JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY Vol.12 - N''4/2(l1?"
Danh gia ket qua sif dung vat canh tay ngoai trong tao hinh khoang mieng sau cat ung thu tai Benh vien Rang Ham Mat Trung uong
Evaluation of the results of using lateral arm flap for oral cavity reconstruction after radical tumor ablation in National Hospital of Odonto - Stomalogy
Nguyen Hong Nhung*, *Benh vien Rdng Hdm Mat Trung umg Nguyin Tai Son** **Benh vien Tmng ucmg Qudn dpi 108
Tdm tat
Muc tiiu: Phuang phap dieu trj hieu q u i nhat trong ung thu khoang mieng I I cat bd rdng rai khdi u, tuy nhien viec cat bd khdi u thudng de lai khuyet hdng Idn trong khoang mieng can dupe che phO.
Chung tdi tien h l n h danh g i l ket q u i sif dung vat canh tay ngoli trong dieu trj khuyet hdng khoang mieng sau cat ung xhu. Doi tugng vd phuang phdp: Tii nam 2013 den t h i n g 3 nam 2017, tai Khoa Phau t h u l t Tao hinh Ham mat, Benh vien Rang Ham Mat Trung UOng, chiing tdi da tien h l n h nghien ctJU sif dung vat da can cInh tay ngoli di^u tri khuyet hdng khoang mieng sau eat ung thu tren 20 benh nhan.
Phuang phap:TieneUu, can thiep l l m sang. Kef qud: 18/20 vat sdng t o l n bp, 1/20vat hoai tif mdt phan, 1/20 vat hoai tU toan bp. Cae ehUe nang sau phau thuat deu dupe cai thien tdt. Ket q u i xa cd 14/19 benh n h i n dat ket q u i tdt, 3/19 benh n h i n dat k^t q u i k h i . Kit ludn: Day la ket q u i bude dau cho thay vat eInh tay ngoli la chat lieu phii hpp de tao hinh khuyet hdng khoang mi^ng sau c i t ung thu.
Tdkhda: Vat canh tay ngoai, tao hinh ludi san m i i n g . Summary
Objective: The most effective treatment in oral cavity cancer is extensive removal of tumors associated with postoperative radiotherapy. However, the removal of the tumor usually leaves a large defert in the oral cavity that need to be covered and reinvened. We evaluated the results of using lateral arm flap for oral cavity reconstruaion after radical tumor ablation. Subject and method: From 2013 to March 2017, in Department of Plastic and Maxillo-facial Surgery, National Hospital of Odonto- Stomatology HN. Progressive study, clinical intervention. Twenty lateral arm flaps w/ere used in reconstruaion tongue and oral base after tumour resection. Result Total of sun/ived flaps were 18/20,1 flap was partial necrosis, 1 flap was entire necrosis. Long term outcome 14/19 patients got good result, 3/19 patients got intermediate result. Conclusion: The lateral arm flap could be considered safe and versatile for defeas In oral cavity.
Keywords: Lateral arm flap, reconstruction tongue and oral base.
Ngdy nhdn bdi: 12/4/2017, ngdy chdp nhgn ddng: 18/4/2017
Ngudi phdn hoi: Nguyin Tdi San, Email: [email protected] - Benh vien Trung uang Qudn dpi 108.
T^P CHfY DUpc LAM SANG 108 Tap12-S6 4/2017
I . D a t v a n d e
Ung t h u khoang mieng thudng I I ung t h u bieu md It chju t i c dpng eua xa trj v l hoa chat, phau t h u l t eat rdng u la phuang p h I p dieu tri hieu q u i nhat [1], Viee eat bd rdng rai t d ehUe benh ly tao nen nhOng khuyet hdng Idn can dugc ehe phu va tai tao lai td chUe. CIc phuong p h I p tao hinh kinh dien ehO yeu sif dung c l e vat tai cho, l l n c l n h o l e ghep da, ghep niem mac. Tuy nhien nhj]mg phUdng p h I p nay khdng the tai tao lai cae eP quan mang u sau phau t h u l t va nguy CO that bai trong phau thuat cao do nhffng han ehe ve chat lUpng v l khdi lUpng t d ehUe tao hinh. Nhd cd ky t h u l t vi phau, nhieu vat t o chife t u do dupc sif dung, trong d d vat da e I n cang tay quay dupe sif dung rdng rai trong tao hinh khoang mieng vi dap Ung dupe Uu diem mdng, mem mai, kieh thude phu hop, nhung de de lai bien chdng nai cho vat nhu seo xau, I n h hudng chife nang van ddng b i n tay. Mdt sd trudng hpp ddng maeh tru khdng dii sufe nudi dUdng ban tay thi khdng the lay dupe vat [2], [3]. TU nam 2013, tai Khoa Phau thuat Tao hlnh Ham mat, Benh vien Rang Ham Mat Trung uong ehung tdi sif dung vat canh tay ngoai tao hinh khuyet hdng phan mem sau cat ung t h u khoang mieng. Muc tieu nghien cufu la Ddnh gid kit qud sd dung vgt canh tay ngodi trong diiu tri khuyet hdng khoang miing sau cdt ung thU.
2. Odi tUtfng va phUtmg phap 2.7. Doi tugng
T i t e l ele benh n h i n dupe c h i n doan ung thU khoang mieng v l dUpc dieu tri phau thuat eat rpng u va tao hinh khuyet hdng bang vat c I n h tay n g o l i tir nam 2013 den t h i n g 3 nam 2017, tai Khoa Phau thuat Tao hlnh H i m mat, Benh vien Ring Ham Mat Trung UPng.
Tieu chudn lua chon
Ung t h u khoang mieng d giai doan T1-T3, NO- N2, Mx theo Hiep hdi ehdng ung thU qude te [1 ].
Benh n h i n khdng m I c cae benh ly he t h d n g kem theo n h u t i m mach, hd hap.
CInh tay viing lay vat khdng cd tdn thuong.
Benh nhan chua qua dieu trj hda, xa trj.
Benh nhan the trang tdt chju dupe ea phau t h u l t keo dai.
Chong chi dinh
Benh n h i n ung thU giai doan cuoi, da di c l n xa.
Benh n h i n ung thU bleu md khoang mieng d l xam lan xuong h i m tren, xUOng ham dudi.
Benh nhan t h ^ trang suy kiet.
Benh nhan c I n h tay hai ben deu bi tdn thuong vting d u kien lay vat.
Benh nhan m I c c l e benh he thdng tim mach, hd hap.
2.2. Phdong phdp 2.2.1. Phuang phdp
Nghien eUu tien eUu, can thiep lam sang khdng ddi eh Ung.
2.2.2. Tien hdnh nghiin cdu
Benh nhan dugc gay me ndi khi q u I n dUdi hd hap dieu khien.
Tien hanh 2 kip phau t h u l t song song.
Kip 1: Cat bd tdn thuang.
Tien hanh phau t h u l t nao vet hach ed, e l t rdng t d n thuang den khi xet nghiem g i l l phau benh tUe thi t d ehUe edn lai tai ria khuyet hdng khdng edn te bao ae tinh. ChuIn bj maeh nhan.
Ki'p 2: Bdc t i e h vat theo yeu eau tao hinh.
Vat e I n h tay ngoai dugc thiet ke v l tinh t o l n dua tren tdn thUOng eu the eiia tifng benh n h i n . Xae djnh 3 mde g i l i phau can thiet khi thiet ke vat canh tay ngoai dd la: Ldi cau ngoai xUOng e I n h tay, diem b I m tan eiia eo delta va mdm cCing vai. Oe t h u I n ldi trong phau thuat ehiing tdi sif dung 2 diem b I m tan eiia cO delta va Idi cau n g o l i xUOng canh tay, ndi 2 diem nay la dUdng di cua eudng maeh va cung lay dUdng thang nay lam trung t i m eiia vat [4].
Phau tfch lay vat da c l n canh tay ngoai: Bat benh nhan n I m ngifa, e I n h tay song song vdi than minh, khuyu hai gap. Tien h l n h rach da va t d ehUc dudi da b d sau ciia vat dupe thiet ke. Bdc tach Idp c l n ndng canh tay v I o bde Id bao co tam dau. Tiep tue bde phia sau ciia vat tU ngoai vi vao trung tam
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bde Id dau ngoai eo tam dau, ven dau ngoai cO tam dau v^ phia sau phau tfch t i mi xudng den eho bam ciia v I c h gian co ngoai v I o cdt mac xUPng canh tay.
Rach da b d trudc ciia vat, qua da t d chUe dUdi da v l can ndng d n h tay, phau tfch theo mat phang dUdi Idp c l n nay cho den khi gap vIeh gian cd ngoai, tach diem b I m ciia cd c I n h tay quay vao vach gian eP ngoai se thay nhanh xuyen cap m l u eho vat ttf ddng mach ben quay sau v l t h i n kinh bl cang tay.
Cd lap va bao ve than kinh quay trong qua trinh bde tach v I c h gian ca n g o l i ra khdi xuong d n h tay. That va eat ddng mach ben quay trUde, phau tieh len tren bdc Id sau dd ti^n h l n h cd lap cudng mach den chd di v I o ranh quay.
Cd ^ n h vat v l phue hdi lUu thdng maeh mau:
Sau khi vat da dUpc bdc xong theo yeu cau tao hinh tien h l n h dua vat den noi nhan ed djnh tam thdi de phuc hdi luu thdng maeh m l u bang ky thuat vi phau.
KhIu ddng vat vao noi n h i n can k h I u can than de t r i n h rd nude bpt vao d md. Dat dan luu ed tranh t u djch.
KhIu ddng trUe tiep d n h tay neu khuyet da cd chieu rpng < 6cm. Neu khuyet da rdng hPn thi lam ghep da.
Canh tay dupe bang ep nhe trong vdng 3 ngay.
Thay bang h l n g ngay v l rut d i n luu sau 24 - 48 gid.
T i t e l d c benh nhan deu dugc sif dung khIng sinh 7 - 1 1 ngay.
2.3. Tieu chudn ddnh gid ket qud 2.3.7. Ddnh gid kit qud gan
Bugc d i n h g i l ngay sau phau t h u l t . La ket qua ndi maeh vat, tinh trang lien thUdng, nhiem triing hay tai bien viing md.
K^t q u i tdt: Vat sdng toan bd, vet md lien ky dau c l ndi cho v l noi nhan.
Ket q u i k h i : Vat sdng t o l n bd h o l e 1 phan.
Vung md nhiem khuan, lien ky 2.
Ket q u i kem: Vat hoai tif.
2.3.2. Ddnh gid ket qud xa
Benh nhan duac theo ddi theo cle mdc thdi gian, 6 t h i n g , 12 t h i n g , 24 t h i n g . Ket qua xa danh g i l sau 24 t h i n g .
Ket q u i tdt: Vat tao hlnh phii hpp vdi khuyet hdng. CIc ehUc n l n g an udng, ndi cOa benh nhan binh thudng. Seo md noi lay vat mem mai, khong co keo hay qua p h l t .
Ket q u i k h i : Vat tao hinh chua phu hop vfli khuyet hdng. Chife nang an udng v l ndi bi anh hudng it. Seo md ndi lay vat mem mai, khdng co keo.
Ket q i i l kem: Vat tao hinh khdng phu hpp vfli khuyet hdng. Chufc n l n g an udng va ndi bj Inh hifdng nhieu. Cd dau hieu tai p h l t u tai vting xung quanh hole di c l n xa. Seo md noi lay vat eo keo, qua phlt.
3. Ket quS
3.1. Dgc diem benh nhdn
Tudi: Tir 29 - 70 tudi, tudi trung blnh la 50 tuoi.
Gidi tfnh: 6/20 benh n h i n nQ (30%), 14/20 benh nhan nam (70%).
Vi t r i u: Ria ludi - san miSng tren 14/20 benh nhan (70%), gdc ludi 4/20 benh n h i n (20%), niem mac m l - hau ham 2/20 benh n h i n (10%).
Bac diem khuyet hdng sau e l t tdn thuong: 1/2 ludi va s i n mieng tren 10/20 benh nhan (50%), 1/3 ludi va san mieng 4/20 benh n h i n (20%), 2/3 ludiva s i n mieng 2 ben 4/20 benh n h i n (20%), niem mac m l - h l u ham 2/20 benh nhan (10%).
3.2. Kit qua Idy vgt
Kfch thudc vat: Kich thUde nhd n h l t la 5 x 11cm;
kfch thudc Idn nhat la 7 x 15cm. Trung binh la 6 x 13cm.
Dang vat sif dung: Vat da can.
Ket q u i ghep vat:
Vat sdng toan bd: 18/20 trUdng hpp (90%).
Vat hoai tif 1 phan: 1/20 trudng hpp (5%).
Vat hoai tuf: 1 /20 trudng hdp (5%).
Tmh trang nai l l y vat:
KhIu ddng trUe tiep: 16/20 trudng hpp (80%}- Ghep da bd sung: 4/20 trudng hpp (20%).
Khdng ed trudng hpp n l o bi nhiem trCing nd lay vat.
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3.3. Ket qud phSu thudt 3.3.1. Kit qud gan Ket q u i tdt: 17/20 trUdng hpp.
K ^ t q u l kha: 1/20 trUdng hpp.
Ket q u i kem: 2/20 trudng hpp.
Ket q u i t d t dUpc danh gia tren d e benh n h i n CO vat ghep sdng hoan toan, kieh thUde vat ghep tao hinh phu hop vdi khuyet hdng.
Ket q u i k h i danh g i l tren ele b&nh n h i n cd vat sdng toan bp, tuy nhien kieh thUdc vat chUa phii hpp vdi khuyet hdng. Vat day q u i gay lap day khoang mieng, hay vat chUa dd day lam ddn san mieng.
Ket qua kem trSn 2 trudng hpp. 1 trudng h c ^ kieh thudc vat q u i d l y , g l y chen ep trong khoang mieng.
Vat b| hoai tif dau xa do chen ep g l y thieu dUdng dupe phat hien sau 1 ngay phau t h u l t . 1 trudng hpp vat hoai tif tren benh n h i n dUdng huyet eao. Viing nhan vat nhiem triing sau 4 ngay phau thuat.
3.3.2. Ket qua xa Kix q u i tdt: 14/19 b f n h n h i n . Ket q u i k h i : 3/19 benh n h i n . Ket q u i kem: 2/19 benh n h i n .
Benh nhan dugc kiem tra djnh ky 3 thang 1 l l n . Ket q u i thu ve sau 24 t h i n g . 14/19 benh nhan dupe danh g i l ket qua t d t vdi vat ghep sdng t d t tai noi nhan, khoang mieng sach se, vat da mem mai v l cd xu hudng niem mac hda. Cle chife nang I n udng, ndi binh thudng.
Ket q u i kha tren 3/19 benh n h i n ed vat ghep sdng tdt. Tuy nhi^n, kfeh thUdc vat khdng phii hpp.
2 benh n h i n cd vat ghep to day g l y vudng, han ehe chife nang an udng va ndi, can can thiep c i t Ipe bdt.
1 benh n h i n ed vat ghep sdng tdt, tuy nhi^n ko dii dp day nen khoang mieng cd xu hUdng Idm gay Ci dpng thUe an v l nUde bpt, han che nudt, can phau thuat thi 2 l l m day khoang mieng.
Cd 2/19 benh n h i n t d vong sau phau t h u l t 4 - 5 thing. 2 benh nhan cd di can xa khdng dupe p h l t hien trude phau thuat. 1 thang sau md d e benh nhan quay lai vdi trieu ehiing tai p h l t hach eiing ben. Sau 3 t h i n g di^u tri hda chat c l 2 benh nhan da chet.
4. Ban luan
Theo Hiep hdi phdng chdng ung thU the gidi, ung t h u dau cd chl^m k h o i n g 10% t d n g sd ele u l e tinh trong dd k h o i n g 40% d khoang miSng [11. Do hau het ung t h u d khoang mieng tien trien am tham, it trieu ehUng, khd p h l t hien d giai doan dau nSn phan Idn b^nh n h i n den k h I m khi ton thUdng da lan rdng, benh ly d giai doan mudn nen viec d i i u trj gap rat nhieu khd khan. Viec eat bd rdng r l i t d ehUc benh ly tao nen nhUng khuyet hdng Idn, I n h hUdng den chUe n l n g hd hap, nhai nudt v l p h l t I m cOa b^nh nhan. Che phii va tao hinh lai cle t d ehUe trong khoang mieng I I yeu cau cap thiet. Trong nghien eUu n l y ele benh nhan ed dp tudi trung binh 50 tudi, bj ung t h u khoang mi^ng giai doan t U T l - T3, N0-N2, Mx. Ty le b6nh n h i n nam cao ban so vdi nU la 2,3:1. Oac diem tam sang n l y phti hop vdi nghien eifu eiia t i e g i l Holger Engel nam 2010 khi nghien cUu tren 104 trudng hpp bi ung thU khoang mieng. Theo c l e t i e g i l trong va ngoai nUdc nguyen n h i n do thdi quen hiit thudc va udng rUpu d nam gidi [4], [5]. Trong nghien cUu nay vj tri khdi u thudng n I m d ria lUdi v l san mieng, dien cat se la 1/2 ludi va san mi^ng. Vdi trudng hpp khdi u n I m d goe ludi, hay d ria lUdi nhUng vdi kieh thUdc Idn xam lan q u i dUdng giUa, chiing tdi e l t 3/4 ludi v l s i n mieng. Dieu nay phu hpp vdi quan diem eua c l e t i e g i l tren the gidi [6].
Vat da d n c I n h tay n g o l i dugc t i c g i l Song R v l ddng nghiep lan dau tien gidi thieu vao nam 1982 [7]. N I m 2008, t i e gia Faria cd nghien ciifu sCf dung 210 vat d n h tay ngoai tao hlnh d c khuyet hdng viing ham mat. Nhieu t i e g i l khIe Xrin the gidi cung sif dung vat d n h tay n g o l i de ddng d e t d n khuyet vifa va nhd vung h i m mat [8]. N I m 2009 t i e gia Nguyen T l i Sdn v l TrUdng Uyen CUdng d l nghien eifu g i l i phau vat da c l n d n h tay n g o l i tren ngudi Viet trudng thanh v l b i t dau ij'ng dung trong l l m sang [9]. Theo t i e g i l Chen IC va cdng sU kfeh thude vat Idn nhat cd the lay 1 1 8 x 1 8 c m [10]. Trong nghien cu'u eiia ehiing tdi kfeh thUde vat Idn nhat la 7 X 15cm, trung binh la 6 x 13cm. Nghien eifu phiJ hpp vdi t i c g i l Nahabedian MY v l Warterhouse N cho rang neu lay vat rdng tren 6em 6 ngUdi trudng
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thanh thi khdng the khau ddng trUe tiep nOi lay vat [7]. Cd 16/20 benh n h i n dupe k h I u ddng trUe tiep nPi lay vat, ed 4/20 trUdng hpp p h l i v l da bd sung.
Ket q u i phau t h u l t ehung tdi dat 18/20 vat sdng toan bd. 1 trudng hpp vat ghep q u i day va Idn so vdi khuyet hdng vting lUdi - s i n mieng, sau khi khau ddng gay chen ep maeh nudi hoai tif dau xa ciia vat. Chiing tdi tien hanh eat loc ngay khi p h l t hiSn ra chen ep. 1 trudng hpp b^nh nhan dUdng huyet eao, vet md vung cd nhiem trOng, vat ghep hoai tif toan bd do nhiem triing p h l i t h I o bd v l l l m sach vting p h l u t h u l t . Ket qua n l y tUong duong vdi c l e ket qua nghien cu'u eiia Faria va Engel [8].
Ket qua theo ddi xa bUde dau sau 2 nam thu dupe 14/19 benh nhan ket q u i tdt, 3/19 benh nhan ket q u i k h i va 2 benh nhan ket q u i kem. Benh n h i n dupe d i n h g i l ket qua tdt vdi vat ghep sdng tdt tai nai n h i n , khoang mieng sach se, vat da mem mai v l cd xu hudng niem mac hda. CIc ehUe n l n g I n udng, ndi dupc dan t r d lai blnh thudng. Ket q u i k h i tren 2 benh nhan ed vat ghep sdng tdt, tuy nhien kieh thude vat khdng phti hpp. Vat to day g l y vUdng, han ehe ehUe n l n g I n uong va ndi, c l n can thiep cat thu nhd vat. 1 benh nhan ed vat ghep sdng tdt, tuy nhien khdng dii dp day nen khoang mieng ed xu hudng Idm g l y ii' dpng thUe I n v l nUdc bpt, han ehe nudt, can phau thuat thi 2 lam day khoang mieng.
Cd 2 benh nhan tif vong sau p h l u t h u l t 4 - 5 t h i n g do dl c l n xa khdng dupe p h l t hien trudc phau t h u l t . 1 t h i n g sau md d e benh n h i n quay lai vdi trieu chifng tai phat bach eting ben v l sau 3 t h i n g dieu tri hda chat ea 2 benh n h i n d l chet. Ket qua xa eiia chung tdi phii hpp vdi nhan xet ciia d c t i c g i l tren the gidi, chiing tdi nhan thay dieu kien sdng eiia benh n h i n dupe e l l thien, khdng edn dau ddn khi sinh hoat I n udng, khoang mieng sach se, c h i m sdc ve sinh 6ugc t d t hPn, ehUe nang I n nhai va nudt dupe d i thien [6], [8], [10]. Tai nai eho vat, chUc n l n g van ddng eua e I n h tay khdng thay ddi. Theo ele t i e g i l lUu y cudng mach vat di kem vdi than kinh quay nen khi phau tfch can can than tranh i l m tdn thuang than kinh quay [5]. Chung tdi phau tich bde vat t i mi tranh tdn thuang than kinh quay. Ket q u i thu ve khdng ed benh n h i n nao bj rdi loan ehUe
n l n g van ddng eung n h u e l m g i l e vung tay phau tfch. Tat ea ele benh nhan deu lien da ky dau, khong nhiem trung nai cho vat.
5. Ket luan
Qua 20 trudng hpp benh nhan ung thU khoang mieng dupe dieu trj theo phUPng phap cattri|tde khdi u, nao vet hach cd v l tao hlnh khoang mieng bang vat da d n d n h tay ngoai vdi thdi gian theo ddi trung binh la 24 t h i n g ehiing tdi riit ra 1 so k^t luan sau: Vat da can d n h tay ngoai dupe lay vdi kich thudc tif 5 x 11 em den 7 x 15cm; trung binh la 6 x 13em phii hop vdi e l e tdn khuyet phan mem viing khoang mieng. Vat ed dp day vifa p h l i , mem mai phii hpp vdi viec tao hinh lUdi va san mieng, niem mac m l trong khoang mieng. Vat ed sUc sdng cao, ed xu hudng nlSm mac hda trong khoang mieng.
Ket q u i xa cd 14/19 benh nhan dat tdt, 3/19 benh n h i n dat kha. Chat lUpng eude sdng eiia benh nhan duac c l i thien tdt hon sau p h l u t h u l t , cac chtfc n l n g I n nhai, nudt, ndi dUpc phuc hdi gan nhubinh thudng. 0 i e u dd eho thay vat d n h tay ngoai II chat lieu tdt de tao hinh trong khoang mieng.
Tai lieu t h a m khdo
1. Pham T u i n (1991) Ung thu hoc/dm song. Ung thif dau ed. Nha Xuat b i n Y hpe.
2. Camaioni A (2008) Anterolateral thigh cutaneous flap vs. radial forearm free flap in oral and oropharyngeal reconstruction: An analysis of 4S flaps. Acta otorhinolaryngologica italica 28:7-12.
3. Gellrieh NC Hara I, Duker J, Schdn R, Fakler 0, Smelzeisen R, Honda T, Satoru 0 (2003) Swallowing and speech function after intraoral soft tissue reconstruction with lateral upper arm free flap and radial forearm free flap. British Journal of Oral and Maxillofacial Surgery41:161-169.
4. Song XM, Yuan Y, Tao ZJ, Wu HM, Yuan H, Wu YN (2007) Application of lateral arm free flap In oralanii maxillofacial reconstruction following tumoi surgery. Med Prine Pract 16(5): 394-398.
5. Reinert S (2000) The free revascularized lateral upper arm flap in maxillofacial reconstructior following ablitive tumour surgery. J of Cranio • Maxillofacial Surg 28:69-73.
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TAP CHf Y DUOC LAM SANG 108 Tap 12-564/2017
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