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for complications to occur. The severity of victims' condition was not determined so much by damage to maxillofacial region as damage to other areas of the body. Implementation of osteosynthesis on admission and during the first 24 hours in 16.8 % of the victims identified the leading component of CT as damage of the brain, and in the group of victims who carried osteosynthesis within 10-days, abdomen and pelvis injuries prevailed. The highest frequency of multiple fractures of MFR (20.0 %) of which only fractures of both jaws were 12.5 %, resulted in a priority of the head as a leading component of CT in victims — those patients carried osteosynthesis mainly on 2-3rd day.
Type of osteosynthesis was determined by localization and nature of MFR fractures. Prevalence of the upper jaw fractures in
the overall proportion of fractures determined a high proportion of intraosteal osteosynthesis applied in 69.8 % of cases. Extrafocal osteosynthesis with V. F. Rudko or Y. M. Zbarzha's apparatus used in 41 patients (20.3 %), mainly with the fractures of the lower jaw.
Surviving victims' average term of hospitalization was 53.2 ± 3.2 days. 95.5 % of victims needed intensive care, and its duration was 6.9-6.4 days in average.
Thus, the variety of osteosynthesis classifications by time of performance, and contradictory data on immediate outcomes, depending on this factor shows inconsistency of purely temporal approach in determining the treatment strategy for combined fractures of maxillofacial region, and necessity to develop new criteria for selection of time, method and amount of traumatologic treatment.
References:
1. Vernadsky Y. I. Traumatology and Reconstructive Surgery Cranio-Maxillo-facial region. - Moscow: Medical Literature, 1999. - 456 p.
2. Datsko A. A. The implementation of modern principles of treatment of injuries of the maxillofacial region//Dentistry. - 2003. -№ 1. - P. 17-22.
3. Lebedev V. V., Okhotskiy V. P., Kanshin N. N. Emergency aid for combined traumatic injuries. - M., 1980. - P. 82-107.
4. Mylnikova L. A. Medical and tactical aspects of medical care to victims of road accidents in the prehospital stage//Ambulance. -2001. - № 2. - S. 7-10.
5. Trunin D. A. Improving the system of care for patients with maxillofacial trauma. Actual issues in dentistrycal practice: Interregional Sat mes. Reports.and articles, dedicated to 35 - anniversary of the Dental Faculty. - Samara, 2001. - S. 124-126.
6. Boudrieau R. Miniplate reconstruction of severely comminuted maxillary fractures in two dogs//Vet. Surg. - 2004. - Vol. 33, № 2. - P. 154-163.
7. Califano L. Morbidity by planning in maxillofacial surgery//Minerva Stomatol. - 2002. - Vol. 51, № 6. - P. 241-245.
Usmanov Bekzod Baymatovich, doctor oncology, department of thoracic oncology; National Cancer Research Center, Republic of Uzbekistan E-mail: usmanov-83@mail.ru Khairutdinov Rafik Vakhidovich, MD, head of the department of thoracic oncology, National Cancer Research Center Yusupbekov Abrorbek Axmedjanovich, MD, deputy director of the National Cancer Research Center
Ismailova Umida Abdullaevna, Postgraduate-student, Department of General Oncology and Radiation Diagnosis, Tashkent Medical Academy
Our experience of thoracoscopy application in diagnostics of pleuritis of unclear etiology
Abstract: This study includes 45 patients with pleural exudate of unclear etiology who underwent diagnostic thoracoscopy (TS). Etiology of pleuritis of unclear etiology was rather diverse, however in 36 (80 %) patients, the cause of exudate accumulation were malignant tumors. Efficacy of thoracoscopy in the differential diagnosis of pleuritis of unclear etiology accounted 100 %. Because of miniinvasiveness thoracoscopy may be recommended as method of choice at this pathology. Keywords: thoracoscopy, exudative pleuritis, methothelioma.
Introduction
Long before the Swedish doctor Hance Hristian Yakobeus the first thoracoscopy with binocular endoscope was performed by the Irish Richard Cruise in 11-year-girl with pleuro-thoracic fistula in 1866 [1]. In XX century this method was used predominantly for diagnosis and treatment of tuberculosis for decades. Now the thoracoscopy has been used both in the benign pathology and malignant neoplasms. The obvious advantages of such operations are as follows: small traumacity, good cosmetic effect, minimal frequency
of complications and fast rehabilitation of the patients. To the present time in the oncological clinic the main indications for thoracoscopy have been developed:
1) pleuritis of unclear etiology;
2) disseminated process in the lungs;
3) précising diagnosis of the pulmonary cancer;
4) lymphoadenopathy of the mediastinum;
5) benign peripheral pulmonary tumor;
6) solitary metastasis;
7) peripheral pulmonary cancer of the first stage (T1-2N0M0);
8) benign tumor of the mediastinum [1; 2].
The reasons of the pleural exudate may be as primary pleural tumors (malignant mesotheliomas), so as secondary (metastatic) its lesions. According to the literary data, from the first reference of the patient to the doctor to the establishment of the reason of pleuritis often lasts 3-4 months [3; 4], that considerably reduces efficiency of treatment and worsens the prognosis. So, the radical surgical treatment of the malignant mesothelioma of the pleura is possible to be performed only in t 7-10 % of the patients, and this, first of all, is connected to difficulties of diagnostics of disease. The pleuritis mostly often complicates progressing of the disseminated pulmonary cancer (25-50 %), breast cancer (15-40 %), ovaries cancer 10 % [5], that testifies to late diagnosis and advanced stage of process, that, in its turn, requires the fastest specification of the diagnosis and beginning of the antitumorous therapy. The difficulties of differential diagnosis of the pleural exudates are well-known [6; 7; 8]. To establish diagnosis on the basis of the results of pleural liquid examination is failed approximately in 20 % of all patients with pleuritis [9]. To establish diagnosis by pleural punctuate may be made only in 50-60 % of patients with metastatic pleuritis and 20 % with mesothelioma of pleura [6, 10]. At the same time, when pleuritis is the first symptom of the tumorous disease one cytological confirmation is insufficient for establishment of the primary tumor. For this purpose there is required performance of histological and some times immunohistochemical confirmation for definition histogenesis of the tumor.
For diagnosis of pleural tumors and exudates of unclear etiology the thoracoscopic methods of examination have been used more widely over the last time [11; 12; 13; 14], which are carried out in order to obtain the high-grade biopsy material under the visual control [12] because cytological investigation of the pleural exudates as well as needle biopcy of the pleural exudates seem to be less effective and are accompanied by high (9 %) number of complications [13; 15]. At the same time diagnostic accuracy of thorascopy in these patients is assessed differently and accounts from 90 up to 100 % in comparison with 44 % at needle biopsy of pleura and 62 % in cytological examination of the liquid [7; 14].
The high efficiency of the TS in the differential diagnosis of pleuritis of unclear genesis is not doubtful [16; 17], but, unfortunately, a number of the authors recommend to apply it in last turn, after the opportunities of less invasive methods of diagnostics are exhausted [18]. This tactics results in loss of time and decrease of efficiency of the subsequent treatment and, as a consequence, to decrease of parameters of survivability.
The purpose of our research was to define efficiency of the thoracoscopy in the differential diagnosis of pleuritis of unclear etiology with use of the highly technological method of TC.
Material and methods of research
This study includes 45 patients, of them males were 24 and females — 21, who received treatment from 2009 to 2013 in the department of Thoracic oncology of the Republic Oncological center of the Ministry of Health of the republic of Uzbekistan. All patients underwent diagnostic TC with purpose to establish causes of the exudative pleuritis. The age of patients accounted from 21 to 70 years (mean age — 44.2 years). The turms from exudates The age of the patients has made from 21 till 70 years (average age — 44.2 years). Terms from exudates revealing to hospitalization was from 3 to 8 months. In 4 (8.9 %) patients there was found bilateral liquid accumulation that aggravate their health state. 12 (26.7 %) patients in terms from 1 till 5 years were treated
due to onological diseases, such as cancer of the lung, thyroid gland, breast, ovarian, kidney. All patients was performed pleural punction with cytological investigation of the pleural exudates. By the results of researches it was not possible in any case to establish accurate diagnosis, that became the cause for performance of diagnostic videothoracoscopy.
The thoracoscopy in all cases was made under endotracheal anesthesia with method of separate lung ventilation with use of endoscopic advice of firm D-Light System/videocamera Telecam PDD SL/(Karl Storz GmbH, Germany). The patients with bilateral were operated on the side of the greater accumulation of the exudates previously performed pleural puncture with maximal liquid evacuation on the opposite side. Under the TC conditions the pleural liquid was evacuated and sent to the cytological investigation.
In cases of pleura lesions there was performed biopsy with forceps from 3-6 its mostly changed sites with the urgent and planned histological investigation of biosamples. The patients with primary tumors revealed (pulmonary cancer, malignant pleural mesote-lioma) were determined degree of the loco-regionary tumorous distribution with purpose to precise resectability.
Results of research and their discussion
At videothoracoscopy (VTS) there was found hemorrhagic liquid in 37 (82.25 %) patients, and serous liquid of volume from 400 to 2200 ml. in 8 (17.8 %) patients. The friable adhesions were determined in 22 (48.9 %) patients, which were easily divided; and in 3 (6.7 %) patients there were revealed extensive pleural adhesions which were divided into volumes required for VTS performance; in 5 (11.1 %) there was noted collabiration of the lung due to fibrous adnesions as the result of long existed exudative pleuritis. The performance of VTS with biopsy provided establishment of etiology of exudative pleuritis in all the patients. The data received are presented in table 1.
Table 1. - Etiology of exudative pleuritis
Number of patients,
№ Etiology of exudative pleuritis n = 45
Abs. %
1 Lung cancer 15 33.3
2 Pleural canceromatosis 10 22.2
3 Diffusive malignant mesothelioma 8 17.8
4 Tuberculosis 4 8.9
5 Sarcoidosis 4 8.9
6 Malignant thymoma 3 6.7
7 Nonspeciphic inflammations 1 2.2
Totally 45 100.0
According to the carried out research the efficiency of VTS in differential diagnosis of pleuritis of unclear etiology accounted 100 %. With the purpose of definition of tactics for treatment at revealing primary malignant neoplasms the loco-regionary distribution of the tumorous process was also specified. So, in 8 (17.8 %) patients with the established diagnosis of "malignant mesothelioma" the tumor was characterized by diffusive distribution both in the parietal and visceral pleura as multiple nodular masses of various sizes. In 13 (86.7 %) from 15 patients, in which the pulmonary cancer was a reason of accumulation of liquid, there were determined multiple defects both in the parietal and visceral pleura in form of micro-granular changes, localizing, mainly, in the lower parts of the pleural cavity. Similar thoracoscopic picture was observed in 3 (6.7 %) patients with malignant thymomas in which the primary tumors occupied the upper and middle floors of the anterior mediastinum and infiltrated its organs.
The results of treatment of exudative pleuritis in 10 patients with pleural canceromatosis were shown in table 2.
Table 2. - The causes of pleural canceromatosis
№ Causes of the pleural canceromatosis Number of patients, n = 10
Abs. %
1 Breast cancer 3 30.0
2 Kidney cancer 2 20.0
3 Soft tissue sarcoma 2 20.0
4 Ovarian cancer 2 20.0
5 Thyroid gland cancer 1 10.0
Totally 10 100.0
The causes of bilateral exudates accumulation in the pleural cavities were pleural canceromatosis in 2 (50 %) patients, malignant lymphoma — 1 (25 %), tuberculosis — 1 (25 %) patients.
It is necessary to note, that in our supervisions the etiology of exudative pleuritis was various enough: pulmonary cancer, metastases of the solid tumors mesothelioma, malignant lymphoma, tuberculosis, nonspecific inflammation and sarcoidosis. Nevertheless, it is extremely important to specify that in 36 (80 %) patients by the reason of pleuritis were malignant tumours. Analyzing results of the study performed, it is possible to conclude, that TS resulted in cardinal change of clinicoroentgenological diagnosis in 9 (20 %) patients, and in the rest 36 (80 %) was essentially specified or complemented. The received data show insufficient reliability of existing noninvasive or miniinvasive (transthoracic section biopsy) methods of clinical examination in differential diagnosis of the exudative pleuritis.
The results of our research have shown, that informativity of TS allows not only to establish the cause of exudation but also adds knowledge about expansion of the tumor impairment. Also according to the data obtained in our investigations at presence of the pleural exudates related to the malignant pleural mesothelioma the use of TS provides assessment both to the character and distribution of the tumor process that is particularly important for determination of the strategy of the further treatment.
The obtained our information about the nature of so-called pleuritis ofunclear etiology, particularly in the oncological patients, confirmed data both of native [11] and foreign researchers [13; 19]
about necessity of the prompt finding — out of their reasons and inadmissibility to use tactics of long unreasonable supervision and treatment. In 5 (11/1 %) patients the complication has arisen as K0AAa6np0BaHHe of the lung on the side of pleuritis, that in some patients resulted in performance ofpulmon- or lobectomy.
According to the results received the diagnostic TS may provide the reliable morphological diagnosis practically in all patients of the given category. It is impossible to say, estimating others devices, though less invasive, but also less exact methods of surgical diagnosis (cytological investigation of the pleural liquid, thin-needle aspiration biopsy of the pleura) which quite often appeared to be insufficiently informative and consequently not always useful at diagnosis of pleural exudates. The above-presented data allow us to share the opinion of the researchers, who consider the wider application of be necessary in relation to the diagnostic TS in the patients with exudative pleuritis, particularly in it long and persistent clinical progressing or suspicion on tumor etiology of disease [11; 14; 15; 20; 21].
On the basis of results of the study performed the following stages of diagnosis of pleuritis of unclear etiology are proposed at performance of the thoracoscopy:
1) evacuation of the pleural exudate, identification of the reasons of its accumulation and differential diagnosis; pleural exudate, revealing of the reason of his (its) accumulation and differential diagnostics;
2) repeated forceps biopsy, shown at presence of pleural neoplasms with subsequent urgent histological investigation of the slides (informative diagnosis — main criterion for diagnosis — basic criterion of diagnostics);
3) definition of the loco-regional distribution of the tumor processes (at primary malignant tumours) with an estimation of resectability.
Conclusion
The researches carried out show, that the diagnosticTS seem to be the method of choice in the differential diagnosis of recurrent pleuritis ofunclear genesis resistant to treatment during 4-6 weeks, particularly in patients, having oncological diseases in the anamnesis. The use of TS in this pathology allows providing optimal way for use of the method with the purposes of improvement, both of diagnosis and subsequent treatment of intrathoracal neoplasms.
References:
1. Solia P., Spaggiari L. Indications and developments of video-assisted thoracic surgery in the treatment of lung cancer//Oncologist. -2007. - Vol. 12, № 10. - P. 1205-1214.
2. Landreneau R., Mack M., Dowling R. The role ofthoracoscopy in lung cancer management//Chest. - 2000 - Vol. 113, № 1. - P. 6-13.
3. Ots O. N. Videothocoscopy in the diagnosis and treatment of exudative pleuritis/O. N. Ots et al//Problemi tuberculosa. - 2001. -№ 9. - P. 34-36.
4. Sokolov V. A. Differential diagnosis of the pleural exudate Differential diagnosis of pleural exudate/V. A. Sokolov et al.//Promeneva diagnostika, promeneva terapia. - № 3. - 2001. - P. 24-28.
5. Perevodchikova N. I. Tumor pleuritis: diagnosis and choice of therapeutic tactics/N. I. Perevodchikova, T. R. Alekseeva//Mejdun-arodniy medicinckiy jurnal. - 2003. - № 4. - P. 88-93.
6. Cohen M. Resolution ofpleural effusions/M. Cohen, S. Sahn//Chest. - 2001. - Vol. 119, № 5. - P. 1547-1562.
7. De Groot M. Thoracoscopy in undiagnosed pleural effusions/M. De Groot, G. Walther// South African Med. S. - 1998. - Vol. 88, № 6. - P. 706-711.
8. Maskell N. Prospective randomised trial of blind Abram's pleural biopsies versus CT guided cutting needle in cytology negative undiagnosed pleural effusions/N. Maskell, F. Gleeson, R. Davies//Eur. Respiratory J. - 2002. - Vol. 20. - P. 538.
9. Wilsher M. L. Medical thoracoscopy in the diagnosis of unexplained pleural effusion/M. L. Wilsher, A. G. Veale//Respirology. - 1998. -Vol. 3, № 2. - P. 77-80.
10. Sigal E. I. Videothoracoscopic diagnosis and treatment of malignant pleuritis/E. I. Sigal et al./Videothoracoscopic diagnosis and treatment/E. I. Sigal et al.//Material ofthe Plenum ofAdministration of the Association ofEndoscopic Surgery. - Kazan, 1999. - P. 81-86.
11. Allakhverdyan A. S. Videothoracoscopy in the diagnosis of pathology of the thoracic organs/A. S. Alakhverdyan et al.//Endoscopi-cheskaya khirurgia. - 2002. - № 2. - P. 8-9.
12. Fedorov I. V. Endoscopic surgery/I. V. Fedorov, E. I. Sigal, V. V. Odintsov. - M.: Geotar Medicina, 1998. - 351 p.
13. Kaeva B. The role of fhoracosopy in the diagnosis of malignant pleural effusions/B. Kaeva et al//European RespiratoryJournal. - 2003, sept. - Vol. 20. - P. 438.
14. Selcuk T. Overview of thoracoscopic findings between 1975 and 2000 in Hacettepe university hospital/T. Selcuk et al//Eur. Respiratory J. - 2002. - Vol. 20. - P. 71.
15. Getman V. G. Clinical thoracoscopy/V. G. Getman. - Kiev: Zdorovia, 1995. - 206 p.
16. Florikyan A. K. Thoracoscopic verification of the etiology of the pleural exudate/A. K. Florikyan, V. V. Bisov, N. N. Veligots-kiy//Ukrashskiy terapevticheskiy jurnal. - 2004. - № 2. - P. 93-94.
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19. Rodriguez-Panadero F. Malignant pleural disease/F. Rodriguez-Panadero//Monaldi Arch. Chest Dis. - 2000. - Vol. 55 (1). - P. 30-33.
Khadjibaev Abdukhakim Muminovich, Phd, ScD, Professor, Director General, Republic Research Center of Emergency Medicine, Tashkent, Uzbekistan, E-mail: uzbek_ems@uzsci.net Baybekov Iskander Mukhamedovich, PhD, ScD, Professor, Republic Specialized Centre of Surgery named after acad. V. Vakhidov, Head of Pathologic Anatomy Laboratory, Tashkent E-mail: baibekov@mail.ru Pulatov Dilmurod Tuhtabaevich, Senior scientific researcher, Republic Research Center of Emergency Medicine, Tashkent, Uzbekistan, E-mail: pulatovd1978@rambler.ru
Barrier-protective complexes of duodenum and their role in initiation and persistence of duodenal ulcers
Abstract: Aggression factors provoking epithelial level barrier complex disorder make possible the micro-organisms penetration and infiltration in deep layers of aggression factors components. It leads to development of pathologic reactions, inflammatory injuries of tissues and formation of micro-collectors which makes possible deeper penetration to stratum of duodenum and stomach wall. All above mentioned leads to appearance of peculiar circulus vituosus which is a structural base of persisting and chronization of gastroduodenal ulcers, development of their complications.
Keywords: gastroduodenal ulcers, barrier-protective complexes, Aggression factors, stomach, duodenum.
One the most important functions of gastrointestinal tract's (GIT) mucous membrane is barrier-protective one which is an important chain of unique process directed to saving of internal environment's constance [2-7; 11; 12].
W. A. Walker [12] divides GIT protective factors into non-im-munological (local intestinal flora, secretions, gastric barrier, gastric motor activity), liver filtrational capacity, antibacterial substances: lysozyme, bile acids and others) and immunological or local immune system.
B. T. Ivashkin et al. [7] define two protection lines: the first is mucous layer produced by cells and the second one — the cells themselves.
Droy et al. [11] divide protective lines into pre-epithelial, epithelial and post-epithelial. They note that mucus, immunoglobulins, saprophytic micro-flora are the components of pre-epithelial protection (including lysozyme, lactoferrin, bacteriostatin and other substances). Saprophytes locating on the enterocytes surface protect them from dehydration, adsorb macromolecules, neutralize physical and chemical aggressines, promote protection from pathogenic microorganisms and their toxins. Epithelial line, by their data, abdicates from glycocalix, epithelial membranes and connective complexes.
The authors pointed that blood flow in mucous membrane besides trophic function provides the post- epithelial protection as well.
The scheme of protective barrier reported by M. T. Droy et al. [11] from morphologic point of view does not include many components providing barrier-protective function.
Investigations underwent on extensive clinical and experimental material covering a broad range of digestive tract different pathologies allowed to characterize in detail the structures of barrier-protective functions in correlation with each other [2-6].
There were defined three levels of protection: luminal, epithelial and connective-tissue [3-6].
Luminal level. From morphologic point ofview it is presented by components of over-epithelial mucous layer having strict structural organization. It is made up from special cells secretions (mucus, pepsin, biologically active substances and others), from migrated epithelial and connective-tissue cells and from parietal micro-flora. Luminal level has an ability of self-regulation but it mostly depends on epithelial layer's conditions.
Epithelial level has been formed by epithelial lining structures. Epithelial cells with their intercellular connective complexes and intercellular spaces, intraepithelial lymphocytes, immunocompetent
