{"id":774,"date":"2026-05-15T14:25:27","date_gmt":"2026-05-15T07:25:27","guid":{"rendered":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/?p=774"},"modified":"2026-05-15T14:25:28","modified_gmt":"2026-05-15T07:25:28","slug":"chuong-130-co-so-giai-phau-cho-noi-soi-than","status":"publish","type":"post","link":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/chuong-130-co-so-giai-phau-cho-noi-soi-than\/","title":{"rendered":"Ch\u01b0\u01a1ng 130: C\u01a1 s\u1edf Gi\u1ea3i ph\u1eabu cho N\u1ed9i soi Th\u1eadn"},"content":{"rendered":"\n
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T\u00e1c gi\u1ea3: FRANCISCO J. B. SAMPAIO<\/strong><\/h3>\n\n\n\n

D\u1ecbch l\u1ea1i: B\u00e1c s\u0129 Ph\u00fa Ngo\u1ea1i Ti\u1ebft Ni\u1ec7u<\/h3>\n\n\n\n
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H\u1ec6 TH\u1ed0NG \u0110\u00c0I B\u1ec2 TH\u1eacN: C\u00c1C \u00dd NGH\u0128A TRONG N\u1ed8I SOI TI\u1ebeT NI\u1ec6U<\/strong><\/h4>\n\n\n\n

C\u01a1 s\u1edf Gi\u1ea3i ph\u1eabu<\/strong><\/p>\n\n\n\n

\u0110\u1ec3 h\u1ed7 tr\u1ee3 c\u00e1c ph\u1eabu thu\u1eadt vi\u00ean n\u1ed9i soi ti\u1ebft ni\u1ec7u h\u00ecnh dung h\u00ecnh \u1ea3nh 3D c\u1ee7a h\u1ec7 th\u1ed1ng g\u00f3p v\u00e0 n\u1eafm b\u1eaft v\u1ecb tr\u00ed kh\u00f4ng gian ch\u00ednh x\u00e1c c\u1ee7a c\u00e1c \u0111\u00e0i th\u1eadn, tr\u01b0\u1edbc khi t\u1ea1o c\u00e1c khu\u00f4n \u0111\u00fac (corrosion endocasts) h\u1ec7 \u0111\u00e0i b\u1ec3 th\u1eadn, m\u1ed9t ch\u1ea5t c\u1ea3n quang c\u00f3 ch\u1ee9a i-\u1ed1t \u0111\u00e3 \u0111\u01b0\u1ee3c ti\u00eam v\u00e0o ni\u1ec7u qu\u1ea3n \u0111\u1ec3 l\u00e0m hi\u1ec7n h\u00ecnh h\u1ec7 th\u1ed1ng g\u00f3p nh\u1eb1m thu \u0111\u01b0\u1ee3c h\u00ecnh \u1ea3nh b\u1ec3 th\u1eadn \u0111\u1ed3 (pyelogram). Sau khi ch\u1ee5p X-quang, ch\u1ea5t c\u1ea3n quang \u0111\u01b0\u1ee3c r\u00fat ra v\u00e0 h\u1ec7 th\u1ed1ng g\u00f3p \u0111\u01b0\u1ee3c l\u1ea5p \u0111\u1ea7y b\u1eb1ng nh\u1ef1a polyester \u0111\u1ec3 t\u1ea1o ra m\u1ed9t khu\u00f4n \u0111\u00fac ba chi\u1ec1u. Nh\u1eefng m\u1eabu th\u1eadn n\u00e0y cho ph\u00e9p th\u1ef1c hi\u1ec7n nghi\u00ean c\u1ee9u so s\u00e1nh gi\u1eefa h\u00ecnh \u1ea3nh X-quang v\u00e0 khu\u00f4n \u0111\u00fac 3D t\u01b0\u01a1ng \u1ee9ng c\u1ee7a ch\u00fang.<\/p>\n\n\n\n

C\u00e1c ph\u00e1t hi\u1ec7n v\u00e0 \u00dd ngh\u0129a L\u00e2m s\u00e0ng<\/strong><\/p>\n\n\n\n

Nghi\u00ean c\u1ee9u so s\u00e1nh gi\u1eefa b\u1ec3 th\u1eadn \u0111\u1ed3 v\u00e0 khu\u00f4n \u0111\u00fac 3D c\u1ee7a h\u1ec7 th\u1ed1ng g\u00f3p \u0111\u00e3 cho ph\u00e9p nh\u1eadn th\u1ee9c \u0111\u01b0\u1ee3c m\u1ed9t s\u1ed1 kh\u00eda c\u1ea1nh gi\u1ea3i ph\u1eabu \u0111\u00e1ng ch\u00fa \u00fd c\u1ee7a h\u1ec7 th\u1ed1ng g\u00f3p th\u1eadn, v\u1ed1n r\u1ea5t quan tr\u1ecdng \u0111\u1ec3 c\u00e1c ph\u1eabu thu\u1eadt vi\u00ean n\u1ed9i soi ti\u1ebft ni\u1ec7u c\u00e2n nh\u1eafc trong c\u00e1c th\u1ee7 thu\u1eadt n\u1ed9i soi.<\/p>\n\n\n\n

S\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a c\u00e1c \u0111\u00e0i th\u1eadn nh\u1ecf vu\u00f4ng g\u00f3c (Perpendicular Minor Calices)<\/strong><\/p>\n\n\n\n

Khi s\u1ecfi n\u1eb1m trong \u0111\u00e0i th\u1eadn nh\u1ecf vu\u00f4ng g\u00f3c (H\u00ecnh 130-1), vi\u1ec7c l\u1ea5y s\u1ecfi s\u1ebd g\u00e2y th\u00eam kh\u00f3 kh\u0103n cho c\u1ea3 t\u00e1n s\u1ecfi ngo\u00e0i c\u01a1 th\u1ec3 (SWL) v\u00e0 l\u1ea5y s\u1ecfi th\u1eadn qua da (PNL). B\u1ec7nh nh\u00e2n c\u00f3 s\u1ecfi \u1edf c\u00e1c \u0111\u00e0i th\u1eadn n\u00e0y kh\u00f4ng ph\u1ea3i l\u00e0 \u1ee9ng vi\u00ean t\u1ed1t cho SWL v\u00ec c\u00e1c \u0111\u00e0i n\u00e0y lu\u00f4n c\u00f3 c\u1ed5 \u0111\u00e0i (infundibula) h\u1eb9p (\u0111\u01b0\u1eddng k\u00ednh nh\u1ecf h\u01a1n 4 mm); do \u0111\u00f3 vi\u1ec7c \u0111\u00e0o th\u1ea3i c\u00e1c m\u1ea3nh s\u1ecfi v\u1ee5n \u0111\u00e3 t\u00e1n s\u1ebd r\u1ea5t kh\u00f3 kh\u0103n. \u0110\u1ed1i v\u1edbi l\u1ea5y s\u1ecfi qua da, vi\u1ec7c ti\u1ebfp c\u1eadn tr\u1ef1c ti\u1ebfp v\u00e0o \u0111\u00e0i th\u1eadn ch\u1ee9a s\u1ecfi l\u00e0 m\u1ed9t h\u01b0\u1edbng ti\u1ebfp c\u1eadn d\u1ec5 d\u00e0ng; tuy nhi\u00ean n\u00f3 l\u1ea1i li\u00ean quan \u0111\u1ebfn m\u1ed9t \u0111\u01b0\u1eddng ch\u1ecdc d\u00f2 \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n m\u00e0 kh\u00f4ng c\u00e2n nh\u1eafc \u0111\u1ebfn m\u1ed1i t\u01b0\u01a1ng quan gi\u1ea3i ph\u1eabu \u0111\u1ed9ng-t\u0129nh m\u1ea1ch v\u1edbi h\u1ec7 th\u1ed1ng g\u00f3p. Lo\u1ea1i ch\u1ecdc d\u00f2 n\u00e0y mang nguy c\u01a1 l\u1edbn g\u00e2y t\u1ed5n th\u01b0\u01a1ng c\u1ea5u tr\u00fac m\u1ea1ch m\u00e1u. Do \u0111\u00f3, trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p s\u1ecfi \u1edf c\u00e1c \u0111\u00e0i th\u1eadn n\u00e0y, n\u00ean s\u1eed d\u1ee5ng \u0111a d\u1ea1ng c\u00e1c \u0111\u01b0\u1eddng v\u00e0o, k\u1ef9 thu\u1eadt v\u00e0 d\u1ee5ng c\u1ee5 an to\u00e0n v\u00e0 tinh vi h\u01a1n.<\/p>\n\n\n\n

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H\u00ccNH 130-1. A, H\u00ecnh chi\u1ebfu m\u1eb7t tr\u01b0\u1edbc c\u1ee7a n\u1ed9i soi b\u1ec3 th\u1eadn ph\u1ea3i cho th\u1ea5y \u0111\u00e0i th\u1eadn nh\u1ecf vu\u00f4ng g\u00f3c \u0111\u1ed5 v\u00e0o nh\u00f3m \u0111\u00e0i th\u1eadn d\u01b0\u1edbi (m\u0169i t\u00ean). B, H\u00ecnh chi\u1ebfu m\u1eb7t tr\u01b0\u1edbc c\u1ee7a n\u1ed9i soi b\u1ec3 th\u1eadn ph\u1ea3i cho th\u1ea5y \u0111\u00e0i th\u1eadn nh\u1ecf vu\u00f4ng g\u00f3c \u0111\u1ed5 v\u00e0o nh\u00f3m \u0111\u00e0i th\u1eadn d\u01b0\u1edbi (m\u0169i t\u00ean) r\u1ea5t g\u1ea7n b\u1ec3 th\u1eadn. C, H\u00ecnh chi\u1ebfu m\u1eb7t tr\u01b0\u1edbc c\u1ee7a n\u1ed9i soi b\u1ec3 th\u1eadn ph\u1ea3i cho th\u1ea5y \u0111\u00e0i th\u1eadn nh\u1ecf vu\u00f4ng g\u00f3c \u0111\u1ed5 v\u00e0o b\u1ec3 th\u1eadn (m\u0169i t\u00ean). M\u1eabu n\u00e0y c\u0169ng cho th\u1ea5y m\u1ed9t \u0111\u00e0i th\u1eadn nh\u1ecf vu\u00f4ng g\u00f3c \u0111\u1ed5 v\u00e0o nh\u00f3m \u0111\u00e0i th\u1eadn tr\u00ean (m\u0169i t\u00ean m\u1edf) v\u00e0 m\u1ed9t \u0111\u00e0i th\u1eadn nh\u1ecf vu\u00f4ng g\u00f3c \u0111\u1ed5 v\u00e0o nh\u00f3m \u0111\u00e0i th\u1eadn d\u01b0\u1edbi (\u0111\u1ea7u m\u0169i t\u00ean).<\/figcaption><\/figure>\n\n\n\n

V\u1ecb tr\u00ed c\u1ee7a c\u00e1c \u0111\u00e0i th\u1eadn so v\u1edbi b\u1edd ngo\u00e0i c\u1ee7a th\u1eadn<\/strong><\/p>\n\n\n\n

V\u00ec v\u1ecb tr\u00ed \u01b0u ti\u00ean \u0111\u1ec3 ti\u1ebfp c\u1eadn h\u1ec7 th\u1ed1ng g\u00f3p l\u00e0 th\u00f4ng qua \u0111\u00e0i th\u1eadn sau, nhi\u1ec1u n\u1ed7 l\u1ef1c \u0111\u00e3 \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n nh\u1eb1m x\u00e1c \u0111\u1ecbnh tr\u01b0\u1edbc m\u1ed5 \u0111\u00e0i th\u1eadn n\u00e0o n\u1eb1m ph\u00eda tr\u01b0\u1edbc v\u00e0 \u0111\u00e0i n\u00e0o n\u1eb1m ph\u00eda sau. \u0110\u1ec3 gi\u1ea3i quy\u1ebft v\u1ea5n \u0111\u1ec1 n\u00e0y m\u1ed9t c\u00e1ch nhanh ch\u00f3ng v\u00e0 \u00edt t\u1ed1n k\u00e9m trong qu\u00e1 tr\u00ecnh can thi\u1ec7p n\u1ed9i soi, khi b\u1ec7nh nh\u00e2n \u1edf t\u01b0 th\u1ebf n\u1eb1m s\u1ea5p, vi\u1ec7c ti\u00eam kh\u00f4ng kh\u00ed v\u00e0o h\u1ec7 th\u1ed1ng g\u00f3p s\u1ebd l\u00e0m kh\u00ed n\u1ed5i l\u00ean c\u00e1c ph\u1ea7n n\u1eb1m ph\u00eda sau nh\u1ea5t c\u1ee7a h\u1ec7 th\u1ed1ng g\u00f3p, gi\u00fap x\u00e1c \u0111\u1ecbnh \u0111\u00e0i th\u1eadn n\u00e0o n\u1eb1m \u1edf ph\u00eda sau (t\u1ea1o \u0111\u1ed9 t\u01b0\u01a1ng ph\u1ea3n th\u1ea5u quang).<\/p>\n\n\n\n

V\u1ecb tr\u00ed c\u1ee7a c\u00e1c \u0111\u00e0i th\u1eadn so v\u1edbi c\u00e1c v\u00f9ng c\u1ef1c v\u00e0 v\u00f9ng gi\u1eefa th\u1eadn<\/strong><\/p>\n\n\n\n

C\u1ef1c tr\u00ean \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi m\u1ed9t c\u1ed5 \u0111\u00e0i \u0111\u01b0\u1eddng gi\u1eefa trong 98,6% c\u00e1c tr\u01b0\u1eddng h\u1ee3p (H\u00ecnh 130-2). V\u00f9ng gi\u1eefa (r\u1ed1n th\u1eadn) \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi c\u00e1c c\u1eb7p \u0111\u00e0i th\u1eadn s\u1eafp x\u1ebfp th\u00e0nh hai h\u00e0ng (tr\u01b0\u1edbc v\u00e0 sau) trong 95,7% c\u00e1c tr\u01b0\u1eddng h\u1ee3p (xem H\u00ecnh 130-2). C\u1ef1c d\u01b0\u1edbi \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi c\u00e1c c\u1eb7p \u0111\u00e0i th\u1eadn s\u1eafp x\u1ebfp th\u00e0nh hai h\u00e0ng trong 81 m\u1eabu (57,9%) (xem H\u00ecnh 130-2A) v\u00e0 b\u1edfi m\u1ed9t c\u1ed5 \u0111\u00e0i \u0111\u01b0\u1eddng gi\u1eefa duy nh\u1ea5t trong 59 m\u1eabu (42,1%) (xem H\u00ecnh 130-2B).<\/p>\n\n\n\n

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H\u00ccNH 130-2. V\u1ecb tr\u00ed c\u1ee7a c\u00e1c \u0111\u00e0i th\u1eadn li\u00ean quan \u0111\u1ebfn v\u00f9ng c\u1ef1c v\u00e0 v\u00f9ng gi\u1eefa th\u1eadn. A, H\u00ecnh chi\u1ebfu c\u1ea1nh c\u1ee7a m\u1eabu \u0111\u00e0i th\u1eadn b\u00ean tr\u00e1i. C\u1ef1c tr\u00ean \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi m\u1ed9t ph\u1ec5u \u0111\u00e0i th\u1eadn \u1edf gi\u1eefa (m\u0169i t\u00ean). V\u00f9ng gi\u1eefa (r\u1ed1n th\u1eadn) \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi c\u00e1c \u0111\u00e0i th\u1eadn gh\u00e9p \u0111\u00f4i \u0111\u01b0\u1ee3c s\u1eafp x\u1ebfp th\u00e0nh hai h\u00e0ng (m\u0169i t\u00ean ng\u1eafn); tr\u01b0\u1edbc v\u00e0 sau. C\u1ef1c d\u01b0\u1edbi \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi c\u00e1c \u0111\u00e0i th\u1eadn gh\u00e9p \u0111\u00f4i \u0111\u01b0\u1ee3c s\u1eafp x\u1ebfp th\u00e0nh hai h\u00e0ng (m\u0169i t\u00ean d\u00e0i). B, H\u00ecnh chi\u1ebfu c\u1ea1nh c\u1ee7a m\u1eabu \u0111\u00e0i th\u1eadn b\u00ean ph\u1ea3i. C\u1ef1c tr\u00ean \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi m\u1ed9t ph\u1ec5u \u0111\u00e0i th\u1eadn \u1edf gi\u1eefa (m\u0169i t\u00ean). V\u00f9ng gi\u1eefa \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi c\u00e1c \u0111\u00e0i th\u1eadn gh\u00e9p \u0111\u00f4i \u0111\u01b0\u1ee3c s\u1eafp x\u1ebfp th\u00e0nh hai h\u00e0ng (m\u0169i t\u00ean ng\u1eafn), tr\u01b0\u1edbc v\u00e0 sau. C\u1ef1c d\u01b0\u1edbi ch\u1ec9 \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi m\u1ed9t ph\u1ec5u \u0111\u00e0i th\u1eadn \u1edf gi\u1eefa (m\u0169i t\u00ean d\u00e0i).<\/figcaption><\/figure>\n\n\n\n

Li\u00ean quan \u0111\u1ebfn s\u1ef1 d\u1eabn l\u01b0u \u0111\u00e0i th\u1eadn c\u1ee7a c\u00e1c v\u00f9ng c\u1ef1c th\u1eadn, nhi\u1ec1u nh\u00e0 nghi\u00ean c\u1ee9u kh\u1eb3ng \u0111\u1ecbnh r\u1eb1ng th\u01b0\u1eddng ch\u1ec9 c\u00f3 m\u1ed9t c\u1ed5 \u0111\u00e0i d\u1eabn l\u01b0u cho m\u1ed7i c\u1ef1c. Trong nghi\u00ean c\u1ee9u c\u1ee7a ch\u00fang t\u00f4i, c\u1ef1c tr\u00ean \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi ch\u1ec9 m\u1ed9t c\u1ed5 \u0111\u00e0i \u0111\u01b0\u1eddng gi\u1eefa trong 98,6% c\u00e1c tr\u01b0\u1eddng h\u1ee3p. Tuy nhi\u00ean, c\u1ef1c d\u01b0\u1edbi \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi c\u00e1c c\u1eb7p \u0111\u00e0i th\u1eadn s\u1eafp x\u1ebfp th\u00e0nh hai h\u00e0ng trong 81\/140 tr\u01b0\u1eddng h\u1ee3p (57,9%) v\u00e0 b\u1edfi m\u1ed9t c\u1ed5 \u0111\u00e0i \u0111\u01b0\u1eddng gi\u1eefa trong 59 tr\u01b0\u1eddng h\u1ee3p (42,1%) (xem H\u00ecnh 130-2). Nh\u1eefng k\u1ebft qu\u1ea3 n\u00e0y r\u1ea5t quan tr\u1ecdng \u0111\u1ed1i v\u1edbi n\u1ed9i soi ti\u1ebft ni\u1ec7u; vi\u1ec7c ti\u1ebfp c\u1eadn n\u1ed9i soi v\u00e0o v\u00f9ng c\u1ef1c \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi m\u1ed9t c\u1ed5 \u0111\u00e0i duy nh\u1ea5t (th\u01b0\u1eddng c\u00f3 \u0111\u01b0\u1eddng k\u00ednh ph\u00f9 h\u1ee3p) s\u1ebd d\u1ec5 d\u00e0ng h\u01a1n so v\u1edbi v\u00f9ng c\u1ef1c \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi c\u00e1c c\u1eb7p \u0111\u00e0i th\u1eadn (xem H\u00ecnh 130-2). V\u00ec c\u1ef1c d\u01b0\u1edbi \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi c\u00e1c c\u1eb7p \u0111\u00e0i th\u1eadn trong 57,9% c\u00e1c tr\u01b0\u1eddng h\u1ee3p, ph\u1eabu thu\u1eadt vi\u00ean ph\u1ea3i ghi nh\u1edb chi ti\u1ebft gi\u1ea3i ph\u1eabu n\u00e0y \u0111\u1ec3 l\u1eadp k\u1ebf ho\u1ea1ch v\u00e0 th\u1ef1c hi\u1ec7n \u0111\u01b0\u1eddng v\u00e0o trong th\u1eadn c\u0169ng nh\u01b0 c\u00e1c th\u1ee7 thu\u1eadt n\u1ed9i soi \u1edf c\u1ef1c d\u01b0\u1edbi. S\u1ef1 d\u1eabn l\u01b0u \u0111\u00e0i th\u1eadn c\u1ee7a c\u1ef1c tr\u00ean v\u00e0 c\u1ef1c d\u01b0\u1edbi c\u0169ng c\u00f3 t\u1ea7m quan tr\u1ecdng t\u1ed1i \u01b0u trong SWL v\u00e0 \u0111\u00e3 \u0111\u01b0\u1ee3c th\u1ea3o lu\u1eadn \u0111\u1ea7y \u0111\u1ee7 trong c\u00e1c b\u00e0i b\u00e1o tr\u01b0\u1edbc \u0111\u00e2y.<\/p>\n\n\n\n

V\u1ec1 s\u1ef1 d\u1eabn l\u01b0u v\u00f9ng gi\u1eefa th\u1eadn (r\u1ed1n th\u1eadn), k\u1ebft qu\u1ea3 c\u1ee7a ch\u00fang t\u00f4i cho th\u1ea5y v\u00f9ng n\u00e0y \u0111\u01b0\u1ee3c d\u1eabn l\u01b0u b\u1edfi c\u00e1c c\u1eb7p \u0111\u00e0i th\u1eadn s\u1eafp x\u1ebfp th\u00e0nh hai h\u00e0ng (tr\u01b0\u1edbc v\u00e0 sau) trong 95,7% c\u00e1c tr\u01b0\u1eddng h\u1ee3p (xem H\u00ecnh 130-2). Nh\u1eefng k\u1ebft qu\u1ea3 n\u00e0y c\u0169ng n\u00ean \u0111\u01b0\u1ee3c c\u00e1c ph\u1eabu thu\u1eadt vi\u00ean n\u1ed9i soi l\u01b0u \u00fd khi ti\u1ebfp c\u1eadn v\u00e0 thao t\u00e1c \u1edf v\u00f9ng gi\u1eefa th\u1eadn.<\/p>\n\n\n\n

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M\u1ed0I T\u01af\u01a0NG QUAN GI\u1ea2I PH\u1eaaU C\u1ee6A C\u00c1C M\u1ea0CH M\u00c1U TRONG TH\u1eacN (\u0110\u1ed8NG M\u1ea0CH V\u00c0 T\u0128NH M\u1ea0CH) V\u1edaI H\u1ec6 TH\u1ed0NG G\u00d3P<\/strong><\/h4>\n\n\n\n

\u00dd ngh\u0129a \u0111\u1ed1i v\u1edbi vi\u1ec7c ti\u1ebfp c\u1eadn trong th\u1eadn b\u1eb1ng \u0111\u01b0\u1eddng ch\u1ecdc d\u00f2<\/strong><\/p>\n\n\n\n

M\u1ed9t trong nh\u1eefng bi\u1ebfn ch\u1ee9ng \u0111\u00e1ng k\u1ec3 nh\u1ea5t trong c\u00e1c th\u1ee7 thu\u1eadt th\u1eadn qua da l\u00e0 t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u. Do \u0111\u00f3, m\u1ed9t m\u00f4 t\u1ea3 gi\u1ea3i ph\u1eabu v\u1ec1 c\u00e1c chi ti\u1ebft tinh vi li\u00ean quan \u0111\u1ebfn c\u00e1c m\u1ea1ch m\u00e1u trong th\u1eadn v\u00e0 m\u1ed1i t\u01b0\u01a1ng quan c\u1ee7a ch\u00fang v\u1edbi h\u1ec7 th\u1ed1ng g\u00f3p s\u1ebd cho ph\u00e9p ti\u1ebfp c\u1eadn trong th\u1eadn qua da an to\u00e0n h\u01a1n b\u1eb1ng c\u00e1ch gi\u1eef nguy\u00ean v\u1eb9n c\u00e0ng nhi\u1ec1u m\u1ea1ch m\u00e1u th\u1eadn c\u00e0ng t\u1ed1t trong khi ch\u1ecdc d\u00f2.<\/p>\n\n\n\n

V\u1eadt li\u1ec7u Nghi\u00ean c\u1ee9u cho C\u01a1 s\u1edf Gi\u1ea3i ph\u1eabu<\/strong><\/p>\n\n\n\n

Nghi\u00ean c\u1ee9u bao g\u1ed3m c\u00e1c h\u00ecnh \u1ea3nh b\u1ec3 th\u1eadn \u0111\u1ed3 ng\u01b0\u1ee3c d\u00f2ng v\u00e0 c\u00e1c khu\u00f4n \u0111\u00fac nh\u1ef1a polyester 3D t\u01b0\u01a1ng \u1ee9ng c\u1ee7a h\u1ec7 th\u1ed1ng g\u00f3p th\u1eadn c\u00f9ng v\u1edbi c\u00e1c \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch trong th\u1eadn thu \u0111\u01b0\u1ee3c t\u1eeb t\u1eed thi t\u01b0\u01a1i. Th\u1eadn \u0111\u01b0\u1ee3c ch\u1ecdc d\u00f2 d\u01b0\u1edbi h\u01b0\u1edbng d\u1eabn c\u1ee7a m\u00e0n t\u0103ng s\u00e1ng (fluoroscopy) v\u00e0 c\u00e1c khu\u00f4n \u0111\u00fac \u0111\u01b0\u1ee3c t\u1ea1o ra v\u1edbi c\u00e1c kim v\u1eabn \u0111\u01b0\u1ee3c \u0111\u1eb7t t\u1ea1i v\u1ecb tr\u00ed ch\u1ecdc (H\u00ecnh 130-3). \u0110\u1ec3 ph\u00e2n t\u00edch so s\u00e1nh, ch\u00fang t\u00f4i nghi\u00ean c\u1ee9u c\u00e1c th\u1eadn \u0111\u01b0\u1ee3c ch\u1ecdc qua c\u1ed5 \u0111\u00e0i (infundibulum) v\u00e0 c\u00e1c th\u1eadn \u0111\u01b0\u1ee3c ch\u1ecdc qua v\u00f2m \u0111\u00e0i th\u1eadn (calyceal fornix).<\/p>\n\n\n\n

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H\u00ccNH 130-3. A, H\u00ecnh chi\u1ebfu m\u1eb7t tr\u01b0\u1edbc c\u1ee7a phim ch\u1ee5p ni\u1ec7u qu\u1ea3n ng\u01b0\u1ee3c d\u00f2ng t\u1eeb th\u1eadn ph\u1ea3i cho th\u1ea5y c\u00e1c v\u1ecb tr\u00ed ch\u1ecdc kim \u1edf c\u1ef1c tr\u00ean (s), gi\u1eefa th\u1eadn (m) v\u00e0 c\u1ef1c d\u01b0\u1edbi (i). C\u00e1c v\u1ecb tr\u00ed ch\u1ecdc kim n\u00e0y \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n sau khi ti\u00eam nh\u1ef1a polyester v\u00e0o h\u1ec7 th\u1ed1ng \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch, khi nh\u1ef1a v\u1eabn c\u00f2n \u1edf d\u1ea1ng gel. L\u01b0u \u00fd r\u1eb1ng nh\u1ef1a \u0111\u01b0\u1ee3c ti\u00eam kh\u00f4ng c\u1ea3n quang v\u1edbi tia X. B, H\u00ecnh chi\u1ebfu m\u1eb7t tr\u01b0\u1edbc c\u1ee7a khu\u00f4n \u0111\u00fac n\u1ed9i soi \u0103n m\u00f2n t\u01b0\u01a1ng \u1ee9ng thu \u0111\u01b0\u1ee3c sau khi lo\u1ea1i b\u1ecf ch\u1ea5t c\u1ea3n quang v\u00e0 ti\u00eam nh\u1ef1a v\u00e0o h\u1ec7 th\u1ed1ng b\u1ec3 th\u1eadn. C\u00e1c kim \u0111\u01b0\u1ee3c gi\u1eef nguy\u00ean v\u1ecb tr\u00ed ban \u0111\u1ea7u. s, v\u1ecb tr\u00ed ch\u1ecdc kim \u1edf c\u1ef1c tr\u00ean; m, v\u1ecb tr\u00ed ch\u1ecdc kim \u1edf gi\u1eefa th\u1eadn; i, v\u1ecb tr\u00ed ch\u1ecdc kim \u1edf c\u1ef1c d\u01b0\u1edbi. C\u00e1c m\u0169i t\u00ean ch\u1ec9 ra \u0111\u01b0\u1eddng \u0111i c\u1ee7a kim. A, \u0111\u1ed9ng m\u1ea1ch th\u1eadn; V, t\u0129nh m\u1ea1ch th\u1eadn; u, ni\u1ec7u qu\u1ea3n.<\/figcaption><\/figure>\n\n\n\n

Ti\u1ebfp c\u1eadn trong th\u1eadn th\u00f4ng qua C\u1ed5 \u0111\u00e0i (Infundibulum)<\/strong><\/p>\n\n\n\n

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  • C\u1ef1c tr\u00ean:<\/strong> Ch\u1ecdc d\u00f2 l\u00e0 nguy hi\u1ec3m nh\u1ea5t<\/strong> khi \u0111i qua c\u1ed5 \u0111\u00e0i c\u1ef1c tr\u00ean v\u00ec v\u00f9ng n\u00e0y \u0111\u01b0\u1ee3c bao quanh g\u1ea7n nh\u01b0 ho\u00e0n to\u00e0n b\u1edfi c\u00e1c m\u1ea1ch m\u00e1u l\u1edbn (H\u00ecnh 130-4). C\u00e1c \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch c\u1ed5 \u0111\u00e0i ch\u1ea1y song song v\u1edbi m\u1eb7t tr\u01b0\u1edbc v\u00e0 m\u1eb7t sau c\u1ee7a c\u1ed5 \u0111\u00e0i c\u1ef1c tr\u00ean. Trong lo\u1ea1t nghi\u00ean c\u1ee9u c\u1ee7a ch\u00fang t\u00f4i, t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u gian th\u00f9y (interlobar\/infundibular vessel) l\u00e0 h\u1ec7 qu\u1ea3 ph\u1ed5 bi\u1ebfn c\u1ee7a vi\u1ec7c ch\u1ecdc v\u00e0o c\u1ed5 \u0111\u00e0i c\u1ef1c tr\u00ean (67% th\u1eadn) (h\u00ecnh 130-5); trong \u0111\u00f3 m\u1ea1ch m\u00e1u b\u1ecb t\u1ed5n th\u01b0\u01a1ng l\u00e0 \u0111\u1ed9ng m\u1ea1ch chi\u1ebfm 26% c\u00e1c tr\u01b0\u1eddng h\u1ee3p n\u00e0y.

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    H\u00ccNH 130-4. H\u00ecnh chi\u1ebfu xi\u00ean t\u1eeb ph\u00eda trong c\u1ee7a m\u1ed9t khu\u00f4n \u0111\u00fac n\u1ed9i m\u00f4 h\u1ec7 th\u1ed1ng \u0111\u1ed9ng m\u1ea1ch (A), t\u0129nh m\u1ea1ch (V) v\u00e0 \u0111\u00e0i b\u1ec3 th\u1eadn t\u1eeb th\u1eadn tr\u00e1i cho th\u1ea5y ph\u1ea7n tr\u00ean c\u1ee7a ph\u1ec5u th\u1eadn g\u1ea7n nh\u01b0 \u0111\u01b0\u1ee3c bao quanh ho\u00e0n to\u00e0n b\u1edfi c\u00e1c \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch ph\u1ec5u. C\u1ea5u tr\u00fac gi\u1ea3i ph\u1eabu n\u00e0y l\u00e0m cho vi\u1ec7c ch\u1ecdc th\u1ee7ng c\u1ef1c tr\u00ean c\u1ee7a ph\u1ec5u th\u1eadn tr\u1edf n\u00ean \u0111\u1eb7c bi\u1ec7t nguy hi\u1ec3m. u = ni\u1ec7u qu\u1ea3n.

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    H\u00ccNH 130-5. A, H\u00ecnh chi\u1ebfu ph\u00eda sau c\u1ee7a phim ch\u1ee5p ni\u1ec7u qu\u1ea3n ng\u01b0\u1ee3c d\u00f2ng t\u1eeb th\u1eadn ph\u1ea3i cho th\u1ea5y c\u00e1c l\u1ed7 ch\u1ecdc \u1edf ph\u00eda tr\u00ean, gi\u1eefa v\u00e0 d\u01b0\u1edbi (m\u0169i t\u00ean ng\u1eafn) v\u00e0 ch\u1ea5t c\u1ea3n quang trong c\u00e1c \u0111\u1ed9ng m\u1ea1ch ph\u1ec5u tr\u00ean v\u00e0 d\u01b0\u1edbi (m\u0169i t\u00ean \u0111en). B, H\u00ecnh chi\u1ebfu ph\u00eda sau c\u1ee7a phim ch\u1ee5p n\u1ed9i soi t\u01b0\u01a1ng \u1ee9ng cho th\u1ea5y t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch ph\u1ec5u tr\u00ean (m\u0169i t\u00ean \u0111en). L\u1ed7 ch\u1ecdc \u1edf gi\u1eefa th\u1eadn (m\u0169i t\u00ean tr\u1eafng) l\u00e0 l\u1ed7 ch\u1ecdc xuy\u00ean qua (hai th\u00e0nh) v\u00e0 l\u00e0m t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch ph\u00e2n \u0111o\u1ea1n tr\u01b0\u1edbc. M\u1ea1ch m\u00e1u b\u1ecb t\u1ed5n th\u01b0\u01a1ng cung c\u1ea5p nh\u00e1nh sau d\u01b0\u1edbi ch\u1ee9a \u0111\u1ea7y ch\u1ea5t c\u1ea3n quang tr\u00ean phim ch\u1ee5p ni\u1ec7u qu\u1ea3n. C\u00e1c m\u0169i t\u00ean ch\u1ec9 ra \u0111\u01b0\u1eddng \u0111i c\u1ee7a kim.<\/li>\n\n\n\n
  • Tai bi\u1ebfn m\u1ea1ch m\u00e1u nghi\u00eam tr\u1ecdng nh\u1ea5t khi ch\u1ecdc c\u1ed5 \u0111\u00e0i tr\u00ean l\u00e0 t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y sau (\u0111\u1ed9ng m\u1ea1ch sau b\u1ec3 th\u1eadn – retropelvic artery)<\/strong>. S\u1ef1 c\u1ed1 n\u00e0y c\u00f3 th\u1ec3 x\u1ea3y ra v\u00ec \u0111\u1ed9ng m\u1ea1ch n\u00e0y b\u1eaft ch\u00e9o v\u00e0 li\u00ean quan \u0111\u1ebfn m\u1eb7t sau c\u1ee7a c\u1ed5 \u0111\u00e0i tr\u00ean trong 57% c\u00e1c tr\u01b0\u1eddng h\u1ee3p (H\u00ecnh 130-6A). H\u00ecnh 130-6B v\u00e0 C cho th\u1ea5y m\u1ed9t ca ch\u1ecdc c\u1ed5 \u0111\u00e0i tr\u00ean trong \u0111\u00f3 \u0111\u01b0\u1eddng kim \u0111\u00e3 g\u00e2y r\u00e1ch ho\u00e0n to\u00e0n \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y sau. V\u00ec \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y sau c\u00f3 th\u1ec3 cung c\u1ea5p m\u00e1u cho t\u1edbi 50% nhu m\u00f4 th\u1eadn, t\u1ed5n th\u01b0\u01a1ng n\u00f3 c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn m\u1ea5t \u0111\u00e1ng k\u1ec3 m\u00f4 th\u1eadn ch\u1ee9c n\u0103ng, b\u00ean c\u1ea1nh vi\u1ec7c g\u00e2y xu\u1ea5t huy\u1ebft.

    \"\"
    H\u00ecnh 130-6. A, H\u00ecnh \u1ea3nh nh\u00ecn t\u1eeb ph\u00eda sau c\u1ee7a n\u1ed9i soi (h\u1ec7 th\u1ed1ng \u0111\u00e0i b\u1ec3 th\u1eadn v\u00e0 \u0111\u1ed9ng m\u1ea1ch) t\u1eeb th\u1eadn tr\u00e1i cho th\u1ea5y \u0111\u1ed9ng m\u1ea1ch ph\u00e2n \u0111o\u1ea1n sau (\u0111\u1ed9ng m\u1ea1ch sau b\u1ec3 th\u1eadn) t\u1ea1o th\u00e0nh m\u1ed9t v\u00f2ng cung v\u00e0 ti\u1ebfp x\u00fac v\u1edbi \u0111\u00e0i tr\u00ean (m\u0169i t\u00ean). B, H\u00ecnh \u1ea3nh nh\u00ecn t\u1eeb ph\u00eda sau c\u1ee7a ch\u1ee5p ni\u1ec7u qu\u1ea3n ng\u01b0\u1ee3c d\u00f2ng t\u1eeb th\u1eadn tr\u00e1i cho th\u1ea5y s\u1ef1 tho\u00e1t thu\u1ed1c c\u1ea3n quang v\u00e0 thu\u1ed1c c\u1ea3n quang trong h\u1ec7 th\u1ed1ng \u0111\u1ed9ng m\u1ea1ch v\u00e0 trong th\u00e2n ch\u00ednh c\u1ee7a \u0111\u1ed9ng m\u1ea1ch th\u1eadn (m\u0169i t\u00ean ng\u1eafn). \u0110\u1ed9ng m\u1ea1ch sau b\u1ec3 th\u1eadn b\u1ecb t\u1ed5n th\u01b0\u01a1ng b\u1edfi kim \u0111\u01b0\u1ee3c ch\u1ec9 b\u1edfi \u0111\u1ea7u m\u0169i t\u00ean. M\u0169i t\u00ean cong ch\u1ec9 v\u1ecb tr\u00ed t\u1ed5n th\u01b0\u01a1ng. M\u0169i t\u00ean th\u1eb3ng ch\u1ec9 \u0111\u1ed9ng m\u1ea1ch sau b\u1ec3 th\u1eadn ch\u1ee9a \u0111\u1ea7y thu\u1ed1c c\u1ea3n quang tho\u00e1t ra t\u1eeb h\u1ec7 th\u1ed1ng thu th\u1eadp. C, H\u00ecnh \u1ea3nh nh\u00ecn t\u1eeb ph\u00eda sau c\u1ee7a n\u1ed9i soi t\u01b0\u01a1ng \u1ee9ng cho th\u1ea5y \u0111\u1ed9ng m\u1ea1ch sau b\u1ec3 th\u1eadn b\u1ecb chia c\u1eaft (m\u0169i t\u00ean th\u1eb3ng) v\u00e0 kim g\u00e2y ra t\u1ed5n th\u01b0\u01a1ng (kim m\u00e0u h\u1ed3ng). M\u0169i t\u00ean cong ch\u1ec9 v\u1ecb tr\u00ed t\u1ed5n th\u01b0\u01a1ng. A, \u0111\u1ed9ng m\u1ea1ch th\u1eadn; V, t\u0129nh m\u1ea1ch th\u1eadn; u, ni\u1ec7u qu\u1ea3n.<\/li>\n\n\n\n
  • V\u00f9ng gi\u1eefa th\u1eadn:<\/strong> Ti\u1ebfp c\u1eadn trong th\u1eadn qua c\u1ed5 \u0111\u00e0i v\u00f9ng gi\u1eefa th\u1eadn g\u00e2y ra t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch \u1edf 23% s\u1ed1 th\u1eadn \u0111\u01b0\u1ee3c nghi\u00ean c\u1ee9u. Nh\u00e1nh gi\u1eefa c\u1ee7a \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y sau b\u1ecb t\u1ed5n th\u01b0\u01a1ng th\u01b0\u1eddng xuy\u00ean h\u01a1n b\u1ea5t k\u1ef3 m\u1ea1ch m\u00e1u n\u00e0o kh\u00e1c.<\/li>\n\n\n\n
  • C\u1ef1c d\u01b0\u1edbi:<\/strong> M\u1eb7t sau c\u1ee7a c\u1ed5 \u0111\u00e0i c\u1ef1c d\u01b0\u1edbi th\u01b0\u1eddng \u0111\u01b0\u1ee3c c\u00e1c b\u00e1c s\u0129 n\u1ed9i soi v\u00e0 b\u00e1c s\u0129 ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh can thi\u1ec7p m\u1eb7c \u0111\u1ecbnh l\u00e0 kh\u00f4ng c\u00f3 \u0111\u1ed9ng m\u1ea1ch. Do \u0111\u00f3, n\u00f3 \u0111\u01b0\u1ee3c coi l\u00e0 v\u00f9ng an to\u00e0n \u0111\u1ec3 ti\u1ebfp c\u1eadn h\u1ec7 th\u1ed1ng g\u00f3p v\u00e0 \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn (nephrostomy tube). Tuy nhi\u00ean, trong kho\u1ea3ng 38% s\u1ed1 th\u1eadn \u0111\u01b0\u1ee3c ki\u1ec3m tra, m\u1ed9t \u0111\u1ed9ng m\u1ea1ch c\u1ed5 \u0111\u00e0i \u0111\u01b0\u1ee3c t\u00ecm th\u1ea5y \u1edf v\u00f9ng n\u00e0y. V\u00ec v\u1eady, c\u00e1c bi\u1ebfn ch\u1ee9ng \u0111\u00e1ng k\u1ec3 c\u00f3 th\u1ec3 ph\u00e1t tri\u1ec3n nh\u01b0 m\u1ed9t h\u1ec7 qu\u1ea3 c\u1ee7a h\u01b0\u1edbng ti\u1ebfp c\u1eadn ph\u00eda sau qua v\u00f9ng c\u1ed5 \u0111\u00e0i d\u01b0\u1edbi v\u1ed1n \u0111\u01b0\u1ee3c cho l\u00e0 kh\u00f4ng c\u00f3 m\u1ea1ch m\u00e1u. Th\u1ef1c t\u1ebf, ch\u00fang t\u00f4i t\u00ecm th\u1ea5y t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch trong 13% s\u1ed1 th\u1eadn m\u00e0 ch\u00fang t\u00f4i \u0111\u00e3 th\u1ef1c hi\u1ec7n ch\u1ecdc d\u00f2 qua c\u1ed5 \u0111\u00e0i c\u1ef1c d\u01b0\u1edbi.<\/li>\n<\/ul>\n\n\n\n

    V\u1ec1 t\u0129nh m\u1ea1ch, trong nhi\u1ec1u th\u1eadn nghi\u00ean c\u1ee9u, ch\u00fang t\u00f4i t\u00ecm th\u1ea5y c\u00e1c th\u00f4ng n\u1ed1i t\u0129nh m\u1ea1ch l\u1edbn \u2014 t\u01b0\u01a1ng t\u1ef1 nh\u01b0 nh\u1eefng chi\u1ebfc v\u00f2ng c\u1ed5 \u2014 xung quanh c\u1ed5 \u0111\u00e0i th\u1eadn (c\u00f2n g\u1ecdi l\u00e0 c\u1ed5 \u0111\u00e0i – calyceal necks). Do \u0111\u00f3, ch\u1ecdc qua c\u1ed5 \u0111\u00e0i c\u1ef1c d\u01b0\u1edbi c\u0169ng c\u00f3 nguy c\u01a1 l\u00e0m t\u1ed5n th\u01b0\u01a1ng m\u1ed9t cung t\u0129nh m\u1ea1ch. T\u1ed5n th\u01b0\u01a1ng t\u0129nh m\u1ea1ch th\u01b0\u1eddng t\u1ef1 l\u00e0nh, nh\u01b0ng xu\u1ea5t huy\u1ebft h\u1ec7 qu\u1ea3 c\u00f3 th\u1ec3 g\u00e2y kh\u00f3 kh\u0103n trong su\u1ed1t th\u1ee7 thu\u1eadt.<\/p>\n\n\n\n

    C\u00e1c ph\u00e1t hi\u1ec7n c\u1ee7a ch\u00fang t\u00f4i ch\u1ee9ng minh r\u00f5 r\u00e0ng r\u1eb1ng m\u1edf th\u1eadn ra da qua c\u1ed5 \u0111\u00e0i th\u1eadn kh\u00f4ng ph\u1ea3i l\u00e0 l\u1ed9 tr\u00ecnh an to\u00e0n<\/strong>, v\u00ec lo\u1ea1i ti\u1ebfp c\u1eadn n\u00e0y ti\u1ec1m \u1ea9n nguy c\u01a1 ch\u1ea3y m\u00e1u \u0111\u00e1ng k\u1ec3 t\u1eeb c\u00e1c m\u1ea1ch m\u00e1u gian th\u00f9y.<\/p>\n\n\n\n

    Ch\u1ecdc d\u00f2 c\u1ed5 \u0111\u00e0i c\u0169ng t\u1ea1o ra r\u1ee7i ro ch\u1ecdc xuy\u00ean th\u1ea5u (hai th\u00e0nh) h\u1ec7 th\u1ed1ng g\u00f3p (xem H\u00ecnh 130-5). V\u00ec c\u00e1c nh\u00e1nh ph\u00e2n th\u00f9y l\u1edbn c\u1ee7a \u0111\u1ed9ng m\u1ea1ch th\u1eadn, c\u0169ng nh\u01b0 c\u00e1c nh\u00e1nh l\u1edbn c\u1ee7a t\u0129nh m\u1ea1ch th\u1eadn n\u1eb1m \u1edf m\u1eb7t tr\u01b0\u1edbc c\u1ee7a b\u1ec3 th\u1eadn, t\u00ecnh tr\u1ea1ng xu\u1ea5t huy\u1ebft nghi\u00eam tr\u1ecdng c\u00f3 th\u1ec3 x\u1ea3y ra do xuy\u00ean th\u1ea5u hai th\u00e0nh m\u1eb7t tr\u01b0\u1edbc. Ngo\u00e0i ra, vi\u1ec7c ch\u00e8n \u00e9p (tamponade) hi\u1ec7u qu\u1ea3 c\u00e1c m\u1ea1ch m\u00e1u m\u1eb7t tr\u01b0\u1edbc b\u1ecb t\u1ed5n th\u01b0\u01a1ng l\u00e0 r\u1ea5t kh\u00f3 kh\u0103n v\u00ec ch\u00fang n\u1eb1m c\u00e1ch xa \u0111\u01b0\u1eddng h\u1ea7m m\u1edf th\u1eadn.<\/p>\n\n\n\n

    \"\"

    H\u00ccNH 130-5. A, H\u00ecnh chi\u1ebfu ph\u00eda sau c\u1ee7a phim ch\u1ee5p ni\u1ec7u qu\u1ea3n ng\u01b0\u1ee3c d\u00f2ng t\u1eeb th\u1eadn ph\u1ea3i cho th\u1ea5y c\u00e1c l\u1ed7 ch\u1ecdc \u1edf ph\u00eda tr\u00ean, gi\u1eefa v\u00e0 d\u01b0\u1edbi (m\u0169i t\u00ean ng\u1eafn) v\u00e0 ch\u1ea5t c\u1ea3n quang trong c\u00e1c \u0111\u1ed9ng m\u1ea1ch ph\u1ec5u tr\u00ean v\u00e0 d\u01b0\u1edbi (m\u0169i t\u00ean \u0111en). B, H\u00ecnh chi\u1ebfu ph\u00eda sau c\u1ee7a phim ch\u1ee5p n\u1ed9i soi t\u01b0\u01a1ng \u1ee9ng cho th\u1ea5y t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch ph\u1ec5u tr\u00ean (m\u0169i t\u00ean \u0111en). L\u1ed7 ch\u1ecdc \u1edf gi\u1eefa th\u1eadn (m\u0169i t\u00ean tr\u1eafng) l\u00e0 l\u1ed7 ch\u1ecdc xuy\u00ean qua (hai th\u00e0nh) v\u00e0 l\u00e0m t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch ph\u00e2n \u0111o\u1ea1n tr\u01b0\u1edbc. M\u1ea1ch m\u00e1u b\u1ecb t\u1ed5n th\u01b0\u01a1ng cung c\u1ea5p nh\u00e1nh sau d\u01b0\u1edbi ch\u1ee9a \u0111\u1ea7y ch\u1ea5t c\u1ea3n quang tr\u00ean phim ch\u1ee5p ni\u1ec7u qu\u1ea3n. C\u00e1c m\u0169i t\u00ean ch\u1ec9 ra \u0111\u01b0\u1eddng \u0111i c\u1ee7a kim.<\/figcaption><\/figure>\n\n\n\n

    M\u1eb7c d\u00f9 ti\u1ebfp c\u1eadn qua c\u1ed5 \u0111\u00e0i l\u00e0 kh\u1ea3 thi trong m\u1ed9t s\u1ed1 ho\u00e0n c\u1ea3nh v\u00e0 ph\u1ea3i \u0111\u01b0\u1ee3c c\u00e2n nh\u1eafc trong c\u00e1c t\u00ecnh hu\u1ed1ng c\u1ee5 th\u1ec3 (v\u00ed d\u1ee5 c\u00e1c tr\u01b0\u1eddng h\u1ee3p gi\u1ea3i ph\u1eabu kh\u00f3), ph\u1eabu thu\u1eadt vi\u00ean ph\u1ea3i \u0111\u00e1nh gi\u00e1 nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch, ch\u1ee7 y\u1ebfu \u1edf c\u1ef1c tr\u00ean v\u00e0 v\u00f9ng gi\u1eefa th\u1eadn.<\/p>\n\n\n\n

    Ti\u1ebfp c\u1eadn trong th\u1eadn th\u00f4ng qua B\u1ec3 th\u1eadn (Renal Pelvis)<\/strong><\/p>\n\n\n\n

    N\u00ean lo\u1ea1i b\u1ecf vi\u1ec7c ch\u1ecdc tr\u1ef1c ti\u1ebfp v\u00e0o b\u1ec3 th\u1eadn trong ph\u1eabu thu\u1eadt n\u1ed9i soi ti\u1ebft ni\u1ec7u. B\u00ean c\u1ea1nh th\u1ef1c t\u1ebf l\u00e0 \u1ed1ng d\u1eabn l\u01b0u th\u1eadn \u0111\u1eb7t t\u1ea1i v\u1ecb tr\u00ed n\u00e0y r\u1ea5t d\u1ec5 b\u1ecb tu\u1ed9t v\u00e0 kh\u00f3 \u0111\u1eb7t l\u1ea1i trong c\u00e1c thao t\u00e1c ph\u1eabu thu\u1eadt, ch\u1ecdc b\u1ec3 th\u1eadn c\u00f2n mang l\u1ea1i nguy c\u01a1 kh\u00f4ng c\u1ea7n thi\u1ebft v\u00e0 b\u1ecb c\u1ea5m \u0111\u1ed1i v\u1edbi t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u sau b\u1ec3 th\u1eadn (\u0111\u1ed9ng m\u1ea1ch v\u00e0\/ho\u1eb7c t\u0129nh m\u1ea1ch).<\/p>\n\n\n\n

    Ti\u1ebfp c\u1eadn trong th\u1eadn th\u00f4ng qua V\u00f2m \u0111\u00e0i th\u1eadn (Calyceal Fornix)<\/strong><\/p>\n\n\n\n

    Khi ch\u00fang t\u00f4i th\u1ef1c hi\u1ec7n ch\u1ecdc d\u00f2 qua v\u00f2m \u0111\u00e0i th\u1eadn, t\u1ed5n th\u01b0\u01a1ng t\u0129nh m\u1ea1ch x\u1ea3y ra \u1edf \u00edt h\u01a1n 8% s\u1ed1 th\u1eadn. Nh\u1eefng t\u1ed5n th\u01b0\u01a1ng n\u00e0y x\u1ea3y ra kh\u00f4ng ph\u00e2n bi\u1ec7t \u1edf c\u00e1c \u0111\u00e0i th\u1eadn c\u1ef1c tr\u00ean, v\u00f9ng gi\u1eefa hay c\u1ef1c d\u01b0\u1edbi. Ch\u00fang t\u00f4i kh\u00f4ng ph\u00e1t hi\u1ec7n b\u1ea5t k\u1ef3 t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch n\u00e0o<\/strong> do h\u1ec7 qu\u1ea3 c\u1ee7a vi\u1ec7c ch\u1ecdc qua v\u00f2m \u0111\u00e0i.<\/p>\n\n\n\n

    K\u1ebft lu\u1eadn, t\u1ec9 l\u1ec7 t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u cao v\u00e0 kh\u1ea3 n\u0103ng x\u1ea3y ra c\u00e1c bi\u1ebfn ch\u1ee9ng li\u00ean quan \u0111\u1ed3ng ngh\u0129a v\u1edbi vi\u1ec7c kh\u00f4ng n\u00ean \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn qua c\u1ed5 \u0111\u00e0i th\u1eadn<\/strong> (xem H\u00ecnh 130-4). <\/p>\n\n\n\n

    \"\"

    H\u00ccNH 130-4. H\u00ecnh chi\u1ebfu xi\u00ean t\u1eeb ph\u00eda trong c\u1ee7a m\u1ed9t khu\u00f4n \u0111\u00fac n\u1ed9i m\u00f4 h\u1ec7 th\u1ed1ng \u0111\u1ed9ng m\u1ea1ch (A), t\u0129nh m\u1ea1ch (V) v\u00e0 \u0111\u00e0i b\u1ec3 th\u1eadn t\u1eeb th\u1eadn tr\u00e1i cho th\u1ea5y ph\u1ea7n tr\u00ean c\u1ee7a ph\u1ec5u th\u1eadn g\u1ea7n nh\u01b0 \u0111\u01b0\u1ee3c bao quanh ho\u00e0n to\u00e0n b\u1edfi c\u00e1c \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch ph\u1ec5u. C\u1ea5u tr\u00fac gi\u1ea3i ph\u1eabu n\u00e0y l\u00e0m cho vi\u1ec7c ch\u1ecdc th\u1ee7ng c\u1ef1c tr\u00ean c\u1ee7a ph\u1ec5u th\u1eadn tr\u1edf n\u00ean \u0111\u1eb7c bi\u1ec7t nguy hi\u1ec3m. u = ni\u1ec7u qu\u1ea3n.<\/figcaption><\/figure>\n\n\n\n

    M\u1eb7t kh\u00e1c, b\u1ea5t k\u1ec3 v\u00f9ng n\u00e0o c\u1ee7a th\u1eadn, ch\u1ecdc d\u00f2 v\u00e0 \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u th\u1eadn qua v\u00f2m \u0111\u00e0i th\u1eadn<\/strong> l\u00e0 an to\u00e0n v\u00e0 ph\u1ea3i l\u00e0 v\u1ecb tr\u00ed \u0111\u01b0\u1ee3c ng\u01b0\u1eddi v\u1eadn h\u00e0nh l\u1ef1a ch\u1ecdn. Ngay c\u1ea3 \u1edf c\u1ef1c tr\u00ean, ch\u1ecdc d\u00f2 trong th\u1eadn qua v\u00f2m \u0111\u00e0i th\u1eadn c\u0169ng kh\u00f4ng g\u00e2y h\u1ea1i (H\u00ecnh 130-7A). Th\u00eam v\u00e0o \u0111\u00f3, khi ch\u1ecdc qua v\u00f2m \u0111\u00e0i th\u1eadn, trong tr\u01b0\u1eddng h\u1ee3p c\u00f3 th\u01b0\u01a1ng t\u1ed5n, th\u01b0\u01a1ng t\u1ed5n lu\u00f4n n\u1eb1m \u1edf m\u1ea1ch m\u00e1u ngo\u1ea1i vi, ch\u1eb3ng h\u1ea1n nh\u01b0 m\u1ed9t cung t\u0129nh m\u1ea1ch nh\u1ecf (xem H\u00ecnh 130-7B).<\/p>\n\n\n\n

    \"\"
    H\u00ccNH 130-7. A, H\u00ecnh nh\u00ecn t\u1eeb tr\u00ean xu\u1ed1ng c\u1ee7a m\u1ed9t m\u1eabu n\u1ed9i soi t\u1eeb th\u1eadn tr\u00e1i cho th\u1ea5y r\u1eb1ng, ngay c\u1ea3 \u1edf c\u1ef1c tr\u00ean, vi\u1ec7c ch\u1ecdc th\u1ee7ng qua v\u00f2m c\u1ee7a \u0111\u00e0i th\u1eadn (m\u0169i t\u00ean) v\u1eabn an to\u00e0n. B, H\u00ecnh nh\u00ecn t\u1eeb ph\u00eda sau c\u1ee7a m\u1ed9t m\u1eabu n\u1ed9i soi t\u1eeb th\u1eadn ph\u1ea3i v\u00e0 m\u1ed9t v\u1ebft ch\u1ecdc th\u1ee7ng \u1edf ph\u00eda d\u01b0\u1edbi \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n qua v\u00f2m c\u1ee7a \u0111\u00e0i th\u1eadn. C\u00e1c m\u0169i t\u00ean ch\u1ec9 ra m\u1ed9t t\u1ed5n th\u01b0\u01a1ng \u1edf m\u1ed9t cung t\u0129nh m\u1ea1ch ngo\u1ea1i vi nh\u1ecf. \u0110\u1ea7u m\u0169i t\u00ean th\u1ec3 hi\u1ec7n \u0111\u01b0\u1eddng \u0111i c\u1ee7a kim. P, b\u1ec3 th\u1eadn; u, ni\u1ec7u qu\u1ea3n.<\/figcaption><\/figure>\n\n\n\n
    \n\n\n\n

    \u00dd NGH\u0128A \u0110\u1ed0I V\u1edaI X\u1eba B\u1ec2 TH\u1eacN N\u1ed8I SOI (ENDOPYELOTOMY)<\/strong><\/h4>\n\n\n\n

    K\u1ec3 t\u1eeb khi \u0111\u01b0\u1ee3c \u0111\u01b0a v\u00e0o l\u00e2m s\u00e0ng, \u0111i\u1ec1u tr\u1ecb n\u1ed9i soi t\u1eafc ngh\u1ebdn kh\u00fac n\u1ed1i b\u1ec3 th\u1eadn-ni\u1ec7u qu\u1ea3n (UPJ) \u2014 x\u1ebb b\u1ec3 th\u1eadn n\u1ed9i soi \u2014 \u0111\u00e3 g\u1ea7n nh\u01b0 thay th\u1ebf ho\u00e0n to\u00e0n ph\u1eabu thu\u1eadt t\u1ea1o h\u00ecnh b\u1ec3 th\u1eadn m\u1edf. N\u00f3 c\u00f3 t\u1ec9 l\u1ec7 th\u00e0nh c\u00f4ng t\u01b0\u01a1ng \u0111\u01b0\u01a1ng ph\u1eabu thu\u1eadt m\u1edf v\u00e0 \u00e1p d\u1ee5ng \u0111\u01b0\u1ee3c cho c\u1ea3 c\u00e1c t\u00ecnh tr\u1ea1ng b\u1ea9m sinh v\u00e0 m\u1eafc ph\u1ea3i.<\/p>\n\n\n\n

    V\u00ec x\u1ebb b\u1ec3 th\u1eadn n\u1ed9i soi d\u1ef1a tr\u00ean nguy\u00ean l\u00fd t\u1ea1o h\u00ecnh b\u1ec3 th\u1eadn c\u00f3 \u0111\u1eb7t \u1ed1ng d\u1eabn l\u01b0u (r\u1ea1ch kh\u00fac n\u1ed1i b\u1ec3 th\u1eadn-ni\u1ec7u qu\u1ea3n sau \u0111\u00f3 \u0111\u1eb7t stent trong 1 \u0111\u1ebfn 6 tu\u1ea7n), \u0111\u1ec3 \u0111\u1ea1t \u0111\u01b0\u1ee3c th\u00e0nh c\u00f4ng, ph\u1eabu thu\u1eadt vi\u00ean n\u1ed9i soi ph\u1ea3i r\u1ea1ch to\u00e0n b\u1ed9 b\u1ec1 d\u00e0y c\u1ee7a l\u1edbp c\u01a1 t\u1ea1i th\u00e0nh h\u1eb9p c\u1ee7a UPJ cho \u0111\u1ebfn khi m\u1ee1 quanh ni\u1ec7u qu\u1ea3n l\u1ed9 r\u00f5. \u0110\u01b0\u1eddng r\u1ea1ch s\u00e2u n\u00e0y ph\u1ea3i \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n d\u00f9 ti\u1ebfp c\u1eadn qua \u0111\u01b0\u1eddng h\u1ea7m m\u1edf th\u1eadn, qua n\u1ed9i soi ni\u1ec7u qu\u1ea3n hay b\u1eb1ng catheter Acucise, v\u00e0 d\u00f9 d\u1ee5ng c\u1ee5 d\u00f9ng \u0111\u1ec3 r\u1ea1ch ch\u1ed7 h\u1eb9p l\u00e0 dao l\u1ea1nh hay \u0111\u1ea7u \u0111\u1ed1t \u0111i\u1ec7n.<\/p>\n\n\n\n

    Vi\u1ec7c r\u1ea1ch UPJ cho \u0111\u1ebfn khi v\u00e0o khoang quanh th\u1eadn r\u00f5 r\u00e0ng mang theo nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u sau ph\u00fac m\u1ea1c. Th\u1ef1c t\u1ebf, bi\u1ebfn ch\u1ee9ng \u0111\u00e1ng k\u1ec3 nh\u1ea5t c\u1ee7a th\u1ee7 thu\u1eadt n\u00e0y l\u00e0 t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u, theo sau l\u00e0 xu\u1ea5t huy\u1ebft tr\u1ea7m tr\u1ecdng v\u00e0\/ho\u1eb7c h\u00ecnh th\u00e0nh th\u00f4ng \u0111\u1ed9ng-t\u0129nh m\u1ea1ch (AVF). \u0110\u1ec3 b\u1ea3o v\u1ec7 c\u00e1c \u0111\u1ed9ng m\u1ea1ch kh\u1ecfi th\u01b0\u01a1ng t\u1ed5n, ph\u1eabu thu\u1eadt vi\u00ean \u0111\u00e3 \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o ki\u1ec3m tra qua n\u1ed9i soi trong th\u1eadn v\u00f9ng \u0111\u1ecbnh r\u1ea1ch \u0111\u1ec3 t\u00ecm b\u1ea5t k\u1ef3 nh\u1ecbp \u0111\u1eadp \u0111\u1ed9ng m\u1ea1ch n\u00e0o v\u00e0 tr\u00e1nh r\u1ea1ch t\u1ea1i v\u1ecb tr\u00ed \u0111\u00f3. Tuy nhi\u00ean, nh\u1ecbp \u0111\u1eadp \u0111\u1ed9ng m\u1ea1ch kh\u00f4ng ph\u1ea3i l\u00fac n\u00e0o c\u0169ng d\u1ec5 d\u00e0ng nh\u1eadn di\u1ec7n qua n\u1ed9i soi trong khi m\u1ed5, ch\u1ee7 y\u1ebfu v\u00ec b\u1ec7nh nh\u00e2n c\u00f3 th\u1ec3 b\u1ecb h\u1ea1 huy\u1ebft \u00e1p do g\u00e2y m\u00ea. Ngo\u00e0i ra, v\u00ec t\u0129nh m\u1ea1ch kh\u00f4ng \u0111\u1eadp, vi\u1ec7c ki\u1ec3m tra n\u1ed9i soi v\u00f9ng \u0111\u1ecbnh r\u1ea1ch kh\u00f4ng hi\u1ec7u qu\u1ea3 trong vi\u1ec7c tr\u00e1nh t\u1ed5n th\u01b0\u01a1ng t\u0129nh m\u1ea1ch.<\/p>\n\n\n\n

    Nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u l\u1edbn trong x\u1ebb b\u1ec3 th\u1eadn n\u1ed9i soi c\u00f3 th\u1ec3 \u0111\u01b0\u1ee3c gi\u1ea3m thi\u1ec3u \u0111\u00e1ng k\u1ec3 ho\u1eb7c th\u1eadm ch\u00ed lo\u1ea1i b\u1ecf n\u1ebfu b\u00e1c s\u0129 n\u1ed9i soi ti\u1ebft ni\u1ec7u hi\u1ec3u v\u00e0 ghi nh\u1edb c\u00e1c m\u1ed1i t\u01b0\u01a1ng quan m\u1ea1ch m\u00e1u ba chi\u1ec1u v\u1edbi UPJ.<\/p>\n\n\n\n

    C\u01a1 s\u1edf M\u1ea1ch m\u00e1u<\/strong><\/p>\n\n\n\n

    Ch\u00fang t\u00f4i \u0111\u00e3 ph\u00e2n t\u00edch 146 khu\u00f4n \u0111\u00fac 3D nh\u1ef1a polyester c\u1ee7a h\u1ec7 \u0111\u00e0i b\u1ec3 th\u1eadn c\u00f9ng v\u1edbi c\u00e1c \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch trong th\u1eadn \u0111\u1ed3ng th\u1eddi tr\u00ean c\u00f9ng m\u1ed9t th\u1eadn.<\/p>\n\n\n\n

    M\u1ed1i t\u01b0\u01a1ng quan m\u1ea1ch m\u00e1u m\u1eb7t tr\u01b0\u1edbc Kh\u00fac n\u1ed1i B\u1ec3 th\u1eadn-Ni\u1ec7u qu\u1ea3n<\/strong><\/p>\n\n\n\n

    Trong 65% c\u00e1c tr\u01b0\u1eddng h\u1ee3p, c\u00f3 m\u1ed9t \u0111\u1ed9ng m\u1ea1ch ho\u1eb7c t\u0129nh m\u1ea1ch n\u1ed5i b\u1eadt, ho\u1eb7c c\u1ea3 hai, c\u00f3 li\u00ean quan ch\u1eb7t ch\u1ebd v\u1edbi b\u1ec1 m\u1eb7t b\u1ee5ng (ventral surface) c\u1ee7a UPJ (H\u00ecnh 130-8). Trong s\u1ed1 c\u00e1c tr\u01b0\u1eddng h\u1ee3p n\u00e0y, 45% m\u1ed1i li\u00ean quan l\u00e0 v\u1edbi \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y d\u01b0\u1edbi<\/strong> (xem H\u00ecnh 130-8C).<\/p>\n\n\n\n

    \"\"
    H\u00ccNH 130-8. A, H\u00ecnh chi\u1ebfu m\u1eb7t tr\u01b0\u1edbc c\u1ee7a n\u1ed9i soi th\u1eadn ph\u1ea3i (h\u1ec7 th\u1ed1ng b\u1ec3 th\u1eadn c\u00f9ng v\u1edbi c\u00e1c \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch trong th\u1eadn) cho th\u1ea5y b\u1ec1 m\u1eb7t tr\u01b0\u1edbc c\u1ee7a ch\u1ed7 n\u1ed1i ni\u1ec7u qu\u1ea3n – b\u1ec3 th\u1eadn (UPJ) c\u00f3 m\u1ed1i quan h\u1ec7 m\u1eadt thi\u1ebft v\u1edbi \u0111\u1ed9ng m\u1ea1ch ph\u00e2n \u0111o\u1ea1n d\u01b0\u1edbi (m\u0169i t\u00ean) v\u00e0 v\u1edbi m\u1ed9t nh\u00e1nh c\u1ee7a t\u0129nh m\u1ea1ch th\u1eadn (m\u0169i t\u00ean). A, \u0111\u1ed9ng m\u1ea1ch th\u1eadn; V, t\u0129nh m\u1ea1ch th\u1eadn; u, ni\u1ec7u qu\u1ea3n. B, H\u00ecnh chi\u1ebfu m\u1eb7t tr\u01b0\u1edbc c\u1ee7a n\u1ed9i soi th\u1eadn ph\u1ea3i (h\u1ec7 th\u1ed1ng b\u1ec3 th\u1eadn c\u00f9ng v\u1edbi c\u00e1c t\u0129nh m\u1ea1ch trong th\u1eadn) cho th\u1ea5y m\u1ed1i quan h\u1ec7 m\u1eadt thi\u1ebft gi\u1eefa m\u1ed9t t\u0129nh m\u1ea1ch d\u1eabn l\u01b0u c\u1ef1c d\u01b0\u1edbi v\u00e0 UPJ (m\u0169i t\u00ean). RV, t\u0129nh m\u1ea1ch th\u1eadn; u, ni\u1ec7u qu\u1ea3n. C, H\u00ecnh chi\u1ebfu m\u1eb7t tr\u01b0\u1edbc c\u1ee7a n\u1ed9i soi th\u1eadn ph\u1ea3i (h\u1ec7 th\u1ed1ng b\u1ec3 th\u1eadn c\u00f9ng v\u1edbi c\u00e1c \u0111\u1ed9ng m\u1ea1ch trong th\u1eadn) cho th\u1ea5y m\u1ed1i quan h\u1ec7 m\u1eadt thi\u1ebft gi\u1eefa \u0111\u1ed9ng m\u1ea1ch ph\u00e2n \u0111o\u1ea1n d\u01b0\u1edbi v\u00e0 b\u1ec1 m\u1eb7t tr\u01b0\u1edbc c\u1ee7a UPJ (m\u0169i t\u00ean). u, ni\u1ec7u qu\u1ea3n.<\/figcaption><\/figure>\n\n\n\n

    Li\u00ean quan \u0111\u1ebfn vi\u1ec7c l\u1ef1a ch\u1ecdn b\u1ec7nh nh\u00e2n \u0111i\u1ec1u tr\u1ecb t\u1eafc ngh\u1ebdn UPJ, vi\u1ec7c ch\u1ea9n \u0111o\u00e1n c\u00e1c m\u1ea1ch m\u00e1u b\u1eaft ch\u00e9o m\u1eb7t tr\u01b0\u1edbc v\u1eabn c\u00f2n g\u00e2y tranh c\u00e3i. Van Cangh v\u00e0 c\u00e1c \u0111\u1ed3ng nghi\u1ec7p nh\u1eadn th\u1ea5y r\u1eb1ng s\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a m\u1ea1ch m\u00e1u b\u1eaft ch\u00e9o m\u1eb7t tr\u01b0\u1edbc k\u00e8m theo th\u1eadn \u1ee9 n\u01b0\u1edbc \u0111\u1ed9 nh\u1eb9 ho\u1eb7c n\u1eb7ng d\u1eabn \u0111\u1ebfn t\u1ec9 l\u1ec7 th\u00e0nh c\u00f4ng l\u1ea7n l\u01b0\u1ee3t ch\u1ec9 l\u00e0 50% v\u00e0 39%. M\u1eb7t kh\u00e1c, Smith cho r\u1eb1ng lo\u1ea1i nghi\u00ean c\u1ee9u n\u00e0y ch\u1ec9 \u0111\u01b0\u1ee3c bi\u1ec7n minh n\u1ebfu c\u00f3 b\u1eb1ng ch\u1ee9ng cho th\u1ea5y c\u00e1c m\u1ea1ch m\u00e1u \u0111\u00f3 l\u00e0 nguy\u00ean nh\u00e2n b\u1ec7nh sinh g\u00e2y t\u1eafc ngh\u1ebdn UPJ ho\u1eb7c n\u1ebfu c\u00f3 nguy c\u01a1 r\u1ea1ch v\u00e0o m\u1ea1ch m\u00e1u trong qu\u00e1 tr\u00ecnh x\u1ebb b\u1ec3 th\u1eadn n\u1ed9i soi. Hi\u1ec7n nay, d\u1eef li\u1ec7u g\u1ee3i \u00fd r\u1eb1ng vi\u1ec7c ph\u00e1t hi\u1ec7n m\u1ea1ch m\u00e1u b\u1eaft ch\u00e9o tr\u01b0\u1edbc m\u1ed5 kh\u00f4ng nh\u1ea5t thi\u1ebft \u1ea3nh h\u01b0\u1edfng \u0111\u00e1ng k\u1ec3 \u0111\u1ebfn ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb \u0111\u01b0\u1ee3c \u0111\u01b0a ra.<\/p>\n\n\n\n

    C\u1ea7n l\u01b0u \u00fd r\u1eb1ng trong lo\u1ea1t nghi\u00ean c\u1ee9u c\u1ee7a Van Cangh, 39% b\u1ec7nh nh\u00e2n c\u00f3 m\u1ea1ch m\u00e1u b\u1eaft ch\u00e9o ph\u00eda tr\u01b0\u1edbc UPJ v\u00e0 t\u00e1c gi\u1ea3 n\u00e0y coi \u0111\u00e2y l\u00e0 c\u00e1c \u0111\u1ed9ng m\u1ea1ch b\u1ea5t th\u01b0\u1eddng. Vi\u1ec7c coi c\u00e1c m\u1ea1ch m\u00e1u n\u00e0y l\u00e0 b\u1ea5t th\u01b0\u1eddng kh\u00f4ng th\u1ed1ng nh\u1ea5t v\u1edbi c\u00e1c nghi\u00ean c\u1ee9u gi\u1ea3i ph\u1eabu m\u1ea1ch m\u00e1u s\u00e2u r\u1ed9ng c\u1ee7a ch\u00fang t\u00f4i. Ph\u00e2n t\u00edch 280 khu\u00f4n \u0111\u00fac, ch\u00fang t\u00f4i t\u00ecm th\u1ea5y m\u1ed1i t\u01b0\u01a1ng quan ch\u1eb7t ch\u1ebd gi\u1eefa m\u1ed9t \u0111\u1ed9ng m\u1ea1ch, t\u0129nh m\u1ea1ch b\u00ecnh th\u01b0\u1eddng ho\u1eb7c c\u1ea3 hai v\u1edbi m\u1eb7t tr\u01b0\u1edbc c\u1ee7a UPJ trong 65,1% c\u00e1c tr\u01b0\u1eddng h\u1ee3p. Trong 45,2% c\u00e1c tr\u01b0\u1eddng h\u1ee3p, c\u00f3 m\u1ed1i t\u01b0\u01a1ng quan ch\u1eb7t ch\u1ebd gi\u1eefa \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y d\u01b0\u1edbi v\u00e0 m\u1eb7t tr\u01b0\u1edbc c\u1ee7a UPJ khi m\u1ea1ch m\u00e1u n\u00e0y \u0111i qua ph\u00eda tr\u01b0\u1edbc v\u00f9ng n\u00e0y \u0111\u1ec3 v\u00e0o c\u1ef1c d\u01b0\u1edbi (xem H\u00ecnh 130-8C). M\u1ea1ch m\u00e1u n\u00e0y kh\u00f4ng ph\u1ea3i l\u00e0 m\u1ea1ch ph\u1ee5 (accessory) hay m\u1ea1ch l\u1ea1c ch\u1ed7 (aberrant), m\u00e0 l\u00e0 m\u1ed9t \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y b\u00ecnh th\u01b0\u1eddng duy tr\u00ec m\u1ed1i li\u00ean quan gi\u1ea3i ph\u1eabu nh\u1ea5t qu\u00e1n v\u1edbi m\u1eb7t tr\u01b0\u1edbc c\u1ee7a UPJ m\u00e0 kh\u00f4ng g\u00e2y ch\u00e8n \u00e9p kh\u00fac n\u1ed1i. S\u1ef1 hi\u1ec7n di\u1ec7n \u0111\u01a1n thu\u1ea7n c\u1ee7a m\u1ea1ch m\u00e1u b\u1eaft ch\u00e9o t\u1ea1i UPJ kh\u00f4ng c\u00f3 ngh\u0129a l\u00e0 ch\u00fang nh\u1ea5t thi\u1ebft g\u00e2y t\u1eafc ngh\u1ebdn.<\/p>\n\n\n\n

    \u0110\u1ed1i v\u1edbi nh\u1eefng b\u1ec7nh nh\u00e2n c\u00f3 m\u1ea1ch m\u00e1u b\u1eaft ch\u00e9o v\u00e0 th\u1eadn \u1ee9 n\u01b0\u1edbc m\u1ee9c \u0111\u1ed9 t\u1ed1i thi\u1ec3u \u0111\u1ebfn trung b\u00ecnh, vi\u1ec7c k\u1eb9p (clipping) v\u00e0 c\u1eaft \u0111\u1ed9ng m\u1ea1ch b\u1eaft ch\u00e9o qua n\u1ed9i soi ph\u00fac m\u1ea1c \u0111\u00e3 \u0111\u01b0\u1ee3c b\u00e1o c\u00e1o. Tuy nhi\u00ean, ch\u00fang t\u00f4i nh\u1ea5n m\u1ea1nh r\u1eb1ng h\u01b0\u1edbng ti\u1ebfp c\u1eadn n\u00e0y n\u00ean b\u1ecb lo\u1ea1i b\u1ecf, v\u00ec n\u00f3 d\u1eabn \u0111\u1ebfn m\u1ea5t nhu m\u00f4 th\u1eadn ch\u1ee9c n\u0103ng. \u0110\u00e3 c\u00f3 minh ch\u1ee9ng r\u00f5 r\u00e0ng r\u1eb1ng t\u1ea5t c\u1ea3 c\u00e1c \u0111\u1ed9ng m\u1ea1ch th\u1eadn \u0111\u1ec1u l\u00e0 c\u00e1c m\u1ea1ch m\u00e1u t\u1eadn c\u00f9ng; do \u0111\u00f3 k\u1eb9p m\u1ea1ch m\u00e1u s\u1ebd g\u00e2y nh\u1ed3i m\u00e1u th\u1eadn. \u0110\u1ed9ng m\u1ea1ch cung c\u1ea5p cho c\u1ef1c d\u01b0\u1edbi (ph\u00e2n th\u00f9y d\u01b0\u1edbi) chi\u1ebfm t\u1eeb 7,4% \u0111\u1ebfn 38% t\u1ed5ng di\u1ec7n t\u00edch nhu m\u00f4 th\u1eadn ch\u1ee9c n\u0103ng. V\u00ec l\u00fd do \u0111\u00f3, n\u1ebfu x\u00e1c nh\u1eadn t\u1eafc ngh\u1ebdn UPJ l\u00e0 do \u0111\u1ed9ng m\u1ea1ch b\u1eaft ch\u00e9o, n\u00ean \u0111\u1ec1 xu\u1ea5t ph\u1eabu thu\u1eadt m\u1edf ho\u1eb7c t\u1ea1o h\u00ecnh b\u1ec3 th\u1eadn n\u1ed9i soi ph\u00fac m\u1ea1c v\u1edbi k\u1ef9 thu\u1eadt chuy\u1ec3n v\u1ecb m\u1ea1ch m\u00e1u b\u1eaft ch\u00e9o (transposition) thay v\u00ec k\u1eb9p b\u1ecf n\u00f3.<\/p>\n\n\n\n

    M\u1ed1i t\u01b0\u01a1ng quan m\u1ea1ch m\u00e1u m\u1eb7t sau Kh\u00fac n\u1ed1i B\u1ec3 th\u1eadn-Ni\u1ec7u qu\u1ea3n<\/strong><\/p>\n\n\n\n

    Trong 6,2% c\u00e1c tr\u01b0\u1eddng h\u1ee3p, ch\u00fang t\u00f4i t\u00ecm th\u1ea5y m\u1ed1i li\u00ean quan tr\u1ef1c ti\u1ebfp gi\u1eefa m\u1ed9t m\u1ea1ch m\u00e1u l\u1edbn (\u0111\u1ed9ng m\u1ea1ch, t\u0129nh m\u1ea1ch ho\u1eb7c c\u1ea3 hai) v\u00e0 b\u1ec1 m\u1eb7t l\u01b0ng (dorsal surface) c\u1ee7a UPJ (H\u00ecnh 130-9). Trong t\u1ea5t c\u1ea3 c\u00e1c tr\u01b0\u1eddng h\u1ee3p c\u00f3 \u0111\u1ed9ng m\u1ea1ch b\u1eaft ch\u00e9o m\u1eb7t l\u01b0ng UPJ (3,5%), m\u1ea1ch m\u00e1u \u0111\u00f3 l\u00e0 \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y sau<\/strong>, c\u00f2n \u0111\u01b0\u1ee3c g\u1ecdi l\u00e0 \u0111\u1ed9ng m\u1ea1ch sau b\u1ec3 th\u1eadn (retropelvic artery)<\/strong> (xem H\u00ecnh 130-9B).<\/p>\n\n\n\n

    \"\"
    H\u00ccNH 130-9. A, H\u00ecnh chi\u1ebfu m\u1eb7t sau c\u1ee7a n\u1ed9i soi th\u1eadn tr\u00e1i (h\u1ec7 th\u1ed1ng b\u1ec3 th\u1eadn c\u00f9ng v\u1edbi c\u00e1c \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch trong th\u1eadn). M\u1ed9t nh\u00e1nh l\u01b0ng c\u1ee7a t\u0129nh m\u1ea1ch th\u1eadn (m\u0169i t\u00ean) v\u00e0 \u0111\u1ed9ng m\u1ea1ch ph\u00e2n \u0111o\u1ea1n sau (\u0111\u1ed9ng m\u1ea1ch sau b\u1ec3 th\u1eadn, m\u0169i t\u00ean) n\u1eb1m g\u1ea7n m\u1eb7t sau c\u1ee7a ch\u1ed7 n\u1ed1i ni\u1ec7u qu\u1ea3n – b\u1ec3 th\u1eadn. A, \u0111\u1ed9ng m\u1ea1ch th\u1eadn; V, t\u0129nh m\u1ea1ch th\u1eadn; u, ni\u1ec7u qu\u1ea3n. B, H\u00ecnh chi\u1ebfu m\u1eb7t sau c\u1ee7a n\u1ed9i soi th\u1eadn tr\u00e1i (h\u1ec7 th\u1ed1ng b\u1ec3 th\u1eadn c\u00f9ng v\u1edbi c\u00e1c \u0111\u1ed9ng m\u1ea1ch trong th\u1eadn) cho th\u1ea5y \u0111\u1ed9ng m\u1ea1ch ph\u00e2n \u0111o\u1ea1n sau (\u0111\u1ed9ng m\u1ea1ch sau b\u1ec3 th\u1eadn) n\u1eb1m g\u1ea7n m\u1eb7t sau c\u1ee7a ch\u1ed7 n\u1ed1i ni\u1ec7u qu\u1ea3n – b\u1ec3 th\u1eadn (m\u0169i t\u00ean). A, \u0111\u1ed9ng m\u1ea1ch th\u1eadn; u, ni\u1ec7u qu\u1ea3n.<\/figcaption><\/figure>\n\n\n\n

    H\u1ea7u h\u1ebft c\u00e1c t\u00e1c gi\u1ea3 khuy\u1ebfn c\u00e1o r\u1eb1ng UPJ n\u00ean \u0111\u01b0\u1ee3c r\u1ea1ch d\u1ecdc theo m\u1eb7t sau b\u00ean (posterolateral), nh\u01b0ng c\u00e1c ph\u00e1t hi\u1ec7n c\u1ee7a ch\u00fang t\u00f4i ch\u1ee9ng minh r\u1eb1ng \u0111i\u1ec1u n\u00e0y \u0111\u1eb7t ra nguy c\u01a1 nghi\u00eam tr\u1ecdng l\u00e0m t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u sau b\u1ec3 th\u1eadn. Th\u1ef1c t\u1ebf, ngay c\u1ea3 khi th\u1ee7 thu\u1eadt \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n b\u1edfi c\u00e1c b\u00e1c s\u0129 n\u1ed9i soi gi\u00e0u kinh nghi\u1ec7m, t\u1ec9 l\u1ec7 xu\u1ea5t huy\u1ebft tr\u1ea7m tr\u1ecdng khi UPJ \u0111\u01b0\u1ee3c r\u1ea1ch \u1edf m\u1eb7t sau b\u00ean l\u00e0 12%. \u0110\u01b0\u1eddng r\u1ea1ch ph\u00eda sau ho\u1eb7c sau b\u00ean t\u1ea1i v\u1ecb tr\u00ed h\u1eb9p UPJ c\u0169ng ti\u1ec1m \u1ea9n kh\u1ea3 n\u0103ng t\u1ed5n th\u01b0\u01a1ng \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y sau, ngo\u00e0i vi\u1ec7c g\u00e2y xu\u1ea5t huy\u1ebft n\u1eb7ng, c\u00f2n c\u00f3 th\u1ec3 li\u00ean quan \u0111\u1ebfn vi\u1ec7c m\u1ea5t m\u1ed9t ph\u1ea7n l\u1edbn m\u00f4 th\u1eadn ch\u1ee9c n\u0103ng do nh\u1ed3i m\u00e1u th\u1eadn. C\u1ea7n l\u01b0u \u00fd r\u1eb1ng \u1edf m\u1ed9t s\u1ed1 c\u00e1 th\u1ec3, \u0111\u1ed9ng m\u1ea1ch ph\u00e2n th\u00f9y sau cung c\u1ea5p t\u1edbi 50% nhu m\u00f4 th\u1eadn (H\u00ecnh 130-10A).<\/p>\n\n\n\n

    \"\"
    H\u00ccNH 130-10. A, H\u00ecnh chi\u1ebfu m\u1eb7t sau c\u1ee7a n\u1ed9i soi th\u1eadn tr\u00e1i cho th\u1ea5y ph\u00e2n \u0111o\u1ea1n sau m\u00e0u \u0111\u1ecf (P), t\u01b0\u01a1ng \u1ee9ng v\u1edbi 49,36% t\u1ed5ng di\u1ec7n t\u00edch th\u1eadn. A, ph\u00e2n \u0111o\u1ea1n tr\u01b0\u1edbc; I, ph\u00e2n \u0111o\u1ea1n d\u01b0\u1edbi. B, H\u00ecnh chi\u1ebfu m\u1eb7t sau c\u1ee7a n\u1ed9i soi th\u1eadn tr\u00e1i (h\u1ec7 th\u1ed1ng b\u1ec3 th\u1eadn c\u00f9ng v\u1edbi c\u00e1c \u0111\u1ed9ng m\u1ea1ch v\u00e0 t\u0129nh m\u1ea1ch trong th\u1eadn) cho th\u1ea5y \u0111\u1ed9ng m\u1ea1ch ph\u00e2n \u0111o\u1ea1n sau (\u0111\u1ed9ng m\u1ea1ch sau b\u1ec3 th\u1eadn) b\u1eaft ch\u00e9o th\u1ea5p h\u01a1n 1,5 cm (0,5 cm) ph\u00eda tr\u00ean m\u1eb7t sau c\u1ee7a ch\u1ed7 n\u1ed1i ni\u1ec7u qu\u1ea3n – b\u1ec3 th\u1eadn (m\u0169i t\u00ean). A, \u0111\u1ed9ng m\u1ea1ch th\u1eadn; V, t\u0129nh m\u1ea1ch th\u1eadn; u, ni\u1ec7u qu\u1ea3n.<\/figcaption><\/figure>\n\n\n\n

    B\u00ean c\u1ea1nh 6,2% m\u1ea1ch m\u00e1u c\u00f3 li\u00ean quan tr\u1ef1c ti\u1ebfp m\u1eb7t l\u01b0ng v\u1edbi UPJ, c\u00f3 th\u00eam 20,5% c\u00e1c tr\u01b0\u1eddng h\u1ee3p c\u00f3 m\u1ed9t m\u1ea1ch m\u00e1u b\u1eaft ch\u00e9o c\u00e1ch m\u1eb7t l\u01b0ng UPJ \u00edt h\u01a1n 1,5 cm v\u1ec1 ph\u00eda tr\u00ean (xem H\u00ecnh 130-10B). \u0110i\u1ec1u n\u00e0y c\u00f3 t\u1ea7m quan tr\u1ecdng l\u1edbn v\u00ec \u0111\u1ec3 \u0111\u1ea1t \u0111\u01b0\u1ee3c UPJ th\u00f4ng tho\u00e1ng, th\u01b0\u1eddng c\u1ea7n ph\u1ea3i k\u00e9o d\u00e0i \u0111\u01b0\u1eddng r\u1ea1ch n\u1ed9i soi v\u00e0o m\u00f4 l\u00e0nh th\u00eam 1 \u0111\u1ebfn 2 cm \u1edf m\u1ed7i ph\u00eda (tr\u00ean v\u00e0 d\u01b0\u1edbi) v\u00f9ng h\u1eb9p UPJ. \u0110i\u1ec1u n\u00e0y c\u00f3 ngh\u0129a l\u00e0 nguy c\u01a1 t\u1ed5n th\u01b0\u01a1ng m\u1ea1ch m\u00e1u m\u1eb7t l\u01b0ng \u0111\u1eb7c bi\u1ec7t l\u1edbn trong c\u00e1c \u0111\u01b0\u1eddng r\u1ea1ch ph\u00eda sau v\u00e0 sau b\u00ean. Do \u0111\u00f3, ph\u1ea3i tr\u00e1nh c\u00e1c \u0111\u01b0\u1eddng r\u1ea1ch ph\u00eda sau v\u00e0 sau b\u00ean t\u1ea1i UPJ<\/strong>.<\/p>\n\n\n\n

    \u0110\u01b0\u1eddng r\u1ea1ch t\u1ea1i v\u1ecb tr\u00ed h\u1eb9p Kh\u00fac n\u1ed1i B\u1ec3 th\u1eadn-Ni\u1ec7u qu\u1ea3n d\u1ef1a tr\u00ean Gi\u1ea3i ph\u1eabu M\u1ea1ch m\u00e1u<\/strong><\/p>\n\n\n\n

    Ch\u00fang t\u00f4i khuy\u1ebfn c\u00e1o r\u1eb1ng \u0111\u01b0\u1eddng r\u1ea1ch s\u00e2u d\u1ecdc theo th\u00e0nh h\u1eb9p UPJ n\u00ean \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n ngay \u1edf ph\u00eda b\u00ean (laterally)<\/strong> (H\u00ecnh 130-11A). \u0110\u01b0\u1eddng r\u1ea1ch t\u1ea1i v\u1ecb tr\u00ed n\u00e0y, n\u01a1i ch\u00fang t\u00f4i g\u1ecdi l\u00e0 “v\u00f9ng kh\u00f4ng m\u1ea1ch m\u00e1u” (nonvascular area)<\/strong> c\u1ee7a UPJ, s\u1ebd tr\u00e1nh \u0111\u01b0\u1ee3c t\u1ea5t c\u1ea3 c\u00e1c m\u1ea1ch m\u00e1u quan tr\u1ecdng c\u00f3 li\u00ean quan \u1edf ph\u00eda tr\u01b0\u1edbc, ph\u00eda sau, ho\u1eb7c ph\u00eda tr\u00ean m\u1eb7t sau c\u1ee7a UPJ \u00edt h\u01a1n 1,5 cm.<\/p>\n\n\n\n

    \"\"
    H\u00ccNH 130-11. A, H\u00ecnh chi\u1ebfu m\u1eb7t tr\u01b0\u1edbc c\u1ee7a s\u01a1 \u0111\u1ed3 v\u1ebd t\u1eeb th\u1eadn tr\u00e1i cho th\u1ea5y v\u00f9ng c\u1ea7n \u0111\u01b0\u1ee3c r\u1ea1ch trong ph\u1eabu thu\u1eadt n\u1ed9i soi b\u1ec3 th\u1eadn (m\u0169i t\u00ean); v\u00f9ng kh\u00f4ng m\u1ea1ch m\u00e1u (NVA) c\u1ee7a ch\u1ed7 n\u1ed1i ni\u1ec7u qu\u1ea3n – b\u1ec3 th\u1eadn. B, L\u01b0u \u00fd b\u1ec1 m\u1eb7t c\u1eaft c\u1ee7a dao Sacks \u0111\u01b0\u1ee3c \u0111\u1eb7t \u1edf v\u1ecb tr\u00ed b\u00ean d\u01b0\u1edbi s\u1ef1 h\u01b0\u1edbng d\u1eabn c\u1ee7a m\u00e1y soi hu\u1ef3nh quang trong qu\u00e1 tr\u00ecnh ph\u1eabu thu\u1eadt n\u1ed9i soi b\u1ec3 th\u1eadn<\/figcaption><\/figure>\n\n\n\n

    Ngay c\u1ea3 trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p c\u00f3 m\u00f4 x\u01a1 v\u00e0 s\u1eb9o r\u1ed9ng t\u1ea1i UPJ, \u0111\u01b0\u1eddng r\u1ea1ch ph\u00eda b\u00ean \u1edf v\u00f9ng kh\u00f4ng m\u1ea1ch m\u00e1u c\u1ee7a UPJ v\u1eabn an to\u00e0n v\u00e0 gi\u00fap lo\u1ea1i b\u1ecf nhu c\u1ea7u ch\u1ee5p m\u1ea1ch m\u00e1u tr\u01b0\u1edbc m\u1ed5. Ngo\u00e0i ra, m\u1ed9t \u0111\u1ed9ng m\u1ea1ch c\u1ef1c d\u01b0\u1edbi kh\u00f4ng \u0111\u01b0\u1ee3c nghi ng\u1edd b\u1eaft ch\u00e9o ph\u00eda tr\u01b0\u1edbc ho\u1eb7c ph\u00eda sau UPJ c\u0169ng s\u1ebd \u0111\u01b0\u1ee3c b\u1ea3o v\u1ec7 kh\u1ecfi th\u01b0\u01a1ng t\u1ed5n.<\/p>\n\n\n\n

    Vi\u1ec7c duy tr\u00ec \u0111\u1ecbnh h\u01b0\u1edbng gi\u1ea3i ph\u1eabu ho\u00e0n ch\u1ec9nh d\u01b0\u1edbi nh\u00e3n quan n\u1ed9i soi \u0111\u00f4i khi r\u1ea5t kh\u00f3 kh\u0103n. Do \u0111\u00f3, kinh nghi\u1ec7m v\u00e0 khuy\u1ebfn c\u00e1o c\u1ee7a ch\u00fang t\u00f4i l\u00e0 h\u00e3y \u0111\u1eb7t d\u1ee5ng c\u1ee5 c\u1eaft \u1edf ph\u00eda b\u00ean v\u00e0 d\u01b0\u1edbi h\u01b0\u1edbng d\u1eabn c\u1ee7a m\u00e0n t\u0103ng s\u00e1ng (xem H\u00ecnh 130-11B) tr\u01b0\u1edbc khi b\u1eaft \u0111\u1ea7u r\u1ea1ch t\u1ea1i UPJ. Thao t\u00e1c n\u00e0y \u0111\u1ea3m b\u1ea3o cho ph\u1eabu thu\u1eadt vi\u00ean r\u1eb1ng \u0111\u01b0\u1eddng r\u1ea1ch s\u1ebd \u0111\u01b0\u1ee3c th\u1ef1c hi\u1ec7n ch\u00ednh x\u00e1c \u1edf m\u1eb7t b\u00ean \u2014 v\u00f9ng kh\u00f4ng m\u1ea1ch m\u00e1u \u2014 c\u1ee7a UPJ.<\/p>\n\n\n\n

    \n\n\n\n

    <\/p>\n","protected":false},"excerpt":{"rendered":"

    T\u00e1c gi\u1ea3: FRANCISCO J. B. SAMPAIO D\u1ecbch l\u1ea1i: B\u00e1c s\u0129 Ph\u00fa Ngo\u1ea1i Ti\u1ebft Ni\u1ec7u H\u1ec6 TH\u1ed0NG \u0110\u00c0I B\u1ec2 TH\u1eacN: C\u00c1C \u00dd NGH\u0128A TRONG N\u1ed8I SOI TI\u1ebeT NI\u1ec6U C\u01a1 s\u1edf Gi\u1ea3i ph\u1eabu \u0110\u1ec3 h\u1ed7 tr\u1ee3 c\u00e1c ph\u1eabu thu\u1eadt vi\u00ean n\u1ed9i soi ti\u1ebft ni\u1ec7u h\u00ecnh dung h\u00ecnh \u1ea3nh 3D c\u1ee7a h\u1ec7 th\u1ed1ng g\u00f3p v\u00e0 n\u1eafm b\u1eaft v\u1ecb […]<\/p>\n","protected":false},"author":1,"featured_media":799,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"pagelayer_contact_templates":[],"_pagelayer_content":"","footnotes":""},"categories":[22],"tags":[],"class_list":["post-774","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-loi-khuyen-tu-chuyen-gia"],"_links":{"self":[{"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/posts\/774","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/comments?post=774"}],"version-history":[{"count":1,"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/posts\/774\/revisions"}],"predecessor-version":[{"id":800,"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/posts\/774\/revisions\/800"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/media\/799"}],"wp:attachment":[{"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/media?parent=774"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/categories?post=774"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/tietnieunamkhoa.pro.vn\/wp\/wp-json\/wp\/v2\/tags?post=774"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}