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HQl NGHI KHOA HOC KY T H U A T M 6 R Q N G LAN THCf XII • BgNH VI$N HOU NGHj V I £ T NAM - CU BA D 6 N G HOI
UNG THLf OAI TRl/C TRANG: PHAU THUAT M 6
a • •
VA PHAU THUAT NOI SOI
• •
Le Manh Nil, Pham Minh Due, Nguyen Doan Van Phu
TOM T A T
Muc dich: Oanh gia chi dinh va ket qua phau thuat ngi soi va phau thuat md trong ung thu dai trdc trang. Phu'dng phap: Tir thang 1/2005 den thang l / 2 0 n . 196 benh nhan ung thd dai trUc trang (104 nam, 92 nii') da dddc phau thuat tai BVTW Hue, trong do co 138 benh nhan dUdc phau thuat md, 58 benh nhan phau thuat ngi soi. Ket qua: 50 benh nhan cSt dai trang phai (32 phau thuat md, 18 phau thuat noi soi), 6 benh nhan cat dai trang ngang (4 phau thuat md, 2 phau thuat ngi soi), 28 benh nhan cat dai trang trai (24 phau thuat md, 4 ngi soi), 42 benh nhan cat dai trang sigma (30 phau thuat md, 12 phau thuat noi soi), 28 benh nhan cat tru'dc thap (18 phau thuat md, 10 phau thuat ngi sol), 42 benh nhan phau thuat Miles (30 phau thuat md, 12 phau thuat npi soi). Ket luan:
Phau thuat ngi soi co nhieu u'u diem hdn so vdi phau thuat md, tuy nhien chi ap dung bleu qua ddi vdi ung thu' giai doan sdm khi u chda xam lan vao cac cd quan lan can.
SUMMARY
COLORECTAL CANCER: LAPAROTOMY SUGERY AND LAPAROSCOPIC SURGERY
Objective: To assess the indication and the result of laparotomy and laparoscopic surgery for colorectal cancer. Methods: From 1/2005 to 1/2011, 196 patients (104 men,92 women) underwent colorectal resection. 138 laparotomy, 58 laparoscopy. Result: 50 cases of right colectomy (32 laparotomy, 18 laparoscopy), 3 transverse colon resection (4 laparoscopy, 2 laparoscopy), 28 left colectomy (24 laparotomy, 4 laparoscopy), 42 sigmoidectomy (30 laparotomy, 12 laparoscopy), 28 low anterior
resection (18 laparotomy, 10 laparoscopy) and 42 abdominoperineal resection (30 laparotomy, 12 laparoscopy). Conclusion: Laparoscopy surgery is more advantageous than laparotomy surgery. However, it is only effective for early cancer when the tumor has not invaded yet into other organs or structures.
I.
OAT VANo l
Ung thu dai true Irimg la benh ly kha thirdng gap d tat ca cac nude tren the gioi.
Vice phau thuat cat dai trang trong benh ly ung thu dii dugc thuc hien vao giira the ky 19 va cho den na\ dd van la phuomg phap duy nhat nham muc dich dieu tri triet de cho benh nhan. Tu>' nhien phucmg phap phau thuat khdng ngirng duofc cai lien nham chuan hoa phuomg phap. han che bien chimg va dem lai nhieu lgi diem cho benh nhan. Vao nhung nSm 1990 phau thuat ndi soi cat dai true trang trong benh l\ ung thu dai true trang da dugc nghien ciru thir nghiem tai cac trung tiim Idn IrcMi the gidi \ ii da cho cac ket qua kha quan. Ngin nay, phau thuat noi soi da dugc ap dung rdng rai de dieu tri ung thir dai trvre trang. Tu\' nhien, khdng phai trudng hop nao ciing cd the phau thuat ndi soi thanh cdng \ a dem lai nhieu lgi diem, ma nhieu trudng hgp can phai phau thuat md. Vi vay, chimg tdi thuc hien nghien cuu nay nham muc tieu nghien cuu cac dac diem Iam sang, can lam sang cua tmg thu dai true trang va qua dd dua ra chi dinh wk kha nang phau thuat noi soi hay phau thuat md.
YHOC VI$T NAM THANG 9 - SO DAC BIET / 2011
II. D6I TUONG VA PHUONG PHAP NGHIEN COU l.Doi ttfong nghien cuu
Tat ca benh nhan dugc phiu thuat cat dai true trang do ung thu tai BVTW Hul, cd dhy du cac xet nghiem hinh anh hgc trudc m6 va ket qua giai phau benh ly sau ni6. Loai trir nhumg benh nhan khong cdt dugc u ma chi noi tat hoac Iam hau mdn nhan tao.
2. Phu-oTig phap nghien ciiu
Nghien cuu hdi cuu, md la, cat ngang.
3. Dac diem nghien ciiu Tuoi, gidi
Vi tri khdi u: Dua vao ndi soi dai trang, CT Scan, quan sat trong md
Bien chimg cua u: TSc ruot, abces quanh u, thiing dai trang
Phuomg phap phau thuat: Phau thuat md hoac phau thuat ndi soi cat dai trang phai, cat dai trang ngang, cat dai trang trai, cat dai
trang sigma, cat trudc thhp va phau thuat Miles. Phau thuat md hoac phau thual ngi soi.
Ty le chuyen mo md.
Tai bien trong mo: Diit nieu quan, thimg ruot, thimg ta trang, chay mau.
Bien chiimg sau mo: Chay mau, 6 dgng dich, mau, do mieng noi, nhiem triing vet m6
Thdi gian nam vien sau mo.
Til' vong phau thuat (trong vong 30 ngay sau mo).
Giai doan benh sau mo.
III. KET QuA NGHIEN CQU 1. Tuoi va gidi
Tuoi trung binh: 53,2 luoi, cao nhat 82 tuoi, thap nhat 21 tudi.
Nam gidi 52 benb, chiSm 53,06%. Nir gidi 46 benh, chilm 46,94%.
2. Vi tri u Vi tri u Manh trang
Oai trang len Dai tranq goc qan Dal trang ngang Dai tranq goc lach Dai tranq xudng Dal tranq sigma Tn/c tranq tren TriTc tranq giu'a Tn/c tranq du'dl Tong
N 12 22 16 6 12 16 42 18 30 22 196
Ty le o/o 6,12 11,23
8,16 3,06 6,12 8,16 21,43
9,18 15,31 11,23 100
3. Bien chiing cua u
Bie'n chii'ng Tac ruot
Abces quanh u Thiing
Dican
N
36 14 10 30
Ty le % 18,37
7,14 5,10 15,31
HOi NGHI KHOA HOC K? T H U A T Md R O N G LAN T H O XII • B^NH V I E N HCTU NGH! V I E T NAM - CUBA DONG HOI
4. j'huong phiip phau thuat
Phu'dng phap md
Cat dai trang phai Cat dai trang ngang Cat dai trang trai Cat dai trang sigma Cat trUdc thap PT Miles
Tong
Mo ndi soi N
18 2 4 12 10 12 58
o/o 9,18 1,02 2,04 6,12 5,11 6,12 29,59
* Trong si) 13(S hcnh nbiin md mcr. cb lb Iruimg hgp mo ngi soi ihiil hai phai chuyen .sang mo niir. Trong dd co 14 truirng hgp do u xam lan rcmg, khong co kha nang phau ihual triet dc qua ngi soi \ii 2 Iruimg hgp phau tliuat Miles cha\' mau phai chuyen siuig nio miy.
5. Tai bien trong mo
2 (1,02%) trudng hgp dirt nieu quan trai trong phau thuat md cat dai trang sigma \a dai trang trai. 2 (1,02%) truomg hgp thiing D2 ta trang do u dai trang gdc gan xam lan la trang. 2 (1,02%) trudng hgp cha\ mau d
benh nhan phiiu thuiit Miles ngi soi, phai chuyen sang mo md.
6. Bien chiing sau mo
2 (1,02%) truomg hgp chay mau sau mo cat dai Iriing phai ndi .soi, 2 (1,02%) truong hgp buc mieng ndi sau md md cat dai trang trai vii phai mo lai, 2 (1,02%) truomg hgp do mieng noi sau mo md cat trudc thap noi may va 16 (8,16"o) truomg hgp nhiem triing vel mo deu do md ma. Khong co benh nhan nao lir ^•ong sau mo. Thdi gian nam vien sau mo trung binh 8.6 ngiiy, thap nhal la 6 ngay, cao nhat 21 rniav.
7. Giai doan benh
Giai doan b^nh
T2 T3 T4 NO Nl N2 MO Ml
Mo md N
0 84 54 6 104
28 106 32*
o/o 0 42,86 27,55 3,06 53,06 14,29 54,08 16,33
Md ndi soi N
10 48 0 12 42 4 54
4
o/o 5,10 24,49
0 6,12 21,43
2,04 27,55
2,04
1
* 32 trudng hgp di cSn gan, trong do cd ung thu dai trang trai, 6 trudng hgp ung thu 20 trudng hgp ung thu true trang, 4 trudng dai trang phai. Tat ca cac trudng hgp di can hgp ung thu dai trang sigma, 2 trudng hgp gan deu dugc tiem cdn tuyet ddi.
Y HOC VIET NAM THANG 9 - SO DAC BIET / 2011
IV. BAN LUAN
Trong 196 benh nhan ung thu dai true trang, chung tdi gap benh nhan chii y§u d lira lu6i trung nien va Idn tu6i, tudi trung binh 53,2 tuoi, khong cd su khac biet v6 gidi tinh, dieu nay cung phii hgp \ di cac nghien ciru khac trong va ngoai nude [1],[2].[31.|9],[12].
Cat dai true trang ndi soi trong ung thu trudc day van cdn thao luan nhicu. Tuy nhien, ngay nay nhieu tac gia nhan dinh din la ky thuat cd the ap dung rgng rai \ di do an loan cao cho mgi benh nhiin. no co din du nhimg uu the ciia phau thual ngi soi mii khong can ban tam den cac > cu to khac ma dac biet la di can d Id trocal \ a ban che ket qua diku tri ung thu [4],[8],[10].[13J. Mot s6 tac gia nhan thay di can Id trocal len den 21%, so vdi md hd 0,6 - 2.5%). Tuy nhien, mot vai nghien cim khac lai cho thay ty le di can 16 trocal chi tir 0 - 2.4% [5],[6],[14].
Thdi gian gan day. viec tuan thu nguyen tac ung thu hgc trong phau thuat ciing nhu thao tac nhuan nhuyen \ e ngi soi da lam cho ty le di can 16 trocat, ty le tai phat tai chd sau m6 cung nhu ly le di can trong phiic mac giam han mgt each cd y nghia trong cac nghien cuu ghn day [7],[11]. Vi xay, trong nghien cuu nay chung tdi khdng dat nang van de hieu qua vk mat ung thu hgc giira ndi soi va m6 md. Thdi gian sdng them va thdi gian tai phat, di can sau md can phai cd nhieu nghien cuu so sanh vdi sd lugng Idn hom va thdi gian theo doi dai hom mdi danh gia day dii va cho kit qua cd y nghia. Trong nghien cuu nay, chiing tdi chi dua ra nhimg kha nang phau thuat ndi soi thanh cdng, an toan va hieu qua.
Tuy nhien khdng phai trudng hgp nao cung CO tha phau thuat ndi soi thanh cong.
Nhimg trudng hgp u da gay bi^n chung nhu tic mot, abces quanh u hay thiing u gay viem
phiic mac thi ngi soi la khong the, ngoai trir khi ngi soi phau thuat tam thdi lam hau m6n nhan tao. Nhumg triromg hgp khac khi u dinh nhicu hoac xiim lan sang cac lang Ian can hoac di can bach thi phau thuat noi soi gap rat nhicu kho khan, khong dam bao nguyen Uic phau lich rgng rai trong ung thu hgc va de giiN nen ciic lai bien trong mo. Vi vay chiing loi cung nhu mgl so cac lac gia khac thong nhat chi phau thuat ngi soi khi u chua co bien chirng, kich thudc u khong Idn lam va t6l nhal doi xoi u d giai doan < T3 [2],[6],[10].
Trong nghien ciru ciia chiing toi, ty le nio md nhieu han han so vdi mo noi soi vi benh nhan chimg toi ihudng den vien mugn khi da co bien chimg nhu lac ruot, abces quanh u hoac khi u da xam lan rgng sang cac tang lan can hoac di can. Chiing toi danh gia bilan trudc md he lh6ng bang chup cat Idp vi tinh, sieu am, kham lam sang... de so bg danh gia giai doan benh va chi chi dinh m6 ngi soi khi chua cd bien chung hoac u chua xam ihn sang cac tang lan can (<T4). Trong 16 truomg hgp chuyen sang mo md thi 14 trudng hgp do u da xam lan rdng, kh6ng dam bao nguyen tac phau tich rgng rai nen chuyen sang m6 md dk dam bao an loan va hieu qua vk mat ung thu hgc, con lai 2 trudng hgp phau thuat Miles ngi soi that bai vi chay mau phai chuyen sang m6 md.
vk mat tai biln trong md, chiing tdi chi gap 2 trudng hgp dut nieu quan trai d benh nhan ung thu dai trang sigma, khdi u Idn xam ian dinh chac vao thanh ben chau hong, co keo nieu quan lam t6n thuomg diit nieu quan khi phau tich va dugc xir trf dat sonde JJ nieu quan. 2 trudng hgp thung ta trang d benh nhan u dai trang gdc gan, d benh nhan nay u dai trang goc gan da gay bien chimg abces quanh u, xam lan vao thanh D2 ta trang, trong qua trinh phau tich cat triet de kh6i u
HQl NGHj KHOA HOC K? THUAT M 6 RQNG LAN THCf XII • BgNH VIgNli&U NGHj VigT NAM - CU BA D 6 N G HOI
da lam Ion thuang lii triing. 2 truirng hgp chiiy niiiu khi ngi st)i phiiu lich mill sau tn/c trang \a phai chiniMi sang md miy dc ciim mau. Ndi chung t\ lc lai bicMi Irong md mir cung nhu nio ngi soi ciui chimg loi luirng doi thap, CO the chiip nhan dugc vii khdng co lai bicMi nimg ne dim ticn Ur \(ing trong mo [5].[6].[121.
Vc mat bii'ii chirng sau mo, 2 Iruimg hgp cha> mau sau cat dai triing phiii ngi soi, mau ch;i> ra qua dan luu ngay dim ra khoang 400ml \a 500nil, sau do giam dan vc so lugng \a mau siic tu cam mini vao ngay thir 3 Nil thir 4 sau md ma khong can pbai can thiep gi, 4 trudng hgp u dai triing goc lach, md md cat dai trang trai, noi tan-tan, hau phau ng^y thu 5 buc mieng ndi dai Irang ga\ viem phuc mac, phai md lai dua 2 dau ra lam hau mdn nhan tao. 2 truomg hgp ung thu true trang tren, ni6 md cat doan true trang. ndi bang EEA, hau phau ngay thu 4 cd it dich phan qua dan luu, benh dugc cho nhin an keo dai va benh dn dinh, khdng can can thiep gi them. 16 benh nhan nhiem trimg vet md deu xay ra d nhdm md md. khdng cd trudng hgp nao tir vong sau md. Ndi chung, ty le bien chumg thap va khdng cd sir khac bi?t cd y nghia ciia ca hai nhom mo md va md ndi soi.
Tuy nhien, ve mat chat lugng sdng, md ndi soi CO nhieu uu diem hom nhu it dau sau mo, thdi gian diing thuoc giam dau ngan han, thdi gian dimg khang sinh ngan ban, b?nh nhan hdi phuc sdm hom va do dd thdi gian nam vi?n ngan hom. Nhiimg uu diem nay deu dugc ghi nhan bdi hau het cac tac gia tren the gidi [3],[10],[11],[13],[14].
V. KET LUAN
Phau thuat ndi soi cd nhieu uu dilm ban so vdi phau thuat md, tuy nhien chi ap dung cd hieu qua khi ung thu cdn d giai doan sdm
< T3 va chua cd cac bien chirng. Thdi gian song them, thdi gian tai phat va di can sau mo giua phau thuat ngi soi va phau thuat mo can phai cd nhieu nghien cim so sanh vdi so lugng Idn ban va thdi gian theo ddi dai hon mdi danh giii day dii va cho ket qua co y nghTa.
TAI LIEU THAM KHAO
1. Iran Minh Hoang, Le Quang Nghia.
Kcl qua sdm ciia phau thual cat truac thap trong dieu tri ung thu true trang. Y I Igc Thanh Pho Ho Chi Minh 2008, s6 4, tr. 62-70.
2. Nguyen Quang Thai, Nguyen Van I lieu, Tran Nam Thang. Nghien ciru ket qua phau thuat ngi soi dieu tri ung thu dai trang tai benh \ ien K. Y Hgc Thanh Pho I Id Chi Minh 2008, sd 4, tr. 71-75.
3. Pham Van Binh, Pham Duy Hien, Nguyen Van Hieu, Biii Long. Ket qua budc dau phau thuat ngi soi cat cut true trang dudng bung tang sinh mdn dieu tri ung thu true trang thap tai benh vien K. Y Hgc Thanh Phd Hd Chi Minh 2008, s6 4, tr. 76-80.
4. Heidi Nelson .And Anne-Marie Boiler.
The Role of Clinical Trials in the Development of Novel Surgical Techniques. Journal of Surgical Oncology 2007;96:704-709.
5. Clinical Outcomes of Surgical Therapy Study Group. A comparison of laparoscopicalh assisted and open colectomy for colon cancer. N Engl J Med 2004;350:2050-2059.
6. Veldkamp R, Kuhry E, Hop WC, et al.
Laparoscopic surgery versus open surgery for colon cancer: Short-term outcomes of a randomised trial. Lancet Oncol 2005;6:477-484.
Y HOC VIET NAM THANG 9 - SO OAC BIET / 2011
7. Nelson H, Petrelli N, Carlin A, et al.:
Guidelines 2000 for colon and rectal cancer surgery. JNCI 2001;93:583-596.
8. Stocchi L, Nelson H: Laparoscopic colectomy for colon cancer Trial update.
J Surg One 1998;68:255-267
9. Basse L, Hjort Jakobsen D, Bardram L, et aL: Functional rcco\er\ after open versus laparoscopic colonic resection: A randomized, blinded stud>'. Ann Surg 2005;241:416-423.
10. Guillou PJ, Darzi A, Monson JR:
Experience with laparoscopic colorectal surgery for malignant disease. Surg Oncol 1993:2: 4 3 ^ 9 .
11. Boulez J: Chirurgie du cancer colo- rectal par voie coelioscopique [Surger\ of colorectal cancer by laparoscopic
approach] (Pre). Ann Chir 1996;50:219- 230.
12. Fleshman JW, Nelson H, Peters WR, et al.: Early results of laparoscopic surgery for colorectal cancer. Retrospective analysis of 372 patients treated by Clinical Outcomes of Surgical Therapy (COST) Study Group. Dis Colon Rectum
1996;39: S53-S58.
13. Melotti G, Tamborrino E, Lazzarctti MG, et al.: Laparoscopic surgery for colorectal cancer. Sem Surg Oncol
1999:16:332-336.
14 Schiedeck THK, Schwandncr O, Baca I, et al.: Laparoscopic surgery for the cure of colorectal cancer. Dis Colon Rectum 2000;43:1-8.
