Nguyen Chu nhiem Khoa Phau thuat Tim mach - Long ngUc 13V.. Chu nhiem khoa Ngoai BV.[r]
Trang 1Y 4
CffP GUU NGOHIKHOH
TAP 2■
(D U N G C H O B A C Si V A H O C VIEN SAU DAI H O C)
Chu bien: GS DANG HANH OE
CD
N H A X U A T BAN G IA O D U C V IE T NAM
Trang 3BO Y TE
TAP 2
(DUNG CHO BAC SI VA HOC VIEN SAU DAI HOC)
MA SO: D01.Z10.W
NHA XUAT BAN GIAO DUC VIET NAM
HA NOI - 2010
Trang 4Chi dao bien soan:• •
VU KHOA HOC VA DAO TAO - BO Y TE
Chu bien:
GS DANG HANH DE
T ham gia to chttc ban thao:
ThS PHI VAN THAM
TS NGUYEN MANH PHA
© Ban quyen thuoc Bo Y te (Vu Khoa hoc va Dao tao)
Anh ngoai bia: Phau thuat thay van 2 la
Tran Hong (1996)
Trang 5Chu bien:
OS DANG HANH DE
Nguvcn Pho Chu nhiem Bo mon Ngoai TrUdng Dai hoc Y Ha Noi
Nguyen Chu nhiem Khoa Phau thuat Tim mach - Long ngUc 13V Viet Dilc Chu nhiem khoa Ngoai BV HCtu Nghi
Tham gia bien soan:
NGUYiN NGOC BICH
1
PGS.TS Pho Tarong Bo mon Ngoai Trifdng Dai hoc Y Ha Noi Tnidng khoa Ngoai Benh vien Bach Mai
] TRAN NGOC BICH PGS.TS Trirong khoa Phiu thuat Nhi BV Vi^t Dire
T
jOANG HANH D$ GS Nguyen Pho Chu nhi6m B6 mdn Ngoai Trudng Dai hoc Y Hei N6i Nguyfin
Chu nhiem Khoa Phau thuat Tim mach - Long ngi/c BV Vi§t Ode Chu nhiem khoa Ngoai BV HQu Nghi
! DONG VAN HE TS Phau thuat vien Khoa Phiu thuat Than kinh BV Viet Dire
! DITONG OAI HA
j TS Phiu thuat vien Khoa Phau thuat Th§n kinh BV Viet OCrc
] DUONG OL/C HUNG TS Pho Truong khoa Phau thuat Tim mach - Long ngi/c BV Viet DCfc
DOAN QUOC HUNG TS Phau thuat vien Khoa Phau thuat Tim mach - Long ngi/c BV Viet DCfc TRAN HIEU HOC TS Pho Truong khoa Ngoai BV Bach Mai
j PHUNG NGOC HOA ThS Phau thuat vien Khoa Chan thuong - Chinh hinh BV Viet D l / c
I k I^UDINH HUNG
i
PHAM o ir c HUAN PGS.TS Pho TrUcing Bo mon Ngoai tn/dng Dai hoc Y Hci Noi, Tn/ong khoa
Phau thuat Tieu hoa BV Viet Dire
NGUYEN XUAN HUNG PGS.TS Truong phong Kham cap cl /U BV Viet Di/c
HOANG LONG TS Phau thuat vien Khoa Tiet nieu BV Viet Due
NGUYEN VAN MAO ThS Giam doc BV Tim Ha Noi
TRAN BAO LONG PGS.TS Phau thuat vien Khoa Gan - Mat BV Viet Due
LE HONG NHAN TS Pho Truong khoa Phau thuat Than kinh BV Viet OCrc
NGUYEN DUC PHUC PGS P h iu thuat vien Khoa Chan thuong - Chinh hinh BV Viet Difc
NGUYEN QUANG TS Phau thuat vien Khoa Nam hoc BV Viet B u t
3
Trang 6HA VANQUYET
- -GS.TS Truong Bo mon Ngoai Tn/dng Oai hoc Y Ha Noi Pho Giam doc BV Viet OCfc
DANG HANH SON TS Phiu thuat vien BV Tim H& Noi
0 6 TRUONG SON TS Phiu thuat vien Khoa phiu thuat tieu hoa BV Viet Dire
HOANG NGOC SON TS Phiu thuat vien Khoa phau thuat Ch£n thuong - Chinh hinh BV Viet DC*:
NGUYEN CONG TO PGS.TS Pho TrUcing Bo mon Ngoai Truong Oai hoc Y Ha Noi Pho Giam doc
BV Viet OCfc
DO t r u O n g t h A nh TS Pho Tru6ng khoa Phau thuat Tiet nieu BV Viet OCfc
LE NGQC THANH PGS.TS Giam doc Trung tarn Tim mach BV E
h A k im t r u n g TS Pho Truong khoa Phau thuat Than kinh BV Viet OCfc
TRINH VAN TUAN TS Phau thuat vien Khoa Cap cCiu Tieu hoa BV Viet OCfc
DOAN THANH TUNG PGS.TS Trudng khoa Phau thuat Gan - Mat BV Viet OCfc
NGUYEN HOU UOC PGS.TS Pho Truong Bo mon Ngoai Truong Oai hoc Y Ha Noi Pho Truong
khoa Tim mach - Long ngUc BV Viet OCfc
4
Trang 7L d l GICJl THIEU
Dao tao nguon nhan lUc can bo chat ltfdng cao la mot trong nhOng moi quan tarn hang dau cua nganh Y te Song song vdi viec dau tu cO sd vat chat cho cac cO s6 dao tao, Bo Y te chu trong tang cUOng cac phUOng tien day va hoc, trong do viec bien soan tai lieu day-hoc dac biet Uu tien
Sach Cap cufu ngoai khoa dUOc bien soan nh&m phuc vu cho viec dao tao sau
dai hoc cua trUOng Dai hoc Y Ha Noi, nhUng cung la tai lieu tot de tham khao cho viec dao tao dai hoc va cho cac bac si ngoai khoa Sach dUOc bien soan v6i phUdng cham: Kien thiic c0 ban, he thong; noi dung chinh xac, khoa hoc, cap nhat cac tien
bo khoa hoc, ky thuat hien dai va thuc tien Viet Nam
Cuon sach nay dUOc bien soan boi cac nha giao, cac nha khoa hoc giau kinh nghiem trong linh vUc Ngoai khoa Sach da dUOc Hoi dong chuyen mon thanh lap
theo quyet dinh so: 1683/QD-BYT ngay 20 thang 5 nam 2010 cua Bo Y te tham
dinh Sach dUdc ban hanh lam tai lieu sU dung chinh thiic phuc vu dao tao dai hoc
va sau dai hoc cua nganh Y te trong giai doan hien nay, dong thdi cung se la tai lieu hu!u ich cho cac bac si tham khao hang ngay
P3o Y te xin chan thanh cam dn GS Nguyen BUu Trieu, Chu tich Hoi dong tham djnh, GS Do Diic Van va GS Ha Van Quyet Uy vien phan bien va cac uy vien Hoi
dong da doc, dong gop nhieu y kien quy bau de cuon sach dUOc hoan thien
Chung toi m on g nhan dUOc y kien dong gop cua dong nghiep va cac doc gia de
sach dUdc h oan chinh hOn cho nhutng lan xuat ban tiep sau
VU KHOA HOC VA DAO TAO - BO Y TE
5
Trang 9L O l n o i d a u
Cap ciiu ngoai khoa luon la mot van de thdi sU khong nhutng cua cac phau thuat vien ma con cua tat ca nhu!ng ai lam cong tac lam sang
Trong the ky trUdc Nha xuat ban Y hoc da xuat ban cuon Cap cvfu Ngoai
khoa, nhUng trai qua nhieu nam vdi nhiing tien bo nhanh chong cua y hoc noi
chung cung nhu sU phat trien cua nganh Ngoai khoa noi rieng, cuon sach do khong con cap nhat niia
Chung toi bien soan lai lan nay nham trU6c het phuc vu cho cong tac dao tao (dai hoc va sau dai hoc trong cac trUdng Dai hoc Y) va sau do la cac dong nghiep d cac tuyen y te trong ca nUdc NhOng ngUdi tham gia bien soan deu la cac can bo giang day trong Bo mon Ngoai trUdng Dai hoc Y Ha Noi vdi nhieu nam giang day
va p h iu thuat tai cac benh vien 16n (Viet Diic, Bach Mai, Saint Paul), thuoc dung chuyen khoa cua minh Vi the chung toi hy vong cuon sach se dap ling dUdc yeu cau cua cac dong nghiep
Noi dung cuon sach chi thu gon trong nhOng cap cCfu ngoai khoa thong
thUdng, rat hy vong trong tUdng lai co the bien soan cuon Ngoai khoa toan tap
(Textbook of Surgery), mot cong trinh 16n doi hoi sU tham gia cua nhieu ngUdi, trong nhieu chuyen nganh khac nhau Sach dUdc bien soan thanh 2 tap:
- Tap 1 gom cac chuyen khoa: Than kinh, Long ngUc va Tim mach, Nhi
- Tap 2 gom cac chuyen khoa: Tieu hoa, Tiet nieu, Chan thUdng
Du da rat co gang nhUng van khong the tranh dUdc nhutng thieu sot do nhting tien bo khong ngting va nhanh chong trong nganh Y noi chung, viec cap nhat kien thiic khong the bat kjp
Chung toi xin chan thanh cam dn ong Phi Van Tham, chuyen vien cao cap Vu Khoa hoc va Dao tao Bo Y te da khuyen khich va tao moi dieu kien thuan ldi de cuon sach dude xuat ban Cam dn ba Nguyen Thi Thanh Binh, Thu ky Bo mon Ngoai da gop phan bien soan cuon sach
Chu bien DANG HANH DE
Trang 11MUC LUC
Ldi gidi thieu 3
Ldi noi d a u 5
P han 4 TIEU HOA
1 Thung thiic q u a n 13
(Pham Dtic Huan)
2 Thung o loet da day - ta trang 24
(Ha Van Quyet)
3 Chay mau do loet da day - ta trang 32
(Ha Van Quyet)
4 Hep mon v i 41
(Ha Van Quyet)
5 Chan doan va dieu tri chan thUdng ta trang 48
(Trinh Van Tuan)
6 Chan doan va dieu tri chan thUdng t u y 58
(Trinh Van Tuan)
7 Tac ruot 69
(Pham Dite Huan)
8 Thoat vi n g h e t 79
(Ha Van Quyet)
9 Xoan r u o t 88
(Nguyen Ngoc Bich)
10 Chan thUdng bung va vet thUdng bung 98
(Ha Van Quyet)
11 Viem ruot thvfa 108
(Pham Di'/c Huan)
12 Viem tui thu'a Meckel 119
(N guyen N goc Bich)
13 Viem phuc mac va cac o ap xe trong o b u n g 125
(N guyen N goc Bich)
14 Thoat vi co h o a n h 136
(N guyen N goc Bich)
15 Chay mau trong o bung khong do chan thUdng 143
(Nguyen N goc Bich)
16 Vet thUdng hau mon - true t r a n g 151
(Ha Van Quyet)
17 Ap xe gan do a m ip 156
(Tran Hieu Hoc)
18 Chan thu'dng va vet thUdng gan 164
(Tran Bdo Long)
Trang 1219 Soi mat va bien chting cap ciiu 173
(Doan Thanh Tung)
20 Viem tui mat 183
(Doan Thanh Tung)
21 Viem tuy c a p 189
(Tran Hieu Hoc)
22 Chay mau do ap ltfc tinh mach ciia 202
(Tran Hieu Hoc)
23 NhCfng cap ctiu thUdng gap vung hau mon trtfc trang 216
(Nguyen Xuan Hung)
24 Bong thiic quan 230
(Do Tritctng Scfn)
25 Chay mau dUdng m a t 238
(Do Trii'dng Scfn)
Phan 5 TIET NIEU
1 Cdn dau quan than 253
(Hoang Long)
2 Vo nieu do tac nghen 259
(Hoang Long)
3 Dai m a u 264
(Hoang Long)
4 Bi dai c a p 268
(Hoang Long)
5 Soi ket nieu d a o 271
(Hoang Long)
6 Chan thUdng than 273
(Hoang Long)
7 Chan thifdng va vet thtfdng nieu q u a n 287
(Hoang Long)
8 Chan thUdng bang quang 293
(Do Triibng Thanh)
9 Chan thUdng nieu d a o 299
(Do Triibng Thanh)
10 Chan thtfdng vung b iu 310
(Hoang Long)
11 Ctfdng dau difdng vat keo dai (Priapism) 313
(Nguyen Quang)
12 Vet thtfdng dUdng v a t 320
(Nguyen Quang)
13 Vd vat hang 327
(Nguyen Quang)
14 Xoan tinh h o a n 332
(Nguyen Quang)
10
Trang 1315 Lf mu than 338
(N guyen Quang) 16 Ap xo quanh th a n 346
(N guyen Quang) 1 7 Ap xe va nhot t h a n 353
(N guyen Quang) 18 Viem tuven tien liet cap tfnh 362
(N guyen Quang) 19 Hoai thu cd quan sinh due: benh Fournier 367
(N guyen Quang) Phan 6 CHAN THl/ONG 1 Vet thUdng phan m em 373
(Phung Ngoc Hoa) 2 Gay xUdng d tie c m 378
(Nguyen Diic Phuc -Phung Ngoc H o d )
3 Gay xUdng h d 383
(Phung Ngoc H od )
4 Gay xUdng co bien chiing than kinh 394
(Nguyen Ditc Phuc - Phung Ngoc Hod) 5 Gay xUdng co bien cluing mach m a u 401
(Nguyen Diic Phuc - Phung Ngoc Hod) 6 Hoi cluing chen ep khoang 406
(Phim g N goc Hod) 7 PhAu thuat cat cut c h i 414
(Phung N goc Hod) 8 Vet thUdng k h d p 425
(P him g N goc Hod) 9 Viem xu'dng 429
(Phung N goc Hod) 10 Hoai thu sinh hdi 436
(P hung N goc Hod) 11 Dai cUdng ve bong 440
(P hung N goc Hod) 12 Dai ciidng ve U xUdng 447
(P hung N goc Hod) 13 Trat khdp v a i 454
(Ph ung N goc Hod) 14 Trat khdp khuyu 460
(Phung N goc Hod) 15 Trat khdp hang 467
(P him g N goc Hod)
Trang 1416. Gav than xUdng canh l a v 478
(Phung Ngoc Hod)
17 Gay tren loi cku xUdng canh tay d tre e m 482
(H oang N goc Sctn)
18 Gay hai xUdng cang tay 494
(Phung Ngoc Hod)
19. Gay dau dudi xUdng quay ngUdi ldn 502
(H oang N goc Scfn)
20 Vet thUdng ban t a y 513
(Phung N goc Hod)
21 Nhiem Lrung ban ta y 522
(Phung Ngoc Hod)
22 Gay xUdng c h a u 532
(Phung N goc Hod)
23 Gav co xUdng d u i 543
(Phung Ngoc Hod)
24 Gav khoi mau chuyen xUdng d u i 550
(Phung Ngoc Hod)
25 Gay than xUdng dui 555
(Phung N goc Hod)
26 Gav d&u dudi xUdng dui 563
•(Phung Ngoc Hod)
27 Gay hai xUdng cang c h a n 568
(Phung N goc Hod)
28 (-lay xUdng co ch a n 577
(Phung Ngoc Hod)
29 Cac ton thuong phan mem vung co c h a n 582
(Phung N goc Hod)
30 Gav mam ch a y 588
(Phung N goc Hod)
12
Trang 15PHAN 4
TIEU HOA
1 THONG THUCQUAN
Thung thiic quan la tap hdp cac ton thiidng tat ca cac 16p cua thanh thiic quan lam thong long thiic quan v6i ben ngoai do cac nguyen nhan khac nhau nhii vet thufdng, chan thiidng va thung thiic quan tii phat hoac do thay thuoc gay ra Du do nguyen nhan nao thi thung thiic quan cung co nhieu diem chung la benh canh lam sang giong nhau, deu co nguy cd viem trung that, nguyen tac va cac phiidng phap dieu tri giong nhau
Thung thiic quan la mot ton thiidng it gap trong ngoai khoa nhUng lai la ton thiidng thung co tien liidng nang nhat trong cac loai ton thUdng thung rua tieu hoa
vi chan doan thiidng muon, dieu tri kho khan va ty le ty vong rat cao (20 — 30%) mac du hoi siic va dieu tri phau thuat da co nhieu tien bo
1 N G U Y E N N H A N
Co rat nhieu nguyen nhan gay thung thiic quan v6i cac cd che gay thung khac nhau nhii la do vet thiidng, chan thiidng tii ngoai vao (vet hiidng do bach khi, hoa khi, tai bien phau thuat), hoac tCf trong ra (noi soi, di vat), hoac la vd thiic quan tii phat do tang ap liic dot ngot trong long lam xe rach thiic quan hoac la do cac benh
ly thiic quan (ung thii thiic quan)
1.1 T h u n g thiic q u a n do tai bien cua phau th u a t, th u th u a t
1.1.1 Tai bien cua noi soi
Thung thiic quan do noi soi la nguyen nhan thiidng gap nhat, chiem tren 50% trong tat ca cac nguyen nhan gay thung thiic quan Ty le thung thiic quan trong noi soi chan doan lidc tinh khdang 0,13 - 0,4% Trong noi soi chan doan, thung thiic quan co the gap khi co thoat vi hoanh, dung ong soi ciing, dat ong soi mo
m lm , khong kiem soat bang mat Trong noi soi dieu tri, nong thiic quan dieu tri cac nguyen nhan hep d thiic quan (seo hep thiic quan sau bong, dieu tri co that tarn vi ) la nguyen nhan gay thung thiic quan hay gap nhat, sau do la cac tai bien trong cac dieu tri tam thdi hep thiic quan do ung thii (dat nong thiic quan, laser), tiem xd cam mau
13
Trang 161.1.2 Tai bien phau thuat
Cac phau thuat 6 vung co nguc va bung tren deu co the gay ra vet thuong thuc quan do cat phai thiic quan do cac ton thudng cua tang lan can xam lan vao thanh thuc quan hoac cac dung cu phau thuat dat tai cho ty de vao thUc quan lau ngav gay thung Cac phau thuat d vung co co the lam thung thiic quan la cat tuyen giap do ung thu hoac tuven giap qua to cac nep, vit cot song co ty de vao thuc quan md khi quan khong dung ky thuat Cac phau thuat d long ngiic nhu cat phoi soi trung that co the gay ton thiidng thuc quan ngitc 0 bung, cac phau thuat
co the gay thung thuc quan la md cd thiic quan ngoai m em mac (phau thuat Hellerv) cat than than kinh X cac phau thuat dieu tri thoat vi hoanh
1.1.3 Cac nguyen nhan khac
Tai bien cua dat bong Blakemore, bong Linton de cam mau trong chay mau do tang ap luc tinh mach ciia thanh thiic quan rat de ton thudng do thieu mau ty ep keo dai cua bong Thung thuc quan do ong noi khi quan va thd may keo dai rat it gap
1.2 V et thifdng va ch an thiidng thiic quan
Vet thiidng thuc quan do bach khi va hoa khi it gap d co, vet thudng thiic quan thudng phoi hdp vdi cac vet thudng mach mau ldn vung co hoac khi phe quan vdi bieu hien lam sang la chay mau ldn hoac tran khi ldn diidi da co hoac trung that
Vd thuc quan do chan thiidng bung hoac chan thiiOng ngiic kin rat hiem gap
va chu yen thay d nhung benh nhan da chan thuong Sii tang ap liic dot ngot trong lon£ thuc quan thudng gay vd thuc quan ngUc 0 doan 1/3 tren thuc quan dUdng
vd d mat tru'dc va thudng kem theo vd phan mang khi quan Mot so trUdng hdp vd thiic quan do hut vao ong hdi co ap luc cao duong vd thiic quan thudng rat ldn
1.3 Vd thufc quan tii phat
Vd thuc quan tu phat la vd thuc quan sau non manh va nhieu, bao gom hoi
chung Boerhaave, hoi chiing Mallory - Weiss va mau tu tu phat thanh thuc quan Hoi chiing Boerhaave dude dinh nghia la ton thuong vd hoan toan cac ldp cua thiic quan ngue khong do chan thudng Cd che vd thuc quan la do non manh gay tang
ap hie dot ngot trong long thuc quan trong khi cd nhan hau dong kin Trong cac trudng hop vd thuc quan tu phat thudng thay co cac ton thudng thiic quan than kinh phoi hop nhu viem thuc quan tang trudng luc cd that diidi cua thiic quan tui thua thuc quan nguc v v Hoi chung Mallory - Weiss co cd che chan thudng tucr.g
tu nhu' hoi chung Boerhaave nhung ton thudng la rach doc m em mac tam vi lop
eO khong bi ton thudng
1.4 Tilling thiic quan do di vat
Nguyen nhan thuong gap nhat ia do nuot phai xuong Vi tri thung tb.v.zr.z :
t