iJAP CHl NGHllN CU'U Y HQC 11. Michael J. Heard and John E. Buster rics and Gynecology, 9th Lippincott Williams &
(2003). Ectopic Pregnancy. Danforth's Obstet- Wilkins Publishers, 9th edition, 72 - 87
Summary
TUBAL PATENCY AFTER LAPAROSCOPIC CONSERVATIVE SURGERY FOR UNRUPTURED ECTOPIC PREGNANCY
The study was carried out to evaluate tubal patency after laparoscopic conservative surgery for unruptured ectopic pregnancy. The result showed that the rate of the tube patency is 64.9%.
Factors such as a history of complicafions of persistent trophoblast, the pelvic adhesion, preoperafive levels phCG, history was pregnant before this pregnancy did not affect the results with the tube patency.
Key words: Ectopic pregnancy
GlAl THU'b^NG NOBEL V^ SINH LY VA Y HOC NAM 2011
GS. Vu T r i f u An Nguydn chu nhidm Bd mdn Mien dich Sinh ly bpnh, Trwdng Dpi hpc Y Ha Npi
Oau tranh sinh tdn Id mft quy ludt khde sau ndy miln djch thu dugc phdt triln. Song nghift cua sg sdng, do mpi sinh vdt tfr thlp cdc kit qua nghien cfru ndy cho thay se thiy den cao thudng ttm ngudn sdng d cdc sinh hai loai ddp frng nay cung tdn tai vd lien quan vdt khde. Ddi vdi sinh vat cdp cao, ddc bift vdi chdt che vdi nhau.
con ngudi thi mdi de doa ludn ludn rinh rap d Miln djch bim sinh (con gpi Id tg nhien xung quanh mlnh, nhit Id tfr ede vi sinh vat hay khdng ddc hifu) la kha ndng tg bao vf md mdt khdng trong thiy dwgc. Con ngudi da sdn cd ngay khi d trgng thai bdo thai vd sau chdng da lgi bing mpi bifn phdp nhung quan khi mdi sinh ra ma mang tinh di truyen. Ndi trpng nhit Id nhd sg d l khdng miln djch cua cdch khde, dd Id kha nang tg bao vf do chinh ca t h i mlnh md cQng ehi mdi bilt rd nhfrng ca c h l khdng ddc hifu tg nhidn gdm nguydn nhdn vd ea c h l tfr cudi t h i ky XIX cdc hdng rdo ngdn cdch ca the vdi mPi trudng (Pasteur, 1822 -1895). ben ngodi nhu da, nidm mac cua dudng fieu
Miln djch id kha ndng ea t h i sdng nhdn ra hod, hd hip..., cdc chit filt cua hdng rdo ca vd fim cdch logi bd ede vdt Ig cd hgi cho nd, hpc ndy dift dugc vi sinh nhu- cdc acid beo, ddc bift Id kha ndng ca ban chdng lgi sg tin enzym...(hdng rdo hod hoc) vd cdc t l bdo vdi cong ciia cde sinh vdt gdy bfnh nhu virut, vi cdc thg t h i filp nhdn cdc vdt Ig cd hgi (hdng khuan, nim, ky sinh trung. Cdc khdm phd tfr rdo sinh hpc) (hlnhl). Dd Id tuyln d l khdng ddu thi ky XX d i n nay eho phdp phdn bift hai miln djch ngogi vi cua ca thi, cd t h i vl nhu td the ddp frng miln djch: mien dich bim sinh ehdc bidn phdng eua mft qudc gia. Hf thdng va mien djch tha dwoc. Theo filn hod thi ndy gifr mft vai trd quan trong ngay ca khi ca miln djch b i m sinh cd trudc vd Id ca sd d l c h l miln djch thu dugc da phdt huy dugc tdc
* Ngay 03 thdng 10 nam 2011, Hdi ddng vi Gidi thudng Nobel Vi^n Hiin Idm Karolinska, Thw Oiin da cdng bo quyet
<^nh nhung bdc hoc dwac gidi thudng vi Sinh ly vd Y hpc lin 102 nSm 2011.
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160 TCNCYH 77 (6)-2011
TAP CHI NGHllN CCPU Y HQC Miln djch thu dugc trong qud trinh trudng
thdnh sau khi ra ddi. Dd Id nhd hogt dfng cua cdc t l bdo cd thim quyln miln djch (bgch c l u cdc loai: t l bdo tua, lymphd, da nhdn...) vd cdc chit filt cua ehung (cytokin, khdng t h i djch thi ...). Chung cd loai cd djnh d cde md nhu- hach, td chfrc lidn kit, cd logi di chuyin tdi moi chd, ra ca ngodi nidm mge ngogi vi, vl nhu- bf phdn trdt tg an ninh nfi bf trong mft qu6c gia. Ddng gdp quan trong cua cdc nhd bac hoc dugc giai thudng ndm nay Id dd ldm ro chfrc ndng cua mdi logi ddp frng cQng nhu moi lien quan cua ehung md cd t h i dugc minh hoa trong hinh 2 trdn.
Tru-dc khi cd nhfrng ddng gdp ndy thi ngay tu- ddu t hi ky thfr XX, khoa hpc cQng dd eho biet nhilu v l ddp frng miln djch b i m smh v l hdng rdo ca hpc hay hod hpc eua da vd nidm mac vdi cdc chit filt tg nhien nhu acid bdo da, cdc enzym trong djch filt, cdc thdnh phan bo thi hay cdc khdng t h i djch the (cua ddp irng thu dugc)... nhung v l vai trd cua cac t l bdo thi vin cQng r i t han c h l . Nhu t l bdo md Langerhans da md ta d dudi da tfr cudi t h i ky thir XIX md cQng chua rd chfrc nang hay nhu- vai tro ciia qua trinh viem trong dap frng miln djch khong dac hifu. Mien djch hpc te bao mdi chl phdt triln tfr khoang gifra t h i ky trudc.
Gan* han vd cQng cd t h i ndi la md d i u cho cdc khdm sau nay Id ndm 1985 cua Chrisfine Nusslein Volhard cung cfng sg (Nobel SL/YH 1995 nhung v l van dk khde Id sg kilm sodt gen trong phdt sinh sdm cua bdo thai), khi nghien cfru v l nhfrng biln ddi gen d rudi d i m da phdt hifn ra mot gen md khi dft biln Idm con rudi trdng r i t la nen ddt ten Id Toll (theo tidng Due Id to Idn) nhung ngodi tdc dgng ldm thay ddi hinh thai thi chfrc ndng cQng chu-a rd;
do Id mft gen r i t cd nen thiy d mpi sinh vdt tu- thdp din cao (1991 mdi phat hifn d sinh vdt cdp cao).
Nam 1996, Hoffmann va cfng sg nghien cfru
v l nhilm trung d rudi d i m ddc bift ddi vdi nim cd chfra endotoxin (mft dfc chat md chu ylu Id lipopolysaecharit) dd phdt hifn ra khi c6 dft biln d mft sd gen nhit Id d gen Toll thi do sfre d l khdng con rudi vdi endotoxin bj giam md eon vft chit. Ndm 1996, dng dd cdng bd nhfrng kit qua chfrng minh Id d rudi dam receptor Toll gifr vai trb chinh chdng Igi nhiem nim. Cdc cdng trinh sau dd dd cho thiy gen Toll md hod mft protein md ca c h l da dugc chfrng minh hoat dfng nhu mft receptor nhdn
•bilt theo miu hlnh (PRR = Pattern Recognition Receptor), nghTa Id c l u true phdn tfr ba chieu cua nd cd mdu hlnh bd cfru vdi mdu hlnh ciia cau thdnh sinh bfnh (PAMP = pathogen- associated molecular patterns) c6 tren virus, vi khuin hay nim. Sau dd, ngudi ta lai thay d sinh vdt c l p cao cd tinh tuang tg ve cau true phdn tfr gifra receptor interieukin-1 vdi Toll ndn dugc x l p trong mot sieu hp vdi ten chung Id receptor tuang tg Toll (TLR, Toll Like Receptor). Hifn nay d ngudi da phdt hien din 10 TLR khac nhau ky hifu tfr 1 din 10, da phan chung cd mat tren cdc te bao tfr ngodi vdo trong ca the nhu te bao bilu bi, te bao ruot, t l bdo tua, dai thgc bdo va nhieu loai t l bao khac. Khi kit hap vdi PAMP thi thdng fin du-gc dua vdo trong t l bdo va hoat hod cdc protein kinase, rdi tin hifu di vdo nhdn hoat hod NF-kB d l tdng hgp vd tilt ra nhfrng cytokin vidm khong ddc hifu nhu TNF, IL-1, lL-6, d l tilp tgc hogt hod cdc te bdo c6 tham quyln mien djch khde cua ddp frng miln djch thu du-gc.
CQng ndm l y , Beutler vd cfng sg dung khdng t h i chdng TNF, mft cytokin quan trong xuat hifn nhilu trong sdc nhiem trung, md tidm cho thd thi thiy con vdt dugc tiem ndy chdng lai du-gc sdc do lipopolysaecharit (hay endotoxin). LPS thay nhilu d trge khuan Gram (-) Id nguyen nhdn cua gdy ra sdc nhilm khuan do nd kich thich qua mfre phan frng miln djch
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Sau dng di sdu vdo xdc djnh gen Toll thi chlnh dd Id gen md cho receptor ddi vdi lipopolysaecharit (tfrc endotoxin) vd ky hifu Id Lps. Ndm 1998, Bruce Beutler lai chfrng minh Id mft du'di Idp 4 cua TLR hoat dfng nhu mft receptor nhfn bilt ra LPS vd phdt hifn d chuft khdng ddp frng vdi LPS Id do ed dft biln ldm m i t chu-c ndng cua TLR4, nhu- vdy LTR4 Id thdnh phin chu chdt cua receptor vdi LPS. 0 ddng chudt ed dft biln nhu- vfy thi cQng thiy d l bj nhilm khuin hay bj vidm kinh diln do thilu khd ndng lidn k i t vd b i t hoat vdi lipopolysaecharit (LPS) c l u thdnh quan trpng d vd vi sinh. Sau cOng phdt hifn thdm Id TLR cd trdn t l bdo da, nidm mge d mpi sinh vft khde vd chung ehlnh Id khdu d i u tidn md LPS vi khuln k i t hgp d l khdi phdt qud trinh vidm khdi phdt sg d l khdng miln djch tg nhidn.
Nhu- vfy, ddng gdp quan trpng cua Hoffman vd Beufier Id khi nghidn cfru sg d l khdng cua rudi d i m vdi nhilm khuin, hai ngu-di dd phdt hifn ra v l vai trd cua receptor Toll vdi vi sinh cd trdn ede t l bdo nhit Id d hdng rdo ngoai vi cua gidng rudi ndy rdi sau dd du-gc md rfng ra ede sinh vdt khde.
Hinh 3. T l bdo tua
Mft khde ndm 1973 Steimann phdt hifn ra mft t l bdo mdi tai cdc ea quan lymphd ngogi vi d chuft md theo hlnh ddng ed nhilu ehdn ndn dng dft tdn Id t l bdo tua (hlnh 3). Sau dd ndm 1978 bdng ky thudt nudi c l y hdn hgp t l
bdo ( t l bdo tua cQng t l bdo lymphd) dng dd xdc djnh du-gc chfrc ndng ciia chiing Id ed khi ndng kich thIch mgnh t l bdo lymphd. Ndm 1985 dng tilp tgc chfrng minh d chuft Id t l bdo bilu bl Langerhans trd thdnh t l bdo tua khi trudng thdnh do bj kIch thieh tfr nhfrng ylu td gdy vidm. Logi t l bdo tua r i t da dang vd c6 mft rfng rdi han d trdn mpi md trong ea thi nhit Id tgi cdc hgch bgch huylt. Chimg ed khd ndng nudt vd thodi hod cde phdn tfr san xult khdng dung quy cdch eiia ca t h i hay la tfr ngodi vdo tfrc Id vai trd chinh eua ddp frng miln djch thu du-gc. VI du nhu- khi gdp cdc vi sinh nhfp vdo trong ca t h i thi nhd cd nhilu tua chung nhanh chdng vd d l ddng tilp xuc vdi ddi tu-gng, dn hay nudt ehung vdo bdn trong md xfr ly vd nhd ed nhilu phdn tfr MHC Idp I vd ldp 11 trdn mdt dem trinh difn cdc clu thdnh khdng nguydn eua vi sinh l y vdi cdc t l bdo cd t h i m quyln miln djch, chii y l u Id t l bdo lymphd T(CD4 hay CD8) nhu- k i t qua thi nghifm nudi c l y hdn hgp dd ndi trdn. Hogt dfng eua chimg dd du-gc ddnh dfng tfr cdc cytokin do ede t l bdo bilu md tilt khi receptor Toll k i t hgp vdi c l u thdnh ngodi mdt (nhit Id LPS) ciia vi khuln. Cdn khi vi sinh dd vu-gt qua hdng rdo miln djch tg nhidn vdo bdn trong ca t h i thi se gdp ede TLR ed trdn mft h l u h i t cdc t l bdo. chiing kich thieh t l bdo tilt ra cdc cytokin gdy vidm kdo cdc t l bdo cd thim quyln miln djch nhit Id t l bdo tua tdi ehd md vi sinh thdm nhdp d l hodn t i t ddp frng mien djch thu du-gc t l bdo hay djch t h i ddc hifu chdng lgi ede vdt Ig l y . Nhu- vfy, Steimenn cung cdc nhd khoa hpc khde dd chfrng minh thdm Id cde tin hifu tfr sg d l khdng b i m sinh (qua receptor Toll) dd ddnh dfng vd hoat hod cde t l bdo tua d l khdi phdt sfre d l khdng thu du-gc tru-dc tien qua cdc chit filt c h i t gdy vidm md hogt hod cdc t l bdo khde eua hf thdng miln djch. Nhd vdy md phdn frng midn djch eiia ea t h i ddnh du-gc ke
162 TCNCYH 77 (6)-2011
TAP CHl NGHllN CCPU Y HQC Ig xdm pham Idnh thd nhu-ng Igi trdnh du-gc
tu- hai mlnh n l u chdng Igi cdc c h i t cua ban than san xuat ra.
Nhd cdc khdm phd trdn md ehung ta h i l u ro hon ca t h i sdng ddc bift Id con ngu-di dd chong Igi s g xdm n h i l m cde vi sinh nhu- t h i ndo, qua do cai filn han nfra nhfrng b i f n phdp phong ngfra chung cQng nhu- h i l u rd han nhu-ng rdi logn do cd d f t b i l n gen md eho cde receptor k i l u Toll.
Khdm phd eua 3 nhd bdc hpc trdn dd cd mft sd frng dung trong y hpc nhu-:
- Hilu rd han v l mdi lidn quan cQa h f m i l n djch bam sinh vdi h f thu du-ac d l cd t h i e l i tiln dugc cde phu-ang phdp gdy m i l n djch thu du-gc bdng vaccin vi dg fim cdch tdc dgng Idn receptor Toll (hay receptor tu-ang tg). Dd cung Id hudng nghidn cfru quan trong ddi vdi cdc khdng nguydn ung thu- hay ca vdi cdc chdt gdy ra chung. G i n ddy, ngu-di ta dd cho bdn tren thj tru-dng logi thude m d Imiquimod hay requislmod Id c h i t d i l u hod mien djch cd tdc dgng Idn TLR7 vd 8 d l han c h l phat t r i l n cua chfrng day sfrng (keratosis); Cd du-gc dung thfr trong ung thu- t l bdo nen da (basal epidermal cell carcinoma), nhu-ng cd thay nhilu tai biln
Hilu ro han tgi sao khi cd rdi loan h f miln djch, ca t h i Igi ed t h i sinh khdng t h i chong lgi chfnh mlnh ( b f n h t g m i n ) vd nhd dd cai tien cdch d i l u trj b f n h cd viem. Vidm l y cd the do CO dot b i l n d i l m d TLR, m f t p h i n frng CO ban Id d l bao v f ea t h i nhu-ng lai cd t h i Idm te bdo tua trinh d i f n ngay khdng nguydn ciia ban thdn d l sinh ra khdng t h i chdng Igi chinh mlnh tfrc h i f n tu-gng x i y ra trong b f n h tu- man.
Bruce A. Beutler sinh ndm 1957 tpi Chicago, My, hpc y a Dpi hpc Chicago. Ndm 1981 dng dd bac sl, rdi sang idm nghien cwu tpi Dpi hpc Rockefeller a New Yori< vd Dai hpc Texas a Dallas.
Tpi day dng da khdm phd ra d rudi dim meeptor Toll la vdi iipopoiysacarit, md diu cho vide md rdng
vai trd eua rexepta iy thiy d mpi sinh vdt Tw ndm 2000 dng Id gido sw vi gen hpc vd miin dich hpc tpi Vidn nghidn cwu Seripps, La Jolla. My
Jules A. Hoffmann sinh ndm 1941 a Echtemach. Luxembourg, dng vdo Dpi hpc Strasbourg. Phdp. ndm 1969. dd PhD. tiip tue sau dai hpc tpi Marburg. Due. Sau dd dng trd vi Strasbourg phu trdch mdt phdng thi nghipm nghien cdu tw1974 din 2009. Ong cung Id gidm ddc Vipn nghidn cwu Sinh hpc phdn tw ti bdo d Strasbourg vd tmng sudt thdi gian 2007 - 2008, dng la chu tjch Vidn Hdn Idm khoa hpc Phdp. Ong kham phd ra gen md eho receptor Toll vd vai trd cua nd trong hoat hod miin djch bim sinh
Hai dng ndy nhdn ehung mdt phin nda tiin giai thwdng tdc khodng 500.000 USD
Ralph M. Stein man sinh ndm 1943 tpi Montreal. Canada, hpc sinh hpc va hod hpc tpi Dai hpc McGill. Sau dd dng sang My hpc tpi Dai hpc Harvard Boston, dng tdt nghipp do bac sl nam 1968. Tw1970 dng lam vipe tpi Dpi hpc Rockefeller New/ York, da la giao sw vi mien djch hpc a dd din tpn 1988, ddng thdi iam gidm ddc Trung tam Miin djch hpc vd bpnh tw nidn cua trwdng. Nam 1973 dng da phdt hipn loai ti bao cd chan d nhieu nai khde nhau tmrig ca thi va dat ten la ti bao tua, sau xac dmh ehung cung Id cung lopi ti bao a da ma Langeriians da ndi din tw cudi the ky XIX. Nhwng dng Id ngwdi da xdc djnh rd mdi iien quan chat che eua Chung vdi tin hieu tw nhung ti bao cd receptor Toll chuyin tdi di khdi phdt sw de khang miin djch thu dwac. Ong nhan phan nda sd tiin thwdng
Gidi thwdng nam nay da giup hieu rd han nhung nguyen ly ehu ehdt trong sw hopt hod dap Cmg miin djch vd mdi lien hp ehpt ehe giwa hai thi dap Cmg, bim sinh va thu dwac. Cho ndn di hiiu gid tri cua cde khdm pha dat dwac giai thwdng xin nhac lpi, ed thi la thda vdi mdt sd dpc gia, nhung nguyen ly ca bdn eua ddp Cmg mien dieh.
TAI LIEU THAM KHAO HAN CH^
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Nobel Prlzes.org
2. Vu Trieu An & J . Claude Homberg (2001).
M i l n dich hpc Nhd x u l t ban Y hpc Ha Npi.
TAP CHl NGHllN CCrU Y HQC
3. VQ Tridu An (2007). Gill thu-dng Nobel Sinh ly hay Y hpc 1901 2007. Nhd xult b i n Y hpc Hd Nfi,
4. Beutler B, Mllsark IW and CeramI AC. Passive immunizafion against caehecfin/
tumor necrosis factor protects mice from lethal effect of endotoxin. Science 30 August 1985,
5. Lemaitre B, Nicolas E, MIchaut L et al (1996). The dorsoventral regulatory gene cassette spptzle/Toll/cactus controls the potent antifungal response in drosophila adults Cell. 86: 973-983,
6. Poltorak A, He X, Smirnova I et al (1998) Defecfive LPS signaling in C3H/HeJ and C57BL/10ScCr mice: Mutations in Tlr4 gene, 282: 2085-2088,
7. Schuler G, Steinman RM (1995)
Murine epidermal Langerhans cells mature into potent immunosfimulatory dendritic cells in vitro. J Exp Med.
8. Steinman RM, Cohn ZA (1973).
Identificafion of a novel cell type in peripheral lymphoid organs of mice. J Exp Med.
9. Steinman RM, Witmer MD (1978).
Lymphoid dendritic cells are potent stimulators of the primary mixed leukocyte reaction in mice. Proc Natl Acad Sci USA.
10. Thao Doan, Roger Melvold & Cari Waltenbaugh (2005) Concise Medical Immunology. Lippincott Williams & Wilkins.
11. Xin Du, Alexander Poltorak et al (2000). Three novel mammalian toll-like receptors: gene structure, expression, and evolufion. European Cytokine Networi<. (11), 3.
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