VIETNAM MEDICAL JOURNAL N°1 - OCTOBER • 2017 phu'dng phap lay mau, vj t r i u nguyen phat, va
phan loai giai doan TNM.
TAI LIEU THAM KHAO
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Lancet Oncol. 11 (8). DD. 753-762
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4. Jing Zhang, Jianming Zheng, Yinghong Yang, Junliang Lu et al (2015). Molecular spectrum of.
KRAS, NRAS, BRAF and PIK3CA mutations in Chinese colorectal cancer oatients: analysis of 1.110 cases. Scientific Reoorts.
a. Neam S.et al (20141 KRAS. NRAS and Bm mutations in Greek and Romanian oatients with oalorectal cancer; a cc^rt studv. Bi^ Ooen 23. e004652.
6. Demunter A. Stas M. Deareef H, et al fZOOiy Analysis of N- and K-ras mutations in the distinctive tumor orocression ohases of melanoma. J Invest Dermatol. 2001:117:1483-1489
7. Voaelstein B. Fearon ER. Hamilton SR. et al fl9981. Genetic alterations durina colorectal-tumor development. N Engl 1 Med. 1988;319:525-S32.
DANH GIA KET QUA sffM PHAU THUAT DIEU TRI U MO DEM (y DA D A Y TAI BENH VIEN K
Tran Dinh Tan', Pham Van Binh', Nguyin Van Hung^
T O M TAT
Muc tieu nghien cuti: Danh qia ket qua sdm phau thuat dieu tri U mo dem du'dng tieu hoa (GIST) d da day. Phu'dng phap: Nghien cu'u mo ta hdi cuXi ket hpp tien CLTU. Doi tUdnq nghien cCru: Benh nhan co Chan doan hoa mo mien dicti ia u mo dem da day, dude phau thuat lan dau tai benh vien K tir thanq 1/2013-6/2017. Ket qua: Co 50 benh nhan bao qom 32 nd va 18 nam, tuoi trung binh 54,4 (22 - 75). Mo md 95%, md noi soi 4%. Co 90% phau thuat triet can, phlu thuat khong triet can 10%. PhUdng phap phau thuat cat hinh chem 72%, cat da day md ronq 10 %, cat ban phan da day chiem 8% ya cat toan bo da day chiSm 8%, co mdt benh nhan mo thong da day 2%. Thcfi gian nam hau phau trunq binh 11,4 ± 5 nqay v6i ti le bien chu'ng sau mo thap 6%, khong co tru'dng hop nao tir vong sau mo. Ket luan: Phau thuat la phu'dng phap dieu tri hieu qua va an toan vdi ty le phau thuat triet can cao, tai bien trong md, bien chuhq sau mo thap doi vdi GIST da day.
Tdkhoa: GIST, da day, phau thuat, Benh vien K.
SUMIVIARY
EARLY RESULTS OF SURGERY I N GASTRIC GASTROINTESnNAL STROMAL TUMOR (GIST)
Aims: To evaluate eariy results of surgery in gastnc GIST. Patient and Methods: This is a retrospective and perspective description study of patients who had gastric GIST and underwent surgical
^Benh vien K
^Daihoc YHa Ngi
Chju trach nhiem chinh: Tran Dinh Tan Email: [email protected] Ngay nhan bai: 12.7.2017 Ngly phan bien khoa hpc: 30.8.2017 Ngay duyet bai: 11.9.2017
management in National Cancer Hospital from January, 2013 to June, 2017. Results: There were 50 patients with 32 females and 18 males. The mean aqe was 54.4 (22 - 75). Laparoscopic surqerv was performed in 2 patients (4%) and conventional ODen surgical resections for 48 patients (96%). Comolete resection (RO resection) was achieved in 45 patients (90%), while palliative surqerv was found in 5 patients (10%). Reqardinq the surqical manaqement, 36 patients (72%) unden^ent gastric wedqe resection, S patients (10%) underwent extended gastrectomv, 4 patients (8%) underwent partial gastrectomy, 4 patients (8%) underwent total qastrectomy, only 1 patient (2%) underwent qastrostomv. The mean lenqth of hospitalization was 11.4 ± 5 days with verv low rate of complication and there was no patient died. Conclusions: Surgery is an effective and safe treatment with high rate achievement of complete resection in gastric GIST. Complication in- postoperative is low.
Keywords: Gastric, GIST, surgery. National cancer hospital.
I. B A T V A N DE
U mo dem du'dng tieu hoa (GIST) la loai u it gap trong cac u cf du'dng tieu hoa chiem ty le du'di 1 % cac tru'dng hdp u du'dng tieu hoa va 5% cac sarcoma, nhutig GIST lai la loai thi/cfng gap nhat trong cac loai u trung mo eiia thanh ong tieu hoa va co the gap d bat ky vj tri nao cua du'dng tieu hoa tuy nhien hay gap nhat lacl da day chiem 60-70%, tuoi trung binh eua GIST la 53 tuoi vdi ti le nam gidi ed xu hu'dng mac nhieu hdn nu' gidi [ 1 ] . GIST dddc phat hien diiJ yeu bang cac phu'dng phap chan doan hinh anh nhu" chup cat idp vi tinh, npi soi du'dng tieu hoa, sieu am npi soi, sieu am 6 bung,.,, tuy nhien cac
TAP CHi Y HOC VigT NAM TAP 459 - THANG 10 - SO 1 - 2017 u nay thirdng bj nham lan vdi u ed trdn lanh tinh
hay ac tinh do cd hinh anh mo benh hoc cd nhii'ng diem tu'dng dong [ 2 ] . Nhd sif phat tnen cua hda mien djch va cac nghien cihj ve gen, cac nha giai phau da tim thay sy dot bien cua gen KTT, mot gen hem nang ung thu' va tim ra SLT boe 16 khang nguyen be mat CD117 cua GIST nen da giup chan doan GIST duWe ehinh xac hdn.
Trong khi dieu tri GIST bang hoa chat va xa trj con _nhieu han che, phu'dng phap dieu tn ehinh van la p h l u thuat vdi dien cat am tinh.
Viec nao vet bach la khdng can thiet vi GIST hiem khi di can hach (ty le du'di 5%) [1]. a Viet Nam ndi chung va Benh vien K ndi rieng van chda CO nhieu nghien cilru day du ve dieu hi GIST, dac biet GIST d da day. Chinh vi nhCirig Ii do do chung
^ i thu'c hien nghjen culi vdi muc tieu: "Oanh gia ket qua sdm phiu thuat dieu iri GIST d da day tai benh vien K".
II. DOI TU'QNG VA PHLTaWG PHAP NGHIEN CIJ'U - Doi tu'dng gom 50 benh nhan du'dc du'dc phau thuat ISn dau cd ket qua mo benh hoe, hoa md mien dich la u GIST da day tir thang 1/2013 den thang 6/2017 tai benh vien K.
- Phu'dng phap nghien cu'u: Mo ta hoi ciTu ket hdp tien cihj.
- Cdmau: Thuan tien.
- Xu* ly so lieu bang phan mem SPSS 16.0.
III. KET QUA NGHIEN CLTU VA BAN USfyn 3.1. D^c diem chung
3.1.1. PhSn bo benh nhan theo nhom tuoi
B^l;Phanbdbenhnhantheocacnhdmtu6i Nhom tuoi
< 20 tuoi 20 - 40 tuoi 40 - 60 tuoi
> 60 tuoi n 0 6 28 16
Tv le ( % ) 0 12%
56%
32%
Trong nghien cu'u ciia chung toi, benh nhan tre tudi nhat la 22 tuoi, Idn tudi nhat 1^ 75 tuoi, dp tudi trung binh 54,4±11,4 tuoi. Trong dd nhom ddi tu'dng trung men (40-60 tudi) hay gap nhat chiem ti le 56%. Ket qua nay ciing tu'dng tiT nhd nhieu ket qua khac du'dc ghi nhan trong nu'de [3] va ngoai nu'de [4], Mientten va edng su"
tien hanh nghien ciTu tren 1765 benh nhan nhan thay ngu'di tre nhat mac GIST da day la 8 tudi,'ti le benh nhan < 21 tudi chiem 2,7% [1]. Nghien cu'u eiia chiing toi tuy so lu'dng khong nhieu nhd Mientten va cong su' nhu'ng cung eho thay rang ti le GIST da day ft gap d ngu'di tre.
3.1.2. Phan bo benh nhan theo gidi:
Trong nghien ciTu eiia chung tdi cd 50 tru'dng hdp trong dd cd 32 benh nhan nu' va 18 benh nhan nam vdi ty le nam/nu' = 0,56. Ti le mac GIST da day d nam va nu" tuy ed sd chenh lech nhu'ng khong cd y nghTa thdng ke. Mot sd tac gia nu'de ngoai nghien ciTu tru'dc day nfiu' Miettinen ed ty ie benh nhan nam gidi ed xu hu'dng mac nhieu hdn nu' [1]. Tuy nhien, nghien cu'u eiia chung tdi cho thay nff gidi chiem ty le eao hdn nam gidi tu'dng tu' vdi mot vai nghien eiTu trong [3], va ngoai nu'de [4],[5],
3.2. Oieu trj phau thuat 3 . 2 . 1 . P h l u thuat Bang 2: Cach thu'c phiu thuat va tlnh triet can
Phu'dng phap phau thuat
Cach thu'c p h l u thuat
Mu'e do triet can
Cach thUc 1^6 md Mo noi soi Cat ronq u (iiinii ciiem)
Phau tiiuat m6 ronq Phau thuat cat doan Cat toan bo da day t^d thonq da day, sinh thiet
Triet can Khong triet can
Benh nhan ( n ) 48
2 36 5 4 4 1 45 5
Ti le (»/o) 96%
4%
72%
10%
8%
8%
2%
90%
10%
Ve phu'dng phap phau thuat: Trong nghien CLTU ciia chiing tdi, benh nhan du'dc chan doan GIST da day chu yeu du'dc phau thuat mo md (chiem 96%), chi cd 2 benh nhan (chiem 4%) du'dc phau thuat npi^soi cd sOrdung stapler. Ti le benh nhan du'dc phau thuat ndi soi trong nghien ciiu cLia toi thap hdn nhieu so vdi mdt so nghien culj trong nu'de [3] va nu'de ngoai [4];[5];[6]
nhu' Min-Chan Kim va cpng su" tien hanh nghien cull da trung tam tren 1057 benh nhan tai Han
Quoc va Nhat Ban sd tru'dng hdp mo ndi soi chiem tl le 37,7% [6]. Sd dl cd si/chenh lech ket qua nhu' vay vi kich thu'de u trung binh trong nghien ciTu cua cac tac gia nay la 4 cm, thap hdn so vdi nghien ciTu ciia ehiing toi (8,1 cm), ngoal ra CO the do trinh dp, kinh nghiem phau thuat vien va trang thiet bj hien dai hdn Viet Nam. Tuy hien tai ti_^le mo npi soi GIST da day cdn thap nhu'ng phau thuat npi soi cat u GIST da day trong nu'de dang tLTng bu'dc du'dc ap dung va
VIETNAM MEDICAL JOURNAL N°1 - OCTOBER - 2017 phat trien ngay cang rdng rai hdn.
l/e mdc dp triet can: Trong nghien eiru eiia chiing tdi cd 45/50 (chiem ti ie 90%) tru'dng hdp phau thuat triet de ^RO), cdn lai 5 tru'dng hdp (chiem ti le 10%) phau thuat khdn_^ triet de_(R2) do u xam lan phiTc tap ehi cd the lay u toi da, trong do eo mot tru'dng hdp phau thuat tham dd sinh thiet, md thdng da day. Ket qua nay eijnq tu'dng tiT nhu' nghien ciTu trong nu'de [3], [6].
Nhl/ vay trong GIST da day ti ie phau thuat du'dc triet de la tu'dng doi cao.
t ^ each thdc phau thuat: Trong nghien cifu ciia chiing tdi benh nhan du'dc chii yeu du'dc phau thuat eat u hinh chem (chiem ti le 72%) vdi dien eat each bd khdi u khoang 2 cm, cdn cac phu'dng phap khac nhu' p h l u thuat eat doan, toan bd da day, phau thuat eat da day md rong chiem ti le thap, dac biet md thdng da day, sinh thiet rat thap chi cd 1 tru'dng hdp (chiem 2%) do u tam vj ian rdng xam ian dm mat tru'dc ddng mach chii bung. Ket qua nay cung tu'dng tu" nhu' cac nghien cu'u tren the gidi [4];[5];[6] va trong ni/dc [3]. Viec phau thuat cat u liinh chem da dem lai nhieu idi ich eho benh nhan, giiip bao ton du'dc chirc nang sinh II ciia da day. Chinh vi vay phau thuat cat u hinh chem chiem ti le cao nhat va phu'dng phap nay eijng du'dc khuyen cao ap dung chii yeu trong phau thuat dieu trj GIST da day.
3.2.2. Tai bien t r o n g m6: Chiing tdi quan sat thay dien bien trong md thuan ldi, chi cd 1 tru'dng hdp chay mau trong mo (chiem ti i§ 2%) do khdi u nam d mat sau da day, lan rdng, xam lan vao laeh va dudi tuy, xam lan mach mac treo dai trang ngang nen phai cat doan da day kem lach va duol tuy, cat dai trang ngang de cam mau, benh nhan phai truyen mau trong va sau mo, tuy nhien ket qua hau phau tot va benh nhan ra vien, ket qua nay ciJng tu'dng tu" nhu"
nghien ciTu eiia Xanxai Soryavong tien hanh tren 35 benh nhan tai benh vien Viet Dire ed 2 benh nhan phai truyen mau trong mo [3].
3.2.3. Thdi gian hau phau: Thdi gian hau phau trung binh 11,1 ± 5 ngay, ngan nhat's ngay, dai nhat 32 ngay. Ket qua eiia chung tdi cho thay thdi gian hau phau dai hdn so vdi mot so nghien ciTu trong nu'de nhu' Xanxai Soryavong thdi gian hau p h l u 8,1 ± 3 ngay [3] va nu'de ngoal nhu' Dalqle C va edng su' chi co 6 ngay [71.
Mdt trong nhutiq u'u diem ciia phau thuat ndi sol la giam thdi gian nam vien hau phlu so vdi mo' md truyen thong, trong nghien CIJ'U cita chiing tdi ti le phau thuat ndi soi chi chiem 4 % thap hdn nhieu so vdi nghien ciTu ciia Xanxai Soryavong (31,4%) va nghien cu'u ciia Daigle C
(82,6%) dieu nay cung If giai trong nghien ciiii eiia ehiing tdi thdi gian hau phlu keo dai hdn so vdi 2 tac gia tren.
3.5.4. Bien chu'ng sau mo: Nhin chung cac benh nhan trong nghien eiru cd ket qua tot sag phau thuat, bien chiTng thap va khdng ed tru'dng hdp nao tir vong sau md. Cd 2 benh nhan bier chu'ng tai cho (4%), 1 benh nhan nhiem triing vet md va rd tuy (2%) da du'dc dieu tri npi khoa dat ket qua,l(2%) tru'dng hdp cdn lai ap'xe tan dd da dddc tach vet md, dat d i n \du va khang sinh, sau do 2 tru'dng hdp nay on dinh, va ra vien. Cd 1 benh ninan (2%) gap bien chii'ng toan than la viem phoi, sau dieu tri khang sinh on djnh. Ket qua nay cQng tu'dng tu" nhu' mot so nghien cu'u trong va ngoai nu'de: Xanjal Soryavong nghien ciTu d benh vien Viet Du'c co'l benh nhan nhiem triing sau mo 1 benh nhan viem phdi [3],
IV. KET LUAN
Qua nghien ciTu 50 benh nhan GIST d da day tai Benh vien K cho thay ket qua sdm ciia phau thuat dieu tri GIST d da day hieu qua va an toan vdi t / ie phau thuat triet can cao 90%, thdi gian hau phau trung binh 11,1+ 5 ngay, tai bien trong md thap 2%, bien chimg sau md chiem 6%.
TAI LIEU T H A M KHAO
1. Miettinen M. Sobin LH. Lasota J. fZOOSV Gastrointestinal stromal tumors of the stomach: a elmicoDatholoaic. immunohistochemical. and molecular aenetic studv of 1765 cases witii lona- term follow-up. Am J Surg Padiol, 29:52- 68. [PubMed]
2. Fletcher C. D., Berman J. J., Corless C, et al, (2002). Diagnosis of gasbointestinal stromal brnios:
A consensus approach. Hum Pathc^, 33(5), 459-65.3P 3. Xanxai ^ o r y a v o n g , {l<ilS).Danh gia ket'^
sdm phau thuat u mo dem da day tai benh wen Hull Nghi Wet Su'c Luari van tot nghiep t h a c ^ naoai knoa. tru'dna dai hoc Y Ha Noi. f i 4. Ki-Han Kim, Min-Chan Kim, GhapOobiig
Jung, et al, (2012). Long term survival results for gastric GIST: is laDarosconic suraerv for l a M aastric GIST feasible?. World J Sura OnaiL 10: "mfi 5. In-Hwan Kim, In-Ho Kim, Sang-Gyu Kwal^P
al, (2014). Gastrointestinal stromal t u f t ^ (GISTS) of the stomach: a multjcenrar retrospective studv of eurativelv resected gastric GISTS. Ann Sura Treat Res. 87f61. 298-303. V 6. Min-Chan Kim. Jeona-Hwan Yook. Han-
Kwana Yana. et al f 2015V Lona-Term Suroical Outcome of 1057 Gastric GISTs Aeeordina to 7tti UICC/AJCC TNM Svstem: Multicenter Obsen/ational Studv From Korea and Japan. Published Medidne (Baltimore). 94f411.
7. Carl Daiale. MD,Adam T. Meneghetti, MD e al (2012). Laparoscopic management of gastrointestinal stromal tumours; review at a Canadian centre. Can J Surg, 55(2); 105-109.
