of the specimens, the origin of the dorsalis pedis artery (DPA) is anterior tibia artery. The mean length of DPA is 7.2 ± 0.83 cm and the mean diameter of DPA is 3 ± 0.6 mm, The mean diameter at the end of the DPA is 2.33 ± 0.35 mm. In conclusion, the vascular artery of the flap is almost consistently. Therefore, it is very convenient to using the central dorsalis pedis flap, Considering to using peripheral reverse pedicled flap due to the anatomy variations as well as end collateral of dorsalis pedis vessels.
Keywords: anatomy, dorsalis pedis artery, dorsalis pedis flap
PHAU THUAT SQM CAC U MACH MAU COA TR^ EM
Dd Dinh T h u a n \ T r l n T h i l t S a n \ Ngd Anh Tu^
'Trwdng Dai hoc Y Ha NOi, 'Bgnh vien Nhi Trung wang Cdc u mach mau cua trd em duxyc ddc trwng bdi sw tiin triin qua 3 giai doan: tdng sinh, on dinh va thodi triin. Thdng thwdng, phau thudt dwgc thgc hidn mugn d giai doan di chdng, sau khi u thodi triin. Tuy nhien, tmng mdt sd tnrdng hgp, phiu thudt sdm cd thi dugc ehi dinh. Nghidn cdu duge thwc hien nhdm xac dinh ede chi dinh, ddnh gid tinh an toan vd higu qud eua dieu tnphau thudt sdm. Kit qua eho thay 41 u mach mau dwgc phiu thudt. hiu hit u d vung diu vd cd (97,56%). Tuoi tmng binh Id 17 thdng (7 - 48 thdng). Chl can mpt lin phdu thudt duy nhit diiu tn ddt didm cho 92,31%. Kit qua sau mo rit khd quan: tdt la 63,89%, kha 33,33%, tmng binh 2,78% cdc trwdng hgp. Tw dd cd thi kit ludn cac u maeh mdu eua tre em gdy rdi loan ehdc nang hoac anh hwdng tdm ly ndng ni cin dwac phau thudt eat bd trwdc tudi thodi then tw nhidn. Diiu tn phau thudt sdm u mach mdu cd kit qud tdt vd bien chdng tdi thiiu.
Tie khda: u mgch mau, p h l u thudt
I DATVANO^
U mgch mau eiia tre em (Infantile Hemangiomas) Id khdi u phd biln nhit d tre em, thdng thudng x u l t hifn trong thang d i u sau sinh, tang sinh nhanh trong 3 - 6 thang d i u , sau dd dn djnh va thodi lui t g phdt chgm nhung thudng todn bd trong vdng 5 - 7 tudi [1,5]. Dga tren xu hudng thoai triln t g nhien nay ciia cac u mgch mdu nen vife xii- ly bao tdn vdi sg theo ddi thudng xuyen thdng thudng la d n thilt.
Tuy nhien, nhQ-ng b i l n chu-ng bao gdm loet, chay mau, su suy y l u chii-c nang cua cac d u true k l efn, cung nhu cac v l n d l tdm ly phat sinh tu- cdc u mgch mdu ldn tang sinh, la nhQ'ng chl djnh eho d i l u tri p h i u thudt. Sg hifn difn ciia nhu-ng u nhu v f y tren mat, dac bift la cac khdi u d mi mat, mdi hoac mui, cd the gay ra cac biln chu-ng tram trpng, ma khdng t h i ludn ludn dugc kilm soat bang d i l u trj ndi khoa. Trong nhQ-ng trudng hgp nay, phau thuft sdm cd t h i dugc chl djnh, nhu 6veac d l nghj bdi nhilu tdc
gia [1,2,3,4,5,8,9,10].
Chung tdi dgt v l n d l nghien cu-u vai trd ciia phiu thuat sdm trong dilu tri cac u mach mau tre em nham eac muc tieu:
1. Xic djnh cic chi djnh phau thuit, th&i diem phau thuit s&m cho cic u mach miu cua tre em.
2. Dinh gii ket qui phau thuit, xic djnh tinh an toin vi hieu qui cua phau thuit s&m.
II. 0 6 l TUONG VA PHUONG PHAP
Bao gdm 41 u mach mdu d 39 bfnh nhan (28 nQ-, 11 nam) 6^ac dilu tri phiu thuft tgi khoa Phiu thuft Tgo hlnh, bfnh vifn Saint Paul, va bfnh vifn Vift Nam Cu Ba, Ha Ndi tu- nam 2006-2010.
Cac u mgch mau dugc chdn doan chii y l u dga vao d c dac d i l m lam sang va filn triln ciia khdi u (tang sinh, dn djnh va thoai lui) va ddi khi k i t hgp vdi sieu am Doppler. Phiu thuat
TCNCYH Phu trwang 77(6) -2011
dugc can nhic khi khdi u de dpa din cdc chu-c nang, gay biln dgng cdc clu triic k l cdn hofc anh hudng din thim my, tdm ly cua tre, sau khi dilu trj nfi khoa thit bgi hofc ddi khi dugc Iga chpn diu tien.
Ky thuat md phg thufc vdo vj trf vd kfch thudc ciia khdi u, vdi mft sd nguydn t i e ca ban nhu sau: (1) Dudng rach trdn ranh gidi cac dan vj, tilu dan vi thim my trdn mft hofc tren dudng cdng da tdi thilu. (2) Xac djnh, xii' ly can thfn cac mgch mau nudi dam bao sg chay mau tdi thilu. (3) Lly bo td chuc seo xlu vd d lodt cung vdi phin da c i t bd. (4) Ddi vdi nhQ-ng khdi u md vj trf vd kich thudc cho phep, ed the cdt toan bp hofc gin todn bp vdi khdu trge tilp. Trong nhQ-ng trudng hgp khde, cd t h i tiln hdnh cit ban phin djnh hinh, phin u cdn Igi cd t h i dilu trj bd sung bang steroide tiem tgi chd, hodc cho phep thodi lui tg nhien.
Tren mdi bfnh nhdn, ghi nhfn Igl tudi phiu thuft, vi tri cua khdi u, chi djnh phiu thugt, phuang phdp phiu thuft, cae biln chu-ng va kit qua phau thuat.
Cac kit qua dugc danh gia eho mdi bfnh nhdn dga tren hinh anh chung cua vung phau thugt, sg giam t h i tich ciia khdi u, sg phgc hdi cac tdn thuang chu-c nang, sg cai thifn cua d u true va hinh anh thim my ciia da, sg hai Idng ciia bd mp bfnh nhdn. Cdc kit qua dugc phdn logi nhu tdt, khd, trung binh, kem.
III. K^T QUA
Chiing tdi cd 39 bpnh nhdn vdi 41 khdi u 6uf<}/c dilu trj phiu thudt, tuyft dgi da sd Id cdc u mgch mdu d mgt vd cd (40/41= 97,56%), bao gdm 28 nO- vd 11 nam, vdi dp tudi trung binh 17 thang (7 48 thang). Trong t i t ca cdc trudng hgp, chi cd mft khdi u duy nhit, ngogi tru- 2 bfnh nhdn ed 2 khdi u mgch mau.
Kich thudc eiia cdc tdn thuang thay ddi tu- 10 X 20 mm - 100 x 100 mm tgi thdi dilm phiu thugt
Trong 5 trudng hgp, dilu trj corticosteroids
da dugc dp dgng trudc phiu thugt (3 trudng hgp udng Prednisolone 2 3mg/kg/ngay. 2 trudng hgp tidm Triamcinolone trong khdi u).
Cd 1 trudng hgp dd 6\jeao dilu trj Laser vd 18 trudng hgp dugc tiem xa vd/hofc xg trj d cdc ca sd dilu trj khde nhung thit bgi vd/hodc 6k Igi spo xlu.
Cd 36 bfnh nhdn trdi qua 1 lln phiu thudt, 3 bfnh nhdn 6wac phiu thudt 2 lln. Phiu thudt bao gdm sg d t bd todn bf khdi u trong 27 trudng hgp, elt bdn phin trong 17 trudng hgp (2 bfnh nhdn cd 2 khdi u, 3 bfnh nhdn dugc md 2 lln). Tat ca cac trudng hgp diu ddng khuylt hdng bing khdu trge tilp (trong dd cd 2 lln khdu theo kilu budc mifng tui), ngogi tru- 1 trudng hgp cd sii- dgng vgt da tgi chd.
Phiu thuft sdm dugc dp dgng eho 5 bfnh nhdn bj ehe thj trudng mpt phin vd 2 bfnh nhdn bj khe khult thj trudng todn bp hodc gin todn bp do cdc khdi u quanh mit phdt triln
nhanh, 11 bfnh nhdn cd u mgch mau mdi (6 mdi dudi, 5 mdi tren) gdy anh hudng chire ndng an udng va biln dgng do biln chu-ng tiln triln hoge dilu tri (tidm xo), 1 u mgch mau diu mQi gdy biln dgng trim trpng sgn cdnh mui, 3 u mgch mau tai gdy biln dgng sgn tai.
Phiu thudt sdm cQng dugc dp dgng cho 19 trudng hgp do eac v l n d l thim my vd tam ly:
spo xlu do biln chirng dilu tri (tiem xa hoge xg trj) d eac ca sd dieu trj khac (8 trudng hgp), thodi triln chdm (2 trudng hgp), khdi u Idn vdi tidn lugng cd di chung sau thodi triln (4 trudng hgp), tien lugng phiu thudt cd hifu qua thim my cao (5 trudng hgp).
Biln chu-ng sau phiu thuft, chung tdi chf gdp 2 trudng hgp hd vlt thuang vao ngdy thu- 7 sau md (vlt khdu bupc mifng tui), vdi sg lien spo 1 - 2 tuin sau dd.
Kit qua phiu thuft, vdi thdi gian theo ddi trung binh la 2 nam (6 - 60 thdng), 6[tac danh gia la tdt 63,89% trudng hgp (23/36 khdi u kilm tra dugc), khd 33,33% trudng hgp (12/36 khdi u), trung binh 2,78% cac trudng hgp (1/36 khdi u).
A B C
Hinh 1. (A,B) Hinh anh tre 11 thang tudi vd'i u mgch mau mi tren phai che l i p g i n toan bd thi trud'ng. (C) k i t qua 2 nam sau phlu thuft
IV. BAN LUAN
Chi djnh phlu thugt
Theo nhilu tdc gia, ed khoang 60 75% cac u mgch mdu thodi triln mdt cdch tg phat ma khdng d l Igi di chu-ng gi ddng k l , vi vdy nen xu- ly bao tdn, ehd dgi va theo ddi.
Dilu tri thudng eh? dugc dgt ra khi u mgch mau de dpa sg sdng, de dpa chu-c ndng cac ca quan, gdy biln dgng ede d u true k l can hoac gay anh hudng thim my, tdm ly eua tre. Nhilu phuang phdp dilu tri da 6\jeac 6k nghj trong qua khip (nhu dp lanh, tiem xa, xa trj) thudng gay biln chu'ng tram trpng nhu: loet, hoai tip, seo xa, teo td chu-c va nguy ea ung thu v l lau dai [1, 4, 5]. Dilu trj bing corticosteroid da dugc dung rpng rdi vd hipn nay vin 6\yac xem nhu lifu phdp dilu tri ndi khoa hang diu, chu ylu thuc diy sg thoai triln sdm, d nhQ-ng u Idn va tang sinh nhanh, ed nguy ca de dpa sg sdng hoac chu-c nang eua mpt ca quan [1,5,6]. Interferon alfa-2a hoac Vincristine cQng da dugc su- dgng cho cac u mgch mdu khdng dap u-ng vdi corticosteroid.
Nhilu logi Laser cung da dugc sir dung, chii ylu 6k dilu trj ede khdi u mach mau ndng hoac cac di chu-ng gian mao mach cdn sdt Igi sau khi u thodi triln. Laser mdu (POL) la logi laser hay dugc sii- dgng nhit va nhieu lan dilu trj la d n thilt [1, 7]. Tu- nam 2008, mdt sd tdc gia da phat hifn hifu qua eua Propranolol trong dilu trj cdc u mgch mau tre em.
Dilu trj phiu thugt, thdng thudng dugc thuc
hifn mupn vao giai dogn di chipng, sau khi u mgch mau da thodi triln toan bp, d l dilu tri cac vln d l thim my do di chu-ng cdn sdt Igi ciia khdi u nhu da thu-a, di tich xa md hoge cac biln dang hinh thi. Dilu nay thudng bd qua eac tac ddng tam ly vd sg hda nhap xd hdi ciia tre.
Ngay nay, nhilu tdc gia d l nghj phiu thuat sdm eho eac u mgch mau d vung dau mgt cd trudc tudi din trudng (trudc 6 7 tudi), ma khdng chd sg thoai triln hoan toan ciia khdi u, ddi vdi nhu-ng u mgch mau ma kha nang thoai triln kem, anh hudng nang n l din tdm ly vd sg hda nhdp xa hdi ciia tre hoac cd thi la nguyen nhdn ciia sg biln dgng khd hdi phgc nlu chd dgi sg thoai triln tg nhien. Mdt vai tdc gia d l nghj dilu tri phiu thugt ngay tu- 2 3 tudi trudc tudi di ldp miu gido, khi ma tre bit diu nhfn bilt v l hinh anh ban thdn [3, 4, 5]. Ddi khi, phiu thudt cung dugc 6e nghj sdm han, ngay trong giai dogn tang sinh (trudc 1 tudi) ddi vdi nhQ-ng khdi u de dpa sg sdng, anh hudng chu-c nang trim trpng, hoge hilm han vi ly do thim my, ma khdng t h i kilm sodt bang dilu tri ndi khoa [2, 3, 4, 5, 8].
Nhu vgy, cd t h i thiy dilu trj phiu thudt sdm hoac phdi hgp vdi dilu trj npi khoa, ngdy d n g dugc chap nhfn nhilu han, trd thdnh mdt su Iga chpn dilu trj trong mpt vai chi djnh dac biet.
NhQ-ng u mgch mdu d mi mit cd thi che khult thj trudng, chen dp nhan d u , din din tft lac mat, chu-ng logn thj va nhugc thj khdng hdi phgc, cd t h i ddi hdi mdt sg phiu thudt sdm cd
TCNCYH Phu trwang 77(6) 2011
tinh chat clp cu-u [2,4]. NhQ-ng u mgch mau mdi cd t h i gdy hd khdp d n , chay nude bpt, hofc mpt sg biln dgng khdng t h i chip nhfn dugc [5,10]. Nhu-ng u mgch mdu diu mQi dfc bift kem thim my vd ed nguy ca gdy biln dgng vTnh viln diu mui vdi sg tach ra xa eua vdm sgn canh mQi [9]. U mgch mdu d vdnh tai ed t h i gdy biln dgng sgn vdnh tai. Vi vfy, cdc u ndy cd t h i dugc chf djnh phiu thudt sdm [3].
Mft sd u mgch mdu d nhQ-ng vj tri khde d mft cd nguy ca gdy anh hudng thim m9 vd nhu-ng tdn thuang tdm ly ciia tre cQng cd t h i cdn nhdc
chi djnh phiu thudt sdm. Trong nhu-ng trudng hgp ndy, khi md hlnh Inh cua nhQ-ng u mgch mdu dd ft hofc khdng thay ddi trong vdng 2 - 3 ndm hofc bdi vl tdn thuang dang anh hudng din sg hod nhdp xd hfi cua tre, phiu thudt sdm theo chung tdi la thfch ddng. Odi khi, phiu thudt cQng cd t h i dft ra ngay trong giai dogn tang sinh. Tuy nhidn, phiu thudt vien phai edn nhac v l tfnh an todn vd hifu qua thim my thu dugc.
NhQ-ng trudng hgp ndy bao gdm cdc u mgch mdu biln dgng d vung trdn, md, d m , trudc tai, thdi duang vd ede vung da dau khac.
A B C
Hinh 2. (A) U mgch mau mdi dual trai d* trd 11 thang tudi anh hu'vng chirc ndng, tham my. (B) K i t qua 3 thang sau phlu thuft. (C) K i t qua 2 nam ru'ai sau p h l u thuft Dilu trj phiu thuft da 6irao 6k nghj eho d c u
mgch mdu bj biln chu-ng nhu loet, dau d p , hogi tii', chay mdu vd bpi nhilm ma khdng ddp u-ng vdi d c lifu phdp dilu trj khde. Tuy nhien, chung tdi khdng d trudng hgp ndo phai chi djnh phiu thugt d p cu-u vi cdc biln chu-ng nhu vdy.
Tinh an toan va hifu qud cua p h l u thuft ChQng tdi khdng gfp bit cu- biln chu-ng gi trim trpng trong vd sau phiu thudt. Vdi sg tiln bp ciia gdy me hdi su-e, ngdy nay phiu thudt cho nhQ-ng tre tren 6 thdng tudi (cdn nfng > 8kg) tuang ddi an todn vd cd t h i chip nhdn dugc.
Nhu nhdn djnh cua mpt sd tac gia [8,9], chung tdi nhdn thiy mu-c dp mit mdu trong phiu thugt la khdng dang k l , khdng cd trudng hgp nao d n phai truyin mdu. Trai vdi quan nifm thdng thudng, chung tdi nhgn thiy u mgch mau khdng phai la cac "tui mau" hay "hd mau'', mala
mpt td chirc nhu md, cd mpt vai mgch mdu nudi dudng, nhung cd t h i kilm soat dugc bing dao difn. Trong mpt nghien cu-u, Achauer va cpng sg [1] da ehi ra ring phau thugt d t bd vd tgo hinh cho nhO-ng kit qua tuyft vdi vdi ty If cao nhit so vdi d c phuang phdp dieu trj khac nhu quan sat. steroid, laser vd lifu phap phdi hgp.
Trong nhdm bfnh nhdn cua chiing tdi. hifu qua cua dilu trj phau thuft da dugc khlng djnh vdi kit qua tdt vd khd trdn 97% d c trudng hgp. Trong da sd trudng hgp, mpt lln phiu thudt duy nhit cho sg dieu trj dirt dilm vdi thdi gian dilu trj dugc riit ngdn.
V. K^T LUAN
Phiu thugt sdm cd t h i dugc can nhac cho nhQ'ng khdi u mgch mdu cua tre em gay anh hudng chu-c nang, gay bien dgng cac td chiPC
k l efn cd nguy ca khdng hdi phgc, hoge gay tdn thuang den tam ly vd sg hda nhdp xd hpi ciia tre, ma khdng t h i k i l m soat dugc b i n g lifu phap bao tdn. Vdi v i f c can nhac thgn trpng cac chi djnh vd vife tuan thu eac nguyen t i c ky thudt dac thu, dilu trj p h i u thuft sdm la mpt phuang phap an toan vd hifu qua trong dieu tri eac u mach mau cua tre em.
TAI LIEU THAM KHAO
1. Achauer BM, Chang CJ, et al (1997).
Management of hemangioma of infancy: review of 245 patients, Plast Reconstr Surg. 99:1301 -1308.
2. Claude O, Picard A, et al (2008). Use of ultrasonic dissecfion in the eariy surgical management of periorbital haemangiomas, J Plast Reconstr Aesthet Surg 61(12): 1479 -1485.
3. Degardin N, Martinet V, Patenotre P (1998). La part chirurgicale dans le traitement des hemangiomes, Ann Chir Plast Esthet. 43:
649 - 658.
4. Demiri EC, Pelissier P, et al (2001).
Treatment of facial haemangiomas: the present
status of surgery, Br J Plast Surg. 54: 665 - 674.
5. Enjolras O, Deffrennes D, et al (1998).
Les tumeurs vaseulaires et les regies de prise en charge chirurgicale. Ann Chir Plast Esthet.
43:455 - 490.
6. Kushner BJ (1985). The treatment of periorbital infantile hemangioma with intralesional corticosteroid, Plast Reconstr Surg.
76:517 526.
7. Landthaler M, Hohenleutner U, El- Raheem TA (1995). Laser therapy of childhood haemangiomas, Br J Dermatol. 133: 275 - 281.
8. Vincent C. Boyd, Dana Bui, et al (2006). Surgery: The Treatment of Choice for Hemangiomas, Semin Plast Surg. 20:163 -168.
9. Waner M, Buckmiller L, Suen JY (2002).
Surgical management of hemangiomas of the head and neck. Open Tech. Otolar. Head Neck Surg. 13(1): 77 84.
10. Zlde BM, Giat PM, Stile FL, Longaker MT (1997). Vascular lip enlargement, 1:
hemangiomas - tenets to therapy., Plast Reconstr Surg. 100: 1664-1673.
Summary
EARLY SURGICAL TREATMENT OF HEMANGIOMA IN INFANTS
Infantile hemangiomas are characterised by their clinical course with 3 phase: proliferation, then stabilisation .and involution. For a long time, surgery has been limited to correct after-effects following involution. Nevertheless, in selected cases early surgery may be justified. The study was conducted to clarify the indications and evaluation the safety and effectiveness of eariy surgical treatment for hemangiomas. Results show that 41 hemangiomas were operated. Almost majority are in head and neck region (97.56 %).The average age was 17 months (7 - 48 months). In the majority of our patients (92.31%) a single operation offered definitive treatment. The postoperative outcomes were very satisfactory: the results were good in 63.89%, fair in 33.33%, and moderate in 2.78% of cases. In conclusion, infantile hemangiomas causing functional disturbance or serious psychological distress deserve surgical excision before the age of expected spontaneous regression; surgery can provide active treatment with good results and minimal morbidity.
Keywords: hemangioma, surgical excision
