Y HOC VIET NAM THANG - SO 2/2014 DANH GIA KET QUA PHAU THUAT CAT TUI MAT NOI SOI DO BENH LY VIEM TUI MAT Nguyin Van Hircmg* T O M TAT Muc tieu: 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(2586) tuoi; Viem tiii mat man tinh 78,24 %, viem tiii m|t cap 21,76%. Khong co trUdng hop nao phai chuyen mo md; Co 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 thu'dng qui, it bien chffng va khong co ty vong va sau mo, TO'khoa: Phau thuat npi soi, Viem tui mat. Cat till mat, SUMMARY 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 treatment cholecystitis . Male/Female ratio was 1.09, 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 Phan bien khoa hoc: GS.TS Le Gia Vinh 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 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 nam 1882. Hdn 100 nam sau, ca cat till mat qua npi soi byng dau tien dffdc Phillip Mouret (Lyon, Phap) thffc hien eong vao thang nam 1987 [ ] , [ ] . Tff tdi phau thuat cat tiii mat npi soi da trd 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 trd lai lam viec binh thffdng [ ] . 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 vdi mue tieu danh gia tinh an toan va ket qua cua PTNS cat till mat benh ly viem till mat tai Benh vien hffu nghi da khoa Nghe An. II. DOI TLTONG VA PHU'aNG PHAP NGHIEN CLTU . . Doi tu'dng nghien 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 _ 2.1.1. 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 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 chdng chi dmh phau thuat npi soi Y HOC VIET NAM THANG - SO 2/2014 2.2. 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 sffdn phai, cd phan ffng viing sddn phai. Cac xet nghiem can lam sang n h d sieu am , chyp 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 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 cat bo cho vao tui va lay ngoai qua lo trocar 10mm d rdn. Lau rffa va dan Idu o bung . - Ghi nhan thdi gian phau thuat, tai bien 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 QUA N G H i l N CU'U . . 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 nam theo ty le bang 1,09.; 95,4% benh nhan sdng d ndng thdn va mien niii; 93,2% la ngffdi ndng dan va c6ng nhan. Bang 1: Phan bo benh nhan theo dp tuoi Phan bo theo tuoi Di/a 31 tuoi 31-40 tuoi 41-50 tuoi 51-60 tuoi >60 tuoi N 4 14 10 12 Ty le % 9,10 9,10 31,8 22,7 27,3 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 Ty le % 56,S Dau Ha sffdn Phat 93,2 Da, ket mac vang Phan ffng vung H5P Tien sff phau thuat o byng Nhuhg trieu chuhg lam sang^ th&dng gap nhit la: dau s&dn phai (93,2), co phan &ng vung s&dn phai 81,8%, 6,8% co tien s&phau thuat dbung. Bangs: Nhffnq clii so smh tioa mau Thonq so sinh hoa X SD(±) Thap nhat- cao nhat 17,7 16,6- 37,8 Bilirubin TP 14,6 38,5- 68,8 50,2 SGOT 62,9 37,5-56,6 57,4 SGPT 90,3 68,4-210,2 77,3 Amylaza 105,5 NhOng chi so men gan, bilirubin TP, Amylaza aia nhil'ng benh nhin nhom nghien c&u tang han binh thudng nh ung & gidi han cho phep Y HOC VIET NAM THANG - SO 2/2014 Bang 4. Hinti anh sieu am Dac diem hinh anh Sieu am N Ty le % 44 100 Thanii day > 4mm 44 100 Dich mat khong thuan nhat 10 Tu dich quanh tui mat Soi ket CO tui mat 11,3 100% benh nhan co tut mat day, va dich mat khong thuan nhit, chi co 10% la co dich d quan tui mat, CO benh nhan (11,3%) co hinh anh viimm tui mat 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 chung toi thffc hien 42 ca sy dyng trocar chiem 95,5%, ca sff dung 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 mo Tinh trang tui mat mo N Ty le »/o Tui mat viem, mac noi dinh 37 84,1 70,5 Tu dich quanh tui mat 31 Dich mat va qia mac d tronq bunq 4,5 Tinh trang tui mat viim, mac noi dinh co 37 tr&dng hdp chiem 84,1 %, chi co tr&dng hdp (4,5%) c ft dich va gia mac d 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 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 thdi gian hau phau X±SD Thong sd Thap nhat- cao nhat ThcJi gian trung tien (gicJ) 32,86 ± 10,37 24-72 Thdi qian dunq qiam dau (nqay) 2,18 ± 0,62 1-4 Thdi gian hau phau (ngay) 4,88 ± 1,7 3-11 Bien chffng sau mo: Cd trffdng hdp bj abcess tdn dff sau mo, trffdng hdp 6\S 10.000/ mm3, cac tieu chuan chan doan viem till mat tren sieu am ( djch quanh tiii mat, till mat day, tfnh chat dich mat .). Trong nghien cffu ciia ehiing toi, sot tren 38 chiem 56,8%, dau sffdn phai chiem 93,2%, 100% tui mat day va djch mat khong thuan nhat. Salam Zakko (2008) nhan xet trieu chffng quan trpng tren sieu am chan doan Viem tui mat cap ia tiii mat day > 4mm va dau Murphy, va mpt nghien cffu khac ciia Y HOC VIET NAM THANG - SO 2/2014 Satambrogio cho rang sieu am khong quan sat dffdc viing tam giac gan mat, 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 vong 72 gid dau se thuan ldi hdn, 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 dai xdday [4]. Qua trinh phau thuat chung toi thffc hien 42 ca sff dung trocar ehiem 95,5%, ca sff dyng 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 trocar de thao tac, nhffng trffdng hdp khd nhff tiii mat viem dfnh qua nhieu phau tieh kho khan, gan trai Idn che phau trffdng dd ehung toi mdi dat them trocar 5mm thao tac. Diing 3troear tranh dffdc mot vet mo tren 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 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 [ ] . 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 cdn mpt sd khd khan 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 , % , djch mat va gia mac bung chiem 4,5%[1],[3]. C6 trffdng hdp bj abcess ton dff sau mo, trffdng hdp dffde chimg toi dieu tn bao ton npi khoa cong bang loai khang smh sau 11 b?nh nhan dinh vien. Trong nghien cffu khdng c6 trffdng hdp nao bi ehay mau sau mo, du'dng mat, ton thffdng dffdng mat chfnh hay tff vong qua trinh phau thuat. Theo Shamiyeh A va cs (2004) ty le to thu'dng dffdng mat phau thuat eat tiii mat npi soi cung rat khac nhau, phu thudc vao kinh nghiem phau thuat vien, tinh trang tiii mat, cd sd vat chat. Manousos M (2004) tong ket nhffng nguyen nhan gay ton thffdng dddng mat bao gom: Nham lan xac dinh ong mat chii, dng gan phai hoac dinh ong gan phai giong nhu' ong ed tiii mat; keo cang qua mffc tiii mat dan tdi keo theo ca ong mat chii; to thddng nhiet hoac to thu'dng thieu mau ong mat chii; yeu td tai cho bao gom sff viem 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 sau mo 2,18 ± 0,62 (dao ddng den ngay); Thdi gian hau phau la 4,88 ± 1,7 (dao dpng den 11 n^ay). So vdi cae tac gia 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 mat tai Benh vien Viet Difc", Tap chi Ngoai khoa, 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, 20, pp 1-16. . MAT NOI SOI DO BENH LY VIEM TUI MAT TOM TAT Muc tieu: 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. 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 trd thanh. khoa Nghe An. II. DOI TLTONG VA PHU'aNG PHAP NGHIEN CLTU 2.1. Doi tu'dng nghien cufu 44 benh nhan (BN) viem till mat dffdc chi djnh mo' cat tiii mat noi soi tai khoa Ngoai