1 5 7 4 TAP CHf KHOA HOC TIEU H 6 A VIET NAM 2011 - TAP VI- S6 23
Nhan xet qua 37 trtfcfng hoTp Ung thtf mom cut da day
Gastric cancer stump: a report of 37 cases
NGUYfeN CUCJNG THINH, DIEM DANG BINH
B V T U Q D 108
Summary
Gastric cancer stump is defined as carcinoma occurring in gastric stump that had undergone partial gastrectomy for benign gastric diseases for at least 5 years. Gastric cancer stump is still regarded as a disease with poor prognosis. Thirty seven gastric cancer stump cases admitted into the Department of Digestive Surgery, 108 Hospital, including 28 males and 9 females with mean age of 51.5 years (range 38 - 88) were enrolled in this study. The interval between primary gastrectomy for benign gastric diseases and occurrence of gastric cancer stump ranges from 5 to 40 years. All 37 patients underwent Billroth II reconstruction in the primary gastrectomy. 28 patients received surgical treatment, 20 patients received radical resection. Esophagus jejunum Roux en Y anastomosis: 15, gastric stump jejunum Roux en Y anastomosis: 5, palliative operation: 8. The study demonstrated that endoscopic follow—up is necessary for patients undergoing partial gastrectomy for benign gastric, especially for those receiving Billroth 11
reconstruction procedure.. Radical resection of gastric cancer stump is feasible and effective option.
Tdm tat
Ung thtf mom cut da day dtfdc xac dinh khi ung thtf xult hidn d mom da day cdn lai sau 5 nam cat doan da day dilu tri loet lanh tinh. Ung thtf mom cut da day la bdnh cd tidn Itfdng xlu. Ttf thang 1/1987 - thang 6/2010 cd 37 benh nhan ung thtf mom cut da day dilu tri tai Khoa Ngoai tidu hoa Benh vidn 108, gom 28 nam, 9 ntf, tudi trang binh 51,5, dao ddng ttf 38 - 88 tudi. Thdi gian sau md trung binh 20,5 nam, dao ddng ttf 5 - 40 nam. Tit ck 37 bdnh nhan deu md theo Billroth IL dilu tri ngoai khoa 28 bdnh nhan, phlu thuat triet de 20 (68,9%) benh nhan, nd'i thtfc quan hong trang theo Roux en Y: 15, nd'i mom da day hdng trang theo Roux en Y:5, phlu thuat tam thdi: 9 bdnh nhan. Nghidn ctfu cho thly nhtfng bdnh nhan da md cat doan da day dilu tri loet lanh tinh cIn phai ndi soi theo ddi, dac bidt nhtfng bdnh nhan md theo Bilkoth II15 - 20 nam. Phlu thuat triet de dilu tri ung thtf mom cut da day cd the thtfc hidn dtfdc va la phtfdng phap hidu qui trong dilu tri ung thtf mom cut da day.
I. Dat van d l mac dii da cd nhilu tid'n bd trong chan doan va Ung thtf mom cut da day (UTMCDD) dtfdc xac <iieu tri, UTMCDD vln la benh ly khd khan trong dinh khi ung thtf xult hidn d mom da day cdn lai phlu thuat va cd tien Itfdng xlu. Chung tdi xin sau cat doan da day dilu tri loet lanh tinh ttf 5 ndu mdt sd nhan xet qua nhtfng tmdng \ rfp UTM- nam trd Idn (Matsui va cdng stf, 2001). Hidn nay, CDD dilu tri tai Benh vidn TWQD 108
TAP CHf KHOA HOC TIEU HOA VIET NAM 2011 - TAP VI - SO 23 1575 II. Bdnh nhan va phtfdng phap nghien ctfu:
Benh nhan: Nhtfng benh nhan bi UTMCDD dilu tri tai Khoa Ngoai Tieu hoa Bdnh vidn TlJQDlOS ttf thang 1/ 1987- thang 6/2010.
Phtfdng phap: Hoi ctfu ho sd, tim hieu v l chin doan bdnh va phtfdng phap md lln dlu, tudi khi ml, dieu tri khi dtfdc chin doan UTMCDD.
III. Kd't qua
37 Benh nhan dtfdc chin doan la UTMCDD ttf 5-40 nam sau md, tmng binh 20,5 nam trong dd cd 28 nam, 9 ntf, tudi ddi ttf 38-88, trung binh 51,5.
1. Chan doan khi md lln dlu:
Loet ta trang: 16(43,2%) Loet da day: 21 (56,8%)
2. Phtfdng phap md: Tit ck 37 bdnh nhan dtfdc mo theo phtfdng phap Billroth II
3. Tudi khi md lln dlu:
Dtfdi 30: 11(29,7%) Ttf 31-50: 21(56,7%) Trdn 50: 5 (13,6%) 4. Dilu tri ngoai khoa
29 benh nhan dtfdc md lai, trong do cd 15 bdnh nhan cat toan bd da day, nd'i thtfc quan-hong trang 1 ldp trtfdc dai trang ngang theo Roux-en Y; 5 BN cat lai da day, lam lai midng nd'i theo Roux-en Y, 3 Bn nd'i vi trang, 5 benh nhan md thdng da day.
8 benh nhan khdng md, do khdng cdn chi dinh md hoac benh nhan ttf chd'i md.
III. Ban luan
Benh sinh cua UTMCDD: nhilu tac gia cho rang: trao ngtfdc dich hdng trang la ye'u td' quan trpng nhat (2,3,4,5,). Szentleleki.K (1990) nghien ctfu thifc nghidm trdn chudt, thly ty Id UTMCDD cao hdn d nhdm md cd trao ngtfdc dich mat bat budc (ty Id 50% sau phlu thuat Billroth II, 28,5%
sau phlu thuat Billroth I); d nhdm cat doan da day kem theo phlu thuat lam giam stf trao ngtfdc cda hdng trang Billroth II + Braun, Roux-Y, ty Id UTMCDD thlp hdn mdt clch cd y nghia. Kd't qua nghidn ctfu cho thly 100% bdnh nhan dlu md theo Billrothll, day la kieu md phd bid'n tai cd sd cua chiing tdi trong nhilu nam qua.
Thd'ng ke thly cd 16 (43,2%) BN loet ta trlng va 21 (56,8%)BN loet da day trong chin doln
bdnh khi md lln dlu. Nhieu tac gil nhan xet ty Id UTMCDD sau cat doan da day gap d bdnh nhan loet da day cao hdn loet hanh ta trang [1,6.9], tuy nhidn, Kaare Liavaag cho rang: Tdn thtfdng ban dlu la loet ta trang hay loet da day khdng cd y nghia vdi nguy cd gay UTMCDD [7]
Vide xac dinh tac nhan gay UTMCDD hidn vln cdn la van dl khd va dang dtfdc ban luan.
Cac tac gia nghidn ctfu vl UTMCDD cho rang cat doan da day gay giam toan, vi khuIn tai chd phat trien tao dilu kien de cac nitrit thtfc an tao ra nit- rosamines, la nhtfng chit dtfdc coi la cd kha nang gay ung thtf. Kuhara va cdng stf (2003) cho rang;
Nhilm kuin Helicobacter pyloi la ye'u td' gay UT- MCDD. Lorasso va cdng stf (2000) cho rang cat doan da day gay nhtfng bid'n ddi ciia niem mac da day: viem teo niem mac, di san rapt, loan sin,...
tham chi din tdi UTMCDD[3,4,5,6,7]
Ty le ciia UTMCDD sau cat doan da day theo cac tac gia khac nhau cho nhtfng ty Id ichac nhau.
Visite (1986) theo ddi 3470 benh nhan sau cat doan da day ttf 25-45 nam. thly 21% UTMCDD.
Rutbstalnikoicz (1990) thly l,5%-2% sau 15 nam, l,4%-4,4% sau 20 nam, 3%-5,7% sau 30 nam, tac gia kd't luan: ty Id UTMCDD tang theo thdi gian sd'ng cua bdnh nhan sau cat doan da day. Chung tdi gap 11 bdnh nhan bi UTMCDD sau md da day lln dlu dtfdi 30 tudi, phii hdp vdi nhan xet ciia cac tac gia ntfdc ngoai la cat doan da day tudi cang tre thi nguy cd UTMCDD cang cao. Luigigiareli thly ty Id nay d nhtfng bdnh nhan sau md tmdc 45 tudi la 2,46%, sau 45 tuoi la 0,54% [2,3,4,7,8,9].
Hlu hd't cac tac gia cho rang dilu tri UTM- CDD dang la mdt vln d l khd khan, nhilu BN dd'n vidn khi bdnh da d giai doan mudn, chi lam dtfdc nhtfng phlu thuat tam thdi, ty Id thtfc hidn phlu thuat triet de thlp do u qua Idn hoac xam lln va di can nhilu ndi (hinh 1) Ke't qua nghien ctfu cho thly 29 bdnh nhan dtfdc md lai, trong do chi 15 bdnh nhan cat toan bd mom da day cdn lai, nd'i thtfc quan-hong trang theo Roux- en Y (hinh 2, hinh 3) va 5 BN cat lai da day, lam lai midng nd'i, 3 BN ndi vi trang, 6 benh nhan md thdng da day, 8 benh nhan khdng md, do khdng cdn chi dinh md hoac benh nhan ttf chd'i md.
1576 TAP CHf KHOA HOC TIEU HOA VIET NAM 2011 - TAP VI- SO 23
Hinh 1: Ung thtf mom cut da day BN Nguyin Van Th, md ngay 8/7/2008
Hinh 2: B6c Id thtfc quan, mom da day con lai.
BN Nguyin Van D, md mgay 05/7/2006.
Hinh 3: Nd'i thtfc quan hdng trang bang may BN Nguyin Van D, md mgay 05/7/2006.
Ty Id md triet de qua nghien ctfu chi thtfc hidn dtfdc d 15 (51.7%) BN, ty Id nay thap hdn nhilu so vdi cac tac gia ntfdc ngoai, do vide chin doln cdn cham. Ty Id md triet de cho BN UTMCDD ciia Chenh va cdng stf (2005) ciing nhtf mdt sd tac gia 50 - 60% [3,5]
Chen va cdng stf (2005), ciing nhilu tac gia cho rang trong phlu thuat triet de d i l u tri UTM- CDD, ngoai viec cat bd tdn thtfdng u, p h l n mom da day cdn lai, ngtfdi ta cd gang vet hach khi quan sat thly, cac tac gia gidi thidu nhtfng vi tri thtfdng thay hach di can gom quanh u va midng nd'i, ddng mach vi trai,, vung rdn lach [3].
Kunisaki va cdng stf (2002) nhan xet nhdm hach di can quanh ddng mach chu bung, mac nd'i Idn, bd tren tuy nen dtfdc lly triet de [7], tuy nhidn chiing tdi nhan thly cIn dtfa vao tdn thtfdng cu the va tinh trang toan than cua ttfng BN de Itfa chpn phtfdng phap phlu thuat hdp ly.
Chen va cdng sif (2005), cimg nhieu tac gia kd't luan viec phat hien sdm UTMCDD cd anh htfdng rlt Idn tdi kha nang dilu tri ngoai khoa tridt de, ciing nhtf kd't quaiau dai cua dieu tri, cac tac gia d l nghi ndn kiem tra ndi soi thtfdng xuyen trong theo rdi nhtfng BN da mo cat doan da day dilu tri loet [3].
IV. Ke't luan
D i l u tri ngoai khoa triet de ung thtf mom cut da day cd the thtfc hien dtfdc va la phtfdng phap hieu qua trong d i l u tri ung thtf mom cut da day.
Nhtfng benh nhan da mo cat doan da day dilu tri loet lanh tinh ndn theo ddi ndi soi, dac bidt d nhtfng benh nhan sau cat doan da day theo Billroth II15 - 20 nam •
Tai li$u tham khao
1. Balfour. DC et al. Factor influencing the life expec- tancy of patient operated on gastric ulcer Ann, Surg, 1992,76,405-8.
2. Banki, GL. Cancer development in gastric stump af- ter partial gastrectomy. Gastric pecancerosed Aka- demia Kiado Budapest 1977, 124-32
3. Chenli et al. Surgical management of gastric stump cance r: a report of 37 cases. J zhejiang Univ SCI 2005 6B (1): 38 - 47.
4. Dahm. K. Werner. B. Das karzinem in operierten mager. Dasch. med. Woschr. 100 (1975)-1073-1078 5. Domellop L. S. et al. Late precanceruos changes and carcinoma of gastric stump after Billroth I resection.
Am. J. Surg, 1976, 132, 26-31
6. Lacaine F, et al. Stomach cancer after partial gastrectomy for benign ulcer discare. A Critial anlisis of epidemiologi- cal reports Hcpatogastroenterology, 1992,39 (1)4-8.
7. Kaare Liavaag. Cancer development in gastric stamp after partial gastrectomy for peptic ulcer. Annal of Surgery,1962, 103 - 106.