VIETHAM MEDICAL JOURHAL N°2 - APRIL - 2017 thdng chii yeu la nam gidi (99,5%) va tuoi tir 19-
29 (51,8%).
- PtiUdng tien van chuyen chu yeu la xe taxi, d td chiem 56%, xe cu'u thu'dng chiem 25,5%.
Hau het nhihig ngu'di bj tai nan giao thdng la nhu'ng ngu'di di xe may (chiem tdi 96%).
- 36,5% benh nhan tai nan giao thdng du'dc xet nghiem mau sau khi uong ru'du bia trong khoang thdi gian tir 4 - 6 tieng, 32% benh nhan dUdc xet nghiem mau trong khoang thdl gian sau 6 tieng.
- Nan nhan udng ru'du tai nan giao thdng cd sd lu'dng bj chan thu'diig sp nao kha cao, chiem tdi 55,5%, sau la chan thu'dng chi va da chan thu'dng chiem 43,5% va 38,5%.
- Hau het nam gidi udng nhieu ru'du bia va cd nong dp con trong mau cao hdn 50 mg/dl chiem tdi 99,4% so vdi tdng so tru'dng hdp bi tai nan giao thdng, nhdm tuoi 19-29 udng nhieu ru'du va cd ndng dp con trong mau cao vu'dt miTc cho phep (tren 50 mg/dl) chiem 51,5%.
- Chan thu'dng so nao d benh nhan tai nan giao thdng tap trung nhieu d nhOng ddi tu'dng cd ndng dp con trong mau cao, chiem tdi 60,9%. Va ngu'di udng ru'du bia nhieu bj chan thutfng so nao cao gap 0,24 lan so vdi ngu'di udng ru'du bia ft.
- K§t qua tmng binh ti le quy doi SAC va BAC la 1,2, trong khoang tir 0,91 - 3,16 vdl dp lech chuan la 0,2.
- Vdi nhu'ng mau mau du'dc xet nghiem trorg khoang thdl gian tir 4-6 tieng hau nhu' ket qua quy ddi nam trong khoang tir 1,0-2,0, va cd mot so tru'dng hdp cd tf le quy ddi cao hdn tir 2 - 3,16.
Mdi lien quan nay la cd y nghTa vdi p < 0,01.
TAI UEU T H A M KHAO
1 . Bo Giao thong van tai (2008), Luat giao thong dudng bg so 23/2008/QH12, tr. 44.
2. Bp Y te (2004), Bao cao toin cau ve phong chdng thddng tich do giao thong dddng ho -Ban tdm tat, Nha xuat ban Y hgc, 95.
3. Cue Quan ly moi tmdng y te (2008), Tffih hinh tit vong do tai nan giao thong tren tDan quoc ^XB-^X6,\^
N5i, truy d p ngay 13/6/2011, lai trang wd) http://203.20.210/homebyt/vn/portal/InfbDetall.iaj7area
=2228L..cat=1911.
4. Cuc Quan ly moi tmdng yte (2009), Tih^ AM ^ ^ itiutsig tkh nam 2009, tnjy cap ngay 13/6/2011, tai t J ^ webhttp://203.162.20.210/homebyt/\ffyportalflnfoliii^^
rea=222&cat=1911.
5. CMC Quan 1^ mdi tru'dng y te (2011), Th6ng bao tmh hinh tai nan thddng tieh ndm 2010 so 256/TB-MT ngay 27/4/2011.
6. Tru'dng D^i hoc Y te cdng cong (2008), 8io cao nghiin cuU tinh hinh tai nan giao diong tai 3 tinh Yen Bai, Da Nang va Binh Dddng.
7. Margie Peden et al. (2004), World repoit on road tiaffic injury prevention, World Healtti Organization Geneva, 217.
UNG THir BONG VATER DI CAN LACH:
B A O CAO 1 TRifaNG H a p
T O M TAT
U thir ph^t d lach do dl can rat hiem gap. Chu'a cd bao cao nao ve ung thU bdng Vater dl cSn lach. Chung toi md ta 1 tru'dng h ^ ung thu' bong Vater di can lach tai benh vien Chd Ray. Benh nhan Nff, 65 tuoi dddc phau thuat cat khoi ta_tuyj<em c3t lach. Cac ket qua hinh anh hpc tru'cic mo chan doan u bong Vater kem theo Wioi u 6 lach nghi ngd do dl can. Glai phau benh sau md cho ket qua carcinoma bong Vater dl cSn^lach.
Thdl gian phiu thuat la 7 gid, n§m vien sau md la 7 ngay, khong co bat cii' biS'n chung gi sau mo. Oay la bao cao dau hen ve ung thU bong Vater dl c3n lach. ttiu'dng phap phau thuit cat khdi ca tuy va c|t lach la lyft chpn phii hdp. B|nh nhan se du'dc hoa trj ho trd sau mo.
Tukhod: ung thu' bdng Vater, cat khoi ta tuy, di cSn l^ch, dl c3n xa toi thl^u
*B$ mdn Ngoai -DHY Ddge Tp.HCM Chiu trach nhiem chi'nh: Phan Minh Tri Email: [email protected] Ngay nhan bai: 5.01.2017 Ngay phan bien khoa hpc: 20.3.2017 Ngay duyet bai: 30.3.2017
Phan Minh Tri*
SUIVIMARY
METASTASIS OF AMPULLARY CARCINOMA TO THE SPLEEN: CASE REPORT Secondary metastatic tumors of the spleen are rare. There have been no reports of ampullary cancer metastasizing to tiie spleen. Vi/e describe a case of ampullary cancer metastasizing to the spleen at Cho Ray Hospital. The patient was a 65 year - old woman who had been performed a pancreatoduodenectomy and splenectomy. The preoperative imaging revealed a tumor of ampullary and a suspicious splenic mass related malignancy. The post-operative anapathology revealed the ampullary carcinoma metastasizing to the spleen. The operating time was 7 hours, postoperative hospital stay was 7 days, there was no any complication. This is the first report about a metastaas of ampullary carcinoma to the spleen. The surgery of pancreatoduodenectomy and splenectomy Is a suitable approach. The patient will be received supported chemotherapy after that.
Keywords: ampullary cancer, pancreatoduodenectomy, splenic metastaas, oligometastasls
23ft
TAP CHi Y HQC V l g T HAM TAP 453 - T H A N G 4 • SO 2 - 2017
I. D^T VAN OE
U thir phat tai lach do dl can chiem khoang 7% trong tat ca cac khdi u tai lach [6].Cac ung thir nguyen phat tir vit, phdi, da thu'dng cho di can tdi lach [6]. Theo tac gia Morgenstern [3] thi bKt ciT ung thu' tir cc^ quan nao cung cd the di can lach. Theo tim hieu ciia chiing tdi, chu'a thay
•CO bao cao nao ve ung thu" bdng Vater di can lach du'dc cdng bd tru'dc day. Chung toi md ta d day mdt tru'dng hdp ung thii bong Vater di can den lach. That khd de ket luan tru'dc md la khoi u tai lach la mot u nguyen phat hay di can. Ket qua gial phau benh sau mo da giup chan doan la carcinoma bdng Vater di can den lach.
II. CA LAM SANG
Benh nhan nu', 65 tudi, vao vien vl vang da kem dau bung viing tren ron. Lite nhap vien, iffinh nhan nang 48 kg, cao 1,55m (BMI: 19), the trang gay. Benh nhan cd tien can cd benh ly
tang huyet ap, lao phdi each 6 nam, chu^ tirng md d vimg bung. Khi kham ghi nhan cd vang da, an dau vting ha su'dn trai.
Xet nghiem sinh hoa cho thay Bilirubin tang 5.09 mg/dl, chu yeu la thanh phan tru'c tiep (4.71mg/dl), AST tang 75 U/L, ALT tang 84 U/L, CA 19.9 tang 71.06 lU/ml, CEA tang 1325 ng/ml, Albumin, Prealbumin, Amylase mau trong gldl ban binh thu'dng. Benh nhan du'dc chup CY scan bung phat hien gian du'dng mat trong va ngoai gan, dng Wirsung dan 5 mm (hinh 2), ton thu'dng giam dam do trong lach kfch thu'dc khoang 3 cm (hinh 3). Khdng cd dau hieu xam lan tmh mach mac treo trang tren hay tinh mach cira. Ndi soi ta trang ghi nhan u viing bdng Vater (hinh 1), cd loet be mat, ket qua sinh thiet u tru'dc md ghi nhan carcinoma tuyen bdng Vater biet hoa trung binh. X quang ngi/c thang khong ghi nhan dl can phoi (hinh 4).
Hinh 2: Gian dng mat chu va dng tuy chinh Hinh 3: U tai lach nghi di can
Hinh 4: Khdng ghi nhan di can phdi
VIETNAM MEDICAL JOURNAL H°2 • APRIL • 2017 Benh nhan du'dc chan doan K bdng Vater di
can lach vao ngay 09 tiiang 12 nam 2016, chung toi tien hanh cat khdi ta tuy kem cat lach cho benh nhSn. Ton thu'dng trong mo ghi nhan khoi u viing bdng Vater khoang 2 cm, chu^ thay cd dau hieu xam lan tinh mach mac treo trang tren va tinh mach cii^, 1 u ki'ch thu'dc khoang 3cm khu tru trcing lach, mat dp chac. Khdng ghi nhan dl can phiic mac. Phau thuat keo dai 7 gid, lu'dng mau mat khoang 200 ml, du'dc truyen 700 ml mau trong mo, benh nhan khdng phai truyen mau sau mo,
Ngay hau phau thiT 1 benh nhan da cd the ngoi day, trung tien du'dc, cac ong thdng mui da day, ong thdng tieu du'dc rut, dau vet md khdng
dang ke. Ngay thu' 2 benh nhan da trung tien diidc, dan lu'u dng tuy ra khoang 100 ml dich tuy, cac dng dan lull bung ra it dich hong, benh nhan du'dc cho udng nu'dc, an soup loang. Benh nhan du'dc xuat vi@n v^o ngay thir 7 sau mo, khdng cd bat ciT bien chu'ng gi trong suot qua trinh hau phau.
Glai phau benh (da thu'c hl§n nhudm hda mo mien dich benh pham u Vater va u dican tai lach) sau md ghi nhan la carcinoma tuyen biet hoa trung binh d bdng Vater (hinh 5), mu'c dp blet hda trung binh (hinh 6), xam lan ta trang v^ tuy, dl can hach ron gan va hach dpc ddng mach mac treo trang trfin , di can lach (hinti 7), cac dien cat khong cd te bao ung thu".
Hinh 5: Carcinoma tuyen tai bong Vatei hum 6 Mirc dd biet hoa trung binh tai bong Vatei hmn 6 Mirc di
Hinh 7: Md lach binh th&dng (vung mdi tSn den). Carcinoma di can lach {vdng hoa tiij)
III. BAN LUiG^NUng thu' bdng Vater chi chiem khoang 0,2%
trong tdng so cac u ac tfnh du'dng tieu hda nhu'ng phd bien thir hai trong cac ung thii vung quanh bdng Vater. Hdn mot nu^ sd benh nhan ung thii bdng Vater cd di can hach bach huyet.
Cac hach bach huyet xung quanh bdng Vater thu'dng la nhu'ng hach d3u tien bi di can, Tiep den la cac hach dpc dpng mach mac treo trang trSn, da day, hach ron gan, hach ron lach ... Ngoai ra con ctio dl can d^n day than kinh va mach mau. Di can xa pho bien nhat la gan
(66%), di can phdi (22%) [ 5 ] , [4]. Da cd tru'dng hdp ghi nhan di can xu'dng va nao [2], ChUci co bao cao nao tru'dc day ghi nhan di can lach. _
Day la tru'dng hdp dau tien du'dc bao cao la ung thu' bdng Vater di can den lach. Mac du da cd cac bao cao ve ung thu* vu, ung thu" phoi, ung thii da va dai trang di cSn tdi lach [ 1 ] , cd che di can xa van cdn chu^ ro vi qua hiem. 6 benh nhan nay, diia tren cac xet nghiem va hinh anh hpc tru'dc md, ket hdp vdi giai phau benh sau mo, CO the ket luan la ung thu' nguyen phat tif bdng Vater cho di can den lach. Di can the nay
TAP CHi Y HOC VlgT HAM TAP 4S3 - THANG 4 - SO 2 - 2017 CO tlie do lan tran te bao ung thu' theo du'dng
phuc mac hoac du'dng mau.
Ung thu' bieu mo tuyen la dang giai phau bgnh thu'dng gap nhat trong ung thu' bdng Vater (theo SEER). Trong do Adenocarcinoma chiem 65% tdng so tru'dng hdp, carcinoma chiem 8,1%, cac dang khac nhii ung thii tuyen nhii [papillary adenocarcinoma) chiem 5,6%, ung thu' tuyen nhay (mucinous adenocarcinoma) 4,7%, ung thu' bleu md te bao vong nhan (signet ring cell carcinoma) 2 % [1,4].
Cac tdn thu'dng ac tfnh tai lach da du'dc md ta thu'dng nam trong benh canh Lymphomas Hodgkin, Lymphomas non -Hodgkin, benh ung ttiu" mau ddng bach cau cap, ung thii mau ddng b?ch cau man va ung thu' di can tdi lach. Trong do ung thu' di can lach chiem 7% trong sd cac Ion thu'dng ac tfnh tai lach [ 2 ] , [ 6 ] . Benh nhan nay cd ket qua giai phau benh tai lach la carcinoma, phu hdp vc^ giai phau t^enh tai vung bong Vater.
Op biet hoa u: biet hda cao khi cdn hinh anh ong tuy^n rd, blet hoa trung binh (cac ong tuyen dinh vdi nhau, nhu'ng cdn cau true ong ro rang), blet hoa kem (khdng r3 hinh dang cau true ong tuyen). Hinh 6 cho thay mirc dp biet hda u d day cl mirc trung binh.
Tac gia Bellman nam 1995 da d u ^ ra khai niem ve di can xa toi thieu - oligometastasls - la tinh trying trung gian ( < 5 dl can) giu'a mpt ung thir nguyen phat va ung thu' di can nhieu ndi. Y nghia lam sang cua khai niem nay cho rang neu khoi u nguyen phat du'dc cat tm, va khoi u di can ciing du'dc kiem soat tiang phau trj ho3c xa trj.
se keo dai them thdi gian song cdn khdng u cho ngu'di benh va tham chf dieu tri khdi. Tren benh nhan cua chiing tdi, cat lach gliip giam khoi te bao ung thu' la mpt chpn liTa hdp ly vi day cung la mpt tru'dng hdp di can xa toi thieu.
IV. KET LUAN
Carcinoma bdng Vater cd the di can den lach.
Viec xac dinh tru'dc mo la khoi u nguyen phat hay di cSn tai lach tu'dng doi khd khan, glai phau benh sau mo' la tieu chuan glup chan doan di can lach. Cd che di can va danh gia glai doan ung thu' cdn chula rd rang. C^n cd nhieu bao cao hdn de xac djnh b'nh chat quan trpng ciia dang di can hiem gap nay.
TAI L l | U T H A M KHAO
1. Albores S., Schwartz AM et al. (2009). Cancers of Itie ampulla of vater: demographics, morphology, and survival based on 5625 c ases from the SEER program. J S urg Oncol. 100(7): 598 - 605 2. loannis A., Stergios D. (2009). Bone and brain
metastases from ampullary adenocarcinoma. World ] Gastroenterol, 15(21); 2665 -2668.
3. Morgenstern L., Rosentierg J., Geller S.(1985).
Tumors of the spleen. World 1 Surg, (9):468-476.
4. Morini 5., Perrone G. et al. (2013). Carcinoma of the ampulla of Vater: morphological and immunophenotypical classification predicts overall s urvival. Pancreas, 42 (1): 60 -6
5. Nafisa K Kuwajerwal et al.(2015). Carcinoma ofthe Ampulla of Vater. Medscape.
o. Shelton J., Michael D.(2012}. The spleen. Sablston.
Elsivier,(19): 1548-1562
a review ofthe literature. Int J Surq Case Rep, fl21:108-11 7. WeidiseltHum R, Hdlman SL (2011).
OOgometastases revlsrted. Nat Rev Oin Ono3i,(8): 378-382.
NGHIEN CU'U GIA TRI CUA B A N G DIEM CURB-65 TRONG VIEC PHAN TANG MU'C DO NANG CHO BENH NHAN
DCT CAP BENH PHOI TAC NGHEN MAN T I N H
T6M TAT
€0t vSii de: Benh nhan COPD vao vien vi ddt cap dillm ty 1| cao tiarig so cac benh nhan cap cihj, sdm ptiSn 3ng nguy cd ciia cac benh nhan ddt cap COPD flScd bi|n phap "xii tri kjp thdi la rat quan trpng. Muc
^^Khoa cap cud binh vien Bach Mai g u trich nhifm chfnh: Nguyen Van Chi Email: [email protected] Ngay nhan bai: 15.01.2017 Ng^y phan bien khoa hpc; 20.3.2017 Ngay duyet bai: 29.3.2017
Nguyin Van Chi*
tieu: Danh gia gia tri ciia bang diem CURB-65trong viec phSn tang nguy cd d nhu'ng benh nhan ddt cap be'nh phoi tac nghen man ti'nh (COPD). Bdi tu^ng va phu'dng phap: Gom 419 benh nhan dcrt cap COPD nhap vien vao cap ciru Benh vien Bach Mai tu" thang 1 nam 2013 den het thang 6 nam 2014. Ket qua: Cd 183 benh nhan (43,7%) phai thong khi nhan tao khdng xam nhapCTKKXN), AUROC cua CURB-65 cho TKKXN tren berih nhan ddt cap COPD la 0,57 vdi 95%
CI la 0,52-0,62. Die'm cat > 1 cd dp nhay la 0,612; do dac hieu la 0,572; gia tri dii doan du'dng tinh la 0,526; gia trj di/ doan am ti'nh: 0,656. Co 41 benh nhan (9,8%) phai thong khi nhan tao xam nhap(TKXN), AUROC cua CURB-65 cho TKXN tren
