- TAP C H ! NGHIEN CIJU Y HQC
CAT KHOI TA TRANG D A U TUY VOI CACH TIEP CAN TLP BO MACH MAC TREO TRANG TREN
Trdn Q u i S g n \ T r i n H i l u H o c \ Masato Nagino^
^Khoa Ngoai tong hop - B$nh vien Bach Mai, Ha Noi
^Khoa phSu thuat ung thw- Benh vien dai hoc Nagoya, Aichi. Nhat Ban Nghien eiru nham dinh gii ket qua eat khdi ta trang diu tuy vdi each tiip cin tir ddng mach mac tmo tring tren Nghien ciru md ti 8 tru&ng hgp dwgc md tgi Bgnh vien Dal hoe Nagoya tir 12/2/2017- 12/3/2017- Tudi trung binh 59 ±9.4 tudi (dao ddng 43 -71 tudi), giii phiu bgnh bgnh bao gdm 7 benh nhin ung thw biiu md dng tgy, 1 tru&ng hop ung thw bieu md dw&ng mit 4 bgnh nhan dwac cit doan ti'nh mach cu-a, 1 benh nhan kem theo cit gan trai. Tat ea bgnh nhan dugc ngo vet hgch md rdng vdi mieng ndi tuy - mgt non kieu Blumgart cd dat stent dng tgy. 6 bgnh nhin dgt mirc RO a tat ca cae dien cat. Thai gian thay tTnh mach cira 19.2 ± 4,3 phut (15-25phiit).sdhgchdicin9,1 ±4,7hgch(3-16hgch). tdng sdhgch ngo vdt35,5 ±4,3 hach (30-42 hgch).
Thdigianmd455±99phut(315-630phut), lugng mau mat tmng binh 562,5 ±204,8 ml (400-1000 ml), ngay nam vign 14,9 ±1,5 (13- 17 ngiy), khdng cd biin chirng vi tir vong Cat khdi ta tgy iS tie bd mach mac treo trang trin cd thi giam Iwong mau mit, liy dwge toan bg mac treo tgy va de dang khi Ihay doan tfnh mach cCra.
lir khoa: c I t khdi ta tyy, cat khdi ta tuy tiSp can t u bo m^c mf c treo, c i t khdi ta tuy nao hach md rpng
Til- vilt t i t : DUil = dogn D2, TL = day chang Treizt, MCV = tTnh mach dai trang giira, MCA = D6ng mach dgi trang giua, SMV=TTnh mgch mgctreo trang tren, SMA=O0ng mach mgctreo trang tren, JA1,2=e6ng mgch hong trang, PLphII=Dam roi than kinhdau tyy, IDPA=DOng mach ta tyy du'di, PANC=Tuy,GDA=09ng mach vita trang, PV = TTnh mgch cda, CHA = Dpng mgch gan chung, EIA= dong mach chau ngoai, ElV = TTnh mach chau ngoai
I. DAT VAN 0£
Vdi cac phuong tidn c h i n doan hign dai, chan doan sdm ung thu tuy cdn nhieu han c h l . Do dd, nhilu trudng hap dugc phau thuat khi khoi u tuy da xam i l m vdo tTnh maeh cua hoac ITnh mgch mgc treo trdng trdn, mo Iridt can la mdt ygu cau khd khan, tidn luang song sau 5 nam giao ddng t d 3,5 - 25% [1, 2] Phau thuat c i t khdi ta trang d i u tyy duoc ap dung de dieu Dja chllien hg Tran Qui Son, bd mdn Ngogi, Trwang Dgi hgc Y Ha ndi
Email: [email protected] Ngay nhgn-27/4/2017 Ngay dwgc chap nhin- 26/6/2017
tri triet can cac khdi u viing bdng Vater Lya chgn bgnh nhan phii hgp, ky thuat va cham sde bdnh nhan trudc vd sau mo l i t da giam ty l§ I d vong dudi 5% d nhilu Irung tam phlu thuat Idn, tuy vay b i l n chung sau mo hien nay dao ddng khoang 20 - 40% sau p h l u thuat e l t tuy [3,4] Khi t i l n hanh e l t khdi la tuy, cac p h l u thuat vien thudng thuc hien thu thuat Kocher de di ddng khung ta trang d i u tuy (1905), danh gia muc dd xam l l n eua khdi u tuyvao ITnh mgch chii dudi hoac xam l l n bd mac mgc treo trang tren, T u thap men 1980, Nakao ap dung phugng phap nay de e l t khdi ta tuy, dng nhan thiy l u l n hoan xung quanh viing dau tuy r i t
•r.ir-VU mfi c^) - 9ni7
TAP CHi NGHIEN C\y\} Y HQC nhilu va gay chay mau Ngoai ra viing d i u tuy dinh vao thanh bung phia sau bdi mac dinh ta tuy, bao gdm hach bach huylt va dam roi t h i n kinh, to chuc lign k i t hay edn goi la mac treo d i u tuy Mac treo nay di lir mat sau tuy den thdnh bgn phai sau dd vdng ra phia sau ITnh mach cua va tTnh mgch mac treo trgng tren Mac treo d i u luy cd hach bach h u y l l dpc theo ddm r l i t h i n kinh tang va eae nhanh tTnh mach nho dl vao tTnh mach cua. Oam rdi nay cd thd la nai cac t l bao ung thu d i u tuy di can d i n (tdi 67% vdi ung thu tuy giai dogn I, 11 va ldn ldi 88% d giai doan III va IV [5] Nam 1981, Nakao ung dyng dgt catheter phan luu mau tif tTnh mgch cua v l tTnh mgch chgu ngoai hoac v l ITnh maeh ehu b i n g dng thdng cd trdng c h i t chdng ddng Vdi phuang phap nay ed t h i giam lugng mau di qua tTnh maeh eua, khdng han che thdi gian khi p h l u tich viing d i u tyy, ed the e l t va thay doan ITnh mgch cua md khdng sa ir trg mgu d rudt hogc thilu mdu gan [6, 7], Trong p h l u thugt ung thu dau tyy, bdc tach khoi u va nao vdt hach hd thing thanh mdt khdi (en-bloc) vdi ty le dien c i t h i t u phy thude mdt phin vao vide ed Ily h i t eae td chuc xung quanh bd mgch mgc treo trang trdn hgy khdng [8]. Vdi each t i l p can qua mac tree rudt n h i m bdc Id bd maeh mgc treo trang tren trudc, thit cac nhanh ddng mach va ITnh maeh di vao vung d i u tyy n h i m gigm luang mau chgy, t i l p can khoi u t u VI tri chua cd u. Do dd, nhilu tac gia tren t h i gidi da cdng bo cac k i t qua nghign cdu, dgc biet trong nhung trudng hgp phdc tgp khi u xam l l n rdng ra to chuc xung quanh nhu xam l l n ITnh mach cua, xam l l n tTnh mach chii [9-11] Tai VietNam, nhilu bao ego v l k i t qua e l t khdi ta tuy nhung ehu y l u la k i t qua ban d i u , ky thugt khae nhau d nhilu tac gia.
Do dd nghien cuu n h i m gidi thieu v l k j thuat mo e l t khdi ta tyy cua cdc tac gia Nhat Ban vdi k i t qua bude d i u
II. D61 TU'aNG VA PHU'ONG PHAP
1. Ddi t u a n g
Bao g i m 8 benh nhan dugc cdt khli ta trang d i u luy, cd hoac khdng kdm theo cat gan trai dugc thyc hidn tgi khoa Phlu thuat tieu hda 1 va II, Benh vien Dai hgc Nagoya, Nhat Ban trong Ihdi gian mdt thdng td 12/2/2017 - 11/3/2017.
Tieu chuan c h i n doan:
- Cac phuong phap-chin doan hinh anh (chyp e l t Idp vi tinh, sieu am ndi soi) xac djnh ed khoi u dau tyy Mdt trudng hap ed khli u dudng matluyp I (theo Bismuth).
- Xet nghiem CA 19 - 9 tang cao - K i t qua smh thilt ton thuong d i u luy qua sidu am npi soi tra ldi ung Ihu
Tieu chuan logi trd:
- Bgnh nhan duac c i t khdi ta tuy nhung ton thuang trudc m l la viem tuy man 2. P h u a n g phap
2.1. Phuo-ng phap mo ta Quy trinh p h l u thugt [12].
B'enh nhan duac dat stent dudng mat tru'dc m l 2 t u i n khi ed b i l u hien t i c mgt (6 b$nh nhan) Mg byng dudng tring gida trdn va dydi rdn Rua byng b i n g nude muoi smh ly 0,9%
Ily 200ml (4 xylanh 50 ml) tim t l bao ung thy Phlu tich mac treo dai trang Md mac treo dai trang tir gdc Treizt d i n bd dudi 02 ta trang, bdc Id dgng mach va ITnh mach mgc treo trang Iren (anh A l , A2).
Phau tich Ily bd hgch. Id chuc xung quanh ddng mgch va tTnh mgch mac treo trang tren (SMV, SMA)' cat dpng mach dgi trang giCra, that ddng mach ta tuy dudi (IPDA), t h i t ddng mach quai hdng trang d i u tidn, lay mac treo tuy d phia sau, nao hach nhdm 14 (anh A3, A4) C i t ddy chang dg day - dai trgng, giai phdng mac noi Idn khdi dgi trang. C i t till mat, phlu tich i l y to chdc, hgch doc ddng mach gan, ong TCNCYH 108 (3)-2017
mat chu (nhdm 12a,b,p). C i t dng gan chung, that ddng mgch vj Id Irdng, nao hgch dgc DM vi phai, gan rieng, than tgng (nhdm 7,8,9),
C i t day ehing dg day - dgi trdng, giai phdng mac noi Idn khdi dai trdng. G i l tiii mat, phau tich i l y l6 chuc, hach dgc ddng mach gan, ong mat chu (nhdm 12a,b,p). C i t ong gan chung, thit ddng mach vjta trang, ngo hgch dgc DM vj phai, gan neng, thdn tgng (nhdm 7,8,9)
cat hang vj da day. C i t ngang eo tyy bang dao thudng, khau e l m mdu didn e l l tyy bang chl Prolen 5-0 C i t quai hdng trang dau tidn, thao b i t ehdo
Liy bd toan bd lo chdc hgch bgch huylt
ll»H^^iN.iay|y.H9,c
kem theo oac nhanh t h i n kmh d phia sau ITnh mgch cira. Khi u xam l l n tTnh mach cira. kep d i u tren va dudi tmh mach cii'a N l u dogn tTnh mach bl xam l l n > 3 cm thi Uiay dogn. Ndu tTnh mach bj xam l l n < 3 cm Ihi t i l n hanh e l t va ndi tan - tan b i n g prolen 6 0,
Lap lai luu thdng tieu hda kilu Whipple Tyy-hdng trang (kilu Blumgart" monosyl 3 0 miii rdi 2 ldp I n g tuy - nidm mac rudt d trong, nhu md tyy - thanh ea rudt, cd ddn luu dng tyy ra ngoai), dng gan - hdng trang (tan - bdn, monosyl 3.0 rdi, khdng d i n luu dudng mat), da day - hdng trang (tan - ben mui rdi, loan the phia trudc mac tree dai trang ngang).
A3. P h l u tich m^c treo diku tuy A4. Cat nhanh mach dpc mac treo trang tren 2.2. Mdt s d quy wcec trong nghien ciru
- MO'C do triet can. phu thudc vao k i t qua sinh thilt ciia cac didn e l t ma k h l i u vCing d i u tuy cd the xam l l n vd di cSn d i n bao gdm di$n o i l dudng mat, didn c i t da ddy, dign e l t h i n g trgng, dien
TCMCYH 108 (3) • 2017
T^p ci^mMmsMi H9^
c l l mgc treo d i u tyy va ily cac hgch h$ thing quanh dau tuy ma cd the khoi u di can d i n Mdc dp tnet cdn dugc phan logi: RO {Khdng edn id chdc ung thu tgi didn e l t ca v l dai the l l n vi the). Rl (Dien cat h i t u v l dai the nhung vi t h i vgn cdn u). R2 (edn ung Ihu ve mat dai thi). Cac dien elt dugc coi la duong tinh (Rl) n l u khoang each tdi u < 1 cm.
- X l p loai giai doan benh theo phgn logi cCig hidp hdi chdng ung thu qudc l l (2002) [13]'
Khdi U (T) Hach (N): phan tich it
Di can xa (IVI) ' Phan loai Giai doan benh Tx- khdng dii thdng lin d l Nx. Khdng du thdng tin MO khdng dl ^ ^ p. .^^ ^^ ^^
phan logi khdi u d l phan logi hgch can xa
Tls: Ung thu tai chd NO; Khdng di can hgch M l : Cd di can ^ ^ |^. j.^ ^ ^ ^^
vCing xa T l : Dudng kinh u Idn nhgt
< 2 cm, gidi han tgi tyy
Nl Cddi can hgch
vung GD IB' T2 NO MO
T2' Dudng kinh u Idn nhat
>2 cm G e i l A : T 3 N 0 M O
T3: U xam lan mdt trong nhung tgng ta trang, I n g mgt chu, td chdc qugnh tyy nhung khdng xdm l l n mach mdu "
GeilBT1-3N1M0 GDIII.T4, N b l t k y , MO
G D I V : M 1 , T v a N b a t ky
T4. U xam lan ddng mach than tang hoac ddng mach mgc treo trdng trgn 3. Ogo diVc trong nghien CIFU
So li$u duac thu thap va theo ddi benh nhan trong mo, sau m l , cdc thdng tin d i u duac ma hda.
K i t qua nghign cdu dugc d l xuat n h i m nang cao hieu qua phau thudt cae khdi u vCing d i u luy ta trang, khdng phyc vy muc dich khac.
III. K^T QUA
Bang 1. Oac d i l m benh nhSn d u v c chi djnh md
STT Gi6i Tuoi Chdn doan Kich t h u d c u Giai doan
(mm) (TNM) Giai p h l u benh
1 Nam 43 U dau tyy T1N0M0 Ung thu bieu md ong
' "^^'^'^ tyy bidt hda vua
TCNCYH 108 (3)-2017
U lan tda tir ron _. ^. , ,, .. . . , thap ong mdt chu ^
3 Nu 56 U ddu tyy Ung thu bieu mdong
tuy bigt hda vira
4 N d 71 U d i u tyy Ung thu bieu md dng
tyy bigt hda vda
5 Nam 68 U d i u tuy Ung thu b i l u md dng
tyy kdm biet hda
6 Nu 52 Ung thu bieu md dng
tyy bigt hda vii'a
7 Nam 62 U dgu tyy Ung Ihu bieu md ong
tuy biel hda cao
Nam 54 U dau luy Ung thu b i l u md dng
tuy biet hda vda
H l u h i t bgnh nhan dixac ehi djnh do ung thu bieu md d i u tyy. Mdt trudng hgp ung thu dudng mat giai doan I (theo phan loai eua Bismuth) duac c i t gan trdi kdm e l t khdi ta tyy
Bang 2. Ogc diem phdu thuat
STT 1 2 3
Dat stent dud'ng mat
Cd Cd Cd
Mieng ndi tuy rudt Blumgart Blumgart Blumgart
P h l u thuat mach mau Khdng Khdng C l l dogn tTnh maeh
cira, ndi tan - tdn
Thdi gian thay tmh mach cua
- -
15
P h l u thuat kem theo
cat gan trai
Blumgart
T h i t ITnh maeh lach, ghdp dogn tTnh mach cua b i n g ITnh maeh
chau ngoai 5
6
7 8
Khong 0 6 C6 Khang
Blumgart Blumgart
Blumgart Blumgart
Khong C i t doan tTnh mach
ciJa, n6i tan - t^n C i t doan tTnh mach CLKa noi tan tan
Khang
-
17 20
-
TAP CHl NGHIEN CCjPUY H O C -
Co sau bdnh nhan duac dgt stent dudng mat trudc md do vang da, Midng n i i tuy - rudt non duac thyc hidn ciing mOt ky thugt n i l Blumgart cd dat stent dng tyy B i n trudng hgp phai e l t tTnh mach cua do khli u xdm l l n trong dd mdt trudng hgp duac ghgp doan b i n g finh mach chau ngoai
Bang 3. Mirc do triet can trong phlu thuat
Hach di can/
STT Giai doan "" Tuy 6ng mgt Da day Mac treo
tdng so hach .
1 2 3 4 5 6 7 8
T1N0M0 T3N1M0 T3N1M0 T3N1M0 T1N0M0 T3N1M0 T3N1M0 T3N1M0
4/31 12/35 5/30 14/38 3/32 9/40 16/42 10/36
RO RO RO Rl RO RO RO RO
RO RO RO RO RO RO RO RO
RO RO RO RO RO RO RO RO
RO RO RO Rl RO Rl RO RO
T i t ea benh p h i m d i u dugc lay cdc nhdm hach lam giai phau bdnh gdm cac nhdm 5,6,7,8,9,12,13,14,17 Hai trudng hap la bgnh nhan s i 4 va s6 6 dien c i t mgc treo luy edn u do u xam l l n tTnh mach cira
Bang 4. Kit qua g i n sau phlu thuat
STT 1 2 3 4 5 6 7 8 Trung
blnh Tudi
43 66 56 71 68 52 62 54 59 ± 9,4
Thai gian ni6 (phut)
315 630 420 550 375 450 420 480 455 ± 99
M i t mau (ml) 500 1000 600 700 400 450 vtOO 450 562,5 + 204,9
Truyen mau (ml) 250 500 250 500 Khang Khong Khong 500 218,7 ±208,6
Bien chipng Khang Khong Khang Khong Khong Khang Khong Khang
Thd'i gian nam vien (ngay)
15 16 13 15 17 16 13 14 14,9 ±1,5
Khdng gap trudng hgp nao chay mau, rd tuy, viem tyy d p sau mo. Thdi gian nam vien trung binh 15 ngay
132 TCNCYH 106 (3)-2017
• TJOIP CHI NGHIEN e u ' u Y HQC
A5. Benh nhan sd 3, u xam lan tmh mach cua. Boc lo d i u tren va dudi d l ghep doan IV. BAN LUAN
cat khdi ta Irang d i u tuy dugc Whipple gidi thieu l l n d i u nam 1935, ke tir dd phugng phap nay da trd ndn phg bien vd la p h l u thuat trigi can d i l u tn cac khoi u viing quanh bdng Vater.
Nhung biln ehung sau mo thudng ggp nhu cham luu thdng dg ddy, rd mieng ndi tuy rudt chay mau sau mo c h i l m 9% - 40% d i n d i n thdi gian n i m vien keo dai hoac phai mo lgi [1, 14, 15]. Rd mieng ndi tuy rudt la biln chung phd bien n h i t gay ndn dp xe, chay mau, gia phinh mach vd tang nguy eg tai phai ung Ihu [9,11] Ty le di can hach chilm 20% - 77% d l i vdi eae khdi u vung dau tuy - ta trang trong dd 67% eae trudng hop cd u di can d i n khu vuc nim sau d i u tyy d l i vdi ung thu tuy giai doan I va II, lang len 88% d giai doan 111 va IV, Do dd e l t khdi td trang d i u tuy ddng thdi ngo vdt hgch, i l y bd loan bd mgc treo vung d i u tuy cd y nghTa ldm tang thdi gian s i n g ciia benh nhan [5]. Vdi t i l n bd vd ky thuat mo, nhung khdi u viing quanh bdng Vater xam i l m vdo maeh mau nhu ITnh mach cua, bd mach mac treo trang trdn khdng edn ta chong ehi dinh eua phlu thuat cat khoi ta tuy. Tuy nhign, khi khdi u da xgm l l n vao ddng mach mac treo trang tren thi chong ehi dmh ciia p h i u thuat tndf can RO [10]. Kiem scat dugc bd mgch mac treo trang tren la mgt ky thuat giiip p h l u thuat vign t i l p cgn cac k h l i u vung d i u tyy cd nguy ca xam
A6. Boc Id tinh mach chau ngoai d l i l y ghep
l l n mach mau bdi nd cd mdt sd uu d i l m [10, 16).
Ve lugng mau m i t trong md that eae nhanh ddng mach ta tuy dudi ddng thdi phau tich viing mdm mdc tuy doc theo bd phai va phia sau eua bd mach mac tree trang trdn t d phia dudi, that cac nhanh ITnh mach d l tryc tidp vdo ITnh mgc cira giiip giam luong mau trong mo, Nhilu nghien ciru cho thiy luang mau m i l g nhdm k i l m soat mach mau vao viing d i u tuy ta trdng it hgn nhdm khdng kilm soat maeh Irudc vdi luang mau m i l trong m l trung binh lan lugt la 435 ml va 642 ml [4], mdt nghidn cdu khgc la 855,6 ml so vdi 973,8 ml [4, 10].
V l mat giai phlu benh hoc' dign e l t RO ed vai trd quyet dmh den ty le lai phat cQng nhu thdi gian sdng them cua benh nhan Trong nghien ciru nay, hai benh nhan dien e l t mac treo tuy d mirc R l . 0" bdnh nhan sd 4, khoi u d i u tuy cd kich thudc 35 x 42 mm xam i l m vao ITnh maeh cua vdi chilu dai han 3 em. Benh nhan ndy duac e l t dggn tTnh maeh cua kgm theo khoi d i u luy khli ddng Ihdi dugc ghgp doan bing ITnh mach chgu ngoai bdn phai. Cf bdnh nhgn so 6, k h l i u cd kieh thudc bd hon 22 X 25 mm nhung n i m d mdm mdc tuy, khoi u tham nhiem ITnh mach cua dogn n g i n , n i i tryc t i l p hgi d i u tan - tan chi prolen 6 0. Thdi gian
-TAP CHI NGHIEN CU^U Y H p C , ^ c i t ndi ITnh maeh cua trung blnh 19 phut, thdi gian ir mdu khdng gay anh hudng d i n rudt trong
suit qua trlnh mo Mdt nghign ciru cho thiy nhdm mo theo phuang phap kiem soat mach co ty le tai phatva thdi gian s i n g Iduhon nhdm mo theo kmh dien (2/15 bdnh nhdn so vdi 5/19 benh nhan) vd (song 38 thang so vdi 10 thang) [10; 18]
Bang 5. So sanh cdt khdi ta tuy nao hach tieu chuan va n^o hach m d rdng [ 1 ; 2; 15]
S6 b^nti nhan (n) Tlidi gian mo (phOl) Truyen mau (U) catTMcL^a So hach nao vet Di cSn hach R0(%) Nim vi^n (ngay) Tip vong Dieu trj bo tri7 S6ng them 1-, 3-, 5-nam Th&i gian s6ng liung blnh (Mng)
Italia Chuan 40 372 1,95
13,3(1-35) 24 (60%) 29 (72,5%) 22,7 2 (5%) Xatri
11,2 Mo- r^ng 41 396 2,07
19,8(3-76) 24 (59%) 32(78%) 19,3 2(5%) Xatn
16,7
My (JH) Chuan 146 (80) 354 O.S 4(3%) 17 82 80%
11,3 6(4%) t^baxaln 80/44/23 (75/34/13) 30 (20)
MoT^ng 148 (82) 384 0,5 4(3%) 28,6 77 95%
14,3 3(2%) Hoa xa trj 77/44/29 (73/38/29) 28 (22)
llly(MC) Chuan 40 378 (22%) 9 (23%) 15(3-13) 55%
76%
13 0 Hoa xa Iri 82/41/16
26 Mo' r^ng 39 450 (44%) 8(21%) 36 (6-74) 68%
82%
16 1 (3%) Hoa xa tri 71/25/17
18,8
NhltBan Chuin 51 426 2,1 24 (47%) 13,3(4-30) 32 (63%) 48(94,1%) 43,8 0 Khong 78/28/16
•19,9
Mcpr^ng 50 547 2,4 24 (48%) 40,1 (15-81) 30 (60%) 45(90%) 42,4 1 (2%) Khong 54/18/6
13,8 JH = Mn Hophns, MC = Mayo Clinic
V l ky thuat can thiep mach; Khdi u vung d i u tuy cd the x a m l l n vao tTnh mach cua, tTnh mgch mgc treo trang trgn x d m l l n vao nga ba gida tTnh mgch laeh vd ITnh mgch c u a . Do d d , phau thuat n h i m dat dien cat RO thi vide can thi$p thay dogn, e l t doan ITnh maeh x g m l l n da t r d ngn pho b i l n d l i v d i cgc khdi u vung ddu tuy d giai doan lien t r i l n . Thay doan finh mgch eua v i n la mdt ky thuat khd ddi hdi kha nang p h l u tich ty mi n h i m bdc Id d u g c hai d i u tTnh mgch cOng n h u k? thuat I l y manh ghep, khdu n i l mach mau Do d d s d l u a n g benh nhan a nhung nghign c u u t h u d n g khdng n h i l u , chiern khoang 2 0 % eae t r u d n g h g p phai e l t khdi ta tyy d cgc trung tam Idn. Nghidn c u u cua dgi hoc Nagoya trong 6 nam t d 2008 - 2013 tren
240 b$nh nhdn mg theg p h u a n g phap dugc gidi thigu b d i tdc gia Nakao [12] thi c d 95 bdnh nhan d u o c e l t dogn ITnh mgch cira (chilm 39,6%) v d i ly le b i l n c h u n g rat t h i p , ehi cd 3 benh nhan (1,25%) chay mau, 2 bdnh nhSn phai m o lai (0,08%), khdng ed trudng hop nao tir vong [7]. Trong 8 benh nhan cua chiing tdi c d t d i b i n bdnh nhdn d u a c e l l doan tTnh mach cira (50%) v d i k i t qua Irong va sau m l khdng c d b i l n c h u n g chay mau hoac t i e mgch do h u y l t khoi. Ba bdnh nhgn c d cd doan Ihgm nhilm n g i n han 3 em ed t h i cho phdp thyc hign midng ndi tdn - tan. Ngugc lai, dggn tham nhigm dai han 3 cm thi phai Ihay the bing tTnh mach chau ngodi, ITnh mach than trai, ITnh mgch hiln Idn, tgo hlnh manh ghep bing TCNCYH 108 (3)-2017
ITnh mgch smh dye hode b i n g mgch nhdn tao Daron, polytetraflouroethylene (PTFE) [17 - 19]. Ty le hep midng ndi tTnh mach cua khi ndi tan - tan la 93% va 90% sau 12 vd 24 thang, ty lg t i c nghen mieng noi chiem khoang 6,9%
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v l so luang hach ngo vgt: Nao vgt hgch, phgm vi cat bd Irong c l l khdi ta tuy duac Fortner gidi thidu ndm 1973 Ngo vgt hgch md rdng da dugc phat triln va trd ndn pho biln d Nhat Ban, My vd mdt sd nude Chau Au [1, 2, 8, 15] Nao vdt hgch tidu chuin bao gom cgc nhdm hach 5, 6, 12b1, 12b2, 12e, 13a, 13b, 14a, 14b va nhdm 17a, 17 khdng kdm theo c l l mac treo tuy Nao hgch ma rgng bao gom nao hach lieu chuin kem theo nhdm hgch quanh ddng mgch ggn ehung (nhdm 8a, 8b), ddng mach thdn tgng (nhdm 9), hach quanh ddng mach chii (nhdm 16a2, 16b1), nhdm hach vimg cudng gan (12a, 12b, 12p) kdm theo todn bp mgc treo dau luy la trdng [1, 8] Nhdm bgnh nhan ciia chiing tdi d i u duoc nao vdt hach md rpng, vdi so luong hgch ngo ngo vel trung binh 35,5 hgch Trdn thg gidi nhilu nghien cuu so sanh hieu qua cua ngo vdt hgch tidu chuin so vdi nao hach md rpng doi vdi cdc khoi ung thu d i u tyy eho thiy khdng cd y nghTa kdo ddi thai gian s i n g nhung ly Id benh nhan bi !a long chi keo dai dudi 12 Ihang sau mo so vdi hon 14 thang so vdi benh nhdn duac ngo vdt hach lieu chuin. Tuy nhign ngo vet hach md rdng gtup keo ddi thdi gian sdng d bgnh nhgn cd hach dl can [15].
V. K^T LUAN
c a t khdi ta tuy b i n g each t i l p can t u bd mach mac treo trang tren id mdt ky thudt hi^u qua, an toan, dd dang e l t cac k h l i u d i u tyy di tir vung chua cd u, thudn Igi khi thay ITnh mach cii'a xam lan vd ngo vdt hgch md rdng.
TAP CHI NGHIEN CU-U Y HQC Lm cam en
Nhdm tae gia Viet Nam xin gui ldi cam an ddn giao su Yashuhiro Kodera - Trudng khoa phlu thuat lieu hda II, Benh vien dai hpc Nagoya, Nhat Ban da true t i l p phau thugt, cung d p sd lieu, tai lieu va tao moi thuan Igi de chiing tdi thue hidn bdi bdo nay.
TAI LIEU THAM KHAO 1,NimuraY.,NaginoM.,TakaoS.,etal{2012) Standard versus extended lymphadenectomy in radical pancrealoduodenectomy for ductal adenocarcinoma of the head of the pancreas:
long-term results of a Japanese multicenter randomized controlled trial Journal of hepato- biliary-pancreatic sciences 19, 3, 230-241.
2 Farnell M.B., Pearson R.K., Sarr M.G., et al (2005), A prospective randomized trial companng standard pancreatoduodenectomy with pancreatoduodenectomy Vi'ith extended lymphadenectomy m resectable pancreatic head adenocarcinoma Surgery 138, 4, 618- 628.
3. Kulemann B., Fritz M., Glatz T , et al (2017). Complications after pancreaticoduodenectomy are associated w/ith higher amounts of intra- and postoperative fluid therapy. A single center retrospective cohort study, Ann Med Surg (Lond) 16, 4, 23-29.
4 Inoue Y , Saiura A., Yoshioka R., et al (2015) Pancreatoduodenectomy With Systematic Mesopanereas Dissection Using a Supracolic Anlendr Artery-first Approach.
Annals of surgery. 262, 6, 1092-1101 5. Negoi I., Hostiuc S., Runcanu A., et al (2017). Supenor mesenteric artery first approach versus standard pancreaticoduodenectomy: a systematic review and meta-analysis Hepatobiliary &
pancreatic diseases international. HBPD INT.
16,2, 127-138
•f/lP / T t _ 9/117
TAP CHi NGHIEN Cii'u Y. HQC
6 Nakao A (2016) The Mesenteric Approach in Pancreatoduodenectomy Digestive surgery. 33,4, 308-313.
7. Fuji! T., Sugimoto H., Yamada S., et al (2014). Modified Blumgart anastomosis for pancreaticojejunostomy. teehniea!
improvement, in matched historical control study Journal of gastrointestinal surgery . official Journal of the Society for Surgery of the Alimentary Tract 18,6,1108-1115.
8. Yeo C.J., Cameron J.L., Liilemoe K.D., et al (2002) Pancreaticoduodenectomy with or without distal gastrectomy and extended retroperitoneal lymphadenectomy for penampullary adenocarcinoma, part 2:
randomized controlled trial evaluating survival, morbidity, and mortality. Annals of surgery 236, 3. 355-366
9 Luttges J., Vogel I., Menke M., et al (1998). The retroperitoneal resection margin and vessel involvement are important factors determining survival after pancreaticoduodenectomy for ductal adenocarcinoma of the head of the pancreas.
Virchows Archiv • an international journal of pathology 433, 3, 237-242.
10. Inoue Y., Saiura A., Tanaka M., et al (2016). .Technical Details of an Anterior Approach to the Superior Mesentene Artery During Panorealieoduodeneetomy Joumal of gastnsintestinal surgery: official journal of the Society for Surgery of the Alimentary Tract. 20, 10,1769-1777,
11. Tarantino I., Warschkow R., Hackert T , et al (2017) Staging of pancreatic cancer based on the number of positive lymph nodes.
The British journal of surgery. 104, 5, 6 0 8 ^ 1 8 ; 12. Imaizumi T., Hanyu F., Harada N., et al (1998) Extended radical Whipple resection for cancer of the pancreatic head: operative procedure and results. Digestive surgery 15,
4, 299-307.
13. Zimmitti G., Wlanzoni A., Addeo P., etal (2016), Laparoscopic pancreatoduodenectomy with superior mesentene artery-first approach gnd pancreatogastrostomy assisted by mini- laparotomy. Surgical endoscopy. 30, 4, 1670- 1671.
14 Yamamoto Y., Sakamoto Y., Nara S., et al (2009). Reconstruction of the portal and hepatic veins using venous grgfts customized from the bilateral gongdgl veins /.ange/jdec/c's archives of surgery 394,6,1115-1121.
15 PedrazzoliS. Exlentoflymphgdeneotomy to associate v/ith pancreaticoduodenectomy in patients with pancreatic head cancer for better tumor staging. Cancer treatment reviews 41, 7, 577-587,
16, Shrikhande S.V., Barreto S.G., Bodhankar Y.D., et al (2011). Superior mesenteric artery hrst combined with uncinate process approach versus uncinate process hrst approach in pancregtoduodenectomy: a compgralive study evaluating penoperative outcomes. Langenbeck's archives of surgery 396,8, 1205-1212.
17.- Peparini N., Chirletti P (2012).
Clearance of the retropancrealie margin in pancreatic carcinomas; total mesopanereas excision or extended lymphadenectomy?
European journal of surgical oncology : the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 38,11,1146 -1157.
18. Pal S., George J., Singh A.N., et . al (2017). Posterior Superior Mesenteric
Artery (SMA) First Approach vs. Standard Pancreaticoduodenectomy in Patients with Resectable Periampullary Cancers a Prospective Comparison Focusing on Circumferential Resection Margins. Journal of gastrointestinal cancer 18, 3, 23 - 44
TCNCYH 108 (3)-2017
Er*8 'CHl NcjHiENrci/u y ijQC • 19 Flis v., Potrc S,, Kobilica N-,, et al al (2004). Pancreaticoduodenectomy >vitti (2016) Pancreaticoduodenectomy for ductal vascular resection margin status and survival adenocarcinoma of the pancreatic iiead witti duration. Journal of gastrointestinal surgery : venous resection. Radiology and oncology. 50, official journal of the Society for Surgery of the 3, 321-328 Alimentary Tract. 8, 8, 935-949'
20 Tseng J,F„ Raut CP., Lee J.E., et
Summary
THE SUPERIOR MESENTERIC ARTERY APPROACH TO PANCREATODUODENECTOMY
This study is to evaluate the results of pancreatoduodenectomy with the mesentene approach. A total of 8 consecutive patients underwent pancreatoduodenectomy at Nagoya University Hospital from 12/2/2017 to 12/3/2017 The median age was 59 ± 9.4 years (range 43-71 years). The diagnosis was carcinoma of the head of the pancreas (n = 7), and carcinoma of the lower common biliary duct (n = 1) Four patients underwent porlal vein resection and one patient also undenwent hepatectomy of the left liver lobe. All patients had the standard Whipple procedure with removal of the antrum of the stomach and extended radical lymphadectomy with placement of the pancreatic duct stent in the pancreatojejunostomy anatomosis. Six patients reached the RO level in all sections The porta! vein replacement time was 19.2 ± 4,3 minutes (15 - 25 minutes), the number of radical lymph nodes removed was 9 1 ± 4.7 nodes {3 - 16 lymph nodes), and the total number of lymph nodes removed was 35 5 ± 4 3 nodes {30 - 42 nodes). The average surgery time was 455 ± 99 minutes (315 - 630 minutes), the mean blood loss was 562,5 + 204.8 ml (400 - 1000 ml), and the mean hospital stay was 14.9 ± 1.5 (13 -17 days); there is no complication and mortality during follow-up. Conclusion, The mesenteric approach in pancreatoduodenectomy can reduce blood loss, permit the removal of the pancreatic head nen/e plexus, and this approach also makes it easy to reconstruct the hepatic portal vein Key words: Pancreatoduodenectomy (PD), the mesenteric approach in PD, Superior mesenteric artery during PD, Extended radical lymphadectomy.
• Abbreviation w/ord: DUll = duodenum II, TL = Treizt ligament, MCV = Middle colic vein, MCA = Middle colic artery, SMV = Superior mesentene vein, SMA = Superior niesenteric artery, JA2 = Jejunal artery 2, JA1 = Jejunal artery 1, PLphll = Plexuses of pancreas head II, 1DPA= Inferior pancreatoduodenal ari:ery, PANC = Pancreas, GDA = Gastroduodenal artery, PV = Portal vein, CHA = Common hepatic artery, EIA = External iliac artery, ElV = External iliac vein.
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