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Section 8. Medical science
Conclusion:
Laparoscopic liquidation RC echinococcectomy capiton-nage of liver, external drainage, abdominisation, omentoplasty accompanied by a significant decrease of the size of the cavity and extends the capabilities ofthe subsequent liquidation of RC.
Laparoscopic elimination of residual cavities reduces the incidence of postoperative complications, reduce the duration of postoperative hospital treatment of the patient.
Application endovideosurgery intervention echinococcosis of liver disease in children, showed its obvious benefits, which makes them promising direction in Pediatric Surgery.
References:
1. Abdufatev T. A. New way to eliminate residual cavity during echinococcectomy in 2, 3, 5, 6 segments of the liver in children./T. A. Abdufatev, S. B. Davlyatov, H. I. Ibodov, etc.//Annals of Surgical Hepatology. - 2006. - T. 11, № 3. - P. 176.
2. Alikhanov R. B. Laparoscopic echinococcectomy: Analysis of short- and long-term results./R. B. Alihanov, S. I. Emelyanov,
M. A. Hamidov//Annals of Surgical Hepatology. - 2007 - T. 12, № 4. - P. 7-10.
3. Aliev M. A., Seisembayev M. A., Doskaliev M. A., Belek J. О., Djorobekov A. D., Alaiku S. M. Echinococcectomy using the laparoscopic technique: Fast lecture. 1 All-Russian conf. for endoscopic surgery. The endoscopic Surgery. - 1997. - 1: 40.
4. Vetshev P. S. Echinococcosis: A modern view on the status of the problem./P. S. Vetshev, G. H. Musaev//Annals of Surgical Hepatology. - 2006. - T. 11, № 1. - P. 111-117.
5. Gergenreter Y. S. Surgical treatment ofhepatic echinococcosis.//Bulletin ofMedical Internet conferences. - 2011. - V. 1, № 1.
6. Nartaylakov M. A. New technologies in the surgical treatment of liver echinococcosis./M. A. Nartaylakov, I. A. Safin, D. R. Musharapov//Annals of Surgical Hepatology. - 2008 - T. 11, № 3. - P. 52.
7. Lotov A. N. Sparing surgery for liver echinococcosis/A. N. Lotov.
8. Karimov S. I. Problems and prospects of surgical treatment of patients with liver and lung echinococcosis./Sh. I. Karimov,
N. F. Krotov, V L. Kim, U. B. Berkinov//Annals of Surgical Hepatology. - 2008. - T. 13, № 1. - P. 56-60.
9. Karimov S. I. Laparoscopic and Video-intervention in surgery of liver echinococcosis./Sh. I. Karimov, N. F. Krotov,
S. E. Mamaradzhabov//Annals of Surgical Hepatology. - 2007 - T. 12, № 4. - P. 91-96.
10. Khamidov A. Dynamics of reduction of residual cavities after liver echinococcectomy./A. I. Khamidov, I. G. Akhme-dov//Annals surgical hepatology. - 2000. - № 5. - P. 38-41.
11. Dagher I. Laparoscopic liver resection: results for 70 patients./I. Dagher, J. M. Proske, A. Carloni et al.//Surg. Endosc. 2007. - V. 21, № 4. - P. 619-624.
12. Yaghan R., Heis H., Bani-Hani K. et al. Is fear of anaphylactic shock discouraging surgeons from more widely adopting percutaneous and laparoscopic techniques in the treatment of liver hydatid cyst?//Am J Surg. - 2004. - 187: 4: 533-537.
13. Kapan M., Yavuz N., Kapan S. et al. Totally laparoscopic pericystectomy in hepatic hydatid disease.//J Laparoendosc Adv Surg Tech A. - 2004. - 14: 2: 107-109.
Table 4. - Postoperative complications after laparoscopic liver echinococcectomy
Types of complications Laparoscopic echinococcectomy n = 89
Suppuration of the residual cavity 2 (2.2 %)
Forming nonparasitic cysts 7 (7.9 %)
Bile leakage from residual cavity 5 (5.6 %)
Altogether 15 (16.9 %)
Hodjimuratova Gulnora Abduvaliyevna, Republican Perinatal center of ministry of Public Health of Uzbekistan, obstetrician and gynecologist E-mail: [email protected]
The state of hemostasis in patients with premature abruptio of normally situated placenta in women with thrombophilia
Abstract: In article the questions, concerning features of a hemostasis of pregnant women are considered at placentary insufficiency, with the increased maternal and perinatal risk at aberrations in system of regulation of an aggregate state of blood against thrombophilia.
Keywords: placental abruption, thrombophilia, pregnancy.
Actuality. The acute placental insufficiency, which devel- Despite the fact that this complication of pregnancy and child-
ops as a result ofpremature abruptio of normally situated pla- birth, occurs with a frequency up to 0.5-1.2 %, it is always
centa, presents specific clinical problem in modern obstetrics. considered as a state of vital danger, as in 30 % of cases it is
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The state of hemostasis in patients with premature abruptio of normally situated placenta in women with thrombophilia
a cause of massive hemorrhage, leading to maternal mortality. Perinatal mortality in case of premature abruptio of normally situated placenta can reach 25 %. Children, who have been born by mothers with placental abruption, have a high risk of neurological pathology development. The hemostatic system plays an important role in the pregnancy development, starting from the ovulation and implantation processes and up to placental complex functioning. It is known that in women who had miscarriages before 12 weeks of pregnancy, most frequent can be observed such complication as severe preeclampsia, the syndrome of fetal growth retardation, intrauterine fetal death, premature abruptio of normally situated placenta (PANSP) [2; 5]. Perhaps exactly hemostatic system failure, which occurs at the early stages of pregnancy, makes negative contribution to the quality and depth of implantation and subsequent placental development.
Nowadays there is no doubt that thrombosis is one of the main causes of deaths in the world. Many researchers indicate that for every 1,000 births fall 2-5 cases of thrombotic complications [3; 8; 9]. Up to 50 % of venous thromboses occur in patients up to 40 years, and, as a rule, they are associated with pregnancy.
Number of works emphases the role of blood coagulation system changes in in the origin of premature abruptio of normally situated placenta [9; 11]. The risk of venous thromboembolic disorders development in pregnant women is 4-10 times higher than in nonpregnant women of the same age. Herewith the risk increases with the pregnancy beginning and reaches a maximum in the postnatal period [6; 7]. To estimate degree of risk of pregnancy complications development in case of thrombophilia, information about the proband’s genetic features is not enough. Most likely, the risk can be adequately assessed only with regard to genetic defects phenotypic manifestations that manifest with clinical symptoms of thrombophilia and can be detected by coagulation system studying [9; 10].
Aim. The aim of this study is to investigate the state of coagulation system in case of PANSP on the background of thrombophilia.
Materials and methods. Investigation of the state of coagulation system has been carried out in 70 (main group) pregnant women with complicated obstetric history and premature abruptio of normally situated placenta (PANSP). The age of patients ranged from 18-40 years, and average meaning was 28.2 ± 0.7 years.
The average gestation term at labor in patients of the main group was 34.2 ± 0,5 weeks. Very early premature labor (VEPL) occurred in 6 patients (12 %) with gestational age of 23-24 weeks, early premature labor (EPL) occurred in 4 (8 %) patients with gestational age of30-33 weeks, premature labor (PL) occurred in 9 (18 %) patients with gestational age of34-36 weeks, and in the rest 51 (62 %) labor occured in gestational age of 37-40 weeks. Therefore, the majority of examined women (88 %) at the time of delivery were in the third trimester of pregnancy, according to the WHO nomenclature.
The control group consisted of 20 women with uncomplicated pregnancy and “physiological hypercoagulation” in similar periods of gestation, which have vaginal delivery. The standardized tests, which can characterize all phases of blood coagulation: activated partial thromboplastin time (APTT), prothrombin time (PT), prothrombin index (PTI), and the level of fibrinogen in plasma, have been used for hemostasis system state examination.
Identification of blood thrombogenic activity markers (thrombinemia) included an assessment of the soluble fibrinmonomeric complexes (SFMC) level.
The state of platelet hemostasis link has been assessed by the number of platelets in citrated blood in the Goryayev’s camera using phase contrast determining.
Results and discussion. According to the obtained data of conducted hemostasis studies (table), the number of platelets in the peripheral blood of the patients from the main group according to the average values did not significantly differ from results obtained from women from the control group (to 211.3 ± 2.1*10 9/l and 218.2 ± 4.3 *10 9/l; p > 0.05) that correspond to the data of V N. Serova, A. D. Makatsaria (1998), M. S. Zainulina [2] (2006) and other authors.
The standard study of the coagulation system, which has been carried out using the traditional methods, did not reveal any abnormalities in women with PANSP. An activated partial thromboplastin time (APTT), which characterize the internal coagulation path, was not significantly different from that of women in the control group (38.2 ± 0.9 seconds and 37.8 ± 1.2 seconds, respectively; p > 0.05) according to the average values. Prothrombin time (PT), which characterize the external coagulation path, was similar with that of women in the control group (15.6 ± 0.4 seconds and 15.6±0.6 seconds, respectively; p > 0.05) according to the average values. The fibrinogen concentration in patients from the main group had no significant differences with the control group (3.7 ± 0.1 g/l and 4.0 ± 0.2 g/l, respectively, p < 0.05), so the results of our studies did not differ from the data obtained by M. S. Zainulina [2] (2006).
However, all women with PANSP have increased level of soluble fibrin-monomeric complexes (SFMC) which are markers of intravascular coagulation, can be found in plasma in dissolved state and reflect the degree of intravascular coagulation intensity (thrombinemia) and the expression of fibrin formation processes. Here the SFMC level exceeded such values of patients from the control group in 1.4 times (6.4 ± 0.3 pg/100 ml and 4.7 ± 0.3 pg/100 ml, respectively; p < 0.001) and correlated with the degree of fibrinogen concentration increasing with the medium positive relationship (r = +0.35).
During the intravascular hemostasis conditions of pregnant women with PANSP study using the coagulation techniques the following trends in the hemostasis system have been observed (table 1).
According to the data in the table 1, in 16 patients (first subgroup) with normal values of platelet count
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Section 8. Medical science
(215.45 ± 4.66x10 9/l; p > 0.05) chronometric hypercoagulation (reliable APTT decreasing up to 28.63 ± 0.51 seconds vs. 37.8 ± 1.2 seconds in the control and PT up to 13.38 ± 0.88 seconds versus 15.6 ± 0.6 seconds, similarly; p < 0.05 and p < 0.05, respectively) has been revealed. Here the fibrinogen concentration, though did not have significant differences with the control group, exceeded its average values. Among members of this subgroup we
observed increased thrombogenic blood activity, which was expressed with reliable increasing of the SFMC level in serum, which in 1.8 times exceed the value of this parameter in the control group (8.43 ± 0.75 pg/100 ml compared with 4.7±0.3 pg/100 ml; p < 0.001). Moreover, the SFMC level in serum correlated with the degree of fibrinogen concentration increasing with the medium positive relationship (r = +0,4).
Table 1. - The coagulogram parameters in women from the main group of pregnant women with PANSP
Hemostasis parameters Control group (n = 20) Main group (n = 70) Main group
I (n = 16) II (n = 38) III (n = 16)
Platelets *10 9/l 218.2 ± 4.3 211.3 ± 2.1 215.45 ± 4.66 211.03 ± 3.03 207.71 ± 2.5
Ht, % 35.8 ± 0.8 35.56 ± 0.57 36.25 ± 0.79 35.82 ± 0.58 34.25 ± 1.92
APTT, sec. 37.8 ± 1.2 38.2 ± 0.9 28.63 ± 0.51* 38.55 ± 0.69 46.75 ± 1.17*
PT, sec. 15.6 ± 0.6 15.6 ± 0.4 13.38 ± 0.88* 15.53 ± 0.44 18.13 ± 0.7*
PTI, % 86.9 ± 1.04 86.31 ± 0.64 89.56 ± 1.96 86.18 ± 0.53 83.38 ± 1.23*
Fibrinogen, g/l 4.0 ± 0.2 3.7 ± 0.1 4.22 ± 0.26 3.51 ± 0.12* 3.52 ± 0.21
SFMC, pg/100ml 4.7 ± 0.3 6.4 ± 0.3 8.43 ± 0.75* 5.66 ± 0.17* 6.03 ± 0.53*
Note: * — p < 0.05 compared with the control group
38 women (second subgroup) on the background of platelets level moderate reduction (211.03 ± 3.03*10 9/l; p > 0.05) have expressed multidirectional violations of coagulation basic parameters conversion of hypercoagulation to hypocoagu-lation (APTT and PT have phase changes), so these indicators did not differ from the control group (p > 0.05 and p > 0.05, respectively) on average value. Here we can observe fibrinogen concentration significant decrease (p < 0.05) and SFMC concentration increase (5.66 ± 0.17 mg/100 ml; p < 0.05). Absence of correlation (r = +0.04) between levels of SFMC in the serum and fibrinogen concentration in the plasma indicated processes of fibrin cross-polymerization as a result of intravascular coagulation observed during deployed clinical picture of premature abruptio of normally located placenta.
Patients from the III subgroup on the background of the continuing platelets level decreasing (207.71 ± 2.5*10 9/l; p > 0.05), have pronounced chronometric hypocoagulation according to the main evaluative tests (prolonged APTT up to 46.75 ± 1.17 seconds vs. 37.8±1,2 seconds, and PT up to 18.13 ± 0.7 seconds versus 15.6 ± 0.6 seconds in the control group; p < 0.05 and p < 0.05, respectively), with significant decreased prothrombin index up to 83.4 % vs 86.9 ± 1.04 % (p < 0.05), moderate decreased fibrinogen concentration up to 3.52 ± 0.21 g/l (p > 0.05) and increased SFMC in serum concentrations up to 6.03 ± 0.53 pg/100 ml compared with 4.7±0.3 pg/100 ml in control group (p < 0.05). The SFMC level in the serum correlated with the fibrinogen concentration with low positive relationship (r = +0.15) or the same reason as in the previous group.
Our results once again confirm the experts’ opinion that the prevailing value in the laboratory diagnosis of DIC
belong not to the identification of hyper — or hypocoagulation shift and hypofibrinogenemia (which is typical for fulminant forms of the disease and the terminal phase of deep blood incoagulability), but to the identification of thrombocytopenia and high levels of thrombinemia markers (SFMC and D-dimer), the physiological anticoagulants consumption, which reduction degree together with expressed thrombocytopenia and the severity of clinical manifestations reflects the DIC severity.
Thus, the hemostatic system of patients with PANSP was characterized by a pathologic activation of intravascular blood coagulation on the background of the normal platelets level, which at the time of delivery in 22.9 % of women came to be a chronic form of DIC with signs of chronometric hypercoagulation and increased SFMC concentration. The laboratory symptom complex of 54.2 % of patients from the main group resemble a subacute form of DIC with phase changes in the main evaluative tests (APTT, PT, PTI) and decreased fibrinogen concentration, and laboratory symptom complex of 22.9 % resemble the initial phase of consumption coagulopathy of the acute DIC.
Conclusions: Study of hemostasis system in patients with such complication of pregnancy as PANSP showed that they have significant changes in the hemostatic system manifested as hypercoagulation in the plasma hemostasis link, coagulopathy of consumption, and hypocoagulation with the occurrence of intravascular coagulation activation markers in plasma (SFMC). Pregnant women with PANSP with a congenital hemostasis system defects the SFMC level exceed similar parameter obtained from the group of healthy pregnant women more than 1.8 times.
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Features of chest trauma in patients admitted to the Republican Research Centre of Emergency Medicine
References:
1. Akopova K. A. The diagnosis gestation complications at the background of thrombophilia of different genesis improvement: Abstract. Dissertation of candidate of medical sciences. - Volgograd, 2010. - Р. 24.
2. Zainulina M. S. Premature abruptio of normally situated placenta: aspects of pathogenesis, predicated risk, prophylaxis. Abstract. MD dissertation. - Sankt-Peterburg, 2006. - Р. 43.
3. Krasnopolskiy V I., Melnikov A. P., Bokarev I. N. Modern problems of blood coagulation disorders in obstetrics.//Russian journal of obstetrics and gynecology. - 2010. - № 2. - Р. 20-27.
4. Liakhno. I. V The management of hemostasis system at pregnant women with preeclampsia: a focus for obstetric bleed-ing.//Emergency medicine. - 2012. - № 3 (42). - Р. 23-27.
5. Yashuk A. G., Maslennikov A. V., Timershina I. R. The state of vascular-platelet hemostasis in pregnancy: signs of norm and pathology.//Russian journal of obstetrics and gynecology. - 2010. - № 4. - Р. 17-19.
6. Hoffmann E., Hedlund E., Perin T. Is thrombophilia a risk factor for placenta-mediated pregnancy complications?//Arch Gynecol Obstet. - 2012. - Vol. 28.
7. Simioni P. Thrombophilia and gestational VTE. Thrombophilia and gestational VTE./Simioni P.//Thrombosis Research. - 2009. - 123: Suppl. 2: 41-44.
Khadjibaev Abdukhakim Muminovich, Republic Research Center of Emergency Medicine, Tashkent, Uzbekistan,
MD, Phd, ScD, Professor, Director General E-mail: [email protected] Rakhmanov Ruslan Odiljanovich, MD., PhD, Senior research worker, Department of emergency surgery
E-mail: [email protected] Sultanov Pulat Karimovich, MD, Senior research worker, Department of emergency surgery
E-mail: [email protected]
Features of chest trauma in patients admitted to the Republican Research Centre of Emergency Medicine
Abstract: Obj ective of the study was to improve the results of treatment of patients with chest trauma by early and wide use of VATS. There analyzed the findings of examination and surgery cases of 1396 patients with chest trauma. They divided into two groups: 552 patients who had been made examination and traditional treatment without VATS and 844 patients who underwent VATS during primary diagnostics and surgery.
Due to VATS we were able to reveal all of the most probable variants of chest injuries and avoid useless thoracotomy. VATS prevails the other noninvasive and minimally invasive methods of diagnostic of chest trauma. VATS also allows eliminating injuries with minimal operation procedures for the patient. Postoperative complications occurred in 25.4 % patients of first group and in 10.9 % patients of second group.
VATS allows diagnosing on time the injuries of thoracic organs. Also it helps to stop bleeding, make hermetic lung ruptures and chest sanation. We can reach early activation of patients, and reduce in-hospital days by using VATS in patients with chest trauma. Surgical approach of treatment for chest trauma needs to be determined not only by the results of primary chest drainage but also by the results of VATS revision.
Keywords: chest trauma, VATS, thoracotomy, complications.
Introduction. One of the important medical and social problems in industrial countries has become an injury of people that require huge financial expenditure [3, 32; 8, 48-52]. Chest trauma takes the third place (30-40 %) after traumatic brain injury (TBI) and extremities trauma. 90 % of injured patients are able-bodied population [1, 42-45; 10, 43-44; 11, 44-50; 15, 111-114; 17, 190-195; 18, 1273-1294]. Chest trauma characterized by long term treatment and
rehabilitation with septic complications (up to 20 %) and high fatal outcomes (17-30 %) [5, 32-38; 6, 4-9; 7, 78-80; 9, 62-63; 14, 479-489; 16, 368-370].
According to literature, 15 % of died patients from chest trauma without fatal injuries died due to medical aid defects. One of them is late diagnostics of injuries in chest trauma [2, 39-43; 12, 509; 13, 328; 19, 3-9]. Poor resolution of simple X-ray of thorax does not allow estimating on time the
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