Tgp cht Tai MOi Hpng Vidt Nam - Volume (60-26). N°2- April, 2015
VI PHAU THUAT TAO HEVH SAU CAT BO K H 6 I UNG THU^
BIEU ]Vlb TE BAO VAY VUNG HQNG MIENG
KM Trung Tr^'^, TSngXudn Thdn^'*, NguySn Binh Phuc", BiiiMaiAnh*, To TudnLinh , Nguyen Hong Hd*
TOM T A T
Ung thu khoang mieng la benh ly dc tinh thudng gdp nhdt d vung diu mgt cd. Phac do didu tri tdi uu dugc iing dung trdn the gidi hien nay Id cit bd rong rai khdi u phdi hgp vdi hod xa trj trudc hay sau phau thuat. Vi phau thudt tgo hinh ehuydn cdc vgt tu do che phu cdc khuyit hdng sau cit bd ung thu ngdy cang cd vai trd quan ttgng. Bdo cao nhan xet nhiing ket qua budc diu phau thuat phoi hgp giua chuyen ngdnh tai miii hgng va phdu thudt tao hinh dieu trj cac khuydt hong sau cat bd ung thu khoang midng tgi benh vien Viet Diic ddng thdi tdi^ ket lgi y vdn.
Tic khod: ung thu khoang mieng, ung thu bieu mo te bdo vdy, viphdu thudt, vgt tu do.
SUMMARY
Free flap reconstruction following oral squamous cell carcinoma ablation:
Preliminary results.
Oral cancer of the buccal mucosa and retiomolar trigone is the most common malignancy of the head and neck region. Now a day the treatment of choice in over the world is to completely remove the primary tumor in combination with chemoradiotherapy.
Free flap transfers play a dominant role in head and neck reconstruction, especially in oral defects coverage. The aim of this paper is to evaluate the premilinary results of combined surgeries between ENT doctors and plastic surgeons for reconstruction post tumor resection defects at Viet Due hospital.
Key words: oral cavity and oro-pharynx cancer, squamous cell carcinoma, microsurgery, free flap.
khli u vdi vide tdi tao lgi khuyit hing nhim phuc hdi lai chiic ndng vd thdm my Viec cit bd cdc khdi u dc tinh viing (.^o ngudi benh. Khi phuang phdp vi phau midng vd hiu hgng con nhieu kho khdn do ^^^ ^hua dugc dp dyng tiii nbimg vat tgi mdu tiiuan gjiia vide ldy bd rgng rai, ttigtdd (.^g Qp^al flaps) tiiudng kho che phii hit vimg mit chit va dem lgi kit qud hgn chl
• Khoa phlu thuSt Tao hlnh - Ham mSt, vd mat chiic ndng ciing nhu tiiim mJ? do Benh vien Viet Diic vay se dnh hudng ddn kit qud dilu tri va
** Bp mon Tai mui hong - Tnrong DHY Ha Npi Thim dinh: PGS.TS. Nguyen Ho^g Son, 1. DAT VAN DE:
Tgp cht Tai MQi Hgng Vi^t Nam -Volume (60-26). N''2- April, 2015
chit Iugng song ciia bdnh nhdn. Sy ra ddi ciia vi ph^u thugt trong vai thdp ky gin ddy da tgo ra budc ngodt thay doi thdi do dieu tri tiong dilu tri phau thugt ung thu diu mdt cl, giiip ehuydn cdc vgt tu do (free flaps) dd che phu cdc khuyit hing ldn dugc tgo ra sau cit bd khli u. Nhd ung thu hge co the cit bo rgng rdi, tri^t dd khli u md khdng qua bdn khodn ddn vimg mdt chat, do dd ca kit qua vl mdt ung thu hgc vd chiic ndng, thim my... ddu dugc cdi thien. Do vgy vi phau thudt dd gdp phan quan tigng vao ket qud dieu tri.
Vat vi phdu lan ddu dugc Seidenberg sii dung dd tgo hinh khuydt hing viing ddu mdt cd vdi vat h§ng tiang tgo hinh thuc quan nam 1959. Trai qua vai thdp ky, nhung hidu biet vd gidi phau cdc vgt ty do va ky thudt frong vi phau thudt cung nhu ttang thiet bi ngay cdng dugc ndng cao. Vi vdy, chuyen cdc vgt ty do vi phau che phii cdc khuydt hong vung diu mgt cd, ddc biet la cdc khuyet sau cat bo khdi u da frd thdnh phuang phap dang tin cdy vd hidu qua trong tgo hlnh vimg dau mat co. Nhiing uu didm vugt tidi ciia phuang phdp tao hinh bdng vat vi phau bao gdm cit u va tao hinh mgt thi;
che phli cdc khuyet hong ldn; tdi tgo td chiic theo khdng gian ba chieu; sir dyng vgt co cam giac hay van dgng ndu cin...
Nghien ciiu ddnh gid kit qud phiu thudt tgo hinh cac khuyit hing sau cit bo khdi ung thu bieu mo td bao vdy vimg hgng midng phoi hgp giita ehuydn khoa Tai Miii Hgng vd Phau thugt Tao hinh tai benh vign Vidt Diic.
2. DOI TirgnVG VA PHU*OfNG PHAP NGHlfeN Ctru
Nghidn cihl hli ciiu cdc tnrdng hgp duge vi phau thudt tao hinh cdc khuyit hdng sau cit bd ung thu bieu md td bdo vay khoang mieng phli hgp giua chuyen khoa Tai Mui Hgng va Phau thugt tgo hinh tii thdng 3 ndm 2013 din thdng 5 ndm 2014 tgi bgnh vign Vigt Dire. Tdt cd cdc bdnh nhdn dugc thdm khdm va chdn dodn xdc dinh bdi cdc chuyen gia Tai Miii Hgng, sau d6 dugc hgi chin tnrdc vdi bac si Phau thuat Tgo hinh nhim xdy dyng kl hoach phau thudt chi tidt ciing nhu phdc dd dieu tri sau phdu thudt. Cdc sl lieu dugc ting kit dya fren hi so bdnh dn, dnh benh nhan tnrdc frong va sau phau thugt, thong tin kham lgi...
3. KET QUA NGHIEN CUtJ Ting sl 9 benh nhdn duge phau thugt, 7 nam vd 2 nu, tuli trung bmh 57 tuli (Bdng 1). Tgo hinh thi ddu sau cdt b6 khli ung thu 5 trudng hgp, 4 trudng hgp che phli khuyit loet sau xa tri khdi u bdng vat tu do. Todn bg bdnh nhan ddu c6 ket qua giai phiu bdnh ly Id ung thu bidu mo te bao vay. Cdc vgt dugc sir dung bao gdm: 5 vat dui tnrdc ngodi, 2 vat xuong mac, 2 vat da cdn cdng tay quay. Tat cd cdc vgt ddu song, 1 trudng hgp cd nhiem trimg, 1 trudng hgp nhidm trimg vd hogi tii vgt mgt phan on dinh sau dilu tii khang sinh vd chdm soc vet tiiuong. Cd hai trudng hgp nhiem trung sau ml ddu nim ttong nhom bdnh nhdn loet sau xg trj. Theo doi trung binh 11 thang, hidn chua cd trudng hgp nao tdi phdt. Hau hit bdnh nhan va gia dinh hdi long vdi ket qua dilu tri.
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Tap chl Tai MOi Hpng Vi$t Nam - Volume (60-26), N°2- April, 2015
STT Tuoi
1 61 2 56 3 47 1 57
5 64
6 58
7 64 8 56 9 54
SCC (squama Gi*i
Nam Nam Nam NO
NO
Nam
Nam Nam Nam
Bdng 1. Danh sdch bfnh nhin
ChSn doein
SCC sdn mi$ng mdn hiu T3N1M0 SCC l<he liin hdm TSNIMO SCCI<helidnhdmT2N1M0 Viem r6 hogi ti> xuong hdm dudi sau
xg trj SCC Vidm r6 hogi tu xuang hdm dudi sau
xg tri SCC Vidm rd hogi ti> xuong hdm dudi sau
xg tri SCC SCC ti^n ainh hdm dudi T3N1M0 Vidm rd sdn mi$ng sau xg trj SCC
SCC xoang 16 T2N1M0
Logi vgt vi ph§u
ALT Vgt da can cSng tay quay
ALT ALT
Vgt xucmg mdc
ALT
Vgt xuong mdc Vgt da cdn cSng quay
ALT
JS cell carcinoma): ung thif biiu mO tS bio vdy, ALT (anterior lateral thigh flap): v^t dill tmdc ngodi
4. BAN LUAN
Trong ung thu khoang midng va hgng mieng thi ung thu bidu md td bdo vdy (squamous cell carcinoma - SCC) chidm ty le nhilu nhit. Podrecca [1] tdng ket 346 trudng hgp ung thu diu mdt cd trong vdng 10 nam tai Milan (Y) thi cd din 260 trudng hgp (75%) Id SCC, Haughey [2] ting kit tgi Washington (M^) SCC chilm 76%
(184/241 trudng hgp). Mdt nghidn ciiu Wide tai Dai Loan cua Hao [3] cdn cho ti Id cao ban (85%), tac gid cho ring mdt sl ydu tl nguy <^ lam tdng ti Id SCC Idioang midng nhu thdi quen dn triu d mdt sd nudc
Ddng A, so ngudi hiit thuoc Id va uong rugu manh nhidu.
Phuang phap dieu tri cdt bd rgng rai ung thu phli hgp vdi xa tri hay hod tri dugc coi nhu phuang phap dieu tti tidu chuin dang dugc dp dyng chu ylu ttdn thl gidi.
Vigc cdt bd khoi u khdng dii rdng se ddn den bdnh tdi phat, ngugc lai ndu cdt bd qua rdng rai khli u thi se kho khan vl mat tao hinh neu nhu chi diing ede vat ghep tai cho do vdy nd ludn Id thdch thiic vdi cac nhd ung thu hgc [4][5].
Vide su dung cdc vgt ghep tu do cd nli vi mach ra ddi dd gdp phin gidi quylt mdu
Tgp ch! Tai MUI Hgng Viet Nam - volume (60-26). N 2- April, 2015
thuan tten, vdi uu didm cua vat ghdp da cdi thien dugc cd kdt qud ve mat cdt bd khli u lan kit qud vd mdt chiic ndng vd thdm my, qua do dem lai chat lugng cugc song tit han cho b^nh nhdn. Xu hudng hien nay vd
ttong tuang lai, cdc vgt ghep tu do sd ngdy cdng dugc sii dung nhieu han dd tao hinh cdc khuyit hdng sau cit bo khli u noi chung ciing nhu vdi ung thu vimg khoang migng vd diu cl.
Hinh 1. Theo chi^u kim ding hd. B$nh nhSn nam, 61 tudi, SCC sdn mi^ng, clt khli u vd tao h1nh bang vgt xu'ong mdc, bao gim ca dao da de tgo hlnh sdn mi$ng. Hlnh trung tdm cho thiy khdp cln dCing sau ph§u thu$t 1 ndm.
Kit qua tit ca vd thim m? vd chi>c ndng. Noi cho vgt s?o dgp, b$nh nhdn di lai blnh thudng.
Tat ca benh nhdn ttong nhdm nghien ciiu ndy ddu co kdt qua giai phau bdnh ly la SCC. 6 Viet Nam, hien chua tim thay sd ligu thdng ke chinh xdc ti Id benh nhdn SCC, b^nh nhan hiem khi dugc phdt hidn d giai dogn sdm, da so ddn vien d giai dogn mugn. Neu eat bo rgng rai khoi u d |iai dogn mugn thi vide ddng kin khuyit hdng hdu nhu chi cd thl dugc thyc hien nhd chuyen eac vgt da tu do vi phau. Trong iih6m nghidn ciiu co 5 benh nhan phau thugt thi dau thi co 3 tnrdng hgp d miic do xam ldn T3, 2 tiirdng hgp d miic dd xdm lan T2. Co the cdc bdnh nhdn nay d giai doan mugn vi da dugc cdc bdc si chuyen khoa Tai miii hgng sang Igc tir trudc khd ndng phli hgp vdi ehuydn khoa Phdu thudt Tgo hinh su dyng cac vat vi phdu dd che
phli khuyit hong sau khi cdt bo u. Tuy nhien, nghien ciiu cua Podecca [1] cung cho thiy 88% SCC din vidn d miic do xdm lin T3 vd T4, dk didu tri cho cac benh nhan ndy khdng the thieu vai tto ciia vi phau thudt.
Nhieu logi vgt tu do dugc sir dyng de tgo hinh d vung ddu mgt ed nhu vgt da can cing tay quay, vgt bd ben ba, vat da co thing bung, vat did trudc ngodi, vat xuong mao chgu, vgt xuong mac... Sd lugng ldn vat da cdn cdng tay quay dugc sir dung d chdu Au vd My, ti le su dyng vgt ndy tron^
nghien ciiu ciia Halle [6] tdi 89,5 % so tiirdng hgp (198/221), Haughey [2] sir dyng ttong 40% sl ca (96/241). Trong khi dd tai chau A co rit nhilu bao cdo su dung vgt ALT nhu la vgt ddu tay ttong tgo hinh phin mdm vd vgt xuang mac frong tgo hinh
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Tap chf Tai MQi Hgng Vi^t Nam - Volume (60-26). N°2- April, 2015
5 ^ 8 [3][7]. Vgt ALT cd kich tiiudc tdi da len tdi 20 x 40 cm, dugc su dung dudi nhieu hinh thiie nhu vgt cdn, vgt da cdn, vgt cdn md hay ldy cung mgt phdn ca va thin kinh vdn dgng dd phuc hdi ehiic ndng vgn dgng, ldy cimg thin kinh cdm gidc cho nhiing vimg can phuc hoi cam gidc. Vgt xuong mac cho khli lugng xuang ldn, thdng,^ cudng vgt cd kich thude ldn va ddi, CO the sii dyng ciing da - ca - xuong.
Trong nhdm nghidn ciiu chiing toi sii dyng 5 vat ALT vd 2 vat da can cing tay quay cho tgo hinh phin mim, ca 2 trudng hgp can tgo hinh xuang diu dimg vgt xuang mde. Sy hing dinh vd mdt gidi phiu, dan gidn trong k5' thugt hoc vat, tinh linh hogt khi sii dung vd thim my nai cho vat la nhung iru didm vugt tr^i cua hai logi vat nay [7].
Ti lg thanh cdng hay ti Id sdng ciia vgt vi phlu d vung diu mat cl tir 87 - 95%.
Cdc ydu td nguy ca ldm tdng cdc biln chiing nhu xg tri, hiit thudc la, nghien rugu, thdi gian thidu mdu vat dai... De gidm thidu cdc nguy ca nay, phau thuat vien cin tien Iugng va cd kd hogeh cy the, dgc bidt frong nhiing trudng hgp tien lugng cdn phdi ghep mgch, cho bgnh nhdn ngimg hiit thulc it nhit Id 2 tuin tnrdc phau thugt [2]. Cac biln chiing chu ylu bao gdm hogi tii vat toan bg hay mgt phin, buc vdt md, tu mdu, nhilm trimg, vidm rd... Nhdm nghien ciiu cua chiing tdi cd 4 tnrdng hgp dugc phlu thudt tao huih thi hai vidm ro sau xg tri s e e , 2 ttong 4 trudng hgp ndy cd bidu hidn nhiem trung chdy dich sau phdu thudt, mac
Hinh 2. Theo chieu kim ding ho. B0nh nhdn nO, 57 tuli, vi6m r6 hogi ti> xuang hdm dydi sau xa trj SCC. Clt r6ng rSi vOng hogi tO, khuyit xuyfin vdo khoang mi$ng.
Chuydn vat ALT ty do chia ddi Idm hai phdn che phu khuyet. Kdt qua tdt sau phlu thudt 3 thang.
dil khong gdy hogi tii vgt nhung phai mit rat nhieu thdi gian de eham sde vdt thuang.
Nghidn ciiu ciia Halle [6] cho thiy xa tri ed dnh hudng rd rang den ti Id xudt hien biln ehiing sau vi phau thugt diu mat cd. Tdc gia khuyen cao rdng nen lam ehuydn vgt thi ddu ngay sau cat bd khdi u rli mdi xg tri, con tiong nhang trudng hgp cd chi dinh xg tri tnrdc phau thugt thi can tiln hdnh phau thudt cdng sdm cdng tit tiong vong 6 tuin ke tir ldn xa tri cuoi cimg nhim lam giam ti 1$ bidn chiing sau phau thudt.
5. KJ&T LUAN
Phoi hgp da chuyen khoa nhdm dem lgi hieu qud dieu tri cao nhit cho ngudi bgnh Id xu the hidn nay tren toan thd gidi.
Vi phau thudt ngay cdng ddng vai ttd quan
Tgp cht Tai MOi Hgng Vi$t Nam - Volume (60-26). N°2- April. 2015
ttgng ttong phau thugt tgo hinh sau cdt b6 khdi u. Chuydn vat tu do la phuong phap ddng tin cdy vd hi^u qua ndu xdy dung kl hoach tgo hinh chinh xdc vd chi tiet, gidm thieu cac yeu td nguy ca. Vdi cac khoi u dc tinh vimg khoang mieng, phau thudt cdt bo rgng rai, tgo lunh che phii bang vat tu do nlu cin, kdt hgp vdi hod xa tri dd frd thanh phdc do dieu tri toi uu nhdm gidm thieu den miic thdp nhat cdc dnh hudng den chiic ndng, tham my cfing nhu tdm ly bdnh nhdn.
TAI L i f u THAM KHAO
1. Podrecca S, Salvatori P, Squadrelli Saraceno M, Fallahdar D, Calabrese L, Cantii G, Molinari R. Review of 346 patients with tiee-flap reconstruction following head and neck surgery for neoplasm. J Plast Reconstt Aesthet Surg.
2006;59(2):122-9.
2. Haughey BHl, Wilson E, Kluwe L, Piccirillo J, Fredrickson J, Sessions D, Spector G. Free flap reconstruction of the head and neck: analysis of 241 cases.
Otolaryngol Head Neck Surg. 2001 Jul;125(l):10-7.
3. Hao SP, Cheng MH. Cancer of tiie buccal mucosa and rettomolar trigone.
Operative Techniques in Otolaryngology (2004)15,239-251.
4. Hassanein KAI, Musgrove BT, Bradbury E. Psychological outcome of patients following tteatment of oral cancer and its relation with functional status and coping mechanisms. J Craniomaxillofac Surg. 2005 Dec;33(6):404-9. Epub 2005 Oct 25.
5. Wolff D, Hassfeld S, Hofele C.
Influence of marginal and segmental mandibular resection on the survival rate in patients with squamous cell carcinoma of the inferior parts of the oral cavity. J Craniomaxillofac Surg.
2004Oct;32(5):318-23.
6. Halle M, Bodui I, Tomvall P, Wickman M, Famebo F, Amander C. Timing of radiotherapy in head and neck free flap reconstruction—a study of postoperative complications. Plast Reconsti Aesthet Surg. 2009 JuU62(7):889-95.
7. Lutz BS, Wei FC. Microsurgical workhorse flaps in head and neck reconstruction. Clin Plast Surg. 2005 Jul;32(3):421-30.
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