HOI NGHj KHOA HOC LAN THtf IV • HOI TIET NIEU - THAN HOC VIET NAM
PHOI HOP
M 6 N G L / C - B U N G T R O N G P H A U T H U A TOIEU TR!
Bl/CJU THAN CO CHOI AN VAO TINH MACH CHU DlJdl LEN DEN CO HOANH: NHAN 3 TRl/ONG HOP TAI BENH VIEN CHO RAY
• • a • •
Thai Minh Sam', Tran Ngpc Sinh', Tran Le Linh Phirong', Dd Quang Minh', Pham Tho Tuan Anh^
Tran Quyet TienS Nguyin Thai An^
TOM TAT
Bat van de. Biidu than co chdi bu'du an vao tTnh mach (TM) than va tmh mach chii (TMC) du'di la the lam sang dac biet. Phau thuat la phu'dng phap dieu tri hieu qua. Day la mdt phau thuat Idn, co nhieu nguy cd. ,
Benh nhan va kit qua: lii 12/2006 den 3/2010, tai khoa Tiet nieu BV Chd Ray da phau thuat cho 3 benh nhan (BN), 2 nO' (25 va 73 tudi) va 1 nam (64 tuoi), du'dc chan doan bu'du than CO choi an vao TMC bung len den cd hoanh (TsbNxMx). Ve vi tri: 2 ben phai va 1 ben trai. Ca 3 du'dc md md ngiic-bung cat than rpng va md TMC lay het chdi bu'du, co 1 tru'dng hdp phai sit dung may tim phoi nhan tao va 2 tru'dng hdp lam cau ndi tam tu' TMC doan du'di than len nhT phai.
Ket qua 3 tru'dng hdp md deu thanh cdng.
Ban luan: Bu'du than co chdi xam lan vao TMC van co chi dinh md, cuoc md tu'dng ddi d l dang neu choi bu'du con nam trong pham vi du'di gan. Khi choi bu'du an len den doan sau gan hay cao hdn cuoc md se khd khan hdn, can kiem soat TMC du'di doan du'di than va doan tren ngi/c tdt de ngan ngira chay mau va ngan ngira bu'du troi ve tim lam thuyen tac phoi... Phau thuat md ngiic nen du'dc tien hanh va can co sii phdi hdp tdt ciia nhieu kip mo: Tiet nieu, Phau,thuat Mach mau. Gay me hoi su'c vdi may tuan hoan ngoai cdthe...
Kit tuan: Tren day la 3 tru'dng hdp dau tien mo cat than rpng do bu'du va lay chdi bu'du trong TMC da len cao den cd hoanh tai BV Chd (1) Khoa Tiet Nieu, Benh vien Chg Rdy.
Ray. Ket qua cho thay da thanh cdng ve mat phau thuat, ket qua lau dai can co thdi gian de theo ddi va danh gia.
SUMMARY
THORACO-LAPAROTOMY FOR RCC RADICAL NEPHRECTOMY WITH TUMOR
THROMBUS IN HEPATIC VENA CAVA.
Objectives: Renal Cell Carcinoma (RCC) can have a tumor thrombus is the renal vein and vena cava. The removing of the thrombus is difficult, if it is high up to the hepatic vein and thoracic inferior veina cava.
Patients and results: Three patients with the age from 25 to 64 (2 females and 1 male). All the patients were diagnosed RCC (T3bNxM0) and underwent a thoraco-laparotomy, radical nephrectomy with ablation of vena cava tumor thrombus (up to hepatic vena cava), and one case was helped by the Cardio-Puimonary Bypass system (CPB), two cases were performed with a temporary bypass from inferior vena cava to right atrium. The operation was cooperated by 3 surgical teams: Urology, Cardiovascular Surgery and CPB. The tumor and almost of tumor thrombus were removed. All of the operating were successful.
Discussions: The laparotomy for radical nephrectomy for RCC and cavotomy for removing tumor thrombus locating in inferior vena cava near the kidney are a great operation but it is not
Y HOC VIET NAM THANG 11 - 5 0 2/2010
difficult. In circumstance, thrombus locating up to hepatic vena cava or higher need to be performed Thoraco-laparotomy, Cavotomy for removing thrombus with the supporting of a temporary shunt (from inferior vena cava to right atrium) or CPB system.
Conclusions: The radical nephrectomy for RCC and cavotomy for removing tumor thrombus locating up to hepatic vena cava, the first-three cases, were performed in Cho Ray Hospital. This is an initial successful step in the operative technique. The long term results need to be followed, and researched more.
LDATVANDE: « ^^^ T Chdi budu an vao tinh mach chu (TMC) la the lam sang dac biet cua budu than [4],[6]. Cat than rdng (cat than tan gdc) va md tinh mach chu don thuan lay chdi chi cd thi thuc hien khi chdi budu cdn khu trii a TMC doan dudi gan, cude md thuc hien qua dudng bung hay that lung cd dien [2],[3].
Khi chdi budu da an len cao den TMC doan sau gan hoac vugt qua khdi co hoanh hay len den tam nhT phai thi can phai can thiep qua dudng nguc bung va cd the phai nhd den tuan hoan ngoai co the. Day la mdt phau thuat ldn ddi hdi su phdi hpp cua nhieu chuyen khoa [6],[8],[9].
Chiing tdi bao cao ket qua phau thuat nhan 3 trudng hpp budu than ldn cd chdi budu an vao TMC dudi len den ngang co hoanh.
n. BENH NHAN VA KET QUA:
BENH AN 1: Benh nhan SREY A, 25 tu6i, qudc tich Campuchia. Hd so sd: 88497.
Vao vien ngay 6/12/2006, vi dau hdng P kem kh6i u vimg than phai va tilu mau. Benh keo dai khoang tren 1 thang.
Kham liic nhap vien: BN tinh, thi trang tmng binh, da niem hdng, mach: 821/p, HA:
120/70mmHg. Bung mem, than (?) to, dau.
Cac CO quan khac chua phat hien benh ly.
Xet nghiem:
- Sieu am: cue tren than (?) cd khdi echo hdn hpp cd vdi boa kich thudc 84x94 mm.
Cd chdi budu trong TMC dudi, dau tren chdi budu each nhT (?) 6 cm, khdng thay chdi trong cac budng tim.
- MSCT: Budu cue tren than (?), chdi budu TMC dudi.
Chan doan: Budu than (?) cd chdi trong TMC dudi len den sau gan (T3bNxMx).
Md ngay 6/12/2006: phdi hpp giiia khoa Tiet Nieu va khoa ?hau Thuat Tim. Phuong phap xir tri: md nguc-bung, cat than phai rdng va md TMC lay chdi budu cd sir dung tuan hoan ngoai co the. Thdi gian md 6h20 phiit. Lupng mau truyen 6 don vi.
Tu-ong trinh phau thuat: Vao bung dudng gitJa tren va dudi rdn, budu than phai to, TM than va TMC dan to chira day chdi budu, chdi budu an len den doan sau gan. Cd nhieu bach viing rdn than kich thudc khoang 20 mm. Lacet kiem soat TMC dudi doan dudi than, TM than ben ddi dien, cudng than phai.
- Tien hanh md nguc bang xe dpc xuong ire, md mang ngoai tim. Dat canule goc ddng mach chu, TMC tren, TMC dudi va TM diii (T). Chay may tuan hoan ngoai co thi.
- Cot cat cudng than, lay bd toan bd than va mo quanh than thanh mdt khdi.
- Md dpc TMC dudi dai 8cm lay bet chdi budu hudng ve phia tim, phia tTnh mach than (T) va tTnh mach chau, budu dinh kha chat vao thanh TMC. Tdng cpng budu lay ra nang khoang 200 gam. Khau lai TMC.
- Dan Itm trung that va mang ngoai tim, ddng nguc. Dan luu hdc than, ddng bung.
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HOl NGH! KHOA HOC LAN THtf IV • HOI TIET NIEU - THAN HOC VIET NAM
Dien tien sau mo: Hau phlu ngay thu nhk BN phai md lai cim mau (sau md 8 gid) do chay mau tir mpt mach mau tuyin thuomg than.
Hau phau: On dinh din, riit bd cac dng dan luu. Xuk vien sau md 16 ngay.
Kit qua giai phlu benh ly: Carcinoma te bao sang than xam nhap tTnh mach chua di can hach, xep dp md hoc dp II.
Sieu am sau md: khdng thay huyet khdi tTnh mach chii dudi. MRI sau md 15 ngay tTnh mach chii thdng, nghi cd huyet khdi tTnh mach chil bung doan dudi than khdng be tac.
Tai kham sau 3 thang: tTnh mach chu bung cd choi nghi budu tai phat. Sau dd Bn khdng tai kham.
BENH AN 2:
Benh nhan Mac Thi N. , 73 tudi, noi d:
Tiln Giang. Hd so sd: 69294. Nhap vien ngay 17/8/2009 vi dau hdng ? va phat hien u viing than phai khoang 3 thang. Tien can: cao
huyet ap 3 nam, dieu tri lien tuc. , Kham luc nhap vien: BN tinh, the trang
trung binh, da niem hdng, mach: 801/p, HA:
120/70mmHg. Bung mem, than (?) to, khdng dau. Cac CO quan khac chua phat hien benh ly.
Xet nghiem: Bun 20mg%, creatinin:
l,3mg%.
- Sieu am: Budu than (?) kich thudc 8x8 cm, cd chdi budu trong tTnh mach than va TMC dudi. Sieu am doppler TMC dudi khdng bat mau, khdng bat phd do huylt khoi TMC dudi.
- MSCT: Budu than (?) xam lin ldp mo quanh than, cd chdi budu trong tTnh mach than ? va TMC dudi, di can hach viing ron than.
- MRI: Budu than P xam lan vd bao va md quanh than. Chdi trong tTnh mach than va TMC dudi len din ngang miic co hoanh.
Chin doan: Budu than (?) xam lan vo bao than, cd choi trong TMC dudi len din viing sau gan ngang miic co hoanh (T3bNxMo).
Ngay 15/9/2009 md phdi hpp giira khoa Tiet Nieu va khoa Phau Thuat Tim. Xir tri:
md nguc-bung, lam cau ndi tam tir TMC dudi - nhT ?, cat than P rpng, md tTnh mach chil lay chdi budu. Thdi gian md 5 gid 40 phut, mau truyen 4 don vi (1400 ml).
Tu-otig trinh phau thuat: Vao bung dudng giiia tren va dudi rdn, bdc Id than P.
Budu than to xam lan den vd than va cd choi budu an vao tTnh mach than va tinh mach chii dudi len den doan dudi gan sat co hoanh, co nhieu hach viing rdn than kich thudc khoang
1 - 2 cm. Tach budu khdi TMC dudi, kiem soat cudng than, TM chu dudi doan dudi than, TM than ben ddi dien.
Md nguc: xe dpc xuong lie, md mang ngoai tim. Dat canule lam cau ndi tam giiia TM chil dudi doan dudi than va tam nhT P.
Kiem soat doan TMC doan tren co hoanh.
Cdt cat cudng than ?, lay toan bp than va mo quanh than thanh mdt khdi.
Md dpc tTnh mach chu dudi theo dudng ck md TM than va md rdng them dudng ngang mat trudc TM chu lay bet chdi budu vl hudng phia tim, lay chdi budu ben tinh mach than (T). Bom nia TM chii, khau lai tTnh mach chu.
Din luu trung that va mang ngoai tim, ddng nguc. Dan lim hdc than, ddng bung.
Y HOC VIET NAM THANG 1 1 - 5 0 2/2010
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Hinh 2: Chdi budu trong tTnh mach chu sau khi lay ra khdi co the.
,,. (BNMgc Thi N. HS sasS: 69294/09)
Dien tien sau mo:
Hau phau: BN dn dinh dan, nit bd cac ong dan luu. Xuat vien sau md 2 tuan.
Ket qua giai phau berth ly: Carcinoma te bao sang than xam nhap tTnh mach chu bung, chua di can hach, xep do md hoc dp II.
Sieu am sau md 2 tuan va 4 tuan: TM chu thdng tdt, khdng thay huyet khdi tTnh mach chil dudi. Sieu am va CT scan bung sau 3 thang khdng phat hien bat thudng. Hien tai Bn khde dn (sau md 11 thang).
BENH AN 3:
- Benh nhan NGUYEN PH., SN: 1946.
H6 so sd: 22138. Nghi nghiep: huu tri. Cu ngu tai TP.HCM. Nhap vien ngay 19/3/2010.
Ly do: dau bung kem u vung hdng lung trai.
Benh khdi phat khoang 1 nam vdi dau am i vimg hdng limg T, tilu binh thudng.
khdng tieu mau. Tien sir dai thao dudng 3 nam nay.
Kham liic nhap vien: Benh nhan tinh, the trang trung binh, da niem hdng, mach: 80 1/p, HA: 120/70mmHg. Bung mlm, than (T) to, cham than T (+). Cac co quan khac chua phat hien benh ly.
Xet nghiem:
- Sieu am: Budu cue tren than (T) kich thudc 132x78 mm, sdi tiii mat.
- MSCT: Budu cue tren than (T) xam nhiem md xung quang, chdi budu trong tTnh mach than (T) va tTnh mach chu dudi, vai bach nhd vung rdn than va canh DM chu bung. Sdi tiii mat.
- BUN: 18 mg%, Creatinin: 1,3 mg%, Glyeemia: 119 mg%.
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HOI NGH! KHOA HOC LAN THtf IV • HOI TIET NIEU - THAN HOC VIET NAM
Hinh 3: Hinh CT scan: budu than P va chdi budu trong TMC.
(BNNguyin Ph., Hdsasd: 22138/10)
Chan doan: budu than (T) cd chdi trong tTnh mach chii dudi len den dudi co hoanh (T3bNxx).
Ngay 30/3/2010 BN dupc md phoi hgp gifta khoa Tiet Nieu va khoa Phau Thuat Tim. Xir tri: cat than (T) tan gdc, bac cau tam TMC dudi - nhT (P), md TMC lay chdi budu.
Tirong trinh phau thuat: Vao bung dudng giua tren va dudi rdn, dimg Book Walter banh vet md, ha dai trang gdc lach.
Budu than T to, chdi budu an vao tTnh mach than va tTnh mach chu dudi len den doan dudi gan (TM than (T) to khoang 30mm, TMC dudi to khoang 40 mm). Khdng thay hach viing rdn than. Tien hanh cat than (T) rdng, lay mdt phan chdi budu trong TM than, khau TM than.
Ha dai trang gdc gan, bpc Id than (P).
Lacet cudng than. Bdc Id TMC bung doan tu dudi than den doan dudi gan. Lacet dau dudi TMC bung, TM than (P).
Md nguc bang each xe dpc xuong lie, md mang ngoai tim. Tao cau ndi TMC bang
each dat canule tir TMC dudi doan dudi than len nhT (P). Lacet TMC doan tren co hoanh.
Md dpc tTnh mach chu dudi dai 8cm lay sach chdi budu. Khau lai tTnh mach chii.
Riit bd canule TMC - nhT (P). Cam mau ky. Dan luu trung that va mang ngoai tim, ddng nguc bang chi thep.
DSn luu hdc than (T) va canh than (P).
Ddng bung.
Mau truyen tdng cpng trong va sau mo:
08 don vi HC ling, 08 don vi Plasma va 2 kit tieu cau.
Dien tien sau mo:
Hau phau: On dinh dan, nit bd cac ong dan lim. Xuat vien sau md 2 tuan.
Kit qua giai phau benh ly: Carcinoma te bao sang than xam nhap tTnh mach chii bung, chua di can hach xep dp md bpc dp II.
Sieu am sau md 2 tuan: TM chii thong tdt, khdng thay budu hay huyet khdi trong tTnh mach chu dudi.
Sieu am va CT scan sau md 1 thang:
khdng phat hien bat thudng. Hien tai BN on dinh (sau md 4 thang).
Y HOC VIET NAM THANG 11 - 5 0 2/2010
i n . BAN LUAN
Budu than cd chdi an vao tTnh mach chu chiem ti le khoang 5-10 % cua budu than [6],[8]. Chi dinh phlu thuat hit siic de dat vi kho kiem soat chay mau. Vdi lugng mau chay ciia vimg tTnh mach chu, benh nhan cd the bi nguy co chet tren ban md.
Ve chan doan: sieu am bung, CT scan va MRI CO gia tri trong chan doan, dac biet la MRI [5],[7].
Gan day vdi nhftng tien bd ve khoa bpc ky thuat dd la cd su hd trg ciia may tim phdi nhan tao, cd the can thiep giiip dieu tri benh triet de hon vdi chat lugng cao hon gdp phan thanh cdng cua phau thuat [8],[9]. Sau md can dieu tri bd sung bang mien dich tri lieu, hoa tri lieu [10].
Chdi trong TMC khdng phai la yeu td tien lugng quan trpng va khdng phai la de chong chi dinh phau thuat. Theo Swierzwski et al (1994) ti le sdng ciia dang budu xam nhap tTnh mach chii dudi co hoanh sau 5 nam la 64% va 10 nam la 57% (n=100) [6]. Theo Novick d Cleveland Clinic, USA (1990) ti le song ciia dang budu xam nhap tTnh mach chii tren co hoanh sau nam la 64% (n=43), cuoc mo nay cd sir ho trg cua CPB [4].
IV. KET LUAN
Phau thuat cat than rdng ket hgp md tTnh mach chii lay chdi budu khi budu cd chdi an sau len tTnh mach chii la kha thi trong dieu kien hien nay tai Benh vien Chg Ray. Su ket hpp gifta khoa Tiet nieu vdi khoa Phau thuat Tim, vdi hd trg cua may tim phdi nhan tao giiip cho ngudi benh an toan hon va phau thuat vien kilm soat mau mat de dang. Day la 3 trudng hgp phlu thuat thanh cdng dau tien tai benh vien Chg Riy sau nhilu nam chddgi.
TAI LIEU THAM KHAO
1. Tran Van Sang (1998), Bdi gidng benh hge Nieu khoa, Nha xuat ban Miii Ca Mau.
2. Nguyin Buu Trieu (2003). Benh hoc Tiit Nieu, Hoi Tiet nieu -Than hoc Viet Nam chu bien, Nha Xuat ban Y hoc.
3. Emil A. Tanagho, Jack W. Mc Aninch (2004). Smith's General Urology Sixteenth edition, Lange Medical Books/ McGraw-Hiils.
4. Novick AC, Kaye MC, Cosgrove DM. et al (1990): Experience with cardiopulmonary bypass and deep hypothermic circulatory arrest in the management of retroperitoneal tumors with large vena eaval thrombi. Ann surg, 212:
472.
5. Walsh P.C. (2002), Campbell's Urology, Eighth Edition, published by Saunders W. B.
Company.
6. Swierzewskl DJ,. Swierzewski MJ, Libertine JA (1994): Radicalnephreetomy in patients with renal cell carcinoma with venous, vena eaval and atrial extension. Am J Surg: 168:
205.
7. Aslam Sohaib SA; Teh J; Nargund VH;
Lumley JS; Hendry WF; Reznek RH Assessment of tumor invasion of the vena eaval wall in renal cell carcinoma cases by magnetic resonance imaging. J Urol 2002 Mar;167(3):1271-5.
8. Chiappini, B, Savini, C, Marinelli, G, et al.
Cavoatrial tumor thrombus: Single-stage surgical approach with profound hypothermia and circulatory arrest, including a review of the literature. J Thor Cardiovasc Surg 2002;
124:684.
9. Welz A; Schmeller N; Schmitz C; Reichart B; Hofstetter A. Resection of hypernephromas with vena eaval or right atrial tumor extension using extracorporeal circulation and deep hypothermic circulatory arrest: a multidiseiplinary approach. Eur J Cardiothorac Surg 1997 Jul; 12(1): 127-32.
10. Zisman A; Wieder JA; Pantuck AJ; Chao DH; Dorey F; Said JW; Gitlitz BJ;
deKernion JB; Figlin RA; Belldegrun AS.
Renal cell carcinoma with tumor thrombus extension: biology, role of nephrectomy and response to immunotherapy. J Uro! 2003 Mar;169(3):909-16.
