DIEU TRI NGOAI KHOA ; UNG THU DAI TRANG-TRUC TRANG Ung thu dai-trye trang la ung thy pho bién thuong gp. ty 1é tir vong dimg hang thir ba, chiém hing dau trong ung thar dudng tiéu hoa tai cde nude MY vi Phap. Trong do, trve tring vi tri thuimg gp nhac cn khung dei ang khong 43% Hau hét ung thu dai truc trang (93%) xuat phat tir mt polyp tuyén cia dai tring, Yéu 18 gdp phan gay ung ther dai trye trang: ehé d6 an udng it chat ba Polyp tuyén dai trang, Di truyén, Bénh viem loét dai trang, C Diéu tr] chit yéu la phau thudt. Cac phuong phap khéc chi bo tite. Ung thu dai truc trang la mt trong sé it bénh Iy Ac tinh e6 kha nang chita lanh bénh va c6 thé phong ngtta duoc. Vi thé s6 Ivong phat hign bgnh ngay cang ting hon 1 triéu ca phat hign do cha déng tim soat ede doi tuong cd guy co cao va diéu tr trigt dé polyp dai tring bang cit qua nOi soi dai tring. TY I tir vong do ung thy dai trwe tring hing nim gidm din. 1. CHAN DOAN Biéu hign trigu ching: - _ Trigu ching lam sang phy thudc vao vi tri khdi U dai trang U dai trang P thuimg biéu hign thiéu mau do xudt huyét ri rd va tiéu Jong phan mau den. U dai tring T va U xich ma Truc trang thuring bidu hidn 140 bén di cau phan nhay mau va dang U vong nhan gay bénh canh tic rudt thap. - Thiéu mau nhuge sit. - Bénh nhén phat hign khi di chu nhdy-mau (60%) + Thay déi thoi quen di edu (43%). va e6 ri loan tiéu héa nhw tio bon, tiéu chiy hose xen ke téo bén va tiéu chay. Di cau ra méu hoge dim nhét, di cd nhigu lin trong ngay hode plain det ah. + _Tigu phan 06 mau d8 Lim véi bénh tr Céc trigu chiing khée: Dau thon héu mén, Tiéu khéng wr chi, Tiéu khong hét phan, T xi lin, ‘Lam sing c6 thé bao gém: ‘+ Bénh sé: phat hign khGng dc higu (mét méi, giim cn) hoge khéng e6 gic’ + Bénh ign trién: Mun hon U lén gay bién chimg: dau byng ving chau (3%) - the rudt (9%), 6 phan ling phic mac thing buéu, chay mau trve tring hong nhiéu, kh6i uw bung sd thay, gan to, bang bung, u git budt, do khdi uw Kham bung phat hign khéi u doe theo khung dai trang Khi Bac si tham kham trge trang: phat hign khéi u trye tring & doan thap. Dah gid tuong ddi mite 46 U xm ln vao co quan lan can Binh gid chite nang co that Banh gid kha nang bio tén co that Xét nghiém mau lam CEA, CA19.9 (carcinoembryonic antigen (CEA), cancer antigen (CA) duge lam Sigu am bung, XQ phéi, X-quang dai trang véi Barium, Noi soi dai true tring Hi tid chuain vang dé xée dinh chan dodn chinh xéc, sinh thiét xc dinh tinh chat khdi u, Siéu Aim: duge chi dinh dé phat hién di ca gan, Hinh anh di edn gan trén sigu am la cae khdi echo day rai ric trong nhu mé gan. -quang dai trang véi Barium: Hinh anh Khéi nho vao long dai trang voi dudng bis khos Lang dai tring bj hep lai déu,Ni soi dai trye trang kém sinh thiét: Thy truc trang c6 U, h ii Phau Bénh dé biét lanh tinh hay dc tinh. Chan doan giai phdu bénh: da sé 1A ung thu biéu mé tuyén (Adenocarcinoma), cic loai sarcom khae it gp: leiomyosarcoma, lympho-sarcoma. C§n Him sing duge Kim dé dainh gid giai dogn bénh, U xdim lin va da di can hay chua: MSCT (hoae MRI): Danh gi giai doan ung thur dai tring, phat hign ung thu tai phat hay di ein Siéu dm trye tring qua nga rye trang: Hign nay 14 phuong php durge chon Iya dé dinh gid mute d6 xm lin qua thanh trye trang (d6 chinh xac 72-94%) va dinh gia di edn hach ving (46 chinh xc 73- 36%). MRI: Co gia tri twong duong hay cao hon sigu im qua nga try trang trong vige dénh gid mize d6 xm. Jan qua thanh tryc trang va danh gid di can hach ving, PET Lam sau phau thudt, dé e6 thé phan bigt ung thu tdi phat, di cain xa, hay sgo xo tai ving migng, A. CHAN DOAN SU’ XAM LAN VA DI CAN 1. Xam lin tai chd + Mit tinh di dOng eta khdi u: chimg t6 khdi u xm nhiém mo chung quanh. - Xam lin gy ré cdc tang lin can khéi a. ~ Cée phuong phép en lim sing dé chin dodn su xm lin eta khdi u: sigu Am byng, sigu am qua ndi soi tre ‘rang, chup eat lop ving chéu, soi bang quang , soi da day... 2. Diean ~ Hach: hach ben, hach thugng din (Troisier), hach ving dai truc trang. = Gan: to, Kin nhén, cimg. Sigu 4m byng, chup efit lop dé xae dinh chan doan, ~ Phdi: X quang phdi cho hinh anh di can la nhiing béng mis trdn nhur bong béng bay 62 phé trudng. - Nao: chup edit l6p so nao phat hign khdi u ung thir di can. - Xwong: hinh anh hiy xwong cua di can xuong Ot cong hoc xucng chu thong gap. B. CHAN DOAN GIAI DOAN Hign nay 04 hai cach xép hang gi bao ung the: 1. Theo Dukes Xép hang durge tée gid Dukes mé t& nim 1952, sau 46 duge cai bién bai tie hac, Xép hang theo Dukes da duge stra doi Giai doan A: ung thu khu teG than trye tring 6 lp niém mac vi lép durdi niém > Giai dogn B: ung thw xm tén 1p co, Lop thanh mge, chua di cin hach = Giai dogn C: di can hach viing + Giai doan D: di cin xa joan ung the dai tye trang dupe dng nhigu nhit tay theo sr xam lin eta t& Astler, Coller va nhigu tae gid 2. Theo TNM T (Cumor) Tx U nguyén phat khéng thé danh gid duro vi e6 mé ta vé mite 46 khéi u, vi théng tin khéng day da. Tis U tai ché con trong lép bigu mo Ty U xém lin top dud nim mac Ty U xm lin lop cor T; U xm fan lép thanh mac hode phic mac nhung khéng dinh bit ky co quan lan edn hoge ede ms Ty U xém Han phiie mac tang va cdc eo quan hay cau trite khae Tab Ung thu di phat trién suyén qua thanh mac cia dai trang va xm nh§p cfc mé Hin cfm hoe ec bd phénN (WNodule) Nx Hach khdng dinh gié duge No Khdng ed hach di can Ni_ Dien vao 1-3 hgch mae treo ving Nia 16 bio ung thur duge tim thay trong I hach bach huyét gin dé Nib té bio ung thu duge tim thdy trong 2-3 hach bach huy&t gin & Nza Din 4 -6 hach mac treo ving Nob Di can hon 7 hach doe theo dubng di cia than mach méut M_ (Metastasis) Mx Di can xa khong danh gid duge Mo Khéng cé di ean xa ‘My # Ung thur da lan réng dén 1 ee quan xa, hode thiét lap cac hach bach huyét xa Mib Ung thu da tan rong dén hon | eo quan xa x6i hode thikt lap cae hach bach huyét xa hoae da lan tran dn ee phan xa ctia phic mae Giai dogn theo TNM Giaidoan Thuong tn a N M 0 ‘Neng (in situ) Tis 7 1 Khu tr TihayT: No My A WA Xim kin B NO Mo BI mB Ta No Mo B2 lic TB No Mo B3 IA earth vine: TI2 NI Mo et me TH NI Mo a mic Tha Nz Mo a. VA Diein xa BitorT Bategn MIB DI VB Dietin xa BitekT — BatewN MIB D2 ll. DIEU TR| NGOAI KHOA. Digu tri ung ther dai truc trar 1a pl tha ket op ha tr A. Vé phn thuat 1. Dai tring duge chin 2 phin + Bai trang phai: tir mank tring dén nica phai dei trang ngang = Dai trang irdi tie nita trai i trang ngang dén 2. Trye tring e6 2 dai trang chu hang va trve tring fich chia Chia 2 phir: wye tring trong 6 bung va trye tring ngodi 6 bung. Nép phiie mac chu ngain 2 phin & each bet hau mon 7-9em, Chia 3 phd ~ 1/3 dui: 0-Sem cach béy hau mén - 1/3 gitta: 6-10em each béy hi mon = 1/3 ten: 11-15em cdch bi hau monB. Dong mgch va tinh mach eiia dai trye tring 1. Bai trang phai Puoe cung cp mau béi dng mach mac treo trang trén (cée nhinh déng mach hdi-manh-tring tring, dng mach dai tring phai, dong mach dai tring gia) va theo he tinh mach mae treo tring trén vé finh mach cia 2. Dai tring trai uve cung cép mau boi ding mach mae treo tring dusi (cae nhinh dong mach dai tring trai, dng mech dai ‘ring chu héng) va theo hé tinh mach mac treo trang duci vé tinh mach eta 3. True tring 1/3 tren: due cung ep mau bai déng mach tr tng trén (tr trén), 1A nhanh cui eta dy tring dudi va din miu theo tinh mach true tring trén, tinh mach mac treo trang dudi ve (Hinh 1). - 1 gitta: duge cung ep mau boi dng mach truc tring gita (tri gitta) tir nhanh cia déng mach ha vi (hay chau trong) ~ 1/3 dudi: duge cung cap mau béi dong mach tre trang duéi (117 duc) tir nhénh dong mech then, mét nhénh ciia déng mach ha vi. Hinh 1. ng mach nudi duréng dai true tring Hinh 2, Hé bach huyét cia dai tring 1, Dong mach mec treo tring trén, 2, DM aac 1, Hach thinh dai tring, 2. Hach canh treo ting duéi, 3. DM. dai ining side dai tring 3, Hach trung gian cia dai 4, DM dai tring tri, 5. DM hi manh dai teing, 4. Hach chinh cua dal ting, 5. trang. 6. DM dat ring ti, 7,89. Cic BM 31 Hach ha vj, 6, Hach ben trang chu hong, 10. DM tye tring ten, 1, DM ba vi 12. DM tye tring ita, 13. DM tye ting dud 2/3 dudi cia truc trang mau durge dan theo tinh mach ha vj vé hé tinh mach chi dui. ©. He bach huyét Cf chudi hach bach huyét doc then eae hé mach méu eta dai true tring (Hinh 2), 2 Chudi hack bach huyét mac treo trang trén: dan lwu cdc hach bach huyét cia dai trang phat Clue hach bach nyét mac treo wring diréi: dn Iu cae hgch bach huyét ciia dai trang trai va phan trén ctia trye tring, Chudi hach bach huvét ha vi: ddim lu céc hach bach huyét cia phan gitta trye tring, Chuét hach bach hnvét vimg ben: Ihru ede hach bach lnuyét eiia phin thap true trang, D. MUC DICH VA NGUYEN TAC DIEU TRI NGOAI KHOA 1. Cat rng rai doan rugt e6 khéi u tn trong bo an toan trén duéi khéi u, mac treo dai true trang, hach ving va cc tang lan edn bi xim Kin (néu duege)- Déi voi ung thu dai trang: edt wen va dui khdi u it nhat la - Boi voi ung thu trye trang: cdt wén uit nhi > 2em (theo tée gid William 1984), 2. Ton trong ky thuat edt ede ly khong dy nim 1967, Sem nhumg cit didi Khoi wit nhit (No-touch isolation technic of resection) ic nhiinh dng tinh mach ctia dai tring tai gée va 2 da rugt truge khi cit mac treo va khdi u, 3. Chuan bj t6t dai tring dé néi ngay sau khi ct, lap lai luu thong tigu héa etia rudt. Chuan bj dai trang that sach dé cho vige khau ndi dat két qua t6t tranh bién chimg bye xi migng ndi sau mé. Thuong dp dung cae bien phap sau day: a. Lam sach long dai trdng bing ~ Ché d@ an long dan trrde md: truée mé 3 ngiy cho bénh nhan an nhg; chéo, sip (truse md 3 ngiy), stta (trade mé 2 ngdy), nude duéng (trude mo | ~ Kem thyt théo lign tiép 3 ngay true mé, phi thut thdo that sach dén nude trong, ~ Hote chi ding Fortrans (PEG 4000-Polyéthyléne 4000), thudc dang b9t pha véi nude uéng dé Kam sach fong dai ting. Cho bgnh nhan uéng 3 g6i, mdi g6i pha vOi | Iit nude, udng tong vong | neay mrde md, ma Khong can thut théo. Nhung khéng duoe diing cho ede trudmg hop c6 bién chimg doa thing dai tring hode trudng hop tic rudt . 8. Khe triong ding ruét z Co thé diing cde loai Khang sinh duimg rugt kat bj sach dai trang ta da, +t hop vi diét vi tring ky khi. Tuy nhién hign nay chi edn chudin E. CHIINH PHAU THUAT Chi dinh ph thusdt trigt dé (hay Giai doan ctia ung thu i} xm lin cia ung ther Mie d6 di can Thé trang cia bénh nhan at can), tam bo, mé rng va Lim sach thy vio ede y 1, Phau thudt trigt 4 hay trigt cin Day 1a phdu thudt clit bd rong rai khdi uw theo nguyén tic ung thu: eft bé dogn rugt mang khéi u dim bao bean todin cia 2 du rut eft, ngo lay hét cdc hach mac treo ving va edt tin gée cc mach mit mudi duong, Phau thud duge chi dinh cho: ~ Nhiing bénh nbn o6 thé trang edn sé ~ Ung ther giai dogn chua di can xa (A, B, C theo xép hang cita Dukes hoac giai doan 0, I, If, II theo TNM). ~ Ung thu e6n khu tri 6 thanh ruét chia xdm lan céc tang chung quanh hode e6 xm lin nhung cit b6 duoc. 2. Phau thugt mérrdng i Day la phiu thufit cit bo rong rai trigt dé, kEt hop ct bd ede cor quan Lin efin bj séim lan va edt bé mot phan hay ton bg cde ear quan di cn. kha nang ‘Thé trang bénh nhin cho phép mot phau thuat Ién. Ung thur xm lin vao cée tang lain en hoge di can ma edn e6 thé cat bo duoe Phi thugt kim sach Phiu thugt edt doan dai tring trye tring ¢6 khdi te rudt, vo khdi u hode trong ede trutmg hop die 4. Phu thuat tam by ‘Thuong thu hién cae phyong phip sau: + NOi tit doan midi trén véi doan rudt dud khéi u. = Hu mén nhan tao trén dong: dua rust trade khdi u ra ngoai } bung lam hgu mén aban tg. ‘voi muc dich lam sach dé trinh cdc bién chimg nhigm triu ma khOng thé ldy duoe hét,Chi dink cho cée tracing hop. Hinh 3. Cit dai trang phai do ung th Hinh 4. Cit dai tring phai do ung thr dai tring len dai tring g6c gan Giai doan tré cia ung thu, khong phdu thuat trigt dé duge: giai dogn D (Dukes) hay giai doan IV (theo TNM), thé trang bénh nhan qué kém khong thé chju dung durge euge md I6n. F. CAC PHU'ONG PHAP PHAU THUAT DIEU TR] UNG THU' DAI TRANG. 1. Diéu trj ung thu dai trang chua bién ching a. Trigt dé ‘Ct dai tring phi Chi dink ‘Ce khdi u ung thu 6 dai tring phai: manh tring, dai trang len, gan 0-Sem, KY that ~ Cit toin bd dai trang phai thanh mét khéi: gm 20cm cudi ctia hoi trang, man tring, dai tring én, gée gan vi 1/3 hoje 1/2 bén phai cia dai trang ngang tay vj tri ctia khdi u, - Cit mae treo dai trang phai vi mach mau vi hach mac treo, ~ Lip lai bru thong rut: ndi hdi trang véi dai trang ngang (Hinh 3 va 4), Se wan, doan dai trang ngang bén phai cach goeHinh 5. Cit doi tring tri do ung tne dai trang xu 6. Cit dai trang ngang do ung thir dai trang ngang Tai bién phau thudt_ ‘Trong phiu thudt cit dai tring phai, khi bée tach mge Told dinh vao sau véi ta tring, nigu quan phai va tinh mach chit dusi nhat la trong hop khdi u to va xm lan dé gay tn thuong ede co quan na - Réch ta trang, + Tén thuong nigu quan phai: dit nigu quan phai hode khau thét nigu quan phi = Rach finh mach chi dui Bién ching sau mé - Bue xi migng ndi gay viém phiic mac, rd phan. + Viém khoang té bao sau phic mae. ~ Tiéw long: that ra day khong phai 1a bién ching ma la hau qua sau edt dai trang phai do eat’b6 phan nurde cia dai trang phi. Tiéu ling thuéng xay ra trong vai tudn 1G dau sau mé. Cit dai trang trai Chi dink Cie knéi w ung thy & dai tring trai: dai tring ngang bén trai céch gée lich 0-Sem, dai trang gée lich, dai trang xwong, phiin dau ctia dai trang chau hong. Ky hut + Cit dai trang trai thanh mt khdi tir 1/2 dai trang ngang bén trdi, dai tring gée lich, dai ring xuéng, phan iu cia dai trang chau hong. = Cit bé mac treo dai tring trai voi mach mau, hach viing, ~ Lap lai luu thong rugt, noi dai trang ngang véi dai trang chau héng (Hinh 5). Tai bién phéu thudt - Voléch, ~ Ton thuomg nigu quan ta dist hoge khau thit nigu quin trai Bién ching saw md + Bue xi migng ndi giy vim phite mac, r6 phan ~ Vigm khoang té bio sau phiie mae. Cit dai trang ngang Chi dink Khdi u ung thur 6 dogn gitta ctia dai tring ngang. AV uae + Cit doan dai tring ngang, = Cit mge treo dai trang ngang, ding tinh mach dai trang gitta va hach mac treo ving.Hinh 7. Cit doan dai tring chau hong ~ Lap Iai lu théng rugt: néi hai dau dai trang ngang phai va trai (Hinh 6). Tai bién pha thudt Tén thong tA trang, tay hiém xay ra, Bin ching sau md Buc xi migng ndi gay vim phic mac, r6 phan. o. Cit dai tring chu hong Chi dink Khdi w ung thu 6 doan dai trang chéw hing. Ky ude ~ Cat doan dai trang chu héng trén va dudi khdi u it nhdt Sem. = Cit mac treo dai tring chu héng va lay hach mge treo ving Lap lai tuu thong rudt, néi hai dau dai trang xuéng va truce trang (Hinh 7). Tai bién phd duct Tén throng nigu quan tréi, d6ng tinh mach ha vi Bién ching sau mé Buc xi migng ndi gay viém phic mae, rd phan, b. Tam bor ©. Phau thugt lam sgch Cit bo dogn dai trang c6 Khdi u, chi + N6i Git doan trén va dwéi kh6i w : : ‘Néi h6i tring-doi trang ngang bén-ben cho céc ung thuré dai trang phai ma khong cét duge; ndi dai tring neang- dai trang chu hong bén-hén cho ede ung thir & dai trang trai ma khong cat duge. Hiju mén niin (go trén dong, An trén va dur6i khdiiu Sem, ma khdng edn ct rong rai. ¢. Cait dai meng qua n6i soi 6 bung Nam 1990, ky thudt edt dai tring qua ndi soi 6 bung duge ap dung & mot sé nuée. Tuy nhién ky thudt nay chusa pho bign vi cn han ché. Vai nim gin diy, mgt s6 bénh vign trong nude da bat du ip dyng ky thuat nay, chi dinh thue hign 6 cae tnutmg hop ung thir dai trang 6 giai doan sém va khu tra. 2. Did a. Tie ruge ‘Trong trudng hop the rudt do ung thu dai tring, didu tri phai gidi quyét: tie rudt va bénh ly ung thir, Do do, néu tinh trang bénh nhan cho phép phdu thudt tigt dé edt dai trang, e6 noi ngay hay khOng tiy tinh trang euia dai ‘ring. ~ Trong the rudt do ung thw dai tring phai, thudng o6 thé néi ngay, nhumg tic rudt do u & dai ting tai thi han ché noi ngay vi thuréng dé bue, chi ndi khi thye hign phuong phép tui rita dai trang that 161 wong mo. ~ Khi khong 66 digu kign edt dgi tring trong ep etiu thi dva dai tring teuée KOi w lam héu mén nhan tao tam va edt 66 dai trang thi sau vai tudn 18. Nhumng da sé trang hop tie rugt, ung thy 6 giai doan mugn, nén hau ht chi thyee hign phaw thust tam bo. tr] ung thu dai tring ¢6 bién chimg1b. Vim phic mac do vo khdi w hay vo dai trang tren khéi w vaio 6 bung + Ct bé doan dai trang c6 khdi ut vor va khdng durge ndi ngay ma Lim hgu mon nbn tgo tam s€ phye hdi lai sau vai th + Holic dua ché va eita dai tring true khéi u ra lam hau mon nhan tao tam va phiu thudt trigt 48 & thi 2 sau vai tuan néu giai dogn ung thw edn cho phép eat duge. &, dp xe think bung do Khdi u va ra thank bung Rach thio mi tai ehd 4p xe Hinh 8. Cit doan dai true wang va néi ‘gi trye trang bang tay ~ Phi thudt tit dé edt dai trang thi 2 néu con ct duge. Trung hyp khong con eit bo duge khdi w tvigt d@ thi néi tit hay Rim gu mon hain tao vinh vign trén dng, 4. Rb cde eo quan lan edn ~ RO dai trang-bing quang: thse hign hau man afin tgo trén dong, sau dé sé phdu thuat mo rong cat dai tring va bang quang. Phau thuit ft thye hign vi thutong c6 di can xa, Hinh 9. A,B, C, D, E: Cét doan dai true tring va ~ RG dai trang-da day: cit dai tring ngang va ‘Ol dei true trang bling may khiiu nbi da diy néu con kha nang cat durge. + RG dai reng-rudt non: edt dai trang va dogn rut non bi 6. e, Xudt née tiéu hda deeb néing do w dei treme Ct bd dai trang c6 khi u trong edp itu dé cdim mau. G. CAC PHUONG PHAP PHAU THUAT DIEU TRI UNG THU TRU'C TRANG 1, Diu tr] ung thor trye trang chua bién ching a. Trigt dé Cit trye trang gitt Iai co vong hgu mén Phau thudt edt dai trang-trye trang tude va néi ngay. Chi dink Cae khdi u & dogn tren va gitta eta true trang, efch bir hdu mén trén Gem. Ky thud Cit b6 doan dai tring chdu hing va trye tring e6 khdi u va néi dai tring may (staplers), Nhg nhiing tién bO vé may khau néi, cée khéi u 6d Khu néi tay khong thé thye hign. New ta di vee tring bing tay (Hinh 8) hay bing ip 06 thé ditge ct bo vt noi lai dure ma i TA dé cit true sing doan thap va néi tan-tanmay Khu néi BEA (Hinh 9) ‘Phu that Hartmann Phau thuat duoc Hartmann thye hién nim 1921 Chi dinh Cée khdi u nim 6 doan true trang giita ma khéng thé khi ndi duge. Hign phiu thugt nay it ap dung khi ed miy khdu néi. Thuong ap dung trong cap cttu va bénh nha thé trang kém, KV dug Hau min SS) ania no daitaing chau héng a Nye Phicmacchiu Hink 10, Phi thudt Flartmann (Cit doan dai trang chau héng va truc trang, Dong mdm trye tring duéi fai va dua dau «én dai tring chéu hong +a hé chau tri lim hau mon ahdn tao (Hinh 10) Ui diém z Phau thudt ebn gift Iai co' vong hgu mén va khong sq bién chimg bue xi sau mé, ty Ig tir vong it. Khuyét diém : . Bénh nhan phai mang haw mn nhan igo suét di me dit hdu mén that con gitt lai va tryc tring van edn bai tiét ra chat nhay cita dogn tru trang edn lai © Phau thugt kéo tue (Pull-through) cia Babcock Bacon va céc ky thugt edi bién Phau thuat nay durgc hai tc gid Babcock va Bacon thyc hign nim 1956 va duge cai bign vé sau. Chi dinh - Cae khéi u é dogn tnre trang thp cach bi hau mon 3-Gem. ~ Ung thu & giai doan sém (Dukes A, B) va kich thuée khéi u <2em. ~ Khéng x4m lan oo vong hau mon. 9 tht At bd ton bg truc trang, kéo tudt dai tring chdu hong qua 1S hu mén va néi dai tring v6i hgu mon theo nga ting sinh mén (Hinh 11). Ui diém Cat bd khéi u va tao Kip liu théng tiéu héa bao dim chite nang sinh ly ciia hu mén. Khayéediém ; Phau thugt kh6 vi u 6 th , bién chimg bue migng ndi va ung thu tai phat tai cl Céc logi phiu thugt khae ~ Phau thude Kraske: cét bo khéi u nbd thinh sau try tru = Phew thueit edt u xuyén qua 15 hau mon: it duge ding, v qua tiga sau xuyén sarong eiing 1g tai phat cao. Cit trye tring Hiy ea co’ ving hau monPhau thudt cit cut true trang theo 2 nga bung va ting sinh mén (phdu thudt Miles): phdu thuat nay duge tic gia Miles thye hign nm 1908, Chi dink Cae khdi w 6 dogn thép cita true trang (1/3 dudi) edch be hau mén < 6em 6 xam lan co yong hau mén va cic khdi u to 6 15 gita true tring kha ning cit durye ma khOng thus hign pha thugt bao ton eo Vong héu mon duge. KY dua Cit bo phan dudi eta dai ming chu héng va toan bé true trang, cde co veng hu mén, co ning hju man, lay lun héu mén véi 2 kip mé: nga bung va tang sinh mén. Dua dai trang chau hdng trén ra ngoai 6 bung &/ho Hau moa K ‘hin tao dai tang chéu hong \ el ‘Tang sinh mon ‘inh 12. Phu thuat Miles tgo vinh vign (Hinh 12), ét khOi u ung thy va hach ving, + Két hop eit b6 rng rai ede ecr quan xm Lin ving chau: tir cung va ém dgo hoge bang quang. Tuy nhién cae phdu thugt m6 rng nay thing rit nang: doan chau sau hay doan chu ton phiin Khuyét diém Phau thugt nang, nhicu tai bign trong mé va bién chimg hau pl ~ Tai bign chay mau tude xwong cing hay gip nhat va cde tén thong nigu quan, bing quang (nam) va Am dgo (nt. ~ Bign ching nh a nigu dao tring vét md tng sinh mon thuimg kéo dai ~ Bénh nhdin phai mang hau mon han tgo vinh vign.8. Tam bg : Thuong Iém héu mén aban tgo G dai tring chu héng hode dai tring ngang tly vao sy tién trién va xam lan cla ung thy. 2 Dieu t a. Tc radt ‘Thudng bénh nhan trong tinh trang nang vavj tri khdi u 6 thip nén phdu thuat tét nhdt la dua dai trang chau +h6ng 6 trén ra lam hu mén nhfn tao dé widi quyét tie rugt. anh gia: ~ Ung thw 6 giai doan con cat bé duge sé can thiép phdu thudt trigt dé thi 2 sau vai tun Ié cé chudn bj dai tring va bénh nhan duoc héi site tot. + Ung thu khong cn kha nang phdw thudt trigt dé duge sé dé hu mén nhan tao nay vinh vign. b. Viém phic: mac Ché vo la Khoi u 6: doan trre trang trong 6 bung hoe c6 trudng hop u & doan true trang ngoai 6 bung, nhung sy V6 tre trang phia trén khéi u trong 6 bung. Nguyén tic 1a dua dai trang chu héng trén ch vO ra lim hau ‘mon nhan tao va khau lai ché thing hode phai edt bo khdi u bi thiing theo phwrong phép Hartmann. Thug bién chiing nay rat nang vi ty If ut vong cao, Phau thuft tri d& sé ean thigp thi 2. ‘ung ther trye trang e6 bién ching &. Ré vao ce quan lan edn Ro true tring-im dao 6 né va rd trye trang-bang quang & nam. Thuong phdu thudt 2 thi: © Thi 1: Lam hj mén nha igo trén dong 6 dai trang chiu héng. O. Phi 2; Phau thudt trigt 48 cit rng ca true trang va co quan bj rd (tir cung, pha quang) phu va am dao hoge bing Ill. THEO DOI SAU MO VA TIEN LUONG Sau mé ung thir dai tryc trang cin phdi theo doi cde bién chimg s6m eta phdu thuat va theo di lau dai su tdi phat va di can. A. THEO DOI CAC BIEN CHUNG SAU MO - Chay mau sau mé, - Bue xi migng ndi, > Nhiém tring vét mé, nhiém tring tang sinh mon (trong pl ~ Cae bién chimg eta héu mén nhan tao. Cac bién chimg dung tide nigu. - Cac bién chimg tim mach, hé hap nhat la 6 cde bénh nhén lon tudi. 8. TAIPHAT Mac dit m6 trigt dé cat rong, nung van c6 mét sé trurng hop ung thu tai phat tai chd hose di cin, ~ Thurong tai phat 6 migng néi gay hep migng néi. ~ Tai phét & mom tye tring cén Iai sau phi thugt Hartmann, Tai phat 6 tang sinh mén va viing ch4u sau phi thuat Miles. + Tai phat 6 15 hu mén nhan tao. + Tai phat 6 vét mé bung. Hign nay, ngubi ta theo doi sy gia ting cia khang nguyén ung thir phoi CEA (Carcino-embryonie Antigen) sau mo dé phat hign s6m sue tai phat ctia ung thr dgi try tring truée khi c6 cae dau higu Lim sing, Nho dé, 66 thé can thigp phdu thuat Iai sm, c. DICAN Thuong di ean gan va di can 6 bung hay phiie mac la nhiéu nhat, ké dén La phoi, it khi gip di can no va xuong, IV. DIEU TRI UNG THU’ TAI PHAT VA DI CAN, A. TAIPHAT ‘Ung thu dai trye tring tai phat néu edn kha ning cat bo lai duoe van ©é chi dinh can thigp phdu thudt, nhung. thuimg sO bénh nhan duge phau thuat Iai hiém. Ba s6 diu tri bS tite bling héa tri két hop thude mign dich (hosic xa tri cho truéng hop ung thr true tring). Neay nay mot s6 tie gid ding xe tri trage md, trong md va sau mo cho cae ung ther trye trang durge mé lan du va xa tri cho eae trong hop ung thu trye trang tai phi. PbB. DICAN Khi ung thu da di can thudng thé trang bénh nhan rit yéu kém, da s6 tae gid khéng can thiép phau thud, chi digu tr] bé tic v6i héa chat hodc két hop vai mign dich, MOt s6 tac gid da diéu tri ct bé mét phan gan hole phéi bj ung th di can néu ung thy nguyén phat tai chd 6 dai trye tring khong tai phat, nhumg ket qua chua kha quan nhiéu va chi dink edn cin nbée, Héa chat thuimg dirge ding [4 SFU (5-Fluoro Uracil) két hop v6i ede thude mign dich Lévamisole hay Acide folinique... dé diéu trj bé tae, Hai phae dé duoe ding nhiéu va c6 higu qua lim cham su tién trién cita ung thu, ting thoi gian séng them Kt hop SFU véi Lévamisole in tinh mach 450 mg/m’ da co thé/ngay x 5 ngay. Ngay thi 28 sau d6 450mg/m? da co wala, + Kem Lévamisole: uéng 1S0mg/ngay x 3 ngay/tuan/ndm. 1 Két hop SFU voi Acide Folinique . ‘Theo Machover 1986, diing lieu trong lén trong thai gian ngin, SFU: truyén tinh mach trong 4 git 400mg/m’ da co thé/ngay x 5 ngay + Acide Folinique: truyén tinh mach trong 1-2 git 200mg/m’ da co thé/ngay x Sngay MOt thang sau nhac lai ligu trén va ding trong 6 thang, céch I thing | aot. Sit dung héa tri edn chi ¥ dén ede tc dung phy va phai e va hay giai doan IIL va IV i djnh ey thé. Chi héa tr] cho ung thu & giai doan C V. KET QUA VA TIEN LUQNG A. KET QUA “Ty le tt vong sau mé: + Ung the dai wring: 3-5% khi chuca o6 bién chitng va 20-30% khi c6 bién chimg + Ung thie orye tring: 1-13% ty theo tée gia B. TIENLUONG anh gia két qua diéu tr] ung thy dai truc tring phai theo doi thoi gian séng thém sau digu tr] $ nam. Tién hong. cia ung thu dai trye tring thuting tot hon cde ung thir khéc & dung tiéu hoa. + Ung thw dai tryc tring: ty 1g séng thém sau 5 nfm i 40-55% va tiy theo eée giai doan: A 70-85% Be 50-60% C 25-45% D 06% Ung thu trye trang: ty 1é sng thém sau 5 nam 1a 50-60% va tity theo cae giai doan: A 80% Be 55.65% C 25-45% D 05% (Theo Francois Yves, 1991).