Y HQC VlgT NAM THAHG 6 - S 6 2/2013
KET QUA PHAU THUAT LAY U TOI DA TRONG DIEU TR| UNG THlT BUONG TRONG GIAI DOAN MUON TAI BENH VIEN K
T 6 M T A T :
Dat van de: Di'eu trj ung thU bu'ong trirng gtai doan mupn can thiet phai lay u toi da va ket hop vdi dieu tn hoa chat. Trong do kich thu'dc u con lai sau phau thuat dUdc coi la yeu to tien lu'dng quan trpng nhat, lien quan den ket qua dieu trj. Ket qua phau thuat phu thupc rat nhieu vao kinh nghiem ciia phau thuat vien, ekip phau thuat. Muc tieu nghien ciTu:
Danh gia ket qua phau thuat lay u toi da trong dieu tn ung thu buong triTng giai doan muon. Doi tu'dng nghien ciru; 342 benh nhan UTBT giai doan I I - IV dieu trj tai benh vien K tiT thang 1 n l m 2011 den thang 12 nam 2012. PhUdng phap nghien ciTu: Mo ta hoi ciru. Ket qua: sau mo u < 1cm: 62,5%BN; u
<2cm: 20,46%BN; u > 2cm: 16,95%BN. Tai bien trong mo: 2,92%BN. Bien chirng sau md: 6,43%BN.
BN nang xin ve 1,8 %BN.
SUMMARY:
TREATMENT RESULTS OF ADVANCED OVARIAN CANCER BY CYTOREDUCTIVE SURGERY
IN K HOSPITAL
Background: treatment of ovarian cancer later stage is needed to get tumor maximum and be combined with chemotherapy. In the residual tumor size after surgery are considered as the most important prognostic factor most related to treatment outcome.
Surgical results depent heavily on the experience of the surgeon, surgical group. Objectives: evaluation of the maximum tumor surgically removed in the treatment of ovanan cancer in the later stage. Subjects: 342 patients ovarian cancer in stages I I - IV were treated in the K hospital from January 2011 to December 2012, Methods: retrospective descnption. Results:
postoperative tumor < 1cm: 62,5% patients; tumors <
2cm: 20,46 % patients; tumors > 2cm: 16,95%
patients. Complications in surgery: 2,92% patients.
Postoperative complications: 6,43% patients. Illed patient v/as given back to home: 1.8% patient.
I. O A T V A N O E :
Ung thd buong tru'ng (UTBT) la nguyen nhan gay tiT vong dirng hang thir ba trong cac ung t h d phu khoa. Tai My, nam 2007 ghi nhan 22,430 tru'dng hdp mac mdi,15,280 phu nU tir
* B^nh vign K
Phan bl?n khoa hpc: PGS.TS Ngo Thu Thoa
N g u y e n V a n Tuyen*
vong vi benh nay. Tai Viet nam, theo thong ke nam 2004, tan xuat mae UTBT la 3,7- 4,4/100.000 dan [ 1 ] . UTBT la benh tien trien am tham,70-80% benh nhan(BN) du'dc phat hien 6 giai doan mudn, khi ung thu' tai buong tru'ng va di can 6 bung da ed kich thu'dc Idn. Oieu trj UTBT bang phau thuat lay u tdi da (eytoreductive surgery) va dieu t r i hoa chat phoi hdp vdi muoi platine da lam tang thdi gian sdng them 5 nam ciia BN [ 4 ] , trong d d kieh thu'dc u con lai sau phau thuat du'dc coi la yeu t d tien lu'dng dpc lap quan trong nhat lien quan tdi ket qua dieu tri [3,4,5]. Tuy nhien, phau thuat lay u tdi da la phau thuat nang, ddi hdi nhieu ky nang khac nhau,ket qua phau thuat phu thupc rat nhieu vao kinh nghiem ciia phau thuat vien, ekip phau thuat,gay me, hoi siTc [ 6 ] . Trong nhiTng nam gan day, benh vien K da dieu tri eho nhieu BN UTBT glai doan mupn, trong d d nhieu BN du'dc phau thuat lay u toi da.
Vi vay, chimg tdi thi/e hien de tai nay v6i muc tieu; danh gia ket qua phau thuat lay u toi da trong dieu t r i UTBT giai doan mupn.
II. o 6 l TUONG VA P H J O N G P H A P N G H I E N CClU:
2 . 1 D d i tu'dng nghien cuTu:
342 BN UTBT giai doan I I -IV va tai phat dieu trj tai benh vien K tiT thang 1/2011 tdi 12/2012, ed cac tieu ehuan sau:
- Cd ehan doan md benh hpe la UTBT - Du'dc phau thuat lay u toi da tai Khoa ngoai phu khoa Benh vien K.
- Cd ho sd day d i i .
2.2 Phu'dng phap nghien a h i : Md ta hoi culi.
2.3 Cac bu'dc t i e n h a n h : BN du'dc ghi nhan glai doan benh, each thifc phau thuat, kich thu'dc ung thu" cdn lai trong 6 bung sau phau thuat, tai bien trong phau thuat, bien chu'ng sau, tir vong sau phau thuat.
2.4 XuT l y s o lieu: Sd lieu du'dc xd ly bang phan mem SPSS 16.6
Y HQC VIET NAM THANG 6 • SO 2/2013 II. KET QUA NGHIEN COU:
3.1. Tuoi mac benh
Bang 3.1: ty le mae benh theo nhdm tudi
Nhom tuoi< 3 0 30-39 40-49 50-59 60-69
>70 Tonq so
So benh nhan 26 34 95 128 52 7 342
Ti ie ( % ) 7,60 9,94 27,77 37,42 15,20 2,05
100
- Tuoi cao nhat: 78, tuoi thap nhat: 17, tuoi trung binh: 50,98 ± 11,2. Nhdm tuoi ed ty le mac cao nhat: td 50-59 tuoi chiem 37,42%.
3.2. Sac diem mo benh hoc
g3.2; Phan loai mo benh heLo9i UT Bieu mo U te bao mam U qiap bien U dem- day SD U loai khac Tonq
)c
So benh nhan 271
36 12 16 7 342
Tv ie % 79,24 10,52 3,50 4,67 2,05 100
- Ung thu' bieu md chiem ty le cao nhat (79,24%).
3.3. Giai doan benh:
Bang 3.3: Phan loai giai doan benh theo Figo
Giai doanI I I I I IV Tai pilat Tonq
So benh nhan 85 157 39 61 342
TV le % 24,85 45,9 11,4 17,83 100
- NhCTng BN tai phat la nhihig BN da dddc md lay u buong triTng, khdng xet nghiem md benh hpc, nhap vien trong tinh trang tai phat.
- Ty le gap nhieu nhat la glai doan III (45,9%).
3.4. Ket qua phau thuat:
3.4.1. Kich thu'dc ung thu" con iai trong dbung sau md Bang 3.4: Y\rd\ thu'dc u cdn lai sau mo theo giai doan benh
Giai doan I I III - IV Tai pliat Tonq so BN (%)
£ l c m 64 116 34 214 (62,5%)
<2cm 17 31 22 70 (20,46%)
>2cm 4 49 5 58 (16,95%)
Tong so BN 85 196 61 342 (100%)
3.4.2. Cac tang phal cat bo khi lay u:
7 3.5: Cac tanq phai cat bo Tang cat bo Cat doan ruot non C3t doan dai tranq Cat doan tri/c tranq Cat lach Catqan Hau mon nhan tao Tonq so BN
SoBN 17 32 15 3 2 43 117
Tv le % 4,97 9,36 4,38 2,34 0,58 12,6 34,21
Y HQC VlgT NAM T H A N G 6 • S 6 2/2013 3.4.3. Tai bien trong md
- Cat phai nieu quan: 3 BN (0,87%) - Thiing bang quang: 7 BN (2,04%).
3.4.4. Biin chihig sdm sau md) - D d t i e u h d a 5 B N ( l , 4 6 % )
- Chay mau sau mo, dieu trj ndi khoa khdi:
15 BN (4,39%)
- T i e njpt sdm sau md - mo lai: i BN (0,58%) 3.4.5. Td vong: 6 BN (1,8%), BN sau md dien bien n3ng xin ve (du'dc ti'nh la tiT vong)
IV. B A N LUAN:
Ket qua phau thuat: phau thuat dieu tri UTBT glai doan mupn (RGO II-III-IV) tieu ehuan gom:
Celt tir cung toan bp va hai phan phu, c3t mac ndi Idn tdi sat bd cong Idn ciia da day, cat rupt thiia, lay tdi da cae u ung thu' lan tran trong 6 bung, lay nhihig hach Idn sau phiic mac. Muc tieu ciia phau thuat la de lai cang it to chdc ung thu'trong 6 bung eang tdt, tdi du (optimal) khi to ehire ung t h i / cdn lai trong o byng ed kieh thudc < 1cm. Kieh thu'dc u cdn lai sau phau thuat cd lien quan mat thiet tdi ket qua dap iTng eua dieu trj hoa chat va du'dc eoi la yeu t d tien lu'dng doe lap quan trpng nhat. Nghien cirtj eiia Eisenhauer EL[4], so sanh thdi gian song them -riia nhuTig BN cd to ehire ung thu' edn lai sau p h l u thuat d mire khdng edn thay u, u< Iem, u<2cm hoac u>2cm cho thay SLT khac biet cd y nghTa thdng ke vdi p <0,001. Nam 1994, Redman va Cs de ra tieu ehuan p h l u thuat dddc eoi la tdi utJ khi t d chiTc ung thu" edn lai < 2cm [5]. Nam 2003, Skirnisdottir I [5] dat ra tieu chuan phau thuat du'dc eoi la tdi uli khi to chiTc ung thu* cdn lai
< l c m va du'dc nhieu tac gia chap nhan, tae gia chu'ng minh rang ty le sdng them 5 nam d nhiiTig benh nhan u< 1 cao hdn 10% so vdi u< 2em (tiT 10-15% len 20-25% sdng them 5 nam d BN LTTBT giai doan III-IV). Nghien ciru ciia chung tdi cho ket qua: ty le BN cdn ung t h d sau mo cd kieh thu'dc u < l c m la 62,5%, u<2cm la 20,46%, u > 2 cm la 16,95 % , nhiTng tru'dng hdp cdn lai cd the ehi cat du'dc mac ndi Idn hoac de lai ung thu' tai nhu'ng vj Iri khd cat bd nhu": cudng gan, mac treo rupt d vi tri sat ddng mach mac treo trang tren, ung thu' di can phuc mac sau gan dfnh vao tTnh mach chii,di can tuy, di can hach chii bung tren than. Ket qua p h l u thuat lay u toi da phy thude rat nhieu vao kinh nghiem cua phau thuat vien va eki'p phau thuat.
Theo Chi DS [2] d nhu'ng phau thuat vien chuyen khoa, ty le BN du'dc lay u optimal la khoang 70- 90%,trc)ng khi d nhiTng phau thuat vien khdng
chuyen khoa, ty le nay la<S0%.G. Michel [6] cho ket qua phau thuat lay u optimal d nh{?ng BN UTBT glai doan I I - I I I la 9 0 % vdi ty le bien chiing can can thiep ngoai khoa la 25%.Oe cd the phau thuat lay u optimal, ddi khi can phal cat doan ong tieu hoa, dit lach trong tru'dng hdp ung thu* xam lan cudng lach, cSt mpt phan cd hoanh trong tru'dng hdp u co du'dng kinh 5cm dinh vao vom hoanh. Ty le cat doan ong tieu hoa theo Eisenkop SM [3] la khoang 30-40% so tru'dng hdp. Nghien cinj ciia chiing tei eho ty le phai cSt bd mot phan cac tang d 21,63% «i BN gom: c3t rudt non 15 BN (4,97%), cat dai trang 32 BN (9,36%),c3t tru'c trang 15 BN (4,38%), cat lach 5 BN (2,34 % ) , cat gan 2 BN (0,58%), 43 BN (12,6%) phai lam hau mdn nhan tao. Mat khac, ngoai nhCTng no liTe eiia phau thuat vien, phlu ttiuat lay u optimal con phu thuoc vao giai doan benh. Potte [7] cho rang, can thiet col viec phai rk bd mdt phan ong tieu hoa la yeu to tien lu'dng tSi.
Tai bien va bien chutig: tai bien trong md chiing tfi gap la cat phai nieu quan 3 BN (0,87%) x ^ ra khi ung thu' xam lan thanh khung chau va phau thuat vien cd gang cat cao bd mach buong tnihg, thung bang quang 7 BN (2,04%) khi co gang lay u toi da xam lan bang quang. Bien ehutig sau mo c^ung ^ gap dd tieu hoa 5BN (1,46%), tac rudt sdm sau mo, phai md lai 2BN (0,58%), 15 BN (4,39%) c6 tinh trang chay mau nhe sau mo dieu tri npi khoa khoi, khdng cd tru'dng hdp nao phai mo tai. Tii vorra: 6 BN (1,8%) gdm nhtirig benh nhan sau md dien bien nang, xin ve, khdng cd benh nhan nao ehet tai benh vien. Qua theo doi BN, chung tdi thay rang: bien chiTng va tiT vong xay ra d nhuTig BN khdng mo lay du'dc u toi da, do vay tinh trang cd the van tiep tuc nhiem ddc do doc tfnh ciia ung ttiu'. 6 nhutig benh nhan lay du'dc u tdi da, tinh trang toan than benh nhan du'dc cai ttiien rat tdt sau mo. Ngoai la, hoi silt trong va sau md eung rat quan trpng. Ludng mau truyen trung binh d nhiJhg BN giai doan n i a 1 drti vj, giai doan III-IV la 2 ddn vj.
V. KET LUAN:
Qua 342 BN UTBT giai doan muon dUdc dieu trj phau thuat lay u tdi da tai benh vien K trong thdi gian tiT thang 1-2011 den thang 12-2012 cho ket qua la: ty le BN du'dc phau thuat optimal, to chiTc u ung thd cdn lai sau mo < 1cm la 62,5%, u < 2cm la 20,46%, > 2cm la 16,95 %, tai bien trong mo la 2,92 % , bien chutig sau mo la 6,43%, tiT vong 1,8%.
96
Y HQC VlgT NAM T H A N G 6 - S 6 2/2013 TAI UEU T H A M KHAO:
1. Nguyin Ba Du'c (2002) "Hda ehat dieu tri benh ung thu", Nha xuat ban Y hpc Ha N6I, trang 105 -110.
2. Chi DS, Eisenhauer EL, Lang 3, Huh J, Haddad L, bu-Rustum NR et al V^hat is the optimal goal of primary eytoreductive surgery for bulky stage IIIC epithelial ovarian carcinoma (EOC)? Gynecol Oncol 2006; 103(2): 559-64.
3. Eisenkop SM, Spirtos NM Friedman RL, Lin WC, Pisani AL, Perticucci S. Relative influences of tumor volume before surgery anid the eytoreductive outcome on survival for patients with advanced ovarian cancer: a prospective study.
Gynecol Oncol 2003;90 (2):390-6.
4. Eisenhauer EL, bu-Rustum NR, Sonoda Y, Levine DA, Poynor EA, Aghajanian C et al. The
addition of extensive upper abdominal surgery to achieve optimal cytoreduction improves survival In patients with stages IIIC IV epithelial ovarian cancer. Gynecol Oncol 2006; 103(3): 1083-90.
Skirnisdottir I , Sorbe B. Prognostic factors for surgical outcome and survival in 447 women treated for advanced (FIGO-stages III-IV) epithelial ovarian carcinoma. Int J Oncol 2007;30(3):727-34.
Michel G, De laco P, Castaigne D, El-Hassan MJ, Lobreglio R, Lhomme C, et al. Extensive eytoreductive surgery In advanced ovarian carcinoma.
Eur ] Gynaecol Oncol 1997 1997; XVIII: 9-15.
Potter ME, Partridge EE, Hatch KD, Soong SJ, Austin JM, Shingleton HM. Pnmary surgical therapy of ovarian cancer; how much and when.
Gynecol Oncol 1991; 40: 195-200.
VAI TRO CUA PHAU THUAT NOI SOI TRONG CHAN DOAN VA DIEU TRI VET THimNG THAU BUNG TAI BENH VIEN VIET DUfC
T 6 M TAT:
Vet thu'cJng thau bung tru'dc day tat ca phai md cd nhieu tru'dng hdp md byng trang hoac khong can thiet. Nghien cirtJ danh gia kha nang ap dung ciia phlu thuat npi soi trong chan doan va dieu tri vet thu'dng thau bung. TU lieu va phu'dng phap nghien ciru: Nghien ciili tien hanh tren 62 benh nhan vet diu'dng thau bung dieu tri tai benh vien Viet dire 2010- 2012. Ket qua: Trong sd 62 trUdng hdp vet thu'dng thau byng cd 48 (80%) c3n can thiep dieu tn ngoai khoa, 3 (5%) co tdn thUdng khong c3n can thiep,_^9 tru'dng hpp (15%) khong cd ton thUPng tang. Phau thuat npi soi giiip giam 10% md bung trang, 5% md bung khong can thiet. Phau thuat npi soi hoan toan diSu trj chiem 35%, 15% npi soi ho trd, 5% chuyen md va 45% npi soi chan doan khong can dieu tn. Ket luan: phau thuat npi soi cd tac dung tot va hieu qua trong chan doan va dieu tri vet thUdng thau byng.
SUMMARY:
THE ROL£ OF LAPAROSCOPIC SURGERY IN DIAGNOSIS AND TREATMETft OF PENETRATING ABDOMINAL
WOUND AT VIETDUC UNIVERSITY HOSPTTAL Abdominal penetraltlng wound was indicated totally surgery but tfiere are cases not nessesary to operate. The study has pupose to evaluate the possibility of laparoscopic surgery in diagnosis and
• B$nh vi^n Vi$t Due Ha N^i
Phire m- k.i^^~^ ^ ^ ' " ^ ^ ' i ' T« Pii^m ^<^c Huin
T r a n Binh G i a n g * treatment of abdominal wound. Patients and method:
prospective cohort study on 62 cases hospitalized in Vietduc university hospital from 2010 to 2012. Results:
There are 80% cases needed surgical treatment and laparoscopic surgery diminue 10% blank laparotomy and treated successfully for 35% cases, assisted laparoscopic surgery in 15% and only 5% needed convert to open laparotomy. Condusion: laparoscopic surgery is a efficace method in diagnosis and treatment of abdominal wound.
1. O A T V A N DE:
Vet thu'dng thau bung (VTTB) la nhutig vet thu'dng gay thung phuc mac lam cho o bung thdng thu'dng vdi mdi tru'dng ben ngoai [1].
Trong chan doan vet thu'dng thau bung, ngoai viec tham kham phat hien cac dau hieu thanh bung thi tham dd tai eho vet thu'dng la dpng tac quyet djnh de xac djnh vet thu'dng cd thau bung hay khdng. Tuy nhien trong mot sd tru'dng hdp nhu" vet thu'dng ngiTc bung, vet thu'dng viing chau hong hay viing lu'ng thi viec tham dd nay rat it gia t n hoac khdng thy'c hien du'dc, do dd viee chan doan vet thu'dng thau bung nhieu khi cdn gap khd khan d i n den xd tri eham hoac bd sdt ton thu'dng.
