NGHIEN CUU DAC DIEM TON THU'DNG DUONG MAT VA KET QUA DIEU TR| NOI SOI TAN SOI MAT QUA DA BANG DIEN THUY Ll/C
Nguyen Quang Nam* Le Trung Hai*,
I. OAT VAN OE
Sdi duong mat la mot benh ly hay gap 6 nude ta voi nhieu bien chung nang. Cho den nay, da co nhidu bien phap chain doan va dieu tri hien dai duoc ap dung gop phan cai thien dang kd ket qua dieu tri soi duong mat. Tuy nhien ty le soi sot sau mo va soi tai phat la con kha cao, dac biet doi vol nhung truong hop soi trong gan gay nen nhung bie'n chung nhu ton thuong dudng mat, viem chit hep duong mat tao ra benh canh lam sang da dang va kho khan trong didu tri. Day la nhuhg vah de duoc cac thay thuoc gan mat rat quan tam.
Nam 1937, P. Huard va D6 Xuan Hop da tien hanh ky thuat choc mat xuyen gan qua da (XGQD). Sau nay nhieu tac gia khac da co nhuhg nghien ciiru vd chup duong mat qua da.
Nhuhg nam gan day, cac ky thuat dieu tri sdi dudng mat bang can thiep it xam hai dang duoc ap dung ngay cang phd bien va mang lai hieu qua cao, mdt trong cac phuong phap dd la tan sdi qua da. Tuy nhien ky thuat nay mdi duoc ap dung tai mdt so co sd trong ca nude, nhuhg cdng trinh nghien ciru vd ndi soi tan sdi qua da cdn chua nhieu.
Bai viet neu len mdt so dac diem tdn thuong dudng mat va ket qua dieu tri ndi soi tan sdi mat qua da bang dien thuy luc tai Benh vien 103, Hoc vien quan y.
II. OOI TUONG VA PHUONG PHAP NGHIEN CUU
1. Ddi tuong nghien ciiru: gdm 60 benh
nhan sdi dudng mat duoc dieu tri ndi soi tan sdi qua da (qua dudng ham Kehr hoac xuyen gan qua da) bang dien thuy luc tai Benh vien 103 tu 3/2007 - 3/2009. Nghien cuu loai tru cac trudng hop cd sdi tiii mat.
2. Phuong phap nghien ciiru:
- Cac may mdc vd trang thiet bi phuc vu nghien ciiu:
+ May sieu am Aloka SSD 2000 ciia Nhat Ban, dau do hinh quat 3,5 Mhz va dau do trdn 5,5 Mhz.
+ d'ng soi mem dudng mat CHF-P20 ciia hang Olympus, dudng kinh 4,9mm. Gian may ndi soi dudng mat va nguon tan sdi dien thtiy luc EL27-Compact, bd dung cu nong chit hep dudng mat, cac may mdc va dung cu lay sdi va cac dung cu khac.
- Nghien ciiu ddc diem Idm sdng, can Idm sdng: Tudi, gidi, tien sir sdi mat va benh ket hop, cac trieu chuhg dau ha sudn phai, sd't, vang da, tieu vang, cac xet nghiem bilirubin va chuc nang gan, sieu am va X quang dudng mat.
- Nghien cuu cac ton thuang dudng mat: viem dudng mat, chit hep dudng mat (theo tieu chuan ciia S.K. Lee), gian dudng mat, ap xe dudng mat va sdi mat.
- Phuang phap npi soi tdn soi mat qua da bdng dien thuy luc:
+ Tan sdi xuyen gan qua da: dat dan luu dudng mat xuyen gan qua da, nong dudng ham xuyen gan qua da tdi dudng kinh dii vUa vdi d'ng soi, soi dudng mat bang d'ng mdm va tan sdi bang dien thtiy luc.
+ Tan sdi qua dudng ham Kehr: sau md
dat Kehr ong mat chu 3-5 tuan, duong ham Kehr da tao lap chac chan, tien hanh npi soi theo duong ham nay vao ong mat va tan soi bang dien thuy luc.
+ Cac ky thuat phoi hpp: bom rira duong mat, nong chit hep duong mat, lay soi bang rp sau tan soi.
+ Thong ke cac chi so: kha nang tiep can soi ciia P'ng npi soi (ong soi co the cham soi hoac tiem can toi soi), thoi gian va so lan tan soi.
- Danh gid ket qua dieu tri: Ty le het soi (dua vao lam sang, x quang, sieu am va npi soi duong mat), ty le sot soi, nguyen nhan ciia con soi, mot so xet nghiem sau didu tri, ty le bien chUng va tir vong.
- Xu ly so lieu: theo chuang trinh Epi.
Info tai Hpc vien quan y.
III. KET QUA NGHIEN CU'U
3.1. Dac diem lam sang, can lam sang:
60 benh nhan (BN) soi duang mat, gom nam 28 BN, nu 32 BN, tudi trung binh: 52,83 + 6,35 (tir 21-87 tudi). Cd tien sir md sdi mat tu
1 lan trd len la 24/60 (40%) BN. Ngoai ra cd 23/60 (38,3%) BN cd tien sir da tirng didu tri npi khoa hoac da dupe xir tri bang thu thuat nhu choc dan luu giam ap dudng mat ma khdng dieu tri ngoai khoa, 3 BN (5%) da phau thuat cat da day va 5 BN (8,3%) mac cac benh man tinh ket hop nhu tidu dudng, benh tim mach.
- Trieu chung lam sang hay gap nhat la dau ha sudn phai 50/60 (83,3%) BN. sd't 31/60 (51,7%) BN, vang da 34/60 (56.7%) BN. Cd 1 trudng hop cd bieu hien sd'c nhidm triing dudng mat.
- Cac xet nghiem bilirubin toan phan tang d 45/60 (75%) BN, trong dd bilirubin true tiep tang d 43/60 (71,7%) BN, bach cau tang d 22/60 (36,7%) BN, amylaza tang d 9/60 (15%) BN.
3.2. Cac tdn thuong dudng mat:
3.2.1. Soi mat:
- Vi tri soi mat: (xac dinh tren sieu am, X quang va dac biet bang npi soi dudng mat):
Sdi trong gan don thuan: 13/60 (21,7%) BN (trong dd sdi gan trai 5 BN, sdi gan phai 1 BN, sdi ca 2 ben gan 7 BN). Sdi trong gan ket hpp vdi sdi dudng mat ngoai gan: 22/60 (38,3%) BN (trong dd sdi gan trai 11 BN, sdi gan phai 5 BN, sdi ca 2 ben gan 22 BN). Sdi dudng mat ngoai gan don thuan: 9/60 (15%) BN.
- Vi tri soi tren cdy dudng mat: sdi dng mat chii (OMC): 46/60 (76,7%) BN, sdi d'ng gan chung: 4/60 (6,7%) BN, sdi dng gan phai: 20/60 (33,3%) BN, sdi d'ng gan trai 22/60 (36,7%) BN. d trong gan muc phan thuy va ha phan thuy (HPT) gap nhieu nhat la sdi d d'ng HPT II: 36/60 (60%) BN, tiep den la sdi d'ng HPT III: 25/60 (41,7%) BN, It nhat la sdi dng HPT IV: 3/60 (5%) BN. Cac vi tri cdn lai khac trong gan.dao ddng tu 20-30%.
3.2.2. Viem dudng mat
Bang 1: Hinh anh tdn thuang viem dudng mat qua ndi soi.
Dang tdn thUdng SdBN Ty le %
Ne+xung huye't. 16/60 267
Ne+xung huyet+gia mac. 29/60 48,3
Ne+xung huye't+mu+gia mac. 3/60 5
Ne+xung huye't+mu+gia mac+d ap xe. 3/60 5
C> 3 truong hop co 6 ap xe gap a: ha phan thuy VII, ha phan thuy VIII va 6 phan thuy sau.
3.2.3. Chit hep dudng mat: gap d 28/60 (46,7%) BN, trong do chit hep nang la 7 BN va nhe la 21 BN. Vi tri chit hep d duong mat ngoai gan la 8 BN, trong gan 20 BN (33,3%). Cac d'ng mat thudng thay bi hep theo thir tu la: cac dng mat phan thuy (8 BN) hay ha phan thuy (8 BN), dng gan trai (6 BN), viing co Oddi (6 BN).
3.3. Phuong phap noi soi tan soi qua da bang dien thuy lire 3.3.1. Ky thuat npi soi tdn soi qua da
- Tan sdi xuyen gan qua da: 50 BN - Tan sdi qua dudng him Kehr: 10 BN
3.3.2. Ket qua tiep can soi theo vi tri duang mat:
Bang 2: Ket qua tiep can sdi theo vi tri dudng mat
—_Tiep can soi Hoan toan Khong hoan toan
Vi tri soi —^ Tan suat Ty If % Tan suat Tyle%
Trong gan don thuan
9 15 4 6,7
Ngoai gan dan thuan
8 13,3 1 1,7
Trong va ngoai gan 34 56,7 4 6,7
Nguyen nhan cua cac trudng hop khdng tiep can duoc het cac vi tri sdi la do Idi ky thuat dan luu (9 BN) ket hop vdi chit hep d'ng mat (7 BN) hoac gap gdc d'ng mat (3 BN).
3.3.3. So lan vd thdi gian tdn soi: Cd 44/60 (73,3%) BN chi tan mdt lan, ndi soi tan sdi 2 lan cd 14/60 (23,3%) BN, cdn ddi vdi ndi soi tan sdi 3 lan va 4 Ian chi cd 1 BN (1,7%). Trung binh la 1,3 lan ndi soi tan sdi qua da/1 BN. Thdi gian mdt lan ndi soi tan sdi ngdn nhat: 20 phut, dai nhat: 240 phut.
3.4. Ket qua npi soi tan sdi mat qua da bang dien thuy lire
- Ty le het sdi la 51/60 (85%) BN. Ty le con sdt sdi la 9/60 (15%) BN: trong dd: sdi trong gan don thuan 4 BN, sdi trong gan ket hpp vdi sdi ngoai gan 4 BN, sdi ngoai gan don thuan 1 BN.
- Trong 51 BN sdi trong gan cd 43 BN (84,3%) het sdi va 8 BN cdn sdt sdi.
- Trong so 28 BN cd chit hep dudng mat cd 5 trudng hpp cdn sdt sdi.
- Ket qua xet nghiem sau ndi soi tan sdi:
11/23 BN cd amylase mau tang hon so vdi trudc khi tien hanh ky thuat. Xet nghiem bilirubin va men gan deu giam hon so vdi ban dau. Theo ddi sau tan sdi khdng thay cd cac bien chiing dang ke va khdng cd tir vong.
IV. BAN LUAN
Trong so cac benh nhan sdi dudng mat ciia chiing tdi cd tdi 85% la sdi trong gan don thuan va ket hpp. Ddng thdi cac BN nay cd tdi 40% da cd tidn sir md mat cu va 38,3% da tirng dieu tri ndi khoa hoac da duoc xir tri bang thu thuat nhu choc din luu giam ap
duang mat. Ngoai ra la tien sir da mo cat da day, co benh man tinh ket hop. Day la nhung yeu td chinh de chi dinh ap dung cac ky thuat it xam hai la npi soi tan sdi qua da bang dien thtiy luc nham tranh nhuhg riii ro va kho khan co the gap do phiu thuat gay nen d cac benh nhin niy.
Qua npi soi duang mat cho thay cac hinh anh ciia viem duong mat la rat da dang, trong do hay gap nhat l i hinh anh niem mac duang mat phu ne, xung huyet va co gii mac, tham chi co mil va d dp xe. Hinh inh viem rd nhat la cac vi tri cd sdi va vung bdng Vater. Vi viy, khi thay mdt viing d'ng mat bi viem, cd nhieu gia mac che khuat thi cd the d phia sau cd sdi.
Ty le chit hep dudng mat ciia chiing tdi la 46,7% cao han so vdi so lieu ciia mdt so tac gia Viet Nam nhu 40,7% ciia Dang Tam (2004), 32,5% ciia Trin Dinh Tho (2006) va Biii Tuan Anh (2008), song thip hon nhieu so vdi so lieu ciia Y.Y. Jan - Dai Loan (1995) va S.K. Lee - Han Qudc (2001) vdi ty le chit hep dudng mat tren 80%.
Chit hep dudng mat vira la hau qua ciia sdi, ciia viem dudng din mat tai didn, keo dai, lai vUa la nguyen nhan tao sdi do gay tdc nghen va U dpng. Chit hep dudng mat cdn gay khd khan Idn cho lay sdi, la nguyen nhan chii yeu ciia sdt sdi. Ti le tii phat sdi luon rit cao d cic benh nhan cd chit hep dudng mat.
Nghien ciiu ciia S.K. Lee (2001) thay ti le tii phat sdi trong gan sau 24 thing d cac trudng hop khdng hep hoac hep d'ng mat nhe l i 28%, trong khi vdi hep nang l i 100%.
Ve ky thuat ndi soi tan sdi qua da:
+ Tan sdi bang dien thuy luc cho ket qua lam vd sdi td't. Khdng cd trudng hpp nio sdi khdng the vd khi diing loai nang lupng phi
sdi niy. Can chii y dieu chinh dau diy tin sdi dung vi tri de trinh gay tdn thuong dudng mat va tang hieu qua lam vd sdi.
+ Lay cic manh sdi vd bdng each day chiing xudng t i tring nhd ip luc ciia ludng nude tudi rira hoiic bdng dung cu. Cd 2 trudng hop hep dudng mat viing Oddi, khdng thd dua d'ng soi qua, sdi da bi tan nhd nhung cung khdng tdng dupe xudng t i trdng, chiing tdi phai dung sonde Dormia de lay mdt phdn theo dudng hdm ra ngoii. Khi soi lai lin sau thay niem mac dudng mat viing Oddi khdng cdn viem nira, dua dupe d'ng soi xudng t i trang va cic manh sdi lai dupe bom day xudng rudt mdt each dd dang.
+ Ddn luu lien tuc dung dich nude tudi rira ra ngoii: dp dung ky thuat din luu lien tuc dich tudi rira ra ngoai giup cho benh nhan khdng phii chiu mdt lupng Idn dich rira vao rudt (cd khi tdi hang chuc lit). Lam cho thdi gian ciia mdt lan tan sdi cd the dupe keo dai hon va do dd, giam thieu so lin tin sdi mdt cich dang ke, rut ngdn thdi gian dieu tri.
Ty le het sdi ciia chiing tdi la 85%, sdt sdi 15%. Rieng ddi vdi sdi trong gan ty le het sdi la 84,3%. Ket qui nay cao han so lieu ciia mdt so tic gii nhu Trin Bio Long (2004) vdi 62,8% lay het sdi trong gan bing phiu thuat.
Trdn Dinh Tha (2006) vdi 64,2% lay het sdi trong gan bdng md md cd sieu am va ndi soi trong md vi tuong duong vdi ket qua ciia Dang Tim (2004) cd ty le lay het sdi bing ndi soi tan sdi qua da la 84,7%, rieng vdi sdi trong gan: 82,8%-84,2%.
Mdt so tdc gia nude ngoai nhu Y.Y. Jan (1995), Otani K. (1999), S.K. Lee (2001), M.H. Huang (2003) cdng bd cac ti le het sdi ciia npi soi tin sdi xuyen gan qua da tir 80- 94%. Vdi cic ket qua ndi tren va khdng cd
cac bien chirng dang ke cung nhu khong co tir vong cho thay hieu qua cao ciia phuong phap npi soi tan soi qua da bang dien thuy luc. Phuang phap nay da dong gop mot phan dang ke trong viec han che ty le sot soi, dac biet la soi trong gan. mot van de kho khan nhat trong didu tri soi duong mat hien nay.
Han che chii yeu ciia npi soi tan soi qua da phu thupc vao vi tri va tinh chat tao duong ham (XGQD hoac qua Kehr). Doi voi XGQD thi can phai them thai gian (10-14 ngay) de' nong va tao mot duang ham vung chdc, do'i vdi duong ham qua Kehr thi phu thupc rat nhieu vao vi tri dat Kehr ciia phdu thuat vien de tranh tao su gap goc duong mat. Ben canh do phdu thuat vien cung dong mot vai tro quan trong, doi hoi phai sir dung thanh thao may mdc, ndm viing dupe giai phau ciia duang mat va co kinh nghiem trong dieu tri soi mat.
V. KET LUAN
- Dac diem ton thuong dudng mat qua ndi soi cho thay hinh anh ciia viem dudng mat rat da dang, trong dd hay gap nhat la niem mac dudng mat phu ne, xung huyet va cd gia mac, tham chi cd mil va 6 dp xe. Hinh anh viem rd nhat la cac vi tri cd sdi va vung bdng Vater. Khi thay mdt viing d'ng mat bi viem, cd nhieu gia mac che khuat thi cd the d phia sau cd sdi. Ty le sdi trong gan dan thuan va ket hpp la 85%. Ty le chit hep dudng mat la 46,7%, trong dd chit hep thudng d dudng mat trong gan (33,3%).
- Phuang phap ndi soi tan sdi qua da (xuyen gan qua da hoac qua dudng ham Kehr) bdng dien thuy luc duoc ap dung chii
yeu cho cac benh nhan cd sdi dudng mat trong gan, sdi tai phat. sdi sdt va cd benh ly ket hpp. Ty le het sot ciia phuong phap la 85% va sdt sdi 15%. Khdng cd cac bien chUng dang ke va khdng cd tir vong. Day la nhung ket qua kha quan cho thay hieu qua va tinh an toan ciia phuang phap it xam hai nay da gdp phdn han che dang ke ti le sdt sdi, dac biet la sdi dudng mat trong gan.
TAI LIEU THAM KHAO
1. Bui Tuan Anh: Nghien cuu ki thuat dan liru mat xuyen gan qua da trong dieu tri soi dudng mat. Luan an tien si y hpc, Hpc Vien Quan Y, 2008.
2. Dang Tam: Xac dinh vai trd cua phuong phap tan sdi mat qua da bdng dien thuy lire.
Luan an tien sy y hpc, Dai hpc y dupe thanh pho Ho Chi Minh - 2004.
3. Tran Dinh Thu: Nghien ciiu irng dung sieu am ket hop vdi npi soi dudng mat trong mo' de dieu tri sdi trong gan. Luan an tien sy y hpc, Dai hpc y Ha Npi - 2006
4. Jan Y.Y. et al: Percutanous transhepatic cholangioscopic lithotomy for hepatolithiasis:
long-term results. Gast. Endos. 42/1995, pp.1-5.
5. Lee S.K. et al: Percutanous transhepatic cholangioscopic treatment for hepatolithiasis:
An evaluation of long-term results and risk factors for recurence. Gast. Endos. 53/2001, pp.18-23.
6. Otani K. et al: Comparison of treatment for hepatolithiasis: hepatic resection versus cholangioscopic lithotomy. The American College of Surgeon, 189/1999. pp. 177-182.
