HOI NGHI KHOA HOC KY THUAT Md RONG LAN THOXII • BENH VIEN HOU NGHI VIET NAM - CU BA OONG HOl
PHAU THUAT NOI SOI UNG THJ DAI TRANG TRAI TAI BENH VIEN
• • • • • •
TRUNG UONG HUE VA BENH VIEN TRJONG OAI HOC Y DLfOC HUE
Le Manh Hii*, Nguyen Van Lieu*, Pham Minh Oiic*, Nguyen Doan \ an Phii*
TOM TAT
Muc dich: Danh gia dac diem lam sang, can lam sang va ket qua dieu tri bang phau thuat no! soi ung thu dai trang (DT) trai tai Benh vien Trung L/Png Hue va Benh vien TrUdng Oai hpc Y DUdc Hue. Odi tu'dng va phu'dng phap: Gom 57 benh nhan (BN) ung thd dai trang trai dddc phau thuat cat dai trang trai, dai trang sigma va nao vet hach npi soi tai Benh vien Trung L/dng Hue va Benh vien TrUdng Dai hpc Y Dddc Hue, tir thang 9/2007 den thang 9/2010. Ket qua:
Tudi trung binh 56,8 ± 17,4 tuoi t i / 40 60 chiem 56,1%. Nam gidi chiem 59,6%, nii' gidi 40,4%, ty le nam/nLi 1,48/1. Dau bung la trieu chirng thu'dng gap nhat 94,7%, rdi loan tieu hoa 50,9%, phan co mau 56,1%, sd thay u d bung trai 14,1%. Npi soi cho hinh anh siii loet chiem ty le cao nhat 40,3% trong do khoi u d dai trang sigma 65,6%. Cat doan dai trang sigma 56,2%, cat nira dai trang trai 19,3%, kich thUdc khoi u >
5cm la 60,4%. Giai doan (GD) ung thd: GO III 59,7% trong do ung thd bieu mo tuyen 98,3%.
Tang CEA tru'dc mo la 63,2%, sau mo 3 thang la 21,9% va sau mo 6 thang la 27,8%. Nhiem trung vet md 5,3%, do mieng ndi 1,7%, khong co tru'dng hdp nao phai mo lai va khong co tir vong sau mo. Ket luan: Phau thuat noi soi ung thd dai trang trai cho thay tinh an toan, de thUc hien.
It bien chu'ng va khang djnh dUdc tinh Uu viet ciia no.
SUMMARY
LAPAROSCOPIC LEFT HEMICOLECTOMY FOR LEFT COLON CANCER AT HUE CENTRAL
HOSPITAL AND HOSPITAL OF THE HUE MEDICAL AND PHARMACEUTICAL COLLEGE.
Perpose: Evaluation of clinic, subclinic characteristics and results from laparoscopic left hemicolectomy for left colon cancer at Hue Central Hospital and Hospital of the Hue medical and Pharmaceutical College. Metholds: Consist of 45 patients with left colon cancer who were operated to laparoscopic left hemicolectomy, sigmoidectomy and lymphadectomy at Hue Centre Hospital and Hospital of the Hue medical and Pharmaceutical College from September 2007 to September 2010. Results: Age: average 56,8 ± 17,4, the most age range from 40 - 60, to take 56,1%. Sex: male 59,6%, female 40,4%, rate male/female 1,48 1. The most symptom was abdominal pain 94,7%, alimentary disorder 50,9%, blood stool 56,1%, touch up the tumors 14,1%. Colonoscopy: malignant ulcer tumore were highest rate 40,3%, tumor positions at sigmoid colon 65,6%. Laparoscopic sigmoidectomy 56,2%, left hemicolectomy 19,3%, size of the tumor > 5cm was 60,4%.
Third stage of TNM 59,7^\i and adenocardnoma was 98,3%. Elevation of CEA serum level upper 5ng/ml: Preoperative was 63,2%, postoperative of three months was 21,9%, postoperative of six months was 27,8%. Wound infection was 5,3%, anastomotic leakage 1,7%, and without reoperative case and without surgical mortality.
Conclusions: Laparoscopic left hemicolectomy for left colon cancer is safe, feasible, few complications and its advantages.
' Benh vien Tnmng dgi hoc v duac Hue
Y HOC VIET NAM THANG 9 - SO DAC BIET / 2011
I. OAT VAN OE
Ung thu dai trang (UTDT) lii benh ly benh ac tinh thudng gap a cac nucVc phat trien, la benh UT gay lir \ong ihir bai sau UT phoi. Tai Phap, ly le mac benh khoang 33500 Irucmg hop/nam, lir \ong do UTDT khoang
16000 trudng hgp/nam. O nude la UTDT dimg thu nam sau VT da din', phoi. vii. \imi hong \a dung thir hai trong L'T duirng lieu hoa sau da day [6].
Dieu trj UTD1" chii yeu bimg phiiu thual (PT), dac biet la PT triet can, cac phuang phap khac nhu hoa tri. xa tri chi lii ho Ira, li le song 5 nam sau mo trung binh la >iy\) linh chung cho cac loai, do db \ ice chan doiin sdm va dieu tri triet dc UTDT gdp phiin liim tang ty le song sau md.
Phau thuat ndi soi ciil DT dugc .lacobs va cong su thuc hien dau lien nam 1991.
Benh vien Trung uang Hue lir 01'2000 \a Benh \ien Truong Dai hoc ^' Dugc Hue tir thang 3/2003 da thuc hien PT noi soi cat dai true trang \ di thdi gian dieu tri sau mo trung binh la 5.6 nga\. theo ddi sau mo cho thay kel qua tuang duong vdi mo md. Cho den nay ky thual na\' da thuc hien ihudng xuyen hon vdi nhung ket qua kha quan.
Xuht phat tir thuc te di^u tri UTDT trai bing phau thuat ndi soi tai hai Benh vien noi tren, chung toi nghien cim de lai: "Danh gia kk qua phau thuat ndi soi ung thu dai trang trai" nham hai muc tieu:
1. Danh gia dac diem lam sang, can lam sang cua benh ung thu dai trang trai.
2. Danh gia ket qua di^u tri ung thu dai trang trai bang phau thuat ndi soi.
II. OOI TUONG VA PHUONG PHAP NGHIEN COU 2.L Doi tu-oTig nghien ciiu
G6m 57 BN dugc chan doan UTDT trai dira vao lam sang, sieu am, noi soi, CT
Scanner bung \'ii dugc PT ciil DT trai, DT sigma \ il nao \ cl hach noi soi lai Benh vien Trung Uang Hue \a Benh vien Trudng Dai hoc \ Dugc Hue lir thang 9/2007 den thang 9'2010.
Ticu chuiin loai trir: PT lam ihi^i, mo mo' hoiic khong co kcl quii giai phiiu benh
2.2. Phuong phap nghien ciiu
Nghien ciru mo la lien ciru co can thiep, theo doi doc \ ii khiing so sanh.
2.3. Dac diem chung
Tuoi, gidi, nghc nghiep \ ii dia du.
2.4. Dac diem liim siing
Thai gian lir khi co trieu chimg den khi
\ iio \ icn: < 6, 6 12 \ ii > 12 thang.
Trieu chiing loan thiin: Gay sut, sol, phii, thieu mau lam sang.
- Trieu chimg ca nang: Dau bung, phan CO mau, ban lac ruot.
Trieu chirng thuc the: Hach ben, hach thugng don, sd lha\' u a bung, gan Idn, bang, tham true trang co mau, viem phiic mac.
2.5. Dac diem can lam sang
Cong thirc mau: So lugng hong cau, hemoglobin, nhom mau.
Chat chi dilm ung thu CEA trong mau.
Xquang phoi: Danh gia mirc do di can ung thu
Sieu am bung: Day thanh DT trai, di can hach. dich 6 phuc mac. di can gan.
Noi soi dai trimg: Xac dinh vi tri, hinh the khoi u kem sinh thill lam giai phau benh trudc md.
- CT scan bung: Danh gia vi tri. kich thudc khoi u, muc do xam lan ciia khoi u vao cac ca quan khac, tinh trang mac noi Idn, 6 phiic mac.
Dac dilm giai phau benh trudc mo.
HOl NGHI KHOA HOC K? T H U A T Md R O N G LAN THCf XII • B^NH VltN HOU NGHI V I E T NAM - CU BA 0 6 N G HOI
.'.' /*^ 1 •' ' ->
^-^
• V
, i i
: . ) ; . ; ; • > !
•^..'
N-.-.^ \
,^ \ / I ^ ... / I 1/
i:,i - - ' • - , S J ^ If
V * 4 - ' '
v . . / - ,
1
r
H I . Phuong phap phau thuat
I ' 1^.
2.6. Ket qua trong mo
Vi Iri khoi u: Phiin Iriii DT ngang. I)T goc lach, D T xudng, DT sigma.
- Kich thudc u: '5, 5-10. > 1 Ocm.
Mirc do xam liin khdi u: IT, r2. T3. T4
Phuang phap mo: Ciil nira DT trai, cfU doan DT trai cao. cdt doan DT sigma.
Ky thuat lai liip luu thdng lieu boa: Noi biing lay hoac bang Stapler vdng.
Thcri gian mo: Tu Iiic dai trocart den khi kit thiic cupc mo. tinh bSng phiit Tai bien trong md: Cha\ mau, ton thuang tang, Iran khi dudi da. lu vong.
Ly do chuyen mo md: U xam lan, chay mau, ruot qua chudng. PT md rdng
Mirc nao vet hach: Ky thual nao vet hach D2, D3 theo Kobavashi M. \ a Okamoto K. [13].
H2. Phan chia ciic nhom hach theo Nhat Ban
Y HOC VIET NAM THANG 9 - SO DAC BIET / 2011
2.7. Ket qua sau m6
Thdi gian co lai trung lien: < 1 ngay. 2- 3 ngay va > 3 ngay
Biln chimg sau md: Chay mau, Iran khi dudi da, nhiem triing vit md, nhiem triing 16 trocart, buc xi mieng ndi, ap xc icm du, uic mach do khi, tir vong.
Thdi gian nam \icn: Tinh lir ngii> mi) den ngay ra vien (nga>).
Dac diem giai phau benh sau m6.
2.8. Phan chia giai doan theo T, N, M 2.9. Ket qua tsii kham sau mo: Tai kham sau 3 thiing va 6 thang.
Liim simg: Toim than, an uong, lang ciin. kha nimg sinh boat, lao dong.
Xcl nghiem mau gom: Cong Ihiic mau, Cl 'A.
Xquang pht)i, sicu am bung, noi soi DT
\ il CT scanner bung.
KET QUA
Ket qua nghien cim dugc tdm tat theo 3 bang sau:
Bang 1. Dac diem chung
Sd lu'dng benh nhan Tuoi
40 - 60 tuoi Tuoi trung binh Gidl Nam/nO' Trieu chu'ng lam sang Oau bung
Silt can Phan CO mau Roi loan tieu hoa Ban tac ruot Sd thay u d bung CEA tru'dc mo (ng/ml)
<5
>5
Noi soi dai trang Sill
Loet Sill + loet Tham nhiem _Pplyp unq thd boa
n = 57
32 56,8 ± 17,4
34/23
54 34 32 29 17 8
21 36
15 8 23
6 5
1 0 0 %
56,1
1,48/1
94,7 59,6 56,1 50,9 29,8 14,1
36,8 63,2
26,4 14,1 40,3 10,5 8,7
HOl NGHI KHOA HOC KY THUAl Md RONG LAN THCTXII • B^NH VIEN HOU NGHI VIET NAM - CU BA DONG HOI
Biing 2. Kcl qua pliiiu thiiiil Vi tri khdi u
Phan trai DT ngang OT goc lach
DT xuong DT sigma
Kich thu'dc khoi u (cm)
< 5 5 - 1 0
N 2 8 10 38
23 32
> 10 3 1 Od xam lan khdi u
1 — "
1 T l T2 j T3
! T4
Phu'dng phap mo Cat doan OT trai cao Cat doan OT sigma CSt nira OT trai Ly do chuyen mo md Loi thiet bi, dung cu U xam lan, dinh Chay mau
Rupt qua chUdng PT md rong
MiTc nao vet hach 02 03
Phan chia giai doan GOI
GO II GO III GO IV
4 12 33 9
14 32 11
0 5 0 2 2 26 31
o/o 3,4 13,7 17,3 65,6
39,6 55,2 5,2
6,9 20,7 56,9 15,5
24,5 56,2 19.3
0 8,7
0 3,5 3,5 45,6 54,4
4 17 34 2
7,0 29,8
59,7 :
* - ' .;Ji
3,5 :
Bang 3. Kii qua sau mo \ ii lai kham
Bien chu'ng sau md Chay mau
Nhiem triing vet mo BUG xi mieng noi Bi tieu
N 0 3 1 4
o/o
0 _ 5,3 _ 1,7 _ _ 7,0 ___
Y HOC VIET NAM THANG 9 - SO OAC BIET / 2011
Giai phau benh sau mo Ung thu' bieu mo tuyen Unq thu' mo lien ket Nong do CEA (ng/ml)
<5
>5
N 56 1 Sau mo 3 thang n = 41
32 9
% 78,1 21,9
% 98,3
1,7 Sau mo 6 thang n = 36
26 10
% 72,2 27,8
IV. BAN LUAN
Ve tuoi Nil gidi: Tong so BN trong nghien ciru la 57, tudi trung binh la 56.8 ±
17,4 thap nhat la 29 tuoi, cao nhiil la 83 luoi, nhom tu6i tir 40 - 60 chiem 5(i,r'o. Kcl qua nay phii hgp xai nghien ciru ciia Pham Nhu Hiep [4] tuoi trung binh 54.5, Nguyen Van Xuyen [6] do tu6i tir 41-60 chimin 54.r"o.
Theo Ngu>en Hoang Bac [1] tuoi trung binb la 64,8 tuoi. Tuoi trung binh ciia mot so lac gia nude ngoai cao han chiing toi, Cheng J M [9] tu6i trung binh la 67.4 ±13.5 (27 93).
Antonios A K T [7] tudi trung binh la 68,8 ± 10,3, tu6i Idn nhat trong nghien cuu ciia Cheng J M la 93 cao hon nghien curu ciia chiing toi, dieu nay cd the lien quan den phuang tien va ky thuat gay me hien dai va ky nang cua cac PT \ien cho phep thuc hien PT tren nhimg BN Idn tudi.
wk gidi tinh, cd 34 nam va 23 nir, ty le nam/nir la 1.48/1. kit qua nay cao hon nghien cim cua Wai L L [17] la 1,02/1. Ty le nam nhilu ban nir ciing gap d nhieu tac gia, Nguyen Hoang BSc [1] ty le nam/nir la 1,8/1.
Tuy nhien ty le nam/nir giua cac lac gia khong gi6ng nhau, mot sd tac gia cd ly le nam bang hoac thip hon nu nhu Cheng J M [9] nam/nir la 0,96/1, Antonios A K T [7]
nam/nu la 0,51/1.
Trieu chimg lam sang: Cac trieu chung lam sang la nhimg ggi y dhu tien giup cho ngudi thay thudc chu y khi tham kham de dua ra chhn doan va quylt dinh can lam sang
cung nhu hudng xir tri. Miiu bet cac BN khi nhap \icn dcu co ciic bieu hien Uim siing trong do dau bung Iii thudng gap nhal 94,7%, g;\y sill 59.6'"o, phan co mau 56,1%, roi loan lieu hoa 50.9",,. Dau bung la mot trong nhung Iricu chiing scVm nhat ciia benh UTDT, hoan canh xuiil hien can dau khong theo mot qu\ luat nao: co the dau bat ky luc nao trong ngiiN, khong lien quan den bira an, vi tri dau thudng d cho UT, theo Pham Himg Cuong [2] IN' le nay la 77,8%.
R6i loan lieu hoa la trieu chirng ciing Ihudng gap liiy tiing vi tri ciia UT va theo nhilu tac gia, lao bon la trieu chimg thucmg gap d UTDT trai. Dai lien phan mau trong nghien ciru cua chung toi la 56,1%, thap hon nghien cuu cua Nguyen Hoang Bac [1] la 63,2%, cin chu y mau lan trong phan d UTDT phai thudng la dd sam, d DT trai it mau sam hon va true trang la mau do tuai nhit [6].
Sd thiy u d bung trai 14.1% tuong duong vdi nghien ciru ciia Nguyen Hoang Bic [1] la 15,8% (3/19). Theo nhilu tac gia khdi u d DT phai de sd thiy u han. U d 2 goc phai va trai DT thudng khd sd thay vi hai bd sucm che lip va khi sd thay u ciia DT thi thudng la BN da den muon.
Noi soi dai trang: Ndi soi DT la "Tieu chuin vang" trong chin doan va tam soat cac benh ly ac tinh ciia dai true trang [10]. Noi soi khong nhiing cho phep quan sat d^c diem dai thi t6n thuang dk hudng din chan doan
H O I N G H I KHOA HOC KY T H U A T Md R O N G LAN T H O X I I • B^NH V I E N H O U NGHI V I E T NAM - CU BA D 6 N G HOI
ma ci)n sinh Ihicl dc chiin doiin giai phiiu benh. Mirc di) sach cu;i DT (.|ii\cl dinh sir thimh cong cua noi soi. Co nhicii phucrng phiip chuiin hi DT chimg ldi iip dung phucmg phap lam sach DT biing PoKclylcnc glycol (Pl'Xi) CO bicl duoc lii lorlrnns. Dimg bang duirng uiMig chiing si- liim liing Ihc lich dich ruot, ihc tich dich ruot khi)ng dugc hiiji llni sc ga> lac dung nhuiin truirng |2J.
Till ca 57 HN nghien ciru dcu duac noi soi DT. Kcl quii 91,3"o phai bicMi duov kli(")i u
\di hinh anh dai the siii loii chiC'iii ly lc cao nhit 40.3"... the siii 26.4".;. ihi- loci 14,1%.
the tham nhicni l().5"o. Noi soi ngoiii vice cho lhii\ hinh anh ci)n cho lha\ mirc d() xam
lin ciia khcM u theo chu vi dai trang, tuy nhien khdng ihuc hien dugc d BN co bien chimg (liic ruol, viem phuc mac...). Theo Nguyen Viin Xuycn [6] phan Idn UTDT Irai lii Ihc thiim nhiem 70,4%), the nay it xam lin vi\o \b chirc xung quanh nhung gay hep lam bit tiic Idng 1)1 iriii dan den lac rudt.
Vi tri, kich ihudc khoi u: Vi tri khoi u la yen td giiip cho PI vien chon lira phuong phiip P r Irong 57 BN nghien cuu cd 65,6%
u a DT sigma, 17,3%) d DT xudng va 13,7%
a DT goc liich. Nghien ciai ciia Anlonios-A K I [7] u D1 sigma la 83,9%) cao hon nghien ciru ciia chimg liu. Bang l\ le % \ i tri khoi u dai trang trai ihco mdl so tac gia
\
Tac gia A. A.K. Tentes [40]
H.Y.S. Cheung [11]
Renato Costi [14]
S.H. Mucci [15]
T.S. Chung [16]
Chiing toi
DT gdc lach 4,8
0 6,7 2,2 5,9 13,7
DT xudng 11,3 12,6 16,2 10,2 17,6 17,3
—-.
DT Sigma 83,9 86,4 77,1 87,6 76,5 65,6
Kich thudc khoi u >5cm chilm 60,4%o, c6 mot BN cd 2 vi tri u d phan trai DT ngang va DT xudng, BN dugc chuyen mo md cat ban phan DT trai do khdi u d DT ngang dinh nhieu. Ty le khoi u >5cm ciia chimg tbi 60,4% cao ban nghien cim ciia Cheng-.! M [9] la 51,5%, theo Nguyen Van Xuyen [6]
kich thudc u trung binh la 4.6 ± 3,1cm, su khac nhau ve kich thudc khoi u trong mo vdi cac tac gia cd the do ddi tugng chpn benh, thdi gian sang loc va phat hien benh sdm \ ii UT giai doan 1 va 2 ciia cac tac gia tren chiem ty le cao ban.
Theo nhieu tac gia, nhirng khdi u kich thudc nho, chua lan ldi thanh mac, chua gay hep long DT nen chua cd ban tic hoac tic ruot ihi cong viec chuin bi DT tdt ban mdt
yeu td rat quan trong de tranh xi dd mieng noi \ i khi md ndi soi khac vdi mo md la khdng sd nan dugc doan DT tren va dudi u dc danh giii co phan trong long DT hay khong.
Phuong phap phau thuat: 57 BN trong nghien cim nin dugc thuc hien PT noi soi trong phiic mac, co 9 BN chuyen mo mcr chiem l\ 1? 15,7"o. Tii> theo vi tri cua u, tinh chill xam lam \ a danh gia trong mo ma dua ra qu\cl dinh ky thuat md [13]. Trong nghien cuu ciia chung tdi, cat doan DT trai cao la 24,5%, cit doan DT sigma 56,2%> va cit nua DT trai la 19,3%o. Kit qua cua chung toi phii hgp vdi nghien cuu cua Nguyen Van Hai [3]
cat doan DT sigma la 63,6%), cit nira DT trai 18,2%), thap ban nghien cuu cua Antonios A
Y HOC VIET NAM THANG 9 - SO DAC BIET / 2011
K T [7] PT ndi soi cit doan DT sigma la 83,9% tuy nhien cao ban nghien cuu ciia Nguyen Van Xuyen [6] tren 135 BN UTDT trai, cit doan DT sigma la 42,5% (37/87 PT triet can).
Ly do chuyen md md: 1) le chu>cn mc3 md trong nghien cim la 15,7% trong do do khoi u dinh hoac xiim lan chiem ly lc cao nhit 8,7%, rudt qua chucVng 3.5"o \a PT ma rong 3,5%. Ve PT md rdng, ciil cac tang do UT xam lan trong md la 3.5"'o, bao gom 1,75% cat gan trai, l,75%o cat doan ruot non.
Kit qua na> phii hgp \cVi nghien cim ciia Nguyin Van XUN en [36] PT cat DT md rong la 5,6%. Theo Bruce V M [8] kich thudc khoi u, muc do viem dinh \a xam lan ciia khoi u, tac rudt nen phau trudng hep hon \ i nhieu quai rudt non chucyng hai, thao tac kho khan hon la nhung yeu td chi dinh chuyen tir PT noi soi sang mo md.
Theo nhilu tac gia [1], [11], [15] chuyen mo md khdng phai la that bai cua PT ndi soi ma vi tinh hieu qua. triet de va an toan cho cuoc mo, \i neu cu cd gang phau tich bang noi soi trong mot tinh the kho khan thi thdi gian mo se keo dai ciing \di nhung bien chung ciia no ve phau thuat, \e gay me, ve
than khi do bam hai d phuc mac va cac bien chirng sau mo.
Mirc d() vet hach: Trong nghien cim ciia chiing loi, ty lc nao vet hach D2 la 45,6%, (D2: nao vet cii 2 nhom bach 1, 2) vet hach D3 la 54.4"^ (D3: nao vet ca 3 nhom bach 1, 2 va 3) dua Ihco phan loai cac nhom hach ciia Nhat Ban [131. ^^^t qua vet bach D3 ciia chung loi phii hcrp vdi nghien cuu ciia Kobayashi M. va Okamoto K. [13] vet bach D3 la 56,5% (13/23).
Trong ngbicMi cim nay, lat ca BN deu dugc danh gia di can trudc mo bang cac xet nghiem huycl hoc, sinh boa va hinh anh.
Trong mb BN dugc danh gia gan, lach, mac noi Idn va phiic mac ngay sau khi dat Trocart vii camera dk phat hien xam lan di can UT.
D6i vdi vet bach D3, ddng mach mac treo trang dudi dugc boc 16 va that sat goc bang buoc chi, bing clip hoac ket hgp ca hai, mo md xung quanh dong, tmh mach mac treo trang dudi dugc cit bd nguyen khoi, cac mach mau nho dugc ddt bang dao dien. Vdi vet bach D2, chi boc lo mot phin din liic thiy ro gdc ciia dong mach ket trang trai va g6c cua ddng mach true trang tren, cac dpng mach sigma.
H3. Vet hach va th^t dong mach mac treo trang du-di [13] (a, b: D3. c: D2)
HOI NGHI KHOA HOC KY T H U A T M d R O N G LAN T H O X I I • B E N H V I E N H O U N G H | V I E T NAM - CU B A D 6 N G H 0 |
BicMi chimg sau ni6: Bi li(?ii sau mi) gap 7"(I, nhiem Iriing \cl mi) 5.3"« vii buc xi mieng noi gin dd ra ngoai ihimh bung 1,7%, khong CO irirdng hgp niio pliai mi) lai vii khong CO lu \ong sau mi). Nghien ciru ciia Nguyen I loiing Bac 111 klionu cn nhiem Iriing \cl llli), luy nhien nhii'iii Iriing duonu lieu hau phiiu lii ^^.T'o. \ icm phdi l(S.2"o diip irng nhanh chong \ai khiing sinh vii 1<S.2%
bien chimg tim mach nimg la nhoi miiu ca lim \ii phii phb\ ciip. khimg cd Inrirng hgp nao tir \ t)ng. liil ca ciic mieng luii dcu liuili loi.
Joel L \a Pascal A [12| gap hicn chimg chung sau ni6 lii 9.()"(), irong do huNcl khoi tinh mach siiu 10,^)" n. chii\ man 2,7%. di) 2,7"o, bien chirng licl nieu 0,9'^) vii liic ruot sau mo l.S"o. sir khiic nhau \c ly lc biC-n chirng nii\ co the do dc)i lugng chgn benh ciia chiing toi la nhirng BN U TD 1' trai chua co bien chimg, i\ le BN tren 80 luoi trong nghien cim cua cac tac gia nude ngoai cao
h(rn nghii-n ciru cua chimg tdi.
Vdi nhiem triing vet md, chiing toi dieu tri bing cit chi scVm, ket hgp khang sinh, thay bang lai cho. Trong nghien cim ciia chung loi ghi nhim 1,7% d6 mieng ndi qua vcl mo, BN dugc dieu Iri ni)i khoa va theo doi. sau 26 ngay bC'nh on vii cho xuiil vien. Theo cac tac gia, ciic bien chirng va lu vong PT hoan loan CO Ihc dugc han che bang \icc hoan thien ky thuat mi) kcl hcrp \ (Vi gay mc hdi sire tot [1 ]. [16].
Phiin chia giai doan: Chiing tdi phan GD theo TNM cua AJCC \a 1 ICC ung thu GD I hi 7%, C;D II 2b.H%. GD HI 59,7% va GD IV hi 3,5%. Kcl qua nghien ciru ciia ( hcng-J M (9| i\ li- ung thu CiD III la 50%). Theo Pham Iliing Cudng [2] ung thu GD II la 46.0% va ihco liic gia \cu td quan trong nhal anh hucrng dcMi ket qua dieu trj la GD ung ihu.
cac yeu to Iam sang hoac giai phau benh khac ciing cd anh hirdng den lien lugng nhimg thirdng la phu thuc)c vao GD lam sang.
Bang ty le % phan chia Tac gia
Pham H.Cu'dng [2]
Cheng-J. Ma [9]
W. L. Law [17]
Chiing toi
G D I 1,9
3 12,1
7,0
giai doan theo mot so tiic gia:
G D I I 46,0
27 36,8 29,8
GD I I I 23,0
50 29,8 59,7
GO IV 29,1
20 21,2
3,5
Nhu vay, trong nghien ciru ciia chimg tdi, ly le BN d GD mudn (III vii IV) chiem da sd 63,2%, dieu nay co the lien quan den kien thirc, trinh do va thdi quen lu chiim scic sire khoe ciia BN chua cao. Kcl qua dieu Iri phu thupc rat nhieu vao GD benh, do dd \icc chan doan sdm UTDT cd y nghTa rat Idn trong viec cai thien ket qua dieu tri.
Chat chi diem ung thu CEA: Binh thudng ndng dp CEA trong mau <5ng/ml.
CEA tang trong mdt so trudng hgp UT dudng tieu hoa, CEA it khi tang d BN UTDT
kem biet hoa [9]. Prong nghien cim cua chimg Icii. i\ le tang Cli.A trudc md la 63,2%
cao hem nghien cim ciia Ngu\cn Hoang Bac [1] liing Cl-A irircVc md la 20%).
Theo 1 arshad Abir [10] trong UTDT dinh lugng Cl-A cd dp nhay chi 7-64% tuy_
theo GD ciia benh, neu tang trudc phau thuat CEA cd the dugc diing de danh gia muc do triet can cua PT, sau PT triet can UTDT tir 4- 8 tuan CEA giam xudng nhanh ve muc binh thudng va tat ca mpi su gia tang ve sau bao dpng mdt UT tai phat hoac di can va theo bao
Y HOC VIET NAM THANG 9 - SO DAC BIET / 2011
cao ciia nhieu lac gia CEA lang cao trudc PT cung mang y nghTa tien lugng xiu [2],[9].
Trong nghien ciru nay, tai kham sau mci 3 thang co 21,9% tang CEA (> 5ng/ml), sau 6 thang c6 27,8% lang CEA, kel qua na> thap hon so vdi ly le CEA tiing trudc mi) lii 63,2%, luy nhien ly le liing CE.A sau md ihiip hon trudc mo chua cd y nghTa Ihdng ke \ di p
= 0.1806 > 0,05.
Nghien ciru cua Cheng ./ M vd .lan S H [9] nhdn thdy 42.S"o (ISI 423) tdng ndng do CEA trudc md. mirc CE.4 huyet thanh sau md CO lien quan vdi vi tri khdi u lien phdt. di cdn hgch. GD T.Wl vd sir tdi phdt sau md [9J. ty le tdng CE.4 sau md trung hinh 2S thdng cua tdc gia Id -/(S'.j cao han so vdi ty le tdng CK.\
sau md 6 thdng cua chiing tdi Id 2''.S%. Sir khdc biet ndy cd the do so luang nghien ciru ciia chimg tdi cdn it. ty le B\ tdi khdm sau mo thdp vd thdi gian theo doi sau md cua chiing tdi chua du ddi.
V. KET LUAN
Qua nghien cuu 57 benh nhan ung thu dai trang trai dugc dieu tri bang phau thuat noi soi tai Benh vien Trung Udng Hue \a Benh vien Truong Dai hpc Y Dugc Hul lir 9/2007 din thang 9/2010 chimg toi rut ra mpt so ket luan sau:
Tuli trung binh la 56,8 ± 17,4, lira tuli gap nhilu nhit la tir 40-60 chiem 56,1%.
Tyle nam/nu: la 1,48/1.
Dau bung la trieu chimg thudng gap nhat 94,7%, roi loan lieu hda 50,9%, phan cd mau 56,1 %, sd thiy u d bung gap 14,1 %.
Hinh anh dai thi: siii loet chilm ty le cao nhit 40,3%, thi siii 26,4%, loet 14,1%.
Vj tri u d dai trang sigma 65,6%), dai trang xuIng 17,3%).
Kich thudc khdi u tren 5cm chiem
; 60,4%.
Cat doan dai trang sigma 56,2%.
Vcl bach D2 lii 45,6%, vcl hach D3 lii 54,4%.
1 y lc chuNcn nici md linh chung la 15,7"(), trong do phau thual md rpng 3,5%.
Ung thu giai doan I la 7%. II lii 29,8%, 111 ki 5^),7"'o \a giai doan IV lii 3,5%.
Ung thu bieu mci lu\cn chiC'm 98,3%.
Timg CEA IrucVc mi) la 63.2'^(), sau mo 3 thang lii 21,9",,, sau mc3 6 thang la 27,8%.
Bien chirng sau mo: Bi lieu 7%, nhiem irimg \cl mi) 5.}% \a do mieng noi 1,7%, khiing co trudng hgp nao phai mo lai va khcing ci) lu vong sau mci.
TAI UEU THAM KHAO
1. Nguyen Hoang Bic, Tran Cong Duy Long, Nguyen Diic Thuan (2008), Phau thuat npi soi mpt thi dieu tri tac rupt do ung thu dai Irang trai, Y Hpc TP Ho Chi Minh, 12(4), tr. 301-307.
2. Pham Hung Cu'dng (2003), Carcinom dai trang kit qua song con va cac yeu to tien lugng, Y Hpc TP H6 Cbi Minh, 7(4). tr. 172-177.
3. Nguyen Van Hai, Le Huy Lun (2009), Dilu tri tic dai trang trai bang phau thuat mpl thi khong rira dai trang trong mo, Y HpcTP Ho Chi Minh, 13(1), tr. 42 - 45.
4. Pham Nhu- Hiep, Le Loc (2004), Phau thuat npi soi trong ung thu dai trirc trang tai benb vien Trung uang Hue, Chuyen dk phau thual npi soi va npi soi can thiep.
Tap chi y hpc Viet Nam, (8), tr. 20-28.
5. Nguyen Quang Thai, Doan Hiru Nghi (2003), Tien lupng kha nang di can bach ung thu dai trang qua danh gia cac dac dilm hinh thai bach khi ml, Y Hpc TP Ho Chi Minh, 7(4), tr. 206-212.
6. Nguyen Van Xuyen (2008), Mot s6 dac dilm lam sang, can lam sang va ket qua 339
HOI N G H I KHOA HOC KY T H U A T M d R O N G L A N T H U X I I • B £ N H V I £ N HCTU NGHI VIET NAM - CU BA DONG HOI
dieu Iri phim Ibiiiil 135 bO'ib nhiin ung thu dai trang Iriii, YUTI I, (4). Ir. 94-97.
7. Antonios A K T, ( haralambos M (2()()7). Radical hnipli noilc rcscclion of the rclropcriloncal area for Icfl-sidcd coU)n cancer. Arch Surg. (V)2), pp. 155-
160.
8. Bruce \ M ct al {2()()^), Laparo.scopic
Left Ilcmicolcclonn and Siunioidcclonn. Laparoscopic Suigcr\ oi'
the Abdomen, pp. 369 378.
9. ( hcng .1 M, .lan S H (2006), Mullixarialc aiiKsis of prognostic dcterminanls Ibr colorectal cancer patients willi high preoperative serum CI'.A lc\cls: prognoslic value of postoperative scrum CEA levels, Taiwan, (22). No 12, pp. 604-608.
10. Farshad A, .Suraj A, Walter E L (2006), The postoperative surveillance of patients with colon cancer and rectal cancer. The American JSurg. (192), pp.
100-108.
11. Hester Y S C, Alex L H L, Chung C C (2009), Endo-laparoscopic colectomy without mini-laparotomy for left-sided colonic tumors. World J Surg, (33).
pp.1287-1291.
12. Joel L, Pascal A, Francesco R, Bertrand C and Jacques M (2005). The impact of obesity on technical feasibility and postoperative outcomes of laparoscopic left colectomy, Ann Surg, (241), pp. 69-76.
13. Kobayashi M, Okamoto K, Namikawa T, (2006). Laparoscopic lymph node dissection around the inferior mesenteric artery for cancer in the lower sigmoid colon and rectum. Is D3 lymph node dissection with preservation of the left colic artery leasiblc? Kochi Medical School, .lapan, (20). pp. 563-569.
14. Renato C , Xavier P, Christine M, Bernard V, (2009). A feared complication during laparoscopic left colcclomv: The torsion of the colonic stump at stapling. Digestive el Urologiquc. Ildpital \'iclor Dupouy, I'rancc, (10), pp. 1007-1011.
15. Stephanie H M, Jean J T, Olivier B, Mmilie L (2006), Emergency subtotal/total colectomy in the management of obstructed left colon carcinoma, Int J Colorectal Dis, (21). pp.
538-541.
16. Tac S C, Seok-B L, Dae K S, Chang W H (2008), Feasibility of single-stage laparoscopic resection after placement of a self-expandable metallic stent for obslrucli\c left colorectal cancer. World J Surg. (32). pp.2275-2280.
17. \>ai L L Joe K F, Jensen T P (2009), Single incision laparoscopic left colectomy for carcinoma of distal trans\erse colon. The University of Hong Kong, Queen Mar\ Hospital, Hong Kong, pp. 360-368.
