NGOAI KHOA S6 3-2011
OliU TRI UNG THU DAI - T R U C TRANG B A N G PHAU THUAT NQI SOI
CO sCr DUNG DAO LIGASURE TAI B$NH VI$N DAI HOC Y HA NQI
Kim Vdn Vy*, Tran Ngpc Dung*, Vfl Thj Phuang*', D§ng Qu6c Ai'"', Hd Vdn Quy^t*"
T6M TAT
Myc tieu: Ddnh gid ket qud ban dau dieu tri ung thu* dai trang bSng phau thuat npi soi cd sir dung dao LigaSure.
Phu'crng phAp: NghiSn cu'u hdl ciiu nhijTig b$nh nh3n ung thU d^i tri/c trang du'dc phau thuat npi sol cd su* dpng dao LigaSure tai Ichoa Ngoai - Benh vien Oai hpc Y Ha Npi.
K€t qua nghiin cuti: Tir thang 12 n3m 2009 den thang 11 nSm 2011 cd 34 benh nhan ung thu* dai Iryt trang du'dc phau thuat npi sol cd sii" dyng dao LigaSure, trong dd cd 7 benh nhan cUt nu^a dai trang phai, 3 benh nhan c3t doan dai trang ngang, 6 benh nhan cat nu^a dal trang trai, 6 benh nhan cSt dai trang sigma, 4 benh nhan dit doan triTc trang va 8 benh nhan c3t cut tn/c trang. Thdi gian mo trung binh ia 176,32 phut, thdi gian n5m vien trung binh la 9,94 ngay.
K€t luan: Phau thu$t npi sol cd su' dung dao LigaSure dieu trj ung thU dai triTc trang i^
phu'dng phap an toan va hieu quk, thiji gian nSm vien ngSn, benh nhan it dau sau mo, tinh tham my cao ma van dat du'dc nguyen tSc dieu trj ung thu'.
SUMMARY
Objective: To assess the early outcome of laparoscopic surgery with LigaSure for colorectal cancer.
Methods: review retrospective gathered
'Bg mdn PTTN - Dai hgc Y Ha Ngi, "Benh vien D§/ hpc Y Hi Ngi
"'Bgmon Ngoai- Dai hgc Y Ha Ngi
database was performed of a consecutive series of laparoscopic rectal-colectomy at the hospital of Hanoi Medical University
Result: From 12/2009 to 11/2011, 34 patients underwent laparoscopic rectal-colectomy with LigaSure, 7 cases of right colectomy, 3 cases transverse colon resection, 6 cases of lelf colectomy, 6 cases of sigmoidectomy, 4 cases of low anterior resecrion and 8 cases of abdominoprineat resection. The mean operation time was 176.32 minutes for alt resections. The mean duration of hospitalization was 9.94 days.
Conclusion: Rectal- colectomy laparoscopic with LigaSure is safe and effective, short time hospitalization, reduce pain postoperation, high cosmetic with the rule of operation for cancer.
I. oiSkT V X N O l
Phlu thuat n$t soi c^t d^ trang d3 dupc th\rc hi^n \h\ dhx tifin tten thfi gidi bdi M.Jacobs nam 1991. T^i Vipt Nam, ca cat d?!
trang npi soi dau tien durprc thuc hipn tai Bpnh vipn D^i hpc Y Dirprc TP HCM nam 2002 [2]. Tir dd den nay. vipc ling dung phau thu|t npi soi trong dieu trj ung thu dai true trang da dupc th\rc hipn d nhieu co sd y te tren ca nudc.
Sir phat tri^n cua cfic trang thilt bj It?
thu^t trong phau thuat npi soi da giup cho cdc phlu thu^t vidn th\rc hi§n ky thuat phlu thu$t
NGOAI KHOA so 3-2011 ngay cang thuan Ipi hon, tir dd giup han che
duac cac bien chung, nit ngin thdi gian phau thuat va thdi gian nam vipn, sdm dua bpnh nhan trd Igi vdi cupc sdng binh thudng han.
T?i Benh vipn Dai hpc Y Ha Npi, ngay tu khi mdi thanh l£ip, phau thuat npi soi da dupc ijmg dung trong dieu tri ung thu dai try:c tr^g va viec ung dung dao LigaSure trong phlu thuat ndi soi dai tr\rc trdng da gdp phSn lam cho sd lupng benh nhan bi ung thu dgi tryic ttang dupc phau thugt npi soi tai Bpnh vipn ngay cang tang len, ky thugt ngay cang duprc hoan thipn va dupc the hien qua chdt lugng dieu trj bpnh nhan ngay cang duac nang cao.
Nham nit ra nhGng kinh nghipm de viec ung d^ing phau thuat ndi trong diSu tri ung thu dgi tr\rc trang ngay cang tdt hon. Chung tdi th\rc hien nghien cuu nay vdi muc tieu: Danh gia kk qua ban dau dieu tri ung thu dai true trang bang phlu thuat ndi soi cd su dung dao Ligasure.
II. PHUONG PHAP NGHIEN CCTU 2.1. B6i turgng nghien cuu: Nhung bpnh nhan bi ung thu dai true trang dupe dilu tri bang phlu thugt ndi soi cd su dung dao Ligasure tai khoa Ngogi - Bpnh vien Dgi hpc Y Ha Npi tu 12/2009 d6n 11/2011.
2.1.1. Tiiu chuin lira chgn: Benh nhan dupc chan doan xac dinh dua vao ndi soi dgi tr^re trang va sinh thidt. Chin doan duprc khang dinh Igi bang k ^ qua giai phlu bpnh trong va sau md.
2.1.2. Tieu chudn logi trit:
Benh nhan ung thu dai true trang dupe difiu hi bang phlu thuat tgm thdi ho§c phau thugt md.
2.2. Thiit ke nghien ciiu: Nghien cihi hdi cdu.
2.3. Phuvng phdp thyc hifn:
2.3.1. Difng eg phdu thu^t: Bp dyng cy chuin bao gdm: Cdc trocar 5, 10, 12, cdc dyng cy elm nim, kpp rupt, moc ddt, keo, ong hlit, dao dot dan eye, dao Ligasure va dan may npi soi Kalstord.
2.3.2. Phirffng phdp phdu thugt: Sd lupng trocar dupc sd dyng thudng la 3-4 vd tuy thupc vdo timg phlu thugt cy th^ md chpn vi tri dat. Khdi u dvtgc cdt bd diing theo nguyfin tde phau tich ung thu: phau tieh tir cdc bd mgch chinh cua dgi trang, tc\fc trdng nhdm dam bao khd ndng nao vet hgch tdi da, kep clip hay bupc cdc mgeh mdu chinh tgn gdc, tifip dd se di dpng dgi trdng va hgn che tdi da cac thao tac chgm vao khdi u, cd the hg dgi trang gdc gan, gdc lach hay di ddng dai trang sigma nfiu can. Sau dd md rdng lo trocar d rdn, tren rdn, dudi rdn, trfin xuang mu hoae mgng sudn phdi, trdi tuy theo vi tri khdi u khoang 4-5 em dfi dua dgi trang ra ngoai va thue hifin cdt ndi ngoai ca thfi, thudng chung tdi ndi tgn-tan mdt lap. Ddi vdi phau thudt Milles dp dyng cho ung thu true trang thdp va dng hgu mdn, sau khi true trdng duac giai phdng tdi sat eae Idp ca eiia tdng sinh mdn, ehiing tdi cdt eyt try:c trdng qua dudng tdng sinh mdn sau dd dua phdn dgi trang edn Igi vao d byng vd dua ra ngoai ldm hgu mdn nhdn tgo vinh vien d hd chgu trai. Sau khi Igp Igi luu thdng rupt, khau Igi thanh byng, ehiing tdi thudng npi soi lai kifim tra. Thdng dg ddy dupe luu den khi bfinh nhan trung tipn dupc hay hau mdn nhan tgo cd khi thodt ra, thdng tieu duac riit vdo ngay Cac ehdng ehi djnh eua phlu thugt ndi hdm sau. Bpnh nhdn dupc duy tri giam dau ngodi mdng cdng sau md 3-4 ngdy, sau dd
NGOAI KHOA S6 3-2011 diing glim dau bang paracetamol ho$c g i ^
dau non-steroid vi cho b?nh nhta v^n d$ng som nham h?n che cic bien chiing h6 hAp, tiet ni$u. Khi b?nh nhan da trung ti^n hojc h?iu m6n nhSn t^io luu thong, b$nh nhdn bat dau dugc uong nu6c sau d6 an I6ng (chao, s&a) va an uong binh thudng sau mo 02 tu4n.
2.3.3. Cac diy ll^u thu th^p: tuoi. gidi, nghe nghidp, chAn dodn . phuong phap phSu thu$t, thdi gian phau thu^t. th6i gian dau sau mo, giai d o ^ u, th6i gian nam vi$n, cdc bi^n chimg v4 tinh thfim my thanh byng.
III. KET Q U A NGHIEN cCru
Trong nghiSn ciru cOa chiing tdi c6 tit c4 34 b$nh nhfin ung thu dai tr^c tring dugc diiu tri bang phlu thufit n$i soi c6 sir d^ng dao LigaSure, trong d6 c6 20 b^nh nhfin nam chilm 58.8% vfi 14 b?nh nhfin nO chiSm 41.2%.
DO tu6i ciia b$nh nhfin trong nhom nghiSn ciiu trung binh Ifi 60,2 . trong d6 benh nhfin trS nhflt la 23 tudi va gia nhfit la 81 tu6i.
Vi tri kh6i u duijic trinh bay d bfing I.
V|lri
n T / 1 %
D^l trdng phii
5 14.7
o?i trang
gdc gan 2 5.9
Bang e^i tring ngang
3 8.8
1: Vj tri khoi u e^i tring
g6c lich 1 2.9
D^l tring trii
5 14.7
e^i tring sigma
6 17.6
Tryc tring cao
4 11.8
Trvrc tring thSp
8 23.5
Bang 2: Cac lo?i phau thujt tuong ung vol th&i gian phau thufit va thdi gian nam vifn.
Phu'dng phip phSu thuit Celt nii^ dai tranq phai
Cit doan dal trang nqanq CSt niici dal tranq trai
Cit doan d^l tring slqma CSt doan tru'c trinq
Cit cgt tr^c tring (phSu thuit lollies)
n
7 3
6 6
4 8
T/l
%
20.6 8.8
17.6 17.6
11.8 23.5
Thdl gian mCi TB (phiit)
157.1 91.7
191.7 165.0
202.5 208.7
Thdi gian nim vlfn TB (ngiv)
10.3 8.3
10.0 9.3
10.8 10.2
Thdi gian mo cho tit cfi cfic loai phau thufit trung binh 176.3 phut trong dd thdi gian mo nhanh nhit 14 75 phut va thdi gian m6 liu nhfit la 270 phiit.
Thdi gian nfim vi$n cho tit ca cac loai phau thufit trung binh la 9.94 ngfiy , trong do, thdi gian nim vi?n ngSn nhit 14 7 ng4y v4 Ifiu nhit 14 16 ng4y.
NGOAI KHOA s d 3-2011
B&ng 3: Cdc bifin chdng xdy ra trong vd sau md
BiSn chiirng
Loai bien chtj'ng Chay mau T6n thu'dng tanq khic
Nhiem triinq vet mo Buc, do mISnq no!
Dd bang quanq, am dao Bien chii^q H M I ^
T i c ruot sau mo
n 1 0 3 0 0 0 0
T/l»/o 2.9
0 8.8
0 0 0 0
Trong nghien cdu eda chung tdi cd 1 trudng hprp cat cyt true trang ed bi^n chung chdy mdu d di$n phau tfch mac treo tryc trang vd phdi npi soi lai de edm mau. Tuy nhien, b$nh nhdn ndy bi xa gan cho nen dd Id y^u to nguy co gdy chdy mdu di$n bdc tdch. Cd 3 bfinh nhdn bi nhiem trung v^t md noi dua dai trdng ra ngodi d byng dfi cdt ndi. Cung trong nghifin cuu ei5a ehung tdi, khdng cd trudng hprp ndo cd bien ehung ve hd hdp, tiet nipu vd tim mach.
Bang 4: Giai doan ung thu dua theo gidi phlu bfinh
Glal tfo^n n T/l »/o
Glal dofin 0 0 0
Giai doan 1 6 17.6
Glal do^n I I 19 55.9
Glal doan I I I
7 20.6
Glal do^n IV
2 5.9 Trong nghifin ciiu cila chung tdi, ung thu
giai doan II chiem 55.9%, giai dogn IV cd 2 bpnh nhan, trong 2 b^nh nhdn ndy, ed 1 bpnh nhan do u dgi trdng trdi qud to, ed nhilu haeh mgc treo vd nhan di cdn d thijy gan trdi nen chung tdi chuydn md md dfi cat niia dgi trdng trdi, nao vet hgch vd cdt thdy gan trai, bpnh nhan cdn Igi, ehiing tdi cSt nura dgi trdng phdi va cat sinh thifit nhdn di cdn d hg phan thiiy V qua ndi soi.
IV. B A N LUi^N
Ung thu dgi tri;c trdng thudng g?lp d lira tu6i tir trung nien trd len, trong nghien ciia chiing tdi cd 34 b^nh vdi dp tuoi trung binh
Id 60.2, bpnh nhdn tre tuoi nhdt trong nghien cihl Id 23 tudi vd nhifiu tudi nhat Id 81 tuoi.
Ung thu dai true trang khdng ed sy khde biet vfi gidi, trong nghien ciiu cua chung tdi, nam gidi chifim 58.8% cdn n& gidi chifim 41.2%, dieu nay cung tuang ty nhu nhieu tdc gid trong vd ngodi nudc khde [1], [2], [3].
Trong nghifin eiiu cua ehung tdi, ung thu dgi tryc trdng ggp d tdt ca cdc vj tri, difiu ndy dupc thi hifin theo ty le phdn b6 d Bang 1, trong dd vj tri u d true trdng thdp ed 8 trudng hp'p chifim ty Ip 23.5%.
PhSu thudt ndi soi da tao ra m^t budc ngo^t Idn trong Ijch sii phat trifin ciia ngogi khoa, tii ea cdt tiii mat ndi soi thdnh edng d^u
NGOAI KHOA $63-2011 tien v4o nam 1987 Aagc Philippe Mouret Xh\fc hi?n, phuang phap phau thufit ngi soi da nhanh chong dui?c phd bien va ph4t trien msuih m8 d cfic nudc Au, My v4 tren the gidi.
Mpt so io»i phiu thufit da trd th4nh "tieu chuan v4ng" trong lya chgn phuoTig ph4p di6u tri nhu cit tui mfit, cit rugt thira, phlu thufit Heller... Trong dieu trj ung thu dai tryc tr4ng, ben c?nh phau thufit kinh dien, phiu thufit ndi soi da dugc img dyng v4 ng4y c4ng phfit trien, dem l?i nhieu Igi ich v4 an to4n cho b?nh nhfin mfi vin d4m bfio nguyen tic phiu thufit ung thu nhu trong phiu thufit kinh dien [6]. Tren the gidi, phiu thufit ngi soi cit dai trfing da dugc thyc hi^n lin diu tien tren the gidi bdi M.Jacobs nfim 1991. T?i Vi$t Nam, ca cit dai tr4ng ngi soi diu tiSn dugc thyc hien tai B?nh vien Dai hgc Y Dugc TP HCM nfim 2002 [2]. Phiu thuat ngi soi ndi chung vfi phau thuat ngi soi cat dai true tr4ng noi rieng ng4y c4ng dugc hg4n thi$n, mgt phfin nhd sy phat tri^n va ling dung c4c trang thilt bi ky thufit nhu dag don cue, dao luong cyc ( Bipolar), dao LigaSure, dao sieu fim.
Trong nghien cuu ciia chiing tdi, tfit cfi b^nh nhfin deu dugc thyc hi?n phau thu^t vdi bg dyng cy ngi sgi chufin cd dao LigaSure.
Ky thufit phau thufit dugc thyc hi?n theo nguyen tic phau tich cac bd mach chinh cua dji tryc trfing, k?p clip hay bugc cac mach m4u chinh tan gdc, han che cac thao tac ch?m vfio khdi u.
Thdi gian phau thufit timg lo^i phiu thu|it I^i khfic nhau. Bang 2 cho chimg ta thiy rd sy khfic nhau do, nhanh nhit 14 phau thu^t cat doan dai tr4ng ngang, trung binh 14 91,7 phut v4 Ifiu nhit Ifi phau thufit cit cut tryc trfing vdi thdi gian trung binh 14 208.7 phut.
Thdi gian md cho tit cfi cfic loai phiu thuat trung binh 14 176.3 phiit.
Trong nghien cim ciia chiing tdi, cd 1 trudng hgp bi chfiy mfiu sau md chiSm 2.9%, b$nh nhfin dugc ngi soi lai vfi cim mau kjp thdi nen vin cho ket qu4 dilu trj tdt. Vi tri ch4y mfiu d di?n phiu tich mac treo true trang trong phiu thufit Milles. Tuy nhien, d b?nh nhfin nfiy cd kem theo xa gan nen cd roi loan ddng miu sau md, di?n phau tich ri rfi chfiy mfiu, b^nh nhfin nfiy sau dd dugc truyin mfiu cho kit qui dilu trj tdt. Trong nghien cim ciia Ph?m Nhu Hi?p, cd 1.1% phau thufit Milles ngi soi bj chay mfiu do tdn ±ucmg dim roi tinh mach mfit trudc xucmg cimg phii chuyin md dl cim mfiu. Nhiim trimg vit md cd 3 b?nh nhan chilm 8.8% trong nghiSn cuu ciia chiing tdi, tat cfi deu nhiim triing vi tri dua dgi trang ra ngoai ca thS de cit ndi, vi?c nhiem triing vet md lam keo dfii thdi gian nfim vi?n cua benh nhfin trong nghien cina ciia chung tdi. Mfic dii vfiy, sau khi vit md dugc dieu trj het nhiem trimg, tinh thim my cua thanh byng b^nh vin cho kit qufi tdt. Ty 1$ nhiim trimg vit mo ciia Nguyen Hofing Bic 14 11.5% [2].
Thdi gian nfim vi?n trong nghien cim cua chiing tdi trung binh cho tit ca cac loai phiu thufit la 9,94 ngfiy, ciia Nguyen Ho4ng Bic 14 7,5 ng4y [2]. Thdi gian nim vi$n trung binh cho timg losii phau thuat dugc thi hi^n qua Bfing 2. Do dfic diem ciia B$nh vi^n chiing tdi khdng bj siic ip ve giudng b$nh nen mac dii ve chuyen mdn, nhieu b^nh nhfin chAng tdi cho ra vi?n sdm, nhung do tam ly ciia nhilu b$nh nhfin khdng yen tam cho dii da dugc gifii thich rd van xin nfim lai vai ngfiy, dilu nfiy gi4i thich cho thdi gian nim
NGOAf KHOA SO 3-2011
Vipn trong nghifin cihi eua chiing tdi cd ddi han mOt sd tdc gid khde.
Mpt yfiu td rdt quan trpng nhlm dem Igi kfit qud tdt trong difiu tri ung thu dd Id dupe chdn dodn sdm. Trong nghien ciiu ciia chung tdi. Bang 4 cho thdy bpnh nhdn dup-c chdn doan d giai dogn II chifim ty Ip cao nhat 55.9%, ed 2 b$nh nhdn d giai dogn IV chiem 5.9%, trong do 1 bpnh nhdn do u dgi trdng trai qua to, cd nhifiu hgeh mgc treo vd nhdn di cdn d thiiy gan trdi nfin chiing tdi chuyen md sau khi dd thdm dd k5^ bdng n^i soi, bpnh nhan edn Igi chiing tdi cdt nda dgi trdng phdi va eat sinh thiet nhdn di can d hg phan thiiy V bdng npi soi. Tat cd cdc bpnh nhSn sau khi dn dinh vfi ngogi khoa d^u dugc difiu tri hda chat theo ket qud giai phau bpnh 1^.
Trong nghifin eiiu ndy, sd bfinh nhan cua chiing tdi chua nhifiu, thdi gian nghifin eiiu chua ducrc dai, nhung nhiing kfit qua ban ddu da eho thdy nhiing ddu hipu tich cyc ciia phuang phap phau thugt ndi soi cd sii dyng dao LigaSure trong difiu trj ung thu dai tryc trang. Tir nhihig kfit qua dd, chiing tdi sfi hoan thipn ky ndng phau thugt va md rdng qui md nghifin ciiu nhdm nit ra nhOng kinh nghipm dfi ndng cao chat lugng dieu tri cho bpnh nhdn.
V. KI'T LUAN
Phau thuat npi soi cd su dyng dao LigaSure trong dieu tri ung thu dai tryc trdng Id phuong phdp dieu tri an toan va hipu qua.
Vipc chdn dodn sdm khdi u cimg vdi sy chudn hda vfi dyng cy vd hodn thipn vfi ky thuat md se giup lam gidm thdi gian md, thdi gian ndm vipn vd bifin chiing, ddng thdi mang Igi tinh thdm my cao hon.
TAI LIEU THAM K H A O .
1. Austin MX, Feurer ID, Holzman MD, et al (2005). The impact of a laparoscopic colorectal surgeon on laparoscopic colectomy an experience of a single academic center.
SurgEdosc. 19:311-5.
2. Nguyen Hodng Bdc (2003), Phdu thugt ngi soi cdt dgi true trdng, Hpi thao chuyen d^ npi soiTPHCM,tr: 160-165.
3. Chang YJ. Marcello PW, Rusin LC, et al (2005). Hand assisted laparoscopic sigmoidcolectomy: helping hand or hindrance? Surg Endosc. 19:656-61.
4. Fleshman J, Sai^ent DJ, Green E, et al (2007). Laparoscopic colectomy for cancer Is not inferiorto open surgery base on 5-year data from the COST Study Group Trial. Ann Surg. 246:655-64.
5. Hayes JL, Hansen P (2007). Is laparoscopic colectomy for cancer cost-effective relative to open colectomy?. ANZ J. Surg. 77:782-6.
6. Martel G, Boushey RB (2006).
Laparoscopic Colon Surgery: Past, Present and future. Surg Clin N Am. 86: 867-97.
7. Phgm Nhu- Hi?p, Le Loc (2006), Phdu thugt ngi soi trong ung thu dgi trdng tgi B?nh vi^n Trung uang Hue, T^p chi Y hpc Vipt Nam, tr:20-28.
8. Jacob BP, Salky B (2005). Laparoscopic colectomy for colon adenocarconoma. Surg Endosc.
9. Kahnamoui K, Caddedu M, Farrokhyar F et al (2007). Laparoscopic surgery for colon cancer; a systematic review. Can J Surg.
50(1): 48-57.
10. Veldkamp R, Gholghesaei M, Bonjer HJ (2004). Laparoscopic resection of colon cancer: Consensus of the European Association of Endoscopic Surgery (E.A.E.S). Surg Endosc. 18:1163-85.
