Y HOC VI$T NAM THANG 5 - s 6 1/2013
PHAU THUAT LOAI TRljrMON Vj TRONG DIEU TRI CHAN THUffNG TA TRANG
Trinh Van T u a n *
T O M T A T
Nghien ciru thi/c hien vdi muc tieu danh gia ket qua ciia phau thuat loai trij' mon vi trong dieu tri chan thu'Ong ta trang. Td 1/2000 den 12/2008 tai benh vien Viet DLTC CO 20 benh nhan du'dc thy'c hien phau thuat nay, trong do nam 16 (80%%), nU 4 (20%); tuoi trung binh 30.3 ± 12,5 (dao dgng tiT 4 - 74 tuoi);
nguyen nhan do tai nan giao thong: 13 (65%), sinh hoat: 5 (25%), vet thu'dng: 2 (10%). Lam sang: soc 3 (15%), viem phue mac 4 (20%), co ciTng thanh bung 8 (40%), dau tren ron 6 (30%). Xet nghiem amylase mau tang 84,6%; chan doan hinh anh thay dUpc chan thu'Ong ta trang tren X quang 20%, sieu am 22.2%, chup cat Idp 80%. Phan Ioai ton thu'Ong ta trang theo AAST trong mo: do I: 1 (5%), dp I I : 11 (55%), do I I I : 6 (30%), do IV; 2 (10%), Thdi gian mo trung binh 4 ± 1.8 gid (tir 1,5 - 9.4 gid). Ket qua sau mo: tdt 70%;
bien chu'ng 25%; tir vong 5%; thdi gian nam vien trung binh 14.1 ± 7.2 ngay {tir 3 - 3 1 ngay), Theo doi xa sau mo gap viem mieng ndi 25%
Td khda: Piiau thuat loai trir mon vi, Chan thUOng ta trang
SUMMARY
PYLORIC EXCLUSION SURGERY OF THE DUODENAL TRAUMA TREATMENT
Study conducted with the aim of evaluating the results of the pyloric exclusion surgery for the treatment of duodenal injury. From 1/2000 to 12/2008 at Vtet Due hospital in Hanoi, there were 20 cases performed this surgery, in which were 16 men (80%), 4 female (20%); the average age was 30,3 ± 12.5 (ranges from 4 - 74 olds) caused by traffic accidents:
13 cases (65%), living accident: 5 (25%), wounds: 2 (10%) Clinical examination: there were a shock of 3 cases (15%), pentcnitts of 4 cases (20%), contracture of 8 cases (40%), epigastnc pain of 6 cases (30%).
Examination of amylase in blood increased 84.6%;
image diagnosis of duodenal injury on radiographs was 20%, ultrasound was 22,2% and CT scan was 80%, Duodenal injury classification according to the AAST in operation: grade I was 1 case (5%), grade I I : 11 (55%), grade I I I : 6 (30%), grade IV: 2 (10%).
Operating time average 1,8 ± 4 hours (from 1,5-9.4 hours). Results after surgery: good was 70%;
complications of 25%; mortality of 5%; the average hospitalization time 14,1 ± 7.2 days (from 3-31 days).
Remote control after surgery with a inflamation of gastrojejunostomy was 25%,
* Dai hoc YHa noi
Phan bien khoa hgc: PGS.TS. Nguyin Du'C Ti§n
I. O A T VAN OE
Phau thuat loai trir mon vi de dieu tri nhiJYig thu'dng ton nang d ta trang do chan thu'dng du'dc Jordan va cpng sy' [ 1 ] thdc hien dau tien vao nam 1977 tai benh vien da khoa Houston Hoa ky.
Bu'dc dau tien cua phau thuat la cat Ipc va khau thu'dng tdn d ta trang. Bu'dc tiep theo la thu'c hien mieng noi vj trang, qua du'dng md da day diing chi tieu cham khau tit niem mac mdn vj de thirc an va dich tir da day khong di qua ta trang.
Cho khau nay se lu'u thong t r d lai vao khoang thang dau sau mo. Cai dich cua phau thuat thu di/dc la loai bd tam thdi ta trang ra khdi \[iu thdng ciia dng tieu hda, tranh tac dung eiia men tuy hoat dong cd the lam buc cho khau, giiip vet thu'Ong mau lien seo. Ket qua dieu tri ciia phau thuat nay giong nhu' phau thuat tui thda hoa ta trang nhu'ng khong can cat hang vj va cat than kinh X. Nam 1983 tac gia da cong bd ket qua dieu tri theo phu'dng phap nay eho 128/313 benh nhan chan thu'Ong ta trang nang tfxjng thdi gian 12 nam vdi ty le bien chimg sau md %, tir vong 22%, theo ddi xa sau mo cd 3% loet mieng noi v\ trang.
6 Viet nam, dieu trj chan thu'dng ta trang cung du'dc mpt sd tae gia [2] de cap vdi nhieu phau thuat khac nhau nhu' khau kin ta trang thi dau ket hpp dan lull, phu'dng phap 3 ong thdng, phau thuat tui thii^ ta trang, eat khoi ta tuy... nhuTig chua cd nghien ciru nao danh gia phau thuat loai trir mon vi trong dieu trj ehan thu'dng ta trang mpt each he thdng. Xuat phat tir djnh hu'dng tren, chung to\
tien hanh de tai tir thang 1/2000 den thang 12/2008 tai benh vien Viet Dire, nham muc tieu: "Danh gia kit qua cua phau thuat loai trd mon vi tmng dieu tri thu'dng ton nang d ta trang do chan tfiudng tai benh vien Viet Ddc".
IL o d l TUONG VA PHUONG PHAP NGHIEN CDU 2 . 1 . Doi tu'dng nghien cu'u: Benh nhan chan doan ehan thu'dng ta trang du'dc dieu tri bang phau thuat loai trir mdn vi tai benh vien Viet Dire tir thang 1/2000 den thang 12/2008.
2.1.1. Tieu chuan Ida chgn - Benh nhan d moi lira tud'i, khong phan biet gidi tfnh.
YHOC VI6T NAM THANG 5 • SO 1/2013
^ - Du'dc dieu tri chan thu'dng ta trang bang phau thuat loai trir mon vj.
2.1.2. Tliu chuan ioai trd
Khdng dat eac tieu chuan neu tren.
Oieu trj thu'dng ton ta trang bang cac phu'dng phap khac khong diing phau thuat toai trir mon vj.
2 . 2 . Phu'crng p h a p nghien cu'u Thiet ke nghien cdu: hoi ciru mo ta.
Chi tieu nghiin cdu: bao gom tud'i, gidi, nguyen nhan chan thu'dng, thdi gian tdi vien, tinh trang liic nhap vien, cac tham dd tru'dc mo, chi djnh dieu tri, phan dp thu'dng ton ta trang trong md theo AAST [ 3 ] , cae can thiep trong md, ket qua dieu t n gan va xa sau phau thuat.
Danh gia kit qua: chia lam 3 mire dp:
-> Tdt: khdi ra vien, khong ed bien chirng, -> Trung binh: cd bien chu'ng sau md"
nhutig nhu'ng du'dc dieu tri khdi.
-* Xau: tir vong sau mo.
So lieu thu thap du'dc xd ly tren eac phan mem thdng ke Y h p c .
2.3. Oao dii'c nghien cii'u: Nghien cuP thy'c hien tru'c tiep tren benh nhan nen cac thong tin rieng
ve benh tat trong ho sd benh an du'dc gan ma sd rieng de dam bao tinh ehinh xac, du'dc bao mat va chi du'dc sir dung cho muc dich nghien ciru.
III. KET QUA
Tir thang 1/2000 den 12/2008 tai benh vien Viet Dire, chung tdi da thu'c hien phau thuat loai trir mon vi eho 20 benh nhan bi ehan thu'dng ta trang, trong dd nam 16 ( 8 0 % % ) , nu' 4 (20%);
tuoi trung binh 30.3 ± 12.5 (dao dong tir 4 - 74 tuoi); nguyen nhan do tai nan giao thong: 13 (65%), sinh hoat: 5 (25%), vet thu'dng: 2 (10%). Kham lam sang: cd sdc 3 tru'dng hdp (15%), viem phue mac: 4 (20%), co cirng thanh byng: 8 (40%), dau tren rdn: 6 (30%). Xet nghiem amylase mau luc nhap vien tang 84.6%;
chan doan hinh anh: thay dddc chan thu'dng ta trang tren X quang bung khong chuan b; 20%, sieu am 22.2%, chyp cat Idp 80%, Thdi gian tir khi tai nan tdi khi den benh vien trung binh 30,8
± 40 gid (dao dong tir 2,7 - 153 gid). Vi tri thu'dng tdn va phan do AAST trong mo xem trong bang 1,
Bang 1. Vi trf va phan dp AAST trong mo chan thu'dng ta trang Vj t r i giai phau
D, D, D.
Conq
0 6 AAST I
1
1 (5%) I I
9 2 U (55%)
I I I 3 2 1 6 (30%)
IV 2 2 (10%)
Cpng 13 (65%)
6 (30%) 1 (5%) 20 (100%) Ton thu'dng phoi hop 4 0 % la vdi cac tang rong, vdi cac tang dac chi co 15% so tru'dng hPp (bang 2).
Tanq ton thu'dng Gan
Than Tuy Da day Ruot non Dai tranq
So benh nhan 1 (5%) 1 (5%) 1 (5%) 1 (5%) 2 (10%) 5 (25%)
Tlidi gian mo trung binh la 4 ± 1.8 gid (tir 1.5 - 9.4 gid). Mau truyen trong mo trung binh la 312.5 ± 532.1 ml (nhieu nhat la 1750 ml). Bien chirng sau md 2 5 % (bang 3).
Bang
a 3. Bien chu'nq sau mo Bien chu'ng Ro ta trangAp xe trong 6 bunq Buc thanh bung Nhiem triinq vet mo Conq
So benh nhan 2 (40%) 1 (20%) 1 (20%) 1 (20%) 5 (100%)
Y HOC VI$T NAM THANG 5 -s6l/2Q13
Tir vong sau mo 1 tru'dng hdp (5%) do viem phoi va suy than. Thdi gian nam vien trung binh la ngay 14.1 ± 7.2 ngay (tir 3 - 3 1 ngay). Theo doi xa sau mo ty le loet mieng noi 2 5 % .
IV. BAN LUAN
Dieu tri chan thu'dng ta trang cho den nay van con dang du'dc tranh
luan vi chu'a cd mot phu'dng phap nao cd the chi djnh du'dc cho tat ca cac thu'dng ton ciia ta trang. Ty le benh nhan chan thu'dng ta trang du'dc dieu tn bang khau ddn thuan, khau kin thi dau ket hdp dan lulj ta trang, tin thifa ta trang, loai trir mdn v| du'dc chi dinh rat khae nhau tiiy theo timg tae gia [2,4].
Nguyen nhan ehan thu'dng: chiing tdi gap chii yeu la chan thu'dng bung kin do tai nan giao thdng (65%), vet thu'dng g^p rat ft (10%).
Nghien cij'u ciia Martin [4] (1983), chan thu'dng ta trang do vet thu'dng bung chiem tdi 77%, do chan thu'dng bung kin chi gap 2 3 % ; ciia Degiannis (1993) [5] chu yeu la vet thu'dng trong dd do hda khf ehiem tdi 75-80% eac tru'dng hdp.
Cae tae gia eho rang thu'dng ton do vet thu'dng bung thu'dng nang hdn vi mat mau va lien quan den nhieu tang nen ty le tir vong rat cao.
Kham lam sang: chan doan chan thu'dng ta trang tru'dc mo tu'dng doi khd vi eae dau hieu eo cii'ng thanh byng, cam irng phiic mac thu'dng la bieu hien ciia hpi chirng v5 tang rong khi thu'dng ton nam mat tru'dc ta trang, Ngu'dc lai, khi thu'dng ton nam d mat sau thi dau hieu lam sang rat kfn dao, khd phat hien sdm. Do do, de chan doan du'dc v5 ta trang can du'a vao eac tham dd ho trd khac nhu' xet nghiem amylase mau va chan doan hinh anh.
Xet nghiem amylase mau trong chan thu'dng ta trang cd ty le tang kha cao 84.6% va thu'dng tang sdm sau tai nan. Vdi eac tham dd hinh anh, ty le chan doan du'pc v3 ta trang qua chup byng khdng ehuan bj va sieu am thu'dng thap (20%, 22.2%), chii yeu du'a vao dau hieu ed hdi quanh than phai. De xae djnh, ed the cho ngu'di benh udng thuoc can quang rdi chup ed the thay thude trao ra khoang sau phiic mac. Chyp cat Idp la each tot nhat de xac dinh chan doan vi kha nang ehan doan dung ciia chyp eat Idp eao hdn hai phu'dng phap tren, dat tdi 9 0 % . Nhieu tae gia [2,4,5] cijng ed ket luan tu'dng t y nghien ciTu ciia Chung tdi.
^ Ve vj trf thu'dng ton giai phau d ta trang, da sd cae nghien eiru ciia eac tae gia nu'dc ngoai [1,4,5] thay vj trf thu'dng gap la d D2. Nghien cu'u
cua chimg toi thu'dng ton d 02 chiem tdi 65% so tru'dng hdp (bang 1).
Ve xd trf ton thu'dng, theo Degiannis [6], vao khoang 70 - 8 0 % thu'dng ton ta trang co the dieu tri bang khau kin thi dau. Tuy nhien doi vdi thu'dng ton nang, raeh rpng > 7 0 % chu vi ta trang nhat la d D2 thi phu'dng phap tren chu^ the dam bao an toan tuyet doi. Hai lu'a chpn khac co the dap irng du'dc trong tru'dng hdp nay la phau thuat till thira ta trang va phau thuat loai trir mon vj. Phau thuat loai trir mon vj thu'dng du'dc lu'a chpn hdn tiii thira ta trang vi ddn gian, hieu qua va ft tdn thdi gian thu'c hien.
Khi thi/c hien phau thuat loai trir mon vi, Martin (1983) [ 4 ] , Charles Frey (1993) [5]
khuyen eao nen lam thii thuat Kocher bang each ha gdc dai trang phai, bdc hSn khoi ta tuy ra khoi thanh bung sau de danh gia ton thu'dng. OS vdi vet thu'dng ta trang, tdn thu'dng thu'dng gon, khong dap nat nhieu to chiTc nen chi can xen gon mep va khau kin vet thu'dng theo chieu ngang de tranh lam hep long ta trang. Ngu'dc lai, doi vdi thu'dng ton do cham thu'dng thi viec xir iy ddi hdi phai co sd danh gia ky luSng vi to chiTc thu'dng bj dap nat rpng, nuoi du8ng kem, de rd hoac buc vet khau ta trang sau mo. Tuy vay viec khau kin thu'dng tdn d thanh ta trang khong phai khi nao cung lam dutfc, nhat la khi vS: thuUng qua rpng ( > 7 5 % chu vi), dap nat, mat nhieu ta ChiTc. Tlneo Vaughan (1977) [1], Degiannis (1993) [6], trong tru'dng hdp thu'dng ton ta trang rpng, Id bdng Vater thi co the dung mot quai rupt 'dda len de va vao vet thu'dng (patch). Chiing toi gap 3 benh nhan bj thu'dng tdn nang d D3 va D^ phai eat bd va du'a 1 quai hong trang len noi vdi D2 kieu Roux en Y.
Nghien ciTu cdn co 1 benh nhan tu mau ldn du'di niem mac ta trang tu'dng du'dng dp I AAST (bang 1), gay hpi chu'ng nhu* hep mon vj cung du'dc thy'c hien phau thuat loai trir mon vj. Theo Charles Frey [ 5 ] , trong tru'dng hdp n a y c h i can noi vj trang de tranh khoi mau tu va dan \du d dpng d da day la dii vl khoi mau tu da bjt kin du'dng xudng ta trang giong nhu" khau tit mon 1^,
Van de m d thong hong trang trong phau thuat loai tru' mon vj, Nghien ciiXi eiia chiing toi cd den 13 tru'dng hdp (65%) co thu'c hien md thdng hong trang nhutig chi cd 2 tru'dng hdp co thu'dng ton phoi hdp vdi 3-4 tang trong 6 bung, khong kem chan thu'dng sp nao. Theo Jordan va
Y HQC VigT NAM THANG 5 - $6 1/2013 cpng SLTJ1977) [1] do phau thuat loai triT mdn vi
khong cat doan da day va than kinh X vi vay nhu dpng rupt phue hoi sau mo thu'dng sdm nen khong can thiet md thong hong trang. Tuy nhien trong tru'dng hdp cd ton thu'dng phoi hdp phai nam dai ngay sau mo nhu' chan thu'dng sp nao, da chan thu'dng thi van can thiet md thong hong trang de cho an.
Bien chuing, tiT vong va bien chimg xa sau mo theo phu'dng phap loai trir mon vi, nghien ciru cua Vaughan (1977) [1] rd ta trang 5%, tiT vong 19%, loet mieng noi 3%; Martin (1983) [4], ro ta trang 5.5% trong dd chet do ro 2 tru'dng hdp (1.6%), loet mieng noi 3%. Nghien ciru ciia chiing tdi, bien chiTng 5 tru'dng hdp (25%), thu'dng xuat hien tir ngay thir 6 den ngay thir 10 (bang 3), trong dd thdi gian du'dc mo sau tai nan cGng cd lien quan den mii'c dp nang nhe ciia bien chiTng. Nhutig tru'dng hdp bien chirng phai mo laj deu la nhiitig benh nhan du'dc mo muon sau 24 gid, nhieu nhat la ro ta trang 2 (10%), ap xe khoang sau phiic mac 1 ( 5 % ) va bye thanh byng 1 ( 5 % ) . Tir vong sau md' 1 tru'dng hdp (5%) vao ngay thir do 10 do suy than va tran dich mang phoi. Theo doi xa sau md chi thay viem mieng noi 25%, khdng thay loet mieng noi trong nghien ciTu. Ket qua sau mo tot 7 0 % ; bien chirng 25%;
tir vong 5%; thdi gian nam vien trung binh 14.1
± 7.2 ngay (tiT 3 - 3 1 ngay).
V. KET LUAN
Phau thuat loai triT mon vj la phu'dng phap dieu trj ehan thu'dng ta trang cd kha nhieu u'u diem so vdi nhu'ng phu'dng phap phau thuat khae
nhu' ty le khdi benh cao, bien ehutig va tiT vong thap, de lam, tdn it thdi gian thy'c hien. Vi the phu'dng phap nay thu'dng du'dc lu'a chpn, nhat la trong cap ciTu chan thu'dng khi ma tinh trang ngu'di benh khong cho phep ap dung nhii'ng phau thuat Idn.
Ldi cam dn: nhdm nghien ciTu xin chan thanh cam dn Khoa phau thuat cap eiru bung, phdng ho sd benh vien Viet Dire da giiip dd trong qua trinh nghien ciTu va thy'c hien de tai.
TAI LIEU THAM KHAO
1. Vaughan GD, Frazier OH, Graham DY, Kenneth LM, Petmecky FF, Jordan GL (1977). The use of pyloric exclusion in the management of severe duodenal Injuries. Am J.
Surg, Vol 134 (6), Dec, 785-790.
2. Trinh Van Tuan (2008). Nghien ciru danh gia ton thUOng giai phau, cac chi dinh va ky thuat xir trf chan thu'Ong ta tuy. Luan an tien sy Y hgc, Tru'dng Dai hoc Y Ha noi.
3. Moore EE, Cogbill TH, Malangoni MA et al (1990). Organ Injury scaling, II: Pancreas, Duodenum, Small Bowel, Colon and Rectum. 3 Trauma, Vol 30, (11): 1427-1429
-I. Martin TD, Feliciano DV, Kenneth LM, Jordan GL (1983). Severe duodenal injuries: treatment with pyloric exclusion and gastrojejunostomy.
Arch Surg; 118(5): 631-635.
5. Charles Frey S., Tatsuo Araida (1993).
Trauma to the Pancreas and Duodenum.
Abdominal trauma, 2^ edition, Vol. 2, 118-159.
u. Degiannis E, Krawczykowski D, Velmahos GC, Levy RD, Souter I , Saadia R (1993).
Pyloric exclusion in severe penetrating injuries of the duodenum. W/orld J. Surg, 17, 751-754.
THUC TRANG DIEU KIEN DAM BAO AN TOAN THin; PHAM CAC CO SO SAN XUAT BUN TAI XA VO HOI HUYEN VU THITTINH THAI BINH NAM 2010
Ninh Thj N h u n g * , To Khanh NhiTa**
TOM TAT
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* Tru'dng dai hoc Y Thai Binh, ** Chi cue A TTP tinh Thai Phan biSn khoa hoc: PGS.TS. Hoang Nang Trong
nhiem (< 50 met). Co 63,0% nen nha che bien ban, CO nude dgng, 95,5% ccf s6 co nen nha che bien co ruoi nhang. Khong thUc hien cac bien phap ve sinh (khong co ndi riTa tay 44% va chi co 32.6% khong co xa phong). He thdng cong thoat nirc thai khong co nap day, 41,3%, cdng nu'dc ir dpng khong thong thoat 36.9%, Thiet bl, dyng cy san xuat che bien biin co nguy cd 6 nhiem chat hoa hoc doc hai tiT viec sir dyng Binh
