" TAP CHt YDL/gc LAM SANG 108 Tap 12-So 6/2017 Ik
Danh gia ket qua phau thuat dieu tri hep khi quan tai Benh vien Trung uotig Quan doi 108
^, Evaluation of the surgical results for tracheal stenosis at 108 Military Central Hospital
. Nguyen Diic Thang*, Tr^n Trong Kiem*, *BSnh vien Trung uang Qudn dgi 108 Nguyin Trirong Giang**, Nguyin Van Nam** **HOC viin Quan y
11 Tomtit
Muc tiiu: Nhan xet ket q u i sdm p h i u t h u l t dieu trj hep khf q u I n . Doi tugng va phUOng phdp: Md t l c i t ngang, 81 trudng hpp hep khf q u I n dupe dieu tn ngoai khoa. Ket gud: 49 nam, 32 nd, tudi trung blnh 47,16 ±11,3. Nguyen n h i n hep khf quan: Sau md k h f q u l n 31 ca (38,27%), ung thU khf q u I n thd ph^t 27 ea (33,33%) trong nhdm nay ung thutuyen giap xam lan khf quan nhi^u nhat 24,7%. Vao vien vl khd thd i 30 ea (37,0%) hoac khdng nit dupe Canuyn khi quan 32 ea (39,5%). Mde dp hep khf q u I n theo Cotton Myer thi do 2 nhieu nhat 32 ea (39,52%). Vj trf hep: Doan ed 57 ca (70,37%) doan ngUe 24 ca (29,6%). C i t ndi khf quan tan - tan 57 ca (70,37%), md khi q u I n vinh vien 19 ca (23,45%). Chieu dai doan khf q u I n cat b d 1 7 - 5 1 m m , t r u n g binh la 27,5 ± 11,2mm, thdi gian p h l u thuat trung binh I I 88 ±25,1 phut, thdi gian nam vien sau mo 11 + 2,7 ngly. Bien ehdng sdm: 16,05%, bien ehdng mupn: 28,39%. Kit ludn: Phau thuat khi q u I n la Ida ehpn tdt cho nhieu tdn thuong khf q u I n , khong chf cat bd dupe tdn thuong ma edn d i m b l o hdi phuc g i l i phau sinh If.
Tdkhoa: Hep khf q u I n , tao hinh k h f q u l n . Summary
Objective: To examine early operation results of tracheal stenosis treatment. Subject and method: A cross-sectional study involved 81 tracheal stenosis patients who were treated by operation. Result: 49 males and 32 females, the average age 47.16 + 11.3. Causes for tracheal stenosis: Post tracheotomy (31 eases - 38.27%), metastatic tracheal tumor (27 eases - 33.33%) in which thyroid carcinoma (24.7%). The number of patients hospitalized due to dyspnea accounted for 37%, eases with unremovable tracheal tube accounted for 39.2%. Level-2 group, referred to Cotton Myer scale, was dominant (39.52%).
Stenosis segments of tracheal: 57 cervical trachea (57 patients), mediastinum tracheal (24 patients). End to end tracheal anastomosis procedures were adopted in 57 cases (70.37%) and permanent tracheotomy was adopted in 19 cases (23.45%). The length of tracheal segments cut off varied from 17 to 51 millimeters and the average length was 27.5 ± 11.2 millimeters. The average operation time was 88 + 25.1 minutes. The average duration of post-operative hospital stay was 11 +2.7 days. The rate of early and late complications were 16.05% and 28.39% respectively. Conc/us/on:Tracheal resection significantly
Ngdy nhgn bdi: 14/4/2017, ngdy chdp nh^n ddng: 19/4/2017
Nguaiphdn hdi- Nguyen Due Thang, Email- surgeonthang@gmail com - Benh vien TWQD 108
JOURNALOF 108-CLINICAL MEDICINE AND PHARMACY
improves a large number of tracheal diseases for the f a a that this method eliminates damaged tissue, reconstructs anatomy as well as recovering tracheal functions.
Keywords: Tracheal stenosis, tracheoplasty.
1. D i t van de
Khi q u I n 11 mdt phan cua bd may hd hap, cd chdc nang chinh la dan khi vao phdi, I I co quan duy nhat khdng ed bu t r d hoae thay the khi bj tdn thdong. Hep k h i q u l n (HKQ) cd nhieu nguyen n h i n nhd lao khi q u I n , u lanh hole l e tinh khf quan nguyen p h l t hole t h d phat, HKQ sau chan thUOng, HKQ di chdng sau dat dng ndi khi q u I n hole m d khi q u I n . . . [1], [6], [91 Ton thupng HKQ tien trien cd nguy cd de dpa tfnh mang benh n h i n gay suy hd hap v l y nen dleu trj HKQ tien trien la bat b u p c Hien nay cd nhieu bien p h i p dieu tri HKQ nhd: Dieu t n ndi khoa b l o tdn, dat stent, phau t h u l t . . . Tuy nhien moi phdong p h i p cd nhdng Uu va nhupe ^ e m khae nhau. Phau thuSt tao hinh dieu t n HKQ tai Benh vien Trung dong Q u I n dpi 108 da va dang ddpc tien h l n h v l mang lai hi&u q u i tdt [1], [3], [6]. Mue tieu:
Nhdn xet kit qud sdm phdu thudt dieu trj HKQ.
2. Doi t u p n g va phUtfng phap 2.1. Doi tugng
81 benh n h i n HKQ ddgc phau thuat do mpi nguyen n h i n tai Benh vien Trung dong Quan dpi 108td01/2012den 12/2016.
Benh nhan ed trieu chdng khd t h d co hpc do HKQ, khdng khd t h d vi benh li nhu md phoi v l phe q u I n , khdng cd benh tim phdi man tinh.
2.2. Phuang phdp
Nghien edu tien cdu md t l e l t ngang.
2.3. Cdc chi tiiu theo doi, ddnh gid kit qua Dudng kfnh eua cho hep nhat do tren CT scan:
D i n h g i l ty le hep dddng kfnh khf q u I n theo phan loai eua Cotton Myer [8], [9].
Dp 1: Dddng kfnh khi q u I n hep t d 0 - 50%.
Dp 2: Dudng kinh khi q u I n hep t d 50 - 70%.
Op 3: Dddng kfnh khf q u I n hep t d 70 - 99%.
Dp 4: Hep hoan t o l n .
D i n h gia lam sang mde dp khd t h d [3].
Vdi d i e trdng khd t h d thi hit vao ed tieng n't thanh k h i q u l n .
Dp 1: Khd t h d khi hoat ddng n l n g . Dp 2a: Khd t h d khi nghi ngoi.
Dp 2b: Khd t h d kem theo thieu oxi n l o , bdt diit kich ddng.
Dp 3: Trieu chdng ngddi s i p ehet: Gilm co keo cac CO hd hap phu, mat tieng rft thanh quan, thd nhanh ndng, I I ngddi, mat Id dd, da tai.
CIc phdong p h i p md, thdi gian md, thdi gian h l u phau.
Tai biin, bien chdng
Tai bien sau m d : C h l y m l u , hd mieng ndi, suy hd h i p , nhiem trung, khan tieng.
Bien chdng sau mo 3 - 6 t h i n g : Khd thd dp 1, tang sinh t d chdc hat, nhuyen khf q u I n , tai hep phai xdtrf.
Xd ly' thdng ki: So lieu dupe xd ly theo phan mem SPSS 13.0.
3. Ket q u i
3.1. Dgc diem chung
B i n g 1 . D i e d i e m chung
Gidi
Nam NOf Tong
So lacmg
49 32 87
%
60,5 39,5 100
Tuoi
L6n nhat Nhi6 nhat Trung binh
17 74 47,I6±1U
; TAP CHiY Dl/ac LAM SANG 101 Tap 12-S6 6/2017
3.2. Ddc diem Idm sang, can Idm sang
B i n g 2 . Nguyen nhan gay hep khi q u i n
Cac nguygn nlian HKQ Sau dat ong NKQ keo dai
Sau m6 khi quan
U khi quan nguyen phat n = 6
Ukhrqu3nthiJphatn = 27
U [anh (u nhay khi quan) U n g t h u t e b a o v a y UngthUbieumo tuyen U carcinoid
Ung thutuyen giap xam lan Ung t h u khac xam lan Lao khi quan
Sau chan thuong khi quan Nguyen nhan khac
Tong
SoIUdng 6 31 1 1 3 1 20 07 4 2 5 8 )
T J I e % 7,40 38,27 1,23 1,23 3,70 1,23 24,7 8,64
7,04
33,33
4,94 2,47 6,17 100
HKQ sau m d khf quan 38,27% chiem t;^ le cao n h l t . Ben eanh dd tdn thUdng u I c tfnh t h d phat khf q u I n do ung t h u t u y e n giap ehiem 24,7%.
Bing 3. Mdc do kho t h d t r i n lam s i n g B i n g 5. Vi tri ton thUtfng HKQ
Lam sang kho thcf Khong kho thd Kho thd d o i Kho thd do 2a Kho tha do 2b Kho thd do 3
Thd qua Canuyn md khi quSn Tong
So iUtfng 17 20 10 2 0 32 87
T y l # % 20,98 24,69 12,34 2,47 0 39,50
100
V j t r i ton thUtfng Khf quan doan CO Khi quan doan ngUc
SdlUtfng 57 24
T y l S % 70,37 29,63 3.3. Ket qud phau thudt
B i n g 6. PhUtfng phap phau thuat
Bing 4. Mii'c do hep khi q u i n tren hinh i n h CTscan theo Cotton Myer
Do hep Soluong 7^16%
D 6 1 14 17,28
Do 2 32 39,5
Do 3 27 33,33
Do 4 3 9,87
Tong 81 100
PhUtfng phap md Md khf quan Cat noi khi quan tan - tan CIt noi khf quan k^t hop cat u IVlo nong tao hinh khf quan
Tdng
Sd lUtfng 19 30 27 5 87
T ^ l c % 23,45 37,03 33,33 6,17 100
Hep do 2 chiem t y \t nhieu nhat, hep do 3, 4 thudng difoc m * khi quan trudc.
M d khf quan vinh viSn 19 ca (23,45%) do: HKQ di chiing khong hop tac theo doi sau mo, u ac tfnh qua chi dinh phau thuat tao hlnh, lao khf quan nhieu vi t r i . Cat noi khi quan tan - tan chlem chCl yeu 57 ca (70,33%).
JOURNALOF 108-CLINICAL MEDICINEAND PHARMACY Vol.12-N'e/IOl?
benh nhan trong nghien edu deu ddpe phau thuat:
Md khi q u I n ed 24,45%, gdm HKQ di chdng khdng hpp tac theo ddi sau md, u I c tinh q u i chi djnh phau thuat tao hinh, lao khi quan hep nhieu vj trf. Cat ndi khf q u I n tan - tan ehiem chu yeu 70,37% do sd lupng tdn thuong HKQ sau dat dng ndi khf quan keo dai, md khi q u I n va u khf q u I n t h d phat.
Dp dai doan khf q u I n eat trong e l t ndi khi quan tan - tan t d khoing 17mm tdi dai nhat la 51mm, dp d l i trung blnh 27,5 ± 11,2mm. Ton thucfng HKQ c l n g d l i thi nguy co that bai cang cao doi vdi phau thuat c i t ndi tan - tan, nen dp dai tdi da ma nhdm nghien cdu thue hien duoc 51mm chiem gan Vi dd d l i khf quan, p h l i phau tfch dpc chieu dai khi q u I n , ha thap xuong mdng, keo khf q u I n doan ngdc tdi da, dau gap tdi da sau md vdi mue dich g i l m I p lde c l n g tai mieng nol. Tuy nhien tac g i l Godehard Friedel et al (2003) [6] da thuc hien e l t doan khi q u I n 110 ca vdi dp dai hon t d 2 - 6,5cm ehieu dai trung blnh 3,5cm, trong dd cd 6 trddng hpp tac g i l p h l i phau tfch l l m di ddng thanh q u I n . Tie gia eung theo doi dai hon ddi vdi benh nhan sau mo ed 91,8% lien kl dau, cd 3 benh n h i n t l i hep trong q u i trinh nam vidn va 3 trudng hpp khac t l i hep sau ra vien.
Thdi gian phau thuat trung binh cua nhdm nghien cdu 88 ± 25,1 phut. Thdi gian nam vien sau md: 11 ±2,7 ngay. Thdi gian nam vien lien quan c h i t che tdi danh gia lien vet thuong, eat chf cd djnh cam ngdc khoing ngay t h d 8 - 1 0 theo doi tiep 1 - 2 n g l y khong cd bat thudng ve lam s i n g chung toi cho ra vien. T i e gia Liberman M et al (2009) [7] eat chi cd djnh cam ngUe d ngay t h d 5 - 7 ngan hon chung tdi nen cd le benh nhan ra vien sdm hon.
Theo doi bien ehdng sdm ed 16,05%, bien chdng mudn 28,39% trong dd tang sinh t d chdc hat khong trieu chdng 14,81% v l 4 trUdng hpp tai hep phai x d t r i dieu t n phau thuat v l can thiep khac nhu ndi soi ddt dien, tiem K cort t d chdc hat tang sinh g l y hep, cd trddng hop p h l i dat dng Mongomery nhung khdng ed trudng hpp t d vong lien quan tdi hieu qua phau thuat. Trong nghien cdu cua t i e g i l Wright CD et al (2004) [10] cd 901 trddng hpp ty le phau thuat thanh cdng la 95%, ty le t d vong 1,2% v l
m d lai 114%. Theo nhieu t l i lieu va nghien cdu trong ndde v l tren the gidi, bien ehdng t l i hep do tang sinh t d chdc hat tai mieng ndi x l y ra k h i phd bi^rt nhdng ed the han che bang eac phuang p h i p khac n h u dat stent khf quan, ddt dien, cham mytomycin C... nhimg hieu q u i lien ki d i u cua mieng ndi khi q u I n t i n - tan cua nhieu t i e gia van dat tren 90% [5], [7], [8].
Mae du ket qua cQa nghien edu va mot sd tac gia khae trong va ngoai ndde cdn ehda dat tdt 100%.
Tuy nhien, phau t h u l t eat doan tdn thdong ndi hoac tao hlnh t h l n h edng se hoi phuc ddpc giai phau - sinh ly dddng t h d , loai bo tdn thdong. Dac biet tot ddi vdi benh nhan m d khf quan l l u ngay dd la: Thd sinh ly qua dudng mui, p h l t am t r d lai, g i l m nguy ccf viem phdi do mat co che b l o ve, khdng cdn tan phe hd hap, chat lupng sdng c l i thien.
5. K^t l u i n
Qua nghien cdu 81 trddng hpp HKQ dupe phau t h u l t tai Benh vien Trung dong Q u I n ddi 108 chung tdi thu dupe nhd sau: Nguyen n h i n HKQ chu yeu sau m d khf q u I n va dat ong ndi khi q u I n keo dai chiem 45,67%. Mdc dp HKQ theo Cotton Myer. Do 2 chiem t J le cao nhat 39,5%. Tdn thdOng khi quIn doan ed chlem 70,37%.
Cac phuong phap m d : Cat ndi khf q u I n tan - tan 37,3%, e l t ndi khi q u I n -i- cat u 33,33%. Dp dai doan khi q u I n cat bd t d 17 tdi 51mm, dd dai trung binh 27,5 ± 11,2mm. Thdi gian phau t h u l t trung binh: 88
± 25,1 phut. Thdi gian n l m vidn sau md: 11 ±2,7 ngay. Bien chdng sdm: Khln tieng 9,87% v l bien chdng mupn: T i n g sinh t d ehde hat khdng tneu chdng 14,81%, mo lai 4,94%.
Phau t h u l t tren khi q u I n dieu tri seo hep tuy khdng hoan t o l n dat ket q u i tot nhdng kha nang thanh cdng cao.
Tailleu tham k h i o
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TAP CHl Y Ddqc LAM SANG 108 rap 12-So 6/2017
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Emedieine.
Godehard F, Thomas K, Andrea L, Heikki T (2003) Long-term results after 110 tracheal resections.
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Liberman M and Mathisen DJ (2009) Surgical anatomy ofthe trachea and techniques of resection and reconstruction. General thoracic surgery 1:
955-965.
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398-405.
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