Псевдокисты поджелудочной железы: какую тактику избрать

ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà, 2001, ÚÓÏ 6, ‹ 2, Ò. 100–105
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
èÒ‚‰ÓÍËÒÚ˚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚:
͇ÍÛ˛ Ú‡ÍÚËÍÛ ËÁ·‡Ú¸?
é. Ä. èÓÍÓٸ‚,
É. É. Äı‡Î‡‰ÁÂ,
ù. à. ɇθÔÂËÌ
éÚ‰ÂÎ ıËÛ„ËË Ô˜ÂÌË
(Á‡‚. – ÔÓÙ. ù.à. ɇθÔÂËÌ)
ååÄ ËÏ. à.å. ë˜ÂÌÓ‚‡
Ç Ì‡ÒÚÓfl˘Â ‚ÂÏfl ‰Îfl ÔÒ‚‰ÓÍËÒÚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ Ì ‚˚‡·ÓÚ‡ÌÓ ˜ÂÚÍËı
ÔÓ͇Á‡ÌËÈ, ÍÓ„‰‡ ÒΉÛÂÚ ÔÓ‚Ó‰ËÚ¸ ıËÛ„˘ÂÒÍÓ ‚ϯ‡ÚÂθÒÚ‚Ó, ÍÓ„‰‡ χÎÓËÌ‚‡ÁË‚ÌÓÂ, ‡ ‚ ͇ÍËı ÒÎÛ˜‡flı ÔˉÂÊË‚‡Ú¸Òfl ‚˚Êˉ‡ÚÂθÌÓÈ Ú‡ÍÚËÍË. ñÂθ ̇ÒÚÓfl˘Â„Ó ËÒÒΉӂ‡ÌËfl – ‚˚flÒÌËÚ¸, ÔË Ì‡Î˘ËË Í‡ÍËı Ô‡‡ÏÂÚÓ‚ ‚ÂÓflÚÌ ‚ÒÂ„Ó ÔÓËÒıÓ‰ËÚ ÂÁÓ·ˆËfl ÔÒ‚‰ÓÍËÒÚ, ‡ Ú‡ÍÊ ͇ÍË هÍÚÓ˚ ‚ÎËfl˛Ú ̇ ‡Á‚ËÚË ÓÒÎÓÊÌÂÌËÈ. Ç ‡·ÓÚ Ô‰ÒÚ‡‚ÎÂÌ ÂÚÓÒÔÂÍÚË‚Ì˚È ‡Ì‡ÎËÁ 210 ·ÓθÌ˚ı Ò ÔÒ‚‰ÓÍËÒÚ‡ÏË
ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚, ÔÓıӉ˂¯Ëı ΘÂÌË ‚ éÚ‰ÂΠıËÛ„ËË Ô˜ÂÌË çàñ
ååÄ ËÏ. à.å. ë˜ÂÌÓ‚‡ Ò 1987 ÔÓ 2000 „„. àÁ 171 Ô‡ˆËÂÌÚÓ‚, Û ÍÓÚÓ˚ı Ì ÓÚϘÂÌÓ
ÔËÁ̇ÍÓ‚ ÓÒÎÓÊÌÂÌËfl ÔÒ‚‰ÓÍËÒÚ, ‚˚‰ÂÎËÎË 70 ·ÓθÌ˚ı, ÍÓÚÓ˚Ï Ì ÔÓ‚Ó‰ËÎË Í‡ÍËÂ-ÎË·Ó ‚ϯ‡ÚÂθÒÚ‚‡. ùÚËı ·ÓθÌ˚ı ‡Á‰ÂÎËÎË Ì‡ ÚË „ÛÔÔ˚: I „ÛÔÔ‡ (n = 28) –
·ÓθÌ˚Â, Û ÍÓÚÓ˚ı ÔÓËÁӯ· ÂÁÓ·ˆËfl ÔÒ‚‰ÓÍËÒÚ Á‡ ÔÂËÓ‰ „ÓÒÔËÚ‡ÎËÁ‡ˆËË
(26.6 ± 13.0 ‰ÌÂÈ); II „ÛÔÔ‡ (n = 22) – ·ÓθÌ˚Â, Û ÍÓÚÓ˚ı ÔÒ‚‰ÓÍËÒÚ˚ ÂÁÓ·ËÓ‚‡ÎËÒ¸ ‚ ·ÓΠÓÚ‰‡ÎÂÌÌÓÏ ÔÂËӉ (4.3 ± 3.7 ÎÂÚ) Ë III „ÛÔÔ‡ (n = 20) – ·ÓθÌ˚Â, Û ÍÓÚÓ˚ı Á‡ ÔÂËÓ‰ ̇·Î˛‰ÂÌËfl ÂÁÓ·ˆËË ÍËÒÚ Ì ÔÓËÁÓ¯ÎÓ. ë‡‚ÌÂÌË ÔÓ ‚ÓÁ‡ÒÚÛ,
‰ÎËÚÂθÌÓÒÚË ÒÚ‡ˆËÓ̇ÌÓ„Ó Î˜ÂÌËfl, ÒÓÍ‡Ï ÒÛ˘ÂÒÚ‚Ó‚‡ÌËfl ÍËÒÚ˚, ÎÓ͇ÎËÁ‡ˆËË Ë
‡ÁÏÂÛ ÔÒ‚‰ÓÍËÒÚ˚ ‚˚fl‚ËÎÓ, ˜ÚÓ ÒÛ˘ÂÒÚ‚ÛÂÚ ‰ÓÒÚÓ‚Â̇fl ‡ÁÌˈ‡ ‚ ‡ÁÏÂ‡ı
ÔÒ‚‰ÓÍËÒÚ ‚ „ÛÔÔ‡ı I, II Ë III (3.8 ± 1.81 ÒÏ; 4.6 ± 1.46 ÒÏ; 6.15 ± 3.68 ÒÏ (p < 0.01) ÒÓÓÚ‚ÂÚÒÚ‚ÂÌÌÓ). éÚϘÂÌÓ, ˜ÚÓ ÔË ‰ÎËÚÂθÌÓÒÚË Á‡·Ó΂‡ÌËfl ‰Ó 1/2 „Ó‰‡ ÔÓËÒıÓ‰ËÚ
ÂÁÓ·ˆËfl 85.7% ÔÒ‚‰ÓÍËÒÚ, ÔË ‰ÎËÚÂθÌÓÒÚË ·ÓΠ1/2 „Ó‰‡ – ÚÓθÍÓ 62%. ë ˆÂθ˛ ‚˚fl‚ÎÂÌËfl Ô‰‡ÒÔÓ·„‡˛˘Ëı Í ÓÒÎÓÊÌÂÌ˲ Ù‡ÍÚÓÓ‚, ·ÓθÌ˚Â Ò ÌÂÓÒÎÓÊÌÂÌÌ˚ÏË ÍËÒÚ‡ÏË „ÛÔÔ˚ I Ë II Ò‡‚ÌË‚‡ÎËÒ¸ Ò „ÛÔÔ‡ÏË ·ÓθÌ˚ı Ò ÓÒÎÓÊÌÂÌÌ˚ÏË
ÔÒ‚‰ÓÍËÒÚ‡ÏË: Ò Ì‡„ÌÓÂÌËÂÏ (n = 25) Ë Ò ÏÂı‡Ì˘ÂÒÍÓÈ ÊÂÎÚÛıÓÈ, ‚˚Á‚‡ÌÌÓÈ ÔÒ‚‰ÓÍËÒÚÓÈ (n = 18). Ç˚fl‚ÎÂÌÓ, ˜ÚÓ Ò Û‚Â΢ÂÌËÂÏ ‡ÁÏÂ‡ ÔÒ‚‰ÓÍËÒÚ˚ Ë ‰ÎËÚÂθÌÓÒÚË Á‡·Ó΂‡ÌËfl, ̇‡ÒÚ‡ÂÚ ˜‡ÒÚÓÚ‡ ‚ÓÁÌËÍÌÓ‚ÂÌËfl ÓÒÎÓÊÌÂÌËÈ. ç‡ ÓÒÌÓ‚‡ÌËË ÔÓÎÛ˜ÂÌÌ˚ı ‰‡ÌÌ˚ı ÏÓÊÌÓ Ò‰Â·ڸ ‚˚‚Ó‰, ˜ÚÓ ıËÛ„˘ÂÒÍӠΘÂÌË ÔÓ͇Á‡ÌÓ ÔË
ÔÒ‚‰ÓÍËÒÚ‡ı ·ÓΠ6 ÒÏ, ‰ÎËÚÂθÌÓ (·ÓΠ6 ÏÂÒflˆÂ‚) ÒÛ˘ÂÒÚ‚Û˛˘Ëı, ‡ Ú‡ÍÊ ÓÒÎÓÊÌÂÌÌ˚ı ÔÒ‚‰ÓÍËÒÚ‡ı ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚.
Pancreatic Pseuodocysts:
What Tactics Should Be Chosen?
O. A. Prokofiev,
G. G. Akhaladze,
E. I. Galperin
Liver Surgery Department
(Chief – Prof. E.I. Galperin)
I.M. Sechenov Moscow Medical
Academy
Surgical treatment of pancreatic pseudocysts is difficult and current problem of pancreatology.
The present study was aimed to find out the combination of indicators for spontaneous resolution of the cysts. From 1987 to 2000, 210 patients were analyzed. Out of 171 patients with
asymptomatic cysts, 70 non operated patients were selected and divided on tree groups:
I group (n = 28) – with resolution during hospital-stay (26.6 ± 13.0 days); II group (n = 22) –
with spontaneous resolution during follow-up period (4.3 ± 3.7 years); III group (n = 20) –
without spontaneous disappearance neither in hospital-stay, nor in follow-up period. No significant difference in age, hospital-stay duration and pseudocysts localization were found, but
the size of pseudocysts in I, II, III group differ significant (3.8 ± 1.81 cm; 4.6 ± 1.46 cm; 6.15 ±
± 3.68 cm (p < 0.01) respectively). Noted, that 85.7% of spontaneous resolution occurred in
pseudocysts, which existed within 1/2 year from acute pansreatitis or trauma, only 62% resolutions occurred in patients with disease more than 1/2 year. In order to find the predisposal
to complication factors, I, II group patients and patients with infected pseudocysts (n = 25)
and jaundice (n = 18) were compard. It is shown, that complication rate correlate with increase
of the size and duration of disease. In conclusion, the surgical treatment is indicate for
pseudocysts greater than 6 cm, chronic (longer than 6 months) and complicated pseudocysts.
ãÓÊÌ˚Â, Ú‡Í Ì‡Á˚‚‡ÂÏ˚ ÔÓÒÚÌÂÍÓÚ˘ÂÒÍËÂ,
ÍËÒÚ˚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ Ô‰ÒÚ‡‚Îfl˛Ú ÒÓ·ÓÈ Á‡Íβ˜ÂÌÌ˚ ‚ ÒÓ‰ËÌËÚÂθÌÓÚ͇ÌÌÛ˛ Ó·ÓÎÓ˜ÍÛ ÒÍÓÔÎÂÌËfl ÊˉÍÓÒÚË, ‚ÓÁÌËͯË ‚ ÂÁÛθڇÚ ‰ÂÒÚÛ͈ËË Ú͇ÌË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚
‚ÓÒÔ‡ÎËÚÂθÌÓ„Ó ËÎË Ú‡‚χÚ˘ÂÒÍÓ„Ó ÔÓËÒ-
ıÓʉÂÌËfl. ÇÓÔÓÒ Ó Î˜ÂÌËË ÔÒ‚‰ÓÍËÒÚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ Ò˜ËÚ‡ÂÚÒfl ÒÎÓÊÌ˚Ï Ë ÌÂ¯ÂÌÌ˚Ï.
åÌÓ„Ë ‡‚ÚÓ˚ ‚ ͇˜ÂÒÚ‚Â ÏÂÚÓ‰‡ ‚˚·Ó‡ ËÒÔÓθÁÛ˛Ú ÚÓθÍÓ ıËÛ„˘ÂÒÍӠΘÂÌËÂ, Ô‰ÔÓ·„‡˛˘Â ̇ÛÊÌÓ ËÎË ‚ÌÛÚÂÌÌ ‰ÂÌËÓ‚‡-
100
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
èêéäéîúÖÇ Ë ‰.
ÌË ÎË·Ó ÂÁÂÍˆË˛ ÊÂÎÂÁ˚ [16, 17, 19, 27, 32]. í‡ÍË ‚ϯ‡ÚÂθÒÚ‚‡ Ú‡‚χÚ˘Ì˚, ‚Ò„‰‡ ËÏÂÂÚÒfl
‚˚ÒÓÍËÈ ËÒÍ ÓÒÎÓÊÌÂÌËÈ. èÓÒΠÔÓ‰Ó·Ì˚ı ‚ϯ‡ÚÂθÒÚ‚ ̇·Î˛‰‡˛ÚÒfl „ÎÛ·ÓÍË ̇Û¯ÂÌËfl ‚
ËÏÏÛÌÌÓÈ ÒËÒÚÂÏÂ, ÔÓ‚˚¯‡ÂÚÒfl ËÒÍ ‡Á‚ËÚËfl ˝ÍÁÓ- Ë ˝Ì‰ÓÍËÌÌÓÈ Ì‰ÓÒÚ‡ÚÓ˜ÌÓÒÚË, ÒÌËʇÂÚÒfl
͇˜ÂÒÚ‚Ó ÊËÁÌË Ô‡ˆËÂÌÚÓ‚ [2]. Ç ÚÓ Ê ‚ÂÏfl fl‰
‡‚ÚÓÓ‚ ‡„ËÚËÛ˛Ú Á‡ ÔËÏÂÌÂÌË ÚÓθÍÓ Ï‡ÎÓËÌ‚‡ÁË‚Ì˚ı ÏÂÚÓ‰Ó‚ ΘÂÌËfl [1, 13, 14, 20, 26, 30].
ùÚË ‚ϯ‡ÚÂθÒÚ‚‡ ÏÂÌ Ú‡‚χÚ˘Ì˚ Ë ‰‡˛Ú
ÏÂ̸¯Â ÍÓ΢ÂÒÚ‚Ó ÓÒÎÓÊÌÂÌËÈ, ÌÓ ÂÒÚ¸ ÔÒ‚‰ÓÍËÒÚ˚, ÍÓÚÓ˚ ‚ÓÁÌËÍÎË Ì‡ ÙÓÌ ‰ÎËÚÂθÌÓ ÒÛ˘ÂÒÚ‚Û˛˘Â„Ó ıÓÌ˘ÂÒÍÓ„Ó Ô‡ÌÍ‡ÚËÚ‡, ËϲÚ
“ÒÙÓÏËÓ‚‡ÌÌÛ˛” ÚÓÎÒÚÛ˛ ÒÚÂÌÍÛ, ÒÓÓ·˘‡˛ÚÒfl
Ò ÔÓÚÓÍÓÏ. ÑÓ·ËÚ¸Òfl Ó·ÎËÚÂ‡ˆËË ÔÓÎÓÒÚË ÍËÒÚ˚ ‚ Ú‡ÍËı ÒÎÛ˜‡flı ÚÓθÍÓ Ò ÔÓÏÓ˘¸˛ χÎÓËÌ‚‡ÁË‚Ì˚ı ÏÂÚÓ‰Ó‚ ·˚‚‡ÂÚ ‰Ó‚ÓθÌÓ ÚÛ‰ÌÓ.
ÑÓ Ì‡ÒÚÓfl˘Â„Ó ‚ÂÏÂÌË ˜ÂÚÍÓ Ì ÓÔ‰ÂÎÂÌÓ,
‚ ͇ÍËı ÒÎÛ˜‡flı ÒΉÛÂÚ ÔÓ‚Ó‰ËÚ¸ ıËÛ„˘ÂÒÍËÂ
‚ϯ‡ÚÂθÒÚ‚‡, ‚ ͇ÍËı – χÎÓËÌ‚‡ÁË‚Ì˚Â, ‡ ‚ ͇ÍËı – ÔˉÂÊË‚‡Ú¸Òfl ‚˚Êˉ‡ÚÂθÌÓÈ Ú‡ÍÚËÍË
[4, 6, 28, 32]. íÛ‰ÌÓ ÓÚ‚ÂÚËÚ¸ ̇ ‚ÓÔÓÒ, ͇ÍËÂ
ÔÒ‚‰ÓÍËÒÚ˚ ÒÔÓÒÓ·Ì˚ ÂÁÓ·ËÓ‚‡Ú¸Òfl Ò‡ÏÓÒÚÓflÚÂθÌÓ, ‡ ͇ÍË ÔÓ‰ÎÂÊ‡Ú ıËÛ„˘ÂÒÍÓÏÛ Î˜ÂÌ˲.
å‡ÚÂË‡Î Ë ÏÂÚÓ‰˚
è‰ÒÚ‡‚ÎÂÌ ÂÚÓÒÔÂÍÚË‚Ì˚È ‡Ì‡ÎËÁ ΘÂÌËfl
210 ·ÓθÌ˚ı (ÍÓ΢ÂÒÚ‚Ó „ÓÒÔËÚ‡ÎËÁ‡ˆËÈ 243) Ò
ÔÒ‚‰ÓÍËÒÚ‡ÏË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚, ̇ıӉ˂¯ËıÒfl ̇ ΘÂÌËË ‚ ÓÚ‰ÂΠıËÛ„ËË Ô˜ÂÌË ååÄ
ËÏ. à.å. ë˜ÂÌÓ‚‡ Ò 1987 „. ÔÓ ‰Â͇·¸ 2000 „.
åÛʘËÌ ·˚ÎÓ 156, ÊÂÌ˘ËÌ – 54, Ò‰ÌËÈ ‚ÓÁ‡ÒÚ
·ÓθÌ˚ı 41.6 ± 8.8 „Ó‰‡ (ÓÚ 16 ‰Ó 79 ÎÂÚ).
Ñˇ„ÌÓÒÚË͇ ÔÒ‚‰ÓÍËÒÚ ·‡ÁËÓ‚‡Î‡Ò¸ ̇ ‰‡ÌÌ˚ı ÛθÚ‡Á‚ÛÍÓ‚Ó„Ó ËÎË ÍÓÏÔ¸˛ÚÂÌÓ-ÚÓÏÓ„‡Ù˘ÂÒÍÓ„Ó ËÒÒΉӂ‡ÌËfl. èË ÔÓ‰ÓÁÂÌËË Ì‡
Ò‚flÁ¸ ÔÒ‚‰ÓÍËÒÚ˚ Ò ÔÓÚÓÍÓ‚ÓÈ ÒËÒÚÂÏÓÈ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ‚˚ÔÓÎÌflÎË ùêèïÉ (n = 19).
èË ÔÛÌ͈ËË Ë ‰ÂÌËÓ‚‡ÌËË ÔÒ‚‰ÓÍËÒÚ ÔÓ‰ ÍÓÌÚÓÎÂÏ ÛθÚ‡Á‚Û͇ (ÒÚËÎÂÚ-͇ÚÂÚÂÓÏ ËÎË ÔÓ ÏÂÚÓ‰ËÍ ëÂθ‰ËÌ„Â‡) Ò ˆÂθ˛ ‚˚fl‚ÎÂÌËfl ‚ÓÁÏÓÊÌÓÈ Ò‚flÁË Ëı Ò ÔÓÚÓÍÓ‚ÓÈ ÒËÒÚÂÏÓÈ ÔÓËÁ‚Ó‰ËÎË
ÙËÒÚÛÎÓ„‡Ù˲ (n = 8).
éˆÂÌË‚‡ÎË ·ÎËʇȯËÂ Ë ÓÚ‰‡ÎÂÌÌ˚ ÂÁÛθڇÚ˚ ΘÂÌËfl. Ç ÓÚ‰‡ÎÂÌÌÓÏ ÔÂËÓ‰Â Ò ÔÓÏÓ˘¸˛
‡ÌÍÂÚËÓ‚‡ÌËfl Ë ÛθÚ‡Á‚ÛÍÓ‚Ó„Ó ËÒÒΉӂ‡ÌËfl
Ó·ÒΉӂ‡ÌÓ 173 Ô‡ˆËÂÌÚ‡. ëÓÍ Ì‡·Î˛‰ÂÌËfl ÒÓÒÚ‡‚ËÎ ÓÚ 1 „Ó‰‡ ‰Ó 11 ÎÂÚ.
ÑÎfl ‚˚flÒÌÂÌËfl ‚ÓÔÓÒ‡ Ó ‚ÎËflÌËË ‡Á΢Ì˚ı
Ù‡ÍÚÓÓ‚ ̇ ÂÁÓ·ˆË˛ ÍËÒÚ ËÁ Ó·˘Â„Ó ˜ËÒ·
·ÓθÌ˚ı, Û ÍÓÚÓ˚ı ÔË ÔÂ‚˘ÌÓÈ „ÓÒÔËÚ‡ÎËÁ‡ˆËË Ì ‚˚fl‚ÎÂÌÓ ÔËÁ̇ÍÓ‚ ÓÒÎÓÊÌÂÌËfl ÔÒ‚‰ÓÍËÒÚ (171 ˜ÂÎÓ‚ÂÍ), ·˚· ‚˚‰ÂÎÂ̇ „ÛÔÔ‡ ËÁ 70 Ô‡ˆËÂÌÚÓ‚, ÍÓÚÓ˚Ï Ì ÔÓ‚Ó‰ËÎË Í‡ÍÓ„Ó-ÎË·Ó
‚ϯ‡ÚÂθÒÚ‚‡. àı ‡Á‰ÂÎËÎË Ì‡ 3 „ÛÔÔ˚: 1-fl –
28 ·ÓθÌ˚ı, Û ÍÓÚÓ˚ı ÔÒ‚‰ÓÍËÒÚ˚ ÂÁÓ·ËÓ‚‡ÎËÒ¸ ÒÔÓÌÚ‡ÌÌÓ, ·ÂÁ ͇ÍËı-ÎË·Ó ‚ϯ‡ÚÂθÒÚ‚,
‚ ·ÎËʇȯÂÏ ÔÂËӉ (26.6 ± 13.0 ‰Ìfl; ÓÚ 14 ‰Ó
49 ‰ÌÂÈ), 2-fl – 22 ·ÓθÌ˚ı, Û ÍÓÚÓ˚ı ÔÒ‚‰ÓÍËÒÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 6
Ú˚ ÂÁÓ·ËÓ‚‡ÎËÒ¸ ‚ ÓÚ‰‡ÎÂÌÌÓÏ ÔÂËӉ (4.3 ±
± 3.7 „Ó‰‡; ÓÚ 1 „Ó‰‡ ‰Ó 11 ÎÂÚ), 3-fl – 20 ·ÓθÌ˚ı, Û
ÍÓÚÓ˚ı Ì ̇·Î˛‰‡ÎÓÒ¸ ÂÁÓ·ˆËË ÍËÒÚ ÌË ‚
·ÎËʇȯÂÏ, ÌË ‚ ÓÚ‰‡ÎÂÌÌÓÏ ÔÂËÓ‰Â Ë ÍÓÚÓ˚Â
ÔÂÂÌÂÒÎË ‚ÔÓÒΉÒÚ‚ËË ‡Á΢Ì˚ ıËÛ„˘ÂÒÍË ‚ϯ‡ÚÂθÒÚ‚‡.
Ç ÚÂı „ÛÔÔ‡ı ·ÓθÌ˚ı Ò‡‚ÌË‚‡ÎË ÔÓ ÒÎÂ‰Û˛˘ËÏ ÔËÁ͇̇Ï: ‚ÓÁ‡ÒÚ, ‰ÎËÚÂθÌÓÒÚ¸ ΘÂÌËfl
‚ ÒÚ‡ˆËÓ̇Â, ‡ÁÏÂ ÔÒ‚‰ÓÍËÒÚ˚, ÒÓÍ ÓÚ ÔËÒÚÛÔ‡ ÓÒÚÓ„Ó Ô‡ÌÍ‡ÚËÚ‡ ËÎË Ú‡‚Ï˚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ‰Ó ÏÓÏÂÌÚ‡  ‚˚fl‚ÎÂÌËfl, ÎÓ͇ÎËÁ‡ˆËfl ÔÒ‚‰ÓÍËÒÚ˚.
ë ˆÂθ˛ ‚˚fl‚ÎÂÌËfl Ù‡ÍÚÓÓ‚, Ô‰‡ÒÔÓ·„‡˛˘Ëı Í ‡Á‚ËÚ˲ ÓÒÎÓÊÌÂÌËÈ, ̇Á‚‡ÌÌ˚ ԇ‡ÏÂÚ˚ ‚ 1-È Ë 2-È „ÛÔÔ‡ı Ò‡‚ÌË‚‡ÎË Ò Ú‡ÍÓ‚˚ÏË
‚ „ÛÔÔ‡ı Ò Ì‡„ÌÓÂÌËÂÏ ÔÒ‚‰ÓÍËÒÚ˚ Ë ÏÂı‡Ì˘ÂÒÍÓÈ ÊÂÎÚÛıÓÈ.
ëÚ‡ÚËÒÚ˘ÂÒÍËÈ ‡Ì‡ÎËÁ ‰‡ÌÌ˚ı ÒÓÒÚÓflÎ ‚
ÓˆÂÌÍ ÒÚ‡ÚËÒÚ˘ÂÒÍÓÈ Á̇˜ËÏÓÒÚË ‡Á΢ËÈ ‚
„ÛÔÔ‡ı Ò ÔËÏÂÌÂÌËÂÏ ÏÂÚÓ‰‡ ‰ËÒÔÂÒËÓÌÌÓ„Ó
‡Ì‡ÎËÁ‡ ÔÓ î˯ÂÛ Ë ÏÂÚÓ‰‡ χ-Í‚‡‰‡Ú. ùÚË ÏÂÚÓ‰˚ ÔÓÁ‚ÓÎfl˛Ú ‚˚fl‚ËÚ¸ ‡Á΢Ëfl ÏÂÊ‰Û ÌÂÒÍÓθÍËÏË „ÛÔÔ‡ÏË ÔÓ Í‡ÍÓÏÛ-ÎË·Ó ÍËÚÂ˲, ‰Îfl ˜Â„Ó ‡ÒÒ˜ËÚ˚‚‡ÂÚÒfl ÚÓ˜Ì˚È ÍËÚÂËÈ F Ë χ2, ‡ Á‡ÚÂÏ Ò‡‚ÌË‚‡˛ÚÒfl Ò Ú‡·Î˘Ì˚ÏË Á̇˜ÂÌËflÏË
‰‡ÌÌÓ„Ó ÔÓ͇Á‡ÚÂÎfl ‰Îfl 95 Ë 99% ‚ÂÓflÚÌÓÒÚË ·ÂÁӯ˷ӘÌÓ„Ó ÔÓ„ÌÓÁ‡. ÑÎfl ÓÔ‰ÂÎÂÌËfl Á̇˜ËÏÓÒÚË ÚÓ„Ó ËÎË ËÌÓ„Ó ÔÓ͇Á‡ÚÂÎfl ÔÓËÁ‚‰ÂÌ ‡Ò˜ÂÚ ÍÓ˝ÙÙˈËÂÌÚÓ‚ ËÌÙÓχÚË‚ÌÓÒÚË ÔÓ ÏÂÚÓ‰Û
LJÔÌË͇–óÂ‚ÓÌÂÌÍËÒ‡, ÍÓÚÓ˚È Ú‡ÍÚÛÂÚÒfl
ÒÎÂ‰Û˛˘ËÏ Ó·‡ÁÓÏ: <0.02 – ÌËÁ͇fl ÒÚÂÔÂ̸ ËÌÙÓχÚË‚ÌÓÒÚË, ÓÚ 0.02 ‰Ó 0.2 – Ò‰Ìflfl ÒÚÂÔÂ̸
ËÌÙÓχÚË‚ÌÓÒÚ¸, >0.2 – ‚˚ÒÓ͇fl ÒÚÂÔÂ̸ ËÌÙÓχÚË‚ÌÓÒÚË.
Ç Ò‡‚ÌÂÌËË Ò ËÒÒΉÛÂÏ˚ÏË „ÛÔÔ‡ÏË ‡Ì‡ÎËÁËÓ‚‡Î‡Ò¸ Ú‡ÍÊ „ÛÔÔ‡ ·ÓθÌ˚ı Ò ÓÒÎÓÊÌÂÌÌ˚ÏË ÔÒ‚‰ÓÍËÒÚ‡ÏË: ·ÓθÌ˚Â Ò Ì‡„ÌÓÂÌËÂÏ ÔÒ‚‰ÓÍËÒÚ˚ (n = 25), Û 9 ·ÓθÌ˚ı ËÁ ˝ÚÓÈ „ÛÔÔ˚ ËÏÂÎÓÒ¸ ÒÓ˜ÂÚ‡ÌË ̇„ÌÓÂÌËfl Ë ‡Á˚‚‡; ·ÓθÌ˚ Ò
ÏÂı‡Ì˘ÂÒÍÓÈ ÊÂÎÚÛıÓÈ (n = 18), ‚˚Á‚‡ÌÌÓÈ ÍËÒÚÓÈ „ÓÎÓ‚ÍË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚.
êÂÁÛθڇÚ˚
ë‰ÌË Á̇˜ÂÌËfl ÔÓ͇Á‡ÚÂÎÂÈ – ‚ÓÁ‡ÒÚ, ‰ÎËÚÂθÌÓÒÚ¸ ΘÂÌËfl ‚ ÒÚ‡ˆËÓ̇Â, ‡ÁÏÂ ÔÒ‚‰ÓÍËÒÚ˚ – Ô‰ÒÚ‡‚ÎÂÌ˚ ‚ Ú‡·Î. 1.
Ä̇ÎËÁ ÔÓ͇Á‡Î, ˜ÚÓ ÔË ÓÚÒÛÚÒÚ‚ËË ‰ÓÒÚÓ‚ÂÌ˚ı ‡Á΢ËÈ ‚ ‚ÓÁ‡ÒÚÂ, ‰ÎËÚÂθÌÓÒÚË ÒÚ‡ˆËÓ̇ÌÓ„Ó Î˜ÂÌËfl ÒÛ˘ÂÒÚ‚ÛÂÚ ‰ÓÒÚÓ‚Â̇fl ‡ÁÌˈ‡
‚ ‡ÁÏÂ ÔÒ‚‰ÓÍËÒÚ ÏÂÊ‰Û „ÛÔÔ‡ÏË.
ÅÓΠ‰ÂڇθÌÓ Ò‡‚ÌÂÌË „ÛÔÔ ÔÓ ‡ÁÏÂÛ
ÔÒ‚‰ÓÍËÒÚ˚, ÒÓÍÛ ÓÚ ÔËÒÚÛÔ‡ ÓÒÚÓ„Ó Ô‡ÌÍ‡ÚËÚ‡ ËÎË Ú‡‚Ï˚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ‰Ó ÏÓÏÂÌÚ‡  ‚˚fl‚ÎÂÌËfl Ë ÎÓ͇ÎËÁ‡ˆËË ÔÒ‚‰ÓÍËÒÚ˚
Ô‰ÒÚ‡‚ÎÂÌÓ ‚ Ú‡·Î. 2. èË ‡Ì‡ÎËÁ ˝ÚÓÈ Ú‡·Îˈ˚ ÏÓÊÌÓ ÓÚÏÂÚËÚ¸, ˜ÚÓ ·ÓθÌ˚Â, ‰ÎËÚÂθÌÓÒÚ¸
Á‡·Ó΂‡ÌËfl ÍÓÚÓ˚ı ÏÂÌ ÔÓÎÛ„Ó‰‡, ÒÓÒÚ‡‚ËÎË
40% (n = 28), ÔË ˝ÚÓÏ ÂÁÓ·ˆËfl ÔÒ‚‰ÓÍËÒÚ ‚
·ÎËʇȯÂÏ ËÎË ÓÚ‰‡ÎÂÌÌÓÏ ÔÂËÓ‰‡ı ̇·Î˛‰‡‹2
2001
101
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
èëÖÇÑéäàëíõ èéÑÜÖãìÑéóçéâ ÜÖãÖáõ
퇷Îˈ‡ 1. éˆÂÌ͇ ‰ÓÒÚÓ‚ÂÌÓÒÚË ‡Á΢ËÈ ‚ „ÛÔÔ I, „ÛÔÔ II Ë „ÛÔÔ III
è‡‡ÏÂÚ
I „ÛÔÔ‡ (n = 28)
II „ÛÔÔ‡ (n = 22)
III „ÛÔÔ‡ (n = 20)
F
ÇÓÁ‡ÒÚ, „Ó‰˚
43.4 ± 11.2
45.1 ± 11.4
41.7 ± 7.1
3.42 (p > 0.05)
ÑÎËÚÂθÌÓÒÚ¸ „ÓÒÔËÚ‡ÎËÁ‡ˆËË, ‰ÌË
26.6 ± 13.0
28.0 ± 9.5
25.8 ± 10.5
4.35 (p > 0.05)
6.15 ± 3.68
12.9 (p < 0.01)
3.8 ± 1.81
ê‡ÁÏÂ ÔÒ‚‰ÓÍËÒÚ, ÒÏ
4.6 ± 1.46
퇷Îˈ‡ 2. ê‡ÒÔ‰ÂÎÂÌË ·ÓθÌ˚ı ‚ „ÛÔÔ‡ı ÔÓ ‚˚·‡ÌÌ˚Ï ÔÓ͇Á‡ÚÂÎflÏ Ò ÓˆÂÌÍÓÈ ‰ÓÒÚÓ‚ÂÌÓÒÚË ‡Á΢ËÈ
ÏÂÊ‰Û „ÛÔÔ‡ÏË ÔÓ Í‡Ê‰ÓÏÛ Ô‡‡ÏÂÚÛ
I „ÛÔÔ‡ (n = 28)
II „ÛÔÔ‡ (n = 22)
III „ÛÔÔ‡ (n = 20)
χ2
p < 0.01
16
8
4
10.3
+
<1
2
6
5
–
–
1–3
8
3
5
–
–
3–5
–
1
–
–
–
>5
2
4
6
–
–
18
16
8
–
–
ÚÂÎÓ
6
2
4
–
–
ı‚ÓÒÚ
4
4
4
–
–
ÏÌÓÊÂÒÚ‚ÂÌ̇fl
–
–
4
9.85
+
‰Ó 5
23
14
10
12.9
+
5–10
5
8
7
–
–
10–15
–
–
2
–
–
>15
–
–
1
–
–
è‡‡ÏÂÚ
ëÓÍ ÓÚ ÔËÒÚÛÔ‡
ÓÒÚÓ„Ó Ô‡ÌÍ‡ÚËÚ‡ ËÎË Ú‡‚Ï˚,
„Ó‰˚:
ãÓ͇ÎËÁ‡ˆËfl:
ê‡ÁÏÂ, ÒÏ:
<0.5
„ÓÎӂ͇
èËϘ‡ÌËÂ: ÔÓ͇Á‡ÚÂÎË Ô˂‰ÂÌ˚ ‚ ‡·ÒÓβÚÌ˚ı Á̇˜ÂÌËflı.
·Ҹ Û 85.7% (n = 24). èË ‰ÎËÚÂθÌÓÒÚË Á‡·Ó΂‡ÌËfl ·ÓΠÔÓÎÛ„Ó‰‡ (60%, n = 42) ÂÁÓ·ˆËfl ÔÒ‚‰ÓÍËÒÚ Ì‡·Î˛‰‡Î‡Ò¸ ÚÓθÍÓ Û 62% ·ÓθÌ˚ı (n =
= 26).
í‡ÍËÏ Ó·‡ÁÓÏ, ‚˚fl‚ÎÂÌÓ, ˜ÚÓ ·Óθ¯ËÌÒÚ‚Ó
·ÓθÌ˚ı, Û ÍÓÚÓ˚ı ÔÒ‚‰ÓÍËÒÚ˚ ÂÁÓ·ËÓ‚‡ÎËÒ¸ ‚ ·ÎËʇȯÂÏ ËÎË ‚ ÓÚ‰‡ÎÂÌÌÓÏ ÔÂËÓ‰Â,
ËÏÂÎË ‰ÎËÚÂθÌÓÒÚ¸ Á‡·Ó΂‡ÌËfl ÏÂÌ ÔÓÎÛ„Ó‰‡.
èË ÏÌÓÊÂÒÚ‚ÂÌÌ˚ı ÍËÒÚ‡ı (n = 4) ÂÁÓ·ˆËË ÌÂ
̇·Î˛‰‡ÎÓÒ¸.
ÑÎfl ÓÔ‰ÂÎÂÌËfl ‚ÎËflÌËfl Í‡Ê‰Ó„Ó Ô‡‡ÏÂÚ‡
̇ ÂÁÓ·ˆË˛ ÔÒ‚‰ÓÍËÒÚ ·˚Î ‡ÒÒ˜ËÚ‡Ì ÍÓ˝ÙÙˈËÂÌÚ ËÌÙÓχÚË‚ÌÓÒÚË. é·Ì‡ÛÊÂÌÓ, ˜ÚÓ ÔÓ͇Á‡ÚÂÎË ÒÓÍ ÓÚ ÔËÒÚÛÔ‡ ÓÒÚÓ„Ó Ô‡ÌÍ‡ÚËÚ‡
ËÎË Ú‡‚Ï˚, ÎÓ͇ÎËÁ‡ˆËfl Ë ‡ÁÏÂ ÔÒ‚‰ÓÍËÒÚ˚
ӷ·‰‡˛Ú ̇˷Óθ¯ËÏË ÍÓ˝ÙÙˈËÂÌÚ‡ÏË ËÌÙÓχÚË‚ÌÓÒÚË. Å˚ÎË ‡ÒÒ˜ËÚ‡Ì˚ ÔÓ͇Á‡ÚÂÎË
ÚÓ˜ÌÓÒÚË, ÒÔˆËÙ˘ÌÓÒÚË Ë ˜Û‚ÒÚ‚ËÚÂθÌÓÒÚË ‰Îfl
Í‡Ê‰Ó„Ó ËÁ ÌËı. äÓÏ ÚÓ„Ó, ӷ̇ÛÊÂÌÓ, ˜ÚÓ ÒÓ˜ÂÚ‡ÌË ˝ÚËı ÚÂı Ù‡ÍÚÓÓ‚ Á̇˜ËÚÂθÌÓ Û‚Â΢˂‡ÂÚ ‚ÂÓflÚÌÓÒÚ¸ ÂÁÓ·ˆËË ÍËÒÚ˚ ‚ ·ÎËʇȯÂÏ ËÎË ÓÚ‰ÂÎÂÌÌÓÏ ÔÂËÓ‰Â. àÁ Ú‡·Î. 3 ÒΉÛÂÚ,
˜ÚÓ ˜ËÒÎÓ ÒÔÓÌÚ‡ÌÌ˚ı ÂÁÓ·ˆËÈ ÔÒ‚‰ÓÍËÒÚ ÍÓ102
ÂÎËÛÂÚ ‚ ·Óθ¯ÂÈ ÒÚÂÔÂÌË ÒÓ ÒÓ͇ÏË ÒÛ˘ÂÒÚ‚Ó‚‡ÌËfl ÔÒ‚‰ÓÍËÒÚ˚ Ë Â ‡ÁÏÂ‡ÏË. ç‡ ÓÒÌÓ‚‡ÌËË ‡Ì‡ÎËÁ‡ ÔÓÎÛ˜ÂÌÌ˚ı ‰‡ÌÌ˚ı ·˚Î Ò‰ÂÎ‡Ì ‚˚‚Ó‰, ˜ÚÓ ÔÒ‚‰ÓÍËÒÚ˚ Û ·ÓθÌ˚ı Ò ‰ÎËÚÂθÌÓÒÚ¸˛
‡Ì‡ÏÌÂÁ‡ Ì ·ÓΠ6 ÏÂÒ. Ë ‡ÁÏÂÓÏ ‰Ó 4.6 ± 1.6 ÒÏ
ÒÔÓÒÓ·Ì˚ ÂÁÓ·ËÓ‚‡Ú¸Òfl Ò‡ÏÓÒÚÓflÚÂθÌÓ.
ÑÎfl ‚˚fl‚ÎÂÌËfl Ù‡ÍÚÓÓ‚, Ô‰‡ÒÔÓ·„‡˛˘Ëı Í ‡Á‚ËÚ˲ ÓÒÎÓÊÌÂÌËÈ ÔÒ‚‰ÓÍËÒÚ, ‚ ÚÓÏ
˜ËÒΠ̇„ÌÓÂÌËfl, Ô‡‡ÏÂÚ˚ ‚ 1-È Ë 2-È „ÛÔÔ‡ı
Ò‡‚ÌË‚‡ÎË Ò Ú‡ÍÓ‚˚ÏË ‚ „ÛÔÔ‡ı ·ÓθÌ˚ı Ò ÓÒÎÓÊÌÂÌÌ˚ÏË ÔÒ‚‰ÓÍËÒÚ‡ÏË.
èË ‡Ì‡ÎËÁ ‰‡ÌÌ˚ı Ó ·ÓθÌ˚ı Ò ÔÒ‚‰ÓÍËÒÚ‡ÏË, ÓÒÎÓÊÌÂÌÌ˚ÏË Ì‡„ÌÓÂÌËÂÏ (n = 25), ‚˚‰ÂÎÂÌ˚ ·ÓθÌ˚Â, Û ÍÓÚÓ˚ı ̇ ÙÓÌ ̇„ÌÓÂÌËfl ÔÓËÁÓ¯ÂÎ ‡Á˚‚ ÍËÒÚ˚ (n = 9). é‰Ì‡ÍÓ ÔË Ò‡‚ÌÂÌËË ˝ÚËı ‰‚Ûı „ÛÔÔ ÌÂθÁfl ·˚ÎÓ ÓÔ‰ÂÎËÚ¸
Á̇˜ËÏÓ„Ó ‚ÎËfl˛˘Â„Ó Ô‡‡ÏÂÚ‡, Ó·ÛÒÎÓ‚ÎË‚‡˛˘Â„Ó ‚ÓÁÌËÍÌÓ‚ÂÌË ‡Á˚‚‡. ë ˆÂθ˛ ‚˚fl‚ÎÂÌËfl ÓÚ΢ËÈ „ÛÔÔ˚ ·ÓθÌ˚ı Ò Ì‡„ÌÓÂÌËÂÏ ÔÒ‚‰ÓÍËÒÚ ÓÚ ·ÓθÌ˚ı 1-È Ë 2-È „ÛÔÔ Ò‡‚ÌË‚‡ÎË
Ò‰ÌË Á̇˜ÂÌËfl ‚˚·‡ÌÌ˚ı ‡Ì ԇ‡ÏÂÚÓ‚
(Ú‡·Î. 4). èÓÎÛ˜ÂÌÌ˚ ‰‡ÌÌ˚ ҂ˉÂÚÂθÒÚ‚Û˛Ú,
˜ÚÓ Ò Û‚Â΢ÂÌËÂÏ ‡ÁÏÂ‡ ÔÒ‚‰ÓÍËÒÚ˚ Ë ‰ÎË-
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 6
‹2
2001
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
èêéäéîúÖÇ Ë ‰.
퇷Îˈ‡ 3. àÌÙÓχÚË‚ÌÓÒÚ¸ ÔËÁ̇ÍÓ‚, ‚ÎËfl˛˘Ëı ̇ ÌÂÔÓÒ‰ÒÚ‚ÂÌÌ˚È ÂÁÛÎ¸Ú‡Ú (Ú.Â. ÍËÒÚ‡ ÂÒÚ¸/ÌÂÚ)
äÓ˝ÙÙˈËÂÌÚ
ËÌÙÓχÚË‚ÌÓÒÚË
íÓ˜ÌÓÒÚ¸, %
ëÓÍ ÓÚ ÔËÒÚÛÔ‡ ÓÒÚÓ„Ó
Ô‡ÌÍ‡ÚËÚ‡/Ú‡‚Ï˚
0.0823
66
68
62
ê‡ÁÏÂ
0.0415
66
74
48
ãÓ͇ÎËÁ‡ˆËfl
0.0213
58
48
81
–
79
84
67
èËÁ̇Í
ëÓ˜ÂÚ‡ÌË ÚÂı ÔËÁ̇ÍÓ‚
ëÔˆËÙ˘ÌÓÒÚ¸, % óÛ‚ÒÚ‚ËÚÂθÌÓÒÚ¸, %
퇷Îˈ‡ 4. éˆÂÌ͇ ‰ÓÒÚÓ‚ÂÌÓÒÚË ‡Á΢ËÈ Ò‰ÌËı ÔÓ͇Á‡ÚÂÎÂÈ ‚ „ÛÔÔ‡ı Ò ÌÂÓÒÎÓÊÌÂÌÌ˚ÏË ÔÒ‚‰ÓÍËÒÚ‡ÏË Ë ‚ „ÛÔÔ‡ı Ò Ì‡„ÌÓÂÌËÂÏ ÔÒ‚‰ÓÍËÒÚ˚
è‡‡ÏÂÚ
ÇÓÁ‡ÒÚ, „Ó‰˚
ê‡ÁÏÂ ÔÒ‚‰ÓÍËÒÚ, ÒÏ
ëÓÍ ÓÚ ÔËÒÚÛÔ‡ ÓÒÚÓ„Ó
Ô‡ÌÍ‡ÚËÚ‡ ËÎË Ú‡‚Ï˚, „Ó‰˚
I „ÛÔÔ‡ (n = 28)
II „ÛÔÔ‡ (n = 22)
燄ÌÓÂÌË (n = 25)
F
43.4 ± 11.2
45.1 ± 11.4
44.4 ± 8.3
–
3.8 ± 1.81
4.6 ± 1.46
9.01 ± 3.13
13.6 (p < 0.01)
ÑÓ 0.5
ÑÓ 0.5
éÚ 0.5 ‰Ó 3
12.3 (p < 0.01)
퇷Îˈ‡ 5. éˆÂÌ͇ ‰ÓÒÚÓ‚ÂÌÓÒÚË ‡Á΢ËÈ Ò‰ÌËı ÔÓ͇Á‡ÚÂÎÂÈ ‚ „ÛÔÔ‡ı Ò ÌÂÓÒÎÓÊÌÂÌÌ˚ÏË ÔÒ‚‰ÓÍËÒÚ‡ÏË Ë ‚ „ÛÔÔÂ Ò ÏÂı‡Ì˘ÂÒÍÓÈ ÊÂÎÚÛıÓÈ
è‡‡ÏÂÚ
ÇÓÁ‡ÒÚ, „Ó‰˚
ê‡ÁÏÂ ÔÒ‚‰ÓÍËÒÚ, ÒÏ
ëÓÍ ÓÚ ÔËÒÚÛÔ‡ ÓÒÚÓ„Ó
Ô‡ÌÍ‡ÚËÚ‡, „Ó‰˚
I „ÛÔÔ‡ (n = 28)
II „ÛÔÔ‡ (n = 22)
åÂı‡Ì˘ÂÒ͇fl
ÊÂÎÚÛı‡ (n = 18)
F
43.4 ± 11.2
45.1 ± 11.4
44.4 ± 8.3
–
3.8 ± 1.81
4.6 ± 1.46
5.93 ± 3.07
11.7 (p < 0.01)
ÑÓ 0.5
ÑÓ 0.5
éÚ 3 ‰Ó 5
9.4 (p < 0.01)
ÚÂθÌÓÒÚË Á‡·Ó΂‡ÌËfl ̇‡ÒÚ‡ÂÚ ˜‡ÒÚÓÚ‡ ‚ÓÁÌËÍÌÓ‚ÂÌËfl ÓÒÎÓÊÌÂÌËÈ.
Ç „ÛÔÔ ·ÓθÌ˚ı Ò ÓÒÎÓÊÌÂÌÌ˚ÏË ÔÒ‚‰ÓÍËÒÚ‡ÏË ·˚· ‚˚‰ÂÎÂ̇ „ÛÔÔ‡ ·ÓθÌ˚ı Ò ÏÂı‡Ì˘ÂÒÍÓÈ ÊÂÎÚÛıÓÈ (n = 18). ì ‚ÒÂı ·ÓθÌ˚ı ÔÒ‚‰ÓÍÍËÒÚ˚ ÎÓ͇ÎËÁÓ‚‡ÎËÒ¸ ‚ „ÓÎÓ‚Í ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ
ÊÂÎÂÁ˚. ê‡ÁÏÂ ‚‡¸ËÓ‚‡Î ÓÚ 2.8 ‰Ó 15 ÒÏ. ëÓÍ
‡Á‚ËÚËfl ÓÒÎÓÊÌÂÌËfl ÓÚ ÔÂËÓ‰‡ ÓÒÚÓ„Ó Ô‡ÌÍ‡ÚËÚ‡ ËÎË Ú‡‚Ï˚ ·˛¯ÌÓÈ ÔÓÎÓÒÚË Û ·Óθ¯ËÌÒÚ‚‡ ·ÓθÌ˚ı (11 ËÎË 61.1%) ÒÓÒÚ‡‚ËÎ ÓÚ 3 ‰Ó 5 ÎÂÚ.
ë‡‚ÌÂÌË Ò‰ÌËı Ô‡‡ÏÂÚÓ‚ Û ·ÓθÌ˚ı Ò ÍËÒÚ‡ÏË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚, ÓÒÎÓÊÌÂÌÌ˚ÏË ÏÂı‡Ì˘ÂÒÍÓÈ ÊÂÎÚÛıÓÈ, Ë ‚ 1-È Ë 2-È „ÛÔÔ‡ı Ô‰ÒÚ‡‚ÎÂÌÓ ‚ Ú‡·Î. 5.
ä‡Í ‚ˉÌÓ, Ë ‚ ÒÎÛ˜‡Â Ò Ì‡„ÌÓÂÌËÂÏ ÔÒ‚‰ÓÍËÒÚ
‚ÂÓflÚÌÓÒÚ¸ ‚ÓÁÌËÍÌÓ‚ÂÌËfl ‰‡ÌÌÓ„Ó ÓÒÎÓÊÌÂÌËfl
‚ÓÁ‡ÒÚ‡ÂÚ ÔÓÔÓˆËÓ̇θÌÓ ‰ÎËÚÂθÌÓÒÚË Á‡·Ó΂‡ÌËfl Ë ‡ÁÏÂ‡Ï ÔÒ‚‰ÓÍËÒÚ˚. ëΉÛÂÚ ÓÚÏÂÚËÚ¸, ˜ÚÓ ËÁ 18 ·ÓθÌ˚ı Û 8 (44.4%) ÔÓfl‚ÎÂÌËfl
ÏÂı‡Ì˘ÂÒÍÓÈ ÊÂÎÚÛıË ÍÛÔËÓ‚‡ÎËÒ¸ ÔÓÒΠÂÁÓ·ˆËË ÔÒ‚‰ÓÍËÒÚ ·ÂÁ ıËÛ„˘ÂÒÍÓ„Ó ‚ϯ‡ÚÂθÒÚ‚‡. é‰Ì‡ÍÓ ˝ÚÓ Ì Á̇˜ËÚ, ˜ÚÓ Û ·ÓθÌ˚ı Ò
ÏÂı‡Ì˘ÂÒÍÓÈ ÊÂÎÚÛıÓÈ, ‚˚Á‚‡ÌÌÓÈ ÔÒ‚‰ÓÍËÒÚÓÈ, ÒΉÛÂÚ Ó„‡Ì˘˂‡Ú¸Òfl ‚˚Êˉ‡ÚÂθÌÓÈ Ú‡ÍÚËÍÓÈ.
ÄççÄãõ ïàêìêÉàóÖëäéâ ÉÖèÄíéãéÉàà ÚÓÏ 6
é·ÒÛʉÂÌËÂ
èÂ‚˚ ÔÓÔ˚ÚÍË Î˜ÂÌËfl ÔÒ‚‰ÓÍËÒÚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ ·˚ÎË Ô‰ÔËÌflÚ˚ ‚ 1761 „.
Morgagni [31] Ë ‚ 1875 „. LeDentu [29], Ӊ̇ÍÓ ‰Ó
̇ÒÚÓfl˘Â„Ó ‚ÂÏÂÌË ÌÂÚ Â‰ËÌÓ„Ó ÏÌÂÌËfl Ó Ú‡ÍÚË͠ΘÂÌËfl Ú‡ÍËı ·ÓθÌ˚ı. åÌÓ„Ë ‡‚ÚÓ˚ ÛÚ‚Âʉ‡˛Ú, ˜ÚÓ ÂÒÎË ÌÂÓÒÎÓÊÌÂÌÌ˚ ÔÒ‚‰ÓÍËÒÚ˚
Ì ÂÁÓ·ËÛ˛ÚÒfl ‚ Ú˜ÂÌË 6 ̉. ̇·Î˛‰ÂÌËfl,
ÒΉÛÂÚ ÔÓ‚Ó‰ËÚ¸ ıËÛ„˘ÂÒÍӠΘÂÌËÂ. é‰Ì‡ÍÓ Ì ÛÚÓ˜ÌflÂÚÒfl, ͇ÍË ˝ÚÓ ÍËÒÚ˚, Ú.Â. ‡ÁÏÂ˚,
ÒÓÍË Ëı ‡Á‚ËÚËfl Ë Ú.‰. éÒÎÓÊÌÂÌÌ˚ Ê ÍËÒÚ˚
ÒΉÛÂÚ Î˜ËÚ¸ ÓÔÂ‡ÚË‚Ì˚Ï ÔÛÚÂÏ ËÎË ˜ÂÒÍÓÊÌ˚Ï ‰ÂÌËÓ‚‡ÌËÂÏ, Ë ÚÓθÍÓ ‚ ˝ÚÓÏ, ÔÓʇÎÛÈ,
ÌÂÚ ‡ÁÌӄ·ÒËÈ.
Ç Ì‡¯ÂÏ ÂÚÓÒÔÂÍÚË‚ÌÓÏ ËÒÒΉӂ‡ÌËË Ôӂ‰ÂÌ ‡Ì‡ÎËÁ χÚÂˇ·, ͇҇˛˘Â„ÓÒfl 210 ·ÓθÌ˚ı Ò ÔÒ‚‰ÓÍËÒÚ‡ÏË ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚ Ò
ˆÂθ˛ ‚˚fl‚ÎÂÌËfl Ô‰‡ÒÔÓ·„‡˛˘Ëı Ù‡ÍÚÓÓ‚,
ÔË ÒÓ˜ÂÚ‡ÌËË ÍÓÚÓ˚ı ÂÁÓ·ˆËfl ÔÒ‚‰ÓÍËÒÚ
‚ÓÁÌË͇ÂÚ ˜‡˘Â. í‡ÍÊ Ï˚ ÔÓÔ˚Ú‡ÎËÒ¸ ‚˚‰ÂÎËÚ¸
Ù‡ÍÚÓ˚, ‚ÎËfl˛˘Ë ̇ ‡Á‚ËÚË ÓÒÎÓÊÌÂÌËÈ. êÂÁÛθڇÚ˚ ËÒÒΉӂ‡ÌËfl ÔÓ͇Á˚‚‡˛Ú, ˜ÚÓ ÔË ‡ÁÏÂ‡ı ÍËÒÚ 4.6 ± 1.6 ÒÏ Ë ÔË ‰ÎËÚÂθÌÓÒÚË Ëı ÒÛ˘ÂÒÚ‚Ó‚‡ÌËfl ‰Ó ÔÓÎÛ„Ó‰‡ ÓÚ ÔËÒÚÛÔ‡ ÓÒÚÓ„Ó
Ô‡ÌÍ‡ÚËÚ‡ ËÎË Ú‡‚Ï˚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚
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2001
103
ÔÓ‰ÊÂÎۉӘ̇fl ÊÂÎÂÁ‡
èëÖÇÑéäàëíõ èéÑÜÖãìÑéóçéâ ÜÖãÖáõ
‚ÓÁÏÓÊÌÓ ‰Ó·ËÚ¸Òfl ÂÁÓ·ˆËË ÔÒ‚‰ÓÍËÒÚ ÍÓÌÒÂ‚‡ÚË‚Ì˚ÏË ÏÂÓÔËflÚËflÏË. àÁ 70 ·ÓθÌ˚ı,
ÍÓÚÓ˚Ï Ì ÔÓ‚Ó‰ËÎÓÒ¸ ͇ÍËı-ÎË·Ó ‚ϯ‡ÚÂθÒÚ‚, Û 28 (40%) ‰ÎËÚÂθÌÓÒÚ¸ Á‡·Ó΂‡ÌËfl ÒÓÒÚ‡‚Ë· ÏÂÌ ÔÓÎÛ„Ó‰‡, ÔË ˝ÚÓÏ ÂÁÓ·ˆËfl
ÔÒ‚‰ÓÍËÒÚ ‚ ·ÎËʇȯÂÏ (26.6 ± 13.0 ‰Ìfl) ËÎË ÓÚ‰‡ÎÂÌÌÓÏ (4.3 ± 3.7 „Ó‰‡) ÔÂËӉ ̇·Î˛‰‡Î‡Ò¸ Û
24 (85.7%) ˜ÂÎÓ‚ÂÍ. èË Ì‡Î˘ËË ÏÌÓÊÂÒÚ‚ÂÌÌ˚ı
ÍËÒÚ ‚ÓÁÏÓÊÌÓÒÚ¸ ÒÔÓÌÚ‡ÌÌÓÈ ÂÁÓ·ˆËË ÏËÌËχθ̇. èÓÎÛ˜ÂÌÌ˚ ̇ÏË ÂÁÛθڇÚ˚ ıÓÓ¯Ó
Òӄ·ÒÛ˛ÚÒfl Ò ‰‡ÌÌ˚ÏË ËÒÒΉӂ‡ÌËÈ fl‰‡ ‡‚ÚÓÓ‚ [9, 12, 15, 28, 35, 37, 38].
èÓÎÛ˜ÂÌÌ˚ ‰‡ÌÌ˚Â Ó ÚÓÏ, ˜ÚÓ Ò Û‚Â΢ÂÌËÂÏ
‡ÁÏÂÓ‚ ÔÒ‚‰ÓÍËÒÚ˚ Ë ÒÓÍÓ‚  ÒÛ˘ÂÒÚ‚Ó‚‡ÌËfl
ËÒÍ ‡Á‚ËÚËfl ÓÒÎÓÊÌÂÌËÈ ‚ÓÁ‡ÒÚ‡ÂÚ, ÔÓ‰Ú‚Âʉ‡˛Ú ‰‡ÌÌ˚ E. Bradley Ë ÒÓ‡‚Ú. [11, 12], ÔÓ͇Á‡‚¯Ëı, ˜ÚÓ ‚ 41% ̇·Î˛‰ÂÌËÈ ÔË ‡ÁÏÂ ÔÒ‚‰ÓÍËÒÚ˚ ·ÓΠ6 ÒÏ ‡Á‚Ë‚‡˛ÚÒfl ÓÒÎÓÊÌÂÌËfl. äÓÏ ÚÓ„Ó, Í‡Í ÔÓ͇Á‡ÌÓ ‚ ËÒÒΉӂ‡ÌËflı L. Johnson
Ë ÒÓ‡‚Ú. [24], ÔË „Ë„‡ÌÚÒÍËı ÔÒ‚‰ÓÍËÒÚ‡ı (·ÓÎÂÂ
10 ÒÏ) Û‚Â΢˂‡ÂÚÒfl Í‡Í ˜‡ÒÚÓÚ‡ ÓÒÎÓÊÌÂÌËÈ,
Ú‡Í Ë ÎÂڇθÌÓÒÚ¸. í‡ÍËÏ Ó·‡ÁÓÏ, ÏÓÊÌÓ ÂÍÓÏẨӂ‡Ú¸ ÔÓ‚Ó‰ËÚ¸ ıËÛ„˘ÂÒÍӠΘÂÌË ͇Ú„ÓËË ·ÓθÌ˚ı Ò ‰Ë‡ÏÂÚÓÏ ÔÒ‚‰ÓÍËÒÚ ·ÓÎÂÂ
6 ÒÏ Ë ‰ÎËÚÂθÌÓÒÚ¸˛ Ëı ÒÛ˘ÂÒÚ‚Ó‚‡ÌËfl ·ÓΠ„Ó‰‡.
ëÔËÒÓÍ ÎËÚÂ‡ÚÛ˚
1. Äı‡Ì„ÂθÒÍËÈ Ç.Ç., ò‡·ÛÌËÌ Ä.Ç., ãÛÍËÌ Ä.û.
ã˜ÂÌË ÎÓÊÌ˚ı ÍËÒÚ ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚.
ÄÌ̇Î˚ ıË. „ÂÔ‡ÚÓÎ. 1999. í. 4. ë. 44–48.
2. Ň„ÌÂÌÍÓ ë.î., äÛ˚„ËÌ Ä.Ä. ïÓÌ˘ÂÒÍËÈ Ô‡ÌÍ‡ÚËÚ. ë.-è·., 2000. 403 Ò.
3. чÌËÎÓ‚ å.Ç., î‰ÓÓ‚ Ç.Ñ. ïËÛ„Ëfl ÔÓ‰ÊÂÎÛ‰Ó˜ÌÓÈ ÊÂÎÂÁ˚. å.: å‰ˈË̇, 1995. 512 Ò.
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ÚÂıÌ. 2000. í. VII. ‹ 1. ë. 80–81.
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1999. ‹ 5. ë. 75–77.
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èêéäéîúÖÇ Ë ‰.
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