Y Hpc TP. Hb Chi Minh * Phu Ban Tap 19 * So 5 * 2015 Nghien cuu Y hpc
SO SANH DAC DIEM LAM SANG, CAN LAM SANG VA KET QUA PHAU THUAT NOI SOI DIEU TRI NANG ONG MAT CHU
G I C A TYP I VA TYP IVA 6 TRE EM
Trdn Ngoc Scm*, Vii Manh Hodn*
TOMTAT
Muc tieu: So sdnh dac dian lam sdng, can ldm sdng vd hSi qud phdu thudt noi soi dieu tri nang dhg mat chu (NOMC) type I so vai type IVa (theo phdn loai Todani) a tre em.
Phucmg phdp nghien cthi: Hoi cuu lai cdc benh -nhan (BN) bi NOMC type I vd type IVa duac dieu tri phdu thudt ngi soi keJioach tqi benh vien (BV) Nhi Trung Wang fif thdng 1/2007 de'n thdng 12 /2012.
Kii qud: Co 517 benh nhdn (BN) thuoc dien nghien ciiu: 303 BN bi NOMC type I vd 214 BN bj NOMC type IVa. So sdnh do tuoi trung binh, giai, thai gian bi benh, ty le BN bi dau bung, non, sa tlidi/ klioi lm sitan phdi giiia 2 nhom kliong co khdc biet co y nghia thohg ke. Nhom IVa co tyle BN bi sot, vdng da, tang GOT, GPT cao hem vd kich thuac tmng binh NOMC l&n hem co y nghm so vai nhom I 314BN duac PTNS not dhg gan chung td trdng (185 BN type 1,129BN type IVa), 203BN duac PTNS noi ong gan chung-hBng trdng (118 BN type 1,85 BN type IVa). Kliong co su klidc hiit giUa 2 nhom ve tluri gian mo h-ung bmh, ty le bieh chung sam vd thai gian nam vien sau mo. Theo doi sau ra vien khd thi 82,6% cdc BN vai thai gian 12-90 thdng. Ty le BN type IVa h^
gidn ducmg mat trong gan 1 thdng vd 12 thdng sau mold 89,5% vd 94,5%. Ty le nhiem Idiuan duang mat sau mod nliom I Id 3,5% vd a nhom IVa Id 2,5% (p>0,05) Cdc BN con gian ducmg mat trong gan sau moco ty li viem mat cao han co y ngliia so vol cdc BN con lai (37,5% so vai 1%, p<0,0001).
Kei lu^n: Cdc BN bj NOMC type IVa thucmg hay bj tac mat, nliiim khuan duang mat trudc mo hon vd kidi thieac nang lan han so vai type I. Sau mohdu hei BN type IVa khong con gidn duang mat trong gan. Khong co su khdc biet ve kei qud dieu trf giita 2 nhom. Cdc BN con gidn dudng mat trong gan sau moco ty le nhiem khuan dudng mat cao han co ^ nghia so v&i cdc BN con lai
Tii khoa: Phdu thuat noi soi dieu tri nang ong mat chu.
ABSTRACT
COMPARISON OF CLINICAL PRESENTATIONS, LABORATORY INVESTIGATION AND RESULTS OF LAPAROSCOPIC TREATMENT BETWEEN CHOLEDOCHAL CYSTS TYPE I
AND TYPE IVA IN CHILDREN
Tran Ngoc Son, Vu Manh Hoan • Y Hoc TP. Ho Chi Minh * Supplement of Vol. 19 - No 5 - 2015- 23 - 28 Ainu To compare clinical presentations, laboratory investigation and results of laparoscopic treatment betweai choledodwl cyst type I and type IVA in dtUdrai.
Methods: Retrospective study of all patiaits undergoing elective laparoscopic surgery Jbr ChC at National Hospital of Pediatncs from 2007 to 2012.
Results: 517 patients were identified: 303 patiaits zaith type I and 214 patients type IVA. There were no significant differaices betweai the 2 groups regarding age, gaider, time from onset of symptoms, rate of abdominal pain, vomiting, palpable mass. Preoperatively, patiaits with ChC type IVA suffered from jaundice and
* Benh vi?n Nhi Trung L'ong
Tdc gid Mil lac: TS. BS Tran Ngoc Son, DT: 0904138502, Email: [email protected].
Chuyen De Ngoai Nhi
Nghien cmi Y hpc Y Hpc TP. Hb Chi Minh * Phu Ban Tap 19 * So 5 * 2015
diolangitis more frequently and had larga- ChC tlmn patients mth type I Tha-e loere no significant d^erena-s betweai the 2 groups regarding operative time, early complications aiui the laigth of postapa-ative hospital slay Follow up 12 -90 months u^ available in 82.6% of Sie patiaits. Inrahepatic biliary dilatation resolved in 895%
and 94.5% ofthe patients with ChC type li^Al month and 12 months afta- the operation. Cholangitis ocairred in 3.5% ofpatiaits wiSi type I and in 2.5% - type Wa Patiaits with pasistent postapa-ative intrahepatic bilimy dilatatioJi had significantly hi^ inadence of diolangitis than the rest (60% vs 2%, p^.002).
Conclusions: Patients with OiC type IVA have higher inddaice cf jaundice and diolangitis preoperativdy and have largo- ChC than patiaits unth ChC type L Intrahepatic biliary dilatation resolves in most patients with ChC type IVA after surgery. There zoere iw signiftcant differaices regarding results of ti-eatment betiveen the 2 groups. Patients with persistait postoperative intivhepatic biliary dilatation have significantly higher inadence of diolangitis than the rest.
Key words: Laparoscopic treatment.
DAT VAN DE
Nang ong mat chii (NOMC) la mot trong nhung benh ngoai khoa thuong gap 6 tre em.
Nam 1977, Todani de xuat phan ioai NOMC thanh 5 loai (type), trong do type I {gian mpt phan hay toan bp duong mat ngoai gan, khong CO gian duong mat trong gan) va type IVa (gian duong mat ngoai gan ket hop vdi gian duong m^t trong gan) la hay gap nhat trong thuc te.
Cho den nay nhieu van de lien quan den NOMC type IVa van con dang dupc tranh luan chua co thong nhat nhu cac hinh thai giai phlu khac nhau, phucmg phap dieu tri toi uu, dien bieh lau dai sau dieu trj phlu thuat va cac yeii to nguy co den viem mat soi trong gan hay ung thu duong m|t. Them nua, mac du da co nhfeu nghien cuu ve NOMC type 1 nhung con chua co nhieu nghien cuu ve NOMC type IVa 6 tre em, dac bi^t la so sanh giua 2 type. Xuat phat tir nhung van de neu tren, chiing toi tien hanh nghien cuu nay nham so sanh dac diem lam sang, can lam sang va ket qua dieu tri phau thuat npi soi nang ong mgt chu (NOMC) type IVa so voi type I (fheo phan loai Todani) 6 tre em.
M\tc tieu nghien cuu
So sanh dac diem lam sang, can lam sang va ket qua phau thuat npi soi dieu trj nang ong mat chii (NOMC) type 1 so vdi type IVa (theo phan loai Todani) d tre em.
DOITUONG-PHUtBSJGrHAPNGHIENajtJ Chiing toi hoi ciiu lai cac b|nh nhan (BN) bi NOMC type I va type IVa dupc dieu tri phau thuat npi soi ke hoach tai BV Nhi Tmng L/ong tu thang 1/2007 den thang 12 120X1. Qc dii lieu dupc tap hpp va phan Mch bao gbm dac diem BN (tuoi, gidi), dac diem lam sang (thai gian bi b?nh, cac trieu chung), cac xet nghiem can lam sang bao gbm chain doan hinh anh, xet nghiem mau, chiic nang gan, dac di§'m trong mo (kich thuac nang, bat thudng dudng mat, dudng kinh mipng noi), phuong phap phau thu§t (noi ong gan chung ta trang hay bng gan chung-hong trang), dien biai phuc hbi sau mo va theo doi sau ra vien,
Phuang phap phau thu|t d tat ca cac BN la sir dung 4 trocar, npi soi cat toan bp NOMC (phia dudi den gan sat ong mat tyy chung, phia tren den ong gan chung gan dudi hpp luu ong gan phai va trai) sau do nbi ong gan chung vdi ta trang hoac hong trang Roux-en-Y, da dupc chiing toi mo ta bxrdc day "•>. Chpn BN nbi ong gan chung vdi ta trang hay hong trang la tiiy thupc chil quan phlu thuat vien.
Cac BN dupc theo ddi dinh ky bang kham lam sang, sieu am bung va xet nghidm chiic nang gan nam dau tien vao khoang 1,3,6 thang sau khi ra vi^n va sau dd mpt Ian hang nam.
Thuat toan thong ke so sanh dupc sii dung la Chi-square hoac Fisher exact test vdi cac bi&i
Chuyen De Ngo^i Nhi
Y Hoc TP. Hb Chi M i n h * Phii Ban T | p 19 * Sb 5 * 2015 Nghien cmi Y hpc dinh tinh va t student test vdi cac bien dinh
lupng. Gia tri pO,05 dupc danh gia la co y nghia thbng ke.
K E T Q U A
Cd 517 BN thupc di?n nghien ciiu: 303 BN bi NOMC type I va 214 BN bi NOMC type IVa. So sanh dp tubi trung binh, gjdi, thoi gian bi bpnh, ty le BN bi dau byng, non, sd thay khbi h? sudn phai giua 2 nhdm khong cd khac biet cd y nghia thbng ke (Bang 1). Nhdm type IVa cd ty le BN bi sbt, vang da, tang GOT, GFT cao han va kich thudc trung binh NOMC ldn hon cd y nghia so vdi nhdm type I (Bang 1,2). Mac du dudng kinh bng gan chung trung binh aia nhdm type IVa Cling Idn hon nhdm type I cd y nghia thong ke, su khac biet nay chi 1mm (Bang 2). 314 BN dupc PTNS nbi bng gan chung ta trang (185 BN type I, 129 BN type IVa), 203 BN dupc PTNS nbi bng gan chung-hdng trang (118 BN type 1 85 BN type IVa). Khong cd su khac biet cd y nghia giija 2 nhdm ve thdi gian mo trung binh va thdi gian nam vien sau mo (Bang 3).
Bdng 1: So sdnh dac dian BN, bieu hiin lam sdng giira NOMC type I vd Type Iva.
B i l n s o s a n h T u i i tmng binh (thing) Gi6'i {nam/nu}
Thd'i gian tmng binh t t > l ( h i b ^ d a u t r i $ i j
chi>ng ( n g i y ) S a u bgng (%) Ndn (%) S 6 t { % ) v a n g d a ( % ) S o - t h l y k h f i i h g s L r & n
phai (%) An tfau h? su'om phdi
(%)
NOMC t y p « 1 n = 303 43,4±35,4
78/225 1S3±265
87,8 48.2 23,8 17,5 5,0 16,5
NOMC type IVa n = 2 1 4 47,0±38,4
51/163 136±307
85,0 41,1 34,1 34,6 7.5 21,5
P
0.34 0,62 0,73 0,36 0,11 0,01
<0,001 0,23 0,15 Bang Z- So sdnh dac diein can ldm sdng vd dqc diem trong md'.
B i l n s o s a n h Ty l# BN CO Bilimbin
cao' (%) T y l e B N G P T c a o (%
NOMC type i 23.6 40,7
NOMC type IVa 45.0 67,5
P
<0,001 0,008
Bien s o s a n h T y l e B N G O T c a o ' { % ) Ty le BN Bach cau cao tren 10G/I (%) Ki'ch thire'c tmng binh
NOMC (airong kinh
\6T\ nhk) (cm) DLTOTig kinh tmng binh
6r^ gan chung (mm) NOMC type
1 41,6 50,6
3,0±1,7
11,7±4.7 NOMC type
IVa 60,6 53,4
3,7±2,3
12,8*4,6 P
<0,001 0,25
<0,001
0,009
'cao hem 2 tan gid tri bmh thiediig Bdng 3: So sdnh kei qud dieu tri.
B i l n s o s a n h P h u c n g phap p h i u thuat (noi ong
gan chung voi ta trang/ noi 6ng gan chung - h 5 n g trang) Thvi gian p h l u thu|1 (phiil) Ty le bi^n chirng s d m sau m6 % Thoi gian n i m vien tmng binh sau
ma (ngay) Ty 1? viem mat sau mo (%) Ty le hep mi^ng n6i phai md lai (%'
Ty le viem da day do trao n g u v c dich mat sau mo {chi nhom noi 6ng
gan chung-ta trang) (%) Ty I f bien chirng chung (%)
NOMC t y p e l 185/118 172±68 3,3 6,5±3,2
3,5 0,3 16,2 12,9
NOMC type IVa
129/85 178±50 2,8 6,4±2,3
2,5 0,9 8,4 9,8
P 0.86 0,28 0,48 0,52 0,5'f 0.37 0,06 0,28
Nh^n xet Bien chiing sam duac ghi nh§n d 16 BN (3,3% d nhdm t}'pe I va 2,8% d nhdm type IVa, khac biet khong y nghia vdi p>0,05) bao gbm 11 trudng hpp ro mat sau mo, 2 BN bi tu dich nliiem khuah, 2 BN bj rd tuy, 1 BN bi xuat huyet tieu hda tren. Chi cd 1 BN bi rd mat phai mb 1^, lam lai mipng nd'i, cac BN khac deu duac dieu tri npi khoa thanh cdng. Theo doi sau ra vien kha thi a 82,6% cac BN (217 BN type I va 200 BN type IVa) vdi thdi gian 12-90 thang. Ty lp BN type IVa het gian dudng mat trong gan 1 thang, 6 thang va 12 thang sau mb tuong iing la 89,5%, 93% va 94,5%. Ty le nhiim khuah dudng mat sau mo d nhdm type I la 3,5% so vdi 2,5% d nhdm type IVa , su khac biet khdng cd y nghia thbng ke (p=0,53). Tuy nhien cac BN cdn gian dudng mat trong gan sau mb cd ty le viem mat cao hon cd y nghia so vdi cac BN con lai trong nhdm type IVa (37,5% so vdi 1%, p < 0,0001) Cling nhu tren toan bd cac BN khdng bi gian dudng mat trong gan sau mb 3 BN bi hep mieng nbi (2 BN d nhdm type IVa, 1 BN d nhdm type I)
C h u y e n D e Ngoai N h i 25
Nghien cmi Y hpc Y Hpc TP. Hb Chi Minh * P h u Ban T^p 19 * Sb 5 * 2015 din deh viem mat nhieu dpt, can thiep nong
mieng nbi khong ket qua phai mb lai lam lai mieng noi. Trong nhdm cac BN dupc nbi mig gan chung - ta trang, cd 12p% BN bi viem da day do trao ngupc dich mat (16,2% d nhdm type I, 8,4% d nhdm type IVa, p>0.05 (Bang 3)).
BAN LUAN
Ty 1| NOMC tj'pe IVa tren tbng so tat ca cac type NOMC theo phan loai cua Todani dupc cac tac gia khac nhau cdng bb la tii 33A5% P'^^^.
Thmg ke ciia chiing tdi cung cho thay ty le NOMC type IVa trong loat BN ciia chiing tdi vao khoang 41% (khi tinh them vao tbng so ca cac BN bj NOMC cac type cdn ]^). Trong nghien Cliu nay ty 1? naminii bi NOMC type IVa la 1:3 tuong tu nhu type I. Trong khi mpt so nghien Cliu cho r ^ g NOMC type IVa thudng gap d nhung BN ldn hon so vdi type I "='•'*', nghien ciiu nay cho thay dJng khdng cd khac biet ve tubi ding nhu thdi gian tu khi bit dau trieu chiing den khi BN dupc nhap vipn dieu tri.
Theo tim hieu ciia chiing tdi, cho den nay chua cd bao cao nao so sanh bieu hien lam sang, xet nghiem chiic nang gan NOMC gjiia type I va type IVa d tre em. Ket qua ciia chiing tdi cho thay &i suat tJc mat viem mat vdi cac bieii hien tuong ling (vang da, tang bilirubin, sot, tang men gan GOT, GPT) d nhdm BN type IVa la cao hon cd y nghia so vdi nhdm type I. Kich thudc TB ciia NOMC nhdm type IVa ding Idn hon so vdi nhdm type I. Day la nhung diem mdi chua dupc nghien ciiu nao de cap.
Trong khi dteu tri NOMC tj'pe I deu dat dupc thbng nhat la phai phlu thuat cSt bd nang, nbi bng gan chung vdi rupt thi dteu tri NOMC type IVa cdn nhteu tranh l u ^ lien quan den danh gia thuong ton giai phau cua BN''^. Da sb cac tac gia van tiep can dteu tri NOMC type IVa nhu vdi type I tiic la chi cit phan dudng mat gian d ngoai gan va nbi bng gan chung vdi hdng trangf-is^, Todani va mdt sb tac gia khac cho ring 1 ty le cao cac BN NOMC typ IVa cd chit h?p dudng mat vimg ron gan va khuyen cao
phai nbi rupt vdi dudng mat sat rbn gan<^3,ia24) Cd tac gia lai ket hpp noi ong gan chung h6ng trang va ca noi nang trong gan vdi hdng trang.
Tuy nhien cd nhiing tac gia khuySi cao cit phsbi dudng mat ngoai gan hi gian cimg vdi cit gan c6 dudng mat trong gan gian dbi vdi cac truong hap cd gian dudng mat trong gan khu tru 6 1 phan gan, hoac cit thiiy gan cpng vdi bdc niem niac phan dudng mat trong gan gian cdn lai ma chua cat dupc het khi c5t mia gan, tham chi cit gan d ca 2 tfiiiy.
Nhiing tac gia khuyen cao cit gan dmg dudng mat gian trong gan cho rang de lai dudng mat gian trong gan ve lau dai cd the gay nen ung thu dudng m?t trong gan ""'^-^i.
Nghien dhi ciia chiing tdi cho thay hau het trudng hpp gian dudng mat trong gan d cac BN bi NOMC type IVa la tu het sau khi phlu thuat cit phan bng mat chii gian va nbi bng gan chung vdi rupt. Kinh nghiem tucmg tu ding da dupc mdt so tac gia khac bao cao trong y van''^"^^*.
Them mja nguy co ung thu dudng mat ding hien hiiu d tren ca dudng m^t trong gan khong bj gian d type I sau khi da cat nang ong mat chii.
Do vay chiing toi cho rang dieu tri NOMC type IVa d tre em van tucmg tu nhu type 1 bang phau fhuat cat ong mat chii gian va nbi bng gan chung vdi rupt. Cd the chi nhiing BN sau phau thuat tren van cdn gian dudng mat khu tni trong mgt thiiy gan ma khdng co hep dudng mat hay mi|ng nbi se phai can nhac can den cit gan.
Nhieu nghien ciiu da cong bb cho fhay BN bi NOMC type IVa cd ket qua dieu tri kem hon, vcd nguy ca bien chiing sau mb (viem m^t h?p nupng nbi, sdi trong gan, ung thu dudng mat) ldn hon so vdi type L Nghien cuu nay cua chiing tdi cho thay ket qua sdm va trung han sau phau fhuat npi soi dieu tri NOMC type IVa d tre em la khdng cd khac biet cd y nghia so vdi type 1. Ty le bien chiing ndi chung (bao gbm ca bien chiing sdm va mudn, ca viem d? day do trao ngupc dich mat sau mb) ciia chiing tdi sau phau thuat npi soi dieu tri NOMC type IVa tuong ducmg vdi type I {9,8% so vdi 12,1%, p= 0,28) va thap
ChuySn De Ngoai Nhi
Y Hpc TP. H b Chi Minh * Phu Ban Tap 19 * Sb 5 * 2015 Nghien cmi Y hpc han so \'di ty le 17-29 % duoc cac tac gia khac
bao cao P.3,15) Chiing tdi cho ring hoan thien ky thuat npi soi, dac biet la khau mieng noi bng gan chung vdi rudt cd the la mdt trong nhiing nguyen nhan cho ket qua hen. Dang luu y la m | c dil ty le BN bi NOMC type IVa trudc mb bi viem mat nhieu han type I, sau mb ty le viem m | t giiia 2 nhdm la khdng cd su khac biet. Ket qua nay cang khang dinh tiep can dieu trj phlu thu§t NOMC type IVa nhu type I cho ket qua tbt.
Trong loat BN ciia chiing toi cd mdt ty lp BN bi NOMC type IVa sau mb vln cdn bi gian dudng mat trong gan. 6 cac BN nay, ty le nhilm khuan dudng mat la cao han hSn so vdi cac BN khdng cdn gjan duang mat trong gan. Nhu vay gian dudng mat trong gan ca trudc hay sau mo la yeu to lien quan den viem dudng mat.
Trong thdi gian theo ddi ciia nghien ciiu nay, chiing tdi chua ghi nhan dupc BN nao bi sdi trong gan hay ung thu dudng mat. Tuy vay can cd thdi gian tiieo ddi BN ciia dning tdi dai hon niia de danh gia them cac bien chiing ndi tren.
KETLUAN
Cac BN bi NOMC type IVa thudng hay bi tic mat, nhiem khuain dudng mat trudc mb han va kich thudc nang ldn hon so vdi type I. Dieu tri NOMC tj'pe IVa d tre em ciing nhu type I vdi phau thuat npi soi cat NOMC va noi ong gan chung vdi rupt cd k§'t qua tot. Sau dieu tri bang phau thuat npi soi hau het BN type IVa khpng cdn gian dudng mat trong gan. Khdng cd su khac biet ve ket qua dieu tri bang phau thuat npi soi giiia 2 nhdm. Cac BN con gian dudng mat trong gan sau md' cd ty le nhiem khuah dudng mgt cao hon cd y nghia so vdi cac BN cdn lai.
CSn cd them nghien ciiu theo ddi dai hon niia de so sanh danh gia them cac bien chiing mupn nhu sdi trong gan hay ung thu dudng mat TAI LIEU THAM KHAO
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Chuyen D e Ngoai Nhi
Nghien cuu Y hoc V Hpc TP. Hb Chi M i n h * Phu Ban T?p 19 * So 5 * 2015
21. Taiduda Y, Takahashi A, Suzuki N, et al (2002) De. d o p m a i t 24 Unishihara \", Fukuzawa H, Fukumolo K, el al (2011). TobDv ofintiahepalicbiliaEj-stonesarterevasionofcholedochalcysts J laparoscopic management of chdedodial cyst Roux^V Pediab-Surg.37(2)Tip-16S-7 leiunc^qunostomy and wide hepaticojejunostomy ivift hilar 2 2 Unishihara N, Fukumoto K. Fukuzawa H, et al (2007) ductoplasty.JUparoendoscAdvSurgTo*A21{4)pp.361-6,
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23, Unishihara N, Fukumoto K, Fukuzawa H et a! (2012) Long- Ngdy nlidn bdi bdo: 23/08/2015 term outcomes afte exaaon oi choledochal cj-sls in a single ^ , , , , . . . , „ -, i - - i - - m ^ m - . ^
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