ehdng lai su nhiem HP K^T LUAN
Qua nghien eipu 75 benh nhan suy than mgn tfnh giai dogn lll-IV dupe diiu tri Ipc mau chu ky va chua Ipe mau, chiing tdi riit ra nhu-ng kit luan sau:
+ Tdn thuang da day qua hinh anh md bpnh hpe cd ty le cao 94,6%, trong dd viem man ndng 72%), viem hogt ddng 33,3%,, viem teo 26,0%), di san 13,3% loan san 4,0%).
+ Qua md benh hpe, bang phuang phap nhupm giemsa, ty le nhierri HP la 48,0%. Nhiim HP cd lien quan vdi hinh anh tdn thuang md bpnh hpe, HP ed mat vdi ty le rat eao trong viem hogt dpng 96,0%), cd ty le cao trong viem teo 65,0%) va loet 66,7%)
TAI LIEU THAM KHAO
1. TA LONG. "Benh ly dg day- ta trang va vi khuan Helicobacter pylori", Nha xult ban y hpe 2003
2. NGUYEN DUY HOAl NAM. "Nghien cipu lam sang, hinh anh npi soi, md bpnh hpe tdn thuang dg day- ta trang d benh nhan suy than mgn dgng Ipe mau chu ky", Luan van thge sy y khoa, Hpe vipn quan y 2007.
3. ABDEL W.M et al. "Helicobacter pylori and uremic gastritis: a histopathologic study and a correlation with
endoscopic and baeteriologie findings". Am J Nephrol 1997;17(2), pp. 165-71.
4. AL-MUEILO SH. "Gastroduodenal lesions and Helicobacter pylori infection in hemodialisis patients", Saudi Med J 2004, 25(8), pp.1010- 32.
5. MISRA V. et al. "Endoscopic and histological changes in upper gastrointestinal tract of patients with chronic renal failure", Indian J Pathol Microbiol 2004, 47(2), pp. 170-3.
6. NAKAJIMA F et al. "Helicobacter Pylori in patients receiving long- term dialysis", Am J Nephrol 2002, 22(5- 6), pp. 468- 72.
7. NARDONE G et al. "Gastroduodenal lesions and Helicobacter pylori infection in dyspeptic patients with and without chronic renal failure", Helicobacter 2005, 10(1), 53-8.
8. SOTOUDEHMANESH R et al. "Endoscopic findings in end-stage renal disease", Endoscopy 2003, 35(6), pp. 502- 5.
9. TSUKADA K. et al. "Helicobacter pylori infection in hemodialysis patients", Hepatogastroenterology 2003;
50(54), pp. 2255- 8.
KET QUA Birorc DAU NAO VET HACH
B A N G P H A UTHUAT NOI SOI TRONG DIEU TRI UNG THIT DA DAY VUNG HANG MON VI
DAT VAN DE
Ung thu da day (UTDD) la mot trong cac loai ung thu phd bien nhat tren the gidi, dung hang dau trong sd cac ung thU di/dng tieu hoa. Hang'nam, tren the gidi cd tdi 900.000 trUdng hdp UTDD mdi mac (chiem
= 9% sd trudng hdp ung thu; mdi va ty le tuf vong do UTDD chiem >10% cac trudng hdp chet do ung thu ndi chung) [3]. Tai Viet Nam, ti le ngudi mac UTDD cung kha cao. Cho tdi nay, phUdng phap dieu tri UTDD chu yeu v i n la p h i u thuat[4]. Cac bien phap khac nhu hda chat, m i l n djch, xa trj dUOc coi la nhijng bien phap hd trd, .tuy theo tinh trang benh nhan va giai doan benh ma cd cac chi <3|nh cu the [2],[3].
Trudc thap ky 90 cua the ky XX, phiu thuat dieu trj UTDD duoc thuc hien bang phUdng phap md md kinh dien. Nhung trong khoang 2 thap ky gan day, phiu thuat npi soi cung da dUdc ap dung de md ung thu da day vdi sd lUdng ngay cang nhieu. Kitano la mot trong nhufng phau thuat vien dau tien ap dung md ndi soi dieu tri benh UTDD [9] va nhufng thdng bao dau tien ve ket qua md npi soi dieu trj UTDD da dUdc cdng bd [10]. Nhieu cdng trinh nghien cufu ve cat da day nao vet hach qua ndi sol cho UTDD sdm cho thay ket qua ban dau rat kha quan so vdi phiu thuat kinh dien [5],[6],[8]. Tai Viet Nam, md ndi soi dieu trj UTDD cung da bat dau ijng dung nhurig mdi chi thUc hien dUdc tai mot sd trung tam Idn cd nhieu kinh nghiem ve md ndi soi va sd benh nhan dUdc dieu tri theo phuong phap nay cdn rat han che [1]. TrUdc thUc te dd, Chung tdi thUc hien de tai: 'Kei qua bu6c dau
D 6 V A N TRANG, TRjNH HONG SON, D 6 DlfC VAN nao vet hach bang phiu thuat ngi sol trong dieu trj ung thu da day vung hang mon vf, vdi cac muc tieu cu the sau day:
1. Danh gia sa bo ket qua nao vet hach bang phiu thuat noi soi
2. Xay dung qui trinh ky thuat nao vet hach bang phiu thuat noi soi
DOI TUONG VA PHl/ONG P H A P NGHIEN CLfU 1. Doi tircJng nghien ciifu: Gom 31 benh nhan dUdc chan doan la ung thu da day vung hang mdn vj d\jgc nao vet hach bang p h i u thuat ndi soi tai Benh vien Viet Dufc va Benh vien Buu dien tir 01/2007 tdi 07/2008.
* Tieu chuan chon benh nhan:
^ Cac benh nhan khdng phan biet gidi tinh tif 15 tuoi trd len.
- DUdc chan doan xac djnh la ung thu da day vung hang mdn vj, cd xet nghiem md benh hoc la adenocarcinome
Khdng cd cac benh phdi hop nhu: Xo gan, suy gan, suy than, dai thao dudng, lao phdi, tai bien mach nao.
2. Phirong phap nghien cufu:
2.1. Thiet ke nghien cihi:
Nghien cijfu md ta tien cljru, theo ddi doc 2.2. Mo ta ky thuat phau thuat:
Chung tdi thudng suf dung scope 30° vdi cac phuong tien ndi soi hd tro khac nhu ven gan, endo- stapler, dao ligasure, bipolaire hoac hamoniscapal.
Benh nhan nam ngCfa, hai chan dang 45°, phiu thuat
82 Y HOC THlTC HANH (773) - SO 7/2011
vien dufng giufa hai chan benh nhan hoac ben phai, ngudi phu dirng hai ben.
KET QUA NGHIEN CQU
Vdi 55 benh nhan dupc chan doan xac djnh la ung thu da day viing hang mdn vi, dugc dieu tri bang phiu thuat ndi soi nao vet hach Di2, tai Benh vien Viet Dufc va Benh vien Buu dien tU 01/2007 tdi 07/2009 chiing tdi sd bd dat dUOc nhung ket qua budc dau nhu sau:
1. Phan theo gidi Gi6l Nam
Nur Tong so
n 23 32 55
Ty le % 42 58 100 Ty le benh nhan nur chiing tdi gSp nhieu hdn nam
gidi.
2. Phan theo tuoi:
Tudi
<40 41-50 51-60 61-70
>70 Tong so
n 7 14
7 18
9 55
Ty le % 13 26 13 32 16 100 Dp tudi gap nhieu nhat tif 41-70 tudi chiem ty le 71%).
Benh nhan tre nhat la 31 tudi.
Gia nhat la 80 tudi. Tudi trung binh la 58,52.
3. Theo dia tri:
Dia chi Thanh pho
Nong thon Tong so
n 39 16 55
Ty le % 29 71 100 Nhufng ngUdI sdng b thanh phd chiing tdi gSp nhieu hdn nhufng ngudi d ndng thdn.
4. Theo nghe nghiep:
Nghe nghiep Lam ruong
Can bo Cong nhan
Huu tri Khac Tong so
n 13 14 2 16 10 55
T9 le % 23.6 25.5 3.6 29.1 18.2 100 Can bp va hUu tri la hai la 2 ddi tUdng gSp nhieu nhat chiem 54,6%.
o. 1 neu cnung lam sang Trieu churng lam sang Tien silrdau tren rdn >1 nSm Dau tren rdn tU 6 thang-1 nam
Dau tren rdn <6 thang Vao vien vi dau tren rdn
Gay silt can > 2kg Gay silt can 1-2kg
Gay sut khong ro Di ngoai phan den (co mau) Day bung, kho tieu, Sn kem
Non, 0 hdi, a chua
khi vao vie n 18 17 20 55 19 13 23 7 25
9 n:
Ty le % 32.7 30.9 36.4 100 34.5 23.6 41.8 12.7 45.5 16.4 Tat ca eae benh nhan nay deu vao vien vi cd dau hieu dau viing tren rdn d mifc dd khac nhau. cd tdi hdn 1/3 so trudng hdp khdng ed tien silf dau tren rdn ro rang ma ehl cd cam giac dau tife khd ehju b viing tren rdn mdt vai thang nay. Hdn mdt nifa sd benh nhan cd dau hieu gay sut ro tif 2 kg trd ien. Sd cdn Igi khdng rd dau hidu
gay sut. Chi cd 7 benh nhan trong tien si^ ed dau hieu chay mau dudng tieu hoa. Cd tdi gan mpt nifa sd benh nhan vao vien cd dau hieu day bung, khd tieu, in kem.
6. Hinh anh noi soi ung thiT da day:
Hinh anh
Ung thu da day 6 giai doan s6m The sui
The sui, loet The loet The tham nhiim
Tong cong
n 22
6 6 15
6 55
Tyle 40 11 11 27 11 100 Tat ca cac benh nhan ciia chiing tdi deu dUde soi da day cd tdn thUdng ung thu, deu ed sinh thiet tra Idi \k adenocarcinome. Trong dd ed 40% sd benh nhan ciia chiing tdi dUde chan doan d giai doan sdm. Cac benh nhan nay deu dUde lam cac xet nghiem sinh hoa, huyet hoc, miin djch tim yeu td nguy ed ung thu, nhifng chi ed 5/55 benh nhan ed CA 19-9 >40 u/ml cdn lgi tat ca deu trong gidi han binh thudng. Cac benh nhan deu dupe lam sieu am d bung va deu chua thay cd dau hieu di cin gan hoSe cac tang khae.
7.Vi tri va so 16 Troeart:
Chiing tdi thudng sif dung 4 hoSc 5 Id troeart trong dd cd 2 ho§e 3 id 10mm tuy tifng trUdng hdp benh nhan va dung eu can thiet phai sif dung:
Sd l6 troeart 4 16 troeart 5 16 troeart Tong sd
n 43 12 . 55
Ty le % 78 22 100 Co 43/55 benh nhan chiem t^ le 78%) chiing toi chl diing 4 Id troeart vdi 2 Id 10mm d giufa dudi rdn va mang sUdn trai, 1 Id 5 mm d dudi sUdn phail Id 5 mm dudi mui Lfe 4-5 cm.
8. Sinh thiet tiirc thi hach nhdm 8:
Di cSn hach nhom 8 Hach nhom 8 khong c6 di cSn
Hach nh6m 8 c6 di cSn Tdng sd
n 39 16 55
Ty le % 71 29 100 Tat ca cac benh nhan trong dien nghien cifu ciia chiing tdi deu dUde lam sinh thiet tife thi hgch nhdm 8 trong md de quyet djnh chl ngo vet hach D2 (bao gdm cac nhdm hach NI va cac nhdm 7,8,9 va1) hay se phai nao vet hach D2 md rpng (lay them cac nhdm 11,12 hoSe nhdm 13,16). Cd 16/55 benh nhan da cd dl can hach nhdm 8.
9. So' lUdng hach dUdc nao vet Sd luOng hach duoc nao vet
5-10 hach 11-15 hach 16-20 hach 21-25 hach
>25 hach Tdng sd
n 7 12 20 9 7 55
Ty le % 13 23 35 16 13 100 Sd lUdng hgch chiing tdi nao vet bang phiu thuat ndi sol It nhat la 5 hach, nhieu nhat la 35 hach. Trung binh la 18,68 hach.
Y HOC THirC HANH (773) - SO 7/2011 83
10. s d lUdng hach co di can ung thU 15. Thdi gian ra vien sau mo So lUdng hach co di can
Ohach 1-6 hach 7-15 hach
>15hach Tong so
21 12 18 55
Ty le % 38 22
100 Cd 21 trudng hpp chua cd di can hach deu b giai doan sdm. 12 trUdng hop di can tU 1 den 6 hach trong dd cd 1 trudng hop di can kieu nhay cdc: Chi cd duy nhat 1 hach nhdm 8 (hach ehang 2) cd di can. Cd 4 trudng hpp di can tren 15 hach, trong dd cd 1 trudng hop chung tdi gap 16/17 hach cd di can.
11. Tai bien gap trong mo:
Trong qua trinh p h i u thuat ndi soi nao vet hach D2, chiing tdi da gap 1 trUdng hpp tdn thuong thanh mac dai trang ngang gde gan, 2 trudng hpp lam thung mac treo dai trang ngang. ca 3 trudng hop khau lai cho ket qua td't.
Chiing tdi chUa gap trUdng hop nao chay mau nhieu phai chuyen md md.
12.Thdi gian mo Thdi gian md
<150 phut 151-180 phut
181-210 phiit 211-240 phut
> 240 phut Tdng sd
n 5 9 17 14 10 55
Tyle 10 16 29 25 18 100 Thdi gian md dai nhat ehung tdi phai tien hanh trong 315 phut, ngan nhat la 145 phut. Trung binh la 220 phut.
13. Thdi gian trung tien.
ThcJi gian trung tien (gid)
<48 49-54 55-60 61-66 67-72
>72 Tdng sd
n 12
9 13
9 5 7 55
Ty le % 22 16 24 16 9 13 100 Thdi gian trung tien sau md trung binh la 58,66h.
Nhieu nhat la 78h, it nhat la 42h.
14. Miifc do dau sau mo:
Mure d6 dau Rat dau Dau nhieu
Dau vifa Dau ft Tong sd
n 0 5 18 32 55
T^ le % 10 32 58 100 Thudng sau md chiing tdi cho benh nhan thuoc giam dau perfalgan Ig vdi lieu 03 Ip TM/ngay. 58% so bpnh nhan ciia chiing tdi ed cam giac dau it sau md. Cd 5 benh nhan dau nhieu chiem ty le 10%.
Thdi qian dieu tri (ngay) 4
5-6 7-8 9-10 11-12
>12 Tong sd
n 12 26 8 3 3 3 55
Ty'le%
22_
47 15 5 5 5 100 Thdi gian ra vien, sau khi phiu thuat trung binh cCia chiing tdi la 5,9 ngay. nhieu nhat la 13 ngay, ft nhat la 4 ngay.
Chung tdi chua gap trudng hop nao cd tai bien trong va sau md phai can thiep bang md md.
Theo ddi xa sau md, chiing tdi gap 1 trUdng hpp tCf vong sau md 6 thang do di can gan. Cac trudng hpp cdn lai cdn sdng va khdng cd di can tai Id troeart
Vdi nhung ket qua ban dau thu dUOc, chung tdi cho rang phiu thuat ndi soi nao vet hach D2 de dieu tri ung thu da day viing hang mdn vi cd the dUOc ap dung td't b cac co sd p h i u thuat cd trang bj he thdng md ndi soi. Tuy nhien day la mdt p h i u thuat ndi soi chuyen sau, ddi hdi p h i u thuat vien can phai cd kinh nghiem va can phai cd mdt e kfp trp giup hpp ly mdi cd the thUc hien td't dUpc phiu thuat nay.
B A N LUAN
Mac dii cho den nay v i n cdn nhieu ngudi hoai nghi ve hieu qua cua viec nao vet hach bang phiu thuat ndi soi trong dieu trj p h i u thuat ung thU da day.
Phan Idn p h i u thuat nay chl dUOc ap dung chO nhufng trudng hpp ung thu da day sdm. Kitano Nhat Ban la ngUdi dau tien da ap dung thanh cdng p h i u thuat nay vao nam 1991. Tiep theo, nhieu cac tac gia khac nhU Huseher, Adachi, Shimizu, Mochiki....cung da cd nhufng bao cao danh gia so sanh ket qua giufa md ndi soi va md md kinh dien trong p h i u thuat dieu trj ung thu da day va deu thdng nhat rang P h i u thuat ndi soi duoc ap dung td't cho nhung trudng hpp ung thu da day sdm.
6 Viet Nam mac du p h i u thuat ndi soi de dieu tri ung thu da day mdi chl dude ap dung tai cac trung tam ngoai khoa Idn nhu Benh vien Cho R i y , Benh vien Oai hoc y duoc TP Hd Chf Minh, Bdnh vien Viet Ou'c, Benh vien TW Quan ddi 108, nhUng budc dau phiu thuat nay da dUOc nhieu ngUdi danh gia la cd hieu qua va cd the so sanh tUOng dUOng vdi mo md.
Trong p h i u thuat nao vet hach 0 2 bang phUdng phap nd[ soi diei^ trj UTDD vung hang mdn vj, viec chpc 4 Id hay 5 Id troeart la tuy thudc vao tUng benh nhan va do thdi quen cOa tUng p h i u thuat vien. Trong phan ldn cac trudng hop (71%), chung tdi chi sil-dung 4 Id va thay rang viec nao vet hach cung nhu viec giai phdng mac ndi Idn khdi dai trang ngang duoc tien hanh kha thuan loi. Viec chon 2 Id 10mm hay 3 16 10 mm tuy thudc vao dung cu sir dung cung nhu vao dac diem cua moi benh nhan. Khac vdi md md kinh d i l n cat da day nao vet hacn trong ung thu chi cd mdt
84 Y HOC THl/C HANH (773) • SO 7/2011
dudng rach bung chung tren rdn, viec thay ddi vi tri ciia eae Id troeart la tuy thudevao tifng benh nhan.
Chung tdi cho rang trong phiu thuat ndi soi, vipe chpn vj tri dat cac troeart ed anh hudng rat nhieu den ket qua eua cas phiu thuat.
Vdi cac ket qua nghien cufu thu dugc, chiing tdi cho rang kha nang nao vet hach D2 bang phuong phap ndi soi trong dieu trj UTDD viing hang mdn vi cd the thuc hien tdt khdng khac gi so vdi md md. Tdng sd hach ehung tdi nao vet D2 tren cac benh nhan trung binh la 18,68 hach. Ket qua ciia chung tdi cung gan tuong dUdng vdi bao cao eua Nguyin Minh Hai - BV Chd Ray (18,5). Trong thdi gian gan day ky thuat md ndi soi da phat trien hOn rat nhieu, ngUdi ta thay rang ed t h i ap dung phiu thuat ndi soi cho ca nhiing trudng hdp ung thu da day d giai doan T2, T3 deu cho ket qua rat dang khfch le. Theo bao cao cua cac tac gia nude ngoai nhu Kitano,Adachi, Shimizu, Mochiki sd lUdng hach lay dupc giu'a md ndi soi va md md la tUdngdUdng nhau. (5J,(8),(9),(10).
Kha nang nao vet hach, cac tai bien giOfa md ndi soi va md md la tUOng dUOng nhau. Tuy nhien thdi gian md ndi soi keo dai hOn so vdi md md. Thdi gian md ndi soi ciia ehung tdi trung binh la 220 phiit, cung tUdng dUdng vdi cac tac gia trong nUdc (1),(7) va nude ngoai (5),(6), da bao cao.
Sau md ndi soi, benh nhan hdi phuc nhanh hOn, thdi gian trung tien ngan hOn, tham my hOn va benh nhan ft dau ddn hdn so vdi md md.
Mac dii sd luong benh nhan nghien cufu cdn ft, nhifng vdi nhung ket qua ban dau thu duoc, chiing tdi cho rang phiu thuat ndi soi nao vet hach D2 hoac D2 md rdng de dieu trj ung thu da day vung hang mdn vi cd the dugc ap dung tdt b cac co sd p h i u thuat.
Viec cat ndi da day vdi rupt non theo phuong phap Billroth 1 hoac Billroth 11 la tuy tUng trudng hpp benh nhan eu the. Chung tdi da cat va ndi da day-hdng trang theo Billroth 11 trude dai trang ngang 16/31 cas, qua theo ddi sau md, chiing tdi khdng thay cd gi khac bipt so vdi ndi qua mac treo dai trang ngang trong md md kinh dien.
KET LUAN
-Kha nang nao vet hach, cac tai bien giu'a md ndi soi va md md de dieu tri UTDD vijng hang mdn vj la tuong duong nhau.
-Viec sinh thiet tii'c thi hach nhdm 8 theo chung tdi la rat can thiet vi nd cho ta biet cd nen phai nao vet hach Chang 2 (D2) md rdng hay khdng.
-Khi can thiet phai nao vet hach D2 md rdng de lay di cac nhdm hach N i l , N12, N13, N16 Viec ap dung phiu thuat ndi soi cd the cho phep thUc hien thuan loi vl trudng mo rdng va nhin rd tdn thUOng.
-Mac dii thdi gian md ndi soi keo dai hon so vdi md md kinh dien nhung kha nang hoi phuc sau md cda benh nhan nhanh hon, benh nhan ft dau hon va tham my hon so vdi md md.
SUMMARY
The initial result of lymph nodes dissection by endoscopes surgery in stomach cancer treatment at pyloric antrum area
Endoscopes are being more and more populariy applied in a number of fields, especially in surgery. In over the worid, endoscopes have been used to operate stomach cancer with an increasing number of cases. In Vietnam, endoscopes for stomach canceris treatment has begun to be applied but only in several big centers which have senior experience on endoscopes, besides the number of patents being treated under this method is still limited. With an initial result of 55 cases which are dissected lymph nodes by endoscopes surgery for stomach cancer treatment at the pyloric antrum area at Viet Due and Telecom hospital. In the authoris point of view, endoscopes can be applied to dissect D2 or expanded D2 lymph nodes for stomach cancer treatment. Despite of a longer time for operation, the lymph nodes is dissection is ability, complications as well as fatalities rate are similar. Recovery ability after operation of patients is faster, reduce pains and increase aesthetic level to patients in compared to normal surgery.
T A I LIEU THAM KHAO
1. Nguyin Minh Hai (2003), "Dinh gii ban dau ve phau thuat cat da day nao hach qua ndi soi hd trg", Y hgc Thinh phd' Hd Chl Minh, so dac biet chuyen di phau thuat ndi soi tr 109-113.
2. Trjnh Hdng Sdn, Od Difc Van (1995), "Nao vet hach trong dieu tri ung thu da diy", Y hgc thuc hinh, Chuyen san ung thu hgc, 11, tr. 30- 33.
3. Trjnh Hdng Sdn, Do Dure Van (1999), "Budc dau dinh gia ket qua nao vet hach trong dieu tri phiu thuat ung thu da diy", Thdng tin Y dugc, 11, tr 62- 65.
4. Dd Difc Van (1993), "Dieu trj phau thuat ung thU da day tai benh vien Viet Difc (1970-1972)", Y hoc Viet Nam, tip VII, tr. 45- 50.
5. Adachi Y., Shiraishi N., Shiromizu A. et al. (2000),
"Laparoscopy-assisted Billroth I gastrectomy compared with conventional open gastrectomy". Arch. Surg., 135, pp 806" 810.
6. Goh P. M., Alponat A., Mak K. et al. (1997), "Early results of laparoscopic gastrectomies", Surg. Endosc, 11, pp. 650-652.
7. Nguyen Minh Hai, Lam Viet Trung (2005), D2 gastrectomy in gastric cancer. Tap chl 6"^ international gastric cancer congress, Yokohama (Japan), May 4-7,
8. Husher C. G. S., Mingoli A., Sgarzini G. (2004),
"Videolaparoscopic total and subtotal gastrectomy with lymph node dissection for gastric cancer", The American J. Surg, 188, pp. 728-735.
9. Kitano S., Iso Y., Moriyama M. et al. (1994),
"Laparoscopy-assisted Billroth I gastrectomy", Surg.
Laparosc. Endosc, 4, pp. 146-148.
10. Kitano S., Shlmoda K., Miyahara M. et al. (1995),
"Laparoscopic approaches in the management of patients with early gastric carcinomas", Surg. Laparosc.
Endosc, 5, pp. 359- 362.
