Y HOC VIET NAM THANG 3 - SO 1/2014
DANH GIA KET QUA DIEU TRI PHAU THUAT VIEM TUY CAP DO s 6 l MAT
T r a n Vinh* va cs T O M TAT
Muc tieu: Nghien cufu dac diem lam sang, can lam sang va danh gia ket qua sdm ciia phau thuat trong viem tuy cap (VTC) do soi mat. Doi tu'dng va phu'dng phap: Nghien ciru mo ta hoi cyu va tien ciru y-en 68 benh nhan (BN) VTC do soi mat dUdc dieu tri bSng phau thuat tai khoa Ngoai benh vien Bach Mai giai doan 2008-2012. Ket qua nghien cu'u: Oau thuong v|, ha su'dn phai 100%, 40 TH (60,47%) co non, 49 TH (72%) cd vang da, bf trung ten la 29 TH (42,6%), bung chudng la 57 TH (83,82%), phan img vung thUdng vi va ha sUdn phai 57 TH chiem 83,82%, kham co khoi tren ron la 4 TH (5,88%), diem sUdn lung dUdng tinh la 20 TH chiem 29,4%. So ngUdi benh co sot tren 37,5°C la 31 TH chiem 45,58%, Siem am cd kha n3ng quan sat duoc tuy la 56 TH chiem 83,35%, CLVT la 65 TH chiem 95,58%, doi vdi sdi mat CLVT CO kha nSng xac dinh duoc 97,67%, sieu am la 94,19%. Phau thuat trUdc 1 tuan d 53 BN: ty le bien chiftig 8/53 BN (15,09%), Phau thuat sau 1 tuan d U BN: Ty 1? bien chyng 2/11 BN (18,6%). Ket qua dieu th: tot la 51 BN chiem 79,68%, trung binh la 9BN cliiem 14,06%, xSu la 4 BN 6,26% trong do td vong 1,56%. Ket luan: Chan doan dya vao dau hieu lam sang cd gia tri djnh hUdng, sieu am va cat Idp vi tinh cd gia tn chan doan xac djnh. VTC do soi mat d the phu, dieu tri phau thuat sdm cho ket qua tot.
Tdkhda: Viem tuy cap, soi mat.
SUMMARY
THE RESULTS OF SURGICAL TRAITMENT FOR PANCREATITIS DUE
TO BILIARY STONE
Objective: To study the clinical characteristics, clinical approach and evaluate early results of surgery In acute pancreatitis due to gallstones. Methods:
retrospective descriptive study and prospective patients over 68 cas by pancreatitis due to gallstones by surgically treated at the Surg. Department of Bach Mai Hospital 2008-2012. Results: epigastric pain, right upper quadrant 100%, 40 cas (60.47 %) had vomiting, 49 cas (72%) had jaundice, flatus secret 29 cas (42.6%), abdominal 57 cas (83.82%), epigastnc reaction and sprawled down to 57 cas (83.82 % ) , with a volume on umbilical examination is 4 cas ( 5,88 %), point back ribs 20 cas posibve is 29.4 % occupied. The
' 0^1 hgc Y Ha N0i
Phin bi$n khoa hpc: PGS.TS. Trjnh Van Tuan
number of patients with fever of 37.5 °C 31 cas accounted for 45.58%. Siem sound capable of pancreas was observed 56 cas for 83.35%, 65 cas CT occupied 95.58% of gallstones CT capable identified 97.67% 94.19% ultrasound. Surgery 1 week before in 53 patients: complication rate 8/53 patients (15.09%). 1 week after surgery in 11 patients: Complication rate 2/U patients (18.0%), Treatment results: good 51 patients accounted for 79.68%, average 14.06% occupied 9BN, bad as 6.26% (1,56% including death). Conclusion:
The diagnosis is based on dinical signs have value onentation, ultrasound and computerized tomography diagnostic value determined. Pancreatitis due to gallstones early surgical treatment gives good results
Keywords: hcute pancreatitis, gallstones.
I. OAT VAN OE
Viem tuy cap (VTC) la mdt tinh trang viem cap tfnh ciia tuyen tuy, benh thydng xuat hien dot ngdt vdi cac trieu chirng lam sang da dang, dien bien nang ne. Nguyen nhan va cd che benh sinh cho den nay van cdn tranh cai, nhyng qua nghien ciTu ciia nhieu tac gia eho thay khoang 30%-60% BN VTC phat hien thay soi tren dydng mat. VTC the phii ehiem 8 0 % va 20% la VTC hoai tir, Chan doan dya vao lam sang chi cd tfnh gdi y, chan doan xac djnh chii yeu dya vao sieu am (SA) va cat Idp vi tinh (CLVT).
Vdi VTC do sdi mat, viee dieu tri nguyen nhan ehii yeu la ngoai khoa. Va ed 2 phypng phap phau thuat nhy mo md va mo ndi soi (NS).
Moi phypng phap deu cd Uu nhypc diem nhat dinh va cd chl dinh rieng, nen viee lya chpn cae phydng phap thfch hdp cho tirng trydng hgp de mang lai ket qua dieu tri cao cho ngydi benh, dd la mdt van de can phai dat ra. Chfnh vi the trong de tai nay chiing tdi tien hanh nghien ciTu nham:
1. Md ti die diem iam sang can lim sang cua viem tuy cip do sdi mat.
2. Dinh gii ket qua sdm cua can thiep phau thuat trong viem tuy cip do sdi mat
II. OOI TU'ONG VA PHUONG PHAP NGHIEN COU 2 . 1 . Ool tiTdng va phu'dng phcip nghien ciru: Nghien ciru md ta, hdi eiru va tien ciru d cac BN cd day dii ho sd benh an, dype chan doan sau mo VTC do sdi mat va dieu tri can thiep
Y HOC VIET NAM THANG 3
bang phau thuat tir nam 2008-2012 tai khoa Ngoai benh vien Bach mai.
2.2. €>ieu tri phiu thuat; th6i diem phau thuat du'cfc ti'nh tir l<hi nhap vien, du'de chan doan xac djnh la VTC do sol mat. Chung toi phan ra lam hai nhom: mo tru'de 1 tuan la sdm va sau 1 t_uan la mugn. Phu'dng phap phau thuat gom:
phau thuat md va phau thuat ngi soi (PTNS) 2.3. Ket qua di'eu trh_Du'dc danh gia trong khoang thdi gian ttr sau phau thuat den khi xuat vien, dua tren tinh trang lam sang, Amylase mau, X quang, sieu am trudc khi ra vien va chung tdi quy djnh phan loai nhu' sau: Loai tot: khi BN sau mo on djnh, ra vien khong co bien chttng.
Loai trung binh: cd bien chtrng nhung dieu trj on djnh bang npi hoac ngoai khoa. Loai xau: BN sau mo khong hoac co hoi phuc nhtrng tien IUdng nang. Td vong trong va sau mo.
2.4. Xit ly so lieu theo chu'dng trinh phan mem SPSS phien ban 10. 0.
III. KET QUA
3.1. Dac diem chung: Nhom tud'i thudng gap nhat la 41-50 co 16 TH chiem 23,5%, nhd nhat la 18 tuoi cao nhat la 88 tuoi trung binh la 48,9 ± 16,8. Nhom CO tien sir sdi mat la 38 TH chiem 55,88%
3.2. Mot so dac diem lam sang: Dau thu'dng vj, ha su'dn phai 100%, 40 TH (60,47%) CO non, 49 TH (72%) CO vang da, bi trung tien la 29 TH (42,6%), bung chUdng la 57 TH (83,82%), phan iing vung thUdng vi va ha su'dn phai 57 TH chiem 83,82%, kham co khdi tren ron la 4 TH (5,88%), diem sUdn ItTng du'dng tinh la 20 TH chiem 29,4%. So ngudi benh cd sot tren 37,5 °C la 31 TH chiem 45,58%, 10 TH cd mach
nhanh >100 Ian/phut chiem 14,7%, HA thap <90 mmHg co 4 TH chiem 5,88% trong dd co 1 BN co bieu hien mach nhanh >120 Ian/phut va HA tdi da thap hdn 90 mmHg chiem 1,47%. Huyet ap dong mach tdi da > 90 mmHg chiem da sd 94,12%, < 90 mmHg cd 5,88%).
3.3. Mot so dac diem can Iam sang:
Amylase mau tang >3 lan binh thu'dng la 63 TH chiem 92,6%, trong i d tang tren 10 lan la 18 TH chiem 26,47%. Amylase nieu tang >3 lan la 64 TH chiem 94,1% trong dd tang >10 lan gap nhieu nhat la 21 TH chiem 30,8%, so BN co amylase nieu khong tang chiem 5,9%.
Tang dudng mau 32 TH chiem 47%, tang SGOT la 56 TH chiem 82,35%, SGPT la 58 TH chiem 85,29%, Bach cau tang >9000/ml la 52 TH chiem 76,47%, tang >15000/ml la 17 TH chiem 25%, Billirubin mau >20 la 58 TH chiem 85,29%.
* Ket qua sieu am va CL VT: Siem am cd kha nang quan sat diTdc tuy la 56 TH chiem 83,35%, CLVT la 65 TH chiem 95,58%, doi vdi sdi mat CLVT cd kha nang xac djnh du'de 97,67%, sieu am la 94,19%
3.4. Chan doan: chan doan tru'de mo VTC do sdi mat 6 64 BN chiem 94,11%, trong dd 57 BN chiem 89,06% la VTC the phu va 7 BN chiem 10,94% la VTC hoai tir. Con 4 BN chiem 4,65% chan doan tru'de mo la VTC, sau mo la : 2 TH viem phtic mac do viem till mat hoai tii, ap xe dtrdng mat vd, tac ruot.
* Clian doan trong mo: VTC the phii la 57 TH chiem (89,06%), the hoai tir la 7 TH chiem (10,94%). Tat ca 64 BN deu cd sdi trong du'dng mat hay dng mat chii (OMC)
3.5. Phu'ong phap va thdi diem phau thu|t
Bang J;Thdi diem can thiep nhau thuat qltTa PT mo md va PTNS Can thiep
TrUdc 7 ngay
Tru'de 2 ngay 2-4 ngay Sau 7 ngay
5-7 ngay Tong
PT mo md
15,38 60,93
20
39,07long
35,9332,8
17,18 100,0Nhan xet:J<i le BN mo trUdc 2 ngay ciia nhdm mo md chiem 41,86%, nhdm md NS chiem 39,7%.
Ty I'e mo sau 7 ngay ciia nhdm mo md chiem 13,95%, nhdm mo NS chiem 16,2%.
Bang 2: PhtTdng phap can thiep tren tuy Vitri
Dan lu'u HCMN
Md bad tuy + dan liTu HCMN
So benh nhan 4 8
Ty le (%)
6,25
12,5
Y HOC VIET NAM THANG 3 - SO 1/2014 Lay to chirc hoai tir -i- DL
DL ap xe tuy Khdng can thiep den tuy
Tdng
6 1 45
9,37 1,56 70,31 6 4 ! 1 0 0 , 0
Nhin xet'Ty le BN khdng phai can thiep tren tuy chiem 70,31, ty le phai can thiep tren tuy chiem 29,69%
Bang J / T y le can thiep dudnq mat va cac
— — — P t i i f d n g p h a p phau t h u a t PP can thiep d u ' d n g m a t — —___
1 2 3 4 5 6 7 8 9 10 11 12
Cat till mat Md OMC lay sdi + Kehr Md OMC lay sdi + Kehr + MTHT Cat TM + md OMC lay sdi + Kehr Cat TM -1- md OMC tham dd -i- Kehr
Md OMC lay sdi+ Kehr + DL ap xe OB Md OMC + Kehr + cat thuy qan trai Md OMC lay sdi+Kehr + ndi tuy ruot CatTM + md OMC + Kehr + MTHT DLTM + l a y s d i T M + MTHT CatTM-I- MTHT
CatTM + md OMC lay sdi + Kehr: DL 6 ap xe dudi tuv + cat doan RN
Td'ng
phUdnq phap pt
PTmd md BN
5 5 14 4 1 3 2 1 1 1 1 1 39
12,82
%
12,82 21,87 10,25 2,56 7,69 5,12 2,56 2,56 2,56 2,56 2,56 6 3 , 2 3
di hdp PTNS BN
19 3 0 1 2 0 0 0 0 0 0 0 25
°/o 76 12 0,0 4 8 0,0 0,0 0,0 0,0 0,0 0,0 0,0 3 6 , 7 7
Tdng BN
24 8 14 5 3 3 2 1 1 1 1 1 6 4
o/o
37,5 12,5 21,87 7,81 4,68 4,68 3,12 1,56 1,56 1,56 1,56 1,46 100 (dc td viet tat: (OMC) dng mat chu, TM (tui mat), DL (dan iWu), MTHT) md thdng hong tring), OB (dbung)
Niian xit: Ty le mo cat tui mat chlem%, md OMC liy sol dan IWu Kehr chiem. Ty le md thdng hong trang chlem%
3.6. Bien chu'ng sau mo
Bing 5.'Ty le bien chifng so vdi tlidi diem can thiep Bien chu'ng
NT (nhiem trunq) vet md Dd mat Tac rudt Rd mat+Rd tuy VTC HT tien trien
Tdng
KQ Chung 4(6,25) 2(3,12) 2(3,12) 1(1,56) 1(1,56) 10(15,6)
< Itu'an N=53
4 1 1 1 1 (15,09)
> Itu'an N = l l
0 1 1 0 0 2(18,0)
The phii N=57
2 1 2 0 1 6(10,5)
Hoai tir N=7
2 1 0 1 0 4(57,1)
Md md N=39
4 2 1 1 1 9(23,07)
Md NS N=2S
0 0 1 0 0 1(4,0) NhinxifTy le bien chu'ng chung la 15,6% trong dd cua PTNS la 4,0%.
3.7. fidnh gia ket qua dieu trj
Bing 4: Ket qua dieu trj theo thdi diem va phydng phap phau thuat vdi eac the VTC
Mo < 7 ngay
<2n 2-4 n 5-7 n Mo >7nqay
Momd Mo NS
Tdt BN 19 17 7 8 28 23
88,1 %
85,0 77,7 72,7 71,79
92,0
Trung binh BN
4 2 1 2 8 1
9,5 %
10.0 11,1 18,2 20,5 4,0
Xau BN
1 0 1 1 2 F l
2,4
%
0,0 11,1 9,1 5,12 4,0
Tir vong BN
0 1
J L j
0,0 %
5,0 0,0 0 0,0 1 2,56 0 i 0,0
Tdng BN 24 20
37,5 %
31,25 r 9 i 14,06 1
11 39
^ 5
17,18
63,23
36,77
Y HOC VIET NAM THANG 3 . , „ . .
VTC the Phil
VTC hoai tir 48
3 88,0 42,85
7 2
9,3 28,56
2 1
2,7 14,28
0 1
0,0 14,28
57 7
89,06 10,94
Nhan xet: Ty Ie KQ tdt tren VTC the phu ne ehiem i(3/7BN).
i,00% {48/57BN), the hoai tii chiem 42,85%
IV. BAN LUAN
4 . 1 . Cac dau hieu lam sang
Trong nhdm nghien CLTU BN trong ed dp tuoi trung binh la 48,9 ±16,8. Nhdm ed tien sii sdi mat la 58,88%. Cac dau hieu lam sang thydng gap: 45,58% BN ed sdt vdi t° > 37,3 °C so sanh vdi ket qua eua eae tae gia khac nhy; Fagnier la 85%, Nguyen Khac Oirc la 6 0 % [ 2 ] . Trong nhdm nghien euU ty le maeh nhanh >100 Ian/phut cd 14,7%, HA thap <90 mmHg cd 5,88%. Vang da la mpt dac diem chung cua viem tuy cap do sdi mat, chiing tdi gap tdi 7 2 % va hau nhy tat ca BN deu cd dau vung thydng vj va HSP 100%, non 60,47%, bi trung tien 44,18%, bung chydng 83,82%, phan uTig vung thydng vi, ha sydn phai 83,82%, ed khdi tren rdn 5,88%, diem sydn lyng dau ehiem 29,4%.
Nhijrig ty le nay so vdi ghi nhan eua eae tae gia khdng cd sy khac biet Idn [ 5 ] .
4 . 2 . Cac dau hieu can lam sang Amylase mau va nieu: theo Benhamon khi tang Amylase mau gap 3 lan binh thydng thi d\idc chan doan la viem tuy cap [ 1 ] . Chung tdi thay tang Amylase mau gap tren 3 lan gap 92,6% ehu yeu la tang tren 10 lan binh thydng 26,14%. Cd 9 4 , 1 % BN Amylase nieu tang gap 3 lan binh thydng va tang tren 10 lan la 30,8%. Sd BN ed tang dydng mau chiem 4 7 % , b/ le tang SGOT la 82,35%, SGPT la 85,29%. Bach cau tang >9000/ml chiem 76,47%. Billirubin toan phan tang >20 mg/l la 85,29%, Hematocrit giam
< 2 5 % ed 7,35%, calci mau va Ure mau khdng thay gi thay doi dang ke. Ket qua phu hdp vdi ket qua cua eac tae gia khac [ 3 ] , [ 5 ] , [ 7 ] .
* Sieu a m : Theo Bank and Chow cho rang SA cd the phat hien nhUng bat thydng cua tuy tii 48-86%. Nghien cifu cua chiing tdi ed ket qua la 82,56% cung phu hdp vdi eae nghien ciru tren, theo nghien culi ciia Ha Van Quyet la 79,6%, nhyng kha nang xac djnh sdi eao hdn 94,19%.
Nguyen Khac Ou'c la 100 [ 7 ] , [ 5 ] , [ 2 ] .
* Cat I6p vl tinh: theo Balthazar phydng phap chup CLVT trong VTC cd do nhay 9 0 % , ket qua trong nhdm NC ciia chiing tdi cd cao hdn la 95,58% phat hien dydc sdi mat, nhy vay qua NC
nay CLVT la mdt phydng phap cd kha nang chan doan cao [ 6 ] ,
* Chan d o a n : trong nghien ciiu ty le chan doan dung trydc md' so vdi trong mo' la 9 4 , 1 % trong dd VTC the phu 89,06% va VTC hoai tir 10,94%. Ty le ehan doan sai viem tuy cap 5,9%, cao hdn Le Manh Cydng 3 % [1] nhyng thap hdn so vdi Nguyen Quang NghTa [ 4 ] 26,16% s y khac nhau nay cd le do ddi t y d n g nghien ctTu va thdi diem khae nhau.
4 . 3 . Phu'dng p h a p can t h i e p t r e n tuy:
hoai tii tuy la mot bien chu'ng hay gap trong VTC chieml9,5-20% cac trydng hdp theo Bradley va Buchler ve phydng phap phau thuat chi dat ra khi cd bien ehirng nhiem triing. Theo ghi nhan eiia Ha Van Quyet ty le can thiep tren tuy la 36,5%, Trong nhdm nghien eiru ciia chiing toi la 2 2 , 6 1 % [ 5 ] .
4.4. Phu'dng phap can thiep tren du'dng mat Theo ghi nhan ciia Ranson 36-63% VTC tai phat khi sdi mat edn de lai, ngydc lai chi co 2-8%
VTC tai phat sau can thiep ngoai khoa lay sdi. Do vay viec ean thiep sdi trong dydng mat la het sire quan trong vi day la nguyen nhan ehinh gay VTC.
Trong nhdm nghien ciru nay tir Bang 3 cho thay;
Chi dinh md OMC lay sdi + Kehr la phydng phap dydc ap dung nhieu nhat 32 BN (50,00%). Cat till mat 35BN chiem 54,68% va md thdng hong trang la 18 TH chiem 28,12%. Qua nghien c\i\s nay chiing tdi nhan thay rang md thdng hong trang rat cd gia trj sau mo, ty le chydng bung sau mo giam han va nhat la cd the cho BN an qua sonde sdm rat tdt cho viec hoi sire. Quan diem nay dydc eac nha hoi sire tich eye rat iing hd.
4 . 5 . Thdi d i e m can t h i e p va bien chd'ng theo eac tac gia Fagnier va Jaeck ghi nhan mo trydc 7 ngay ty le bien chirng 4 0 % , tir vong 3 0 % ; mo sau 7 ngay ty le bien chirng 2 1 % va tir vong 14%. Nhy vay trong phau thuat 64 BN ed sdi dydng mat dyde chi dinh phau thuat trydc 7 ngay 82,82%, phau thuat sau 7 ngay 17,18%.
Theo chiing tdi thdi diem mo phu thupc chinh vao dien bien lam sang cua ngydi benh khi dieu tri npi khoa phdi hdp khdng ed tien trien tot, nhat la ddi vdi nhiing BN dydc chuyen tii tuyen dydi
Y HOC VIET NAM THANG 3 - SO 1/2014 len ho3c dieu tri tai nha khdng dung vdi phae do
dieu tri VTC. Neu xac dinh VTC do sdi mat nen chi dinh giai quyet nguyen nhan bang phau thuat md hay npi soi hoac lay sdi qua ERCP neu sdi ddn thuan d dydng mat ehinh. Day la van de can phai CO nghien CLTU tong the hdn.
Bien chyng gap d thdi diem phau thuat trydc 7 ngay la 8/53 BN (15,09%) gom 4 BN n h i l m trung vet mo, 2 BN rd mat, IBN rd mat - rd tuy, va cd 1 BN VTC tien trien so vdi bien chirng d thdi diem phau thuat sau 7 ngay la 2/11 BN (18,18%) gom 1 BN rd mat va 1 BN tae rudt. Ty le bien chu'ng sdm sau mo ciia chiing tdi la 10 BN chiem 15,6%, cao hdn do vdi nghien ciTu ciia Le Manh Cydng 14/304 (4,6%), Nguyen Khac Dure la 8,9% nhyng thap hdn Ninh Viet Khai 2 6 , 1 % [ 1 ] , [ 2 ] , [ 3 ] .
4 . 6 . Ket qua deu trj
4.6.1. Kit gui chung: Trong 64 BN dieu tri phau thuat VTC do sdi mat chung tdi thu dype k i t qua nhy sau; tot la 51 BN ehiem 79,68%, trung binh la 9BN chiem 14,06%, xau la 4 BN 6,26% trong dd tir vong 1,56%. So vdl Nguyen Khac Dure ty le tot 6 4 , 1 % , trung binh 25,7%, xau 6,4%, tir vong 3,8%. So vdi ty le tir vong 19,6%
ciia Ninh Viet Khai nghien eiru tren nhdm VTC khdng do nguyen nhan cd hpc thi ty le tir vong nhdm NC ciia chiing tdi thap hdn nhieu 1,1%.
Nhy vay qua ket qua NC nay VTC do sdi mat ed tien lypng tot hdn so vdi VTC khdng do nguyen nhan cd hpc.
4.6.2. Ptian ticii ket qui: Theo ghi nhan tal bang 4. Vdi ket qua tot trung binh la 79,68 % trong dd phau thuat mo md cd ket qua tdt la 71,79% SO vdi PTNS la 92,0%. Ciing vdi ket qua nay VTC the phii cho ket qua tot cao hdn 84,21 % so vdi VTC hoai tir 42,58% va thdi diem mo trydc 1 tuan cho ket qua tdt 81,13% so vdl thdi diem mo sau 1 tuan la 72,7%. Qua ket qua tren cd s y khac biet dang ke giUa cae phydng phap phau thuat, thdi diem phau thuat va cac the VTC. Tir do qua nghien ciru nay chiing toi thay rSng VTC do sdi mat dieu tri sdm bSng phau thuat cho ket qua kha quan hdn. The hoal tir trong viem tuy cap ludn la moi de dpa doi vdi tien lypng ciia BN sau md". Phydng phap mo md hay npi soi phy thupc vao s y chi djnh ddi vdi tiitig BN va kinh nghiem cua phau thuat vien.
Ket qua trung binh 9 BN ehiem 14,06%, khdng ed s y khac biet dang ke so vdi cae thdi diem can thiep, ddi vdi VTC the hoai tir va phydng phap phau thuat mo md cd ket qua trung binh eao hdn do vdi VTC the phu va PTNS .
Ket qua xau 4 BN (6,26%) trong dd ed 1 BN (1,56%) tir vong deu la VTC hoai tir dydc phau thuat md md vdi thdi diem can thiep trydc 1 tuan la 3 BN, sau 1 tuan la 1 BN. Phan loai theo nhdm phydng phap md thi ty le xau d nhdm mo md la 2/39 BN ehiem 5,12% va 1 BN tir vong sau mo (2,56%), nhdm PTNS ty le xau la 1/25 BN chiem 4,0%, khdng cd tir vong.
V. KET LUAN
Trong NC vdi 64 BN dype dieu trj phau thuat VTC do sdi mat chiing tdi ed mpt sd nhan xet sau:
- Chan doan dya vao dau hieu lam sang ed gia tn dinh hydng, sieu am va eat Idp vi tfnh cd gia t n chan doan xac djnh.
- VTC do sdi mat d the phii, dieu tri phau thuat sdm eho ket qua tdt.
TAI LIEU T H A M KHAO
1. Le Manh Cu'dng (2003); "Nghien ciTu d3e diem lam sang, can lam sang va danh gia ket qua gan dieu tn can thiep viem tuy cap do soi giun tai Benh vien Viet Ou'c". Luan an thacsy Yhoc J.. Nguyen Khac Dii'c (2000), "Nghien cyu dSc
diem lam sang, can lam sang va thai do xy tri ngoai khoa viem tuy cap do soi mat", Luan in thacsy Yhoc.
3. Ninh Viet Khai "Danh gia ket qua dieu trt phau thuat viem tuy cap hoai t y khong do nguyen nhan cd hoc tai benh vien Viet QiSc tii hll^Ql den 10/2005". Luan an tot nghiep bac si ngi tru 4, Nguyen Quang NghTa {1995), "Nghien ciru
dieu trt phau thuat viem tuy cap tai Benh vien Viet Diic", Luan in phd tieh sy khoa hgc Y dWOc. Dai hoc YHa Ngi
3. Ha Van Quyet, Le Quang Cu'dng (2004) "
Nghien ciru chan doan va dieu tn can thiep VTC so 501 - giun tai benh vien Viet- Ddc".Y hgc thwc hanh s6491tr: 176-180
6. Balthazar R.J, Robinson D. L (1990); "Acute pancreatibs:Value of CT in etablishing prognosis";
Radiology 174:331-336.
7. Bank and Chow (1994); "Diagnostic Tests in chronic Pancreattis" The gastroenteroigist 2(3):224-32
