Эффективность водоструйного диссектора при резекции печени

ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà, 2004, ÚÓÏ 9, ‹ 1, Ò. 49–59
èÖóÖç¸
ùÙÙÂÍÚË‚ÌÓÒÚ¸ ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡
ÔË ÂÁÂ͈ËË Ô˜ÂÌË
é. É. ëÍËÔÂÌÍÓ,
ç. ç. Ň„ÏÂÚ,
É. î. òÂÂÏÂڸ‚‡,
á. ë. ᇂÂÌflÌ,
É. Ä. ò‡Ú‚ÂflÌ,
à. ã. ÜˉÍÓ‚
êÓÒÒËÈÒÍËÈ Ì‡Û˜Ì˚È ˆÂÌÚ
ıËÛ„ËË (‰Ë. – ‡Í‡‰. êÄåç
Å.Ä. äÓÌÒÚ‡ÌÚËÌÓ‚) êÄåç
èË ÏÌÓ„Ëı Á‡·Ó΂‡ÌËflı Ô˜ÂÌË Ë ÊÂΘÌ˚ı ÔÛÚÂÈ ÂÁÂ͈Ëfl Ô˜ÂÌË ÓÒÚ‡ÂÚÒfl ÓÔÂ‡ˆËÂÈ ‚˚·Ó‡. çÂÒÏÓÚfl ̇ ̇ÍÓÔÎÂÌÌ˚È ‚ ‡Á΢Ì˚ı ωˈËÌÒÍËı Û˜ÂʉÂÌËflı
ÓÔ˚Ú ‚˚ÔÓÎÌÂÌËfl ÔÓ‰Ó·Ì˚ı ÓÔÂ‡ˆËÈ Ë Òڇ̉‡ÚËÁ‡ˆË˛ ÚÂıÌËÍË ÂÁÂ͈ËË, ÔÓ͇Á‡ÚÂÎË ÎÂڇθÌÓÒÚË, ‡ Ú‡ÍÊ ˜‡ÒÚÓÚ˚ ËÌÚ‡- Ë ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÓÒÎÓÊÂÌÂÌËÈ ÓÒÚ‡˛ÚÒfl ‰Ó‚ÓθÌÓ ‚˚ÒÓÍËÏË. àÒÔÓθÁÓ‚‡ÌË ÒÓ‚ÂÏÂÌÌÓ„Ó Ó·ÓÛ‰Ó‚‡ÌËfl ÔË ÂÁÂ͈ËË
Ô˜ÂÌË ÒÔÓÒÓ·ÒÚ‚ÛÂÚ ÛÎÛ˜¯ÂÌ˲ ÂÁÛθڇÚÓ‚ ΘÂÌËfl.
è‰ÒÚ‡‚ÎÂÌ Ò‡‚ÌËÚÂθÌ˚È ‡Ì‡ÎËÁ ÂÁÛθڇÚÓ‚ ‚Ó‰ÓÒÚÛÈÌÓÈ ‰ËÒÒÂ͈ËË Ë ÏÂÚÓ‰ËÍË ‡Á‰‡‚ÎË‚‡ÌËfl Ô‡ÂÌıËÏ˚ ÔË ÂÁÂ͈ËË Ô˜ÂÌË ‚ ˝ÍÒÔÂËÏÂÌÚ ̇ ÏËÌË-Ò‚Ë̸flı
Ë ‚ ÍÎËÌ˘ÂÒÍÓÈ Ô‡ÍÚËÍÂ. èÓ͇Á‡Ì‡ ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ Ë ·ÂÁÓÔ‡ÒÌÓÒÚ¸ ‚Ó‰ÓÒÚÛÈÌÓ„Ó
‰ËÒÒÂÍÚÓ‡ ÔË ˝ÚÓÈ ÓÔÂ‡ˆËË. ä‡ÚÍÓ ÓÒ‚Â˘ÂÌ˚ ÓÒÌÓ‚Ì˚ ÏÂÚÓ‰˚ ‰ËÒÒÂ͈ËË Ô˜ÂÌË, ÔËÏÂÌflÂÏ˚ ‚ ÒÓ‚ÂÏÂÌÌÓÈ ıËÛ„˘ÂÒÍÓÈ Ô‡ÍÚËÍÂ.
Effectiveness of the Water-jet Dissector
in the Liver Resection
O. G. Skipenko,
N. N. Bagmet,
G. F. Sheremetyeva,
Z. S. Zavenjan,
G. A. Shatverjan,
I. L. Zhidkov
Russian Scientific Centre
of Surgery (Director – Acad.
RAMSci B.A. Konstantinov)
The liver resection in many cases of liver and hepatic duct diseases remains as a method of
choice. Despite cumulative experience in different medical centers intra- and postoperative
morbidity and mortality rates still seem to be too high. Application of modern technologies
promotes to improve results.
In the article clinical and experimental experience of liver water-jet dissection and standard
parenchyma disclasion is compared and analyzed. Effectiveness and safety of the water-jet
dissector in the liver resection is stated. A brief revue of different modern methods of the liver
dissection in presented.
êÂÁÂ͈Ëfl Ô˜ÂÌË ÓÒÚ‡ÂÚÒfl ÓÔÂ‡ˆËÂÈ ‚˚·Ó‡
ÔË ÏÌÓ„Ëı Á‡·Ó΂‡ÌËflı Ô˜ÂÌË Ë ÊÂΘÌ˚ı ÔÛÚÂÈ. çÂÒÏÓÚfl ̇ ̇ÍÓÔÎÂÌÌ˚È ‚ ‡Á΢Ì˚ı ωˈËÌÒÍËı Û˜ÂʉÂÌËflı ÓÔ˚Ú ‚˚ÔÓÎÌÂÌËfl ÔÓ‰Ó·Ì˚ı ÓÔÂ‡ˆËÈ Ë Òڇ̉‡ÚËÁ‡ˆË˛ ÚÂıÌËÍË ÂÁÂ͈ËË, ÔÂËÓÔÂ‡ˆËÓÌ̇fl ÎÂڇθÌÓÒÚ¸ ÓÒÚ‡ÂÚÒfl
‰ÓÒÚ‡ÚÓ˜ÌÓ ‚˚ÒÓÍÓÈ, ‰ÓÒÚË„‡fl 4–20% [16, 27,56],
˜ÚÓ Á‡˜‡ÒÚÛ˛ Ó·ÛÒÎÓ‚ÎÂÌÓ Á̇˜ËÚÂθÌÓÈ ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÓÈ ÍÓ‚ÓÔÓÚÂÂÈ Ë ‡Á‚ËÚËÂÏ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÓÒÎÓÊÌÂÌËÈ. ÇÚÓ˘Ì˚ ÍÓ‚ÓÚ˜ÂÌËfl ËÁ ÍÛθÚË Ô˜ÂÌË ‚ÒÚ˜‡˛ÚÒfl Ò ˜‡ÒÚÓÚÓÈ
ÓÚ 2 ‰Ó 18% [8, 40], ·ËΡÌ˚ ÓÒÎÓÊÌÂÌËfl ÔÓÒÎÂ
ÂÁÂ͈ËË Ì‡·Î˛‰‡˛ÚÒfl Û 3.5–9.8% ·ÓθÌ˚ı [31,
35]. éÒÓ·ÂÌÌÓÒÚË ÒÚÓÂÌËfl Ô˜ÂÌË (ÔÎÓı‡fl ÒÓÍ‡ÚËÚÂθ̇fl ÒÔÓÒÓ·ÌÓÒÚ¸ Ô‡ÂÌıËÏ˚) Ë ÔÂʉ ‚ÒÂ„Ó ÓÒÓ·ÂÌÌÓÒÚË Â ÒÓÒÛ‰ËÒÚÓÈ ‡Ì‡ÚÓÏËË (‡Á‚ËÚ˚È “ÒÍÂÎÂÚ” ËÁ ÍÛÔÌ˚ı ÒÓÒÛ‰Ó‚, ÓÚÒÛÚÒÚ‚Ë Í·ԇÌÓ‚ ‚ ‚Â̇ı Ó„‡Ì‡, ÁËflÌË ÔÓÒ‚ÂÚ‡ ÒÓÒÛ‰Ó‚
ÔË ÔÂÂÒ˜ÂÌËË) Ô‰˙fl‚Îfl˛Ú Í ÏÂÚÓ‰ËÍ‡Ï ‰ËÒÒÂ͈ËË Ë Í Ó·ÓÛ‰Ó‚‡Ì˲, ÔËÏÂÌflÂÏÓÏÛ ‰Îfl
˝ÚÓÈ ˆÂÎË, ÓÒÓ·˚ Ú·ӂ‡ÌËfl. Ä̇ÚÓÏ˘ÂÒÍÓÂ
‡ÒÒ˜ÂÌË (‰ËÒÒÂ͈Ëfl) Ô‡ÂÌıËÏ˚ Ô˜ÂÌË, ‚˚Á˚‚‡˛˘Â ÏËÌËχθÌÛ˛ Ú‡‚χÚËÁ‡ˆË˛ Ú͇ÌË, fl‚ÎflÂÚÒfl Ó‰ÌËÏ ËÁ ‚‡ÊÌ˚ı Ù‡ÍÚÓÓ‚, Ô‰ÛÔÂʉ‡˛˘Ëı ËÌÚ‡- Ë ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ ÓÒÎÓÊÌÂÌËfl
[6, 39].
ëÓ‚ÂÏÂÌÌ˚ ÚÂıÌÓÎÓ„ËË ‰ËÒÒÂ͈ËË Ô‰ÔÓ·„‡˛Ú ÔËÏÂÌÂÌË ÏÂÚÓ‰ËÍ, ÓÒÌÓ‚‡ÌÌ˚ı ̇ ‡Á΢Ì˚ı ÙËÁ˘ÂÒÍËı ÔË̈ËÔ‡ı, ̇˜Ë̇fl ÓÚ ˜ËÒÚÓ
ÏÂı‡Ì˘ÂÒÍÓ„Ó ‡Á‰ÂÎÂÌËfl Ú͇ÌÂÈ Ë Á‡Í‡Ì˜Ë‚‡fl
‚ÓÁ‰ÂÈÒÚ‚ËÂÏ ÛθÚ‡Á‚Û͇ Ë Î‡ÁÂÌÓ„Ó ÎÛ˜‡.
çÓ‚˚Ï Ì‡Ô‡‚ÎÂÌËÂÏ ‚ ˝ÚÓÈ Ó·Î‡ÒÚË ÒÚ‡ÎÓ ËÒÔÓθÁÓ‚‡ÌË ÒËÎ˚ ‚Ó‰ÌÓÈ ÒÚÛË. èÂ‚Ó̇˜‡Î¸ÌÓ
ÚÓÌ͇fl ‚Ӊ̇fl ÒÚÛfl, ‚˚·‡Ò˚‚‡Âχfl ÔÓ‰ ·Óθ¯ËÏ ‰‡‚ÎÂÌËÂÏ, ̇¯Î‡ ÔËÏÂÌÂÌË ‚ ÔÓÏ˚¯ÎÂÌÌÓÒÚË ‰Îfl ÂÁÍË ‡Á΢Ì˚ı χÚÂˇÎÓ‚ [30].
èË ÔÓ‰·Ó ÒÓÓÚ‚ÂÚÒÚ‚Û˛˘Â„Ó ‰‡‚ÎÂÌËfl Ë ‰Ë‡ÏÂÚ‡ ÒÓÔ· Ú‡ÍÓÈ ÔË·Ó ÏÓÊÌÓ ÔËÏÂÌflÚ¸ ‰Îfl
ÒÂÎÂÍÚË‚ÌÓ„Ó ‡ÒÒ˜ÂÌËfl ÒÚÛÍÚÛ, Ëϲ˘Ëı ‡Á΢ÌÛ˛ ÔÎÓÚÌÓÒÚ¸ (̇ÔËÏÂ, ‡Á‰ÂÎflÚ¸ ·ÓÎÂÂ
Ïfl„ÍÛ˛ Ô‡ÂÌıËÏÛ Ô˜ÂÌË, ÒÓı‡Ìflfl ·ÓΠÔÎÓÚÌ˚ ÒÓÒÛ‰˚ Ë ÊÂΘÌ˚ ÔÓÚÓÍË). Ç êÓÒÒËË ˝ÚÓÚ
‡ÔÔ‡‡Ú ÔÓÎÛ˜ËΠ̇Á‚‡ÌË “‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ” ËÎË “‚Ó‰Ì˚È Ò͇θÔÂθ”. ÇÔÂ‚˚Â Ó Â„Ó ÔËÏÂÌÂÌËË ÔË ÂÁÂ͈ËË Ô˜ÂÌË ÒÓÓ·˘ËÎË ‚ 1982 „.
D. Papachristou Ë R. Barters [45]. Ç ÍÎËÌË͇ı Ö‚ÓÔ˚, ëòÄ, ä‡Ì‡‰˚ Ë üÔÓÌËË ÔË·Ó ÒÚ‡ÎË ËÒÔÓθÁÓ‚‡Ú¸ ÚÓθÍÓ ‚ ÔÓÒΉÌË „Ó‰˚, Ô˘ÂÏ Ì‡Ë·Óθ¯ËÈ ÓÔ˚Ú Â„Ó ÔËÏÂÌÂÌËfl ÔË ÓÔÂ‡ˆËflı ̇
Ô˜ÂÌË Ì‡ÍÓÔÎÂÌ ÌÂψÍËÏË ıËÛ„‡ÏË [10, 12, 53].
ñÂθ˛ ËÒÒΉӂ‡ÌËfl fl‚Ë·Ҹ ÓˆÂÌ͇ ˝ÙÙÂÍÚË‚ÌÓÒÚË ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ ÔË ‚˚ÔÓÎ49
4
èÖóÖç¸
ùîîÖäíàÇçéëíú ÇéÑéëíêìâçéÉé ÑàëëÖäíéêÄ
(‡)
(·)
êËÒ. 1. é·˘ËÈ ‚ˉ ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ “Helix
Hydro-Jet” (“Andreas Pein Medizintechnik” ÒÓ‚ÏÂÒÚÌÓ c
ERBE, ÉÂχÌËfl) (‡) Ë ‡ÔÔÎË͇ÚÓÓ‚ (·).
HJ-ÁÓ̉
ÇӉ̇fl Ò‰‡
ëÓÒÛ‰
ÇӉ̇fl
Ò‰‡
êËÒ. 2. ÑÂÈÒÚ‚Ë ‚Ó‰ÌÓÈ ÒÚÛË Ì‡ Ú̸͇ Ô˜ÂÌË
ÌÂÌËË ÂÁÂ͈ËË Ô˜ÂÌË ‚ ˝ÍÒÔÂËÏÂÌÚÂ Ë ‚ ÍÎËÌ˘ÂÒÍÓÈ Ô‡ÍÚËÍÂ.
å‡ÚÂË‡Î Ë ÏÂÚÓ‰˚
Ç ‰‡ÌÌÓÈ ‡·ÓÚ ÔË ÂÁÂ͈ËË Ô˜ÂÌË ·˚Î ËÒÔÓθÁÓ‚‡Ì ‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ “Helix HydroJet” (“Andreas Pein Medizintechnik” ÒÓ‚ÏÂÒÚÌÓ c ERBE, ÉÂχÌËfl) (ËÒ. 1‡). êÂÊÛ˘‡fl Ò‰‡ (ÒÚÂËθ50
Ì˚È ÙËÁËÓÎӄ˘ÂÒÍËÈ ‡ÒÚ‚Ó, ÛÔ‡ÍÓ‚‡ÌÌ˚È ‚
Ó‰ÌÓ‡ÁÓ‚˚È Ô·ÒÚËÍÓ‚˚È ·‡ÎÎÓÌ Ò ÔÓ¯ÌÂÏ
‚ÌÛÚË) ÔÓ‰‡ÂÚÒfl ÔÓ‰ ‰‡‚ÎÂÌËÂÏ (‰Ó 150 ·‡ =
= 15 åè‡) ˜ÂÂÁ ÒÓÔÎÓ ‰Ë‡ÏÂÚÓÏ 120 ÏÍÏ, ‚ÏÓÌÚËÓ‚‡ÌÌÓ ‚ ‡·Ó˜Û˛ ÛÍÓflÚÍÛ (‡ÔÔÎË͇ÚÓ)
(ËÒ. 1·). äÓÌÒÚÛ͈Ëfl ÔË·Ó‡ ÔÓÁ‚ÓÎflÂÚ Ô·‚ÌÓ
„ÛÎËÓ‚‡Ú¸ ‰‡‚ÎÂÌË ÌÓÊÌÓÈ Ô‰‡Î¸˛. íÓ̘‡È¯‡fl ·ÏË̇̇fl ‚Ӊ̇fl ÒÚÛfl ÒÓ ÒÔË‡Î¸ÌÓ Á‡ÍÛ˜ÂÌÌÓÈ ÔÓ‚ÂıÌÓÒÚ¸˛ ÔË ‚ÓÁ‰ÂÈÒÚ‚ËË Ì‡ Ú̸͇
Ô˜ÂÌË Ó·‡ÁÛÂÚ ÔÓÒÚ‡ÌÒÚ‚Ó ‡Ò¯ËÂÌËfl, ÔÓÒÚÛÔ‡˛˘‡fl ‚ ˝ÚÓ ÔÓÒÚ‡ÌÒÚ‚Ó Êˉ͇fl Ò‰‡ ‡Á‰‚Ë„‡ÂÚ Ú̸͇, “‚˚Ï˚‚‡fl” „ÂÔ‡ÚÓˆËÚ˚, Ú.Â. ‡ÒÒÂ͇ÂÚ Â (ËÒ. 2). èË ˝ÚÓÏ ÚÛ·˜‡Ú˚ ÒÚÛÍÚÛ˚
(ÒÓÒÛ‰˚, ÊÂΘÌ˚ ÔÓÚÓÍË) ÓÒÚ‡˛ÚÒfl ÌÂÔÓ‚ÂʉÂÌÌ˚ÏË, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ Ëı ÔˆËÁËÓÌÌÓ ÎË„ËÓ‚‡Ú¸ ËÎË ÍÎËÔËÓ‚‡Ú¸ Ë ÔÂÂÒÂ͇ڸ. Ç ÔË·Ó
‚ÒÚÓÂ̇ ÒËÒÚÂχ ÓÚÒÓÒ‡, ÍÓÚÓ‡fl Ô‡‡ÎÎÂθÌÓ
Û‰‡ÎflÂÚ ËÒÔÓθÁÓ‚‡ÌÌ˚È ‡·Ó˜ËÈ ‡ÒÚ‚Ó, ÍÓ‚¸
Ë Ú͇Ì‚˚È ‰ÂÚËÚ ËÁ ÓÔÂ‡ˆËÓÌÌÓ„Ó ÔÓÎfl. í·ÛÂÏ˚ ÛÓ‚ÌË Ï‡ÍÒËχθÌÓ„Ó ‰‡‚ÎÂÌËfl Ë Ô‡‡ÏÂÚ˚ ‡·ÓÚ˚ ÓÚÒÓÒ‡ ÛÒڇ̇‚ÎË‚‡˛ÚÒfl Á‡‡ÌÂÂ.
èË·Ó Ó·ÓÛ‰Ó‚‡Ì ‰ËÒÔÎÂÂÏ Ò ‚ÓÁÏÓÊÌÓÒÚ¸˛
‚˚·Ó‡ flÁ˚͇ ÏÂÌ˛ (‡Ì„ÎËÈÒÍËÈ ËÎË ÛÒÒÍËÈ), ̇
ÍÓÚÓÓÏ ÓÚ‡Ê‡˛ÚÒfl ‚Ò ̇ÒÚÓÈÍË. ê‡ÒıÓ‰Ì˚Â
χÚÂˇÎ˚ (‡ÔÔÎË͇ÚÓ˚, ·‡ÎÎÓÌ˚ Ò ÂÊÛ˘ÂÈ
Ò‰ÓÈ Ë Ú.‰.) fl‚Îfl˛ÚÒfl Ó‰ÌÓ‡ÁÓ‚˚ÏË. ëÓÁ‰‡Ì˚
‡ÔÔÎË͇ÚÓ˚ ‰Îfl ‚˚ÔÓÎÌÂÌËfl ·ԇÓÒÍÓÔ˘ÂÒÍËı ÓÔÂ‡ˆËÈ. èÓ‰„ÓÚӂ͇ ÔË·Ó‡ Í ‡·ÓÚ Á‡ÌËχÂÚ Ì ·ÓΠ5 ÏËÌ. éÒÌÓ‚Ì˚ ÚÂıÌ˘ÂÒÍË ı‡‡ÍÚÂËÒÚËÍË ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ Ô˂‰ÂÌ˚ ‚ Ú‡·Îˈ 1.
Ç ıӉ ÓÔÂ‡ˆËË ÔÂ‰ ̇˜‡ÎÓÏ ‰ËÒÒÂ͈ËË ˝ÎÂÍÚÓÌÓÊÓÏ Ì‡‰ÒÂ͇˛Ú ͇ÔÒÛÎÛ Ô˜ÂÌË. á‡ÚÂÏ, ÒÓ‚Â¯‡fl ÍÓη‡ÚÂθÌ˚ ‰‚ËÊÂÌËfl ‡·Ó˜ÂÈ ÛÍÓflÚÍË (‡ÔÔÎË͇ÚÓ‡) ‚ ÔÎÓÒÍÓÒÚË, ÔÂÔẨËÍÛÎflÌÓÈ
ÔÓ‚ÂıÌÓÒÚË Ô˜ÂÌË, ÔÓ Ô‰‚‡ËÚÂÎÌÓ Ì‡Ï˜ÂÌÌÓÈ ˝ÎÂÍÚÓÌÓÊÓÏ ÎËÌËË ÂÁÂ͈ËË ÔÓ¯‡„Ó‚Ó
ÒÍÂÎÂÚËÛ˛Ú ÚÛ·˜‡Ú˚ ÒÚÛÍÚÛ˚ Ô˜ÂÌË, ÍÓÚÓ˚ Á‡ÚÂÏ ÍÎËÔËÛ˛Ú Ë ÔÂÂÒÂ͇˛Ú (ËÒ. 3). ëÓÒÛ‰˚ ‰Ë‡ÏÂÚÓÏ ÏÂÌ 1 ÏÏ ÏÓÊÌÓ ÍÓ‡„ÛÎËÓ‚‡Ú¸.
ÑÎfl ‡ÎËÁ‡ˆËË ÔÓÒÚ‡‚ÎÂÌÌÓÈ ˆÂÎË ËÒÒΉӂ‡ÌËfl ·˚Î ‚˚ÔÓÎÌÂÌ ˝ÍÒÔÂËÏÂÌڇθÌ˚È ‡Á‰ÂÎ
‡·ÓÚ˚, Ô‰¯ÂÒÚ‚Ó‚‡‚¯ËÈ ‚̉ÂÌ˲ ÌÓ‚ÓÈ
ÚÂıÌÓÎÓ„ËË ‚ ÍÎËÌ˘ÂÒÍÛ˛ Ô‡ÍÚËÍÛ.
ùÍÒÔÂËÏÂÌڇθÌÓ ËÒÒΉӂ‡ÌËÂ
(χÚÂË‡Î Ë ÏÂÚÓ‰˚)
Ç Í‡˜ÂÒÚ‚Â ˝ÍÒÔÂËÏÂÌڇθÌÓÈ ÏÓ‰ÂÎË ·˚ÎË
‚˚·‡Ì˚ 3-ÏÂÒfl˜Ì˚ ÏËÌË-Ò‚ËÌ¸Ë Ï‡ÒÒÓÈ 25–30 Í„.
ÇÒÂÏ 11 ÊË‚ÓÚÌ˚Ï (9 Ò‡ÏÓÍ Ë 2 ҇ψ‡) ÔÓ‰ ÍÓÏ·ËÌËÓ‚‡ÌÌ˚Ï ˝Ì‰ÓÚ‡ı‡θÌ˚Ï Ì‡ÍÓÁÓÏ ‚˚ÔÓÎÌÂ̇ ÂÁÂ͈Ëfl ΂ÓÈ Ï‰ˇθÌÓÈ ‰ÓÎË Ô˜ÂÌË. Ç
ÓÒÌÓ‚ÌÓÈ „ÛÔÔ ÊË‚ÓÚÌ˚ı (8 Ò‚ËÌÂÈ) ‰ËÒÒÂÍˆË˛
Ô˜ÂÌË ÔÓËÁ‚Ó‰ËÎË Ò ËÒÔÓθÁÓ‚‡ÌËÂÏ ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡, ‚ ÍÓÌÚÓθÌÓÈ (3 Ò‚Ë̸Ë) – ÔÛÚÂÏ ‡Á‰‡‚ÎË‚‡ÌËfl Ô‡ÂÌıËÏ˚ Á‡ÊËÏÓÏ.
ÑÎfl ÓÔ‰ÂÎÂÌËfl ı‡‡ÍÚÂ‡ Ë „ÎÛ·ËÌ˚ ÔÓ‚ÂʉÂÌËfl Ô‡ÂÌıËÏ˚ Ô˜ÂÌË ÔË ‚ÓÁ‰ÂÈÒÚ‚ËË
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
èÖóÖç¸
ëäàèÖçäé Ë ‰.
(·)
(‡)
êËÒ. 3. ÑËÒÒÂ͈Ëfl Ô‡ÂÌıËÏ˚ Ô˜ÂÌË Ò ËÒÔÓθÁÓ‚‡ÌËÂÏ ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ (‡) Ë ÍÎËÔËÓ‚‡ÌË ‚ÌÛÚËÔ˜ÂÌÓ˜Ì˚ı ÒÚÛÍÚÛ (·).
‚Ó‰ÌÓÈ ÒÚÛË ËÎË ÔË ÏÂı‡Ì˘ÂÒÍÓÏ ‡Á‰‡‚ÎË‚‡ÌËË Ô‡ÂÌıËÏ˚ Ô˜ÂÌË ÔÓ‚Ó‰ËÎË „ËÒÚÓÎӄ˘ÂÒÍÓ ËÒÒΉӂ‡ÌË ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË ÂÁˆËÓ‚‡ÌÌÓ„Ó Ò„ÏÂÌÚ‡ Ô˜ÂÌË. éˆÂÌÍÛ ‰Ë̇ÏËÍË ÙÓÏËÓ‚‡ÌËfl Û·ˆ‡ ÓÒÛ˘ÂÒÚ‚ÎflÎË ÔÛÚÂÏ Á‡·Ó‡ Ë
ËÁÛ˜ÂÌËfl „ËÒÚÓÎӄ˘ÂÒÍÓ„Ó Ï‡ÚÂˇ· ̇ 7- Ë
14- ÒÛÚÍË ÔÓÒΠÓÔÂ‡ˆËË. ë ˝ÚÓÈ ˆÂθ˛ ÔËÏÂÌflÎË ‡Á΢Ì˚ ÏÂÚÓ‰ËÍË ÓÍ‡ÒÍË ÔÂÔ‡‡Ú‡:
„ÂχÚÓÍÒËÎËÌÓÏ Ë ˝ÓÁËÌÓÏ, ÔÓ ‚‡Ì ÉËÁÓÌÛ Ë
òàä-Â‡ÍˆË˛.
äÎËÌ˘ÂÒÍÓ ËÒÒΉӂ‡ÌËÂ
(χÚÂË‡Î Ë ÏÂÚÓ‰˚)
Ç ÓÚ‰ÂÎÂÌËË ıËÛ„ËË Ô˜ÂÌË, ÊÂΘÌ˚ı ÔÛÚÂÈ
Ë ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ êçñï êÄåç ‚ ÔÂËÓ‰
Ò Ë˛Îfl 1990 „. ÔÓ Ï‡Ú 2003 „. ‚˚ÔÓÎÌÂÌÓ 70 ÂÁÂ͈ËÈ Ô˜ÂÌË ÔÓ ÔÓ‚Ó‰Û ‰Ó·Ó͇˜ÂÒÚ‚ÂÌÌ˚ı (35)
Ë ÁÎÓ͇˜ÂÒÚ‚ÂÌÌ˚ı (35) Á‡·Ó΂‡ÌËÈ Ô˜ÂÌË. àÁ
ÌËı ‚ ËÒÒΉӂ‡ÌË ·˚ÎÓ ‚Íβ˜ÂÌÓ 20 Ô‡ˆËÂÌÚÓ‚
(ÓÒÌӂ̇fl „ÛÔÔ‡), ÍÓÚÓ˚Ï ÂÁÂÍˆË˛ ÔÓËÁ‚Ó‰ËÎË Ò ÔËÏÂÌÂÌËÂÏ ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡.
êÂÚÓÒÔÂÍÚË‚ÌÓ ·˚· ÒÙÓÏËÓ‚‡Ì‡ ÍÓÌÚÓθ̇fl „ÛÔÔ‡ ËÁ 20 Ô‡ˆËÂÌÚÓ‚, Û ÍÓÚÓ˚ı ‰ËÒÒÂÍˆË˛
Ô‡ÂÌıËÏ˚ Ô˜ÂÌË ÓÒÛ˘ÂÒÚ‚ÎflÎË ÏÂÚÓ‰ÓÏ ‡Á‰‡‚ÎË‚‡ÌËfl ËÌÒÚÛÏÂÌÚÓÏ.
Ç Ó·˘ÂÈ „ÛÔÔ ԇˆËÂÌÚÓ‚ ·˚ÎÓ ‚˚ÔÓÎÌÂÌÓ
20 Ô‡‚ÓÒÚÓÓÌÌËı „ÂÏË„ÂÔ‡Ú˝ÍÚÓÏËÈ (ËÁ ÌËı
5 ‡Ò¯ËÂÌÌ˚ı), 20 ΂ÓÒÚÓÓÌÌËı „ÂÏË„ÂÔ‡Ú˝ÍÚÓÏËÈ (ËÁ ÌËı 1 ‡Ò¯ËÂÌ̇fl, 14 ·ÚÂ‡Î¸Ì˚ı ÂÁÂ͈ËÈ) (Ú‡·Î. 2).
ë‰ÌËÈ ‚ÓÁ‡ÒÚ Ô‡ˆËÂÌÚÓ‚, ‚Íβ˜ÂÌÌ˚ı ‚ ËÒÒΉӂ‡ÌËÂ, ÒÓÒÚ‡‚ËÎ 47.5 ± 14.9 „Ó‰‡ (ÓÚ 15 ‰Ó
73 ÎÂÚ). åÛʘËÌ ·˚ÎÓ 13, ÊÂÌ˘ËÌ – 27. ëÓÓÚÌÓ¯ÂÌË ÏÛʘËÌ˚/ÊÂÌ˘ËÌ˚ ‚ ÓÒÌÓ‚ÌÓÈ „ÛÔÔ ÒÓÒÚ‡‚ËÎÓ 1:1, ‚ ÍÓÌÚÓθÌÓÈ „ÛÔÔ ÔÂӷ·‰‡ÎË
ÊÂÌ˘ËÌ˚ (ÏÛʘËÌ˚/ÊÂÌ˘ËÌ˚ = 1 : 5.7). èÓ ÓÒڇθÌ˚Ï ÔÓ͇Á‡ÚÂÎflÏ (Ò‰ÌËÈ ‚ÓÁ‡ÒÚ, ‡ÒÔ‰ÂÎÂÌË ÔÓ ‚ÓÁ‡ÒÚÌ˚Ï „ÛÔÔ‡Ï, ÔÓ͇Á‡ÌËfl Í ÓÔÂ‡ˆËË) Ò‡‚ÌË‚‡ÂÏ˚ „ÛÔÔ˚ Ì ‡Á΢‡ÎËÒ¸.
퇷Îˈ‡ 1. éÒÌÓ‚Ì˚ ÚÂıÌ˘ÂÒÍË ı‡‡ÍÚÂËÒÚËÍË ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ (“Helix Hydro-Jet”, “Andreas
Pein Medizintechnik” ÒÓ‚ÏÂÒÚÌÓ c ERBE, ÉÂχÌËfl)
éÔËÒ‡ÌËÂ
è‡‡ÏÂÚ˚
35(ò) × 35(É) × 122(Ç)
ɇ·‡ËÚÌ˚ ‡ÁÏÂ˚, ÒÏ
å‡ÒÒ‡, Í„
75
ÑˇԇÁÓÌ ‰‡‚ÎÂÌËÈ, ·‡
1–150
ëËÒÚÂχ ÓÚÒÓÒ‡
ÇÒÚÓÂÌ̇fl, Ò ·ÂÒÒÚÛÔÂ̘‡Ú˚Ï „ÛÎËÓ‚‡ÌËÂÏ ‚ ‰Ë‡Ô‡ÁÓÌ ÓÚ 0 ‰Ó –800 Ï·‡
ùÎÂÍÚÓÔËÚ‡ÌËÂ
230Ç/50Ɉ, 16 Ä
ÄÔÔÎË͇ÚÓ˚
ëÚÂËθÌ˚ ӉÌÓ‡ÁÓ‚˚Â
ÑˇÏÂÚ ÒÓÔ·, ÏÍÏ
120
äÓÌÙË„Û‡ˆËfl Ë „ÂÓÏÂÚËfl ÒÚÛË äÓ„ÂÂÌÚ̇fl ˆËÎË̉˘ÂÒ͇fl ÒÚÛfl ÒÓ ÒÔË‡Î¸ÌÓ Á‡ÍÛ˜ÂÌÌÓÈ ÔÓ‚ÂıÌÓÒÚ¸˛,
‰ÎË̇ ÍÓ„ÂÂÌÚÌÓÒÚË ÓÚ 5 ‰Ó 30 ÒÏ (‚ Á‡‚ËÒËÏÓÒÚË ÓÚ ÛÓ‚Ìfl ‰‡‚ÎÂÌËfl)
êÂÊÛ˘‡fl Ò‰‡ (‡·Ó˜ËÈ ‡ÒÚ‚Ó) ëÚÂËθÌ˚È ÙËÁËÓÎӄ˘ÂÒÍËÈ ‡ÒÚ‚Ó ‚ ÒÚÂËθÌÓ ÛÔ‡ÍÓ‚‡ÌÌÓÏ ·‡ÎÎÓÌÂ
Ó·˙ÂÏÓÏ 500 ÏÎ.
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
51
4*
èÖóÖç¸
ùîîÖäíàÇçéëíú ÇéÑéëíêìâçéÉé ÑàëëÖäíéêÄ
퇷Îˈ‡ 2. é·˙ÂÏ ‚˚ÔÓÎÌÂÌÌ˚ı ÓÔÂ‡ÚË‚Ì˚ı ‚ϯ‡ÚÂθÒÚ‚
ÉÛÔÔ‡
é·˙ÂÏ ÓÔÂ‡ˆËË
ÓÒÌӂ̇fl
ÇÒ„Ó
ÍÓÌÚÓθ̇fl
‡·Ò.
%
‡·Ò.
%
‡·Ò.
%
‡Ò¯ËÂÌ̇fl Ô‡‚ÓÒÚÓÓÌÌflfl „ÂÏË„ÂÔ‡Ú˝ÍÚÓÏËfl
2
10
3
15
5
12.5
Ô‡‚ÓÒÚÓÓÌÌflfl „ÂÏË„ÂÔ‡Ú˝ÍÚÓÏËfl
8
40
7
35
15
37.5
‡Ò¯ËÂÌ̇fl ΂ÓÒÚÓÓÌÌflfl „ÂÏË„ÂÔ‡Ú˝ÍÚÓÏËfl
1
5
–
–
1
2.5
΂ÓÒÚÓÓÌÌflfl „ÂÏË„ÂÔ‡Ú˝ÍÚÓÏËfl
2
10
3
15
5
12.5
΂ÓÒÚÓÓÌÌflfl ͇‚‡Î¸Ì‡fl ÂÁÂ͈Ëfl
7
35
7
35
14
35
20
100
20
100
40
100
è‡‚ÓÒÚÓÓÌÌflfl ÂÁÂ͈Ëfl (n = 20)
ã‚ÓÒÚÓÓÌÌflfl ÂÁÂ͈Ëfl (n = 20)
àÚÓ„Ó (n = 40)
èÓ͇Á‡ÌËflÏË Í ‚˚ÔÓÎÌÂÌ˲ ÓÔÂ‡ˆËÈ ‚ 5
(12.5%) ̇·Î˛‰ÂÌËflı ÔÓÒÎÛÊËÎË ‰Ó·Ó͇˜ÂÒÚ‚ÂÌÌ˚Â, ‚ 26 (65%) – ÁÎÓ͇˜ÂÒÚ‚ÂÌÌ˚ Ә‡„Ó‚˚Â
Á‡·Ó΂‡ÌËfl Ô˜ÂÌË, ‚ 7 (17.5%) – Ô‡‡ÁËÚ‡Ì˚ Ë
‚ 2 (5%) – ÍËÒÚÓÁÌ˚ Á‡·Ó΂‡ÌËfl Ô˜ÂÌË. ë‰Ë
ÁÎÓ͇˜ÂÒÚ‚ÂÌÌ˚ı Á‡·Ó΂‡ÌËÈ 77% ÒÓÒÚ‡‚ËÎË
‚ÚÓ˘Ì˚ ÔÓ‡ÊÂÌËfl.
ÇÂ‰Û˘Â ÏÂÒÚÓ ‚ Ô‰ÓÔÂ‡ˆËÓÌÌÓÈ ‰Ë‡„ÌÓÒÚËÍ Á‡·Ó΂‡ÌËÈ Ô˜ÂÌË Á‡ÌËχÎË ìáà (100%
Ô‡ˆËÂÌÚÓ‚), ÍÓÏÔ¸˛ÚÂ̇fl ÚÓÏÓ„‡ÙËfl Ó„‡ÌÓ‚
·˛¯ÌÓÈ ÔÓÎÓÒÚË (90%) Ë Ï‡„ÌËÚÌÓ-ÂÁÓ̇ÌÒ̇fl
ÚÓÏÓ„‡ÙËfl (12%). èË ÔÓ‰ÓÁÂÌËË Ì‡ ÁÎÓ͇˜ÂÒÚ‚ÂÌÌ˚È ı‡‡ÍÚÂ ÔÓ‡ÊÂÌËfl Ô˜ÂÌË ÓÔ‰ÂÎflÎË
ÛÓ‚Â̸ ÓÌÍÓ-χÍÂÓ‚ (28/68%) – α-ÙÂÚÓÔÓÚÂË̇ Ë ‡ÍÓ‚Ó-˝Ï·ËÓ̇θÌÓ„Ó ‡ÌÚË„Â̇. ÑÎfl ÛÚÓ˜ÌÂÌËfl ‡ÒÔÓÒÚ‡ÌÂÌÌÓÒÚË ÔÓ‡ÊÂÌËfl Ë Â„Ó ÂÁÂÍÚ‡·ÂθÌÓÒÚË ‚˚ÔÓÎÌflÎË ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÓ ìáà
(57.5% Ô‡ˆËÂÌÚÓ‚).
èË Ó·‡·ÓÚÍ ÂÁÛθڇÚÓ‚ ËÒÔÓθÁÓ‚‡Ì ‡Ì‡ÎËÚ˘ÂÒÍËÈ Ô‡ÍÂÚ ÔÓ„‡ÏÏ˚ Excel ‰Îfl Windows
Ë ÔÓ„‡Ïχ Statistica for Windows 6.0.
êÂÁÛθڇÚ˚
ùÍÒÔÂËÏÂÌڇθÌÓ ËÒÒΉӂ‡ÌËÂ
ÇÒ 11 ÊË‚ÓÚÌ˚ı ÔÂÂÌÂÒÎË ÂÁÂÍˆË˛ Ô˜ÂÌË,
ÓÔÂ‡ˆËÓÌÌÓÈ ÎÂڇθÌÓÒÚË Ì ·˚ÎÓ. éÒÌÓ‚˚‚‡flÒ¸ ̇ ‰‡ÌÌ˚ı ÎËÚÂ‡ÚÛ˚ Ë ÒÛ·˙ÂÍÚË‚Ì˚ı Ó˘Û˘ÂÌËflı ıËÛ„‡, ÓÔÚËχθÌ˚Ï ‰‡‚ÎÂÌËÂÏ Ò˜ËÚ‡ÎË 50–60 ·a, ÔË ÍÓÚÓÓÏ ÓÒÚ‡‚‡ÎËÒ¸ ÌÂÔÓ‚ÂʉÂÌÌ˚ÏË ÒÓÒÛ‰˚ ‰Ë‡ÏÂÚÓÏ 0.8–1 ÏÏ. ê‡ÁÏÂ˚
ÂÁˆËÛÂÏÓÈ ‰ÓÎË Ô˜ÂÌË Ë ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ Ó·‡ÁÛ˛˘ÂÈÒfl ‚ ÂÁÛθڇÚ ÓÔÂ‡ˆËË ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË Ì ‡Á΢‡ÎËÒ¸ ‚ Ó·ÂËı „ÛÔÔ‡ı. ë‡‚ÌÂÌË ÔÓ‰ÓÎÊËÚÂθÌÓÒÚË ÓÔÂ‡ˆËË Ë ‚ÂÏÂÌË,
Á‡Ú‡˜Ë‚‡ÂÏÓ„Ó Ì‡ ÔÂÂÒ˜ÂÌË ԇÂÌıËÏ˚ Ô˜ÂÌË, Ì ‚˚fl‚ËÎÓ ‰ÓÒÚÓ‚ÂÌ˚ı ‡Á΢ËÈ ‚ Ó·ÂËı
„ÛÔÔ‡ı. é·˘‡fl ÍÓ‚ÓÔÓÚÂfl Ë ÍÓ‚ÓÔÓÚÂfl ̇
˝Ú‡Ô ÂÁÂ͈ËË ·˚ÎË ÏÂ̸¯Â ‚ ÓÒÌÓ‚ÌÓÈ „ÛÔÔÂ
(86 ± 52 Ë 76 ± 48 ÏÎ) ÔÓ Ò‡‚ÌÂÌ˲ Ò ÍÓÌÚÓθÌÓÈ
52
(153 ± 95 Ë 135 ± 85 ÏÎ), Ӊ̇ÍÓ ˝Ú‡ ‡ÁÌˈ‡ Ì fl‚Îfl·Ҹ ‰ÓÒÚÓ‚ÂÌÓÈ ( < 0.05). Ç ÓÒÌÓ‚ÌÓÈ „ÛÔÔÂ
‰Îfl ‰ÓÒÚËÊÂÌËfl ÓÍÓ̘‡ÚÂθÌÓ„Ó „ÂÏÓÒÚ‡Á‡ ÔÓÚ·ӂ‡ÎÓÒ¸ ÏÂ̸¯Â ‚ÂÏÂÌË (5 ± 2 ÏËÌ ÔÓÚË‚
12 ± 2 ÏËÌ,  = 0.01) Ë Ì‡ÎÓÊÂÌËfl ÏÂ̸¯Â„Ó ˜ËÒ·
ÎË„‡ÚÛ (1–2), ˜ÂÏ ‚ ÍÓÌÚÓθÌÓÈ (5–7;  = 0.004)
(Ú‡·Î. 3).
Ç ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌÓÏ ÔÂËӉ ÒÎÛ˜‡Â‚ ‚ÌÛÚË·˛¯ÌÓ„Ó ÍÓ‚ÓÚ˜ÂÌËfl Ë ÔËÁ̇ÍÓ‚ ̉ÓÒÚ‡ÚÓ˜ÌÓ„Ó „ÂÏÂÚËÁχ ÊÂΘÌ˚ı ÔÓÚÓÍÓ‚ Ì ·˚ÎÓ
ÓÚϘÂÌÓ ‚ Ó·ÂËı „ÛÔÔ‡ı. Ç ·ÎËʇȯÂÏ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌÓÏ ÔÂËӉ (˜ÂÂÁ 5 ˜ ÔÓÒΠÁ‡‚Â¯ÂÌËfl ÓÔÂ‡ˆËË) ÔÓ„Ë·ÎÓ Ó‰ÌÓ ÊË‚ÓÚÌÓ ËÁ ÓÒÌÓ‚ÌÓÈ „ÛÔÔ˚. èË ‚ÒÍ˚ÚËË ÔËÁ̇ÍÓ‚ ‚ÌÛÚË·˛¯ÌÓ„Ó ÍÓÓ‚ÓÚ˜ÂÌËfl Ë ÊÂΘÂËÒÚ˜ÂÌËfl ËÁ
ÍÛθÚË Ô˜ÂÌË, ‡ Ú‡ÍÊ ÔÓ‚ÂʉÂÌËfl Í˯˜ÌÓÈ
ÒÚÂÌÍË ËÎË ÒÚ‡Ì„ÛÎflˆËË Í˯ÍË Ì ‚˚fl‚ÎÂÌÓ. éÒڇθÌ˚ 10 ÊË‚ÓÚÌ˚ı ·˚ÎË ‚˚‚‰ÂÌ˚ ËÁ ˝ÍÒÔÂËÏÂÌÚ‡ ÔÓ Ô·ÌÛ Ì‡ 7-Â Ë 14- ÒÛÚÍË ÔÓÒΠÓÔÂ‡ˆËË.
ÉËÒÚÓÎӄ˘ÂÒÍÓ ËÒÒΉӂ‡ÌË ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË ÍÛθÚË Ô˜ÂÌË ÔÓ͇Á‡ÎÓ, ˜ÚÓ ÁÓ̇ ÔÓ‚ÂʉÂÌËfl Ô‡ÂÌıËÏ˚ ‚ ÍÓÌÚÓθÌÓÈ „ÛÔÔ ·˚· ‰ÓÒÚ‡ÚÓ˜ÌÓ ÛÁÍÓÈ (3 ÏÏ), ËÏ· Ó‚Ì˚È Í‡È Ë
˜ÂÚÍÛ˛ Ó‚ÌÛ˛ „‡ÌˈÛ, ÓÚ‰ÂÎfl˛˘Û˛  ÓÚ ÌÂÔÓ‚ÂʉÂÌÌÓÈ Ô‡ÂÌıËÏ˚ (ËÒ. 4‡). Ç ÓÒÌÓ‚ÌÓÈ
„ÛÔÔ ˝Ú‡ ÁÓ̇ ÔÓ‚ÂʉÂÌËfl Ô‡ÂÌıËÏ˚ ·˚·
¯Ë (‰Ó 6 ÏÏ), Ò ÌÂÓ‚Ì˚Ï Í‡ÂÏ Ë ÔÓÌË͇· ‚
‚ˉ ·ÍÛÌ ‚ ÌÂÔÓ‚ÂʉÂÌÌÛ˛ Ô‡ÂÌıËÏÛ Ô˜ÂÌË
·ÂÁ ˜ÂÚÍÓÈ „‡Ìˈ˚ Ë ·˚· ̇Ò˚˘Â̇ ÊˉÍÓÒÚ¸˛
‚ ‚ˉ ‚‡ÍÛÓÎÂÈ (ËÒ. 4·). ç‡ 7- ÒÛÚÍË ÔÓÒΠÓÔÂ‡ˆËË ‚ ÍÓÌÚÓθÌÓÈ „ÛÔÔ ‚ ӷ·ÒÚË ÙÓÏËÛ˛˘Â„ÓÒfl Û·ˆ‡ ËÏÂÎËÒ¸ ‚˚‡ÊÂÌÌ˚ ۘ‡ÒÚÍË ÌÂÍÓÁ‡ Ë Ó·Ëθ̇fl ÎËÏÙÓˉÌÓ-ÍÎÂÚӘ̇fl ËÌÙËθÚ‡ˆËfl, ·˚ÎË ÓÚϘÂÌ˚ ̇˜‡Î¸Ì˚ ÔËÁ̇ÍË
‚ÓÒÒÚ‡ÌÓ‚ÎÂÌËfl ÙÛÌ͈ËË „ÂÔ‡ÚÓˆËÚÓ‚ (òàä-‡͈Ëfl), ÔËÎÂʇ˘Ëı Í ÙÓÏËÛ˛˘ÂÏÛÒfl Û·ˆÛ.
Ç ÓÒÌÓ‚ÌÓÈ „ÛÔÔ ÙÓÏËÓ‚‡ÎÒfl ÌÂ‡‚ÌÓÏÂÌ˚È ۷ˆ, ÔÓÌË͇˛˘ËÈ ‚ ‚ˉ ÓÚÓ„Ó‚ ‚ Ô‡ÂÌıËÏÛ Ô˜ÂÌË (¯ËË̇ 5 ÏÏ). Å˚ÎÓ ÓÚϘÂÌÓ, ˜ÚÓ
ÎËÏÙÓˉ̇fl ËÌÙËθÚ‡ˆËfl ‚˚‡ÊÂ̇ ‚ ÏËÌË-
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
èÖóÖç¸
ëäàèÖçäé Ë ‰.
퇷Îˈ‡ 3. êÂÁÛθڇÚ˚ ˝ÍÒÔÂËÏÂÌڇθÌÓ„Ó ËÒÒΉӂ‡ÌËfl ˝ÙÙÂÍÚË‚ÌÓÒÚË ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ ÔË
ÂÁÂ͈ËË Ô˜ÂÌË
ÉÛÔÔ‡
˝ÍÒÔÂËÏÂÌڇθ̇fl
(8 ÊË‚ÓÚÌ˚ı)
èÓ͇Á‡ÚÂθ
Ò‰Ì ‰Ë‡Ô‡ÁÓÌ
ÍÓÌÚÓθ̇fl
(3 ÊË‚ÓÚÌ˚ı)
Ò‰ÌÂÂ
‰Ë‡Ô‡ÁÓÌ

èÎÓ˘‡‰¸ ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË ÍÛθÚË, ÒÏ2
27 ± 8.3
15–35
24.7 ± 11.5
13–36
0.714
èÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÓÔÂ‡ˆËË, ÏËÌ
40 ± 5
33–45
47 ± 9
37–55
0.099
èÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÔÂÂÒ˜ÂÌËfl Ô˜ÂÌË, ÏËÌ
12 ± 3
8–16
16 ± 4
8–13
0.119
5±2
2–8
12 ± 2
9–13
0.01
86 ± 52
45–200
153 ± 95
60–250
0.155
76 ± 48
40–180
135 ± 85
50–220
0.169
3.2 ± 2.8
1.3–10
5.1 ± 1.2
3.8–6.1
0.302
1–2
6±1
5–7
0.004
ÇÂÏfl ‰ÓÒÚËÊÂÌËfl ÓÍÓ̘‡ÚÂθÌÓ„Ó „ÂÏÓÒÚ‡Á‡, ÏËÌ
é·˘‡fl ÍÓ‚ÓÔÓÚÂfl, ÏÎ
äÓ‚ÓÔÓÚÂfl ̇ ˝Ú‡Ô ÂÁÂ͈ËË, ÏÎ
äÓ‚ÓÔÓÚÂfl/ÔÎÓ˘‡‰¸ ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË,
ÏÎ/ÒÏ2
óËÒÎÓ ÎË„‡ÚÛ ̇ ÍÛθڲ Ô˜ÂÌË ‰Îfl ‰ÓÒÚËÊÂÌËfl „ÂÏÓÒÚ‡Á‡ 1.1 ± 0.8
χθÌÓÈ ÒÚÂÔÂÌË (ÔÂËÏÛ˘ÂÒÚ‚ÂÌÌÓ ‚ÓÍÛ„ ÎË„‡ÚÛ), ÍÓ΢ÂÒÚ‚Ó ÌÂÍÓÚ˘ÂÒÍËı Û˜‡ÒÚÍÓ‚ ÌÂÁ̇˜ËÚÂθÌÓ ‚ ÔÓΠÁÂÌËfl. îÛÌ͈Ëfl „ÂÔ‡ÚÓˆËÚÓ‚ ‚
ÔËÎÂʇ˘ÂÈ Ô‡ÂÌıËÏ ڇÍÊ ̇˜Ë̇· ‚ÓÒÒڇ̇‚ÎË‚‡Ú¸Òfl. ç‡ 14- ÒÛÚÍË ÔÓÒΠÓÔÂ‡ˆËË ‚ ÓÒÌÓ‚ÌÓÈ „ÛÔÔ ‚˚fl‚ÎflÎË ·ÓΠÁÂÎ˚È ۷ˆ, ˜ÂÏ
‚ ÍÓÌÚÓθÌÓÈ, ÙÛÌ͈Ëfl ÔËÎÂʇ˘Ëı „ÂÔ‡ÚÓˆËÚÓ‚ ·˚· ÔÓÎÌÓÒÚ¸˛ ‚ÓÒÒÚ‡ÌÓ‚ÎÂ̇ (ËÒ. 5).
í‡ÍËÏ Ó·‡ÁÓÏ, ‚ ˝ÍÒÔÂËÏÂÌڇθÌÓÏ ‡Á‰ÂÎÂ
ËÒÒΉӂ‡ÌËfl ·˚· ÓÒ‚ÓÂ̇ ÏÂÚÓ‰Ë͇ ‚Ó‰ÓÒÚÛÈÌÓÈ ‰ËÒÒÂ͈ËË. Ç˚ÔÓÎÌÂÌË ÂÁÂ͈ËË Ô˜ÂÌË Û
ÊË‚ÓÚÌ˚ı Ì ÒÓÔÓ‚Óʉ‡ÎÓÒ¸ ÚÂıÌ˘ÂÒÍËÏË
ÚÛ‰ÌÓÒÚflÏË. èË ‡Ì‡ÎËÁ ÂÁÛθڇÚÓ‚ ˝ÍÒÔÂËÏÂÌÚ‡ Ì ÓÚϘÂÌÓ ÒÚ‡ÚËÒÚ˘ÂÒÍË ‰ÓÒÚÓ‚ÂÌÓÈ
‡ÁÌˈ˚ ÏÂÊ‰Û Ò‡‚ÌË‚‡ÂÏ˚ÏË „ÛÔÔ‡ÏË ÔÓ Ú‡ÍËÏ ‚‡ÊÌ˚Ï ÔÓ͇Á‡ÚÂÎflÏ, Í‡Í ÔÓ‰ÓÎÊËÚÂθ-
(‡)
ÌÓÒÚ¸ ÓÔÂ‡ˆËË Ë ‚ÂÏfl ‰ËÒÒÂ͈ËË, ‡ Ú‡ÍÊ ÔÓ
Ó·˙ÂÏÛ ÍÓ‚ÓÔÓÚÂË, ıÓÚfl Ëı ‡·ÒÓβÚÌ˚ ‚Â΢ËÌ˚ ·˚ÎË ÏÂ̸¯Â ‚ „ÛÔÔÂ, „‰Â ËÒÔÓθÁÓ‚‡ÎË
‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ. äÓÏ ÚÓ„Ó, ÂÁÂ͈Ëfl Ò
ÔËÏÂÌÂÌËÂÏ ‚Ó‰ÌÓ„Ó Ò͇θÔÂÎfl Ú·ӂ‡Î‡ ÏÂ̸¯Â ‚ÂÏÂÌË Ë ¯Ó‚ÌÓ„Ó Ï‡ÚÂˇ· ‰Îfl ‰ÓÒÚËÊÂÌËfl
ÓÍÓ̘‡ÚÂθÌÓ„Ó „ÂÏÓÒÚ‡Á‡ ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË
ÍÛθÚË Ô˜ÂÌË. àÁÛ˜ÂÌË ‰Ë̇ÏËÍË ÙÓÏËÓ‚‡ÌËfl Û·ˆ‡ ÔÓ͇Á‡ÎÓ, ˜ÚÓ ‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ
ÔË‚Ó‰ËÚ Í Ó·‡ÁÓ‚‡Ì˲ ·ÓΠ¯ËÓÍÓÈ ÁÓÌ˚ ÔÓ‚ÂʉÂÌËfl ÔË ÔÂÂÒ˜ÂÌËË Á‡ Ò˜ÂÚ ÔÓÔËÚ˚‚‡ÌËfl Ô‡ÂÌıËÏ˚ Ô˜ÂÌË ‡·Ó˜ËÏ ‡ÒÚ‚ÓÓÏ, ÌÓ,
ÌÂÒÏÓÚfl ̇ ˝ÚÓ, ËÒ˜ÂÁÌÓ‚ÂÌË ‚ÓÒÔ‡ÎËÚÂθÌ˚ı
ËÁÏÂÌÂÌËÈ Ë ÒÓÁ‚‡ÌË Û·ˆ‡ ÔÓËÒıÓ‰flÚ ‚ ·ÓÎÂÂ
‡ÌÌË ÒÓÍË.
(·)
êËÒ. 4. áÓ̇ ÔÓ‚ÂʉÂÌËfl ÔË ‰ËÒÒÂ͈ËË Ô‡ÂÌıËÏ˚ Ô˜ÂÌË ÏÂÚÓ‰ÓÏ ‡Á‰‡‚ÎË‚‡ÌËfl Á‡ÊËÏÓÏ (‡) Ë ‚Ó‰ÓÒÚÛÈÌ˚Ï
‰ËÒÒÂÍÚÓÓÏ (·). éÍ‡Ò͇ „ÂχÚÓÍÒËÎËÌÓÏ Ë ˝ÓÁËÌÓÏ. ì‚. 180.
‡ – ÁÓ̇ ÔÓ‚ÂʉÂÌËfl Ô‡ÂÌıËÏ˚ (Û͇Á‡Ì‡ ÒÚÂÎÍÓÈ) ‰ÓÒÚ‡ÚÓ˜ÌÓ ÛÁ͇fl (3 ÏÏ), ËÏÂÂÚ Ó‚Ì˚È Í‡È Ë ˜ÂÚÍÛ˛ Ó‚ÌÛ˛
„‡ÌˈÛ, ÓÚ‰ÂÎfl˛˘Û˛  ÓÚ ÌÂÔÓ‚ÂʉÂÌÌÓÈ Ô‡ÂÌıËÏ˚; · – ÁÓ̇ ÔÓ‚ÂʉÂÌËfl Ô‡ÂÌıËÏ˚ ¯Ë (‰Ó 6 ÏÏ), Ò ÌÂÓ‚Ì˚Ï Í‡ÂÏ Ë ÔÓÌË͇ÂÚ ‚ ‚ˉ ·ÍÛÌ ‚ ÌÂÔÓ‚ÂʉÂÌÌÛ˛ Ô‡ÂÌıËÏÛ Ô˜ÂÌË, ·ÂÁ ˜ÂÚÍÓÈ „‡Ìˈ˚, ̇Ò˚˘Â̇ ÊˉÍÓÒÚ¸˛ ‚ ‚ˉ ‚‡ÍÛÓÎÂÈ (Û͇Á‡Ì˚ ÒÚÂÎÍÓÈ).
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
53
èÖóÖç¸
ùîîÖäíàÇçéëíú ÇéÑéëíêìâçéÉé ÑàëëÖäíéêÄ
(·)
(‡)
êËÒ. 5. Çˉ Û·ˆ‡ ÍÛθÚË Ô˜ÂÌË Ì‡ 14- ÒÛÚÍË ÔÓÒΠÓÔÂ‡ˆËË Ò ÔËÏÂÌÂÌËÂÏ ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ (‡) Ë ÏÂÚÓ‰ËÍË ‡Á‰‡‚ÎË‚‡ÌËfl Ô‡ÂÌıËÏ˚ Ô˜ÂÌË (òàä-‡͈Ëfl, ì‚. 180).
‡ – ÁÂÎ˚È ۷ˆ, ÙÛÌ͈Ëfl ÔËÎÂʇ˘Ëı „ÂÔ‡ÚÓˆËÚÓ‚ ‚ÓÒÒÚ‡ÌÓ‚ÎÂ̇; · – ÒÓÁ‚‡˛˘ËÈ ۷ˆ, ÙÛÌ͈Ëfl „ÂÔ‡ÚÓˆËÚÓ‚
Ì ÔÓÎÌÓÒÚ¸˛ ‚ÓÒÒÚ‡ÌÓ‚ÎÂ̇, ‚ˉÌ˚ ÍÓ‚ÓËÁÎËflÌËfl ‚ ÔËÎÂʇ˘ÂÈ Í Û·ˆÛ Ô‡ÂÌıËÏÂ.
äÎËÌ˘ÂÒÍÓ ËÒÒΉӂ‡ÌËÂ
èËÓ·ÂÚÂÌÌ˚ ‚Ó ‚ÂÏfl ˝ÍÒÔÂËÏÂÌڇθÌÓ„Ó
ËÒÒΉӂ‡ÌËfl ̇‚˚ÍË ‡·ÓÚ˚ Ò ‚Ó‰ÓÒÚÛÈÌ˚Ï
‰ËÒÒÂÍÚÓÓÏ ÛÒÔ¯ÌÓ ËÒÔÓθÁÓ‚‡Ì˚ ̇ÏË ‚ ÍÎËÌ˘ÂÒÍÓÈ Ô‡ÍÚËÍÂ. ÑÎfl ‚˚ÔÓÎÌÂÌËfl ÂÁÂ͈ËË
Ô˜ÂÌË Ò ÔËÏÂÌÂÌËÂÏ ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡,
Í‡Í Ô‡‚ËÎÓ, ·˚ÎÓ ‰ÓÒÚ‡ÚÓ˜ÌÓ Ó‰ÌÓ„Ó ·‡ÎÎÓ̇
‡·Ó˜Â„Ó ‡ÒÚ‚Ó‡ (Ò‰ÌËÈ ‡ÒıÓ‰ 70 ± 38.2%
Ó·˙Âχ ·‡ÎÎÓ̇, ÒÓÒÚ‡‚Îfl˛˘Â„Ó 500 ÏÎ). èÓÎÛ˜ÂÌÌ˚ ÂÁÛθڇÚ˚ Ì ‚˚fl‚ËÎË ‰ÓÒÚÓ‚ÂÌÓÈ ‡ÁÌˈ˚ ÏÂÊ‰Û „ÛÔÔ‡ÏË ÔÓ ÔÓ‰ÓÎÊËÚÂθÌÓÒÚË
ÓÔÂ‡ˆËË Ë ‚ÂÏÂÌË, Á‡Ú‡˜Ë‚‡ÂÏÓÏÛ Ì‡ ‰ËÒÒÂÍˆË˛ Ô‡ÂÌıËÏ˚ Ô˜ÂÌË, Ó·˘ÂÏÛ Ó·˙ÂÏÛ ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÓÈ ÍÓ‚ÓÔÓÚÂË, Ó·˙ÂÏÛ „ÂÏÓÚ‡ÌÒÙÛÁËË Ë ‰ÎËÚÂθÌÓÒÚË ÒÚÓflÌËfl ‰Â̇ʇ ‚ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌÓÏ ÔÂËӉ (Ú‡·Î. 4).
èËÏÂÌÂÌË ‚Ó‰ÌÓ„Ó Ò͇θÔÂÎfl ÔË ‰ËÒÒÂ͈ËË
Ô‡ÂÌıËÏ˚ Ô˜ÂÌË ÔÓÁ‚ÓÎËÎÓ ‰ÓÒÚÓ‚ÂÌÓ ÒÓÍ‡-
ÚËÚ¸ Ó·˙ÂÏ ÍÓ‚ÓÔÓÚÂË Ì‡ ˝Ú‡Ô ÔÂÂÒ˜ÂÌËfl
Ô‡ÂÌıËÏ˚: ‚ ÓÒÌÓ‚ÌÓÈ „ÛÔÔ ÓÌ ÒÓÒÚ‡‚ËÎ 509 ±
± 403 ÏÎ, ‚ ÍÓÌÚÓθÌÓÈ – 812 ± 544 ÏÎ ( = 0.04).
Pringle-χÌ‚ ÔËÏÂÌËÎË Û 6 Ô‡ˆËÂÌÚÓ‚ ËÁ ÍÓÌÚÓθÌÓÈ „ÛÔÔ˚ Ë ÚÓθÍÓ Û 2 Ô‡ˆËÂÌÚÓ‚ ËÁ ÓÒÌÓ‚ÌÓÈ. ÑÎfl ‰ÓÒÚËÊÂÌËfl ÓÍÓ̘‡ÚÂθÌÓ„Ó „ÂÏÓÒÚ‡Á‡ ÍÛθÚË Ô˜ÂÌË ‚ ÓÒÌÓ‚ÌÓÈ „ÛÔÔ Á‡Ú‡˜Ë‚‡ÎË ÏÂ̸¯Â ‚ÂÏÂÌË (24 ± 15 ÏËÌ), ˜ÂÏ ‚
ÍÓÌÚÓθÌÓÈ (30 ± 17 ÏËÌ;  = 0.048), ‡ Ú‡ÍÊ ̇
ÓÒÚ‡ÌÓ‚ÍÛ ÍÓ‚ÓÚ˜ÂÌËfl ËÁ ÏÂÎÍËı ÒÓÒÛ‰Ó‚ ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË Ô˜ÂÌË ÛıÓ‰ËÎÓ ÏÂ̸¯Â ¯Ó‚ÌÓ„Ó Ï‡ÚÂˇ· (ÓÒÌӂ̇fl „ÛÔÔ‡ – 6.1 ± 3.9 ÎË„‡ÚÛ˚, ÍÓÌÚÓθ̇fl – 14 ± 7.5 ÎË„‡ÚÛ˚;  = 0.004).
îË·ËÌ-ÍÓη„ÂÌÓ‚Û˛ ÒÛ·ÒÚ‡ÌˆË˛ “í‡ıÓÍÓÏ·” Ò
ˆÂθ˛ ‰ÓÒÚËÊÂÌËfl ÓÍÓ̘‡ÚÂθÌÓ„Ó „ÂÏÓÒÚ‡Á‡ ̇Í·‰˚‚‡ÎË Ì‡ ‡ÌÂ‚Û˛ ÔÓ‚ÂıÌÓÒÚ¸ Ô˜ÂÌË 6 Ô‡ˆËÂÌÚ‡Ï ËÁ ÍÓÌÚÓθÌÓÈ „ÛÔÔ˚ Ë 11 Ô‡ˆËÂÌÚ‡Ï
ËÁ ÓÒÌÓ‚ÌÓÈ. éÒÎÓÊÌÂÌËÈ ‚ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌÓÏ
퇷Îˈ‡ 4. êÂÁÛθڇÚ˚ ÍÎËÌ˘ÂÒÍÓ„Ó ÔËÏÂÌÂÌËfl ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ ÔË ‚˚ÔÓÎÌÂÌËË ÂÁÂ͈ËÈ Ô˜ÂÌË
ÉÛÔÔ‡
èÓ͇Á‡ÚÂθ
ÓÒÌӂ̇fl
ÍÓÌÚÓθ̇fl

Ò‰ÌÂÂ
‰Ë‡Ô‡ÁÓÌ
Ò‰ÌÂÂ
‰Ë‡Ô‡ÁÓÌ
363 ± 128
150–680
372 ± 131
130–615
0.82
29 ± 15
10–58
22 ± 10
13–33
0.43
é·˘‡fl ÍÓ‚ÓÔÓÚÂfl, ÏÎ
920 ± 699
250–3200
1047 ± 564
300–3000
0.56
äÓ‚ÓÔÓÚÂfl ̇ ˝Ú‡Ô ‰ËÒÒÂ͈ËË, ÏÎ
509 ± 403
100–1500
812 ± 544
200–2500
0.04
é·˙ÂÏ „ÂÏÓÚ‡ÌÒÙÛÁËË, ÏÎ
476 ± 347
0–2000
544 ± 390
0–1250
0.64
óËÒÎÓ ÎË„‡ÚÛ ‰Îfl „ÂÏÓÒÚ‡Á‡ ÍÛθÚË Ô˜ÂÌË, ¯Ú.
6.1 ± 3.9
0–38
14 ± 7.5
6–29
0.004
ÇÂÏfl, Á‡Ú‡˜Ë‚‡ÂÏÓ ̇ „ÂÏÓÒÚ‡Á, ÏËÌ
24 ± 15
10–75
30 ± 17
24–43
0.048
18.2 ± 8.4
8–37
26.5 ± 17.7
9–74
0.047
èÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÓÔÂ‡ˆËË, ÏËÌ
ÇÂÏfl ‰ËÒÒÂ͈ËË Ô‡ÂÌıËÏ˚ Ô˜ÂÌË, ÏËÌ
èÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ Ô·˚‚‡ÌËfl ‚ ÒÚ‡ˆËÓ̇Â
ÔÓÒΠÓÔÂ‡ˆËË, ÍÓÈÍÓ-‰ÌË
54
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
èÖóÖç¸
ëäàèÖçäé Ë ‰.
ÔÂËÓ‰Â, Ò‚flÁ‡ÌÌ˚ı Ò ÌÂÛ‰Ó‚ÎÂÚ‚ÓËÚÂθÌ˚Ï „ÂÏÓÒÚ‡ÁÓÏ, Ì ̇·Î˛‰‡ÎË. ÇÏÂÒÚÂ Ò ÚÂÏ, Ì„ÂÏÂÚ˘ÌÓÒÚ¸ ÊÂΘÌ˚ı ÔÓÚÓÍÓ‚, ÔÓÚ·ӂ‡‚¯‡fl ‰ÓÔÓÎÌËÚÂθÌ˚ı Θ·Ì˚ı χÌËÔÛÎflˆËÈ (ÔÛÌ͈Ëfl
ÔÓ‰ ÍÓÌÚÓÎÂÏ ìáà), ËÏ· ÏÂÒÚÓ Û 1 (5%) Ô‡ˆËÂÌÚ‡ ‚ ÓÒÌÓ‚ÌÓÈ „ÛÔÔ (ÒÍÓÔÎÂÌË ÊˉÍÓÒÚË Ò
ÔËÏÂÒ¸˛ ÊÂÎ˜Ë ‚ ÎÓÊ ۉ‡ÎÂÌÌÓÈ ‰ÓÎË) Ë Û 7
(35%) Ô‡ˆËÂÌÚÓ‚ ‚ ÍÓÌÚÓθÌÓÈ (ÒÍÓÔÎÂÌË ÊˉÍÓÒÚË ‚ ÎÓÊ ۉ‡ÎÂÌÌÓÈ ‰ÓÎË – 4, ̇ÛÊÌ˚È ÊÂΘÌ˚È
Ò‚Ë˘ – 2, ‡·ÒˆÂÒÒ ·˛¯ÌÓÈ ÔÓÎÓÒÚË – 1) ( = 0.014).
äÓÏ ÚÓ„Ó, ‚ ÓÒÌÓ‚ÌÓÈ „ÛÔÔ ÓÚϘÂÌÓ ÒÓÍ‡˘ÂÌË ‰ÎËÚÂθÌÓÒÚË Ô·˚‚‡ÌËfl Ô‡ˆËÂÌÚÓ‚ ‚ ÒÚ‡ˆËÓ̇ ÔÓÒΠÓÔÂ‡ˆËË (‚ Ò‰ÌÂÏ 18.2 ± 8.4 ‰Ìfl, ‚
ÍÓÌÚÓθÌÓÈ „ÛÔÔ – 26.5 ± 17.7 ‰Ìfl;  = 0.048).
Ç ˆÂÎÓÏ ÔË·Ó ·˚Î ÔÓÒÚ Ë Û‰Ó·ÂÌ ‚ ‡·ÓÚÂ.
ᇠҘÂÚ ‚˚ÒÓÍÓÈ ÒÂÎÂÍÚË‚ÌÓÒÚË ‚ÓÁ‰ÂÈÒÚ‚Ëfl ̇
Ú̸͇ Ô˜ÂÌË Â„Ó ÔËÏÂÌÂÌË ÔÓÁ‚ÓÎËÎÓ ÒÓÍ‡ÚËÚ¸ Ó·˙ÂÏ ÍÓ‚ÓÔÓÚÂË Ì‡ ˝Ú‡Ô ‰ËÒÒÂ͈ËË, ÛÒÍÓËÚ¸ „ÂÏÓÒÚ‡Á ÍÛθÚË Ô˜ÂÌË Ë ÒÓÍ‡ÚËÚ¸ ‡ÒıÓ‰ ¯Ó‚ÌÓ„Ó Ï‡ÚÂˇ· ‰Îfl ˝ÚÓÈ ˆÂÎË. èÓÏËÏÓ
ıÓÓ¯Ëı ËÌÚ‡ÓÔÂ‡ˆËÓÌÌ˚ı ÂÁÛθڇÚÓ‚ ÔËÏÂÌÂÌËfl ‚Ó‰ÌÓ„Ó Ò͇θÔÂÎfl, ‚ ÓÒÌÓ‚ÌÓÈ „ÛÔÔÂ
Ô‡ˆËÂÌÚÓ‚ ·˚ÎË ÛÎÛ˜¯ÂÌ˚ ·ÎËʇȯË ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ ÂÁÛθڇÚ˚ ΘÂÌËfl, ˜ÚÓ ÔÓfl‚ËÎÓÒ¸
‰ÓÒÚÓ‚ÂÌ˚Ï ÒÓÍ‡˘ÂÌËÂÏ ˜‡ÒÚÓÚ˚ ·ËΡÌ˚ı
ÓÒÎÓÊÌÂÌËÈ Ë ‰ÎËÚÂθÌÓÒÚË Ô·˚‚‡ÌËfl Ô‡ˆËÂÌÚ‡ ‚ ÒÚ‡ˆËÓ̇ ÔÓÒΠÓÔÂ‡ˆËË.
é·ÒÛʉÂÌËÂ
ëÓ‚ÂÏÂÌÌ˚ ‰ÓÒÚËÊÂÌËfl ‚ ıËÛ„ËË Ô˜ÂÌË
·ÂÒÒÔÓÌ˚ – ÒÌËÊÂÌ˚ ÔÓ͇Á‡ÚÂÎË ˜‡ÒÚÓÚ˚ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÓÒÎÓÊÌÂÌËÈ Ë ÎÂڇθÌÓÒÚË. ÇÏÂÒÚÂ Ò ÚÂÏ ÏÌÓ„Ë ‚ÓÔÓÒ˚, ͇҇˛˘ËÂÒfl ÂÁÂ͈ËÓÌÌ˚ı ‚ϯ‡ÚÂθÒÚ‚ ̇ ˝ÚÓÏ Ó„‡ÌÂ, Ì ËÏÂ˛Ú Ó‰ÌÓÁ̇˜ÌÓÈ ÓˆÂÌÍË.
ëÛ˘ÂÒÚ‚Û˛˘Ë ̇ Ò„ӉÌfl¯ÌËÈ ‰Â̸ ÏÂÚÓ‰˚
‰ËÒÒÂ͈ËË Ô‡ÂÌıËÏ˚ Ô˜ÂÌË ËÏÂ˛Ú Ò‚ÓË ‰ÓÒÚÓËÌÒÚ‚‡ Ë Ì‰ÓÒÚ‡ÚÍË [1]. ë‡Ï˚È ÔÓÒÚÓÈ ÏÂÚÓ‰ –
‰Ë„ËÚÓÍ·ÁËfl (ԇθˆÂ‚Ó ‡Á‰‡‚ÎË‚‡ÌË ԇÂÌıËÏ˚), Ô‰ÎÓÊÂÌ̇fl Lin ‚ 1958 „. Ë ÔÓÁ‚ÓÎfl˛˘‡fl
˜ÂÁ‚˚˜‡ÈÌÓ ·˚ÒÚÓ ‚˚ÔÓÎÌflÚ¸ ÂÁÂÍˆË˛ Ô˜ÂÌË [33], ÌÓ ÒÓÔÓ‚Óʉ‡˛˘‡flÒfl Á̇˜ËÚÂθÌ˚Ï
ÍÓ‚ÓÚ˜ÂÌËÂÏ Ë ‰Ó‚ÓθÌÓ ‚˚ÒÓÍÓÈ ˜‡ÒÚÓÚÓÈ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÓÒÎÓÊÌÂÌËÈ [10, 15, 41, 42]. ÅÓΠÛÒÓ‚Â¯ÂÌÒÚ‚Ó‚‡ÌÌ˚Ï Ë ÏÂÌ Ú‡‚χÚ˘Ì˚Ï ‡Ì‡ÎÓ„ÓÏ ‰Ë„ËÚÓÍ·ÁËË fl‚ÎflÂÚÒfl ÏÂÚÓ‰Ë͇
‡Á‰ÂÎÂÌËfl Ô‡ÂÌıËÏ˚ Ò ÔÓÏÓ˘¸˛ ËÌÒÚÛÏÂÌÚ‡.
ùÚÓÚ ÏÂÚÓ‰ ‚ÒΉÒÚ‚Ë ÚÂıÌ˘ÂÒÍÓÈ ÔÓÒÚÓÚ˚ Ë
‰ÓÒÚÛÔÌÓÒÚË Ì‡Ë·ÓΠ¯ËÓÍÓ ‡ÒÔÓÒÚ‡ÌÂÌ ÔË
‚˚ÔÓÎÌÂÌËË ÂÁÂ͈ËË Ô˜ÂÌË [18, 36, 47, 55].
àÏÂÌÌÓ ˝ÚÓÚ ÏÂÚÓ‰ ·˚Î ‚ÁflÚ ‚ ͇˜ÂÒÚ‚Â Òڇ̉‡Ú‡
‰Îfl ÙÓÏËÓ‚‡ÌËfl ÍÓÌÚÓθÌÓÈ „ÛÔÔ˚ ‚ ̇¯ÂÏ
ËÒÒΉӂ‡ÌËË.
ÄÔÔ‡‡Ú˚, ‚ ÓÒÌÓ‚Â ‰ÂÈÒÚ‚Ëfl ÍÓÚÓ˚ı ÎÂÊËÚ
‚˚ÒÓÍÓ˜‡ÒÚÓÚÌ˚È ˝ÎÂÍÚ˘ÂÒÍËÈ ÚÓÍ ËÎË Î‡ÁÂÌÓ ËÁÎÛ˜ÂÌËÂ, ÔÓÁ‚ÓÎfl˛Ú Ó‰ÌÓ‚ÂÏÂÌÌÓ ‡ÒÒÂ͇ڸ Ô‡ÂÌıËÏÛ Ô˜ÂÌË Ë ÍÓ‡„ÛÎËÓ‚‡Ú¸ ÒÓÒÛ‰˚,
Ӊ̇ÍÓ ‰Ë‡ÏÂÚ ÒÓÒÛ‰Ó‚, ÔÓ‰‰‡˛˘ËıÒfl ÍÓ‡„ÛÎflˆËË, Ì Ô‚˚¯‡ÂÚ 1–1.5 ÏÏ, ÔÓ˝ÚÓÏÛ ÍÓ‚ÓÚ˜ÂÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
ÌË ËÁ ·ÓΠÍÛÔÌ˚ı ÒÓÒÛ‰Ó‚ ÔË‚Ó‰ËÚ Í Á̇˜ËÚÂθÌÓÈ ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÓÈ ÍÓ‚ÓÔÓÚÂ [1, 26,
28]. äÓÏ ÚÓ„Ó, ÔË ËÒÔÓθÁÓ‚‡ÌËË ˝ÚËı ÏÂÚÓ‰Ó‚
ÙÓÏËÛÂÚÒfl ‰Ó‚ÓθÌÓ „ÎÛ·ÓÍËÈ ÌÂÍÓÁ Ô‡ÂÌıËÏ˚ [5, 38]. ç‡ Ò„ӉÌfl¯ÌËÈ ‰Â̸ ‚ ÒÙÂ „ÂÔ‡ÚÓ·ËΡÌÓÈ ıËÛ„ËË ˝ÚË ÔË·Ó˚ ̇ıÓ‰flÚ ÔËÏÂÌÂÌË ÔÂËÏÛ˘ÂÒÚ‚ÂÌÌÓ ‚ ͇˜ÂÒÚ‚Â Ò‰ÒÚ‚ ‰ÓÒÚËÊÂÌËfl „ÂÏÓÒÚ‡Á‡ [4, 21, 23]. Ä̇Îӄ˘ÌÓÂ
ÏÂÒÚÓ Á‡ÌËχ˛Ú ÛθÚ‡Á‚ÛÍÓ‚ÓÈ („‡ÏÓÌ˘ÂÒÍËÈ)
Ë Ô·ÁÏÂÌÌ˚È Ò͇θÔÂθ [3, 20, 30]. èË ‚˚ÔÓÎÌÂÌËË ÂÁÂ͈ËË Ô˜ÂÌË ‚˚ÒÓÍÓ˜‡ÒÚÓÚÌ˚È ˝ÎÂÍÚÓÍÓ‡„ÛÎflÚÓ ÔËÏÂÌflÎÒfl ̇ÏË ÚÓθÍÓ ‰Îfl ‡ÒÒ˜ÂÌËfl ͇ÔÒÛÎ˚ Ô˜ÂÌË Ë ˜‡ÒÚ˘ÌÓ ‰Îfl ‰ÓÒÚËÊÂÌËfl
ÓÍÓ̘‡ÚÂθÌÓ„Ó „ÂÏÓÒÚ‡Á‡ ÍÛθÚË Ô˜ÂÌË ‚ ÂÊËÏ “spray”.
èÂÒÔÂÍÚË‚Ì˚Ï Ì‡Ô‡‚ÎÂÌËÂÏ ¯ÂÌËfl ÔÓ·ÎÂÏ ‰ËÒÒÂ͈ËË Ô‡ÂÌıËÏ˚ Ô˜ÂÌË ÒÚ‡ÎÓ ÒÓÁ‰‡ÌË ÏÂÚÓ‰ËÍ, ÔÓÁ‚ÓÎfl˛˘Ëı ‚˚‰ÂÎflÚ¸ ÒÓÒÛ‰˚ ËÁ
Ô‡ÂÌıËÏ˚ Ô˜ÂÌË ‰Ó ÏÓÏÂÌÚ‡ ÔÂÂÒ˜ÂÌËfl, ‡ Á‡ÚÂÏ ÔˆËÁËÓÌÌÓ Ëı ÍÎËÔËÓ‚‡Ú¸ ËÎË ÎË„ËÓ‚‡Ú¸
Ë ÛÊ ÔÓÒΠ˝ÚÓ„Ó ÔÂÂÒÂ͇ڸ, ÔË ÌÂÓ·ıÓ‰ËÏÓÒÚË
ÔËÏÂÌflfl ‡Á΢Ì˚ ÒÔÓÒÓ·˚ ‰ÓÒÚËÊÂÌËfl ÓÍÓ̘‡ÚÂθÌÓ„Ó „ÂÏÓÒÚ‡Á‡ ÍÛθÚË Ô˜ÂÌË (Ôӯ˂‡ÌËÂ, ˝ÎÂÍÚÓÍÓ‡„ÛÎflˆËfl, Í΂˚ ÒÛ·Òڇ̈ËË Ë
Ú.‰.). í‡ÍÓÈ ÚËÔ ‚ÓÁ‰ÂÈÒÚ‚Ëfl ̇ Ú̸͇ Ô˜ÂÌË Ó·ÂÒÔ˜˂‡ÂÚ ‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ [24, 49, 50, 51].
èÓ ‰‡ÌÌ˚Ï ÎËÚÂ‡ÚÛ˚, Â„Ó ÓÒÌÓ‚Ì˚Ï ÔÂËÏÛ˘ÂÒÚ‚ÓÏ fl‚ÎflÂÚÒfl ‚˚ÒÓ͇fl ÒÂÎÂÍÚË‚ÌÓÒÚ¸ ‚ÓÁ‰ÂÈÒÚ‚Ëfl ÔË ‚˚‰ÂÎÂÌËË ÚÛ·˜‡Ú˚ı ÒÚÛÍÚÛ, ˜ÚÓ ÔÓÁ‚ÓÎflÂÚ ÛÏÂ̸¯ËÚ¸ ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÛ˛ ÍÓ‚ÓÔÓÚÂ˛ Ë ÔÓÚ·ÌÓÒÚË ‚ ÔÂÂÎË‚‡ÌËË ÍÓ‚Ë [2, 30,
49, 61]. éÔÚËχθÌÓ ‡·Ó˜Â ‰‡‚ÎÂÌËÂ, Ó·ÂÒÔ˜˂‡˛˘Â ÌÂÓ·ıÓ‰ËÏÛ˛ ÒÂÎÂÍÚË‚ÌÓÒÚ¸ ‚ÓÁ‰ÂÈÒÚ‚Ëfl Ë „ÎÛ·ËÌÛ ÔÓÌËÍÌÓ‚ÂÌËfl ‚Ó‰ÌÓÈ ÒÚÛË, ÒÓÒÚ‡‚ÎflÂÚ 50–80 ·‡ ÔË ‰Ë‡ÏÂÚ ÒÓÔ· 0,1 ÏÏ [30,
49] (ËÒ. 6 Ë 7).
èӂ‰ÂÌÌÓ ̇ÏË ËÒÒΉӂ‡ÌË ·˚ÎÓ ÓÒÌÓ‚‡ÌÓ Ì‡ Ò‡‚ÌÂÌËË ÏÂÚÓ‰ËÍË ‚Ó‰ÓÒÚÛÈÌÓÈ ‰ËÒÒÂ͈ËË Ë ‰ËÒÒÂ͈ËË ÔÛÚÂÏ ‡Á‰‡‚ÎË‚‡ÌËfl Ô‡ÂÌıËÏ˚
Ô˜ÂÌË ËÌÒÚÛÏÂÌÚÓÏ – ÏÂÚÓ‰‡, ̇˷ÓΠ¯ËÓÍÓ
ÔËÏÂÌflÂÏÓ„Ó ‚ ‡Á΢Ì˚ı Θ·Ì˚ı Û˜ÂʉÂÌËflı ÔË ÂÁÂ͈ËË Ô˜ÂÌË ·Î‡„Ó‰‡fl ÚÂıÌ˘ÂÒÍÓÈ
ÔÓÒÚÓÚÂ Ë ‰ÓÒÚÛÔÌÓÒÚË [18, 36, 55]. èÂ‚˚Ï ˝Ú‡ÔÓÏ ·˚ÎÓ ‚˚ÔÓÎÌÂÌÓ ˝ÍÒÔÂËÏÂÌڇθÌÓ ËÒÒΉӂ‡ÌËÂ, ÔÓÁ‚ÓÎË‚¯Â ÔËÓ·ÂÒÚË Ì‡‚˚ÍË ‡·ÓÚ˚ Ò ‚Ó‰ÓÒÚÛÈÌ˚Ï ‰ËÒÒÂÍÚÓÓÏ, ÔÓÎÛ˜ËÚ¸ Ô‰‚‡ËÚÂθÌ˚ ‰‡ÌÌ˚Â Ó Â„Ó ˝ÙÙÂÍÚË‚ÌÓÒÚË Ë
·ÂÁÓÔ‡ÒÌÓÒÚË ÔË ÂÁÂ͈ËË Ô˜ÂÌË, ÓÔ‰ÂÎËÚ¸
ÒÚÂÔÂ̸ Ú‡‚χÚËÁ‡ˆËË Ú͇ÌË Ô˜ÂÌË ‚Ó‰ÌÓÈ
ÒÚÛÂÈ. ÇÚÓ˚Ï ˝Ú‡ÔÓÏ ‚Ó‰ÓÒÚÛÈ̇fl ‰ËÒÒÂ͈Ëfl
·˚· ‚̉Â̇ ‚ ÍÎËÌ˘ÂÒÍÛ˛ Ô‡ÍÚËÍÛ.
ë‡‚ÌËÚÂθÌ˚È ‡Ì‡ÎËÁ ‰‚Ûı ÏÂÚÓ‰ËÍ ‰ËÒÒÂ͈ËË Ô‡ÂÌıËÏ˚ Ô˜ÂÌË Ì ‚˚fl‚ËÎ ‚ ˝ÍÒÔÂËÏÂÌÚÂ
Ë ÔË ÍÎËÌ˘ÂÒÍÓÏ ËÒÔÓθÁÓ‚‡ÌËË ‰ÓÒÚÓ‚ÂÌ˚ı
‡Á΢ËÈ ÔÓ ÒÎÂ‰Û˛˘ËÏ ÔÓ͇Á‡ÚÂÎflÏ: ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÓÔÂ‡ˆËË; ‚ÂÏfl, Á‡Ú‡˜Ë‚‡ÂÏÓ ̇
ÔÂÂÒ˜ÂÌË ԇÂÌıËÏ˚ Ô˜ÂÌË; Ó·˙ÂÏ Ó·˘ÂÈ
ÍÓ‚ÓÔÓÚÂË Ë ÍÓ‚ÓÔÓÚÂË Ì‡ ˝Ú‡Ô ‰ËÒÒÂ͈ËË,
Ó·˙ÂÏ ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÓÈ „ÂÏÓÚ‡ÌÒÙÛÁËË (ÔË
ÍÎËÌ˘ÂÒÍÓÏ ËÒÔÓθÁÓ‚‡ÌËË; ‚ ˝ÍÒÔÂËÏÂÌÚ „‹1
2004
55
èÖóÖç¸
20
18
16
14
12
10
8
6
4
2
0
ùîîÖäíàÇçéëíú ÇéÑéëíêìâçéÉé ÑàëëÖäíéêÄ
14
0.10 ÏÏ
0.15 ÏÏ
0.20 ÏÏ
12
10
8
6
4
20
40
60
80
2
0
20
40
60
80
êËÒ. 6. óËÒÎÓ ËÁÓÎËÓ‚‡ÌÌ˚ı ÒÓÒÛ‰Ó‚ ̇ 1 ÒÏ2 ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË ÔË ‡Á΢Ì˚ı ‡·Ó˜ÂÏ ‰‡‚ÎÂÌËË Ë
‰Ë‡ÏÂÚ ÒÓÔ·.
èÓ ÓÒË ‡·ÒˆËÒÒ – ‰‡‚ÎÂÌË (‚ ·‡‡ı), ÔÓ ÓÒË Ó‰ËÌ‡Ú –
˜ËÒÎÓ ËÁÓÎËÓ‚‡ÌÌ˚ı ÒÓÒÛ‰Ó‚.
êËÒ. 7. ÉÎÛ·Ë̇ ÔÓÌËÍÌÓ‚ÂÌËfl ‡·Ó˜Â„Ó ‡ÒÚ‚Ó‡ ‚
Ú̸͇ Ô˜ÂÌË ÔË ‡Á΢ÌÓÏ ‡·Ó˜ÂÏ ‰‡‚ÎÂÌËË (‰Ë‡ÏÂÚ ÒÓÔ· 0.1 ÏÏ).
èÓ ÓÒË ‡·ÒˆËÒÒ – ‰‡‚ÎÂÌË (‚ ·‡‡ı), ÔÓ ÓÒË Ó‰ËÌ‡Ú –
„ÎÛ·Ë̇ ÔÓÌËÍÌÓ‚ÂÌËfl ‡ÒÚ‚Ó‡ (‚ ÏÏ).
ÏÓÚ‡ÌÒÙÛÁËfl Ì ÔӂӉ˷Ҹ). àÁÛ˜ÂÌË ‚ÂÏÂÌÌ˚ı Ô‡‡ÏÂÚÓ‚ ‚Ó‰ÓÒÚÛÈÌÓÈ ‰ËÒÒÂ͈ËË ÔË
ÂÁÂ͈ËË Ô˜ÂÌË ÔÓ͇Á‡ÎÓ, ˜ÚÓ ˝ÚÓÚ ÏÂÚÓ‰ Ì ÛÒÚÛÔ‡ÂÚ ÔÓ ÒÍÓÓÒÚË ‰ËÒÒÂ͈ËË ÏÂÚÓ‰ËÍ ‡Á‰‡‚ÎË‚‡ÌËfl ËÌÒÚÛÏÂÌÚÓÏ. èÓÎÛ˜ÂÌÌ˚ ÂÁÛθڇÚ˚
ÔÓ‰ÂÏÓÌÒÚËÓ‚‡ÎË, ˜ÚÓ ÔËÏÂÌÂÌË ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ ‰‡ÂÚ ‚ÓÁÏÓÊÌÓÒÚ¸ ‰ÓÒÚÓ‚ÂÌÓ
ÒÓÍ‡ÚËÚ¸ ‚ÂÏfl, Á‡Ú‡˜Ë‚‡ÂÏÓ ̇ ‰ÓÒÚËÊÂÌËÂ
ÓÍÓ̘‡ÚÂθÌÓ„Ó „ÂÏÓÒÚ‡Á‡ ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË
ÍÛθÚË Ô˜ÂÌË, ‚ 1.3–2 ‡Á‡ Ë ‡ÒıÓ‰ ¯Ó‚ÌÓ„Ó Ï‡ÚÂˇ· ‰Îfl „ÂÏÓÒÚ‡Á‡ ÔÛÚÂÏ Ôӯ˂‡ÌËfl ‚ 2–5
‡Á. ÑÓÔÓÎÌËÚÂθÌÓ ÔËÏÂÌÂÌË ÙË·ËÌ-ÍÓη„ÂÌÓ‚˚ı ÒÛ·Òڇ̈ËÈ (‚ ̇¯ÂÈ ‡·ÓÚ ËÒÔÓθÁÓ‚‡Ì
“í‡ıÓÍÓÏ·”) ÔÓÁ‚ÓÎflÂÚ ‰Ó·ËÚ¸Òfl ·ÓΠ̇‰ÂÊÌÓ„Ó „ÂÏÓÒÚ‡Á‡.
åÂ̸¯‡fl Ú‡‚χÚ˘ÌÓÒÚ¸ ÏÂÚÓ‰‡ ‚Ó‰ÓÒÚÛÈÌÓÈ ‰ËÒÒÂ͈ËË ÔÓ Ò‡‚ÌÂÌ˲ Ò ÏÂÚÓ‰ËÍÓÈ ‡Á‰‡‚ÎË‚‡ÌËfl Ô‡ÂÌıËÏ˚ ËÌÒÚÛÏÂÌÚÓÏ ·˚· ÔÓ‰Ú‚ÂʉÂ̇ ‚ ˝ÍÒÔÂËÏÂÌÚÂ. èË ËÁÛ˜ÂÌËË „ËÒÚÓÎӄ˘ÂÒÍÓ„Ó Ï‡ÚÂˇ· ·˚ÎÓ ÛÒÚ‡ÌÓ‚ÎÂÌÓ, ˜ÚÓ ‚
„ÛÔÔ ÊË‚ÓÚÌ˚ı, ÍÓÚÓ˚Ï ÂÁÂ͈Ëfl Ô˜ÂÌË ‚˚ÔÓÎÌÂ̇ Ò ÔËÏÂÌÂÌËÂÏ ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡, ÔÓËÒıÓ‰ËÎÓ ·ÓΠ‡ÌÌ ÙÓÏËÓ‚‡ÌËÂ
Û·ˆ‡, ˜ÚÓ Òӄ·ÒÛÂÚÒfl Ò ‰‡ÌÌ˚ÏË ‰Û„Ëı ËÒÒΉӂ‡ÚÂÎÂÈ [2, 44].
ÇÓ‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ, Ó·ÂÒÔ˜˂‡fl ıÓÓ¯ËÈ ‚ËÁۇθÌ˚È ÍÓÌÚÓθ ÁÓÌ˚ ‰ËÒÒÂ͈ËË, Ôˉ‡ÂÚ Û‚ÂÂÌÌÓÒÚ¸ ıËÛ„Û, ˜ÚÓ Ó·˙ÂÍÚË‚ÌÓ ÔÓfl‚ÎflÂÚÒfl ·ÓΠ‰ÍËÏ ÔËÏÂÌÂÌËÂÏ Pingle-χÌ‚‡,
fl‚Îfl˛˘Â„ÓÒfl ‚˚ÌÛʉÂÌÌÓÈ ÏÂÓÈ ÔÓ Ô‰ÛÔÂʉÂÌ˲ ÍÓ‚ÓÚ˜ÂÌËfl ËÁ ÍÛθÚË Ô˜ÂÌË Ë ÒÔÓÒÓ·ÒÚ‚Û˛˘Â„Ó ‰ÓÔÓÎÌËÚÂθÌÓÈ Ë¯ÂÏËÁ‡ˆËË ÂÁˆËÓ‚‡ÌÌÓÈ Ô˜ÂÌË.
éÒÌÓ‚Ì˚Ï ÔÓÎÓÊËÚÂθÌ˚Ï ÂÁÛθڇÚÓÏ, ̇
̇¯ ‚Á„Îfl‰, fl‚ËÎÓÒ¸ Á̇˜ËÚÂθÌÓ ÒÚ‡ÚËÒÚ˘ÂÒÍË
‰ÓÒÚÓ‚ÂÌÓ ÒÓÍ‡˘ÂÌË ˜‡ÒÚÓÚ˚ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÓÒÎÓÊÌÂÌËÈ Ò 35 ‰Ó 5%. ïÓӯ ‚·‰ÂÌËÂ
ÓÔÂËÛ˛˘ËÏË ıËÛ„‡ÏË ÚÂıÌËÍÓÈ ÂÁÂ͈ËË Ô˜ÂÌË Ë ÏÂÚÓ‰‡ÏË „ÂÏÓÒÚ‡Á‡ ËÒÍβ˜ËÎÓ ‡Á‚ËÚËÂ
ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÍÓ‚ÓÚ˜ÂÌËÈ, ˜‡ÒÚÓÚ‡ ÍÓÚÓ-
˚ı, ÔÓ ‰‡ÌÌ˚Ï ÎËÚÂ‡ÚÛ˚, ÒÓÒÚ‡‚ÎflÂÚ 2–18% [8,
40]. ùÙÙÂÍÚË‚Ì˚Ï ‚ ˝ÚÓÏ ÓÚÌÓ¯ÂÌËË Ó͇Á‡ÎÓÒ¸
ÔËÏÂÌÂÌË ÙË·ËÌ-ÍÓη„ÂÌÓ‚ÓÈ ÒÛ·Òڇ̈ËË
‰Îfl ÛÍ˚ÚËfl ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË ÍÛθÚË Ô˜ÂÌË.
éÒÌÓ‚ÌÓ ˜ËÒÎÓ ÓÒÎÓÊÌÂÌËÈ ·˚ÎÓ Ò‚flÁ‡ÌÓ Ò Ì‰ÓÒÚ‡ÚÓ˜Ì˚Ï „ÂÏÂÚËÁÏÓÏ ÊÂΘÌ˚ı ÔÛÚÂÈ. Ç˚ÒÓ͇fl ÒÂÎÂÍÚË‚ÌÓÒÚ¸ ‚ÓÁ‰ÂÈÒÚ‚Ëfl ‚Ó‰ÓÒÚÛÈÌÓ„Ó
‰ËÒÒÂÍÚÓ‡ ÔÓÁ‚ÓÎË· ÔˆËÁËÓÌÌÓ ‚˚‰ÂÎflÚ¸ ˝ÚË
ÒÚÛÍÚÛ˚ Ë ÒÓÍ‡ÚËÚ¸ ˜‡ÒÚÓÚÛ ÔÓ‰Ó·Ì˚ı ÓÒÎÓÊÌÂÌËÈ. ëΉÒÚ‚ËÂÏ ÛÏÂ̸¯ÂÌËfl ˜‡ÒÚÓÚ˚ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÓÒÎÓÊÌÂÌËÈ fl‚ËÎÓÒ¸ ÒÓÍ‡˘ÂÌËÂ
‰ÎËÚÂθÌÓÒÚË Ô·˚‚‡ÌËfl Ô‡ˆËÂÌÚ‡ ‚ ÒÚ‡ˆËÓ̇Â
ÔÓÒΠÓÔÂ‡ˆËË ‚ Ò‰ÌÂÏ ‚ 1.5 ‡Á‡ (Ò 26 ‰Ó
18 ‰ÌÂÈ). ùÚÓ Ì ÚÓθÍÓ Ò‚Ë‰ÂÚÂθÒÚ‚ÛÂÚ Ó· ÛÎÛ˜¯ÂÌËË ·ÎËʇȯËı ÂÁÛθڇÚÓ‚ ΘÂÌËfl Ô‡ˆËÂÌÚÓ‚, ÌÓ Ë ËÏÂÂÚ ·Î‡„ÓÔËflÚÌÓ ˝ÍÓÌÓÏ˘ÂÒÍÓ Á̇˜ÂÌËÂ, Ú‡Í Í‡Í ÛÏÂ̸¯‡ÂÚ ÒÚÓËÏÓÒÚ¸ ΘÂÌËfl Ô‡ˆËÂÌÚÓ‚ Ò ıËÛ„˘ÂÒÍËÏË Á‡·Ó΂‡ÌËflÏË Ô˜ÂÌË.
56
éÚÒÛÚÒÚ‚Ë ÒÚ‡ÚËÒÚ˘ÂÒÍË ‰ÓÒÚÓ‚ÂÌÓÈ ‡ÁÌˈ˚ ÏÂÊ‰Û Ò‡‚ÌË‚‡ÂÏ˚ÏË „ÛÔÔ‡ÏË ÔÓ fl‰Û ÔÓ͇Á‡ÚÂÎÂÈ (Ó·˙ÂÏ ÍÓ‚ÓÔÓÚÂË, ÔÓ‰ÓÎÊËÚÂθÌÓÒÚ¸ ÓÔÂ‡ˆËË), ‚ÂÓflÚÌ ‚Ò„Ó, Ò‚flÁ‡ÌÓ Ò Ì‰ÓÒÚ‡ÚÓ˜Ì˚Ï ÍÓ΢ÂÒÚ‚ÓÏ Ì‡·Î˛‰ÂÌËÈ. ç‡ Ì‡¯
‚Á„Îfl‰, ÓÚÌÓÒËÚÂθÌ˚Ï Ì‰ÓÒÚ‡ÚÍÓÏ Ôӂ‰ÂÌÌÓ„Ó
ËÒÒΉӂ‡ÌËfl fl‚ÎflÂÚÒfl ÓÚÒÛÚÒÚ‚Ë ÚÂÚ¸ÂÈ „ÛÔÔ˚
Ô‡ˆËÂÌÚÓ‚, ÍÓÚÓ˚Ï ÂÁÂ͈Ëfl Ô˜ÂÌË ·˚· ·˚ ‚˚ÔÓÎÌÂ̇ Ò ÔËÏÂÌÂÌËÂÏ ‰Û„Ó„Ó ÔË·Ó‡ – ÛθÚ‡Á‚ÛÍÓ‚Ó„Ó ‰ËÒÒÂÍÚÓ‡, ‚Ò ¯Ë ‚̉flÂÏÓ„Ó ‚
ÍÎËÌ˘ÂÒÍÛ˛ Ô‡ÍÚËÍÛ ‚ ÔÓÒΉÌË „Ó‰˚ Ë Ô‰ÒÚ‡‚Îfl˛˘Â„Ó ÒÓ·ÓÈ ÚÂıÌÓÎӄ˲, ‡Î¸ÚÂ̇ÚË‚ÌÛ˛
‚Ó‰ÓÒÚÛÈÌÓÈ ‰ËÒÒÂ͈ËË. ëÂÎÂÍÚË‚ÌÓÒÚ¸ ‚ÓÁ‰ÂÈÒÚ‚Ëfl Ì ‡Á΢‡ÂÚÒfl ‰ÓÒÚÓ‚ÂÌÓ ÔË ÔËÏÂÌÂÌËË
˝ÚËı ÏÂÚÓ‰Ó‚ ‰ËÒÒÂ͈ËË (˜ËÒÎÓ ËÁÓÎËÛÂÏ˚ı ÒÓÒÛ‰Ó‚ ̇ ‰ËÌËˆÛ ‡Ì‚ÓÈ ÔÓ‚ÂıÌÓÒÚË ÍÛθÚË Ô˜ÂÌË: ‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ 3.28 ± 0.49 ̇ 1 ÒÏ2;
ÛθÚ‡Á‚ÛÍÓ‚ÓÈ ‰ËÒÒÂÍÚÓ 3.65 ± 0.61 ̇ 1 ÒÏ2)
[49]. Ç ÓÒÌÓ‚Â ‰ÂÈÒÚ‚Ëfl ÛθÚ‡Á‚ÛÍÓ‚Ó„Ó ‰ËÒÒÂÍÚÓ‡ (ultrasonic dissector, “Cavitron Ultrasonic Surgical Aspirator” ËÎË CUSA) ÎÂÊËÚ ÔÂÓ·‡ÁÓ‚‡ÌËÂ
˝ÎÂÍÚ˘ÂÒÍËı ÍÓη‡ÌËÈ ‚ ‚˚ÒÓÍÓ˜‡ÒÚÓÚÌ˚ ÏÂ-
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
èÖóÖç¸
ëäàèÖçäé Ë ‰.
퇷Îˈ‡ 5. ùÙÙÂÍÚË‚ÌÓÒÚ¸ ‡Á΢Ì˚ı ÏÂÚÓ‰ËÍ ‰ËÒÒÂ͈ËË Ô‡ÂÌıËÏ˚ Ô˜ÂÌË [49]
åÂÚÓ‰ ‰ËÒÒÂ͈ËË
èÓ͇Á‡ÚÂθ
‚Ó‰ÓÒÚÛÈÌ˚È ÛθÚ‡Á‚ÛÍÓ‚ÓÈ ‡Á‰‡‚ÎË‚‡ÌËÂ
‰ËÒÒÂÍÚÓ
‰ËÒÒÂÍÚÓ
Ô‡ÂÌıËÏ˚
(n = 78)
(n = 153)
(n = 230)
äÓ‚ÓÔÓÚÂfl, ÏΠ̇ 1 ÒÏ2 ÔÓ‚ÂıÌÓÒÚË
ÇÂÏfl ‰ËÒÒÂ͈ËË, ÏËÌ Ì‡ 1 ÒÏ2 ÔÓ‚ÂıÌÓÒÚË
17.3
28.7
0.35
74.6
0.82
1.28

<0.001
0.001
éÒÎÓÊÌÂÌËfl, %
ÜÂΘÌ˚Â Ò‚Ë˘Ë
3.8
5.2
3.0
Ä·ÒˆÂÒÒ˚ ·˛¯ÌÓÈ ÔÓÎÓÒÚË
2.6
5.9
3.5
ãÂڇθÌÓÒÚ¸ („ÓÒÔËڇθ̇fl)
5.1
2.6
3.1
ı‡Ì˘ÂÒÍË (˜‡ÒÚÓÚ‡ 23 ËÎË 36 ÍɈ, ‰ÎË̇ ‚ÓÎÌ˚
100 ÏÍÏ). èË ˝ÚÓÏ Ó‰ÌÓ‚ÂÏÂÌÌÓ ÒÓ‚Â¯‡ÂÚÒfl
ÚË ÔÓˆÂÒÒ‡: ÛθÚ‡Á‚ÛÍÓ‚‡fl ͇‚ËÚ‡ˆËfl, ËË„‡ˆËfl Ë ‡ÒÔË‡ˆËfl [48]. ìθÚ‡Á‚ÛÍÓ‚˚ ÍÓη‡ÌËfl
̇ÍÓ̘ÌË͇ ÒÂÎÂÍÚË‚ÌÓ ‡ÁÛ¯‡˛Ú ÍÎÂÚÍË Ô˜ÂÌË, ÒÓı‡Ìflfl ÌÂÔÓ‚ÂʉÂÌÌ˚ÏË ÚÛ·˜‡Ú˚Â
ÒÚÛÍÚÛ˚ ‰Ë‡ÏÂÚÓÏ ·ÓΠ1 ÏÏ, ˜ÚÓ ‰Â·ÂÚ ‚ÓÁÏÓÊÌ˚Ï Ëı ÎË„ËÓ‚‡ÌË ¢ ‰Ó ÔÂÂÒ˜ÂÌËfl [34].
ìθÚ‡Á‚ÛÍÓ‚ÓÈ ‰ËÒÒÂÍÚÓ Ì ӷ·‰‡ÂÚ „ÂÏÓÒÚ‡Ú˘ÂÒÍËÏË Ò‚ÓÈÒÚ‚‡ÏË, ÔÓ˝ÚÓÏÛ ÔÓÒΠ‚ËÁÛ‡ÎËÁ‡ˆËË
ÒÓÒÛ‰ËÒÚ˚ı ÒÚÛÍÚÛ „ÂÏÓÒÚ‡Á ÓÒÛ˘ÂÒÚ‚ÎflÂÚÒfl
Ó·˚˜Ì˚ÏË ÏÂÚÓ‰‡ÏË [44]. äÎËÌ˘ÂÒÍË ÂÁÛθڇÚ˚ ÔËÏÂÌÂÌËfl ÛθÚ‡Á‚ÛÍÓ‚Ó„Ó ‰ËÒÒÂÍÚÓ‡ ÔÓ‰Ú‚Âʉ‡˛Ú Â„Ó ˝ÙÙÂÍÚË‚ÌÓÒÚ¸ ÔË ÂÁÂ͈ËË Ô˜ÂÌË: ÛÏÂ̸¯‡ÂÚÒfl Ó·˙ÂÏ ÍÓ‚ÓÔÓÚÂË Ë „ÂÏÓÚ‡ÌÒÙÛÁËË, ÒÌËʇÂÚÒfl ˜‡ÒÚÓÚ‡ ÓÒÎÓÊÌÂÌËÈ [7, 9,
17, 19, 60]. éÚϘÂÌÓ, ˜ÚÓ ÛθÚ‡Á‚ÛÍÓ‚ÓÈ ‰ËÒÒÂÍÚÓ Á‡ Ò˜ÂÚ ÓÚÒÛÚÒÚ‚Ëfl ÔÂÌÓÓ·‡ÁÓ‚‡ÌËfl Ó·ÂÒÔ˜˂‡ÂÚ ÎÛ˜¯ËÈ ‚ËÁۇθÌ˚È ÍÓÌÚÓθ [49].
ë‡‚ÌËÚÂθÌÓ ËÁÛ˜ÂÌË ˝ÙÙÂÍÚË‚ÌÓÒÚË ‡Á΢Ì˚ı ÏÂÚÓ‰ËÍ ‰ËÒÒÂ͈ËË Ô˜ÂÌË (‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ, ÛθÚ‡Á‚ÛÍÓ‚ÓÈ ‰ËÒÒÂÍÚÓ Ë ‡Á‰‡‚ÎË‚‡ÌË ԇÂÌıËÏ˚ Ô˜ÂÌË) ‚˚fl‚ËÎÓ ÒÓÍ‡˘ÂÌË ӷ˙Âχ ËÌÚ‡ÓÔÂ‡ˆËÓÌÌÓÈ ÍÓ‚ÓÔÓÚÂË,
„ÂÏÓÚ‡ÌÒÙÛÁËË Ë ‚ÂÏÂÌË ‰ËÒÒÂ͈ËË ÔË ËÒÔÓθÁÓ‚‡ÌËË ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ ·ÂÁ ‰ÓÒÚÓ‚ÂÌÓÈ ‡ÁÌˈ˚ ‚ ˜‡ÒÚÓÚ ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÓÒÎÓÊÌÂÌËÈ [2, 49, 50, 54, 61] (Ú‡·Î. 5).
ÇÓÁ‚‡˘‡flÒ¸ Í ‚ÓÔÓÒÛ Ó ‚Ó‰ÓÒÚÛÈÌÓÈ ‰ËÒÒÂ͈ËË, ÌÂÓ·ıÓ‰ËÏÓ ÓÚÏÂÚËÚ¸, ˜ÚÓ ‚ÂÓflÚÌÓÒÚ¸
ÔÓ‚ÂʉÂÌËfl Ó„‡ÌÓ‚ ·˛¯ÌÓÈ ÔÓÎÓÒÚË ‚Ó‰ÌÓÈ
ÒÚÛÂÈ Ì‚ÂÎË͇, ÌÓ Ó̇ ‚Ò Ê ÒÛ˘ÂÒÚ‚ÛÂÚ Ë Ó·
˝ÚÓÏ ÌÛÊÌÓ ÔÓÏÌËÚ¸. í‡Í, ÔË ‰‡‚ÎÂÌËË 100 ·‡ Ë
‰Ë‡ÏÂÚ ÒÓÔ· 0.1 ÏÏ ÚӘ˜ÌÓ ‚ÓÁ‰ÂÈÒÚ‚Ë ̇
ÒÚÂÌÍÛ Í˯ÍË ‚ Ú˜ÂÌË 6–7 Ò Ò ‡ÒÒÚÓflÌËfl ÏÂÌÂÂ
3 ÒÏ ÏÓÊÂÚ ‚˚Á‚‡Ú¸ ÔÂÙÓ‡ˆË˛, Ӊ̇ÍÓ Ô‡ÍÚ˘ÂÒÍË Ú‡ÍÓ„Ó Ì ÔÓËÒıÓ‰ËÚ [49].
àÒÔÓθÁÓ‚‡ÌË ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ ÔË
ÂÁÂ͈ËË Ô˜ÂÌË ÔÓ ÔÓ‚Ó‰Û ÁÎÓ͇˜ÂÒÚ‚ÂÌÌ˚ı ÌÓ‚ÓÓ·‡ÁÓ‚‡ÌËÈ ‰ÓÒÚ‡ÚÓ˜ÌÓ ·ÂÁÓÔ‡ÒÌÓ, Ú‡Í Í‡Í ÌÂ
‚˚Á˚‚‡ÂÚ ‰ËÒÒÂÏË̇ˆËË ÓÔÛıÓ΂˚ı ÍÎÂÚÓÍ ÔÓ
·˛¯ÌÓÈ ÔÓÎÓÒÚË Ë Ì ÔË‚Ó‰ËÚ Í ÒÓÍ‡˘ÂÌ˲
5-ÎÂÚÌÂÈ ‚˚ÊË‚‡ÂÏÓÒÚË [30].
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
ÇÓ‰Ì˚È Ò͇θÔÂθ ̇ıÓ‰ËÚ Ò‚Ó ÏÂÒÚÓ Ë ‚ ·ԇÓÒÍÓÔËË. ëÓÁ‰‡Ì˚ ‡Á΢Ì˚ ÏÓ‰ËÙË͇ˆËË
ÚÓÌÍËı Ë Î„ÍËı ‡ÔÔÎË͇ÚÓÓ‚, ÍÓÚÓ˚ ÏÓÊÌÓ
ÔÓ‚ÂÒÚË ˜ÂÂÁ ·ԇÓÒÍÓÔ˘ÂÒÍË ÔÓÚ˚ [14,
57]. ë‡‚ÌÂÌË ÂÁÛθڇÚÓ‚ ÂÁÂ͈ËË Ô˜ÂÌË Ò
ÔËÏÂÌÂÌËÂÏ ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡, ‚˚ÔÓÎÌÂÌÌÓÈ Î‡Ô‡ÓÒÍÓÔ˘ÂÒÍË Ë ˜ÂÂÁ ·ԇÓÚÓÏÌ˚È
‰ÓÒÚÛÔ, ‚˚fl‚ËÎÓ ÒÓÍ‡˘ÂÌË ÔÓ‰ÓÎÊËÚÂθÌÓÒÚË
ÓÔÂ‡ˆËË (‚ 1.5 ‡Á‡) Ë Ô·˚‚‡ÌËfl ‚ ÒÚ‡ˆËÓ̇Â
ÔÓÒΠÓÔÂ‡ˆËË ‚ ÓÒÌÓ‚ÌÓÈ „ÛÔÔ (‚ 1.5 ‡Á‡). çÂ
·˚ÎÓ ÓÚϘÂÌÓ ‰ÓÒÚÓ‚ÂÌ˚ı ‡Á΢ËÈ ‚ ‰ÎËÚÂθÌÓÒÚË ÓÔÂ‡ˆËË Ë Ó·˙ÂÏ ÍÓ‚ÓÔÓÚÂË [52].
àÌÚÂÂÒÌ˚Ï Ë ÔÂÒÔÂÍÚË‚Ì˚Ï Ì‡Ô‡‚ÎÂÌËÂÏ
ÔËÏÂÌÂÌËfl ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ fl‚ÎflÂÚÒfl
ıËÛ„˘ÂÒÍӠΘÂÌË ԇ‡ÁËÚ‡Ì˚ı Ë ÌÂÔ‡‡ÁËÚ‡Ì˚ı ÍËÒÚ Ô˜ÂÌË. ÇÓ‰ÓÒÚÛÈ̇fl ‰ËÒÒÂ͈Ëfl
ÔÓÁ‚ÓÎflÂÚ “ˉ‡θÌÓ” ‚˚‰ÂÎflÚ¸ Ú‡ÍË ÍËÒÚ˚, ‚
ÚÓÏ ˜ËÒÎÂ Ë ‡ÒÔÓÎÓÊÂÌÌ˚ „ÎÛ·ÓÍÓ ‚ Ô‡ÂÌıËÏÂ
Ô˜ÂÌË [29]. ì Ó‰ÌÓ„Ó ÓÔÂËÓ‚‡ÌÌÓ„Ó Ì‡ÏË Ô‡ˆËÂÌÚ‡ ‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ ·˚Î ÔËÏÂÌÂÌ ‰Îfl
ÔÂˈËÒÚ˝ÍÚÓÏËË ˝ıËÌÓÍÓÍÍÓ‚ÓÈ ÍËÒÚ˚ ËÁ ÓÒÚ‡‚¯ÂÈÒfl ΂ÓÈ ‰ÓÎË ÔÓÒΠÔ‡‚ÓÒÚÓÓÌÌÂÈ „ÂÏË„ÂÔ‡Ú˝ÍÚÓÏËË ÔÓ ÔÓ‚Ó‰Û ÏÌÓÊÂÒÚ‚ÂÌÌÓ„Ó ˝ıËÌÓÍÓÍÍÓÁ‡.
çÂÓ·ıÓ‰ËÏÓ ÓÚÏÂÚËÚ¸, ˜ÚÓ ‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ ̇ıÓ‰ËÚ ÔËÏÂÌÂÌË ‚ ‰Û„Ëı ӷ·ÒÚflı ıËÛ„ËË, ÔÓÏËÏÓ „ÂÔ‡ÚÓ·ËΡÌÓÈ, – ‚ ÌÂÈÓıËÛ„ËË [25, 28, 43, 46], ÛÓÎÓ„ËË [11, 13, 58], ÚÓ‡Í‡Î¸ÌÓÈ ıËÛ„ËË [32], ˜ÂβÒÚÌÓ-Îˈ‚ÓÈ ıËÛ„ËË [37,
59], Ô·ÒÚ˘ÂÒÍÓÈ ıËÛ„ËË [62], ÓÚÓÔ‰ËË [22].
á‡Íβ˜ÂÌËÂ
êÂÁÛθڇÚ˚, ÔÓÎÛ˜ÂÌÌ˚ ‚ ‰‡ÌÌÓÏ ˝ÍÒÔÂËÏÂÌڇθÌÓ-ÍÎËÌ˘ÂÒÍÓÏ ËÒÒΉӂ‡ÌËË, ÔÓ͇Á˚‚‡˛Ú, ˜ÚÓ ÏÂÚÓ‰ ‚Ó‰ÓÒÚÛÈÌÓÈ ‰ËÒÒÂ͈ËË ÔË ÂÁÂ͈ËË Ô˜ÂÌË ÔÓÁ‚ÓÎflÂÚ ÒÂÎÂÍÚË‚ÌÓ ‚˚‰ÂÎflÚ¸
ÚÛ·˜‡Ú˚ ÒÚÛÍÚÛ˚ Ô˜ÂÌË Ë ÔÓËÁ‚Ó‰ËÚ¸ Ëı
ÔˆËÁËÓÌÌÛ˛ Ó·‡·ÓÚÍÛ, Ó·ÂÒÔ˜˂‡fl ıÓÓ¯ËÈ
‚ËÁۇθÌ˚È ÍÓÌÚÓθ ÁÓÌ˚ ‰ËÒÒÂ͈ËË Ë ÏÂ̸¯Û˛
Ú‡‚χÚËÁ‡ˆË˛ Ô‡ÂÌıËÏ˚ ÍÛθÚË Ô˜ÂÌË. äÓÏ ÚÓ„Ó, ÔË ËÒÔÓθÁÓ‚‡ÌËË ‚Ó‰ÓÒÚÛÈÌÓ„Ó ‰ËÒÒÂÍÚÓ‡ Û‰‡ÂÚÒfl ÂÊ ÔËÏÂÌflÚ¸ Pringle-χÌ‚,
‹1
2004
57
èÖóÖç¸
ùîîÖäíàÇçéëíú ÇéÑéëíêìâçéÉé ÑàëëÖäíéêÄ
˜ÚÓ ÒÓÍ‡˘‡ÂÚ ‚ÂÏfl ˯ÂÏËË Ô˜ÂÌË. ÇÒ ˝ÚÓ ‚
ÍÓ̘ÌÓÏ ËÚÓ„Â ÒÌËʇÂÚ ÒÚÂÔÂ̸ Ú‡‚χÚ˘ÌÓÒÚË
ÓÔÂ‡ˆËË, ÒÔÓÒÓ·ÒÚ‚ÛÂÚ ·ÓΠ·˚ÒÚÓÏÛ ÒÓÁ‚‡Ì˲ Û·ˆ‡ ÍÛθÚË, ‡ „·‚ÌÓÂ, ÛÏÂ̸¯‡ÂÚ ˜‡ÒÚÓÚÛ
ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ı ÓÒÎÓÊÌÂÌËÈ Ë ‰ÎËÚÂθÌÓÒÚ¸
Ô·˚‚‡ÌËfl Ô‡ˆËÂÌÚ‡ ‚ ÒÚ‡ˆËÓ̇ ÔÓÒΠÓÔÂ‡ˆËË, Ú.Â. ÛÎÛ˜¯‡ÂÚ ·ÎËʇȯË ÔÓÒÎÂÓÔÂ‡ˆËÓÌÌ˚ ÂÁÛθڇÚ˚ ΘÂÌËfl. í‡ÍËÏ Ó·‡ÁÓÏ, ‚Ó‰ÓÒÚÛÈÌ˚È ‰ËÒÒÂÍÚÓ ÏÓÊÌÓ ˝ÙÙÂÍÚË‚ÌÓ Ë ·ÂÁÓÔ‡ÒÌÓ ÔËÏÂÌflÚ¸ ÔË ÂÁÂ͈ËË Ô˜ÂÌË, ÔÓ‰ÓÎʇfl
ÔÓËÒÍ ÔÛÚÂÈ Â„Ó ÛÒÓ‚Â¯ÂÌÒÚ‚Ó‚‡ÌËfl.
14.
15.
16.
17.
ëÔËÒÓÍ ÎËÚÂ‡ÚÛ˚
1. į‡ÙÓ‚ Ä.Ä., ŇÈ‡ÏÓ‚ ç.û., åÂÎËÍÓ‚‡ å.Ñ.
ëÓ‚ÂÏÂÌÌ˚ ÏÂÚÓ‰˚ ‡ÒÒ˜ÂÌËfl Ô‡ÂÌıËÏ˚ Ô˜ÂÌË // ÄÌ̇Î˚ ıË. „ÂÔ‡ÚÓÎ. 2000. í. 5. ‹ 2. ë. 54–
60.
2. ÅÛÎ˚ÌËÌ Ç.à., è‡ıËÒÂÌÍÓ û.Ä., ÉÎÛıÓ‚ Ä.Ä. Ë ‰.
ëÚÛÈ̇fl ‰ËÒÒÂ͈Ëfl Ú͇ÌÂÈ ‚ ıËÛ„ËË Ô˜ÂÌË //
ïËÛ„Ëfl. 1996. ‹ 2. ë. 108–109.
3. LJÙËÌ Ä.á., ÄȉÂÏËÓ‚ Ä.ç., ä‡Á‡ÌˆÂ‚ ë.Ä. èÂÒÔÂÍÚË‚˚ ÔËÏÂÌÂÌËfl Ô·ÁÏÂÌÌÓ„Ó Ò͇θÔÂÎfl ‚
ıËÛ„ËË Ô˜ÂÌË. Ç ÍÌ.: “çÓ‚˚ ÚÂıÌÓÎÓ„ËË ‚ ıËÛ„˘ÂÒÍÓÈ „ÂÔ‡ÚÓÎÓ„ËË”. ë.-èÂÚÂ·Û„. 1995.
ë. 109–110.
4. Ç˯Ì‚ÒÍËÈ Ç.Ä., óÊ‡Ó Ä.ç, ç‡Á‡ÂÌÍÓ ç.Ä. Ë ‰.
ëÓ‚ÂÏÂÌÌ˚ ÔË̈ËÔ˚ ÚÂıÌËÍË ÓÔÂ‡ÚË‚Ì˚ı
‚ϯ‡ÚÂθÒÚ‚ ̇ Ô˜ÂÌË // ÄÌ̇Î˚ ıË. „ÂÔ‡ÚÓÎ.
1996. í. 1. ë. 15–23.
5. ÖÙËÏÂÌÍÓ ç.Ä., Ç.Ö. êÓÁ‡ÌÓ‚, Ç.É. äÛ‰fl‚ˆÂ‚, Ä.à. á‡ËÍËÌ. ëÓ‚ÂÏÂÌÌ˚ ÚÂıÌÓÎÓ„ËË „ÂÏÓÒÚ‡Á‡ ÔË ÓÔÂ‡ˆËflı ̇ Ô˜ÂÌË // ÄÌ̇Î˚ ıË. „ÂÔ‡ÚÓÎ. 1998. í. 3. ‹ 3. ë.189.
6. å‡ÌËθ˜ÛÍ Ä.Ç., ëÓÎÓ‚¸Â‚ Ç.Ä., ÄÚ‰Û‚ Ç.Ä. èÓÙË·ÍÚË͇ ÓÒÎÓÊÌÂÌËÈ ÔÓÒΠÂÁÂ͈ËË Ô˜ÂÌË. Ç
ÍÌ.: “çÓ‚˚ ÚÂıÌÓÎÓ„ËË ‚ ıËÛ„˘ÂÒÍÓÈ „ÂÔ‡ÚÓÎÓ„ËË”. ë.-èÂÚÂ·Û„. 1995. ë. 125–126.
7. è‡Ú˛ÚÍÓ û.à., 뇄‡È‰‡Í à.Ç., äÓÚÂθÌËÍÓ‚ Ä.É. Ë ‰. èËÏÂÌÂÌË ÒÔˆˇθÌÓÈ ıËÛ„˘ÂÒÍÓÈ ÚÂıÌËÍË ÔË ÂÁÂ͈ËË Ô˜ÂÌË. Ç ÍÌ.: “çÓ‚˚ ÚÂıÌÓÎÓ„ËË ‚ ıËÛ„˘ÂÒÍÓÈ „ÂÔ‡ÚÓÎÓ„ËË”.
ë.-èÂÚÂ·Û„. 1995. ë. 126–127.
8. ëÍËÔÂÌÍÓ é.É., åÓ‚˜ÛÌ Ä.Ä., Ö‡Ï˯‡ÌˆÂ‚ Ä.ä.,
ò‡Ú‚ÂflÌ É.Ä., ÇÓÒÍÂÒÂÌÒÍËÈ é. Ç. éÔ˚Ú ÔËÏÂÌÂÌËfl ÔÓÍ˚ÚËfl “í‡ıÓÍÓÏ·” ÔË ıËÛ„˘ÂÒÍËı
‚ϯ‡ÚÂθÒÚ‚‡ı ̇ Ô˜ÂÌË Ë ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ // ïËÛ„Ëfl. 1998. ‹ 1. ë. 11–14.
9. ò‡ÎËÏÓ‚ Ä.Ä., ò‡ÎËÏÓ‚ ë.Ä., ä‡ÎËÚ‡ ç.ü. Ë ‰.
çÓ‚˚ ÚÂıÌÓÎÓ„ËË ‚ Ô˜ÂÌÓ˜ÌÓÈ ıËÛ„ËË. Ç ÍÌ.:
“çÓ‚˚ ÚÂıÌÓÎÓ„ËË ‚ ıËÛ„˘ÂÒÍÓÈ „ÂÔ‡ÚÓÎÓ„ËË”. ë.-èÂÚÂ·Û„. 1995. ë. 151–152.
10. Baer H.U., Stain S.C., Guastella T., Maddern G.J.,
Blumgart L.H. Hepatic resection, using a water jet dissector // HPB. Surg. 1993. 6(3). P. 189–96.
11. Basting R.F., Djakovic N., Widmann P. Use of water jet
resection in organ-sparing kidney surgery // é Endourol.
2000. Aug. 14(6). P. 501–505.
12. Bengmark S. Leberchirurgie // Chir. Gastroenterol.
1987. 3. P. 5–11.
13. Corvin S., Oberneder R., Adam C., Frimberger D. et al.
Use of hydro-jet cutting for Laparoscopic partial nephre58
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
31.
32.
ctomy in porcine model // Urology 2001 Dec. 58(6).
P. 1070–1073.
Cuschieri A. Experimental evaluation of water-jet dissection in endoscopic surgery. End. Surg. 1994. ‹ 2.
P. 202–204.
Edward C.S., Sheung T.F., Chung-Mau et al. Hepatic resection for hepatocellular carcinoma // Ann. Surg. 1995.
221(3). P. 291–298.
Elias D. et al. What are the real indications for hepatectomies in metastases of colorectal origin // Gastroenterol. Clin. Biol. 1998 Dec. 22(12). P. 1048–1055.
Fan S.T., Lai E.C., Lo C.M., Chu K.M., Liu C.L.,
Wong J. Hepatectomy with an ultrasonic dissector for
hepatocellular carcinoma // Br. J. Surg. 1996 Jan. 83(1).
P. 117–120.
Fan S.T., Lo C.M., Liu C.L. et al. Hepatectomy for hepatocellular carcinoma: toward zero hospital death // Ann.
Surg. 1999. 229(3). P. 322–330.
Fasulo F., Giori A., Fissi S. et al. Cavitron Ultarsonic
Aspirator (CUSA) in liver resection // Int. surg. 1992.
‹ 77. P. 64–66.
Gertsch P., Pelloni A., Guerra A., Krpo A. Initial experience with the harmonic scalpel in liver surgery //
Hepatogastroenterology 2000 May–Jun.
47(33).
P. 763–766.
Helpap B. The morphological consequences of thermosurgery // Res. Exp. Med. Berl. 1983. 183(3). P. 215–
225.
Honl M., Rentzsch R., Lampe F., Muller V., Dierk O.
et al. Water jet cutting for bones and bone cement – parameter study of possibilities and limits of new method //
Biomed. Tech. (Berl). 2000 Sep. 45(9). P. 222–227.
Iwatsuki S., Starzl T.E. Personal experience with 411 hepatic resection. Ann. Surg. 1988. 208. P. 421–434.
Izumi R., Yabushita K. et al. Hepatic resection using water jet dissector. Jpn. J. Surg. 1993. 23. P. 31–35.
Jakob S., Kehler U., Reusche E., Friedch H.J., Arnold H.
Endoscopic use of the water jet dissector in cerebral ventricle system – an experimental study // Zentralbl Neurochir. 2000. 61(1). P. 14–21.
Joffe SN. The neodymium: YAG laser in general surgery // Contem Surg. 1985. 27. P. 17.
Jourdan J.L. et al. Hepatic resection for metastases in
colorectal carcinoma. NZ Med. J. 1999 Mar. 26.
V. 112(1084). P. 91–93.
Kaduk W.M., Stengel B., Pohl A., Nizze H., Gundlach K.K. Hydro-Jet cutting: a method for selective surgical dissection of nerve tissue. An experimental study
on the sciatic nerve of rats // é Craniomaxillofac Surg.
1999 Oct. 27(5). P. 327–330.
Kjossev K.T., Losanoff J.E. Surgery for deeply located
hydatid cysts of the liver: a simple alternative // HPB
Surg. 2000. 11(5). P. 307–310.
Kockerling F., Schwartz S.I. Liver surgery. Operative
techniques and avoidance of complications // J.A. Barth,
Heidelberg. 2001.
Lam C.M., Lo C.M., Liu C.L., Fan S. Biliary Complications during Liver Resection // World J. of Surgery. October 2001. V. 25. ‹ 10. P. 1273–1276.
Lesser T. Atypical lung parenchyma resection with the
Hydro-Jet – initial experimental and clinical experiences // Chirurg. 2000 May. 71(5). P. 592.
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
‹1
2004
èÖóÖç¸
ëäàèÖçäé Ë ‰.
33. Lin T., Tsu K. et al. Study on lobectomy of the liver //
J. Formosa. Med. Assoc. 1958. 57. P. 742–759.
34. Little J.M., Hollands M.J. Impact of the CUSA and operative ultrasound on hepatic resection // HPB. Surg.
1991. 3. P. 271–277.
35. Lo C.M., Fan S.T., Liu C.L., Lai E.C.S., Wong J. Biliary
complications after hepatic resection: risk factors, management and outcome // Arch. Surg. 1998. 733. P. 156.
36. Lucas C.E., Ledgerwood A.M. Prospective evaluation of
hemostatic techniques for liver injuries // J. Trauma.
1976. 16. P. 442–451.
37. Magritz R., Jurk V., Reusche E., Siegert R. Water-jet dissection in parotid surgery: an experimental study in
dogs // Laryngoscope 2001 Sep. 111(9). P. 1579–84.
38. Martis G., Miko I., Szendroi T., Kathy S., Kovacs J.,
Hajdu Z. Results with collagen fleece coated with fibrin
glue (TachoComb). A macroscopical and histological
experimental study // Acta-Chir-Hung. 1997. 36(1–4).
P. 221–224.
39. Miyagawa S., Makuuchi M., Kawasaki S., Kakazu T.
Criteria for safe hepatic resection // Am. J. Surg. 1995.
P. 769–589.
40. Nagino å., Kamiya J., Uesaka K., Sano T., Yamamoto H., Nimura Y. Complications of Hepatectomy for Hilar Cholangiocarcinoma // World. J. of Surgery. 2001.
25(10). P. 1277–1283.
41. Nakamura S, Sakaguchi S. et al. Agressive repeat resection for hepatic metastases of colorectal carcinoma //
Jpn. J. Surg. 1992. 22. P.260–264.
42. Ochsner G.M., Jaffin J.H. et al. Major hepatic trauma.
Surg. Clin. North. Am. 1993. 73. P. 337–352.
43. Oertel J., Gaab M.R., Knapp A., Essig H., Warzok R.,
Piek J. Water jet dissection in neurosurgery: experimental results in porcine cadaveric brain // Neurosurgery.
2003 Jan. 52(1). P. 153–159.
44. Ottow R.T., Barbieri A.S., Sugarbaker P.H., Wesley R.A.
Liver transection: a controlled study of different techniques in pigs // Surgery. 1985 May. 97(5). P. 596–601.
45. Papachristou D.N., Barters R. Resection of the liver
with a water jet // Br. J. Surg. 1982. ‹ 69. P. 93–94.
46. Piek J., Wille C., Warzok R., Gaab M.R. Waterjet dissection of the brain: experimental and first clinical results.
Technical note // J. Neurosurg. 1998. Nov. ‹ 89(5).
P. 861–864.
47. Pinkerton J.A., Sawyers J.L., Foster J.H. A study of the
postoperative course after hepatic lobectomy. // Ann.
Surg. 1971. 173(5). P. 800–811.
48. Putnam C.W. Techniques of ultrasonic dissection in resection of the liver // Surg. Gynecol. Obstet. 1983.
P. 157–158.
49. Rau H.G. Apparative und methodische Entwicklung des
Jet-Cutting fuer den Einsatz in der Leberchirurgie.
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 9
“Doktors der Chirurgie an der Ludwig-MaximiliansUniversataet”. Germany. 1994. 151 p.
50. Rau H.G., Schardey H.M. et al. The comparison of different techniques for liver resection: blunt dissection, ultrasonic aspirator and jet-cutter // Eur. J. Surg. Oncol.
1995. 21. P. 183–187.
51. Rau H.G., Buttler E., Baretton G. et al. Jet-Cutting supported by high frequency current: New technique for hepatic surgery // World. J. Surg. 1997. 21. P. 254–260.
52. Rau H.G., Buttler E., Meyer G., Schardey H.M., Schildberg F.W. Laparoscopic liver resection compared with
conventional partial hepatectomy – a prospective analysis. Hep. Gastroenterol. 1998. 45. P. 2333–2338.
53. Rau H.G., Wichmann M.W., Schinkel S., Buttler E., Pickelmann S., Schauer R., Schildberg F.W. Surgical techniques in hepatic resection: Ultrasonic aspirator versus
Jet-Cutter. A prospective randomized clinical trial // Zentrabl. Chir. 2001 Aug. 126(8). P. 586–590.
54. Savier E., Castaing D. Use of a water-jet dissector during hepatectomy. Ann. Surg. 2000 May. 125(4). P. 370–
375.
55. Scheele J., Stang R. et al. Resection of colorectal liver
metastases // World. J. Surg. 1995. 19. P. 59–71.
56. Schmidbauer S., Hallfeldt K.K., Sitzmann G., Kantelhardt T., Trupka A. Experience with ultrasound scissors and
blades (UltraCision) in open and laparoscopic liver resection // Ann. Surg. 2002 Jan. 235(1). P. 27–30.
57. Schöb O.M., Schlumpf R.B., Uhlschmid G.K., Rausis C.,
Spiess M., Largiader F. The multimode water jet dissector – a technology for Laparoscopic liver surgery / End.
Surg. 1994. 2. P. 311–314.
58. Shekarriz B. Hydro-jet cutting for Laparoscopic partial
nephrectomy in porcinr model // Urology. 2002
Jul. 60(1). P. 199–200.
59. Siegert R, Magritz R, Jurk V. Water-jet dissection in parotid surgery – initial clinical results // Laryngorhinootologie 2000 Dec. 79(12). P. 780–784.
60. Takayama T., Makuuchi M., Kubota K., Harihara Y.
et al. Randomized comparison of ultrasonic vs clamp
transection of the liver // Arch. Surg. 2001 Aug. 136(8).
P. 922–928.
61. Vollmer C.M., Dixon E., Sahajpal A., Cattral M.S. et al.
Reduced blood loss using hydro-jet technique for hepatic parenchymal dissection // J. Gastrointest. Surg. 2003
Feb. 7(2). P. 283.
62. Wanner M., Jakob S., Schwarzl Ä., Honigmann K.,
Oberholzer M., Pierer G. Water jet dissection in fatty
tissue. Swiss. Surg. 2001. 7(4). P. 173–179.
‹1
2004
59