170 TCYHTH&B s6 5-2014

NHAN XET BUdC DAU KET QUA UfNG DUNG PHAU THUAT CAT MO HOAI TLT BANG DAO THUY LI/C

TRONG DIEU TR! VET THUONG MAN TINH

Pham Trjnh Qudc Khanh, Dinh Phuxyng Ddng Khoa Bdng - Tao hinh thim mp - B$nh vidn Trung Vuang

T6M TAT

D0t van de: Phiu thudt cdt bd md hoai tCr id bidn phdp c6 hidu qui tich ci/c di chuin bi giu-dng vit thuang. Dao dt thuy li/c Versajet Id mdt cdng nghi mdi vdi co chi vira tudi nki vira cdt, hd thing niy c6 nhidu uu diim trong dt md hoai td.

Doi tu^ng vd Phuxmg phip nghidn cuu: Tir 6/2013 - 6/2014, chOng tdi 6a 6iiu trj 50 bdnh nhdn vdi vit lodt m$n tlnh duqc phiu thudt cdt md hoai tir bdng dao thOy luc.

Kit qui: Thi/c hidn dt hoai td trdn 50 bdnh nhdn vdi 6a s6 Id vit lodt do ddi thdo dudng, do tl dd; trong dd 60% vit thuong c6 hSc. ngdc ngdch. ChOng tdi nhdn thiy ty 1$ s^ch md /)og/ tif sau phiu thudt cit md hoai tir lin diu tidn bing dao thdy iwc chiim tp 1$ cao 62%; tlnh trang nhiim khuin vit thuong man tlnh gidm rd r^t sau phiu thudt cit md hoai tir bdng dao thOy l^rc, t} Id ciy khuin duong tlnh giim tir 76% trudc phiu thudt xuing cdn 22% sau phau thudt. 100% cdc trudng hgp duv^ theo ddi diu liin thuong tdt.

Kit iu^n: Dao thOy lux: Id mdt cdng c\j huu ich trong phiu thudt dt md ho^i tir d vit thuang man tlnh.

ABSTRACT

Background: Hydrosurgegy for debridement is an effective methode in preparing the wound bed. Versajet system Is a new device which combines lavage and sharp debridement, it has more advantages in debridment than traditional methods.

Subjects and Methods: from june,2013 to June 2014, we treated 50 patients with chronic wound. We have used the hydrosurgery system for wound debridement on those patients.

Results: we done hydrodebridment on 50 patients in which almost are diabeitc foot ulcers and pressure sore; 60% chronic wound has sinus tracts, fistulas, tunnels... We noted that the rate of clean wound after the f hydrosurgery is very high: 62%, and the state of wound infection significantly reduce from 76% positve bacterial culture pre-op to 22% post-op. And 100% monitored patients have good resultat of wound.

Conclusion: The Versajet is safe and useful in debridement on chronic wound.

Key words: chronic wound, hydrodebridment.

Phin bi$n khoa hqc: TS Mai Xudn Thdo

TCYHTH&B s6 5-2014 171

I.DATVAND£

v i t thuang man tinh gdy ra mdt gdnh ndng ddng k i doi vdi cdc hd thing y te ci v i ti suit bdnh vd tl Id tu vong cua nhan logi [10]. Mue tidu quan trpng cua diiu trj vit thuang mgn tinh Id phai loai bd md hogi tu vd che phu vit thuang sdm nhit cd thi [24].

Phiu thudt cit bd md hogi tCr Id bi$n phdp c6 hiiu qua tich eye, id mdt ciu thdnh quan trpng trong cdng thCrc chdm sdc chuin bj giudng vet thuang [4]. IVIyc dich Id logi bd t i l da md hogi tCr, giO- Igi md lanh giOp cho qud trinh liin vit thuang diin ra thudn Ip'i vd rut ngin thdi gian dieu trj.

Tip ndm 2006, phuang phdp kit hp'p tudi rCra vd logi bd md hogi td vdi thiit bj phdu thudt bdng thOy IM'C dd dup'c mi ta. K thudt ndy dupe thyc hlin phi biin. Ddy Id mdt ky thu$t ed hi$u qui cao trong phlu thu^t cit mi hogi lu" md mim, hgn chi dupe tin thuang md Idnh, hgn chi mit mdu trong qud trinh phdu thudt.

Tgi Vi0t Nam chua ed tde gia ndo nghien cCru sdu ve dao cdt thOy lue. Trdn ca sd rut kinh nghi$m nhCtng nghidn cCru cua cdc tdc gia trong nude vd trdn the gidi. Chung tdi tien hdnh nghign cdu d i tdi: "Nghiin CLPU Ci'ng d^ng dao thOiy Iv'c trong c i t Ipc md hoai tiJ' d i didu trj v l t thwo-ng man tinh" vdi cde myc tidu sau:

1. Xdc djnh mit so ddc diem Idm sdng cua vet thuang mgn tlnh.

2. Ddnh gid hidu qua Idm sdng cua dao thuy Iyc trong cit Ipc md hogi tir d vet thuang mgn tinh.

1.1. T6ng quan tdi lieu

1.1.1. Vet thuxyng man tinh

Thudt ngQ- "vit thuang mgn tinh" da dupe chip nhdn mdt cdch rdng rSi, nhung cho den ngdy nay vi$c dmh nghTa vin chua thong nhat Hiip hdl I' n vit thuang Hoa Ky chip nh$n djnh nghTa cua Lazarus vd edc ding nghidp de

xudt ndm 1992: Cdc vit thuang man tlnh Id nhu-ng vet thuang khdng hdi phyc theo trinh ty binh thudng, hodc vit thuang qua qud trinh phuc hii nhung khdng khfli phyc Igi kit qua v i giai phiu vd chCrc ndng [22], [23].

v i t thuang man tinh cd the dupe phdn logi dien hinh vd khdng diin hinh. Vit thuang dien hlnh bao gim ton thuang bong, lodt do bdnh ly mgch mdu, lodt dinh dudng thin kinh vd hai the ridng bidt: lodt chdn ddi thdo dudng vd vidm lodt ti dd. Cdc dgng vit thuang man tlnh kh6ng dien hinh gdy ra bdi rii logn ty midn, bdnh truyin nhiim, bdnh ve mgch mdu, bdnh chuyin hda, dl truyin, ung thu... Nhiiu binh he thing (bgnh Crohn) hodc phan Ci'ng miin dich bat thudng do b$nh h$ thing (mu da gangrenosum, hii chCrng edn ung). Tat ea ede vit thuang deu cd the trd thdnh mit vit thuang mgn tinh [23].

Cdc ton thuang mgn tinh dp ddi thdp dudng, do bgnh ly mgch mdu, do ti dd, do bong cd phdn logi rifeng. Cdc vit thuang man tlnh khdng dien hinh dupe chin dodn d i sdu giong ton thuang bdng [23].

1.1.2. Ton thuxmg bdng va giong bdng

Cdc vit thuang man tinh khdng diin hinh dupe xde ^nh dO sau giong tin thuang bdng [23],

Phdn chia d i sdu ton thuang bdng theo Ld Thi Trung [27]. Trong dd bdng ndng bao gdm bdng dd I, II, III vd bong sdu bao gom dd VI, V.

Bdng dp I: vidm da cip sau bong, bieu hidn ban dd, ne, dau rdt

Bdng dO 11: bong bieu bl, Idm sdng d$c trung Id nit phong vdm mdng, ehCra djch trong hodc vdng nhgt, ddy mdu hong udt chCra djeh xuat tiet, dau nhieu.

Bong dp 111. bdng trung bi dupe chia lam hai nhdm:

Bong trung bi ndng: Idp bieu bl bj hogi tCr todn bd, Idp nhCI tnjng bl bj ton thuang, vin cdn nguydn cdc phan phy cua da.

172 TCYHTH&B so 5-2014

1. Bdng trung bi sdu: tdn thuang phan Idn trung bi, ehi cdn mdt phdn sau cua tuyen mo hdi.

2 Bong sdu dd IV: bdng todn b i Idp da hodc bong sdu tdi cdc to chCrc dudi da

3. Bong dd V' t i n thuang sdu den Idp edn, gdn, ea, xuang, khdp, than kinh, mgch mdu, tgng cd the bj bdng. Bdng dd V hay gdp trong bdng dien, bdng do tiep xue kim loai, bdng lira do ty thidu, ngudi m i t tri giac bi bdng.

1.3. P h l u thuat c i t md hoai tu '

Djnh nghTa

Phau thudt cdt md hogi tCr Id vl^e logi trCr m i chit, md bj ton thuang de giup cai thi$n qud trinh Idnh v i t thuang d i in ra thudn Ipi. Vi$c logi bd md hogi tu cd nhieu phuang phdp khdc nhau nhu ph iu thudt, ca hpc, hod chat, ty phdn huy. hay dOng au tmng njdi dn phan md hoai tu [27], [4].

PhSn loai cdt md hofi tie: [27]

1 Theo mCre dd cdt md hogi tu:

+ c i t todn bd md hogi tu .

+ Cdt mdt ph in hogi td.

2. Theo k? thu i t cdt bd hogi tu, chia ra c i t todn Idp vd cdt tiep tuy in .

+ C i t bd todn bd Idp hogi tu:

+ C i t md hogi tu tCfng Idp k i iu t i ip tuyin

Mat mdu trong phau thu$t cat md hoai tO

Herndon D.N (1989, 1991). IVIonafo W.W (1992), thay nhdm b§nh nhdn cdt md hogi tu' c i n nhi iu mdu han nhdm d i iu trj b^o t i n , lupng mdu m i t trong phdu thudt cdt 1 % hoai tu to-172 d i n 616 ml mdu [7].

1.3.5. Phuxmg phdp cat md ho^i tu bang dao thuy ILK "Vesajet":

H$ thong cdt md hogi tu thuy Iyc Versajet dd dupe c h i p thu^n bdi Cyc quan 1^ thye

pham vd dup'c pham Hoa ky (FDA) trong phiu

thudt cdt Ipc v i t thuang [9].

H i thdng edt thuy Iyc Versajet™ (Smith & Nephew, Largo, FL) vdi tia nude mu i i v6 khuan vdn tdc cao eho phdp e i t Ipc sach m6 hoai tu' vd dich t i i t ; them vdo dd hd th ing ndy cd t h i dieu chlnh dp iyc ddng nude vd di iu khien edt Ipc chlnh xac vdo md hogt tu [16].

Dao cit md hoai td bing thOy li/c "Versajet" hdng sdn xuit Smith & Nephew, Anh; hd thing ndy bao gdm ba thdnh phin:

Toi nirdnc nui&

Hinh 2.1 he thong dao thCiy lu-c.

1. Tay c i m : dd du-p'c vd trCing dupe su dgng de cdt vd Idm sgch md hoai ti> d vet thuang.

2. Not d i i u chinh: B i ph§n ndy tgo ra phan Iyc cho phdp ngu in nude vdo tay dao d l ph iu thu^t

3. Bdn dgp: (Vidt bdn dgp cho phip chuyen doi cdch su dung .

- Hogt ddng

4. Mdy dup'c kich hogt bdng cdch su- dyng bdn dgp.

5. Nude m u i i 0.9% vd triJng chay qua dudng ong dp Iyc thap dupe tgo ra bdi h$ thong cua bang d i i u khien.

6. Nude muoi 0,9% dupe tgo ra dudi dp Iyc rat cao thdng qua m i t i n g hCit phan Iyc nho vdo c u i i handpiece, san x u i t mdt ddng nude t i e dd cao, vd tgo rg mdt lye hCit chdn kh ing .

TCYHTH&B 86 5-2014 173

7. Nu&c mu6i vi cSc m6 hoai tCp di^cc thu thSp bShg hoi vSo trong mOt thCmg chija chat thai.

- Tieu chuin cua van t6c nu'dc v^ ip iyc dbng cit:

8 VSn toe nyd'c trong d6ng chay 90mi/phut- 230ml/phut

9. Ap Iyc cua d6ng chSy ty 1500 psi den 12000 psi.

10. cat vi hilt sgch c^c mo hoai ty.

- Ci'ng dung ciJa dao thuy life; Thy nghiem cho thiy dao thuy iyc logi bo dyoc 88% c4c hgt so v6i 22% l<hi sy dgng tyW rya bing nyd'c ap Iyc cao thong thyd'ng [16]. Nam 2006 Mark GranicIc trinh bSy ve phycng phap cit md hogi tO bing dao thOy iyc. Hi tgo nln vlt thyo'ng Mcgrdie bio cSo tlnh hu'u ich cua cdng cy dao thuy Iyc trong vi^c iogi bo md hoai ty d' nhO'ng vet loet bSn chSn dai thio dydng [14], [15]. Tir nam 2007, Raffi Gurunluoglu da dl xult si> sung dao thuy Iyc iam giai phap thay thay thi cac phyang phap khac cho cat md hogi tir a md mem mOt s6 vi trl.[17l, [18]. Marco Apperti, Adrigna Di Lucia (2008), ket luan ring sy dgng hi thing Versgjet giilp iam giam thd'i gign phlu thujt va hgn chl ton thyong md lanh khi cit md hogi tir [13]. Roy M. Kimbie, Jonathan Mott. Jehan Joethy (2008) kit iuSn ring sO dyng h$ thing thuy iyc Versajet ISm giam thieu mat mau so vd'i cit Ipc bing dao phiu thuat va dao dot di^n [21]. Att Nitiphon MD nh$n djnh cit Igc bing dao thuy iyc cd thi tilp c$n md hogi ty d" nhOng vj tri cd hie hay dydng him ma dgo binh thydng khdng thi tiep can dycc [1].

Tgi Vi^t Ngm: Nam 2010, Phgm Trjnh Quic Khanh da nhSn xdt cat md hogi ty bing dao thuy Iyc cd yu dilm cho phap cit bo hogi ty ma It t in thyong din mo lanh, thdi gian ISn md hoc sdm hon, ciy djch vlt thyong, vlt bdng am tlnh, da ghap song t6t[10] Nam 2012, Dinh Phyong Ddng cd nghidn cyu Crng dyng dao cit thuy Iyc trong dilu trj vet thyong bdng[4].

2, B 6 | TmprNG VA PHUONG PHAP NGHIEN CI>U

2.1. Thilt k l nghien cipu - D6i tvong nghien ciru

i. Thilt k l nghidn ci>u: Thyc nghidm khdng nhdm chdng md ta hang logt eg.

il. B l i tyong nghiSn cyu: 60 bdnh nhan bi vlt thyong mgn tinh dilu trj nli tru tgi Don vi dieu trj vlt thyong Khog Bdng-Tgo hlnh Thim mj B#nh vi#n Clp cyu Tnrng Vyong, khdng phan bi$t dd tuli, gidi tinh. (td thang 06 nam 2013 din thang 06 nam 2014).

+ TiSu chuin li/a chon b0nh nhin nghiin ciru:

- Benh nhan cd 01 vet thyong do dai thao dydng phan logi dd II, III, IV, V theo Wagner

- Bgnh nhan cd vlt loet ti de vung cdng cut dd III, IV theo Hdi dong ty vin iodt Quic gig Hog kJ.

- Bgnh nhan cd ton thyong mgn tlnh do bdnh iy mgch mau dp VI.

- cac vet thyong man tlnh khdng diln hinh phan logi gilng tin thyong bdng dd Ills, ddIV, dpV.

- B l mat vlt thyong cd md hdgi ty cln cit

+ Tiiu chuin loai trir

- Bdnh nhan cd b^nh iy nOi khog kit hop qua ngng ASA dd IV,V khdng thi phiu thuat [Error! Reference source not found.].

- Benh nhan hoac ngydi nha banh nhan khdng dong y tham gia nghien cdu.

2.2. Chit l i|u nghien cu>u

Dyng cy x6t nghigm vi sinh

Dyng cy cit thijy Iyc: Dao thuy Iyc Versajet.

2.3. cac bu-d c tien hanh

Thu thap cac biln s l ngay khi b$nh nhan nhap vidn dieu tn nil tru tgi khog Bdng- Tgo hinh Thim my.

Ipc.

174 TCYHTH&B so 5 - 2014

+ Cdc biin s6 thu thdp trudc phiu thudt dt md ho$i tu:

1. Tudi: bien s i djnh lupng theo nhdm. Chia nhdm tu i i 19-30, 31-40, 41-50, 51-60, 6 1 -70, 71-80, 81-90 vd nhdm tren 90 tuoi.

2. Gidi tlnh: b i in so djnh tinh. Hai nhdm: nam, nO-.

3. Bdnh ly g ic : b i in so djnh tinh. Chia Idm 4 nhdm: B$nh ly ddi thdo dudng, lodt do ti dd, b inh ly tdc mgch, b$nh ly khdc.

4. Kich thudc v i t thuang: b i in so djnh lupng theo nhdm. Do didn tich v i t thuang theo chieu ddi vd chi iu rdng tCr do tinh ra didn tich. Chia tdm 6 nhdm: vet thuang nhd £ 20 cm^ , 20-40 cm^ 41-60 c m ^ 61-80 em^ 81-100 cm^ vd tr6n 100 cm^.

5. Vj tri v i t thuang: B i in s i ^ n h tinh. Chia 4 nhdm: Chi t r in , chi dudi , vCing cCing cyt, vj tri khde.

6. Tlnh ch i t hdo ngdc ngdch: ddnh gid khi thdm khdm b§nh nhdn: Gdm 2 nhdm: cd hie, ngdc ngdch vd kh ing cd hoc ngdc ngdch.

7. Phdn dd v i t thuong lodt bi in so dinh tinh.

8. Tinh trgng nhidm khuin tgi v i t thuang tnrdc phdu thudt cdt Ipc md hogi tu bdng dao thuy Iyc: C iy djch v i t thuang tnjdc ph lu thudt.

+ Cic biin s6 thu thdp sau phiu thudt cit md hoai ft>;

1. c i y djch v i t thuang: ngay sau c i t md hogi tCr vdi dao thOy Iyc.

2. Md hogi tCr: Ghi nhdn tinh trang md hogi tu- b i m$t v i t thuang 1 ngdy sau phdu Ihu^t e i t Ipc l in 1.Chia2nhdm:

Sgch md hogi tCr: b i m$t v i t thuang

khdng cdn md hogi t u .

Cdn rai rdc md hogi tu : b i mdt v i t

thuang edn md hogi tif.

3. Djch t i i t tgi chd v i t thuang: ddnh gid dya vdo lupng djch x u i t t i i t t h i m vdo bdng ggc trong qud trinh chdm sdc v i t thuang sau ph iu thu0t Chia 3 nhdm: it lupng djch xuat t i i t , vCra vd nh i iu .

4. Len md hgt: Ghi nhdn s y Idn md hgt trong 7 ngdy sau p h i u thu i t c i t md hogi tCr. Chia 2 nhdm:

Bo deu md hgt mpc dd vd d i u kh ip be m$t v i t thuang.

Khdng deu: b i m^t v i t thuang md hgt mpc rii rdc .5. S i l i n ph iu thu$t c i t m i hogi ti>: Ghi nh$n so lan ph iu thugt p cdc b^nh nhdn nghi in cCru.

6. Ty Id Idnh vet thuang: Theo ddi k i t qua d i iu trj d i n khi bdnh nhdn x u i t v i i n .

2.4. X I P ly sd l ieu: X u ly s trinh SPSS 20.0.'

3. K ^ QUA NGHIEN CUU

I li$u theo chuang

3.1. M§t so dac d iem d jch t l cOa b^nh nhan nghien cO'u: Nghidn cu-u t r i n 50 bgnh nh in .

(. Phdn b6 theo nhdm tudi

Bieu do 4.1: ti 1^ phan bo theo nhom tudi

TCYHTH&B 865-2014 175

Nh$n xet: Tudi nhd nhit 19, Idn nhit 93 tuii. Da s6 bdnh nhdn ttiupc nhdm tuii trung nidn vd cao tuii, ddy Id ICra tuoi thudng cd nhCrng benh ly nil khoa kdm theo.

ii. Phdn b6 theo gidi tlnh: Nam gidi nhidu hon nO' gidi, 5d%so vdi 42%.

Hi. Nguydn nhdn gdy ra vdt thuang man tlnh

Bang 4.1: Nguyen nhan gay ra v ^ thyong m^n tinh

Nguyen nhSn

Lo t do ti d^

Lo6t do dai tii^o Suitng

Lo^l do b^nii ly macii mau

Nguyen nhan khic

S6n

S6n

20

28

2

2

50

Ty 11 %

40

52

4

4

100

Oa s i binh nhdn cd vit thuang mgn tinh Id do bdnh ly ddi thdo dudng vd do tl dd

iv. Lidn quan gida tudi, gidi vd nguydn nhdn gdy ra vit thuong man tinh

Nguyen nhSn

Dai thao di^frng

Lo t ti m

rSc mach

<h4c

S6n

Bang 4.2: li§n quan gii>a tuSi va nguyi n nhan

Nhom tu6i

<30

1

0

2

0

3

3040

1

2

0

0

3

41.50

5

1

0

0

e

51-60

7

4

0

0

11

61-70

4

3

0

1

8

P= 0,03< 0.05

71-80

2

4

0

0

6

81-90

6

4

0

1

11

>90

0

2

0

0

2

Sdn

26

20

2

2

50

Lidn quan giO-a tuii vd nguydn nhdn cd y nghTa thing kd, bdnh nhdn bj vit thuang man tinh do loet ti dd cd s6 tudi cao han b$nh nhdn bj vit thuang mgn tlnh do ddi thdo dudng vd nguydn nhdn khde.

Lidn quan giCra gidi vd nguy&n nhdn vet thuang mgn tinh khdng cd -j nghTa thong kd.

3.2. IVIot sd dgc diem ciia v i t thu'ang trong nhdm nghien cu'u

/. Vi tri vit thuang dugx: cat IQC md ho^i tu

BSng 4.3: Vj tri vlt thuang dupe cdt Ipc md hogi tip

Vi tri c i t h09i ty

Viing cung cgt

Chi IrSn

Chi duiii

Son

s i n

20

3

27

50

Tylf%

40

6

54

100

176 TCYHTH&B s6 5-2014

C^c vet thyang ioet trong id nghidn CLPU chu y l u khu tru d chi dyd'i va vung cung cut.

Ii. Diin tich thuung tdn (cm^)

Da so c^c v l t thyang (17 bn) cd d i l n tich dyd i 20 cm^.

iii. Tinh chat md hogi ty b l m j t v l t thyang: Md hoai ty d" be m| t vet thyang man tlnh chu yeu b i lu hien tr6n iam s^ng dyd'i hinh thirc hogi t i i y * t (26 bn) vd hoai ty k i t hap vya khd vya y d l (19 bn).

iv. D i e diem v l t thyang cd h ic , ngdc ngdch hay khdng: Da so v l t thyang cd hoc vi ngdc ngSch chiem ti 1$ 60%. Bay \i mpt trong nh&ng khd khSn trong vigc t i l p c^n vd ioai bo md hogi t y .

V. Tinh trang n h i l m k h u i n tai v l t t h y a n g t r y d x p h l u t h u | t c i t Ipc mo hoai tir:

Bi lu dd 4.2: Di^n tich thucng t i n

Vdi 38/50 (76%) m i u c l y dyang tlnh cho th iy v l t thyang mgn tlnh ludn di kdm vdi tinh trgng nh i lm khuin tgi c h l ego. Cdc chOng vi khuin g#p nhi lu nhat \i P. aeruginosa, S. aureus vi E. coil.

vi. Lidn quan giOa vi tri vdi kich thydc vi nguydn nhdn gdy ra vet thyang mgn tinh: Lodt hogi ty chl dyd'i chu y l u trdn bdnh nhSn cd bgnh iy ddi thSo Sirtmg. icdt ti dd thi v l t thyang chu y l u 1^ i> viing cdng cut. Sy iidn quan giOa nguydn nhdn gdy lodt vd vj tri v l t thyang cd J nghla th ing kd (P=0,00<0,05).

Vi tri v l t thyong lidn quan cd i nghla th ing kd vdi di^n tich v l t thyong (P= 0,00< 0,05). V l t thyang lodt o chi dyOi da s6 cd didn tich nhd £ 20 c m ^ . Vet thyang lodt ton da s i t^p trung vOng cOng cgt.

vii. LiSn quan gi&a kich thydc vd nguydn nhdn gdy rg vet thyong man tlnh: Lidn quan cd y nghla th ing kd (P=0,001< 0,05) da s l v l t lodt kich thyd'c < 20 cm^ Id do nguydn nhdn ddi thdo dyd'ng, vet lodt do ti dd cd kich thydc ldn han.

Bieu do 4.3: phan bo vi khuan tai v l t thycrng man tinh t ruw: ph iu thuat

TCYHTH&B s6 5-2014 177

viii. Lidn quan glQ-a nguyin nhdn vd tlnh chit md hogi tu: Lien quan khdng cd y nghla thong ke (P=0,063> 0,05).

ix. Lidn quan giua nguydn nhdn vd tinh trgng nhidm khuan trade cdt md hogi td: Tlnh trgng nhiim khuin tgi chd vit thuang lidn quan khdng ed y nghTa thong ke vdi nguyfen nhdn {P=0,554> 0,05).

X Lidn quan gida vj tri vd tlnh vd tinh trang nhidm khudn trudc phdu thudt:

Tlnh trgng nhiem khuan tgi chd vet thuang \\dn quan khdng cd y nghla thong ke vdi v| tri thuang t6n(P= G,499> 0,05).

3.3. Tinh trang vet thuang sau phiu thudt cit IQC md hoai td bing dao thOy lux:

i. So lin cit igc md hoai tO': trong Id nghidn cu-u cua chCing tdi da s i cdc vit thuang dugc edt md hogi td m t lan chiim 70%, so lin cit md hogi tu nhieu nhat Id hai lin.

ii. Liin quan giQ-a nguyen nhdn vd so lin phau thudt cat md hoai tu: So ldn cdt hogi to lidn quan khdng cd y nghTa thong kd vdi nguydn nhdn gay ra vet thuang mgn tinh (P=0,426> 0,05).

///. Lien quan giO^ Idch thudc va so lin phiu thu$t cit md hoai tif: Sy lidn quan giu-a so lin cdt hogi tu vd kich thude vit thuang khdng cd j nghTa thing kd {P= 0,256> 0,05).

iv. Liin quan giO-a vi tri vd so lin phau thudt cat mo ho^i tir: lidn quan gida so lin cdt hogi tu vd vj tri vet thuang khdng cd y nghTa thong kd (P= 0.418> 0.05).

v. Lidn quan giira be mit vet thuxyng vd s6 lin phau thu$t cat md ho^i tu: lidn quan giCra b i mdt vit thuang vd s6 lan edt hogi td khdng cd y nghTa thdng kd (P=0,059> 0,05).

vi. Tinh tr^ng md ho^i tu sau dt Igc bang dao thuy lyx: lan 1:

Sau cit IQC bing dao thuy Iyc lin 1, da so cdc trudng hvp sgch hodn todn mfi hoai tCr d vet thuang chiem 62%, 38% cdn lai tinh trgng md hogi tu edn rai rdc.

vii. Lien quan giira tinh tr^ng mo hoai tif sau cat Igc va vi tri thuxmg ton:

Lien quan giO-a tinh trgng md hoai td sau cdt hogi tu" idn 1 va vj tri vet thuang cd y nghla thdng ke, da sd trudng hp'p cdn rai rdc md hogi tu' \idn quan din vet lodt vung cCing cyt

Bdng 4.4: lien quan giua tinh tr^ng mo ho^i ttr sau cat Ipc va vj trf thuang t i n

Viin

v^t thuang

chi tren

chi du^i

cung cut

Son

Tinh trang md hoai ti>

Sach mo h09i tir

2

21

8

31

Con rai r ic mo hoai tiJ

1

6

12

19

S6n

3

27

20

50

P= 0,03< 0,05

viii. Lidn quan gida tlnh trgng md hogi tO sau cit IQC vd tlnh chit hoe ngdc ngdeh tgi vit thuang:

Bang 4.5: Men quan glQ'a tinh trgng md ho^i ti> sau cat I9C va tinh tr^ng h ic , ngoc ngach t^l v4t

tiiuang

Hoc, ngdc

ngacil

C6

Khong co

Son

Tinh trang mo ho^i ty

Sfch mo h09i to

15

16

31

Con rai rdc mo hoai ti>

15

4

19

S6n

30

20

50

P= 0,032< 0,05

Lien quan glQ'a tinh trang md hogi tu- sau cit hoai tu lan 1 vd tinh trgng ngdc ngdeh cd y nghTa thong ke. Cdc vit thuang cd hic, ngdc ngdch cd ti 1 cdn md hoai tu cao

ix. Djch tiit t^i cho vit thuang:

Sau phdu thudt cdt loc md hogi tu bing dao thuy lye da so vet thuang xuit tiit djch d muc dO vCra (46%) vd it (38%).

178 TCYHTH&B so 5-2014

Lidn quan giira dich tidt d vdt thuong vdi tinh trang md hoai tu sau cdt loc:

Sau phdu thudt edt Ipc md hogi tCr bdng dao thuy Iyc da s6 vit thuang xudt tiit djch d mirc d$ vua vd It. Sy li^n quan gida tinh trgng

sgch md hoai tu vd dich tiit cd y nghTa thing kd (P= 0,00<0,05).

I, Tan suit eay vi khuin {+) trdn vet thuang trudc vd sau cdt hogi tu-

Biiu 66 4.4: Lodi vi khuan vd t in suit cay (•<

Ty I i ciy vi khuan b i mdt vit thuang trude vd sau khi cdt Igc md hogi tu- bing dao thuy lye dd giam rd r$t, sy khdc bigt ndy cd y nghla thing kd (p=0.03<0,05).

//. Lidn quan gida tinh tr^ng nhiim khuin vdi nguyin nhdn:

Lidn quan giua tinh trgng nhiim khuin vdi nguydn nhdn gdy ra vit thuang mgn tlnh khdng cd y nghTa thing kfi (P= 0,409>0,05).

///. Ldn md hat d vit thuang sau cit ho^i td bing dao thOy /(jc;

Sau cit hogi tu- bing dao thuy Iyc da s i cdc trudng hp'p (66%) md mpc nhanh do vd diu tao diiu kidn thudn Ip'i de qud trinh Idnh vet thuang didn tiin nhanh, thudn \<?\ eho sy bdm dlnh eua mSnh da ghep eung nhu vgt da.

iv. Kit qui Idnh vit thuong

Bang 4.6: Kit qua dl^u trj

Lfinh vlt thucng

Kliong theo doi du(rc

Sdn

Sd b^nh nhan

44

6

50

Tyl?%

88

12

100

88% so vlt thyong man tinh sau cat hogi ty cho kit qua lanh vlt thyong. Chi cd 6

) try6c vS sau cat hoai tu' bang dao thdy 1 ^

trydng hap (ty Id 12%) vet thyong khdng theo ddi dyoc.

4. BAN LUAN

4.1. Oac diem tu l i , gidi, nguyen nhan

Lien quan den tuoi vd gi&i

Vidt Nam Id mdt nydc dang phdt trien, ddi sing ngyo'i dan ngdy cdng dyac ndng cao. tuoi thp trung binh cung tdng Idn kdo theo mO hlnh b$nh tgt thay dli; kdm theo dd Id cdc bdnh ly 6' ngyd'i lOn tuli: tdng huylt dp, ddi thdo dydng.... cQng nhy cdc biln chCrng cua cdc bdnh ly trdn: vet thyong mgn tlnh; theo nghidn cyu cug t l chyc y te thi gi6i (WHO), ngodi nhOng vin de cua cdc bdnh ly mgn tinh, cdc bgnh iy nhiem khuin cQng chilm ti Id ego trong mo hinh bgnh tdt ndi chung [28]. Vdi 50 bdnh nhdn nghidn ciru, Chung tdi nhdn thiy da s l b0nh nhdn c6 tuoi tir 40 tro Idn, vd cd hai mic chilm ti lg cao nhat Id nhdm ty 40-50 tuli vd nhdm 80-90 tuoi (Bilu do 4.1); djc bidt nam gidi chilm ti ig cao hon (29/21); cdc kit qui trdn phii hap vOi nghidn cO'u ciJa t l chO-c y t l thi gidi.

U§n quan den nguy&n nhin

Chdng tdi ghi nhdn da s l cdc tryOng hop trong Id nghidn cyu Id hdu qua cOa ddi thdo d\rirng vi ti dd.

TCYHTH&B s6 5-2014 179

Bdnh ly dai thdo dudng Id mpt trong nhCrng nguygn nhdn hdng diu ddn din vit lodt bdn chdn mgn tinh. vet lodt vCing eung cyt do ll d i thudng di kdm vdi mdt nguyen nhdn khiin b0nh nhdn phai nim bit dpng mit chd. Diiu ndy phu hp'p vdi cdng bo cua To chuc y t i thi gidi. I\fldt din hai phin trSm ddn so d cdc nude phdt triin cd vit thuang mgn tinh trong cudc ddi eua hp.

Theo To ehu'c Y t i thd gidi vd Li6n dodn Bdi thdo dudng, Vigt Nam la mpt trong nhOng nude cd ty 1$ gia tdng b6nh ddi thdo dudng nhanh nhit thi gidi. Rit nhieu ngudi b$nh vd gia dlnh eOng nhu cde ea sd y te dang phai chju nhO'ng gdnh ndng ve kinh te eho ehi phi rat Idn trong diiu trj edn b$nh ndy [28].

Chung tdi ghi nhdn sy lidn quan cd y nghla thing k i giija nguydn nhdn gdy ra vit thuang mgn tlnh vd tuoi bdnh nhdn (Bang 4 2).

nhung nguyen nhdn gdy ra vet thuang man tinh lidn quan khdng y nghTa thing ke vdi gidi tinh cua b^nh nhdn. Diiu ndy phCi hp'p vdi nhdn djnh cua to chdc Y td the gidi, tuii thp cua ddn sd cdng cao thi ty Id mdc cdc binh ly man tlnh cdng tdng.

i-Hinh 5.1: Nhiim khuin hogi tu mgt trudc cing

chan phai d m^t b^nh nhan dai thdo dudng (Bdnh nhan N.V.N s6 hi sa 5152)

Hinh 5.2: Ton thuxmg loet viing cung cut dp IV (B^nh nhdn L.T.N s6 hi so- 32114)

Mgt so d$c diem cua vet thuxmg

i. Vjtri v i t thu-ang:

Trong nghiin cCru cua ehCing tdi, da so tin thuang d chi dudi vd vCing cung cyt (Bang 4.3). Vi tri ton thuang liin quan ed y nghTa thing k i vdi nguyfin nhdn gdy ra vit thyang. Kit qua trin cung phu hp-p vdi cdc nhdn ^nh cua Sharon Baranoski cdc tin thuang do bgnh ly ddi thdo dudng dgi da s6 khu tru d chi dudi.

edc ton thuang do ti dd thudng khu trCi tO- thdt lung trd xuong [23].

ii. Dien tich v&t thu'O'ng: Da s6 b$nh nhdn ed diin tieh vit thuang

dudi 100 em^ (Bieu do 4.2). Diin tich vi t thuang lidn quan cd y nghTa thong kd vdi vj tri vit thuang. Vit thuang lodt d chi dudi da s i cd didn tieh nhd s 20 cm^vd lidn quan ehu yeu din b$nh ly ddi thdo dudng. Vit thuang lodt Idn cd di§n tich Idn han 60cm^da so tdp

180 TCYHTH&B so 5-2014

trung vCing cQng cut vd lien quan din ti dd. Kit qua trdn phu hp'p vdi mpt so tdc gia cho ring dign tich vit thuang man tinh thdng thudng Id nhd han 1% dien tich ca thi vd cung lien quan den nguydn nhdn cung nhu vj tri vit thuang [10], [23].

Hi. Tfnh phifc tap cua v i t thu-ang: hdc, ngdc ngach

Vit thuang cd hoe vd ngdc ngdeh Id mOt trong nhdng khd khdn trong viec ddnh gid mCrc d i thuang ton, tiep cdn vd loai bd md hogi tu. IVlit trong nhO'ng d^c diem cua vit lodt mgn tinh Id thudng ton tgi hoe va ngdc nghdeh. Trong Id nghidn cuu cua chCing tdi 60% trudng hp'p tin thuang ed hoc vd ngdc nghdeh. Kit qua ndy tuang ddng vdi nghidn cCru eua Jan Stryja (2010) [8].

Iv. Tinh chit md hogi tCp:

Bang 4.2 trong nghidn cdu eua ehCing tdi thay ring hlnh thdi md hoai tCr d be m$t vit thuang mgn tinh chu yiu Id hoai tu udt 52% vd hogi tCr kit hp-p vCra khd vCra udt chiim t j \d 38%, trong khi hogi tu khd thap han chi chiim 10%.

Tenia Cs Cubision, Gurunluoglu, Klein MB, Hunter S, Hembach DIVI, da nghien cdu su dyng dao thuy Iyc tren 91 vit thuang cd hogi ti> udt dd dua ra kit lugn: dao thuy lye giCip phiu thudt vidn kiem sodt dup'c chinh xde md hogi tu- cin cdt bd vd hut sgeh hi§u qua hogi tu trdn nen vit thuang , nd Id giai phdp hi$u qua de cit sgeh md hogi ti> udt eho cdc vit thuang md mim [12], [17], [18], [26]. SCr dyng dao thuy Iyc 6k cit md hoai tu- d nhdm vit thuang mgn tinh cung cho chOng tdi kit qua tit tuang dong vdi nghidn edu cua cdc tdc gia trdn. Sau edt Ipc bdng dao thuy luc 31 trudng hp'p sgch hodn todn md hogi tu d b i m$t vet thuang 62%, 19 trudng h^p cdn rai rdc md hogi tu chiem 38%.

0$c diim vi khuin tai vet thu^yng man tinh: Trong qud trinh liin vit thuang, nhidni khuan

Id biin chO'ng ndng vd hay gdp, ldm chdm qud trinh liin vit thuang.

v i t thuang cip tinh thudng tin tgi vi khuin thudng trii d da, nhu ty cau vd cde tryc trCing Cf vit thuang mgn tlnh vdi mdi trudng ddc bigt thudng cd s6 lup'ng cOng nhu c c Chung vi khuin nhiiu han d vit thuang cip tinh Vet thuang mgn tinh cd \\dn quan din vi khuin ky khi vd nhiiu chiJng vi khuin eCing li c trdn vit thuang [2], [19], [25].

Trong nghifen cCru cda chOng tdi, cd thi thiy ring cdc vi khuan gdy nhiim khuin chill yeu tgi chd vit thuang mgn tlnh Id: P. aeruginosa duang tlnh Id rit cao (34,2%), S.aureus (26,3%), vd E. Coli (23,7%) trudc khi cit md hogi tir. (Bdng 4.4), ddy Id vi khuin vin khdng ed d trdn da idnh. Do dd, ed thi ndi nhiim khuin vit lodt mgn tlnh Id khd trdnh khoi bdi tlnh dd d nhiem cua vit thuang. Han nda P. aeruginosa vd S.aureus Id hai logi vi khuin nguy hiim bdi chCing ed tlnh khdng thuoe cao.

Trong Id nghifin cCru cua chdng tii, tlnh trgng nhiem khuin d vit thuang mgn tinh trudc phdu thu§t lidn quan khdng cd y nghTa thing kd vdi nguydn nhdn cung nhu vj tri vit thuang.

3.2. Danh gia hlfu qud cdt md hogi tu> bdng dao thuy li^c

///. S6 lin dt md /Jog/ td

Trong nghiin cd-u cOa chung tdi da s6 cdc vit thuang mgn tlnh dyp'c cdt Ipc hogi tCr 1 lin, nhiiu nhit td hai lan. S i lin cdt hogi tu khdng Ii6n quan vdi vj tri, kich thudc vd nguydn nhdn gdy ra vet thuang mgn tinh.

S6 lan cit md hogi tu' lidn quan khdng ed y nghTa thing kd vdi tinh phuc tgp cua vit thuang mgn tinh.

iv. Tinh tr?ng md ho^i tusau phau thu^t

Vi0c cit md hogi tu bdng dao phlu thuOt hodc cdc phuang tiin khdc thudng liy di mi Idnh nhiiu han mong mu6n, Idm vit thuang

TCYHTH&B s6 5-2014 181

sdu han. Mdt s i bdo edo cua ede tde gid khde cho thay vide si> dung h i thong edt md hogi tCr thuy Iyc ed higu qua cao trong logi bd hau hit t i chCrc hoai tu, it ton thuang md Idnh, ldm giam tinh trgng nhilm khuin tgi cho vit thuang[10], [6], [20].

Hinh 5.3: Be mgt vit thuang sau cit mo hogi tCr bang dao thuy Iyc

(Bdnh nhdn N.V.N s6 ho sa5152)

Theo Att Nitiphon (2012) hg thong dao thuy Iyc cd uu diem vupt trdi so vdi cdc phuang ti$n phiu thudt thdng thudng dii vdi nhCtng ton thuang sdu cd dudng him vd ngdc nghdeh [1].

Tania CS Cubison. , S. A. P. (2006); Frank L. Bowling, Daryl S. Stickings (2009); Raffi Gunjnluoglu (2007) dd ghi nhdn dao thuy Iyc cho phdp phdu thudt vien kiim sodt dugc chinh xdc md hogi td ein cit vd hCit sgch higu qua hogi tu* trfen nen vet thuang [5], [17], [26].

Trong nghidn cCru cOa chOng tdi md hogi tCr d b i m$t vit thuang mgn tinh chu yiu Id hoai tu udt (52 %) vd hogi ti> kit hp'p vCra khd vCi-a udt chiem ty Id 38%, Sau 1 lin phdu thudt da s i cdc trudng hp'p sgeh hodn todn md hoai to d vit thuang chiim 62%, 38% cdn lai tinh trgng md hogi tCr cdn rai rde. Tlnh trgng cdn md hogi tu cd lidn quan ed y nghTa thing kd din d$c diim ed hoc vd ngde ngdeh cOa vit thuang (B^ng 4.5). Vide logi bo md hogi tu vdo sdu trong nhOng ngdc ngdch ndy rit khd khdn khi sO dyng dao phiu thudt thdng thudng. Vdi dao thuy Iyc, ehCing tdi nhdn thiy ring vide

tiip cdn vdo nhO'ng ton thuang ndy dan gian vd d i ddng han rit nhiiu. Sy lien quan glQ'a tinh trgng md hoai ti> sau cdt hoai tCr lin 1 vd vi tri vit thuang ed y nghTa thing kd, da so trudng hp-p edn rai rdc md hogi tu- lien quan din vet lodt vung ciJng cut (Bang 4.4). Sy lien quan giCra tlnh trgng md hogi tu sau edt hogi tCr lin 1 vd tlnh trgng ngdc ngdch cd y nghla thong ke (Bang 4.5). Tuy nhidn, theo Roy M. Kimbie, cdt md hogi tCr bing dao thuy Iyc vdn Id mdt ky thudt dan gian, an todn vd kha thi [21]

iii. Tinh tr^ng nhidm khuan sau dt hoai td:

Frank L. Bowling, Daryl S, Stickings (2009) cho thiy vai trd eua dao thCiy lye Idm giam muc dp phdt tdn vi khuan ra cdo vCing Idn cdn nhd kha ndng vO-a cit vCra hut sgch vi khuin trdn nin vit thuang [5].

Theo Dinh Phuang D6ng(2012), ty Id ciy khuin duang tlnh sau cit hoai td gidm rd rgt d vCing cit bing dao thuy Iyc so vdi vCjng cdt hogi td bing dao lagrot [4].

Pham Trinh Quic Khanh (2012) cho thiy cit md hogi tu bdng dao thuy Iyc ldm giam tdi thiiu vide d i Igi cdc tdc nhdn gdy nhiim phau trudng, phuang phdp ndy cdn Idm giam mOt cdch cd y nghTa thing k i tlnh trgng nhiim khuan eua bgnh nhdn [10].

Trong kit qua nghien cCru cua chOng tdi, ty I i cay khuin duang tinh sau cit md hogi td giam rd rdt {Bieu d i 4.4) tCr 76% tardc phau thugt xuong cdn 22% sau phau thudt. Dieu ndy the hidn rd ndt han vai trd eCia phuang phap phdu thudt ndy trong cdt md hogi tu d vit thuang mgn tinh. Kit qua Idm sdng vd c|in Idm sdng sau cit md hogi tu bing dao thuy Iyc cho thiy: Nen vit thuang dup'c Idm sgeh den viing Idnh, tan suit vd s i lup'ng vi khuin giam rd r t. Diiu ndy phu hp'p vdi nhdn djnh cua cde tdc gia d trin cung nhu eua Mayer Tenenhaus: Vigc edt md hogi tCr bdng dao thuy Iyc logi bd dup'c hiu hit md nhiem khuan; kit qua cay vJ khuin sau phau Uiu^t bdng Versajet giam rd rdt v i so lup'ng so vdi trudc khi phlu thudt [16].

182 TCYHTH&B so 5-2014

iv. Dich tiit tai chi vit thuang sau cit md hog/ td:

Hinh 5.4: T i n thuvng loet vCing cung cut sau c i t md hoai ti> bang dao thuy ly-c (Benh nhdn L. T.N s6 hi s c 32114)

nhanh, ghgp da sdm han vd da ghgp sing tit han eung nhu giCip eho sy bdm dlnh ciia vgt da tit han. Kit qua nghien cdu ndy cOng phCi hp'p vdi nhdn djnh eua David L. Steed 1996 trong vigc dieu trj loit bdn chdn ddi thdo dudng, trong nghidn cdu cua dng, cd bing chCrng rdng vigc cit Ipc md hogi tCr giCip di thign qud trinh Idnh vet thuang [16].

Trong nghidn cCru cua chung tdi da so vet thuang sau cit md hoai tCr xuat tiet djch it vd trung binh. Sy lidn quan cd y nghTa thdng kd giu'a tlnh trgng sgch md hogi tu vd djeh tiet. & nhdng vit dup'c cdt sgch md hogi tu bing dao thuy Iyc, tinh trgng xuat tiit djch it vd trung binh. Cdn nhO'ng vit thuang xuit tiit djeh nhiiu ed liin quan din tinh trgng cdn ton tgi md hogi td. Diiu ndy eOng phu hp'p vdi nh$n djnh cua cdc tdc giS khdc, md hogi tu la mdi tnj-dng thudn Ip'i de vi khuin phdt tnen [4], [23].

V. Tlnh trang md hat:

Chuin bj nen vit thuang Id cdng tdc rat quan trpng, anh hudng tdi kit qua ghdp da vd chuyinvgtda[41, [10], [4].

Kit qua cua chCing tdi eho thay uu diim Idn nhat eua dao thuy lye la su dung d i cdt md hogi tu-; ca ehi Id tudi rCra, cdt hOt sgch tCrng Idp vl v$y Idm sgch t i i da md hogi tu trin nen vet thuang. Bleu d i 4.3 ddnh gid nin vit thuang sau cit md hogi tu-: nen vit thuang phing diu, vit thuang con tiit It dich, cd it gia mgc rai rdc trin b i mat, quan trpng Id sgch hogi tu" vd md hat dd diu. Kit qua trin eho thay su dyng dao thuy lye ed thi eit sach hogi tu din vung ti$m c$n cOa md Idnh, vi khuin gi m tit nhit sau cdt, giCip eho thdi gian Idn md hgt nhanh han, chuan bj nen vet thuang tot, Giup qud trinh Idnh vit thuang diin tiin

4. K^T QUA LANH V&T THUUNG:

Frank L Bowling; Raffi Gurunluoglu; Klein MB; dd nghiin cCru dng dyng eit md hoai tO bing dao thuy Iyc vd ghdp da ngay ISn viing vet thuang sau cdt cho kit qua tit. [5], [12], [17], [18

Hinh 5.5: Tin khuyit m$t frudc cing chdn da dup-e ehe phu bdng vgt dg tgi ch5 vd gh6p da bdo (Binh nhdn N. V.N s6 hi sa 5152)

Hinh 5.6: Ton thuang lo6t vung cung cut da CirqfC che phli bing vat da nhdnh xuyfin dOng mgch mong

tren (B?nh nhanLT.N s6h6sa32114)

TCYHTH&B so 5-2014 183

Theo Phgm Trjnh Qudc Khanh, Dinh Phuang Ddng cdt md hogi tu- b ing dao thuy Iyc cho k i t qua sgch md hogi ti>, tao d i i u ki^n cho s y Idnh v i t thuang dup'c d i i n t i i n t i t [4], [10].

Trong nghidn cCru eua chung tdi 88% so

b0nh nhdn sau edt md hogi t u b ing dao thuy

Iyc cho k i t qua Idnh vet thuang ty nhidn ho$c

sau ghdp da, chuyen vgt da, cd 6 tru-dng hp-p

(12%) khdng theo ddi dup'c (Bang 4.6), nhu-ng

trudng hp-p ndy da ph in do bgnh nhdn sau cdt

Ipc tinh trgng bgnh ly ndi khoa khdng Sn dinh

khflng t h i t i i p tuc phdu thudt che phCi ton

khuyet vd xin ve dieu trj tai nhd.

5. K ^ LUAN

Dgc d i i m djch t i vd Iam sdng:

* Bgnh nhdn bj v i t thuang mgn Unh da s i

cd tu i i tCr 40 trd lgn. Bdnh nhdn nam gidi

chiim ti Ig eao han nD-.

* Da ph in d lodt bdn chdn ddi thdo dudng

vd lodt ti dg vOng cDng cyt. Thudng cd h i c vd

nhieu ngdc ngdch.

Tlnh trgng nh i lm triing tgi chd v i t

thuang cdn r i t cao.

* Tu i i vd nguy in nhdn lien quan cd y

nghTa th ing kd, bgnh nhdn bi v i t thuang mgn

tinh do lo i t tl dd cd s6 tuoi eao han bgnh nhdn

bj vet thuang mgn tinh do ddi thdo dudng vd

nguygn nhdn khdc.

* Vj tri v i t thuang lidn quan cd y nghTa

thing kd vdi dign tieh vet thuang. V i t thuang

loit d ehi dudi da so cd didn tieh s 20 cm^. Vet

thuang lodt Idn da s i tdp trung vCing ciing cyt.

' KIch thudc vd nguygn nhdn gdy ra v i t

thuang lidn quan cd y nghla thong ke. Da s6

vet lo i t kleh thudc ^ 20 cm^ Id do nguygn nhan

ddi thdo dudng, kich thude 51-100cm^ Id v i t

lodt do t i d d ( p < 0,05).

Hieu qua cOa dao thi iy Iyc t rong

cdt md hogi tu- d vdt thu-ang man t i nh :

* Ty Id sgch md hogi tu- sau mdt lan ph lu

thudt chiem ty 1$ cao 62%.

* Giam nh i lm khuan v i t thuang mgn tlnh sau phdu thudt c i t md hogi td b ing dao thuy Iyc. ty Ig c i y k h u i n duang tinh giam tCr 76% trudc p h i u thudt xuong cdn 22% sau p h l u thudt.

* V i t thyang x u i t t i i t djch d mdc dd vira

vd It 84%. Tlnh trgng dich tiet vd ttnh trgng

sgch md hogi ttr sau ph lu thu^t lidn quan cd y

nghTa thong kd

* K i t qua d i i u tri 88% bgnh nhdn sau c i t md hoai td b i ng dao thuy Iyc d i l n tien Idnh v i t thuang ty nhign hay sau ghdp da, chuyin vgt da.

TAI U%U THAM KHAO

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2. Benjamin A Lipsky, John M Embil, Warren S Joseph, Adolf W Karchmer, Pinzur IWIS, Senneville E, (2012), '2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections', Oxford Joumal of Clinical In^cSous Diseases, V.54(12), pp.132-173.

3. Dan R. Berlowitz, Denise I Richardson and Courtney H. Lyder (2012), 'Regulation and Wound Care". Wound Care Esser)tials, Llppincott Williams & Wilkins. Six Edition, pp.21~36.

4 Dinh Phuong D6ng(2012), 'Nghidn cOv Ong dung phiu thuat cdt ho^i tO- bing dao thuy li^c trong 6ihu tri vet Sarang bon^. Lugn v3n Thgc sT Y hpc, Hpc vi$n Quan Y.

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17 Raffi Gurunluoglu (2007), "Expenences with wateijet hydrosurgery system in wound debridement". World Joumal of Emergency Surgery, V.2(10). pp.2-10.

18. Raffi Gurunluoglu, Marie Glasgow (2009), "Clinical Expenences witli the Hydrosurgical Debridement Tool at a Level I Trauma Hospital", Open Reconstructive and Cosmetic Surgery, V.2. pp.1-6.

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20. Robin Martin, Nick Allan, Merle Olson, Dennis Nagel (2011), "The impact of hydrosurgical debridment on wounds containing bacterial blofilms", Bums. V.37s, pp s i8

21 Roy M Kimble, Jonathan Mott, Jehan Joethy (2008), "Versajet hydrosurgery system for the debridment of pediatric burns', Bums, V.34, pp.297-298,

22. Samantha Holloway. Keith Harding, Joyce K. Stechmilier, Gregory Schultz (2012), "Acute and Chronic Wound Healing", Wound Care Essentials, Lippincott Williams & Wilkins, Six Edition, pp. 83-100,

23 Sharon Baranoski, Elizabeth A. Ayello, Diane K. Langemo (2012), "Wound Assessment", Wound Care Essentials, Lippincott Williams & Wilkins. Six Edition, pp. 101-125.

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28. Le Gia Vinh (2000)." C^p mau cho da", T^p chi hint) thdi hoc Ting h& Y Du^c hoc Vi$t Nam, t$p 10. s6 l.lr. 66-71.