Nghien a i u Y hoc Y Hoc TP. Ho Chi Minh • Phu Ban Tap 19 • So 5 • 201S
SO SANH KET QUA G I C A M 6 MO VA MO NOI SOI
TRONG DIEU TRI TAC TA T R A N G BAM SINH 6 TRE SO SINH
TrSnNgQC Son*, Hodng Hau Kien"
TOM TAT
Muc tieu: So sniA « qiw giiia inomi (MM) va mSnSi soi (MNSj trong dieu tri tiic ta triing bim smh (TnBS)c tri sa sinh.
Phuong phap nghien aiu: Hoi cm lm cic imh nhin (BW sa sitA co can nang hanlSOO g vi khmg c6 ii tat tiiu hia khic time plmu thuat dim tri tac ta trimg ham sinli lai binh vien Nlii Trung iXang lit thing 1/2009 dm thing 7/2015 va so sank kii qua giiea MM va MNS
Kei qud: ColOlBN thuoc doi tuang nghien oht v&i tuoi trung binh vi can nangkhi moli 11,3 ± 11,3 ngay vi2491± 445g 44 BN dirac MM m 57 BN duac MNS Khong co su khac biel co y nghia fhSng kl giira 1 iMm ve tuoi, giii, can nang khi mo, cic di tat kem Iheo, cic chi soxet nghiim. Thai gim tmng binh MM va MNS la 95 phiit va 96 pliiit (p>0,05). So vcn MM, BN sau MNS cd ty le bieh chitng thSfi lum lian (3,5% so vai 36,4%, p<0,001), CO thcri gian tnoig binh bat ^u cho dn duimg mieng va nam vien sau mo'ngan han (tuong inig la 4,1 so vai 7,1 ngiiy va 8,9 so vol 12,9 ngay, fK0,05). BN sau MNS co kB qua tham my lot han MM.
Kei ludm MNS giam tyle bim chimg, nil ngh thiri gian phuc hoi vi nam vien salt mo, co ket qua tham wy tSi lum so ICT MM vido do nen la lua dion hang dau Irong diiu tri TTTBS a Ire sa sinh co dim loc.
Tif khoa: Moma, mo noi soi, tie ta trang bam sinli.
ABSTRACT
COMPARISON BETWEEN OPEN AND LAPAROSCOPIC SURGERY IN MANAGEMENT OF CONGENITAL DUODENAL OBSTRUCTION / N NEONATES
Tran Ngoc Son, H o a n g Huu Kien" V Hoc TP. Ho Chi Minh * S u p p l e m e n t of Vol. 19 - N o 5 - 2015:18 - 22 Objective: To compare the results betivem opm surgery (OS) and laparoscopic surgery (LS) in management of congenital duodaial (d/strudion (CDO) in neonates
Methods: Medical records of all iKonalcs with weight over ISOOg and without other gastrointestinal anomalies which uiulenomt surgery for CDO in National Hospital of Pediatrics for the period betwem Imuary 2009 and July 2015 were reviewed. The results between OS and LS were compared.
Results: 101 patiaits were identified, wilh mean age and weight at surgery 11.3 ± 113 days and 2491 ± J J 5 s respectively. 44 patimts underwent OS and 57 patients - LS. There were no significant differmces between Ihe 2 groups regarding age, gender, weight at surgery, assodated anomalies, laboratory investigations. The meaii operative tinu of OS and LS was 95 and 96 minutes (p>0.05). In comparison to OS, LS group had lower rale of postoiieratix complications (35% vs 36.4%, p<0.001), wilh shorter lime to oral feeding and postoperatve hospital slay (4.3 vs 7.1 days and S.9 vs 12.9 days respectively, pO.05). Patimts after LS had better postoperaUve cosmesis than OS.
Conclusions: LS decreases the complication rate, reduces the recovery time and postoperative hospital stay with better posloperative cosmesis in comparison to OS and therefore should be Ihe first choice in manageniml of CDO in selected neonates.
* B?nh vi?n Nhi Trung l/ong.
rac gia lien lac: TS BS Tran Nigoc Smv DT: 0904138502, Email drtransonSfyahoo.c,
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Y Hoc TP. Hb Chi M i n h * Phu Ban Tap 19 * So 5 * 2015 Nghien curu Y hpc
Key words: Open surgery (OS), laparoscopic surgery (LS), management of congenital duodaial obstruction (CDO).
D A T V A N D E
Tac ta trang bam sinh (TTTBS) la mot trong nhung nguyen nhan hang dau gay tSc mot cao o tre so sinh. EHeu tri qui chuah cho TTTBS 6 tre so sinh la tno mo (MM), voi ky thuat pho bien nhat la noi la-ta trang va it hon la noi ta-hong trang hogc cat mang ngan">. Bax va cpng su da thuc hien c^u ben mo ngi soi (MNS) dieu tri TTTBS bling noi ta-ta trang vao nam 200F',
Cho den nay nhieu trung tam da ling dung MNS trong dieu tri TTTBS^-^ nhung mai chi co mpt vai nghien cihi so sanh ket qua giua MNS va MM trong dieu tri TTTBS 6 tre so sinh voi so lupng benh nhan h ^ che va ket qua cung khong dong nhat**''-". O Viet nam cho den nay chua co bao cao nao ve de tai nay.
Muc tieu nghien cum
So sanh ket qua dieu tri TTTBS giua 2 phucmg phap MM va MNS.
DOITl/ONG-PEIUONGKIAPNGHIENCUtJ Chung toi hoi ciiu lai cac benh nhan (BN) so sinh CO can nang honlSOO g voi chah doan TTTBS va khong co di tat tieu hoa khac duoc dieu tri phau thuat tai benh vien Nhi Trung uong tu thang 1/2009 den thang 7/2015. Chan doan tSc ta trang bam sinh 6 day bao gom teo ta trang va tac ta trang do tuy nhin. Cac dj tit tieu hoa phoi hpp la tieu chuah loai tru khoi nghien cuu bao gom teo thuc quan, khong h?u mon, di tat rupt quay do dang. Ky thuat mo dieu tri TTTBS duofc chpn cho dong nhat giua 2 nhom la noi ta-ta trang hoac noi ta -hong trang. Chi dinh BN cho MM hay mo NS la phu thuoc vao chu quan va kinh nghidm cua phau thuat vien. Cac dix li?u duoc tap hpp va phan tich bao gom ngay tuoi, gioi, can nang luc mo, di tat khac kem theo, xet nghiem mau va sinh hoa truoc mo, chan doan nguyen nhan TTTBS trong mo, thai gian mo^ tai bien va bien chiing, ket qua som sau phau thuat (phuc hoi luu thong rupt, thai gian
nam vien sau mo) va so sanh ket qua giua MM vaMNS.
Phuong phap sii dung so sanh giua cac bien dinh lupng la t - test dpc lap, giua cac bien dinh tinh la chi square hoac Fisher's exact test. Khac biet dupc cho la co y nghia thong ke khi pO,05.
K E T Q U A
Co 101 BN thupc doi tuang nghien ciiu voi tuoi trung binh va can nang khi mo la 11,3 ± 11,3 ngay va 2491 ± 445g. 44 BN duoc MM \'a 57 BN dupc MNS. Khong co su khac biet co y nghia thong ke giiia 2 nhom ve tuoi, gim, can nang khi mo, cac di tat kem theo, cac chi so xet nghiem, nguyen nhan gay tac ta trang (Bang 1).
Bang 1: So sdnh binh nhdn giim 2 nhom moma vd mo'ngi soi.
Bien so sanh Tu6i tmng binh (ngay)
Gion (nam/nir) Can nang tnjng binh luc mo
(g) Co dl tat kem theo ty !# %
Tim b i m sinh HOI chimg (Down Xet nghiem mau.
Hemoglobin tmng binh (g/l) f y l# prothrombin tmng binh%
Bilimbin toan ph^n ( Nguyen nhan TTTBS (t/ le %)
Teo ta trang type 1 (mang ngan) Teo ta trang type 111 (teo gian
doan) Tgy nhSn
Mdm6>
n = 4 4 13,3±13,7
22:22 2547±489
18,1 4,5 13,6 20,2±13,3
79±24 257±101
6 3 6 15,9 20,5
M 6 n o i s o i n = 5 7 9,8±8,8 2 9 2 8 2447±400
10,8 5,3 7,0 20,2±13,3
77±19 228±123
75,4 14,0 10,6
P 0,12 0,93 0,26
>0,05
>0,05
>0,05
Tat ca cac BN dupc MNS deu dupc noi ta-ta trang trong khi a nhom MM co 42 BN dupc noi ta-ta trang va 2 BN noi ta-hong trang. Thai gian trung binh MM va MNS la 95 phut va 96 phiit (p>0,05). So voi MM, BN sau MNS co ty le bien chiing thap hon han (3,5% so voi 36,4%, p<0,001), CO thiri gian trung binh bat dau cho an duang mieng va nam vi^n sau mo ngan hon (tuong iing la 4,1 so vai 7,1 ngay va 8,9 so voi 12,9 ngay.
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Nghien cuu Y hpc Y Hpc I P . Ho Chi Minh * P h u Ban Tap 19 * So 5 * 2015
p<0,05) (Bang 2). BN sau MNS co ket qua tham my tot hon MM.
Bdng 2: So sdnh kB qud dieu tri tdc td trdng bam sinh giua moma vd mo noi soi
Biin so sanh m d i gian mo tmng binh
(phut) Tai bien tronq m i (%) Bi4n chirng sau mA. ty le
Ro mi^ng n6i H?p/tac mieng n6i
Vigm ph5i Nhigm khuSn huy^
Chay mau sau m&
Nhiem khuJin v4t m6 Tir vong/nang xin v^ sau
m6{%) TTidi gian tmng binh bit 3iu cho Sn 6\iimg mieng
sau m6 (ng^y) Th^ gian nlim vi|n tmng
binh sau m i n=44 96±28 0 36,4%
2.3%
4,5%
2,3%
6,8%
0 18.2 2,2 7±4,6 12,9±7.9
M o n ^ i s o n=57 95±17 0 3,5%
0 0 1,7%
0 1.7%
0 1,7 4±2,2
8,8±4,9 P 0,78
<0,0001
0,68
<0,0001
0,002 Khong CO BN nao trong nhom MNS phai chuyen mo mo. Bien chiing sau mo bao gom viem phoi, nhiem khuah huyet, hep mieng noi, chay mau sau mo (do roi Io?n dong mau), nhiem khuan vet mo. Nhom MM co 1 BN bi ro mi^ng noi, nhiem khuan nang tir vong ngay thu 9 sau mo va nhom MNS co 1 BN viem phoi n§ng suy ho hap tii vong ngay thii 17 sau mo (mac dil BN nay da phye hoi liru thong tieu hoa). So vai MM, BN sau MNS co ty le bien chiing thap hon han (3,5% so vai 36,4%, p<0,001). D^c bi?t nhom BN dupc MNS khong CO nhiem khuan vet mo, khong bi nhiem khuah huyet, khong bi tac/hep mi^ng noi. 2 BN trong nhom MM bi hep/tSc mi^ng noi: 1 BN dupc nong thanh cong bSng npi soi tieu hoa tren va 1 BN phai mo lam lai mi^ng noi.
BAN LUAN
Nhung uu diem noi chung ciia MNS so voi MM nhu giam sang chah hon, giam dau hon sau mo, CO the giiip nguoi benh phuc hoi tot hon, nit ng3n thai gian nkm vi?n sau mo, ket qua thain my tot hon da dupc nhieu nghien aiu de cgp trong y vSn, d^c bi?t tren cac BN nguoi lon. Day
cOng la nguyen nhan MNS ngay cang dupc iing dung rpng rai 6 tre e m Tuy nhien MNS tren hre so sinh voi cac benh ly nhu TTTBS duoc danh gia la mpt trong nhiing phau thuat nhi kho nhati^-'. Da co mpt so nghiSn ciiu dupc cong bo ve ket qua cua MNS dieu tri TTTBS o tre em voi ket qua tot, trong do co ca nhiing bao cao ciia benh vien Nhi Trung U'ong^"'^-^. Tuy vay mpt so nghien ciiu cho thay ty le MNS phai chuyeh MM cao toi 35%(^', thai gian MNS lau hon so voi MMP'^', ty le bien chiing tir den 27%P)da dat ra cau hoi heu MNS trong dieu tri TTTBS co thuc su uu diem han so voi MM?
Theo tim hieu cua chiing toi, cho den nay trong y van moi co 3 nghien ciiu so sanh gjiia MNS va MM trong dieu tn TTTBS va ket qua cung chua dong nhat. NghiSn ciiu ciia Spilde T va cOng su nam 20098) y^ 29 BN (15 BN mo npi soi, 14 BN mo mo) cho thay MNS nit ngSn thoi gian hoi phuc luu thong tieu hoa sau mo, gjam thoi gian nam vien so voi MM. Tuy nhi&i nghiSn Cliu cua Hill S nam 2011^1 tren 58BN (22 BN mo npi soi, 36 BN mo ma) va nghien ciiu ciia Jensen A nam 20131^' hen 64 BN (20 BN mo npi soi, 44 BN mo mo) cho thay ket qua chiic nang sau MNS va MM la khong co khac biet co y nghia trong khi MNS co thoi gian mo keo dai hon so voi MM.
NgJiiSn Cliu nay ciia chiing toi dupc dua tren so lupng BN lon nhat cho toi nay. Ket qua ciia nghiSn aiu nay da khang dinh u\i tiie ciia PTNS so voi MM: MNS nit ngin ttioi gian phuc hbi luu thong tiSu hoa, giam thoi gian nam vien sau mo so voi MM. Dang chu y la ty le bien chiing sau MNS thap hon co y nghia so voi MM, dac biet la cac bieh chung lien quan toi mieng noi, nhiSm khuah vet mo, viem phoi va nhiem khuain huySl Chiing toi cho rSng MNS vai dp phong d?i cao ciia camera gop phan khau noi chinh xac hon, lam giam ty IS bieh chiing mieng noi. Uu the'ciia MNS gjam ty le nhiim khuah sau mo mo la vupt troi so vol MM. Tuy nhien trong nghiSn Cliu nay, fy IS nhiem khuah sau MM (ke" ca
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Y Hpc TP. H o Chi Minh * Phu Ban Tap 19 * So 5 * 2015 Nghien cmi Y hpc
nhiem khuan ve't mo va nhiSm khuah huyet) la kha cao so voi cac bao cao khac tren the" gioi*^-^-^'.
Mpt nghien cuu khac tai bSnh vien Nhi Dong 2, ttianh pho Ho Chi Minh nam 2013 cung cho thay bien chiing nhilm khuah sau MM dieu tri TITBS rat cao toi 59,6%. Nhu vay day cung la dieu dang luu tam can cai thi?n khi dieu tri cac BN mo ma TTTBS khong chi tai l?enh vien aia chiing toi ma con a Viet nam noi chung. Ket qua ciia nghien oiu nay cho thay MNS chinh la mpt each tiep c^n de giam cac bien chiing noi tren.
Thoi gian MNS trong loat BN ciia chiing toi ding tucmg duong, khong lau hon so voi MM.
Dieu nay la khac biet so voi cac tac gia khac^'^i.
Oiling toi cho rSng thai gian thao tac noi ta ta trang trong MNS co tiie lau hon so vdi MM nhung bil lai MNS khong mat thoi gian mo bung va dong bung, cung vai hoan thi?n ky nang khau npi soi la nguyen nhan cho ket qua nay.
Mac dil chua dupc danh gia voi thang diem khach quan, uu the ve tham my sau MNS theo chu quan cuachiing toi la vupt troi so voi MM va la mot trong nhung yeu to khie'n gia dinh BN hai long hon.
Ket qua ciia MNS trong nghiSn ciiu nay la tuong duong hoac tot hon so voi cac tac gia khac tren the gioi, tiep tuc ket qua ciia chiing toi da cong bo truoc day'''^. Ky thuat noi soi noi ta-ta trang kiS'u cheo don gian ciia chiing toi la co the"
la mpt ye'u to quan trpng cho thanh cong nay.
Chung toi ciing chia se quan diS'm ky nang va kinh nghiSm MNS ciia phau thu^t vien cung vol kha nang va kinh nghiem hoi siic so sinh sau mo la ye'u to can thiet khac de co ket qua tot
Han che aia nghiSn cuu nay la tinh chat hoi Cliu, cac b?rih nhan chua dupc phan nhom ngau nhien va khong co dong nhat giiia ky nang oia ph^u thu^t vien MM va MNS, tuong tu nhu 3
nghiSn ciiu so sanh khac da cong h&^^'*>. Tuy nhien vai so lupng BN nghien ciiu lon, nghiSn a i u nay da dua thSm bSng chiing thuc tS* gop phan khang dinh uu the oia MNS so voi MM.
Dua tren ket qua nghien ciiu oia minh, chiing toi tin r ^ g MNS nen la lua chpn hang dau trong dieu tri TTTBS 6 tre so sinh voi chi dinh chpn lpc. Can CO IhSm cac nghien ciiu khac danh gia ket qua iing dung MNS trSn tre bi TTTBS co kem di tat tieu hoa khac nhu rupt quay do danng, teo thuc quan.
KETLUAN
MNS CO thoi gian mo tuong duong, giam ty le bie'n chiing, nit ngan thai gian phuc hoi va nam vien sau mo, co kS't qua tham my tot hon so voi MM va do do nen la lua chpn hang dau trong dieu tri TTTBS 6 tre so sinh vol chi dinh chpn lpc.
TAI LIEU THAM KHAO
1 Applebaum H, Lee SL, Puapong DP (2006) Duodenal atresia and stenosis- Annular pancreas. In: Grosfeld JL, Onall JA, Fonkalsmd EW, Coran AG (eds). Pediatric Surgery, ff' ed Philadelphia. Mosby Elsevier, pp 1399-1405
2 Bax N H Ure BM, van der Zee D Q van TuijI I (2001) Laparoscopic duodenoduodenostomy for duodenal atresia, Surg Endosc 15(2):pp 217.
3 Hill 5, Koontz CS, Langness SM, Wulkan ML (2011).
Laparoscopic versus open repair of congenital duodaial obstruction in mfants, J Laparoendosc Adv Surg Tedi A 21(lD):pp % l - 3 -
4 Jensen AR. Short SS, Anselmo DM, Tones MB, Frjfanan PK, Shin CE, Wang K, Nguyen \ ' X (2013) Laparoscope veisus open treatment of congenita] duodenal obstruction; Multicenter short- term outcomes analj'sis. J Laparoendosc Adv Surg Tedi A,23pp.
876-880,
5 Kay a Yoder S, Rothenberg S (2009) Laparoscopic duodenoduodenostomy in the neonate.) Pediatr Surg 44(5jpp 906-8,
6 Riquelme M. Aranda A, Riquelme-Q M, Rodriquez C {2C08) Laparoscope treatment of duodenal obstruction, report on first expenences in Latin America Eur J Pediatr Surg 18(5):pp. 334-6, 7 Son TN, LJem NT, Kien HH (2015) Laparoscopic ample obbque duodenoduodenostomy in management of congenital duodenal djstruction in children. ) Laparoendosc Adv Suig T a i \ A.i5<2)pp. 163-166
S Spilde TU St Peter SD, Redder SJ, Holcomb GW 3rd, Snyder CL, Ostlie DJ (2008) Open vs laparoscopic repair of ctngenital duodenal obstructons. a concurrent senes J Pediatr Surg 43(6)-pp-1002-5.
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Nghien oxu Y hoc Y Hpc TP. Ho Chi Minh * Phu Ban Tap 19 * So 5 * 2015
'f. Tran NgQC S o a N'guven Thanh Uem. Hoang Huu Men (2014) 12. VanderZeeDC{2011) L a p a n o s c o p i c r e p a i r o / d u o d m a l a t i ^ Phau thuiit n ^ s d «siu tri tic ta tirang bain a n h o tre em. Hieu revisited WorldJSurg 35(8)pp 1781-4
qua cua ky thujt ncS ta-ta trang kieu dwo don gian. Y hpc Viet nam.,416pp 70-74
10 Tran Tiianh Tri, Lam Thier Kim (2013). Danh gia k S qua dieu Ngdy nlidn bdi bdo: 23/08/2015 In tic ta trang o t i ^ em. Yhpc thanh pho Ho Chi Mnh, phij ban ^ , , , , , . , , , - , , . - , - - , , „ „ .
tap i7(3)T>p. 26-31. Ngay phan bicti'^^ xet bai bao: 24/08/2015
11. Valusek PA. Spilde TL, Tsao K et al (2007). Laparacopic Ngdy bdi hdo dUOC ddng: 01/10/2015 (hiodenal atresia repair usmg surgical U-dips a novel
technique Surg Endosc. 21(6):pp 1023-1
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