NGOAI KHOA S6 BAC B[$T 1, 2, 3/2012
K^T QUA 156 TRUaNG HOT C A T GAN
K^T Hgp PHU'CNG PHAP TON THAT TUNG VA LORTAT • JACOB OI^U TR! UNG THU" BIEU MO TE BAO GAN
Le Van Thanh, Nguyen Cu-dng Thinh, Lu-ffng Cong Chanh (*)
T O M TAT
Muc dich: danh gia ket qua cat gan ket hdp phydng phap Ton That Tiing va Lortat - Jacob dieu tn ung t h y bleu mo te bao gan
Doi tifdng va phu'dng phap nghien c&u:
Trong thdi gian tir" thang SjlOQl den thang 10/2011, 156 benh nhan ung t h y bieu md te bao gan dydc cat gan ket hdp phydng phap Ton That Tung va Lortat - Jacob tai Khoa Phau thuat Tieu hoa Benh vien TWQD 108. P h i u thuat cat gan dydc tien hanh bdi cac phau thuat vien co kinh nghiem.
Kit qua: Co 116 nam va 40 n i i tuoi trung binh 47.8 ± 12.5 (dao dong 19- 79), HbsAg dydng tinh: 130 (83,3%) benh nhan Child- Pugh A: 156 (100%) benh nhan. AFP > 200 ng/ml;
113 (72,4%) benh nhan. Cat gan phai: 36 (23%) benh nhan, cat gan trai 51 (32.6%) benh nhan, cat gan trung tam 12 (7,6%), cat phan thiiy sau 29 (18.5%) benh nhan; cat thiiy trai 23 (14,7%) benh nhan; cat ha phan thuy 5 (3,2%) benh nhan. Thdi gian mo trung binh 112 ±21.2 phiit, lydng mau mat trung binh 300± 232 ml, so benh nhan phai truyen mau 35 (22,2%). Tuf vong va bien chimg 1 (0.64 % ) va 2 2 . 1 %
Kit luan: cat gan ket hdp phydng phap Ton ThatTiing va Lortat - Jacob dieu tri ung t h y bieu mo te bao gan la phydng phap an toan va hieu qua
S U M M A R Y
Objective: this study assessed the results of hepatectomy using the combined methods of Lortat Jacob and Ton That Tung in the treatment for hepatocellular carcinoma.
Material and method: During period from May 2007 to October 2011, 156 consecutive patients with hepatocellular carcinoma underwent hepatectomy at the Department of Digestive surgery of 108 hospital.The hepatectomy were performed by a surgical team specialized. The case notes have been reviewed and to study the clinical features, the types of hepatectomy, the results of operation and the postoperative morbidity and mortality.
Results: There were 115 (74,3%) males and 40 (25,6%) females, median age 47.8 ± 12.5 years (range 19 to 79 years), HbsAg (+) ( N=
130) Child- Pugh A: (N=156 ), right hepatectomy (N= 36), left hepatectomy (N= 51), left hepatic lobectomy (N 23), central bisectionectomy (N=12 ), segmentectomy (N= 5). The mean time operation 112 ± 21,2 minutes, the mean operative blood loss; 300 ± 232 ml, the blood transfusion rate; 22,2%; Overal motality and mortality were 0,64% and 2 2 . 1 % .
Conclusion: Hepatectomy using the combined methods of Lortat - Jacob and Ton That Tung in the treatment for hepatocellular carcinoma is safe and effective .
(*)Binh vien Trung &dng Quan doi 108
DAI HOI HOI NGOAI KHOA VN LAN THUXII VA HQI NGH] KHOA HOC NGOAI KHOA TOAN QU6C LAN^THOXIV, I. OAT VAN OE
Ung thu bi^u mo te bao gan (UBTG) la benh ly ac tinh thudng gap, hang nam tren tha gioi CO 500.000-1000.000 trudng hgp moi mic va khoang 500.000 ngudi chel vi benh ly nay. UBTG gap d nam gidi cao gap 2-4 lan so vdi nii gidi. thudng xuat hien tren n8n benh gan man tinh, tien lugng xiu [1,2,3,9,11,12]. Hien nay. co nhieu phuong phap diSu tri UBTG: nhiet cao tan, tiem con hoac acid acetic, tac mach hoa dau chgn Igc, ghep gan...Trong do, phau thuat cat gan van la phuang phap diSu trj co ban va hieu qua nhat.
Chung toi ti^n hanh nghien ciiu nay nham danh gia kh qua phau thuat cat gan ket hgp phuang phap Ton Thit Tung va Lortat- Jacob di^u yj ung thu bilu mo te bao gan, ndu Ien mot s6 kinh nghiem de cac ban dong nghiep tham khao.
II. o6l TUONG VA PHUONG PHAP NGHIEN COU 1. Doi tu-ffng nghien ciiii
Trong thdi gian tir thang 5/2007 den 10/2011, CO 156 hardng hgp UBTG dugc cit gan ph6i hgp phuang phap Ton That Timg va Lortat - Jacob tai Khoa Phau thuat Tieu hoa Benh vien TWQD 108
2. Phirong phap nghien cihi H6i ciiu ho so, tim hi8u dac diem lam sang, loai phiu thuat, tai bi^n, bi^n chiing va ket qua phau thuat
- Chuin bi benh nhan (BN) trudc phau thuat: BN dugc chan doan xac djnh UBTG;
chi djnh cit gan thyc hien theo Hudng dan thuc hanh ung thu ciia Mang cac Qu6c gia V'Q ung thu (National Comprehensive Cancer Network) (NCCN) nam 2010 dua vao: chiic nang gan (danh gia theo Child - Pugh); tinh trang u (kich thudc, s6 lugng...); thi tich gan con lai; u chua xam Ian mach mau Idn [8].
- BN dugc gay me ngi khi quan.
- Ky thuat m6: rach da theo hinh chii J (dudng tring giiia tren ron sang dudi bd sudn phai) hoac dudng dudi bd sudn 2 ben trong nhung trudng hgp u co kich thudc Idn; cat gan phoi hgp phuong phap Ton That Timg va Lortat- Jacob: khdng che cac thanh phan cua cudng gan (DM, TM, 6ng gan) (phuong phap Lortat- Jacob), sau do kep nhu mo gan bdi kim Kelly, tim cac mach mau va dudng mat khau buoc bang chi Prolene, mach mau nho dugc clip hoac dot bang dao dot luong cue.
Phan loai cat gan theo Hiep hoi Gan Mat Tuy Quoc te hgp tai Brisbane nam 2000[10].
III. KET QuA
Bang 1: Dac diem lam sang Tuoi
Gidi (Nam/ Nl?) HBsAq + Child- Puqh A AFP > 200 Sieu am thay u
CT tliav hinhi anin die trtrnq cua unq tiiiT qan Clioc sinil thiet u
N= 156 47,8± 12.5 116/40 (74,3/25.6%) 130 (83.3%) 156 ( 100%) 113 (72,4%) 156 (100%) 148 (94,8%) 35 (22,4%)
44
NGOAI KHOA S6 Bf.C BIET 1,2,3/2012
Bang 1 cho thay ty le mic benh d nam > nu: (74,3% so vol 25,6%), benh nhan co benh ly gan man tinh: 130 (83,3%). 100% benh nhan co chiic nang gan Child - Pugh A. Sieu am thiy u 156 (100%) BN, CT thiy hinh anh dac tnmg cila ung thu gan 148 (94,8%) BN.
Bang 2: Loai phiu thuat Loai phau thuat
Cat qan phai Cat qan trai Cat thuy trai Cat qan trunq tam Cat phan thuy sau Cat ha phan thuy Tong so
N f»/o) 36 (23%) 51 (32,6%) 23 (14,7%) 12 (7,6%) 29 (18,5%)
5 (3,2%) 156 (100%)
Bang 2 cho Ihay: cat gan tr.i chiem ty le cao nhit 51 (32.6%)BN, sau do la cit gan phai 36 (23%) BN.
Bang 3: Kel qua phau thuat Thdi qian mo trunq binh (phut)
Lydnq mau mat trunq binh (ml) So benh nhan truyen mau Thdi qian nam vien trunq binh (nqay)
112 ± 21,2 300 ± 232 35 (22,2%) 12 ± 3,5
Bang 3 cho thay: thdi gian mo trung binh 112±21,2 phiit, lugng mau mat trung binh 300
±232 ml, thdi gian nam vien trung binh: 12 ± 3,5ngay.
Bang 4: TaJ bien va bien chiing Tai bien va bien chu'ng
Chay mau sau mo 0 donq dich Ro mat sau mo Tran dich manq phoi Co chydnq Tu" vonq tronq mo Tonq conq
N (o/o) 1 (0,64%)
9 (5,7%) 4 (2,5%) 12 (7,6% ) 8 (5,1% ) 1 (0,64%) 35 (22,1%)
Bang 4 cho thay: tran djch mang phoi 12 (7,6%)BN, co chirong 8 (5,1%) BN. 1 (0,64%) truong hgp tu vong trong mo do ton thuang tinh mach chu duoi.
IV. BAN LUAN
1. Dac diem lam sang: nghien cuu cho thiy tuoi trung binh cua BN 47,8 ±12.5 (Dao dong 19- 79 tuoi), ty le nam gap nhieu hon nQ 116/40. KSt qua nghien ciiu thu dugc tucmg tit ciia Cescon va CS (2009) cung nhu
mot s5 tac gia khac [1,2,9]. Bang 1 cho thay 130 (83,3%) CO HbsAg (+), nhu vay hiu h6t BN bi nhiem vi riit viem gan B. Cescon va CS cung nhieu tac gia cho rang UBTG thuong phat trien tren nen benh gan man tinh: viem gan, xo gan [1,7,8,9,11]. Ket qua
BAI HQl HQl NGOAI KHOA VN LAN THCf XII VA HQl NGHj KHOA HOC NGOAI K H O A T O A N QOOC L A N T H O X I V
cho thiy AFP > 200 ng/ ml gap 113 (72,4%) BN, sieu am phat hien u gan 156 (100%) BN, chup cat lap vi tinh thay hinh anh dien hinh cua ung thu gan: 148 (94,8%)BN. Hudng dan thyc hanh ung thu ciia Mang cac quoc gia ve ung thu (2010) cho rang nhii'ng BN bi benh gan man tinh nen sieu am dinh ky kiem tra, sieu am la phuong phap chan doan thuan loi va thudng dugc thuc hien dau tien d cac BN ung thu gan. Trudng hop BN bi benh gan man tinh khi sieu am thay khoi bat thudng d gan, nen dugc tiep tyc thir dau an ung thu AFP, chup cat Idp vi tinh [8].
Quan diem hien nay trong chan doan UBTG da CO nhtmg thay doi, chan doan hinh anh CO vai tro quan trgng trong chan doan xac dinh UBTG. Hau het cac tac gia thong nhat khi thay hinh anh dac trimg ciia u gan:
tang tudi mau d thi dong mach (Hinh 1) tren 2 phuong phap chan doan hinh anh thi benh nhan dugc chan doan xac dinh UBTG, neu tren mot phuong phap chan doan hinh anh thay dau hieu dac trung cua u gan va AFP >
200ng/ ml BN cilng dugc chan doan xac dinh UBTG [1,8].
Tren the gidi, cac nha nghien ciiii ve benh ly gan mat da co nhilTig cupc hoi thao
chuyen de vB chii dh co nen choc sinh thiet gan de chan doan UBTG hay Ichong va ket luan chi sinh thiet khi chdn doan hinh anh khong ro rang [3,8,9,12]. Vi vay, ket qua 6 Bang 1 cho thiy chi 35 (22,4%) BN dugc chi dinh chgc sinh thiet.
Chi dinh mo dugc thuc hien chat che dua theo Hudng din thyc hanh ung thu cua Mang cac quoc gia ve ung thu NCCN (2010), chi mo nhiing BN dugc danh gia chirc nang gan thay d Child- Pugh A: 156 (100%) BN.
Ngoai ra, cac chi lieu quan trgng de quyet dinh cho phau thual bao gom: tinh trang u (kich thudc, so lugng...); the tich gan con lai dii; u khong c6 xam lan vao cac mach mau Idn. Nhiing khoi u ly tudng cho viec cat gan khi < 5 cm. Tuy nhien, nhieu tac gia cho rang dieu quan trong de chi dinh cat gan la lh8 tich gan con lai de dam bao chiic nang gan sau mo. Neu the tich gan dam bao thi cac phau thuat vien van cat nhiing khdi u Idn nhkm muc dich giam dau va chong cac bien chiing vo, chay mau, dong thdi keo dai thdi gian sdngchoBN [2,4,5,6,7,8].
Hinh 1. Hinh anh dac trung tang tudi mau thi dong mach BN Nguyen Due Tr. chup ngay 2/6/2007
NGOAI KHOA S6 OAC BlgT 1,2, 3/2012
2. Loai phSu thuat: cho tdi nay co rat nhieu phuong phap dihu tri UBTG. Tuy nhien, cat gan dugc coi la hieu qua va co ban nhdt [1,4,10]. Bang 2 cho thay cat gan trai chiem ty le cao nhat 51 (32,6%) BN, sau do la cat gan phai 36 (23%o) BN, cat phan thuy sau 29 (18,5%) BN, Steven AC va CS nam 2010 ciing nhu mot so tac gia khac nhan xet cat gan phai va cat gan trung tam co ty le tii vong va bien chiing cao nhat do suy chiic nang gan sau mo [4,10,11,12,13].
Phan loai cat gan dua theo Hiep Hoi gan mat tuy Quoc te hop nam 2000 tai Brisbane [10]. Cat gan phai gom cat phan thiiy 5, 6, 7
va 8, cat gan trai khi cat cac phan thuy 2,3 va 4. Troimg nghien ciiu, ky thuat cat gan dugc thuc hien bdi su phoi hgp phuong phap Ton That Ting va Lotat- Jacob: sau khi m6 bung danh gia cac ton thucmg, bgc Ig va khong che cac thanh phan ciia cuong gan (phuong phap Lotat- Jacob) (hinh 2), tien hanh kep nhu mo gan bang kim Kelly, cac mach va ong gan Idn dugc buoc bang chi prolene, cac mach nho dugc cam mau b^ng clip, dao d6t (phuong phap Ton That Tung). Nhd ph6i hgp 2 phuong phap nen giam dugc lugng mau mat, tai bien va bien chiing trong va sau mo.
„ , . . - / > ^ - _ ^
fp
Hinh 2. Khong che cac mach mau (BN Nguyen Dire Tr m6 ngay 4/6/2007) 3. Ket qua phSu thuat: Bang 3 cho thay
thdi gian mo trung binh 112 ±21,2 phiit, lugng mau mat trung binh 300 ± 232 ml, so BN huySn mau 35 (22,2%) BN, thdi gian n4m vien trung binh 12 ± 3,5 ngay. Ket qua nghien ciiu thu dugc tuong ty thong ke ciia Steven AC va cong sy ciing nhu mot so tac gia khac [4, 6,7, 10]
Chay mau trong mo la mot trong nhirng yeu to quan trgng lien quan den ty le bien chiing va tir vong. Cac phau thuat vien cat gan dang co gang tim nhiing bien phap nham han che mit mau trong mo, cac tac gia deu
thOng nhAt lugng mau mat la tieu chuan quan trgng de du doan bien chimg va tir vong sau m6. Trong qua trinh nghien ciiu, viec sir ket hgp 2 phuong phap Ton That Tung va Lotat- Jacob nham han che chay mau khi mo. Ty le truyin mau trong nghien cim thap hon thong ke cua Cesson M va CS 36,5% [2]
Bang 4 cho thay Iran dich mang phoi, 6 dong dich va co chudng la nhiing bien chimg hay gap: 7,6%, 5,7% va 5,1%. Ty le cac bien chiing ciia nghien ciiu tuong tu thong ke cua Steven AC va cong sy (2010) ciing nhu mot s6 tac gia khac gap tir 17-31,45%. (bang 5).
BAI HQl HOI NGOAI KHOA VN LAN THCTXII VA HQI NGHj KHOA HOC NGOAI KHOA TOAN QU6C LAfOHOXIV^
B a n g S. S o s a n h t y le b i e n c h i m g v a tii v o n g g i u a c a c t a c g i a
Bien chu'nq Tii" vonq
Jia- Mei Yang 31,45%
3,48%
Steven AC
30%
7%
Van Tan
17%
4 %
Trinh Hong s o n
11,3%
Nghien cu'u
2 2 . 1 % 0,64%
Ket qua nghien cuu cho thay tu vong 1 (0,64%)BN trong khi mo, do rach tTnh mach chu duoi gay mat mau cap, khonng xii tri kip.
Day la mot tai bien nang ne, do vay can can nhac rat ky ve chi dinh khi khoi u kich thuoclon. trong khi mo va gay me phai san sang day du cac phuang tien cQng nhu chii dpng kiem soal mach mau, mat khac khong cau toan co lay u khi ton thucmg xam lin mach mau Ion [13]. Ty le ti^ vong qua nghien cihi thap hon cua cac tac gia khac gap tir 3,48-11,3% (bang 5).
V. KET LUAN
1. Mot so dac diem lam sang cua ung thu bieu m.6 te bao gan: tuoi trung binh 47,8
±12,5, ty le nam/nii 116/40.; HbsAg (+): 130 (83.3%) BN, Child- Pugh A: 156 (100%) BN. sieu am phat hien u: 156 (100%) BN, chup cat lop thiy hinh anh dac trung HCC 148 (94,8%) BN; AFP> 200ng/ml 113 (72,4%) BN
2. cat gan phai 36 (23%) BN, cat gan trai 51 (32,6%) BN, cit phan thiiy sau 29 (18,5%) BN, cit thiiy trai 23 (14,7%) BN, cit gan trung tam 12 (7,6%) BN. Thoi gian m5 trung binh 112 ± 21,2 phiit, lugng mau mit trung binh 300± 232 ml. Ty le benh nhan phai truySn mau 22,2%. Biin chimg: 22,1%.
Tir vong 0,64 %
Phau thuat cat gan ket hop phuong phap Ton That Timg va Lotat - Jacob dieu tri ung thu bieu mo te bao gan an toan va hieu qua.
TAI LIEU THAM KHAO.
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2. Cescon M, Cucciietfi A, Grazi GL, et al (2009). "Indication of the extent ot hepetectomy for carcinoma on cinrhosis by simple algorithm based on preoperative variables". Arch Surg. 144:
57-63; discussion 63
3. J o n a t h a n M S et al (2008). "Clinical Features and diagnosis of acute primary hepatocellular ca]:cmoma'\v.'wwuptodate.
com
4. Lai E C , Fan ST, Lo C M , et al (1995).
"Hepatic resection for hepatocellular carcinoma. An audit of 343 patients".
^K« Surg ;221;291-298.
5. M a k u u c h i M (2009). "Remodeling the surgical approach to hepatocellular cai-cuioma". Hepatogastroenterology.
49:36-40.
6. Malassagne B, C h e r q u i 1), Alon R, et al (1998). "Safety of seleciive vascular clamping for major nepaiectornies". J Am Co/ZSwrg; 187-482-486.
NGOAI KHOA SO DAC BI$T 1,2, 3/2012
Matsumata T, Kanematsu T, Shirabe K, et al (1990), "Decreased morbidity and mortality rates in surgical patients with hepatocellular carcinoma". Br J Surg; 77: 677-680.
NCCN Clinical practice guidelines in oncology (2011) "Hepatobiliary cancers"www. nccn. org.
Ronnie T Poon et al (2004) "Improving perioperative outcome expands the role of hepatectomy in management of benign and malignant hepatobiliary diseases analysis of 1222 consecutive patients fi-om a prospective datahaso"Annals of surgery, 249: 698 - 709.
10. Steven AC et al (2010). "Surgical resection for hepatocelluar carcinoma".
wwwuptodate. com
11. Ton That Tiing (1971) "cat gan" Nha xuat ban Khoa hoc ky thuat Ha noi.
12. Vigano L et al (2009). "Laparoscopic liver resection: a systematic review". J Hepatobiliary Pancreat Surg. 16: 410- 421.
13. Wei AC, Tung-Ping Poon R, Fan ST,Wong J (2003). "Risk factors for perioperative morbidity and mortality after extended hepatectomy for hepatocellular carcinoma". Br J Surg ; 90:33^1.
