1

B Y T

S: 3338 /Q-BYT

CNG HA X HI CH NGHA VIT NAM

c lp- T do- Hnh phc

H Ni, ngy 09 thng 9 nm 2013

QUYT NH

V vic ban hnh Hng dn Quy trnh k thut

khm bnh, cha bnh chuyn ngnh Ung bu

B TRNG B Y T

Cn c Ngh nh s 63/2012/N-CP ngy 31/8/2012 ca Chnh ph quy

nh chc nng, nhim v, quyn hn v c cu t chc ca B Y t;

Xt Bin bn hp ca Hi ng nghim thu Hng dn Quy trnh k thut

khm bnh, cha bnh chuyn ngnh Ung bu B Y t;

Theo ngh ca Cc trng Cc Qun l Khm, cha bnh,

Quyt nh:

iu 1. Ban hnh km theo Quyt nh ny 279 Hng dn Quy trnh k

thut khm bnh, cha bnh chuyn ngnh Ung bu.

iu 2. Cc Hng dn Quy trnh k thut khm bnh, cha bnh chuyn

ngnh Ung bu ny p dng cho tt c cc c s khm bnh, cha bnh c

iu kin thc hin theo quy nh hin hnh.

iu 3. Quyt nh ny c hiu lc t ngy k v ban hnh.

iu 4. Cc ng, B: Chnh Vn phng B, Cc trng Cc Qun l Khm, cha bnh, Chnh thanh tra B; cc V trng, Cc trng cc V, Cc

ca B Y t; Gim c cc Bnh vin, Vin c ging trc thuc B Y t, Gim

c S Y t cc tnh, thnh ph trc thuc trung ng; Th trng Y t cc B,

ngnh v Th trng cc n v c lin quan chu trch nhim thi hnh Quyt nh

ny./. Ni nhn: - Nh iu 4;

- B trng ( bo co);

- Lu: VT, KCB.

KT. B TRNG

TH TRNG

k

Nguyn Th Xuyn

2

B Y T CNG HA X HI CH NGHA VIT NAM c lp - T do- Hnh Phc

DANH MC HNG DN QUY TRNH K THUT

KHM BNH, CHA BNH CHUYN NGNH UNG BU (Ban hnh km theo Quyt nh s: 3338/Q-BYT ngy 09 thng 9 nm 2013

ca B trng B Y t)

STT HNG DN QUY TRNH K THUT

1 Phu thut s dng vt rnh mi m to hnh khuyt hng sau ct b ung

th sn ming

2 Phu thut ton b tuyn gip trong iu tr ung th

3 Phu thut vt hch c trit cn

4 Phu thut ct b khi u trung tht

5 Phu thut ct u nang ph qun (u nang phi)

6 Ct mt thu phi v mng thnh ngc trong ung th

7 Ct mt thu phi do ung th

8 M ngc thm d trong ung th phi

9 Phu thut ct b u nang mng tim

10 Phu thut ct u sn ph qun

11 Phu thut bc kn mng phi

12 Phu thut ct kn kh phi

13 Phu thut bc u thnh ngc

14 Phu thut ct u xng sn

15 Phu thut ni soi lng ngc ct b khi u trung tht

16 Sinh thit kim xuyn thnh ngc di hng dn ca chp ct lp in ton

17 Sinh thit m xuyn thnh ngc bng kim nh (Da vo phim ct lp vi

tnh)

18 Ct thc qun do ung th to hnh thc qun bng d dy- phu thut

LEWIS-SANTY

19 Ct on trc trng do ung th, ct ton b mc treo trc trng (TME)

20 Ct ct trc trng ng bng tng sinh mn

21 Ct trc trng gi li c trn

22 Ct u trc trng ng hu mn ng di

23 Ct bn phn d dy cc di do ung th v vt hch h thng D2

3

24 Ct ton b d dy do ung thu v vt hch h thng D2

25 M thng d dy nui dng

26 Ct khi t tu do ung th u tu

27 Phu thut ct ton b tuyn tin lit, ti tinh v bng quang

28 Phu thut ct ton b b phn sinh dc ngoi ca nam gii do ung th

29 Phu thut ct ton b b phn sinh dc ngoi ca nam gii do ung th v

vt hch bn hai bn

30 Phu thut ct ton b bng quang km to hnh bng quang bng rut trong

iu tr ung th bng quang

31 Phu thut ct ton b bng quang km to ti cha nc tiu bng mt

quai rut non

32 Ct b thn ung th c hoc khng vt hch

33 Ct c hai tinh hon iu tr ung th tin lit tuyn

34 Phu thut ni soi ct, t ung th bng quang nng kt hp vi bm BCG

ni bng quang

35 K thut ct bung trng trong iu tr ni tit ung th v

36 K thut ti to tuyn v sau phu thut ung th v

37 Phu thut ct tuyn v vt hch nch

38 Ct mt phn tuyn v, vt hch nch

39 K thut sinh thit hch ca (Sentinel node biopsy) bng ch th mu trong

nh gi di cn hch nch ca ngi bnh ung th v

40 Sinh thit tn thng tuyn v bng sng sinh thit

41 Sinh thit tn thng tuyn v c nh v bng kim dy

42 Phu thut u x tuyn v

43 X tr bng my gia tc

44 X tr ngoi ung th v

45 X tr p st iu tr ung th c t cung

46 X tr p st liu thp

47 X tr p st liu cao

48 Ra m o, c t cung trc x tr

49 X tr p st liu cao ung th vm hng

50 X tr iu bin liu ung th vm hng

51 X tr bnh ung th h hng

52 X tr ung th tuyn yn

53 o, chun liu chm Electron (in t) dng trong x tr

54 o, chun liu trong k thut iu bin chm tia vi h Collimator c lp

(JO-JAW ONLY)

55 o, chun liu trong k thut iu bin chm tia vi h Collimator a l -

4

MLC (Multi Leaf Collimator)

56 Lp k hoch x tr p st bng my m phng

57 Chun liu hp th trong mi trng tng ng m c th

58 khun c ch che chn, bo v cc c quan quan trng trong trng

chiu x

59 Lm mt n c nh u c

60 M phng lp k hoch x tr

61 Lp k hoch x ngoi bng my m phng

62 nh v trng chiu x trn da ngi bnh

63 Lp k hoch x tr bng my vi tnh (TPS)

64 Truyn ho cht tnh mch trung tm qua bung tim

65 Truyn ho cht nhanh (Bolus)

66 iu tr ho cht bng ng ung

67 X tr cho ngi bnh b phn ng khi tim truyn thuc ho cht

68 Chm sc v iu tr cho ngi bnh c nn v bun nn do ho tr

69 Chm sc v iu tr cho ngi bnh vim nim mc hng ming do ho tr

70 Phng v x tr bin chng thot mch trong khi ho tr

71 iu tr ho cht v x tr ng thi

72 Thng kh trong phu thut ung th kh ph qun

73 Gy t khoang mng phi gim au sau m ung th vng lng ngc

74 Gy t ngoi mng cng phi hp gy m trong m u vng lng ngc

75 K thut gy t ngoi mng cng gim au sau m ung th

76 Quy trnh nh gi ngi bnh trc phu thut ung th phi

77 Thm d chc nng ti mu phi trong ung th bng SPECT

78 Ni soi chn on ung th ng tiu ho trn

79 Ni soi chn on ung th i trc trng

80 Mt s k thut xt nghim ch im khi u

81 nh lng PRO-GRP (Pro-Gastrin Releasing Peptid)

82 nh lng CA 72-4 (Cancer antigen 72-4)

83 nh lng CA 19-9 (Carbohydraqte antigen 19-9)

84 nh lng CYFRA 21-1 (Cytokeratin fragment)

85 nh lng HE4 (Human Epididymal Protein)

86 nh lng Tg (Thyroglobulin)

87 nh lng FREE PSA (Free Prostate-Specific Antigen)

88 Chp x quang tuyn v

89 Chp ng tuyn sa cn quang

5

90 Chp v nh v kim dy dn hng sinh thit m

91 Siu m tuyn v

92 Siu m hch nch

93 Siu m v dn hng sinh thit kim

94 Xt nghim t bo hc

95 Sinh thit v c nh bnh phm

96 K thut m hc thng quy nhum Hematoxylin v Eosin (HE)

97 Sinh thit tc th (Sinh thit ct lnh)

98 K thut nhum PAS (Phn ng acid Periodic-schiff)

99 Nhum PAPANICOLAOU

100 K thut xt nghim ho m min dch

101 Phu thut ct u nang vng c

102 Phu thut ct u v r ca nang gip mng (phu thut SISTRUNK)

103 Phu thut ct mt thy gip trng

104 Phu thut vt hch c chn lc

105 Phu thut ct b u sng hm

106 Phu thut ct li bn phn trong iu tr ung th li

107 Phu thut ct u v bao dy thn kinh schwannoma vng c

108 Ct mt thu phi km ct mt phn thu phi khc in hnh do ung th

109 Ct mt bn phi do ung th

110 Ct mng thnh ngc trong u mt hoc nhiu xng sn

111 Ct ton b i trng do ung th km vt hch h thng

112 Ct on i trng sigma do ung th c vt hch h thng

113 Ct on i trng ngang do ung th vt hch h thng

114 Ct na i trng phi do ung th km vt hch h thng

115 Ct na i trng tri do ung th km vt hch h thng

116 Phu thut ni soi ct ton b d dy do ung th v vt hch h thng D2

117 Ct bn phn d dy cc di do ung th v vt hch h thng D2 bng

phu thut ni soi

6

118 Phu thut ni soi ct ung th i trng phi

119 Phu thut ni soi ct ung th i trng tri, i trng sigma

120 Phu thut ni soi ct ct ung th trc trng

121 Phu thut ni soi ct on ung th trc trng

122 Phu thut ni soi ct thc qun do ung th to hnh thc qun bng d dy

123 Ct d dy ton b do ung th v vt hch

124 Ct ton b d dy do ung th c to hnh bng rut non

125 Ct li i trng do ung th

126 Phu thut cc khi u sau phc mc

127 Phu thut ct u mc treo (km theo ct rut non)

128 Phu thut ct u mc treo (khng ct rut non)

129 Phu thut ung th dng vt vt hch bn hai bn

130 Phu thut ly u trong dy chng rng

131 Phu thut ly u y chu v u tiu khung

132 Phu thut ct bung trng, hai phn ph trong iu tr ung th v

133 Phu thut Wertheim Meig iu tr ung th c t cung

134 Phu thut ung th bung trng

135 Ct t cung ton b + vt hch chu hai bn

136 Phu thut ct u thnh m o

137 Ct c t cung cn li trn ngi bnh m ct t cung bn phn

138 No bung t cung

139 Khot chp c t cung

140 Ct m h n thun

141 X tr gia tc a phn liu trc phu thut ung th trc trng

142 X tr Coblalt -60

143 X tr ngoi cc ung th no tr em

7

144 X tr ung th tin lit tuyn

145 X tr u nguyn bo thn tr em (u Wilms)

146 X tr ngoi gim au do di cn xng

147 X tr ung th dng vt

148 X tr nng bng tia X

149 X tr Ulympho c tnh tr em

150 X tr trng chiu rng iu tr Ulymph c tnh

151 X phu

152 Chp x hnh xng

153 Chp x hnh tuyn gip

154 Chp hnh chc nng thn

155 Chp x hnh hnh th thn vi DMSA

156 Chp x hnh u mao mch gan vi hng cu 99m

Tc

157 Chp x hnh khi u vi 99m

Tc

158 Chp x hnh khi u tuyn v vi 99m

Tc - MIBI

159 iu tr ung th gip trng th bit ha sau phu thut bng I131

160 Chp hnh chc nng c tim

161 Chun h thng my o liu dng trong x tr

162 o, chun liu cc ngun dng trong x tr p st

163 o liu Invivo (kim tra liu lng x tr ung th)

164 Kim chun, nghim thu k thut h thng my gia tc x tr

165 Kim sot v m bo cht lng, x tr ung th

166 o liu tng i

167 o liu tuyt i

168 o, chun liu vt l h thng my gia tc tr sau lp t (Commissioning)

8

169 o, chun liu cc chm Photon (Tia - X) nng lng 6 MV

170 o, chun liu cc chm Photon (Tia - X) nng lng 15 MV hoc ln hn

171 o, chun liu chm tia Gamma ngun Cobalt 60 dng trong my x tr

ngoi.

172 ng dng bung ion ho phng, song song o liu chm electron t my

gia tc x tr

173 ng dng bung ion ho hnh tr o liu chm electron (in t) t my gia

tc x tr

174 Kim tra cho (Audit check) trong tnh phn b liu x tr ngoi.

175 Kim sot liu chiu x vi nhn vin x tr, chn on hnh nh v y hc

ht nhn.

176 Gy dnh mng phi bng ho cht

177 Truyn ho cht tnh mch ngoi vi

178 Truyn ho cht tnh mch trung tm qua catheter

179 Bm truyn ho cht lin tc (12 - 24 gi) vi my infuso Mate - P

180 Chm sc v iu tr cho ngi bnh ha tr c km theo bnh l tim mch

181 Chm sc v iu tr cho ngi bnh ha tr c km theo bnh l v gan

182 iu tr ho cht cho nhng ngi bnh c km theo bnh l v thn

183 iu tr ho cht cho ngi bnh c virut HIV

184 iu tr ho cht cho ngi bnh cao tui

185 Chm sc v iu tr cho ngi bnh ha tr c h bch cu

186 Chm sc v iu tr cho ngi bnh c bin chng h tiu cu do ho tr

187 Chm sc v iu tr cho ngi bnh c bin chng tiu chy do ho tr

188 Chm sc v iu tr cho ngi bnh b to bn do ho tr

189 Chn on v iu tr hi chng ly gii u do ha tr

190 Phu thut t bung tim truyn di da

9

191 K thut t bung tim truyn ngoi da

192 Tim ha cht ni ty sng

193 Thng kh mt phi trong phu thut ung th vng lng ngc

194 Ct Polype ng tiu ho trn qua ni soi ng mm

195 Ct Polype i trc trng qua ng ni soi ng mm, phi hp kp clip vi

nhng polype cung ln.

196 K thut ni soi chn on ung th ng h hp

197 K thut ct ung th bng quang nng qua ng ni soi ng niu o

198 Sinh thit kim chn on m bnh hc tn thng thn di hng dn ca

siu m

199 Sinh thit kim chn on m bnh hc tn thng thn, ty, tuyn thng

thn di hng dn ca chp ct lp vi tnh

200 Siu m tuyn gip

201 Siu m dn hng chc ht t bo bng kim nh chn on tn thng

gip trng

202 Siu m chn on hch bnh l ngoi vi

203 Sinh thit kim chn on m bnh hc hch bnh l ngoi vi di hng

dn ca siu m

204 Sinh thit kim chn on m bnh hc cc tn thng u- hch bng khng

thuc tng di hng dn ca siu m

205 Sinh thit kim chn on m bnh hc cc tn thng u- hch khoang sau

phc mc di hng dn chp ct lp vi tnh

206 Phu thut ly hch c chn on v iu tr

207 Phu thut ct ton b tuyn mang tai bo tn dy thn kinh VII

208 Phu thut ct chu sn ming trong ung th sn ming

209 Phu thut ct ton b u tuyn nc bt di hm

210 Phu thut ct ton b thanh qun

211 Phu thut ct u nang tin nh mi

212 Phu thut ct ung th Amidan

10

213 Phu thut ct u mng tim

214 Sinh thit u phi, u trung tht qua phu thut ni soi lng ngc

215 Ct hai thy phi km vt hch trung tht

216 Phu thut ct nhu m phi khng in hnh do ung th

217 Phu thut ct u nang trong nhu m phi

218 Ct d dy li do ung th

219 Phu thut ni soi ct h phn thy gan

220 Phu thut ct chm nang gan

221 Ct gan phi do ung th

222 Ct gan tri do ung th

223 Phu thut ni soi ct gan ln

224 Ni mt-Hng trng do ung th

225 Tht ng mch gan iu tr ung th hoc chy mu ng mt

226 Ct chm nang gan bng ni soi

227 Ct lch bnh l, ung th, p xe

228 Phu thut ung th m h m vt

229 Bc nang tuyn Bartholin

230 Phu thut ct ct cnh tay (trong iu tr ung th)

231 Tho khp na bn chn trc do ung th

232 Tho khp c chn do ung th

233 Thc hnh x tr ung th u c

234 K thut x tr ung th tuyn gip

235 X tr cho khi u no c tnh nguyn bo thn kinh m: Anaplastic

astrocytoma v glioblastoma multiorme

236 X tr ung thu di cn no

237 iu tr p st trong ung th khoang ming

238 iu tr p st trong ung th sn ming

239 iu tr tia x i vi u lymph c tnh nguyn pht no

240 X tr trit cn ung th da vng u c (loi ung th biu m t bo vy v

ung th biu m t bo y)

241 U lymph c tnh

242 X tr b tr ung th da vng u c (loi ung th biu m t bo vy v

ung th biu m t bo y)

11

243 X tr cho cc khi u ngoi nhn cu

244 X tr cho cc khi u ni nhn cu

245 X tr ngoi ung th thc qun

246 iu tr ho cht liu cao v kt hp vi truyn t bo gc d gien

247 Chm sc v iu tr cho ngi bnh gim s ngon ming do ho tr

248 Chm sc v iu tr cho ngi bnh c c tnh thn kinh ngoi vi do ha

tr

249 Chm sc v iu tr cho ngi bnh c c tnh trn da do ho tr

250 Bm ho cht mng phi

251 Truyn ho cht ng mch

252 Truyn ho cht tnh mch ngoi vi

253 Tim truyn ho cht vo mng bng iu tr ung th

254 iu tr ha cht liu cao kt hp vi truyn t bo gc t thn

255 K thut chm sc ngi bnh ung th giai on cui (cn t)

256 nh gi ton trng ngi bnh ung th

257 iu tr gim au bng thuc

258 nh gi au

259 S dng Morphin tim di da bng bm tim in

260 S dng Morphin cho ngi bnh kh th

261 Cp cu ng c Morphin

262 S dng Morphin ng ung

263 S dng ming dn Fentanyl

264 Cp cu tc rut ni khoa ngi bnh ung th giai on cui

265 Cp cu ngi bnh di cn xng ct sng c chn p ty sng

266 Ni soi bng quang

267 Sinh thit ty xng

268 Xt nghim t bo trong dch no ty

269 Xt nghim t bo trong dch mng phi

270 nh nhm mu h ABO, RhD bng phng php Gelcard

271 Pht mu bng phng php Gelcard

272 Xt nghim t bo hc c t cung bng k thut thin PREP

273 Nhum SISH (Ventana)

274 Xt nghim Fish

12

275 Xt nghim xc nh t bin Gen EGFR v K-RAS bng gii trnh t

chui AND trn khi PARAFFIN

276 Sng lc pht hin sm ung th khoang ming

277 Sng lc pht hin sm ung th i trc trng

278 Sng lc pht hin sm ung th v

279 Sng lc pht hin sm ung th c t cung

( Tng s: 279 quy trnh k thut)

KT. B TRNG

TH TRNG

k

Nguyn Th Xuyn

13

MC LC

TT Tn bi Trang

I. u - mt - c

1. Quy trnh sng lc pht hin sm ung th khoang ming

2. Phu thut ly hch c chn on v iu tr

3. Phu thut vt hch c trit cn

4. Phu thut ct u nang vng c

5. Phu thut vt hch c chn lc

6. Phu thut ct li bn phn trong iu tr ung th li

7. Phu thut s dng vt rnh mi m to hnh khuyt hng sau ct b ung th sn ming

8. Phu thut ct chu sn ming trong ung th sn ming

9. X tr p st trong ung th khoang ming

10. X tr p st xut liu cao trong ung th sn ming

11. Phu thut ct ton b tuyn mang tai bo tn dy thn kinh VII

12. Phu thut ct ton b u tuyn nc bt di hm

13. Phu thut ct ung th Amidan

14. Phu thut ct u nang tin nh mi

15. Phu thut ct b u sng hm

16. Phu thut ct u v bao dy thn kinh schwannoma vng c

17. Lm mt n c nh u c

18. X tr p st liu cao ung th vm hng

19. X tr iu bin liu ung th vm hng

20. X tr bnh ung th h hng

21. X tr cho cc khi u ngoi nhn cu

22. X tr cho cc khi u ni nhn cu

23. Xt nghim t bo trong dch no ty

24. X tr ngoi cc ung th no tr em

25. X tr cho khi u no c tnh nguyn bo thn kinh m

14

26. X tr ung thu di cn no

27. X tr ung th tuyn yn

28. iu tr tia x i vi u lymph c tnh nguyn pht no

29. Siu m tuyn gip

30. Siu m dn hng chc ht t bo bng kim nh chn on tn thng gip trng

31. Chp x hnh tuyn gip

32. Phu thut ct u v r ca nang gip mng (phu thut SISTRUNK)

33. Phu thut ton b tuyn gip trong iu tr ung th

34. Phu thut ct mt thy gip trng

35. iu tr ung th gip trng th bit ha sau phu thut bng I131

36. K thut x tr ung th tuyn gip

37. Thc hnh x tr ung th u c

II. Lng ngc, tim mch, phi

38. K thut ni soi chn on ung th ng h hp

39. Phu thut ct ton b thanh qun

40. Thm d chc nng ti mu phi trong ung th bng SPECT

41. Xt nghim t bo trong dch mng phi

42. Sinh thit kim xuyn thnh ngc di hng dn ca chp ct lp in ton

43. Sinh thit m xuyn thnh ngc bng kim nh

44. Sinh thit u phi, u trung tht qua phu thut ni soi lng ngc

45. nh gi ngi bnh trc phu thut ung th phi

46. Gy t khoang mng phi gim au sau m ung th vng lng ngc

47. Gy t ngoi mng cng phi hp gy m trong m u vng lng ngc

48. Thng kh trong phu thut ung th kh ph qun

49. Thng kh mt phi trong phu thut ung th vng lng ngc

50. M ngc thm d trong ung th phi

51. Phu thut ct u nang ph qun (u nang phi)

15

52. Ct mt thu phi v mng thnh ngc trong ung th

53. Ct mt thu phi do ung th

54. Phu thut ct u sn ph qun

55. Phu thut bc kn mng phi

56. Phu thut ct kn kh phi

57. Ct mt thu phi km ct mt phn thu phi khc in hnh do ung th

58. Ct mt bn phi do ung th

59. Ct hai thy phi km vt hch trung tht

60. Phu thut ct nhu m phi khng in hnh do ung th

61. Phu thut ct u nang trong nhu m phi

62. Gy dnh mng phi bng ho cht

63. Bm ho cht mng phi

64. Chp hnh chc nng c tim

65. Phu thut ct b u nang mng tim

66. Phu thut ct u mng tim

67. Phu thut ni soi lng ngc ct b khi u trung tht

68. Phu thut ct b khi u trung tht

69. Phu thut bc u thnh ngc

70. Phu thut ct u xng sn

71. Ct mng thnh ngc trong u mt hoc nhiu xng sn

III. Tiu ha - Bng

72. Ct thc qun do ung th to hnh thc qun bng d dy- phu thut LEWIS-SANTY

73. Phu thut ni soi ct thc qun do ung th to hnh thc qun bng d dy

74. X tr ngoi ung th thc qun

75. Ni soi chn on ung th ng tiu ho trn

76. Ct Polype ng tiu ho trn qua ni soi ng mm

77. Ct bn phn d dy cc di do ung th v vt hch h thng D2

16

78. Ct ton b d dy do ung thu v vt hch h thng D2

79. Phu thut ni soi ct ton b d dy do ung th v vt hch h thng D2

80. Ct bn phn d dy cc di do ung th v vt hch h thng D2 bng phu thut ni soi

81. Ct d dy ton b do ung th v vt hch

82. Ct ton b d dy do ung th c to hnh bng rut non

83. Ct d dy li do ung th

84. M thng d dy nui dng

85. Ni mt-Hng trng do ung th

86. Quy trnh sng lc pht hin sm ung th i trc trng

87. Ni soi chn on ung th i trc trng

88. Ct on trc trng do ung th, ct ton b mc treo trc trng (TME)

89. Ct on i trng ngang do ung th vt hch h thng

90. Ct on i trng sigma do ung th c vt hch h thng

91. Ct ton b i trng do ung th km vt hch h thng

92. Ct na i trng phi do ung th km vt hch h thng

93. Ct na i trng tri do ung th km vt hch h thng

94. Phu thut ni soi ct ung th i trng phi

95. Phu thut ni soi ct ung th i trng tri, i trng sigma

96. Ct li i trng do ung th

97. Ct Polype i trc trng qua ng ni soi ng mm, phi hp kp clip vi nhng polype cung ln.

98. Ct ct trc trng ng bng tng sinh mn

99. Ct trc trng gi li c trn

100. Ct u trc trng ng hu mn ng di

101. Phu thut ni soi ct ct ung th trc trng

102. Phu thut ni soi ct on ung th trc trng

103. X tr gia tc a phn liu trc phu thut ung th trc trng

17

104. Phu thut ni soi ct h phn thy gan

105. Phu thut ct chm nang gan

106. Ct chm nang gan bng ni soi

107. Ct gan phi do ung th

108. Ct gan tri do ung th

109. Phu thut ni soi ct gan ln

110. Tht ng mch gan iu tr ung th hoc chy mu ng mt

111. Ct khi t tu do ung th u tu

112. Ct lch bnh l, ung th, p xe

113. Phu thut cc khi u sau phc mc

114. Phu thut ct u mc treo (km theo ct rut non)

115. Phu thut ct u mc treo (khng ct rut non)

IV. V - Ph khoa - Tit niu - Sinh dc

116. Quy trnh sng lc pht hin sm ung th v

117. Chp x quang tuyn v

118. Chp ng tuyn sa cn quang

119. Chp v nh v kim dy dn hng sinh thit m

120. Chp x hnh khi u tuyn v vi 99mTc - MIBI

121. Siu m tuyn v

122. Siu m v dn hng sinh thit kim

123. Sinh thit tn thng tuyn v bng sng sinh thit

124. Sinh thit tn thng tuyn v c nh v bng kim dy

125. Sinh thit hch ca bng ch th mu trong nh gi di cn hch nch ca ngi bnh ung th v

126. K thut ct bung trng trong iu tr ni tit ung th v

127. Phu thut ct bung trng, hai phn ph trong iu tr ung th v

128. K thut ti to tuyn v sau phu thut ung th v

129. Phu thut ct tuyn v vt hch nch

130. Ct mt phn tuyn v, vt hch nch

18

131. Phu thut u x tuyn v

132. X tr ngoi ung th v

133. Chp hnh chc nng thn

134. Chp x hnh hnh th thn vi DMSA

135. Sinh thit kim chn on m bnh hc tn thng thn di hng dn ca siu m

136. Sinh thit kim chn on m bnh hc tn thng thn, ty, tuyn thng thn di hng dn ca chp ct lp vi tnh

137. Ct b thn ung th c hoc khng vt hch

138. X tr u nguyn bo thn tr em (u Wilms)

139. Ni soi bng quang

140. Phu thut ct ton b bng quang km to hnh bng quang bng rut trong iu tr ung th bng quang

141. Phu thut ct ton b bng quang km to ti cha nc tiu bng mt quai rut non

142. Phu thut ni soi ct, t ung th bng quang nng kt hp vi bm BCG ni bng quang

143. K thut ct ung th bng quang nng qua ng ni soi ng niu o

144. Phu thut ung th m h m vt

145. Ct m h n thun

146. Bc nang tuyn Bartholin

147. Phu thut ct u thnh m o

148. Quy trnh sng lc pht hin sm ung th c t cung

149. Nhum PAPANICOLAOU

150. Xt nghim t bo hc c t cung bng k thut thin PREP

151. Khot chp c t cung

152. Phu thut Wertheim Meig iu tr ung th c t cung

153. Ct c t cung cn li trn ngi bnh m ct t cung bn phn

154. Ra m o, c t cung trc x tr

155. X tr p st iu tr ung th c t cung

19

156. Ct t cung ton b + vt hch chu hai bn

157. No bung t cung

158. Phu thut ung th bung trng

159. Phu thut ly u trong dy chng rng

160. Phu thut ly u y chu v u tiu khung

161. Phu thut ung th dng vt vt hch bn hai bn

162. X tr ung th dng vt

163. Ct c hai tinh hon iu tr ung th tin lit tuyn

164. Phu thut ct ton b tuyn tin lit, ti tinh v bng quang

165. X tr ung th tin lit tuyn

166. Phu thut ct ton b b phn sinh dc ngoi ca nam gii do ung th

167. Phu thut ct ton b b phn sinh dc ngoi ca nam gii do ung th v vt hch bn hai bn

V. Da - Phn mm - Xng - Khp

168. nh v trng chiu x trn da ngi bnh

169. X tr trit cn ung th da vng u c (loi ung th biu m t bo vy v ung th biu m t bo y)

170. X tr b tr ung th da vng u c (loi ung th biu m t bo vy v ung th biu m t bo y)

171. Phu thut ct ct cnh tay (trong iu tr ung th)

172. Tho khp na bn chn trc do ung th

173. Tho khp c chn do ung th

VI. Cn lm sng

174. Siu m hch nch

175. Siu m chn on hch bnh l ngoi vi

176. Sinh thit kim chn on m bnh hc hch bnh l ngoi vi di hng dn ca siu m

177. Sinh thit kim chn on m bnh hc cc tn thng u- hch bng khng thuc tng di hng dn ca siu m

178. Sinh thit kim chn on m bnh hc cc tn thng u- hch

20

khoang sau phc mc di hng dn chp ct lp vi tnh

179. Mt s k thut xt nghim ch im khi u

180. nh lng PRO-GRP (Pro-Gastrin Releasing Peptid)

181. nh lng CA 72-4 (Cancer antigen 72-4)

182. nh lng CA 19-9 (Carbohydraqte antigen 19-9)

183. nh lng CYFRA 21-1 (Cytokeratin fragment)

184. nh lng HE4 (Human Epididymal Protein)

185. nh lng Tg (Thyroglobulin)

186. nh lng FREE PSA (Free Prostate-Specific Antigen)

187. nh nhm mu h ABO, RhD bng phng php Gelcard

188. Pht mu bng phng php Gelcard

189. Sinh thit ty xng

190. Xt nghim t bo hc

191. Sinh thit v c nh bnh phm

192. K thut m hc thng quy nhum Hematoxylin v Eosin (HE)

193. Sinh thit tc th (Sinh thit ct lnh)

194. K thut nhum PAS (Phn ng acid Periodic-schiff)

195. K thut xt nghim ho m min dch

196. Nhum SISH (Ventana)

197. Xt nghim Fish

198. Xt nghim xc nh t bin Gen EGFR v K-RAS bng gii trnh t chui AND trn khi PARAFFIN

199. o, chun liu chm Electron (in t) dng trong x tr

200. o, chun liu trong k thut iu bin chm tia vi h Collimator c lp (JO-JAW ONLY)

201. o, chun liu trong k thut iu bin chm tia vi h Collimator a l - MLC (Multi Leaf Collimator)

202. Lp k hoch x tr p st bng my m phng

203. Chun liu hp th trong mi trng tng ng m c th

204. khun c ch che chn, bo v cc c quan quan trng trong

21

trng chiu x

205. M phng lp k hoch x tr

206. Lp k hoch x ngoi bng my m phng

207. Lp k hoch x tr bng my vi tnh (TPS)

208. Chp x hnh xng

209. Chp x hnh u mao mch gan vi hng cu gn 99mTc

210. Chp x hnh khi u vi 99mTc gn MIBI

211. Chun h thng my o liu dng trong x tr

212. o, chun liu cc ngun dng trong x tr p st

213. o liu Invivo (kim tra liu lng x tr ung th)

214. Kim chun, nghim thu k thut h thng my gia tc x tr

215. Kim sot v m bo cht lng, x tr ung th

216. o liu tng i

217. o liu tuyt i

218. o, chun liu vt l h thng my gia tc tr sau lp t (Commissioning)

219. o, chun liu cc chm Photon (Tia - X) nng lng 6 MV

220. o, chun liu cc chm Photon (Tia - X) nng lng 15 MV hoc ln hn

221. o, chun liu chm tia Gamma ngun Cobalt 60 dng trong my x tr ngoi.

222. ng dng bung ion ho phng, song song o liu chm electron t my gia tc x tr

223. ng dng bung ion ho hnh tr o liu chm electron (in t) t my gia tc x tr

224. Kim tra cho (Audit check) trong tnh phn b liu x tr ngoi.

225. Kim sot liu chiu x vi nhn vin x tr, chn on hnh nh v y hc ht nhn.

VII. X tr (Phn tng hp)

226. X tr bng my gia tc

227. X tr p st liu thp

22

228. X tr p st liu cao

229. X tr Coblalt -60

230. X tr ngoi gim au do di cn xng

231. X tr nng bng tia X

232. X tr Ulympho c tnh tr em

233. X tr trng chiu rng iu tr Ulymph c tnh

234. X phu

235. Ulymph c tnh

VIII. iu tr Ni khoa v Chm sc gim nh (Phn tng hp)

236. Tim ha cht ni ty sng

237. Truyn ho cht tnh mch trung tm qua bung tim

238. Truyn ho cht nhanh (Bolus)

239. iu tr ho cht bng ng ung

240. X tr cho ngi bnh b phn ng khi tim truyn thuc ho cht

241. Chm sc v iu tr cho ngi bnh c nn v bun nn do ho tr

242. Chm sc v iu tr cho ngi bnh vim nim mc hng ming do ho tr

243. Phng v x tr bin chng thot mch trong khi ho tr

244. iu tr ho cht v x tr ng thi

245. Truyn ho cht tnh mch ngoi vi

246. Truyn ho cht tnh mch trung tm qua catheter

247. Bm truyn ho cht lin tc (12 - 24 gi) vi my infuso Mate - P

248. Chm sc v iu tr cho ngi bnh ha tr c km theo bnh l tim mch

249. Chm sc v iu tr cho ngi bnh ha tr c km theo bnh l v gan

250. iu tr ho cht cho nhng ngi bnh c km theo bnh l v thn

251. iu tr ho cht cho ngi bnh c virut HIV

252. iu tr ho cht cho ngi bnh cao tui

253. Chm sc v iu tr cho ngi bnh ha tr c h bch cu

23

254. Chm sc v iu tr cho ngi bnh c bin chng h tiu cu do ho tr

255. Chm sc v iu tr cho ngi bnh c bin chng tiu chy do ho tr

256. Chm sc v iu tr cho ngi bnh b to bn do ho tr

257. Chn on v iu tr hi chng ly gii u do ha tr

258. iu tr ho cht liu cao v kt hp vi truyn t bo gc d gien

259. Chm sc v iu tr cho ngi bnh gim s ngon ming do ho tr

260. Chm sc v iu tr cho ngi bnh c c tnh thn kinh ngoi vi do ha tr

261. Chm sc v iu tr cho ngi bnh c c tnh trn da do ho tr

262. Truyn ho cht ng mch

263. Truyn ho cht tnh mch ngoi vi

264. Tim truyn ho cht vo mng bng iu tr ung th

265. iu tr ha cht liu cao kt hp vi truyn t bo gc t thn

266. Phu thut t bung tim truyn di da

267. K thut t bung tim truyn ngoi da

268. K thut gy t ngoi mng cng gim au sau m ung th

269. K thut chm sc ngi bnh ung th giai on cui (cn t)

270. nh gi ton trng ngi bnh ung th

271. iu tr gim au bng thuc

272. nh gi au

273. S dng Morphin tim di da bng bm tim in

274. S dng Morphin cho ngi bnh kh th

275. Cp cu ng c Morphin

276. S dng Morphin ng ung

277. S dng ming dn Fentanyl

278. Cp cu tc rut ni khoa ngi bnh ung th giai on cui

279. Cp cu ngi bnh di cn xng ct sng c chn p ty sng

24

QUY TRNH SNG LC PHT HIN SM

UNG TH KHOANG MING (UTKM)

I. I CNG

Khoang ming bao gm mi trn, mi di, sn ming, phn li di ng (2/3

trc li), nin mc m, li hm trn, li hm di v vm khu ci.

Ung th khoang ming l loi u c tnh c th xut hin bt k v tr no trong

khoang ming nh li, li, mi, m, vm ming v sn ming. Thng k trn th

gii cho thy UTKM l mt trong su loi ung th thng gp nht.

Trn th gii t l mc bnh ung th khoang ming hng nm khong

11/100.000 dn, t l nam/n l 2/1. Ti M nm 2006 c tnh khong 30.990 TH

mi mc v 7.430 TH t vong do ung th khoang ming . Ti Vit nam, t l mc

l 2,7/100.000 dn. Theo thng k ca bnh vin K, H ni trong nm 2000 s ca

UTKM l 1740, nhng n nm 2010 s ca UTKM ln n 2385 (tng 43 )

Nn UTKM thng c pht hin giai on kh mun, c biu hin xm ln

hay di cn hch, gy hn ch nhiu n cc chc nng quan trng ca c th nh

dinh dng, pht m, h hp, thm m v quan trng nht l iu tr rt kh khn,

tn km, m kt qu iu tr li khng cao, thi gian sng thm ngn, tng t l ti

pht.

Xy dng qui trnh khm sng lc UTKM ti tuyn tnh v tuyn huyn ph

hp iu kin Vit nam l ht sc quan trng, c ngha thc tin ln

phng v tng hiu qu vic pht hin v iu tr UTKM.

II. I TNG NGUY C UTKM

- Nam gii trn 45 tui

- Ngi s dng thuc l

- Ngi nghin ru

- Ngi c thi quen nhai tru

- Ngi b nhim mt vi tp ca virut HPV

- C tin s c chn on UTKM trc .

III. CHUN B

1. i tng chuyn giao

- Cc bc s chuyn khoa rng hm mt

- Cc bc s chuyn khoa tai mi hng

25

- Cc bc s ung th

- Cc bc s TBH, GPB

- Cc bc s phng khm a khoa

- Nhn vin y t ca x.

- Nhn vin y t c o to chuyn su.

2. i tng sng lc

- c chn mu ngu nhin

- Nm trong nhm nguy c

3. Phng tin

- Khm khoang ming bng n hunh quang, nhn nh s b cc dng tn

thng.

+ Ly b rng gi nu c.

+ Quan st k tt c cc vng ca ming v thm khm bng ngn tay b mt

cc vng nin mc c nghi ng tn thng.

+ Nga c v quan st, thm khm vng sn ming.

+ Ko m rng ra hai bn quan st vng nim mc m v phn sau li

+ Dng gng quan st cc vng chn rng v vng su v trn.

+ Ko li ra phi ngoi v quan st k hai mt, cc b ca li.

+ Khng qun quan st v s nn k tm khi bt thng vng c hai bn v

vng di hm.

- Cc tn thng lnh tnh:

+ Cc tn thng vim + U mu lnh tnh

+ U tuyn nc bt ph

+ U nh nim mc ming

- Cc tn thng tin ung th :

+ Cc mng trng trong khoang ming (bch sn):

+ Cc mng trong khoang ming (hng sn):

+ Cc mng trng, trong khoang ming (hng- bch sn)

+ Cc tn thng lot d chy mu, kh lin.

- Cc tn thng ung th, nghi ng ung th:

26

+ Cc tn thng lot si, si mn nt, d chy mu, hoi t.

+ Cc vng dy cng bt thng trong khoang ming.

+ C cc hoc khi bt thng vng c.

IV. CC BC TIN HNH

1. Quy trnh khm sng lc ti tuyn huyn

- Gio dc truyn thng v sc khe rng ming, cc UTKM bi cc nhn vin y t, t ri truyn thng, h thng loa truyn thng...trc tip ti i tng nguy

c v i tng c sng lc.

- T chc cc bui khm khoang ming ti cng ng.

- T vn v chuyn mn nu pht hin thy cc tn thng.

- Hn ti khm sng lc theo thi gian qui nh

- Chuyn tuyn tnh cc tn thng cn sinh thit hoc phu thut.

- o to cc chuyn gia y t x v huyn cch thc nhn nh v x l cc tn thng tin ung th hoc nghi ng.

- Trin khai h thng s sch ghi chp, thu thp v qun l s liu nh k bo co ln tuyn tnh v kt qu theo d i KSL

2. Quy trnh khm sng lc ti tuyn tnh

- Tin hnh khm li ton b khoang ming.

- nh gi tn thng.

- Lm xt nghim TBH hay sinh thit, v cc XN khc ( CT, MRI...)

- Phu thut cc tn thng lnh tnh hoc cc tn thng nghi ng ung th hay cc tn thng ung th giai on sm.

- Chuyn ngi bnh ln tuyn trung ng.

- o to, h tr v gim st cc hot ng khm sng lc UTKM ca tuyn huyn.

- Trin khai h thng thu thp s liu, qun l thng tin.

- Thng tin phn hi vi y t tuyn di v tuyn trn v s lng UTKM

27

S M HNH KHM SNG LC UTKM TI TUYN TNH

Khm khoang ming xc nh tn thng

Xt nghim TBH, sinh thit

Tn thng lnh tnh Tn thng c tnh

Cc xt nghim

nh gi giai on

iu tr v theo d i

Ti khm iu tr

Theo d i Chuyn tuyn

Trung ng

Ti

pht

28

29

PHU THUT LY HCH C

CHN ON V IU TR

I. NH NGHA

L phu thut ly b 1 hch vng c iu tr hay chn on gii phu bnh

trong cc trng hp ung th nguyn pht cha xc nh hoc cha xut hin

trn lm sng.

II. CH NH

- iu tr cc trng hp xc nh nguyn nhn nh: ung th, hch vim, hch c cha r nguyn pht, hch n c, hch lao.

- chn on m bnh hc khi nghi ng b ung th hch hay b di cn ca ung th v u nguyn pht cha xut hin hay cha c chn on gii phu bnh l

chnh xc.

III. CHNG CH NH

Ngi bnh c bnh tim mch, bnh tiu ng nng

IV. CHUN B

- Chun b nh phu thut khi u phn mm ni chung.

- Xt nghim c bn, Xquang c nghing

- Dng c m cnh c.

V. CC BC TIN HNH

1. T th

- Ngi bnh nm nga hi n, quay u v bn i din vi hch l r vng hch c

- Phu thut vin ng cng bn hch c, ngi ph ng bn i din.

2. V cm: gy t ti ch hoc gy m ton thn.

3. K thut

Th 1: rch da c th i theo ln da c hoc theo ng b trc c c-n-

chm vo dy hch cnh hoc theo b trc c thang vo nhm gai.

Th 2: bc tch cn nng, cn c gia bc l bao hch.

Th 3: bc tch xung quanh bao hch ly b hch.

Th 4: khu phc hi 2 lp cn v da sau khi cho bt khng sinh v t dn lu.

VI. THEO DI V X TR TAI BIN

30

- Chy mu: m li cm mu

- Nhim khun vt m: khng sinh + chng nhim khun

- Thay bng hng ngy

- Rt dn lu sau 24h

- Ct ch sau 7 ngy

31

PHU THUT VT HCH C TRIT CN

I. I CNG

Trong iu tr ung th ni chung, ung th u mt c ni ring. Vn vt

hch c ng mt vai tr quan trng trong chu trnh iu tr. S xm ln hch c l

mt yu t quan trng trong vic tin lng qu trnh tin trin ca ung th biu

m, c bit i vi ung th biu m khoang ming v ung th biu m ng h

hp, tiu ho trn. V nguyn tc iu tr phi x tr hch vng cng vi khi u

nguyn pht. Nu tn thng nguyn pht khng c xc nh (hch c di cn

cha r nguyn pht) th vic vt hch c cng phi c t ra trc tin so vi

cc phng php iu tr khc.

II. CH NH

Ch nh vt hch c trit cn: C th p dng vi tt c cc loi bnh l ca

s di cn hch. Loi vt hch ny c ch nh trong trng hp hch ln hn

3cm (c nguy c ph v v) v kch thc ca tn thng nguyn pht d cho di

cn hch. Ch nh trong cc trng hp hch b xm ln, ph v v hch, tnh cht

d gy ph v v hch ca u nguyn pht. Hoc hch c nhiu mt bn m

khng r u nguyn pht.

III. CHNG CH NH

- C hch khi u ang pht trin nhanh (c th iu tr tia x hoc ho cht trc, sau nh gi kh nng phu thut)

- Hch khng th phu thut c do xm ln ti ch (hch N3 c nh pha su).

- Hch hai bn.

- Ngi bnh qu gi yu, suy tim, suy thn nng, khng c kh nng chu ng c phu thut ln.

- Khng c vt hch c trit cn 2 bn trong cng mt lc.

IV.CHUN B

1. Ngi thc hin: Phu thut vin chuyn khoa u c, c kin thc vng vng v gii phu sinh l chc nng vng c. Cn mt phu thut vin v hai ph m

c kinh nghim.

2. Phng tin

- B dng c phu thut phn mm.

- Phng tin v cm: Ni kh qun.

32

3. H s bnh n

- Theo qui nh ca b y t

- Ch m t h thng hch c, u nguyn pht th gii phu bnh, cc bnh ton thn khc phi hp nu c (tim mch, i ng, suy thn)

V. CC BC TIN HNH

1. T th ngi bnh

Ngi bnh nm nga, mt nghing v 1 bn lnh, n mt gi mng phn

vai c bn b bnh bc l ton b vng c bn b bnh.

2 V cm: Ni kh qun.

4. ng rch da

Bt u t di cm i xung di ngay trn sn gip v mng cnh (ch

phn chia ng mch cnh trong v ng mch cnh ngoi) sau ko ln trn v

ra sau (ngang gc hm ra khong 2cm). ng rch ny hnh cnh cung. Sau t

y hnh cnh cung rch di xung im gia ca xng n gn ging ch Y.

ng rch qua da, t chc di da, cn c c nng cm mu bng dao in

lng cc.

- Bc tch vt da c pha trn ln ti b di xng hm. Pha di xung st mt trn xng n. Pha sau ti cc c nhm gai sng pha trc ti b ngoi

sn gip v kh qun bc l ton b cc nhm hch vng c.

- Nhm I: Nhm di cm, di hm.

- Nhm II: Nhm cnh cao Nhm III: Nhm cnh gia.

- Nhm IV: Nhm cnh di.

- Nhm V: Nhm sau di

- Nhm VI: Nhm trc c.

5. Vt hch c trit cn

- Bt u t h thng hch di cm - ct b tuyn di hm

- Tht ng mch mt: pha trn ch dy thn kinh mi di ct ngang qua ng mch mt v song song vi b di xng hm. pha di tht trn c

nh thn. Nu c to hnh cn cung l ng mch mt th bo tn ng mch

ny.

- Ct b c nh thn b sau - ct u trn c c n chm cch mm trm chm 1cm bc l mng cnh

- Tht tnh mch cnh trong di c nh thn

33

- Ko c c n chm xung pha di cng vi tuyn dui hm hch di cm hch nhm I v II.

- Phu tch ct ton b h thng hch t nhm I n nhm VI xung h thng n.

- Ct b u di b c v b n ca c c n chm

- Tht u di tnh mch cnh trong ngang mc xng n

- Ly ton b h thng hch cng c c n chm, tuyn di hm, c nh thn b sau, tnh mch cnh trong, thn kinh gai thnh mt khi. Ch cn li cc

cu trc sau: ng mch cnh, dy thn kinh ph v, thn kinh giao cm c, thn

kinh honh, thn kinh di li, nhnh thn kinh cm mt. Phu tch cm mu

k - ch nu bn tri khi phu tch vng thng n c ng ngc, cn thn

trng bo tn trnh lm rch. Nu lm rch khu li bng ch 6.0.

- t sonde dn lu. Rt sau khi dch khng cn chy ra qua dn lu. Thng thng rt dn lu sau 72 gi

VI. THEO DI TAI BIN V X TR

1. Chy mu: Do cm mu khng k.

X tr : M li cm mu

2. Chy dch bch huyt do rch ng ngc: T chc dch dn lu c nh nc vo go.

X tr: Nu dch c di 100ml/24h theo d i, nu dch cng ngy cng

nhiu ln - nn m li tm vt rch ca ng ngc khu li.

3. Tc dn lu: Phi thay n lu khc phng dch vng c.

4. Kh th: t gp.

34

PHU THUT CT U NANG VNG C

I. I CNG

Khi u nang vng c c phn nhm theo v tr. Bao gm khi u vng c

gia v khi u vng c bn.

* Khi u vng c gia bao gm:

- U nang gip mng (nang, ng gip li) hay gp nht.

- U nang biu b: Thng nm vng di cm khng di ng phu thut d dng, rch m ly nang.

- U nang tuyn c: t gp hn.

* Khi u nang vng c bn:

Ch yu l nang khe mang nhng hay gp nht d tt xut pht t khe mang

th 2 sau l khe mang th 3. Nang khe mang th 4 cng c phng on

nhng cha c chng minh v phng din lm sng.

V tr nang khe mang th 2 nm dc t 1/3 pha trn xung gia c c n

chm, nang khe mang th 3 nm dc t gia xung 1/3 di c c n chm. Ti

nhng v tr ny mt ng dn ti xoang hoc ng d c l bn ngoi.

* Trong bi vit ny chng ti xin trnh by phu thut ct u nang khe mang th 2

v th 3.

II. CH NH

Phu thut ct b nang khe mang khi nang khng b nhim trng.

Nu nang b nhim trng th dng khng sinh cho ngi bnh v tr hon

qu trnh phu thut cho n khi nang tr li bnh thng.

Nu nhim trng, p xe ha th rch dn lu trc chm sc n khi lnh.

Siu m li, theo di nu ti pht s m ly trn.

III. CHNG CH NH

Ngi bnh gi yu, suy tim, suy thn nng khng c kh nng chu ng

c phu thut.

IV. CHUN B

1. Ngi thc hin

Phu thut vin chuyn khoa u c, c kin thc vng vng v gii phu

sinh l chc nng vng c. Cn mt phu thut vin v mt ph m c kinh

nghim.

35

2. Phng tin

- B dng c phu thut phn mm

- Phng tin v cm: Ni kh qun

V. CC BC TIN HNH

1. V cm: Gy m ni kh qun.

2. T th ngi bnh: Ngi bnh c t t th nm nga, mt nghing v

bn lnh, n mt gi mng vng vai c bn b bnh bc l ton b vng c

bn b bnh. Phu thut vin ng pha bn m. Ph m ng bn i din.

3. K thut

Th mt: ng rch da

Thng rch nang v nh hng vt rch theo mt np nhn t nhin da.

ng rch di hay ngn ph thuc vo v tr, kch thc khi u. Nu cn rch mt

l bn ngoi th nn tin hnh vi mt hnh elp nm ngang.

ng rch qua da, t chc di da.

Th hai: Bc tch vt da

Bc tch vt da 2 pha trn v di. Nu u to th c th tch rng ln trn v

xung pha di. Banh rng trng m bng khu si ch ko ln trn v xung

pha di hoc bng banh t ng.

Cn l mt khong ln to iu kin cho vic xc nh v bo v cc

cu trc mch v thn kinh quan trng.

Th ba: Phu thut ly u

Thng khi u trn hay bu dc, ranh gii r , mt cng v n hi nm

di cn c gia, dc theo b trc c c n chm, trc b mch cnh, thng

hay dnh vo tnh mch cnh trong. Bt u, nang c chuyn t mp trc v

mt gia ca c c n chm. Cn ht sc ch trnh gy tn thng cho cc

nhnh dy thn kinh gai sng. gia nang c chuyn trong khu vc bao mch

cnh. Phu tch ly gn u trnh lm rch v bao khi u. Nu c ng d th phi

ct ng d.

Th bn: Phu thut ct ng d

Phi xc nh ng d, ct thm v pha trn khu vc phn nhnh mch

cnh. Xc nh v bo v dy thn kinh h thit v quai dy thn kinh c. C mt

s tnh mch khu vc dy thn kinh h thit, chng phi c kim sot mt

cch chnh xc. to thun li cho vic ct ti khu vc ny, hy di chuyn bng

sau ca c nh thn v ko n ln pha trn.

36

Sau khi ng d c di chuyn ti khu vc chia nhnh mch cnh, c th

ln theo n ti hng. Mt ng d khe th 2 i qua gia cc ng mch cnh

trong v cnh ngoi. Trn thn kinh h thit v thit hu. Mt ng d khe th 3

nm sau bn ng mch cnh trong. N nm pha trc dy thn kinh ph v v

trn dy thn kinh h thit. Sau ng d nm gia h thng ng mch cnh

do n ko di v pha bn xoang l. Qu trnh ct t m cho php xc nh v bo v

cc cu trc ny khi di chuyn ng d.

Cui cng trong qu trnh ct l tch ng d khi pha bn ca hu. C

th cn phi ct mt phn nim mc nh trong hc Amian (khe th 2) hoc xoang

l (khe th 3). c bit nu cn rch mt l bn trong.

Th nm: Cm mu v khu vt m

Cm mu k, ra sch vt m, t 1 sonde dn lu v tr su so vi c da

c. ng vt m theo cc lp gii phu (ch t tiu), khu da mi ri.

Chm sc dn lu. Rt dn lu khi khng cn dch chy ra, thng thng rt

sau 72 gi.

VI. THEO DI TAI BIN V X TR

- Chy mu: Do cm mu khng k.

X tr: M li cm mu.

- Nhim trng vt m.

X tr: Dng khng sinh theo khng sinh , chm sc vt m hng ngy.

* Ghi ch:

Ct b hon ton nang v ng d l vic rt cn thit ngn vic chng

ti pht.

- Trnh phu thut trn nang ang b nhim trng.

- Nn trnh rch v ht dch.

37

PHU THUT VT HCH C CHN LC

I. I CNG

- S xm ln hch c l mt yu t quan trng nh gi qu trnh tin trin ca ung th vng u mt c nh: ung th biu m khoang ming, ung th h hng

thanh qun, ung th tuyn gip, ung th da, ung th tuyn nc bt Vic iu

tr phu thut khi u nguyn pht vng u mt c phi i song song vi vic

no vt hch vng c mi mang li kt qu tt.

- C 6 vng hch c phn nh sau:

+ Nhm I: nhm di hm, di cm

+ Nhm II: nhm cnh cao (bao gm nhm c nh thn v nhm hch gai trn) chia thm nhm nh l II bis v nhm cnh gai

+ Nhm III: nhm cnh gia

+ Nhm IV: nhm cnh di

+ Nhm V: nhm cnh di (bao gm nhm gai gia v di, phn sau ca nhm hch c ngang)

+ Nhm VI: nhm trc c

II. CH NH

- Vt hch c chn lc: p dng i vi trng hp hch nh, cha xm ln, hch

38

V. CC BC TIN HNH

1. V cm: gy m ni kh qun.

2. T th ngi bnh: ngi bnh nm nga, u nghing v pha lnh, c dui

na chng, lt gi di vai v 1 phn di c.

3. ng rch: tng ng vi cc v tr nhm hch cn vt.

4. K thut vt hch c chn lc:

- Rch da, t chc di da, rch t cc th ca c bm da c nng v bao x c c n chm, bc tch vt da c.

- Tu tng v tr hch m c th ct b cc thnh phn nh tuyn di hm, ng mch mt, t chc bao x ca c c n chm - bao cnh (nu phu thut vt

hch chn lc nhm I, II). Nhm III, nhm IV c th ly ton b h thng

hch nhm cnh gia, cnh di.

- Nhm V, nhm VI trong cc trng hp hch di cn ung th gip trng, lao hch ly ton b h thng hch nhm gai gia v di, phn sau ca nhm hch

c ngang v nhm hch trc kh qun.

- Bo tn tt c cc c quan cn li: mch mu, thn kinhnhng nu b hch xm ln vn c th ct b nu khng gy hu qu nghim trng

V. THEO DI V X TR TAI BIN

1. Chy mu: Do cm mu khng k.

- X tr: M li cm mu

2. Chy dch bch huyt do rch ng ngc: Dch dn lu c nh nc vo go.

- X tr: Nu dch c di 100ml/ 24h theo d i, nu dch cng ngy cng nhiu ln - nn m li tm vt rch ca ng ngc khu li.

3. Tc dn lu: Phi thay n lu khc phng dch vng c.

4. Kh th: t gp

39

PHU THUT CT LI BN PHN

TRONG IU TR UNG TH LI

I. I CNG

- Ung th li l ung th thng gp nht trong cc ung th vng khoang ming, pht sinh t s bin i c tnh biu m ph li hoc cc m lin kt cu trc

li.

- hu ht cc trng hp ung th li khng tm c nguyn nhn bnh sinh, tuy nhin ngi ta thy rng c mt s yu t nguy c lin quan n bnh bao

gm: ht thuc l, ung ru, nhai tru, tnh trng v sinh rng ming, nhim vi

sinh vt

- Gii phu: Li nm trong ming gm c hai mt (trn v di), hai b (phi, tri), mt u nhn pha trc v mt y pha sau tng i c nh.

Phn li di ng c gii hn pha sau bi cc tr trc ca Amygdal v

vng V li, pha bn v pha trc bi sn ming m n c tch bit ra bi

rnh li.

- Bch huyt: Tun hon bch huyt ca li rt phong ph, c nhiu vng ni gia mng li di nim mc vi mng li trong c v hai bn li. Cng v

vy m ung th li c kh nng di cn hch i bn

II. CH NH

- iu tr ung th biu m t bo vy ca li (T1,T2,T3).

- T1: ct mt phn li hoc ct m bo din ct cch ra u >1cm. Nu c iu kin lm sinh thit tc th din ct + no hch c chn lc.

- T2, T3: phu thut ct li bn phn + vt hch c chn lc hoc tn gc.

III. CHNG CH NH

Ngi bnh qu gi yu, mc cc bnh mn tnh nh lao phi, suy tim, suy

thn...

Bu xm nhim ti chng gia

IV. CHUN B

1. Ngi thc hin

Phu thut vin chuyn khoa ung th u c, c kinh nghim, kin thc v

gii phu vng u c.

Cn 2 ph m c kinh nghim.

40

2. Phng tin

- B m ming, my ht, farabeuf, kp hnh tim, kp phu tch c mu v khng mu, ko phu thut, dao m, dao in, km mang kim, ch tiu, pince phu

thut, meche va gc phu thut.

- Phng tin v cm: b ni kh qun.

3. Chun b trc m

- K giy m, gii thch v bnh, tin lng bnh, cc bin chng c th xy ra.

- nh gi cn lm sng.

- Ni soi tai mi hng loi tr cc khi u ng tiu ha, h hp trn.

- V sinh rng ming.

V. CC BC TIN HNH

1. V cm: bng gy m ni kh qun ng mi.

2. T th ngi bnh

- Ngi bnh nm nga, u t vng trn gi.

- t sonde d dy.

3. K thut

- Phu thut vin chnh ng pha bn m u li, ph m s 1 ng bn i din, ph m s 2 ng pha trn u.

- St trng sch khoang ming bng Betadine, st trng quanh ming v vng c vt hch (nu c vt hch).

- M ming ngi bnh bng b m ming.

- Lm sch khoang ming bng my ht.

- Dng kp mm hoc khu ch la 2.0 vo u li bn lnh, ko li ra pha ngoi.

- t 1 meche vng hng trnh dch v mu trong lc phu thut chy vo vng hu hng.

- Dng Farabeuf ko mp v nim mc m bn u bc l r khi u.

- Sau khi quan st y tn thng Phu thut vin chnh rch ng ct xung quanh tn thng. Ra nim mc nn t c t nht l 1 cm. C th ct bng

dao in, dao ct lnh, vt ct ko xung qua nim mc v c li, ng ct t

phn u li xung phn V li (theo hng trc - sau), ct mt trn li

trc, mt di sau, (ch khng ct hm li). iu quan trng l ct b tn

thng thnh mt khi.

41

- Ph m s 1 dng kp phu tch h tr phu thut vin ct li v cm mu, ph m s 2 mt tay ko Farabeuf, tay cn li cm u ht h tr lm sch

ng m. Lu trong th ny trnh dng c phu thut chm vo khi u,

y l 1 nguyn tc trong phu thut ung th, m bo din ct rng, khng cn

t chc ung th.

- Phu thut vin cm mu k bng dao in hoc buc bng ch nu cn thit.

- Tho b kp hnh tim u li

- Khu din ct li bng ch tiu (thng dng ch Vicryl 3.0 hoc 2.0 ty theo phu thut vin). Ch mi khu phi m bo ly ht phn y ca din ct

trnh ng dch v trnh chy mu sau m, mi khu m bo hai phn nim

mc khp kn li th vt m s tt hn. C th khu theo cc lp, vi cc lp su

c khu bng ch vicryl 3.0 v lp nim mc li c khu bng ch vicryl

4.0.

- Ra sch li khoang ming bng dung dch NaCl 0,9 pha vi dung dch Betadine.

- Kim tra li khoang ming nu c rng b m, hng th nh i.

- Rt b meche t vng hng, dng my ht lm sch li khoang ming.

- t li 1 meche vo v tr ct li, rt meche khi ngi bnh tnh.

- C nh li sonde d dy. Ngi bnh n qua sonde khong 2 n 7 ngy sau m th rt b sonde.

4. Hu phu

Sau m ngi bnh iu tr thuc khng sinh, thuc chng vim v gim au.

VI. THEO DI TAI BIN V X TR

1. Bin chng chy mu

X tr:ty theo tnh trng chy mu v s lng chy nhiu hay t, c th t

meche ti ch hoc m li cm mu.

2. Bin chng kh th: Do chy mu, ph n vng li sau m.

X tr: trng hp kh th do ph n nhiu do t mu cn nhc nn m kh

qun trc sau m li cm mu.

3. Bin chng nhim trng

X tr: v sinh ti ch tt bng dung dch st khun khoang ming, iu tr

khng sinh, chng vim ton thn theo khng sinh .

42

PHU THUT S DNG VT RNH MI M TO HNH KHUYT

HNG SAU CT B UNG TH SN MING

I. I CNG

- C nhiu phng php to hnh khuyt hng vng sn ming sau phu thut ct b khi u nh ghp da ri, vt da c c cung, vt da c t do...

- Vt rnh mi m l vt cn da, c trc mch chnh l ng mch mt v cc nhnh tn v cc nhnh bn gm ng mch mi trn, ng mch mi bn. Cc

ng mch ny nm su trong c nn t khi c nm trc tip trong vt, nui

dng cho da ca da trn nhng nhnh xin t cc ng mch ny.

- Vt rnh mi m c s dng trong to hnh khuyt hng sn ming l loi vt o cung di c th c hoc khng km theo phu tch ng mch mt.

II. CH NH

Cc trng hp ung th sn ming c th xm ln mng xng nhng cha

xm ln xng hm di, d kin sau phu thut ct b li khuyt hng c

kch thc khng qu 5 cm.

III. CHNG CH NH

- Cc trng hp c xc nh l khng th phu thut ct b u hoc no vt hch trit hoc c di cn xa.

- Ngi bnh gi yu, suy dinh dng hoc mc bnh ton thn (tim mch, tiu ng, h hp... cha iu tr n nh khng c ch nh gy m ni kh qun

hay c nguy c vt m khng lin.

- Ngi bnh c x tr trc .

IV. CHUN B

1. Ngi thc hin: phu thut vin chuyn khoa.

2. Phng tin

- B dng c phu thut to hnh.

- Siu m Doppler xc nh v v ng i ca ng mch mt.

- Dao in, tt nht l dao in lng cc hoc dao siu m

- Cc phng tin gy m ni kh qun.

3. Ngi bnh

- c gii thch v k hoch phu thut, nhng tai bin khng mong mun v vn li so vng rnh mi m.

43

- c v sinh c nhn v tht tho v c dn nhn n ung trc phu thut.

4. H s bnh n: theo quy nh ca B Y t.

V. CC BC TIN HNH

1. V cm: gy m ni kh qun.

2. Cc th phu thut

Dng bt ch v trn da phc tho ng rch. Chn ca vt phi pha

di mp 1-1,5 cm. Chiu rng t 2,5 - 3 cm. Trc ln nht ca vt song song vi

rnh mi m v hng v gc trong ca mt. im cc trn ca vt cch gc trong

ca mt 1cm.

Da theo hnh phc tho, rch qua lp da, di da cho ti tn lp c ca

mt. Sau gii phng vt da ny khi nn c. Dng ko thc hin ng tc

ny. Bt u t cc trn n cc di. Trong qu trnh phu tch phi i st mt s

c bm da mt m cc c ny nm trn ng i ca cc nhnh tn ca dy thn

kinh mt. Ch khng lm tn thng cc nhnh ng mch mt ca vt da. Nn

phu tch phn chn ca vt da sao cho rng ca phn chn khong 1,5 cm

to iu kin thun li cho vic khu ng vng cho vt c tt nht.

Sau lun vt ny xuyn qua m pha sau c nng mi trn v c vng

mi, pha trc li cu nh ca xng hm di. Dng ko Mayo lun vt da.

Ch l xuyn qua phi gn nht vi ra rng ca xng hm di, phn tng

ng vi khuyt hng sn ming trc. a c vt da qua pha trn ra li

phi nh rng nanh v hai rng hm nh.

Khu da v nim mc cng lp bng ch Vicryl 2.0 hoc 3.0.

t mt cc gc p ln trn vt da, c nh bng hai mi ch, lu li trong

48h vt da tip tt vi t chc pha di.

Lc ra ca vng da cho vt khong 7 mm mi bn v khu ng hai lp sau

khi cm mu k.

t mt dn lu c p lc m vo h m. Rt dn lu khi lng dch t hn

30 ml trong vng 24gi

Trong trng hp mt t chc sn ming rng hn th c th s dng hai vt

rnh mi m.

Trng hp ct sn ming khng km theo ct xng hm, cn phi phu

tch ng mch mt c th lun vt t pha di xng hm, a vo khuyt

hng vng sn ming.

VI. THEO DI

44

1. Tnh trng sng ca vt rnh mi m da vo nh gi mc nhn mu ca

vt, trng thi ca vt c b hoi t khng, tnh trng ch khu ni.

2. Kh nng phc hi chc nng vng c ti to: chc nng cch ly khoang

ming, tnh trng ni cho vt ...

3. Cc bin chng sau phu thut nh ng r, nhim trng...

VII. X TR TAI BIN

Hoi t vt hon ton hoc khng hon ton. Trong trng hp hoi t mt

phn c th ct lc ti ch v dng khng sinh, chng vim tch cc. Nu vt hoi

t hon ton, phi ct lc ton b v to hnh li khuyt hng bng vt khc.

ng r: iu tr khng sinh, chng vim tch cc. Trng hp ng r

nh c th t lin. Nu ng r khng t lin phi phu thut ct ng r.

45

PHU THUT CT CHU SN MING

TRONG UNG TH SN MING

I. I CNG

- K thut ny bao gm vic ct mt phn sn ming gii hn pha trn l nim mc sn ming v pha di l lp c hm mng. Thnh phn gm tuyn di

li, ng Wharton, v phn gn xng hm di ca cc c cm mng v cm

li.

II. CH NH

Khi u c tnh vng sn ming c xc chn bng m bnh hc.

III. CHNG CH NH

- Khi u lan rng khng c kh nng ct b rng ri hoc khng c kh nng vt hch c trit hoc c di cn xa.

- Ngi bnh gi yu, suy dinh dng, mc bnh ton thn (tim mch, tiu ng, h hp cha iu tr n nh) khng c ch nh gy m ni kh qun

hoc nguy c vt m khng lin.

- Ngi bnh c x tr trit cn trc .

IV. CHUN B

1. Ngi bnh

- Ngi bnh c lm y xt nghim c bn: huyt hc, sinh ha. Xquang, siu mc tht tho, v sinh c nhn t ngy hm trc.

- Ngi bnh c thng bo v mc ch phu thut cng nh cc tai bin c th xy ra

- T th ngi bnh nm nga trn bn phu thut, u c c nh thng, k gi vai

- Bc s phu thut ng bn bnh, ngi ph mt ng i din bc s m chnh, ngi ph hai ng pha trn u ngi bnh

2. V cm

Gy m ni kh qun qua ng mi hoc qua ng m kh qun (ty trng

hp c th).

3. Dng c: b dng c phu thut hm mt.

4. H s bnh n: theo quy nh ca B Y t

V. CC BC TIN HNH

46

1. Ct chu sn ming trc

Th 1: Rch da

Rch da theo hnh cung, i t vng di mm chm ti vng di cm.

Tt nht l hai ng rch khng to thnh mt gc nhn. ng rch ny to

thun li cho th vt hch.

Th 2: Ct u (qua ng ming)

u tin xc nh gii hn ct bng cch dng dao in v mt ng nt t,

thun tin nn ko ngc li ln bng mt si ch c nh.

* Gii phng phn trc

Bao gm:

- Rch mt ng pha trc ngang mc vi mo rng i vi cc ngi bnh mm.

- Tch mng xng mt trong xng hm di phn pha trn ch bm ca c hm mng.

- Ct phn bm vo xng hm di ca cc c cm li v cm mng.

* Gii phng phn bn

Chnh l s tip tc ca gii phng phn trc sang hai bn ti tn rng hm

nh s 2.

Dng mt chic panh ko cc bn pha tri ca sn ming, t t phu tch ti

tn cc bn phi ca sn ming.

* Phu tch phn sau

Ct cc c cm li v cm mng pha sau da vo cm gic ca tay v s

thm nhim ca khi u. Sau ct nim mc mt di ca li.

Th 3: ng h m

C th thc hin bng cc cch sau y.

- ng trc tip, nu li hn ch di ng thng c to hnh th 2 bng mt ming ghp tin nh ming.

- S dng mt hay hai vt rnh mi m.

- S dng mt vt li hay c.

Mt s bin tu trong cch ct u

i vi nhng ngi bnh khng b mm, ct pha trc ngang mc vi rng

khng th thc hin c. Thay vo , ch cn rng u, thng th ct ngang

47

mc vi mt trong ca xng hm di cch ra rng 10 - 12 mm, trong th ng

phi tch lp x nim mc m lc trc c khu vo b khc.

2. Ct chu ming bn

M kh qun

Thng m kh qun.

Th 1: Rch da

Theo hnh cung t vng di mm chm ti vng di cm theo kiu vn dng

vt hch.

Th 2: Ct u

Dng mt panh banh ming v mt si ch ko li ln, tin hnh xc nh ranh

gii ng rch.

i vi nhng ngi bnh mm ng rch ngang vi mc rng, trong

trng hp vn cn rng th ng rch mt trong xng hm di pha di ra

rng 6 mm. pha sau, ng rch t ra rng ti vng tip ni ca li,

pha trc, ng rch giao vi b li mc mt phn ba trc hoc mt phn

ba gia. phn li di ng, ng rch thng vt qua b li.

ng rch c thc hin t trc ra sau i trn lp c hm mng. pha

trong ng rch n su vo c mng li pha trc v phn trc c trm li

pha sau.

Th 3: ng h m

Thng d dng, trong ct chu ming bn, v thng thc hin c ng trc

tip.

C th ct rng hn v pha trong lm mt mt phn ln ca li di ng v v

pha sau ti phn ni, n c tr trc amydal. Trong trng hp ct rng, c th

s dng hoc vt da c mt hoc vt cng tay quay.

Th 4: Vt hch

Vt hch di hm c khi.

Lu :

- K thut ny c p dng vi cc khi u sn ming cha xm ln ra rng, mng xng v xng hm di.

- i vi nhng khi u sn ming cha xm ln xng nhng lan ti ra rng v n su, xm ln li cn ct chu ming, mt phn li v mt phn pha

trc xng hm di khng t on.

48

- i vi khi u sn ming xm ln xng hm di, thc hin ct chu sn ming v xng hm di t on.

VI. THEO DI V

- Chy mu.

- Nhim trng.

VII. X TR TAI BIN

- L xng hm: chm sc ti ch n khi vt m sch, phu thut li nhm che ph phn l xng.

- R t khoang ming ra da: cn chm sc ti ch v dng thuc khng sinh, chng vim. Nu ng r khng lin, phi phu thut ct ng r.

- Hoi t vt da-c-xng: ct lc t chc hoi t, chm sc ti ch, dng khng sinh, chng vim. Khi vt m sch, t chc ht mc tt, c th xt phu thut

to hnh li bng mt vt khc.

- Lit nhnh thn kinh b hm di ca dy VII: nu l lit tm thi do vim, c th dng khng sinh, chng vim phc hi dn. Trong trng hp dy thn

kinh b t hon ton, c th phu thut ghp thn kinh t thn.

49

X TR P ST TRONG UNG TH KHOANG MING

I. I CNG

X tr p st l mt hnh thc x tr, m ngun bc x c t bn trong hoc

bn cnh cc khu vc cn iu tr bn trong c th, mc ch l lm cho khi u

nhn bc x mt liu cao nht m t nh hng n cc v tr m lnh xung quanh,

gim thiu sai s do x ngoi gy ra k c ngi bnh co di lch, di chuyn.

X p st thng c s dng iu tr hiu qu cho ung th c t cung, tuyn

tin lit, v, ung th vm hng, da, ung th khoang ming v cng c th c

dng iu tr cc khi u khc trong c th. X tr p st c th c s dng

ring l hoc kt hp vi cc liu php khc nh phu thut, x tr ngoi (EBRT)

v ha cht.

Hin nay x tr p st thng s dng ngun x c sut liu cao nhm gim

thiu thi gian iu tr cho ngi bnh. X tr p st cho php mt liu bc x cao

c p dng cho mt khu vc nh. Hn na, do cc ngun bc x c t trong

hoc bn cnh cc khi u mc tiu, nn cc ngun x vn duy tr v tr ca chng

trong mi lin h vi khi u khi di chuyn ngi bnh hoc c bt k chuyn ng

no ca c th. iu ny cho php bc s tnh ton t c mt mc liu x

cao ph hp - tc l m bo ton b khi u nhn c mt mc ti u ca bc

x. N cng lm gim nguy hi cho cc m lnh ln cn, c quan hoc cc cu

trc xung quanh khi u, nh vy nng cao c hi cha bnh v bo v cc c quan

chc nng.

Vic s dng x tr p st cho php thi gian iu tr gim so vi x ngoi

(EBRT). Do thch hp cho nhng ngi bnh ang phi lm vic, ngi bnh

ln tui, hoc nhng ngi bnh xa ni iu tr, m bo h tun th k

hoch iu tr. Rt ngn thi gian iu tr gip nng cao hiu qu ca x tr.

Hai loi chnh ca iu tr x p st v v tr ca cc ngun phng x:

- Cc ngun c t trc tip vo cc m mc tiu nh tuyn tin lit, khoang ming, v.

- Ngun c t trong khng gian cnh m mc tiu l khoang ca c th nh c t cung, t cung, m o, kh qun, thc qun hoc bn ngoi nh da.

Ung th khoang ming chim 5- 10 cc loi ung th. Bao gm ung th li

di ng, ung th sn ming, ung th khe lin hm, ung th tuyn nc bt ph,

ung th khu ci v ung th li hm. 90 ung th khoang ming l loi ung th t

bo vy xut pht t nim mc biu m khoang ming.

http://en.wikipedia.org/wiki/Radiotherapyhttp://en.wikipedia.org/wiki/Radiationhttp://en.wikipedia.org/wiki/Cervical_cancerhttp://en.wikipedia.org/wiki/Brachytherapy#cite_note-GEC-ESTRO-Cervix-0http://en.wikipedia.org/wiki/Brachytherapy#cite_note-GEC-ESTRO-Cervix-0http://en.wikipedia.org/wiki/Prostatehttp://en.wikipedia.org/wiki/Breasthttp://en.wikipedia.org/wiki/Skin_cancerhttp://en.wikipedia.org/wiki/External_beam_radiotherapy

50

Kt qu iu tr ung th khoang ming cng nh hu ht cc loi ung th khc

l ph thuc phn ln vo giai on ca bnh.

II. CH NH

X tr p st iu tr trong ung th khoang ming giai on sm.

giai on mun th cn phi phi hp vi cc phng thc iu tr khc nh

ho cht, phu thut, x ngoi

III. CHUN B

1. Ngi thc hin: Cc bc s, k thut vin chuyn nghnh ung th c

o to, nm vng cc quy trnh iu tr, ch nh, thng tho cc thao tc trong

quy trnh, vn hnh tt cc thit b, my mc chuyn khoa, nm vng v sn sng

x tr khi c tai bin.

2. Phng tin: B dng c np ngun, my np ngun (c cha ngun x),

catheter, my chp X quang m phng, my siu m, h thng tnh liu. My ni

soi cho mi v tr cn x tr p st. Phng tin phu thut, gy m cp cu khi cn

thit. Thuc gy t, gy m, gim au.

Lu : ngun x h phi c bo qun k cng, ni ging bit, cc tiu

chun an ton bc x phi theo tiu chun ca b y t, v IAEA.

3. Ngi bnh

- nh gi ton trng ngi bnh, tn thng giai on...

- Thm khm k cng.

- Ln k hoch chun b v liu lng x.

- Chun b v tinh thn cho ngi bnh bng cch gii thch k cc vic phi lm ngi bnh c s phi hp tt vi nhn vin y t.

- C phng n x tr c th khi c tai bin xy ra trong khi thc hin.

4. H s bnh n: ghi theo mu bnh n in sn theo qui dnh cu B Y t

IV. CC BC TIN HNH

- Khm lm sng ton din nh gi giai on bnh.

- Chn on hnh nh c s dng bit c hnh dng v kch thc ca khi u v lin quan cc m v c quan.

- X-quang, siu m, chp ct lp trc tnh ton (CT hay CAT), qut v chp cng hng t (MRI). Cc d liu t nhiu ngun ny c th c s dng

to ra mt hnh nh 3D ca khi u v cc xung quanh m.

- S dng cc thng tin ny, lp k hoch phn b ti u cc ngun bc x p dng cho tng loi x p st. iu ny bao gm xem xt cc cch thc t

51

ngun, tnh liu x ni iu tr. Catheter l khng phng x v thng l kim

tim hoc ng thng bng nha. Cc loi hnh c th ca catheter c s dng

s ph thuc vo loi ung th c iu tr v cc c tnh ca cc khi u mc

tiu.

Lp k hoch gip m bo rng khi u s nhn liu cao nht v c quan lnh

s c bo v.

- Trc khi ngun phng x pht tia n khi u, cc catheter phi c a vo ng v tr ph hp vi k hoch ban u, s dng Xquang, siu m.. kim

tra hon thin k hoch iu tr. Qut CT v MRI cng c th c s dng.

- Sau khi catheter c a vo, c nh Sau khi xc nhn l ang c v tr chnh xc, hnh nh c th tip tc c thc hin hng dn lp k hoch

iu tr.

- Cc hnh nh ca ngi bnh vi cc catheter ti ch c nhp vo phn mm lp k hoch iu tr v ngi bnh c a vo mt phng bo v chuyn

dng iu tr. Cc phn mm lp k hoch iu tr cho php nhiu hnh nh

2D ca ni cn iu tr c 3D o, trong v tr ca cc catheter c th

c xc nh. Cc mi quan h khng gian gia catheter, ni iu tr v m

lnh trong vng ny ca ngi bnh o "l mt bn sao ca cc mi quan h

trong cc ngi bnh thc t.

- Ti u ha cc k hoch chiu x

xc nh s phn b khng gian v thi gian ti u cc ngun bc x trong

catheter ca cc m cy ghp hay khoang, phn mm lp k hoch iu tr tnh

toan ti u cho v tr cn iu tr. Phn mm ny cho thy s phn b liu x nhm

c k hoch ti u, ph hp vi cu trc ca mi ngi bnh.

- Cc ngun bc x s dng cho x tr p st lun c cha trong mt contener khng phng x. Cc ngun thng c di chuyn thng qua mt k thut

c gi l afterloading, trnh nhim x cho nhn vin y t

Trong afterloading ngun c a vo catheter bng iu khin bn ngoi.

Sau khi t c chnh xc v tr catheter ngi bnh, chng c ni vi

my tnh mt 'afterloader' (c cha ngun phng x) thng qua mt lot cc ng

dn kt ni. Cc k hoch iu tr c gi n cc afterloader, sau kim sot

vic cung cp cc ngun dc theo ng dn vo cc v tr nh trc trong vng

phun. Qu trnh ny ch tham gia khi nhn vin ra khi phng iu tr. Cc ngun

pht theo k hoch iu tr, sau chng c tr li cng cc ng afterloader

ny.

Sau khi hon thnh nhim v ca cc ngun phng x, cc catheter c cn

thn ly ra khi c th.

52

Ht nhn phng x Pht tia Thi gian bn hy Nng lng

Sesium-

137 ( 137 Cs) 30,17 nm 0,662 MeV

Cobalt-60 ( 60 Co) 5,26 nm 1,17, 1,33 MeV

Iridium-192 ( 192 Ir) 74,0 ngy 0,38 MeV (trung bnh)

It-125 ( 125 I) X 59,6 ngy 27,4, 31,4 v 35,5 keV

Palladium-

103 ( 103 Pd) X 17,0 ngy 21 keV (trung bnh)

Rutheni-

106 ( 106 Ru) 1,02 nm 3,54 MeV

V. BIN CHNG V X TR

- Tt ngun: Khn trng iu khin cho ngun chy vo qua afterloading.

- Chy mu: kp thi cm mu bng cc phng php ni khoa, ngoi khoa.

- Nn, bun nn trong x tr p st vng u c: dng thuc chng nn

- Ngi bnh phi c theo d i mch, nhit , huyt p sau x tr.

http://en.wikipedia.org/wiki/Caesium-137http://en.wikipedia.org/wiki/Caesium-137http://en.wikipedia.org/wiki/Cobalt-60http://en.wikipedia.org/wiki/Iridium-192http://en.wikipedia.org/wiki/Iodine-125http://en.wikipedia.org/wiki/Palladium-103http://en.wikipedia.org/wiki/Palladium-103http://en.wikipedia.org/wiki/Ruthenium-106http://en.wikipedia.org/wiki/Ruthenium-106

53

X TR P ST XUT LIU CAO

TRONG UNG TH SN MING

I. I CNG

Ung th sn ming chim khong 8-12 cc loi ung th u c. Triu chng

lm sng l tn thng lot lu lnh tin trin thnh tn thng si, lot rng gy

kh nut, kh ni, ngng, chy mu ...

X tr p st l phng php s dng ngun x p st v tr khi u cn iu tr,

mc ch l lm cho khi u nhn liu x cao nht v gim thiu ti a liu lng

nh hng n m lnh xung quanh. X tr p st thng c s dng hiu qu

cho ung th c t cung, tuyn tin lit, v, ung th vm hng, da, ung th khoang

ming v cng c th c dng iu tr cc khi u khc.

Hin nay x tr p st thng s dng ngun x c sut liu cao (HDR) nhm

gim thiu thi gian v nng cao cht lng iu tr cho ngi bnh.

II. CH NH

- Ung th sn ming giai on sm T1, T2.

- giai on mun th cn phi phi hp vi cc phng php iu tr khc nh ho cht, phu thut, x tr ngoi.

III. CHNG CH NH

- Ngi bnh b ri lon ng mu, bnh tim mch, tm thn.

- Th trng yu.

IV. CHUN B

1. Ngi thc hin: Cc bc s, k s vt l, k thut vin chuyn nghnh ung th

c o to, nm vng cc quy trnh iu tr, ch nh, thng tho cc thao tc

trong quy trnh, vn hnh tt cc thit b, my mc chuyn khoa, nm vng v sn

sng x tr khi c tai bin.

2. Phng tin: B dng c np ngun, my np ngun (c cha ngun x),

catheter, my chp Xquang m phng, my siu m, h thng tnh liu. Phng

tin phu thut, gy m, gy t, cp cu khi cn thit. Thuc gy t, gy m, gim

au.

Lu : Ngun x phi c bo qun an ton, ni ring bit. Cc tiu chun an

ton bc x phi theo tiu chun Vit Nam.

3. Ngi bnh

- nh gi ton trng ngi bnh, tn thng, giai on...

http://en.wikipedia.org/wiki/Radiationhttp://en.wikipedia.org/wiki/Cervical_cancerhttp://en.wikipedia.org/wiki/Brachytherapy#cite_note-GEC-ESTRO-Cervix-0http://en.wikipedia.org/wiki/Brachytherapy#cite_note-GEC-ESTRO-Cervix-0http://en.wikipedia.org/wiki/Breasthttp://en.wikipedia.org/wiki/Skin_cancer

54

- Lp k hoch chun b v liu lng x.

- Chun b v tinh thn cho ngi bnh bng cch gii thch k cc vic phi lm ngi bnh c s phi hp tt vi nhn vin y t.

4. H s bnh n: ghi theo mu bnh n in sn theo qui dnh ca B Y t

V. CC BC TIN HNH

1. Cm catheter

- a ngi bnh vo phng th thut.

- Gy t ti v tr khi u, hoc c th gy m.

- Cm cc applicater vo vng khi u sn ming, su ca applicater ph thuc vo mc xm ln ca khi u, theo chiu t trn xung di hoc t di ln

trn, mt applicater ty thuc vo th tch khi u v ngun pht x. t cc

catheter ph hp vi applicator.

Ch khi cm catheter sao cho vic ni vi dy dn ngun x phi c thun

li.

2. M phng: Chp CT hoc Xquang c bit vng sn ming kim tra v tr

cm catheter v ly s liu tnh liu x. Cc d liu ny c k s vt l x tr

s dng to ra mt hnh nh 3D ca khi u v cc t chc m lnh xung quanh.

3. Tnh liu: Bc s, k s vt l x tr dng my tnh lp k hoch phn b ti u

cc cc ng ng liu p dng cho tng loi ngun x ti khi u. Lp k hoch

gip m bo khi u s nhn liu cao nht v bo v c quan lnh xung quanh.

Chuyn k hoch iu tr sang h thng iu khin. Tng liu t 60-80 Gys thng

phn thnh 2-3 phn liu

4. iu tr

- a ngi bnh vo bung chiu x. Ni ng dn ngun x vi catheter.

- Ra lnh pht x t bung iu khin vi liu x c tnh ton.

- Trong qu trnh pht x ngi bnh phi c theo d i st qua camera.

5. Tho cc applicator: Khi pht x xong ngun x s t ng tr v container.

a ngi bnh tr v bung th thut. Tin hnh tho catheter v rt cc

applicator.

6. Theo di: Ngi bnh phi c theo d i st cc tai bin sau khi iu tr, theo

d i ton trng v nht l tnh trng chy mu.

- Ngi bnh phi c theo d i mch, nhit , huyt p trc sau x tr.

V. X TR TAI BIN V BIN CHNG

- Tt ngun: Khn trng iu khin cho ngun chy v container.

55

- Chy mu: Kp thi ngng x tr, cm mu bng cc phng php ni khoa, ngoi khoa.

- au: Ngi bnh phi c gim au k cng, c th phi gy m.

- Nn, bun nn trong x tr p st vng u c: dng thuc chng nn

56

PHU THUT CT TON B TUYN MANG TAI

BO TN DY THN KINH VII

I. I CNG

Phu thut ct ton b tuyn mang tai bo tn dy VII l ch nh phu thut

hay gp trong iu tr phu thut tuyn mang tai v i hi phu thut vin phi

lm ch v k thut trnh tn thng khng hi phc dy VII, li di chng

cho ngi bnh.

II. CH NH

- Cc khi u lnh tnh (thng l u tuyn a hnh) c kch thc ln hn 3 cm hoc u nm thy su ca tuyn.

- Cc khi u c tnh tuyn mang tai.

III. CHNG CH NH

- Khi u lan rng khng c kh nng ct b rng ri hoc khng c kh nng vt hch c trit hoc c di cn xa.

- Ngi bnh gi yu, suy dinh dng, mc bnh ton thn (tim mch, tiu ng, h hp cha iu tr n nh) khng c ch nh gy m ni kh qun

hoc nguy c vt m khng lin.

III. CHUN B

1. Ngi bnh

- Ngi bnh c lm y xt nghim c bn: huyt hc, sinh ha. Xquang, siu m,c tht tho v v sinh c nhn t ngy hm trc.

- Ngi bnh c thng bo v mc ch phu thut cng nh cc tai bin c th xy ra c bit l tn thng dy VII.

- T th ngi bnh nm nga trn bn phu thut, u c c nh nghing sang bn lnh

- Bc s phu thut ng bn bnh, ngi ph ng i din bc s m chnh

2. V cm

- Gy m ton thn cng vi t ng ni kh qun qua ng mi. Gin c ch dng khi tht cn thit trnh nh hng cho th thn kinh bng bt th.

3. Dng c: b dng c hm mt, bt th thn kinh.

4. H s bnh n: theo quy nh ca B Y t

IV. CC BC TIN HNH

57

Th 1: Rch da v bc l dy VII

ng rch c in l rch da theo ng Redon hnh li l bt u t trn

np tai 1 cm, theo rnh trc tai sau chy xung di di tai n chy theo

b trc c c n chm 1 cm sau b t do ca n xung di tip ni vi mt

phng ca xng mng. che bt so lm tng tnh thm m, c th s dng

ng rch da trong phu thut cng da mt (lifting).

ng rch i qua da, t chc di da v c cm mu. B mch thi dng

nng c tm v tht v tr cao nht c th. Khng nn bc tch qu nhiu v dy

VII, c bit l nhnh mi di thng i ra nng rt sm. Dng dao in hoc

ko bc tch cn v phn dnh vo tuyn nh ng tai sn, b trc c c n

chm.

Bc l dy VII: gii phng mt sau ca tuyn ra khi b trc ca c c n

chm, bc l c nh thn. Dy VII xut hin b trn v trong ca c theo hng

ng phn gic ca gc chm - nh. Bt th thn kinh s gip phu thut vin xc

nh chnh xc dy VII v t y dy VII c bc l theo mt ngoi t sau ra

trc n tn ch chia i.

Th 2: Ct thy nng

Dng ko i theo mt phng ca thn kinh v chy gia mt phng ny vi mt

phng nng, men theo cc nhnh ca dy VII bc tch ton b thy nng ca tuyn

trong khi bo tn c dy VII. Qu trnh bc tch ny thng xuyn b cn tr

bi s chy mu cn ti cm mu bng dao in lng cc. ng mch ngang mt

cng nh cc tnh mch mt sau, tnh mch sau hm, tnh mch ni cn c tht.

Th 3: Ct thy su

Bc tch thy su ra khi mt phng thn kinh v nng nh cc si thn kinh

nhng khng qu cng. Trong trng hp cn thit, vic tht ch ng mch cnh

ngoi c thc hin nhm mc ch trnh khng cm c mu khi ng mch

hm trong b tn thng v chui vo khuyt Juvara. Ton b thy su c ly ra

khi vng tuyn. Kim tra cm mu v hot ng ca thn kinh trc khi ng.

Th 4: ng vt m theo 2 lp, c t dn lu p lc m. Bng p nh.

VI. THEO DI

- Chy mu

- Nhim trng

VII. X TR TAI BIN

1. Lit mt

- Lit mt tm thi: lit mt mt phn hay ton b xut hin ngay lp tc sau khi ct tuyn mang tai cho d dy thn kinh vn c bo tn. Thng thng, loi

58

lit mt ny s t bin mt sau vi tun hoc vi thng. Thng xy ra nhnh

mi di bn c phu thut. Nguyn nhn l sang chn thn kinh VII do

s p, s co li hay b kh trong qu trnh phu thut hoc do thiu mu,

thng xy ra khi dy thn kinh gn l trm chm, ni c nhnh ca ng

mch trm chm nui dng n hoc do cc thao tc vi dy thn kinh qu

mnh.

- Lit mt vnh vin: xy ra khi dy thn kinh mt b u ph hy hoc do vic hy sinh dy VII v tnh hoc c ch ca phu thut vin. Nu dy thn kinh b

tn thng c ch th cn phi sa cha hoc gim thiu hu qu ca lit

mtbng cch m ghp thn kinh hoc ghp thn kinh hoc ni ghp thn kinh

h thit cng bn vi nhnh thn kinh VII.

2. Hi chng Frey

- Xut hin sau phu thut khong vi thng, thm ch vi nm sau vi biu hin , cm gic nng, tit m hi vng mang tai khi c mt kch thch no

lm bi tit nc bt nh n, ung

- Nguyn nhn do tn thng dy thn kinh tai - thi dng trong qu trnh phu thut tuyn mang tai. Khi dy thn kinh ny t phc hi, mt vi si giao cm

ng l phi i vo nhu m tuyn th li i sai ng, phn nhnh vo cc tuyn

m hi ca da v cc tiu ng mch di da.

- C th hn ch hi chng ny bng cch:

+ Ct b hon ton dy thn kinh tai-thi dng trong qu trnh phu thut

+ Dng phenol v alcohol chn thn kinh

+ Ct b thn kinh giao cm.

Ni chung hi chng ny thng nh v ngi bnh t ch nhiu nn t phi

can thip iu tr.

3. R tuyn nc bt: him gp. C th khc phc bng cch bng p. Hoc x tr

vi liu thch hp khong 2000 rads s lm gim tm thi hot ng ca phn

tuyn nc bt cn li di ng r b lp li. Nu khng c tc dng, c th

phu thut lm sch hoc thm ch ct b ri ng vt m theo tng lp.

59

PHU THUT CT TON B

U TUYN NC BT DI HM

I. I CNG

- Cc khi u tuyn nc bt chim t l 3 n 4 trong tng s cc khi u vng u c.

- Khong mt na s khi u vng di hm l khi u c tnh.

II. CH NH

- Cc khi u c tnh ca tuyn di hm.

- Cc khi u lnh tnh tuyn di hm c nhiu hoc kch thc ln.

- Vim tuyn di hm mn tnh, x ha iu tr ni khoa khng p ng.

III. CHNG CH NH

- Khi u lan rng khng c kh nng ct b rng ri hoc khng c kh nng vt hch c trit hoc c di cn xa.

- Ngi bnh gi yu, suy dinh dng, mc bnh ton thn (tim mch, tiu ng, h hp cha iu tr n nh) khng c ch nh gy m ni kh qun

hoc nguy c vt m khng lin.

IV. CHUN B

1. Ngi bnh

- Ngi bnh c lm y xt nghim c bn: huyt hc, sinh ha. Xquang, siu mc tht tho v v sinh c nhn t ngy hm trc.

- Ngi bnh c thng bo v mc ch phu thut cng nh cc tai bin c th xy ra

- T th ngi bnh nm nga trn bn phu thut, u c c nh nghing sang bn lnh, k gi vai

- Bc s phu thut ng bn bnh, ngi ph ng i din bc s m chnh

2. V cm

- Gy m ton thn cng vi t ng ni kh qun qua ng mi

3. Dng c: b dng c phu thut hm mt

H s bnh n: theo quy nh ca B Y t

V. CC BC TIN HNH

1. Cc khi u lnh tnh v vim tuyn di hm mn tnh

60

Th 1: Rch da v bc tch vt

- Rch da theo ng ngang pha di v song song vi b di ca xng hm. trnh gy tn thng nhnh b hm di ca dy thn kinh mt, nn rch da

cch rnh hm-mt khong 1-2 cm.

- Bc tch vt mc di c bm da ln pha trn ngang mc xng hm di, xung pha di ngang mc xng mng.

Th 2: Ct tuyn di hm

- xc nh nhnh b hm di ca dy thn kinh mt, tm v tht ng mch v tnh mch mt bng 2 mi ch Vicryl 3.0 (nm pha di nhnh thn kinh)

ri ct i. Cc hch nm pha trc v pha sau dy thn kinh nn c ly

i cng vi bnh phm phu thut trong trng hp khi u nghi ng c tnh.

- Phu tch dc theo b di ca tuyn, phn tip xc vi bng trc v bng sau ca c nh thn. Sau khi c hm mng c bc l, c th nhn thy dy thn

kinh li khi vn c ny ln trn v pha cung rng v ko tuyn di hm

xung di. S lin h gia cc hch di hm v cc nhnh ca dy thn kinh

li l sau khi c ct b cc nhnh ny s cho php vn dy thn kinh ny ln

pha trn vo di xng hm mt cch an ton.

- Tip tc gii phng phn tuyn di hm pha trc nm su trong c hm mng, phn tip xc vi cc sau ca tuyn di li. a s cc trng hp

khng nhn thy r dy thn kinh di li (dy XII) trong qu trnh phu tch

v khng nn ng chm n.

- Kp v ct ng tuyn di hm cng gn vng sn ming trc cng tt. Vo lc ny, tuyn di hm ch cn c gn vi ng mch mt. Kp v ct ng

mch mt hon thnh vic ct b tuyn di hm cng vi mt on ng

mch mt.

Th 3: ng vt m

- t 1 dn lu ti h m.

- Khu ng vt m theo 2 lp: c bm da v da.

2. Cc khi u c tnh

- Khi khi u xm ln hoc ph v v tuyn, cn thc hin phu thut no vt vng di hm thnh mt khi theo nguyn tc ung th ph hp. Nu cn thit

c th phi hy sinh cc c v dy thn kinh ln cn nh nhnh b hm di ca

dy thn kinh mt, c nh thn, c vai mng hoc cc c di mng.

- Ch nh vt hch c tn gc trong nhng trng hp xc nh c hch di cn trn lm sng. Nu hch xm ln ti thiu, ch cn vt hch c bin i bo tn

61

dy thn kinh IX. Trong trng hp khng s thy hch trn lm sng, ch nh

vt hch c chn lc nu khi u kch thc ln v c m hc cao.

- i vi ngi bnh ung th biu m tuyn di hm giai on mun, khi u c th xm ln xng hm hoc sn ming, kh c th phn bit c khi u c

tnh xut pht t sn ming hay tuyn di li trn lm sng. Trong nhng

trng hp ny, thng phi ct b tuyn di hm cng vi mt on xng

hm di v to hnh bng mt vt da-c-xng mch mu.

VI. THEO DI

- Chy mu

- Nhim trng

VII. TAI BIN V X TR

- Chy mu do khng kim sot c ng mch mt: ng mch mt l nguyn nhn chnh gy nn chy mu s lng nhiu trong phu thut ct ton b

tuyn di hm. V vy, vic kim sot ng mch ny l rt quan trng, c

bit l phn ng mch gn ch tch ra khi ng mch cnh ngoi do p lc

ng mch y mnh.

- Lit nhnh thn kinh b hm di ca dy VII: nu l lit tm thi do vim, c th dng khng sinh, chng vim phc hi dn. Trong trng hp dy thn

kinh b t hon ton, c th phu thut ghp thn kinh t thn.

- R t khoang ming ra da: him gp. Thng ch gp trong trng hp ung th tuyn di hm giai on mun xm ln ln sn ming, khi phu thut ct b

tuyn di hm cng vi mt on xng hm. Cn chm sc ti ch v dng

thuc khng sinh, chng vim. Nu ng r khng lin, phi phu thut ct

ng r.

- Hoi t vt da-c-xng: ct lc t chc hoi t, chm sc ti ch, dng khng sinh, chng vim. Khi vt m sch, t chc ht mc tt, c th xt phu thut

to hnh li bng mt vt khc.

62

PHU THUT CT UNG TH AMIDAN

I. I CNG

L phu thut ct amidan khu ci, tr trc hoc tr sau, nu cn khu tr hoc

ct rng thm vo mn hu, y li khi ung th lan rng

II. CH NH

- Ung th biu m amidan cn khu tr ti amidan

- Ung th biu m ca tr trc hoc tr sau amidan, cha lan vo khoang bn hng.

- Ung th biu m amidan ang gy tn thng amidan tr trc, mt phn tr sau

III. CHNG CH NH

Ung th xm ln rng trn ngi bnh c th trng yu, bnh tim mch

IV. CHUN B

- V sinh hng, khoang ming hng ngy.

- Cc xt nghim c bn theo quy nh.

- CT Scanner vng amidan, Xquang c nghing.

- Dng c ct amidan, dao in.

V. CC BC TIN HNH

1. T th

- Ngi bnh nm nga c n gi di vai.

- Phu thut vin chnh ng u, ngi ph m ng i bn

2.V cm: gy m ni kh qun

3. K thut

- Th 1: t ming kiu David-boy v chn bc di h hng

- Th 2: ct b tr trc, c th dng dao in.

- Th 3: ct b amidan cng tr trc.

- Th 4: ct b 1 phn tr sau cng 1 khi vi amidan v tr trc.

- Th 5: kim tra cm mu v c th khu hng bt phn nim mc hng, tr sau v c th t ng thng thc qun cho n.

VI. THEO DI V X TR TAI BIN

63

- Chy mu: nu chy mu nng th tht ng mch cnh ngoi

- Nhim khun: khng sinh - chng vim

- Cho n qua ng thng

- Kim tra theo d i hng hng ngy.

- C th cho xng kh dung sau ngy hu phu th 3

64

PHU THUT CT U NANG TIN NH MI

I. NH NGHA

- L phu thut ct b 1 khi u nang nm di nim mc ca mi trc c th do rng hoc khng do rng

II. CH NH

C u ca mi trc khng phi l ung th

II. CHNG CH NH

C bnh tim mch: suy tim, tiu ng nng

II. CHUN B

1. Ngi thc hin: phu thut vin chuyn khoa u mt c

2. Phng tin: b dng c phu thut phn mm

3. Ngi bnh

- V sinh vng rng ming, nh thuc st khun mi trc m vi ngy

- H s bnh n v cc xt nghim c bn theo quy nh

V. CC BC TIN HNH

1. T th: ngi bnh nm nga c gi u, phu thut vin ng chnh bn phi;

ph m 1ng bn i din; ph m 2 ng pha u ngi bnh

2. V cm: Gy t ti ch hoc gy m ni kh qun

3. K thut

- Th 1: rch nim mc rnh li mi, i nh v mng tch dn ti v nang

- Th 2: bc tch nim mc trnh vo v nang

- Th 3: bc tch ly ton b nang

- Th 4: kt thc, khu li nim mc li mi, dn lu. t 1 on mche ngn p da, nim mc tin nh mi xung cho mau lin. Kim tra nu c rng ngm,

tha th nh i

VI. THEO DI V X TR TAI BIN

- 1.Chy mu: thng nh

- 2.Nu nht mche: rt sau 24h

- 3.V sinh rng ming

- 4. Nhim khun: dng khng sinh + chng vim

65

66

PHU THUT CT B U SNG HM

I. I CNG

Cc khi u hc mi-sng-hm, lnh v c tnh, v mt nh khu c phn

chia thnh 3 loi tng ng vi 3 loi phu thut.

* Khi u tng trn: Pht trin t trong xoang sng c xu hng lan v pha hc

mt, xoang trn, xoang bm, v tng trn ca hc mi. m ng vo ti khi

u, ngi ta p dng phu thut - m hc mi cn cnh mi (phu thut Sebileau).

* Khi u tng gia pht trin t trong hc mi hay xoang hm, c xu hng lan v

pha ca mi sau hay vm hng, phu thut m ng vo thng l phu thut

m xng hm v xoang hm kt hp vi m hc mi, gi chung l phu thut -

m xuyn mi hm (phu thut ct cu trc trong xng hm trn).

* Khi u tng di pht trin t sn hc mi hay y xoang hm, vm khu ci,

cung rng trn, cn p dng phu thut Moure kt hp thm ct b vm khu ci

v ct b b li rng, tc l phi phi hp vi mt phu thut rng-hm - mt

(phu thut ct cu trc di xng hm trn).

Mt s trng hp khi u tng trn hoc tng gia lan trn nhiu vo hc

mt i hi phi no vt hc mt, nh vy phi phi hp thm chuyn khoa mt.

* Trong bi vit ny chng ti xin trnh by phu thut m hc mi cn cnh

mi.

II. CH NH

Phu thut c ni dung l rch m cnh mi (ng m webber ferguson) v

rnh mi, ct b xng sng mi mt bn, v ct b thm mt phn ca nhnh ln

xng hm nhm to mt ng m rng i vo hc mi v hng mi.

- Ch nh tt c nhng khi u lnh hay c tnh tng trn ca hc mi m khng ly c qua ng mi thng thng, v d: nhng khi u lin bo sng hm,

u lin kt sng hm.

III. CHNG CH NH

Khi u c tnh qu kh nng phu thut lan qu chng gia, xm ln no

y s; lan rng ti ch ti vng.

Ngi bnh qu gi yu, ngi bnh suy tim, suy thn khng c kh nng

chu ng c phu thut.

IV. CHUN B

1. Ngi thc hin

67

Phu thut vin chuyn khoa u c, tai mi hng c kinh nghim, kin thc

vng vng v gii phu, sinh l tai-mi-hng. Cn mt phu thut vin v 2 ph

m c kinh nghim.

2. Ngi bnh: Khm ton thn k cng, ch cc bnh tim mch, h hp. V

sinh mi, hng, rng, ming trc phu thut.

3. Phng tin dng c

B dng c phu thut bao gm: Banh soi mi, dao m, ci rc xng, bc

tch, mt b c xng li thng v lng mng, cc tha no thng v khu u vi

c to v nh, km gm xng m di, banh vn Farabeuf, kp khu u, ko, ng ht,

kp kocher, km ct xng (km Liston), kp Museux.

Phng tin v cm: B ni kh qun, sp xng (bonewash), meche.

V. CC BC TIN HNH

1. V cm: Ni kh qun.

2. T th ngi bnh

Ngi bnh nm nga, u t trn gi. Phu thut vin ng pha bn m.

Ph m s 1 ng trc mt, ph m s 2 ng gia hai ngi pha u ngi

bnh v ph trch ng ht.

3. K thut

Th mt: Rch da v t chc di da

ng rch bt u t u trong lng my i theo rnh mi - m, i vng

quanh ht cnh mi v i ti ca mi. ng rch i su xung tn xng, v cui

cng ct t mi trn nhn chung bng mt mi ko.

Th hai: Bc tch phn mm v ct mc

Dng Rugine to, no bc tch ct mc bc l trn khp mi trn 1cm

trong vo ng khp gia 2 xng chnh mi, i ln ti ca xng trn. Pha

ngoi, dng bc tch nh bc tch rnh l v vn ti l ra ngoi bng mt ci

banh Farabeuf nh. Tip tc bc vn l ton ngnh ln ca xng hm trn.

Buc cc mch mu chy. Dng kp Museux kp gi cnh mi v ko vn n vo

trong l r ton h m.

Th ba: Ct b xng

Dng km ct xng, trc tin ct t b trong ca xng chnh mi, st

vi vch ngn, i ln tn khp trn. Tip li a km vo hc mi ct t nhnh

ln ca xng hm trn, hng ct ln cao theo st b trong ca h mt, trong khi

ph m dng mt banh Farabeuf nh che v vn nh ti l ra pha ngoi.

68

Sau khi hai ng ct bng km lm xong, phu thut nn dng mt li

c thng t ngang st khp trn mi, ri c ni lin hai ng xng ct

bng km. Ly b mnh xng v nh vy bc l tt c phn trn ca hai hc

mi cng vi khi u nm trong . Mun lm r thm na, c th c thm ln

pha cao gn trn vo khi sng.

Th bn: Thm d xc nh khi u, ly b khi u

Dng mt c lng mng rng ngang h rnh to cho vo nc hc mi v

vo khi sng y dn nh nhng t trc ra sau, dc theo mnh sng, mt cong p

xung di, n st thn xng bm. Dng c l m by nh khi u theo hng

t trn xung di t sau ra trc. Nu khi cn mc cht trong hc mi, dng

mt tha no to, lun dc theo sn mi ra st ca l mi sau, dng tha y by nh

khi u ra trc nh vy s ly c ton b khi u ra khi hc mi mt cch d

dng.

Th nm: Kim tra v lm sch h m

Kim tra t m thn trng ton b hc mi, nht l ch bm ca chn khi u,

xem c cn st th ly nt bng th no hoc nhng ch kh nghi b thm nhim

cng cn phi ly i bng dao hay ko ct. Phi thn trng c bit khi khi u

lan vo nhng b phn quan trng nh sn no, phn trong h mt, thnh ngoi

xoang bm Cng phi thn trng na v phu thut ly khi u thng gy chy

mu nhiu.

Th su: Cm mu v nht meche hc m

Thng thng nhng phu thut ny chy nhiu mu phi cm mu tng th

m. Nhng chy mu nhiu nht l th ct b khi u. V vy th ny phi lm

cng nhanh cng tt sau phi cm mu cn thn c th dng dao in cm mu

tng di v gia ca hc mi. Tng trn tuyt i khng c dng dao in v

e do gy tn thng mng no.

Dng bc nht cht hc m, t l mi sau ra trc theo kiu n xp, on

cui a ra ca mi, nht mi sau nu thy cn thit.

Th by: Khu ng m

t li phn mm v v tr c, dng kim v ch nh khu tht cn thn, ch

trng khu cnh mi m bo vt m lin p, bng ngoi vt m bng gc v

khun. Bng na mt, che kn hc m v hc mt