tp ch y - dc hc qun s s 4-2011

Nghin cu chn on v kt qu phu thut ni soi ct rut tha vim

Chan Tha Vong*; L Trung Hi**
* Bnh vin 103, Lo ** Bnh vin 103, Vit Nam
Phn bin khoa hc: GS. TS. Phm Gia Khnh

Tm tt
Ni soi bng c gi tr cao trong chn on vim rut tha cp (VRTC) vi nhy 100%, c hiu 66,7%, gi tr tin on dng tnh 99,2%, gi tr tin on m tnh 100% v t l chn on sai 0,8%. Phng php chn on ni soi c nhy cao nht v t l chn on sai thp nht so vi cc phng php chn on lm sng v chn on siu m. Phu thut ni soi (PTNS) ct rut tha trong iu tr VRTC l mt phng php iu tr an ton v c hiu qu. Bnh nhn (BN) hi phc sau m nhanh, ngy nm vin ngn, tnh thm m cao. T l bin chng thp (1,6%) v khng c t vong sau m.

t vn Vim rut tha cp l bnh hay gp nht trong cp cu ngoi bng. Nhng trng hp triu chng lm sng in hnh, vic chn on s thun li hn. Tuy nhin, nhiu trng hp VRTC, bnh cnh khng in hnh, c din bin a dng v phc

tp, gp nhiu kh khn trong chn on. Nm 1980, Semm l ngi u tin tin hnh ct rut tha ni soi. Lc u, PTNS ct rut tha gy ra nhiu tranh ci. Mt s tc gi cho rng k thut ny thc hin kh, thi gian m ko di, chi ph tn km, t l bin chng nhim khun bng nhiu hn m m.

Tuy nhin, cho n nay nhiu tc gi tha nhn PTNS ct rut tha c nhiu u vit hn so vi m m nh: gim bin chng sau m, au, phc hi lu thng tiu ho sm, ngy nm iu tr ngn v ngi bnh nhanh chng tr li hot ng bnh thng. Trn th gii v Vit Nam c nhiu cng trnh nghin cu v PTNS ct rut tha trong iu tr VRTC. Tuy nhin, vn cn c nhng kin khc nhau v vai tr ca PTNS trong iu tr VRTC. Xut pht t thc t t nc Lo vi dn s cn t, nhng bnh VRTC vn ng hng u cc bnh cp cu ngoi khoa. Trn thc t hin nay, my mc, trang thit b mi c trin khai, c th p ng nhu cu iu tr. ti gp phn nghin cu gi tr chn on ni soi v nh gi kt qu PTNS ct rut tha vim ti Bnh vin 103. i tng v phng php nghin cu 1. i tng nghin cu. 125 BN c chn on vim rut tha cp v thc hin PTNS ct rut tha vim ti Bnh vin 103 t 8 - 2009 n 11 - 2009. 2. Phng php nghin cu. * S liu chung: Tui, gii, thi gian BN c triu chng lm sng n khi vo vin, thi gian t khi vo vin n khi phu thut. * Nghin cu chn on VRTC: - Nghin cu chn on lm sng: + Triu chng lm sng: au bng vng h chu phi (HCP), st, ri lon tiu ha, n im Mac-Burney au, c phn ng thnh bng, nghim php Shotkin Blumberg (+), c co cng thnh bng... + Xt nghim bch cu: s lng bch cu, t l bch cu a nhn trung tnh. - Phng php chn on siu m: siu m chn on rut tha vim c t nht mt trong nhng du hiu sau: ng knh rut tha > 6 mm, c dch xung quanh rut tha, n au khi siu m, rut tha ct ngang thy hnh bia, ct dc thy hnh ngn tay i gng, thnh rut tha dy > 3 mm. - Phng php chn on ni soi: + Mc tn thng i th ca rut tha: theo phn loi ca Saminov A.A. (1987): rut tha xung huyt (rut tha sng to, thanh mc th, gin mch, xung huyt, xut tit), rut tha m (rut tha sng to, thanh mc xung huyt v m c c ph t huyt, lng rut tha cha y m, mc treo n xung huyt), rut tha hoi t (vim m lan ra t chc rut tha, vo mc treo rut tha gy nn huyt khi cc mch nui dng rut tha, rut tha to, b mt thanh mc c nhng m hoi t. Thnh rut tha mu xm d v, khi v c dch m t trong lng rut tha chy ra). + Cc bin chng v v tr rut tha.

- i chiu phng php chn on lm sng, siu m, ni soi vi kt qu gii phu bnh l. * PTNS ct rut tha vim: - Chun b BN, trang thit b v dng c ni soi. - K thut m ni soi ct rut tha vim: t trocar v bm hi phc mc. Ct rut tha ni soi trong bng: kp nng cng mc treo rut tha. Gii phng mc treo v cm mu ng mch rut tha. Kp cc clip v ct rut tha. Ly rut tha v ng cc l trocar. * nh gi kt qu PTNS ct rut tha vim: - Ghi nhn cc ch tiu: s lng trocar, dn lu bng, thi gian phu thut. - Thng k tai bin trong m, nguyn nhn v t l chuyn m m, s ngy dng khng sinh sau m, thi gian au sau m, thi gian trung tin, thi gian n c sau m, thi gian nm vin, bin chng v t vong sau m. - nh gi kt qu chung sau m: tt, trung bnh v xu. * X l s liu: theo chng trnh phn mm Epi. info ti Hc vin Qun y. Kt qu nghin cu 1. S liu chung. Tng s 125 BN, tui trung bnh 33 15 (10 - 79 tui), nam 68 BN (54,4%), n 57 BN (45,6%), thi gian BN c triu chng lm sng n khi vo vin trung bnh 24,84 14,22 gi (4 - 74 gi), thi gian t khi vo vin n khi phu thut trung bnh 5,18 2,27 gi (1 - 12 gi). 2. Kt qu chn on. * Chn on lm sng: - Cc triu chng lm sng trong VRTC: au bng vng HCP: 125 BN (100%); st: 87 BN (69,6%); ri lon tiu ha: 92 BN (73,6%); n HCP hoc im Mc Burney au: 125 BN (100%); c phn ng thnh bng: 125 BN (100%); nghim php Shotkin- Blumberg (+): 96 BN (76,8%); c co cng thnh bng: 6 BN (4,8%). - 108 BN (86,4%) xt nghim mu: s lng bch cu > 10.000/mm3 mu, 105 BN (84%) c t l bch cu a nhn trung tnh > 70%. - i chiu chn on lm sng vi gii phu bnh l: nhy 96,7%, c hiu 66,7%, gi tr tin on dng tnh 99,2%, gi tr tin on m tnh 33,3%, t l chn on sai 4%. 3. Chn on siu m. - 109 BN (87,2%) c du hiu siu m ca VRTC, 16 BN (12,8%) khng c du hiu siu m.

- i chiu chn on siu m vi gii phu bnh l: nhy 88,5%, c hiu 66,7%, gi tr tin on dng tnh 99,1%, gi tr tin on m tnh 12,5%, t l chn on sai 12%. * Chn on ni soi: Bng 1: Kt qu chn on ni soi so vi gii phu bnh l.
Chn on gii phu bnh

VRTC Chn on ni soi VRTC Khng bnh Tng s 122 0 122

Rut tha Tng khng vim 1 2 3 123 2 125

- nhy 100%, c hiu 66,7%, gi tr tin on dng tnh 99,2%, gi tr tin on m tnh 100%, t l chn on sai 0,8%. T l chn on ng qua ni soi 99,2%. - Xc nh c dch trong bng: 109 BN (87,2%), vim phc mc: 7 BN (5,6%). - V tr ca rut tha: sau manh trng: * So snh gi tr cc phng php chn on: Bng 2:
Phng php nhy c hiu T l chn on sai

22 BN (17,2%), gia cc quai

rut: 4 BN (3,2%), v tr bnh thng: 99 BN (79,2%).

Chn on lm sng Chn on siu m

96,7 % 88,5 %

66,7% 66,7% 66,7% > 0,05

4% 12% 0,8% < 0,05

Chn on ni soi 100% p < 0,05

* Kt qu chn on gii phu bnh l: Bng 3:

Phn loi gii phu bnh l

n = 125

Rut tha khng vim VRTC xung huyt Vim rut tha m

3 41 32

2,4 32,8 25,6

Vim rut tha hoi t

49

39,2

3. Kt qu iu tr PTNS ct rut tha. - Cc ch tiu phu thut: + S lng trocar: t 3 trocar: 121 BN (96,8%), 4 BN t 4 trocar do rut tha dnh v qut ngc sau manh trng. + Dn lu bng: 17 BN (13,6%). + Thi gian phu thut trung bnh: 48,44 12,12 pht (15 - 90 pht). - nh gi kt qu phu thut: + Tai bin trong m: khng gp. + T l chuyn m m: 2 BN (1,6%), nguyn nhn: 1 BN c ti tha manh trng vim m v 1 BN VRTC hoi t c kh khn v k thut. + S ngy dng khng sinh trung bnh: 5,02 1,03 (3 - 7 ngy). + Thi gian au sau m trung bnh: 23,2 8,68 gi (10 - 68 gi). + Thi gian trung tin sau m trung bnh: 22,32 7,44 gi (12 - 48 gi). + Thi gian n ung c sau m trung bnh: 25,62 11,76 gi (10 - 48 gi). + Bin chng sm sau phu thut: 2 BN (1,6%) c nhim khun nh l trocar. + Khng c trng hp no t vong sau PTNS. + Ngy iu tr trung bnh: 5,33 1,14 ngy (3 - 7 ngy). bn lun 1. V chn on VRTC. - Chn on lm sng VRTC da ch yu vo cc triu chng lm sng m thy thuc pht hin c, ngoi ra cn tham kho xt nghim mu, siu m. Vic chn on lm sng ph thuc vo trnh , kinh nghim ca thy thuc v thi gian theo di BN trc m di hay ngn. Nu thi gian di, chnh xc cao, ng ngha vi b l c hi m sm VRTC. Kt qu nghin cu cho thy: chn on lm sng c nhy 96,7%, c hiu 66,7%, t l chn on sai 4%. Mun gim t l chn on sai, thy thuc phi khm xt t m, chi tit, khng nn b st mt du hiu no. Kt qu thu c qua nghin cu tng t kt qu ca mt s tc gi trong v ngoi nc. - Kt qu siu m: 87,2% BN c du hiu ca vim rut cp. So snh vi chn on gii phu bnh cho thy: siu m c nhy 88,5%, c hiu 66,7%, t l chn on sai 12%. Kt qu ny tng t vi nghin cu ca Davidson P.M (1999), Triu Triu Dng (2002) c nhy 80 - 90%, c hiu 95 - 100%. Nhiu tc gi cho rng siu m c gi tr tt trong chn on VRTC, nht l chn on lm sng cha r, hoc trong nhng trng hp cn theo di.

- Ni soi gip xc nh rut tha vim hay khng vim: hnh nh rut tha c camera truyn phng i ln mn hnh nn quan st rt r. Kt qu chn on ni soi c nhy 100%, c hiu 66,7%, t l chn on sai 0,8%. Cc kt qu ny cho php chn on xc nh VRTC trc khi quyt nh ct rut tha vim. Thng k ca Enochsson (2004): ni soi chn on VRTC c nhy 98 - 100%, c hiu 90 - 96%. Nhiu tc gi nh gi cao vai tr ca ni soi trong chn on VRTC, c bit n ang tui sinh v gip phn bit vi cc bnh sn ph khoa. y l mt u vit ln ca PTNS so vi m m ct rut tha cng nh cc phng php chn on khc. Ni soi cn gip pht hin cc bnh km theo. Brian C.O (1996) a ra bc thang quyt nh cho ct rut tha trong chn on ni soi - phu thut. + Rut tha vim c ch nh ct b rut tha. + Rut tha khng vim nhng c bnh ca c quan nm trong tiu khung nh: u nang bung trng, vim phn ph, bnh Crohn th nn ct b rut tha trnh nhm ln gia vim rut tha vi cc bnh ny. + Nu rut tha khng vim, nhng c bnh khc r rng trong bng xa v tr rut tha, tin hnh iu tr bnh tin pht m khng ct rut tha. - Ni soi khng ch xc nh rut tha c vim hay khng m cn nh gi mc tn thng ca bnh, lm c s a ra phng php iu tr hu hiu, ng thi tin lng bnh (pht hin c dch bng, vim phc mc cng nh v tr ca rut tha...). - So snh chn on ni soi vi chn on lm sng v chn on siu m, ni soi chn on c nhy cao nht (100%), t l sai thp nht (0,8%) gip lm tng chnh xc trong chn on bnh VRTC v phn bit vi cc bnh khc. 2. V kt qu PTNS ct rut tha vim. - Kazemier G (1997) cng nhiu tc gi nhn xt: thi gian phu thut ct rut tha ni soi thng di hn phu thut m. Thi gian ct rut tha ni soi rt ngn khi phu thut vin c hun luyn tt, thnh tho trong k thut m ni soi. Kt qu nghin cu cho thy: thi gian phu thut trung bnh: 48,44 12,12 pht, tng t nh thng k ca Kum C.K (1993): thi gian m ni soi khng di hn m m, cn Pier A. v Gotg F (1993) thy thi gian ct rut tha ni soi ngn hn r rt so vi m m. T l chuyn m m ca chng ti l 1,6%. Theo nhiu tc gi, t l chuyn m m c th ti 6,4 - 7,6% v ph thuc vo ch nh cng nh trnh phu thut vin. Khi nh gi, tin lng nhng trng hp m ni soi phc tp, nn chuyn m m, gip trnh cc tai bin v bin chng. - Kt qu sau m: thi gian trung tin sm, t au v c th cho n ung sm sau m cho thy u th ca PTNS ct rut tha vim. Nhn xt ny ph hp vi

nhiu tc gi khc v c gii thch do PTNS t gy tn thng cc tng bng, vic phc hi sau m sm hn. Vi cc u im khc nh t bin chng sau m (1,6%), thi gian nm vin ngn (trung bnh 5,33 1,14 ngy), thi gian hi phc sau m nhanh hn v tnh thm m cao cho thy PTNS ct rut tha l mt k thut an ton v c hiu qu tt trong iu tr VRTC. Kt lun Qua nghin cu 125 BN c chn on VRTC v PTNS ct rut tha ti Bnh vin 103 t 8 - 2009 n 11 - 2009, chng ti rt ra mt s kt lun sau: - Ni soi c gi tr tt trong chn on VRTC vi nhy 100%, c hiu 66,7%, gi tr tin on dng tnh 99,2%, gi tr tin on m tnh 100%, t l chn on sai 0,8%. Phng php chn on ni soi c nhy cao nht v t l chn on sai thp nht so vi cc phng php chn on lm sng v chn on siu m. - PTNS ct rut tha trong iu tr VRTC l mt phng php iu tr an ton v c hiu qu tt. BN hi phc sau m nhanh, ngy nm vin ngn, tnh thm m cao. T l bin chng thp (1,6%) v khng c t vong sau m. Ti liu tham kho
1. Triu Triu Dng. Nghin cu chn on VRTC qua ni soi. Lun n Tin s. 2002. 2. Nguyn Cng Thnh. So snh phu thut ct rut tha ni soi v ct rut tha m trong iu tr VRTC. c san Tiu ho Vit Nam. 2005. 3. Brian C.O. Laparoscopic appendectomy. Principles of laparoscopic surgery, basic and advandced techniques. 1996, 15, pp.268-276. 4. Davidson P.M, Douglas C.D, Hosking C.S. Graded compression ultrasonography in the assessment of the tough decision acute abdomen in childhood. Pediatr Surg Int. 1999, 15 (1), pp.32-35. 5. Enochsson L, Gudbjartsson J, Hellberg, Fenyo G. The fenyo-lindberg scoring sytem for appendicitis increases poritive predictive value in fertile women. Surgical Endoscopy and Other Interventional Techniques. 2004, 18, pp.1509-1513. 6. Kazemier G, Zeeuw G.D, Lange J.F, Hop W.C.J. Laparoscopic vs open appendectomy: a randomized clinical trial. Surg Endosc. 1997, 11, pp.336-340. 7. Kum C.K, Ngoi S.S, Goh P.M, TeKant Y, Isaac J.R. Randomized controlled trial comparing laparoscopic and open appendicectomy. Br J. 1993, 80 (12), pp.1599-1600. 8. Pier A, Gotz F, Bacher C, Ibald R. Laparoscopic appendectomy. World T Surg. 1993, 17 (1), pp.29-33.