OAI HQI HOI NGOAI KHOA VN LAN THtf XII VA HQl NGHj KHOA HOC NGOAI KHOA TOAN Q U 6 C l A N J i j O X i y ^
OANH GIA KET QUA DIEU TRj BENH TRI BANG PHAU THUAT LONGO TAI BENH VI$N TRUNG UONG HUE
Doan Chi Thanh, Nguyen Van Lu-ffng, Pham Nhu^Hiep, Ho Hfru Thien, Pham Anh Vu, Phan Hai Thanh, NguySn Thanh Xuan, Tran Nghiem Trung, Van Tiln Nhan, Pham Trung Vy (*)
TOM TAT
Muc tieu: Danh gia ket qua dieu t n benh tn bang phUPng phap Longo tai Benh vien Trung ypng Hue.
Ddi t&dng va ph&dng phap nghien c&u: Tu' thang 2 nam 2010 den thang 11 nam 2011, chiing tdi da thyc hien phau thuat Longo dieu t n 426 benh nhan tn dp I I I , IV cd kem hoac khdng cd tri vdng va trT hon hpp. Cac benh nhan sau mo du'dc theo ddi va danh gia nhijng ket qua trong thdi gian nam vien va ket qua tai kham sau 1 thang va 3 thang.
Kit qua: TrT dd I I I chiem ti le cao nhat (63,6%) vdi tudi trung binh 48,2 ± 18,4 tudi. Ty le nam/nii' la 1,49.; Cac tai bien trong md" gom cd chay mau, va cac tai bien lien quan den dung cu cat trT. Chay mau sau md" cd 1 8 , 1 % , tuy nhien chi 1,6% la can phai can thiep lai bang phau thuat. Chen bong Foley hau mon giiip cam mau trong da sd tru'dng hpp cd chay mau trung binh va nang. 80,3% benh nhan sau mo dau it hoac khdng dau. Thdi gian nam vien sau mo' trung binh la 3,1 ± 1,82 ngay. Tai kham sau 1 thang va 3 thang cho thay 80,7% benh nhan cd ket qua tdt. Chi cd 2 (0,46%) benh nhan bi hep hau mdn can phai phau thuat lai.
Kit luan: Phau thuat Longo cd ket qua phau thuat tot, cd nhieu u'u diem dang ke so vdi cac phypng phap mo truyen thdng nhy giam dau sau mo, ty le bien chu'ng sau mo thap, thdi gian nam vien du'dc riit ngan.
* Benh vien trung udng Hue
S U M M A R Y
EVALUATION THE RESULTS OF LONGO PROCEDURE I N TREATMENT OF PROLAPSE
HEMORROIDS
Objective: lo evaluate the results of Longo procedure in treatment of prolapse hemorroids at Hue central hospital.
Material and method: From February 2010 to November 2011, 426 patients with hemorroids nf H I , IV degrees with or without a ring and mixed hemorroids were treated by Longo procedure. The posoperative patients were monitor and evaluate the results of procedure, hospital stay and the results of follow-up after 1 month and 3 month.
Results: 426 patients with the mean age of 48.2 ± 18.4 years. Rate of male/female is 1.5.
Proportion of I I I degree hemorroids was highest (63.6%). The intra-operative complications included bleeding, and complications related to Longo devices. Post-operative bleeding was 1 8 . 1 % , but only 1.6% was needed o reoperating.
Placed intra-rectum a baloon of Foley catheter helped stop bleeding. 80.3% of patients had no or less posoperative pain. Post-operative hospital stay was 3.1 ±1.82 days. Re-examination after 1 and 3 months showed that 80.7% of patients had good results. Only two (0.45%) patients with anastomosis stenose needed surgery again.
Conclusion: Longo procedure has good operative results. I n addition, there are many
NGOAI KHOA S6 BAG BIET 1.2,3/2012 significant advantages over traditional surgical
methods such as reduced posoperative pain, low post-operative complications, hospital stay is shortened.
I. DAT VXN of
Benh trT la benh ly phd bien va dung hang dau trong cac benh ly ciia viing true trang - hau mdn. Sd lieu thdng ke d nuoc ngoai cho thay, cd tdi hon 75% dan sd bi trT, nhiiu nhat d dp tudi 45 - 60 [6], [10]. C) Viet Nam, tren 50% sd ngudi trong dp tudi lao dpng bi benh tr!
K.y thuat cat trT bang phucmg phap Longo dupe tac gia Antonio Longo ap dung di6u tn tir nam 1993 [9], su dung may cat khau khoanh niem mac true trang (d tren dudng lupc) de dieu tri benh trT, va cho nhieu mi diem nhu: it dau sau md, rut ngan thcd gian nam vien..., nen da khac phuc dupe nhieu han che cua cac phuong phap md trudc day.
Den nay, nhieu benh vien va cac trung tam da trien khai phau thuat Longo rpng rai cho benh nhan trT va budc dku cho nhimg ket qua kha quan [1], [2]. Chung tdi thuc hien dh tai nham muc tieu: Danh gia kk qua phau thuat trT bang phuang phap Longo.
IL o6l TUONG VA PHUONG PHAP NGHIEN CCfU Doi tiTffng nghien cmi
426 benh nhan, nam/nir la 1,49; trT dp III, IV, tudi trung binh 48,2 ± 18,4; cd hoac khdng kem trT vdng, trT hdn hpp dupe phau thuat bang phuong phap Longo tir 2/2010 ddn 11/2011 tai BVTW Hul
PhuoTig phap nghien ciru
Nghien cim lam sang tien ctina md ta cd can thiep. Tat ca benh nhan deu dupe md theo mdt quy trinh ky thuat chuan. Cac thdng sd ghi nhan bao gdm tudi, gidi, ly do vao vien, phan dp trT trudc md, cac tai bien trong md, cac bien chimg sau md, ket qua theo doi BN.
III. KET QUA Dac diem chung
Bang 1: Mdt sd dSc diem cua nhdm nghien cuu Dac diem
Trieu chu'ng:
Dai tien ra mau Satrl Oau rat iiau mon Phan 66 tri:
C o i n 06 IV 06 III, IV phoi help 06 III, IV CO tri vonq
n (%) 124 (29,0) 426 (100,0)
96 (22,5) 271 (63,6) 74 (17,4) 63 (14,8) 18 (4,2)
BAI HOI HOI NSOAI KHOA VN U^N THUXIIVA HQI NSHI KHOA HOC NSOAI KHOA TOAN Q j 6 c \M THJXIV Ket qua phau thuat
Bang 2: K6t qua phlu thuat Ket qua
Chay mau trong mo : Chay mau nhe Chay mau nang
Tai bien lien quan den dung cu l<hau nd1 ; LU5i dao khong cat niem mac
Oinh ichong ghim
Kh6ng cat niem mac + dinh l<h6ng ghim Chay mau sau mo :
Nhe Vira Nang Dau sau mo:
Oau nhe (1-3 diem) Oau VLTa (4-7 diem) Oau nhieu (8-10 diem) Thdi gian nam vien trung binh :
n (»/o) / TB (Min-Max) 122/426 (28,6)
116 (27,0) 8 (1,3) 7/426 (1,6)
2 (0m46) 3 (0,7) 2 (0,5) 77/426 (18,1)
43 (10,1) 27 (6,3) 7 (1,6) 426/426 (100,0)
342 (80,3) 68 (16,0) 16 (3,7) 3,1 ± 1,82 ngay ( 1 - 1 2 ) Ket qua theo doi
Bang 3. Ket qua tai kham sau 1 thang va 3 thang
Trieu cnung Dai tien
Tinh trang sa bui trT Dau hau mon
Chay mau i<hi dai tien Hep hau mon
Binh thu'dnq Kho Khonq tu" chu
Khonq con Con tn noi Con trT nqoai
Dau Kh6nq dau Co chav mau Khonq chay mau
Khonq hep Hep nhe Hep nanq
Sau 1 n = 251
245 6 0 220
7 24
8 243
14 237 245 4 2
thang Ti le C/o)
97,6 2,34 0 87,6
2,8 9,5 3,2 96,8 5,6 94,4 97,6 1,6 0,8
Sau 3 n = 178
176 2 0 156
2 20
0 178
5 173 178 0 0
thanq Ti le (%)
98,9 1,1 0 87,6
1,1 11,2
0 100 2,8 97,2 100 0 0
NGOAI KHOA s d BAC BlfT 1,2, 3/2012
IV. BAN LUiE^N
Nghien ciru chung tdi cd trT dp III chiem ti le cao nhat (63,6%) vdi tudi trung binh 48,2 tudi. Ket qua nay cung phu hop vdi cac nghien ciiu cua nhieu tac gia khac [3], [5], [8].
Ve chi dinh phau thuat, trT ndi sa dp IV cd kem theo trT ngoai thuyen tac van cd the chi djnh phau thuat theo phuang phap Longo.
Trong nghien cim cua chung tdi cd 14,8%
benh nhan cd trT phdi hpp dupe phlu thuat thanh cdng bang phuang phap Longo. Tuy nhien, cd mdt benh nhan bi dau sau md rat nhieu, va chay mau sau md vao ngay thir 7, phai md lai ma nguyen nhan la do biii trT ngoai thuyen tac hi hoai tir chay mau. Do dd chung tdi thay rang nen lay bd mau cue hoac cat bd cac bui tri ngoai bi thuyen tac nhu la bien phap them vao.
Bien chimg trong mo hay gap nhat sau khi bam dinh ghim la chay mau. Mdt sd tmdng hpp chay mau nhe (27%) dung chi dem spi 4.0 khau vai chiJ X cd the dl dang kiem soat chay mau. Tuy nhien, mdt sd tmdng hpp mau chay nhieu (1,8%), dac biet trong trudng hop cac bui trT qua to, cam mau rat khd khan. Chung tdi thay giit nguyen vdng nong hau mdn sau khi nit siing lam cho qua hinh de thuc hien hon.
Mdt sd bien chirng lien quan den dung cu di trT, mSc dii r^t hiem gap (1,64%), nhung hau qua rat nang. Dung cu cd dau dinh lap vao va mdt sd dung cu chat lupng kem la loai rat hay gay tai bien. Vi vay chung tdi khuyen khdng nen diing cac loai dung cu nay.
Chay mau sau md la mdt bien chung hay gap nhat. Nghien cuu ciia chung tdi cd 18,1 % benh nhan cd chay mau sau md. Tuy nhien 10,1% la chay mau nhe, mau tu cam ma khdng dn phai can thiep gi. Cd 7,9% benh nhan chay mau vira. Nhftng truong hap nay
chung tdi nhet meche hoac dimg bdng Foley chen vao hau mdn. Da sd trudng hpp mau tu cam. Chi 1,6% can phai chuydn md lai dd cam mau. Xir tri khi mo lai bao gdm khau tang cuong vi tri chay mau, cat bui trT chay mau va khau biii trT chay mau. Do dd, chiing tdi khuyen nen chen bdng Foley trong vdng 6 gid trudc khi cd chi dinh md lai dm mau.
Chung tdi khdng gap trudng hop nao chay mau mudn sau md do nhiem triing dudng khau. Chiing tdi chua chimg minh duac nhung khang sinh sau md vdi hai loai cephalosporin the he 3 va metronidazole dupe cho thucmg quy trong nghien citu cua chung tdi.
Mdt uu diem ndi bat cua phucmg phap Longo la it dau sau md. Su dung bang danh gia dp dau (visual analog scale), nghien cuu cua chiing tdi cd 80,3% benh nhan khdng dau hoac dau nhe sau md (1-3 diem), khdng can dimg giam dau. Nhieu tac gia khac ciing cho kdt qua tucmg ty [2], [4], [7]. 16% benh nhan dau vira sau md (4-6 diem), de dang kiem soat bang giam dau. Chi 1,3% benh nhan dau nhieu (7-10 diem). Nhu."ng benh nhan nay thudng cd cac bien phap them vao nhu cat biii trT thuyen tac, cat mdt phan ca that.
Thdi gian nam vien sau md trung binh la 3,1 ± 1,82 ngay. Ket qua nay gidng vdi da sd nghien ciiru khac.
Ket qua tai kham sau 1 thang va 3 thang, phan Idn benh nhan cam thay hai long.
87,6% benh nhan khdng cdn tinh trang sa bui trT. 2,8% benh nhan cdn tinh trang sa biii trT ndi, kham lai sau 3 thang chi cdn 1,1%. Ddi vdi cac trudng hop nay, chiing tdi cho rang danh gia tinh trang sa niem mac true trang trudc md chua chinh xac. Neu can trong mdt sd truong hpp phai chi dinh phau thuat STARR hoac phuong phap khac.Tuy nhien, sau mdt thang cd 9,5% benh nhan van cdn
BAI HQl HQl NGOAI KHOA VN LAN THCTXII VA HQI NGHI KHOA HOG NGOAI KHOA TOAN QUgCLANTHCfXIV
biii trT ngoai va 3 thang ty le nay la 11,2%.
Nhu vay tinh trang trT ngoai khdng cai thien trong qua trinh theo ddi. Do dd, chung tdi dd nghi cd the cat bd cac biii trT ngoai qua to, xa, thuyen tac nhu la phuang phap bd trp cho phau thuat Longo. Bien chimg hep hau mdn mac dii rat thap d ca hai nhdm tai kham. tuy nhien day la bien chiing nang, cd 2 benh nhan phai md lai de cat vdng xa. Ket qua tai kham sau phau thuat lan 2 deu tdt. Ca 2 benh nhan nay deu lien quan den tai bien khdng cat dupe niem mac do dung cu cat trT. Ddi vdi cac benh nhan hep nhe, chi can nong bang dung cu vai lan la dii.
V. KET LUAN
Dieu tri benh trT bang phau thuat theo phuang phap Longo cho ket qua phau thuat rat tdt. Ngoai ra phuang phap nay mang lai nhiing loi diem dang ke so vdi cac phuang phap md truyen thdng nhu giam dau nhieu sau md, ty le bien chiing sau md thap, thdi gian nam vien dupe rut ngan hon do dd sdm tra lai sue lao ddng cho gia dinh va xa hdi.
TAI LIEU THAM KHAO
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2. Nguyen Van Lieu, Nguyen Doan Van Phu, Nguyen Thanh Phuc (2011),
"Nghien ctm ung dung dieu tri cat trT theo
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3. Nguydn Manh Nham (1993), "Gdp phin nghien ciiu dieu tri trT qua ket qua phau thuat 77 benh nhan theo phucmg phap Milligan - Morgan", Luan dn Tien sy Y hoc, Hpc vien Quan Y.
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" Anorectal Disorder", Surgery Scientific Principles and Pratice, 50, pp. 1158-1183.
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AFPK. Randomized controlled trial of open and closed haemorrhoidectomy. Br JSurg. 1997;84:1729-1730.
8. Keighley R. B., Williams N. S. (1998),
"Haemorrhoidal Disease", Surgery of the Anus, Rectum and Colon, 13, pp. 295- 363.
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Hemorroidectomia por grampeamento:
estado atual. Arq Gastroenterol 2005;
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