Лечение метастазов печени колоректальной этиологии (с

ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà, 2004, ÚÓÏ 9, ‹ 1, Ò. 95–103
Ô˜Â̸
ã˜ÂÌË ÏÂÚ‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË ÍÓÎÓÂÍڇθÌÓÈ ˝ÚËÓÎÓ„ËË
(Ò Ó·ÁÓÓÏ ÒÓ‚ÂÏÂÌÌÓÈ ÎËÚÂ‡ÚÛ˚)
É. à. ÇÓÓ·¸Â‚,
á. ë. ᇂÂÌflÌ,
è. Ç. ñ‡¸ÍÓ‚,
ç. ç. Ň„ÏÂÚ,
Ç. ç. 䇯ÌËÍÓ‚,
Ä. ã. ʼnʇÌflÌ,
Ä. Ä. íÓˈÍËÈ,
é. É. ëÍËÔÂÌÍÓ
êÓÒÒËÈÒÍËÈ Ì‡Û˜Ì˚È ˆÂÌÚ ıËÛ„ËË (‰Ë. – ‡Í‡‰. êÄåç
Å.Ç. äÓÌÒÚ‡ÌÚËÌÓ‚) êÄåç,
ÉÓÒÛ‰‡ÒÚ‚ÂÌÌ˚È Ì‡Û˜Ì˚È
ˆÂÌÚ ÍÓÎÓÔÓÍÚÓÎÓ„ËË
åËÌÁ‰‡‚‡ êî (‰Ë.–‡Í‡‰.
êÄåç É.à. ÇÓÓ·¸Â‚), åÓÒÍ‚‡
äÓÎÓÂÍڇθÌ˚È ‡Í Ô‰ÒÚ‡‚ÎflÂÚ ÒÓ·ÓÈ ÒÂ¸ÂÁÌÛ˛ ÔÓ·ÎÂÏÛ ÒÓ‚ÂÏÂÌÌÓÈ Ï‰ˈËÌ˚. êÂÁÂ͈Ëfl Ô˜ÂÌË ÓÒÚ‡ÂÚÒfl ÏÂÚÓ‰ÓÏ ‚˚·Ó‡ ÔË Î˜ÂÌËË ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË Ë ÔÓÁ‚ÓÎflÂÚ ‰Ó·ËÚ¸Òfl 5-ÎÂÚÌÂÈ ‚˚ÊË‚‡ÂÏÓÒÚË Û 26–55% ·ÓθÌ˚ı.
èÓfl‚ÎÂÌË ÙËÁ˘ÂÒÍËı ÏÂÚÓ‰Ó‚ ÎÓ͇θÌÓ„Ó ‚ÓÁ‰ÂÈÒÚ‚Ëfl ̇ ÓÚ‰ÂθÌ˚ ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍË ÛÁÎ˚ Ô˜ÂÌË („ËÔÓ- Ë „ËÔÂÚÂÏËfl Ë ‰.), ‡Á‡·ÓÚ͇ Ë ‚̉ÂÌË ÌÓ‚˚ı ÒıÂÏ
ıËÏËÓÚÂ‡ÔËË Á̇˜ËÚÂθÌÓ ‡Ò¯ËËÎË ‚ÓÁÏÓÊÌÓÒÚË Î˜ÂÌËfl ÍÓÎÓÂÍڇθÌÓ„Ó ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍÓ„Ó ‡Í‡ Ô˜ÂÌË, ‚ ÚÓÏ ˜ËÒΠҘËÚ‡‚¯ËıÒfl ‡Ì ËÌÍÛ‡·ÂθÌ˚ÏË ÏÌÓÊÂÒÚ‚ÂÌÌ˚ı, Ë ÓÒÓ·ÂÌÌÓ ·ËÎÓ·‡Ì˚ı ÔÓ‡ÊÂÌËÈ. ëÎÓÊÌÓÒÚË Á‡˜‡ÒÚÛ˛ ‚ÓÁÌË͇˛Ú
ÔË ÓÔ‰ÂÎÂÌËË Ú‡ÍÚËÍË Î˜ÂÌËfl Ë ‚˚·Ó ÏÂÚÓ‰Ó‚ ÓÔÚËχθÌ˚ı, ‚ ͇ʉÓÏ ÍÓÌÍÂÚÌÓÏ Ì‡·Î˛‰ÂÌËË.
Ç Òڇڸ ÓÒ‚Â˘ÂÌ˚ ÒÓ‚ÂÏÂÌÌ˚ ÏÂÚÓ‰˚ ΘÂÌËfl ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË, Ô‰ÒÚ‡‚ÎÂÌ ÒÓ·ÒÚ‚ÂÌÌ˚È ÓÔ˚Ú, ‡ Ú‡ÍÊ Ô‰ÎÓÊÂÌ ‡Î„ÓËÚÏ ÍÓÏ·ËÌËÓ‚‡ÌÌÓ„Ó Î˜ÂÌËfl.
Modern Issues of Colorectal Limer Metastases Management
G. I. Vorobyov,
Z. S. Zavenjan,
P. V. Tsarkov,
N. N. Bagmet,
V. N. Kashnikov,
A. L. Bejanjan,
A. A. Troitskyi,
O. G. Skipenko
Colorectal cancer is a serious problem of the modern medicine. The liver resection still
remains as a method of choice in the treatment of the liver metastasis that enables to maintain
5-year survival in 26–55% of patients. Methods of new physical effect (hypo- and hyperthermy and etc.) on the liver local lesions and introduction of the new schemas of the chemotheraphy widened possibilities of the liver metastatic tumor management, even in considered
earlier as incurable cases of bilobar lesions. Complicacies appear in determination of options
of methods in concrete cases of this severe pathology. The modern issues of management
accompanied personal experience of combined management is presented.
Russian Scientific Centre
of Surgery RAMSci
(Dir. – Prof. B.A. Konstantinov),
State Scientific Centre
of Coloproctology
of the Russian Ministry of Health
(Dir.– acad. G.I. Vorobyov)
äÓÎÓÂÍڇθÌ˚È ‡Í Ô‰ÒÚ‡‚ÎflÂÚ ÒÓ·ÓÈ ÒÂ¸ÂÁÌÛ˛ ÔÓ·ÎÂÏÛ ÒÓ‚ÂÏÂÌÌÓÈ Ï‰ˈËÌ˚. é·
˝ÚÓÏ „Ó‚ÓflÚ ‰‡ÌÌ˚ ÒÚ‡ÚËÒÚËÍË: ÂÊ„ӉÌÓ ‚ ÏË „ËÒÚËÛ˛Ú ÓÍÓÎÓ 800 Ú˚Ò. ‚ÔÂ‚˚ ‚˚fl‚ÎÂÌÌ˚ı ·ÓθÌ˚ı ˝ÚËÏ Á‡·Ó΂‡ÌËÂÏ, Ô˘ÂÏ Í
ÏÓÏÂÌÚÛ ÛÒÚ‡ÌÓ‚ÎÂÌËfl ‰Ë‡„ÌÓÁ‡ Û 20% ·ÓθÌ˚ı
ÛÊ ÂÒÚ¸ ÏÂÚ‡ÒÚ‡Á˚ (ÒËÌıÓÌ̇fl ÙÓχ), ‡ Û 50%
ÓÌË ‡Á‚Ë‚‡˛ÚÒfl ‚ ‰‡Î¸ÌÂȯÂÏ [2, 35]. Ç ˆÂÎÓÏ
·ÓΠ60% ÏÂÚ‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË ËÏÂ˛Ú ÍÓÎÓÂÍڇθÌÓ ÔÓËÒıÓʉÂÌËÂ. ë Û˜ÂÚÓÏ ‚˚ÒÓÍÓÈ ˜‡ÒÚÓÚ˚ ÔÓ‡ÊÂÌËfl Ô˜ÂÌË ËÏÂÌÌÓ ÏÂÚ‡ÒÚ‡Á‡ÏË ÍÓÎÓÂÍڇθÌÓÈ ˝ÚËÓÎÓ„ËË, ΘÂÌË ˝ÚÓÈ „ÛÔÔ˚
Ô‡ˆËÂÌÚÓ‚ Ú·ÛÂÚ ‚̉ÂÌËfl ÌÓ‚˚ı ÔÓ‰ıÓ‰Ó‚ [4].
ıËÏËÓÚÂ‡ÔËË Á̇˜ËÚÂθÌÓ ‡Ò¯ËËÎË ‚ÓÁÏÓÊÌÓÒÚË Î˜ÂÌËfl Ô‡ˆËÂÌÚÓ‚ Ò ÏÂÚ‡ÒÚ‡Á‡ÏË Ô˜ÂÌË
ÍÓÎÓÂÍڇθÌÓÈ ˝ÚËÓÎÓ„ËË. åÌÓÊÂÒÚ‚ÂÌÌ˚Â,
ÓÒÓ·ÂÌÌÓ ·ËÎÓ·‡Ì˚Â, ÏÂÚ‡ÒÚ‡Á˚, Ò˜ËÚ‡‚¯ËÂÒfl
‡Ì ËÌÍÛ‡·ÂθÌ˚ÏË, ̇ Ò„ӉÌfl¯ÌËÈ ‰Â̸ ‚
fl‰Â ̇·Î˛‰ÂÌËÈ ÔÓ‰‰‡˛ÚÒfl ΘÂÌ˲ Ò ËÒÔÓθÁÓ‚‡ÌËÂÏ Ëϲ˘Â„ÓÒfl ‡ÒÂ̇· Θ·Ì˚ı ÏÂÓÔËflÚËÈ. ëÓ‚ÂÏÂÌÌ˚ ÏÂÚÓ‰˚ ‚ËÁۇθÌÓÈ ‰Ë‡„ÌÓÒÚËÍË (ÛθÚ‡Á‚ÛÍÓ‚Ó ËÒÒΉӂ‡ÌËÂ, ÒÔË‡Î¸Ì‡fl
ÍÓÏÔ¸˛ÚÂ̇fl ÚÓÏÓ„‡ÙËfl, χ„ÌËÚÌÓ-ÂÁÓ̇ÌÒ̇fl Ë ÔÓÁËÚÓÌÌÓ-˝ÏËÒÒËÓÌ̇fl ÚÓÏÓ„‡ÙËfl) ӷ·‰‡˛Ú ‰ÓÒÚ‡ÚÓ˜ÌÓÈ ˜Û‚ÒÚ‚ËÚÂθÌÓÒÚ¸˛ Ë ÒÔˆËÙ˘ÌÓÒÚ¸˛ (80–100%) Ë ÔÓÁ‚ÓÎfl˛Ú ÒÚ‡‚ËÚ¸
‰Ë‡„ÌÓÁ Ò ‚˚ÒÓÍÓÈ ÚÓ˜ÌÓÒÚ¸˛ [14, 49, 58]. èË
ΘÂÌËË Ô‡ˆËÂÌÚÓ‚ Ò ÍÓÎÓÂÍڇθÌ˚ÏË ÏÂÚ‡ÒÚ‡Á‡ÏË Ô˜ÂÌË ÒÎÓÊÌÓÒÚË Á‡˜‡ÒÚÛ˛ ‚ÓÁÌË͇˛Ú ÔË
ÓÔ‰ÂÎÂÌËË Ú‡ÍÚËÍË Î˜ÂÌËfl Ë ‚˚·Ó ÏÂÚÓ‰Ó‚
ÓÔÚËχθÌ˚ı, ‚ ͇ʉÓÏ ÍÓÌÍÂÚÌÓÏ Ì‡·Î˛‰ÂÌËË.
Ç ‰‡ÌÌÓÈ Òڇڸ Í‡ÚÍÓ ÓÒ‚Â˘ÂÌ˚ ÓÒÌÓ‚Ì˚ ÒÓ‚ÂÏÂÌÌ˚ ÏÂÚÓ‰˚ ΘÂÌËfl ÍÓÎÓÂÍڇθÌ˚ı ÏÂ-
ëÓ‚Â¯ÂÌÒÚ‚Ó‚‡ÌË ÚÂıÌËÍË ÂÁÂ͈ËÓÌÌ˚ı
‚ϯ‡ÚÂθÒÚ‚ ̇ Ô˜ÂÌË, ÒÔÓÒÓ·ÒÚ‚Û˛˘Â ÒÌËÊÂÌ˲ ÎÂڇθÌÓÒÚË Ë ˜‡ÒÚÓÚ˚ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı
ÓÒÎÓÊÌÂÌËÈ, ÔÓfl‚ÎÂÌË ÙËÁ˘ÂÒÍËı ÏÂÚÓ‰Ó‚ ÎÓ͇θÌÓ„Ó ‚ÓÁ‰ÂÈÒÚ‚Ëfl ̇ ÓÚ‰ÂθÌ˚ ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍË ÛÁÎ˚ Ô˜ÂÌË („ËÔÓ- Ë „ËÔÂÚÂÏËfl Ë ‰.),
‡Á‡·ÓÚ͇ Ë ‚̉ÂÌË ‚ Ô‡ÍÚËÍÛ ÌÓ‚˚ı ÒıÂÏ
95
Ô˜Â̸
ãÖóÖçàÖ åÖíÄëíÄáéÇ èÖóÖçà äéãéêÖäíÄãúçéâ ùíàéãéÉàà
퇷Îˈ‡ 1. éÚ‰‡ÎÂÌÌ˚ ÂÁÛθڇÚ˚ ÂÁÂ͈ËÈ
Ô˜ÂÌË ÔÓ ÔÓ‚Ó‰Û ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚
Ä‚ÚÓ˚
ÉÓ‰
óËÒÎÓ èflÚËÎÂÚÌflfl
ÓÔÂ‡- ‚˚ÊË‚‡ÂˆËÈ
ÏÓÒÚ¸, %
퇷Îˈ‡ 2. èflÚËÎÂÚÌflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸ ÔÓÒΠÂÁÂ͈ËË Ô˜ÂÌË ÔÓ ÔÓ‚Ó‰Û ÏÌÓÊÂÒÚ‚ÂÌÌ˚ı ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚ [34]
óËÒÎÓ ÏÂÚ‡ÒÚ‡ÁÓ‚
Ç˚ÊË‚‡ÂÏÓÒÚ¸, %
1
37
D. Nadig Ë ÒÓ‡‚Ú. [47]
1997
275
26
K. Hardy Ë ÒÓ‡‚Ú. [27]
1998
100
55
2
34
Y. Fong Ë ÒÓ‡‚Ú. [21]
1999
1001
37
3
9
M. Minagawa Ë ÒÓ‡‚Ú. [44] 2000
235
38
4
18
Ú‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË Ë ÔÛÚË ¯ÂÌËfl ÌÂÍÓÚÓ˚ı Ú‡ÍÚ˘ÂÒÍËı Á‡‰‡˜.
ã˜ÂÌË ÍÓÎÓÂÍڇθÌ˚ı
ÏÂÚ‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË
êÂÁÂ͈Ëfl Ô˜ÂÌË. ç‡ Ò„ӉÌfl¯ÌËÈ ‰Â̸ ÏÂÚÓ‰ÓÏ ‚˚·Ó‡ ÔË Î˜ÂÌËË Ô‡ˆËÂÌÚÓ‚ Ò ÍÓÎÓÂÍڇθÌ˚ÏË ÏÂÚ‡ÒÚ‡Á‡ÏË Ô˜ÂÌË fl‚ÎflÂÚÒfl  ÂÁÂ͈Ëfl
[28]. ë‰Ìflfl ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÊËÁÌË Ô‡ˆËÂÌÚÓ‚ Ò ÍÓÎÓÂÍڇθÌ˚ÏË ÏÂÚ‡ÒÚ‡Á‡ÏË, ÔÓÎÛ˜‡‚¯ËÏË ÚÓθÍÓ ÒËÏÔÚÓχÚ˘ÂÒÍӠΘÂÌËÂ, Ì Ô‚˚¯‡ÂÚ 5 ÏÂÒ [11]. èË ‚˚ÔÓÎÌÂÌËË ÂÁÂ͈ËË Ô˜ÂÌË
ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÊËÁÌË Ô‡ˆËÂÌÚÓ‚ Û‚Â΢˂‡ÂÚÒfl Ë 5-ÎÂÚÌflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸ ÍÓηÎÂÚÒfl ÓÚ
22 ‰Ó 55 % [56] (Ú‡·Î. 1).
ÑÂڇθÌÓ ËÁÛ˜ÂÌË ‡Ì‡ÚÓÏËË Ô˜ÂÌË Ë ÒÓ‚Â¯ÂÌÒÚ‚Ó‚‡ÌË ÚÂıÌËÍË ÓÔÂ‡ÚË‚Ì˚ı ‚ϯ‡ÚÂθÒÚ‚ ÔÓÁ‚ÓÎËÎË Á̇˜ËÚÂθÌÓ ÛÏÂ̸¯ËÚ¸ ˜ËÒÎÓ
ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÓÒÎÓÊÌÂÌËÈ (15–35%) Ë ÎÂڇθÌÓÒÚ¸ (0–11%, Ô˘ÂÏ ‚ ·Óθ¯ËÌÒڂ ωˈËÌÒÍËı ˆÂÌÚÓ‚ Ó̇ ÌËÊ 5%) ÔË ‚˚ÔÓÎÌÂÌËË
ÂÁÂ͈ËÈ Ô˜ÂÌË [13, 19, 20, 34].
èÓ ÔÓ‚Ó‰Û ÓÔÚËχθÌ˚ı ÒÓÍÓ‚ ‚˚ÔÓÎÌÂÌËfl
ÂÁÂ͈ËË Ô˜ÂÌË ÒÛ˘ÂÒÚ‚ÛÂÚ ÌÂÒÍÓθÍÓ ÏÌÂÌËÈ.
ë Ó‰ÌÓÈ ÒÚÓÓÌ˚, ÓÔÂ‡ˆË˛ ÌÛÊÌÓ ÔÓ‚Ó‰ËÚ¸ ͇Í
ÏÓÊÌÓ ÒÍÓ ÔÓÒΠÛÒÚ‡ÌÓ‚ÎÂÌËfl ‰Ë‡„ÌÓÁ‡ Ò ˆÂθ˛ ÔÓÙË·ÍÚËÍË ‚ÓÁÏÓÊÌÓ„Ó ÎËÏÙÓ- Ë „ÂχÚÓ„ÂÌÌÓ„Ó ‡ÒÔÓÒÚ‡ÌÂÌËfl ÔÓˆÂÒÒ‡. A. Lambert
Ë ÒÓ‡‚Ú. Ô‰·„‡˛Ú ‰ËÙÙÂÂ̈ËÓ‚‡ÌÌ˚È ÔÓ‰ıÓ‰ Í ¯ÂÌ˲ ˝ÚÓÈ ÔÓ·ÎÂÏ˚ [38]. èÓ Ëı ‰‡ÌÌ˚Ï, Ôӂ‰ÂÌË ÍÓÌÚÓθÌÓÈ ÍÓÏÔ¸˛ÚÂÌÓÈ ÚÓÏÓ„‡ÙËË ‚ ÒÓÍË ÓÚ 2 ‰Ó 6 ÏÂÒ ÔÓÒΠ‚˚fl‚ÎÂÌËfl
Ô˜ÂÌÓ˜Ì˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚ Ì Ó͇Á˚‚‡ÂÚ Ì··„ÓÔËflÚÌÓ„Ó ‚ÎËflÌËfl ̇ ÔÓ„ÌÓÁ. êÂÁÂÍˆË˛ ‚˚ÔÓÎÌfl˛Ú ÚÓθÍÓ ÚÂÏ Ô‡ˆËÂÌÚ‡Ï, Û ÍÓÚÓ˚ı Ì ‚ÓÁÌË͇˛Ú ÌÓ‚˚ ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍË ÛÁÎ˚. í‡Í Í‡Í Á‡
‚ÂÏfl ̇·Î˛‰ÂÌËfl ÍÛÔÌ˚ ÏÂÚ‡ÒÚ‡Á˚ ÏÓ„ÛÚ
ÒÚ‡Ú¸ ÌÂÂÁÂÍÚ‡·ÂθÌ˚ÏË (̇ÔËÏÂ, ‚ÒΉÒÚ‚ËÂ
ÔÓ‡ÒÚ‡ÌËfl ÓÔÛıÓÎË ‚ ÓÒÌÓ‚Ì˚ ÒÓÒÛ‰ËÒÚ˚Â
ÒÚÛÍÚÛ˚ ËÎË ‡ÒÔÓÒÚ‡ÌÂÌËfl ̇ ÒÓÒ‰ÌË ӷ·ÒÚË), ÍÛÔÌ˚ ÛÁÎ˚ (·ÓΠ4 ÒÏ) ÌÂÓ·ıÓ‰ËÏÓ ÂÁˆËÓ‚‡Ú¸ ·ÂÁ ÔÓωÎÂÌËfl. ë ‰Û„ÓÈ ÒÚÓÓÌ˚,
ÏÂÎÍË ÏÂÚ‡ÒÚ‡Á˚ (ÏÂÌ 1 ÒÏ), ÓÒÓ·ÂÌÌÓ ÂÒÎË
ÓÌË ‡ÒÔÓÎÓÊÂÌ˚ ‚ ÌÂÒÍÓθÍËı Ò„ÏÂÌÚ‡ı Ë ÚÂ·Û˛Ú ‚˚ÔÓÎÌÂÌËfl ·Óθ¯ÓÈ ÂÁÂ͈ËË, ÒΉÛÂÚ
ÓÔÂËÓ‚‡Ú¸ ˜ÂÂÁ 3 ÏÂÒ ÔÓÒΠÍÓÌÚÓθÌÓÈ ÍÓÏÔ¸˛ÚÂÌÓÈ ÚÓÏÓ„‡ÙËË. èÓ ÏÌÂÌ˲ Ä. Lambert Ë
96
ÒÓ‡‚Ú. ڇ͇fl Ú‡ÍÚË͇ ÔÓÁ‚ÓÎËÚ ‚˚‰ÂÎËÚ¸ Ô‡ˆËÂÌÚÓ‚ ÒÓ ÒÚÂÏËÚÂθÌ˚Ï ÔÓ„ÂÒÒËÓ‚‡ÌËÂÏ Á‡·Ó΂‡ÌËfl, Ëϲ˘Ëı Ì··„ÓÔËflÚÌ˚È ÔÓ„ÌÓÁ.
Ç˚ÔÓÎÌÂÌË ÂÁÂ͈ËË Ô˜ÂÌË ‚ÓÁÏÓÊÌÓ Ó‰ÌÓ‚ÂÏÂÌÌÓ Ò Û‰‡ÎÂÌËÂÏ ÔÂ‚˘ÌÓÈ ÓÔÛıÓÎË Í˯ÍË
ËÎË ‚ÚÓ˚Ï ˝Ú‡ÔÓÏ, ˜ÚÓ ‚Ó ÏÌÓ„ÓÏ ÓÔ‰ÂÎflÂÚÒfl
ÎÓ͇ÎËÁ‡ˆËÂÈ ÔÂ‚˘ÌÓÈ ÓÔÛıÓÎË Ë ÏÂÚ‡ÒÚ‡Á‡.
é·˚˜ÌÓ ÒËÌıÓÌÌÓ Û‰‡ÂÚÒfl ‚˚ÔÓÎÌËÚ¸ Ò„ÏÂÌÚ- Ë
·ËÒ„ÏÂÌÚ˝ÍÚÓÏ˲, ‡ Ú‡ÍÊ ‡ÚËÔ˘ÌÛ˛ ÂÁÂÍˆË˛.
J. Sheele Ë ÒÓ‡‚Ú. [61] Ì ÂÍÓÏÂÌ‰Û˛Ú ‚˚ÔÓÎÌflÚ¸
·Óθ¯Ë ‡Ì‡ÚÓÏ˘ÂÒÍË ÂÁÂ͈ËË Ô˜ÂÌË Ó‰ÌÓ‚ÂÏÂÌÌÓ Ò Î˛·˚Ï ‚‡ˇÌÚÓÏ ÂÁÂ͈ËË Í˯ÍË.
èË ıËÛ„˘ÂÒÍÓÏ Î˜ÂÌËË ÍÓÎÓÂÍڇθÌ˚ı
ÏÂÚ‡ÒÚ‡ÁÓ‚ ıËÛ„Ë ‚Ò ˜‡˘Â ÓÚ͇Á˚‚‡˛ÚÒfl ÓÚ
‚˚ÔÓÎÌÂÌËfl ‡ÚËÔ˘ÌÓÈ ÂÁÂ͈ËË Ô˜ÂÌË, ÓÚ‰‡‚‡fl
Ô‰ÔÓ˜ÚÂÌË ‡Ì‡ÚÓÏ˘ÂÒÍÓÈ ÂÁÂ͈ËË („ÂÏË„ÂÔ‡Ú˝ÍÚÓÏËfl, Ò„ÏÂÌÚ˝ÍÚÓÏËfl). àÒÒΉӂ‡ÌËÂ
R. DeMatteo Ë ÒÓ‡‚Ú. [17]Ì ‚˚fl‚ËÎÓ ‡Á΢ËÈ ‚
Ó·˙ÂÏ ÍÓ‚ÓÔÓÚÂË, ‚ÂÏÂÌË ÓÔÂ‡ˆËË, ˜‡ÒÚÓÚÂ
Ë ı‡‡ÍÚÂ ÓÒÎÓÊÌÂÌËÈ ÔË ‚˚ÔÓÎÌÂÌËË ‡ÚËÔ˘ÌÓÈ Ë ‡Ì‡ÚÓÏ˘ÂÒÍÓÈ ÂÁÂ͈ËË. é‰Ì‡ÍÓ ‚ ÒÎÛ˜‡Â
‡Ì‡ÚÓÏ˘ÂÒÍÓÈ ÂÁÂ͈ËË Á̇˜ËÚÂθÌÓ ÒÌËÁË·Ҹ
˜‡ÒÚÓÚ‡ ӷ̇ÛÊÂÌËfl ÓÔÛıÓ΂˚ı ÍÎÂÚÓÍ ‚ Í‡Â
Ô˜ÂÌÓ˜ÌÓÈ Ú͇ÌË, ÓÒÚ‡‚¯ÂÈÒfl ÔÓÒΠÂÁÂ͈ËË Ò
16 ‰Ó 2%, ωˇ̇ ÊËÁÌË ‚˚ÓÒ· Ò 38 ‰Ó 53 ÏÂÒ.
åÌÓ„Ó˜ËÒÎÂÌÌ˚ÏË ËÒÒΉӂ‡ÌËflÏË ·˚Î ‚˚fl‚ÎÂÌ fl‰ Ù‡ÍÚÓÓ‚, ‚ÎËfl˛˘Ëı ̇ ÔÓ„ÌÓÁ ÔË ÂÁÂ͈ËË Ô˜ÂÌË ÔÓ ÔÓ‚Ó‰Û ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚ ‚ Ô˜Â̸.
1. ê‡ÒÒÚÓflÌË ÓÚ Í‡fl ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍÓ„Ó ÛÁ· ‰Ó ÎËÌËË ÂÁÂ͈ËË. ÑÓ ÒÂ‰ËÌ˚ 90-ı „Ó‰Ó‚ Ò˜ËÚ‡ÎÓÒ¸, ˜ÚÓ ‡ÒÒÚÓflÌË ÓÚ Í‡fl ÏÂÚ‡ÒÚ‡Á‡ ‰Ó ÎËÌËË
ÂÁÂ͈ËË Ì ‰ÓÎÊÌÓ ·˚Ú¸ ÏÂÌ 1 ÒÏ [13]. àÒÒΉӂ‡ÌËfl, Ôӂ‰ÂÌÌ˚ Á‡ ÔÓÒΉÌË ÌÂÒÍÓθÍÓ ÎÂÚ Ë
Ò‡‚ÌË‚‡‚¯Ë ‰Ó‚ÓθÌÓ ·Óθ¯Ë „ÛÔÔ˚ Ô‡ˆËÂÌÚÓ‚ (·ÓΠ80), Ì ‚˚fl‚ËÎË ‰ÓÒÚÓ‚ÂÌÓÈ ‡ÁÌˈ˚ ‚
‚˚ÊË‚‡ÂÏÓÒÚË ÒÂ‰Ë Ô‡ˆËÂÌÚÓ‚, Û ÍÓÚÓ˚ı ‡ÒÒÚÓflÌË ‰Ó ÎËÌËË ÂÁÂ͈ËË ·˚ÎÓ ÏÂÌ 1 ÒÏ, Ë Û ÚÂı, Û
ÍÓÚÓ˚ı ˝ÚÓ ‡ÒÒÚÓflÌË ·˚ÎÓ ·ÓΠ1 ÒÏ [18, 20,
60]. ç‡ Ò„ӉÌfl¯ÌËÈ ‰Â̸ ÚÓθÍÓ ÂÁÂ͈Ëfl Ô˜ÂÌË
‚ Ó·˙ÂÏ R0 fl‚ÎflÂÚÒfl ‡‰Ë͇θÌÓÈ. ìÏÂ̸¯ÂÌËÂ
ÓÔÛıÓ΂ÓÈ Ï‡ÒÒ˚ Ò ÔÓÏÓ˘¸˛ Ô‡ÎΡÚË‚ÌÓÈ ÂÁÂ͈ËË (Ó·˙ÂÏ R1) Ì ÛÎÛ˜¯‡ÂÚ ÔÓ„ÌÓÁ ÔÓ Ò‡‚ÌÂÌ˲ Ò ÒËÏÔÚÓχÚ˘ÂÒÍÓÈ ÚÂ‡ÔËÂÈ [24].
2. óËÒÎÓ ÏÂÚ‡ÒÚ‡ÁÓ‚. ç‡Î˘Ë 3 Ë ·ÓΠÏÂÚ‡ÒÚ‡ÁÓ‚, ‡ Ú‡ÍÊ ·ËÎÓ·‡ÌÓ ÔÓ‡ÊÂÌË Á̇˜ËÚÂθÌÓ ÛıÛ‰¯‡˛Ú ÔÓ„ÌÓÁ (Ú‡·Î. 2), ÌÓ, ÌÂÒÏÓÚfl
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
Ô˜Â̸
ÇéêéÅúÖÇ Ë ‰.
퇷Îˈ‡ 3. ŇÎθ̇fl ÒËÒÚÂχ ÓˆÂÌÍË ÔÓ„ÌÓÁ‡
èÓ„ÌÓÒÚ˘ÂÒÍËÈ Ù‡ÍÚÓ
ŇÎÎ˚
èÓ‡ÒÚ‡ÌË ÒÂÓÁÌÓÈ Ó·ÓÎÓ˜ÍË ÔÂ‚˘ÌÓÈ ÓÔÛıÓθ˛
1
èÓ‡ÊÂÌË ÎËÏÙ‡Ú˘ÂÒÍËı ÛÁÎÓ‚
1
èÂËÓ‰ ÓÚ Û‰‡ÎÂÌËfl ÔÂ‚˘ÌÓÈ ÓÔÛıÓÎË
‰Ó ‚˚fl‚ÎÂÌËfl ÏÂÚ‡ÒÚ‡ÁÓ‚ ÏÂÌ 2 ÎÂÚ
1
óËÒÚÓ ÏÂÚ‡ÒÚ‡ÁÓ‚ ·ÓΠ3
1
è‰ÓÔÂ‡ˆËÓÌÌ˚È ÛÓ‚Â̸ êùÄ:
5–30 ÏÍ„/Î
1
·ÓÎÂÂ 30 ÏÍ„/Î
2
ê‡ÒÒÚÓflÌË ÓÚ Í‡fl ÏÂÚ‡ÒÚ‡Á‡ ‰Ó ÎËÌËË
ÂÁÂ͈ËË ÏÂÌ 1 ÒÏ
1
̇ ˝ÚÓ, ‚ ̇ÒÚÓfl˘Â ‚ÂÏfl ·Óθ¯ËÌÒÚ‚Ó ‡‚ÚÓÓ‚
Ì ҘËÚ‡˛Ú ̇΢ˠÏÌÓÊÂÒÚ‚ÂÌÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚
(·ÓΠ4) ÔÓÚË‚ÓÔÓ͇Á‡ÌËÂÏ Í ÂÁÂ͈ËË ÔË ‚ÓÁÏÓÊÌÓÒÚË ‚˚ÔÓÎÌÂÌËfl  ‚ Ó·˙ÂÏ R0 [32, 33, 44,
60, 70]. ãËÏËÚËÛ˛˘ËÏ Ù‡ÍÚÓÓÏ ‚ ‰‡ÌÌÓÏ ÒÎÛ˜‡Â fl‚ÎflÂÚÒfl ÚÓθÍÓ ÌÂÓ·ıÓ‰ËÏÓÒÚ¸ Û‰‡ÎÂÌËfl ·ÓΠ70% Ô‡ÂÌıËÏ˚ Ô˜ÂÌË.
3. ÇÌÂÔ˜ÂÌÓ˜Ì˚ ÏÂÚ‡ÒÚ‡Á˚ ÛıÛ‰¯‡˛Ú ÔÓ„ÌÓÁ. é‰Ì‡ÍÓ Ì‡Î˘Ë ÂÁÂÍÚ‡·ÂθÌ˚ı ‚ÌÂÔ˜ÂÌÓ˜Ì˚ı ÔÓ‡ÊÂÌËÈ (·Û‰¸ ÚÓ ˆˉ˂ ÔÂ‚˘ÌÓÈ
ÓÔÛıÓÎË ËÎË ÏÂÚ‡ÒÚ‡Á˚ ‚ ΄ÍËÂ) Ì fl‚ÎflÂÚÒfl ÔÓÚË‚ÓÔÓ͇Á‡ÌËÂÏ Í ıËÛ„˘ÂÒÍÓÏÛ Î˜ÂÌ˲, ÔÓÁ‚ÓÎfl˛˘ÂÏÛ ‰ÓÒÚË„ÌÛÚ¸ 5-ÎÂÚÌÂÈ ‚˚ÊË‚‡ÂÏÓÒÚË
Ì ÏÂÌ 25% [40]. ÑÎfl Ò‡‚ÌÂÌËfl: ÒÂ‰Ë Ô‡ˆËÂÌÚÓ‚ Ò ÌÂÂÁÂÍÚ‡·ÂθÌ˚ÏË ‚ÌÂÔ˜ÂÌÓ˜Ì˚ÏË ÏÂÚ‡ÒÚ‡Á‡ÏË 2-, 3- Ë 5-ÎÂÚÌflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸ ÒÓÒÚ‡‚Îfl˛Ú 36, 11% Ë 0 ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ [8].
4. ÇÂÏfl ÔÓfl‚ÎÂÌËfl ÏÂÚ‡ÒÚ‡ÁÓ‚. èÓ„ÌÓÁ Û
Ô‡ˆËÂÌÚÓ‚ Ò ÏÂÚ‡ıÓÌÌ˚ÏË ÏÂÚ‡ÒÚ‡Á‡ÏË ÎÛ˜¯Â,
˜ÂÏ Û Ô‡ˆËÂÌÚÓ‚ Ò ÒËÌıÓÌÌ˚ÏË. èÓ ‰‡ÌÌ˚Ï
K. Hughes Ë ÒÓ‡‚Ú. [32], ÔË ‚˚fl‚ÎÂÌËË ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍÓ„Ó ÔÓ‡ÊÂÌËfl Ô˜ÂÌË ·ÓΠ˜ÂÏ ˜ÂÂÁ 1 „Ó‰
ÔÓÒΠۉ‡ÎÂÌËfl ÔÂ‚˘ÌÓÈ ÓÔÛıÓÎË 5-ÎÂÚÌflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸ ÔÓÒΠÂÁÂ͈ËË ÒÓÒÚ‡‚ÎflÂÚ 42%, ÂÒÎË
Ê ÏÂÚ‡ÒÚ‡Á˚ ӷ̇ÛÊÂÌ˚ ÏÂÌ ˜ÂÏ ˜ÂÂÁ 1 „Ó‰
ÔÓÒΠۉ‡ÎÂÌËfl ÔÂ‚˘ÌÓ„Ó Ó˜‡„‡ – 24%. Ä̇Îӄ˘Ì˚ ÂÁÛθڇÚ˚ ÔÓÎÛ˜ÂÌ˚ ‰Û„ËÏË ‡‚ÚÓ‡ÏË
[21, 59, 70].
5. ìÓ‚Â̸ ‡ÍÓ‚Ó-˝Ï·ËÓ̇θÌÓ„Ó ‡ÌÚË„Â̇ ‚
Ô‰ÓÔÂ‡ˆËÓÌÌÓÏ ÔÂËӉ ‚˚¯Â 200 Ì„/ÏÎ fl‚Îfl-
ÂÚÒfl Ì··„ÓÔËflÚÌ˚Ï Ù‡ÍÚÓÓÏ ÔÓ„ÌÓÁ‡ [21,
29, 68].
ÇÓÁ‡ÒÚ Ë ÔÓÎ Ô‡ˆËÂÌÚ‡, ÔÓ ‰‡ÌÌ˚Ï ÎËÚÂ‡ÚÛ˚, ‰ÓÒÚÓ‚ÂÌ˚ÏË Ù‡ÍÚÓ‡ÏË ÔÓ„ÌÓÁ‡ Ì fl‚Îfl˛ÚÒfl. è‰ÔÓÎÓÊÂÌËÂ Ó ‚ÎËflÌËË ‡ÁÏÂ‡ ÓÔÛıÓÎË Ì‡ ÔÓ„ÌÓÁ [20] Ì ÔÓ‰Ú‚Â‰ËÎÓÒ¸, Ë ˝ÚÓÚ Ù‡ÍÚÓ Ì ‰ÓÎÊÂÌ ‚ÎËflÚ¸ ̇ ÔËÌflÚË ¯ÂÌËfl Ó
Ôӂ‰ÂÌËË ÓÔÂ‡ˆËË [60].
î‡ÌˆÛÁÒÍÓÈ ıËÛ„˘ÂÒÍÓÈ ‡ÒÒӈˇˆËÂÈ ·˚ÎÓ Ôӂ‰ÂÌÓ ËÒÒΉӂ‡ÌË 1568 Ô‡ˆËÂÌÚÓ‚, ÍÓÚÓ˚Ï ‚˚ÔÓÎÌflÎËÒ¸ ÓÔÂ‡ˆËË Ì‡ Ô˜ÂÌË ÔÓ ÔÓ‚Ó‰Û
ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚. ç‡ ÓÒÌÓ‚‡ÌËË ÔÓÎÛ˜ÂÌÌ˚ı ÂÁÛθڇÚÓ‚ ·˚· ÒÓÁ‰‡Ì‡ ÒËÒÚÂχ ·‡ÎθÌÓÈ ÓˆÂÌÍË ÔÓ„ÌÓÁ‡ [48] (Ú‡·Î. 3).
ì Ô‡ˆËÂÌÚÓ‚, Ëϲ˘Ëı 1–2 ·‡Î·, ‚ÂÓflÚÌÓÒÚ¸
ˆˉ˂‡ Á‡·Ó΂‡ÌËfl Ì‚˚ÒÓ͇ Ë ÓÊˉ‡Âχfl
2-ÎÂÚÌflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸ ÒÓÒÚ‡‚ÎflÂÚ ÓÍÓÎÓ 80%.
ë Û‚Â΢ÂÌËÂÏ ÍÓ΢ÂÒÚ‚‡ ·‡ÎÎÓ‚ ÛıÛ‰¯‡ÂÚÒfl
ÔÓ„ÌÓÁ: ÔË Ì‡Î˘ËË 5 ·‡ÎÎÓ‚ Ë ·ÓΠ2-ÎÂÚÌflfl
‚˚ÊË‚‡ÂÏÓÒÚ¸ Ì Ô‚˚¯‡ÂÚ 35%.
çÂÓ·ıÓ‰ËÏÓ ÔÓÏÌËÚ¸, ˜ÚÓ ÚÓθÍÓ ‚ 20% ̇·Î˛‰ÂÌËÈ ÏÂÚ‡ÒÚ‡Á˚ fl‚Îfl˛ÚÒfl ÂÁÂÍÚ‡·ÂθÌ˚ÏË
‚ ÏÓÏÂÌÚ ÛÒÚ‡ÌÓ‚ÎÂÌËfl ‰Ë‡„ÌÓÁ‡ [39], ÔÓ˝ÚÓÏÛ
·Óθ¯ËÌÒÚ‚Ó ËÒÒΉӂ‡ÌËÈ ‡ÍˆÂÌÚËÓ‚‡ÌÓ Ì‡ ÔÓËÒÍ ÒÔÓÒÓ·Ó‚ ÔÓ‚˚¯ÂÌËfl ÂÁÂÍÚ‡·ÂθÌÓÒÚË Ë
Ô‰ÛÔÂʉÂÌËfl ˆˉ˂ËÓ‚‡ÌËfl ÏÂÚ‡ÒÚ‡ÁÓ‚
Í‡Í ‚ Ò‡ÏÓÈ Ô˜ÂÌË, Ú‡Í Ë ‚ ‰Û„Ëı Ó„‡Ì‡ı. ê‡Á‡·ÓÚ‡ÌÌ˚ ÏÂÚÓ‰˚ ÏÓ„ÛÚ ÔËÏÂÌflÚ¸Òfl Í‡Í Ò‡ÏÓÒÚÓflÚÂθÌÓ, Ú‡Í Ë ‚ ÍÓÏ·Ë̇ˆËË, ‡ Ú‡ÍÊ fl‚ÎflÚ¸Òfl
‰ÓÔÓÎÌÂÌËÂÏ Í ÂÁÂ͈ËË Ô˜ÂÌË, ÒÓÒÚ‡‚Îflfl, Ú‡ÍËÏ Ó·‡ÁÓÏ, ÓÒÌÓ‚Û ÍÓ̈ÂÔˆËË ÍÓÏ·ËÌËÓ‚‡ÌÌÓ„Ó ÔÓ‰ıÓ‰‡ Í Î˜ÂÌ˲ ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË.
èÓ‚ÚÓÌ˚ ÂÁÂ͈ËË. êˆˉ˂˚ ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍÓ„Ó ÔÓ‡ÊÂÌËfl Ô˜ÂÌË ‡Á‚Ë‚‡˛ÚÒfl Û 14–61%
Ô‡ˆËÂÌÚÓ‚ ÔÓÒΠÔÂ‚˘ÌÓÈ ÂÁÂ͈ËË, Ô˘ÂÏ
ÚÓθÍÓ Û 15–25% ÓÌË Ó„‡Ì˘ÂÌ˚ Ô˜Â̸˛ [15, 31,
70]. ì Ô‡ˆËÂÌÚÓ‚ ˝ÚÓÈ „ÛÔÔ˚ ‚ÓÁÏÓÊÌÓ ‚˚ÔÓÎÌÂÌË ÔÓ‚ÚÓÌ˚ı ÂÁÂ͈ËÈ, ÍÓÚÓ˚ ËÏÂ˛Ú Ô‡ÍÚ˘ÂÒÍË Ú‡ÍÓÈ Ê ÔÓ„ÌÓÁ, Í‡Í ÔÂ‚‡fl ÂÁÂ͈Ëfl,
˜ÚÓ ‰Â·ÂÚ ÓÔ‡‚‰‡ÌÌ˚Ï Ëı ‚˚ÔÓÎÌÂÌË [65]
(Ú‡·Î. 4).
çÂ‰ÍÓ ÔË ÎÓ͇ÎËÁ‡ˆËË ÏÂÚ‡ÒÚ‡ÁÓ‚ ‚ Ô‡‚ÓÈ
‰ÓΠӄ‡Ì˘˂‡˛˘ËÏ ÂÁÂÍÚ‡·ÂθÌÓÒÚ¸ Ù‡ÍÚÓÓÏ fl‚ÎflÂÚÒfl χÎ˚È Ó·˙ÂÏ Ô‡ÂÌıËÏ˚ ΂ÓÈ ‰ÓÎË,
ÓÒÚ‡˛˘ÂÈÒfl ÔÓÒΠÂÁÂ͈ËË. ë ˆÂθ˛ Û‚Â΢ÂÌËfl
ÂÁÂ‚Ó‚ ΂ÓÈ ‰ÓÎË Ô˜ÂÌË Á‡ Ò˜ÂÚ ÍÓÏÔÂÌÒ‡ÚÓÌÓÈ „ËÔÂÚÓÙËË Ô‰ÎÓÊÂÌÓ ‚˚ÔÓÎÌÂÌË ÔÂ‰
ÓÔÂ‡ˆËÂÈ ˝Ï·ÓÎËÁ‡ˆËË ËÎË ÔÂ‚flÁÍË Ô‡‚ÓÈ
퇷Îˈ‡ 4. èflÚËÎÂÚÌflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸ ÔË ÔÓ‚ÚÓÌ˚ı ÂÁÂ͈Ëflı Ô˜ÂÌË ÔÓ ÔÓ‚Ó‰Û ˆˉ˂Ì˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚
Ô˜ÂÌË ÍÓÎÓÂÍڇθÌÓÈ ˝ÚËÓÎÓ„ËË
ÉÓ‰
óËÒÎÓ ÓÔÂ‡ˆËÈ
íÂıÎÂÚÌflfl
‚˚ÊË‚‡ÂÏÓÒÚ¸, %
èflÚËÎÂÚÌflfl
‚˚ÊË‚‡ÂÏÓÒÚ¸ %
K. Riesenger Ë ÒÓ‡‚Ú. [55]
1996
25
53
36
S. Bines Ë ÒÓ‡‚Ú. [12]
1996
13
–
23
R. Adam Ë ÒÓ‡‚Ú. [5]
1997
63
60
41
Ä‚ÚÓ˚
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà 7
ÚÓÏ 9
‹1
2004
97
Ô˜Â̸
ãÖóÖçàÖ åÖíÄëíÄáéÇ èÖóÖçà äéãéêÖäíÄãúçéâ ùíàéãéÉàà
‚ÂÚ‚Ë ‚ÓÓÚÌÓÈ ‚ÂÌ˚. ùÚÓ ‚ϯ‡ÚÂθÒÚ‚Ó ÏÓÊÂÚ
·˚Ú¸ ÔÓËÁ‚‰ÂÌÓ ıËÛ„˘ÂÒÍËÏ, ·ԇÓÒÍÓÔ˘ÂÒÍËÏ Ë ˜ÂÒÍÓÊÌ˚Ï ÒÔÓÒÓ·ÓÏ. ìÊ ˜ÂÂÁ 2 ̉
ÔÓÒΠÔӈ‰Û˚ ÔÓËÒıÓ‰ËÚ Û‚Â΢ÂÌË ӷ˙Âχ
΂ÓÈ ‰ÓÎË ‚ Ò‰ÌÂÏ ‚ 1.5 ‡Á‡ ÓÚ ËÒıÓ‰ÌÓ„Ó [10].
èË ·ËÎÓ·‡ÌÓÏ ÔÓ‡ÊÂÌËË ‚ÓÁÏÓÊÌÓ Ôӂ‰ÂÌË ‰‚Ûı˝Ú‡ÔÌÓÈ ÂÁÂ͈ËË Ô˜ÂÌË: ÔÂ‚˚Ï ˝Ú‡ÔÓÏ Û‰‡Îfl˛Ú Ó‰ÌÛ ‰Óβ Ò ÛÁ·ÏË, ‚ÚÓ˚Ï, ÔÓÒÎÂ
‡Á‚ËÚËfl „ËÔÂÚÓÙËË ÓÒÚ‡‚¯ÂÈÒfl ‰ÓÎË, ‚˚ÔÓÎÌfl˛Ú ÎË·Ó Ò„ÏÂÌÚ‡ÌÛ˛ ÂÁÂÍˆË˛, ÎË·Ó ÎÓ͇θÌÛ˛ ‰ÂÒÚÛÍˆË˛ ÛÁÎÓ‚ [6].
ïËÏËÓÚÂ‡ÔËfl, ‡ÒÒχÚË‚‡‚¯‡flÒfl ‡Ì ͇Í
‰ËÌÒÚ‚ÂÌÌ˚È ÏÂÚÓ‰ ΘÂÌËfl ÌÂÂÁÂÍÚ‡·ÂθÌ˚ı
ÔÓ‡ÊÂÌËÈ Ô˜ÂÌË, Ú‡ÍÊ ̇ıÓ‰ËÚ ÏÂÒÚÓ Ò‰Ë
ÏÂÚÓ‰Ó‚ ÍÓÏ·ËÌËÓ‚‡ÌÌÓ„Ó Î˜ÂÌËfl ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚.
çÂÓ‡‰˙˛‚‡ÌÚ̇fl ıËÏËÓÚÂ‡ÔËfl. èÓ‚˚ÒËÚ¸
ÂÁÂÍÚ‡·ÂθÌÓÒÚ¸ Ô˜ÂÌÓ˜Ì˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚, ‡ Ú‡ÍÊ ‚ÓÁ‰ÂÈÒÚ‚Ó‚‡Ú¸ ̇ ÏËÍÓÏÂÚ‡ÒÚ‡Á˚ Ô˚Ú‡˛ÚÒfl
ÔÛÚÂÏ Ôӂ‰ÂÌËfl ÌÂÓ‡‰˙˛‚‡ÌÚÌÓÈ ıËÏËÓÚÂ‡ÔËË. R. Adam Ë ÒÓ‡‚Ú. [7] ÒÓÓ·˘‡˛Ú Ó Ôӂ‰ÂÌËË
ÌÂÓ‡‰˙˛‚‡ÌÚÌÓÈ ıËÏËÓÚÂ‡ÔËË 701 Ô‡ˆËÂÌÚÛ Ò
ÌÂÂÁÂÍÚ‡·ÂθÌ˚ÏË ÍÓÎÓÂÍڇθÌ˚ÏË ÏÂÚ‡ÒÚ‡Á‡ÏË ‚ Ô˜Â̸. ì 13.6% Ô‡ˆËÂÌÚÓ‚ ·˚Î ÓÚϘÂÌ
ÔÂÂıÓ‰ ÏÂÚ‡ÒÚ‡ÁÓ‚ ‚ ÂÁÂÍÚ‡·ÂθÌÓ ÒÓÒÚÓflÌËÂ.
ùÚË Ô‡ˆËÂÌÚ˚ ·˚ÎË ÓÔÂËÓ‚‡Ì˚, 5-ÎÂÚÌflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸ ÒÓÒÚ‡‚Ë· 34%, ˜ÚÓ ÒÓÔÓÒÚ‡‚ËÏÓ Ò ÂÁÛθڇڇÏË ÔÂ‚˘Ì˚ı ÂÁÂ͈ËÈ. Ç ˆÂÎÓÏ ‡‚ÚÓ‡Ï Û‰‡ÎÓÒ¸ ÔÓ‚˚ÒËÚ¸ ÂÁÂÍÚ‡·ÂθÌÓÒÚ¸ Ò 20 ‰Ó
30%.
ĉ˙˛‚‡ÌÚ̇fl ıËÏËÓÚÂ‡ÔËfl. ñËÍÛÎËÛ˛˘Ë ‚ ÍÓ‚Ë ÓÔÛıÓ΂˚ ÍÎÂÚÍË Ó·Ì‡ÛÊË‚‡˛Ú Û
40% ·ÓθÌ˚ı ÍÓÎÓÂÍڇθÌ˚Ï ‡ÍÓÏ [67]. äÓÏÂ
ÚÓ„Ó, ‚˚Ò‚Ó·Óʉ‡˛˘ËÂÒfl ÔÓÒΠÂÁÂ͈ËË Ô˜ÂÌË
Ù‡ÍÚÓ˚ ÓÒÚ‡ ÒÚËÏÛÎËÛ˛Ú Ì ÚÓθÍÓ ‰ÂÎÂÌËÂ
ÌÓχθÌ˚ı „ÂÔ‡ÚÓˆËÚÓ‚, ÌÓ Ë ÓÔÛıÓ΂˚ı ÍÎÂÚÓÍ [51, 53]. ùÚÓ fl‚ÎflÂÚÒfl Ó·ÓÒÌÓ‚‡ÌËÂÏ ÌÂÓ·ıÓ‰ËÏÓÒÚË ËÒÔÓθÁÓ‚‡ÌËfl ‡‰˙˛‚‡ÌÚÌÓ„Ó Î˜ÂÌËfl
ÔÓÒΠ‡‰Ë͇θÌ˚ı ıËÛ„˘ÂÒÍËı ÓÔÂ‡ˆËÈ Ì‡
Ô˜ÂÌË [3, 9, 67]. çÂψÍË ËÒÒΉӂ‡ÚÂÎË ÔÓ͇Á‡ÎË, ˜ÚÓ Ôӂ‰ÂÌË ‡‰˙˛‚‡ÌÚÌÓÈ ıËÏËÓÚÂ‡ÔËË
ÒÌËʇÂÚ ËÒÍ ÒÏÂÚË ÓÚ ÔÓ„ÂÒÒËÓ‚‡ÌËfl Á‡·Ó΂‡ÌËfl Ì ÏÂÌ ˜ÂÏ Ì‡ 15% [41].
ÇÓÁÏÓÊÌ˚ ‡Á΢Ì˚ ÒÔÓÒÓ·˚ ‚‚‰ÂÌËfl ıËÏËÓÔÂÔ‡‡ÚÓ‚ ‚ Ó„‡ÌËÁÏ: ÒËÒÚÂÏÌÓÂ, ‚ÌÛÚˇÚÂˇθÌÓÂ, ‚ÌÛÚËÔÓڇθÌÓÂ Ë ËÌÚ‡ÔÂËÚÓ̇θÌÓÂ. ïÓÚfl ÓÔÚËχθÌ˚È ÏÂÚÓ‰ ¢ ÓÍÓ̘‡ÚÂθÌÓ Ì ÓÔ‰ÂÎÂÌ [42], ÌÂÍÓÚÓ˚ ËÒÒΉӂ‡ÚÂÎË
‰ÂÏÓÌÒÚËÛ˛Ú ÔÂËÏÛ˘ÂÒÚ‚Ó ‚ÌÛÚˇÚÂˇθÌÓ„Ó ‚‚‰ÂÌËfl, ÒÓÁ‰‡˛˘Â„Ó ·ÓΠ‚˚ÒÓÍÛ˛ ÍÓ̈ÂÌÚ‡ˆË˛ ıËÏËÓÔÂÔ‡‡Ú‡ ‚ ÓÔÛıÓÎË Ë ÒÌËʇ˛˘Â„Ó Â„Ó ÒËÒÚÂÏÌÓ ÚÓÍÒ˘ÂÒÍÓ ‰ÂÈÒÚ‚ËÂ. í‡Í,
N. Kemeny Ë ÒÓ‡‚Ú. [36] ‚˚fl‚ËÎË Û‚Â΢ÂÌË ÍÓ΢ÂÒÚ‚‡ ·ÓθÌ˚ı ·ÂÁ ˆˉ˂ӂ ‚ Ú˜ÂÌË 2 ÎÂÚ
ÔÓÒΠÂÁÂ͈ËË Ô˜ÂÌË ÔÓ ÔÓ‚Ó‰Û ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚ Ò 60 ‰Ó 90% ÔË ‚ÌÛÚˇÚÂˇθÌÓÈ ıËÏËÓÚÂ‡ÔËË ÔÓ Ò‡‚ÌÂÌ˲ Ò ÒËÒÚÂÏÌÓÈ.
Ç Í‡˜ÂÒÚ‚Â ÏÂÚÓ‰ËÍ, ÔÓ‚˚¯‡˛˘Ëı ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ ‚ÓÁ‰ÂÈÒÚ‚Ëfl ıËÏËÓÔÂÔ‡‡Ú‡ ̇ ÓÔÛıÓ΂˚Â
ÍÎÂÚÍË, ‡ÒÒχÚË‚‡˛Ú ÏÂÚÓ‰ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË
98
Ô˜ÂÌÓ˜ÌÓÈ ‡ÚÂËË, Ó·ÂÒÔ˜˂‡˛˘ËÈ ÒÂÎÂÍÚË‚ÌÓ ̇ÍÓÔÎÂÌË ıËÏËÓÔÂÔ‡‡Ú‡ ‚ ÓÔÛıÓÎË Ë ‚˚Á˚‚‡˛˘ËÈ Ë¯ÂÏ˘ÂÒÍËÈ ÌÂÍÓÁ ÌÓ‚ÓÓ·‡ÁÓ‚‡ÌËfl, ÛÒËÎË‚‡˛˘ËÈ ÚÂ‡Ô‚Ú˘ÂÒÍËÈ ˝ÙÙÂÍÚ ·ÂÁ
Á̇˜ËÚÂθÌÓ„Ó ÔÓ‚ÂʉÂÌËfl ÌÓχθÌÓÈ Ô‡ÂÌıËÏ˚ [1]. éÒÌÓ‚Ì˚ ÓÒÎÓÊÌÂÌËfl ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË
(3–4%): Ô˜ÂÌӘ̇fl ̉ÓÒÚ‡ÚÓ˜ÌÓÒÚ¸ ËÎË ËÌÙ‡ÍÚ˚ Ô˜ÂÌË, Ô˜ÂÌÓ˜Ì˚ ‡·ÒˆÂÒÒ˚, ·ËΡÌ˚ ÌÂÍÓÁ˚, ‡Á˚‚ ÓÔÛıÓÎË, ıÓΈËÒÚËÚ, ÌÂÍÓÌÚÓÎËÛÂχfl ˝Ï·ÓÎËÁ‡ˆËfl ÒÓÒÛ‰Ó‚ ÊÂÎۉ͇ Ë/ËÎË Í˯˜ÌË͇; ÎÂڇθÌÓÒÚ¸ ‚‡¸ËÛÂÚ ÓÚ 1 ‰Ó 4% [37,
58, 64]. ïËÏËÓ˝Ï·ÓÎËÁ‡ˆËfl ‚ ÓÒÌÓ‚ÌÓÏ ‡ÒÒχÚË‚‡ÂÚÒfl ‚ ͇˜ÂÒÚ‚Â ÔÓÒΉÌÂ„Ó ËÁ ÏÂÚÓ‰Ó‚ ΘÂÌËfl ·ÓθÌ˚ı Ò ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍËÏ ÔÓ‡ÊÂÌËÂÏ Ô˜ÂÌË, Û ÍÓÚÓ˚ı Ô‰¯ÂÒÚ‚Û˛˘‡fl ÒËÒÚÂÏ̇fl
Ë/ËÎË „ËÓ̇θ̇fl ıËÏËÓÚÂ‡ÔËfl ·˚· ̽ÙÙÂÍÚË‚ÌÓÈ. ëÚ‡·ËÎËÁ‡ˆËfl ËÎË ˜‡ÒÚ˘̇fl „ÂÒÒËfl ÓÔÛıÓ΂˚ı Ó˜‡„Ó‚ ÓÚϘÂ̇ Û 59–72% ·ÓθÌ˚ı, ‚ 17% ̇·Î˛‰ÂÌËÈ ÓÚ˜‡Î‡Ò¸ ÔÓÎ̇fl „ÂÒÒËfl. ÄÍÚÛ‡̇fl 1- Ë 2-„Ӊ˘̇fl ‚˚ÊË‚‡ÂÏÓÒÚ¸
ÒÓÒÚ‡‚Ë· ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ 68–86% Ë 37–55%. å‰ˇ̇ ‚˚ÊË‚‡ÂÏÓÒÚË ÔÓÒΠÔÂ‚ÓÈ ıËÏËÓ˝Ï·ÓÎËÁ‡ˆËË ÒÓÒÚ‡‚Ë· 8–10 ÏÂÒ [37, 58, 64].
ãÓ͇θ̇fl ‰ÂÒÚÛ͈Ëfl ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍËı ÛÁÎÓ‚.
èÓÔ˚ÚÍË ÎÓ͇θÌÓ„Ó ‡ÁÛ¯ÂÌËfl ÏÂÚ‡ÒÚ‡ÁÓ‚
Ô‰ÔËÌËχÎËÒ¸ ‰‡‚ÌÓ. é‰ÌËÏ ËÁ ÔÂ‚˚ı Ë Ì‡Ë·ÓΠÔÓÒÚ˚ı ÏÂÚÓ‰Ó‚ ·˚ÎÓ ÔËÏÂÌÂÌË ˝Ú‡ÌÓÎÓ‚Ó„Ó ÒÔËÚ‡.
ǂ‰ÂÌË ˝Ú‡ÌÓ·. ùÚ‡ ÏÂÚÓ‰Ë͇ ÓÒÌÓ‚‡Ì‡ ̇
‚‚‰ÂÌËË ‚ ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍËÈ ÛÁÂÎ (ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÓ ËÎË ˜ÂÒÍÓÊÌÓ) ÔÓ‰ ÍÓÌÚÓÎÂÏ ìáà 96%
ÒÔËÚ‡. åÂÚÓ‰ ‚Ò ¢ ËÒÔÓθÁÛÂÚÒfl ÔË Î˜ÂÌËË
ÌÂÂÁÂÍÚ‡·ÂθÌ˚ı ÓÔÛıÓÎÂÈ Ô˜ÂÌË, ˜ÚÓ Ó·ÛÒÎÓ‚ÎÂÌÓ Â„Ó ÓÚÌÓÒËÚÂθÌÓÈ ÔÓÒÚÓÚÓÈ Ë ‰Â¯Â‚ËÁÌÓÈ.
èË ˝ÚÓÏ 3-ÎÂÚÌflfl ‚˚ÊË‚‡ÂÏÓÒÚ¸ ÒÓÒÚ‡‚ÎflÂÚ ‰Ó
39% [58]. Ç ˝ÍÒÔÂËÏÂÌÚ ·˚ÎÓ ÔÓ͇Á‡ÌÓ, ˜ÚÓ ÌÂÔÓÎ̇fl ‰ÂÒÚÛ͈Ëfl ÓÔÛıÓÎÂ‚Ó„Ó ÛÁ· ÔÓËÒıÓ‰ËÚ
‚ 89% ÒÎÛ˜‡Â‚ [26]. ǂ‰ÂÌË ÒÔËÚ‡ ÏÓÊÂÚ fl‚ÎflÚ¸Òfl ‡Î¸ÚÂ̇ÚË‚Ì˚Ï ÏÂÚÓ‰ÓÏ Î˜ÂÌËfl Ì·Óθ¯Ëı ÌÂÂÁÂÍÚ‡·ÂθÌ˚ı ÓÔÛıÓÎÂÈ, Ӊ̇ÍÓ Â„Ó ÌÂ
ÒΉÛÂÚ ÂÍÓÏẨӂ‡Ú¸ ÔË Î˜ÂÌËË ·ÓΠÍÛÔÌ˚ı ÓÔÛıÓÎÂÈ ËÁ-Á‡ ÚÂıÌ˘ÂÒÍËı ÒÎÓÊÌÓÒÚÂÈ, Ò‚flÁ‡ÌÌ˚ı Ò Ôӈ‰ÛÓÈ ËÌ˙Â͈ËË, ‡ Ú‡ÍÊ ËÁ-Á‡ ÌÂÛ‰Ó‚ÎÂÚ‚ÓËÚÂθÌ˚ı ÓÚ‰‡ÎÂÌÌ˚ı ÂÁÛθڇÚÓ‚ Ë
Ì‚ÓÁÏÓÊÌÓÒÚË ÍÓÌÚÓÎËÓ‚‡Ú¸ Ó·˙ÂÏ ‡ÁÛ¯‡ÂÏÓÈ Ú͇ÌË. Ç ÔÓÒΉÌË 3–5 ÎÂÚ ˝Ú‡ ÏÂÚÓ‰Ë͇
Òڇ· ÛÒÚÛÔ‡Ú¸ ÏÂÒÚÓ ·ÓΠÔÓ„ÂÒÒË‚Ì˚Ï Ë ˝ÙÙÂÍÚË‚Ì˚Ï ÏÂÚÓ‰‡Ï – ‡‰ËÓ˜‡ÒÚÓÚÌÓÈ ‡·Î‡ˆËË
(‰ÂÒÚÛ͈ËË, êóÄ) Ë ÍËÓ‰ÂÒÚÛ͈ËË.
ꇉËÓ˜‡ÒÚÓÚ̇fl ‰ÂÒÚÛ͈Ëfl (‡·Î‡ˆËfl – êóÄ).
ùÚÓÚ ÏÂÚÓ‰ Ô‰ÒÚ‡‚ÎflÂÚ ÒÓ·ÓÈ Ì‡„‚‡ÌË Ú͇ÌÂÈ ‚ÓÍÛ„ ÒÔˆˇθÌÓ„Ó ˝ÎÂÍÚÓ‰‡ ÔÓ„ÛÊÂÌÌÓ„Ó ‚ ÓÔÛıÓ΂˚È Ó˜‡„ ÔÓÒ‰ÒÚ‚ÓÏ ‡‰ËÓ‚ÓÎÌ
˜‡ÒÚÓÚÓÈ 450–500 ÍɈ, Ó·ÂÒÔ˜˂‡˛˘Ëı ̇„‚
ÓÍÛʇ˛˘Ëı Ú͇ÌÂÈ ‰Ó 80–110°ë, ˜ÚÓ ÔË‚Ó‰ËÚ
Í ÍÓ‡„ÛÎflˆËÓÌÌÓÏÛ ÌÂÍÓÁÛ. èÓÒΉÌË ÏÓ‰ÂÎË
˝ÎÂÍÚÓ‰Ó‚ Ò ‚˚‰‚ËÊÌ˚ÏË Ë„Óθ˜‡Ú˚ÏË Í˛˜Í‡ÏË ÔÓÁ‚ÓÎfl˛Ú ÓÒÛ˘ÂÒÚ‚ÎflÚ¸ ÍÓ‡„ÛÎflˆË˛ Ó·‡ÁÓ‚‡ÌËÈ ‰Ë‡ÏÂÚÓÏ ‰Ó 7 ÒÏ. ó‡ÒÚÓÚ‡ ÓÒÎÓÊÌÂÌËÈ
ÔÓÒΠêóÄ ÒÓÒÚ‡‚ÎflÂÚ 0–12 %, ÎÂڇθÌÓÒÚ¸ 0–1%
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
Ô˜Â̸
ÇéêéÅúÖÇ Ë ‰.
퇷Îˈ‡ 5. ùÙÙÂÍÚË‚ÌÓÒÚ¸ ÍËÓ‰ÂÒÚÛ͈ËË Ë ‡‰ËÓ˜‡ÒÚÓÚÌÓÈ ‰ÂÒÚÛ͈ËË ÌÂÂÁÂÍÚ‡·ÂθÌ˚ı ÓÔÛıÓÎÂÈ
Ô˜ÂÌË [50]
臈ËÂÌÚ˚/ÏÂÚ‡ÒÚ‡Á˚
éÒÎÓÊÌÂÌËfl, %
(p < 0.001)
ëÓÍ Ì‡·Î˛‰ÂÌËfl,
ÏÂÒ.
êˆˉ˂,
% (p < 0.001)
äËÓ‰ÂÒÚÛ͈Ëfl
54/88
40.7
15
13.6
êóÄ
92/138
3.3
15
2.1
åÂÚÓ‰
[16, 69], ˆˉ˂˚ ‚ ÏÂÒÚ ‰ÂÒÚÛ͈ËË ‚ÓÁÌË͇˛Ú
‚ 6–18% ̇·Î˛‰ÂÌËÈ [54, 63].
äËÓ‰ÂÒÚÛ͈Ëfl. åÂÚÓ‰ Óı·ʉÂÌËfl ÓÔÛıÓ΂˚ı ÍÎÂÚÓÍ ‰Ó ÚÂÏÔÂ‡ÚÛ˚, ‚˚Á˚‚‡˛˘ÂÈ Ëı „Ë·Âθ. ó‡ÒÚÓÚ‡ ÓÒÎÓÊÌÂÌËÈ, Ò‚flÁ‡ÌÌ˚ı Ò ÍËÓ‰ÂÒÚÛ͈ËÂÈ, ‰Ó‚ÓθÌÓ ‚˚ÒÓ͇ (15–50%), ÎÂڇθÌÓÒÚ¸ ÓÍÓÎÓ 4%, ˜‡ÒÚÓÚ‡ ˆˉ˂ӂ ÒÓÒÚ‡‚ÎflÂÚ
10–15% [23, 52, 72].
ùÙÙÂÍÚË‚ÌÓÒÚ¸ ÍËÓ‰ÂÒÚÛ͈ËË Ë ‡‰ËÓ˜‡ÒÚÓÚÌÓÈ „ËÔÂÚÂÏËË ÔË Î˜ÂÌËË Ô‡ˆËÂÌÚÓ‚ Ò ÌÂÂÁÂÍÚ‡·ÂθÌ˚ÏË ÏÂÚ‡ÒÚ‡Á‡ÏË Ô˜ÂÌË Ô˂‰Â̇
‚ Ú‡·Î. 5.
ä ÌÓ‚˚Ï ÏÂÚÓ‰‡Ï ÎÓ͇θÌÓÈ ‰ÂÒÚÛ͈ËË ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍËı ÛÁÎÓ‚ Ô˜ÂÌË, ̇ıÓ‰fl˘ËÏÒfl ‚ ÒÚ‡‰ËË
ËÁÛ˜ÂÌËfl Ë Ì ÔÓÎۘ˂¯ËÏ ÔÓ͇ ¯ËÓÍÓ„Ó ‡ÒÔÓÒÚ‡ÌÂÌËfl ‚ ÍÎËÌ˘ÂÒÍÓÈ Ô‡ÍÚËÍÂ, ÏÓÊÌÓ
ÓÚÌÂÒÚË ÏËÍÓ‚ÓÎÌÓ‚Û˛ Ë ËÌÚÂÒÚˈˇθÌÛ˛ ·ÁÂÌÛ˛ ÍÓ‡„ÛÎflˆË˛.
åËÍÓ‚ÓÎÌÓ‚‡fl ÍÓ‡„ÛÎflˆËfl. Ç ÓÒÌÓ‚Â ÏÂÚÓ‰‡
ÎÂÊËÚ ‚˚ÒÓÍÓ˜‡ÒÚÓÚÌÓ ËÁÎÛ˜ÂÌË (˜‡ÒÚÓÚ‡ ‰Ó
2450 åɈ), ‚˚Á˚‚‡˛˘Â „ËÔÂÚÂÏ˘ÂÒÍÓ ‡ÁÛ¯ÂÌË ÓÔÛıÓ΂˚ı Ó˜‡„Ó‚ ‰Ë‡ÏÂÚÓÏ ‰Ó 3 ÒÏ.
ÑÎfl ˝ÚÓ„Ó ÒÔˆˇθÌ˚È ‡ÔÔÎË͇ÚÓ ‚‚Ó‰flÚ ‚ ÛÁÂÎ
ÎË·Ó ˜ÂÒÍÓÊÌÓ, ÎË·Ó ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÓ. èÓÎÌ˚È
ÌÂÍÓÁ ÓÔÛıÓ΂ÓÈ Ú͇ÌË ‰ÓÒÚË„‡˛Ú Û 72% Ô‡ˆËÂÌÚÓ‚ [30, 43]. éÚ‰‡ÎÂÌÌ˚ ÂÁÛθڇÚ˚ ÔËÏÂÌÂÌËfl
˝ÚÓ„Ó ÏÂÚÓ‰‡ ÒÓÔÓÒÚ‡‚ËÏ˚ Ò ÂÁÛθڇڇÏË ‡‰ËÓ˜‡ÒÚÓÚÌÓÈ „ËÔÂÚÂÏ˘ÂÒÍÓÈ ‰ÂÒÚÛ͈ËË [25].
àÌÚÂÒÚˈˇθ̇fl ·ÁÂ̇fl ÚÂÏÓ‰ÂÒÚÛ͈Ëfl. ã‡ÁÂÌÓ ËÁÎÛ˜ÂÌË ÔÓ‰‡ÂÚÒfl Í ÓÔÛıÓÎË ÔÓ
ÒÔˆˇθÌÓÏÛ Ò‚ÂÚÓ‚ÓÎÓÍÌÛ. Ç Ú͇ÌË ˝ÚÓ ËÁÎÛ˜ÂÌË ÔÂÓ·‡ÁÛÂÚÒfl ‚ ÚÂÔÎÓ‚Û˛ ˝ÌÂ„˲. ÑˇÏÂÚ
‡ÁÛ¯‡ÂÏ˚ı Ó˜‡„Ó‚ ‚ Á‡‚ËÒËÏÓÒÚË ÓÚ ÏÓ˘ÌÓÒÚË
„ÂÌÂ‡ÚÓ‡ Ë ÚËÔ‡ ÔÓ‚Ó‰fl˘Ëı ‚ÓÎÓÍÓÌ ÒÓÒÚ‡‚ÎflÂÚ ÓÚ 2 ‰Ó 8 ÒÏ [30, 45].
ìÒËÎËflÏË ‰‚Ûı ωˈËÌÒÍËı Û˜ÂʉÂÌËÈ
(Éçñä åËÌÁ‰‡‚‡ êî Ë êçñï êÄåç) ̇˜‡Ú‡
‰Ó΄ÓÒӘ̇fl ÍÓÏÔÎÂÍÒ̇fl ÔÓ„‡Ïχ ÔÓ ËÁÛ˜ÂÌ˲ ‚ÓÁÏÓÊÌÓÒÚÂÈ ÒÓ‚ÂÏÂÌÌ˚ı ÏÂÚÓ‰Ó‚ ΘÂÌËfl ÍÓÎÓÂÍڇθÌ˚ı ÏÂÚ‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË. чθÌÂȯ ‡Á‚ËÚË ˝ÚÓ„Ó Ì‡Ô‡‚ÎÂÌËfl ÓÒÌÓ‚˚‚‡ÎÓÒ¸ ̇ ÛÊ Ëϲ˘ÂÏÒfl ÓÔ˚ڠΘÂÌËfl ˝ÚÓÈ
„ÛÔÔ˚ Ô‡ˆËÂÌÚÓ‚.
ë ÒÂÌÚfl·fl 2001 „. ÔÓ Ï‡Ú 2003 „. ·˚ÎÓ ‚˚ÔÓÎÌÂÌÓ 28 ÂÁÂ͈ËÈ Ô˜ÂÌË ÔÓ ÔÓ‚Ó‰Û ÒËÌıÓÌÌ˚ı
(9/32%) Ë ÏÂÚ‡ıÓÌÌ˚ı (19/68%) ÍÓÎÓÂÍڇθÌ˚ı
ÏÂÚ‡ÒÚ‡ÁÓ‚. ë‰ÌËÈ ‚ÓÁ‡ÒÚ Ô‡ˆËÂÌÚÓ‚ ÒÓÒÚ‡‚ËÎ 56.4 ± 9.7 „Ó‰‡ (42–73 „Ó‰‡), ÏÛʘËÌ ·˚ÎÓ 12,
ÊÂÌ˘ËÌ – 16 (ÒÓÓÚÌÓ¯ÂÌË 1 : 1.3). èÓ͇Á‡ÌËfl Í
‚˚ÔÓÎÌÂÌ˲ ÓÔÂ‡ˆËË Ì‡ Ô˜ÂÌË ÓÔ‰ÂÎflÎË
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
ÚÓθÍÓ ÔÓÒΠ‡‰Ë͇θÌÓ„Ó Û‰‡ÎÂÌËfl ÔÂ‚˘ÌÓÈ
ÓÔÛıÓÎË. Ç 75% ̇·Î˛‰ÂÌËÈ ËÒÚÓ˜ÌËÍÓÏ ÏÂÚ‡ÒÚ‡ÁËÓ‚‡ÌËfl ·˚· ÓÔÛıÓθ ÔflÏÓÈ Í˯ÍË, ‚ 18% –
Ó·Ó‰Ó˜ÌÓÈ, ‚ 7% – ÒË„ÏӂˉÌÓÈ. åÂÚ‡ıÓÌÌ˚Â
ÏÂÚ‡ÒÚ‡Á˚ ‚˚fl‚ÎflÎË ‚ Ò‰ÌÂÏ ˜ÂÂÁ 19.7 ± 9.1 ÏÂÒ
(7–31 ÏÂÒ) ÔÓÒΠۉ‡ÎÂÌËfl ÔÂ‚˘ÌÓÈ ÓÔÛıÓÎË
Í˯ÍË. ÑÎfl ‰Ë‡„ÌÓÒÚËÍË ÔÓ‡ÊÂÌËfl Ô˜ÂÌË ËÒÔÓθÁÓ‚‡ÎË ìáà Ó„‡ÌÓ‚ ·˛¯ÌÓÈ ÔÓÎÓÒÚË, äí,
ÒÔË‡Î¸ÌÛ˛ äí Ò ‚ÌÛÚË‚ÂÌÌ˚Ï ÍÓÌÚ‡ÒÚËÓ‚‡ÌËÂÏ, åêí, ·ԇÓÒÍÓÔ˲. èË Ó·¯ËÌÓÏ ÔÓ‡ÊÂÌËË Ë Ì·Óθ¯ÓÈ Î‚ÓÈ ‰ÓΠ‡ÒÒ˜ËÚ˚‚‡ÎË
ÚÓ˜Ì˚È Ó·˙ÂÏ ‰ÓÎÂÈ Ô˜ÂÌË Ì‡ ÓÒÌÓ‚‡ÌËË äí-ÂÍÓÌÒÚÛ͈ËË. èÓ‡ÊÂÌˠ΂ÓÈ ‰ÓÎË ‚˚fl‚ÎÂÌÓ Û
7 (25%) Ô‡ˆËÂÌÚÓ‚, Ô‡‚ÓÈ – Û 9 (31%), Ó·ÂËı ‰ÓÎÂÈ – Û 12 (44%). óËÒÎÓ ÏÂÚ‡ÒÚ‡ÁÓ‚ ‚‡¸ËÓ‚‡ÎÓ
ÓÚ 1 ‰Ó 5. ëÓÎËÚ‡Ì˚È ÏÂÚ‡ÒÚ‡Á ËÏÂÎÒfl Û 44%
·ÓθÌ˚ı, 2 ÏÂÚ‡ÒÚ‡Á‡ – Û 12%, 3 ÏÂÚ‡ÒÚ‡Á‡ Ë ·ÓΠ– Û 44% ·ÓθÌ˚ı. ÑˇÏÂÚ Ò‡Ï˚ı ÍÛÔÌ˚ı
ÛÁÎÓ‚ ÍÓη‡ÎÒfl ÓÚ 2 ‰Ó 10 ÒÏ (‚ Ò‰ÌÂÏ 5.7 ± 2.7 ÒÏ).
Ç˚ÔÓÎÌÂÌ˚ ÒÎÂ‰Û˛˘Ë ÓÔÂ‡ˆËË: 14 Ô‡‚ÓÒÚÓÓÌÌËı „ÂÏË„ÂÔ‡Ú˝ÍÚÓÏËÈ (ÉÉù) (ËÁ ÌËı 2 ‡Ò¯ËÂÌÌ˚Â), 5 ΂ÓÒÚÓÓÌÌËı (‚ ÚÓÏ ˜ËÒΠ2 ‡Ò¯ËÂÌÌ˚Â) Ë 9 ·ÚÂ‡Î¸Ì˚ı ΂ÓÒÚÓÓÌÌËı ÂÁÂ͈ËÈ Ô˜ÂÌË. èË ‰ËÒÒÂ͈ËË Ô‡ÂÌıËÏ˚ Ô˜ÂÌË Û
11 Ô‡ˆËÂÌÚÓ‚ ËÒÔÓθÁÓ‚‡ÎË ‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ (“Helix-HydroJet”), ‰Îfl ‰ÓÒÚËÊÂÌËfl ÓÍÓ̘‡ÚÂθÌÓ„Ó „ÂÏÓÒÚ‡Á‡ ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË Ô˜ÂÌË Û 17 ËÁ 28 ·ÓθÌ˚ı ÔËÏÂÌflÎË ÙË·ËÌ-ÍÓη„ÂÌÓ‚Û˛ ÒÛ·ÒÚ‡ÌˆË˛. ì 10 Ô‡ˆËÂÌÚÓ‚ ÔËÏÂÌÂ̇
ÚÂıÌÓÎÓ„Ëfl êóÄ ÏÂÚ‡ÒÚ‡ÁÓ‚ (RITA Medical Systems, Inc, Model 1500): ‚ 6 ̇·Î˛‰ÂÌËflı ‚Ó ‚ÂÏfl
Ô‡‚ÓÒÚÓÓÌÌÂÈ ÉÉù, ‚ 2 – ÔË Î‚ÓÒÚÓÓÌÌÂÈ ÉÉù
Ë ‚ 2 – ÔË ·ËÎÓ·‡ÌÓÏ ÔÓ‡ÊÂÌËË Ô˜ÂÌË Í‡Í Ò‡ÏÓÒÚÓflÚÂθÌ˚È ÏÂÚÓ‰. ÑË̇Ï˘ÂÒÍÓ ̇·Î˛‰ÂÌËÂ
Á‡ ÁÓ̇ÏË ‡‰ËÓ˜‡ÒÚÓÚÌÓ„Ó ‚ÓÁ‰ÂÈÒÚ‚Ëfl ÔÓ‚Ó‰ËÎË
Ò ÔÓÏÓ˘¸˛ ìáà Ë äí, ÍÓÚÓ˚ ÔÓ‚ÚÓflÎË ˜ÂÂÁ
1 ̉ Ë 1 ÏÂÒ ÔÓÒΠÓÔÂ‡ˆËË. ì 2 Ô‡ˆËÂÌÚÓ‚ êóÄ
ÔÓ‚Ó‰ËÎË ‚ÚÓ˚Ï ˝Ú‡ÔÓÏ ˜ÂÂÁ 2.5 Ë 3 ÏÂÒ ÔÓÒÎÂ
ÂÁÂ͈ËË Ô˜ÂÌË ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ, ̇ ÙÓÌ ‡Á‚Ë‚¯ÂÈÒfl ÍÓÏÔÂÌÒ‡ÚÓÌÓÈ „ËÔÂÚÓÙËË ÓÒÚ‡‚¯ÂÈÒfl
‰ÓÎË Ô˜ÂÌË.
êÂÁÛθڇÚ˚
àÌÚ‡ÓÔÂ‡ˆËÓÌÌÓÈ Ë „ÓÒÔËڇθÌÓÈ ÎÂڇθÌÓÒÚË ÔÓÒΠ‚˚ÔÓÎÌÂÌÌ˚ı ‚ϯ‡ÚÂθÒÚ‚ Ì ÓÚϘÂÌÓ. ë‰Ìflfl ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÓÔÂ‡ˆËË ÒÓÒÚ‡‚Ë· 335 ± 90 ÏËÌ. (180–490 ÏËÌ.), ÓÔÂ‡ˆËÓÌ̇fl ÍÓ‚ÓÔÓÚÂfl – 943 ± 578 ÏÎ (250–2250 ÏÎ).
èÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ ÓÒÎÓÊÌÂÌËfl ÓÚϘÂÌ˚ Û
8 (28.6%) Ô‡ˆËÂÌÚÓ‚: Ô˜ÂÌӘ̇fl ̉ÓÒÚ‡ÚÓ˜‹1
2004
99
7*
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ìÒÎÓ‚ÌÓ ÂÁÂÍÚ‡·ÂθÌ˚Â
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ùÏ·ÓÎËÁ‡ˆËfl,
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(êóÄ, ÍËÓ‰ÂÒÚÛ͈Ëfl)
Ä΄ÓËÚÏ ÍÓÏ·ËÌËÓ‚‡ÌÌÓ„Ó Î˜ÂÌËfl ÏÂÚ‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË ÍÓÎÓÂÍڇθÌÓÈ ˝ÚËÓÎÓ„ËË.
ÌÓÒÚ¸ – 1, ̇ÛÊÌ˚È ÊÂΘÌ˚È Ò‚Ë˘ – 2, Òԇ˜̇fl
Í˯˜̇fl ÌÂÔÓıÓ‰ËÏÓÒÚ¸ – 1, ÔÓ‰‰Ë‡Ù‡„χθÌÓ ÊˉÍÓÒÚÌÓ ÒÍÓÔÎÂÌËÂ, ÔÓÚ·ӂ‡‚¯Â ˜ÂÒÍÓÊÌÓÈ ÔÛÌ͈ËË ÔÓ‰ ÛθÚ‡Á‚ÛÍÓ‚˚Ï ÍÓÌÚÓÎÂÏ –
4, ̇„ÌÓÂÌË ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌÓÈ ‡Ì˚ – 1. ë‰Ë
Ô‡ˆËÂÌÚÓ‚, Û ÍÓÚÓ˚ı ‚Ó ‚ÂÏfl ÓÔÂ‡ˆËË ÔËÏÂÌflÎË ‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ Ë “í‡ıÓäÓÏ·” ÓÒÎÓÊÌÂÌËÈ, Ò‚flÁ‡ÌÌ˚ı Ò Ì‰ÓÒÚ‡ÚÓ˜Ì˚Ï „ÂÏÓÒÚ‡ÁÓÏ Ë Ì„ÂÏÂÚ˘ÌÓÒÚ¸˛ ÊÂΘÌ˚ı ÔÓÚÓÍÓ‚ ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË ÍÛθÚË Ô˜ÂÌË, Ì ÓÚϘÂÌÓ.
ꇉËÓ˜‡ÒÚÓÚÌÓÈ ‰ÂÒÚÛ͈ËË ÔÓÒΠ‚˚ÔÓÎÌÂÌËfl
ÂÁÂ͈ËË ÔÓ‰‚Â„‡ÎË Ó˜‡„Ë ‚ ÓÒÚ‡˛˘ÂÈÒfl ÍÛθÚÂ
Ô˜ÂÌË. ë‰ÌËÈ ‰Ë‡ÏÂÚ ÏÂÚ‡ÒÚ‡Á‡ ÒÓÒÚ‡‚ËÎ
2.5 ± 1.2 ÒÏ. ì 2 Ô‡ˆËÂÌÚÓ‚ ÔË Ô‡‚ÓÒÚÓÓÌÌÂÏ Ë
ˆÂÌÚ‡Î¸ÌÓÏ ‡ÒÔÓÎÓÊÂÌËË ÏÂÚ‡ÒÚ‡Ú˘ÂÒÍËı ÛÁÎÓ‚ Ë Ï‡ÎÓÈ Ï‡ÒҠ΂ÓÈ ‰ÓÎË êóÄ ÔËÏÂÌËÎË ·ÂÁ
ÂÁÂ͈ËË Ô˜ÂÌË, ÔË ˝ÚÓÏ Ò‰ÌËÈ ‰Ë‡ÏÂÚ ÛÁÎÓ‚
ÒÓÒÚ‡‚ËÎ 3.2 ± 0.9 ÒÏ. Ñ‚Ûı˝Ú‡ÔÌÓ ‚ÓÁ‰ÂÈÒÚ‚Ë ̇
Ó‰ËÌ Ë ÚÓÚ Ê Ә‡„ Ò ¯‡„ÓÏ 1 ÒÏ (Ò ˆÂθ˛ ‡Ò¯ËÂÌËfl ÁÓÌ˚ ‰ÂÒÚÛ͈ËË) ÔËÏÂÌÂÌÓ Û 4 ·ÓθÌ˚ı.
èÓÒΠêóÄ ÔË ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÓÏ ìáà ‚Ó ‚ÒÂı
̇·Î˛‰ÂÌËflı ÓÚϘ‡ÎË ÔÂÍ‡˘ÂÌË ÍÓ‚ÓÚÓ͇
Ë Û‚Â΢ÂÌË ˝ıÓ„ÂÌÌÓÒÚË Ò ÔËÁ͇̇ÏË „ËÔÂÂÏËË Ô‡ÂÌıËÏ˚ Ô˜ÂÌË, ‡ÒÔÓÎÓÊÂÌÌÓÈ ÔÓ ÔÂËÙÂËË ÁÓÌ˚ ‰ÂÒÚÛ͈ËË. ìáà ˜ÂÂÁ 1 ̉. ÔÓÒÎÂ
ÓÔÂ‡ˆËË Ôӂ‰ÂÌ˚ ‚ÒÂÏ ·ÓθÌ˚Ï. ìáà Ë äí
˜ÂÂÁ 1 ÏÂÒ ÔÓÒΠÓÔÂ‡ˆËË ‚˚ÔÓÎÌÂÌ˚ 5 Ô‡ˆËÂÌÚ‡Ï. èË ÍÓÌÚÓθÌ˚ı ìáà Ë äí Û‚Â΢ÂÌËfl ‰Ë‡ÏÂÚ‡ ÛÁÎÓ‚ Ë ÔËÁ̇ÍÓ‚ ÔÓfl‚ÎÂÌËfl ÍÓ‚ÓÚÓ͇ ‚
100
ÁÓ̇ı ‰ÂÒÚÛ͈ËË Ì ÓÚϘ‡ÎÓÒ¸. ïËÛ„˘ÂÒÍËı
ÓÒÎÓÊÌÂÌËÈ, Ò‚flÁ‡ÌÌ˚ı Ò êóÄ, ÔÓÒΠÓÔÂ‡ˆËÈ ÌÂ
·˚ÎÓ. 4 Ô‡ˆËÂÌÚ‡Ï ‚ ÒÓÓÚ‚ÂÚÒÚ‚ËË Ò ‡Á‡·ÓÚ‡ÌÌ˚Ï ÔÓÚÓÍÓÎÓÏ ÔÂ‰ ÓÔÂ‡ˆËÂÈ ÔÓ‚Ó‰ËÎË ÌÂÓ‡‰˙˛‚‡ÌÚÌÛ˛ ÚÂ‡Ô˲. èÓÒΉÌË 10 Ô‡ˆËÂÌÚÓ‚
ÔÓÎÛ˜‡ÎË ‡‰˙˛‚‡ÌÚÌÛ˛ ıËÏËÓÚÂ‡Ô˲ (5-ÙÚÓÛ‡ˆËÎ, ÎÂÈÍÓ‚‡ËÌ). Ñ‚ÛÏ Ô‡ˆËÂÌÚ‡Ï Ò ÏÌÓÊÂÒÚ‚ÂÌÌ˚ÏË ·ËÎÓ·‡Ì˚ÏË ÏÂÚ‡ÒÚ‡Á‡ÏË ‚Ó ‚ÂÏfl ÓÔÂ‡ˆËË ÛÒÚ‡ÌÓ‚ÎÂÌ ËÌÚ‡‡ÚÂˇθÌ˚È ÔÓÚ ‰Îfl
Ôӂ‰ÂÌËfl „ËÓ̇θÌÓÈ ıËÏËÓÚÂ‡ÔËË. Çϯ‡ÚÂθÒÚ‚Ó ÔÓ¯ÎÓ ·ÂÁ ÓÒÎÓÊÌÂÌËÈ.
í‡ÍËÏ Ó·‡ÁÓÏ, ÏÂÚÓ‰ÓÏ ‚˚·Ó‡ ÔË Î˜ÂÌËË
ÏÂÚ‡ÒÚ‡ÁÓ‚ Ô˜ÂÌË ÍÓÎÓÂÍڇθÌÓÈ ˝ÚËÓÎÓ„ËË
·˚· Ë ÓÒÚ‡ÂÚÒfl ÂÁÂ͈Ëfl Ô˜ÂÌË. ëÓ‚ÂÏÂÌÌ˚Â
ÏÂÚÓ‰˚ ΘÂÌËfl ÔÓÁ‚ÓÎfl˛Ú ‡ÒÒχÚË‚‡Ú¸ ‡ÌÂÂ
Ó‰ÌÓÁ̇˜ÌÓ ÌÂÓÔÂ‡·ÂθÌ˚ı ·ÓθÌ˚ı Í‡Í ÔÓÚÂ̈ˇθÌÓ ÓÔÂ‡·ÂθÌ˚ı. èÓ‚˚¯ÂÌ˲ ÂÁÂÍÚ‡·ÂθÌÓÒÚË ÏÓÊÂÚ ÒÔÓÒÓ·ÒÚ‚Ó‚‡Ú¸ Ôӂ‰ÂÌË ÌÂÓ‡‰˙˛‚‡ÌÚÌÓÈ ıËÏËÓÚÂ‡ÔËË. èË “ÔÓ·ÎÂÏÌÓÈ”
(χÎÓÈ) ΂ÓÈ ‰ÓΠ‚ÓÁÏÓÊÌÓ ‚˚ÔÓÎÌÂÌË ˝Ï·ÓÎËÁ‡ˆËË ËÎË ÔÂ‚flÁÍË Ô‡‚ÓÈ ‚ÂÚ‚Ë ‚ÓÓÚÌÓÈ ‚ÂÌ˚, ÒÔÓÒÓ·ÒÚ‚Û˛˘ÂÈ ÍÓÏÔÂÌÒ‡ÚÓÌÓÈ „ËÔÂÚÓÙËË Î‚ÓÈ ‰ÓÎË. ë ˆÂθ˛ ÔÓÙË·ÍÚËÍË ‰‡Î¸ÌÂÈ¯Â„Ó ÏÂÚ‡ÒÚ‡ÁËÓ‚‡ÌËfl ÔÓ͇Á‡ÌÓ Ôӂ‰ÂÌËÂ
‡‰˙˛‚‡ÌÚÌÓÈ ÚÂ‡ÔËË ÔÓÒΠÂÁÂ͈ËË Ô˜ÂÌË.
èÂÒÔÂÍÚË‚Ì˚Ï Ì‡Ô‡‚ÎÂÌËÂÏ ÏÓÊÌÓ Ò˜ËÚ‡Ú¸
ËÒÔÓθÁÓ‚‡ÌË „ËÓ̇θÌÓÈ ‚ÌÛÚˇÚÂˇθÌÓÈ ıËÏËÓÚÂ‡ÔËË, ÓÒÓ·ÂÌÌÓ ‚ ÒÓ˜ÂÚ‡ÌËË Ò ÂÁÂ͈ËÂÈ Ô˜ÂÌË, ÎË·Ó Ò ÎÓ͇θÌ˚Ï ‡ÁÛ¯ÂÌËÂÏ ÏÂ-
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
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2004
Ô˜Â̸
ÇéêéÅúÖÇ Ë ‰.
Ú‡ÒÚ‡ÁÓ‚. ïËÏËÓ˝Ï·ÓÎËÁ‡ˆËfl ‚ÂÚ‚ÂÈ Ô˜ÂÌÓ˜ÌÓÈ
‡ÚÂËË fl‚ÎflÂÚÒfl “ÏÂÚÓ‰ÓÏ ÓÚ˜‡flÌËfl” Ë ÏÓÊÂÚ
‚˚ÔÓÎÌflÚ¸Òfl ÔË Ì½ÙÙÂÍÚË‚ÌÓÒÚË Ì‡Á‚‡ÌÌ˚ı
‚˚¯Â ÏÂÓÔËflÚËÈ. ãÓ͇θÌÛ˛ ‰ÂÒÚÛÍˆË˛
(êóÄ, ÍËÓ‰ÂÒÚÛ͈Ëfl Ë ‰.) ˆÂÎÂÒÓÓ·‡ÁÌÓ ÔËÏÂÌflÚ¸ Í‡Í ‰ÓÔÓÎÌÂÌËÂ Í ÂÁÂ͈ËË Ô˜ÂÌË ÔË
ÏÌÓÊÂÒÚ‚ÂÌÌ˚ı, ÓÒÓ·ÂÌÌÓ ·ËÎÓ·‡Ì˚ı, ÏÂÚ‡ÒÚ‡Á‡ı ËÎË Í‡Í Ò‡ÏÓÒÚÓflÚÂθÌ˚È ÏÂÚÓ‰ ÔË Ó‰ÌÓÁ̇˜ÌÓ ÌÂÂÁÂÍÚ‡·ÂθÌ˚ı ÏÂÚ‡ÒÚ‡Á‡ı (ÒÏ. ËÒÛÌÓÍ).
á‡Íβ˜ÂÌËÂ
åÌÓ„ÓÓ·‡ÁËÂ Ë ÌÂÒڇ̉‡ÚÌÓÒÚ¸ ÍÎËÌ˘ÂÒÍËı
ÔÓfl‚ÎÂÌËÈ ÔÓ‡ÊÂÌËfl Ô˜ÂÌË ÍÓÎÓÂÍڇθÌ˚ÏË
ÏÂÚ‡ÒÚ‡Á‡ÏË ÌÂ‰ÍÓ Ú·ÛÂÚ Ë̉˂ˉۇθÌÓ„Ó
ÔÓ‰ıÓ‰‡ Í ‚˚·ÓÛ Ú‡ÍÚËÍË Î˜ÂÌËfl Ë ÔËÏÂÌÂÌËfl
ÍÓÏ·Ë̇ˆËË ‡Á΢Ì˚ı ÏÂÚÓ‰Ó‚ (ÂÁÂ͈Ëfl, ÎÓ͇θ̇fl ‰ÂÒÚÛ͈Ëfl ÛÁÎÓ‚, ‡Á΢Ì˚ ÂÊËÏ˚
ıËÏËÓÚÂ‡ÔËË Ë ‰.). ç‡ÍÓÔÎÂÌÌ˚È ÓÔ˚Ú Á‡Û·ÂÊÌ˚ı ÍÓÎ΄ Ë Ì‡¯ ̇˜‡Î¸Ì˚È ÍÎËÌ˘ÂÒÍËÈ
ÓÔ˚Ú ÔÓ͇Á˚‚‡˛Ú, ˜ÚÓ ÍÓÏ·ËÌËÓ‚‡ÌÌ˚È ÔÓ‰ıÓ‰
Í Î˜ÂÌ˲ ˝ÚÓÈ „ÛÔÔ˚ ·ÓθÌ˚ı ÏÓÊÂÚ ËÒÔÓθÁÓ‚‡Ú¸Òfl ‰ÓÒÚ‡ÚÓ˜ÌÓ ·ÂÁÓÔ‡ÒÌÓ Ë ÒÓÔÓ‚Óʉ‡Ú¸Òfl
ÌËÁÍÓÈ ÎÂڇθÌÓÒÚ¸˛ Ë ÔËÂÏÎÂÏ˚Ï ÛÓ‚ÌÂÏ ÓÒÎÓÊÌÂÌËÈ. ÑÎfl ÓÍÓ̘‡ÚÂθÌÓ„Ó ¯ÂÌËfl Ú‡ÍÚ˘ÂÒÍËı ‚ÓÔÓÒÓ‚ Ë ÒÓÁ‰‡ÌËfl ‡Î„ÓËÚÏÓ‚ ΘÂÌËfl
Ú‡ÍËı Ô‡ˆËÂÌÚÓ‚ Ú·ÛÂÚÒfl Ôӂ‰ÂÌË ‰‡Î¸ÌÂȯËı ÔÓÚÓÍÓθÌ˚ı ÏÛθÚˈÂÌÚÓ‚˚ı ËÒÒΉӂ‡ÌËÈ Ò ÓˆÂÌÍÓÈ ÓÚ‰‡ÎÂÌÌ˚ı ÂÁÛθڇÚÓ‚.
ëÔËÒÓÍ ÎËÚÂ‡ÚÛ˚
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