CC BY
23
The table shows that at inclusion of the drug Phosphogliv into the basic therapy of patients on the background of HAART the positive dynamics was retraced in the biochemical parameters: there was noted reduction of the total bilirubin contents, activity of the hepatic enzymes — AlAT and AsAT, thymol test, alkaline phosphatase and y-glutamiltranspeptidase (GGTP) There was noted insignificant decrease in the contents of cholesterol and glucose in the blood.
The values of thymol test in the patients of the studied group were reliably reduced (P < 0.05) even to the second week, that was not noted in the control group.
It is necessary to note though on the background of HAART the mean level of the AlAT and AsAT parameters reduced in the patients of control group to the normal values, in 23 % ofpatients in this group after prescription ofART there was noted increase in activity of these enzymes and contents of the total bilirubin in the blood, and in 3 patients there was found marked increase both in activity AlAT and the contents of total bilirubin with predominance of the direct bilirubin. Evidently, it was connected to early unfavorable adverse (hepatotoxic) effect of antiretroviral drugs on the enzymatic and pigment liver function.
Consequently, the use of hepatoprotectors at prescription of HAART for the patients with HIV-infection associated with chronic viral hepatitis C may be considered as rational due to clinical-laboratory efficacy.
Thus, there has been studied efficacy of the drug hepatoprotec-tor "Phosphogliv" in the complex of specific HAART in the patients with HIV-infection associated with chronic viral hepatitis C, and it
has been established that the positive dynamics has been noted as in relation to clinical symptoms (attenuation and/or elimination of clinical expressions of disorders in the hepatobiliary system), so as in the biochemical characteristics, which has been expressed by reduction in the contents of total bilirubin, activity of transaminases, thymol test, AP and GGTP, insignificant reduction of the contents of cholesterol and glucose in the blood. The above-described features indicated about advisability of application of drug Phosphogliv at prescription of HAART in the patients with HIV-infection associated with chronic viral hepatitis C in order to reduce hepatotoxic effect of the used antiretroviral preparations and to contribute to the improvement of the quality of life in the patients by HAART optimization.
Conclusions:
1. Use of drug Phosphogliv on the background of HAART provides for positive effect on the clinical and biochemical parameters, that is expressed by improvement of the general health state, elimination or attenuation of the clinical symptoms and reduction of the level of liver transaminases.
2. Phosphogliv as effective hepatoprotector serves as perspective addition to HAART in the patients with HIV-infection associated with chronic viral hepatitis C.
3. Application of Phosphogliv results in decrease in hepatotoxic manifestations of HAART in HIV+HCV co-infection.
4. The monthly monitoring of the biochemical blood characteristics on the basis of HAART in the patients with HIV-infection associated with chronic viral hepatitis C will allow improvement of the quality of life in these patients.
References:
1. Becker S. Liver toxicity in epidemiological cohorts//Clin. Inf. Dis. - 2004. - V.38. - Suppl. 2. - P. 49-55.
2. Dejesus E., Mills A., Bhatti L., Conner C., Storfer S. A randomised comparison of safety and efficacy of nevirapine vs. atazanavir/rito-navir combined with tenofovir/emtricitabine in treatment-naive patients//Int J. Clin. Pract. - 2011. - 65: 1240-1249.
3. Dieterich D. T., Robinson P. A., Love J. et al. Drug-induced liver injury associated with the use of nonnucleoside reverse-transcrip-tase inhibitors//Clin. Inf. Dis. - 2004. - V. 38. - Suppl. 2. - P. 80-89.
4. Gonzalez J. S., Batchelder A. W., Psaros C. et al. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis//J AIDS. - 2011. - 58: 181-187.
5. Ipatova O. M. Phosphogliv: mechanism of action and application in the clinic/under ed. of academician of the RAMS A. I. Archakov. -M.: Publ. of GUSRI of biomedical chemistry of RAMS, 2005.
6. Jones M., Nunez M. Liver toxicity of antiretroviral drugs//Semin Liver Dis. - 2012. - 32: 167-176.
7. Sulkowski M. S., Thomas D. L. Hepatitis C in the HIV-infected person. Annals of Internal Medicine. - 2003. - 138: 197-207.
8. Sulkowski M. S. Drug-induced liverinjury associated with antiretroviral therapy that includes HIV-1 protease inhibitors//Clin. Inf. Dis., 2004. - V. 38. - Suppl. 2. - P. 90-97.
9. Uchaikin V. F., Kovalev O. B. Study of clinical efficacy of Phosphogliv in acute and chronic viral hepatitis//Medicinckiy Vestnik. - M., 2006. - № 3. - P. 346.
10. Wit F. W., Weverling G. J., Weel J. et al. Incidence of and risk factors for severe hepatotoxicity associated with antiretroviral combination therapy//J. Infect. Dis.. - 2002. - V. 186. - P. 23-31.
Berkinov Ulugbek Bozorbaevich, Professor in the department of faculty and hospital surgery of the Tashkent Medical Academy, Republic of Uzbekistan
Khalikov Sarvar Pulatovich, Assistant in the department of faculty and hospital surgery of the Tashkent Medical Academy, Republic of Uzbekistan E-mail: sarvar_khalikov@yahoo.com
Optimization of the surgical treatment for high cicatricle tracheal stenosis
Abstract: Benign cicatricle process of the breathing tube is often localized in the subplical area of the larynx and upper trachea and therefore, resection and anastomosis in the upper segment of the respiratory tract represent a separate problem. The
paper reflects the experience of treatment of 86 patients who underwent intubation, mechanical ventilation, tracheostomy in the intensive care units of the Tashkent Medical Academy. The integrity of the airway restored by imposing of the tracheal anastomosis in 54 (62.8 %) patients. Tracheolaryngeal anastomosis was imposed in 32 (37.2 %) patients. The clinic has been developed and applied in 17 patients a new method of imposing of the tracheolaryngeal anastomosis at high cicatricle tracheal stenosis, which allowed to reduce the number of complications in the early and late postoperative period in half.
Keywords: trachea, cicatricle tracheal and larungeal stenosis, tracheolaryngeal anastomosis.
The urgency ofthe problem. The incidence of cicatricial stenosis ofthe trachea after resuscitation, accompanied by long-term artificial lung ventilation (ALV), and later tracheostomy, continues to be high and, according to recent data, ranges from 0.2 to 25 % in comparison with other post-operative complications. But by the third day of mechanical ventilation in the cartilage of the trachea occur pathological processes which result in the loss ofcartilage support function, which eventually leads to scarring and stenosis of the trachea [5; 11].
Further, causes of the tracheal stenosis may be surgery on the trachea or tumors of the trachea or surrounding organs and tissues, with invasion into the lumen of the respiratory tube, and injury of the neck organs [1; 6].
Some importance has increased activity of fibroblasts in patients with severe trauma, as well as individual features of connective tissue that contribute to the formation of rough scars, including on-site deep damage to the tracheal wall [12].
This group of patients requires complex and aggressive laryngotracheal plastic surgery up to the circular resection of the affected area of the trachea with the imposition of direct anastomosis "end to end" [8].
The analysis of published data and a review of the patent documentation has shown that the development of reconstructive and plastic surgery on the tracheobronchial tree is still an important issue today in pulmonary surgery. The most difficult problem of this section is surgery of trachea-tracheal formation, especially trachea-laryngeal anastomoses.
In this context, the aim of our study was, warning of the insufficiency of the trachea-laryngeal anastomosis and prevention of restenosis of the trachea by improving the technology of surgical treatment of cicatricial stenosis of the trachea and larynx.
Clinical material and methods of research. From 1984 to the present time in the clinic of the Tashkent Medical Academy (TMA) were treated 186 patients with the cicatricial stenosis of the trachea aged from 15 to 68 years. Among them were 112 male patients and 74 — female. Most patients, 172 patients (92.4 %), were young and middle-aged. Most often the stenosis of the trachea occurred after respiratory resuscitation in trauma patients, the frequency of which is higher in young and middle age, especially in males. In identifying the causes of cicatricial stenosis of the trachea has learned that, in the history of these patients had mechanical ventilation, tracheostomy, injuries or transferred inflammatory diseases of the trachea.
The most common mechanical ventilation was carried out at a craniocerebral trauma (35.2 %), the heart and internal organs operations (14.8 %), chest and abdominal trauma (8.8 %), neck injury (6.0 %), poisoning with chemicals (5.6 %), throat edema (5.3 %). The ventilation duration varied from a few hours to 25 days. Symptoms usually occur within the period of 7 to 60 days after removal of the tracheostomy or endotracheal tube. With a functioning tracheostomy hospitalized 87 (46.8 %) patients. Persistence stoma varied from several weeks to several years. Retracheostomy at different times after decannulation was performed at 23 (12.4 %) patients.
Most often, in 125 (67.2 %) of patients, the cicatricial stenosis was located in the cervical trachea, in 32 of these patients it was combined with narrowing of the subplical area of the larynx. The
defeat of the cervical-thoracic trachea was observed in 45 (24.2 %) and breast — in 16 (8.6 %) patients. In 4 cases the SCT was complicated by esophageal-tracheal fistula at the level of cervical trachea, and in 2 of them are in the process of scar was involved lower larynx. The patients were mostly from the II—III rumen degree of airway narrowing. In 44 (23.6 %) patients on admission was marked stridor. Cicatricial-granulation tracheal stenosis was diagnosed in only 10 (5.4 %) patients. This type of contraction is considered as the early stage of cicatricial stenosis, when the granulation tissue is tender and has not yet been transformed into a rough coupling.
Indications for surgical treatment of cicatricial stenosis of the trachea established in 86 (46.2 %) patients. In 100 (53.8 %) patients were used endoscopic techniques to expand and maintain the tracheal lumen. Surgical treatment consisted of resection surgery (circular resection of the trachea or the larynx). In 10 patients at admission was diagnosed posttracheostomic cicatricial stenosis of the cervical trachea I and II degree, which does not cause difficulty in breathing and did not require surgical correction.
Results and discussion. Circular resection of the trachea with the anastomosis end-to-end is a radical operation that allows to remove the affected segment and restore the integrity of the airway. Arsenal of modern methods of ventilation (standard ventilation, shunt system — breathing, high frequency ventilation) allows to choose the most convenient for the surgeon and for the patient safe way to maintain gas exchange for each stage of surgery [3].
We produced 86 circular resection of the trachea. The indication for surgery was limited cicatricial stenosis of the trachea, when it was possible to restore the integrity of respiratory tract using anastomosis. The resection length varied from 2 to 12 cartilaginous half-rings. On average, it is safe to resect 3-4 cm. of the trachea, which is 5-8 cartilaginous half-rings. It is necessary to take into account the constitutional-anatomical features of the patient, technical capabilities, experience of the surgeon, as well as the previous intervention on the trachea.
The location and extent of cicatricial stenosis determined the choice of surgical approach. Surgical access is to create a user-friendly approach to the affected segment of the trachea, to ensure the implementation of its broad mobilization and anastomosis. In 65 patients used the isolated cervical access (cervicotomy by Kocher), in 21 — cervicotomy with the partial longitudinal-transverse sternotomy. The broad mobilization of the trachea reduces the tension of the linkable anastomosis edges. This is particularly important when combined thoracic tracheal stenosis with peritracheal cicatricial process in the neck after tracheostomy.
The integrity of the respiratory tract was restored by imposing the tracheal anastomosis in 54 (62.8 %) patients. The tracheo-laryngeal anastomosis was performed in 32 (37.2 %) patients. The indication for tracheo-laryngeal resection was cicatricial stenosis of the cervical trachea and larynx to the upper limit of scarring at least 1.5-2 cm. from the vocal folds while maintaining the latter function.
The tracheo-laryngeal resection is the most difficult in the trachea surgery. Since J. Gerwat [4] and F. Pearson [10] demonstrated the ability to secure th tracheo-laryngeal resection with anastomosis between the trachea and larynx, surgical approach for this
localization of stenosis has become more aggressive. The tracheo-laryngeal resection is dangerous because of possible damage to the recurrent laryngeal nerve with the post-operative paralysis of the larynx. This complication arises in the allocation of the posterolat-eral wall of the larynx and trachea from the surrounding tissues, which are recurrent and laryngeal nerves. It should be noted that the subplical diameter of the larynx is greater than the diameter of the cervical trachea, which is important in relation of the edges of tracheo-laryngeal anastomosis for prevention of restenosis.
At present, in the cases of non-compliance of the diameters of the resected ends of the breathing tube used different versions of the anastomosis. The principle of "telescope" when the cartilage of the smaller the diameter of the lumen of the trachea is held in most of the diameter of the larynx in the 1-2 mm., and membranous part sewn edge to edge. Sometimes, to adapt the different diameters of the resected portions of the trachea or the larynx using the so-called "rotary anastomosis" when the membranous part of the trachea and larynx are displaced relative to each other by 30-60 degrees. This makes it possible to stretch the portions to prevent the narrowing of the lumen of the anastomosis and reduce its tension [9].
Also discloses a method of comparing the airway with various diameters after the tracheo-laryngeal or tracheal resection. After resection of the breathing tube obliquely impose the direct snap to the excess portion. With the twisting of the wrist the captured cartilage are breaking. The clamp is removed. Sewn wedge-shaped portion of the cartilaginous and membranous tissue by placing side hardware seam clamp track. After that impose an anastomosis between the stumps [2].
Or, after resection ofthe trachea at the edge of the fibro-cartilage of the joints impose a single provisionally, and then sipping for them, impose a provisional continuous encircling stitch the entire membranous wall ofthe tracheal ends. Knotted first provisionally seam stitching and the same form all the fibro-cartilaginous portion of the anastomosis. Then, sipping the ends of the continuous seam and sealed correlate membranous wall of the anastomosis, knotting the ends of the ligatures with the ligatures of the first guide joints. The anastomosis line strengthened by suturing of the flap of mediastinal pleura [7].
The disadvantage of this method is the inability to use only continuous suture in the formation of the front and rear semiperimeter of the anastomosis when applying tracheo-laryngeal anastomosis due to the mismatch of diameters of the fragments, as well as the fact that the use of the flap mediastinal pleura to enhance tracheal sutures, as practice shows, is not able to reliably prevent the spread of purulent-inflammatory process in insolvency seams.
The clinic of the Tashkent Medical Academy developed and applied in 17 patients a new method of imposing of the tra-cheo-laryngeal anastomosis at high cicatricial stenosis of the trachea, which includes a comparison of the sutured fragments of
anastomosis, the imposition of provisional stitches on anastomosis wall, tying the ends of ligatures provisory seams and stitching, while the cross-linkable moieties anastomosis are the trachea and larynx. For comparison, the diameter of the trachea and larynx, first perform a longitudinal section of a length of 1-1.5 cm. in the caudal part of the anastomosis in the midline of the trachea cartilage semicircle, crossing the half-ring tracheal cartilage, and then on the walls of the anastomosis is applied provisionally sutures with Vicryl or PDS thread 2-0 or 3-0 with the atraumatic needle on individual seams through all layers. When suturing the front wall in the region of intersection of the cartilage stitched with the capture of the previous half-rings of the trachea, then the ends of provisional ligature knotted stitches alternately from the medial wall toward the side, first at the rear, then the front.
The laryngeal circumference is greater than the tracheal circumference and does not comply with the anastomosis, that's why we offer a change (increase) the configuration of the circumference of the anastomosis linkable edges after tracheal resection by crossing one half rings of cartilage anterior tracheal wall. After suturing and anastomotic matching edges, crossed tracheal cartilage is expanded in different directions, and the discrepancy of the circle of the larynx and trachea linkable wound edges. That is, when comparing the stitched edges ofthe anastomosis of the trachea crossed semicircle, pushing increases the inner circumference of the distal end of the anastomosis. As a result ofthis discrepancy is eliminated diameter loose-ends of the tracheo-laryngeal anastomosis, which is important in the prevention of insufficiency of the tracheo-laryngeal anastomosis and prevention of restenosis of the trachea in the early and late postoperative period.
Conclusions
1. In the application of the proposed method in patients with cicatricial stenosis of the upper respiratory tube the signs of anasto-mositis of the tracheo-laryngeal anastomosis and its insufficiency in the postoperative period were notobserved. In the control group of patients this complication observed in 2 cases.
2. The follow-up of patients in the period from 1 to 3 years, showed no signs of restenosis in all patients operated on the proposed method. While in the control group the signs of restenosis in the late postoperative period were observed in 2 patients.
Therefore, the resection of cervical trachea with the restoration of the integrity of the airway with anastomosis is well developed and, as a rule, do not cause trouble, when localization of the pathological process not in the tracheo-laryngeal segment. Despite the rapid development of technology and the anesthetic, the latest intervention more difficult in technical terms, as well as the possible development of postoperative complications and therefore even today the tracheo-laryngeal types of anastomoses in need of further research and discussion.
References:
1. AcuffT. E., Mak M. J., Ryan W. H. Simplified placement of a silicone tracheal Y-stent//Ann. Thorac. Surg. - 2007. - Vol. 57, № 2.
2. Bertelsen S., Howitz P., el-Kadi N. B. Injuries to the trachea and bronchi//Thorax. - 2002. - № 27. - P. 188.
3. Couraud L., Jougon J., Velly J. F., Klein C. Iatrogenic stenoses of the respiratory tract. Evolution of therapeutic indications. Based on 217 surgical cases//ann. Chir. - 2013. - Vol. 48, № 3. - P. 277-283.
4. Gerwart I., Bryce D. P. The Management of subglottic laryngeal stenosis by resection and direct anastomosis//Laringoscope. - 1974. -Vol. 84. - P. 940-957.
5. Korber W., Laier Groeneved G., Criee C. P. Endotracheal complications after long-term ventilation. Noninvasive ventilation in chronic thoracic diseases as an alternative to tracheostomy//Med. Klin. - 2009. - Vol. 94. - Spec No. - P. 45-50.
6. Korpela A., Aarnio P., Sariola H. Bioabsorbable self-reinforced poly-L-lactide, metallic, and silicone stents in the management of experimental tracheal stenosis//Chest. - 2008. - Vol. 115, № 2. - P. 490-495.
7. Lancelin C., Chapelier A. R., Fadel E. Trancervical-transtracheal endoluminal repair of membranous tracheal disruptions//Ann. Tho-rac. Surg. - 2011. - № 70. - P. 984-986.
8. Merty-Ane C. H., Picard E., Jouquet O. Membranous tracheal rupture after endotracheal intubation//Ann. Thorac. Surg. - 1995. -№ 60. - P. 1367-1371.
9. Parshin V. D., Porhanov V. A. Surgery of trachea with the atlas of the surgical interventions. - Moscow, 2010.
10. Pearson F. G., Cooper J. D., Nelems J. M. Primary tracheal anastomosis after resection of cricoids cartilage with preservation of recurrent laryngeal nerves//Thorac. Cardiovasc. Surg. - 1975. - Vol. 70. - P. 806-816.
11. Shiraishi T., Okabayashi K., Kuwahara M. Y-shaped tracheobronchial stent for carinal and distal tracheal stenosis//Surg. today. -2012. - Vol. 2, № 83. - P. 328-331.
12. Nazirov F. G., Khudaybergenov Sh. N., Eshonkhodjaev O. D. The method.recommendations. - Tashkent, 2016.
Bakhritdinova Fazilat Arifovna, Tashkent Medical Academy, Department of eye diseases, Doctor of medicine, professor E-mail: bakhritdinova@mail.ru
Narzikulova Kumri Islamovna, Department of eye diseases, PhD, senior teacher E-mail: kumri78@mail.ru
Mirrakhimova Saidakhon Shukhratovna, Department of eye diseases, PhD, docent E-mail: saidakhon.m@mail.ru
Khera Akshey,
ophthalmologist, Ophthalmological Clinic "Vedanta", Tashkent
E-mail: retinauz@gmail.com
Biochemical parameters of the effect of laser radiation in the experiment
Abstract: Was studied effect of different modes of photodynamic irradiation in 80 rats on indicators of endogenous intoxication in dynamics.
PDT in 300 mJ pulsed mode (630 nm. for 3 minutes) does not cause endogenous intoxication and intensification of lipids peroxidation (LPO), that allow to use the appropriate mode in the practice of ophthalmology. Using of 300 mJ pulse mode (890 nm. for 3 minutes), 60 J PD mode (630 nm, 15 seconds) and particularly 120 J PD mode (630 nm. for 30 seconds) leads to gradual accumulation of average-weight molecules (AWM) and intensification of LPO in the circulating blood of animals, that leads to development of endogenous intoxication, therefore such dosage cannot be used in vision organ.
Keywords: photodynamic therapy, photodynamic doses, experiment, endogenic intoxication, molecules of average molecular weight, malon dialdegidis.
Introduction. Achievements of photobiology laid a solid foundation for the development and practical application of lasers, including the field of ophthalmology. There are widely known stimulatory, microcirculatory and anti-inflammatory effects of therapeutic doses of radiation exposure. It is appropriate to mention that one of the promising areas in ophthalmology is photodynamic therapy based on the selective destruction of proliferating cells as a result of photochemical reactions caused by reacting of accumulating therein photosensitizer (PS) which is activated by the light of particular wavelength [4, 25-30; 9, 55-58; 10, 167; 11, 155-162].
The development and introduction of photodynamic therapy (PDT) and fluorescence diagnosis (PD) in the treatment of cancer has caused deep interest ofresearchers to the possibility of using these techniques in other fields of medicine and in particular in ophthalmology [7, 39-40; 8, 23-25;13, 45-51; 15, 740-746; 18, 228-232].
Today, the perspectives of PDT treatment are associated with treatment of choroidal neovascularization of various etiologies, especially in age-related macular degeneration, diabetic retinopathy, high myopia complicated and ocular oncologic diseases [2, 45-47; 3, 265; 12, 66-68; 14, 752-763; 15, 740-746; 17, 747-752].
Over the last 5 years, there are many publications concerning the use of PDT at non-cancer ophthalmic diseases, however,
it should be noted that very few studies are devoted to the fundamental aspects of this trend [13, 45-51]. At the same time, such an important aspect as the impact of the so-called photodynamic doses (PDD) on biological tissues is not studied yet.
Having a cytotoxic effect PDT undoubtedly affects the processes of oxidative stress in the body. However, there is no information in the available literature on the study of the effects on the processes of lipid peroxidation (LPO), depending on the mode of action of PDT [5, 3-8; 6, 15-18].
The introduction of PDT in clinical practice of ophthalmology in Uzbekistan was significantly constrained by high cost of foreign trade photosensitizers (PS) and laser equipment.
In Uzbekistan there was developed an apparatus working in a range of630 nm., output power up to 5 W. (Mavlyan-Khodzhaev R. Sh. and S. Sadykov R. A., 2009) and was used in purulent infected hardhealed wounds in surgery, dentistry and dermatology [9, 55-58; 10, 167].
However, there are still no works on the application of PDT in the treatment ofeye diseases in Uzbekistan, using domestic laser systems.
Objective: To evaluate the effect of electromagnetic radiation on the eyes of rats at doses used for photodynamic therapy, on the level of malon dialdegidis (MDA) and its relationship with indicators of endogenous intoxication in rats in the experiment.
