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researches noted that ligature of the anterior one third of the sag-gital sinus can cause venous ischemia ofbrain matter and secondary lesion of brain, the result of which can be lethal outcome in some cases [6]. In the studies of Romani R. group of other researchers (2011, 2012) it was also noted that injure and ligature of the anterior one third of the saggital sinus and anterior collector cerebral veins significantly increase the risk of postoperative edema of brain matter and venous infarction of brain [8; 9].
In spite of the fact, that LSO approach was easy, fast, less traumatic and preserving the anatomical integrity, as well as all other
approaches had its shortcomings, such as impossibility of circle of Willis posterior part upper segment aneurysm exposure and shortcomings fir giant aneurysms of brain.
Conclusions. Thus, lateral supra orbital approach can be used as an alternative for classic approaches in surgery of circle of Willis anterior circulation aneurysm. And it diminishes not only the time of operative intervention, but also lesions of anatomic structures. It does not cause cosmetic defects during postoperative period and, what is the most important, diminishes grinding of scull base and the risk of complications linked with that procedure.
References:
1. Al-Mefty O., Anand VK.: Zygomatic approach to skull-base lesions. J. Neurosurg. 1990 73: 668-673.
2. Figueiredo E.G., Deshmukh P., Zabramski J.M., Preul M.C., Crawford N.R., Spetzler R.F.: The pterional-transsylvian approach: an analytical study. Neurosurgery. 2008 Jun; 62 (6 Suppl 3): 1361-7.
3. Gonzalez L.F., Zabramski J.M.: Anatomic and clinical study of the orbitopterional approach to anterior communicating artery aneurysms. Neurosurgery. 2004 Apr; 54 (4): 1031-2.
4. Hernesniemi J., Ishii K., Niemela M., Smrcka M., Kivipelto L., Fujiki M., Shen H.: Lateral supraorbital approach as an alternative to the classical pterional approach. Acta Neurochir Suppl. 2005; 94: 17-21.
5. Krayenbuhl N., Isolan G.R., Hafez A., Ya^argil M.G.: The relationship of the fronto-temporal branches of the facial nerve to the fascias of the temporal region: a literature review applied to practical anatomical dissection. J. Neurosurg. Rev. 2007 Jan; 30 (1): 8-15.
6. Nakamura M., Roser F., Struck M., Vorkapic P., Samii M.: Tuberculum sellae meningiomas: clinical outcome considering different surgical approaches. Neurosurgery. 2006 Nov; 59 (5): 1019-28.
7. Reisch R., Perneczky A., Filippi R.: Surgical technique of the supraorbital key-hole craniotomy. Surg. Neurol. 2003 59: 223-227.
8. Romani R., Laakso A., Kangasniemi M., Lehecka M, Hernesniemi J.: Lateral supraorbital approach applied to anterior clinoidal meningiomas: experience with 73 consecutive patients. Neurosurgery. 2011 Jun;68 (6): 1632-47.
9. Romani R, Laakso A, Kangasniemi M, Niemela M, Hernesniemi J.: Lateral supraorbital approach applied to tuberculum sellae meningiomas: experience with 52 consecutive patients. Neurosurgery. 2012 Jun;70 (6): 1504-18.
10. van Lindert E., Perneczky A., Fries G., Pierangeli E.: The supraorbital keyhole approach to supratentorial aneurysms: concept and technique. Surg. Neurol. 1998 49: 481-490.
11. Zabramski J.M., Kiris T., Sankhla S.K., Cabiol J., Spetzler R.F.: Orbitozygomatic craniotomy. J. Neurosurg. 1998 Aug. 89: 336-341.
Masharipov Fakhriddin Ataevich, Musayev Tahir Sadikovic, Dadamyants Natalia Gamletovna, Nizov Oleg Nikolayevich,
Akhmedov Rustam Alimdzhanovich
Republican research Centre of Emergency Medicine (RRCEM)
Tashkent, Uzbekistan
Dynamics of brachial artery blood flow indexes at complicated transcondylar and supracondylar humeral fractures in children
Abstract: Surgical treatment results 51 children with trans- and supracondylar humeral bone fractures complicated by brachial artery injuries. Main clinical symptoms, significance of applying up-to-date technologies (pulsioxymetry, color duplex scanning) in diagnostics of brachial artery injuries and peculiarities of blood flow dynamic control on injured limb in the post-operative period have been illustrated. At well-timed diagnostic and active surgical correction of injured brachial artery peripheral circulation on injured limb has been recovered in 96,5% of cases.
Keywords: trans — and supracondylar humeral bone fractures, brachial artery injury, blood circulation disorder, pulsioxymetry, color duplex scanning.
Introduction
Trans- and supracondylar humeral fractures in children are not only the most frequent but they are the most serious bones injuries which can be complicated by neurovascular column injury. By different authors' data trans- and supracondylar humeral fractures in children from 2 to 14% cases can be complicated by neurovascular
column interposition which provokes limb ischemia and peripheral nerves disorders [1; 2; 5; 8]. Victims are performed closed reposition or bones fragments operative stabilization by emergency indication, but vessels and nerves injuries are revealed later when nonreversible changes have already developed in the limb. Majority of authors [3; 4; 6; 7] think that these injuries refer to a special
Dynamics of brachial artery blood flow indexes at complicated transcondylar and supracondylar humeral fractures in children
group which do not comply general rules of fractures diagnostics and treatment. Opportune diagnostics and treatment of trans- and supracondylar humeral fractures in children remain actual issue in children's traumatology.
The aim of research is surgical treatment efficiency estimation at trans- and supracondylar humeral fractures in children with complicated brachial artery injuries based on instrumental investigations data.
Materials and methods
51 children have been cured in children's traumatology department of RRCEM from 2007-2014 with trans- and supracondylar humeral fractures with bones fragments displacements complicated by blood circulation disorders signs of injured limb. There were 39 (76,5%) boys and 12 (23,5%) girls. Blood circulation disorders on the left upper extremity were in 33 (64,7%) victims, on the right
one — in18 (35,3%). Children's age varied from 1 to 14 years and the biggest quantity of fractures (29) was noted in children at the age from 4 to 8 years.
Diagnostics of blood circulation disorder at trans- and supracondylar humeral fractures in children has been based on objective data and instrumental investigations. There were typical clinical signs in patients with blood circulation disorders. In elbow joint area it has been noted a rough prominence-shaped deformation, sharp end of the central fragment projected under elbow bend's skin, there was visualized round and cyanotic discoloration macula — the result of soft tissues formation injury (pict. 1 a), weakening or absence of pulsation in the radial artery has been noted by palpation. Pulseoximetry of injured limb and brachial artery colored duplex scanning (CDS) have been used as instrumental diagnostic method (pict. 1b).
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a) b)
Figure 1. Local signs and investigations at patient's admission with trans- and supracondylar humeral fractures: a — typical macula in elbow joint area- the result of soft tissues formation injury; b — performing pulseoximetry — signs of peripheral blood circulation disorder
Pulseoximetry has been carried by «Nihon Kohden — BSM-2301K» (2002) with comparing ofhealthy and injured limbs. In the case ofpulse wave absence on pulsoximetry (pict.1b.) CDS has been used for blood flow speed investigation on the brachial artery and on forearm arteries. CDS has been performed by HD 11XE (Philips, 2010) with broadband linear transducer of 7,5 MHz frequency in colored Doppler mapping (CDM) mode, energetic Doppler mapping (EDM) and in impulse-wave mode. At CDS it has been performed investigation ofbrachial artery distal part, ulnar and radial arteries ostiums in standard
diagnostic points comparatively to injured and healthy limbs. After conducting CDS ofbrachial and forearm arteries, trans- and supracondylar humeral fractures in children complicated by brachial artery injuries, treatment tactics has been determined. Collateral blood flow type has been detected in 18 patients, statistically significant differences ofDop-plerographic blood flow indexes between injured and healthy brachial arteries have been detected in 19 children. Brachial artery blood flow was not detected in 14 cases, lumen was not mapped, in all cases there were indications for revision ofbrachial artery in elbow joint area.
Figure 2. Performing CDS of brachial artery
Results and discussions. Treatment tactics at trans- and supracondylar humeral fractures complicated by brachial artery injuries was as follows: primary it has been performed bones fragments stabilizing by the method of extrafocal osteosynthesis with the use of devised apparatus of RRCEM (patent № FAP 00772). Taking into account that procedures for correlation of bones fragments at bone-vascular injuries can lead to additional injury of the main vessels and aggravation of blood circulation, we did not perform reposition ofbones fragments. Retrospective analysis of operation protocols before adopting our devised surgical treatment tactics has shown that single-stage elimination of lateral, anteroposterior and rotary displacement by Ilizarov's apparatus often led to entrapment of brachial artery between bone fragments with additional injury. That is why based on our offered tactics, first we performed only fixing ofbone fragments by apparatus without their reposition. Then it has been done revision of vascular-nervous column in the fracture area by anteromedial approach in the elbow's one-third part with transition to elbow bend area. It should be noticed that the presence of apparatus has facilitated surgical interventions performed by angio-surgeon, has allowed to displace the ends of bone fragments without the risk of separating structures secondary injury during the revision. In all cases when at pulsoximetry and at CDS of brachial and forearm arteries there were detected blood circulation disorder signs and vessel's injury has been proved intra-operatively. Revision of brachial artery has been performed together with angio-surgeons. There were revealed the following injuries of brachial artery at the revision: arteriospasm has been noted in 16 cases, intima's injury — in 5 patients and in 10 cases brachial artery thrombosis at fracture's level has been detected. In 20 cases interposition of brachial artery (entrapment, compression by fragments' ends) was a cause of blood circulation disorder. In all cases brachial artery injury has located lower than origin of brachial artery's deep vien and that's why in the majority of cases blood circulation disorder was compensated. 3 patients were transfered from other hospitals after performed closed reposition with putting plaster. Due to traumatic edema and compression of origin of brachial artery's deep vien area, IIB-IIIA level ischemia by V. S. Saveliev has been developed. Irreversible IIIB level ischemia has been detected in a child who has been treated by healer during 3 days. After revision and surgical correction of injuried brachial artery, visually and under optical converter control we managed to perform a final reposition of bones fragments by hospital's apparatus.
It should be noted that at some traumatological hospitals where there are no angio-surgeons, elimination of blood circulation disorder has been performed by posterior approach to elbow joint. It is impossible to perform total visualization and estimation of brachial artery's injury nature at that approach. There are the cases of brachial artery blood circulation disorder's relapse and repeated surgical intervention.
With the aim circulation recovery estimation and dynamic control of blood flow indexes in injured limb in the early post-operative period pulsoximetry and CDS with comparison of injured and healthy limbs. Decreasing of carbonation indexes (SPO2)
from normal ones, difference or absence of pulse wave amplitude at pulsoximeter have not been revealed in patients. At spectral blood flow analysis on the brachial artery we have estimated the form of Doppler curve, analyzed blood flow hemodynamic indexes: peak systolic speed (Vmax), final diastolic speed (Vmin), Resistivity Index (RI) — vascular resistance index, and also we paid attention on blood flow types and brachial artery lumen mapping.
Patients were under dynamic observation 6-7 days, got medica-mentous cure by drugs improving peripheral blood circulation and preventing vessels reflex spasm, thrombotic complications. Patients were performed dynamic control of blood circulation on the brachial artery before discharging, after apparatus removal and 4-5 weeks later by pulsoximetry and CDS. SPO2 indexes on pulsoximetry and pulse wave amplitude were normal and equal both from injured and healthy sides. Doppler indexes analysis showed that artery lumen is completely mapped at the place where arteriolitis has been performed and Vmax and RI indexes are significantly quickened in compare with healthy one. For surgical treatment results estimation we used the following criteria of anatomic and functional recovery of injured fracture consolidation, joint deformation, limbs difference by length, upper extremities scope difference, fingers sensitivity and movement disorder.
Due to performed treatment tactics and blood flow dynamic control scheme in children with trans- and supracondylar humeral fractures complicated by brachial artery injuries we got positive outcomes in 50 (98,1%) cases. They were manifested as complete recovery of movement in elbow joint and sensitive functions in fingers. Unsatisfactory result was noted in 1 child with continuous ischemia when surgery was performed 3 days after getting injury (a child with irreversible IIIB level ischemia by V. S. Saveliev, who has been treated by healer). Clinic of ischemic contracture of fingers has been developed in that child.
Conclusions
1. At suspicion on brachial artery injury at trans- and supracondylar humeral fractures in children pulsoximetry and CDS is obligatory to be performed and they are highly informative non-invasive diagnostic methods at such cases.
2. Blood flow absence on brachial artery and statistic significant differences of Doppler indexes of blood flow between healthy and injured arteries are direct indications for revision of brachial artery in elbow joint area at trans- and supracondylar humeral fractures in children.
3. At complicated at trans- and supracondylar humeral fractures in children for performing valuable visualization and injury nature estimation for adequate surgical intervention on injured vessel the most optimal approach is anteromedial one on the elbow joint.
4. For efficiency estimation of performed operative intervention at complicated at trans- and supracondylar humeral fractures in children with blood circulation disorder it is necessary to perform pulsoximetry and CDS of brachial artery in dynamics with comparison of healthy limb.
References:
1. Akhundov A. A. Trans- and supracondylar humeral fractures in children. Baku., 1973. P. 235.
2. Bajanova N. N. Differentiated approach to cure of trans- and supracondylar humeral fractures in children: dis... PhD. Moscow., Russian state medical university. 2008. P.44.
3. Bairov G. A. Fractures in elbow joint area in children. L, Medicine, 1976. P. 423 c.
4. Zavyalov P. V., A. M. Shamsiev. Stale and old humeral fractures in children. Tashkent. Medicine 1978. P. 152.
5. Safarov J. M. Surgical treatment of supracondylar and soft tissue humeral fractures in children: dis. PhD. Dushanbe. 2006. P. 121.
6. Sondibaev Sh. O. Treatment peculiarities of transcondylar humeral fractures in younger children: dis. PhD Samarkand 2002. P. 165.
Metods of surgical treatment and postoperative complications of hirschsprung's disease in adults
7. Ravi K. Bashyal et all. Complications After Pinning of Supracondylar Distal Humerus Fractures//J Pediatr/Orthop- Volume 29, Number 7, October/Novtmber 2009. P. 704-708.
8. Ritabh Kumar, Vivek Trikha and Rajesh Malhotra. A study of vascular injuries in pediatric supracondylar humeral fractures//Journal of Orthopaedic Surgery 2001, 9 (2): 37-40.
Mirzachmedov Murad Mirchaidarovich, Tashkent Medical Academy. E-mail: myradbek@mail.ru
Metods of surgical treatment and postoperative complications of hirschsprung's disease in adults
Abstract: The material of the study has formed 82 sick, found on stationary treatment in Republican Scientific Centre Coloproktoloii since 1993 on 2014 years.
As it is seen, 82 sick mans was 58 (70,7%), womans 24 (29,3%). 21 (25,6%) sick were at age from 15 before 19 years, 32 (39%) at age from 20 before 24 years, 16 (19,5%) at age from 25 before 29 years and 5 (15,9%) sick from 30 years.
Diagnosis of Hirschsprung's disease in adults requires a comprehensive assessment of clinical symptoms, these studies X-ray inspection and results of functional studies of colon and rectal sphincter apparatus, morphological study. The best way to surgery for Hirschsprung's disease in adults is abdominal-anal resection of the rectum with bringing down the proximal colon to the anal canal, which, in terms of removal of hypo- or aganglionizis area meets the requirements of radicalism. Our proposed form of surgical treatment to reduce the number of postoperative complications, contributes to early recovery of motor-evacuation function of the colon and the normalization of self-defecation. Keywords: agangliozis, hipogangliozis, megacolon.
Introduction
Despite the progress made to date advances in the treatment of Hirschsprung's disease in adults, the problem is still far from being solved, as evidenced by very comforting percentage of the so-called secondary pathology, and most importantly — continuing treatment in specialized hospitals of patients undergoing primary corrective surgery [1; 3]. The reason for such appeals are persistent functional abnormalities that contribute to disability. In this context, efforts aimed at improving the treatment outcome of adult Hirschsprung's disease are highly relevant. Most researchers now suggest that Hirschsprung's disease is more common than diagnosed now. There are certain prerequisites for a slow, sometimes latent flow Hirschsprung disease in adults, is the existence of variants of congenital morphological changes, such as the short zone aganglioza, gipoganglionarnye form in the absence of marked degenerative processes in muscle tissue distal colon. Requires careful study and analysis of the causes of unsuccessful outcomes of surgical interventions, the improvement of a differentiated approach to the selection and determination of optimal methods for their correction, which was the goal of our work. [2; 4].
Various methods of surgical procedures and their modifications. In the arsenal of methods of surgical treatment of Hirschsprung's disease in children, there are various types of operations: Swenson, Soave, Duhamel and others in adults using these classical methods of pediatric surgery is difficult because of gross changes in the colon, the pelvic anatomy and relationships of the pelvic organs. At the same time, most attention in these publications is given to the results of surgical treatment of anomalies, and information regarding the clinic, diagnosis and surgical treatment for Hirschsprung's disease in adults, are presented only factual information without analysis because of the paucity of clinical observations.
The aim of our work was to study and analyze the causes of unsuccessful outcomes of surgical interventions and improvement of a differentiated approach to the selection and definition of best practices in surgery for Hirschsprung's disease in adults.
Material and methods
The Republican Scientific Centre Coloproctology in 19932014 years there were 82 patients with Hirschsprung's disease at the age of 16-30 years.
12 patients out of 82 patients in childhood have been performed different types of surgical treatment of Hirschsprung's disease (Swenson, Isakov, Soave). The program consisted of a survey of patients with functional studies closing apparatus of the rectum (sphincterometry, electromyography), rectoromonoscopy, colon X-ray inspection, endoscopy, ultrasound of the abdomen and pelvis. And also to clarify the diagnosis was performed transanal biopsy of the muscle layer of the rectum by Swenson. The differential diagnosis of Hirschsprung's disease in adults requires an individual approach, a comprehensive assessment of clinical symptoms, X-ray data and research results of functional studies of colon and rectal sphincter apparatus, morphological study. Radiographic methods allow to evaluate and determine the severity of megacolon, reveal a characteristic pattern of restriction and suprastenoticheskogo expansion. Particularly difficult diagnosis is very short (anal or overanal) hypo-or aganglios colon. It is not necessarily the presence of classical paintings in a narrower (hypo-or aganglios) area, as in children, is the physiological norm of the internal anal sphincter relaxation under tension received feces.
Results and discussion
Materials and methods
Consisting of ten subdivisions in which there is presented general characteristic of the patients, instrumental, laboratory, functional methods of examination and biopsy by Swenson. The work is based on the analysis of the data of examinations obtained from 82 patients (males — 58 and females — 24) with Hirschprung's disease at the age above 15 years, who received stationary treatment in The Research center of Coloproctology of the Ministry of Health of the Republic of Uzbekistan during the period from 1993-2014. Of them 21 (25,6%) patients were at the age 15-19 years, 32 (39%) — at the age 20-24 years, I6 (19,5%) — at the age 25-29 years, 5
