Thy Chung 05 - 11 CHUYN : UNG TH D DY Cu 1: Chn on x K DD giai on tin trin I.

i cng

1. K d dy cc tn thng c tnh tnh t tm v ti mn v, ng hng u trong s cc ung th

TH, trn 90% xut pht t cc biu m tuyn ca d dy.( Adenocarcinoma)

2. Bnh gp ch yu ngi nhiu tui, nam gii, hay gp chu lin quan n ch n giu
Nitrat nh c kho tht hun khi, Nitrosamin nh da chua, c tnh cht gia nh, HP c vai tr trong tin trin ca K 3. K d dy tin trin l nhng K xm ln qua lp c nim ca d dy hoc xa hn sang cc tng xq, K dd hay c c g ny tn l mun, tin lng xu

4. Ngy nay, nh NS + sinh thit p dng ngy cng ph bin => t l pht hin K DD sm
ngy cng cao. 5. iu tr ch yu l PT II. Chn on x: LS + XQ + NS, ST => GPB K dd g tin trin thi k u: Lm sng: rt ngho nn, c yn gi lm cc thm d CLS Tin s : thng c lot dd_tt mn tnh 1. C nng: m h, ko c hiu

au tc thng v nhiu thng, ko c tc chu k, ko lq n ba n Cm gic y bng, m ch, kh tiu, chn n, n khng tiu, Bun nn, , n vo c cgic au nhiu hn
2. Ton thn: cng ko r rng

Mt mi, gy st nh, thiu mu nh.

3. Thc th: ko c du hiu r rng Vi bnh cnh trn xy ra nam gii, nhiu tui, cn tin hnh chp XQ DD, ni soi, sinh thit x c Cn lm sng: 1. Chp i quang kp ( c th thy nhng tn thng c coi l EGC, t x thm bng NS ) Cc hnh nh Ung th g sm: + ng thuc trn b mt + Hnh nim mc hi t + Mt on cng K DD 1

Thy Chung 05 - 11 2. Ni soi: c th hin di 3 dng

Th U li ( type 1) : + tn thng ch hi li trn b mt, vi nt nh, mu sn si, ranh gii

tng i r + C th thy r qua ng NS, mn hnh, or c th bm xanh methylen hay congo s thy r hn

Th b mt ( type 2) : + tn thng ch nm b mt dd, c khi ch l 1 vt cht nng trn np nim mc to, ph i, ranh gi ko r. + Tn thng di 3 hnh thi 2a (Elevat), 2b (Flat), 2c (Depressed) pht

hin qua s bin i mu sc ca tn thng.

Th lot ( type3): + Tn thng l nhng lot nng b ko u, hi li cao, nim mc mt c khi sn si

im quan trng ca NS l phi tin hnh ST x tn thng K, ST nhiu mnh, nhiu vng bao gm vng tn thng, vng ranh gii gia tn thng v vng bnh thng, v ST nhiu ln. K dd g tin trin thi k cui: LS, CLS rt r Lm sng 1. C nng:

au tc bng trn rn, ko di, ngy cng tng, khng theo cn, ko c tnh cht chu k, au lin
tc, au tng sau khi n.

Bun nn or nn, b khi khi u vng hang mn v gy hp. Chn n, y bng, kh tiu, bn hon ton ko thm n.
Nut nghn khi K tm v 2. Ton thn: Gy st nhanh trong thi gian ngn ko r nguyn nhn Th trng suy kit. Thiu mu mn tnh: da xanh, nim mc nht.

Da mai mi kiu vng rm

Ct ngy st 37.5 38, ko di 3. Thc th:

Trc ti d dy: S thy khi u vng thng v c ranh gii r or 1 mng cng ko r ranh gii, di
ng or ko di ng, n au tc hoc ko au K DD 2

Thy Chung 05 - 11

C th pht hin di cn xa: gan to ln nhn, lch to, bng c chng, hch thng n tri
(Troisrer), u BT ph n (h/c Krukenberg) Cn lm sng: 1. Chp Xquang DD c baryt or chp i quang kp -> hnh nh tn thng in hnh:

Th u si: hnh khuyt, thnh DD li v lng m nt, b nham nh. Nu gia c lot hoi t
s thy 1 ng thuc, or c th thy h/ ct ct, gy cht hp hon ton.

Th lot: ng thuc ln, b nham nh, b cng, mt ht cc np n.mc hi t hocc nhng

lot ln gia khi u li vo trong lng dd => thy hnh thu knh.

Th thm nhim (t gp hn): + H.a trng l 1 on b cong cng thng xuyn (thm nhim 1 on, 1 phn DD) + H.a DD co rt, teo nh v thun di thnh hnh ng cng (thm nhim ton b DD)
+ Hnh thm nhim cng c th l hnh khuyt or hnh cao nguyn, hnh cht hp, hnh ct ct or tn thg ng mn v Mt s tn thg khc

Hp mn v: DD dn to hnh y chu, thuc chm qua DD K tm v: ng thuc TQ, nu nm u dc -> thnh v dy, c bng m ca khi u.
2. Ni soi DD ng mm - sinh thit : - C gi tr chn on nht -> x c thng tn, v tr, mc thm nhim, kt hp sinh thit cho kq GPB l tc vng gip x - Cc hnh nh tn thng

+ K th lot: y nng, nham nh, c m sn si, b li lm ko u, g cao, xq nm mt

np, i khi c m cht nng ri rc.

+ K th u si: L khi u si vo trong lng DD, u to nh ko u, gia v trn b mt n

vo trong t chc khi u, c nhiu tc hoi t, mu trng sm li lm, nhiu hc. Hoc nhng lot y trng, cng l r nhng mch mu en /tm sm. Hoc khi u si thm nhim ht 1 phn hay ton b DD.

+ K th thm nhim cng: tn thg thng nm vng hang mn v/ lan khp ton b DD,
lng DD b cht hp, trn b mt l m lot cht nng ri rc, c tng m t/c hoi t vi gi mc trng bm thnh tng mng.

K DD

Thy Chung 05 - 11 - V tr ly ST tt nht l ni ranh gii gia t chc nm c v lnh v ch c lot / khi u. Ko nn ly trung tm lot hay u v thng ch thy t chc hoi t. - ST 6-8 mnh: nu GPB (+) -> chn on x, nu GPB (-) m tn thng l lot nghi K th cn ST li. 3. Siu m ni soi: x mc thm nhim

4.
_ _

Xt nghim TB hc: Ly dch dd quay li tm tm tb K: t c lm Ni soi sinh thit bng chi qut trn b mt dd tm tb K Xt nghim cht ch th U: CEA khng c hiu do cng tng trong c K khc

5.

_ CEA, CA 19.9 -> c gtr theo di s tin trin, kt qu tr, pht hin ti pht sau iu tr. CEA tng khong 65% cc trng hp l dh bo hiu ung th lan rng.

6.

Cc thm d x m di cn:

S bng: p.h di cn gan, lch Xq phi: ct thy h.a th bng CT Scanner: p.h cc tn thng thm nhim cc tng K dd g tin trin khi c bin chng Nhiu trng hp ch c x c khi c bc: thng DD, CM d dy, HMV Khi ni soi hay m mi khng nh l Kd dy

7.CTM: HC, Hb, Hct gim gp trong khong 40% cc trng hp.

III. Chn on phn bit: 1. Cc trng hp khng s thy khi u: a. Lot d dy t trng: + TS: au bng thng v c chu k, hi, chua, ko chn n, ko gy st. + iu tr thuc dd + XQ: h/a lot dd _ tt in hnh + NS chn on x, n cn ST lm GPB b. Vim d dy: + Xut hin sau n t/ chua, ung thuc CVPS or corticoid + NS : lot cht nng hay nm sng n rc vng hang mn v or km thm vim ttrng TH vim teo dd: cc np nm teo, hang v co rt, b mt c nhng m vim ri rc, mn v co nh = > GPB chn on c. Polyp d dy: K DD 4

Thy Chung 05 - 11 + Polyp n c c cung => d phn bit khi soi + Polyp cung ngn, u to, nhiu mi sn si => GPB chn on d. Vim tu mn tnh: + t gp, cn au ko di, c tng cn d di, n t hi nhiu + Chp XQ, NS ko thy g + S si tu or nang gi tu e. Mt s bnh khc: Thot v honh, tro ngctrchng ko in hnh, NS gip chn on. 2. Trng hp c s thy khi u: a. U lnh tnh d dy: (u c trn, u tk) + LS khng r + XQ: c hnh nh y li vo lng dd + NS: u y t ngoi vo, nm bthng, nghi ng => ST, GPB chn on b. U gan, U tu, U TN : + Khi u c th phn bit c trn LS d dng + Nu ko phn bit c th phi kt hp XQ, NS, CT scanner. c. Ph n: + Khi thy khi u bung trng cn x l Krukenberg hay ko ? + Chn on x : XQ, NS IV. Chn on giai on bnh: Thng c chn on trong m 1. Theo TNM T: T1 : nim mc T2: lp di nm, lp c T3: xm ln thanh mc v ngoi thanh mc T4: U xln ton b dd v cc tng xq N: No: ko di cn hch N1: di cn nhng hch u tin cng u N2: di cn hch cnh, xa U, 2 b cong M: M0: khng di cn xa M1: di cn xa

2. cc giai on tin trin:

_ Giai on 1. T1 T3 _ Giai on 2. T4 T1 T4 _ Giai on 3. _ Giai on 4. T1 T4 T1 T4 N0 N0 N1 N2 N0 N2 M0 M0 M0 M1 M0

3. Phn loi theo Dukes:

K DD 5

Thy Chung 05 - 11 _ _ _ Dukes A: UT nm, di nm, or vo lp c thnh dd Dukes B: UT lan ti thanh mc. Dukes C: a: di cn 1-> 6 hch B: di cn >= 7 hch Cu 2: Nguyn tc iu tr Kd dy 1. Nguyn tc chung: PT l pp ch yu, bn cnh c phng php ha cht v tia x iu tr h tr tr K d dy ko phi l cp cu ngoi khoa nn cn cb tt v la chn pp gii quyt ti u cho bn 2. Cn c la chn pp tr: a. Giai on ca K d dy (qt nht) G sm: UT mi ch nm hoc di nm hay ko c di cn hch. Tt nht l c c g ny, kq tr s tt. c x: Ni soi + ST ng vtr qt nht G tin trin: thng tn xm ln lp c, thanh mc hay xln sang cc tng xq. G ny cn c sm thi k u. C x da vo: LS, CLS, qt nht l Ni soi v cc thm d khc: S, CT Scanner c g bnh, c yn trong tlng v la chn pp tr b. nh gi m lan trn ca ung th: ung th cng mun di cn cng xa, cng nhiu Di cn theo chiu su Di cn theo chiu rng Theo h thng bch huyt Cc tng ln cn Di cn xa theo ng mch mu

X m di cn bng: Trc m: S ni soi, S bng, CT Khi m: ktra ton b d dy, cc hch, tng xq. Da vo xm ln u, di ng d dy, m di cn m C PT trit hoc tm thi c. V tr khi u: a ra pp tr thch hp d. Tnh trng bn: bn c kn chu ng c cuc PT khng 3. C phu thut: K DD K g u, c = ni soi v GPB: PT trit cn K g tin trin cn ct PT c: ct C PT trit / tm thi

Thy Chung 05 - 11

K g cui: ko c C PT, ch PT tm thi khi c bc gq bc K c bc cp (cm, thng, HMV): C phu thut l cn thit nhng PT tm thi / trit cn ty thuc K di cn: 1 s trng hp Kd dy xm ln gan, T tn tnh trng ton thn cn tt ct C phu thut, ty thng tn ct PT tm thi / trit

4. Chun b trc m: _ _ _ _ _ Bilan trc m nh gi ton trng bn Sonde dd: ht dch d dy Sonde tiu Truyn dch, mu, m m bo dinh dng tt cho bn Chun b i trng sch => c th phi ni tt

5. Cc phng php iu tr: 5.1. Phu thut: PT trit

Nguyn tc: Ct b rng ri khi u: ly ht khi u, vt qu t chc lnh pha trn khi u t nht 5 cm, di ct ly ht mn v. Nu nghi ng cn tc K, ct ct rng ri ln trn, ct rng sang cc tc khc (ui ty, TN, gan, ti mt...). Khi ct ct lm xn GPB nhanh Ly ton b tc hch ca DD, no vt hch k, cp ct cung mch tn gc Lp li lu thng TH Cc phng php: Ct on DD: C: thng tn hang, mn v DD, tn thng nng cha lan KT: Ct 2/3, 3/4, 4/5 DD ( gm hang mn v v 1 phn thn v) No vt hch trit Lp li lu thng rut theo Bill 1/ Bill2 + : Gi li nhiu DD K DD 7

Thy Chung 05 - 11 PT t kh khn hn ct tb DD T l TV sau m thp hn + N: Tnh trit v mt ung th hc thp hn Ti pht ngay ti din ct

+ C:

Ct cc trn DD:

Ung th vng tm v, cha lan ln cao hay xm ln ra xq Hoc tn thng tm v xln TQ nhng cha c k ct dd ton b + KT:

o Ct 1/3 di TQ v cc trn dd o Ni TQ vi phn dd cn li o No vt hch trit

+ C: Ung th vng thn v / tm v Tn thng lan ln trn thn v / tm v Ung th th thm nhim cng tb DD + KT: o Ct tb DD Ct ton b DD:

o ly ht MNL o Cp ct cung mch st gc

o No vt hch o Lp li lu thng theo: Rouxen Y, Omega, Tomoa + + : Gii quyt trit v mt TBH cao N: L PT nng n i vi BN Ct DD m rng: ngoi ct DD ton b / ct on DD cn ct thm 1 hoc nhiu tng khc ln cn do K xln ti K DD 8

Thy Chung 05 - 11 o Ct ui ty, mc ni ty lch o Ct gan tri o Ct lch, mc ni v lch o TN o MNL. MNN * Vn no vt hch: Theo cc nh K NB chia di cn hch thnh 3 chng gm 16 hch => no vt hch theo kiu cun chiu R1: 1v2: cnh TV 3: BCN 4: BCL 5v6: trn v di MV Phu thut tm thi C: KDD g mun c bc: HMV, cm, thng m kh nng PT trit ko th thc hin c KT: o Ct DD km theo no vt hch ko trit / ko no vt hch i vi u cn kn ct b o Ni v trng: K hang mn v o M thng DD: K tm v R2: 7 : vnh v 8: gan chung 9: thn tng 10: rn lch 11: M lch R3: 12: cung gan 13: sau tu 14: mc treo RN 15: MTTN 16: M ch

o M thng hng trng: KDD lan rng duy tr => thm s sng cho bn
o Tht M o PT Newmann: thng DD gy VPM mun, ton trng bn nng 5.2. tr phi hp: a. Ha cht: Mc ch: o Gim au, lm chm pht trin khi u o Phi hp PT Phc :

o thng a ha tr liu ( polychimiotherapies) o FA / MTX ( 5 fluoro_uracile,adrimycine,Methotrexat) o EAP ( etoside_adrimycine_cisplatine) o hoc 5-FU + acide folimiques + cisplantine
K DD 9

Thy Chung 05 - 11 b. Tia x: thng dng 25 grays nhng t tc dng. Cn phi hp PT + No vt hch + tia x + ha cht c. Hormon: thng dng KN n: ang nghin cu d. Min dch: ASLEM 0,3mg * 2/ngy trong 30 ngy sau 2 tun / ln v 2/ln.

K DD

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