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So our work is the first to show the importance of LQ studies in women with GP not only during surgery, but also impact of permanent contraception method on LQ which does not require additional surgical procedures, and related costs, and also the physical and emotional trauma. In the era of evidence-based medicine using questionnaires for the study of LQbefore and after surgery is highly desirable. Since, it will allow estimating the place of different operations in modern obstetrics. In our study, LQ questionnaires allowed to make science-based conclusions on the effect of surgical correction of pelvic organ prolapse with simultaneous VSC on all aspects of patients' life.
Thus, in prolapse and partial GP, as well as the presence of this disease in combination with uterine neck elongation, our proposed methods of surgical treatment with simultaneous VSC are optimal for women of reproductive age, as far as they contribute preservation and restoration of specific functions of female body — menstrual and sexual, which positively affects LQ of these women.
Conclusions:
1. LQin GP depends on the severity of the underlying disease and the social status of women — 42.7 % of patients have uterine neck elongation, in which no significant differences were revealed in indexes of LQ compared to the control group.
Deterioration in general health observed regardless of the degree of prolapse. Reliably significant appeared the pain intensity index (p < 0.05).
2. The quality of sexual intercourse increased by 83 % during performing this method of contraception in women with prolapse of the vaginal walls, reflecting the positive impact of removing genital prolapse with simultaneous VSC on LQof women. Negative emotions during intimacy diminished significantly. It was observed a tendency to increase the frequency of sexual desire.
3. The effectiveness of surgical treatment, as well as characteristics of the LQof women after surgical treatment with simultaneous VSC, allows suggesting this method the most efficient in patients of reproductive age. The use of the proposed system of medical measures, including a new method ofVSC, can improve the results of surgical treatment and LQ. This system has a significant economic savings in direct medical costs.
Recommendations
In women of late reproductive age, suffering from prolapse of the vaginal walls for the prevention of unwanted pregnancies and with the written voluntary informed consent and presence of qualified surgeon-gynecologist, it is recommended to perform VSC with access to fallopian tubes through the front wall of the vagina simultaneously with surgical treatment of the underlying disease.
References:
1. Tegerstedt G., Miedel A., Schmidt M. M.et al. Obstetric riskfactors for symptomatic prolapse: Apopulation-based approach//Am.J. Obstet. Gynecol. - 2006. - Vol. 194, № 1. - P. 73-81.
2. Trivers K. F. et al. Oral contraceptives and survival in breast cancer patients aged 20 to 54 years//Epidem Biomarkers Prev. -2007. - 16, 9: 1822-1827.
3. The effect of age on short-term outcomes after abdominal surgery for pelvic organ prolapse/H. E. Richter, P. S. Good, K. Kenton et al.// J. Am. Geriatr. Soc. - 2007. - Vol. 55, № 6. - P. 857-863.
4. The surgical technique and early postoperative complications of the Gyncare Prolift pelvic floor repair system/A. Lucioni, D. E. Rapp, E. M. Gong et al.//Can. J. Urol. - 2008. - Vol.15, № 2. - P. 4004-4008.
5. Turkey Demographic and Health Survey 2003. Hacettepe University, Institute of Population Studies, General Directorate of Mother and Child Health/Family Planning, Ministry of Health, State Planning Organization and European Union Ankara, Turkey (in Turkish).
6. Validation of telephone administration of 2 condition-specific quality of- life questionnaires/E. J. Geller, E. R. Barbee, J. M. Wu et al.// Am. J. Obstet. Gynecol. - 2007. - Vol. 197, № 6. - P. 632.el-4.
7. Vessey M. et al. Mortality in relation to oral contraceptive use and cigarette smoking//Lancet. - 2003. - 362: 185-191.
8. Vessey M et al. Oral contraceptive use and cancer: Findings in a large cohort study 1968-2004//Br J Cancer. - 2006. - 95: 385-389.
9. Wadhwa A., Surendra J. B., Sharma A. et al. Laparoscopic repair of diaphragmatic hernias: experience of six cases//Asian J. Surg. -2005. - Vol. 28, № 2. - P. 145-150.
10. Ware J. E., Snow K. K., Kosinski M. et al. SF-36 health survey: Manual and Interpritation guide. - MA: Boston, 1993.
11. Ware J. E. The status of health assessment 1994//Public Health. - 1995. - Vol. 16. - P. 327-354.
12. Webster G. D. Management of type 3 stress urinary incontinence, using the artificial urinary sphincter//Urology. - 1992. - Vol. 39. - P. 499.
13. Weak VLPP and MUCP correlation and their relationship with objective and subjective measures of severity of urinary inconti-nence/Martan A. [et al.]//Int. Urogynecol. J. - 2007. - Vol. 18. - P. 267-271.
14. Whiteside J. L., Weber A. M., Meyn L. A., Walters M. D. Risk factors for prolapse recurrence after vaginal repair//Am. J. Obstet. Gynecol. - 2004. - Vol. 191. - P. 1533-1538.
15. Wildemeersch D., Schacht E., Wildemeersch P. Performance and acceptability of intrauterine release of levonorgestrel with a miniature delivery system for hormonal substitution therapy, contraception and treatment in peri and postmenopausal women//Maturitas. -2003. - 44: 237-245.
Otamuradov Furqat Abdukarimovich, Tashkent Pediatric Medical Institute E-mail: furkatnet@mail.ru
Rectovestibular fistula with normal anus
Abstract: The anorectal malformations are presented by wide spectrum of nosological forms. Many aspects of the surgical
treatment of the rectogenital fistulas in normally formed anus remain to be debatable because they are described insufficiency in
the literature.
Rectovestibular fistula with normal anus
Material and methods. During the period from 2004 to 2015 in the clinic there were treated 210 girls of the age from one day to 15 years with ARM, of them 17 (8.1 %) girls were with rectovestibular fistula with normal anus (H-type). The patients were examined and underwent the operative treatment by the developed technique.
Results. In 4 (23.5 %) patients localization of the malformatiom was related to the anovestibular type, in 8 (47.1 %) — to rectovestibular — intermediate form, in 5 (29.4 %) — high form of which 2 had rectovaginal fistula. Invaginational extirpation by A. I. Lyonushkin was performed in 3 (17.6 %) patients, fistula liquidation by anterior-sagittal approach — 5 (29.4 %). In 9 (53 %) patients including repeated surgeries in the recurrences were carried out by the technique developed in the clinic.
Conclusion. In intermediate forms and lower localizations of the fistulas there were indicated one-step correction, comparatively better results were obtained in liquidation of the fistula with pulling-through of the anterior wall of the rectum. In high (rectovaginal) fistulas this type of operation should be performed after application of the preventive double sigmostoma.
Keywords: anorectal malformations, H-fistulas, girls, diagnosis, treatment.
Introduction
Anorectal malformations (ARM) are common congenital abnormalities are a big part Proctologic childhood diseases. The frequency of the ARM in recent years does not tend to decrease and, according to different authors, ranges from 1 in 2000-9000. More frequent fistulous form — up to 90 %. The frequency of certain clinical entities are also different. Boys more frequently rectourethral atresia with fistula, the girls — with rectovestibular fistula [2; 3; 4; 6; 16; 12]. Numerous works are mainly devoted to aspects of diagnosis and surgical treatment of atresia with rectovestibular fistulas in girls. These rare forms a fistula with normal anus formed remain poorly understood. H-type fistula at the ARM first described Bryndorf and Medcen in 1960 (op. Ja in P. et al.). The frequency of this type of structure in the anorectal abnormalities, based on different authors, ranged from 2.4 to 3.2 % [1]. According to Le L. I. et al. (2010), generalized the clinical material one clinic, from 1274 patients with ARM 182 (14.29 %) consisted of patients with H-type fistula. Pathology is observed in boys, but less frequently than in girls, is more common among the inhabitants ofAsia than in North America and European countries [14].
The choice of surgery for fistula with normal anus formed is not defined. In the publications of different authors stated that the intervention was completed by one of the methods included in the spectrum of operations at the International Congress in Krikenbeke. In most publications, the girls are given preference front anorekto-plastike [9; 14] or transanal access [13]. In the works of individual authors surgeries were performed without preventive colostomy [5; 14]. At low forms most of the authors consider it expedient to surgery without imposing stoma [13], and in cases of rectovaginal fistula — required the formation of colonic fistula. The complication rate — from 5 to 30 %, among them the most frequently observed fistula recurrence. In some observations noted independent recurrent fistula closure. But often held repeated surgical interventions [8; 13].
The purpose of research — to analyze the clinical and anatomical features, diagnosis and results of surgical correction of the H-type fistula with normal anus formed for girls based on the clinic.
Materials and methods
The clinical bases of the Department of Hospital Pediatric Surgery with the course of oncology TashPMI were in 2004-2015, at the examination and treatment of 210 girls aged from 1 day to 15 years from the ARM; of which 17 (8.1 %) consisted of patients with H-type. Distribution of patients according to nosological forms and evaluation of surgical correction of the results carried out in accordance with the International Classification adopted in Krikenbeke, in 2005 [1]. Patients underwent a comprehensive clinical studies to evaluate the anatomical and functional condition of the perineum and sphincter apparatus of the rectum and beam
diagnostic techniques: ultrasound of the internal organs in order to identify co-morbidities; contrast X-ray examination of the rectum; MSCT spine.
Results and discussion
Analysis of the material showed that the ARM in girls — is a variety of abnormalities, characterized by atresia, contraction or expansion of different length at the level of the distal rectum with fistula sexual or perineum, or presented in the form of bezsvischevyh forms or cloaca with large anatomical variations. 4 patients had a combination of various types of anorectal anomaly: in 3 — cloaca with rectal pouch, from one H-type fistula with stenosis of the anus. The age ofpatients with H-type fistula during surgery corresponded to 3 months. up to 1 year in 7 (41.1 %); from 1 year to 3 years in 2 (11.8 %); 3 to 6 years, 6 (35.3 %); from 7 to 15 in 2 (11.8 %). The reason for the parents of sick children to be served vulvovaginita progression of events and the selection of liquid feces and gas from the vestibule. The amount of discharge of patients was different depending on the diameter and location of the fistulous opening in the lumen of the colon. In broad fistulas constantly observed a noticeable amount of discharge. In a narrow fistula during discharge volume increased during the act of defecation.
The history of all patients observed the phenomenon of urinary tract infection and external genital organs as vulvovaginita. Two girls suffered perianal abscess at the age of 1 and 2 months., On a residence conducted conservative treatment. In 7 (41.2 %) patients had intermittent diarrhea with mucus. In 1 (5.9 %) was observed delay of a chair, in the course of the survey set short anorectal stenosis.
In most cases, the clinical diagnosis was not easy. The main profit for diagnosis inspection of the perineum, external genitalia, and rectum. In 16 (94.1 %) children anus was formed normally, only 1 (5.9 %) marked by the phenomenon of stenosis. In 13 (76.5 %) patients with the typical localization of the anus, in 3 (17.6 %) there was a forward displacement of the anus: in 2 small (index anal position — 0.38), and 1 — a marked (index anal position — 22). In 11 (64.7 %) patients with fistulous diameter more than 5mm was clearly visible place opening of the fistula in the vestibule. In 3 (17.6 %) patients during the fistula with a narrow and 2 (11.8 %) ofrectovaginal fistula with pinpoint localization fistula bellied managed using a probe inserted through the mouth of the fistula from the vestibule or in the lumen of the rectum. Thus it is possible to reliably determine the level rektogenitalnogo reports and the final form of the anatomical localization of H-type fistula by A. Holschneider and J. Hutson, 2006 (Fig. 1).
The mouth of the fistula in the rectum lumen was located at different distances from the mucocutaneous transition rectum: to gear lines — 4 (23.5 %), at the level of — 8 (47.1 %), above — 5 (29.4 %). In 4 (23.5 %) of patients corresponded anovestublar localization of H-type — "crotch channel" (Fig. 1a); in 8 (47.1 %) — rec-
tovestubular — an intermediate form (Fig. 1b); one of them in the (29.4 %) presence of rectovestibular messages marked as pararectal fistula; 5 (Fig. 1c).
high form, in 2 of them — with a rectovaginal fistula
a)
Fig. 1. H-type
In the study of the function of the obturator apparatus of the rectum in 14 patients (82.4 %) patients with the expressed disturbances were observed in 3 (17.6 %) showed slight reduction in front pole of the external sphincter.
It is necessary to conduct special research methods to identify associated anomalies of other organs and systems. Ultrasound and CT scan — a study of the spine should be performed in all cases to clarify the often combined spinal abnormalities, urinary tract and cardiovascular system. Associated malformations were observed in 4 patients, two of them — multiple. One — sided uretrogidronefroz, malformation of the spine; in the second ageneses coccyx and dolichosigma.
All patients with H-type rektogenital anastomosis performed surgical correction. 14 (82.4 %) children of primary surgery performed in our clinic. 3 (17.6 %) were relapsed after surgery in-vaginative extirpation fistula in other hospitals. In 15 (88.2 %) patients initiated radical correction without imposing stoma. In 2 (11.8 %) — after the imposition of double-barreled sigmasto-my: one child of H-type fistula due to severe somatic background, due to anemia; the second child with a rectovaginal fistula. Invagina-tive extirpation by A. I. Ljonyushkin made 3 (17.6 %) patients, the elimination of fistula anterior sagitall access — 5 (29.4 %). 9 (53 %) patients were reoperations for recurrent conducted by adopting the procedure liquidation of the fistula with bringing down the front wall of the rectum we developed ways to "Surgical correction at intermediate and low sinus forms of anorectal abnormalities in children" (Patent for invention of the Republic of Uzbekistan UZ IAP 04995). Adapted from the method carried out as follows. Fringing cut mobilized fistula hole, slit continues distally in front of the perineum in the middle of the seam to the upper contour of the anus. Next we continue the incision in a crescent along the perimeter of the anus, covering 2/3 of its circumference, leaving intact the posterior pole. Dissection of the perineum muscles, mobilization of fistula and rectum from the surrounding tissue in a distal direction along the side surface of the wire to the mucocutaneous junction. Implemented by the department of the rectum from the posterior vaginal wall and levatornyh muscles in the proximal direction. The length of the mobilization, and relegated resection depends on the localization of the fistula in the rectum. Mobilization of the proximal part of the rectum is achieved around the entire circumference of its relegation to 2-2.5 cm. Subsequently, as you move the front of its walls and floor fixation with the restoration of the integrity of the muscle complex at a distance of 0.7 to 1 cm. is possible to free relegated front body wall outside the ring above the anal rectal fistula hole. Resection relegated anterior rectal wall, bearing the fistula, fistula is conducted
b) c)
fistulas in girls
from the top in an oblique direction to the corners of the skin incision wounds to normal after excision of the rectum wall stood at the semilunar skin incision, and fistula — within the excision zone. Rebounding front portion of the external sphincter. By the edges of the crotch crescent wounds on interrupted sutures stitched circle Resected front wall of the rectum. Perineal wound sutured in layers.
The high efficiency of this type of operation when H-type ano-rectal abnormalities in girls confirmed in publications by other authors. Of the 14 initially operated in our clinic patients, 11 (78.6 %) postoperative period was uneventful. In 3 (21.4 %) patients had complications. Two were from rectovestibular fistula, one — with a rectovaginal fistula in the presence of rectal fistula recurrence of stenosis occurred. These patients conducted invaginative extirpation fistula (1) and the front anorectoplastik (2).
The results of treatment were studied in 13 (76.5 %) of 17 children operated on in a period of 1year to 5 years after surgery. Treatment efficacy was assessed by objective data on the basis of clinical examination, the appearance of the perineum and performance of functional studies closing apparatus of the rectum. A good result was observed in 10 (77 %) — the normal form of the perineum, the absence of the act of defecation disorders. functional studies Parameters closing apparatus of the rectum within the normal or moderately reduced. A satisfactory result in 2 (15.4 %) — the normal form of the perineum in the presence of moderate defecation disorders. functional studies Indicators sphincter apparatus of the rectum are reduced. Unsatisfactory results in 1 (7.6 %) — deformation of the perineum, the signs of stenosis or insufficiency of the anal sphincter with distinct manifestations of disorders of defecation (persistent constipation). Indicators of functional studies of the sphincter apparatus of the rectum sharply reduced.
Conclusions
1. Our observations correlate with the literature on the rarity of the H-type fistula among ARM (8.1 %) and the probability of having rectogenital fistula with congenital or acquired origin different localization levels. The presence of an inflammatory component increases the risk of fistula.
2. Diagnosis of low variants of H-type fistula publicly available clinical methods, however, to identify associated anomalies and assessment of the obturator rectum apparatus requires a set of relevant studies.
3. The choice of operation depends on the height of fistula localization. At intermediate and high localization, recurrent fistula preferred intervention, involving the elimination of fistula with bringing down the front wall of the rectum.
References:
Holschneider Alexander, Hutson John, Pena Albert, Bekhit E., Chatterjee S., Coran A. et al. Preliminary report on the International Conference for the Development of Standards for the Treatment of Anorectal Malformations//J Pediatr Surg. - 2005. -40: 1521-1526.
Determination of biomechanical characteristics of dentine and dental enamel in vitro
2. Levitt M. A., Peña A. Anorectal malformations//J Rare Diseas. - 2007. - 33(2): 1172-1186.
3. Ljonjushkin A. I. Hirurgicheskaja koloproktologija detskogo vozrasta. - M.: Medicina, 1999. - P. 85. (in Russian).
4. Pena A. Surgical treatment of female anorectal malformations//Birth Defects Orig Artic Ser. - 1988. - 24(4): 403-423.
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6. Sinead H., Stella S., Amy H. T., Keith H. 10-Year outcome of children born with anorectal malformation, treated by posterior sagittal anorectoplasty, assessed according to the Krickenbeck classification//J Pediatr Surg. - 2009. - 44(2): 399-403.
7. Holschneider A., Hutson J. Anorectal Malformations in Children. Embryology, diagnosis, surgical treatment, follow-up. - Heidelberg: Springer, 2006. - P. 251.
8. Rintala R. J., Mildh L., Lindahl H. H-type anorectal malformations: incidence and clinical characteristics//J Pediatr Surg. - 1996. -31: 559-562.
9. Kulshrestha S., Kulshrestha M., Prakash G., Gangopadhyay A. N., Sarkar B. Management of congenital and acquired H type anorectal fistulae in girls by anterior sagittal anorectovaginoplasty//J Pediatr Surg. - 1998. - 33: 1224-1228.
10. Yazici M., Etensel B., Gursoy H., Ozklaclk S. Congenital H-type anovestibuler fistula//WorldJ Gastroenterol. - 2003. - 88(4): 881-882.
11. Chen Y. J., Zhang T. C., Zhang J. Z. Transanal approach in repairing acquired rectovestibular fistula in females//World J Gastroenterol. - 2004. -10: 2299-2300.
12. A. Di Cesare, Leva E., Macchini F., Canazza L., Carrabba G., Fumagalli M. et al. Anorectal malformations and neurospinal dysraphism: is this association a major risk for continence?//Pediatr Surg Int. - 2010. - 26(11): 1077-1081.
13. Li Le, Ting-chong Zhang, Chong-bin Zhou, Wen-bo Pang, Ya-jun Chen, and Jin-zhe Zhang. Rectovestibular Fistula with Nor-mal Anus: A Simple Resection or an Extensive Perineal Dissec-tion?//J Pediatr Surg. - 2010. - 45(3): 519-524.
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Utyuzh Anatolij Sergeevich, Ph. D., Assistant Professor, Head of the department of Prosthetic Dentistry, I. M. Sechenov First Moscow State Medical University
Yumashev Aleksej Valerievich, Ph. D., Professor, Department of Prosthetic Dentistry, I. M. Sechenov First Moscow State Medical University
Zagorsky Vladislav Valerievich, Teaching Assistant of the department of Prosthetic Dentistry, I. M. Sechenov First Moscow State Medical University
Zakharov Aleksej Nikolaevich, assistant, Department of Prosthetic Dentistry, I. M. Sechenov First Moscow State Medical University
Nefedova Irina Valerievna, doctor-intern in the department of Prosthetic Dentistry, I. M. Sechenov First Moscow State Medical University E-mail: rinairis777@yandex.ru
Determination of biomechanical characteristics of dentine and dental enamel in vitro
Abstract: Hardness characteristics of the hard tissues of a tooth are widely used in dentistry practice, both in diagnostics and in therapy, they are also very important for individual selection of restoration and other specialized materials. During examination of enamel and dentine hardness, it is very important to handle information that beside its theoretical value also has high practical value. For this purpose, we suggest to calculate hardness of tooth tissue on the basis of quantitative indicator of Vickers microhardness. This method allows to get precise values of hardness characteristics separately for enamels and dentine areas of different localization making a complete picture regarding their biochemical characteristics.
Keywords: change, hardness, microhardness, Vickers method, hard tooth tissues, dentine, enamel.
Studying of physical and chemical characteristics of hard velopment [1, 92-95]. Of no less value is taking into account tooth tissues has invaluable applied significance for dentistry biochemical characteristics of hard tooth tissues during treatment practice. Specialists examine these characteristics directly dur- process itself in order to choose an adequate therapeutic tactic, ing diagnostic testing in order to determine defect or violation tools and special materials required for reconstruction, correc-of integrity of tooth tissues, identify form of affection, type of tion and other types of dentist treatment. The indicator that is clinical progression of a disease and prognosis of its further de- used most frequently for qualitative estimation of biochemical
