Y HOC VIET NAM SOPAC BIET THANG 10/2010
Danh gia ket qua dieu tri viem ruot thiJa cap bang ph^u thuat noi soi tai Benh vien Quan y 211
Evaluation the efficacy of laparoscopic surgery for appendicitis in 211 Military Hospital
Le Dinh Ngoi, Dinh Trung Kien, Nguyen The Vinh, Benh vien Qudn y211 Nguyen Thi Lan, Vo Hai Dudng
Tom tat
Nghien cud hol ciTu 566 benh nhan (nam: 256, nif: 310) dddc phau thuat npi sol dieu tri viem rupt thira cap tai Benh vien 211 tir thang 9 nam 2005 den thang 4 nam 2010. Tudi trung binh: 30,79 ± 13,21. Chi dinh md gom:
viem rupt thira cap chda bien chirng (60,08%); viem phiic mac khu tru: 22,44% va viem phiic mac toan the:
11,48%. Khd khan chii yeu trong md la dinh rupt. Phau thuat an toan, khdng co tir vong, bien chdng thap (3,89%) vdl thdi gian phuc hoi trung tien nhanh: 17,96 ± 7,96 gid. Thdi gian nam vien ngan: 5,65 ± 2,37 ngay.
Ket qua chung: tdt 97%; trung binh: 3%; khong co ket qua xaiu. Dan Idu viing hd chau phai la mot bien phap cd gia trj nhSm ban che ty le bien chu'ng sau md. _. '
Summary
A retrospective study of 566 pabents (male: 256, female: 310) were treated laparoscopy acute appendicibs at 211 Military Hospital from September 2005 to April 2010. Average age: 30.79 ± 13.21. The indicabon included:
ordinary appendicitis 60.08%; peritonitis region 22.44% and overall peritonitis 11.48%. The difficulties encountered in operationy is stick of small intestinal bow/el. This is a safety technique, no mortality, low complicabons (3.89%) with the intestinal transit recovery bme fast: 17.95 ± 7.96 hours and short hospitalization time: 5.55 ± 2.37 days. Overall results: The best 97%, average: 3%, no bad results. Drainage of Douglas to be a valuable measure to limit the rate of postoperative complicabons. ': •
1. Dat van de 2. Doi tu'dng va phu'dng phap nghien eu'u Viem rudt thira cap (VRTC) la mpt cap ciru ngoai Nghien ciTu hoi ciiu 566 hd sP benh nhan (BN) khoa hay gap. Phau thuat npi soi (PTNS) cat rudt thira viem rudt thira cap ddpc PTNS cat rupt thira tai BVQY dang ddpc ap dung rpng dai trong hau bet cac cP sd 211 tir thang 9 nam 2005 den thang 4 nam 2010. Ghi dieu trj va da khang dinh tfnh du viet ciia ciia nd nhan cac sd lieu ve: tuoi, gidl, nghe nghiep, thdi gian [1][2][3]. Tir nam 2003, Benh vien Quan y 211 (BVQY mac benh, cac trieu chu'ng lam sang va can lam sang.
211) da bat dau irng dung PTNS trong dieu trj can Chan doan benh chii yeu dda vao trieu chu'ng lam benh nay. Chiing tdi tien hanh de tai nay nham muc sang va sieu am, PTNS cat rudt thira ddpe thdc hien dich: Danh gia ket qua PTNS trong dieu tri VRTC tai bang 3 trocart vdi t d the benh nhan nam ngira, phau Benh vien Quan y 211. thuat vien va ngddi phu diing ben trai. Chi djnh PTNS khi chda cd bieu hien viem phiie mac hole ap xe. Ghi
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Phan bien khoa hoc: TS. N G U Y I N ANH T U A N
CHAO MdNG 45 NAM NGAY TRUYEN THONG BENH VIEN QUAN Y 211 - QUAN DOAN 3 (31/12/1965 - 31/12/20iq)_
nhan tai bien, bien chirng va tir vong phau thuat, thdi gian mo va thdi gian nam vien. Ket qua phau thuat ddpe chia lam 3 loai: tdt (phau thuat khdng cd tai bien, bien chu'ng, BN ra vien trddc 7 ngay), trung binh (ed cae bien chirng nhe, xd ly bang npi khoa dat ket qua tdt). Ket qua xau (ed eac tai bien, bien chirng, phai md lai). Sd lieu ddpc thu thap va xd ly tren may tinh vdi phan mem SPSS 11.5. Cac thdng sd ddpc coi la ed y nghla khi p < 0,05.
3. Ket qua nghien eu'u
Trong thdi gian ben hanh nghien ciTu, ed 605 BN viem rudt thira cap ddpc md tai benh vien, trong dd
cd 566 BN ddpc md bang phau thuat ndi soi chiem ty le 93,5%. Benh nhan gdm: 256 nam (42,2%), 310 niT (58,8%), tud'i trung binh 30,79± 13,21 (tir 8 den 73 tudi), 6,89% BN cd tien sir md bung. Da sd la VRTC khdng ed bien chdng (60,1%), viem rudt thira muon chiem ty le 39,9% trong dd ed 22,4% BN viem phiic mac khu tru va 11,5% BN da cd viem phiie mac toan the. Hau bet cac BN chimg tdi phai dat dan Idu sau khi eat rudt thira (95,1%), trong dd dan Idu dPn thuan till eiing Duoglas 75,3%, dan Idu hd chau phai 9,7%, dan Idu ca Douglas va hd chau phai 10,1%
Bang 3.1. Vj trf rudt thira Vi trf
Binh thddng Sau manh trang Trong tieu khung Dddi gan
Tdng
SL 460 62 25 19 566
Ti le % 81,27 10,95 4,42 3,36 100,0 Rudt thira d vj tri binh thddng la chii yeu: 81,27%.
Bang 3.2. Nhu'ng khd khan trong phau thuat Khd khan
Rudt dinh nhieu Chay mau Chuyen md md
Tong
SL 11 07 09 566
Ti le % 1,95 1,23 1,59 100,0
Ket qua theo ddi sau md cho thay: thdi gian cd trung ben sau md trung binh 17,9±7,9 gid (tir 6 den 48 gid), thdi gian nam vien trung binh 5,3±2,4 ngay (tir 2 den 21 ngay).
Bang 3.3. Bien chirng sau md Bien chirng
Tran khi dddi da Nhiem khuan lo trocar Tu dich viing hd chau phai
Tdng
SL 05 06 11 22
Ti le % 0,89 1,06 1,94 3,9
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Y HOC VIET NAM S O P A C BIET THANG 10/2010
Bang 3.4. Ket qua sdm sau md
Ket qua
Tdt Vira Xau Tong
VRTC khdng bien chiTng SL
371 03 00 374
Ti le % 99,2
08 00 66,1
Viem phuc mac khd tru
SL 124
03 00 127
Ti le % 97,6
2,4 00 22,4
Viem phiie mac toan the
SL 54 11 00 65
Ti le % 83,1 16,9 00 11,5
Tdng
549 (97,0) 17 (3,0)
00 566(100,0)
Ket qua chung: tdt: 97%; trung binh: 3%; khdng cd ket qua xau.
4. Ban luan
Ket qua nghien
CLTUciia chung tdi cho thay phau thuat npi soi la mdt phdPng phap an toan va bleu qua trong dieu trj VRTC. PhdPng phap khdng ed tir vong phau thuat vdi ty le bien chu'ng rat thap (3,89%), ehi cd 1,94% BN tu djch hd chau phai, 1,06% BN nhiem khuan lo trocar va 0,89% BN tran khf dddi da quanh lo trocar. Dac biet la khdng cd trddng hpp nao bj ap xe tdn Idu phai mo lai. Cac trddng hpp tran khi dddi da quanh id trocar deu td khdi, cae trddng hpp nhiem khuan lo trocar deu khdi sau khi cat chi va giai thoat mil. Trong 11 trddng hpp tu djch hd chau phai ehi ed 2 trddng hpp phai chpc hiit djch, cdn lai deu td khdi sau lieu trinh khang sinh (ket hpp 3 thude tir 7 den 10 ngay). Viec chda de trddng hpp nao bj ap xe tdn Idu cd the do chimg tdi ludn ehii trpng viee lau rira d bung va dat dan Idu khi nghi ngd cdn dpng djch trong d bung (b le dat dan Idu la 95,05%). Chimg tdi eho rang, t\ le ap xe tdn Idu thap chfnh la do chimg tdi da md rpng chi djnh dat dan Idu sau md. Cac tac gia khac cd ket qua ve ap xe tdn Idu nhd sau: Le van Khoa la 2,86% (ti le dat dan Idu la: 15,7%)[3]. Le Minh The la 0,69% (ti le dat dan Idu la: 62,91%)[5]
Ve cae bien chirng xa, den nay chimg tdi chda gap trddng hpp nao vao vien vdi bien chiTng tae rupt hay thoat vj qua lo trocar.
Khd khan chii yeu trong phau thuat thuat la dinh rupt nhieu (1,95%) gap trong cae trddng hpp da ed phau thuat bung tiT trddc, dae biet la phau thuat viing bung dddi rdn. Cac trddng hpp da phau thuat tren rdn cung cd dinh rudt nhdng it hPn va nd cung khdng
anh hddng den PTNS eat RT. Mdt sd trddng hpp di'nh rudt nhieu do qua trinh viem eiia rupt thira thddng de bde tach va khdng gay khd khan cho eupe md. Khd khan thiT 2 la chay mau nhieu trong khi md (1,23%), cac trddng hpp nay do viem phii ne mac treo rudt thira, tang sinh mach mau. Trong sd cae benh nhan gap khd khan tren hau het ddpc xd trf thanh edng bang PTNS, ehi ed 1,6% phai chuyen nio md va chii yeu trong thdi gian mdi bat dau trien khai PTNS, day la mdt ti le kha thap so vdi mdt sd bao eao khae: Le Van Khoa la 4,3% [3], Le Minh The la 2,0% [5].
Trong nghien ciTu ciia ehiing tdi, eac BN cd VPM khu trii hoac VPM toan the van ddpe tien hanh PTNS.
Viee tien hanh PTNS eho VPM RT cung cd nhieu thuan lpi nhd phau trddng rdng, de quan sat va viec tddi rira ddpe thdc hien den khap eac ngdc ngach ciia khoang phiic mac, tuy nhien cung gap mdt sd khd khan dd la viec hiit lai Idpng djch tddi riTa cdn khd triet de, neu khdng dat dan Idu tdt thi de gay ap xe tdn Idu sau md. Viee quyet djnh dat dan Idu la tiiy theo mirc dp VPM va tinh trang tiet djch, cd the chi dat dan Idu d Douglas, hd manh trang hoac ed the dat dan Idu d ca tiii cimg Douglas va ho manh trang.
Viee dat dan Idu sau mo ed nhieu du diem vi sau khi md, tinh trang viem nhiem tai khu vde tuy da ddpe giai quyet nguyen nhan nhdng phiie mac van cdn tinh trang tiet djch nhat la khu vdc hd manh trang va thddng chay xudng tui cimg Douglas. Chiing tdi da tien hanh dat dan Idu eac loai eho 95,05% trddng hpp, tat ca eac trddng hpp nay deu ed mdt Idpng djch dang ke ddpe dan Idu ra gdp phan nang eao ket qua
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CHAO MdNG 45 NAM NGAY TRUYEN THONG BENH VIEN QUAN Y 211 - QUAN DOAN 3 f31/12/1965 - 31/12/2010)
dieu trj, ha thap ti le ap - xe tdn Idu sau md. Ti le dat dan Idu sau md ciia chimg tdi cao hPn nhieu so vdi cae bao cao trddc day (Le Van Khoa, 2009 la 15,7%
[3]. Le Minh The la 62,91%[5]), chiing tdi chi de dng dan Idu den khi nao het djch, thdng thddng khoang 24 gid sau phau thuat. Viee dat dng dan Idu sau mo vira khdng khd, viTa mang lai hieu qua cao trong dieu trj, vira khdng gay anh hddng den tham my do chiing tdi dat dan Idu qua 1 trong cae id trocar va cung it kha nang gay dinh rupt vi tren thdc te chung tdi chda gap trddng hpp nao vao dieu trj do bien chirng tac rupt sau PTNS dieu trj VRTC.
Mdt du die'm khae cua PTNS la nhiTng trddng hpp RT nam d vi tri bat thddng. Trong nghien ciru, ehiing tdi gap 10,95% RT sau manh trang, 4,42% RT d trong tieu khung va 3,36% RT dddi gan. PTNS trong trddng hpp RT d vj trf bat thddng nay cd du die'm hPn han so vdi md md thdng thddng, viec tien hanh phau thuat cat RT khdng khac gi so vdi RT d vj trf binh thddng, trong khi phau thuat md thddng mat rat nhieu thdi gian cho viec tim kiem RT dong thdi viee cat bd RT cung gap nhieu khd khan do lue nay thddng phai md rpng vet md va rudt thira nam d sau so vdi vet md tren thanh bung. Rieng nhiTng trddng hpp RT nam trong bao thanh mac eiia manh trang thi phai chuyen md md vi viec bdc tach de giai phdng RT bang PTNS thddng gap nhieu khd khan, gay keo dai thdi gian md.
Ket qua sdm sau md cho thay da sd cac BN rat nhanh ed trung tien vdi thdi gian trung binh la 17,96
± 7,96 gid. Chiing tdi cho BN an ngay sau khi cd trung tien lan dau tien. Thdi gian nam vien trung binh: 5,65 ± 2,38 ngay. Ket qua chung cho thay: tdt la 97%, trung binh la 3%, khdng cd trddng hpp nao xau. Ket qua nay cung tdPng t d nhieu tac gia khac [3][4][5].
5. Ket luan
Phau thuat ndi soi ed the ap dung trong dieu trj viem rudt thira cap khdng ehi d giai doan sdm ciia benh ma ea khi da cd viem phiic mac, phdPng phap cdn cd y nghTa hPn trong nhiTng trddng hpp rudt thira nam d vj trf khd. Khd khan chii yeu la dinh rudt va benh nhan da md cu viing dddi rdn. Dan Idu viing hd chau phai la mdt bien phap ed gia trj nham ban ehe ty le bien chirng sau md.
Tai lieu t h a m khao
1. Do Minh Dai, Nguyen Hoang Bae, Nguyen Tan Cddng, Nguyin Dinh Tddng Lan (2003), Phau thuat ndi soi dieu trj VPM RT. Tap ehi Y hpc, Dai hpc Y Ddpc TP Ho Chf Minh, tap 7.
2. Vd Van Himg, Dinh Van Trung, Nguyin Van Phiic (2004), Mo cat rudt thira qua ndi soi tai Benh vien Da khoa trung tam Tien Giang tir 20 thang 11 nam 2001 den 15 thang 11 nam 2002. Y khoa NET, http://vvww/.google.com.vn.
3. Le Van Khoa (2009), Nghien ciiu iing dung ky thuat ndi soi trong chan doan va dieu trj VRTC tai Benh vien 7A - Quan khu VII. Luan van tdt nghiep bac sT chuyen khoa cap 2, Hpc vien Quan y-
4. Do Thj My Oanh (2004), Dieu trj VPM viing do VRT bang PTNS. Luan van thac si Y hpc, Dal hpc Y Ddpc TP Ho Chf Minh.
5. Le Minh The (2009), Nghien ciTu ehi djnh, ky thuat va danh gia ket qua phau thuat VPM RT tai Benh vien Nguyen Dinh Chieu tinh Ben Tre. Luan van tdt nghiep bae sT ehuyen khoa cap 2, Hpc vien Quan y.
