B Y T TRNG I HC Y H NI NGUYN DUY ễNG ĐáNH GIá KếT QUả ĐIềU TRị H ẹP NIệU QUảN THứ PHáT SAU PHẫU THUậT TạI BệNH VIệN VIệT ĐứC Chuyờn ngnh: Ngoi - Tit niu Mó s : CK 62720715 LUN VN BC S CHUYấN KHOA CP II Ngi hng dn khoa hc: PGS.TS TRNG THNH H NI - 2014 LI CM N Trong quỏ trỡnh hon thnh lun ny tụi ó nhn c nhiu s dy d, giỳp ng viờn ca cỏc thy cụ, ng nghip, bn bố v gia ỡnh Vi lũng kớnh trng v bit n sõu sc, tụi xin chõn thnh cm n ti: - Ban Giỏm Hiu, phũng Sau i hc, B mụn Ngoi - Trng i hc y H Ni - Ban giỏm c, khoa Phu thut Tit niu - Bnh vin Vit c - PGS.TS Trng Thnh, ngi thy ó tn tỡnh ch dn, ch bo, úng gúp nhiu ý kin quý bỏu cho tụi hon thnh lun ny - PGS.TS Nguyn V Khi Ca, PGS.TS Hong Long ngi thy ó ch bo, truyn t cho tụi nhiu kin thc lõm sng quý bỏu - Tp th cỏc cỏn b, nhõn viờn khoa Phu thut Tit Niu - Bnh vin Vit c - Ban giỏm c - Bnh vin a khoa tnh Hi Dng, Khoa phu thut Tit niu Bnh vin a khoa tnh Hi Dng, ni tụi cụng tỏc ó h tr tụi rt nhiu quỏ trỡnh hc v lm lun ny - Tp th lp Chuyờn khoa II khúa 26 chuyờn ngnh Ngoi Trng i hc y H Ni - Tụi xin by t lũng bit n sõu sc ti m, v con, anh ch em, bn bố ó to iu kin v ng viờn tụi cuc sng v s nghip hc - Tụi vụ cựng bit n ton th bnh nhõn v gia ỡnh bnh nhõn nghiờn cu ó tn tỡnh cng tỏc giỳp tụi thc hin nghiờn cu ny H Ni, thỏng 11 nm 2014 Nguyn Duy ụng LI CAM OAN Tụi l Nguyn Duy ụng, hc viờn lp CKII khúa 26, Trng i hc Y H Ni, chuyờn ngnh Ngoi khoa, xin cam oan õy l lun bn thõn tụi trc tip thc hin di s hng dn ca thy PGS.TS Trng Thnh Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan, ó c xỏc nhn v chp nhn ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 10 thỏng 11 nm 2014 Ngi vit cam oan Nguyn Duy ụng MC LC Chng TNG QUAN TI LIU 1.1 I CNG V GII PHU SINH Lí NIU QUN 1.1.1 Gii phu niu qun [],[],[] 1.1.2 Sinh lý hc ca niu qun [] 1.2 SINH Lí BNH, NGUYấN NHN GY H P NI U QUN SAU PH U THUT 10 1.2.1 Sinh lý bnh tn thng hp niu qun [],[],[],[] 10 1.2.2 Nguyờn nhõn v bin phỏp phũng nga tn thng niu qun phu thut 11 1.3 CHN ON HP NIU QUN SAU PHU THUT .13 1.3.1 Chn oỏn sm sau m (24 gi u) 13 1.3.2 Chn oỏn mun sau m (sau 24 gi) 14 1.4 IU TR HP NIU QUN SAU PHU THUT .17 1.4.1 G dớnh - t ng thụng niu qun 17 1.4.2 Phu thut to hỡnh niu qun [],[],[],[] .17 1.4.3 Phng phỏp nong niu qun ni soi di hng dn ca X-quang 26 1.4.4 Ct x hp niu qun qua ni soi 26 1.4.5 t sonde niu qun hay stent niu qun 27 1.4.6 Ct thn 27 1.5 MT S NGHIấN CU V HP NIU QUN TH PHT SAU PHU THUT 28 1.5.1 Trờn th gii 28 1.5.2 Vit Nam .28 Chng 30 I TNG V PHNG PHP NGHIấN CU .30 2.1 I TNG NGHIấN CU .30 2.1.1 Tiờu chun chn bnh nhõn 30 2.1.2 Tiờu chun loi tr .30 2.2 A IM V THI GIAN NGHIấN CU 31 2.2.1 a im nghiờn cu: ti khoa Phu thut Tit niu bnh vin Vit c 31 2.2.2 Thi gian nghiờn cu: t thỏng 01 nm 2009 n thỏng nm 2014 31 2.3 PHNG PHP NGHIấN CU 31 2.3.1 Phng phỏp 31 2.3.2 Phng phỏp chn mu .31 2.3.3 Cỏc bc tin hnh 31 2.3.4 Cỏc ch tiờu nghiờn cu .32 2.3.5 Xỏc nh nguyờn nhõn hp niu qun 35 2.3.6 ỏnh giỏ kt qu iu tr np niu qun 36 2.4 X lý s liu 39 2.5 o c nghiờn cu 39 3.1 C IM CHUNG .40 3.1.1 Tui, gii .40 3.1.2 S bnh nhõn hp niu qun th phỏt theo nm 41 3.1.3 Thi gian t phu thut n c chn oỏn hp NQ 42 3.2 NGUYấN NHN GY HP NIU QUN 43 3.2.1 Nguyờn nhõn hp niu qun th phỏt sau phu thut 43 3.2.1.3 Cỏc phu thut sn ph khoa gõy hp niu qun 43 3.2.2 Liờn quan gia nguyờn nhõn gõy hp niu qun v tuyn phu thut 44 3.2.3 Liờn quan gia nguyờn nhõn v bờn hp niu qun 45 3.2.4 Liờn quan gia nguyờn nhõn v v trớ hp niu qun 45 3.2.5 Liờn quan gia nguyờn nhõn v triu chng c nng 45 3.2.6 Liờn quan gia nguyờn nhõn v triu chng thc th 46 3.2.7 Liờn quan gia nguyờn nhõn v mc nc thn 48 3.2.8 Liờn quan gia nguyờn nhõn v chc nng thn 50 DANH MC CC BNG DANH MC CC BIU DANH MC HèNH DANH MC CC CH VIT TT BN : Bnh nhõn BQ : Bng quang BT : Bỡnh thng BTNQND : B thn niu qun ngc dũng CLVT : Ct lp vi tớnh CNQVBQ : Cm niu qun vo bng quang MSCT : Chp ct lp vi tớnh a lỏt ct cú dng hỡnh (Multi-slice computer tomography) NQNS : Niu qun ni soi NTM : Niu tnh mch NQ : Niu qun PT : Phu thut TN : Tit niu T VN Hp niu qun c c trng bi s thu hp ca lũng niu qun, gõy cn tr chc nng dn lu nc tiu t thn xung bng quang Hp niu qun cú th nguyờn phỏt hoc th phỏt sau cỏc phu thut, si hoc bnh lý ca bn thõn niu qun nh u niu qun, lao tit niu v gp sau iu tr tia x [],[] Hp niu qun th phỏt sau phu thut l mt bin chng thng gp cỏc phu thut trờn niu qun, cỏc phu thut bng, sau phỳc mc v phu thut sn ph khoa (PTSPK) Theo Trng Thnh (2012) cỏc trng hp hp niu qun sau phu thut vựng chu cú 75% l PTSPK, sau ú l phu thut si niu qun (17,33%) v cỏc phu thut ghộp thn [] Hin PTSPK v phu thut ni soi bng c ỏp dng rng rói cỏc c s khỏm cha bnh, mt khỏc trỡnh k thut cỏc tuyn iu tr cha ng u dn n tai bin tit niu cú xu hng ngy cng gia tng [] T l chn oỏn sm hp niu qun sau phu thut l rt thp Theo Bennani (1994) [] v Neumann (1991) [] thỡ ngoi nhng trng hp thiu niu, vụ niu v rũ nc tiu c chn oỏn sm, cỏc tn thng cũn li u chn 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Khỏm: Vựng tht lng trỏi y, nn au tc, thn trỏi to Cn lõm sng: Siờu õm, chp ct lp vi tớnh thy hỡnh nh b thn gión, bi tit thuc chm Niu qun gión n 1/3 trờn Xột nghim sinh húa, huyt hc gii hn bỡnh thng Chn oỏn: nc thn trỏi hp NQ trỏi sau m ly si X trớ: M theo ng sn lng bờn trỏi, bc l NQ khú khn dớnh sau m c Niu qun chớt hp hon ton ti v trớ ly si, on hp khong 1,5cm Tin hnh ct on NQ hp ni tn - tn trờn sonde JJ 7Ch iu tr sau m bng khỏng sinh, gim au, truyn dch Bnh nhõn n nh, vin sau ngy Kt qu iu tr: Khỏm vin bnh nhõn au nh, khụng st, vt m khụ Sau m thỏng bnh nhõn c khỏm li, siờu õm thn bt gión, c rỳt sonde JJ Bnh nhõn c hn, tỏi khỏm theo nh k thỏng, nm Kt qu bnh nhõn khụng au tht lng, tiu bỡnh thng, thn khụng to Siờu õm, chp NTM thn gión nh, bi tit tt Hỡnh nh chp CLVT trc m Bnh ỏn Hỡnh nh chp NTM sau m nm H v tờn: Bựi Th H 48 tui Gii: n S bnh ỏn: 12150 Ngy vo vin: 23/4/2014 Lý vo vin: au tht lng phi Bnh s: Bnh nhõn cú tin s tỏn si ni soi bng laser cỏch nm au õm vựng vựng tht lng phi, khụng st, cú tiu but rt Khỏm: Bnh nhõn khụng st, vựng tht lng phi nn au tc, thn phi to Cn lõm sng: Siờu õm, chp ct lp vi tớnh thy hỡnh nh b thn gión Niu qun gión n 1/3 di Cú mt viờn si niu qun 3mm nm sỏt ch vo bng quang Mc gión ca thn khụng tng xng vi si Xột nghim sinh húa, huyt hc gii hn bỡnh thng Chn oỏn: nc thn phi hp niu qun phi sau tỏn si niu qun ni soi, si nh niu qun phi X trớ: M theo ng h chu phi, NQ gión 1,5cm n sỏt ch vo bng quang, cú mt on chớt hp hon ton 1cm Trờn ch hp cú mt viờn si nh (khong 3mm) Tin hnh ct on hp, cm NQ vo BQ theo phng phỏp Lich - Grộgoire iu tr sau m bng khỏng sinh, gim au, truyn dch Bnh nhõn n nh, vin sau ngy Kt qu iu tr: Khỏm vin bnh nhõn au nh, khụng st, vt m khụ Sau m thỏng bnh nhõn c khỏm li, siờu õm thn gión nh, c rỳt sonde JJ Bnh nhõn c hn, tỏi khỏm sau thỏng Kt qu bnh nhõn khụng au tht lng, tiu bỡnh thng, thn khụng to Siờu õm, chp NTM thn gión nh, bi tit tt Hỡnh nh chp CLVT trc m Hỡnh nh chp CLVT sau m thỏng Bnh ỏn H v tờn: Lờ Th L 35 tui Gii: n S bnh ỏn: 19620 Ngy vo vin: 20/6/2014 Lý vo vin: au bng, st Bnh s: Bnh nhõn cú tin s m ct u bung trng trỏi cỏch nm Cỏch tun c m ct u nang bung trng phi Sau m thy au vựng tht lng phi v h v, kốm theo st, tiu khụng but rt Khỏm: Bnh nhõn st 38,5C, vựng tht lng phi nn au tc, chm thn õm tớnh H chu phi n au Cn lõm sng: Siờu õm, chp ct lp vi tớnh thy hỡnh nh b thn gión, quanh thn phi cú lp dch 12mm, thn bi tit thuc chm Niu qun gión n 1/3 di, cú hỡnh nh ct ct NQ Xột nghim sinh húa, huyt hc gii hn bỡnh thng Chn oỏn: nc thn phi hp niu qun phi sau m ct u nang bung trng X trớ: M theo ng trng gia di rn (vt m c), NQ gión 1,2cm, vựng tiu khung cú mt on NQ b khõu nhiu mi ch gõy hp hon ton Tin hnh ct b ch khõu c, kim tra thy an NQ bm dp nhiu Tin hnh ct on hp, cm NQ vo BQ theo phng phỏp Lich - Grộgoire iu tr sau m bng khỏng sinh, gim au, truyn dch Bnh nhõn n nh, vin sau ngy Kt qu iu tr: Khỏm vin bnh nhõn au nh, khụng st, vt m khụ Sau m thỏng bnh nhõn c khỏm li, siờu õm thn gión nh, c rỳt sonde JJ Bnh nhõn c hn, tỏi khỏm sau thỏng Kt qu bnh nhõn khụng au tht lng, tiu bỡnh thng, thn khụng to Siờu õm, chp NTM thn gión nh, bi tit tt Hỡnh nh chp CLVT trc m Hỡnh nh chp NTM sau m thỏng Ph lc BNH N NGHIấN CU I Phn hnh chớnh - H v tờn: Tui - Gii: N Nam - Ngh nghip: Cỏn b Nụng dõn Hc sinh T - a ch: - in thoi: - H tờn ngi bỏo tin cn: - a ch ngi bỏo tin cn: - in thoi ngi bỏo tin cn: II Tin s Bn thõn: Tin s phu thut: - Bnh phi phu thut: - Phng phỏp phu thut: - Thi gian c phu thut: - C s phu thut: Tin s bnh khỏc: Ngh khỏc III Khỏm lõm sng Thi gian b bnh: Triu chng c nng - St: Cú Khụng - au tht lng: Cú Khụng - ỏi but Cú Khụng - ỏi c: Cú Khụng - ỏi khú 1.Cú Khụng - ỏi mỏu 1.Cú Khụng - ỏi rt 1.Cú Khụng Triu chng thc th - Thn to Cú Khụng - Thiu niu - vụ niu: Cú Khụng - Rũ nc tiu: Cú Khụng IV Xột nghim cn lõm sng Huyt hc - S lng HC (T/l) - S lng BC (G/l) Sinh húa mỏu - Ure: (mmol/l) - Creatinin: (àmol/l) Sinh húa nc tiu - HC niu, BC niu Cú Khụng - Protein niu, ng niu Cú Khụng V Kt qu thm khỏm chn oỏn hỡnh nh: Chp h tit niu khụng chun b: 1.1 Khụng thy gỡ c bit 1.2 Búng thn to 1.3 Si NQ cựng bờn hp 1.4 Si thn cựng bờn 1.5 Si NQ bờn i din 1.6 Si thn bờn i din Siờu õm h tit niu: 2.1 i b thn gión 2.2 Niu qun gión 2.3 Hỡnh nh si NQ 2.4 Hỡnh nh NQ chớt hp 2.5 Hỡnh nh si thn 2.6 Khi nc tiu sau PM Chp niu tnh mch 3.1 Tt 3.2 Kộm 3.3 Sau 2h khụng ngm Chp NTM BN thn cũn chc nng: 4.1 i b thn gión 4.2 NQ gión 4.3 Hỡnh nh thuc dng ch si - hp Chp niu quan b thn ngc dũng: 5.1 Hỡnh nh NQ hp 5.2 Thuc dng ti v trớ hp 5.3 Khụng t c mỏy Ct lp vi tớnh: X hỡnh thn: VI Phng phỏp iu tr v kt qu iu tr sm Phng phỏp phu thut: 1.1 Phng phỏp ca Lich - Gregoire 1.2 Phng phỏp Politano - L eadbetter 1.3 Phng phỏp Boari 1.4 Phng phỏp khỏc () Thi gian iu tr sau m ngy Tai bin v sau phu thut: 3.1 Khụng bin chng 3.2 Chy mỏu 3.3 Thng phỳc mc 3.4 Hp 3.4 Tro ngc nc tiu 3.5 Bin chng khỏc Kt qu vin 4.1 Tt 4.2 Trung bỡnh 4.3 Xu VII Kt qu iu tr xa Khỏm lõm sng 1.1 Thi gian khỏm: 1.2 Triu chng c nng - St: Cú Khụng - au tht lng: Cú Khụng - ỏi but Cú Khụng - ỏi c: Cú Khụng - ỏi khú 1.Cú Khụng - ỏi mỏu 1.Cú Khụng - ỏi rt 1.Cú Khụng 1.3 Triu chng thc th - Thn to Cú Khụng - Rũ nc tiu: Cú Khụng Xột nghim cn lõm sng 2.1 Huyt hc - S lng HC (T/l) - S lng BC (G/l) 2.2 Sinh húa mỏu - Ure: (mmol/l) - Creatinin: (àmol/l) 2.3 Sinh húa nc tiu - HC niu, BC niu Cú Khụng - Protein niu, ng niu Cú Khụng Kt qu thm khỏm chn oỏn hỡnh nh: 3.1 Siờu õm h tit niu: i b thn gión Niu qun gión Hỡnh nh si NQ Hỡnh nh NQ chớt hp Hỡnh nh si thn Khi nc tiu sau PM 3.2 Chp niu tnh mch Tt Kộm Sau 2h khụng ngm 3.3 Chp NTM BN thn cũn chc nng: i b thn gión NQ gión Hỡnh nh thuc dng ch si - hp Ct lp vi tớnh: Kt qu xa ca iu tr: Tt Trung bỡnh Xu H Ni, ngy thỏng nm Ngi lm bnh ỏn