Nghiên cứu vạt nhánh xuyên động mạch mông trên kết hợp hút áp lực âm trong điều trị vết loét mạn tính cùng cụt (Luận án tiến sĩ)

UV

NG M CH
TH

U TR V

T

- 2018


UV

NG M CH
TH

U TR V

T
:
: 62 72 01 28

Anh

- 2018


L
uc
li u, k t qu

b trong b t k m

lu

Nguy


M CL C
Trang
Trang ph
L
M cl c
Danh m c ch vi t t t trong lu
Danh m

ng

Danh m
Danh m
Danh m

nh

TV

................................................................................................... 1
NG QUAN ................................................................................. 3

1.1.

V

.........................................................................3

1.1.1.

................................................................................................ 3

1.1.2.

iv

1.1.3.
1.1.4.

...........................................................................3

nh c a v

..............................................................................4

u tr v

t..................................................................7

1.2.

T DO T

1.2.1.

.................................9

........................................................................................9

1.2.2.

b nh sinh c

t do t

1.2.3. Nh ng y u t thu n l

................................10
t.............11

1.3.

U TR

T.....12

1.3.1.

u tr

............................................................................................12

1.3.2.

u tr t i ch .................................................................................................12

1.4.

U GI I PH U CU NG V T DA
NG M

1.4.1. M t s
1.4.2. Gi i ph

m gi i ph

....................................18
........................................................19

ng m

............................................21


1.5.

NG D NG V

NG M CH

U TR

TM

..27

1.5.1.

gi i....................................................................................................27

1.5.2.

c......................................................................................................30
U .................. 31

2.1.

U......................................................................31

2.1.1.

u gi i ph u cu ng v
ng m

.....................................................................................31

2.1.2.

......................................................................................31

2.2.

U ...............................................................31

2.2.1.

.................................................................31

2.2.2.

.......................................................31

2.3.

U.................................................................32

2.3.1.

...................................................................32

2.3.2.

.........................................................33

2.4.

U...............................................................34

2.4.1.

uv

2.4.2.

......................................................................................41

2.5.

THI T K

2.6.

X

U...........................................................................57
LI U ...........................................................................................58

2.7.

U..........................................................................58
T QU

3.1.

..........................................................................................34

U ........................................................... 59

K T QU V GI I PH U CU NG V T...............................................59

3.1.1. Tu i..................................................................................................................59
3.1.2. Gi i ..................................................................................................................59
3.1.3. S
3.1.4.

ng m
s

.............................................60
a

ng m

...................................................................................................................61


3.1.5.

c

3.1.6.

chi

3.1.7.

chi

ng m

.................................62
n ............................62

ng v

...................................................63

3.1.8. S

............................................................64

3.2.

AB

U ............65

3.2.1. Tu

ic ab

u .......................................................65

3.2.2. B

nc ab

u........................................................66

3.2.3.

ng v

ng c a b

3.2.4. Th i gian t khi b
3.2.5.

3.3.

n khi nh p vi n ...................................................67

t qu c t l c

3.2.6.

u..........................................66

......................................................................68

c

..........................................................69

K T QU

U TR H

TR

C A LI

O N N CHO
3.3.1.

..............................................72

nh h c t i ch v

K T QU

U TR

3.4.2. S
3.4.3. Chi
3.4.4.

b n nhu m HE ..........73
T B NG

V
3.4.1. Lo i v

................................70

i vi khu

3.3.3. Bi
3.4.

T.......................70
ab

3.3.2. Bi

C

NG M
ph i h

..........................78

t.....................................................................78
...................................................................................79

ng v t........................................................................................81
c v t.................................................................................................81

3.4.5. T l v t s ng sau chuy n v t (n= 38)...........................................................82
3.4.6.
3.4.7.

cu ng v t trong v

t ......................................................82

ng th i gian......................................................................................83

3.4.8. Bi n ch ng ......................................................................................................84
3.4.9.

t qu s m.....................................................................................86

3.4.10.

t qu xa........................................................................................87


N .................................................................................. 90
4.1.

M GI I PH U C

NG M CH

................................................................................................90
4.1.1. Tu

................................................................................90

4.1.2. S

...................................................................................90

4.1.3.

.......................................................................92

4.1.4. Chi

............................................................................93

4.1.5. Chi

ng v

4.1.6. S
4.1.7.

a
ng chu

n ...............94
..................................................................95

..........................................................................................96

4.2.

AB

U ..........100

4.2.1. Tu i, gi i .......................................................................................................100
4.2.2. B
4.2.3.

nc ab
v

u......................................................101

ng .........................................................................................102

4.2.4. Th i gian m c b

n th

m nh p vi n............................................102

4.2.5.

t

i ch ..........................................................................103

4.2.6. M c

t

y s ng .......................................................................105

4.2.7.
4.3.

t qu c t l c
K T QU

..............105

U TR H

TR

C A LI

O N N CHO
4.3.1.

T.....................106

.......................................................................................................106

4.3.1.1.

ng d ch ti t...............................................................................107

4.3.1.2.

i ch ng lo

4.3.1.3. Thu h p di
4.3.1.4.

ng vi khu n..................................108

................................................................................109
u qu

4.3.2. Th
4.4.

C

K T QU V

nh h c................................................109
...............................................................................111
U TR

T B NG V T
NG M

.......................112


4.4.1. Lo i v

ph i h

4.4.2. V k thu t ph

t...................................................................112
t .............................................................................114

4.4.3.

t qu s m sau m .....................................................................121

4.4.4.

t qu xa ......................................................................................122

4.4.5. Bi n ch ng trong ph u thu t .......................................................................123

4.4.6. V th i gian ph u thu t................................................................................124
4.4.7. V th

u tr ......................................................................................124

K T LU N ................................................................................................... 127
DANH M
N LU
TAI LI U THAM KH O
PH L C

................................................................... 127


DANH M

VI T T T

: B ch c
BN

: B

CS

: C ng s
:

ng m

:

ng m

TCH

: T ch c h t

VAC

:

i


DANH M
B ng
2.1.
2.2.
3.3.
3.4.
3.5.
3.6.
3.7.
3.8.
3.9.
3.10.
3.11.
3.12.
3.13.

3.15.
3.16.
3.17.
3.18.
3.19.
3.20.
3.21.
3.22.
3.23.
3.24.
3.25.
3.26.
3.27.
3.28.
3.29.

S
T l m
T l

NG
ng

Trang

t qu s m sau ph u thu t .................................................. 47
t qu xa sau ph u thu t ..................................................... 48
ng m
............... 64
t

nh n n ............................................. 66
ng v

ng theo b nh n n ............................................. 67
c c t l c ................................................ 68
t l c ................................................... 68
i ch
.................................. 69
c
.................................................................................. 69
a
........................................ 70
ng d ch .......................................................................................... 70
Di
...................................................................................... 71
Th i gian th c hi
....................................................... 71
Bi
n trong
..................... 73
S
ki
iv
c chuy n v t ............ 79
S
i v t trong chuy n v t ......................... 80
S
i cu ng v t ........................ 80
Chi
ng v t .............................................................................. 81

c v t ...................................................................................... 81
ng v t sau chuy n v t .............................................................. 82
Th i gian li n v
..................................................................... 83
Th
u tr ................................................................................. 84
Th
u tr
................................................................ 84
K t qu
u tr sau chuy n v t t 1 .................................... 87
K t qu t 3 .......................................................................... 87
K t qu t 7 ........................................................................ 88
K t qu sau 25 .................................................................. 89
K t qu t 37 ....................................................................... 89


DANH M
Bi

Trang

3.1.

Gi

3.2.

S

3.3.

S

................................................................................................ 59
n ............................................. 60
ng m

3.4.

chi

3.5.

chi

3.6.

tu i c a b

n ...................... 62
ng v

3.7.

T l BN theo gi

3.8.

Th i gian t khi b

3.9.

S l

3.10. Lo i v
3.11.

.... 61

n vi khu
ph i h

ng m

...... 63

u.............................. 65
......................................................................... 65
n khi nh p vi n............................................ 67
......................... 72
t ........................................................... 78

t ........................................................................................ 82

3.12. Th i gian ph u thu t ............................................................................ 83
3.13.

n ch ng trong ph u thu t .......................................................... 85

3.14. K t qu t sau 13 -

................................................................ 88


DANH M
Trang
2.1.

u................................................................................... 57


DANH M
Trang
aH

1.1.
1.2.
1.3.

c gia Hoa K .................... 10

ic

......... 17

Gi i ph u m

................................. 20

1.4.

t hi

1.5.

.................... 22

ng m

............................ 23

1.6.
1.7.

.................. 24
V

i ph

.................................................. 25

1.8.

ng n i t gai ch

1.9.

nh thi t k

2.1.
2.2.

c

t ......................... 26

t qu che ph

ph n c a d ng c
D ng c

c a

t b ng v
thu t ti

29

................ 33

ng m ch ........................................................ 34


DANH M
nh
2.1.

NH
nh

ng m ch ch

Ph
m

Trang
t ng d

cc

ng m

.................. 35

2.2.

mc
n i t gai ch

2.3.

ng

t..................................... 36

nh ph

cl

ng m

ng r ch da t gai ch
c t ..................................................................................................................37
2.4.

n b ng

c

Palmer .................................................................................................. 38
2.5.

ng v t t n
c

2.6.

nv

i da b

V

c Palmer ......... 39

nh v b

2.7.
2.8.

m chia

n quang ......39
nb

Ch p X-

.............................................................. 41

2.9.

t l c ho i t

2.10.

c Palmer .40

a d ch ti t c

2.11. Thi t k v

....... 42
.......................................... 43

t V-Y d

cb

m tay .......................................................... 50

2.12. Ph

tt v

2.13. Che ph

ng v

2.14. Thi t k v

u xa c a v t ..................................... 51
t V-Y ...................................................... 52

t v
n
u b ng m

nh b

m tay

cc av

x chi u r ng 7cm .................................................................................. 53


nh

nh

Trang

2.15. Ph

t ........................................................................ 54

2.16. Ph

t ........................................................................ 55

3.1.

nh c

n ch p X-

gai ch u
3.2.

ng chu n
t ................................... 64

X- quang c

.... 64

3.3.

nh h

................................................ 74

3.4.

nh h

................................................ 75

3.5.

nh h

................................................... 76

nh h

................................................... 77

3.6.

n


1

TV
t do t

ng g p, chi m t l

lo i t

[1], [2].
t do t

ng s v
cH

nm

t nh

m

[2], [3].

u tr

i Hoa K

n n ng. T

m: t

hi

u gi m c, d ch ti t

i, lan r

m

khu n huy

d

n t vong [4].
u tr qua nhi

u tr

t l c t ch c ho i t , lo i b
n nt

o

ch, d ti p nh

u tr

t da t
tr

k th pv i

u tr b

n [4].

d ng h th ng h
ti t, gi

m lo i b d ch

tt iv

c

gi i thi u b

, 1993)
c ng d ng r

m

gi

u tr v

t

[5], [6], [7], [8].
gi

u s d ng

v

che ph

t do ngu n c p

mb
ch u tr ng l
u thu t hay
nh ng b

mt

t

n ch

t

n ch

mm

c.
ng m

ng c t

u thu

u ng d

n v

u tr

a
d ng v t

u tr cho b

[9]. Trong
m

i

gi i t p trung
ng

t nh m gi

n ch


2
c

u tr

c [4], [10], [11], [12].

Vi t Nam, m t s

k t qu

d ng v

us

t qu kh
n Vi t Ti n (2010), Tr

d ng v
u tr cho

cho k t qu t t [13], [14]

uv

t

u tr

c bi
ph

u v gi i

ng m

i Vi

u tr v
ng m

uv
th

v t. V i mong mu

u tr

p nh t cho b
m
v
tr v

n

nb n n

i Vi t Nam b

tm

III,

u
ng m

th

u

c t

m gi i ph u cu ng m ch v

u qu v
h

hi u qu ,

u tr

ng m ch

ng m
t.

t


3

1.1.
1.1.1.
v
tc av

[15]

nc

tr li n v

ph
tv

n

u
c

nv

i lo n

i ch [16]
n qu c gia c a M v
xu t b n m t b

ng d

v

c

[17]

m

tv

n tri

ng ng l i

n c a s li n v

m

c

ng

bi n ch ng t i ch
ct v
cg

tv
[18], [19].

1.1.2.
V

i sau [20]:

-

ng.

-

i do suy gi m ch

-

n kinh ngo

-

u chi do thi u gi m ch

(Calci-

ch.
ng m ch.

ng m
ng g p

-

i da

b

n cu i).
ng b

m d ng thu

m h mi n d ch,
ng.

4
-

n ch ng c a b ng.

-

ch b ch huy t.

-

t m nhi m khu n hay t c m

cb .

ub
c av

id
m li n v

iv t

u tr hi u qu

ho

as

[21].
1.1.3.
1.1.3.1.

-T

t i ph

al

li n v t

t ngu n t t
ut t

i

m, s

o

n ph c a da, k t h p

v i bi
-T

(l p bi
t ch

t n

i
n

li n v

ng di n

[22], [23], [24]:

n III: giai

1.1.3.2.
- Li n v
l i s o l i. Lo

u: v
ng g p

n trong 7 t m s ch, v t c

ng


5
t

b m t da. Li n v
it

bi

t

n th ba -

om

[25].
- Li n v

n trong 7 -

tr

n

ng
nt

um

v

n

[25].

- Li n v

li n v
nh

s

nh ng v

t
i c t ch s m

do bi n ch ng, c t l c do ho i t

m khu n [25].

1.1.3.3.

- Tu i:

ng t i nhi

nh c

nv

nv
m [26].

- Nhi m khu

nv

S. aureus

c

mt

c khu n m xanh (P. aeruginosa

m li n v
-

i

[26].

ng:
Thi

m li n ho

nv tt

M ts
n thi

ng h p
ng h p collagen b d ng

l i, trong khi collagenase v n ti p t

ng h
m

t collagen. Vitamin A
i. N u cung c p

ng l n vitamin A b

ng u

d ng vitamin

p t i ch s
ut
thi

ng c n thi t cho ch

tc n
u t c n thi t cho kho ng


6
120 ph n ng c a enzyme, c n thi t cho s

n

c
Oxy: r t c n thi

nv

ng v
ng ch m li n do thi u oxy.

ng ch

i th

ch c

c oxy t do [27].

-

ng y u t
Gi m m

ho

ng c a y u t

gi m s

ng y u t

ng so v i v

b
m cd

ut

nb
nv

S m

ng: v

ng [28].

ng gi

u t

c ch proteinase: ho t

ng c a proteinase
d

ns

nb

v

ng c a c

[28].

Nh ng t

suy gi m ti

tri

n tu i th c

i trong v t

suy gi
th d

ns

ng v

s

[28].

1.1.3.4.
-

n ph n

h

n t ph n

ng trong s li n v

v

u ho

tt
s

am t
nv t

n t i ch c a da, t ch
av

u ki

ch m
l

[28], [29].
-V

n ph n

n


7
ct t

o mao m

t b d ng l i. Lo i v

ng g p

b

i cao, b

ng, b

suy gi m mi n d ch hay b
v

u hi

u d

t

u hi u xung huy
(d u hi u xung huy

ng g p

v

i) [28], [30].
-

n ph n

n
nh ic

o ra nhi u
ut

Nhi u l p m

ng t i ch .
ng nhi m khu n

ng bi u hi

ng tr ng nh t
n b ng m

ng. L

ut
n [28], [30].
- Nh ng y u t
S

cc

S

c c a collagen.

V

nh

t.

nhi m b n, d

b t

p.
1.1.4.
V

nt

nv

ng t

u tr

tr ng

t.
u tr :
-

oxy:
C tl

u ki
ch hay

ng m

ng h

t.
i.


8

-

t hay ho i t :
lo i b

it t iv

l cv

s d

n ph m ch

ch u

t

pv

c th thu t c t l c.
-

u hi n c a nhi m khu n:
u tr t i ch

n

u hi u

nhi m khu n.
S d

ph

-T

u tr nhi m khu n t i ch .

ng m:

Gi

n s l a ch

g

p.
-

t: Li

gi

VAC t

m v a ph i.
-

sung

-

v

t.

pt cb t

BN m i 2 gi m t

l
- Gi

c gi

-

u tr

-

c khi thay

n.
t

ng, v
i ch
u tr . [28], [30].

i ch
li u, ch
l i ch

ih pv
li

ng trong vi
ng cho BN sau


9
1.2.
t do t

i da, n m

tt

gi

t ph

[17].

1.2.1.
Vi
vi

t s c quan tr ng,

ng r t nhi u

n

theo H

ng

ph u thu

gi
u tr

c gia Hoa K (2007) [17].

a H

u tr

c gia Hoa K

-

t iv
cc

th
-

II: m t ph n l p

m

h ng ho
-

t ph
III: m

l p da. T ch c m
l . Ho i t

ng h
ho i t

ch huy

xu t hi

c

i da.
IV: m
im
ch.

it
at

t ho
c


10

A

B

C

D

1

aH

n

c gia Hoa K
[17]

1.2.2.
Nhi
t

gi
ct

ch
u oxy t i t ch

t
m ch ch

mv
c mao m
it t

khi lo i b l c t
ng. T

nh
ct