- Ap xe tuy.
4.5.2.Dieu trj ngoai khoa
3. PHAN LOAI VIEM TUY MAN
4.5.2.Dieu trj ngoai khoa
Doi vdi viem tuy man va soi tuy thi dieu tri ngoai khoa ngay cang co khuynh htfdng diidc quan tam va phat trien. Benh nhan den benh vien da phan vdi trieu chiing dau bung ma dieu tri noi khoa, cac thuoc khong ket qua thi phau thuat la mot liia chon mang tinh tich ciic va co hieu qua. Dau trong viem tuy man dude biet do nhieu nguyen nhan nhii do to chiic xd phat trien chen ep cac nhanh than kinh, do chit hep doan cuoi ong mat chu, vi to chiic xd lam cho li mat vang da, do chen ep mach, chen ep mon vi ta trang... nhiing mot nguyen nhan diidc coi la “ nhan to' can ban gay ra sii dau” do la tang ap liic trong ong tuy.[4,6]. Day co le cung la cd sd de thiic hien nhiing giai phap phau thuat phan liiu tuy trong dieu tri viem tuy man va soi tuy4.5. Chi dinh phau thuat:
Chi dinh Phau thuat doi voi benh nhan VTM va soi tuy can phai can nhac diia tren nhieu yeu to" de di den quyet dinh quan trong do la phau thuat.
Co nhieu quan diem co the cho la trai ngiidc nhau trong van de dieu tri viem tuy man. Carter va Trede[7] cho rang Viem tuy man khong phai la mot benh phau thuat ma chu yeu do la benh Noi khoa.Vi phau thuat khong the dao ngiidc qua trinh ton thiidng huy hoai dan cau true tuy.Tuy nhien khoang tren 40% so benh nhan sau qua trinh dieu tri bang cac thuoc giam dau, an kieng, bu men tuy... nhiing van khong co ket qua va cuoi cung lai diidc dieu tri phau thuat.
Cung co y kien cho rin g Viem tuy man khong the dieu tri noi khoa ma hau het phai phau thuat.
Carter va Trede [7] cho rang chi dinh phau thuat VTM nham 3 muc dich chinh;
- Giam dau
- Giai quyet cac bien chiing cua benh
- Nghi ngd mot carcinoma tuy trong khi hien thdi chiia co kha nang loai trii triidc phau thuat
Trong do nhiing bien chiing diidc ke den: - Tac mat
- Hep, tac ta trang hay dai trang - Tac ong tuy
- U nang gia - Chay mau tuy - Ro tuy
Dtfa vao nhiing triidng hdp cu the ma liia chon, chi dinh nhiing phiidng phap phau thuat khac nhau.
4.5.2.1. Phtfong phap d in ltfu ong tuy
Dtfdc Duval tien hanh nam 1954, bao gom cat duoi tuy +cat lach sau do noi tuy - ruot. Ngay nay phau thuat nay it dtfdc ap dung vi dau tai phat co le vi mieng noi tuy ruot bi hep lai.
Hinh 4.17. Phau thuat Duval [ 13 ]
ruot tren quai Y vdi muc dich dan ltfu tuy ra phia sau. Tuy nhien phtfdng phap nay sau mo nhanh chong tai phat [13,14] Nhieu tac gia nhan ra rang nguyen nhan do hep tai phat mieng noi vi trong Duval thi van ton tai ong tuy vdi khau kinh nho. Chung toi co 2 trtfdng hdp dtfdc ap dung khi cat duoi tuy c lt lach do ton thtfdng khu tru vung duoi tuy.Chung toi nhan thay trong 2 benh nhan nay deu dat ket qua sdm giam dau to'. Danh gia cua cac tac gia thi ket qua giam dau khoang 80%[14,16].
4.5.2.2. PhL/ang phap phau thuat noi tuy ruot ben - ben
Ky thuat Puestow &Gillesby thiic hien (1960). Co mot sii cai tien trong phufdng phap nay de khac phuc tinh trang hep mieng noi tai phat.Tien hanh cat lach va md rong duoi tuy. thay vi mot mieng noi tuy ruot theo chieu tan - tan thanh mot mieng noi theo chieu ben ben
Hinh 4.18 PT Puestow& Gillesby
Tuy tao diidc mot mieng noi rong hdn nhiing (Puestou& gillesby)con mang mot.Nhiidc diem 16n nhat do la v in phai cat bo lach trong phau thuat va the la lai co mot sii cai tien trong phau thuat noi tuy ruot.
PhUdng phap nay diidc da so cac p h iu thuat vien lia chuong hdn vi ong tuy diidc md rong ra, sau khi lay soi tuy se
noi tuy ruot.Hdn nufa trong phau thuat nay lach diidc bao ton thi se loai tru! diidc nhiem trung huyet sau c it lach.Hien nay chung toi thiidng lam phau thuat nay.
Jeju n u m 4Jejuno- jejunostorrry restores continuity of Gl tract PancfCdt*CO)C5ur>ostomy allows pone. ju < e to enter jejunum Sccton^l ww o f ( V l T K f r M « > K .u n o s t o m y
Hinh 4. 19. Phau thuat noi tuy- ruot ben - ben (Parington, Rochelle - 1960)
4.5.2.3. PhUOng phap phiu thuat Frey[13]: cung diia tren quan diem cua Parington va Rochell do la dan liiu tuy rong rai duoc Frey (My) cong bo' nam 1987. P h iu thuat nay diidc ap dung lan dau tien tai benh vien Viet Diic nam 2002.[2] va da p h iu thuat cho nhieu triidng hdp.