B GIO DC V O TO B Y T TRNG I HC Y H NI THAI DINAL ĐặC ĐIÊM LÂM SàNG, CậN LÂM SàNG Và KếT QUả ĐIềU TRị VIÊM RUộT THừA PHụ Nữ MANG THAI Chuyờn ngnh: Ngoi khoa Mó s : CNG LUN VN THC S Y HC Ngi hng dn khoa hc: PGS.TS Trnh Vn Tun TS Nguyn Ngc Hựng H NI - 2016 MC LC DANH MC BNG DANH MC HèNH T VN Viờm rut tha cp hin l mt nguyờn nhõn ph bin nht chn oỏn phu thut ngoi khoa v cng l nguyờn nhõn gõy hu qu nhiu nht quỏ trỡnh can thip phu thut ca ph n thi k mang thai Viờm rut tha mang thai chim t l t khong 1/1250 v 1/1500 ph n mang thai [1];[10];[11];[23];[38] Thi k mang thai l mt giai on ca cuc sng ú cỏc triu chng bnh lý cú th c coi nh l nhng thay i sinh lý, thay i ni tit gõy bun nụn, nụn, chua, tro ngc d dy-thc qun v niu o gión thai k, t cung to lờn lm nh hng n v trớ ca cỏc cn au [12] Do vy d t bỏc s chn oỏn nhm v khú khn v lõm sng v siờu õm bnh nhõn b viờm rut tha [3];[5];[17];[24] Theo Vừ Duy Long v ỡnh Cụng tui sinh , viờm rut tha thng b chn oỏn lm vi bnh sn ph khoa Nguyờn nhõn thng ớt biu hin cỏc triu chng v sn ph khoa v cha khai thỏc y cỏc triu chng ca sn ph khoa [39] T l m lm cũn cao t 20-40% c bit ph n tui sinh [40];[41] Mt khỏc v vic quyt nh phu thut hay khụng phu thut (hoc trỡ hoón) cng l mt khú khn vỡ nu rut tha v ra, gõy bin chng thỡ t l sy thai hoc sinh non sau m v cỏc bin chng khỏc cng tng lờn Sy thai thng xy 3-15% ph n viờm rut tha cú bin chng tam cỏ nguyt u tiờn, nhiờn cú th tng lờn ti 20-30% [20];[29], vi t l non l 15-45% [20] v tng nguy c sy thai t nhiờn, non, tng t l mc bnh v t vong chu sinh [28] T l t vong ph n mang thai b viờm rut tha cp t 2,5% - 3%, cao hn 10 hoc nhiu ln so vi khụng cú thai [6],[27],[36] Trc õy, phu thut ct b rut tha bnh nhõn cú thai thng c thc hin qua ng m m vựng h chu phi ng cnh gia hoc ng trng gia Hin vi s tin b ca chuyờn ngnh phu thut ni soi v s tin b ca chuyờn ngnh gõy mờ hi sc, ó cú nhiu trung tõm phu thut ln trờn th gii cng nh nc v phu thut ni soi ct rut tha, ct tỳi mt, cỏc u phn ph khỏctrờn ph n mang thai nhiu mc v gúc khỏc vi kt qu kh quan Hin ti Bnh vin Hu ngh Vit-c, phu thut ct rut tha c m m v ni soi ph n mang thai ó c ỏp dng rt nhiu Vỡ vy gúp phn cú mt kt lun khoa hc khng nh tớnh an ton v hiu qu ca phu thut, chỳng tụi chn ti Nghiờn cu c im lõm sng, cn lõm sng v kt qu iu tr phu thut ct rut tha ph n mang thai ti Bnh vin Hu Ngh Vit c nhm mc tiờu: Mụ t c im lõm sng v cn lõm sng ca viờm rut tha ph n mang thai ỏnh giỏ kt qu iu tr phu thut ct rut tha ph n mang thai ti Bnh Vin Hu Ngh Vit c nm 2012-2017 Chng TNG QUAN 1.1 LCH S NGHIấN CU BNH VIấM RUT THA Rut tha c mụ t ln u tiờn vo nm 1522 bi Berengarius Carpus, giỏo s phu thut ti Pavia Pologna ễng ta ó mụ t rut tha l phn thờm vo on cui manh trng, chiu rng nh hn ngún tay ỳp v chiu di khong inches hoc xp x [4] Claudius Amyand (1735) ó ghi li vic ct b rut tha ca ngi quỏ trỡnh phu thut thoỏt v Mestivier (1759) ó núi vi Handcock v m ỏp xe rut tha u tiờn, iu ny c xem l s mụ t cn c vo bnh lý ca viờm rut tha Nm 1886 Reginald H Fitz Boston quan sỏt thy triu chng ca 209 trng hp viờm phỳc mc tng t triu chng ca 257 trng hp quan sỏt thy rut tha thng, v khuyn cỏo rng ct rut tha l phng phỏp iu tr tt cho kt qu tt nht v phi c thc hin giai on sm ca bnh ễng ta ngh dựng t viờm rut tha thay th cho thut ng viờm quanh manh trnh n nm 1989 McBurney a cỏc triu chng kinh in chn oỏn v cỏc loi vi khun gõy bnh viờm rut tha ễng cng a cỏc mc bnh lý, ng m v cỏch thc phu thut m n c ỏp dng [4] 1.2 GII PHU SINH Lí RUT THA 1.2.1 Gii phu rut tha v v trớ rut tha Rut tha l on cui ca manh trng, lỳc u cú hỡnh chúp nún ln ngc u v phớa ca manh trng, nhng quỏ trỡnh phỏt trin khụng ng u ca manh trng ch yu bờn phi phớa trc lm rut tha xon dn vo phớa sau v lờn trờn ngi trng thnh ba di dc c ca manh trng gp ti ch ni manh trnh v rut tha cỏch gúc hi manh trng khong 2,5cm ngi Vit Nam, theo Xuõn Hp, rut tha di t 20cm ng kớnh t 57mm [43] Gc RT l c nh, nhng u RT li cú nhiu v trớ khỏc bng so vi manh trng [19] Theo Nguyn Quang Quyn (1993) RT HCP chim 53,3%, RT sau manh trng: 30%, cũn li RT tiu khung, sau hi trng v vo bng gia cỏc quai rut [18] Ngoi y vn, mt s v trớ c bit ca RT cng c nờu v cng gp thc t lõm sng nh: - Rut tha sau phỳc mc - Rut tha mc sau manh trng - Rut tha h chu trỏi trng hp o ngc ph tng - Rut tha quỏ di, u rut tha chy sang h chu trỏi viờm gõy au vựng h chu trỏi - Rut tha cú th thng v, cnh d dy hay di gan phi trng hp rut xoay khụng hon ton - Khụng cú rut tha - Cú rut tha Hỡnh 1.1 v trớ ca rut tha ph n cú thai, th tớch t cung to dn lờn theo tui thai, lm thay i v trớ ca rut tha bng rut tha b y lờn T cung thai di 10 tun T cung thai 11 n 20 tun T cung thai 21 n 30 tun T cung thai 31 n 40 tun Hỡnh 1.2 v trớ ca rut tha mang thai 1.2.2 Cu trỳc mụ hc: Cu trỳc rut tha tng t vi cu trỳc manh trng, th t cỏc lp gm: - Lp mc rt mng, chớnh l phỳc mc tng bao bc quanh rut tha v liờn tc vi lỏ ca mc treo rut tha Lp mc dớnh vi lp c, nhng rut tha viờm cú th búc tỏch d dng - Lp c: gm lp c vũng v lp c dc; hai lp c ny kộm phỏt trin - Lp di niờm mc l t chc liờn kt bao gm cỏc dõy thn kinh v mch mỏu - Lp niờm mc: Gm ba lp: lp biu mụ, lp m, lp c niờm + Biu mụ: ging biu mụ i trng ba loi t bo ú l nhng t bo hp thu, t bo hỡnh i tit nhy v t bo a bc + Lp m: l mụ liờn kt cú nhiu tuyn Lieberkuhn, nhng nang bch huyt ln v nh phỏt trin xung c lp di niờm mc + Lp c niờm: l di c trn khụng liờn tc, mng v b ngt quóng bi nang bch huyt Lp niờm mc v di niờm mc rt dy nờn lũng rut tha rt hp v cú b bớt li ngi gi, s lng v kớch thc ca cỏc nang bch huyt ny gim, song song vi quỏ trỡnh ny l s phỡ i ca niờm mc v gia tng t chc x lp di niờm mc [42],[43] Hỡnh 1.3 cu trỳc mụ hc ca rut tha 10 1.2.3 Sinh lý Cỏc nghiờn cu cho thy rut tha cú chc nng chớnh: - Chc nng dch: Gorgollon cho rng rut tha l t chc lympho phỏt trin vi chc nng dch Fichtelius xem rut tha nh l c quan bch huyt trung tõm, liờn quan n quỏ trỡnh trng thnh ca t bo lympho B - Chc nng bo v: E.I Sinhennhicop v Gross cho rng rut tha cú nhiu ỏm bch huyt úng vai trũ quan trng chc nng bo v c th chng li vi trựng Chc nng phũng chng nhim trựng ca rut tha (h thng bch huyt rut tha) cng khụng kộm phn quan trng nh chc nng ca h thng bch huyt ca Amygdale vũm hng - Chc nng tiờu húa: rut tha tit cht dch kim, gm cỏc men nh Amylaza, Pepsin v cht nhy Trong 24 gi rut tha ngi trng thnh tit khong 2ml dch nhy, Amylaza v cỏc men tiờu Protide 1.3 GII PHU BNH Lí: Phõn loi gii phu bnh: Mac Burney ch phõn bit hai loi: - Viờm rut tha khụng thng Viờm rut tha thng Vit Nam, Nguyn Quý To [50] phõn viờm rut tha lm ba loi: - Viờm rut tha long: tn thng gii hn lp niờm mc, di niờm mc - Viờm rut tha lan rng: tn thng ti lp c v mc - Viờm rut tha hoi t: cú hin tng hoi t, thng, v Theo Nguyn Vn Khoa [48] phõn loi giai on sm, mun ca tn thng chia lm ba mc : - Mc I: viờm xung huyt, viờm ty Mc II: viờm m, viờm hoi t cha v 29 Nhn xột: 3.2 IU TR V KT QU IU TR 3.2.1 Phng phỏp phu thut Bng 3.10 phng phỏp phu thut theo tui thai Phu Thut M m Tui thai n % Ni soi n % Tng n % 12 tun 13 24 tun > 24 tun Tng s P Nhn xột: 3.2.2 V trớ ca rut tha bng Bng 3.11 V trớ ca rut tha phu thut Phu thut V trớ ca RT Vựng HCP Khỏc Tng s p M m n % M ni soi n % Tng n % 30 Nhn xột: 31 3.2.3 Tỡnh trng rut tha bng Bng 3.12 Tỡnh trng rut tha bng Tỡnh trng rut tha Bỡnh thng Xung huyt Tỡnh trng rut tha Viờm m Hoi t, hoi t ó v u V trớ v Thõn Gc Bỡnh thng Tỡnh trng gc RT N + mn n % Nhn xột: 3.2.4 Tỡnh trng bng Bng 3.13 Tỡnh trng bng Tỡnh trng bng Khụng cú dch Dch bng Cú dch M Gi mc n % Nhn xột: 3.2.5 X lý tỡnh trng bng Bng 3.14 X lý tỡnh trng bng Phng phỏp x lý bng Lau bng + khụng dn lu Lau bng + dn lu S trng hp T l % 32 S dn lu Nhn xột: 3.2.6 Thi gian phu thut Bng 3.15 Thi gian v phng phỏp m Phu thut Thi gian (phỳt) 60 60-120 >120 Tng s p M m n % M ni soi n % Tng n % Nhn xột: 3.2.7 Kt qu gii phu bnh ca rut tha Bng 3.16 Kt qu gii phu bnh lý ca rut tha Kt qu RT khụng viờm RT xung huyt viờm cp RT viờm m RT hoi t Tng s n T l (%) Nhn xột: 3.2.8 Khỏng sinh sau m Bng 3.17 S dng khỏng sinh sau m Khỏng sinh Khỏng sinh Tng n T l (%) 33 Nhn xột: 3.2.9 Thi gian dựng khỏng sinh sau m Bng 3.18 Thi gian dựng khỏng sinh sau m Phu thut Thi gian 1-5 ngy 6-10 ngy 11-15 ngy Tng s p Nhn xột: M m n % M ni soi n % Tng n % 34 3.2.10 Thi gian dựng thuc gim co c sau m Bng 3.19 Thi gian dựng thuc gim co c sau v phng phỏp m Phu thut Thi gian 1-5 ngy 6-10 ngy 11-15 ngy Tng s p M m n % M ni soi n % Tng n % Nhn xột: 3.2.11 Thi gian dựng thuc gim au sau m Bng 3.20 Thi gian dựng thuc gim au v phng phỏp m Phu thut Thi gian 1-3 ngy 4-5 ngy ngy Tng s p Nhn xột: M m n % M ni soi n % Tng n % 35 3.2.12 Thi gian nm vin sau m Bng 3.21 Thi gian nm vin v phng phỏp m Phu thut Thi gian 1-5 ngy 6-10 ngy 11-15 ngy 16 ngy Tng s p M m n % M ni soi n % Tng n % Nhn xột: 3.3 BIN CHNG SAU M 3.3.1 Bin chng sm sau m Bng 3.22 Bin chng sm v phng phỏp m Phu thut Bin chng M m n % M ni soi n % Tng n % Nhiờm trựng vt m p xe tn d Nhim trựng l trocart Khỏc Khụng bin chng Tng s p Nhn xột: 3.3.2 Bin chng sn khoa sau m rut tha Bng 3.23 Bin chng sn khoa v phng phỏp m Phu thut Bin chng M m n % M ni soi n % Tng n % 36 Khụng biờn chng Da non non Da sy thai Sy thai Tng s p Nhn xột: CHNG D KIN BN LUN D KIN KT LUN D KIN KIN NGH 37 TI LIU THAM KHO Brown JJ, Wilson C, Coleman S, Joypaul BV (2009) Appendicitis in pregnancy an ongoing diagnostic dilemma Colorectal Dis; 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