Y HQC VigT NAM T H A N G 2 - s 6 2/2013 va hoi nghi khoa hoc- Hpi phu san khoa va sinh de
coke hoach Viet Nam, tr.107-111.
Nguyen Quang Thanh(2006): Nghien cdu giam dau trong chuyen da de bSng gay te NMC phoi hdp Marcain, Xylocain va Fentanyl do san phu tif dieu khien, Luan v3n bac sy chuyen khoa cap I I , trffdng Dai hpc Y Ha Npi.
Camorcia, Michela M.D; Capogna, Giorgio M.D(2005): "Minimum Local Analgesic Doses of Ropivacaine, Levobupivacain and Bupivacaine for Intrathecal Labor Analgesia", Anesthesiology- Volume 102- Issue 3. p 646-650,
Clarkson C.W, Hohdies L. M (1985):
"Mechanisms for bupivacain depression of cardiac conduction fast block of sodium chanels during the
action potential v/ith slow/ recovery ftom blodc during diastole". Anesthesiology; 62, p 396.
Marcel P. Vercauteren, Guy Hans, Koen De Decker and Hugo A. Adriaen5en(2001):
"Levobupivacaine Combined with Sufentanil and Epinephrine for Intrathecal Labor Analgesia: A compararison with Racemic Bupivacain". Anes^
Analg; 93, p 996-1000.
Wang Li-zhong, Chang Xiang-yang, Uu XIa and Tang Bei-lel(2010): "Comparison of bupivacaine, ropivacaine and levobupivacaine with sufentanil for patient-controlled epidural analgestg during labor: a randomized dinical trial". Chin Med J; 123 (2), p 178-1S3
NGHIEN ClifU OAC DIEM LAM SANG, C A N LAM SANG VA DANH GIA KET QUA P H A U T H U A T UNG THlT OA DAY TAI BENH VIEN H O U NGHI (GIAI DOAN 1/2008 - 6/2011)
TOM TAT:
Doi tW^ng va phu'dng phap: 130 BN UTDD phau thuat tai Bv Hdu Nghi 1/2008-6/2011. Ket qua:
Nam 105 BN, nff 25 BN, tuoi TB 69,4 ± 8,9; Phdi hdp tang huyet ap 46,2%, tim mach 16,2%, dai dUdng 15,4%...Trieu chffng thUdng gap dau bung tren ron (80%); Thu'Ong tdn nhieu 6 hang, mon vi (50%); The loet nhieu nhat (46,2%); UT bleu md tuyen chii yeu (88,5%); Giai doan muon 43,1%. Mo phien 96,9%;
C3t da day 87,7%; Bien chffng sau md 12,3%; Tff vong 0,8%; Thdi gian song 3; 2 va 1 nam; 45,8%;
51,7% va 73%, trung binh 27,7 ± 1,7 thang: khong c3t u 5,8 ± 5,4 thang, d t u 30 ± 1,7 thang. Kit iuan: benh chiem ty le cao d nam gidi, ngUdr cao tuoi, nhieu benh phdi hdp. Phau thuat tnet can cho ket qua kha quan.
SUMMARY:
EXAMINE THE CLINICOPATHOLOGIC FEATURES AND EVALUATE THE RESULT OF SURGICAL TREATMENT FOR GASTRIC CARCINOMA AT THE FRIENDSHIP HOSPITAL (FROM 1/2008 TO 6/2011)
Methods: a prospective study. Results: 130 patients: 105 males, 25 females; mean: 69,4 ± 8,9.
Accompanied with: hypertension 46,2%;
cardiovascular diseases 16,2%; diabetes 15,4%...
* Benh vien Huv Nghi, " B$nh vi^n Viet BCK Phan bi?n khoa hpc: PGS.TS Cong Quy&t T h i n g 66
Hoang V i e t D u n g * ; Trjnh Hong S d n * *
Common symptom abdominal pain 80%. Locations;
antrum, pylorus and pre-pyloros 50%. Lesion;
ulcerated type 46,2%, adenocarcinoma 88,5%;
Modified differentiation 36,2%. Stage III and IV;
43,1%. Selective surgery: 96,9%. Gasb-ectomy 87,7%;
Postoperative complications 12,3%; Mortality rate 0,8%. The 3-year, 2-year, 1-year overall survival 45,8%; 51,7% and 73%. Medianoverall sun/ival 27,7
± 1,7 months; without tumor resecbon 5,8 ± 5,4 months, tumor resection 30 ± 1,7 months.
Conclusion: the typical patient is male, the etderiy, with many accompanied diseases. Radical surgery improved survival.
I. OAT V A N o f :
Ung thff da day (UTDD) la benh ac tinh gay tff vong hang thir hai tren the gidi sau ung thff phoi. Nhat ban cd ty le mac benh cao nhat, 75- 100/100.000. Chau Au ty le UTDD hang nam 35,7/100.000 [7]. Tai My JTDD 6dng thd 10 trong cac benh ung thff, ty le tff vong du^g tiiOf 7, moi nam khoang 22.000 trffdng hdp chan doan, 13.000 trffdng hdp td vong [4]. 6 Vi&
Nam, hang nam ty le m'Sc 9,3 - 25,7/100.000 d nam va 9,1 - 2,5/100.000 d nff gidi [1],[2].
Y HOC VigT NAM THANG 2 - SO 2/2013 Tai Benh vien Hu^ Nghj da so benh nhan
(BN) cao tuoi, nhieu benh phoi hdp, den l<ham l<tii benh d giai doan muon trong do co UTDD.
De tai nay nghien cuXi (NC) nham muc dich: Mo ta^dac diem lam sang, can lam sang va danh gia Ket qua phau thuat UTDD tai benh vien (Bv) Hifu Nghi giai doan 1/2008 - 6/2011.
II. 061 TUONG VA PHUONG PHAP NGHIEN CUU:
2.1. Boi tu'dng NC: Cac BN UTDD mo tai Bv Hii'u Nghj tCr 01/2008 den 6/2011. Day du ho sd benh an, danh gia, theo doi sau m6 djnh 1^.
Loai tru* cac tru'dng hdp: khong co giai phau benh (GPB) hoac GPB Idiong phai la ung thu.
2.2. Cac chi tieu NC:
- fi^c diem lam sang, can 13m sang:
Tuoi, gidi, benh phoi hdp. Cac trieu chutig lam sang, mii'c do thieu mau (neu: hemoglobin <120 g/l d nif) va <130 g/l 6 nam, hematocrit <33%), chat chi diem lihoi u (CEA tang neu: >10 ng/ml, CA 19-9 tang neu: >37 U/ml), vi tri thu'dng ton, thUdng ton dai the (theo Hiep Hoi Nghien ciJu Ung Thi/ Nhat Ban), thifdng ton vi the (theo WHO nam 2000), do biet hoa (theo WHO nam 2000), giai doan benh (theo AJCC va UICC nam 1997 va 2002).
- KSt qua dieu tri: chi djnh mo, phu'dng phap phiu tfiuat, tai bien va bien chimg, dieu tri hoa chat, l<et qua xa.
' - Phu'dng phap NC; Mo ta tien cilli; Xii' \y so lieu bang phan mem SPSS 15.0.
III. KET aU& VA BAN LU^N:
1, Oac diem lam sdng, c|n lam sang
» 5 t
* 1
] H] n
Bieu do 2; Phan bo theo gidi
Chiing toi thay benh chii yeu d nam, tuoi trung binh la 70, cao hdn so vdi cac NC khac trong nu'dc [1],[2]. Mpt vai NC cho thay tuoi cao CO anh hudng den gay me hoi su'c va ket qua sau mo [7].
Bii'u do J.'Phan bo theo nhom tuoi ^
Tir 01/2008 - 6/2011, 130 LTTDD dUdc phau thuat tai Bv Hifu Nghj. Nam 105 (80,8%); Nu' ^5 (19,2%); ty ie Nif/ l^am: 1/4,2. Tuoi tif 40 den
?6, TB 69,4 ± 8,9. BN cao tuoi 86,2% (BN cao tuoi la tir 60 tuoi trd len).
Bfnh ly khilc U phi del TLT Btnh l> ho hap B;nh lim mf ch TiinsiiXHTII
Ting huyef Hp Nglu^n rvyu Hill Ihuoc Id
" "• •'"^' ' '
|^a)iK^-l
^IS.S'l-
6.2%
.z%
41.9%
46.1%
Bieu do J.-Phan bo benh phoi hdp
Hau het BN den vien khi cac trieu chimg tang len hoac xuat hien trieu chiitig thUc the hoac dieu trj npi khong dd.Chan doan UTDD muon cung la tinh trang chung d Viet Nam, ngoai dac diem lam sang khong dien hinh, mpt phan do y thirc ciia ngu'di benh (sd soi da day), mot phan do thay thuoc d l chan doan viem loet da day cho thuoc dieu trj ma khong soi da day.
Khuyen cao khi co trieu chu'ng day bung, kho tieu, chan an phai dUdc npl spi da day ngay [4].
Tai Nhat Chan dpan sdm gan 50% cac trUdng hdp, 6 Chau Au va Bac My dUdi 10%, tai Viet Nam chan doan OTDD sdm chiem ty le rat nho (3,6%) [1].
Trieu chipng lam s&ng S&thayu bung Dau bynq tr6n ron Sut can Day bunq, khd tieu Chan an 0" hai, 0 chua
n 14 104
64 85 87 49
%
10,8
80,0
41,5
65,4
66,9
37,7
Y Hpc VigT NAM THANG 2 • s6 2/2013
Trigu chti^nq lam sangN6n, bu6n n6n S6t
Hoa m^t, chdnq m$t Ndn mau Bi nqoai phan den Bung cd ascite
n 50 5 26 12 28 11
%
38,6 3,8 20,0
9,2 21,5
8,5 Bang 2; Xet nqhiem mau
Thcim dd c$n l i m sdng Thi4umau(N=130) CEA tanq (N=86) CA 19-9 tang (N=72)
n 73 16 11
%
66,1 18,6 15,3
BN cua chung tdi cd nhieu benh kem theo nhff tang huyet ap, benh tim mach, hd hap, dai dffdng...day cijng la diem dae thu eua Bv Hffu Nghj, cae yeu to nay cung gdp phan eho tien Iffdng benh nang them. I^pt so NC thay ty le bien chffng ve tim mach, hd hap, nhilm trung tang len sau md d nhffng BN ed nhffng benh phdi hdp nay. Ve lam sang chu yeu la dau bung tren ron (80%) tffdng tff vdi eac NC trong nffdc [1],[2].
Chung tdi thay dau hieu sd thay u, di ngoai phan den eao hdn cac NC khac, day cung la cac dau hieu bieu hien giai doan mudn. Gay sut can 41,5%, trong dd giam it nhat la 2 kg, nhieu nhat la 17 kg, TB 4,6 ± 2,5kg, BN it de y den dau hieu nay, chi khi can kiem tra mdi thay sut can so vdi trffdc. BN ung thff deu ed roi loan chuyen hoa, dae biet la glucose, cho nen da sd BN UTDD bj sut can va gay.
Hdn mdt nffa BN cd thiSu mau (56,1%).
Thieu mau trffc tiep do ton thffdng gay XHTH hoSc gian tiep do giam sff hap thu cac chat tao mau: Fe, vitamin 812, Axit Folic. CEA, CA 19-9 tang 18,6% va 15,3%, vai trd cua chat ehi diem khdi u trong UTDD ndi chung, khdng cd y nghTa thffc hanh trong I3m sang.
Thffdng tdn d hang, mdn vi la nhieu nhat (50%), cung tffdng tff nhff cae NC trong nffdc [1],[2]. Gan day, eac NC tren the gidi nhan thay UTDD t§ng Ien d 1/3 tren (tff 29,1% 6m 52,2%); Cae khoi 1/3 giffa 15% - 30%; 1/3 dffdi 35%, khoang 10% u chiem toan bd da day [6].
Bang 3: Vj tri thffcJng tdn da day Vi tri thu'O'ng t6n
TSm VI, phinh vi Bd conq nhd Bd conq Idn Than vi Hang vi IVldn VI, tien mdn VI IVli6nq noi Toan bp da day Tonq so
n 5 33 2 11 39 26 7 7 130
3,8
%
25,4 1,5 8,5 30,0 20,0 5,4 6,4 100,0
The loet ehiem nhieu nhat (46,2%), tffdng tff mdt sd NC trong nffde [1],[2]. Tuy nhien kich thffdc thffdng tdn >5cm chiem tcfi 60%, day cung la dac diem bieu hien den mudn cua BN. Cae NC tren the gidi thay thffdng ton loet ehiem nhieu nhat, dae biet d BCN va hang mdn vi. TTiuWng ton u sui hay gap vijng tien mon vj, the tham nhiem cd the gap toan bd da day va kfch thffdc thuWng tdn cung phan anh sff tien then eua benh.
Bang 4.'ThUdnq ton dai the
^^Xhu'O'ng t6n Kich t h u ' d x ^ ^ ^
< 5 cm S 5 c m Tonq s6
T h ^ s i i i SL
9 32 41
%
6,9 24,6 31,5
T h i lo6t SL 39 21 60
%
30,0 16,2 46,2
Tham nhiSm SL
3 23 26
%
2,3 17,7 20,0
Khonq xep lo^i SL
1 2 3
%
0,8 1.5 2,3
T6nq s6 SL 52 78 130
%
40,0 '60,0 100,0
Bang J / T h U d n q ton vi the Thu'O'ng t 6 n v i the UTBIVI tuyen UTBM te bao nho GIST Lymphoma Leimyosarcoma Tong
n 116
2 7 3 2 130
88,5
%
1,5 5,4 2,3 1,6 100,0
Bang 6; Giai doan benh theo TNM Giai doan
Giai dogn IA - IB Qiai doan li Giai ddan i l l A - I I I B Giai doan IV Tdnq so
n 32 42 24 32 130
%
24,6 3 2 , 3 , 18,5.
24,6 100,0
Y HOC VIET NAM THANG 2 - SO 2/2013
"' Ttiffdng tdn vl the: UTBE^ tuyen chiem chu ygu (88,5%), Dp biet hda vu^a 36,2%; kem biSt hda 5 5 , 4 % ; biet hda cao 17,7% va khdng b i | t hoa 10,8%, tffdng tff NC eua mot so tae gia trong nffde [ 1 ] , [ 2 ] . Chung tdi thay nhdm ung thff khong bieu md (11,5%) chiem t^ IS cao hdn so vdi cac NC trong va ngoai nffdc, day cung la nhom ung thff cd tien Iffdng tot hdn. Tren the gidi chu yeu ia ung thff bleu md tuyen, trong khi ung thff khdng bieu md chiem ty le rat nhd ( < 5 % ) [ 3 ] .
Giai doan mudn (giai doan I I I - I V ) chiem gan mot nffa (43,1%), eao hdn cac NC trong nffdc khae [1],[2]. Day la cae trffdng hdp thffdng tdn da ra thanh mac va cd di can hach.
2. Ket qua dieu t r i Bang 7: Ch\ djnh phau thuat
Chl dinh va loai PT M 6 C^P CO'U
11/16 phian Mo md"
Mo npi soi M 6 m d Mo ndi Sdi T6ng s6
n 4 0 124
2 130
3,1
%
0 95,4
1,5 100,0 Chi dinh: Mo cap effu 3 , 1 % trong benh canh XHTH soi da day cam mau khdng ket qua. 2 BN md ndi soi: thffdng ton loet ndng, 2R <5 cm, chffa di can xa. Cat bd da day qua ndi soi cd nhieu ffu diem xong chi phi cao, thdi gian md keo dai, tuy nhien vdi sff thanh cdng 2 trffdng hdp cat da day ndi soi khang djnh sff ve trinh dp eung nhff kha nang phat trien cat da day no! soi trong tffdng lai tai Bv Hffu Nghj.
Sang A'Phffdng phap phau thuat Phuvng phap
Md thdnq hdnq tranq Noi vi tranq
€4t DD
c a t doan cat toan bO c a t iai mienq noi c a t hinh cham Tdnq so
n 12 4 97 8 5 4 130
9,2
%
3,1 74,6 6,2 3,8 3,1 100,0 r, .Phu'dng phap phau thuat: Cat da day thu'c hien 87,7%. Phau thuat tam thdi: noi vj trang, md thong hdng trang ket qua nghed nan, thdi gian song TB sau md dUdi 6 thang [ 5 ] .
Bang 9; T'/ le nad vet hach Nao vet hach
Nao vat Dl
Nao vat D2 Nao vat D3 Tonq so
N = 1 1 0 46 18 46 110
41,8
%
16,4 41,8 100,0
Nao vet hach ehiem 96,5% trong dd: 41,8%
nao vet D l ; 16,4% D2 va 41,8% D3; nhieu nhat25, TB 6,7 ± 4,1 hach. Cd mdt sd y kien eho rSng ngffdi eao tud'i khdng nen nao vet hach do tang cac nguy cd, tuy nhien ehung tdi van thffc hien nao vet hach theo quy chuan va khdng thay cd tai bien hay bien chffng. Nao vet D2 trd thanh tieu chuan d Nhat Ban. Nao vet rgng rai (D3) thffc hien khi nhffng hach nay nghi ngd, nhat la giai doan tien trien [ 2 ] . Cac NC d Chau Au, d V\y cho thay tien Iffdng eua UTDD phu thupc vao so Iffdng hach di can hdn la nhdm hach bj di can [6].
Bang 10: Cac bien chffng sau mo Bien chu'ng
Ndi khan lipt hoi quy Viem phoi Nhiem triing mau Bidai Chay mau sau mo Nhiam trunq vet mo Dd tieu hoa Thoat vi thanh bunq Tac rudt khdnq mo Tac rudt phai mo T i l vonq
n 1 2 1 1 2 3 2 1 3 1 1
0,8
%
1,5 0,8 0,8 1,6 2,3 1,5 0,8 2,3 0,8 0,8 Tai bien va bien chffng: Tai bien 0,8%. Bien chffng 12,3%: do phau thuat 9,2%: NT vet md 3 , 1 % ; dd TH 2,3%; tac rudt 2,3%; chay mau sau md 1,5%; viem phoi 1,5%; NT mau 0,8%; thoat V! thanh bung 0,8%. 1 BN (0,8%) tff vong sau md. Trff 1 trffdng hdp ehay mau sau md do loi ky thuat, eac trffdng hdp bien chffng khac do BN cao tudi, benh phdi hdp, thffdng ton Idn, lan tran giai doan mudn. Ty le bien chffng lien quan tdi kinh nghiem PTV sd ca p h l u thuat, giai doan benh [ 5 ] . '
Bang 11: Dieu trj hda chat sau mo Hda chat
Phac do FUFA Phac do EOX Phac do ELF Xeloda don thuan Khac T6nq
n 31 10 5 3 11 60
51,7
%
16,7 8,3 5,0 18,3 100,0 Oieu trj hoa chat:Dieu trj hda chat 46,2%, cac trUdng hdp ung thU da ra thanh mac va di can hach. Nhin chung BN dap irng kha tct vdi hda chat mac dii da phai trai qua cupc phau thuat nang ne. Chiing tdi diing cac phac do hien nay tren the gidi dang sir dung nhieu nhu FUFA, ELF va EOX [ 1 ] ,
69
Y H p c VigT NAM T H A N G 2 - S6' 2/2013 Ket qua xa sau m d : T h d i gian theo ddi
ngan nhat 2 thang, dai nhat 43 t h a n g , TB 15,8
± 11,2 thang.
Bang 12: W le STSI^ tdan bd (true tiep)
STSIM
3 nam 2 nam 1 nam
N 24 35 39
IIAittIn 0 4 2
Cdn s6ng 11 16 27
45,8 %
61,7 73,0
Ty le STSM tdan bd sau 3 n3m, 2 nSm va 1 n5m la: 45,8%; 51,7% va 7 3 % (phUdng phap true tiep). Thdi gian sdng them TB (theo Kaplan - Meier): 27,7 ± 1,7 thang.Bang 13; STSM nhdm Au (true tiep)
STSM
3 nam 2 nam 1 nam
N 16 34 36
M^ttin 0 4 2
Cdn s6nq 8 18 27
%
50 60 79,4
Bang 14Nhdm Ko cat u catu
•STSM(Kaplan-l^eier) Song
thSm 7,9 30
SE 2,0 1,7
95% CI 4,0-11,8 26,6-33,5
Ty le STSM d nhdm cat dffdc u sau 3 nam, 2 nam va 1 nam: 5 0 % ; 6 0 % va 79,4% (phffdng phap trffc tiep). Thdi gian song them TB nhdm khdng cat dffdc u la 5,8 ± 5,4 thang, ngan nhat 3 thang, dai nhat la 23 thang (phffdng phap trffc tiep). Thdi gian song TB nhdm eat dffdc u: 30 ± 1,7 thang, nhdm khdng eat dffdc u: 7,9 ± 2 thang (theo Kaplan - Meier).Bii'u do 3: STSM (Kaplan-Meier) 9 (Suppl 1); A66.
Chung tdi thay cd sff lien quan g i i j ^ giai doan benh vdi thdi gian STSM { p < 0,001); thdi gian STSM giam d the kem biet hda, va b i ^ hoa v i j ^ (p = 0,004); thdi gian STSM giam khi thffdng tdn xam lan tdi Idp ed v^ thanh mac (p < 0,001) va di can h?eh (p = 0,029).
IV. KET LUioiN:
Qua NC 130 BN UTDD tai Bv Hu\i Nghj ehung tdi thay: benh gSp chu yeu gap d nam gidi (tren 80,8%), ngffdi cao tuoi chien tren 86%, aft nhieu benh phoi hdp nhff: tang huyet ap 46,2%, benh tim mach 16,2%, dai dffdng 15,4%. Oau bung la dau hieu chu yeu, tuy nhien nhieu BN den vdi cac dau hieu mudn nhff sd thay u, XHTH, thieu mau... vdi ty ie d giai doan muon la 43,1%, 96,5% BN cat dffdc u dffdc nao vet hach vdi ty if STSM sau 3 nam, 2 nSm, 1 nam: 50%; 60%;
79,4% va thdi gian sdng TB la 30 ± 1,7 thang.
TAI LIEU T H A M K H A O :
1. Do Trpng Quyet (2010). Nghien cffU dieu tri ung thu" da day bSng phlu thuat cd ket hop hoa ch^
ELF va mien djch trj lieu Aslem. Luan an tien siY /ipC/Tru'dngdai hpc Y Ha Ndi.
2. Trjnh Hong Sdn (2001). Nghien cihj nao v ^ hadi trong dieu trj phlu thuat ung thff d^ day. Luin in den si Y hoc, Trudng dai hoe Y Ha Nra.
3. David W. Mercer, Emily K. Robinson (2004).
Gasff-ic Neoplasms. Sabiston Texttxxjk of Surgery, 17"" edition; p.l302- 1315.
4. Dong-Yi Kim, 3ae-Kyoon 3oo, Seong-Yeob Ryu (2005). Clinicopathologie characteristics of gastric carcinoma in elderly patients: A comparison with young patients. World J Gashventenjifliil):
p.22 - 26.
5. Eugenijus S., Egidijus S., Sigitas Z. (2002).
Stomach cancer; Surgical Trea&nent, Postoperative Complications Lethality. Acta media Lituanicai 9 (1): p.53 - 57.
6. JeffreyD., M a r k s . (2007). Tumors of the Stomadi, Duodenum, and Small Bowel. ACSSiffgery: Priixples
& P/actke, 6* Edition; p.819 - 834.
7. Guida F.,^ Antonino A., Conte A. (2009).Gastric cancer in elderly: dinico-pathological features and surgical treatment. BMC Geriatrics
