Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi S TAY NGOI KHOA LM SNG

D HU MN
1-i cng: D hu mn l mt ng hm, thnh c lt bi m ht, u (l) trong nm ng hu mn, u (l) ngoi nm phn da quanh ng hu mn. p-xe cnh hu mn c nh ngha l mt khi nung m vng cnh hu mn. 95% d hu mn c ngun gc t vim ng tuyn hu mn. ng tuyn hu mn b vim dn n hnh thnh mt nung m (p-xe) cnh hu mn. p-xe cnh hu mn, khi tm ng thot m ra ngoi hay vo lng trc trng, s to thnh ng d. Trong 5% cc trng hp cn li, d hu mn c ngun gc t: Chn thng Ung th Cc bnh l vim nhim mn tnh vng trc trng hu mn: lao, Crohn, vim ti tha, nhim Clamydia, actinomycoses Nt hu mn (gy p-xe v d di da) Nu d hu mn c ngun gc t ng tuyn hu mn, l trong s nm trn ng lc. Th lm sng duy nht ca d hu mn do vim ng tuyn hu mn m l trong nm thnh trc trng l d hu mn ngoi c tht. Nu d hu mn do cc nguyn nhn khc, l trong s nm v tr bt k, trong c th xut pht t thnh trc trng. Bi ny ch cp n d hu mn v p-xe do vim ng tuyn hu mn. Phn loi p-xe cnh hu mn (do vim ng tuyn hu mn) (hnh 1): p-xe di da (quanh hu mn) p-xe gian c tht p-xe trn c nng hu mn p-xe h ngi trc trng p-xe kt hp, trn c nng v h ngi trc trng (p-xe hnh qu t) p-xe trn c nng hu mn l ngun gc ca d hu mn th ngoi c tht: khi p-xe tm ng v vo lng trc trng v v ra da, ng d hu mn th ngoi c tht s hnh thnh. Phn loi d hu mn: Theo tnh cht n gin hay phc tp: D n gin: C mt l trong, mt l ngoi v mt ng d nguyn pht ni hai l. nh lut Goodsall (hnh 2): BN nm xp, nu l ngoi nm trn ng ngang qua ng hu mn, l trong s nm trn ng gia. Nu l ngoi nm di, l trong s nm trn ng hng tm (c im ny s thay i nu l ngoi nm cch ri hu mn 2-3 cm) . D phc tp: C mt l trong, mt ng d nguyn pht v mt hay nhiu ng th pht, mi ng d c mt l ngoi. D mng nga: l trong nm phn sau hu mn, ng d nguyn v th pht i vng ra hai bn, trong h ngi-trc trng. Theo phn c tht c lin quan (hnh 3):

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi S TAY NGOI KHOA LM SNG
c ng dng nhiu trn lm sng v c lin quan n vic chn la phng php iu tr. Tu theo khi lng ca phn c tht c lin quan (phn c tht nm gia ng d v b mt biu m ca ng hu mn), d hu mn c phn thnh 4 loi chnh: D gian c tht (70%) D ngang c tht (24%) bao gm d ngang c tht thp v d ngang c tht cao D trn c tht (5%) D ngoi c tht (1%)

Hnh 1- V tr ca p-xe cnh hu mn trong mi tng quan vi cu trc gii phu ca ng hu mn

2-Chn on: 2.1-Chn on p-xe cnh hu mn: Lm sng ngh n p-xe cnh hu mn khi BN than au nhc vng hu mn km st. Khi thm khm, tu vo v tr ca p-xe m BN c cc du hiu thc th sau: p-xe gian c tht: cnh hu mn c mt khi g ln, nng, , au. Cc np nhn ra hu mn mt. Nu thm trc trng (khng cn thit v s lm cho BN au n): khng cn cm gic xit cht bnh thng ca c tht, thay vo l mt khi, mt bn ng hu mn, p vo ngn tay.

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi S TAY NGOI KHOA LM SNG
p-xe h ngi trc trng: khi sng, nng, , au nm gia ra hu mn v ngi, cc np nhn da ri hu mn cn. Cn thm trc trng loi tr p-xe hnh qu t. p-xe trn c nng hu mn: ch pht hin khi thm khm trc trng: mt phi php phu cnh bn trc trng.

Hnh 2- Mi lin quan gia l trong v l ngoi ca mt ng d hu mn theo nh lut Goodsall

Hnh 3- Cc kiu d hu mn: a-D gian c tht, b-D ngang c tht, c-D trn c tht, d-D ngoi c tht.

Cn chn on phn bit p-xe cnh hu mn vi cc bnh l sau: p-xe tuyn apocrine (hydradenitis suppurativa) Nhim trng nang lng Nhim trng nang vi thng b (inclusion cyst) p-xe tuyn Bartholin n 2.2-Chn on d hu mn:

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi S TAY NGOI KHOA LM SNG
Chn on lm sng: BN b chy nc vng ko di vng hu mn. Khm: cnh hu mn c mt nt sn, gia c l, n nt sn dch vng c tro qua l. S nn phn da gia nt sn v hu mn c cm gic mt dy cng. Thm trc trng c th s c l trong, nm trn ng lc. i vi cc ng d n gin (mt l ngoi, l ngoi nm ln cn ra hu mn), khng cn thit phi c cc phng php chn on hnh nh, tr ni soi hu mn trc trng loi tr cc nguyn nhn khc ca d hu mn khng xut pht t ng tuyn hu mn (u bu, vim nhim). Vic nh gi ng d s c thc hin trong lc m. Trong trng hp d phc tp, cc phng php chn on sau c th c ch nh: X-quang ng d: bm thuc cn quang vo l trong, chp nhiu t th (trc sau, nghing, cho). Siu m qua ng hu mn-trc trng: c ch nh khi khng tm thy l trong hay nghi ng ng d i cao (trn c tht, ngoi c tht). Vic bm oxy gi vo l ngoi s lm tng nhy ca chn on. o p lc c tht: c ch nh trong trng hp d ti pht sau m, d trn c tht, hay BN c bnh l lm gim trng lc c tht (ngi gi yu, sang chn sn khoa) 3-iu tr: 3.1-iu tr p-xe cnh hu mn: p-xe cnh hu mn, nu khng c dn lu m kp thi, c th gy vim ty lan rng vng tng sinh mn. Nguyn tc: ch yu l dn lu m. Khng nn c gng ct ng d, tr trng hp p-xe ti pht trn BN c chn on d hu mn, ng d n gin v nh hnh r. Chun b trc m: cho khng sinh v thuc gim au. Ni dung phu thut: Phng php v cm: thng l gy m tnh mch. Nu p-xe c du hiu php phu r, ch cn tin m vi cc dn xut ca morphine l . p-xe ti pht trn BN c d hu mn: x tr nh d hu mn (ct ng d hay t seton). p-xe gian c tht: rch da hnh vng cung 2cm cnh hu mn, trn khi p-xe, tch lp nng ca c tht vo p-xe, bm ra vi dung dch povidone-iodine hay oxy gi, nht mt bc gc tm povidone-iodine vo p-xe. Ch khng ph rng p-xe v c th lm tn thng nhiu c tht. p-xe h ngi trc trng: rch da, tch lp m trong h ngi trc trng vo p-xe. Sau khi bm ra, t mt thng c u hnh nm (Pezzer, Malecot) vo p-xe (hnh 4). p-xe hnh qu t: ng rch da nh p-xe h ngi trc trng. Sau khi bm ra p-xe, t mt thng c u hnh nm (Pezzer, Malecot) a ln trn sao cho u nm ca thng nm trong p-xe trn c nng hu mn. p-xe trn c nng hu mn: dn lu m qua thnh trc trng. Chm sc hu phu: Tip tc s dng khng sinh 3-5 ngy sau m Thay bc gc mt vi ngy u i vi p-xe gian c tht, sau cho BN ngm hu mn hng ngy vi nc m pha povidone-iodine cho n khi vt thng lnh hn. Phn ln cc p-xe gian c tht c th lnh hn m khng chuyn thnh d hu mn. Nu c t mt thng hnh nm vo p-xe, bm ra p-xe hng ngy trong vng hai tun u. Mi ln bm ra ch quan st xem c chy dung dch bm ra qua ng hu mn hay khng. S chy dch qua ng hu mn mi ln bm ra chng t c s tn ti ca l trong. Nu khng c s chy dch qua ng hu mn, rt thng, cho BN ngm hu mn hng ngy vi nc m pha povidone-iodine cho n khi vt thng lnh hn. Nu sau hai tun m l trong vn tn ti (50% cc trng hp), BN nn c iu tr d hu mn bng phu thut.

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi S TAY NGOI KHOA LM SNG

Hnh 4- t thng u hnh nm trong p-xe h ngi trc trng

3.2-iu tr d hu mn: 3.2.1-Ct m ng d (fistulostomy): Nguyn tc: ct ng d t l trong ra l ngoi, m ng d ra b mt (bin ng hm thnh ng ho). ng d s lnh t y ln b mt. Phng php ny cng ct phn c tht c lin quan. Nu phn c tht b ct nhiu, BN s khng kim sot vn gi phn (sn phn hay tiu khng t ch) Ch nh: D gian c tht D xuyn c tht thp (tr ng d 1/2 trc hu mn BN n) Chun b trc m: Tht tho trc trng Cho khng sinh K thut (hnh 5): Nong hu mn, t m vt Tm l trong. Trong trng hp khng thy l trong, c th p dng cc bin php sau: Bm oxy gi, xanh methylene, savo l ngoi, ng thi quan st cc cht ny si ln v tr l trong. Li ko l ngoi, l trong s nh ln tht vo trn thnh ng hu mn. Dng que u t lun nh nhng t l ngoi theo ng d vo l trong. Sau khi a c que t l ngoi vo l trong, dng dao ct da, m m di da, phn c tht trong pha trong que. No sch m ht Nu ct b m x trn thnh ng d, thi gian lnh s nhanh hn. Gi cc mu m c ct n phng gii phu bnh loi tr cc nguyn nhn khc ca d hu mn. Chm sc hu phu: Tip tc dng khng sinh khong 3 ngy sau m.

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi S TAY NGOI KHOA LM SNG
Ngm hu mn ngy 2 ln. Khi ngm, dng ngn tay mit vo vt thng cho vt thng lnh t y ln trn, t trong ra ngoi, ng thi hn ch nguy c hp hu mn. Thi gian lnh hn vt thng trung bnh 6 tun, him khi qu 12 tun.

Hnh 5- K thut ct m ng d trong iu tr d hu mn

3.2.2-t seton: Nguyn tc: ct ng d dn dn, ng d lnh m vn bo tn c chc nng c tht. Ch nh: BN n c ng d 1/2 trc hu mn D ti pht D phc tp D xuyn c tht cao, trn hay ngoi c tht D hu mn BN c trng lc c tht thp Ni dung iu tr: Cc bc u tng t nh ct m ng d Khng ct c tht. Lun mt si ch silk to hay di cao su (Penrose) t l ngoi vo l trong, buc quanh phn c tht c lin quan (hnh 6). Sau m, xit dn seton mi khi BN ti khm, cho ti khi seton ct xuyn qua phn c tht v rt ra ngoi.

Hnh 6- So snh ct m ng d (hnh tri) v t seton trong iu tr d hu mn.

3.2.3-Bt ng d bng keo fibrin: Cc bc chnh ca phng php bt ng d bng keo fibrin trong iu tr d hu mn:

Trng i hc Y Khoa Phm Ngc Thch- B mn Ngoi S TAY NGOI KHOA LM SNG
No sch m ht thnh ng d Khu kn l trong Bm keo fibrin vo ng d Phng php ny cho t l lnh ng d thp. 3.2.4-Chuyn vt ni trc trng (endorectal advancement flap): Nguyn tc: tch mt mnh nim mc thnh trc trng, chuyn xung v khu che ln l d trong. C th kt hp vi bm keo fibrin vo ng d. y l phng php l tng iu tr cc ng d cao. 3.2.5-Kt qu v bin chng: Kt qu: Sau ct m ng d, t l ti pht 0-17%, t l sn phn 3-7%. Sau t seton, t l ti pht 0-18%, t l sn phn 0-17%. Bin chng sau m: Chy mu Sn phn: do mt phn ng k c tht hu mn b ct t, hay ct m ng d BN c trng lc c tht thp. Hp hu mn: c th xy ra, nu sau ct ng d m si x pht trin qu mc.