TINH HINH XI DO MIENG NOI DAI TRlTC TRANG TAI BENH VIEN BINHDAN
Do Bd Hung', Yd NgQc Anh Tudn"
T O M T A T
Muc dich: Ngbien ciiu niy dugc thilt ke de dinh gia viec dieu tn xi mieng ndi dai true tring.
Phuang phdp: NghiSn ciiu hdi cuu dugc thyc hien vdi 13 benh nhan xi mieng noi sau phau thual rudt non va dai tryc tring tai Benh vien Binh Dan tu ngly 1 - 1 - 2008 din ngay 1 - I - 2009. Tat cl cac trudng hgp xi mieng ndi thyc quan v l da day dugc loai bd.
Kit qud: Ti le xi mieng ndi 11 2,28%. 46% benh nhan khdng dugc chuin bi rupt Uudc md vl chi 3 benh nhan dugc phau thuat cd ndi soi hd trg. Ti IS xi miengndi cao nhit la trong phau thuat cit noi d dai trang trli (30,8%). 53,8% benh nhan dugc dat din lim d lan phlu thuit ban diu. Tit ca benh nhan dugc phlu thuat lan 2 bing cich dua 2 dau mieng noi lam hau mon nhin tao.
Tif khod: Xi mieng twi / cdt dgi trdng
ANASTOMOTIC LEAKAGE COMPLICATIONS AFTER LARGE-BOWEL SURGERY m BINH DAN HOSPITAL
ABSTRACT
Purpose: To evaluate the results of anastomotic leakage treatment due to colorectal surgery.
Methods: a retrospective review was performed that identified 13 patients with anastomotic leakage after large-bowel surgery in Binh Dan Hospital between January I, 2008 and January 1, 2009. All patients with esophageal and gastric leaks were excluded.
Results: The leak rate was 2.28 percent. Forty-six percent of patients were managed without bowel preparation and only three patients were treated with endoscopic surgery. The leak rate in left-side colorectal resection is highest (30.8%). 53.8 percent (n=7) were discharged after initial operation. All patients with anastomotic leakage were underwent second operation by colostomy.
Key words: Anastomotic leakage after Colonectomy D A T V A N D E
Xi mieng ndi dai tryc trang 11 mdt trong nhiJng bien chung quan trong vl nguy hiem cua phau thuat cat ndi dai true trang. Ti le xi mieng ndi sau cit ndi dai tryc trang thay ddi theo ti IS tu 3% den 2 l % ' ^ ' ' ^ - ° ' , va ti le tu vong lien tquan vdi xi mieng ndi cd trieu chung 11 6 den 22%""*. Xi mieng ndi dai tryc trang tuy thugc ySu td ldn nhit 11 ki thuat khau ndi ciia bic sT phau thuat"'', tuy nhien hien tugng xi mieng ndi tham chi cd the xuat hien trong nhirng trudng hgp thuan Igi, va cugc phlu thuat vdi nhiing ki thuat tdt khdng thS dim b i o dugc sy hdi phuc khdng bien chung. Ben canh do sy khd khin tiem an trong viec hdi phuc sdm, linh trang viem phiic mac tien tnen v l nhiSm triing huySt cd the Inh hudng bat lgi den ti le song sdt boi vi sy gia ting ti le tai phit cua carcinoma"^' vl suy giam chuc nang cua ca the*'^'. Da cd nhieu nghien cim cd ging xlc dinh nguySn nhan cua xi mieng ndi, dac biet trong nhihig nim gan diy sy su dung phd bien ciia TME (total mesorectal excision) trong diSu tri ung thu dai true tring"" •' ', vl nhieu yeu td nguy ca d l dugc md tl: tdng quit la cic ySu td lien quan dSn dan sd v l riSng biel 11 nhiing yeu td lien quan anh hudng den Id thuat cua cac phlu thuat viSn.Cac yeu td cin thiSt cho viec chiia lanh mieng ndi bdi sy truyen dich v l sy oxy hoi cua bd mieng ndi, vl tit cl ySu td khic cd quan he tryc tiSp hay gian tiSp dSn cic thi ca ban ciia viec lanh mieng ndi. Viec nghien cuu cac yeu td niy bet sue khd khim do sy phu thugc giiia cic yeu tdva thyc su khdng dl ding de danh gii cic ydu td rieng biet cua tCmg benh nhan. Mac dau cd
Benh vien Binh Dan
" Dai Hoc Y Pham Ngoc Thach
Dja chi lien Iac: THS.BS. Do B l Hiing DT:u908322098 Email: [email protected] 260
nhiSu nghien cuu dinh gii cac ySu td nguy ca cua xi mieng ndi trong dan sd, cd it ban bao cao danh gii v,c dieu tri v l quan li benh nhin xi mieng ndi. Them vao do, cac ban nghien ciiu chi dinh gii kl thuat va xu hudng din den viec xuat vien sdm v l tinh trang xi mieng ndi d nhiing b?nh nhan dieu tri ngoai tru" . NghiSn cim niy dugc thiet ke de danh gia sy dieu tri xi mieng ndi dai tryc trang d nhimg benh nhin dang dugc dieu tri tai benh vien va phan tich cac ySu td cd lien quan den viec xi mieng noi trong phlu thuit dai true yang.
DOI TirONG VA PHlTONG PHAP NGHIEN C t U
Mdt nghien cuu hdi cuoi dugc thyc hien tai benh vien Binh Din dugc thyc hien da nhan ra 13 benh nhan cd xi mieng ndi sau phau thuat rugt non va dai true tring tir ngay 1 - 1 - 2{X)8 den ngay 1 - 1 - 2009. Xi mieng noi dugc xlc dinh lam sang tu 570 phlu thuat dai true trang tu viec trieh luc hd so. Xi mieng ndi tren lam sang dugc nhan dinh d nhung benh nhan hau phlu thdng qua su hien dien cua cac trieu chung nhu dau bung, diu hieu tic rugt, viSm phiic mac, danh gia sd lugng bach cau qua NGFL. sdt hay CT scan va khang dinh diSu do thdng qua phlu thuat. Nhirng benh nhin vdi xi mieng ndi tiiyc quin hay da diy da dugc loai bd.
Cac thdng tin vS qui trinh nam vien va phau thuat dugc ghi nhan lai gdm tudi benh nhan, gidi tinh, dia chi, chan doan, cac xet nghiem can lam sang can thiet, chi djnh phau thuat, cac phuang phap phau thuat da thyc hien (phau thuat md hay ndi soi) va ki thuat khau ndi rugt (1 lap, 2 lap hay bang stapler). Nhung yeu td nguy ca vS mat xa hdi, benh ly va phau thuat duac xlc dinh tir benh sir trudc md va thdng tin duac ghi nhan Iai day dii hay thieu sdt (Bangl).
Ti le benh tat va tir vong sau phlu thuat dugc dinh gia. Nhirng yeu td xung quanh cupc phlu thuat dugc dinh gii bao gdm: thai gian nim vien, bieu hien lam sang vl cac diu hieu can lim sing ciia xi mieng ndi, sy diSu tri xi mieng ndi bang phlu thuat hay diSu tri ndi.
Cic kSt qui giai phlu benh l^ dugc ghi nhan de dua ra chin doan benh hpc chinh xac va sy nguyen v?n cua mieng ndi.
Cac loai phlu thuit c^p ciin hay chuang trinh dugc ghi nhan trong nghien cuu. Sy chuan bi rudt bang thudc udng hay cac phuang phip ca hpc, su dung khing sinh dudng rupt trudc md bang dudng udng vl khang sinh dy phdng dudng tinh mach cung dugc ghi nhan lai.
BSn canh dd cdn cd cic chi tiSt khic bao gdm tinh trang xoang bung khi phlu thuat, dat dan luu xoang bung, tinh trang dinh duang thdng qua dich truySn va che dp an, thudc khing sinh va thudc giam dau sau phau thuat.
Bang 1: Cic yeu td nguy ca ciia xi mieng ndi dai tryc trang Cic yeu td Cac yeu td nguy Cic yeu td nguy nguy CO vS xl ca vS dinh co cua phau
hdi hay benh duang thuat tat ^
HiJt thudc The trang benhChi sd ASA Nghien rugu nhan Su dung thudc Benh dli thaoHematocrit < 28 khang ddng dudng Albumin < 3,5 Chan doin hinh Benh ly machTPN hien tai anh viing bung vanh Sir dungva vung chau Benh l>? machcorticoid Tic rudt mlu ngoaiChi sd khdi caThdi gian diSu biSn thS (BMI) > 30 tri cip cuu B^nh ly mach Thdi gian phau mau nao thuat > 2 gid Suy than TruySn mlu COPD yong phlu thuat
Sir dung din luu trong xoang bung
COPD: chronic obstructive pulmonary disease; ASA: American Society of Anesthesiologist KET QUA
13 benh nhan hien dien vdi 13 truoTig hgp xi mieng ndi dai tryc trang cua 570 mrdng hgp phlu thuat cit not dai tryc trang vl rudt non vdi ti IS xi mieng ndi chung la 2.28%.Ti le naminu =11:2. Da sd benh nhan yen 40 tudi (84,6%). Trong 13 trudng hgp nay, 6 Irudng hgp dugc phlu thuat trong tinh trang cap cim (46,15%), cdn lai dugc phau thuat chuang trinh (53,85%). Tat ca cic benh nhan phlu thuit chuang uinh deu dugc chuin bj rugt bing thudc udng hay nia rudt, su dung khang sinh dudng rudt udng va khing sinh dy phdng dudng tinh mach, cdn cac trudng hgp phau thuat cip cim thi cac benh nhan khdng dugc chuin bj rudt ma chi dugc sir dung khlnh sinh dy phdng dudng tTnh mach. Trong cic trudng hgp tren chi cd 3 trudng hgp md not soi va cac trudng hgp cdn lai deu md hd.
• Phiu thu^t nOi soi
• PhSu thugt ma
Khi phlu thuat lin 1, tinh yang xoang bung sach chiem ti IS 76,9% (n=10), cdn lai cac trudng hgp khic dugc phlu thuat uong trinh yang xoang bung cd nhiSu dich dye v l gia mac.
Tat ca nhung trudng hgp cd djch due hay gia mac trong xoang bung deu dugc ciy djch vl lam khang sinh dd.
K d^i tring P K dai trang T K tnrc trar>g Oong HMNU If do phlu Ihual
JTinh 3 minh boa cho chan doan v l If do phau thuat ciia 13 benh nhan xi mieng ndi rudt non va dai tryc trang
Trong 13 benh nhan xi mieng ndi dai tryc trang, chi cd 4 benh nhan cd benh ly ndi khoa di kem (bao gdm cao huySt ap, dai thao dudng, benh Iy tim mach nhu thieu mau ca tim va benh ly viSm da day), khdng cd benh nhan nio cd tien sir trong viec sir dung corticoid keo dai hay cic berth Iy suy giam mien dich
Cic bac sT phau thuat sir dung kT thuat khau ndi rugt non hay dai tryc trang bing tay (1 Idp, 2 Idp) hay bing stapler va cd dat dan luu hay khdng dat din luu trong xoang bung dugc thS hien d bang 2.
BCI thuat khau noi Dan luu
H o p 2 lop Stapler
Co Khong
Cap cuu 2 3 1 3 3
Chuong ttinh 6 1 0 4 3 Bing 3 the hien k' do phau thuat Iin 2
DSn luu
Cd Khdng
Bung thanh bung 0 3
ViSm phiic mac ilu phau
5 3
Ong dan lunra djch bat thudng
2 0
Dan luu Co Khong
Phan UTig thanh bung C6
3 2
Kh6ng 4 4
Thdi gian hau phau phat hien bien chiing xi mieng noi sdm nhat la 3 ngay (n=l) va tre nhat la 13 ngay (n=l), da sd phat hien xi mieng ndi vao ngay thu 5 den ngay thu 7 (n=IO), yong do sd trudng hgp xi mieng ndi rugt phit hien vio ngly thu 5 11 nhieu nhat (n=5) Tat cl cac trudng hgp nay phau thuat lin 2 dSu cd chung 1 hudng xu tn' la dua 2 dau mieng noi ra lam hau mdn nhin tao.
BAN LUAN
Mdi quan he giiia ban than bac sT phlu thuat vl ti IS xi mieng ndi dai tryc tring thi rd rang d phau thu^t tryc trang. Ti le xi mieng ndi yen lam sang sau phlu thuat cit ndi dai tryc ylng dugc bao cio thay ddi tir 1,8% dSn 5%"^-'^' hay tham chi len dSn 15%"^'^" d yong viec ndi thap d true trang. Bdi vi bien chung nay thi phd biSn vl cd the de doa tfnh mang ciia benh nhan vl lien quan rd ring dSn ti IS tir vong va do do keo dai thdi gian nim vien va do do gia ting chi phi dieu trj, that la quan trpng mpi thu phai lam de phdng chdng, ngan ngira va dieu yj bien chiing viec xi mieng ndi rudt. Chting tdi nhan thiy viec chuan bj mdt trudc md cd the 263
khona cin thiSt uona phau thuat cii noi dai hire trang"'", tuy nhien do gidi ban ciia nghien cim niy, chiing tdi khdng cd du dk chiing to hieu qua cua viec chuin bj rudt trudc md. Mot liSu khaiig sinh yudc phlu thuat thi cin thiSt yong phlu thuat dai yyc ylng. Xi mieng ndi cd hay khdng cd chuin hi midc md thi thudng lien quan den viSm phiic mac do phan va hiu het dieu niy din dSn viec cit bd mieng noi va lam hau mon nhan tao. Cupc phau thuat mdi sau xi mieng ndi la rat khd khan.
Nghien cim hoi cihi liSn he cac yeu td nguy co nhu giai tinh, finh hang nghien rugu.
hiit thudc'^la, benh ly dli thio dudng, benh phdi tic nghen ni^n tfnh (COPD), benh ly tim mach, chi sd albumin thip, corticosteroid, viSm phuc mac hay tic rudt, Unyen mlu yong phau thuat, tinh yang American Society of Anasthessiologist (ASA) va khoang cich tir bd hau mdn
< 5 cm dSn 7 cm vdi ti IS xi mieng ndi dai yyc trang"'^-^^'. Ti IS xi mieng ndi rudt ndi chung la tir 3% dSn 7% dugc bao cio trong vdng 20 nim nay. Ti IS mic va tu vong lin lugt 1140% vl 70%. Han nua, nhiing bao cio gin day cho thiy su gia tang su tii phat khu yu va ti le tir vong tir K dai yyc yang uong nhung benh nhan cd xi mieng ndi thi dugc khing dinh'^-''^"'^^-'^'.
Ti IS xi mieng ndi yong phau thuat md vl phlu thuat cd ndi soi ho yg hoan loan khdng khic nhau vi tai benh vien Binh Dan viec phlu thuat ndi soi yong benh 1;? ung_thu dai tryc yang chii ydu chi la hd yg, viec khau ndi rudt holn loan dugc thyc hien vdi phlu thuat md. Khi so sinh tl le xi mieng ndi vdi finh yang xoang bung d phlu thuat lin I, chiing tdi nhan thay phlu thuat Uong tinh Uang xoang bung sach hay cd djch due dSu cd nguy ca xi mieng ndi, quan trpng 11 bac sT phlu tiiuat phli nia sach xoang bung yudc v l sau khi khau ndi
rudt. . The American Society of Anasthesiologists ghi nhan mdi quan he vdi ti IS tu vong
trong viSm phiic mac dai ylng yii, vdi vi tri nhiem tinng trong phlu thuat' \ va d dd vdi sir gia tang nguy ca xi mieng ndi. Nguy co xi mieng ndi rudt gia ting a mieng ndi true yang thip da dugc chiing minh rd rang. Ci nghiSn ciru ciia Finnish, tat ca xi mieng ndi xuit hien d nhung mieng noi each bd hau mdn < 7cm*'^*. Kinh nghiem cua Rullier va cgng sy"^' cho thiy ring nguy CO xi mieng ndi rudt d nhiing vj tri each bd hau mdn tang 6.5 lin so vdi mieng ndi d cich ba hau mdn > 5 cm. Trong nghiSn cuu ciia chiing tdi cung cho ket qui tuong ty nhu ti le xi mieng ndi rudt xly ra nhieu nhit d dai trang yai va tryc ylng.
Trong nghiSn cuu niy chiing ldi khdng fim thay mdi quan he giiia ti IS xi mieng noi rudt vdi benh ly ndi khoa ciia benh nhin, dac biet la i>enh ly dai thio duong. Ben canh dd thS trang cua benh nhin cung Inh hudng nhieu den tl le xi mieng ndi rudt. The trang kem thi lien quan vdi su lanh vet thuang vl biln chiing nhiSm triing huyet"^*. Beo phi tao ra su khd khan trong phau thuat d vimg chau, dac biet ddi vdi nhung mieng ndi each bd hau mdn < 5cm . Benh nhin beo phi \ a qui can trai qua nhiing cupc phau thuat cat bd khdi u dai tryc trang thi mat mlu va cic bien chung tuang duang nhung thai gian phau thuat keo dli ban so vdi nhung benh nhan the ttang trung binh"^''. Tuy nhien chung tdi gap nhieu khd khin yong viec dinh gii yen vi khdng thu thap du chi tiet ve can nang, chieu cao khi trieh luc hd sa.
Chung tdi nhan thay viec xi mieng ndi khdng lien quan dSn kT thuat lua chpn kt thuat khau ndi rudt bang tay (1 lap, 2 lap) hay khau ndi bang stapler, quan ygng la cic buac khi cic bac sT phlu thuat khi thyc hien cac kT thuat do. Viec dat dng din luu ttong xoang bung sau phlu thuat thi tuy theo finh trang cua cic cugc phlu thuat 11 can thiet hay khdng can thiet. Tuy nhiSn chung tdi nhan thiy ring viec dat dng din luu cung cd y nghTa trong vi?c phat hien sdm finh yang xi mieng ndi thdng qua dich ra d dng dan luu. Ben canh dd dng dan luu hieu qua cung gdp phan lim giim finh trang viSm phuc mac khi cd bien chung xi mieng ndi.
KSt qua cua nghiSn cim niy nhan thay biSn chiing xi mieng ndi thudng xay ra chii yeu tir ngay thir 5 den ngay thii 7, diSu nay phii hgp vdi y van, tuy nhiSn can phai thim khim 11m sang mdt each can than tir ngay hau phlu dau tien cho den khi benh nhan ra vien vi biSn chung xi mieng ndi cd the xay ra bat cu Iiic nao.
264
Bdi vi bien chimg xl mieng ndi thi hen quan den sy gia ting ti IS tu vong vl benh tat, keo dli thdi gian nim vien, ting chi phf dieu trj va Inh hudng nhieu den cic ySu td khic, nen cich giai quyet tdt nhat ciia viec xi mieng ndi 11 dua 2 diu mieng ndi ra lam hau mdn nhan tao.
KETLUAN
Xi mieng ndi rudt Uong phlu thuat rugt non va dai true ttang la biSn chimg nguy hiem va quan trgng. Mac dii cd nhieu nghien cuu nhimg xi mieng ndi vin xay ra vdi ti IS benh va tir vong cao. Moi quan he giua xi mieng ndi va ki ning ciia cic bac sT phau thuat la rd rang, tuy nhien viec xi mieng ndi con lien quan dSn nhieu yeu td nguy ca ma ddi khi cac bac sT phlu thuat khdng the kiem soat dugc. Tdm Iai didu quan trgng nhat la lam mgi each dS ngin chan va dieu tri bien chung vdi phuang phap tdi im nhat. Vi thdi gian ban che do do nghien cuu Clia chung tdi chua neu hSt dugc cac van dS nSn cin cd cic nghien cuu khic ldn ban ttong tuang Iai.
TAI LIEU THAM KHAO
1 Arena] JJ, Benito C, Concejo MP, Ortega E. Colorectal resection and primary anastomosis in patients aged 70 and older a prospeclive study. Eur J Surg 1999,165 716-8
2 Bokey EL, Chapuis PH, Fung C, el al. Postoperative morbidity and mortality following resection of the colon and rectum for cancer. Dis Colon rectum 1995,38 480-7
3 Golub R, Golub RW, Cantu R, Stem HD. A multivariate analysis of factors contnbuting to leakage of intestinal anstomoses J Am Coll Surg 1997;184:364-72
4. Graf W, Glimelius B, Bergstrom R, Complications after double and single stapling in rectal surgery Eur S Surg 1991;157:543-57
5 Hallbook 0, Sjodahl RJ. Anastomotic leakage and function outcome ater anterior resection of the rectum. Br J Surg 1996;83:60-2
6 Heald RJ, Moran BJ, Ryali RD, Sexon R, MacFarlane JK. Rectal cancer: The Basingstoke expenence of total mesorectal excision: 1978-1997 Arch Surg 1998;133:894-9
7. Karanjia ND, Corder AP, Beam P, Heald RJ Leakage from stapled low anastomosis after total mesorectal excision for carcinoma ofthe rectum BrJSurg 1994,81:1224-6
8 Kiran RP, Delaney CP, Senagore AJ, Steel M, Garafalo T, Fazio VW Outcomes and prediction of hospitai readimssion after inteslinal surgery, J Am Coll surg 2004;198:877-83
9 Law WI, Chu KW, Ho JW, Chan CW Risk factors for anstomoUc leakage after low antenor resection with total mesorectal excision. Am J Surg 2000;179:92-6.
lu. Laxamana A, Solomon MJ, Cohen Z, feinberg SM, Stem HS, McLeod RS. Long term results of antenor resection using the double-stapling technique. Dis colon rectum 1995;38:1246-50
11. Longo WE, Vigro KS, Jonson FE, et al. Outcome after proteccomy for recta! cancer in Department of Veterans. Affairs Hospitals a report from National Surgical Quality Improvement Program Ann Surg 1998;228 64-70
12. MaruschF, Koch A,Sch[mdlU, etal. Value of a protective stoma in low anterior resections for rectal cancer. Dis Colon Rectum 2002,45.1164-71
13. Meard F, Yahchochi E, Hay MJ, Fingerhut A, Laborde Y, Langlois Zantain O. Prophylatic abdominal drainage after elective colonic resection and suprapromotory anastomosis: a multieenter study controlled by radomization. French Association for Surgical research Arch Surg 1998;227:800-11
14 Mitlenen RP, Laitinen ST, Makela JT, Paakkonen ME. Bowel preparation with oral polyethylene glycol electrolye solution vs. no preparation in elective open colorectal surgery: prospective, randomized study. Dis Colon Recium 2000;43:669-70
15. Nesbakken A, Nygaard K, Lunde OC. Outcome and late fiinction results after anastomotic leakage following mesoreaal excision for rectal cancer. Br J Surg 2001 ;88:400-4.
16. Pakkastie TE, Lukkonen PE, Jarvinen HE. Anastomotic leakage after antenor resection of the rectum. Eur J Surg 1994; 160: 293-7
17. Petersen S, Freitag M, Hellnuch G, Lukwig K. Anastomotic leakage: Impact on local recuixence and survival in surgery of colorectal cancer. Int J colorectal Dis 1998;13:160-3
18 Poon RT, Chu KW, Ho JW, Chan CW, Law WL, Wong J. Prospecuve evalution of selective defunctioning stoma for low antenor resection with Iota! mesorectal excision World J Surg 1999;23'436-8,
19. Rullier E, Laurent G, Garrelon JL, Michel P, Sane J, Parneix M. Risk factors for anastomotic leakage afetr resection of rectal cancer. Br J Sugr 1998,85 355-8
20 Sorensen LT, Jorgensen T, Kirkeby LT, Skovdal J, Veniiis B, Wille-Jorgensen B Smokmg and alcohol abuse are major nsk factors for anastomotic leakage in colorectal surgery. Br J Surg 1999,86:927-31
21. Vanna JS, Chan AC, Li MK, Li AK. Low anterior resection using double stabling technique. Br J Surg 1990;77:888-90 22. Vignali A, Fazio WW, Lavery ICet al Factors associated with the occurrence of leaks m stapled rectal anastomoses, a
review of 1014 patients. J Am Coll Surg 1997.185:105-13
23. Zaheer S, Pemberton JH, Farouk R, Dozis RR. Wolff BG, Ilstrup D Surgical treatment of adenocarcinoma of the rectum. Ann Surg 1998;227:800-11
