NGOAI KHOA SO 2/2010 MOT SO KET QUA GHEP GAN
T i f N G E * O T C H O S O N G O- v i i : r N A M
Le Trung Hai* va cong sir
I. OAT VAN Of
Tren the giai. ghep gan tir ngudi cho song da duac chap nhan va tra thanh mot bien phap co hieu qua dd dieu tri nhirng benh ly gan mat giai doan cuoi.
C> Viet Nam benh ly gan mat gap kha phd bien va so benh nhan gan mat co chi dinh ghep gan la rat dang ke. Chung ta co phuang phap cat gan ndi tieng ciia Ton That Tung va nhung cong trinh giai phiu gan ung dung trong ghep gan ciia Trinh Van Minh.
Sau nhirng thanh cong vd ghep than tir nguai cho song vao nam 1992. cac nha khoa hoc Viet Nam da co nhuhg chuin bi cong phu ve nhieu mat cho ghep gan. Ngay 31/1/2004 trudng hap ghep gan dau tien tren ngudi d nude ta da dugc thuc hien thanh cdng tai Hgc vien quan y.
Den nay. tai Viet Nam da cd 14 trudng hgp ghep gan tir ngudi cho sdng dugc tien hanh tai 4 trung tam la Hgc vien Quan y, Benh vien Nhi Trung uong, Benh vien Viet Dire va Benh vien Nhi ddng II Thanh phd Hd Chi Minh.
Bdi viet neu len mot so ket qua ghep gan tic ngudi cho sdng a Viet Nam.
II. CHi OjNH GHEP GAN VA CONG TAC CHUAN Bj TRU6C GHEP
2.1. Chi dinh ghep gan:
- Benh dudng mat: Xa gan mat tien phat, viem dudng mat xa hda tien phat, teo
* Benh vien 103
dudng mat, benh Caroli.
- Benh te bao nhu md gan: Xa gan mat bu do cac nguyen nhan: sau viem gan do virut B, C; do ruou; khdng rd nguyen nhan;
do tir midn. Benh Wilson va mdt so benh chuydn hda khac.
- Cac benh khac: Ung thu gan, hdi chiing Budd-Chiari, suy gan tdi cap
2.2. Tuyen chon cap ghep
- Trong tuyen chgn ngudi cho gan da tien hanh tren 30 nhdm chi tieu chuyen mdn, trong dd cd chup cit ldp vi tinh (CT) gan vi tiem thud'c can quang dinh gii the tich gan ciia ngudi cho.
- Ddi vdi ngudi nhan gan da tien hanh tren 30 nhdm chi tieu chuyen mdn de chuan bi trudc ghep.
2.3. Chuan bi ngudi cho gan
- Vao vien trudc md 3 ngiy, lam cac thu tuc hinh chinh va ky giay md.
- Cac kip kham xet trudc md ve lam sang, cic chi so sinh ton vi ddi chieu cic xet nghiem va cac chi tieu tuydn chgn. Chuin bi 1000 ml miu toan phin ciing nhdm vi 600 ml huyet tuang tuai lanh (FFP)
- Ngiy trudc md: an nhe, ve sinh, thut thao - Thudc an than trudc md: seduxen 5mg x 1 vien udng trudc khi di ngu.
2.4. Chuan bi ngudi nhan gan
- Chuin bi mau cung nhdm: khdi hong ciu da lgc bach ciu cd chieu xa, huye't tuang tuai lanh, khdi tidu cau. Du tru tdng so the
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NGOAI KHOA SO 2/2010 ti'ch che pha'm mau (tinh bang lit) tuong
duong voi trong lugng co the' benh nhan (tmh bang kilogam). Co the tien hanh thay huyet tuong (PE), sieu loc mau (CHDF), truyen Albumin, huyet tuong tuoi lanh.
- Trudc ghep: cho an nhe, dung khang sinh pho rong, truyen dich va dien giai, diing thuoc nhuan trang, nguoi nhan gan lam don xin m6, cac kip kham xet trudc m6. cho thuoc an than, thut thao, ve sinh viing md.
III. KET QUA GHEP GAN Tlf NGUdl CHO S6NG 6 VIET NAM
3.1. So lieu chung:
Tu 1/2004 den 12/2009 da co 14 truong hgp ghep gan tu nguoi cho song dugc thuc hien tai 4 benh vien (BV) d Viet Nam.
- Trong dd nam 2004: 1 trudng hgp, nam 2005: 2 trudng hgp, nam 2006: 4 trudng hgp, nam 2007: 3 trudng hgp, nam 2008: 3 trudng hgp va nam 2009: 1 trudng hgp.
- Cac co sd ghep gan: Hgc vien quart'y: 1 trudng hgp, Benh vien Nhi Trung UOng: 5 trudng hgp, BV Nhi ddng II: 7 trudng hgp.
BV Viet Due: 1 trudng hgp ngudi Idn.
3.2. Dac diem nguoi cho gan:
+ Me de: 5 trudng hgp + Bd de: 4 trudng hgp + Ba ndi: 3 trudng hgp + Chau trai: 1 trudng hgp + Chii rudt: 1 trudng hgp
- Tud'i ngirdi cho gan: tir 29-56, trung binh la 38,6 tuoi
- Manh gan lay:
+ Thuy gan trai: 10 trudng hop (trong dd cd 1 trudng hgp cd 2 ddng mach ciia thuy gan trai)
+ Thuy gan trai + thuy dudi: 1 trudng hgp
+ Gan phai: 3 trudng hgp (1 cd dudng mat phan thuy sau gan phai dd vao d'ng gan trai, 1 cd bat thudng ddng mach gan trai va 1 trudng hgp ghep cho ngudi Idn)
- Trong md cat lay gan tir ngudi cho song da irng dung cac ky thuat nhu:
+ Ky thuat treo gan (thu thuat Belgiti) + Ky thuat cap cud'ng gan (thu thuat Pringle)
+ Ky thuat cat nhu md gan vdi dao sieu am (CUSA)
+ Tao hinh tTnh mach ciia manh ghep + Sieu am Doppler mach mau gan va chup dudng mat trong md
- Ket qua sau md ddi vdi ngudi cho gan: 100% deu ra vien khoe manh.
3.3. Benh nhdn ghep gan:
- Gidi: nU 12 benh nhan (BN), nam 2 BN.
- Chan doan:
+ Teo dudng mat bam sinh: 10 trudng hgp vdi cac bien chung nang nhu xo gan, tang ap luc tinh mach cira, chay mau tieu hda ...
+ Xo gan chua ro nguyen nhan: 3 trudng hgp vdi cac bien chirng cd chudng, tac mat keo dai ...
+ Ung thu gan nguyen phat tren ndn xo gan, viem gan B man: 1 trudng hgp
- Lira tudi benh nhan ghep gan:
+ Chin trudng hgp ghep d tre nhd (tu dudi 1-2 tudi).
+ Bd'n trudng hgp ghep cho tre Idn (tir 5- 16 tudi)
+ Mdt trudng hgp ghep gan ngudi Idn (47 tudi) - Trong md ngudi nhan gan: da ung dung cac ky thuat nhu ap dung vi phau dd ndi ddng mach gan va ndi dudng mat nhd; Tao hinh tinh mach cira, tinh mach tren gan; sieu am Doppler mach mau trong va sau md ...
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NGOAI KHOA SO 2/2010 - Mot sd dac diem ky thuat xir tri
trudc, trong va sau ghep:
+ Trong so 9 trudng hop ghep gan a tre nho (< 2tu6i): cd 1 benh nhan do d'ng gan trai qua nhd (dudng kinh 1 mm), sau ghep 1 tuan cd bien chung tdc mat va phai md lai ndi mat rudt. Cd 3 trudng hop phai tao hinh (venoplasty) tinh mach cira d ngudi nhan do tinh mach cira bi tdc hoac qua nhd. Manh ghep tinh mach sir dung trong tao hinh dugc lay tu tinh mach buong trung hoac tTnh mach mac treo trang dudi ciia ngudi cho. Mdt trudng hgp mdi ghep gdn day cd the trang khi vao vien rat nhd (12 thang tudi song nang cd 6,5 kg va cao 64 cm), phai nudi dudng tich cue trudc ghep.
+ Trong so 4 truong hop ghep gan a tre Idn (tit 5-16 tuoi): cd 1 trudng hgp phai ndi tinh mach cira den 3 Idn do hep va tac mieng ndi dugc phat hien qua sieu am Doppler mach mau trong md. Cd 1 trudng hgp (BN so 9) sau ghep ngay thU 2 da cd bien chuhg thai ghep cap rat sdm va da dugc xir tri dn dinh.
Rieng trudng hgp ghep gan ddu tien trong qua trinh dieu tri sau ghep da cd 3 lan bien chirng thai ghep cap (cd sinh thiet gan kem theo), 2 lan qua lieu thud'c uc che mieh dich (cyclosporine va tacrolimus) va da dugc xir tri dn dinh. Benh nhan ghep gan thu 2 cd bien chirng cd chudng dai ngay sau ghep, sau nay da dugc phdu thuat cdt lach va ndi lach than dieu tri cd chudng.
+ O 1 trudng hop ghep gan cho ngudi Idn: da sir dung tinh mach hien ciia ngudi nhan de tao hinh cho tinh mach gan ciia ha phan thuy V. Sau ghep ngay thu 2 BN nay phai md lai do bien chirng chay mau. Sau xir tri benh nhan dn dinh.
- Ket qua chung sau ghep:
+ Kit qua s&m sau ghep:
. Mudi ba benh nhan ghep gan da ra vien dn dinh.
. Mdt BN (ca ghep gan so 7) tir vong trong thang dau do suy gan.
+ Ket qua xa sau ghep:
. Hai benh nhan da tir vong sau ghep: BN ghep gan so 9 tir vong sau ghep 18 thang do benh ly ac tinh bach huye't va BN so 13 tir vong sau ghep dugc gdn 1 nam do nhidm EBV va cd hdi chirng thuc bao mau.
. Cac benh nhan cdn lai: kidm tra dinh ky sau ghep cho thay chuc nang gan td't va sue khoe benh nhan dn dinh. Benh nhan ghep gan dau tien den nay da dugc tren 6 nam, da tang them tren 20kg thd trgng, hgc gidi, sue khoe va chuc nang gan td't.
IV. NHAN XET VA KET LUAN
- Cac trudng hgp ghep gan tir ngudi cho sdng ciia Viet Nam chii yeu da dugc chi dinh cho nhirng trudng hgp tre em bi teo dudng mat bdm sinh da cd nhirng bien chung nang, ngoai ra la cac benh ly xa gan mat bu va ung thu gan tren nen xa gan d benh nhan ngudi Idn cd viem gan virut B.
- Nhung ket qua budc ddu qua 14 trudng hgp ghep gan tir ngudi cho song d nude ta la rat dang khich le. Thanh cdng ndi tren md ra trien vong dieu tri cho nhung ngudi bi benh ly gan mat giai doan cudi va thuc day phat trien nhieu chuyen nganh y hgc khac.
- Thuc hien td't cdng tac tuyen chon cap ghep, hoan thien vd ky thuat md va nhat la theo ddi, dieu tri td't sau ghep la nhuhg yeu to quan trgng quyet dinh den chuc nang gan ghep va she khoe benh nhan sau ghep gan.
Van de chinh la phai dam bao an toan ddi vdi ngudi cho gan.
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NGOAI KHOA SO 2/2010 TAI LIEU THAM KHAO
1. Pham Gia Khanh, Le Trung Hdi, Hoang Manh An, Vu Huy Niing vd CS: Ket qua budc dau ghep gan tren ngudi tai Hoc vien quan y. Tap chi Y Duoc hoc quan sir, Hoc vien quan y, 30/2005, trang 10-17.
2. Le Trung Hdi va cong su: Ghep gan tu ngudi cho song: Kinh nghiem ciia Nhat Ban va tr- udng hop dau tien cua Viet Nam. Tap chi Y hoc thirc hanh, Bo Y te, Sd 491/2004, trang 146-149.
3. Le Trung Hdi, Trdn Dong A, Trdn Minh Dien, Nguyen Quang Nghia vd cong su:
Tinh hinh ghep gan tu ngudi cho sdng d chau a va Viet Nam hien nay. Tap chi Y hoc Viet Nam, So 12/2006, trang 264-267.
4. Le Trung Hdi: Ghep tang - Mot sd kien thuc chuyen nganh va quy trinh ky thuat. Nha xuat ban Y hoc, Ha Noi, 2009.
5. Le The Trung: Ghep gan - Nhung kho khan va cac trien vong. Tap chi Thong tin Y Dugc, so 7/2004, trang 6-9.
6. Ton That Tiing: Cat gan. Nha xuat ban Khoa hoc va ky thuat. 1971, trang 211-225.
7. S.T. Fan et al: Living donor liver transplantation.Takungpao Publishing, Hong Kong, China, 2007
8. K.Ozawa: Living related donor liver transplantation. Karger, 1994, pp 46-54.
9. K. Tanaka et al: Living donor liver transplantation - Surgical techniques and innovations. Prous Science, 2003, pp 29-95.
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