B GIO DC O TO B Y T TRNG I HC Y H NI ễN QUANG PHểNG NGHIÊN CứU ứNG DụNG PHẫU THUậT NộI SOI MộT Lỗ ĐIềU TRị CáC U TUYếN THƯợNG THậN LàNH TíNH LUN N TIN S Y HC H NI - 2017 B GIO DC O TO B Y T TRNG I HC Y H NI ễN QUANG PHểNG NGHIÊN CứU ứNG DụNG PHẫU THUậT NộI SOI MộT Lỗ ĐIềU TRị CáC U TUYếN THƯợNG THậN LàNH TíNH Chuyờn ngnh: Ngoi tiờu húa Mó s: 62720125 LUN N TIN S Y HC Ngi hng dn khoa hc: GS.TS Trn Bỡnh Giang PGS.TS Nguyn c Tin H NI - 2017 LI CAM OAN Tụi l ễn Quang Phúng, nghiờn cu sinh khúa 31 trng i hc Y H Ni, chuyờn ngnh Ngoi tiờu húa, xin cam oan: õy l lun ỏn bn thõn tụi trc tip thc hin di s hng dn ca: - GS.TS Trn Bỡnh Giang - PGS.TS Nguyn c Tin 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 thun ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni ngy thỏng nm 2017 Ngi vit ễn Quang Phúng CC CH VIT TT ACTH : Adreno-Cortico-Trophine-Hormone (Húc mụn kớch thớch v thng thn) ASA : American Sociaty of Anesthesiologist (Hip hi gõy mờ Hoa K) BN : Bnh nhõn BMI : Body Mass Index (Ch s c th) BV : Bnh vin CHA : Chn oỏn hỡnh nh CHT : Cng hng t CLVT : Ct lp vi tớnh CRH : Corticotropin Releasing Hormone (Hocmon gii phúng ACTH) CS : Cng s M : ng mch MCB : ng mch ch bng MTT : ng mch thng thn T : ỏi thỏo ng FSH : Follicle Stimulating Hormone (Hormon kớch thớch nang noón) GPB : Gii phu bnh HA : Huyt ỏp HC : Hi chng HS : H s LA : Laparoscopic adrenalectomy (Phu thut ni soi tuyn thng thn) LH : Luteinizing Hormone (Hocmon kớch thớch hong th) LN : Ln nht NN : Nh nht NPUC : Nghim phỏp c ch NT : Nc tiu P : Phi Pheo : Pheochromocytome (U ty thng thn) SA : Siờu õm SPA-A : Single port access adrenalectomy (Phu thut ni soi l tuyn thng thn) T : Trỏi TB : Trung bỡnh TKGC : Thn kinh giao cm TM : Tnh mch TMCD : Tnh mch ch di TMGPG : Tnh mch gan phi gia TMHD : Tnh mch honh di TMTT : Tnh mch thng thn TMTTC : Tnh mch thng thn chớnh TMTTP : Tnh mch thng thn ph TTT : Tuyn thng thn UIV : Urograhie Intra Veineuse (Chp niu tnh mch) XN : Xột nghim MC LC T VN .1 Chng TNG QUAN .3 1.1 Mụ hc .3 1.1.1 V thng thn 1.1.2 Ty thng thn 1.1.3 V ngoi .5 1.2 Cu to gii phu tuyn thng thn 1.2.1 Hỡnh th ngoi, v trớ liờn quan 1.2.2 Phõn b mch mỏu v thn kinh .11 1.2.3 Bch huyt v thn kinh 17 1.3 Sinh lý tuyn thng thn 17 1.3.1 V thng thn 17 1.3.2 Ty thng thn 18 1.4 Cỏc bnh lý, hi chng u TTT 19 1.4.1 Hi chng Cushing tng tit cortisol 19 1.4.2 Hi chng tng tit aldosterone nguyờn phỏt: Hi chng Conn 21 1.4.3 Hi chng tng tit androgene (Apert-Gallais) 22 1.4.4 U tu thng thn (Pheochromocytome) .23 1.4.5 U TTT thn phỏt hin ngu nhiờn (incidentalome) [39] 25 1.5 Cỏc phng phỏp thm dũ u TTT 29 1.5.1 Thm hỡnh th .29 1.5.2 Thm chc nng 32 1.5.3 Cỏc nghim phỏp chõn oỏn u TTT 33 1.6 Cỏc phng phỏp phu thut u TTT .35 1.6.1 Phng phỏp m kinh in (m m) .35 1.6.2 Cỏc phng phỏp phu thut ni soi u TTT 39 1.7 Nhng cụng trỡnh nghiờn cu v bnh lý v iu tr phu thut u tuyn thng thn 43 1.7.1 Th gii 43 1.7.2 Vit Nam 44 1.7.3 Phu thut ct u TTT ni soi l 45 1.7.4 Cỏc bin phỏp cm mỏu m 46 Chng 48 I TNG V PHNG PHP NGHIấN CU 48 2.1 i tng nghiờn cu .48 2.1.1 Tiờu chuõn la chn 48 2.1.2 Tiờu chuõn loi tr 48 2.2 Phng phỏp nghiờn cu 49 2.3 Thit k nghiờn cu 49 2.3.1 C mu nghiờn cu 49 2.3.2 Cỏc bc tin hnh nghiờn cu .50 2.3.3 Phng phỏp thu thp s liu 51 2.4 Quy trỡnh phu thut u TTT qua PTNS l 57 2.4.1 Phng tin, Dng c: 57 (nhúm nghiờn cu) 59 2.4.2 Phng phỏp vụ cm: .59 2.4.3 Mụ t k thut 60 2.5 Phng phỏp x lý s liu .66 2.6 o c nghiờn cu: 66 Chng 67 KT QU NGHIấN CU .67 3.1 S liu tng quỏt .67 3.1.1 S lng bnh nhõn 67 3.1.2 Thụng tin chung v i tng nghiờn cu 67 3.2 c im lõm sng, cn lõm sng ca u TTT c ng dng PTNS l 68 3.2.1 Tin s bnh 68 3.2.2 c dim lõm sng 68 3.2.3 Bnh hc, v trớ v kớch thc u TTT 71 3.2.4 c im chõn oỏn hỡnh nh u TTT 73 3.2.5 Gii phu bnh 74 3.2.6 c im ni tit u TTT 74 3.2.7 Cn lõm sng khỏc 75 3.3 ng dng PTNS l iu tr u TTT .76 3.3.1 Nguy c phu thut 76 3.3.2 ng dng phu thut .76 3.4 Kt qu PTNS l iu tr u TTT 80 3.4.1 T l ct u v ton b tuyn thng thn 80 3.4.2 Cỏc tai bin m .80 3.4.3 Thi gian m 81 3.5 Bin chng sau PTNS l iu tr u TTT 83 3.6 Kt qu iu tr sau phu thut .85 3.6.1 Thi gian dựng thuc gim au .85 3.6.2 Thi gian trung tin 86 3.6.3 Thi gian dựng thuc khỏng sinh 87 3.6.4 Thi gian nm vin 87 3.7 Khỏm li sau m .88 Chng 91 BN LUN 91 4.1 c im dch t hc mu nghiờn cu 91 4.1.1 V tui: 91 4.1.2 V Gii 92 4.2 Bn lun v c im lõm sng, cn lõm sng cỏc u TTT c ng dng PTNS l ti bnh vin Vit c 93 4.2.1 c im lõm sng cỏc u TTT c ng dng PTNS l 94 4.2.2 c im ca siờu õm v chp ct lp vi tớnh u tuyn thng thn lnh tớnh c ng dng PTNS l 100 4.2.3 Xột nghim sinh húa c hiu v khụng c hiu .103 4.2.4 Cỏc xột nghim cn lõm sng khỏc 106 4.3 Bn lun v ng dng v kt qu ca PTNS mt l ng qua phỳc mc iu tr cỏc u tuyn thng thn 106 4.3.1 Bn lun v phu thut ni soi thụng thng v PTNS mt l 106 4.3.2 ng dng phu thut ni soi mt l .108 4.3.3 Chõn oỏn: 111 4.3.4 Gõy mờ: 112 4.3.5 K thut PTNS l 112 4.3.6 K 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Zhi Chen, MD, Yan-Cheng Luo et al (2014), Laparoendoscopic Single-Site Retroperitoneoscopic Adrenalectomy for Pheochromocytoma Case Selection, Surgical Technique, and ShortTerm Outcome Journal Of Endourology, Volume 28, Number 1, January 2014 pp 5660 MT S HèNH NH MINH HA V trớ trocart u TTT T M phỳc mc thnh sau (nhúm nghiờn cu) bờn T (nhúm nghiờn cu) Phu tớch, kp TMTTC (nhúm nghiờn cu) Kp ng mch thng thn di gii phúng mt sau tuyn (nhúm nghiờn cu) So m bnh nhõn u TTT P (bnh nhõn s 51) So m bnh nhõn u TTT T (bnh nhõn s 71) MU BNH N NGHIấN CU Hnh chớnh - H tờn Tui Nam N - Ngh nghip - a ch: Tel - Ngy vo vin: Ngy vin: - Ngy m: - H s s: Mó bnh ỏn:Mó h s: Tin s trc m - Cao Huyt ỏp: - H Kali mỏu: - Cỏc tin s khỏc (ghi rừ thi gian): Lõm sng Hi chng Cushing Tng cõn Bộo cc b U m sau gỏy Mt trũn da Rn da Thõm tớm Trng cỏ Rm lụng Gim trớ nh Trm cm-Ri lon nhõn cỏch au u Mt mi Teo c au xng Mt-ri lon kinh nguyt Hi chng Conn Cao huyt ỏp Co rỳt c ỏi nhiu Khỏt nhiu Suy nhc c th Ri lon nhp tim Pheochromoxytome Tng huyt ỏp thng xuyờn Tng huyt ỏp kch phỏt au u Ra m hụi Nhp nhanh lo lng Run chõn tay Mt mi, suy nhc Khú th Thay i th lc Gy sỳt U hch TKGC Cao huyt ỏp au bng Khỏc m vt to Tng huyt ỏp ỏi thỏo ng Cỏc thm dũ cn lõm sng Thm dũ cn Lõm sng in tõm Siờu õm M thn Siờu õm tim XQ phi Siờu õm bng CLVT( CHT) bng Kt qu Dy tht trỏi Bỡnh thng Dy tht trỏi Bỡnh thng Cú U Cú U Hỡnh thỏi, tớnh cht U (ghi rừ kớch thc mm) Hỡnh thỏi, tớnh cht Tớnh cht S Tớnh cht CT, CHT Kớch thc Kớch thc S CT,CHT Nang Hoi t Vụi húa Chy mỏu Hch bng ố y (ghi rừ cq) Xột nghim sinh húa mỏu (ghi rừ kt qu): Xột nghim Bỡnh thng Dopamin Adrenalin Noradrenalin Cortisol Kali Natri Canxi Clo Glucose Chõn oỏn - U TTT Phi: - U ty thng thn: Khụng bỡnh thng U TTT Trỏi: U v thng thn: - U Thng thn khụng ch tit: Nang thng thn: Kt qu Gii phu bnh: Phõn loi trc m theo ASA: ỏnh giỏ m - S lng Trocart: Trocart l Thờm Trocart Tỡnh trng bng: Tỡnh trng U: Thi gian m: - Ct ton b tuyn: Ct chn lc U: Lng mỏu mt m: - Khú khn, tai bin m (ghi rừ): - Chuyn phng phỏp m: Chuyn PTNS TT: M m: Dn lu: Bin chng Trong m Sau m Tng Huyt ỏp Tt Huyt ỏp H ng huyt H Kali mỏu Suy TTT ng dch Nhim khun Khỏc (ghi rừ) iu tr sau m S ngy iu tr khỏng sinh: S ngy dung thuc gim au: S ngy rỳt dn lu: S ngy iu tr sau phu thut: Thi gian trung tin: Khỏm li sau m - Lõm sng Hi chng Cushing Tng cõn Bộo cc b U m sau gỏy Mt trũn da Rn da Thõm tớm Trng cỏ Rm lụng Gim trớ nh Trm cm-Ri lon nhõn cỏch au u Mt mi Teo c au xng Mt-ri lon kinh nguyt m vt to Tng huyt ỏp ỏi thỏo ng Hi chng Conn Cao huyt ỏp Co rỳt c ỏi nhiu Khỏt nhiu Suy nhc c th Ri lon nhp tim Pheochromoxytome Tng huyt ỏp thng xuyờn Tng huyt ỏp kch phỏt au u Ra m hụi Nhp nhanh lo lng Run chõn tay Mt mi, suy nhc Khú th Thay i th lc Gy sỳt U hch TKGC Cao huyt ỏp au bng Khỏc Xột nghim (ghi rừ kt qu s nu cú): ỏnh giỏ s hi lũng vt m: Cú so li: Khụng cú so li: Khỏc (ghi rừ ý kin ngi bnh) 4,6,7,8,11,12,14,15,41,57-65,67,86 1-3,5,9,10,13,16-40,42-56,66,68-85,87-170,172- ... 2 017 B GIO DC O TO B Y T TRNG I HC Y H NI ễN QUANG PHểNG NGHIÊN C U ứNG DụNG PH U THUậT NộI SOI MộT Lỗ ĐI U TRị CáC U TUYếN THƯợNG THậN LàNH TíNH Chuyờn ngnh: Ngoi ti u húa Mó s: 6272 012 5 LUN... phỏp phu thut ni soi u TTT 39 1. 7 Nhng cụng trỡnh nghiờn cu v bnh lý v iu tr phu thut u tuyn thng thn 43 1. 7 .1 Th gii 43 1. 7.2 Vit Nam 44 1. 7.3 Phu thut ct u TTT ni soi l... 10 6 4.3.2 ng dng phu thut ni soi mt l .10 8 4.3.3 Chõn oỏn: 11 1 4.3.4 Gõy mờ: 11 2 4.3.5 K thut PTNS l 11 2 4.3.6 K thut m ni soi l phỳc mc ct u tuyn thng thn .11 6 4.3.6.2