Phan loai cua Tran Ngoc Bich... Trao ngi/dc vao phoi 4..[r]
(1)PHAN 3
NHI KHOA
1 TEO THUC QUAN - RO KHI THUC QUAN
1 D A I C U O N G
Teo thtfc quan dtfdc W illiam Durston mo ta lan dau tien vao nam 1670 Nam 1913, Richier mo that duong ro - thtfc quan Nam 1929, Vogt da mo ta cac di dang cua thtfc quan, co the benh ro - thtfc quan Vao cuoi nhiing nam 30, nhieu tac gia da mo ta cac phtfdng phap nhieu thi mo chtfa teo thtfc quan Tdi nhiing nam 50, phtfdng phap mo mot thi da ddi va ty le song sau mo mot cao nhd tien bo cua gay me—hoi siic, cua ky thuat dieu tri triidc, va sau mo
Trong di tat teo thtfc quan, co nhieu the benh, co the chi co teo thiic quan ddn thuan nhiing c6 the benh ce ro thiic quan va co the benh chi co ro thiic quan ma khong co teo thiic quan nen ve thuat ngii da co cac ten goi cho di tat la:
-T e o thiic quan bam sinh - Ro - thiic quan
-T e o thiic quan bam sinh va ro - thiic quan
C) ten goi thii ba nay, da co du cac the benh cua di tat
2 B A O T H A I H O C
Teo thiic quan xay co roi loan ve sii phat trien cua bao thai d giai doan thai tii - tuan D ieu giai thich teo thiic quan hay ket hdp vdi mot so di tat khac nhii tim, cot song, he tiet nieu va ong tieu hoa
Theo sii phat trien binh thtfdng cua bao thai thi nu quan xuat hien d tuan le thii va 5, ruot nguyen thuy diidc biet hoa phan tach quan trtfdc va thtfc quan sau Stf phan tach thtfc hien ttf thap len cao va stf phat trien cua quan ttf cao xuong thap chd tdi luc hinh hai mom phe quan phoi d tuan le thtf
Stf phat trien cua thtfc quan theo hai htfdng, len tren va xuong dtfdi
C) thdi ky nay, co the xay stf phat trien bat thtfdng, d i n tdi di dang true - thtfc quan va mot sd di dang khac kem theo
(2)Su bat thudng qua trinh hinh vach ngan gitfa — thuc quan li nguyen nhan gay teo thuc quan va ro thuc quan
- Su chuyen vi tn vach — thuc quan sau gay teo thuc quan - Su dong khong kin vach - thuc quan gay ro - thuc quan
3 GIAI PH AU
Cau tao thuc quan gom ba ldp: ldp cd ldp dtfdi niem mac ldp mem mac khong co ldp mac nhu ruot
Cap mau cho thuc quan la cac mach mau ttf cac mach d co dong mach hen sudn dong mach chu nguc Cac dong mach chay doc theo thtfc quan Su cap mau o mot phan ba tren thuc quan phong phu hdn
Trong teo thuc quan doan thtfc quan phia tren cho teo gian to day co cap mau tot nen thuan ldi cho kha nang phau tich lam dai toi da va co the thuc
■>
hien duoc dudng rach vong tron het ldp cd nhung ngoai niem mac de lam dai them doan thuc quan dau tren ma khong sd thieu mau phan tui cung tren thtfc quan Con doan thuc quan dudi cho teo thudng nho mong phau tich de keo dai len phai chu y khong duoc cat vao cac mach mau di vao thtfc quan va day than kinh phe vi di ben canh
Do khong co mac che phu nhtf da day - ruot nen kha nang lien vet khau noi thuc quan kho hdn Dudng mo va ky thuat noi thuc quan ngoai phe mac se bao ve duoc ldp phe mac nguc sau de che phu m ieng noi vav se gop phin giup hen nneng noi giam ty le ro - buc mieng noi
4 P H A N LO AI TH E B E N H
4.1 Phan loai cua L add va G ro ss: chia loai
- Loai 1: teo gian doan dau thuc quan va khong co ro thuc quan Hai diu thuc quan cach vdi dai hon dot song nen thudng khong noi diu thuc quan duoc hoac noi rat kho khan vdi ty le bien chtfng cao T in suat gap khoang T - 10°c tong so teo thuc quan
- Loai 2: gap khoang l 'c so teo thuc quan Hai dau thtfc quan teo cach xa nhung co ro dau thuc quan tren vdi quan
- Loai va 4\ thuo'ng gap vdi ty le ttf 75 - S5°o theo cac tac gia Hai dau thuc cuan tec voi khoang cach khong xa nhu d loai va Dau thuc quan tren bit kin 0
v: tn ttf dot song lung toi lung Dau thuc quan dudi thong vdi quan (loai 3) h oa; phe quan goc pha: ■ loai 4>
(3)- Loai 5: loai teo dac biet vdi dau thtfc quan deu thong vdi quan Khdang cach giufa dau thtfc quan thtfdng khong xa
Hinh 3.1 Phan loai cua Ladd va Gross
4.2 P h an lo cu a B e tte x M -K u ffe r F -S c h a r li A : loai - Loai 1\ teo thtfc quan day xd, it gap
- Loai 2: teo thtfc quan gian doan, khong co ro — thtfc quan, it gap
- Loai 3: teo thtfc quan gian doan, co ro - thtfc quan The benh lai dtfdc chia loai:
+ Loai 3a: ro tui cung tren thtfc quan vdi quan, it gap
+ Loai 3b: ro dau dudi thtfc quan vdi quan, hay gap (> 90%) + Loai 3c: ro ca dau thtfc quan vdi quan, it gap
-L o a i 4\ ro thtfc quan, khong teo thtfc quan, it gap
Hinh 3.2 Phan loai cua Bettex M -K u ffe r F -S c h a rli A
(4)4.3 Phan loai cua M y e rs va A b e rd e e n : loai
- Loai A. teo thuc quan co ro dau dtfdi thtfc quan vdi quan Hay g$p - Loai B: teo thuc quan cd ro dau tren thtfc quan vdi quan
- Loai C: teo thuc quan co ro ca dau thuc quan vdi quan - Loai D: teo thtfc quan khong co rd thtfc quan
- Loai E: ro - thtfc quan khong co teo thuc quan
Hinh 3.3 Phan loai cua Myers va Aberdeen 4.4 De nghi p han loai cua ch u n g toi
Muc dich cua phan loai nham de co chan doan va chon ky thuat mo phu hdp nen chung toi thay co the phan teo thtfc quan loai:
- Loai 1: teo thtfc quan khong co ro thtfc quan
Khoang cach cua dau thuc quan co the gan d teo the mang ngan hoac xa cach vai dot song
- Loai 2: teo thuc quan co ro thuc quan Loai chia the:
+ Loai 2a: teo thtfc quan co ro dau dudi thtfc quan vdi quan The benh hay gap nhat
- Loai 2b: teo thuc quan co rd dau tren thuc quan vdi quan, it gap - Loai 2c: teo thuc quan co ro ca dau thuc quan vdi quan, it gap
- Loai 3: khong teo thtfc quan nhung co ro thtfc quan vdi quan Loai it gap
rA
2a 2b 2c
(5)5 T A N SO
Ty le m lc d tre sau de la 1/2.500 Ty le mac benh giiia tre trai va gai ttfdng dtfdng
6 DI T A T P H O I H P
- Can nang: thieu can (< 2500 gam) vad khdang 20% so benh nhan
- Mac di tat khac: khoang 50% so benh nhan Bao gom cac di tat thuoc ve cot song, tim mach, dtfdng tieu hoa, he tiet nieu v.v , nhtf tac mon vj, tac ta trang, dj tat hau mon trtfc trang, than nieu quan doi, nieu quan lac cho v.v
7 TIEN SIT - T R IE U CHlTNG L A M S A N G
7.1 Trtfdc de
Me benh nhan bj teo thtfc quan thtfdng bj da di Day la dau hieu san khoa can chu y de phat hien dj tat ong tieu hoa trtfdc de bang sieu am Sieu am thay da day nho va co the thay dtfdc phan thtfc quan gian phia tren
7.2 Sau de
Tuy thee the leai dj tat ma trieu chtfng lam sang co nhtfng bieu hien khac
7.2.1 Trieu chiing lam sa n g cua the benh teo thtfc quan gian doan, co rd dau dtfdi thtfc quan vdi q u a n -p h e quan
Day la the benh hay gap nhat
- Sui "bot cua": sau sinh ra, tre co nhieu ntfdc bot trao ngoai m u i-m ien g mot cach bat thtfdng, trdng nhtf "bot cua"
- Tim moi, kho thd: co ntfdc bot trao hoac sau an stf a ttf lan dau tien - Viem phoi, suy ho hap: ntfdc bot hit vao va dac biet djch da d a y -m a t trao ngtfdc vao dtfdng ho hap qua ro — thtfc quan Viem phoi thtfdng xay sdm Nghe phoi thay co nhieu ran am
Co the co suy ho hap vdi cac ddt ngtfng thd keo dai
- Doi la mat n tfd c-d ien giai: vi khong an dtfdc va thieu nuoi dtfdng dtfdng tinh mach
- Sot: viem phoi va roi loan ntfdc dien giai
- Bung: thtfdng trtfdng nhe ttf phe quan qua dtfdng ro vao da day, ruot
- Dat ong th ong vao da day khong dtfdc, ong thong thtfdng chi vao sau l l - c m ke ttf m ui, neu co day sau vao thi dau ong thong co the chui mieng
Dat ong thong vao da day cho tat ca tre sd sinh co dtfn nhieu ntfdc bot m u i-m ie n g la mot thu thuat can phai lam sdm de chan doan sdm teo thtfc quan
(6)1 Trao ngi/dc ni/dc ngot + Trao ngi/dc vao phoi Khong vao da day Khong an uong di/dc
Hinh 3.5 Sd trieu chung teo thuc quan, rd thifc quan
7.2.2 Trieu chiing lam sang cua the benh teo gian doan thtfc quan, cd rd
dau tren thtfc quan vdi quan
Tim moi va kho thd, dau hieu viem phoi xuat hien rat sdm ntfdc bot vao nhieu phoi Bung xep vi khong co hdi ruot va da day Dat ong thong qua mui vao da day thi ong thong co the vao phe quan va hut dich ntfdc bot hit vao
7.2.3 Trieu chiing lam sang cua the benh teo thtfc quan, co rd dau thuc quan vao quan
Co cac trieu chtfng lam sang gan nhtf hai the benh tren nhtfng dau hieu viem phoi xuat hien rat sdm dich ntf6c bot chay vao nhieu phoi va trao ngtfdc dich da day vao phoi
7.2.4 Trieu chiing lam sang cua the benh teo thtfc quan md khdng cd rd k h i - t ht f cquan
Trieu chtfng gan nhtf the teo, co ro dau dtfdi thtfc quan vdi khf quan nhtfng bung benh nhan xep, khong co hdi da day — ruot
7.2.5 Trieu chiing lam sang ciia the benh rd - thtfc quan, khdng cd teo thiic quan
(7)8 X Q U A N G
La phadng phap kham de chan doan: co teo thtfc quan khong, co ro - thtfc quan khong hang chup ngtfc va bung, co bdm thuoc can quang vao tui cung tren cua thtfc quan
Hinh 3.6 Tui cung thuc quan tren d dot song nguc III va hinh hdi da day - ruot 8.1 X a c d in h tui cu n g tren
Bang cach bdm khong hoac thuoc can quang hoac dat ong thong co can quang vao tui cung tren thtfc quan roi chup ttf the thang dtfng
Neu bdm khdng qua ong thong thi bdm lam gian tui cung tren va chup dang bdm
Neu bdm thuoc can quang thi dung khdang 0,5 - 1ml loai thuoc can quang nhtf telebrix, hypaque Ltfdng thuoc can quang chi can trang d day tui cung la du, sau chup phai hut lai thuoc da bdm vad
Dung ong thong co can quang hoac dau ong thong co vat can quang dat vao tui O ' )
cung tren thtfc quan cung la mot cach lam de chan doan 8.2 X a c d in h co k h o n g k hi c1 tro n g da day - ruot
Thtfdng chup n g tfc-b u n g cung mot phim chup tui cung tren Chup d ttf the thfing dtfng de xac dinh vi tri cua tui ctfng thtfc quan tren d ddt s6ng ngtfc thtf may va d ben phai hay trai cot song
8.3 Cac k h a n a n g ch a n d oan teo thtfc qu a n sau ch u p p h im
8.3.1 Co teo thuc quan gian doan khi
Thuoc can quang dong d ttfi cung tren cua thtfc quan
Thuoc can quang d tui cung tren vao phe quan trtfdng hdp co ro dau tren thtfc quan vdi quan C6 the lam them sdi quan hdac thtfc quan de xac dinh chan doan
2 2-CC NGOAI KHOA T1
(8)8.3.2 Cd rd thtfc quan dau dudi vdi k h i - p h e quan
Khi co hdi da day - ruot ma co teo thtfc quan gian doan la co ro - thtfc quan
Trong mot s6' trtfdng hdp co the thay dtfdc hinh thtfc quan ttf lo ro - thtfc quan tdi da day neu chup dtfng thi hit vao cua tre va qua dtfdng ro vao da day Lo ro thtfdng d mat sau quan, phia tren chd chia doi hai phe quan goc nen vi tri lo ro thtfdng d ddt sdng ngtfc thtf IV
8.3.3 K hong co rd dau dudi thtfc quan vdi - p h e quan
Khi da day - ruot khong co hdi
8.3.4 Xac dinh vi tri tui cung tren thtfc quan va cd rd - thtfc quan cd gid tri tien ltfdng cho cuoc mo, dinh hinh kha nang md mot thi hoac nhieu thi
- Neu co rd thtfc quan dau dtfdi vdi quan md:
Ttfi ctfng tren thtfc quan d vi tri dot song ngtfc III hoac IV thi khoang cach gitfa hai dau thtfc quan thtfdng ngan va mo mot thi thuan ldi
Ttfi ctfng tren thtfc quan d vi tri ddt song ngtfc thtf II thi co kha nang noi thuc quan dtfdc nhtfng c6 khd khan
Tui cung tren thtfc quan d dot song ngtfc I thi thtfdng khong noi thtfc quan thi mo dau dtfdc
- Neu khdng cd rd kh i - thtfc quan:
Khdng tfdc ltfdng dtfdc khdang cach gitfa hai dau thtfc quan Chi biet dtfdc vj tri dau tren thtfc quan nhd chup can quang Khoang cach co the ngan neu teo thtfc quan gian doan the m ang ngan hoac hai dau thtfc quan dinh g in nhau, va khoang cach gitfa dau thtfc quan cung co the cach nhieu dot song
- Neu tui ciing thtfc quan tren d hen trai kh i quan, cot sdng:
Phai nghi ngd quai dong mach chu va dong m ach chu ngtfc n&m ben phai cot song, nen de chan doan xac djnh co the chup dong mach chu bang bdm thuoc can quang qua dong mach ron hoac chup cat 16p, cong htfdng ttf.
Neu xac djnh dtfdc quai dong mach chu va dong mach chu nam d ben phai thi mo md ngtfc ben trai
Khi mo md ngtfc ben phai phat hien quai ddng m ach chu ben phai thi v ln nen p h iu tich giai phdng dau thtfc quan de noi Giai phong va keo dai thtfc quan diu tren se co kho khan hdn De c6 bien chtfng r6 m ieng noi
Trong trtfdng hdp khdng the noi dtfdc dau thtfc quan dd dong mach can trd mdi dong ngtfc ben phai va md ngtfc ben trai de mo tiep
9 S IE U A M
Nen sieu am ngtfc - bung de phat hien cac dj tat phoi hdp neu co
Hien nay, sieu am da co mot vai tro quan trong chan doan cac dj tat bam sinh trtfdc de
(9)10 D IE U T R I
10.1 Trtfdc m o
Khi tre dtfdc sinh ra, neu da chan doan dtfdc hoac nghi ngd co teo thtfc quan thi chuyen benh nhan tdi benh vien co phau thuat nhi Khi di chuyen benh nhan va thdi gian chd phau thuat, c in lam:
- Dat benh nhan d ttf the ntfa ngoi ntfa nam de giam nguy cd trao ngtfdc dich da d a y-m a t qua dtfdng ro dau dtfdi thtfc quan vdi quan
- Hut dich d tui cung thtfc quan tren de tranh ntfdc bot trao ngtfdc va hit vac phoi Dat mot ong thong chat deo (sonde plastique) hoac ong thong b in g cao su (sonde Nelaton) so qua mui vao tui cung thtfc quan tren de hut lien tuc vdi ap ltfc nhe hoac hut cach quang —10 phut mot lan
- Gitf than nhiet: bang long ap hoac u du am - Khang sinh dtfdng tinh mach
- Nuoi dtfdng dtfdng tinh mach: co the stf dung tinh mach ron de truyen dich, cung cap ntfdc, dien giai va nang ltfdng cho benh nhan
- Danh gia dung tinh trang benh nhan: can nang, tinh trang nhiem khuan, cac di tat phoi hdp, c h in doan the loai teo thtfc quan Ttf de chi dinh thdi diem me, cac dieu tri can co trtfdc mo, chon loai ky thuat mo, mo mot thi hay mo nhieu thi
10.2 M o
10.2.1 Ltfa chon phtfcfng phap mo mot thi hay nhieu thi
Chi dinh mo co chan doan teo thtfc quan, toan trang ttfdng doi on dinh, danh gia dtfdc cac di tat phoi hdp
Co hai loai p h iu thuat dtfdc chi dinh: phau thuat mot thi va p h iu thuat nhieu thi
10.2.2 Phau thuat m ot thi
- Chi dinh khi:
Hai dau thtfc quan gan nhau, co the noi dtfdc, tinh trang toan than on dinh, khong co viem phoi va cac di tat nang phoi hdp
•> - Ky thucit md:
Nguyen t ic ky thuat: C it, khau lai dtfdng ro d quan va noi hai d iu thtfc quan tan tan
Ky thuat thudng thtfc hien dtfdc tui cung tren cua thtfc quan d dot sdng ngtfc IV, III, II va co ro 'khl - thtfc quan:
+ D if (frig mo:
Dtfdng ngtfc sau ben theo khoang lien stfdn III hoac IV ben phai, ngoai phe mac
(10)Sau rach da, da c lt va tach ldp cd d ngtfc dung dao dien cat dan lopcdo khoang lien stfdn tdi phe mac De tranh rach phe mac luc p h iu tich chung tdi thtfdng tach phe mac khoi ngtfc d vi tri cuoi dtfdng mo ve phia ltfng trtfdc r6i tach dan len phfa tren, boc tach phe mac b ln g ngon tay va tam pon nho
Dung Ecarteur Finochietto md rong vet mo va van mem day mang phoi-ph6 sang trai du boc lo vung can phau tich
+ Cach tim hai dau thtfc quan va dtfdng r6 thtfc quan: tim tinh mach Azygos, p h iu tich tach va dung chi catgut de keo tinh mach Azygos len Dau dvfdi thtfc quan thtfdng d dtfdi tinh mach Azygos va thtfdng thong vdi quan mat sau tren cho chia hai phe quan goc O thi thd vao, dau dtfdi thiic quan thtfdng phong len ttf quan sang Chung toi thtfdng dtfng chi PDS -0 khau v it thtfc quan sat quan de ng&n khong ttf quan sang thtfc quan, sau mdi tim dau tren thtfc quan b ln g cach nhd bac si gay me day sau ong thong dat qua mui vao thtfc quan Phau tich giai phong lam dai toi da thtfc quan dau tren de tfdc tinh khoang cach gitfa hai dau thtfc quan Tiep tuc p h iu tich tach thtfc quan phia dtfdi de keo len tranh c&ng m ieng noi Bao ve cac mach mau tdi thtfc quan C lt rdi thtfc quan dau dtfdi khoi quan va kMu v it lai mieng dtfdng c lt sat quan b ln g chi PDS -0
+ Ndi hai dau thtfc quan: dau tren thtfc quan thtfdng to, day cap mau tot dau thtfc quan dtfdi thtfdng nhd, mdng Md d l u tren thtfc quan va md rong dau thtfc quan dtfdi Noi hai dau thtfc quan tan tan mot ldp toan the Chung toi thtfdng dtfng chi PDS -0 khau mui rdi, khau mat sau trtfdc vdi nut buoc ben trong, roi khau mat trtfdc vdi nut buoc ben ngoai Khi khau xong mat sau thi day ong thong plastic qua mieng noi vao da day
Ngoai cach khau m ieng noi nhtf tren, cd nhtfng cach khau khac nhtf:
* Khau mieng noi d mat trtfdc xong roi dtfng nut chi buoc d hai goc ben de quay ntfa m ieng ndi phia sau trtfdc de khau noi Sau dd quay lai mieng noi nhtf ban dau Nut chi buoc ben ngoai mieng noi
* Khau thtfc quan dau dtfdi vdi ldp niem mac cua thtfc quan d lu tren roi khau ldp thtf hai b ln g cach khau cd cua dau thtfc quan tren vdi thtfc quan ben dtfdi Cach hien it lam vi de gay hep m ieng noi
* Khau noi thtfc quan ta n -ben : it lam
Trong trudng hdp sau da p h iu tich tdi da hai dau thtfc quan ma cdn sd cang mieng noi thi lam them ky thuat Livaditis de lam dai them thtfc quan dau tren
Ky thuat Livaditis thifc hien nhif sau:
(11)Ngoai cach md mot vong cd nhif tren, c6n co the md nhieu vong co hay md thed vong xoan lo so
Sau noi thifc quan, dat dan lifu canh mieng no'i va cho hut lien tuc vdi ap life nhe Dan luu rut sau mo -
Theo chung toi, hien vdi dieu kien tot ve gay me, hoi siic va vdi du loai khang sinh manh, nen thtfc hien phau thuat mot thi neu khoang cach gitfa hai dau thuc quan teo ngan va co the noi dau thifc quan difdc Con phau thuat nhieu thi chi non thifc hien khong the noi dtfdc hai dau thtfc quan dd khoang cach gitfa hai dau thtfc quan xa
Stf ltfa chon phtfdng phap mo ttfy thuoc vao chan doan the loai teo thtfc quan Do vay, can co chan doan dung ve the benh trtfdc mo Dtfa vao phim chup can quang dau tren thtfc quan va chup bung, co the chon loai ky thuat mo mot hay nhieu thi
Xgoai phtfdng phap mo md tren, teo thtfc quan dtfdc mo bang noi soi
Hinh 3.7 Ky thuat mo teo thtfc quan
Cach mo: H1 T uthe benh nhan va duting rach da; H2 Tim hai dau thiic quan: dau tren (1),
dau difdi (2), tinh mach azygos; H3 cat dau dudi thuc quan khoi quan, khau lai quan;
H4 Noi dau quan tan tan; H5 Ky thuat Livaditis
(12)10.2.3 Phau thuat nhieu thi
- Chi dinh khi:
Nhieu di tat nang phoi hdp Viem phoi nang
Hai dau thiic quan teo xa nhau, khong the noi difdc Teo thifc quan nhifng khong co ro - thifc quan
- Ky thuat mo nhieu thi:
+ Thi m ot: Tuy theo the benh, tinh trang benh nhan, dieu kien mo, kinh nghiem cua phau thuat vien ma co cac loai ky thuat sau:
* Md thong da day de nuoi difdng
* Md thong da day va dan lifu dau tren thifc quan da d co
* Md ngifc de cat va khau lai difdng rd d khf quan, ddng km dau dtfdi thuc quan, md thdng da day, dau tren thiic quan co the van de nguyen long ngiic hoac difa da d co
+ Nhiing thi sa u: thiic hien nhiing phan lai: Cat va khau ro khf quan neu co
Noi lai hai dau thiic quan
Tao hinh thay the thiic quan bang dai trang ngang, bang da day neu khong the ndi lai dtfdc hai dau thtfc quan
- Cach mo nhieu thi:
+ Cho the benh teo thiic quan, khong co ro kh i thiic quan:
Neu chup bung khdng thay cd hdi da day - ruot, xac dinh the benh khdng cd rd khf - thiic quan Cdn khoang cach giiia hai dau thiic quan teo chiia xac dinh difdc, cd the gan sat hoac cd the xa nhieu dot song mac du d iu tren thiic quan cd the d vi tri thap nhif dot song ngiic III hoac IV
*M o thi d a u: Chi md thdng da day ddn thuan de nuoi dtfdng
Neu cd the, mo chup can quang dau diidi thiic quan qua cho md thong da day de xac dinh khoang cach giiia hai dau Neu khoang cach giiia hai dau thiic quan ngan thi md ngiic de ndi hai dau thiic quan Cdn neu khoang cach gitfa hai dau thiic quan xa thi cung cd the mo dlin luu dau tren thiic quan da Cdn neu khdng thi tien hanh chup dau difdi thiic quan sau mo vai ngav
+ Cho the benh teo thiic quan co ro thiic quan nhiing khoang cach giiia hai dau thiic quan xa nhau:
Neu chup bung cd hdi da day - ruot, nhifng dau tren thiic quan d vi tri cao d dot song ngiic I hoac II, kha nang noi thiic quan la khdng difdc (vdi tui cung d vi tri dot song ngiic I) va noi kho, m ieng noi cang (khi tui cung d dot song nguc II)
(13)Md ngifc, cat va khau lai difdng rd - thiic quan, danh gia lai kha nang noi hai dau thuc quan Neu khdng noi difdc thi co the thuc hien mot trdng nhiing ky thuat sau:
* Ngay thi mo dau:
Khau kin dau difdi thuc quan, co dinh va danh da'u vi tri vao ngUc sau Md thong da day de nuoi dudng
Co the dan luu dau tren thUc quan da d co * Thi mo sau:
Co loai ky thuat: lam dai thUc quan dau tren de no'i vdi thifc quan dau dudi hoac tao hinh thay the thuc quan
Lam dai doan thifc quan tren bang hai ky thuat: • Phiidng phap Kimura:
Mo nhieu thi de keo dai thUc quan da dan lUu d da co M oi lan mo co the keo dai them — 3cm va dau thuc quan van dan lUu da ngUc Khi da keo dai them du dai can co, mo giai phong doan thuc quan dudi da va dua vao long ngUc de no'i vdi dau thifc quan dudi.
• Phiictng phap Howard - Myers:
Lam dai thuc quan d dau tren bang cach dat ong thong vao tui cung tren thuc quan de hut lien tuc hoac cach quang dong thdi day ong thong sau xuong de nong, lam dai dan thiic quan N goai lifdng cua nUdc bot cung co tac dung lam dai tui cung tren Tif - tuan sau, thuc quan dau tren thudng du dai de md tiep no'i hai dau thuc quan Xac dinh vi tri tui cung tren bang chup can quang
Hinh 3.8 Phtfdng phap H o w a rd -M y e rs
(14)Tao hinh thay the thtfc quan bang cac ky thuat sau:
- Bang dai trang ngang biet lap: dai trang dtfa len theo difdng dtfdi da ngo&i xtfdng tfc (hien rat it lam), theo dtfdng sau xtfdng tfc roi noi mot dau vdi thtfc quan d co mot dau noi vdi mat trtfdc da day, hoac theo dtfdng qua trung th£t Dtfa dai trang qua trung that la sinh ly nhat nhtfng ky thuat md phtfc tap hdn
- Bang mot quai hoi - dai trang biet lap
- Bang mot quai hoi trang co cuong mach va noi mach vi phau - Bang bd cong ldn cua da day (ky thuat Heim lich - Gavriliu) - B^ng dtfa da day len ngtfc
11 SA U M O
Thtfdng rut noi quan sdm benh nhan da ttf thd De ong noi quan lau la dieu kien thuan ldi tang nguy cd benh mem sun quan Hut cac chat xu£t tiet d mieng—hong
Ttf the benh nhan van nen dat d ttf the dau cao de tranh nguy cd trao ngtfdc ttf da day len
Nuoi dtfdng: bang dtfdng tinh mach — dau
Bdm stf a qua ong thong da day de nuoi dtfdng bat dau ttf thtf 1, sau mo vdi so ltfdng tang dan
Khang sinh: dtfng khang sinh loai cephalosporin the he Theo doi than nhiet, stf dung long ap neu cd
Cd md thong da day khong ?
Mot sd tac gia chu trtfdng md thdng da day mot cach he thdng de dtfa ong thdng xudng hong trang cho an
Mot sd tac gia khac lai chu trtfdng khdng md thdng da day ma chi dat dng thdng qua mui, mieng noi thtfc quan vao da day de cho an
Chung tdi thay md thdng da day cung cd nhtfng bien chtfng cua nd va dat dng thdng qua mui, m ieng ndi vao da day de bdm stfa nudi dtfdng la bien phap ddn gian nhtfng hieu qua va khdng bien chtfng, nen dtfdc ap dung
12 B IE N C H l/N G S A U M O M O T T H i
Noi thtfc quan va cat - khau dtfdng rd 12.1 B ien chufng sofm
- Thdng kem gay xep phoi, dieu tri bang thd may - Viem phdi: dieli tri bang khang sinh
(15)- Ro m ieng noi: thtfOng xay sau md - Bieu hien bang dau hieu ho hap va nhiem khuan Chup can quang thtfc quan xac dinh dtfdng ro
Neu ro nho, dat ong thong qua mieng noi thtfc quan de hut, dat lai dan ltfu ngtfc de hut lien tuc, md thong da day cho an, hut chat xuat tiet d mieng, hong Ket qua dieu tri thtfdng tot, het ro nhtfng co nguy cd bi tai phat lai rd thtfc quan va hep m ieng noi
Neu buc m ieng noi, md lai de dong kin dau dtfdi thtfc quan va dtfa dau tren thtfc quan da d cd Md thdng da day de nuoi dtfdng Thi md sau tad hinh thtfc quan
12.2 B ien chufng m u o n
12.2.1 Hep m ieng noi
Trtfdc het soi, nong m ieng noi, neu khong ket qua thi md lai de cat cho hep va ndi lai thtfc quan
12.2.2 Luong trao ngtfdc da day - thtfc quan: cung co the xay sdm
Nguyen nhan co the lam thtfdng tdn day than kinh phe vi md hoac co the phau ti'ch keo doan thtfc quan phia dtfdi len noi vdi thtfc quan dau tren
Thtfdng xay sau md the benh teo thtfc quan ma khoang cach gitfa hai dau thtfc quan xa va co ro dau dtfdi thtfc quan vdi quan
- Chan doan: bang chup thtfc quan - da day, sieu am, soi thtfc quan va do pH d dich trao ngtfdc len thtfc quan
- D ieu tri: trtfdc het la dieu tri noi khoa bang ttf the sau an, thudc giam tiet acide d djch da day, thudc bang boc bao ve niem mac thtfc quan va thuoc giam nguy cd trao ngtfdc
Cac thudc thtfdng dtfdc dung nhtf: motilium, prepulsit, gaviscon, phosphalugen v.v M otilium cd tac du ng gay tang co that d vung thtfc quan tam vj va md rong cd mon vj, tang co bop vung hang vj da day de day thtfc an da day xu ong ta trang
G aviscon vao da day thi tan va ndi len tren be mat cua djch da day Khi djch da day trao ngtfdc len thtfc quan thi Gaviscon len theo va trang - boc niem mac thtfc quan nen bao ve dtfdc niem mac tranh loet
- Chi dinh dieu tri ngoai khoa khi:
+ Dieu trj noi khdng ket qua
+ Viem thtfc quan lien tuc ton tai, nguy cd cao gay hep m ieng ndi + Cd benh mem sun quan phoi hdp
Mo de tao van chong trao ngtfdc da day - thtfc quan Tao van theo ky thuat Nissen hoac T upper hoac Thai
(16)12.2.3 Mem sun quan
Bieu hien bang xep vong sun quan d thi thd H ay gap khi teo thuc quan co ro thtfc quan va rat hiem gap teo thtfc quan kh on g co ro khi thtfc-quan
Nguyen nhan gay benh co the stf chen ep bdi tui cung tren thtfc quan gian to, ro dich da day qua lo ro, lo ro lam gian doan ldp xd chun d quan Sun quan mem thtfdng khu tru
12.2.4 Rd - thuc quan tdi p h a t
Ro - thtfc quan tai phat sau mo it gap N guyen nhan n h ilm trung cho mieng noi va cho quan dtfdc khau
Benh bieu hien bang dau hieu viem phoi lien tuc, co the co ho, sac bu. Chan doan bang soi thtfc quan, soi va chup phe quan can quang Dieu tri bang phau thuat
13 TIEN L tfd N G
Phu thuoc vao can nang, mtfc viem phoi, cac di tat khac phoi hdp va mile nang nhe cua di tat Theo mot thong ke thi:
- Neu can nang > 2500g, khong viem phoi, khong di tat phoi hdp, d the benh co the noi thtfc quan dtfdc thi ty le song sau mo dat tdi 90%
- Neu can nang ttf 2000 g - 2500g, viem phoi nhe, cd di tat nhe phoi hdp thi ty le song sau mo vao khoang 70 %
- Neu can nang < 2000g, cd di tat nang kem viem phoi nang thi ty le song sau mo chi dat khoang 20%
TAI L IE U T H A M K H A O
1 Bargy F.: Atresie de l’oesophage In: Helardot.P, Bienaym e J., Bargy F., Carcassonne M 1990
Chirurgie digestive de l'enfant, pp 117 -1 Doin editeurs - Paris
2 Bettex M, Kuffer F Sharli: Atresie de l'oesophage In: Bettex M., Kuffer F., Scharli A Precis de chirurgie infantile, pp 87 - 91 M asson, Paris 1978
3 Carroll M Harm on, Arnold G Coran (1998): C ongenital Anom alies of the Esophagus In: Jam es A O ’Neill, Jr., M arc I Row e., Jay L G rosfeld., Enc W Fonkalsrud., Arnold G.Coran Pediatric surgery, V olu m e 1, th Edition, pp 941 - 967 M osby— St Louis
(17)4 Jaubert de Beaujeu.M: Atresie de l’cesophage In: Pellerin D Techniques de chirurgie pediatrique, pp 176-186 Masson, Paris 1978
5 M icheal E H urllwarth, Paola Zaupa: Oesophageal Atresia In: P.Puri, M.E H urllwarth Pediatric Surgery, pp 29-48 Spinger - V erlag Berlin Heidelberg Germany 2006
6 Nguyen Thanh Cong, Tran Ngoc Bich, Nguyen Thanh Liem: Ket qua dieu tri teo thtfc quan tai Vien Nhi Ha Noi 1997— 1999 2000
Nhi khoa (Ky yeu cong trinh nghien ciiu khoa hoc) tr 532 — 537
(18)2 THOAT V| HOANH
1 D IN H N G H IA
Thoat vi hoanh la stf di chuyen cac tang o bung vao long ngtfc qua mot lo bam sinh hoac mac phai cua cd hoanh
2. B E N H S IN H H O C
2.1. Di tat bam sinh
Gom cac nguyen nhan sau:
- Ton tai dng Phe - phuc mac: thieu trung md dem gitfa phe phuc mac, tao khuyet hong d cd hoanh, qua dd cac tang d o bung chui len khoang mang phoi (thoat vi Bochdaleck)
- Co dinh long leo cua thtfc quan bung gay Thoat vi qua khe thiic quan.
- Cdn khe Larrey: thoat vi canh tfc hay sau mui tfc - stfdn hoac Thoat vi Morgagny.
2.2. T h oat vi h o an h m ac phai Gom cac nguyen nhan sau:
- Sau vd mot o ap xe dtfdi hoanh vao khoang mang phoi qua cd hoanh - Vd cd hoanh chan thtfdng
- Nhao cd hoanh (relaxation - eventration): cd ca nguyen nhan bam sinh va mac phai
C) ben trai: thtfdng bi toan bo cd hoanh
O ben phai: thtfdng chi bi mot phan cd hoanh
4
Hinh 3.9 Co hoanh va cac 16 thoat vj
1 Lo cua tinh mach chu dudi; Khe thi/c quan; Lo dong mach chu; Khe Larrey; Tam giac su'dn lutig, Lo dc su'dn hay Id sau mui dc sifdn (thoat vj Morgagni);
(19)3 T H O A T VI H O A N H Q U A O N G PHE P H U C M A C
La thoat vi bam sinh qua lo sau ben: thoat vi Bochdaleck 3.1 T he giai phau
Vi tri lo thoat vi d ranh ben cua cot song, co dtfdng kinh ttf 3cm tdi mot phan vom hoanh
Thoat vi ben trai gap nhieu hdn phai Cac tang thoat vi:
Ben trai: da day, lach, ruot non, ruot gia, thuy gan trai, than trai Ben phai: gan (co the dai trang hoac ruot non)
Co tui thoat vi la thoat vi thtfc stf, nhtfng cung co the khong co tui thoat vi Phoi ben thoat vi: thtfdng bi bien dang, xep, giam sinh
Ruot quay bat thtfdng co the kem theo 3.2 S in h ly benh
Sau de, tre nuot khong Khong vao da day, ruot bi thoat vi va ep vao phoi, day tim sang ben doi dien va ep vao phoi ben dan tdi roi loan trao doi khi: ap luc oxy dong mach giam, ap ltfc C 2cua dong mach tang, gay toan mau Nhung bien loan lam tang stfc can cua mach mau phoi va lam tang shunt (noi tat) phai-trai qua ong thong dong mach hoac qua lo bau due
Neu cac tang thoat vi dtfdc dtfa xuong o bung thi phoi gian nd, qua trinh tren co the trd lai binh thtfdng
Neu benh nhan co phoi giam sinh nang van co the chet sau mo 3.3 L am sa n g : tuy theo dien bien benh ma chia cac the benh sau
3.3.1 The cap tinh
Thtfdng gap d sd sinh vdi cac trieu chtfng
- Suy ho hap: tim moi, co cac cdn kho thd dac biet nang len an stfa, co keo cd ho hap
- Ngtfc go, bung lom
- Nghe phoi (ben bi benh): ri rao phe nang mat hoac giam, tim bi day sang ben ddi dien, cd the nghe dtfdc tieng "loc soc" cua ruot
- The trang yeu
3.3.2 The ban ccip
Thtfdng d tre bu me va tre nhd
- Benh khoi phat m uon va it tram hdn the cap ti'nh Kho thd tang dan, tim tai, co keo cd hd hap, hay xay sau an
(20)- 6 the nhe hdn: co the bieu hien:
+ Thtfdng bi nhiem khuan dtfdng ho hap + Roi loan tieu hoa: ia phan long
+ Hoi chtfng kem hap thu lam tre cham tang can + Tim bi chen ep, bi day sang ben doi dien
3.4 X q u a n g
3.4.1 Chup nguc
Bong tim bi day sang ben doi dien Hdi cua ruot va da day d 16ng ngtfc Cd hoanh ben thoat vi khong co
3.4.2 Chup cdn quang ong tieu hod - Chup da day ruot non:
Thay hinh da day, ruot d tren 16ng ngtfc
- Chup khung dai trdng (Chi dinh chup da day ruot non khong ro thoat vi) Thay hinh dai trang d tren long ngtfc
Hinh 3.10 Ruot non len khoang mang phoi trai 3.5 C han d oan trtfdc sinh va ch an d oan p h a n b iet
3.5.1 Chan doan trudc sinh