V Hpc TP. H o Chi Minh * Tap 16 * So 4 * 2012 N g h i e n cuu Y hpc L I 100%* I Phutigp I I 100 I cung nhu thoi gian huah luj'en danh gia VD SS
* Idtoks^ coug 2 tneang hap^ mong dgi lan liivt Id phu hgp ^^ ^JVYT. Vi kinh nghiem thuc te' va trinh do acdllSnvdKn khdng phii hgp roi Kr2 phit hgp.
KETLUAN
chuyen mon dong vai tro quan trgng, phai tang cuong thoi gian thuc hanh danh gia VD lam Trong linh hinh y te'nuoc ta hien nay, viec sang, va trinh do chuyen mon nia NVYT cang danh gia miic dp VD SS bang mat dong vai tro tha'p thi thai gian thuc hanh cang phai dai hon.
ra't quan trpng, cho phep phat hien som cac Cim NC them de khang dinh ke't qua nay.
truong hpp VD can xac dinh miic BM, nhltm du TAIUEUIHAMKHAO
phong tiai hieh toi tang BM nang. Tuy nhien, i American Academy of Pediatnc (2004). Tvlanagement of SO li§U NC cho thay chi co 45,4% NVYT danh hyperbilirubinemia in the newborn infant 35 or more weeks of gia miic dp Kramer phu hop voi miic BM. De E«st.tlo„-.p»«.(n.>, 114, pp. 297-316.
2. Kramer U. (1969), "Advancement of dermal icterus in Ihe cai thien kha nang nay, ket qua phan tich chung pundi«dn«vbom.".in,jK=cww,n8,pp 454-458.
cho tha'y can cai thien phuong phap huMi luyen
CHLfC NANG HO HAP SAU MO CAT TUYEN HUNG QUA P H A U THUAT NOI SOI LONG NGLfC 6 BENH NHAN NHU'OC CO
Pham Ngoc Trung*, Nguyen Hoai Nam*
TOMTAT
Muc tieu: Ddnh gid nhirng dnh hie&ng dia ph&u thudt ngi soi long ngifc len chuc nang ho Imp benh nhdn nhiegc ca.
Tiin hdnh nghien can: Hoi cuu loat tneang hgp ldm sang tie thdng 01/2005 deh thdng 12/2009 tai benh vien Chg Rdy.
Kh qud: Tong cong la 59 benh nhan, thdi gian rut ngi khi qudn sau mo trung binh la 30,2 gia, trong do 73% benh nhdn dugc rut ngi khi quan s&m tiu&c 24 gia. Klwng co su lien quan gifea thai gian rut noi kin qudn hdu phdu vd cdc ym totlun gian mdc benh, miec do dieu tri ngi khoa tru&c mo, do nang cua benh, u tuyen hung vd chuc ndng ho hap tieh phau.
Kh /uan: Phau thudt ngi soi phu hap vd co hiin vgng ieng dung doi v&i benh Nhugc ca, vi it dnh hieang dm chiec nang hd hap dia benh nhdn Nlnegc ca.
Tic khoa: Cdt tuyen hung ABSIRACr
POST THORACOSCOPIC THYMECTOMY RESPIRATORY FUNCTION IN MYASTHENL\
GRAVIS PATIENTS
Pham Ngoc Trung, Nguyen Hoai Nam * Y hoc TP. Ho Chi Minh * Vol. 16 - No 4 - 2012: 225 - 230 Background: Respiratoryfailure was the common complication of postoperative thymectomy
Objectives: To value the infiuences of thoracoscopic thymectomy on post operative respiratory fiindion of myasthenia gravis (MG) patients.
Methods: Reti-ospective study from Jan 2005 - Dec 2009 at Cho Ray hospital.
• Bp mon Ngoai Long nguc - Tim mach
Tdcdd mi lac BS. Pham Ngpc Trung DT 0903920815 Emaih
Nghien cuu Y hpc Y Hpc TP. H o Chi M i n h * Tap 16 * So 4 * 2012 Results: We liad 59 accepted patimi chaiis. Mean time of postopei-ative endotraclieal tiibe (ET) removal was 30.2 hours with 73% patients had ET removal earlier than 24 hours post operation. There was no significant relationship between time cfET removal and the riskfactors cf post-operative respiratoryfailure (Imgth cfMG, severity (fMG, pre-operative medical treatnimt, thynwma by CT Scan, pre-operative respiratory function).
Conclusions: Thoracoscopic thymectomy had a minimal infiumce on respiratory function cf myasthenia gravis patients.
Key word: Thymedoniy DATVANDE
Benh nhupc co la roi loan thaui kinh-co thirong gap, dac trung boi su yeii co do nhung cii dpng lap lai, giam bot khi nghi ngoi, do khang the khang thu the acetylcholin, pha hiiy thu the acetylcholin 6 mang hau synape than kinh CO. Ve mat dieu tri, con nhieu van de chua giai quyet dugc vi: benh thuong dien tieh toan than, hieu qua dieu tri ngi khoa khong cao va dien tieh sau dieu tri ra't thay doi.
Phau thu^t da dugc chap nhan rpng rai trong dieu trj b?nh nhupc co. Tuy nhien, cho den nay, van con nhieu quan niem khac nhau xung quanh each tie'p can trong phau thuat cat tuyen hung. Jaretzki bao cao each tie'p can r0ng rai, phau thuat ck hiyen hung toi da bang each mo nguc dgc xuong lic ke't hgp mo ngang co. Cac phau thuat vien khac iing hp mo dpc xuong lic don thuan, h o | c mo xuong tic ban phan, hoac mo ngang co. Nghien ciiu hi#n nay cho tha'y chua co su khac biet ro rang ve miic dp hi$u qua ciia cac loai tie'p can phau thuat khac nhau trong dieu tri benh nhupc co.
Cac each tie'p can cang rpng rai thi bieh chung sau mo cang nhieu, dac biet la tinh trang ho ha'p sau mo. Dieu nay rat quan h-png vi b#nh nhan nhupc co da co roi loan than kinh CO, co dia rat de bi ton thuong va con nhugc co de xay ra do nhiing kich thich dau, nhilm trung va bieh chiing hau phau khac.
Dieu nay cang Iam cho vah de ho hap sau mo, nhilm trimg, chay mau va cac tai bieh phau thuat tro nen quan trgng. BarakaP) cho rling ban than phau thuat qua nga che dgc xucmo^
lie Cling lam tang nguy co tho may sau mo.
Voi su tieh bp a i a phau thugt npi soi va dpng cu ho trp npi soi, phau thugt npi soi long nguc ciing co nhiing budc tiai bp vupt bac.
Phau thuat ngi soi long nguc co uu diem so voi phau tiiuat md xuong lie kinh dieh la can thiep toi thieu, it gay dau, tha'y ro rang cac ca'u tnic trong long nguc, it bie'n chung chay mau va nhiem trimg, co kha nang giam nguy co suy ho ha'p va su xuat hien con nhupc co hgu phau.
Phau thugt noi soi long nguc cSt tuyen hung trong dieu tri b^nh nhugc co da dupe thuc hien 6 Viet Nam va chung toi thyc hi|n nghien ciiu nay nham danh gia nhiing anh huang ciia phau thugt npi soi long nguc len chiic nang ho ha'p benh nhan nhupc co.
Muc tieu nghien cuu
1. Ihohg ke thai gian nit npi khi quan hgu phau
2. Phan tich moi tuong quan cac ye'u to' nguy ca suy ho hap hau phau va thai gian nit npi khi quan hau phau
D O i n / O N G VA PHUONG PHAP Thiet k e nghien cuu
Hoi cuu mo ta loat truang hgp Thoi gian va dia diem
Tif thang 1/2005 deh thang 12/2009 tgi khoa Phau thuat long nguc - mach mau benh vien Chg Ray
Doi tupng nghien cuu
Nhiing benh nhan dupe chaoi doan xac djnh la benh nhupc co va dupe phlu thuat cat tuyen hung qua npi soi long ngtrc.
Tieu chuan chon hmh Tuoi: 15-60 tuoi
Y Hpc TP. H o Chi M i n h * Tap 16 * So 4 * 2012 N g h i e n ciiu Y hpc Nhupc CO toan than (miic do II tro len theo
phan logi Osserman va Genkins (1971)) Hoac CO ba't thucmg tuye'n hung tren CT Scan nguc (u tuye'n hung hoac tang sinh tuye'n hung).
Tieu chuan loai trd
Benh nhan co cho'ng chi dinh phau thuat ngi soi long nguc: qua gia, khong chiu dung dupe viec CO Igp mgt phoi, phoi qua dinh, tien can phau thuat long ngirc
Co dau h i | u xam lah co quan lan can ciia u tuyen hung tren CT Scan nguc
Benh nhan nhupc co, phau thuat npi soi long nguc de cat tuyeh hung, phai chuyen sang mo h o vi phoi qua dfnh hogc thao tac kho khan do u qua dinh vao cau tnic lan can.
Cac yeu to phan tich nguy co suy ho hap Dua vao cac nghien ciiu tien lupng nguy CO suy ho ha'p sau mo, nghien cuu lan lugt phan tich cac ye'u to'tien lugng sau:
Thai gian mac benh tren 06 nam.
Lieu pyridostigmine dang sir dung (hon 750mg/ngay, tu 240-750mg/ngay), hoac co sii dung corticoids.
Phan dp IIB tro len Co u tuye'n hung
Co roi logn chiic nang ho hap truoc mo.
Cac tieu chuan Thai gian nit npi khi quan
Thoi gian rut npi khi quan la thai gian tir Ilie ke't thiic cugc mo de'n luc tinh trgng ho ha'p ciia benh nhan on dinh va co the nit noi khi quan.
Thoi gian riit noi khi quan dupe chia ra 2 miic dp:
Sam: dudi 24 gio sau mo Muon: hon 24 gio sau mo Phan loai Iam sang
Chiing toi sir dung phan loai lam sang ve miic dp Benh nhupc ca theo tieu chuan Osserman va Genkins (1971).
Thu thap so lieu va xu Iy
Cac so' lieu dupe xir ly theo phan mem thong ke SPSS for Windows 13.0.
Khi so sanh giira hai nhom, chiing toi dung phep kiem trung binh Student, %^.
Khi ap dung cho mau nho, co hon 20% 6 trong bang tuang quan co gia tri nho han 5, chiing toi diing phep kiem Fisher's exact.
Cac phep so sanh, he so tuong quan co y nghia tho'ng ke khi p < 0.05.
KETQUA
Chung toi thu thap dirge 59 truong hpp vdi cac ket qua sau:
Thai gian nit npi khi quan hau p h l u Thoi gian nit npi khi quan tir 3 - 198 gio.
Thoi gian nit npi khi quan trung binh: 30,2 + 39,9 gio. Riit npi khi quan som: 73% (43 truong hpp). Rut ngi khi quan muon: 27% (16 truong hpp).
Cac yeu to nguy co suy ho hap sau mo Thai gian mdc benh
Trong nhom nghien eiiu, co 04 benh nhan CO thoi gian mac benh tren 06 nam, chie'm 7%.
Tuong quan giua thoi gian m i c benh va nhom thai gian rut npi khi quan
Thdi gian nit noi khi quan
Yeu t6 nguy eg - thqi gian mac benh Khong nguy eg Co nguy eg
Kiem dinh Fisher's exact p=1.0 Dieu tri tien phau
Thong ke dieu tri pyridostigmine trudc mo, chia thanh 03 nhom dua vao lugng pyridostigmine sii dpng moi ngay.
Ur^ng Pyridostigmine Duwi 240nig TLp240aen750mg
Tren 750mg
S6 tnrimg hap 42 17 0
Ti l# % 71%
29%
0%
Tho'ng ke dieu tri corticoid truoc mo, chia thanh 2 nhom dua vao: co hay khong sir dung corticoid.
227
Nghien cuu Y hpc Corticoid
Co Khong
SdtriKmghop 29 30
Tlie 49%
51%
Y Hpc TP. H o C h i M i n h * T^p 16 * So 4 * 2012 ^
Tuong quan yeu to n g u y co u tuyen hung va thai gian nit npi khi quan
Phan nhom nguy co suy ho hap sau mo, dua vao dieu tri truac m o
Ne'u b | n h nhan co sii diing corticoid: 1 diem
Co su dung pyridostigmine tir 240mg deh 750mg: 1 diem
Neu b0nh nhan co sir dyng pyridostigmine > 750 mg: 2 diem
Tho'ng ke nguy ca suy ho ha'p dua vao ye'u to dieu tri trudc mo: khong nguy co (39%), nguy CO it (17%), nguy co cao (44%). Ggp chung nhom khong nguy co va nhom nguy co it thanh mgt nhom nguy co tha'p, nhom nay CO ti le 83% (49 trudng hpp).
Tuang quan giira dieu tri tien phau va thoi gian nit npi khi qiian
Then gian Kit n^i Ichiquan
Sdrn Mu$n
Y4U t6 nguy eg - dilu tri t i l n phiu Nguy eg thip
38 11
Nguy eg cao 5 5 Kiem dinh Fisher's exact: p=0,116.
Yeii to dp nang cua benh, phan do Osserman
Co 22 benh nhan (37%.) thupc phan dp nhe (I,IIA) va 37 benh nhan (63%) thugc phan do ngng (IIB,ni,IV). Tuong quan vdi thoi gian rut ngi khi quan sau mo:
Thoi gian nit n ^ Ithi quan
SOTTI Mu$n T6ng cOng
Y6u to nguy eg - phin d$ lim sang Khong eo nguy eg
18 4 22
Co nguy eg 25 12 37 Kiem dinh Chi binh phuang: p=0,234 Yeu to u tuyen himg dua tren CT Scan ngirc
Co 30 truong hgp co u tuye'n hung dugc xac djnh tren CT Scan nguc, dupe xep vao nhom CO nguy co suy ho ha'p sau mo.
Thgi gian n i t npi khi quan Scmn Muon l o n g cong
Y I U td nguy ca: u tuydn hung Khong eo nguy cv
20 9 29
Co nguyeg 23
7 30 Kiem dinh Chi binh p h u o n g : p=0,506 Yeu to chirc nang ho hap truoc mo
Co 30 truong hgp co roi logn chiic nang ho hap, dua tren cac chi so do dugc tir ho hap ky, dil la tac nghen, han che^ hay hon hpp, dugc xep vao nhom co nguy ca suy ho hap sau mo.
Tuong quan giira y e u to chiic nang ho hap va thai gian nit npi khi quan
Ttigi gian nit npi khi quan
Som Muon Tong c^ng
Y§u td nguy co*: chirc ndng ho hip Khdng co nguy eg
21 8 29
Co nguy eg 22
8 30 Baem dinh x": p=0,937,
BANLUAN
Thoi gian riit ngi khi quan
Mo'i quan tam hang dau ciia cac phau thugt vien khi thuc hien phau thuat tren b?nh nhan nhupc co la kha nang xay ra nhung ro'i logn ho ha'p sau m6''">. Nhiing benh nhan nhupc CO la co dia ra't de xay ra eon nhugc co sau phau thugt va cac ro'i logn hau phau khac.
Baraka cho rang bie'n chiing dang sp nha't chinh la suy ho ha'p.
Y van van chua tho'ng nha't each xit tri hau phau cat tuye'n hung 6 benh nhan nhugc co, nha't la va'n de giiip tho co hgc, khi nao nit ngi khi quan. Co tac gia de nghi giiip tha 24 gio hau phau vdi ta't ca trucmg hgp de de phong kha nang dien tie'n khong thuan Ipi ciia tinh trang ho hap, tuy nhien, hau het tac gia deu cho rang nit npi khi quan sdm se giiip dien
Y Hpc TP. H o Chi M i n h * Tap 16* So 4^ 2012 N g h i e n cihi Y hpc tieh hau phau thugn Ipi hon, nhung phai theo
doi sat, phat hien va xir tri cae trudng hpp suy ho ha'p va con nhugc ca kip thoi. Tieu chuan nit ngi khi quan va phan nhom thoi gian nit npi khi quan eiing chua dugc tho'ng nhat va sir dung trong y van, tuy nhien, da so' cac tac gia xe'p "nit noi khi quan truoc 24 gio hau phau" vao nhom nit npi khi quan sdm, "nit npi khi quan tix 24 de'n 72 gio hau phau" vao nhom thoi gian giiip tho vira va "nit ngi khi quan sau 72 gio hau phau" vao nhom nit ngi khi quan tre. Mgt vai tac gia ggp chung 02 nhom thoi gian giiip tho vira va riit npi khi quan tre, thanh nhom giiip tho keo dai sau mo. Dya vao phan nhom nay, nguoi ta xem nit ngi khi quan sau 24 gio n h u la trudng hgp dien bien ho hap khong thuan Igi hau phau.
Trong nghien ciiu ciia chiing toi, thdi gian nit npi khi quan trung binh la 30.2 gid, hic la nhieu h a n ranh giai phan chia nit noi khi quan sdm va giiip thd keo dai (24 gid) theo Toolabif"'. Dieu nay co y nghia la: noi chung viec nit ngi khi quan sdm van cdn la mgt van de d hau phau. Tuy nhien, da so benh nhan (73%) trong nhdm nghien ciiu nay dupe nit ngi khi quan sdm b a n 24 gid hau phau, cho tha'y kha nang cd nhieu benh nhan qua nang, can phai giiip thd keo dai qua lau, lam keo dai thdi gian giiip thd trung binh, cdn da so thi dien tieh sau md cung thuan Ipi. Ne'u so sanh vdi nghien cuu ciia tac gia Nguyen Cong Minh(*> vao nam 2005, bao cao cac trudng hop giup thd keo dai hon 24 gid hgu p h l u chiem 95,2%, cd the nhgn xet thay nhung tieh bp kha nang hoi sire va cham soc benh nhan nhupc CO va kha nang ung dung ciia p h i u thuat npi
Cac yeu to nguy co suy ho hap
Suy hd ha'p, giiip thd keo dai, se dan deh nhiing bie'n chiing ve phoi: xep phoi, viem phdi, loet ti de, nhiem triing... va lam ton kem trong dieu tri. Tuy nhien, y van lai ghi nhan ra't it nghien ciiu ve nhiing bie'n chiing nay, ciing n h u nhihig ye'u to' nguy co suy hd ha'p, giiip thd keo dai hau phau. Nam 1980, Leventhal*^) bao cao nhiing yeii to nguy co suy hd ha'p hgu phau d benh nhan nhupc co, de'n nay van cdn nhieu tae gia ap dung''*'^*.
Nhimg ye'u to'nay la:
Thdi gian mac benh hon 6 nam Tien can benh Iy hd ha'p man ti'nh Sir dung pyridostigmine vdi lieu hon 750mg/ngay
Chiic nang hd ha'p: VC <2,9 L
Mpt vai tac gia khac cung dua ra mpt so' ye'u to: miic dp nang cua benh (dae biet la miic dg cac trieu chimg hau hgng, khd thd), cd u tuye'n hung hay khdng (cd u tuye'n hung dupe xem nhu cd nguy co suy hd hap hau phau), trong khi Gracey*^' cho rang chi cd ye'u to' miic dp nhupc ca tien phau, cu the la miic dp trieu chiing hanh nao, la ye'u to' tien lupng kha nang phai giiip thd keo dai hau phau.
Hien nay, do su phdi hpp dieu tri pyridostigmine va corticoids, nen it cd trudng hgp nao sit dung lieu pyridostigmine cao de'n 750mg nhu trudc kia. Akashi'^' dua ra miic 240mg do'i vdi pyridostigmine hogc co sir dung corticoids la ye'u to'tien lupng kha nang giiip thd keo dai. Trong nghien ciiu nay, chiing toi lan lupt phan tich timg ye'u to nguy CO suy ho ha'p sau mo (thdi gian mac benh tren 6 nam, dieu tri ndi khoa trudc md bang lieu cao pyridostigmine hoac corticosteroid.
229
N g h i e n c u u Y hpc Y Hpc T P . H o C h i M i n h * Tap 16 * So 4 * 2012
benh nhan nhupc co IIB trd len, cd u tuyen hung hoac cd ro'i loan chiic nang hd ha'p trudc md) deu tha'y su khac biet ve thdi gian nit ngi khi quan sau md (dai dien cho dien bien hd ha'p sau md) giiia nhom cd nguy ca va khdng cd nguy co khdng co y nghia thd'ng ke. Can nh3c lai la nhiing ye'u to ke tren dupe nghien ciiu va nit ra tir nhirng khao sat tren phau thuat rdng rai. Su khac biet khdng cd y nghta thd'ng ke nay (thuc hien phau thuat ndi soi cat tuye'n hung tren mau nghien ciiu ciia chiing tdi(g6m da so'benh nhan cd phan do lam sang thupc logi nang, ciing cd the so sanh dupe vdi nhiing mau nghien ciiu khac)) cho tha'y phau thuat npi soi la mgt phau thuat it anh hudng den chiic nang hd ha'p ciia benh nhan nhupc ca.
KETLUAN
Vi|c cham sdc hd ha'p ciia benh nhan nhugc co sau phau thuat cat tuyen hung co nhieu tie'n bp rd r^t.
Phau thuat npi soi la phau thugt it anh hudng deh chiic nang hd ha'p ciia benh nhan nhupc ca, cd kha nang iing dung ra't cao ddi vdi CO dia hd ha'p de man cam vdi phau thuat nhu nhupc CO.
TAIUEUTHAMKHAO
1 A k « ^ A, Hazama K, Miyoshi 5, Minami M, Malsuda H, Kjdo T, et aL (2O0I), "An anatyas of vicfeo-asssted thoraroscopc resection for mediastir^ masses in 150 cases. An overview of the panstemal approach, histology, and aMnplicadons". Suig Endosc 15(10U167-I170.
2 Baraka A (2001), "Anesthesia and critical care of thymectomy for myasthenia gravis". Chest Surg d i n N Am, 11(2), 337-361.
3 Gracey DR, Divertie MB, HowanJ FM, Payne WS (19M),
"Postoperative resfriratory care after transstemal thjTneclomy in myasthaiia gravis. A 3-year expenenoe m 53 patients" Oiest, 86(1), 67-71.
4 Heitmilier RF (2005). Surgery for myasthenia gravis. In Advanced therapy in thoradc surgery (2nd e d , pp. 408417).
5 Leventhal SR, Orkm FK, Hirsh RA (1980), "Prediction of die need for postoperati\'e medianica] ventilation in myasthenia gravis". Anesthesiology, 53(1), 26-30.
6 N g i ^ w Cong Minh (2007), T h a u thuat npi soi dt hiyai hung trong dieu tn benh nhui?c CO tai benh vien Cligr Ray trong 2 nam (2004-2005)". Y h?c TPHCM, Chuyen de Ngoai khoa, ll(PBl), 320-326.
7 NguyenCOTigMinh.(2008).E>ieu tri ngoat khoa benh nhu^c CO Dieu trj hpc N g o ^ khoa Long ng^ic - Tun mach (tr. 109-125).
Nha xuat ban Y h o c
8 Mguj-en Diic Tho (2001), "Lien quan t h u c nang ho ha'p va rngt so bieu hien lam sang kei qua dieu tii ngo^u khoa b | n h nhan nhuoc CO", Sinh ly hoc Viet Nam, 5(2), 42-46.
9 Nguyen Hoai Nam (2008), "Cac buoc i * a t trien o i a fAilu thuflt rwi soi long nguc" V hpc TP H o C b ' Minh - Chuyen de Ngoji - Chuyen nganh Ngoai Long n g g t 12(PB4), 237-243.
lu. Nguyen Van Tho (1990), " G a tn cua d t tuyeh hung trong dfilu tti n h u p c co". Ngoai khoa, H a Ngi, 18(3), 10-14.
11. Toolabi K, Amiruan A , Javid MJ, Harirchian MH, Rabani A, Darabnia J (2009), "Mid-term results of thoracoscope th>'mectomy for myastherua gravis". Neurol India, 57(4), 402-
