VIETHAM MEDICAL JOURHAL H''2 - MARCH - 2017
DANH GIA KET QUA M^^ THONG DA D A Y RA DA BANG NOI SOI (PEG) TAI BENH VIEN E TRUNG UONG
Vu H^ng Anh*, Do Nguyfit Anh*, Vu Du'c Djnh*
TOIVI T A T
Md thdng da day ra da blng ngi soi la giai phap tot cho nhOtig benh nhan piiai nuoi du3ng qua^ sonde lau dai. Tai benh vien E, ky t h u i t mdi duWc trien khai da dem den nhutig ket qua tot cho benh nhan can nuoi duBng qua sonde. Muc t i e u : "Oanh gia k&: qua ve iam sang va iv thuat'ciia phudng phap md thong da day ra da bang noi soi". OSi tu'tfng va phu'dng phap nghien c u l i : 35 benh nhan cSn nuoi dffSng bang du'dng heu hoa keo dai da 6d(3c md thong da day ra da bang nor sot. Ket qua: 35 benh nhan trong do CO 5 b§nh nhan nff (14,3%) va 30 tienh nhan nam (85,7%), tuoi tren 60 chiem 97,1%. K? thuat thanh c6ng vdi ty" l§ 94,3%. Thu thugt dt/cJc tien hanh tai phong noi soi, benh nhan co the du'dc gay me (28,6%) hoac gSy t§ tai cho k i t hdp an than (71,4%).
Ty le bien chijhg 24,1%. NhUng chi 6 mffc do nhe va vu^, xff iy dffdc bang dieu trj ngi khoa. Ket lu$n: Ky thuat PEG giup dinh duSng cho benh nhan khong 3n dutfc d u ^ g mieng trong thdi gian^ dai. PEG la thii thuat ngi soi ddn gian, tu'dng ddi de thu'c hlin va an toan cho binh nh§n, cd the thi/c hien d cac cd sd y te CO may ngi soi da day.
SUIVIIVIARY
RESULT OF PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (PEG) I N E HOSPITAL -4/Vns; Evaluate the Clinical and technical result of Percutaneous Endoscopic Gastrostomy (PEG) in E hospital. MethodsiiS patients who are indicated for long tenn enteral nutrition. Results: PEG placement sucKssfijI rate was 94,3%.There were mild complications (almost of them were PEG site infection). All complications were resolved by medication management. Conclusiorr.lt is safe and simple to perform PEG. It can be carried out In the hospital where have gastroendoscpy equipment.
L O A T V A N D E
Ddi vdi cac benh nhan nang (sau tai bien mach nao, ehan thu'dng, bdng, sau phau thuat...) ben canh dieu trj cac thudc dac hieu, cung cap day du cheit dinh dudng giiip *cd ttie chong dd b$nh t$t cung het^siJc quan trpng. Cd hai hinh thufc nudi duQng: bang du'dng tmh maeh va bang dudng tieu hoa. Ooi vdi eac benh nhan chu'e
*Benh vi^n E
Chju b-ach nhiim chfnh: Vu HSng Anh Email: [email protected] Ngay nhan bai: 13.12.2016 Ngay phan blen khoa hoc: 8.2.2017 Ngay duyet b^l: 24.2.2017
nang h$ tiSu hoa binh thu'dng, nen du'dc nuof.
dudng bang du'dng tieu hoa (Enteral nutrition) vi hinh thu'c nay cd cac UXJ diem: phu hdp vdi chifc nang sinh ly, ehuyen hoa cua du'dng tigu hoa, it nguy ed cho benh nhan va gia thanh thap hdn so vdi nudi duSng bang du'dng tmh mach. Neuitficfl gian nudi du'dng du'di 4 tuan, ed the dung sonde mui-da day hoac sonde mui- hong trang nhuhg vdi thdi gian nudi duQng lau dai hdn, can ap dung cac thii thuat md thdng da day bang phau thuat hoac ndi soi. Vdi uli diem do an toan, cao,tu'dng ddi de thu'c hi$n, md thdng da day W' da bang npi soi la mdt thu thuat du'dc lii^ chgn va ap dung d nhieu nu'dc tren the gidi. Lan diu tien du'de gidi thieu vao nam 1980[5], trong thcfi gian ngan, ky thuat nay da du'de pho bien rong rai d nhieu nu'dc tren the gidi. fai My, cd 61.000 ea vao n§m 1988 den nhu'ng nam 2000 co khoang 216.000 ca moi nam [4][5].
Tai Viet nam, ky thuat md thong da day ra da bang npi soi da du'de ap dung d mpt so benh vien nhu" Viet Oite, Bach Mai, Chd Ray, Xanh- Pdn... Benh vien E iBn dau tien ap dung ky tiiuat nay vao thang 11/2010. Do nhan thay phu'dng phap nay cd nhieu ulj diem hdn so vdi nuoi an bang sonde mui da day va phau ttiuat md thong da day dac biet ddi vdi benh nhan bj tai bien mach nao can nudi duSng bang sonde da day bong tiidi gian dai, chung tdi tien hanh nghien CiJu ^'Danh gia ket qua md thong da day ra da bai§
ngi soi tsi Benlf vien E" nham muc tieu "Banh gia ket gua ve lim sang va ky thuit cua phddng phi>
md thdng da diy ra da lying ngi soi" ^
II. odi TUQNG VA PHirONG PHAP NGHIEN COU 2.1 Doi tu'dng nghien cu'u: Cac benh nhan cd ehi djnh nudi duSng bang du'dng tieu hoa keo dai (tren 4 tuan) tai benh vien E Trung u'dng tif thang 11/2011 den thang 7/2016
Tieu chui'n lu& chgn: Cd chu'e nang tieu hoa binh thu'dng
Tieu chuan ioai trCr: Co chudng to; Gan trai to; Lach to; Rdi loan chu'e nang ddng mau; C3t da day.
2.2 Phu'dng phap nghien clU'u Thiii ke nghien di'u: Nghien euli md ta cat ngang cd theo ddi doc
Tien hanh thu Oiuat: Kip tiii/c hien tliii thuat: 2 bae sT noi soi va 1 dieu du'dng phu,i|,
w
TAP CHi Y HOC VigT NAM TAP 452 • -mANG 3 - SO 2 - 2017 ac sT gay me (trong tru'dng hdp benh nhan can
l3y me tmh mach hoac gay me toan than) - Ndi thi/e hien: tai phdng npi soi hoac tai {lu'dng cua khoa lam sang.
- Chuan bj benh nhan: Benh nhan nhjn an nidc khi lam thu thuat 8h-12h
+ Ve sinh khoang mieng + Ve sinh va sat trung vung bung + Khang sinh dii phdng
+ Kiem tra sieu am d bung: Khdng cd lach to, chong ed ton thu'dng vung gan trai, than trai (vi Ju: u gan, u than, nang gan, nang than kich hVdc Idn).
+ Ky cam doan dong y lam thu tiiuat + Gay te tai cho bang Xylocain, neu bSnh ihan kich thich an tiian bang Midazolam hoac 3ay me tinh mach bang Propofol
- Chuan bj phdng npi soi: Khuf khuan bang len CLfc ti'm
TTfu fftipvi xiy 1]^ so lieu: Cac so iieu dddc thu tiiap va xu' ly theo chutfng trinh SPSS 13.0
Danh gia ket qua: Dy^ vao cac chi so
1. Cac chi so lam sang: Dau, sot, ehifdng bung sau thu thuat 24 gid.
' 2. Ky thuat
-Thdi gian tien hanh thu thuat -Phu'dng phap vd cam -Ket qua sau 24h:
+ Tai eho: dau vet mo + Bung mem hay ehu'dng + Chay mau chan sonde + Chay dich chan sonde -Ket qua sau 1 tuan +Nhiem trung chan sonde + Bien Chung khac 111. KET QUA VA BAN LU^N
Trong thdi gian tii thang 11/2011 den thang 7/2016 TO 35 benh nhan dutfc md thdng dauday m da bang ndi soi, trong dd benh nhan nam 30 (85,7%), 5 benh nhan nd (14,3%). Taf benh vien E, benh nhan du'de lam ky thuat nay ed tudi cao, nhdm tudi tren 60 chiem ty le 97,1%, chi cd 1 b|nh nhan du'di 30 tudi (2,9%)'
Bang 1. Nhom bSnh
___^ Nhom Benh "
Tai bien mach nao Liet hau hon^
Viem nao liet cu'ng U thu'c quan U hau honq Tong
So lu'dng benh nhan 31
35
TV le Vo 88,6 2.85 2,85 2,85 2,85 100 Benh nhan dutfc lam thu thuat phan Idn cd
ton tiiu'dng he than kinh, trong dd 88,6% benh nhan tai bien mach nao, hdn me d cac mi?c dp khac nhau; Ibenh nhan di chutig viem nao, lift dihg. Cd 1 benii nhan liet day DC, X.XI khdng ndi va nuot du'dc mae du b|nh nhan van tinh tao va di Iai binh thu'dng. 1 benh nhan_u thi/c quan va 1 b€nh nhan u vung hau hpng. 6 cae nu'dc da ap dung ky thu$t nay nhieu nam, chi dinh rat rdng rai ngoai benh nhan bj tdn thutfng lie than kinh vTnh vien am chi dinh cho benh nhan mat chu'e nang vung hau hpng, ehan thu'dng nang va benh
nhan bdng. Tai Viet nam, trong mdt nghien cdu tai Benh vien Xanh Pon tien hanh d 86 benh nhan, phan ldn lat>enh nhan chan thu'dng sp nao (81,4%), chi cd 13,95% tai bien mach nao va 4,65% do nguyen nhan Wiac [1]. Tai Benh vien E, chi djnh phan ldn eho eac b|nh nhan cd .ton tiiu'dng he than kinh va cd tai bien mach nao tai khoa hoi su'c ti'ch CLfcTai benh vien E, chi djnh eho thu thuat nay cd the md rdng cho cac bdnh nhan chan thu'dng so nao hdn me lau ngay can nudi dudng qua sonde.
Bing 2. Thdi gian bi benh Thdi gian
1-3 thang
>3- 6 thang
>6 thanq Tong
So lu'dng benh nhdn 6 21 8 35
Ty le »/o 17,1
60 22,9
100 Ba sd benh nhan ed thdi gian bj benh dai tren 3 thang ehiem 82,9 %, cac benh nhan nay deu du'dc nudi dudng du&ng tieu hoa bang sonde mui -da day. Khi du'dc md thdng da day ra da qua ndi soi, tdn thu'dng hay gap trong da day la viem trdt hoac loet niSm mac da day va thiTe quan.
VIETHAM MEDICAL JOURNAL N*^ - MARCH - 2017 Bing 3. Phifdng phip vo cam
Phu'dng phap yo cam So lu'dng benh nhan TyleP/o J
Gay me tmh maeh 10 28,6
Gay te+ An than 25 71,4
Gay te tai eho Tong
Thu thuat du'dc tien hanh tai phdng ndi soi hoac tai giu'dng khi khdng di chuyen du'dc benh nhan. 71,4% benh nhan du'de gay te tai eho ket hdp vdi an than (Midazolam), 28,6% phai gay me tTnh mach bang propofoldo b$nh nhan kieh thich giay giua nhieu ho5c liet cdng gay khd khan khi thu'c hien thu thuat. Ddi vdi cac truidng hdp gay mS tTnli maeh, bac sT gay me se phdi Bang 4. T/le tpanh cdng cua thu thuit
hdp vdi bac sT ndi soi. Q eac nu'dc khac, tuy ttlH tru'dng phai ma rac chuyen gia chi su" dung ^ te tai clio hoac gay me toan than. Trong nghll culJ cua .Cellier ya cong sd Iai a5 tren 50%. ben nhan gay me toan than [2]. Tai b$nh vien Xan Pon 100% benh nhan chi gay te tai eho va ga te ket hdp an than[l]
Thdi gian Thanh conq Khonq thanh conq
Tong
So lu'dng benh nhan 33
2 35
TV le % i l 94,3 l
5,7
100 i Ty le thanh edng eua thO thuat la 94,3%. Thu
thuatkhdng thanh cdng d 2 benh nhSn chiem ty le 5,7%. Mpt tru'dng hdp bSnh nhan u thiTc quan chiem gan liet chu vi Idng thLTe quan nen dng ndi soi khdng qua dddc. Chinh vi vay khi lu^ chpn bpnh nhan cd u thu'c quan chung ta ran can nhSc ve kich thu'dc khoi u. Ong soi se di qua cho
hep khd ,khan va de gay ehay nhiSu mau tai khJ u trong qua trinh tien hanh thu thuat. Mc tru'dng hdp benh nhSn cd khdi u vung hau honi gay khd nuot, tuy du:a ong soi qua du'dc khSi i nhuYig ghf chay mau nhieu, nguy cd ti^o ngtra mau vao phdi nen chung tdi duYig thu thuat.
BingS. Thdi gian tiin hinh thu thuit Thdi gian
<20 ohiit
>20 phiit
So lu'dng benh n h i n 28
5
T6ng 1 33
TV l§ »/o 84,8 15,2 100 ;i Thdi gian tien hanh thCi thuat khoang 10 den
25 phut. Thdi gian lam thu thuat dai hdn d benh nhan bj liet eutig sau viem nao, tai bien mach nao lau ngay cd phdi hdp vdi nhiem trCing phoi ning. O cac benh viSn khac, thu thu$t trung binh khoang 12 phut ho^c 10 den 25 phut [1].
Qua mpt tiidi gian trien khai thii thuat chung ^ i
thay rang vdi kip thu'c hien thanh thao, chi djl chinh xacthu thuat se tien hanh nhanh, ty li thanh edng cao. Chinh vi vay, thu thuat nay o th^ thu'c hien d tat ea cac cd sd cd may n^^
da day. Ky tj^uat nay gdp phSn rCit ngan^thc gian nam vien va cham sde benh nhan tai n t i ^ dang hdn so vdi sonde mui- da day. 1 Binge. Triiu Chung ngar sau
Trieu chChig f)au tai vet mo
Sot Chu'dnq bunq Chav mau chan sonde Chav dich Chan sonde
thii thuit So benh nhan
33 1 0 0 3
Til le »/o
!
100 3,0 0 0 9.1
^ Sau 24h cac benh nhan deu c6 trieu chiJng dau vet mo nhulig mijc do dau nhe hoac trung bin 5iung ttiuoc giam dau thong thu'dng giup giam trieu chutig. Sau 3 den 5 ngay hau het c^c benh nlia het trieu chiJng nay. Mot bSnh nhan sot do nhiem trijng thanh bung.
Bing 7. Cic biin chtfhg Bl§n chihig Nhigm trtinq chan sonde Nhiem trfln^ thanh bunq
Di lech onq sonde
• Chav mau
So lu'dng benh n h i n 4 1 2 0
T* l§ % 12,1
3,0 6,0 0
TAP CHi Y Hpe Vlgr NAM TAP 452 - T H A N G 3 - S6' 2 - 2017 Viem phi
Ap xe, loet.chan sonde 3,0
Khong bien chdng 75,9
T o n g 33
Ty le khdng biin ehuYig dat 75,9%, ty l | bien Jiilhg 2 4 , 1 % . Bien chutig gap nhieu d cac benh ihan trong tiidi giandau mdi trien Wiai thu thuat do
^ung l£i chu^ cd kinh nghiem trong khau lu^
:hpn benh nhan eung nhu" eham sde sau thu thuat.
Cac bien chuVig chu yeu xay ra trong tuan 3au sau dat sonde. Nhiem trung chan sonde
±iem ty le 1 2 , 1 % . Cac benh nhan nay deu tuoi :ao (>65 tuoi) bj iBi bien mach nao lau ngay [h-gn 6 thang), the trang yeu va ed benh kem theo nhu' tieu du'dng, tang huyet ap, suy kiet.
Mhiem triJng cjian sonde cung la bien chutig hay gap nhat khi tien hanh thu thuat nay d cac nu'dc kiiac. Trong mpt nghien cufu tren 1041 benh nhan cdng bd nam 2011, H-J Richter-Schrag va cong sif thay t y le nhiem trijngtai chan sonde la
^ ^ 9 ehay mau tai ehan sonde 0,5% va viem BBupcic 1,3%. Cac bien chutig gap t / le cao d cac benh nhan ung thu', xd gan hay sau xa trj[6].
Trong nghien culi tai Viet Nam cua Benh vien Xanh Ron, ty le nhiem trung chan sonde klia thap, chi cd 2,32%. Oe dieu trj faifn chuhg nay, chung tdi cho thay t)ang hang ngay, sat trung tai di5. Sau 1 tuan vung ehan sonde het phij ne, Bien chutig nang hdn la nhiem triJng thanh bung. Cd mdt benh nhan bj bien chutig nay va dirdc dieu t n bSng dan Iu'u m u , thay bang sat tiding tai cho hang ngay, thay khang sinh dda vao khang sinh do cua vi khuan d djch mu thanh bung. Khang sinh d y phdng tru'dc thii thuat cd vai tro rat quan trpng lam giam ty le nhiem trung chan sonde ya tiianh bung. Do d d , cae benh nhan du'de chi djnh lam tiiu ttiu$t deu du'dc dung khang sinh dd phdng. Theo ddi theo thdi gian, diung ^ i nhan thay sd benh nhan nhiem trung Chan sonde ngay sau thu thuat giam so vdi thdi gian dau mdi trien khai thu thuat nay. Cd hai benh nhan di lech dng sonde do benh nhan tiT klo. Benh nh3n du'dc dat Iai ngay. De khac phuc bien ctiutig nay, cdng tac cham sde benh nhan can du'de lulj y hdn.
Luiiy vikythu$tgidp tang tyle thanh cdng:
- Khu' t m n g saeh phdng lam tiiu thuat - Ve sinh rang mieng sach - S ^ tiling sach vj t r i dat sonde
- Du'dng rach vda du dddng kinh eua dng sonde (khdng qua hep va khdng qua rdng)
- Khdng nen ed dinh qua chat hai nuted djnh trong thanh da day va nut ngoai thanh bung de
tranh kem nudi dudng tai cho va khd ve sinh tai chan sonde trong nhu'ng ngay dau sau thu thuat.
Theo doi benh nhin sau khi ra viem Benh j i h a n sau khi ra vien du'dc cham soc tai nha.
Ngu'di nha du'de hu'dng dan each cho an qua sonde da day ra da va cham soc sonde, sau 6 den 9 thang benh nhan du'dc thay sonde m ^ vdi ky tiiuat ddn gian hdn m d thdng lan dau. Do benh nhan du'dc m d thdng da day bang phu'dng pliap PEG khdng tai kham hoac tai nhap vien theo hen day du nen ehung tdi khdng tong ket du'dc toan bd thdi gian benh nhan idu sonde. Cd ' ft nhat 2 benh nhan cd thdi gian lull sonde lau
nhat la 4 nam.
V . KET LUAN
Ky thuat PEG giup dinh dddng cho benh nhan khong an du'dc du'dng mieng trong thdi gian dai.
Qua thdi gian trien khai ky thuat m d thdng da
; day ra da bang npi soi tai Benh vien E vdi 35 tienh nhan, ehung tdi ed mdt sd ket luan sau:
- Ty le thanhcdng dat 94,3% . - Thu thuat an toan va de thu'c hien - Khdng cd bien chutig nang. Cae bien diutig deu du'de Wiac phuc nhanh bang dieu tn ndi khoa.
T A I UEU THAIVI K H A O
' 1. Du'dng Mai Hu'dng, Nguyen Thi Quy, Phung Hoang Hiep.(2011), "Ket qua md tiiong da day noi soi tai Benh vien Xanh Pon "Cong trinh nghien cdu khoa hoc - H61 nghi khoa hoc tieu hoa lan thil"
VI- Hpi tieu hoa Hanoi, 49-55.
2. Cellier C,Seyrig IA, Gordin J, Chou^Ennan M, Donnadieu S, (iudron J, Bartser J.P. (IQasX^Gastromiee peniitanee endoscopiqueJndication et suivi chez 52patiOTts". F^n Gastraentrol. Hepatd, 24,n7,343-345 3. Chr.Loser C, G. AschI, Hebuteme, et al.(
2005),"ESPEN guidelines on artifidai enteral nutrition by percutaneous endoscopic gastrostomy"
Qinical Nutiition; 24:848-861.
4. Christopher R.Lynch, John C.Fang.(2004},
"Prevention and management of complication of Percufaneous endoscopic gastrotomy (PEG) tube".
Practice gashTienteroIogy, 66-76.
5. Gauderer MV, Ponsky JL, Zznat 10.(1980), Gastrostomy without laparascopy. A percutaneous endoscopic technique. J Pediatr Surg,; 15:872-875.
6. H-3 Richter-Schrag et a l . (2011), "Risk fectors and complications following percutaneous endoscopic gastrostomy: A case series of 1041 patients" Can J Gastroenterol;25(4):201-206.
/ . HunM,Raw!ingsJ,MonayFoetal(1993),"Auditof oub33me of long tern entEial nutrSion by percutaneous endoscopic gastitJdomy".lanQe!t;341:8e9-872.
