TCNCYH Phu truung 80 (3A) - 2012
PHAU THUAT D l i U TRI U GAN O TRE EM
Tran Nggc S(yn, Vu Manh Hoan, Nguyen Thanh Liem Benh vien Nhi Trung wang
U gan a tre em khi chdn doan thudng co kich thuac lan, gay kho khan cho diSu tn ph§u thuat Tir thang 12/2004 ddn thang 10/2011 co 75 benh nhi bi u gan duac phdu thuat tai khoa Ngoai. benh vien Nhi Trung wang Tu6i trung binh cua benh nhan la 36 ± 44 thang. U kich thwdc trung binh la 8,1 ±2.7 cm. dai da so la ac tinh (61 benh nhan 81.3%,). trong dd phd bidn nhit la u nguyen bao gan (52 benh nhan 69,3%) 23 benh nhan (30,7%) dwac md tham do smh thtdt u va 52 benh nhan (69.3%) dwac phiu thuat cat gan. trong do 25 benh nhan dwac cdt tir nira gan tro len. Khong co benh nhan nao bi tu vong quanh mo Chl CO mpt benh nhan (1,9%,) bi biSn chirng tu dich 6 bung keo dai sau mS. duac didu tn noi khoa thanh cong Thcri gian didu tn sau md tai khoa Ngoai trung binh 5,7 ± 2.9 ngay Kdt qua nay cho thiy phSu thuat cit gan didu tn u gan a tre em co thd thwc hien an toan ma khong co tii vong vai ty le biin chO'ng th6p 6 cac trung tam cd nhieu kinh nghiem
Tip khoa: U gan tre em, phlu thuat cat gan
I.OATVANOE
U gan a tre em la tuang doi hilm gap. chi chiem khoang tu 1 - 3 % cac khli u a tre em Hai phan ba cac u gan a tre em la ac tinh trong do hay gap nhat la u nguyen bao gan (hepatoblastoma) [4]. Phiu thuat c l t bo khli u cho d i n dien gan ianh v i n la dilu tri qui chuan cho dai da s l u gan a tre em [4] Cat gan a ca nguai lan va tre em d i u la mot p h l u thuat kho, CO nguy ca t u vong va bien chung cao [2, 5, 7 - 9] Them nOa, cac khli u gan a ire em khi duac chin doan thuang co kich thuac lan hoac r i t lan, gay kho khan dang ke cho phlu thuat dieu tn [4] O t h i giai chl' CO s l It cac nghien cuu duac cong b l ve phlu thuat dilu tn u gan a tre em Q Viet Nam cung chua co nhilu bao cao v l d l tai nay Do vay chung toi tiln hanh nghien cuu nay nham muc tieu: Bao cao l<lnh nghiem phau Ihuat dieu tn u gan o tre em tai khoa Ngoai, benh vien Nhi Tmng wong va danh gia ket qua som sau mo.
II. DOI T U g N G VA PHU'aNG PHAP Day la hoi cuu mo ta loat ca benh. O i l tuang nghien cuu bao gom tat ca cac benh
nhan da dugc phau thuat tal benh vien Nhi Trung uang vai chan doan la u gan (duac khing dinh qua ket qua giai phlu benh sau mo) trong giai doan tu thang 12/2004 den thang 10/2011 Cac dO' lieu duac tap hap phan tich bao g i m dac dilm benh nhan, dac diem cac khoi u, dieu tn phau thuat va k i t qua sam sau m l .
Chung toi thuc hien cat gan bang ca 2 ky thuat cat gan diln hinh (66 kilm soat cac mach mau truac khi cat nhu mo gan) va clt gan khong diln hinh (clt nhu mo gan va ding thai kilm soat cac mach mau trong nhu mo gan) Nhu mo gan dugc clt bing dao CUSA (Cavitron Ultrasonic Surgical Aspira- tor) hoac bang ky thuat cap nat nhu mo gan bing panh Kelly (Kellydasia). Cap cuong gan (thu thuat Pnngle) khi cat gan duac ap dung theo kilu tifng dat (intermittent) 10 - 20 phiit, nghl giCca cac dat 5 - 1 0 phiit. Dien c l t gan duac elm mau bang dao dien luang cuc (Bipolar) kit hgp vai nuac muli sinh ly III. KET QUA
Co 75 benh nhan thuoc d l i tuang nghien cifu, bao g i m 41 tre nam (54,7%), 34 tre nCy
1
TCNCYH Phu truong 80 (3A) - 2012
(54,7%), udi 36 tuoi trung binh 36 ± 44 thang (dao dong) tLr 1 thang den 16 tu6i) Cac benhi nhan c6 can nang trung binh 11,5 ± 7,3 l<g (dao dong 2,5 - 45 kg) 36 benh nhan du'O'c dieu tri hoa ch§t trwac m6 (vcri chin doan la hepatoblastoma) Kich thiuac u trung binh la 8,1± 2,7 cnn (dao dong 3,5 - 15 cm ) Oac diem cac khoi u du'O'c trinh bay a bang 1 Pho bien nhlt la cac khoi u a gan phai va chiem 1 - 2 phan thuy,
23 benh nhan (30,7%) du'oc m6 tham do
sinh thiet u va 52 benh nhan (69,3%) duo'c phau thuat cat gan Cat gan di6n hinh du-gc thuc hien tren 31 benh nhan (59,6% benh nhan cat gan), cat gan khong dien hinh 6 21 benh nhan (40,4%)- Cat gan Ion (2 - 3 phan thuy gan) du'O'c thu'c hien o 25 benh- ntian (48,1%), trong do nhiju nhlt la cat gan phai mo rpng (cat ha phan thuy 4, 5, 6, 7, 8) - 14 benh nhan (26,9%) va cat gan phai (ha phan thiiy 5, 6, 7. 8) - 6 benh nhan (11.5%) (bang 2),
Oac diem cac khoi u V i t r i " "
Thuy phai Thuy trai Ga2thuy
Bang 1. Dac diem cac khoi u gan tren 75 benh niian nghien cu-u
n = 75 % 46
14 15 65 10 16 29 21 9
61,3 28,7 20,0 86,7 13,3 21,3 38,7 28,0 12,0 So luang cac khoi u trenl benh nhan
1 khoi u
> 2 khoi u
'PhanloaTtheo'PRETEXf "^ ~ ~ I. u chf chilm 1 phan thiiy gan, 3 phan thuy gan
canh nhau khong co u
ll: u chilm 1 - 2 phan thiiy, con 2 phan thuy gan canh nhau khong cd u
III: u chilm 2 - 3 phan thiiy, khong co 2 phan thiiy canh nhau khong eo u
IV u chilm ca 4 phan thiiy gan Trong so cac benh nhan duac md sinh thilt (nghi nga u nguyen bao gan), co 10 benh nhan (43,5%) la do khli u khong clt duac con lai 13 benh nhan mac dii khli u c6 the clt duac nhung chung toi chu dpng chi smh thilt theo phac do eua SIOPEL (International Society of Pediatric Oncology Liver Tumor Study Group) [3, 5]
Trong cat gan, thu thuat Pnngle duac SLP dung tren 24 benh nhan (46,1%) Co 1 benh nhan cat gan phai ma rong va c l t ha phan
thuy 1 phai su dung ky thuat kilm soat hoan toan mach mau gan (cap cuing gan, cap tTnh mach chii duai tren va dual gan). Thai gian mo trung binh la 182 ± 83 phiit (dao dpng 60 - 390 phut) d l l vai cac benh nhan duac cat gan 36 benh nhan (69,2%) phai truyln mau trong mo, vai luang mau truyln trung binh la 38,4 ± 26.3 ml/kg can nang, Khong co benh nhan nao bi t u vong trong va sau m l . Biln chiKng chi co 1 benh nhan (1,9%) bi tu dich keo dai canh mat c l t gan sau m l , duac dilu
TCNCYH Phu trwang 80 (3A) -2012
tn noi khoa thanh cong. Thai gian dilu tn sau mo tai khoa ngoai trung binh 5,7 ± 2,9 ngay.
Ket qua giai phlu benh sau m l cho thly p h i biln nhlt la u nguyen bao gan 52 benh nhan (69,3%), hamartoma trung mo gan 10 benh nhan (13,3%), ung thu te bao bilu mo
gan 8 benh nhan (10,7%). Cae loai u khac it gap han nhu u mau gan 3 benh nhan (4%), adenoma t l bao bleu mo gan 1 benh nhan (1,3%) va sarcoma khong biet hoa 1 benh nhan (1,3%). Nhu vay dai da s6 la u ac tinh, 61 benh nhan (81.3%).
Bang 2. Phau thuat cac benh nhan bj u gan tai khoa Ngoai benh vien Nhi Trung u-cng 12/2004 d i n 10/2011 Cach thirc phau thuat
Cat gan Cat gan diln hinh
c l t gan phai ma rong (ha phan thiiy 4, 5, 6, 7, 8) Cat them ca ha phan thiiy 1
Cat gan phai (ha phan thiiy 5, 6, 7, 8) c l t phan thCiy ben trai (ha phan thiiy 2, 3) c l t gan trai (ha phan thiiy 2, 3, 4)
c l t gan trai ma rpng (ha phan thuy 2, 3, 4, 5, 8) Cat gan khong dien hlnh
c l t 1 ha phan thuy c l t 2 ha phan thiiy
Cat phan thiiy ben trai (ha phan thuy 2, 3) Cat 3 ha phan thiiy
c l t gan trung tam (ha phan thuy 4, 5, 8) Tham do sinh thiet
Do khli u khong cat duac
Khli u CO t h i cat duac nhung chu dpng chi smh thilt (theo SIOPEL)
= 75 52 31 14 1 6 6 4 1 21 5 12
4 4 2 23 10
% trong nhom
Too
59,6 26,9- 1,9 11,5 11,5 7,7 1,9 40,49,6 23,1
7,7 7.7 3.8 100 43,5
% chur 69,3 41,3
28
30,7 13,3
13 56,5
IV. BAN LUAN
Cac khli u gan d tre em thuang c6 ty le ac tinh cao, kich thuac lan, luon la thach thirc d l l vai cac bac sT phlu thuat [4] C l t .gan la mot phlu thuat khd va phit-c tap, vai nhilu nguy ca biln chirng trong va sau mo lien quan d i n mach mau, dudng mat,, nhiem triing, suy gan va cac roi loan khac. co the d i n d i n tLP vong [7, 9].
Vdl su phat tnen cua phlu thuat, gay me hll SU'C, kit qua phlu thuat c l t gan dilu tn u gan d tre em da duoc cai thien dang ke Ty le tu' vong quanh m l c l t gan d eac nghien ciru
dugc cong b l gan day la khong qua 5% va tiln tdi 0% Tuy nhien ty le bien chii'ng sau cat gan vin con kha cao, tir 11,2 - 29% [2, 5, 7 - 9] (bang 3) Cac bien chirng nay chu ylu la chay mau, ro mat, tac mat. suy gan. tu dich keo dai, ap xe I bung, nhilm trung Trong nghien ciru nay toi tren so luang kha ldn 52 benh nhan c l t gan, vdi g i n mot nua sd benh nhan dugc clt gan ldn, khong eo benh nhan nao tir vong trong va sau mo, dac biet la ty le biln chirng sau m l cua chung toi rit thip, chi CO 1 benh nhan (1,9%) Day co the noi la mot kit qua dang tu hao khi so sanh vdi cac trung tam khae tren t h i gidi (bang 3).
TCNCYH Phu truang 80 (3A) - 2012
Bang 3. T y le bien chu'ng
Tac gia
SchnaterJM(Ha lan) [7]
Chittmitrapap S (Thai lan) [2]
Tov^u E (Anh) [9]
PhamTH (My) [5]
Snukla PJ (An Do) [8]
T r l n Ngoc Son
va tCr v o n g sau Thcci gian nghien cu'u 1 9 9 0 - 1 9 9 4 1 9 9 6 - 2 0 0 5 1 9 7 8 - 2 0 0 2 1 9 7 5 - 2 0 0 5 2000 - 2007 2 0 0 4 - 2 0 1 1
phi au t h u a t cat g a n digu trj u
n 128 52 56 52 18 52
Ty le bien chiJng (%)
18 29 22 29 11,2
1,9
gan tre e m Ty le t u vong quanh m6 (%)
5 0 2 0 0 0
Theo kinh nghlem ciia chimg tol, ky thuat cat gan dien hlnh va khdng dien hinh deu-c6 t h i irng dung dilu tri u gan d tre em vdl kit qua tot Chf dmh cho clt gan khong diln hinh ia cac khli u nho, nam ngoai vi, vdi the tich gan du kiln phai c l t bo 1 - 3 ha phan thiiy Cat gan khdng dien hinh vdi khong che mach mau trong nhu md gan cung co t h i duac su dung an toan trong phlu thuat c l t gan trung tam (ha phan thuy 4, 5, 8) nhu d 2 benh nhan trong bao cao nay Clt phan thiiy ben trai (ha phan thiiy 2, 3) deu co the thuc hien duac an toan bang ca ky thuat c l t gan diln hlnh hoac khong diln hinh.
Nghien ciru nay cung cho thly cat nhu mo gan bang CUSA hoac panh Kelly, diing dao ludng euc cam mau dien c l t gan, kit hap vdi cap cuing gan ngat quang cho phep cat gan hieu qua, an toan va bien chirng thap Trong trudng hap khli u vi tri sat hgp luu cac tTnh mach gan ldn, cap hoan toan tTnh mach chu dudi d tren va dudi gan la ky thuat co t h i ap dung gliip cho phlu tich cat gan an toan
Mac dil cat gan v i n la nen tang trong dilu tri cac khoi u gan ac tinh d tre em, vai tro cua hoa tn iieu ngay cang duac khang dinh lam tang hieu qua dilu tn [3,5 - 7,9] Oilu tn hoa chit trudc m l cho cac khli u ac tinh co the lam giam kich thude khoi u, tang kha nang phlu thuat cat bo tnet de khdi u [3,5 - 7,9], Do do, g i n day chiing toi da ap dung phac d l
dilu tn u nguyen bao gan eiia SIOPEL [3, 6], phlu thuat lan d i u sinh thilt cho cac benh nhan nghi u nguyen bao gan ( k l ca cac khli u CO the clt duac ngay), dilu tn hoa chat trudc, sau do mdi m l cat gan. Theo doi benh nhan sau ra vien mot each he thing se la cin thilt dk danh gia k i t qua dilu tri lau dai tren eac benh nhan trong nghien ciru nay V. KET LUAN
U gan ac tinh chilm tdi han 80% cac trudng hap trong phlu thuat dilu tn u gan d tre em, trong do p h i biln nhlt ta u nguyen bao gan Vdi su hoan thien ky thuat mo va tiln bp cua gay me hOi sire, phlu thuat cat gan dilu tn u gan d tre em co the thuq hien an toan ma khdng cd tir vong vdi ty le biln chirng thip
TAI LIEU THAIVI KHAO 1. Aronson DC, Schnater JM, Staalman CR, et al (2005). Predictive value of the pre- treatment extent of disease system in hepato- blastoma results from the International Soci- ety of Pediatnc Oncology Liver Tumor Study Group SIOPEL - 1 study. J Clin Oncol 23 (6).
1245-1252
2. Chittmittrapap S, Imvlsed T, Vejchapipat P. (2008). Resection for primary liver tumors in children: an experience of 52 cases at one institution J Med Assoc Thai.
91 (8) 1206-1211.
TCNCYH PhiJ trwcyng 80 (3A) - 2012
3. Czauderna P, Otte JB, Aronson DC,et al. (2005). Guidelines for surgical treatment of hepatoblastoma In the modern era - rec- ommendations from the Childhood Liver Tu- mour Strategy Group of the International So- ciety of Paediatric Oncology (SIOPEL), Eur J Cancer 41 (7) 1031 - 1036
4. Finegold MJ, Egler RA, Goss JA, et al. (2008). Liver tumors: pediatric population Liver TranspL 14(11) 1545-1556.
5. Pham TH, Iqbal CW, Grams JM,et al (2007). Outcomes of pnmary liver cancer in children- an appraisal of experience. J Pediatr Surg 42 (5) 834 - 839.
6. Pritchard J, Brown J, Shafford E, el al (2000). Cisplatln, doxorubicin, and delayed sur- gery for childhood hepatoblastoma a success-
ful approach - results of the first prospective study of the International Society of Pediatnc Oncoiogy. J Cim Oneol 18 (22): 3819 - 3828.
7. Schnater JM, Aronson DC, PJaschkes J, et al. (2002). Surgical view of the treatment of patients vyith hepatoblastoma results from the first prospective trial of the International Society of Pediatnc Oncology Liver Tumor Study Group. Cancer 94(4). 1111-1120
8. Shukia PJ, Barreto SG, QureshI SS,et al (2008). Hepatoblastoma: a single institu- tional experience of 18 cases Pediatr Surg Int. 24(7)' 799-802
9. Towu E, Kiely E, Pierro A et al (2004).
Outcome and complications after resection of hepatoblastoma. J Pediatr Surg 39 (2) 199-202
Summary
SURGICAL TREATMENT FOR LIVER TUMOR IN CHILDREN
Childhood liver tumors are usually quite large at the time of diagnosis, making their surgical treatment challenging. From December 2004 to October 20i1, 75 children v\/ere operated for liver tumor at Surgical Department, National Hospital of Pediatrics, Hanoi, Vietnam. There were 41 boys and 34 girls (45.3%), v/ith mean age of 36 ±-44 months (range- 1 month - 16 years).
Mean size of the tumors was 8.1 ± 2.7cm (range. 3 5-15 cm). The most common pathologic types were hepatoblastoma - 52 patients (69 3%), mesenchymal hamartoma - 10 patients (13.3%) and hepatocellular carcinoma - 8 patients (10.7%). Liver biopsy v\/as done in 23 patients (30 7%) and llver'resection - in 52 (69.3%). Major liver resection (hemihepatectomy or extended hemihepatectomy) was performed In 25 patients (48.1%) Mean operative time for liver resec- tion v\/as 182 ± 83 minutes (range' 60 - 390 minutes) There was no mortality or complication but one patient with prolonged postoperative perihepatic fluid collection, resolved by medical treat- ment. Mean postoperative stay In surgical department was 5.7 ± 2.9 days Our results shows that hepatoblastoma Is the most common liver tumor indicated for surgery in children. Hepatic resections for treatment of pediatric liver tumor can be done with minimal complication and with- out mortality in experienced centers
Keywords: Liver tumor, children, surgery