TAP CHI NGHIEN CIFU Y HpC —
KET QUA PHAU THUAT DI^U TRj 296 TRU'CNG HO'P THOAT V! C a HOANH B A M SINH B A N G P H A U THUAT NQI SOI
L 6 N G NGyc
Nguydn Thanh L i e m \ Trdn Thanh Tii^
^Bdnh vign da khoa Vinmec, ^Bdnh vi$n Nhi Tmng wang Nghien cuu nhim dinh gii kit qui diiu trj thoit vi eo hoanh bim sinh bing phiu thudt ngi soi Idng ngwc. Nghidn eiru hoi ciru cie bgnh an cua tit ci bgnh nhan da dupe mo thoit vj eo hoinh bing phiu thudt ndi soi ling ngwc tir nam 2001 - 2012 tai bgnh vidn Nhi Tmng wong. Trong thdi gian nghien c&u di cd 296 bdnh nhi bi thoit vi ca hoanh bam sinh dwac phiu thudt bing ngi soi Idng ngwc bao gdm 149 tre sasinh va 147 tre ngoai sa sinh 30 (10,1%) bdnh nhin phai chuyen sang mo md. Th&i gian phiu thugt tmng binh li 70,1 ± 27,5 phut cho nhdm so sinh va la 75.8 ± 25.6 phut cho Ire ngoii so sinh. Khdng cd tO-vong tmng mo.
42 (14,2%) bdnh nhin tir vong sau md. Nguyen nhan chu yeu la nhiem tning va ting ip Ipc d0ng mach phoi Thdi gian nim vign tmng binh cho cic bdnh nhin edn sdng d so sinh li 13,3 ngiy vi la 12 ngiy d nhdm ngoii sa sinh. Phau thuat ngi soi long ngwc kha thi, an toan va higu qui dd diiu trj thoit vj ca hoanh bim sinh d tre em bao gdm ca tre sa sinh.
Tip khda: Thoat vj c a hoanh b i m sinh, p h l u thU$t npi soi
I. DAT
V A NDt
Thodt vi CO hoanh bam sinh (TVCH) qua Id sau bdn hay edn gpi Id thodt vi qua l3 Boehdaleek Id sy di chuyen eua ede tang ndm trong 6 bung nhu dg day, rudt non, dai trdng, gan, Idch ldn tren long ngyc. Cae tang td o byng chui ldn long ngyc ldm cho phoi ci;ing bdn bj giam sinh dong thdi day trung that sang bdn doi didn chdn dp vdo .phoi vd Idm gidm sinh phoi doi dien Muc dd ton thuong phoi phy thude thdi gian xay ra thodt vi, cdc tgng Idn 0 byng cdng sdm thi phoi bj giam sinh cdng ndng.
Thodt vj CO hoanh gay ndn tinh trgng suy hd hap n|ng d tre sa sinh, niu khdng dupe dieu trj kip thdi se ddn den tCr vong.
Bia ch! lldn hd: Nguyen Thanh Li&m. -Bdnh vidn da khoa Vipmec
Email [email protected] ngiy nhdn: 06/5/2014 Ngiy tfupc chip thudn: 29/8/2014
Cho din nay phau thu$t Id phuang phdp duy nhit de dieu tri thodt vj co hodnh Tnjdc kia phdu thudt dilu trj thodt vj ca hodnh bim sinh duac thyc hign blng phiu thudt qua md nguc hay md bung Phiu thudt ndi soi long nguc d tuoi vj thdnh nidn duac Silen thyc hidn lln diu tidn ndm 1995 vd chCing tdi thuc hidn lan dau tien d sa sinh ndm 2002, [1; 2].
Mdc dCi dd cd nhieu cdng trinh nghidn Quu vd phau thudt ndi soi ling nguc dilu tn thoat vi CO hoanh nhung ehua cd mdt nghidn cCru ndo cd thdi gian ddi vd s6 lupng b§nh nhdn Idn du d l ed ede ddnh gid vd kit lu^n ve nhO'ng uu dilm vd hgn che cOa phuang phdp ndy.
Myc dich eua bdo cdo ndy Id nhim ddnh' gid kit qua dilu trj thodt vj eo hodnh vdi 296 trudng hap tgi bdnh vidn Nhi Trung uong trong thdi gian 11 ndm, tu ndm 2001 din ndm 2012.
TCNCYH 89 (4) - 2014
• TAP CHl NGHIEN CO'U Y M < ) 6
II. D6\ TU'ONG VA PHU'ONG PHAP III. K^T QUA
Nghidn cCru h i i c u u dua trdn ho s a eua cdc bdnh nhi bj thodt vi co hoanh d u o c p h i u thudt b l n g ndi soi l i n g ngyc tCr thdng 1 ndm 2001 d i n thdng 12 nam 2012 tai bdnh vidn Nhi Trung uong.
Tieu chuin lya chon: Tat ea bdnh nhdn b[
thodt vi ea hodnh b i m sinh dupe p h i u thu^t blng ndi soi long nguc l l n d i u .
Tieu chuan to?/frur thodt v i e o hodnh do chin thuang. thodt vi c o hodnh tdi phat.
Nghidn c u u d u a e thdng qua Hdi dong dao ddc bdnh vidn Nhi Trung u o n g ngdy 30 thdng 12 ndm 2012.
Trong thdi gian nghidn edu, tong so ed 296 bdnh nhdn bj thodt vj co hodnh dupe phdu thuat bdng npi soi l i n g nguc bao gdm 185 (62,5%) nam. 111 (37,5%) nO'. Cd 149 tre Id s a sinh (50,3%) vd 147 bdnh nhdn ngodi t u l l so sinh (49,7%).
Thanh p h i n khoi thodt vj d nhdm tuoi so sinh chu yeu Id rudt non, dgi trdng, mac ndi vd laeh, thdnh phan ehu y l u eua thodt vi c a hodnh d nhdm tuoi ngodi s o sinh Id da ddy vd gan (bieu dd 1),
So' smh M g o a l s o ' S i n h
RLiOlnon RLI61I:;I.I Da doy (j,in L.icll Th^n Mac nOi Bidu d d 1 . Thdnh phdn k h d i t h o a t vj
Ty l§ thodt vj e a hodnh cd mang bpe Id 35,8 % d tuoi ngodi s o sinh t h i p hon vdi thodt vj c o hodnh d tuoi so sinh (64,2%). S u khde bi^t cd ^ nghTa thong kd (OR = 0,23, p < 0,05).
Phuang phdp x u li Id thoat vi d y o c trinh bdy trong bang 1
Cd 30 t r y d n g hap da phai chuyen sang mo m d (10,1%). TI Id chuyen mo m d khdng khac nhau d nhdm t u l i s o sinh so vdi nhdm tuoi ngodi so sinh (bang 1}
TCNCYH 89 (4) - 2014
T*P CHl NGHIEN CCPU Y HOC -
Bang 1. Phircrng phap xip tri 16 thoat vj Tre so> sinh Ngoai sc sinh
Mieng va nhan taoC(S
3.3(22,1%) 116(77,9%)
14(10%) 133 (90%)
2,7 (1,3-6,7)
Phuoyig phap khau
ThSnh ngyc 90 (60,4%) 42 (30%) 3,8
Gi.in>Sp02 Lo TIU..II VI I6n r).i., kh6iTV khac
\iiiint> kha khan
Bilu dd 2. Li do ehuydn mo ma
ThiJi gian mo trung binh * nhSm tre sa sinh \i 70,1 ± 27,5 (pliut) 6 nhim tu6i sa smh \i 75,8 ± 25,6 (phiit)
CSc bien chiJng sau m6 nhu- tSng Sp lu-o ding mach, tran dich, trSn khi sau mo a tre so sinh cao hon so vii tre ngoai tu6i so smh NhUng sv khSc biet nSy deu c6 > nghTa thong kS (p < 0,05) (bang 2).
Bang 2. Biln chirng sau m5
Bien s6 Tre so* sinh Ngoai s a sinh Tang ip lyv dgng mach phoi sau
" 0 38 (97,4)
Cb 111(43,2) 1 (2,6)
146 (56,3)
< 0,001 50(8,1 -2038)
Trin dich, ftlii mang phoi
C6 24 (88,9)
3(11,1) = 0,001TCNCYH 89 (4) - 2014
- T ^ P G H r k G H I E N CO-UY i4pGr Tong so ed 42 bgnh nhan tu- vong (14,2%), bao gdm 38 tre sa sinh vd 4 tre ngoai tuoi so sinh, su' khac biet ed y nghTa thdng kd, {p < 0,001}.
Cae nguyen nhdn t u vong du-ac trinh bdy trong bang 3.
Bang 3. Nguyen nhan tu' vong
Nguyen nhan tu> vong S a sinh (N, %) Ngoai s a sinh (N, %>) Tdng Nhiem trung
T5ng ap lire d6ng mach ph6i R6I lo?n dong m^u
35(92,1) 21 (56,3) 6(15,8)
4(100,0) 1 (25.0)
0
39 22 6 Tong cdng
Thdl gian nam vien trung vi cua cdc benh nhan sdng ra vidn d nhdm so sinh Id 13,3 ngdy vd 1;
12 ngdy d nhdm ngodi s o sinh
IV. BAN LUAN
Ket qua nghidn eCru cung eho thdy phdu thugt ndi sol l i n g ngyc an toan de didu tn thodt vi CO hodnh Khdng cd trudng hap bidn chung vd tCr vong ndo xay ra trong mo
Phdu thugt ndi soi l i n g nguc ed the tidn hdnh de dieu trj thodt vi c o hodnh ea a tre so smh vdl ti Id thdnh cdng eao Ti Id chuyen mo md trong nghidn cCru eua chung tdi thdp hon so vdi cdc tac gia khac [3; 9]. Cdc nguydn nhdn chuyen mo m d ehu yeu Id khd khan khi dua thdnh phan thodt vi trd Igi 6 bung. Id thoat vj rpng vd giam dp bdo hda o xy cua bdnh nhdn. Chiing tdi eho r i n g d l giam ti le chuyen mo m d can ehu y d i n mdt so van de sau'
- Vl tri ddt troca' Dat eac trocar cdng eao cdng t i t . Vdi cdch bo tri trocar cao chCing tdi ludn ed mdt khdng gian du rdng de thuc hien cae thao tdc p h i u thugt. Cd the ddy la ydu td quan trpng k h i l n ti le chuyen mo m d eua ehCing tdi t h i p han eac tdc gia khde rdt nhieu 13; 4; 8]
- KJ thudt day ede tgng thodt vj ve 6 bung:
day ede tgng ve 6 byng Id thi khd khdn nhat trong m l thodt vi eo hodnh bdng dudng ndi
SOI Idng ngyc Can xdc dmh d u o c Id thodt vj trudc khi day cdc tgng v l d bung B i t ddu bdng day rudt non, dai trdng vd cuoi eCing la Idch DCing 2 panh kep rudt cap rudt nhg nhdng va luan phien nhau day rudt t h i n g gde vdl Id thoat vi. Day Idch can het sue t l nhi vi dd ldm v d laeh. Cap nhe vao mac noi vi ti d i y mac ndi vj ti xuong 6 bung J o n g thdi dung 1 panh khac hoac 1 que tam pong day nhg vdo b d laeh- Khi Id thodt vi bd e I n phai m d rdng bang c i t mep eo hoanh trudc khi day ede tang v l 6 bung,
Ky thudt khdu Id thoat vj da s l cdc trudng hap. Id thodt vi cd the d u o c che kin b l n g khau tryc tidp hai mdp ca hodnh vdi nhau Tuy nhien trong nhieu trudng hpp gde tao thdnh gida 2 mep ea hodnh vd thdnh ngyc khd rdng khdng the l i p kin b l n g khau 2 mep ea hoanh vdi nhau. Day Id mdt diem yeu vd la vj tri d§ gdy thodt vi tdi phdt Trong eae trudng hap nay ehCing tdi thuc hidn lap kin gde giii'a 2 . b d CO hoanh vd thdnh ngyc b l n g khau 2 mdp CO hodnh vdi thdnh ngyc. Rach da trdn thdnh ngyc, xuydn kim t u ngodi thanh nguc vdo
TfyP CHi NGHIEN CUOJ Y H p C -
trong long ngyc, khau lay mdp trudc co hodnh sau do khau Idy tidp bd ea hodnh ddi didn, xuydn kim trd lai thdnh nguc vd ldm not bude d ben ngodi thdnh ngyc Khi id thodt vi qud rdng (thudng trdn 2 khoang lien sudn) khdng ndn CO khdu 2 mdp co hoanh vdi nhau vi co hodnh se bi rach do dp lyc. Giai phdp tot n h i t Id dCing m i i n g va nhan tgo. Midng vd phai Id logi khdng tham nude de trdnh djch t u 6 bung bl hCit Idn trdn ngyc do ap lue am d Idng ngyc
Ty Id t y vong trong nghidn eCru eua chung tdi Id 14,2%, TCr vong xay ra chu yeu d nhdm tuoi so smh. Ddy la mdt tl Ig khd thap trong dieu th thodt vi c o hodnh so vdi nhL^'ng ndm tryde ddy vd eOng t y a n g d y o n g vdi n h i l u bdo cdo khde trdn t h i gidi [3, 9].
Nguydn nhdn tCr vong chu y l u la do nhidm trCing huyet ed lien quan d i n thd mdy vd tdng dp lye dpng mach phoi. T h y c te ndy eho thay tl Id t d vong cd the giam thap n i u chung ta thyc hidn cdc bien phdp ehdng n h i i m khuan vd dieu tn tang dp lue ddng mgeh phoi t i t hon
P h i u thudt ndi soi Idng ngyc dieu tn thodt vj CO hodnh" cd nhieu y u diem. Do ede eo thdnh bung hodc thanh nguc khdng bi e i t dut ndn ehCre ndng hd hap it bi anh hudng hop so vdl m d bung hoac m d ngyc Do ong tidu hda it b! dung chgm trong qud trinh p h i u thugt ndn luu thdng rupt cOng ehdng trd lai han. K i t qua ve t h i m mT cung tot hon do vet m l bd hon.
Quan nggi ldn n h i t Id thdi gian mo kdo ddi tuy nhidn thdi gian mo se rCit n g i n d i n khi kmh nghidm tdng len, Trong nghidn cCru eua chung tdi thdi gian mo trung binh Id 67,3 ± 37,3 (phijt).
So vdi p h i u thuat ndi soi o byng. p h l u thudt ndi soi long ngyc eho phep t i l p cdn Id thodt vj dd hon do khdng bj rudt can t r d Mdt so bdo cdo dd cho thay tf Id c h u y i n m l m d trong phdu thuat ndi soi 6 bung cao hon phdu thu^t npi SOI long nguc [8]
M^e dCi p h i u thudt ndi soi l i n g ngyc cd n h i l u y u diem nhung cung can edn nhde cho tre ed cdn ndng thap < 2000 gam vl phlu trudng khd hgp. P h i u thudt ndi soi long ngyc eOng khdng ndn chT dinh cho cdc trudng hpp ed dj tdt tim phdc tap phoi hp'p vi dd cd cdc b i l n logn kh( mdu vd huydt ddng tram trpng trong mo.
V. K £ T LUAN
Phau thudt ndi soi long ngyc kha thi, an todn vd higu qua de dieu trj thodt vi co hodnh bam sinh d tre em bao gom ea tre s o sinh,
L o ' i c a m o r i
Chung tdi xin chan thanh cam o n t§p t h i edn bd khoa ngoai, khoa h l l sue ngogi, phdng mo, phdng djch td vidn nghidn cuu sCre khoe tre em, bdnh nhi vd gia dinh ngudi bdnh dd giOp ehCing tdi hodn thdnh nghidn ciru ndy,
TAI LIEU THAM K H A O
1. Silen M. L., Canvasser D. A., K u r k c h u b a s c h e A . G et al (1995). Video- assisted thoracic surgical repair of a foramen of Boehdaiek hernia. Ann Thorac Surg, 60, 448 - 450
2. Nguyen T h a n h L i e m , Le A D (2006), Thoracoscopic repair for congenital diaphrag- matic hernia' lessons from 45 cases, J Pediatr 'surg, 41(10), 1 7 1 3 - 1 7 1 5 ,
3. Area M. J . , B a r n h a r t D. C , Leili J . L. et al (2003). Early experience vi/ith minimally Invasive repair of congenital diaphragmatic hernias results and lessons learned. J Pediatr Surg 38 ,11, 1 5 6 3 - 1 5 6 8 .
4. Yang EY, AMmendinger N, J o h n s o n SM et al (?005» Neonatal thoracoscopic repair of congenital diaphragmatic hernia, selection criteria for successful outcome. J Pediatr Surg 2005,40, 1 3 6 9 - 1 3 7 5 ,
TCNCYH 89 (4) - 2014
• TifiiP CHf N G H I | N 5. Guner YS, Choltshi N, Aranda A et al
(2008). Thoracoscopic repair of neonatal diaphragmatic hernia J Laparoendosc Adv Surg Tech A, 18, 875 - 880.
6. Schaarschmidt K, Strauss J , Kolberg- Schwerdt A, et al (2005). U Thoraco- scopic repair of congenital diaphragmatic her- nia by inflation-assisted bowel reduction, in a resuscitated neonate: a better a c c e s s ' Pediatr Surg int. 2^. 806-BOB.
7. Cho SD, Krishnaswami S, Mcliee JC, et al (2009). Analysis of 29 consecu- tive thoracoscopic repairs of congenital dia-
phragmatic hernia In neonates compared to histoneal controls. J Pediatr Surg, 44, 80 - 86.
8. Gomes Ferreira C, Reinberg O, Becmeur F et al (2009) Neonatal minimally invasive surgery for congenital diaphragmatic hernias: ci multicenter study using thoraco- scopy or laparoscopy. Surg Endosc, 23, 1650 - 1 6 5 9 .
9. Kim AC, Bryner BS, Altay B et al (2009), Thoracoscopic repair of congenital diaphragmatic hernia in neonates, lessons learned. J Laparoendosc Adv Surg Tech A. 19 (4), 575 - 580.
OUTCOMES OF THORACOSCOPIC REPAIR FOR 296 CASES OF CON- GENITAL DIAPHRAGMATIC HERNIA
The study was to evaluate early outcomes of thoracoscopic repair of congenital diaphragmatic hernia (CDH). A retrospective study was carried out by reviewing all medical record of children with CDH who underwent thoracoscopic repair for CDH from 2001 - 2012 at the National Hospital of Pediatries of Vietnam. During the study period, 296 children unden/i/ent thoracoscopic repair for' CDH including 149 newborns and 147 infants and toddlers. Conversion to open surgery was required in 47 patients (10,1%). Mean operative time was 70 1 minutes ± 27,5 for newborns and 75,8 ± 25.6 minutes for infants and toddlers There were no intraoperative deaths or complica- tions, 42 patients died postoperatively. The main causes of death were sepsis and pulmonary arterial hypertension. Median postoperative hospital stay was 13.3 days for newborn group and 12 days for infants and toddlers. In conclusion, thoracoscopic repair is feasible, safe and effective for CDH,
Key words: Congenital diaphragmatic hernia, thoracoscopic
TCNCYH 89 (4) - 2014
