1566 TAP CHf KHOA HOC TifeU H O A VIET NAM 2011 - TAP VI- s d 23
Phat hien sd^m va dieu tri
Tac mach mac treo ruot cap tinh
Early diagnosis and management of mesenteric ischemia
VAN TAN, HOANG DANH TAN BV Binh Dan- TPHCM
Abstract
Background: Acute mesenteric ischemia-induced intestinal gangrene is a very high-risk entity in ab- dominal emergency with estimated incidence being about 1/1000 of admitted patients. The mortality rate ranges from 67 to 80%, mostly due to septic and toxic shock with visceral failure. Acute mesenteric artery obstruction may result from clot, thrombus, or vascular constriction.
Objective: To investigate etiologic factors of mesenteric ischemia.
Patients and Method: Retrospective review of massive intestinal ischemic patients with/without gan- grene undergoing surgical treatment at Binh Dan hospital from 2000 to 2009.
Results: A total of 12 patients hospitalized with acute superior mesenteric ischemia were collected.
Acute abdominal complaints were almost invariable symptoms. On laparotomy a massive intestinal isch- emia, even gangrene were found. Surgical procedures varied from 2 to 7 times because of complica- tions and the death rate was 58%. All the complications were due to progressive intestinal ischemia and gangrene with remote organ failure such as respiratory, renal and heart insufficiency. 5 patients were alive with long-term treatment and rehabilitation at ICU for multiorgan failure and short gut syndrome (<70cm). In the follow-up of 3-12 months, 3 of them died as consequence of malnutrition and its related complications.
Conclusion: Acute mesenteric ischemia is a very high-risk disease with high mortality rate as con- cequence of intestinal gangrene due to delayed diagnosis
Tdm tat
Thie'u mau ruot d p tinh gay hoai ttf ruot non gin hd't, ke ca dai trang la mdt nguy cd cao trong d p ctfu bung. Dp xay ra chie'm 1 trdn 1000 trtfdng hdp nhap vidn [21]. Ttf vong giao ddng ttf 67 dd'n 80%
[12] [22]. Nguydn nhan thtfdng la tac long mach d p tinh do mau cue ttf xa dd'n, do chen dp mach \xi ben ngoai hay do co mach keo dai.
Muc tieu nghien ctfu: Tim nguydn nhan de phdng ngtfa, phat hien benh sdm de dilu tri hidu qui.
Bdnh nhan va phtfdng phap: Ttf nam 2000 de'n nam 2009, tai khoa d p ctfu bdnh vien Binh Dan cd 12 bdnh nMn bi tac mach mac treo trang tren, nhap vidn. Mdi bdnh nhan phai md It nhat la 2 lln, nhieu nhlt la 7 lln. Bie'n chtfng sau md 100%, ttf vong sau md la 58% vi mdt hoai ttf tiep lai them bid'n chiing cIc tang quan trpng nhtf phdi, than, tim, rd'i loan ddng mau. 5 bdnh nhan cdn lai, dilu tri va nudi dtfdng
NAM 2011-TAP V I - s o 23 1567
tich ctfc qua dtfdc cac bid'n chtfng cua hdi chtfng mdt ngan (<70cm), suy kiet din va da tur vong hd't 3 trong thdi gian theo ddi ttf 3 thang de'n 12 thang.
Ban lu$n: Ngoai cac nguyen nhan tac mach do mau cue, do chen ep, tac ddng mach mac treo trang tren con do co mach d benh nhan nang vi ha huye't ap, cung Itfdng tim thlp, sd'c nhilm trung, gay td ngoai mang ctfng va diing thud'c co mach, hlu hd't cac benh nhan ttf vong vi suy da tang va nhilm triing huye't.
Thieu mau din dd'n hoai tii mdt la hau qua tit yd'u nhtfng tai ttfdi mau khi mdt bi thid'u mau lau cung gay ra bie'n chtfng tai hai lam cho hoai ttf ruot nang thdm, lam tdn thtfdng d cac tang xa nhtf phdi, tim.
than, rdi loan ddng mau...
Thlo xoan mdt non, giki phdng thoat vi ben nghet, kep rdi nha kep ddng mach chu, ngtfng chay may tim phoi nhan tao, hoi sd'c da chan thtfdng, sd'c nhilm trung deu cd the gay ra nhtfng tdn thtfdng cua hpi chiing thidu mau - tai ttfdi mau. Mudn tranh hdi chtfng nay cIn phat hidn bdnh sdm khi tinh trang thie'u mau chtfa anh htfdng de'n chuyen hoa md nghia la chtfa gay hoai tu" mdt sau.
Trong thtfc hanh lam sang, xac dinh thid'u mau mdt sdm rlt khd, thtfdng mdt da bi hoai tuf mdi phat hidn dtfdc. Ngoai dau bung cdn, cac trieu chtfng khac thtfdng rat md ho va khoa lap bdi cac bdnh nang khac nhtf nhilm trung, vidm ndi tam mac, mau cue trong tim hay bdnh xd vtfa mach mau he thdng.
Thieu mau mdt chi dtfdc xac dinh khi md bung tham sat tha'y mdt bi hoai ttf. Trong tmdng hdp md bung thly rudt nghi bi hoai tii vln dd la cd nen md thdng ddng mach hay cat bd mdt sdm de tranh hdi chtfng thieu mau tai ttfdi mau lam cho mdt hoai ttf rdng thdm va lam suy cac tang xa; cd each nao phong ngiia cac ddc chit thii ra do hdi chtfng thid'u mau, tai ttfdi mau sau md lam cho bdnh trim trpng them la nhiJng vln din cIn nghidn ctfu.
Kit luSn: Tac mach mac treo trlng tren gay thid'u mau mdt d p thtfdng rat khd chin doan sdm, ke ck ling dung cac phtfdng phap hinh anh hidn dai. Hlu he't benh nhan dtfdc chin doan tri, rudt da bi hoai tuf dai. Hoi stfc khdng dly du, md khdng triet de cd the gay ra hdi chtfng thid'u mau - tai ttfdi mau.
Nghien ctfu cac chit chi diem mdi nhtf D-lactase, GST vl iFABP de phat hien thie'u mau mac treo ruot sdm trtfdc khi rudt bi de dpa hoai ttf la phtfdng phap cd nhilu trien vpng. Ve phdng ngiJa hdi chtfng thieu mau - tai ttfdi mau vdi cac khang the ddn ddng chd'ng kd't dinh tieu clu vdi ndi mac mach mau va cdc dtfdc chit polyphenol antioxydants hlu bao ve rudt vl cac tang xa ciing dang dtfdc nghidn ctfu.
D^tVlndl
Thie'u mau mdt d p tinh gay hoai ttf mdt non gin het, ke ca dai trang la mdt nguy cd cao trong dp ciJu bung. Dp xay ra chid'm 1 tren 1000 trtfdng hdp nhap vidn [21]. Ttf vong giao ddng ttf 67 de'n 80% [12][22]. Nguydn nhan thtfdng gap la tac long mach cap tinh do mau cue, do xd vtfa hay do CO mach keo dai dap tfng vdi giam cung Itfdng tim vi soc, vi diing thud'c co mach de nang huye't
^p lam gikm mau dd'n cac tang trong d bung. Khd ch^n doan sdm. Trieu chtfng lam sang dau bung
thtfdng hien dien nhtfng khdng dac hieu. Chin doan hinh anh cho thly tac mach thi da tri. Dii sao, de chin doan phan biet gitfa 3 nhdm tac mach tren, can chup hinh mach mau. Dieu tri cap ctfu cIn thich hdp vdi tufng nhdm vl ttfng trtfdng hdp. Hoi stfc tich ctfc, phlu thuat phuc hoi ddng chay hay cat rudt hoai tu" rdng rat can can nhac de tranh hdi chtfng thid'u mau tai ttfdi mau [23] [24]. Trong nghien ctfu nay, chiing tdi chi gidi han cac trtfdng hdp tac mach mac treo trang trdn tai gdc hay gin gd'c.
1568 TAP CHf KHOA HOC TIEU HOA VIET NAM 2011 - TAP VI- s 6 23
Muc tidu nghidn ctfu:
1- Hoi ctfu cac bdnh nhan bi tac mach mac treo da dtfdc dilu tri de tim each chan doan sdm.
2- Tim phtfdng phap xtf tri td'i tfu nham tranh hdi chtfng thid'u mau - tai ttfdi mau.
Dd'i ttfdng va phtfdng phap:
1- Tit ca bdnh nhan bi tac ddng mach hay tinh mach mac treo da md tai khoa d p ctfu bdnh vidn Binh Dan ttf 2000 de'n 2009.
2- Hoi ctfu, phan tich ca lam sang.
3- Ban vl cd che' thid'u mau tai ttfdi mau va khuyd'n cao cac phtfdng phap dilu tri.
Kd't qua:
Trong thdi gian tuf nam 2000 dd'n nam 2009, tai khoa d p ctfu bdnh vidn Binh Dan da md cho 12 bdnh nhan bi tac mach mac treo do mau cue ttf xa dd'n, do huyd't khd'i hinh thanh tai chd xd vtfa thanh mach hay viem ndi mac/nhilm triing huyd't hay do co mach keo dai gay hoai tu" gin he't mdt non va ca dai trang phai.
L§m sang va ch^n doan:
Lam sang Dau bung cdn Viem phuc mac Sd'c nhidm triing
Suy hd hip Suy than
Suy tim Rd'i loan ddng mau
SdBN 12 07 02 04 03 03 04
Tudi
<50
>50 Tong
Nam 3 6 9
Ntf 1 2 3
TS 4 8 12 Tudi trung binh 57,33 tudi
Lam sang Dau bung cdn Viem phuc mac Sd'c nhilm triing
Suy hd hip Suy than
Suy tim Rd'i loan ddng mau
SdBN 12 07 02 04 03 03 04
Xet nghidm Het < 30%
BC > 8.000/mm3 Tieu clu < 70.000/mm3 Fibrinogene < 200mg/dl
TQ > 30 giay TCK > 15 giay
Pa02 < 70%
Creatinine > lOOumol/L Potassium > 5mmol/L
Glucose > dmmoiyL Bilirubine > 1.5umol/L
AST < 37U/L ALT < 42U/L
Phosphatase kilm < 300U/L Amylase mau < 250U/L Protein < 60g/L (albumin <35g/L)
SdBN 06
11 04 02 02 04 04 07 02 03 02 03 04 02 06 08
TAP CHl KHOA HOC l i t u HUA vi±ii INAM 2011 - TAP VI - SO 23 1569
Hinh Inh Phdi b i t thtfdng Bung bat thtfdng
MSCT:
Nghe DMMMTT Tac TMMTTT- TMC Co mach keo dai do sd'c va DT
S d B N 05
11 09 02 01 Sieu am
Tim b i t thtfdng, EF < 60%
Bung b i t thtfdng
S d B N 11 10
H la, lb: 207/08790 D V Th. 52t, tac DM mac tree trang trdn, trdn DM DT gitfa
(VTan/BD Hosp)
^ ^ ^ ^ ^ B ^ ^ ^ R K / ^
W/^^m.A. " ^ M
^ 1
|V4J
H 2a, 2b: 209/16963 Dinh Van B. 68t, tac DM mac treo trang trdn, trdn DM DT gitfa
(VTan/BD Hosp)
H 3a, 3b: 207/12400 TrIn Minh Th. 47t, tac
TM mac treo trang trdn (VTan/BD Hosp)
ECG Thieu nang vanh Nhanh nhip xoang
Fibrillation
SdBN 04 03 02 Chin doan tmdc md
Vidm phuc mac chtfa rd ly do Thung tang rdng
Vidm tuy nang, hoai ttf, nhiem trung, xult huyd't
Tac long mach (mau cue, xd vtfa, chen dp), hoai ttf mdt
SdBN 08 01 02 06 Chin doan sau md
Tac DMMMTTT hoan toan
• mau cue
• xd vtfa
• CO mach Vi tri tac
. > DM DT gitfa
• < DM DT gitfa
Tac TM hoan toan mau cue
• TMC
• TMMMTT Tinh trang mdt
• hoai ttf rdng
• de doa hoai ttf rdng
• chtfa thly da'u hoai ttf
SdBN 03 08 01 08 02 01 01 09 02 01
1570 TAP CHI KHOA HOC TIEU H 6 A VIET NAM 2011 - TAP VI- SO 23
Xtf tri:
Hdi stfc: dich tmyin khang sinh Phlu thuat:
Phlu thuat
Phlu thuat lln dlu
• Cat mdt rdng
• Phuc hdi mach mau Phlu thuat lai (2"^ look/48h)
• hoai ttf rudt them: cat /nd'i
• khdng hoai tu" rudt them: cat/ndi
SdBN 11 01 07 02 Bid'n chtfng
Bid'n chtfng Hoai ttf rudt them
Suy tang xa (suy hd hap: 4, suy than: 6, suy tim: 3,suy da tang: 4)
Nhilm trung huyd't Dich bang
SdBN 07 08 05 02 Rudt ngan va hau qua
Suy dinh dtfdng/rd'i loan tidu hoa Nhilm trung dich bang
Rd tidu hoa Hoai tiJ gan
SdBN 09 01 02 01
H 4: 207/08790 D v Thdm 52t, hoai ttf gan / tac DM mac treo trang trdn, trdn DM DT gitfa
(VTan/BD Hosp)
Ttf vong Sdm (< 48 gid) Mudn (trong 30 ngay)
Tdng
_ S d B N _ 04 03 07 (58%) Ly do TV sdm: Sd'c khdng hdi phuc 2; suy da tang, hdn md 2.
Ly do TV sdm: Suy kiet 2; suy hd hap, nhilm trung 1 Ban ludn:
Tac mach MTTT din dd'n thie'u mau mdt d p , gay hoai tvl mdt la mdt bdnh canh trim trpng trong d p ctfu bung ngoai khoa. Nhieu nghidn ctfu d cac trung tam d p ctfu qud'c te cho bidt dp xay ra chid'm 1 tren 1000 trtfdng hdp nhap vidn [21]. Tuf vong rat cao, giao dong ttf 67 dd'n 80% [12] [22].
H 5: Sd dl DMMTTT [34]
HflM^ssh-^ artery —
H 6: Sd dl cung Riolan [34]
TAP CHf KHOA HOC TIEU HOA VlfeT NAM 2011 - TAP VI - S 6 23 1571
Nguyen nhan thtfdng gap: (1) tac long mach do mau cue trdi tif xa (tim) de'n; (2) hoac do cue mlu hinh thanh tai chd vidm loet ndi mac hay xd vtfa thanh mach; (3) hep khiu kinh long mach do suf dung thud'c co mach de nang huye't ap d mdt sd trtfdng hdp nhtf sd'c m l t mau, sd'c nhilm trung, gay te ngoai mang ctfng [23] [24]. Hien ttfdng co mach keo dai gay ra hdi chtfng ttfdng ttf nhtf tac d6ng mach mac treo va h l u hd't txi vong do hoai ttf mot, suy da tang va nhilm trung huye't. Ngoai ra, d cac bdnh nhan xoan mdt doan dai mdt (do thoat vi, day dinh) da cd hoai tii rudt, ne'u thao xoan se gay sd'c nhilm trung - nhilm ddc, suy da tang do hoi chtfng thieu mau tai ttfdi mau, ttfdng ttf nhtf hpi chtfng thao garrot.
Khi mdt bi thie'u mau d p tinh, cac nhung mao bit dlu bi tdn thtfdng sau 15 phut va hoai tu* sau 3 gid. Thid'u mau tie'p tuc, nidm mac mdt rdi dtfdi niem va cd niem se bi hoai ttf. Nd'u tuIn hoan d mdt dtfdc phuc hoi tmdc giai doan nay thi nidm mac mdt se tai sinh nhanh va cd the hoan tit sau 24 gid [33]. Nd'u khdng, thanh mdt se phii n l , xu- lt huye't va hoai tuf. Dtfdi tac ddng cua hydrolases, dich mat va vi trung, dich ndi mach se thoat nhanh vao long mdt, thanh mdt, mac treo va phuc mac gay ra sd'c giam the tich.
Cac nghien cihi cho thly nguydn nhan chinh gay t& vong la do cac ddc chat thai ra tuf cac md trong trong tid'n trinh thie'u mau roi tai ttfdi mau. Cd che thie'u mau tai ttfdi mau gay tdn thtfdng d mdt rat phtfc tap, bao gom nhieu qua trinh chuyen hoa dap ling vdi oxy (ROS), vdi nitd (NO) va td bao lym- pho (PMNL). Day la mdt thach thtfc ma cac nha y hpc qua nhilu thap ky vln chtfa tim ra Idi giai dap dd dilu tri cd hieu qua [4] [26]. Mdt sd' gia thuyd't cho rang, khi thid'u oxy, td' bao lympho bi kich boat va kd't dinh roi phdng thich chat tiln viem, hinh thlnh nhtfng gd'c ttf do [27-29]. Hdn ntfa, NO dtfdc sin sinh se trd thanh anion peroxynitrite (ONOO) dtfdi t i c ddng cua nitric oxide synthases (iNOS).
c a c gd'c tuf do, NO, peroxynitrite theo mau dd'n cac md va tang gay tdn thtfdng md Ian toa, tdn thtfdng
cac tang d va lai tie'p tuc san sinh ra cac gd'c tuf do, NO, peroxynitrite [3] [5] [30]. Suy da tang d xa la bie'n chtfng thtfdng xay ra sau khi phuc hoi tuIn hoan dd'n mdt da bi ton thtfdng, do qua tnnh vidm dap tfng mdt each cd he thd'ng, thai ra cac chit ddc hai nhtf ROS, RNS gay tdn thtfdng chtfc nang phoi, gan, tim, than [6-8].
Cac nghien ctfu cho thay chinh bach cau phln tfng vidm da phdng thich ra cac gd'c ttf do va ket dinh vdi ndi mac mach mau gay ra ton thtfdng mdt va cac tang xa trong hdi chtfng thie'u mau - tai ttfdi mau [33]. De chtfng minh hau qua nay, ngtfdi ta tmyIn mau khdng cd bach clu cho sinh vat da gay hdi chtfng thie'u mau - tai ttfdi mau thi thly mdt bi hoai tu" thdm it hdn. Mdi day, ngtfdi ta dung khang the ddn ddng chd'ng lai mang bao glycoprotein lam giam ke't dinh bach clu vdi ndi mac mach mau cung cho kd't qua ttfdng ttf nhtf tmyIn mau cd it bach clu.
Cling do bach clu gay ra, nd'u hdi chtfng nay xay ra lap di, lap lai ttfng chu ky ngan se gay ton thtfdng nang n l hdn la mdt chu ky keo dai.
Nhtf vay, htfdng dilu tri trong ttfdng lai se la diing khang thd ddn ddng (ICAM-1, ELAM-1) d l ngan stf kd't dinh bach clu vdi ndi mac mach mau hay ngan stf tid'p xiic gitfa nhtfng thu the cua te' bao ndi mac vdi bach clu. Mdi day, cd cac nghien ctfu thtfc nghidm tren sinh vat diing chit chd'ng exit hoa [1][31][32]: polyphenol antioxydants trong nhdm procyanidins nhtf procyanidins, prodelphinidins, propelargonidins, profisetinidins, prorobinetidins, proteracacinidins, va promelacacinidins. Chit pro- cyanidins da dtfdc tim thly trong rtfdu chat do, tra, chocolat, trong rau qua nhtf nho, tao, pears va cran- berries, c a c nghidn ctfu cho thly cac chit polyphe- nol nay cd tac dung ngtfa dtfdc phln nao hdi chtfng thid'u mau tai ttfdi mau.
v l chin doan, trong thtfc hanh lam sang, rlt khd chin doan sdm thid'u mau mdt, thtfdng phat hien khi mdt da bi hoai tuf nhilu hay It [25]. Trieu chtfng dau thtfdng lln Idn trong vidm phiic mac.
Ngoai dau bung cdn, cac trieu chtfng khac thtfdng rat md h i va bi che l i p bdi cac bdnh nang khac nhtf
1572 TAP CHf KHOA HOC TIEU H P A VlfiT NAM 2011 , i- SO 23
nhilm trung, vidm ndi tam mac, mau cue trong tim hay benh xd vtfa mach mau he thd'ng. Thid'u mau mdt chi dtfdc xac dinh khi md bung tham sat [11].
Cac phtfdng tien chin doan hinh anh hidn dai cung chi cd gia tri ban che. CT thtfdng khdng xac dinh dtfdc mdt bi thie'u mau [13][15]. MRI, CT-A ddng mach mac treo mdt d trtfdng hdp co mach khdng giiip chan doan [14]. Dac bidt la trong trtfdng hdp benh nang, sinh hieu khdng on, dang giiip thd thi khdng the thtfc hien dtfdc cac chin doan tren, vi vay thtfdng bd sdt. O cac trtfdng hdp cd tac long mach, CT-A cd the cho thay mach mau mac treo mdt bi tac va DM cd hinh anh chudi xiic xich (xd vtfa) va dau hieu mdt da bi hoai tuf nhilu hay It. Cac xet nghidm kinh dien khac nhtf amylase, bach clu, dif trtf dtf, cd dac mau... se thay doi nhuftig thtfdng rat tri va khdng dac hidu. Mdt so nghien ciiu gin day cho thly chat chi diem mdi nhtf D-lactase, GST va iFABP cd the cho biet kha sdm khi md mdt mdi bat dlu thie'u mau nhtfiig chi lam dtfdc d cac phdng xet nghiem hien dai vdi dp chinh xac cao [16][18-20].
Nhtf vay, cIn chup hinh mach mau mac treo rudt cac bdnh nhan cd cac trieu chtfng bao hieu thie'u mau mdt nhtf dau bung sau khi an (sd an) va sut can nhanh hay cd tac tinh mach sau ngoai bien de tie'n hanh thdng mach mau sdm. Dd'i vdi cac tmdng hdp bdnh nang d san soc dac bidt, khi hdi stfc cang it dung thud'c co mach cang td't trtfdc khi bdi hoan du dich tmyIn, mau va ludn canh giac hoai tu" mdt gay vidm phiic mac do hdi chtfng thie'u mau tai ttfdi mau.
v l dilu tri, khi chin doan dtfdc rlt sdm, tmdc 3 gid [12], mdt dtfdc bao ton khdi bi cat rdng bang each phuc hoi mach mau dd'n. Khi mdt da bi hoai ttf, ngoai cat bd rdng, bao vd mdt cdn lai cdn phai phdng ngtfa tdn thtfdng cac tang xa (hdi chtfng thidu mau tai ttfdi mau) bang each diing chit chd'ng cac gd'c tif do hay xanthine oxydase, hoi stfc that td't va md bung xem lai midng ndi khi khdng dtfa 2 dlu mdt ra da.
Nhtf vay mudn bao vd rudt khdi bi cat bd rdng hay bi hoai tu" thdm thi (1) phat hien bdnh rlt sdm
trtfdc khi mdt bi hoai tuf hd't ldp nhung mao (villous) dd'n cac hd (crypt) vao ldp cd nidm; (2!^ -i s re ihM td't, cang It dung thud'c co mach cang tot; (3) chdng bach clu kd't dinh phi buy nidm mac mdt.
Dii vay, cac nghidn ctfu [33] cho thay 10% trtfdng hdp sau khi phuc hdi mau de'n mdt, rapt van bi hoai tu" rdng them va suy nang them cac tang xa. Ly giai la cd the do he finh mach rapt khdng dap tfng kip thdi khi mau dd'n tang dot ngdt lam cho thanh rapt, long rapt, mac treo rapt phii nl, tf mau.
Khi rapt da cat bd hdt stfc tie't kiem va da nd'i lai hay dtfa 2 dlu ra da thi cIn dtfa vao lam sang, hinh anh va quan sat nidm mac rapt de theo ddi cd ndn md lai hay khdng (2nd look). Khi cac tang xa mdi bi suy, cIn dilu tri sdm khdng de tdn thtfdng nang thdm va Ian ra nhilu tang khac.
Kd't ludn: Thie'u mau rapt d p tinh gay hoai tuf rapt rdng la mdt benh canh lam sang trim trpng trong nhdm bung d p ctfu ngoai khoa.
Cin canh gilc d cac bdnh nhan cd trieu chtfng bao hidu thie'u mau rapt hay tf mau rapt do tac tinh mach sau viing bung de chup hinh mach mau mac treo rapt sdm. Dd'i vdi cac trtfdng hdp bdnh nang d san soc dac bidt, cang it diing thud'c co mach cang td't tmdc khi bdi hoan du dich trayen, mau cho bdnh nhan va ludn canh giac cd the cd thie'u mau rapt gay hdi chtfng thid'u mau - tai ttfdi mau.
Chi cd chin doln sdm tmdc khi radt chtfa bi hoai tuf mdi khdi cat bd nhilu mdt.
Khi doan mdt da bi hoai ttf, sau khi hoi stfc dly du, cIn cat bd rdng doan mdt da bi hoai ttf, tranh hdi chtfng thid'u mau tai ttfdi mau, se bao vd dtfdc doan rapt cdn lai va ngtfa dtfdc tdn thtfdng cac tang xa •
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TAP CHf KHOA HOC TEEU HOA VIET NAM 2011 - T A P VI - SO 23 1573
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