau mdn: cat gian co that trong toan bd hay mdt phan, sau do theo mat phang nay di Ien cho den khi gap mat phang phau tich nga bung. Keo true trang mang u qua nga hau mdn, cat doan nipt mang u, mat cat each khdi u it nhat 2 cm, ndi dai trang dng hau mdn tan - tan 2 Idp bang tay. Trong trudng hop II Idn hon dudng kinh dng hau mdn khdng the lay u qua nga hau mdn, md dudng md nhd lay u qua nga bung. Khdng md hdi trang ra da ma dat dan luu ra tang sinh mdn trong tat ca cac trudng hpp.
III. KET Q U A
Dac diem benh nhan va tinh chat u Trong thdi gian tir thang 09/2009 d^n thang 03/2011, chung tdi da thuc hien dupe phau thuat cat doan true trang th4p qua ngi soi vdi mieng ndi dai trang - dng hau mdn khau tay qua dudng hau mdn cho 28 benh nhan. trong dd cd 15 nam (53,6%) va 13 nii (46,4%), tudi trung binh la 56,39 ± 11,09 tudi, thap nhat la 37 tudi, cao nhat la 80 tudi.
Tat ca cac trudng hpfp deu la u trirc trang thSp 1/3 dudi. Giai phau benh: 100% la carcinome tuyen true trang.
T SoBN
Tl 0
T2 6
T3 17
T4 5
Thdng so cuoc mo
Thdi gian md trung binh la 226 ± 76 phiit. Khdng cd trucmg hap phai chuydn sang md md. Cd 5 trudng hpp khdng thd liy u qua nga hau mdn do u qua to, phai md dudng md nhd lay u qua nga bung. Luang mau mIt khdng dang ke (khdng cd benh nhan nao phai
truyen mau). Khdng cd trucmg hop nao tii vong phau thuat. Ket qua xet nghiem vi th^
dudng cat dudi u khdng ed le bao ung thu a tat ca cac trudng hpp. Cac benh nhan ddu cam thay it dau sau md, trung tien cd sdm, khoang nea_\ thu 1 - 2 sau md. Thai gian nam vien trung binh la 16,68 ± 3,49 ngay.
NGO*l KHOA S6 B4C BI|T 1,2,3/2012 3 som sau mo
Ro mienq noi Nhiem trljnq vet mo Thoat VI vet mo Hep mienq noi
S6BN 2 1 1 1
Tyle 7,1%
3,6%
3,6%
3,6%
Ve bien chung muon
Tai phat tai cho Di can xa
SoBN 4 1
Tyle 14,3%
3,6%
Ve chii'c nang s hau mon true trang So lan di cau / ngay
< 3
> 3
1thang 2 (7,1%) 26 (92,9%)
6 thang 12 (42,9%) 16(57,1%)
IV. BAN LUJEiN Ve chi dinh phau thuat
Kdt qua cho thay tudi trung binh cua b?nh nhan cao, phii hpp vdi dich te hpc ciia ung thu true trang, tudi cang cao ti le mac ung thu tr\rc trang cang cao. Dieu nay din dSn nguy co phau thu|it cao vi benh nhan cao tudi thudng cd cac benh ly kem theo nhu tim mach, hd hip va cac benh ly man tinh khac.
Qua dd cang thi hien rd dupe uu thd cua ky thuat nay (md ndi soi) so vdi md md hay phau thuat Miles.
Y6u td quan trpng di chi dinh phlu thuat bao tdn co thit la khoang each tir bd dudi u den mep hau mdn la 2cm thi an toan, cac u each bd h?u mdn <2cm chiing tdi da lam phau thuat Miles. Ydu td thu hai la muc xam lin u >T3 se cIn khoang each xa hon 4-5cm ndu khong se tai phat mieng ndi sau md.
Chung tdi nhan thay da sd benh nhan den diiu tn d giai doan mudn (79% d T3, T4), dan din nguy co tai phat va ti le sdng cdn ciia benh nhan giam thIp. Theo nghien ciiu ciia Nguyen Minh Hai [7], benh nhan d giai doan
T3, T4 dupe hda xa trudc md cd the lam giam giai doan ung thu va giiip tang kha nang thanh cdng cua phau thuat. Trong nghien ciru cua chimg tdi khdng cd trudng hop nao dupe hda xa tri trudc md do nhiing hieu biet ve ung thu va ky thuat hda xa tri trudc md cdn han che. Trong tuong lai, chiing tdi by vong nhimg tien bd ve ung thu hpc cung nhu hda xa tri trudc md se lam tang hieu qua cua phau thuat nay.
Ben canh dd, cac u d giai doan T4 thudng qua to dan den nguy co phai md dudng md bung nhd de lay u do qua to khdng thi liy qua dudng hau mdn dupe. Do do lam mat di nhthig uu diem ciia mdt cupc phau thuat ndi soi so vdi md md. Trong nghien ciru cua chiing tdi cd 5 trudng hap u d T4 phai liy qua dudng md bung. Do dd chiing tdi khdng khuyin khich thuc hien phau thuat nay tren benh nhan cd u qua to hoac d giai doan T4.
Ve ket qua sdm cua phau thuat Trudc day, diiu tri ung thu true trang thIp mdt phin ba dudi ddng nghia vdi phSu
DAI HQI HOl NGOAI KHOA VN LAN T H U X I I VA HQI NGHj KHOA HOC NGOAI KHOA TOAN Q U 6 C L A N THCf XIV
thuat Miles. Tuy nhien, vdi su tien bd ve ung thu hpc, sang chau hpc [3,10] cho phep thuc hien phlu thuat cat doan dai true trang. bao tdn CO that ma vin dam bao an toan ve mat ung thu hpc d nhirng benh nhan nay nham 2 muc tieu quan trpng: khdi benh va cai thien chit luong cupc sdng sau md, ma chii yeu la duy tri chiic nang hau mdn true trang. Ndi dai trang dng hau mdn thudng di kem tinh trang suy giam chiic nang hau mdn true trang, tuy nhien benh nhan van de dang chap nhan ban la hau mdn nhan tao vTnh vien. l/u diim ciia phlu thuat nay la phdi hop thi giai phdng true trang qua ndi soi va cat gian ca that qua nga hau mdn, nhat la d benh nhan cd khung chau hep va dai. Cat gian ca that qua nga hau mdn ciing phai dam bao dien cat each u it nhit 2cm [9,3,10]. Trong 28 trudng hpp ciia chiing tdi khdng cd trudng hpp nao cdn sdt ti bao u thu. Mieng ndi khau bang tay ciing giup lam giam chi phi. Phau thuat qua ndi soi va keo benh pham qua nga hau mdn nen benh nhan rat it dau, tranh dupe dudng md bung, phuc hdi nhanh cQng la xu hudng hien nay ciia phau thuat qua nga tu nhien tren thi gidi*^-^'^*.
Qua mdt nghien cim da trung tam vdi 612 benh nhan (da sd md hd) cho thSy ty le tir vong chung la 1,6%, rd mieng ndi la 10,5%, hep mieng ndi 5,8% [11]. Tai Viet Nam ciing da cd mot sd bao ve ky thuat nay vdi kit qua thu dupe budc dau rat kha quan [2,5,7]. Trong nghien cdu ciia chiing toi khdng cd benh nhan tir vong phau thuat, cd 2/28 trudng hop (7,1%) rd mieng ndi qua Id din luu tang sinh mdn, 2 trudng hpp nay sau do dupe dieu tri ndi khoa, tu lanh, khdng can phai md lai, 1 trudng hop (3,6%) nhiem triing vet md dupe dieu tri ndi khoa dn, 1 trudng hpp (3,6%) hep mieng ndi 2 thang sau phau thuat can phai nong hau mdn trong 4
thang d giai doan hda tri va 1 trudng hpp (3,6%) thoat vi hdi trang qua Id trocart ben phai gay hoai tu hoi trang d ngay thir 8 hau phau, benh nhan dupe md md lai de ddng lo thoat vi, cat doan hdi trang ndi tan - tan.
Chiing tdi nhSn thiy kit qua ban dau chap nhan dupe, tuy nhien can phai cd cd mau Idn ban de cd the danh gia chinh xac hon.
Ve ket qua ngan han cua phau thuat Theo Tilney H.S va CS qua 21 nghien cuu tir 13 trung tam tren the gidi tren 612 benh nhan cho thay ty le tai phat tai chd la 9,5%, ty le sdng them 5 nam sau md 1^ tren 81,5% [11] va mot sd nghien cuu khac [1,7,8,12] cho thay hieu qua tdt cua phau thuat ve mat ung thu hpc. Ket qua ngan han cua chung tdi cho thay cd 4 trudng hop tai phat tai chd, trong dd cd 1 trudng hpp dupe md ndi lai dai trang - dng hau mdn thanh cdng, I trudng hop phai lam phau thuat Miles, 1 trudng hgp di can d bung gay tac ruot chi cd the lam hau mdn nhan tao vTnh vien va 1 trudng hop tir chdi phlu thuat lai.
Cd 1 trudng hop phat hien di can gan sau 2 nam, Trong qua trinh theo doi chua ed benh nhan nao tir vong.
Ve chirc nang hau mon trirc trang Ndi dai trang dng hau mdn thudng di kem tinh trang suy giam chiic nang hau mdn true trang, tuy nhien benh nhan van de dang chap nhan han la hau mdn nhan tao vinh vien. Cd nhieu nghien cim trong va ngoai nude cho thay chiic nang hau mdn suy giam nhieu sau md va hdi phuc dan theo thdi gian [5,7,8,12]. Mot sd nghien cuu cho thiy ndi dai trang - dng hau mdn kieu tiii J cd the cai thien chiic nang di tieu hon kieu ndi tan - tan thdng thudng [1,8,12]. Trong nghien ciiu ciia chiing tdi, benh nhan sau md dupe tai kham theo ddi moi thang trong vong 6 thang dlu.
Do khdng cd dly du phuang tien nhu may do
NGOAI KHOA SO D A C BIET 1, 2, 3/2012 ap luc hau mdn, chiing tdi chi cd the danh gia
so lupc ve chirc nang hau mdn qua sd lan di cau mdi ngay va cam giac hai Idng ciia benh nhan qua hdi benh. Ket qua cho thay cd 26/28 benh nhan (92,9%) sau md di clu tren 3 lan / ngay trong thang dau va sau 6 thang ti le nay giam cdn 57,1% (16/28). Day la ket qua ban dau tam chap nhan dupe, tuong tu ket qua nghien ciru ciia Nguyen Hoang Bac[5]. Trong tuong lai, chung tdi se xem xet ky thuat J-pouch de cai thien chiic nang hau mdn.
V. KET LUAN
Qua nhiing ket qua ban dau, chiing tdi nhan thay phau thuat cat doan true trang thap qua ndi soi vdi mieng ndi dai trang - dng hau mdn khau tay la mdt phau thuat kha thi va cho ket qua tdt ve mat chirc nang hau mdn va ung thu hpc neu dupe chi dinh thich hop.
Day la mdt lira chpn cho nhung trudng hop ung thu true trang thap. Can tiep tuc nghien ciiu ket qua lau dai ve ung thu hpc.
TAI LIEU THAM KHAO.
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2. Hoang IVIanh An, Nguyen Trong Hoe (2005). Mpt sd kit qua phau thu^t cit true trang bao ton ca that. Ngoai khoa sd 4:14-19.
3. IMartel, Nguyen Xuan Hung, Gallot D (2003). Cat true trang bao tdn - Dau la gidi han? Ngo^i khoa - sd 3: 1 - 8 .
4. Merino M, Parini U, Giraudo G et al (2003). Laparoscopic total mesorectal excision. A consecutive series of 100 patients. Ann Surg 237: 335 - 342 5. Nguyen Hoang Bac, Nguyen Hfru Thinh
(2009). Ket qua budc dau phau thuat cat gian CO that diiu tri ung thu true trang thIp. Y Hpc TP. Ho Chi Minh *Vol. 13 Supplement of No 1 : 2 9 - 3 1 .
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7. Nguyen Minh Hai, Vo Tan Long, Lam Viet Trung, T r i n Vu ©irc (2010). Danh gia ket qua sdm ciia phau thuat cat doan true trang thap qua ndi soi vdi mieng noi dai trang - hau mdn khau tay qua dudng hau mdn co bao ton ca that trong ung thu true trang thap.
Ngoai khoa so dat biet 4-5-6: 119-125.
8. Prete F, Prete F.P, De Luca R, Nitti P, Sammarco D, Preziosa G (2007).
Restorative proctectomy with colon pouch- anal anastomosis by laparoscopic transanal pull-through: an avaiable option for low rectal cancer? Epub 2006 Oct 23, Surg EndoscJan;21(]):9] - 9 6 .
9. Rothenbcrger DA, Ricciardi R, Madoff RD (2010). Procedures for rectal cancer.
ACS Surgery: Principles and Practice.
10. Rullier E, Laurent C, Bretagnol F, Rullier A, Vendrely V and Zerbib F (2005).
Sphincter-saving resection for all rectal carcinomas. The end of the 2-cm distal rule.
Annals of Surgery 241 (3): 465-469.
11. Tilney H.S, Tekkis P.P (2007). Extending the horizons of restorative rectal surgery:
intersphincter resection for low rectal cancer.
Colorectal disease 10: 3 - 16
12. Uchikoshi F, Nishida T, Ueshlma S, Nakahara M, Matsuda H (2006).
Laparoscope assisted anal sphincter- preserving operation preceded by transanal procedure. Tech Coloprocto!, Epub 2006 Mar 1510, discussion 9.(1): 5 - 9 .
