TCNCYH 65 (6)-2009
NGHIEN CL/U P H A U THUAT CAT BE CUNG GIAC MAC CO GHEP MANG d l DIEU TRI TANG NHAN AP TAI PHAT SAU MO GLOCOM
Tran Thanh T h u y \ Vu Thi Thai^
' 6 e n / i vien Hifu Nghi, -Benh Vien Mit Trung Uang
Su that bai cua phiu thuat (PT) cit be cimg giac mac (CCM) chii yeu do tang sinh xa sau md. Ming di ngtfdi cd dac tinh ifc che tao xa. Nhieu bang chdng khoa hgc khang dinh ming di cd lic dung lrong PT Id ro. Muc tieu: Dinh gii ket qua ctia phiu thual cit be cimg giic mac cd ghep mang di vi nhan xet diic diem ky thual niy. Bdi tUgng va phuang phap nghien cdu: 34 mit gidcdm da PT dl be CCM that hai cd seo xa xau. Nghien ct'fu md la lam sing tie'n cifu khdng ddi chdng. Kdt qua: Nhiin ip (NA) Irung hinh ha tif 31,79 ± 6,395 mmHg (trtfdc md) xudng 16,21 ± 2,382 mmHg (sau md). Mifc ha NA trung binh tif 15,05 mml lg (47,3%) den 19,64 mmHg (61,8%o). Sd loai thude tra ha NA trung binh giim Id 1,18 trudc PT xudng 0,45 sau PT. Thi luc (TL) sau PT dn dinh hoac tang ban trUdc. Thdi diem cudi cimg theo ddi, sea bgng lot chiem 27,3%; sea khi la 72,7%o; khdng cd seo xau. Bien ehifng trong vi sau md khdng xay ra. Ket luan: PT dl be CCM ghep ming di cd bleu qui va an toan, cd the li 1 lUa chgn tdt ddi vdi nhifng trtfdng hgp tang nhan ip til phit sau md Id rd.
Tff khoa: phau thuat cat be, ghep mang di
I. D A T V A N D E
Flien nay, I^T cat be C G M la phfldng p b l p chu yeu dieu trj gidcdm. Tuy nhien cung vdi Ihdi gian, ty le ha NA cua PT cd xu hfldng g i l m d a n . C I c cdng trinh nghien cflu cho t h i y nguyen nhan that bai cua PT cd nhieu ly do nhflng chu yeu I I sfl tang sinh xd sau PT. De k h l c phuc tinh trang nay, tren t h i gidi va Viet Nam da cd nhieu bien p h i p . l)ac biet viee sfl dung thud'c chd'ng c h u y i n h o i Mitomycin C va 5 Fluorouracil trong va sau PT c i t be ngay cang phd bien. Phfldng phap nay chd ke't qua ha NA td't hdn PT e l t be ddn thuan nhflng cd n h i i u t i c dung khdng mong mud'n nhfl: viem giac mac, phu hcang d i i m do nhan ap t h i p . . . va dac biet I I nguy cd rd vd see bpng dfla den n h i i m trung seo bpng va nhiem trung npi nhan.
Mang d'i ngfldi la md sinh hpc vd mach vdi nhflng dac tinh sinh hpc iiti viet nhfl k h i nang flc che q u i trinh tao xd, I'i'c che qua trinh tang sinh mach mau, chdng viem, k h l n g khuan, flc che mien djch, khdng bj thai loai manh ghep. Tren t h i gidi, PT eat be CGM ghep mang d'i da dflpc tien hanh tfl nhflng nam dau
the ky 20. Nghien ci'iti cua Lu H (2003), Stavrakas P (2008) deu dfla ra nhan xet sff dung I^T cat be CGM ghep mang di hieu q u i va an toan.
Do vay chung tdi lien hanh thflc hien do tai n l y vdi muc tigu: ' "'' ' " " ' 1. Banh gia kdt qua cua PT cat be CGM cd ghep mang di. ;•<;.; f mi'f.
2. Nban xet dac diem ky thuat cua PT cat be CCM cd gbcp mang di. „.. ; , . , j ^ j , ^
I I . D O I T U O N G v A P H U O N G P H A P N G H I E N CL/U . i^i'-WiytJi
1 . Ddi tfldng nghign cffu
34 mat gidcdm goc ddng, gde md nguyen p h l t da PT c i t be cung giac mac nhan ap khdng dieu chinh ( > 21 mml-lg do b l n g NA k l Goldmann) kham t h i y see xo x i u tfl thang 08/2007 den thang 1 1/2008 tai khoa gidcdm vien Mat Trung Udng.
2. Phffdng phap nghign cffu
Sfl dung phfldng phap md ta lam s i n g tien cflu kbdng ddi chflng.
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TCNCYH 65 (6) - 2009
Phfldng p h i p p h i u thuat cat be C G M ghep thud'c tra ha NA bd xung); d i i u chinh tfldng dd'i (<
m i n g d'i: v l cd b i n la PT cat be thdng thfldng 21 mmHg khi dung thud'c tra ha NA bd xung), kem them thi l l m sach mang d'i, dat mang d'i dfldi khdng d i i u chinh ( > 21 m m H g du da dung thud'c va tren vat cung mac cd khau co djnh. tra ha NA bd xung).
Ke't qua PT dfldc d i n h g i l khi ra vien, sau 1 - Seo bpng: td't (bpng t h i m tda lan, b l mat t u l n , 2 t u l n , 1 t h i n g , 3 t h i n g , 5 thang. bpng vd mach); kha (bpng t h i m tda lan nhflng b l
Trong mdi l l n k h l m , benh nhan dfldc k i i m tra '^^^ " ^ i l u mach mau); x i u (khong tao bpng).
thj Iflc, nhan I p , mep md, see bpng, g i l c mac, - Sd loai thudc tra ha NA trung binh dfldc tfnh tien phdng, ddng tfl, the xViuy tinh, gai thi, b i i n b l n g tdng sd cac loai thud'c tra cua t i t ca cac ddi chflng trong va sau md. tfldng nghien cflu chia trung binh.
Danh g i l k i t q u i : Xfl ly sd lieu thdng ke b l n g chfldng trinh Epi info 2008 va SPSS 16.0.
Thj Iflc; b i i n ddi thj Iflc cd y nghTa khi:
S;<t-
+ Thj Iflc > 1/10 cd bien ddi it n h i t mdt hang | | | . K E T Q U A theo b l n g thi Iflc Landolt. ^ „„.
° 1. Ket qua sau PT
-I-Thi Iflc < 1/10 cd b i t k'y sfl thay ddi nao. ^, . , .^, , . , .„ . ,,> , , > . . - Thi lUc: TL cai thien tang dan theo thdi gian.
- Nhan I p dflpc chia thanh c l e mflc: d i i u Khgng ^.^^^^ ^ao bj giam TL trong sudt thdi gian chinh tuyet dd'i (< 21 m m H g khdiig c l n dung nghien cflu.
Bang 1. Bien ddi thi lUc co chinb kinh sau PT.
Bie'n ddi TL Tang ^ ^ O" di"h ' "
j j , „ g Thdi gian So mat (%) So mat (%)
Ra vien Sau 1 tuan Sau 2 tuan Sau 1 thang Sau 3 thang Sau 5 thang
15 20 21 22 23 24
(44,1) (58,8) (61,8) (64,7) (67,6) (73,5)
19 13 13 11 11 9
(55,8) (41,2) (38,2) (35,3) (32,4) (26,5)
34 (100,0%) 34 (100,0%) 34 (100,0%) 34 (100,0%) 34 (100,0%) 33 (100,0%)
2. Kg't qua NA thdi d i i m . NA trung binh trfldc md la 31,85miTiHg c -' .- u ^ MA 1- - , *u J-'- --* - ha xudng cdn 12,15 mmHg (ra vien), 13,21 mmHg
Sau mo, tmh trang NA da CO sfl thay doi rat ro - 5 o , , , b
ret. NA ha xudng n h i i u rdi dn djnh ngay sau 2 ^'^'^ ^ ' ^ ^ " ' ' ^^'^S mmHg (sau 2 tuln), 16,74 mmHg t u l n . Thdi d i i m 5 thang dd'i tfldng nghien cflu chl '^^u 1 thing), 16,65 mmHg (sau 3 thing), cdn lai 33 m i t vi 1 trfldng hdp d t h i n g thfl 3 sau l ^ ' ^ ^ mmHg (sau 5 thang). Mflc ha NA d c l e thdi PT, NA khdng d i i u chinh mac du da dung thud'c d i i m sau m l se vdi trfldc md dao dpng tfl ha NA nen da c h u y i n sang PT k h l c . 15'05 ' ^ ' ^ ^ g (47,3%) d i n 19,64 mmHg (61,8%).
, , , ^ n , , . , - Miic ha NA nhieu n h i t d thdi d i i m ra vien.
NA trung bmh tai cac thdi diem theo doi ha ro '
ret so vdi tn/dc mo cd y nghTa thdng ke tai t i t c l cac - Oanh gia mufc dieu chinb NA sau PT:
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TCNCYH 65 (6)-2009
Bang 2. Mde dieu chinb NA sau PT
Thdi gian
Nhan ap
Trfldc PT 1 thang 3 thang
Digu chi'nh tuyet 0 (0,0) 24(70,6%) 21 (61,8%)
dd'i Di ieu chfnh tffdng 0 (0,0) 8 (23,5%) 11 (32,4%)
dd'i Khdng dieu chinh 34 (1 00,0%)
2 (5,9%) 2 (5,9%)
Tong 34 (100%) 34 (100%) 34 (100%) 5 thang 22 (66,7%) 11 (33,35%) 0 (0,0%) 33 (100%)
Tai thdi d i i m 1 t u l n sau md g i n nhfl tdng sd' c i c m i t d i u cd NA d i i u chinh trong dd cd 4 mat p h i i dung them 1 loai thud'c tra ha NA. O nhflng thdi diem theo ddi tiep sau, mac du van cd 32 mat (88,2%) cd NA nam trong gidi han binh thfldng tuy nhien so m i t p h i i dung them thud'c ha NA bd sung da tang len den 7 m i t (20,6%) rdi 8 mat (23,5%) va 11 mat (32,4%).
- Thudc tra ha NA sau PT: So vdi tritdc md sd' loai thud'c tra ha NA bd xung trung binh da g i l m tfl 1,18 ± 0,521 (tnfdc I^T) xudng 0,18 ± 0.576 (sau 1 tuan), 0,24 ± 0,496 (sau 2 tuln), 0,38 ± 0,652 (sau 1 thang), 0,45 ± 0,711 (sau 5 thang).
Mflc ha nay la 61,8% (sau 5 thang) vdi p < 0,001.
- Seo bong sau phau thuat. Giai doan sdm sau PT, h l u h i t seo bpng d i u td't (91,2%). Ty le nay giam d i n theo thdi gian ngflpc lai ty le see k h i tang dan thee thdi gian luc ra vien la 8,8% ma sau 5 thang la 72,7%.
- Bign chffng: Chung tdi khdng gap b i i n chflng gi dac biet trong va sau PT.
2. Dac diem ky thuat
- Thi lam sach mang d'i: Dung gelaspon gat sach Idp trung san mac d mat sau.
- Thi dat mang d'i dffdi vat cung mac: Mang d'i dflpc kep gifla vat cung mac va nen cung mac vdi kich thfldc rdng hPn nap vat cung mac.
- Thi dat mang di trgn vat cung mac: Mang d'i t r i i tren nap cung mac va khau cd djnh vao sat
ria C G M . P h l n cdn lai se dflpc d i y trflpt ra phia sau I p vao b l mat cung mac de tao dieu kien d i n lflu ra phfa sau.
IV. BAN LUAN
1. Kg't qua sau PT
- Thi lUc: sd mat cd tang TL sau md cua chung tdi kha cao bdi trfldc md h l u h i t benh nhan d i u cd NA r i t cao, cac mdi trfldng trong sudt bj phu n b i l u . Sail md, NA ha td't va h l u nhfl khdng cd bien chflng gl trong va sau md nen n h i i u mat trong nhdm da cd TL cai thien hdn. Fuy nhien do c i c m i t da bj benh d giai doan nang nen TL cd tang nhflng khdng n b i l u .
- Kdt qua vc nhan ap: Mflc ha NA se vdi trfldc md n b i l u n h i t la thdi diem ra vien. Nhfl vay PT p h l t huy t i c dung tdi da sdm sau me va duy tri hieu qua sau 2 tuan. Chung tdi cd the ly giai hien tfldng nay bdi mang di cd t i c dung va sau dd tieu di trong vdng 36 ngay 11]. D l y la thdi d i i m sfl tang sinh xo, phan flng viem, m i i n djch x u i t hien nen mang d'i phat huy hieu q u i dung luc. K i t qua cua chung tdi tfldng tfl Lu H, Stavrakas P nhan ap sau PT d i l l ha r i t td't.
- Bien ddi tbudc ha NA trUdc va sau md: Sau md, sd loai thud'c tra ha NA trung binh sau md so vdi trfldc md cua chung tdi g i l m di rd ret cd y nghla thd'ng ke. Mflc dp ha nay cua chung tdi (61,8%) khae nghien cflu cua Stavrakas P (78,1%) do nhdm dd'i tflpng cua tac gia nfldc ngoai la
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TCNCYH 65 (6) - 2009
gidcdm goc md nen sd' loai thud'c ha NA dung khi trfldc md cua hp la k h i nhieu.
- Ket qua giai phau: Ngay sau md, t i t ca seo bpng d i u td't. Tuy nhien sau PT 1 thang, chung tdi n h | n t h i y kfch thfldc, dp gd cua seo van dflpc on djnh nhflng theo thdi gian x u i t hien mach mau tren b l mat seo. Do v l y sd see td't g i l m d i n thay vao dd see kha tang tfldng flng. D l g i i i thfch hien tflpng nay, met sd t i c gia cho r i n g khi mang d'i cdn tdn tai thi ludn t i l t mdt sd' ye'u t d endostatin, thrombospondin - 1, PEDF (pigment epithelium derived factor) ... |2, 3] nen cd k h i nang flc c h l tang sinh tan mach nhu'ng khi mang d'i tieu t i c dung bj han c h l d i p h l n nao.
3. Big'n chffng
- Bidn chdng trong PT: Cung nhfl ket qua nghien cflu cua n b i l u tac g i l tren the^ gidi trong q u i trinh PT, ehung tdi khdng gap bie^n chflng.
- Bidn chdng sau PT: Khac vdi nghien cflfi cua chung tdi Lu H, Stavrakas P gap mpt sd b i i n chflng nhe nhfl p h l n flng tien phdng, bpng nang bao tenon.
4. Dac diem ky thuat
- Thi lam sach mang di: Mang phai dflpc l l m c l n g sach c l n g td't vi Idp trung s i n mac van bam thi hdi hoac nfldc se n g i m vao l l m cho mang di phu len r i t khd khau c d dinh.
- Tbi dat mang di dUdi vat cung mac: Chinh vat cung mac I p xudng khi khau se cd t i c dung gifl mang d'i khdng xe djch, khdng co dum va khdng chui vao mieng Id rd. hldn nfla, thad tac khau se de d i n g hdn vi mang d'i khdng b] cd dum, dd trdn trflpt, dd bung nhung.
- Tbi dat mang di tren nap vat cung mac: Sau
dfnh c d djnh mang d'i b l n g 2 mui chl d s i t ria phan cdn lai chung tdi trai dai ra sau (phfa cung do) ma khdng khau . C i c h lam nay se don g i l n h o i thao tac ky thuat vi cung dd chat hep-
V . K E T L U A N
PT da cd tac dung ha NA r i t td't, TL, d mflc dn djnh hoac tang hon trfldc m d , khdng ed trfldng hpp nao see x i u , khdng bj bien chflng. Trong PT chu y l l m sach mang d'i sau dd dat tren va dfldi n i p vat cung mac vdi kfch thfldc Idn hdn n i p cung mac se giup viec khau c d dinh mang di de dang hon.
T A I LIEU T H A M KHAO
1. Barton K, et al (2001), "Glaucoma filtration surgery using amniotic membrane transplatation".
Invest Ophthainol Vis Sci, 42(8), 1 762 - 1 768.
2. Dua S.H, Gomes J.A.P, et al (2004), "The amniotic membrane in ophthalmology". Survey of Ophthalmology, 49(1), 51 - 77.
3. Hao Y (2000), "Identification of antiangiogenic and antiinflammatory proteins in human amniotic membrane". Cornea, 19(3), 3 8 4 - 3 5 2 .
4. Lu H, M a i D (2003), "Trabeculectomy combined amniotic membrane transplatation for refractory glaucoma", Yan Ke Xue Bao, 19(2), 8 9 - 9 1 .
5. Stavrakas P (2007), "Amniotic membrane transplantation in glaucoma filtration surgery:
c o m p a r i s o n b e t w e e n a m n i o n s h i e l d e l trabeculectomy and standard trabeculectomy".
Online Abstract Submission and Invitation System.
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