Ung th d dy

I- i cng: N: Ung th DD l nhng tn thng c tnh nm DD trong phm vi t tm v cho n l mn v. - ng u trong s UT ng tiu ho. - a s c pht hin G mun tc l UT DD tin trin, khi u xm ln ht b dy thnh DD, cc hch vng ln cn hoc cc tng xung quanh. Tin lng rt km d c m ct c khi u. - Nh c NS DD ng mm v sinh thit -> c kh nng pht hin khi u G sm, khi khi u cha xm ln qua lp c nim, mi ch khu tr lp nim mc v di nim mc. Tin lng tt hn sau khi ct b khi u. A- Ung th d dy sm: I- N: UT DD sm hay cn gi l ung th nng: khi khi u mi ch khu tr lp nim mc v di nim mc, cha xm ln qua lp c nim. II- Chn on: - Cn xc nh nhng i tng c nguy c cao pht hin sm - Phng tin chn on l ni soi v sinh thit. 1- i tng c nguy c cao: - Ngi > 40 tui c nhng biu hin sau: + m ch kh tiu, chn n khng r nguyn nhn. + Thiu mu, gy st + au bng trn rn, au nng rt. - Ngi c tin s vim nim mc DD mn tnh - Ngi c lot DD c chn on l lnh tnh phI I khm li thng xuyn. - Ngi c tin s ct 2/3 DD do lot lnh tnh qu 5 nm. 2- Lm sng: C nng: - Ch c cm giac chn n khng r nguyn nhn. - m ch ,y bng, kh tiu. - au bng vng trn rn, au nng rt. Ton thn: - H/c thiu mu khng r.

- Gy st cn nu ch . Thc th: - G ny khm thng khng thy g c bit. 3- Cn lm sng: XQ: - Thng kh pht hin tn thng, ngay c khi chp i quang kp. - Cc dh m Guttman miu t nh: hnh tm vn bp bnh, hnh cao nguyn...trn thc t t thy. Ni soi: L phng tn duy nht c hiu qu pht hin tn thng UT DD nng. Quan st t tm v cho n mn v Cc hnh nh quan st c chia 3 loi: - Loi I: U th li i nim mc ln cao (Polip) + Tn thg ch ni g trn b mt, vi nt nh, sn si, ranh gii tng i r. + C th soi nhn trc tip hoc bm xanh Metylen or Cnggo thy r hn. - Loi II: U b mt, ranh gii khng r. Pht hin qua s thay i mu sc ca tn thng. Chia lm 3 loi: + IIa: U i nim mc, ch hI nh ln. + IIb: U phng dt + IIc: U ko nim mc hI lm xung. - Loi III: U lot nng, lot in hnh. Sinh thit theo nguyn tc: + nhiu v tr + Nhiu mnh + Nhiu ln. + Nu nghi ng th lm sinh thit mng: triple Biopsy Nhng trng hp nghi ng -> Hn soi li sau 3-6 thng. Mt s phng php chn on sm khc: - ChI nim mc DD ri ly cht chI c soi tim Tb ung th. - Ra DD bng nc mui: ri ly dch nhum soi tm tb ung th. III- iu tr: 1- Nguyn tc: Phu thut l ch nh bt buc, t l sng > 5 nm sau m l rt cao 95%. Phu thut trit :

- Ct b rng ri khi u, trn u 6-10 cm. Ly mc ni ln. - Sinh thit tc thi trong phu thut, kim tra ko li t chc ung th: + p t bo or ct lnh t chc nghi lnh: pht ln tiu bn soi xem cn t chc ung th hay khng. - No vt hch rng ri (Chng 3) - Lp li lu thng tiu ha. 2. K thut ct d dy: - Ct on d dy: + Ct on d dy cc di: p dng cho cc thng tn vng thp ca d dy nh hang v mn v. + Ct on d dy cc trn (phu thut Sweet): Hin nay t dng, p dng cho cc thng tn vng cao ca d dy nh tm v trong thc qun b xm ln khng th ct ton b c, ming ni thc qun d dy c th qua ng ngc hoc ng bng. --> Lp li lu thng tiu ha: Kiu Billroth I,p dng cho ct DD cc di - Ct ton b d dy: Thng hay lm: l phu thut trit . + Ung th tm v. + Ung th thn v. + Ung th hang v lan ln thn v. --> Lp li lu thng tiu ha: Kiu Roux en Y (Ni thc qun tn tn vi 1 u rut a ln, sau ni tn bn on hng trng vo on rut a ln), Omega. 3. No vt hch: Theo nghin cu ca hi ung th Nht Bn th s di cn theo h bch huyt ca d dy gm 3 chng vi 16 nhm hch. Trong ung th d dy giai on sm cn no vt hch rng ri n chng 3 (R3):

Nhm 1.2 3 4 5.6 7 8 9 10 11 12 13 14 15 16

V tr Cnh tm v B cong nh B cong ln Trn di mn v ng mch v tri ng mch gan chung ng mch thn tng Rn lch ng mch lch Cung gan Sau ty Mc treo rut non Mc treo i trng ngang Trc ng mch ch

Chng 1 (R1)

2 (R2)

3 (R3)

4. Khng cn dng ha cht sau m: Tin lng rt tt

B- Ung th d dy tin trin: I- N: l khi u xm ln ht thnh DD, cc hch vng ln cn v cc tng xung quanh. Tin lng km d m ct b khi u. II- Chn on xc nh: 1- Lm sng: C nng: - au bng vng trn rn khng c chu k - y bng, m ch kh tiu. - C mu trong phn. - Chn n, bun nn, nn. Ton thn: - Gy st cn nhiu. - H/c Thiu mu (+) or vng da nh kiu vng rm. Thc th: tu theo s tin trin c th thy: - S thy khi U ranh gii r, di ng, n au tc. - Mng cng khng di ng, ranh gii khng r. - Du hiu mun: Hp mn v: bng lm hnh thuyn, nn nhiu, ra thc n cch my ngy. - DH di cn: + Hch Trousier: L 1 m hch thng n bn tri. S c th thy 1 hch to nht trong m hch. + Khi U bung trng ph n: Hc Krukenburg + Dh di cn gan, ti mt, tu lach... Trng hp nng: Bn n vin trong bnh cnh: - Suy kit, gy st nhiu - Thiu mu r - hch thng n. - C dh di cn gan: gan to, ln nhn nhiu nhn, tun hon bng h... 2- Cn lm sng: XQ d dy c thuc cn quang: Ngh n u khi: - Hnh dng d dy bt thng. - Hnh bt thng tn ti nhiu phim. - Hnh nh in hnh:

+ hnh ng thuc: tng ng vi tn thg lot, thng lot hnh thu knh. + Hnh khuyt: tng ng vi tn thng si: Hnh khuyt nham nh, hnh li to,hnh bnh ng (tn thg ng mn v), hnh ct ct. + Hnh thm nhim cng: 1 on or ton b d dy . Hnh nh co rt, thun nh, ko di. . Mt tnh mm mi ca nhu ng. -u im: + Chn on s b v tr tn thng. + Nhn vo phim c th a ra hng x tr -> tin lng. - Nhc: + Kh pht hin c G sm + Khng xc nh c u lnh or u c. - Cc hnh nh tn thng khc: + Hnh DD gin: hp mn v, vi hnh nh 3 mc: cht cn quang, dch v hi. + K tm v: ng thuc thc qun. - V tr tn thng: Hang mn v (50-60%) -> BCN (2530%) -> Tm v (10%) -> BCL v phnh v ln (t gp). - T th chp Bn: + Phim ton th: Bn ng thng. + Phim hng lot: . U on DD thp: Bn nm nga . U on DD cao (tm v): Bn nm sp, nghing tri. Ni soi chn on v sinh thit: L pp c gi tr nht. C cc hnh nh sau: - Th lot: y cng, b nham nh, d chy mu. + nim mc xung quanh mt np, c th c m trt nng 1 phn DD, sinh thit kh ly c lp di nim mc. - Th si: U si vo lng DD, to nh khng u. + Trn b mt khi U c th c hoi t or lot, l r y cng, mch mu tm en. - Th thm nhim: + Thm nhim mt phn or ton b DD. + Ch yu lp di nim mc thm nhim cng, lp nim mc b i ln, khng c u. + C th DD cht hp lm ng soi khng xung c. + Sinh thit trong trng hp ny kh ly c t chc.

* Sinh thit: + PhI ly c t nht 6 mnh. + V tr ly l ranh gii gia t chc nim mc DD lnh vi tn thng, khng nn ly trung tm khi u v ch thy c t chc hoi t. + Nu sinh thit ln 1 khng thy TB K, cn hn khm v sinh thit li sau 3-6 thng. CTM: - H/c Thiu mu mn tnh: HC nh, nhc sc. Sinh ho, nh lng CEA v CA 72-4: - Tng cao nhng khng c hiu, - Ch c gi tr trong theo di iu tr. CLVT: - nh gi s xm ln di cn ca ung th: Gan ,tu, lch, hch... 1 s XN khc: - XQ tim phi tm di cn. - Siu m bung trng, phn ph tm di cn bung trng. Ngoi ra pgt hin tn thng di cn gan. - Sinh thit Hch thng n. - nh lng nng Acid trong DD, ngy nay t dng. III- Chn on phn bit: 1- Trng hp khng s thy U: Chn on xc nh qua ni soi v sinh thit cc bnh sau: - Vim DD - Lot DD-TT. - Polyp DD. - HC tro ngc Mallories- Wiess. 2- Trng hp s thy U: U gan tri: - U di ng theo nhp th. - Chn on X: S, nh lng Alpha FP. U lnh DD: - t TC LS - Chn on X: NS DD, CT-Scan. U tu: - Khi u y DD ra pha trc. - Chn on X: CT-Scan.

 U T ngang: - DH bn tc, a mu, RL tiu ho. - Chn on X: NS i trng + sinh thit. 3- Chn on bin chng: Hp Mn v: - Nn: ra thc n nhiu ngy trc. - Bng lm hnh thuyn. - Chn an X: chp DD c thuc cn quang, NS DD. Chy mu DD: - HC chy mu ng tiu ho trn. - NS chn on v cp cu. Thng DD: - au t ngt d di, bng cng nh g. - XQ o hnh nh lim hI di vm honh (F) or c 2 bn. Di cn gan: - Gan to. S thy nhiu nhn ln nhn. - CX: S + CT-Scan. IV- iu tr: Phu thut trit : 1- Nguyn tc: - Ct trn khi U >6 cm - Ct n t chc nghi lnh ri sinh thit nhanh bng pp p t bo or ct lnh: nu vn cn t chc UT cn ct tip. - Ly sch t chc hch xung quanh n chng 3. - Lp li lu thng tiu ho. 2- Ct on DD: Tu theo v tr khi U: Ch nh: - Khi u khu tr phn trn or phn di DD. - Tn thng cha lan rng ra xung quanh. - Ton trng BN tt, chu c PT, PTV c kinh nghim. Ct on DD cc di: - p dng cho khi u hang-mn v, on di thn v. - Pha trn khi U 6 cm, pha di ct ti Hnh t trng. Ct on DD cc trn: Phu thut SWEET: ngy nay t dng. - p dng cho nhng khi u cao nh tm v, y vi, trong thc qun b xm ln, phu thut ni thc qun DD c th qua ng bng or ngc.

 Lp li lu thng theo phng php BILLROTH I v BILLRTH II - Nhc im ca pt Polya: Ming ni DD ni vi 1 quai hng trng khng thu hp mm DD: d gy ra h/c Dumping: do ming ni ln lm thc n qua DD nhanh xung hng trng. + Biu hin: au bng + V m hI + Nm ngh th thy ht ngay. + iu tr ni khoa. u nhc im: - u im: + Phu thut d dng hn ct ton b DD. + Gi c DD cc trn. + T l t vong thp hn. - Nhc im: + T l tI pht ti ngay din ct cao. + Tnh trit v mt t chc ung th km hn. 3- Ct ton b DD: ngy cng c p dng. C: - Ung th tm v - Ung th thn v - Ung th t hang v lan ln thn v. Ct ton b DD ri lp li lu thng theo pp ROUX EN Y or OMEGA.
4- Ct d dy m rng: Ngoi ct d dy ton b hay ct on d dy cn ct thm mt hay nhiu tng khc ln cn do ung th xm ln ti + Hay gp l ct gan tri. + Ct i trng ngang, ct lch. + Ct b ui ty v mc ni ty lch + Ct lch v mc ni v lch. + Bc phc mc thnh sau. + Ly b mc ni ln, mc ni nh.... 5- No vt hch xung quanh: Theo nghin cu ca hi ung th Nht Bn th s di cn theo h bch huyt ca d dy gm 3 chng vi 16 nhm hch. Trong ung th d dy giai on sm cn no vt hch rng ri n chng 3 (R3):

Nhm 1.2 3 4 5.6 7 8 9 10 11 12 13 14 15 16

V tr Cnh tm v B cong nh B cong ln Trn di mn v ng mch v tri ng mch gan chung ng mch thn tng Rn lch ng mch lch Cung gan Sau ty Mc treo rut non Mc treo i trng ngang Trc ng mch ch

Chng 1 (R1)

2 (R2)

3 (R3)

V- iu tr tm thi: C: - Khi U di cn xa khng c kh nng ct b. - Th trng Bn qu gi hoc qu yu, suy kit. Cc phng php:

- M thng DD: p dng cho khi u cc trn DD. + S dng Sonde Petze. - Ni thng thc qun hng trng: - Phu thut m thng hng trng: Phu thut MAIN: Khi khi u lm DD tham nhim ton b. L bin php bt c d cui cng. - Tht cc M. - Phu thut Newman. VI-iu tr phi hp: 1- Ha cht: - Tc dng: iu tr h tr: Gim au, lm chm pht trin khi u. - Ch nh: + Cho mi giai on: iu tr theo nguyn tc. + Khi ung th di cn. - Nn dng a ho tr liu phi hp vi phu thut. - Phc thng dng: + FAMTX: 5FU (5-Fluoro-Uracil) + Adriamycin+Methotrexat + EAP: Etoporit + Adriamycin + Cisplastin + 5FU + Acid Folic + Cisplastin 2- Min dch: Thng dng khng nguyn n, hin nay ang nghin cu thm. ASLEM ha cht non-steroid kch thch min dch. VII- Tin lng. Ph thuc: - Mc pht trin ti ch: tng quan vi cc tng ln cn. - n su ca U vo tng ln cn. - Di cn hch ko, nu c th di cn n chng th my. - Mc bit ho: khi U cng bit ho th tin lng cng tt.