BAI H6l HOl NGOAI KHOA VN LAN T H J X I I VA HOI NGH| KHOA HOC NGO»l KHOA TOAN Q U 6 C LAN T H O X I V
P H A U T H U A T PHiNH DONG MACH CHCI BUNG D U 6 | THAN QUA OUdNG NGOAI PHUC MAC
Nguyen Duy Tan, Nguyen Van Khoi, T r a n Quyet Tien, P h a m Tho Tuan Anh, Nguyen Diic Khue, Ha Thanh Binh (*)
T O M T A T
Muc tiiu: Danh gia ket qua bu'dc dau phau thuat PDMCB dUdi than qua du'dng ngoai phiic mac tai khoa ngoai Long ngiic - Mach mau BV Chg Ray.
Ddi t&dng va ph&dng phap nghiin c&u:
Nghien citu cat ngang tat ca tru'dng hOp mo POMCB du'di than qua dUdng ngoai phuc mac tii"
thang 1- 2007 den thang 12- 2010.
Kit qua: Q6 24 tru'dng hdp du'dc md PDMCB du'di than qua dUdng ngoai phiic mac. Du'dng rach da theo dudng canh ben bd ngoai cO thang bung ben trai, tii du'di ha su'dn den ngang ron hdi cheo sang phai. 21 tr.h (87,5%) nam, 3 tr.h (12,5%) niJ. Tudi trung binh 72, 24 tr.h (100%) nhap vien vi dau bung hoac lu'ng, kich thu'dc trung binh tui phinh 6 cm, 24 tr.h (100%) cd PDM chau hoac cd tac DM chau dui di kem, 1 tr.h (4%) cd mo bung tru'dc do. 1 tr.h(4%) ghep dng thang sd 16mm, 23 tr.h (96%) ghep bang dng chu" Y sd 16- 8 m m . Trong dd no! tii OM chu xudng ben phai: OM chau 19 tr.h (83%), OM dui 4(17%). Ben trai: DM chau 21 tr.h (91%), OM dui 2 tr.h ( 9 % ) . Thdi gian md" trung binh 4 gid, thdi gian trung binh nam 6 hoi su'c 10- 18 gid, cho benh nhan bat dau an gid thLT 24, thdi gian nam vien 7- 10 ngay. TLT vong Itr.h nU (4%) do suy hd hap keo dai, Itr.h cd thoat vi thanh bung.
Tat ca 22 trUdng hdp cdn lai ket qua tdt, dUdc theo doi moi thang.
Kit luan: PDMCB la benh nang, the thoai hda thanh mach kem xd viJa thu'dng gap d ngUdi
Idn tuoi cd nhieu benh di kem chiem ty le cao.
Phau thuat cat tui phinh qua dUdng ngoai phiic mac cd nhieu Idi diem lam giam cac bien chiTng, dac biet ddi vdi the loai phinh tren.
Tu" khoa: Phinh ddng mach chu bung dulJi than, p h l u thuat qua du'dng sau phuc mac
S U M M A R Y
RETROPERITONEAL APPROACH TO INFRARENAL ABDOMINAL AORTIC ANEURYSMS
Objectives: Aim to evaluate begin results of retroperitoneal approach to abdominal aortic at Thoracic- Vasculair sugery department Cho Ray Hospital.
Material and method: Cross- section studies from January - 2007 to December- 2010 with patients operated retroperitoneal approach to infrarenal /\AA.
Results: 24 cas infrarenal AAA has performed incision at the left from below flank extending the lateral border of the rectus sheath to umbilical. 21 cas (87.5%) in men, 3 cas (12.5%) in women, mean age 72 year old, 24 cas (100%) abdominal or back pain, Mean diameter of aneurysms 6 cm, 24 cas (100%) aneurysms or atherosclerosis iliac- femoral artery. 1 cas (4%) previous abdominal surgical procedure, 1 cas (4%) Dacron "tube" graft 16 size is selected and 23 cas (95%) use to bifurcation Dacron graft (Y) 16- 8 size. The left side: anastomosis to iliac artery 21 cas (91%) and femoral 2 cas ( 9 % ) , the ritgh side
(*)Khoa Ngoai Long ngi/c - Mach mau, Benh vien Chd Ray
250
NGOAI KHOA S6 flAC BlgT 1,2, 3/2012 anastomosis to iliac artery 19 cas (83%) and
femoral artery 4 cas ( 1 7 % ) . Mean time of operation 4 hour and remove ICU department 10-18 hour. Hospital length of stay from 7 to 10 day. 1 cas ( 4 % ) patient die due to long time respiratory failure, 1 cas (96%) abdominal wall hernia. 22 cas outcome well.
Conclusion: AAA happens elderly most associate hypertension, ischemie coronary, COPD, chronic artery obstructive, diabetes, .cause by high risk of .deaths.
Advantages of retroperitoneal approach AAA resection aim to degree complication for patients.
Keywords: infrarenal abdominal aortic aneurysms, retroperitoneal approached surgery
I.O^TVANOI
Phinh dgng m^eh ehii bung (PDMCB) xay ra d DMC tir dudi co hoanh va cd duong kinh dan ldn hon 1,5 lan dudng kinh binh thudng, trong dd PDMCB dudi than chiem hon 80% eae loai. Do nhieu nguyen nhan gay nen nhu: bam sinh, chan thuong, nhiem triing, nhiem sieu vi...nhtmg voi the thoai hda thanh maeh kem xo vGa gap d ngudi Ion tudi ed nhieu benh ly di kem ehiem ty le cao (1).
Cd hai each tiSp can DMCB, md qua phiic mac vao d bung va ducmg ngoai phiic mae. Nhung md duong ngoai phiic mac ed mot sd loi diem: tranh tiep xiie true tiep vdi radt cd the gay nhieu bien chung sau nay (liet rugt, dinh rugt, tac ruot...), giam nguy co suy ho hap sau md, giam ha than nhiet trong liic md, giam tinh trang mat nude dien giai, it dau...Ngoai ra mo PDMCB qua dudng ngoai phuc mac dugc chi dinh trong eae trudng hgp: viem tiii phinh, the trang beo phi, than hinh mdng ngua, dac biet benh nhan ed md b\mgtrudcdd(4,7)...
Vi thd, vdi nhiing Icri didm nhu tren md PDMCB qua ducmg ngoai phiic mac se lam
giam nguy co tdi thieu cac bidn chimg, r^t phii hop vdi benh nhan ldn tudi cd nhieu benh di kem.
Muc tieu nghien cuu: Danh gia kdt qua budc dau phau thuat PDMCB dudi than qua dudng ngoai phiic mae tai khoa ngoai Ldng ngue - Mach mau BV Chg R§y.
II. Do'l TUONG VA PHUONG PHAP NGHIEN COU
Nghien cuu tien cuu eat ngang, ghi nhan danh gia phan tich eac benh nhan md PDMCB dudi than qua duong ngoai phiic mac tir thang 1-2007 ddn thang 12-2010.
III. KET QUA 1. Gioi tinh
Nam 21 trudng hgp (87,5%), nQ 3 trudng hgp(12,5%).
2. Tuoi trung binh 72 3. Lam sang
24 trudng hgp (100%) nhap vien vi dau bung ho^e dau lung
24 trudng hgp (100%) cd phinh hoac tac nghen do xo vu'a Dm chau- dui.
Kich thudc trung binh tiii phinh 6 cm.
Cd tien can md bung trudc dd 1 trudng hgp (4%).
Benh di kem: Tang HA: 22 trudng hgp (92%), Thieu mau eo tim 12 trudng hgp (50%), COPD 4 trudng hgp (17%), tidu dudng 3 trudng hgp (12,5%).
4. Phau thuat
Dudng md: 24 trudng hgp dugc md PDMCB duoi than qua duong ngoai phiie mac. Ducmg rach da tir phia dudi ha sudn trai, keo dai canh ngoai co thang bimg den ngang rdn hoi chech qua ben phai. Qua dd bdc taeh can co den phiie mac, chech ra phia ngoai sau PM va di phia trudc than- nieu quan tidp can DM chu- ehau.
251
BAI HQI H 5 | NGOAI KHOA VN LAN T H J X K VA HQI NGHI KHOA HOC NGOAI KHOA TOAN QUOC L A N T H J X I V
Cat tui phinh ghep bang dng Dacron:
dng thang sd 16 mm 1 trudng hgp (4%), dng ehCr Y sd 16- 8 mm 23 truang hgp (96%).
Trong dd ben trai ndi xudng DM chau 21 trudng hgp (91%.), DM diii ehung 2 trudng hgp (9%). Ben phai ndi xudng DM chau 19 trudng hgp (83%), DM diii 4 truong hgp (17%).
Thdi gian md trung hinh 4 gid.
Thdi gian trung binh nam d hau phau 10- 18 gid.
Benh nhan dugc cho an sau 24 gid.
Thdi gian nam vien tir 7- 10 ngay.
5. Ket qua sau mo
1 trudng hgp tir vong (4%) a BN nir beo phi do suy hd hap keo dai
1 trudng hgp thoat vi thanh bung (4%).
22 trudng hgp edn lai cd ket qua tdt, theo ddi mdi thang kiem tra bang sieu am Doppler khdng ghi nhan bien chung.
IV. BAN LUAN
* Gidi: so sanh mdt sd tae gia tren the gidi Zarins va Gewertz ty le benh nam gidi gap 8 lan phu hgp vdi sd Heu.
* Tudi: Theo A. Carroccio va H. Holier ty le mac benh tang theo tudi tir 65 tudi trd 16n nguy co cang eao. Theo sd lieu chiing tdi benh nhan thudng den nhap vien vi dau bung, tudi trung binh 72. Khi lam chan doan CT Scan kich thudc tiii phinh trung binh 6 cm. Dac biet day la the PDMCB do thoai hda thanh mach kem xo viia mach mau he thdng va thudng gap 6 ngudi ldn tudi, do dd theo sd lieu thu thap dugc cd 24 tr.h (100%) phinh hoae xo viia gay tSc DM ehau- dui, dieu nay giai thich hau het ehiing tdi thay chii yeu bang dng ghep chu- Y.
Mat khac, thudng nhiing benh nhan ldn tudi nay ed nhieu benh di kem lam tang nguy eo bien ehung cho benh nhan:
- Tang HA chidm da sd lam nguy co sau md ed thd gay tai bidn MM nao, nhdi mau co tim hoae chay mau mieng ndi.
- Thieu mau co tim cd the gay nhdi mau eo tim liie dang md va sau md.
- 6 nhirng benh nhan COPD ma kem benh ly PDMC se lam tang nguy co suy ho hap tram trgng, do su thoai hda elastin lam giam lugng alphal- antitrepsin.
* Phuong phap phau thuat
+ Cd hai each tiep can DM chu bung- chau: md qua phuc mac vao d bung va mfl ngoai phuc mac. Md ngoai phiic mac tiep c3n DMC bung cd Igi the:
Trong liic md: tranh khdng tiep xiic eac tang trong d bung dac biet rugt ( gay liet rugt, tac rugt do dinh sau nay...), giam nguy eo ha than nhiet, giam tinh trang mit nuoc dien giai...
Sau md: tranh liet rugt keo dai, giam nguy CO suy hd hap, dau it hon...
+ Dudng rach da: d ben trai canh ngoai bd CO thang bung, bat dau tir dudi bd sudn vai cm keo dai den rdn hoi cheeh sang phai (de md DM ehau- diii phai). Bdc tach den phuc mac, hudng ra ngoai sau phiic mac phia trudc than- nieu quan. Tac gia A. Carroccio va H. Holier thuang dudng rach da theo duang cheo xuat phat tir dau xuong sudn so 11 hudng ve rdn. Theo ehiing tdi, dudng rach da canh bd ngoai co thang bung hudng sang phai se cung cap phau trudng rdng rai, dong thdi phau thuat sang ben phai eung de dang hon.
-I- Khi vao den khoang ngoai phuc mac ed 2 each bdc Id DM ehu- chau: bde tach theo mat trudc hoae sau than- nieu quan. Vdi nhdm benh nhan tren, chii ydu md PDMCB dudi than cho nen bdc tach theo mat trudc than- nieu quan se phii hgp hon, cdn phSu
252
NGOAi KHOA SO DAC BlfT 1, 2, 3/2012
thuat theo mat sau than- nieu quan se phii hop trong PDMCB tren thSn.
+ Nhu da trinh bay trong nhdm benh nhan nay chiing tdi thuc hien 23 tr.h (96%) hlu het bang dng ghep Dacron chii Y (do phinh va xo vira DM chau- diii), tuy thuc hien rach da canh ba ca thang bung ben trai nhung vin thuc hien ndi dng ghep vao DM chau phai 19 tr.h va DM diii phai 4 tr.h cho kk qua tdt.
+ Thdi gian benh nhan nam theo doi tai hdi siic trung binh 10-18 gid, hau het benh nhan dugc riit ngi khi quan sdm 2, 3 gid sau
+ Do md ducmg ngoai phiic mac khdng 3, loi keo rugt nen sau md benh nhan khdng ed biSu hien liet rugt, vi vay thudng eho benh nhan an sau sau 24 gidf.
+ Ket qua theo ddi sau md: 4, 1 trudng hgp (4%.) tu vong d benh
nhan nir ldn tudi cd co dia beo phi rat nhieu, sau md phai tho may keo dai sau do tu: vong. 5.
• 1 trucmg hgp (4%) khi bdc tach cd gSy rdch phiic mac va dugc khau lai, nhung sau dd gay tae rugt do rach phiic mac chd 6.
khau.
• 22 trudng hgp (92%)) dat ket qua tdt, b?nh nhan xu4t vien tir 7- 10 ngay sau md, va 7.
b?nh nhan dugc kiim tra theo doi djnh ky hang thang bang sieu am Doppler.
V. KET LUAN 8.
PDMCB la benh nang, co nhidu nguyen nhan gay ra, trong do the thoai hda thanh mach kem xa viia ddng mach thudng gap 6
ngudi ldn tudi va cd nhieu benh di kem, ddng thdi ehiem ty le rat cao so vai eac thd phinh khac. Phlu thuat cSt tiii PDMCB qua dudng ngoai phiic mac cd nhieu Igi diem lam giam nhieu cac bien chiing trong va sau md.
TAI LIEU THAM KHAO.
1. Pham Tho Tuan Anh "Chgn lira dudng md trong phau thuat dgng maeh ehii" Tap chi Y hge TP HCM Chuyen dd HN KH KT BV Chg Ray 2009. Trang 14- 23.
2. Ainio Caroccio and Lary H. Hollier 2004 "AAA Vasculair sugery.
Haimoviei; 703- 729".
Ahmad F. Bhamad F. Bhatti, Tonya P.
Jordan and David Tilson 2004
"Etiology of AAA" Vasculair Sugery;
196-205.
Caalvin B.Ernst 2004 "Retroperitoneal approach AAA" vasculair sugery vasculair sugery; 342- 347.
David C. Brewster, M.D 1995
"Prosthetic graft" vasculair sugery 492- 508.
David C Sagiston, Jr, M.D 1994
"Resection of AAA" Atlas of general sugery; 16-24.
Frederic L, Hoff, Kyle Muller, and William Pearce 2004
"Computetomography in vasculair deseases" vasculair sugery; 87- 102.
Ouriel Rutherfort 1998
"Retroperitoneal to AAA" Atlas of vasculair sugery; 111- 119
253