Nghiên cứu chẩn đoán và điều trị chấn thương gan tại một số bệnh viện tỉnh miền núi phía bắc tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF NATIONAL DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL SCIENCE RESEARCH PHAM TIEN BIEN DIAGNOSIS AND TREATMENT LIVER TRAUMA AT THE NORTHERN MOUNTAINOUS HOSPITALS Speciality : Gastroenterology surgery Code : 62720125 ABSTRACT OF PHD THESIS Ha Noi – 2020 STUDY ARE COMPLETED AT 108 INSTITUTE OF CLINIC MEDICAL SCIENCE RESEARCH Science instructor: Prof Trinh Hong Son Referee 1: Referee 2: Referee 3: The thesis will be defended in front of the Institute's Thesis Evaluation Council at:… hour … , day … month … year … Thesis can be found at: National Library 108 institute of clinic medical science research’s Library LIST OF PUBLISHED RESEARCH ARTICLES RELATED TO THE THESIS Pham Tien Bien, Nguyen Hoang Dieu, Trinh Hong Son (2020), “Diagnosis of liver trauma in northern mountain hospitals”, VietNam medical Journal, (2): 13-16 Pham Tien Bien, Nguyen Hoang Dieu, Trinh Hong Son (2020), “Treatment of liver trauma in northern mountain hospitals”, VietNam medical Journal (2): 29-32 INTRODUCTION Liver trauma (LT) is a solid organ trauma that is common in closed abdominal trauma (15-20%) According to statistics, 31% cases (TH) of multiple traumas had closed abdominal trauma, of which 16% were recorded with LT Today, with knowledge about anatomy, physiology, traumatic mechanisms, and the development of computerized tomography made a breakthrough in LT diagnosis and treatment In terms of treatment, previously surgery was indicated for LT popularly Nowadays, with the advancements in resuscitation anesthesia, surgical techniques, the trend of non-operative management for patients with grade I, II and III and stable hemodynamics is increasing and achieving good results Many recent studies show that about 70-90% of LT is treated with non-operative management and successfullyrate is 85-94% The Northern mountainous provinces have underdeveloped economies, difficult life, inadequately developed health systems, inadequate human resources, limited and uneven qualifications, and lack of modern medical equipment, making it difficult to diagnose and treat surgical diseases, including LT Trinh Hong Son's study found that the diagnostic protocol and indications for treatment were inconsistent due to the lack of diagnostic equipment, the lack of diagnostic doctors, many surgeons who had no experience in assessing and difiniting lesions that lead to wrong indications, some hemostatic and resectiontechniques of liver rupture are not proficient, increasing the rate of complications In order to improving the effectiveness of LT diagnosis and treatment in Northern mountainous hospitals, we carry out the project with two objectives: To study about LT diagnosing at Northern mountainous hospitals To evaluate early results of LT treatment at Northern mountainous hospitals NEW CONTRIBUTIONS OF THE THESIS The study was conducted on 124 patients (BN) diagnosed LT, treated at 11 Northern mountainous hospitals from November 2009 to the end of May 2013 - Regarding diagnosis of LT: 60.5% patients had stable hemodynamics upon admission 96.8% patients had abdominal ultrasound, 85% found liver lesions, 40.3% patients had computerized tomography Patients who had computerized tomography had a higher rate of non-operative treatment than the group didn’t have CT (69.4% versus 11.3%) The accuracy of computerized tomography detecting abdominal fluid is 93.33%, detecting liver lesions is 100% - Regarding treatment results: 50% patients were given nonoperative treatment and 50% were given emergency surgery 74.2% were treated with non-operative management and then 25.8% failed The reason for changing to surgery in the non-operative management group was mainly due to increased abdominal distention, increased pain level, accounting for 43.75% During surgery, a grade IV liver rupture was observed (47.43%) Liver suturing accounted for 92.3% The rate of complications related to surgery is 24.4% Four patients(3.23%) died during treatment coursewere in the surgical group - Evaluation of early results: + Non-operative management group: Good results accounted for 74.2% + Surgery group: Goodresults(67.9%), averageresults(26.9%) and poorresults(5.2%) These contributions expose reality and contribute to raising the status quo, thereby improving the efficiency of diagnosis and treatment LT at Northern mountainous hospitals STRUCTURE OF THE THESIS The thesis consists of 133 pages: 2-page introduction, 36-page literature review, 23-page study subjects and research methods, 25-page research results, 43-page discussion, 2-page conclusions, 1-page recommendations articles, 39 tables, 05 charts, 11 pictures 158 references Chapter LITERATURE REVIEW 1.1 Liver surgery 1.1.1 Devices holding the liver’s place 1.1.2 Hepatic artery, ven and biliary tract 1.1.3 Liver division Currently, Ton That Tung's liver lobes division is most used and convenient in liver surgery, especially liver resection 1.2 Diagnosis of LT 1.2.1 Clinic Systemic symptoms: Pay attention to the whole body condition, hemodynamics and signs of blood loss shock, multiple traumatic shock Physical symptoms: - Abdominal exam: Abdominal distention, abdominal skin scraping, abdominal wall reaction, abdominal puncture - Comprehensive examination, avoiding missed coordination injuries 1.2.2 Subclinic 1.2.2.1 Blood tests Complete blood count, transaminase (GOT, GPT), Bilirubin 1.2.2.2 Diagnostic imaging - Ultrasound: is a simple, money and time savingtestthat can be done in a hospital bed Most Northern mountainous hospitals have been equipped with color or black and white ultrasound machines, so this is a very important imaging test, consistent with the conditions of the hospitals, which helps to make a preliminary assessment as well as orientations for diagnosis, monitoring and treatment of LT Ultrasound definite abdominal fluid in short time and it is very meaningful in emergency when patients have multiple traumas, unstable hemodynamics, can replace abdominal puncture Ultrasound can detect direct signs in liver trauma such as: parenchymal contusion, rupture lines, hematoma in the parenchyma, subcortical hematoma or indirect signs: enlarged liver size, blood clots , fluid around the liver, abdominal fluid, helps orient damaged organs - CT scan: For patients havestable survival signs, abdominal or systemic CT scan is a useful technique to quickly detect all possible lesions in one scan and allow the doctor to evaluateabdominal fluid and gas; lesions of solid organs, gastrointestinal tract, excretion route, timely detection of associated lesions with high sensitivity and accuracy, prognosis and thereby making decisions about non-operative management or surgical treatment in multiple traumapatients Images of liver lesions caused by abdominal trauma on CT scan: Abdominal fluid, images of liver trauma (hematoma under the liver capsule, parenchymal tear or rupture, contusion and hematoma in the parenchyma) Classification of liver rupture according to CLVT: There are many ways to classify liver damage in closed abdominal trauma Nowadays, the grading system LT of American Association for the Surgery of Trauma (AAST) in 1994 is most applicable This classification system is based only on anatomical damage of the liver According to AAST1994, LT is classified into degrees, based on the type of liver injury, lesion site, surface area of injury and other related lesions - Angiography - Biliary cholangiopathoscopy (ERCP) - Magnetic resonance imaging (MRI) 1.3 Treatment of LT 1.3.1 History 1.3.2 Surgical treatment Indication: - Patients admitted to the hospital in the state of severe blood loss shock (need to move straight to the operating room) or unstable hemodynamics, not responding to resuscitation fluid, blood - Indication of surgery due to associated injuries such as hollow organ perforation or in some multiple traumatic cases with accompanying abdominal trauma - Indication of non-operative treatment but through monitoring, bleeding or rupture of the liver was not controlled and/or peritonitis Management of surgical lesions - Temporarily hemostasis: Manually squeezing the liver, Pringle procedure, inserting hemostatic gauze, clamping the aorta or blocking the aorta below the diaphragm - Complete hemostasis: electro-surgery or hemostatic suture, selective hepatic artery ligaturing, liver resection 1.3.3 Non-operative treatment Most of the authors believe that non-operative treatment can only be used for patients with stable hemodynamics, patients who are hospitalized in a state of shock have a very high rate of emergency surgery In addition, it is necessary to exclude coordinated lesions in the abdominal cavity requiring emergency surgery, especially perforation lesions, hollow organ rupture Some other conditions that are needed to decide on monitoring and non-operativetreatment: + Having conditions for close and continuous monitoring of clinicic, subclinicic, image diagnosis (ultrasound, CT, emergency angiography) + Facility have capable of surgery at any time, a team of surgeons have experience in liver surgery, including major liver resection 1.4 Current situation of LT diagnosis capability in northern mountainous hospitals 1.4.1 The basic features of geography, economy and population The Northern mountainous provinces still face many socioeconomic difficulties: they have a large area, quite complex topography, many high mountain ranges, large slopes, limited transportation,far distance from Hanoi capital and remote areas The main area is the mountainous forests have few advantages in natural resources and trading, people are mainly ethnic minorities, the main economy is agriculture, and the income is still very low This condition effect on diagnosis and treatment of LT and surgical diseases 1.4.2 Human resources and LT diagnostic facilities The lack of human resources as well as equipment systems limit the development of diagnostic techniques: CT scans, magnetic resonance imaging, endoscopic ultrasound, so that some diagnostic diseases are not adequate, especially multiple traumatic cases, closed abdominal trauma has many associated lesions 1.4.3 Situation of LT diagnosis in Northern mountainous provinces Trinh Hong Son's study on 40 LT patients at 12 general hospitals in the northern mountainous provinces: 47.5% of patients are ethnic minorities (H.Mong minority 20%) The main cause of LT is traffic accidents (35%), CT was performed on 9/40 (22.5%) patients, abdominal lavage was performed on 5/40 (12.5%) patients 1.5 Current situation of LT treatment in Northern mountainous hospitals Due to the lack of gastrointestinal surgical specialists and image diagnostic equipments The techniques of measuring liver volume or imaging intervention have not been transferred and applied in the Northern mountainous hospitals, lead to a high rate of LT surgery Most hospitals have implemented basic techniques such as hemostatic swab inserting, hemostatic suturing, but liver resection in LT surgery is still difficult, not widely applied Trinh Hong Son's study had 2.5% of patients were indicated to non-operative treatment, 39 patients (97.5%) were indicated to surgery Indications for emergency surgery were shock (23.0%), abdominal distention increased (51.3%), peritonitis (7.7%); patients (18%) had stable hemodynamics but the reason for surgery was only due to the detection of liver lesion There were LT patients (18%) of grade I and II alone and 22 LT patients (56.4%) of grade III ordered surgery 19 patients (51.4%) had an intra-abdominal blood volume