DANH GIA KET QUA PHAU THUAT CAT TUI MAT NOI SOI DO BENH LY VIEM TUI MAT T O M TAT Muc t i e u : Danh gia ket qua phau thuat noi soi dieu tri viem tiii mat cap va man tinh tai benh vien
Trang 1DANH GIA KET QUA PHAU THUAT CAT TUI MAT NOI SOI
DO BENH LY VIEM TUI MAT
T O M TAT
Muc t i e u : Danh gia ket qua phau thuat noi soi
dieu tri viem tiii mat cap va man tinh tai benh vien
hffu nghj da khoa Nghe An
Doi tu'dng va phu'dng phap nghien cffu:
Nghien cffu mo ta hoi cffu ket hpp tien cffu 44 benh
nhan viem tui mat cap va man tfnh dUdc PTNS cat tiii
mat tai Benh vien hffu nghi da khoa Nghe An tff
01/2009 d^n 12/2013
Ket qua: Tff thang 1/2009 den 12/2013, 44 benh
nhan du'dc phau thuat npi soi cat tui mat vdi 23 Nam,
21 na theo ty le 1,09; tuoi trung binh 52,0 ±
14,2(25-86) tuoi; Viem tiii mat man tinh 78,24 %, viem tiii m|t
mo md; Co 1 benh nhan (2,3%) ap xe ton dU sau mo
Th6i gian phau thuat 50,22 ± 16,3 (30-120) phiit; Thdi
gian hau phau 4,88 ± 1,7 (3-11) ngay
Ket luan; Phau thuat cat tui mat noi soi di'eu tr;
viem tui mat cho ket qua tdt va trd thanh thu'dng qui,
it bien chffng va khong co t y vong trong va sau mo,
TO'khoa: Phau thuat npi soi, Viem tui mat Cat
till mat,
S U M M A R Y
ASSESSMENT OF RESULTS OF
TREATMENT FOR CHOLECYSTITIS
LAPAROSCOPIC CHOLECYSTECTOMY
Objective: Asessment of results of laparoscopic
surgery for treatment cholecystitis in Nghe an general
friendship Hospital
Matrials and Methods: Retrospective
descriptive study combined a prospective of 44
patients with acute cholecystitis and chronic
endoscopic surgery cholecystectomy from January
2011 to December 2012 in Nghe an general friendship
Hospital
Results: from January 2011 to December 2012,
fourty- four patents were laparoscopic surgery for
average age was binh 52,0 ± 14,2(25-85), Acutes
cholecystitis was 21.76 percent and Acutes
cholecystibs was 78.24 percent No conversion to
tradihonal laparoscopic or open surgery There was
one patient (2.3%) Posoperation abscess; mean
operative time was 50,22 ± 16,3 (30-120) minutes;
Hospital stay was 4,88 ± 1,7 (3-11) days
* Benh vien HuU nghi Da khoa Nghe An
Nguyin Van Hircmg*
Conclusion: Laparoscopic cholecystectomy
cholecystitis treatment gives better results and become routine, fewer complications and no deaths during and after surgery
keywords: Laparoscopic surgery, cholecystitis,
cholecystectomy
I DAT V A N OE
Benh ly viem tui mat la benh mpt benh kha pho bien tai Viet Nam Mo cat tui mat bang dffdng md bung kinh dien lan dau tien dffdc thyc hien bdi Carl Joham Langenbueh (Berlin, Offc) thang 7 nam 1882 Hdn 100 nam sau, ca cat till mat qua npi soi 6 byng dau tien dffdc Phillip Mouret (Lyon, Phap) thffc hien thanh eong vao
thang 3 nam 1987 [ 1 ] , [ 2 ] Tff do tdi nay phau
thuat cat tiii mat npi soi da t r d thanh phffdng phap dieu trj ngoai khoa chuan cho nhffng benh nhan viem tui mat cd trieu chffng nhd nhffng IAJ viet cua no so vdi cat tiii mat m d nhff hau phau nhie nhang, dffdng rach nho, thdi gian nam vien ngan va ngffdi benh nhanh ehdng t r d lai lam viec binh thffdng [ 3 ]
Tai Benh Vien Hffu Nghi Da khoa Nghe An, ehiing tdi da thffc hien phau thuat cat tui mat npi soi ap dyng dieu tri benh nhan tij cac benh ly tOi mat Chung tdi thyc hien de tai nay vdi mue tieu danh gia tinh an toan va ket qua cua PTNS cat till mat trong benh ly viem till mat tai Benh vien hffu nghi da khoa Nghe An
II DOI TLTONG VA PHU'aNG PHAP NGHIEN CLTU
2 1 D o i tu'dng n g h i e n cufu
44 benh nhan (BN) viem till mat dffdc chi djnh mo' cat tiii mat noi soi tai khoa Ngoai Benh vien Hffu Nghj da khoa Nghe An tff thang 1/2009 den thang 1 2 / 2 0 1 1 3 _
2.1.1 Tieu chuan chpn benh
Benh nhan dffde chan doan viem tiii mat dffa tren trieu chffng lam sang gdi y va ket qua sieu
am ft nhat 2 lan vdi bac sT sieu am Cd kinh nghiem ket hdp vdi chup CT scanner dffdng mat (neu cd)
2.1.2 Tieu chuan ioai triy
Benh nhan cd vet mo cu tren ron va co
Trang 22.2 Phu'dng phap nghien cu'u:
Nghien cffu mo ta hoi ciTu ket hdp tien cffu
2.3 Cac bffdc tien hanh nghien cu'u:
Ghi nhan cac trieu chffng lam sang nhff dau
ha sffdn phai, cd phan ffng viing ha sddn phai
CLVT, sinh hda, huyet hoc Ket qua dieu tri phau
thuat npi soi
Phu'dng tien, dung CIJ phau thuat va cac
bu'dc thu'c hien Dan phau thuat ndi soi ciia
hang Karl - Storz
- Ky thuat mo;
+ Gay me npi khf quan
+ Benh nhan nam ngii^, dau cao, nghieng
trai; Phau thuat vien ddng d ben trai benh nhan,
ngffdi phu mo dffng canh ben trai phau thuat viem
+ Oat cac trocar: chung tdi sff dyng 3 lo
trocar theo kinh dien d tren ron, thffdng vj va d
mang sffdn phai
+ Oanh gia tinh trang tiii mat va cae tang
xung quanh: tien hanh tham sat tham dd 6' byng, till mat, giai phong viem dfnh quanh tui mat, bdc tach bpc^ Id viing tam giac gan mat ( tam giac Calot) de bdc 16 ro tiii mat, ong co till mat, ong mat ehii
+ Tien hanh cat tui mat theo ky thuat ngddc dong hoac cat xudi ddng
Tru'dng hdp tiii mat cang to, khd kep tien hanh chpe hiit dieh mat lam xep tui mat, giai phdng giu'dng tiii mat bang hook Tiii mat ddpc 10mm d rdn Lau rffa va dan Idu o bung
- Ghi nhan thdi gian phau thuat, tai bien trong phau thuat
- Theo doi sau mo bao gom; thdi gian trung tien, cac bien chffng sau mo, thdi gian nam vien.,
2,4 Xff ly so lieu: bang phan mem SPSS 16.0
III KET Q U A N G H i l N CU'U
3 1 Dac diem doi tu'dng nghien cu'u
Nghien'cLTu 44 benh nhan viem tiii mat cap va man tfnh dffdc chi djnh phau thuat cat tui mat npi soi tai benh vien Hffu nghj da khoa Nghe An tff thangl/2009 den thang 12/2013 gom 21 nff va 23 dan va c6ng nhan
Bang 1: Phan bo benh nhan theo dp tuoi
Phan bo theo do tuoi
Di/a 31 tuoi
31-40 tuoi
41-50 tuoi
51-60 tuoi
>60 tuoi
N
4
4
14
10
12
Ty le % 9,10 9,10 31,8 22,7
Dp tuoi th&dng gap la d trin 40 tuoi; Tuoi trung binh 52,00 ± 14,2 (25-86) tuoi
3.2 Dac diem iam sang, can lam sang
Bang 2: Dac diem lam sang
Trieu chu'ng lam sang
Sot tren 38 do
Dau Ha sffdn Phat
Da, ket mac vang
Phan ffng vung H5P
Tien sff phau thuat o byng
Ty le %
56,S
93,2
Nhuhg trieu chuhg lam sang^ th&dng gap nhit la: dau ha s&dn phai (93,2), co phan &ng vung ha s&dn phai 81,8%, 6,8% co tien s&phau thuat dbung
Bangs: Nhffnq clii so smh tioa mau
Thonq so sinh hoa
Bilirubin TP
SGOT
SGPT
Amylaza
X
17,7 50,2 57,4 77,3
SD(±)
14,6 62,9 90,3 105,5
Thap nhat- cao nhat
16,6- 37,8 38,5- 68,8 37,5-56,6 68,4-210,2
NhOng chi so men gan, bilirubin TP, Amylaza aia nhil'ng benh nhin trong nhom nghien c&u tang han
Trang 3Bang 4 Hinti anh sieu am
Dac diem hinh anh Sieu am
Thanii day > 4mm
Dich mat khong thuan nhat
Tu dich quanh tui mat
Soi ket CO tui mat
N
44
44
4
5
Ty le %
100
100
10 11,3
100% benh nhan co thanh tut mat day, va dich mat khong thuan nhit, chi co 10% la co dich d quanh tui mat, CO 5 benh nhan (11,3%) co hinh anh viimm tui mat do soi ket d co tui mat
3.3 Ket qua dieu trj phau thuat npi soi c^t tui mat
3.3.1 Vi tri dat Trocar: Trong nghien cffu nay chung toi thffc hien 42 ca sy dyng 3 trocar chiem
95,5%, 2 ca sff dung 4 trocar v) qua trinh phau tfch bpc Ip tam giac Calot khd khan va khdng co trffdng hdp nao chuyen mo md
3.3.2, PhWdng phap cit tui mat va thdi gian phau thuat: Cd 38 trffdng hdp dffdc cat till
mat ngffdc ddng chiem 86,4%, va 13,6% dffdc eat tui mat xudi ddng.Thdi gian phau thuat: 50,22 ± 16,3 phiit ngan nhat la 30 phiit, dal nhat la 120 phiit
Bang 5: Tinh trang tui mat trong mo
Tinh trang tui mat trong mo
Tui mat viem, mac noi dinh
Tu dich quanh tui mat
Dich mat va qia mac d tronq 6 bunq
N
37
31
2
Ty le »/o 84,1 70,5 4,5
Tinh trang tui mat viim, mac noi dinh co 37 tr&dng hdp chiem 84,1 %, chi co 2 tr&dng hdp (4,5%) co
ft dich va gia mac d ha s&dn phai
Cach dat dan Iffu: Tat ea cac trffdng hdp mo cua chiing toi deu dffdc dan Iffu dffdi gan chiem 100% trffdng hdp; chiijeu la datl dan Idu
Theo doi hau phau; Trong thdi gian hau phau, cd 29 benh nhan dffdc sff dung phdi hdp 2 loai
khang sinh ( Metronidazol + Cephalosporin the he III) chiem 65,9% va 15 benh nhan sff dyng khang
sinh ddn thuan
Bang 6 Cac thong so theo ddi trong thdi gian hau phau
Thong sd
ThcJi gian trung tien (gicJ)
Thdi qian dunq qiam dau (nqay)
Thdi gian hau phau (ngay)
X ± S D 32,86 ± 10,37 2,18 ± 0,62 4,88 ± 1,7
Thap nhat- cao nhat
24-72
1 - 4
3 - 1 1
Bien chffng sau mo: Cd 1 trffdng hdp bj abcess tdn dff sau mo, trffdng hdp nay 6\S<ic ehung toi
dieu tri bao ton npi khoa thanh c6ng Khdng cd trffdng hdp nao bj chay mau sau mo, dd dddng mat, ton thffdng dffdng mat chfnh hay tff vong trong qua trinh phau thuat
Ket qua giai phau benh ly: 100% la viem tiii mat
IV BAN LUAN
Tff nam 1882, Langebuck da tien hanh eat
till mat theo phffdng phap kinh dien dau tien
Qua tren 100 nam ton tai, den thang 3 nam 1987
ca cat till mat npi soi dau tien dffde Phillip Mouret
thffc hien thanh cong Hien nay phau thuat noi
soi cat till mat dffdc coi la tieu ehuan vang trong
dieu tri ngoai khoa benh ly viem tiii mat cap,
man tfnh [1],[3],
Chan doan trffdc mo dffa vao trieu chffng
lam sang, can lam sang va chan doan hinh anh
doan viem tiii mat khi cd eac yeu to: sdt, an ha sffdn phai dau, phan ffng ha sffdn phai, so Iffdng bach eau > 10.000/ mm3, cac tieu chuan chan doan viem till mat tren sieu am ( djch quanh tiii mat, thanh till mat day, tfnh chat dich mat ) Trong nghien cffu ciia ehiing toi, sot tren 38 do chiem 56,8%, dau ha sffdn phai chiem 93,2%, 100% thanh tui mat day va djch mat khong thuan nhat Salam Zakko (2008) nhan xet 2 trieu chffng quan trpng tren sieu am chan doan Viem tui mat cap ia thanh tiii mat day > 4mm va dau Murphy, va mpt nghien cffu khac ciia
Trang 4Satambrogio cho rang sieu am khong quan sat
dffdc viing tam giac gan mat, do dd can phai ket
hdp vdi CY Scanner de nhan dmh va tien tffdng
tot hdn cho cupc phau thuat[2]
Theo Chris N Daniak va cpng sff (2008) va
mot so tac gia khac cho rang doi vdi vien tui mat
cap nen mo trong vong 72 gid dau se thuan ldi
hdn, do khi viem tiii mat cap cdn sdm, cd dinh
quanh tui mat nhieu nen de phau tfch vi cd dich
viem quanh till mat chffa to chffe hda thanh dai
xdday [ 4 ]
Qua trinh phau thuat chung toi thffc hien 42
ca sff dung 3 trocar ehiem 95,5%, 2 ca sff dyng
4 trocar vi qua trinh phau tich bpe Ip tam giac
Calot khd khan va khong cd trffdng hdp nao
chuyen mo md
Trong phau thuat ehung toi hau nhff chi
diing 3 trocar de thao tac, trong nhffng trffdng
hdp khd nhff tiii mat viem dfnh qua nhieu phau
tieh kho khan, gan trai Idn che phau trffdng khi
dd ehung toi mdi dat them 1 trocar 5mm thao
tac Diing 3troear tranh dffdc mot vet mo tren
thanh byng, lam tang tinh tham my ciia cupc
phau thuat
Trong nghien cffu nay, kh6ng ed trddng hdp
nao chiing tdi phai chuyen mo md co le do so
Iffdng phau thuat edn it, chan doan trffdc mo cd
sy ket hdp giffa sieu am va CT Scanner Chiing
toi dong y vdi y kien cho rang chuyen mo md
khong phai la that bai cua phau thuat npi soi An
toan cho benh nhan dffdc dat len hang dau Van
de la phau thuat vien phai biet liic nao can phai
chuyen mo md Theo Samer KA, Murayama KM
(2002), cupc mo npi soi tien trien khong tdt sau
60 phiit nen chuyen mo md [ 6 ]
Thdi gian phau thuat trung binh ciia ehiing
tdi la 50,22 ± 16,3 phiit ngan nhat la 30 phiit,
dai nhat la 120 phiit, So vdi Nguyen Cffdng
Thinh: 41,4 phut (dao ddng tff 20 - 180 phiit);
Hoang Ngpc Ha; 75 ± 26 phut Thffc te thdi gian
phau thuat phy thudc chii yeu vao tinh trang tui
mat nhff dinh, viem cap phii ne, mun de chay
mau, Ngoai ra cdn mpt sd khd khan do trang
thiet bj nhff Camera, khf Co2 Trong phau thuat
chung toi gap tinh trang tui mat viem, mac noi
dfnh cd 37 trffdng hdp chiem 8 4 , 1 % , djch mat va
gia mac 6 bung chiem 4,5%[1],[3]
C6 1 trffdng hdp bj abcess ton dff sau mo,
trffdng hdp nay dffde chimg toi dieu tn bao ton
npi khoa thanh cong bang 2 loai khang smh sau
11 ngay b?nh nhan 6 dinh ra vien Trong nghien
sau mo, do du'dng mat, ton thffdng dffdng mat chfnh hay tff vong trong qua trinh phau thuat Theo Shamiyeh A va cs (2004) ty le to thu'dng dffdng mat trong phau thuat eat tiii mat npi soi phau thuat vien, tinh trang tiii mat, cd sd vat nhan gay ton thffdng dddng mat bao gom: Nham lan khi xac dinh ong mat chii, dng gan phai hoac cang qua mffc tiii mat dan tdi keo theo ca ong mat chii; to thddng nhiet hoac to thu'dng do thieu nhiem, chay mau, cat va giai phong giu'dng tiii mat qua sau; tut Clip dng co till mat [5],[7] Trong nghien cffu ciia ehiing toi thdi gian trung tien trung binh la 30,18 ± 7,57 gid ( dao dpng 24 den 50 gid); Thdi gian diing giam dau ngay); Thdi gian hau phau la 4,88 ± 1,7 ngay (dao dpng 3 den 11 n^ay) So vdi cae tac gia trong ndde nhd Nguyen Cffdng Thinh, Hoang Ngoc Ha hay cae tae gia nddc ngoai nhff Shamiyeh A, Chris N Daniak, Muhammas SP cung
CO ket qua tffdng tff [2], [ 4 ] , [ 7 ] TAI UEU T H A M KHAO ^
1 Do Kim Sdn, Nguyen Thanh l o n g (2003),
"Nghien cffu nguyen nhan va phUOng phap xir ly tai bien, bien chyng cua phau thuat npi soi cat tiii
so 3, tr 9-14
z Hoang Tuan Viet, Nguyen Hoang Linh, Biii Quang Kinh (2008), "Danh gia ket qua cat tui
mat noi soi tai benh vien Da khoa Sai Gon" Tap chi rhoc TR Ho Chi Minh, tap 12(1), tr 1-7
3 Nguyen Cu'dng Thjnh, Diem Dang Binh (2008), " Danh gia ket qua cat tiii mat noi soi qua
1231 trudng hop", Tap chi Y hoc TP Ho Chi Minh,
tap 12(4), tr 11-15
4 Chris N Daniak et al (2008), "Factors associated with time to laparoscopic cholecystectomy for acute cholecystitis",World J Gastroenterol, 14 (7);
1084 - 1090
s Manousos M et al (2004), Inraoperative finding and postoperative complication in laparoscopic cholecystectomy: The Greek experience with 5539 patient in a single center", Journal of laparoscopic and advanced surgical techniques, 14, pp 31-36
u Samer KA., Murayama KM., et al (2002) "Risk factors for conversion from laparoscopic to open cholecystectomy", Journal of Surgery Reserch'vol 106, no.l:20-24
7 Shamiyeh A et al (2004), "Laparoscopy choiecystectomy: Early and late complication and their treatment ", Langenbecks Archive of Surgery,