Tap chi GAN MAT VIET NAM so 29-2014 65
Phau thuat c^t than - duoi tuy noi soi: K^t qua buo'c dan Initial results of laparoscopic distal pancreatectomy
Nguyin Tdn Cuang''^, Pham Him Thien Chf, Dodn TiinMf, Phan Minh Tri', Le Ben Bat'. Bang Tran Khiim'-Nguyin Thanh Thoai^
Tom tat
Mtfc tiiu: Phau thuat cat tyy npi soi cham duac cong nhan rpng rai do cau tnic giai phau va sinh ly tuyen tuy phiic tap. Muc tieu ciia nghien ciiu nay la phan tich cac ket qua budc diu, nhin manh dSn tay ngh6, kinh nghiem va each tan ^ thuat m6 cua phiu thu|t vien
Fhirong phap nghien cihi: mo ta hang loat ca.
Kit qua: Tt thing 5/2005 dSn thing 05/2014, tai khoa Ngo^ Gan- Mat- Tuy benh vien Chp Rly co 37 ca cat than- duoi tyy qua npi soi vdi ti le nam:nu la 1:2,4, tuoi tnmg binh 40,3 (14-75), thdi gian mo tmng binh li 280 phut (135-460). Ti 1? md npi soi thanh cong li 26/31 ca trong do co 9 ca can ky thi4t ban tay ho frp. Co 5 tnrdng hpp chuySn mo md. Bi6n chiing sau m6 bao g6m: I tmdng hpp chay niau phai mo lai bang
npi soi 0 bung, 1 fnidng hpp nhiem tmng thanh byng, 1 tmdng hpp viem phoi, 4 tmdng hpp rd tyy sau mo chi can dieu tri bao ton. Giai phlu b?nh bao gom: 7 ca in- sulinoma, 5 nang tuyen lanh tinh, 8 ung thu tuyen tuy, I ung thu te bao than kinh npi tiet, 10 viem tyy m^n- nang gia tuy, 3 u the dac gia nhii giap bien ac, va 3 u mach dang hang xa hoa.
Kit luan: Cit thin - duoi tuy noi soi an toan va khi thi, vdi ti le tai bifin va bien chiing chap nhan dupc, khong cd hi vong. Day cd the la dieu tri chpn liia doi vdi cac u lanh, kich thudc vira phai tai cac tnmg tam CO dung lupng benh nhan ldn, phiu thuat vien co kinh nghifim mo npi soi.Cit than- du6i tyy bao tdn lach co the la dieu tn chpn lira doi vdi benh nhan tre tuoi.
Tiir khoa: Mo ngi soi- Ch than- du6i tyy nOi soi - Ung thu
Abstract
Background: Laparoscopic pancreatic sur- gery has been slow to gain wide acceptance due to the complex pancreatic anatomy and physiol- ogy. The aim of this study was to analyze our pre- liminary results and highlight the impact of centtalization on surgeon workload and pancreatic surgical innovation Methods: Case series de- scriptive report
Results: We conducted the research on 37 cases of laparoscopic distal pancreatectomy at the department of hepato-biliaiy-pancreatic, Cho ray hospital,from May 2005 to January 2013. The male: female ratio was 1 : 2,4 average age was 40,3 (14- 75), mean time of operation was 280 minutes ( 135- 460). Successfiil rate of laparo- scopic procedure was 26/31 cases, in which 9 cases required hand-assisted technique,5 cases converted to open laparotomy. Postoperative com- plications included 1 case of bleeding that under- went laparoscopic coagulation, 1 case of incisional infection, 1 case ofpneumonia, 4 cases of pancreatic fistulas that healed spontaneously.
Pathological results included 7 cases of insuli- noma, 5 cases of benign pancreatic cyst, 8 cases of pancreatic carcinoma, 1 case of pNET, 10 cases of chronic pancreatitis with pseudocyst, 3 cases of borderline solid pseudopapiUary epithelial neo- plasm, and 3 cases of fibrosis cavernous heman- gioma.
Conclusions: Laparoscopic distal pancreatec- tomy is a safe and feasible procedure with accept- able morbidities and complications, without mortality recorded. It could become the treatment of choice for benignor moderate size tumor at a high workload center with experienced laparo- scopic surgeons. Distal pancreatectomy should be performed, if possible, with spleen- preserving technique, especially in young patients.
Keywords: Laparoscopy- Laparoscopic distal pancreatectomy- Pancreatic cancer
Thu tir liin lac: PGS TS Nguyen Tan Cucmg, Khoa Ngoai Gan- M^t- Tyy, B V Chp Riy, 201B Nguyen Chi Thanh, TP. HCM, email: tan- cuongng@yahoo .com
'Bp mon NgO(ii. D^ hpc Y Dirpc TP. HCM. -Khoa Ngo^i Gan-Mat-Tyy, BV Chp Ray. 'Khoa >
Phan bi?n Khoa hpc: PGS TS Le Lpc.
1, BV da khoa Hoan My
66 Tap chi GAN MAT VIET NAM so 29-2014 1. M&ddu
cit kh6i ta - tuy qua npi soi duac ip diing diu tien vao nam 1994 va cit than- duoi tuy npi soi dau tien vio nim 1996 (1,2). Sir tidn trien vd so luong cimg nhu hoan thien ky thuat tuong doi cham vi cac ly do sau: 1. tuy nam sau phuc mac CO giii phau hpc khi phiic tap nhat la su lien quan voi cac mach miu Ion xung qumih, 2. Dac diem sinh ly tuy hen quan den bien chiing ding ngai li ro tuy sau m6 3. Thcd gian cat tuy npi soi con khi dii, 4. cit tuy npi soi vin chua duac xem li phiu thuat chuin so vdi cit tuy bing phuong phap mo ma, nhat la doi voi ung thu tuy, von co dp ac cao.
Tuy nhien trong vii nam gan day, so lupng cong trinh cat tuy npi soi tang din da chiing minh cat tuy npi soi van c6 vi tri so vai nhiing phau thuat mo ma kinh dien ciia tuy. Sau 7 nim ip dung phuang phap cat tuy npi soi mpt each than trpng tai khoa ngoai gan mat tuy Benh vien Cha Riy, chiing toi muon tong ket lai nhiing truang hpp cat tuy npi soi qua do rut ra nhirng thanh cong va thit bai ve ky thuat, kinh nghiem ve chpn lira benh nhan ciing nhu de ra chi dinh hpp ly cho loai phiu thuat nay.
2. Benh nhdn vd phuang phdp nghiin cuu Thiet ke nghien ciiuinghien ciiu chpn mau lien tuc, CO man benh an bao gom cac tham so ghi nhan truac mo, trong mo vi cic biSn chiing sau mo.
Dan so nguon: Benh nhan dupc dieu tri tai khoa Ngoai Gan Mat Tuy benh vien Chp Riy tu tiling 5/2005 d^n thing 05/2014.
Tieu chuin chpn benh: Tit ci cic benh nhan dupc chan doan la u vimg than va duoi tuy duac chi dinh mo npi soi tai khoa ngoai Gan Mat Tuy benh vien Cha Ray tir tiling 10/ 2005 din tiling 05/2014.
Tieu chuan loai trii
- U xam lan npi tang lan can tien CT - scan.
- U the dac c6 dudng kinh tien 10 cm.
Qui trinh phau tiiuit
Benh nhan dupc chuin bi nhu cupc mo bung dai phiu.Phuang phap vo cim la me noi khi quan.
Tu thd benh nhin: nam ngua, nghieng phii 30°, hai chin dang, phiu thuat vien diing ben phii b?nh nhin, ngucri phu mo 2 cam camera diing
giua hai chan benh nhan, nguoi phu mo 1 va dung cu vien diing ben (T).
. Su dung 4trocar:
Hinh 1- Vi tri dat ti-ocar
y
- 2 trocar 12mm + r6n: bom C02 theo ky thuat Hasson, ap luc I2nunHg (camera) + hoQg (T): tren duong trung don (tay phai PTV)
- 2 trocar 5mm: thupng vi (tay trai PTV) hong (T) (nguoi phu)
Surg Endosc (2011) 25:3364-3372 Cac buac tien hinh phiu thuit:
• Cat than- duoi tuy + c^t lach
- Xe mac noi vi-dai tiing de vio hau cung m^c noi (sii dung dien don cue, luong cue hoac Har- monic scalpel)
- Ven da diy len tren, hoac khau co dinh ba cong Ion da day len thanh bung voi 2-3 miii chi nylon 1.0, phoi bay kh6i u thin hoac duoi tuy
- N6u u tuy khong thiy tren hh mat, co thk dung sieu am qua npi soi -qua tiocar 12mm- hoac cho ban tay vao h6 tig (HALS). Cin than ti-anh gay ton thuang cic nhanh ttnh mach nho cua tinh mach lich
- Ba duoi ciia tuy dupc di dpng ddn khi tiily ro toan bp mat sau tuy. Liic nay co thd thay tmh mach lach chay dpe ba duoi tuyi kep va cit cic nhanh tinh mach nho tii tijy d6 ra TM lach.
- Bo mach vi ngin duac cit voi harmonic scalpel hoac kep vai clip va cit
- Co the thay dpng mach lich nim sau tinh mach dpe tiieo ba tren tuy. Kep vi cit bo mach lach (clip, hemoloc)
- Doi vai u a viing than gin diu tuy, c6 tiid phiu tich viing c6 tuy dpe tiieo tiiic TM MTTT- TMC- TM lach, lu6n 1 6ng thong cao su (nhu Nelaton) de nang tuy ra tiiroc, va sii dung stapler tiling CO khop gip (Echelon hoac Roticulator) voi
Tap chi GAN MAT VIET NAM stf 29-2014 67 kich ca khac nhau de cat va cam miu. (chieu cao
ciia kim bam tii 3,5-4,2 mm), tuy theo chieu diy h o ^ dp cling chic cua mo tuy
- Tuy dupc cat xuoi dong (antegrade). Can phij tuydn thupng than (T) v i bao ihan (T) dupc xe dpe hi (P) sang (T), cac day ching freo lich voi phiic mac duoc cat roi
- Dd d i m b i o mat cat khong chay m i u hoac ro tyy, CO did sii dung 4-5 clip nho k^p tang cuang dpe theo duong cat ciia mom tuy, hoac sii dung
Hinh 2. Cat mac noi vi- dai trang Nang da day ra truac, cat mac noi lach- dai trang va ven dai trang xu6ng duoi de bpc lp hgu cung mac noi. Bat diu phiu tich doc bc»
duoi tuy
Prolene 2.0, 3.0 dd khau tang cuang (miii khau vit)
- Co thd xit fibrin glue (Tisseal; Baxter) v i o mom tuy hoic nai ti m i u
Tuy va lich dupc cho v i o bao, keo ra qua tro- car r6n. Co thd cit lich thinh nhieu manh hoac mof rpng lo trocar thdm dd giam toi da kich thuoc vdt mo.
• c i t than- duoi tyy + bao t^n lach Hai ly do chinh khidn phiu thuit vien cin ddn
Hinh 3. Nh^n dien TM lach
Sau khi di dpng than tuy khoi mo sau phiic mac
Hinh 4. Cat cac nhanh dpng mach va tinh m&ch lach vin. dao cit dot sieu am (that 1-2 nhinh DM-TM qua nai dinh cat tuy)
Hinh 5. Cat than tyy vdi stapler Chiia l^i bo m?ch lich.Cung co the sir d\mg dao sieu am de cat tyy, sau do khau l^i mat cat v6i cic mui chii U rai.
68 Tap chi GAN MAT VIET NAM so 29-2014
Hinh 6. L?it h;y ra phia tnrac Tidp tyc phau tich doc bo mach lach, that 4-5 nhinh DM-TM ddn viing r6n lach, chua Igi cac nhanh DM vi ngan den nuoi Iach.Tach duoi tuy khoi ron lach.(3,4)
Kiim tra cdm mdu vd ddn luu: ong dan Imi Nam : nii 1:2,4 nam canh mom cat tuy.
Theo doi sau mo: cic diu hidu phuc hoi luu „ - - i, i.- .t - ^" 1.' 1-:! t-' '^ - L " L' Hoan canh nhap vie thong tieu hoa, men chung ro tuy va bien chung
chiy mau.
3. Kit qua
Tong so bdnh nhin n=37 Bdng 1. Bg.c diem thucmg ton
Tuoi tiimgbmh(nam) 40,9 (tii 14 den 77) Dau bi^g trdn ron dan thuan 26/37 Hpi chiing ha duang huydt 7/37
Tmh CO 03/37
Kich thuac u (n)
\^dm dmh quanh u (n
<1 cm 3/37
1-5 cm 15/37 14/37 Nang gia tuy - vidm tuy 6 ca
>5 cm 19/37
Ung thu tuydn 7 ca Vidm dinh c6 tiie do qui trinh vidm va do ung thu xam lin. Day li nguydn nhan lam cho cupc m6 kho khin phii h6 tra bing tay hoac chuydn thinh ma bung
Bdng 2. Dac diem cuoc mo
D|c dilm Chay mau nhidu tiong khi phlu tich Can den ky thuat ban tay hd tip Truyen mau trong mo Chuyen mo ma Sii dung stapler de cat tuy
Cat tuy vci ban tay ho trp (khong stapler) Thai gian mo trung binh (phiit)
So ca (N=37) 14 9 15 4 31
6 268(108-460) ky thuat ban tay h5 trg la u insulin qua be khong
thay tren be mat tuySn tuy(hinh anh CT hoac MRI ciing khong ro rang) hay u dinh nhi6u. Ly do chinh cua chuyen mo mo la chay mau trong khi
phau tich (2 ca) hay viem dinh qua nhilu do ung thu (2 ca) lam cho phau thuat vien khong thS tiSp tiic phau tich tuy dugfC.
T^p chi GAN MAT VlfeT NAM stf 29-2014 Bang 3. Biin chimg sau mo vd xu tri
Bien chirng Bi^n chirng sau mS Rdtvy
Chay mau bd cong ldn da day Nhilm triing v6t mo Viem phoi Ket quS T6t
(n=37) 7 4
1 1 1
7
Ti lc (%) 18,9 10,8
2,7 2,7 2,7
Xfttrf
2,7 2,7 5,4
19,9
1 Din luu qua sieu am, ERCP 1 Dat stent nieu qiwn JJ 2 DiSu tri n6i Mo nOi soi lai cim mau Dieu tri n6i Di6u tri npi
Trudng hpp nam vidn liu nhit 38 ngiy li do ro tyy sau cit tyy npi soi. Bon trucmg hpp ro tyy deu li ca mo kh6, chiy miu va can ttuydn mau trong mo, tix)ng do 2 ca phii chuydn mo ma (1 do ung thu tyy, 1 do u mach hang xa hoa). Hai tiirong hpp chuyen mo ma niy c6 1 cat tuy vi khiu mat cat bang tay, 1 cit bing stapler co khiu ting cuang
mat cit Truong hpp ro tiiy con 1^ xay ra trdn m6t b?nh nhin hi nang gii tuy do vidm tyy man vi tyy dupc cat bing stapler. Ci 4 tru6ng hpp r6 tyy niy didu tri bio ton ddu thinh cong, khong cin mo lai.
Truang hpp bidn chiing chiy miu sau mo duy nhat.dupc phit hidn vi mo npi soi lai tiong ngiy, vi tii chiy mau li 6f ba cong lan da day Bdng 4- Bdc diim Gidi phdu b$nh U nang tuyen tify lanh tinh
U nang tuyen tuy lanh tinh U tiet insulin Ung thu tuyln tuy
Ung thu \k bao than kinh noi tiet (pNET) Viem tuy xo hoa- nang gia tyy U thi d§c gia nhu giip bien ac U mach d ^ g hang xa hoa Tong
5 7 8 1 10 3 3 37 Nhimg b$nh nhan co bdnh cinh nhap vi^n li
h? dudng huyet d^u dupc khoa npi tiet giai thi?u vi nghi bu<5ru tyy tidt msulm.Khi do lupng ducmg tiong miu b?nh nhin tai phong mo, chiing toi ghi nh^n tat ca 7 trudng hpp u tidt insulin deu bieu hi^n dudng huyet tang din ngay sau cat u.
Ci 8 trudng hpp ung thu tuy viing duoi deu c6 chi s6 CEA, CA 19.9 binh thudng,vi deu c6 hinh inh vidm dinh it nhidu tdn phim CT scan byng CO cin quang.
Cic y^u to lien quan den chuyen mo md'
70 Tap chi GAN MAT VlfiT NAM sS 29-2014 Bdng 5: Cdc yiu td lien quan den chuyen mo ma
^ ^ ^ C h u y e n mo mo"
Cac yeu to ^ ^ ^ ^ Kfch thirds u (cm)
< 5
> 5 Ch^y mau trong mo
Chay it Chay nhieu T5n thinmg n$i tang
TT noi tang Tut clip TM Khong
Khong (n = 32)
TS
%
Cd(E TS
- - --«---
18 19
48,6 51,3
22 10
59,5 27 , hoac„ JSi dd ky thu^t
00 00 00
00,0 00,0 86,5
0 5
1 4
2 1 2
= 5)
%
00,0 16,2
2,7 10,8
5,4 2,7 5,4
P
. m
0,038*
. „...,-.
0,087**
< 0,0001
(*) Test Cramer i V. chay mau trong mo va chuyen mo ma, su khac - Nhom 5 trucmg hop chuySn m6 ma dta rai bi?! nay khong co y nghia thdng ke, vdd P=0,087.
vao nhdm cd kich thudc u tren 5cm. Su khac biet Chuydn mo md do tdn thuang ndi tang hay do ky nay cd y nghla thdng ke vdi P=0,038. Vay nen can thuat, su tuang quan nay cd y nghla thong ke vdi nhac khi chpn nhirng tnrdng hop u ldn hon 5cm P=0,0001.
de thuc hien phlu thuat noi soi. Lien quan giira Cac y6u t6 lien quan den bien chihig sau mo Bdng 6. Cdc yeu to lien quan den bien chung sau mo
^ ^ ^ ^ B i e n chung Cac ylu to ^ ^ ^ ^ Chuyin md md*
Co Khong Khau tang cirfmg
Cd Khong Giai phau b|nh
Viem Ung thu Binh thudng
Khdng TS
01 29
19 11
04 07 19
n = 30)
%
' '1 ,
2,7 78,3
51,3 29,7
•rMvini.::i k 10,8 18,9 51.4
Cd(ii TS
4 3
7 0
< 7 . V , .
4 2 1
= 7)
%
10,8 8,1 I'l v,''i3«f"
18,9 00,0
10,8 5,4 2,7
P
„ s 0,001*
, i^'^sMJ
0,038**
• " ^ ^ ^ ^
0,027*
- J
Tap chi GAN MAT VIET NAM so 29-2014 71 (*) Test Cramer's V.
Trong bang trdn ta nhan thiy cd su hen quan giua bisD. chiing sau mo vdi nhom chuydn md md.
4/ 5 trudng hop chuyen mo md co tai bidn, so vdi 3/23 trong nhom khong chuydn mo md. Su khac bidt niy cd y nghia thong ke vdi P^,001.
Trong nhom co khau tang cudng mom tuy li 14, thi gin phan nua co bien chiing sau md. So sinh vdi nhdm khong khiu thi khac biet niy cd y nghTa thdng ke P=0,038. Didu nay phu hpp vdi nh|n dinh cua phiu thuat vien trong md, Nhung tnrdng hpp cd tai bidn thudng cd vidm dinh hay u kich thudc ldn ma trong qui trinh md phiu thuit vidn than dinh md tuy co tiie khdng mem mai hay supng Cling vi ba... Giii phau bdnh sau mo cd vidm hay ung thu cd lidn quan ddn bidn chiing sau mo. Khi so sinh vdi nhdm khdng vidm hay ung thu con lai thi su khic bidt nay cd y nghia thong ke P=0,027.
4. Bdn luan
Phau thuat cit than- dudi tuy ching nhiing cho hinh anh phdng dai giiip phiu tiudng ro ring han ma con giiip benh nhan chdng hdi phuc vdi ti le tai bidn va bidn chiing chip nhan dupc (3). Vdi hinh inh dupc phdng dai, cic nhanh nhd cua tinh m^ch va dpng mach lich dl ding dupc phau tich khdi nhu md tyy vi kep clip, dong tiidi lira tang tiem nang bio tdn dupc lach. Cat than - dudi tuy qua ndi soi dac biet thich hpp vi khdng can phii
khiu ndi d mat cat. Cac nghien ciiu da tnmg tim vdi sd tieu benh nhin ldn deu cho ring ndn ap dyng phau thuit npi soi cit thin- dudi tuy ddi vdi cic u linh, mac du cic nghien cuu gan day cho thiy md ndi soi cd ket qua tucmg duang vdi md md, ngay ci ddi vdi ung tiiu tuydn dng ciia tyy (3,4). Nhimg trudng hpp u tidt insulin cd kich thudc nhd khdng gay khd khin cho phiu thuit vien khi phau tich thin - dudi tyy. Mdt khd khan trong thuc td cit tyy ndi soi nhung trudng hpp u tidt insulin li lim sao dinh vi dupc khdi u neu nd khdng nam gin be mat md tyy. Neu khdng cd sidu am qua npi soi d bung thi phiu thuat vidn phii cin ky thuat ban tay ho trp.
So vdi md md, thdi gian cat tyy ndi soi dai hem die bidt nhung trudng hpp viem dinh nhieu quanh tyy.Thdi gian md ciia nhiing ca cat tyy dau tidn ciia cic tic gii Nhit Bin thudng la 10 gid. Tuy nhidn de cupc md khdng qua lau ndn chang chung ta ndn chpn md ndi soi vdi bin tay hd tip ngay tu diu neu thay nhiing diu hieu viem dinh tien CT scanner bung cd can quang.
Cd vai cdng trinh chiing minh khdng cd su khic biet vd ti Id rd tyy sau cat thin - dudi tyy giiia khiu bang tay vi bing stappler. Chiing tdi chpn giii phap an toan li khiu tang cudng mom cat tyy sau khi ddng bang stappler. Ti Id rd ciia chiing tdi la 12,9% (4/31), cd the chip nhin dupc khi so sanh vdi cac bai bao cao ngdai nudc Garde day.
I f i s t u l a I " I n o f i s t u l a p = 0 . 0 4 3
70 •
1 1
^ ^ H
~- - !
C? ,.,r
' 1 E
1 B 00 E 50 O- 30
£ o
— ' --:-
'
-
no-PFC PFC
Bidu dd A:
So sanh ti 1? rd tyy sau cat tyy npi soi d hai nhdm cd va khdng cd ip d\mg ky thuit ep md tyy (PFC)
Bieu dd B:
So sinh ti Id nang gii tyy sau cit tyy npi soi d hai nhdm cd va khdng cd ip dyng ky tiiuat ep md tyy (PFC)
72 Tap chi GAN M A T VIET NAM so 29-2014 Tie gii Nasafiimi Nakamura va ddng nghiep (17) gidi thidu ky tiiuit dp md tuy trudc va sau khi cit bang stappler (Peri-firmg compression) se giiip lim gian nguy co rd tyy (p< 0,05). Tuy nhien 3 ca rd tuy cua chiing tdi xay ra tren 2/19 trudng hpp sii dung stapler (1 khiu ep tang cudng vi 1 khdng khau dp), vi ti-en 1/8 tiudng hpp cit ti^y bing dao di$n thdng thudng cd kem khau dp mom cat tuy.
Khdng cd su khac bidt vd ti Id rd giiia 2 nhdm sur dyng stapler va nhdm cat bang dao didn. Chiing tdi thidt nghi edn nhidu ydu t6 khac inh hudng ddn ti Id rd tyy nhu cupc md dd hay khd, thdi gian md ngin hay dai, chay miu trong md it hay nhidu, nhan dinh ranh gidi mat cit rd rang hay khdng, chat lupng md tyy bd hay chic v.v..
U tidt Insulin la u ndi tidt gay ha dudng huydt hiem gap (trung binh 4 benh nhin/1 trieu dan/nam), chidm 70-80% cac u te bao dao Langer- hans cd trieu chiing, thudng gap d Ilia tudi 30-50 (5,6). Phau thuat la phuang tien dieu tri duy nhit cd hidu qui. H^u het u tidt Insulin la lanh tinh,don doc va 2/3 khu tni d viing tiiin vi dudi tuy do do khodt u dan thuan, bio tdn md tuy va md lan can la phuang phip didu tri thudng su dimg nhit-Do trieu chiing gay ha dudng huydt dac thii, thudng cd tiid phat hidn u vdi kich tiiudc nhd <20mm.
Cac phuong tien chin ddan hmh anh cd thd bd sdt sang tiiuang, do dd dinh vi that chinh xac vi tri khdi u tiTidc md li tiiidt ydu cho sir thanh cong ciia phiu thuit, tranh cat mii mo tuy. Sieu im qua ndi soi la phuong tidn him hidu dd xic dinh u tuy nhd, chim siu tiong nhu md ma tai BV Chp rly chiing tdi sir dung ban tay hd ti-p dd tham sit rit hidu qui.
Chiing tdi thudng md rdng Id tiocar rdn khoing 6cm dd cho bin tay trai vio d bung hd tip md ndi soi, can ca thanh bung dupc khau vit vdi nylon 1.0 vua khit c6 tay, tranh xi CO2 (HALS:
Hand- assisted laparoscopic surgery). Trong md npi soi, mit cam giac tidp xiic tiirc tidp bing tay vi mit^sir phdi hap giiia tay vi mat. Vdi ban tay tiong d bung, cd tiid xic dinh khdi u tuy kich diudc nhd, khdng che chiy mau, tach khoi u khoi cac tang lan can dd dang hon. Trong nghien ciiu niy, CO 9 trudng hap chiing tdi da cho ban tay vio ho ti-p md ndi soi, tranh phii chuydn thanh md
bung Midng cin ihidt. Chi dinh bao gdm 4 tmdng hpp cit tuy do u tidt insulin (1 do khdng tihay u tren bd mat tuy, sd tay thiy td chiic suong d duoi tuy khoang 18mm-1 do chay miu tihh mach lich- 2 do bdnh nhan beo phi khdng bpc Id dupc khdi u), 4 trudng hpp cat tuy do nang tyy (2 do u vidm dinh nhidu-1 do bam stapler hi that bai-1 do khdi ip-xe tuy vd) va 1 trudng hpp la ung thu dudi tyy to 75x92mm duih nhidu vao mo lin can.
Trong nghien ciiu cd 3 ca la u thd die gii nhu giap bidn ic tien 3 benh nhan nir trd cd tudi ddi la 17,25 va 27. Day la loai u ngo^ tidt tuy hidm gap nhit (1-2%). Chiing cd dp ic thip vi thudng xay ra ti-en bdnh nhin nii da mau d dd tudi 20-30, mac du ddi khi ciing cd bio cio xiy ra tren bdnh nhan tre em vi nam gidi (7-12). Franz la ngudi diu tidn mo ti bdnh niy nam 1959, va sau dd dugc T6 chiic y td thd gidi phan loai nam 1996 vdi cai tdn la SPT (Solid PseudopapiUary Tumor) (13,14)
Trong giai doan diu, mot sd tac gia da cho rang khdng ndn mo npi soi ddi vdi ung thu than- duoi tyy, vi ti Id cat dupc thap han ung thu dau tyy nhidu (15). Ly do la vi bdnh nhin ung thu thin- dudi tuy thudng ddn bdnh vidn d giai doan mupn ban. Cac phin iing vidm va xa hda quanh kh6i u khidn cho vide bdc tich qua ndi soi rat khd khan.
Tuy nhidn md npi soi ciing cd im didm cho du li khdi u khong cat dupc qua npi soi. Thir nhit, di can gan hoic phiic mac hi bd sdt tren phim CT- scan cd thd chin doin qua npi soi, giiip trinh dupc vide md bung khdng can thidt. Thu hai, bdnh nhin se dupc chuydn didu tri hda x^ tri hoac cac can tiiiep khdng phiu thuit khac sdm hon. Han niia, phau thuat ndi soi ciing khdng Iam tang kha ning phat tin td bio ung thu trong d bung hoac qua 16 tiocar (16). Cung nhu cac nha ngpai khoa trdn tiie gidi, chiing tdi chua thd ban luan khia canh ung thu hpc trong cit tiiy npi soi, dii ti-ong nghien ciiu cd 8 tiirdng hop cd giii phlu bdnh ung tiiu tuy Vic Velanovich (16) so sanh 15 ca md ndi soi vdi 41 ca md md cit tiian- dudi tuy va kdt luan rang mo npi soi ciing an toin nhu md md, tai bidn va bidn chiing tuang duang, nhung md npi soi cd uu diem hon vi ngay didu tii ngin ban vi thdi gian phuc hdi sdm hon md md.
T?p chi GAN MAT VIET NAM s6 29-2014 73 Cit than dudi tyy hoan toan khi thi vdi ti Id
thinh cdng cao ddi vdi u linh tinh hay giap bien ic ciia dudi tyy. Hai nguydn nhan chinh gay Idid khan vd mat ky thuit li frong viem tyy man tinh va ung thu tyy. Thdi gian md se ngan Iai ndu chiing ta chpn lpc bdnh nhan chat che hon vi phlu thuat vidn tich luy nhidu kinh nghiem hon.
Tii lidu tham khao
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