CO)U:P)KAHHE

4acTb I ................. .............................. ....................... ........................................................................ 4

OCTPhIH ATITIEH):(l1IJ;I1T ... ....... ........ .... .... ............ .. ... .... ..... .... .. ......... .................... .... ............. 4
)l{E.nqEKAMEI-Il-IA5I EOJIE3H1 ...... ...... ..... ............ .............. ........... ........ .... ..... ... .................. 16
OCTPhIH DAHKPEA TI1T ....... ... .... ......... .... .. ......... ..... ........................................... ..... .... ........ 3 5
KMJlIEqHA5I HEITPOXOJJY[MOCTb ................ ....... ........................ ............................... 45
3TAJIOHbl OTBETOB HA TECTOBbIE 3A~ .. .. ..... ............................... ............ 59

I1JIIDOCTP.AI(lill .................................................................................................... ......... 59

PEKOMEI-I,n:YEMA.51 JII1TEPATYP A ............................................................................. 59

4acTb II ... .. ....... ... ...... .............. ... ......... ... ...... ..... ... ....... ..... ... .......... .. .... ........ .. ... ... ..... ........... .... ....... 60
5I3BEHHA5I EOnE3Hb )KEJIY)J;KA, 12-IIEPCTHOH KHllIKM I1 EE OCJIO)Kl-lEI-IlUI .. 60
PAK )l(EJIY,[(KA ........... ..... ....... .. ............. ...................... ............ ....... ....................................... 73
TPABMA )l(MBOTA .............. .................................................................................................. 87
IIEPI1TOHI1T .. .. ....... .... ... .. .......... .. .. ....... ........ ........... .. ... ..... .. .......................... ............. ... .... ... 104
3TAJIOH1I OTBETOB HA TECTOBhIE 3A)J:AHIDI ..... ............................................. 120
I1JIJIIOC.'fP A.I...U1H ........................................................................................................... 120
PEKO'tvIBH)J:YEMA.51 JIHTEP A TYP A: ......................................... ....... .... ............. .. .... ... 120

4acTb Ill ....................................................................................................................................... 121

3AEOJIEBAI-ill5I JIEfKMX I1 ITJIEBPbl.. ................................................. .......................... . 121
OCTPhIE A5CU£CChI VI f AHrPEHA JIEfKI1X .... ..... .. .. .. .......... .. .............. .. ... ................ . 135
3MIIBEMA TIJIEBPhl (fHOI1H:hIH ITJIEBPilT) ........ .. ....... ...... ....... ... ... ........ .. ............... ... 146
PAK JIEfKOfO .................... ... ......... .. ...... .... .. ..... ... .... ... ....... ... ....... .. ... ............... .. .... ............. . 163
3ABOJIEBAI-IIDI Ill11QEBO)J:A (AXAJIA3:IDI KAPAffiil, 0)K0fil,
PYBUOBhIE CTPI1KTYPhl ~BO)J:A, PAK Dl1II(EBO.D:A) ..... .. ............. .. .... ............ 187
3TAJI OH1I OTBET OB HA TECTOBhIE 3A)J:AHIDI .. ... .... ....................... .................. 207
I1JIJIIOCTP A~ ..... ....... .. ......... .... ...... ............. .. ... ....... .. ........ ..... ..... .............. ...... ...... .. . 207
PEKOMEH,n:YEMAJ:I JII1TEPATYP A: .... ... ...................... ... ..... ..................................... 207

4acTb IV ...................................................... .. ........................ ................................ ......... .............. 208

3AlJOJIEBAI-IIDI MOJIOlffiOH )l(EJIE3bl ... ......... ..... ...... ........... ... ... ....... ... .... ................... . 208
fP1DKI1 EPIOillHOH CTEHKil ....... ..... ........ .............. ................. ............... ...... ............... .. .. 218
3AEOJIEBAJITT.5I I1P.5IMOH KilllIKM .................. ............. .... .. ... ........ .. ................... ..... .... ... . 232
3AEOJIEBAHI15I BEH lllDKHilX KOHE1IHOCTEH ............. .. ............ ........ ...................... 255
3TAJIOHbl OTBETOB HA TECTOBbIE 3A)J:AHIDI .................................................. 279
ilJIJIIOCTP AUilI1 ........................................................................................................... 279
PEKOMEH)J:YEMAfI JII1TEP ATYP A: .... .. .. ... .... ... .. ........... ....... .. .... .... ........... .... ........... 279

OCTPLIH AilIIEH)UIIJ:HT
OcTpoe socnaneH111e 4epseo6pa3Horo OT-
pocTKa ( OCTpblM anneH,QWLIWT) 51Bm:leTC51 caMblM
pacnpocTpaHeHHblM x111pypr1.1YecK111M 3a6onesa-
HllleM. E>KefOAHO 1113 Ka)f(AblX 200-250 YenoBeK
OAlllH 3a6onesaer ocrpblM anneHAlllU.lllTOM.
)KeHll.llllHbl 6onet0T B 2-3 pa3a 48ll.le, YeM MY>K-
YlllHbl. nocneonepau,1110HH8Sl neT8JlbHOCTb co-
crnsm1eT 0,2-0 ,3%, B OCHOBHOM 38 C4eT ocno>K-
HeHl.'1111 , p83Bl'1BW1t1xcs:1 y 6onbHblX, onep111posaH-
Hb1x s noJAHllle cpoK111 or HaYana 3a6onesaHl.'151 .
OC06EHHOCTt1 AHATOMt1t1
Cnenas:1 KlllWKa 111 Yepseo6pa3Hblli1 orpocrnK
06b14HO pacnonarat0Tcs:1 s npasoi:i H1t1>KHeli1 YacT111
6pt0wHoil1 nonocrn, Yall.le scero (oKono 80%) B
pai:ioHe npasoi:i nOAB3AOWHOil1 SlMKlll . LJaCTb
6plOWHOll1 CTeHKlll , COOTBeTCTBYIOLl.\YIO npoeK4111111
3TOfO pai:ioHa, H83blBalOT npasoi:i nOAB3AOWHOll1
o6nacTblO.
1113 MblWeYHoro Macc111ea Ta3a o6pall.laeT Ha
ce6s:1 BH1t1MaH111e m .ileopsoas, 06paJyt0111as:1cs:1 1113
nepenneTeH111s:1 sonoKoH m.psoasmaior 111
m.iciacus BblnOnHS'leT co6ol0 nOAB3AOWHYIO S'IM-
KY, a BOJlOKHa ee seepoo6pa3HO CXOAS'ITCS'I Ill
BMecTe c Hli1>KHell1 YaCTbtO m .psoasmaior np111-
Kpenns:1ioTcs:1 K ManoMy sepTeny 6eApa. B 3Toli1
CBSl31i1 np111 nOAH51Tlllli1 Hli1>KHeli1 KOHe4HOCTli1 6plOW-
KO MblWL\bl COKpall.\aS'ICb ysenlll41!1BaeTCSl, a np111
porau,111111 6eApa KHapy>K111 p8cn1r111sas:1cb ynno-
111aeTcs:1. 111 s TOM 111 APYroM cnyYae socnan111-
TenbHO 1t13MeHeHHb1!11 Yepseo6pa3Hbrll1 OTpocTOK
nOABepraeTCS'I MexaHlt14eCKOMy B03Aeil1cTBllllO,
4TO conpOBO)f(AaeTC51 6oneBblM 011\YLl.\eHl/leM
(c·Mbl 06pa3t.4oea, Koyna)
"lacm&I
AnnEH.QMUIAT,
XOI1EU"1CT"1T,
nAHKPEATIAT,
K"1WE4HAs:I HEnPOXO.QIAMOCTb
Cnena51 KlllWK8 y 6onbWlllHCTBa nt0Aeli1
pacnon8r8eTcs:i s npasoi/1 noAB3AOWHor:;1 51MKe.
0,QHaKO OH8 MO>KeT cnycKaTbCS1 Ill 3H841!1TenbHO
Hlll>Ke, u,en1t1KOM HaXOA51Cb B M8nOM Ta3y , 111n111
MO>KeT p8cnonar8TbCS'I ssepxy - noA caMor:;1 ne-
YeHbto. B p8HHeM B03p8cTe KlllWKa o6brYHO
CTOlllT 3H841!1TenbHO BblWe, 4eM B nocneAYIO-
Ll.\eM . 3To, 6e3ycnoBHO OTpa>KaeTCS'I Ha KnlllHli1-
4eCKOll1 C1t1MnTOM8T1t1Ke OCTporo anneHA1114111T8.
4epseo6pa3Hblil1 oTpocroK (8ppendixver-
micularis) OTXOAlllT OT 38,D,HeBHyTpeHHero cer-
MeHT8 cnenoi:i KlllWKlll B TOM 4111Cne, rAe CXOAS1TCS1
see Tp111 ee neHTbl (taenia). OcHOB8H1t1e ero or-
cro111T Ha 0,5-5 CM OT MeCTa Bn8AeHlllSl nOA-
B3AOWHor:;1 KlllWKlll . l!lHOrAa OTpOCTOK MO>KeT OT-
XOAlllTb OT C8MOll1 Hlll>KHell1 48CTlll KlllWKlll , OT 38A-
Her:;1 nosepXHOCTlll, OT sepxHero OTAena BOCXO-
AS1LI.1ei:1 o60A04HOll1 Kli!WKlll Ill T-A- Cyll.leCTByer 5
TlllnOB OTXO)f(AeHlllS'l 4epseo6p83HOfO OTpOCTKa OT
cnenoi:i KlllWKlll.
I rnn - MeA1118nbHbrll1 H111cxoAS'lll.11t1i:1 : orpoc-
TOK OTXOA!i!T M8Ali18nbHO Ill BHli13.
II Tllln - M8Ali18JlbHbJr:;1 BOCXOA51Ll.\llli:1: OTpoc-
TOK OTXOAlllT MeAli18JlbHO Ill BBepx, AOCTli1raS1 lllHO-
rAa o6nacrn npasoro n0Ape6epbs:1 .
Ill Tllln - narepanbHbli:1 H1t1CXOAS'lll.11t1i:i: oTpoc-
TOK OTXOA!i!T naTepanbHO Iii BHl/13, JlOKan1i13ys:icb B
nOAB3,D,OWHOll1 51MKe .
IV Tliln - narepanbHbli:1 BOCXOAS'lll.lli!M: I.fall.le
scero 3TO coYeTaeTcs:1 c peTpou,eKanbHblM, s He-
KOTOpblX cny4aS1X 3KCTpanepli1TOHeanbHblM p8C-
nono>KeH1t1eM .
v rnn - MeA1t1anbHblli1: OTpOCTOK OTXOAlllT 3a
TepM!i!H8JlbHblM OTAenoM no,D,83,QOWHOi:1 KlllWKlll
no HanpaeneH1t110 K nyno4Hoi:1 06nacT1i1 (p111c. 1).
 2 3
Puc. 1. BapuaHmb1 omxo>KaeHUR llepeeo6pa3HOW ompocmKa: 1 - rvieauanbHblU HucxoaRu..wa;
2 - MeauanbHb/U BOCXOdRUJ,UiJ; 3 - namepanbHbfiJ HUCXOdRUJ,UCi; 4 - namepanbHb/U BOCXOdRW,UiJ (pempou,eKaflbHbliJ); 5
- MeauanbHbliJ.
,IJ.m1Ha OTpOCTKa MO)f(eT 6biTb BeCbM8 pa3-
nll1Y HOlll - OT 0,5 AO 30 CM 111 6onee , B cpeAHeM
)f(e KOI1e6neTC51 OT 7 AO 1OcM. ,1J.111aMeTp 3AOPO-
soro orpocTKa 06b14HO He npesb1waer 0,4-0,5
CM . KaHan ero OTKpb!BaeTC51 B cnenylO KlllWKy
y31<111M, 3HaYWTeJlbHO MeHbWWM , YeM w11p11Ha
KaHana , orsepcr111eM , rAe 111MeeTcs:1 HenocT05IH-
Has:1 nonynyHH851 CKn8AK8 Cili13111CTOM o6onOYKll1;
nocneAHelll He1<0TOpb1e aBTOpb1 np111n111cb1san111
ponb KnanaHa, npens:1TCTBY10L11ero nocrynneHllllO
s orpocroK coAep)f(lllMOro KlllWKlll . B AeTCKOM
803pacre BXOA B OTpOCTOK HepeAKO npeACT88-
n51eTC51 sopOHK006pa3HblM, YTO o6b51CH51eTC51
HenonHbtM e~e pa3s111r111eM opraHa. BopoHKoo6-
pa3Hoe OCH088Hllle OTPOCTKa y B3pocnblX BCTpe-
48eTC51 B 7% .
Puc.2. nonepel/Hb/U pa3pe3 4epeeo6pa3HOCO
ompocmKa.
- cnu3ucmaR o6onol/Ka; 2 - noacnu3UcmaR mKaHb; 3
- nuM<jJamul/ecKuD <jJonnuKyn;
4 - u,upKynRpHb/lJ Mb/Wel/HbfU cnou; 5 - npodOflbHbfU
Mb1wel/H&1u cnou; 6 - cepo3HaR o6onol/Ka;
- 6pbt)l(eiJKa.
Cn1113111cTa5! o6ono4Ka co,aep>KlllT MHOro4111c-
neHHble n111Mcparn4ecK111e cponn111Kynb1, 111 Ha ee
nosepxHocn1 OTKpb1B8IOTCs:I OTBepCTlllH 38IlO-
)f(eHHblX s o6onoYKe Tpy6YaTblX >Kene3 . Kon111Ye-
CTB0 cponn111Kynos B cn1113111croM oYeHb sen1111<0;
~Hor,a a 0H111 , cn1-1sas:1cb, 06pa3y10T 6m1wK1-1 6onee
wrn MeHee 3Ha4111TeI1bHOCi senw-n1Hbl. Me>K,D.y
C!lllf3111CTOC1 111 MblLUeYHOCl o6onoYK8MVI pacnona-
aeTCS'I C8Mbilll TOilCTblM - nO,D,CI11113111CTbli:1 cnoCi.
OH CTOIH 1113 6orarnM n111Mcp0.1t1,llHb1M111 1<neTKaM.1t1
5
4 5
coep,111H111TenbHO!li TK8H111 , B KOTOpOCi npOXOP,S'IT
KposeHOCHbte 111 n111Mc:j:JaT111Yec1<111e cocyp,bl (p111c.2).
KposocHa6)f(eH111e ocy~ecrsns:1eTcs:1 1113 seT-
s111 a.mesenterica superior - a. lleocolica, KOTO-
pas:1 nepexo,a111T Henocpep,crseHHo B a. appen-
dicularis. ApTep11fl pacnonaraeTcfl B~OJlb cso-
6op,Horo Kpas:1 6pb1>1<ei111<111 4epseo6pa3Horo OTpo-
CTKa 111 OT.£1aeT K OTPOCTKY noYrn nepneH~i1KY­
ns:ipHo OT 7 p,o 12 sereell\ (p111c. 3).
3
Puc. 3. KpoBocHa6)1(eHue uneou,eKanbHoiJ
o6nacmu. 1-ompocmoK; 2-cnenaR KUWKa;
3-eocxoaRw,aR KUWKa; 4-nodB3dOWHO-
o6oaol./HOKUWel/HaR apmepuR; 5-apmepuR
l/epeeo6pa3Hoeo ompocmKa; 6-noae3aowHaR KUWKa.
BeHbt Yepseo6pa3Horo orpocTKa no ceoeMy
pacnono)f(eHlllto COOTBeTCTBYIOT seTBs:IM apre-
p111111. OHlll Hecyr KPOBb B BepXHIOIO 6pb!)f(ee4Hy10
seHy. OnoK n111M¢b1 1113 orpocTKa ocy~ecTsns:1-
eTCfl e .n1-1M¢arn4ecK111e Y3!1bl , pacno.no)f(eHHbre y
111neoL1e1<a11bHoro yrna, 3aTeM s rpynny noA-
s3,.qowHo-060,.qoYHblX m1McparnYecK11X y3noa 11
,aa.nee - B y3.nbl y KOpHs:I 6pbl:>KeMKlll . VlHHepsa-
L\11151 OTpOCTKa o6ecneYll1BaeTC5! aepxHll1M 6pb1-
)f(eeYHblM cnnereHllleM , YaCTb eerseCi Koroporo
HanpasnHeTcH K 111neoL1eKanbHOMY yrny no ne-
p111sacKyns:1pHo~ KneTYaTKe 111 y MecTa ,aeneHlllfl
nOP,B3P,OWH0-060A04HOKlllWe4HOlll apTep1111t1 o6-
pa3yer 111.neoL1eKaI1bHOe HepsHoe cnneTeH111e.
OHO pacno.naraercs:1 s )f{ltlposoCi KneT4aTKe noA
nap111eranbHblM Ill/ICTKOM 6pl0Wli1Hbl Ha paccT051-
Hll1111 2-3CM or 111neol\eKanbHOro yma 111 OTp,aer
BeTBl/1 K BOCXOAHW,elli KlilWKe, KOHe4HOMY orp,eny
nop,s3,aowHoil1, K cnenolll KlllWKe 111 4epseo6pa3-
HOMY OTPOCTl<}I. BeTB111, Hanpasnfltoll.(111eCfl I< OT-
poCTKY, pacnonaratoTCfl s ero 6pb1>KelilKe no XOAY
COCYAOB.
Ha KJ1111Hll14ecKoe Te4eH111e ocTporo anneH-
A111L\111Ta Mo>KeT BI111151Tb s3a111MoOTHoweH111e oTpo-
CTKa 111 6p10Wll1Hbl. Pa3Jlll14alOT (p111c. 4) a - non-
HOCTblO BHYTp1116piow111HHoe; 6, s - 4aCTlll4HO 3a-
6p10WlllHHoe pacnono>KeH111e; r - nonHOCTblO 3a-
6plOW111HHOe pacnono>1<eH111e OTpOCTKa.
B 3as111c111MocT111 OT noKan1113aL1111111 TepM111-
HanbHOro OTAeJla 4epseo6pa3HOro OTpOCTKa 111
cp111KcaL1111111 ero cnalilKaMlll K pa3nlll4HbtM opraHaM
6plOWHOlil nonOCTl/1 , 3aBll1Cll1T n0Kan1113al..\llls:l 30H
napecrn3111111 111 n0Kan1113al..\llls:l AecpaHca 6p10WHOlll
cTeHKlll .
3H10/10ft1fl t1 nA TOfEHE3
3T111onaToreHe3 ocTporo anneHAlllL\lllTa
OKOH4aTenbHO He s:iceH , no:noMy Cyli.\eCTBYfOT
A 5
Puc. 4. 83aUMOOmHOWeHU.R Me)l(OY 6plOWUHOil, cnenoil u BOCXOO.RLJ.leil o6odo4HOU KUWKOU,
4epeeo6pa3HblM ompocmKOM u no4Koil (no ,a.H. fly6o~KoMy) .
TeopuR 3acmoR. np111 Hanlll'-1111111 B npocseTe
4epseo6pa3HOro OTpOCTKa KanOBblX KaMHelil,
reJlbMlllHTOB cpopM111pyeTCs:l 11130IllllpOBaHHas:l no-
JlOCTb , B KOTOpoill npOlllCXOAlllT pa3BlllTllle socna-
neHll1s:l.
MOP<POJ70ft11../ECKt1E t13MEHEHt1fl
B ps:iAe cny4aes Kn111H111YecK111e npo51sneH111s:1
xapaKTepHbte AI151 OCTporo anneHAlllL\lllTa HOC51T
KpaTKOBpeMeHHbtill xapaKTep, caMOCTOs:lTenbHO
npOXOAs:IT 111 He conpOBO>f<AalOTCs:l pa3Bll1Tl/1eM
eocna11111TenbHblX 1113MeHeH111iil cTeHKlll 4epeeo6-
pa3Horo OTPOCTKa. 3TO COCTOs:lHll1e HOCll1T Ha3Ba-
Hllle anneHAMKynHpHOM KOnMKM.
Kamapan1:.H1:.1(J npoL1ecc s oTpocTKe He-
peAKO MO>KeT npeTepneeaTb o6paTHoe pa30111-
nie, HaCTYnaeT KJ1111Hll14eCKOe Bb13AOPOBI1eH111e.
np111 3TOlil cpOpMe OTpOCTOK He3Ha4t.1TeflbHO
yTOflli.\eH, r111nepeM111poeaH, HO 6necK cepo3Horo
noKposa coxpaHeH . np111 cpne2MOH03HOU ¢>op-
Me eocnaneHll1s:l, OTPOCTOK pe3KO 111HbeL\lllPOBaH,
cTeHKlll ero YTOflli.\eHbl. Cepo3Has:i o6ono4Ka no-
Kpb1saeTcfl cp1116p111H03HO-rHolilHbtM HaneToM . Bee
Cf10111 pe3KO 111Hcpll1IlbTpll1pyfOTC51, MeCTaMll1 B Hll1X
o6pa3ylOTCfl MeilKllle rHOlilH111Klll, B npocseTe OT-
pOCTKa - rHOlllHo-reMoppar1114ecKas:l >K111AKOCTb.
n111TaHll1e OTpOCTKa pe3KO Hapywa:iTCs:l, 4TO nplll-
6
HeCKOJlbKO Teop111ill, KOTOpbte OCHOBbtBafOTCs:l Ha
onpeAeneHHbtX npeApacnonarafOU\lllX np1114111Hax.
AH2uoHeepomu1.1ecKafl meopufl (PUKKep).
BocnaneH111e o6bs:ICH5llOT HapyweHllleM Helilpo-
reHHOlil peryns:IL\111111 TDHyca cocyAOB. Ha cpoHe
BeH03HOro CT838 aKTlllBlll3111pyeTCs:l KlllWe4Ha51
¢>nopa, pa3s111saeTC5! rHolilHoe socnaneH111e.
VfH<j.JeKu,uoHHafl meopufl (Awocpcp) . Bocna-
n111TenbHb1e 1113MeHeHlll51 OTpOCTKa CBs:l3btBalOT c
cpopM111posaH111eM AecpeKTa cn1113111cTolil 06011041<111
(nepBU4HblU acpcpeKm) .
Annepw1.1ecKaF1 meopuFI (<Puwep) . nospe-
>KAeH111e c111113111cToi1 o6ono4Klll 4epseo6pa3Horo
OTpOCTKa L\lllPKYI1111PYIOU\111Mll1 B KpOBll1 111MMYHHbl-
Mll1 KOMnJleKCaMll1 .
B r
BOAll1T K pa3Bl/ITll1IO eaH2peHbl, KOTOpas:1 HepeAKO
BeAeT K nepcpopal.(UU OTpOCTKa.
Knacc111cp111KaL1111fl 8 .111. Konecosa (1992) ,D,a-
eT AOCTaT04HO nonHoe npeAcrnsneH111e o cpop-
Max socnaneH111s:1, He 111cKJ1104as:1 xapaKTep111cT111ey
¢>opM xpoH1114ecKoro anneHAlllL\lllTa.
Kflt1Ht1KA
Kn111H1114ecKoe npoflsneH111e ocTporo anneH-
AlllL\111Ta secbMa sap111a6enbHoe.
Knacc1114ecKoe Ha4ano 3a6oneeaH111fl xapaK-
Tep1113yeTcs:1 nocTeneHHo yc111n111sa10li.\lllM111cs:1 , yMe-
peHHO Bb1pa>KeHHbtM111 6ons:1M111 s >1<111s0Te. B ps:iAe
c11y4aes 6011111 BHa4ane npoeL1111pyfOTcs:1 s 3n111ra-
cTp111111, no4Tl/I scerAa conpOBO>f<Aas:ICb TOWHOTOi1,
111HOrAa psoroill, cnycTfl 3-4 4 3Tll1 6om1 cMeli.\afOT-
cs:i s npasy10 noAB3AOWHYIO 0611acTb. TaKoe «ra-
cTporeHHoe» Ha4ano ocTporo anneH,D,lllL\lllTa no-
ny4111no Ha3BaH111e c111MnTOMa Koxepa - BonKo-
eu'la. 111HorAa 6on111 cMeli.\alOTCH s npasy10 noA-
B3AOWHYIO o6naCTb 1113 OKOI10nyno4HOi1 0611acT111
(c111MnTOM KIOMMenR) .
np111 06beKTl/IBHOM o6cne,D,OBaHll1111 60flbHblX
MO>KHO BblHBll1Tb 8CUMMempwo nepeaHeU
6plOWHOU cmeHKU np111 my6oKOM BAOXe, ,D,ecpaHC
s npasoVi noAB3AOWHoi1 o6nacrn c Ha1116011bwei1
6one3HeHHOCTblO s T04Ke MaK - 6ypHeR 1113
MHOrQ4111CneHHblX ClllMnTOMOB OCTporo anneHAlll- nocne npo,D,a8m118aH1115! nepe,D,Heill 6p10wH0Vi
L\lllTa uenecoo6pa3HO 111cnonb30BaTb caMb1e lllH- CTeHKlll) . f
cpopMaT111BHb1e. C111MnTOMbl no,o,pa3,o,em110TC5I Ha C111MnTOM Pa3oonbcKoao (3oHa nepKYTOP-
06l1.\llle Ill naTorHOMOHlll4Hble . HOVI 6one3HeHHocrn) np111 nocne,D,oBaTenbHOVI
06~ 11t e ClltMnTOMbl, C8111,D,eTenbCTBYIOlJ..lllle nepeycc111111 6p!OWHOVI CTeHKlll OT lllHTaKTHblX 06-
0 JlOK8JlbHOM socnaneHllllll 6plOWlllHbl: nacTei/1 (npa8oe no,o,pe6epbe, 3nv1racTp111 i/1, ne-
C111MnToM MeHdenR (cpasH111TenbHa5T nep- soe no,qpe6epbe, nesa51 6oK08851 o6naCTb) B
eycc11151 6plOWlllHHOVI CTeHKlll) . CTOpOHY npasoVI nO,D,830WHOVi o6nacrn Bbl518m'l-
C111MnTOM UlemKuHa-6moM6epea (yc111ne- eTC51 rpaH1114a 6one3HeHHoVI nepeycc111111 , KoTopaH
H111e 6one3HeHHOCTlll np111 pe3KOM OTH51Tllllll pyK111 orpaHll141118aeT 30HY Pa3oanbcKoao 1113Mep51e-
MYIO s caHT111MeTpax.
KJ1nuuq ec1rnsr KJiaccmpu1rnQHS1 anneu).lUQnTa
AnrreH,ll;IHU1T
I

r- - - - - - ,
OcTpbIM ---- I
XpoID1qecr<11il
I I
I
I

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;:i ~ anneH~MI.JJIT
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(1)
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----- -·

0 CJI0'1<H CHH11 OCTporo a n DCHJlU U:HTa

A nneH,JJJ1Kym1pHbIM mHpmi bTpaT Pa3JTHTOH nepJ1TOHHT

AnneH,lU'.lKYllilPHbIH a6c.uecc Tiuneqrne6HT

3a6pIOIIIMHHM qmerMm-m CencHc

3I< C Tpaa6~0MIIBanbH1Ie OCJIQ)J<Hemur

(rrrreBpMT, rrHeBMOJ-UUI)

naTOrHOMOHllt'-IHble ClltMnTOMbl : KlllWKlll . 3ro CB513aHO c perporpa,D,HblM CM81.1.\e-

C1t1MnTOM BocKpeceHcKoeo (c-M CKOflb>Ke-
HUfl unu py6awe1.1Hb/U c-M) -(yc11111eH111e 6011e3-
HeHHocrn B npasoi/1 nop,83,D,OWHoVI o6nacrn np111
nosepxHOCTHOM CKOJlb3511.1.\eM c nerKlllM H8}f{lt1MOM
npose,o,eH111111 pyK111 8pa4a OT Me4es111,o,Horo oTpo-
crKa 8 no,o,s3,o,owHble 0611acT111 nosepx HarnHy-
rnVI Ha }f{111sore py6awK111) . Ha4111HaTb era onpe-
,o,e11eH111e HY'f<HO c 3a8e,D,OMO 3,D,Op080VI CTOpOHbl.
C111MnTOM Pos3uHea (c-M cMeU(eHuR aa-
3oaou sonHbl) - yc1;1neH111e 6011111 a npasolll no,o,-
83,D,OWHolil 0611acrn cnpa8a np111 TOJ14Koo6pa3-
HOM Ha,D,8811111B8Hllllll Ha 6plOWHYIO creHKY B ne-
80'1 no,D,B3,D,owHoVI o6nacrn np111 o,o,HospeMeH-
HOM c,o,asneHl/1111 )J,LllCTaJlbHOro OT,D,ena TOJlCTOVI
7
HllleM ra30BOlli 80J1Hbl Ill nepepaCTH>KeHllleM cne-
noVI KlllWKlll.
C111MnTOM 06pa31-4oea - yc111neH111e 6oneill 8
npasoill nop,83AOWHOVI o6nacrn np111 nOAH51TOVI
8blnp51MJ1eHHOVI npasoill Hlll}f{Heill KOHe4HOCTlll
(coKpaL11eH111e 6plOWKa m. ileopsoas c MexaH111-
4ecK111M 803,D,eVicTBLlleM Ha 4epseo6pa3Hblli1 OT-
pocrnK) .
ClllMnTOM CumKoacKoeo - yc111neH111e 6oneill
8 npasoill noAB3,D,OWHOVI 06nacr111 np111 nosopore
6onbHOro Ha 11esb111i 6oK npo111cxo,o,111T lll3·3a nepe-
MelJ..leH1115! KLllWe4HLllKa Bneso - 8Hlll3 Ill HaT51}f{eHlll51
6pbt}f{ei/1K111 socnaneHHoro 4ep8eo6pa3Horo oTpo-
CTKa. 3TOT naTorHOMOHlll4Hblil1 ClllMnTOM y }f{eH-
ll.\lllH Ill rp111Mecrpa 6epeMeHHocrn MO>KeT 6b1Tb
0Tp1114aTenbHblM 111 Ami nOATBep>K,QeH111s:1 At11arH03a
peKoMeHAYeTcs:i onpeAeneH111e c111MnT0Ma Cum-
KOBCKoeo Hao6opom (yc111neH111e 6onelli np111 no-
sopoTe 6epeMeHHOlli >KeHLL\lllHbl Ha npaBbll4 6oK).
np111 3TOM npolllCXOAlllT AaBneHllle Ha 4epseo6-
pa3Hbllli OTpOCTOK 6epeMeHHOlli MaTKOlli .
Ct11MnTOM 6apmoMbe-MuxenbcoHa - yc111-
neH111e 6onelli np111 nanbna4111111 npasol4 noA-
B3AOWHolli o6naCTlll B nOJlQ)l(eHllll/I 6onbHOro Ha
nesoM 6oKY (1113-3a cMeu.ieH111s:i sneso 6onbworo
canbH1t1Ka 111 APYrlllX noABlll)l(HblX opraHoB 6p10w-
Hol4 nonocrn , 4epseo6pa3Hbllli oTpocToK cTaHo-
s111Tcs:1 6onee AOCTYnHblM AJ151 nanbna4111111).
C111MmoM «CMew,eHUR ompocmKa» - yc111-
neH111e 6onel4 np111 cMeLI.1eH111111 pyKol4 seepx 111
pe3KOM ornycKaHllllll OTBll1Cal0ll.\el4 6plOWHOlli
cTeHKlll B nono)l(eH111111 6onbHOro Ha nesoM 6oKy.
np11 3TOM npOltlCXO,.QltlT pe3KOe Han:J)f{eHMe 6pb1-
>KelliKll1 Yepseo6pa3HOro OTpOCTKa, np111BOA51ll.\ee
K yc111neH11110 6onelli .
ClllMnTOM Koyna - yc111neH111e 6onelli np111 ne-
pepa3r1116aH111111 Hl/l)l(Helli KOHeYHOCTlil B Ta3o6eA-
peHHOM cycTaee np111 nono)f{eH111111 6onbHoro Ha
neBOM 6oKY 111n111 np111 p0Ta4111111 KHapy)l(t11 npasolli
cTonb1 np1-1 nono)f{eH111111 6onbHOro «Ha cn111He» .
np1t1 KamapaflbHOM anneHA1114111Te lllHOrAa
MO>KHO 3aMeTll1Tb acUMMempUl/HOCmb 6p10WHOU
cmeHKU npu abJXameflbHOU 3KCKypcuu. np1113Ha-
KOB pa3Apa>KeHlll51 6pl0Wlt1Hbl BHaYane He OTMe-
YaeTC51 , 33 lllCKnlOYeHllleM flOKanbHblX 6onelli nplll
rny6oKol1 nanbna4111Y1 B TOYKe MaK-EiypHefl . Halil-
6onee xapaKTepHbllli nplil3HaK s KarapanbHOlli
Q:>a3e anneH,D,lilL\lllTa - 30Ha rnnepecTe31i1111 KO)l(lil ,
YTO cneAyeT paccMaTp111eaTb KaK npos:ieneHlile
opraHHO-eyT3HHOrO peQ:>neKCa . np111 CT861i1JlbHO-
CTlll KaTapanbHoro npo4ecca MO)l(HO onpeAen111Tb
cuMnmoM Poa3uHea, cuMnmoM CumKoacKo-
20,cuMnmoM 6apmoMbe -MuxenbcoHa, cuM-
nmoM «CMeU(eHU.R ompocmKa».XapaKTepHblMlll
AI151 Bcex CT8A11111i pa3BlilH151 OCTporo anneHAlllL\lil-
Ta 51Bn51toTC51 cuMnmoMbl 06pa3~oea, 111 Koyna.
<Pne2M0Ho3Hb1D anneHauuum. CaMafl 1.1ac-
Ta5! Q:>opMa ocTporo anneHAlllL\lllTa. 6on111 B npa-
eol4 nOAB3AOWHOL4 o6nacrn HOCS'IT lllHOrAa nynb-
ClilPYIOLL\llllli xapaKTep, OHlil 6onee nocTOSIHHbl Ill
conpoBO>K,QalOTC51 Yacrnl4 TOWHOTOL4 6e3 PBOTbl.
)\{visoT 3aMeTHO OTCTaeT B Ab1X8Hlilll1 , oco6eHHO
npasa51 ero nono0111Ha. npvi nosepxHocTHolli
nanbna4111111 onpeAens:ieTcsi HanpS1>KeH111e Mb1w4 e
npasolli noAB3AOWHolli 06nacT111. np111 Q:>nerMo3-
HOM anneH,.q1114111Te e 6onbWl-1HCTBe cnyyaee
np051BnfleTC51 Ha1116onee AOCTOBepHbllli CUMnmoM
U/emKUHa - 6n10M6ep2a , cuMnmoM Pa3oonb-
CK020, 111 30Ha Pa3oonhcKoeo 1113Mep51eMa51 e
caHrnMeTpax, cuMnmoM BocKpeceHCKoeo.
BHaYane 3Tlil c111MnTOMb1 BblflBnS110TCS1 HaA cne-
nolli KlllWKolli , np111 AanbHelliweM pacnpocTpaHe-
HrAlll socnanrATenbHoro npo4ecca, cwMnTOMbf
npos:iBmllOTCfl BO scex OTAenax >KtitBOTa .
../'
8
,Qn51 2aH2peH03H00 cjJopMbl xapaKTepHo T51-
>Kenoe COCTOS'!Hlile 6onbHOro , 6oneeol4 ClilHAPOM
111n111 pe3KO yc1.1n1110aeTcs:1 1.1n111 coeceM lilCYe3aeT
ecne,QCTBlile r1116em-1 HepBHblX oKOHYaH11111i. KaK
np051BlleHi.1e 6blCTpO HapacTalOLL\elli lllHTOKClllKa-
4111111 nos:isns:ieTcs:i 3Cf¢>op1M1, anantfl, 06e3so>K111-
BaH111e, T8Xl/IKap,Q11151 , MO>KeT Ha6nlOA8TbC51 ClllM-
nTOM «HO>KHlllL\» - HeCOOTBeTCTBl/le 43CT0Tbl cep-
AeYHblX COKpall.leHllllli Ill TeMneparypbl Tena .
npo6oaHafl cjJopMa ocTporo anneH,JJ,lilL\lilTa
xapaKTep1113yeTCfl B03HlllKHOBeHll1eM pe3KlllX 60-
nect s npaeolli nOAB3AOWHolli o6nacrn , KOT0pb1e
nocTeneHHO ocna6esatoT, noeTopHoi.1 peorni.1 ,
nporpecc111py10ll.\el4 111HTOKC111Ka4rAei.1 111 , no Mepe
pa3BlllTlll51 nopa>KeHlll51 6ptoWlllHbl , Knl/IHlilKOlli pa3-
JllllTOro nep111rnH1.1Ta.
AT/lln/111./Hb/E c/JOPMbl
3MnueMa yepeeo6pa3Horo orpocTKa
scTpeYaeTc51 B 1,2% cny1.1aes ocTporo anneHAlll-
L\lllTa. 5on111 cpa3y )Ke n0Kan1113y10TCS1 B npaeolli
nOAB3AOWHOlli o6naCTlll , HOCSIT nynbClllPYIOLL\llllli
xapaKTep, AOCT111raioT MaKc111MyMa K 3-5 AHIO 3a-
6oneBaH1115! . Mb1weYHoe Hanps:i>KeH111e nepeAHel4
6plOWHOlli CTeHKl-1 , a TaK>Ke ClllMnTOMbl pa3Apa-
>KeHlllfl 6plOWlllHb1 MOryT orcyrCTBOBaTb, np111
3TOM Bb1s:ienritoTCfl xapaKTepHble Ans:i ocTporo
anneHAVIL\lllTa cuMnmOMbJ CumKoacK020, Poe-
3UH2a, 6apmoMbfrMuxenbcoHa. 3MnllleMy
Yepseo6pa3HOro OTpOCTKa HepeAKO MO>KHO 06-
Hapy>KltlTb np111 Y3V1 6p10WHOlli nonocT111.
Pempou,eKanbHblD anneHauu,um cocTasm1-
eT 8 - 20% cnyYaeB ocTporo anneHAlllL\lllTa. Ha-
yano 3a6onesaH1115! np111 3TOM TaKoe >Ke, KaK 111
np111 rnn1111.1HoC1 n0Kan1113a4111111. 0AHO 1113 xapaKTep-
HblX Knl/IHlllYeCKVIX np051BneHllllli peTpot..1eKanbHOro
anneH,QlllL.llllTa - >KlllAKlllL4 HeOAHOKpaTHblCl cryn ,
KaK pe3ynbTaT sosneYeH1115! s npo4ecc cnenolli
Kl/IWKlll . nplil 3KCmpanepumoHe8flbHOM pacnono-
)l(eHl-1111 oTpocTKa B03MO)f{HO no51sneH111e Alll3yp111111
1113-3a KOHTaKTa c MOYeTOYHlllKOM 111n111 noxaHKOlli
nOYKlll. np1113H3Klll pa3Apa>KeHlll51 6plOWlllHbl npVI
3TOM , KaK npaBlllJlO, OTCyTCTBYIOT l/IIll/I pe3KO oc-
na6neHbl , np111 06cne,QoeaHV1lil nof!CHlilYHolli 06-
nacT111 Bbl51Bn51eTC51 Hanp5!)KeH111e MblWL\ cn111Hbl
1t1m1 c111Myn1t1pyercs:i cuMnmoM nacmepHaqKoao.
naTOrHOMOHVIYHblMl/I Cl/IMnTOM3Mlil peTpo4e-
K8llbHOro anneHAlllL\lilTa s:ien51eTc51 Bb151BneHlile
ClllMnTOMa 06pa3~oea, Koyna 111 Rype - Po3a-
Hoaa (6one3HeHHocmb npu nanbnau,uu a noRc-
HUl/HOM mpey2onbHUKe cnpaea) .
Bocnan111TenbHari KaprnHa Kpoe111 xapaKTep-
Ha Anfl ecex CTaAllllli pa30111T1115! peTpo4eKanbHoro
anneHAlllL\lllTa . OYeHb YacTo Hap51AY c 3TlilM on-
peAen51eTC51 nelliKOL\lllTYPlllfl , 3p111TPOL\111TYPlll51 r.43-
38 KOHTaKTa Yepseo6pa3HOro OTpOCTKa c MOYe-
TOYHlilKOM , YTO Tpe6yeT Alil¢Q:>epeH4lilaJlbHOlli
,QlllarHOCTl/IKl/I c noYeYHOlli KOlllllKOlli , OCTpblM n111e-
noHeQ:>pt11TOM .
Ocmpb1u ma3oeb1u anneHauu,um 51Bn51eTC51
pe3ynbTaToM eocnaneH111s:i yepseo6pa3Horo OT-
pocTKa, pacnono>KeHHoro B ManoM Ta3y. Y MY}l(-
4111H OH cocTasns:1er 11 % scex n0Kam13a1.-1111Vi , y
)l{eHll.(lllH 21 %. ~111arHocrn1<a ocrporo anneH,a,11-
4111Ta Ha1116onee rpyp,Ha y >KeHl..J..\lt1H , y KOTOpblX
Hepep,Ko B03HL1Kaer ocrpoe socnaneH111e np1.1-
AaTKOB MaT1<L1. B KnL1Hw-1ec1<oiil KaprnHe xapa1<-
repHo nosrnneH111e 4acToro )1(111,IJ,Koro cryna c re-
He3MaM111 , scnep,CTBl/le KOHTal<Ta c np$1MOVI KlllW-
KOiii . npM3HaK1'1 pa3,[lpa)l{eHli15l 6pl0Wli1Hbl ,[lOnro
MOryT He onpep,en$1TbCS'I . V1CKnl041/1TenbHYIO A111-
arnocrn4eCKYI{) 1.-1eHHOCTb np1.106peTal{)T sar111-
HanbHOe 111 pe1<ranbHOe 111ccneA0BaH111e, np111 Ko-
ropblX yp,aeTCS'I BbtS'IBlllTb He TOnbKO 6one3HeH-
HOCTb s 06nacr111 p,yrnacosa npocrpaHcTsa, HO 1i1
onpe.Qen111Tb Han1114111e Bbinora B 6pl{)WHOVI no-
nocr111 111n111 socnamHenbHOro lllHcplllnbTpara, Bbl-
HCHlllTb cocro5tHllle reH111Ta11111ill 111 AP- XapaKTep-
HblM S'IBnS'leTcs:i noS'lsneH111e cuMnmoMa Koyna.
TeMneparypHas:t peaKL\1115'1 111 neillK04111ro3 Bbtpa-
>KeHbl yMepeHHO.
Ocmpb10 noanel./eHol./HbliJ anneHou4um co-
nposo)K,QaercS'I pe3Kll1Mlll 6ons:1M111 B npasoM nop,-
pe6epbe, Hanpfl)l{eH1-1eM MblWL( npasolll nonoa111-
Hb1 >KlllBOTa. 06bl4HO np111 paccnpoce Bb15'1CHHer-
c5l , YTO npLi1cryn 6oneill HaYancS'I B 3n1.1racrpanb-
Hoiii o6nacrn, BMecrn c TOWHOTOlll li1 PBOTOJA, 3a-
TeM 6on111 nepeMecnm111cb a o6nacTb npasoro
nop,pe6epbs:t, HO 111ppap,111a1.-1111111 a Hap,nne4be, a
WeK>, nonaTKY, KaK 3TO CBOillCTBeHHO )J,m'I xone-
l..\IACTltlTa, He OTMe4aeTC$1 .
fleeocmopoHHUU anneHou4um scTpe4aeTc5'1
secbMa pe,QKO, o6bl4HO np111 o6paTHOM pacnono-
)l{eH111111 scex opraHoB, HO TaK>Ke 6b1saer np111 nop,-
BIA)f{HOill cnenoii'r KlllWKe c ,IJ,nlilHHOlli 6pbl}f(eti11<orli
orpocr1<a. B ,o,111arHocr1111<e nesocropoHHero an-
neHAlllL\lllTa noMoralOT ,o,aHHbte, nop,Tsep)K,QalO-
ll.(llle o6parnoe pacnono>1<eH111e opraHOB (nepKYC-
ClllH , aycKynbTa1.-1111s:i, Y3111 , nanapocKom1H) .
,n,onof7Ht1TEJ7bHb/E METO,D,bl
t1 CCJ7 E,ll, 0 BAH t1fl
B 6onbWlllHCTse cny'laes AnH KaTapanbHoro
anneHAlilltlllTa xapaKTepHo noBblWeH111e TeMne-
parypbt Tena, HO He Bbtwe 37 ,5-38,0 °c, a Tal{)l(e
9 npoHsneH111.si ocTporo anneH,D,lllL\lllTa B nepsoi/1
ysen1114eH111e nei:1KOL\lllTOB ,D,O 10-12x10 . np111
pa3BlllTllllll p,ecTpyKTlllBHOro npol(ecca reMnepa-
rypa Tena, KaK npas111no, nosb1waeTcs:1 p,o 38-
9
38,5 °c, nei:1KOL\l!IT03 AOCT111raer 16-20x 10 , no-
Rsm1eTCR nan04KOR,[lepHbllA C,QBlilr ,QO 5-8%. ,Qns:l
raHrpeH03HOro anneH,o,111u,111ra xapaKrepHo pe3KOe
noBb1weH111e reMneparypb1 Tena AO 38,5 °c 111
9 CTlll Bblpa>KeHO xopowo, HO B n03,D.Hllle CpOKlll 6e-
BbtWe, ysen111YeH111e nell1Kol..\lllTOB p,o 20x10 , pe3-
Klllill na.no4K05lAepHblill C,[\Blllr ,IJ,O 10% Ill BblWe .
np111 pa3BlllTllllll BOCnaneHlt15'1 B 4epBeo6pa3HOM
OTpOcTKe nOBblWaeTCS'I COOTHOWeH111e Heil1rpo-
cp111Ilbt/n111MQJOl..\lllTbl (lllHAeKc Kpe6ca) Bb1we 3
e,QlllHl/ll(.
AocrosepHOCTb Yf7bmpa3eyKoeo20 MeTOAa
,[\1t1arHOCTlllKlll ,D,OCTlllraer 90% nplll Tlllnlll4HOM
pacnonO)KeHll!lll Iii pa3BWTllllll ,a,ecTpyKTWBHblX
cpopM. np111 3TOM B T04Ke MaK-6ypHe5l OT4eT.nlll-
9
so s1113yan1113111pyercs:i oKpyrnaH r111no3xoreHHa$1
TeHb c n..mep3xoreHFfffi.1 BHyrpeHHei/1 CTPYKTYPOll1
- c111MnTOM «1<01<app,b1» . Helll3MeHeHHbrc:i yepse-
o6pa3Hbli:1 OTpOCTOK He B1t13yan1113111pyeTC5l . VlH-
cpopMaTlllBHOCTb Y3Vl s cnopHblX cny4a5lx ,o,oc-
raT04HO Hlll3Ka5l , OKOno 4%. 0,QHal<O, BbtnOnHe-
Hlile ynbTpa3sy1<osoro 111ccne,o,osaH1t1s:1 Heo6xo-
AL1MO y Bcex 6o!lbHblX c no,[\03peHlileM Ha OCT-
pbllA anneHp,1111...wlT, ,QnH ,Q111cpcpepeH41'lanhHOll1 ,Qlll-
arHOCTlllKL1 c APYflllMlt! x111pyprn4ecKlllMlll 3a60.ne-
saH1t1s:iM111 opraHOB :>KlllBOTa.
B COMHl!ITenbHblX cny435lX, Ill ,Qnfl ,[lltlcpQ:>e-
peHl..\L18nbHOli1 AlllarHocTlllKlll Ha1116onee onpas-
,o,aHHbtM 5'1BnHeTC5'1 np111MeHeH111e nanapocKonuu.
np111 3TOM MO)l{HO nony4111Tb np5!Mble np1113HaKlll
ocTporo anneH,o,1114111Ta (socnan111renbHble 1113Me-
HeHlllfl, cooTBeTCTBYK>ll..\We KOHKpernoii'r cpopMe).
np111 HeB03MO:>KHOCTlll OCMOTpeTb 4epseo6pa3-
Hbliii OTPOCTOK, MO:>KHO nony4111Tb KOCBeHHble
np1-13Ha1<11 ocrporo anneH,D,lllL!lr!Ta (r111nepeM111fl
nap111eranbHOiii 6p10UJlllHb1 111n111 socnan111renbHb1ill
KoHrnoMepaT npasoill no,o,s3p,owHoi11 06nacr111 ,
BblnOT 8 6plOWHOill nonoCTlll).
PeHneHonorn4ec1<oe 111ccne,o,osaH111e He
lllHcpopMaTlllBHO .o.ns:i p,111arHOCTlllKlil OCTpblX cpopM
anneH,[\1114111ra.
/l,t1<:/J<:/JEPEHU,UAJlbHbf ft ,D,t1AfH03
COMHeHllls:! B AlllarH03e OCTporo anneHAl-11..(111-
Ta rpe6yioT npoBeAeH1115'1 A1t1¢cpepeHL\lllanbHOil1
AlllarHOCTlllKlil c OCTpblM racTp03HTeplllTOM, OCT-
PblM naHKpear111roM, np111Kpb1roill npo60AHOVI 5l3-
sot71 )l(eny,D.Ka 111n111 ,o,seHa,D,L\aT111nepcrnoill K111w-
1<111 ,ocTpb1M xone1.-11.1cT111TOM , 3a6oneeaH111s:iM111 op-
raHos M04enonosoill c111creMbl, anonneKClll$1 >11114-
HlllKa 111 npepsaswei:1cS'I BHeMaToYHOill 6epeMeH-
HOCTbfO. X111pypry Heo6XOAlllMO 3HaTb nplll3HaKV!
1<an111nn5lpoT0Kc1111<03a (6one3Hb WeHnetliH-
reHoxa) , ry6epi<yne3a , onyxon111 cnenoill KlllWKlll 111
1<apl\lllHOlllAa.
Oco6eHHOCTlll Te'ieH1.u1 ocTporo anneH-
AMU.111Ta y 6epeMeHHblX, AeTeilt 111 n111u. no}f{111no-
ro aoJpacTa.
Ocmpb10 anneH8u4um y 6epeMeHHblX.
nonos111He 6epeMeHHocr111 HJ.1YeM He 0Tn111Yaerc.si
oT o6bl'IHblX ero npoHsneH111iii . Bo BTopoiii nono-
BlllHe 6epeMeHHocr111 n0Kan1113a4111$1 6onei/1 cMe-
L4aeTc$1 s npasy10 cpnaH1<0By10 06.nacTb 111.n1.1 06-
nacrb npasoro no,o,pe6epb5'1 . Hanps:1>KeH1.1e MblWU,
6plOWHOll1 CTeHKlll B paHHllle cpOKlll 6epeMeHHO-
peMeHHOCTlil , scnep,cTBl.1e Cl/lnbHOro paCTH>KeHlll5'1
MblWL( )l{lllBOTa, BblS'IBV!Tb lllX 3all..(lllTHoe Hanps:i)Ke-
Hllle 6b1saeT p,osonbHO TPYAHO. BH111MaTenbHbli/1
pacnpoc no3son$1eT ycraHOBlllTb Ha'!ano 6onei/1 s
3nL1racrpanbHO~ 06nacr111 111 nocreneHHoe cMe-
U\eH 111 e 111x K Mecry na1<an1113au,111111 4epseo6pa3HO-
ro oTpocrKa (cuMnmoM Koxepa-BonKoBu'la).
Psora He 111MeeT pewa1011.1ero 3Ha4eH111s:i, raK Ka1<
OHa HepeAKO Ha6n10,o,aeTC$1 np111 6epeMeHHOCTlt1
soo6w,e. CuMnmoM Ulem«uHa - 6n10M6ep2a
o6bl\.JHO xopowo Bb1pa>1<eH . Ec11111 socnaneHHbll-1
\.Jepseo6pa3Hbli.1 orpocroK pacno110>1<eH no3a,o,111
yseillll'·leHHOlli MaTKlll , TO Cl/IMnTOMbl pa3,D,pa>Ke-
Hl/IS'I 6plOWl/IHbl MOryT He onpe,o,emlTbCS'I .
n p111 lllCCile,D,oBaHllll/I >KlllBOTa He06XO,D,lllMO
Y4111TblBaTb noKan1t13aL-!llllO 4epseo6pa3Horo oT-
pocTKa, K0Topb1l.1 cMell-!aeTcs:i KBepxy no Mepe
ysen1114eHlllS1 CpOKOB 6epeMeHHOCTlll (CM . p111c. 5).
Puc. 5. OmmecHeHue cnenoa KUWKU u
4epaeo6pa3Hoao ompocmKa 6epeMeHH00 MamKoiJ
abf3 b/aaem Heo6xoauMocmb U3MeHeHUR
XUpypW4eCKOZO aocmyna.
TaK111M o6pa3oM , noKanbHas:i 6one3HeH-
HOCTb np111 OCTpOM anneHAlllL!lllTe BO BTOpoi:.1 no-
JlOBl/IHe 6epeMeHHOCTLt1 6y,o,eT onpe,o,enS'ITbCS'I He
s npasolli no,o,s3,o,owHolli 06nacT111 , a 3Ha4111Tenb-
HO Bb1we. Bcne,qcrs111e pacrn>1<eH111s:1 6piowHolli
CTeHKl/I ysem14eHHOi:.1 MaTKOlli IlOKailbHOe Hanps:1-
)l{eH111e MblWL\ Bblpa)l{eHO CI1860. np111 n03,ll,HlllX
cpo1<ax 6epeMeHHOCTlll , Kor,o,a cnenas:i KlllWKa 111
ee OTpOCTOK HaXO,ll,S'ITCfl no3a,D,lll yBeI11114eHHOlli
MaTKl/I C-M lJ.lemKUHa - 6n10M6ep2a Mo>KeT
6b1Tb 0Tp1114aTeilbHblM . L.lenecoo6pa3HO 111ccne-
,o,osarb 6epeMeHHyio Ha nesoM 6oKY.
Bcex 6epeMeHHblX, 3a6onesw111x ocrpblM
anneH,o,1114111rnM, Heo6xo,o,111Mo onep111posarb .
P111cK BbtKlll,llbtwa nplil BbtnOnHeH111111 anneHA3KTO-
Mllll!1, ,D,a>Ke B n03,lJ,Hl/le cpOKl/I 6epeMeHHOCTll1, He-
Beill/IK.
Ocmpb1u anneHou4um y oemeu. Y ,D,eTei:.1
ocTpb111i anneHA1114111T scrpe4aercs:i Yaw,e a so3-
pacre crapwe 4 ner. B 6onee paHHeM B03pacre
OCTPbllli anneH,D,lllL!lllT BCTpe4aercs:i 04eHb pe,D,KO,
xorn 1113secrnb1 cny4a111 ocrporo anneH,o,1114111ra
,o,a>Ke y rpy,D,HblX ,o,erelli . TeYeH111e 3a6onesaH111s:1 y
,o,erelli s 4enoM 6onee TS'l>Kenoe, 4eM y 83poc-
IlblX. np111 3TOM pe>Ke npOlllCXO,D,lllT OTrpaHl/l4eHllle
npo4ecca 111 4all-!e pa3s111saercs:1 pa3Jll/ITolli nep111-
TOHlllT. V1Hor,o,a orcyTcrsyioT aHaMHecr111\.Jec1<111e
10
ClllMnTOMbl cMeU\eHlllS'I 6onelli 1113 3n111racrp111s:1 11111111
OKOJlonyno4HOl-1 o6naCTl/I I/I naTOrHOMOH1114Hble
6onesb1e Cl/IMnTOMbl y ,o,erelli MOryT onpe,o,e-
ns:iTbCfl s o6nacTl/I nynKa. TeMneparypa rena ,
KaK npaBl/IJlO, AOCTlllraeT cpe6p111IlbHblX 4111cpp B
caMoM Ha4ane 3a6onesaH111f! 111 conposo>K,D,aeTCfl
TOWHOTOlli Ill MHOroKpaTHOlli psornlli >Keily,D,04HblM
co,o,ep>KlllMblM c np111Mecbto >Keil\.Jl/I. B CBS13111 c
3Tl-1M B03HlllKaior rpy,o,Hocrn ,D,111cpcpepeH4l-1a11b-
Holli ,o,111arHocT1111<111 anneH,D,l/IL!l-1Ta y ,o,ereVI . C OA-
Holll CTOpOHbl , PflA 111HcpeK4l/IOHHblX 3a6011esaH11111i
y HlllX npoTeKalOT c 6ornlMlll B >Kl/IBOTe , c ,o,pyrolli -
anneH,o,1114111r y ,qeTeVI MO>KeT nporeKaTb c Bb1pa-
>1<eHHb1M111 S'IBJleHl/lf!Ml/I l/IHTOKClllKa41/11/1 6e3 MeCT-
HblX nposmneHl/llli . no3TOMY ,D,eTl/I np111 >Kano6ax
Ha 6onl/I B >Kl/IBOTe rpe6ylOT 60JlbWOfO BHlllMaHl/IS'I
scex spa4elli . XapaKTepHolli S'IBnS'leTCfl no3a
6onbHOro pe6eHKa. OH ne>1<111T Ha npaBOM 60KY
111n111 Ha cm1He, np111se,o,51 Horn K >Kl/IBory 111 nono-
}l(lllB PYKY Ha npasyt0 no,D,B3,D,OWHYtO o6nacTb ,
3aU\l/lll..\aeT ee OT OCMOTpa Bpa40M. np111 OCTO-
pO>KHOlli nanbna41111/1 3,0,ecb Hepe,o,Ko y,D,aercfl Bbl-
51B1'1Tb rnnepecre3JIJIO, Hanp51>KeHv.e MbJW4 111 30HY
Ha1116011bwei:.1 6011e3HeHHOCT111 . ,D,a>Ke B nepsb1e
4aCbl 3a6oneBaHl/lfl 6bl88IOT Bblpa>KeHHble Cl/IM-
nTOMbl lJ.lemKuHa - 6n10M6ep2a, BocKpeceH-
cK020, 6apmOMbe - MuxenbcoHa. HenerKo
l/IHor,qa 0Tnl/l4111Tb nHeBMOHllllO, 6plOWHOlli Tl/IQJ,
c1<apnan1Hy, rn111cTHyto 111Hsa3111to, 6one3Hb WeH-
nelliH-leHoxa. nHeBMOHl/IS'I y ,D,eTei.1 Ha41/1HaeTC51,
KaK npas111110, ocTpo, conposo>K,D,aercS'I KawneM ,
O,ll,blWKOlll , 4111aH030M . 5a3aJlbHble nHeBMOHllll/I,
nneeptHbl Moryr conpoeo)l{,lJ,aTbCS'I Hanp.s:i>KeH!r!eM
Mb1W4 nepe,o,Helli 6plOWHOl/i CTeHKl/I , 6onbl0 B
npasoi:.1 nO,D,83,D,OWHOlli 0611acT111 , O,D,HaKO OHi/i Me-
Hee Bb1pa>1<eHbl , YeM np111 ocrpoM anneH,o,1114111re.
PflA ,D,eTCKV1X V1HcpeK41/1l.1 conpOBO>K,D,aeTC5l BOC-
nanMTenbHO~ peaK~Me~ J1111Mcf:JaTM48CK!r!X )K€J1e3
6ptoWHOVl nOJlOCTlll , oco6eHHO B 111neo4eKaJlbHOlli
0611aCTl/I.
B cny4ae 3Ha41/1TeilbHblX 3aTPYAHeHl/IVI B
,o,111cpcpepeH4111anbHOM ,o,111arH03e , ecn111 OTCYTCT-
BYIOT c111MnTOMb1 pa3,£:\pa)f(eH111s:1 6p10WV1Hbr, .QO-
nycr111Mo ,o,111HaM111Yec1<oe Ha611to,D,eH111e 3a pe6eH-
KOM B Te4eH111e 6-12 48COB.
BMecre c TeM cne,o,yeT noMHlllTb, 4TO an-
neH,o,1114111T y ,o,erelli nporeKaer 3Ha41/1TenbHO 60-
nee 6ypHO, 4eM y B3pOCJlblX, Ill Hepe,D,KO y)l{e B
re\.JeH111e nepsb1x cyToK 3a6011esaH111s:1 pa3s111sa-
eTc5l ,o,eCTPYK41/15l orpocTKa. V1CXO,D,5l 1113 Toro, y
,D,erelll Xl/IPYPrL14eCKa5l TaKTl/IKa B 4e110M ,ll,OJ1>KHa
6b1Tb 6onee aKTl/IBHOVI , 4eM y 83pOCilblX.
00)l(Uflble 60flbHble. f<nlllHl/l4eCKllle npOS'IB-
JleHl/IS'I ocrporo anneH,D,lllLJ,l/ITa y nO>Kl/IJlblX nio,o,elll
MOryT Hl/l4eM He OTI11114aTbCS'I OT np05lBileHV111i 3a-
6onesaHl/lfl y Ill-14 Mono,o,oro I/I cpe,o,Hero B03pac-
ra . 0,o,HaKo B 20% c11y4aes re4eH111e ocrporo
anneH,o,1114111Ta 6b1saeT crepTblM , 111 KillllHV14ecK111e
npof!BJleHl/IS'I MOryT 6b1Tb He Bblpa>KeHbl , HeCMOT-
p5l Ha pa3BlllTllle ,o,ecrpyKTlllBHoro npo4ecca. '-lac-
To TaK111e 6onbHb1e nociynaioT s cTaL\1110Hap Ha 2-
3 C)'TKlll OT Ha'-lana 3a6onesaH111Sl, MoryT AOnroe
speM51 3aH111MaTbC5l caMo.ne1.JeH111eM . Ha cpoHe
C£1CTeMHOfO aTepoc1mepo3a 14 CHL'1)1(eHHOW pe3£1-
CTeHTHOCTl/I opraHll13Ma, y no)f(ll1.flblX 60.flbHblX
4all..le pa3s111saercSl nepBll14HO-raHrpeH03Hbrlli an-
neH.Qlt1L\lllT. np111 npose,QeH111111 ,Q111cpcpepeHL\1t1a.nb-
Horo Al.llarHo3a spa'-ly Heo6xoA111Mo noMHll1Tb 06
onyxom1x npasolli no.nos111Hbl TO.flCToro KlllWe'-lHll1-
Ka, KOTOpb1e MOryT conpoBO)f(,QaTbCSl ll1HTOKCV1Ka-
4111elli 111 60.neBblM ClllHAPOMOM B npasolli no,a-
83,QOWHOlli o6nacrn. Cne,QyeT noMHlllTb, 1.JTO y
CTapl.1KOB OCTpblW anneHA"11.-!111T BCTpe4aeTC.R
peAKO, noaroMy Heo6xoA111Mo 111cKnt04111Tb Apyrne
x111pypr1114ecK111e 3a60.nesaHrM1.
OC/70H<HEHt1fl OCTPoro AnnEH,D,t1U,J1TA
K ocno)f(HeHIMlM ocrporo anneHA£11...1VlTa oT-
HOCSlTcs:i L1Hcp111nb TpaTbl lt1 rHOlliHlllKl/I B 6ptOWHO~
nonocrn, pa3m1Totr nep111TOHlllT, n111neqme6111T,
cenCL-IC, 3KCTpaa6AOMl/IHanbHble OC.flO)f(HeHL-!SI.
AnneHOUKyflflpHb/U UHc/JUJ1bmpam - KOHr-
noMepaT, cocTOSlll..111111i L-13 socnamne.nbHO-
lt13MeHeHHbtX nere.nb K111WOK lt1 y4aCTKOB ca.nbHlll-
Ka, cnas:iswl-lxcsi Me>K,l\y co6olli 111 nap1.1eranbHot1
6ptOW111HOl/i, orrpaHll14111Batoll..111111i OT CB060AHOW
6p10WHOIA nonocrn socnaneHHbll1 4epseo6pa3-
Hbllli OTpOCTOK Ill CKOn1t1BWll111iCS1 BOKpyr Hero 3KC-
cy,a,aT. Bbr,a,emuoT ,a,se cpa3bl 111Hcp11111brpara:
pb1xnoro 1t1 nnorHoro.
PbtXflb/U UHc/JUnbmpam cpopMVlpyeTCSl 4e-
pe3 2-3 CYTOK C Ha4a.na 3a6o.neBaHlllSl . np111 era
pa3BL4Tl/ll/I OCTpble 6om.1 CTlllXalOT, CTaHOBSlTCSl
rynblMlll, T51HYl.J..lll1Ml/I. TeMneparypa Te.na ocraer-
CSl cy6cpe6p1t1nbHOVt . np111 3TOM 4epseo6pa3Hbll/i
OTpOCTOK MO)f(eT 6b1Tb ,lleCTpyKT11!8HO 1113MeHeH,
npasas:i noAB3AOWHas:i 06.nacrb orrpaH1114eHa OT
6piowHo~ nonocrn pb1x.nb1M111, .nerno pa3,Qen5le-
Mb1Mfll cp1116plllH03HblMlll cpall..leH111SlMlll nere.nb Klt1-
we4H111Ka, 60.nbWOro C8IlbHll1Ka.
np111 nanbnaL\l.'1111 )Kl.-1BOTa MO>KeT OTCYTCTBO-
BaTb Hanpsi>KeH1.-1e Mblllll-!, onpeAensieTCSI 5o.ne3-
HeHHOCTb B npasolli n0,£183,llOWHOlli 06.nacrn.
3,riecb >Ke nanbnL'lpyeTCSl naTonorn4ecKoe 06pa-
3osaH111e, noYrn HenoAB111)f(Hoe, ,D,OBOJ1bHO nnor-
Hoe, c 4eTKl.-1Ml.-1 KoHiypaM111. B Kpos1.-1 onpe,Qem1-
10T 11ei..'.1KOL.llt1T03, CABlttr .nei'iiKOL\lllTapHoi'ii cpopMy-
fibl Bneso, ysenw.1eH111e C03.
nnomHbJiJ uHcfJunbmpam ¢opM1t1pyercs:i K 7
cyrKaM . OrrpaHlll41t1Batoll..lllle cp1116p111Ho3Hble cpa-
ll..1€HL'151 3aMell..latorcsi rpy6olli coeAl/IHll1TenbHOV!
TKaHblO. KmAH111YecK111e npmmneH111s:i, KaK npas111-
no, OTCyTCTBYIOT. B npasoVI nOAB3AOWHOIA 06-
naCTlll nanbn111pyercs:i nnorHoe, Mano6one3HeH-
Hoe 1.-111111 6e36o.ne3HeHHoe 06pa3osaH111e. TaKoJ/1
1.-1cXOA anneHAlllJ<Yns:ipHoro 1t1Hcp1ttnbTpara scrpe-
4aerc5l , KaK npas1t1no, s rpynne 60.nbHblX no>K1.-1-
.noro B03pacra. A.ns:i 111cKntoYeH1.-1S1 onyxo.n1.-1 c.ne-
nolli Kl.-1WKlll Tpe6yeTC51 nposep,eH111e 111HCTpyMeH-
11
TanbHOro 111ccne,QosaHL1Sl, BK.fllO'-laSl 111pp111rocKo-
n1.-110 Ill ¢1t16pOKOJ10HOCKOnllllO.
np111 pa3Ell.-1TlllL1 AeCTpyKTlllBHoro npOL\ecca B
npasolli noAB3AOWHolA o6nacrn ¢opM'1pyerc5i
anneHauKyn~pHbti1 a6c~ecc. no .noKan1t13aL11.-1111
:no MOryT 6b1Tb a6c4eccbr npaBOVJ nO,[\B3AOWHOVJ
SlMKL'1 , Ta3osb1e, peTpo4eKanbHble , no,Qne4eH04-
Hble, no,Q,QL'1acpparMan1:.Hb1e Me)f(Kll1We4Hble. Co-
CTOf!H1.-1e 6onbHoro yxy,D,waercf!, reMnepaiypa
Tena CT8HOBlt1TCSl BblCOKOVl , npll1HL'1MaeT reKT1.-1-
4ecK1.-1lli xapaKTep . Yc111n1ttsa10TC7! 6on111 s npasotl
no,QB3AOWHO~ 06nacT1.1, r,Qe nanbnL'1pyeTcs:i pe3-
KO 6one3HeHHb11A 111Hcpi.inbrpar. OH nocreneHHo
ysen1t14L'1saercsi , pa3MSlr4aeTcsi , KOHTYPbl ero
cTaHOBSlTCs:t He4eTKl.-1ML'1. Ha.Q 30Hot..1 a6cL1ecca
onpeAensierc51 cuMnmoM ll.lemY.uHa - 6n10M-
6epea. B aHan1113e Kpos111 - BblCOK111VI nelliKOL\lllT03
co CABll1roM .neJllKOL-!lllTapHOlli Q:>opMy.nbl Bneso,
yse111114eH1tte C03.
PacnpocmpaHeHHbJiJ nepumoHum MO)l{eT
pa3BL'1TbCs:t B pe3yfibTaTe OTCYTCTBl.-151 onpaHlll'-le-
Hlllfl socnanlllTeflbHoro npo~ecca so1<pyr yepse-
o6pa3HOro orpocTKa 1.-1n1.-1 npopb1sa anneH,QL'1KY-
.nsipHoro a6c4ecca s cso6oAHYIO 6ptowHyio no-
nocTb . Kn111HL14eCK111e npoSlBneHlllSl pa3.n111Toro ne-
p1.-1ToH1.-1Ta anneH,QlilJ<YfiSlpHoro npo1.-1cxo)f(,QeH111Sl
He OT.fllt143IOTC51 OT npos:isneH11111i neplllTOHVITa
,Qpyroro reHe3a.
nunecfJne6um rHolAHoe aocnaneH111e
sepxHeJll BOPOTHOl/i BeHbl, Be,Qyll..lee K pa3Bll1Tlt110
a6cl...\eccos neYeHf.11, cenc111cy. npf.11 nepcpoparns-
HOM anneHAll14L'1Te 3TO OCJ10)f(HeHllle B03HJttKaeT
np111MepHo s 3% c.nyYaes. Cocros:iH1t1e 60.nbHblX
KpaVIHe TSl>Kenoe, Bblpa>KeHa 111HTOKCL1KaL\L1Sl.
TeMnepaiypa rnna reKTl/l4ecKasi . Henocpe.QcT-
seHHOIA npli141/1HOlli B03H111KHOBeHL151 n1t1.ne¢.ne61.-1Ta
c.ny>KJttT o6bl'-lHO raHrpeo3Hbllli anneHAlllL\L-1T, np111
KOTOPOM HeKpOTll!4eCKV1H npo1...1ecc nepeXOAV1T Ha
6pbl>K€€4J<Y '-lepseo6pa3HOro OTpOCTKa Ill ee Be-
Hbl. ,[\anee npo4ecc np111H1t1Maer socxo,QH!l..lllllli
xapaKTep, 6b1crpo pacnpocrpaHsieTcs:i Ha 6pb1-
>Kee4Hbte seHbl 1.-1neou,eKanbHoro yrna, a Yepe3
2-3 CyTOK, KaK npas111no AOcrnraeT BOpOTHOlli se-
Hbl 111 3aTeM peTporpa.QHO pacnpocTpaHs:ieTcs:i Ha
cene3eHo4HYto L'1 p,pyrne 6pb1)Kee4Hb1e seHbl.
B cny4ae n1t1necp.ne61t1ra nocne anneHA3K-
TOM1t11t1 He 6b1saer HlllKaKoro csernoro npoMe>KyT-
Ka: y 6onbHblX nosb1waeTC7! TeMnepaiypa Tena c
1-ro )f(e AHSI nocne onepa4L111t1, xapaJ<TepHa 6yp-
HO pa38111Bal0ll..1351C51 KapTlllHa Cl/ICTeMHOVI socna-
J1111TenbHOlli peaK4L'1L'1 . np1t1 OCMOTpe )f(l/IBOTa Bbl-
SlB11Sl€TCSl MeTeOplll3M, pa8HOMepHas:i 6one3HeH-
HOCTb B npasolli no.nos111He 6e3 pe3KO Bb1pa>K.eH-
HblX c1.1MnTOMOB pa3,£lpa)f(eHl.1SI 6piow1..1Hbl. B
cneAYIOll..leM nocne nepexo,Qa npo4ecca Ha ne-
4eH04Hble seHbl, so3H1111<aer )l{enryxa, ysen1114!-1-
eaerc51 ne4eHb, nporpecc111pyeT ne4eHo4HO-
no1.te4HaSl He,QOCT8T04HOCTb, 1.-1 6onbHble yMl.-1pa-
IOT yepe3 7-10 AHelli OT Ha4a.no 3a6onesaH111S1 .
/1E4EHJAE. OCT8BlllTb MlllKpo111pp111rarop AflS1 BBeAeHlllH aHTll1-
BCE COMHEH/Afl B ,D,JAAfH03E PEWAIOTCfl 61r10T111KOB s nocneonepal..\lllOHHOM nep1110,Qe.
B no/1b3Y onEPAT/ABHQ(Q /1£1../EH/Afl.
Ocrpb1i::1 anneHAVIL.\VIT noAne)f(VIT x111pypr1114e-
cKoMy ne1.1eH11110. 0Ho 38Knl04aeTC71 (np111 orcyr-
CTBVIVI OCflQ)f(HeH11ti::1 3a6onesaHlllS1) B 3KCTpeHHOC1
anneHA3KTOMVIVI . B 6onbWVIHCTBe cny4aes nonb-
3yiorc.s:1 nanapoTOML'telll , np111 paHHelll AV1arnocr111-
Ke, ysepeHHOCrn B A1118rH03e Ill OTCYTCTBVIVI npo-
TlllBOnOK838HL1111 B03MO)f(H8 3HAOCKOnlll4eCKa51
--- B
anneHA3KTOML'IS1 .
LJaw,e scera np111MeHS1t0T KoconepeMeHHbllll
AOcryn B npasot.':1 noAB3AOWHOC1 o6nacrn no
Bon«oau•w -,£11:.R«oHoay (pL1c. 6} .
np111 HeysepeHHOCTL-1 B A1118rH03e OTA8IOT
npe,o.no4TeH1r1e cpeAlllHHOt.':1 nanaporoM111111.
Kynon cnenolll KlllWKVI BMecre c 4epseo6-
pa3HblM OTpOCTKOM BblBOA71T B paHy, n111rnpyt0T
cocy.Qbl era 6pbo1<etll1<111 , Yepseo6pa3Hbrtll orpoc-
TOK nepeBS13blB8IOT y OCHOB8HlllS1 Ill OTCeKatOT, a
era KYflbTtO norpy)f(atOT 1<111ceTHblM 111 K111we\.IHblM
Puc. 6. Xupyp2u4ec1<ue oocmynbl, ucnonbJyeMble
Z-o6pa3HblM WB8Mfll (p111C. 7}. nposepS110T TW,8-
onR anneH03KmoMuu.A - 1<ocoO nepeMeHHblO
TeflbHOCTb reMocTa3a, BBOAS1 An1t1HHb11'1 y31<111C1 (BonKOBU48 - ,[/bRKOHOsa). 5 - napapeKmanbHb/U
raMnoH s 6piowHyto nonocTb K ManoMy ra3y. (fleHaHoepa). B - HWKHuO cper3uHHb10. I - Har3no61<osb1u
PaHy 6plOWHOll1 CTeHKlll yw111Ba10T Hamyxo. np111 («6UKUHU »).
AecrpyKTlllBHOM anneHAlllL.\lllTe l_\enecoo6pa3HO

., , ~=::.:·
\• . / ~ . ·1
,,........_.
f ;- I
"·-, ··... ;f. .; .- II
·. :i If _ .1
\ ·,·,} ;: .I
'\.·"

A 6 B
Puc. 7. 3manb1 munu4Ho0 anneH03KmoMuu: A - 5pboKee4Ka ompocm1<a nepesRJaHa. nepesR3Ka
ocHosaHUR anneHOUKca paccacb1Ba10w,eucR HUmb10 nocne pa3oaenusaHuR e20 3a>KUMOM. 5 - Hano>KeHue 1<ucemH020
wsa so1<py2 ocHosaHuR 4epseo6pa3Ho20 ompocm1<a Komow,erJ mpasMamu4ec1<oO u2noO
c Hepaccacbrsa10w,eOcR HUmbJO u omce4eHue anneHouKca. B - 3asepweHue anneH03KmoMuu oso0Ho0 UHBa2uHau,ueu
Kynbmu ompocmKa s 1<ucemHb1u u Z - o6pa3HblrJ UJsbl.

np111 peTpOLJ,eK8flbHOM 111fllll T830BOM pacno- H8Jllll4Vllll 3a6p10Wll1HHOll1 cpnerMOHbl, HeHa,Qe)f(-

JlO)f(eHVllll l.fepseo6pa3HOro OTpOCTKa , KOfAa Bbl-
BeCTlll era sepxywey s paHy He y,l\aeTCS1 , l_\ene-
coo6pa3HO npo1113secr111 peTporpaAHOe YAane-
H111e 4epseo6pa3Hora orpocTKa. ,IJ,m1 3TOra era
nepeBSl3blB8IOT y OCHOBaHlll71 111 nepeceKalOT.
Ky11brt0 norpy)f(ator KlilCeTHblM Iii KlilWel.fHbrM Z-
o6pa3HblM wsaM111, a caM orpocTOK YA8nS110T,
no3TanHO n111rnpy71 COCYAbl 6pbl)f(el/1Klll (p111c. 8) .
noK838HVls:IMlll K OCT8BfleHllllO TaMnOHa B
6pt0wHoll1 no.nocrn np111 anneHA3KTOM111111 S1B.nS1-
t0Tcs:r Heno11Hoe y.QaneHlile Yepaeo6pa3Horo oT-
pocTKa, yAaneH111e ero 1113 11tHcp11tnbrpara, np111
scKpb1T111111 anneHAlllKYnS1pHoro a6cl_\ecca, np111
HOCTlll norpy)f(eH111S1 eynbTlll orpocrna.
PeTponep1.noHeanbHas::r anneHA3KTOM 111s::r .
B peAKlllX c.ny4a51x 4epseo6pa3Hblll1 orpocroK
111n111 .Q11tcranbHa5l 4acTb ero pacno.naraerc5l 3a-
6piow111HHO. B CBH3111 c 3TlllM YAaneH111e 3a6pro-
WlllHHO pacno.no)f(eHHOra OTpOCTKa 5lB.ns::reTC5l
Ha1116onee TPYAHblM sap111aHTOM anneH.Q3KTOMVllll .
Bcrpernaw111cb c noAo6Holl1 aH0Man111ell1, nocry-
nat0T cne,o.yt0li.\lllM o6pa30M . Pacw111pS110T onepa-
TlllBHb1rl1 ,Qocryn 38 C4eT M8KCVIM8JlbHOro pa3Be-
,QeHlll5l BHyrpeHHerli KOCOrli Iii nonepel.fHOrli MblWL.\ Ill
H8ACe4eHlllfl Kpafl snarafllllli.\8 npHMOll1 MblWU,bl
(p111c. 9) .

12
 A
'='empo2pa0Ha>1 anneH0:3KmoMu>1: A - ocHoe8Hue ompocmKa nepee>13aHo.
- C5I nocne H8flO>KeHUfl 38>KUM8. 5 - Ha 6pbl>K881./K'j H8flO>KeH 38)/(LJM.
p aemc>1 e KucemHblD woe.
::: .; <JacwupeHue Kocoao nepeMeHH020 oocmyna 38 c1.1em p8cce1.1eHu>1 nepeoHeD u 3aoHeD cmeHoK
:: - pRMOiJ Mb /W/.,jbl >KUeoma.
nOA OCH088Hllle 4ep0eo6pa3Horo OT-
_ _,_.,...
- - •BOAS'IT Map.ne0y10 TeCeMK}' VI Mo6111.n111-
n cnenolii KlllWKlll, pacceKas:i nap111e-
- r - IOWlllHY 60K080ro K8Hana Ill OTO,D,Blllras:i
KY Me,D,1118IlbHO. npoHlllKHY8 TaKlllM
~ -.o3C1A111cnenoK111we4HYIO KneT4aTK}', oc-
e.ns:iior 1113 Hee ,D,lllCTa!lbHYIO 4aCTb
-...,...-,.._= ' 111 3TOM oco6oe 8H1t1MaH111e 06paL1.1a-
Ta3 , raK KaK n111weHHb11ii cepo3Horo
---;.-·-==-'""' -6 0eo6pa3Hbllii OTpOCTOK lllHTlllMHO CBS'l-
_ __ ....,.,._,.,,,IOLl.lelii KneT4aTKolii. B 3TOlii )Ke KneT-
.q111T 111 aprnp111s:i yepseo6pa3Horo oT-
PYIO o6s:i3aTenbHO HY}f{HO OTblcKaTb 111
a Hee n111raTYPY· nocne BblAeneH111s:i
- 3e06pa3HOro OTpOCTKa Ill nepeBS'l3Klll
onH s:ilOT anneH,D,3KTOMllllO. Bc.neA 38
!OT Henpepbl8HblM W80M pacce4eH-
8IlbHYIO 6pt0WlllHy.
anneHauKynflpHoM UHcjJUnbmpame,
paccacb1BaH11110, onepa4111s:i He noKa-
- --~- MY n po80AflT KOHcepsaTll1BHoe ne-
3 -epsb1 e 5-7 ,D,Heiii H83HaYalOT nocTenb-
- - • . Alll eTY, XOilOA Ha npasylO no,D,-
o6n aCTb, aHr11161110T111K111. nocne Hop-
13
Man1113a4111111 TeMnepaTYpb1 Tena H83Ha4atOT Ten-
nosb1e npo4e,D,ypb1 , YBLJ. noc.ne paccacb1BaH111s:i
anneAlllK}'ns:ipHoro 111Hcj::>111.nbTpaTa 4epe3 2-3 Me-
CflL\a BblnOilHS'llOT anneH,D,3KTOMllllO ,D,Ilfl npe,D,OT-
spaL1.1eHlll5! peL\lll,D,11188 3a6o.ne8aHlllS'I . np111 a6CL\e-
,D,lllpOB8Hll1111 Heo6XOA111MO BCKpb1Tll1e 111 ,D,peH111po-
BaH111e rHoiiiH111Ka . B 3TOM cny4ae npe,D,no4rn-
TenbHee BHe6p10Wll1HHb11ii AOCTYn. TaKoe )Ke
BMeWaTenbCTBO Heo6XO,D,111MO nplll 803HlllKH08e-
Hllllll a6cL1eccos 111 B APYrlllX OT,D,enax 6piowHolii
nonocT111 .
AnneH,D,111Kyns=ipHb11ii a6cL1ecc, pacno.no)f{eH-
Hbliii 8 npa001ii nO,D,83,D,OWHOiii S'IMKe BCKpblB8IOT
npa80CTOpOHHlllM 6oK08blM 8He6pt0Wl/IHHblM
,D,OCTYnOM no H.111. n111poro0y. np111 3TOM 4epse-
o6pa3Hbllii oTpocToK y,D,ans=ttOT n111Wb 8 Tex cny-
4as=ix, KOr,D,a OH MO)f{eT 6b1Tb .nerKO y,D,aneH. Bo
0cex APYrlllX cny4as=ix np111 aKTll1BHblX MaH111ny.ns=i-
L\lllS'IX B03MO)f{HO nospe)f(,!J,eH111e cTeHKlll c.nenolii
KlllWKlll BXO,D,S'!Ll.lelii B lllHcPlllilbTpaT Ill npOHlllKHOBe-
Hllle rH051 8 C8060AHYIO 6plOWHYIO nonOCTb .
ApeH111posaH111e nonocrn a6cL1ecca ocyL1.1eCTB-
ns:it0T c111rapoo6pa3HblM APeHa}f{eM . AHanor1114 -
Hbllii ,D,OCTYn 111cno.nb3YIOT Ill ,D,Ils:I ,D,peHlllp088Hlllfl
peTpol..\eKailbHblX a6cL1eccoB. BcKpb1T111e 111 ,Qpe-
H111poBaH111e a6cL1eccoB .QyrnacoBoro npocTpaH-
CTBa ocyll.leCTBm1IOT 4epe3 npHMYIO KlllWKY VIJlVI
3a.QHV1Lil cao.Q Bnaran111LI..1a y )f(eHl..l.\lllH.
<PAPMAKOTEPAnt1fl OCTPOTO
AnnEH/l,t1Ll,t1TA /If Ero OC/70>KHEHt1M
AHrn61.10T1.1Konpo<ln111aKT11tKa ( O.QHOKpaT-
HO) o6S13aTeJlbHO 3a 30 MVIH ,QO pa3pe3a, BBeCTlll
BIB O.QlllH 1113 yKa3aHHblX npenapaToB:
• aMOKCllll..llllJlJllllHIKilaBynaHaT 1,2 r
• 111n111 aMn111u111nm1Hlcynb6aKTaM 1,5 r
• 111n111 L1ecpyp0Kc111M 1,5 r
• 111n111 uecpa3on111H 1,0 r
AHT11t6aKTep1.1anbHClff TepanMH
np111 A0CTPYKTlllBHblX cpopMax anneH,QlllL..\111-
Ta nocne onepal..\111111 noKa3aHo np111MeHeH111e O.Q-
Horo 1113 nepe4111cneHHblX npenapaToB:
• aMOKClllL..\lllilJllllHIKilaBynaHaT 1,2 r x 3
pa3a B C}'TKVI BIB
• aMOKCVIL..\lllI1JlVIHICynb6aKTaM 1,5 r x 3-4
pa3a s cyTKlll sis, slM
• aMmn-1111nn111H111Hlcynb6aKTaM 1,5 r x 4
pa3a 8 cyTKVI BIB , BIM
• L1ecpTplllaKCOH 1-2 r x 1 pa3 B C}'TKlll BIB,
slM + MeTpOHlllA830n 0,5 r x 3 pa3a B cyTKlll s/s
• L..\ecpOTaKCVIM 1 r x 3 pa3a BIB. BIM + MeT-
pOHlll,Q830Jl 0 ,5 r x 3 pa3a B C}'TKVI BIB
nplil nOS'IBfleHlllVI nepVICTaflbTlllKVI Ill yny4We-
Hllllll COCTOS'IHlllS'I nepeXO,QlllTb Ha Ta6neT111poBaH-
Hble cpopMbl (cTen -Tepan111s:1):
• aMOKClllL..\lllnJllllHIKilaBynaHaT 1 r x 2 pa3a B
C}'TKlll BO BpeMS'I e,Qbl
• lllJllll 8MOKClllL..\lllI1Jl111Hlcynb68KT8M 1,5 r x
2 pa3a B cyTKlll BO BpeM51 e.Qbl
,QmnenbHOCTb Tepan111111 3 - 5 - 7 .QHeLil, B
38BlllClllMOCTlll OT TS'l)f(eCTlll COCTOS'IHlllS'I .
14
AnnEH/l,t1KY/7flPHb/M t1H<Pt117b TPAT
ne4€Hllle:
1.HeMe,[\l/IKaMeHT03HOe:
• nocTeJlbHbli::1 pe)f{lllM .
• XOJlO,Q Ha o6nacTb VIHcpVIIlbTpaTa .
• ~a.QHl..l.\aS'I .QVleTa.
2 . MeAlllKaMeHT03Hoe
2 .1. AHT1116aKTep111anbHas:1 rnpan1115l: np111Me-
HeH111e O.QHoro 1113 nepe4111cneHHblX npenapaToB:
• aM0Kc1114111nn111H I KnaBy11aHaT 1,2 r x 3
pa3a B cyTKlll BIB
• aMOKClllL..\lllnn111H I cy11b6aKTaM 1,5 r x 3-4
pa3a B cyTKlll BIB, BIM
• aMnllll...\VlllJlVIHlllH I cynb6aKTaM 1,5 r x 4
pa3a B cyTKVI BIB, BIM
• L..\ecpTp111aKcoH 1-2 r x 1 pa3 B CYTKlll slB,
BIM +MeTpoH111Aa3011 0,5 r x 3 pa3a B cyTKlll BIB
• L..\eQJOTaKClllM 1 r x 3 pa3a BIB. BIM + MeT-
pOHlll,[\830n 0 ,5 r x 3 pa3a s cyTKlll BIB
* 8o3MO>KHO 1.1cnonb30BaH111e aMnm.ivi11111.1Ha
1,0 x 4 pa3a B CYTKlll BIB, BIM (nplll ycnOBVllll Hlll3-
KOLil pe3111CT8HTHOCTlll 8 KOHKpeTHOM nnY) + MeT-
pOHlll,Qa30Jl 0 ,5 r x 3 pa3a B cyTKlll BIB
np1.1 nOHBfl0Hl.11.1 nepl.1CT3flbTMKM M
yny'iWeHl.1111 COCTOSIHMH nepeHTM Ha Ta6neTl.1-
posaHHble ct>opMbl (cTen -Tepamrn):
• aMOKClllL..\lllI111111HIKilaBynaHaT 1 r x 2pa3a B
cyTKlll BO BpeMS'I e,[\bl
• 11111111 aM0Kc111u111n11111Hlcy11b6aKTaM 1,5 r x
2 pa3a B cyTKVI BO speMH e,D,bl.
- ,Qn111Te11bHOCTb aHTV16aKTep111a11bHOLil Te-
pam1111 5 -7 ,QHeLil , B 3aBlllClllMOCTlll OT TS'l)f(ecrn
COCTOS'IHlllS'I .
2.2 . VIHcpy31110HHa5l BIB Tepan111s:1 (coneBble
paCTBOpbl , paCTBOpbl , CO,Qep)f(81..l.\llle rnlOK03Y) ,QO
1,5 - 2 JllllTPOB B CYTKlll np111 ycnOBllllll OTCYTCTBlll51
caMOCTOS'ITenbHOro ynoTpe611eHlllS1 )1{111,[\KOCTlll
(5-10 % p-p rnlOK03bl BIB., 0,9 % p-p NaCl BIB.,
p-p PHHrepa BIB .
 )l(EJillEKAMEHHAH .liOJJE3Hb
>KenlfeKaMeHHas:i 6one3Hb (>KK6) - 06-
MeHHOe 3a6onesaH111e renaT06111n111apHolll c111cTe-
Mbl, xapaKTeplll3YtoL1.1eec51 06pa3osaH111eM )f{eJ14-
HblX KaMHelll B neYeH04HblX }l(ell4Hb1X npoTOKax,
B 06Ll.leM )f(en'-IHOM npoTOKe 1.m1t1 B )f(en'-IHOM ny-
3blpe.
OC06EHHOCTM XMPYPfM4ECKOM
AHATOMMM >KEJNHb/X nYTEM
K BHene4eH04HblM )f{eJ14HblM nyT51M OTHO-
C51T )f(eJlL!Hbllll ny3blpb, 06L1.1111lll )f(eJlL!Hbllll Ill 06ll.lllll.1
ne4eH04Hbllll npOTOK"1 Ill lllX 48CTlll.
>Ken4Hbllll ny3blpb pacnonaraeTc51 B 51MKe
)f(€D4Horo ny3b1ps:1 - nepeAHeM OTAene carnT-
TanbHolll 6op03Abl npasoll! nonoB1t1Hbl neL1eH111.
Puc. 10. CxeMa 6p10wuHHoao noKpoea >Ken4Hoao ny3blpfl.
Ha1.16onee Y3KaR 4aCTb )l{en4Horo ny3blpfl -
well1Ka era - Ha1116onee nOABVl}l(Has:i 4aCTb ny3bl-
p51 (p111c.11). ,Qn111Ha ee 15-18MM, .1:1111aMeTp 7-8
MM. OT well!K111 (oT sepxHe-6oKosolll nosepxHOCTlll
ee) OTXOAl/IT ny3blpHblilt npOTOK.
np111 3TOM 06pa3yeTcs:1 cnenoll! KapMaH wel/1-
Klll , TaK H83blBaeMbllll rapmMaHOSCKUU KapMaH.
y BblXO,qa B ny3blpHbl"1 npoTOK lt!MeeTCs:I CQJlt!HK-
Tep (cc/>uHKmep fl10mKeHca). BcTpe4aeTcs:i
MH0)1{€CTBO saplllaHTOB ¢opMbl )f(eJ14HOro ny3bl-
ps:i Ill npOTOKa (plllc.12). KorAB AHO )f(eJ14HOro ny-
3blps:! BblCTYnaeT 1113-nOA Kpas:i ne4eHlll, TO 3TO
MeCTO npoel...\1APYeTC51 Ha 6ptoWHyto CTeHKy B
T04Ke nepece1.JeH111s:1 Hapy>t<Hora Kpas:i npasolll
np51MOW MblW~bl 111 pe6epHOVr ,ayrn. )/{en4Hbllll
ny3blpb np111ne)f{lllT K nonepeYHoo6oAo4HOlll KIAW-
Ke, a welllKa era HanpasneHa Ha3aA 111 sneso 111
AGXOAVi\ AO sopm neu.eH'A . Ansi. AGcl':{na K npa-
BbtM 3fleMeHTaM aopor ne4eHu llacro Bb1aaer
He06XOAIAMblM nepece4b ny3blpHbllil npOTOK.
ny3blpHblW npoTOK Jl€)f{lllT B TOilll.le ne4e-
H04HO-,QBeHa.a~anmepcTHot.1 CBR3Kltl. OH npe,a.-
crnsn51eT co6o!A rpy6Ky AltlaMeTpOM OKOilO 3MM .
ny3blpHb1171 npOTOK OTXOAlllT OT nosepXHOCTl/I
we!AK111 ny3b1ps:1 , .aenaeT 1.-13r1116, Hanpasns:is:icb K
sopoTaM ne4eH111 , .aanee AenaeT BTopolll 1113rlt16 111
nOA OCTpblM yrnoM yxoP,l/IT K ne4eH04HOMY npo-
TOKy. B HOpMe Bna,D,eH111e ny3blpHoro npoTOKa B
ne4eHOl.!HbllA npo111cXO,.Qll1T s6nll131t1 OT WeVrKlt1
>1<en4Horo ny3blps:i. ,Qn111Ha ny3blpHoro nporn1<a 3-
4cM, HO see asropbl yKa3blBator Ha 6onbwyto
sap111a6enbHOCTb AnL-1Hbl, rnnorpa¢111111 111 r111na
16
OH 111Meer rpyweB111AHYto ¢opMy, np111 3TOM
6onbWa51 WlllpOK851 48CTb ero HOCll1T Ha3BaHlt1e
Tena, a 6onee Y3Kas:1 - welAK111 ny3blp51. Cnenolll
KOHel...\ Tena HOCl/IT H8388Hllle AHa ny3blps:1 . EM-
KOCTb )1{€fl4HOro ny3blp51 KOne6neTC51 OT 30 .ao70
Mn , a A11111Ha ero 7 - 1OcM. W111p111Ha ny3blps:i 3-4
CM . Teno ny3btps:i css:i3aHo c ne4eHbto pb1xnol7l
coe,.Ql/IHlllTeJlbHOlll TKaHblO, KOTOpas:i nerKO pa3Ae-
ns:ieTCs:I . >Ken4Hb11it ny3b1pb n0Kpb1T 6ptow111Ho!A 3a
IACKilto4eH1t1eM nonocK111, conp111KacatoL1.1et7ics:i c
ne48Hbl0 . np111 3TOM B03MO}l(Hbl Bap1t1aHTbl , np111
KOTOpblX )f{8Jl4HbJVr ny3blpb n11160 noKpblT 6pto-
LUl/IHOlll co scex CTOpOH Ill lllMeeT 6pbl)f(€84Ky, Jll/l-
60 BO BCIO TOilll.IY pacnonaraeTCs:I B TKaHl/I ne4e-
HIA (plllC.10).
sna,.QeHll151 ny3b1pHoro npoToKa s ne4eH04Hbiilr
(pJAc.13).
Puc.11. }f(en4HbJU ny3blpb u >Ken4Hble npomoKu.
,Qn111Ha ny3blpHoro npoToKa Mo)l<eT Kone-
6aTbC5'1 OT 2 AO 10cM. Cyll.leCTByer TPlll rnna
sna,qeH111s:i ny3blpHoro npoToKa s ne4eH04Hbtilt .
np111 nepsoM sap1.1aHre 33-80% ny3blPHblC1 npo-
TOK He 04eHb AlllllHHblVl Ill BnaAaeT B npasyto 60-
KOBYIO nosepxHoCTb ne4eH04Horo nporoKa. np1.1
BTOpOM nme (12-49%) ,D,JllllHHbllll ny3blpHblfA npo-
TOK OT 2 ,Qo 5cM 111.QeT naparmenbHO ne4eH04HO-
My, CBs:!3aH c Hl/IM TeCHO Ill BnaAaeT ne4eH04HblW
npoToK no,q ocTpb!M ymoM. np111 3TOM rnne sna-
.aeHL/151 cn111s:1H111e ny3blpHoro 111 ne4eHo4HOro npo-
TOKOB MO}l(eT npOlllCXOAlllTb 04eHb Hl/l3KO A8>Ke
no3a,D,IA ABeHaAuarnnepCTHOfA Kl/IWKIA IAJllll B
ronll.le ronosK111 no,D,>t<enyAo4HOll! )f{ene3bl. np111
TP8Tb8M Tlllne Clll/ls:!Hll1s:I npoTOKOB (8-38%) ny-
3blpHblill npoTOK cn1.1pallbHO o6XOA1t1T ne4eH04-
Hblill 111 sna,llaeT s Hero c3a,.Q1t1, cnesa 111 ,.Qa)f(e
cnepeA111. nocneAHllle ABa T111na snaAeHll\51 ny- AfilllHa paBHS'!eTCS'! OT 5 AO 7 CM , HO MO>KeT AOC-
3blpHoro npoToKa B ne4eHo4HblVI 4pesaTbl no- mraTb 12 CM .
spe)l{,l:leH11eM nocne,QHWX npw onepamBHblX ,awaMerp nporn1<a oKono 5 MM, Ho Ha npo-
BMewaTenbCTBax. Ts:i>KeH111111 npOTOK pacwL<1pS'!eTCS'! Ha yYaCTKe AO
noA>1<enyA04HOVi >1<ene3bl 111 cy>1<111eaercs:i a 4acrn,
( ·~.
npoxoAs:ill.\eVI 4epe3 Hee. B naronor1114ec1<111x cny-
,,.,,. ...... , \
\
\ . 4as:ix 06w,111VI >Ken4Hbllll npOTOK MO>KeT 3Ha4111Tenb-
\ \ HO pacwl.1ps:!TbCS'!, AOCTlllras:i WlllPlllHbl AO 2-3 CM . B
:/~~ o6Ll.\eM }l(en4HOM nporoKe pa3n1114at0T 4 4acrn :
cynpa~yo,QeHanbHYtO, peTPOAYOAeHanbHyt0,
I 9
naH1<pearn4ecKYto 111 eHyTp1t1cTeH04HYIO (AYOAe-
HanbHYto). CynpaAYOAeHanbHas:i 4aCTb nporoKa
--· -·· ····- ne}l(lllT B Kpae ne4eH04HO-ABeH8AL\8Tl.1nepcTHOVI

~)/
- ·-

. CBS'!3Klll, BblCTYnas:i 3a KpaVI sopoTHOVI BeHbl Ha

. 5 MM. y nonOBll1Hbl nt0Ael1 npOTOK nepeKpew,111-
":;)
eaeT >1<enyA04HOAYOAeHanbHas:i apTep111s:1 c ABY-
MH seHaM111. PeTpOAYOAeHanbHa.s:i 4aCTb nporoKa
ne>1<1t1T no3aAlll ABeHaAL\8T1t1nepcrH0Vi Kll1WKll1 111
Puc. 12. Pa3nul./Hb1e cpopMbl >Kenl./Hoao ny3b1pR u no3a,D,111 nporoKa pacnonaraeTcs:i eoporHas:i seHa.
oco6eHHOcmu cjJopMbl weOKU. naHKpearn4eCK8s:I 48CTb npOTOKa AillllHOVI 3CM
06ll.l111Vi ne4eH04HblVt npoToK 111Meer ,Ql!la- ne>K111T Me>K.Qy ronos1<oti\ no,Q>KenyA04Hoti\ >Kene-
Merp 4MM , Afill1HY 2-5CM c KOne6aHlllS'!Mlll OT 1 AO 3bl 111 ABeHaAL\arnnepcrnoti\ KlllWKoti\ . BHyTp111CTe-
1OcM . OH pacnonaraeTc51 cnpasa oT Kpa;i so- H04Has:i 4aCTb npoToKa AI1111HH0(;1 1-2 cM npoxo-
poTHoVI seHbl. l!1HorAa era cnepeAll1 nepeKpeLl.\111- AlllT s KOCOM HanpasneH1111t1 111 sna,QaeT B ABeHa-
saeT ny3blpHas:i apTep111s:i. An111Ha ne4eHOYHoro AL\arnnepcrHytO KlllWKY B 30He 6onbWOro AYOAe-
npoTOKa Kone6neTCfl r.1 38BHClllT OT ypoBHs:I Bna- HanbHOro COC04Ka. CH1113Y OT Hero npoX0,[\11\T
AeHlllS'! B Hero ny3blpHoro npoToKa C 3Toro MecTa rnaBHblVt naHKpearn4eCKL1111 npoTOK, np111 3TOM
npoTOK H83blBaeTCS'! 06Ll.\lllM >Kel14Hb1M npOTOKOM nporo1<111 a 18% cny4aes cn111sat0rc51 nepeA
(Ductus choledohus) . anaAeH1-1eM a KL<1WKY. Bap111aHTb1 noKa3aHbt Ha
06w,111VI >1<en4Hb1VI npoTOK lllMeeT pa3n1114Hb1e p111cyHKe (p111c. 14)
pa3Mepbl Ill 38BlllC5'1T CHiii OT ypoBHs:I snaAeHllls:I
ny3blpHoro npoTOKa a ne4eH04HblVi. B cpeAHeM

Puc. 13. BapuaHmb1 anaaeHUR ny3blpHoao npomoKa a net/eHOt/HbliJ.

Puc.14. BapuaHmb1 coeauHeHUR o6w,eao >Kent/Haao npomoKa c npomoKoM noa>Kenyaot/HOO >Kene3bl.

17

3 BOli1 ne4eH04Holi1 K neaolii 6oKOBO!i1 noaepxHocrn
Puc. 15. Tunul.fHbtO xoa o6w,ea nel.feHOLfHoD
apmepuu u ee eemeeiJ. 1 - co6cmeeHHO nelfeH04Hafi
apmepuR; 2 - >1<enyao4Ho-ayoaeHanbH8fi apmepuR; 3 -
o6w,afl ne4eH04Hafi apmepuR; 4 - 4peeHaR apmepuR.
B MeCTe sna.QeH11111 o6~ero }f{en'"!Horo npo-
TOKa B ,!IB8Ha.Lil\aT111nepcTHyto KL-1WKY VJMeeTC51
CJ10}f{HO ycTpOeHHbili1 CcplllHKTep 0,LJ,.QL-1 . ne4eH04-
Ha51 apTepVISl npOXOAVIT B ne4eH04HO - ABeHa-
Puc.1 6. BapuaHmbt ny3btpHou apmepuu no WyMaxepy.
Puc. 17. BapuaHmbt omHoweHUfi ne4eHOl./HOU
apmepuu K ne4eH04HOMY npomoKy no Puo-5paHKO.
n111McpOOTTOK OT )f{8J14HOro ny3blp51 ocy~e­
CTBn11eTC5! B n111Mcpoy3Jlbl B ne'-leH04HO-
ABeHaAL.laTlllnepcTHOli1 CB513Ke, 1-13 KOTOpblX O,D,lllH
18
Al\arnnepcTHOlii CB513Ke snepe.Qlll nesoro Kpa11
sopoTHolii aeHbl (p1-1c.15). B aopornx ne4eH1<1 ap-
Tep11111 A8Jll-1TCS1.
npvi aToM neaa11 aeTBb ee 11s1111eTc11 npo-
AOJl}f{eHVJeM cocy,D,a , a npasa11 1-1,0,eT snpaao no-
3ap,111 npoToKa . Cne.QyeT 3HaTb, 4TO y 20% rno-
.Qelii npasa11 seTBb apTep111vi 111.QeT snepe.Q111 npo-
TOKa. OT npaaolii ne4eH04HOli1 apTepl-1V1 OTXO,IJ,VIT
nyJblpHasi apTep111si . ,Qo6aso4Hb1e ne4eHOYHble
apTeplill-1 BCTpe4alOTC51 TOJlbKO y 25% Jll0,Qeli1 .
Tvin1<14Hb11i1 XOA apTep1-1111 1<1MeeTC5l y 55% mo,[\elii .
B ocTanbHblX 45% cnyi.1aea 111Me10TCfl sap111aHTbl
,D,eneHL-151 ne4eHo4HO!i1 apTep111111 (p1-1c.16).
ny3bipHa5l apTep1115l B 90% OTXOAlllT OT npa-
well!K111 )f{en4Horo ny3b1p11. ,Qn111Ha apTep1111-1 1-
2cM, .QlllaMeTp ee 1-2MM. ApTep1115l .Qem11TC5l Ha
,o,ae aeTBlll , 111,D,y~1-1e no nepeAHelll 1-1 3a,D,Heli1
CTeHKe ny3blp51. Bap111aHTbl COCYAOB ny3blpHoli1
apTep1<1111 nocxeMe Pvio-5paHKO npe.QcTasneHbl
Ha (p111c.17).
ne}f{lllT y MecTa npoxm1<,D,eH11t5! ny3blpHolll apTe-
p1-11-1, a BTopoC-1 B AlllCTaJlbHOC-1 4acrn CB513Klll 803-
ne o6~ero >Ken4HOrO npOTOKa. nocne,QHllll/1 Y38Jl
np111 ysen1<14eHllllll MO}f{eT C.QaBJllllBaTb npOTOK,
Bbl3blB85l MexaHL-148CKYIO }f{8J1TYxy.
X111pypr, onep111pyio~111C1 Ha )f(en4HblX nyT11x,
AOJl}f{eH 4eTKO npe,QcTas1111Tb ce6e aHaTOM1<1t0
}f{8n4HblX nyTelii Ill 3HaTb lllX aHOMaJlVJlll , 4TO npe-
,llynpe,lllllT nospe~eH111e npoTOKOB so speM51
onepal\111111.
nA TOfEHE3 >KEINHOKAMEHHOM
6017E3H/ll
06b51CH518TC51 HapyweHll1eM MeTa60llVl3Ma
xo11ecTep1-1Ha 1-1 )f(eJlYHblX K1<1c110T (xo11ecTep111Ho-
Bb1e KaMHlll) 111n111 npespa~eHllleM 611111111py6111Ha
(6111n111py61<1HOBble 111m1 n111rMeHTHb1e KaMH111) .
Ha 06pa3osaH1<1e xo11ecTep111HOBblX KaMHeJ.1
Bnl-15llOT TPlll OCHOBHblX cpaKTopa: oca>K,QeH111e
MOHOr111,Ll,paTa xo11ecrep1<1Ha B 8111,D,e KplllCTaJlJlOB,
nepeHaCb1~eHHOCTb ne'-leHO'-IHOIA )1{8114111 xone-
CTeplllHOM Ill HapyweHllle cpyHKL\111111 )l{en4HOro ny- He onpeAen.s:it0TCR nepsa.s:i crap,11151 >KK6 Mo>KeT
3blpS1 . Ecn111 Kon1114ecTBO 3TlllX ABYX xonecTep111- npOAOJl)KaTbCfl B Te4eHllle MHOrlllX neT. ne4e6-
HyAep)l(111Ba10U\lllX cpaKTOpOB CHl!l)l(aeTCS1 Hl!l)l(e Hble Meponp1!1S1Tlll51 OCHOB8Hbl Ha noHll1M8Hllllil Me-
Kp111Tlll4eCKOro ypoBHS1 , C03P,alOTCS1 6naronp111S1T- xaHll13Ma o6pa3osaHlll51 n111ToreHHOVI )KeI14111 111

Hble ycnoe1.-1si Ansi eb1naJ!,eH1M1 ~oneeTept.lHa ~ ~l<fl~W~~~ ~~lil~U p~p~~WUWM~U~ M~UM , ~U8-
OCaP,OK. npep,nOCblnKOCi K 1113MeHeHllllO cp1113111KO- TeMaTlll4eCKYIO cp11131114eCKYIO Harpy3KY, paL\1110-
XlllMlll4eCKlllX CBOCiCTB >Ken4111 , np111 KOTOpOM HanbHOe AP06Hoe n111TaH111e , npep,ynpe)l(IJ.eH111e
)l(eJ14b CTaHOBlllTCS1 JllllTOreHHOVl, T. e . cnoco6HOC1 0>1<111peHl/l5I Ill HapyweHl/151 cpyHKL\111Vl >Keny,Q04HO-
K o6pa30BaHllllO xonecTeplllHOBblX KaMHeVI, S1BJ151- KlllWe4HOro rpaKTa , ycTpaHeH111e JaCT051 )Ken4111;
eTCS1 B3al/IMOOTHOWeH111e TaKlllX cpaKTopos , KaK B03MO:>KHa Mep,111KaMeHT03Ha51 KoppeKL\11151 ne4e-
r eHeT111YecKas:i npeApacnono>KeHHOCTb, Hepa- H04HO-KneT04HOC1 111 >Ken4HonyJblpHoC1 Alllcxon111111.
L\lllOHanbHoe n111TaH111e, HapyweH111s:i o6MeHa ae- BmopaR cmaoufl >KK5 (naTeHTHafl , 6ec-
U\eCTB Ill peryns:ipHOCi ne4eH04HO-KlllWe4HOC1 L\lllP- c111MnTOMHaS1 , KaMHeHOClllTeilbCTBO) xapaKTep111-
KYilflL\111111 OCHOBHblX COCTaBHblX 4aCTeC1 )l(en4111. 3yeTC5I TeMlll )l{e cp1113111KO-XlllMlll4eCKlllMlll 1113MeHe-
V1Hp,eKC n111ToreHHOCTlll npeACTaBnS1eT co6oC1 H11151Mlll B COCTaBe >KeI14111 , 4TO Ill B nepsoe\ CTa-
4acrHoe OT p,eneHlllfl Kon1114ecTBa xonecTep111Ha, P,111111, c cpopM111poBaH111eM KaMHeCi B )l{eJ14HOM ny-
HaXOAflU\erocfl B 111ccnep,yeM0Vi nopL\111111 )l(eJ14111 , 3blpe. 0AHaKO flPKlllX KnlllHlll4eCKlllX npoflBileHlllCi
Ha MaKClllMailbHOe KOI11114eCTBO era , KOTOpoe MO- 3a6onesaHlll51 B 3TOC\ CTaAl/1111 ell!e HeT. npo1..1ecc
)f(eT 6b1Tb pacrnopeHO np111 p,aHHOM COOTHOWe- KaMHeo6pa30BaHlll51 Ha 3TOM 3Tane CBfl3aH He
Hllllll )l(eJ14HblX KlllCnOT Ill cpoccpon111nlllAOB B Tpe- TOJlbKO c cplll3111KO-XlllMl/l4eCKlllMlll 1113MeHeHlll51Mlll
yronbHblX Koopp,111Harnx Ap,M111paHp,a 111 CMonna )Ken4111 , HO 111 c np111coep,111HeH111eM >Ken4Hony3blp-
(p111c. 18) . Hb1X cpaKTopoa narnreHe3a (3acrnC1 :>Ken4111 , no-
ape)l(IJ.eH1t1e cn1113111crot1 o6ono4Klll , noab1wat011lee
npoH111L1aeMoCTb cTeHK1t1 ny3blps:i AI151 )l(enYHblX
KlllCJlOT, aocnaneH111e) , HapyweHlllS1Mlll B KlllWe4HO-
ne4eH04HOC1 L\lllPKYI151L\llllll >1<en4HblX K111cnoT 111 AP-
,D,111arH03 )f(K6 BO BTOpot1 CTap,111111 OCHOBbl-
aaeTC51 Ha pe3ynbTarax xoneL1111crnrpacp1111t1 1t1
Y3V1 .
Tpembfl cmaoufl )f(K6 - KJllllH1114eCKaS1
(KailbKYile3Hblill xoneL\lllCTlllT) . Kn111H1114ecK111e npo-
51BileHlllS1 >KK6 3aa111c5IT OT pacnono>KeHlll51 >Ken4-
HblX KaMHeill, I/IX pa3Mepoa , COCTaBa Ill KOillt14eCT-
Ba , aKTlt1BHOCTlll BocnaneHlllfl , cpyHKL\lllOHailbHOro
COCT051Hlll51 >KeJ14eBblP,eJ1111TeilbHOill ClllCTeMbl, a
TalOKe OT nopa)l(eHlllfl p,pyrnx opraHoB n1t1U,\eBa-
100
peH111S1. )f(K5 MO:>KeT conpOBO)l(IJ.aTbCS1 KnlllHlllKOill
)KeJiqHbJe K-Tbl (MMOJih /JI)
xpoH111YecKoro xone1..11t1cT111Ta a cpa3e 06ocTpeH111f1,
Puc. 18. TpeyaonbHb1e KoopouHamb1 AoMupaHoa u
JaTYXalOU,\ero 06ocTpeH1115I (HenonHaS1 peM111c-
CMona
(no3sonH10uwe onpeoenumb uHoeKc numoaeHHocmu c111fl) Ill peMlllCCllllll, a TalOKe OCTporo XOileL\lt1CTl/ITa.
>Ke!14U} .
C/JOPMbl >1<1<6
• naTeHTH8fl (KaMHeHOClllTeilbCTBO)
K/7t1Ht14ECl<t1E CTA,D,t1t1 t1 C/JOPMbl • ,D,111cnenrn4ecKas:i (6onb B sn1t1racrp1t1111 ,
>KE/71./HOKAMEHHO//J E0/7E3Ht1 1113)l(Ora, MeTeoplll3M , Heycrnill4111Bblt1 CTYn);
B HaCTOflU,\ee apeMH BblAeilfllOT Tp111 CTaAllllll • )f(en4H8S1 KOJllllKa lt1 xpoH1t14eCKlll-
111 wecTb cpopM >KK6 . peL\lll/J.lllBlllPYIOU\8fl cpopMa (pe3Kllle 6on1t1 , TOW-
nepBafl cmaoUfl >KK5 cp1113111KO- HOTa, psora, 6e3 np1113HaKoB aocnaneH111.s:i);
XlllMlll4ecKaR 8 3TOC1 CTaP,111111 ne4eHb npOAYL\lllpy- • 6oneaas:i (nocTOS1HHble AaBS1U\llle 6on111 a
eT )f(eJ14b, nepeHaCblU\eHHYIO xonecrnplllHOM, c npaaoM nop,pe6epbe) ;
y MeHbWeHHblM cop,ep)l(aHllleM B Hee\ )Ken4HblX • CTeH0Kapp,111rn4ecKaS1 (111ppap,111aL11t1S1 60-
KlllCilOT 111 cpoccpon111n111p,os (n111rnreHHas:i )l(en4b). neill B o6nacTb cepp,4a);
Ha 3TOM 3Tane y 6onbHblX 0TcyTcTsyt0T Kn111H111- • ClllHAPOM CetlHTa (>KK5 + p,111acpparManb-
4ecK111e ClllMnTOMbl 6one3Hlll , p,111arH03 OCHOBblBa- HaS1 rpbl:>Ka + AlllBeprnKYile3 TOilCTOl.1 KlllWK1t1) .
eTCS1 Ha pe3ynbTaTaX 111ccnep,oeaH111s:i p,yop,e-
HanbHoro CO,Qep)l(lllMOro, B 4aCTHOCTll1 ny3blpHOVl X0/7ELl,t1CTt1T
>KeJ14111 (nOpL\lllfl B). np111 111ccnep,oeaH111111 >1<en4111
Knacc1t1QJlllKaL11t1S1 V1 .H . lp1t1Wl11Ha (1989) AOC-
Bbl51BnS1IOT HapyweHll1S1 MlllL\enflpHblX CBOVlCTB ee, TaT04HO nonHo orpa)Kaer ace npos:ianeHlllfl xo-
06Hapy)f(111Ba10T xonecTep111HOBb1e «xnonb51»,
neL\lllCrnTa . Heo6xop,111Mo raK>Ke yY1t1Tb1BaTb 111
Kp111crannb1 111 111x npeL1111n111TaTbl. KaMHll1 s :>Ken4-
OTJllt14aTb OT xone1..1111cT111Ta >Kefll./HYIO KOflUKy,
HOM nyJblpe np111 xoneL1111crnrpacp111111 111 ynbTpa-
npoTeKalOU\YIO c KnlllHlllKOCi KaTapanbHOro xone-
3BYKOBOM 111ccnep,0BaHllllll (Y3V1) B 3TOC1 crap,111111
19
 4111cn.na 111 0Tn1114at0L1..1eillc51 or nocne,QHero oT-
cyTCTBllleM MecTHolll 111 06L1..1eill socnamnenbHOlll
peaKL\111111 .
OcTpbt~ xoneUHCTHT - O.QHO 1113 Ha1116onee
pacnpocTpaHeHHblX x111pypr1114ecK111x 3a6onesa-
H111ill Ill no 4aCTOTe 3aHlllMaeT BTopoe MeCTO no-
cne anneH.QlllL\LHa .
3Tt10/10(t1fl t1 nATOrEHE3 OCTPOro
XOl1E4t1CTUTA.
Bo3HlllKH0BeH111e ocTporo xoneL1111CrnTa, 1<a1<
C4111T8IOT MHOrllle asTOpbl , CB5l38HO c ,Qeli1CTBllleM
He O,QHOro, a HeCKOflbKlllX 3TlllOflOrlll4eCKlllX cpaK-
ropoe. 0,qHaKo ee,qylJ..la5l ponb s pa3e111rn111 ero
np111Ha,Qne)l{lllT 111HcpeK4111111 . B }l(en4Hblill ny3blpb
111HcpeKL111171 npoH111KaeT TpeM5l nyrnM111: reMaTo-
reHHblM, fili!McporeHHblM Ill 3HTeporeHHblM.

KJlaccu<t>nKauust xoJleUHCTHTa

aJibKYJie3HbIM (85 -90%)

1--~

I I XoJieQBCTDT
I I ecKaMeHHbIM (10-15 %)
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I I Xpomit.IecKHii.
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• qrnerMOH03Hblli • nepBHqHo-xpOiflilleCKliH
I tr: I • raHrpeH03HbIM • xp. peuH.Li:HBMpy10m,ID1
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I ~ I • rrpo6o.1IHOH • pe3H,LI)'aJ[bI-IbIH
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I I ~---------------. Oc.r10:1KHCHHH:
-rro-qet.n10-rre'leHO'ffillil
i i IKmrn1rqecKoe Te"'!em1e HeJ1.0CTaTO"'IHOCT1
I I ~-- - - - - - - - - - -- - - '
I I -rranKpeaTHT
I I -XOJie)lOXOJIBTlia3
L _ _ _I Perpeccupyromcc
( 3c_P<]:JeKTIIBHOe KOHcepBa THBHOe - Mex.)l(enryxa
rre-qem1e) -XOJiaHTIIT
llporpeccHpyromee -renann
(c He3¢cpeKTliBHbIM KOHCepBa- -liHQHIJibrpaT
TliBHbIM rreqeHJieM) - rr/rr a6cue.LnlpoBaHHe
Ilcp<t>opanuB 3KCTpaa6)lOMliHaJibHbie:
( c pa31IBTbIM rrepHTOHHTOM) - Hl.n: rrHeBMOHHJI
-rrneBpMT - cerrc11c

np111 reMarnreHHOM nyn1 111HcpeKL\lll5l nona- L\lllPOBaHHoe AYOAeHanbHoe co,Qep)l{lllMOe MO)t(eT

,QaeT B )l{en4Hblli1 ny3blpb 1113 06L1..1ero Kpyra Kpo-
soo6paL1..1eH1115l no c111cTeMe 06L1..1eill ne4eH04Holi1
apTep111111 111n111 1113 KlllWe4HOro TpaKTa no BOpOTHOlll
seHe 111 ,qanee s ne4eHb. C4111TaeTC5'l , 4TO reMaTo-
reHHblill nYTb 5lBn5leTC5'1 OCHOBHblM nyTeM lllHcplll-
L\lllPOBaHlllS'l )t(en4Horo ny3b1p5l .
n111McporeHHblM nyTeM nona,QaHllle lllHcpeK-
L\111111 B )l{efi4Hblli1 ny3blpb B03MO:>KHO scne,[\CTBllle
06w111pHblX CB5l3eli1 n111Mcparn4eCKOlll ClllCTeMbl
ne4eH111 111 )l{en4Horo ny3blp5l c opraHaM111 6pt0w-
Holi1 nonocrn.
3HTeporeHHblill nyTb pacnpocTpaHeH1115l lllH-
cpeKL\111111 B }l(en4Hblli1 ny3blpb B03MO)l{eH np111 33-
6oneBaHlll5lX TepM1t1HanbHOro OT.Qena 06L1..1ero
}1(8fi4HOro npoTOKa , cpyHKL\lllOHanbHblX Hapywe-
H1115lX ero ccp111HKTepHoro annapaTa , KOrAa 111Hcp111-
3a6paCblB3TbC5l B )l{en4Hble npOTOKlll.
OcTpb1e xoneL\lllCTlllTbl, B03H111Kat0L1..1111e Ha
no4Be KaMHei/i }l{efi4HOro ny3blp5l , COCTaBn5llOT
85-90%. 6ecKaMeHHble xone4111crnTbJ scTpeYa-
IOTC5l 3H84111TenbHO pe>Ke Ill npe111MyL1..1eCTBeHHO y
nllll..\ npeKnOHHoro so3pacTa. Y no}l{lllflblX 6onb-
HblX COCYAlllCTble HapyweH1115l , CB5l38HHble c 803-
paCTHblMlll 1113MeHeHlll5lMlll, MOryT Bbl3blB8Tb pa3-
BLi1Tl/le ,[:\eCTPYKTLilBHblX cpopM OCTporo xonel.\111-
CTlllTa (nepBlll4Has:i raHrpeHa }l{efi4HOro ny3blp5l).
Bcne,llcTs111e TecHo~ aHaTOM0-
¢1113111onor1114ec1<011i CB5l3111 >Ken4eBblBOA5llJ..llllX ny-
Telll c BblBOAHblMlll npoTOKaMlll nO,Q)l{eny,Q04HOlli
c/JepMeHmamue-
>1<ene3bl B03MO>KHO pa3s111T111e
HblX xonequcmumoe. 111x B03H1<1KHoseH111e CB5l-
3aHo He c ,Qei/icrn111eM M1111<po6Horo cj:>aKTopa , a c
3areKaH111eM naHKpeaTl/l4eCKOro COKa B )l{efi'-!Hbl~

20
ny3blpb 111 nospe}l{,Qa101..4111M p,eliicrn111eM naHKpea-
Tlt14eCKlllX cpepMeHTOB Ha TK8Hb ny3blp11 . nona-
,D,8Hllle naHKpeaTW-teCKOro COKa B >1<en4Hbllii ny-
3b1pb MO>KeT npOlllCXO,IJ,lllTb nplll Hanlll4111111 061..4elii
aMnynbl ,qm1 >1<en1..1Horo 111 naHKpearn1..1ecKoro
npoTOKOB "' naronorn4eCKlt1X lt13MeHeHIA£°1, Bbl3bl-
Bal01..4111X 38CTOlii ceKpeTa B npoTOKaX. ,0,eCTpyK-
TlllBHble 1113MeHeHlll11 B >KeJ14HOM ny3blpe Ha no4Be
,qeliicTs11111 cpepMeHTOB naHKpearn1..1ecKoro coKa
COl/tTIJIOTCJf, /fli/f ll/}8811!70, C /}8JJ7J11/flb/MJ1 l/J01J-
MaM111 ocTporo naHKpearnTa. Co4eTaHHble cpop-
Mbl ocTporo naHKpeaT111Ta 111 xone4111crnTa pac-
cMaTp111sa10T KaK caMOCT011TenbHOe 3a6onesa-
H111e, nony4111swee Ha3BaH111e «xone4111cTonaH-
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,D,lllAfHOCTlllKA OCTPOro XOllEL.J,lllCTJ.1TA
OcTpb11ii xone1_1111crnT scTpe4aeTc11 y mop,elii
pa3Horo B03pacTa, HO 4a1..4e lllM 3a6onesa10T n111-
L.la cTapwe 50 neT. 5onbHble no>K11111oro (60-74
JleT) Ill CTap'-leCKOfO (75- 89 neT) 803paCTOB co-
CTaBJls:llOT 40-50% OT o6l4ero 4111c11a 3a6ones-
w111x OCTpblM XOJleLllllCTlllTOM.
3a6onesaH111e Ha4111HaeTc11 BHe3anHo . Be-
AYll.\lllM ClllMnTOMOM ocTporo xone4111cT111Ta 11s-
ns:ieTcs:i ClllJlbH811 Ill noCTOs:IHH811 6onb B >KlllBOTe ,
111HTeHc1t1BHOCTb Kornpolii no Mepe nporpecc111po-
saH11111 3a6011esaH11111 HapacTaer, 0Tn1114111renb-
Holii oco6eHHOCTblO 6011111 11811s:l9TCs:l Jl0K8Jllll3a-
Llllls:I ee s npasoM nop,pe6epbe c 111ppap,111a14111elii B
npasy10 Ha,LJ,Knl041114HYIO o6nacTb , n11e1..10, 110-
naTKY 11111111 s nos:icHlll'-IHYIO 0611acTb . 111Horp,a 60-
11111 111ppap,111111py10T B 0611aCTb cepp,14a , 4TO MO>KeT
pac4eHJ.188TbCfl KaK nplilCTyn CTeHOKap,lllilJIJ (xo-
ne14111CTOKOpOHapHblli1 c111Hp,poM , on111caHHb1!11 C.
n . 60TKlllHb1M).
nocTOs:IHHble ClllMnTOMbl OCTporo xo11e14111-
CTlllTa - mowttoma u noemopHaR peoma. no-
Bb1weH111e TeMnepaTypbl Tena OTMe4aeTcs:i c
nepsb1x AHew 3a6onesaH1Afl. XapaKTep ee so
MHOfOM 38BlllClllT OT my6111Hbl naTOMopcpo11or111-
'-1eCKlllX 1113MeHeHlllC1 B >Ke114HOM ny3blpe.
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4TO 3aBlllClllT OT Ts:l>KeCTlll OCHOBHOro 3a6oneea-
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B KlllLUe4HlllK, 4TO MO>KeT 6b1Tb CBfl38HO c saey-
nopKolii )1{9114HOfO npoTOKa KaMHeM 11111111 co
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>Ke11YHoro nporoKa.
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np111 nepexop,e socna11111renbHOro npo4ecca Ha
nap111era11bHY10 6p10w111Hy B03H1t1Kaer Hanp7!>1<eH111e
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21
KOTOpble Mbl ornecn111 K pa3p,e11y 06ll.\lllX ClllMnTO-
MOB: CUMnmoM IJ.lemKUHa - 6n10M6ep2a u
cuMnmoM Pa3iJon1:.cK020 (MO)l{HO onpep,e11111Tb
30HY Pa3,IJ,OflbCKoro). :>Ke114Hbli1 ny3blpb yp,aeT-
cs:i na11bn111poBaTb np111 P,eCTPYKTlllBHblX tj:lopMaX
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pa3Mepax Ill CTaHOBlllTCs:l nnOTHblM . 0AH8KO nplll
3Ha4111T€11bHOM MblWeYHOM Hanps:i)l{eHllllll npOll.\Y-
naTb ero He scerAa B03MO>KHO.
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LIVICTlllTa - 3TO c111MnTOMbl OpTHepa-lpeKosa, Ke-
pa, Mepcp111 111 Mt0cc111-leoprnescKoro (cppeH111eyc-
ClllMnToM).
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noKonaY111BaH111111 npasoi1 pe6epHoll1 p,yr111 corHy-
TblM 111 nanb14aM111 Kl!ICTlll (4e11ecoo6pa3Ha cpaBHlt1-
Te11bHas:i nepeycc11111).
CuMnmoM Kepa - no11s11eH111e T04e4Hoi1
6011e3HeHHOCTlll B npoeK1_1111111 >Ke114Horo ny3blpTI
nplll rny6oKOM BAOXe .
CuMnmoM Mepcpu - nos:ie11eH111e 6011111 nap,
nepBblM (11111111 BTOpblM) na11b4eM pacKpblTOlA
npasoiii 1<111crn, np111,qep)l{.111Ba10ll.\eiii 6p10WHY10
CTeHey 60J1bHOro BO epeMs:i rny6oKoro sp,oxa,
np1t1 3TOM nepBbliii (111n111 BTopoi1 nane1..1) ,!lOn>KeH
pacno11araTbC5I B npoeK4111111 >Ke114Horo ny3b1p51.
CuMnmoM M10ccu-reop2ueecK020 - 6o-
ne3HeHHOCTb np111 na11bna14111111 Me}l{,Qy HO>KK8Mlll
npaaoiii rpy,lllAHO-KJll04JA4HO-COC~eBlll,l:IHOC1 MblW4bJ.
B KJ11t1H1t14ecKoM aHan1113e Kpos1.1 OTMe4aeTC71
BblCOKll1i1 nei1K04111T03, CABlllr 11ei1Ko1..1111TapHoi1
cpopMy11b1 s11eso 111 yse11111YeH111e CKopocT111 oce-
,!laHL151 3plllTPOL\lt1TOB .
nPOCTOU (KATAPA/lbHb/U) XO/lEU,t1CTt1T
3To Ha1116011ee 11erKaR tj:lopMa 3a60-
11esaH111s:i , xapaKTep1113y10LL1as:ic51 Henpop,011>1<111-
Te11bHb1M111 , yMepeHHOlii lllHTeHClllBHOCTlll 60J111Mlll
B npaBOM nop,pe6epbe, TOWHOTOlA Ill O,[l,HO-, ABY-
KP8THOiii pBOTOlA .
06ll.lee cocroRH111e 6onbHoro crpaAaeT Ma-
no. nynbc MO>KeT Y48Llt8TbC11 AO 90 yp,apoB B 1
MlllH . np111 na11bna4111111 )1{111BOT8 OTMe4aeTCs:l no-
Ka11bHas:l 6one3HeHHOCTb B npaBOM no,l\pe6epbe,
Clt1MnTOMbl pa3p,pa)l{eHll1s:l 6plOWll1Hbf OTCYTCTBY-
IOT. :>Ke11YHb1!11 ny3blpb o6bl4HO He ysen1114eH 111 He
na11bn111pyerc11, o6nacTb ero 6011e3HeHHa . TeM-
nepaTypa Tena nosb1waeTC5I He3Ha41t1Te11bHO
(pe,[J,KO ,D,OCTlllraeT 38 °C), 4111CnO nel/1KOLllllTOB B
9
KpOBlll MO>KeT yse11111Y111BaTbC5I AO 11x10 /11 6e3
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np111 KaTapa11bHOM eocna11eH111111 >1<e114Horo
ny3b1p11 3a6onesaH111e MO>KeT 3aKOH4111TbC51 no11-
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pa4111111. np111 8KTlllBHOM Me,D,lllKaMeHT03HOM Jle4e-
Hllllll socnan111Te11bHb1e s:isneH111s:i e )l{eJ14HOM ny-
3blpe eyn111pyt0TCs:l K 6- 8-My ,IJ,HIO c MOMeHTa 3a-
6011esaHll1s:I. Ec11111 np111 cT1t1XaH1t1111 BocnanL>1Te11b-
Horo npo4ecca coxpaH11eTc11 Henpoxop,111MOCTb
ny3blpHoro npoToKa ec11ep,crn111e Yl4eMneH111R s
HeM KaMHSl, o 6pa3yeTCSl BO,QSlHKa )f{e114HOro ny-
3blp51. np111 BO.Q51HKe )f{eJlYHbJVJ ny3blpb MO)f{eT
,QOCTlllraTb 60JlbWlllX pa3MepoB 1113-3a CKon11eHl.1Sl
B npocseTe era 6ec1..1BeTHOil1, c111.13eno.i:106Hoi11
cTep11111bHOVi )f{lll.QKOCTlll . OH nanbn111pyeTC.7I B s111-
.i:1e :rnacTl/IYHoro 111 6e36o.ne3HeHHoro 06pa3osa-
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ny3blpSl MO:>KeT Cyl.l..\eCTBOBaTb ,Qonroe speMSl Ill
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11onaTK111 V111111 nneYo . 6011bHblX 6ecnoKos:rT
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pa:>KeHbl cna6ocTb VI He,llOMOraHVle. TeMnepa-
Typa nOBblWaeTCSl AO 38-39 °C Ill ,Qep:>KlllTCSl B
TeYeHVle HeCK011bKVIX ,QHeill.
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)f(eCTlll . l.JaCTOTa ny11bca CBblWe 90 YA8POB B
1 MlllH. rl3blK cyxoill. >KlllBOT B3AYT, pe3KO 6011e3-
HeH B npaBOM no.i:1pe6epbe 111 Hepe.QKO B 3n111ra-
CTpanbHoill 0611acTlll . no4Tlll scerAa l/IMelOTCSl
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9
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sneso.
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ny3brps:i TeYeHVle 3a6onesaHV17I Mo:>KeT VIMeTb
pa3n1114Hb1Vi xapaKTep . 5naronp111s:iTHoe TeYeH111e
c KJll/IHVIYeCKlt1M Bbl3.QOPOB11eHllleM Ha611JO,Qaercs:r
np111 csoespeMeHHOVi rocn111Ta111113a1..1111111 60.nbHOro
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pan111111. Kyn111posaH111e socna11111Te11bHoro npo4ec-
ca B CTeHKe )f(eJ14HOro ny3blp71 VI 6ptoWHOVJ no-
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n111eMbl ny3blp71. np111 3MnllleMe )f{eJlYHblVJ ny3b1pb
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ne3HeHHoro o6pa30B8HVls:I , ClllMnTOMbl pa3Apa-
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:>Ke11YHoro ny3b1p71 111 pacnpocTpaHs:reTcs:r Ha na-
p1.1eTanbHYJO 6plOWlllHY Ill COCeAHl.1e opraHbl. B
ps:r,o,e cnyYaeB 3TO npVIBO,D,VIT K nnoTHOMY cna.71-
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22
socna11111renbHOro V1Hcp1t1nbTpaTa yMeHbWatoTcs:r
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MeHT03HOil1 Tepan111111 npOVICXO,QVIT 4epe3 1,5 - 2
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nporpecc111posaHV1e socnanV1renbHoro npol\ecca
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rn '-lecKoro woKa .
rHolf1Hb18 X0118Hr111Tbl npOT8K8IOT 06bl'-lHO C
Bbipa>KeHHOM KJllllHlll4eCKOM K8pT111HOM 386011esa-
Hl1>l. XapaKTepHbJM ,l1n>:i rHolliHoro xonaHnira >:iB-
Il$leTc51 TplllaAa KJll/IHlll'-leCKlllX np1113HaKOB (mpua-
oa WapKo):
• Hapacratoll.lee )J{enrywHoe 0Kpaw111saH111e
KO>Klll £1 CKI1Sp,
• 60J1b,
• nep1110,Q1114ecK111e no,JJ.beMbl reMneparypbl
AO 38-39° C (reKT1114eCKoro xapaKTepa).
np111 na11bnau,111111 )J(lllBOT8 Hap51AY C ClllMnTO-
MaMlll ocrporo xoneu,111crnra MO)J{HO BblSIBlllTb
ysen111'-leH111e a pa3Mepax ne'-leH111 111 cene3eHKlll . B
Kpos111 onpe,JJ.ell5llOTC~ Bb1coK111!4 llel4Ko4111ro3 111
pe3KlllM CJJ.Blllr llelllKOL\lllTapHOM cPOPMYJlbl BlleBO.
nporpecc111pytoll.l8e Te4eHl/le rHOlf1HOf0 XOllaHrlll-
Ta nplllBOAlllT K H8,[\0CTaTO'-lHOCTl/I cPYHKLl,111111 ne'-le-
Hl-1 111 no4eK, 4TO npo51sm1erc51 yse111114eH111eM s
KpOBlll ypoBHs:I 6111n111py6111Ha, rpaHC8MlllHa3bl , MO-
,JJ.111ype3a (neHTaAa PeillHo).
llEl/EH/llE XOJ7AHft1TA
OnepamueHoe ne4eHue - s 3KcrpeHHOM
nop51,D.Ke (AeKOMnpecClll51 611111111apHOM ClllCTeMbl) .
B ycnos11151x 6111n1118pH0!4 r111nepTeH3111111 np111
xonaHnne caMOCTosirenbHOe 3Ha4eH111e KOHcep-
sar111sHolll r epan111111 orHoc111re11bHO Hesen111Ko 111
ee u,e11ecoo6pa3HO paCCM8Tp111B8Tb lll/IWb K8K
lllHTeHClllBHYIO KpaTKOBpeMeHHYIO no,D.roTOBKy
6011bHOro K npose,L1eH11110 cpo4Hol4 ,qeK0Mnpec-
c111111 )f{8Jl4HblX npOTOKOB.
KoHcepsa1111sHoe lle4eH111e:
1 rono,ll s Te4eHV1e 2-3 .QHelli.
2 . noK8llbHa51 r111nOT8PMlll5! - np111MeHeH1t1e
«ny3blP51» co Ilb.D,OM Ha o6nacTb npasoro no.D,-
pe6epb~ .
3. npoMbJBaH£1e >Keny,l!Ka np1t1 H8Jllll4lt1111
TOWHOTbl 111 pBOTbl.
4. 06e36omrnaH111e :
A) HeHapKOTlll48CK1t1e aHa11brernK111 :
• MeraMt.13011 HaTp111s:i - 1-2MI1 50% (500 Mr
-1000Mr) x 3 pa3a s cy11<111 s/M , s/s. MaKc1t1-
Ma11bHa51 p830Basi A038 - 1 r , cyro4Ha51 - 2 r
• Keropo11a1<- 30 Mr* 2-3 pa3a B cyTKlll
5) Cna3M0111-1TJAKlll
• Aporasep1t1H no 40-80 Mr (Ernyrpb 111n111
B/M) x 3 pa3a B CYTKlll , lllillll
• Me6esep111H - no 1 Kancy11e (200 Mr) x 2
pa3a B CYTKlll 38 20 MlllHYT AO e,JJ.bl (yrpoM Ill Be-
4epoM), 111n111
• n111Hasep11151 6pOMlllA 50Mr(1ra6) x 3 pa3a
BO speM51 e,.Qbl , 3an111sa51 60JlbWlllM KOJ11114eCTBOM
80,llbl 111!1111

23
 • f 1!10CLl,111Ha 6yrnn6pOMll1,IJ, 10-20Mr (1-2
Ta6.) x 3 pa3a B CYfKlil
B) KoM6111H111poBaHHb1e npenapaTbl (aHanb-
ren1K111+cna3Mo11111T111K111)
• Cna3Mam1H 5 MJl 2-3 pa3a B cyTKl/I Bl, BIM
r) HOBOKal.1HOBa51 6110Ka,£1a Kpyrnoi1 CB513KVI
ne4eHll1 .
1. AHT1116aKTep111aI1bH85'1 Tepan1115'1. npenapa-
Tbl Bb16opa
np111MeHeH111e OAHOfO 1113 nepe4111CJleHHblX
npenaparos:
• aM0Kc111u,111nn111Hl1<11aBynaHaT 1,2r x 3 pa3a
B cyTKlil BIB
• aMOKc111u,11mn111Hlcynb6aKTaM 1,5r x 3-4
pa3a B cyTKVI BIB, BIM
• aMn111u,111nn111H111Hlcynb6a1<TaM 1,5r x 4
pa3a B cyTK111 BIB, BIM
• u,ecpTplilaKCOH 1 r x 1 pa3 B cyTKl/I BIB, B/M
+MeTpOHl/l,IJ,830!1 0,5r x 3 pa3a B CYTK111 BIB
• Lle¢orn1<c111M 1 r x 3 pa3a s/s. s/M + MeT-
poH111p,a3on 0,5r x 3 pa3a B CYTKll1 BIB
• L.\e¢onepa30Hlcynb6aKTaM 2-4r x
2pa3alcyTKl/I BIB, BIM
AnbTepHaTlllBHble npenapaTbl :
• W111npocpn0Kcau,111H 750Mr x 2 pa3a B cy-
TKlll BHYTPb (400Mr x 2 pa3a BIB) + MeTpoH111p,a-
3on 0,5 x 3 pa3a B cyr1<w sHyTpb, s/s w11w
• feHTaMll1L.\lllH 5Mr1Kr x 1 pa3 B cyTK111 , BIB,
BIM + aMn111L-1111nm1H 1,0 x 4 pa3a B cyT1<111 , BIB,
BIM + MeTpOHl/l,IJ,830!1 0,5 x 3 pa3a B cyTKl/I BIB,
BHYTPb
• L\ecpen111M 1-2,0x 2 pa3a B CYTKll1 BIB, BIM
+ MeTpoH111p,a3on 0 ,5 x 3 pa3a B cyrK111 BIB
6. V1HQJY3l/IOHHO-KanenbHas:i repanl/ls:i He Me-
Hee 2 nlcyrK111 (o6beM onpeAenS'ltoT B03pacToM
60JlbHOro 111 COCT05'1Hll1eM cepp,e4HO-COCYAlllCTOl/1
ClilCTeMbl):
• 5-10 % p-p rI1IOK03bl BIB
• 0,9 % p-p NaCl BIB
/lfHCTPYMEHTMb HAR /l,/lfATHOCTMl<A
OCTPQ(Q XOJ1EU,/11CTV1TA
CH111)1(eH111e YacroTbl ow11160YHb1X ,l!WarH030B
np111 ocrpoM xoneu,111cr111Te 5'1BJ151eTc5'1 Ba)f(HOll1 3a-
p,a4e'1 npaKTll14eCK0'1 x111pypr111111. OHa MO)f(eT 6b1Tb
ycneWHO peweHa TOJlbKO np111 WlilPOKOM 111cnonb-
30B8Hlllll1 T8Kli1X COBpeMeHHblX p,111arHOCTll14eCKVIX
Merop,oB, KaK peHmaeHoapacjJufl, Y30, pempo-
apaaHafl naHKpeamoxonaHauoapacjJufl (PnXr),
KDMnbJOmepHafl m0Moapacpu>1 (pMc. 19).
K 3XonpM3HaKaM ocTporo xoneu,111crwTa OT-
HOC5'1TCS'I ymon~eHue CTeHKlil )f(eJ14HOf0 ny3blpS'I 111
3XOHeaamusHbJt1 o6oaoK BOKpyr Hero.
8b1co1<a5'1 p,1i1arHOCT111YeCKa5'1 T04HOCTb 11ana-
pocKon1r11r1 («AMarHOCTM~ecKaR 11anapocKo-
n11tR») np111 «OCTpoM )f{ll1BOTe» no3BOJ15'1eT WlilpOKO
1.1cnOJ1b30B8Tb MeTOA c ..QJ.1cp¢epeHl..lJ.18JlbHO-
A1118rHOCTVl4eCKOi1 1...1enbto. no1<a3aH1i15'1 K nanapo-
c1<on111111 np1.-1 ocTpoM xone1...1111cr111re cneAYIOll.\We:
1. HesicHoCTb p,111arH03a B CB5'13111 c Hey6ep,111-
reJlbHoll1 1<11111H1111<01/1 ocTporo xoneu,111cT111Ta 111 He-
24
B03MO>KHOCTb ycraHOBlllTb APYrll1Mli1 p,111arHocT111-
4ec1<111M111 MeTO,IJ,8M"1 np1114111HY «OCTporo >KlilBOTa».
2. Tpyp,HocT111 B onpep,eneH111~1 KJ11<1H1114ec1<111-
M111 MeTo,QaM111 cTeneHlil T5'1>Kecr111 socnamtrenb-
HblX 1113MeHeH111111 B >KeJ14HOM ny3blpe Ill 6plOWHOli1
nonocr111 y 6onbHblX c BblCOKOl/1 creneHblO one-
pa41110HHoro p111cKa.
3 . Tpyp,Hocrn Bb16opa cnoco6a ne4eHlll51
(KOHCepBaTlilBHOro 111!1111 onepaTlilBHOro) np111
«CMa3aHHOli1» KJlli1Hlll4eCKOll1 KapT111He ocrporo»
xonel..lVICn!Ta.
np111 Hanl/14111111 npOTll1BOnOK838H"11/1 K onepa-
TlilBHOMY Jle4eHll1IO (B03pacr, conyrCTBYIOll.\lile 3a-
6oneBaH111S1) B03MO)f{Ha 11e\fe6HaR 11anapocKon1r1Sl
no AeAepepy (caHaL.\1115'1 nop,ne4eH04HOro npo-
CTpaHcTBa, 6no1<ap,a 1<pyrno~ CBS13111 neYeH111 , nop,-
KOHTPOI1bHa5'1 4pecneYeH04Ha5'1 nyHKL.\1115'1 )f(eJ14Horo
ny3blP5! c 4e11bl0 ,aeKOMnpeCCJ.1J.1, npOMblBaHIAS'I
pacTBOpOM HOBOK8lt1H8 Ill APeHll1POB8H11151).
Pwc. 19. .Qono.nHwTe.nbHble MeTOAbl
wccneAOBaHMSl. (CM. BKJ13AKy).
np111 ocno)f(HeH1t1111 ocrporo xone1...1111cr111ra
MeXaH1114eCKOll1 )f{enryxoi/1 111!1111 XOJ18Hfli1TOM Ba)f{-
HO ,l!O onepa41A1" VIM8Tb TOYHble cse,aeHl/l5! 0
np111Y111Hax 111x pa3Bli1Tll1S1 111 ypoBHe Henpoxop,1.-1-
Mocrn >KeI14HblX nporoKoB. Ecn111 AI15'1 nony4e-
H111s:1 p,aHHoi/1 111HcpOpMau111111 HeAocraro4HO Y3111 111
KT, npo1113BOA51T Pnxr nyTeM KaHtornn-1111111
6onbworo ,qyop,eHanbHOro cocKa noA KOHTpo-
neM p,yop,eHoc1<ona.
Pnxr ,£1om1<Ha npoJ.13Bo,a111rbc5! s Ka>K,QoM
cny4ae ocrporo xone41<1cT111Ta, npoTeKatoll.\ero c
Bblpa>KeHHblMW Kfl111Hll1YeCKll1M"1 np1113HaKaMW Ha-
pyweHW5'1 OTTOK8 )f{eJ14111 B Kli1We4Hll1K. np111 yc-
neWHOM BblnOJlHeHllllil KOHTpaCTHOro 111ccnep,0Ba-
Hl/IS1 "1MeeTCS1 B03MO>KHOCTb BblS1BIATb KaMHfll
)f{eI14HblX npoTOKOB, onpep,eJllilTb VIX JlOKan1113a-
411110 111 ypoBeHb 3aeynopK1<1 nporo1<a, ycraHoBlilTb
npOT51)f{eHHOCTb cy>KeHl.15'1 >KeI14HOro npoTOKa.
Onpep,eneH111e xapaKTepa naTonor111111 B )f(eJ14HblX
npOTOKaX c noMOll.\blO 3HAOCKOnli14eCKOro MeTO-
p,a no3Bons:ier npaBll1JlbHO pewaTb Bonpocb1 o
cpoKax onepa1...1111vt, o6beMe oneparnsHoro sMe-
warenbcTBa Ha BHenel.feH04HblX >Ken4HbJX npo-
roKax, a TaK>Ke 0 B03MO>KHOCTll1 BblnOnHeHll1S1 3H-
AOCKOnli148CKOll1 nan111nnoToM1<1111 AI15'1 n1111<B111p,a4111111
np"14111H , Bb13sasw111x MexaHlll4eci<ylO >Kenryxy 111
XOJ18Hr111T.
J7El../E5HAR TAl<Tt11<A nPt1 OCTPOM
XOJ7EU,Jt1CTV1TE
neYe6Has:i raKTJAKa x111pypra npltl ocrpoM xo-
neL.\ll1CT111re p,ornKHa 6b1Tb 8KTll1BHO-
Bbl)f{"1,D,aTeJlbHOll1 . nop04HOli1 npli13H8H8 Bbl)f{li1,D,a-
TeJlbH8S'I TaKT111Ka, 1.-160 CTpeMneHllle pa3peW111Tb
Bocnan111renbHblli1 npo1...1ecc KoHcepBaTVIBHblMlil
MepaMVI np111BO,Qli1T K cepbe3Hb1M 0Cfl0)f(HeHll15'1M 111
3ano3p,anb1M onepaL.\1115'1M .
Cy1.1-1ecrsy10T no1<a3aH1115'1 K 3KcrpeHHoli1 paH-
Heli1 OTCP04eHHOli1 111 nnaHOBOll1 x111pypr1114eCKOC1
onepaL.\111111 np111 ocTpoM xoneL.\111cT111Te.
 1. noKa3aHV!SlMVI K 3KCmpeHHOU onepa4V1L1
.-............=...nn «C Ko.nee») , KOTopaSl BbfnO.nHS1€TCS1 B
-=;..c;,;;:w-.._ - _ c MOMeHTa rocn1.1Tam13a41.11.1 60.nb-
- iOTCS1 raHrpeH03HblC1 L1 npo60AHOC1 xo-
a TalOKe xo.ne41.1cT1AT, oc.no>KHeHHb1C1
MJU1 pa3.nL1TblM nepL1TOHL1TOM.
aHVISlMVI K paHHeU (cpO\.IHO~) one-
pa51 npOV13BO,D,IATCS1 cnycTS1 12- 24 4
_.,,.,....,"'-':--a ocryn.neHVIS1 60.nbHOro B CTa4VIOHap,
0 CYTCTBVle 3cpcpeKTa OT KOHCepBa-
e'leHVI S1 npVI coxpaHeHVIVI CllfMnTOMOB
"1 "1 MeCTHblX nepVITOHeanbHblX s:IB-
. a -aJOKe c.ny4aL1 HapacTaHIA5! o6ll.leC1 VIH-
1-1 nos:iB.neHIASl CIAMnTOMOB pa3,D,pa-
"1H bl.
OTCYTCTBIAIA CIAMnTOMOB VIHTOKCIAKa-
ecTH blX nep!ATOHea.nbHblX SlB.neHV!i:i
poBO,D,VITCs:I KOHCepBaTIABHOe ne4e-
B pe3ynbTaTe KOHcepBaTIABHblX Mepo-
aeTcs:i KYn!ApoBaTb BocnanV1TenbHb1e
s )!(ef14HOM ny3b1pe, onepaTIABHoe
!:>CTBO y ,D,aHHOC1 KaTerop!AVI 60J1bHblX
B «XOJ10,D,Hbli:i» nep!AO,D, (He paHee 14
ana 3a6oneBaHV1s:i), KaK npaBVlno, He
6on bHblX IA3 cTa41AoHapa (omcpo-
epa1.4u.R).
• 3aHVl eM K nnaHOBOMY onepaTIABHOMY
XB.Ils:leTCs:I xpOHV14eCK!Atli xone41ACTIAT.
-epeY"1cneHHblX noKa3aHVltli cne,D,yeT,
-cepBaTL1BHblC1 MeTO,D, neYeHVls:I MO>KHO
TOJlbKO np!A KaTapanbHOC1 cpopMe
a L1 B cnyYaSlX cpnerMOH03HOro XO-
- npoTeKalOll.lero 6e3 nepL1TOHL1Ta VIJlVI
,.......=:r,....,blpa>KeHHblMVI npL13H8K8ML1 MeCTHOro
a . Bo Bcex ocTanbHblX cny1.1as:ix 6011b-
xon e4V1CTL1TOM ,D,On>KHbl 6b1Tb one-
---.-=:::- B 3KCTpeHHOM VIJlfA cpOYHOM nops:!AKe .
ex on epa4V1V1 np111 ocTpoM xone4111cTL1Te
38BL1CVIT OT Ka4eCTBa npe,D,onepa4V1-
roTOBKVI VI npaBVIJ1bHOC1 opraHVl334VllA
-epa4111V1. np111 3KcTpeHHotli onepa41A1A
;:> lfy')K.[\8IOTC51 B KpaTKOBpeMeHHOtli L1H-
-=~'""'- - epam1111, HanpaBneHHoi:i Ha A8TOKCL1-
-a "13M 8 VI KOppeK41AIO HapyweHVIC1 Me-
x npo4eCCOB. npe,D,onepa41AOHH8Sl
He AOfl>KHa 3aH111MaTb 6onee 2-3 1.1 .
-:JBATJt1BHOE J1EYEHJt1E OCTPOro
--- CTJt1TA
eHIA e KOHCepsarnBHOC1 Tepamrn B
o6beM e IA B paHHIAe cpOKIA 3a6o.neBaHIASl
BOnSleT KYnVlpoBaTb Bocnan1.1renb-
_ecc B >KeJ1YHOM ny3blpe IA ycTpaHIATb
Heo6XOAL1MOCTb cpOYHOfO onepa-
ewaTeJlbCTBa, a npi.1 6onbWOM cpoKe
51 - noArOTOBL1Tb 6onbHOfO K one-
cepsaTIABH as:i TepanlASl, OCHOBaHHas:i Ha
...,.._:o,...;::r"\j(\.18CKIA X np1AHL1L1nax, BKnlOYaeT B ce6Sl
ne1.1 e6HblX Meponp1As:!TL1C1 , KOTOpb18
Ha yny4weH111e OTTOKa )f{8J1YIA B Klil -
opM a111i133L..\lillO HapyweHHblX npo4ec-
25
COB MeTa60J11A3Ma IA BOCCTaHOBJ18HL1e HOpMaJlb-
HOW ,D,eSlTenbHOCTIA ,D,pyrnx c111cTeM opraHIA3Ma .
B KOMnneKce ne4e6HblX Meponp111s:iT111C1 Heo6xo-
,D,IAMO Bbl,D,811SlTb:
HeMe.llfAKaMeHT03Hoe ne4eH111e
I. ,[J,1AeT1.11.1ecK1Ae peK0MeH,D,a41A1A
Crnn NQ 5a
-B pa41110H o6s:i3aTeflbHO BKnlOY8IOT MOJ104-
Hbl8 npo,D,yKTbl (TBOpor), OBOll.llil , cppyKTbl, SlfO,D,bl,
COKL1
-Co,D,ep>KaHL1e nerKOYCBOSl8MblX yrneBO,D,OB
He ,D,OJ1)!(HO npeBblWaTb cp1113111onor1114ecKY10 HOPMY
-061AnbHoe n111Tbe
-nlATaHIAe ,D,po6Hoe, He6011bw111M111 nop4111Sl-
Mlil . 6nt0,D,a OTBapHb1e IA npoTepTbJe
MeA!i1KaMeHT03HOe ne4eHV1e
1. Cna3MOIU1TMKM (o.qMH M3 nepelfMC-
neHHblX npenapaToe):
• ,[J,pOTaB8pL1H no 40-80 Mr
(1-2 Ta6) x 3 pa3a B cyTKIA
• Me6eBep!AH - no 1 Kancyne
(200 Mr) x 2 pa3a B cyTKlil 38 20 MlllHYT ,D,O eAbf
(YTPOM Iii Be4epoM)
• nlAH8B8plilSl 6pOMlil,D, 50Mr (1Ta6) x 3 pa3a
BO BpeMSl eAbf , 3an111Bas:i 6onbWlllM KOJllilY8CTBOM
BO,D,bl
• r1110CL..\lllH8 6yTll1116pOMlllA
10-20Mr (1-2 Ta6.) x 3 pa3a B CYTKlll
• Cna3Man111H 1-2 ra6neTKL1 x 2-3 pa3a B
cyTKVI , He p83}!{€BblB851 , 3anV1B8Sl He60flbWlllM
KOJllAYeCTBOM}KVl,lJ,KOCTVI
2. AHanbreTMKM
• MeTaM!i130.n HaTplilSl - 1-2MJ1 50% (500 Mf
-1000Mr) x 3 pa3a B cyTKlil BIM 1A11111 BIB. MaKClil-
ManbHaSl pa3oBas:i A03a - 1 r, cyTo4Has:i - 2 r
• Keropo.naK - 30 Mr * 2-3 pa3a B cyTKlil
3. AHrn6aKTep111anbHas:i rnpan111Sl.
npenapaTbl Bbl60pa fnp111MeHeH111e OAHOrO
1113 nepe1.1111cneHHblX npenapaToB) :
• aMOKCV14V111111AHIKJ1aBy.naHaT
1 ,2r x 3 pa3a B CYTKVI BIB
• aMOKCL1L..\lllf111111HICynb6aKTaM
1,5r x 3-4 pa3a B cyTKL1 BIB, BIM
• aMnL1L.,!lil.n.nL1HV1Hlcy.nb6aKTaM
1,5r x 4 pa3a B CYTKL1 BIB, BIM
• 4eq:>TpL1aKCOH 1 r x 1 pa3 B CYTKL1 BIB, BIM
+MeTpOH111,D,a3o.n 0,5r x 3 pa3a B cyrKIA BIB
• 4ecpOTaKCVIM 1 r x 3 pa3a BIB. BIM + MeT-
pOHV1,D,a30il 0,5r x 3 pa3a B cyTKlil BIB
• 4eQ:>onepa3oHlcy.nb6aKTaM
2-4rx 2pa3alCYTKIA BIB, BIM
AnbTepHarnBHb1e npenapaTbl:
• L1111npocp.n0Kca4111H 750Mr x 2 pa3a B cy-
TKVI BHYTPb (400Mr x 2 pa3a B CYTKL1 BIB) + M€T-
POHL1,D,a30J1 0,5 x 3 pa3a B CY"fKVI BHyTpb, BIB VIJ1L1
• reHT8MVl4VIH 5Mr1Kr 1 pa3 B cyTKIA, BIB,
BIM + aMm114111.n.n111H 1,0 x 4 pa3a s cyTKL1 , BIB , BIM
+ MeTpOHL1,D,830.n 0,5 x 3 pa3a B CYTKVI BIB,
BHYTPb
• L1ecf:>enV1M 1-2,0 x 2 pa3a B cyTKVI BIB, BIM
+ MeTpoH111Aa3o.n 0 ,5 x 3 pa3a B cyTKVI BIB
 3. l.1H<f>Y3MOHH3jt Tepani.tff:
8\B BB8A8Hllle )KlllAKOCTeill (5-10 % p-p rmo-
K03bl B/B, 0,9 % p-p NaCl B/B, peaM6eplllH
400Mn) He MeHee 2 n/cyTKlll (o6beM onpeAem1t0T
B03paCTOM 6onbHOro 111 COCT051HllleM cepAe4HO-
COCYAlllCTOii1 c111cTeMb1) .
Ba>KHblM KOMnoHeHTOM ne4e6HblX Mepo-
np1M1Tlllili np111 OCTpOM XOJl84lilCTJ/IT8 5!Bm1ercs:i
BblnOnHeHllle 6noKaAbl Kpyrnol-1 CB513Klll ne4eH111
0,25% pacTBOpOM HOBOKalllHa B KOJllll4eCTBe 200-
250 Mll . 0Ha He TOJlbKO CHlllMaeT 6oneBble
Oll!Yll..18HlllH, HO lll yny4waeT OTTOK lllHcPWl~lllpO­
BaHHOlil >Ken4111 1113 )Ken4Horo nyabtp51 111 )Ken4Hbtx
npoTOKos 6naro.1:1apH yc111neH111to coKparnrenbHOill
cnoco6Hocrn ny3blpfl 111 CHf!TllllO cna3Ma CcPlllHl<-
repa 0AAlll. BoccrnHosneH!lle ,apeHa)KHOW ¢YHK-
L\llllll >Ken4Horo ny3blp51 111 onopo>KHeH111e ero or
rHoillHoill }1(8114111 cnoco6crnyioT 6brCTpoMy crnxa-
H1t110 socnan111TenbHOro npol.\ecca.
X/llPYPf/llL/ECKOE 11EL/EHME OCTPoro
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}f(en'-IHOMY ny3b1pl0 lll BHene'-leHO'-IHblM }f(efi'-IHblM
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5 - r10 <beoopoay; B - aepxHutJ cpeouHHbltJ.
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np111 OCTPOM XO!lel.\"1CTL'1Te OH onpep,emteTC51
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CTlt1BHOro aHaCTOM038.
26
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MeTOAbl AlllarnocT111Klll.
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AnSl yTO'-!HeHlllH He TOnbKO xapaKTepa, HO Ill IlOKa-
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27
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28
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B8THOe 8H€CTe31110IlOrlll4eCKOe noco61i1e , KOTopoe
AOI1>KHO o6ecne4111Tb xopowyt0 Mb1We4HYIO pe-
naKcau,11110 , AOI1}f(Hblrli ypOB€Hb aHanre3111111 , OT-
CYTCTBllle aKTlilBHblX ABlil}f(€Hlillll AlilacpparMbl 111
neplllCT8IlbTlllKlll KlllWe4HlllK8 .
He,D.oou,eHKa 3TlilX ycnoe111rll 38TPYAH51eT s111-
3yanbHb1rll KOHTpOJlb B 30He BMeWaTenbCTBa Ill
MO>KeT CT8Tb nplll4111HOJA T51}1(eI1blX nospe)l{,ll.eHlllJA
opraHOB 6piowHorli nonocrn.
OcHOBHblMlll 3TanaM111 nanapocKon1114ecKoiA
onepau,111111 51BI1Sl€TCSl C03,D.8Hllle nHeBMOneplllTO-
HeyMa Ill BBeAeHllle B 6p10WHYIO nonoCTb Tpoa-
Kapos 1113 4 He60JlbWlllX pa3p€30B 6pt0WHOVl
CT€HKlll (B napayM6111I1111K8JlbHOJA o6nacTlll - BblWe
11111111 Hlll}l(e nynKa ; s 3n111racTp111111 Ha 2-3 CM. Hiii)!(€
Me4eBlll,D.Horo OTpOCTKa Iii AB8 - B npaBOM nOA-
pe6epbe nepeAHeiA nOAMblWe4HOIA 111 no cpe,D.He-
Knl041114HOIA I1111Hlil51M (plilC. 27) .
Ill
Puc. 27. nanapocKonullecKafl xoneu,ucm3KmoMufl.
CmaHoapmHbJe mOl/KLJ Hano>KeHufl L1emb1pex nopmos.
nanapocKon aaooflm L1epe3 yM6unuKanbHbJD nopm.
l./epe3 namepanbHbJU nopm 3H003a>KLJMOM
3aXaambl8aemCfl aHo >KeflHOl/HOZO ny3blpfl.
29
 nocne Blll3Y8JlbHOtA 04eHKlll COCT051Hlll51
6ptowHoCf nonocrn 111 aHaTOM1114ecKoCf c1ttrya41r11r1
B noAne4eH04HOM npocTpaHCTBe nyHKTlllPYIOT Ill
acn111p111py10T coAep)f{lllMoe )f{en4Horo ny3blp51,
oT,D,emuor ero or 0Kpy)f{a10L1.11t1X opraHoB. 3areM
Bblp,enfllOT ny3blpHblW npoTOK It! ny3b1PHYIO apTe-
PllllO, KOTOpb1e noo4epeAHO Kfl1Arn11py10T 111 nepe-
ceKatoT (p111c.28). vfasne4eH111e 1113 6ptowHo171 no-
nocT111 socnan111TenbHO 1t13MeHeHHoro )f{eJ14Horo
ny3blpfl c l<OHKpeMeHTaMlll npe,LJ.n04TlllTenbHO
np01113BOAlllTb B KOHTelAHepe, BO 11136e)f{8Hlllll1 lllH-
cp1114111poBaHll15! 6 ptoWHOVl nonOCTlll .
Puc. 28. nanapcoKonu4ecKafl xo.ne1..iucm:JKmoMufl.
ny3blpHblU npomoK LI ny3blpHaR apmepufl 8blOBflfl/OmCR
u nepeceKaJOmcR nocne mo20, KBK Ha Hux pa3oenbHO
HBkf1BObl88/0mCfl kflUnCbl.
3H,!J,OCKOnlll4eCKa51 xone4111CT3KTOM11151 OTHO-
C111TC51 K 4111Cny M8JlOlllHBa3111BHblX Ill 3cpcpeKTlllB-
HblX oneparnsHblX BMewarenbCTB . 0AH8KO OHa
MO)f{eT )J,aB8Tb OCJlO}f{HeH11151, KOTOpbie nplll OCT-
pOM xone4111crnre B03H111Ka10T 4all.le, 4eM B nna-
Hoso!A x111pypr111111. no:3ToMy np111 Bb16ope 3HAO-
cKon1114ecKoro MeTo,LJ.a y,LJ.aneHlll51 }f{en4Horo ny-
3blp51 np111 OCTpOM xoneU,lllCTlllTe Heo6xo,o,111MO
crporo y4111Tb1BaTb noKa3aHlll51 lll npoT111sonoKa3a-
Hlll51 K HeMy. Onepau,11110 AOn>KeH BblnOJlH51Tb KBa-
n111cp1114111posaHHb11A x111pypr, 111Met0L1.1111IA onblT or-
Kpb1TblX onepaL.1111171 Ha >1<en4HOM ny3blpe 111 )l(en4-
HbJX npoTOKax, B cosepweHCTBe OCBOlllBWllltl
nnaHOBYIO nanapOCKOnlll4eCKYIO xoneL.\lllCT3KTO-
MllllO.
XoneyucmocmoMuR. HecMoTp51 Ha nan-
n111arnBHbJIA xapaKTep 3TOIA onepa1..1J11J11, oHa 111 s
HacT051Ll.lee speM51 He YTParnna csoero npaKT111-
4ecKoro 3Ha4eH1115l . KaK ManoTpasMaTlll4Ha51
onepau,11151, xoneu,111crocroM1115l np111MeH5leTc5l y
HaJ116onee H!)l{eJlbJX 111 ocna6neHHbJX 6onbHblX,
Korp,a creneHb onepau,1110HHoro p111cKa oco6eHHO
BblCOKa (p111c. 29).
np111 yBeJ11114eHHOM )f(eJ14HOM ny3b1pe C03-
,Q3IOT XOJ181..llllCTOCTOMY nyreM nO,llWJllB3HJll~ ,llHa
ny3b1p51 K nap111eTanbHOVI 6p10W111He (xone14u-
cmocm0Musi "snnomHylO"} , a np111 raHrpeHe
)l(eJ14HOro ny3blp51 11111111 BHYTp1t1ne4eH04HOM ero
pacnono)l{eH111w ,.qpeHwpy10r nyJblpb Ha nporn>Ke-
30
H111111 (xone4ucmocmoMuR "Ha npomR)l(eHuu")
c nop,Be,D.eH111eM K HeMy OTrpaHltf41118810ll.(lllX TaM-
noHOB.
Puc. 29. Xonei..iucmomoMUfl. 3man onepauuu.
Onepau111111 Ha BHene"leHO"IHblX >Ken"IHblX
nporoKax. Co4eTaH111e ocTporo xoneL11t1CTlllTa c
nopa>1<eHll1S'IMll1 BHene4eH04HblX >KeJ14HblX npOTO-
KOB Tpe6yeT pacw111peH1115l o6beMa oneparns-
Horo BMewarenbCTBa, BKill0485! BCKpb1Tll18 06L1.1e-
ro >1<en4Horo nporoKa. B HaCT05IL1.1ee speM5! no-
Ka3aHlll51 K xoneAOXOTOMl/1111 4eTKO onpe,LJ.eJleHbl, Ill
111Mlll 51BJ15llOTC51 :
1. MexaH1114ecKa>i >Kemyxa np111 nocrynne-
H111111 Ill B MOMeHT onepa4111111 ;
2 . xonaHrnr;
3. pacw111peH111e sHene4eHo4HblX }f{eJ14HbtX
npoTOKOB;
4. K8MHll1 )f(eJ14HblX npOTOKOB , onpeAen51e-
Mbte nanbnaropHo 111 Ha xonaHrnorpaMMax;
5. CTPlllKTYP8 TepMll1H8JlbHOro OTAena 06-
111ero )1{8JlYHoro npornKa, no,.qrnep)l{,LleHHaSJ pe-
3ynbraraM111 111Hrpaonepau,1110HH0L1 xonaHrno-
rpacp111111 111/11111111 30HA1t1posaH1t1SJ 6onbworo AYOAe-
HanbHOro COCKa.
Ba)l{HbJM 3TanoM onepaL1J11M 51smiercSJ npa-
s111nbHbllA Bb16op cnoco6a 3asepweHlll5l xone,LJ.o-
xoroM111111. CyL1.1ecrsytor pa3n1t14Hb1e nyrn ee
OKOH'-18Hlll51 :
1. ywJ11saH111e paHbt o6ll.lero )l{en4Horo npo-
TOKa Harnyxo;
2. Hapy>KHoe APeH111posaH1Ae )f{en4Hb1x npo-
TOKOB;
3. COJAaH111e 6V?n1110-,.q111recr111sHoro coycTbfl
nyreM cpopM111pOBaHl.151 xoneAOXO-AYOAeHoaHaC-
TOM03a 111n111 TpaHCAYOAeHaJlbHOtA nan111nnoc-
cp111HKTepOTOMllllll.
Hapy}f{Hoe APeH1itpoeaH111e }f{en1.1HblX
nporoKoB. Ka)KAa51 xone,LJ.oxoToM1115!, npe,LJ.np111 -
H51Ta51 nplll OCTpOM XOJ18l..llllCTlllT8 c A1118rHOCTl/14e-
CKOVl 111n1.1 ne4e6HoL1 u,enbto, np111 pacw111peH111111
xonep,oxa He 6onee 1,5 CM 111 Han1114111111 O,lllt1H04-
HblX B HeM KaMH8tA, p,omKHa 38K8H4111B8TbC51 Ha-
PY)f{HblM ,LJ.peH111posaH1t1eM >Ken4HblX npoTOKOB
np111 ycnOBll1111 111X CB060AHOL1 npoxo,Q111MOCTll1 .
 Hap}')l<HOe opeHupoeaHue >KeI14HblX npo-
TOKOB MO>KeT 6b1Tb npm13Bep,eHO cnep,ytoll.\111Mll1
cnoco6aM111:
1. no Kepy - T-o6pa3Hb1M naTeKCHblM p,pe-
Ha>KOM .
2. no n111KOBCKOMY - C pacli.(enneHHblM KOH-
L\OM naTeKcHoro p,peHa)f{a .
3. no A.B .B111wHeBCKOMY - p,peHa>KeM-Clt1CpO-
HOM.
4. no XoncTe,ay-n1r1Ko_scK0My. (p1r1c. 30).

A 5
Puc. 30. BapuaHmbJ H8PY>KHoao apeHupoeaHUfl >Kenl/Hbrx nymeiJ: A - no Kepy; 5 - no nuKoecKoMy; B - no
BuwHeecKoMy; I - no Xoncmeay-nuKoecKOMY.
K Bbt6opy cnoco6a p,peHa)l{a o6li.(ero )l{eI14-
Horo npoToKa nop,xop,51T c yYeToM naronor111111 s
npornKax 111 xapaKTepa x111pypr111YecKoro BMewa-
renbcrsa .
np111 TpaH3111TOpHOi/1 )f(eJ1YHOi/1 r111nepTeH3111lt1 ,
BOJH1t1KatoLJ.1erl1 nocne nto6oro BMewarenbcrsa
Ha )f{eJl4HblX npOTOKaX, p,peH111poBaH111e 111X cne-
p,yeT npo1113sop,1t1Tb yepe3 KYilbTto ny3blpHoro
nporoKa. Oraep,eH111e >1<en4111 Hapy~ no p,peHa~
KYilbTlll ny3btpHoro npornKa n03sons:1er ycTpa-
HlllTb )f{eJl4HYto r111nepreHJlllto 111 npep,ynpep,lllTb
TeM caMbtM npocay111eaH111e .>1<en4111 4epe3 WBbl
o6u..iero )KenYHoro npoToKa, a raK.>Ke ao3MO)K-
Hocrb 3a6pacb1aaHV15I .>1<enY111 a naHKpean14ecK111i/1
npornK c pa3a111T111eM nocneonepa1..11110HHOro naH-
Kpearnra . np111MeHeHllle TaKoro BlllP,a ,QpeHa)Ka
noKa3aHo a cnep,ytou..i111x cny4a51x:
B r
1. nocne p,111arHocrw-1ecKoli1 xonep,oxoro-
M1t1111.
2. nocne neYe6Holi1 xonep,oxoToM111111, npep,-
np111H5norl1 p,m1 1113sneYeH1115I KaMHerl1 1113 nporoKOB
111 TpaHG,llyo.aeHailbHOro pacceYeHll151 COCOYJ<a.
3. np111 conyrcTBytoli.\eM ocrpoM naHKpeaTlll-
re , cp,asn111satoli.(eM repM1.-1HanbHbt"1 orp,en 06-
u..iero .>1<enYHoro nporoKa.
BHyrpeHHee APeH111poeaH111e )l(eJlYHblX
nporoKoe BKnto4aeT B ce651 cynpap,yop,eHanb-
HYto xonep,oxop,yop,eHocroM1.-1to (p111c.31 ), xone-
1..1111crnracrpo-, xone4111cro,£1yo.aeHo-, xone4111crn-
3HTepocrnM111to (p111c. 32) (KaK sap111aHT xonep,o-
X03HTepocroM111to) 111 rpaHcp,yop,eHanbHYto na-
n111nnoc¢111HKTeporoM111to (p111c. 33 a, 6) .

·· :. ~ .
r,·· . , .
. ....
. .
~":.

A f,

Puc. 31. CxeMa cynpaoyooeH8flbHOaD xoneooxoayooeH0-8HacmOM038 (C,[/X,[/A) no IOpawy-BUffOapaooey: A -

cpopMupoeaHue JaaHeiJ ay6b1 aHacmoMoJa, E - Hano>1mHue nepeoHeao pRoa weoe.

31
 r
Puc. 32. BapuaHmbt BHympeHHeao opeHupoaaHUfl 6unuapHoD cucmeMbt: A - xoneu,ucmoaacmpocmoMufl; 5 -
xoneu,ucmooyooeHocmoMufl; B - xoneu,ucmo3HmepocmoMUfl Ha KuweYHoD nemne c 3acnywKoi1 no WanuMoay; r -
xoneu,ucmo3HmepocmoMUfl no Py

I
~
J

Puc. 33a. TpaHcoyooeHanbHafl nanunnoccfJuHKmepomoMUfl u nanunnoccfJuHKmeponnacmuKa (3manbt onepau,uu).

Puc.336. Aa~opcKafl Memoow<a annap~mHou ccPuHK;,,~ponanunnomoMuu u ccfJUHKmeponanunnonnacmuKu: 1-

ccfJuHKmeponanunnomoMuR; 2 - 6ecKpoaHaR ccfJLJHKmeponanunnomoMUR.

CynpaAYOAeHanbHbllA xoneAOXOAYAeHoa- ¢1.o1naKTV1KV1 pel\VIA"'1Ba xoneAoxonV1rna3a np111

HaCTOM03 MO>KeT 6b1Tb np111MeHeH c L1enb10 npo- MHO>KeCTBeHHblX MenKVIX KaMHHX B >Ken4HblX

32
npOTOKaX, oco6eHHO KOf,Ila lllMelOTC5l nO,II03pe-
HJ/1>1 Ha Heno.nHoe YAaneH1.1e 111x 1113 renarnKoxo-
ne,l:1oxa, a Ta/Ol<e np11 3Ha411TenbHOM pacw111pe-
HJ/IJ/I nocneAHero 111 aTOHlllJ/I era cTeHoK, np111 yc-
JlOBlillil YAOB11ersop1itTeJlbHOCi npoXOAJ/IMOCrn
Ali1CT8JlbHbtX OTAellOB }l(ellYHbtX npoToKOB 111 oT-
cyrcTBlllJ/I rHOlliHoro xonaHrt.na.
,D,n>'! cf:lopMlilpOBaHJ/ISl xoneAOXOAYOAeHoa-
H8CTOM03a Ha1116011bwee pacnpocTpaHeH111e no-
ny4111nJ/I cnoco6bt IOpawa, <PnepKeHa u <PuH-
cmepepa, a TalOKe 111x MOA111cfl111Kal..\111111.
TpaHCAYOAeHanbHaH nan11111noctjJ1t1HKTepo-
TOMJ/11l np111 A06poKaYeCTBeHHblX HapyweHl.15lX
npoXOJl,JllMOCTlll ,[\lllCT811bHOro OT,Ilena }l(enYHOro
npoTOKa 1lBJ15leTC1l Ha11160.nee cpyHKL.\1110HaJlbHO~
J/I 3¢¢eKTJ/IBHolA onepaL.\lllelA, no3son>110ll.!el1 ycr-
, -
paHll1Tb cTa3 Ill rnnepTeH3J/llO KaK B }f(e114H0111 , TaK
J/I naHKpeaTllf4€CKOrif CJ/ICTeMax.
11E4EHUE XPOHU4ECKOrO
KAllbKYflE3HOro XOflELJ,J!ICTJ!ITA
I. 06li,\J/le peKOMeHA8L.\111111
- CaHal..\111s:l 04aros xpoH1t14ecKo~ l-1HtjJeKL.\111111
- 6opb6a c aA111HaM111e~ . O}l(1t1peH111eM .
II. ,D,111eTw-1ecK111e peKoMeHAaL.\111111
VlcKnl04aercS'.I :
- nepee.QaHlile, nplileM mm.(J/I Ha H04b
- >K111pHaH, ocTpa11, >1<apeHas:i n111li.\a, 11ilil..\a,
cnaAOCTl-1 , KOn4eHOCTJ/I , np111npaBbl
Pe1<0MeHAYeTc11:
- ,D,po6Hoe n111TaH111e 1<a>K,LJ,b1e 3-4 4aca
- np111eM }f(ll1AKOCTJ/I He MeHee 1,511 B AeHb
- ,[\OCTaT04HOe KOm1YeCTBO Kn8T48TKJ/I c
Ao6aBneHJ/leM oTpy6e~
- 0TKa3 OT npJ/leMa 3CTporeHOB 111 cp1"6pa-
TOB
Ill. MeAll1KaMeHT03HaS'.I Tepan1r1S'.I.
1. nepopallbH8fl mlfTOllllln14eCK8S'I Tepamrn
(To.nbKO B c11y4ae Hanlr141r1S'.I He AillllTe.nbHo cyli,\e-
CTBYIOli.\li1X xonecrep111HOBblX KaMHeVi pa3MepoM
1-1,7CM J/I QJYHKL.\lrlOHJ/IPYIOli.\111~ >Ke114Hbl~ ny-
3blpb):
- ypcoAeOKCJ/IXOileBaS'.I K111CllOTa 10-15
Mr/Kr/cyTKJ/I, He pa3}f(eBblBaS'.I, 3anJ/IBaS'.I MOilOKOM,
YaeM, COK8MJ/I - 1 pa3 nepep, CHOM , 11111111
- xeHOA80KClllXOJ18BaSl KlllCllOTa - 15Mr/Kr,
He p83)1{8BbJBas:i,- 1 pa3 nepe,Ll CHOM ,111n1r1 o6a
33
npenaparn a ,II03e 7-8 Mr/J<r O,IIHOKpaTHo Be1..1e-
poM.
An111TenbHOCTb Tepan111111:
KoHrponb 3cpcpeKT1t1BHOCT1t1 1<a)K,D,b1e 3-6
Mee. Llepe3 6 Mee. np111 He3¢cpeKT111BHOcT111 ne-
4eHJ/IS'.I Heo6XOAll1MO OTMeHll1Tb. np111 nOllHOM
pacrBopeH111111 KaMHeL1 npoA011}f(lr1Tb np1r1eM ypco-
Aeo1<cV1xo11esoll1 1<111c110Tbl eli.\e 3 Mee . B A03e 250
Mr/Kr.
2. Kyn111posaH111e 6011eBoro ClllHApoMa:
Cna3Mo.n1r1T111K111 (o,D,J/IH lr13 nepe4111cneHHblX
npenaparns):
- ,D,pornsep111H Ta6. no 40-80 Mr 3 pa3a B
CYTKJll
- Me6esep111H - no 1 Kancy11e (200 Mr) x 2
pa3a B cyr1<111 3a 20 MlllHYT 11.0 e/1,bl {yrpoM 111 se-
YepoM)
- n111Hasep11151 6pOMlll,ll, 50Mr (1ra6) x 3 pa3a
BO speMS'.I eAbl , 3an111BaS'.I 6onbWlr1M KO.nlt1Y€CTBOM
BOA bl
- tJ/IOCL.\lr1Ha 6yTJ/ln6pOMl.1A 10-20Mr (1-2
Ta6.) x 3 pa3a B CYTKll1
3.AHT1r16aKTep1r1a.nbH85! Tepan11151 (np111 060-
crpeH1111r1)
npenapaTbl Bb16opa (OA111H 1.13 nepe4111C-
neHHblX npenaparns):
- aMOKClr1L.\lllI1IllllH/KnaBynaHaT 1,2r x 3 pa3a
B CYTKJ/I BIB ,
- aMOKCll1l.4J/IJ1JlJ/IH/Cynb6aKTaM 1,5r x 3-4
pa3a B cyTKflf sis, s/M,
- aMn111L1111nn111H111H/cy11b6aKTaM 1,5r x 4
pa3a B CYTKlll BIB, B/M,
- L.\eQJTp111aKCOH 1r x 1 pa3 B CyTKll! BIB, B/M
+MeTpOHll1Aa3on 0,5r x 3 pa3a B cyTKll1 BIB,
- L.\8cf:loraKCJ/IM 1 r x 3 pa3a B cyTKJ/I BIB. B/M
+ Merp0Hlr1Aa3011 0,5r x 3 pa3a B cyTKll1 BIB,
- Lle¢onepa3oH/cynb6aKTaM 2-4r x
2pa3a/cyrK111 BIB, B/M.
AnbTepHaT111BHb1e npenapaTbl:
- L1111npo¢noKcaL.\li1H 750Mrx 2 pa3a s cy-
TKlll BHYTPb (400Mr x 2 pa3a B cyTKlr1 BIB) + MeT-
poHlllAa30J1 0,5 x 3 pa3a s cyr1<111 BHYTPb, sis
- J/1Illr1 leHTaMlr1L.\lllH 5M r/Kr x 1 pa3 B cyTKJ/I,
B/B, B/M + aMn111u111nnJ/IH 1,0 x 4 pa3a B cyTKJ/I, BIB,
B/M + MerpoHJ/l,D.a3on 0,5 x 3 pa3a B cyTKlr1 BIB,
BHyTpb.
4. OneparnBHoe fle4eH111e B nnaHosoM no-
ps:iAKe .
 OCTPl>IH IIAHKPEATHT
noA OCTpblM naHKpeaTMTOM nOHlllM8IOT
pa3111114Hble no :nl!1onor111111 AecrpyKTlllBHble li13Me-
HeHlll51 nOA>K8JlYA04H0171 >K8Jl83bl , npe111MyUJ,eCT-
aeHHO ayrnmff114ec1<01A np111p0Abl Ja c1.1eT BHYT-
pl!lnpoTOKosoill aKTlllBaU.llll!I cpepMeHTOB.
X/lf PYPf/11'-IECKAfl AHA TOM/lffl
no,D,>KEllY,D,O'iHOtlt >KEllE3bl
noA>Keny,llOYH871 )l{ene3a pacnono)l{eHa 38-
6plOWlllHHO Ha yposHe I 111 II nos:1cHL114HblX no3BOH-
KOB, 3aHlllM851 nono>KeHlll8 Me>K;D,y AB8HaA1.1ar111-
nepcTHolli KlllWKOlli l 1 80pOT8Mlll ceneJeHKlt1 . ,011111-
Ha ee cocraans:ieT 15-20 CM ., w111p111Ha 3-6 CM .,
TonUJ,lllHa 2-3 cM., Macca )l{ene3bl B cpeAHeM 70-
90 r. (p111c. 34) .
Puc. 34 . CuHmOnUR aseHadl.,lamunepcmHOU
KUWKU.
B nOA>KenyA04Hoill >1<ene3e pa3n1t14a10T ro-
noBKY, Teno 111 xsocr. ronoaKy orn6aer ABeHa-
Au.arnnepcrHaH Kl!IWKa; Teno nOA>KenyA04HOill
:>t<ene3bl csoeill nepeAHeill nosepXHOCTblO npeA-
ne)J{lllT K 38,!\Heti nosepXHOCTlll )1{8I1YAK8. 3Tlll op-
raHbl APYr oT Apyra yJKOill w,enblO - canbHlllKO-
soill cyMKoill (bursaomentalis) (p111c. 35).
38AH5151 nosepXHOCTb nOA>KenyA04HOlli >Ke-
neJbl npeAne>KlllT K Hlll>KHeill nonosoV. seHe,
sepxHe6pbl:>Kee4H0171 BeHe Ill OAHOlt1M8HH0171 ap-
rep111111, 6piow,Hoill aopTe , Hlll>KHS'ls:I - conp1111<aca-
ercs:1 c Hlll>KHerop11130HTanbHoill BeTBblO ABeHa-
,llU.arnnepcTHol4 l<lllUJKl1. no3a,lllll nO,ll)l(8IlY,llOYHOH
)f{eneJbl B MecTe nepexo,l\a ee ronos1<111 B Teno
npoxoAs:iT sepxH111e Me3eHTepanbHble cocyAbl, a
Ha ypoaHe sepxHero 1<pas:1 >Kene3bl no Hanpas-
neH11110 K ee xsocry - cene3eH04Has:i aprep111s:1.
Cene3eH04H851 seHa pacnono>KeHa noJaAlll )l(e-
ne3bl.
rnasHblill npoToK no.o,>Keny,l\o4H0171 )l(eJleJbl
(BflfpCyHroB npoTOK) 06pa3yerc~ flf3 CilflfHHlll71
MeilKlllX npOTOKOB (p111c. 36).
35
..{ - - - -
3 ----
Puc.35. CaeumanbHblD pa3pe3 6p10wHoi1
nonocmu: 1->KenydoK; 2-nod>Kenydol/HaR >Kene3a; 3-
nonepe4Ho-o6odol/HaR KUWKa; 4- canbHUKosaR cyMKa.
A111aMerp ero 1<one6neTcs:1 OT 0,5 ,.o,o 2 MM B
XBOCTOBOlll 4acrn , 2-6 MM - B o6nacrn 60J1bWOro
.o,yo,l\eHanbHoro coco4Ka . B ronoBKe nOA>Keny-
A04Hoill >Kene3bl s111pcyHroB npoToK coe,l\111Hs:1eTcs:1
c ,L106aso1.1HblM npoTOKOM. B 10 % cny1.1aes ,ll0-
6aso4Hblill npOTOK 6epeT Ha ce6s:i OCHOBHYIO
AP8H8)f{HYIO cpyHKU.llllO nD,l\)1(8JlY,D,Ol..fHOll1 )1{8Jl83bl.
83a111MOOTHoweH1115l KoHe4HblX or,l\enos nporoKa
1.1 npoToKa nO,l\)l(eny,l\04H0171 >Kene3bl pa3n1114Hbl.
5onee 4acrn o6a npornKa 06pa3yioT o6w,yio
aMnyny, KOTOpas:i OTKpblB88TC51 Ha 6onbUJOM co-
C04Ke ABeHaAu.aTV1nepcrnol4 1<111w1<111 (67%) , 111Ho-
rAa aMnyna OTCYTCTByeT (30%). 06UJ,111"1 }f{8Jll/-
Hblill npoTOK Ill npOTOK nO,£:\)K8IlYA04H0171 )f(8Jl83bl
np111 3TOM sap1.1aHTe snaAatOT s ABeHaAL1arnnep-
CTHY10 KlllWKY pa3A8IlbHO. lt1HOrAa OHl.1 COeAlllH51-
IOTC51 Apyr c APYrDM Ha 3Ha4111TenbHOM paccros:1-
H111111 OT 60ilbWOro COCOYKa ,.QBeHa,.Q4arnnepcTHO~
KVIWKll1 (3%) Ill OTKpb1BatOTC71 OAHlllM OTBepCTl/leM ,
He 06pa3y51 aMnyny. B ps:iAe cnyl..faes A06aso4-
Hbllli npoTOK BnaAaeT B ,D,BeHaAu.ar111nepCTHYIO
KlllWKY caMocTos:irenbHO B ManoM AYOAeHanbHOM
COC04Ke, pacnono>KeHHOM Ha 2-3 CM BblWe
6onbworo AYOAeHailbHOro coco4Ka.
KposocHa6>1<eH111e nOA}f{enyA04HOill }f{ene3bl
ocylJ..!eCTBmleTCH BeTBHMl.1 naHKpeaTO,llYO,lle-
HaJlbHOill aprep1.1111 (a.pancreaticoduodenalis) ,
KOTOp871 CH86>KaeT 6onbWYIO 48CTb ronoBKli1
(plllC. 37) .
 Puc.36. AHamoMU'lecKoe nono>KeHue noo>Kenyoo'IHOiJ >KeneJb1: 1- aonoeKa noo>Kenyool./HOD )l(eneJb1; 2- eepXHflfl
naHKpeamooyooeHanbHBfl apmepuR; 3- sopomHafl seHa; 4- o6u.iafl nel./eHOl./HBfl apmepuR; 5- HU>KHRR nonaR eeHa; 6-
aopma; 7- ceneJeHOl./Hb1e apmepuR u seHa; 8- neeb1iJ Haonol./el./HUK,. 9- xeocm noo){(enyool./HoiJ >Kef/e3b1; 10- ceneJeHKa;
11- neeaR no'IKa (noo 6pJOWUHo0); 12- meno noo>Kenyool./Hou >Kene3bl; 13- npomoK noo>Kenyool./HoO >KeneJbt; 14-
eepxHue Me3eHmepuanbHbte apmepuR u eeHa; 15- HU>KHUe naHKpeamooyooeHanbHbte apmepuR u eeHbt; 16- 6onbwou
COCOl./eK OBeHaou,amunepcmHDU KUWKU; 17- o6u.iua )l(efll./Hb/U npomoK; 18- M8flb/U COCOl./BK OBeHaou,amunepcmHDU
KUWKU; 19- 0068801./Hb/U npornOK nOO>KenyOOl./HOll >K8flB3bt; 20- 088H80U,8mUnepcmH8R KUWKa; 21- >Kefll./Hb/U ny3btpb.

no.Q>Ke.ny.Qo4Hotlt >KeJ1e3bl, B sopoTax ce.ne3eHKlll

f l\lllelil no,Q)f(eny.Qo4HOll1 >Kene3bl, .QBeHa.QL1arn-
Puc. 37. Apmepuu noo>Kenyool./HOiJ )l(ene3bl: 1-
HWKHUe noo)l(enyool./Ho-oeeHaou,amunepcmHble
apmepuu; 2- mblflbHBfl noo>Kenyool./HaR apmepuR; 3-
mbtnbHBR nOO>KenyoOl./H8f/ apmepUR; 4- 60flbW8fl
noo>Kenyool./HaR apmepuR; 5- noapaHU'IHBR apmepuR; 6-
apmepuR xeocma n>K; 7- HWKHRR noa)l(enyool./HaR
apmepuR; 8- ceneJeHOl./HBR apmepuR.
BeTBIA sepxHetlt 6pb1>Kee4HOtlt apTep111111
o6ecne4111sator KposocHa6>KeH111e ronoBK111 vi Te-
na, a sers111 cene3eHo4Hotlt aprep111111 (a. lienalis) -
Tena Ill XBOCTa nO,Q)f(eny,Q04HOlit >Kefle3bl. BeHbl
111,[lyr COBMeCTHO c aprepi115!MVI B BepXHIOIO 6pbi-
>Kee4HYIO Ill cene3eH04Hyto BeHbl, no KOTOpblM
Kposb orreKaeT s sopornyto seHy (v. porta) .
n111McpOOTTOK npOIACXO,QlllT B fl111Mcp8Tlll4e-
CK111e y3.nbr, pacno.no>KeHHble no sepxHeMy Kpato
36
Ill ne4eH04HO-,QBeH8Al\8Til1nepcTHOL1 CB5!3Ke.
4aCT1114HO m1Mcpa OTTeKaeT B 3a6ptollllllHHble
n111McpaT111YecK111e y3nb1 no XOAY a6AOM111HaflbHOro
oT.Qe.na aopTbt 111 Hlll>KHetlt no.nosoL1 seHbl. n111M-
cparn4ecKaH c111cTeMa no.Q>Keny.Q04HOL1 >Kene3bl
TeCHO CB5!38Ha c m1Mcparn4ecKOL1 CVICTeMoi.1 >Ke-
I1YAK8, K111we4Hll1Ka, ABeHaAL1ar111nepcTHol4 KlllWK111
111 )f(en4eBblBO.Q5lll.\lllX nyreili.
V1HHepB8l\1115! nO,Q)f(efly):I04HOlit )f(efle3bl
ocyll.leCTB.n5!eTC5l BeTB5lMlll 4peBHOro, ne4eH04-
HOro, cene3eH04Horo 111 sepxHe6pb1)f(eeYHoro
cnnereH1.-1i.1 . V1Meercs:i recHa5l CB5!3b c lllHHepsa-
nepcrHoili KllllllKlll , n~YeH111, )f(en4eBblBOA5lll.\lllX
nyTetlt vi >Ken4HOro ny3blp5! , 4TO so MHoroM on-
pe.Qen51er IAX cpyHKL\lllOHaflbHYIO 38BlllCVIMOCTb.
3Tt10110ft1l/ECKl1E <PAKTOPbl
nAHKPEATl1TA
1.MexaH1114ecKas:1 6noKa.Qa aMnynb1 <Parepa:
a) >Kefl4Hbte KaMH111;
6) nammnocreHo3;
B) cTeH03 Manora COC04Ka ,QBeH8Al.18Tlll-
nepcTHoili KlllWKlll
(pancreasdivisum);
r) AYO.QeHaflbHble ,QviseprnKy.nb1;
2.TOKClll4eCKllle il1 MeTa60.n1114ecK111e cpaKTOPbl:
a) anKoronb;
6) rnnepTp111m11114ep111.QeM111H ;
 B) nmepKanbl...\llleM1115i (Ha no4Be r1.11nepna-
paT111peo111p,1113Ma 111n111 3K3oreHHaSl) ;
r) neKapcTBeHHb1e npenapaTb1;
A) nocne TpaHcnnaHTal...\lllVI no4Kli1;
3.111Hcpe1<L11t1fl:
a) BVI PYCbl (anV1,D,eMV14eCKOfO napOTlllTa ,
ap,eHOBVlpyc, KOKCaK111);
6) MlllKonna3M03;
B) rm1CTH851 lllHB83111s:t (acKaplll,D,03) .
4.V1weMIMI:
a) L\lllPKYmnopHbli.1 woK (Hanp111Mep, npVI
onepal..\111"1 Ha cep,D,l..\e) ;
6) B8CKYnlllTbl ;
s) aM6on1115i ;
r) rnnonpoTe111HeM11rn;
A)3noKa4eCTBeHHas:t apTep111anbHas:t r111-
nepTOHlllfl.
5.0nyxomf:
a) neps1114Hb1e onyxom1 nOA}f{enyp,01.JHoLii
>Kene3bl;
6) MeTacTa3bl B no,D,:>Kenyp,o4HYIO :>Kene3y.
6.5epeMeHHOCTb {naHKpearnT, He o6y-
cnosneHHblil1 xonem'1Tl.lla30M 111 rnnepnaparnpeo-
111.LlH3MOM).
7 .Apyrne 3a6onesaH1.rn :
a) 6one3Hb KpoHa ;
6) neHeTpV1pyt0U1111e )l{enyp,o4Hble s:t3Bb1 ;
B) KVICT03Hbli°:1 ¢1116po3 nop,>Keny,D,04HO~
)f{eJJe3b1;
r) lllHTepMlllTTlllPYIOll.lllle nop¢111p111111 ,
A) TpoM601..1111rnneH111YecKas:t nypnypa .
L. Hollender (1983) cpe,D,VI npV14111H ocrporo
naHKpeanna Bbl,D,emrn cnep,yio~111e
3rnonorn4ecK111e ¢aKTopb1:
1) Xone1...1111cToxone,D,oxon111TV1a3 .
2) An1<ororn1JM.
3) BHyTp1116p10WHble onepal_\111111 - nocne-
onepal\V10HHb1IA naHKpeaTVIT.
4) 3H,D,OCKOnV14eCKllle BMewaTeflbCTBa Ha
>KeI14HblX Ill naHKpeaT1114eCKVIX npOTOK8X.
5) Tynas:i TpasMa :>K111s0Ta.
n amo2eHe3
B HacTo>1~ee speMs:t Ha1116onee WVlpoKoe
np1113H3HVle nony4V1na ¢epMSHT3TlllBHas:t TeOpllls:t
ocrporo naHKpeaT111Ta . BcneACTBVle HapyweH111s:t
onoKa naHKpeaTw-1ecKoro coKa (nan111nn111T,
SKJJHHeHHblCt KaMeHb 6,QC H T.l{.) , 803HH1<aeT
aHympunpomoKoaafl wnepmeH3Ufl. 3TO npVIBO-
AlllT K pa3pyweH111t0 napeHXlllMbl nop,)l{enyp,o4HOLI!
:>Kene3bl 111 ab1xoay mKaHeaoiJ u,umoKUHa3bJ . Ha
3TOM cpoHe H81.fVIHaeTCfl aKT111Ba1...1111s:1 cpepMeHTOB
s napeHx111Me no,Q>Keny,LIOYHoi.1 >Kene3bl (Tp111nc111-
HoreHa, anacra3bl , mma3bl, ¢ocnomma3bl 111 AP.)
111 npol(ecc 111,QeT no rnny 1..1enHow peaKL\111111. ne-
pexop, Tp111ncV1HoreHa B Tp111nc111H o6ecne4V1Baer
8KTlllB8L\llllO Kann111Kpe111H-KlllHlllHOBOll1 ClllCTeMbl ,
4TO npVIBOAVIT K o6pa30B3HVllO 6pap,VIKlllHV1Ha.
A eil1 cTs111e Tp111ncV1Ha Ha Ty4Hble KJJeTKlll npl.llBOAlllT
K 8b16pocy rncTaMll!Ha Ill cepOTOHll!Ha, Bbl3bl-
Bal0ll.ll.llX naBblUJeHl.'1e npoHlllL1aeMocrn cocyp,os
37
c cepo3Hb1M OT8KOM )K8Il83bl , KOTOpbli.1 nO,D,Aep-
>KVIBaeT cp,asneHVle nporoKoB . AKTlllBal...\111>1 s Kpo-
BVI ¢aKTopa XareMaHa npVIBO,QVIT K pa3BlllTVllO
TpoM6oreMopparw-iecKll!X paccTpoi.1cTB c pa3BVl-
rneM TPOM60308 H KPOBOl..13m1f!Hll!H 1<aK 8 caMOH
>Kene3e , TaK VI B p,pyrnx opraHax (ne4eHb, no4KVI ,
nerKVle) .
AKTl.llBaL\1117! anacTa3bl yc111n111saer omeK VI
nospe:>K,D,aeT oKpy>KalOll.lYIO KneT4aTKY, a n111na3a
npVIBO,QVIT K >KUPOBOMY HeKp03Y >KeJ1e3bl VI OJ<py-
:>K3IOU\lllX TKaHei.1 . 3a C48T noTepVI >KVl,D,Koi.1 48CTVI
KpOBVI HacrynaeT rnnosoneMlil>l c reMOKOHL\eH-
Tpa4111ell1 , YXVAWalOTCs:t peonorn4ecKV1e csoi.1cTsa
KpOBlll . nocrynfleHll!8 61110Jl0fl/148CKVI 8KTVIBHblX
se~ecTB B KPOBb crnHos111rcs:1 111cT04HVIKOM 3HAO-
reHHoil1 VIHTOKCl/1K8L\VIVI . B nocne,D,YIOL1.\8M B 30H8X
MeKp03a npOll!CXO,QJIJT lllHQJll!L!ll!POBaHVle, Ill see
6onbwee 3Ha4eH111e npl.'1o6peTaer 6aKTepll!anb-
Has:t VIHTOKCVIK3L!Vlfl .
0Cf70JKHeHUfl
1. naHKpeaTJ1Jl.leC1<1'1iil JIJHQJl'1Ilb TpaT
2 . naHKpeaTOreHHblill a6CLJ,eCC
3. nepll!TOHlllT:
- cpepMeHTaTlllBHbl i.1 (a6aKTep111anbHb1 1i1 )
- 6aKTepV1anbHb11/1
4. CenTV1YecKas:t ¢nerMoHa 3a6p10WlllHHO~
KneT'-!aTKVI :
naH1<pearnyec1<0Vi
napaKOJlVl4eCKOll1
napaHecfJpanbHoill
T830BOl.1
5. App03UBHoe Kpoaomel.feHue
6. MexaHUl/ecKafl >Kenmyxa
7. nceBOOKUCma:
- CTepV!nbH8>l
- lllH¢111LIVIPOBaHH8>l
8. BHyTpeHHVle VI Hapy)l{Hble CBVl~VI )Keny-
AOYHO-KVIW84HOfO TpaKTa
KJ1accuq, uKauna oCTporo nam,;.:peaTHTa
(CilIA, ArnaHTa, 1992)
CTeneHb TSl>t<ecnt
- HeTfl)Kenbli.1 (6e3 CVICTeMHblX VI MeCTHblX
OCJlQ)KHeHVIH) .
- TS1>KeJ1blill (c Cll!CT8MHblMVI II! MeCTHblMlll oc-
IlO>KHeHVlflMVI) .
Mopcf>onornlfecKHe H3MeHeHH.R
- VIHTepCTlllU,1118flbHblill OTeK
- HeKp03
EiaKTepvianbHblM COCTas
- CTepll!IlbHbli.1
- ll!HcplAL!lAPOBaHHbli.1
floKallbHbl e OCilO>KHeHMH
- naHKpeaTl.ll48CKVl8 HeKp03bl
- a6c1.1eccb1
- «0CTpble» >K.Vl,D,KOCTHble CKOnfleHVlfl
- nceB,L10K1'1CTbJ
K11uHulleCKue npoRa11eHUR
1. 6onesoe\ Cf/IHApOM
2. Kn111Hfill./ecK11e nposrnneHl<ffl sHewHeceK-
peTopHoiil He.QOCTaT04HOCTf/I
3. Kn111H111l./ecK111e npos:isneHf/151 BHYTp111ceKpe-
TopHolA He.QOCTaTOl./HOCTLll
4. C111H.QpoM 6111n111apHoii1 r111nepTeH3111111 (xo-
necrn3a)
5. HapyweH111e npoxo.Q111Mocrn AnK
6. CerMeHTapHafl noprnnbHafl r111nepTeH-
7. C111MnTOMbr nopa)f{eH"1fl L!HC.
TEl/EHJllE OCTPoro nAHKPEATJllTA
1. neplitOA reMOAlitH3Mlit"l0CKlitX Hapywe-
HlitM lit naHKpeaToreHHOro WOKa.
An111TenbHOCTb nepsoro nep1110,Qa Kone6-
neTcs:i OT HecKonbKlllX l./acos AO 2-3 CYTOK. OH
xapaKTep1..13yeTcfl reHepanlll30BaHHblMlll Hapy-
weHIMlMf/I MlllKPOLllllPKyilfll..lf/1111, CHl/l)f(eHllleM Ol_!K,
noBbrWeH111eM o6li.(ero nepti1¢epr1!4ecKoro cocy-
.Qf/ICToro conpon1BneH1115! . 3T111 paccTpoillcrna xa-
paKTepHbl ,QI15l 60ilbHblX c naHKpeoHeKp030M.
np111l./ll1HOlll Cl./f/ITaeTCS'l YKilOHeHf/le npoTeOillllT11-
l./eCKf/IX ¢epMeHTOB B KpOBb, pacnpe,o,eneH11e
:>KLllAKOCTLll Me:>K.Qy cocyAf/ICTblM, Me:>KTKaHeBblM 111
Me:>KKJleTOl./HblMLll npocTpaHCTB8Mll1 .
np111 naHKpeoHeKp03e paCCTpO!ACTBa MLllK-
pOL.ILllPKyil5ll..1111A pa3BIABalOTCSl nocne,QOBaTeilbHO
111 y">Ke Yepe3 6 Yacos OT HaYana 3a6onesaH111R
Ha6n10A810TCR so scex opraHax 11 TKaHsix. Ha-
pyweHLllSl MLllKPOL.lf/IPKyflSll..ILllLll npLllBOAf/IT 11 K f/13Me-
HeHLlllO TpoM6oreHHOro COCT051HLll5l CLllCTeMbl re-
MOCT83a Ill yxyAWeHf/llO peonOrll1l./eCKLllX CBOIACTB
KpOBLll, l./TO C03A8eT npe,QnOCblilK11 K B03HLllKHO-
BeHf/llO CLllHAPOMa AL11cceM111H111posaHHoro BHyTp111-
cocyA111cToro csepTblBaHf/ISl. HapyweH111e reMo-
AL11HaM111K1..1 s nepsy10 o4epeAb nposisns:i10TC5I s
yMeHbWeHtlftlf MfilHYTHOro 06beMa cep,[\4a. na-
pannenbHO npo111cxoA1t1T yMeHbWeH111e yAapHoro
o6beMa, 4TO npf/180,Qf/IT K TaXlt1K8PAll1111 f/I f/ICTOli.(e-
HLlllO 3HepreTL111..1eCKLllX pe3epBOB MLllOKap,[la . 1113-
MeHeHLlle OL\K 3as111c111r OT cpopMbl 3a6onesaH111s:i .
npf/I )i(f/IPOBOM naHKpeoHeKp03e OL\K yMeHbWa-
ercs:i He3Ha1..11..1TenbHO (Ao 6% ), np111 reMoppar111-
4ecKoM Ae¢111L1111T OL\K AOCTLllraeT 30% 1..1 6onee .
2. neplitOA cf.>YHK~lllOH3IlbHOM H0AOCTa-
TOlfHOCTff napeHXlllMaT03HblX opraHOB.
OH Ha1..1111HaeTc5I c 3-7 cyrnK 3a6onesaHf/151 111
S'lBilS'leTCSl OCHOBHOiil npllll..lf/IHOIA CMeprn 60ilbHblX
B Te4eH1t1e nepBblX 2 He.Qenb 6one3Hlt1 (21 ,3%) .
.ab1xamenbHaR Heoocmamol/Hocmb Ha-
6n10AaeTc.51 B 31 ,5% 6onbHblX naHKpeoHeKpo-
30M. 0Ha npos:isns:ieTC51 O,QblWKOrli, Bblpa)l(eHHblM
B pa3Illll'-IHOii1 CTeneH111 8KPOL.11118H030M, 1113MeHe-
Hlll5lMf/I Kll!C, 1..1ali.(e B crnpoHy .QeK0MneHc1t1po-
saHHoro .QbrxaTenbHoro anKOIT03a , CHlll)!(eH1i1eM
napL1111anbHoro AaBneH111s:i K111cnop0Aa B apTep111-
anbHOVi KpOBLll . nnesponynbMOH8JlbHble OCilO)!(-
38
HeHLll.51 on111cb1Ba10T KaK nesocropoHHf/le nnes-
panbHble BblnOTbl , np11 nyHK4111111 KOTOpblX Bbl,[\e-
Ilfl8TCfl reMopparn4eeKWii1 3Keey,QaT e nOBblWeH-
HblM eo,[\ep)!(8Hl1eM 6enKa 11 ¢epMeHTOB nOP,)l(e-
IlYA04HOii1 )!(efle3bl , areneKTa3br 111 naHKpeaTo-
reHHb1e nHeBMOHf/1111 .
HapyweHue <PYHKu,uu nel/eHu Ha6n10.Qa10T-
cs:i s 18-65% cny1..1aes . B pe3ynbTaTe naHKpearn-
reHHoro TOKCLllYecKoro nospe:>K.QeH111s:r ne1..1eH111
pa3Bf/IBalOTCs:i AlllCTpo¢1111..1eeK111e i-t3MeHeH111s:r re-
naTOLllATOB, Hapywa10TC5l npaKT1111..1ecK111 see ne-
1..1eHOYHb1e tj:>yHKl..{WW w 6no1<£-1pyeTCR peTLllKYn0-
3HAOTeilLll8IlbH8S1 c111creMa . Bee 3TO cocTasm1eT
cyli.(HOCTb CLllHAPOMa naHKpearoreHHOIA renaTap-
ff/1111, naTorHOMOHlll4HOro AI15l TOKCf/14eCKOro rena-
TLllTa 111 ocrpoiil naHKpearnreHHOIA p,111cTpo¢111111
ne1..1eH111 .
nopa>KeHUe nOl/BK BCTpe1..1aeTC5l y 12-17,5%
60ilbHblX. ll13MeHeHl/ls:I B MOl..le Ha6mo,o,atoTCS'l B
80% cny1..1aes B Bi-tAe on111royp111111, aHyp111111 (6%) ,
anb5YMLllHYPWR, npoTeMHYPlllR Ill AP.). np111..111Ha-
Ml1 51BmllOTC5l CHf/l)l(eHllle KpOBOCHa6)!(eHll15l no1..1eK
(rnnoTOHlllSl, r111nosoneM111fl) 111 111HTOKc111KaL11t15I
LILllPKyilLllPYIOli.\LllMLll B KpOBOTOKe naHKpearn1..1e-
CKLllMf/I cpepMeHTaMLll , B8308KTLllBHblMLll areHT8MLll
111 npo.QyKTaM111 pacna.Qa TKaHeBblX 6enKOB.
HepeAKLllM npos:isneH1t1eM He.Qocrnro1..1Hocrn
napeHXLllM8T03HblX opraHOB 51BJls:leTC51 paccTporlr-
CTBO neLllXL/14eCKOii1 ccpepbl (3HL1e¢anonaTL11s:r) . B
3TOT CtlfMnTOMOKOMnneKe BXO~RT: 1) Ha4aJlbHble
paccTpOIACTBa ncf/IXLllKLll (27,3%)- 6ecnOKOVrCTBO,
B036y:>K,QeHLlle Ill 31/1¢op111s:i y O,QHLllX, 38TOpMO)!(eH-
HOCTb 111 HeaAeKsaTHOCTb peaK4111rlr y APyrnx; 2)
naHKpeaToreHHbllA Aen111p111ii1 (30 ,8%) - cnYTaH-
HOCTb eo3H8Hf/1Sl , 6pep,, railJllOL!lllH8LllllLll, CLllMnTO-
Mbl opanbHoro aBTOMaTLll3Ma; 3) naHKpearoreH-
HaH KoMa. B ronosHoM M03re 06Hapy)f<111Ba10Tcs:i
OTeK IA Ha6yxaHL1e Ha ¢oHe pe3KO Bblpa)!(eHHblX
paccrpoiACTB MIAKPOL{1ApKYn.RL{£1W: MWKPOTpOM6o-
3bl , CT83, nep111Ba3ailbHbli1 OTeK Ill KpOBOlll3Jlf/ls:IHLll5l.
3. neplitOA AereHepaTlitBHblX lit rHOMHblX
OCI10}1(H0HlitH.
4epe3 1-2 He.Qen111 HeKpoTL114ecK111IA npoL1ecc
B :>K.ene3e npeKpall\aeTcH 111 , s 3as111c111MocT111 OT
BLllpyneHTHOCTlll BTOpLlll..IHOIA LllHcPeKL!LllLll Ill nyreiil
ee BHeApeHf/lfl, penapaTLllBHble npoL1eCcb1 lllAYT
Illll6o no acenTL/11..leeKOMY (HeOCJlO)l(HeHHOMY Ill
ocno:>1<HeHH0My), nvr6o no cenr1r11..1ec1<0My nyrn. B
nepsoM cny1..1ae s rn1..1eH111e 1,5-2 Mees:i4es 111 60-
nee o4arvi HeKpo3a 111HKancyn111pyioTcs:i , paceaeb1-
satoTcs:i Ill 3aMell\8IOTCs:I coe,Qf/IHLllTeflbHOCi TKa-
HblO, B pe3yilbTaTe 4ero pa3Bl/IBaeTCft lllHTepCTL1-
l..ILll8IlbHbli1 LllJlf/I KLllCT03Hblii1 cfl1116po3 Ill K8Ilbl..ILllH03
nop,)!(enyA04Horlr )l(ene3bl.
K11accu<fJu1<a4uR nocmHe1<pomuYec1<ux
OC/IOJKHeHuu:
A). AereHeparnBHbre:
- napanaHKpearn4ecK111ii1 111H¢111nbTpaT;
 - KlllCTa nO,.Q>Keny,.QO'-IHOrii }l{ene3bl (111CTlllH-
Ha51 111m1 Jl0)1(Ha51).
5) . IHOlAHble:
- a6cl.(ecc no,£p1<eny,llOYHori1 >1<ene3b1 11m1t1
cailbHlilKOBOIA cyMKlil;
- cpnerMoH03Hb1"1 1t1n111 anocrnMaTo3Hbl"1
naHKpearnr;
- a6c4eccbl 3a6ptOWl/IHHblX KJleTYaTOYHblX
npocrpaHCTB (Me30KOI10H Ill napaKOilOH) Ill
6pt0wHoll1 nonocrn (no,a,a111acpparManbHb1e, no.a-
ne4eHOYHble, M8)1(KlllW84Hble) ;
- cpnerMoHa 3a6pt0WlllHHOii! KJleTYaTKVI,
6onbWOro CailbHlllKa Ill cpeAOCTeH1t151 ;
- nep111TOHlilT.
B). B1t1c4epanbHb1e:
- Hapy>KHble Ill BHyTpeHHllle CBlilU\VI : naH-
KpeaTlil'-18CKVle, )l(eJlYHble, )1(€IlYA04Hble, KlllWeY-
Hble, naHKpeaTo>Keny,L10YHb1e 111 AYOAeHanbHble,
naHKpearo6poHx111anbHb1e 111 nnespanbHb1e;
- app03111BHble KpOBOTe4eHlll$1;
- OKKill03VIOHHble nopa)l{eHlll51 (cp,aBI18Hlile Ill
TpOM603) eerselA 6pt0WH0"1 aopTbl , BOPOTHOIA
B8Hbl Ill ee nplllTOKOB.
,fl, t1AfHOCTMKA
,IJ.aHHb1e 1113 aHaMHe3a: 3a6onesaHV1s:t ne4e-
Hlll Ill >KeI14eBblBOA51U\lllX nyre!A, npV1eM ofo1JlbHOlA
COKOfOHHOiil VI )1(8Jl4eroHH0"1 nVIU\VI (ocrporii, }l(Vlp-
HOL:l, }l(apeHHolA) 3noynorpe6neH111e anKoroneM .
nocrn51HHbJMlll c111MnT0MaM111 np111 ocrpoM
naHKpear111re srnm1t0rc51 ono5lcb1Bat0u.ia51 6onb s
sepxHeM 3Ta>Ke 6pt0WH0"1 nOilOCTVI, MHoroKpaT-
HaR psora ,.qyo,.qeHanbHblM co,.qep)KV!MblM 11 Me-
reopV13M.
1. 6011b: sHe3anHa51, pe3Ka51 , o4eHb lllH-
TeHClllBHaH 8 sepXHlllX OT,[\enax )Kl/IBOTa c 111ppa-
,[\lila4111e"1 B cn111Hy (on0Rcb1sat0U\a5I 6onb}, 3a
rpy,a111Hy, E3 nonaTKy. 6on111 HOC51T nocT051HHbl"1
xapaKTep. XapaKTepHaH no3a 6onbHblX np111 ocr-
poM naHKpear111re - KoneHHo-noKTesoe nono>Ke-
Hlile n11160 ne)KaT HenoABlll)l(HO, 6oHCb nowese-
fllilTbC51.
2. Peora: HOClilT MHOroKpaTHbllA , HeyKpO-
TlllMb1"1 xapaKTep, o6ner4eHlll51 He np111Hoc1.1r.
3. MereopH3M CB513aH c nape3oM none-
pe4HO-o6o,.qo4Holl1 KlilWKlll.
naTOrHOMOHH'tHble CMMnTOMbl:
-C-M rei.'.1HeKe (B3P,yrne Iii Bblpa>KeHHbli;.l
TlilMnaHlllT B sepXHlllX OT,D,enax >KlllBOTa, BCI18ACT-
Bllle nape3a >KenyAKa 111 nonepe4Holl1 o6o,D,o4Holl1
KlllWKVI};
-MSlrKMM, 6one3HeHHblM >KMBOT np111 OT-
cyTCTBllllll Cl/IMnTOMOB pa3Apa}l{8Hl.151 6pt0WlllHbl ;
-c-M BocKpeceHcKoro (orcyrcrs111e nynb-
ca4111111 6pt0wH0"1 aoprb1);
·C·M Melllo-Po6coHa (6one3HeHHOCTb np111
nOKOJ1841i1ElaHllllll B neBOM pe6epHo-no3EIOH04HOM
yrny;
39
-c-M 4yxpHeH1<0 (6onb s o6nacrn nO,ll)l(e-
ny,ao4HOi;.1 >KeneJbl np111 corp51ceH111111 Hlll>KHelA 4ac-
Tlll >1<111sora no HanpasneH111t0 K >Keneae);
-c-M Kepre (6one3HeHHOCTb 111 pe31t1creHT-
Hocrb nepe,[1He"1 6pt0WH0"1 CTeHKlll , COOTBeTCT-
BYIOU\8"1 npoeK4111111 no.a>Keny,ao4Ho"1 >Kene3b1);
-c-M <l>peHKenff (6onb 111 noHs11eH111e row-
HOTb1 np111 nocryKlllB8Hllllll no Me4eBll1,QHOMY orpo-
CTKY);
-c-M flarepnecpa (4111aH03 n1114a 111 KOHe4HO-
cTe111);
-c -M MoHAopa (cp111anerosb1e rnnHa Ha n111-
4e 111 rynos111u.ie) ;
-c-M Ky1111eHa (>KenrywHOCTb BOKpyr nynKY)·
,n,onOJ7HMTEJ7bHbfE MCCJ7E,il,OBAHV1fl
Ila6oparopHble noKa3arenH:
a) 06u.i111"1 aHaJ11113 l<pOBlll (ne"1KOL\lllT03,
C.QBLff neVIKOL\lllTapHolll cpopMyilbl sneso, n111M-
cponeH1115!, ysen1114eH111e C03, npV13HaKlll cryu.ie-
Hlll51 KpOBlll) ;
6) 6lllOXlllMlll4eCKllle noKa3aTeJllll KpOBlll (no-
BblWeHllle ACT, AnT, nOBblWeH111e ypoBH51 6111n111-
py6111Ha, r111nonpore111HeMlllH, ,Q111cnpore111HeM111H,
CHlll)l{eH111e yposHs:t K, Na, Cl, Ca, Mg);
B) noBb1WeH111e ypoBH51 aMlllJ133bl KpOBlll
(N=3,8-9,0 MMOJlb/Il),
r) r111nep.Q111acra3yp1115! - (6onee 64 e,Q. no
BonbreMyry).
A) awma30J<peaT11JHll1HOBbJJ°;1 lllH,lleJ<C (AKl/J)
no cpopMyne:
Amu x Crpl
.AK.H= x l 00%, rJJ.e
Amp! xCru
Amu 111 Ampl - a-aM111na3a MO'-llil 111 nna3Mbl
Kpos111 s OAlllHaKoBblX e,[l11Hw~ax, Cru 111 Crpl-
KpearnHVIH M04111 111 nna3Mbl Kpos111 s MKil/n. Be-
n1114111Ha AKl/1 6onee 6% npe,anonaraeT Han1114111e
ocrporo naHKpearnra.
Y11bTpa3eyK0Bb1e MeTOAbl a.tcc11eA0Ba-
HMS1:
,IJ.oonepa41110HHOe lllCCJle,[\OB8Hlile npOEIO,[\lllT-
C51 s Blll.Qe AByxMepHoro Y31/J opraHoB 6pt0wH0"1
nonocr111 VI aa6pt0WlllHHoro npocrpaHcrsa, a raK-
)l(e ,aynneKCHOro CK8HlllPOBaHlll51 a6,aoMl/IH8J1bHblX
111 BHyrp111opraHHblX cocy.aos (p111c. 38).
PHc. 38. CoHorpaMMa ocrporo naHK-
pearMra: 1- >KMAKOCTHblM KOMnOHeHT; 2- yee-
mt'leHHaff 6e3 'leTKHX KOHT}'pOB mK.
C noMo~blO ABYXMepHoro Y31A eoaMo>K-
HO CileAYIO~ee:
- onpe.aeneH111e pa3Mepa, cpopMbt, KOHTY-
pa 111ccne,QyeMblX opraHOB 111 naronorn4eCKlllX
crpyKTyp;
- OL\8HKa 3XO-CTPYKTYPbl opraHOB Ill 01.Jaro-
BblX o6pa30BaH111lil ;
 - BblSrnneHl/le p.111cpcpy3HblX Ill Ol..farOBblX 3a-
6oneBaH111~;
- AlllarHOCTlllKa COCTOS'IHlllS'I npoTOKOBO~
ClllCTeMbl n>K 111 )f(en4HblX nyre~ ;
- onpep.eneH111e B38111MOOTHOWeHl/ls:I Bbls:IB-
neHHblX naronor111YecK111x 06pa3osaH111~ c p.pyrn-
Mlll opraHaM111 111 cocy,D,aM111 .
.QynneKCHOe HCCile,QOBaHHe COCYAOB no-
3B011SleT onpe.QenHTb:
- cp1113111onornyecK111e xapaKTep111cT111K111 Kpo-
so101<a (m1He~Ha.s:i Ill o6beMHas:i CKOpOCTb, Ha-
npasneH1t1e 111 rnn KposoroKa, yposeHb nep111cpe-
p1t1YecKoro conpornsneH1t1s:i);
- lt13MeHeH1t1e reMO,[\lt1H8Mlt1Kl.1 B a6,D.OMlt1-
HaJlbHblX cocy,D,ax scne,D,crs111e 04arosb1x 111 ,D,111cp-
cpy3HblX nopa)f(eH111~ 111ccne,D,yeMblX opraHoB, OKK-
mo3111py10ll.\l.1X npo14eccos B aprep111s:ix 111 seHax;
- oco6eHHocrn KposoroKa so BHyrp111op-
raHHblX cocyp.ax s HOpMe 111 np111 3a6onesaH111s:ix
n>K.
nepBblM nplll3H8KOM OCTporo naHKpearnra
np111 Y3V1 s:ism1ercs:i ysem1YeH111e pa3Mepa )f(ene-
3bl. OreYHas:i cpopMa conposo)f(,ll,aercs:i yMepeH-
HblM ysen111YeHV1eM o6beMa )f(ene3bl, KOHTYP >Ke-
ne3bl ocraercs:i poBHblM 111 YeTKlllM . <t>opMa >Kene-
3bl 1113MeH51eTC51 nplll noKanbHOM OCTpOM naH-
Kpearnre. 4all.le scero axo-cryKrypa HepasHo-
MepHo rnnoaxoreHHas:i .
np111 ,D,ecrpyKTlllBHO~ cpOpMe pa3Mepbl >Ke-
ne3bl o6bll..fHO 3Ha4111TenbHO yse11111YeHbl. KoHryp
>Kene3bl cMa3aHHbl~ , He4eTKlll~ , oHa c rpyp.oM
orrpaH1111.1111saercs:i oT oKpy>KalOll.\lllX TKaHe~ . 3xo-
crpyKrypa rereporeHHa , co 3HaY111renbHblM cH111-
>KeH111eM axoreHHocrn .
np111 yBel11!14eHllllll ronOBKlll n)I{ MOryT Ha-
6nKJ,D,8TbCs:I np1113H8Klll cp.asneH1t1s:i o6ll.lero >Ken4-
Horo npOTOKa, npo51BJ15ll0ll.\111€C51 ClllMnTOM8Mlll
MexaHlll'·JecKo~ >Kenryx111.
B 20% np!A OCTPOM naHKpearnTe B 6plOW-
HO~ nonoc1111 onpep.ens:iercs:i H8n111Y111e cso6o,D,-
HO~ >K"1AKOCT1t1. TaK>Ke OHa MO>KeT onpep.ellSlTbCSl
s n11espanbHO~ no11ocrn, cpe,D,ocreH111111 11111111 p.a-
>Ke no11ocrn nep111Kap,D.8.
V1306pa>KeH111e a6c14ecca np111 Y3V1 3as111c1111
or crap.111111 era pa3s1111111s:i . CcpopM111posasw111~cS1
a6c1..1ecc lllMeer l..feTKllle POBHble KOHrypbl , 3XOHe-
raTlllBHYIO CTPYKTYPY c yc11111eHHblM axo-pecp11eK-
coM 38 AOp3anbHO~ CTeHKO~.
PEHTTEHOJ10fl11./ECKOE l1CCJ1E,fl,OBAHJ1E
np111 OCTpOM naHKpearnTe Ha1t16onee lllH-
cpOpMaTlllBHO peHrreH011orn4ecKoe 111cc11e,D,osa-
H111e opraHos rpyp.Ho~ KneTKlll . C111MnTOMbl Ha111-
6011ee Bb1pa>KeHbl Yepe3 12-24 Yaca c MoMeHra
nos:isneH111s:i nepBblX np1113HaKOB 3a6onesaH111Sl.
PaHHlllMlll np1t13HaKaM111 Sls11s:iercs:i BblCOKoe croSl-
Hllle 111 orpaH111YeH111e nop.s1t1>KHocr111 nesoro eyno-
11a ,D,111acpparMb1. B 6a3anbHblX cerMeHrax 11er-
40
K111X, I.fall.le cnesa, nos:isns:iiorcs:i .QlllCKOB111.QHble
are11eKTa3bl , s n11espa11bHo~ no11ocT111 peaKTlllB-
Hbl~ BblnOT.
Ha 063opHblX peHrreHorpaMM8X 6pt0wHo~
nonoc1111 Ha1116011ee 4acro onpe.Qens:iercs:i B3AY-
Tllle OT,D.ellbHblX nerenb TOHKO~ KlllWKlll {CUM-
nmoM oe»<ypHoil nemnu) 111 yYacTKOB ro11cro~
K1t1wK111 c HeYeTKlllMlll yposHs:iM111 >Klll.QKOCTlll (p111c.
39) .
PMc. 39. 06JopHast peHTreHorpaQ>Mst
6pt0WHOM nonOCTM: C-M«Ae>KypHOM neTnH».
KOMnblOTEPHAR PEHTfEHOBCKA
J1 MATHJ1THO-PE30HAHCHAR
TOMOTPA<PJ1fl.
PEHTTEHOBCKAR KOMnblOTEPHAR
TOMOfPA<PJ1fl
.Q111arHOCTlllK8 ocrporo naHKpeaTlllTa COCTOlllT
B OL\eHKe rny61t1Hbl Ill npOTSl>KeHHOCTlll nopa>Ke-
HlllH, BblflBneHllllll T8KlllX OCllO>KHeHlll~ , KaK HeKp03,
a6cL1e.Q1.1posaH111e, 3KcrpaB838L\lt1fl naHKpeaTl/l4e-
cKoro ceKpera s TKaHb >Kene3bl 111 38 ee npe.Qe-
nb1. T111n111YHblMlll .Qns:i ocrporo naHKpeaT111Ta s:is-
llSllOTCSl ,[\lllcpcpy3Hoe 11111111 6011ee orpaH1114eHHoe
ysem1YeH111e opraHa, noH1t1)f(eH111e era nno1Hoc1111,
HepoBHOCTb lt1 He4eTKOCTb KOHTypoB, lllHorp.a
oreK 111 cKonneH111e >Klll.QKoc1111 s napanaHKpeaT111-
4ecK111x TKaHSlX.
np111 Tfl)f(enblX cpopMaX naHKpeaTl/ITa, n)I{
pe3KO ysem1!1..fl/IB8eTCfl , KOHTYPbl ee CTaHOBSlTCfl
He4eTKlllMlll Ill HepOBHblMlll , crpyKrypa HeOAHO-
pO,[\HO~ , B03MQ}l{HQ cpopM111posaH111e orpaHlll'·leH-
HblX ceKsecrpos , napanaHKpean14ecK111x a6c-
L1eccos (p111c. 40).
PMc. 40. MPT ocTporo naHKpeaTMTa
(>KeneJa o6oJHaYeHa crpenKaMH).
MAfHJ1THO-PE30HAHCHAR
TOMOTPA<PJ1fl
np111 OCTpOM naHKpearnTe Blll3Y8111113111pyeTCS'I
YB€111114€HHblX pa3MepOB n:>t<:, H€0.QHOPOAHOCTb
ee crpyKrypbl, He4eTKOCTb KOHrypoB. MO)f(HO
Bbls:IBlllTb creneHb sosne4eH111s:i s socnan1111enb-
Hbll1 npOL\€CC napanaHKpeaTl/l48CKO~ KJ18Tl..f8TKlll .
MPT s:isns:iercs:i 4yscrs111renbHblM Mero.QOM AnH
06Hapy>KeH111s:i 04aros Kposo1113n111s:iH111~ np111 naH-
KpeaT111re.
f7AnAPOCKOnJ1R
K p.ocrosepHblM np1.13HaKaM naHKpeaT111Ta
OTHOCSlT (plllC. 41) :
- 6nRWKU cmeamoHeKpo3a Ha s111cL1e-
panbHOIA Ill nap111eTanbHOIA 6pKJWl/IHe;
- np111 Han1t141t11t1 nep111roHea11bHoro c111Mnro-
Ma 11111111 6e3 Hero xapaKTepHa cepo3HaS1 lllH-
cp11111b1pal..\1t1fl («cme1<11oeu0Hb1u omeK») KneT-
4aT04HblX 06pa3osaH111~, np111ne>Kall.\lllX K nop.>Ke-
;l)'AO'-lHOVi )f(ene3e, 6onbworo 111 Manoro canbHl/I-
' Kpym oVI CB513Kll1 ne1.1eH111;
- Bb16yxaH1-te CTeHKll1 )f(eilYAKa KnepeAlt1 ;
- zeMoppazu'lecKuii sbmom 111 111M61116111-
51 canbHll1Ka , BblnOT 3a6111paerc51 Ha cpepMeH-
-an1 BHbli..1 8Hailll13.
P MC. 41. nanapocKonw-1ecKaff KapTMHa
ocTporo naHKpeanna: 1- reMopparnTM"le-
cirnM BblnOT; 2- cTeaTOHeKp03bl.
llP/EHf/fE
n e4eH111e OCTporo naHKpeaTll1T8 - OAHa 1113
aKTY8IlbHblX npo6neM a6AOMll1HailbH0!..1 x111pyp-
•n1. B HacT05l1.4ee speM51 061.4enp1113HaHo, 4TO
OCHOB0!..1 Ile4eHl-151 3TOro 3a6onesaHll151 51BI15leTC51
. MnneKCHa51 KOHCepBaTll1BHa51 Tepan111s:1 . ne4e-
- e 6a3111pyeTC5I Ha Tpex ocHoBHblX np111Hu11max:
1. ne4eH111e socnaneHll151 noA)f(enyA04HOVi
ne3bl 1i1 naHKpeaToreHHOro nep1i1ToH1i1ra :
A) eyn111posaH111e Cl/IHTe3a 111 ayroaKr111sau111111
naHKpearnYeCKl.1X cpepMeHTOB:
1) pernoHapHa51 ( BHyrp1116p10WH85I I/I BHYT-
aprnp111anbHafl) 111Hcpy3111s:1 111Hr1116111ropos npo-
-ea3;
2) cpapMaKorepan111fl npenaparaM111 aHrn-
:nepMeHTHoro 111 ceKpeT06noK111pyio1.4ero AeVlcT-
3 ;i :
• aTpon111H 0,1%-1 Mn
• KOHTPHKan (or 80000 Tll1E npw a6opTHBHOM
)f(111posoM naHKpeoHeKpo3e, AO 120000-160000
t1E npw reMopparwYecKoM) s/B KanenbHo;
• Tpac111non (or 150000 AO 800000 Kl/1 E B
3aBHCl1MOCTlll OT cra,.q1111) B/B KanenbHO;
• 5-cpropypa1..1111n (5Mr/Kr) BIB Ha 500Mn .
5% p-pa rill-OK03bl ;
• AanaprnH B Blt1Ae nocT051HHOV! 111Hcpy3111111
CKOpOCTbl-0 50-55 MKr/Kr B yac;
• OKTpeOHIA B Bl/IAe nOCT051HHOVI 111Hcpy31/1111
co CKOpOCTblO 3,5 MKf /Kr 8 yac;
• caHAOCTaTll1H 0, 1Mf/Mn OT 3 AO 6 aMnyn
3 pa3a s ,1:1eHb.
3) 06ecneYeH111e cp1113111onorn4ecKoro noKos:i
:LVKeny,.qOYHOW )f{€Ile3e:
- ronoA;
- noKanbHas:i ninoTepM111fl (xono,.q Ha )1{111-
~ , opoweH111e >KenyAKa 4epe3 BBeAeHHblVI B
ero 30H,Ll ne,Ll51HOVI BO,LIOVI l/IIll/I J<YC04KaMl/I
bAa);
- y,L1aneH111e 38CTOV!Horo COAeP>KlllMOro 1113
nyp,Ka;
- npenapaTbl yMeHbWat01.4111e >Keny,o,o4HYIO
ce1<Peu11110 (H2-fLllCT8Mi.1H0-6noKaTOPbl - cpaMO-
-..tnl-1H; 6noKaTOpbl npOTOHHOVI noMnbl - OMe3) .
6) Bo3AelilcTBl/le Ha socnan111renbHblC1 npo-
_ecc:
1) npornsosocnan111renbHa5I Hecneu1t1cpi.14e-
oca51 cpapMaK0Tepan111s:i:
- peHrreHrepan11151;
41
aHTl11rll1CTaMlllHHble (,D,lllM8Apon , cynpa-
CTlllH) ;
KOPTVIKOCTepolllAbl (fLllAPOKOprn30H );
2) KOppeKl...!11151 noKailbHblX paccTpoticTB
Mll1KPOl..\lllPKYI1511..1111111 KpOBll1 111 IllllMcpb1;
3) cp1113"1TepaneBTll14eCKl.1e MeTOAbl (M8f Hl/l-
TOTepam'151 , Y3 M8TOAbl ne4eHlll71 Ill Ap .);
4) x111pypr1114eCKll1e MeTOAbl.
noKa3aHMSIMi.t K onepaTMBHOMY n e"leHVUO
SIBIUltOTCSI: 1) HeyeepeHHOCmb 8 ouaaHo3e; 2)
nelfeHue emopUlfHOU UHcpeKU,UU (C048TaHllle
OCTporo naHKpeaTl/ITa c AeCTPYKTll1BHblM xone-
4111crnTOM , lllHcpV141i1poBaHV1e HeKpOTVll./8CKOCf TKa-
Hlll >Kene3bl , fHOJAHlllKlll B 3a6plOWlllHHOVI KneT4aT-
Ke , pacnpocrpaHeHHb!ti fHOWHblti neplllTOHVIT,
a6c1..1eccb1 B 6p10WHOC1 nonocrn , ecn111 HeBo3-
MO>KHO neYeH111e 4peCKO>KHb!M ,D.peH1t1poaaHllleM
noA KOHTponeM Y3111 ; 3) npozpeccupy10w,ee
yxyoweHue cocmoRHUR 6onbHoao, HecMorps:i Ha
aAeKBaTHOe 111HT8HClilBHOe _ne4eHlll8 (B TOM 411lcne
np111 6e3ycnewHocrn nanapocKon111~ecKoro na-
Ba>Ka 6plOWHOVI nonocrn) , 4) MaCCUBHb/e KpO-
eomel/eHUR.
T exH1t1Ka rpaA111L.\1110HHoro BMewarenbtTBa
np111 nanaporoM1111.1 3aKn10YaeTcs:i s paccel./eH111111
)f(enyA04HO-o60A04HO!li CB513Klll Ill AeTaJ1bHOti pe-
61113111111 canbHll1KOBOVi CYMKlll, n}f{, 3a6pKJWl/IHHoro
npocrpaHcTsa , 6piowHoC1 nonocrn , no3ap,111- ron-
CTOKll1We4HblX KneT4aT04HblX npocrpaHCTB, no-
IlOCTll1 Manora Ta3a, 30Hbl KOpH71 6pbl>KelAK"1 TOH-
KOCf Ill TOilCTOti KlllWKL.1.
L\enblO x111pyprn4ecKoro ne4eH1115I 51BI151eTC51
YAaneH111e 111Hcp1t1L.\1t1poeaHHblX HeKpor1113111posaH-
HblX y4acTKOB TKaH111 AO pa3Bll1T11151 HarHOeHi.151,
onrnManbHoe APeH111posaH1t1e 6p10wHolli nonocri.-1
,o,ns:i ne4eH111s:1 nep111roH111ra 111n111 YAaneHi.151 )1("1,D,KO-
cr111 , COAep>Ka1.4eVI 60ilbWOe KOillt14eCTBO cpep-
MeHTOB no,n,)l(enyA04HoiJI >Kene3bt. B nocneAHeM
cnyYae B canbHll1Kosyio cyMJ<Y, no XOAY no,o,>Ke-
ny,D.01.tHolA >Kene3bl (p111c. 42) 111 B 3a6piow"1HHY10
KneT4aTKY (p111c. 43) (np111 ee nopa>KeH111111 ) BBOA51T
nepcpopi.1posaHHb1e APeHa>KHble rpy6K111 , yAan5151
He TOilbKO 3KCcyp,aT 111 cop,ep)f(a1.4111ec51 B HeM
cf>epMeHTbl, HO 111 06pa3osasw111!..1cs:1 s pe3ynbTaTe
pacnnasneHll151 TKaHelli A8TPVIT. Tpy6Kl.1 Bb1BOA51T
H8PY>KY 4epe3 60KOBble OT,D.enbl >KlllBOTa . 0AHY
111ni.1 ,D,Be rpy6K111 ycraHasn111sa10T s nonocT1t1 Ma-
noro ra3a . B re1.teH"1e cyroK 4epe3 Hi.1X BBO,D,51T
,o,o 10 n pacTBopa , co,D.ep>1<a1.4ero 5,6 r HaTp11151
XJ10Pli!Aa, 5,09 r naKTaTa HaTplll51, 0,52 r K8Ilb(.IVl51
xnop111,o,a, 0,15 r MarHi.151 xnop111p,a, 15 r mioKo3bl ,
AO 1000 Mn ,D.lllCTlltnillllpOBaHHO!li 80,[J,bl (OCMO-
Il51pHOCTb pacTBopa 360 MOCM/n). K pacTBopy
MO)f{HO ,D.o6asnf!Tb aHrn6111ornK!;t no no1<a3aH!;tf!M .

Puc. 42. ,lJpeHupoeaHue canbHUKoeoO cyMKU.
Hlll:>KHero KpaS1 nOA:>K€IlYAOl.lHOr.:1 :>Kefle3bl;
6)a6AOMMHM3al.\MIO nOA>Ke11YA0'-4HOM >Ke11e3bl
(p1o1c. 44). Cyrb 3Tor.:1 onepal.\111111 3aKnl04aeTc5! s
«nepeMell.\eH111111» nocne,aHerii s 6p10WHY10 no-
IlOCTb . 3TO AenaeTcS1 AI1S1 11130I1S1l.\llllll 3a6p10W111H-
Horo npocTpaHCTBa OT nporpecc111py10ll.\ero na-
TOI10rvt4ecKoro npoL1ecca 111 ,1weH111posaH111S1 ero.
Teno Ill XBOCT :>Kene3bl BblAeJ1S1IOT 1113 3a6plOWlllH-
Horo npOCTpaHCTBa, noA }Kene3y nOABOASIT CB0-
60AHbllil KOH€L! caJlbHlllKa Ill OeyTblB8IOT lllM :>Kene-
3y. Me:>KAY )l{ene3or/i 111 canbHlllKOM yKna,[lblBalOT
APeHa:>KHYIO Tpy6ey c 60KOBb1M111 0TsepcT1115!Mlll ,
KOTOPYIO BblBOASIT 4epe3 OT,D,enbHbllii pa3pe3 B
no5!CHlll4HOrii o6nacrn ;

~
B) MapcynMaflM33l.\MtO C311bHMKOBOM
CYMKM. 3Ta M€TOA111Ka BKill04aeT B ce6S1 cplllKCa-
L!llllO caflbHlllKOBOlil cyMKlll K 6plOWlllHe Ill 6plOWHOr.:1
I '
CTeHKe Y3IlOBblMlll WBaMlll TKaHer.:1 , OKpy:>KalOl.l.\lllX
f \ n}f{ (cTeHKlll nonepe4HO o60,Q04HOlil KlllWKlll Ill :>Ke-

I ny,D,Ka , canbHlllKa), co3,D,aBaS1 coycTbe Me:>KAy no-

pa:>KeHHblM opraHOM Ill BHeWHelil cpeAOrii . PaHy
np111 3TOM cnoco6e He 3aKpbrBalOT Harnyxo, 4T0-
6bl C03,[\8Tb ycnOBlllS1 AI1S1 OTTOKa neplllTOHeanb-
HOro 3KCCy,[\aTa B nOB5!3KY (p111c . 45) .

, ·---------<:_·\:~-21.-~
- -· -------- .
ii. "'
<
~-

&:·

Puc. 43. !JpeHupoeaHue 3a6p10WUHHOGO

npocmpaHcmea.

K eapMaHTaM onepaTMBHoro 11e1.teHMH

AeCTPYKTMBHOro naHTKpeaTMTa OTHOCHT: a)
OMeHTOnaHKpeaToneKCMtO, KOTOpasmp01113BO-
AlllTCS1 nocne pacce1.JeH1t1S1 :>KenyAOl.lHo-
noA:>KenyAOl.lHblX CB5!30K. npS1Ab 6onbWOro
canbHlllKa npoBOA5!T 1.Jepe3 0TsepcT111e s }l(eny-
A04Ho-060Ao1.JHOl'.il CBS13Ke Ill cpvtKClllPYIOT OTAeflb-
HblMlll WB8Mlll K Ill!ICTKY 6plOWlllHbl y sepxHero Ill Puc. 44. A6doMUHU3BllUR nod>Kenydo1.1HoO >Kene3bt.

(
r !

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Puc. 45. Cnoco6b1 cjJopMupoeaHUfl paH Ha 6p10wHoiJ cmeHKe.

42
 1. npegynpe)K,lleHllle Ill ne4eH111e ClllHApOMa
8Hf<P88TOf8HHOl4 TOKCeMWW, TOKC8Mlll4eCKlllX oc-
; O)f{H 8Hlr114 Iii HapyweHt.114 06MeHa B8l.J..18CTB:
a) geT0Kc1r1Ka4ws:i: ynpasns:ieMas:i reMog111mo-
s:i B CO\.leTaHi.11'1 c cpopc1i1poBaHHblM A1'1ype3oM ;
6) BHYTPlllBeHHas:i aHT111cf:>epMeHTHas:i Tepa-
Ms:i (1r1 Hr1116111Topbl npoTeaa, nnaaMa, reMogea);
s) nepcpya1r1s:i 6p10wHoti nonocrn, ,D.peHwpo-
38.Hll1 e rpygHoro npoTOKa ;
r) ne48Hllle ClllHgpoMa .QlllCC8MlllHlr1poBaHHO-
o BHYTPWCocy,L1111crnro csepTbt8aHws:i: renap111Ho-
"'Cpan111s:i 8 co4eTaH111111 c peonon1r1rn10KlllHOM , Hlr1-
. On1HOBOl4 KWCJlOTOti Ill aycpwnnlllHOM;
.LI) Clr1HAPOMHas:i Tepan111s:i rnno0oneM111111 111
WOKa nape3a :>KenyA04HO-KlllW8\.lHOro TpaKTa ,
er04HOti, ne4eH04HOti lr1 n0484HOti cpyHKL.\t.10-
an bHOi::i H8AOCTaT04HOCTt.1 Ill HapyweHwe L\HC;
e) KOpp111r111py101JJ,as:i Ill 38M81l.l810ll.l891 lllHcpy-
3HOHHas:! Tepam1s:i: 1<oppeK4111s:i BO,LIH0-3neKTpo-
ITTHOf0 6anaHca 111 K[.LtC, 1<0MneHca41r1s:i aHepre-
48CKlr1X norepb (napeHrepanbHOe nwraH111e) ,
3aMecrnTenbHas:i repan111s:i .
2. ne48Hlll8 naHKpeaTOf8HHOfO WOKa:
a) Kyn1r1po0aH111e 6onesoro clr1HApoMa
- HeHapK0Tw-1ecK111e 111 HapKorn4ecK111e
aHan br8H1Klll (KpOMe Mopcp111Ha) ;
- napaHecf>paJlbHbl8 6nOKa,D.bl.
6) BocnonHeH111e OUK (rn101<oao-conesb1e p-
bt Kp111cranno111Abl, nna3Ma);
B) KoM6111Hlr1POB8HHa91 Tepan111s:i y.QapHblMlll
038Mlll 111Hrlll6111TOp08;
r) ne4eHllle HapyweHllliil MlllKPOLllllPKJ'fls:ll..\111111
IQ)OBlll (Kplr1CTannOlll.Qbt) ;
43
A) npocf>111naKT111Ka Ill Jl848Hllle H8,£lOCT8T04-
HOCTlr1 ner1<111x, ne4eH111 111 noYeK.
3. npe,£1ynpe>K,L1eH111e 111 ne4eH111e nocrHe1<-
por111Yec1<1r1x ocnm1<HeH1r1i;:,:
a) KoHcepsaT1r1BHble MeTop.br aHri.i6aKTepvi-
anbHas:i (aHrn6111or111K111 w111po1<oro cneKTpa ,L1eticr-
0111s:i), lllMMYHHas:i 111 Hecne4111cf>111Yec1<as:i (renap111H ,
aHa60Jllll\.l8CKlll8 ropMOHbl) Tepan111s:i;
6) X111pypr111Yec1<111e MeT0,£1b1: pa3n1114Hb1e s111-
Abl pe3eK4111t1 no,a>1<.eny.Q04Hol4 >1<.ene3bl B 3a0111-
c111Mocrn or yposHs:i nopa>1<.eH1r1s:i , HeKpceK0ecr-
paKToM111s:i 111 ,L1pyr111e onepa4111111 no no00AY rHoi;:,-
HblX lr1 BlllC4epanbHblX OCJ10>KH8Hll114 .
PE3YJ1bTATbl
np111 CB088p8M8HHO H848TOM Jl848Hlll111
6onbHOro ygaercs:i 0 6onbw111HcTBe cnyi.iae0 Bb1-
0ecT111 1113 COCTOHHlllH ¢epMeHTaTlllBHOVt lllHTOKClll-
Ka4111111 Ill CTa61r1f11113111pOBaTb )f(ll13H8HHO 88>1<.Hble
cPYHKL.\111111 8 Te4eH111e 2-3 Hegenb. B 10-20% cny-
4aes OCTpbliil naHKpeaTViT nepeXO.QlllT B xpOHlll48-
CKllli;:, . K111crno6pa300aH1r1e , KaK 111cxo,[\ ocTporo
naHKpearnra Ha6n10,[\aeTcs:i B cpe,[lHeM 8 2-10%
cny4aes, a nplll .Q8CTPYKTlllBHblX cpopMaX 48CT0Ta
Aocniraer 50% . B nocneonepal..\MOHHOM nep1110-
.Qe no nOBO.QY OCTporo naH1<peaT111Ta B03MO>KHO
o6pa30BaH111e naHKpeaTlll\.leCKlllX CBllll.J..1814. 3TO
Ha6n10,D.aercs:i B 1-3% cny4ae0.
noKa3aTeJlb neTanbHOCTlll np111 OCTpOM naH-
Kpeanne 1<one6neTcs:i s npe,[lenax OT 7,5% AO
29,3% no ,[laHHblM pa3HblX a0ropos, np1114eM np111
A8CTPYKTlllBHblX cpopMaX neranbHOCTb AOXOAlllT
AO 43,3%.
 KHllIE1IHMI HEilPOXO)J;IIMOCTb

OcTpaH Klr1We'-IHaH HenpoxoAMMOCTb sonpoc o 4enecoo6pa3HOCTVI BblAeneHlilfl cocy-

(TO'-IHee • HenpoXOAlr1MOCTb Klr1We'-IHl.1Ka!) xa-
paKTep1113yeTCfl HapyLUeH111eM nacca>Ka KVILUeLtHo-
ro c0Aep)K111Moro no HanpasneHlilfO OT )!(eJlyAKa K
3aAHeMy npoxo,£1y . Bo3HlilKHYB, 3TO naTonornLte-
cKoe COCTOf!Hlile npoTeKaeT no eAlilHOMY «c4eHa-
p1i110» , Bbl3blB8fl lllHTOKCVIK84lilf0 Iii B0,£1H0-
3JleKTpOJlVITHble paccTpoi::icTBa, conpos0>1<,D,aeT-
cfl TVlnlil'-IHblMlil KJllilHVl4ecKlilMVI npoflBneHVlflMVI . B
CBfl3111 c 3TlllM ,£1V1arHOCT11tLteCKaf1 lit Jlel!e6Hafl TaK-
TlllKa so MHoroM eAlilHa np111 Hecxo)!(eJ/1 no csoeJ/1
np11tp0,£1e HenpoX0,£1111MOCTVI .
l<J7ACC/114J/11KA4/11fl OCTPOi1 l</11WEL/HOi1
HEnPOXO,LJ,/llMOCT/11
AaHHafl Knaccvi¢1.1Ka4V1fl AOCTaTOl!HO nonHo
oTpa)!(aeT see npoflsneHlilfl Kviwe4HOll1 Henpoxo-
AVIMOCTl!t. y MHOrnX asropoB MO>KeT B03HVIKHYTb
AMCTOM KVILUel!Hoi::i Henpoxo,£1111Mocrn. Ho ecnvi
yLteCTb, '-ITC npvi HapyweHVIVI Kposoo6paw,eHV1fl B
KlilWe'-IHVIKe (apTep111aJlbHbil/1 lilJllil BeH03Hblli1
rpoM6o3) ecrecTBeHHO pa3avisaercfl nape3 , ne-
peXOAflW,Vli::i B napaillilll KVIWe'-IHlilKa, '-ITO COOT-
BeTcTByeT COCTOf!HlllfO nplil napam'ITllllleCKOl/1 KVl-
weLtHOi::i HenpoXO,J:IVIMOCTlll, TO see CTaHOBVITCfl
flCHblM 111 sonpocos He AOJl>KHo Bbl3blBaTb.
CTA,LJ,/11/11 K/11WEL/HOi1 HEnPOXO,LJ,/llMOCT/11
I CT3AMH - CT3AMH OCTporo HapyweHIAff
KHWe'4Horo nacca:H<a (nepexo,qHaR - Hapywe-
Hllle BHYTPVICTeHOllHOi::i reM04V1pKym11.~V1V1) ;

KJIACCII<l>IIKAUIDI
OCTpa5I IIO,D:OCTpa5I xpmrn:qecKM

cnacTW:IeCKa.51 apTep1rn.JibHa51

BeH03H3.5I
cMernaHHa5.I

)J;HH3Mll'leCK3H Cocy,LJ;HCTaSI

BoICOKM
lfu3Ka5I
BpmI<)leHHa5.I KumeIIHaSI uenpoxo- PaHHAA (,no 24 11acoB)
I1p1rn6peTe1rn3.5I ,LJ;HMOCTh Il03,D:HAA (> 24 l'.JaCOB)

HapyrneIIBe
apTepirn.m,Horo
KpOBOTOKa > 270°

06'rypaD,HOHHaSI Hapyrneirne
BeH03HOro KpOBO-
TOKa 180-270°

3H.LJ.OllHTecnrna.JIDHM ymeMnemie

3K30RHTeCTMHaJibHa5I 3aBOpOT
y3noo6pa30Bam1e

Cl\-1emaHHaSI
( MHBarHHa"QAA)
45
 II cTaAMH - my6oKi.te naTonornl.fecKi.te
M3MeHeHi.tst s peJynbTaTe AeK0MneHc111posaHHo-
ro HapyweHlll51 MOTOpHoll1 cjJyHKL..\111111 KlllWe4HlllKa ;
Ill CT3AM.H - pa3BMTMe nepi.tTOHMTa.
,D,t1HAMt1l/ECKAfl Kt1WEl/HAf1
HEnPOXO,D,t1MOCTb
A111HaM1114ecKas:1 HenpoxOAlllMOCTb 06ycnos-
n111saeTCS1 cjJyHKL!lllOHailbHblMlll HapyweHlllS1Mlll
MOTop111K111 MycKynarypb1 KlllWe4HlllKa . MexaH1114e-
cKoe npens:ITCTBllle npOABlll>KeHllllO KlllWe4HOro
COAep>KlllMOro np111 3TOM OTCYTCTByeT. <PyHKL..\1110-
HailbHble HapyweH111s:1 , BblJblBatOli..\llle Henpoxo-
AlllMOCTb, 6b1BatoT pa3m14Horo xapaKTepa: cna-
cmuL/eCKoeo 111 napanumuL/ecKoeo. B CBS13111 c
3TlllM np111Hs:1To pa3n1114aTb ABe cjJopMbl AlllHaM111-
4ecKoll1 KlllW€4HOll1 HenpoXOAlllMOCTlll - cnacTM-
1.feCKYtO I.II napani.tTMl.feCKytO.
CnacTi.t"4ecKaH HenpoXOAMMOCTb pa3s111-
saeTcs:1 B pe3yilbTaTe ompaeneHUR CBlllHL!OM,
cons:1M111 APYrlllX Ts:1>t<enb1x MeTannos, np111 acKa-
puoo3e, nopcj:Jupuu, Heapo3ax, ucmepuu. Ha1.J111-
HaeTcS1 Ja6onesaH111e BHeJanHo, 6e3 npeAsecT-
HlllKOB, Ha cjJoHe o6li..\ero 6narononyo..i111s:1 . B >KlllBO-
Te noS1BilS1IOTC5! ClllilbHble cxaamKoo6pa3HbJe,
6e3 onpeoeneHHOtl flOKBflU3BU,UU 6onu. 60ilbHOll1
6ecnoKoeH , Meo..ieTcs:1. Ha6ntoAaeTc5! JaAep>t<Ka
cryna 111 raJos. XapaKTepHo , llTO o6li..\ee cocTOS1-
H111e 6onbHOro 06blllHO Mano MeH5!eTC51 . :>KlllBOT
4ali..\e He B3AYT, naabeBUOHOU cj:JopMbl, nplil
nanbnal...\111111 Mano6one3HeHHblll1. HanpS1>KeHlilS1
nepeAHei/1 6pt0WHOl/1 CTeHKlll HeT. np111 peHTreHO-
norW·leCKOM 1ttccneA0BaHlillil xapaKTepHblX AI15!
OCTpoi/1 KlilW8'-lHOll1 HenpOXOAlilMOCTlll AaHHblX
o6bl4HO nony41!1Tb He YAaeTcs:1 .
A111arHOCT111Ka cnacrn1.JecKoll1 KlilWellHOll1 He-
npoXOAlilMOCTlll npeACTaBil5!8T onpeAeneHHble
TPYAHOCTlll . Heo6XOAlllMO lllCKnl041!1Tb Apyrne Ja-
6onesaH111s:1 conposo>t<Aat0li..\1Aec51 np111crynoo6-
pa3Hb1Mlll 60I1S1Ml!1 B >KlllBOTe. 06blllHO 6on111 np111
cnaCTlll'-leCKOll1 KlllWe'-lHOll1 HenpoXOAlilMOCTlll Ky-
n111pyt0TC5! caMOCT05!TenbHO 111n111 nocne np111Me-
HeH111s:1 cnaJMon111T111KoB. Pe>t<e BblCTasns:1t0TC5!
noKa3aH111e K onepaTlllBHoMy ne1.JeH111t0 - pe3e~
l...!111111 cnaJMlilpOBaHHOro yllaCTKa KlllWKlll.
napanl!1Tlllll€CKa51 KlllWellHa51 HenpoXOAlll-
MOCTb (nKH) pa3Bl!1BaeTC51 np111 OCTPblX 111n111 xpo-
HllllleCKlilX 3a6onesaH111s:1x opraHos 6pt0wHoll1 no-
nocrn (nep1t1TOHlllT, naHKpeaT111T) , 3a6p10WlllHHoro
npocTpaHCTBa, TpaBMaX Iii reMaTOMax 6pbl}l(eil1Klll
TOHKOi/1 lllillll o60AO'-lHOll1 KlllWKlll , 3a6oneBaHlllS1X Ill
nospe}l{AeH111s:1x L!eHTpanbHblX Iii nep1ttcpep1114e-
CKlllX HepBHblX o6pa30BaHlllll1 , np111 rnnoKanllleMllllll ,
nmoHaTp111eM111111 , A111a6eT1111.JeCKOM KeToJe. CaMoi/1
1.Jacrni/1 np1111.J1t1Holl1 napeJa >KenyAo4HO-
K111we1.JHoro TpaKTa 5!BnHeTcs:1 nep111TOHlllT.
nATOTEHE3
napanlllTlll4eCKa51 KlllW8'-lHa5! HenpOXOAlll-
MOCTb 4ali..\e pa3s111saeTcs:1 np111 socnamnenbHblX
npoL1eccax s 6pt0wHoll1 nonocT111 , o6ycnosneH-
HblX pa3BlllTllleM 6aKTep1ttanbHOll1 lllHcjJeKL..\111111 (T.e.
46
6aKTep111anbHblll1 nep111TOHlllT). B 3TOM cnyllae
lllMetOT MeCTO CileAYIOli..\llle 1113MeHeHlll51:
a) 06e3so>K111BaH111e opraHlllJMa c npe111My-
li..\eCTBeHHblM o6e3BO>KlllBaHl/leM BHeKneTO'-IHOro
npocTpaHcrna 111 yMeHbWeH111eM Kon1114ecrna
L!lllPKYillllPYIOli..\ei/1 KPOBlll , nOBblWeHl/le ypOBH5! re-
MaTOKp1!1Ta;
6) CHl/l>KeHlile ypoBHS1 6enKa B CblBOpOTKe
(npOHlllKHOBeHlile 6enKa B 6pt0WHYIO nonOCTb,
ysen1114eH111e KaTa6on111JMa 6enKa, JaAep>t<Ka 3H-
AOreHHOll1 BOA bl) ;
B) CHlll>KeHlile YPOBH5! HaTplll5! (noTep5! Ha-
Tp11151 Hapy>t<y, nepeMeli..\eHllle ero BHyTpb KneTOK,
3aAep>t<Ka 3HAOf8HHOll1 BOAbl);
r) nosb1weH111e ypoBHS1 Kan11151 (npornKaeT co
cH111>t<eH1tteM 0611..lero COAep>t<aH111eM 0611..lero co-
Aep>t<aHl/151 Kan111S1 s opraH1113Me , a nosb1WeH111e
ypoBH51 ero BO BHeKneT04HOM npocTpaHCTBe Bbl-
JBaHO BblAefleHllleM era 1113 KneTOK, fAe OH 3a-
Meli..\aeTCS1 HaTpllleM, Ill 3aA€P>KKOili ero BO BHe-
KneT04HOM npocTpaHCTBe B pe3yilbTaTe CHlll>Ke-
HlllS1 cjJyHKL!lillll nolleK);
A) aL!lilA03 (s pe3ynbTaTe HaKonneHlllS1 KlllC-
IlblX npOAYKTOB pacnaAa >KlllpOB Ill 6eJlKOB) ;
e) nOBblW8Hllle ypoBHS1 MO'-l8BlllHbl Ill aMl/IHO-
KlilCilOT, a B HeKOTOpblX cnylla5!X Ill aMMlilaKa
(yc111neHHb11/1 pacnaA 6enKa s KlllWe4HlllKe np111
paccTpoll1cTBe cjJyHKL!lillll nol.leK, a lilHOrAa np111
paccTpOlACTBe cjJyHKL..\1111!1 ne4eHlll).
Kil t1 H//1 KA
np111 napaillilTlll'-leCKOl/1 KlilWe4HOi/i HenpOXO-
AlllMOCTlll 6onu He3Ha41/1TeilbHbl, HOCS1T nOCT051H-
Hblll1 xapaKTep , nocTeneHHO HapacTatOT. OcTporo
Hal.Jana JAeCb HeT, Ja6onesaH111e pa3s111saeTCS1
MeAneHHO. Paoma noS1BnS1eTcS1 noJAHO, lilMeeT
3acToi11Hb1i11 xapaKTep ( «KanosaS1 psorn» ). 3a-
oep>KKa cmyna U ea308 CTOi11K111e. :>KlllBOT B3AYT
paBHoMepHo, nplil nanbnal...\111111 onpeAenS1eTCS1
pe3111CTeHTHOCTb nepeAHeili 6pt0WHOlii CTeHKlll no
Tlilny MS1'-la (cuMnmoM Mottoopa).
np111 nepKYCCllllll >KlilBOTa onpeAeI1S18TC51 Bbl-
COKlllili TlilMnaHlllT, a np1!1 COTpS1CeHlillll nepeAHeili
6pt0wHoll1 cTeHKlll - wyM nnecKa (cuMnmoM
CKnRpoea). nplil ayCKYilbTal_\111111 B 6plOWHOll1 no-
JlOCTlll neplllCTailbTlllKa He BblCilYWll1BaeTC51
(cuMnmoM "2po6oeou muwuttb1'') . Ha 3TOM
cjJoHe MO>KeT BblCilYWlilBaTbC51 wyM naAatOli..\eill
Kann111 (cuMnmoMCnacoKyK01..4Koao), a TaK >Ke
AblXaTenbHble WYMbl 111 cepAellHble TOHbl (cuM-
nmoM nomeiicceHa) . 0611..lee cocTOS1H111e 6onb-
Horo BHallane He 1113MeHs:1eTc5! . B AanbHell1weM
pa3BlllBa€TC51 KapTlilHa OCTpoi/1 HenpoXOAlllMOCTlll
KlllWe'-lHlllKa c S18Jl€Hlll51Mlll T5!>Kenoll1 lilHTOKCl/IKa-
l...!111111 Ill o6e3BO>KlllBaHlll51.
PeHTreHonornlleCKlll onpe,QenS1eTCS1 B3AYTl!le
KaK TOHKOro, TaK Ill TOilCTOro KlllW€4HlllKa c 6onb-
Wlt1M coAep>t<aH111eM ra30s 1t1 >Klt1,QKocrn. Kon1t11.Je-
CTBO ypOBHeili >KlllAKOCTlll ('law Knoii6epa) (p111c.
46) He6onbwoe, KOHTYPbl 111x 06b1'-IHO HelleTKlile.
noJAHee nHeBMaT1113111posaHHb1e nem111 K1t1We4-
H111Ka cjJopM111pyt0T ClllMnTOM "opaaHHblX mpy6"
(p1t1c. 47)co cn111paneB1t1AHOll1 111c1.Jep4eHHOCTbt0
 Vlnn10CTp81..\VIVI K 1 4acn-1

A 6

B
Puc. 19. ,QononHumenbHbie Memoobi uccneooaaHuR: A) Xone4ucmoapaMMa. MHo)KecmaeHHbte «nnaaa10u.iue»
xonecmepuHoeb1e KBMHU e )l(efll./HOM ny3b1pe. 5) Ynbmpa3eyKoeoe uccneooeaHue )/(enl./Hoao ny3b!pR. 8 npoceeme
BbtRenRemcR nnomHaR 3XocmpyKmypa (KaMeHb) , HWKe onpeoenRemcR aKycmul./eCKaR «OopoJKKa» . BJ PempozpaoHaR
naHKpeamoxonaHzuoapaMMa. Xoneooxonumua3, cmpuKmypa mepMuHanbHOZD omoena o6u.ieao )/(en'IH080 npomoKa.
OmMel./aemc11 3H81./umenbHoe pacwupeHue o6u.ieao )l(enl./Hoao npomoKa, e eao mepMuHanbHOM omoene - asa
oecpeKma HanonHeHuR (KaMHU) . KoHmpacmHoe eeU.{ecmao He nocmynaem e mepMUHanbHbliJ omoen o6U.{eeo
)l(efll./HOeO npomoKa, KOmOpb!U pe3KO Cy)l(eH. /) KOMflblOmepHaR mOMOepacpUR: KOHKpeMeHm 8 oucmanbHOM omoene
xoneooxa. Omel./HbliJ naHKpeamum, nepunaHKpeamum.

47
 Puc. 38. CoHoapaMMa ocmpoao naHKpeamuma: 1- )l{UOKocmHbJU KOMnoHeHm; 2- yeenul/eHHaR 6e3 l/emKux
KOHmypoe n>K.

Puc. 39. 063opHaH peHmaeHoapacjJuR 6pJOWHOu nonocmu: c-M«Oe)l{ypHou nemnu».

48
 V1nmocrpaL1li1li1 K 1 4acrn

Puc. 40. MPT ocmpoao naHKpeamuma (yeenu<ieHHaR aonoeKa )f(ene3bl o6o3Hal./eHa cmpenKaMu).

Puc. 41. flanapocKonul./eCKaR KapmuHa ocmpoao naHKpeamuma: 1- aeMoppaaumul./ecKi.JiJ e&mom; 2-

cmeamoHeKp03bl.

49
 ~~'t,·S~.
~.·. ~i'.';
,- .....,...
' .. . .
~.-·~

:,;.:·";'. . ."<1::.··~
Puc. 46. 063opHaH peHmceH02paMMa 6p10wHoD nonocmu. ToHKOKuwel/Hbte ypoeHu »waKocmu
u lfawu Knou6epa.

; .

.~JJ~.f~=-· .
Puc. 47. 063opHaH peHm2eH02paMMa 6p10wHoD nonocmu. Kuwel/Hbte apKu.

Puc. 48. 063opHaH peHm2eH02paMMa 6p10WHOU nonocmu. CuMnmoM KepKpUH2a

(pacmFmymoD npy»<LJHbt).

50
3TVIX nerenb (cMMnTOM KepKpMHra) (p111c. 48) .
,0,VlacpparMa CTOVIT BblCOKO , ManonO,[\Blll>KHa. npvi
Y31t1 - WV1poK111e nemVI KlilWe4Hl!I Ka (6onee 3,5
CM .) 6e3 nep111cranbT111Klll, co,[lep>Kar 6onbwoe
Konvi4ecrso ra3a - 6onbwe, 4eM >KlllAKOCTlll. Co-
p,ep>K111Moe K"1We4HV1Ka cosepwaer "Ma5lTHlllKO-
o6pa3Hble" ABV1)f(eHV15l .
PMc. 46. 06JopHaff peHTreHorpaMMa
6ptowHoi.1 nonocnt. ToHKOK1t1Wel.fHb1e
ypoBHlll >KlllAKOCTlll 1,11 l.faWlll Knolll6epa.
P111c. 47. 06JopHa.ff peHTreHorpaMMa
6ptowHolll nonocT111. K111wel.fHb1e apK111.
P111c. 48. 06JopHa.ff peHTreHorpaMMa
6ptoWHOH nonocT111. C111MnToM KepKp1t1Hra
(paCT.ffHYTOM npy>KlllHbl).
17El/EHt1E nKH
np111 Bblpa60TKll1 CTp8Ter"1111 fle4eHll15l 6onb-
HOro c nape30M Kll1We4Hll1Ka Heo6X0,[\111MO npe}f(-
p,e scero 4eTKo Bbl5lCHll1Tb, He HBnHeTcH n111 na-
pe3 npo5lsneH111eM KaKoro - n11160 socnamnenb-
Horo 3a6onesaH1115l (HanpviMep, nepV1TOH"1Ta)
Tpe6ytoli.\ero Heomo}f(HOIA onepau,111vi . np1.-1 oT-
cyTcTs1.-1111 nep1.-1cTanbT"1KV1 scne,[ICTBVle nocne-
onepau,1.-10HHOro nape3a Kl!IWe4HVIKa cyli.\ecrsyer
onpep,eneHHaH ne4e6Ha5l TaKT"1Ka. 0Ha 3aKnto-
P-p HaTp"15l xnopvi,[la 10 % - 40 Mn. }
3% nepeKVICb BO,[\Opop,a - 30 Mn. HeOP,HOKpaTHO 4/3 0,5 - 1 48C
lm11u,ep1.-1H - 30 Mn.
np111 OTCYTCTBVIVI 3cpcpeKTa OT KOHcepBaTVIB-
HOlA repanVl"1 K 5 cyrKaM , He06XO,[\lilMO BblCTaB-
n5lTb noKa3aHlll5l K nanaporoM"1VI, raK KaK, ,[la)f(e
nplil OTCYTCTBVIVI opraHVl4eCKOlA nplil4111Hbl K1!1We4-
H"1K HaCTOflbKO pacrnHyr, 4TO caMOCTosnenbHO
MblWLJ,bl Kl!IWe4HVIKa csol/1 TOHYC BOCCTaHOBVITb
y>Ke He Moryr. Bo speMH onepau,111111 Heo6xo,[IVIMO
BBeCTVI B KOpeHb 6pbl>KelAKVI TOHKOlA KlllWKlll 80
Mn . 0,5% pacTBopa HOBOKal!IHa VI YAafllilTb Klil-
w e4HOe cop,ep)f(VIMOe nyreM "1HTY6aLJ,VIVI TOHKOro
111 rnncroro KVIWe4HlllKa (30HA A66orn-M111nnepa) .
il1HTY6aTOpb1 o6blYHO OCTalOTC5l B K"1WeYHlllKe p,o
nonHoro soccraHosneHl!lfl nepV1cranbT111Klil B no-
cneonepau,1.-10HHOM nepVIOAe.
06TYPAL.Jt10HHA.R Kt1WEl/HA.R
HEnPOXO,D,11MOCTb
06mypa~UOHHaR HenpoXOOUMOCmb B03-
H"1KaeT npVI nonHOlA "1f1VI YaCTlllYHOll1 3aKynOpKe
npocseTa KlllWKVI KaK o6pa30BaHll15lM"1 , H8XO,[ls:l-
li.\"1M"1C5l see npocsere - 3HoouHmecmuan&HaR
KH (onyxonb, 1.-1Hopop,Hoe Teno, }f(eflYHbllA 1.-1nvi
K8f10BbllA KaMeHb), TaK VI BHe npocseTa - 3K30-
UHmecmUH8flbH8R KH (c,L1asneH111e onyxonbto ,
cnall1Koll1, sepxHe6pbl}f(ee4HOll1aprepV1ell11.-1 T.,[1.).
51
4aeTC5l , npe}l(,[le ecero, B onopo>KHeH1111t1 }f(eny-
A04HO-KlilwellHOro rpaKTa nyreM Bb1se,L1eH1t1fl co-
,Qep>K111Moro Vl3 }f(eny,[IKa 1.Jepe3 nocT05lHHblll1 Vlfllll
speMeHHbllA 30H,[\.
no,[lroraBnlilB85'1 60flbHOro C napanl!ITlll4e-
CKOlA Klt1Wel.JHOll1 HenpOXO,[\VIMOCTblO, Bbl3B8HHOll1
nep111TOHlllTOM , K onepau,111111 s reYeH111e nepBblX
cyToK eMy cne,QyeT ssecrn 2-4 nVITpa )1<111,[IKocrn.
OT MOMeHTa yny4weHll15l ,[11t1ype3a np1116asn5ltoT
80 mEq Kan111fl s cyrKlil . Cne.Qyer raK}f(e KOMneH-
c111posaTb o6beM u,111pKyn111pytou.iell1 Kpos1.-1 , nepe-
n111sa51 u,enbHYto KpOBb 111 nna3MY 111n111 u,enbHYto
Kposb "1 ,[leKcrpaH.
,D.anee np111MeH5llOT aHTlllXOf1VIH3CTepa3Hble
npenapaTbl, aKTlllBVl3"1PYtoU\Vle napac1t1Mnarn1.Je-
cKyto HepsHyto CVICTeMy - npo3ep1t1H ( 1-2 Mn.
0,05% pacTBopa 3 pa3a s cyTK1.-1) 1.-1n111 yM6peTMA
(1 Mn 0,001 % pacTBopa 1 pa3 s 2-3 AHfl) . ,D,nfl
CT"1Myns:iu,V1111 nep1.-1cranbT"1Klll KlilWel.JHVIKa "1C-
nonb3yerc5l BHYTPMBeHHoe crpyi.1Hoe ssep,e-
H"1e rnneproH1t1YecK111x pacrsopos:
P-p HaTp1.-1s:i xnopV1,[1a 10% - 60 - 80 Mn
P-p rntoK03bl 40% - 40 Mn
P-p KanbU,"15'1 xnop1.-1,[1a 10% - 10 Mn
P-p HosoKa"1Ha 0,5% - 10 Mn
Xopowee crnMyn1-1pytoli.\ee nep1-1craJ1bTl-1Ky
K"1We4H111Ka ,[\ell1cTBVle, "1MetoT MV1Kp0Knlt13Mbl lt1f1"1
KnVl3Mbl no OrHesy:
nATOfEHE3
np1.-1 06TYp8U,"10HHOlil MeXaH1t1YeCKOlil Henpo-
XO,[\VIMOCTVI OCHOBHblM cpaKTopoM , OT KOTOporo
3as111c111r KJJll1HV11.JecKa5l KaprnHa 3a6onesaH"1fl,
HBnHercs:i norep5l BO,[\bl , 6enKa , 3neKTpon1t1TOB. B
Te4eHVle cyToK y 3,Qoposoro YenoseKa B npocseT
}f(eny,[\04HO-K"1Wel.JHOro TpaKTa Bblp,en5leTC5l 8-10
flVITpOB n111u.iesap111TeflbHblX COKOB. B HOpManb-
HblX ycnos111s:ix 6onbwafl 1.-1x 1.Jacrb pea6cop61.-1py-
erc5l. np111 K"1We4HOlA HenpOX0,[\"1MOCTVI np1t1BO-
,ll5ll118s:I nern5l pacrnrnaaeTC5l }1<1-1,llKOCTblO 111 ra-
30M . - np0"1CXO,[llilT ceKBeCTp"1pOB8Hll1e }f(ll1,[IKO-
CTll1 , cpopM111pyercH "TpeTbe npocrpaHcTBo". Co-
,aep}f(ll1Moe Kll1WK"1 Bbl,llenf!eTCfl Hapy~ c paornlll ,
np111 3TOM opraH"13M TepSleT He TOflbKO )1<111,[\KOCTb,
HO VI 6onbWOe KOnVl4eCTBO 6enKa VI 3neKTpon111-
TOB, B oco6eHHOCTVI HaTp1115l VI xnopa. B OTBeT Ha
pa3BVIBatoli.\YIOC5l rnnosoneM111to VI ,L1ern,[1para-
41.-1to s opraHll13Me yc111n1.-1saeTC5l sb1pa60TKa aH-
Tlll,[llilypern1.JecKoro ropMoHa "1 anb,[locrepoHa.
3TO npl!IBO,[\lllT K COKpaU\eHVllO ,lllilype3a, pea6-
cop64111111 HaTp"15l 111 Bbl,[\eneHll1IO Kan111s:i c MOYO!ll 111
psoTHblM"1 MaccaM111. B pe3ynbTaTe pa3a111saeTc5l
rnnoKan1.-1eM"15l 111 cB5l3aHHb1e c Helll HapyweH1115l
TOHyca MblWU,, COKparnrenbHOlA cnoco6HOCTlll
M"10Kap,o.a, K111we1.JHolA nepV1cranbTlllK"1. l1.-1n0Ka-
11111eM1t17l np111BOA1t1T K nepepacnpeAeneH111to Kam1171 :>K) lllHOrAa yposeHb M04e8111Hbl B KPOBll1 no-
Me>KAy KJleTKOlll 111 BHeKJleT04HOll1 )f(l/lAKOCTblO . BblWeH .
MeCTo 1110HoB Ka111115I B KJleTKe 3aH111MatoT 1110Hbl Lil3MeHeHMR, KOTOpble MMelOT MeCTO npM
HaTpll151 111 BOAOPOAa . 4TO np111BOA1t1T K pa3s111rnto 06T)'pa~lrfOHHOM HenpoXOAHMOCTH B 6onee
BHYTPll1KneT04Horo a141t1A03a 111 BHeKJleT04Horo nol.QHeM nepHOAe, T.e. oHa AflHTCR 6onbwe
a11Ka1103a (a11Ka1103 Aepo). nornp51 6enKa , oco- 24 1.1acoe, MO>KHO oxapaKTepM30BaTb cne-
6eHHO anb6YMll1HOB , np111BOA111T K CHll1)f(eHllllO OH- AYIO"-'lllM o6pa3oM :
KOTll14eCKOro AasneHll171 B cocyA111CTOM pycne , 4TO a) o6e3BO)f(111BaH111e opraHll13Ma , YacTo , OA-
BeAeT K BblXOAY )f(ll1AKOCTll1 1113 COCYAOB B TKaHlll . HaKo, He nporpecc111pytoL11ee , a y HeKOTOpblX
3TO npll1BOAll1T K 111X OTeKY, pe3KOMY HapyweHll1IO 6onbHblX Aa:>Ke CKJlOHHOCTb K pacw111peHll1IO BHe-
MeTa60J11113Ma , HapyweHll1IO M111KP04111PKY11514111111 111 KJleT04HOro npocTpaHCTBa ( o6e3BO:>Kll1BaH111e
pa3Bll1Tlllto ClllHAPOMa All1CC111M111H111posaHHoro KJleT04HOll1 MaCCbl) ;
BHYTp111cocyAll1CTOro csepTb1BaH111s:1 (ABC) . 6) noeb1weH111e ypoBH51 reMaT0Kp111Ta ;
np111 Hll13KOli1 HenpOXOA111MOCTV1 pBOTa He 6bl- B) yMeHbWeHllle KOJ11114ecrna 4111PKY11111pyto-
saeT TaKolil HeyKpOTlllMOlll , OHa no51BJ171eTC51 no3- llleli1 :>K111AKOCTll1 ;
)f(e, no4eMy 111 nornp51 )1<111,IJ,KOCTelil HaPY>KY 6yAeT r) CHltl)f(eHl!le YPOBHS! HaTplr171 B nna3Me ;
MeHbwelll. XapaKTep aneKTpo11111THblX pac- A) nosb1weH111e ypoBH71 KaJ111151 B nna3Me ;
cTpolilcTB 6y,D,eT TaKlllM )Ke , KaK 111 np111 BblCOKOlil e) pocT ypoBH51 M04eBll1Hbl B KpOBlll ;
HenpoXOAlllMOCTlll, OAHaKO OHlll pa3Bll1BatoTC71 60- :>K) nepeMeL11eH111e peaK4111111 Kpos111 e Ha-
nee MeAneHHO , a onacHOCTb naAeH111s:1 apTep111- npasneH111111 84111A03a.
anbHoro AasneH1117! e HaYaJlbHOM nep1110Ae He
TaK se11111Ka. noaTOMY np111 HenpoXO,IJ,lllMOCTlll Ta- Kflt1Ht1KA
KOro B111Aa He OTMe4aeTC51 cepbe3HblX pac- Ha4ano 06TYpa41110HHOi.:1 Kll1We4HOi.:1 Henpo-
CTpOlllCTB Kll1CJlOTHO-L11eJ104HOro paBHOBeCll171 B XOAll1MOCTll1 06bl4HO OCTpoe. .QOMll1Hll1PYIOll\111M
nepBOM nep1110.o.e. y 3Tll1X 60JlbHblX MO)f(HO ClllMnTOMOM 51BmleTC51 6onb, H0Cf/UJ,8fl cxeam-
paHbwe HaYaTb eee,D,eH111e conelll Ka1111171 np111 K006pa3Hb/U xapaKmep , 4TO CB513aHO c yc111neH-
BBe,D,eH111111 lllM )f(ltlAKOCTelil , TaK KaK paccTpolilcTBa HOll1 nep111cTa11bT111Koli1 K111weYH111Ka . B MoMeHT
.o.111ype3a s nepsoM nep1110Ae y Hlllx 6011bw111e . B np111cTYna 6onbHble 6ecnoKoli1Hbl , He MOfYT Halil-
nepBOM neplllOAe cne.o.yeT BBeCTlll 1000 MJl. 5% rn nono:>KeH1117! , 06nerYatoL11ero 6011111 . BHe np111-
paCTBOpa rJllOK03bl B BO,D,e , np1116aBJ15151 K 3TOMY cTyna 6011111 o6bl4HO 111cYe3atoT. XapaKTepHblM
40 mg Ka11111s:1 s B111Ae x11op111.o.a . npll13HaKoM 51B1171eTc51 peoma. BHaYane oHa HO-
B paHHeM nepMOAe (Ao 24 1.1acoe) Bb1co- c111T pecpneKTopHbllil xapaKTep , HO no Mepe nepe-
KOM 06-rypa~MOHHOM HenpOXOAMMOCTM lrfMe- nonHeH1117! npOKCll1MaJ1bHblX OT,D,eJlOB :>KenyA04HO-
tOT MeCTO cneAYfO"-'Me lrf3MeHeHMR B opra- K111We4HOro TpaKTa PBOTHble MaCCbl np11106pern-
HM3Me: IOT xapaKTep K111weYHoro co,1J,ep)f(111Moro c Henp111-
a) o6e3BO)f(ll1BaH111e opraH1t13Ma c npeo611a- 5ITHb1M Ko111116a4111nn5lpHblM 3anaxoM ("KanoeaR
,D,aH111eM o6e3BO)f(ll1BaH1117! BHeKJleT04Horo npo- peoma"). 0,D,Hll1M 1113 MeCTHblX npll13HaKOB 06TY-
CTpaHcTsa; pa41t10HHOll1 Kll1We4HOll1 HenpOXOA111MOCTll1 51BJ151eT-
6) pOCT ypoBH71 reMaTOKPlllTa ; C51 B3AYTll1e :>KlllBOTa. ~HOrAa OHO np11106peTaeT
s) yMeHbWeH111e KOJ11114eCTBa 4111PKY11111pyto- HepasHoMepHbli.:1 xapaKTep 3a cYeT 6onee Bbl-
llleli1 nna3Mb1 ; pa)f(eHHoro nepenonHeH11151 cerMeHTa Kll1WKlil Bbl-
r) HopManbHbllil yposeHb HaTp111s:1 s nna3Me; we yposH51 npen5ITCTB111s:i (cuMnmoM BanR).
A) noH111:>KeHHb11i1 yposeHb Ka1111171 B nna3Me ; 06bl4HO onlilCblBas:i 3TOT ClllMnTOM, Bbl,D,efl5llOT
e) TeHAeH411171 K anKa1103y; 4eTblpe MeCTHblX npll13HaKa: 6UOUMYIO acuM-
)f() lllHOrAa noBblWeH111e ypoBH51 M04eBll1Hbl B MempulO >1<ueoma, npoL11ynb1saeMoe onyxone-
KPOBlll. euiJHoe 6one3HeHHoe 06pa3osaHllle , eb1cnyw111-
B paHHeM nepMOAe AO 24 1.1acoe HM3KOH saeMyto aKTll1BHO nepucmanbmUKy, CflblWll1Mb1i.:1
06T)'pa~MOHHOM HenpoXOAlrfMOCTlrf H3MeHe- np111 nepKYCClllltl Bb/COKUU muMnaHum. y xy,D,blX
HHff 6YAYT HecKonbKO APYntMM, a MMeHHo: 6onbHblX VIHOr,lla onpe,L1ens:1eTcs:i BV1,ll1t1MaR nep1i1-
a) 06e3eo:>K111BaH111e opraHll13Ma c npe111My- cTaflbT111Ka Ha nepeAHe'1 6ptoWHOi.:1 CTeHKe (CUM-
L11ecrneHHblM o6e3BQ)f(ll1BaHll1eM BHeKJleT04HOro nmoM UlnaH2e) . np111 COTp51CeHll1111 :>Kll1BOTa, B
npocTpaHCTBa , HO B MeHbWelil CTeneHl!l , 4eM np111 nepenonHeHHOi.:1 )f(lllAKOCTblO 111 ra30M K111We4HOi.:1
BblCOKOlll HenpoXO,IJ,111MOCT111 ; neTf1e onpep,em1eTC5I wyM nnecKa (cuMnmoM
6) nosb1weH111e ypoBH71 reMaTOKp111rn ; CKI1.Rpoea) .
B) yMeHbWeHl!le KOJ11114eCTBa 4111PKY11111pyto- .Qm1 Ha4aJ1bHOi.:1 CTaA111111 06TYpa41110HHOi.:1
llleli1 KpOBlll (nna3Mbl} B MeHbWelil CTeneHll1 , 4eM K111We4HOll1 HenpOXO,IJ,111MOCTll1 xapaKTepHa 0)f(lllB-
:no 111MeeT MeCTO np111 BblCOKOlll HenpoXO,D,lllMO- JleHHa51 neplilCTaJlbTlllKa , KOTOpa51 B ,IJ,8JlbHelilweM
cm ; nocTeneHHO np11106peTaeT naTonor1114ecK111'1 xa-
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Me)l{,IJ,y )f(e.nyAKOM 111 ne4eHblO pacno.naraeTcs:1 npOXOAs:lll\851 B,[\OJ1b 6onbWOili Kpll1B1113Hbl B >Keny-
neLJeHoLJHo->KenyaoYHafl ce.F13Ka (Manb111i ca.nb- A04H0-060A04HOIA CB513Ke. 0Ha C08A111H518TC51 c
H111K). Me)l{,IJ,y AHOM >KenyAKa 111 ce.ne3eHKOLil Haxo- aHanor1114HO~ seTBblO , 111,0,yUJ,e~ cnpasa 1113 nel.le-
,[\111TC51 >KenyOOl./HO-cene3eHOl./H8fl C8f/3Ka. c no- H04HO~ apTep111111 , npaBolli >KenyA04HO-
nepeYHOili 060,.Q04HOili KlllWKOili >Keny,.qoK coeAlll- C8J1bHll1KOBOlli aprnp111eili.
HeH np111 nOMOUJ,111 >Kenyaol./HO-o6oao4HOU CBR3KU. Bcs:1 BeH03Has:i KpOBb 1113 >KenyAKa on-eKaer
Me)l{,[ly 38,D,Helli nosepXHOCTblO Te.na , K8PA111111, B c111creMy sopornolli BeHbl. BeHbl pacnonaraioT-
,.QHa )f{e.ny.1:1Ka 111 sepXH111M KpaeM no,a)l{e.ny.1:10YHOH cs:1 P51AOM c o,QHOll1MeHHblM111 apTep111s:1M111. B 06-
>Kene3bl pacno.naraeTcs:1 >1<enyaol/Ho-noa>1<eny- .nacrn K8PAll1111 BeHbl >Ke.ny,QK8 8H8CTOM03111py10T c
ool/HaR CBf/3Ka. Hll1}!{HlllMll1 BeHaMll1 nll1U,\eB0,[\8. np111 nopT8JlbHOl/i
AHTpanbHas:i cn1113111cras:i o6onoYKa pacnpo- nmepTeH3"11A 3TIA aHaCTOM03bl 48CTO 6bl88H)T
cTpaHs:1eTcs:1 no Manoill Kp11101113He s cpe,QHeM Ha 111CTOl.IHll1KOM KPOBOTe4eHll151 .

60

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yoaneH).
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TOpble o6pa3YIOT BHe)KeI1YA04Hble HepBbl Ill lllH-
TpaMypa.nbHble cnneTeH111s:i. C111Mnarn4ecK111e
HepBbl OTXOA51T K )l(eTIYAKY OT conHe4HOro cn.ne-
TeHlll5l Ill conposo~atOT COCYAbl, OTXOA5lll.lllle OT
4peBHOC1 apTepllllll. napaClllMnaTlll4eCK85l lllHHep-
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B 84 % cny4aes 611y)l{,Qa10ll.l1t1e Hepeb1
pacno.narat0TC5l B BlllAe 4eTKO pacnOJlO)KeHHblX
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Hero nepexo..QlllT Ha npasyt0 cropoHy, noaroMy
Hlll)Ke ,.QlllacpparMbl (a6AOMlllHanbHblill OT,.Qell)
pa3I111148IOT nepe,D.HlllCi Ill 38,D.HlllCi CTBOilbl. OT .ne-
soro (nepeAHero) 6ny>K,l:\a10ll.lero Hepsa cpa3y
)Ke no,D, .a111acpparMoi11 OTXOAlllT neYeH04Ha51
seTBb, Koropas:i 111.aer s sepxHeM or,D.e.ne Ma.noro
ca.nbHlllKa K sopoTaM neYeH111, rAe oHa Aemnc51
Ha BeT04Klll , KOTOpble lllAYT K neYeHlll , )KeJlYAKY Ill
ABeHaA4arnnepcrHotl1 KlllWKe . '-law,e lllMeeTcs:i
OAHa ne4eH04Has:i BeTBb, HO np111 paCCblnHOM
rnne crpoeH111s:i .nesoro 6.ny~at0Ll.lero Hepsa
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soro (nepeAHero) 6.n~at01..L.1ero Hepsa OTXOAlllT
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yro.nbHlllKe, orpaH111YeHHOM npaeoC1 HO}f{KOC1 Allla-
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soill )KeilYAOYHOill apTep111eill CHlll3y. Or Hero OT-
XOAlllT 4peBHa5l BeTBb, KOTOpa51 lllAeT K COI1He4-
HOMY cnneTeHllllO no nesot/1 )l{enyAOYHot/1 apTe-
pi.rn 11111111 He60I1bWOM pacCTOs:IHllllll OT Hee.
V1HTpaMypanbHble cnneTeH111s:i :>1<enyAKa
npe,D.CTaBJleHbl ayap6axOBCKlllM Me)f(MblWellHblM
M Mei1cHepoBCKlllM nOACJlL13111CTblM cnnereHlll5lM.
\ ' N}U ff;.~~\
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1
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Ayap6axoscKoe cnnereH111e 111rpaer sa)KHYIO ponb
B MOTOpHoCi A8s:ITeilbHOCTlll }f{€I1YAK8, 0 '-!eM ro-
BOpl.ff ysen111YeH111e lllllCna HepBHblX aneMeHTOB
cn.nereH111s:i no HanpasneHllllO or Kap.a111111 K np111-
spaTH111Ky. MelllcHepoecKoe cnneTeH111e yYaCTsy-
eT 8 peryns:IL\111111 CeKperopHOlll .aes:iTe.nbHOCTlll )Ke-
ny,D.Ka.
fl111M<j)aTlll'·tecKaH ClllCTeMa )KeI1YAK8 Ha-
4111Haercs:t n111M¢ar1114ecK111M111 Kan111nns:ipaM111 c.n111-
3111croC1 )Keny,[\Ka , nepeXOAflll.llllMlll s p51A cnnere-
HlllCi : nO,[\CI11113111CTOe, lllHTpaMypa.nbH08 Ill cepo3-
HO-nOACepo3HOe.
Sappey (1874), Guneo b Delamare (1900),
Rouvier (1932) , A.B . Me.nbHlllKOB s 3as111c111Mocrn
OT HanpasneHVl51 TOKa n111Mcpb1 pa3Aen111n111 no-
sepXHOCTb }f{eilYAKa Ha Tepp111Top111111 , CBs:l3aHHble
c n111Mcpoy3naM111 , pacnonara10ll.lll1MVIC5l BAOilb
n111ral01..L.1VIX )Keny.QOK COCYAOB (p111c. 2).
YcrnHosneHo , llTO }f{eny.QOYHas:i ceKpel\Vls:I
ocy1..L.1eCTBn5leTc5l B TPlll cpa3bl cno>KHO-
pecjJneKmopHyJO, HepBHO-XUMU'-leCKYJO Ill KUWe'-1-
HYIO. B nepsot/1 , 111n111 cnmKHo-pecpneKTopHot/1,
cpa3e )Keny,[\oYHaH ceKpe411151 crnMyn111pyeTc5l
yc.noBHblMVI (BlllA , 3anax n1111..L.1111) 111 6e3ycnoBHb1M111
()KeBaH111e, npOABlll)KeHllle nlllll.\€BOro KOMKa) pa3-
,D,pa:>KlllT€Ils:IMlll. CrnMy.n111py10ll.\VI€ BI11115!HlllS'I Ha
)KenyAoK nepeAalOTC51 Yepe3 6ny~at0Ll.l111e Hep-
Bbl , KOTOpble ,[\e~CTBYIOT Henocpe,[\CTBeHHO Ha
maBHble 111 o6KJ1aAOYHble KJ1eTKll1. B pe3ynbTaTe
Bbl,[\en51eTC51 COK c 6onbWlllM COAep)K8HllleM nen-
CVIHa Ill MeHbWVIM KOilVIYeCTBOM KlllCJ10Tbl. Top-
M03Hble lllMnynbCbl B nepsyt0 cpa3y )Ke.ny,D.OYHOCi
ceKpe4111111 TaK}f{e nepe,L:!alOTC51 no 6.ny~alOLl.llllM
HepsaM.
nocne noc-rynneH1115! nlllli.\111 B :>KeflYAOK npo-
s:is.ns:1eTcs:i BTopari , 111n111 HepBHO-XlllMVIYeCKas:i, cpa-
3a )1{€I1YA04HOC1 ceKpel_4111111 , s MexaHVl3Me AeCicT-
61
Biiis:! KOTOpoVI maBHoe MeCTO 38HlllMaeT ropMOH
racTplllH . B HacTOs:ilJ.lee speMs:i Hana>KeH c111Hre3
racTp111Ha Gregory . racTplllH Gregory 111 Tracy ,
Ha1t16onee 1t13y4eHHbl'°1 111 nony41t1Bw111iil pacnpo-
cTpaHeH1t1e, COCTOlt1T lt13 17 aMlt1HOKlllCIIOT , lllMeeT
MOJleKYns:!pHbliil Bee 2114. ¢11131110IlOr1114eCKYIO
Puc. 2. CxeMa aeneHLJR >KenyaKa Ha nuMcpamu4ecKue 30Hbt no Pysbepy-CanneJO. I - 3oHa nesoiJ >Kenyao4HOiJ
apmepuu; ll-cene3eHo4HoiJ apmepuu; Ill- ne4eH04HoiJ apmepuu. J1uMcjJoy3nb1: 1->Kenydo4HO-canbHUKOBbJe; 2-
cy6nunopu4ecKue, 3- nel./eH04Hbte; 4- neso>Kenydo4HbJe; 5- napaKapouanbHb1e; 6- cene3eH04HbJe.
nonaraKJT , 4TO MecroM 06pa3osaH111s:i racr-
p111Ha S'IBIISlKJTCSl HepBHble KJleTKlll CJ11113111CTOil! aH-
TpyMa. Bb1AeneH111e racTp111Ha css:iJaHo c cpyHK-
L1111eH MeiilcHeposcKoro cn11eTeH111s:i . Ferguson
(1969) on111can ABa BlllAa KileTOK B CI11113111CTOH
aHrpyMa, s KOTOpoiil 06pa3yercs:i 111 Bb1Ae11s:ieTc5!
racTplllH: 4YBCTBlllTeJlbHble , HaXOASllJ.lllleCSl B no-
sepXHOCTHblX >Kene3aX, Ill 3HAOKp111HHble, pacno-
Jlo:>KeHHble rny6)1{e. nepBble , no ero MHeHl'110,
nepeAalOT lllHQJOPM8L\llllO c nosepXHOCn1 CJ11113111-
CTOVl (pH , MeXaHlll4eCKOe pa3Apa>KeH111e) , BTOpble
Bb1pa6aTb1Ba10T 111 Bb1p,ens:i10T racrp111H. B cp11131110-
nor1114ecK111x p,03ax racTp111H oKa3blBaeT c111nbHoe
Cn1Myn111py10U1ee AeHCTBl/le Ha Bb1pa60Tt<y BHYT-
peHHero cpaKTopa , ceKpel\llllO cons:iHoiil KlllCilOTbl ,
cpepMeHTOB nOA)l(enyAO'-!Hoiil )l(ene3bl , cna6oe
so3p,elltcrn111e Ha Bb1pa60Tt<y nenc111Ha , o6beM 111
6111Kap60HaTHYIO LJ.1eJ104HOCTb COKa nOA>Keny-
A04HOH >Kene3bl 111 ceKpeL111110 )f{e114111 . OH yc11111111-
saeT nep111cTailbTlllKY >Keny,QKa Ill TOHKOro KlllWe4-
HlllKa , a TaK)f{e CHlll>KaeT apTep111a11bHoe ,Qasne-
H111e.
cPL1311\0J10flllSl TpeTbelll, KlllWe4HOVI , cpa3bl
>KellYAO'-IHOilt ceKpel.1111111 1113Y4eHa He,D,OCT8T04HO.
0,QHlll aBTOpbl C4111T8IOT, 4TO B sepXHlllX OT,Qenax
TOHKOro KlllWe4HlllKa o6pa3yeTC51 ropMOH 3HTepo-
racTplllH, KOTOpblilt OK83blBaeT CT111Myn111py10li,\ee
,Qeiilcrn111e Ha >Keny,Q04HYIO ceKpel\llllO ,Qpyrne
no11ara10T, 4TO K111We4Ha51 cpa3a 06ycnos11eHa
rncTaMlllHOM , 06pa3y1eLJ.1111Mcs:i np111 pacna,Qe 6en-
Ka Ill BC8CblB8IOLJ.1111MCs:! 1113 TOHKOro KlllWe4HlllKa.
ToHKMilt KlllWe4HlllK oKa3blBaeT He TOilbKO
CT111Myn111py10U1llliil , HO Ill TOpM03HOH 3cpc:f:JeKT Ha
>KenyAo4HYKJ ceKpeL11t110 . T opM03Hollt 3cpcpeKT
62
8KTlllBHOCTb ero CBs:!3blBalOT c aKTlllBHOCTblO 4e-
Tblpex nocne,QHlllX 8Ml/IHOKlllCJ10T . 5b1Il npe,QJlO-
>KeH npenapaT, COAep>K8lJ.llllrli yKa3aHHYIO 8KTlllB-
HYIO rpynny , - neHTaracTplllH .
TOHKOro KlllWe4HlllKa npos:ism1erc.f! np111 sseAeH111111
COJlSlHOVI KlllCJlOTbl B ,D,BeH8AL\aT111nepcrnyto KlllW-
KY Ill H84anbHble OT,Qeilbl TOHKOro KlllWe4HlllKa.
T opM03HblM 3cpc:f:JeKTOM o6na,o,aKJT TaK)f{e ceKpe-
TlllH , XOilel.llllCTOKlllHlllH. BBeAeHllle COJlSlHOiil Klll-
CJlOTbl B ,D,BeH8AL\8TlllnepcrHyto KlllWKY 3,D,OPOBblM
Ill 60JlbHblM c Sl3BOiil ,QBeHa,QL\8Tlllnepcrnolll KlllW-
Klll Bbl3blBaeT TOpMO>KeHllle )f(eny,Q04HOiil CeKpe-
l.\111111 , Bb13BaHHOe racTplllHOM . XapaKTepHO, 4To
TopMO)l{eH111e )f{eny,Q04HOiil ceKpel\111111 npos:isns:ieT-
cs:i TOilbKO np111 coxpaHeH111111 sarycHollt lllHHepsa-
L\111111 TOHKOro KlllWe4HlllKa . .[laycrnpoHHSlSl CTBOJlO-
Bas:i saroTOMIMI (oco6eHHo nepece4eH111e 38,QHe-
ro 6.ny~a10LJ.1ero Hepea) Bbl3breaer 3Ha41>1Te11b-
Hoe ysen1114eH111e )l{e11y,Q04HOH ceKpel\111111.
B pe3ynbTaTe )l{enyAO'-IHOiil ceKpe41.11.1 06pa-
3yeTcs:i oKono n1-1Tpa }f(eny,Qo4Horo coKa, co,qep-
>KaU1ero COJ151HYto KL>lCilOTY . cpepMeHTbl (nenc1>1H ,
Karenc1>1H) 111 6eflKOBble BeLJ.1eCTB8 . no,Q BJllllS'IHL-1-
eM KlllCJlOTbl Ill cpepMeHTOB npo1>1CXO,QlllT pacU1en-
JleH1>1e 6enKoe n1>1LJ.1111 ,o,o anb6yMo3 111 nenTOHOB. B
6enKOBblX BeUleCTBax >Keny,o,o'-IHOro COKa co-
Aep)l{lllTCSl MyKonpore~H (sHyrpeHHlllill cpaKTop) ,
KOTOpblH Bbl,QemleTCSl p,o6aB04HblML>1 KJleTKaMlll,
pacnono)l{eHHblMlll s weiilKe rnaeHbrx )l(ene3 }f(e-
11YAKa, 111 MyKonpoTeo3, 3aLJ.1111LL1atoU1111ili cn1>131>1-
CTY10 >Keny,QKa OT so3,qeiilcTs111s:i >Keny,Q04Horo
CO Ka.
06pa6oraHHas:i B >Keny,QKe n1>1LJ.1a nopl.llllSlMlll
nOCTYnaeT B ABeH8AU,8TlttnepcTHYIO KlllWt<y . nop-
L\lllOHHOe nOCTYnileH111e nl>llJ.1111 38BL>1CL>1T OT cpyHK-
l..1111111 n111nopoaHrpanbHoro or,o,ena - «>Keny,o,oYHO-
ro Hacoca». YAaneH111e :noiil 4acT1>1 )l{eny.o.Ka so
speMS'I pe3eKL\llllll cnoco6crsyeT pa3BlllTll1IO ,o,eM-
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Horne xvipyprn CTpeM51TC5l XOT51 6bl '-laCTL14HO
coxpaHL1Tb cj:>yHKU,L1IO 3TOro OT,D,ena )/(8JlY,D,Ka.
K/7ACC/11<P/11KAU,/11f1
no Johnson pa3JlL1YalOT TpL1 TL1na s:!3Bbl )!(e-
ny,D,Ka: I - 513Bbl Manoi:-1 KpL1B1113Hbl ; II - KOM6111Hlll-
poBaHHble s:!3Bbt )/(eny,qKa L1 ,o,seHa,!J,u,anmepcT-
HOVi KL1UJKVI; Ill - npen1.1nop1.1'-lecK1.1e 513BbL nep-
sb1i-1 rnn Ha6nioµ,aeTcs:i npL16mil3L1TenbHO y 60%
6onbHblX, II - y 20% , Ill - TaK)!(e y 20% (pL1c. 3).
P111c. 3. PeHTreHorpaMMa :menyAKa 111
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s:t3Ba ManoM KpMBH3Hbl (c-M «HMWr.1»). T111n I
no Johnson
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KJ18CC111cpL1KaU,llllt1 .~6, npe,D,JlO)!(eHHOLli n .R rp1.1-
ropb8BblM (1986), CYLLleCTBeHHYIO po11b 111rpaeT
nocne,o,H1.1Lli pa3,[len - Knacc...ict>MKa4HJ1 ocno)f{-
HeHL1M:
I nepcpopau,1.1s:i
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IV cTa,ll,RR. 2. IleHeTpaQHH IWH KaJI-
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BMewarenbcTsa HY)!(HO Bbl,!J,ens:irb :
Cpo~Hoe BMewarenbCTBo - s re4eH111e
6.mnrailiw111x 4acos nocne nocrynneHL1s:i (nepcpo-
pau,11151);
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an111rHL138U,lt1s:! peU,L1AlllB KpOBOTe4eHL151, neHeT-
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nnaHoaoe BMewaTenbCTBO - ocnm1<HeH111e
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METOAbl 11£1./EH/ltfl f13BEHHOM 60/1E3H/11
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eHllle o6beMa pe3eu111pyeMot/1 4acrn opraHa, s
3aBl.1CVIMOCTV1 OT ycraHosneHHblX pe3ynbTaTOB
ccn e,!J,osaHlll51 L1 noKa3aH111Lli.
n o,!J, noHs:!TltleM «nOJlOBlllH8» no,!J,pa3yMeBa-
e cs:i yposeHb nepece4eH111s:i Me}f(,qy op111eHrnpa-
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1.1M aH111e 4eTblpe OCHOBHblX cpaKTopa:
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63
II nepeXO,!J, s:!3Bbl B paK (M8JlL1rHL13aU,L1s:!)
Ill. ,O,ecpopMa41.1s:i )l{eny,!J,Ka 111 creH03bl 12-
nepcTHoili Kll1WKlll ,!J,O CTeneHl/I HapyweHlll51 3Ba-
Ky8U,111111
IV. racTpop,yo,QeHaJlbHble 513BeHHble Kpo-
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no,ane)!(aLL1111tll opraH)
VI. ~hsa c ¢opML1posaH111eM ,o,111sepT111Kyna
Kon1.1yecTso nnaHOBbtX onepau,1.1!11 np111 513-
seHHoi-1 6one3HL1 B HaCT05ILL1ee speMs:i pe3KO co-
Kparnnocb. 3rn css:i3aHHo c pa3pa6oTKOLli cxeM
cj:>apMaK0Tepan111111 Ha OCHOBe cospeMeHHblX
npe,o,cTasneH111i-1 06 arnonorn111 1.1 naToreHe3e 513-
seHHOLli 60J1e3Hlt1. 8 TO )/(8 speMs:i 3HaYlt1T8JlbHO
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HeH HbtX cpopMaX, YTO CBlll,!J,eTeJlbCTByeT 0 Heon-
paB,!J,8HHOM OTK83e OT onepaTl/IBHOro J1848Hlll51 B
noKa3aHHblX cnyYas:ix.
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cneAY10LL1L1e rpynnbt (ra6m11_\a 1).
Ta6nui1a 1
0TH OCI-rfeJTuHbJe
1. OrcyTcTBHe TeH.lleHUHM K 3aJKHBJieHMJO
H3BhI npH rretJ:emm 6onee 6 He,ri:enr:..
2. Peue.UMBJ>I H3Bhl :lKeJ1Y,ll,Ka 6orree ABYX
pa3 B I'O.ll B TetJ:emre l ro,ri:a, H3BhI J2-
neocTHOH KHillKH - B retJ:eHHe 3 JieT.
2) npe,!J,pacnono)l(eHHOCTb 6onbHOro K pa3-
BlllTll1KJ nocrracTpope3eKU,lllOHHbtX paccTpoiilcTB;
3) 06LL1ee cocrn.s:1H111e 6onbHoro (so3pacT,
non , Macca rena , nmonor1114ecK111e oco6eHHocr111
Bbtcweili HepsHotll ,o,e51TenbHocrn, Han11141t1e co-
nyrcTBYIOLl..IL1X 3a6onesaH111Lli);
4) aHaT0Mo-Mopcj:>onorn4ecK111e oco6eHHO-
crn s:i3seHHoro npou,ecca.
3anoroM ycnexa x111pyprn4ecKoro ne4eH1115I
s:i3seHHotl1 6one3Hlll >KellYAKa 111 ABeHaAu.aT111nep-
crnoill KlllWKlll s:ism1eTcs:i P,L1cpcpepeHu.111posaHHb1t/1
Bb16op onepaTvtBHoro sMewarenbCTBa no cTporo
o6ocHOBaHHblM noKa3aH11151M np111 ycnos1.1111 npa-
s111nbHoro TeXHL14ecKoro BbmonHeHl/!51 onepau,111111 .
T aKotll nop,xo,a no3som:1eT ycrpaH111Tb He6naro-
np1115ITHb1e nocne,!J,CTBlll51 Toro 11111111 VIHoro MeTo,!J,a
ne4eHlll51 111 nony41t1Tb ny4w111e orp,aneHHble
cPYHKL!lllOHaJlbHble pe3ynbTaTbl.
Bee MeTOAbl onepaTlllBHoro ne4eHlll51 513-
seHHOl.1 6one3Hlll >Keny.QKa MO)f{HO pa3,!J,em1Tb Ha:
I - pa,qMKanbHb1e BMewarenbcTBa - pe-
2
3eKL\L151 )l{eny,!J,Ka B o6beMe /3, %, cy6roranbHoi:'.l;
II - 1.14a,qR1.14He BMewaTenbcTsa - pe3eKu,111s:i
)!(enyp,Ka B o6beMe %, aHTPYM-pe3eKu,1.1111, n111no-
coxpaH>110LL1L1e pe3eKU,L1111 ;
Ill - opraHocoxpaHR1-0IJ.4Me sMewarenbcT-
sa - saroTOMllllll (crsonosa51 , ceneKT1t1BHas:i, ce-
neKTlllBHas:i npOKClt1ManbHas:i).
 r

Puc. 4. CxeMa onpeoeneHufl pa3Mepos yaanReMotJ t/acmu >1<eny0Ka no AA. WanuMosy

06'.beM pe3er<u:i111 OpaeHmp Ha Marroif KpRBH3He OptteHrnp Ha 6oJibllIOH KJJHBH3He

A 112 4 CM. OT IHimeBO,JJ,a Ilo cpem-1eif Jimnnr

E 2/3 2-3 CM. OT ImmeBo.na BJieBo OT cpe.n:Heti JIHHHH Ha 6-8 CM nmr
MeCTO opraHHOfO aHaCTOM03HpoBamu1 Jie-
BOH H npasoi1 :>Ke.rry,n:ol!Ho-caJibHHKOBbIX
aQTe2HH
B 3/4 1-1 ,5 CM. OT IIHIUeBo,JJ,a Y mDKHero nomoca cene3eHKM
r cy6TOTaJil>Ha51 0,5 cM. OT mi:meBo.ua rpam1ua 1/3-]/4 HH:>KHero cerMeHTa
cene3eHirn

A E
Puc. 5. CxeMa eoccmaHoeneHUfl >Kenyoo'IHO-Kuwet/HOtJ Henpepb1eHocmu npu pe3eKLjUflX >1<eny0Ka. A- cnoco6
Teooopa 5u.nbpoma I. 5- cnoco6 Teooopa 5u.nbpoma II.

¢1r13111onornL1HblM cL1111TaeTcf'.I aacmpooyooe-

PaouKa11bHb1e BMewame11bcmaa HoaHacmoMo3 (I cnoco6 6111nbporn) - eynbrn
Cy~ecTsyeT p,sa cnoco6a peJeKL.1111111 >t<e- >Keny,QKa aHaCTOM031!1pyeTCS'l c 12 nepCTHOVr
nyp,Ka, npep,nonarato~111x pa3m14Hoe aHaCTOM0- KlllWKO~ (TepMltlHO-TepMlllHanbHbl~ 111n111 TepMlllHO-
3111poaaH111e >KenyAKa c KfllWe4HblM TpaKTOM. narepanbHblVr aHaCTOM03). 8 3TOM cny4ae soc-

64
cTaHasn1-1saeTcsi ecTeCTBeHHbtCl nacca)f( coAep-
)f(f/IMoro }l{eny,a1<a no 1<11we1.1HfllKY (Plilc.5 A).
II cnoco6 5LilponbTa (5-11) npeAnonaraeT
aHaCTOM03"1pOB8H"1e J<YilbTLil >KenyAKa c Ha4anb-
HblM OT,aenoM rn1.1.1eC1 KLllWKlll («Ha KOpOTKOCl neT-
ne» - MOAlil¢111KaL1111Sl rocpMeiilcTepa - <P111HcTepe-
pa; «Ha .i:1n111HHotlt neme» - no 5anb¢ypy; rnp-
M111Ho-rnpM111HanbHbtC1 aHaCTOM03 no Py). B 3TOM
cnyLJae, co,Qep)l{lilMoe }l{eny,QKa 3B8J<YLilpyeTcsi B
OTBOASlll.ILillll oT,aen KLllWKlll , a 6orarne n1111.1.1esapLi1-
TenbHbtM111 COK3Mfll , ¢epMeHTaMlll co.n.ep)l{111MOe
12 nepcTHoii1 KlllWKf/I 3B3J<Y111pyeTCSl B OTBOASlll.IYIO
KlllWKY «B,QOroHKY», o6ecne41/1B8Sl KLllW84HOe n111-
1.1.1esapeH11e (p11c. 55).
ll.{aaRw,ue aMewameflbcmaa
Knacc1114ecKasi pe3eKL\lllSl }!{eny,D,Ka BbtnonHs:t-
eTcs:t np111 513BaX )f(enyAKa, T.K. OHf/I CKJlOHHbl K Ma-
n1-1rHfll38L\llllll , a TaK}!{e JJ.€KOMneHC111pOB8HHOM cTe-
H03e BblXO,D,HOro OT,D,ena }!{eny,llKa, KOr,lla Li!MeeTC51
Bbtpa)f(eHHOe HapyweH111e cPYHKL\111111 aHTpanbHOCl
4aCTlll c noTepeC1 COKpaT111TenbHOii1 cnoco6HOCTlll
)l{eny,aKa. XapaKTep onepal\111111 so MHoroM onpe-
p,ensieTcsi IlOK8Ill/l3al\111€Cl Sl3Bbl. np111 ee pacnono-
}1{€Hlt?f/I 8 ,l:llt?CTailbHOlA nonOBlllHe }l{eny,aKa npOLi13-
BO,D.SlT ALllCTanbHYIO pe3eKL\llllO OT 50% )f{€IlYAKa,
np111 Me,Q111aracrpanbHbtX Sl3Bax - pe3e1<4111si }i{e-
nyp,Ka c coxpaHeH111eM np111spaTH111Ka (p111c. 6) .
Puc. 6. nunopocoxpaHf!JOll.!851 pe3eKl.4lJH >KenyoKa.
a- nuHUR aHacmoMo3a; 6- npuepamHuK.
Op2aHocoxpaHR10UJ,ue BMewameflbcmaa
Pe3eKL\lllSl )l{eny,QKa He MO)l(eT nonHOCTblO
y.n.osneraops:tTb sceM Tpe6osaHLi!s:tM, npe.Qb5IB-
m1eMbtM K MeTo,QaM onepan1BHoro ne4eHlllsi
.R3BeHHOi.:f 6one3Hlt1 }l{enyAKa 1t1 ABeHaA4arnnep-
CTHOll1 Kl.1WKLll, a l.1MeHHO: HaAe>KHO ycTpaH"1Tb
K111cnoTHo-nenrn1.1ecK111ii1 Q:>aKTop, nocTpe3eK4111-
0HHble ocnO)f{HeHlllSl (AeMn111Hr-cLi1HAPOM 1-1 APY-
rne) , yMeHbW"1Tb neranbHOCTb. V13y1.1eH111e ¢111 -
3111onor111£1 >1<eny,a1<a , 3r111onor111111 Iii naroreHe3a
Sl3BeHHoilt 6one3HLll noKa3ano, l.JTO OAHOlll 1,.13
65
np1114111H B03HlilKHOBeHl.1Sl nenTlil4€CKll1X Sl3B SlBnSl-
eTC.fl HeycrpaHeHHb1w aarycHblW MexaHlil3M pe-
rymu-1111111 }!{eny,o,01.1Horll ceKpel\111111 . B CBSl31i1 c
3TlllM, Hapsi,Qy c pe3eKL\LileC1 )f{eny,o,Ka 8 H8CTOfl-
1.1.1ee speMs:t B ne1..1eH111111 Sl3BeHHoC1 6one3Hlll w111-
p0Ko 111cnonb3YIOT onepal\111111 Ha 6nyw:Aa101.1.1111x
Hepsax - earoToMi.-u.1.
CyTb MeTo,o,a 3aKnl04aeTC51 B napac1.1Mna-
T1114ceKoii1 ,[leHepBal\111"1 Tena 111 AHa )l{eny,[!Ka, T.e.
K111cn0Tonpo,o,yl\111py10ll.\el7t 30Hbl , npLil coxpaHeH111111
lilHHepBal\111111 aHTpanbHOro OT,D,ena. 3TlllM ,D.OCTlll-
raeTCfl a.QeKBaTHoe CHlll)l{eH111e :>t<eny,D,o4Harll ceK-
pel..\Lillll, a coxpaHeH1.1e cpyHKL\111111 np111spaTHl.1Ka 111
nop1...11110HHa5I 3Ba1<Yal.(111.R 1113 }l{eny,aKa 111rpatoT
Ba)f{HylO ponb B npocpLi1naKT111Ke ,aeMnLi1Hr-
c111H,o,poMa 111 ,o,111ape1,1.
B KmtHMYecKolil npaKTMKe e HaCTOSHl.\ee
epeMff pacnpocTpaHeHbl cneAytO~Me BMAbl
earoTOMMM B KOM6MH3~MM c onepaTMBHblMM
BMewaTeflbCTB3MM Ha >kenyAke:
a) ABYCTOpOHHSlSl CTBOilOBaSl (TOT8flbH8fl)
saroToM111fl ; 6) gsycTOpOHHSlSl ceneKTL1BHafl )f{e-
ny,£104Hafl sarornM1.-rn; e} npoKClilManbHasi ceneK-
TlllBHas:i )f{enyA04H8fl saroTOMlllSl .
CTBOflOBaff (TOT3flbH3ff earoTOMl.Ut) (Ex-
ner, Dragstedt). nepece4eHllle CTBOnos 6rty}l{-
,D.810ll.1111X Hepsos, "1AY1.1.1"1X PHAOM c n1111.1.1eBOAOM K
>Keny.n.KY 111 gpyrnM opraHoM 6p10wH011! nonocrn,
TeXHllll.JeCKlil npOll.\e BCero ocy1.1.1eCTBlllMO 1113
4pe36plOWlllHHOro ,qocryna. 3TO BMewaTenbCTBO
HOClllT H83B8H"1e nOA,D,llla¢parManbHOVt CTBono-
BOCl saroTOMllllll. HaA.Q111a¢parMailbHasi saroTo-
MlllSl 1,13 4pe3nnespanbHOro p,ocryna (Dragstedt)
cetlt4ac no4Tlll He np111MeH5leTc5'l 111 111cnonb3yercsi
s pe,q1<111x cny4a.flx nosrnpHblX onepal...!MW no no-
BOAY peL1111,1J,111sa nem1-14ec1<0C1 Sl3Bbl. .QeTartbHO
pa3pa60TaHHa.fl aHaTOMlllSl 6rty>K,D.al0ll.\111X HepBOB
p,111a¢parMbl cny)f{lilT Knl040M K 3TOC1 onepal\111111 .
noHSlTHO , 4TO nepece4eH!-1e flesoro (nepe,D,Hero)
cTsona Hepsa o6ecne4111saer ,aeHepsaL11t110 ne-
peAHlllX OT,D,enos )l(eny,o,Ka Ill O,D,HOBpeMeHHO
np111BO,Q"1T K ,lleHepB8L\"11i1 ne4eHl/I Ill }l{en4eBbJBO-
ASlll.llllX nyTetlt. nepece4eHlile npasoro (3aAHero)
crsona nonHOCTblO 3asepwaeT ,o,eHepsal\llllO
)f{eny,o,Ka Lil Hsm1eTcfl no cyll.\eCTBY saranbHOC1
,o,eHepsaL1111eii1 no,a}!{eny,D,01.1Hoi/1 )l(eJle3bl Lil KLil-
weYHlr!Ka (p1r1c. 7).
PMC. 7. CTBOflOBa.ff BaroTOMMff. 1-ne-
BblM 6ny>K.Qat0114MM Heps; 2- npaBblM 6ny>K-
Aat0114111ill Heps.
0,o,HaKo nepBbtC1 >Ke onblT 111cnonb30BaHL1Sl
CTBOJ10BOC1 saroTOMllllll ,D,afl OTpllll\8TenbHble pe-
3ynbTaTb/. y onep111poBaHHb/X B03Hlt?Kam1 aTOHll!f!
}!{eny,o,Ka c HapyweHl-ls:tMl.1 3BaJ<Ya41-1Li1, noHoc.
B CBS'l31.1 c 4eM 6btno npe,ano>KeHO ee C04eTaTb c
p,peHlilpy101.1.1eC1 onepaL11;1et7t (raCTp03HTepo-, ra-
cTpo,o,yo,aeHocTOM111erll no }f{a6yfleio , n111nopo-
nnacrnKolil no /J,>Ka.Q/J,y, rell!HeKe-M111J<Yn1114y,
<DlllHHelO Lil T.,D, .) (p111c. 8) .
 PHC. 8. .QpeHHPYIOW.He onepa~HH.
A - nH11opon11acTHKa no realiHeKe -MHKY-
IlHlfy; 5 - nH11opon11acTHKa no <l>HHHet0; B -
racTpOAYOAeHOaHaCTOM03 no >Ka6y11et0;
r - racTp03HTepoaHaCTOM03.
CE/7EKTMBHAfl >KE/7Y,ll,0'-IHAf/
BAfOTOM/11f/
,D.n51 ycTpaHeH111S'I He6naronpLr151THblX no-
cne,QCTB111!:1 CTBOI10BOL1 saroTOMll1111, CBS138HHblX c
AeHepsa4Lr1e~ BHyTpeHHll1X opraHOB, 6bina npe,Q-
no>KeHa ceneKTll1BHa51 )f{eny,Qo'-IHaS'I earoTOMll151.
CMblCn 3Toro B111Aa BMewaTenbCTBa cocTo-
IAT a nepeceYeHHIA scex )j{eny,lloYHblX seTBelA
nepe,QHero 111 3a,QHero cTsonos 6.ny>K.Qatoll\111X
HepBOB np111 HenpeMeHHOM coxpaHeHLr1111 Ba>KHblX
B cpyHKL\1110Ha.nbHOM OTHOWeHll1111 BeTselA, 111AYl.l.\111X
K neYeHLr1 111 YpeBHOMY cnneTeHll110 (p111c. 9) .
B 06w111pHo~ .n111rnpaTYpe o npe111Myll\eCT-
sax 3Toro cnoco6a saroTOMlllll1 nepe.Q cTsonoso~
MO>KHO Ha~Tlll .QOBOilbHO npornsope1.1111sb1e AaH-
Hble OTHOCl/ITeilbHO '-laCTOTbl B03Hll1KHOBeHll1S'I
pa3n1111.1HblX nocTBaroToM1111.1ecK111x HapyweH111L1.
PHc. 9. Ce.neKTHBHas:t saroTOMHs:t. 1-
11eeb1ili 6ny>K.Qat0W.Hili Heps; 2- npa0b1ili
611y:>t<Aat0W.Hili Heps; 3-nelfeHo4Has:t eeTBb
11eeoro 611y>K.Qat0w.ero Hepea; 4-4pesHas:i
eeTBb npaeoro 6ny:>t<Aat0w.ero Hepea.
ITep$opaTHBHhie racTpo,uyo,uenaJihHbTe H3BI.I. Knaccml>ttKa1.vu1
no JIOKanH33UIUI Ilo BM.UY nepcpopau1m
1 . .5.I3Ba )J(eny.nKa: Manoli Kpll- 1. npo6o.nett.rre B cB06o)JJf)'lO
Bll3HhI, rrepe.ntteli creHKH, 33.D.- 6p10nrny10 rroJIOC'th.
He:ti creHKH. 2. npo6o.nea.rre rrp.rrxphnoe.
2 . .5.I3Ba .nBeHa.ni.lanepcrnoli 3. Ilpo6o.nett.rre arnnwmoe.
KHIIIKH: rrepe;rnei'I cremcn, 3a,n:-
Heli creHKH.
KflUHUKO
nepcpopal..\1115l 513Bbl pa3Bll1BaeTCS'I OCTpO, XO-
TS'I y 20% 60.nbHblX YA8EffC51 Bbl51BlllTb npo,Qpo-
ManbHbl~ nep1110A: 3a 3-4 .QH51 AO nepcpopaL\111111
yc[l1.n111sa10Tcs:i 6on111, nos::ism1eTCS'I rnwHora , pso-
Ta. nepcpopal..\11151 conposo>K,QaeTC51 Knacc1111.1e-
cKoili Tp1118AOili np1113H8KOB , on111caHHO~ r. MoH-
AOPOM: KUH)K8flbHafl 6onb, oocKoo6pa3Hoe Ha-
npR)KeHue Mb/WL( )KLJ8oma, f/38eHHb/U 8H8MHe3 .
npu 06beKmU8HOM o6cneCJ088HUU: np111 OC-
MOTpe >KlllBOT s aKTe AblX8Hll151 He y1.1acTByeT, n111-
60 OTMe4aeTC5l 1113BP81.l.\eHHblili rnpaKoa6,QOM111-
HanbHbfrli nm ,QbfXaHlllS'I - BTS'lrl!fBaH1.11e 6ptoWHOrli
CTeHKll1 np111 BAOXe (CMMnTOM oeM.nM), MO>KeT
6b1Tb B111AHa nonepe1.1Has:i CKn8AKa HaA nynKOM
(cMMnToM '"lyraeea), Bblpa>KeHbl nepeMbl'-IKll1
np51MblX MblWL\ )f(ll180Ta (CHMnTOM ,Q31-06aHOB-
CKoro-'"lyraeea). np111 nepeycc111111 111 nanbnaL\111111
>Kll1BOT pe3KO 6o.ne3HeHHblili, Hanps:i>KeH CHa1.1ana
s sepxH111x, a 3aTeM so scex OTAenax. Pe3KO no-
66
B .i:1anbHe~weM w111p0Koe pacnpocTpaHeH111e
nonyY111na ceneKTHBHa.si npoKCMMaJlbHa.si ea-
roTOMM.si, 3aKntoYatoLl.las:ics:i B ,QeHepBal..\111111 Tena
111 AHa >KenyAKa, npOAYL\111PYIOll\111X cons:iHylO K111-
CI10TY, 111 B coxpaHeHll1111 111HHepB8L\111111 aHTpanbHO~
YacTlll >KenyAKa. 5onee TOYHO nepeAaeT cyll.1-
HOCTb MeTO,Qll1Kll1 Ha3BaHll1e aMep111KaHCKll1X aBTO-
pos - ceneKTll1BHas::i earoToM111s::i o6KIJa.QO'-IHblX
KneTOK (pltlC. 10).
PHc. 10. CeneKTHBHa.si npoKCHMaJlbHasi
aarOTOMH.SI. 1-neablM 611y}l{Aa10W.HM Hepa;
2- npaab1ili 6ny:>t<Aat0W.Hili Hepa; 3-
nelfeH04Hasi seTBb 11eeoro 6ny>KAat0w.ero
Hepsa; 4-4peeHasi eeTBb npaeoro 6ny>1<-
Aat0w,ero Hepsa; 5-BeTBb Jlarnp>Ke 11eeoro
6.ny>K.Qat0w.ero Hepea; 6-eeTBb JlaTap>Ke
npasoro 6.ny>K.Qat0w.ero Hepea.
5naro,Qaps::i :noL1 onepaL\111111, coxpaHs::itoTC51
TOpM03Hoe en1115IH111e 6ny>K.Qatoll.lero Hepsa Ha
Bblpa6oTKy racTpltlHa Ill MOTOpHaS'I cpyHKL\11151 aH-
TpanbHO~ '-18CTll1 >KenyAKa.
OcHOBHblM Bll1.QOM onepaT1t1BHoro .ne1.1eH1t15I
S'l3BeHHO~ 6one3Hli1 ABeHa.QL\aT111nepcTHolA Kll1WKltl
cne,1weT C'-llllTaTb ceneKTll1BHYIO npOKClllManbHYIO
saroTOMll1to. 0Ha noKa3aHa np111 n111nopo,QyoAe-
HanbHblX 513Bax, ecn111 ceKpeL\11151 conS'IHolA K1t1cno-
Tb1 He npeBblWaeT 60 MMO.nb/n .
no K.iIHHHqecKOivJY reqeRHIO
1. Cra.nmT rnoKa
2. Cra.nmi: MHMMoro 6narouo-
JIYIJHJL
3. Cra.nmr Bhlpa)l(eHHoro
rrepHTOHHra.
nO>Kll1TenbHblL1 CMMnTOM «AOCK006pa3HOro
>KHBOTa». V1c4e3aeT 111n111 3H84111TenbHO yMeHb-
waeTCS'I neYeHOYHas::i TYnocTb (cMMnToM >Ko6e-
pa), no5isn51eTcs:t np111TYnneH111e B npasoM 6oKo-
BOM K8Hane 111 npasoL1 nO,QB3AOWHOJ:1 51MKe
(cMMnToM KeepeeHa). Bb1cnyw111saeTc5I «A111a-
cpparManbHOe TpeH111e» Me>K.Qy A111acpparMo~ 111
B3AYTblM )f(e.ny,QKOM (CMMnTOM EipyHHepa), a
TaK }Ke cep.i:1e1.1Hb1e TOHbl AO ypoBH51 nynKa (cMM-
nToM Ky1.1cT0Ha). 4acrn OTMe1.1aeTC5I nono>K111-
TenbHb1ill cppeH111eyc-c111MnTOM. Onpe,Qens::ieTCS'I
wyM nnecKa np111 noKa1.1111saH111111 6onbHoro 3a KOC-
rn Ta3a (c111MnToM fe<Jnepa- LI..t1m1114111Ha). He
c.ne,QyeT 3a6b1saTb 111 o B8)f{HOCTlll peKTanbHoro
o6cne,QOB8H111S1, np111 KOTOpOM MO>KHO Bbl51Bll1Tb
pe3KYIO 6one3HeHHOCTb 06.nacrn ,[lyrnacosa
npocTpaHCTBa (TaK H83blB8eMbl~ «KPMK ,Qyr.na-
ca» ). nynbc s nepsyJO cra.i:1111to HepeAKo yp51)f(eH
- (CMMnTOM fpeKoea).
Cnycrn 5-6 4acos OT Ha4ana 3a6onesaH1115I
Knll1Hll1'-lecKa51 KapT111Ha KaK 6bl crnpaeTC51, H8CTY-
naeT MH1t1Moe 6naronony4111e. Hanpsn1<eH111e MblWU.
epeAHet1 6plOWHOt1 CTeHKlt1 yMeHbWaeTC51 , np111
nanbna4111111 OTMe4aeTc51 yMepeHHa51 6one3HeH-
ocTb, 8bl518fi5llOTC51 nono:>Kvne.nbHble Clt1MnTOMbl
pa3Apa>KeHlt151 6pl0Wlt1Hbl (CL1MnTOM Ll.leTKL1Ha-
5moM6epra). nep1.1cranbrnKa ocna6neHa, ne4e-
HO'-!Ha51 TYnOCTb OTCYTCT8yer. nynbC y'-lall\aeTC51 ,
reMnepaTYpa re.na noab1waerc5I .
3aTeM , '-!epe3 6-12 4acoa nocne nepcpopa-
111111 , COCT051Hllle 60J1bHblX nporpeCClll8HO yxyA-
aeTC51 , cH111>Kaerc51 nynbco0oe Aa0neH111e , 003-
H111KaeT 03p,yn1e >1<1t10orn , nep1t1cTanbT1t1Ka orcyr-
cr0yer - pa301.-10aerc51 Kn1t1H1t14ecKa51 KaprnHa
nep1t1TOH1t1Ta .
np11Kpb1TaS1 nep<J>opa'-'11S1 803H1t1KaeT np111
38Kpb1Tlt11t1 OT8epcrn51 B >KenyAKe 1.-1 A8eH8Al...\aTlt1-
epcTHOt1 Klt1WKe COCeAHlt1Mlll opraHaMlt1 , cj:l1116p1t1-
HOM, 4acr1111..1ei1 n1t1ll\eBblX Mace. Km1H1t14ecKa51
Kapn1Ha B T8Klt1X cny4a51X CT8HOB1t1TC51 MeHee
ab1pa>1<eHHoill. nocne xapaKTepHoro Ha4ana npo-
111cxoA1t1T np111Kpb1rne ornepcr11151 111 orpaH1t1'-leH111e
po4ecca. B C8060AHYIO 6plOWHYIO nonoCTb no-
nap,aeT cpaBHlllTenbHO He6onbWOe KOfilll'-leCT80
>Klt1AKOCT1t1 1.-1 803,D,yxa. 6onb Ill Hanp51>1<eH111e MblWI..\
nocTeneHHO yMeHbW8IOTC51, COCT051Hllle 6onbHblX
yny'-! waeTC51 . Ha6nioAaeTC51 nocTeneHHoe nepe-
Mell\eH1t1e 60.n1.-1 8 Te4eH1t1e 2-4 4aco0 no npa00-
MY 60Ko00My KaHany p,o npa0oi1 nOAB3AOWHoi1
51MKlll , c1t1Myn111py51 c111MnToM Koxepa-
B onKoBM'la np111 anneH,n,1.-11..1111re. XapaKTepHoi1
Kn111 Hlt14eCKOt1 oco6eHHOCTblO np1t1KpblTOVt nepcj:lo-
pa41.-1 111 518.n51eTC51 p,n1t1TenbHOe CTOVJKOe Hanp5l>Ke-
111e MblWI..\ nepeAHet1 6plOWHOt1 CTeHKJ.1 8 npa-
80M aepxHeM K88ApaHTe >Klll80Ta np111 06lJ..leM
xopoweM cocT051Hllllt1 6onbHoro (c111MnToM PaT-
Hepa-BlllKKepa). A111arHocrn1<a TaKlllX nepcj:lopa-
u.111i1 6b1aaer TPYAHOill , no3TOMY np111 noA03peH1t11t1
Ha np111KpblTYIO nepcj:lopal..\llllO nOK838HO HeOT-
n o>KHOe oneparn0Hoe 8MewarenbCT80.
Ar111n111'1Hb1e nepcj:lopa1..1111111 He conpoao>1<-
Aa10TC5I nep111ToHeanbHb1M111 c111MnT0MaM111 , 6on111
B >K111BOTe He Bblpa>KeHbl. np111 nepcpop81..\lt11t1 3a-
6plOWlt1HHOrO OT,D,e.na 12 nepCTHOVt Kl.-1WKL-1 Ha-
6n10p,aeTC5I 3Mcp1113eMa BOKpyr nynKa (ClllMnTOM
8111 r111a'-'a) . np111 nepcpopal..\1.-11.-1 1<app,1t1aJ1bHOro OT-
p,en a )f(enyp,Ka pa30111aaeTC5I Kn1t1H1.-1Ka Mep,1.-1acr111-
H111ra : 3Mcplt13eMa 8 ne0ot1 no,D,Knl0'-llt14HOt1 06-
nacrn (c11MnToM noAJlaxa), 3Mcp1t13eMa neaoi1
non OBll1Hbl rpyp,Hot1 KneTKL-1 111 >Kl.-1BOTa (CL1MnTOM
Kopaxa) . np1.-1 peHrreHorpacp1.-11t1 Ha6niop,aeTC51
CMM nTOM "npoceeTJleHHOro" cpeAOCTeHlllSI .
np111 nepcj:lopa1..1111111 Manot1 Kp11101113Hbl rena >1<e11yA-
Ka 8 KneT'-laTO'-lHOe npocrpaHCTBO Me)f(,D,y n1t1CT-
KaM1t1 ne'-leHO'-lHO-)f(enyp,o4HOt1 C8513K111 6YAYT OT-
CYTCT808aTb nepll1TOH811bHble Clt1MnTOMbl , HO 6y-
p,eT cj:lopM111po0aTbC5I nanbn1t1pyeMb1i1 6one3HeH-
Hbli1 lt1HQJ111nbTpaT, conpo80)f(,D,810ll\lt1t1C51 lt1HTOK-
Cll1K81..\lt1ei1 111 anocnep,crn1111.1, c B03MO)f(HblM a6c-
u.eA111po0aH1.-1eM .
67
AuazHocm w<a
np111 nepcj:lopa4111111 nonoro opraHa o630pHafl
peHm2eH02pacpuR 6p10wHoiJ nonocrn no3aon5leT
8bl5181t1Tb cso6op,Hbtt1 ra3 nop, t<ynon oM .a.111acj:lpar-
Mbl y 75% 6onbHblX. B COMHlllTenbHblX c.ny4a51X
cne.a.yer nposecrn nHeBMoracrporpacj:l1t110 (npl'l-
eM Mei.lio - 00ep,eH1t1e 500 Mn 003p,yxa s )f(enyp,oK
4epe3 30H,D,}, 8 pe3ynbT8Te 4ero AOCT08epHOCTb
111ccne.a.00aH1115I nosb1waerc51 AO 95% .
Y3t1 6p10wHoiJ nonocmu no3aon51er Bbl-
51Blt1Tb cao6o,D,HYIO >KL-1,D,KOCTb B nop,ne4eH04HOM
npocrpaHcrne.
33ocpa202acmpooyooeHocKonuR no3aon5leT
yro'-!Hlt1Tb p,111arH03, ycraHOBlt1Tb T04HYIO n0Kan111-
3a1..1111io Ill pa3Mepbl 513Bbl , o6Hapy>Klt1Tb COnYTCT-
BYIOll\111e OCJ10)f(HeHll151 : CTeH03 , Han111'-!111e CO'-le-
TaHHOi1 cj:lopMbl 513BeHHOi1 6one3Hll1 , BTopoi1 513-
Bbl , KpOBOTe4eHL-1e 1.-13 KOTOpot1 y)f(e B03Hlt1Kn0
lllfilt'I MO>KeT pa3Bll1TbC51 (p1t1c. 11 ).
P111c. 11. racTpOCKOnlllSI. npo60AH3SI
Sl3Ba nepeAHeH CTeHKM aHTpa.nbHOro OTAe-
.na >Ke.nyAKa (cTpe.nKa).
flanapocKonufl noMoraer yTo'-lH1t1Tb p,111arH03
111 Bb16parb ap,e1<aaTHb1t1 nnaH neYeHL-151 np1t1 He51c-
Hoi1 Knll1Hll1'-lecKoill Kapr1t1He , a a p51p,e cny4aea no-
300.n51er y6e,D,lllTbC51 B 803MO>KHOCTll1 BbJnOnHeHlt151
roro 111n111 111Horo onepar1110Horo BMewarenbcrsa.
3ro oco6eHHO aa>1<Ho Ansi 6onbHblX c raK Ha3bl-
aaeMoi1 np111Kpb1Toi1 nepcj:lopa4111ell1 513Bbl.
11a6opamopHoe uccneooeaHue 1<pos1.1 no-
3aonsier KOHCTarnposaTb 6blCTpO HapaCT810ll\lt1t1
neil1KOl..\111T03 co C,D,Bll1rDM neil1KOl..\lt1TapHOi1 cj:lop-
Mynbl aneao.
Xupyp2uYeC1<aR ma1<mw<0
Ha.n1.-1'-l111e nepcpoparnsHot1 racrpop,yop,e-
Ha.nbHoi1 513Bbl 51Bfi51eTC51 noKa3aHll1eM K 3KCTpeH-
HOi1 onepa4111111.
YwueaHue nepcj:loparnaHot1 513Bbl >Keny,n,Ka
111 p,aeHap,4arnnepcTHoi1 K1t1w1<111 51Bn51eTC51 onepa-
41.-1et1 Bbt6opa, oco6eHHO y 6onbHblX c pacnpo-
crpaHeHHblM «n03AHlt1M» nepll1TOHll1TOM 1.-1n1t1 np111
BblCOKOi1 creneHlt1 onepa1..11.-10HHO-
aHeCTe31t10110rlt14eCKOro p1t1cKa.
flanapocKonul/ecKoe ywueaHue noKa3aHo y
Mono,D,blX 6onbHblX s rex cny4asix, Korp,a nep-
cpop111pyer rat< Ha3btaaeMa51 HeMa51 513Ba, a
aHaMHe3e orMe4aerc51 .nareHTHoe 1t1n1t1 6naro-
np1t15ITHoe Te4eH1t1e 3a6one0aH1115I , a pe3ynbTaTbl
.a.oonepa41t10HHOt1 p,111arHOCTlt1Klt1 CBlllAeTenbCTBY-
IOT 06 OTCYTCTB1t11t1 APYrlAX OCJ10:>KH€Hlt1111 5138eHHOi'.1
6o.ne3Hlt1 .
B p51p,e Kn111H1t1K 3onorb1M craHp,aproM np111
ne4eH1t1111 6onbHblX c nepcj:lopar1t10Hot1 AYOAe-
HanbHOi1 51380171 C4lt1T8IOT ceneKmUBHYIO npOKCU-
MBflbHYIO eaeomoMUIO c UCCel/eHLJeM fl38bl u nu-
noponnacmUKOU, s moM L/Ucne nanapocKonul/e-
cKUM MemoooM (IO.M. naHl..\blpea) .
 Pe3eKu,uio >1<eny0Ka BblnOflH.fllOT 6onbHbtM c CTHOll1 Klt1WK1t1, ocnO)f(HeHHaS'I KpOBOTeYeH1t1eM ,
nepcpopaTIABHOVt 5!3BOVt )f(eflYAKa np111 HeBblCOKOM COCTaBn.fleT He MeHee 40% cnyYaeB OCTpblX ra-
onepa4ll10HHO-aHeCTe3ll10flOfl/14eCKOM plllCKe, CTPOAYOAeHaflbHblX KposoTeYeH1t1VI.

Kane3HOVI $13Be. KnaccucfJw<au,uR 1<poaomel.feHUR

noc11eonepa4uoHHb1iJ nepuoo
Cpa3y nocne 3asepweH111P. yw1t1saH1t15l nep-
¢oparnsHoll1 513Bbl - onepa1..11t11t1 , He Bfl1t15!10ll.\ell1
Ha naroreHe3 5!3soo6pa3osaH1t1.fl , 6onbHblM npo-
BOA.flT KYPC npoT1t1BO.fl3BeHHOll1 Tepan111111 , JaTeM
nocne Bbtn1t1CK111 111x nepeAalOT noA Ha6n10AeH111e
Tepanesrn racrpo3HTeponora. Oco6eHHOCTbto
BeAeHll15l 6onbHblX nocne opraHocoxpaH.flfOll.\lllX
onepa41t1ll1 c saroToM1t1eV! P.Bfl5leTc5l npocp111naKT111-
Ka paccTpoll1cTB MOTOpH0-3B8KY8TOpHOll1 cpyHK-
Llllllll oneplllposaHHOro )l{enyAKa np111 Hanll14ll1ll1 co-
YeTaHHOro OCJlO)f{HeHl/IS'I B B111Ae CTeH03a (npena-
paTbl rpynnbl npoKl/IHeTIAKOB, 30HA 38 o6naCTb
CB513Klll Tpell1L\a, KOTOpblVt MO)f(HO "1CnOflb30B8Tb
KaK Afl.fl AeK0Mnpecc1t1111 )f(eflyAKa , TaK 111 AflP. 3H-
TepanbHoro n111TaH111P.).
no J.A. Forrest
Fla - npoAOfl)f(alOll.\eec.s:i crpyV!Hoe Kposo-
TeYeH1t1e ;
Fib - np0Aom1<atol1.(eecs:i 1<amrnm:1pHoe, a
BlllAe AlllQJQJY3HOro npoca4111saHl115! KpOBOTeYe-
H1t1e;
Fiia - BlllAlllMbllil KpynHblll1 rpoM6111posaHHblVt
COCYA;
Fllb - nnoTHO cp111Kc1t1posaHHblll1 K P.3BeHHO-
MY KpaTepy TpOM6-crycToK;
Fiie - MenK1t1e TpoM6111posaHHbte cocyAbl s
Bll1Ae OKpaweHHblX nmeH;
Fiii - 0TcyTcrn111e cr111rM KposoreYeHlllP. B
513BeHHOM Kparepe .
Ha AOrocn1t1TanbHOM 3Tane AOCTaT04HO
111HcpopMaT1..1BHbtM s onpeAeneH111111 o6beMe Kpo-
son0Tep111 MO>KeT 6b1Tb «VIHAeKc Anbrosepa»
(VIA) 111n1t1 «WOKOBblVt lt1HAeKc» :

OCTPb/E fl3BEHHb/E p
TACTPO,D,YO,D,EHAJ7bHb/E KPOBOTEl/EHt1fl - - - - = HOpMa 0,5
HA
AKTYaflbHOCTb 3TOll1 npo6neMbl B nepsylO cucm
OYepeAb onpeAeflS'leTCS'I BblCOKOVt 06ll.\ell1 ne- All
T8flbHOCTblO, KOTopaS'I AOCT111raer 10-14%, a np1t1
onepaT111BHOM BMewaTeflbCTBe Ha BblCOTe KpO-
C yYeTOM o6beMa 1113n111swell1cs:1 Kpos111 Kpo-
BOTe\.feHll151 - AO 35 %. HecMOTpS'I Ha 06ll.\enp111-
sonorep51 MO>KeT 6btTb .nerKolil crnneH111 (norep.s:i
3HaHHYIO 3QJcpeKT111BHOCTb cospeMeHHblX npOT"1-
KpOBvt B o6beMe 750 Mll., lt1H,[\€KC Anbrosepa
B0513BeHHblX cpeACTB , YlllCflO 60flbHblX, y KOTO-
(VIA) XAO 1,0), cpe.QHelil CTeneHlll (norepp, KpOBll1
pblX B03HlllK8IOT 513B8HHble raCTPOAYOAeHaflbHble
OT 750 AO 1500 Mn; VIA - 1, 1-1,4) 111 T.SUKenoi.1
KpOBOTeYeHlt15! , nocTOS'IHHO ysefllll'-1"1BaeTCS'I Ill co-
crnneHlll (> 1500 Mn .; VIA> 1,4)
CTaBJlS'leT 90-100 Ha 100 Tbtc. B3pocnoro Hace-
B CTaL\lllOHape creneHb Kposon0Tep111 MO)f{HO
neHlllS'I B roA. Y MY)f(\.flt1H AaHHoe ocno>KHeH111e
onpeAen111Tb c yYeToM cneAYIOLl.\lt1X noKa3aTeneV! .
BCTpeYaeTCS'I B Tplll pa3a \.fall.le, YeM y )f(eHll.\lt1H .
H3BeHHa51 6one3Hb )f(eflyAKa 111 ABeHaA1..1ar111nep-

K11accmJ>nKa~usi cTeuenu KposonoTepu

CTeneHb KPOBonoTepH
IloKa3aTeJib
JierKM coe.nHIDI TJD:KeJIM
Koll-60 ::;pumoouumoe > 3,5 x l012/n 3,5-2,5 x1012/rr < 2,5x J 012/n
I'eM02Jl06UH, c/!l >100 83-100 <83
l(BJJ (c:w <wo.cm.) 5-15 <5 <O
llv.'1bc (yol;wun) ,ll,o 80 80-100 > 100
AJJ cucm. (MM om.cm.) HOpMa 100-90 <90
Ht > 0,30 0,25-0,3 0 < 0,25
Jluvoe3 (Jw1hv1w1) 1-1 ,2 <0,5 <0,2
JJer/Juuum Ol(K (%) .no 20 20-30 >30

,D,ua2Hocmu1<a
B npOL\eCce ,D,1118fHOCTl.11<1.1 Heo6XO,D,l.1MO OT- CuMnmoMamuKa
e.e111\\b Ha \\)\/\ OCHOBHb\X 80\\\)0Ca: ·\10 \\OCn\{-
1 Kl11AHIA4eCKlt\e m;>O)\BneHll\$\ OCT\)blX, oco6eH-
)f{lt1IlO 111CT04Hll1KOM KPOBOTe4eHlt15l, npOAOfl>KaeT- HO MaCCl.1BHblX, raCTPOAYOAeHanbHblX KpOBOTe-
CS'I fllll KPOBOTeYeHl/le Ill KaKOBbl ero TeMnbl , KaKOB YeHl.1111 AOCTaTOYHO 51pKl.1e 111 CKI18Abl88IOTC51 "13
o6beM Kposon0Tep1.1 . 06ll.\lllX Cl.1MnTOMOB, CBOVtCTBeHHblX Kposonorepe
(reMopparn~ecK111lil ClllHAPOM): pe3Kas:i cna-

68
6ocTb, ronosoKpy>1<eH111e , no51sneH111e «MyweK» rpynnbl li1Hr1116111TOpOB npOTOHHO!li noMnbl (HeKCl-1-
nepe,D. rna3aMlll, xono,D.Hbli.1 nor, 6ne,D.HOCTb KO)l(- yM , noceK) , reMocraT1114ecK111e npenapaTbl (Allll..llll-
HbJX noKpOBOB, ClllHfOWHOCTb CJ11113 111CTblX 060110- HOH , 8L/1Kacon, 3nCLllJlOH-aMlllHOKanpoH08851 Klll-
'-leK, rax111Kap,D.1115I , cH111>1<eH111e AA. noTep51 C03Ha- CJlOTa) .
Hlll51; Ill ClllMnTOMOB , xapaKTepHblX A1151 KpOBOTel.Je- Y 6onbHblX, y KOTOpblX cy~ecrsyer yrpo3a
Hl/151 B npocseT >Keny,D.Ol.JHO- KlllWeYHOro TpaKTa : peLJ,Lll,D.11183 KPOBOTe4eHlll51 Ill KOTOpbJM ,D.OJl)l(HO
psora cse)f(ei.1 1.m111 BlllA01113MeHeHHoi.1 KpoBbfO 6b1Tb npoBe,D.eHO x111pypr111YeCKOe Jl848Hllle B 3KC-
("Ko¢>elitHaH ryl.1'a") , llepHbli.1 Kan , a np111 npocpy3- rpeHHOM nop51,D.Ke , speMeHHbil/1 reMocra3 no300-
Hb1x KpOBOTelleHlll51X - MeJleHa. np111 3TOM xapaK- 1151er nposecTl/I COOTBeTCTBYIO~YIO no,D.roTOBKY K
TepHble 6011111 Henocpe,D.CTBeHHO nepeA KpOBOTe- Heorn0>1<Holli onepaL1111111 . np111 Bb1pa}f{eHHOll1 yrpo-
4eHllleM MOryT CTlllX3Tb (np1..13H3K 5eprMaHa) . 3e peLJ,111,D.11188 KpOBOTeYeHL/151 y 60ilbHblX, KOTO-
Pe3ynbmamb1 cjJu3uKanbHOBO o6cneooeaHuR pblM x111pypr111Yec1<oe ne4eH111e npoT111sono1<a3aHo
no3BOJ15llOT onpeAeJllllTb CTeneHb T51>KeCTlll KpOBO- 8CI18,D.CT81118 KpalllHe BblCOKOll1 creneHLll onep81..llll-
norep111 111 npe,D.nonm1<111renbHO ero lllCT04H~1K . OHHO-aHeCT831110IlOrlll48CKOro plllcKa , 3HAOCKOnlll-
4eCKlllll1 reMocra3 c nocne,D.y10~elli AlllHaM111Ye-
,ll,ua2HocmuYeCKue Memoab1. cKolli 3H,D.oc1<on111elli no3som1er npeAOTBpaTlllTb
HeornO)f(Has:i ¢1116poracrpo,D.yo,D.eHocKon11151 , peLJ,111,D.1118 Kp080Te48HL/151 .
6e3yc110BHO , 518mleTC51 OCHOBHblM M8TOAOM on- noK838HUR K HeOmJ70>KHb/M onepamUBHb/M
peAeJleHlll51 111cTOl.JHlllKa, nma 111 xapaKTepa Kpo- BMewamenbcmaaM ycraHasn111sa10rc51 s roM
sore4eHlM1 (p111c. 12). cny4ae, ecm1 AOCTlll4b HaAe}f{HOro reMocra3a c
noMO~blO Hex111pypr1114eCKLllX MeTO,D.08 HeB03-
P11tc. 12. 3H.QOcKonw-tecKa.R KapTMHa MO}f{HO.
H3BeHHoro Kpoeorel!eH1..1.R. A-crpylitHoe 31<crpeHHa5I onepau,11151 noKa3aHa 6onbHblM
KpOBOTe4eHMe (crpenKa). 6-.QMcpcpy3HaH c npocpy3HblM npo,D,OJl)l(alO~LllMC51 KpOBOTeYeHlll-
KpOBOT041!tBOCTb (crpe11Ka). eM ; 60f1bHblM c MaCClllBHblM KPOBOT848Hlll8M ,
KOTOpoe He y,D.aeTC51 OCTaHOBLllTb c nOMO~blO
na6opaTOpHble MeTO,D.bl ,D.lllarHOCTlllKlll no-
KOHcepsaTV'IBHblX Meponp11151nil!l, BKJ1to4a51 ne-
380J151fOT nonyl.JlllTb Ol.JeHb Ba>KHble o6beKTlllBHbl8
Ye6Hy10 3HAOCKOnLlllO, a TaK>Ke np111 peLJ,LllALllBe
,D.aHHbl8 0 creneHlll T51>K8CTlll KpOBOT84eH11151 Ill Ha-
KpOBOTeYeHL/151 B KJlLllHlllKe .
pyweHllls:IX B ClllCTeMe CBepTblBaHlll51 .
Cpo1.1Ha5I onepal..llll51 no1<a3aHa 6onbHblM c
npe>K,D,e lleM onpe,D.enlllTb lllCTOl.JHlllK )f(eny-
513BeHHblM KPOBOTeYeHL/leM , OCTaHOBKa KOTOporo
,D.OYHO-KlllW8l.JHOro KpOBOTeYeHlll51 Heo6XO,D.lllMO
KOHcepB8TLllBHblMLll cnoco6aMlll 6b1na He,D.OCTa-
CHaYana CTa6111n1113111posaTb COCT051Hllle 6onbHO-
T04HO H8,D.8}f{HOll1 , Ill lllM810TC51 ,D.8HHble, CBL11,D.e-
ro, A06111ew111cb a,D.eKsaTHoro yposHs:1 aprep111-
T8f1bCTBYfO~L11e o BblCOKOM p1t1cKe peL1111,D,111Ba
anbHoro ,aasneH111s:1. lllHor,D.a norep51 Kpos111 npo-
Kposore4eHLll5l. 6onbHblM 3TOll1 rpynnb1 onepa-
111cxoA111T HaCTOJlbKO lllHT8HClllBHO Ill 6blCTpO , YTO
TLllBHOe BMewaTenbCTBO npOL113BO,D.lllTC51 , KaK
06Hapy>1<eH111e lllCTOYHlllKa Kp080TelleHlll51 np080-
AlllTCs:I 111Hrpaonepau,1110HHO, 6e3 npe,D.wecrnyt0-
npas111no , B Te4eH111e 12-24 4acos nocne nocryn-
neHL/151 - speMeHli1 , Heo6xoAL11Moro ,D.Il51 no,Qro-
~ell1 ,D.oonepau,1110HHoi.1 ,D.111arHOCT111K111 .
ros1<111 6onbHoro K onepau,111111 .
fiel!e6HaH TaKTMKa y 60JlbHblX C KpOBOTe-
nnaHOB851 onepaU,11151 Bbln0JlH518TC51 Yepe3
l!eHl..1eM MJ H3Bbl )l{eny.QKa 11t ABeHaA"'ar1..1nep-
crHoiil KMWKl..1. TaKTlllKa neYeH1115I 6onbHblX c 513- 2-3 Hep,en111 ne4eHlll51 6onbHOro B racrpo3HTepo-
nor1111.1ecKOM or,D.eneH111111.
seHHblM racrpo,D.yo,D.eHanbHblM KposoreYeH111eM
OCH08blBaeTCs:I Ha aKTlllBHOM .o,111cp¢epeHU,lllpO-
Bbt6op Memooa Heorno}f{HOro BMewarenb-
crsa 38Bli1Cli1T OT T71>1<8CTLll COCTOS'IHL/151 60f1bHOro ,
B8HHOM no,D.XO,D.e, npe,D.yCM8TplllB8IO~eM HeOT-
creneH111 onepaL1L110HHo-aHecre3111onor111YecKoro
JlO>KHbli.1 xapaKTep ,D.lllarHOCTllll.JeCKlllX Ill J184e6Hb1X
p111cKa, n0Kan1113au,111111
111 xapaKTepa Kposoro4a-
Meponp111m1111/1 c Alllcf:>¢epeHu,111posaHHblM onpe,D.e-
~ei:l 513Bbl. rnaBHblM Tpe60B8Hlll8M K onep8L\lllLll
neHllleM noKa3aHlll~ K HeoTnO>KHOMY onepaTlllBHO-
My 8MewarenbcTBy. B OCH08e HeonepaTlll8HOro np111 Kposore4eH1111r1 cnep,yer cY111rarb yoaneHue
ne4eHlll51 fl3BeHHbJX racrpoAyo,D.eHanbHblX Kposo-
caM020 R3BBHH020 cy6cmpama, o6ecne4111Ba5I
OKOH4arenbHbllli reMocra3. Mero,D., 3aKI110Ya10-
Tel.JeH111i.1, c KOTOporo HaYl/IHalOT OK838Hl/le HeOT-
~111!4c71 B npOWlllB8HLlllll KpOBOTOYa~ero cocy,D.a ,
JlQ)KHOi.1 noMO~lll 60JlbWlllHCTBY 60ilbHblX, Jle)l(l!1T
COY8TaHH08 np111MeHeH111e MeTO,D.08 Ilelle6Holl1 3H-
cne,D.yer C4LllT8Tb nop04HblM , T.K. B 50% TaKlllX
cnyYaes Hacrynaer pel.\lllAlllB 1<posoreYeH111.>1 .
AOCKOnlllLll Ill cospeMeHHblX cpeACTB KOHcepBaTl/18-
,QaHHbllli cnoco6 AOnycTlllM TOnbKO a cny4ae
HOlli repan111111 513BeHHolli 6one3HLll.
1<palliHelli T51}f{eCTlll 6onbHoro, 1<or,D.a p111cK pacw111-
MemoobJ nel./e6Hou 3HoocKonuu 111cnonb3Y-
peH1115I o6beMa onepau,111111 yrpo}f{aer >1<1113H111 na-
IOT c l..l8Jlbl0 speMeHHolli , a s p51,D.e cny4aes
4111eHra. np111 KpOBOT8Y8HLlllll 1113 XpOHL/148CKOl/1 513-
OKOH4aTeJlbHOll1 OCTaHOBKlll Ill npo¢111naKTlllKLll
Bbl }f{eny,D.Ka MeTO,D,OM Bbl6opa 5!Bf1518TC5l pe3eK-
Kp080T8l.J8Hlll51. np111M8H5llOT MOHOaKTlll8HYfO ,D.1118-
l..llll51 }f{enyp,Ka , XOT51 nplll LllCKJll04111TenbHblX o6-
TepMO- 11111111 na3epHy10 Koarym1L1L1110, 1i1Hbe1<4111111
CT051TenbCTB8X, CB513aHHblX c Kpall1Helli creneHblO
3T8HOI18 ' KI188BYIO annn1i1KaLJ,lllfO, KJlLllOlllpOBaHLlle.
p111cKa pa,D.LllKanbHOro BMewarenbCTBa 111 npo-
K cpeACTBaM MeouKaMeHm03Ho20 nel./eHUR
,D,On)l(lllTenbHOCTlll onepal..lllllll , p,onycKaerc51 B03-
OTHOC51TC51 aHTL/ICeKpeTOpHble npenapaTbl 1113
69
MO)f{HOCTb VICCe4eHl/lf! s:l3Bbl, TaK H83blBaeMas:i
3KCTparacTpal\1115l . np!A KpOBOTe'-leHl/1111 1113
ABeHaA1..1aT11m epCTHOlli KIAWKlll npeAn04TeHllle
cneAyer OT,Q8B8Tb VICC848HllllO s:l3Bbl , n111nopo-
nnacrn1<e c saroTOMllleVt 111111.1 6e3 ra1<osoi7t , a nplll
neHerpa1..11111.1 - 3Kcrpa,D,yo,D,eHlll3al..lllllll . B ps:iAe
cny4aes He noreps:ina csoero 3Ha4eH111s:i 111 pe-
3e1<1..1111s:i )f{811YAKa .
noc11eonepau,uoHHbli1 nepuoa
na1..1111eHT8M, KOTOpblM 6blJ18 BblnOJ1HeHa op-
raHOC6eperatoLl.18s:I onepa1.1111s:1 , s nocneonepa1.1lll-
0HHOM neplllOAe Ha3H84aercs:i npOTl.1BOs:l388HHa5l
Tepamrn . nocne BblnlllCKlll 1113 CT81.\lllOHapa 60J1b-
Hble no,qne)f{aT ,q111cnaHcepH0My Ha6nto,QeH11110 y
racTp03HTeponora, KOTOpbrilt onpe,D,em1er Heo6-
xo,a111Mocrb npose,D,eH111s:i no,D,,D,ep)f{l.1BatoLL1ei:1 Me-
AlllKaMeHT03HOi:1 repanllllll s:13seHHoi:1 6one3Hlll ,
HanpasneHHOVt Ha CHlll)f{eHlll8 4111Cila pe4lll,D,lllBOB
513BeHHOlli 60I183Hlll Ill npe,D,OTBP8ll.\8Hllls:I noBTOp-
HblX KpOBOTe4eHl/IVt.
fl3BeHHb1iJ nu11opoayoaeHa/1bHb1i1 cmeHo3
n111nopo,D,yO,l\eHaJ1bHblVt CTeH03 pa3BlllBaeT-
Cs:I y 5-47% 60JlbHblX, CTp8,Q8IOU\lllX 513B8HHOlli
6one3Hbto .
Cra,D,11110 n111nopOAYOAeHanbHoro creHo3a
MO)f{HO onpe,D,enlllTb JllllWb np111 conocTasneH111111
KI11.1Hl/l4eCKlllX , peHTreHOI10r1114eCKl.1X, 3HAOCKOnlll-
4eCKl.1X ,D,aHHblX Ill pe3YilbTaTOB lllCCJle,l\OBaHl.151
MOTOpHolli cpyHKL.11111.1 )f(eny,qKa .
K11accucpu1<au,uR nu11opoayoaeHa11bHblX
cmeHo3oB
I CTa,D,1.151 - cpopMlllPYIOL4111VtC51
II CTa,D,lllfl - KOMneHc111posaHHb1 i7t
Ill CTa,D,llls:I - cy61<0MneHc111posaHHblVt
IV CTa,D,llls:I - ,D,e1<0MneHc111poBaHHb1r:.1
nATOC/Jt13t10f/Oft11../ECKt1E t13MEH£Ht1fl B
OPfAHt13ME
,lJ,ecpopMal.\11151 111 cy)f(eH111e n111nopo,D,yo,D,e-
HanbHOi:1 o6naCTlll p83Blll88IOTC51 scne,D,CTBllle
py64eBaHl115l MHOroKpaTHO pel.\lllAlllBlllPYIOLl.llllX
5138 , 4TO sneYeT aa co6or:.1 TY 11111111 111Hyto creneHb
ee HenpOXO,l\lllMOCTlll , HapyweHllle )f(eny,D,04HOVt
3Bat<Ya1.1111111 . C nporpecC111posaHllleM cTeH03a )f(e-
ny.n,oK rep5leT csovi KoMneHcaropHble cnoco6Ho-
crn , pacn1r111saeTC5I , ysen111L11.1BaeTcs:i B cso111x
pa3Mepax, oc11a6esaer ero nep111cTaJ1bT111Ka, 4TO
eLL1e s 6011bweL1 crnneHlll ycyry6ns:ier Hapywe-
Hllle )f(eJ1yA04HOr.1 3B8f<Y8l..lllllll . LlT06bl KOMneHClll-
posaTb onopO)f(HeH111e )f(e11y,D,1<a , Hacrynaer rn-
nepr po¢111s:i era Mb1we4Hoi7t o6ono4Klll 111 yc11111e-
H111e ,QB111raTenbHOIA aKT111sHocr111 . 0,QHaKo raKas:i
pa6ora He 6ecnpe,D,enbHa 111 nocTeneHHO nos:is-
ns:1torcs:1 np111aHa1<111 ee ,D,e1<0MneHca1..1111111 . Psora
)f{eny,l\04Hb1M CO,D,ep)f(JllMblM , 3aMe,D,J1eHllle 3Ba-
Ky8l\lllVI n!ALl.1111 1113 )f(eny,QKa HapywatoT n111raH111e 111
)f(l/l3He,D,es:!TenbHOCTb 6onbHOro. np111 cy6- Ill Ae-
KOMneHClllposaHHOM CTeH03e OTM84atoT
rpeCCV1PYIOL4Vlr:.1 M8Ta6011111L1eCKlllVt 8J1K8J103, Ha-
5l3B pyweH111e BOAH0-3neKTpon111rHoro IA 6enKosoro
6anaHca.
/l,U02HOCmUKO
/{f1UHUl./eCKQR CUMnmoMamuKa
np111 I CTa,D,111111 CT8H03a OTMe4atoTC5l KJ11/1HV1-
4eCKl/le npos:1sneHV15l ocHOBHoro 3a6onesaH111s:1 -
5\3BeHHOr:.1 6one3Hlll . 06w,ee COCT05\Hlll8 6onbHOro
He HapyweHo .
np111 II CTa,D,111111 H8p51,D,Y c «fl388HHblMV1» 6o-
Il51Mlll H8CTOVt4111BO npos:isns:iercs:i 4YBCTBO nepe-
nonHeHl/ls:I s 3n111racrp111111 nocne np111eMa nlllLl.llll.
3nV130Alll4ec1<111 nosmns:ieTcs:1 psora , Koropas:i np111-
Hoc111r 60JlbHOMY 0611er4eH111e Ha HeKOTOpoe
speMs:1 . np111 30H,Q111posaH111111 )f(eny,QKa acnwp111py-
eTc>1 yMepeHHO ysen1114eHHOe (200-500 Mil) KO-
J1lll4eCTBO )f(eJ1YA04HOro CO,D,ep)f(lllMOro c KlllCJlblM
CJlerKa Henplll71THblM 3anaXOM lll npV1M8CblO He-
,D,aBHO np111H>1TblX n111LL1eBblX Mace. 06LL1ee co-
CT0>1HV1e 60J1bHblX He HapyweHO.
np111 Ill CTaAllllll 6oJ1bHOr:.1 OL4YLL1aeT noCT051H-
HOe 4YBCTBO nl)f(eCTlll Ill nepenonHeH l/l s:I B 3n111ra-
CTpaJlbHOi:1 o6nacrn , KOTOpble C04eTatoTCfl c 60-
nbto 111 orpbl)f(KOi:i B03,D,yxoM . E)f(e,D,HeBHO no He-
c1<011bKO pa3 B ,D,eHb 6blBaeT 06111nbH85! pBOTa
cpa3y 111m1 1.1epe3 1-2 Yaca nocne eAbl TOnbKO
4TO npV1H51TOi:1 Ill Cbe,D,eHHOr:.1 Ha KaHyHe n111LL1eVt
6e3 np1113HaKoB J)po)f(eH111s:i . HaToLL1aK s )f(enyAKe
nplll 30HAlllPOB8Hllllll onpe,D,eJ15leTCs:I 60J1bWOe KO-
J1lll4eCTBO co,D,ep)f(lllMoro . B 3Toi7t CTaAlll lll cTeHo3a
6011bHOrll OTMe4aeT noxyAaH111e .
np111 IV CTaAllllll pa3Blll88IOTCs:! nporpeccl.1-
PYIOW,111111 )KenyAOl.\Hbllil cTa3 , pacrs:i)KeHwe )l{eny,[\-
Ka . CocT0>1H111e 6onbHoro yxy,D,waerc51 , Ha611to-
,D,aercfl pe3Koe o6e3BO)f{lllBaH111e. XapaKTepHa
3eMJ1"1CT85l OKpacKa norep>!BWlllX ryprop KO)f(HblX
noKposos . HeAOMoraH111e , anaTVlfl w ss:inocTb no-
,D,asns:itoT ,D,pyr111e ClllMnTOMbl 60J183Hlll . '-lyBCTBO
pacn111paH111>1 B ::in111racTp111111 3acraBn>1eT 6onbHoro
Bbl3B8Tb psory . PBOTHbte MaCCbl 8 orpOMHOM
KOJ11/14eCTBe co,qep)f(aT 3JlOBOHHOe pa311arato-
ll.\eecfl COAep)f{lllMOe c OCTaTKaMltl nlllLl.1111 , Cbe-
,D,eHHOrll MHOro ,D,HeVt H838A. 3neKTp011111THble Ha-
pyweHllls:I s opraHlll3Me , cs>1JaHHb1e c noTepelA
V10HOB K8J1lll51 V1 xnopa , MOryT np111BeCTl11 K pa3Blll-
Tlllto cy,D,opor ( «)f(eny,D,o4Ha>i reraHlt151» ).
/l,aHHble c/JU3UK0/1bH020 06c11eaoaaHUR
np111 Ha4anbHblX CT8,D,lll.51X CTeH038 06LL1ee
COCT0.51Hllle 60J1bHblX He crpaAaeT, pa3Mepbl )f(e-
ny,D,Ka OCT8lOTCfl HOpManbHblMlt!, It! Bblf!Blt!Tb Ka-
KlllX-J1lll60 cne1...1111¢1114eCKlllX ,D,1151 CTeH03a C"1MnTO-
MOB He npe,D,CTaBI151eTC51 B03MO)f(HblM . np111 n03A-
HlllX CTaAlllSIX nporpecc111pyeT n0Teps:1 Maccbr rena ,
3848CTyto 6onbHOVt lllCTOLl.leH , nepKYTOPHO onpe-
Aens:ieTC71 ysen1t14eH111e rpaH1114 )!{eny,D,Ka, np111 ay-
ceynbTal..lllll'I Bb1>1s11s:1erc>1 wyM nnecKa . np111 30H-
AlllposaH111111 1113 )KenyAKa acn111p111pyior s 6onbWOM
Kon1114ecTBe (6onee 500 Mn) aacrnllrHoro )f(eny-
npo- A04Horo co,D,ep)f{111Moro c Henp1115ITHblM 3anaxoM .
70
Jliua2Hocmuyernue Memodb1
PeHrnaeHonoau4eCKoe uccneaoaaHue - 3To
OCHOBHOl.1 MeTOA onpeAeneHlils:! CTaAllllAHOCTlll
pa3BlllTll1s:I CTeH03111pOBaHlll51 np111spaTHlllKa. np111
KOMneHclllpOBaHHOIA CTaAllllll, KpoMe py64oso-
S13 BeHHO~ gecpopMal...llillil s n111nopogyoAeHan1:>Hoi:1
30H e, OTMeYaercs:1 yMepeHHoe ysem1YeH111e pa3-
Mepos >KenyAKa, 3a.qep>KKa 3saKya4111111 6ap111s:1 AO
12 '-laCOB. np1i1 cy6KoMneHC8U,IA\11 - 4epe3 24 48C8
60nbWa51 48CTb 6aplll5l OCTa€TC51 8 >KenyAKe. np111
AeK0MneHca1..1111111 Bb15lsmuorc51 pacw111peH111e 111 oc-
.na6.neH111e nep111cranbTll1Klil )l{e.nyAKa c 3a.qep)l{Ko\'.:1
scei.:1 nop1..1111111 6ap111s:1 s >KenyAKe 4epe3 24 Yaca.
330cf;aaoaacmpoayoaeHocKonuH. Ha paH-
H111 x CTaAll151X CT€H03a B n111nopo6ynb6anbHOIA
30He Bb151BJ151eTC51 rpy6a51 py640BO-s:l3BeHHaSl
,llecpopMal.111151 c OTHOCll1T€JlbHblM cy)l{eHllleM f:laH-
HOVi o6nacrn , He npens:1rcrny10U\ll1M npoBeAeHllllO
3HAOCKona B Hlil>Kene>KaU\111€ OTA€flbl ABeHaA1..1a-
rnnepcTHOlil KlllWKlll . np111 n03AHlllX CT8Alll51X CTe-
H03a Bb1s:1sns:iercs:i pe3Koe cy>1<eH111e n111nopoAyo-
AeHanbHOro KaHana, Aena10U\ero HeB03MO>KHblM
npOBe,[\eHllle 3H,0,0CKona Ill OCMOTp Hlrr>Kene)l(a-
U\lllX or,o,e.nos ABeHa,n,1..1arnnepcTHoi:1 KlllLUK111;
KpOMe roro , orMeYaercs:1 3Ha1.1111renbHoe ysen111-
YeH111e pa3Mepos >KenyAKa c np1113HaKaM111 Hapy-
weH111s:1 3saKya4111111 1113 Hero.
na6opaTOpHa51 ,lllll8fHOCTlllKa (nplll n03AHlllX
CT8Alll51X CTeH03a) onpeAen51eT nplll3H8Klll MeTa-
6onlil4eCKOro anKano3a, r111noKa.n111eM111111, r111no-
npore111HeM111111 .
/7el..feHue
KoHcepeamueHafl mepanufl np111 n111nopo-
AYOAeHaflbHOM cTeHo3e_i:is.ns:1erc51 no csoei.:1 cy-
Tlil npeAonepa41110HHOIA nOAfOTOBKOi:i 6onbHblX K
nnaHOBOMY x111pypr1114eCKOMy BMewarenbcTBy.
0Ha HanpasneHa Ha 3a>K1rmneH111e aKTlllBHoi.1 s:13-
Bb1 c np111MeHeH11teM cospeMeHHblX aHTlllCeKpe-
TOpHblX cpeACTB Ill 8HTlllX€JllllK06aKTepHblX npe-
napaTOB.
KpoMe roro , np111 111MeKlll.\lllXcs:1 paccrpolil-
crnax ne1.1eH111e .QOJl>KHO 6b1Tb HanpasneHo Ha
KoppeK41111<J o6MeHHblX npo4ecCOB 111 BOCCTaHOB-
neHIAe Maccb1 rena . 3ro AOCT111raercs:i napeHTe-
panbHblM BBe.QeH111eM coneBblX 111 6enKOBblX pac-
rsopos, a raK>Ke npoBeAeH111eM 30HAOBOro 3HTe-
panbHoro n111TaHll15! np111 Bblpa)f(eHHblX CTaAlllSlX
CTeH03a (30HA npOBOAlllTC51 Hlil>Ke 06nacT111 cre-
H038 c noMOU\blO 3HAOCKOnlil'-18CK0"1 TeXHlllKlll).
Ba>KHoe 3Ha4eH111e cneAyer YAen111rb soc-
craHosneHlllto 11111111 yny'-ILUeH11110 AB111rarenbHOIA
cpyHKU,111111 }l(eflyAK8, C03A8B ycnOBIAs:! Afls:I npo<;p111-
naKTlllKlll pa3s111r111s:1 nocneonepa1..11110HHblX ocno)f(-
HeH111Vi , BKfll04alOU\lllX MOTOpH0-3BaKyaTOpHble
paccrpoVicrsa. C 3Toiil 1...1enbKl np1r1MeH5llOTC5I co-
speMeHHb1e npoK1t1HernK1r1 , a TaK)f(e AeKoMnpec-
Clilfl >KenyAKa (cppaKL!lllOHHOe 30HAlilPOBaHll!e )f(e-
IlYAKa n11160 nocros:1HHas:1 acn111pal...!111s:1 Yepe3 Ha3o-
racrpanbHbl"1 30HA) -
71
Xupyp8U4ecKaR maKmuKa. A6comoTHblM
noKa3aH111eM K onepal...!111111 s:1sm:110rcs:1 no3AH111e (Ill
1i1 IV) craAll1lil n111nopo,LWOAeHan1:>Horo creHo3a.
Onepal...!111ei:1 Bb16opa 51sns:1ercs:1 pe3eKL!Lr1Sl )f(enyA-
Ka. (nepsa5l pe3e1<4111s:1 >KenyAKa no noBOAY H3-
BeHHOIA 6one3Hlil 6b1Jla BblnOJlHeHa 8 1881 ro,D,y
HeML1eM P111A111repoM lllMeHHO no noBOAY creHo-
3a) . KaK sap111aHT y 6onbHblX, HaXOAHL41t1Xcs:1 a
nn1<.enoM cocTos:iH111111, Aonycr111Ma racTpo3HTepo-
111n111 racrpo,ayoAeHOCTOMll1fl.
3aAa4ei:1 cospeMeHHOVi racrpo3Hreponor111111
51Bn51eTC51 CBOeapeMeHHOe Bbl51BJ18Hlr1e 6onbHblX
513BeHHoi:1 6one3Hbto 111 111x aAeKsaTHoe ne'-leH1i1e,
Aa6b1 He AonycTMTb pa3s1r1rnH rs:n1<enb1x ocno>1<-
HeH111t1 . np111 111X 803Hlr1KH088Hllllil x111pypr111 AOJl>KHbl
He ronbKO o6ecne4111Tb xopow111e 111 oTJ11114Hble
Henocpe,D,cTBeHHb1e pe3yflbTaTbl, Ho 111 C03AaTb
ycno0111s:i Ami 6b1crpeiiiwei:1 pea6111n111ra1...1111111 nal...!111-
eHTOB s paHHeM nocneonepa41110HHOM nep1110,D,e
111 npegorspall..\eHll!fl peu,111,ll,111sos s:t3BeHHoiii 6o-
ne3Hlll .
nEHETPVIPYIOLLWIE R3Bbl
neHeTpa4111.S1 ff3Bbl - 3TO pacnpOCTpaHe-
Hllle Sl3BeHHOro ,QecfleKTa 3a npeAenb1 cepo3Hoi.1
o6ono4Klll >KenyAKa 111n111 12 - nepcTHoi.1 KlllWKLr1 ,
np111 3TOM AHOM 513Bbl s:isns:iercs:i COC€AH111Lii opraH:
• no,Q>KenyAo'-IHaH >Kene3a,
• ne'-leHb,
• Kll!We4HlllK,
• ne48H04H0-12-nepcTHa51 CBH3Ka,
• canbHlilK.
XapaKTepHbl:
- ,QJllllTeilbHbli'.:1 s:!3BeHHbli'.:1 aHaMHe3 ;
- 1113MeHeH111e xapaKTepa 6onei:1 (y>KecroYe-
Hllle 6oneiii , 111x nocros:iHHblill xapaKTep, 111ppa.q111a-
4111H s cn111Hy - ClllMnTOM Eioaca);
- He3cpcfleKTll18HOCTb KOHCepB8Tlt1BHOfO ne-
'-leHlilSl .
PeHTreH011ornL1ecK111:
- 513BeHHas:i «HlllWa» 6onbw111x pa3Mepoa
(p111c. 13);
P111c. 13. neHeTp111pyt0u.taS1 .Sl3Ba Tena
}f(enyAKa.
Eio11bwoe .Qeno B3eec111 cy11b<J>aTa 6ap111.S1
BHe KOHT}'pa >KeJly,QKa.
- Tpexcnoi.1HOCTb 8 Sl3BeHHOIA «HlllWe» : 6a-
p1r1esafl 838€Cb, >KlllAKOCTb, B03AYX;
- nanbnaTOpHas:I HenOABlll)f(HOCTb ,D,OnOJ1Hlr1-
TenbHOro 06pa3osaH11rn;
- Han1114111e nepewei.1Ka;
- AillilTenbHaSl 3a,D,ep>KKa s3sec111 6ap111s:i s
«Hlr1W8» .
fie"leH111e:
- oneparnsHoe no ycnosHo-a6con10THblM
noKa3aH111s:1M .
 PAK )l{EJIY,nKA
HecMoTp51 Ha ycToi1Y111sy1-0 B nocneAH111e ABa
AeC51Tll1fleTll151 TeHAeHL..11111-0 K CHll1>KeHll11Q 3a6one-
saeMOCT111 , paK >1<enyAKa 51BI151eTc51 OAHOIA 1113 ca-
MblX pacnpocTpaHeHHblX cpopM 3flOKaYecTBeH-
HblX onyxoneii1 YenoseKa . E>t<eroAHO B M111pe pa-
KOM >1<enyAKa 3a6onesa1-0T 6onee 1 MflH. Yeno-
seK, yAeflbHbllA sec 3TOIA naTonor111111 cocrnsn51eT
15,4%, a CMepTHOCTb AOCT111raer 31 ,3% Ha
100000 HaceneH1115I. ,lJ,n51 scex 3aper111cTp111po-
saHHblX 6onbHblX 5-neTH5151 Bbl>Kll1BaeMOCTb co-
CTaBI1518T 10-15%. 3a6onesaeMOCTb paKOM >Ke-
nyAKa HeOAHOpOAHa li1 3HaYli1TenbHO pa3nli1YaeT-
C51 B pa3HblX CTpaHax 111 pernoHax M111pa, YTO ro-
BOp111T 0 Bf111151Hllllll Kflll1MaToreorpac:jJ111YeCKll1X, 6bl-
TOBblX, nli11.l..!8BblX 111 APYrlllX c:jJaKTopos Ha ero
B03Hll1KHOB8Hll1e. 3a6onesaeMOCTb paKOM >Ke-
IlYAKa nOBblwaeTC51 c B03paCTOM 111 Ha1116onee
YacTo scTpeYaeTc51 y n111L1 cTapwe 50 neT. My>1<-
Yll1Hb1 6one10T s 2-2,5 pa3a Yal.l..!e, YeM >KeHl.l..!111-
Hbl , np111YeM y nO>K111IlblX nal..11118HTOB 3Ta pa3Hll1l..18
ysen111Y111saeTC5I el.l..!e s 6onbwelA creneH111. MaK-
c111ManbHb1ii1 yposeHb 3a6onesaeMocr111 paKOM
>KenyAKa B M111pe OTMeYeH y MY>KYll1H ~nOHll1111
(114,7 Ha 100 TblC. HaceneH1115I) , a M111H111Manb-
Hbti.4 y 6enb1x >K8H1.1..!111H CWA (3,1 Ha 100 Tbtc.) .
Bb1c0Ka5I 3a6onesaeMOCTb paKoM >KenyAKa oT-
Me4eHa s K1r1rae, 5enopycc1r11r1 , Pocc1111r1 , 3cro-
H111111, naTBll1111 , Hosolli 3enaHAlr1111 (Maop111).
3a6onesaeMOCTb paKoM )l(enyp,Ka B Pocc111111
111 Meer reHAeHL..11111-0 K cH111>1<eH11110. Ecm-1 B 2001
roAY "rpy6b1Vi noKa3aTenb" 3a6oneeae~ocrn co-
crnsn51n 38,4 Ha 100 TblC. HaceneH1Mr, TO B 2010
roAy 3TOT noKa3aTef1b cocras111n 30,3 Ha 100000
HaceneHlll51.
,lJ,1t1HaM111Ka 3n111AeM111onor111YeCKll1X 111CCI18AO-
BaHlllVi , npOBOAVIMblX B pa3IllllYHblX CTpaHaX Miil-
pa, no3son5leT CAenaTb BbtBOA o non1113rnono-
rli1YHOCT111 paKa )f(8IlYAKa, pa3BlllTll1e KOTOporo on-
P8A8I1518TC51 L1ef1blM P51AOM BHewH111x 111 sHyTpeH-
H111x MOA111¢111Llli1PYI01.1..!111X cpaKTOPOB . K nepBblM
OTHOC51T c:jJaKTOpbl BHeWHelA cpeAbl, B03AeiAcT-
BIAe KaHu,eporeHHblX areHTOB, oco6eHHOCTlll n111-
TaHlll5I , KO BTOpblM - 111M810l.l..!111eC51 np11106peTeH-
Hble lr1fllll HacneACTBeHHbte HapyweHVl51 lllMMYH-
HOIA 3al.l..!111Tbt, c:jJoHOBble 3a6onesaHlll51 >KenyAKa,
cTapeH111e, reHeT1r1YecKa5I npeApacnono>KeH-
HOCTb. 061.l..!enpVl3HaHO, YTO paKY >KenyAKa 3aKO-
HOMepHO npeAwecrnyeT P51A 3a6onesaH1r1Vi, Ko-
Topbte xapaKTep1113YIOTC51 KaK npeApaK. PeKo-
MeHAyerc51 Bb1A8Il51Tb npeApaKOBbte COCT051Hlll51
(¢aKYflbT8TlllBHbllli npeApaK) Ill npeApaKOBble 1113-
MeHeHf/151 - AVICnJ1a31i151 (06n111raTHbti1 npeApaK).
K npeApaKOBblM COCTOHHMHM OTHOCHTCH:
• xpOHUl/eCKUU 2acmpum pa3JllllYHOi1 3TlllO-
Il0rli1111 , B TOM YlllCfle ayrOlllMMYHHbtVi racTplllT Tl/I-
na A, conposo)f(Aa10l.l..!lllii1c51 nepH111l..llll03Hoi1 aHe-
M111elll ;
• aaeHoMamo3Hble nonunb1 >KenyaKa;
73
• xpoHullecKafl fl3ea >KenyaKa ;
• pe3eU,UpOB8HHblU >KenyooK no noeoay
006poKa11ecmeeHHb1X 3a6oneeaHuu;
• 6one3Hb MeHempue.
XpoHUl/ecKuiJ eacmpum (HeKOTOpb1e 111c-
cneAOBaTen111 ero paccMaTp111satoT KaK racTpona-
Tlr1s:! , T.K. aTpoc:jJ111YecK111e 111 npon111c:jJepaT111BHb1e
npo1..1eccb1 npesan111py10T HaA socnan1r1rnnbHbl-
Mll1) npeAW8CTByeT B03HlllKHOB8Hlr11Q paKa >Ke-
IlYAKa s 73,5-85% cnyYaes.
~3 scex Tll1nOB racTpll1Ta B 3HaYlllT8IlbHOi1
Mepe npeo6naAaeT xpoH111YecK111IA xen111Ko6aK-
rnpHb1Vi racTpll1T rnna B. XpoH111YecKoe nepc111-
crnpy1-0l.l..!ee 111Hc:jJ111L1111posaH111e H.pylori Bbl3blBaeT
raCTp111T c 3n111TemianbHblMlll nospe)f(AeH111s:1M,
All1CTpoc:jJ111ei1, oYaraMlll pereHepaL..1111111 3n11rnn11151 B
KaM6111anbHblX 30Hax, KOTOpas:i , B CBOIO oYepeAb,
CB513aHa c noBblWeHHOtll npomi1cpepaTlllBHOVi aK-
TlllBHOCTblQ Cflli13bCeKpernpyl-Ol.l..!8rO 3nli1T8f111151 ,
o6ycnosneHHotll 3Kcnpecc111etll npoTOOHKoreHoB
bcl-2 , bcl-x. r111nepnna3111posaHHbte KfleTK111 no-
KposHa-HMOYHoro 3n111Ten111s:1 noCTeneHHO 3aMe-
L1.1a1-0T 3n111Ten111Vi cne1.1111an11131r1posaHHbtX >1<ene3,
YTO Bbl3blBaeT lllX aTpoc:jJ1r110. c TeYeH111eM spe-
M8Hll1 npOlllCXOAlr1T pacnpocTpaHeHllle aTpocp111Ye-
CKOro npm_\ecca \113 n1t1nopoaHrpanbHoro OTAena
B o6naCTb Tena 111 AHa )f(8flYAKa. no3TOMY AJ151
xpoH1r1YecKoro racTp111Ta rnna B xapaKTepHbt 60-
nee rny60K111e aTpoc:jJ1r1YecK1r1e 1113MeHeH111fl >Kene3
aHTpanbHoro OTAena opraHa , YeM Alr1CTanbHblX
oTAenos. B c:jJ111Hane pa3s1r1saeTC5I Heo6parnMa51
ar pocp1r151 3n111Ten11151 >Kene3 scex OTAenos cn1113 111-
croi1 060110YK111 >1<enyAKa. 111 Aa>Ke nocneAYl-01.1..!ee
nOflHOe lllCKopeHeH111e H.pylori He BeAeT K BOC-
CTaHOBI18HllllO MOpc:jJonornYeCKll1X xapaKTep111CTll1K
Ill cpyHKL..1111111 cneL1111an11131r1posaHHblX Kf18TOK >Kene3.
nATOMOPC/J0/10(Vffl. C/JOPMbl POCTA.
K11accucj:JuKau,uR paKa )l(e11y0Ka
B >Keny,llKe BblAefls:!l-OT sepxH111i1 (C), cpeA-
Hli1ii1 (M) 111 H111>KHll1ii1 (A) OTA8Ilbl , rpaHli1l..lbl KOTOpblX
ycnOBHO npoBeAeHbl Yepe3 TOYK111, pa3Aef15110-
w,111e paBHble TpeTbl/1 Y8CTlll Manotll 111 60ilbWOlll
Kpli1Bll13Hbl. nonepeYHa51 OKPY>KHOCTb >KenyAKa
pa3Aef1518TC51 Ha 4 paBHble Yacrn , OTHOC511.l..!1118C51
K Manolli 111 6onbwo~ Kp111s1113HaM , nepeAHelli li1
3aAHelli cTeHKaM . 4aw,e scero paK nopa>KaeT n111-
nopoaHTpanbHb1Vi OTAen >KenyAKa (60% Ha6n10-
AeH111i1). Ha ManoVi Kp111Bll13He Kapf.1111HOMa pa3Blll-
BaeTC51 y 20-25% 6onbHblX, B npoKCll1M8flbHblX
oTAenax - y 10-15%, Ha nepeAHeVi 111 3aAHetll
CT8HKax - B 2-5% Ha6I11-0A8H1111\ TOTailbHOe no-
pa>KeH111e per111cTp111pyeTcH y 5% naL11t1eHTOB.
PaK >KenyAKa nop,pa3,ll8Il5llOT Ha ABe OCHOB-
Hble KaTerop1111r1 - paHHll11A 111 pacnpocTpaHeHHblii1.
)J.n51 Mopc:jJonor1114ecKoill xapaKTep111crnK1t1 pac-
npoCTpaHeHHoro paKa )f{enyAKa np1t1MeHs:ieTC5!
KJ18CCl!IQJl!IKaL\lt151, npeAJlO)f{eHHa51 B 1926 r.
R.Borrmann . ComacHo 3TOL1 KnaccucjJuKau,uu
np111H51TO BblAens:iTb 4 rnna K8PL\l!IHOM :
I rnn - nonuno3HBf1 (rp1t16os1t1,o,Has:1) cpopMa;
II rnn - U3bf13BneHHaf1 (6nt0AL\eo6pa3Has:i)
cpopMa;
Ill rnn - 513BeHH0-1t1HQJ1t11lbTparnsHa5! cpop-
Ma;
IV rnn - aucjJcjJy3Ho-uHcjJunbmpamuBHaf1
cpopMa onyxon111.
Ho Ha npaKT1t1Ke 6onee yp,o6Hoi1 s:isns:ieTcs:i
pa3,o,eneH1t1e Ha Tpl!I Mopcpo11or1114ecK1t1X rnna
pocTa paKa )f{enyp,Ka . c HlllMl!I MO)f(HO CB513aTb
oco6eHHOCTlt1 Knlt1Hlt14eCKOL1 Clt1MnTOMaTlt1Klt1 3a6o-
neBaHl!l51 l!I xapaKTep MeTaCT831!1pOB8Hl!l51.
• 3K30<l>MTHblH (no111t1nOBlt1,D,Hbli1, rp11160-
Blt1,D,Hbli1, 6JllO,D,L\e06pa3Hbli1 , 6mH.UKOBlt1,D,Hbli1)
poCT onyxo111t1 xapaKTep1113yeTC5! 4eTKlllMlt1 rpaH1t1-
L1aM111.
• Ha1116onee 31lOKa4eCTB8HHO npoTeKaeT
paK :>Kenyp,Ka, OTnlt14atOL4111i1C51 3HAO<l>MTHblM
(uHcjJUnbmpamu8HblM) T1t1noM pocTa.
• TaK)f{e cyll!ecrnyeT cMewaHHblH rnn
pocTa onyxon1t1 , Kor,o,a npo1t1cxop,1t1T co4eTaH111e
3118M8HTOB Kai< 3K30-, Tai< lt1 3H,D,OQJIATHOfO pocra
onyxo111t1.
r1t1cTonor1t14eCK08 CTpOeHl!le paKa :>Kenyp,Ka
OTJ11/14aeTC51 6onbWlt1M MHOroo6pa31118M , 4TO OT-
pa31!1fi0Cb B C03A8Hl!ll!I MHOrD41!1Cfi8HHblX Knac-
Cl!IQJl!IKaL11t1L1. An51 yH1t1cp111KaL11111t1 r111cTonor1114ecK1t1X
3aKJlt04eH111lll paKa >Keny,o,Ka npe,o,11o>KeHa Me>K-
p,yHapoAHa51 Knacc1t1cp1t1KaL1111s:1 803 (1977). Co-
macHo :Holl! Knacc1t1¢1t1KaL11t11t1 BblAeneHbl: aAe-
HOKapQMHOMa - nanunnflpHafl, my6ynRpHaf1,
cnu3ucmaR 111n1t1 MYL\l!IH03Has:i (Konno1t1AHb111! paK) ;
nepcmHeBuaHoKnemolfHaR; HeaucpcpepeHu,upo-
8aHHb1D paK; >Kene3ucmonnocK0KnemolfHb1D paK;
nnocKoKnemol./HbliJ u HeKnaccucjJuu,upyeMbJiJ
pa Kl/I.
Ap,eHOKapL\l!IHOMbl nOApa3Aefi51IOTC51
CTeneHM AM<l><l>epeHQMPOBKM Ha:
a. BblCOKOJJ,lt1QJQJ8peHL\l!IPOBaHHYIO, npl!I KO-
ropolll 3n111Ten111a11bHb1e KOMnneKcb1 BblCTJlaHbl
BblCOKl!IM L\l!lfilllH,D,p1t14eCKl!IM 3n1t1Ten1t1eM ;
b. yMepeHHOA1t1¢cpepeHL11t1poBaHHYIO - 3n1t1-
re111t1L1 KOTOpoi':1 o6pa30BaH 6011ee ynllOL48HHblM
Ky61t148CKl!IMl!I KneTKaMl!I l!lfilll o6pa3ytOT COfil!IP,-
Hble cn1t1sat0w,111ec51 ,o,pyr c ,o,pyroM KneT04Hble
nnacTb1;
C. He,o,111cpcpepeHL\lllPOBaHHOMy, K KOTOPOMY
orneceHa onyxonb He ¢opM1t1PY10LJ.!af1 >1<eneJ1t1-
cTonop,06HblX CTPYKTYP, KneTKlll KOTOpolll 111Met0T
"paccbmHoL1" xapaKTep pocTa. Bo MHornx c11y4a-
s:ix 06Hapy)K111Bat0TC5! C04eTaHlt151 pa3nl!l4HblX rlt1C-
TOJ10rlt148CKl!IX cpopM paKa >Keny,o,Ka.
METACTA3//1POBAH//1E. CTA,ll,//1//1 PAKA
>KEJ7Y,D,KA
PaK menyAKa MeTacTa3i.tpyeT:
• flUMcjJoaeHHO;
• aeMamoaeHHo;
UMnnaHmau,UOHHO unu KOHmaKmHO no
6p10W1t1He.
Ho MOryT BCTpe4aTbC5l pa3111!14Hble KOM61t1-
HaL11t11t1 scex Tpex nyTelil MeTacTa31t1posaH1t1R PaK
)Kenyp,Ka npelllMYL48CTBeHHO MeTaCTa3111pyeT
n111McporeHHblM nyTeM . 4al4e OTMe4aerc51 cne-
AY10W,a5! nocne,o,osare11bHOCTb Meracrn31t1posa-
H1t1f1: BHaYane nopa)f(alOTCfl pernoHapHble nwM-
cparn4ecK111e 6apbepbl (n111McpaT1114ecK111e Y31lbl ,
pacnono)KeHHble B CB513Kax )f{eny,o,Ka) , 3arnM
11111Mcparn4ecK111e y3nb1, conposo)f(Aatow,111e Kpyn-
Hble aprnp111111 n111rniow,111e )f{eny,o,oK 111 B ,[lallbHeL1-
weM 3a6pt0WVIHHbl8 nlt1MQJOY3Ilbl 111 opraHbl
6p10WHOL1 nonocrn.
Pa3111114atoT 4 6acceMHa 11111McporeHHoro ny-
r111 MeTacTa3111pOBaHl!l51 (no A.B.MenbHll1KOBy,
1960) (p111C. 14).
/
62
ee3-,~~~
.e c;.o
•.) 4
Puc 14. l/emb1pe 6accei1Ha nuMcpo2eHHOZO nymu
Memacma3UpoeaHUfl no A.B MenbHUKOBY (cxeMa -
noRcHeHUR s meKcme).
I. nepsb1V! 6acceV!H: onoK 11t.-1Mcpb1 npo111c-
xo,o,111r t.-13 6011bwolil KP111Blt13Hbl n11111op1114ecKoro
DTAena, a TaK>Ke np111nera10w,111x nepeAHeL1 111
no Ja,D,HeV! crnHoK. Ko11neKTOpb1 n1t1Mcpoon0Ka: 1)
)f{eny,D,01.1Ho-060A04Has:i CB513Ka, 2) peTpomrno-
p1114ecK1t1e Y31lbl , 3) 6pbl)f{eV!Ka Ha4anbHDlll YacTt.-1
TOHKOL1 KVIWKVI, 4) 3a6plOWlllHHble n111MQ:>aT1114e-
CKl!le Y31lbl (napaaopTallbHble).
II. BropoV! 6accell!H - n111MQJOTOK 1113 Manoi1
Kpl!IBL13Hbl n11111opt.-14ecKoro OTAena 111 np11111erato-
w,eV! nepe,[lHeL1 1t1 3a,[lHeV! creHoK. Ko1111eKTopb1:
1) no ManoV! Kp111s111JHe, 2) no XOAY npasolil >Ke-
11y,o,ol!ttoV! apTep1111.1, 3) soporn nel.JeH1t1 , 4) BHYT-
pL1 ne4eH111.
Ill. Tpernt4 6acce'4H - OTTOK nt.ifMQJbf 1113 Te-
na )f(enyAKa , KapA111anbHOro OTAena Manolll Kp111-
Blll3Hb1 , M8Alt18JlbHOL1 l.JaCTlll CBOAa >Keny,o,Ka.
KonneKTopbi: 1) Manb1V! ca11bH1t1K; 2) )f{e11y,o,ol.JHO-
noA)f(enyA04Has:i CB513Ka; 3) 3a6plOWlllHHbl8 Ha,[l-
naHKpeaTl!l48CKlll8 l!I napaaoprnnbHble nl!IMQJO-
Y3Ilbl , 4) cpeAOCTeH111e - napa33ocpareanbHble
Y31lbl BblWe ,D,1t1acpparMbl.
IV. LJernepTbllll 6acce171H - 1!13 sepT111KanbHO-
ro OTAena 6onbwoV! Kplt1Bl'13Hbl , np111neratow,eV!
74
nepeAHetA Ill 3aAHell1 CTeHKlll , 3Ha4111Te.nbHOtA 4ac-
rn CBOA8 :>KenyAK8. KonneKTOpbl: 1) :>KenyAO'-IHO-
o6oA04H851 CB513Ka, 2) )l{e.nyA04HO-
cene3eHOl.JH85l cs513Ka, 3) sopoTa ce.ne3eHKlll , 4)
ce.ne3eHKa.
PaKY :>Ke.ny,D,Ka csoi.:1cTBeHHO pacnpocTpa-
H51TbC51 no :>Ke.nyA04HOtA CTeHKe BBepx no TOKY
fHIMQJbl B CTOpoHy Manoi.:1 Kp11181113Hbl )l{e.ny,D,Ka Ill
:>Ke.nyA04HO-nO,D,)l{e.nyA04Hoi.:1 CB513K111 , rAe pacno-
.no)l{eH r.naBHbli.'.1 Ko.n.neKTop .n111McpOOTTOKa :>Ke-
.nyAKa.
0AHaKO, c.no:>Klll8WllleC51 npeACTa8.neHll151 0
nocne,D,o8aTenbHocrn , 3TanHocrn .n111Mcpoon0Ka
Iii MeracTa3wposaHJA5l He scer.Qa onpaB.Qb1Ba10T-
C5l . nplAMepHO 8 25% CJly1.Jae8 OTMe4alOTC51 "Ha-
pyUJeHi/15111 3TanHocT!ll .n111McporeHHoro MeTacTa-
3111po0aH1115I . Bee 3TO onpa8,LJ,b1BaeT np111MeHeH111e
onepa~1.-1!.1 pacw1.-1peHHblX n"1MQJaAeH31<TOM"111 ,
oco6eHHO np111 nopa:>KeH111111 paKoM Tena :>Ke.ny,D,Ka ,
Kap,LJ,111a.nbHOi.:1 1.JaCT!ll 111 TOTaJlbHOM nopa:>KeHll1111
opraHa .
.RnoHCKlllM o61..L(eCT80M no 1113y4eH!t!IO paKa
)l{e.ny,D,Ka (1981) 6b1.na pa3pa6ornHa K.nacc111cp111-
Kau,11151 rpynn n111McpT111'-lecK111x y3.no0 , Ha1116onee
'-lacrn nopa:>Katol..L(lllXC51 MerncTa3aM111 np111 paKe
)l{eny,D,Ka, 8 KOTOpOtA on111caHO 20 KOHKpeHTHblX
perl!IOHapHblX JllilMcpoy3.n08 8 KOTOpblX noc.ne-
P,OBaTe.nbHO npOlllCXO,Ll,111T MeT8CT83111p088Hlile.
YacToTa nopa:>KeHlll51 pa3Jllil'-IHblX rpynn perno-
HapHblX .n111McpaT1114eCKlllX y3.no8 388lilClilT OT .no-
K8Jllil38U,llllil nepBlil'-IHoi/1 onyxon111 111 npo111cxo,LJ,111T
3T8nHO OT N 1 AO N3.
• N1 - mtM<jloy3nbl (n/y) nepsoro no-
PHAKa:
o npa0b1e napaKapp,111a.nbHb1e n/y
o nesb1e napaKapA1.-1anbHb1e nly
o n/y Manoi;\ Kpli1Blil3Hbl :>Keny,D,Ka
o .n/y 6onbwoi.:1 Kp111s1113Hbl :>Keny.o.Ka: 4s (11e-
0a51 rpynna) - .n/y 0p,onb ne001/i >Kenyp,o'-IHO-
canbHll1KOBol1 apTeplillil Iii KOpOTKlllX apTep111!11 :>Ke-
nyp,Ka, 4d (npasaH rpynna) - n/y 8,LJ,Onb npa00!11
:>Keny,D,O'-IHO-ca.nbHlllKOBOi/1 apTep111111
Tnn xnpy pn1qec1rnro RMeU1aTeJI1:.cTsa ea ocHosaeun o6beMa
Tun BMeuraTeilbcTBa
Crau.n.apTHaJI racrp3KTOMM5.1 D l
CraH,n:apTHa.sr pa,nuKarrI>Ha5.I raCTp3KTOMIDI D2
PacmHpeHHM pa.n.uKaJibHaJl racTp3l<TOMirn D3
PMc. 15. A - nMMcpaAeHOAMcceKUlll.ff
D 2, 6 - npasb1w :nan m1Mct>aAeHOAHcceK-
UMlll D 3. A) KYilbTst nesolil >KenyAO\.fHOH ap-
TepMM; 2-o6~aS1 ne\.feHO\.fHaSI apTepMH;
3-racTpO,QYOAeHail bHaSI apTepMSI;
75
0 Ha,D,np111spaTHlllKOBble .n/y
o nop,np111spaTH1t1KOBb1e n/y
• N2 - nMMQJOY3nbl BTOporo nopSIAl<a:
o n/y 8,IJ.Oflb nesoi/1 :>Keny,o.o'-IHOl1 apTep111111
o nly BAOflb 061.1.(eCf ne4eH04Hoi1 apTep111111
0 n/y BOKpyr 4peBHOro CTBOfla
o n/y 0opoT cene3eHK111
o n/y B,LJ,Oflb cene3eHO'-IHOll1 apTep111111
• N3 - nMM<jloy3.nb1 TpeTbero nopHAKa:
o n/y ne4eHO'-IHO-,D,BeHa,D,u,anmepcTHOi.:1
CB513Klll
o peTponaHKpeaT1114ecK111e n/y
0 .n/y KOpH51 6pbi:>Kel1Klil
o n/y BoKpyr cpe,D.Hei.:1 o6o,D,o4HOll1 apTep111111
o napaaoprn.nbHble n/y
o Hlll:>KH111e napa33ocpareanbHble n/y
o ,D,111acpparMaflbHb1e n/y.
B CB513111 c yKa3aHHoi.:1 rpynn111posKoll1 np111 pa-
Ke :>Keny,D,Ka 6b1.no onpe,D,eneHo noHHrne Tpex
CTeneHei/1 pa,LJ,lllK8flbHOCTll1 f1111Mcpa,D,eH3KTOMll1lil.
Bos.ne4eH111e m1Mcpan14ecK111x KonneKTopos N1 -
N2 paccMaTp111saeTcs:i KaK pernoHapHoe MeTa-
CTa3111posaH111e, np111 nopa)l{eH111111 .n111Mcpoy3nos
Kon.neKTopa N3 cY111TaeTc5l oT,D,aneHHblM MeTa-
cTa31AposaH1AeM . y naljl!1eHTOB c BOBfleYeHHO-
CTblO OT 0,IJ.HOro AO wecrn JllllMcpoy3flOB 5-
f18TH51S'I 8bl>t<111BaeMOCTb COCTaB111.na 45 ,5%, OT
CeMlll AO 15 - 5-.neTHS'lS'l Bbl:>KlllBaeMOCTb 6b1Jl3
29,7%, IA y naljlAeHTOB c MeTaCTa33MIA 60.nee
4eM B 15 .n111McpOy3flOB , 5-neTHSUI BbDi<lllBae-
MOCTb COCTa8111.na 10,4%. Pa3nll1YHble Bap111aHTbl
mt1McpaAeH3KTOMllllll llln1!1 mitMcpO,lllllCCeKU,111111 xa-
paKTept-13YIOT o6beM oneparnsHblX BMewa-
TenbCTB (Ta6.n111u,a 2, p111c. 15 111 16). Cor.nacHo
3TOi.:1 K.nacc111cp111Kau,111111' sap111aHT J1111McpO,D,lllCCeK-
U,111111 K.nacc111cp111u,111pyeTc5I Ha ocH0BaH111111 nocneA-
Hero 3Tana MeTacra3titposaH1t1s:t.
Ta6ma1a 2
JI1tM<IJo.u ucce1.:.~nn
06'beM rrwMcpo.n.11cceK.u:1u1
Nl N2 N3
+ - -
+ + -
+ + +
4-co6CTBeHHaSI ne\.feHO\.fHaSI apTepMSI;
5-xoneAox.; 6-i<yilbTff npasolil >KenyAO\.fHOM
apTepMM; 7-eopoTHa.st eeHa. 6) 1-aopTa;
2-HM>KHstSI nonaH eeHa; 3-neeast nonaH se-
Ha; 4-HM>KHSISl 6pbDtcee\.fHaSI apTepMS1.
 leMaroreHHO Ha1116onee 4acro paK >1<enyp,Ka
Meracra3111pyer B ne4eHb. Pe>Ke Meracra3bl 06-
Hapy>1<111sator B nerKlllX, Hap,no4e4HlllKaX, KOCHIX,
nop,Ko>KHoi:;l Kner4arKe 111 AP· 111MnnaHral.!1110HHble
Meracra3bl cpopM111pytorcfl np111 KOHTaKTHOM ne-
peHoce onyxoneBblX KneroK, B pe3ynbrare no-
5'1Bnfltorcfl MHO>KecrBeHHble MeraCT83bl no 6pto-
WV1He B Blllp,e MenKo6yrplllCTblX BblCbln8HVli;! -
K8PL.!111HOMaro3a 6ptoWL1Hbl, conpoBO>K,QalOLJ.lero-
Cfl aCL.!111rOM.
P111c. 16. IleebtH 3Tan .n111McpaAeHOAlllC-
ceK1-'llllll D 3. 1-ce.ne3eHol.IHasi apTep111si;
2-ce.ne3eHOLIH3SI BeHa; 3-eepXHSISI 6pb1>Ke-
e1..1HaS1 eeHa; 4-eepxHSISI 6pb1>Kee1..1Hasi apTe-
p111si; 5-.neeasi no1..1e1..1Hasi eeHa; 6-neeasi ro-
Ha.QHasi BeHa; 7-.neBblH MOLleTOLIHlllK;
8-nO,Q>KeJlyAOLIHaSI >Ke11e3a; 9-KYilbTSI JleBOH
>1<e11y.Qol.IHOH apTep111111 ; 10-.neeasi no1..1e1..1Hasi
apTep111si; 11-neeasi no1..1Ka (s pyKe acc111-
cTeHTa), eepxHlllH nomoc noc.ne aApeHa-
113KToM111111.
HeKoropb1e orp,aneHHble Meracra3bl np111
paKe >1<eny.QKa, nony4111sw111e asropcK111e Ha3Ba-
Hlllfl, B03HlllKatoT n111Mcf:>oreHHblM nyreM KaK no
o6bi4HOMY TOKY n111Mcpb1 , raK 111 B perporpa,QHOM
HanpaBneHL1L1 . np111MepOM L1MnnaHr8L!L10HHblX
Meracra30B f!BnfltoTCfl Meracra3bl 111n111 onyxo11b
KpyKeH6epra B f!L14HVIKL1 . T111n1114HblM p,nfl paKa
>1<enyp,Ka f!BnfleTcfl nopa>1<eH111e n111Mcf:>oy3nos
nesoi;! Ha,QKnto4L14Hoi;! o6nacrn (MeTacTa3 81.1p-
xoea) no TOKY n111Mcpb1 4epe3 rpyp,Hol4 n111Mcf:>arn-
4ecK111l4 nporOK. np111 perporpa,QHOM TOKe fiL1M-
cpb1 , B03HL1K8IOLl\eM B cny4ae MeTaCTaTL14eCKOi:;l
6n0Kap,b1 oprorpap,HblX OTBOAfllJ.llllX n111Mcf:>arn4e-
cK111x nyrei:;l Kpyrnoi:;l CBfl3KL1 ne4eH111 , B03HL1Kator
Meracra3bl s nynoK - MeTacTa3 cecTpbt >f<o3ec1:>.
B ,QaneKo 3awep,wei:;l cra,[1111111 3a6onesaHL1fl Mo-
ryr 6b1rb MeracTa3bl paKa >1<eny.QKa B napapeK-
ranbHYto Kner4arey p,Ha ra3a (MeTacTa3 WH111'-'-
11epa).
,lJ,nfl yH111cf:>111Ka4111111 crap,111poBaH1115l pacnpo-
crpaHeHHocr111 paKa >1<enyp,Ka npep,no>1<eHa Me-
>K.QyHapoAHaSI KI13CC111cl:>lllK3'-'lllSI npOTlllBOpa-
KOBOfO COI033 no ClllCTeMe TNM (1997):
• T- neps1111..1Has1 onyxo11b
o Tx - creneHb 111Hsa3111111 creHKL1 >1<enyp,-
Ka He ycraHosneHa.
o TO - nepBL14Hafl onyxonb He onpe.Qe-
m1erc5l .
o Tis - npe1ttHBa3L1BHa5'1 K8PL!L1HOMa: 111H-
rpa3n111ren111anbHafl onyxonb 6e3 111H-
sa3111111 co6crseHHoi:;l nnacr111HK111 cn111-
3L-1croi:;l o6ono4KL1 (carcinoma in situ).
o T1 - onyxonb orpaH1114eHHafl cn1113111-
crol4 o6ono4Kol4 >1<enyp,Ka 111 nop,cn111-
3111crb1M cnoeM.
o T2 - onyxonb 111Hcp111nbrp111pyer creHKY
>1<enyp,Ka AO cy6cepo3Hol4 o6ono4KL1.
76
o T3 - onyxonb npopacraer cepo3HYto
o6ono4KY (B111c4epanbHYIO 6ptoWL1HY)
6e3 111Hsa3111111 s cocep,H111e opraHbl.
o T4 - onyxonb pacnpocrpaHf!eTcfl Ha
coce,QHllle opraHbl
• N- pernoHapHbte 11111Mcl:>aTlll'·tecK111e y3-
Ilbt. N-pa3pewaeTcsi oTMe"'laTb TOilbKO noc11e
r111cro11or111"'lecKoro 111ccneA0BaH111S1 yAaileHHO-
ro npenaparn;
o Nx - Hep,ocraT04HO p,aHHblX p,nfl
OL!eHKL1 pernoHapHblX m1M¢an14ec-
KlllX y3nos.
o NO - Her np1113HaKOB Meracrar1114ec-
Koro nopa>1<eH111fl pervioHapHblX n111M-
cparn4ecK111x y3nos.
o N 1 - 111 Metorcfl Meracra3bl B 1-6 pe-
nt10HapHblX n111Mcf:>arn4ecK111x y3nax.
o N2 - 111MetoTCfl Meracra3bl s 7-15 pe-
rnoHapHblX n111Mcf:>arn4ecK111x y3nax.
o N3 - 111MetoTCfl Meracra3bt 6onee 4eM
B 15 perllloHapHblX fill1McP8TL14eCKlllX
y3nax.
• M - OTAaneHHbte MeTacTa3bt.
o Mx - Hep,ocraro4HO ,QaHHblX p,m1 on-
pep,eneHlllfl orp,aneHHblX Merac-
ra3oB.
o MO - Her np1113HaKoB or,QaneHHblX Me-
racra3oB.
o Ml -111MetoTC5l KnlllHlll4ecK111e , peHrre-
Honorn4ecK111e 111m1 onepaL11t10HHb1e
p,aHHble o Han1114111111 orp,aneHHblX Me-
racra3oB , BKnto4a5'1 n111Mcf:>oy3nb1,
KpOMe pernoHapHblX.
Cra,QL1i:;1Hocrb paKa >Kenyp,Ka Ha OCHOBaHL1111
rpa,Qa4111L4 csol4crn onyxon111 no TNM xapaKTep111-
3yerc5l cne.QytoLl\lllM o6pa3oM (ra6. 3A):
K11111H111"'lecKaS1 Kapr111Ha. C111HAPOM ManbtX
nplll3HaKos - «c111rHanb1 Tpeeorn». C111MnTo-
Mar111Ka paKa >KeI1YAK3 pa3HOH IlOK3Illll331.4111111 Ill
cl:>opMbl pocTa. KnlllHll14eCKa5'1 ClllMnTOMaTIAKa
paKa >1<e11y,QKa orn1114aercf! MHoroo6pa3111eM 111
OTCYTCTBllleM flPKlllX narorHOMOHlll4HblX CVIMnTO-
MOB. Bee MHoroo6pa3111e >1<ano6 , c KoropblMIA
6onbHble o6paLJ.18IOTC5'1 K Bpa4y, MO>KHO pa3p,e-
m11rb Ha ,QBe rpynnb1:
• lll3MeHeHl/lfl 06Ll\ero COCTOf!Hlllfl ;
• racrp111rn4ecK111e >1<ano6b1 (xapaKTepHble
.Qnfl xpoH1114ecKoro racrpvira), Koropb1e Ha6nto-
,Qatorcfl y 2/3 6onbHblX paKoM )f(eny.QKa.
no XapaKTepy re4eHl/lfl 6one3Hlll pa3fllll48IOT
rp111 OCHOBHblX KnlllH1114eCKIAX saplllaHra re4eHIA5'1
paKa >1<eny.QKa:
• naTeHTHbtH;
• 6e36011eeoV.;
• c 6oneBblM ClllHAPOMOM.
 Ta6llU'tfB JA
CTa~uuuocTb paKa ~e11y;:v<:a ua ocuosauuu rpa~aunu csoucTB orryxoJin no TNM
Cra.TIJill T N M
CTa,!lJBI 0 Tis NO MO
e r a.mm. IA Tl NO MO
Tl Nl MO
Cra;urn: IB
T2 NO MO
Tl N2 MO
CTat UHI II T2 NJ MO
T3 NO MO
T2 N2 MO
Cra_nttj{ IIIA T3 NJ MO
T4 NO MO
Cra.ITTIB IIIB T3 N2 MO
T4 Nl , N2, N3 MO
Cra;:uur IV Tl, T2, T3 N3 MO
Jho6M T Jho6rur N Ml

6onbw111e TPYAHOcrn npeAcTasm:1eT A11tar-
HOCTL11Ka paKa )l(eilYAKa Ha paHHll1X CT8AlllSlX, Ill
sa)l(HO 111cnonb30B8Tb A11tarttocrnYecK111e Kp111Te-
p111111 , KOTOpble no380Jll/IJ1111 6bl 3anOA03pll1Tb Ha-
m14Ll1e onyxonesoro npo1...1ecca a >Keny,l:\1<e, 4T06b1
Hanpas111Tb na1...1111eHTa Ha peHTreHonorw-1ecKoe
111ccneA0BaH111e 111 racTpocKon11110. HaYailbHble
KI1111HlllYeCKll1e npOSlBJleHl/lfl paKa )1(8IlYAKa 06be-
A111HeHbl s ClllHAPOM "MailblX npt113HaKos" , np111
3TOM 88)1(H0 BblAeilSlTb He OTAeilbHble nOA03p111-
TeilbHble ClllMnTOMbl, a BeCb Cl/IMnTOMOKonneKC.
CMHApoM Ma11b1x np1.13HaKoe BKfll04aeT cne-
AYIOLIWIO c111MnroMaT111Ky :
• HeMOTlllB111pOB8HH8fl 06LJ..\8Sl cna6oCTb ,
cH111)1(eH111e TPYAOcnoco6HocT111, 6blCTpas:i yroM-
ns:ieMOCTb;
• aHopeKClllSl - H6MOTlllB111posaHHOe CTOlllKoe
CH"1>KeH"1e annernra BnJlOTb ,QO OTBP8LJ..\eH"1fl K
nl.1Ll..\e , npe111MyLJ..\eCTBeHHO MflCHolll ;
11
• s:isneHlllfl )1(enyA04HOro A111CKOMcpoprn" -
Oll.lYll.leH111e nepenonHeH111s:i >KenyAKa, 4yscrno
A8Bnett111s:i , Hl)l(ecrn 111 6oneJHeHHocn1 s 3n111ra-
cTp111111 . 5onbHble orpaH1114111Ba10T Kon1114ecrso
nplllHlllMaeMoi;\ nlllLJ..\111, CTaHOBflTCfl pa360p4111Bbl-
11
Mlll , "Kanp1113Hb1M111 s Bb16ope ee ;
• 6ecnp111411tHHoe noxyAaH111e ;
• nc111x111YecKas:i Aenpecc111s:i, anarns:i , HeKo-
Topas:i OT4y>K,D,eHHOCTb , noTeps:i lllHTepeca K OK-
PY)l(8IOLJ..\8MY , YTO paHbwe Bbl3b1sano lllHTepec.
Km11H1114ecKa51 AlllarHocrnKa paKa )l(enyAKa
OCHOBblBaeTCSl Ha Bblf18Jl8HWlll ClllMnTOM8Tltll<ltl
paKa )l(eilYAKa: >Kano6, aHaMHe3a , OCMOTpa, cp111-
3111K8JlbHblX MeTO,D,OB o6cneAOB8Hlllfl: nanbna4111111 ,
nepKycc111111 , aycKynbTa4111111 111 AP .
>KenyoKe, noHoc, ompbt>KKY 111 peomy. Ha1116onee
HaCTOpa)l(lllBalOLJ..\lllMlll )l(ano6aMlll flBJlfllOTCfl CHlll-
noxyaeHue, cHu>KeHue
)l(eH111e annernrn , 6011111 ,
pa6omocnoco6HOCmU, oenpecCUR, BXO,l:\Slll..\llle B
11 11
CL11MnTOMOKOMnneKC' M8flblX npU3H8K08 • bOilltl
np111 paKe }Keny,[\Ka HanoM111Ha10T 6011111 np111 racT-
p111Te c ceKpeTOpHolll HeAOCTaT04HOCTblO. 0,[\Ha-
KO np111 racTplllTe 6011111 HeCTOll!Kllle Ill cpaBHlllTeJlb-
HO nerKO nOAA8IOTC51 TepaneBTl/l4eCKOMY ne4e-
HllllO. 5onee 4eM y nonOBlllHbl 60ilbHblX paKOM
>1<enyAKa 6onb oTcyTcrnyeT. 5onbHble paKoM
>1<eny,£1Ka MoryT npe,[1b51BilflTb )l(ano6b1 Ha noxy-
AaH111e. B OCHOBHOM ,[\Jlfl paKa )l(eilyAK8 xapaK-
TepHo MeAneHHoe noxyAaH111e. Op,HaKo , np111
pa3s111rn111 n111nopocTeH03a B03MO}KHO 111 6b1cTpas:i
noTeps:i seca , HepeAKO AO 15 Kr B Te4eH111111 3-6
Mecs:i1...1es. np111 A11t¢cpepeH1...1111anbHOlil Alll8rHOCTlll-
Ke paKa )Keny,1:11<a 111 xpoH1t14ec1<oro racrp111ra cne-
AYeT y4ecTb , 4TO y 6onbHb1x np111 Heocno)l(HeH-
Hoi1 cpopMe xpoH1114ecKoro racTp111Ta o6Ll..\ee co-
cTos:1H111e o6bl4HO He HapywaeTcs:i . Mo}KeT Ha-
6n10A8TbCfl CHll1)1(eH111e M8CCbl Tena, HO 3H84111-
TeJlbHOe noxyAaH111e HecsolllcTBeHHo. Oco6o
cneAyeT o6paTlllTb BHlllM8Hllle Ha T8KOlll ClllMnTOM
KaK 6ecnp111411tHHoe cH111>KeH111e 111 n0Teps:1 anneT111-
Ta , 111 oco6eHHO ornpall..\eH111e K Ms:icy. nocneAHllllll
ClllMnTOM B C04eTaHllllll c 6ecnp1114111HHOlll cna6o-
CTblO Ill noxy,l:\8Hll18M .D,OJl)l(Hbl scerAa HaCTOpa-
>KlllBaTb OTHOClllTeilbHO paKa )l(eilYAKa. PaK )l(e-
ny.o,Ka MO>KeT npoTeKaTb c npeo6naAaH111eM Klll-
we4HOVI Cll!MnTOM8TltlKltl. np111 3TOM 6onbHble 48-
Ll.le scero npeAbflBilfllOT )1(8Jl06b1 Ha 3anopb1 ,
pe>Ke on.11e4a10TCfl noHOCbl. Mo>KeT oTMe4aTbCfl
MeTeop1113M , yp4aH111e, "nepen111saH111e" B >KlllBOTe .

>KA/705bl AHAMHE3
5onbWll1Hcrso 6onbHblX paKoM )l(eJlyAKa 5onbwoe 3Ha4eH1t1e np111 A11tarHoCT111Ke paKa
npeAbSlBilSllOT Te 11111111 11tHb1e racrp111r1114ecK111e )l(a- >Keny.o,Ka 1t1MeeT Tll.laTenbHO co6paHHblVr aHaM-
no6b1 s BlllAe 014y14eHuR mm1<ecmu, nonHombt e He3. ,IJ,n111TeJlbHOCTb >KeI1YA04HOfO 8H8MHe3a y
77
nau.111eHTOB paKOM :>KenyAKa MO:>KeT pa3nW-tHOL4 . 111MeTb :>KenTYWHb1L4 oneHoK. MoryT Ha6rnop,aTb-
OH 6b1saeT 04eHb KopoTK(llM or OAHOro AO rpex cR Hec1<onb1<0 ocyHysw1.1ecH YepTbl n1.11-1a , TYCK-
MeCf!U,eB 111n111 , Hao6opoT, O'-ieHb Anlt1TenbHblM OT nb1L4 B3rilflA· np111 AaJleKo 3aWeAWeL4 CT8AVIV1 pa-
4-6 AO 20-25 06w,aR cna6ocmb, 6brcmpaR
neT. Ka )Ke11y,q1<a y 60llbHOfO nO>iBmleTCSi 8HflOCmb,
ymoMnReMoCmb, noeb1weHHaR pa3apa>Kumenb- Ha6n10aaemCR HeyeepeHH8R noxoaKa . 0AH8KO
Hocmb, ncuxullecKaR oenpeccuR, noxyoaHue, 06ll\VIL1 B\.1A 6onbHOro He scerAa COOTBeTcTByeT
nocmoRHHble HoJOw,ue 6onu e 3nucacmpanbHou CTeneHYI nopa:>KeHVl5l >K811YA K8 .
o6nacmu , lll HOrAa yc111n111sa10ll\1t1ecfl nocne np111e- npVI nanbna4111111 MOryT 6b1Tb nony4eHbl
Ma eAbl , l/yecmeo 6b1cmpoao HaCblUJ,eHUR, om- A8HHble, xapaKTeplll3Ytoll\llle pacnpocTpaHeHVle
pbl>KKa "myXflblM" MOryT Ha6mO,ll8TbCfl np111 5l3- npou.ecca s 06nacT111 nynKa , ne'-ieHVI , B p5lp,e
BeHHOL4 6one3HYI , xpoH1i14ecKoM racTp1i1Te 1.1 APY- cny'-iaeB MO>KHO onpeAeJllllTb MeTaCT83bl B Hlll)l{-
r111 x naTOJl0ntl4eCKlllX COCT05lHlll5lX . np111 nOAp06- HVllA OTJJ,en )l{VIBOTa. y :>K8Hll\VIH MO:>KHO o6Hapy-
HOM paccnpoce sa:>KHO npocneAVITb p,111HaM111Ky :>KVITb Han1114111e OTAaneHHblX MeTacTa30B np111 sa-
pa3BVITlll5l 3TlllX CY!MnTOMOB , a 1113MeHeHVle np111- r111HanbHOM 111cc.ne)J,OB8Hllllll (MeTaCTa3 B fll/l4HVIKlll
Bbl'-iHOL4 )J,Jl5l 60ilbHOro CVIMnTOM8TYIKlll p,omKHO KpyKeH6epra) . nanb4esoe Vlccne,QOB8Hl/le 1.tepe3
H8CTOpO:>KL1Tb Bp848. np111 BHlllMaTeilbHOM OTHO- np5lMYto KVIWKy no3so.ns:1er p,111arHocT111posaTb Me-
WeHJAIA I{ aHaMHe3y IA o6beKTJABHblM JJ,aHHblM rncTa3bl s ra3osoe ,LIHO (MerncTa3 WH1114nepa) .
MO:>KHO 3anOA03pVITb paK )KeJlYAKa Ill HanpaBlllTb Heo6xop,1i1Mo nanbn111posaTb Ha)J,Kfll041114Hb1e 30-
6onbHoro ,llnR AOo6cne,lloBaHll'!R. Hbl, oco6eHHO nesoi:i Ha,LIKill0411fYHOi:1 o6nacrn,
rp,e MO)l{eT noKan1113osaTbC5l MeTacTa3 B111pxosa,
06bEKTUBHOEUCCflEAOBAHUE ltf ,llpyrne nep£-tcpep1t1Yec1<1t1e n1t1McparnYec1<1r1e y3-
npouecc 06c.neA0BaH111s:t (ocMorp , nepKyc-
c111s:1 , aycKynbTan1.1s:1 , na.nhnau111s:1 ) AOn)KeH nposo- Kn(l(H1114ec1<111e npoHsneHitl51 paKa )l{eny,q1<a
AVITbCfl ue.neycTpeM.neHHO , c y4eTOM aHaMHe- 38BVICS'IT OT JlOKan 1113a41!1 111 onyxon\.1 B )l{eJlyAKe
CTl.-148CKl.4X A8HHblX. (rn6n. 35) , cTaAl/1111 3a6onesaH11t5l, aHaTOMVl4e-
np111 OCMOTpe c.ne,llyer o6paTlllTb BH\.1MaH111e cKoro nma pocTa onyxon 111, npeAwecTBYIOL4VIX VI
Ha 06ll\ee COCTOS'IH\.1e na4111eHTa , u.seT KO:>KHblX conyTCTBYIOLltVIX 3a6oneBaH 1t1 £1 , OCJlO)l{HeHlllCi ,
noKpOBOB \.1 8111,lllllMblX CJ11.13111CTblX o6o.no4eK. pacn pocr paHeHVl51 Ha cocep,H111e opraHbl.
5o.nbHble , CTP8A810ll\\.18 paKOM )K8IlYAKa , MOryT
6bJTb VICTOLlteHbl , 6.neAHbl. Ko)Ka Mo)KeT np1t1H111-
MaTb 38MJ1\.1CTblill OTTeHOK, repfleT HOpMa.nbHblill
TYpr op , CTaHOBillTC71 cyxoi;i , 1113pe,q1<a MO)l{eT
Ta6.r1ui1a 3E
Oco6e1111ocTu KJlHHH~leCK0 1·0
Teqe11m1 B 3a B H CHM OCTH OT JIOlcaJin3a1•nH
pacnpocTpauennoro paKa )KCJ-.YJJ.Ka
Jlo1caJ11t3aa.ust paKa J Be.uymue npH3HaKu
,[{m.:ran1>nhili oT.n.err (IHDKHIDI en ,) Hapywemie 3Baxyan.HH BCJle.n.crnHe rnrnopocTeHo3a: no>IBrremre oT-
Tp p.bDI<KH u .n:a)Ke pBOTbI mrn:i eu.
Teno )f(eJIYJJ.I<a (BepXHID! TpeTb) 06mne cnMnTOMhI : liHTOI<CHKaI(JUI, aHeMIU1
IlpoKCHMaJIJ,HbIH OT.n:err (Bepxm!JJ
,[{uccpanut, o6mae CHMilTOMbI, racTpOI<ap.nnaJihifbIR KOMIIJJeKC
TpeTh)
T oTaJihHoe rropa)l{eHne
IlpopacTamre B ITO)l,)Kerry ).J.O'IBYlO )l(.eJie3y' CHH,llpOMhl naHKpeaTHTa,
3a.nwrn: cTeHKa
pa,lIHKy JIHTa

AMArHOCTUKA. y 6onbHblX paKOM }l{enyp,Ka MOryT Ha6nlO-

J7A50PATOPHb/E, PEHTrEHOJ10rW-IECKUE
U 3H,D,OCKOn/11'-IECK/llE /llCCflE,LJ,OBAH/llH
PaK )l{eny,D.Ka Ha paHH(llX cra,aHHX pa3sm111H
06bl4HO He npos:tsm1eTC5l K8K111Mlt1-Jllil6o OTKJlOHe-
H1!15tM(I( na6opa1opHb1x noKa3aTenel1.
H\.1s:t pa31lVll.tHblX BlllAOB 06MeHa B OCHOBHOM CBS'l-
38Hbl c npe,Qp8KOBblMlll COCT051HVl5lMlll, KOTOpble
npep,wecTByioT V1n111 conposo>KJJ,atoT
paKOBoro HOB006pa30B8HVl5l (arpocp1114eCKVIVI ra-
)J,8TbCS'I fl8Hb1e u cKpb1mb1e Kpoeome4eHUR. Ecn111
B Kane CO,D.ep}l{VITCS'I He3H84VITenbHOe KOJlVll.teCT-
BO KpOBlll (TaK H83blBaeMble MlllKpOKpOBOTe4e-
Hllls:t) , TO OKpacKa Ill KOHC\.1CTeHU1115l ero He MeHs:t-
IOTC51 Ill H8fli.1411Je KpOBl-1 MO)!{HO Bb1518111Tb TOflbKO
Hapywe-
nyTeM nOCTaHOBKVI 6eH3VIA\.1HOBoi;i npo6bl.
Te4eHV1e Ucc11eaoaaHue Kpoau
npVI paHHeCi HeOCJ10)1{HeHHOL1 cpopMe paKa

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82
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83
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KamemepoM a c<jJopMupoaaHHOM KaHane no nummMaHH 11.

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Mlll.s:I} .

84
 2
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30M B L\8Jl51X YB8.nVl48Hl/l51 3¢cP8KTVIBHOCTlll no- 60.nbHbfX paKOM }f(811YAK8 3H841/1TellbHO OTnlif48-
Cn8AYIOL1\8171 ny48B0171 VI Xl/IMVIOT8panVIVI . IOTCfl B pa3Jll/l4HblX CTpaHaX M1t1pa, 4TO 06bflCHfl-
npOTVIBOnOKa3aHVl51MVI K npOB8,D,8HllllO na.n- ercfl oco6eHHOCTf!Mlif pa3HblX x111pypr1114eCKlifX
JllllaTVIBHOVI p838KL\VIVI 51BmllOTCs:l MeTaCT83bl B WKOJl lll npeVIMYLL\8CTB8HH0171 npVIB8p}f(8HHOCTblO
6plOWlllHY, 6pbl)f{e171ey, canbHlllK , aCL\VIT, OT,D,an8H- 41/ICTO x111pypr1114eCKOMY liflllif KOMnneKCHOMY Me-
Hble MeTaCTa3bl B KOCTVI , ronOBHOVI M03r, n8rKlife TOAY ne4eHllf51 . TaK ecnlll 5-neTHH51 Bbt}f(l/IBae-
lll T.,D,. , T51)1{8no8 06ll\ee cocT05IH111e 60.nbHoro. MOCTb no ,D,aHHblM 60.nbWVIHCTBa flnOHCKVIX as-
nannlllaTl!lBH08 y,D,an8Hllle nepBV14Horo o4a- TOPOB COCTaBn51eT 98% nplil I CT8Allllif 3a6o.nesa-
ra n03son5leT yMeHbWlllTb Macey onyxo.n111 111 T8M Hlif51 , 85% - np1t1 II, lll 52% - npvt Ill cra,o,111111 , TO K
C8MblM CHl!l3l11Tb TOKClif48CKOe ee Bnl/l51Hllle Ha op- np111Mepy B AHrnliflif 3TVI noKa3aTenlif COOTBeTCT-
raHlll3M 60.nbHOro , ycTp8HlllTb l/ICT04Hl/IK Henpo- BeHHO COCTaBnfllOT 70% , 30% lll 7%.
XO,D,lllMOCTVI VI KpOBOT848HV151 , 4TO no3BOJ1518T Heyp,os.nernopV1TenbHb1e pe3ynbTaTbt x111- ·
6onbHoMy )f{lllTb HeKoTopoe speM51 c Meracra3a- pyprn4ecKoro MeT0,1:1a ne4eHlif51 paKa >1<enyAKa
MVI. B OCHOBHOM nannl!laTl/IBHbl8 p838KL\Vllll Bbl- 5181/lnlilCb npeAnOCblJlKOVI K pa3pa6oTKe KOM61.1-
nonH5llOTCfl c L1enb10 ,D,anbHeVlwero npose,D,eHl!l51 HMpoeaHHOro MeTOAa nel.leHHSL Pe3eKU.UR >Ke-
XlllMl/IO- Ill .ny4esol71 repanl!llif. 06XOAHble 8H8CTO- nyaKa lllJllif racTp3KTOMlif51 npOlil3BO,lll/ITCfl B C04e-
M03bl , racTpo- 1t1 8IOHOCTOMbl TaK)l{8 o6n8r4alOT c nyl/eBbJM 11111111 xuMuomepaneemul/eCKUM
TaHlt11/1
npoB8,QeHl!le neKapcTBeHHoro ne4eHlif51, no- so3aeucmsueM Ha onyxonb s npeA- 11'111111 noc.ne-
cKonbKY ocna6neHHbtili ronOAOM 6onbHOil! , He B onepaL\VIOHHoM nepviop,e . 0,QHaKO, BblCOK851 pa-
cocTOf!Hllllll BbtA8P)f{8Tb ne4eHlll8 . Yny4W8HVle ,[IVIOpe3lifCTeHTHOCTb paKa }f(811Y,l1Ka orpaHVl41/1Ba-
cocTof!Hlll51 nal\llleHTa noc.ne Ha4ana n111TaH1115I er nplilM8H8Hlife 11Y48B0171 Tepanllllif . ny4eBylO Te-
48pe3 cToMy s ,[\8JlbHe171weM no3sonlllT np111Me- panVllO paK )1{811Y,llKa B OCHOBHOM npOBO,llflT np111
HlllTb x1t1Mlllorepanlll10 . TexHlllKa raK1t1x onepal\111171 JlOK8JlbHOKOHTpOnlllpyeMblX ¢opMax - nplil Kap-
TaKaf! )1{8, K8K lt1 06bl4H0171 pe38KL\lt1lll }f(eny,[\Ka, HO ,[IVl8llbHOM VI Kap,ll,VI0-330cf:iareanbHOM paK8 , np111
6e3 YAaneHl!l51 nl!lMcf:iaTl!l4eCKlifX y3.nos 111.nl!l Mera- KOTOpOM PVICK pa3Bli1Tlif51 11y4esoro nospe}f(,QeHl/151
cra30B. OTHOClilT8JlbHO H8B8J1lifK Ill npeACKa3yeM. npe,D,O-
0T,Qan8HHbt8 pe3y.nbT8Tbt x111pypr1t14ecKoro n8p8L\VIOHHOe o6ny48Hl/l8 no l/IHT8HCVIBH0171 M8-
ne48Hlt151 paKa }f(enyAK8 38BVIC51T OT CT8Aliflll 38- TOAlifKe MO}f(8T ysenlif4li1Tb KOJ1lif48CTBO pa,1:1111-
6o.nesaHlt1fl, rncTOnor1114ecKot:;i CTPYKTYPbt onyxo- KallbHblX BMewaTellbCTB [If n51Tl/IJ18THIOIO Bbl}f(Vl-
.n111, OT 3anyLJ..1eHHocrn npol\ecca 111 csoespeMeH- BaeMOCTb.
HOCTVI Ha4aToro ne48Hlif51. nplll Ha4anbHblX cf:Jop- Ha1116on8e 3¢¢eKT111BHbfMlif npenaparaMVI
MaX paKa n51TlllneTH51s:l Bbl}f(lllBaeMOCTb COCTaB- nplll .ne48HlllVI 60llbHblX paKOM )1{8nyJ1,Ka 51BJlf!IOT-
nfleT CBbfWe B cpe,D,HeM 90%, ,D,eC51TlllneTH5151 - C51 5-cJ>Topypa'-'1.1n , MMTOMlifl\lifH C , 8APlll8Mlifl\lifH ,
75%. 0AHaKo , 6onbW8 nonoBlllHbt naL11t1eHTOB 3rono31t1A, np8napaTbl nnaTVIHbl. B 6onbWVIHCTB8
paKOM >1<enyAKa nocrynaer Ha ne4eH111e s 3any- c.ny4ae0 paK >KenyAKa TaK)l{e 51BJ15llOTC51 XlifMlifO-
85
pe3111cTeHTHoVI onyxo.nblQ, a c111cTeMHaS1 BHYTPlll-
seHHaS1 XlllMlllOTepan11151 60.nbHblX paKOM >1<enyAKa
s HaCTOS1LL1ee epeMS1 He 1t1Meer nepcneKT111B B
CB513111 c Hlll3KOVt KOHL\8HTpa4111e~ npenapaTOB B
onyxom1 . no3TOMY B8>KHblM nOAXOAOM nplll .ne-
YeHllllll 60I1bHblX c paKOM )f{enyAKa 51BJ1518TC51
cnoco6bt BB8A8Hltl51 Ill AOCTaBKlll XlllMlllOnpenapa-
TOB K onyxo.neBoMy 01.1ary. Hat.160.nee aAeKBaT-
HblM nyTeM AOCTaBKl/1 XltlMlllOnpenapaTOB K paK0-
80'1 onyxomr HBnfleTCfl nps:lMoe sse,QeHwe s co-
CYAbl , n111Ta10LL11t1e onyxonb , 1.1epe3 KaTeTep ycrn-
Hos.neHHbtVI B npasoVI >KenyAO'-IHO-canbHlllKOBOVI
14m1 nesoVI >1<eJJyAOYHotl aprnp"1"1. TaKa51 rnpa-
n11151 Ha3blBaeMa51 BHyTp111apTep111a.nbHOVI He-
oaAbl08aHTHa51 no.n11tXlllMlllOTepan11151 (BAnXT)
MO)f{eT BblnOJlH51TbCS1 He TOJlbKO Ha npeAonepa-
L\lllOHHOM 3Tane neYeHlll51 , HO 111 y Heonepa6enb-
HblX 60.nbHblX. np111 Cp8BHeHllllll 3cpcj:>eKTl!IBHOCT"1
.neYeHlll51 y 6onbHblX c paKOM >Ke.nyp,Ka OK838-
JlOCb, 4TO Ha1t160I1bW85! ,D,eCS1TlllI1€TH5151 Bbl>Klll-
B8€MOCTb AOCT1.1raerc51 np111 np111MeHeH111111 ce.neK-
TlllBHoVI BAnXT c nocneAY10LL1eVI onepal!t.1eVI
(64%) Ill npaKT1t14eCKlt1 He MeH51eTCS1 np111 Cll1CTeM-
HOil! x111M111orepan111111 c nocneAY10LL1eill onepa4111eVI
111 TOJlbKO IlltlWb x111pypr1114eCKOM .neYeHllllll (28%) .
8 HaCTOHU\ee npe,Q.nO)f{eHa 6onbWa51 rpynna
MOA111¢111KaTopoe paJ.nli14Horo MeXaHlll3Ma ,QeV!cT-
s11151 - .neBOMlll30J18, neVIKOBOplllHa, lllHTepcpepoHa,
T-aKT1t1BHHa, 14epynonna3M1t1Ha, eypaHrnna, aM-
cporep1114111Ha, 4111MeT111,Q111Ha , APO}f{)f{eBblX no.n111-
caxap1t1.QOB, aHTll10KC111,Q8HTHblX KOMnneKCOB, 3H-
3"1MOB, QJ"1TOa,l:lanToreHOB. 611aro,aap51 a,l:leK-
B8HTHOVI AOCT88Ke XlllM1110npenapaTOB K onyxo.n111
111 np111MeHeH11110 MO.QymlTopoe np111 neYeHllllll paKa
)1(€I1YAK8 CT8HOBlllTC51 snonHe B03MO>KHblM nepe-
BOA paKa )l(eny,QKa 1113 "ttepe3eKTa6enbHoro" B
"pe3eKTa6e.nbHOe" COCTOS1Hllle .

TECTOBhIE 3A)J,AHIDI
Bb16ep111Te O,D,1t1H npas111.nbHb1VI oTBeT.

PAK >KE/7Y/l,KA
1. nPo~rnnrtETCrt AV1C<PArV1Ell1 PAK >KEnY.QKA, noKAnV13YIOll.\V1lllCrl
1) s 06.nacrn ,QHa
2) B Kap,Qllla.nbHOM OT,Qene
3) B Telle
4) B aHTpanbHOM OT,l:lene
5) B 06.nacrn np111spaTH1t1Ka
2 . HAV150nEE YACTO PAK >KEnY.QKA METACTA3V1PYET B
1) nern111e
2) neYeHb
3) 511114HIAKlll
4) KOCTlll
5) U\lllTOBlll,QHYIO >Kene3y
3. METACTA3 WHV1L\nEPA noKAnV13YETCrt
1) s neYeH111
2) B np51MOKlllW€4Ho-ny3blpHoVI CKila,D,Ke
3) B 511114HlllK8X
4) Ha.Q .neaorli K.nlOYlll'L\eVI
5) e 06nacr111 nyn1<a
4. METACT A3 KPYKEH6EPrA noKAnV13YETCrt
1) B npS1MOKlllWe4HO-ny3blpHorli CKila,QKe
2) s nynKe
3) B 511114HlllKax
4) Ha.Q neeoVI KillOYll1L\e'1
5) B neYeH111

5. MET ACT A3 BV1PXOBA nOKAnll13YETCrt

1) s neYeH111
2) B np51MOKll1W84HO-ny3blPHOVt CKil8AKe
3) B S11114HlllK8X
4) Hap, .neeoVI Kil10Y1114eVI
5) B .nerKlllX

86
 TP ABMA )J(IIBOTA
KoHel\ XX li1 Ha'-lano XXI seKa xapa1<Tep1it3y-
erc71 pe3Kli1M pocroM rpaBM8Tlt13Ma, 4TO CB7!33HO
c 803pacTalOl.lllilMVI TpaHcnopTHblMlll noTOKaMvt ,
BblCOTHblM crpo111renbCTBOM L1 KplilMlllHaI111138L.\lll-
e!A o6UJ,ecrsa . Oco6eHHO 3aMeTHbl 3Tli1 reHAeH-
L.\111111 s KpynHblX ropo,[lax. 3a 111CKnl04eH111eM 4e-
penHo-Mo3rosoiit rpaBMbt a6goM111HanbHb1e no-
spe>K,£1eH1t17! 7!BmllOTC7! C8Mb1Mlt1 onaCHblMltl, T.K.
conposo)l{,[la10rcs:i 6onbW1t1M 4111cnoM ocno.>KHe-
H111iit, BblCOKll1M yposHeM neranbHOCTIA 111 lt1HB8Illt1-
All133L.\llllll. XapaKTepHbtMli1 4epraM111 cospeMeH-
HblX a6,qoM111HanbHblX nospe)l{,[leH111&71 s:ism1ercs:1
TpaBMa )101BOTa
0TKphlTa5.I
He rrpoHMKaIOm:M ITpoHMKarom:a>I
TpanMa noJibIX
opraHoB
0TKpblTa5l rpasMa COMHeHlllVt B AlllarH03e Ill
raKT111Ke segeHlll51 nocrpagaswero He Bbl3b1Baer.
A6con10THb1iit npli13HaK paHeH1115! 3TO Han1114111e
paHbl , a a6COJ1IOTHblM nplll3H3KOM npOHlllK8101..L1e-
ro paHeHll151 51smierc51: Bbina,aeH111e 1113 paHbl
BHyrpeHHltlX opraHoB 111 rKaHetll (4aU(e scero -
np51.Qb 6onbworo canbH111Ka , pe)f{e nern.fl TOHKoro
Kli1We4H111Ka), lllCTe4eHli1e 1113 paHbl KlllWe4Horo co-
Aep>KlllMOrD, >Ken\.1111, MO'-lvt. KocseHHb1e np1113Ha1<111
nospe)l{,[leHlll51 BHyrpeHHlt!X opraHOB 3TO Cl/IMnTO-
Mbl, yKa3blBalOUJ,li1e Ha Haflli14111e B 6plOWHO!A no-
nocrn naronor1114ecKoro co,[\ep>K1t1Moro (KpOBb,
Klt1We4HOe cogep>KlllMOe, M04a), np1t13H3Klt1 06-
L11etA Kposonorep111, np1113HaK111 111HTOKC11tKaL111t1t1 li1
neplllTOHltlTa.
np1t1 OTCYTCTBltlltl np51Mb1X nplt13H8KOB npOHlt1-
Ka10L118fO paHeH111s:i xapaKTep paHbl yro'-lH5lerc5l
np!il nepB1114HOVt x111pypr111YecKoiil o6pa6oTKe,
synbHeorpaQ:>111111 . Kp1itreplileM npoH111Ka101..L1ero
paHeH1t15I 51Bn5leTc5l nospe}l<,IJ,eH111e napllfeHra.nb-
011 6ptoWllfHbl. B 20% c.nyYaes npoH1t1Kato1..L1ee
aHeH111e )l<lr1Bora nporeKaer 6e3 nospe}l(,lJ,eHllf 51
3 yrpeHHlr1X opraHOB.
Ecn111 B orHoweH1.1111 TaKTlllKltl np1.1 npoH1r1-
Ka10lllli1X paHeH1115lx pa3H04TeHli1iil Her - Heo6xo-
-4MM a peBllf311f71 paHbl Iii BHyTpeHHlllX opraHOB, TO
MHO.>KeCTBeHHblili xapaKTep, BblCOKa>i neranb-
HOCTb ,IJ,0 25-70% 111 60ilbW851 4aCTOTa nocne-
onepal\lllOHHblX ocno.>KHeH111ill AO 35-83% .
TpasMa :>1<111sora MO>Ker 6b1Tb c nospe)l{,[le-
HlileM KO>KHblX no1<pOBOB - <<OTKpb1TaAn rpaBMa Iii
6e3 111x nospe>K,£1eH1115! - «3aKpb1TaA» rpaBMa >t<111-
sora. 0TKpb1Tble paHeHlll51 MOryT 6b1Tb npOHll1-
Ka10L111t1e 111 HenpOHlllK8IOL1111le B 6plOWHYIO no-
IlOCTb. «0TKpblTa51» Ill «3aKpblT851» rpaBMbl MO-
ryr 6b1Tb c nospe>K,L1eH111eM 111n111 6e3 nospe)K,Lle-
Hlll51 BHyrpeHH111X opraHOB.
3aKpnITa5.I
C rroBpe)l()::(emreM 1Je3 IIOBpe)l{;::i:eHIDI
BHyrpeHHMX op- BHJ"TpeHHMX op-
raHOB raHOB
3a6p10rrnu-rnM TpaBMa rrapeH-
reMaToMa XMMaT03H:OIX
opraHOB
nplll «ryno1.l1» TpasMe )f(llfBOTa Ba)f(HO KaK MO>KHO
paHbwe 111 AOCTosepHee ycrnHOBli1Tb 111n1t1 111cKmo-
41t1Tb nospe}l<,IJ,eHllfe BHyrpeHH1'1X opraHOB. no-
3TOMY Heo6XOA1t1MO np1'16erHyTb K cpe,D,CTBaM
li1HCTpyMeHT8JlbHOJ.1 ,IJ,1118fHOCTli1Klll.
,ll,ono11Hume11bHble Memoobl
ucc11eaoaaHu11:
1. YnbTpacoHorpa¢1'1s:i. npocroiit B 1t1cnon-
HeHlllll1 cnoco6 , c 6onbworli T04HOCTblO xapaKTe-
pl!13yeT COCT051Hll1e napeHXVIM8T03HblX opraH06 ,
Bbl5lBmleT CB060AHYIO >Klll,IJ,KOCTb B 6plOWHOili no-
nOCTIA , 3a6p!OWIAHHYIO reMaTOMY B Kon1114ecrse
6onee 50 Mn. He Tpe6yer cneL1111anbHorli no,1J,ro-
TOBK111 Ill He orpaHli14eH T5l)f(eCTblO COCT05!Hlt15l no-
cTpa,D,aBWlllX.
2. 063opHas:i peHTreHorpaQ:>1t1R Bb1T1sns:ieT
1t1Hopo.QHbre rena 6ptowHoiit nonocrn (nyn111 , oc-
Komm, ,IJpo6b u AP·), npu3Haxu nHesMonepuro-
HeyMa , .[locrosepHO Bbl5lBI151eT CB060.QHYIO )Kllf,Q-
KOCTb B KOI11114eCTBe 6onee 500 Mil. npo,QOil>Kli1-
TeJ1bHOe no speMeHVI , MO>KeT 6b1Tb Heo6XO.Qlll-
MOCTb no,qrorOBKltl nocrpa,qaswero.
3. BynbHeorpacp1M1. BseAeH1.1e BOAOpac-
rsop111Moro KoHrpacra li1Jlll1 B03.Qyxa s paHesoiit
KaHan. noKa38Ha nplll CJlO>KHblX cpopMaX paHe-
87
HlllVi, KOrAa BlllA nospe>K,D,eHlllH HeB03MO>KHO OL.\e-
HlilTb np111 neps1114Hoill x111pypr1114ecKoVi o6pa6oTKe.
npoBOAlllTCR B nepsytO 04epeAb AflR lllCK.nto4e-
HlllH npoH111Kat0u..iero xapaKTepa paHeH111ill 111 yTo4-
HeHlil5l BlilAa nospe>K,D,eHl/15l BHyTpeHHlllX opraHOB.
4. W111cTorpacp111s:i, ypeTporpacp111H . PeHne-
HOKOHTpacrnoe 111ccneA0BaH111e M04eBoro ny3bl-
p51 111 ypeTpbr. lt1cnonb3yeTCH .c1ns:1 111cKnf04eH111H 111x
nospe>K,D,eHlils:I np111 TpasMax, YT04HeHlillil xapaK-
Tepa paHeHlilR Ill CBR3111 c 6plOWHOill nonoCTblO
111.n111 3a6p10WlilHHblM npocTpaHCTBOM.
5. nanapOL\eHTe3. C l!ICnO.nb3088HlileM Me-
TOAlilKlil «Waps:iu..iero» KaTeTepa. ,1J,111arHOCTL114e-
CKlllVi npoKon nepeAHeill 6plOWHOVi CTeHKlll B TOY-
Ke Ha 2 CM BblWe nynKa no cpe,lllllHHOti JllllHllllll.
Ba>KHO npeAsap111TenbHoe pacce4eH111e KO>Klil c
nOAKO>KHOlA K.neT4aTKOJA Iii nOAHHTlile 6ptoWHOVi
cTeHKlil Ha wsax-Aep)f{a.nKax B Bl!IAe «napyca»
nepeA npoKo.noM. Hanpas.neH111e BBeAeH1115l
TpoaKapa BHL/13 no cpe,D.lllHHOIA .n111H111111. BsoAlilTC5l
OH c OCTOpO>KHOCTblO, MeA.neHHblM spau..iare.nb-
Hb!M ,llBl·'DK8Hlil8M. nplilM8HH8TCH ,.QflH BblHBfl8Hlils:I
CB060AHOJA >KlilAKOCTlil B nonocrn 6ptoWlllHbl
(KpOBb, M04a, >Ke.nYb , KlilWeYHoe COAep)f{lilMOe).
,lJ,ononHl.HenbHOe BBeAeHllle MHrKOJA lilJU-1 >KeCT-
KOVi APeHa>KHoVi Tpy61<1i1 no3BO.nHeT lilccneAOBaTb
ornorne Mecrn 6ptowHoVi no.nocrn (6oKOBble Ka-
Ha.nb1 , no.nocTb Manora Ta3a). C AlllarHOCTlilYe-
cKoill L\e.nbto Yepe3 KaTeTep MO)KHO BBO,LllilTb Iii
acn111p111posaTb npo3pa4Hblill csernb11A acem111Ye-
cK111Vi pacTBOp, cpaBHlllBaH o6beM Ill L\B€T BBe-
,D.eHHOill Iii y,D.aneHHOVi >KlllAKOCTlt1 .
6. nanapOCKOnlllH, KOTOpaH MO>KeT 6b1Tb Ill
.neYe6HblM BMewaTenbCTBOM. OcMorp 6pt0wH0Vi
no.nocTlll c 111cnonb30BaH111eM 3HAOB111Aeox111pyprlil-
yecK0Vi ycTaHOBKlil Ill cnel.\1118.nHblX lilHCTpyMeHTOB.
7. AHr111orpacp111H . V1cno.nb3yeTcH np111 cTa-
6111.nbHOVi reMoA111HaM1.1Ke y nocTpaAaBw111x c Alll-
arnocrnposaHHblMlll nospe>K,D,eHlllHMlll napeHx111-
MaT03Hb!X opraHos ,D.nR peweHlllH sonpoca o
T8KTl/IKe .ne4eHlllH . nplilM€H€Hlile 3H,D.OBaCKY.nHp-
HOrO reMOCTa3a nyTeM 3M60!111138L\llllll HaMHOro
pacw111ps:1eT B03MO>KHOCTlll x111pypr1114eCKOro .ne4e-
HlllS1 TH}f{e.nblX nospe>K,D,eHlllVi napeHXLllMaT03HblX
opraHOB 111 Mar111cTpa.nbHblX cocyAoB.
8. KoMnbtoTepHaH r0Morpacp111H . KaK 111 aH-
rnorpacp1.-1s:i noKasaHa ,o,nR ,o,warHocrnKlil cocros:i-
Hllls:i napeHXlllM8T03HblX opraHoB 6ptoUJHOVi no-
.nocrn Ill 3a6plOWlllHHOro npOCTpaHCTBa . np111Me-
HH€TCfl He TOflbKO Aml BblHBneHl/151 cpaKTa no-
spe>K,D,eHlllH , HO Ill A!lH KOHTponH 38 06beMOM
He60.nbw111x no pa3MepaM «L\eHTpa.nbHblX» re-
MaToM ne4eH111, 3a6ptoWLllHHOill reMaToMe np111
KOHcepB8TlllBHOM T8KTlilK8 JleYeH"1H. npoBO,lllilTCH
npl.1 cra6lllnbHOM COCTOHHllllll nocTpaAaBWlllX
9. CL.\lllHT111rpacp1t1R Pa,D.lllOHYK.nlll,D.Has:1 ,D.111ar-
HOCT111Ka B HaCTOHu..\ee speMH 111cno.nb3Y€TCH A!1H
OL.\eHKlll cpyHKL\lilOHanbHOro COCTOHHLllH napeHXlll-
M8T03HblX opraHos s pa3.n1114Hb1e cpOKLll noc.ne
TP88Mbl. ,IJ,aer B03MO>KHOCTb OL\€HlllTb BOCCTa-
HOB.neHllle ¢YHKL\111Lll np111 6naronp111HTHOM TeYeHll1111
88
nocnpasMaT111'-tecKoro nep1110,L1a 1-1.n111 HapyweH111e
¢YHKL\llllll nplil cpopM111posaH111111 ocno>KHeH111Vi .
noK030HUR K onepamuBHOMY 11eYeHUIO
1. nplil paHeHlllHX )f{lllBOTa mo6oe COMHeHlil€
0 B03MO>KHOM nospe>K,D,eHlillll BHyrpeHHlllX opra-
HOB pewaeTCS1 B nonb3Y onepal.\111111.
2. Ha.n1111.1111e HBHblX np1113HaKoB BHyrp111-
6ptowHoro KPOBOTe4eHlllS1 y nocTpaAaBWlllX c
3aKpblTOVi rpaBMOill >KlilBOTa c.ny>KlilT a6comOTHblM
noKa3aH111eM K HeMe,o,neHHoill onepal.\111111, Hesas111-
c111Mo OT TR>K€CTlll COCTOSlHlllR nocTpa,D.aBwero Ill
COCT05lHlllSl reMO,[\lilHaMlllKlil.
3. nocTpaAaBWero C K.nlilHl/14eCKOVi KapTlll-
HOVi pa3pbrsa nonoro opraHa TaK>Ke Heo6xo,D.111Mo
He3aMeA!1111TellbHO onep111posaTb.
4. Han111Y111e Ae¢eKTa 6ptoWlllHbl np111 npo-
BeAeHlillil nepBlll4HOIA x111pyprlil'-tecK0Vi o6pa6orKe
paHbl s:isns:iercs:i noKa3aH111eM K w111p0Koill cpeAlllH-
HoVI 11anaporoM111111 .
nol<G3GHUR I< OU02HOcmu4eCKoiJ
11anapom0Muu
npu «mynou» mpaaMe JKuaoma
1. CTOIAKoe Hanp5!>KeH111e MblWL\ nepe.1:1Hei1
6plOWHOM CTeHKlil 11111111 60.ne3HeHHOCTb nplil
nanbnal.\111111;
2. nt06ble He06b51CHlllMble Cll1MnTOMbl, Bbl-
5l8Jl5leMble np111 Ka>K,D,OM 111cc.neAOBaHlillll >KlilBOTa;
3. np1113HaKlil WOKa Iii KpOBOnorep111 ;
4. naT0!10r1114eCKlile l/13MeHeHlll51 nplll lilHCT-
pyMeHTaJlbHOM 111cc.ne,llOB8Hll1111 6ptoWHOVl no.noc-
Tlll , s .na6opaTopHblX A8HHblX .
noMlllMO Meponp11151Tlllill , ofo13aTe.nbHblX np111
no,D.roroeKe 60.nbHblX K nnaHosoill onepa1..11trn , ne-
peA AlilarHOCTll14ecKoill nanapornM111eill nposoAHT:
1. YcraHOBKY Ha3oracTpanbHoro 30H,[\a.
2. YcraHOBKY nocroRHHOro M04esoro KaTe-
Tepa.
3. napeHTepa.nbHOe BBe,D.eH111e aHTlil6lllOTlll-
KOB (nplll nOA03peHllllll Ha TpaBMy >KenyAKa l/1!1111
KlllWeYH'1Ka, TR>KenoM WOKe, 06w111pHb!X noape>K-
,D.eHll1RX) .
4. ,lJ,peH111posaH111e n.neepa.nbHOVi no.nocTlll
(nplil npoH111Katou..i111x paHeHlllRX 111 TYnoVI rpasMe
rpyAlil c nplll3HaKaMlll nHeBMOTOpaKca) .
OnepaTlllBHblVi AOCTYn - cpeAlllHHas:i .nana-
poTOMLlls:I. Pa3pe3 ,D.O.n>KeH 6b1Tb AOCTaTo4HblM ,
YT06b1 o6ecneYll1Tb ocMoTp aceiil 6p10wHoiil no-
.nocT111. OnepaTlllBHoe ne4eH111e HanpasneHo Ha
ycTpaHeH111e noape>f<AeHLllill (yw111eaH111e paH no-
.nblX opraHOB, Ha.nO)f{€Hlile pa3rpy304HblX KlllW€4-
Hb1X CTOM , OCTaHOBKa napeHXlllMaT03HOfO KpOBO-
Te4eH11151), APeH111poaaH111e 6ptowHolA nonocTlll.
Memooww
1. OCMOTp 6plOWHOVi no.nocTl/I Alls:! o6Ha-
py>KeHlllS1 LllCT04HlilKOB KpOBOTe4eHlilR.
2. BpeMeHHaS1 ocraHOBKa KpoeoTe4eHl/151:
TaMnoHaAa - nplil noape>K,D,eHLlllll napeHXll1MaT03-
HblX opraHos ; Hano>1<eH111e 38>KlllMOB - np111. no- Hoe Ha6n10AeH111.e 3a nocTpaAaBWIAM B Te4eH111e
spe}l\D,eHl/1111 Mar111CTpa11bHblX aprnp11111i; np111>1<arne 611111>Kalliw111x 48 Yacos. KoHcepsarnsHoe 11e4e-
nallbl..\eM - np111 nospe)f(.AeH111111 KpynHblX seH . Hllle BKJlto4aeT B ce6Sl raK >Ke socno11HeH111e Kpo-
3. Bo3Mell.\eH111e o6beMa L\lllPKYlllllpy10ll.lelli son0Tep111, npoBe,QeHl/le npOTlllBOWOKOBblX Mepo-
KPOBl/1 H84111H8IOT noc11e speMeHHOlli OCT8HOBKll1 nplllSlTllllli, BBe,QeH111e reMOCTaTlll4eCKlllX cpep,CTB .
KpOBOTe4eHl/ITI. noc11e BbtBe.QeH111T1 nocTpa,Qaswero 1113 woKa
4. nospe)K,IJ,eHHble neTlllll KlllWKlll 060p84111- npOBOATIT MeponplllTITlllTI , HanpaBlleHHble Ha
BalOT ca11cpeTKOlli Ill BblBOATIT Ha 6plOWHYIO CTeH- 6opb6y c nape30M )l{e11y.1:104HO-KlllWe4HOro TpaK-
Ky. 3To npeAynpe)K,IJ,aeT A8llbHelliwee 3arpT13He- Ta: Ha3oe10Ha11bHaT1 111Hry6a4111Sl , BHyTp111seHHoe
H111e 6p10WHOl.:1 nOllOCTlll COAep>KlllMblM K1!1We4Hlll- BBeAeH111e pacrsopos , co.1:1ep)l{au..i111x Ka1111111i , r111-
Ka. 60llbWllle 11111111 HapaCTalOll.\1118 3a6pt0WlllHHble neproH111YecK111e KJ11113Mbl.
reMaTOMbl 4enecoo6pa3HO BCKpblTb , ycTaHOBlllTb
lllCT04Hll1K 111 OCTaHOBlllTb KpOBOTeYeHl/le. noBPE>KAEH"1.fl nonblX OPrAHOB
5. 0KOH4aTellbH8TI OCTaHOBKa KpOBOTe4e-
H1115i: H8llO)l{eH111e cocy,QlllCTblX WBOB, nepeBTl3Ka noBPE>K,D.EHt1f1 >KEJ7Y,D.KA t1
cocyp,os; yw111saH111e paH , pe3eKL\lllTI ne4eH111 , pe- ,D,BEHA,D.Lf,ATt1nEPCTHOU Kt1WKt1
3eKL\lllTI 11111111 yp,a11eH111e no4Kll1 , ce11e3eHK111. B TpaBMaT111YecK111e nospe)K,IJ,eH111T1 >Ke11y,QKa ,
KpalliHlllX CllY48TIX lllCT04HlllK KpOBOTe4eHl/ITI T8M- no A8HHblM Jll!1Teparypb1 , COCT8BllSllOT 0,9-5, 1
noH111py10T 111 snocnep,crn111111 nposop,TIT pe11anapo- % scex JaKpblTbtX TpaBM >KlllBOTa . Pa3pb1Bbl >Ke-
TOMllllO. llYAKa BCTpe4atoTCTI B 5,1-6,6% c11y4aes. Lfau..ie
6.
Yw111saH111e paH 11111111 pe3eK4111T1 )l{enyp,Ka 111 Ha611toAatoTCTI C04eTaHlllTI nospe)K,IJ,eHlllSl >KellyA-
Kl/IWe4HlllKa . Ka c nospe)K,IJ,eH111T1M111 ne4eH111 , ABeHaA4arnnep-
7. npoMblB8Hll1€ 6pt0WH011i nOllOCTlll 60llb- CTHoi.:1 KlllWKlll, nO,Q>KeflYA04HOlli )l{elle3bl' cene-
WlllM K0111114eCTBOM cp1!131110110rlll4eCKOro paCTBO- 38HKlll.
pa , ec11111 oHa 6b111a 3arpT13HeHa co.1:1ep>KlllMblM nospe}l(,L\eHlllTI >Kelly,QKa OTHOCSlT K KaTero-
KlllWe4HlllKa . pllllll TTl)l{eJlblX, OHlll conpOBO}l(,L\alOTCSl BblCOKOlli
8. Pes111311171 6ptowHoi.:1 no11ocrn , BKJlto4aTI 11eTa11bHOCTbto - AO 72%. 3aKpb1Tble TpaBMbl
BCKpblTllle canbHlllKOBOl.:1 cyMKlll Ill OCMOTp nO,Q)l{e- )l{e11YAKa MOryT conpoBO)K,IJ,aTbCTI 3H841/1TellbHbl-
nyp,o4HOlli )l{elle3bl. np111 06HapY>KeHllllll KpOBOl/13- Mlll pa3pb1BaM111 111 Aa}f{e nollHblM oTpblBOM opraHa
lllllTIHllli.:1 11111111 OTeKa noKa3aHbl M061111111138L\lllTI 111 OT .nnK, OT np111spaTHl/IKOBOi1 4acrn ; 4awe BCTpe-
nonHbllli ocMoTp noA>Kenyp,oYHoi.:1 >Ke11e3bl. Ami 48IOTCSl pa3pb1Bbl nepe,llHelli CTeHKlll , pa3M03>Ke-
OCMOTpa 38,QHelli CTeHKlll ,QBeHa,QL\aT111nepcTHOlli Hllle - 38AHei1.
KlllWKlll npoBOATIT ee Mo6111111113aL1111to no Koxepy. K11111H111YecKaSl KapT111Ha nospe>K,l\eH111Sl >Ke-
9. nosTopHbti.:1 ocMoTp scex nospe)K,IJ,eHHblX llYAKa He OT111114aeTCTI OT Klll/IHlll48CKOi1 KapTlllHbl
opraHos, wsos 111 T.n .; rya11eT 6ptowHolli no11oc- nepcpoparnsHolli Tl3Bbl. Pe3KaR 6onb s >KlllBOTe ,
rn , ycTaHosKa KOHTpo11bHb1x .1:1peHa>Kei.:1, noc11ol.:1- peoma «Kocf.JeOHoiJ zy~eiJ» 111n111 cse>Ke!.1 KpOBbto ,
Hoe yw111saH111e paHbl 6pt0WHOl.:1 CTeHKlll. HanpT1>KeH111e (cuMnmoM «AOCK006pa3HOfO»
10. np111 TIBJleHlllTIX neplllTOHlllT8 11111111 TIBHOM >KlllBOTa) lllJllll JlOK8J1bH8Sl 6one3H€HHOCTb ne-
111Hcp1114111posaH111111 6p10wHolli nonocrn KO>KY 111 noA- peAHe!.1 6pt0wHolli cTeHKlll , (c111MnToM LUeTKlll-
KO)l{Hyto KJleT4aTt<y He 38WlllB8IOT, cpe,QlllHH8TI Ha-6moM6epra) , scrpeYatoTcSl c Ta Ko Iii :>Ke
paHa 3aKpb1saeTcT1 Ha wsax - Aep>Ka11Kax. 4aCTOToi1 np111 nepcpoparnBHblX Sl3Bax 111 TpasMe
Bo speMTI 11anapoToM111111 Heo6xo.1:1111Mo pe- KlllWe4Hl/IKa .
WlllTb sonpoc o pe111Hcpy3111111 Kpos111 np111 Kposono- V1cc11e.1:1osaH111e nep111cpep1114ecKoi1 Kpos111 s
Tepe 6011ee 500 Mll . AV1HaM111Ke no3so11SleT KOHcTar111posaTb o6u..iyto
BOcna11111Te1lbHYIO peaKL\llllO (11ei.:1KOL\lllT03, Helli-
npomusono1<a30HUR OnR peuH<jJy3UU Tpocp11111bHbllli CABlllr sneso, 11111Mcpo4111roneH111T1,
1 nospe)K,IJ,eHllle nOllblX opraHOB . ycKopeHHaTI C03) 11111111 HapacTatoll.IYto nocrre-
2. Bb1pa)l{eHHb111i reMOJ11113. Moppar1114ect<yto aHeM111to (cH111>KeH111e reMomo6111-
3. BpeMTI 6011ee 24 48COB c MOMeHTa Ha, KOlllll4eCTBa 3p111TPOL\lllTOB , reMaTOKplllra).
TpaBMbl. 063opHaSl peHrreHorpacp111Sl 6p10wHow nonocrn
TIBllTleTCTI 06T13aTe1lbHblM MeTOAOM lllCClle,[\OBa-
KoHcepsamuBHOe nel.feHue HlllTI. PeKoMeHAYeTcTI nanapo4eHTe3 111 nanapo-
nposo,Q111TcT1 np111 yw1116ax nepe.QHew 6pt0w- CKon111T1. neYeH111e nospe>K,l\eH11111i )l{e11y.1:1Ka scerAa
Holli CTeHKlll, He601lbWlllX Ill CTa6111JlbHblX no pa3- onepar111sHoe . PaHbl >1<e11yAKa yw111satoT ABYX-
Mepy L\8HTpallbHblX reMaTOMax napeHXlllM8T03- PSlAHblM WBOM. np111 06w111pHblX pa3pblB8X CTeH-
HblX opraHoB. KoHcepsaTlllBHOMY neYeHllllO noA- Klll >KenyAKa 111 0Tpb1sax era B n11111op1114ecKol71 30-
11e>KaT nosepXHOCTHble KOJlOTO-pe3aHHble paHbl He OT .nnK B03MO>KHO Bbln011HeH111e pe38KL\llllll
6ptoWHOlli CTeHKlll ,QaBHOCTblO 6011ee 24 48COB, )l{eJ1yAK8 11111111 HallO:>KeHllle raCTPOAYOAeHOaHa-
y>Ke lllHQJlllL\lllposaHHble. B raK111x cny4aTlx npo1113- CTOM038 . np111 OTpblBe )l(elly,[\Ka B K8p,Q1118llbHOi1
BOAlllTCTI nepBlll4H8TI x111pypr1114ecKaT1 o6pa60TKa 48CTlll TaK >Ke B03MO)l(H8 npoKCll1M8llbHaTI pe3eK-
paHbl pacTsopoM aHT111cenT111Ka, noBTl3Ka , aKT111B- L\lllTI }f{eny,l\Ka.

89
 TpasMaT1114ecK111e nospe}l{,QeHlllfl ABeHaA1..1a-
nmepcTHOill KlllWKlll orn1114atoTC51 TPYAHOCTflMlll
A111arHocT111K111 111 T51>KeCTbto Te4eHlll51. OH111 scTpe-
4atoTC51 s 6-10% OT scex nospe}l{,QeH111ill >1<eny-
A04Ho-K111we4Horo TpaKTa 111 AJ151 3TlllX nospe}l{,Qe-
H111ill xapaKTepHa BblCOKa51 neTaJlbHOCTb (AO
50%), VI 60JlbWas:I \.laCTOTa (50-70%) Ts:l>KeJlblX
nocneonepa1..11110HHblX ocno>1<HeH111!:1 : AYOAeHanb-
Hblill CBlllLL\, 3a6ptoWVIHHa5I cpnerMoHa, npocpy3-
Hoe racTpo,o,yoAeHanbHoe KposoTe\.leH111e, nep111-
TOHlllTb1. Pe,qKoCTb 1113on111posaHHoill TpaBMbl ABe-
HaAU,aTvinepcTHoill K111WKVI CBfl3aHo c pacnono-
>1<eH111eM 3TOro opraHa . np111 3aKpblTOill TpaBMe
4all\e scero nospe)K,LlaeTC51 HVl>KHerop11130HTanb-
Hb1ill OTAeJl (45,8%), KOTOPblill, He VJMe51 B03MO>K-
HOCTl/I CMeCTl/ITbCfl, pa3AaBJlVJBaeTC51 0 Teno Ill
noHCH1114HOro n03BOHKa; pe>Ke TpaBMVlpytoTCH
HlllCXOA51LL\111lA (33,8%) Ill BepxHeropVJ30HTanbHblill
(20,4%) ee OTAeJlbl.
TpasMarn11ecK111e nospe}f{,QeHH.R .QBeHa-
A~anrnepcTHoiil KlllWKM noApa3AenfltoT:
• yw1116bl CT8HKVI KlllWKlll 6e3 HapyweHlll51 ce-
p03HOlll Ill CJ11/13111CTOlll o6onoYKlll c H8Jllll4111eM 3a-
6ptoWlllHHOil! reMaTOMbl.
• YW1116bl CT8HKlll KlllWKlll C 11130Illllp088HHblMlll
reMaToMaMl/I B nOACJ1Vl3111CTOM cnoe Ill HaJ11/14VJeM
reMaTOMbl B 3a6ptoWlllHHOM npocTpaHCTBe 111!1111
6e3 Hee.
• pa3pblB cepo3HOill o6ono4Klll 111 MblWe4HOro
CI1051 c coxpaHeHl/leM 1..1enoCTHOCTlll CI11113111CTOill
o60J104Klll Ill HaJ1Vl41/1eM 3a6ptoWVIHHOill reMaTOMbl.
• nOI1Hbl€ pa3pblBbl (eAlllHlll4Hble Ill MHO>Ke-
CTBeHHble) CTeHKlll ABeHa,o,1..1aT111nepcTHOlll KlllWKlll
c 3a6ptoWlllHHOlli reMaTOMOill (c coxpaHeHl/leM
lllilVI HapyweHl/leM 1..1enOCTHOCTlll nap111eranbHOll!
6ptoWl/IHbl) .
• 0Tpb1B ABeHa,q4arnnepcrnoill KlllWKlll c 3a-
6ptoWlllHHolll reMaToMoc-1 (c coxpaHeHllleM 111n111 Ha-
pyweH111eM L1enocrn nap111ernnbHOill 6ptoWlllHbl) .
• nonHbJe pa3pb!Bbl KlllWKlll B C048TaHllllll c
nospe)K,LleH1115IMlll APYrlllX opraHOB 6ptoWHoill no-
nocr111 111 3a6ptoWlllHHoro npocTpaHCTBa .
Ywi-t6b1 ABeHaAL(arnnepcrHol.1 KlllWl<lil npo-
51BJlfltoTCfl 6onbl0 B npaBOM nOApe6epbe, OT-
pbl>KKOlll Ill 4YBCTBOM T51>KeCTlll B 3n111racTpanbHOl:l
o6nacrn nocne np111eMa nlllll\VI . np111 lllHTpaMy-
panbHalll reMaToMe 6on111 lllHTeHClllBHble , a peora
H0Cl-1T ynopHbllA xapaKTep Ill 6blCTpO nplllBOAlllT K
06e3so>K111BaH111to . VIHTpaMypanbHa51 reMaToMa
MO>KeT Bbl388Tb nonHyto 06TYP8L.lllllO KlllWKlll 11111111
BCKpblTbC51 B 6ptoWHYIO nonoCTb.
Kn111H1114eCK851 KapTlllHa BHyrp1116plOWlllHHblX
pa3pb1BOB ABeHaA1..1arnnepcrnoill KlllWKlll CXOAHbl
c TaKOBblMlll np111 nospe)KAeH111flx APYrlllX nonblX
opraHoB . Aoonepa1..11110HHa5I A1t1arHocT111Ka 3aKpbl-
TblX TpaBM ABeHa,o,1..1arnnepcTHOlll KlllWKlll CJlO>KHa,
nOCKOJlbKY npaKT1114eCKlll HeT ClllMnTOMOB , naTor-
HOMOHlll4HblX nospe}l{,QeH111to 3Toro opraHa. TeM
He MeHee cneAyeT o6pall\aTb BHlllMaH111e Ha
lllM810ll\YIOC51 6onb B >KlllBOTe, KOTOpa51 MO>KeT
6bllb pa3HOill lllHTeHClllBHOCTlll Ill JlOKan1113a1..1111111.
90
BnocneACTBllllll MO>KeT np111coe,D,1t1H5ITbCfl cyxocTb
513b!Ka, TOWHOTa, psoTa. A111cpcpy3Hae Hanp51>Ke-
Hllle MblWU, nepe,o,Hei.1 6ptoWHOi.1 CTeHKlll CBlllAe-
TeJlbCTByeT 0 pa3BlllBatoll\eMC51 neplllTOHlllTe.
06beKTlllBHOe 06cne,D,OBaH111e no3BOJ15'1eT Bbl-
flBlllTb BT5lrV1BaH111e 6ptoWHOill CTeHKlll Ha BAOXe
(CMMnTOM 5eillmt) , lllC483HOBeHl/le ne4eH04HOill
«TYnocrn» np111 nepKYcc111111 (CMMnTOM >Ko6epa),
wyM TpeHlll51 ,o,viacpparMbl np111 aycKYJlbTa1..1111111 >Klll-
eora (c111MnTOM 6pyHHepa) . nanbL!eBoe 111ccne-
,1:10BaH111e np51MOill KlllWKlll MO>KeT Bbl51BJ151Tb HaB111-
caH111e nepe.QHelil cTeHKlll (c111MnTOM KysmeH-
KaMncpa) Ill Bbl3blB8€T pe3KYIO 6one3HeHHOCTb
(KpuK ,lJyanaca). 3Ha4111TenbHOe cKonneH111e Klll-
We4Horo c0Aep>K111Moro B 6ptowHolll nonocrn co-
npoeo}l{,QaeTc51 no51sneH111eM wyMa nnecKa np111
noKal.JlllBaHllllll 6onbHOro lil3 CTOPOHbl B CTopoHy
38 KOCTlll Ta3a (ClllMnTOM recpTepa-
Wl/lnM~blHa). Oco6eHHO 3aTPYAH1t1TenbHa ,Q111ar-
HocrnKa nospe>K,D,eHlllfl nplil coxpaHeH/11111 L(enocT111
6ptow111Hbl a nepsb1e 4acb1 nocne TpaBMbl. Ta Kiiie
nospe}l{,QeH111>1 He 4acTo BblflB1151toTC51 p,a>Ke np111
nanapOCKOnllllll. noepe>KAeHlllH ,QBeHa,Q~aTl/lnep­
CTHOill KlllWKl/1 He Alll8rHOCTlllPYIOTC51 ,Qa>Ke BO
epeM51 onepaL..\111111 y 10-15% noCTP8A8BWVIX.
3a6plOWlllHHoe nospe>K,[1eH111e p,seHa,llL18Tlil-
nepcTHolll KlllWKlil npornKaeT Tfl)f{eJlo 111 csoeo6-
pa3HO . B nepsb1e 48Cbl nocne TpaBMbl HeT 4eT-
Koll1 KapTlllHbl KaTaCTpOcpbl B 6ptoWHOli1 nonocrn.
Ho np111 3TOM e nepeb1e 4acbt nocne TpasMbl Bbl-
pa>KeH 6oneeou cuHopoM, HepeAKO conposo}l{-
Aatoll\llllllc51 WOKOM, nornpelll C03H8H11151, pBOTOl/1;
s nocne,o,ytoll\eM 6onb yMeHbWaeTc>1. nep1110,o,
MHlllMOro 6naronony41115'1 AJ1111TC51 OT 6-8 4 AO 3-4
cyT., a emopaR 6oneeaf/ eonHa AOJl>KHa HacTo-
pa>K111saTb x111pypra. na71BJleHllle >KBY4UX 6oneu B
npasoill nonoBlllHe >KlilBOTa , npe111Myll\eCTBeHHO B
no,o,pe6epbe 111 no>1cH1114Hoill 0611ac1111 , nono>K111-
TenbHOro CLJMnmoMa nacmepHa~KOBO, omeKa U
Kpenumau,uu B nof!CHlllYHol1 o6nacrn, no,aKO)l(-
Hoill 3Mcplil3eMbl BOKpyr nynKa (c111MnTOM B1.1rna-
'-'a), np111coep,111HeH111e ClllMnTOMOB lllHTOKClllK8Llllllil ,
cny)f{aT y6eA/llTenbHblMlll np1113HaKaM/ll no-
spe}l{,QeH111s:1 3a6ptow111HHoro OTAena ABeHa,1:1u,a-
T11JnepcTHol11 KlllWKlil Ill HBJ15'llOTC51 n03AHlilMlll ClllM-
nTOMaMlll. B nocne.QYtoll\eM np111coe,QlllHHeTc7I
KJll/IHlll4eCK851 K8PTlllHa nepl!ITOHlllTa BCJleACTBl!le
pacnnasneH1115I 38AHero n111cTKa 6p10WlllHbl.
np111 peHTreHOJ10f1114eCKOM lllCCJle,[\OB8Hll151
>KlllBOT8 OTMe4aeTC51 Bb/COKOe CmOflHUe OLJa-
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nporn>1<eH111111 He 3al..l.\llll..l.\8Ha KocTHbrM cKeneroM.
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Ha my6oKO B 6plOWHOili no110CT111, 3aH111MaeT
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pe4Hafl o60,Q04Ha5l KltlWKa, B KaKof.1-To CTeneHltl
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OCTaeTC5'1 Ha BblCOKOM ypoBHe - 50-70% , a
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91
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er 50% np111 yw111eaH111111 orHecTpenbHOl.1 paHbl
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6onbWJ.1Hcrse cny4aes B03HlifJ<aer scne,QcTs1t1e
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HarHoeH111>1 nocneonepau,1110HHb1x paH c aeeH-
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B AwarnocrnKe nospe:>!\[\eH111iii K1t1weYHV1Ka
Ba)f(Hyio ponb 111rpaer BblHCHeH111e MexaHVl3Ma
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no.nO>KlllTeJlbHbl€ Cll1MnTOMbl pa3.Qpa)f{eHIMl np111 orcyrcrs111111 Macc1110Horo 3arps:13HeH111s:1
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co4eraH111e .noKanbHolii 6one3HeHHocn1 111 orcyr- Ha 3aH1t1Maer He 6onee 1/2 nep111Merpa , HeKoro-
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(cll'IMnTOM Ky1111eHKaMncpaJ - y 1/4. 1113 111HcT- Kpas:1 paHbl, yw1t1Tb ee, nocne Yero nposecrn 3KC-
pyMeHranbHblX MeTO.QOB 111CCile.QOBaHll171 111cnOilb- rpanep111ToH1113aL11t11-0 c no.QBe.QeH111eM rpy64aroro
3Yl-OT nanapou,eHme3 111 auaaHocmul.fecKuiJ na- p,peHa)l{a . Ecn111 }l{e nospe)f{,IJ,eH111e 3aH111Maer
ea>K6p10wHolii nonocr111 . 0.QHaKo nplil 111som1po- 6011bwe nonos111Hbl oKpy}l{HOCTlll K111WK111 , ro nocne
saHHOM nospe)f{,IJ,eH111111 KlllWKlil s nepsb1e 4acb1 yw111saH1117I paHbl p71A asropos npo1113BOA~IT Ha-
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npoxoAlllT no cpe1-1Heill Me}l{,IJ,onesoill i.uem1, op111- cerMeHT ne4eH111 111MeeT co6cTBeHHYIO cocy1-1111-
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c~ 8K"fY8IlbHOlli npo6neMolli He TOilbKO BOeHHOro, onepaL\lllH BbtnOilHHeTCH caoespeMeHHO. 0AH8-
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np111 npoH111Ka10i.u1i1x VI 3aKpblTblX nospe)!(,D,eHVlflX, nop,A111ac:pparManbHbttll a6cL1eccb1, reM0611111111H,
ycrynas::i no 48CTOTe TpaBMlilpOBaHlllH TOilbKO Klll- KposoTe4eH111e, nocnpaBMaT1114eCKVllli renarnT,
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flX co4eraHHOi:i rpasMbl ,aocrnraeT 80%. noape- flOCTb, ceKBecrpa1..4111111 TKaHlif ne4€Hlll B OKpy>KHo-
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cny4aes. AaHHbte KillllHVIL\VICTOB o 4acT0Te 3a- ne4eHVI 111 APeH1t1posaH111H, Hepacna3HaBaH111s::i co-
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T8KTVl4ecK111x ycTaHosoK no y311osb1M sonpocaM onepaL\lllOHHblX OCJlO)f{HeHllltA.
npo6neMbl, YTO OTp11J4arenbHO CKa3blBaeTCfl Ha npe;:inOflO)l{lilTb HanlilYllle nospe>K,D.eHlilfl ne-
pe3yilbT8TaX Ile4eHVIH. 4eHlll MO)f{HO Ha OCHOB8Hllllll 1113y4eHVIS1 o6CTOfl-
TeilbCTB TpaBMbl, )l(a1106 60JlbHOro , p,aHHblX Killll-
94
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95
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arnocrn4ec1<as:i nanapocKon111S'l a 99% cny4aes
no3Bons:ieT Bbl5lBll1Tb nospe)l{,D,eH111e ne4eHL1 , no-
3TOMY oHa B nocneAHL-1e rDAbl nony4aer w111po-
1<oe np111MeHeH111e B KnlAHlll4€CKOM npaKTlllKe.
/1el.feHue
0CHOBHOl.1 MeTOA ne4eHlllS'l TpasMaTll14eCK!llX
nospe~eH11i.1 neYeHlll - onepamueHb1D. no3TDMY
np111 nposeAeH111111 onepaLJ,111111 Ha ne4eH111 Afls:! aAe-
KBaTHoro ero BbinonHeHll1S'l x111pypr AOJ1)1{eH op111-
eHrnposaTbcs:i so B3a111MoornoweH"1s:ix ee BHYT-
p1.1opraHHblX CTPYl<TYP· Bli13Y811bHbliil OCMOTp He-
AOCT8T048H Ans:i onpeAeneH111s:i cTeneH111 nospe-
)l{,D,eHL1s:t. Y4111Tb1sas:i, 4TO np111 rny60K111x pa3pbtsax
w paHeH1t1s:tx BHyrp1-1opraHHb1e COCYAbl 111 )KeJ14-
Hble XO,ll,bl MOryT 6b1Tb li1HTat<THblM111 111 , HanpornB,
u,enocTHOCTb L-1X MO)!{eT OKa3aTbCT! HapyweHHOVJ
nplil, Ka3aflOCb 6br, He3Ha41i1TeflbHOfli TpaBMe,
ycnewHo np111MeHS'lercs:i xonaH2uo2pacpufl, TaK
KBK )f{eJ14Hble XOAbl nosrop~HOT BeTBJ1eHl!l.R cer-
MeHTapHblX cocyAOB 111 nospe}l{,QalOTCS'I sMecre c
HIAMllL ,[laHHa.R MeTO,.QJAl<a TeXHJAYeCKlll npoll.le aH-
rnorpaQ:>111111, lilMeer 6011bWYIO 111HQ:>opMaTlilBHOCTb
111 He Tpe6yer cne4111a11bHb1X aHr111orpacp111YecK111x
TeXH0110rllltA . )J,11.R Bbl$1Bl1eHl!191 nospe}l{,QeHHblX
)f{enYHblX nporoKos noc11e AOCT111)f{eH111S'I reMocra-
3a B )f{eJ1YHbltA ny3blpb 11111111 B renaTlllKOXoneAOX
MO)f{HQ BBOAIATb paCTBOp MeTlllneHoBoro ClllHero.
I eMocTa3 neYeHlll np111 nosepxHOCTHbrx no-
Bpe~eHlllS'IX ,.QOCT111raeTC$1 c nOMOLI.lb!O 61..1onor111-
YeCKll1X Knees MK-6 111 «CynbQ:>aKp11111aT», npena-
paros «TaxoKoM6», «AnnoreM», KCeHoreHHolA
6ptow111Hbr. TaK>Ke 111cnonb3YIOTCS'I 1<oarym1posa-
H111e 3nerpoKayrepoM, pa,.Q111ocKa11bne11eM, 11a3e-
poM, nna3MeHHblM cKanbneneM. ,lln.R npw1<pb1T111.R
paHeBolA nosepxHocrn neYeHlll, TaMnOHa,.Qbl pa-
Hbl' a TalOKe 8 KaYeCTBe no,.Ql<IlB,.QKIA no,.Q WBOB
A11fl npe,.Qynpe>K.QeHlll.R era npope3b1BaH1t1S'! 111c-
noJlb3ytoT nps:1,.Qb 6011bworo ca11bH111Ka 11Jm1 ceo-
6oAHYIO MblWeYHYIO n11aCTlllKY, )i(l!lpOBylO KneT-
YaTKY, ayrn,llepMa11bHY10 nonocKY. npenaparb1 1113
cep111111 «AnnonnaHT», KceHoreHHYto 6pt0w1t1Hy.
np111 nospe>K.QeHll151X I creneH111 ,.Qonycr111Mo
orpaH111Yt11TbC5l Koarym14111elA paHbt c 4enbto re-
Mocra3a np111 napeHXlllMaT03HOM KpOBOTel.JeHllllll,
6e3 Ha110)f{eHlll51 reMOCTaTl111.JeCKll1X WBOB Ill oc-
raeneHlllS'! c1t1rHanbHoro AP8Ha)f{a Ha 1-2 cyroK.
A,o,eKBaTHblM BMewarenbCTBOM nplll nospe}l{,Qe-
Hlll51X II - Ill creneH111 51sn.s:ierc51 Ha11o)f{eH111e rny-
6oKlllX reMOCT8Tl.1Y8CK1!1X WBOB Ha BCIO rny61t1Hy
paHbl, YTO c11y)f{t11T MepolA npo¢11111aKT111K111 reMo-
611111111111. C 3rofli 1...1enbt0 111cno11b3YIOT Marpal..\Hbre
11111111 n-o6pa3Hble WBbl, ABOtAHOtA neTnlllCTbltA
WOB, BOCbMlll06pa3Hblt'.1 Ill n-o6pa3Hblfli WOB, no-
CJ10tAHbltA WOB, WOB Ky3H840Ba-neHCl<OfO. npo-
WlllBaHlrle cocy,.Qos Henocpe,.QCTBeHHO B paHe ne-
YeH111 np01113BOAlllTC51 np111 pa3pbtBaX 111-IV CTe-
neHlll npe.r1sap111TeJlbHO ocyll.leCTBJAB speMeHHbli:;i
reMOCTa3 nepe)f{aTllleM renaTOAYOAeHaflbHOtA
CBs:!31<111 B TeYeHllle 10- 30 MlllH : OTCYTCTBll18 reMO-
CTa3a np111 3TOM CBlllAeTenbcTByeT 0 nospe>K.Qe-
Hllllll neYeHOYHblX BeH lil11lll BHyTplllneYeHOYHOro
OTAena HllDKHelA nonolA seHbl.
l.4aA51ll.lafl X1Apypr111YecKas:i o6pa6orKa paHbt
neYeHlll no3eons:ieT 11136e}KaTb T51)f(enorlt lllHTOKClll-
Ka41111t1 npoAyKTaM111 pacnaAa. o6pa30BaH111s:i a6c-
L.leccos. Pe3eK4111io neYeHlll BbtnOnHS'ltOT np111 Mac-
c111BHOM pa3pyweHll1lll AOn111 neYeHlll, CKB03HblX
orHecrpenbHbtX paHeH111flX, conposo>K.Qatoll\lllXCfl
MaCCll1BHblM KpOBOTeYeHllleM, nplll nospe>K.Q8Hllls:!X
neYeHoYHblX seH 11111111 sHyrp111ne11eHOYHOro OTAe-
na H1!1)f{HetA nonolA seHbr. Ar111n1114HYto pe3eKL.llllto
no Tlllny Kpaesot1, KillllHOBlllAHOt1 t.fmt nonepe4HOt1
c yYeTOM BHyrp111opraHHOCf ronorpaQ:>111111 cocy,.Qos
lrl npoTOKOB BblnO.nH.ReT np111 nospe)f{,.QeHltllil YaCTlll
cerMeHTa 11111111 Aon111, a np111 nopa)l<eH111111 L\enolA
aHaTOMll!YecKo~ o6nacrn 111n1A cocy.£.lWCTO-
96
ce1<pernofli HO}f(Klrl npo1113so,L1.RT cerMeHrapHylO
pe3eK4111io 11111111 reM111renaT3KTOM11110 . Knacc111¢111-
KBL!1t1fl pe3eKL(ft1W neYeHH OCHOBaHa Ha y'-leTe
cerMeHTapHoro crpoeH111s:i neYeHlll , a TaK)f{e xa-
paKTepe BbtnOnHeHll1.R onepa41-11A (rn6n. 6).
Pe3eKL.lllls:I neYeH111 AO c111x nop conposo}l{,Qa-
erc5l BblCOKOlil J18TaJ1bHOCTblO - OT 19 AO 70%.
0CH08Hble np111YlllHbl 11eTal1bHblX lllCXOAOB: lllH-
rpaonepa41110HHOe KpOBOTeYeHJAe, neYeHOYHO-
no4eYHa51 HeAOCTaToYHOCTb, HeKp03 TKaHlll ne-
Y8Hll1 . HeyAoBnersoplllTenbHble pe3ynbTaTbt pe-
3eK41111A l.laLI.le scero CBS'l3aHbl c BbtCOKOIA rpasMa-
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A810ll.llllX rexHlllKOIA AaHHolA onepal.l1t11t1. 111cnonb-
30BaH111e MeXaH111YecKoro wsa np111 npoBeAeH111111
ar111n1114HolA pe3eK4111111 no3so.ns:ier ynpocT1t1Tb o6-
pa6oTKY coCYAlllCTbrx CTPYKTYP neYeH111 111 nosb1-
c111rb HaAe)f{HQCTb reMOCTa3a. np111 npoBeAeH1!1e
TaKft!X onepa4111~ peKOMeH,llyeTCH HaKna,llblB8Tb
MexaHlll4eCKll11A woe 4epe3 nnacrnHy KCeHoreH-
HOCf KOHCepBWp088HHOH 6plOWIAHbl. n.nacrnHa
KCeHo6plOUJlllHbl noBblwaeT npoYHOCTb cPJAKCa-
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rypaM 111 O,QHOBpeMeHHO MO)f{eT lllCnOflb30BaTbCs:!
A115l nep111roH1113a4111111 paHesolA nosepxHocr111 ne-
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6111patoTCfl 1!1H,D,lllBIAAYanbHO 111 ee KOJ11t1YeCTBO He
orpaH111YeHo. TaKoct cnoco6 BbtnonHeHlllS'I onepa-
L.\111111 HOCl!1T Ha3B8Hllle annapaTHO-fl11aCTll1YeCKOtA
pe3eK41111A neYeHlll (p111c. 35).
PHc. 35. AnnapaTHo-nnacTHl.lec1<aR pe-
3eK'-'1.u1 ne"leHllt (cXeMa): nnaCTl!tH3 KCeHO-
reHHOH 6pfOWHHbl (1 ), QJHKCHpOBaHHaff npH
npow11taaH11t11t Tpy6"1aTblX cTpyKryp (2) Me-
xaHHlfecKHM WBOM (3)
np111 He3cpcf>eKTlllBHOCTlll Meponplll.RTlllCf no
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renbHOIA Ailfl 60ilbHOrO C4111TaeTC$1 TaMnoHaAa
30Hbl nospe>K.QeHf.151. TaMnoHaAa 30Hbl KposoTe-
YeHlll5l s apceHane onepaTlllBHbtX noco61111A np111
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noc11e,llyt0ll.leM 3TO npe,.QnaraeT crn6111111113a1...1u10
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nonHOM o6beMe - snnOTb AO pe3e1<1..11i1111 neYeHJ.1.
c 4811bl0 npoQ:>lllnaKTlllKlll B03MO)f{Hb1X oc-
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3aHbl np111 pa3pbteax I creneH111 , a Ha.n111Y111e B
6plOWHOrA no110CTlll 6onee 400 Mn KPOBll1 S'!BJ1fl-
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onepal\11151M.

K.rrnccuit>nKai.-ust pe3eK1~uii
IIpaBocropoHHAA pacnrnpeHHa51 reMttrerranKTOMH5I (IV, V, VI, VII, VIII±I)
ITpaBocropomuIB re:r.rnrenaT3KTOMH5J (V,VI,VII,VIII)
JleBocropomuur pacumpeHHa5I reMHrerraT3KTOMH51 (II, III, IV±V±VIII±I)
JleBocropot11urn reMttrerranKTOMFUI (Jl, III, IV±I)
JleBocropoHIDI5I KaBaJihHM nofoKroMmI (II, III)
CerMeHT3KTOMH51 (yKa3hIBaIOTC51 HOMepa cerMeHtoB)
TaK111M o6pa3oM , pe3ynbTaTbl x111pyprnYe-
cKoro ne4eHll151 rpasMarn4eCKll1X nospe)f<,D,eH111tl
neYeH111 3as111c5IT, npe)f<,D,e scero, OT csoespe-
MeHHolll All1arHocrnKvt c 111cnoilb30BaH111eM cospe-
MeHHblX TeXHOilOr111tl Ill CBoespeMeHHO BblnOil-
HeHHOJA aAeKBaTHOIA onepau111111 . B csofO oYe-
peAb , lllCXOA oneparnBHblX BM8W8TeilbCTB 388111-
C\.'IT OT xapaKTepa 111 o6beMa . nospe:>K,LJ,eH1115l ne-
4eH111 , aAeKsarnocT111 111cnonb3yeMblX cnoco6os 111
caoeapeMeHHOCTlrl reMOCTB3a, OT Ksam-1Q:>lllL.!lllPO-
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3vtBHb1x x111pyprn4eCKll1X T8XHOJ10fll1111 B x111pypr111-
48CKOM Il848Hll1111 rpaBM ne4eHll1 raK>Ke He Bbl3bl-
Ba8T COMH8H1111il. lt1x w111poK08 BH8ApeHll18 B
npaKTll148CKYfO x111pypr111f0 no3BOJ151T CHll13111Tb
YA8JlbHbltl sec Bb1coKorpaeMaT1114HblX oneparns-
HblX BMewaTeJlbCTB, nopolll He onpaBA8HHblX
plri A8HHblX c111ryau1115IX, 4TO, KOHe4HO >Ke, no-
3BOJ1111T yny4w111Tu noKa3aTen111 neYeH1115l AaHHOlll
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OBPEH<,11,EHt1fl CE/lE3EHKt1
nospe)f<,D,eHll18 C8Jl83eHKlil 38HlllMa8T no
acrore 2- 3 Mecro. neranbHOCTb np111 rpasMax
cen eJeHKlil, no AaHHblM pa3Jlll14HblX asropos,
COCTaBJ1518T OT 13 ,LIO 57% . TalOKe OCTaeTCS'I Bbl-
COKOtl 48CTOTa nocneonepau1110HHblX OCJlO>KHe-
111'1 - OT 23 AO 40%. Ecn111 paHbW8 np111 mo6oM
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a He BbJ3bJsa11 coMHeH111lll 111 nonbJTKJ,! coxpaHe-
97
Ta6llU1fO 6
nettenu BRISBANE
Hlil51 cene3eHKll1 Kareropw-1ecK111 ocy>K.Qan111cb 1113-
38 onacHocr111 pa3e111r1115l nosropHblX npocpy3Hb1X
KpOBOTe48Hll1111, TO B HaCT0511.l.\8e Bp8M51 opraHOC-
6eperafOU\851 111 3aMecr111renbHa5l x111pypnrn cene-
3eHKll1 H8XOAll1T see 60ilbWe CTOPOHHll1KOB Ll.\a-
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u1110HaJlbHOlll 8KTlilBHOCTbfO TKaHlil ceI1838HKll1 111 ee
cnoco6Hocrbf0 K pereHepau111111.
AHamoMo-cjJu3U0/102u1.Jec1<ue
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V13y4eH111e cpyHKl.(111111 cene3eHKlll 4all.\e npo-
111cxoA111no np111 aHan1113e nocrcnneH3KTOMll14ecKo-
ro COCTOHHlllH. Cny1..1a111 neroYHblX OCJ10>KH8Hllli1 Ill
paHesolll 111HcpeK411n1 orMe4am1cb Yal.l..le nocne
cnneH3KTOMlilll1 , 4eM np111 APYrll1X onepau11151x.
CnneH3KTOMll151 CB513aHa c ysen111YeH111eM 1..1acro-
Tbl lllHcj:leK41110HHblX OCI10>KH8Hll1111 111 CMepTHOCTlil.
Ha1116onee 48CTblM 111 onacHblM ocnO>KHeH111eM
nocne cnneH3KTOMlilll1 raK )f(e c4111ra10T rpoM6o-
3M6on111fO. Ecrb HeOAHOKpaTHb1e Ha6moAeHll151
MonH111eHocHoro cenc111ca, pa3s111sweroc51 nocne
cnneH3KTOMlt1111. Bo36yA111reneM 3Tll1X ll1Hcp8KL11t1-
oHHblX OCJ10>KH8Hll1111 srnmieTC51 He TOilbKO
Streptococcus pneumonia, HO 111 Neisseria
meningitis, B.coli, Hemophilus inbluenzae,
Staphylococcus aureus, Streptococcus,
Pseudomonas. np1114eM 6aKTep1t1eMlil5! AOCrnraer
106 /Mn 111 6onee, np111 3TOM xapaKTepHo BHyTp111-
cocyA1t1crne All1CCeM111H111posaHHoe csepTb1saH111e
KpOBlll. 06bl4HO cenc111c B03HlllK8eT B Te4eHllle
nepBblX 11.syx neT nocne cnneH3KTOM(ll(ll.
06L4enp111Hsnoe cpe11.111 1<11lllHlllL..llllCT0B MHe-
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comOTHO 6e3on8cHoi::1 An51 opraHlll3Ma, 38 no-
cneAHllle 15-20 neT 3H84111TenbHO 1113M€Hllll10Cb.
Vlccne,qosaTem1, pa60Tat0t1.(we B 3TOW o6nacrn
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Ka Bbln011H51eT pO!lb cp1t1nbTp8 Ill MeXaH1113M8
06e3spe)f{111BaH1115I M111Kpo6os 38 c'-leT co11.ep)f{a-
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H111TeTa, cene3eHK8 TaK)f{e aKTlllBHO y4aCTByeT B
06pa3osaH111111 cneL1111cp1114ecK111x lllMMyHorno6yn111-
HOB Ill 6111onorn4eCKlll aKTlllBHblX nenTlllAOB, Heno-
cpeACTBeHHO crnMyn111py10IJ..llllX ClllCTeMy cparo-
l...llllT03a Hei::lrpocp111nos noaTOMY nocne cnneHaK-
TOMllllll p83BlllBaeTC51 lllMMYHHbllil p,ecpllll...llllT, 4TO
npep,p8cnonar8eT K reHepan1113a1..1111111 111HcpeKL1llllll 111
B03HlllKH0BeH111t0 cenc111ca y 1-2% s3pocnb1x no-
cTpa.Qasw111x 111 y 4-5% ,llereiil. Cenc1<1c MO)f{eT
pa3BlllTbc51 4epe3 nto6oV! lo1HTepsan speMeH111 no-
cne cnneH3KTOMllllll Ill conpOBO)f{/1,8TbC51 BblCOKOi::l
neranbHOCTbto - AO 50-80% . nocne cnneH3K-
TOM111111 senlllKa onacHOCTb pa3Blo1T11151 paHHlllX oc-
llO)f{HeH111V!: nHeBMOHllllll , nnesp111Ta, naHKpear111ra,
no11.11.111atj:>parManbHoro a6cL1ecca, HarnoeH1t15I
paHbl, cenc111ca. Y 6onbWlo1Hcrna 6onbHblX nocne
cnneH3KTOMlo11o1 "1Meerc51 noBb1WeHHa51 socnp1i1-
111M4111BOCTb K ocTpbiM pecn111paTopHblM s111pyc-
HblM lo1HcpeKL..111151M , 8Hr111H8M , nHeBMOH11151M .
CnneH3KTOMlll5l Bbl3b1saer HapyweHl-151 Me-
xaH"13MOB reMocTa3a. nocne cnneH3KTOM111111 pa3-
svraaeTc51 rpoM6ou111ro3, 4TO cnoco6creyer rpoM-
603y BeH Hlll>KHlllX KOHe4HOCTeV! Ill 3M6on111111 ne-
ro4HOll! aprep111111 . TaK)f{e oKa3anocb, 4TO acnne-
Hlll3M ornrow,aeT Te48Hllle lo1 lllCXOA ny4eBOVl 6o-
ne3Hlll, ocna6nHeT npoL1eccb1 11.eTOKClllKaL..11111<1 s
renaroL(l1TaX 1i1 111x 3Heproc6epe)f{eHHe. Y n111L(,
nepeHecw111x cnneH3KTOMlllto, OTMe'-laercH 6onb-
wa51 4aCTOTa 3I10Ka4eCT88HHblX HOBOo6pa30Ba-
Hlo1Vt. no3TOMY x1o1pypr, y11.an5151 cene3eHKY, H1<1Ko-
r11.a He MO>KeT 6b1Tb ysepeH B COCT051Hllllll 3/1,0po-
Bbfl 11 Ka4eCTBe )f{l13Hl1 6onbHOro B 6y,!ly1.4eM.
CTpoeH111e 3KCTpa- 111 lllHTpaopraHHblX cocy-
AOB cene3eHKlll, xapat<Tep seTsneHlllH aprep111-
KJJaccmlnrn:auusi nospe)K)J.eRuii cene3eui-:u
IIoB e)K,IJ,emrn ceJre3eHKR
P33pbIBbl Cy6KancyIDipHbie p33pbIBhI P33phIBbI B npe.nerrax KpoBo-
Kane JTuI c 06 330B3HMeM reM3TOM CH36)J(aeMoro cerMeHTa
B 1<11111H1114ecKOM re4eH111111 noape)f{/1,eH111VI ce-
ne3eHKlll (llMeeT 3Ha4eH111e, 6e3ycnoBHO, o6beM 111
cKopocTb Kposonorep111. Hal!l6onee nonyn71pHoV!
51Bn51eTC.51 1<11acc111¢111Ka4111H Cloutire, Zaepfel
(1958), xapat<Tep1113yiow,a51 Kpoaore4eH(ll51 no
speMeH111 npo51sneH1115I :
1. 5blCTpoe KpOBOTe'-leH111e c paHHlllM KOJl-
nancoM.
98
anbHOV! Ill BeH03HOV! ClllCTeM Ill VIX B3alt1MOOTHO-
W8H!lle CB(ll,IJ,eTenbCTBYIOT, 4TO OCHOBH0!.1 CTBon
cene3eH04HOlll aprep111111 B 66,0% cnyyaes Ae-
n111rc51 Ha ABe rnaBHble BeTBlll , B 15,9% - Ha Tplll
rnaBHb1e seTs111, a B ocranbHblX cny4a51x serselli
MO>KeT 6b1Tb 60llbWe. no3TOMY pa3nlll'-latOT Ae-
neHlife ocHOBHoro crsona ceneJeHOYHo~ apTe-
p111111 no cneAyt0~1t1M rnnaM : 0/1,HOCTBOllbHbllli
(yHlllTPYHKallbHblVt) , ABYCTBOJlbHblVl (6111cpypKaL1111-
0HHbli:1} , TpexcTBOnbHblVt (Tp111cpypKal...llllOHHblCi} Ill
MHorocTBOJlbHblVl (MHoropa311.enbHbtlli}. B nep-
BOM cny4ae ceneJeHo4Haf! aprep1115-l nocne,Qosa-
renbHo 11.aer PHA BeTselll K opraHy. np111 6111cpyp-
KaL11t10HHOM T111ne AeneH11151 cene3eH04Ha51 apre-
plil51 p,en(llTCS'I Ha BepXHIOKJ Ill Hlll)f{HIOIO BeTB(ll , nplll
Tp111cpypK8l...llllOHHOM - Ha sepXHlllVt, cpeAHlll!li Ill
HJIDKHllllli CTBOJlbJ.
3HaH111e o6w,lllx np111HL1111nos pacnpe,a,eneH(ll51
sHyTp111opraHHb1x cocy11.os cene3eHK1t1 no3son5leT
x111pypry Bbt6paTb Ha1116onee nplileMneMbli:1 111
Mopcponorn4ecK111 o6ocHoBaHHbliil cnoco6 c6epe-
rarenbHOill onepaL.1111111 np111 ee nospe~eH111111.
Bers1o1 ceneJeHOYHolil aprep111111 s napeHXlllMe op-
raHa AenHTcf! Ha HeCKOnbKO nop51AKOBblX ser-
selll , OCHOBHblMlll 1-13 KOTOpblX 71Bl151tOTC71 cerMeH-
TapHble 111 cy6cerMeHrapHble. ,D.eneH111e 111Hrpaop-
raHHb1x BeTBelil cene3eHOYHOVl aprep111111 HOClllT, B
OCHOBHOM, nocne11.osaTenbHblVl AlllXOTOMlll4eCK(lli/i
xapaKTep. Bee ocHoBHb1e MarncTpanbHble apTe-
p111anbHb1e crsonbr 111 111x seTB(ll pacnonara10TC5I (II
BeTBS1TC51 B HenocpeACTBeHHO~ 6n1t130CTll1 K
sHyrpeHHeill 111 nepe,a,Helli nosepxHocrn cene3eH-
Klll, MenK111e pa3sersneH1115I HanpasmHoTC51 K Ha-
py)l(Hoiil noaepxHocr111. BeHbl ceneJeHKlll nosTo-
p5110T xo,a, aprep(llr/i. CerMeHTapHoe p,eneH111e
pacnpe11.eneH111e apTep111anbHblX BeTBelli , np(llBO-
AlllT K cpopM111poBaHllllO OTHOClllTenbHO 6eccocy-
,IJ,(llCTblX noneV! opraHa. Op(lleHrnpoM Ailfl onpe-
p,eneH111S1 BaCKYns:tpHblX 30H MOryT C!lY)f{lllTb 30-
HaJlbHble 3KcrpaopraHHble cocy,.Qbl, nepeBHJKa
KOTOpblX cnoco6cTBYeT 3Ha4111TenbHOMY yMeHb-
weHlo1IO KpOBOTe4eHlll51 nplll paHeHllllll COOTBeTCT-
sytow,ero y4acrKa cene3eHKlll. «Bb1pe3Kl!l-3apy6-
Kt11>> Ha Kpae ceneJeHKlll, Ha6nt011.aeMb1e s 80,0%
cnyYaes, 11n111 coxpaHVJBWaHc51 ,.QOnbYarocTb, raK
)1{€ COOTBeTCTBYIOT rpaH(lll...laM 30H (II cerMeHTOB.
Pa3M03)J(emie mm OT-
bIBhI l{enoro o raHa
2. CKpb1TOe KpoaoTe4eH111e.
3. Orcpo'-leHHoe (srop(lllJHoe) KposoTe4e-
Hlile.
,11,ua2Hocmw<a
CsoespeMeHHa7111.111arHOCT111Ka nplil rpasMax
cene3eHKlll - TaK)f{e at<TYanbHaH npo6neMa. Oc-
Hoay p,111arHOCTlllKlll COCT8Bl15llOT 11.aHHble aHaMHe-
3a, KJllllH1114eCKoli1 KapTlllHbl 111 AOnonHlllTenbHblX
na6opaTopHblX Ill cplll3111KanbHblX MeTOAOB lllC-
cn e,.qosaHIArA .
Kn111H1114ecK111e npmmneHllls:t 3aKpblTblX no-
spe>K,D,eH1111i1 cene3eHKlll MHoroo6pa3Hbl, He sce-
rAa nocT051HHbl Ill 3aBlllC51T OT TS'l>KeCTlll Ill xapaK-
r epa rpaBMbl. Bm1<Ho ycraHoBlllTb MexaHlll3M no-
ny4eHlll5l rpaBMbl 111 ,D,a:>1<e He3Ha41t1TenbHb1e 1113-
MeHeHllls:t cocros:tHllls:t nocrpaAaswero cpa3y no-
cne rpaBMbl. nplA 3TOM Heo6xo~IAMO Y41rfTblBaTb,
I.ITO 111HOrAa 6onbHble npocTo He 06paw,a10r
sH111MaH111e 111n111 3a6b1Ba10r npo He3HaY11nenbHb1e
yw1i1 6b1 s 06nacr111 no,o,pe6epbs:i 111n111 Hlll:>l<HlllX or-
,[\enos rpyAHOli1 KJleTKlll, KOTOpb1e Moryr 51BlllTbC51
np111 4111Hoi4 pa3pbJBa opraHa. Ka1< 111 np111 1<posore-
eH1.1 1.1 n10601/1 ,o,pyroli1 :m11onorvi111 Heo6xoAL.1MO
o6paw,aTb BH111MaH111e Ha TaK111e npoHsneH111s:i 2e-
Moppa2ul/ecK020 CUH8poMa , KaK no51BlllBWYIOC51
cn a6ocrb, ronoso1<py:>1<eH111e , MenbKaH111e «MY-
eK» nepep, rna3aM111 , KparKospeMeHHYIO nore-
plO co3HaHlllSl (cMMnTOM Ma1<-KpaKeHa) no nmy
eps1t1 4Horo 06Mopo1<a. 3rn CIAMnroMarnKa xa-
paKTepHa p,n51 cpopM111poBaH111s:i cy61<ancym1pHoli1
reMaTOMbl , KOT0p851 MO:>l<eT 3aBepWlllTbC51 BTO-
pMY HblM (p,syxcpa3HblM») pa3pblBOM Yepe3 YaCbl ,
~Hlil He,o,em1 nocne neps111YHoli1 TpaBMbl. ,O,syx-
¢la3Hblli1 pa3pblB ceJle3€HKlll OYeHb KOBapeH, no-
3TOMY onepaTlllBHoe neYeH111e cy6KancynHpHoli1
reMaTOMbl a6COfifOTHO nOK838HO. nepenoM HllDl<-
MX pe6ep c pe3KOli1 6one3HeHHOCTblO Ill Bblpa-
eHH Oli1 Mb1WeYHOli1 38lL\lllTOli1 M0)1(8T C111Myn111po-
B8Tb nospe>K,D,eH111e cene3eHKlll .
Ha1116onee LtaCTblM npos:1sneH111eM nospe)I(-
• eH1'1ili mo6oro napeHXIAMaT03Horo opraHa s:isn7!-
e c51 KnlllHlllKa reMoppar111Ltec1<oro woKa. 3ro
p051BJlS'leTC51 6ne,D,HOCTblO KO>KHb!X noKpOBOB ,
xon o,D,HblM noTOM, aKpOL\i.18H030M, TaXV1Kap,o,111eli1
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MeM reMaT0Kp111ra, Kon111Yecrsa 3p111rpo41i1ros,
aprep111anbHoro AaBneH111>1.
np111 OCMOTpe nocrpap,aswero o6pa!.1..!aeT Ha
ce65l BHlllM8Hi.1e orpaH111LteH111e 3KCKypc111111 6p10W-
oi:1 creHKlll np111 ,D,b1XaH111111 . ,Qns:t nospe>K,QeH111s:t
cen e3eHKlll xapaKTepeH Cll1MnToM «B3HbKM-
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coxpaHl!ITb 1.1cxop,Hoe nono)f{eH111e rena np111 no-
blTKe era 1113MeHeH111s:i). 5om'1 YaU,\e no-
~1113YIOTC,>i B o6nacrn nesoro nop,pe6epb51 Iii
6oKosoii\ 06nacT111 111 conposo>K,D,atoTCs:t Hanps:i>Ke-
'MeM MblWL\ nesoro sepxHero KBaApaHra. 5onee
en<ylO J10K8Jllll38L\llllO 6one3HeHHOCTlll MO>KHO
3 BlllTb onpep,eneH111eM c111MnT0Ma XeAPM (111p-
pa,Q1r1a~1t1fl 6on111 s nesoe noApe6epbe npw noe-
pe>KAeH111111 cene3eHK111 np111 ronYKoo6pa3HOM Ha-
_,asmrnaH111111 Ha MeYeBVl,D,Hblii\ OTpOCTOK rpy,D,111-
). V1Hor,o,a, np1.1 cpopM111posaH111111 oKonocene3e-
OYHoi:1 reMaTOMbl, Bbl5lBJ15lerc5l npM3HaK Bellt-
Hepra (plllflll,LlHOCTb MblWLl neBOli1 60KOBOli1 06-
acrn >K111sora), onpe,o,en5leMas:t np111 cpasH111-
-en bHOr.1 nanbnal(lllllf. np1113HaKoM BHyrp1116ptow-
oro KpOBOTeYeHlll51 flBJ151eTc51 HeCOOTB8TCTBllle
99
Me>K,Qy pe3KOli1 6one3HeHHOCTblO 6plOWHOli1 CTeH-
Klll np111 nanbnau,111111 1i1 orcyrcrs111eM Mb1weYHOi:1
38ll..lll1Tbl (cMMnTOM Ky1111eHKaMn<J>a).
Cnep,crn111eM rpaBMbl cene3eH1<111 Slsns:terc7i
cpopM111posaH111e csepTKoB Kpos111 s nesoM no,o,-
pe6epbe 111 nesoM 6oKosoM KaHane 1.1 c1<onneH111e
)1(111,D,KOIA KpOBlll , YTO np111 nepf<YCCllllll nesoli1 q:>naH-
KOBOli1 06nacr111 06ycnasn111saer cpeHoMeH «He-
cMe!.l..!aeMoiJ mynocmU» - np1!13H3K n111rca !A
5enneHca. 3ro np11rrynneH111e Heo6xO,lllilMO
p,111cpcpepeHL\lllposarb c HecMew,aeMblM np111ryn-
neH111eM np111 nepf<YCCllllll ornorvix Meer >KlllBora
np111 cpopM111posaH111111 06w111pHoli1 3a6p10WlllHHoli1
reMaTOMbl (c111MnTOM ,[l.>KOHCa).
Y He1<oropbJX 6onbHbJX c nospe~eHJAeM ce-
ne3eHKlll Bbls:!BJl51eTC5l nonmKlllTeJlbHbli:1 «cfJpeHU-
Kyc-cuMnmoM» cnesa (c111MnroM 3ereccepaJ 111
111ppa,o,111aL1111s:i 6oneli1 B nesyto KnlOYlllL\Y 111 6one3-
HeHHOCTb ee nplll nepf<YCCllllll (C111MnTOM 3neKepa)
111n111 nonarKY (CMMnTOM Kepa). np111YeM s nono-
>KeH111111 TpeHp,eneH6ypra 3r111 c111Mnr0Mbl 6onee
Bblpa>KeHbl. 0,llHL1M IA3 6onee no3AHlilX npm~sne­
Hlllli1 noBpe~eH1111i1 cene3eHKlll 11sn51erc51 Mereo-
p1113M (CMMnTOM relilHeKe), YTO TO)f{e CB5138HO CO
CKonneH111eM KpOBlll B 6plOWHOli1 nonocTlll.
HeAOCTaTOYHas:t 111HcpopMaT111BHOCTb Kn111H111-
YeCKlilX Iii peHrreHonorlllYeCJ<lllX ,Ll8HHbJX B ,a1t1ar-
HOCTlllKe nospe>K,D,eH1111i1 cene3eHK111 3acras1i1nw
111cKaTb .Qpyrvre cnoco6b1 A111arnocrn1<111 . YITbmpa-
coH02pacfJuR s:tBn5leTc5l npocrb1M s 111cnonHeH111111,
lllHcpopMaTlllBHblM Ill npaKTlll4eCKlll He 1.1MelOU,\lllM
npornsonoKa3aH1111i1 A111arHocr111yecK111M cnoco6oM .
Merop, no3son5ler Bbl5lBlllTb cso60,o,Hy10 >KlllA-
KOCTb B 6plOWHOl4 nonocrn (3XOHeraTll!BHble re-
Hiil B OKpy)f{HOCTlll cene3eHKlll , ClllMnTOM <<nna-
B310ll.{MX nerenb» ), CHlll)f{eHllle 3XOf8HHOCTlll Ill
ysen1114eH111e pa3Mepos cene3eHK111. ,0,111arHocr111-
Yec1<a5l TOYHOCTb ynbrpac0Horpacp111111 np111 rpaB-
MaT1.1Ltec1<111x nospe>K.QeH111s:ix cene3eHKlll cocras-
ns:1er 96% .
ApmepuoapacfJuR, HecMorps:i Ha CJlO)l{HOCTb
He CTOJlbKO caMoro 111ccne,1J,OBaHllls:! , CKOJlbKO ero
opraHlll38L\llllll , n03BOm'leT c 6onbweii\ TOYHOCTblO
p,111arHocrnposarb pa3pb1Bbl cene3eHKlll 111 ne4eH111.
B nocne,o,H111e rop,bl orHoweH111e K nanapo-
~eHme3y, KaK BbJCOKo lilHQJOpMarnsHoMy Alilar-
HOCTlll4ecKoMy 111ccneAOBaH11110, crano 6onee on-
peAeneHHblM. Pa3pewa10w,as:i cnoco6Hocrb 3TO-
ro 111ccnep,osaH111s:t , no MHeHllllO MHOrlllX asropos,
,D,OCTlllraer 97+2% . 3ro 3H8Yl.1T, YTO ,IJ,aHHbli:1 Me-
TO,Q ,D,lllarHOCTlllKlll nospe>K,QeH1111i1 opraHOB 6plOW-
HOli1 nonocrn ,o,on>KeH 6onee w1.1p0Ko 111c-
nonb30aaTbCfl a Heornm1<HoiA x111pyprn111. Oco6y10
Ba>KHOCTb 3TO lilCCileAOBaH111e np1i106peraeT np1i1
COYeTaHHblX yepenHO-M03fOBblX TpaBMaX.
Cpep,111 111Hsa3111sHblX Merop,os 111ccnep,osa-
Hllls:i Hal.'16onee nonHoL\eHHblM, 6e3ycnosHo, s:ia-
ns:ierc5! nanapocKonuR, ,QOCTosepHOCTb Koropoiii
,D,OCTlllraer 100%. 0,o,HaKO TeXHlllYecKoe Bbl-
nonHeH111e nanapoc1<on111111 y 6onbHbfX c KOM61AHlll-
posaHHoiii Ill COYeTaHHOJA rpaBMOli1 lllMeeT CBOlll
 cnm1<Hocrn, 06ycnosneHHb1e onacHOCTbto co3- Hll151 K Hll1M (p1t1c. 39). Pe3e1<L11t1ll1 cene3eHKlll - Tex-
AaH1t15! o6bl4HOro no o6beMy nHeBMonep111rnHe- Hw-1ec1<£.1 cno>1<HaS1 npol(egypa, npe>K,D,e scero,
yMa B ycnOBlt151X B03MO>KHOro nospe>K,1J,eH1t15! 1113-3a ronorpacpo-aHaTOM1t14ec1<111x oco6eHHOCTei:1
A1t1acpparMbl 111n1r1 B03AYWHOll1 3M6on111111 np1r1 no- pacnono)l{eH1t1s:i opraHa, sap1r1a6enbHOCT111 yposHi::i
spe>K,1J,eH1t11t1 1<pynHblX ne4eHo4HblX cocyAoB. ,QeneH111i::i cene3eH04Ho!A apTep1t1111, 1<on1114ecTsa
np"' TpasMarnYeCK!llX nospe>K,1J,eH!ll5'!X cene- KOHe4HblX ee sernei;J. no3TOMY cerMeHTapHaSl
3eH Klr1 OCHOBHblM 51Bn5'1eTC51 xupypau4eCKUU Me- pe3SKL\lt1i::I npOlr13BOAL'1TC$1 B eAlllHlllYHblX cnyYai::ix.
moo ne4eHUR. X1r1pypr1114eCKa51 TaKTlt1Ka lr1 ne4e-
Hlr1e nospe>KAeH111"1 cene3eHKlr1 5'1Bns:itoTC5'1 OAHll1M
'113 cno>KHbfX 111 Mano1113yYeHHblX pa3,Qenos a6Ao-
M1t1 Han bHoll1 x111pypr1111r1 . HecMoTpi::i Ha npeAno-
>KeHHb1e MHorOYlllcneHHb1e cnoco6b1 reMocTa3a
np1r1 opraHoc6eperatou..t111x onepal..\llls:tx, 4acT0Ta
cnneH3KTOM"1!11 npeo6na.QaeT.
noKa3aHllleM K cnneH3KTOM1111r1 i::ism1toTcs:i
nlllWb cny4a111 pa3M03>KeH1r1i::i 1r1n1r1 0Tpb1sa L1enoro
opraHa. Bo scex ,Qpyrnx cny4ai::ix, npw 111cnonb-
30B8H!ll!ll MeTO.Q!llKW 06ec1<posn1t1saH1t1H nospe>K-
AeH HblX 30H, a B Ka4eCTBe nnacTlr14eCKOro MaTe-
p1t1ana 1<ceHoreHH0'1 6ptoW1t1Hbl, coxpaHeH1t1e
KpOBOCHa6>KaeMoi:1 cpyHKL.\lr10HlllPYIOL1.\e"1 48CTlll
opraHa - 3a,Qa4a snonHe BbtnonHHMafl . .Qa>Ke a
cny4a51x yAaneH1t15! cene3eHKlr1 soccTaHosneH1r1e
ee cpyHKL.\IA!ll enocne,QCT81111r1 B03MO>KHO np1t1 lt1M-
nnaHTal..\lr11r1 pa3Menb4eHHoll1 napeHx1t1Mbl s Kap-
MaH 6onbworo canbHHKa.
TaKlllM o6pa3oM , MO>KHO onpe,o,eneHHO CKa-
3aTb, 4TO c6eperaTenbHai::i onepal..\1t1s:i np111 no-
spe)l(,QeH111111 cene3eHKlll AOn>KHa 1t1 MO)l{eT s:is-
IlfffbCfl onepal(weti Bbl6opa. oOilbWYIO pOilb B
3TOM sonpoce 1t1MeeT Teopern4ecKas:i 111 npaKT1r1-
4ec1<a5! nOArOTOBneHHOCTb x1r1pypra.
np111 pa3pb1se 1<ancynb1 cene3eHKlr1 1r1 oT-
cyTcTs1111 ycTOl1411Boro caMonpo113sonbHOro re-
MOCTa3a MO)l{Ho orpaHll141r1TbC51 APeH1r1posaH1t1eM
nesoro nOA.QlllacpparManbHOro npacTpaHCTBa, a
np111 npa,Qamf<alOL1.\8MC51 He3H84111TenbHOM Kp0BO-
T848HIAJA reMocra3 ,Qocrnra10r annn111<aL111elA pa-
Hbl reMOCTaTl/l4SCKOll1 ry6Kolli 1r1n111 reMOCTan-Ne-
CKOlA Mapnei'.1, cp1111<caL11r1ei:1 np5!,Q1t1 6onbworo
canbHlllKa (p111c. 36).
Puc. 37. YwusaHue paHbl cene3eHKU wsaMu Ha
C 3Tl1Mlil )f{e L!8I151Mlt1 1t1cnonb3YIOT npenapar npoKrraaKax U3 KCeHOceHHOU KOHCepBUpoeaHHOlf
«TaxoKoM6» , 3fiSKTPO- lt1, paAL'104aCTOTHYIO Koa- 6p10WUHbl, (cxeMa)
rymll._\llllO. np111 Hafi0)1{8Hll11r1 reMOCT8Tll148CKlt1X
wsos Ha paHbl cene3eHKlt1 4all.\e scero npo1r1cxo-
A1t1T 1r1x npope3bJBaHJAe c ycMneH111eM 1<posoTeYe-
H1t1i::i, 4TO HeKOTOpble 06b51CHi::llOT cna60CTblO co-
8AlllHlt1TSI1bHOTK8HHOro OCTOBa opraHa , no3TOMY
np111 lr1X np111MeHeHl!llr1 He06XO,Q"1MO 1t1cnonb30BaTb
nOAKna.Q04HbJllJ Marnplllan (1<ceHoreHHa5I 6p10-
w111Ha, ny4Klr1 KeTryTa, npi::iAb 6onbworo canbH111-
1<a, 111 AP-) (p111c. 37).
np1r1 MHO)f{SCTB8HHblX pa3pb1B8X cene3eHK111,
oco6eHHO B 06nacn1 BOpOT, B03MO)f{H0 n111rJ11pO-
BaH1r1e COOTBeTCTBYtoLJ..\el/1 cerMeHTapHol/1 aprn-
P~·H1 c nocneAYtoll.\eVI nnacrn1<oi:1 paHbl MeTOAOM
,,61r1HTOB8Hll151" (plllc.38).
Ha ocHosaH1r1111 Knll1HL'1K0-3Kcnep111MeHTanb- Puc. 38. !7uwpoeaHue apmepuiJ (1)
HblX p,aHHblX 06 aBTOHOMHOM cerMeHTapHOM L(eHmpanbH020 ce2MeHma cene3eHKLJ u «6uHmoeaHue»
1<posocHa6>1<eHJ11111 cene3eHKlll pa3pa6oTaHbl cno- paHbl (2) KCeHoceHHOU 6plOWUHOU (3), (cxeMa)
co6b1 cerMeHTapHoi/1 pe3eKL\111111 opraHa 111 not<a3a-

100

Puc. 39. nuwposaHue cocydos (1) sepxHeao
ceaMeHma cene3eHKU u pe3eKqllfl sepxHezo nomoca.
npowusaHue omaenbHblX cocyaos paHesoiJ
nosepxHocmu (2), (cxeMa)
L.\enecoo6pa3HO coBMecTVITb pe3eKU,i.1to ce-
n e3eHKL-1 c np111MeHeHV1eM reMOCT8TV14eCKll1X npe-
napaTOB MecTHoro Aeli1crn11151: TaMnoH111posaH111eM
6onbwol/1 Kp111Bi.13Holl1 )f{enyAKa, 6onbwi.1M canb-
HVIKOM , cp1-1Kcau,1-1el/1 nnacrn4ecK111x Marnp111anos
(p111c. 40).
Puc. 40. nuauposaHue cocydos (1) HU>KHeao
cezMeHma cene3eHKU u pe3eK~Ufl HU>KHezo nomoca.
n nacmuKa KCeHOZeHHOU 6plOWUHOiJ (2), (cxeMa)
AyroTpaHcnnaHTau,11151 np111 0Tpb1Be 1-1n111
pa3M03)f{eHllllil cene3eHKlll MO)f{eT np01113BO,D,lllTbC51
pa3Menb4eHHOll1 napeHX111Moll1 s 6onbwol/1 canb-
HVI K, B 6pbl)f{el/1Ky TOHKOll\ KlilWKL-1 , B 6pbl)f{ell\Ky
TOnCTOVt KlilWKlll, B 3a6ptowi11HHOe npocTpaHCTBO
M B MblWU,bl nepeAHell\ 6ptoWHOll\ CTeHKL-1.
TaK1-1M , o6pa3oM, x111pypr1114ecKa51 TaKT1t1Ka
np111 TpasMe cene3eHKlil pa3pa60TaHa AOCTaTo4-
HO AeTanbHO , HO B c111ny o6beKTi.1BHblX nplll4111H
sHe,o,peH111e ee s npaKTll!4eceyto x111pyprnto He no-
ny4111no AOn>KHoro pa3Bi11T11151 , XOT51, Y4111Tb1Ba>1
MHOrorpaHHble cpyHKU,111111 cene3eHK111 , 60J1bWll1H-
CTBOM Kn111Hll1U,111CTOB OC03HaHa He06XOAVIMOCTb
opraHoc6eperatoll.leli1 111 opraHo3aMecrnrnnbHOC1
TaKTlllKVI . no p,aHHblM n111TepaTYpbl, YAenbHblll\
sec opraHoc6eperatoll.lli1X 111 3aMecrnTenbHblX
on epau,11111\ B o6Ll.leM Kon1114ecrne onepaT111BHblX
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Bbln OJ1HeH11151, HVl4TO:>KHO Man VI 8 06U,\eM cocraB-
nR eT oKono 25%. MHorne asrnpb1, pa3pa6oras-
101
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>KE/7E3bl
TpasMant4ecK111e nospe:>KAeH1115I no,[p1<eny-
A04H0171 :>t<ene3bl cocrasm1toT 4,3-9,5%. nocne-
onepal\1110HHb1e ocno>KHeHlil51 B03HlilKator y 66-
75% nocTpaAasw111x; Ha1116onee 4acTblMV1 oc-
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31118Hble KpOBOTe4eHlll51, a6cu,ecCbl canbHlllKOBOll\
cyMKV1 11111111 nceBAOKVICTbl , naHKpeaTll14eCKll1e
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,ll,O 80% .
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a Ha cpoHe MHO>KeCTBeHHblX nospe)f{AeH1111/1 He-
B03MO)f{Ha. ~3on111posaHHoe nospe)f{AeH111e noA-
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cTpaAasw111x c 3aKpb1Toi.1! TpasMoi/1 111 npaKT1114e-
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(yAaP pyneM asT0Maw111Hb1) . BcKope B03Hll1KaeT
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peAens:ieTcs:i HanpR>KeHue Mb1wu, nepeoHeiJ
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cuHopoMa scneAcTs111e naHKpeoHeKpo3a. ~3 na-
6opaTopHblX MeTOAOB np111MeH5leTC5I viccneAO-
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scex 6onbHblX 111 He oT111114aeTcsi 6onbwoi.I! cne-
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3ya111113au,11151 nop,>KenyA04H0'°1 )f{ene3bl 111 3a6p10-
w1i1HHoro npocTpaHcTsa np111 ynbTpacoHorpacp1111t1
lt1 KOMnbtoTepHoi:1 TOMOrpacpVIVI, peHTreHOCKOnll151
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111 pa3pblBOB nOA)f{enyA04HOll\ :>Kene3bl B HaCT05l-
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 np111 nonHoM nonepe4HOM pa3pbrBe nO,Q)f{eny-
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pV1cpepw-iecKV1ri! ee orpe30K aHaCTOM03V1py10r c
neTnerl! TOfl.\erl! KlllWKlll , BblKnlOLfeHHOri! no cnoco6y
Py, LfTO n03sons:ieT coxpaHVITb cene3eHKY, KOTO-
pa.s:i o6brLfHO y,Qam1eTc.s:1 npVI .QlllCTanbHOrll pe3eK-
L\lllfll , a KYnbTIO 4eHTpanbHoro orpe3Ka npow111-
sa10r CWlllBalOfl.\lllM annapaTOM. npVI pa3M03)f{e-
HVIVI ronOBKVI nO,[\)f{eny,[\04HOri1 )f{ene3bl O,[\Hlll Xlll-
pyprn orpaHV1LfV1Ba10rcs:i p,peHV1posaHV1eM canb-
HlllKOsolA cyMKVI c noKanbHOrA 6noKa,[\OrA 0,25%
paCTBOpOM HOBOKafllHa c V1HrV16111ropaM111 npore-
a3 , T.e. np111MeHs:110T TY )f{e TaKTVIKY, LfTO VI np111
yw1t16ax 111 nosepxHocTHblX pa3pb1sax nO,[l)f{eny-
AO'-IHolA )f{ene3bl , ,l:\pyrne efl.\e y,[\am110T He)f{Vl3-
Hecnoco6Hble yYaCTKVI opraHa TpeTbVI npV16era-
10T K naHKpearop,yo,D,eHanbHOri! pe3eK4V1V1 .
B cnyYas:ix T.s:i>Kenorl! coYeTaH1t1or:.1 TpaBMbl
ronOBKVI nO,Q)f{8IlYAOLfHOIA )f{ene3bl lt1 ,ll,88Hap,4a-
Tlllnepcrnorl! KlllWKlll nocne ywV1BaH111s:i paHbl KlllW-
KVI ee OTKnl0'-18IOT OT )f{eny,[\Ka npOWlllBaHfll8M
np111spaTH1t1Ka , cf:>opM111py10T o6XO,[\Hor:.1 racTp03H-
repoaHaCTOM03, xone4f11CTOCTOMY Ill p,peHlllPYIOT
canbHV1Kosy10 cyMKY 111m11 BbrnonH5llOT naHKpea-
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IlOBKlll nO,D,)f{enyp,OLfHOri! )f(8Jl83bl OT ,D,BeHap,4aT111-
nepcTHOi-1 KlllWKlll np111MeH5llOT nnaCTlllKY 06fl.\ero
)f(eJlLfHOro VI BlllpcyHrosa npoTOKOB Ha CKpblTOM
p,peHa)f{e 111 xone41t1cToe10HOaHacToM03 111n111 naH-
Kpearop,yo,[\eHanbHYIO pe3eK411110.
TaKlllM o6pa30M, s neYe6HO-A111arnocT1114e-
cKorl! nporpaMMe nocTpap,asw1t1x c TpasMaTw-ie-
CKlllM111 nospe)f{,QeH111.s:1M111 nO,[l)f{eny,[\oLfHOrll )f{ene-
3bl cosepweHcTsyiorc.R cy11..1ecrsy1011..111e MeTO.Qbl.
Pa3Bf11Tllle nanapocKon111YecK111x rexHonornlA, no-
.s:1sneH111e MOfl.\HblX 6noKaTopos ceKpe4V1V1 noA-
>KenyA04HolA >Kene3bl Tl/Ina caH,[\OCT8TfllHa, CTlt1-
naM111Ha , WlllpOKOe BHep,peHflle cop641t10HHblX Me-
TOAOB no3son111n111 no-HOBOMY OCMblCilfllTb XV1pyp-
n148CK}'IO TaKT11K}' np1t1 neYeH111111 naronor111111 no,a-
>Keny,Q04 Hoi-1 >Kene3bl .
102
B Hacro.s:ifl.\ee speMs:i AV1arHOCT111Ka , x1t1pyp-
r1t1YecKoe ne4eH111e 1t1 npocf:>V1na1m1Ka ocnm1<He-
H111ri1 TpaBMbl >KlllBOTa see 8fl.\e OCTalOTC51 4pe3-
Bbl4arl!HO aKTYailbHblMfll npo6neMaMlll ypreHTHOIA
x111pyprn1t1. TS1>Kenb1e nocrpasMarn4ecK111e oc-
JlO)f(HeH111s:i Ill neranbHOCTb He lllM810T TeH,ll,8H4111111
K CHlll>K8Hlt1IO lt1 B yny4WeHfllfll ,QaHHblX noKa3aTe-
nerl! 88)1{HYIO ponb, KOH8LfHO )Ke, ,[\On)f{Hbl Cblr-
paTb Helt1HBa31/18Hble Ill MlllHlt1ManbHO-
lllHBa3VIBHbl8 x111pyprlll48CKlll8 T8XHOI10rlt1111 , opra-
HOC6eperal0fl.\lt1e 1t1 opraHo3aMecrnrnnbHbfe
onepa4V1111.
npe)f{,Qe scero, nocTpaAaBWfl1M ne4e5Ho-
AfllarHocTlll4ecKVle Meponp111s:1TV15! Heo6xo,Q111Mo
Ha48Tb c MOMeHTa nOCTYnneHlll51 B cra41110Hap , a
np111 H8IlfllLfVIVI C04eTaHHOri! rpaBMbl VI rpaBMaTVl-
Ko-reMoppar1114ecKoro woKa AaHHbre Meponp1t1.s:1-
r111s:i p,on)f{Hbl npoBOAVITbcs:i napannenbHO s cne-
4V1anbHOM peaHVIM8L\lllOHHOM Jane c np111sneYe-
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CTOB. np111 npoBe,QeHllllll ,[\1118rHOCTlll48CKOIA na-
napOCKOnf/1111 111 ynbrpac0Horpa¢111111 y nocrpa-
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AlllMO yroYHlllTb xapaKTep 111 creneHb nospe)f(,Qe-
Hllls:i, 803MO)f{HOCTb BblnOI1H8Hlt151 3H,[\OCKOn1114eC-
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ne4eHllle 60nbWVIHCTB8 cnyYaeB nOBpe>K-
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- monbKO onepamueHoe. B cny4ae coYeTaHHolA
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H111e Mo)f{eT 6b1Tb p,syx- 111n111 rpex3rnnHblM. B
nepsy10 04epeAb Heo6XOAlllMO Illt1KBlt1AlllPOBTb
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KposoTe4eH111e, yw111Tb paHy K111weYH1t1Ka , c¢op-
M111posaTb KlllWe4HYIO croMy. OcranbHbre peKoH-
cmpyKmUBHb1e 3manb1 onepal.\111111 ,[\On)f{Hbl npo-
BOAlllTbC51 monbKO nocne cma6unu3auuu co-
cmoRHUR nocrpa,[1asw111x u nonHoM eb1eeoeHuu
ux U3 WOKB B OT,[\eneHIMIX peaHlllM3L.Jlllll1 lt1 lllHTeH-
ClllBHOri! repan111111 .
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A111MO nposecr111 pe111Hcf:>yJ11110 Kpos111 . nospe)f(,Qe-
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 IlEPlITOHllT
nepMTOHMT - 3TO OCTpoe MilM XpOHM\fe-
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A3tolJ.4eecff K3K MeCTHblMM, TaK lit 06l14MMM
CMMnTOM3MM 3a6011eeaHMff c HapyweHMeM
4>YHKLU.U.t opraHOB lit ClitCTeM opraHl!t3Ma.
nepumoHUm - :no OAHO L'13 T51>Kenei/IWL'1X
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nospe>KAeH1111i1 opraHoB 6piowHolil nonocrn. npo-
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3aren111 neranbHOCTL1 , Kone6moll.\L1ecs:1 B npeAe-
nax 25-90%. Ha nporn>KeHL1111 nocneAHlllX 20 ner
3Tlll noKaJaren111 He cH111>KanL1Cb .
B 1113y4eH111111 111 pa3pa60TKlll MeTOAOB ne4e-
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BKnaA 111 oTe4ecrneHHolil WKOJlbl x111pypros. B
1881 rDAY A.111. WMlllAT npOlll3Ben nepsyio B ML1-
pe nanaparoM111t0, a B 1924 rDAY C.111 . CnacoKY-
KOl..lKWW snepBble 3aWIAJl nanapaTOMHYtO paHy
Hamyxo. 5onee era ner nepL1TOHL'1T np111sneKaer
BHL'1MaHVle x111pypros, Ho 111 ceroAH51 comacHo
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Xt1PYPfllfl./ECJ<Afl AHATOMt1fl 6PIOWt1Hbl
5piow1<1Ha n0Kpb1saer creHKlll nonocrn }1{111-
sora 111 Manora. nosepxHoCTb 6piowL1Hbl cocras-
m1er 20 400 cM 2 111 pasHa KO>KHolil nosepxHocrn
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6p10WL1Hbl Me>KAy napL'1eHTaJ1bHOlll 6p10WlllHOlll Ill
cep03HblM noKpOBOM opraHOB lllJlL1 Me}l{Ay OT-
,QeJlbHbJMJA opraHaMlil Ha3bJBaeTC5l CB5l3KOt1,
ligamentum, plica, 6pb1>1<elilKolil , mesenterium .
OpraH, n0Kpb1Tb1!11 co scex cropoH 6p10w111-
HOlll, pacnono>KeH BHyrp1116pt0WlllHHO l.111111 lllHTpa-
nepltlTOHeanbHO; opraH, no1<pb!Tb1!11 6p10W1t1Hoi.:i c
rpex CTOpOH 1-1 He noKpblTbllil 6ptOWlllHOlil c OAHOlll
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6pb1>Keil1Ky, KOTOpa51 CB513b1Baer VIX c npL1CTeH04-
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nonocy y Mecra npV1KpenneH1115l o6Ha>KeHHo~
CTOpOHbl - HenoKpblTYIO 4aCTb , pars nuda.
 OrpaH111YeHHoe 6p10w111Holli npocTpaHCTBO
nonocrn )l{!llBOTa H83blBaeTC>I 6plOWlllHHblM, lllillll
nonocTblO 6ptoWlllHbl , cavum peritonei. 3Ta no-
nocTb 3aKntoYaeT B ce6e 6onbwelli YaCTblO He-
napHble 6p10WHb1e opraHbl, TOr,[!a KaK napHble
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BOTa OTrpaHlllYlllBaer 6plOWlllHHYIO noilOCTb OT
3a6p10w111HHoro npocTpaHcrna, spatium retroperi-
toneale; o6a 3Tlll npocTpaHCTBa o6pa3ytoT
6p10wHyto nonocTb, cavum abdominale. B css:i3111
c TeM YTO 6ptoWlllHa npeAcTaBns:ieT KaK Ha CTeH-
Kax, raK 111 Ha opraHax cn11owHolli noKpos , TO 111
6plOWlllHHaH nonOCTb cosepweHHO 38MKHyra.
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6piow1t1Hbl , Apyroi.1 - 4epe3 no11ocrb MaTKlll ee-
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3nt1,D,EMJ10/10ft1fl, KJ1ACCJ1<Pt1KAU,t1fl
111 3Tt10!10ft1L/ECl<Afl CTPYl<TYPA
n EPJ1TOHt1TA
LlacToTa BCTpet.iaeMOCTl/1 neplllTOHlllTa co-
CTaBnHeT 3 - 4 ,5% OT KOillllYeCTBa 60JlbHblX c
x111 pyprnt.ieCKlllMll1 3a6onesaHlllHMlll . no AaHHblM
ayronc11111i 3TOT noKa3aTeJlb 60ilbWe Ill COCTaBilH-
eT 11 - 13% . OcTpbte x111pyprn4ecK111e 3a6one-
saH"1H opraHoB 6p10WHOll! nonocrn s 80% cny-
1.i aes HBJlHIOTCH np1114111HOi.1 nep1t1TOH1t1Ta, 4-6%
cocraBJlHIOT 3aKpblTble TpaBMbl )l{lllBOTa Ill B 12%
cny4aes nepltlTOH!lff B03Hl/IKaeT, KaK OCilO}f(HeHllle
nocne onepau111111. neranbHOCTb npV1 pa311111rb1x
cpopMax nepttnoH111ra s Pocc111111 6onee 33% .
1<11accuc/JuKau,uR nepumoHuma
1. nepBlll4Hbllli neplllTOHlllT
A. CnoHTaHHbllli nep111ToH111T y AeTelli
B. CnoHTaHHbttil neplllTOHlllT y s3pocnb1x
C. nepl!ITOHlllT y 60ilbHblX C nOCTOHHHblM
nep111roH111anbHblM A11181111130M
D. Ty6epeyne3Hbllli nep111TOHlllT
2. BTOplllYHbllli nep1t1TOHlllT
A. Bbt3BaHHbllli nepcpopau111elli 111 AeCTpyK4111-
ei:1 opraHOB 6p10wHolli no11ocrn
B. nocneonepa4l40HHbllli nepl4TOHl4T
C. nocnpasMar1114ecK111lli nep111ToH1t1T
D. nepl!ITOHlllT BCileACTBl/le Hecocromenb-
HOCTlll aHaCTOM03a
nepBlll4Hbllli neplllTOHlllT Kpall1He peAK8H
¢ opMa nep111roH111Ta reMaToreHHoro npo111cxo)l{-
eH1t1H c lllHQJlll4111POBaHllleM 6ptoWlllHbl 1113 3KCT-
panep111TOHlll8IlbHOro 111croYH111Ka. Ha1116onee 4ac-
r o B03HlllKaeT y 60ilbHblX c LllllPP030M ne4eHlll, a
aK)l{e np111 reH1t1TanbH011i naTonorn111 )l{eHli.\lllH.
04eHb 4aCTo B036YAlllT8Ilb He sepV1cp1114111pyeTCH .
y ,aerei.1 nepB"14Hbl"1 neptlfTOHlllT B03Hll!Kaer 1111160
B HeOH8T8JlbHbllli neplllOA, 1111160 B 4-5 11er Ha
cpoHe ClllCTeMHblX 3a6onesaH1t1ll1 (KpacHaH ClllC-
105
TeMHas:i son4aHKa). Ha1116onee YaCTbllli so36yA111-
renb crpenTOKOKK Ill nHeBMOKOKK.
Brop1111.1Hb111i nep111roH111T - Ha1116onee 4acras:i
cpopMa a6,[loM111HanbHOll1 111Htj:)eK4111111. B 80% cny-
1.1aes oH B03HlllKaer scne,[!crs111e ,[lecrpyK4111111 op-
raHos 6ptowHolli nonocrn 111 20% np111xoA1t1TCH Ha
nocneonepa41110HHb111i nep111roH111T.
Cmaouu 2HoiJH020 nepumoHuma
1. PeaKT1t1BHas:i (nepsb1e 24 4aca, AflH nep-
cpoparnsHblX cpopM ,D,O 6 Yacos)
2. ToKc1114ecKas:i (24-724aca , AilH nepcpopa-
TlllBHblX cpopM 6 - 24 4aca)
3. TepM1t1HanbHas:i (6onee 72 4acos Ail.s:t
nepcpoparnBHblX cpopM 6onee 24 4acos) .
Oco6eHHOCmU OU02HOCmUKU cmaouiJ
nepumoHuma
1. PeaKTlllBHas:i cra,D,111s:i: npeo6na,[\aH111e Me-
CTHblX, IlOK8IlbHblX ClllMnTOMOB H8,[\ 06li.\lllMlll,
xorn so3MO)l{Hbl rax111KapAlllH, rnnepTepMllls:t , pso-
ra .
2. ToKc1111.1ecKas:i cTa,[\1115'r AI1H Hee xapaK-
repHo npeo6na,[\aH111e o6u.iell1 c111MnroMaT111K111 HaA
MecrHolli: psora , nape3 K111we4HlllKa, HapyweH111e
ClllCT8Mbl Kposoo6pau.ieHlllH , HeCKOilbKO ocna6e-
saer Hanps:i)l{eH1t1e MblWLI 6ptowHolli creHKlll 3a
C4eT lllCTOli_\eHlllH BlllC4epo-MOTOpHblX pe¢neK-
COB. HapacTaeT Mern6on1114ecK111ll1 a4111,[\03, r111no-
Kan111eM111s:i , rnnonpore111HeM111s:i . Ecn111 np111coe,[1111-
H>1eTcH OnH, TO flilnepKan111eMllls:t CO'-leTaeTCH C
Mera60111114ecK1t1M a4111,[\030M .
3. TepM111HanbHaH cra,[\1t1H: KfllllHlllKa cem111-
YecKoro woKa.
no xapaKrnpy 3KccyAaTa pa3.mt4aK>T:
- Cepo3Hb111i ;
- Cepo3Ho-¢1116p11tH03Hb11/1;
- Cepo3Ho-reMopparn1.1ecK11111i ;
- rHolliHblM ;
- Kanosbrfl;
- >Ken1.1Hb11/1;
- Mo4eBoil1;
- <t>epMeHT8TlllBHblil1 ;
- X111M1114ecK111e nep111roH111Tb1.
nocneAHllle 4 ¢opMbl OTHOCs:tT K 6aKTep111-
8IlbHblM nep111roH1t1TaM. TaK)l{e BblAen.s:ttoT oco-
6b1e cpopMbl nep1t1TOHlllTa: Kapl.\lllHOM8T03Hbllli Ill
cp1116ponnacrn4ecK1111/1 (s:irporeHHbl Iii).
CornacHo A8HHolli Knacc111cp111Ka4111111 MecT-
Hbli.1 orpaH1t11.JeHHbllli neplllTOHlllT lllMeer 48TJ<YIO
BHyrp1116ptoWlllHHYIO IlOK8Illll381...!llllO B O,[\HOIA 11111111
H8CKOilbKlllX o6Jl8CTHX 6plOWHOlli nonocrn, Mecr-
Hbll'.-1 HeorpaH1111.JeHHb1i.1 nep111roH111T 3aH111MaeT He
6onee ABYX aHaToM1111.1ecK111x o6nacrell1 6ptowHolli
nonocrn . np111 A111¢cpy3HOM nep111ToH111re naTono-
rn1.JecK111L1 npoL1ecc 3aH111Maer 2-5 o6nacrelli , a
np1t1 pa3n111roM socnaneH111111 pacnpocrpaH.s:terc.s:t
6011ee 4eM Ha 5 0611acTelli 6ptowHolli nonocrn .
 KJiaccu<1>nKaum1 nepnTOH HTa
PEAKTllBHAfI TOKC:WIECKA.51
24/611ac. JJ:o 72/24 qac.
~ t
I CTA)U111
t
I TIEPHTOHHT
11ECTIIblH I p ACI1POCTP AHEHHblH
I
OrPAIDl'IEIDThill
\
IIEOn>AIIIl'IEHill>Iii JUIlf>lf>Y3Hl>Ill
,QO 5 AHATOM . OEJL )lO 2 AHATOM. OEJI. OT 2 )lO 5 AHATOM. OEJI.
no xapaKTepy cfmOpbl, BblCeeaeMOM 1113
6ptoWHOM no110CTlll, pa311111'13IOT nepl!ITOHlllT,
Bbl3B3HHblM:
1. Hecneu111¢1114ecKotll , 6aHanbHOtll , narn-
reHHotll QJilOpot/I . npw.ieM 43ll.le 3TO CMeWaHHa.S'I
aspo6Ho - aHaspo6Ha.s:i Q::inopa. np111 scex rnnax
nep111ToH111Ta AOMlllH111pyeT rpaM0Tpllll..\8TeilbHa.s:1
<Pnopa (Enterobacteriacaeas) , KaK npas111no, s
co4eTaH11u1 c aHaspo6aM111 (Bacteriodes spp.,
Clostridium spp. 111 Ap.), pe}l{e Bb1Aem1t0Tc.s:1 crn-
¢111noKoKK111 Ill 3HTePOKOKKlll.
2. Cnel..\111QJll14ecKol1 Q::inopolll : Ty6epKYne3-
Holi1 vtHQJeKL..\elll, fOHOKOKKOBOl.1 , nHeBMOKOKKOBOl.1
npullUHbl p038UmUR nepumOHUma
1. ,IJ.eCTpyKTlllBHblM anneHAVIL\lllT- 15- 60%;
2. ,IJ.eCTPYKTlllBHbllll xonel..\lllCTlllT - 3,7 - 10%;
3. nepQ:JopaTltlBHble raCTPOAYOAeH8IlbHble
5'13Bbf - 7 - 24% ;
4 . TpasMa opraHOB 6ptowHo171 nonocT111 - 8 -
10%;
5. nepcpopal..\1115'1 KlllWK111 - 3% ;
6 . 0. naHKpeaT111T - 3 - 5%;
7. OKH -13% ;
8. Me3eHrnp111a11bHb1tll TpoM6o3 - 2%;
9. 3a6onesaH111!.1 )l(eHCKlllX reH111Tan111tll - 3%
nATOfEHE3 nEP/.1TOHUTA
npeApacnonaratoll.1111Mlll Q:JaKTopaMlll pa3Blll-
Tlll5'1 pacnpocTpaHeHHoro nep111ToH111Ta .s:1Bn5'leTc.s:1
nospe)l{AeH111e cep03Horo noKposa naToreHHblMlll
M111KpoopraHlll3MaM111. K npo1113BOAS!ll.llllM Q::iaKTo-
paM OTHOC.S'IT AeCTPYKTlllBHble npOL\eCCbl B opra-
Hax 6pt0wHotll nonocrn pa3nlll4HOL;l sT111onor111111,
111weM1114ecK111e 1113MeHeH111.s:1 3TlllX opraHoB, BHYT-
p1116pt0wHotll rHol1Ho-socnan111renbHb1l1 npol..\ecc.
106
TEPMID-IAilhHA5I
Eorree 72/24 qac .
/
I
I \ PA3JillTOH
EOJIEE 5 AHAT. OEn.
no.s:1B!leH111e Ill pa3MHQ)f{eHllle MlllKpoopraHlll3MOB B
6plOWHOCi nonoCTlll nplllBOAlllT K B036y)l{AeHllllO
lllHTpapel..\enTOpOB, nOSIBil8HllllO 6onesoro ClllH-
APOMa, nosb1weH11110 rnHyca c111MnaT1114eCKotll
HepBHOVI ClllCTeMbl. noBblW8eTC5'1 Tp8HCCYA8L..\L15'1
)f{l/IAKOCTlll B 6pt0wHyto nonocTb. B ycnos111six na-
rnnor1114ecKoro npol..\ecca B 6pt0wHotll nonocT111
aKT111s111pyt0TCS1 see y4acTK111 6pt0w111Hb1 , APeHa)l{-
Ha.s:1 QJYHKL.\1115'1 IllllMQJ8T1114eCKlllX nyreC\ CHl/l)f{aeTCS'l ,
4TO, B KOHe4HOM LllTOre , nplllBOAlllT K CKonneHllllO
)f{lllAKOCTlll B 6pt0WHOtll nonocrn . 4epe3 6-8 48COB
3KCCYA8T B nonoCTlll )l(L/IBOTa CTaHOBV!TbCSI rHOtii-
HblM (npeo6naAat0T HetllTpocp111nb1 , BbrnaAaeT
cp1116p111H) . B 3TOT )f{e neplllOA speMeHlll BOCCTa-
H88IllllBaeTC5'1 APeHa)f{Ha.s:i QJYHKL\1115'1 n111MQJ8T1114e-
CKlllX nyrntll. np111 BblCOKOtll e111pyneHTHOCTlll MlllK-
poopraHlll3MOB L/1/11111111 M8CClllBHOCTlll lllHQJlllL..\lllPO-
B8HlllSI npOlllCXOAlllT 6blCTpoe pacnpocrpaHeHl/IS!
socnamtreJJbHoro npol.(ecca B 6pt0wHotll nonoc-
Tlll . <t:>1116p111H cny)f{lllT MexaH1114ecK111M 6apbepoM,
npemncTBYIOL4111M QJ8fOL\lllT03y MlllKpoopraHlll3-
MOB Ill 38ll.ILllTOtii nocneAHlllX OT Aelii CTBlllS'I aHTlll-
61110T111KOB.
Bb1Aensit0T '1eTb1pe acneKTa naroreHe3a
nep111TOHL11Ta: MexaHLll3Mbl orpaH1114eH111s:i narono-
r1114ecKoro npol..\ecca B 6p10WH0Vi nonocTlll , lllM-
MyHoreHe3, naroreHe3 BlllCL\epanbHOtll QJYHKL..\111111
Ill 3HAOTOKClllK03 .
nepBblM acneKT - 3TO CTlllMYilSIL.\1115'1 MeCT-
HOfO lllMMYHLllTeTa 111 Bb16poc 6onbWOro KOillllYe-
CTBa cp1116p111Ha, aKTlllB8L..\lllSI cnae4Horo npol..\ecca.
5pt0WL11Ha caMa cnoco6Ha orpaHLllYlllBaTb 04ar
socnaneHlllS'l 3a C\.feT BblCOKOVi nnaCTlll4HOCTlll, a
TalOKe aa C4eT 6aKTepllll..\lllAHblX CBOCICTB, 4TO, B
KOHel.IHOM Cl.leTe, cnoco6cTByeT IlOK8Illll38L..\llllll
socnan111TenbHoro npo1.1ecca s 6plOWHOtll nonoc-
Tlll. MecTHbllii lllMMYHlllTeT css:i3aH c nosb1weH111eM
KOHL\eHTP8L\llllll B OYare socnaneHlllH L\lllTOKlllHOB
(IL-1 , IL-6, TNFa) .
BTopoH acneKT paJBMTMfl nepMTOHMTa -
3TO lllMMyHoreHe3 . CyMMapHbliil 3cpcpeKT, OK83bl-
saeMbllA MeAV1aTopaM111 eocnaneH111s:i , cpopM111pyer
ClllHAPOM ClllCTeMHOIA Bocnan111TenbHOiil peaKL\111111
(CCBP), pa3BlllTllle KOTOporo MO)f(HO P83Aen111Tb
Ha TPlll 3Tana:
nepsb1iJ sman. noKanbHoiil npOAYKL\111111 L\111 -
TOKlllHOB . npoAyl\eHTaMlll 3TlllX M8,l\1118TOpOB 518-
mHOTCH neiilKOL\lllTbl (HeV!Tpocp111nbl , MaKpocparn),
a TaK)f(e TpoM60L\lllTbl. B oYare socnaneH111s:1 4111-
TOKlllHbl yYaCTBYIOT B npo4eccax 38)1(1!1BneHl/l51
paH Ill 38W.111W.8IOT KfleTKlll OT naToreHHblX M111Kpo-
opraH1113MOB.
Bmopou sman. Bb16poc Manora Kon111YeCTBa
L\lllTOKlllHOB s c111cTeMHb1iil KposoTOK. Manas:1 YaCTb
L\lllTOKlllHOB scne,llCTBl!le noBblW8Hlll5l npoHlllL\88-
MOCTlll 3HAOTen111s:i nona,llaeT B ClllCTeMHbliil Kpo-
BOTOK, rp,e 8KTlllBlllPYIOT nelAKOL\lllTbl Ill TPOM601...1111-
Tbl , a T8K)f(e Bbl3bl88IOT Bb16poc l-13 3HAOTem1s:i
MoneKYn 8,llre3111111.
Tpemuu sman. reHepan1113osaHHas:1 socna-
n 111TenbHas:i peaKL\l'15l opraHlll3Ma. B cnyyae He-
B03MO)f(HOCTlll opraHlll3Ma naL1V1eHTa nO,D,,llep)f(aTb
6anaHc Me}f(,lly nposocnanl'!TenbHblMlll 111 aHT111-
socnan111TenbHblMlll MeA11taTopaM111 socnaneHllls:t,
ocyw.ecTsns:ieTCH ,lleCTPYKTlllBHblVl 3cpcpeKT npo-
socnan111TenbHblX L\lllTOKlllHOB. BcneACTB111e 3Toro
pa3BlllB8IOTC51 HapyweHl.1s:! roMeOCTa38 Ill opraH-
Has:i AlllCQJYHKL\llls:l . B KaYeCTBe cpaKTopos ClllC-
TeMHOro nospe}f(,lleHlils:t MoryT Bb1crynl'1Tb n106b1e
HapyweHlilfl roMeocrn3a, cnoco6Hble socnp111H111-
MaTbCH lllMMYHHOIA Cll'ICTeMoiil KaK nospe}f(,llal0-
w.111e 111n1.1 noTeHL1V1anbHO nospe}f(,llalOW.lile.
K cl:>aKTopaM, cnoco6creyt0114MM reHepa-
nM3a~MM eocnan111TenbHoro npo~ecca OTHo-
CflT:
• Macc111BHOCTb lllHcpeKTa , era BlllAOBas:1
cnel.llllcPlilYHOCTb, 6111onor111YecK111e oco6eHHocrn
M111KpoopraH11t3Ma;
• Pa3Mepb1 111 xapaKTep neps111YHOro 0L1ara
ll'I Hcp8KL\l.1lil ;
• nosTOpH85l CeHCV16V1nll'l38L\1115l opraHlll3Ma;
• V1HAlllBlllAY8flbH8Sl pe31/1CTeHTHOCTlll opra-
Hlil3Ma nau,111eHTa.
np1.1 HeB03MO)f(H0CTlll CAep)f(aTb AeCTpyK-
TlilBHbllA 3cpcpeKT nposocnan1.1TenbHblX L\lllTOKlll-
HOB nospe}f(,llaeTCH 3H,IJ,OTen111Vi Ill nOBblWaeTCH
n poH111L1aeMOCTb cocyA11tcrolll cTeHKlll , a TaJOKe
y sen111Y11saeTcs:1 arpera4111s:i TpoM60L\lllTOB 111 npo-
111cxoA111T 6noKa,lla ClllCTeMbl MlllKPOL\lllPKYfl5ll\llllll.
0AHOBpeMeHHO , c BblWe on111caHHblM npOL\8C-
COM, aKTl/IBlilpyeTCS'I ClllCTeMa csepTblBaHlllS'I KpOBlll
Iii yMeHbWaeTC5l COA8P)f(8Hllle B KpOBlll ecTeCT-
seHHblX aHTlllKOaryn5lHTOB (aHTlllTPOM61i1Ha 111 , Ill
n p0Te111Ha C) . OcHOBHblM Me,ll11taTopoM, aKT111s111-
PY10ll\lllM KoarynHL\lllOHHb1!11 KacKaA, CYlllTaeTcs:i IL-
6. np111 HapyweHllllll peryn5ll\llllil MeX8Hlil3Mbl BOC-
n aneHlllSl Ill csepTblB8Hllls:! KpOBlll 6YAYT nocros:iH-
107
HO yc111n111BaTb Apyr Apyra , YTO MO)f(eT ycKOplllTb
npoL1ecc 06pa3oeaH1115l TpoM6os s cocyAlllCToiil
c1.1cTeMe c nocnep,yiow.111M pa3B"1TlileM 1.1weM111111
opraHoB Iii opraHHblX AlilccpyHKL\llliil .
Bee BblWe onMcaHHble MexaHM3Mbl np111-
BO,D,SIT K cpopMMpoeaHMtO Tpex narocpM3Mono-
rn~ecKMX CMHAPOMoe:
1. nepepacnpep,eneHllllO o6beMa L\lilPKYnlll-
pyiow.elll KpOBlll;
2 . .Q111c6anaHcy B ClilCTeMe Klilcnopop,rpaHc-
noprnoiil cpyHKL\111"1 KpOBlil (KTct:>K);
3. nepeCTpOIAKe OCHOBHblX MeTa6on111Ye-
CKlilX npOL\8CCOB.
nepepacnpe,QeneH111e o6beMa L\lllPKYfllll-
pyiow.eiil KpOBlil CB5l3aHO c nOBblWeHlileM Kanvm-
m1pHoiil npoH1t1L1aeMOCTlll , pacw111peH111eM cocy-
AOB , ceneKTlllBHblM cocyA1t1CTblM cna3MOM, noTe-
pelA MexaHlil3MOB COCYAlllCTOIA ayrnperynHL\111111 ,
TpoM6o3oM cocyAOB MlllKPOL\lllPKYnHL\111111 , TKaHe-
BblM OTeKOM , HapyweHllleM cpyHKL\lillll Mll10Kapp,a Iii
soneM111YecK111M A1t1c6anaHCOM.
PacCTpoiilcTBa KTct:>K xapaKTep1t13yeTcs:1
BHyrp111nerYHblM wyHTlllPOB8HlileM KpOBlil , Hapy-
WeHll'leM COOTHOWeHll15l BeHT111fl5IL\V15l/nepcpy3111s:1,
nOBblW8Hl/leM noTpe6HOCTlll TKaHel'.1 B Klilcnopop,e .
Bo3Hll1Kwas=1 r111n0Kc111s:1 s:1sns:ieTcs:i cpaKTopoM nep-
c1.1crnpyiow.ero TeYeHlll5l c111cTeMHoro socnane-
Hllls:i . 3ToT cpeHoMeH o6ycnosneH ysen111YeH111eM
3Kcnpecc111111 KfleTOYHblX peL\enTopos 111 KfllOYeBblX
npoeocnan111renbHb1x L\111TOKlllHOB c nosb1weH11teM
111x ceKpeL\111111 MaKpocparaM111.
HapyweH111e Mera6onlil3Ma npo111cxo,Q111T no
rnny rnnepMern6onlil3Ma , rnnepKaTa6onlll3Ma.
TaKMM o6pa3oM, HaM6onee cno}l{HblM
acneKTOM pa3BMTMH nepMTOH&Ha RBIIHeTCR
acneKT MMMYHOreHe3a. npeo6naAaHMe CCBP
BeAeT K TS:nKeJlblM HapyweHMRM roMeocTa3a M
yxyAwaer nporHo3 rn~eHMH 3Toro Ja6onesa-
HMH. OpraHHaR AMCcpyHKL\MH cpopMMpyeTcH e
cny~ae npeo6naAaHMR cMcTeMHoro socna-
neHMR. Pa3BMBat0114i.tecR OAHoepeMeHHO c
cwcTeMHblM eocnaneHMeM 3HTepanbHaH He-
AocTaTo~HOCTb HBIIReTCH MeXaHM3MOM noA-
Aep}l{aHMe opraHHOM AMCcl:>YHKl.\MM.
TpeTMM acneKT pa3BMTMH nepMTOHMTa -
3TO HapyweHllle BlllCL\epanbHOIA cpyHKL\111111 , B Ya-
CTHOCTlll - 3HTepanbHa51 HeAOCTaTOYHOCTb. Co-
rnacHo A8HHblM nlllTeparypbl , B OCHOBe TOpMO-
)f{eHlll5l neplllCTanbTlllKlll Kl/IWeYHlllKa ne)f(lllT Hapy-
WeH111e 6anaHca c1t1MnaT111YecK111x 111 napac111Mna-
n1YecK111x CTlllMynos: Ha cpoHe nosb1weHl'15l ToHy-
ca ClllMnarnYeCKOiil HepBHOiil ClllCTeMbl, Bbl51Bn51-
eTcs:i yrtternH111e cpyHKL\111111 napac111MnaT111YecKoiil
ClllCT8Mbl. noBblWeHllle aKT111BHOCTlll ClllMnaTlllYe-
Cl<Oiil ClilCTeMbl fllilWb O,[\Ha 1113 np111L1111H Ill .o,aneKO
He rnaBHa5l pa3Bll'ITlll5l 3HTepanbHOVl He,[\OCTa-
TOYHOCTlll . .Qeno B TOM , YTO KlllWeYHlllK l/IMeeT
CBOIO aBTOHOMHYIO lilHTpaMeAyns:ipHylO MeTa-
ClllMnaTlllY8CKYIO lllHHepBal..\llllO . 0Ha peryn111pyeT-
cs:i MlilOTponHblMlll MeXaHlll3MaMlll Iii co6CTB€HHblM
neV!cMeKepoM , 3a.o,aiow.111M p111TM 111 pacnono)f(eH-
HblM B P,BeHap,4aT1t1nepcTHOVI Klt1WKe . 8 HeM B03-
Hlt1KaeT 1t1MnyJlbC ,as1t1raTeJlbHOVI aKTlt1BHOCTlt1, no-
.ny41t1BW1t1VI Ha3BaHlt1e «M1t1rp1t1pyt0L111t1VI Mlt103JleK-
Tp1114eCKlt1VI KOMnneKC» (MMK). 8 OTm14111e OT
cepp,e4Horo nell1cMeKepa, s Kll1We4Hll1Ke pea.n1t1-
3yeTcfl He Ka)f(,lJ,bllA lllMnyilbC. np111 a6P,OMlllHailb-
HOM cenc111ce s Ha4ane nop,asm1t0Tcs:i HeVlpo3H-
AOKp1t1HHb1e MexaHlll3Mbl nep1t1cTaJlbTlt1Klt1 Klt1We4-
Hlt1Ka, HO coxpaHs:iercs:i cpyHK4111s:i sop,1t1Tens:i p111T-
Ma, XOTfl 111HAYKL..\lt15'1 MMK TalOKe nop,aBilfllOTC51 . B
p,anbHeVlweM npo111cxop,111T pacrn>1<eH111e cTeHK1t1
KlllWe4HlllKa , ee 111weMlllfl, 4TO nplllBOAlllT K rnnoK-
Ci.-14eCKOVI 6noKap,e MMK. Pa3s111saeTcs:1 A1t1HaM1t1-
4ecKas:i K111we4Has:i Henpoxop,1t1MOCTb, B ycnos111s:ix
KOTOpoVI yc111n111saeTC5'I Bblpa6oTKa 3HP,OTOKClt1HOB
M111KpoopraH1113MaM111 , Haxop,5'lll\1t1M1t1C5l s npocseTe
K111we4H1t1Ka. TopM0>1<eH111e nep111cranbrnK111 Klt1-
we4HlllKa MO)KHO oTHecT111 K nepaoi1 cmaauu 3H-
mepanbHOi1 Heaocmamol/Hocmu. Ecn111 B p,anb-
HeVlweM np111coep,1t1H5leTcs:1 pecpneKTopHoe Hapy-
weH111e Kposoo6paL11eH1115l Klt1We4HOVI creHKlll, yr-
HeTatOTC5'1 npo4eCCbl BCaCblB8Hll151 B KlllWe4Hlt1Ke,
npeKpaL11aeTC5l 39aeya41t15l cop,ep>1<111Moro, TO
pa3s111saerc51 smopafl cmaaufl cuHapoMa 3Hme-
panbHoi1 He8ocmamol/Hocmu. ,Qn51 3Toi.:1 crnp,1t11t1
xapaKTepHo BHYTp1t1nonocTHoe cKonneH111e >K1t1A-
KOCT111 . Bo3H111Kat0L!..11t1VI 3acToVI >Klt1AKOCTlll BHYTPlll
KlllWe4HlllKa conpoBo)f(,lJ,aercfl nosb1weH111eM Me-
crnoro seH03Horo p,asneH11151 , 4TO HapywaeT
scacb1BaH111e ra3oB. Korp,a se.n1t141t1Ha p,asneH1t1S1 s
K111we4H1t1Ke p,ocT111raeT ypoBH51 p,111acTon1114ecKoro
p,asneH1115l , npeKpaL11aercs:1 scacb1BaH111e 1t1 >KlllA-
KOCTlll , 4TO Bbl3b1saeT ,QailbHeVlwee pacrn>1<eH1t1e
Klt1We4HblX nerenb 111 HapyweH111e rpocp111K1t1 Klll-
we4HoVI cTeHKlt1 . TpeTb51 crnp,11151 c1t1HAPOMa 3H-
repanbHOVI Hep,ocTaT04HOCTlt1 CB513aHa c rpaHC-
cyp,a4111eVI >KlllP,KOCTlll B npocseT Klt1We4Hlt1Ka . ne-
pepacrn>KeH1t1e K111We4Hb1X nerenb np111sop,1t1T K
nosb1weH111t0 BHYTp1t16pt0wHoro ,QasneH1115l ,
yMeHbWeHlt1IO 3KCKYPC1t11t1 ,Ql.1acpparMbl lt1, B pe-
3YilbTaTe, K HapyweH111t0 ,Qb1xaH1t15l. HapacTaH1t1e
TKaHeBoVI r1t1nOKClt1lt1 ycyry6n51eT Ts:t>KeCTb COCTOS1-
Hlt151 na4111eHTa. B cospeMeHHOVI Il1t1Teparype 3H-
repanbHa51 HeP,OCT8T04HOCTb paccMaTp111BaeTC5'1 ,
rnaBHblM o6pa30M, KaK Ha4aJlbHOe 3BeHO B pa3-
Bl.1Tllllt1 opraHHOVI p,111ccpyHKL\l.1lt1. 1113MeHeH1t1e npo-
H1t14aeMOCTlll Kl.1We4HOVI CTeHKl.1 B OTHOWeHl.11.1 K
3HP,OTOKCll1HaM 111 rpaHCilOKa411151 M111KpoopraHl.13-
MOB CT8HOB51TC51 np1114111HOVI ClllCTeMHOro socna-
neHlt151 1t1 opraHHoi/1 p,111ccpyHKL\1t11t1 .
no3TOMy m1U-'eBap111TeJlbHblM TpaKT lll Ha-
3blB3IOT «He ApeH111pyeMblM a6c1.4ecc», «Mo-
Top» opraHHOM .QlllCcpyHKL\llllll.
lfeTeepTblM acneKT pa3BlllTlllH neplllTOHlll-
Ta - 3TO 3HP,OTOKC!.-1K03, nop, KOTOpblM nOHll1M8IOT
rpynny 3a6onesaH1.1VI , B narnreHe3e KOTOpblX
ocHOBHYtO po.nb 111rpaer so3p,eli1cTs1t1e Ha opra-
Hl.13M TOKCl.14eCKlt1X npop,yKTOB, o6pa3YIOU\l.1XC5'1 B
HeM . Km11H1.14ecK1t1M npo51sneH1.1eM 3HAOTOKC1t1Ko-
3a 51BJ151eTC5'1 Cl.1HAPOM 3HP,oreHHOVI l.1HTOKC1t1Ka-
4111111, KOTOpbllll Bbl3blBaeT B38111MOCB5138HHble 111
108
s3a1.1Moor5lraL11at0L111t1e npo4eccb1 , cpopM1t1pyt0-
L11111e opraHHYIO p,111ccpyHKL..\llllO.
M111Kpo61t1onor1114ecK111il1 KOMnoHeHT c111Hp,po-
Ma 3HP,OreHHOll1 lt1HTOKCll1Ka41t11.1 y na41.1eHTOB ne-
plt1TOHll1TOM lllMeeT Tpl.1 lt1CT04HlllKa: cne41.1cp1.14e-
CKllle npop,yKTbl >Klll3Hep,e51TeilbHOCTl.1 Ill r1116en111
MlllKpoopraHll13MOB, aKT111sa411151 nporeomn1.14e-
CKl.1X cpepMeHTOB 1.1 TOKClt14eCKl.1e cy6cTaHL..\lt11t1
HapyweHHOro MeTa60I11113Ma. 3HP,OTOKCll1Hbl
np111H41t1n1t1anbHO onpep,eneHbl KaK cy6cTpaTbl ,
Bb1p,enfleMb1e rpaMHerarnsHblMlll M1t1Kpoopra-
H1t13MaM111 nocne 111X pa3pyweHlll51, a 3K30TOKCl.1Hbl
KaK BeL11eCTBa, KOTOpble npop,y41t1pyt0TC5l l.1Illt1
ceKpernpytOTC51 s111pyneTHblMll1 WTaMM8Mlll rpaM-
n031.1Tlt1BHblX Ml.1KpoopraHll13MOB. B TO >Ke speMs:i
Bell\eCTBa, 111Met0L11111e CBOVICTBa 3K30TOKCll1HOB
Moryr 6b1Tb nony4eHbl nocne ayron1113a rpaMHe-
rarnBHblX Mll1KpoopraH1113MOB. 111 , Hao6opor, n1t1-
3aTb1 rpaMn03111TlllBHblX M111Kpo6os MOfYT lllMeTb
xapaKTepHble CBOlllCTBa 3HAOTOKClt1HOB. no Me-
X8Hll13MY p,eti1CTBlll51 see TOKClllHbl , Bbtp,enHeMble
M111KpoopraHlt13M8Ml.1 , p,eI151T Ha:
1 nospe)f(,lJ,at0L11111e KJleT04Hble MeM6paHbl ;
2. yrHeTalOLl..\111e 6eJlKOBbtll1 ClllHTe3 ;
3. aKT1t1BaTOpbl MeTa60ill.13Ma ;
4 . l.1Hr1t161.1TOpbl BblP,eileHlll51 Helllp0Mep,111a-
Topos;
5. aKTll1BaTOpbt lllMMYHHOro OTBeTa M8Kpo-
opraHl.13Ma.
8 cplt131110JlOrlt14eCKlt1X yc.noBlt151X cpnopa Klll-
We4Hll1Ka He socnp1.1H111MaeTC5l KaK 4y>t<epop,Ha51.
np1.1 3TOM cpopM1.1pyeTC5l Clt1M61t103 Ml.1Kpoopra-
Hll13MOB 1.1 3n111ren1t1ailbHblX KJleTOK Klt1We4Hlt1Ka .
Bo3MO>KHO, 3TO npo111cxop,111r 6narop,ap5'1 cpeHo-
MeHy «MOileKYI151pHoll1 Ml.1Ml.1Kp1t11t1» (Ham'141t1IO
o6L!..llllX aHT1t1reHos y wraMMOB E . coli 111 Bacter-
oides spp. 111 3n111ren11151 K111we4HlllKa) .
CneKTp M1t1KpoopraH1t13MOB, Bb1p,ens:1eMbtX lt13
3Kccyp,aTa 6pt0WHOll1 nOilOCTlll , y 60ilbHblX c ne-
PlllTOHVITOM npep,cTasneH Enterobacteriaceae
spp. (58%) , Bacteroides spp. (17%), Pseudomo-
nas spp. (13%), Streptococcous spp . (8%) ,
Staphylococcus spp. (7%) . B OCHOBHOM 3TO
rpaMHeraTlllBH851 cpnopa , 3HAOTOKClllHOM KOTOpoi/1
51BI151eTcs:i mmonon1.1caxap1t1A (nnc) . OH npep,-
crasn51eT co6oi.:1 KOMnoHeHT KileT04HOV! cTeHKlll
Ml.1KpoopraHl.13Ma. Moneeyna nnC COCTOlt1T 1113
non111caxap111p,Hoi1 06nacT111 , KOTopa51 nocpep,cT-
BOM KOBaileHTHOVI CB513111 coeP,lllH51eTC51 c mm111p,-
HOVI 06nacTbt0, Ha3blBaeMoli1 .n1t1n1.1p, A. MoneKY-
na n111n111p,a A o6nap,aer ocHOBHblMlll 61t1onor1114e-
cK1.1M111 CBOlllCTBaMl.1 3HAOTOKCll1HOB: Bbl3blBaeT
n1t1xopap,ey, cH1.1>1<aer aprep111anbHoe p,asneH1t1e,
06ycnasn1t1saer pa3s111T111e woKa , .QBC - c111H-
APOMa. OH TaK)Ke aKT1t1B1t1pyeT c111creMy KoMnne-
MeHra , KaCKap, MeTa60I11113Ma apaXlllP,OHOBOlll Klt1-
CJ10Tbl, neil1KOL..\lt1Tbl. 8 cny4ae no51BJ1eHlt151 3HAO-
TOKCll1Ha B KpOBlll H84111HaeT cpopM111pOB8TbC51
CCBP (MexaH1113M on1t1caH Bbtwe). Ecn111 3HAO-
TOKClt1H He B03MO>KHO Heil1Tpanlt130BaTb, TO B03-
HlllK810T pa3Hoo6pa3Hbte HapyweH1115l MeTa6o-
nlt13Ma, HeKpOTIA4eCKllle 1113MeHeHlll51 B TKaHHX,
T.S1)f(enas:i lllHTOKClllKa4111s:1 111, B KOHe4HOM lllTOre,
pa3s111saeTcs:1 a6AOM1t1HanbHb1ill cenc111c.
TaKlllM o6pa3oM , cnoeo6HoCTb 3HAOTOKC111Ha
aKTlllB"1pOBaTb 4111TOKlllHOBbliil KaCKa,D, , a TaK)f(e
oneoH1113a411110 111 arn0Mepa411110 3HAOTen111anbHblX
KneTOK e noeneAYIOW,eill aKT111Ba4111eill ClllCTeMbl
KOMnneMeHTa Ill HeiilTpocp111noB MO)f(eT np111BO-
A111Tb K 06w111pH0My nopa)f(eH11110 3HP,0Ten111s:1, 4TO
51Bfl51eTe51 KpaeyronbHblM K8MHeM B pa3BlllTl!le
opraHHOiil p,111ccpyHKL\llllll .
lthaK, on111caHb1 see 4eTb1pe acneKTa pa3Blll-
Tlllfl nep111ToH111Ta. Heso3MO)f(HOCTb MaKpoopra-
Hlll3Ma noKan1113osaTb 111HcpeK41110HHb1ill npo4eee s
OAHOM 1113 OTAeflOB 6plOWHOiil nonOCTlll , MaCClllB-
Hblill Bb16poe Me11111arnpos socnaneH111s:1 111 npo-
HlllKHOBeH111e lllX HapHAY e 3HAOTOKClllHaMlll B
KpoBb. A TaK)f(e HapyweH111e pa6oTbl Klllwe4HlllKa,
KOTopoe nop,p,ep)f(l!IBaeT c111eTeMHoe BocnaneH111e
3a C4eT TpaHCflOKal..4111111 MlllKpoopraH1113MOB I/IX
TOKClllHOB B KpOBb Ill nopa)l(eH111e 3HP,OTen111s:1 -
Bee 3TO MexaHJ.43Mbl pa3BlllTlll51 opraHHOL4 P,lllC-
cpyHK4LllLll , OCflO)f(HfltoW,eiil Te4eHL/le pa3flLllTOro
neplllTOHlllTa .
/{flJlfHJlfKA PACnPOCTPAHEHHoro
nEPJlfTOHJlfTA
>Kano6b1 6onbHOro xapaKTepHbl Aflfl 3a6o-
nesaHlll51 rnro 111n1t1 lllHOro opraHa 6ptowHol4 no-
nocTlll, noeny)f(1t1Bwero np11141t1Hol4 nep1t1TOHL11Ta.
KnLllHL/14eCKL/le np051BfleHL/151 nepl!ITOHlllTa
CKnaP,blBalOTCH L/13 C04eTaHL/lfl CLllMnTOMOB oc-
HOBHOro 3a6onesaHlll51 Lil KnLllHLllKlll HenocpeACT-
BeHHO nepLllTOHlllTa. B cny4ae pa3BLllTlll5l pacnpo-
eTpaHeHHoro nep1t1TOHL11Ta OTMe4aeTefl HapaeTa-
HLiie Tfl)f(eCTlll eoeTOflHL/151 na41AeHTa, IA , npe)f(Ae
seero , 51BfleHIAiil 3Hp,oreHHOt1 LllHTOKe"1K8L\lt1111 (nu-
xopaoKa, maxuKapoufl, peoma, mowHoma).
Ha 3TOM cpoHe yc1.4n111saeTcfl 6oneeou cuH-
iJpoM. 5on111 HOCflT pa3n111rnlll xapaKTep 111 yc111n111-
Ba10TCfl nplil 1113MeHeHllllll nonO)f(eHlllH Tena. n0Ka-
n1113a41.451 6on111 3aBl!IClllT OT n0Kan1113a4111111 nep-
B1114Horo soenan111Te!lbHoro 04ara. .Qnfl yMeHb-
w eHlllfl 6on111 nat..1"1eHTbl cTapalOTefl ne)f(aTb He-
noABJ.4)f(HO Ha 6oey e npLllBeAeHHblMJ.4 K )f(J.4BOTY
oraM1r1 , 1r136era.fl J11r1WH!r1X ,llB!r1)1(eH1r1lll.
np111 06beKTLllBHOM 111eeneAOB8HlilLll OTMe4a-
eTC51 6neAHOCTb KO)f(HblX noKpOBOB , a B TepMLll-
H8flbHOiil CTa,D,lllLll np111coep,LllHHeTeH aKpOL\1118H03,
3aocTpH10Tefl 4epTbl n1114a , 3ana11a10T ma3HbJe
s:1 6noK111 (nuqo runnoKpama) . Cn1i13111eTafl o6o-
no4Ka poTosoill nonoeTlll eyxas:i, 513bJK cyxoill Lil
o6flO)f(eH TeMHblM HaneTOM . .Qnfl 6onbHblX nep111-
0HJ.4TOM xapaKTepHa maxuKapOUfl, CHWKeHHOe
apmepuanbHOe iJaeneHUe.
np111 J.4Cenep,OB8HlllJ.4 )f(LIJBOTa OTM848eTe51
ozpaHU'leHHafl noOBWKHOCmb 6p10WHOU
cmeHKU np111 Ab1xaH111111 . npl.4 nepeycc111111 rnMna-
H"1T 3a C4eT nape3a K"1We4Hl.4Ka , npumynneHue
nepKymopHozo 3ey«a npu cKonneHuu 3Ha-
'1Umen1:.Hoeo Konul./ecmea 3Kccyoama s mill
109
111n1.4 111Hoill 06nacT111 6p10wHot1 nonocrn . np111 no-
BepxHOCTHoill nanbna4"1L11 )l(lllBOTa OTMe4aeTC51
3aW,"1THoe Hanp5l)f(eHl.4e MblWL\ nepep,Heill 6ptow-
Hot1 eTeHKlll COOTBeTeTBeHHO 30He Bocnan111Tenb-
H0-1113MeHeHHOL4 nap111eTanbHOl/l 6plOWlllHbl. npl.4
my6oKoill nanbna41.41.4 MO)f(HO onpep,en111Tb soe-
nan111TenbHb1t1 111Hcp111nbTpaT. XapaKTepHbJM c111M-
nT0MoM MeCTHOro nepl!ITOHlllTa 51BJ151eTe5l CUM-
nmoM 11.JemKuHa - 6n10M6epza, KOTOpb1t1 60-
nee Bblpa)f(eH B 30He ocHOBHora 04ara soenane-
Hlllfl. B cnyYae «npo6op,Hora» nep111TOHlllTa OTMe-
4aeTcs:i Tp111ap,a c111MnTOMos: ,llbenacpya (pe3KO
Bb1pa)f(eHHa5l 6onb), cuMnmoM KpacHo6aeea
(P,OCK006pa3Hbllll )f(lllBOT) Ill >Ko6epa (yMeHbWe-
HJ.4e lllJllA OTCYfCTBlll51 ne4eH04HOlll rynocTl!I).
,LJ,ua2Hocmw<0 nepumoHuma
.Qnfl noCTaHOBKlll P,LllarH03a «neplltTOHlltT»
He06XOAlllMO on111paTbC5! Ha cnep,ylO~llle ClllM-
nTOMbJ :
1.5onb, KOTOpa51 HOCLllT pa3JllllTOiil xapaKTep c
P,OMJ.4HlllpOBaHllleM 6on111 B 3as111e111MOCTlll OT noKa-
fl"13al..lllllll nopa)l(eHHoro opraHa. 6onb ye111n111saeT-
Cfl np1.-1 1113MeHeH111"1 nono)f(eHl!lfl Tena, na4111eHT
nplllHlllMaeT BblHy)f(AeHHOe nono)f(eH"1e Ha cn111He
111n111 Ha 6oey c noArnHyrblMlll HOraMJ.4 . Pa3nlllTDiil
xapaKTep 6on111 CB513aH c oco6eHHOCTbto lllHHep-
sa4111111 6plOWlllHbl , KOTOpafl nony4aeT 4yBeTBlll-
TeflbHOe socnplll51Tllle OT Me)f(pe6epHblX HepBOB,
pear111py10w,111x Ha see s111p,b1 so3p,eillcrn1115!. Ta3o-
sas:i 6plOWlllHa He lllMeeT COMaTl!l4eCKOiil "1HHepsa-
L\111111, no3TOMY np111 nep111TOH111Te Manora Ta3a oT-
cyrcrnyeT ClllMnTOMbl HanpH)f(eHlllfl 6plOWJ.4Hbl;
2. Tax111KapA1115! ;
3. ll13MeHeH111e A,IJ,; np111 Me3eHTepanbHOM
TPDM6o3e, KaK npas111no, 3TO rnnepTeH3"151 , a np1t1
nepcpopa41111t1 nonoro opraHa Hao6opoT rnnoTOH11151 ;
4 . f1111xopap,Ka: 06bl4HO cpe6pL11nbHaf1 , HOeLllT
nocT051HHbllll xapaKTep, pe)f(e reKT1114ecKa5l, ;
5 . .aeflt1AP8Ta4111fl aeneACTBllle pBOTbl, TOW-
HOTbl, lllHOrAa Alllapel.4 . Cyxot1 513bJK, CHL11>1<eH111e
rypropa TKaHet1 , cH111)f(eHHb1t1 p,111ype3;
6. T111MnaH111T (np111 no51sneH111e ra3a B
6p10wHolll nonocTlll) 111n111 yKopo4eH111e nepeyTop-
Horo 3ByKa np111 Ham14111111 3Kecyp,arn;
7. Has1.i1caH1.i1e nepe,llHelll creHKl.il npS1MOill
KlllWKlll np111 peKTanbHOM 111ceneAOBaHllllll, np111 ne-
plllTOHlllTe Manora Ta3a (cTp . 42) .
8. np111 nanbna4111111 )f(lllBOTa onpeAenfleTCfl,
np111 pacnpocTpaHeHHblX npo4eecax, Bb1pa)f(eH-
Ha5! Mb1We4Ha51 3aw,111rn, (c111MnTOM KpacHo6ae-
sa) a s cny4ae noKanbHora npo1..1eeea - ClllMnTOM
Ll.\eTKlllHa - 6n10M6epra.
9 . C111MnTOM lecprnpa - W111n1111..1111Ha (wyM
nnecKa B )f(lllBOTe);
10. ,Qnfl «npo6oAHblX» nep111TOHlllTOB xa-
paKTepHa Tp111ap,a ClllMnTOMOB: CLllMnTOM ,IJ,bena-
cpya («KlllH>KanbHafl 6onb» ), e111MnTOM KpacHo-
6aesa («AOCK006pa3Hbliil )f(LIJBOT») Ill ClllMnTOM
>Ko6epa (yMeHbWeH111e 111n111 0Tcyrern11151 ne4e-
H04Holll rynocrn);
 11. 111 , HaKOHeL.1. BHeWHllllll BlllA 60JlbHOro -
n1111.10 l111nnoKpaTa , 111 1113spaU1eHHb1ll1 rnn AblXaH1115l
(ClllMnTOM 6ell1n111) .
Puc. 42. HaaucaHue rynona npRMoiJ KUWKU npu
peKmanbHOM uccneaoaaHue
/1,ono11Hume11bHbte Memoabt ucC11eaoeaHuR
• 061!1111111 aHam.13 Kpos111 (nell1KOl.llllT03 c
Hell1Tpocf:J111ne30M) ;
• PeHTreHorpaqm51 opraHoe 6ptowHoll1 no-
nocT111 (ra3 noA Alllacf:JparMolll , BblCOKoe CT051Hllle
(4M+3f0+2n+C)x(nn+1)
n111111=
(IllllMcPOL.llllTbl+MQHOl_\l/ITbl) x(3+1)
l.1HAeKc MaMxaMepa y'f1rtTb1eaeT (e 6an-
nax):
• Bo3pacT 6onee 50 neT - 5 6annos;
• >KeHCKllllil non - 4 6anna;
• Han1114111e onyxon111 - 4 6anna;
• TeMneparypy 6onee 24 4acos - 4 6anna;
• nopa)f{eHllle TOJlCTOlll KlllWKlll - 4 6anna;
• Pa3n111Tolll nep1inoH111T - 6 6annos ;
3KccyAaT: - cepo3Hbllll - O 6annos, rHoll1-
Hb1ll1 - 6 6annos , KanOBbllll - 12 6annos
Kp111rn4ecK111ll1 noKa3arenb cocTos:1H111s:1 111 npo-
rHo3a 29 .:!:. 0,6 6anna.
B HaCTOs:lll.lee apeM.s:i 01.1eHKa T5l)f{ecrn 111
nporH03a COCT051Hl/l51 na1..1111eHTOB c nep111TOHL'1TOM
npm-13BOAlllTbC51 no wKanaM APACHE II u
APACHE 111 , s KoropblX Y4111Tb1Batorcs:1 AeMorpa-
cf:J1114ecK111e noKa3aTeJllll , COCTOs:IHl/le ClllCTeM KPO-
soo6paU1eHll15l 111 Ab1xaH111s:1 , Mern6on1113M, a TaK)f(e
npeMop6111AHb1Ci cf:JoH na4111eHTa. Kp111rn4ecKa.s:i
sen1114111Ha 6onee 20 6annoa.
OCJ70>1<HEHl!tfl nEPl!tTOHl!tTA
Pa3n1114atoT lllHTpaa6AoM111HaJlbHb1e 111 3KCT-
paa6AOMlllHanbHble ocno)f{HeHl/ls:I nep1.-1TOHl/ITa. K
nepBblM OTHOC5!T:
1. HarHoeH111e nocneonepa141110HHOCI paHbl
2. 3BeHTpa1411110
110
A111a¢parMbl Ha crnpoHe nopa)f(eH1115l , 4aw111
Knoll16epa np111 OKH).
• Y3111 6ptowHoll1 nonocrn (ra3 111/ 111n111 )f(lllA-
KOCTb) ;
• nanapo1.1eHTe3 (HaJ11114111e naTOJ10fl.14eCKOl/1
)f(lllAKOCrn B 6plOWHOlll nonocT111);
• nanapacKom1.s:i (Ham14111e socnan111TenbHo-
ro 04ara s 6ptowHolll nonocrn , 1113MeHeH111e 1.1seTa
6ptow111Hb1 , Hanw-1111e s 6ptowHolll nonocrn narn-
norn4ecKoro 3KccyAaTa) ;
• nanapOTOM11151 .
06be1<mueHaR 04eH1<a mRJKecmu
cocmoRHUR
HaAo noMHlllTb, 4TO o6beM nopa)f(eH111s:1
6ptoWlllHbl np111 nep111ToH111Te He scerAa Koppen111-
pyeT C Ts:l)f(eCTblO COCT051Hlll51 na1.1111eHTa. np1t141/1-
Hbl 3Toro MHOrocf:JaKTOpHble 111 3aBlllC51T OT co-
CT051Hlll51 caMoro na1.1111eHTa - B03pacT, non , co-
nyTCTBYIOll.laH naTOJlOfl/151 , a TalOl<e B036YA111Tens:1
111Hcf:JeKL.1111111- BlllpyneHTHOCTlll , pe3111CTeHTHOCTl/I K
aHTlll6lllOTlllKaM Ill np04111e.
,Qns:1 o6beKTlllBHOlll 01..1eHKlll Ts:l)f(eCTl/I COCTOH-
Hllls:I np111MeHs:110T pa3n1114Hb1e wKailbl. Ha1116onee
npocTolll s:1sns:1eTcs:1 onpeAeneH111e nell1Ko4111TapHo-
ro lllHAeKca 111HrnKc111Kau111111 (nllllll) no Kanb-
Kan111cf:Jy (1941).
6naronpllls:!THbllil lllCXOA 4, 1± 0,6
He6naronp1115!THb1ill 111cxoA 3,2 ± 0,6
3. lllHcf:J111nbTpaT 6ptowHolll nonocrn
4. A6c1.1eccb1 (p1.-1c. 43)
5. K111we4Hble CBlllll.1111
3KCTpaa6AOMl/IHaJlbHble :
1. Ho30KoM111anbHb1e nHeBMOH111111 ;
2. A6AOMl/IHanbHblill cenc1.-1c;
3. A6AOM111HanbHb111i KOMnaprnMeHT ClllH-
APOM 1/1111/1 Cl/IHAPOM BblCOKOro BHyTpl/l6ptoWHOro
AasneHl/ls:! , KorAa AaBneH111e s 6ptowHoei nonocT1t1
CTaHOBlllTbCH 6onee 10 MM pT.CT.
nooouacfJpaaManbHblU a6c4ecc. np1t141/1HOCI
5lBJ151eTCH OCTpblill xonel.ll/ICTl/IT, OCTpbllll anneH-
Al/ILll/IT, npo60AHas:1 5!3Ba )f(enyAKa, HecocrnH-
renbHOCTb WBOB I/I nOAKO)f(Hbllll pa3pbl8 ABeHa-
Al.18TlllnepcTHOlll Kll1WKl/I . Cnesa a6c1.1ecc B03Hlll-
KaeT np111 HeCOCTOHTeJlbHOCTlll n1t1U1eBOAHblX aHa-
CTOM030B, naHKpeoHeKp03e.
Kn1.1H1t14eCKl/I nOAAl/lacf:JparManbHblill a6c1.1ecc
npOflBJ15leTCfl 6oneBblM Cl/IHAPOMOM . 6onb 111p-
paAL1L1pyer a HaAnne4esyto o6nacrb 111 6oKOsyto
nosepxHocTb we111 Ha cTopoHe nopa>KeHlll51 . TaK-
)f(e OTMe4aeTcs:1 np1.1coeA1.1HeH111e n111xopaAKlll ,
np111H111MatoU1elll reKT1114ecK111lll xapaKTep , pe31.1-
CTeHTHolA K npOBOAlllMOIA aHrn6aKTep111anbHOlit
Tepan111111. ,Q111arH03 noATBep~aeTC5l AaHHblMlll
Y3111 . ne4eH111e oneparnsHoe. OAlllH 1/13 sap111aH-
 1!1nrnocrpal.(1tt1tt K2 Llacrn
,___ __ ----- - -,

Puc. 3. PeHmaeHoapaMMa >KenyaKa u

aeeHaaLlamunepcmHOU KUWKU. XpOHUl/ecKaf/ f/368 Mano(J Puc. 7. Cmeonoaafl eaaomoMUfl. 1-neeb1i1
KpUBU3Hbl (c-M «HUWU»}. Tun I no Johnson 6ny)/(aa10~uu Hepe; 2- npaeb1i1 6ny)f(aa10~ui1 Hepe.

Puc. 8. /1peHupy10~ue onepaLlUU.

A - nunop~nnacmuKa no leiJHeKe -MuKynutfy; 6 - nunoponnacmuKa no <PUHHe/O; a - aacmpoayoaeHoaHacmoMo3 no
>Ka6yne/O, I - aacmpo3HmepoaHacmoM03.

Puc. 9. CeneKmueHafl eaaomoMUfl. 1-neebliJ
6n}'>Kaa10~uu Hepe;2- npaeb1i1 6n}'>Kaa10~uu Hepe; 3-
el/eHol/Hafl eemeb neeoao 6ny>Kaa10~eao Hepea; 4-
peeHafl eemeb npaeoao 6n}'>Kaa10~eao Hepea.
I
5-------'
Puc. 10. CeneKmueHafl npoKcuManbHafl
eaaomoMUfl. 1-neebJiJ 6ny)f(aa10~ui1 Hepe; 2- npaeb1i1
6n}'>Kaa10~ui1 Hepe; 3-netfeHOlfHafl eemeb neeoao
6n}'>Kaa10~eao Hepea; 4-lfpeeHafl eemeb npaeoao
6n}'>Koa10~eao Hepea; 5-eemab namap>Ke neeoao
6njl>Kaa10~eao Hepea; 6-eemBb flamap>Ke npaeoao
6n}'>Kaa10~eao Hepea.

111
 Puc. 11. lacmpOCKOnUR. npo60iJHaf/ f/38a nepeiJHeU
crneHKu aHmpanbHoeo omoena )f(enyoKa (crnpenKa).

Puc. 12. 3HiJocKonul/ecKaR KapmuHa R3BeHHOBO

Kpoeome'leHuR. A-cmpyuHoe Kpoeomel/eHue
(cmpenKa). 5-iJu<P<PY3Haf/ KPOBOmOl/UBOCmb
(cmpenKa) .

Puc. 13. neHempupy>0LJ4aR f/38a mena >KenyiJKa.

Puc. 15. A - nuM<jJaiJeHoiJucceKu,uR D 2, 5 - npaebtu 3man nuM<jJaiJeHoiJucceKu,uu D 3. A) KynbmR neeou

)f(enyool./HoiJ apmepuu; 2-o6U4BR ne'leHol./HaR apmepuR; 3-eacmpooyooeHanbHBR apmepuR; 4-co6cmeeHHBR
ne'leHO'IHaR apmepuR; 5-xoneiJox; 6-KynbmR npaeou )/(enyool./Hou apmepuu; 7-eopomHaR eeHa. 5) 1-aopma; 2-HU)l(HRR
nonaR eeHa; 3-neeaR nonaR eeHa; 4-HU)l(HRR 6pbt)l(ee4HaR apmepuR.

112
 lllnn10cTpal...lllll'I K2 4acrn

Puc. 16. fleeb1iJ 3man nuMcpaiJeHoiJucceK~uu D 3. 1-cene3eH04HaR apmepuR; 2-cene3eH04HaR eeHa; 3-eepxHRR
6pbt)l(ee4HaR eeHa; 4-eepxHf/R 6pbl)l(ee4HaR apmepuR; 5-neeaR noLJeLJHaR eeHa; 6-neeaR aoHaiJHaR eeHa; 7-neebJiJ
M04emo4HUK; 8-noiJ)l(enyiJOl./HaR )l(ene3a; 9-KYnbmR neeoiJ >KenyiJoLJHOU apmepuu; 10-neeaR no4e4HaR apmepuR; 11 -
neeaR noLJKa (a pyKe accucmeHma), eepxHuiJ nonioc nocne aiJpeHan3KmoMuu.

••

Puc. 17. PeHmceHoapaMMa KoHmpacmupoeaHHoao Puc. 18. PeHmaeHoapaMMa iJucmanbHoeo omiJena

)l(enyiJKa npu myaoM 3anonHeHuu. B o6nacmu yana
)l(enyiJKa onpeiJenflemcR iJecjJeKm HanonHeHUR c
Hep06Hb/MU KOHmypaMU c U3bfl36fleHUeM 6 ~eHmpe.
/113bR3eneHHb1iJ paK )l(enyiJKa
nu~eeoiJa u )l(enyiJKa npu myaoM HanonHeHuu.
nopa)l(eHUe KapiJuanbHOeO omiJena )l(enyiJKa U HU)l(HeiJ
mpemu nu~eeoiJa . KapiJuo33ocjJaauanbHblU paK.

113
 Puc. 19. <Pu6poaacmpocKonuR. 3K3oc/JumHbti1,
2pu6oauiJHbti1 paK >KenyiJKa Puc. 20. <Pu6po2acmpocKonuR. 713BeHHo-
UHc/JunbmpamuaHbti1 paK 6onbwoi1 KpUBU3Hbt >KenyiJKa

Puc. 35. AnnapamHo-nnacmu'lecKaR pe3eKU.UR

ne1.JeHu (cxeMa) : nnacmuHa KCeHoaeHHou 6plOWUHbt (1),
Puc. 21. J7anapocKonuH. Kapu,uH0Mamo3 c/JUKCUP068HH8R npu npowuaaHUU mpy61./ambtX
cmpyKmyp (2) MexaHUl./eCKUM WBOM (3)

114
TOB - 3TO APeH111poaaH111e a6c4ecca nap, KOHTpo-
neM Y3111 . B cny4ae HeacpcpeKTlllBHOCTlll noKa3a-
Ha onepa1..1111s:1 KnepMoHa (p,ocryn MO:>KeT 6b1Tb
KaK TpaHca6AOMlllHanbHblM, TaK Ill TpaHCTOpa-
KaflbHblll1 no MenbHlllKoay), no30ons:1toLL1as:1 cpa3y
npoHlllKHYTb B nepep,Hee 111 38,D,Hee nop,p,111cppar-
ManbHOe npocTpaHCTBO. Pa3pe3 12-14 CM. no
6oKoaoll1 nosepxHOCTlll :>KlllBOTa napannenbHo
pe6epHOJl1 p,yre . np111 pacce'-leHllllll 6ptoWHOJl1
CTeHKlll , onacHOCTb BCKpblTlllfl 6ptoWHOll1 nonOCTlll
MlllHlllM8J1bHa , HO BMecTe c TeM B03MO:>KHO ,Qpe-
HlllpOBaHllle noA,D,111acpparMallbHOro npocTpaHcT-
aa 111 naTepanbHoro KaHana (p,ocryn no MenbHlll-
KoBy). B HeKOTOpblX cny'-!as:1x L\enecoo6pa3eH
nyHKL\lllOHHblll1 MeTOP, no,Q KOHTpo.neM Y3111.
MECTHblM OfPAHl1YEHHbJM nEPl1TOHl1T
- A5CL(ECC 5PIOWHOM nOf70CTl1
Puc. 43. Hau6onee l/acmb1e n0Kanu3auuu
a6cueccoe 6p10WH0D nonocmu: 1,2-
nooouacppaaManbHblU a6cuecc; 3- noonel/eHOl/HblU
a6cuecc; 4- napa-anneHduKynBpHb1iJ; 5- a6cl!ecc
Manozo ma3a; 6, 7- Me)l(KUWel/HbJiJ a6cuecc
A6cl.{ecc M8!10BO ma3a. Ha1116onee '-laCTble
nplll4111Hbl - 3TO ,QeCTpyKTlllBHblti anneHP,VIUi.1T,
rHOll1Hblll1 canbn111Hrl.'1T, HeCOCTOs:!TeJlbHOCTb WBOB
TOJ1CTOJl1 KlllWKVI. Kn111H111Ka: 6on111 B Hlr13Y :>KlllBOTa,
BblCOKas:i TeMneparypa, All13yp111'-!eCK111e pac-
cTpoll1cTBa, TeHe3Mbl , B03MO:>KHO p,1r1apes:1 . Ami
a6cL1ecca Manoro ra3a xapaKTepeH c111MnTOM
Koyna , a TalOKe Has111caH111s:1 nps:iMoilt KlllWKlll np111
peKTallbHOM m160 aarnHaJ1bHOM lilCcfle,QOBaHllllt1.
BcKpb1T111e a6c1..1ecca npo11t3BOAflT 4epe3 nps:1Myto
KlllWKy, a y >KeHW,lllH 4epe3 3a,QH111111 CBOA Bnara-
J1111LU8 nap, KOHTponeM lllrllbl, BBe,D,eHHOll1 B 06-
nacTb Ha1116011bwell1 cpm0Krya1..1111111. B nonocTlll
a6cL1ecca OCTaBrn:llOT p,peHa:>KHyto Tpy6Ky, KOTO-
pyto cp111Kc111pytoT KeTrYTOM K Cillil3111CTOll1 0601104Ke
nps:1Mo~ KlllWKlll . B p,aflbHe~weM 3-4 p,Hs:1 nonocTb
a6cL1ecca npoMblBalOT 111 np111 OTCYTCTB111e rHOfl
.QpeHa:>K yp,ans:1toT.
Me>KKUWel/HbJiJ a6cl.{ecc. Ew,e op,Ho oc-
11o>KHeH111e nep111TOH!r1Ta, '-laCTO B03HlllKaeT np111
He,D,OCTaTO\.lHOlA C8H84111VI 6ptoWHOlA nonocrn, a
115
TalOKe np111 npo6op,HoM p,111seprnKyn111Te, npo6op,-
Hol4 racTpo,Qyo,QeHailbHOl4 513Be, HeCOCTOs:ITeilb~
HOCTlll WBOB Ill aHaCTOM030B TOilCTOlll lr1 TOHKOll1
KlllWOK. ,0,111arHocT111Ka cnQ)KHa. Ha nepsoe MecTo
BblXO,D,SH nplll3H8Klll 3H,QOreHHOl4 lllHTOKC1r1K8L\lillll Ill
IlVIWb no Mepe cpopM111pOB8HlllS'I HarHOlllTeilbHOro
111Hcp1t1nbTpara, nos:1sns:1ercs:1 Kn1t1H111Ka noKanbHoro
HarHOlllTeilbHOro npo1..1ecca. ne48Hlile onepaTlllB-
HOe. Pa3pe3 npo1113BO.QS'IT B npoeKL\111111 Ha1116onb-
wero Bb16yxaH111s:1 rHOIAHlllKa. Me:>K1<11We'-1Hb1!4 a6c-
1.1ecc BCKpb188IOT TynblM nYTeM , OCTOpO>KHO pa3-
,QB111ras:r neTn111 cnas:1HHblX K111wo1<. nonoCTb a6c-
1..1ecca raMnoH111pytoT.
Xl1PYPft11../ECKOE J7El../EHl1E
PACnPOCTPAHEHHoro nEPl1TOHl1TA
PenanapomoMuu
neplllTOHlllT s:IBJl5leTCS'I a6COJllOTHblM noKa3a-
HlileM p,.ns:i onepa1.1111111. 6onee 85% ycnexa ne1.1e-
Hlllfl pacnpocTpaHeHHoro nep111ToH111Ta - 3TO one-
paTl!lsHoe BMeWaTel1bCTBO, 3ap,a'-laM111 KOTOporo
S'!Blls:llOTCS'I :
1. YcrpaHeH111e lllCT04HlllKa 111HcpeK1..11.-1111;
2. Yp,a11eH111e 3Kccy.Qara 111 111Hcp111nbTp111po-
BaHHoro MaTep111ana ;
3. Mexatt1111.1ecKOe O'-llllW,eHVJe 6piowHoiil no-
nocTlll ;
4. AeK0Mnpecc111s:1 Kli!We4H111Ka;
5. ,O,peH111posaH111e 6ptowHoVI nonocTlll;
6. 3aKpb1T111e noc11eonepa1..11110HH0!4 paHbl.
,O,ocryn np1r1 pacnpocTpaHeHHOM nep111ToH111-
Te - npaKT111Yec1<111 acer,Qa cpep,111HHas:1 .nanaporn-
M111s:r, 6narop,ap51 KOTOpolA 803MO>KHa nonHOL\eH-
Has:r pes1113111s:1 6piowHol4 nonocrn . CaM o6beM
onepa1..11r1111 MlilHlllManbHbllll: np111 anneHp,1111..1111re -
anneH.Q:3KTOM111s:1 , xone1.1111cT111Te - xone1..1111cnKTo-
Mllls:I , np111 nepcpopa1..11111r1 racTpOAYOAeHailbHblX
5138 - lllCCe4eHllle lllJllll YWlllB8Hllle 513Bbl. np111 ony-
XOilS'IX KlllWe'-IHlllK8 - HaJJO>KeHlllS'I CTOMbl , TaMno-
HlllpOBaH111e, no,QBe,QeH111e ,QpeHa>KelA. 6onbw111e
onepal\111111 Ha cpoHe pacnpocTpaHeHHoro nep111-
TOH111Ta CTporo npOTVIBOnOKa38Hbl. noc.ne y.Qa-
neHllls:I lllCTO'-IHlllK8 lllHcpeKL\111111 6plOWHas:I nOilOCTb
ocywaerc51, yAans:reTcs:r pb1xnb1il! ¢Vi6pVIH, caMa
nonocTb npOMbtBaeTcs:1 aHT111cenT1111<0M. Cne-
AYtoLUlllM 3TanoM c L\eilblO ,Qe1<0Mnpecc111111 npo-
BOAHT lllHTy6a~11110 K111We4HlllKa ABYX npocseTHblM
30HAOM , cTapas:rcb .£\OBecT111 30HA AO 11111eo1.1e-
K8IlbHoro yrna, Ill BBe,QeHllle 0,25% paCTBOpa HO-
BOK8111Ha (100 - 120 Mn .) B KopeHb 6pbl>Kei4Klll .
ApeH111pyeTcs:1 6ptowHas:1 nonocTb 4 - 5 p,peHa-
)l{aM111 (p111c. 44): cnpaaa - no,1:1 ne4eHblO, cneaa
noA p,111acpparMolA, npaab1IA 6oKOBOll1 KaHan 111
nonocTb Manoro Ta3a.
ApeH111posaH111e Mo:>KeT co3A8Tb na>KHoe
1.1yscTBo 6e3onacHocrn . TaK111M o6pa30M, TaKT111-
1<a Be,QeH111s:1 na1..1111eHTOB c nep111TOHlllTOM npocTa 111
8 OCHOBHOM CBO,QlllTCs:I K ABYM pa3HOBlll,D,HOCTs:IM
KOHTpon.51 : KOHTPOilb HaA lllCT04HlllKOM lllHcpeKL\111111
IA KOHTpOnb Ha,[\ nospe~eHlll51M111, Bbl3BaHHblMll1 Tbl ne4eHlllfl nep111TOHL1Ta cneµyer o6paTlllTbCfl K
3TO!il lllH¢eKL\llleC1. ,[\BYM KOHL\enL~lllflM:

KoHTponb HaA 111CT04Hll1KOM 111H<t>eKu111111 1. noBTOplltTb BMeLUaTeJlbCTBO L1 YAOBJ1e-

CsoespeMeHHoe x111pypr1114ecKoe sMewaTenbcT-
so , uenb KaToporo - npepsaTb pacnpocTpaHe-
H111e 111HcPeKU,111111.
TBOp111TbCS'I B KOHTpone 3a lllCTOYHlllKOM 11tH¢eK-
u111111, Ill BTOpoe - npOAOJ1)f(l/ITb KOHTp011b 3a MOp-
cponor1111.1eCKll1M 1113MeHeH111flMlll (Damage control).
nepsoe - 3TO nnaHOBble penanapOTOMllllll, KOTO-
pbl€ HaMe4alQTCfl y.>Ke so epeMfl nepsolil onepa-
u111111, Ill MOryT cny.>KlllTb TalOKe nowoTOBKOLif K pa-

\ AlllK8J1bHOlil onepa1..1111111.
Penanapor0Mw111 npoBOAHT Yepe3 24 - 48
Yacos nocne nepso&l onepa4111111, Ho noKa3aH1M1-
MIA ,D,011.>KHO 6b1Tb He flBHOe yxy,D,weH!Ae COCT051-
Hltl5! na1...w1eHTa , a HapyweH111e cpyHK4111111 opraHOB,
OTCYTCTBlt1e ,ll111H8MlllKL1 COCTOflHL1fl.

nnaHoBble caHau1110HHb1e 11anaporoM111111 no-

Puc. 44. npaeuno opeHupoeaHUfl 6p10WHOU
nonocmu y na4ueHmoe nepumoHumoM
KoHTponb Ha,a noape?l\AeHllleM BKJ11Q4aeT
-ryaneT 6ptoLUHOlil nonocrn. ,[\oKa3aHo, 4TO nep111-
ToH111anbHb1lil A111an1113 He cH111}Kaer noKa3aTenb
neTaJ1bHOCH1, KaK Ill BHyTp1116ptoLUHOe BBeAeH111e
aHT11161.'10TlllKOB.
He scerAa nepsafl onepau,11151 cocTosnenb-
Ha, HO np111 3TOM He HaAO ~aTb nOflBJleHlllS'I np111-
3H8KOB nepc111cT111pytow,eV! 111HcP€KL\llllll Ill opraHHOi.1
HeAOCTaT04HOCTll1 KOTOpble CJly)f(aT noKa3aHlllS'IMIA
K penanaporoM1111.-1. LIT06b1 yny4WlllTb pe3y11bTa-
Ka3aHbl s cnep,ytol.J.llllX c111-ryau111flx:
1. B ToKc1114ecKoill CTaAllllll nep111roHL1Ta c s:1s-
11eH111s:1M111 non111opraHHOlil He,LIOCTaT04HOCTlll.
2. B repM111HanbHOVI CTaAllllll nep111ToH111Ta .
3. np111 nocneonepau1110HHOM nep111ToH1.-1re
Ha no4se HeCOCTOSITeJ1bHOCTll1 WBOB nonblX op-
raHOB Ill aHaCTOM030B.
4 . npw K.nl/IHl.i14eCKOC1 1<aprnHe aHa3p06HOfO
nep1t1TOHl.1Ta .
5. np1i1 OCTasneHHOM IACTOYH"1Ke nepli1TOHll!Ta.
B cospeMeHHbfX ycnos11151x MeTOA caHau111-
0HHblX nporpaMM1.1pyeMblX penanapOTOMllli:i lllJllll
HeKpceKBecTp3KTOMVllll srnn51ercs:i AOcTaroYHo
3¢¢eKTVIBHblM cpeACTBOM Jll/IKBlllAaU,11111 pacnpo-
cTpaHeHHoro nep1i1ToH1.1Ta. 3To no3Bon5leT npe-
AYnpe,L1V1Tb pa3s111T111e cem1114ecKL11X AlllCTaHTHblX
OCJlO)f{HeHl/li:i.

IlporpaMM«pycMMe cattaa;nom1ble peJianapoTOMHH

l . IJ.omt oueHHfill caHaruu1 6p10urnoii rronocrn:.

2. CBoeBpeMeHI-ra51. )lBarnocTMKa H KoppeKuirn BHy-rp11.6pIOillHbIX ocJIO)KHeHHH.
3. Bo3MO:>KHOCTh aKTMBHoro .!1,pe11up0Bamu1 6p10rnHoli nonocrn.
He~ocTanrn
l. O-rp.11u:ar enbHOe cncTeMHOe nocrre.n.crnue UOBTopHbIX BMernateJlbCTB (BTOpHqff&Iii Me)l11aro3 c p3.3BfITH-
eM cerrmqecI<oro lllOKa).
2. IloBropHa51. rpaEMa 6pIOlllHOR creHK!l H opraHOB 6pIOIUHOH rronocrn.
3 . .D:n11.renbH351 HHT)'DaUH.51 K!lllle'-IHIH<a, .TpaxeH c BhICOKHM pMCKOM. pa3BliTR51. H030KOMHaJlhHOM nHeBMO-
mm.
4 . .D:mrreJI&HM HBn.
5. .D:mnen1Hrur KarerepH3au;mr cocy.n:oB-3TO pncI< aHrnoreHHoro cennrca.
6. BbICOKflH pH.CK o6pa30B3HIDl KHIUeqHhIX CBl1UleM H BH)'Tptt6p10nrnoro KpoBOTe'-TeHH5l.
7 . .D:nHTeJibHOe npe6bIBaHHe B CTfil(liOHape.

2. Bropafl KOHu,em.t1115l . 0Ha B03H111Kna AaB-
HO 111 6b1na cneACTBVleM He YAOB11ersop111renbHO-
ro pe3yJ1bTaTa Jle4eHlll5l nep111TOHll1Ta. no3TOMy
B03H1!1Kna 111,ae5l oTKpb1TOro )f{lllBOTa. JlanapocTo-
M!llVl KPOMe 803MO)l(HOro KOHTp0115l , COKpal.1..(alOT
Kon111Yecrso penanapoTOMVl"1, CHVl)f{BIOT BHYTPlll-
6ptowHoe AaBneH1.1e, HO np111 nanapocTOMllllll 6b1-
no nony4eHO 6oJlbWOe KOnlll'~eCTBO OCJ10.>KHeH111V!
111 n03TOMY OHi/i noKa3aHO TOJlbKO:
1. np111 KPVlTL14eCKOM COCT051Hfltfl1 naLl,llleHTa ;
2. npVl IA36b!T04HOM Bl.1CL(epanbHOM OTSKe,
npemlTCTBYIOll..IVlM 3aKpblTIAIQ 6piowHolll nonocrn ;

116
 3. np111 06w111pHblX p,ecpeKTaX 6p10WHOVI no-
110eTlll ;
4. np111 Hen011HblX HeKp3KTOMll171X;
5. np111 HeyBepeHHOeTl/1 B )f(ll13HeCnOC06HO-
eTl!1 OCTaBneHHblX neTenb Kll1We4Hll1Ka.
Cyll\eCTBYIOT p,Ba cnoco6a npoeep,eHll171 na-
napocrnM111111: nepBblVI - 3TO 3aKpblTOVI 3Bll1el..le-
pal..\111111 , Korp,a K111We4H111K 3aKpb1saeTC7! cancpeT-
KaM111 c aHT111cenrn1mM 11111111 Ma37!Mll1 11111111 ceTKOVI
1113 no11111MepoB. BTopoVI cnoco6 - 3TO enoco6
OTKpbJTOVI 3BIAC4epa4111111 , KOr,.qa Kll1W84Hll1K He Ha-
KpblBaeTCSl, a npoMblBaeTeSl noeTOS'IHHO 18 - 40
nleyTKl/1. np111 nanapOCTOMll1111 3aKpb1BalOT 6p10W-
HYIO nonoeTb Ha npoe1113opHble WBbl 11111111 3aCTe)f(-
Kll1 «MOJlHl/1111)}. 111Horp,a B)f(l/1BJ1S'llOT rll1Jlb3Y p,ns:i
nanapcKon1114ecKoro KOHTpons:i .
TaK111M o6pa30M, x111pypr111yeeKoe 11e1.1eH111e
neplilTOHlllTa p,o KOHL(a He 1113y1.1eHO, f/IMefOTCR
npe111Myll\eeTBO Ill He,QOCTaTKlll Toro 11111111 111HOro
MeTO,Qa.
nepuonepOU,UOHHOe aeaeHue nau,ueHma C
nepumoHumoM
Bee 111ccnep,osaTen111 , 3aH111Ma10ll\ll1ecs:i npo-
6neMaM111 J1848HlllS'I nepll1TOHlllTa, yKa3blB8IOT Ha
He06XOP,lllMOCTb npep,onepal..\1110HHOVi nop,roTOBKll1
B TeYeH111e 2 - 6 yaeos. K OCHOBHblM nplllHL..\111naM
npe,Qonepal..\ll10HHOL1 no,QrOTOBKlll OTHOeS'IT:
1. MaKC111ManbHb1Vi o6beM 111ccnep,0BaH111s:i
nplll MlllHlllMaflbHOM epeMeHll1 no,QroTOBKll1 (06ll\llliit
aHan113 Kpos111 , 611ox11M117! Kpos11, peHTreHorpa-
QJlllSl rpyp,HoVI KJ18TKlll, p,111ype3) .
2. KareTep1113al..\11171 L..\€HTpanbHoi71 seHbl.
3 . 30HA B )f(enyp,oK.
4. 111HQJY31110HHa71 noA,Qep}f(Ka npOBO,QlllTC71 B
o6beMe 25-50 Mn/Kr Maccb1 rena c 4enb10 no-
Bb1WeH1117! npep,Harpy3Klll 111 onT111MV13aL1111111 eep-
p,eYHoro Bb16poca . nporpaMMY 111H¢Y31110HHOilt
nop,p,ep)f(Klll COCTaBJlS'llOT c y4eTOM np111MeHeH111s:i
KplllCTa11noVl,QOB Ill K011110111,QOB B COOTHOW€HllllA
3:1. B HaweVI npaKT111Ke crnpTOBblM pacrnopoM
06blYHO eny}f(lllT 7,5% paeTBOp xnop111eroro Ha-
Tp11171 lllHOrp,a B COYeTaHllllll c BOJllOBeHOM (BeHo-
QJYHA111HOM). OcHoBHblM pacrsopoM 111Hcpy31110H-
HOVI nop,p,ep}f(Klll 71B117!eTeSl 0.9% pacreop XJlop111-
cToro Harp111s:1 .
5. leMOTpaHCQJY3111Sl BKJllOYaeTC71 B npo-
rpaMMY npep,onepal..\lllOHHoilt nop,roTOBKll1 np111
ypoBHe reMomo6111Ha y 6011bHoro Hlll)f(e 70 r/11 .
6. C L1enb10 noBb1WeH111S'I eep.QeYHoro Bb16po-
ca, yaem'1YeH115! ,LIOCTaBKll1 K111enopo,.qa 111 reM ca-
MblM ynyYWeHlll71 nepcpy3111111 TKaHeVI opraHlll3Ma
6011bHOro 111en011b3YfOT lllHOTponHyfO no,QAeP)f(KY c
yYaCTllleM CT1t1MymnopoB a,t:\peHopel..\enTopos
(,a,onaMlllH , p,o6yTaMlllH , HOpa,t:\peHaJllllH).
OCHOBHO!lt MeTOA aHecTe3111111 np111 neplllTO-
HIATe - 3TO MHOroKOMnOHeHTHOe e6anaHc111po-
B8HHOe o6lf.\ee 06e36om1saHwe, rAe 3TO B03-
MO)f(HO, B eo"!eTaHllllll c 3n111p,ypa11bHOiil aHeCTe3111-
eilt. OeHOBHOe Tpe6osaH111e K HapK03Y - OH He
117
p,on)f(eH 6b1Tb cn111WKOM my60K111M . lny6oKoe yr-
HeTeH111e onepal..\lllOHHoro erpecea np111eop,111r K
lllMMYHOP,enpecc111111 Ill 8 3TOM KpoereSl O,QHa 1113
np1111.1111H 111HcpeK4111111 B o6nacrn x111pypr1111.1ecKoro
BMewaTeJlbCTBa, a TaK)Ke AI1111Te11bHO TeKYll\ero
Cll1HAPOMa KlllWeYHOVI HeP,OCTaTOYHOCTlll, Heco-
CT071T8JlbHOeTlll aHaCTOM030B, nocneonepa4111-
0HHblX nHeBMOH111ilt, Meraera3111posaH1117! 111 peL1111-
p,111s111posaH1117! onyxon111 np111 OHKOXl~pyprn4eCKll1x
onepaL11M1x. np111 nf06oM sap111aHre o6~eilt aHe-
cre3111111 BO MHOrlllX pa6oTaX cy~eCTBYIOT peKo-
MeH,[184111111 np111MeHeH111~ 1!1HTpaonepa41110HHO HO-
BOK8111HOBO!lt 6noKaP,bl KOPH71 6pbl)f(ei71Kll1 TOHKO!lt,
nonepe4H0060P,04HOL71 Ill ClllrMOBll1AHOlll Kl/1WKll1 .
0nTlllM8JlbH8Sl nporpaMMa 111HTeHelllBHOV!
Tepan111111 nep111ToH111ra BKilfOYaer:
1. KoppeKTHoe nocneonepa1...11110HHoe 06e3-
6on111BaH111e;
2. lr1Hcpy31110HHYIO nOAAeP>KKY e KoppeK1...1111eVI
BOAH0-3JleKTpOillllTHblX HapyweH111Vi;
3. lr1HorponHyt0 nop,p,ep}f(KY c 1...1enb10 onrn-
ML138L..\L1111 TpaHenoprn KL1enopo.Qa;
4 . Pecn111paTOPHYIO nO,D,AeP)l{KY, 1...1enb KOTO-
poVi TaK)Ke, tiTO 111 y 111HoTponH0Vi;
5 . TepanL1IO ClllHAPOMa K111weYHOL1 Hep,ocTa-
TOYHOCTlll Ill paHHee 3HTepanbHOe n111TaH111e;
6. AHT1116aKTep111anbHYIO Tepan11110 (AOJl)f(Ha
npOBO,D,L1TbC71, H8YL1H851 c nepBblX 4aeoB noeryn-
neHlllSl Ill HOCll1Tb p,e33CKana1...11110HHblVi np1t1HL1111n c
B03MO)f(HOL1 nocnep,y10ll\ei;i, cryneHYaroVi repa-
n111eilt) .
KOHCEPBATUBHOE /1El/EHUE
1. ~Hcj)y3MOHH<l$1 Tepamrn
• P-pbl Ha OCHOBe rnp,pOKCl/13TlllnKpaxMana
• P-p HaTp111Sl xnop111p,a 0 ,9% , P-p lnlOK03bl
10% , pacrnop Kan11171 xnop111Aa 7,5% Ha pacrBo-
pe 10% ln10K03bl KanenbHO 80-120
MMOnblcyTKl/1 , peaM6ep111H 400 Mn BIB Kan, co
CKopoeTblO 90 Kan/MlllH (1-1 .5 MfllMlllH) , L..\lllTOQJ-
naBL1H 10 M11 BIB Kan Ha 10% rnlOK03e
2. AHTM6aKTepMa.nbHaSI TepamtR (Ha3Ha-
'4aeTCSI B nepBblM '43C OT MOM0HTa nocTyn.ne-
HMSI)
MecmHb1i1, eHe6onbHU4Hb1i1 nepumoHum:
*npenapaTbl Bb16opa:
• L\e<Pen111M 1-2 r. x 3 pa3a B ,o,eHb BIB
• L\ecporaKCL1M 2 r. x 2 pa3a B p,eHb BIB
• L\ecprp111aKcoH 2 r. x 1 pa3 B p,eHb BIB
Bee npenapaTbl B co1.1eraH111111 c MerpoH111p,a-
3onoM 0,5 Mr x 3 pa3a B cyTKlrl BIB.
*AnbTepHaTlllBHaH Tepan111H:
• M0Kc111cp110Kca1...1111H 400 Mrx 1 pa3 B CYTKll1
BIB
• neBOQJ110KC81...1!JIH 0,5 r x 2 pa3a B eyrKlll BIB
• L\1t1npocpn0Kea1...1111H 0,4-0,6 r x2 pa3a B eyrK111
• AMOKClllL..\llll1JllllHIKJ1aBy11aHaTa 1,2 r x 3-4
pa3a B CYTKIA BIB
 PacnpocTpaHeHHbliii nep111TOHlllT, rocn111-
TanbHafl lllHQ:>eK4111R
*npenapaTbl Bb16opa:
• lt1M111neHeM - 0,5 x 4 pa3a s cyTKlll s/s
MeAJleHHO.
• MeponeHeM 0,5-1 r x 3 pa3a s CYTKlll sis
• )J,op111neHeM 0,5 x 3 p B CYTKlll BIB Kan
• 3pTaneHeM 1 r - 2 r x1 pa3 B CYTKlll (np111
ycnOBllllll OTCYTCTBlllH Cl.llHerHoiiiHoiii nano4Klll)
• l...lecponepo3oH/cynb6aKTaM 2-4 r x 2 pa3a
s cyrK111 ·s/s
* AnbrepHaTlllBHbte npenaparb1:
• We¢en111M 1-2 rx 2 pa3a B cyTKlll BIB, BIM
• l...leQ:>Ta3111AlllM 1-2 r x 3 pa3a B CYTKlll B/B,
B/M
• nesocpn0Kca4111H 0,5 r x 1-2 pa3 B CYTKlll
BIB
• L1111npoQ:>noKca4111H 0,6 r x 2 pa3 B cyTKlll
• + MeTpOHlll,Qa30Jl 0,5 r x 3 pa3a B cyTKlll
BIB
Porn4111H aHr11161110T111Kos 48-72 4aca np111 yc-
nos111111 orcyTCTBlllR AlllH8MlllKl/I B COCTOHHllllll 60J1b-
Horo.
06ll.\aH npOAOil}f(lllTeJlbHOCTb 8HT1116aKTep111-
aflbHOiii repan111111 7- 10 AHeiii.
Kp111rep111iii OTMeHbl aHni61110T111Kos:
• TeMneparypa < 38°C 111 > 36°C .
• LICC < 90/MlllH .
• LIM < 20/MlllH.
• neiiiKOl..llllT03 < 12 x1Q 9/n .
• nono>KliffeJ1bH8R ;:ll-1H8MlllK8 Cli!MnTOMOB
a6AOMlllH8JlbHOiii lllHQ:>eKL.1111111 .
• BoccraHOBJ1eH111e ¢YHK4111111 >KKT.
118
-npocp111naKT111Ka TpoM603a my60K111x BeH
(I A) :- OAlllH 1113 npeAJ10}KeHHblX npenapaTOB:
• r enap111H 5 Tblc. EA Ka)l<Able 6 4acoB n/K
• 3HOKcanapl.llH HaTp1·1H 0,4 n/K 1 pa31CYTKlll
n/K
• HaAponap111H Kailb4111R 0,3 n/K 1 pa3/cyrK111
n/K
• ,D,amenap111H HaTp111R 0,5 n/K 1 pa3/cyTK111
n/K
1. npocfnmaKTMKa o6pa30B3HL.UI CTpecc-
H3B.
VIHrn6111TOpbt npoTOHHoiii n0Mnb1: Bb16parb 1
npenapar
1. pa6enpa3on - 10-20 Mr 1 pa3 B cyrK111 (a
30HA)
2. OMenpa30Jl - BHYTPb 20 Mr x 2 pa3a B
CYTKlll
3. naHconpa3on - BHYTPb - 30 Mr x 1 pa3a
B CYTKlll (B 30HA)
4. 330Menpa3oJl - BHYTPb - 20 Mr - 40 Mr x
1 pa3 B CYTKlll
5. naHronpa3on - 20 - 40 Mr x 1 pa3 s CYTKlll
2. Hyrpr.tTHBHas:i noMep>KKa.
• napeHTepailbHOe n111TaH111e - 1000 Jl B cy-
TKlll - He MeHee 2000 KKan (B c11y4ae OTCYTCTBlllS'I
nep111cranbTlllKlll) (cM . np111no}f(eH111e)
30HAOBoe n111TaH111e - AO 2000 MJl. B CYTKlll
(np111 HaJllll'·lllllll nep111CT8JlbTlllKlll)
3. "1MMYH03aMeCTHTenbHaR TepanHR (I A).
BHyrp111seHHb1iii 111MMyHomo6yn111H (neHTOr-
1106111H) - 5 Mr/Kr B CYTKlll 5-7 AHell\.
! AKT111s111posaHHb1iii npore111H C (APOTpeKo-
rlllH anbcpa, A1Arp111c) - y 6onbHblX cemw-1ecK111M
WOKOM . (I A) 24 MKr/Kr B 4ac B Te4eH111e 96 48COB.

3A60JlEBAHIA.s:t IlEfK"1X IA nllEBPbl,
3Al>OJIEBAHIDI JIEI'KHX H IlJIEBPbl
OcTpbte rnolliHo-,o,ecTpyKrnBHbte nopa)f{eH11rn
nerK111x, 3Mn111eMa nnespbt, 6poHX03KTa3111111 111 paK
nenmro 38HltlM81-0T B HaCTORll.lee speMR BeAy-
ll\8e Mecro s CTPYKTYPe x111pyprn4ecK111x 3a6one-
saH111Ili AbIXarenbHolli cl4CTeMbl.
5POHX031<TATl44ECl<Afl 50/7E3Hb
J<pamJ<Ue caeaeHUR 06 3M6pU02eHe3e,
aHmeHama11bHOM u nocmHamo11bHOM
p03aumuu 11e21<ux
3HaHll1e oco6eHHOCTelli aHTeHaTanbHOfO Ill
nocrHaranbHOro pa3s111r111s:1 nem111x no3sons:ier
nOH71Tb reHe3 OT,[18JlbHblX 3M6p1110HanbHblX no-
pOKOB pa3s111r111s:1 11ern111x, a TaK)f{e naronor1114e-
cK111x npou,eccos, pa3s111saiow,111xcs:1 s nocrHa-
rnnbHOM nep1110,D,e.
AHmeHama11bHoe pa3aumue 11e21<ux
3aKnaAKa AbtXaTenbHOili c111cTeMbt npo111cxo-
AlllT y 3M6plllOHa B KOHU,e 3 Ha4ane 4 He,D,enlll
pa3s1t1T1117!. OpraHbJ ~bJXaH.11171 B03H.111KaJOT KaK Me-
AlllaJlbHoe sbins:t1..1111saH111e 3n111Te11111s:t Kay,D,anbHoro
orpe3Ka nepeAHelli KlllUJKlll, cocros:iutee 1113 nep-
Blll4Horo n111li_\eB0Aa 111 rpaxeanbHoro 3a4aTKa.
,aanee rpaxeanbHbJVJ 3ayaroK or,D,em1ercs:t or m1-
tlleBo,D,a roH1<111M cnoeM Me3eHXlllMbt - npo111cxo-
AlllT nonHoe pa3,D,eneH111e AblXaTenbHOW 111 n1111L1e-
sap111renbHow rpy6oK. TpaxeanbHas:i rpy6Ka 6br-
crpo pacTeT KH1113Y Ill ,[leJ1111TC71 Ha ,GBe nepBW·IHble
6poHx111anbHbte no'-IKlll. nocne,D,Hllle pacnonara:
IOTCs:! B Me3eHXlllMe Ha nosepxHOCTlll nepe,D,Helll
Klll WKlll 111 npeACTasmnor co6orli Ja4aTKlll npaaoro
Ill neeoro rnaBHblX 6poHXOB. lt13 Me3eHXlllMbl B
,D,anbHeVlweM ¢opM111pyioTcs:1 xpsill\111, coeAlllHlll-
TenbHOTKaHHbte 3neMeHrb1 111 COCYAbl AbtXa-
renbHoti c111creMbt, a .QlllcpcpepeHL(lllpoBKa nep-
BM l.JHbJX 5pOHXlt1aJlbHblX no1..1eK K 5 He):lene pa3-
121
9t[acm& 111
PAK IlErKoro.
3A60JlEBAHIA~ nlALUEBOAA.
s111r111si np111BOAlllT K nos:tsneHllllO 6poHxonynbMO-
HanbHbIX no'-leK BTOporo nops:t,D,Ka - AOneebtX:
cnpasa - Tp1t1, cnesa - ,aae, 4TO coornercrny-
er pa3BlllTllllO Tpex ,D,onet/1 s npasoM nerKOM lt1
ABYX - s neBOM. AanbHet/1wee pa3s1t1T111e 3M-
6p1110Ha xapaKTep1113yeTcs:1 nocne,D,OBaTenbHbtM
,aeneH1t1eM 6poHxonynbMoHanbHblX no4eK. 8 re-
1..1eH111e 5-6 He,D,en111 nos:1sns:t10TCH 3aYaTKlll cerMeH-
rapHbIX 6pOHXOB , a 1113 eeTBeVI 4eTsepTOI/1 Ill wec-
TOtil nap )f{a6epHblX apTep111ti1 06pa3yercs:1 CTBon
nero4HOW apTep111111, apacTa101L1Wllr s nerK1r1e no
XOAY nepsW-lHblX 6poHxoe. Y 6-8 HeAeilbHOro
:3M6p1110Ha cpopM111py10TCs:t OCHOBHbte apTe-
p111anbHble 111 seH03Hbte Ko.nneKTopbt nerKlllX. K 14
HeAene pa3s11rnfl y 3apo,abrwa o6pa3yeTc7!
np111MepHo 70 % o6w,ero Kon1111..1ecrna reHepaL1111VI
6pOHXOB, nOHBns:tlOTCs:! cy6cerMeHrapHble 6poH-
Xlll , npolllCXOAlllT 3aKJ1aAKa 6pOHXlllailbHblX )f{eJle3,
HaY11HaJOT pa3s11saTbCfl XPfltllesow 11 MbrWeYHbrtli
KOMnoHeHTbl CTeHKlll 6pOHXOB Ill cpopMlllPYIOTCs:t
38'-laTKlll 6pOHXlt1ailbHblX apTep1111A - np01113BOA-
HblX 6onbworo Kpyra Kposoo6pauteH111R Ha 16
He,aene pa3Blt1Tl1H 3aKaH1..111saerc51 06pa3osaH1r1e
6poHx111anbHbIX sernet/1 AO TepM111HanbHbtX 6poH-
x1t1011 BKI110'-!111renbHO. B HopMe KOJ11114ecrso re-
Hepal...\1111.1 6poHx111anbHbIX pa3seTsneH111L1 AO
6p0Hx11on COCTae.ns:ieT OT 18 ..QO 24 11 OCTaeTCs:!
He1113MeHHblM Ha npOTs:t)f(eHllllll BCeW )f{lll3Hlt1. C 20
no 24 HeAen111 Ha6n10Aaercs:1 6b1crpb1VI pocr co-
CYAlllCToll1 c111cTeMb1 nerKlt1X 111 Ha1..1111HaeTcs:1 aHTe-
HaranbHaH 1...11t1pKY.nHL11t1H Kpos111. K ::iroMy speMe-
Hlll 06pa3yiorcH pecn111paropHb1e 6p0Hx1.1onb1 ,
KOTOpbte B Te'-leHl/le 22-26 He,D,enb A111¢cpepeH-
L(lllPYIOTCH AO anbeeonHpHblX xo,o;oB. c 28 He,ae-
Jllll pa3s111rne 6poHxonero1..1HolA c111creMb1 xapaK-
rep1113yercs:1 nos:isneH111eM anbseon, T. e. cpopMl4-
poBaH111eM pecn111paTopHoro oTAena 6p0Hx111anb-
Horo ,LJepesa 111 KOHL!Y 32 He,qemr BHyrpvryrpo6-
Horii >t<lll3Hlll 6poHx111anbHoe Aepeso B L\eiloM H1t1e Ha cy6cerMeHTapHble (4eTaepToro nops:tAKa)
ccpopMlllPOBaHo . 111 T.A. Ha41t1Hafl c cerMeHTapHblX, 6poHXlll pa3-
B AailbHerllweM , ennoTb AO po)t<AeH111s:1 pe- seranfll0Tcfl AlllXOTOMlll4eCKlll , T.e . Ka}t<Ablrll 6poHX
6eHKa, npo111cxoA111T 111HTeHc111sHas:1 A1t1¢cpepeHL\lll- Aen1t1Tcs:1 Ha ABe seTSVI . l!1c1<J110YeH111eM 1113 3Toro
poBKa TepMlllHailbHblX Iii pecn111paTOPHblX 6poH- npae111na s:isnfleTcs:t 6p0Hx111 wecroro (S 6) 111 Aecs:i-
XlllOil , anbBeom1pHblX XO,QOB Iii MeW04KOB, T.e . roro (S 10) cerMeHTOB npasoro nerKoro 111 6p0Hx111
o6pa3oBaHVle cpyHKL\VIOHanbHblX €AVIHVIL\ nerKVIX sepxywe4H0-3ap,Hero (S 1_2) , wecrnro (Ss), aocb-
(a411Hycos). Moro (Ss), Aecs:irnro cerMeHros (S10) nesoro ner-
Ta1<111M o6pa3oM, y)f(e c 28-32-He,.qenbHoro Koro, KOTOpble ,Qen5!TC5! Ha Tplll cy6cerMeHTapHblX
nep1110Aa pa3BlllTVIS'I ner1<111e HacTOnbKO A1t1c:PQ:>e- 6poHxa. B HopMe npocser 6poHxos nocreneHHo
peHL\1t1posaHbl , 4TO MoryT 06ecne4111saTb cpyHK- yMeHbWaercs:i OT L\eHTpa K nep1r1cpepV11t1 . '-l111cno 111
L\lllVI BHewHero AbrxaH111s:1 111 ra3006MeHa. nono>KeH1t1e AOneabrX 6poHxoa scerAa cra6111nb-
Ho, TOrAa KaK 6onee MenK111e 6p0Hx111 - cerMeH-
nocmHamanbHoe pa3aumue ne2Kux rapHble 1-1 cy6cerMeHrapHb1e 111Me10T pa3n111YHb1e
B nocTHaTanbHOM nep1110Ae 3asepwaeTcs:t eap111aHTb1 non0>1<eH111s:i 111 sen111Y1t1Hbl sersei;, .
npol\ecc pocTa 111 A1t1¢cpepeH41t1pos1<1t1 CTPYKTYP
ner1<oro. Cpa3y nocne po>f<AeHtirfl "' Ha4anoM Abl-
xaH111s:1 Ha41t1HaeTcfl 1t1HreHcwsHb1rll pocr anbseon.
K nepsoMy roAy >t<Vl3Hlll pe6eHKa AbJXaTenbHa.s:i
nosepxHOCTb nerKVIX ysen1114111saeTcs:t s 3 pa3a.
nepsb1e ,o,sa roAa >t<Vl3HVI pe6eHKa xapaKTep111sy-
10Tcs:t 6blCTpb1M pOCTOM Tpaxe1t1 Ill rnaBHblX 6poH-
XOB, OAHOBpeMeHHO npOlllCXOAlllT A1t1¢cpepeHL\lll-
POBKa 111 ,o,pyrv1x CTPYKTYP, 06pasyioL1.11t1X nerKoe -
Me>t<yT04Hoi.1 111 ::macr1114ecKoflf TKaH111 nernoro, ne-
pecrpofl!Ka Manora Kpyra Kposoo6paweHi.ts:i.
Ba)l(HO OTMeTl!ITb, l./TO ner1<111e HOBopo~eHHblX
6orarbJ n111MQ:>arnYec1<111M111 cocy,qaM111 , np111 3TOM
Kancyna n111MQ:>oy3noB cna6o Bblpa>t<eHa, no3ro-
MY n111Mcpoy3nb1 ner1<111x y .QeTerll nerno no,o,sep-
raioTcs:i r1.1nepnna3111111. B paHHeM AeTcKOM sos-
pacrn (Ao 4-x ner) B 1t1HTepcr1114111111 nerKlllX npe-
o6naAaer HeA111¢cpepeHL.(111posaHHas:t pb1xnas:i
COeAlllHlllTenbHaS'I TK8Hb, no3TOMY nero4Hble
cerMeHrbr y Aererll nepBblX ner >t<lt13Hlil xopowo
orrpaH1t14eHbr , a 1<onnarepanbHb1e Me>Kanbseo-
m1pHb1e CB5131A (nopbl KoHa) Me~y cerMeHraM111
OTcyrcrnyioT. Bee 3TO npeApacnonaraer 1< Ha- JO 1Jl
pyweH11110 6pOHXlllailbHOrll npOXO,D,lllMOCTlll Ill crorll- Puc. 1. AHamoMU'lecKaR cxeMa 6poHxuanbHoao
KVIM aTeneKTa3aM napeHXlllMbl nerK111x. K 7 roAaM aepesa
I - anaBHbte 6poHxu; II - eepxHeooneebte 6poHxu: 1 -
npOL\eCc AVIQJcpepeHL\l-1POBKVI 6pOHXonerol./HblX sepxywe4HbJU ceaMeHmapHbJU BpoHx (cneea -
aneMeHTOB 3asepwaeTcs:i, B neperopOAKax Me>K- eepxywe4H0-380HUU 1 +2), 2 - 3aCJHuiJ ceeMeHmapHbtU
AY cerMeHTaM1t1 noYTlll nonHOCTblO 111c4e3aer co- 6pOHX, 3- nepeOHUU ceeMeHmapHb/U 6pOHX; /11-
eA1t1H111renbHas:i TKaHb , rpaH1-14b1 cerMeHTOB cma- cpeoHeCJoneao(J 6poHx: 4 - namepanbHbtU
)f(li!BalOTCfl Iii nerKll!e no BHeWHeMy BlllAY Iii apx111- ceaMeHmapHb/U 6pOHX (cneea - eepXHUiJ R3bNl<OBb!iJ),
re1<TOH"1Ke He orn1-1l./atorcfl or ner1<1-1x aspocnbtX 5 - MeouanbHblU ceaMeHmapHblU 6poHx (cneea -
HU>KHUU R3b/<IK0Bbli1); IY - HU>KHeooneeoiJ 6poHX1: 6 -
IllOAerll.
sepxywe4HblU (aepxHuu) ceaMeHmapHblU 6poHx, 7 -
B nocne,qy10L1.11t1e ro,Qbl >t<1113Hlll npoi..iecc pa3- MeiJuan6Hb1iJ (cepoe4Hb1/J) 6aJanbHbti1 ceaMeHmapHbJD
B1t1TrM1 nerKl!IX npOlllCXOAl-1T 6onee MeAneHHO Ill 6poHx (cneaa omcymcmayem), 8 - nepeaHuCi
1t1AeT 3a c4eT poem cy6cerMeHrapHblX 6poHxos 6a3anbHb1Ci ceaMeHmapHbliJ 6poHX, 9 - namepanbHblCi
(np111MepHo AO 12-15 ner) 111 ysen111YeH111s:i nnoL1.1a- 6a3BJ7bHb/U ceaMeHmapHb/U 6pOHX, 10- 380HUU
6a3anbHbtCi ceaMeHmapHbli1 6poHx; Y -
Alll anbaeon (AO 25-28 neT). Ha4111Has:i c 40-45-
np0Me>1wmo4Hb/U 6pOHX.
nernero so3pacTa , B nernVl'J.. pa~BWoo\<)1C'il ll'.HBo-
n10rnaHb1e npm-'eccbr.
5poHx111anbHoe Aepeeo cny>1<ll'.T aHaTOM1t11..\e-
cK111M OCTOBOM, eo1<pyr l<OToporo cl:>OPMlllPYIOTCs:I
Bee oc1anbHb1e o6pa3oBaH\/\51 nen<.11\X. BeTsneH\/\e
~~<::)-n~~~ "'""e~' c'~<:>~ '<:l ~a\<..O\-\C>'N\e.Q\-\O~b -

maettbl'1 6pottx \nepsoro nops:tAKa) Aemnc71 Ha ' ~~}Yo'OO. 'l\\l\'l¥-.'l\'C~(.)\\<C'i'!.~"' 'i")~~\\'1-- "0.\\0.""'\~~\l\"''C­
p,ones61! d/!!JJ/111/i!!J/)010 !JOj)}}j)JffJJ )JOJJ~~1:11e - CKVI no;ismieTc~
m11wb s Tex cny4as:ix, KOrAa 6po1-1x
Ha cerMeHrapHble (rperbero nopfl.QKa), nocneA- wecroro cerMeHra orXO,!!#T llHJrB YCThf? C/)8,llHe-
,a,oneeoro 6poHxa.
122
Ce2MeHmapHafl aHamoMUfl 11e2Kux
CTpoeHVle 6poHxos onpeAenSleT CTPYl<TYPY
cerMeHTOB. noA nero4HblM cerMeHTOM cneAyeT
noH1t1MaTb 4acTb AOnVI nerKoro , BKill04alOU,.\eVI
6poHx rperbero nopSlAKa, cerMeHrapHyto apTe-
p1i110, seHb1 , Hepsb1 VI n1t1M¢arn4ecKV1e cocyAbl. B
u,eHTpe cerMeHTa HaXOAJ.1TCSl cerMeHrapHblVr
6poHX, conpOBO)f{,QaeMblVr OP,HOJ.1M€HHOVr BeTBblO
nero4HOVI apTepvieVI . BersVI nero4HbJX seH sa-
H0Men1rnarypa nero11HblX cen1eHTOB (Jloui:.ott, 1949)
noasoe nerKoe
1 - sepxywe4Hb1Vr cerMeHT
BepXHSlfl
2 - 33AHJ.1Vr cerMeHT
,[IOfls:!
3 - neoeAHVIVr cerMeHT
4 - naTepanbHblrA cerMeHT Cpep,HSls:!
5 - M€AVlanbHblVI cerMeHT AOflSl
6 - sepxywe4Hb1Vr 1i1n111 sepXHVIVr cer-
M€HT
7 - M€AV1anbHbll.:1 6a3anbHbliA cerMeHT
8 - nepeAHVllA 6a3anbHblrA cerMeHT HVl>KHSlSl
9 - naTepanbHblrA 6a3anbHblVr cer- p,onSl
M€HT
10 - 3ap,H111ril 6a3anbHb1Vr cerMeHT
Puc.2. Pacnono>KeHue 6poHxonynbMOHanbHblX ceaMeHmoe neaKux u ux omHoweHue K 6poHxuanbHOMY 8epeey.
0 CHOBonono}l{HJ.1KOM yYeHlllSl 0 6poHX03KT3-
3aX S1 Bfls:!€TCs:! P. na3HH€K (R.laennec), KOTOpblVr
3 181 9 roAY snepBbJe on1i1can pacw111peH111e
- HXOB aHaTOMJ.14€CKVI VI o6bS1CHVln pa3BVITVle
3a5on esaHJ.1Sl socnaneHV1eM 6poHxos c 3aAep>K-
ceKpern 1i1 ynopHblM KawneM.
123
p1i1a6enbHbl , 4aCTb Vl3 H"1X 06pa3yeT L\eHTpanb-
Hyto BeHy BHYTPVI cerMeHTa, Apyrne npOXOA5H B
Me}l{cerMeHrapHolA nnocKocrn , KYAa oneKaeT
KpOBb OT ABYX cMe>KHblX cerMeHTOB . B npasoM
nerKOM pa3nJ.1YalOT 10 cerMeHTOB, 8 neBOM - 9.
0rnVl4VleM cerMeHTapHoro crpoeH"1s:! nesoro
nerKoro SlBns:!eTcs:! ro , 4TO s nesoM ner1<0M oT-
cyTcTByer ceAbMOIA cerMeHT, a nepsb11A VI sropo!A
cerMeHTbl 06beA1t1HeHb1 s eA1t1HbllA sepxywe4H0-
33AH"11A cerMeHT.
Ta6Itu1fG 1.
nesoe nerKoe
1+2 - sepxywe4H0-3aAH"1Vr
cerMeHT
BepxH>15!
3 - nepeAH"1Vr cerMeHT
P,OflSl
4 - sepXHVIVr Sl3bl4KOBblrA cerMeHT
5 - HJ.1)f{Hll1Vr s:!3bl4KOBblVr cerMeHT
6 - sepxywe4Hb1Vr 1i1nv. sepxH1i1IA
cerMeHT
7 -OTCyTCTByeT
8 - nepeAHVIVr 6a3anbHblrA cer- HVl>KHSlfl
M€HT AOns:!
9 - narnpanbHblrA 6a3anbHblVr
cerMeHT
10 - 33AHJ.1Vr 6a3anbHblVr cerMeHT
5pOHX03KT33bl (CJ.1H. 6pOHX03KTa3VIVI) - 3TO
croiilKoe pacw1i1peH111e npocsern npeVIMyLI..\ecr-
seHHO cerMeHrnpHblX 111 cy6cerMeHrapHblX 6poH-
xos, o6ycnosneHHoe AecrpyKL\VlelA 111n1i1 Hapywe-
HVleM H€PBHO-MblWe4HOro TOHyca J.1X creHOK,
BCfl€ACTBJ.1e socnaneHVISl, AVICTpOQJJ.1111 , CKI1epo3a
11111111 r111nonna3111111 CTPYKTYPHblX 3neMeHTOB. He-
06xoA1t1Mo nOA4epKHYTb , 4TO lllMeHHO CT01i1K1t1e
aHaTOMlll4eCKlile lil3MeHeHlils:I CTeHKlll 6poHxa OT-
m14afOT 6poHX03KTa3111111 OT cpyHKL\lllOHaJlbHblX
pacw111peH1t1ii1 6pOHXOB, Ha6JlfOAaeMblX np111 06-
paTlllMOl.1 o6CTPYKL\llllll 6pOHXOB Ill o603Ha4aeMblX
2
KaK AlllCTeH3111fl , 111n111 penaKCaL\lllfl 6poHxa .
CornacHO Me)l{,QyHapoAHoi:i cTaT111cT1114ecKol.1
Knacc111cp111Kal.\1t1lll 6one3Hel.1 111 npo6neM, cBs:i3aH-
HblX co 3ADPOBbeM X nepecMoTpa (MK5 X) pa3-
n1114afOT epo>K,QeHHble 6poHX03KTaJbl (Q 33.4) 111
6poHX03KT3Tlll'ieCKYK> 6011e3Hb (J 47.0).
Bpo)l{,QeHHb1e ( neps1114Hb1e) 6poHX03KTa3111111
OTHOCS'IT K lllCTlllHHblM nopoKaM BHyTplllyTp06Horo
pa3s111rns:1. 8b1s:1sns:110Tcs:1 OHi/i He 6onee 4eM y 0,3
- 6 ,5 % 6onbHblX 111 HepeAKO co4eraf0Tcs:i c APY-
flllMlll BpO)l{,QeHHblMlll aHOMallllls:IMlll - CTpenoBlllA-
HblM He6oM , 3as:1Ybei11 ry6oi11, nopoKaM111 cepAL\a 111
cocy.1:1os, He.1:1opa3st-1rneM nm11eao.1:1a, nonosblX
opraHOB Ill T.A.
To4Ka 3peH111s:1, 4TO np11106peTeHHble (BTO-
Plll4Hble) 6poHX03KTaJ111111 5!Bns:110Tcs:1 lllCKnl04111-
TenbHO 111CXOAOM pa3111114Hb1X no csoeill np111p0Ae
1!1HcpeK4lllOHHblX Bocnan111TenbHblX npOL\eCCOB
nern111x, 3a nocneAHllle roAbl npeTepnena 3Ha4111-
TenbHb1e 1/13MeHeHlllS'l. c BH8AP8HllleM B nosce-
AHeBHYIO Knl/IHlll4eCKYfO npaKTlllKY KOMnblOTepHoill
TOMorpacp111111 ycTaHOBneHO, 4TO 6pOHX03KTa3111111
Bb15IBI1Hf0Tcs:1 np111 ps:iAe HacneACTBeHHblX Ja60-
neBaH111l.1, c111cTeMHblX 3a6onesaH111s:ix (KOnnare-
Ho3ax), nepB1114HblX Ill BTOpllll.JHblX lllMMYHOgecp111-
L\lllTHblX COCTOs:!Hllls:!X, socnan111TeJlbHblX 3a6one-
BaHllls:IX KlllW84Hl/IKa, BAblXaHl/1111 TOKClllHOB Iii T.A.,
HO np111 3TOM KJll/IHllll.J8CKlll Hllll.JeM ce6s:i He npOs:IB-
mHOT.
CocTos:iH111s:i accoL\111111posaHHb1e c 6poHX03K-
TaJaM111 (Barker A.F ., 2002)
1. nocT111Hcp8KL\lllOHHble:
1.1. HecneL\111cf:>1114ecKa>1 MlllKpocpnopa
1.2 . M1t1Ko6aKTep111111 ry6epKYne3a
1.3. rp1116b1 poAa Aspergillus
1.4. B111pycb1 (aAeHos111pycb1 , s111pyc Kop111,
s111pyc lllHcpill03HL\bl, Blllpyc lllMMYHOAe¢1111.-1111ra
YenoseKa)
2. HacneAcTBeHHb1e 3a6onesaH111s:i:
2.1 . nepBlll4Has:i L\lllillilapHas:I AlllCKlllHe311151
2.2. Aecf:>111L\111T anbcpa-1 aHrnTp111nc111Ha
2.3 . MyKOBlllCL\lil,Q03
2.4 . Tpaxeo6poHXOMeran111s:i (ClllHAPOM
MyHbe-KyHa)
2.5. 5poHxoMailS'IL\lilH ( ClllHAPOM Blllnbs:iM-
ca-KeMn6enna)
2.6. CeKBecTpaL\llls:I nerKOro
2.7. ClllHAPOM MapcpaHa
2 yaen111YeH111s:i 3a6onesaeMocr111 , oco6eHHO oc-
<l>yHK41<10HanbHb1e pacw1-1peH1<15l cTeHKl-1 6poHxa
HepeAKO pa3Bi.1BalOTC5l np1-1 KpaTKOBpeMeHHOM npe6b1Ba-
Hi.1i.1 i.1HOPOAHblX Ten B 6poHxe, np1-1 T5lJKenblX np11cTynax
6poHx11anbHoi;i acrMbl, TOKCl1Ko-anneprn4ecKoM nopaJKe-
1-1111111 HepBHO-MblWe4Horo annapaTa 6poHxoa 111 nocne
ne4eHl15l ocHOBHoro 3a6011esaHl15l cnoHTaHHO 11c4e3a10T.
124
3. 111MMYHOAecf:>lilL\lilTbl
3. 1. neps111YHb1e:
3.1 .1. r111noraMMarno6ym1HeMllls:I
3.2. 8TOp1114Hble:
3.2.1. np111 XpOHl/IY8CKOl.1 neii1K8Mllllll, Xlll-
MlilOTepan111111 111n111 Tepan111111 L\l'1TOCTaTlllKaMlll
(TpaHcnnaHTaL\11151 nerK111x)
4 . nocneACTBllls:! lllHralls:JL\111111 TOKC1114HblX Be-
w,ecTB 111n111 acn111pal.\llllll
4.1. Xnop
4 .2. 111HOPOAHbl8 Tena 6pOHXOB
5. C111cTeMHb1e 3a6onesaH111s:i:
5.1 . PesMaT01t1AHb1ii1 apTplllT
5.2. C111cTeMHas:i KpacHaS'I son4aHKa
5.3. ClllHAPOM CberpeHa
5.4. Pe4111,ll111a111py){)l.l.1YJe non1.1XOHAPl!1TbJ
6 . npo4111e
6.1. BocnamnenbHble Ja6onesaH111s:i K1t1-
we1.JH1t1Ka (Hecnel.\l11cpl11'-leCKlilii1 fl3B8HHbll.1 KOJ1111T,
6one3Hb KpoHa)
6.2 . C1t1HAPOM 71Hra (sroplll4Has:i L\li1I11t1ap-
Has:i AlllCK111He3111s:i)
6.3. ClllHAPOM )f(enTblX HOrTeill ()f(e.nTb1e
HOITll1 Iii n111M¢eAeMa)
Kn1t1Hl/IYeCKYIO 3Ha'-ll/IMOCTb 6pOHX03KT33bl
(He3aBlllClllMO OT lllX npo111CXO)l{,QeH111s:i) np11106pe-
Ta10T Ill/IWb TOrAa , KOr,Qa B HlllX pa3Bli1BaeTCS'l lllH-
cpeKL\11151 . <t>opM111pyiow,111lllcs:i B 6pOHX03KTa3aX
XpOHVl4eCKlllii1 rHoil1HO-BOCnan111TenbHbllil npol..\eCC
lllMeeT csoeo6paJHYIO 1<J11t1Ht14ecry10 KaprnHy,
cTaA111111 pa3Bli1Tllls:i 111 conposo)l{,QaeTcs:i JHaY111-
TenbHb1M111 lil3MeHeHVls:!Mlil cf:>YHKL\1!1111 BHyTpeHHlllX
opraHoB 111 c111cTeM scero opraHll13Ma , 4To no3so-
ns:ieT paccMaTp111saTb VIHQJlllL\lllPOBaHHble 6poH-
X03KTa31/1111 KaK nero'-lHOe 3a6onesaH111e - 6poH-
X03KTarn'-leCKYfO 6one3Hb.
TaKVIM o6paJOM , 6poHX03KTarnYecKas:i 60-
neJHb - 3TO neroYHoe 3a6011esaH111e, paJBlilsaio-
w,eecs:i Ha OCHOBe 111Hcp111L\lilPOBaHHblX 6pOHX03K-
Ta3111lll (Bpo)l{,QeHHblX 111Illll np11106peTeHHblX) Iii
npos:!BilHfOW,eecH xpOHVIY8CKlllM rHoillHblM 6poH-
XlllTOM B OTAellbHblX cerMeHTax 111n111 Aone (AO-
m1x) nerKoro, c nocne,QylOW,1!1M pacnpocTpaHe-
HVleM 111HcpeKL\lllOHHoro (socnamnenbHoro) npo-
L1ecca Ha napeHx111My 11erK111x.
HecMoTps:i Ha MHOro1.J111c.neHHb1e 111ccneAo-
saH111s:i 6pOHX03KTaTlil'-leCKOii1 6one3Hlil , ee lllCTlllH-
Has:i pacnpocTpaHeHHOCTb cpeAVI HaceneHl/ls:i AO
HacTOs:ILl.lero speMeH111 HelilJE!ecTHa . BMecTe c
TeM, no nporH03Y s XXJ seKe cne,L1yeT O)f(lil,QaTb
no)f(HeHl;lblX cpopM 6pOHX03KTaTl!l4eCKOll1 6one3-
Hlll, BCI18ACTBlile pocTa pecn111paTOpHblX B1!1pyc-
Hb1X 111HcpeKL\lili/1 (oco6eHHO Ha cpoHe CnVl,Q) VI
Ja6onesaeMOCT111 TY6epKYne3oM nerK111x, peJKoro
coKpaLJ..\eH111s:i onepaTlllBHblX BMewaTenbcTB no
noso,D,y 6poHX03KT83111 ill B ,D,eTCKOM Ill no,D,pOCTKO-
BOM B03pacTe Ill npeo6na.o.aHllllll KOHCepsaTl/IBHOV!
TaKTl/IKlll B ne4eHllllll 6onbHblX c 6poHX03KT8Tl.14e-
CKOill 6one3Hbl0.
3Tl10!10fMR 111 nATOrEHE3
Be.o.yLJ..\eVI np1114l11Hoil! pa3BlllTlll5l 6poHX03KTa-
Tll14ecKoill 6one3Hlll s:ismiercft nopa>1<eH111e Abtxa-
TenbHblX nYTeVI B paHHeM ,D,eTCKOM B03paCTe ,
KOrAa np0Aon>1<aercfl aKrt.iBHbll.1 pocr 11 A"1Q:)(pe-
peH1..1111poBKa nero4HblX CTPYKTYP· V1MeHHO B 3TOT
nep1110A nerKllle 4pe3Bbl4ali1Ho 4YBCTBll1TenbHbl K
nto6blM BHeWHll1M 803,D,eillcTBll1SIM , oco6eHHO ll1H-
tj:>eK4lllOHHblM . Pa3n1114Hb1e s111pycHb1e 111 s111pycHo-
6aKTep111anbHb1e 111HcpeK4111111 (Kopb, rp111nn , KOK-
ntow} , OCTpble rHOVIHO-,D,eCTPYKTlllBHble npo4ecCbl
nerKlllx, a TaK>Ke croll\K111e aTeneKTa3bl nero4HoV!
TKaHl.1 nocne nepeHeceHHblX ocTpb1x nHeBMOHlllill ,
B HeManoll\ CTeneH111 cnoco6cTBYIOT 803Hll1KHOBe-
HllllO 6poHX03KTa3111V! y ,D,eTeV! . Ba>1<Hyto ponb np111
3TOM 111rpa10T KaK TOKC"14eCKOe nopa>1<eH111e Heps-
HO-Mb1We4Horo annaparn 6poHxos, Ta K 111 nps:i-
Moe nospe>K,D,eH111e CTeHKlll 6pOHXOB lllHQJeK4lllOH-
HblMll1 areHT8Mlll , YeMy cnoco6CTBYIOT aHaTOMO-
QJlll3lllOnOrlll4eCKllle oco6eHHOCTlll ,D,eTCKOrO nerKo-
ro : cna60CTb 6pOHXll18TibHOV! CTeHKlll , ,D,etj:>1114111r
cypcpaKTaHTa, Bblpa)l{eHHa5l pea1<~1115l n111Mcparn-
4ecKoro annaparn c rnnepnna3111eV! m1tMtj:>oy3nos
111 C,D,asneHl!leM 6poHXOB 1!13BHe ysenl.14eHHblM ll1
n111Mcpoy3naM111 , a TaK>Ke oco6eHHOCTlll peaKT111s-
Hocr111 111 pe3111creHrHocrn ,D,ercKoro opraHl!13Ma -
BblCOKa5l peaKTll1BHOCTb B C04eTaHllllll c Hlll3KOtit
conpornBmleMOCTbto K 1t1HcpeK41t1111.

IlaTOfCHC3 6 pOHXOJ K Ta3HU ( c xeMa)

---------------..
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Ofrrypamu1 6poHXOB MoKpoToll.

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Cy)l(eHJ.Ie rrpocsern 6poHxa, nmoBeHTHJUlll;IDI ,noIDI nernoro

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TIOBblillCHMe Btryrp116p01-IX.liaJI:bHOro ,Ua.BJieHIDI ( CeKpeUIDI MOKpOTbl)

•
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HeHlllL1 srnns:teTCS! CHl/l>KeH111e )f{l/13HeHH0'4 eMKOCTl/I
nern111x. KaK npas111no , y 6onbHblX 6poHX03KTa-
3111S'IMll1 111MelOTCs:I He TOnbKO pecTpll1KTll1BHble 1113-
MeHeHl..Ul <l>B.[\ , HO 111 o6CTpyKTll1BHble, CB513aHHble
c 6poHxocna3MOM 111 Han1114111eM eocnan111renbHO-
ro ceKpeTa s npocseTe 6poHXOB, nosToMy 06b-
eKT111BHas:1 01...1eHKa CTeneHll1 Bblpa)f{eHHOCTll1 Ha-
pyweH111l71 <l>BA 803MO)f{Ha J1111Wb B CTaAll110 pe-
Mi.1CCll1111 3a6oneeaH111s:1 .
np111 111CCJ1eAOBaHll1111 cep,D.e4HO-COCYA111CTOL1
CltlCTeMbl Ha paHHltfX CTa~ltl51X 3a6onesaHltlfl OT-
KnOHeH1t1L1 He Bbls:tBns:teTCfl. np111 nporpeCC111pOBa-
Hll1111 6poHX03KTaTll148CKol71 6one3Hll1 Ba)f{HO 06-
pa[UaTb BHll1MBHll1e Ha lt13MeHeH11151 3neKTpoKap-
A1t10rpaMMbl 111 Bblpa)f{eHHOCTb nero4Hai.1 rnnep-
TeH3111111 : Ham14111e nplll3HaKOB CTOi.1Kol71 rnnepTpo-
¢>111111 npaBblX OTAenos cepA1...1a Ha 3Kr 111 ysen111-
4eH111e cpe,D.Hero ,D.asneH111s:1 s nero4HOLll apTep1111-1
BblWe 35 MM PT. CT no ,D.aHHblM 3XOKap.o,111orpa-
tj:l111111 CB111,D.eTeJlbCTBYIOT 0 cpopM111poeaH111111 nero4-
HOfO cep,D.1...1a .
PeHTreHonor1114ecKoe 111ccne,D.0BaH111e nerK111x
- O,D.lllH 1113 Be,D.y[Ull1X MeTOAOB ,D.111afHOCTl/IKl/I
6pOHX03KTa3111l71 , np1114eM o6b8KTl/IBHas:t 01...1eHKa
Bbls:IBileHHblX 1113MeHeH111i.1 MO)f{eT 6b1Tb ,D.aHa
TOJlbKO no peHTreHOBCKi.1M CHll1MKaM , BblnOnHeH-
HblM B nep1110A peM111cc111111 3a6onesaH111s:t.
8 HaYanbHo'4 cTa~1111t1 3a6onesaH111fl Ha o6-
30pHblX peHHeHorpaMMaX 6pOHX03KT831/11/1 Hlll-
48M ce651 He npo51BJ15llOT. no Mepe nporpeCClll-
posaHLtt51 3a60.nesaH1t15! OTMe4aeTcs:t yc111neH111e
nero4Horo p111cyHKa 3a C4eT nep1-16poHx111anbHOro
cKnepo3a. ,D.m1 6onee Ts:t)f{enblX nopa)f(eH111l71 xa-
paKTepeH ceT4aTbll71 l/lfllll s:t4el/ICTbll71 p111cyHOK Ha
cf:ioHe 3aTeMHeHl/ls:I , KOflbL1eBll1,D.Hb1e TeHlll, l/IHOf,D.a
c ropLtt30HTaflbHblMi.1 ypoBH51Mlll )f(lll,D.KOCT111 , cer-
MeHTapHble 11111111 ,D.onesb1e aTeneKTa3bl. Ecn111
nopa:>KeHbl Hlll>KH£11e OT,£1enb1 nern111x, TO Ha o6-
30pHblX peHTfeHorpaMMax 3H1 1113MeHeHllls:I BlllA-
Hbl TOnbKO np111 npaBOCTOpOHHeM nopa)f{eHl/1111 ,
cnesa OHi/i CKPblBatoTCSl 3a TeHblO cep,D.1...1a . Koc-
eeHHblM nplll3HaKOM areneKTa3a H111)f(Hl/IX OT,D.e-
JlOB nern111x s:1sns:1eTcs:1 Bb1c0Koe CT05IH1t1e KYnona
A1t1a¢>parMb1 111 cMeL1.1eH111e cepp,1...1a s nopa)f(eHHyto
crnpoHy. 60K0Bble peHTreHorpaMMbl B ,D.aHHOM
cny4ae noMoraeT yT04H111Tb All1arHo3.
P1.1c. 3. npstMast peHTreHorpaMMa (a):
3aTeHeH1.1e e npoeKu,1.11.1 HM>KHei:i .QOill.1 neeo-
ro nerKoro, yMepeHHoe cMew,eH1.1e cpe.Qo-
cTeH111st eneao; 6oKoaast peHTreHorpaMMa
(6): BHKapHaSI rnnepTpocfJHSI aepxHerli .QOJlH
neeoro nerKoro, aTeIJeKTa3 Hll'l>KHeM .QOill.1
neaoro nerKoro (yKa3aH cTpenKoi:i).
128
5pOHXOCKOnl148CKOe wccne,D.oBaHwe y
6onbHblX c 6poHX03KT831/1S'IMlll S!BJ151eTC91 o6si3a-
TeilbHblM 111 no3sons:1eT 01...1eHlllTb pacnpocTpaHeH-
HOCTb 111 xapaKTep socnaneH111s:t cn1113111cTol71 o6o-
f104Kll1 6pOHXOB (3HP,06pOHXl/ITa} , BblS'IBlllTb JlOKa-
Illl138l...lllllO lllCT04HlllKa nocrynneHll1S'I rHOMHOV! MOK-
poTbl , ,D.e¢>opMa1...1111to 111 c6n11t)f{eH111e ycTbeB cer-
MeHTapHblX 6poHXOB , o6Hap~lt1Tb onyxonb l/IJll/I
l/IHOPO,D.HOe Teno. y B3pOCJ1blX 6poHXOCKOnll1to
BblnOflHS'llOT ¢>1116po6pOHXOCKOnOM no,D. MeCTHOi.1
aHecre31i1eiil , .QernM noKaJaHa no.QHapK03Ha~
6poHxocKon111s:1 )l(eCTKlllM 6poHXOcKonoM. Bo spe-
M51 6poHxocKon111111 Heo6xop,111Mo B351Tb MOKpory
Ha 6aKTep111onor1114eCKOe 111 4111TOJ10fll148CKOe lllC-
cne,D.OBaHl/le, BblnOJlHIATb 6111onc111to Cf11/13111CTOVi
6poHxa 111 3asepw11tTb 111ccne,o,osaH111e caHa1...1111el71
6poHXl/lailbHOfO ,CJ.epesa nopa)f(eHHOV1 CTOpOHbl.
.O,o nocne,D.Hero speMeH111 OKOHYarenbHbrM
MeTOAOM p,111arHOCTlllKl1 6pOHX03KT83111Vi 6bina
6p0Hxorpatj:l111si . Ha 6poHxorpaMMax 6poHX03K-
ra31111-1 onpe,o,en.s:itorc.s:i KaK crol71K1t1e pacw111peH1t15!
6pOHXOB , nplA KOTOpblX ,D.l/laMeTp nopa)f(eHHOro
creona paseH 111n111 npesb1waer ,D.lllaMeTp 6poHxa
npeP,blAYLl.lero nopHAKa . 6poHxorpacp111YecKoe
111ccne,D.osaH111e no3sons:1eT ycTaHOBlllTb n0Kan111-
3a41t1to, pacnpocrpaHeHHOCTb 111 rnn 6poHX03KTa-
3oB (1...1111Ill/IHAP1i148CKl/le , MeWOT48Tb18, BepeTeHO-
o6pa3Hbl€ 111n111 cMewaHHbre) , 06Hapy)f(WTb p,e-
cpopM111pytoL1.1111i.1 6pOHX11T, 04eHll1Tb cpyHKl...llllO-
HaflbHble HapyweHl/l51 6poHx111anbHOro ,o,epesa .
npoTlllBOnOK83aH1118M ):\JlSl 6pOHXOrpacp11111
s:1sns:1ercs:1 : TS'l)f(enoe 06L1.1ee cocT05IH1t1e 6onbHO-
ro , Bb1c0Kas:1 n111xopa,D.Ka , nero4Hoe KposoTe4e-
H111e , 60ilbWOe KOJ11114eCTBO MOKpOTbl, ry6epKY-
ne3 B tj:la3e 06ocTpeH111s:1 111 T5l)f(enb1e ,o,ereHepa-
T1t1BHb1e nopa)f(eHlllS'I BHyTpeHHlllX opraHOB.
P111c. 4. 6poHxorpacfJ1.1S1. .QayxcTopoH·
HSISI 6poHxorpaMMa: aTeIJeKT3Tl!tlleCKl.1e
CMeWaHHble 6pOHX03KT33bl (U,111Illl'IH.Qp1!1'"1e·
CKll'le lr1 MeWOTll3Tble) cpeAHeH 1.1 Hll'l>KHeM
.Qon1.1 npaaoro nerKoro; acne.QCTBMe o6"b·
eMHOro yMeHbWeHl.1SI cpe.QHeH lr1 Hl!t>KHeM
AOill.1 npaBblM BepxHe.QoneBOM 6poHX
CMew,eH BHl.13.
nos:1eneH111e cn111paJ1bHblX KOMnbtoTepHblX
TOMOrpacpoB 3H84111T8JlbHO pacw111p111n111 B03MO)f(-
HOCTll1 paHHeL1 Ill TO'-IHOV! A1118fHOCTlllKl/I 6poHX03K-
Ta31111/1 . 0 KOMnbtoTepHblM TOMOrpaMMaM Alll8fH03
6pOHX03KTB30B CTaBSlT B TOM cny4ae, ecn111
sHyrpeHHl!fl:f p,111aMeTp 6poHxa 6onbwe P,ltfaMeTpa
conposo)f(,!J.a10L1.1el71 op,Ho111MeHHoli1 aprep111111 , a
nep111cpep111YecK111e 6p0Hx111 npocne)f(111BatoTcs:1 s 1
CM OT nosepXHOCTl/I KOCTanbHOi.1 l/lfll/I Me,D.1118CTlll-
HanbHOM nnespbi. 3TOT M8TOA B HaCTOSl[Uee
speMS'I cran OCHOBHblM B ,D.1118fHOCTll1Ke 6poHX0-
3KT8Tl/l4eCKOl/1 6one3Hll1 Ill npaKTll148CKlll BblTeCHlllJl
6p0Hxorpacp111to .
P1.1c. 5. KoMnbtOTepHafl TOMorpacp1.1H.
 L_\111m1HAP1114eCKllle 6poHX03KTa3bl nepep,He- Bbl51Bf151KJTC51 l..1111flll1HAp11148CKll18 Ill M8WOT48Tbl8
o cerMeHrn(S111) npasoro nernoro (yKa3aHbl 6pOHX03KT83bl, CTeneHb lllX pacnpoCTpaHeHHOCTll1
CTp8IlKOVl) . pa3!11114Ha, H8P8AK111 2-x cTOpOHHllle nopa)f(8Hlll51,
xapaKTepHO nos:tBJ18Hll18 opraH11148CKlllX 1113M8H8-
PHc. 6. KoMnbtoTepHaff TOMorpacpHff.
HlllVl napeHXlllMbl nerKlllX B B111A8 ¢1116po3a, 3MQJll1-
a - MeWOT4aTble 6pOHX03KTa3bl cpeAHelit ""
3eMbl Ill aT8Jl8KT8308 . .Qo6111TbC51 CT01i1Ko1i1 peMll1C-
HM >KHeilt AOIIH npaBoro nerKoro, eAHHH4-
Cll1til KOHC8pB8TlllBHblMlll Meponplll51Tll151Mlll y)f(e He
H ble l..1"1JllllHAPH4eCKHe 6pOHX03KTa3bl Hlll>K-
yAaeTc51. Bo speMs:i peM111cc111111 coxpaHS'18TC51
HeM AOmt nesoro nerKoro; 6 - aTeIJeKTaTH- sna)f(Hblill Kawenb, H8A nopa)f{eHHb!Mlll OTAenaM111
YecKMe L\l1Ill1HAPW~ecKllle 6pOHX03KTa3bl nerKlllX BblCnyw111BaKJTC5I Bfla)f(Hble Xplllnbl, KOm-1-
HM>KHel:t AOill-1 nesoro nerKoro. 48CTBO KOTOpblX yMeHbWa8TC51 nocne ne48H11151,

no AaHHblM 6pOHXOrpaQ:>111111 Ill KOMnbKJTep-

HO nOJlHOCTbKJ xp111nb1 He 111C4838KJT. y 6onbHblX
3TOll1 rpynnbl pa3B\.1B88TC51 flOCT051HHa51 ,[\b\Xa-
ol.1 rnMorpa¢111111 n0Kan111Ja1..111151 6poHX03KTa3111ill
0 48CTOTe BblrI151AlllT CJ18AYKJli.\lllM o6pa30M: TeJlbHa51 HeAOCT8T04HOCTb.
a li.\e scero nopa)f{aeTc51 Hlll)f{H5151 p,on51 111 513bl4- Ill cTaAi.1ff - sucu,epanbHb/X OCflO>KHeHUU.
Bble cerMeHTbl nesoro nernoro, p,anee cneAY- ,IJ,1151 Ill CTaAl.-1111 6pOHX03KTaTlll4eCKOVl 6one3Hlll
T Hlll)!(Hs:ts:i AOI151 npasoro nerKoro , cpe.QHfls:t AO- xapaKTepHblM 51BJ1518TC51 nOCT051HHblVI Kawellb c

. Hlll)f(Hs:tfl 111 cpeAH5151 AO!llll npasoro nerKoro, BblAeneHllleM rHOVlHOill MOKPOTbl OT 100 MJl 111 60-

aepXH5151 p,on51 npasoro nerKoro, TOTanbHoe no- nee 3a cyTKll1, MOKpOTa 3aCTOillHas:t , c pe3Kll1M He-

pa>1<eH111e npasoro nerKoro. 0AHOCTopoHHllle np11151THblM 3anaxoM, 4acrn KposoxapKaHbe , He-

6pOH X03KTa3111111 BCTpe4aKJTC51 B 70 % cny4aes, peAKO nepeXOAs:lW,ee B ner04HOe KpOBOTe4eH111e,

Bblp8)1{8Hbl npo51BneH11151 rHOillHoVI 111HTOKCti!K8l..lllllll.
49yxcrnpoHH111e - s 30 %.
KaK npas111110 , onpeAen51KJTC51 crnt.:1K111e Hapywe-
Hlll51 co cropoHbl BHyrpeHHll1X opraHos : nero4HO-
KllMHt1L/ECKOE TEL/EHt1E t1
cepp,e4Hafl HeAOCTaT04HOCTb c ¢opM111posaH111-
OC06EHHOCTt1 HEKOTOPblX <POPM
eM 11ero4HOro C8PAL1a, BblCOK851 nerol.fHas:I rlll-
E5POHX03HTAT/11YECKOM E50!1E3H/11 nepTeH311151, aM111no111Ao3 no4eK. PeHTreHonorn4e-
no K.f1111Hlll48CKOMY T848HlllKJ MO)!(HO Bbl.Qe- CKll1 111MeeTC51 P.BYXCTOpOHHee nopa)f(8Hllle nerKtitX
ITTb 3 CTaAllllll pa3BlllTlll51 6poHX03KTaTlll48CKOVl C L!lllI1111H,D,plll48CKti!Mlll 111 MeWOT48TblM!lt 6pOHX03K-
6one3Hlll . Ta38Mll1, Bblpa)f(eH ¢1116po3 f18rKlllX. 50JlbHble B
I cTa.QM.ff - Hal/aflbHaR , xapaKTep1113yeTc7! 3TOVI CT8,llllllll , K8K npas111no , H8TPYAOCnoco6Hbl ,
enocTOS'IHHblM KawneM c BblAeneH111eM CKYAHO- nporHo3 3a6oneeaH1115I nnoxot.:1 .
Kon1114ecTsa Cn1113111CTOVl lllJllll CI11113111CTO-
B 4tACne oco6b1x Knll'IHtA4ecKtAX Q'.)opM Bb!Ae-
ol.1H OVl MOKpOTbl , P8AKlllMlll o6ocTp8Hlll51Mlll mu-0T TaK H83blBaeMb18 "cyx111e 6pOHX03KT831.11111 " 111
~poHXOnHeBMOHllllll B nopa)f(8HHOM OTAene ne~ " Maflble" Q:>opMbl 6poHX03KTa3titt.:1 .
oro, xopOWlllM 3QJQJ8KTOM OT KOHCepBaTlllBHOlll .Qn51 "cyx111x" 6poHX03KTa3oB xapaKTepeH
-epan111111 111 p,n111TenbHblMlll (lllHOrAa rop,aM111) pe- KaWeilb co CKYAHOl.:1 MOKpOTOVI , KposoxapKaHbe ,
cc111s:iM111 . Bo speM51 peM111cc111111 y TaKlllX 6onb- pe1..1111A1t1Bbl nero4HblX KpOBOT848H111t.:1 , HapacTaKJ-
Kawenb Ill Bb1A8f18Hllle MOKpOTbl npeKpaLLJ,a- li.\a51 OAblWKa 111 Ab1XaTenbH851 Hep,ocTaT04HOCTb.
cs:i , a xp1..mb1 s nerK111x oTcyTCTBYKlT. Ha 06- )J.1151 " MallblX" Q:>opM 6pOHX03KTa3111Vl xapaK-
pH blX peHTreHorpaMMaX 8 Ha4aflbHOVI CT8A111111 TepHa M0381114H851 nOK8Jlll138l..111151 B OTAenbHblX
8 H8Hlllt.:1 He onpeA8I1518TCs:!, n11160 OTM84aeTC51 cerMeHTax, 48CTble ABYXCTOpOHHllle nopa)f(eH111s:i,
e3Ha4111TenbHOe yc111neH111e nero4Horo p111cyHKa Han1114111e Ae¢opM111pyiow,ero 6p0Hx111Ta B cer-
3a C48T nep1116pOHXlllaflbHOrD CKI18p03a . np111 MeHTax, CM8)f(HblX c nopa)f(8HHblMll1. "Mal1ble"
n bKJTepHot.:1 TOMorpa¢111111 (6p0Hxorpa¢111111) Q:>opMbl xapaKTeplll3YKJTC51 Heo6paTlllMOCTblO,
s:! BI151KJTC51 l..llllI1111HAP11148CKlll8 6pOHX03KT83bl C CKflOHHbl Knporpecc111posaH111KJ. KoHcepsar111eHa5l
-0KaJ1 1113a1..1111et.:1 npo1..1ecca s OAHOVI, pe)f(e ABYX repan11151 nplllHOClllT Jlll1Wb BpeMeHHblill 3Q:>Q:>eKT,
.:,OlllX nerKoro. Km11H1114ecKlll AblXaTenbHOill He- 3aAa4111 )f(e onepa1111sHoro ne4eHll151 ocno)f{H~KJT­
..:OCTaTo4HOCTlll H8T, HO OHa MO>K8T 6b1Tb Bbl51B-
c51 1113-38 pacnpocTpaHeHHOCTlll naTonor1114ecKoro
-eHa np111 lllHCTPYM8HTaflbHOM lllCCI18AOB8Hllllll npoL1ecca, 4TO He no3som1eT BblnOllHlllTb paAlll-
3 . 3Ta Q:>opMa Ja6onesaHll151 o6bl4HO Ha6nKJ- KanbHYKJ (s CMb1cne YAaneH1115I scex 1113MeHeH-
..:aeTc51 s A8TCKOM so3pacrn. HblX cerMeHTos) onepa1..1111KJ .
II cTa.QM.ff - Bblpa>KeHHbJX KnuHul/ecKux npo-
e Hu iJ. nepeXOA BO BTopyKJ CTaAlllKJ xapaKTe-
/l,Ucj)(jJepeHU,UGflbHblU auazH03
8 TC51 nocT051HHblM KawneM co CI11113111CTO-
npaKTW-leCKOe 3H84eHll1e lllM8KJT Bpo~eH­
-Ho ill 111!1111 rHOil!Hoill MOKpOTOVI, KOI111148CTBO K0-
Hble nopoKlll Ill aHOMaJlllllll pa3BlllTlll51 6pOHXOJle-
1.1 MO>K8T AOCTlllraTb 50 - 100 Mil 3a CyTKlll ,
rol.fHOro annapaTa 111 OTA8IlbHb1e HacneACTBeH-
- - fllOA88TC51 KposoxapK8Hb8, B03MO)!(H0 nero4-
Hble 3a6onesaH1115l.
- oe i<pOBOT848Hlll8. 060CTpeHlll51 CTaHOB51TC51 ce-
Bpo)f(AeHHble nopoK111 111 aH0Man111111 pa3BIATlll51
b!Mlll 111!1111 B03HlllKalOT 4aW,e 2-3 pa3 B roA,
rpaxe111, 6poHxos 111 napeHXlllMbl nerK111x, conp~­
8 K8KJT C 51BI18Hlll51Mlll lllHTOKClllK8L\111111. np111
BO)f(AaKJLLJ,1t1ec51 o6pa3088Hlll8M 6pOHX03KTa3111111 ,
bKJTepHOVI TOMOrpa¢111111 (6p0Hxorpa¢111111)
129
Bbls:!BmHOTCs:I y 9-10 % 6onbHblX c XpOHlll4eCKlllMlll
socnamnenbHblMlll 3a6onesaH111s:iM111 nerKlllX.
Cio.Qa MO>KHO OTHeCTlll rnnonna3111io nernoro,
ClllHAPOM B111nbs:1Mca-K3Mn6enna , Tpaxeo6poH-
xoMeran111io 11 ceKsecTpau,111io nernoro. np111 spo-
>K,D,eHHblX aH0Man111s:ix nnoxoL:i ,t:\peHa>K MOKpOTbl
111 HapyweH111s:i KposocHa6>1<eH111s:i TKaH111 nernoro
cyw,ecrsy10r 1113Ha4anbHO. f1106as:i pecn111parop-
Has:i 111HQ:>eKu,111s:i nposou,111pyer pa3s111r111e rHOL:iHoro
6pOHXll!Ta, n03TOMY Knl/IHll!Ka 6pOHX03KTaTlil4e-
CKOl.1 6one3Hl!I npos:iam1eTcs:i y>Ke B paHHeM .QeT-
CKOM B03pacre.
runonna3UR ne2Koeo 111Meer MHO>KeCTBO
sap111aHros: npocras:i rnnonna311151 , KlllCT03Ha51 rn-
nonna3111s:i , rnnonna311151 .Qon1i1 nernoro 1i1n111 scero
nernoro. Hepe.QKO nmonna311151 nernoro co4era-
ercs:i c nopoKaM111 pa3s111r111s:i cep,Qu,a 111 cocy,t:\OB.
npocmaR eunonna3uR neeKoeo - nopoK
pa3BlllTlll51, xapaKTep1113YIOl.l.!lllL:iC51 yMepeHHblM
yMeHbWeH1i1eM napeHXlllMbl nerKoro 111 pe,QyKu,111ei:1
serneL:i 6poHx1t1anbHoro ,[\epesa AO 5-10 (10-14)
reHepau,111111 BMeCTO 18-24 B HOpMe. KnlllHlll4eCKa>i
Kapr111Ha srop1t14Horo HarH0111TenbHoro npou,ecca
np1t1 npocrow nmonna3111111 nerK111x npos:ianHeTcfl a
paHHeM ,QeTcKoM B03pacre. Aern orcralOT s ¢111-
31114ecKoM pa3s111r111111. XapaKTepHblM >iBnHercs:i
8ClilMMeTplils:! rpy,QHOL:i KneTKlil c 3ana,QeHli1eM lil
ynnoll!eH111eM ee Ha cropoHe nopa)f(eH111s:i, Ha.Q
nopa>KeHHblM nerK111M nepKYTOPHblL:i 3BYK yKOpo-
YeH, AblXaHlile ocna6neHo, np111 06ocrpeH1111t1
rHOlllHoro 6pOHXlllTa Bb1cnyw111Ba10TC>I JlOK8Jllll30-
BaHHble sna>KHble xp111nbl , B cra,QllllO peMl/ICClillil -
cyx111e xp111nbl. OCHOBHblM M8TOAOM ,o,111arHOCTli1Klt1
3roro nopoKa Hsm1erc>1 6p0Hxorpa¢111s:i 111n1t1
KOMnblOTepHaH TOMorpacp111s:i (Heo6XOAlilMa non-
Ha>i peKOHCTPYKLJ,11151 6pOHXlll8JlbHOro ,Qepesa).
Kucmo3HaH eunonna3UH (ClilHOHlllMbl: no-
n111K111cT03, corosoe nernoe) - nopoK pa3s111r111s:i
nernoro 111n111 4acr111 era, c ¢opM1r1posaH111eM KlilC-
T03HblX nonocrei/1 Ha pa3nll1YHblX ypoBHHX 6poH-
x111anbHOro p,epesa.
P11tc. 7. K11tcroJHas:t rnnon11aJ11ts:t 11esoro
11erKoro.
.QeyxcropoHHsu1 6p0Hxorpa<t>11ts:1: repM11t-
HBJlbHb1e OT,QeJlbl cerMeHTapHblX 6poHXOB
11eeoro 11erKoro pacw111peHbl e B11t.Qe «rpo3-
AbeB BlllHorpaAa»; BTOplltYHble "13MeHeHl!tSI
npaeoro 11erKoro - ~1111111tHAP11tYecK11te6poH­
xo3KTa3bl B HW>KHeM AOne nernoro.
Heo6XOAlllMO OTMeTl/ITb, YTO np111 Kll1CT03HOl/1
r111nonna3111111 HapyweH111e pa3s111r11151 MO)f(eT Ka-
caTbCH TOJlbKO 48CTlll nerKoro, np111 HOpMailbHO
c¢opM111posaHHblX ocranbHblX AOilHX nerK111x lil
ror,Qa KlllCT03Has:i rnnonna3111s:i nerKoro ,Qmnenb-
Hoe BpeMH MO)f(eT npoTel<aTb 6eCClllMnTOMHO.
Bpo>K,LJ,eHHas:i rnnonna3lils:t ,Qon111 nerKoro
(Yall.le cnesa) npo.srnm:1eTcH 1<m1H1111<oi:1 xpoH111Ye-
CKOro HarH01.-nenbHOro npoLJ,ecca c paHHero ,QeT-
CKOro Bo3pacra, ror,Qa KaK rnnon11a31r1s:i scero
nernoro ,Qonroe speMs:i MO>KeT npoTeKaTb 6ec-
130
ClllMnTOMHO Ill Bbl51BJ151TbC51 KaK HaXO,QKa np111 nna-
HOBOM peHTreHonornYeCKOM 111ccne,QoBaHlillil.
nplil BHeWHeM OCMOTpe y 60JlbHblX C rnnonna-
3111el/I nerKoro onpeAenHercH Ae¢opMaLJ,lilH (3a-
na,t:\eH111e) rpy.QHOl/1 KneTKlll Ha cropoHe nopa)f(e-
H111s:i , cy)f(eH111e Me)f(pe6epHblX npoMe>KyTKOB Ill
He60JlbWOe onyll!eHl/le yrna nonaTKlll . np111 rnno-
nna3lillil scero nerKoro peHrreHonornYecKoe 111c-
cne,QosaH111e sb1smn71er JaTeHeH111e 111 yMeHbwe-
H111e reM111ropaKca c pe3KlilM cMell!eH111eM opraHos
cpe,D,ocreHl'1.s:J s nopa)!{eHHYIO cropoHy, a npw r111-
nonna3111111 p,on111 nerKoro - yMeHbWeH111e reM111To-
paKca c yMepeHHblM CMell!eH111eM cpeAOCTeHll!Sl B
cropoHy He,Qopa3s111roi/1 .Qon111 nerKoro. XapaK-
TepHa Bll!KapHaH r111neprpo¢1115l KOHrpanare-
panbHoro nerKoro (Ha npornsonono)f(HOlll cTopo-
He). OcHOBHblM MeTOAOM p,111arHOCT111KL1 ,QaHHoi/1
naTOJlOrllllil 518JlS1eTC5l KOMnblOTepHa5l TOMOrpa-
cj:>lll5l c BHyrp111seHHblM KOHTpacrnpoBaH111eM co-
cyp,oe nernoro.
P11tc. 8. ri,mon11a311ts:t 11eeoro 11erKoro.
KoMnbt0TepHaff TOMorpa<t>11tst (a - aKc11tailb-
Haff npoeK~lltst, 6 - <t>poHTa1lbHaff npoeK-
UHst): rnnon11a3111st 11eeoro 11erKoro, Ha Mec-
Te neeoro 11erKoro - KlltCT03Hble 06pa3oea-
H11tff, pe3KO Bb1pa>KeHHaff B11tKapHast rnnep-
Tpoqrnst npaeoro nerKoro, opraHbl cpe,Qo-
cTeHHst CMe~eHbl BJleBO.
P111c. 9. f1itnon11a3111st Hlll>KHeiil A01111t ne-
eoro 11erKoro.
KoMnbt0TepHast TOMorpa<t>11tst: rnno-
n11a311tst Hllt}l{Heilt ,QOJ111t 11eeoro 11erKoro (yKa-
3aHa CTpellKOr.1), BlltKapHaR rnnepTpo<t>11tst
npaeoro nerKoro, opraHbl cpeAocTeHHst
cMe~eHbl eneeo, eepxHstst A01lst neeoro
nerKoro npaKT11tYecK111 JaH11tMaeT Beeb ne-
Bbliil reMlllTOpaKc.
Cutt<JpoM BunbRMca-KeMn6enna - nopoK
pa3BlllTlll5l , B OCHOBe KOTOporo Jle)f(lilT HeAopa3-
BlilTllle XP5lll!eBblX KOJleLJ, 6poHXOB 3-8 nop51,QKa,
YTO npo5lBJ15leTC51 no5lBJleHl.1eM y 60JlbHblX reHe-
pan1113osaHHblX Cll1MMeTp1114HblX 6pOHX03KT830B.
B pe.QKlllX cnyYaHx .QeQ:>eKT MO)f(eT 6b1Tb orpaHlll-
YeHHblM O,QHlilM nerKlllM.
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ro,Qa >Klll3Hl1 B 811,Qe nHeBMOHIAlA IA XPOHIAYeCKOro
fHOll1Horo 6poHXll1Ta c o6crpyKTll1BHblM KOMnOHeH-
TOM . OCHOBHblMlil MeTO,QaM111 AlllarHOCTl/IKll1 518Jl5l-
IOTCs:l 6p0Hxorpa¢1115l Ill KOMnblOTepHaSl TOMOrpa-
QJlll5l, np111 3TOM xopowo Blilfl.Hbl pacw111peHHb1e
cerMeHTapHble 111 cy6cerMeHrapHb1e 6p0Hx111 .
P111c. 10. C11tHAPOM B11tilbstMca-KeMn-
6enna.
6p0Hxorpacp1u1: ,llMJlaTa~wR cerMeHTapHblX
111 cy6cerMeHTapHblX 6poHxoe neeoro 11er-
Koro, BblWe lit Hllt}Ke MeCT A11tJ1aTa~11tllt 6poH-
Xllt3JlbHOe Aepeeo He "13MeHeHO.
 Tpaxeo6poHXOMe2anuR (ClllH.QpOM MyHbe- PMc. 12. BHyTp11111eroYHa.R ceKeecTpa-
KyH a ) - spo)K,L\eHHoe pacw111peH111e Tpaxe111 111 L.J,lllst. np.RMa.R peHTreHorpaMMa (a): Henpa-
Kpyn HblX 6pOHXOB, CB5!38HHOe c HeAOP83Bl/ITlll8M BlllJlbHOH cpopMbl 3aTeHeH Me B n poeK4111 111
xps:i ll\e L'il, Ae¢111u,111ToM 3nacT1114ecK111x 111 MblWe4- Hlll>KHeH AOil lll nesoro nerKoro; aopTo r pa-
HblX sonoKOH MeM6paH03HOL'il 48CTlll Tpaxe111 . cp111st (6): ceneKTMBHoe 3anonHeH 111e a6ep-
3a6onesaH111e npos:ism1eTcs:i B B03pacTe 20- paHTHoro COCYAa, OTXOAHU4ero OT aopTbl IA
30 neT np111crynoo6pa3HblM nalOLL\lllM KawneM ,
CHa6>1<atoU4ero KpOBbto ceKBeCTpMpOBaH-
OAblWKOL'il 111 np111crynaM111 YAYWbS'I . KaK npas111no , y
HblH y'-laCTOK nerKoro BHYTPlll HM>KHeH AOIIM
scex 6onbHb1x 111MeeTC5! KnlllHlllKa rHoL'ilHoro 6poH-
nesoro nerKoro.
x1ina . B cospeMeHHblX ycnos111s:ix Tpaxeo6p0Hxo-
Me r an111s:i AlllarHocrnpyeTcs:i 111 B paHHeM ,QeTCKOM neYeHllle C8KB€CTpaL.J,111111 TOnbKO x111pypr111Ye-
B03pacTe , oco6eHHO y AeTeL'il c lllMMYHOAe¢111u,111- CKOe . X111pypraM Heo6xop,111Mo noMHlllTb o Han111-
TOM. ,LJ,111arH03 Tpaxeo6poHXOMeran111111 no,QTBep- 4111111 TaKoL'il aH0Ma11111111 so scex cnyyas:ix onepau,11111\
>K,L\aeTcs:i MeTOA8Mlll n111HeL'ilHOL'i1 TOMOrpac:P111111 , np111 xpOHlllY€CKlllX H8rHOL'1TenbHblX 3a6oneBaH1115'1X
Tpaxeo6p0Hxorpac:p111111 Ill KOMnblOTepHOL'il TOMO- nerK111x, oco6eHHO np111 n0Kan1113a4111111 npou,ecca s
rpac:P111111 , np111 3TOM Bb1s:isns:ieTcs:i pacw111peH111e Hlt1>KHlllX ,1:1ons:ix nernoro . np111 noA03peH111111 Ha
Tpa xe111 , AlllaMeTp KOTOpoL'il npesocxop,111T p,111a- BHYTp111nero4HYIO ceKsecTpau.11110 npocp111naKT111KolA
MeTp HOpManbHOL'il Tpaxe111 B 1,5-2 pa3a (Hop- B03MO>KHOro M8CClt1BHOro KpOBOTeYeHlll5! 5!BI15!€T-
M8n bH85! w1..1p111Ha Tpaxe111 - 20 MM) , O,D,HOBpe- CS'I nopu.1110HH85! , nOA KOHTponeM 3peHlll5! Mo6111-
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peH111 e rnaBHblX 6pOHXOB (B HOpMe w111p111Ha npa- XO,lllllT aHOM8IlbHbJL'il cocy,1:1.
soro rnasHoro 6poHxa - 16 MM , nesoro - 14 MM) . 5pOHX03KT83111111 MOryT conpOBO)K,L\8Tb u,e-
nblL'il ps:ip, HacnedcmeeHHbtX 3a6oneeaHuu. Y
PMc. 11. Tpaxeo6p0Hx0Meran111R.
p,eTeL'il CXOAHYIO c 6poHX03KT8Tlll4€CKOL'il 6one3-
Tpaxeo6poHxrpaMMa: pacw1ApeH111e TpaxeM 4
Hbl0 KnlllHlllYeCKYIO KapTlllHY p,aeT MYKOBlllCLJ,lll,D,03 .
H maBHblX 6poHXOB, cnpasa BHyTpeHHl/le np111 MYKOBlllCLJ,111,l\03€ HapyweHa cPYHKLJ,1115! 3K30K-
KOHTYPbl TpaxeM IA maeHoro 6poHxa cpec- p111HHblX >Kene3 scero opraHlll3Ma , np111 3TOM
TOH YaTble, r.naBHble 6poHXIA npoeK41AOHHO 6poHx111anbHbtM111 }Kene3aM111 BbJ,Qens:iercs:i Ha-
Hacna111satoTCS1 APYr Ha Apyra . cTonbKO BS'l3KlllL'il CeKpeT, YTO 3TO nplllBO,QlllT K Me-

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pa3 s111rns:1 , xapaKTep1113Y10LL\lllL'ilcs:1 Han111Y111eM yYa- lllTOre - K lllX paCWlllpeHllllO . np111coe,1:1111HeHlll€ lllH-

CTKa aHoManbHOL'il neroYHOL'il TKaH111 , pacnona- cpeKLJ,111111 Ill pa3BlllT111e rHOL'ilHoro 6pOHXlllTa nplllBO-

ra10 LL\erocs:1 1..1n111 BHYTPlll AOn111 nernoro (111HTpano- ,QlllT K CTOL'i!KOMY nopa>KeHllllO CTeHKlll 6pOHXOB Ill

6ap Has:1 ceKBeCTpau.111s:1) , 111nlll OT,QenbHO OT nerKO- p,syxcTopoHHlllM 6poHX03KTa3aM. 5poHX03KT83bJ

ro (3KCTpano6apH85! ceKBeCTP8L\11151). AHOManb- np111 MyKos111cu,111p,03e Yall\e scero u,111n111Hp,p111Ye-

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p111 anbHolA KpOBblO 1113 apTep1111A , OTXO,Q5lll\lllX He-
noc peACTBeHHO OT aopTbl , Torp,a KaK BeH03HblL'il
OTTOK OCYLL\eCTBn5leTC5! no ClllCTeMe neroYHblX
seH. Mopcponor1114ecK111 ceKsecTp111poBaHHb1L'il
Y4 8CTOK nero4HOL'il TKaH111 npep,cTasns:ieT co6oL'il
Klll CTY 111n111 rpynny KlllCT, BHYTPeHH5!5! cTeHKa KO-
TOpblX BblCTnaHa ey6"1YeCKlllM , L!lllnlllH,D,plllYeCKlllM
BlllCLJ,111,Q03e BTOPlll4HO Hapywaerc~ cPYHKLJ,1115!
nop,>Kenyp,o4Hoi1 }Kene3bl , ne4eH111 , K111weYHlllKa 111
nonosb1x )f(ene3 . 3a6onesaH111e OTI11114aeTC51 3Ha-
4111TeflbHblM Kn111Hl/IY€CKlllM nonlllMOPcPlll3MOM , no-
3TOMY ,D,lllarHOCHIKa ero B03MO}KHa TOnbKO Ha
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Kn1t1H1114ecK111e oco6eHHocT111 3a6onesaH111s:i 111 pe-

1m1-1 M ep1..1arenbHblM 3n1Arem1eM IA pacnonaraer- 3Yilb TaTbl psi,Qa na6opaTOpHblX TeCTOB. 06bl4HO

cs:1 B HllJ}KHlllX OT,D,enax nerKOfO. np111 H8fHOeHllllll nepsbte np1113HaK111 3a6onesaH111s:i nosisns:i10TC5! s

COAep}KlllMOe KlllCT npopblBaeTcs:t B 6pOHX Ill paHHeM ,QeTCKOM B03pacTe B BlllAe cyxoro, Ma-

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nonpo,QyKTlllBHoro Kawns:i. C np111coe,Q111HeH111eM

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cp opM8L\1115! 6pOHXOB , KOTOpbJe or1116a10T 30HY ce- KOKK, reMoc:P111nbHas:i , a B p,anbHeL'ilweM - c1i1He r -

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p oBaTb BHyTp111p,oneBy10 ceKBecTpa1..111110 OT Me-
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MO>KeH np111 aoprnrpacp111111.
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noTa (noToBa51 npo6a) no MeTOAY r1t16c0Ha 111 Ky- tjJeKTaX ¢aro41t1TapHOi11 ClllCTeMbl noKa3aHa KOM-
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OCJlO)f{HeHVIVi co CTOpOHbl onepVlposaHHOro ner-
KOro (06ocrpeH111s:1 rHoLllHoro 6p0Hx111Ta, nHeBMO-
Hllllll , arnneKTa3a) Ill OCJlO)f(HeHllJl.1 co CTOpOHbl
n.nespanbHoill nonocrn (3MnV1eMb1), 4TO AOcrnra-
eTcff
1. A,QeKBaTHblM 06e360.nti1BaHV1eM 60JlbHblX
- B nepsb1e 4-5 cyro1< nocne onepau111111 noKa3aHo
Ha3Hal.leH111e aHanreTVIKOB (B/M, BIB) HecTepOlllA-
Horo P51Aa (nepcpanraH, KeroHan), npVI Heo6xo-
AlllMOCTlll - HapKOTlll4eCKlllX aHa.nreTlllKOB B C04e-
T8HJIJJIJ c 8HH1rlllCT8MJIJHHblMJIJ cpe,QCTB8MJ.1 , 4TO
nosso.ns:ieT H8l.18Tb paHHIOIO 8KTVIBlll381..\1'1IO 5o.nb-
HblX - Ha 2 cyr1<111 nocne onepau111111 60.nbHbte
,QOJl>KHble BCT8B8Tb Ill XOAflfTb no nanare. 0,QHO-
speMeHHO npoBOAlllTC51 ,QblX8T8J1bHa51 rl!IMH8CTlll-
Ka , ne4e6Ha51 cp1113f<Y.nbrypa .
2. PaHHVIM nonH04eHHblM nV1TaH111eM - n111L1..1a·
AOJl)l{Ha 6b1Tb MexaHllll.leCl<lll VI XLi!Mllll.leCKlll Ll..18-
As:ILl..lelll , 6orarolll s111TaM111HaMV1 .
 3. noKa3aHbf fl!HraJ1511..(flfflf MYKOJlfifTlll4eCKlllX Ill
6pOHX011111Tlll4eCKlllX npenapaTOB, Ha3Ha4eH111e
aHr1116111or111KoB. B paHHeM noc11eonepau1110HHOM
nep1110Ae aHr1116111ornK111 Ha3Ha4atOT c u,e11bt0 npe-
Aynpe>K,[\eH111s:i peaKT111sau,111111 xpoH1114eCKoro
6poHXlllTa Ill npocp11111aKTl/IKlll nHeBMOHllllll , no3TOMY
AO onepau,111111 06s:i3arenbHO onpeAe11eH111e 4yscr-
s111 re11bHOcr111 MlllKpocp11opb1 MOKpOTbl K aHT11161110-
T111KaM , 4TO Ill npeAOnpeAe11s:ier lllX Bb16op y KOH-
KpeTHOrO 6011bHoro.
4 . Heo6XOAlllM AV1HaM1114ecK111&:;1 peHTreHono-
r1114ecK111&:;1 KOHTpOnb 38 COCTOs:!HllleM onep111po-
saHHOro nerKoro - np111 nos:isneH111111 r111noseHr11111s:i-
u111 111 11111111 areneKTa3a 3AOPOBblX OTAe11os onep111-
posaHHoro 11erKoro noKa3aHa Heor11o)l(Has:1 caHa-
1..(lllOHHa>'i 6pOHXOCKon111s:i Ill BOCCTaHOsneHllle npo-
XOAlllMOCTlll 6pOHXOB.
5. no Mepe npeKP8t1.!eHlllS'l 803.QYXOTe4eHllls:!
111 3KccyAau.111111 ApeHa)l(111 1113 nnespanbHoa:;l nonoc-
OCTPhIE AEC:QECChl H r AHrPEHA JIErKHX
OcTpb1lll a6c'-'ecc nerKoro - 3TO rH0&:;1Hb1&:;1
li!Jllll rHlllJlOCTHbfei pacna,D, nero4HOilr TKBHlll , conpo-
BO)l(Aat011.1111ilrcs:i o6pa30BaHllleM OAHOilr 11111111 He-
CKOJlbKlllX nonocTea:;l AeCTPYKL..1111111 , orrpaHlll4eHHblX
or Henopa)l(eHHblX y4acrKos nerKoro socnam1-
rnnbHblM lllHQJlllilbTparoM (n111oreHHO~ Kancyno!A).
raHrpeHa nerKoro - 3TO 06w111pHblW HeK-
p03 nerKoro c rHlllJlOCTHblM pacna,D,OM TK8Hlll , 6e3
4eTKOlA ,D,eMapKal..(111111, c TeHAeHl..(lllelA K 6blCTpOMY
pacnpocrpaHeH111t0 Ha 3Aoposb1e y4acrK111 nernoro.
raHrpeH03HblM a6c'-'ecc nerKoro - sap111-
aHT OTHOClllTenbHO 6naronp111RTHOro Te4eHltffl
raHrpeHbl nerKoro , KOrAa npo111cxop,111r orrpaH111-
YeH111e y4acrKa rnoa:;1Ho-rH111nocrHoro pacnaAa c
06pa3osaH111eM ceKsecrpa nero4HO~ rKaH111 s no-
nocr111 a6c1...1ecca, 4TO 111 npeAonpeAens:ieT era
oco6eHHocr1t1 - 3arn)l(Hoe re4eH1t1e w 4acrb111f ne-
pexoA B XpOHlll4eCKYIO CTaAllllO.
3muo1102uR u namo2eHe3
OrMe4eHo, 4TO nero4Hb1e HarnoeH111s:i (a6c-
4eccb1 1t1 raHrpeHa) 481.1..!e scero pa3s111sat0Tcfl y
MY)l(4111H pa6orncnoco6Horo B03pacra, 38Hlll-
Mat0t1.!111xcs:i Hlll3KOKBan111¢1111...1111posaHHblM TPYAOM,
3n oynorpe6ns:it0t1.!lllX anKoroneM 111 crpa.QatOt1.!lllX
xpoH1114eCKlllM 6poHx111ToM, scneACTs111e KYPeH111s:i
ra6aKa 111 B03,llewcTBltf51 npo¢ecc1110HanbHblX
BpeAHOCTea:;l.
<PaKTopbl, npep,pacnonara10t1.!llle K pa3s111-
rn t0 a6c1...1eccos 111 raHrpeHbl nerKoro , MO)l(HO
pa3AeI1111Tb Ha MeCTHble Ill 06t1.!llle .
K MecTHblM ¢aKTopaM , noH1t1>1<at01.1.!WM co-
nporn sns:ieMocrb opraHlll3Ma 111 neroYHoa:;l TKaH111,
OTHOCs:tT: areneKT83bl, 3Mtj:>lil3eMy, xpOHlil4eCKllle
HecneL1111¢1114ecK111e 3a6onesaH111s:i nerK111x (6poH-
Xl.ff, 6pOHX03KT83111111) , spo)l(AeHHble aHOMan111111
pa3BWTltffl rpaxew It! 6poHXOB, HapyUJeHWfl KPOBO-
o6pat1.!eHL'171 B nerKlllX MeCTHOro Ill ClllCTeMHDrO
xapaKTepa.
135
rn Heo6xoA1t1Mo YAan111rb. 8 AanbHeilrweM KOH-
rpo11b 3a HaKon11eH111eM 3KccyAara s nnespanb-
Hoa:;l nonocrn ocyt1.!ecrsns:iercs:i peHrreH011or1114e-
cK111 , 11111111, 4TO lllHQJOpMaTlllBHee, np111 noMOl.1.\111
ynbTpa3BYKOBOro illCC11eAOBaHllls:I nnespanbHOi;:\
nonocr111, 3KccyAaT YAans:iercs:i np111 noMOli.1111
nyHKl..(111&:;1 .
np111 HeOC110)1(HeHHOM Te4eHllllll nocneone-
paU,lllOHHOro neplllOAa 6onbHble Bblnl/ICblB8IOTC51
1113 CT81..(lllOHapa 4epe3 2 HeAeJll/I.
np111 OAHOCTOpOHHlllX, 4eTKO JlOK8J111130B8H-
HblX (oco6eHHO areneKTaTl/l4eCKlllX) 6pOHX03KTa-
3111s:IX nonHOe Bb13AOPOBJleH111e 11111111 3H841/1Tenb-
HOe KJllllH1114eCKOe yny4weH111e OTMe4aeTC51 y 75-
85 % 6onbHblX. YAos11ersop111renbHb1e pe3y11b-
rarb1 , r.e. yMeHbWeH111e Kawns:i 111 M0Kporb1 , pe-
1..\lllAlllBOB 3a6onesaH111s:i , Ha6ntOA810TCs:I y 8-10 %
onep111posaHHblX 6onbHblX. Onepa4111s:i He3cpcpeK-
TlllBHa y 3-5 % 6onbHb1x.
06~111e cpaKTOPbl , npeApacnonara10t1.!llle K
pa3B1t1T11t0 3a6onesa1-1111R: xpoHw4ecKwilr anKoro-
Illll3M, HapK0MaH111s:i , caxapHb1&:;1 Al!la6er, as111r a-
MlllH03, an111MeHrapHas:i AlllCTpocp1115! , An111renbHoe
np111MeHeH111e lllMMYHOAenpeccaHTOB Ill mtOKOKOp-
TlllKOlllAHblX ropMOHOB.
0CHOBHb/Ml1 1t1H¢e1<1..(ll10HHb/MW B036YAll1Te-
Jls:!Mlll OCTpblX rHoa:;lHO-,lleCTPYKTlllBHblX 3a6onesa-
Hllla:;l nern111x s:isns:it0rcs:i naroreHHble cracplilnOKOK-
Klll (S . aureus, S. haemolyticus) 111 crpenroKOKK111
(St. pneumoniae), Hecnopoo6pa3y10t1.!llle aHa-
3po6b1 Bacteroides spp. (B. fragilis, B. melanino-
genicus) , Fusobacterium spp. (F. nucleatum, F.
nerophorum) , aHa3po6Hble KOKKlll (Peptostrep-
tococcus spp., Veilonella spp.) , pe.>Ke - naroreH-
Hble BlllAbl Clostridia 111 rpaMorp1111...1arenbHble
M1111<poopraH1113Mb1: Klebsiella pneumoniae, Pseu-
domonas aeruginosa , Escherichia coli 111 AP· Y
30-40 % 60ilbHblX BblAe!ls:!IOT M111Kpo6Hble acco-
1..\11181..\111111. B pep,KlllX cny4a71x 3Tlilonor1114ecK111M111
cpaKTopaM111 a6cueccos nerKoro 7IBns:it0TC7I rp1116b1
(Candida spp., Aspergillus spp.) 1111111 npocreV!-
w111e (Paragonimus westermani , Entamoeba his-
tolytica).
Y 6onbHblX c ocrpblM a6c1...1eccoM 111 raHrpe-
Hoa:;l nerKlllX sa.>KHO lllAeHTlllQJllll..(lilposaTb BeCb
cne1rrp M1111<poopraHlll3MOB, no3TOMY np111 3a6ope
Marnp111ana Ha M111 Kpo6111onor111YecKoe 111ccne,Qo-
saH111e AOJl)l(Hbl np1t1MeHs:tTbCs:t MeTOAlllKlll, no3so-
ns:it0t1.!llle 111AeHr111Q:>1111...1111posaTb KaK a3po6Hb1e, TaK
111 aHaapo6Hb1e MlllKpoopraHlll3Mbl.
Pa3n1114a10T cne,L1y10111111e nyrw npoH1111<Hose-
Hlll7I 111HcpeKu111111 B 11erK111e: 6poHxoreHHb1&:;1 , reMa-
roreHHbla:;l , TpasMaT111Yec1<111&:;1 111 11111MQ:>oreHHb1&:;1.
no 6pOHXOreHHOMY nyrlll pa3BlllB8IOTCs:I
nocrnHesMOHlll4eCKllle 111 acn111pa1...11110HHb1e a6c-
L1eccb1 11ern111x. CJOAa )l{e Heo6xDAL1MO ornecrn
nero4Hb1e HarHoeH11151 , scneAcrs111e 06rypau111111 111
HapyweHllls:I ,llpeHa)l(Hoa:;l QJYHKL..1111111 6pOHXOB np111
paKe nerKoro, lllHOPOAHblX Tenax Ill 6pOHX03KTa-
T1114eCKOi71 6one3Hl/I .
nocTnHeBMOHl/l4eCKl/le a6Cl.leCCbl B KJH1HlllKe
BCTpe4atoTC51 Ha1.16onee 4aCTO. naTOnOfllt4eCKl.111i
npou,ecc o6bl4HO Ha4111HaeTc51 c a3poreHHoro,
pe)l(e - reMaToreHHOro 111Hcp111u,1.1posaHl.15I nero4-
HOlll TKaH111 . nporpecc1.1posaH1.1to socnaneHl.151
cnoco6crsytor croi7IK111e HapyweHl.151 npoxo,q1.1Mo-
cT111 MenKl/IX 6pOHXOB L1 paccTpoiilcTBa MlllKpou,111p-
KYfl5IU,llllll , conposo)f{,IJ,atoll.\lllec51 rvinoseHT111m11_\111-
ell1 Ill TPOM6030M MenKlllX cocy,qos COOTBeTCT-
BYIOU\ero cerMeHTa (,qon111) nerKoro. np111 He-
csoespeMeHHOM 111 HeaAeKBaTHOM ne4eH1.1111
nHeBMOHl.1111 nep1.10,q ceporo one4eHeHlllfl 3arnrvi-
saercfl, 4TO nplllBOAlllT K HeKp03Y nero4H0171 TKaHlll
111 co3,qaeT 6naronp1115ITHyt0 no4sy ,D.nfl pa3BlllT11151
BTOp1114HOi71 rHOepoAHOlli 111HcpeKLJ,L1111 Ill c:jJopMlllpo-
BaHlll/O a6cu,ecca wm1 (npw H1113KOl1 conporns-
m1eMocrn opraHlll3Ma) raHrpeHbl nerKoro.
0TMe4eHO, 4TO KOnlll4eCTBO OCTpblX a6c-
u,eccos nerKoro ysen1111.11110aeTC5! ao speMH rpi-m-
no3HblX 3n111,qeM111iil . B111pyc rp111nna Bbl3b1Baer
HeKpo3 6poHx111anbHoro 111 anbseon51pHoro 3n111-
remrn , TOKClllYecKoe nopa>KeH111e cocy,q111crnro
3HAOTem15I, a BTOplll4HOe lllHcplllLJ,lllpOBaH111e naro-
reHHOlli 6aKTep111anbH011i cpnopolli cnoco6cTBYeT
3aTR>KHOMy Te4eHllllO nHeBMOHll1111 Ill C03AaeT yc-
noBlll51 ,qm1 pa3BL1Tlll51 a6cu,eccos nerKoro.
B ocHose acn111pa41110HHblX 111 06Typau,1110H-
HblX HarHoeH111iil ne)l{lllT nepBll14Hbliil aTeneKTa3
y4aCTKa nerKoro, a socnaneH111e 111 nocneAYtoll.\llllli
HeKp03 ner04HOIA TK8HL1 pa3BlllBatoTC51 BTOplll4HO .
Ha1116onee 4acrn acn1.1pau,1110HHb1e nHeBMOH111111
per111cTp1.1py10Tcfl np111 rn>1<enb1x 4epenHo-
Mo3roBblX rpaBMax, OTKpblTblX nospe)f{,IJ,eHL151X
4entocTHo-n111u,esol-1 o6nacrn , PflAe Hesponor111-
4ecK111x 3a6onesaH111ili , ocno)l{H5110U\lllXC51 KOMa-
T03HblM COCTOflHllleM, Ae¢eKTax npose,qeHI.151
o6w.elli aHecTe3111111 (cMHAPOM MeHAenbCOHa) ,
cocT051HL1111 Bb1pa)l{eHHOro anKoronbHoro onb5IHe-
H111.s:i. 06bl4HO acn111p111pyeTC5I Cl11113b 1113 HOCOfnOT-
Klll , cmoHa, KYC04Klll nL1U\lll, KPOBb 111 T.A. LJall.\e
nopa)l{aerc51 npasoe nerKoe , n0Kan1113y10rc51
rnolliHlllKlll npe111Myl.l.leCTBeHHO so II, YI , IX, X cer-
MeHTax nerKoro.
B OCHOBe nero4Hb1X HarHOeHllllli np111 reMaTo-
reHH0-3M60fllll4eCKOM nyn1 paa0111rns:i 3a6onesa-
H1115I ne)l{aT MlllKpOlllHcpapKTbl nero4H0171 TK8Hlll ,
TaK KaK MlllKp03M6onb1 1113Ha4anbHO L1Hcp111LJ,111po-
BaHbl , socnaneH111e 111 HeKpo3 c nocneAYIOW.lllM
HarHoeH111eM s 30He lllHcpapKTa nerKoro pa3s111-
sa10Tc5I 6blCTpo, rHOiilHlllKlll HOCs:lT MHO>KeCTBeH-
Hbllli xapaKTep 1.1 pacnonara10Tc5I o6bl4Ho s Kop-
T111KanbHolli (cy6nnespanbHOi/i) 30He nerK111x.
'-law.e scero reMaToreHH0-3M6on1114ecK111e a6c-
4eccb1 nerKlllX pa3s1110a10Tcs:i np111 3aT51)1{HOM cen-
Tlll4eCKOM 3HAOKapAl..ffe, lllHcplllLJ,L1posaHHblX
TpOM6oc:jJne6111Tax BeH Hlll)f(Hl/IX KOHe4HOCTel-1,
ocTeoM1.1em1Tax pa3n1114H0171 n0Kan1113au,111111 , cen-
T111Kon111eM1111.1. np111 AnlllrenbHOiil KaTeTeplll381..1111111
lllCT04HlllKOM lllHcjJ1114111posaHHblX 3M6onos MOryT
136
CTaTb KpynHble Ll,eHTpanbHble BeHbf (BHyTpeHH51fl
s:ipeMH8SI, nOAKn1041114H8fl 111n111 6eApeHHafl) .
nocnpaBM8Tlll4eCKllle a6cLJ,eCCbl nerKlllX B
KJllllHlllKe BCTpe4alOTC51 peAKO, B OCHOBHOM nocne
Tf!)l{e11blX TpaBM rpyAlll , KOHTY3111C1 11111111 paHeH111C1
nerKoro, scneAcTB111e 111Hc:jJ111LJ,111posaH11151 sHyrp111-
nero4HblX reMaToM .
KaK peAKOe ocno)l{HeH111e a6cu,ecc nerKoro
MO)l{eT B03HlllKHYTb B pe3ynbTaTe pacnpOCTpa-
HeHlllfl Ha nero4HYIO TKaHb rHOiilHOro 111n111 rHlllno-
CTHOro npou,ecca c coceAHlllX opraHOB 111n111 TKa-
Hel71 no n111Mc:jJarn4ecKlllM nyn1M , Hanp111Mep, np111
rHOiilHOM MeAlllaCTlllHlllTe, OCTeoM111en111Te n0380-
H04HlllK8, pacna,qa10L1.1eMc5I paKe n111w.es0Aa ,
noAAV1acjJparMa11bHOM a6cLJ,ecce .
l<naccucj:Jw<au,uR
no KmtHl-tKO-MOptjJonOrH'-leCKz.1M OC06eHHO-
CTs:lM pa3n1114a10r:
• ocTpb1C1 a6c4ecc ;
• orpaH111YeHHy10 raHrpeHy (raHrpeH03Hbllli
a6c4ecc);
• pacnpocrpaHeHHyio raHrpeHy nerK111x.
no 3TlllOfl0rl/llll :
• a6c4eCCbl , Bb13BaHHble a3p06Hoi71 MlllKpo-
cpnopolll;
• a6cLJ,eCCbl , Bbl388HHble aHa3po6Hol71 MlllK-
pocpnopoill ;
• a6c4eCCbl , Bbl3BaHHble CMeWaHHOM Ma.1K-
pocpnopol71 ;
• a6c4eccb1 , Bbl3BaHHble He6aKTep111anbHbt-
M111 areHTaMfll (rp1116b1, npocTet1wwe 111 ,1:1p.).
no naroreHe3y:
• a6c4eccb1 acn111paLJ,lllOHHb1e (s TOM 4titcne -
06rypa41110HHb1e) ;
• a6cl!eccb1 nocmHeBMOHlll4eCKllle;
• a6cueccb1 reMaroreHH0-3M6on1114ecK111e;
• a6c4eccb1 nocnpasMaT1114ecK111e;
• a6c4eccb111111Mc:jJoreHHb1e.
no JlOK8nJ.-138l.ltillll:
• a6cLJ,ecc 4eHTpanbHblC1 (np111KopHesoill) ;
• a6cu,ecc nep111c:jJep1114ecK111l71 (KoprnKanb-
HbllA, cy6nnespanbHbtl;i).
no pacnpocTpaHeHHOCTlll:
• a6cLJ,ecc eAlllHlll4Hb1ill ;
• a6cueccbl MHO)l{eCTBeHHble (OAHO- 11111111
ABYCTOpOHHllle) .
no Hanlll41/1!0 OC110)1{HeHllliil :
• a6cu,eCCbl He OCflO)l{HeHHble;
• a6cLJ,eccb1 ocno)l{HeHHble (11ero4Hoe Kpo-
soTe4eH111e, n111onHeBM0TopaKc, cenr111Kon111eM1115!
1-1 AP.).
l<nuHUL/ec1<aR cuMnmoMamu1<a ocmpo20
a6cu,ecca ne21<020
B rnn1114HblX cnyYasix MO)l(HO Bb1,qen111Tb Tp111
nep1110,qa 3a6onesaHlll5! . ·
nepab1u nepuoa - c:jJopM111posaH111e a6c-
4ecca. B 3as111c111Mocrn oT MexaHlll3Ma Harnoe-
Hlll5! , B111py11eHTHOCTlll MlllKpotjJnopbl , peaKTlllBH0-
CTlll Ill pe3111 CTeHTHOCTlll opraHlll3Ma 3TOT neplllOA
3a HVIMaeT B cpep,HeM OT HeCKOnbKlllX )J.Helll AO
Hep,enb 111 nposrnm1eTcs:1 :
• BblCOKOlll n111xopaAKOlll (39-40 a C) Ill lllHTOK-
ClllKau,111ei/1: cna60CTbfO, nOTnlllBOCTbfO , 6blCTpolil
yroMns:1eMOCTb10 , noTepei/1 anneT111Ta , CHlll)l(eH111 -
eM MaCCbl Tena VI T.)J..;
• cyx111M KawneM 111 6ons:1M111 B rpyp,Holll KneT-
Ke Ha cTOpoHe nopa)l(eH111s:1 ;
• orpaHlll48HllleM nO)J.BVl)l(HOCTVI fPYAHOlil
Kn eTKlll , npvnynneH111eM nero4Horo 3ByKa , 6poH-
x111 anbHblM p,b1xaH111eM (pe)l(e - AblXaH111e ocna6-
n e Ho) , wyMoM TpeH111s:1 nnespbl VI pa3H0Kan1116ep-
Hb1M 111 BJla)l(HblMVI xpi.maMlll HaA nopa}f{€HHblM
Y4 aCTKOM nerKoro;
• TaXV1Kapp,V1elil' CHVl)l(€HVleM aprepVlaJlbHOfO
A aBneH111s:1 ;
• na6opaTOpHo : BblCOKolll C03 , neli1KOL..\111T0-
30M c pe3Kll1M C,D,BVlfOM nel'1KOLIVITapHOl'1 cpopMy-
Jl bl BJ1€80 (np111 CHll1)1(€HHOlll peaKTlllBHOCTVI opra-
Hlll 3Ma xapaKTepHa nelilKo- 111 nV1Mcj)oneHV1s:1) , AlllC-
n p ore111HeM111elil co CHll1}1{€HllleM anb6YMll1HOB
n OBblW8Hll18M cppaKU.1111'1 a.1 111 a.2 mo6yn111HOB , no-
Bbl WeHll1eM ypoBHS'I cpeJJ,HVIX MoneKyn KPOBVI,
cp111 6pV1HoreHa , yrHeTeH111eM Kn€T04HOfO VI ryMo-
p anbHOro VIMMYHll1TeTa , CHlll}f{8Hlll8M cparou.111T03a ;
• peHTreHOJlOrl.14eCKVI: lllHTeHCVIBHOlll socna-
JllllTenbHOlll VIHcpVIIlbTpa1..1V1ellt TKaHVI nerKoro ; Ha
TOMOrpaMMax B u.eHTpe lllHcj:JVIJlbTpara MO)l(HO
o6H apy)l(VITb y4aCTKlll paHHelil ,D,eCTPYKLIVIVI
f 04H Olll TKaHlll .
Bmopou nepuoo - s:isHoro a6cu.ecca , Ha-
CTYnaeT c MOMeHra npopb1Ba rHoHHVIKa 4epe3
,qpeHVIPYfOLL\lllH 6pOHX 111 np051BJ1518TCSl:
• OTKaWJlVIB8HV1€M 60JlbWOro KOJlVl4€CTBa -
200 MJl VI 6onee 38 cyTKVI fHOHHOH MOKpOTbl c
Hen pllls:!THblM 3anaxoM (np111 MVIKpOCKOnVllll B Ta-
Kolil MOKpore BblS'IBJlSleTCSl 60JlbWOe KOJ1Vl48CTBO
n elilKOU.VITOB , 3p111TpOU.VITOB, AeTp111Ta , 6aKTepV11il,
3Jl aCTV148CKVIX BOJlOKOH) ;
• yny4W8HVl€M 06Ll..\ef0 COCTOS'IHVISI: CHVl}f{e-
111eM TeMnepaTYpbl rena VI yMeHbWeHVleM VIH-
TOKClll K8L..\Vllll ;
• nos:1sneHV1eM Ha peHTreHorpaMMax nerK111x
O,D,H Olil VIJllll HeCKOJlbKlllX nonocrelll c ypoBHeM
>Klil)J.KOCTVI , OKpy)l(eHHblX socnan111TeJlbHblM
cplllil bTpaTOM (p111c. 13).
PHC. 13. OcTpblH a6cu.ecc HH>KHeH AO-
IlH npaeoro nernoro nps:iMas:i peHTreHo-
rpaMMa (a), KOMnbtoTepHafl TOMOrpaMMa
(6): B npoeK4HH HH>KHeH AOilH npaeoro
nerKoro onpe.Qens:ieTCfl nonocTb .QecTpyK-
LIHH c ropH30HT311bHblM ypoeHeM, OKpy-
>KeH H3Sf nepHQJOK311bHOH HHQJHilbTpa4HeH.
np111 6naronp11151THOM T848Hllllll 3a6oneB8Hlll5'!
HacTYnaeT mpemuu nepuoo - 3m1<V1aneHV1s:1
a6cu.ecca, KOTOpb11il xapaKrep1113yercs:1 crolllKolil
HOpM 8JlVl3al..\lllelll TeMnepaTYpbl, lllC483HOB8HllleM
HOlil Hol'1 MOKPOTbl, yny4WeHl18M noKa3aTenei/1
reMorpaMMbl. PeHneHonorn4eCKVI OTMe4aeTcs:1
2 VIC483HOBeHVle socnaml!TeJlbHOlll lll Hcj:JVIJlbTpau,VIVI
VI yMeHbweHVle pa3Mepos rHolllHolll nonocTV1 s
nerKoM , annoTb AO ee nonHolll nVIKBVIA8l..\VIVI .
f aH2peHa 11e2Ko20
Pa3BVITVle nero4Horo Har HoeHV1s:1 no TV1ny
r aHrpeHbl xapaKTep1113yeTcs:1 Ts:l)l(€JlblMVI npos:ia-
neHVls:IMVI VIHTOKCVIK8l..IVIVI VI 6ypHblM Te4eHVleM
rHOlAHO-AeCTPYKTVIBHOro npou.ecca .
B TV1n1<14HblX cny4as:ix raHrpeHa nernoro Ha-
4V1Haercs:i ocrpo , c pe3Koro nosb1weHV1S1 reMne-
paTYpbl , noTps:icafOLL\ero 03Ho6a, 6onelll a rpyA-
Holil KneTKe VI Bblpa>KeHHOlil VIHTOKCVIKal..\VIVI . PaHO
nos:isns:iercs:i rHlllJlOCTHbllil 3anax np111 AblXaH111111 111
KaWeJlb c 60JlbWVIM KOJ1Vl48CTBOM 3JlOBOHHOH,
rps:i3Ho- ceporo VIJlVI woKona,D,Horo u.sera (V13-3a
np111MeCV1 KPOBVI) neHVICTOllt MOKpOTbl. npVI raH-
rpeHe nerKoro MOKpOTa pa3,D,8JlSl8TCSI Ha Tplll
CJlOS'I: sepXHllllil cnolll - CJlVl3111CTO-fHOlllHbllll , neHlll-
CTbllll , cpe,QHVllll - cepoaHbll'1 , )l(VIJJ.KVllil, 6yporo
Ill U.BeTa Ill HVl>KHllllil - COCTOS'lll..\111111 1113 o6pb1BKOB ne-
ro4HOlil TKaHVI 111 rHolllHblX npo6oK ,D,V1rp111xa . He-
cMorps:i Ha 06V1JlbHOe OTKawm1BaHV1e MOKpOTbl
yny4WeHlllS'I COCTOS'IHlllS'I y 6onbHblX c ra HrpeHolll
nerKoro He npOVICXOAVIT. noarnpHble 03H06bl B
co4eTaH111111 c n111xopaAKOlil re1<T1114ecKoro T111na 111
HapaCTafOLL\as:I lllHTOKClllK8L..\11151 CBlllAeTeJlbCTBYIOT
o pacnpocTpaHeHV1111 npou.ecca Ha HOBbte y4acT-
K111 nerKoro .
ne-
B ps:1Ae cny4aes r aHrpeHa nerKoro paaa111-
saercsi Me,QneHHo , 6ea s:ipKolll KJ1111HVIKlll , 4TO xa-
paKTepHo Ansi HeKoTOpblX cj:lopM aHa3po6HblX
,D,8CTPYKU.Vllil VI npVI CHVl>KeHVIVI 06U1elll peaKTVIBHO-
CTVI 60JlbHOrO BcneACTBllle VIMMYHO,D,ecj:JVIU,lllTa .
Cneu.V1cj:JV14ecKVIX cj:JVl3VIKanbHblX npV13HaKos
raHrpeHbl nerKoro HeT. HaA nopa)l(eHHblM nerKVIM
OTMe4aeTC51 6oneaHeHHOCTb fPYAHOlll KneTKVI Vl3-
3a paHHero sosne4eHVISl a aocnanV1TeJlbHbllil npo-
u.ecc nneapbl VI TYnolll nero4Hbllil 3BYK np111 nep-
KYCCVIVI ; ayCKYilbTaTVIBHO onpeAens:ieTCSI 6pOHXVl-
8JlbHOe AblXaH111e, paaH0KanV16epHb1e ana:>1<Hb1e
XpVlnbl , wyM TpeHVISI nneBpbl. Co CTOpOHbl cep-
A€4HO-COCYAVICTOlil CVICTeMbl Bblpa}f{eHa TaXVI Kap-
AlllS'! , apTepVlanbHOe AaBneH111e CHVl:>KeHo.
AnneTVIT npVI raHrpeHe nerKoro OTCYTCTBY-
VIH-
eT, np111 3afJlaTblBaHVllll rHOlllHolil MOKpOTbl MOryT
pa3BVITbC51 SIBJ1€HVISI racTp03HTepVITa . noA BJlVISl-
HVleM TOKCVl4€CKVIX B8Ul€CTB yBeJlVl4VIBaeTCSI ne-
4eHb, ceneaeHKa , KaK npas111no , He np01..1.1ynb1sa-
ercs:i .
B reMorpaMMe OTMe4a10rcs:i Bb1pa)l(eHHb1e
Vl3MeHeHVISI - BblCOKVllil nelilKOU,lllT03 , pe3Kllllil GABI/Ir
nelilKOL..\lllTapHolil cj:lopMyJlbl BJ1880, TOKC1114eCK8SI
3€PHLi1CTOCTb HelllTpOcpVIJlOB, paHO nos:1sns:ieTCfl
aHeM111s:1 , a np111 A8IlbHelilweM nporpecc111posaH111111
raHrpeHbl nerKoro pa3s111saerc~ nelilKo- 111 n111M-
cj:loneH111s:1 , Hepe,D,KO - 8H303111HOcj:JlllJlli1SI.
np111 peHTr€HOJ10fVl4€CKOM lllCCJ1€.[\088HVllll B
H848JlbHOllt CT8A111111 raHrpeHbl nernoro BblflBJlSl-
eTCSI M8CCLi1BHOe H€0,ll,HOpO,D,HOe 3aTeHeH111e 3Ha-
137
41.HenbHOfO y4aCTKa ner04HOli1 TKaHlll - 06bl4HO
.i:1on111 111n111 .i:1syx .i:1onet1 nerKoro (p111c. 14).
Pll'IC. 14. nHeBMOHll'ISI BepxHeH AOilll'I
npasoro .nerKoro - Ha~a.nbHaR cTaAll'lst raH-
rpeHbl .nerKoro.
npRMafl (a) 11'1 60KOBast (6) peHTreHO-
rpaMMbl: n.noTHoe roMoreHHoe 3aTeHeHll'le
sepxHeH AOI111'1 npasoro .nerKoro, c HaMe-
Tll'IBWll'IMll'ICR o~araMll'I AeCTPYK411'111'1 11ero~­
HOH TKaHll'I.
PeHTreHonorn4ecK111 orMe4aeTCSI 6b1cTpaS1
OTPlllL\aTenbHafl .QlllHaM111Ka 3a6onesaH111S1 - noS1B-
neH111e MHO>KeCTBeHHblX nonocTelii ,[\eCTPYKL..\111111 B
nerK111x, B Ha1116onee KpynHblX 1113 HI/IX onpe.i:1em1-
10TCS1 ceKBeCTpbl nero4Hoill TKaHl-1 , paHo np111coe-
.QlllHS1TCS1 3KCCy,[laTlllBHblli1 nneBplllT (p111c. 15).
Pll'lc. 15. PeHTreHorpaMMbl 11erKHX Toro
>Ke 60.nbHoro ~epeJ 6 AHel::t.
nporpeCCMpOBaHll'le npo4ecca: pac-
npOCTpaHeHHe socna11ll'ITe11bHOro ll'IH-
cpHilbTpaTa Ha cpeAHl-01-0 AOill-0, nORBil~Hll'le
n11eBpll'ITa; Ha cpoHe ll'IHcpHI1bTpa4H11'1 B
sepxHeH AOile npasoro 11erKoro BHAHbl
MHO>KeCTBeHHble y~aCTKM npocBeTileHll'ISI -
HeKpOJ 11'1 pacnaA 11ero~HOH TKaHll'I c cpop-
Mll'lpOBaHll'leM rnraHTCKOro raHrpeHOJHOro
a6c4ecca.
Oc110Jt<HeHUR ocmpb1x a6cu,eccos u
2aH2peHbJ 11e21wx
Ha1116onee 4acTb1M111 ocno>KHeH111S1Mlll ocTpo-
ro a6cL1ecca 111 raHrpeHbl nerKlllX S1BI1S110TCS1: ne-
ro4Hoe KpOBOTe4eH111e, n111onHeBMOTOpaKc (3M-
n111eMa nnespb1) , cenc111c (cenrnKon111eM111S1), no-
pa)f{eH111e KOHTpanarepanbHoro nerKoro (scne.i:1-
crn111e 6poHxoreHHoro pacnpocTpaHeHlllfl rHolii-
Holii MOKPOTbl).
npo2Ho3
nporH03 3a6oneBaHl/IS1 onpe,QenS1eTCS1:
1 . MexaHl13MOM pa3BlllTlllS1 Ja6onesaHl1S1
(acn111paL\lllOHHblli1 , nocrnHeBMOHlll4eCKlllli1 , 3M60-
m14eCKlllli1 a6c4ecc l1 T..Q .).
2. XapaKTepoM M111Kpo¢nopb1.
3. CocTOS1HllleM MaKpoopraHlll3Ma (xpoHlll4e-
CKllle HarHOl1TenbHb1e 3a6onesaH111S1 nerK111x, rn-
)f{enb1e 06L11ecoMaT111YecK111e 3a6onesaH111S1 ,
Bpe,[\Hble np111Bbl4Kl1, Hanl/l4l1e lllMMYHO,[\eQJ111L\lllTa
Ill T.,£1 .).
4.0co6eHHOCT51Mlll ne4e6HO-,[llllarHOCTl/l4eC-
KlllX Meponp111S1r1111i1 (csoespeMeHHOCTb rocn111Ta-
n1113al.\llllll s npo¢111nbHoe or.i:1eneH111e, paHHflfl no-
craHOBKa .i:1111arH03a 111 o6beM ne4e6Hb1X Mepo-
np111S1T1111i1 Ill T. ,[\.).
5. Hanl14111eM ocno>t<HeH1111i1 .
B 3as111c111Mocrn or Bb1wenepe4111cneHHblX
cfJaKTopos, ocrpb11i1 a6cL1ecc nerKoro nporeKaer:
138
1.c TeH,[\eHL\lllelii K Bbl3,[10pOBileHllllO, KOr,[\a
no,[\ BillllflHl/leM KOMnneKCHOro ne4eHl/IS1 Km'1Hl/l4e-
CKl/le npoSIBJleHlllSI 3a6oneBaHl/IS1 nl<IKBlll,[llllPYIOTCS1,
nonoCTb rHOliiHlllKa yMeHbWaeTCS1 Ill Ha MeCTe
a6cL1ecca 06pa3yerc5l 1rn60 04ar nen1111crnro
¢1116po3a (nonHoe Bbl3.QoposneH111e) , n11160 cyxaS1
nonocTb (Bbl3.QoposneH111e c ".i:1ecfJeKToM") ;
2. 3a)f(111BneH111e a6cuecca npol<lcxoAlllT
Me,llneHHO, nonoCTb onopO)!{HS1eTCS1 OT rHOS1 He-
,[\OCTaT04HO, cn8,[laercS1 nnoxo, npoueccb1 pere-
Hepau111l1 3aMeAneHbl - ocTpb11i1 a6cuecc craHo-
s111TcS1 xpOHlll4eCKlllM ;
3 . y 60JlbHblX c COnYTCTBYIOLl\elii narnnorn-
elii , np111 oco6o s111pyneHTHoli1 l<IHQJeKL..\111111 111 nno-
xoM APeH111posaH111111 a6cuecca 4epe3 6poHx, 3a-
6onesaH111e nporpecc111pyer c pa3s111r111eM ocno)f(-
HeHl<llii , o6pa30B8Hl/leM HOBblX rHoliiHlllKOB B KOH-
rpanarepailbHOM nerKoM (3a6poc rHoliiHoill MOK-
p0Tb1) 11111111 BHyrpeHHlllX opraHax {MeTaCT8Tlll4e-
CKllle a6cueccb1), HapyweHl<leM cep,[\e4Holi1 AeS1-
renbHOCTlll , QJYHKL..\111111 no4eK, ne4eHlll Ill MO>KeT
np111secrn K cMeprn 6onbHOro.
5naronp111S1THoe re4eH111e raHrpeHbl nerKoro
6b1Baer peAKO Ill TOilbKO np111 KOMnneKCHOlii l/IH-
TeHClllBHOill Tepan111111 (aHT1116lllOTlllKlll, caH8L\l1Sl
6pOHXlll8DbHOro ,[lepesa, lllMMYHH8Sl KOppeKl..!11151 Ill
T.A.). 4TO B nocne.i:1y1a1.L.1eM He lllCKfll04aer Heo6-
XOAlllMOCTlll onepaTlllBHOro BMewarenbCTBa.
/l,ucf)(jJepeHu,uanbHblU oua2Ho3
A111¢¢epeHL\lllanbHb111l .i:1111arH03 ocrpb1x a6c-
4eccos nerKoro npOBO,[\lllTCSI B OCHOBHOM co 3IlO-
K84eCTBeHHblMlll HOB006pa30B3HlllSIMlll , ry6epKY-
ne30M , HarHOlllBWlllMlllCSI Kl/ICT8Mlll Ill 3XlllHOKOKKOM
nerKoro.
A6c1..1eA111poeaH111e np111 paKe nerKoro He S1B-
nS1eTcS1 pe,[IKOCTblO. np111 L\eHTp8IlbHOM paKe 111
nonHolii 06cTpyK4111111 6poHxa onyxonblO HarHoe-
Hllle pa3s111saeTcS1 B 30He aTeneKTa3a 11111111 06-
CTPYKTlllBHoro nHeBMOHlllTa, np111 nep111¢ep1114e-
CKOM paKe nerKoro - B L\eHTpe HOBOo6pa30BaHlllSI,
Ha cfJoHe HeKpo3a l1 pacna,[la onyxonesolii TKaH111 .
np111 A111¢¢epeHL\1118JlbHOli1 A1118fHOCTl/IKe
Heo6xo.i:1111Mo Y4111TblBaTb so3pacr 6onbHOro,
8H8MHe3, pa3HlllL\Y B Bblpa)f(eHHOCTlll OT,[\eJlbHblX
KfllllH1114ecK111x c111MnTOMOB, AlllHaMlllKY 3a6onesa-
HlllS1 B npo4ecce npoBO,[\lllMOro KOHCepBaTlllBHO-
ro ne4eHl1SI .
5onbwoe 3Ha4eH111e 111Meer MeTOA1114eCKlll
rpaMOTHOe (He MeHee 5 8H8I111130B) L!lllTOnorn4e-
CKOe 111ccneAOBaH111e MOKpOTbl: np111 a6c1..1eccax 111
raHrpeHe nerKoro BblflBnflercs:i 6onbwoe Kon111-
4ecrso He1.hpocfJ111nbHblX neli1Ko4111ros, :macT1114e-
cK111e BOflOKHa , KfleTKlll 6poHX1118JlbHOro 3nlllTeJ1111S1
c Bb1pa>t<eHHb1M111 AlllCTpocp1114ecK111M111 1113MeHe-
HlllS1Mlt1; .QilSI paKa nerKoro r111n1114HO 06Hapy>KeH1t1e
onyxoneBblX KfleToK.
np111 peHTreHOJ10r1114eCKOM lllCCJle,[\OB8Hllllll
AflSI paKa nerKoro xapaKTepHo orcyrcTs111e ne-
p111cfJ0KanbHblX 1113MeHeHlllli1, 4eTKO 04ep4eHH8Sl
nnOLl.l8Ab nopa>t<eH111s:1 , Han1114111e aTeneKTa3a
(cy6cerMeHra , cerMeHra, ,qomr nerKoro), no-
OCTb AeCTPYKU.lt11t1 pacnonaraeTCH 3KCU.eHTPlt14-
o; Ha 6onee n03AH1t1X CT8Alt1HX pa3Blt1Tlr1H paKa
nerKoro nos:isns:iercH AOPO)!(Ka paKosoro n1t1M-
cpaHro1t1ra , cBH3blBatoll.laH onyxonb c KopHeM ,
onpeAens:ieTcH ysen1114eH111e np1t1KopHeBblX n1t1M-
cpoy3nos . ,D,n.s:1 a6cu.ecca nerKoro xapaKTepHa
Bb1pa:>KeHHa5l 1t1Hcp1t1.nbrpa41t15l .nero4HOlll TKaHlll
6e3 4eTKlt1X rpaH1t1L1 , nonoCTb AecrpyK41t11t1 pacno-
n o:>KeHa B L1eHTpe 1t1HQ)1t1.nbrpara, CTPYKTYPa Kop-
HSl nerKoro o6bl4HO coxpaHeHa. 111MetoTC5l raK:>Ke
pa3Jllt14J11Sl 8 KOHrypax Hapy)l{HbJX Jll BHyTpeHHJllX
CTeHOK nonocrn np1t1 paKe 1t1 a6c4ecce nerKoro:
npvi nep1t1cpepV14eCKOM paKe Hapy)l{Hble KOHTypbl
TeHlt1 6yrpV1CTble, MeCTaMlt1 He4eTKlt1e, c HanV141t1-
eM He}f{HblX Hl}f{ei.:1, 1'f,LJ,Yll.("1X B neroYHYIO TK8Hb
(paKOBblill m1McpaHro1t1T, corona maligna) , np1r1
a6c4ecce nerKoro Hapy)f(Hble KOHTYPbl TeHlll He-
4eTKvie (pa3Mb1Tb1e); BHyTpeHH1t1e cTeHKVI nonoc-
T"1 np1t1 nepvictJepW·leCKOM paKe HepOBHble -
«6yxroo6pa3Hble» , np1t1 a6c4eccax, KaK npas1r1-
no, BHyTpeHH1t1e cTeHK1t1 rnaAK1t1e, 4eTK1t1e; B cny-
4ae a6c4ecca Ha np1114e.nbHb1x TaMorpaMMax
O)f(HO yB1t1AeTb npocseT APeH1r1pytoll.lero a6c-
u.ecc 6poHxa, np1t1 paKe nerKoro APeH1-1pytoll.(1t1ill
6poH X He Blt1A8H .
KoMnbtoTepHas:! TOMOrpa¢1-1s:1 B pH,Qe cnyYa-
eB 1r1M eer pewatoll.lee 3HaYeH1.1e , T.K. 6onee or-
Yern111so Bb1s:isns:ier KaK caMy onyxonb, TaK 111 JllH-
Ba3l-1 BHblill xapaKTep ee pocra , a TalOKe Han1r14111e
np1t13HaKOB BHyTp1t1rpy,qHOi:1 m1Mcpa,qeHonarn1t1 .
3HAOCKOnV14eCKOe 1t1ccneAOBaH1t1e B C04eTa-
lt1 fll c A8HHblMV1 6111onc111111 (Bb1s:isneH111e s 6vionrare
onyxoneBblX KneToK) virpaer pewatoll.lYto ponb
np1.1 u.eHTpanbHOM paKe nerKoro; np1-1 nepvicpep1t1-
\.lecKoM paKe OKOHYaTenbHYIO 1t1HcpopMa41r1to MO)f(-
0 nony41t1Tb np1t1 TpaHCTopaKanbHOlll nyHKL.11.10H-
HOlll (acnvipa41-10HH0!11) 61.1onc1t11-1 - 06HapY'f<eH1t1e
KJleTOK 3fiOKaYecTBeHHOlll onyxon1t1 B nyHKTaTe
(acn1t1pare) noATBep)f<AaeT AVlarH03 paKa.
P1.11c 16. nep1.11cpep11t4eCKMH paK npaeoro
n erKoro. npS1MaS1 peHTreHorpaMMa (a): na-
ro.norn4ecKoe TeHeo6pa3oeaH1.11e c nono-
CTbto pacnaAa 1.11 ropr.t30HTaflbHblM ypoe-
HeM e npoeK41.111.11 eepxHeH AOnr.11 npaeoro
n erKoro, nep1.11cpoKanbHaS1 1.11Hcp11tnbTpa4111S1
OTCYTCTByeT; TOMorpaMMa 3TOro :>Ke 6onb-
Horo (6): Ha MHTaKTHOM nerOlfHOM none
onpeAen~eTCSI HOB006pa3oBaHwe B BHAe
y3na c HeCKOilbKMMH 3KCU.eHTp1.114HO pac-
non o>KeHHblMl.ll nonocn1M1.11 pacnaAa.
P1.11c 17. AecTpyKTMBHaSI nHeBMOHMSI
npaaoro nerKoro. npS1MaS1 peHTreHorpaMMa
(a) : Macc1.11eHaS1 eocnan1.11TenbHaS1 MH-
cpi.m bTpal.lM~ a npoeKL.lYIM aepxHelit M cpe.Q-
Hei.1 AOnr.11 npaeoro nerKoro; TOMorpaMMa
3TOro >Ke 60/lbHOro (6): Ha Q:>oHe HHQ:>HnbT·
pal.IHI.II onpeAenSleTCSI noJlOCTb AeCTPYKU.1.11111
n erolfHOM TKaHM, xopowo BMAeH npoceeT
139
~peH111pyt0U(ero a6c1.1ecc 6poHxa (yKaJaH
cTpenKolit).
B nocneAHL1e roAbl ysem14111nocb y111cno
60JlbHblX c 6JlOKHp088HHblMVI a6c1...1eccaM111 ner-
KVIX. noA 6noK1.1posaHHblM a6c4eccoM nernoro
cnep,yer noH"1MaTb Ha11111Y111e s nerKoM orpaH111-
4eHHoill 30Hbl HecneL11t1¢VIYeCKOro HarHOeHlt151 c
nonHblM 111n1.1 4acT1114HbtM HapyweHV1eM npoxo-
AlllMOCTVI APeH1t1pytoll.lero 6poHxa. Y ,D,syx rperelll
6onbHblX 6noK1t1posaHHb1e a6c4eccb1 nerKoro
nporeKatoT 6e3 Bb1pa)f(eHHblX KflVIHVl4eCKlt1X npo-
s:isneHlllVI lt1 Bbl51BJ15llOTCfl peHTreHOJl0rlt14eCKVI KaK
oKpyrnolll VIJ1VI osanbHoill cpopMbl 3aTeHeHVlfl c
4eTKlllMVI , 6yrp111CTblMltl KOHrypaMltl, HepeAKO Ha
lllHTaKTHOM Jl8rD4HOM Q::>oHe. noK8filt130BaTbCfl
6noK111poBaHHble a6CL1eCCbl MOryT B caMblX pa3-
Hb1X OT,l:jenax nerKoro.
P11tc 18. 6noK1.11poeaHHb1i.1 a6cu.ecc
HLll>KHeH Aonr.11 neeoro nerKoro. npsiMasi
peHTreHorpaMMa (a), 60KOBaSI TOMOrpaMMa
(6): MHcpMnbTpa41.11si nero'IHOM TKaHM B npo-
eKU.MYI wecTOfO cerMeHTa, Ha cpoHe MH-
cpr.11.nbTpaTa onpeAensitOTCSI HeCKOflbKO
3Kcr.teHTPM4HO pacno110Jf<eHHblX no11ocrew
AeCTPYKU.1111.11 nerolfHOH TKaHlit.
B AV1arHocrnKe 6noK1t1poBaHHblX a6c4eccos
nern1i1x 1i1Meer 3HaYeH1i1e r11.1arn11bHO co6paHHb11i1
aHaMHe3 c u.eneHanpasneHHblM no1t1cKoM Kn1t1H111-
YeCKHX npOflBJleHHH Ha4a.na "1 Te4eHlt1fl 3a6011e-
BaH1t1fl , yYeT AlllHaM1t1K111 na6oparopHb1x 1.1 peHTre-
HonorwyecK"1X AaHHblX, 3HP,OCKon111Yec1<0VI Kaprn-
Hbl s conocrasneHV11t1 c 3cpcpeKT1t1BHocTbto npo-
BOA1t1Moro ne4eHlt1.51 . np111 6noK1t1posaHHblX a6c-
1..1eccax AecrpyK41t1to nero4HOl/I TKaH1-1 yAaercH
Bb1s:is1t1Tb Ha ToMorpaMMax. B yTO'-lHeH1t11.1 Alt1ar-
H03a noMoraeT ceneKTVIBHafl 6p0Hxorpacp1r1s:i -
narorHOMOHlt14HblM p,ns:1 a6c4ecca nerKoro flBns:1-
ercs:1 3ano.nHeHV1e nonocr1t1 a6c4ecca KOHTpa-
croM 4epe3 4aCTlll\.IHO 3aKpblTblVl 6pOHX, J1V160
4epe3 coce,D,H1t1e 6p0Hx1i1 . np111 orp1r1L1arenbHOM
pe3ynbrare ceneKTVIBHolll 6p0Hxorpacp1111-1 Heo6-
xo.Q1t1Mo BblnOJlHl-1Tb TpaHc6poHXlllaJlbHYIO lr1Jllll
rpaHcropaKanbHYIO 6111onc111to 06pa3osaHV1Sl - Ha-
n1114111e 1...1111ronornyecv.0VI KaprnHbl Hecne1...1111cp11Ye-
CKoro rHOV!Horo socnaneH1r1.s:1 (Hei;;rpocpV1nbHb1e
J1€WKOL1HTbl B CTa,QHH J1"13HCa, fHOHHblCi ,[leTpHT,
MaKpocparn, rVICTlllOL11t1Tbl , rHoepOAHa51 MVIKpo-
c:pnopa) 111 orcyrcrsvre onyxonesblX KileTOK no-
3sons:ier y noAaBn7ltoll.lero 6onbW1t1HCTBa 6011b-
Hb1X lt1CKill041t1Tb ,D,Vl8rH03 nepV1¢eplt148CKOro paKa
nerKoro.
,D,111cpcpepeH4111anbHOL1 .Q1t1arnocrnKe ocrporo
a6c4ecca nerKoro 111 1t1Htj:>V1nbrparnsHo-nHeBMO-
HV14ecKoro ry6epeyne3a e cpa3e pacnaAa noMo-
rator AaHHble aHaMHe3a (npocpeCClt1fl , KOHTaKT c
6onbHblM1t1 ry6epeyne3oM) , 1.1ccne,D,0BaH1-1e MoK-
poTbl, npOMblBHblX BO):l 6poHXOB, noces MOKpOTbl
Ha cne4V1anbHb1e cpeAbl c L\enbto Bb1s:isneHV1H
Mli1K06aKTep111VI ry6epeyne3a , 6pOHXOCKOnlllfl c
6V1onc1t1elll CJllll3VICTOlil o6ono4KV1 6pOHXOB, lt1H-
TeHCll1BHOCTb OTBeTa Ha ry6ept<y1lll1H (npo6a
MaH-ry), 111MMyHocpepMeHTHbtill aHan1113 (onpeAe-
neH111e aHTll1Ten K M111Ko6aKTep111s:iM) , a TalOKe
peHTr8HOnOrtll48CKOe 111ccneAOBaH111e, oco6eHHO
KOMnblOTepHble TOMOrpaMMbl nerKLllX, Ha KOTO-
pblX HepeAKO YAaeTcs:i Bb1s:is111Tb P51AOM c nono-
CTblO A8CTPYKL.\LllLll CB8}1(1118 -ry6ept<yI183Hble 04ar111
(oYarn «OTceea»).
P11tc 19. ~Hcp11t.nbTpaT11tBHblH Ty6epKy-
.ne3 eepxHeH ,aom., nesoro nerKoro c pac-
naAOM.
KoMnbt0TepHaS1 TOMOrpaMMa: MHcpLll.nbTpa-
~LllSI sepxHeM AOflH .neeoro .nerKoro, PstAOM c
11tHcp11t.nbTpaToM eepxHe&'.1 AOflLll .neeoro .ner-
Koro - OllarM «OTCeBa» (yKa3aHbl CTpenKaMM).
HarH0111aw111ec51 Kll1CTbl nerKLllX npoTeKalOT c
MeHee Bbtpa>KeHHOVl KilLllHLllKOVl , He)f{em1 a6CL18C-
Cbl nerKoro: Kawenb yMepeHHbtill , MOKpoTa cn111-
3111cTO-rHoillHas:i, 6e3 3anaxa , n111xopaAKa ASP>KLllT-
CS'I 2-3 cyroK Ill nOA BJ111151Hll18M aHT1116lllOTlllKOB 6bf-
CTPO 111c4e3aeT. PeHTreHonor1114ecK111 KlllCTbl ner-
Koro 111M8IOT xapaKTepHblVl B111A - 3TO OAll1H04Hbte
TOHKOcTeHHb1e nonocrn OKpymollt 111n111 osanbHOVI
cpopMbl , c TOHKlllMlll CTeHKaMLll 6e3 nep111cpoKaJlb-
HOJA socnanlATeJlbHOJA IAHQJli1JlbTP8Llli11A.
P11tc. 20. 803AYWHaSI KMCTa npaeoro
.nerKoro (a - np.HMas:i peHTreHorpaMMa,
6 - KOMnbt0TepHaS1 TOMorpaMMa)
KnL11HLll48CKa51 KapTLllHa HarHOLllBWerocs:i 3XLll-
HOKOKKa nernoro He OTJ11114aeTCSl OT OCTporo a6c-
L.\8CCa nerKoro. B AL11arHocT1t1Ke noMoraeT aHaM-
He3 , yYeT 803M0)f{HOro npe6bf88Hf/151 60JlbHOro B
3HA8Mll14HblX 30Hax , 06Hapy)f{eH1t1e s MOKpoTe
aneMeHTOB x111rnHosoi1 o6ono4Klt1 napa31t1Ta , no-
JlO)f{11tTenbHb1e ceponor1114ecK"1e peaKL.\"1111 (na-
TeKc-arrn10T1t1Hal...\"11t1 , HenpSlMOtlt reMarrmon1Ha-
4111111), IAMMyHocpepMeHTHbllA aHan1113 - 06Hap}l)l<e-
H1Ae aHT111TeJl K 3XlllHOKOKKy. np111 r11t6em1 3XLllHO-
KOKKa 111 0TcnoeH111111 t<yT1t1t<yns:ipHotlt o6ono4KLll na-
pa3111Ta OT X111T"1HOBOM Me)f{Ay Hll1Mll1 nos:iens:ieTCSl
nonocKa B03Ayxa - «Cll1MnTOM OTCnoeHll15l», B
6onee no3AHeM nep1110Ae , npo"1cxo.Q1t1T orno)f{e-
H"1e coneill Kanbl...\lt15l Lil 06bt388CTBJ18HHaSl X"1Tll1-
HOBas:i o6ono4Ka napa3"1Ta xopowo BLllAHa Ha
o6bl4Hb/X peHTreHorpaMMax.
Cne.QyeT noMH1t1Tb, '!TO o6Hapy)f{eHvte c1t1H-
p,p0Ma nonocrnoro vinvi wapoBvtAHOro 06pa30-
aaH111s:i s nerK"1X y 6onbHbtX crapwe 45-50 neT
Tpe6yeT B nepsylO 04epeAb vtCKJll048Hlt151 paKa
nerKoro Ill Bbl)f{IA,D,aTeJlbHa51 TaKTlllKa 3,£leCb HS,QO-
nycrnMa. np111 nop,03peH1t1111 Ha paK 111 Heso3MO)f{-
HOCTb AOK83aTb 3TOT A"1arH03 H8111HB83"1BHblM"1
MSTO.Q8MW noKa3aHa .QWarHOCTlll4SCK8Sl onepa-
L.\"15l - Bll1,[\80TOpaKOCKOnll151 "1J1"1 TopaKOTOM"1S'l co
cp04HblM n1CTOJ10r11148CK"1M 111CC118AOBaH111eM
onepa~"10HHoro Marep111ana (TKaH111 nerKoro,
n111Mcpoy3nos, nnespb1) , 4TO OKOH4aTenbHO pe-
waer sonpoc ,1:11.1arH03a IA onpe,1:1en>1eT ,1:1anb-
He1Awy10 TaKTvtt<y ne4eH"1H 6onbHoro.
140
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~a
60JlbHble c a6c1..1eA"1PY10ll.letlt nHeBMOH"18111
Moryr ne4vtTbcs:i s cnel...\111an"13vtposaHHOM nynb-
MOHonor1114ecKoM OT,[\eneHll1111 MHOronpocpf/IIlbHOtlt
6onbH1t14b1. 6onbHblX c ocTpblM a6c4eccoM vi
r aHrpeHoill nernoro rocmnan"13vtpylOT s OT,[\ene-
H111e rnpaKallbHotlt xvipypr111"1 . Heo6xo.QvtMblM yc-
nos111eM s:isns:ierc.s:i ·1113omll.(fl!s:i 6onbHOro s oT-
AellbHYIO nanary, o60PYAOB8HHYIO C"1CTeMOtil
nop,a4111 ysna)f{HeHHoro K"1cnopoAa . .0,"1eTa
,D,OJl)f{Ha 6b1Tb M8X8H"1'1eCKLll "1 XlllM"1Ll8CK"1 Ll.la-
AS'!Ll.leill , BbtCOKoKanopvtlAHolA , o6orall.leHHOIA 6en-
1<aMJ.1, BJ.1TaMWHaMJ.1 J.1 MJ.1Kp03neMeHT8Ml.1.
Ba>1<Hetltw111M ycnos"1eM ycnewHoro ne-ie-
H1<1s:1 a6c4eccos vi raHrpeHbl nerK111x s:isns:ieTc5"'1
BblS1BneH"1e np111-i111Hb1 3a6011esaH1t15! . TaK, np1t1
acnvipal...\"10HHOM MexaH"13Me , s nepsy10 04epe,l\b
He06XO,l:llAMO BOCCT8HOBll1Tb HOpMaJlbHbttlt ,1:1pe-
H8)f{ 6poHXOB (y,[\anvtTb VIHOpO,[\HOe Teno) , np"1
o6cTPYKL.\"1111 6poHxa onyxonblO Pa.l:\"1KanbHblM
6y,1:1eT oneparnsHoe ne4eH111e , np111 reMarnreH-
HblX a6c4eccax - conyrcTBy10ll.lee ne4eHvte oc-
HOBHOro 3a6onesaH"15! , np111sep,wero K cpopM"1-
posaH1t110 TpOM603M6onoB "1 T.,[\.
KoHcepsamusHoe /leLfeHue
OcHOBHbiMVI COCT8BJ15110ll.lll1MLll KOHCepsa-
n1BHOro Jl8Ll8Hll1Sl S'IBJ1S1IOTC5l: nOBblL.UeHl!le npo-
XO,D,"1MOCTll1 AblXaTenbHblX nyTetlt , aHrn6aKTep111-
anbHasi Tepan111s:i, li1Hcpy3"10HHaSl Tepanlf!s:i , KOP-
pe1<1..(J.1H J.1MMYHJ.1TeTa , nepcf:>y3J.10HHble MeTO,D,bl
p,eTOKC1!1Kal...\llllt1 opraH"13M8.
BoccraHosneH"1e 6poHx111anbHOVI npoXOA1t1-
MOCT1t1 Ha CTOpoHe nop8)f{8H"151 s:isns:ieTCSl OCHOB-
HblM ycnos"1eM ,l\1151 xopowetlt caHal..\111"1 a6c4ecca
(raHrpeHbl) nernoro.
no31AL.\lllOHHbltA p,peH8)f{ 6pOHXOB lt1 ,D,blXa-
TeJlbHYIO rll1MH8CTll1t<y 60llbHOtlt c OCTPblM a6c-
L.\8CCOM "1 raHrpeHolii nerKoro ,[\On:>KeH BblnOJlHS'!Tb
e)f{eAHeBHO , LITO n03BOJ151eT yp,an111Tb HaKon"1B-
WYIOC51 3a H04b MOKpory, a np111 OTKpblTOM .Qpe-
HV1PYIOLl.l8M 6poHxe - rHoill 1113 nonocT111 a6c4ecca .
Ecn"1 no3sonHeT cocT051H"1e , no31111...\li1DHHbltA APe-
Ham: 6pOHXOB nosrop5110T B T848Hf/le ,QH51 He-
CKOJlbKO pa3 .
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111cnonb3YIOT MYKOJ1"1Tlt1K"1 IA npoTeomn111-iecK1t1e
cpepMeHTbl.
My1<onlllT1AKli1 CTIAMyntApylOT Bblpa6orny CJlll/-
3LllCTOro ceKpeTa, yMeHbW8IOT B513KOCTb "1 nOBbl-
walOT MYKOL\11111"18PHbltlt KI1"1p8HC MOKPOTbl. 3¢-
cpeKTlllBHblM MYK011V1T"1KOM s:iens:ieTcs:i aM6po1<con .
npenapaT Ha3Ha4aeTC51 per OS (Ta6neTKvt , K8n-
CYllbl) no 30 Mr 2-3 pa3a/cyrK111 , s B"1,D,e 1t1Hrans:i-
L.\"1tlt 4epe3 He6ynalA3ep no 30 Mr 2-3 pa3a/cyrK1t1 ,
8
A6c4eA111py101.1.1aH nHeBMOHlllH - npoMe:>Kyro1.1HaH
(Me)l(,D,y nHeBMoH111eiil 111 a6c4eccoM) cj:JopMa HarHoeH111H
nero4HOiil TK8Hll1 , np111 csoeBpeMeHHOM 111 8AeKB8THOM
ne4eHl1111 MO>KeT noJlHOCTblO pa3peWl/1TbC~ .
napeHTepanbHO (nlK, BIM, BIB) no 15-30 Mr 2-
3 pa3a/cyrK111 .
AL\eTlllm..\lllCTelllH (AL\L\, MYKOMlllCT) H83H8-
4aercs:i per os no 200 Mr 2-3 pa3alcyrK111 , BIM no
300 Mr 1 pa3lcyrK111 , B BlllAe l.1Hrans:il.\111Vi no 300 Mr
1 pa3lcyTKlll .
B Ka1.1ecTBe 6poHXOA111naTaTopoB 111cnonb-
3y10r (3 2 - aroHlllCTbl 111 3ytj?111nm1H. Canb6yraMon
(6epoTeK) H83H8Y8IOT no 1-2 BAOX8
3 pa3a/cyrKlll . 3ycp111n11111H BBOAs:lT BHYTPlllB8HHO
no 10 Mn 2,4 % pacTsopa 1-2 pa3alcyrK111, npe-
napaT noMlllMO 6poHXOAlllI1aT111py10U\ero AeVicr-
Bllls:l, CHlll)l(8€T A8BJ1€Hllle B M8J10M Kpyre KPOBO-
o6pall.\eHlllS1 Ill cn1Mym1pyeT noYeYHblVi KpOBOTOK.
npoTeOJ1111T"14€CKllle cpepMeHTbl 06Il8A810T
MHOroKoMnOHeHTHblM AeViCTBllleM: yMeHbW810T
B513KDCTb MDKPOTbJ sa cYer rlil,llpom1sa nenTYJ,llHbJX
CB5l3eVi , cnoco6crsy1ar n1113111cy 6aKTep111Vi , BHyr-
p111cocyA111CTblX TpoM60B, Q:>1116p111Ha B 30He Bocna-
J18Hlll5l , nOBblW8IOT cp8rDL\lllT03 . OCHOBHblMlll npe-
naparaMlll f!BJlS110TCfl Tp111nc111H , XlllMOTplllnClllH ,
ep p111n111T111H , p11160HyKnea3a 111 A€30Kc111p11160HyK-
n ea3a. nepeA BBeAeHl/leM cpepMeHTOB 60J1bHOVi
AOil>KeH Bb1nonH111Tb no3111L\lllOHHb1Vi APeHa)I( 6poH-
xoB Ill TU\8TeJlbHO OTK8WJ15lTb MOKpory.
B Blll,D,e lllHranfll\lllVi rp1.rnc111H np111MeHf!IOT no
10-50 Mr, npeABap111TeJ1bHO paCTBOPlllB B 5 MJl 0,9
% 1>130ToH1111.1ecKoro pacTBopa; Ae30Kc111p11160HyK-
nea3y no 6 Mr (3 Mn 0,2 % pacrBopa) s re4eH111e
10-1 5 MlllHyr no 2-3 pa3a B .QeHb; repp111n111T111H no
100 npor eom11rw-1ecK111x e,D,lllHlllL\ (nE) Ha 5 Mn 0,9
Yo 111 30TOHlll1.JecKoro pacTsopa 2 pa3a B A8Hb.
He yrpar111n111 csoero 3Ha1.JeH111f! 111 rpaAlllL\111-
oHHble orxapt<V1B8IOU\111€ cpeACTBa: H8CTOlll rpaB
1.1 a6pel.\a , 6arynbHlllKa , repMonc111ca , npenapaTbl
MOAa Ill T.A.
np111 60J1bWOM KOilllll.JeCTBe rHOViHOVi MOKpO-
Tbl Ill HeacpQ:>eKTlllBHOM Kaume (HeB03MO>KHOCTlll
OTK8WJ15lTb MOKpory) noKa3aHa 6pOHXOCKon1111.1e-
CK8S1 caHaU,lllfl npw nOMOU\W qm6po6pOHXOCKona.
C aHau1110HHb1e 6poHxocKon111111 AOil)f(Hbl Bbmon-
HSnbcfl e>KeAHeBHO. Bo speMfl 6poHxocKorn11111
eo6XOAlllMO Tll.\aTenbHO y,D,an111Tb rHoViHylO MOK-
pory, crycrK111 cp1,-16p111Ha , npoMblTb nopa)l(eHHble
6pOHXlll TennblM (37° C) pacrnopoM cpypm-11,-1n-
m1H a 1:5000 (Mo>KHO 111cnonb3osaTb 0,1 % pac-
rnop conacpypa 111n111 1 % pacrsop AlllOKClll,D,lllHa c
cpM3111 0JlOrlll4eCKlllM pacrsopoM B p83BeAeHlll"1
1: 1). 06LJ.!ee KO/llll4€CTBO C8HIAPYIOU\ero pacrno-
pa Kone6neTC5l OT 40 AO 100 Mil . no OKOH48H"1111
npoueAYPbl s nopa>KeHHble OTAenb1 nernoro He-
06xoA111Mo BB8CTlll nporeOJllllTlll48CKllle cpepMeH-
: 20-40 Mr rp1,-1nc111Ha 1,-1m1 X"1Morp1,-1nc111Ha pa3-
se,D,eHHoro s 5 Mn 0,1 % pacTBopa cpypar111Ha
HJllll 5 MJl 1 % pacTsopa AlllOKClllAlllHa .
Ha KYPC ne1.1eH111f! Heo6xoA111Mo s cpe,D,HeM
5-7 C8H81..\lllOHHblX 6pOHXOCKom1Vi , HO He MeHee
3-x 6pOHXOCKon111Vi B H8.Q8Jll0.
HeacpcpeKT111BHOCTb caHaL\lllOHHblX 6p0Hxo-
a<on111 Vi 5lBil5leTcs:i noK838HllleM K 3HAo6pOHXlll-
141
anbHOMY ,D,peH111poBaH11110 111 caHal.\111111 nonocn1
a6CL\ecca nOA KOHTponeM peHTreHreneB"131110H-
HOro 3KpaHa . 3ro B03MO)KH0 TOJlbKO B MHOro-
npoQ:>lllJlbHOM CTal..\lllOHape, np111 H8Jlllll.Jllllll Heo6-
XO,D,"1M oro o6opyAOB8Hlllfl Ill no,D,roTOBJ18HHblX
cneL\1118JllllCTOB (Bp848-3HAOCKOnlllCTa, TOpaKaJlb-
HOro x111pypra).
np1'1 yrp03€ neroYHOro KpOBOTeYeHlllfl npe,D,-
n04TeHl/le cneAyer DTAasaTb nDAHapK03HOVi
6pOHXOCKOm1111 np111 nOMOl.1.\111 >K8CTKOro 6poHXO-
CKOna9. Ecn111 )K€CTK111Vi 6poHxocKon cHa6)KeH lllH-
)KeKTopoM KlllCilOPOA8, TO 4epe3 ry6yc )K8CTKOro
6pOHXOCKona MQ)KHO nposecrn 06bl4Hb1Vi cp1116-
po6poHXOCKOn 111 c era noMOU\blO AOnonH111TenbHO
C8HlllpOB8Tb cy6cerM8HTapHble 6poHXlll , YTO no-
BblClllT 3cpcpeKTlllBHOCTb ne1.Je6H0Vi 6pOHXOCKOn111L1 .
np111 OTCYTCTBllllll 6pOHXOCKOna c 48Ilbl0 ca-
H8L\llllll rpaxeo-6poHx111anbHOro Aepesa 111cnonb-
3y1ar Tp8HCH838IlbHYIO KaTeTep11138L\llllO Tpaxe111 Ill
KpynHblX 6poHXOB lllJllll MlllKporpaxeocTOMllllO.
AHmu6a1<mepua11bHOfl mepanuR
B nepBble AHlll 3Mn111p1114ecK111 Ha3Ha4aeTc5l
KOM6111Hal\"1S1 6aKT€PlllL\lllAHblX 8HTlll6lllOTlllKOB
WlllpOKOro cneKTpa A8il1CTBlll51 . npenapaTaMlll Bbl-
6opa 5IBil5!10Tc.s:i: aM0Kc1111.41111111111H/KJlasyaHar: s/s
3-4 r (AO 6 r)lcyTKlll B 3-4 BB8A8Hlllfl ; l..\8Q:>onepa-
30Hlcynb6aKTaM : BIB 2-4 (AO 8 r)lcyTKlll B 2 BBe-
A8Hlllfl ; KOM6111H8L\lllfl uecpoTaKClllMa: BIB 3-4 (AO 8
r/cyTKlll}, KI1111HA8MlllL\111Ha 0,3-0,9 (AO 2,4 rl cyTK"1)
Ill MeTpOHll1A830Jl8 1,5 r/ cyTKlll B cyTKlll B 3-4
BBe,QeH11t5l ; lllMl/lneHeMIL.1111Il8CTaTlllH: BIB 2-4
rlcyTKlll B 3-4 BB€A8Hlllfl ; MeponeHeM 3 rlcyTKlll B
3 BB8AeH111S1 ; uecpT83111AlllM : BIB 3-6 rlcyTKlll c
8MJ.1Kal..\J.1HOM 1,5 r/cyTK1'1 B 3 BBe,.QeH1'1fl; JlJ.1HKO-
MlllL\lllH 1,2-2 ,4 rlcyTKlll c L\lllnpocpnoKCaL\lllHOM
0,4-1 ,2 rlcyrKlll B 2 BBe,l:\eHllls:l .
nocne 111.QeHr111cp111Kau111111 naroreHHoi::i M"1K-
pocpnopb1 , BblnOJlH5l€TCfl KOppeKL\11151 Tepan111111 c
y1.1eTOM pe3yJlbT8TOB 8HTlll6lllOTlllKOrpaMMbl.
Ha nepBOM arane ne4eH111s:i aHrn61110T111K111
Heo6xoA111Mo BBOA"1Tb BHyrp111seHHo, a no Mepe
ynyYWeHlllS1 COCTOS1H"1S1 60JlbHOro - BHyrplllMbl-
weYHO. ,[\Jl.fl npocp1'1naKT1'1KJ.1 KaHAJ.1A03a c nepBb!X
AHeVi noKa3aHo Ha3Ha4eH111e aHrnrp1116KOBb1x
npenaparos: cpnyK0Ha3on 6-10 MrlKrlcyrK111 , raK-
>Ke MO)f(HO lllCnOJlb30B8Tb HlllCT8TlllH B Ta6neTKax
no 500 Tblc. EA 4 pa3a s A€Hb 111n111 neBop111H no
250 TblC. EA 4 pa3a s ,D,eHb.
HeyAosnersop111renbHb1e pe3ynbTaTb1 Me,D,111-
KaMeHT03Horo Jl848Hlllfl OCTpblX nero4HblX Ha-
rHoeHlllVi CBf!38Hbl c TPYAHOCrnM111 co3A8Hlll5l ne-
4e6HblX KOHL\8HTpa4111Vi 8HTlll6lllOTlllKOB HenqcpeA-
CTBeHHO s rKaHS1X naronor1111.JecKoro o4ara. no-
aroMy Heo6xoA111Mo w111pe 111cnonb30B8Tb AOnon-
9
np111 pa3Bli!Tlillil nero4HOro KpOBOTe4eH lilfl BO Bpe-
Mfl caHa4111111 6poHx111anbHoro Aepesa ~ecTKlll~ 6poHXo-
cKon no3BOJlfleT BblnOJlHlllTb BpeMeHHYIO OKK.lll03lill0
6poHxa noponOHOM Iii HaAe~HO OCTaHOBlllTb KpOBOTe4e-
Hiiie .
Hlt1TeJlbHble nyrn BBeAeHlt151 JleKapCTBeHHblX npe-
napaTOB: sHyi-p1t1TKaHeso~ 3neKTpotjJope3 aHT1t1-
61t1ornKOB, Henp51MylQ Illl!McpoTpOnHylQ TepanVllQ.
MeTOA BHyTpmKaHeeoro 3IleKTpotjJope3a
OCH088H Ha C04eTaHHOM npV1MeHeHV11t1 aHT1t16V10-
Tlt1KOB BBOAll1MblX BHyTp111eeHHO 111 nocT051HHoro
3IleKTpw-iecKoro ToKa , nponycKaeMoro 4epe3
rpyAHYID KJleTKY s npoeKu,vi111 30Hbl AecTpyKu,1t1111
Jlero4HO~ TKaHVI. np111 3TOM npol/ICXOA111T 3JleK-
Tp03Jl111Mll1H8U,11151 aHrn61110T111Ka 1113 KPOBOTOKa B
nopa)f{eHHble TKaH1t1 , rAe OH KOHU,eHTp1t1pyeTC5I B
Ha1116onbweel crnneH111 .
Henps:iMas:i n1t1McpOTponHas:i Tepanv.s:i no3BO-
m1eT C03AaB8Tb BblCOKltle KOHU,eHTpau,1t11t1 aHT1t1-
61t10Tll1KOB Henocpe,D,CTBeHHO B o4are nopa)f{e-
HL151 , 111cn0Jlb3Y51 np111 3TOM 3H84111TeJlbHO MeHb-
W1'1e A03bl npenapaTa . Ue11ecoo6pa3HO co4e-
TaTb BHyTpVJseHHbliil nyTb sse,LleHVJ.s:i aHrn6VJorn-
Kos c 3H,IJ,Oillt1McpaTll148CKll1M , KOrAa OAVIH 1113 aH-
T1116aKTep111ailbHblX npenaparne BBOA51T BHYTPVl-
aeHHO, ,.Qpyroi-1 - 3H,.QOnVJMcparnYeCKlll.
_
MeTOA111Ka Henp51MOCI JllllMcbOTPOnHoel Tepa-
nt11t11: Henocpe,o,crseHHO noA Me1.JeBll1AHb1~ orpoc-
TOK B K848CTB8 m1MtjJOTponHoro cpe,D,CTBa BBO,IJ,flT
64 E,D, n111p,a3bl (npep,sap111renbHo nt11p,a3y pacreo-
ps:it0T B 2-3 MJl 0,5 % pacTBopa HOBOKa111Ha); 4e-
pe3 5 M£1HYT, He BbfH£1Ma5'1 1t1r.ny, BBOAS'IT 1/2 cy-
T04HO~ A03bl aHT11161t10Tll1Ka w111p0Koro cneKTpa.
np111 Ts:l)f{eJlOM nporpecc111pyt0ll\eM Te4eHll1lll
3a6onesaH111s:i B03MO)f{HO nps:iMoe esep,eH111e aH-
r1116ii10T111KOB B fPYAHOCi Jlll1Mcf:JaT11148CKiilel npOTOK,
a TaK>Ke B 6pOHX1118JlbHble apTep111111 Ha CTOpOHe
nopa)f{eH111s:i.
npOA0Jl)f{ll1T8JlbHOCTb 8HT1116aKTepll18JlbHO~
1epan111111 onpep,ens:iercs:i 111Hp,iiiB111AyanbHO. CTo~­
Kas:i HopMailt113au,11151 TeMneparypbl rena, 111c4e3-
HoseH111e 111Hcp111nbrpau,111111 111 n111KBll1AaU,lll51 nonoc-
re~ p,ecrpyKu,111111 B nerKoM, HOpMan1113au,ii151 reMo-
rpaMMbl' 51BJ151tQTC51 Kpmep11151M111 AI151 OTMeHbl
8HT1116111on1KOB.
He npeyMeHbwas:i 3Ha4eH111s:i aHT1t16111or111KoB
B KOMnneKCHOM ne4eHll1111 OCTpblX nero4HblX Ha-
rHOeHiiiel , Heo6XOA111MO nOA4epKHYTb , 4TO ycnex
aHrn6a1<rep111anbHO~ Tepan111111 np111 mo6oM cno-
co6e BBep,eHll15l npenapaTOB BO MHOroM 38Bll1Cll1T
oT cBoespeMeHHoro 111 aAeKBaTHoro ,o,peH111poBa-
H1-1.s:i rnoi.1HblX BHYTpVJnero4HblX nonocTeiil .
/11HcfJY3UOHHOR mepanuR
L(enblO 111Hcpy31110HHOi:1 Tepan1111t1 518Jl51eTC5l
06ecne'-teH1t1e 3HeprernyecKoro 6anaHca, napeH-
TepanbHoro n1t1TaH1t151 , KoppeKU,11151 BOileMl/IYeCK111X
Ill peonOr1t1YeCKll1X HapyweH1t1i:1 , p,e3"1HTOKCll1K8U,lt151
opraH"13Ma.
BcnoMorarenbHoe napeHrepanbHOe n111ra-
H1t1e p,on>KHO o6ecneYlllTb nocrynneH1t1e B opra-
Hlt13M 6onbHOro He MeHee 8 - 16 r a3ora B CYTKll1,
4TO COOTBeTCTByeT B/B BB8AeHVllO 0,5-1,0 Jl aMltl-
HOKVICilOTHblX pacTBOPOB (aM1t1HOCTep111n , non1t1-
aM111H , aM111Hocon 111 ,o,p.) B cMec1t1 c 25-40 % rnio-
K030~ AO 1,5 - 2 n/cyTKVI .
142
,Qns:i Ae31t1HTOKCll1Kau,1t1111 opraH1113Ma np1t1Me-
Hs:l10T pacTsop peaM6ep1.1Ha. 83pocnb1M peaM-
6ep1t1H BBOA5lT BHyTp1t1BeHHO KaneilbHO co CKOpo-
CTblO He 6onee 90 Kanenb/Mll1HYTY B o6beMe
400-800 MJl/CYTKVI . CKOpOCTb sse,o,eHlllS'l npena-
para "1 ,Q03111pOBKY onpep,eI15llOT B COOTBeTCT8111lt1
co cTeneHblO TH>Kecn1 3a6onesaH111s:i 6onbHoro .
Ans:i KoppeKu,111111 r111nonpore111HeM111111 111cnonb-
3yioT 5 % 111n111 10 % pacrsop anb6yM1.1Ha, Ans:i
ne4eHlll51 aHeMJ..1111 - CBe>Ke3afOTOBileHHYIO 3plllT-
pou,111TapHylQ Macey.
Cne,LlyeT y4111rb1BaTb, 4TO 06ll\1t1~ o6beM
BBO,!J,VIMO~ 60JlbHOMY >KVIAKOCTVI (BKill04as:I 3HTe-
panbHOe n1t1TaH1t1e) He AOJl)f(eH npeBblWaTb
40 Mn/Kr/cyrKM .
8b1c0Kas:i npoTeon111rn4ecKas:i aKTll1BHOCTb
CblBOpOTKl/1 KpOBl-1 np111 rHO~Ho-p,ecrpyKTll1BHblX
npol...(eccax nerK111x 7!Bns=1eTcs=1 noKa3aH111eM K Ha-
3Ha4eH1t1t0 aHrncf:JepMeHTHblX npenaparoe: KOH-
Tp111Kana no 80 TblC. E.Q/cyTKl/1 111n111 ropAoKca 300
TblC. E,lJ/cyTKlll B Te4eHltle 7-10 ,D,Hew.
,D,m111111KBll1Aau.1111.1 peonorn'-tecK111x HapyweH1t1V! ,
ynyYW8Hll151 Mlt1KpOU,111PKYI151U,111111 B 30He socnaneHVIS'I
noKa3aHo Ha3HaYeHltle MaJlbfX A03 Hlll3KOMOileKY-
ns:ipHoro renap111Ha: 3HOKcanap111Ha HaTp1115l (KileK-
caH) no 40 Mr n/K 1 pa3/cyrK111, H8Aponap111Ha Kanb-
U,11151 (cppaKc1t1nap1t1H) 0,3-0,6 Mn /CYTK111 ll1Jlll1 06bl4-
Horo HecppaKu,1.10H111posaHHoro renap111Ha no 5000
E)J. 3-4 pa3a/cyrK111. npoTVIBOnoKa3aH"18M )J,Jl51 Ha-
3Ha4eHlll5l renap111Ha ~sns:ieTC5l KposoxapKaHbe ll1
yrpo3a nero4Horo KposoTe4eH111s:i.
nosbJWeHue conpomua11ReMocmu
Op20HU3MO
li1MMyHocynpecc111s:i np111 rHoillHo-
AeCTPYKT111BHblX npou,eccax nerK111X BO MHOroM
onpeAen~eTC51 fHOVlHOi:1 VIHTOKClllKa4111~ . n03TOMY
ceoespeMeHHOe ,o,peH111poBaH1t1e rHO~HblX oYaros
B nerKlllX 3aMeTHO nOBblWaeT 3cpcpeKTll1BHOCTb
lllMMYHOKopp111rnpyioll\eW rnpan111111. Uenecoo6-
pa3HO C048T8Tb KaK nacc111BHble, TaK 111 aKTVIBHble
MeTOAbl CTlllMYils:IU,lt1111 lllMMYHVITeTa.
np111 AOK838HHOW CTacPlllI10KOKKOBOW 3nfOJ10-
rltllt1 3a6oneBaHltls:l lt1CnOJlb3YIOT aHTl/ICTacpll1IlOKOK-
KOBYIO rnnepll1MMYHHYIO nna3MY no 150-200 Mn 2-
3 pa3a B HeA8IllO, cratjJVIJ10KOKKOBbli:1 raMMa-
mo6y11111H B/M no 9 Mn B Te4eH111e 3 AHeVI. BblCO-
K03cpcpeKT"1BHO np1.1MeHeH1t1e cracpltlnOKOKKOBOro
6aKTep111ocpara B so3pacrat0Ll..le~ p,o31t1posKe: 0,5-
1,0-1,5-2-2,5 Mn s/M e>Ke,D,HeBHO 1.1n1t1 4epe3 p,eHb
(6aKTep111ocpar111 MO)f(HO BBOAll1Tb 3HA06pOHXL1aJlb-
HO, a TalOKe Henocpe.QcreeHHo s nonocTb a6c-
u,ecca), cracp1.1noKOKKosoro aHaTOKClllHa no 0, 1-
0,3-0,6-0,8-1 Mn Ill T.,Ll. ,[10 2 Mil n/K Ka}l\l\ble 3 AHR
Ocno)f(HeHHoe Te4eH111e 3a6onesaH111s:i (pa3-
B1t1T111e cenc1t1ca) s:iBm:1eTcs:i noKa3aHllleM K Ha3Ha-
4eH£1IO lllMMyHorno6yn111HOB. c 3TOM 1...1e11b10 wc-
nOilb3YIOT OTeYeCTBeHHbl~ VIMMyHomo6yn1t1H 4e-
noBeKa HOpM8IlbHblVl no 25-50 Mil/CyTKl/1. npe-
napaT npe,a.sap111TeilbHO pa3so,q~T 0,9 % l.430TO-
 4eCKlllM paCTBOpOM lllJllll 5 % paCTBOpOM rntO-
bl ,Qnfl lllHbeK1..1111lli 1113 paC'-leTa 1 48CTb npena-
oarn 111 4 4acrn pa3BOAS'lll.\ero pacTBopa, BBO.QS'IT
3. B co CKOpOCTblO 8-10 Kanenb B MlllHyTy, Ha KYPC
e4eHlll51 OT 5 AO 10 TpaHCcPY3Vliil.
3¢cpeKTlllBHblM lllMMYHOKOppeKTopoM S'IBJlS'l-
eTCS'I non1110KCV1,QOH111ili , KDTOpb1i4 HaJHa4aeTcs:i no
6 Mr BI B (BIM) e>Ke,llHeBHO, 8 T€4€H£.1e 3 AHe£1,
~ 4epe3 ,Q8Hb, Ha eypc ne4eH£.151 10-12 £.1Hb-
m oMamuYecKoe neYeHue ·
3ceM 6onbHblM c a6c4eccaM111 111 raHrpeHoi4
OKa3aHa ClllMnTOMaTl/l48CKaS'I repan111s:i.
lllJ18KTlllKlll Ill ne4eHlllS'I AblXaTenbHOlli Ill
crcocy,QlllCTOlli HeAOCTaT04HOCTlll np111-
0Kc111 reH0Tepan111t0 yBna}l<HeHHblM Klll-
--~-- ~M, cep,Qe4Hble m111Ko311t,Qbl: BIB cTpo-
0.05 % 1 MJl Vlnlll KOprillllKOH 0,06 % 1
- ~ oacrnope rnlOK03bl 5 % - 100 Mn B col.le-
e npenapaTaM111 Kan11151: Kan11151 xnop111,Q 7,5
.u1 111n111 naHarnH 20 Mn, no noKaJaHlllS'IM
- - - aJOT canypernK111 (Q:>ypoceM111.Q). np111
~ - OCTllt K rlllnOTOHllllll - cynbtj)OKaM¢oKalllH no
- 2-3 pa3a /cyrK111 ; AfiS'I KoppeK4111111 rnnep-
- nep¢anraH no 100 Mn BIB 111n111 pacrnop
= ,=-"' a 50 % 2-4 Mn B C04eTaHl/IVI c ,QlllMe,QpO-
: - 1 Mn B/M; ,QnS'I HOpMan1113a4111111 CHa -
:::i!r::10-ap6111Tan B rn6neTKax no 0,1 Ha H04b.
bl aemo1<cu1<a4uu u
0
0UKOM eHm03HOU UMMYHOKOppeK4UU
nporpecc111pyt0ll.leM re4eH111111 rHoi4Ho-
BHoro npo1..1ecca s nern111x TpaA1111..11110H-
e OAbl neKapcTseHHoro ne4eHlllS'I Mano-
BH bl, n03TOMY B KOMnneKCHYIO repan111t0
Heo6XOAlllMO K8K MO)l(HO paHbWe
3KcrpaKopnopanbHb1e MeTO.Qbl AeTOK-
111 lt1 MMYHHOi4 KOppeK1..1111111: o6MeHHbli4
-==~111at:p1ep e3 , ynbrpa¢111oneT0Boe 06nyL1eH111e
:::llil"-,.•......,.8"1 , Henps:iMOe 3JleKTpOXlllMlll4eCKOe
e nna3Mbl KPOBlt1.
GOK03¢¢eKTlllBHblM Mero.QOM KOppeK'-11111-1
er a, peonor1114€CKl/IX Ill reMOCT8T1114eCKVIX
1.1~ S'I BJlS'leTCfl KOM6ll1Ha1..1111s:i nna3Mac:Pe-
: JaMell.\eH1t1eM YAaneHHolli nnaJMbl cBe}l<e-
~il-o::~P-H H o i4 AOHOPCKOJ/1 nna3MOi4 (nyywe -
-.a3 oC1) , Ha3H848HllleM 111Hr1116111TOPOB npo-
"1 ManblX A03 renap1t1Ha. Ha KYPC ne4e-
XOAlllMO He MeHee 3-5 npo4e,Qyp.
;t,Tpatj)111onernBoe 06nyYeH111e ayT0Kpos111
B 3KCTpaKopnopanbHOM KOHType ocy-
T np111 noMOll.\111 annaparns "ll130nbAa"
- .a.le>KJJ,a'', B Kon1114ecrse 1,5-2 Mn/Kr seca
o. Ha KYPC neYeH1115! ,Qocrnrn4HO 5-6 ce-
• <DOAK (1t1HTepsan Me)K,Qy ceaHcaM111 - 48
- Hen p51MOro 3JleKTpOXlllMl/l4eCKOro OKI/IC-
a3Mbl Kpos111 111cnonb3YIOT ayTonna3My,
IO BO BpeM51 nna3Matj)epe3a. nnaJMY
143
06pa6arb1satoT pacrsopoM r111noxnop111ra Ha-
Tp1115!, nony1.JaeMoro ex tempore Ha annapaTe
"3,[\0" lit BBO,D,S'IT BHYTPlt1BeHHO (B 1..1eHTpanbHble
seHbl!) . Ha KYPC neYeH111s:i AOCTaTOYHo 5-6 111Hcpy-
3111J/1 ayTonna3Mbl c lllHTepsanoM 48 4acos .
3KcrpaKopnopanbHb1e MeTOAbl AeT0Kc111Ka-
1..1111111 Ill lt1MMYHOKOppeK1..1111111 , s:lBJls:ls:lCb no Cyll.\eCTBY
csoeMy naroreHeTwYeCKlllMllt MeTop,aM11t ne4e-
HUR, n0380flRIOT He ronbKO 3cfJc/JeKTUBHO y4a-
n111Tb 3HAOTOKClllHbl Ill KOpp111r111poBaTb lllMMYHHbll'il
roMeOCTa3, HO Ill Jll/IKBlllAlllPOBaTb HapyweHl/IS'I
peonor111111 KPOBVI , yMeHbWlllTb ffllnOKClltlO TKaHei4 ,
CT111Myn111poBaTb MeXaHfll3Mbl ecTeCTBeHHOi4 Ae-
TOKClt1K81..1111111 opraHVl3M8.
onEPAT/llBHOE llE'-IEH/llE
,D,peHupoBaHue nonocmu a6cu,ecca
,[1,peH111posaH111e nonocrn a6c4ecca nyTeM
TopaK04eHTe3a OTHOCVITC51 K MaJlOVIHBa3111BHblM
Mern.QaM x111pypr1114ecKoro ne4eHlll51 6onbHblX c
OCTpblM a6c4eCCOM nernoro. noKa3aHllleM K
,QpeH111posaH111t0 5!Bn5lt0TC5! nnoxo onopo)l(Hflt0-
ll.\lllec51 4epe3 6poHx nep111Q:>ep1114ecK111e ocTpb1e
a6c4eccb1 nerKlllX c .QlllaMeTpoM nonocrn 6onee
5 CM . Heo6xo.QlllMblM ycnos111eM .Qn51 BbmonHe-
HVl51 onepa1..1111111 flBnfleTC51 Ham14111e cpall.\eH111i4
nerKoro c nap111eTanbHOi4 nnespoi4 B npoeK4111111
a6c4ecca.
TexH111Ka APeH111poBaH1115! a6c4ecca nernoro:
no,Q KOHTponeM peHTreHTeneBl/l31110HHOro 3KpaHa
Ha rpy.QHDlli l<JleTKe onpe,Qem110T T04KY ,Qml
nyHK4111111 a6c4ecca. Co6nt0,Qas:i npas1r1na acem111-
K111, BblnOJlHS'llOT MeCTHYIO lllHcPVIIlbTpa1..11110HHYIO
aHeCT€3VllO MflrKlllX TKaHelli pacTBOpOM HOBOK8Vl-
Ha 0,5 % - 20 Mn , nyHKn1pytoT rHolliHVIK. Y6e-
AlllBWlllCb , 4To 111rna HaXo.QlllTC51 B nonocrn a6c-
1..1ecca (peneHKoHrponb), np111crynat0T K APeH111-
posaH111t0. P>iAOM c 111rnoi4 cKanbneneM npo1113so-
A~n pa3pe3 KO)l(l/I AI1111HOlli AO 1 CM , cneAYfl no
111rne, np111 noMOll.\111 rpoaKapa-KaTerepa c Ha-
PY)l(HblM ,QlllaMeTpoM 5,3 MM (16Ch), BblnOJ1H5ltoT
TOpaKOL.1eHTe3. npoXO)l(,Q€Hllle TpOaKapa B no-
JlOCTb a6c1..1ecca nOCTO>IHHO KOHTpon111py10T
peHTreHocKon1114ecK111. T poaKap-KaTeTep norpy-
)KalOT s nonocTb a6c4ecca Ha rnyforny He 6onee
3-4 CM , nocne 4ero MernnmNecKVli4 cT111neT yAa-
IlfllOT, a KaTeTep (AP€H8)1() cPlllKCVIPYIOT K KO)l(e 1-
2 y3noBblMV1 wsaMVI , nOAKnl04atOT no 5t0nay 111n111
K npoT04Ho-acn111pa1..11110HHOif1 c111cTeMe (ny4we
cpa3y 111cnonb30B8Tb TpoaKap-KaTeTepb1 c AO-
nonH111TenbHb1M K8H8J10M ,Qnfl BBe,QeHlllfl caHlll-
PYIOll.\ero pacrnopa). np111 raHrpeHo3HOM a6c-
1..1ecce nepe,Q ycTaHOBKOi4 APeHa)l(a 1..1enecoo6-
paJHo Bb1nonHlllTb OCMOTp nonocTlll a6c1..1ecca -
ropaKoa6c1..1eccocKon11110 111, np111 Han1114111111 cBo-
6oAHO ne}l<8ll.\lllX ceKBecTpOB, OCTOpO}l<HO y.Qa-
Jll/ITb I/IX MeXaHl/l4eCKlllM n)ITeM .
npoMblBaH111e nonocrn a6c4ecca aHrncen-
TV1KaM1-1: pacrnop c:pypaJ.1111nn1-1Ha 1:5000 (0,05 %
xnopreKClll,QlllHa 6111rnt0KOHaTa, 0,1 % ¢ypar111Ha)
c nocTOflHHOi4 aKTlllBHolil acn111pa4111elli rnolliHoro
3KCCy,QaTa Ill pa3pe>KeH111eM 5-10 CM. 80,Q . CT.
cnoco6cTsyeT 6blCTpoi1 JllllKBJ11AaL1J11J11 socnane-
HIMI 111 3Ha1.1111renbHo ycKops:ier npOL-1eccb1 pereHe-
pa4111111 nerOYHOi1 TK8Hlll. np111 3cp¢eKTlllBHOM p,pe-
Hlllp088Hl.11.1 a6cL-1ecca y>1<e Ha 2-3 cyrK1.1 yMeHb-
waeTcs:i l.1HTOKCl.1Kal..\111Sl 111 CH111>1<aeTcs:i reMnepary-
pa rena.
noK838Hll18M ,D,JlSl yp,aneHlllSl p,peHa>Ka 51BJ1Sl-
8TC5l lllCY83HOB8Hll1e socnan111renbHOtA 111HcPll1JlbT-
pal..\111111 111 nonocrn rHol7IH111Ka, 4TO noArsep>K,D,aer-
cs:i peHrreHonor1.1L1ecK111 .
np111 M8HbW8M ,D,lllaMeTpe rHOi.1HoJ/t nonOCTVI
(OT 3 ,D,O 5 CM) MO>KHO n!llKBJll,D,!llPOBaTb a6c4ecc
nyHKL..\lllOHHO. 3acny>K111BaeT BHlllM8H11151 nyHK4111-
0HH85l Merop,111Ka neL1eH111s:i ocrpb1x a6c4eccos
nerKoro c 111cnonb30BaH111eliA Hei1poMeA111aropa
OKClllTOL..\lllHa, pa3pa6oraHH8Sl COTPYAHlllKaMl.1
OpeH6yprcKoi1 MeAlllL..\~1HCKoi.1 aKaAeM111111 111 VIH-
crnryra KneTOYHOro Jll BHyrp111KneT04HOro ClllM-
611103a YpanbcKoro or,lleneH1115l PAH. 0Kc111ro4J11H
3HaL1111renbHO ycJ11n111saer npor111soMJ11Kp06Hoe
AetACTBllle MHOrl.1X aHT1116lllOT111KOB B OTHOW8Hllllll
pa3Jllll4HOtA rHoepOAHOl.1 MlllKpoQ:>nopbl , B 1,2-1, 7
pa3 CHlll>KaeT cnoco6HOCTb MlllKpoopraHlll3MOB K
lllH8KTll1B8L..\llllll c:PaKTopoB ecrecTB8HHOtA pe3111-
CT8HTHOCTlll YenoBeKa Ill onocpep,oBaHHO, Yepe3
p,elllCTBllle Ha rpaHcnopT lllOHOB K8Jll.1Sl, CT111Myn111-
pyer npon111¢eparnBHble npol..\eCcb1 , ycKops:is:i
reM caMblM npm..iecc 3a>1<111eneH111e paH .
Mero,g111Ka: so speMs:i peHrreHonor1111.1ecKoro
JllCCile,D,OB8HJll5l Ha rpy,D,HOl.1 f<JleTKe HaMe4aeTC5l
caMas:i H1113Kas:i T04Ka rHolllH111Ka . Mecro nyHK4111111
npep,sap111renbHO aHecre3111pyercs:i 0,5 % pacrso-
poM HOBOK8111Ha. nyHKL..\11151 npOBO,D,lllTCSl no Bepx-
HeMy KpalO pe6pa TOJlCTOtA 111rno!A c BHyrpeHHLo1M
,D,1118MeTpOM 0,2 CM , C08AlllHeHHOtA co wnp1114eM
ClllJ1111KOHOBOtA rpy6Koi1 , repMeTl/l4HO cPll1KC111pOBaH-
HOi1 K KaHIOJle lllfJlbl. Bo apeMH MaH11nynHL..\lt!lt!
npocser 111rnb1 nep111op,114ecK111 np0Mb1saercs:i pac-
rsopoM HOBOKa111Ha. np11 nonaAaH111111 s nonocrb
rHoi1H111Ka B03Hll1Kaer ou.iyu.ieH111e "nposana", a np111
acn111pa4111111 s wnp1114e nos:ism1ercs:i rHolA. nocnep,-
H111!.1 3BaKy111pyercs:i wnp1114eM "Ao nocnep,HeJ/t Kan-
n111". nonocTb fHOi.1Hll1K8 MHOrOKpaTHO 3anonHsieT-
C.s'I aHrncenrnYeCKlllM pacrsopoM (cpypa~111nn1.1H
1:5000 ll'ln111 0,05 % pacrsop xnopreKc111p,111Ha 6111r-
n10K0Hara). Konw-1ecrno BBOA111Moro pacrsopa He
,D,OJl>KHO npeBblW8Tb 2/3 06beMa 3B8Ky111pOB8HHO-
ro rHof! . npoMb1BaH111e ocyU-1ecrsns:iercs:i AO nony-
L1eH111s:i Yll1CTblX npOMblBHblX 80,D,. nocne 3TOrO B
nonOCTb rHOtAHlllKa BBO,D,111TCSl cpe,D,HerepaneBTlll-
YecKa51 A03a aHrn6111ornKa w111p0Koro cnet<Tpa
p,etACTBl.151 Ill 2,5 - 5ME OKCll1TOL..\111Ha. nyHKL..\111111 C
npoMb1BaH111eM nonocrn a6c4ecca 111 ssep,eH111e
neKapcraeHHblX npenaparos Heo6xop,111Mo npo-
so,a,11Tb e>1<e,a,HeBHo. Mecm ,1:111s:i nosrnpHoi:i nyHK-
4111111 Bb16J11paercs:i , orcrynas:i Ha 0,5 - 1 CM or Mec-
ra npe,D,bl,D,Yl!-lero p,ocryna. Jle1.1eH111e nposop,ll'lrcs:i
AO npeKpau.ieH111s:i 06pa3osaH111s:i rHolAHoro 3Kccy-
p,ara 111n111 cMeHe rHolAHoro xapaKTepa 3Kccyp,ara
Ha cep03Hbllll. B All1HaM111Ke ne4eHll151 3BaKy111pye-
Mas:i >K111AKOCTb noABepraeTC5l 4111TQJ10f11148CKOMY
lllCCJ18,D,OB8HllllO Ill nO,D,CYlllTbJBaeTCH neWKOQJOPMY-
144
na. 3HaYlllT8JlbHOe CHlll>K8HJ/le KOJllllY8CTBa neC1KO-
L..\lr1TOB (,D,o 30 - 50 s none 3peH111s:i) 111 npeo6nap,a-
H111e B neVIKo¢opMyJ1e J1111McPOL\111TOB, HOpManll13a-
L\1115l reMneparypbl Tena 111 aHan1113a nep111cpep111Ye-
CKoi.:1 KpOBl.1 51BJ1Sl8TC51 6naronpll151THblM nporHO-
CTll148CK111M npll13HaKOM, nocne KOTOporo MeCTHOe
neYeH111e MO>KHO C4JllT8Tb 3asepweHHblM.
np111 Wl1pOKOM C006li.\8Hll1111 a6c4ecca C
6poHXOM nonHOL\eHH8Sl C8H8L..\111Sl B03MO>KHa
n111wb nocne speMeHHOIA OKKnl03111111 ,o,peH111py10-
L1.1ero a6c4ecc 6poHxa (Yal!-le AOneaoro) . 3ro
HCKJlKJ4aeT 3areK11 rHos:i s 3.QopoBble y4acTK1t1
nerKoro 111 no3BOI15leT aKTll1BHO npOMb1BaTb no-
nocTb a6c4ecca, cnoco6crayfl ee CKopeViweV!
J1111KB111A8L\11111 .
nHeBMOmOMUR (mop01<006c4eccocmoMUR}
nHeBMOTOMll151 (BCKpblTll1e a6c4ecca), OCTa-
ercR MeTO,llOM Bbl6opa y 6onbHblX c BblCOKlt!M
p111cKoM npoBeAeHll15l paA111KanbHblX onepa411111!
(no63KTOMll1111 111Jllt1 nHeBMOH3KTOM111111), 88111,D,Y Ul-
>KeCTl/I 111X COCT051Hlt151, Bblpa>KeHHOl.1 111HTOKCll1Ka-
L..\111111 111 .QblXaTeilbHOl.1 HeAOCTaT04HOCTll1, a TaK>Ke
y 6onbHblX c rn>1<enb1M111 conyrcrsy10L1.1111M111 3a60-
neBaH111s:iM111. nonOCTb a6c4ecca BCKpb1BaeTC51
'-lepe3 no)l{e YacrnYHO pe3e4111posaHHoro pe6pa,
YAans:ilOT cso6o,D,Ho ne>1<au.i111e ceKsecTpb1 , or-
Kpb1Ba10u.i111ecs:i B nonOCTb MeJlKll18 6poHXll1 yw111-
Ba10T np111 nOMOLl.1111 arpaBM8Tll148CKll1X 111rn c pac-
C8CblB8IOl!..\111M111C51 H111TSlMll1 (non111cop6, BlllKp111n),
a6c4ecc npOMblBalOT paCTBOpOM 8HTlllC8nTlllKa,
ApeH111py10T, paHy 38WJllB8IOT c Hana>K111B8Hll1eM
npoTOYHo-acn111pa1..11110HHoro npoMblB8Hll151 nonoc-
T111 a6CL\8CCa .
B P51Ae cny1.1aes (raHrpeH03Hble 111n111 MH0-
>1<ecrneHHb1e a6c4eccb1 nerKoro) cpopM111py10r
ropaKoa6c4eccocroMy: npi-i 3TOM Kpas:i BCKpblTo-
ro 1r1 ca1-11r1posaHHOro a6c4ecca n0Aw1r1sa10r K
nnespe 11111111 anoHespo3y, 3aKaH4111BalOT onepa-
L\111IO BB8A8Hll18M B nonoCTb a6c4ecca TaMnOHOB
C Ma3bl0. np111MeHs:JIQT MHOfOKOMnOHeHTHbl8 Ma-
3111 Ha BOAopaCTBOPlr1MOtA OCHOBe: nesOClllH, ne-
BOMeKOJlb, A1110KClr1KOnb 111 np. BbinonH5llOT 3ran-
Hb1e caHaL.1111;1 nonocrn a6cl(ecca co cMeHow
TaMnoHoB. Hepep,Ko nocne nHeBMOTOM1t1111 (ropa-
Koa6c4eccocroM111111) ¢opM111pyercs:i cyxa.s=i ocra-
TOYHa51 nonOCTb B nerKOM , pe>Ke - MHO>K8CTB8H-
Hb18 6poHxonnespanbHble CBll1li.\111 ("peweTYaroe
nerKoe"). Ecn1r1 cyxas:i ocraro4Has:i nonocrb He
rpe6yer cne4111anbHoro neyeH111s:i, To croi1K111e
6po1-1xonnespanbHb1e (rnpa1<anbHb1e) cs111ut1t1 m1-
KBlr1All1PY10TC5l B A8JlbHetAW8M TOJlbKO onepaTll1B-
HblM nyTeM.
Pe3e1<4UR ne21<020
noKa3aHll1SlMll1 K TOpaKOTOMll1111 111 pe38Kl..\lllll1
nerKoro np111 ocrpoM a6cL-1ecce 51BJ15llOTC51:
1. A6c4ecc nerKoro, ocno)KHeHHbl.tA nero'-1-
HblM KpOBOT848Hll1eM.
2. MHo>KeCTBeHHb1J/t xapaKTep nopa>1<eH111s:i
nerKoro 111 He3cpcpeKTll1BHOCTb KOHCepsaTVIBHOro
ne4eHlllfl, BKnf04as:i p,peHlllPYIOLl.11118 onepa1..1111111.
 3. Croll1K111ll1 Konnanc nernoro np111 n111onHeB- XpoHuLteCKue a6cl{eccb111e2Kux
MOTopaKce L'1 He3¢cpeKTll1BHOCTb AP8HlllPYtoll.\lllX 0TCYTCTBlll8 3cpcpeKTa OT lllHT8HClllBHOro ne-
onepau,111111 , BKJlto4as:! speMeHHYIO OKKJll03 111 IO 48Hllls:! ocTporo a6cu,ecca nerKoro s Te4eH111e
6pOHXa. rpex MeCRL\eB 111nw )/{e nosTopHoe 06ocrpeH111e
noKa3aH111s:1M111 K pe3eKu,111111 nerKoro np111 raH- HarHoeH11151 s cyxolil ocTaT04HOil1 nonocT111 no3so-
rpeHe s:!Bils:!IOTCs:! : 11HIOT C4111TaTb a6CL\8CC xpOH11148CKlllM .
1. PacnpocTpaHeHHas:i 111n111 orpaH1114eHHas:i Mop¢onor1114eCKOIA OCHOBOll1 xpOHlll48CKOro
r aHrpeHa nerKoro , ocnO)l<HeHHas:1 nero4Hb1M Kpo- a6CL\8CCa S'!Bllfl8TCS'I nonocTb c cp1116p03HOll1
soTe4eH111eM . CTeHKOlil , noKpblTas:! 1113HYTPlll rpaHyJlHL\lllS'IMlll Ill
2 . nporpecc111pyiou.ia5! raHrpeHa nernoro np111 coo6u.iatou.ias:1cs:1 c 6poHx111anbHblM ,QepesoM OA-
H83cp¢eKT111BHOCTlll lllHT8HClllBHOll1 KOHCepsarnB- HlllM 11111111 H8CKOJ1bKlllMll1 CBlllLI..\aMlll.
HOCi Tepam11t1 8 T848Hll18 10-14 AH8111 (np111 6ypHO 0CHOBHblM111 np1114111HaMlll , cnoco6cTBYIOl1.\111-
n porpecc111py10ll.\elil raHrpeHe cpoK111 npeAonepa- Mlll nepeXOAY OCTporo a6CL\8CCa 8 xpoHll148CK111111 ,
u,1110HHolil nOAfOTOBKlll COKpau.iaioTC51) . S'IBJlS'llOTCS'I :
npornsonoKa3aH111s:!Mll1 K paA111K81lbHOMY 1) HeaAeKBaTHoe ne4eH111e ocTporo a6cL\eC-
onepaTlllBHOMY BM8WaTeJ1bCTBY np111 OCTpOM ca nernoro (no3AHSlH A111arHocrnKa , ne4eH1t1e BHe
a6cu,ecce 111 raHrpeHe nernoro 51B115llOTC51: npocplllJlbHOro OTA8118Hll1S'I , OTCYTCTBll1e KOM-
1. AsyxcropoHHee nopa)l<eH111e nerK111x. nneKCHOro nOAXOAa 111 T. A.).
2. Bb1pa)l<eHHa5! nero4Ho- cep,Qe4Ha51 , ne4e- 2) H8AOCTaT04Hbllil OTTOK fH051 1113 nonocrn
HOYHa51 111J1111 n0484Ha51 H8AOCTaT04HOCTb. a6CL\8CCa , BCJ18ACTBll1e:
3. T f!)l<ena51 aHeM111s:1 111 r111nonpoTe111HeM1115!. - HapyweHHOlil 6pOHXlllaJ1bHOiA npOXOA111MO-
4 . KaxeKc111s:1 . CTlt1 (111HOPOAHOe Teno s 6poHxe, pa3s111rne rpa-
5. Cenc111c, rHoll1Hblll1 nep111KapA1llT . HYllHL\111111 11111111 py6L10Bblll1 CTeH03 AP8HlllPYIOl1.\8rD
np111 ocTpoM a6CL\ecce nerKoro o6beM one- 6poHxa , Hosoo6pa3osaH111e 6poHxa) ;
pau,111111 3aK1ll04aeTc51 s pe38KL\111111 AOn111 nerKoro - - HaJ11114111S'I C8KB8CTpOB, npenHTCTBYIOl1.\l'1X
n o63KTOM111111 , 111n111 ABYX AOnell1 nerKoro - fa1110- J1111KBll1AaU,111111 nonOCTlll a6CL\8Cca ;
foKToM111111, pe)l<8 - nHeBMOH3KTOM111111 . np111 pac- - oco6eHHocTeil1 naTonor1114ecKoro npou,ec-
npOCTpaH8HHOll1 raHrpeHe nernoro o6bl4Ho Bbl- ca: MH0)1<8CTB8HHble a6CL\8CCbl, JlOKan1113au,111H 8
nonH5llOT nHeBMOH3KTOMllllO . Hll1)1<HlllX OTAenax nerKlllX, pe3111CT8HTHOCTb Mll1K-
Heo6xoAlllMO OTMeTlllTb, 4TO paA111KanbHb1e pocpnopbl K aHT11161110T111KaM Ill T. A -
onepal.\111111 s ocTpoM nep1110Ae 3a6011esaH1115! TeX- 3) conyTcTBytou.i111e 3a6onesaH1t15I: xpoH1114e-
HW·!ecK111 CJ10)1<Hbl , TpasMaTll14Hbl , AalOT MHOro CKlllll1 6pOHX111T, 6poHX03KTa3111111, T51)1<8JlaH 6poH-
OCJlO)l<H8Hlllll1 111 conpOBO)l<,QalOTC51 BblCOKOll1 ne- x111anbHaS'I acTMa , 3Mcp1113eMa 11erK111x, caxapHblll1
TaJlbHOCTblO. no3TOMy, 8CJ1111 p111CK paA111KaJ1bHOll1 Allla6eT, xpoH1114eCKll11A a11Koro111113M , HapKoMaHlll51
onepal.\111111 4pe3Bbl4all1HO BblCOK, a KOHCepBaTlllB- 111 AP-
HOe ne4eH1118 6ecnepcneKTlllBHO M8TOAOM Bbl60- Km1H1114ecKoe Te4eH111e xpoH1114ecKoro a6c-
pa ocTaeTc51 nHeBMOTOMlll51 (rnpaKoa6cu,ecco- L1ecca nerK111x xapaKTep1113yeTc5I L\lt1K11111YHOCTblO
crnM1115!) . 3a6onesaH111H c nep1110A1t1YecK111M111 06ocrpeH1115IM111 .
nocTOSlHHblM Cll1MnTOMOM 51BJ1518TCS'I KaWeJlb C
Pe3YJ7bmambl 11eLteHLJR ocmpb!X a6CL~eccos OTA8I18Hlll8M rHOIAHoll1 MOKPOTbl , lllHOrAa c np111Me-
u 2aH2peHbJ 11e21wx Cbl0 Kpos111 . B nep1.10Abl 06ocTpeH111lil Kon1114ecTso
1. nonHoe Bbl3,QOpOBJ18Hllle - OTCYTCTBll1e MOKpOTbl ysenll14111BaeTC51 , noHBI1S'l8TCS'I Henplll51T-
KJ1111Hll148CKll1X 111 peHTreHonorll148CKll1X np1113HaKOB Hbllil 3anax MOKpOTbl , yc11111111saeTCSl O,QblWKa Ill 60-
3a6onesaH1115I c 06n111Tepal.\111ei/1 nonocrn AeCT- 11111 s rpy,[IHOili KneTKe Ha crnpoHe nopa)l<eHll151.
PYKL\111111 Ha6nioAaeTC51 y 25-35 % 6onbHblX. BcerAa 111Me10TCSl np1113HaK111 xpoHlll4ecKoll1 ll1HTOK-
2. Km1H1114ecKoe Bb13AOpos11eH111e - Ha111114111e c111Kal.\li1ll1 - cna6ocTb, norm1socTb, nnoxoCi anne-
peHneHOJ10r11148CKlllX nplll3HaKOB B BlllAe cyxoll1 Tlt1T, noxy,QaHli1e , 6neAHOCTb KO>Kli1 111 lt1KT8p1114HOCTb
OCTaTOYHOili nonocTlll B nerKOM , np111 OTCYTCTBllllll CKnep. np111 OCMOTpe rpy,QHa51 KJ18TKa Ha CTOpOHe
K11111Hlll48CKlllX np051BJ18H1lllil 3a6onesaHlll51 , OTMe- nopa>KeH111H oTcTaeT np111 ,QblXaH111111 , nanbl.\bt s
4 aeTCs:! np111MepHO y 50 % 6onbHblX . cpopMe "6apa6aHHblX nan04eK", HOrTl'1 8 BlllA8
3. Y11y4weH111e - coxpaHeH111e OTAenbHblX "4acOBblX CTeKon" . ¢11131i1KaJ1bH851 Cll1MnTOMaT111Ka 8
K1llt1Hlll48CKlllX Ill peHTr8HOJ10rlt148CK111X nplll3HaKOB nep1110JJ,bl peM111cc111Ci CKYAH8H: Hepe3KO ocna6-
3a6oneBaHllls:!, H8CMOTp51 Ha npOB8A8HHOe ne4e- neHHoe AblXaH111e, e,Qli1H1114Hb1e sna>KHble xp111nb1;
Hll1e . y 3TlllX 601lbHblX se11111Ka TpaHccpopMaL\11151 np1-1 06ocrpeH1-11t1 npOL\ecca s nerKOM HaJJ, 30HOll1
OCTporo a6CL\8CCa B xpoHlll48CKlllll1 , 4TO lllMeeT nopa>KeHL-151 noHsns:ieTC51 4eTKoe np1-1TYnneH1-1e
M8CTO y 5-10 % 601lbHblX. nero4Horo 3ByKa, 6poHx111anbHoe AblXaH111e,
4. YxyAW8Hl/le COCT051Hlll51 Ill CMepTb. 06u.ias:i sna)l<Hble 111 cyx1-1e pa3HOKa111116epHb1e xp111nb1 , lllHO-
neTanbHOCTb nplll OCTpblX a6CL\8CCax nerKlllX B rAa cnb1WeH wyM TpeHlllH nnespbL
cneL\111an1113111posaHHblX cTaL\lllOHapax Kone6neTC51 B nep1110A peMli1cc1-11-1 s Kpos111 onpeAens:iercH
OT 5 % AO 10 %, a np111 pacnpocTpaHeHHolil raH- aHeMli1H 111 ycKopeHHasi C03; npli1 060CTpeH111111
rpeHe nerKoro AOcrnraeT 35-40 % 111 Bb1we . 3a6onesaH111s:1 - nell1KOL\111T03 co CABVlroM nelAKo-
u,1.-napHolil cpopMynb1 sneso, ysem14111saeTcH

145
C03, HapacrneT rnno- 111 AJ11CnpOTe111HeM1115l .
,D,m.-nenbHO npoTeKa10L111J1e a6cL1eccb1 nernoro
Bbl3blBalOT aMlllI10l-1A03 no'-ieK, 4TO np05lBns:1eTC5l
np0Te111Hyp111ell1, L\lllillilHAPYPlilel/1 , rnno- Iii !J130CTe-
Hyp111ell1 .
PeHTreHonor1114ecK111e 1113MeHeH1115l nerolJHol/1
TK8H!J1 B CTCl,l\11114 peMlllCCl-1111 CileAYIOLl.l!Jle: 3TO
OAlllH04Hble lllillll MHO)l(eCTBeHHble noilOCTlll , He-
peAKO HenpaBlllilbHOl/1 cpopMbl c OTCYTCTBl/leM
nepvicpoKailbHoro socnaneH1115l, BOKpyr nonocrn
Bblpa)l(eH nHeBMOCK!lepo3. np111 6poHXOrpacpllllil
yAaeTc5l 3anonHlllTb nonocTb a6cL1ecca KOHTpa-
cTHblM Bell.leCTBOM, npl-1 3TOM BOt<pyr nonocTlll
MO}f{HO o6Hapy}f{lllTb Ae¢opM111py10l4lllli1 6poHXlllT
Ill BTOplil4Hble 6pOHX03KTa3bl.
P1.1c. 21. XpoHM"leCKMM a6c4ecc npaeo-
ro nernoro.
npRMaR peHTreHorpaMMa (a): B Cpe.Q-
H0M AOIT0 onpeAeITReTCR MHT0HCMBHOe He-
OAHOPOAHOe 3aTeHeHMe - MHcpMI1bTpa14MR
nerolfHOH TKaHH; TOMorpaMMa (6}: B l.(eHTpe
MHcpHITbTpaTa BMAHa nonocTb ,D,eCTPYKl.(MM,
npocseT cpeAHe,o,oneeoro 6poHxa He on-
pe,o,ensteTCR (6ITOKMpOBaHHblM a6cl.(ecc).
KoHcepsaTlllBHoe ne'-ieH111e xpOHlilllecKlllX
a6c4eccos ner1<111x 6ecnepcneKTlllBHo 111 5lBI15leTC5l
nOAfOTOBlllTeilbHblM 3TanoM K pap,111KailbHOMY
oneparnBHOMY ne1.1eH11110 (no63KTOM111111, nnespo-
no63KTOMllllll, 6111n063KTOMlillil, pe)l{e - nHeBMOH3K-
TOM111111) . np111 He60!lbWlllX pa3Mepax a6CL\8CCa Iii
no1<an1113aL\llllil a6c4ecca B 1<opT1111<anbHOll1 30He
nernoro B03MO}f{Ha aT111n1111.1Ha5l KI1111HOBlll,D,Ha5l pe-
3eKL\1115l ner1<oro.
3MIIHEMA IIJIEBPLI (rHOHHLIH IIJIEBPHT)
AHamoMUR nnespbl
nnespa (rpe4 . pleura - cTOpOHa, 601<) - ce-
po3Ha5l o6ono4Ka, noKpb1BatoL11a5l napeHxl-1MY
nerK!JlX (s1.1c4epanbHa5l nnespa) 111 Bb1crnnatoL11a5l
1113HYTP14 CTeHKl-1 rpyp,HO~ nonoCTlll (nap111eT8Ilb-
H85l nnespa). 06a n111cTKa nneBpb1 s o6nacrn
KopHel/1 nerK111x coep,111H5l10TC5l 111 o6pa3ylOT p,sa
38MKHYTblX cepo3HblX MeWKa . YcnosHoe npo-
cTpaHcTso Me)l{,D,y p,syMsi nnespanbHblMll1 Mew-
KaMl-1 Ha3blBalOT nnespanbHOll1 nonocTblO. B
HOpMe s nnespanbHoti nonocrn coAep)l{lllTC5l He
6onee 1-2 Mil )1{111,D,KOCT!Jl, 6nl-13KOll1 no CBOeMy
XlllMlllLJeCKOMY cocrasy K TKaHeBol/1 )1{111,0,KOCTlll
(n111Mcpe) 111 Heo6xop,111Mo~ p,n5l cso6op,Horo ne-
peMeL11eHlll5l ner1<111x BHyrp111 rpy,D,Hol/1 KneTKlll
(nnespanbHoill nonocrn) . ,D,asneH111e s nnes-
panbHoll1 nonocT111 no,D,Aep}f{l-1BaeTc5l Ha yposHe
cy6aTMOCcpepHoro , T. e. OTPlllL\8TeflbHOe.
B111c4epanbHa5l nnespa noKpb1saeT nerKoe
He TOflbKO B o6nacrn pe6ep , ,o;111acpparMbl 111 cpe-
AOCTeH111si, HO Ill B Me)l{,D,OileBblX L11em1x Ill nnoTHO
cpaw,eHa c nosepXHOCTblO ner1<oro .
B nap111eTanbHotli nnespe pa3n111Ya10T pe-
6epHyio, ,D,lilacpparManbHYIO Iii Me,D,111acT111HaJlbHYIO
146
065l3aTenbHOll1 5lBI15leTC5l npeAonepaL\lllOH-
Ha5l nop,roTOBKa 60JlbHblX, 3aKI110Ya10L11a5lC5l B
MaKClllM8IlbHOll1 IllilKBlll,D,8L\lillil socnan111TeilbHOfO
npOL\ecca B nerKlllX Iii BOCCTaHOBJleHJ/1111 3ali.\lllTHblX
ClllJl opraHlll3Ma, 4TO BKillO'-iaeT 065l38TeJlbHbli71
OTKa3 OT KYPeHl!l5l Ta6aKa Iii APYrlilX Bpe,QHblX np111-
Bbl4eK, caHa411110 Tpaxeo-6poHx111anbHoro p,epesa,
pa41110HaI1bHYIO aHT1116lllOTlllKOTepan11110 (AO onepa-
L\111111 Heo6XO,D,lllMO onpe,Qenll1Tb LJYBCTBlllTeJlbHOCTb
MlllKpocpnopbl MOKpOTbl K aHT1!161!10TlllKaM) , CTlllMY-
Il5lL\llllO lllMMYHlllTeTa, BlllTaMJ.1HOTepan11110, no no-
Ka3aHJ.15lM - TpaHccpy3llllO 3PlllTPOL\111TapHoll1 Mac-
Cbl , aMlllHOKlllCilOT, 6enKOBblX npenapaTOB, 06y-
1.1eH111e 6onbHoro AblXaTenbHOl/1 rl!IMHacrnKe.
B nocneonepa1.11110HHOM nep111op,e 38,0,aLJlll
Me,D,lllKaMeHT03HOro ne4eHlll5l Te )l{e, LJTO Ill AO
onepa4111111 . ny4well1 npocp111naKT111Koli1 nocneone-
pa41110HHblX OCflQ}KHeH111!11 (aTeneKTa3a, 6pOHXlll-
anbHOro CBlilll.la, 3Mn111eMbl nnespb1 , HarHoeHll15l
paHbl 111 ,o,p.) 5lBn5leTc5l xopowa5l npep,onepa4111-
0HH85l nop,roTOBKa 60JlbHoro, rpaMOTHOe Bbl-
nonHeHl!le onepaL\1111.1 111 aKTl!IBHOe sep,eH111e no-
cneonepa41110HHoro nep1110,1J,a: paHHllll/1 Ha 2 CYTKlll
nop,beM 6onbHoro c nocTem1 , xopowee 06e360-
n111saH111e, ne4e6Ha5l cp1113KYilbrypa , ,D,blXaTeilbHasi
rlllMH8CTl!1Ka , lllHf8Il5lL\111111 6pOHXOI1111Tll1KOB, 8KTll1B-
HOe OTKaWflll1BaH111e MOKPOTbl , pa41110H8IlbHa5l
8HTll16lllOTlllKOTepan111s:1 , KOppeKL\11151 lllMMYHll1TeTa,
Tli.\aTeilbHasi acn111paL\l.15l BbtnoTa 1113 nnespanb-
Hol/1 nonocTl-1 nap, KOHTponeM ynbTpa3sy1<osoro 111
peHTreHonorn4ecKoro 111ccne,1J,0BaH111ti .
neTailbHOCTb nocne onepa41.11/1 np111 xpo-
Hlil4ecK!J1X a6cL1eccax ner1<111x Kone6neTc5l OT 5
,[108 %.
4aCTb. Pe6epHafl (KocTanbHafl) nnespa np111ne-
}!{1J1T 1113HYTPlll K BHYTpeHHe~ nosepxHOCTlll xps:i-
L11eBblX Iii KOCTHblX 4aCTeli1 pe6ep, K Me)l{pe6ep-
HblM npoMe~KaM , 38,D,HeVI nosepXHOCTlll rpyp,111-
Hbf, 6oKOBbfM nosepxHocrnM Ten rpy,llHblX no-
3BOHKOB Iii OT,D,eneHa OT HI/IX TOHKOlil cp1116p03HOi.1
nnacT!JlHKOi-1 - BHyTp111rpyp,Hoi11 cpac1..11J1ell1 . BH1113y
pe6epHa5l nnespa nap, ocTpblM yrnoM nepexo-
AlllT Ha rpyp,o6ptowHyio nperpaAy 111 npo,o,om1<a-
eTcs:i 3,0,ecb B s111p,e p,1.1acpparManbHoi.1 nnespb1;
cne,o;y51 cnepe,o;111 OT rpy,o;111Hb1 111 c3a,o;111 oT no3so-
H04H111Ka , pe6epHa5l nnespa nepexop,111T B cpep,o-
CTeHHYIO (Mep,!JlaCTlllHailbHas:i) nnespy.
Me>K.Qy pe6epHotli nnespotli 111 sHyTp111rpy,o;-
Holi1 cpacL1111eill 111Mee1cs:i cnoi/1 pb1xnoll1 KneT4aTKl.1
(no,D,nnespanbHa5l K!leT4aTKa), KOTOpb1ill ny4we
acero Bbtpa}f(eH na t<ynone nneapb1, OT I ,qo IY
Me)f(pe6epbs:J Iii B 0KOJ10n03BOH04HOtli o6naCTlll .
OT IY p,o YI I pe6pa 111 s o6nacrn ronosoK pe6ep
nnespa cp1111<c111poaaHa npo4Hee , a o6nacTb oT Yll
pe6pa AO ,D,lllacpparMbl s:lBJ15leTC51 MeCTOM Ha11160-
nee npo4HOtli cp1111<CaL1111111 nnespbi. B MecTax pblX-
nol/1 cp1111<ca1..1111111 pe6epHas:i nnespa MO)l{eT 6b1Tb
oTcnoeHa, 4TO sa)l(HO Ails:i Bb1nonHeH111s:1 ps:iAa
onepau111L1.
,Q111acpparMaJ1bHa7! nnespa noKpb1saeT
sepXHIOIO nosepXHOCTb rpy.r106pt0WHOlll nperpa-
Abl 111 np04HO cpaLUeHa 3AeCb c BHyTpll1fPYAHOll\
QJ8CL\111Sll\. 0TASI1111Tb nnespy B 3TOM MeCTe 6e3
ee nospe>K,D,eH111s:1 HeB03MO)KHO, 3a 111cKilto4eH111eM
Y3Koll\ nonocbl , np11111erato1.11ell\ K pe6epHo-
.i:1111a¢parManbHOMY ci.1Hycy, r.Qe 1>1Meercfl cnoi.1
pb1xnoll\ KJ1er4aTKlll npeAA1t1acpparMaJ1bHoe
npocTpaHcrso. B 3TOM o6nacrn nnespa MO)f{eT
6b1Tb OTp,eneHa OT .i:1111acpparMbl , T8K111M o6pa30M
MO>KHO nony4111Tb nps:1Moll\ 111 6e3onacHb111\ AOcryn
K A111acpparMe 111 nOA.Q111atj:lparManbHOMY npo-
crpaHCTBY (p111c. 23).
TOI10r1114eCKOll\ )K111AKOCTblQ (KpOBb , 3KCCY.Q3T,
rHolli 111 Ap.).
lpaHVIL\bl nap111eTailbHOlli nneBpbl 38BlllCs:IT OT
cpopMbl CTpOeHll1.fl rpy,[IHOM KneTKlll . no.[\ rpaHll1L18-
MVI nap111ernnbHoll\ nnespbl noH111Mat0r npoeKL..\111!0
Ha rpy,QHOlll KileTKe Il111Hlllll\ nepexo,Qa OAHOro OT-
,Qena nap111eranbHOll\ nneepbl s Apyroll\. Pa311V1-
4aior nepeAHVle 111 Hll1>KH111e rpaHlllL\bl nnespbl.
nepe,QHl-18 rpaHlllL(bl nneBpbf - :no npoeK-
L\lllfl IllllHV1111 nepeXOAa KOCT8IlbHOll\ nnespbl 8 Me-
P,ltlaCTlllH8JlbHYIO, 0H111 Ha npasoi:i 111 nesoi:i cropo-
Hax pacnOJ10)1(eHll1111 HeClllMMeTplll4HO (p111c.24).

a·-i:.-~-~~~"""-=-i

54· ---+~c"<:-
4-+----+-it<:'\.
wmo....._,,_,._.

Puc. 24. lpaHULlbl nneep&1 u neaKux cnepeau.

(nyHKmup - apaHULla nneep&1, nuHUR - apaHULja neaKux)
1 - area thymica; 2 - area pericardiaca;
3- sinus phrenicocostalis;
4 - lobus inferior; 5 - lobus medius;
6 - /obus superior.

H111)KHl.1e rpaHlllL\bl n11eBpb1 npeAcrasmuor

npoeKL\llllO 11111H111111 nepexo.Qa KOCTanbHoll\ nnespb1
B nnespy Altlac:PparMailbHYIO (/I COOTBeTCTBYIOT
MeAf!1acrnHanbHas:1 nnespa noKpbrsaeT rpaH111L{aM pe6epHO-Afl1aQ:>parManbHOro CltlHyca
sepXHIQIO, nepeAHIOIO VI 38AHIOto nosepXHOCTVI (p111c.25).
l<OpH71 nerKJ.1X J.1 opraHbl Cpe,LIOCTeHJ.151. y HJ.1)1{Hero
Kpa71 KOpH51 nerKoro nepeAHIAM VI 38AHll111\ JllACTOK
nneBpbl COeAIAHSllOTCSl , 06pa3y51 nero4HYIO C8fl3-
Ky. B BepXHltlX OTAenax cpeAOCTeHlll71, KaK c npa-
soll\, raK c nesoll\ cropaHbJ Me>K,D,y opraHaM111
cpeAOCTeHf/151 fl1 MeAfl13CTfl1HaJlbHOL1 nnespolli
L1Meercs:i Bb1pa>KeHHb111\ cnoll\ pb1xnolll KJ1eT4aTKVl ,
YTO no3aon.s:ieT np111 He06X0,[1111MOCTlll CB060,[IHO
OTAens:irb nnespy.
Llacrn nnespanbHOll\ nonocrn , pacnono-
)!(eHHb1e s Mecrnx nepexoAa pa3Jlltl4HblX oTAe-
nos napfl1eTanbHOll! nnespbl APYr s Apyra, HOCHT
H83BaHltlfl c111Hycos. Pa3n1114at0T TPlll c111Hyca: pe-
6epHo-A111atj:lparMaJ1bHbl 111, pe6epHo-MeA1.1acrn-
HanbHb11'1 111 ,[1111acpparMaJlbHO-Me.r1111acrnHanbHb11'1.
Bo speMfl BAoxa c111Hycb1 4acrn4HO 11111111 nonHo-
CTbtO 3anonHfllOTCfl nerK111Mll1, BO speMs:I BblAOXa
nerK111e yMeHbWalOTCfl s o6beMe 111 nnespanbHbJe Puc. 25. rpaHUL1b1 nneep&1 u neaKux c38au.
IlVICTKltl BHOBb nnorHo conpltlKacat0Tcs:1 Apyr c 1 - /obus superior; 2 - lobus inferior;
ApyroM . Kn111H1114eCKoe 3Ha4eH111e c111Hycb1 np11106- 3- sinus phrenicocostalis.
pera10T s rex c11y4as:1x, KOrAa 3ano11Hflt0Tcs:1 na-

147
 Bap111aHTbl H111>1<H111x rpaHlllL\ nnespb1 no A.B. MenbHlllKosy np111seAeHb1 s Ta6m14e 1.
Ta6JIUlfa 1.
Hm1mne rpaHHULI nJieBpbl
CTOpoHa Linea Linea Linea Linea Linea Linea
rpy,qHolli paraster- medioclavi- axi/laris axi/laris axillaris scapu!aris
KJleTKl/I nalis cularis anterior media posterior
Bap111aHT Bb1co1<oro pacnono)f{eH111s:i
Cnpasa H11rn<H1111ii Hlll)f(Hllllii BepxH111lii BepxH1111ii BepxH111lii Hlll)KHllllii
Kpalii xp51~a Kpalii xp51~a Kpalii YIJJ Kpai;l IX Kpai;lX Kpai;lXI
YI pe6pa YI pe6pa pe6pa pe6pa pe6pa pe6pa
Cnesa BepxH1111ii BepxH111lii BepxH111lii
CepeAlllHa CepeA111Ha CepeAl/IHa
Kpalii xps:tll.\a Kpalii XP5ILL\8 Kpalii Ylll
IX pe6pa X pe6pa XI pe6pa
Y oe6pa Ylpe6pa pe6pa
Bap111aHT Hlll3KOro pacnono)l{eH111s:t
CnpaBa B6n1113111 B6n1113111
BepxH1.-1lii BepxHwlii
Hl/l)l{Hero sepxHero CepeAlllHa X H111)1{e XII
Kpalii IX KpalA XI
Kpas:t XP51LL\8 Kpas:t XP51LL\a pe6pa pe6pa
pe6pa pe6pa
Yll pe6pa Ylll pe6pa
Cnesa Hl/l>t<Hll1t1 BepxH1111ii H111)1{Hlt11ii HL1)1{Hlt111\ BepxH1t1Vi
H1i1)1{e XII
Kpail\ XP51LL\8 Kpail\ xps:tll.\a Kpalii IX KpalA X pe6- KpaliiXI
pe6pa
YI pe6pa YI pe6pa pe6pa pa pe6pa

MeA111acrnHanbHa5l 111 pe6epHas:t nneBpa, eynon nneBpb1 HanoM111HaeT KoHyc, noAHl/IMato-

coe,qwHs:ts:tCb Me>K,Qy co6olii s o6nacrw sepxHelii LL\Wtllcs:i BblWe I pe6pa Ha 4 CM Ill 6onee. npw WW-
aneprypbl rpyAHolii KneTKlll o6pa3ytor eynon pOK0£1 rpyAHOi:1 KneTKe eynon nneBpbl B03BblWa-
nnespb1. np111 Y3KolA 111 ,llillllHHolii rpy,llHOlii KfleTr<e eTC51 Ha,q I pe6poM He 6onee YeM Ha 2-2,5 cM.

A 5
Puc. 26. Kynon nneepb1 u eepxywKa neaK020 npu KpauHux cpopMax eepxHeu anepmypb1 apyaHou KnemKu: npu
wupoKoiJ (a), npu Y3KoiJ (6) no AHmenal3a.

3HaH111e rpaHl/ll\ nnespb1 111 ee sap111aHTOB B810LL1ero s111ctwpanbHY10 nnespy Me3oren111s:1

Heo6XOAl/IMO npl/I onepa41/15IX Ha rpyAHOi:1 KJleTKe
VI pa3nl/l4Hbrx MaH111nyns:14111s:1x: nyH1<4111111 111 APeH111-
posaHV1V1 nnespanbHOlii nonocTVr, KaTeTep1113a4111111
4eHTpanbHblX BeH (s:tpeMH0£1, nOAKill041/14HOIA) .
0cHOBHblMlt1 "1CT04H"1K8Ml/I KPOBOCHa6JKeHl/l51
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aprep111111, a TafOKe aprep111anbHb1e aeTBlll oT
BHyTpeHHelii rpyAHOlll apTep111111 I/I nep111K8PAl/lanb-
HO-,[llllacj)parManbHOti aprnp1111i1, BaCKym1p1i13au1-151
s111c4epanbHolii nneBpb1 ocyLL1eCTBns:teTcs:t 1/13 c111c-
TeMbl nero1..1Ho£1 VI 6poHx111anbHblX apTepV1£1. Be-
H03Hb111! OTTOK OT napV1eTaJ1bH0£1 111 BlllCL1epanb-
HOlii nnespbl npOlllCXOAl/IT no BeHaM , nonHOCTblO
COOTBeTCTBYIOLL\lllM pa3seTBneHVl5IM apTep11111!.
J1111McpaTl/l4€CKa51 Cl/ICTeMa BlllCL\epanbHOVI Ill
napV1ernnbH0£1 nnespb1 pa3nvr4aercs:t no crpoe-
Hl/llO Ill CBOl/IM QJYHKL\11151M . J1vrMcpaTl/l4€CK851 ceTb
svrc4epanbHolA nneBpb1 OTAeneHa OT noKpbl-
148
cnoeM coeAl/IHll1TeJlbHOlii TK8Hlt1 VI CB513aHa 6onb-
WlllM KOJ11/14eCTBOM aHaCTOM030B c BHyTpvrop-
raHHOlli n111McpaTvr4ecKotll ceTblO nerKoro. OnoK
Ill/IMQJbl OT Blt1CL1epanbHOi:1 nneBpbl 111AeT B CTO-
poHy KOpHs:t nernoro no nvrMcjJar111c..iecKvrM cocy-
AaM Me}f(,QOJlbKOBblX neperopoAOK, Aanee - B
npasbri:i 111 neab1ti I1V1M¢arn4ecK111e nporn1<w .
ll1HTpaopraHHb1e n111McpaTvr4ec1<111e cocyAbl
nap1-1eTanbHOiA nneapbl o6pa3ylOT ,.qse cern : no-
BepxHocTHYIO - naKyHapHylO 1-1 rny6oeyio - OTBO-
,l\5ILL\YIO. 0TTOK Jll/IMQJbl OT nap111eTanbHOi:1 nnes-
pbl lt1A€T no HeCKOJlbKVIM HanpaBJ1€Hl/l51M: OT ne-
peAHl/IX OTAenos pe6epHo£1 nnespb1 s n111McpaT111-
4ec1<V1e 06pa3osaH111s:t, pacnonara10LL1111ecs:1 BAOilb
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s nVIMcpoy3nbl, pacno.no}f(eHHble B 06.nacrn ro-
nosoK pe6ep. OT Al/lacpparManbHoi:1 111 MeA111a-
CTl/IHanbHOlli nneBpb1 m1M¢a one1<aeT no TpeM
HanpasneHlllS1M'. nepeAHeMy, CBSl3aHHOMY c
JllllMQlOY3JlaMlll B,D,Oilb BHY,-peHHei/1 rpyAHOVi BeHbl
(cTepHaJlbHbii/1 nyTb OTTOKa JllllMcpbi), nepe,D,HeMy
MeA111acrnHanbHOMY - no XOAY A111acpparManbHO-
nep111Kap,D,111anbHOVi 86Hbl Ill 38AHeMy Me,D,1118CTl/l-
HanbHOMY - no xop,y n111u.ieso,£1a, HenapHot.4 111
nonyHenapHor/1 seH . LlacTb nlllMQJbl OT Alllacppar-
MaJlbHolll nnespbl oneKaeT 4epe3 p,111acpparMy s
OKOJlOaopTailbHble Y3Ilbl. n111McpaT1114eCKllle cocy-
,D,bl nap111eTanbHOill nnespb1 CBS13aHbl c nnes-
panbHoi:1 nonocTblO np1'1 noMOLI..!llJ CTOM. nocne,£1-
Hllle npe,D,CT8BJ1S1IOT co6olll OB8JlbHOlll cpopMbl
KaMepbi, o6pa30BaHHble ny4K8Mlll KOJlJlareHOBblX
Ill 3JlaCTlll46CKlllX BOJlOKOH, Henocpe,D,CTBeHHO B
CTOMbl OTKPblB8IOTCSI J18KYHbl , npep,CTaBJ1S1IOU,\l/le
co6olli pacw111peHHb1e oTBeTBneH111S1 nosepxHocT-
Holll JllllMQJarn4eCKOlil ceTlll. nnaTHOCTb Jl111Mcpa-
2
Tlll4eCKlllX CTOM Ha CM KOJle6neTC51 B npep,enax
OT 100 a pe6epHoill 4acrn nneapb1 p,o 8000 a
p,111a¢parM8IlbHOill ee 48CTlll , a ,D,l/laMeTp OT 1 AO
40 M111KpoH . CTOMbl C4111T8IOTC51 cne4111cpw-1ecK111M
annapaToM scacb1saHlllS1 1113 nnespanbHblX no-
nocTelll TBepp,btX 4aCTlllL\ 111 )f{lll,D,Kocrn. B Hacrns:i-
1.4ee speM51 ycTaHOBJlSHO, 4TO y 46JlOBeKa B
HOpMaJlbHblX ycJlOBlllSIX nnespailbH8SI )f{lll,D,KOCTb
06pa3yeTC5! B an111KaJlbHOi/1 48CTlll napllleTaJlbHOill
n11espb1, a ee scacbrsaH111e npm1cxop,111T
nocpe,D,CTBOM Jl111Mcparn4eCKlllX CTOM Hl11)KHlllX OT-
p,enos nap111eTanbHOlll nnespb1. TaKlllM o6pa3oM ,
cp11tnbTpa4111s:i 111 pea6cop64111s:i nnespanbHOill )f{lll,D,-
Kacrn 51BJ1516TCS1 cpyHKL\1116171 napllleTaJlbHOVi
nnespb1. B cf:>i11311Jonorr111..1ec1<J11X ycnoa11151x s111c-
4epanbHas:i nnespa B cplllilbTpal\111111 nnespanbHoill
)f{IAAKOCTIA He y4acrsyeT.
!i1CT04HlllK8Mll1 ll1HHepsa1..1111111 napllleTaJlbHO~
nneBpbl HBJ151IOTCSI Me)f{pe6epHble 111 Avtacppar-
MaJlbHble HepBbl. B lllHHepsal\111111 s111c1..1epanbHaill
nneepbl y4acTBy10T nero4Hbte cnneTeHlllSI, cpop-
M1A PY10U\lllecS1 38 C46T 6ny)f{,llalOLI..!6fO Hepsa,
sersew norpaH111YHoro craona, ,a111acpparManbHblX
Hepsos 111 cn111HHOM03roBbtX y3nos. 0Tcl0,D,a pa3-
Il1114Has:i 4YBCTBlllTeJlbHOCTb nap111eTaJ1bHOW 111
s111c4epanbHOill nnespb1. narn11or1114ecK1.1e npo-
1..1 eccb1 c sosne4eH111eM nap111eranbHOVi nneBpbt
acerp,a conposo~alOTCS1 Bblpa)f{eHHOCi 60Jlb10,
Tor,D,a KaK pa3p,pa)f{eH1.1e s111c4epanbHOr/1 nneapbr
He conpOBO)f(,D,86TCSI 6oneBblMl.1 OU\Yll.\eHlllS1Mlll.
3MmfeMa nnespbt (rHOHHbtH nneBP'-'IT) -
3TO orpaHl.14eHHoe 111m1 A111¢cpy3Hoe socnaneH111e
BIACL\epanbHOill 111 nap111eranbHOill n.neBpb1 , npore-
Ka10u.iee c HaKonneH111eM rHOSI a nnespanbHOlll
no.nocr111 .
3muo1102uR u namo2eHe3
Ocrpa51 Hecne1..1111¢1114ecKa5l 3Mn111eMa nnes-
pbi HB.n5leTC51 nOJ11113TlllOI10rl.14HblM 3a60.nesaH111-
eM . AHa3po6Hbte M1.1KpoopraH1113Mbl a 41.1CTOM
Blr1,Lle Bbl,Llen5llOTCS1 8 35 % cny4aeB OCTpblX He-
cne4111cp1114eCKlllX 3Mnll1eM nneBpbl, B OCHOBHOM
3TO 6aKTep111111 rpynnbt Bacteroides,
Fusobacterium, Peptostreptococcus. A3po6Hbre
149
6aKTep111111 51BI15llOTC51 B036y,D,111Tem1Mlll 3Mnll1eM B
25 % cny4aes, 3TO pa3Il1114Hble Blll,D,bl rHoepop,-
HblX CTacplllJlOKOKKOB, nHeBMOKOKKlll Ill rpaMOTPlll-
L\8TenbHble Mlr1KpoopraHll13Mbl - Cll1HerHOi1Ha51 Ill
KlllWe4HaSI nano4Ka , nporelll , 1<J1e6c111enna 111 p,p. Y
40-45 % 6onbHblX 3Tll!OflOrlil4eCKOrlr np111Yll1HOW
3MnllleMbl nneBpbl SIBJ15leTcSI CMewaHHaSI MlllK-
pocp.nopa - co4eTaH111e aHa3po6Hb1x 111 a3po6HblX
6aKTep111Vi.
npaKTll14eCKlll BCe OCTpbte 3MnllleMbl nneBpbr
BTOpiA'-IHbl Iii Yau.ie acero 51BI1SllOTC>I ocnO)l{HeH.111-
eM OCTpblX Ill xpoH11146CKl.1X BOCnan1.1TeilbHblX 3a-
6oneBaHllllll nerKlllX, TpaBMbl rpy,0,111 111.n111 onepa-
TlllBHblX BMewaTSJlbCTB Ha opraHax rpyAHOVi
KJleTKlll.
nyrn npoHlllKHOB6Hlll51 VIHcpeKL.1111111 B nneB-
pa.nbHYIO nonoCTb pa3J11114Hbl , 4TO C03AaeT 1113-
BeCTHble TPYAHOCTlll B paHHeill ,D,lllarHocrnKe 3TOlll
naTOilOrrAltl.
Ha1116onee 4acro 3Mn1.1eMa n11espb1 pa3Blll-
saeTcs:i no 6poHxo-nero4HOMY nyi-111 : np111 pac-
npocrpaHeH111111 VIHQJeKL.1111li1 1113 TKaHvi nerKoro, 51B-
mrncb OCJlO)f{H6Hll1eM rHOlllHO-,D,eCTPYKTll1BHblX
3a6onesaH1.11it nerKlllX (a6cl\ecc, raHrpeHa) 111n1.1
6aKTep111aJlbHOW nHeBMOH111111; pe)f{e 3MnllleMa
pa3Bli1BaeTCS1 np111 pa3pb1Be HarHOlllBWeV.cS1 K111CTbl
nerKoro, cnoHTaHHOM nHesMoropaKce, pacna-
.QatoLI..\eMCSI paKe nerKoro.
n1.1McporeHHblit. nyTb pa3BlllH151 3Mn111eMbl
n11eapb1 B03MO)f{eH np111 nop,p,111acpparManbHOM
a6c4ecce, naHKpeoHeKpo3e , rnoiltHoM napaHecp-
p111Te, a6cJ..1ep,1t1py10U,\eM BHyTp1"rpyp,HOM I1111Mcf:>a-
A6Hll1Te; reMaroreHHblVi - np111 cenc111ce, cenrnYe-
cKoM 3H,D,OKap,D,111Te, rHOVlHOVI aHrnHe, anneH,[11.1-
KYilSIPHOM a6c4ecce.
B 6onee pe,D,KlllX cny4aSIX 111CT04Hll1KOM ll1H-
cp1114111 poBaH111S1 nnespanbHOi1 nonocT111 Moryr
6b1Tb: rHOillHblill Me,D,1118CTlllHll1T, rHOlllHbii/i nep111-
KapAll1T, cnoHTaHHbtr/1 pa3pb1B n1.1u.ieso,D,a, pacna-
p,aioil.(wtfcfl paK m1U(eso,aa, rHOHHOVl XOH,D,p!AT IA
OCT60Mll18Jlll1T pe6ep (rpy,D,lllHbl, no3BOH04Hl.1Ka).
Oco6b11it pa3p,en ropaKa.nbHoC1 x111pypr111111 co-
CTaBJlSllOT paHeBble 3MnllleMbl nneBpbl, pa3B111B-
Wl.16CS1 scnep,cTBllle paHeH1.1i1 1.1 TpaBM rpy,D,HOlll
KneTKIA, a ra10Ke S1TporeHHb1e 3Mn1.1eMbl - nocne
onepa4111C1 Ha nerK111x 111 n1.11.4esop,e, B ocHoBe Ko-
ropblX ne)f{lllT Hecocro5trenbHOCTb KYilbTlll 6poH-
xa 111n111 n111u.ieso,QHOro aHaCTOM03a.
YcnosHo MO)f{HO Bbtp,en111Tb 3 crap,111111 pa3-
s111r111s:i 3a6onesaH111S1.
nepB851 CTa,D,1.151 - 3KCcy,D,aTl.1BHaSI, xapaKTe-
p1113yeTCSI HaKonneH111eM 3Kccyp,ara B ceo6op,Hoill
nnespa.nbHOf.1 nonocrn. no xapaKTepy 3Kccyp,aT
Ha nepsor/1 cTap,1111.1 MO)f{eT 6b1Tb cepo3HbtM 111n111
cepo3Ha-cp1116p111Ho3HbtM. np1.1 npopbtBe a6c1..1ec-
ca nerKoro B cso6aAHYIO nnespanbHYIO nonocTb
3Kccyp,ar y)f{e Ha nepsoill cTap,111111 3a6onesaH111S1
111MeeT rHoit.Hbtlll xapaKTep. MaKpocKon1.14ecK111 Ha
3TOIA crap,111111 nosepxHOCTb nneBpbt rycKna51, we-
poxosarnSI, oTe4HaSI, Bbrpa)f{eHa VIHbeKL(lllS1 co-
cy,aos, HaneTbl cp1116p111Ha; r111CTOJ10flll48CKlll OTMe-
4aeTC.S1 Bblpa)f{eHHas:i nei:1K0411TapHas:i llJHQJllJilbT-
pa41As:i nnespanbHblX nlACTKOB. Heo6xo,o,1AMO OT-
MeTIATb, 4TO ecnlA Ha 3TOlli CTa,D,IAIA Ha4aTb ne4e-
HIAe: nyHKLllAIA nnespanbHOlli nonocrn, aHrn6aK-
Tep1Aa!lbHY10 TepanlAIO, ,o,anbHelliwee pa3BIAT1Ae
3Mnll1eMbl nnespbl MO)f{HO OCT8HOBllJTb.
Bropas:i CTaA1115! - QJ1A6p111Ho3Ho-rnoii1Has:i , xa-
paKTepllJsyeTcs:i n111s111coM Bbmaswero cpV16p111Ha,
cpopM111posaH1t1eM pblXIlblX cnaeK B nnespanbHoiil
nonocrn 1t1 ocyMKOBaH1AeM 3KccyAaTa . noA sos-
Aeiilcrs111eM M111KpoopraHIA3MOB nocne,o,HVliil npV1-
06peraer Bblpa)f(eHHbtlA rHoiAHbllA xapaKTep, Ha
4TO yKa3blBaer ero BblCOKVIJA nelAK041t1T03 - npVI
MllJKPOCKOOllJlll 6onee 50 ner.1KOL(lllTOB B none 3pe-
HllJS1 IA nonO)f(llJTeilbHble pesynbTaTbl noceea
nnespailbHOJA )f(llJ,[lKOCTllJ. rllJCTOI10rllJ4eCKll1, OAHO-
speMeHHO c socnamHeilbHb/MW, npoWCXO,LIWT
HapacraHllJe npOAYKTl1BHblX peaK4llJIA: o6pa3ylOT-
C5! rpaHyns:i4111111 sa C4eT nponV1cpepa4111111 cpl16-
po6nacros l J rllJcTllJOL.lllJTOB, IA,Qer HoBoo6pasosa-
HllJe cocyAOB. TaK cpopMIApyeTcs:i "n111oreHHa5l
MeM6paHa" ' KOTOpas:i orrpaHIA41ABaeT CKOnlAB-
WIAJACs:! B nnespanbHoiil nonocrn rnoiilHbllA aKccy-
AaT 111 npe,[lynpe)f(,[laeT ero pacnpocTpaHeHIAe Ha
OKpy)f{alOLl.llAe TK8HIA.
TpeTb51 cTaAIA51 - cra,o,1As:i opraH1.13a41A1.1 . Ha
3TOiil CT8,[llAIA, IA3-3a BC8CblB8HIAS1 llJ3IllAWKOB BO,D,bl
llJ AanbHelAwero HaKonneHIAs:i AeTp111Ta, 3KCCYAaT
cTaHoBIATC.s:! rycTblM. MopcponornYecK111 Ha4111Ha-
10T npeo6naAaTb penapar111BHb1e npo4eccb1 : o6-
pa30BaH111e 3penolA coeAIAH111renbHoiil TKaH111 ,
OKOH4aTe!lbHO cpopMIApyeTCfl nonoCTb 3Mnfll€Mbl.
KnaccucjJuKa4uR
I. no KI1l1Hfll4€CKOMY Te4eHllllO:
1. OcTpb1e (,llo 2 Mecs:i4es)
2 . XpoHl14ecK111e (csb1we 2 MeCflL\eB)
II. no npolllCXO}l(,l\eHIAIO:
1. nepBli14Hble:
a) KplAmoreHHble (Kor,D,a lllCT04HIAK 1AHcpllJ4fll-
poBaH111S1 nnespanbHoiil nonocrn Bbls:!Bfl!Tb He
y,D,aeTcs:i)
2. 8TOPL14Hble:
a) nplA pacnpocrpaHeHIAJ.1 1AHcpeK41A1A IA3 APY-
rnx opraHoB 111 TKaHeii!
6) paHesb1e (rpasMarn'-leCKIAe) - nocne or-
KpblTblX paHeHIAiil rpy.0.111, rpaBM rpy,[lHOi::l KI1€TKIA Ill
nlALl.leBoAa, conposo)f{Aa10ll.lfllXcs:i nospe)f(,[leHl1eM
nnespanbHblX Ill/ICTKOB
B) 51TporeHHble - nocne onepa4llJIA Ha nerK111x
IA opraHax cpe,D,ocreH1AS1, nocne Hano:>KeHIAs:i 111c-
eyccrseHHoro nHeBMOTopaKca
Ill. no xapaKTepy so36y,D,111Tens::i :
1. Hecne41Acp1A4eCK1Ae (Bbl3BaHHble rHoe-
po,llHoi.1 ¢nopoi.1, Bl<Jll04as:i aHa3po6HbJe so36y-
,D,1Aren1A)
2. Cne4111cp1A4eCKIAe (ry6epeyne3Hble, rp1A6-
KOBb1e, CMeWaHHble)
IY. no xapaKTepy 3KCCYAara:
1. rHOWHble
2 . rHlllilOCTHble
150
Y. no pacnpocTpaHeHHOCTfll Ill pacnOI10)f(€-
Hl/llO rHOlliHoro 3Kccy,o,arn:
1. Cso60AHb1e 3Mn1.1eMbl (cy6roranbHble,
TOTailbHb1e).
2. OcyMKOBaHHble 3Mn111eMbl (an111KanbHb1e,
napaKOCT8IlbHble, M€,[lfll8CTlllHailbHbl€, 6a3ailb-
Hble, M€}1(,l\OI1€Bble)
3. AsyxcTopoHHllle aMn111eMb1 (cso60.o.Hb1e(
orpaH1114eHHb1e)
YI. no xapaKTepy coo6Ll.leH111fl c BHewHeiil
cpeAoi.:1:
1. 3aKpblTble (BKI1KJ4a51 nnespo-opraHHble
CBL1Ll.llA, He coo6Ll.la10ll.lfllecs::i c BHeWHeL1 cpe,[loiil)
2. OTKpblTbre:
a) c 6poHxonnespanbHblM CBfllll.l€M
6) c nnespOKO)f(HblM C81All.l€M
8) c 6poHxonnespOK0)1{1:fblM CBlllU.jeM
r) c APYrVIMlll 6poHxoopraHHblMfll CBIALl.laMIA
(coo6Ll.la10LI_\lt1MlllCS1 c nOilblMIA opraHaMllJ IA BHeW-
Helli cpe,qoL1)
Yll. no xapaKTepy ocno)f(HeH111L1:
1. He ocno:>KHeHHble.
2. Ocno:>KHeHHble (cy6neKTopanbHOIA cpner-
MoHoiil, KapH111cp111Ka4111elA nerKoro, MeA111acrnH111-
TOM, nepllJKap,D,IATOM , MeTaCTaTlt1'-leCKll1M a6cuec-
COM M03ra, ne4€Hfll Ill ,[lp.).
KnuHul.feCKaR KapmuHa
An51 3Mn111eMbl nnespbl xapaKTepHo ocTpoe
Ha4ano 3a6onesaHllJ51 c pe3Koro no,o,beMa reM-
neparypb1 111 norps::icatoll.lero o3Ho6a, 3Ha4111Tenb-
Horo y4aLI..\eH111s:i nynbca (Ao 120-130 B M111Hyry} ,
noHsneH1115l c.111nbHb1x 6onetii s rpygHotlf KfleTKe 111
o,D,b1WKll1. TeMneparypa y 6onbWIAHCTBa 6onb-
HblX nOCT05!HHO ocraeTC51 Ha BblCOKlllX 4111cppax
{39-40 ° C), a np1t1 rH111nocTHoi.1 3Mn111eMe n1t1xo-
pa,[lKa HOCWT p€Mll1TTll1PYKJLI..\flllA xapaKTep, c cy-
T04HblMIA Kone6aHlllflMll1 2-3 ° C, pe3KlllMl1 osHo-
6aM111111 npOillllBHblM noTOM.
MeCTHblMlll c111MnTOMaM1A 3Mn1AeMbl nnespbl
S1B!ls:!IOTCS1 nOCTOSIHHble 6om1 B rpy,QHOM KileT-
Ke - Yallle KOiltoLL1ero xapaKTepa, yc11m.111sat0LL1.111e-
c51 np111 ,D,b1xaH111111, Kawne, nepeMeHe nollo)f(eHlllfl
Tena. no Mepe H8KOnileHll15! 3KCCy,D,aTa B nneB-
p8flbHOL1 nonoCTll1 6011111 B rpy,o,Holli KI1€TKe CTL1-
XaKJT 111 CMeHS1IOTC51 4YBCTBOM TS1}1{eCTlt1. ll13-3a
6oneill 1.1 cKann111aaioll.leroc.s:i aKccy,o,aTa 6onbHble
Hepe,D,KO nplllHlllMalOT BblHy)l{AeHHOe nonyc111-
AS1~ee no11o>KeH111e 111n111 npegno4111Ta10T ne>KaTb
Ha 6onbHOM 6oKy.
06U\lllM AilH 3Mn111eM nnespb1 s:isn51eTc51 Ha-
f11A41.1e rHOtAHOtA lllHTOKCl/IKaLlllllA, Bblpa>KeHHOCTb
KOTOpoill np51MO 3aBlllClllT OT nllOLl.laAlll nopa)f(e-
Hl.151 nnespb1, xapaKTepa so36yA111Ten5l 1.1 peaK-
rnsHocrn opraH"13Ma 6onbHOro. f HotiiHaS'I 1itHTOK-
c111Ka411151 npo51BI151eTC51 HapacTato~el:1 cna6o-
CTbto, noTn111eocTbto, noTepel:1 anneT111Ta,
TOWHOTOH, peoTow, HapyweHH.RMlll nc111xHKH -
OT 6eCCOHHll1l\bl, ncfllXOMOTOpHoro B036y)f(,[leHL151
IA 3lAcp0plAIA AO COCTOS'IHIAS'I yrHeTeHHOro C03HaHl/IS1
(conop).
 np111 OCMOTpe 60nbHOro o6pall.\aeT BH1t1Ma-
H1t1e OTCTaBaH111e rpyAHOVt KfleTKll1 nopa)l(eHHOll\
CTOpOHbl np111 AblXaHl/1111, a np111 60JlbWOM CKOnne-
Hl/1111 rH05'1 n05'1BmleTC$1 Bb16yxaH111e rpy,qHOVt KJleT-
Kll1, crna)l(eHHOCTb Me)l(pe6epHblX npoMe~TKOB ,
OTeK KO>Kltl Ill nOAKO)f{HOi1 KneTl./aTKlll Ha nopa>KeH-
HOll\ cropoHe. ronocosoe APO)l(aH111e HaA MecroM
cKonneH1115l rH051 ocna6neHo 111n111 orcyrcrsyeT.
np111 cpaBH1!1TenbHOil1 nepKYCCl/1111 Bbl5'1Bfi5'1eT-
C51 np1,1rrynneHMe nerol!Horo 3ByKa B o6nacrn
CKOnJleHlllSl 3KCCy.[\aTa. np111 CB060,[jHblX 3Mnllle-
M8X nnespbl sepxHs:is:i rpaH1114a ::iKccyAara onpe-
Aem:rercs:i B Bti1Ae mtHHH 3nmtca-.QaMya3o.
np111 ayCl<YfibT8L\tillll B Ha48JlbHOll\ CTaAlllVl
3a6oneeaHlt1S'I MO)l(HO BblCJlyWaTb wyM TpeHMSI
nneepb1, Koropbtil\ 1ttc4e3aer no Mepe HaKonne-
Hlt151 rHOSl - npltt 3TOM onpeAeJl5leTC51 pe3KOe oc-
na6neHHe se3HKynsipHOfO ,QblXaHMSI, BOJ10Tb
AO era nonHoro orcyrcrs1t15l .
Ha ¢oHe C"1HAPOMa rHo!l1Hoili "1HTOKrn1<a4"1111
npo51sn51erc51 cepoel./HO-cocyoucmaR, nelleHo'-1-
HaR u nol./el./H8fl Heaocmamol./Hocmb B B1t1Ae
CTOVtKOVt T8X1t1Kapp,111111, rnyxocrn cep,Qe4HblX TO-
HOB, 3KCTpacli1CTOJllttlt1 , rnnoreH3lttlt1 , 1113MeHeHll1Vt
3Kr , i.1"'Tepll14HOCTVf CKJlep VI KO}!{HblX noKpOBOB,
ysem14eH1t15l ne4eHlll , 6oneilt np1t1 noKona41t1BaH111111
B no51CH1114Hoili o6nacrn.
np111 He6naronp1t1SlTHOM Te4eHl!1lt1 3a6onesa-
Hlt151 COCT051Hltte 60JlbHblX nocreneHHO yxyAWa-
eTC51. KmKHbJe no1<p0Bbl craHoss:irc51 cyXMMlll 111
np11106peTat0T 3eMJlfllCTblVt 4BeT. 8btCOK8fl meM-
nepamypa, cMeHRemcR cy6cfJe6punumemoM
lt1Jllt1 HOpMan1113yeTC5l, 4TO 51BJ15leTC51 nporHocrn-
1..{ eCKfll He6naronp1115lTHblM npV13HaKOM , CBfllAe-
r enbCTBYIOll.\lttM 0 pe3KOM CHVl)l(eH!illtt peaKT!ilBHO-
CTVl opraHlll3Ma. 50JlbHble cTaHOB51TC51 B51JlblMlll lt1
anarn4HblM111. ,.Q111crpocp1114ec1<111e 1'13MeHeHL151
MfllOKapAa, ne4eHlil, no4eK, HaAn04€4Hlt1KOB np111-
BOA5lT K Bblpa)f(eHHblM HapyweHfll51M lttX ¢YHKL..\lt1Vl .
Bb1secrn na41tteHra lt13 cocT051Hlt151 rHolitHo-
pe3op6rnsHoro 1t1CTOll.\eH1tts:i KpalitHe TPYAHO, npo-
rH03 np1t1 3TOM nnoxoi/J .
Oco6eHHOCmu omaenbHblX KflUHUl..feCKUX
cjJopM
np1t1 nocrnHeBMOHlil4ecKoi71 3MnVleMe nnee-
pb1 , c111MnTOMbJ 3a6onesaH111S1 no>!Bn5llOTC51 111
yc1ttn1t1Ba10Tcs:1 cnycrs:1 3-5 AHeC1 nocne crnxaH1tts:i
ClttMnTOMOB socnaneHlllS'I nerKOfO, KaK BTOpas:i
sonHa 1t1HcPeK41111t1 . Han1t14V1e rnoC1Horo Bbmora B
nnespanbHYIO nonocTb YTOl./Hs:ierc51 peHTreHono-
flttl./eCKVIM VI ynbTpa3BYKOBblM 1ttccneAOBaH1tteM,
nOATBep)f{,D,aerc51 nyHKl..(1t1eilt nnespanbHOtlt no-
n ocr111.
Ha ct>oHe reHepan1t130BaHHolit 1t1HcPeK41t11t1
(cenc1ttc) , paHH1tte npo5lsneH1ttfl ocrpoL1 3Mn1tteMbl
nneBpbl Hepe,D,KO M8CK1ttpyt0TC5l KfllttHVIKOVt oc-
HOBHOro 3a6onesaH1t15l 1t1 HarHoeH1tte s nnes-
panbHotlt nonocrn Bbl51Bns:iercs:i no3,QHO. 8 ,o,aH-
HOM cny4ae n111wb p,V1HaMV11.1ecKoe peHrreHono-
rn4ec1<oe 111ccneAOBaH1r1e opraHOB rpy,aHotf Kner-
151
Kitt (nos:isneH1tte n1tteM1t14ecK111x a6c~eccos s na-
peHX1t1Me nerKlllX) lt1 ynbTP83BYKOBOe 1i1ccneA0Ba-
HV1e nnespanbHOC1 nonocTvi (Han\1\1.llile 3KCCYAaTa
c MHO)!{eCTBeHHblMlll rnnep3xoreHHblM\ll TeH5!Mlll)
n0Morat0r nocraB1t1Tb npae1i1nbHblil1 A1ttarH03 .
Oco6o"1 TR>KeCTb/O 0Tn1ttL/a10TCR aHa3po6-
Hbre ::iMnvieMbr nnespb1 , 1<oropb1e npos:ism110rcs:i
pe3KO Bblpa)f(eHHoili VIHTOKC1t1Ka4111et.1 , reKT1t11./eCKOL1
reMneparypotlt, nporpecc1ttpy10ll.\1t1M1t1 nonV1op-
raHHblMt-i HapyweHVIS'!Mlil , paccrpotltcrsaM1t1 co3-
HaHV15l ennorb ,o,o ,o,enV1p111s:i 111 KOMbJ. XapaKTep-
HblMltt MeCmHblMU CUMnmoMaMU 8H83p06HOLJ
3MnueMbl S'IB!lS'llOTCS'I OTe~HOCTb Iii nOAKO)f(HaH
3McpM3eMa MSUKHX TKaHei.11 rpy,D,HOVt KneTKVI Ha
cropoHe nopa)f(eH1tts:i; np1t1 nyHKL..\lttlll nneepanbHOtlt
nonocr111 3KCCYAaT CKYAHblM , rpst3Ho-ceporo
._.eera M1n1 reM011MJMpoeaHHblM (4sera «Ms:ic-
HblX nOMOeB») co 3J10BOHHblM 3anaxoM . 8 KpOBl4
onpeAen51ercs:i Bb1pa)KeHHb1i11 neil1Ko41ttro3 c pe3-
Klr!M c,aB1ttroM neL1KOQJOPMYJlbl sneao.
B ps:iAe cny4aes ocTpb1e 3MnV1eMb1 nnespb1
nporeKalOT ropn1t1AHO , 6e3 51pKOVt KflVIHlt14eCKOVt
K8pTlt1Hbl , HO c Bb1pa>1<eHHOili lt1HTOKCV1Ka~1tteilt , np1.1
3TOM B reMorpaMMe MO>KeT He 6b1Tb Bblp8)f(€H-
HOfO neKOMl.J,ffT038 (Hepe,{l,KO OTMeL/aeTCR ,o.aJKe
neil\KoneHVls:i) , 4To TaK)f(e xapaKTepHo ,o,ns:i aHa-
3po6HoL1 1t1HcpeKL\1t11t1 .
np1t1 8KTlt1BHOM ry6epKYlle3e nerKVIX 3Mn1tte-
Ma nnespbl MO>KeT npo51BJ15lTbC51 OCTPO - BblCO-
KOVl JllllXOpa~KOL1 c T51)Kenoi/J lt1HTOKC1t1KaL\1t1etlt lt1
Hao6opor, Alllt1TbC51 roAaM1t1, He Bbl3b1sas:1 oco-
6brX )1(8!106. ,Q1r1arH03 no,qrsep)l():laerc51 np1r1 Bbl-
AeJleH1t11t1 lt13 rHOfl M1t1Ko6aKTep111tlt ry6epKYne3a .
Ecn111 nop,o3pesaercs:i ry6epKYne3Hbllit xapaKTep
3MnltteMbl Heo6XOAL1MO M8KC!i1MaJlbHO 6b1crpo
nOATBepA1t1Tb All1arH03 , 111cnonb3Ys:t secb cospe-
MeHHbll.1 cneKTp na6opaTOpHblX ltl £1HCTpyMeH-
T8flbHblX MeTOAOB VlCCJleAOBaHlt15'1, BKfllOl..{85l TO-
paKOCKOnltttO lt1 6111onCV1IO nneBpbl.
np1i1 orpaHl!14eHHblX 3Mnll1eMaX Kfllt1HVl4eCK851
KaprnHa 3a6onesaH1tts:i so MHOroM onpeAens:iercs:i
KOJllt14eCTBOM lt1 JlOK8Jllt138L..\1!1eJ/1 fHOs:I B nneB-
panbHOC1 nOJlOCTltt.
np1r1 fHOlfrHOM naHKp€OHeKp03e, rHOlfrHOM
napaHecpp1ttre e socnan1ttrenbHbllli npo4ecc He-
peAKO BOBJleKaercs:i 3a6p10Wli1HHas:i KneTl./8TKa, a
np1t1 noA,D,1!1acpparManbHOM a6c4ecce - Allla-
cpparMa 1t1 np111nerat0ll.\a.s:t K He!/1 A1ttact>parManb-
Ha5I nnespa. np111 3TOM s nnespallbHOi-1 nonocrn
MO>KeT Ha1<ann111saTbC5l 3KcCyAaT. Ecn1t1 nyHK-
l\fll51Mlt1 nnespanbHolli nonocrn peaKTlllBHblil\ Bbl-
nor BOBpeMs:i He fllt1KBlt1Alt1POB8Tb, nocJleAHllllA
6blCTPO lttHcPlttL..\lttpyeTC51 c ¢opM111posaH1tteM 3M-
n111eMbl nnespbl. noaTOMY y BblWeyKa3aHHOil1 Ka-
reroplilltl 6onbHblX, np1t1 Ali1HaM1t14ecKOM ynbrpa-
3BYKOBOM KOHTpone 38 Te4eH111eM OCHOBHOro 3a-
6oneBaHVl51, Heo6XOAlt1MO ,qonOJlHlttTeJlbHO Bbl-
nonH51Tb 1ttccne,[\0BaH111e nnespanbHblX nonocrerli
Ha npeAMeT H8Illt14lt15l B HlttX 3KCCYAaTa.
 6onbwoe 3HaYeH111e B AV1arHocT1111<e 3Mn111eM
nneepb1 L11Me10T peHrreHonor111Yec1<111e MeTO,Qbl
IACCJleAOBaHlll5l.
np111 0630pHOL4 peHTreHorpacf>111V1 B npSlMOi.1 Ill
60KOB0£1 npoeKJ..11115lX He60ilbW0£1 no KOJ11114eCTBY
Bbinor (200-250 Mn) npo5!sm1er ce6s:i crna)l{eH-
HOCTblO pe6epHO-Alllacf>parManbHOro ClllHyca VI
Ka~ll.llllMCfl BblCOKIAM nono)l{eH111eM Kynona
A1t1acf>parMbl. np111 3MnllleMaX co cKonneHl!leM B
nonocm 6onee 500 Mn 3KccyAaTa, nocne,llHHH
Bbls:!Bm1ercs:i B nps:iMOi.1 npoeKL.1111111 B BLllAe lllHTeH-
C"1BHOro 3aTeHeHll151 TpeyronbHOi.1 cf>opMbl , w111po-
Koe OCHOB8HV1e KOTOporo CJlV1BaeTC51 c TeHblO
Alllacf>parMbl 111 no,LIJ\111acpparManbHblX opraHoB.
nporpecc111py10L.Uee HaKonneH111e 3KCCyAaTa np111
TOTailbHOL4 3MnllleMe xapaKTep1113yeTc5l 3aTeHe-
H111eM sceilt nonOBlllHbl rpyAHOi.1 KneTKlll.
P1.1c. 28. Ocrpaff .neaocTopoHHSlff 3M-
n1.1eMa n.neepbl.
npstM3SI peHTreHorpaMMa: MHTeHCl.18-
HOe cy6ToTa.nbttoe 3areHett1.1e .neeoro re-
- MMTOpaKca.
np111 orpaH1114eHHblX (ocyMKOB8HHblX) KOC-
TallbHblX 3Mn111eMax Ha peHTreHorpaMMax onpe-
Aem1ercsi 1<pyrna51 111n111 osanbHasi TeHb c w111po-
K1t1M OCHOB8HllleM y rpyAHOVt KneTKlll Lii BblnYKilblM
4eTKll1M Hapy>KHblM KOHTYPOM; AI151 Me)f(,D,oneBblX
3Mm1eM xapaKTepHo nosisneH111e I1LllH3oo6pa3Hoi.1
TeHVI c AB051KOBblnYf<JlblMVI 1<0HrypaM111 111 Jaocr-
peHHblMLll Kp851Mli1 B npoeKL.1111111 Me>K,[\oneBblX l.Lle-
nei.1 .
P1.1c. 29. OrpaHM'·leHHasi napaKocra.nb-
Hasi 3MmteMa n.neBpbl cnpasa. npRMaff
peHTreHorpaMMa (a): MHTeHCMBHOe napa-
KOCTaJlbHOe 3areHeH1.1e npasoro reMMTO-
paKca, Wlr1pOKl.1M OCHOB3Hlr1eM np1.111era10-
~ee K rpyAHOM KJleTKe; npsiMaff TOMorpaM-
Ma (6) roro >Ke 60.nbttoro: onpe,Qe.nffercsi
~eTKaff rpaH1r1~a ocyMKoaaHHoro rHoi1Horo
3KCCy,QaTa B Blit,Qe BblnYKJlOM Jll.1Hl.111t, 06-
pa~eHHOM e cTopotty npaeoro .nerKoro.
B A111arHocrn1<e m10nHesMoropa1<ca peHrre-
Honorn4ecK"1Vt MeTOA 51Bn51eTC51 Be,l:iyl.LlLllM. np1i1
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MeHeH111111 nOJlO)l(eHlll71 Tena 60ilbHOro. np111 H8-
npR}l(eHHOM nHeBMOTOpaKce OTMe1.1aeTCR non-
Hbli:1 Konnanc nerKoro Ha nopa)l(eHHo£1 cTOpoHe,
' WlllPOKlll£1 yposeHb >KlllAKOCTlil B nnespanbHOL:i no-
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3Aoposyio crnpoHy , HepeAKO pa3B111Baerc51 3M-
¢1113eMa cpeAOCTeHlll51.
P1.1c. 30. .QecrpyKTMBHasi nHeBMOHMff
nesoro nerKoro, ocn0>1<HeHHaff ttanpJ1>KeH-
HblM .neBOCTOpOHHMM n1.1onHeBMOTOpaK-
COM. npsiMaJI peHTfeHorpaMMa: noflHblM
153
Ko.nnanc .neeoro .nerKoro, Ha cpoHe KoTopo-
ro BlitAeH roplll30HTaJJbHbJM yposeHb 3KC-
CyAaTa B neBOM n11espa.nbHOH no.noCTM,
CMe~eHlite TeHM cpeAOCTeHlitff B npaayio
CTOpoHy, 3Mcpl>t3eMa cpeAOCTeHl>tR (orrec-
HeHHbte nneepa.nbHble n1.1cTKM o6o3Ha~e­
Hbl nyHKTlitpHblMlit CTpe.nKaMl.1).
B HaCT05ll.J.lee speM51 np~1 ,Q111arHocr111Ke
nneapanbHOro BblnOTa WlllpOKO nplilMeHs:ieTCs:I
ynbTpa3BYKOBOe lllCCJ1€AOBaHllle (Y3V1) nneB-
panbHO~ nonocrn, a B OTAenbHblX cny4as:ix -
M8rHlllTHo-pe30H8HCH851 111 peHTreHOBCKa51 KOM-
nblOTepHa5l TOMOrpacf>lll51 .
np1t1 nOMOl.J.llt1 YilbTP83ByKa MO)l(HO Bbls:lBlllTb
A8>Ke He60JlbWOe KOJ11114eCTBO rHOs:l B nneBpanb-
HOi.1 nonocr111 (oT 10-20 Mn) 111 yKa3aTb era ro4-
Hoe pacnonoX<eH111e.
Pwc. 31. Ocrpast 3MmteMa nnespb1.
Y.nbrpa3syKoeoe 111cc.ne,Qosatt1.1e nnes-
panbHOM no.nocn1: B n.nespa.nbtto.:1 nonoc-
TH napaKOCTBJlbHO onpeAemteTCff 3Kccy,QaT
c MHo>KeCTBeHHblMlit rnnep3XoreHHblMM
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OTTecHeHO 3KCCy,QaTOM.
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TOMorpacplils:i AalOT B03MO>KHOCTb 0Tnl/14Li1Tb >KlllA-
KOCTHble (rHOi.1Hbl£1 3KCcy,QaT np111 3Mn!AeMe) OT
nnoTHblX 06pa3osaH1t1rli (areneKTa3, onyxonb
nnespbl) , OL(eH"1Tb COCT051Hll1e coceAHlllX opraHOB
111 T04HO yKa3aTb Ha pacnono)l{eH111e rHos:i B nnee-
panbHOlii nonocrn.
An51 OKOH'-laTeJlbHOro ycTaH0BneH1115l Alllar-
Hosa pewaiol.Llee 3Ha4eH111e 111Meer nyHKL.111151
nnespanbHoil! nonocrn .
MeroA111Ka: nyHKJ..lllllO BbmonH5llOT e nepeBS1-
304HOM Ka6111HeTe lilJllll Manoi.1 onepal..\lllOHHOH ,
co6nio,.Qafl npas111na acenTlllKlll Iii aHr111cenn1K"1 .
Ha6op AJ151 nyHKL.\111111 BKI1104aer: wnp111l..\ o6beMoM
10 lil!ll/1 20 MJl c TOHKOi.1 111rnoilt An5l MeCTHO~ aHe-
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c ABYMs:i KaH10ns:iM111 (OAHa 1113 1<aH10nb AOil>KHa
nOAXOAlllTb no ,QlllaMeTpy K nyHKL\lllOHHOi.1 111rne,
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Hbli.1 MaTep111an , 0,5 % - 1 % pacTBop HOBOKalllHa
(Ha nyHKLIVllO AOCTaT04HO 10-15 Mn HOBOK8111Ha);
OTAenbHO ,QOJl)l{Hbl 6b1Tb np111roroeneHbl noToK
A1151 np111eMa 3KCCyAaTa Ill BaKyyMHbli.1 OTCOC.
6onbHoro yca)l(111Baior Ha cryn c ynopoM Ha pyK111 .
np14 cao6oAHOi1 3Mn1i1eMe nyHKL.\1115! nneapanbHOi:i
nonocr111 BblnOJlH51ercs:i B Ylll Me>Kpe6epbe Me>K-
AY nonaTOYHOIA 111 38AHeL4 no,QMblWe4Holii m1H111-
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no,D,aer x111pypry crep1.1nbHblM n111HueroM . nocne
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aHrncenT"1KOM nocneAOBarenbHO BblnOilH51eTC51
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pbS1 . CMeHlllB TOHKYIO 111my Ha 111my c AlllaMerpoM
1,4 MM MaH111nyn51411110 nosrop5110T: no sepxHeMy
KpalO H111>1<ene>1<aLI_\ero pe6pa , cnerKa noArs:irnsas:i
nopweHb wnp1114a, npoBOA51T 111my B nnespanb-
HYIO nonocTb. MoMeHT BXOAa vffilbl s nnespanb-
HYIO nonocrb onpeAens:iercs:i no xapaKTepHoMy
"nposany" 111rnb1 111 nocrynneHllllO rnoil1Horo 3Kccy-
AaTa. Y6eAlllBWlllCb, 1.no 111ma HaXDAlllTCs:i B
nnespanbHOll1 nonocTlll , npoc5!T 6onbHOro Ha Ko-
poTKoe speM5l 3aAep>1<aTb AblXaH111e , nocne 4ero
cH111Ma10T wnp1114 111 K 111me np111coeAlllH5!10T nepe-
XOAHlllK c HailO>KeHHblM Ha Hero 3a>KlllMOM. 3KC-
cy,[laT yAam~ercs:i np111 noMOU.\111 wnp1114a 111n111 sa-
KYYM-acn111paTopa . np111 speMeHHOM npeKpaLI_\e-
Hllllll acn111pa4111111 , so 11136e>1<aH111e pa3repMern3a-
L\llllll nnespanbHoi/1 nonocrn , npe>K,Qe 4eM CH5!Tb
wnp1114 (111n111 OTKill04111Tb BaKYYMHblil1 acn111parop)
Ha nepeXOAH111K npe,[lsap111renbHO HaKilaAblBaer-
C5l 3a>1<111M (p111c.32) .
PHc. 32. nyHKU.Hfl nnespanbHoLll no-
nocTH. nono}f{eHHe pyK xHpypra: npH Bbl-
nonHeHHH nyHK~i.rn (a); npH acnHpau,HH
3KCCyAaTa (6).
nocne MaKClllMailbHOro YAaneHlll5l rH05l Ill
TU.\aTeilbHoro npoMb1BaH111s:i 3MnllleMHoll1 nonocr111
aHTlllCenTlllKaMlll 4enecoo6pa3HO BblnOilHlllTb
nnesporpacp11110. He 1113sneKas:i 111mb1, lllHrpannes-
panbHO Me,[\IleHHO BB0,[\5!T OT 50 AO 100 Mil BO-
AOpacrsopll1MOro KOHrpacrnoro seLI_\ecrsa 10 111
BblnOilH5llOT peHTreHOBCKllle CHlllMKlll B 3-x npoeK-
L\1115IX (np5!MOll1 , 60KOBOll1 co CTOPOHbl nopa)f(eHl/151
111 B nono>1<eH111111 Ha 3AOposoM 6oKY). nnespo-
rpacp11151 no3son5leT nony4111Tb AaHHb1e o pa3Me-
pax 111 KOHcp111rypa4111111 nonocT111, CTeneH111 1113MeHe-
Hlll5l nnespailbHblX IllllCTKOB, HaI11114111111 6poHXlll-
anbHOro CBlllW,a Ill ero IlOKan1113a4111111. nony4eH-
Hble pe3ynbTaTbl 111cnonb3YIOTC5l AI15l nocrpoeH1115l
nporpaMMbl 06LL1ero 111 MecTHoro ne4eH111s:i.
PMc. 33. nnesporpacpHs:i: orpaHH~eH­
Hafl (napaKOCTaJlbHafl) JleBOCTOpOHHflfl 3M-
nHeMa nneBpb1. nps:iMas:i (a) " 6oKosas:i (6)
peHTreHorpaMMbl rpyAHOM KJleTKH: Ha cpo-
He BBeAeHHOro BOAOpacTBOpHMOro KOH-
TpacTa onpeAeneHa TonorpacpHfl nonocTH
3MnHeMbl, ee pa3Mepbl, COCTOflHMe BHC~e­
paJlbHOro (yKa3aH CTpeJlKOM) M napHeTaJlb-
Horo JlHCTKOB nneBpbl.
Acn111p111posaHHb1!11 3KccyAaT s nepsy10 o4e-
peAb 04eH111saeTC5I MaKpOCKon1114ecK111 (Biii,[\,
4BeT, KOHClllCTeHL\1115!, 3anax) . .O.n.51 3MnllleMbl
nnespbl xapaKTepHblM 51BI15leTC51 3KCCYAaT B 8111-
Ae rycroi/1 MyrHoi/1 >KlllAKOCTlll >1<enTo-3eneHoro
10
Han1114111e anneprn111 K lilo,o,y sisrn1ercsi a6comor-
HblM npornsonoKa3aH111eM K 111HrpannespanbHOMY see,o,e-
H11110 n106oro so,o,opacreop111Moro KoHrpacra.
154
4seTa, c Henp11151THblM , Hepe,[\KO 3IlOBOHHblM 3a-
naxoM .
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• MlllKpOCKOnllllO 3KCCYAaTa, KOTOpa5! BKill0-
4aeT OKpaCKY Ma3Ka no rpaMy Ill W111n10-
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• 4111ronor1114ecK111il1 aHan1113;
• noces 3KccyAara Ha Han1114111e MlllKpo-
11
cpnopbl Ill onpe,[leileHlll51 4YBCTBlllTeilbHOCTlll
Bbl,[\eileHHOll1 MlllKpocpnopbl K aHTlll6lllOTlllKaM .
M111KpocKon1114ecK111 np111 3Mn111eMe nnespbl
Bbl51BI151eTC51 o6111IlbHOe KOI11114eCTBO Heil1rpo-
cp111IlbHblX neil1Ko4111ToB (6onee 50 B none 3pe-
H11151) , KileT04Hblil1 pacnaA, Ml.11Kpo6Ha5l cpnopa, a
B oQ:>opMlllBWlllXCS'I rHoil1HblX 3KCCy,[\arax - ,[\eTplllT,
>1<111posb1e wapbl , Kp111crannb1 xonecrep111Ha, MlllK-
po6Ha5l cpnopa . Heo6XOAlllMO onpe,[1en111Tb He
TOilbKO KOI11114eCTBO .neil1KOL\l'1TOB, HO Ill neil1KOL\lll-
TapHylO cpopMy.ny 3KCCYAaTa, np111 3TOM BblCOKllli/1
IllllMcpOL\lllT03 MO>KeT yKa3blBaTb Ha ry6epKYI1e3
nnespbl , c111cTeMHoe 3a6onesaH111e Kpos111 111n111
XlllilOTOpaKC. OKpacKa no rpaMMy no3som1eT
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W111.n10-HlllilbCeHy - ry6epKYile3Hble nan04Klll . np111
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WlllXC5l 3MnllleMoil1 nnespbl, L\lllTOnor1114ecKoe 111c-
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BeHHble KJleTKlll .
,fl,ucjJcjJepeHUiUOflbHblU auacH03
napanHeBMOHlll4eCKa51 orpaH1114eHHa51 3M-
nllleMa nnespbl HepeAKO MaCK111pyeTC5l MaCClllB-
HOll1 socnan111TeilbHoil1 111Hcp111nbTpa4111ei/1 nero4HOll1
TKaH111 . Ha pa3s111T111e ocTpoilt 3Mn111eMbl nnespb1
MOryT yKa3blBaTb 3aTS1>KHOe Te4eHllle nHeBMO-
Hllllll, coxpaH5l10U.\a5lC5l n111xopaAKa, neil1Ko4111To3,
0TcyTcTs111e nono>1<111TeilbHoil1 peHrreHonor1114e-
cKoli1 AlllHaM111K111 111Hcp111nbTpaTa s nerKoM , coxpa-·
H5l10U.\eec51 np111creH04Hoe 3areHeH111e nopa>KeH-
Horo reM111TopaKca Ha 6oKOBblX peHTreHorpaM-
Max (ToMorpaMMax) nerK111x. YT04HlllTb AlllarHo3
noMoralOT KOMnblOTepHas:i TOMorpacp111s:i Ill YilbT-
pa3BYKOBOe 111ccne,[\OBaH111e rpyAHOll1 KneTKlll Ha
CTopoHe nopa>1<eH1115l c np1114enbHoil1 nyHK4111ei/1
nnespanbHOll1 nonocrn .
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6onesoro ClllH,D,poMa 111 noKanbHoro 3areHeH1115l
nerKoro c nepeXO,[\OM Ha rpyAHYIO CTeHKY Heo6-
XO,[\lllMO ,D,lllcpcpepeH4111posaTb orpaHlll4eHHYIO
aMnllleMy nnespbl c nep111cpep1114ecK111M111 Hosoo6-
pa3osaH1115lM111 nerKoro c 111Hsa3111ei'.1 s rpy,D,HYIO
creHKY 111 neps1114Hb1Mlll onyxon5!Mlll nnespbl. Oc-
HOBHb1M111 MeTO,[\aMlll ,[\lllarHOCH1Klll 51BI1S1IOTC5l
KoMnblOTepHa51 TOMorpacp11151 111 ynbTpa3syKosoe
111ccne,D,osaH111e c np1114e11bHOi11 6111onc111ei/1 (nyHK-
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11
0,o,HospeMeHHO Heo6xo,o,111Mo np111MeHS1Tb cne1.1111-
anbHYJO rexH111Ky 3a6opa rnolilHoro 3Kccy,o,ara ,o,nsi onpe-
,o,eneH111si aHa3po6Hol1 MlllKpocpnopbl.
 ATeneKTa3 nerKoro peHTreHonor1111-1ecK111
npos:1em1eTC5l TOTanbHblM 3aTeHeHllleM OAHOiil 1113
nonoe111H reM111TopaKca. Yro4H111Tb A1118rH03 noMo-
raior o63opHasi peHTreHorpacp111si (rnMorpacp111si) :
np1i1 aTeneKTa3e TeHb cpe,L:1ocTeH1i1s:1 cMell\eHa e
cropoHy areneKTa3111poeaHHoro nerKoro, a np1i1
TOTanbHOiil 3MnllleMe nnespbl TeHb cpeAOCTeHlllS!
cMel1.(aeTC51 B npoTlllBOnonmKHYIO OT BblnOTa
crnpoHy; ynbTpa3syKosoe 111ccnep,osaH111e nnes-
panbHoill nonocTlll yro4H5ler Han1i141i1e 111 xapaKrnp
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p,o6poHXlllaJlbHOiil naTonor111111 (06TYPaL~111s:1 onyxo-
JlblO, CTeH03 6pOHXa).
npaKTlll4eCKOe 3Ha4eHllle lllMeeT orpaHlll4eH-
H85l 6a3anbHo-np111creH04Has:1 ocrpas:1 aMnllleMa
nneBpbL np111 3TOM B socnan111renbHb1l4 npol..\ecc
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nol.f111Ta10T ne>KaTb s op,HOM nono)f{eH111111 Ha
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KOe OTCTaSaHllle rpyAHOVl KJleTKlll Ha CTOpOHe no-
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eepxHoCTHoe AblXaH111e , Kawenb, noAbeM c no-
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3aJlbHOro Bbrnora B03MO}l{Ha 111Hsepc11151 nesoro
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nocnpaBMaTlllLf8CKllle p,111acjJparMaJlbHble
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KaprnHoill rnp,pornpaKca (nHeBMornp,poTopaKca) .
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MO o6pa~aTb BHlllMaHllle Ha H8J11/14111e B aHaMHe-
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155
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no3eonsieT YT04HlllTb np111pop,y ra3osoro ny3b1psi
c roplll30HTanbHblM ypoBHeM , ycraHOBlllTb Bblna-
,D,eHllle )f{e.nyp,Ka a n.nespa.nbHYI<) nonocrb 111 11tc-
Kf1104111Tb 3Mn111eMy; np111 BblnaAeH1111t1 roncroill
KlllWKlll p,ns:1 yro4HeH111s:1 p,111arH03a noKa3aHa 111pp111-
rocKon1115I .
P111c. 34. JlesocTopoHHstst nocnpasMa-
T1111.1ecKas:1 ,D.MacpparManbHas:I rpbl>Ka.. nps:i-
Mas:I peHTreHorpaMMa (a): Ha cpoHe nerKoro
B nesoM reMMTopaKce BMAHbl .a.ea ropw-
30HTanbHblX ypoeHs:i 111 y1.1acToK npocser-
neH111st B npoeK~111111 .a.yrn aopTb1; np1it~enb­
Has:1 nps:iMas:i peHTreHorpaMMa (6): 111pp111ro-
cKon1its:1 - B neBoM nnespanbHOM nonocTH
KOHTpaCTMpyH>TC.R nenrn TOJlCToro KMWel.l-
HMKa (yKa3aHbl CTpenKaMM)
J1eYeHue
6onbHb1e c Hecnel..\111cp1114ecKoill 3Mn111eMoil1
nneBpb1 p,on)f(Hbl rocn111Tan1113111posaTbC5t e cne-
L..\1'1an1113111poBaHHble ropaKanbHble orp,eneH111s:i
lllJllll OT)J,8Jl8Hlll51 rHot1Hoill x111pypr111111 no,[\ KOHTpOnb
rnpaKanbHoro x111pypra .
ne4eH111e 3Mn1t1eMb1 nnespb1 scerp,a KOM-
n.neKcHoe 1.1 noMlllMO KOHcepB8TlllBHOill Tepan111111,
BK.flf()Yaer ,o,peH111posaH111e nnespanbHOiil nonoc-
Tlll , MeTOP,bl 3KCTpaKopnopanbHOi/1 p,eTOKCV1Ka4111111 ,
pa3n1114Hbte onepaTlllBHble BMewarenbcTsa. He-
06xop,111Mo noMHlllTb , 4TO ycnex a ne4eH111111 so
MHOfOM 3881'1CJllT OT caoespeMeHHOill ,[IJllarHOCTJll-
Klll 111 ne4eH111s:1 nepB1114Horo 3a6onesaH1115l , np111-
eep,wero K pa3e111T1111<) 3Mn111eMbl nneep1:,1, a TaK}l{e
conyrcTBYl<)LlllllX 3a6onesaH111ill , reYeH111e KOTO-
pblX ycyry6ns:1ercs:1 Han1114111eM 3Mn111eMb1.
l<oHcepsamusHoe 11eYeHue
KoHcepsaTlllBHa5l repan111s:1 BK.fll04aer:
• nyHKL(lillll nnespa.nbHOrli (3MOlll8MHOrli) no-
JlOCTlll;
• pal...\ltlOHanbHYIO aHT1116aKTep111anbHYIO Te-
panVll<);
• caHal...\llllO rpaxe111 111 6poHxos;
• KOppeKJ.IWIO so.neMVIYeCKJllX HapyweH111ill;
• MeTOP,bl 3KCTpaKopnopanbHOil1 ,D,eTOKClllKa-
L..\l.1111 opraHlll3Ma;
• lllMMYHOKopp111r111py10ll\YIO Tepan111to;
• 06Ll\eyKpennsi10L11YIO Ill ClllMnTOMaTlll4eCf<YIO
Tepan1111<).
nyH1<4uu n11espa11bHOU (3MnueMHoiJ)
nonocmu
neYeH111e 3Mn111eMbl nnespb1 ecerp,a Heo6xo-
,D,111Mo Ha4111HaTb c nyHKL..\1!1ill nnespanbHoVI nonoc-
T111 12 . nyHKL\1110HHO C8HlllpylOTCSI He60JlbWlt1e no
06b8MY (AO 500 Mil) OCTpbl8 3Mnll1eMbl nneBpbl
6e3 6poHxonneBpanbHoro CBJl!ll.la "1 ,LvnnenbHO-
CTblO 3a6oneBaHll1SI He 6onee 1 MeCS14a. nyHKl..\111111
BbJnOJ1HSltoT e)f{eAH8BHO c nonHoiil acn111pa4111eiil
rHofl 111 npoMb1saHl!leM nonocrn 3MnHeMbl pacrso-
paM111 aHTll1CenTl/1KOB: cpypa4111nn111HOM 1:5000 111Jlll1
0,05 % xnopr8KC111A111HOM 6111rntoK0HaTOM ,o,o 4111c-
TO!li npOMblBHOM )f{lil,D,KOCTlll c nocne,QylOll.llllM lllH-
TpannespanbHblM BB8A8Hlll8M npoTeonll1Tlll48CKll1X
cpepMeHros: crpenTOKlllHa3bl 250000-500000 EA
111n111 Tepp111I1111TlllH8 600-1000 nE C aHT1116lllOTll1K8Mlll
w111p0Koro cneKTpa Aeiilcrs111si B 06L1.18np111HS1TblX
A03aX. B Ka4ecTBe nporeon111T1111.1ecK111x cpepMeH-
TOB MO)f{HO 111cnOilb30BaTb npenapaTbl Tp111nc111HO-
soro pHAa: Tp111nc111H - AO 100 Mr Ha BBe,D,8Hllle
(x111Morp111nc111H, x111Monc111H) 111 AP·
nplil MlilKCT-lilHcpeKL\lillil 3cpcp8KT1i1BHO M8CT-
HOe np1t1MeHeH1t1e n111onon111cpara, 1<oropb11il sso-
AS!T B nn8spanbHYfO nonoCTb nocne YAaneHlilSI
rHOH Iii caHa41t1111 aHTll1C8nTl/IKOM B KOI1111'-18CTB8
100 Mn 1 pa3 s cyTKlll. 8BeAeH1t1e n111onon111cpara
nosTop~toT 8)1{8,D,HeBHO, Ha eypc ne4eH111e 5-7
BBeAeH111iil.
np111 Ka)l<,IJ,Oiil nyHKL\lillil H806XO,D,lllMO MaKClil-
M8JlbHO acn1-1p1i1poBaTb npoMblBHO!A pacrnop 111
C03A8Tb OTp1i14arem,Hoe pa3pSl)K8Hlile (BaKyyM) B
nn8BpanbHOlit nonocr111, '-ITO cnoco6crsyer pac-
npasneH11110 nen<oro 111 rn,,1Ks111,o.al(111111 ocraT01.1Ho!A
nneepanbHOlit nonocT111 .
3cpcpeKTlilBHOCTb Tepan111111 KOHTpon111pyeTCH
pe3yllbTaTaM"1 KfH1HW./€CKOro, na6opaTOpHOro,
peHTreHonorn4ecKoro Iii ynbrpa3ByKosoro
(nnespanbHoiil nonocT111) o6cne,o,osaHlllH .
K p8AKlilM ocno)l{HeH1t1S1M nyHK4111iil nn8B-
panbHOiil nonOCTlll cneAyeT OTHeCTlll paHeH111e
nen<oro, KpynHblX cocy,o,oe, cep,D,4a, A111acppar-
Mbl , opraHos 6piowHoiil nonocrn, pa30111r111e Ha-
rHoeH111iil rpy,D,HOiil CTeHKlil no xo,o.y nyHKL\lllOHHOro
KaHana.
AHmu6aKmepuanbHOR mepanuR
06L1.1aS1 aHT1116aKTep111anbHaS1 T8pan111H noKa-
3aHa n111wb np111 pacnpocrpaHeHHblX 3Mn111eMax
nneBpbl , conposo)l<,IJ,atoll.llllXCSI Bblpa)f{eHHOiil BOC-
nanJi!TeilbHOl.1 peaKL(111e!A opraHW3Ma, a TalOl<e npJil
Han1111.1111111 Kn111H1114ecK111x 111 peHrreHonor1114ecK111x
np1113HaKOB npo,o,on)KatoL1.1erocsi eocnan111renbHO-
ro npol(ecca s nen<oM . .Qo nony4eH1M1 ,D,aHHblX
6aKTep111onorn1.1ecKoro 111ccne,o,osaH111H rHoiilHoro
3Kccy,o,ara 4enecoo6pa3HO Ha3Ha4eH1t1e KOM61t1-
Hal..(1.1111 aHrn61.1ornKOB wti1po1<oro cneKTpa AeiilcT-
BlllH , Hanp111Mep, 4ecpanocnop1-1Hos Ill noKoneH111H:
4ecprp1t1aKCOH no 2 r BHYTPlilBeHHO s C048TaHlillil c
MeTpOH111A830nOM no 500 Mr BIB 2 pa3a B cyTKlil .
npenapaTaMlll Bbl6opa MOryT 6b1Tb TaK)Ke: lilMVI-
12
PaHHee ApeH111poeaH111e 3Mn111eMHoi;i nonocrn He-
peAKO np111BOA111T K pa3Bll1Tll1t0 06w111pHblX OKOnOApeHa)l(-
HblX cpnerMOH rpyAHOi;i CTeHK111 ; np111 aHa3p06Hoi;i 111HcpeK-
l.\111111 Te'leH111e raKll1X qmerMOH MO)l(eT 6b1Tb MOnH111eHOC-
HblM.
156
neHeM/41t1nacTaT111H: BIB 2-4 r/cyTKll1 B 3-4 BBeAe-
HlllSI , M8poneHeM 3 r/cyTKlil B 3 BBe,a,eHlil~ , aMOK-
ClllUlllnnJi!H/KJlaByaHaT: BIB 3-4 (..QO 6 r)/cyrKlll B 3-
4 BBeAeHlllSI . np111 CMeHe 8HT1116lllOTl/1KOB (Yepe3 5-
7 AHeiil) op1t1eHrnpytoTCSI Ha pe3ynbT8Tbl aHTlil ~
61!10nlKOrpaMMbl y KOHKpeTHoro 6onbHOfO.
CaHa4UR mpaxeo-6poHXUOflbH020 oepeBO
CaHa4111H rpaxeo-6poHx111anbHOro ,a,epesa
noKa3aHa so scex cny1.1asix ocTpblX rHoiilHo-
AecrpyKTlilBHblX npoueccos nerKlllX, ocno)f{HlllB-
w111xcH 3Mn1t1eMolli nneBpbl. Ha3Ha4alOT ynbTpa-
3BYKOBbte 111Hram:1u111111 c aM6poreKcanoM 111 6epo-
AyanoM (20 Mn aM6poreKcana 111 1 Mn 6epo,o,ya-
na) : 111Hran111posaTb no 5 Mn 3-4 pa3a/AeHb; np1t1-
eM orxapK1t1satoL1.1L-1X MlilKcryp: HaCTOlil rpas -
TepMonc1-1ca, 6arynbH1t1Ka, MaTb-111-Ma1.1ex1t1, KopHfl
conoAKl/1 Ill T.A.; 111HranHUlt1111 68Ta - aroH1t1CTOB:
acTMoneHT (canb6yraMon, 6epoTeK) no 1 s,o,oxy
2-3 pa3a B ,[leHb, 6poHxocna3MOnlllTlilKOB: BIB
paCTBOP 3ycp1t1nn1t1Ha 2,4 % - 10 Mn 1 pa3/cyTKll1 .
06si3aTenbHa AbtxarenbHasi rnMHacrnKa , a
nplll 60ilbWOM KOillllYeCTBe rHOl-1Ho!A MOJ{pOTbl -
caHa41110HHble 6pOHXOCKOnlt1lil .
KoppeKU,UR eooHo-3neKmponumHblX
HapyweHUU
c OTTeK81Qll.llilM rHOeM Ill MOKpOTOiil Tep~eT-
CSI 6onbWOe KOnlil4eCTBO 6enKa Iii 3neKTponll1TOB,
n0Tep111 KOTOpblX o6si3aTenbHO AOJl)f{Hbl 6b1Tb
BocnonHeHbl AOnonH111TenbHblM napeHrepanb-
HblM n111TaH111eM, O,JJ,HOBpeMeHHO npecne,IJ,ytoll.llilM
4enb KOppeK4111111 soneMlll4eCKlilX paccTpOLl!CTB. c
3TOC1 48nbto 111cnonb3YIOT: 5 % lilnlil 10 % aMlilHO-
KlilCnOTHble CM8Clll (aMlllHocon , 8MlllHOnna3Manb
111 ,o.p .). CyTo4Ha~ .n,03a aM1t1HoK111cnoT np1t1 6enKo-
BOM ,.Qecp111u111re cocraBn~eT np111MepHo 30 Mn/Kr/ -
cyr1<111. C :noiil )Ke 4enb10 Ha3Ha1.1a10T pacrnop
anb6yM111Ha lil3 pac4era 1-2 r 6enKa Ha 1 Kr Mac-
CbJ Tena B cyr1<111. .Qn71 YTlllI11113al..lllJlll BBO,allJMbJX
6enKOB o6si3aTeJlbHO e)l{eAHeBHOe Ha3Ha'-leHllle
KOH[.\eHTplilpOBaHHblX paCTBOpOB rntoK03bl - 40 %
1000 Mn s cyrKw c o6fl3aTenbHblM ,o.o6aaneHweM
111Hcyn111Ha lil3 pac4eTa 1 EA 1t1Hcyn111Ha Ha 4 r
rntoK03bl. YcsoeH1t1e BBO,D,lilMOro a3oTa TaK)Ke
nOBbfWaeTCSI nplil COYeTaHHOM 111cnonb30B8Hlillll
aHa6on1114eCKlilX ropMoHos : Hepo6on, pera6on111n
no 1 Mn BIM 1 pa3 B 7-10 .n,Heiil.
CneAyeT noMHlilTb, '-ITO cMec111 , nocrpoeH-
Hble Ha pacrsopax rnt0K03bl KOH4eHrpa4111eiil He
Bbl We 10 %, MO)f{HO BBOA111Tb B nep111cpep1114eCKllle
B8Hbl, ror.n,a KaK 1i1Hcpy31i151 40 % paCTBOpa rnto-
K03bl B03MO)l{Ha TOnbKO nyreM KaTeTep1113a41111t1
4eHrpanbHblX seH 111 npoBep,eH111S1 KaTerepa B
sepxHtoto nonyio BeHy Bo 1t136e)f(aH111e pa30111rn~
cpne6111rn.
MemOObl oemOKCUKa4uu op20HU3MO,
KOppeK4UR ,D,BC-CUHOpOMO
C uenbto AeroKClllKal(wH np111MeH7!10T peaM-
6ep111H 400-800 Mn/cyTKlll. np111 Bblp8)1{eHHOiil
 fHOlliHOVI 111HTOKCli1K8L..\llH1 111 He3cpcpeKTll1BHOCTli1
rpaAll11..l1110HHblX MeTOAOB ne4eHll15l 8 KOMnneKC-
HYIO Tepan11110 Heo6xo,o,wMo BKill04aTb scnoMora-
TenbHb1e M8TO,llbl 3KCTpaKopnopanbHOlli ,qeTOK-
C111KaL..\llllll opraHlll3Ma: o6MeHHblil1 nna3Macpepe3 ,
napeHTepanbHOe sBeAeH111e rnnoxnop111Ta Ha-
Tp11151 .
np111 TR)KenOM Te4€H!tl£.1 OCTpotf 3MnllleMbl
nnespbl scer,qa pa3BJllBaeTC.5'1 ,qecp1t11..1J11r nna3-
MeHHblX cpaKTopos csepTbl88Hl/151 KP081i1 (ABC-
C111 HAPOM) , 4TO 5!Bm1eTcs:i noKa3aHlll8M K TpaHc-
cpy3lllli1 cBe)l{e3aMopo}l(eHHoi:.1 AOHopcKoill nna3Mbl
B o6beMe 700-1000 IV!n/cyi-Kw B C048TaHVIVI c VIH-
n161t1TopaM1t1 np0Teom13a: BIB KOHTplllKan 80
Tblc.EA/cyTKlll 111n111 rop,o,OKC 300 Tblc .EA/cyTKlll .
np1.1 rnnepKoarynm~1t1111 H83Ha4atoT renap111H
no 5000 EA 4 pa3a /cyTKL-1 1.1nl-1 3H0Kcanap111H Ha-
rp111si (KI1eKcaH) no 40 Mr/cyi-K1.1. KposoxapKaHbe
5!Bm1eTc5! a6contoTHblM npornsono1<aJaH1t1eM K
Ha3H848HllllO 8HTlllKOaryn.5'1HTOB.
np111 Hanl-141.1111 aHa3po6Holli lllHcpeKL..\111111 B
KOMnneKCHYIO Tepan111to Heo6XOAlllMO BKill04aTb
ceaHCbl rnnep6ap1114eCKOL-1 OKCl/lf8H8L..\llllll: AO 5-6
ceaHcoa Ha KYPC neYeHl/151.
V1MMYHOKOppu2upyKJU{Qfl mepanuR
u <jJazomepanuR
YMeHbWeH111e rHoil1Hoi::1 lllHTOKClllKaL_\111111
scne,o,crs111e csoeBpeMeHHolli aeaK)'au.111111 rHos:t 1113
nnespanbHOLil nonocrn, caH8L..\1115! Tpaxeo-
6poHx1t1anbHoro ,[lepesa, 111HQ:>y31110HHa5! repan11151
B COYeTaHl/1111 c MeTo,QaMl/I 3KCTpaKopnopanbHOlli
A8TOKC1t1Kau1111.1 B 3Ha4111renbHOlli Mepe cnoco6cr-
eytoT BOCCTaHOBI18HllllO cpyHKL..\111111 lllMMYHHOl71 ClllC-
TeMbl. Ho 3Toro 6b1saeT HeAOCTaT04HO np111 6b1-
crpo nporpecc111pytoL1.1eM HarHoeH1t1111 s nnes-
panbHOlli nonocrn , oco6eHHO np111 reHepan1113a-
L.\llllll 111Hcp8KL..\"1111 , n03TOMY Ba>KHOe 3H848Hllle B
KOMnneKCHOlli Tepan111111 lllMeeT Ha3H848Hl.18 [llM -
MYHHblX npenapaTOB.
np[ll 6bfCTpo nporpeccwpylOli.(lllX OCTpblX
3Mn"1eMax nnespbl Jll Bblpa)J{eHHOM BTOp"1YHOM
1AMMyHo,o,ecp111L..\lllTe noKa3aHa 3aMecrnrenbHaSl
lllMMYHHas:i Tepan111s:i. c3TOlli L_\eilblO np111MeHSl-
IOTC5! paCTBOpbl fOTOBblX lllMMYHOmo6yn111HoB :
xyMamo6111H no 200-300 Mr/Kr/Maccb1 Tena 1
pa3 B 7 ,llHe,;i; oTe4€CTB€HHbl!li J/IMMyHorno6y-
fl"1H 4enoBeKa HOpManbHbllA ("1MMYHOB8H"1H)
25-50 Mn/cyTKlll , Ha Kypc ne4eHlllSl OT 5 AO 10
TpaHccpy3111i11 ; L11HTparno6111H s A03e 0,4-1
r/Kr/MaCCbl Tena OAHOKpaTHO .
nplil CTaQJlilflOKOKKOBOi:f 3Tlil0fl0fltn-I 3Mn[lle-
Mbl xopow111M ::icpcpel<TOM o6na,qaer rnnep111M-
MYHHas:i aHrncTacp111noKOKKOBa5! nna3Ma no 200-
250 Mn 4epe3 1-2 AH51 , OT 3 AO 5 TpaHccpy3[11if1 Ha
KYPC. np111 OTCYTCTBl/1111 r111nep"1MMYHHOi..1 8HTlll-
CTaQJfllI10KOKKOB0£1 nna3Mbf noKa3aH 8HTl!ICTaQJfll-
.JIOKOKl<OBbllli y-rno6yJ11'1Ha , nocne,D,H"111i BBO,D,S!T
eHyTp111Mb1We4HO no 9 Mn B Te4eH111e 3-x AHelli .
0AH08p8M8HHO noKa3aHo np111MeHeH[lle CTacpvi-
IlOKOKKOBOfO 6aKTep111ocpara B Bo3pacratow,ei..1
157
A03e : 0,5-1-1 ,5-2-2 ,5 Mn s/M e>Ke,qHeeHo 11111111
4epe3 AeHb (MO>KHO co4eTaTb c lllHTpannea-
panbHblM 88€,D,€Hltl€M) .
np111 yMeHbW8Hllllll fHOJliHOJli lllHTOKC1t1Kal..jli11i1 111
yny4WeHlll51 COCTOSlHlllSl 6onbHOfO , naCClllBHyto
111MMYH1113al.\llllO He06XOAlllMO gononHSHb 8KT[llB-
HOC1 , c 3TOlli L..\8Ilbl0 np111MeHs:JIOT CTacp111nOKOKKO-
Bblilr aHaTOKClllH no 0,5 - 1 Mn c lllHTepsanoM B 2
- 3 ,[1H51, YeM ,[IOcrnraeTC5! no,[\beM T1npa aHrn-
TOKClllHOB 6onee 4€M B 4 pa3a .
ll1MMYHOKOpp111r111py10W,lllM 111 8HTlllOKClllA8HT-
HblM AeillcTB"1eM o6nagaeT non1110KC[llAOH111il1 , KO-
ropbr£1 H83Ha4afOT s/M no 6 Mf/CYTKVI, AO 10-12
J/IHbeK1.1111&.1 Ha K)'pC.
06U{eyKpen11RKJU{OR
u cuMnmoMamu4eCKaR mepanuR
A111era 6onbHblX c 3Mn111eMolil nnespb1
,qon>KHa 6b1Tb Bb1CoK0Kanop111i..1Hoi..1 , 6oraToi..1 6en-
KOM , BVITaMHHaMlil It! M!t1Kp03neMeHT8Mli1. 06f!3a-
reneH xopow11111t yxo,o, 38 6onbHblM . L1enecoo6-
pa3Ho Ha3H848Hllle aAanToreHOB: HaCTOlliKlll ::ine-
yi-epOKOKKa , KlllTaillcKOfO Jl[llMOHHlllKa 111n1.1 >KeHb-
W8H51 B o6w,enp111H5!TblX ,D,038X, npOAYKTOB nYe-
nOBOACTBa: Me,D,a , nponon111ca Iii AP· no no1<a3a-
Hlll51M (6onesollt C"1H,D,poM , rnneprepMlllS!) HaJHa-
YatoT HeHapKOT111YecK111e aHameTVIKlll : e/M KeTo-
Han no 2 Mn (100 Mr) 2-3 pa3a/cyTK111 111n111 nep-
cpanraH 100 Mil 2 pa3a/cyTKlll BIB , C048Ta51 I/IX c
,D,eceHc[ll611tn1t1J[llpytow,111M111 npenapaTaM1t1 : ,D,111-
Me,apon 1 % 1 Mn ; np11 nclllXOMOTOpHOM B036y)J{-
,D,eHllllll noKa3aH c1,16a30H 0,5 % 2 Mn s/M (pena-
H[llyM , ce,D,yKceH) ; np"1 pacrpoi11cTeax cHa: cpeHo-
6ap6111ran a ra6nerKax no 0,1.
np111 AblXaTenbHOJ..1 H€AOCT8T04HOCTlll , no-
Mlt!MO 3¢cpeKTli1BHOH caH81.11i11i1 6pOHX1118flbHOro
,qepeaa, noKa3aHa 111Hcycpn51L\11151 yenm1<HeHHoro
K"1cnopo,qa 4epe3 HocomoTo4Hb1e KarerepbL
np111 rHOlliHOM nneBplllTe Hepe,D,KO pa3B[llB8-
eTC51 aHeMl/151 , reHe3 KOTOpoi..1 CB5!38H c OAHOJA
cropoHbr yrHeTeHllleM KpoeeTBopeHll!S'I Ha cpoHe
HJ)f{eno~ 1t1HTOKC1t1Ka~111111 , c ,llpyro!;i - o6ycnosneH
nornpei::t :>Kene3a BMecTe c oneKatow,lllM 3Kccy-
,QaToM. ne48Hllle aHeMl/1111 KOMnneKCHOe Ill Bl<Jll0-
488T np111MeHeH111e npenaparos :>Kene3a B 06U,\e-
np1t1H5!Tb1x A038X (BIB , B/M , per os) ; BlllTaMVIHa 81 2
no 500 y 1 pa3/CYTKl1 ,.QO 10 l1Hb8KL_\l1M Ha K)'pC.
3cpcpeKT"1BHblM CTlllMyns:irnpoM 3p111Tpono-
33a 51Bns:ieTCs:I 3p111Tp0CTlllM - OTe4eCTB€HHbliil
peKOM6111H8HTHbllli 3p111Tpono3TlllH , KOTOpbllli BBO-
ASlT BIB no 2 Mn 4epe3 A8Hb , Ha KYPC AO 10 [11Hb-
€K4"1i:f .
no noKa3aHl!151M (reMomo6111H 70 r/n 111
MeHbWe) BblnOnHs:tlOT TpaHccpy3L.1IO 3p111Tp0L..\[ll-
TapHoiil MaCCbl.
OnepamuaHoe nel.feHue
X111pyprn4ecK1t1e M€TO.£!bl ne4eHlt!fl BKT1104a10r
• .IJ,peH111poeaH111e nnespanbHOl71 nonocrn ;
• Mano111Hsa3111BHble onepal_\111111 c B[llAeonoA-
A8P>KKoi71 ;
 • paA111KanbHb1e onepau,111111;
• OTKpb1Tbl8 MeTOAbl caHaL.J,111111 3Mnlll8Mbl
nneBpbl (TOpaKOCTOM11151) .
,D,peHupoaaHue nneapanbHOiJ nonocmu
Ecn111 s Te4eH111e 5-7 AHeill nyHKL.J,lllOHHoill Te-
pan111111 OTCYTCTByeT TeHAeHL.J,11151 K pacnpasneHllllO
nernoro, noKa3aHo APeH111posaH111e nnespanbHOill
nonocrn .
np111 OCTpOVt 3MnllleMe nneBpbl , pa3BlllBWei/i-
C51 scneACTB1118 H8COCT051TenbHOCTlll KynbTlll
6poHxa onep111posaHHoro nernoro, a TalOKe np111
Hanp51>KeHHOM n111onHeBM0TopaKce APeH111posa-
H111e nnespanbHOill nonocT111 ocyll\eCTBn51eTC51 B
3KCTpeHHOM nops:tAKe.
MecTO An51 TOpaKou,eHTe3a yrn4H51ercs:t no-
cne non111no3111u,1110HHoro peHTreHonor1114ecKoro
111ccneAOBaH111s:i, nnesporpacp111111 111 (111n111) Y3V1
nnespanbHOVt nonOCTlll - OHO AOfl>KHO COOTB8TCT-
BOB8Tb Hlll)KHeMy OTAeny rHOVtHOVt nonoCTlll.
TopaKou,eHTe3 c nocneAYtoll\lllM ApeH1t1po-
saH111eM nnespanbHOill nonocr111 51Bn51eTC51 one-
par111BHblM BMewarenbCTBOM 111 AOn>KeH Bbinon-
H51TbC51 B ycnOBlll51X nepeB51304HOVt x111pypr1t14e-
CKOro OTAeneHlllfl (111n111 onepaL.J,lllOHHOVt) c COOT-
BeTCTBYIOU\lllM 0¢opMneH111eM B lllCTOpllllll 6one3-
Hlll npeAonepau,1110HHoro 3n111Kp1113a, nnaHa 111 npo-
ToKona onepar111BHoro BMewaTenbCTBa.
MeTOAlllKa: npeABap1.-1renbHO BbmonH518TC51
AlllarHocr1114ecKas:t nyHKL.J,11151 . Y6eAlllBWlllCb, 4TO
111rna HaXOAlllTC51 s nneepanbHOill nonocrn (a
wnp111u, AOn>KeH cso6oAHO nocrynaTb rHoillHblVt
3KccyAaT), np111crynator K APeH111posaH111to. 3Kc-
cyAaT 48CTlll4HO acn111p111pytoT, a no XOAY npeA-
nonaraeMoro npoBeAeHl/151 rpoaKapa AOnonH111-
renbHO BBOA51T B TK8Hlll Me>Kpe6epHoro npoMe-
>KYTKa 20 Mn 1 % pacrnopa HOBOKal/1Ha. Ps:!AOM c
111rnoill OCTpOKOH84HblM CKanbneneM np0111380-
AlllTC51 pa3pe3 t<O)Klll 111 noAKO>KHoill Kner4aTKll1
,[\nlAHOVI AO 1 CM , nocne Yero 1t1rny IA3Bne1<ator.
np111 nOMOLJ.\111 TpOaKapa BblnOflH518TC51 TOpaKO-
L.J,eHTe31 3 (plllC. 35). npoXO>K,l\eHllle TpOaKapa B
nonocrb 3Mn111eMbl OLJ.\YLJ.\8eTcs:i B BlllAe "nposa-
na", crnneT TpoaKapa YA8Il51toT, s nnespanbHOill
nonocr111 ocrasnfltoT non111xnops111H111nosb1ill p,pe-
Ha>K c BHyrpeHHlllM AlllaMerpoM 0,5-0 ,7-1 CM Ill 3
60KOBblMlll OTBepCTllls:IMlll Ha KOHL.J,e. Bo 11136e>Ka-
Hlll8 neper1116a, APeHa>K AOn>KeH 6b1Tb norpy>KeH
s nneepanbHYto nonocTb He 6onee 4eM Ha
5-7 CM , nocneAHee 6oKosoe OTBepcrne APeHa>Ka
AOfl)KHO OTCT051Tb OT BHyTpeHHeill nosepXHOCTlll
nnespanbHOill (3Mn111eMHOill) nonocr111 He 6onee
4eM Ha 2 CM. ,D,peHa>K cPll1KC111pyeTC51 K KO>Ke 1-2
13 B HacTmlll.lee speMH 111MeeTC5l w111poK111ili Bbl6op
c111cTeM OAHopa30BblX TpoaKapos AJ151 APeH111posaH1115l
nnespanbHOili nonocrn B KOTOpblX non111xnops111H111nosb111i
APeHa>K H8AeT Ha crnneT - TpoaKap COOTBeTCTBYIOLl.lero
ALi1aMeTpa; nonHoe cooTBeTcrs111e AL11aMeTpa ApeHa>Ka
paHeBoMy KaHany OT rnpaKOL1eHTe3a cnoco6cTByeT cH111-
>KeH11110 KOnli14eCTBa rHOiliHblX ocnO>KHeHLi1ili co CTOpOHbl
onepa1.11110HHoili paHbl.
158
WB8Mlll, nOAKnl04a8TC51 no M8T0,[\111Ke 5tonay 11111111
K npOT04HO-acn111pau,1110HHOVt ClllCTeMe.
P1.1c. 35 . .QpeH1.1posaH1.1e nnespanbHOL'.i
nonocnt (TopaKOL-'0HTe3). a, 6 - non0>1<eH ~
paK x1.1pypra nplA BblnOJlH0Hl.11.1 TOpaKOL-'0H-
Te3a c noMo~blO TpoaKapa.
,D,peHa)f{ nOAKJllOYaercs:i K B8KYYMHOMY ycT-
poillCTBY c peryn111pyeMb1M pa3pe>KeH111eM. Ycra-
Hasn111saeMa5I creneHb pa3pe)f{eHll151 s nnes-
panbHOill nonocrn w111p0Ko sapb111pyer: or 20 cM .
BOA. CT. AO 150 MM pr. CT. Ill 6onee, YTO 3aBlllCll1T
or cpoKOB 3a6onesaH1115I , Bb1pa)f{eHHOCTlll socna-
n111renbHblX 1113MeHeH111ill s nerKOM , Han111Y1t1s:t
6poHx111anbHoro CBlllU\a 111 T.A. B AanbHeillweM
OCYLJ.\8CTBns:teTC51 MHOroKpaTHOe (AO 10-12 pa3 B
cyTK111) npoMb1BaH111e nnespanbHOill nonocT111 Ten-
nblM paCTBOPOM cpypau,111nn111Ha 1 :5000 (0 ,05 %
pacrnopoM xnopreKClllAlllHa) . Cyro1.1Hoe Kon1111.1e-
crso BBOAlllMoro lllHTpannespanbHO pacrsopa
8HTlllCenTlllK8 onpeAens:teTC51 lllHAlllBlllAY8flbHO Ill
nplll 06w111pHblX 3MnllleMax COCTaBn51eT B cpeA-
HeM 3-4 n/cyrK111 .
np111 Hanlll4111111 6pOHXOnnespanbHOfO CBlllLJ.\8,
HeCMOTp51 Ha 3KTlllBHYIO acn111pau,111to, npOlllCXOAlllT
HenpepblBHoe nocrynneH111e B03Ayxa B nnes-
panbHYIO nonocTb, 4TO nplllBOAlllT K ee nocT051H-
HOMY 111Hcp111u,111posaH111to 111 npenmcreyeT nonHoMy
pacnpasneH11110 nerKoro. C l_\enbto n111KBlllA8l\\llL-1
MaCClllBHOro c6poca B03Ayxa 4epe3 6pOHXO-
nnespanbHblVt CBlllU\, yMeHbWeHlll51 npo51sneH1t1ill
AblXaTenbHOill H8AOCTaTOYHocr111 111 3cpcpeKTlllBHOill
caHau,111111 aHrncenr111KaM111 nnespanbHOill nonocrn
pa3pa6oTaHa MeTOAlllK8 speMeHHOlli OKKnl03111111
6poHxa noponoHoM .
MeTO,lJ,lllKa speMeHHoill OKKnto3111111 6poHxa: s
ycnOBlll51X lllHry6au,1110HHOro HapK03a np111 noMO-
U\111 )f{eCTKOro 6pOHXOCKona ¢p111A8J151 nocneAO-
BaTeJlbHO ocyll\eCTBJls:tlOT nOlllCKOBYIO OKKJll03111IO
nplllBOA51LJ.\8fO (B03AYX) 6poHxa noponoHOBblM
o6TypaTopoM. Ecm1 np111BOA5!U\lllll1 6poHx 06ry-
p111posaH npas111nbHO - B03AYXOTe4eH111e no Ape-
Ha>KY 1113 nnespanbHOlli nonocrn pe3KO yMeHbWa-
erc51 111n111 npeKpalJ.\aerc51 sosce. TaKlllM o6pa30M
no51sns:1torcs:1 ycnoslll51 Ans:t lllHTeHClllBHoro npo-
MblBaH111s:t n111onHeBMOTOpaKca aHrncenr111KaM111 c
OAHOBpeMeHHblM C03AaHl!1eM B nnespanbHOlli
nonocT111 0Tp111u,aTeJ1bHoro pa3pe>KeH111s:t, YTO cno-
co6crnyer 6b1crp0My pacnpasneH11110 cnaswero-
C51 nerKoro. nocne cTOillKoro pacnpasneHl/151 ner-
Koro, 06b11.1Ho 3To npo111cxoA111T s cpoK111 oT 10 AO
14 AHeill , 6poHxoo6rypaTOp YA8J15llOT.
BpeMeHHa51 oKKnto311151 6poHxa no3som1er
6blCTpo yny1.1w1..nb COCT051Hllle 6onbHblX, l<Yn111p0-
B3Tb npos:isneHlll51 ocTpoi/l AblxarenbHoill HeAoC-
raTOYHocrn , npep,ynpeAlllTb acn111paL.J,lllOHHyto
nHeBMOHlllto npornsonono)f{Horo nernoro 111 3cP-
cpeKTlllBHO caH111posaTb 3MnllleMHYIO nonoCTb.
Kp111rep111s:1M111 3Q:JcpeKT111sHolli caHau,111111 nnea-
panbHoill nonocT111 np111 aMn111eMe 51Bn51toTCff CH1t1-
>KeH111e TeMneparypb1 rena 111 yMeHbWeH111e rnoi/1-
- - "1HTOKCl/IKa4111111, yny4 weH111e aHan1113a KpOBlll
e vi e ne~KOLl\11T03a \11 yMeHbWeH1t1e nano4-
~ - ep oro GABI/Ira) , CMeHa rHOi.:1Horo 3KCCYAaTa
-a cepo3Hbllil , a TalOKe 111c4e3HOBeH11e naroreH-
- - MV1Kpocpnopb1 1113 nnespanbHoi.:1 nonocTlll np111
ecKOM 6aKTep1wnor111YeCKOM 111ccneAo-
ccyAaTa.
opaKocKonuLteCKue onepa4uu
- aHlll5! An5! B11tAeoropaKocKon1114ecKoi.:1
,_....'=-...--" nnespanbHOIA nonocT111 Heo6xo,a111Mo
:> KaK MO:>KHO paHbWe, AO cpopMlllpOBaHl/l5!
- nvioreHHolll Kancynb1 (Ha cra,Q111111 pb1X-
6pvi Ho3HblX cpa1.J.1eH111i.:1) . Bo BpeM5! Blll-
OCKOnllllll np111 nOMOll.1111 cne4111anbHblX
eHTOB nonHOCTbto pa3pywator 111Hrpan-
...,;"'4J'C-1 bHble cp1116p11tHHble cpa1.J.1eHlll5! , MaKClll-
y,Qan5!toT c nosepXHOCTlll s111c4epanbHOLi1
e an bHoi.:1 nnespbl Hano)l(eH1115! cp1116p111Ha,
-ens1 toT (no B03MO)l(HOCTlll) Me)l(,QoneBble
, KOHTpon111pytor pacnpasneH111e nerKoro.
....lC.l.£il"l ... 1>1BatoT Blll,QeoropaKOCKOnlllto ynbTpa3BY-
- Kas1.na4111eLi1 3Mn111eMHolll nonocrn (ore4e-
bl!ll annapar YPCK-7H , YPCK-?H-22), lffO
son51eT 6b1crpee n111KB111,a111poBaTb socnane-
- e "1 3Ha4111TenbHO COKpaTlllTb cpOKlll ne4eHl/l5!
MeTOAlllKa ynbTpa3syK0Bolll Kas111ray111111 3M-
e Holll nonocT111: nocne MexaHL-i4ecKoro y.Qa-
-~ '45! rHOLilHoro 3KCCy,QaTa Ill HannacTOB8Hllllll
p111Ha nnespanbHyto nonocrb 3anonH5!toT
oacrsopoM aHrncenT111Ka (cpypa4L-innL-iH 1 :5000,
opreKClllAlllH 0,05 %). noA KOHTponeM onrnK111 c
" 6"
~ ··
Puc. 36. J]eKopmuKau,ufl neaKoao (B.K. /ocmuu.1,ee. OnepamueHafl eHoiJHafl xupypeufl, 1996): a) nonocmb
sMnueMbl; 6) yoaneHue (oeKopmuKau,ufl) HannacmoeaHuiJ cfJu6puHa Ha eucu,epanbHoii nneepe; e) pacnpaeneHHoe
neaKoe.
B 6onee no3AHll1e cpoK111 AeKoprnKa4111to
n erKoro Heo6xoA1t1Mo ,QononH5!Tb nnesp3KTOMlll-
elll, T.e. y,Qan51Tb Beeb 3Mnll1eMHbllll MeWOK BMe-
CTe c y4acTKOM nap111eranbHolll nnespbl.
Co4eraH111e ,qeKopr111Ka4111111 c pe3eK4111elA
cerMeHra (cerMeHroe), ,Qon111 (AonelA) nerKoro
np111 ocrpolA aMn111eMe nnespbr noKa3aHo np111 Ha-
n1114111111 conyTCTBYtol.l.lero ,QeCTPYKTlllBHOro npo-
4ecca B ner04HOlA TKaHlll (6pOHX03KT83111111 , Kap-
H1t1cp111Ka411151 nerKoro, a6c1.1ecc, MHO)l(ecrseHHble
6poHx111anbHb1e CBl..11.J.1111 111 T..Q.).
159
noMOl.J.lbto ynbrpa3BYKOBoro reHeparopa B Te4e-
H\11e 7-~0 M\11H npoeo,n.~T ynbTpa:my1<oey10 o5pa-
6orey nnespanbHOLi1 nonocrn Hlll3K04acrorHblM
ynbTpa3BYKOM (np111 3TOM ynbTpa3BYKOBOlil BOn-
HOBOA He ,QOn)l(eH KacaTbC5! nosepXHOCTlll nerKo-
ro 111 nnespbr!) . nocne caHat...!111111 nnespanbHYto
nonOCTb ,QpeH111pytoT, ,QpeHa>K nO,QKnto4alOT K
c111creMe ,Qn5! aKTlllBHoi.:1 acn111pal..!111111 . np111 Heo6-
xo,Q111Mocr111 BblnOnH5110T nOBTOpHble CaHal..!111111 c
lllHTepsanoM B 3 ,QH5!.
Paaw<aflbHbJe onepau,uu
Ecn111 nyHK41115!Mll1 111 3aKpb1TblM APeH111posa-
H111eM c aKTll1BHOLi1 acn111pa411eLi1 He yAaerc5! nL-iK-
Blll,QlllpoBaTb 3Mn111eMHYto nonocrb, a nocne s111-
,aeoropaKocKon1114ecK0Li1 caHal..!111111 nerKoe nonHo-
CTbto He pacnpaBn5!eTC5! (coxpaH5!eTC5! ocraT04-
Ha51 nnespanbHa51 nonocrb) noKa3aHo pa,q111-
KanbHoe oneparnBHoe BMewarenbcrso.
CpoK111 BbrnonHeH1115! paA111KanbHb1x onepa-
1..111111 np111 ocrpolll 3Mn111eMe nnespbl y Ka)l(,Qoro
6onbHoro onpeAen5!toTC5! 111HA111B11tAyanbHO. LJa-
l.l.le scero BbrnonH5!eTc51 AeKoprnKa41115! nerKoro.
noKa3aHll151 K 3TOLi1 onepa4111111 He06XO,QlllMO CTa-
Bll1Tb He n03,QHee 1-1 ,5 MeC5!L1eB He3cpcpeKTlllB-
HOlA repan111111 , BKnto4a5! BlllAeoropaKOCKon1114e-
cK111e caHa4111111 . TexH111Ka onepa4111111 cocro111r B
y,aaneH111111 HannacroBaH111IA cp1116p111Ha c nosepx-
HOCTHblMlll cno51Mll1 s111c4epanbHolll nnespbl 111
pacce4eH111111 tjJ111Kc111pytol.J.lll1X nerKoe cnaeK. 3ro
06ecne4111saer pacnpasneH111e cnasweJ/lc51 4acT111
nernoro 111 n111KB111.Q111pyer 3Mn111eMHyto nonocrb
(p111c. 36) .
r;i ·
K oneparnBHblM MeTo,QaM ne4eHll151 ocrpolA
3Mnl..1eMbl nneBpbi TaK>Ke OTHOCll1TCs:I OTKpblTOe
,QpeH111posaH111e nnespanbHOIA nonocrn - ropaKo-
CTOMlll51 . 3ra onepa41115! noKa3aHa np111 nporpec-
c111posaH111111 rHolAHoro npo4ecca B nerKoM 111
nnespe, KOrAa nyHKLllll~M"1 111 aKTlllBHblM 3aKpb1-
TblM ,QpeH111poBaHllleM He y,QaeTC5! ,QOCTlll4b no-
nO)l(ll1TenbHOro 3cptjJeKTa, a BbrnonHeH111e pa,Q111-
KanbHolll onepa4111111 HeB03MO)l(HO 1113-Ja rn)l(enoro
COCT051Hlll5! 6onbHOro.
 <DopM111posaH111e TopaKOCTOMbl ocy1..L.1ecTBm1-
eTC5l nYTeM OKOH48TOLli nOAH8AKOCTH1114HOLli pe-
3eKL.1111111 1-2 pe6ep s npoeK1..1111111 3MnllleMHoro
Ecnlll B re1.JeH111e 2 MeCs:tl..leB c MOMeHTa Ha-
48Jla ne1.JeH111s:t ocTpas:t aMn111eMa nnespbl He noA-
sepmacb o6paTHOMY pa3BlllTllllO ee MO)f(HQ C4111-
T8Tb xpOHlll4eCKOLli .
XpoHuYecKaR 3MnueMa n11eapb1
XpoH1111.JecKas:t 3Mn111eMa nnespb1 - Ka1.JecT-
seHHO HOBOe COCTOs:tHllle , xapaKTep1113YIOl..L.leecs:i
Han1114111eM CTOLliKOLli OCTaT04HOLli nonocrn B KOTO-
polli nOAAep)f(111saeTcs:t rnolliHoe socnaneH111e. ne-
pexoA ocrpolli 3Mn111eMb1 s xpoH1111.JecKy10 npo111c-
XOAlllT o6bl4HO He3aMerno, Ha cpoHe YAOBneTso-
p111renbHoro cocro51Hllls:t 60llbHblX . KaK npas111no,
noCTOS'IHHas:t acn111pa411151 rHOS'I nplllBOAlllT K OTHO-
ClllTenbHOLli caHa4111111 OCTaTOYHOLli nonoCTlll - y
6onbHblX yMeHbWaeTC51 111n111 speMeHHO lllC4e3aeT
rHO!l1Ha51 lllHTOKClllK8411151 , npeKpa1..L.1a10TC5I 6om1 B
rpyAHOLli KJleTKe, HOpMan1113yeTC5! TeMnepaTYpa,
OAH8KO B KpOBlll coxpaHs:teTC5! r111noxpOMHas:t
aHeM111s:t , ycKopeHHa51 C03, yMepeHHbllli neil1Ko-
4111To3, AlllCnpore111HeM111s:t. 0THoc111renbHO YAOB-
neTBop111TenbHOe COCTOS'!Hllle HeycTOLliYlllBO Ill np111
Manell1w111x cp11131114ecK111x neperpy3Kax, nepeox-
na)f\D,eH111111 , cTpecce, np111coeA111HeH111111 lllHTePKYP-
peHTHolli 111HcpeK4111111 (rp111nn 111 Ap.), pa3s111saercs:i
06ocrpeH111e 3a6onesaH111s:t, conposo)f\D,a101..L.1eecs:i
nosb1weH111eM reMnepaTYpb1 , 03Ho6aM111, yc111ne-
H111eM Kawns:t c rnoil1Hoil1 MOKporoi/1 , nos:isneH111eM
neil1Ko4111ro3a s Kpos111 111 pe3Koro CABlllra s nelll-
Ko4111rapHoil1 cpopMyne sneso, 3Ha4111renbHO yse-
Illll1.J111saercs:i Kon111YecTso rHoil1Horo OTAens:teMoro
no ApeHa~ 111n111 4epe3 rnpaKanbHb1!11 CBllll..L.I. He-
CMOTps:t Ha npOBOAlllMOe neYeHllle nocreneHHO
nporpecc111pyeT nnesporeHHbllli 1..1111ppo3 nerKoro 111
rpy,llHOlil KJleTKll1 , YTO np05!Bn51eTC51 pe3Kll1M oc-
na6neHl/leM AblXaH111s:t , nos:tsneH111eM nocros:tHHblX
Blla)f(HblX xp1.mos s nopa)f(eHHOLli YaCTlll nerKoro 111
o6111JlbHOll1 rHOLliHOVl MOKpOTbl ; npOlllCXOAlllT Ae-
cpopMa4111s:t rpyAHOLli KJleTKlll Ha nopa)f(eHHOLli CTO-
poHe: yMeHbWeH111e Ill lllCYe3HOBeHllle Me)f(pe6ep-
HblX npoMe~Kos, ony1..L.1eH111e nneYa . Haps:tAY c
HapacraH111eM nplll3HaKos AblXarenbHoi/1 HeAOC-
raro4HOCTlll paHo 111n111 no3AHO pa3Blllsaercs:t
aM111110111A03 BHYTPeHHlllX opraHoB, 4TO B KOHeY-
HOM lllTOre nplllBOAlllT 60JlbHblX K CMeprn .
160
MewKa. nocne YAaneH111s:t rHos:t , nonocTb npoMbl-
saeTcs:t aHrncenrnKaM111 111 pb1xno raMnoH111pyeTcs:t
c Ma3s:tMlll Ha BOAOpacTBOplllMOLli OCHOBe. ,.--...._
A111arH03 xpoH111YecK0Lli aMn1t1eMbl YTOYHs:teT-
cs:t np111 noMOl..L.1111 peHrreHOI10n14eCKlllX MeTOAOB
lllCCileAOBaHl/!51: 063opHolli peHTreHorpacp111111 B
nps:tMOLli Ill 60KOBOLli npoeK4111s:ix, peHrreHTOMO-
rpacp111111 , nnesporpacp111111 (cp111cTYnorpacp111111) 111 ,
eCillll Heo6XOAlllMO 04eHlllTb COCTOS'!Hllle nerKoro
AeTaJlbHO, KOMnblOTepHolli TOMOrpa¢111111 (Mar-
HlllTHO-pe30H8HCHOLli TOMOrpacp111111). Pe)f(e lllC-
nOJlb3yercs:t aHr111onynbMOHorpacp1115I - OTcyTcT-
s111e Kan111nns:tpH0Lli cpa3bl Ha aHr111onHesMorpaM-
Me y6eA1t1TeJlbHO CBlllAeTeJlbCTByeT 0 pa3BlllB-
weMC51 nnesporeHHOM 4111ppo3e nerKoro.
P1.1c.38. XpoH1.14ecKasi 3Mn1.1eMa n11es-
pb1. MarHl.1THo-pe3oHaHcHaH TOMorpaMMa
11erK1.1x: aKc111a11bHasi (a) 1.1 6oKosasi (6) npo-
eK1..t1.1S1: B 3aAHe-6a3aJ1bHblX OTAe.nax .neso-
ro reM1.1TopaKca B"1AHa no.nocTb 3Mn1.1eMb1,
cTeHKl.1 no11ocT1.1 pe3Ko yTo.nuteHbl, H"1>KHHH
AOm1 .nesoro .nerKoro yMeHbWeHa B pa3Me-
pax - n.neeporeHHbli'll u1.1ppo3 H"1>KHeill .Qo111.1
.nesoro .nerKoro.
ne4eH111e XPOHl!14eCKOLli 3MnllleMbl - x111pyprn-
4eCKOe. KoHe4Hoi.1 1..1enb10 oneparnsHoro ne4e-
Hllls:t 5!8Jls:teTC5l JllllKBlllAal..111151 OCTaT04HOLli nneB-
pallbHOLli nonocrn 111 ycrpaHeH111e 111HcpeKL11t10HHoro
npo1..1ecca. 8b16op MeTOAa onepa1..1111111 y Ka)f\D,oro
60JlbHOro lllHAlllBlllAyaneH Ill BO MHOfOM onpe,Qe-
Jls:teTCs:t nepBlll4HOLli naTOilOfltleLli , np111BeAWeLli K
pa3BlllTllllO XpOHlll4eCKOLli 3MnllleMbl nneBpbl. npe-
AOnepaL11t10HHas:t noArOTOBKa 3aKJll04aeTC51 B
Tl..L.laTeJlbHOLli caHa4111111 nOilOCTlll 3MnllleMbl Ill Me-
ponp111s:tr111Lli 06L1..1ero xapaKTepa: KoppeK1..1111111 Ha-
pyweHHoro 6eJ1KOBOfO o6MeHa, JllllKBlllAa1..1111111
111MMYHOAecjJ1114111ra, aHeM111111, ne4eH111111 conyrcr-
BY101..L.1ero rHolllHoro Tpaxeo6p0Hx111Ta 111 T.A.
OcHosHolli onepa1..1111elll ocraeTcs:t n.r:iesp3K-
TOMlll51 (yAaneHllle 3MnllleMHOfO MeWKa). np111 Ha-
JllllYllllll conyrcTBY101..L.1eil1 naronor111111 s nerKOM 111n111
fPYAHOLli KileTKe (6poHX03KTa3111111 , xpOHlll4eCKlllLli
a6c1..1ecc, KapH111cp111Ka1..1111s:i , ocreoM111en111r pe6ep 111
AP·), nnesp3KTOMllls:t AOnonHs:teTcs:t pe3eK4111ei/1
nernoro (nnespono63KTOM111s:t), YAaneH111eM He-
)f(1113Hecnoco6HbtX y4aCTKOB pe6ep (fPYAlllHbl) .
Ecn111 s npo~ecce onepa~111111 06Hapy}f{111saeTc5!, 3a ToTanbHoro nHesMocp1116po3a - noKa3aHa
l.ITO cPYHK~i1151 nerKOro nonHOCTblO yTpa'-leHa 1113- nnesponHeBMOH3KTOMills:!.

A 5 B
-;nesp3KmOMUfl (B.K rocmuw,es. OnepamUBH8fl ZHOUH8fl xupypzufl, 1996): a) omaeneHue
·• nneepbt; 6) yaaneHue 3MnueMHoao MewKa; e) neaKoe, pacnpaeusweecfl nocne yaaneHUfl MewKa

- - OAXOA Heo6xo,£1V1M npVI xpoH111'-leCKoi4 TOYHOW nonoCTblO (TopaKonnaCTIAKOill). ne4eH£1e

OCTaTO'-lHOW nnespanbHOW nonoCTlll B
6p OHXf/18flbHblM CBf/111..(0M nocne pa-
onepau111ill Ha nerK111x. B nepsyto
_,...,""_.c;_;) eo6XOAlllMO flillKBlllAillpOB8Tb 6pOHXlll-
- - CBHW, (cs111w,111) . He6onbw111e 6poHxon-
e cs111 w,111 Ha nep111¢epillill nernoro Jlill-
:OT npl-1 noMOW,L1 MbJWel.IHOVr nnacTL1KL1 B
1.1 c pe3eKL\llleill '-lacrn pe6ep HaA ocra-
CBlllW,etli rnaBHblX 6pOHXOB (nocne nHeBMOH3K-
TOMlllL1) rpe6yeT CflO>KHbfX onepaTL1BHbfX BMewa-
TeflbCTB - peaMnyTaL\illill J<YilbTill 6pOHXa 1.1epe3
nonOCTb 3MnilleMbl , TpaHCCTepHanbHblM illllill
KOHTpanaTepanbHblM AOCrynoM.
TopaKonnacn1Ka KaK caMOCT051TenbHa51
onepa411151 s HaCT051W,ee apeM>i sbmonHs:ierc51
P6AKO.

161
 PAK JIErKoro
no AaHHblM Me)l<,qyHapop,Horo areHTcTsa no
1113yYeHllllO pa1<a B Mlllpe e)J{erDAHO ,lllllarHOCTlilpy-
IOT 6onee 1 MnH . HOBblX cnyYaes paKa nernoro,
YTO cocmsnf!eT 6onee 12 % OT 41Acna scex Bbt-
sisneHHblX 3nOKa4eCTBeHHblX 3a6oneBaH111iii .
3noKaYecTBeHHb1e onyxom'1 nernoro 3aH111Ma10T
nepsoe MecTo s CTPYKTYPe OHKonor1114ec1<ollt 3a-
6onesaeMocrn MY)J{CKoro HaceneH111si CTpaH 3a-
na,llHOiii 111 L\eHTpanbHOli1 Esponbl , nocTcoseTCKlllX
rocyAapcTB, CesepHoill AMep111K1.1, I0>1<Hoill Acpp1.1-
1<1-1, AscTpanww w HosolA 3enaH,lllAIA . 5onee YeM B
30 CTpaHaX Mlllpa paK nernoro 5lBJ15leTCs:I OAHOiii
L13 rnaBHblX npll14111H CMepTHOCTIA OT 3J10Ka4eCT-
BeHHblX Hoeoo6pa3oBaHL1111 y MY>K4111H.
B Pocc111111 paK nerKoro s nocneAHL1e 2-3 Ae-
csirnneT111s:1 TaK>Ke 3aHV!MaeT nepsoe MeCTo B
CTpyKfype OHKonorn4eCKOiii 3a6oneBaeMOCTll1 .
E)J{ero,qHo ero .QJAarnocrnpylOT 6onee YeM y 57
TblC. YenoseK. B KpynHblX ropoAaX paK 3Toiil no-
1<am13aL.J,ti1£1 Ha6n10,t:1aercR 4a~e . 4eM s cenbcKof!
MecrnocT111 . My)i(\.lli\Hbl 3a6onesat0T s 8-10 pa3
'-18LL\€ )KeHLL\lllH .
3a6onesaeMOCTb lllMeer '-!eTKyKJ CBs:l3b c
cpaKTopaMlll 01<py>1<a10LL\e"1 cpeAbl , ycnos111siM111
rpy,l\a , spe.£1Hb1Mlll np111sb1YKaM111, nepeHeceHHbl-
Mlll 111 1.1Me10ll..\ll1M111cs:1 3a6onesaH111siM111 nern111x.
P1,.1c1< pa3B"1rnR paKa nernoro Ha1116onee BblCOK y
KYPHLL\lllX My)f(YlllH crapwe 60 neT. Cyll.\ecrseH-
HOe 3arp513H€Hllle OKpy)f(alQLL\ei:.i B03AYWHOi:.i
cpeAbl KaHL.J,eporeHHblMlll npOAYKTaML1 Bbl3b1Ba-
IOT AB111raTen111 sHyrpeHHero cropaH11rn 111 npo-
Mb1wneHHb1e Bbl6pocbl B aTMOCcpepy. CpeAL1
npocpecc1.1i:.i 3aMeTHO Bb1we 3a6onesaeMocTb
paKOM nerKoro y pa60YJllX ypaHOBb!X py,llHIAKOB,
Mernnnypr111YecKoiii L1 Aepesoo6pa6aTb1Ba10ll.\eiil
npoMb!WneHHOCTIA, 1<epaMti14eCKOro, ac6ecTO-
L.J,eMeHTHOro L1 cpoctj::>aTHOro npoL13BOACTBa; y
n1.1u,, KOHTaKT111PYIOll.\L1X c COeAL1HeHL151ML1 xpoMa ,
nOABepralOll.\L1XC5l B03AeiiicTBL1IO KaMeHHOiil nbl-
J1L1 , 3aH5lTblX B Hl.1Kenesol.1 L1 anlOML1HllleBOiii
npOMbJWneHHOCTlll. 0TMeYeHa CB513b 3a6one-
saeMOCTlll paKOM nerKoro c nocny6ep1<yne3Hb1-
M111 py6L.J,OBblMl!1 W3MeHeHfll.RMIA B nerKWX w xpo-
Hl!t'-!eCKL1Mlll Hecne1..1111¢111'-!ecK111ML1 socnan1.1renb-
HbtMlll 3a6onesaHlllS1Ml!t nerKl!tX, oco6eHHO y KY-
p111nbll.\l!tKOB.
OnpeoeneHue3a6oneaaHUR
PaK nernoro (c11tHOHlllMb1: paK 6poHxa,
6poHxoreHHa.R Kap1..11.1H0Ma, 6poHxonero4Hbllif
paK) - 3TO 3J10Ka'-!ecTBeHHasi onyxonb, pa3Blll-
BalOLL\as:ics:i 1113 MeTanna3111posaHHoro 3n111Ten111si
Cnli13lllCTOJ/t o6ono'-IKlll 6poHXOB, 6pOHXL1anbHblX
>1<ene3 111/111n1.1 an11tTen111s:1 anbseon.
namonOcU'-leCJ<OR OHamOMUR
np111 L.J,eHTpanbHOM pa1<e ner1<oro onyxonb
pa3BlllBaeTC5l B 6poHxax 1-IY nopsiAKa (maBHblX,
163
Aonesb1X, cerMeHrapHblX 111nlll cy6cerMeHTap-
HblX). nepJAcpep1i1YecK111M pa1< 1ier1<oro Yal!.le scero
pa3Bl!tBaeTcsi 1113 an1.1ren111si Men1<1;1x 6poHxos
(6p0Hx1.1on) nnall.(esot.1 30Hbf nerKoro a BfllAe
onyxonesoro y3na. L\eHTpanbHasi L1 nep1i1cpep1.1-
'-!ecKasi cpopMbl paKa nernoro Ha6nt0,1J,atorcsi
np111MepHo c OAlllHaKoBoi/1 '-lacToToiii . XapaKTep-
Hasi no1<an1i13a1..1111si paKa nernoro - nepeAHllle cer-
MeHTbl sepXHl!tX ,o,onellt (Siu) 111 sepxH111e cerMeH-
Tbl (Sy1) Hl!t)f(HlllX Aoneiii nernoro.
Poer onyxonw npe111Myll.leCTBeHHO s npo-
cseT 6pOHXa Ha3blBalOT 3H,IJ,06pOHXl!tanbHblM 11111111
3K30tj::>[..1THblM , a B CTOPOHY nerKoro - nep1i16poH-
x1.1anbHblM , 3K306poHXlllanbHblM 111n111 3HAOQJ111T-
HblM .
l11Hcf)111nbTp111pytoll.\L1iil pocT nep111cpep1114ec1<oiii
onyxonl!t 6e3 '-!eTKlllX rpaHlllLI HOClllT H83B8Hl!te
"nHeBMOH1i1eno.i:106Hoi-1" Q:>opMbl paKa , a nopa>Ke-
H111e M8,IJ,l!taCTlllHanbHblX J1111McpaTlll4eCKlllX y3nos
6e3 BblRBm1eMoro nepswL/Horo OL/ara
11
MeA111acrnHanbHOll1" cpopMoiii paKa nerKoro. B
cny4ae HeKpo3a u,eHTpanbHolif '-!aCTl!t onyxon1i1 ,
pa30111saeTcsi TaK Ha3blBaeMas:i "nonocrnasi"
cpopMa paKa nernoro.
P1.1c. 40. Onepau,HOHHble MaKponpena-
paTb1: a - u,eHrpanbHblM paK sepxtteAone-
soro 6poHxa, Bblpa>KeH paKOBblM «nHeB-
MOHWT» (eepXHRfl AOIIR pacce4eHa, B
sepxHeAonesoM 6poHxe - onyxonb c npe-
HMy~ecTBeHHO 3K30Ql"1THblM poCTOM); 6 -
nepHcj>epw~eCKt.1" paK nernoro (y3noeaR
cj>opMa).
MeracTa31;1posaH111e pa1<a nernoro npo1i1cxo-
AlllT n1i1McporeHHblM 1i1 reMaroreHHblM nyreM. Pe-
rnoHapHblMlll An51 ner1<111x s:isns:itoTcsi BHyrp111rpyA-
Hble (napeHx111MaT03Hble, 6poHxonynbMOHanb-
Hble, MeAL18CTlllHaJ1bHble) Ill HaAK.nl041!t'-IHble
n111McpOy3nbl. rpaHWL(er/i, OT,ll€ns:llOl.l.!8H6poHXO-
nynbMOHanbHble nL1MQJOY3J1bl OT MeAl!tacrn-
HaJlbHblX, 51BI151eTC51 JlLllHlllfl nepeXOA8 nap1i1e-
TanbHOJlt MeAVl8CTll1HanbHOiii nneBpbi B Bl!tCL.J,e-
panbHYIO. K Me,D,111acrnHaJ1bHOL:1 rpynne n1.1Mcpo-
y3nos OTHOCSITCSI Tpaxeo6poHXL18J1bHble, 61i1cpyp-
K8LllAOHHble, napa33ocpareanbHb1e, cy6aopTanb-
Hble, npe- Iii naparpaxeanbHble, a TaJOKe sepx-
HL-le cpeAOCTeHHb1e n111Mcf)oy3nb1 (p111c. 41 ).
,QpeHa>K n111Mcpbt B ner1<1i1x ocyl.l.!ecrnns:ieTcR
OT nep111cpep1i1111 nernoro K ero L.J,eHTpy, no3TOMY
Ha nepBoM 3Tane n111McporeHHoro MeTacTa31i1po-
saH111R nopa)f(alOrcsi 6nl!t3KO pacnono>1<eHHb1e K
onyxon111 napeHXl!tMaT03Hb1e (nynbMOH8J1bHb1e) l!t
KOpHeBb1e (6poHxonynbMOHanbHb1e) n111Mcparn-
4ecK111e y3nb1. B AanbHel.1weM MeracTa3bl paKa
pacnpocrpaHRIOTCfl a Me.i:i1.1acrnHanbHb1e n1.1M-
cpoy3nb1. B P51Ae cny4aes 3ToT nop~AOK Hapy-
waeTcsi 1i1 Ha6nt0Aa10TC5l "npbtratOLI.\l!te" MeracTa-

3bl, KOr,Qa MlllHYH O,QlllH 1113 6apbepos, MeTaCT83bl
paKa 06Hapy:>K1t1BatoTcs::i B n111Mcpoy3nax 6onee
BblCOKOro ypoBHH .
-----------.._
reMaTOreHHOe MeT3CT33111pOB3Hllle paKa
nernoro c Ha1116onbwelll nocneAoBaTenbHOCTblO
npOlllCXO,QlllT B ne4eHb, HS,Qn04e4HlllKlll , ronoBHOll!
M03r 111 KOCTlll .

O napaaopT3flbHble

UleitHble "npecKaneHHble @
(Ha,11.Kn10'-m'IH1>1e)
3
npe - II napaTpaxeanbHbl0
/ID ,!l,oneei,1~
@ MeJK,0,oneeb1e
® flero•rnoli CBll3Kll

Puc. 41 . PeauoHapHbJe nuMcfJamu4ecKue nuMcpoy3nb1 n eeKux (cxeMa)

s) nonocTHaH cpopMa nep111cpep1114ecKoro

Knaccuc/Ju1<au,uR
npaKTlt14eCKOe 3H848Hllle lt1M810T Knlt1Hlt1KO-
aHaTOMlt14eCK871 , r111cTonor1114ecKas:1 111 Me)f(,[lyHa-
po.QHas::i Knacc111cjJ111Ka411151 paKa nerKoro no c111cTe-
Me TNM .
CornacHo Kn111H1t1KO-aHaToM1114ecKolll Knac-
c111cp111Ka4111111 pa3n1t11-1ator a) 4eHTpanbHb1lll paK
nerKoro, lllCXOAHll.1111111 1113 6pOHXOB 1-IY nopH,QKa
(rnasttoro, ,Qonesoro, cerMeHTapHoro, cy6cer-
MeHTapttoro); 6) nep111cpep1114ecK1t1ill paK nerKoro,
lllCXO,Q51ll.lllllll 1113 ,QlllCTanbHO pacnono)f(eHHblX
seTsneH111ll1 6poHx111anbHOro Aepeea snnoTb AO
6p0Hx111on (6poHx111onoanbseom1pHb1ill paK) .
KnuHUJ<O-aHamoMu1..1ec1<aR 1<naccuc/Ju1<a4uF1
pa1<a ne21<020
(A.t1. Caau41<uu, 1957)
1. WeHTpanbHbllil paK:
a) 3H.Qo6poHxlllanbHblll1 y3nosolll ;
6) nep1116pottx111anbHbllil y311os011l ;
B) nep1116pOHX111anbHbllil lllHcjJlllJlbTpaTlllBHbllll
(pa3BeTBileHHbllll).
2. nep111cpeplll48CK1t11i1 paK:
a) y3nosas:1 cpopMa (KpyrnaH onyxonb);
6) nHesMoH111eno.Qo6Hbllll paK;
164
pa Ka.
3. Anm1114Hble cpopMbl , css::i3aHHb1e c oco-
6eHHocTHMlll poem Ill MeTaCTa3111pOB8Hlll51:
a) Me,Q111acrnHaJlbH85! cpopMa;
6) L1epe6panbHa5I cpopMa;
B) Mlllm1apHbllll Kap4111HOM8T03;
r) paK sepxywK111 nerKoro (paK neHKOcTa).
OcHOBHbte 2ucmono2u4ec1<ue aapuaHmbt
pa1<a ne21<020:
HeMenKoKneT04Hbllil paK:
- nnocKOKneTO'-IHbllll (3fflll,QepMOlllAHbllil paK)
- a,QeHOKap41t1HOMa ()f(ene3111CTbllll paK)
- KpynHOKneTOYHblW paK
MenKoKneT04Hbllll paK
Kap4111Ho1t1.Q 6poHxa
Cne.QyeT noMHlllTb, 4TO B onyxonesoM yJne
MOryT C04eTaTbCH pa3Jn14Hble MOpcponorn4e-
CKll1e Tlllnbl paKa nerKoro (Alll- 111 TPlllMOpcpHbllll
paK), 111Met0L111t1e pa3Illll4HYto cTeneHb .Q1t1cjJcpe-
peH41t1posK111 Ill, COOTBeTCTBeHHO, pa3Illt14HYIO
cnoco6HOCTb K Il111Mcpo- Ill reMaToreHHOMY MeTa-
CT83111pOB8HllllO .
MeJKdyHapoaHaR 1<11accucjJw<0u,uR no
cucmeMe TNM
Knacc111q:n1Ka41115I paKa no Me>KAyHapOAHOill
c111creMe TNM (T - onyxonb, N - n111McpaTw1e-
CK111e y3nb1, M - MeracTa3bl) s HaCTOS'lll\ee spe-
MS'I 51BI151eTC51 OCHOBHOti . Knacc111cp111Ka411151 nocrn-
S'IHHO cosepweHcrsyeTcS'I , nocneAHlllill nepe-
cMorp 6bin BbinonHeH s 2009 rop,y. Pa3n1.14aior
cTNM - KJ11.1Hl.14eCKYIO Knacc111cp111Ka41.110, KOTO-
pa51 OCHOBaHa Ha AaHHblX AOonepa41110HHoro o6-
cneAOBaHl.1s:! na4111eHra 111 pTNM - nocneone-
pau,1110HHY10 (narnrncrnnorn4ecKY10) KJ1acc111cp111-
Ka411110, Y'·H.nbtBalOLl\YIO A8HHble onepa41.1111 1.1
Mopqmnorw.1ecKoro 111ccneA0BaH1115I YAaneHHoro
npenapara nerKOro Iii Ill.1Mcpoy3J10B. noMlllMO KO-
/J.VIQJlllKa41.11.1 no cvicreMe TNM , Me}f(,llyHapOAHOill
Knacc111cp111Ka4111ell1 npeAycMoTpeHo pa3AeneHlile
paKa nerKoro Ha 4 cra,z:i1t1111, 1113 Koropb1x nepsyt0,
BTOPYIO Ill TpeTblQ pa3,0,emHOT Ha nOAKaTeroplillil -
A1118.
KnaccucjJw<au,ufl TNM (7-e U3ooHue, 2009}
T - neps1114Ha51 onyxonb
TX - He,z:iocraroYHO ,.qaHHblX ,.qm1 04eHKlll
nepBlil4Hoill onyxon111 111n111 onyxonb AOKa3aHa
TOfibKO H8Il1114111eM onyxoneBbJX KneTOK B MOKpO-
Te 111m1 npOMblBHblX BOA8X 6pOHXOB, HO He Bbl-
51811S'leTC51 MeTOAaM111 s1.13yan1113a4111111 111m1 np111
6pOHXOCKOnl.1lil.
TO - nepsw1Ha5I onyxonb He onpeAen51erc51 .
Tis - npeA111Hsa3111sHa5I Kap4111H0Ma (carci-
noma in situ).
T1 - Onyxonb He 6onee 3 CM B Ha1116onb-
weM l.13MepeH111111 , oKpy)f{eHHaS'I nero1.1Holil TKa-
HblO 111n111 s111cu,epanbHoill nnespoill , 6e3 BlllAlllMOlli
111Hsa31.1111 , npoKc111ManbHee AOnesoro 6poHxa
np111 6poHxocKon1111.1 (6e3 nopa)KeHl.151 rnasHoro
6poHXa):
T1 a Onyxonb :::> 2 CM s Ha6onbWeM 1.13Me-
peH111111
T1 b Onyxonb > 2 CM , HO :::; 3 CM 8 Halil-
6onbWeM 1113MepeH111111
T2 - Onyxonb 6onee 3 CM, HO :::; 7 CM B
HaL46onbWeM 1113MepeH111111 111n111 onyxonb, xapaK-
rep1113y10ll\85ICS'I mo6b1M t.13 npti13HaKos, nepe4wc-
neHHb1x Hlll)f{e:
C sosneYeHweM masHoro 6poHxa, npoKc1t1-
ManbHb1ill Kpaill onyxo.n111 pacno.naraeTcS'I Aa.nbwe
2 CM OT KBplllHbl
Onyxo.nb mo6oro pa3Mepa, npopacraioll\a5'1
s111c4epanbHY10 n11espy
Onyxo.nb, conposo}l(,[\a10ll\a5lc5I areneKTa-
30M 111.nvt o6crpyKTlllBHoill nHeBMoH111elli, pacnpo-
crpaHS'llOLl\aS'lc.s:i Ha KopeHb 11erKoro, Ho He 3axsa-
TblBatoll\a5I see .nerKoe
T2a Onyxo11b > 3 CM , HO :::; 5 CM B H8111-
6onbweM 1113MepeH111111
T2b Onyxonb > 5 CM , HO :::; 7 CM B Halll-
6onbweM 1113MepeH111111
T3 - Onyxo.nb > 7 cM 11111111 nto6oro pa3Mepa,
Henocpe,D,CTBeHHO nepeXOAS'lll.\aS'I Ha rpy,IJ,HYIO
165
creHKY (BKnl04aS'I onyxon111 sepxHelll 6op03Ab1) ,
AlllacpparMy, AlllacpparManbHblM Heps, MeA111a-
crnHanbHYto nnespy, nap111eTanbHb1ill n111croK ne-
p111KapAa; Li1n111 onyxonb c nopa)f{eH111eM rnasHoro
6poHxa (pacnonaraeTcs:i 6n111>t<e 2 CM oT KaplllHbt),
HO 6e3 BOBJ1e4eH1115l KapL'IHbl ; 111n111 onyxonb, KOTO-
paS'I np111sena K pa3s111r11110 areneKTa3a 111n111 o6-
CTPYKTl-1BHoi:1 nHeBMOHllllil scero nerKoro , 111.n111 or-
A811bHbJe onyxonesb1e 01.1arn (o4ar) B Toill :>Ke
Aone , 4TO Lil nepBl-14Ha5l onyxonb.
T4 - Onyxonb .n106oro pa3Mepa , Henocpe,D,-
crneHHO nepeXOAHLl\BR Ha cpeAocreH111e, cep,z:i-
4e, KpynHble cocy,D,bl, Tpaxeto , n111Ll\eBoA, rena
no3soHKoa, Kap!AHy, wnw OTAenbHble onyxo11e-
Bb1e 04ar111 (oYar) B 111nc111naTepanbHOM nerKOM 3a
npe,.qenaM111 Aon111, nopa)f{eHHot1 nepa11!4Hoi-i ony-
xonbto.
N - PernoHapHble 11111Mtj:Jar1114ecK111e y3nb1
NX - HeAOCTaT04HO ,qaHHblX AnS'I 04eHK111
pernoHapHblX n111Mtj:Jar1114ecK111x y3nos .
NO - HeT np1113HaKos MeTacTaT1114ecKoro no-
pa)f{eH1115l pernoHapHblX n111McpaT1114ecK111x yJnos.
N 1 - 111Meerc51 nopa>t<eHL'le nepLi16poHx111-
anbHb1x Lil (11111111) nLi1McpaT1114eCKlllX y3nos KopHS'I
nerKoro 111 BHyrp111nero4HblX n111Mcparn4ecK111x y3-
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s npornsono.no>KHoM nerKoM; onyxonb c nnes-
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11111111 conposo)f{,IJ,aerc5l nnespanbHblM 111n111 nep111-
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posKa
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G2 - Cpe,D,HS'IS'I creneHb AW<PcfJepeHL\lllPOBKL'I
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G4 - He,q111cpcpepeH4111posaHHbre onyxonftf
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CTa,L11t15! O Tis
CTaA1t1fl IA T1 a,b NO MO
Cra,D,1t15! 18 T2a NO MO
Cra,o;111s:i llA T1a,b N1 MO
T2a N1 MO
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CTaAlilfl JIB T2b N1 MO
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CTa,llVl51 lllA T1-3 N2 MO
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CTa,D,11151 IV nto6oe T , mo6oe N, M1 a,b
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np1t1 L\eHTp8IlbHOM paKe nerKOro 8 KI1111Hlt14e-
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AalOT OTKJlOHeHll11A OT HOpMbl. 06Hapy)l{eHlt1e re-
naTOMeran111111 111 8CL\111Ta np111 paKe nerKoro roso-
p111T o 3anyLL\eHHocrn 3a6oneBaH1t15I.
LfumonOZU'leCKOe UCCneooeaHUe MOK·
pombl (He MeHee 3-5 MeTOA1114eCKfll npaBlt1JlbHO
co6paHHblX aHan1113a) - o651JarenbHblVI MeTOA
111ccneAOB8Hlll5I, KOTOpb1'1 n03Bom1eT o6Hapy)l{lllTb
paKOBble KneTKfll B TeX CI1Y4851X, KDrAa peHTre-
HOJlOrf114eCKli1 HlllK3Kli1X OTKJlOHeHllllA co CTOpOHbl
ner1<111x He Bbt5lsns:ierc51 (peHTreHHerarnsHas:i
CT3Ali151 paKa: Tx, Tis).
LllJMeHeH1t15I B reMorpaMMe - aHeM111s:1 , neVl-
KOL\lllT03, ycKopeHHa51 C03 , KaK npae111no, yKaJb1-
sat0T Ha Te 111n111 lllHble ocnO)l{HeH1t15I paKa nerKo-
ro . Cne,QyeT noMHlllTb, I.fro aHan1113bt Kpos111, .Qa>Ke
np111 Hosoo6pa30BaH111s:1x nerKoro 6onbWli1X pa3-
Mepos, MOryT He OTKJlOH51TbC51 OT HOpMbl.
OCHOBHblM ltlHCTpyMeHTaflbHblM MeTOAOM
Bb151sneHli151 paKa nerKoro AO HaCT051LL\ero spe-
MeH111 ocraercs:i peHrreHonorw-iecKoe 06cne,Qo-
saH111e: ¢nt0oporpaqn151 11111111 peHTreHorpa¢11151
nerKlllX. np1t1 4eHrpanbHOM paKe Ill 3HA06poHXlt1-
anbHOM pocTe onyxon111 cy)l{eH1t1e npocsera
6pOHXa np111BOAli1T K HeAOCTaT04HOMY nocrynne-
Hli1IO B03.Qyxa s .QpeHL1pyeMbt'1 cerMeHT nerKoro,
npo3pa4HOCTb nocneAHero yMeHbUJaeTc51 , pa3-
s111saerc51 cerMeHTapHa51 rnnoseHr111n5141115I, KOTO-
pa51 Bli1AHa B ¢a3y M8KCll1M8IlbHOrO BAOXa. no
Mepe pocra onyxonb nonHoCTblO JaKpb1saeT
npocser 6poHxa, YTO npli1BOAL1T K pa3s1,1rnio are-
neKTa3a (p111c. 45.)
Pwc. 45. LteHTpanbHbti.1 paK sepxHei.1
AOJ1H neeoro nernoro. nps.MaR {a) ..., 6oKo-
eaR (6) peHTreHorpaMMa: 3aTeHeH111e rpe-
yro11bHOM cpopMbl B npoeKUMllt nepeAHero
168
cerMeHTa 11esoro 11ernoro - aTeneKTa3 5111
{yKa3aH crpe11Koa:1). I
YroYHli1Tb 111crnHHY10 np111pOAY cerMeHrapHo- \
ro (Aoneeoro) aTeneKTaJa MO)l{HO np111 noMOLL\111
TOMorpacj}111111 . n111HeVIHble TOMorpaMMbl , BbtnOJl-
HeHHble B pa3J11114HblX npoeKL\1115IX, no3BOn5llOT
yT04HlllTb Hanw-me onyxon111 , ee pa3Mepb1 , CB513b
onyxon111 c aHaToMfll4ecKVIM'1 crpyKrypaM111 KaK
caMoro nerKoro, TaK rpyAHOVI KileTKlll, Bb1s:1s111Tb
onyxoneBbtVI cTeH03 6poHxa 111 ero npoT51)1{eH-
HOCTb, BHyTp111rpyAHYIO .n1t1MQ:>aAeHonaTll1IO
(p111c.46).
P1itc. 46 . UeHTpallbHblH paK eepxHelll
AOilllt 11eeoro 11erKOro {TOT >Ke 60J1bHOM).
npSIM3SI (a) 111 60KOB3.ff (6) TOMOrpaMMbl: B
npoeKu1it111 nepeAHero cerMeHTa neeoro
nerKoro onpe,Qen.ffeTc.ff Hosoo6pa30BaH111e
B BMAe y311a c 6yrp11tCTOH nosepxHOCTbtO,
AOp0>1<Ka K KOpHtO 11ernoro - paKOBblM
IllitMcpaHroMT, yeeJllit'·leH11te KOpHeBblX
I1HMcpOy3I10B (yKa3aHo CTpe11KaM1it).
.ana nepucj:Jepul/ecKoao paKa neaKoao xa-
paKrepHa TeHb HenpaBMilbHolli no111itroHanb-
Hoi.:t 11111111 wapOBlllAHOlli cpopMbl , cpe,QHei:f li1H-
TeHClllBHOCTli1 , pacnOJ10)KeHHa51 Ha lllHT8KTHOM
111n1.1 Mano1113MeHeHoM nero4HOM Q:>oHe, c He-
4eTK111Mll1 (I1Y4111CTblMli1 11111111 pa3Mb1Tb1Mli1 3a C4eT
30Hbl "MaToeoro creKila" no nep111¢ep111111) li1 He-
posHblMlll (BOnHL1CTblML1 , 6yrpL1CTblM111) KOHTy-
paMltl (p111c. 47) .
Pwc. 47. nepwcpepH'leCKHM paK sepx-
HeH AOJllit npaeoro 11erKoro. np.ffM3.ff peHT-
reHorpaMMa (a): OKpymolll cpopMbl Hoeo-
o6pa3oBaHMe e eepxHellt AOne npaeoro
11erKoro c HepOBHblMH, 6yrpHCTblMH KOH-
TypaMllt Ha MHT3KTHOM 11erO'fHOM cpoHe;
TOMorpaMMa (6): no KpaSIM onyxon1it 3a-
MeTHa JlY"IMCTOCTb - paKOBblM JlJIJMcJ>aHfOJIJT
("corona maligna").
np11 pacna,Qe paKOBOfO y3.na 06pa3yeTCR
nonocTb c TOJ1CTblMl1 cTeHKaMlll Ill HepoBHOIA ,
6yrp111CTOV! BHyTpeHHeVI nosepXHOCTblO, 4TO Tpe-
6yer Alll¢¢epeH1...1111anbHOLil AlllarHOCTlllKlll c APY-
rf11Mli1 nonocTHblMlll 06pa3osaH1t15IM111 nerKll1X -
xpoH1t14ecK11M a6c4eccoM nernoro, acneprn.n.ne-
30M, ry6epeyne3oM 111 T.A. (p111c. 48) .
PHC. 48. nep111cJ>epw-1ecKHM paK HH>KHeM
AOilM npaeoro .nernoro (nonocTHa.ff cpop-
Ma). np.ffM3.ff peHTreHorpaMMa (a) 111 TOMO-
rpaMMa (6): wapOBMAHOH cpopMbl HOB006-
pa30BaHMe B Hllt>KHelll Aone npaeoro 11erno-
ro c 3KcueHTpwmoilf nonocTbtO pacnaAa,
BHyTpeHHHe CTeHKlit nOilOCTllt HepOBHble,
6p0Hx111 6a3anbHblX cerMeHTOB 06ryp1itpo-
eaHbl onyxoneeolll TKaHblO.
CoepeMeHHbte cxeMbl peHrreHonor1114ecKo-
ro 06cneAOBaH1115I np111 Hosoo6paaosaHlll51X ner-
Klll X o6H3aTenbHO BKnlOY8IOT KOMnblOTepHylO TO-
MOrpacpllllO nerKlllX. nocneAH5151 n03BOnHeT YT04-
Hl11Tb pacnono)KeHllle, pa3Mepb1 lll CTPYKTYPY Ho-
soo6pa3osaHlllH, CB513b onyxonlll c BHyTplllneroY-
HblMlll CTpyKrypaMlll lll rpy.1:1Hoi'.1 KneTKoi'.1, Ol.\eHlllTb
COCT051Hllle pernoHapHblX nl11Mcpan1YeCKlllX y3noB,
Hanll!Yllle 111n111 OTCyTCTBllle BHyTp111opraHHOro Me-
TaCTa31!1poBaHlll51, nopa>KeHli1e nnespbl. np111 pa-
Ke neHKOCma MeTOAOM Bbl60pa 51Bn51eTC51 Mar-
HLi1THO-pe30HaHCHa51 TOMorpacp1115I, KOTOpa51 no-
3BOn51eT 6onee 1.1eTKO onpe.1:1en111Tb CB513b onyxo-
11111 c 0Kpy>t<al0Ll.\111Mli1 CTpyKrypaMlll : npopaCTaHllle
cocy.1:11i1cToro ny1.1Ka, pe6ep, no3BOHKOB 111 T.A.
(P111c.49) .
PMc. 49. KoMnbHlTepHaSI TOMorpaMMa
nerKMX (a): nep11tcpep11t1.1ecKm1 paK aepx-
HeM AOJ111t npaaoro nerKoro; MarHMTHO-
peJoHaHcHast TOMOrpaMMa (6): paK neH-
KOCTa
5poHxocKonul.fecKoe uccneooeaHue 51BI151-
eTc51 OCHOBHblM MeTOAOM Mopcponor1111.1ecKOH
sep111cp111Ka4111111 L\eHrpanbHoro paKa nerKoro. K
np51MblM 6pOHXOCKOnll14eCKlllM np1113HaKaM paKa
nerKoro ornoc51r: a1113yanbHO onpe.1:1enHeMyto
onyxonb 6poHxa , 111HcplllnbTpaTbl cn1.131.1croVI
6poHxa , p1t1rn.1:1Hoe cy>1<eH111e npocsera 6poHxa c
1113MeHeH111eM p1t1cyHKa CI11!13111CTOH 111 pa3MblTO-
CTblO XP51Ll.\e'4 ; K KOCBeHHblM: ynnoTH8Hll1e CTeHKll1
6poHxa np111 111HcrpyMeHranbHoi4 nanbnal\111111 ,
cMeL11eH111e 1t1 ,1J,ecpopMa1..111110 ycTbeB cerMeHTap-
HblX 6pOHXOB, ynnoll.\eHl!le KaplllHbl 61.1cpypKa1..11.1111
Tpaxe111 , nape3 OAHOH 1113 ronocosblX CB5130K. Bo
speMfl npose.1:1eHlll5! cp1116po6poHxocKon111111 0651-
3arenbHO BblnOnHf!IOT: 3a6op npOMblBHblX BOA,
M83Kll1-0TneYaTKll1 111 COCK06 CJ11.13111CTOl/f 6pOHXOB
nopa)l{eHHO~ CTOpOHbl Ha aTl!lnlll4Hb\e Kne"TK\11,
6111onc111t0 lt13MeHeHHblX yYaCTKOB cnll131!1CTOi4
6poHxa 1.1n1.1 Blt1Ali1MOH onyxo111.1 An51 L\ll1Tor111cro-
nor1114ecKoilf sep1.1cp111Ka1..11111.1 npo1..1ecca. An51 yro4-
HeHl.17l np111pOAbl M8All1aCT111H8J1bHOilf n111Mcpa.1:1e-
Honarn111 BbmonH51eTc51 rpaHc6poHx1r1anbHa5I 111r-
nosa11 61r1onc1t15I n111Mcpoy3nos cpe.1:1ocreH1115I , no-
cneAH5151 noKa3aHa TaK)Ke np111 nep1r16p0Hx111anb-
HOM pocre onyxon111 .
PMc. 50. UeHTpanbHblM paK nerKoro
(3HA0cpOTO)
B HaCT051Ll.\ee speM51 AnH .1:1111arHocT111K111 paH-
HlllX tj>opM 1..1eHTpanbHoro paKa nerKoro, oco6eH-
HO ero nepBli!LtHO-MHO>KeCTBeHHblX n0Kan1113a1..1111i/f ,
np1r1MeH518TC51 0111.1:1eo6pOHXOCKOnlll5I BblCOKoro
pa3peweH111s:1 B 6enoM csere 111 B NBI - pe}\(l/IMe,
ayrocj:>moopopec1..1eHTHa5I s111.1:1eo6poHxocKom151 111
anaceHC (5ALA) - lllHAYL\lllPOBaHH851 cpnlOopo-
pecL\eHTHa51 6poHXOCKon11151; 3HAOCOHOrpacpi-rn;
1!1MMyHOL\lllTOXlllMll14eCKOe 111ccneAOB8Hl!le CKap111-
cp111KaTOB CJ11!13111CTOlll o6onoYKll1 6poHxa Ha 3n111-
Tem1aJlbHbl ill MYL\lllH (MUC-1 ).
C 1..1enb10 sep111cp111Ka4111111 AlllarHo3a np111 ne-
p111cpep1111.1ecKoM paKe nernoro 111cnonb3YIOT
169
TpaHc6pOHX111anbHYIO KaTeTep11138l.\llllO c 6111onc111-
ei4 HOB006pa30B8Hl!151 Ill rpaHCTOpaKaJlbHYIO 111~
JlOBYIO acn111pal.\l!lOHHYIO 6111onc111t0 nOA KOHTpo-
neM peHTreHTeneBl!131110HHOro 3KpaHa. 3Tlll Me-
TOAlllKlll lllCCneAOBaHlll51 B03MO)KHbl TOnbKO B yc-
noBlll51X MHoronpocplllnbHoro cra1..11110Hapa. T 01.1-
HOCTb ,q111arnocT111K111 nep111cpep1111.1ecKoro paKa np111
rpaHcropaKanbHoi:1 111rnosoi/f acm1pa41110HHoilf
6111oncllllll ,qocrnraer 90 %. Ocno>t<HeHlllHMlll nyHK-
L\lll\11 5'1BI15llOTC51 nHeBMOTOpaKC (10-15 %), Kpo-
soxapKaHbe, 3Ha1.1111TenbHO pe)l(e - 111MnnaHTa411151
paKOBblX KneTOK no xop,y nyHKL\l!lOHHOro KaHana c
pa3s111rneM MeTacTa30B onyxon111 . TpaHcropa-
KanbH851 (TpaHc6poHx1t1anbHa51) 6111onc11151 onyxo-
m1 npornsonoKa3aHbl nplll Bb1pa)f{eHHO!lt ,1J,b1xa-
TenbHO!lt HeAOCT8T04HOCTlll, neroYH0!4 rnnepreH-
3111111, C111HAPOMe "sepxHeilf nonoi/f seHbt", Hapywe-
Hllll!l csepTblB810ll.\e'4 Cll1CTeMbl KpOBlll.
An~ 1t1CKJltoLteH1115I OT,QaneHHblX Meracra30B
paKa nerKoro 111cnonb3YIOT ynbrpa3syK, KoMnb10-
repHyt0 TOMOrpacpl!llO, pa,qlllOHYKnlA.[\HOe CK8Hlll-
pOB8Hllle KOCTeilf CKenera, n03111TpOHHYIO 3MlllC-
ClllOHHYIO TOMorpacp111t0.
Ynbrpa3syKosoe 111ccne.1:1osaH111e BKntoLtaer
ocMorp nnespanbHblX nonocre!lt , opraHos
6pKlWHOilf nonoCTlll , 3a6pt0WIAHHOro npocrpaHCT-
Ba , opraHos Manero ra3a 111 pernoHapHblX ,q1151
nerKoro HaAKnlOYl!lYHblX JllllMcpoy3nOB.
Ysen1.1LteH111e HaAKJ1to41114HblX m1Mcpoy3nos ,
Bbl51BneHHoe np111 ynbrpa3syKosoM 111ccne.1:1osa-
H111111 , 51Bfl51eTC51 noKa3aHllleM K nyHKL\llll!l n1t1Mcpo-
y3nos. np111 OTPlllL\8TeJ1bHOM pe3ynbTaTe nyHK-
l.\llllll noKa3aHa npecKaneHHa51 6111onc11151: y,qane-
Hl!le n111McpaT111YecK111x y3nos, pacnono)f(eHHblX s
Kner1.1arne Ha nepe,qHei4 necTHlll4HO!lt Mb1w4e c
L\enblO lllX rncronorn4eCKOro lllCCJleAOB8Hl!151.
06Hapy)l{eH111e MeTac1a3os paKa nenmro s Ha,Q-
KJltOLtlllLtHblX (111 lt1HblX n111Mcpoy3nax BHe rpyAHO!lt
KneTKlll) cs111,qeTenbcTsyer o Bb1xo,qe onyxon111 3a
npeAenbl rpy,qHoi'.1 KneTKlll 111 reHepan1113a41111.1 3a-
6onesaHll151 .
PMC. 51. npecKaneHHaSI 6MOOClltSI ( cpo-
TO): a - o6~MM BM,Q onepa~MOHHOro nom1;
6 - MeTaCTaTMl.feCKM 1113MeHeHHblH nMMcpo-
y3e11 a npe,QnecTHM"IHOM 1<J1eT1.1aTKe.
Aa)f(e He6onbwoi'.1 Bbmor B nnespanbHOilf
nonocrn , Bbl51BneHHblill nplll Y3-111ccne.1:1osaHV1lll y
6onbHb!X paKoM nerKoro, 51Bn51eTc51 noKa3aH1.1eM
.1:1n51 .1:11t1arHOCT1i1LtecKoilf nyHKL\llllll . 3Kccy,Qar acn111-
p111py10T nonHOCTblO lll ornpaBJ15llOT Ha L\l!ITOJ10rli1-
4eCKOe 111ccne,qosaH111e. Han1111.1111e paKOBblX Kne-
TOK B nnespanbHOM 3KCCy,qare no3BOJ151eT OTHe-
CTl!l 3a6oneBaHllle K IY CT8,l\l!llll (M1 ).
Yse11111LteH111e MeA111acrnHanbHblX n111Mcpoy3-
nos 51BJ17leTC51 nOK838Hll1eM K 1!1HB83111BHblM MeTO-
A8M ,1:1111arHOCTl!1Klll - Me.1:11.1acr1t1HOCKon111111 , napa-
crepHanbHO!li Me,Qvt8CTll1HOTOMl!1111 , Bll1AeOTOpaKo-
CKOn"1lll c 1..1enbt0 pes1113111111 111 3a6opa MaTep111ana
An51 MopcponornLtecKoro 111ccne.1:1osaHl115I.
 MeA111acT111HOCKon111s:i 111 napacTepHanbHas:i
MeAl!laCTlllHOTOMlils:I - x111pypr1114eCKlile MeTOAbl
pes1113111111 nepeAHeeepxHero cpeAOCTeH111s:i 111
4aCTlil4HO KOpHelli nerKlllX. no XOAY 111ccneAOBa-
Hlil5! 3a6111patoT Ans:i r111cTonorn4ecKoro 111ccne-
AOBaH111s:i n111McpaT1114ecK111e Y311bl , a TaK>Ke no-
A03p111TenbHb1e B nnaHe onyxonesoro nopa>Ke-
Hlils:I TKaHlil .
B nocnep,H111e roAbl w111p0Koe pacnpocTpa-
HeH111e no11y411111a BlilAeoTopaKocKon111s:i - x111pyprn-
4ecK111ili MeTOA, no3BOJ151IOW,lillli lilCCJleAOBaTb KaK
nepeAHee, TaK 3aAHee cpe,[1ocTeH111e, 04eHlllTb
COCT051Hlile n11eBpbl, 11erKoro Iii B351Tb He06XOAlil-
Mbllli MaTep111an A1151 4111TorncTonorn4ecKoro 111c-
c11eAOBaH1115I.
Hosb1M MeTOAOM Bb1s:isneH111s:i neps1tt4Holli
3JlOKa4eCTBeHHOlli onyxon111 111 ee MeTacrn300 s:is-
11s:ieTcs:i no3111TpOHH851 3MlilCClllOHHa51 TOMOrpacp111s:i
(n3T) . B OCHOBe MeTO,[\a ne>KlttT 04eHKa KneT04-
Horo Mera6om13Ma paKOBblX KJleTOK OCHOBaHHas:i
Ha lilCnOJlb30B8Hlillil paAlllOcpapMaKOJlOrlil4eCKOrO
npenapara - 18F
cp11toop0Ae0Kc111rntoK03bl. PaKosb1e KnerK1,11
aKTlllBHO 3axsaTblB8IOT 18F cprnoopoAeOKClilrJllO-
K03Y , nplil 3TOM Ha n3T CKaHaX o6pa3ytoTC51
CBeTnble ns:iTHa. nocne,[lytow,ee COBMeW,eHlile
Mera6on1114eCKlllX n3T lil306pa>KeHlillli Ill aHaTO-
Mlil4eCKll1X KT 111306pa>KeH11111i B OAHY KaprnHy no-
3Bons:ieT Bbls:!BIHb Iii T04HO 110K8Jllil30BaTb 04arlil
nepBV14Holli onyxo11i.1 , Meracra3bl B pernoHapHblX
n111Mcparn4ecK111X y3nax 111 OTAaneHHblX opraHax
pa3MepaMll1OT5 MM.
P111c. 52. PaK nerKoro: cosMel.l4eHHb1e
n3T-KT cKaHbl. a - nep111cpepw·1eCKll1M paK
sepxtte.:1 Aon111 .nesoro .nernoro; 6 - Mera-
cra3 paKa e HaAKI1K>4H4Hble .n111McpoyJ.nb1.
MeTOA s nepcneKT1110e AOn>KeH 3aMeHlllTb
ynbTpa3ByK, KT (MPT) Iii CKaH111poBaH111e KOCTelli
CKeneTa. LJyBCTBl/lTeJlbHOCTb n3T B OTHOWeHl/1111
3JlOKa4eCTBeHHblX HOB006pa30BaHlillli nerKlllX co-
CTaans:ieT 88-96 %, a cne4111cp1114HOCTb 70-90 %.
Bo MHOrlllX KJ1111Hlil4ecKlllX c111Tya4111s:ix 111HcpopMa-
TlllBHocTb n3T OKa3blBaeTC51 BblWe TP8Alll4111-
0HHblX rnxHonornlli Mopcponor1114ecKolli e1113ya-
111113a4111111 .
AKTlllBHble aocna11111TenbHb1e npo4eccb1 a
11erK111x, BKntoYas:i ry6epKy11e3, Moryr 6b1Tb np111-
YlllHOL1 JlO>KHOnOilO>KlllTenbHOro pe3y11bT8Ta
n3T, n03TOMY pe3ynbTaTbl 11to6oro lllHCTpyMeH-
TanbHOro MeTOAa, Aa>Ke caMoro cospeMeHHoro,
AOH>KHbl aHanll13111pOBaTbC51 apaYOM B KOMnneK-
ce c KnlllHVIKolli 3a6011eaaH111s:i , AaHHblMltt 11a60-
paTopHblX 111 APYn1X lllHCTpyMeHTa11bHblX 111ccne-
AOBaH111L1 .
,D,ucjJcjJepeH4ua11bHbtU oua2Ho3
l_\eHTpanbHblli1 paK Heo6xoAlllMO A111¢¢e-
peHu.111poeaTb c ry6epKY11e30M, 38T51>KHOH nHeB-
MOHl!leH , aTeneKTa3oM nerKoro scneACTB111e:
6pOHXOCTeH038, 06Typa4111111 lilHOPOAHblM TenoM,
170
8,[\eHOMOlli 6pOHXa. np111 ,[1111cpcpepeH4lilaJlbHOlli
,[llllarHocTl!IKe nep111cpep1111.1ecKoro paKa Heo6xo-
AlllMO lilCKJ1to4aTb A06poKaYE7TBeHHble onyxon111
111 KlilCTbl nerKoro, apTep1110-.:seH03Hb1e aHesp1113-
Mbl, HOB006pa30BaHlll51 cpe,[lOCTeHlllS'I , n11eBpbl Ill
fPYAHOlli CTeHKlll , MeTaCT83bl 3JlOKaYeCTBeHHblX
onyxonelli ,[lpyrnx opraHoB s nerK111e.
np111 AlllcpcpepeH4111anbHOlli Alil8fHOCTlllKe He-
o6X0,[\111MO np111MeH111Tb secb KOMnneKc cospe-
MeHHblX KJ1111Hlll4eCKlllX Iii lllHCTpyMeHTa11bHblX Me-
TO,[\OB 06cneAOB8Hll151. np111 He5!CHOCH1 ,[\1118fH038
111 coxpaHs:llOli.\eMcs:i no,[lo3peH111111 He paK nerKoro
noKa3aHa BV1AeoropaKOCKOn111s:i 11111111 ,[\1118fHOCTll1-
YeCKas:i TOpaKOTOMl/151 c 6111onc111ei/i TKaHlil Ill cpoY-
HblM (Ha onepa1..11110HHOM crone) L\111TOJlOrlil4eCKlllM
Ill rlilCTOJ10rlil4eCKlllM lilCCJleAOBaHlileM .
flELf EH/.1£ PAKA /7ETKOTO
Xupyp2u'-lec1<oe ne'-leHue
X111pypr1114ecKoe ne4eH111e paKa nerKoro oc-
raercs:i Ha1116onee pa,[11AKa11bHblM MeTOAOM np111
pe3eKrn6enbHblX cpopMax 3a6onesaH111s:i .
noKa3aHltt51Mltt K onepa41ttlll nplil HeMe11KO-
KJ1eTOYHOM paKe 11erKoro 51B115llOTC51 :
1. noKaJlltt30B8HHbllli xapaKTep nopa>KeHlttS'I C
so3MO>KHOCTbto pa,[11ttKanbHoro yAaneH1tts:i nep-
B1114Holli onyxon111 Iii pernoHapHblX BHyTplilfPYAHblX
11111Mcpar1114ecK111x y311os Ha crnpoHe nopa>KeH111s:i ;
2. Orcyrcrs111e OTAa11eHHblX MeracTa30B;
3. <PyHKL\lllOHaJlbHas:i onepa6enbHOCTb
6011bHoro.
OcHOBHb1M111 onepa4~1s:iM111 np1tt paKe nerKoro
71B115llOTC51 :
1. no63KTOMll151 (6111no63KTOM11151, nHeBMO-
H3KTOM1tt51), BblnOJlHeHHble B CTaHAapTHOM (6e3 .
YAa11eH1r1e MeA111acr111HanbHblX n111Mcpoy311oe) 11111111
pacwlilpeHHOM sap111aHTe (c YAaneH111eM MeA1tta-
CT111HanbHblX Jllt1MQJOY3IlOB Iii KJ1eTYaTKlt1 cpeAO-
CTeHlllfl). HaKon11eHHb1i.1 3a nocneAHllle roAbl
onblT noKa3an, YTO 111cnonb30BaH111e cerMeHT3K-
TOMVIVI, a TeM 6011ee KJlVIHOBlil,l:IHblX pe3eK4111i;l
np111 paKe nerKoro, Aa>Ke c np111MeHeH111eM nlilM-
¢aAeH3KTOM111111, He onpaBAaHO c OHKOJ10fl/14e-
CKlttX no3111411111i .
2. KoM6111H111poeaHHb1e BMewarenbcrea
(yAa11eH111e 1.1acr111 11erKoro c pe3eK1...1111ell1 coceAHe-
ro opraHa, KpynHoro cocyAa, AlilacpparMbl 111 T. .£1).
KoM6111H1t1posaHHb1e onepa4111111 np1tt paKe nerKoro
- onepa1...11tt111 HecraHAapTHble. T aK111e onepa41tt111
4enecoo6pa3HO BblnOJ1H51Tb s TOM cny4ae, KOrAa
MO>KHO YA8111i1Tb BCIO onyxonb, He ocTasns:is:i pa-
KOBblX KneTOK no nlilHllllll pe3eK4111111 , a TaK>Ke
n111Mcparn1.1ecK1r1e Y311bl Ha cropoHe nopa>KeH111~ .
3. 6poHxonnacrn1.1ecK1tte onepa4111111: no63K-
TOMlttH c pe3eK4111ell1 lit nnaCTlllKOH AOileBblX 6poH-
XOB. 5poHxon11acrn1.1ecK1tte onepa41i11tt 1.1aw,e sce-
ro BbmonHHIOTcs:i np111 paKe ycTbH sepxHe,[loneso-
ro 6poHxa (cnpaea 111m1 cneea) 111 no3eonfltoT co-
xpaHlllTb 48CTb napeHXlllMbl nerKlllX (cpe,QHIOIO Ill
Hlll>KHIOIO AOnltt cnpasa VI Hlll)l(HIOIO ,QOJllO nerKoro
cnesa) , OHlll noKa3aHbl y 6onbHblX co CHlll}l{eH-
HblMlll AbJXarenbHblMlll pe3epsaM111.
B111AeoTopaKocKon1114ecK111e (B111Aeoacc111cr111-
posaHHb1e) pe3eK4111111 nern111x, KaK MeTOA paAlll-
KanbHoro ne4eH111s:i paKa nerKoro, Moryr 6b1Tb
peKoMeHp,osaHbl Am:i npaKT1114ecKoro np111MeHe-
H111s:i Ha cTaAllllll T 1No-1 3a6onesaH111s:i . ,Qns:i Bb1non-
HeH111s:i nO,[l06HblX onepa4111ilt He06XOAlllMO AOPO-
roCTOs:!LL!ee 06opy,QoBaH111e 111 cne4111anbHb1l4 111H-
crpyMeHrap111ilt . TopaKanbHble x111pypr111 , Bbinon-
Hs:!IOLL!llle Blll,[\80TOpaKOCKOn4eCKllle pe3eK4111111
nerK111x, AOn}l{Hbl s cosepweHCTBe sna,[leTb Tex-
HlllKOilt KnaCCl/l4eCKlllX pe3eK4111ilt nerKoro, 4T06bl B
cny4ae Heo6XOAlllMOCTVI nepelllTVI Ha onepa4111io
4epe3 TOpaKOTOMHblilt ,[\Ocryn.
nanm1ar111BHb1e onepa4111111 Hepe,[IKO Bbinon-
Hs:!IOTcs:i no :>K1113HeHHblM noKa3aHVl5lM (nero4HOe
Kposore4eH111e, HarHoeH111e s 30He areneKTa3a ,
nporpecc111py10U.\as:i AblXaTenbHas:i HeAOCTaT04-
HOCTb BCJleACTBl/le MaCCVIBHOfO nnespanbHOro
BblnOTa Ill T.,[l.). K HlllM OTHOCl/ITC5l 3H,QOCKOnlll4e-
CKOe yAaneH111e - peKaHan1113a4111_s:i onyxon111
KpynHblX 6pOHXOB np111 nOMOU.\111 MOU.\HOfO He-
0,[\VIMOBOro - Nd :YAG na3epa, 4111Topep,yKT111BHb1e
BMewaTenbCTBa, nepeBs:!3Ka OCHOBHOro CTBOna
nero4Holil aprep111111 Ha cropoHe nopa)KeH1115l, 3M-
6on1113a4111s:i 6poHx111anbHblX aprep111ilt , rnpaKocKo-
n111s:i 111 nnespo,D.e3 (rnnbKOM) np1t1 Kap41t1HoMaT03-
HOM nnesp111Te.
npo6Hble TOpaKOTOMlllVI - onepa41111t1 npeA-
np111H5lTble no nosop,y paKa nernoro s XOAe KO-
TOPblX y,[laneH111e onyxon111 np1113HaHo HeB03-
MO}l{HblM .
A6comomHbJMU npomusonoKa3aHURMU K
onepau,uu Ha ne2KoM npu paKe RBfTRJOmrn:
1. Macc1t1sHa5l 111H¢111nbTpa4111s:i onyxonblO
KJleT4aTKlll cpeAOCTeH"1s:! c W"1p0KlllM spacTaH\.-leM
onyxon111 B sepXHIOIO nony10 seHy, aopry, n1<1U.\e-
BOA, Tena no3BOHKOB.
2. napanlll4 803BpaTHOfO ropTaHHOfO Hep-
Ba.
3. nopa}l{eHl/le Ha,[\Knl041114HblX nl/IMQJOy3nOB
- N3.
4 . Mop¢onorn4ecK111 noATBep}l{,[leHHble Me-
racTa3bl s OTAaneHHblX opraHax
5. PaKOBb1L.1 nnesp111T (nep111Kap,[1111T);
6. <l>yHKL.\lllOHanbHas:i Heonepa6enbHOCTb
na4111eHTa (KpaVIHe Hlll3Kllle cPYHKL.\lllOHailbHble
pesepsb1 AbtxaHV15l: >KEn MeHee 50 %, Ab1xa-
renbHas:i He,[locraT04HOCTb Ill crnneH111, xpoH111-
4ecKas:i cep,[le4Ha5l He,[\OCTaT04HOCTb Ill CTeneHVI,
AeK0MneHc111posaHHb1VI 4111ppo3 ne4eH111, xpoH111-
4ecKas:i no4e4Ha5l He,[\OCTaT04HOCTb Ill CTeneHlll ,
KaXeKCllls:!).
Ha MOMeHT ycraHosneH1115l AlllarHo3a n111wb
OKOJlO 20 % na4111eHTOB l/IMelOT JlOKaJ11/130BaHHYIO
cra.n.11110 3a6onesaH1115l 111 Moryr 6b1Tb onep111posa-
Hbl, np1114eM 1113 HlllX pa,[1111KanbHas:i onepau,11151
B03MO:>KHa Jll/IWb )LZQ-80 o/o 60J1bHblX.
/ 4eH111111 , np111 conyrcTBylOU.\eM ry6epKY.ne3e ner-
183
Pe3y11bTaTb1 x111pyprn4ecKoro ne4eH1115l He-
MenKoKI1eT04Horo paKa nerKlllX 3aBlllCs:!T OT CTa-
A~1111 3a6onesaH1115l. TaK, np111 I cTaAllllll 5-neTH5ls:i
Bbl:>KlllsaeMOCTb nocne pa,[l111KanbHoL.1 onepau,111111
KOJle6neTC5l OT 50 % AO 60 %; npL1 II CTa,[\111111 -
OT 30 % AO 40% . Ha Ill crn,D.111111 pa,D.111KanbHa5l
onepa4111s:i B03MO}l{Ha np111 OTCYTCTBllllll MeTaCTa-
308 B Me,D,lllaCTlllHaJlbHblX JllllMcj:>oy3nax, 5-Jl8TH.SU1
Bbf)KlllBaeMOCTb npL1 3TOM COCTaBJls:!8T 19 %. np111
nopa)l{eHllllll M8,QlllaCTlllHanbHblX n111MQJOY3Il08
(N2), ,[la)l{e np111 KOM6111HlllpoBaHHOM ne4eH111111 ,
cyMMapHas:i 5-neTHs:!s:! Bbl:>KlllBaeMOCTb y 60ilbHblX
He npesb1waeT 10 %.
nocneonepa41110HHa5l neranbHOCTb sa no-
cneAH111e ,[\Ba ,QeC5lT111JleTV15l CHlll3111JlaCb Ill KOJle6-
neTCs:! B pa3HblX KJllllHlllKax OT 3,2 AO 6,2 %.
np111 MeJlKOKneT04HOM paKe noKa3aHlll5l K
onepa4111111 orpaHlll4111BalOTC5l T1-2 N0-1 crnp,111s:iM111
3a6011esaH111s:i .
Jlyl..feBaR mepanuR
ny4esoe Jle4eHllle paKa nerKOfO np111MeH51-
eTC5l KaK KOMnoHeHT KOM6111HV1pOBaHHOf0 ne4e-
Hllls:! (s co4eraH111111 c onepau,111ei.1), s Ka4eCTBe ca-
MOCTomenbHoro ne4e6Horo B03AeL1cTB11151 , s
KOMnneKce c x1.1M1110Tepam1elll 1.1 KaK nan-
11111aTV1BHOe cpe,[ICTBO ,D,Jls:! ycTpaHeHlllS'l TS'l}l{eJlblX
npo51s11eH111L1 6one3Hlll . 3¢¢eKT OT 11y4esoro ne-
4eHll15l 06yc11os11eH nornoll.\eH111eM 06ny4aeMblM
o6beMOM TKaHelll 3Hepr111111 lllOHlll3111PYIOU.\ero 11!3-
ny4eHll1S'l. 3rn 3Hepr111Y1, nony4aeMaY1 3a secb
KYPC .ne1.JeH1115l , Ha3b1saeTcs:i cyMMapHoi.1 04aro-
soi.1 A030L1 (CO,Q) 111 1113Mep5leTcS'l s rpes:ix (rp).
0,D,lllH rpei.1 5lBJ1HeTCs:! QJlll3V14eCKOL1 BeJll.'14111HOL1 ,
xapaKTep1113YfOU.\elll A03Y nornoll.\eHHoro 1110H1113111-
PYfOU.\ero 111311y4eH1115l, KOr,[\a 1 Kr BelJ.leCTBa no-
11y4aeT 1 ,Q)l{OYJlb 3Hepr111 Ill .
nyYeBa5l TepanL15l no paOUKanbHOU npo-
2paMMe KaK sap111aHT C8MOCT05lTeJlbHOrD ne4e-
HlllS'l HeMenKoKfleT04Horo paKa nerKoro noKa3aHa
6onbHblM c Mopcponor1114ecK111 no,D.TBep}l{,[leHHblM
,D.1118fH030M , y KOTOpbiX HeB03MO:>KHO BblnOJlHlllTb
paA111Ka11bHY10 onepa411110 1113-3a Hll13KL1X noKa3a-
Tenelll QJYHKl...\111111 BHewHero ,[\blXaH111S'l , Bblpa}l{eH-
HOVI nero4Ho-cepAe4Holll HeAOCTaT04Hocrn 111
OTKa3a oT x111pyprn4ecKoro ne4eHV1s:t. PaAlllKanb-
Hafl nporpaMMa Bb1nonH111Ma np111 YAOBneTsop111-
TellbHOM o6~eM COCTOS'lHllllll 6onbHOro np111 1-11
crap,111s:ix 3a60.nesaH111Y1 . 06beM 0611y4eH111s:1 np111
paA"1KanbHOli1 nporpaMMe (o6nacTb ne4e6Horo
B03Aeli1crs1115l) oxsaTblBaer neps1114HYIO onyxonb
111 pernoHapHble 11111M¢aTV14eCK111e y311b1 He3as111-
c111Mo OT H3Jllll4"151 lllJ1V1 OTCYTCTBlll5l KnV1Hlll4eCK"1
onpeAenS'leMblX B HlllX Meracra3os onyxo11111 . ,Qns:i
p,ocT111:>KeH111s:i peM111cc111111 3a6011esaH1115! AOCTaTo4-
Ha ,[\03a 65 rp .
PaA111KanbHa5! 11y4esas:i nporpaMMa npoT111-
sonoKa3aHa np111 H811V14111"1 OT,QaneHHblX MeTacTa-
30B, pacnaAe onyxo11111 (Ho He np111 nonocrnoi'.1
cpopMe paKa nerKoro), np111 nero4HOM KposoTe-
KVIX, npVI Bblpa)l{eHHblX HapyweHVl51X cpyHKL\VIVI
,D,blXaH\.151 lll Kposoo6paU,\eHlll51 .
nannuamusHafl npo2paMMa noKa3aHa
npVI paKe nerKoro c MeTacTaTVIYeCKVIM nopa)l{e-
Hl/1111 Me,D,l/laCTlllHallbHblX Ill Ha,D,KJllOl.JVIHblX m1Mcpo-
Y3ll0B, nocne npo6Holil TopaKOTOMlllVI , 3Ha4lll-
TenbHOM p8cnpocTpaHeH111V1 onyxonVI Ha rpy,o,HylO
cTeHKY, nep1r1Kap,o,, nesoe npe,o,cep,o,111e, ,o,111a-
cpp8rMy, Mar111cTpanbHb1e cocyp,b1 cpe,o,ocTeHllls:I.
np111 XOpOWeM COCTOf!Hl/1111 60JlbHblX Ill Bblpa>KeH-
HOM perpecce onyxon1r1 B03MO>KeH nepexo,o, Ha
pap,viKanbHYIO nporpaMMY o6ny4eHV151. B 4aCTVI
cny4aes 0611y1.JeH111e MO>KeT no,o,roTOBlllTb 6onb-
Horo K onep8H1BHOMY ne4eHllllO 38 c4eT 4aCTlll4-
Holil pe3op64111111 onyxon111 .
C1r1MnT0MaT1rt1.JecKoe ny4esoe ne1.JeH111e
np111MeHs:ieTC5I np1r1 HallVIYlllVI 6onbwolil onyxon111 111
06w111pHblX MeTacTaJax ,o,m1 0611er1.JeH1115I TaK111x
CVIMnTOMOB, KaK KposoxapKaHbe , 6onb, VIHTOKCVl-
Kal..\11151 np1r1 arnneKTa3e, ClllH,D,poMe c,o,asneH111S'I
sepxHelil nonolil seHbL
noc.neonepau,uoHHOR ny11eaaR mepanuR
no1<030HO 60flbHbJM:
- VIMelOll.\VIM MeTaCTa3bl B Me,D,VlaCTVIHallb-
HblX n111Mcpoy3nax no AaHHblM Mopcponorn1.JecKO-
ro V1ccne,o,osaHlll5I yp,aneHHoro npenapaTa - pN2 ;
- onyxonesb1e KIJeTKlll no n111H111111 pe3eKL\lllVI
6poHxa - R1 ;
- np111 n8nn1118TL11BHOM xapaKTepe BMewa-
TellbCTBa 111 ocTasneHVllll pe3111,o,yanbHOlil onyxonvi
- R2 .
,0,111cTaH41110HHas:i ny4esas:i Tepan111s:i a caMo-
cTos:iTenbHOM sap111aHTe B pe>Kl/IMe KJlaCCVILJeCKO-
ro cppaKL\lllOHlllpOBaHVls:l He n03Bom1eT nonyYVITb
CTOlilKYIO KI1111HVl4eCKYIO peMlllCCllllO y 60JlbWVIHCT-
Ba na4V1eHTOB, ee 3cpcpeKTVIBHOCTb no KpVITepVllO
5-JleTHelil Bbl>KlllB8eMOCTlt1 np111 1-11 CTaAVls:!X 38-
6oneBaHlll51 He npesb1waeT 10-12 %.
B HaCTOs:lll.\ee speMs:i c L\8Ilbl0 nosb1weHV1s:l
3cpcpeKTlllBHocrn nyyesow Tepan111111 paKa nerKoro
pa3pa6aTblB8IOTC51 HOBble nO,D,XO,D,bl , KOTOpble
BKill04alOT pa3pa60TKY HeTpa,D,lllL\lllOHHblX pe>1<111-
MOB cppaKL\lllOHlllpOBaHllls:I VI pa3Jllll4Hble cnoco6bl
pa,o,1110MO,D,V1cp111Ka4V1V1 - ynpasneHllle TKaHesolil
P8Alll04YBCTBl/ITeJlbHOCTblO nyTeM 111cn0Jlb30Ba-
Hllls:l XlllMlllOnpenap8TOB, r111nep6ap111YeCKOlil OKClll-
reHa1..4111111, r111nepTepMllllll c O,D,HOBpeMeHHblM VIC-
nOJlb3088Hl/leM AOCTlll>KeHllllil TeXHlllKVI nocne,o,He-
ro noKOJleH111s:1 : pa3JlVl4HblX MO,D,V1cp111Ka41r1ill Jllll-
HelilHblX ycKOPlllTeJleW 3JleKTpOHOB, VICnOJlb30Ba-
HVle CTepeoTaKClll4eCKOfO o6ny4eHllls:l MO,D,yn111po-
BaHHOro no lllHTeHClllBHOCTlll - «K1t16ep-Ho>1<» VI AP -
XuMuomepanuR
X111M1110Tepan111s:r paKa nerKoro MO>KeT np111-
MeHs:!Tbcs:i B Ka4eCTBe caMOCTOSlTeJlbHOro MeTO-
,o,a neLJeHlll51 paKa nerKoro, a TaK>Ke B cocrase
KOM6VIH111p088HHOro ne4eHVls:l - B C04eTaHVllll c
ny4esow Tepan111ew VI onepaL1111elil a BVIAe He-
184
oap,blOBaHTHolli VlllVI a,D,blOBaHTHolli cxeM ne4e-
HVl51 .
He3aBVICVIMO or CTa,D,VIVI , Heoa,D,blOBaHTHafl
XlllMVIOTepan11151 51BJls:leTC.S1 OCHOBHblM MeTO,D,OM
ne4eHVls:l 6onbHblX c MenKOKJleT04HblM paKOM
nerKoro, no3B0Jls:llOLJ..\VIM ,D,06VITbCs:I peMVICCVIVI 3a-
6onesaHV1s:I. B cospeMeHHblX ycnos111s:ix npena-
paTaMVI Bbl6opa ne4eHVIS1 JlOK8Jllll30B8HHOli! cra-
,D,111111 MeilKOKJleT04HOfO paKa 51BmllOTCS1 L\VICnna-
2
TVIH 111 3TOno3111A - cxeMa EP : 1.1111cnnarnH 80 Mr/M
2
BHYTPlllBeHHO B 1-w ,D,eHb, 3TOn03111,D, 120 Mr/M
BHYTPVIBeHHO B 1,2,3-111 ,D,HVI . Kypc ne'-leH\1151 no-
BTOpS1eTC51 1 pa3 B 3 He,o,en111 . ,O,m1 AOCTl/l>KeHlllS1
peM111cc111111 Heo6xop,111Mo nposep,eHV1e He MeHee
4-6 Kypcos x111M111orepan1r1111 , nocne 1.Jero ,o,onon-
HlllTenbHO nposop,111Tcs:i 06nyYeH111e ronosHoro
M03ra (30 rp).
np111 pacnpOCTpaHeHHOW cpopMe MeJlKOKJ1e-
T04HOro paKa np111MeH5llOT cxeMbl : EP (3Tono3111A
+ 1..4111cnnarnH), CAV (4111 KnocpoccpaMV1A + ,o,0Kco-
py61r14V1H + BVIHKp111crnH), CDE (4111KnocpoccpaMV1A
+ ,D,OKCopy61111_\l11H + 3TOn03Vl,D,} , c ,o,ononHVITenb-
HblM o6ny4eHVleM oYaros nopa>1<eHV1S1 . Co1.JeTa-
H111e XVIMVIOTepanVIVI c O,D,HOBpeMeHHblM o6ny4e-
HVleM (ny4esolli Tepan1.1ew) nepBVILJHoro 048ra,
KOpH51 nerKoro VI cpe,o,ocTeHVls:J c nop,sep,eHV1eM
CYMMapHOlil 048fOBOlfi ,D,03bl 30-45 rp yny4W8IOT
pe3yllbTaTbl JleLJeHl/151 6onbHblX c MeJlKOKJleT04-
HblM paKoM nerKoro.
MeA111aHa Bbl>KlllBaeMocrn 6onbHblX c noKa-
llVl30BaHHOW cpopMOW MenKOKJleT04HOro paKa
np1.<1 1.<1cnonb30BaH1.<11!1 KOM61.<1HV1pOBaHHOfO ne4e-
Hllls:l COCT8BJ151eT 16-24 Mecs:14a, np111 3TOM 2 -
neTHs:t51 Bbl>KVIBaeMOCTb p8BHa 40-50% , 5 - ner-
H51s:l - 10% . np111 pacnpOCTpaH€HHblX cpopM8X
MenKOKI1€T04Horo paKa nernoro pe3ynbTaTbl 38-
Merno xy>1<e, TpexneTH111VI nepVIOA He nepe>KVIBa-
er Hiii OAlllH 60JlbHOW .
B HacTOT11J..1ee speMs:i onep1.1pyeTc5I He 60-
nee 5 % 6onbHblX c JlOKanlll30BaHHOW CTa,D,111€111
MenKoKneT04Horo paKa nerKoro (T1. 2 N0•1) . .Qoc-
TOBepHoe ysenlll4€Hlll€ npOAOH>Kl.<IT€JlbHOCil.<I
>Klll3Hlll onep1.1posaHHblX 60JlbHblX AOCTVlraeTCS1
TOnbKO np111 VICnOJlb30B8HVIVI a.QblOB8HTHOlli Xlll-
MlllOTep8n111111 no cxeMe EP (He MeHee 4 KYPCOB) ,
,o,ononHeHHotli 06nyYeH111eM ronosHoro M03ra
(30 rp) . 8bl>KVIB8€MOCTb B T€4€Hllle 5 neT y one-
pVlposaHHblX 60JlbHblX c a,D,blOBaHTHOlil X"1MlllO-
Tepan111elli cocTasns:1eT 25-30 % , Allfl 6onbHblX c
1-i:i cTaA111elil - 50 % . TaKlllM o6pa3oM , pe3ynbra-
Tb1 x111pyprV14eCKOro ne4€HVIS'l p8HHVIX CT8AVIW
MenKOKfleT04HOro paKa B C04eTaHllllll c aAblO-
B8HTHOlil XVIMVIOTepanVleW , 3aMeTHo nyYwe pe-
3YllbT8TOB O.QHVIMVI XlllMlllOnpen8p8T8Mlll.
Ha pa3HblX 3Tanax ne1.JeH1115I AO 80 % 6onb-
HblX HeMeJlKOKileT04HblM paKOM JlerKoro Hy>K,D,a-
IOTCS'I B neKapCTBeHHOM ne4eHVIVI : ,o,ns:i 6onbHblX
c ,D,111cceMV1HV1posaHHblM onyxoneBblM npo~eccoM
XlllMlllOTepan111s:i S1BJ15!€TC51 OCHOBHblM MeTO,D,OM
ne1.JeHV1S1, np111 MecTHopacnpocTpaHeHHblX cpop-
Max p8K8 nerKoro npoBO.QlllTcs:i npe.Qonep841.<10H-
 Has:! (HeOa,llblOBaHTHas:i) Tepamrn, Ha paHHll1X
craA11151X B ps:iAe cnyYaes L\enecoo6pa3HO npo-
BeAeH111e nocneonepaL\1110HHoll1 (aAbtOBaHTHoill)
Tepan111111 , a np111 Heonepa6enbHOM MeCTHopac-
npocrpaHeHHOM paKe nerKoro onr111ManbHo Ha-
3HaYeH111e COYeTaHHOill X111MVIOnyYesoi71 Tepan111111.
CospeMeHHble cxeMbl neYeH111s:i HeMenKo-
l<JleTOYHoro paKa nerKoro npeAycMaTp111sa10T
KOM6111HaL\111111 naKf1111TaKcena , reML\ll1Ta6111Ha , AO-
L\eTaKcena , nepeMeKce,Qa c L\ll1Cnnar111HOM (Kap-
6onnar111HoM) ; He yrparnna csoero 3HaYeHl!151
cxeMa EP (:non03111A + L\V1CnnaT111H).
HeoaAblOBaHTHas:i x111M111orepan111s:i np111Me-
Hs:iercs:i KaK 3neMeHT npeAonepaL\1110HHoi71 no,llro-
TOBKll1 6onbHblX c HeMenKOKneTOYHblM paKOM
nernoro np111 AOKa3aHHOM MeracrarnYecKoM no-
pa)KeH111111 M8,llll1aCTVIHanbHblX n111Mcpoy3noB - CTa-
A11151 lllb (Heo6xaA111Ma MeA111acrnHocKon111s:i 111n111
Bll1AeoropaKacKon1115!). HeoaAbtOBaHrnas:i x111M1110-
Tepan111s:i , comacHo AaHHblM MHoroY111cneHHblX
111ccneAOBaH111ill, ynyYwaer noKa3aTen111 6e3peL1111-
All1BHoi7l 111 06LL1ei7I Bbl~BaeMocrn y 6onbHblX c Ill
CTaA111ei7I .
V1ccneAOBaHll151 no 1113YYeHll1IO aAblOBaHTHOlli
x111M111orepan111111 cospeMeHHblMll1 npenaparaM111
nocne paAll1KanbHblX onepal.\111111 no noBOAY He-
MenKoKneTOYHoro paKa nerK111x noATBepA111n111,
YTO 8,D,blOB8HTHa51 Xll1Mll10Tepan11151 y 6onbHblX c
1-111 cTa,[\111elli HeMenKoKfleTOYHoro paKa nerKoro
AOCTOBepHO ynyYwaer 6e3p€L\111,D,111BHYIO 111 4-5-
neTHIOIO Bbl)Kll1BaeMOCTb 6onbHblX.
np111 M8CTHOpacnpOCTpaHeHHOM paKe ner-
KOro 111cnonb3Y€TC51 Xll1M1110-IlYYeBa51 repan11151 B
KOHKypeHTHOM pe)Kll1Me, Kor,o.a Xll1Mll10npenapa-
Tbl 111rpa10T ponb MO,D,111cp111Karopos nyYesoi71 pe-
aKL\111111 .
185
Pa3pa60TKa 111 BHeApeH111e HOBblX Knaccos
x111M111onpenaparos (raprernas:i repan111s:i) y)Ke B
He,D,aneKOM 6YAY!.L\€M no3BOnll1T nepeCMOTpeTb
Hawe OTHOWeH111e K aAblOBaHTHOlli Xll1Mll10Tepa-
n111111 pa3Illl1YHblX rncronornYecK111x sap111aHTOB
paKa nernoro.
cPomoOUHOMUlfeCl<OR mepanuR
<PomoOUHBMUL/eCKBR mepanuR - OTHOCll1-
TenbHO HOBbllli MeTOA neYeHll15l paHHll1X CTa,[\111111
L\€HTpanbHOro paKa KpynHblX 6poHxos - Tis, T1
(3K30Q:>111THblll1 pocr npOT51>K€HHOCTblO He 6onee
1 CM) . 5onbHOMy BBOAs:!T cporoceHCll16111Jlll13aTOp
(cpororeM , cpornceHc, paAaxnop111H) , 3areM c
noMO!.L\blO 6poHxocKona ocyLL1eCTBI15!10T 06ny-
YeH111e onyxon111 ny1.JaM111 na3epa onpeAeneHHai71
Afl111Hbl BOilHbl. HenocpeACTBeHHble pe3ynbTaTbl
neYeH1115I 3TlllM MeTOAOM xopow111e - perpecc
onyxon111 AOCrnraercs:i np111MepHo y 80-90 %
6onbHblX. BMecTe c TeM , aHan1113 OTAeneHHblX
pe3ynbTaTOB cpOTOA111HaMll1Y€CKOi71 repan111111 pa-
Ka nernoro He cronb YTeW111TeneH , y 30-50 %
6onbHblX pa3s111sa10TC5I pel.\111A111Bbl 3a6onesa-
H11151 , na3TOMY MeTO,D, MO>KeT 6b1Tb peKOM€H,QO-
BaH Ans:i Y3Koi71 Karerop111111 6onbHblX, 111Me10!.L\ll1X
Hll13Kll1e cpyHKL\1110HanbHble noKa3aTen111 , 6onb-
HblX c paHH111Mll1 cpopMaMll1 nepBll1lJHO-
MHO>KeCT88HHOi71 IlOKan1113aL1111ei7I paKa KpynHblX
6pOHXOB , a TaK>Ke np111 pel.\111,[\1118€ paKa 11111111 Me-
TaXpOHHOM paKe nernoro nocne npose,[\eHHoro
oneparnsHoro ne1.JeH1115! np111 H1113Kll1X cpyHKL\1110-
HanbHblX pe3epsax, He no3som110!J..\ll1X Bbinon-
Hll1Tb noBTOPHYIO onepal.\111IO.
 3AI>OJIEBAHIDI Illfll(EBOM
(AXAJIA3lHI KAPJUIH, O)KOrH, PYJ>D;OBbIE CTPHKTYPhl Illlll(EBO,l(A,
PAK IIHIIJ,EBO)I;A)
B nocne,n,H111e ro,D,bl 3a6oneBaH111s:i n111LL1eBo- Mbl ,l\O Mecrn nepexot:1a n111LL1eBo,J:1a B )f(eny,lloK.
,n,a np111sneKat0T K ce6e nosb1weHHoe BH111MaH111e, ,Qn111Ha era 1-3 CM.
4TO CBSl3aHO c nos:iBneHllleM OT'-leTJ1111BOli1 TeH-
,l\eH~llllll K yBeJ11114eHllllO YaCTOTbl ,l\aHHOli1 narono-
fllllll . PacnpocTpaHeHHOCTb He O,lllllHaKoBa s pa3-
Jllll4Hb1X pernoHaX Mlllpa 111 3H84111TeJlbHO pa3Jllll-
48eTCs:l B pa3BlllTblX CTpaHax 3ana,[\a lll B CTpaHax
fOro-BocT04HOli1 A3111l-1 .
B CTPYKTYPe scex 3a6oneBaH111li1 n111LL1eBo,n,a
npeo6na,[\at0T:
• PaK n111LL1eBo,[\a - 60-80% (np1116n1113111-
Te!lbHO 3,5 % OT Bcex onyxonei/1 , 6 - 7-e Mecro)
• Axana3111s:i Kap,n,111111 3 - 20%
• Py6~0Bble CTp111KfYpb1 0,5%
• ,Q111seprnKYnb1 0,6%

Xupyp2uLfecKaR aHamoMuR nuw,esooa

n111LL1eBOA npe,n,crnBns:ieT co6oli1 nonyt0,
flll6KYIO , coe,[\111Hs:ll0Ll..\YIO fnOTKY c )f(eny,QKOM,
Mb1We4HYIO Tpy6KY, BblCTilaHHYIO BHYTPll1 CJlll13111-
CTOli1 o6on04KOi/1 111 OKpy)f(eHHYIO coe,D,111HlllTeJ1b-
HOlii TKaHblO (p111c. 52). n111lJ..leBO,l\ pacnonaraeTCS'I
no3a,n,111 Tpaxel-1 111 Knepe,n,111 OT nosBOHKOB. Y
B3pocnoro YenoseKa n111LL1eBOA HaY111HaeTcs:i s
MecTe nepexo,n,a rnoTK111 s n111LL1eBOA Ha yposHe
VI weli1Horo no3BOHKa, Ha rpaH111~e Hll1)f(Hero Kpas:i
nepcTHeB1t1,QHoro xps:il.lla 111 oKaH4111saercs:i s Mec-
Te nepexo,n,a B )f(eny,£:10K, Ha yposHe XI rpy,n,Horo
n03BOHKa .
,Qn111Ha ero B cpe,n,HeM 25-30 CM y MY}f{4111H 111
23-24 CM y )f(eHlJ..1111H Ill 3a8111ClllT OT ,D,m1Hbl Tena.
np111 Har1116aH111111 ronosbr snepe,n, 111 np111 s,n,oxe,
Kor,1:1a t:1111acpparMa noAH111Mae-rcs:i , .QillllHa n111LL1e-
so,n,a yMeHbwaercs:i , np111 sanpoK1t1.QblBaH111111 rono-
Bbl HasaA 111 so epeMs:i Bbl,D,oxa - ysem1Y111saeTcs:i.
B n111LL1eBo,Qe 111MeeTcs:i 4eTb1pe cy)f(eH111s:i: 1)
nepcmHeBUOHOBflOmOL/HOe (KpUKocpapUHB88flb-
HOe) cy>1<eHue , 2) aopmanbHoe cy>1<eHue Haxo-
,1:1111Tcs:i s Mecre nepece4eH1'1Sl c ,Qyroi/1 aoprb1, 3)
6poHxuanbHoe cy>1<eHue pacnono)f(eHo Ha MecTe
nepece1.1eH1'1Sl n111LL1eBo,Qa c nesb1M 6poHXOM 4)
OUacppaBM8flbHOe cy>KeHUe - cerMeHT n111lJ..leBO,Qa
a o6nacrn npoxm1<,D,eH111s:i Yepe3 ,n,111acpparManb-
Hoe KOilb~O.
6onbWlllHCTBo aeropoe ,n,ens:iT m1LL1eso,J:1 Ha
Tpl-1 OT,D,ena: 1) weiJHbliJ- OT Hlll)f(Hero Kpas:i nep-
CTHeBll1,QHOro xps:ill.la Ha yposHe VI weli1Horo no-
3BOHKa ,l\O s:ipeMHOli1 Bblpe3K1'1 Ha yposHe 1-11
rpy,QHblX no3BOHKOB. ,Qn1t1Ha ero 5-6 CM; 2) apyo-
HOU omoen - OT s:ipeMHOli1 Bblp83Kll1 ,l\O MecTa
npoxo}f{,lleH111s:i n111LL1eBo,J:1a 4epe3 n111LL1eBO,J:1Hoe
ornepcrne .Q111acpparMbl Ha yposHe X-XI rpy.QHblX
no3BOHKOB. ,Qn111Ha ero 15-18 CM ; 3) 6pJOWHOU
omoen - OT n111LL1eBO,J:1Horo ornepcT111s:i ,n,111acppar-
Puc. 52. XupypaullecKaR aHamoMUR nu11,1eaoaa. 1
- aopma,2- 6w:pypKa~uR mpaxeu.
n111LL1eBo,J:1 oKpy)f(eH cnoeM pb1xnoli1 coe.Q111-
H111TenbHoli1 TKaH111 , B KOTopoi/1 npOXO,l\SlT IllllMcpa-
Tll14eCK1'1e 111 KposeHOCHbte cocy,Qbl , o6a 611y)f(-
,n,at0LL1111X HepBa 111 seTBll1 c111MnaTw.iecKoli1 ~eno'-l­
Kll1 . 5naro.Qaps:i Han1111.1111t0 3TOro cnos:i o6ecne4111-
sat0Tcs:i nep111cranbrn1.1ecK111e .QB1t1>KeH111s:i n111LL1eBo-
.Qa. B CTeHKe nll1Ll..18BO,D,a pa3Illll48IOT Tplll cnos:i :
CI11113111CTYIO o6on04KY, no,QCI11113111CTbllii 111 Mb1We4-
Hblli1 cno111; cepo3Holi1 o6ono'-IKlll y n111LL1eBo,J:1a HeT,
3a 111cKnt01.1eH111eM ero a6,1:10M111HaJlbHoro OT.Qena.
KpoBOCHa6>KeH111e mt~eBOAa. n111LL1eBO.l\
Ha pa3HOM ypoBHe 111M88T pa3Jllll4Hble lllCT04HlllKll1
KpOBOCH86)f(eH111Sl. WeUHb/U omoen nony1.1aeT
KpOBb 1113 Tpex lllCT04Hll1KOB: 1) BeTBll1 OT Hlll}f{Hll1X
Ll..\111TOBlll,l\HblX apTep1111ii, 111.J:IYLLllllX no 6oKaM nlllll..18-
BO,Qa Ill npe,QCT8BilS'llOLl..\111X OCHOBHOlll lllCT04Hll1K
KpOBOCHa6}f{eH111s:i. (cnpaBa apTep111s:i 6onee Kpyn-
HaH) ; 2) TOHKll1e BeTBlll OT cpap111HreaflbHblX apre-
p1111i1, cnycKatOlJ..lllleCSl Ha 38,D,HIOIO noBepXHOCTb
n111LL1eBO,Qa Ill 3aKaH411188IOlJ..lllleCH Ha 60KOBblX no-
BepXHOCTS'IX n111LL1eBO,lla; 3) HenocTOS'IHHble BeTBll1
OT nO,QKJll0'-11114HblX apTeplllli1 (apTeplllll1 nt0wKa) .
lpyoHou omoen n111LL1eso.Qa Bb1we AYflll aoprb1
nony'-laeT KpOBb 38 C'-leT TepMlllHanbHblX BeTO'-leK
aprep1t1i/1 nt0wKa, a np111 111X OTCYTCTBll1111 - 3a C'-leT
Hlll}f{HlllX B8T04eK OT Hll1)f(Heli1 Ll..\111TOBll1,l\HOli1 apTe-
p111111 111 BOCXO,l\s:lll..lelii BeTBlll 6pOHX111anbHOli1 apre-

187
p111111 . KposocHa6>1<eH111e cpeAHerpyAHoro OTAena
n111L1"'eBOAa ocyu.iecTBn51eTC51 B OCHOBHOM 3a C4Eff
6poHx111a11bHblX apTep111tll. KposocHafo1<eH111e
omaena n111u.ieBOAa npOlllCXO,Ql/IT
6p!OWHOZO
rnasHblM o6pa3oM 3a cYeT 330¢aro¢yHAanbHb1x
BeTBetll, lllAYLl.llllX OT neso!A >t<enyAOYHOVI Ill nesoi/1
Ht11>t<HeA111a¢parManbHOll1 apTep111111. Me>t<AY apTe-
pt115'IMt11 n111u.ieBOA8 l/IMetoTC51 MHO>t<eCTB8HHble
aHaCTOM03bl: B BepxHeM ero OTAene - M8>t<AY
n111u.ieBOAHblMlll B8TB51Ml/I H"1>KHl/IX Ll.llllTOBlllAHblX Ill
6poHx111anbHblX apTep111ll1 , s cpep,HeVI ero Yacrn -
Me)K,[1y BeTBs:/Mlll 6poHXVlanbHblX VI co6cTBeHHO
n111L1.1eBOAHblX apTep111!11, B Hlll>KHeM OTAene - aHa-
CTOM03bl n111u.ieBO,QHblX apTep111!11 c BeTBS'IMlll ne-
80111 >t<eny,Qo4HOVI , a lllHOrAa cene3eH04HOll1 111
Ha,Qn0484HlllKOBOll1 apTep111el11.
OnoK 1113 seH n111u.ieso,o.a cosepwaeTc5'1 no
BeHaM, COOTBeTCTBYIOLl.llllM nlllTalOLl.llllM n111u.ieBOA
apTep1115!M.
JllitMcl>aTM'·leCKaff CMCTeMa nr.t111eBOAa o6-
pa3oBaHa ABYM51 rpynnaM111 n111McpaT111YecK111x co-
cy.QoB - OCHOBHOVI ceTVI B no,QCfllll31/1CTOM cnoe Ill
ceTlll B Mb1We4HOM cnoe, KOTOpa5'1 XOTb OTHOClll-
TenbHO Ill He3aBlllCl/IMa, HO 4aCT1114HO coep,lllH51eT-
C51 C nO,QCfllll31/1CTOJ/1 C8Tbl0. np111 3TOM nt11McpOOT-
TOK B npo,[\OflbHblX n111McpaT1114eCKlllX cocy,[\aX B
sepxH111x 2/3 n111u.ieso,Qa 111.QeT B HanpasneH111111
BBepx, a B Hlll>t<HeVI TpeTl/I n111L1.1eB0Aa - BHl/l3.
3TlllM o6b51CH518TC51 MeTacTa3111poBaH111e He TOnb-
KO s 6n111>1<ai:tw111e, Ho 111 s OT.QaneHHbre n111M¢arn-
yecK111e y3nb1.
"1HHepB3L\Mff nr.t111eBOAa npot11CXOAlllT B
OCHOBHOM 3a C48T 6ny>t<Aatou.i111x HepBOB, o6pa-
3YIOL1.1111X KpynHoneTnl/ICToe noBepXHOCTHOe
cnneTeH111e, a TaK>t<e my60K111e lllHTpaMypanbHble
cnneTeH1115'l - Me>KMblWeYHOe Ay3p6axoso 111 noA-
cn1113111cToe Me111ccHeposo.
AXAJ7A3 /II R KAP,D, /II /II
Axana3Mff KapAMM - OAHO 1113 Ha1116onee
pacnpocrpaHeHHblX HepsHo-MblW84HblX 3a6one-
saH111ll1 n111u.iesop,a . OcHOBHblMlll Knt11Ht114eCKlllMlll
npo5!BneHt115'IMlll ero 5'1Bn51toTC51 At11ccpar11151 111 pe-
rypr111Tau,111fl, 803HlllKal-OU4Vl8 BCne,D,CTBVle CTOHKOfO
HapyweH1115I pecpneKTopHoro oTKpblTVl51 Kap,0,111111
np111 moTaH111111, 1113MeHeHlll51 nep111cTallbTt11K111 111 oc-
na6neH1115I ToHyca cTeHKlll n111u.ieso,Qa. B oTeYecT-
seHHOVI 111 3apy6e>t<Hotll n111Teparype 3TO 3a6one-
saH111e lllMeeT 111 .Qpyr111e Ha3BaHlllfl - «axana311151
n111u.ieso,o,a», «Kap,o,111ocna3M», «111,o.111onaTt114ec1<oe
111n111 Kap,QlllOTOHlll4eCKOe pacw111peHllle».
4aCTOTa axana3111111 Kapp,111111 no OTHOWeHllllO K
APYrlllM 3a6onesaH111flM m1u.iesop,a Kone6neTcfl
OT 3 AO 20% . no c60pHblM CTaTlllCTlll4eCKl/IM
AaHHblM oTeYecrneHHblX 111 3apy6e>t<HblX x111pyp-
ros oHa JaH111MaeT sTopoe MecTo nocne paKa
n111u.ieso,o,a 111 KapAllllll. 3a6onesaH111e scTpeYaeTC51
npe111MyUJeCTBeHHo y m1u, Mono,Qoro 111 cpe,£1Hero
803pacTa (OT 20 AO 40 neT) , XOT51 B03MO>t<HO ero
npOS'IBileHllle Ill y AeTeVI. np111MepHO OAlllHaKOBO
188
YaCTO Bbl51BI15llOTC51 np1113HaK111 axana3111111 KapAllllll
y MY>K4111H Ill >KeHLl.llllH .
3muono2ufl u namo2eHe3
3rnonornH axana3111111 Kap,q111111 ,a.o Hacros:iu.ie- \
ro speMeHlll OKOHYaTeilbHO He Bbl5lCHeHa. BMe-
CTe c TeM, eCTb see OCHOBaHlllfl C4111TaTb, 4TO se-
AYLl.llllMlll 3T111onor111YecK111M111 c:PaKTopaM111 3a6one-
BaH1115I 51Bil5llOTC51: KOHCTlllTYUlllOHailbHble Hespa-
CTeHllllll c npeApacnono>KeHHOCTblO K B03HlllKHO-
BeHllllO noA Bill/l51HllleM sceB03MO>t<HblX BHeWHl/IX
pa3,D,pa)f{111Tene~ HesporeHHO~ .QlllCKoopp,111Hau,111111
MOTOplllKlll n111u.ieBOAa, B TOM 4111Cne Ill ero TepMlll-
HailbHOro OT,D,ena; pecpneKTOpHbl8 p,111ccpyHKUllllll
n111u.ieso,Qa c cpopM111posaH111eM axana3111111 KapAlll-
anbHOro ccp111HKTepa; spo>t<AeHHble aH0Man111111
pa3s111Tt115I HepsHoro annaparn 111 n111u.ieso,o.a ,
npeApacnonaratou.i111e K pa3BlllTllllO 6one3Hlll np111
onpe,D,eJleHHblX ycnoBVlflX; 1'1H¢e1<1.41AOHHOTOKCJ..1-
YeCKl/le 111n111 BlllPYCHbre nopa>t<eHlll.fl HepBHblX
cnneTeH111l4 n111u.ieso,Qa 111 Kap,Q111111.
naronorn'-lecKasi aHaToMMH. Ma1<pocKon111-
YecK111 ssepx OT nepexop,Horo OT.Qena )KenyAKa
onpep,en51eTc51 cy>t<eHHblli1 yYaCTOK n111u.ies0Aa Ha
nporn>1<eH111111 2-5 CM. 8b1we Hero n111u.iesop, pac-
w111peH, lllHOr,D,a ,D,O 16-18 CM B ,D,J..1aMeTpe.
no xapaKTepy pacw111peH1115I rpyp,Horo oTp,e-
na n111L1.1eBo.Qa pa3n1114atoT ,QBa Tl/Ina axana3111111.
np111 nepBOM rnne, BCTpe4atoll..\eMC51 B 60-70%
cny4aes, noM111Mo cToli1Koro HapyweH111fl npoxo-
AlllMOCTlll repM111HanbHOro cerMeHTa n111u.ieso,D,a
Ha6ntop,aeTc51 yMepeHHoe pacw111peH111e ero sbr-
wene>t<au.i111x oT,qenos. n111ll..\eBoA np111H111MaeT
u111n111H,Qp1114ect<yto 11111111 sepeTeHoo6pa3HYIO cpop~
My. Mb1WeYHb1ll1 cnoJ/1 pacw111peHHOll1 YaCTlll n111-
u.ies0Aa yMepeHHO r111nepTpocp111posaH , B cy>KeH-
Hoi/1 Yacrn ero OTMe4aeTc.fl Bbrpa:>KeHHaH rnnep-
Tpo¢111.fl. np111 nporpeCClllpOBaHllll/I naTOilOrlllYe-
CKOro npouecca s cn1113111cTol11 o6ono4Ke OT4eT-
n111sb1 npoHsneHlll51 33ocpar111Ta snnOTb AO ee
1113b513BneH111l11. B oKpy>Katoll..\lllX n111u.ieeo,o. TKaH51X
Bbl51BI15llOT Bbtpa>t<eHHblVI nep111330cparnT. np111
axana3111111 KapAllllll BToporo T111na Bbl51Bn51toT 3Ha-
4virenbHOe y,a.nviHeH111e 111 MewKOBlll,D,Hoe pacwvi-
peH111e m1w.eso,o,a c S-o6pa3HblM 111c1<p111sneH111eM
ero (p111c. 53). 0T4ern111so onpeAen51erc51 r111nep-
Tpocp111.51 4111pt<yn5lpHoro cno51 MblWL\ n111u.ies0Aa,
OTeKl/I no,£1cn1113111cToro cnoH. B 6onee no3AHlllX
CTaA11171X, KorAa pacw111peH111e n111u.ieso,o.a co4eTa-
eTc5l c YAI1111HeH111eM 111 1113r11160M, Mb1We4Hblll1 cnoi/1
n111u.ieso,1:1a aTpo¢111pyeTcfl, nporpecc111pyeT c1<ne-
po3 noAcn1113111cToro cno51 c pa3pacTaH111eM rpy-
6osonoKH111croi/1 coe,Q111H111TenbHOll1 TKaH111 .
Ocno>1<HeH1115I axana3111111 Kapp,111111 HOC51T
06b14HO BTOp1114Hbli/1 xapaKTep. K HlllM OTHOCSH
nporpecc111pyiou.i111ll1 33ocpar111T, pa3pbrBbl nlllll..\e-
ao,o.a c pa3s111rneM MeA111acrnH111Ta, perypr111rn411151
c 3a6pocoM n1111.11eab1X Mace a rpa?<eo6poHx111-
anbHoe p,epeso. ,l],n111renbHb1~ 33ocpar111T npep,-
pacnonaraeT K pa3BlllTlllto paKa n111u.ieso,o.a.
 P1o1c. 53. PeHTreHorpaMMbJ rpy.QHOM
KJleTKM B np~MOM npoeK4MM c KOHTpaCTM•
poeaHMeM nMu.teBOJJ.a. npoceeT nMu.teBO,IJ.a
pacwi1peH, nMu.teeo.a. S-o6pa3HO 1113MeHeH.
K11accucfJu1<au,uR
B HacTmll.Llee speMS'l 1113secTeH PS1A 1<J1ac-
c111¢111Ka41111i1 axana3111111 Kapp,111111. B OCHOBY 60J1b-
WlllHCTBa 1113 HlllX nonmKeHbl KJllllHlllKO-
peHTf8HOJ10nA48CKlll8 111 Mop¢onorn4eCK111e np111-
3HaK111 , p,n111TenbHOCTb 3a6onesaH111S1 , np111coep,111-
HS1t01.LllllecH OCJ10>KH8HlllS1.
3Ha4111T8J1bH8S1 4aCTb lllCCJ18AOBaTenelil
np111p,ep>K111saeTCS1 CTaAllllilHolil Knacc111¢111Ka4111111
axana3111111 Kapp,111111, npep,nonaraH nepeXOA 3a60-
nesaH111S1 np111 nporpecc111posaH111111 naTonorn4e-
cKoro npo4ecca 1113 Ha4anbHblX CTaA111lil B nocne-
AYIOLl..lllle . B npaKT1114ecKolil pa6oTe Ha1116onee
4acTo 111cnonb3yeTcs:i Knacc111¢111Ka4111s:i T.A. Cy-
eoposo'1 (1959) c p,ononHeH111eM A.fl. fpe6He-
ea (1969), comacHo KOTopolil Bb1p,ens:it0T p,sa
rnna axana3111111 Kapp,111111 , 111 Tplll cTap,111111 Te4eHlllS1
3a6onesaH111S1.
np1i1 nepaoM mune axana3lillil Hlll>KHliliil oTpe-
30K nllll.Ll8BOAa cy>KeH, OTMe4aeTCS1 O,D,HOBpe-
M8HHaS1 P,lllCTPOQJlllS1 Ill r111neprpo¢111S1 era l...11APKY-
J1S1pHblX MbtWe4HblX sonoKoH . 8b1wene>Kal.J..l111iil
oTp,en m11.J..lesop,a yMepeHHO pacw111peH , secb
opraH lilMeeT l...llllJ1111HAPIA4eCKYIO lllJ11A sepeTeHO-
o6pa3HYIO ¢op My.
np1;1 amopoM mune axana3111111 Hlil)f<HfAl(l or-
pe3oK n1111.J..leBop,a pe3Ko cy>KeH, Mb1W84Has:i o6o-
no4Ka era arpo¢1114Ha, 111MetoTCS1 npocnot(1Klil rpy-
6osonoKH111crolil coep,111H111TenbHOlil TKaH111. 8b1we-
ne>Kal.J..l111e 0Tp,enb1 nlill.Llesop,a pe3KO pacw111peHbt ,
cTeHKa opraHa 4al.J..le scero yMepeHHO yronl.LleHa
3a c4eT r111neprpo¢111111 MbtWe4HOro cnos:i , a s He-
KOTOpbtX cny4aS1x arpo¢1114Ha.
I cTaAHR - cy6KoMneHcau,uu ( nep111op,b1
p,111c¢ar111111 pep,Klll Ill He HapywatoT caM04YBCTBlllS1
Ill 061.J..lero COCTOs:!Hllls:I 60J1bHOro);
II CTaAM~ - oeKOMneHcau,uu (Ha6niop,aeTCS1
3Ha4JATenbHaS1 3ap,ep>KKa n1111.LleBblX Mace B n111-
Ll..l8BO,D,e, HapywaeTcs:i n111TaH111e, yMeHbwaeTcs:i
Macca re11a 6onbHOro, Hepep,Ko Ha6nio,1:1aercS1
48CTlll4H8S1 Ill o6111JlbH8S'I perypr111ra4111S1 ; H81111141/1e
3Ha4111T8J1bHOf0 pacw111peHV1s:t nllll.LleBop,a Ill 48C-
rot(1 perypr111Ta4111111 yrpo>KaeT B03HlllKHOBeHllleM
ner04HblX OCJ10)1(H8Hlllt(1 ;
Ill CTaAIMI -pe3KOU OBKOMrTeHCBU,UU (pe3-
KO HapyweHO n111TaH111e, KaXeKClllH, ,D,111CTpOQJVl4e-
CKllle IA3MeHeHlllS1 opraHoB, ,1:1er111p,para4111S1, aBIA-
TaMlllH03) .
K11UHUKQ
0CHOBY KJll/IHlll48CKOt(1 KapTlllHbl COCTaBnHeT
TpMaAa CMMnTOMOB, COCTOS'll.Lll/IX 1113 ouccfJaaUU,
peaypaumau,uu 111 6onu.
189
HaL16onee paHHlllM 111 xapaKTepHbJM ClllM-
nroMOM S1BJlS1eTC51 auccpaauf/. B 60J1bWlllHCTBe
cny4aes oHa pa30111saercs:1 nocTeneHHO. ,Q111ccpa-
r1114ec1<111e S1BJ18HlllS1 , BHa4ane HeOT48TJ1111Bble Ill
pe,D,Kllle, c Te48Hl/18M BpeMeHlll B03HVIK8IOT see
481.J..le Ill CT8HOBSHCS1 S'lCHee , noKa He np111HlllM8IOT
rnn1114HYto ,1:1ns:i AaHHoro 3a6onesaH111s:1 ¢opMy.
np111MepHO y 30% 60J1bHblX ,[\lllCQJ8fl/IS1 nOs:IBJ151-
8TCS1 cpeAlll «nonHoro 3AOPOBbS1» cpa3y, BHe-
3anHo 111 B AanbHet(lweM coxpaHs:ier ry )Ke 111HreH-
c11aHocTb 111111 nocreneHHO nporpecc11pyer. B
ra1<11x cny4as:ix oHa o6bl4HO B03HlllKaeT nocne
c111nbHb1x nepe>K111saH111iil 111n111 so speM51 nocnew-
Holil eAbl 111 npomaTb1saH111111 KpynHoro, nnoxo
pa3>KesaHHoro KYCKa nlllll.\111 . C :noro MOMeHTa
HapyweHl/151 moTaHlll51 OTMe4alOTCS1 np111 Ka>KAOM
np111eMe n1111.Lllll , 6onbHb1e nocreneHHO Ha4111Ha10T
TepS1Tb B Macce, np111coep,111HS1toTC5I 111 ,o,pyrne
ClllMnTOMbl 3a6onesaH111s:i. BMecTe c TeM np111
TLl..laTenbHOM paccnpoce na4111eHTOB Hepe,D,KO
y.1:1aeTcs:1 nop,MeTlllTb B npownoM f?BneH111s:1 p,wc-
KOM<fJopra, CB513aHHble c moTaHllleM, KOTOpble
npe>KAe 6b1n111 cna6o Bb1pa>KeHb1 111 6011bHb1e He
np111,D,asan111 lllM 6onbworo 3Ha4eHlllS1. Pa3nlll4Hbte
He6naronp1115ITHb1e cpaKTopb1 (cnewKa, 3arnarb1-
saH111e nnoxo nepe>KesaHHblX KYCKOB nlllll.\111 , n111-
Tbe XOJ10,[\HOlll BO,D,bl Ill ,D,p.) Be,D,yT K 81.Lle 60J1b-
LUeMy yc111neHV110 paccrpot(lcrs moraHlllS'l . ,Q111c-
¢ar11151 TaK>Ke yc111n111BaeTCs:I BCJle,D,CTBllle OTp11114a-
TeJlbHblX 3MOL.tlllli1 , BOJlHeHllllll, nepe>K111BaH111iil , 1113-
IllllWHero BHfllMaHfll51 oKpy>KalOLl.\lllX. Hanporns
np111eM nony>K111,D,Kolll n1t11.Lllll , 3an111saH111e ee rennoi.1
so,[lolil o6ner4aer npo,D,B1t1>KeH111e nllll.Ll8BbtX Mace
1113 nllll.J..l8BO,D,a B >Keny,D,OK.
Y 6onbw111Hcrna 6onbHblX c axana3111elli
Kapp,111111 Ha611iop,aercS1 peaypaumau,uR. B cny4a-
S1X He6onbworo pacw111peH111S1 n1111.LleBop,a, o6bl4-
HO BHa4ane 3a6oneBaHVls:!, OHa nOS1BJ1s:l8TCH BO
speMS'l e,[lbl 11111111 scKope nocne Hee. n1111.LleBb1e
MaCCbl Henp01113BOJ1bHO nocrynatoT B noflOCTb
pra 11111111 Bb1p,enS1t0TCS1 HaPY>KY· B no3P,HlllX cra-
,D,111s:ix 3a6onesaH111s:t, KOr,D,a m'ILl..leBo,D, pacw111peH 1.1
BMel.LlaeT AO 2 JllllTPOB >KlllP,KOCTlll, perypr111ra4111s:i
6btsaeT 6011ee pep,Kot(l , HO 061i1nbHot(1 . 04eHb
4aCTO y 60J1bHblX co BTOpblM TlllnOM axana3111111
Kapp,V1111 perypr111ra411151 Ha611iop,aeTcs:1 so speMs:i
cHa. B nerKolll ¢opMe oHa npos:isns:ieTcs:i s s111p,e
BblTeKaHlllS'l cop,ep>K111Moro n1111.LleBop,a Ha nop,yw-
KY - «CHMnToM MOKpol'.1 nOAYWKM».
4yscrso i'JaaneHufl u 60.flu 3a apyouHoiJ
TaK>Ke S1BJ1s:llOTCH 4aCTblMlll Cl/IMnTOMaMlll axana-
3111111 Kapp,111111. OH111 06yc11os11eHbl , rnaBHblM o6pa-
30M , paCTS1>K8HllleM n1111.LleBo,D,a, ero HepBHblX
cnneTeH1..1!11, c,D,asneH111eM HepBHblX CTPYKTYP
cpep,ocTeHlllS'l 111 ycyry611S110TCS1 np1t1coep,111HS110-
Ll..llllMcs:i 33ocparocna3MOM. B paHH1111(1 nep1110A 3a-
6011esaH111S1 6011111 Hoc.sn cnacr1114ecK1111(1 xapaKTep.
y 60JlbWlllHCTBa na4111eHT08 6on111 38 rpy,D,lllHOH
B03H111Ka10r np111 nepeno11HeH111111 n1111.LleBop,a 111 ycr-
paHS110Tcs:i nocne cpbtrnsaHltffl 11111'1 npoxo}l{AeHltf~
n111LI..(111 s )f(eny,lloK. Hepe,llKO OHlll B03Ht-tKaKJT H0- n111LJ..(eso,D,a . l<poMe Toro, nocKOJlbf<Y B no,Qas-
4bl0 , 6e3 Henocpe,D,CTB8HHOll1 nplll411lHbl , o6bl4HO n5!10LUeM 60JlbUJlllHCTBe cnyyaeB 3JlOKa4eCTBeH-
OYeHb ClllJlbHble, 111ppa,[lllllllPYIOT B cn111Hy, WelO, Hble onyxom1 aTol/1 n0Kan1113a14111111 51Bf15llOTC51 Kap-
48JllOCTlt1 . no Mepe pacw111peHlll5l nlllll.1880,D,a lllH- AL'1033ocparanbHblML'1 , TO peHrreHonor111YeCKL1 AO-
TeHClllBHOCTb 6oneil1 yMeHbwaeTC51, n051BJ15llOTC51 nonH111TeflbHO Bbl51BJ15llOTC51 conyrcTBYIOLl..lllle lil3-
TYnbre , pacn111pa10LL1llle 6oneBble OLLIYLL1eH1t15l 3a MeHeHlll5! Ill B npoKCL'1M8flbHOM OT,D,ene )f{eny,o,Ka .
rpy,D,lllHOl/1 . np111 py6L(08b/X cmeH03aX, pa3BlllB810Ll..llllXC51
no4TVI y BCeX 60JlbHblX C Te48Hlll8M speMe- Ha no4se 513Bbl , 33ocpar111Ta , XlllMlll4ecKoro o>Kora ,
Hlll oTMe4aeTc51 6onee 111n111 MeHee 3Ha4111TeJlbHoe npoT51)KeHHocTb c~eHHoro y4acTKa HaMHoro
noxy,D,aH111e. nporpecc111poeaHvie axana3111111 Kap- 6onbwe , YeM np111 axana3111111 , a pacw111peH111e 111
,D,111111 , KaK npaBll1JlO , np111BO,D,lt1T K pa3B111Tlt110 330cpa- oco6eHHO y,D,n1t1HeH111e opraHa He Ha6n10,D,a10TC5l.
rnra c lll3b~3BneHl!leM n1t1LL1eso..Qa , neroYHbJM oc- 33ocparoc1<0n1115! (p111c. 54) B coMHlllTenbHb!X
JlO)f{HeHlll51M , paKoBoMy nepepo>1<,LJ,eH1t110 . Pa3Blll- cny4a51x no3BOJ151eT yTOYHlllTb A1t1arH03 111n111 npo-
TlllKJ 330cpar111Ta , B pa3JllllYHOlli CTeneHlll Bblpa- aeCTM ,a111cpcpepeHL1lil8JlbHYIO ,£11t1arHOCTltlKY c .Qpy-
>KeHHOro, cnoco6CTBYIOT ,lJ,JllllTeJlbHblil1 3aCTOl/1 B rlllMlll KnlllHL'14ecKL1 CXO)f{lllMlll 3a6onesaH1t15!M111.
n111LL1eBO,D,e n1t1LL1eBblX Mace , Cfll/13111, B03HlllKHOBe- Cn1113111cry10 o6ono4KY nyYwe ocMaTp111saTb no-
Hllle B Hlt1X rHlllJlOCTHblX npOL..\8CCOB c nocne,D,yl0- cne npe,D,sap111TenbHoro npoMblBaHlllfl n1t1i.ueso,D,a
llllt1M 111H¢1t1L11t1posaH111eM cTeHKlll opraHa 111 Kpoeo- 1..1epe3 30H,D,. Cn1113111cTa5l o6onOYKa o6bl4HO 1t1Me-
TeYeHl!feM . nep!.10,llflfY8Cl<Oe ,llJlflfT8JlbHOe 3aTeKa- eT Bb1pa)KeHHb1e naTonorn1..1ecKL1e 1113MeHeHlll51 .
Hllle B ,D,b1xaTenbHb1e nyr111 co,D,ep>K111Moro n1t1LL1e- 0Ha r111nepeM111posaHa , oTe4Ha , yroni.ueHa , nerKo
BO,L1a np111 perypr1t1Ta4111111 cnoco6crnyeT cpopM111- KpOBOTOYV!T npw ,D,OTparnaaHWM, MeCTaMW Ha-
posaH111t0 xpoH1114ecKoro 6p0Hx111ra, acn111pal..\V10H- 6nl0,D,8IOTC71 lll3b513BneHli151. Kap,D,11151 nnoTHO 3a-
Hoi11 nHeBMOHV1111 , a6cL1ecca nernoro , 6poHxoaK- Kpb1Ta. 0T4eTnlllBO Blll,D,Hbl neplllCT8flbTlll4eCKllle
Ta3oB. coKpai.ueH1115l nL'11.L1eBo,D,a. B cny1..1a51x T51)f{eJ1blX
socnan111TenbHb1x 1113MeHeH111VI B Hlll>KHel/1 Tper111
/J.U02HOCmUKO U oucjxpepeHU,UOflbHblU n111U-1eBo,D,a ,D,f151 111cKnt04eHL151 Mar1111rH1113aL11t1lll He-
OU02H03 06xo,D,111Ma 6111onc11151 TKaHeil1.

A111arHOCTV1Ka axana3vi111 Kap,D,lllVI noM111Mo

P1.1c. 54. 3HAOCKOm'11.1ecKaH Kapn1Ha
aHaMHe3a 111 KnlllH1t1YecK111x npo5!BneH11111i 3a6one-
axana31.11.1 K3PAl.1lil. A - SIJBeHHblM ,qecpeKT
BaH1115l, OCHOBblBaeTC51 Ha ,D,aHHblX nyl/eeoao uc-
Cfllil31i1CTOM, B - KapntHa 33ocparnTa.
cneooeaHUR, 330cfJaaOCKOnUU Ill 330cfJBZOM8HO-
MempUU, cjJapMaKOfl08LJl1BCKUX npo6. 33ocparoMaHOMeTp'151 lllMeeT 60JlbWYIO ,Qfll-,
Ha1116onee 111HcpopMaTV1BHblM 51Bn51eTC51 arHOCTlll4eCKYIO 4eHHOCTb B ,D,L18fHOCTlllKe axana-
peHmaeHonoauLJecKuiJ Memoo, no3aom1t0LL1Mi1 3111111 K8PA!o1111 . Ha1o160.nee nocT051HHblM 1113MeHeH1o1-
T04HO ycTaHOBlllTb ,D,lllarH03 y no,D,8BJ15110UJ,ero eM K1t1HeT111K111 n1111.L1eBo,o,a 51Bf151eTc51 0TcyrcTs111e
6onbWlllHCTBa 60flbHblX c axana3111ei11 K8PA11111l . pecpneKTopHoro paccna6neHlll51 Kap,D,111anbHoro
OcHOBHblMlll cL1MnT0MaMV1 ,D,aHHoro 3a6onesa- CQllllHKTepa np111 rnOTaHL-1111 . 0TYeTJ1111Bbl Ill Hapy-
Hlt151, KOTOpble 06Hapy)f{1t1Bat0TC5! np111 peHTreHO- weHlll51 nep1.1cTanbrnK111 , oco6eHHo s cpe,D,Hel/1 111
KOHTpaCTHOM 111ccne,D,OB8Hllllll n1t1LL1eBO,D,a, 51BJ151- Hlll)f{Helii rpern n111LL1eso,D,a . np111 axana3111111 Kap,D,111111
IOTC51 cy>1<eHue nuw,eeooHo->1<enyoollHOao nepe- nepsoro T111na 3Tlll HapyweH1115l npoTeKalOT s Blll,D,e
xooa , 3ampyoHeHue npoxoJKoeHuR KoHmpacm- 33ocfJaaocna3Ma; np£1 sropoM rnne - c npeo6-
Hoao ee~ecmea s 3TOll1 06nacT111 111 oucpcpy3Hoe na,D,aH111eM npoapeccupy10~ea aunomoHUU u
pacwupeHue npoKcuManhHbJX omoenoe n111111e- cnacmul/ecKou aunoKuHe3uu.
BO,D,a. KoHKpeTHble npo51sneHlll51 3TlllX 1t13MeHeH111il1 B u,enoM cne,D,yeT nO,D,4epKHYTb, 4TO ,D,1.1ar-
3as111c5IT OT rnna axana3111111 Kap,D,111111 111 cTa,D,111111 na- H03 axana311llll Kap,!:\"1111 scerAa ,qon>KeH ocHOBbl-
Tonor1114ecKoro npo4ecca . BaTbC51 Ha pe3ynbTaTax KOMnnet<cHoro 06cne,D,o-
,Q111<p<IJepeH~1r1poeaTb axana3111t0 Kap,D,111111 saH1115l 6onbHoro , no3son5lt01.L1ero o6ecnel!lllTb
Heo6XO,D,lllMO c paKOM n1t1LL1eBO,D,HO- paHHt0t0 ,D,lllarHocTVIKy 3a6onesaHfll5l 111 ceoeepe-
)Keny,D,04HOro nepexo,D,a 111 py6L(o8b/M cmeHo- MeHHo nposecrn a,D,eKBaTHoe ne1..1eH111e .
30M 3Tolii 06nacT111 .

B nonb3Y axana3111111 cs111,D,eTenbCTBYt0T Ha-

!TUl./Ue CK!TBOOK CfTU3UCmoD 060!10'-IKU 6 30He KoHcepsanrnHoe ne1..1eH111e axana3111111 Kap-
cy>KeHLJR, omcymcmeue aa3oeoao ny3b1pri >1<e- A1t11t1, 111Me10LL1ee o6bi4HO speMeHHbll/1 acpcpeKT ,
ny0Ka, MHoaonemHuu aHaMHe3 3a6onesaHl'15! . B np1t1MeH5!10T s Ha4anbHbrX CTa,Qlll5'1X 3a6onesa-
orn11141t1e OT :noro An51 onyxonesoro nopa)f{eH1115l
H1t15l. 0Ho s1<11101..1aeT ,D,llleTY (Kawm-1eo6pa3Ha51 ,
xapaKTepHbl 8ClllMMeTplll4HOCTb cy>KeHlll51 , He- XJ.llMJ.llYeCKJ.ll Ll.la,[.151Ll.la51 n1t1LI..(a c ,[.IOCTaTOYHbJM KO-
poBHOCTb KOHTYPOB aToro y1..1acTKa 111 0TcyrcTs111e n1t11..1ecrnoM 6enKos 111 B1t1TaM1t1HoB) , MeCTHble
s HeM o6bl4Horo penbecpa cn1113111cToi11 06ono1..1Kvi, aHecTeTV1K1t1 , cna 3 MonlllTlllKlll, ce,D,aTlllBHble npe-
yMepeHHoe npecmeHomu11ecKoe pacwupeHue napaTbl.
190
 B HacTos:iu.iee speMsi Ans:i ne4eH111s:i axana-
3vH1 K8PAli1111 np111MeH5llOT ABa OCHOBHblX MeTOAa -
Kapouoounamau,u10 111 onepamueHoe nec.reHue.
Kapouoou11ama4ua
no MHeHll110 6onbWlt1HCTBa XlllpyproB, 3aHlll-
M810li.\lllXCS'I :nol/1 npo6neMoll1, KaPAlllOA111naTal.\lll10
cneAyer np111MeH5ITb B I 111 so II CT8AVIS'IX 3a6one-
saH111s:i. npoTlllBOnOKa3aHllleM K K8PAlllOA1t1naTa-
L\VIVI 51Bn5llOTC51: Ts:l)f(8Jlaf! cepAe4Ha51 HeAOCTa-
T04HOCTb, xpOHll148CKa51 111WeMll148CKa51 6one3Hb
CePAL\a c 4aCTblM111 npV1crynaM111 CTeHOKapAVllll,
sap111K03Hoe pacw111peH111e seH m11u.ie00Aa, Bb1pa-
)f(eHHb1!11 33ocpar1t1T, CTeHo3 np1t1BpaTHl/IKa, n03,D,-
HMe cpOKlll 6epeMeHHOCTM, 3a6onesaHM51, co-
npoBo>K,QalOU,\Vlecs:i naTonornei:.1 reMocrn3a .
KapAVIDA1t1naraL1111to cneAyer npoBOAVITb B
CTal.\lllOHapHblX ycnos111s:ix Ha cpoHe npe,o,wecT-
BYIOutei:.1 npeMe,L\eKaL\111111 . npoBO,L\s:IT aHeCT83111IO
rnorK111 . nocne HacrynneH111s:1 aHecre3111111 noA
peHrreHOI10rlt14eCKlllM 111n111 3HAOCKOnlll4eCKlllM
KOHTponeM B n111u.iesoA ycrnHasn111satoT Kap,Q1110-
A1t1naTarop. HarneraH111eM B03Ayxa npo1113so,o,s:ir
pacw1t1peH111e K8PA111111 B Te4€Hllle 10-20 MlllHYf.
L.Jepe3 2-4 AHs:i npoBOAS'IT nosropHble MaH111nyn5l-
L\llllll. 06u.iee 4111cno 111x cocrasns:ier or 2 AO 7. B
MOMeHT KaPAlllOAlllilara4111111 60ilbHble o6bl4HO
ou.iyu.iataT 6onee 111n111 MeHee c111nbHyto 6onb 3a
fPYAVIHOl/1, KOTopas:i nocne OKOH48Hlll51 npo1.1eAy-
pbl npOXOAVIT caMOCTOS'ITenbHO (p111c. 55).
PMC. 55. 6annOHHas:t AMJls:tTa'-'Ms:t.
Ha1116onee T51)f(€Ilb1Mlll ocnO)f(HeHll151Mlll Kap-
AllfOAVlnarnL..1111111 s:isns:itoTcs:i nepcpopal.\11151 111 pa3-
pblB nlllU,\eBOAa , KpOBOTe4eHll1e 1113 opraHa. no-
A 5
Puc. 56. 33o<f>aaoKapouoMuomoMuR npu axana3uu nuuiesooa. A - pacce'leHue MbtWe'lHoao cnoR cmeHKU
nuuieeooa. B - pacce1.1eHue ~upKyn.RpHblX Mb1we1.1HblX eonoKoH cmeHKu nuuieeooa.
191
3TOMY TaK Heo6XOAlllMO BHl/IMaTeilbHOe Ha6nto-
AeH111e 3a 6onbHblMli1 B nocneAytou.i111e cyrK111.
Xupy2uLteCKoe 11eYeHue
X111pypr1114ecKoe ne4eH111e axana3111111 Kap,[\111111
B 3Ha41/1TeilbHO~ creneHlll 51Bn51eTC51 CVIMnTOMa-
Tlll4eCKlllM, ycTpaHs:ilOU,\lllM rnaBHoe cTpaAaH111e -
HenpoXOAVIMOCTb n111U,\€BO,[\HO)f(eilyA04HOro ne-
peXOAa. MHorne 1113 npe,o,no)f(eHHblX paHee one-
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L\llli.1. np111 O)l{Orax I CTeneHll1 AecpeKTbl B 3n111Te- MOM 8AK111X B8l1.18CTB .
11111a11bHOM cnoe 3a>1<111sat0T 6e3 06pa3osaH1115I
rpaHyl151L\111Ci, 111 npo111cxoA111T nonHa51 pereHepa- Knaccucj:Ju1<au,uR
L.\11151 3n111Te1111151 . ,D,1151 o>Koros II 111 Ill cTeneH111 soc- B 3as111c111MocT111 OT rny6111Hb1 nopa>KeH1115I
CTaHosneH111e L\8110CTHOCTlll TKaHei.1 npoXOAlllT TKaHei.1 O>KOflll nL<1l1.18BOAa np1!1H51TO nOAP83A8-
Yepe3 06pa3osaH111e rpaHyl15IL\lllCi. LllHTeHClllB- Jlf!Tb Ha Tplll CTeneHJll:
HOCTb npOL\8CCa o6pa3oBaHl/l51 rpaHyl151L\lllCi Ill I cTeneHb - nospe>K.LJ,at0TC5l nosepxHOCTHble
KaYeCTBO pereHepal.\111111 yTpaYeHHblX TKaHei.1 3a- CJlOJll 3nJllT811111fl Ha 60l1bW8M JllJ1111 M8HbW8M yYa-
BlllCll1T OT peaKTlllBHblX CBOCiCTB opraHlll3Ma, a CTKe nlllll.\8BOAa ;
rnK>Ke OT rny6111Hbl 111 nnOll.\8Alll 0>1<ora . Heso3- II crnneHb - xapaKTepHbl 6onee rny601<111e
MO>KHOCTb n011HOL\8HHOro n111TaHlll5! , cenTlll48CKOe 1113MeHeHll151 B BlllAe HeKp030B, KOTOpble M8CT8Mlll
COCT051Hll18, 111HTOKClllKal.\11151 CHll1>KalOT peaKTlllB- pacnpocTpaHs:tlOTCfl Ha BCIO r11y6111Hy CJ11113111CTOCi
HOCTb opraHlll3Ma Ill 3aM8An5HOT pa3BlllTlll8 rpa- 06011041<111 n111ll.\eBOAa;
HY115IL\llli.1, KpOMe Toro, OHi/i YaCTO pa3pywa10TC5I Ill CTeneHb O>Kora - HeKp03 38XB8TblBaeT
np111 np111eMe nllll.1..1111 111 6y>t<111posaH111111 . B pe3ynbTa- CJ11113111CTYIO 060J104t<y, nOACJ111131ACTbli.1 IA MblW84-
Te npOL\8CCbl 3nll1T8111113al.\111111 OTCTalOT OT pa3Blll- Hbli.1 c1101.1 n1All.\eB0Aa. HepeAKO OH pacnpocTpa-
Tl/151 111 C03pesaHlll51 C08AlllHlllT811bHOCi TKaHll1. HfleTCfl Ha napa33ocpareanbHy10 KJ1eTYaTt<y,
nstTaSI CT3AMR - py6L1eBaH111e - 3TO 6onee nnespy, JllHOrAa Ha nep1111<apA l.'1 3aAHIOIO CTeHKy
n03AH111Ci 3Tan pa3Bll1Tll151 Jll C03peBaHJll51 C06AJllHJll- Tpaxe111 .
T8J1bHOCi TKaHlll. B pe3yJlbTaTe pa3Bll1Tlll51 py6L\O-
BOCi TKaHlll B03HJllK8IOT cy>KeHll1S'I nJlll1.18BOAa, CTe-

194
 KnuHu1<a u oua2Hocmu1<a
KrnAHlll4eCKasi KapTlllHa 0>1<oro8oii1 Tpa8Mbt
MO>KeT 6btTb necKoiJ, cpeoHeiJ 111 mR)f(enotJ cre-
neH111 . Te4eHl/le 3a6oneeaHlllSI Ill nporHo3 onpe-
AenS1toT ocnmKHeHIASI . O>K0f08. np1t1 ne2KOU
cmeneHu O)f{ora 111 nospe~eH1t11t1 TOnbKO no-
8epxHoCTHbtX cnoe8 3n1;1ren1t1S1 cocTDS!Hllle 6onb-
Horo ocTaeTCSI yp,08neT8op111renbHblM . Heno-
cpeJJ.CT8eHHO nocne 803JJ,e~CTBIASI X111MlllYeCKOro
8ell\eCT8a Ha6moJJ,aeTcs:i pect>neKTOpHaSI pso-
Ta , KaK npas111no, 6e3 np111Mec111 Kpos111. 3aTeM
6onbHbte )f{anytoTCH Ha 6onb s rnoTKe np1t1 npo-
rnarbt8aH1.1111 cntoHbt 111 nlllll\L1 , oco6eHHo ropS!Yeiil
111 cyxoiil Iii OTM848fOT OOBblWeHHYfO cam1ea-
L\llllO . lllHOr,Qa MO)f{eT 6biTb 4YBCTBO HeaoMoaa-
HUR, cy6cj:Je6punbHaR meMnepamypa B Te4eH1t1e
1-2 cyTOK. Mo)f{eT Ha6mo.QaTbCSI 6btcTpo npoxo-
aR~aR ocunnocmb aonoca 8Cne.QcT8111e O)f{ora
ropTaHlll . l/13-3a 6oneii1 np111 moraHllllll 6onbHbte a
nep8ble ,Qsoe cyroK orpaHlll4111sat0T ce6s:i s
npL1eMe n1t1ll\"1 111 )f{111,QKOCTll1 , 111HOrJJ,a OTMeYalOT
>1<a~y , onvirypvito 11 3a,_qep>1<ey cryna . 8 Kposvi
o6Hapy)f{111BaeTCSI He60J1bWOe noBbtWeH111e KOnlll-
4eCTBa neii1KOLlll1Tos. B Te4eHl/le 2-5 cyroK see
ClllMnTOMbi npoxo.1:1m, Ill HacrynaeT nonHoe Bbl-
3.QoposneH111e. np111 Q)f{Ore nlllll\eBOJJ,a cpeiJHe{J
cmeneHu TSl)f{eCTll1 K MeCTHblM npos:i9neHlllSlM
np1.1coeJJ,lllHHIOTCH 06ll\111e ClllMnTOMbt. Cpa3y no-
cne 803.QeiilcTBllls:i 06)f{111ratoL11ero Bel1\eCTBa Bo3-
HIAKaeT MHOroKpaTHaSl PBOTa, 4aCTO c npuMeCblO
Kpoeu.
Heo6xO,QIAMO 3H8Tb OCHOBHble np1113HaKll1
orpasneHt-ffl pa3nllll/Hb1Ml4 1<wcnoTaM111 w Ll(eno-
4aMIA. np111 OTpaeneHll11A cepHOiil KIACJlOTOiil Q)j(Qf
noKpbiT 4epHoii1 1An111 cepoiil KOpKoiil, np111 0Tpas-
neH1111i1 830THOL4 Kli1Cfi0TOl.4 - KOpKOl.4 )f(enroro
Ll88Ta , a xnopl.1CT080AOPOAHOii1 - 6enOBaToii1 .
nplll OTpasneHl/llll opraHll148CK111M111 Kli1CfiOT8Mll1
MeCTHbte 1113MeHeHlllSI 6bl88IOT Bbtpa)f{eHbl B 3Ha-
41ATeJ1bHO MeHbWeiil creneHIA , YeM np1.1 orpa8ne-
HvH1 HeopraHlll48CKlllMl/l KlllcnoTaMll1 , HO 38TO Ha
nep8bliil nnaH 8btcrynatoT npll13H8Kll1 UHmOKCUKa-
u,uu Ill aeMonu3a.
npl4 OTpasneHllllll l1\8fl04aM!4 MeCTHOe no-
8pe~eHllle 6b1Baer 6onee TSl>KenblM , 4eM .Qa)f{e
np111 orpasneHllllll HeopraHl/l4eCKlllMll1 K1AcnoTaM111 .
06pa3YIOl1\111iilCSl nplll 3TOM MSlfKllliil 111 pb1XJ1blii1
CTpyn nerno TpaBMIApyeTCSI IA HepeJJ,KO Bbl3bt8aeT
061AJ1bHble KPOBOTe4eHl/lSl , '-18l1\8 803HIAKalOT
nepcpopaL1111111 n111ll\eBOJJ,a.
Cpa3y nocne O)f{Ora Ha6moJJ,aercS1 Bbtpa-
.>KeHHaR aucct;awH. DOJ1bHblX 6ecnOKOl/lT >KB>Koa,
06111nbHas:i psora . B nep8ble cyr1<1A OTMe4aeTCSI
onuaypw:i , OTMel.faeTcsi 3aaep>1<Ka cmyna Ha 2-3
OHH, a 3areM Mo>KeT nos:is1t1TbC):I oeameo6pa3HbtiJ
cmyn. CnycT51 2-3 AHSI COCTOSlHll1e 6onbHblX He-
CKOfibKO yny4WaeTC51. np111 OTCyTCT81/llll OCJlQ)f{-
HeHll1ii1 (nHe8MOH111111 , n11esp111Ta , nep111<ap.Q111Ta 111
T.A.) COCTOs:!HIAe 6onbHblX K KOHLIY nep8oii1 He,Qe-
11111 3Ha41ATenbHO yny4waeTcs:i . YMeHbWatorcsi , a
3aTeM 111 lllC4838IOT 6on111 B rnOTKe , 38 rpy.Q111HOlli .
195
5onbHble HaY111Hat0T rnoTaTb cHa1..1ana )f{lllAf<YIO , a
3aTeM 111 rycryio m1l1\Y, yMeHbwaeTcs:i can1A8aL11As:i
w )1(8}1(,D,a , HOpMaJ1!43yeTCfl GOH. K 12-15-My AHIO
A111Ccparnsi no'-!Tlll nonHOCTblO npoxo.QIAT, rnoTa-
Hllle CTaH08111TCSI 6e36one3HeHHblM , HO coxpaHs:i-
eTCSI nnoxol.4 annenn, Moryr oTMeYaTbCSI Heno-
CTOSIHHble rynb1e 6on111 3a rpy.Q111Hot/i 111 a 3n111racT-
panbHOii1 06nacT111 , lllHOrAa YYBCT80 Tfl>KeCTlll ,
4all\e no HOYaM.
0THOCIATeJ1bHOe 6naronony4111e 06b51CHSleT-
C51 TeM , 4To npoxo.Q111r ocTpoe socnaneHIAe. EMy
Ha CMeHy nplllXOAlllT neplAOA pa3Bi11n!SI rpaHynsi-
L.lllliil IA py6L1eBaHll1SI , B pe3yJlbTaTe KOTOpblX pa3-
814888TCR py6upeoe cy>KeHue nuw.eeooa"' s He-
K0Topb1x cny'-laSlx n11111op111'-!ecKOro OTAena )f{e-
nyJJ,Ka. nep8blM np1A3H8KOM nporpeCClllPYIOl1\8fO
py6L10Boro cy)f{eHll151 nlllll\8BOJJ,a SIBnHeTCSI nOR8-
neHUe U MeoneHHOe HapacmaHue 8uccpaauu.
nosisneH111e YYBCTBa TSl>K8CTl/l B 3nlllraCTpanbHOl.4
o6nacrn nocne nplAeMa nllll1\lll , conpo8o~aio­
l1\eecsi p8oTOii1 , nplllHocs:ill.\eiil o6ner4eHllle , C811l-
,aeTenbcTsyer o B03MO)f{HOM pa3s1r1rne py6L!oso-
ro cy>t<eHll1Sl np1118paTHlllKa . B o,aHIAX cny'-lasix Ha-
pyweH111e npoxoJJ,lllMocrn nlllll.\eBO.Qa nporpecc111-
pyer 6btCTpO (AHii! liffllil He,D,enltl) , B ,D,pyrnx pacrs:r-
fll1888TCSI Ha MeCSILlbl.
CocTos:iH111s:i , yrpo)f{atoll\llle )f{ll13Hlll 6onbHoro
B nepBbte 48Cbl VI AHIA nocne Q)f{Ofa, COOT8eTCT-
BYIOT mRJKenoii cmeneHu Te4eH111si 3a6onesa-
HlllS1. 3To MO)f{eT 6b1Tb cne,QCTBIAeM mf1>1<eno20
WOKa , UHmOKCUKa~uu lllfilA 3H84111TenbHblX MeCT-
HblX nospe)f(.QeH111VI, conposo~al0l1\111Xc51 pa3Blll-
rneM rpo3HbJX ocno>1<HeHllll4. TH)f{ena.i:i lllHTOKCV1-
KaL1lllS1 111 WOK MOryT 6b1Tb nplll4111HOii1 CMeprn
6onbHblX y)f{e B nepsbre YaCbl Ill cyrKlll nocne
O)f{Ora . B rex cny4aSlx, 1<or.1:1a y.Qaerc51 cnpasli!Tb-
csi c WOKOM 111 yMeHbWl/lTb lllHTOKClllKaL.11!110, co-
CT051Hl'1e 60J1bHblX y11y4waeTCSI Ha cpaBH111Tenb-
HO KOPOTKllllA cpoK, a 38TeM BH08b yxyJJ,waeTCSI B
CBSl31'1 c np111coe,D,1AHl/lBWlllMIACS'I ocnO)f{HeHIASIMlll,
MHOfll1e lll3 KOTOpblX T8K)f{e MOryT nplllBeCTll1 K
CMepTIA , HeCMOTPSI Ha J1848Hll1e.
OcnoJKHeHUR
PaHH111e ocno>1<HeHlllS1 O)f{oros n111ll\e80.Qa
B03HIAKalOT nplA II 111 Ill CTeneHlll Q)f{Ora IA 8 20-
30% cnyYaes S!BfiSllOTCSI np1114111HOr.:1 CMeprn
6onbHblX. Ha1116onee 4acTo scTpe4atoTCSI cne-
AY10L11111e ocno)f{HeH11rn : nepcpopaL1111S1 nllllL\e8o,D,a
Ill )f{8fiYAKa , M8,QIA8CTll1Hll1T, nep1111<apJJ,lllT, nne8plllT,
o6pa30BaH111e nllll1\e80.QHo-6poHx1.1anbHoro 111n111
nllll.Ll8BO,[IHO-TpaxeanbHOro CBllll.Ll8, nHeBMOHl/lSl IA
a6cL1eccb1 ner1<oro, OTeK nerKlllX, acqm1<c111s:i.
/lel..feHue
ne48Hllle nOCTpaJJ,38Wero 8 OCTpOt/i CTaJJ,ltll.1
O)f{Ora n1AL11eBo,Qa 3a81/lClllT OT C80lACTB Bel1\eCTBa ,
Bbl38a8wero O)f{Of, a Taf{)f(e OT BpeMeHl.1 , KOTO-
poe npowno c MOMeHTa Hec4acrns:i. EcnlA spe-
MeHIA AO OKa3aHll151 nep80Vt MeAllll.!111HCKOV! noMO-
ll\111 npowno HeMHoro, TO ace .QOfi)f{HO 6btTb Ha-
npasneHO Ha He0mp8J1U3BLl,UIO L1 yoaneHUe eo-
KOBO selU,ecmsa U3 nonocmu pma, anomKu, nu-
lU,esooa , >KenyaKa.
nocne npoMblBaHL151 mmieso.Qa 1-1 .>1<eny,QKa
6onbHOMY A810T BblnL1Tb 300-500 Mn MOnOKa.
06bl4HO nocne o.>1<ora y 6onbHoro noML1MO 60-
nesoro CL1H.QpoMa sb1pa.>1<eHb1 1-1cnyr 1-1 so36y.>1<-
AeH1-1e, noaToMy s nepsb1e cyTKL1 1...1enecoo6pa3HO
H83H84€Hlt1e o6e360flU8810lU,UX 1-1 ceoamU8HblX
cpeocmB . nocne OKa3aHL1S'I HeOTJlQ)KHOJA Me.QL1-
L.IL1HCKOJA noMOli.\L1 nocTpa.Qasw1-1Vi AOn.>1<eH 6b1Tb
cpollHO rocn1-1Tan1-131-1posaH . AanbHeVlwee ne4e-
H11Je npoBOAS'IT 8 38BL1CL1MOCT!.'1 OT 06li.\ero co-
CTOS'IHL1s:! 6onbHoro 1-1 Ts:t)l{eCTL1 o>Kora. OcHOBHoe
BHL1MaH1-1e AOn>KHO YAeJJSHbC51 npeAynpe.>KAeHL1to
L1 6opb6e c WOKOM, a TalOl<e .Q€3L1HTOKCL1Kal\L1L1
opraHL13Ma . Ecn1-1 6onbHOMY yrpo.>1<aeT ac¢1-1Kc1-1s:1
scne.QCTBllle nopa.>1<eHlll5! Ha,o.ropTaHHlllKa 1-1 sepx-
H11X ,llblXaTeJlbHblX nyTei'.1, Heo6XO.QWMO cpOl.!HO
HaJJO)l{lllTb TpaxeocroMy 1-1 nposecrn nasa.>1< Abl-
xaTenbHblX nyTeJA. n1-1TaHL1e 60JlbHOrO B nepBble
AHL1 ocyli.\ecTBmleTc51 napeHrnpanbHo 1-1n111 3HTe-
panbHblM nyrnM Yepe3 Ha3oracTp8JJbHblVI 30H.Q.
CosepweHHO Heo6xo,q1-1Mo Ha3H848Tb s
6onbWL1X ,o,03ax 8Hrn61-1orn1<111 w1-1p0Koro cneKTpa
AeVicTBL15l. B p51Ae cne41-1an1-131-1posaHHblX OTAe-
neHL1VI nposo.Qsn paHHee (npocjJunaKmul/ecKoe)
6y>KuposaHue nulU,esooa. Ero Ha4L1HatoT nocne
CTL1XaHl1s:! OCTpblX socnamffenbHblX 51BJJeHlt1M 8
opr8He, o6bl4HO c 7-10 OHR nocne O>Koea. npo-
L1e,i:wpy sb1nonHs:110T 2 pa38 s HeAemo s TeYeH1-1e
3-4-x M8CS'IL\€B co cpoKaMlll HaXO.>KAeHL1S'I 6y.>Ka 8
npocsern nlllli.\eBo,D,a 20-30 ML1HYT. B nocne-
AYIOli.\eM np0Aon.>1<a10T 6y)l{1-1pos8HL1e pa3 s Me-
CS'IL\ s TeYeH111e ro.Q8 . Heo6xo.QL1MO noMHl-1Tb o
B03MO>f<HblX OCJl0}f{HeHlt1s:!X, csoespeMeHHO L1X
pacn03H8BaTb Ill npoBOAlllTb COOTBeTCTBYIOli.\ee
ne4eH111e. B .QanbHeV!weM np1-1 ycnewHoM ne4e-
HL11t1 O)f{oros n1111.4eso,Qa, KaK npas1mo, pa3s111sa-
eTc5! era py6L\OBa.s:i CTPL1KTYp8 , Tpe6ytoli.\a5l cne-
L\lllanbHblX MeTO.QOB Jle4eHL1s:!.
PY540Bb/E CYH<EH/.1R n/.1UJ,EBOAA
Py64oeaS1 cTpMKTypa n1.1114eBOAa - cy.>1<e-
HL1e npocBeTa nL1li.\eBOA8 TOJA lllJllll L1HOJA CTeneHlll ,
B03HlllKalOLL\851 np111 MHOn1X 3a6oneBaHlll5lX 3Toro
opraHa (ocTpblX Ill xpoHlll4eCKL1X socnan1-1Tenb-
HblX npOL\eccax, nenTL148CKL1X 513B8X, XlllMlll4e-
CK"1X, O}f{OfOBblX 1-1 .Qpyrnx nospe)f{,lleHw.s:ix), npJ.11-
BOA5'lli.\ee K HapyweHllllO npoxo)l{,QeH111s:1 nlllli.\lll no
n1<1li.\eBOAY. conposo>K,D,atoli.\eecs:1 paccTpoikTBOM
BO.QH0-3JleKTp0JllllTHOro, .>KL1posoro, 6enKOBOro Ill
AP· 811l.QOB o6MeHa 1-1 3aKaH411l88toli.\eec5l an111-
MeHTapH0Vi AlllCTpo¢111eVI.
l<naccuc/;u1<a4uR
Me.>KAyH8POAHbltA TepMlllHOJ10n14€CKllllA KO-
ML1TeT BceMMpHoro 06U1eCTBa 3H.QocKom11111 op-
raHos nJ.11L1..1eB8peH1-1.R - OMED (Organisation
Mondiole d'Endoscopie Digestive, 1996) pa3.Qe-
196
mm .Qo6poKa4ecTBeHHb1e opraH111YecK111e cy>Ke-
HL151 nlill.l.l8BO,Qa Ha:
1. Cy>1<eH111s:t nlllli.\e8o.Qa: nepeMbl4K111 , Konb-
2. CrplllKTYPbl nlllli.\880.Qa: cy.>1<eH1t15! cerMeH-
Ta nlilli.\eBo,Qa OT 1 AO 3 CM , cy>KeH1!15'l npOTs:!}f{eH-
HOCTblO 6onee 4 CM;
Py6L\OBble cy}f{eHL151 nlllli.\e8o.Qa pa3AeI151toT-
C.R:
1. no 'IMc.ny nopa>KeHHblX opraHoB (1-130-
n111posaHHb1e, coYeTaHHble - nopa)l(eHllle n111li.\e-
BOAa 111 }f{eny.QKa 1-1n111 .QBeHa.QL1arnnepcTH0Vi KlllW-
Klll);
2 . no npOTJt>KeHHOCTM (MeM6paH03Hbte -
AO 1 CM, KOpOTKllle (cTplllKTypbl) - AO 5 CM, npo-
T51.>K€HHble (CT€H03bl) - 6onee 5 CM) ;
3. no 'IMC.ny cy}l{eHMM B nM1.l4eBOAe (e.Qlll-
Hlll4Hble, MHO>K8CTBeHHble);
4 . no CTeneHH py640BblX H3MeHeHUH B
CTeHKe n1.1"-'eB0Aa (HeccpopM1-1posaHHb1e,
c¢opMlllPOB8HHble (c cynp8CTeHOTL14eCKlllM
pacw1t1peH1-1eM));
5. no HaflM'IMtO AeCTpyKTMBHblX 1113MeHe-
HMM (ynb4ep111po0aHHble (lll3b513BneHHb1e), npo-
CTble (He "13b513BJleHHble) ;
6. no CpOKaM <PopMMpOBaHMfl (paHHllle -
AO 6 MeC51L\8B, no3,QHllle - OT 6 MeC51L\88 111 60-
nee) ;
7. no CTeneHlil 06Il"1Tepa~J.11111 npOCBeTa nlt1-
LL\e80A3 (nonHble, 4acrn4Hb1e) ;
8.no BMAY pacno.no>KeHMfl ycTbH cy}l{e-
HMSI (c np51Mb1M pacnono}f{eHlileM 8XO.Q8, c 3KC-
l..\eHTplll4HO pacnono>KeHHblM 8XOAOM) .
l<nUHUl<G U aua2HOCmUl<O
OcHoBHblM Cli1MnTOMOM 5IBJ15!eTcs:1 .Q111ccpar11151
opraHlil4eCKOro Tl/Ina, KOTOpas:! MO}f{eT 6b1Tb Bbl-
pa)l{eHa B pa3Jllll4HOJA CTeneHlll - OT Henpllls:!THblX
OL1..1YL1..1eH11i1 Ja rpy,[1111Hol1 so speM.s:i npornaTb1sa-
H111s:1 nL1li.\L1 AO nonHoVI He803MO.>KHocrn nplllHL1-
MaTb nio6yto nlllli.\Y. no Mepe nporpecc1t1poB8Hlll5!
cy>KeHlll5l 6onbHble nocreneHHO nepecTatoT np111-
HlllMaTb 8H848ne T8epAyto, 38TeM }f{L1AKYIO L1 no-
IlY.>KlilAKYIO nlllli.\Y· C411lT8eTc51 , 4TO Alllccf:>arns:i nplll
Me.QneHHo nporpecc1t1pytoli.\eM c~eHMlll He Ha-
cTyn8eT, noKa AlllaMeTp nllll.l.leBo.Qa He AOCTL1rHeT
4-5 MM (B HOpMe 13-15 MM). 3aTeM nonHas:! He-
npoXOAlilMOCTb nllllL\eBo.Qa HacTynaeT sHe3anHo
npw CJlyYaMHOM 3arnaTblBaH"1"1 KpynHoro KyCKa
nMli.\lll , np111 3TOM so3HlilKaeT OU\Yli.\eH111e Aasne-
HL151 38 rpy.QlllHOJA . Hepe,QKO 60JlbHble T04HO Jl0-
K8Jllt13YIOT yposeHb 38,Qep}f{Klll nlllll.\lil 38 rpy,QlilHOlA,
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HeHlll51 B >KenyAKe, .n11160 paHee nepeHeceHHb1e
onepal.\ltllil (pe3eKL\fllH >Keny,QKa, racTpocToM111s:1 lil
T.A.). Ha1116onee BblfOAHblM "' MeHee TpaBMa-
Tll14HblM XltlpyprnYeCKf/IM ,QOCT)lnOM C41t1TaeTCs:I
rpacxlilaTanbHbrlA nyTb 33ocparoracTponnacTlilK111.
OnepaL\lilelA Bb16opa cneAyer c4111raTb 3KCTlilpna-
411110 nlllU,\eBoAa c 3aAHeMe,Qlil8CTll1H8flbHOlA nna-
CTVIKOIA 1t13onep111cTa11bT1114ecKoill >KenyA04HOIA
Tpy6Kolii. B cny4as:1x HeB03MO>KHOCTll1 111cnonb30-
sarb AI151 nnaCTlilKll1 nlilU,\eBoAa >Keny,QoK nplilMe-
Hs:llOT rpaHcnnaHrar 1113 TOHKoVI lilJlltl roncToilt
K1t1WK1t1. neTanbHOCTb nocne raK111x onepal.\111111 s
cneL11t1aJ1ll131t1pOBaHHblX CT8L\IAOHapax He npeBbl-
waeT 6-8% . (p111c.63).

a 6 6
Puc. 63. CxeMamul/ecKoe U3o6pa>KeHue HeKomopbtX cnoco6oa co3daHuR UcKyccmaeHH020 nuU(eaoda.
(A - c nOMOU(blO mOHKOiJ KUWKU (no Py-lepu,eHy-IOouHy}; 5 - c nOMOl.LJ,blO nocKyma, 8blKpoeHHOZO U3 cmeHKU
6onbwoil KpU8U3Hbt >KenydKa (no laepunuy); B - c noMOU(blO >KenydKa, nepecel/eHH020 e o6nacmu Kapduu (no
KupwHepy); I - c noMOUl,b/O npaeoiJ nonoeUHbl nonepeYHo-o6ooo4HOiJ KUWKU (no PoiJmy);,lJ - c noMoll(blO neeoiJ
nonoaUHbl nonepe4Ho-o6oaol/HOil KUWKU (no OpcoHu u Tyne) . 1 - npoKCUManbHblil omaen nuU(eeoda, 2 - nuU(eeodHo-
KUWel/HblU aHacmOM03_. 3 - moHKBR KUWK8, 4 - >KenyooK, 5 - nonepe4HO-o6odo4H8R KUWK8, 6 - Me>KKUWel/Hb/U
aHacmoMo3, 7 - cmpuKmypa nuU(eaoda, 8 - nuU(eeoaHo->1<enydol/HblU aHacmoM03, 9 - mpaHcnnaHmam, BblKpoeHHblU
u3 cmeHKu 6onbwoi1 KpueU3Hbl >1<enydKa, 10 - KapduanbHbtil omden >KenydKa, 11 - aHacmoMo3 Me>Kdy nUU(eeodoM u
moncmoa KUWKOU, 12 - 8HacmOM03 Me)f{dy nonepel/H0-06oool/HOU KUWKOU u )f{enydKOM, 13 -
uneompaHceep3oaHacmoM03, 14 - aHacmoMo3 Me>Kdy >KenydKoM u Hucxoanw,eu l/aCmblO nonepe4Ho-o6oao4Hol7
KUWKU, 15 - moncmoKuwel/HbtU aHacmoM03.

PAK nt1LLJ,EBO,ll,A HlllM8eT 9-10-e MeCTO. 3a6onesaeMOCTb paKOM

PaK - Ha1116onee 4acro scTpe4atolJ..leec.51 3a-
6onesaH111e n111U,\eso,Qa. ~3 scex 3a6onesaH111IA
nJAlJ..leBo,Lla 70-90% np111Ha,ane>KlilT pal<)f. B crpy1<-
rype 3a6onesaeMOCTll1 3nOKaYeCTBeHHblMf/I HO-
soo6pa3osaH1A5IMlll YenoseKa pa1< n1111.J..leBOAa 3a-
199
n111U,\eBo,lla B Pocc1111t1 111MeeT reHAeHL!IAIO K CHlil-
>KeH1t110, «rpy6b11i1» noKa3aTenb 3a6onesaeMocr111
B 1992 ro,qy cocTasn51n 6,4 Ha 100000 Hacene-
Hll151, B 2001 fOAY - 5,2 Ha 100000 HaceneHllls:I,
y6blflb no1<a3arens:1 cocTas111na 18% 3a ,qec.51Tb
neT. Ha1i16onbWlllMlll «rpy6b1e» noKa3aTen111 3a-
6onesaeMOCTL-1 3a6onesaeMocrn paKOM n1i1w,e-
so,Qa B 2001 ro,Lty 6bJJ11'1 s Pecny6n1'1Ke Caxa
(71Kyrns:i) - 10 Ha 100000 HaceneHllls:t, Pecny6n111-
1<e 5aw1<0pTocraH - 9,6 Ha 100000 HaceneHws:t,
AcTpaxaHcKolll o6nacrn - 9,6 Ha 100000 Hace-
neH11151. PaK n111w,es0Aa 1.1aw,e BCTpe4aeTcs:i y
MY>K'-llllH, >1<eHW,lllHbl 6oneioT B 2-3 pa3a pe>1<e.
3TO B OCHOBHOM 3a6oneBaH111e DIOAelll no>Kwnoro
so3pacTa, s rpynne nau1-1eHTOB cTapwe 60 neT
HaXOAlllTCs:t AO 80% ecex 3a6oneew111x. B B03-
paCTe AO 30 neT paK nww,eBOAa on111caH TOflbKO B
BlllAe eAL-1Hlll4HblX Ha6moAeHlllli1.
K cpaKTopaM, cnoco6crnyiow,111M B03HlllKHo-
seH11110 paKa nL-1W,eBOA8, OTHOC51T ClllCTeM8Tlll4€-
CKL-1171 np111eM rops:t4el71 , 06>1<L-1raiow,el71, rpy6ol71,
nnoxo nepe}f{eBaHHoi1 n1t1w,1r1, norpe6neH1t1e
1<pen1<111x anKoronbHblX HanL-1TKOB L-1 KYPeH111e . 3rn
cpaKTopb1 Bbl3blBalOT xpoHw-1ecK111e socnan111-
renbHble npol...\eCCbl, KOTOpble np111 AflL-1TenbHOM
cyw,ecTBoBaHlr!L-1 np111BOA51T K pa3BlllTllllO 3flOKa4e-
CTBeHHblX HOB006pa30BaH111171. 3,[leCb >Ke cne..c:1yer
oTMeTL-1Tb npoueccbl sneKYW,llle 3a co6o171 pa3Blll-
rne py61...1os, xpoH111YecKvtX socnanvtTenbHblX vt3-
MeHeHlllVi- nocneo>1<orosb1e CTPlllKTYPbl, 33ocpar111-
Tb1 Ha no4Be rpbl>Klil n111w,eBOAHOro OTBepcTllls:t
AlllacpparMbl, «KOpOTKoro» nL-1W,eBOAa 111 AP-
Pa3BL-1TllllO paKa n111w,es0Aa cnoco6crny10T 111
,.q111seprnrynb1, s KoTOpblX no,.q,.qep>K111saiorcs:t xpo-
Hlll4eCKL-1e socnan111renbHb1e npol...\eccb1. 6onb-
wy10 ponb B pa3BlllT"1111 paKa n111w,eBOA8 OTBOAflT
ne171KonnaKL-1L-1. neVIKonnaK11151 Cfllll3L-1CTOi.1 o6ono4-
KL-1 nepexOAL-1T B paK nv1w,eBOAa B 48% cny4aes.
no:HOMy 6onbWlllHCTBO lllCCne,QOBaTenelll C4111-
TalOT neVIKonna1<11110 o6m'1raTHblM npep,paKoM.
0TMeYeHa CB513b Me~y pa1<0M m1w,eso,lla 1r1 c1r1-
,QeponeH 1114eCKL-1 M ClllHAPOMOM , B03HlllKalOW,lllM
BCI1€ACTBl/le nOHlll>KeHl/151 COAep>KaHJ/151 >1<ene3a B
nna3Me (c111AeponeH111s:1) . C111,QeponeH1114eCKL-1i.1
ClllHAPOM (c111,o.eponeHll14eCKas:t ,QL-1ccpar111s:t , ClllH-
APOM nnaMMepa-81t1HcoHa) xapaKTep1t13yeTC51
Alllccpar111el7I, axL-1nL-1e171, xpoH1114ecK111M rnocc1t1TOM
"' xeC1mtTOM, paHHWM Bbrna,QeH111eM sonoc 111 no-
Tepe171 3y60B, Bblpa>KeHHOill rnnoxpOMHOL.1 aHe-
MltleVI. OnpeAeneHHoe 3Ha4eH111e B pa3Bli1TL-1L-1 pa-
Ka m1LI..1eBOAa L-1Me10T non111nb1 111 ,D,o6poKa4ecT-
BeHHble onyxon111. 0AHaKo 3TL-1 3a6onesaH111s:t ca-
Miil no ce6e BCTpe48IOTC51 OTHOClllTenbHO pe,.QKO,
a np111 pa3a111sweMcs:1 paKe He scer,D,a YAaeTcs:i
ycraHOBlllTb cne,D,bl cyLI..1ecrsosaswero paHee
naTonor1114ecKoro npol...\ecca.
namOfl020DHOmOMUYeCKLJe BapUOHmbJ U
Memacma3upoaaHue
Llacrora nopa}f(eH111S1 onyxonsiM111 pa3n1114Hb1X
aHaTOMl!14eCKlllX 4acTe171 n111Ul,eBOAa pa3Il1114Ha.
PaK weV!HoV! 111 sepxHerpyAHOVi 4aCTeV! n1t1ll\eBo-
,Qa COCTaBmleT 10%, cpe,D,Herpy,c:\HOVI 48CTL-1
60% , Hl-1)f{Herpyp,Ho171 111 6p10WHOL-1 4aCTeVI nlllll\e-
BO,l!a - 30% .
Pa3m14alOT Tp1t1 cpopMbl paKa n111w,eso,D,a:
200
• ff3BeHHblM (6n10A1..teo6pa3Hb1171, Kparepo-
o6pa3Hb1171) pacTeT 3K30QJlllTHO s npocBeT m1w,e-
so..c:1a npe1t1MYll.leCTseHHo no ..QJ1J11He;
• y3noeollt (rp11160Bll1AHblVl, nan111nnoMaT03-
Hb1'7!) lllMeeT Bli1A l...\BeTHOlli KanycTbl, 06ryp111pyeT
npocseT nlllll\eBOAa, np111 pacna,D,e MO}f(eT noxo-
Ali1Tb Ha s:t3BeHHblJA paK;
• 111HcplilI1bTp111pylOl1'111M {CKlllpp, CTeH0311l-
py10LI..11!1li1) pa3s111saercs:1 B n0Acn11131t1CTOM cnoe,
L.1111Pf<Yn5lpHO OXB8TblBaeT nww,eBOA, npos:tBn5leT-
C51 B BlllAe 6enecosaToli1 nnOTHOVl Cfllll3111CT0171 Ha
Q:>oHe KOTopoVI MOryT B03Hli1K8Tb L-13b513BneHl!151 ,
CTeH0311lPYIOll\L-1171 l...\lllPK}'fl51pHbl171 pocT npeo6na-
,D,aeT HaA pocrnM no An111He opraHa .
no n1CTOJ10rJllYeCKOMY CTpOeHl-11-0 B 97-99%
cny4aes paK n111ll\eB0Aa s:1sm1eTcs:t nnocKOKne-
TOYHb!M pa3J11114Hoi.1 creneH111 3penocrn: c oporo-
seHL-1eM 111 6e3 oporoBeH111s:i . B 1-3% cny4aee 06-
Hapy>1<111Ba10T )l(ene3111CTble cpopMbl , pa3BL-1Ba10-
w,111ecH 1113 >Kene3 c111113111cr0Vi o6ono4Kli1 n1111..L!eBo-
Aa 111nL-1 1113 Ali1CTOn111posaHHoro 3n111ren111s:1. B peA-
Kl-1X cny4a51X o6Hapy}f(lr!88eTC51 HW3KO,!l1Acp¢epeH-
L\lllPOBaHHbllii paK..
Meracra31-1posaH111e paKa n111UJ,eBOAa 3as111-
c111T oT r111cTonor1114eCKoro CTpoeH111s:1 onyxon111 L-1
CBOeo6pa3HO pa3BlllTOVI cern J11t1MQJ8Tl/l4eCKlllX
cocy,D,OB. nocKOJ1bK}' B no,QCJ1(1!3JllCT0171 OCHOBe
n111UJ,eBOA8 111MeeTC51 MOW,HOe cnneTeHllle n1.11M-
cpamyec1<111x cocy,llos, Ans:t paKa xapaKTepHo
BHYTPL-1CTeH04Hoe pacnpocTpaHeH111e onyxone-
BblX MeTaCTa30B no n111McpaT1t14eCKlllM nyTs:tM Ha
paccTOSIHl/le 4-5, a lllHOr,D,a 111 10 CM . OT B!t1A111MOro
1<pas:1 onyxon111 . HepeAKO Ha6nioAalOTCs:t TaK Ha-
3blsaeMble "nbmesb1e" MeTaCTa3bJ Ha c111113111cToi!J
o6ono4Ke ropa3AO Aanbwe (o6bl4HO BblWe) on-
peAens:ieMoro M1111<poc1<onw-1ecKlif Kpas:i onyxon1-1.
BropblM 3TanoM Meracra3111poaaHL-1fl flsns:iercs:t
pacnpocTpaHeH111e onyxon1t1 s n1t1Mcparn4ec1<111e
Y3J1bl. Ka:>t<Abl171 or.aen n111w,eso,Qa 111MeeT cso111
nyT111 n111McpooTT0Ka. TaK, MeTacra3wpoaaHllle
paKa weV!Horo or,D,ena m1l1\eBo,lla npowcxOAHT s
rny60K1t1e welilHbJe n1t1MQ:>arn4ec1<111e Y3Ilbl sepx-
Herpy,D,Horo L-1 cpe,D,HerpyAHOro orp,enos - B na-
pa33ocpareanbHb1e, rpaxeo6poHx111anbHb1e 111
3a,D,Hllle cpeAOCTeHHb1e n111McpaT1.114ec1<111e y3nb1 , a
Hlll)f{Herpy,D,HOro 111 6plOWHOf0 oT.r:ienoB - 8 J1VIM-
cpaTl/l4eCKllle y3.nbl, Haxo,D,s:1w,111ecs:t no,Q Alllacppar-
Molli: napa33ocpareanbHbre, napaKap,q111anbHble,
111 y3nb1, pacnonmKeHHble BAOJ1b Mano171 1<p111s1113-
Hb1 >KenyAKa 111 nesoll! >1<enyA04Ho171 aprep111111.
LJacTb nL-1Mtj:>aTL-14eCKlllX COCYAOB n111ll.leBO,Qa sna-
A8eT Henocpe,D,CTBeHHO B rpyAHOVi npoToK. He-
pe,llKl-1 cnyi.1a1-1 06Hapy}f{eH1r15I Meracra3os pa1<a s
n1t1McpaT1114eCKL-1X y311ax Manora canbH1t1Ka, BAOJ1b
nesoVI >1<enyA04Hoi1 apTep111111 np111 nopa>KeHL-1111
sepxHerpyAHOVi 4acrn n1t1UJ,eBo,D,a, 111 s we171Hb1X L-1
H8,D,Knl041114HblX n111Mcp8T1114eCKlllX y311ax np111 paKe
Hlll}KHerpy,QHol-1 4acrn m11.11eso.i:ia. Or.i:ianeHHb1e
n1i1Mcpo- 111 n111McporeMaroreHHb1e MeTacra3bl pa-
r<a nwl1\eBOAa 1-1a6n10,llaioTcs:t s ne4e1-1111, nerr<wx,
pe)l{e B KOCTHOVl ClllCTeMe .
Kflaccu<j:JUKQL{UR He paHHlllM Cl/IMnTOMOM paKa nllllJ..leBO,D,a S!BmleT-
Ans:i npas1r1nbH0!::1 OL\eHKlt1 pacnpocTpaHeH1r1s:1 CS'I auccjJaauB- HapyweHIAe rnoraH1115! n111w,111 . 3rn
npo4ecca, Bb16opa MeTO,[la ne4eHJA$'1 111 ,[IOCTo- c111MnTOMbJ Ha6rno..Qa10TC5! 6onee YeM y 75%
sepHolil OL\eHKIA OTAaneHHblX pe3ynbTaTOB ne4e- 6onbHblX paKoM n1i1w,es0Aa. B HeKOTOpblX cny-
HIAS1 nonb3YKHCS'I Knll1HIA4eCKOlil 1<J1acc1r1¢111Kal,\1Aelil 4as:ix Alllccpar!A51 HOCIAT nepvtOAIA4eCKIAlA xapaKTep
paKa m11..L.1eBo,l\a no c1.-1cTeMe TNM Me:>K,QyHa- 111 Ha6n10p,aeTCS1 n111wb B cny4a51x nocnewHoro
pOAHoro npornsopaKosoro coto3a (1997) np111eMa n1t11..L.1111, npornaTbJBaH111S1 6onbw111x, nnoxo
• T - neps1A4Has:i onyxonb pa3)1(€BaHHblX KYCKOB. no Mepe nporpecc1t1posa-
o TX - He,[\ocTaT04HO ):laHHblX ,[lns:i 04eHK1i1 HlllS1 3a6onesaH1AS1 , A111Ccpar111s:1 craHOBlllTCS'I no-
nepBlll4Ho~ onyxon111 CT051HHO~ . y HeKOTOpblX 6onbHblX nepBbtM CIAM-
o TO - nepslll4Has:i onyxonb He onpe,[.1em1- nTOMOM 3a6onesaHlll51 .s:ismieTCS1 o6unbHOe cmo-
eTCS! Homel/eHue. nocneAHee 06bl4HO nOS1Bn518TCS'I
o Tis - npe111Hsa3111sHas:1KaPL\li1HOMa (carci- np111 pe3KlllX creneHs:ix cy>t<eHi.-t51 n1.-1w,ee0Aa.
noma in situ) no 1<J1acc111cJl111Ka._..,,.,, .q111ccJlarn111 no
o Ti - onyxonb 111H¢1AnbTp111pyeT cTeHKY n111- A.VI. Cae11t~K0My np111HS1TO pa3n111YaTb 4 crnneHIA
w,eB0Aa AO nOACAl.-131i1CTOro cnos:i ee Bblp8}1(8HHOCTlll:
o T2 - onyxonb 111Hcp1r1nbTp111pyer cTeHKY • I creneHb - 3arpyp,HeH111e npoxm1<,D,eH1115I
m11.11es0Aa AO Mb1We4Horo cnos:i rsep,llo~ n111w,111 no ni.-tw,eBOAY (xne6 , M51co) ;
o T3 - onyxonb 111Hcj:l111nbTp111pyer creHKY • II cTeneHb - 3arpy.c1HeHlll5!, B03H"1Ka10ll\11te
n111w,eBOAa ,o,o a,o,seHTlllL\111111 np111 np111eMe Kaw1114eo6pa3HO~ 111 nony>t<lllAKO~
o T4 - onyxonb pacnpocTpaHS1eTcs:i na co- n111w,111 (Kaw111 , n10pe);
cep,Ht-te CTPYKTypb1 • Ill cTenettb - 3arpyp,HeH1M1 np1i1 rnoTaHlillr!
• N- per1110HapHb1e n111Mcj)aT1114ecK111e y3nb1 >Klll,0,KOCTei/i;
o NX - HeAOCTaT04HO A8HHblX An51 OL\eHKlll • IV cTeneHb - nonHaSt Henpoxo,o.i.-tMocrb
pernoHapHbix n1.1Mcparn4ec1<wx y3noa m11J.1eBO..Qa.
o NO - HeT npli13HaKos MeTaCTaTli14eCKoro np111MepHO B 17-20% cny4aes 3a6oneB8HIAe
nopa>t<eHIAS1 pernoHapHblX n111McpaT1114eCKlllX y3- np051Bns:ieTCS'I 60flbl{) 38 rpyJJ,IAHOili IAillA B H8,ll-
nos 4peBHO~ o6nacrn, e cm'1He . Llall\e 6onbHbte or-
o N1 - 111Meercs:1 nopa>KeH111e per1110HapHblX MeYaior TYnyio, T>lHYIJ..lYIO 6onb 3a rpyAlllHO~ ,
n111Mcj:larn11ecK111x y3nos Meracrn3aM1.1 pe>t<e Yyscrso c,o,asneHlll51 111m1 c>t<arn51 s o6nacrn
• M- OTJJ,aneHHble MeTaCTa3bl cepAL\a, pacnpocTpaH5110IJ..l"1ecfl ssepx Ha weio .
o MX - HeAOCTaT04HO AaHHblX Anfl onpe- 5onb MO>KeT 803HlllK8Tb B MOMeHT rnoTaHIAS'I Ill
,L\eneHlllfl OT,L\aneHHblX MeTacTa3oa 111c4e3aTb Yepe3 HeKoTopoe apeMfl nocne roro,
o MO - HeT nplA3HaKoB oTp,aneHHblX Mern- KaK nm1-'esop, ocso60,ll1ATcs:1 OT n111w,111. Pe>t<e 6onb
cTa3oB Hoc111r nocrns:iHHbl~ xapaKTep 11J yc111n111saeTc51 npi.-t
o Ml - 1-1Me10rc51 or,.qaneHHb1e Meracra3bl npoxo)l{,[leH111111 n111llj111 no nw1..L.1eso,riy. 5onb np111
paKe n111w,eso,D,a MO>Ker ow.yll\aTbCS1 np111 pa3-
f pynnupoaKa no cmaduRM APa>KeH11J111 HepBHblX OKOH4aH111ili s lll3Mt3s111swelA-
CTa,[llll51 0 Tis NO MO cS1 111 pacnap,aiow,e~c51 onyxon111 npoxop,s:ill\1AM111
CTaAIA51 IA T1 NO MO n1r11J..leBblMli1 MaccaM111 . B ra1<111x cny4a51X 6onbHble
CTaAIAS1 fB T2 NO MO 4YBCTBYIOT, Kai< n1.1ll.(eBoi;f KOMOK, npoXO,[!fl 4epe3
CTap,11151 llA T3 NO MO onpe.o.eneHHoe Mecro nlAIJ..leBO,lla, "~apanaem" ,
CraAIAS'I llB T1 ,T2 N1 MO "o6)1<uaaem" era. 5onb Mo>t<eT B03HlllKaTb np1t1
Cra,[11.15'1 Ill A T4a NO MO ycwneHHblX cnacrn1.1eCKlllX coKpall\eHW51X n1-1ll\e-
T3 N1 MO eo.o.a , HanpasneHHbtX Ha npoTanK1r1saH111e n1111J..le-
T1,T2 N2 MO soro KOMKa Yepe3 cy>t<eHbtlA yYacTOK m11.-4eB0Aa,
Crat.1V1fl lllB T3 N2 MO a TalOl<e np111 npopacraH111111 onyxon111 s 0KpJ01<a10-
CraAli1S1 lllC T4a N1 ,N2 MO w,111e n111w,eso.o. rKaHIA 111 opraHbl co c.o.asneHIAeM
T4b .mo6as:i N MO cocyp,os w Hepsos cpep,ocreH£1fl. B TaKOM cny-
nio6as:iT N3 MO 4ae OHa He CBS'138Ha c aKTOM rnoTaHlll51 IA HOClllT
CTa,[llllS1 IV nio6af! T nio6as:i N M1 nocrns:iHHbt~ xapaKTep.
nplll paCCMOTpeHHlll KnlllHlll4eCKlllX npa5'1Bne-
KnuHul.feCKaR KapmuHa Hlt1!:1 pacnpocTpaHeHHoro paKa n1.1w,es0Aa cne-
K paHHlllM nplA3HaKaM paKa n1111.lleBoJJ,a cne- AYeT oco6oe BHlllMaHIAe o6paTIATb Ha o6w,ee co-
p,yer ornecrn npoapeccupy10w,ee yxyoweHue crof!H1t1e 6onbHoro. KaK npaa111no, y 6onbHbJX
o6w,eeo cocmo.RHUR 6onbHblX, CHWKeHue anne- paKOM n1111.-4eBO,ll8 OTMe4aeTCS1 AecfJVIL..\lllT MaCCbl.
muma , HapacmaHue o6w,eD cna6ocmu, CHWKe- noreps:i Maccb1 css:i3aHa npe>KJJ,e scero c orpaH1t1-
HUe pa6omocnoco6Hocmu, nomeplO Maccb1 me- YeHHb1M nocrynneHIAeM s opraHlll3M 6onbHoro
na. Hapacra51 nocTeneHHo, 3TIA srnneH1115I AnlA- nlllll.1111 , a He c TOKCIA4eCKIAM Bnli1flHllleM pacnpo-
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np111 onyxonS'lx 6onbw111x pa3Mepos , K CO)f{ane-
H1t110 6onbWlllHCTBO asrnpos 3a51BnsteT o npeo6-
na,QaH111111 onepal.\lllill np111 pacnpocTpaHeHHbtX
onyxonesbtX npol.\eccax.
06ecne4111saeT ny4w111e cpyHKL\lllOHanbHbte pe-
3YilbTaTbt (OTCYTCTBllle pecpntoKC-330cpar111ra) ,
O,QH8KO sepxH111e OT,QeJlbl BHyrp111rpy,QHOro OT,Qe-
na n111ll.\eBo.Qa ocTalOTCst He,QocrynHbtM111 .QI151 pe-
3eKL\111111 (weil!Hbtill, sepxHe-rpy.QHOill OT.Qenbt) .
crse TpaHcnnaHTara B PS1Ae cnyl.faes 1.1cnonb3Y-
IOT l<pOMe )1{8J1YAl<a TOHKylO £1nV1 roncrylO KV'IWKY.
CneAyeT yKa3aTb Ha B03MO>KHOCTb Bbtnon-
HeHlllst nann111aT1t1BHbtX BMewarenbcrs np111 Hepe-
3eKTa6enbHOM paKe rpy,QHoro or,Qena s B1t1.Qe
wyHrnpoaaH111s:1 onyxoneaoro cTeHo3a >Keny,QKa
Hano)f(eH111eM o6xo,QHoro aHaCTOM03a. B cny4ae
Hepe3eKTa6enbHoill onyxon111 B03MO)f(HO Hano)f(e-
H111e racTpOCTOMbl. 5onbHble paKOM nlllll.\eBO,[la c
Hano)f(eHHOlA raCTpOCTOMOlA , MOryT 6b1Tb nOA-
seprHyTb! nyl/esoi.1 repan1t11t1.
KoMnneKcHoe " KOM6MHMpoeaHHoe ne-
'lemte paKa nuu.ceao.Qa ocrneTcR e,[!111HcTBeH-
HblM MeTOAOM nel/eHVl5l AI15l 6onbWVIHCT8a
6onbHblX, KOTOpb1M oneparnsHoe ne4eHl.1e npo-
rnsonoKa3aHo BBLllAY Han111L/V1s:t conyTcTBy10w,ell1
naTanorn1-1 (BbJpa>KeHHble paccTpo!AcTBa cep-
,1:1e4HO- cocy,D,VICTOlll , ,[\blXaTeJlbHOlA CVICTeMbl VI
,o.p .) npeKnOHHOro 803pacTa 60flbHblX, OTKa3e
6onbHblX OT onepau,111111 . B P51Ae cnyYaes ny4e-
soe ne4eH111e HOCVIT V13HaYanbHO nann111aTV1BHOlli
xapaKTep (nocne npoBe,[!eHHOl/1 paHee nanapo-
TOM111111 VI racTpOCTOMllllll) .
np111MeHeH111e cospeMeHHb1x MeTO,D,VIK o6ny-
4eHVl51 no3son51eT ,1:106V1TbC5! VIC4e3HoseHlll51 T51ro-
CTHblX KJlVIHVIL/eCKVIX npos:isneHVIJA 3a6onesaHVIS'I y
35-40% 6onbHblX.
Wenbt0 06nyYeH1115! 51Bns:teTc51 co3,[!aH111e s
06nacT111 06ny4aeMoro opraHa rnpaneBTVIL/ecKolA
,[\03bl B 60- 70 rp . 0,D,HOBpeMeHHO KpoMe nopa-
>KeHHOro opraHa B o6nacTb o6ny4eHVl51 AOn>KHbl
BK11t04aTbC51 30Hbl pacnono>KeHvrn n111McpaT1111.te-
cK111x y3nos B03MO}l{HOro MeTacTa3111posaH111~t: na-
pa33ocpareanbHble rmMcparnYecK111e Y3!lbl, 30Ha
n111MQ:JaT111YeCK111x y3nos napaKapA111anbHblX, 06-
nacr1t1 nesoi.1 >1<eny,l!OYHow aprep1t11t1 1t1 4pesHoro
CTBona, H8AKfll04Vl4HblX o6nacTelli . KnacCVIL/e-
CK!tlM MeTO,llOM o6ny4eHi.1R RBnReTCR 5 ceaHCOB
nyl!esolil Tepan111V1 s HeAenio, B pa3osolli 04aro-
soi1 ,ll03e 1,5-2 rp. (l<IlaCCIA4eCKOe ¢paKUIAOHW-
posaH111e A03bl) . npw APYrlllX sap111aHTaX ¢paK-
UMOH1t1posaH1t17! ,[103bl, nOABO,[lltlMbJe B TeYeH111e
,D,H51 MOryT MeH51TbC51 , KaK MOryT MeH51TbC51 "' pa-
30Bble 04arosb1e A03bL
X111MV1orepan11151 np111MeH~eTC5! np111 Hlll3Ko-
A111QJcpepeHL\1.1posaHHblX cpopMax paKa n111w,eso-
,D,a Ill npVI M8f1KOKneT04HOM paKe n111w.eBOAa.
np111MeHeH1t1e ny4eBOro Ill X111Mll10TepaneBTll14e-
CKOrO ne4eHlll51 He06XO,IJ,ltlMO npoBO,D,VITb Ha QJOHe
Tepan111111 HanpasneHHOIA Ha npep,ynpe>KAeH111e VI
Kyn111poBaH111e B03MO>KHblX HapyweHllllil 3p111Tp0-111
nei11Kono33a, 111MMyHo,1:1enpec111111 (nepen111saHV1e
205
npenapaTOB KpOBVI , lllMMYHOCTVIMYflfll.\11151 , VIHQJY-
3lt!OHH8fl Tepanl.-151 , BltlTaMlt!HOTeapnlilfl) . ns:ir1t1-
f18TH5151 Bbl>KlllBaeMOCTb 6onbHblX nocne KoM6Vl-
HWPOBaHHOro neYeH1t1R .Qocrnraer 56,6% np1t1
pap,111KanbHOM xapaKTepe oneparnBHblX BMewa-
renbCTB 1t1 7,0% nocne nann1Aan10HblX. np111
KOMnneKCHOM neYeHlllVI nocne nann111anrnHblX
onepa1.11i1J;1 Bbl)l(Ji1BaeMocTb .r:1ocrnraeT 30,8% .
PaK n111w,eso,1:1a s 6onbWVIHCTBe cnyyaes
51Bf1518TC51 OTHOCVIT8IlbHO Me,D,neHHO nporpecc1t1-
py10W,VIM 3a6oneB8HllleM . no CTeneHVI 3flOKa4e-
CTBeHHOCTll1 OH HaXOP,VITC51 Me}l{,D,y caMblMVI 3no-
Ka4eCTBeHHO TeKYW.VIMlll 3a6onesaHll151MVI 111 T8Mll1 ,
KOTOpb1e ,1:1ocTaT04Ho A06poKa4eCTBeHHbl. He-
neYeHHbllil paK VIMeeT nnoxolli nporHo3. Cpe,[IH5151
npO.QOfl>KL4TeflbHOCTb )l(l/13HVI TaKVIX 6onbHblX He
npeBblWaeT 5-8 Mee. c MOMeHTa n051BfleHllJ51
npll13HaKos 6one3Hlll . Xorn np111 paHHelA AlllarHo-
crnKe 3aper111crp111posaHb1 cnyYaVI npo.Qon>K111-
TenbHOCTV1 >K1113Hlll AO 6 neT 6e3 KaKoro-n11160 ne-
4eH1115l .
nporHo3 aa6onesaH111s:i npVI nyYesolli Tepa-
n111111 3as1t1cV1T OT cj:lopMbl pocra onyxom1. Ha111-
xyp,wV1Mlll 51BJ15llOTC51 pe3yilbT8Tbl nplll 3H,1J,OQJVIT-
HOM cj:lopMe pocra onyxon111 . TpexneTHvte pe-
3ynbTaTb1 np111 3TOJ°;1 Q:JopMe pocTa COCTaBf15llOT
6,0%, rnrp,a KaK npvt 3K30cpli!TH0£1 cpopMe pocra
OH lll COCTasns:ieT 27%.
npO,[lOn)l{ltlfeflbHOCTb )l{lt13Hli! nocne pa,llltl-
KanbHblX onepa1..11111/1 no nosop,y paKa n111w.esop,a
RBnfleTC~ OCHOBHblM IA Ha1116onee Ba}l{HblM noKa-
3aTeneM 3QJcpeKTVIBHOCTlll x111pyprn4ecKoro 111
KOM6111HV1pOBaHHOfO Jl84eHlt151. np111 XMpyprnYe-
CKOM nel/eHll1VI , cpep,111 nepeHeCWIAX pa.QJAK8flb-
Hble onepa4111111 , 5 neTHllli1 cpoK Bbl)l(!i1BaH1115I 3a-
s111c111T OT pa3nV14HblX 06CT051TeflbCTB. np111 pa3-
MepaX onyxon111 T1 nflrnneTH5151 Bbl>KVIBaeMOCTb
COCTaBm1eT 46,9% , np111 T2- 42,9%, np111 T3 -
33,7% , T4- 25% . Hanllll/Vle MeTacra3os B n111M-
¢arn4ecK111e Y3Ilbl 51Bf151eTcf! He6naronp1115ITHblM
Q:JaKTopOM Ill 3Ha4111T8flbHO yMeHbWaeT cpoK n7!-
TlllJleTHeJ/1 BbDl<111Ba8MOCTVI.

3A60JlEBAHVIS1 MOJ104HOVI >KEJ1E3bl,
fPbl>KVI 6PKlWHOVI CTEHKVI,
3A60J1EBAHVl.fl nPS1MOM KVIWKVI,
3AEOJIEBAHIUI MOJIOqJJOH JKEJIE3hl
Ha1116onee pacnpocTpaHeHHb1M111 naTOnor111-
4ecK111M111 npo1...1eccaM111 B Mono4HblX )f(ene3ax S'IB-
m110Tcs:t pa3nli14Hble cpopMbl MacTonaT111111 111 paK
MOI104Holli )f(ene3bl. MacTOnarnelli cTpaAaeT Ka-
)KJJ.aS'I 2 )f(eHLl.llllHa, a PM}I{ Bb1s:isns:ieTcs:i y 68
)f(eHLI..\lllH Ha 100 000 YenoseK.
Xupyp2ul./eC1<aR aHamoMUR N1011ol./HOU
JKe11e3bl
Mono11Hb1e )f(ene3bl Hsm11orc51 napHblM op-
raHoM, pacnono)f(eHHblM Ha nepeAHelil nosepx-
Hocrn rpyAHOlil CTeHKll1 OT Ill AO V pe6pa. napeH-
XVIMa MOnOl.lHOlil )f(ene3bl COCTOl.ff 1113 Tpy611aTO-
anbseons:ipHblX CTPYKTYP, crpynn111posaHHblX B
MenK111e AOnbKf..1, KOTOpble cn111Ba10TCS'I B 6onee
KpynHble AOI1111. Ka)KJJ,as:t AOI151 lllMeeT BblBOAHOlli
npOTOK C BblXOAOM Ha COCKe. napeHXlllMa MO-
nOl.lHblX )f(ene3 3aKnl011eHa Me)f(Ay ABYMS'I n111cr-
KaM111 cpaCL..\111111 - nosepXHOCTHblM Ill 38AHlllM. no-
3aA111 Mono4HblX )f(ene3 pacnono)f(eHa perpo-
MaMMapHas:i )f(111posas:i KneTl.laTKa (pLllC. 1 a, 6)
P1o1c. 1. A - HOpMaJlbHa}l aHaTOMlo1}'1 Mo-
JlO'IHOM }f{eJle3bl no Daniel F.Hayes, 6 - ro-
norpa<f>w.1ecKaS1 aHaTOMHSI MOJlO'IHOM }f{e-
Jle3bl no CeM1o1ma3oey B.B.
KposocHa6)f(eH111e Mono4HOl/l )f(ene3bl ocy-
L11ecrnm1eTcs:i BeTBS'IMll1 nOAMblUJ€4HOlil 111 BHyT-
peHHelil rpyAHOlli aprep11111i , KOTOpble aHaCTOM0-
3111PYIOT c BeTBS'IMlll Me)f(pe6epHblX aprep111i.1
(p111c. 2).
P1o1c. 2. KpoeocHa6}f{eH1o1e MOJlO'IHOM
}f{eJle3bl no CeM1o1ma3oey B.B.
208
"lacm&IV
3A60J1EBAHVl.fl BEH
P1o1c. 3. PernoHapHble 111o1M<f>aT11t'lecK11te
y311b1 "' cocy.Qbl MOJlO'IHOM }f{eJle3bl no Ce-
M11tma3oey B.B.
n111McpaTL114eCKa51 ceTb MOnOl.lHOlli )f(ene3bl
cocro111r 1113 sHyTp111- Lii sHeopraHHOlli 4acTelli
(p111c. 3).
MacmonamuR
no onpeAeneHVllO 803 (1984), MacTOnarvis:i
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paKTep1113YIOLI..\as:tcs:i HapyweH111eM COOTHOWeHllllli
3n111re11111anbHOro Ill COeA111Hli1TeJ1bHO-TKaHHOro
KOMnOHeHTOB, Wll1pOKll1M cneKTpOM npo11111cpepa-
Tli1BHblX 111 perpeCCVIBHblX Vl3MeHeHVllli TKaHelli M0-
1101.lHOlli )f(ene3bl.
Pa3n111YHb1M111 cpopMaM111 MacronaTL11111 cTpa-
A810T 50-75 % )f(eHLl.lll1H penpoAYKTlllBHoro B03-
pacra. Ha111114vie npo11111cpeparnsHoL;l cpopMbl
MacTonarn111 nosb1waeT pLllCK pa3s111rns:i paKa MO-
no11Holll >Ke11e3bl Ha 5-32 %. r111cTOnOfl!14eCKlll B
46 % c11y4aes PM}I{ co4eraercf! c cp1116po3HO-
K111cro3Hollt 6one3Hbl0.
K11accu<f;wwu,uR
B nocneAHllle rDAbl npeAilO)f(eHa KnLllHlllKO-
peHTreHonornYecKas:i Knacc111cpL11Ka4111s:i, YA06Has:i
,D,!151 111cnOflb30BaHll151 B Knli1Hlll4eCKOlli npaKTL/IKe VI
no3aonfl10LL1afl Bbl,llemHb ,£1111cpcpy3Hbre 111 y3no-
Bb1e cpopMbl, KOTOpble ALllarHOCTlllPYIOTCS'I c no-
MOLI..\blO peHTreHorpacp111L11, ynbTpa3BYKOBOro
CK8Hli1pOBaHll151 111 MOpcponorn4eCKOro 111CCI1€AO-
BaHll1Sl .
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mo3HOU Macmonamuu (<PKM) :
- Avt¢¢Y3Has:t MacTOnaTll'ITI c npeo6naAa-
Hll'leM Kll'ICT03Horo KOMnOHeHTa ;
- Avt¢cpy3Hasi MacTOnarnsi c npeo6naAa-
H1t1eM qm6p03HOro KOMnoHeHTa;
- CMewaHHaSl ¢opMa AlilcPcPY3HOll1 Macrn-
narn1t1;
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2. Y3nosafl <:PKM
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onpe,[\em1eTCSl ycnoBHO , no COOTHOWeHlt1IO co-
eA1t1H1t1TenbHOTKaHHOro , :>Kene311'1CTOro KOMnOHeH-
TOB 111 >Kll'lpOBOVt TK8Hlt1 .
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ct>K5 sisnReTCR A06poKaYecTBeHHblM 3a60-
nesaH1t1eM . 0AHaKo B Ps:tAe cnyyaes AaHHas:t na-
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nocKonbKy A06poKaYeCTBeHHble 3a6oneBaHli1Sl lt1
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BeHHble 3a6onesaHll'IS1 MOflOYHblX )f(eJle3 B 70%
cnyYaes co1.1eTa10TCs:I c pa3Jlll'l4Hb1Mlll Hapywe-
Hll'ISlMll'I B Hei/1p03H,[\OKPlt1HHOVt lt1 penpo,o.yKTll'IBHOCi
CVJCTeMax.
Ha o6l.1..(HOCTb ,[\1t1cropM0HanbHO~ naTOnor111111
Mono4Hb1X )f(ene3 111 p51,o.a r111HeKonor1111.JecK1t1X 3a-
6onesaH111il1 yKa3bfBBIOT MHorne aBTOpbl , KOTO-
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3111Sl 3K30- 111 3H,o.oreHHblX ¢a1<ropos onpe,[\ens:iio-
LJ.\ll'IM s naToreHe3e ,£:\o6poKa4eCTBeHHblX 3a6o-
nesaHIAii! MOnOYHblX >Kene3 f!Bns:teTcsi Hapywe-
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a B03Hll'IKWll'lil1 np111 3TOM ropMoHallbHbllll A"1C6a-
naHc Bb1pa>1<aeTCSl B a6comOTHOVt ll'lflll'I OTHOClll-
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recrepoHa .
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rn111 3a6oneBaH111il1 MOJlOYHblX >Kene3 OTBO,lllllTCS1
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TOpblX 11'136blTOK 3CTporeHOB Bbl3b1Baer nponlll-
cpepal..\ll'llO scex TKaHeL1 >1<ene3bl .
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naTll'IVt 11'1 paKa MOnOYHOlll >Kene3bl BO MHOrDM
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pa3s1.n1.151 .QaHHoro 3a6onesaHJ.151 , nocKonbKY
MacTonarnfl - MynbrncpaKTopHoe 3a6onesaH111e,
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TaK "' c tjJaKTopaMll'I 0Kpy>Ka10l.1..(eil1 cpe,[lbl.
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poMHasi ponb oTBOAlllTCs:i cocmoRHUIO 2unoma-
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T1t1BHb1x npou,eccos B ropMOH8JlbHO 38Bll'IClllMblX
opraHaX, 8 TOM YVJCne 11'1 8 TKaH51X MOflOYHblX >Ke-
ne3 , KOTOpble 51Bf1SllOTCSl Mlt1WeHblO Ans:! CTepo-
11'1,[\HblX ropMOHOB Slll'l4Hll'IKOB, nponaKTll'IHa, nna-
1...(eHTapHbfX ropMOHOB Iii onocpe,lloBaHHO ropMO-
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nOHll1M8Hll'lll'I npl!IYll'IH B03Hll'IKHOB€Hlt1S'I MaCTonaTll'lll'I
111MetoT ..qaHHble o nepeHeceHHbJX 111 oco6eHHO
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111 speMeH111 HaYana MeHcTpya4V1V!. YY1t1Tb1Ba10T
B03pacT HacrynneH1t1s:t nepsoi/1 6epeMeHHOCTVI ,
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CKOflbKY 11'13BeCTHO, 4TO OAHll'IM 11'13 seAYU\ll'IX np111-
Yll'IHHblX ¢aKTOpOB B03HlllKHOBeHlt1S1 MaCTOnarn111
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209
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KnL-iHVIYeCKOe o6cne,[IOBaHlile BKfllOYaeT B MOCT VI OT cpa3bl MeHCTpyanbHOro l..(lllKila (yc111ne-
ce6s:i ocMoTp 111 MaHyanbHoe 111ccneA0BaH111e, np111 H111e 6onesoro ClllHAPOMa BO 2 cpa3e MeHCTPY-
KOTOpOM 1113yYalOTC5l crnneHb cjJopM111poBaHlll5l aJlbHOro L\VIKila) ;
}l{ene3 , cpopMa , pa3Mepbl , COCT05lHllle KQ)f{HblX - yn.noTHeH111e TKaHlll MOn04HOill )f{ene3bl ;
noKpOBOB , cocKa , Ham14111e KO)f{HblX py6L\OB , srn- H3Jll!14111€ o6pa30BaHVlfl B MOfl04HOrli )l(e-
}l{eHlllill , Bb16yxaH111ill , n111rMeHTal..\111ill 111 T. A · ne3e ;
npoBOAll1TCfl nosepXHOCTHafl Iii rny6oKa5l Bbl,qeneHVIS1 1113 COCl<a .
nanbnal..\11151 )f{ene3 111 pernoHanbHblX m1Mcparn4e- 2. AHaMHecmul./eCKUe aaHHbJe:
CK111x y3nos , Koropas:i no3somieT onpe,Gen111Tb - Han111Yvie ,lllllCcPYHKL.(111111 r111noranaMo-
KOHClllCTeHL\llllO MOn04HblX }l{ene3 , Cll1MMeTp1114 - rnnocp1113apHo-s:11114HlllKosotll ClllCTeMbl , ClllHAPOMa
HOCTb , Hanw-1111e ynnorneH111rli, 111x xapaKTep , pac- Mern6on1114ecK111x HapyweH111r.1 ;
npocTpaHeHHOCTb , Hanll14111e OTeKa 111 COOTHowe- - Han1114111e r111HeKonorn4ecK111x 3a60.neBa-
Hl!le c OKpy)l(alOIJ..llllMlll TK8HHMl!I. H11trli Bocnan111TenbHoro xapaKTepa 111 a6opros s
Oco6oe BH1t1MaH1t1e y,D.ens:110T 111Me10ll.\ll1Mcs:i aHaMHe3e ;
y3nosb1M o6pa3osaHltlHM, onpep,enmor VIX pa3- - H3Jlli!Yllle 3a6onesaH1t1rli HepBHOW ClllCTe-
Mep , nnoTHOCTb, OAHOPOAHOCTb , Kon1114ecrso , Mbl , ll.\lllTOBlllAHOlil )f{ene3bl , ne4eHlll , HaAn04e4Hlll-
nop, Bfll}l{HOCTb . KOB.
A1114>4>Y3Hast MacTonanut Kn111H1114eCKll1 3. 06beKmUBHble aaHHble:
npOflBDHeTCS'l 6one3HeHHblM Ha6yxaH111eM MO- - CHH,QpOM AH<f:><f:>Y3HblX H3MeHeHHH B
.no4Hb1X )f{ene3 , KOTOpoe MO)f{eT yc1t1n111BaTbC5l BO MOilO'IHOV! >Ke11e3e (nanbnaropHo Mono4Hble
aropor/i cpa3e MeHCTpyanbHoro 4111Kfla, noHans:i- )f{ene3bl nnoTHbte c A111¢cpy3Ho pacnono11<eHHb1-
IOTCS'I Bb1AeneHll15l lt13 COCKOB . np111 nanbnal..\111111 Mlll y3naM111 (r111nepn.na3111poBaHHb1e AOnbKlll) , He-
MonoYHblX )l{ene3 onpe11enHeTC5l rpy6afl 11onb- pe31<0 orrpaHlt1 4eHHb1Mlt1 OT OKpy>KalOIJ..llllX TKaHel4 ,
4aTOCTb , T5l}l{lllCTOCTb Ill MenKa5l 3epHlllCTOCTb, Ill pe3KO Bblp8)1{8HHOC1 Q:>1116poT11138Ulllelil CTpOMbl);
Bblpa)l(eHHble B O,llHOW !Amt o6e1AX MOfl04HblX - CHHAPOM naTOilor w1ecKoa.f ceKpe~ww
)l{ene3ax. 5om1 111 ynnorHeH111s:1 B Mono4HblX >Ke- 1113 cocKa (Han1114111e BblAeneH111IA 1113 cocKa BHe
ne3ax IA Bbl,[1eileHIA5l 1113 COCKOB nplA ,£!1AcpcpyJHOW nep111op,a 6epeMeHHocrw 1t1 na1<Ta41t11r1 . Bb1,aene-
MaCTOnaTl/1111 6blBalOT HenocT05lHHblMIA 111 MOryT H11t5l 6b1Ba!OT KpOB5lHlllCTble , cepo3Hble , MOn03111B-
neplllO,.QIAYeCKl/J yc111n111saTbCB 111n111 yMeHbill8TbC5l , Hble, rHoee111p,Hb1e , cn1r131itcTble VI ,.qp. KpoBHH1tt-
oco6eHHo nocne Ha4ana MeHcrpya4111r/i . BcTpe- cTb1e BblAeneH1i1.fl .5lBn.fltoTC5l np"13HaKoM BHYTPlll-
Yaercs:i 3Ta Q:>opMa Yallle y MOflO,LlbJX, MeHcTpy111- npoT0Kosb1x Hoeoo6pa3osaH111!1 - nan111nnOMbl 111
PY10LJ.1111x )f{eHLJ.llllH. paKa . Mono3111BHble Bbl,D.eneH111S'I YaLI..\e scero
Y311oeaJt MacTonaTMJt 5lBnHeTc.5l c.ne,ayio- CBlllAeTellbCTBYIOT 0 rnnepnponaKT1ttHeM11111 Ha
ll.\eill CTaA11teli1 3a6onesaH1115l . 0Ha xapaKrep1113y- cpoHe MlllKpoa,qeHOMbl rnnocp1113a 11111111 naTonorn111
ercs:1 nos:1sneH111eM nocTOS'IHHblX o4aroB ynnoTHe- LI..\lllTOBlllAHOrA )l{eJle3b1);
H111s:1 B OAHOrli 111n111 06e111x MOfl04HblX >Kene3aX, - ClllHAPOM YJilOBoro o6pa3oBaHMst B
np1114eM 3Tlll ynnoTHeHlllS'I MoryT 6b1Tb OAlllH04Hbl- MOilOlfHOM ')l(ene3e (nanbnaropHO B MOnOYHOH
Mlll 111 MHO>KecTBeHHblMlll . KpoMe 3TlllX ynnoTHe- )f{ene3e onpeAens:1eTc5l o6pa30BaH111e c poBHblMlll
HlllVI , coxpaH5lfOTC5l np1113H8Klll ,q111Q:>cjJy3HOli1 Mac- Y8TKl4MIA KOHTypaMl/J, xopowo OTrpaHllJ4eHHOe OT
TOnarn111 : rpy6aS1 ,!J.OJlb4aTOCTb, 3epHlllCTOCTb , oKpy)f{alOl.LllllX TKaHelil , no.QBlll)l{HOe , 111Hor,D.a yMe-
T5l)f{VICTOCTb, Bb1,qeneH11t5l 1113 COCKOB . Orn11t4111- peHHO 6oneJHeHHOe) ;
renbHblMVI np1!13H3K3Mlll OT OHKOJ10rL14eCKlllX 3a- - c111MnTOM KeH1rtra noilO)KMTeilbHb1ill
6oneBaHlllVI 5lBJ1HeTC51 OTCyTCTBllle TaKVIX ClllM- (np111 nonb1TKe 3acp111KcwposaTb y3noaoe 06pa30-
nTOMOB , yM6unuKau,uu, flUMOHHOU KOpKU,
KaK BaH111e pyKolil OHO «BblCKanb3blBaeT» 1113-nOA
yrnonw,eHUR cKnaaKu apeon&1, smR>KeHue cocKa Hee).
yBen111YeH111e pernoHapHblX n111Mcpoy3nos. 4. JiononHumenbHb1e Memoab1 uccneaoea-
Pa3AeneHllle MacronaT111111 Ha ,D.1t1cpcpy3Hy10 111 HLJfl:
y3nosyio cpopMbl YA06Ho AI15l KnlllHlllL\lllCTOB, OA- 4.1 He11tHBa311tBHble MeTOAbl 1i1ccneA0BaH1115!:
HaKo MOptj)onorn4eCKlll np111 ,Q06poKa4eCTBeHHblX - ynbmpac0Ho2pacj.Jufl (HapyweHwe napeH-
A111Cn.na3111S1X pa3nlll4alOT ABe OCHOBHble cPOPMbl: x111MaT03Ho-cTpoManbHoro COOTHOW8Hl<1S'I, Blll-
HenponucpepamuaHy1-0 u nponucpepamue- 3yan~3a4111.fl aHJxoreHHoro o6pa3oBaH~~ c poe-
Hy1-0 . K co6CTBeHHO npe,o.paKY OTHOC5lT npon1.-1- HblM 4eTKlllM KOHTyPOM (KlllCTa) 111n111 o6pa3oBaHl/IS'I
cpepaT111BHb1e Q:>opMbl MacTOnaT111111 c r111nepnna- nOBbJWeHHOJA 3XOfeHHOCT~ c aHaJlOr1114HbJM KOH-
cT111YecK111M111 pa3pacTaH11t5lMlll 3n1.-1Ten111s:1 111 Alllc- rypoM Ill aQ:>cpeKTOM «MS'lrKlllX» aKYCTlll4eCKlllX 60-
nna31-1eil\ . KOBblX TeHeW (¢~6poaAeHOMa) (p~c. 5. a, 6, B);
 - ynbmpacoHocpacpuR c mexHonocueu Mi- 3HaKoM npocTolli KlllCTbl; Ham11.1111e p,ecpeKTa Ha-
croPure (no3Bom1eT BblS'IBlt1Tb CKonneH1t1s:1 Mli1Kpo- nonHeH1117! - L..\IACTaAeHonan111nnoMb1) ;
Kailbll,1t1HaToB B TKaHs:IX >K8Jl83bl lt1 npolt13Becrn - TOHKOll1fOilbHaS'I nyHKL..\IAOHH8fl acn111paL1111-
np1111...1enbHYIO 6£100CV!IO. 0HHafl 6vioncwH {sb1RsneH1t1e rnnepnna31t11t1 , Me-
- eupmyanbHBR ynbmp83BYKOB8R ayKmO- ranna31111t1 , A111cnna3111111 I, II , Ill creneH111 111 arnm-i1t1
cpacfJuR (n03BOils:l8T OU.8Hlt1Tb COCTOs:IHlt18 npoTO- 3n111Tenl-17I AOI1eK, npoTOKOB 111 Bb1crnnK111 KlllCTbr) ;
KOBOl/i Clt1CT8Mbl MOilOl.IHOIA }f{8Jl83bl) . - TpenaH- 6111onc11151 naTonor1t11.1ecK111x TKaHelA
(no3sons:1er no.ny1.1111Tb crn.n6111K TKaHIA Ails:I r1t1crn-
PMc. 5. YnbTpacoHorpaMMbl MOflO'iHOH
norw-1ecKoro viccne,[!0BaH111fl ; onpe,llen1t1Tb Mop-
>Kene3bl: A - HOpMa; 6 - KMCTa MOflO'iHOH
cponorn4ecK1t1lli nm <PKM 111n111 onyxon1t1) ;
>Ke.ne3bl; B - cjnt6poa.QeHoMa. - np111u.enbHafl nyHKU.1110HHas:i 6111onc111s:1 nap,
- aonnnepCOHOcpacfJUR - ll,B8TOBOe OT0- KOHTponeM Y3V1 11111111 peHTreHorpacfJ111'JecK1t1X
6pa)f(eH1t1e KpOBOTOKa s per1110HapHolli cocy,JJ,1t1- crepeoTaKCW·l8CK111X KOMnblOTepHblX ycraHOBOK
croH cern - y3nosb1e .a.06poKa4ecrneHHb1e 06- (no1<a3aHvieM K npoaeAeH11110 51BnHeTc71 HanviYvie
pa3oeaH1t1s:1 xapaKTep1t13YIOTCs:I OTCYTCTBlt18M yc1t1- Henanbn111pyeMoro o6pa30BaH1117! B Mono4HOlli
Jl8Hlt1s:I KpOBOTOKa B 30He naTOI10rlt11.18CKOro o6b- )f(ene3e; nonyYeHHbllli Marep111a.n Hanpas.nS'llOT Ha
et<Ta 3a cYeT ysen1t1YeH1t1s:i KOI11t1YecTBa cocy,JJ,oB 1t1 U.111TOJ10rlt11.18CKOe 111 rlllCTOJ10flll4eCKOe 111CCI1SAOBa-
cyMMapHoro 06b8MHOro KpOBOTOKa ; H11171).
- peHmceHOBCK8R M8MMOepacfJuR - nposo-
35 neT B I cpa3e
AlllTCS'I nau.1t1eHTKaM crnpwe f1e4eHue
MeHcrpyanbHOro U,1t1Kna (np1t1 A1t1¢cPY3HblX cfJop- Pa3B1t1rne Macronarn111 4acTo npo1t1cxoA1t1T
Max <PKM onpe)J,8Jls:llOTCS'I MHO)f(8CTB8HHble TeHlt1 Ha cpoHe xpoH1111.1ecK111x socnanltlrenbHblX npo-
HenpaBlt1IlbHOIA cfJopMbl c pacnnblB4aTblMltl KOH- u.eccoa a nonoBblX opraHax, AlllccpyHKU.111111 S'lll14Hll1-
rypaMltl , KOTOpb1e a cosoeynHocrn ,lla/OT HeO,llHO- KOB, 3a6onesaH11w w,viroB1t1AHOW >Kene3bl, neYeHltl
po,JJ,HYIO TeHb , 3aH111MafOW,YIO BCIO MOI104HYKl )f(8- B C048TaHlllll1 c cPYHKU,1110HaJlbHblM111 paCCTpolli -
Ile3y; p,ns:i y3n0Bb1x cfJopM xapaKTepHo Han1114111e CTBaMIA HepBHOi/i ClllCTeMbl. y Ka)f()J,0111 60JlbHOlli
T8Hltl c pOBHblMll1 48TKl-1Mlt1 KOHrypaMlll , c o60)J,KOM Macrnnarnelli cneAyeT BblS'IBlllTb OCHOBHYKl np111-
npocBeTneHllls:I no Hapy}f{HOMY KOHTJ'PY 06pa30- '-l1t1Hy 111Jlltl cPOH, Ha KOTOpOM pa3Bll1J10Cb 3a6one-
88Hlt1fl) (pltlc.6.); BaH1t1e. fle4eH1t1e He06XO,llll1MO Ha4111H8Tb c 803-
AeiAcTBlllS'I 111MeHHo Ha Bb1s:isneHHY10 np1111.1111Hy , 4TO
P11tc. 6. MaMMorpaMMb1: A - cp11t6po-
B psip,e cny4aeB MO>KeT nOJ10)f(lt1TeJ1bHO CKa3aTb-
aAeH0Ma MOflO'iHOH >Kene3bl, 6 - Ai..t<f>cpy3- C71 Ha KI1111Hlt14eCKOlli ClllMnTOMarnKe )J,lllcPcPY3HOli1
Ha.R cpopMa cp11t6p03HO-KlltCT03HOH 6o.ne3Hlll. M8CTonaTll1111. 60JlbHOlli MOryT 6b1Tb p,aHbl COBeTbl
- KOMnb/OmepHaR u M88HUmHo- B OTHOW8HIAl4 HOpM8J1143al.!Wl1 nonoaoi1 >KIA3HVI ,
pe30H8HCH8R mOMOcpacfJuR (no cpaBHeHllllO c Heo6xoA1t1Mocrn 111MeTb 6epeMeHHOCTb , POAbl c
MaMMorpacfJltleV! o6na,JJ,aKJT 6onee BblCOKOV! pa3- o6713aTeJlbHblM AillATeilbHblM KopMneH111eM pe-
pewa10w,ei:1 cnoco6HocTblO , no3BOI15lS'I OL..\8Hlt1Tb 6eHKa fPYAbKl.
06pa3oeaH111s:1 rno6olli nnornocrn , see OTAeilbl MeA111KaMeHT03Has:i repan111s:1 ,lllllcPcPY3Holli
MOI104HblX >Kene3, BKn/04aR perpoMaMMapHoe <PK6:
npOCTpaHCTBO, aKC111Jlils:IPHYKl Ill napacTepHailb- I. HeMeauKaMeHmo3Hoe nelfeHue:
HYIO 30Hbl, 6e3 ny1.1esolli Harpy3Kll1 Ha nau.111eHTKy) ; • HopMan1t13au.1t1s:1 nonoaolli 111 penpoAyK-
- u,umonoeul/ecKoe uccneaoeaHue ebtae- rn BHolli cpyHKL..\IAIA ;
neHuO U3 COCK8 (npOBO,D,111TCS'I TpoeKpaTHo; Ha- • KOppeKL..\11151 A1118Tbl, HanpaBneHHOl/i Ha
npas.neHa Ha BblRBneH111e rnnepnna31i1111 , Mera- ycrpaHeHltle MeTa6om148CKOro Clt1H/WOMa ;
nna3ltlll1 , p,111cnna3111111 I, II, Ill creneHl-1 111 arnn111111 • aAeKB8THbllli no,JJ,6op 6fOCTf8IlbTepa
3nll1T8Jlll171 npoTOKOB); ne48Hll1e 60J1bHblX C Y3fl080U c/JOpMOU
- copMoHanbHbte uccneaoeaHUR Kpoeu Macmonamuu cneAyeT H84111HaTb c ceKTopanb-
(HapyweHll1e COOTHOW8Hll1s:I 3CTpap,111on- HOV! pe38KL!ll11A MOJ104HOlli }f{8Jle3bl c o6s:i3aTe.nb-
recTocrepoH , ,llecpm..iwr nporecrepoHa, mnep- Hb/M cpOYHb/M fltlCTOilOflll48CKHM 111ccne,llOBaHH-
nponaKT111HeM1t1s:1 111 p,p . HapyweH111s:1). eM
4.2 t1Hea3UBHbJe Memoab1 uccneaoeaHuR: II. MeauKaMeHm03Hoe nel./eHue:
- p,yKTorpacfJ111s:1 (p,ecfJopMau.111s:1 npOTOKOB c 1. HeropMoHanbHas:i Tepan111s:1:
HepaBHOMepHblM pacw1t1peH1t1eM Kan1116pa Ha OT- a) B111rnM1t1Hb1 - npop,om1<111renbHOCTb np111e-
,lleJlbHblX yyacrKax; Ham14111e ,lleQJeKTa HanonHe- Ma 3-6 Mee.:
HIAS'I nOI1111L..\111Kflllll.!8CKOVl cfJopMbl , c ,D,OBOilbHO YeT- • PeT111Hon - 3300 ME/cyr 1.1epe3 10-15
KIAMIA pOBHblMIA KOHrypaMl/1 B npoeKL..\IAIA BHYTPIA- MIAH nocne eAbl.
npOTOKOBOlli nanll1111J10Mb1); • ToKocfJepona au.eTaT 100 Mr/cyT BHYTPb
- nHeBMOK1t1crnrpacfJ1t1s:1 (orcyrcTB111e p,e- IAJllA B/M
¢eKTa HanonHeHltlf/ c YeTKWMlll KOHTJ'P8Ml1 71Bnfl- + n111p1t1AOKCll1H - BlllT 86 0,005 r x2 p/cyr.
eTC51 A111<P¢epeH~111anbHO AV1arHocrnYecK1t1M np111- 30 AHeVI , eypc noernp7110T 4epe3 2 Mee .
• AcKop61t1HOBa5l KIACJlOTa 0,05 r/cyT.
211
 • ll10A1t1A Kan1t1~ 100 Mr/eyT 6 Mee.
6) renamnpornKTOpbl:
• 3cceHL.\1t1anbHb1e cpoecpon1t1n1t1Ab1- 300 Mr
x 3 pa3a B cyTKltl, nocne eAbl
• p-p peMaKeo.na- 400 Mn sis
• D1t1s-52 - 2-3 Ta6. x 3-4 pa3a B eyTKltl no-
ene eAbl
s) CeAaTltlBHble npenapaTb1:
• HaeTOli1Ka sanep1t1aHbl - 20 Kan. Ha HO'-lb
• Hoso-naee1t1T- no 1 rn6 . Ha HO'-lb 3-6 Mee.
r) <t>1t1ToTepanesrn4eeK1t1e cpeAeTBa :
• MaeTOAltlHOH H - no 30 Kan. x 2 pa3a B
e}'TKlll 3-6 Mee.
• ArnyKaeToH - no 20-30 Kan. yTpoM 3-6
Mee .
• 111HAlllHOfl no 1 Kan . x 3 pa3a B AeHb AO 6
Mee.
2. lopMoHanbHa~ Tepan111s:i
a) lecrnreHb1:
• nporecTepOH - 10 Mf/CyTKltl B/M 1 pa3 B
,[\eHb c 16 no 25 ,[\eHb MeHeTpyanbHOfO L.\lt!Kna 3
Mee .
• nporeeTepOH (AIOcjJaeTOH , YTPO)f(eeTaH) -
Kane. - 1DO Mr x 2 p. B .i:ieHb c 16 no 25 ,lleHb
MeHcTpyanbHOro L.\ltlK.na 3 Mee.
+ nporeeTepOH renb
6) KoM6111H111posaHHb1e 3erporeH-reerareH-
Hb1e npenapaTb1:
• 3Tlt1Hltln3CTP8Alt10n
+Ae3oreeTpen/nesoHoprecTpen - Ta6n. - no 1
T. e 1-5 AH~ MeHeTpyanbHOfO L.\lt!Kna 21 AeHb,
3aTeM nepepblB 7 ,QHeli1 1t1 np1t1eM Ta6neTOK lt13
HOBOli1 ynaKOBKVI no TOli1 )f(e exeMe - 3-4 Mee.
B) AHT1t13eTporeHHb1e npenapaTb1 :
• TopeM1.1cpeH -Ta6.n. 20 Mr/eyT. 3- 6 Mee.
r) 5noKaTOPbl rnnocp1t13apHblX ropMOHOB:
• ,[\aHaJon - Kane. 100 Mr/cyT. 3-6 Mee.;
• 6poMOKp1t1nTlllH - Ta6n . 2,5 Mr/ CyT. BO
BpeM~ eAbl BeYepoM 4-6 Mee. nOA KOHTponeM
nponaKTVIHa KpOBltl;
• Ka6epron1t1H (Aoen1HeKe) - rn6n. - 0,5 Mr
1 pa3/HeA . 8 - 12 HeA.
Y3noBble <j>opMbl <l>K5- no,[lne)f(aT x1t1pyp-
r111YecK0My ne4eH1t110 no eneAYIOll\ltlM MeToA1t1-
KaM :
1. ceKTopanbHa~ pe3eKl..1L1~ MOJlOYH0£1 )l{e-
ne3bl (Tpa,D,VIL.\lt10HHa~ (/[ 3HAOeKon1114eeKa~);
2. 3HyKnea41t1~ Q:>1116poaAeH0Mb1 ;
3. CKnep03li1pOB8H1!1e KlilCTbl (3TaHOJlOM ,
«CynbcjJaKp111naToM», nposeAeH111e na3ep1t1HAY-
L.\ltlposaHHoli1 TepMOTepan1t11t1) nOA Y3111 KOHTpo-
neM .
4. Da3epHa~ ltlHTepCTlllL.\ltlOHanbHa~ TepMO-
Tepan111~ (na3epHoe CKnep03111pOB8Hltle) KlllCT MO-
J104HOli1 >1<ene3bl.
PAK MOI104HOVI >KEI1E3bl
PaK Mono'"IHOlll >Kene3bl - 3noKa4eeTseH-
Hoe HOBoo6pa30BaH1t1e MonOYHblX >Kene3, 6epeT
eaoe HaYa.no 1113 3nlATenm1,lloneK11 npoTOKOB.
212
3nudeMUOfl02Ufl
B CTpyKType OHKOJlOfltl'.JeCKOW 3a60.nesae-
MOCTlt1 111 cMepTHOeT1t1 PM)K 3aH1t1MaeT I MecTo,
coeTaBn~~ 20 ,5% 1t1 16,5%. n~Tlt1Jl8TH~~ Bbl>Kltl-
BaeMOeTb eocTaBn~eT np111 I eTa,Qllllll - 95 %, nplll
II CTa,D,ltlltl - 70-75 %, np111 Ill eTaA111111 - 45-50 %.
n~TltlneTH~~ Bbl>KltlBaeMoeTb 60JlbHblX npltl IV
CTa,D,1111if np1t16Jl1t1}1(88TC~ K 0 %.
<t>aKTopbt p1t1cKa paKa Mono4HOli1 )Kene3bl
ycnOBHO MO)KHO pa3,Q8Jllt1Tb Ha 3H,QOreHHble (/[
3K30feHH ble.
l<naccu<j:Jw<au,uR tj:Ja1<mopoe puc1<a pa1<a
MOllOYHOU JKefle3b/
1. <t>aKTOpbl , xapaKTep1t13YIOll.\ltle cjJyHKL.\lt10-
H111pOBaHlile, penpOAYKTlllBHOli1 CltleTeMbl opraHlll3-
Ma:
a) MeHcrpyanbHa~ . nonosa~ , .QeTopo,[lHa51,
naKT8L.\lt10HH851 Q:>yHKL.\lllltl ;
6) rnnepnnacT1t14eeK1t1e 1t1 socnan1t1TenbHb1e
3a6onesaHIAJ:I Hlil4HL1KOB Ill MaTKlil.
2. 3HAOKp1t1HHO-MeTa6on1t14eCKltle cpaKTOpbl,
o6ycnosneHHble eonyTeTBYIOll.\ltlMlil 1.1 npeAweeT-
BY10U\lilM1t1 3a6onesaH1t1~M111:
a) O}K1<1peH1t1e;
6) rnneproH1t14ecKa~ 6one3Hb;
s) eaxapHblli1 A1t1a6er;
r) aTepocK.nepo3;
A) 3a6onesaH1t1s:t ne4eH111 ;
e) 3a6onesaH1t1~ L111t1TOB1t1AHOi1 }Kene3bl ;
>K) .Q1<1eropM0HanbHb1e rnnepnna3Vllt1 Mono4-
HblX *ene3.
3. leHeT1t14eeK1t1e cjJaKTOPbl (HOCl-1TeJ11-1 reHOB
BRCA1 1t1n1t1 BRCA2)
4. 3K3oreHHble cpaKTOpb1:
a) lt10Hlt13VIPYIOIJ..lee lt13J1y4eH1t1e;
6) KYPeH111e;
8) anKoro11b;
r) 1t136b1T04Hoe noTpe6neH1t1e }Klt1BOTHblX }Klil-
pos, sb1coK0Kanop1t1IAHas:t A1t1ern;
p,) X1t1M1t14eCKlile KaH4eporeHb1 , 06L11111e Amt
scex noKan1113aL1111li1 onyxoneli1.
Mop<PonontlfecKwe oco6eHHOCTH cTpoe-
H111s:t paKa Mono4Holi1 }Kene3bl 111Me10T 6onbwoe
3H84eHVle B Bb16ope ne4e6Holi1 TaKTltlKltl Iii OK83bl-
BalOT eyL11eCTBeHHoe sn1t15IH1tte Ha nporHo3 . Cpe-
Alil 3J10Ka4ecTBeHHblX onyxonei1 Mono4HOli1 }Ke-
ne3 (B03 , 1981) pa3n1t14a10T:
1. He1t1HBa31t1BHb1e: BHyTp1t1npoT0Kosas:1 111
AOnbKosa~ Kapl..\lllHOMb1 ;
2. VIHsa31i1sHb1e: BHyTp111npornK0Bas:t , ,llOflb-
Kosa~ . cn1t13111eTa~. MeAynn~pHa~ . nan1t1nn~pHas:t
Kapl..\lt1HOMbl.
3. PaK cocKa (paK ne,a,)l{eTa) - nnocKoKne-
T04Hblli1 paK.
MeTacTa3111pyeT paK MOil04Holi1 }Kene3b1
npe1t1MyL11ecrneHHO n1t1McporeHHblM 111 reMaToreH-
HblM nyTeM c nopa}KeH1t1eM KOeTeli1 cKenern, ne-
YeHlll , nerKlilX, ronOBHOro M03f8.
 T - nepu...,~Hast onyxonb

Pa3Mep onyxo.n "1 Pa3Mep ooyxo.nM Pa3Mep onyxo11..., Onyxo.nb npopacTaeT

A02CM 2 - 5.CM >!iCM 0 KO:itCY 11111"1 B nepo,QHIOK>
r pyAHYIO CTeHKy
D.Vl¢>Q>)'3Hble ct>OPMbl PM:>f<
N - pentoHallbHbte nMM¢>aTM'"leCKMe Y3.J'.lbl

Pe·ri.10Han~Hble ·JTY na.nbTl 1t1 py10T~ nanbn111pyK>T~ Mc:.n-acTa3bt

He n a111:mlllpyt0Tcs:i e.o.Hf-11-1'-fH~O CMew aeMl:d6 HecMew.aeMble B 3arP YA"1HHblC
nOAMbfW e 'IH bl"e .ny . no.aMbiwe'"IHble JlY J.1 H Bp.IClllO'i"1t.tHble JlY

M - O TAa lleHHble MeTaCT83bl

0,.A3neHHble MeTaCTa3~ OTl:i.arte1tHb1e ~e-raCTa3t>I Bt>1s:ie11eHb1

UC SblABJlSHbl Ol'CYTCTBYIOT OTAl:Ul eHffble Me-racTa3bl

Puc. 7. KnuHuYecKaR KnaccucpuKal.{Ufi paKa MonOYHOil >Kene3bl no Daniel F.Hayes, 2000.

T - nepB1t14Has:i onyxonb np111Me48H1t1e: lpy,D,HaSl CTeHKa BKill048eT

Tx HeAOCTaT04HO A3HHblX p,ns:i 01..1eHK1t1 pe6pa, Me)f{pe6epHb1e MblWL\bl , nepep,HIOIO 3y6-
nepBlt14Ho.;, onyxon111 48TYIO MbJWL\Y, HO 6e3 rpy.£1Hb1X MbJWL\.
TO nepB1t14Hasi onyxonb He onpep,ensieTc71 T4a PacnpocTpaHeH1t1e Ha rpyp,HylO
Tis npe111HB33111BHa51 Kap1..1111HOMa: 111HTpa- CT8HK'f
AYKTaJlbHa5l 11111111 no6ynsipHa5l K8PLl1t1HOMa in T4b OreK (BKill04as:i «fl1t1MOHHY10 Kopo4-
Situ, 111n111 60ile3Hb nep,)f{eTa COCKa 663 Ham1141115l Ky» ); 111flll1 lt13bs:l3BJleHll1e KO)f{ltl MOfl04HOlli )f{efle3bl,
onyxonesoro y3na 1t111111 caTe11111t1Tbl B KO)f{e )l(ene3bl
np1t1Me4aH1t1e: 50J183Hb nep,)f{eTa, np1t1 KO- T4c np1t13H8Kll1, nepe41t1cneHHbl8 B 4a 111
TOpo.;, nanbn111pyeTcs:1 onyxonesb1.;, y3en, Knac- 4b
c111¢1t1L11t1PYeTcs:i no ero pa3MepaM. T4d Bocnan111TenbHas:1 cpopMa paKa
T1 Onyxonb p,o 2 cM s Ha1116onbWeM 1t13Me- np111Me4aH111e : Bocnan111TeflbH85! Q::iopMa pa-
peH111111 Ka Mono4Ho.;, )f{8Ile3bl xapaKTep1113yeTcs:1 p,111c:jJ-
T1 mic (Mlt1Kp0111HBa3v15l) ,IJ,o 0,1 CM B QJY3HblM yTOnlJ..18Hll18M KO)f{ll1 c nnoTHblMll1 Kpa51-
Hall160flbWeM lt13MepeHlt11t1 Mll1, o6bl4HO 6e3 nop,ne)f(alJ..le.;, nanbn111pyeMo.;,
T1a /J,o 0,5 CM B Ha1t160flbWeM li!3Me- Ma CC bl.
N - pernoHapHble n111MQ::iarn4ecK111e Y3flbl
T1 b ,[\o 1 CM B Ha1t16onbW8M lt13Mepe-
HI/Ill! Pe2uoHapHblMU flUMtj:Jamul.feCl<UMU
T1 c ,IJ,o 2 CM s Ha1116onbweM 1113MepeH1111t1 y3naMu RBnmomrn:
T2 Onyxonb p,o 5 CM B Ha1t160ilbWeM 1113Me- 1. nop,Mb1We4Hble (Ha CTOpOHe nopa)f{e-
peHlt1V1 Hltlfl): 111Hrepne1<TopanbHble (n111McparnYecKwe y3-
T3 Onyxonb 6onee 5 CM s Ha1116011bWeM nb1 PoTTepa) 111 n111MQ::iarn4ecK1t1e y3nb1, pacnona-
1t13MepeH1t11t1 ra10lJ..11t1ecs:1 B.QOilb aKc111nns:ipHo.;, BeHbl 111 ee np111-
T4 Onyxonb mo6oro pa3Mepa c npsiMblM TOKOB, n0.£1pa3,QeJ151IOTC51 Ha cne.QYIOL1.\111e ypoBHll1:
pacnpocTpaHeHll18M Ha rpy,o,HylO CT8HKY 11111111 • YposeHb 1 (Hll1)1(H1t1e no,D,MblW84Hble):
KO)f{Y n111MQ::iaT1t14ecK111e Y3Ilbl pacnono)f{eHHble naTe-
panbHO no OTHOWeHll1IO K 6oKOBO.;, rpaHltll\8 Ma-
noi;, rpy,D,HO.;, MblWL.lbl;
213
 • YposeHb 2 (cpeAH111e noAMblWe4Hb1e):
.n111Mcj:.>arn4ecK111e y3.nb1 , pacno.no.>1<eHHb1e Me}f{,[ly
Mep,111a.nbHblM 111 .naTepanbHblM KpaeM Ma.noili
rpyAHOili MblWL\bl 111 111HTepneKTopa.nbHble (.n111M-
cparn4eCKll1e y3.nb1 Ponepa) ;
• YposeHb 3 (an111KanbHb1e no,D,Mb1We4Hble) :
n111Mcparn4ecK111e y3nb1 pacnono.>1<eHHb1e Mep,111-
a.nbHO no OTHOWeHll1IO K MeA111a.nbHOMY KpalO Ma-
no!A rpyp,Hoili MblWL\bl, BKnl04a51 no,D,Knl041114Hble
111 an111KanbHb1e.
2 . BHyTpeHH111e .n111Mcparn4ecK111e y3nbl MO-
no4Hoili >1<ene3bl (Ha cTopoHe nopa.>1<eH1115I} pac-
no.nara10TC5I B 3HAOTopaKa.nbHOili cpac4111111 Ill
Me>Kpe6epHblX npocTpaHcTsax sp,o.nb Kpa51 rpy-
AlllHbl.
n106b1e p,pyrne n111McpaT1114ecK111e y3.nb1 , no-
pa.>1<eHHb1e MeTacTa3aM111, BK.nl04a51 HaAKnl041114-
Hble, welAHble, 111.n111 KOHTp.naTepa.nbHble BHYT-
peHHl/18 .n111Mcparn4ecK111e y3nb1 Mono4Hoili >1<ene-
3bl o603Ha4alOTC51 KaK OTAaneHHble MeTaCTa3bl
M 1.
Nx - HeAOCTaT04HO AaHHblX An51 04eHK111
COCT051H11151 pernoHapHblX .n111Mcj:.>aT1114eCKlllX y3.nos
NO -HeT np1113HaKoB nopa>1<eH1115I MeTacTa-
3aM111 pernoHapHblX n111Mcparn4eCKlllX y3.nos
N1 -MeTaCTa3bl s cMeL1.1aeMb1x noAMb1We4-
HblX .n111Mcparn1.JecK111x y3nax(e) Ha cTopoHe no-
pa.>1<eH1115I
N2 -MeTaCTa3bl s no,D,Mb1weYHblX n111Mcpa-
rn4ecK111x y3.nax(e), cp111Kc111posaHHblX APYr c APY-
roM 111n111 c p,pyrnMlll CTPYKTYPaM111 , Ha cTopoHe
nopa>1<eH1115I; .n11160 nopa.>1<eHo >4 n/yposH51
N3 -MeTacTa3bl s nop,Knl041114HbJX .n111Mcpa-
Tlll4ecK111x y3.nax c/111.n111 6e3 MeTacTa30B s nop,-
Mb1We4HblX .n111Mcpoy3.nax, 111.n111 B H8AKf110Yll14HblX
.n111Mcj:.>oy3.nax Ha crnpoHe nopa.>1<eH1115I c/111n111 6e3
MeTacTa3os so sHyTpeHHlllX .n111McpaT111YecK111x y3-
nax(e) MonoYHoili >1<ene3bl Ha cTopoHe nopa>1<e-
Hll151
M - OTAaneHHble MeTacTa3bl
Mx - Hep,ocTaT04HO p,aHHblX AI151 onpep,e-
.neHlll51 OTA8IleHHblX MeTaCTa30B
MO - HeT nplll3HaKos orp,aneHHblX MeracTa-
308
M1 - 111MelOTC51 oT,o,a.neHHbJe MeTacTa3bl
lpynn111posKa no CTa,D,11151M
CTap,11151 O TisNOMO
CTaA11151 I T1 NOMO
Crap,11151 llA TON1 MO; T1 N1 MO;T2NOMO
CTap,11151 llB T2N1 MO; T3NOMO
Crap,111s:1 lllA TON2MO; T1 N2MO ;T2N2MO; T3N2MO
CTaAVIH lllB T 4 n106as:1 NMO; n106as:1 T N3MO
CTaA111s:1 IV n106b1e T 111 NM1
,Q11tarHOCTHl.leCKHM anropHTM
1. >Ka1106b1:
- Ha.n1114111e o6pa30BaHlll51 (yn.nOTHeH1115!) B
MOJ104HOili .>1<e.ne3e;
- ,o,ecpopMa411rn Mono4Hoili >1<ene3bl ;
- 6om1 s Mo.no4Holil >1<ene3e;
214
- BTS'l.>1<8Hli1e COCKa;
- reMopparn4ecK111e 111n111 cepo3Hble Bb1p,e-
11eH1115I 1113 COCKa;
- H8fllll41118 o6pa30BaHll15! B nOAMblWe4HOili
06.nacrn ;
- OTeK TKaHeili M01104HOCi >1<e.ne3bl (110Ka11b-
Hblili 11111111 ,D,111cpcpy3Hblili (np111 lllHcplll.nbTpaTlllBHblX
cpopMax PM>K);
- 1113bs:J3Bfl8Hllle COCKa (np111 paKe neA>K8Ta).
2. AaHHb1e 06be1<mueH020 ucC11eaoeaHuR:
- B TK8HS'IX MOJ104HOCi )f(8J183bl np111 na11b-
na4111111 onpep,em1ercs:1 KaMeHlllCToili n11ornocrn
o6pa30BaH111e c HepOBHblMlt1 HeYeTKlt1Mlt1 KOHTY-
paMlll , cnas:1HHoe c 0KpY.>1<a10L1.1lllMlll TKaHs:1M111 ;
- C-M «nno1J4a.QKM» - OTCyYCTBll1e CM8l1.\8-
Hlll5! onyxo11111 no OTHOWeHllllO K y4aCTKY KO>Klll ,
pacno110.>1<eHHOMY Ha,D, Helli (p111c. 8.);
P11tc. 8. C11tMnTOM nno1.14aAK11t np11t paKe
MOilOl.IHOM >KeJle3bl.
P11tc. 9. l11tnepeM11tJt KO>Kllt 111 .QecpopMa-
1.\H~ KOHTypos MOJ101.1HOM >Kelle3bl np&.1 pa-
Ke.
- C-M «yM611tS111tKaU,lllM» - 8T5!)1{8Hllle K0.>1<111
Hap, onyxo11b10;
- C-M rnnepeMHH KO>KM (xapaKTepeH ,D,1151
111Hcp11111brpar111BHblX cpopM PM>K; 06yc.nos11eH
pacnpocTpaHeH111eM onyxo.n111 no BHYTPll1KO.>l<HblM
.n111McpaT1114eCKlllM npOTOKaM) (p111c. 9) ;
- C-M «IlHMOHHOM KOpKH» - OT8K K0.>1<111
M01104HOili )l{e.ne3bl , 803HlllKWll1ili scneACTBllle 3a-
CT051 .n111Mcpb1 1113-3a 6110Ka,D,bl onyxo11b10 11111Mcpa-
T1114ecK111x COCYAOB;
- c-M Kpay3e - oTeK cocKa 111. YT011ll.\eH111e
apeo.ns:ipHoiA cKna,o,K111 np1t1 cy6apeo.ns:1pHOM pac-
no.no.>1<eH 111111 onyxo.n111 ;
- c-M np11t6paMa nonm1<11trenbHb1t.ll
cMell.\eH111e onyxon111 scneA 3a cocKoM ( «+» c111M-
nToM 06yc.nos11eH pacnpocTpaHeH111eM onyxon111
no npoToKaM) ;
- C-M nat.llpa nOilO>KHTeflbHblM - CB111Ae-
T811bCTByeT 0 npopaCTaHllllll onyxom1 B 6011bWYIO
rpy,D,HYIO MblWLIY Ill ee cpac411110 (MOfl04HYIO >Ke-
.ne3y 3axsaTb1sa10T c p,syx crnpoH or onyxo.n111,
noc.ne,D,HIOIO CM8l1.\alOT 1113 CTOpOHbl B CTOpoHy,
np111 3TOM KO)l{a co61t1paeTCS'I He B Bll1A8 npOAOflb-
HOili CKna,D,Kl-1 , a B 8111,D,e Me11KOJA nonepe4HOJA
cKnaA4arncrn) ;
- Ha111111.1111e nnoTHblX, yse1111t1.1eHHb1x
nHMQlOY3IlOB (Hepe,D,KO B Bl-1Ae KOHr.nOMepaTOB)
B no,D,Mb1We4HOM , noA- 111 Ha,D,K.nl041114HblX 30Hax.
Ype3Bbl4ailiHo sa.>1<HblM p,1151 npas111nbHoro
Bb16opa pa41110HanbHOro .ne4eH111s:1 paKa M01104-
Hoili )l{e.ne3bl s:1sns:1eTC5! onpep,eneH111e ero K.n111H111-
4ecKoiA cpopMbl. no rnny poem onyxo11111 , Korn-
pb1ili 111 onpeAens:1eT K.nlllHlll4ecKYIO cpopMy 3a60-
11esaH111s:1, pa3n1114alOT y3.nosb1e 1-1 A1t1¢cpy3Hble
cpopMbl.
 Y3IlOBbte cf>opMbt PM>K. 8CTpe4aioTcs:i
H8Vl6onee 4aCTO. nanbnaTOpHO onpeAens:ieTC51
AOBOnbHO 4eTKO 04ep4eHHOe, OKpyrnoe, nnOT-
HOe o6pa3oBaHVle c MenKO- VI KpynHo6yrpli1CTOilt
nosepXHOCTblO, orpaHVl4eHHO nOABVl)l{HOe no OT-
HOWeHVllO K TKaHVI )f{ene3bl B CB5'13VI c L1HcpV1nbT-
pa4111elA OKpy>t<alOLL.\lllX TKaHeli1 . B 3aBVICL1MOCTlll OT
Ham14Vl51 111n1t1 OTCYTCTBL151 VIHcp1t1nbTpauviV1 OKPY-
)l{alOll.\VIX CTpyKTyp pa3nL14alOT MeCTHO-
J/IHQ:WJnbrpaTL1BHO L1 orrpaHL14eHo pacryl.ll.llle y3-
nosb1e cpopMbl PM>K.
.QmfJ<f>Y3HblH paK. np11 3TOil! cpopMe paKa
onyxoneBbllA y3en s Mono4HolA )l{ene3e, 1<a1< npa-
s1,1rno, He Bblf!BnHeTCH. nanbnlilpyeTCH li!HcplllflbT-
paT 6e3 4eTKL1X rpaHlllU , 3aHlllMalO~lllVl 3Ha4111-
TenbHYIO 48CTb )l{ene3bl. 8ra cpopMa paKa o6b-
eAlllHs:ier
• Ore4HO-VIHQJVIJlbTpan1BHbtVI pa1<;
• naHL\VIPHbtilt paK;
• BocnanV1renbHb111\ paK - po>t<V1cTonoA06-
Hb1tlt, MacrnTOnOA06Hblt/t.
Bee 3Tlt1 cpopMbl nporHocrn4eCKVI He6naro-
np.1115!THb1, xapaKTep.1113YIOTC51 Kai< 6blCTpb1M poc-
TOM vi pacnpocrpaHeHllleM nepBV14HOlll onyxom1 s
caMOM opraHe, TaK 11 paHHVIM o6wl1pHblM JlVIM-
cpo- 111 reMaToreHHblM Meracra3111posaH111eM.
0TelfHO-"'Hcf>HI1bTpaTHBHblH paK. Mo1104-
Ha5I )l{ene3a ysenV14eHa, ynnorHeHa, KO}f{a ee
(HepeAKO Iii COCOK c apeonoC1) yron~eHa VI OTe4-
Ha , VIMeeT BlllA «nlllMOHHOVt KOPKlll» . np111 3TOM
OTAenbHble onyxonesb1e y3nb1 He onpe,[1em1ior-
cR OreK o6ycnosneH cAasneH1t1eM onyxonesblM
lllHtj:)VlnbTpaTOM nVIMcpaTV14eCKL1X nyrel/1 caMOH
)l{eJle3bl 111n111 I/IX 6noKa,[\HOilt MeTaCTaTlt148CKlt1MVI
3M6onaMVI.
naH'-'MPHbtM paK. XapaKTep1t13yerc51 ony-
xonesotl\ lllHQJlllilbTpauV1elll KaK caMolA )l{ene3bl,
TaK VI KO)l{J.11. nocne,[\H5151 CT8HOBlllTC51 nnoTHOVl,
n111rMeHTV1posaHHOIA , nnoxo cMell.\aerc>1. Moryr
n0'1B1151Tbcfl MHoroY111cneHHb1e BHYTPL1KO)l{Hb1e
onyxonesb1e y3nb1 ; np111 0TcyrcTB1t1V1 ne4eH1115I 0H111
1t13bfl3Bm11orcf! 1t1 noKpbtBalOTCfl Kop1<aM1t1. B
A8JlbHeli1weM Mono4Ha51 )l{ene3a yMeHbwaeTCfl ,
noArnrnaaeTCH KBepxy, CMOpli.(111BaeTC51 - KaK 6bl
n0Kpb1Ta naHL11t1peM 1113 ynnoTHeHHolA 111HQ:>111nbT-
pV1posaHHOL4 KO)l{L1 .
V13 AV1¢cpy3HblX cpopM paKa naH~111pHa>1
cpopMa npoTeKaeT Ha1116onee arpecclllBHO.
Po>1<1.1cTonoA06HblM paK. Ko)l{a Mono4Hoill
)l{ene3bl pe3KO r111nepeM111posaHa, Bbl5!Bn>110Tc>1
n51THa c HepoBHblMlll Sl3blK006pa3HblM111 Kpa51Mlil ,
HanoM1t1Ha10~111e o4arl/I pO}l<lt1CTOro socnaneHIMI.
noKpacHeHllle o6ycnOBneHO pacnpOcTp8HeHll1eM
onyxoneBblX KJleToK no Kammn>1paM VI n111Mcpa-
rnYeCKlllM cocy,qaM 111 1<0MneHCaTopHbJM pacw1i1-
peHV1eM nocneAHlllX (KapuVIHOMaT03HbllA n1t1M-
cpaHnAT). 4al.J.le 3a6onesaH£11e npornKaeT ocTpo,
c 6oneBblM ClllHAPOMOM Ill nOBblWeH111eM TeMne-
parypbl rena, HO 6onb "' reMneparypa MeHbUJe,
\.feM np111 po)f{1t1CTOM socnaneH1111t1. ,IJ,m1 3To171
¢opMbl paKa xapaKTepHbl BblCOK8$'1 3IlOKa4eCT-
215
eeHHOCTb , 6blCTpoe MeTacTa3111posaH111e. BcKope
nocne M8CT3KTOMVllll (B cny4ae ee BbinonHeHV151)
no51BD5'11-0TC51 peu1t1AV1Bbl , lt1CT04Hlt1KaMlll KOTOpblX
cny)l{aT onyxonesb1e KileTKVI 111 3M6onbl B KO)KHblX
VI no,D,KO)l{HblX IlVIMcj:>aTVIYeCKlt1X cocyAaX.
MacnnonoA06HbtM paK. Yall.\e 111MeeT 60-
nee 6ypHoe Te4eH111e . Mona4Has:i )f{ene3a 3Ha4111-
TeJlbHo ysenV14eHa, Hanp5DKeHa, nnoTHa51, rnne-
peM111posaHHa5I , OTMe4aeTC51 noKanbHoe nosb1-
weH1t1e TeMneparypbL B my6L1He :>1<ene3.111cro~
TK8Hlll MOryr npOLL.\ynblB8TbC51 Alllc:f:lcpy3Hble yn-
JlOTHeHVls:!. npol..(ecc 6blCTpO pacnpOCTpaHReTCfl,
nepexOA111T Ha SCIO )f(8Jle3y, MO)KeT conpOBO)l{-
,[18TbC5l nosb1weH111eM TeMneparypb1 Tena . Yacrn
M8CTlllTOnOA06Hbllll paK npVIHlllMalOT 3a HeilaKTa-
L\1110HHblVl Macn.n, noABepra51 6onbHblX x111pypr111-
4ec1<111M BMewaTenbcTBaM.
Y4111Tbtsasi ocrpoe TeYeH111e socnanVITeilb-
HblX cpopM , VIX 6b1cTpoe MeTacrn3111posaHV1e, ne-
4eH111e B 3TlllX CI1Y4851X, KaK npas1-1no, KOHCepsa-
Tli1BHOe .
3. ,lJ,ononH111Te11bHble MeTOAbl lilccne,o,osa-
HVl51:
3.1. He111Hsa3111BHble:
3.1 .1 . PeHTreHoecKaJI MaMMorpa<j:>MJI -
Han1114111e HeO,D,HOPOAHO~ TeH111 c He4eTKlt1M KOH-
TYPOM , m1160 3Be3,D,4aTO~ cpopMbl; M1t11<poKanbL1L1-
HaTb1; Aec:f:lopM8L\1115'1 KOHrypos MOI104HOll1 )K8Jle-
3bl, yronli.(eH1t1e KO)l{1t1; ysenw-1eH1t1e no,t:1Mb1we'"l-
HblX n111Mcpoy3nos (p111c.1 O);
PMc. 10. MaMMorpaMMa 6onbHOM c pa-
KOM MOflO"IHOM )l{ene3bl B KpaHJ..10-
K3YA3I1bHOi1 npoeK'-'lllM.
PMc.11. YnbTpacoHorpaMMa na'-'111eHTKlll
c paKOM MOflO"IHOH >Ke!le3bl (MapKepaMlll
BblAeneHbl rpaHM'-'bl onyxon111).
3.1.2. AyKTorpacl>MJI - Vl3beAeHHOCTb KOH-
rypos npornKa, aMnyrn1...w1s:i npoToKa;
3.1.3. YnbTpacoHorpacf>MSl - Han1114111e na-
rnnornYecKoro o6pasosaHlllfl c HepoaHblMlll He-
4eTKlllMlll KOHrypaML1 ' HeOAHOPOAHO noHVl)l(eHHOVl
3XoreHHocrn c AOpcanbHoC1 aeycrnYecKot.1 reHblO
(p111c. 11 );
3.1.4 . .QonnnepocoHorpacf>MJI - Ham1Y111e
rnn1114Ho171 onyxonesollt AOnneposcKo171 Kp111solA,
KOHL1eHTpau111>1 cocy,o,os s onyxon111, ycV1neH111e
saceym1pL13au111111 06pa3oeaH111S1 (p111c. 12);
PMc . 12. YnbTpacoHorpaMMa paKa Mo-
IlO"IHOH >K0I103bl B pe>KlllMe '-'BeTHOro ,Qon-
n11epOBCKOro KapTMpoBaHMJI.
3.1.5. KoMnbioTepHast TOMorpa<f>Mst, Mar-
HlilTHO-pe30HaHCHaR TOMorpacf>H.R (BblCOKOlt1H-
cpOpMaTVIBHble MeTO,[\bl ,D,lt1arHOCTVIKVI Henanbnlll-
pyeMblX o6pa3oBaHvtL1 MonoYHoi.1 )f(ene3bf; no-
3son>110T 6011ee 1<a4ecrseHHO oueHlllTb creneHb
pacnpocTpaHeHHOCTlll onyxonesoro npol..\ecca no
cpasHeHVllO c MaMMorpacp111elA 111 Y3V1);
 3.1.6. CU.MHT111rpacp111st (paAMOlll30TOnHoe
111ccneA0BaH1r1e) - Bb1s:1aneHV1e 04aroe naTono-
r1114ecKoro HaKonneHVls:I 1113orona e opraHVl3Me,
COOTB8TCTBYIOLL\lllX MeTacTaTlll4eCKOMY 111!1111 nep-
Blll4HOMY nopa>KeHVllO opraHos onyxonb10;
3.1.7. n111Mcporpac:jJ111s:i.
3.2. V1HBa3L1BHble:
3.2.1 . Acn1.11pau.1r10HHast 61r1onc1r1st M ~lllTO­
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A8I18HV1iit 1113 cocKa, orne1.1aTKOB c paHesoiit no-
aepxHocrn, nyHKTaros onyxom1 1t1 n1t1M¢oy3nos).
3.2 .2. TpenaH-6111onc1r1s:1 L1 Mopc:jJonorn1.1e-
cKoe VICCI18AOBaH111e.
3.2 .3. VlHLJ,L13VIOHHa5l 61r1oncV15l .
3.2.4. 3KCL\11131110HHas:i 6111oncV1s:i.
3.2.5. CeKTOpanbHas:i pe3eKU,V15l Mono1.1Hoiit
}f(8Jl83bl co cpOl..fHblM rV1CTOJ10rlll48CKlllM Vlccne-
AOB8HllleM.
Xupyp2ul..feCKoe nel..feHue
I. OpraHocoxpaHHb1e onepau.1111r1 - ceKTo-
panbHas:i pe3eKu,Vls:i MO!lOYHoiit >K.ene3bl c noA-
K!ll04Vl4HO-noAnonaro4HO-noAMb1We4HOiit JlVIM-
c:PaA8H3KTOMVleiit (M0)!{8T AOnOI1H5lTbC5l OAHOMO-
MSHTHOlll 1.1m1 orcpoYeHHOlil nnaCTIAKOill Ae¢e1<Ta
MOJ104HOll1 >Kene3bl CI1€AYIOW.VIMlll TK8H5lMVI : noc-
KyTOM w111po4aiitweiit MblWL\bl cnVIHbl , TOpaKOAOP-
38JlbHblM, KO>KHo-¢acu,111anbHblM , TRAM- nocKy-
ToM , cpparMeHTOM 60I1bWOiit rpy.QHOiit MblWLL\bl VI
AP·) (pVlc. 13).
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HO" }l{e.ne3bl: A - TRAM-.nocKyToM; 6 - TO-
paKO-AOp3a.nbHblM nocKyTOM no Daniel
F.Hayes, 2000.
noK030HUR:
- I VI II cTaAVllll onyxonesoro npo4ecca;
- y3nosas:1 cpopMa PM>K;
- orcyrcreV1e MYI1bTV1L\eHrp1114Horo pocra
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II. AMnyrau,1r1s:1 Mono1.1Hoiit >Kene3bl (npocras:1
MaCT3KTOMVls:!) - YAaneHV1e TOilbKO MOJl04HOi1
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1. I cTaAV15! PM>K y no)!{V1!1b1x 6onbHblX c
rn)!{enoll\ coMaT1111.1ecKoiit naronornell\ ;
2. HanV11.1111e pacnaAa VI Kpoeore4eHV1s:1 1113
onyxon111 y na4V1eHTOK c IV craAV1ell\ PM>K (s 1<a-
1.1ecrse nann111ar111sHoro cV1MnroMaTV14ecKoro
BMewarenbcTBa).
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coxpaHeHV1eM 06e111x rpy.QHblX MblWLJ, 111 y.QaneH111-
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Puc. 14. 06beM yaam1eMblX mKaHeiJ npu
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naMVIMO X1t1pypV11..f8CKOrO BMeWaTeJlbCTBa ,
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3
Puc. 16. CxeMa cmpoeHuR apb1>Ku
1 - 2pb1>1<eBble Bopoma;
2 - cpbl>K8BOe coaep)KUMOe;
3 - cpbf)KeBOD MeWOK.
K/laccufjJwwu,uR 2pb!J1C 6p10wHoiJ cmeHKU
1. no npOl.1CXO>K,D.eHllllO:
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2.no IIOKBnltl3BU,111111:
a) 4aCTble (nax0Bb1e, 6e,D.peHHble, nyno4-
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218
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rpb1>KeBoM MewKe pa3Jll.14atOT we!At<y, reno 1.1
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>t<eBblX BOpOT. <PopMa Ill B€f11114111Ha Bbtns:l4111BaHll151 naxosas:i rpb1>t<a (p111c . 18) - caMaf! 4acTa5!
pa3H006pa3Hbl Ill 38BlllC5H OT noKaf1Li13a4111111 Ill f10Kaf111138~111SI Hapy)f(HbiX 6plOWHblX rpbl)f(. lo-
cTa,.q1-11-1 c:popM1-1posaH1t1>l rpbl)l{.111 . pa3,[\0 Yal.Lle BCTpe4aeTcs:i y MY>K4111H , 4eM y
)f(€Hll.1Li1H. CpeA111 Bcex Hapy>t<HblX rpbl>K )f(lllBOTa
,D.nfl rpbl)I{ xapaKTepHbl mpu cuMnmoMa.
COCTaBJ15'1€T 70-80% .

219

Puc. 18. naxoeaR 2pb1>1<a.
l<naccucj:Juau,uR naxoebJX 2pbl}f(
1. no npOlllCXO)l{,QeHllllO - BpO)l{,QeHHble, np111-
06peTeHHbl8 ,
2. no rnny - np51Mbl8, K0Cbl8
3. no JlOKam13a4111111 - OAHOCTOpOHHllle, ABY-
CTOpOHHl.'le,
4. no T848Hllll0 - CB060JJ,Hbl8 (BnpaBlllMble) ,
ocno>KHeHHbte.
5. no CT8,Qll151M pa3BlllTlll51 - Ha4111HalOLL.\851CS'l ,
KaHaflbHaH , nonHaS'l , naXOBO-MOWOH04Ha51 .
Bo speMR BHyrp111yrpo6Horo pa3s111rns:i 511114-
KO cnycKaeTCS'l B MOWOHKY 4epe3 naXOBbll/1 KaHan
(p111c. 19). 0Ho BbtnH4111BaeT snepe,Q111 ce6s:i n111c-
TOK nap111eTaJ1bHOtA 6plOW111Hbl. K MOM8HTy po>K-
A8Hll151 pe6eHKa 3TOT n111cTOK 6piow111Hb1 Bbtwe
Rlil4Ka o6bl4HO 06111.1rep1t1pyeTCR (p1t1c. 21 ). EC11"1
3TOro He npolllCXO,QlllT, TO 6plOWHaH noflOCTb co-
06LL.\aeTCS'l c He3apaLL.\eHHblM OTpOCTKOM 6p10w111-
Hbl , KOTOpbltA MO>KeT 6b1Tb rpbl>K8BblM MeWKOM
spo)l{,QeHHOtA naxosot.1 rpbl>Kllt (p111c. 20) . Y MY>K-
Puc. 20. Bpo>1<oeHHaR naxosaR 2pb1>Ka
np111 np51MOtA rpbl>Ke (plllC. 22) Bbtn514111BaHllle
npoxo.QlllT Yepe3 3a.QHIOIO cTeHKY naxosoro KaHa-
na, COOTBeTCTBeHHO Me,Q111anbHYIO S'lMKY (foviae
inqvinalis medialis) , Bbtn514111BaH 111n111 pa3pywaH
220
3
Puc. 19. CmpoeHue naxoeo20 KaHana:
1. sHympeHHee omaepcmue naxoso20 KaHana;
2. naxoab10 KaHan;
3. Hapy>1<Hoe omaepcmue naxoao20 KaHana.
YlllH B naXOBOM KaHane npOXO,[!VfT ceMeHHOW Ka-
HaTlllK, y >KeHLL.\lllH - Kpymas:i CB513Ka MaTKlll .
,0,m1Ha naxosoro KaHana 4-5 CM , ero ne-
peJJ,H5151 creHKa o6pa3oBaHa an0Hespo30M Ha-
PY>KHOtA Kocot/1 MblWL.lbl >KlllBoTa , 3aAHS'l51 - none-
peYHow <Pac~"1eitl , sepXHRfl CTeHKa - Hl.4)j{HHMl.4
Kpas:iMlll BHyTpeHHelll KOCOtA Vt nonepe4HOl/1 MblWLI
>KlllBOTa, Hlll)l(HHs:i - naxosol/1 CB513Kotll. BHyTpeH-
Hee oTBepcrne o6pa3oBaHo ynnorHeHHblMlll so-
noKHaM111 nonepeYHot/1 cpac4111111 111 Haxo.Q111Tcs:1 Ha
38,[!Hetll creHKe naxosoro KaHana. Hapy>KHoe or-
sepcr111e 06pa3osaHo ABYM51 HO>KKaM111 anoHeB-
po3a KOCOtll MblWL.lbl )l(lllBOTa.
np111 KOCOt/1 rpbl>Ke rpbl>KeBOtA M8WOK npoxo-
AlllT Yepe3 BHyTpeHHee OTBepcrne naxosoro Ka-
Hana, 4TO COOTBeTCTByer naTepanbHO!il RMKe B
nap111eTanbHOll1 6piow111He (foviae inqvinalis later-
alis) , npOXOAlllT B 3fleMeHTax ceMeHHOro KaHaTlll-
Ka , BblXOAlllT 4epe3 Hapy>KHoe orsepcrne, 4acrn
onycKaeTCH B MOWOHKY. Kocb1e rpbl)l(lll YaLL.\e
BCTpe4alOTCR y MOJ10,[!blX, 111M810T npo,D,onrosa-
TylO cpopMy.
Puc. 21 . npuo6pemeHHaR naxoeaR 2pb1>Ka
nonepe4HYIO cpac1..1111to. OHlll YaLL.\e scrpe4aiorcs:i y
no>KlllJlblX 60JlbHblX, lllMelOT OKpyrnyio cpopMy,
Hepe.QKO 6b1Ba10T ABYCTopoHHlllMlll .
 Puc. 22. np>1Ma>1 naxosaR apbt>Ka.
BHaYane nanbn111pyioT noHHb1ill 6yropoK. B
HOpMe Hapy>KHoe 0TsepcT111e naxosoro KaHana
nponycKaeT KOHYlllK nanbua . 3aTeM onpeAem1eT-
c51 CMMnTOM Kawneeoro TOn'"IKa . np111 KOCOill
rpb1)f{e Bbln5lYlllBaH111e pacnonaraeTcs:i KHapy>K111 oT
ceMeHHOra KaHarnKa , np111 np51MOill - KHYTPlll.
111HorAa YAaeTC51 onpe,D,eillllTb nynbca4111io HaA-
YpeeHoill aprnp111111 . np111 Kocoill rpb1)f{e nynbcau111s:i
ee onpe,D,en51eTC51 KHyTp111 , np111 np51Moill rpb1>Ke -
KHapy>K111 OT rpbl>Keeora MewKa.
np111 naXOBblX CKOilb351~111X rpbl>K8X, OC0-
6eHHO nps:!MblX, B COCT8B rpbl>Keeora MewKa
BXOAlllT cTeHKa opraHa, pacnono>KeHHoro Me-
30nep111ToHeanbHO (MoYeeoill ny3blpb, cnena51
KlilWKa). Kn111HlllYeCKlll , np111 H8Ty>KlllB8Hllllll lllillll
nanbnau111111 rpbl>Kesora Bbln514111BaHlll51 6011bHb1e
MoryT 111cnblTb1BaTb no3b1Bbl K MOl.!e111cnycKa-
H1t110. Bo epeM51 rpb1>Kecel.!eH111si Heo6xo,D,111Mo
C06lll0,D,8Tb oco6yio OCTOpO>KHOCTb . LIT06bl He
BCKpblTb no11b1ill opraH , rpbl>Keeoill MewoK 111cce-
Ka10T 3KOHOMHO, CTapa51Cb He 3aTparlllB8Tb
CTeH KY 3TOra opraHa.
OnepaTlllBHoe 11e4eH111e naxoBblX rpbl>K, e
OCHOBHOM , npOlll3BO,D,lllTC51 no,D, MeCTHOill aHeCTe-
31/!eill (p111c. 24).
np111 3TOM , BCKpb1BaeTC51 naXOBblill K3H811 ,
ceMeHHOill KaHaTlllK 11111111 Kpyrna51 CB513K8 M8TKlll
6epeTC5l Ha JJ,ep>K811KJ', OKOHYaTeJlbHO ycTaH8B-
mrnaeTC51 rnn rpbl>Klll (np51M851, Koca51) .
221
Puc. 24 ,[Jocmyn K naxosoMy KaHany.
P111c. 25. Bb1AeneH111e rpb1>1<esoro Mew-
Ka.
np111 KOCOil! rpbl>Ke BCKpblB8IOTC51 060llOYKlll
ceMeHHOra K8H8TlllK8 , 1113 era 3lleMeHTOB Bbl,D,e-
ll51eTC5l rpb1>Kesoill MewoK, npolll3BOAlllTC>i era
o6pa6orKa (p111c. 25,26 ,27 ,28 ,29) .
P111c. 26. BcKpb1T111e rpb1>1<esoro MewKa.
P111c. 27. BnpasneH111e rpb1>1<esoro co-
Aep>KMMoro.
P1.1c. 28. npow111saH111e weMKlll rpbnKe-
soro MeWKa.
P111c. 29. OTce'"leH1>1e rpb1>Keeoro MewKa.
noc11e :noro BOCCT8H8BJllllB8eTC51 l..\ellOCT-
HOCTb o6onol.!eK ceMeHHora KaHaT111Ka, a TaK )Ke
yw111sa10T 3Ha4t-1TenbHO pacnmyroe sHyrpeHHee
naxoeoe KOllbl..\O (cnoco6 Hocpcpe) . np111 npsi-
Moill rpbl>Ke rpbl>Keeoill MeWOK lllCXO,D,lllT 1113 38A-
Heill creHKlil naxosora KaHa11a. 06bl4HO OH 6b1-
eaeT M8HbWlllX pa3Mepoe , HO nplllBOAlllT K o6pa-
30B8HllllO 60llbWlllX ,D,ecpeKTOB B nonepeYHOill
cpacu111111 . noc11e 06pa60TK111 rpbDKeaoro MewKa,
ero KYllbTIO ue11ecoo6pa3HO nepeMeCTlllTb noA
nonepeYHYIO MblWUY (cnoco6 KpacuHqeaa -
5apKepa) . 8b16op cnoco6a n11acrnK111 naxoeora
KaHa11a 3ae111c111T OT MHornx cpaKTopoe : no11a 111
B03pacTa 60.nbHOfO, nma rpbDKL-1 1-1 MeCTHblX >KeHll.11-lH AonycrnMo Bb1nonHeH111e nnacrnKL-1 ne-
aHaTOMIAl/eCKIAX oco6eHHOCTel1 - BbJCOTbJ naxo- pe,.qHe!.1 creHKVJ naxoeoro 1<aHana (no YepHM,
BOro npoMe>K'fTKa, npo4HOCTll1 anoHespo3a Ha- Py, >KMpapy, CnacoKyKo'-'KoMy ).
py>KHolll KOCOlll MblWL\bl >Kll1BOTa 1-1 TA y AeTelll 111

1 2 3 4
Puc. 30. CxeMa nnacmuKu nepeaHeiJ cmeHKU naxoeozo KaHana: no l./epHu (1); no PY (2); no >Kupapy (3);
no CnacoKyKou,KoMy (4) .

Y MY>Kl.ll-lH , oco6eHHO np111 nps:iMolll rpbl>Ke Heo6XOAL-1MO BblnonHeH1-1e nnacrn1<1-1 38AHelll creHKll1 na-
xosoro KaHana (no 6acc1-1H1-1 , 3HApt0cy, neppacy, nocTeMncKoMy.

2 3 4
·-·
Puc. 31 . CxeMa nnacmuKu 3aaHeiJ cmeHKU naxoeozo KaHana : no 5accuHu (1); no 3 .A. 3Hap10cy (2); no neppacy
(3); no nocmeMncKoMy (4).

B Hawelll KI1L-1H111Ke 6blBWL-1M 3aBeAYIOll.llllM np111 cpopM111poeaH111111 3aAHei::i cTeHK111 naxo-

Kacpe,l\poi::i npocpeccopoM B.V1 .Ky3Hel.\OBblM pa3-
pa6oTaH op111rnHanbHb1i::i cnoco6 n.nacrn1<111 38,.Q-
Hei::i cTeHKL-1 naxosoro 1<aHa11a, ro,.QHbli::i Ails:I Kop-
pe1<4111111 KOCblX Ill npRMb/X rpbl>K.
n11acr1111<a naxosoro Ka Hana
B.H.Ky3Heqoay (pltlc. 32) COCTOll1T lt13 H8CK0Jlb-
Kll1X :nanos:
CHa1.Ja11a yw1-1saeTcs:1 BHyrpeHHee OTBep-
crne naxosoro KaHa.na (1),
Boro KaHa.na K nynapTosolll cas:i3Ke no,.qw111saercs:1
06be,.Q111HeHHoe cyxo)l(111.n111e nps:iMolll MblWl.\bl >1<1-1-
BoTa (2) .
2- y1<penneH111e 3a,.QHe'1 creHKlll naxosoro
no KaHaJla nyTeM no,QLUll1B8Hll15'.l Hll1>KHero JlOCt<yTa
anoHeBp03a Hapy>KHOi-1 KOCOi-1 MblLUl.\bl >K111BOTa:
Me,q111a.nbHO - K o6be,[\111HeHHOMY cyxo>Klt1J1111IO
BHyTpeHHei::i KOCOl/l 111 nonepe4HOi::i MblLUl.\, 11arn-
pa.nbHO - K aepxHei-1 creHKe naxoaoro KaHana
(p111c. 33).
222

Puc. 32. nnacmuKa 3aaHeiJ cmeHKU naxoeoao
KaHana no B.t1. Ky3Heu.oey (f 3man onepau.uu)
3aTeM M8AVlanbHO VI naTepanbHO OT YWVITO-
ro BHyTpeHHero ornepcnrn K nynaproso!A CBSl3Ke
noAWVIBalOTCSl HVl)f{HVle Kpasi BHyTpeHHeiA Koco!A VI
nonepeYHO MblWL\ )f{ll1BOTa (pVIC. 34)
Puc. 33. nnacmuKa 3aaHeiJ cmeHKLJ naxoeo20
KaHana no B.t1. Ky3Heu.oey (II 3man onepau.uu)
nocneAHVIM 3TanoM yKpenm1eTC5! nepeAH5151
cTeHKa naxosoro KaHana nyreM noAW111BaH1115!
sepxHero nOCKYTa anoHeBp03a Hapy>KHOlii KOCOL'.1
MblWl..lbl )1{111BOTa K naxoso!A CB513Ke nosepx ce-
MeHHOro KaHarnKa.
B cno>KHblX cnyya51x - np111 6onbWVIX rpb1-
>1<esb1x sopoTax 111 pe1..1111AV1BHblX rpb1>1<ax, noKa3a-
Ho BbinonHeHVle nnacrnK111 no fluxmeHwme(tHy
c 111cnonb30BaHVleM annoTpaHcnnaHTaTa - npo-
neHosolii ceTKll1. Ee 111cnonb3YtoT Ansi 3aKpblTVl51
3aAHelll cTeHKVI naxosoro KaHana (p111c. 35) .
5eapeHHb1e 2pb1JKu
6eApeHHblMll1 Ha3bl88IOT rpbDKll1, KOTOpble
BblXOAs:!T Yepe3 6eApeHHbllA KaHan (p111C. 36). no
Y8CTOTe o6pa30B3HVl51 OHVI COCTaBil5110T 5 - 8%
or scex rpbl>K >1<111s0Ta. 6eApeHHb1e rpbl>K1'1 Yaw,e,
YeM naxosb1e, npeACTaBn51toT TPYAHocrn AI151
223
,[\111arHOCTll1K111 VI Yaw,e yUJ,eMI15llOTCSl. y >KeHUJ,VIH
OHl/1 BCTpeYatoTCSl B 5 pa3 yaw,e , YeM y MY>KY"1H,
T.K. y >KeHUJ,VIH 6onee W111pOKVlll1 Ta3 VI 6onbWa51
Bblpa>KeHHOCTb Mb1We4HOl/1 Ill COCYAVICTOL'.1 naKYH ,
MeHbWaSl npoYHOCTb naxosolii CB513Kll1.
---:;.,~--- .... ;;..--;;..:_.:-~ .
.-,.__..t.
Puc. 34. nnacm 3aaHetJ cmeHKU naxoeo20 KaHana
no 8 .t1. Ky3Heu.oey (/ff 3man onepau,uu)
Puc. 35. nnacmuKa naxoeo20 KaHana no
nuxmeHwmeilHy.
PMc. 36. 15e.o.peHHaff rpbDKa.
Me>t<Ay naxoso!A CB513KOlii VI KOCTSIMIA Ta3a
111Meercsi npocrpaHCTBO, KOTopoe c noMOU4bto
nop,B3,IJ,OWHO-rpe6ewKOBOl.1 CB513Kll1 pa3,L:1ensieTCSI
Ha ABe naKYHbl - MblWeYHYIO VI cocyAVICTyto. Ye-
pe3 Mb1We4HYIO Ha 6eApO npoXOASIT npoXOA51T
nOAB3AOWHO- no51CHVIYH851 MblWL\8 IA 6e,QpeHHblt.':1
Heps. Yepe3 COCYAVICTylO naKYHY npOXOAS!T 6eA-
peHH851 aprep1AS1, 6e;::ipeHHaS1 seHa, Hepsb1 IA
nlAMcparnYecKVle cocy,£\bl. Ha1A6onee cna6oe Me-
cro - 6ep,peHHOe KOflbl.IO, pacnonaratow,eecS! B
caMOM MeJJ,1AanbHOM OTAene naKYHbl 111 orpaHIA-
YeHHoe MeJJ,1.1anbHO - I18KYHapHot.':1 CB513KOIA , cne-
peAIA - naxoso!A CB513Koll\, C38Al.1 - 1<Yneposc1<01A
CBSl3KOlA, naTepanbHO - 6eApeHHOlA B8HOJA . 6eA-
peHHOe KOnbl..10 3anonHeHo )f{Lo1p0BOlll KneTYaTKOVt
VI n1<1Mcpoy3noM n1-1poroBa-Po3eHMtonnepa .
8HyrpeHH"1M ornepcrneM 6e,llpeHHoro KaHana
51Bns:teTC51 6eApeHHOe KOnbl..\O , Hapy>KHblM -
OB8nbH851 51MK8, OTBepcrne B WlllpOKOlli cp8CL\llllll
6eApa, 4epe3 Kornpoe npoXOAlllT 6onbwaH noA-
KO>KHas:i BeHa. lllHOrAa, MeAlll8nbHO , K 6eApeHHO-
MY 1<aHany npe,llne>Kl!IT 3an111paTenbHa.11 aprep111.11
("KopoHa cMeprn"), np111 nospe)l(,lleH111111 KOTopoi::1
MO>KeT pa3BlllTbC>I onaCHOe ,[ln51 >K1113Hlll KpOBOTe-
4eHllle .
np111 cpopMlllpOB8Hllllll 6eApeHH85l rpbl>K8
npOXOAlllT 3 CTaAllllll - H848IlbHyto, KaHanbHYIO Ill
nonHyto. Ha1116onee xapaKTepHblVI ee KnlllHt114e-
cK111IA np1113HaK - Ham14111e rpbl>Kesoro Bb1ns14111sa-
H111s:t B o6nacrn 6e.QpeHHo-naxosoro crn6a.
06b14HO, 3TO rnaAKOe nonyccpep1114ecKoe o6pa-
30BaH111e He6onbw111x pa3MepoB, pacnonarato-
111eec51 Hlll>Ke naxoeoVI CB513Klll KHYTPlll OT 6eApeH-
HblX cocy,QoB. no5lBI15ls:tCb e eeprnKanbHOM no-
no>KeH111111 Ill nplt1 H8TY>Klt1B8Hlt1111, OHO MO>KeT nerKO,
4acrn c yp4aHHeM, enpaensiTbCs:t e 6ptowHyto
nonocTb.
A1t1¢¢epeHL\ll1POBaTb 6eApeHHYto rpbl>KY
4a~e scero np1-1xo,Ql'7Tc.11 c naxosolA rpbDKelA,
n111M¢aAeH1noM , n111noMoVI , sap1t1K03HblM y3noM
60ilbWOVl no,QKO>KHOVJ B8Hbl, aHeBplll3MOl71 6eA-
peHHOi:1 apTep111111. OT naxoeolli rpb1>K111 6eApeHHasi
0Tn1114aeTc5l TeM, 4TO pacnonaraeTcs:t Hlt1)f(e na-
xoeolA CB>i3Kl'7, a naxoeas:i - Bb1we. np"' n!'7noMe
onpeAens:teTc5l ee AOilb4aToe cTpoeH1t1e, oHa
nOABlll>KHa, He CB5l38H8 c H8PY>KHblM OTBepcrneM
6e,QpeHHOro KaHana . np1t1 Illt1Mcp8A8HlllT8X yse-
Illll4eHl/le I1111Mcpoy3Il0B 48CTO 6blBaeT ClllCTeM-
HblM. npl'7 IlOK8IlbHOM 6e,Qp8HHOM Il1'7Mcpa,QeHl'7Te
He06XOAlllMO lllCK8Tb BXOAHble BOpOTa l/IH¢eKL\111111
Ha Hll1>KHei::1 KOHe4HOCTll1 c :nol.1 CTOpOHbl , KpOMe
Toro, B OTml14llle oT rpbDKlll, n111M¢oy3en nerKo
38XB8TblBaeTC51 nailbl..\8Mlll Ill nOATS'lrlllB851 era
MO>KHO ycrnHOBIHb orcyrcTB1'7e CB.1131'7 c 6e,llpeH-
HblM KaHanoM . Bap111Ko3Hbll71 y3en c111HesaTOro
L\BeTa, KOHClllCTeHL\lt15l ero 04eHb M5lfK85l. AHeB-
Pll13M8 6e,QpeHHOVl BeHbl nynbc1t1pyeT, Ha,Q Heti
BblCilYWlllBaeTC5'l ClllCTOnlll48CKllllli wyM.
B ne4eH111111 6eApeHHbrx rpbl)f( 1.1cnonb3YtoT 2
Blll,Q8 ,QOCryna K 6eApeHHOMY KaHany - 6eAp8H-
Hbllli 111 naxoBbll.1. 1/13 6eApeHHblX Ha1116onbwee
pacnpocTpaHeH111e nony4111n cnoco6 nnacT111K111 no
6acc111H111 (p111c. 37).
P111c. 37. nilaCntKa 6e,QpeHHoro KaHaila
no 6acc111H111.
np111 3TOM cnoco6e ,Qocryn ocy111ecTsns:iercsi
co CTOpOHbl Hapy)f(HOro 6e,QpeHHOro OTBepCTlll5l .
nocne Bbl,QeneHl/l.11 111 o6pa60TKlll rpbl>KeBOro
MewKa, npoll13BO,Q.11T no,QWlllB8Hl/le OT,QenbHblMll1
y3noBblM1it wsaMi.-t naxosoi.1 css:t3K"1 K HaAKOCTHi.-t-
L\e IlOHHOVl KOCTll1 (KYneposol.1 CBS13Ke). He,QOC-
T8TKOM cnoco6a s:iem1ercs:i yeem14eH111e naxoeo-
ro npoMe>KYTK8, 4TO MO>KeT np1t1Becrn K B03HlllK-
HOB8Hlt1IO naxoeoVI rpb1>1<111. An5l npe,QoTBpa111eH111s:i
ra1<oro ocnm1<HeH111.R np111MeH.RIOT naxosb1C1 cno-
224
co6. Ha1116onee 1i13secrnb1IA - cnoco6 PyA)f{IA-
napnase440 (p111c. 38).
P111c. 38. n11aCTlllKa 6e,QpeHHoro KaHana
no Py.Q>1<111-nap11aee't'to.
np111 3TOM cnoco6e scKpb1satoT naxosb1i71
KaHan' OTBO,QHT Ha Aep.>1<anKaX Kpyrnyto CB513KY
MaTKIA 1'7nlA ceMeHHOill KaHaTlllK, pacceKatoT none-
pe4Hyto cpac1...1111io, rpb1.>1<esoVI MewoK nepeso,QHT B
naxosyto o6nacTb, r,Qe ero 1t1 06pa6aTb1BatoT.
nocne ::noro YWlllB8IOT OAHOBpeMeHHO Ill naxo-
BblW npoMe>KYTOK V1 6eApeHb1Vl KaHan, nOAWlllBas:i
HIA.>KHIAW KpalA nonepe4HOlA lll BHyTpeHHeill KOCOi/1
MblWL\ >K111BOT8 BMeCTe c naxosoVI CB513KOVI K KY-
neposoVI CB5l3Ke. 3aTeM BOCCTaHaBI1111BaeTCS1
38,QHHs:t cTeHKa naxosoro KaHana, YKI18Ab1saeTcs:i
Kpyrna5l CB513Ka M8TKll1 lt1Illll ceMeHHOi/1 KaHaTll1K Ill
npolA3BO~IATCH nnaCT/AKa nepe,llHeill CT8HKl'7 na-
xoeoro KaHana.
nynOYHOR 2pb!JKO
nocne orna,QeH1.1s:i nynos111Hbl nyno4HOe
KOilbl..\O 38Ts:tr111saeTC5'l py6L\OBOW TK8Hbl0. Cno111
COCTOHT 1113 KO>KV1 , cpa111eHHOVl c TKaHblO nyno4-
H0"1 cpac41111A "' 6ptoWMHbl.
Pa3ni.-t4ator
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no JleKcepy.
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MeHo.
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225
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226
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paL.1111111 , npope3atoTeSI see WBbl 111 BHyTpeHH111e
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paL\lllOHHas:i rpbl}l{a.
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227
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ponb pe3KOro nOBblW8Hll171 BHyrp1116pt0WHOro
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pyweHO Kposoo6pall.!eH111e. Ha Mecre c>KaTll171
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228
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229
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snpas111MoCTb He s:is115leTC5l noKa3aHvieM AJ15l 3KC- Bblns:!4V1BaH111eM scKpb1saeTcs:! ¢nerMoHa. Yll..leM-
rpeHHolil onepat.1111111 , Ho ecn111 ecTb coMHeHllls:! s neHHas:i nerm1 KlllWKlll y.Qam1eTC5l , 6piow111Ha
TOM, HeT 11111 3AeCb yL11eM11eH111s:! - s 3TOM c11y4ae yw111saercs:i , a paHa ocraercs:i OTKpblTOl/l 111 ,Qpe-
onepat.11115! AOJl)f{Ha 6b1Tb npose,QeHa He3aMe,Qn111- H111pyerc5l. repHVIOnnaCTlllKa He BblnOJlH5leTC5l, a
renbHO . npoV13BOAlllTC51 cnycr5l HeKoropoe speMs:i nocne
KonpocTa3 Ha6n10Aaerc51 np111 Hesnpas111- caHat.1111111 rHolilHolil paHbl.
Mb1x rpbl)f{8X y 60JlbHblX, CKJlOHHblX K 3anopaM .
Hs11eHV15! KOnpocTa3a pa3BVIB8IOTC51 Me,QJleHHO VI

230
 3AEOJIEBAHIDI IlP~OH KIID.IKH
np5!M85! KlllWKa (rectum - naT., proctOS-
rpe4.) npeACTaBmteT co6olil AlllCTaflbHbllil OTAe11
ro11crolil K111WKL1, pacno11o>KeHHblli! B nonocrn Ma-
nora Ta3a 111 3aKaH41t1Ba10l.l.\1t1li!c51 s 06nacT111 npo-
Me>KHocrn .
KpOBOCH06)1{eHue npRMOU KUWKU
np51MYIO KlllWKy KpOBOCHa6)1{alOT 5 apTep111J/i
(p111c. 52) . HenapHa5! sepXH5151 np51MOKll1We4Ha51
Puc. 52. Apmepuu u eeHbl npRMoiJ KUWKU. 1. BepxHRR npRMOKuwe1.1HaR apmepuR, eeHa. 2. CpeiJHue
npRM0Kuwe1.1Hb1e apmepuu, eeHbl. 3. .QuacppaeMa maJa. 4. Hu>KHUe npRMOKUWel./Hble apmepuu, seHbl
8eH03HbltA OTIOK npHMOill KllJWKJ.1 ocyu.iecTB-
m1eTC5! B ABe BeH03Hble ClllCTeMbl - Hltl)l(Heill no-
1101/i L1 BOpOTHOtA BeH . np111 3TOM o6pa3ylOTC51 Tplil
BeH03HblX cn11eTeHL15! - nOAKO)l{HOe, nOACI1L13111-
CTOe 111 noAc.Pac4L1anbHoe. noAKO)f(Hoe cnneTe-
Hlile pacno11o>KeHo noA KO>Kelii . 3AeCb Moryr
cpopM111poBaTbC5! Hapy)l{Hble reMoppOL1Aan bHb1e
y3nb1. Ha1116011ee Bb1pa)l{eHo noAcnvi3111cToe se-
H03Hoe cnneTeHllle , pacnono:>KeHHoe B caMOM
AlilCTanbHOM OTAene np5!MOC1 KVIWKVl , B 30He
npOAOilbHblX CKJlaAOK CJllil3VICTOV! o60J104KL1 8M-
nyflbl. BeH03Ha51 KpOBb OT sToVi 30Hbl orre1<aeT
no sepxHeC1 npflMOKlllWe4HOlil BeHe B Hlll>KHIOIO
6pbl>Kee4HYIO aprepllllO, B ClllCTeMy BOpOTHOlil
seHbl. OT noAKO>KHoro cnneTeHvi51 - B ClilCTeMy
Hlll>KHeVI no11olil BeHbl no Hlll:>KHlllM Ill cpeAHL1M
np51MOKll1W84Hb1M BeHaM.
8 1963 rOAY <P. CTeI13HepoM (F. Stelzner)
1113V4eHbt IA on111caHbt COCVAIACTbte renbu.a np51-
Moill KlilWKL1 (corpus cavernosus recti) c Kpoao-
232
(BeTBb Hlll)l(He6pbl)l(ee4Hoill apTep111111) 111 gse nap-
HblX - cpegH1t1e np51MOKL1We4Hble (BeTBL1 BHYT-
peHHeC1 nOAB3AOWHOJ/i aprep111111) lt1 Hlll>KHL1e np51-
MOK1t1We4Hble (seTBvi BHYTpeHHelil nonosoill ap-
replilL1) . OCHOBHblM apTeplilaJlbHblM CTBOilOM
npHMOr;i KltlWKltl f!Bilfl8TCfl sepxHflfl npRMOKltlW84-
H85! apTeplil5! .
CHa6>KeHJ.1eM L13 CJ.1CTeMbl sepxHeill np5!MOKJ.1-
W84 HOil! apTep11u.1 (p111c. 53).
3Ta apreplil51 lllMeeT npOAOilbHOe no OTHO-
weHL1IO K CTeHKe KlllWKL1 HanpaBI18Hllle, B OTJllll-
41118 OT aprep1111A npOKClllMaflbHblX OTAeflOB TOJl-
CTOill KlllWKlll . A. rectalis superior 51BI15!eTc5! He-
napHor;i. noAXOA5! HenocpeACTBeHHO K np5!MOlll
KVlWKe, OHa AeflVlTCSl Ha 3 BeTBll1 , 111AYLL\1118 no JlV1-
Hll151M, npoe4111py10l.l.\lllMC5! Ha 3, 7 L1 11 4aCOB no
ycnosHoMy 4111cpep6nary 4acos (npL1 nono:>KeHvivi
Tena Ha cn1-1He). 111MeHHO s 3TlllX y4acrKax Ill
cpopM111pyeTc.s:i 3 rpynnb1 1<asepH03HbJX Tene4.
3rn renb4a 111n111 Ko11neKTopb1 - He naT011ornS1, a
HOpMaJlbHble nel.l.\8Pll1CTble o6pa30B8H11151, 3a-
KI18AbJBalOLL\VleC51 B npo4ecce sM6p111oreHe3a, 111
L1Me10l.l.\V1ec5I y IllOAelil n106oro B03pacTa, B TOM
4Vlcne 111 y AeTeC1 . Ao 16-18 neT KasepH03Hble
renb4a pa3Bll1Tbl nnoxo, pa3Mepbl VIX He6onb-
Wlile.c B03p8CTOM lllX senlt141t1H8 B03paCTaeT.
Oco6eHHocmu cmpoeHuR 1<aaepH03Hb1x
meneu,
B CTeHKax KasepH03HblX seH L'IMelOTcs:i Men-
Klile aprep111111 , Koropb1e, He pacnaAa51Cb Ha Ka-
nL'lnn5!pb1 , orKpb1sa10rc51 np51MO s npocser seHbl
(p111c. 54) . 3rn BHyTplilCTeH04Hble aprep111111 H83bl-
9d:rt}6
Puc. 53. KposocHa6>KeHue KasepH03HblX KonneKmopoe u3 eepxHeu npRMOKUWB4HOU apmepuu (cucmeMa HWKHeu
6pbf)KBB4HOU apmepuu).
KasepHo3Hble seHb1 pacnono)f(eHbl s noA-
cn1113111croM cnoe aHaJlbHoro KaHana , Ha yposHe
3y6YaToVI n111H1111i1 rpynnaM"1 , K0Topb1e HanoM111Ha-
10T B"1HorpaAHYIO rp03Ab "1 H83bl88IOTC51 Kasep-
H03Hb1Mlll TeJlbl\SMlll 111Jlli1 KasepH03HblMlll KOJlJleK-
TOpaMlll . 0TAeJ1bHble KasepH03Hble seHbl MOryT
pacnonaraTbC5l 1113om1posaHo.
BeH03HbliA OTTOK OT KOJlJleKTopos ocyLL\eCT-
BmleTC51 no seHaM, 111Me10LL\"1M o6bl4Hoe crpoe-
Puc. 54. CmpoeHue KaeepH03Hoti eeHbt (cxeMa): noKa3aHo pa3aumue apmepuanbHOW Kpoeomel../eHue npu
noepe>KdeHuu ee cmeHKU.
llfHHepaau,uR npRMOU KUWKU
npoMe)f(HOCTHblill OTAeJl np51MOVI KVIWKL-1
(Hapy)f(HblVi ccj:>1t1HKTep) 1t1HHeps"1pyercs:i coMarn-
4ecK0Vi HepBHOVl ClllCTeMoVI - cpaMHblM HepBOM ,
KOTOpblVI COAeP)f("1T AB111raTeJlbHble "1 4YBCTBlll-
renbHble HepBHble OKOHYaHlll51 .
233
salOTC51 yn111TKOBblML'l . OH111 51BJ15llOTC51 KOHe4HblML'l
seTB51Mlll sepxHeVI np5!MOK111We4HOVI aprep111111 .
CreHKa KasepHo3HOVl eeHbl VIMeer HeCKOJ1bKO
my60KlllX CKJlaAOK, KOTOpble np111 HanonHeHllllll
aprep111anbHolA KpOBblO pacnpasn5110rcs:1, ysen111-
4111sa51 npocseT seHbl.
KaaepHo3Hbl i:i Ko1111eKTop
H"1e. 0H"1 conposo>tW,aior co"1MeHHb1e aprep"1111 .
BepXH5151 np51MOKlllWe4Ha51 seHa He 111MeeT Kila-
naHos, s orn111Y111e OT cpeAHeVI 111 Hlll)f(HeVI . Me)l{,qy
3Tli1M"1 seHaM"1 lllMelOTC5l aHaCTOM03bl.
<byHKL\"151 KasepH03HblX Tenel\: HanOJ1H5151Cb
KpOBblO , 3Tlll o6pa3oBaH"151 repMeTli13"1pylOT
aHaJlbHbli.4 KaHan ' ,QOnonHflfl cpyHKL.(VllO ccplllHK-
Tepos.
CreHKa
KaaepH03HOi1 8€Hbl co
CKJ1a,D.KaMlt1
0CTaJ1bHa5'! 4acn, np5'!MOC1 KlllWKlll lllMeeT
c111Mnan1YeCKY10 L-1 napac111Mnar111YeCKY10 ABlllra-
renbHyio "1 4yscrs111renbHY10 "1HHepBaL\"1IO . C111M-
naT"14ecK111e BOJlOKHa 803HlllKalOT 1113 Hlll)f(Hero
6pbl)f(ee4Horo 111 aopranbHOro cnnereH111Vi . napa-
c111Mnarn4ecK"1e - 1113 nOA4PeBHblX (Ta30Bb1X)
cnnereH111Vi.
 . :··
. ·~··

M. 1phincter---
;rni in?ernu.s

Puc. 56. CmpoeHue cmeHoK npRMoiJ KUWKU. CnuJUcmaR o6onot/Ka

/1UMc/Joommo1< om npRMOU l<UWl<U

Bb1,Qem110T 3 30Hbl B OTHOWeHV11t1 OITOKa
J11t1Mcpbl OT np51MOIA K111WK111: HIA>KHIOIO, cpe,QHIOIO Ill
sepXHIOIO (plAC. 55). 0TBO,Q51~1/1e cocy,Qbl "13
Hl1l>KHelli 30Hbl - npoMe>KHOCTHoro OT,Qena nps:i-
MOL'.1 KlttWKlll (HIA>Ke 6 CM OT aHopelCfallbHOH n111-
Hllllt1) Hanpas115ltoTC5! s naxosb1e n111McparnyecK111e
Y311bl (Hlll>KH111i1 nyrb). 0TBOA51~111e cocy,Qbl cpe,Q,-
Helli 30Hbl (6o11bWa51 YaCTb aMnynbl) 3aKaHYV1-
satorcs:i s n111Mcpoy3nax nepsoro arana, pacno-
no>KeHHblX no3aAIA np71MOL1 KIAWKIA. 0TCIOAa
J1111Mcpa OTTeKaer BO BHyrpeHHl!le no,QB3,QOWHble Puc. 55. CxeMa 5paiJ~eea B. P. fluM<jJOommoK
npRMOU KUWKU.
y3nb1, B y3nb1 o6nacrn Mb1ca Kpecn_\a 111 60KOBb1e 1- eepxHuiJ nymb ommoKa nuMcj:Jbt, 2-6oKoeoO nymb, 3-
Kpecr40Bble (60KOBOt:1 nyTb). HU>KHuiJ nymb ommoKa nuMcj:Jbt.

234
 0TBO.QS'IU\llle COCY.Qbl eepxHeiil 30Hbl -
eepxHeaMnyns:ipHoro 111 Ha.QaMnyns:ipHoro OTAe-
nos (BblWe 6 CM OT 8HOpeKTanbHOL4 fllllHllllll) Ha-
npasmHOTCS'I KBepxy (sepXHllll4 nYTb) , no XO.QY
sepxHe!li nps:iMoK111weYHO!li aprepm1 , snnoTb .QO
,\\. lcvator ani- -~
Puc. 57. CmpoeHue cmeHoK npRMoO KLJWKLJ. Mb1We'-IH8R o6ono'-/Ka.
c/JyHKU,UU npRMOU KUWKU
0CHOBH8S'I cplll3lllOnOrlll'·lecKaS'I cpyHKLllllS'I
npS'IMOlli KlllWKlll - CKonneHllle Ill 3BaKYa1..1111111 Klll-
we4HOro CO,Qep>KlllMOrO. nt11Ul8 OT npllleMa
BHYTPb 4epe3 poT .QO Bb16pacb1BaH111s:i s Blll.Qe Ka-
noBblX Mace 4epe3 38,D,Hllllli npoxo.Q npe6b1saeT s
)f{eny,Q04HO-K11We4HOM rpaKTe 18-24 48Ca. rep-
MeTlll3lllpytOU\YIO pOilb ccj:>lllHKTepa ,QOnonHS'llOT
K8BepH03Hbl8 KonneKTopbl reMopp0111A8IlbHOlli
30Hbl , 3anonHeHHb1e apTep111anbHOlli KPOBbtO.
235
y3noB Hlll>KHelli 6pb1>KeeYHOlli apTep111111 . 3TO -
rnaBHbll4 nYTb OTTOKa JllllMcpbl OT npS'IMOL4 KlllWKlll,
noCKOflbKY fllllMcpa OT Hlll>Kene>K8U\lllX OT,Qenos
48CTlll4HO OTTeKaeT Ill no 3TOMY nyTlll .
~~;;: Ttm !c:i mum1faris
• {stra.1mn loogi!ud1n1de)
- -i.impull a rec! i'
: ~ ~M. sphincter ani .extern us
0,QHa 1113 cj:>yHKL\llllli npS'IMOlli KlllWKlll - BC8Cbl88Hllle.
Bcacb1saH111e 1113 npS'IMolli KlllWKlll npo111cXOAlllT 6b1-
cTpee , YeM 1113 )!{eny.QKa . Ero 3aMe.QneH111e npo-
lllCXOAlllT nplll neplllTOHl.He, OCTPOM XOfl8L\lllCTlllTe ,
np111 socnan111renbHblX 111Hcj:>t11nbrparnx e ManoM
Ta3y , 3Tlll BOCnanlllTeJlbHble S'IBJleHlllS'I 6noK111pyt0T
n111M¢arnYec101e cocy,!lbl nps:iMoiA Kll!WKl.-1, 3a-
rpy.QHS'llOT OTIOK 1113 Hee (p111c. 56, 57).
 rEMOPPOM
TepMlllH «reMoppoili» BBeAeH B MeAlllLllllHY
l111nnoKpaToM: haiµa (rpe'-1.)-KpOBb, rhea (rpe'-1 .)-
TeK'f, 111cTeKa10. OcHOBHoVI np1113HaK 3a6onesaH111s:i
- peKTa11bHble KpOBOTe4eHlllfl . reMoppoL1 - Halll-
6onee YacTo scTpeYa10w,eecs:i Heonyxonesoe
3a6oneeaH111e nps:iMoL1 KlllWKlll . leMoppoL1 e
CTPYKTYPe npoKT011orn4ecK111x 6one3HeL1 3aH111-
MaeT nepsoe MecTo - 42 ,1- 63 ,9% (P111BKlllH B.
n., 2001). Bo3pacT na1.1111eHTOB - oT 18 AO 45 neT.
CpeAlll 6onbHblX reMoppoeM MY)l(4111Hbl cocTaB-
m:110T AO 70%.
l<naccucfJw<au,uR 2eMoppoR
(rocyaapcmaeHH020 HayYH020 11eHmpa
1<ononpo1<mono2uu, Moc1<aa, 2001 .)
I. no flOl<QflU30U,UU
1. BHyrpeHHIAVI reMoppoVI
2. Hapy)f(Hb1L1 reMoppoL1
3. KoM61.1H111poBaHHblili reMoppoili
II. no l<flUHULfeCl<OM npORBfleHUflM
1. 5eCCVlMnTOMHblL1 reMoppoili
2 . leMoppoL1 y 6epeMeHHblX.
3. XpoH111'-lecK111VI reMoppoVI :
1 cmaauR - peKTaJlbHble KPOBOTe4eHVlfl 6e3
BblnaAeH111s:i BHyrpeHH111x reMoppo111p,anbHblX y3-
nos;
2 cmaouR - y311b1 ebmaAalOT np111 p,ecpeKa-
U.\A\A , a ~a1eM, nocne AeQ:leKa\,,\lt\lt\ caMocTofl-
Ten bHO, B011eBblM COKpaLL1eHllleM Cqll.-1HKTepa
BnpaBmtlOTCfl B aHanbHbllll KaHan (c KpOBOTe\.\e-
HVleM 1t111111 6e3 Hero);
3 cmaauR - Y3Ilbl Bblnap,alOT np111 p,ecpeKa-
l...1"1111 , 1t1MeeTcs:i Heo6xoA1t1MocTb 111x PY4Horo
enpae11eH111s:i B aHa11bHblili KaHaJl nocne AecpeKa-
l. .1111111 (c KposoTe'-leH111eM \1\11\ll 6e3 Hero);
4 cmaauR - nocros:iHHoe Bbma,(leH111e BHYT-
peHHlllX y3noe np111 p,ecpeKaL11t11t1 11111111 cpV131114ecKoll1
Harpy3Ke VI Hey,llepJKaHIAe VIX B 8H8JlbHOM KaHane
nocne PY4Horo enpae11eHV1fl (c KpoeoTe4eH1t1eM
11111111 6e3 Hero).
Ocmp&tiJ aeMoppoiJ:
1 cTeneHb, 2 cTeneHb, 3 cTeneHb
3muono2un u namo2eHe3 2eMoppofl
,Qo cepeAVIHbl npow11oro BeKa C41t1Tanocb,
l.!TO reMoppol/1 - n~no11orns:i 06bl4HblX BeH nps:i-
MOlA Kll1WK\ll , VIX eapVIK03HOe pacw111peH111e (no
aHa11orn111 c eap1t1K03HblM pacwV1peH111eM eeH nV1-
LL1eeop,a 11111111 Hlll}f{HlllX KoHe4HocreL1). B nocnep,-
HIAe 40-50 ner npe,llcras11eH111e o naroreHe3e
reMoppos:i Kap,D.lllHaJlbHO 1113MeHlllJ10Cb. reMOp-
p01.1,ll8JlbHble Y31lbl B03HlllKator scneACTBllle 1113-
6blT04HOro pa3BlllTVl.s:I neLL1ep111cToll1 TKaHIA B 06-
11aCTlll K01111eKTOpOB 1113-3a nOCTOflHHoro naTOJ10-
flll4eCKOro nepenonHeH111s:i Kposbto KaeepHo3Hb1x
BeH. np1114111Hbl flllnepn11a3111111 KasepH03HOL1 TKaHVI
- 3arpyAHeH111e OTIOKa KpOBl.1 no np5lMOKlt1We4-
HblM seHaM , a ra10Ke yc11meH1t1e aprep1.1a11bHOro
nplllTOKa no npHMOKlllWe'-IHblM aprepllls:!M.
236
3aTPYAHeHllle OTTOKa KpOBlll no npHMOKlll-
we4HblM eeHaM B03HlllKaer no cneAYIOLUll\M np111-
4111HaM:
- C111cTeMaT111'-leCKoe nosb1WeH\lle sHyrp111-
6ptowHoro ,QaBJleHlll5l 1113-3a COKpaLL1eHV15l MblWLI
nepep,HeVI cTeHKlll )f(VIBOTa - xpoHll\4eCKllle 3ano-
pb1, pa6oTa, css:i3aHHas:i c nOAHHTllleM Hl}f{ecn.1.
- MexaHlll4ecKoe CAaBneH111e eeH Ta3a -
pa6oTa B nono)l{eH111111 «Cll\Afl», onyxom1 6ptow-
Hoill nonocrn , socnan111renbHb1e 111Hcpll\flbTpaTb1
Manora Ta3a.
- 5epeMeHHOCTb 111 po,D.bl np111 epo)t{AeHHOVJ
HeAOCTaT04HOCTlll CTpOeHVlfl eeH03HOiil CltlCTe-
Mbl. B KOHL.le 1 11\Jllll B Ha4a11e 2 Tp1t1MecTpa 6e-
peMeHHOCTll\ npo111cxo.QlllT AOno11H111re11bHOe
CA8BfleHllle BeH Manoro T838 6epeMeHHOlil MaT-
KOll1 . ,Qmne11bHb1VI nory}f{HOL1 neplilOA po.QOB Bbl-
3b1Baer pe3Koe noeb1WeH1t1e sHyrp1.-16ptowHoro
p,asneHlilfl Ill 38TPYAHeHVle OTIOKa no eeHaM Ta-
3a.
- nopTanbH8fl flllnepTeH311\fl
lt136blT04Hblili nplttTOK apTeplllaflbHOili KpOBlll
B03Hll\Kaer no C118AYI01.IJ,lllM np1t1'-11t1HaM:
- nocTos:iHHoe ynorpe611eH1t1e pa3p,pa-
}f{ato1..L1ell1 ocrpoill n111LL1111, 6oraroili cne1.1111s:iM111 ,
4eCHOKOM , yKcycoM Ill np. ;
- 4acrb1ili np1t1eM a11Korom1;
- noBb1weH1.-1e apTep1i1anbHoro AaBneH111s:i
np111 rnnepTOH1114ecKoll1 6one3Hlll.
YKa3aHHble MexaHlll3Mbl m;:HABOJJ,5\1' K r1Ane~­
n11a3111111 KaBepH03HOL1 TKaHlll Ill cpopM111poBaHlillO
yeen1t14eHHblX reMoppo111p,a11bHblX y311oe. n0Kpb1-
satou_ia51 11\X CI11113\.1CT85l o6on04K8, CT8HOB\.1TCfl
TOHKOl/1 Ill paHl!IMOL'.1. nnoTHble K8110Bble MaCCbl
11erKo noepe)f(JJ.atoT ee np111 sarpyAHeHHol-1 Aecpe-
Kat.1111111 . Bo3H111KaeT peKTanbHOe KpoeoreYeHll\e.
nocKOJlbKY KaBepH03Hble BeHbl 3anOJlHfllOTCfl
apTeplttaJlbHOi.1 KPOBblO 1113 snap,810l..Lllt1X B Hlt1X
y11111TKOBbJX apTep111i..1, KposoTe4eH111e np1.1 reMop-
poe Hoc111T apTep1.-1anbHbllil xapaKTep.
B MexaH1113Me Bbmap,eH111s:i eHyTpeHHVIX re-
Moppo111,D,aflbHblX y311os 111MeeT 3Ha4eH1.1e Mexa-
H1t11.1ecK111IA (AlllCTpocp1t14eCKlllVJ) cpaKTOp.
IJucmpocpu'-lecKue npo~eccbt npoucxo-
oRm a coeoUHUmenbHOU mKaHU noocnUJU-
cmoeo cnoR 111 B CB5'13Ke napKca , yp,ep)f(111eaio-
LL1elA KaeepH03Hble rellblla B aHanbHOM KaHane.
npolllCXO,[lltfT nOCTeneHHOe «COCKa11b3blBaH1t1e»
yseJ11t14eHHbJX BHyTpeHHlllX reMoppo111.aanbHblX
Y3fl0B OTHOClllTeJlbHO nO,QCJTlt13111CTOi.1 OCHOBbl II\
111x Bbma.aeH111e 1.13 aHanbHoro KaHana np111 co-
KpaUJ,eH111111 MblWLI Ta30BOro AHa.
l<flUHULfeCl<OR KapmUHQ
K11111HV14ecKas:i KapT111Ha 3a6011esaH111s:i 3as111-
c1.1r or cpopMbl reMoppos:i, comacHo np111eep,eH-
Ho!A Kl18CCll\cplllKa4111111.
6eccuMnmoMHb1i1 2eMoppoiJ
Y onpe,lleneHHoro 41t1c11a 111114 np111 na11b4e-
BOM peKT011bHOM lllCCJleAOBaHllllll lt1J1111 np111 aHO-
CKOn!Alll, peKTopollilaHOCKOn1t11t1 cp1116poKOJlOHOCKO-
m11t1 s cTeHKax aHanbHoro Ka Hana Ha 3, 7, 11, 1..1a-
cax ycnosHoro L\l.1cpep6nara Bb1s:ism110Tcs:i 3 Bbl-
ns:iY111BaH1..1s:i CJ111131.1CTOVI (cpopM111pytow,111ecs:1 BHyT-
peHHl/le reMoppOJ.1.L:laJJbHbJe y3nb1), M5!rK111e, no.L:1-
Bll1)1{Hb1e, 6e36one3HeHHble, He KpOBOTOYaw,1..1e.
feMoppou y 6epeMeHHb1x
leMoppolll B03HlllKaeT y Ka)!(,D,olll ns:1Tolll 6e-
peMeHHOVI )l{eHW,l.1Hbl. 4acro co1..1eTaH111e reMop-
pos:i 6epeMeHHblX 111 sap111Ko3Horo pacw111peH1..1s:i
B8H Hlll>KHMX KOH8YHOCTei:1.
np111 n0518JleHlt1111 T111nll1YHOro reMoppOlll,[lanb-
HOro Cll1HAPOMa - a)He6onbWll1e lllHTepMlllTTlll-
pytow,111e KpOBOTe1..1eHll1s:I anolll KpOBblO Kanns:iMlll
BO speMs:i AecpeKaL\L-1111; 6) Bbln8A8Hllle BHyTpeH-
HlllX reMoppo111,[lanbHblX y3nos 2 cTa,[1111111 (caMo-
npo1113sonbHo snpasns:itow,111xcs:1 s aHanbHbllll Ka-
Han nocne npoxo)!(,D,eH111s:1 Kana) ;
B)He3H34111TeJlbHble, nep1110,[11114eCKlt1e HOIOW,111e
6on111 s aHanbHOM KaHane, 1..1aw,e AO ,[1ecpeKaL11i11t1,
- noKa3aHO TOJlbKO KOHCepBaTll1BHOe ne1..1eH111e
(CM. Hll1)1{e) .
XpoHul.feCKuu zeMoppou
Knacc1..11..1ecK111!'.1 reMoppo111.QanbHb1VI c1t1H.QpoM
BKnto'-laeT s ce6s:i )f{ano6b1 Ha:
A) . He6onbw111e l4HTepML4TT111pyiow,111e Kpo-
soTe4eH111s:1 anolll KpOBblO Hanps:i)f{eHHblMll1 Kan-
ns:iMlll lilfllll CTpyl/11<0111 . leMoppOlilA8JlbHble KPOBO-
Te4eHll151 H84l/IHalOTC51 o6bl'-IHO O,[IHOBpeMeHHO c
Ha1..1anoM AecpeKaL.11..1111 . 8b1AeneH1..1e Kpos1..1, 06b1Y-
HO, npeKpaw,aercs:i nocne npoxo}i(,l:\eH111s:1 Kana
4epe3 3a,[1Hllllll npoxo,[I, T. K. CJllll3lllCTa51 Ha.Q ,[19-
cpeKTOM cTeHKlll y3na cKJJe111saeTcs:1. AHaflbHb1e
KpOBOT949Hlt151 BCTpe4alOTCs:I y 85% 60JlbHblX
reMoppoeM .
6). BbmaAeH111e ysen1t11..1eHHblX sHyTpeHHlllX
reMoppo1t1AaflbHb1X y3nos 3a npe,[18nb1 3aAH8ro
npOXOAa. 3TO npOlllCXOA111T BO speMs:I A8cpeKa-
L\111111 , 4aW,8 nOCJl8 AfllllTSJlbHoro 3anopa. np111 2
cTa,[11111..1 3a6onesaH111s:i, nocne cryna, y3nb1 caMo-
cTomenbHO snpasns:1toTcs:1 s nps:iMyto Kll1WKY . B
cny4as:1x ,l!aneKo 3awe,l!wero naronorn4eCKoro
npoL1ecca, AJJS1 snpas.neH111s:1 sbmasw111x y3nos
Tpe6yeTcs:1 py4Hoe noco61119 (3cTaA111s:1) . np111 4
CTa,[11111..1 np0111CXOA~1T nOCTOs:IHHOe Bblna,[leHl/18
BHyTpeHHlllX y3nos np111 AecpeKal.\111111 111n1..1 np111 Ma-
n8i::iwei:1 cp11131111..1ecKoi:1 Harpy3Ke 111 H8YA8P)f{8Hlll8
111x s aHanbHOM KaHane nocne pyl.!Horo snpasne-
HltlH.
B) . He3Ha4111TenbHb1e, nep1110Alll4ecKllle
HOIOW,111e 60111..1 8 aHaJlbHOM KaHane , 1..1aw,e AO
,[1ecp8Kal.\llllll . 3TO MO)l{8T C048TaTbC51 (np1..1 Bbma-
A8Hllllll BHytp8HHlllX Y3J10B) C '-IYBCTBOM BJ18)1(HO-
CTlll , }\{)1{9Hll151, 3YAOM B npoM8)f(HOCTlll , nOBblW8H-
HOll1 4YBCTBlllT8IlbHOCTblO neplllaHaflbHOi::i KO)l{lll .
,D,ua2Hocmw<a
- OcMoTp 3aAH8ro npoxo,[la. Ysenwl.leHHble
Hapy)f(Hble reMoppo1t1Aa1lbHb1e Y3I1bl nerKo 38-
237
MeTHbl nOA nept11aHaflbHOL1 KO)f(ei::i . 0Hlll MOryT
6bJTb HeCKOilbKO C"1HIOWHbl, M5lrK1t1e Ha ow,ynb,
nerKo cnaAatoTC51 np111 nanbnal.\llllll, 6e36one3-
HeHHbl (p111c. 58).
P111c. 58. XpoHw-iecKHM reMoppoM.
A. XpoHw-iecKHM reMoppoM 2 cTa,D,111111.
6. XpOHH~eCKHM reMoppow 3 CTa,IJ,HH. npo-
H3BO,IJ,eHa HHTpaonepa~HOHHaH AHBYflbCHH
aHanbHoro )f{OMa. CTpenKoM o6o3Hal-!eHa
3y6'--13TaH flHHHH.
- nanbl.\8808 peKTaflbHOe lt1CCJl8,[IOBaHllle .
ToHyc ccp111HKTepa coxpaHeH 111n111 Mo)f(eT 6b1Tb
HeCKOJlbKO CHll1)f(eH nplll BblnaAeHll1111 BHyTpeHHlllX
y3nos 2 -3 cTeneH111. Ysen1t11..1eHHb1e BHyrpeHHllle
y3nb1 nanbnlllpytoTcs:i e Bll1Ae M5lrK111x, noABlll)f(HblX
«CKnaAOK» CJ11113111CTOVI Ha 3, 7 , 11 Yacax no yc-
IlOBHOMY 1..11.1cpep6nary s nono}l{eH1.1vt na1..11.1eHTa
Ha cn111He s npoKTonor1111..1ecKoM Kpecne . Bo3MO>K-
Ho 1..1ccne,D,0BaH1t1e B KOJ1€HHO-JlOKTeBOM nOJJO)f(e-
H111lll .
- 111HcTpyMeHTailbHOe 111CCJ1€AOBaHllle.
06H38T€JlbHa aHOCKOnlllH (plllC. 59) )1{€CTKlllM
aHOCKOnOM 111 peKTopoMaHOCKOnll15l peKTopoMa-
HOCKOnOM IAJlV! cp1,.16pOKOilOHOCKOnvt5l, T . K. no,D,
MaCKOi:i reMoppos:! M0)1(8T CKpblBaTbCH , npe)!(,D,e
ecero, paK nps:1Moi:1 Kll1WKll1 , a TaK)f(e ,D,06poKa'-le-
crneHHb1e ee onyxon1..1 , non1t1nb1 111 ,[lpyrne nopa-
>KeHllls:I TOJ1CTO!ll Kll1WK111 , Tpe6ytow,1..1e ,o,pyrolll TaK-
Tll1Kll1 ne1..1eHws:1 .
P&11c. 59. AHocKon&11st npH noMo~H aHo-
cKona "" peKTopoMaHocKona Karl Storz A.
Ysen1.1'--!eHHb1e eHyTpeHHHe reMoppo&11-
.QaI1bHb1e Y3flbl. CTpeIIKOM o6o3Ha'leH .Qe-
c.j>eKT BO BHyTpeHHeM reMoppOM,QaflbHOM
y3ne - MeCTO 6b1Bwero KpOBOTe'leH&ilff. 6.
AHocKon Karl Storz. 8. >KecTKHM peKTopo-
MaHocKon Karl Storz B pa306paHHOM BH,IJ,e.
fleYeHue xpoHUYeCK020 ZeMoppOR
B cTpaHax Esponb1 111 CWA c1.1111raeTcs:1, 4To
KoHcepsaT111sHa5l Tepan1t1s:1 noKa3aHa 20-45%
nal.\lll€HTOB CTP8AatolJ..llAX reMoppoeM . B OCHOB-
HOM - 3TO 60JlbHble c 1 CT8,1J,lll9Vl XpOHlt14eCKOro
reMoppofl (peAKlife Kposore4eHV1fl 6e3 Bb1na11e-
H1As:1 BHyTp8HHll1X Y3JJOB) .
KoHcepsamuBHoe 11eYeHue
0AHoo6pa3Has:1 pa6oTa e nono>1<eH111111 c111,D,s:1
CB513aHa c 38CTOeM KpOBlll 8 BeHaX Ta3a lll nepe-
nonHeHllllO KasepH03HblX TeneL.1 nps:1Moi:1 KlllWKJA .
3roMy }Ke cnoco6crsyer 3anop (cryn pe}Ke 1
pa3a B cyTK111), CBfl3aHHbli:1 c o6pa3oM )f{lll3Hll1 1..1
np111Bbl'-IKaM1i1, HeyMepeHHblVI np111eM a11Koro.ns:1 111
ocTpoi::i n111w,11 . nal.\llleHry cneAyeT peKoMeH,[lo-
saTb nep"10AV1'16CK1t1e «T€XH0110r1A'-18CK1116» nepe-
pblBbl e Te1..1eH111e pa6ol.lero AHH co cMeHoi::i no-
J10)1(8Hll151 Tena, OTKa3 OT ocrpolll nllllJ..lltl IA ynoT-
pe6neH/Afl anKoronR.
 I. HeMeauKaMeHm03HaR mepanuR
1. OrpaHl!l4eH111e no.QH51Tl!l51 rs:1>1<eere0l .
2. ne4e6Has:1 cp1!13KYilbrypa (n11aBaH111e, 6er,
XO.Qb6a), ynpa>1<HeH111s:1, HanpaBneHHble Ha yKpe-
n11eH111e MblWL.1 Ta30BOro ,QHa, rl!IMHaeTl!IKY
aHanbHoro ecp111HKTepa 3-4 pa3a B ,QeHb: no 10-
15 e>1<aT111~ 111 paee11a6neH111~ aHanbHoro :>KOMa.
3. .Q111era e 111eKn104eH111eM oerpo~ nllllJ..1111,
np111npaB 111 anKorons:1
4. Km113Ma Maem1Has:1 nepe,Q erynoM (no,Q-
eonHe4Hoe Maeno 50-70 Mn +06nen111x0Boe
Maeno 1 4a~HaH no>1<Ka) 7 - 14 ,QHe~ B nep1110,Q
KpoBoTe4eH111ill . Kypeb1 -2 pa3a B ro,Q.
II. MeouKaMeHm03HaR mepanuR
4J11e6omponHble npenapamb1 (Bb16pamb
oouH npenapam)
A). ,[JUOCMUHbl 8 -10 He,Qenb, 2 pa3a B ro,Q
• <l>ne60A111a - 600. (Ba3oKeT, A111oseHop-
600) - 1 ra6n. BHYTPb 1 pa3 B eyrK111
• AerpaneKe (BeHapye, BeHO.Ql!IOil) - no
1Ta6n. BHYTPb 2 pa3a B eyTKl!I.
5). Pymo3Uab1
• Tp0Kceea3111H 6era-rn,Qp0Ke1113rnn - py-
T03111.Q (e111HOHll1Mbl: BeHopyTOH , TPOKeepyT111H)
BHa4ane npenapar Ha3Ha4alOT napeHrepanbHo
(B/M 111n111 BIB ll1HbeK41111!1) no 5 Mn 4epe3 .QeHb (He
MeHee 5 l!IHbeKL.11!1111), 3areM nepopanbHO no 2-3
Kaneynb1 B .QeHb BO BpeMfl e.Qbl. Kype - 4 He,Qe-
n111, 2 pa3a B ro.Q.
• BeHopyToH 300 - 6era-rn.Qp0Ke1113Tl!ln-
PYT03111.Q no 1 Ta6nerKe 3 pa3a B eyrK111, seHopy-
TOH 500 - no 1 Ta6neTKe 2 pa3a B CYTKl!I (yrpoM Ill
Be4epoM) BO BpeMfl e,Qbl. Kypc - 4 He.Qen111, 2
pa3a B ro,Q.
5) . C/Jne6omponHb/e npenapambl opyGUX
apynn
• rn111eeHOI1 - (Cl!IHOHll1M: Tp1!16eH031!1.Q) -0,8
- 0, 12 B cyTKl!I B 2 -3 np111eMa. Kypc ne4eH111s:1 1,5-
2 Mecs:14a, eypeb1 2 pa3a B ro,Q.
• AHaeeHon - (KoM61!1Ha1..111151 ,Q111rl!IAP03p-
roKp111crnHa (anbcpa a,QpeHo6noKarop), 3ceyn111Ha
(6111!130K K 3CL.llllHY) 111 pyr111Ha) no 2 p,pa>Ke 3 pa3a
B ,QeHb B Te4eH111e He,Qen111, a 3aTeM 1 ,Qpa>1<e 3
pa3a B ,QeHb, eypc 2-3 Mecs:11..1a 2 pa3a B ro,Q.
• r111HKOp <l>OpTe (300 Mr TpOKCepyrl!IHa,
14 Mr 3KeTpaKTa ,QepeBa rnHro ABY.QOJlbHoro 111
300 Mr renraMl!IH011a xnop111.Qa). no 2 Kancynb1 2
pa3a e>Ke,QHeBHO nepBble 15 ,QHeill, B nocne-
AYIOLJ..1111e 30 ,QHe~ - no 1 Kaney11e 2 pa3a.
I//. TonUl./BCKUe npenapambl (cpeacmaa anR
MecmHoao npuMeHeHuR)
• Pen111<P AAeaHc - cBe4111 111 Ma3b p,11s:1 peK-
TallbHoro 111 Hapy>t<Horo np111MeHeH111R 1 cynno3111-
rop111ill co,Qep.>K111T Maeno ne4eH111 aeynb1 3% 111
6eH3oKal!IH (MeeTHblH aHeerernK) 10,3%. Ma3b -
B 1 r :Maeno ne4eH111 aeynb1 3% (30 Mr) 6eH30Ka-
l!IH 20% (200 Mr). np111MeHeH111e - AO 4 pa3 B cy-
TKll1 , 14 ,QHeill np111 6ons:1x B reMoppo111,QanbHb1x y3-
nax
238
• Pen111<t> - eynno3111rop111111 peKTanbHb1e 111
Ma3b AI151 peKTailbHOro 111 Hapy>KHOro np111MeHe-
Hll151 .1 cynno3111rnp111ill eo,Qep>1<111r: Maeno ne'-leHl!I
aeynb1 75 Mr (3% }, cpeH111n3cpp111Ha rn,Qpoxnop111-
A8 (a11b¢a-ap,peHOM111Mer111K) 6,25 Mr (0,25). B 1
r Ma3111 Maeno ne'-leH111 aeynbl 30 Mr, cpeH111n3cp-
p111Ha r1!1,Qpoxnop111,Qa 2,5Mr. np111MeHeH111e - ,QO 4
pa3 B CYTK111, 14 ,QHeill np111 peKTailbHblX KpOBOTe-
'-l€Hll151X
+ npoKTO-rill/IBeHOil eBe4111 11111111 M83b 2-3
pa3a B ,QeHb ,QO 14 ,QHeill np111 OTeKax Hapy>KHblX
Y3JlOB.
Ma11ouHBG3UBHbte Memoob111eYeHUR
xpoHUYeCK020 2eMoppoR
B noe11ep,H111e 10 ner no11y411111111 w111p0Koe
pacnpocrpaHeH111e Mano111HBa3111BHb1e na11n111a-
Tll1BHb1e BMewareilbCTBa np111 xpOHl/11.JeCKOM re-
Moppoe, KOTOpble B03MO>KHO np01113BO,QlllTb B aM-
6ynaTOpHblX yenos111s:1x:
• CKneporepan11151 BHyrpeHHlllX HeBbma-
,QalOlJ..1111X KpOBOTO'-lalJ..1111X reMoppo111,QallbHbJX Y3-
JlOB
• 111HcppaKpacHafl cporoKoarynflL.lll1fl BHYT-
peHHl!IX reMoppol!lp,a11bHblX y3110B.
• n111rnpoBaH111e Bblna,QalOlJ..1111X BHyTpeHHll1X
y3noB 11areKcHo~ walll6olll c noMOlJ..lblO BblKYYM-
Horo 11111raropa
CK11epomepanu.R BHympeHHUX
2eMoppouoanbHbtX y311oa
noKa3aHll151: Hamt'-lll1e He6onbWlllX BHyrpeH-
Hll1X reMoppo111,QailbHb1x y3noB c peKTanbHblMll1
KpOBOTe'-leHll151Mll1 (xpOH1114eeKll1~ reMoppolll 1
CTa,Q1111!1).
npoTl!IBOnOKa38Hll151 : OeTpblill reMop-
poill,6onbHble rnneproH1111.JeeKoill 6one3bl0, Bbl-
na,QeHl!le BHyrpeHHll1X reMoppol!l,QallbHblX y3noB
CKnepo31!1PY10LJ..1111e pacrnopb1: 5% pacrnop
cpeHona B nepc111KOBOM Macne, 2-3% pacrBopb1
rpoM6oBapa, 3TOKC111CKnepona l!I p,p .
AHecre31!151 MecrHaH, Ma3b c nl!l,QOK81!1HOM ,
np01!13BO,Ql!ITe51 aM6y11aropHO.
npl!IHU,L-1n BMeWaTenbeTBa: 1,5 - 2 MJl
cKnepo3111pyioLJ..1ero pacrnopa no,Q nocroHHHblM
Bl!l3Y8IlbHblM KOHTPOileM BBO,Ql!ITCfl '-lYTb npoKCl!l-
MaJlbHee Ka)f{,IJ,oro reMoppm1,QanbHoro y3na B
npocrpaHeTBO Me)f{,IJ,y no,Qe111!131!1CTOH oeHOBOll! l!I
MblWe'-lHblM CilOeM (He 6011ee '-leM B 2 y311a npl!I
O,QHOM BMewaTellbCTBe).
flameKCHOe /1U2Up08GHUe BHympeHHUX
y311oa c noMOW,blO BblKYYMH020 11u2amopa
(Karl Storz, repMOHUR)
noKa3aHlll51: Bblna,QeHllle 11130Ill!lpOBaHHblX
BHyrpeHHl!IX y3noB c xopowo ccpopMIAPOBaHHbl-
Mlll «HO>KKaMlll». npOTlllBOnOKa3aHlll51: KOM61!1Hl!l-
p088HHblH reMoppolll OCTpblH reMoppoi/I .
 06e36om1saH1.1e: MeeTHoe, Ma3b e n1.1,n,o-
KaV1HOM . npoBOAVITCs:I aM6ynaTOpHO. AnnapaT:
BaKYMHblVI rrnraTOp (PVle. 60).
np111H4111n BMeWaTeJlbeTBa . Ha pa60"IYIO
\.laeTb n111raTopa Ha,n,esalOT naTeKcHoe KOilbL\O .
BHYTpeHHVIVI reMoppo111AaI1bHb1!4 y3en BaKYYMOM
BTs:1r111saeTcs:1 B pa6o_;y10 "lac;b annapaTa , npe,n,-
cTasns:i10LJ..lY10 co60111 nonb11t1 u,1,1n111H,n,p. nocne
:noro 3nacTV1\.IHOe KOilbl\O Ha)f(aTVleM pb1"lara
«C6pacblBaeTCs:I» Ha OCHOBaH1t1e y3na , CTporo
Bb1we 3y6"laToL4 nVIHVIVI . C,n,asneH111e HO)f(KVI y3na
Bbl3blBaeT ero VIWeMVllO VI HeKp03 (Piiie. 61 ).
4epe3 3-4 ,QH5l nepe..QasneHHa5l HO>KKa y311a
HeKpOTVl3VlpyeTcs:i , y3en «onopraeTes:i». Ell.le
"!epe3 2-3 ,D,Hs:I OTTopraeTCs:I VI wai46a. ne4eH111e
nposo,n,111Tes:1 B 1-3 eeaHca.
Puc. 61 . nuauposaHue Bbtnaaa10uwx sHympeHHux y3nos nymeM caasneHuR ux cocyaucmoa «HO)l(KLJ » nameKcHou
wau6ou c noMOUJ,bJO saeyyMHoao nuaamopa (cxeMa)
Mcj:JpaKpacHafl cj:Jom0Koa2w1R4Ufl
eHympeHHux 2eMoppouoa11bHb1x y311oe
noKa3aHf/15l: XpOHVl4eCKVIL4 BHyTpeHHVIL4 re-
MOppoVI 1 CTa,QVIVI np111 HaJ11t14VIVI B aHaMHe3e
pe,D,KVIX Heo6VlflbHblX KpOBOTe4eHVIVI, OAHOro,
ABYX 06ocTpeH111L4.
npOTVIBOnOKa3aHVls:I: KOM6VIHVlpOBaHHbll4 re-
MOppoL4 , Bblna,D.eHVle BHyTpeHHVIX Y3Jl0B, OCTpbll4
reMoppoL4 .
06e35on1.1saH111e: Mecrnoe, Ma3b e n111,n,o-
KaV1HOM.
npoBOAlt1TCs:I B CTal..\lt10Hape B nnaHOBOM no-
ps:!,D.Ke, B03MO>KHO aM6ynaropHoe npose,n,eH1.1e
npm-1e,n,ypb1. AnnapaT: VIHcppaKpacHbll4 Koaryns:i-
TOP (P111e. 62).
npOV13BO,D.LHCs:I JlOKaJlbHa51 KOaryfls:ILJ,Vls:I eI1V1-
3VICTOL4 o6ono4Klt1 aHaflbHOro KaHana B npoeKL\V1"1
coey,n,111cTOVI HO)f(KVI reMoppo1i1,n,anbHblX KOIIJleK-
TOpOB, IIOKaIIVl30BaHHblX Ha 3-x, 7-Mi.1 "1 11-TVI
4acax no 41i1¢ep6naTY s nono>KeH1i11i1 6onbHoro
Ha Cn"1He. rny6111Ha CTpyna CTporo onpe,D.eileHa
VI 3aBVICl.ff OT 3KCn031Al.llAVI cseTOBOAa (pVIC. 62 -
A). YcTaHasm1BaeTes:i OHa x111pyproM np111 noMo-
. , ., ,,- .. ~<;,:, _ .
- :~_-_ '_ · ~-~·..;.;:\ .-.·_ . -~:-~b:_ :1·;.---; . -_·,
c;p;-;,· 7.,: -:'. ·-):~_ ~ .','_-if·~-F~-~-. ·. .
.•J, -..iif -IJ..,,:- ·. ·-1 ,~ ~ _ 1 ,. -_ -..
": !~-:~~: If[·_·"-_, ·:•\'·j;-- :'>/ J·
-~ ~ - .tvJ . . . ' 'i· t .:
_.....,=:c....EU~~-.c,,;.
Ba1<yyMHbtt'I
111-1 raTOp
ll.\"1 perymnopa (pli1C. 62 - 6). np1i1 my61i1He CTpy-
na 1,5 MM a 30HY Koaryns:11..1.V1111 nona,llaJOT no-
cnoVIHo - CIIVl3VICTa51 , no,D,CJ1Vl31t1CTblVI cnoVI 1,1 Ha-
XOA51ll.\VllAC51 s HeM apTep111anbHb1L4 cocy,n, - o,n,Ha
Vl3 seTBeVI a.rectalis superior, no KornpoMy no-
CTYnaeT KpOBb B reMoppo111,n,ailbHbll4 KOIIIleKTop .
Pi.tc. 63. Jle\.je6ttoe AeHCTBMe MHcppa-
KpacHoH Koarym11.-1MM Ha BHyTpeHHMe re-
MoppOMAaflbHble Y3flbl. A, 6, B - TeXHM\.je-
cKi.te MOMeHTbl Koaryflffl.-!MM; r, ,Q,, E - BMA
cTpyna "1epe3 1 \.lac, 1 HeAemo, 2 HeAenM
nocne Koarynffl.-!MM.
npVI HaJ11114VIVI 4-5 CTpynoB B 06JlaCTVI apTe-
pVIVI (p1.1c. 63 - A, 6, 8) cTeneHb sepos:iTHOCTVI
nona,QaHVl51 ee B 30HY Koaryils:ll..\VIVI BeCbMa BblCO-
Ka. npo1.1cxo,n,1i1T 06n1.1Tepau,1.1s:1 npocsern cocyAa
3a c4eT nospe)f(,ll,eH111s:1 ero VIHTVIMbl, cpe,n,Hero
enos:i 111 a,n,seHTVIL\lllVI . HanonHeHVle KonneKTopa
KpOBblO pe3KO CHVl)f(aeTes:I. r1i1nepnna31t1s:I K8Bep-
H03HOVI TKaHVI npeKpalJ..laeTes:I. reMopp0111,D.aflb-
Hbl£1 y3en a re4eHIAIA o~Horo - ~syx Mec511.1es
no,n,sepraeTcs:i o6paTHOMY pa3Blt1TVllO, 3Ha4111-
239
TellbHO yMeHbW851Cb B pa3Mepax. np111 OCMOTpe
cnlll31t1CTOVt aHanbHOro KaHana B OTAaneHHOM
nocneonepa~1t10HHOM nep1110,o,e (p1t1c. 63 - r.
)J,, E)
Mbl BlllAIAM y TaKlllX na1...1111eHTOB, BMeCTO ysem1-
uc. 62. llfHcjJpaKpacHbJtJ Koa2ynRmop (/RC) : CTL-38031010 - Lumatec (lepMaHuR)
Bepxwrn
Ilp5t:MOKHllle<IHM
cocy;rrncTOM HOJl(J<J1 KaBepH0.3HOro KOJlllCKTopa
ap-repllil
Puc. 64. flfcfJpaKpacHaR cpomoKoa2ynRlWR eHympeHHux 2eMoppouaanbHbJX y3noe (cxeMa) .
Padw<allbHOe xupyp2uYeCJ<0e 11eYeHue
xpoHUl.feCK020 2eMoppoR
3aKpbnas:1 reMoppo111A3KTOM11151 c nonHblM
BOCCTaHOBJleHi.-ieM Cili.13i.1CTOVt aHallbHOro KaHana
(p111c. 65 , 66), np111MeHf!eTCfl y 74,8% na1...1111eHTOB
c xpOHll'l4eCKlllM reMoppoeM 3-4 CTa,IJ,ll'li.1 , nOCTY-
nalOl.1.lll'IX B npoKTonor1111.1ecK111e 111 06L1.1ex111pypr111-
1.1ecK111e cTa1...11110Hapb1.
noKa3aHt.rn : XpOHl!'l4eCKlllVt KOM6111HlllpOBaH-
Hblill reMoppow c sbina,aeHIAeM y3nos 3, 4 cra,a1.1ill
(c KPOBOTe4eHlllf!Mi.1 111n111 6e3 HlllX).
npoTVIBOnoKa3aHlllfl: n!)l(eJlafl conyTCTBYIO-
l.1.1851 COMaTlll4eCKaf! naTOnOrlllfl.
06e36on111saH111e: Cn111HanbHaf! aHecrn3111s:i.
Onepa1...1111fl npoBO,IJ,lllTCfl B CTaLlll'IOHape, B nnaHO-
BOM nop51,D,Ke.
1.1eHHblX reMoppOlllAanbHblX y3nos m1wb 3anyc-
TeBW111e ,1.J,ynm.1KaTYpb1 cn1113111crnill (p111c. 64) . Kpo-
BOTe1.1eH111e 1113 TaKlllX y3nos 6onee He B03HlllKaeT.
.. ..·
.,,..._.,
Mecra noKturr,Holi Koarymuun1 cnH3HCToli
o6ono 'IKH anaJIE.Roro Km1ana B rrpoe1<Uim
P11tc. 65. reMoppOHA3KTOMHSf C BOCCTa-
HOB.neHHeM Cfl"13"1CTOM aHaflbHOro KaHa.na.
3ranb1 onepa1...1111111
- )J,111eynbc111si aHaflbHOro KaHana peKTailb-
HblM «3epKanOM» AO CMblK8Hlllfl era 6paHweill no
,1.J,111ar0Han5!M OKPY)l(HOCTVI 3aAHero npoxo,D,a (P111c.
65-A)
- ct>111Kca1...11111=1 pacw111peHHoro cQ:i111HKTepa
pattopacwi.-ip111TeneM
- no,D,THrlllBaHllle BHyTpeHHero Y3lla Ha 11
1.1acax 3a)l(lllMOM nio3pa (Plllc.65- 5)
- nepe)l{aTllle ,£11.1CTailbHOr;! 4aCrn y3na CHa-
p°Y)Klll BHYTPb 6e3 3aXBaTa cocy,1.J,111cro~ HO>KKlll
3a>1<111MoM 5111nbporn (p111c. 65 - B)
240
 - 0Tce4eH111e y3na HaA 3a)f{111MOM AO cocy-
,ri1..1cToll1 HO)f{Kl..1 (P1..1c.65 - B) .
- npoWIABaHllle, nepeB513Ka HO)f{Kl/I KeTryTOM
111 ee OTCe4eH111e (Plllc.65- r)
BepxHRR npRMOKV1we4HaR aprep111R
Puc. 66. J!fcce<JeHue eHympeHHeco aeMoppouaanbHoao y3na ao cocyaucmoa HD)l(KLJ (A), nepece<JeHue u
nepeBRJKa cocyaucmoD HO)l(KLJ (5) , eoccmaHoeneHue aecpeKma cnu3UcmoD o6ono<JKU y3noeb1Mu weaMu (B) (cxeMa) .
- 111cce4eHVJe Hapy)f{HblX y3nos c yw111saH111-
eM KO)l{HblX paH .
- BBeAeHl/le B nps:iMylO KlllWKY pe3111HOBOll1
Tpy6Klll, o6epHYT0'1 TaMnOHOM c Ma3bl0 Ha 1 CYTKlll
B nocneonepa41110HHOM nep1110Ae AllleTa -
1CTOJ1 no neB3Hepy. nocTeJlbHbli/1 pe}l{l/IM B Te-
lJeHllle 1 cyrnK. nepeA nepBblM crynoM - olJ111-
cT111TenbHafl KJ11113Ma (spalle6Has:i npo4eAypa) .
PaA1AKaJlbHOll1 reMoppOl..1A3KTOMlll"1 csoll1cT-
seHHbl onpeAeJleHHble He,QOCTaTKlll : B TelJeH111e 3-
4 AHeef nocneonepa41110HHaro nep1110,lla na~111eH­
Tbl Hy)l{,QalOTCS'I B HapKOTl!14eCKVIX aHanbreTlllKax
1113-3a sb1pa)l{eHHoro 6onesoro ClllHAPOMa; y no-
)l{lllJlblX na4111eHTOB nocne BMewarenbcTsa He-
peAKO B03HlllKaeT paccTpoll1cTso M04e111cnycKa-
Hlllfl , Tpe6yio~ee cne4111anbHblX MeTOAOB ne4e-
HlllS'I. Heo6xoAlllMO An111renbHoe npe6b1BaH111e B
cra41110Hape (7-10 ,[IHetf). nep1110,Q yrparbJ Tpy-
AOcnoco6Hocrn AOCTlllraeT 3-4 H8A8Jlb. VIMeHHO
no3TOMY s HacTos:i~ee speMs:i see w111pe np111Me-
Hfl10Tcs:1 Manol/IHBa31/1BHble BMeWaTeJlbCTBa.
OCTPblM rEMOPPOM
Y na4111eHTOB, cTpaAatO~lllM xpoH1114ecK111M
reMoppoeM MO)f{8T B03Hl/IKaTb COCTOS'IHl/le, lllMe-
HyeMoe «OCTpbli/1 reMoppoll1» . 3TO COCTOS'IHl/le,
lllJllll cpopMy 3a6oneBaHVIS'I "1HOfA8, He COBCeM
sepHO H83blB8IOT «y~eMneHHblli1 reMoppoli1» lllJllll
«TpOM603 reMoppOIA,[18JlbHblX Y3JlOB». npaBIAJlb-
HOe Ha3BaH111e - ocTpb1il1 reMoppoi/1 T.K. B narnre-
He3e 3a6onesaH111s:1 y4acTsyeT HeCKOJlbKO Mexa-
Hlll3MOB.
241
- BoccTaHosneH111e paHbl cn1113111cToli1 Keny-
TOBblMlll wsaMVJ (Plllc.65 - r)
- V1cce4eH1..1e noA06HblM )f{e o6pa3oM y3-
nos Ha 3 1..1 7 4acax. V1cce4eH111e 6onee 4eM 3
y3noa HeAonycrnMo.
3muo1102uR u namozeHe3 ocmpo20
2eMoppoR
Lla~e scero ocTpb1i/1 reMoppoi/1 B03HVIKaeT
nplll C048T8HHOM Ill OAHOBpeMeHHOM ,Qeli1CTBllllll
H8CKOJlbKlllX 3TlllOnarnreHen1lJ8CKlllX cpaKTopos,
pOJlb KOTOpblX B pa3BVITlllVI xpOHlll48CKOro reMop-
pos:i yKa3aHa paHee.
Ocrpb1li1 reMoppoi/1 MO)f{HO onpeAen111Tb KaK
OCTpoe B03HlllKHOBeH111e «KOHfJlOMepara Bbmas-
WlllX, y~eMlllBWl/IXCS'I , TpOM6VlpOBaHHblX Ill BOcna-
Jll/IBUJl..1XCS'I BHYTpeHHVIX reMoppo111,QanbHblX y3-
nos» (PVIC. 67) .
803MO)f{HO VICKJll04eHVle 1113 3TOro onpe,Qe-
neHl/IS'I, ecn111 naTonorn4ecK111il1 npo4ecc KacaeT-
Cfl TOJlbKO Hapy>KHblX reMoppo111,QanbHb1x y311os.
B 3TOM cnyYae , BbmaAeHlllfl 111 y~eMneHlllS'I 111x
pa3yMeercs:i Her, T. K. Hapy}l{Hbre y3nbr pacno-
no>KeHbl nOA KO>Kei/1, nosepXHOCTHee BOJlOKOH
Ccj:)lllHKTepa.
PHc. 67. OcTpbu.1 reMoppo~ 3 cTeneHH
1113 nepe41t1CJleHHblX naTOJlOflllYeCKVIX MO-
M8HTOB VIMeeTCS'I Jll/IUJb lt1X TpOM603 Ill socnane-
Hlife T. e. B 3TOM cnyYae peYb 111,.QeT 0 TpOM6H-
poBaHHblX "' eocnaJlHBWHXCH Hapy>KHblX re-
Moppo1i1,QaJlbHblX Y3IlaX. nop,o6Hafl KJ1VIHlt14e-
CKafl KapTVIHa xapaKTepHa ,QJ151 1 CTeneHlll OCTpO-
ro reMoppofl .
Kflaccuc/JuKau,uR ocmpo20 2eMoppoF1
(rocyoapcmaeHH020 HOYYH020 u,eHmpa
KOflonpoKmof102uu, MocKaa, 2001.}
1 cmeneHb - He6onbw1t1e nOAKO>KHble, cner-
Ka 60ile3HeHHble o5pa30BaHlt151 . nailbl\eBOe peK-
TaJlbHOe lt1CCileAOBaH1t1e 6oJle3HeHHO, HO 803-
MO>KHO. Bocna11eH111e TpoM6111posaHHb1x, Bbl-
naew111x y311oe KillllHlll'-1ecK111 He onpeAenHeTCH
(P1t1c. 68-A) .
2 cmeneHb - OnpeAen51erc51 He6onbwoi/1
KOHrilOMepaT BblnaBWlrlX, nilOTHblX, Clt1HtoWHblX
HeBnpaBI151tol.1\lt1XC51 BHyrpeHHlrlX reMoppo1t1AaI1b-
HblX y3nos. VIMetOTCH np111JHaK111 eocnaneHlllH
TpOM6MpOB3HHblX, Bbln3BWMX yJnoe. nanb-
l\eBoe peKTailbHOe lt1CCI1eAOB8Hlt1e HeB03M0)1{H0
1t13-3a 6on1t1 (P1t1c. 68-5).
3 cmeneHb - Bc51 oKpy>KHOCTb 38AHero npo-
xoAa npeACTaBI151eT co6oill pe3KO 6one3HeHHblill
nilOTHblill lt1HQJlt1IlbTpar. "1MetOTCJI nplll3H3Klll
eocnaneH111H noAKO>KHOM K11eP1aTKM 111 nep111a-
Ha11bHOM KO>Klll. 6arposo-c111H1r1e Y3Ilbi Hanp51)f(e-
Hbl. Ko)f(a BOKpyr ore1.1Ha , rnnepeML1posaHa . Bo-
Kpyr 38AHero npOXOAa 6one3HeHHblii1 nnOTHbliil
1t1Hcp11u1brpar 3Ha41t1TeilbHblX pa3Mepos. Ha cn1.1-
31r1croii1 o6ono4Ke Moryr 1r1MetoTbC5i y4aCTKlt1 HeK-
po3a cepo-3eneHoro 1t1n1r1 4epHoro l\Bera. Boc-
naneH1t1e nep1t1aHailbHOiil KO:>Klt1 pe3KO Bblpa:>KeHo
(P1t1c. 68-B, r) .
P111c. 68. KnaccL11cpL11Ka'-'111.R ocTporo re-
MoppoR. A. OcTpb1ilt reMoppoilt 1 cTeneH111.
5. OcTpbllil reMoppoilt 2 CTeneHM. 8, r. OcT-
pblM reMoppollt 3 cTeneHM.
KfluHu1<a ocmpo20 2eMoppoF1
:>Kano6b1 Ha 04eHb C1t1IlbHb1e, Herepn1t1Mb1e
6on1t1 B 3aAHeM npOXOAe lt1 Han1t11.11t1e Bbln8BW1t1X,
nnoTHblX, HesnpaBIAMblX BHYTP8HH1t1X reMppo1t1-
AanbHblX y3nos. V1HorAa MO)f{eT 6b1Tb cy6¢e6-
p1t1IlbHas:1 TeMneparypa. 6om1 pe3KO yc1r1111t1sator-
C.5l np1t1 p,e¢eKaL11t11t1 , naL1111eHT crpeM1t1Tcs:1 3aAep-
)1{8Tb onopO)l{HeH1t1e np51MOll1 Klt1WKIA .
AHaMHe3 3a6onesaH1t1s:1 . Ha4a.no ocrpoe.
06b11.1Ho 6onbHOil1 o6pal.1\aercs:i K spa1.1y s re4e-
H1t1e nepBblX CYTOK 6one3Hi11. Ha4a110 3a6onesa-
H1t1.s:i nal\IAeHT CB513b1Baer c nOAH.s:lTIAeM 3H841A-
T8IlbHOilt Ts:l)l{8CTIA , np1t18MOM 60.nbWOro KOI11!14e-
CTBa anKorons:i , ocrpoill n1t11.1\1t1 .
/1,ua2Hocmu1<a
,D,111arH03 ocrporo reMopposi nerno Bb1cra-
B1t1Tb y)l{e np111 OCMOTpe 3a,[\Hero npOXO,D,a. nono-
)f{eHllle nal\111eHra - Ha cn111He s npoKTonor1111.1e-
CKOM Kpecne 111Illt1 Ha KyWeTKe B KOJleHHO-
IlOKTeBOM nono>KeH111111. Kn111H1111.1ecKasi KaprnHa,
Bbls:IBJls:leMas:I np111 OCMOTpe yKa3aHa BblWe np111
KJlaCCl!1QJll1Ka4111111 ocrporo reMopposi .
np1r1 2, 3 creneH111 ocrporo reMopposi nanb-
1..1esoe peKTaJlbHOe l!1 111HCTPYM8HT8JlbHbl8 lr1C-
cne,[\0BaH1t15l pe3KO 6one3HHeHHbl 1t1 np1r1 nocryn-
neHl!11r1 60ilbHOro B KI11t1Hl!1Ky He np01r1380,D,SlTCSl.
242
0,o,HaKO, 1.1epe3 6-8 AHeill, nocne CTlt1X8Hlt151 OCT-
pblX s:1sneH1t1il1 , KOrAa Bb1nasw1t1e yJnbl nonHo-
CTbto snpaBlt1IllACb B nps:!MYIO Klt1WKy, o65138T8Ilb-
HO BblnOI1H518TC51 peKTopoMaHOCKOnlt151 )f(8CTKll1M
peKTopoMaHOCKOnOM p,ns:i Ol\eHKlt1 COCTOs:!Hlt1Sl
BHyrpeHHIAX y3nos 1t1 onpeAeneH1t1s:i noKa3aH1t1il1 K
onepaTIABHOMY ne4eH1t110 , a TaK)f(e An.s:i 111cKnto4e-
Hll1Sl APYrlllX nopa>KeHIAlA TOJlCTOlA KIAWKL1 , rpe-
6ytol.1\IAX Apyroi/1 raKT1t1K1t1 ne1.1eH111s:i .
f7eYeHue ocmpozo 2eMoppoR
ne4eHll1e KOHCepB8Tlt1BHOe, aM6ynaTOpHOe.
noKa3aHa Bb1A848 Illl1CTKa BpeMeHHOill HeTPYAO-
cnoco6HOCTlt1 . Pe)f{1t1M nocrenbHbllA -1-2 cyroK.
,D,111era CTOil NQ 1 no neB3Hepy. HaCll1IlbCTBeHHOe
snpasneHl!1e y3nos Karerop1t14eCKl!1 H8Aonycrn-
MO. nepL18H8IlbHbl8 HOBOK8l!1HOBbl8 6nOK8Ab1 B
HaCTOSll.1\88 speMSl C4l!1TatoTCSl ycrap8BW1t1M 111
onacHblM cnoco6oM snpasneHl!1Sl yl.1\eM1t1BWl!1xcs:1
Y3IlOB.
I. HeMeP,l!1KaMeHT03Has:i repanl!1s:i
1. OrpaH1t14eH1t1e nop,H51Tlt151 n1>Kecrei/1.
2. ,D,111era c 1t1cKn101.1eH111eM ocrpoiil n1r11.4111 ,
np111npas 111 anKoron51
II. MeA111KaMeHT03Has:i repan111.s:i (Bb16paTb
npenapar lt13 Ka)f(AoiA rpynnbl)
A) . ,D,1110CMll1Hbl
• ,QeTpaneKC (BeHapyc, BeHOAlllOil) 2
ra6nerKl!1 x 3 pa3a - 4 AHSl, 2ra6nerKll1 x 2 pa3a
- 3 AH51 , 1 ra6neTKa x 2 pa3a B p,eHb - AO 60
AHeill
• <1>11e60A111a -600 1ra6nerKa 3 pa3a s
p,eHb 7 AHeill , p,anee 1 ra6nerKa a ,[\eHb 60 AHeiA .
6). Hecrepo1t1AHb1e npornsosocnan111renb-
Hb1e npenaparb1
• Me110Kc111KaM 0,0075 1 pa3 s AeHb (np111
513BeHHoil1 6one3Hll1 )f(enyAKa 111 12 nepcrHoiil -
Kll1WKll1 He Ha3Ha4aTb, np111 racrp111rax 111 AYOAeHl!1-
rax H83H848Tb c OCTOpO)f{HOCTblO!) - 10-14 AHeill .
B) . ,D,eJarperaHTbl
• TpeHTan 400 (neHTOKc1t1¢111nn111H 400
Mr)1r. x 2 pa3a B AeHb, 10 AHeill, 3areM 1 ra6-
nerKa yrpoM - AO 3 -4 Hep,enb
111. Ton1r14ecK1t1e npenapaTbl
• MaJb renap111HoeaH Mecrno (renapo111A,
renarpoM6111H, rpoM6necc, n1t10TOH 1000) - 4
pa3a B A8Hb. Ma3b Ha y3nax AOil>KHa npll1CYTCT-
sosarb nocros:IHHO B re1.1eH111e cyroK!
np111 ocrpoM BHyrpeHHeM reMoppoe -
• H111renaH - peKTanbHble cynno3111ropl!11t1 x
3 pa3a B ,D,eHb, BM8CTO yKa3aHHblX Ma3eil1.
Mecrnoe ne1.1eH1t1e. renap1t1H0Ba5'! M83b,
M83b «TpoKceB83111H» , H1t1renaH . K rpynne KOM61A-
H111posaHHblX npenaparos Mecrnoro A8Llicrs111s:1,
C0,[1ep)f{81.1\IAX o6e360I11AB8IOl.1\111e, rpoM6on111T111-
l.lecK111e 1r1 npornsosocnan111renbHb1e KoMnoH8HTbl
orHocs:ircsi np0Kroce,Q1r1n 1r1 renarorpoM61t1H r ,
BblnYCKa8Mble B BIA,Qe Ma3eBblX, reneBblX OCHOB
1r1 cynno31r1rop1r1es. r enaTpoM6111H r cop,ep>K111T rp1r1
KOMnOH8HTa: MeCTHblill 8H8CT8Tlt1K nonll1,QOK8HOn ,
npeAHL'l3onoH L'I renapL'IH. PeKTanbHble cynno3L'l-
TOPL'IL'I lenarpoM6L'IH I 880AHT 8 nps:1Myto Kl.1Wt<y
nocne AeQ:>eKaL\l.1L'I 1-3 pa3a 8 cyrKL'I. Ma3b MO>K-
HO TaK>Ke BBOAL'ITb L'I B nps:!MYIO KL'IWKy. Kypc ne-
4eHL'l71 lenarpoM6L'IHOM I COCTaBJJS'leT OT 7 ,LlO 14
AHeLll . lenarpoM6L'IH I, MO>KHO npL'IMeHHTb npvi
6epeMeHHOCTV1.
npL'IMeHS'llOT so,aopaCTBOplilMble M83lil, 06-
JlaAalOLl.\L'le nponrnosocnanLiirenbHblM Aell1cTBL'l-
eM (ne8aCL'IH, nesoMeKonb, MacpL'IHL'IA) .
npL'I crnxaHL'IL'I OCTpblX SIBJleHL'lll\ npOL'l3BO-
AL'ITCH peKTopoMaHOCKOnL'ls:t AilH VlCKiltoYeHL'IH
,llpyrwx Ja6oneBaHVJLll TOJlCTOW KVIWl<l4. 8bJCTa8-
JlHIOTCH noK838HV1H K onepaTVlBHOMy ne4eHL'llO
reMoppOL'IA3KTOML'IL'I KOTopaH BblnOJ1Hs:teTCHYepe3
1-2 MeC5lL\a, nocne t<ynviposaH111Si ocTporo npo-
L\ecca. noK838HL'IH - Te )1(8, 4TO YK838Hbl B pa3-
.o,ene «XpoHL'IYeCKL'IW reMoppoi.1». Bb1nonH5'!eTcs:1
CTaHA8PTHas:t 3aKpblT8S'I reMoppOL'IA3KTOML'l51 c
nonHblM L'IIlL'I 1.1acrn4HblM yWL'IBaHL'leM paH
aHaJlbHOfO KaHana 1r1n1r1 OTKpblTaH reMoppOlrl,ll3K-
TOML'IS'I (6e3 yw111saHL'IH paH) B TOM cny4ae, ecnL'I
L'ICnOilb3YIOTCS'I BblCOKOTeXHOJ10fLi14Hb18 MeTOAbl
KOarymlL\L'IOHHOfO pacceYeHL'lfl TKaHell\.
AHAnbHA~ TPEU.UAHA
AHanbHas:t Tpell.\1t1Ha B HaCTOHLl.\ee 8peMs:t
ycrynaeT no 1.1acrnre n111wb reMoppoto , L'I scrpe-
Yaercs:t y 11, 7% na1..11AeHTDB, 06parn8W1t1Xc5! K
npoKTonory. Llall.\e crpa,D,ator >KeHLl.\L'IHbl B rpy-
,D,ocnoco6HoM so3pacre .
nepsoe ynoML'IH8Hlt18 Ha pycCKOM S'l3b1Ke 0
rpell.\L'IHe 38,D,Hero npoxo,D,a npL'IBeAeHo s 1863
rop,y B AOKTOpCKOli1 ,D,L'ICCepT8L\111VI I. nerp08a «0
rpeLl.\L'IHax 8 3a,D,HeM npoxoAe» .
3mUOf102UR u namozeHe3 GHGflbHOU
mpeUJ,UHbt
np1114L'IHOLll B03Hll1KHOBeHl/15'1 aHaJlbHOi.1 Tpe-
Ll.\L'IHbl S'l8J1518TC51 rpaBMa aHOA8PMbl TB8PAblML'I
48CTLi!L\aML'I Kana . fierKO Tp8BML'lpyeTC51 pb1XJ185l
cn1r1s111cras:1 o6ono4Ka, co CHl!l)l{eHHblMlrl 3nacrn-
YecKL'IMVI csoll\crsaM111, KaKas:t 6b1saer np111 xpoHV1-
4ecK111x npoKTL'ITaX, npoKTOCL'lrM0111A111TaX L'I AP·
socnanvirenbHbtX 3a6onesaH1.1s:1x roncro,;:; Kt..1WKll1 .
HenocpeAcTBeHHoLll np1A4L'IHOLll pa3pbt8a aHOA-
)l{epMbl Lil 06pa3osaHl.15l rpe1.41..1Hbl o6bl4HO cny-
>KL'IT 3anop. AHanbHYto rpe1.41..1Hy, cyLl.\ecrsyto-
Ll.\YIO AO 6 HeAeilb H83blB8IOT ocrpoLll. XpOHL'l4e-
Cl<aS'I aHa.nbHaH rpe1.1.111Ha (XAT) cy11.1ecrayer 60-
nee 6 He,Qenb.
CL'lllbHaH 6onb s MOMeHT pa3pb1sa cn111JL'l-
croll\ o6ono4Kll1 Bbl3blsaer pe3KL111\ cna3M BHyr-
peHHero ccpL1HKTepa 3a,D,Hero npoxop,a. C¢111HK-
rep HaXO,!lli!TC.11 B COCT051Hlt1J.1 noBbJWeHHOro TO-
Hyca L'I Me>K,lly 6oneBblML1 np111crynaML'I . Cna3M
CcPL'IHKTepa yc111n1..1saer 6onb, Bbl3blBaeT 3anop,
Mewaer 3a>1<1..1s.neH1i1to rpel.J.llt1Hbt. Bo3Hll1KaeT no-
po4Hblll1 Kpyr. AnLiirenbHOe TOHL'l4ecKoe coKpa-
1.J.leHL'le MblWL\bl ccp1t1HKTepa 8bl3b1Baer 3aMeLl.\e-
H111e ee BOJlOKOH coeA1t1H1t1TeJlbHOL1 TK8Hbl0. Bo3-
243
HL'IKaeT ¢1116po3 CcpL'IHKTepa (neKTeH03), KOTOpbii.1
ycyry6.ns:1er cna3M .
B naroreHe3e XAT t.1Meer 3Ha4eH111e L'I
111weML'IH aHanbHOro KaHana s o6nacrn 3ap,Heil1
cnall\K111, 111 nosb1WeHHas:1 TpaBMarn3aL.\lil51 arol1 >Ke
30Hbl cf>eKanbHblM 6ontoCOM L'l3-38 pa3J11114HOll1
Hanpas.neHHocrn ocei/1 aHanbHoro KaHa.na L'I aM-
nynb1 nps:1Mo£1 KlllWKL'I. He.Qocraro4Hb1£1 C"1HTe3
OKClllA8 830Ta B 3HAOTen111L'I COCYAOB aHOAepMbl
n08b1waer roHyc ccpL'IHKTepa.
MopcjJ011owR OHOflbHOU mpew,UHbJ
AHanbHafl rpell.lwHa BblrflH,lllrlT r<aK Ae¢eKT
aHOAepMbl Ll.\e.nes1i1AHOlil ¢opMbl. Pacno.no>KeHa
oHa Ha rpaH111L\e Ko>K111 111 aHOAepMbl. PeAKO 6b1-
saer H8CKOJlbKO aHaJlbHblX rpeLl.\L'IH (4%). ,IJ,JlL'IHa
p,ecpeKTa o6b14HO cocrasns:ter 1,0-1 ,5 cM, w111-
pL'IHa 2-4 MM, r.ny6L'IHa XpOHll14eCKOll1 TpeLl.\lllHbl 2-
3 MM, ocrpoll\ - 1:.1,s MM . XpOHL'l48CKaH aHaJlb-
Haf! rpell.\1t1Ha cyw,ecrsyeT HeCKOnbKO HeAenb, L'I
a pesynbrare xpoH"14ecr<oro 8ocna.neH1t1H ee
CTeHKL'I 111 AHO nOKpb1B8IOTCH rpaHyns:14111S'!Mlt1 , KO-
TOpble c Te4eHll1eM speMeH111 npespal.J.latoTC5l s
py6u,b1. Y Hapy>KHoro, a 111Hor,D,a 111 y BHyrpeHHero
yrnos TP8Ll.\L'IHbl o6pa3ytoTCH raK H83blBaeMble
«CMrHa.nbHbJe» 6yropK111. OH111 npep,cras11~10T
co6oll\ BblpOCTbl coe,D,lllHL'ITeJlbHOLll TKaHl/1 p030BO-
ro L\BeTa BblCOTOlil 1-2 MM , (PL'IC. 69) . Ha AHe
xpoH1t14ec1<oi.1 aHa.nbHOi.1 rpeLl.\1t1Hbl Moryr 6btTb
BL'l,D,Hbl BO.nOKHa CQ)l.1HKTepa, pacnOJlO}l{eHHble
nonepeK Ae<fleKTa aHOAepMbt.
3rn 3 Mop¢onorn4ecK1t1X npL'l3HaKa 6e3yc-
.nosHo yKa3blBatoT Ha xpoH1t14ecK111L1 xapaKTep
rpe1.1.1wHbl. Ocrpas:t rpe11.11r1Ha 3TlrlX oco6eHHocre£1
He 111Meer.
P111c. 69. XpoHM'-lecKa.R aHa.nbHast Tpe-
ll.\HHa. A - 38AH.R.R, 5. - 6oKoBa.R A. "1H-
Tpaonepau,1110HblM OCMOTP 3aAHeM aHa.nb-
HOM Tpe~MHbl. 1- BHyTpeHHlllM ClllrHaJlbHblM
6yropoK. 2- Hapy}l{HbtM cMrHaJtbHblM 6yro-
poK. CTpenKoi:t yKa3aHo .QHO TpeutMHbJ, no-
Kpb1roe <fl1116p111HoM. 5. Aoonepau,MOHHOe
Bbl.RB.neH111e 60KOBOM aHaflbHOM Tpell.\MHbl
1<11UHUKO xpoHUl..feCKOU GHOflbHOU
mpew,uHbt
XpoH1t14eCKas:1 aHa.nbHaH rpeLl.\1t1Ha npos:18-
m1eT ce651 rnm14HOiii Kn1t1H1t1YecKoiii J<apn1Hoiii .
TpLiia,Qa CL'IMnTOMOB (no B. A . <DeAopoay): 1)
60.nb B 3aAHeM npoxo,qe npL'I Ae¢eKaL\111L1 1.1 no-
cne Hee; 2) Kposore4eHL'le np111 AecpeKal.\L'IL'I s
BL'IAe no.nocKL'I anoro l\Bera Ha Ka.ne; 3) cna3M
c¢111HKTepa. HepeAKO co4eTaH111e np1113HaKoB
xpoH1t14eCKoll\ aHanbHOVt rpeLl.\l.1Hbt 1t1 xpoH1t14ecKo-
ro reMoppos:1.
>Kano6b1:
- 6onb pe3K851, «Kll1H)!(8JlbH8S'I» B 3a,D,HeM
npoxo,Qe c V1ppap,L'lal\l.1elil B KpecTe4, npoMe>K-
HOCTb np111 Ae¢eKaL\111L'I 1..1 nocne Hee;
 - He3Ha4111TenbHOe KposoTe4eH1.1e np1.1 Ae-
cpeKa1..11.11.1, 4all.le s 01.1,L:1e no11ocK1.1 anoro 1..1sern Ha
Kane;
- 3anopb1 - Aect>eKal\11151 1 pa3 B 2-3 AH51.
60JlbHOiil CTpeMlllTC51 3a,[\ep)f(aTb cryn , 4T06bl
1.136e)f{aTb 6on111 «cryno6os:13Hb).
- np1113HaK111 conyTcTBYIOll.lero raeTplllTa ,
AYO,l\eH111ra , Ct.1H,l\POM8 pa3Apa)l(eHHOiil Toncroill
KlllWKlll, AL11e6aKTep11103a 111 np.
,LJ,ua2Hocmww aHanbHou mpeLJ1UHbl
AHaJlbHa51 Tpell.llllHa Bb151Bn51eTc51 np111 oc-
Morpe 3aAHero npoxoAa. Heo6xOAlllMO nanbna-
TOpHo pa3A81.1HYTb nep1.1aHailbHb1e paA1.1anbHb1e
eKJlaAKlll KO>Kl.1 np111 naTepa11bHOlil TpaKl..1111111 51ro-
,l\lllL.I. Tpell.ll.1Ha BL1,QHa Ha rpaHL1L1e KO)f{l.1 L1 CnL13111-
eTolil 8 Blt1Ae Ae¢eKTa M51rKlllX TKaHelil , «5138bl»
ll.leJleBl.1,l\HOi::\ L1Jll.1 TpeyronbHOi::l cpOpMbl (Piiie. 70,
71 ).
Puc. 70. Hau6onee <.1acmoe pacnono)l(eHue
xpoHUl.JecKoil 8H8flbHOil mpeUJ,UHbl
no oKp}'>KHocmu aHBflbHoao KaHana.
6onee 4aeToe paeno11o)f(eH1.1e Tpell.llllHbl Ha
6 4aeax o6b51eH51eTe51 , so-nepBblX, l<YAWlllMlll ye-
noBlll51Mlll Kp080eHa6>KeHlll51 aHO,llepMbl B 3TlllX
0611aeT5IX - 3AeCb 11er4e HacrynaeT 111weM1.15I np111
cna3Me CQJlllHKTepa; 80-8TOpblX - OCHOBHOe Aa8-
neHl!1e KanoBbtX Mace np111 3BaKyal\llllll c0Aep)l(111-
Moro aMnynbl npt.1XO,QlllTC51 Ha 3a,l\HIOIO CTeHKy
aHaJlbHOro KaHana 1.1 oHa 4all.le nospe)K,llaeTc51.
PMc. 71. AHanbHa.ff rpeutMHa (.Qoone-
pau,1110HHblM ocMoTp). A. OcTpast aHanbHast
rpeutMHa. 6. XpoHM'·tecKa.ff aHanbHa.ff rpe-
IJ.tMHa. 81.<f,QHbl «nO,QpblTble», HaBMCal-Outllte
Kpa.Sl xpoHMlfeCKOM rpeutMHbl.
lleLfeHue OHGflbHOU mpeW,UHbl
OcTpyl-0 aHanbHYIO Tpell.llllHY 111 xpoH1.14e-
eKy10 aHanbHYIO rpell.llllHY 11e4aT KOHeepBaTlllBHO
,l\O 6 - 8HeAeJlb .
I. HeMeAt.1KaMeHT03Ha51 repan11151
1. OrpaH1114eH111e noAH51n1.51 T51)1(eeTei:1 .
2. A111eTa c li1CKn10YeH111eM ocrpoi::\ nll1ll\111,
np111npa0 1.1 anKoronfl, np111eM 6onbworo Kom14e-
eTsa paernTe11bHoi:1 KneT4aTKll1 (eseKna , Kanyern,
MOpKOBb, Ka6a4K111 , TblKBa, 4epHOCJlt.18 xne6 t.13
244
p>t<aHolil MYKlll rpy6oro noM011a, osc51Ha51 111 rpe4-
Hesa51 Kawa)
I I. MeouKaMeHm03Hafl mepanuR (0b16paTb
OA111H npenapar 1113 rpym1b1)
A). A1.1oeMlllHbl
• AerpaneKc 1 Ta611eTKa x2 pa3a 8 .a.eHb -
,l\O 60 AHelil 11111111
• <l>.ne6o.qMa - 600 1 ra6neTKa s ,lleHb -60
,l\HeVf .
5). HeernpOlll,l\Hble socnan1.1TenbHb1e npe-
napaTb1 np111 Bblpa)l(eHHOM 6oneBOM CVIH,[\pOMe
• MoeanMc (MenoKe111KaM) 0,0075 1 pa3 a
,a.eHb (np111 513BeHHoi:1 6one3Hlll )f{eny,a.Ka 1i1 12
nepCTHOVf - KlllWKlll He H83H848Tb, np111 racrp1.-nax
111 AYOAeH111rnx Ha3Ha4aTb e oernpo>KHOCTbl-0!) -
10-14 .Q.Helil.
r). Cna3MOnlllTlllKlll
• .Q1-0cnaTanMH 1 ra6neTKa x 3 pa3a s
AeHb -10 ,aHelil
• TpMMeAaT 200 Mr 1 ra6neTKa x3 pa3a a
,[\eHb
Ill. Ton1114ecKt-1e npenaparb1
• HMTpornM4epHHOBaff M33b 0,2-0,4%
Mecrno, 2-3 pa3a s AeHb, ,LIO 6-8 He,llenb, no.a.
KOHTponeM A\Q
• Pem1Cp-ynbTpa (coAep)f{lllT rn10KOKOpT1.1-
KOlllAbt) 1 cse4a x1 pa3 s AeHb -5-7 AHei::1 . )J,anee
- ceelfM «HaTaflbCM.Q» no 1 cse4e x 3 pa3a s
.a.eHb 111111.1 «Kyp11103111H - renb» ann11111Kau111111 x 3
pa3 B AeHb
• Aypo61otH Ma3b (eo,llep)f(111T rn10KOKoprn-
K0111Ab1)- 2 pa3a B AeHb- 10 AHei::l
• flelfe6Hble MMKPOKf1"13Mbl no 200 MJl c
pacrsopoM cpypau.L1nmtHa 1 :5000, L1mt 0 ,3%
pacTBop KOililaprona Ha H04b. nepe,l\ CTYllOM ,
yTpoM - 11e4e6Hble MlllKPOKI1l-13Mb1 : paernTe11bHoe
Maeno 50 M11 + 0611en111xosoe Maeno 2 4ali1Hble
nO)l(Klll .
PaouKanbHoe xupyp2uYecKoe neYeHue
noKa38Hll1Sl: XPOHlllYecKaSl aHanbHaSl Tpe-
ll.ll.1Ha, pe31ACTeHTHa51 K KOHeepBaTlllBHOl.1 Tepan1.1111
6onee 6-8 HeAenb.
npoT11180nOK83aHlll51 : Tfl)f{ena51 conyTcTBylO-
ll\851 COMaTlll4eCKa51 naT0110rl.151. 06e36on111BaH1.1e:
BHYTPlllBeHHbli::l HapKo3, cn111HH0Mo3ro0a5I aHe-
CTe311151.
BbmonHSllOT Q:>1.1ccyp3KT0M1.110 no ra6p1.1en10
Ill 3a,QHIOIO ,ll03t.1p088HHYIO t.1111.1 60K08YIO nOAKO)f{-
HYIO ccp111HKTepoToM11110. 3Tanb1 onepau,1.1111.
- ,0,1110ynbc1.151 38,L:IHero npoxo,Qa (p111c. 72 -
A) ,
- lllcce4eH111e aHa11bHoL1 rpell.l111Hbl (p111e. 72 -
5) ,
- 3aAH5151 ,l\03111posaHH851 ccpL1HKTepoTOMIMl
(p111c. 72 - B).
np1.1MeH5llOT Ill 60KOBYIO nOAKO>KHYIO CcplilHK-
TepoTOMllllO. ,lJ,03111pOBaHHa51 ccplllHKTepoTOMLllfl
Bbl3bleaer KpaTKospeMeHHblt1 nape3 aHanbHblX
ecpLllHKTepoe, 4eM AOCrnraeTcfl noKolil aHailbHOro
)l(OMa. Ycnos111s:i Ans:i Ja)l(111sneH111s:i Tpell.\lilHbl cTa-
Hosmcs:i 6onee 6naronplil51THblMlll .
y MY>f<4lilH pacceKalOT C$lllHKTep Ha rny6111Hy
0,8 CM, y >KeHLl.\VIH - 0,5 CM. He,llOCTaTKVI onepa-
Tlt1BHOro sMewaTenbcTBa: ,IJ,11111renbHbllil 6onesolll
ClllHAPOM . 3a)l(lllBJleHllle paHbl BTOp1114HblM Harn-
)l(eHlileM AOBOJlbHO AfllilTenbHOe. npe6b1BaH111e 8
CTaL\lt10Hape - He MeHee 6-7 AHelll . HeTPYAOCno-
co6HOCTb - AO 3-X HeAenb . np111MepHO y Tpern
naL\llleHTOB B03Hl/IKalOT HapyweHl/151 aHaJlbHOlll
KOHTltlHeHL..\111111 pa3HOlll CTeneHlil Ill AI1111TenbHOCTll1 .
CTolilKas:i 1t1HKOHrnHeHL\ll15I B03Hl11Kaer peAKO. B
css:13111 c 3Tlt1M a Hacros:ill.\ee speMs:i see 6onee
WlllPOKO np111MeHs:ieTC5! 1t1HcppaKpacHa5! Koaryn51-
L\11151 ocrpolll 111 xpOHl/14eCKOlll aHaJlbHOlll Tpell.\11\Hbl.
PHc. 72. l.4cceYeHHe aHallbHoVI rpe~H­
Hbl no ra6pH3JlK> C 33AHeH A03HpOB3HHOH
CQ>litHKTepOTOMHeH.
J1<j:Jpa1<pacHaR <j:Jomo1<oa2w1R4uR
xpOHULfeCKOU OHOflbHOU mpeUJ,UHbl
noKa3aHlllS1: XPOHl/14eCKll1111 aHaJlbHa51 rpe-
Ll.\111Ha 6e3 3cpcpeKTa KOHcepsarnsHolA Tepan111111 6-
8 He,qenb.
npoTlilBOnOKa3aHlll51 : HeT.
06eJ6om11saH111e: sHyTp111seHHb111l HapKo3,
npOBOAlilTCS1 B CTaL\1110Hape B nnaHOBOM nop51A-
Ke. Annapar 111HcppaKpacHb1IA Koaryns:irop.
npolll3BO,l\l/ITCS1 HenonHaS1 ,l\lllBYilbCl/151
aHaJlbHoro >KOMa peKTanbHblM 3epKanoM. l..lene-
coo6pa3Hee 111cnonb30BaTb onepaL\lllOHHbllA aHo-
CKon. HaKoHe4HlllKOM annapara npm13so,q111rcs:i
Koaryn51L\lil5=1 CTeHOK Iii ,QHa Tpell.(fl!Hbl (pfllC 73).
Mecra
Koa rym:n.1,1111
CTeHOI< 11 p,Ha
rpeUJ,11Hbl
Puc. 73. l1Hcf:JpaKpacHaR KoazynRU,UR xpoHU4ecKo0
8H8flbHOU mpe~UHbl
KoazynRmopoM CTL-38031010 - Lumatec (cxeMa)
Lfall.le scero, 3a)l(111sneH111e rpeLl.\lllHbl npo111c-
XOA1t1T nocne nepsolA npoL\eAYPbl. V1Hor.Qa Tpe-
6yercs:i 2 BMeWaTeJlbCTBa. npe6blBaH1t1e nal..\111-
eHTa s cTaL\lilOHape - 3 AH51 .
PAK nP~MO~ KlllWKlll
3nuaeMUOf102UR paKa npRMOU KUWKU
PaK nps:iMolA KlllWKlil cocrasns:ieT 2-10% cpe-
Alil scex 3noKa4eCTBeHHblX 3a6onesaH111IA, 3aHlil-
Ma51 no YacrnTe 6-8 Mecrn. Cpe,q111 3JlOKaYecr-
seHHblX onyxonelA )l(eily,l\OYHO-KlilWeYHoro TpaK-
245
Ta eMy nplilHa,QJle)l(lllT 2 - 3 MeCTO. no ,[\aHHblM
803 3a6onesaeMOCTb paKOM np51MOlll KlilWKlll
B03pacTaeT 3a fO,l\ B cpeAHeM Ha 1%. nHT111JleT-
Hflfl Bbl>KIABaeMOCTb B pa3Bl1TblX CTpaHax co-
CTaBn51eT 60% , B CTpaHax c orpaHl/14eHHblMVI pe-
cypcaMltl - 40%. B Pocc111111 5-neTHs:is:i Bbl)l(lilBae-
Mocrb Bcex nepB1114HO Bbl51BneHHblX 6onbHblX B
HaCT051Ll.\ee speM51 COCTasns:ier OKOJlO 30% .
<Pa1<mopb1 puCKa
• Bo3pacr crapwe 50 ner,
• cpaKTopbl BHewHelll cpe,qb1 ,
• oco6eHHocrn n111raH1t1S1,
• reHeTlil4eCKlile ClilHAPOMbl,
• Ha111114111e aAeHoMaT03HblX nommos nps:i-
MOIA KlllWKlll , HecneL\L1$1t14eCKllllA 513BeHHbllA KOnlilT,
6one3Hb KpoHa ,
• paHee nepeHeceHHbllA paK o6oA04HOIA
K1t1WK1t1, pa Hee nepeHeceHHb1i.1 paK )l{eHcK111x reH111-
ra111111A lllJllll MOJ104HOIA )l{eJle3bl.
BoJpacr. 3a6onesaeMocTb paKoM 3TOIA 110-
Kan1113al..\llllll naL\llleHTOB crapwe 55 ner s 10 pa3
BblWe , YeM naL\llleHTOB AO 30 neT. YposeHb 3a-
6onesaeMOCTlll s soJpacTe nocne 75 neT nocre-
neHHO CHl/l)l{aeTC51 .
<l>aKTOpbl BHewHeVI cpeAbl. B HaCT051Ll.lee
speM51 l/IMeeTCS1 ,l\OCTOBepHa51 KOppeJlS1L\111S1 lJac-
TOTbl paKa npS1MOlll KlllWKll1 111 KOHL\eHrpaL\111elll B
aTMOCcpepe apoMaTlil4eCKlilX yrneBO,QOpO,l\OB, B
YacrHocrn 6eHJn111peHa. KpoMe rnro, paKoM
np51MOlll Kl/IWKll1 AOCTOBepHO Yali.le 6onelOT nto,[\111 ,
3aH51Tble B npOltl3BO,l\CTBe ac6ecra.
<t>aKTOpbl mHaH1..u1. B Ja6onesaeMocrn
paKOM nps:iMolli Kl/IWKll1 3aMeTHyto ponb 111rpa10T
cpaKTopb1 n111raH1t15!. 4acrnra 3TOro 3a6011esaH111s:i
B03paCTaeT s Tex per1110Hax, rAe s n111TaH111111 Ha-
ceneH111s:i npeo6na,qator 6enK111 111 )l{lllpb1, 111 Kor,qa s
nlllll.le lilMeeTC51 Mano paCTlllTenbHblX BOnOKOH .
,IJ,ns:i nepesap111BaH1t15! )l{lllpOB Heo6XO,l\lilMO 3Ha4111-
TeJlbHOe KOJll/14eCTBO )l{eJ14HblX KlllCJlOT, np111 Me-
ra60111t13Me KOTOpblX o6pa3ylOTC51 KaHL\eporeHbl.
np111 He,[\OCTaTKe paCTlllTeJlbHblX BOJlOKOH KaJlO-
Bbllil KOMOK MeAneHHee npO,l\BlllraeTC51 no TOJl-
CTOlll KlllWKe. 8Jlll151Hll1e KaHL\eporeHOB Ha CJll/13111-
cryto o6ono4KY craHos111rcs:i 6onee ,qn111renbHblM .
Hanp111Mep , Ha lilHAycrp111anbHOM cesepe CWA
3a6onesaeMOCTb paKOM np51MOlll KlllWKlll BblWe,
4eM Ha cenbCKOX0351lllCTBeHHOM tore. 3To CB513a-
HO 111 c «fllHAYCTp111an1113a4111elA» n111TaH1t15!, npeo6-
na,qaH111eM s paL\1110He nerKo ycsa111saeMolll )l{lllp-
Holll nlilll.\111 , 6oraToiA 6enKaMlll. npOAYKTbl pacna-
,qa 6enKos Moryr 6b1Tb Marep111anoM AilH Kl11We4-
Horo c111HTe3a N-H1t1Tpo3aM111Hos 111 APYrlllX Mera-
6on111rns, 06na,lla10ll.\lllX KaH4eporeHHOlll aKT111B-
HOCTb10. Ype3MepHas:i OYlllCTKa ymeBOAOB np111-
BOAlllT K CHlll)l{eHllllO MaCCbl HescaCblBaeMolll 4e11-
JllOJ103bl, Kornpas:i HBns:iercH csoero po,lla a,q-
cop6eHTOM Afi51 3K30- 111 3HAoreHHblX KaHL\epore-
HOB.
KpoMe rnro , KaH4eporeHHb1e Bell.\ecrsa Mo-
ryT o6pa30BblBaTbC51 np111 HeKoTOpblX cnoco6ax
o6pa6oTKll1 n111Ll.\111: KOn'-leH111111 M51Ca 111n111 pb16b1,
MHOroKpaTHOM )f(apeHll11t1 npOAYKTOB B OAHOM 111
TOM )f(e )f(ll1pe (nonyns:ipHas:i fast food) .
no//Unbl npRMOU KUWKU:
1. He3n111Ten111anbHb1e: Kap4111HOll1A, n111n0Ma,
nelAOMll10Ma, HeBpll1HOMa, cp1116poMa.
2. 3mnen111anbHb1e:
aAeHOMa (ry6ym1pHas:I, ry6yns:ipHO-
sopC111H'-laTas:I, BOpC111H'-laTas:i)
- rnnepnnacT111'-leCK1t1e nommb1.
no K0.!1Ul.feCmBy o6p03080HUU:
1 . 0A111H04Hble
2. MHO)f(€CTBeHHble (6onee 2) :
- rpynnosb1e
- pacce5lHHb1e no pa3HblM OTAenaM
3. .Q111cpcpy3HbllA ceMelAHbllA non111no3 Ton-
cToil1 K111WKll1
V1HAeKc Man111rH1113a1...1111111 OA111HOl.JHblX non111-
nos cocrasns:ieT 2-4% , MHO)f(eCTBeHHblX - AO
20%, BOpC111H4aTblX o6pa30BaHll1111 - 40% .
f13aeHHb1iJ 1<01wm u 60.11e3Hb KpoHa
(2paHy11eMOm03Hb/U KO//Um).
na1...1111eHT8M C 513BeHHblM KOJ1111TOM 111nll1 6o-
Jl€3Hbl0 KpoHa peKOMeHAyeTcs:i npo1113BOA111Tb
cp1116pOKOJlOHOCKOnll1to He pe)f(e 1 pa3a B rDA , .o.a-
)f{€ Ha cpoHe KJ1111Hll1l.JecKoro 6naronony'-l111s:1 Ails:I
J.1CKJlto4eHJ.15l KonopeKTanbHOro paKa.
Memacm03Up080HUe paKa npRMOU KUWKU
Merna (rpe4 .) ,o,s111)f(eH111e, nepeMell.\eH111e;
cma3uc (rpeY.) nono>KeH111e . T .e. MeracTa3111po-
saH111e - nepeMe1.J.1eH111e nono)f(eH111s:1 neps1114HOIA
onyxon111. 3TOT npo4ecc npo111cxoAll1T 3 nyT5lM111:
n1t1MQ:>oreHHblM , reMaToreHHblM , 111MnnaHTa1...11110H-
HblM.
JlnMfj>oreuuoe MeTacTa3npoBanne pa1rn npRMOH
KHWKH «CXeMa l>panu:eBa»
Puc. 74. CxeMa 6pau~eea B. P. fluMcpoommoK
npHMOU KUWKU.
1 - eepxHuii nymb ommoKa nuMcpbt, 2-6oKoeou nymb, 3-
HWKHUii nymb ommoKa flUMcpbl
246
np111 pacnono>KeHll1111 onyXOJ1111 AO 6 CM OT
3aAHero npoxoAa MeTacTa3111posaH1t1e npo111cxo-
A1t1T BHf..13 1t1 narnpanbHO , np111 pacnono)f(eH1t1111
Bb1we 6 CM - ssepx 1t1 naTepanbHO (p111c. 74). Ta-
KOe MeTacra31t1posaH111e 51Bns:ieTC5l opTopaAHblM ,
npHMbJM.
fo11Mcpa OT onyxon111, pacnono)f(eHHOil1 BblWe
6 CM OT aHopeKTaJlbHOIA Jlf..1Hf..1f..1 Hanpasns:ieTCs:I no
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111 no 6oKOBOMY nyTlll c COOTBeTCTBYIOLl.\€111 CTO-
pOHbl n111Mcpa OT onyXOJ1111, pacnOJlO)f(eHHOIA Hlt1)f(€
6 CM OT aHopeKTanbHOIA n111H111111 Hanpasns:ieTc5'1 no
Hlll>KHeMy nyTlll 111 no 60KOBOMY nyTlll c COOT-
BeTCTBYIOLl.\€lA CTOpOHbl.
BepxHlllM nyTb: no n111Mcparn4eCKli1M cocy-
A8M BAOJlb OCHOBHOro CTBOna sepxHei:i nps:iMo-
Kl!fWe4HOC1 aprnpllfllf e nllfMQJOY3flbr, pacnono-
)f(eHHb1e y OCHOBaHlt1H Hll1)f(HelA 6pbl)f(€€4HOVl ap-
Tep1t11t1 1t1 Aanee B 3a6ptow1t1HHb1e napaaopTanb-
Hble n111M¢arn4ecK111e y3nb1. TaKIAM o6pa30M,
sepxH111IA nyTb - 3TO sepxH1t1e peKTanbHb1e Y311bl ,
pacnono)f(eHHb1e s napapeKTanbHOVi KneT4aTKe 111
H1t1)f(He6pb1)f(ee4Hb1e y3nbl.
6oKoBOM nyTb: naTepanbHO, B cTopoHbl,
no n111McpaT1114ecK111M cocyAaM BAOnb cpeAH111X
np51MOKll1W€4HblX aprep111V! B nOA4peBHble 111 no,Q-
B3AOWHble n111Mcparn'-1ecK111e KonneKTopb1. T.e.
6oKosoil1 nyrb - cpeAH111e peKTanbHble , 3an111pa-
TeJlbHble, BHyrpeHHll1e nOAB3AOWHble li1 06Ll.\f..1e
no,LlBJAOWHb1e yJnbJ.
H111>KHlllM nyTb: OT onyxon111 , pacnonmKeH-
HOIA H111)f(e 6 CM OT aHopeKTanbHOIA Jlf..1Hf..1f..1 BH1113 ,
no Hf..1)f(Hll1M np51MOKll1W€4HblM n111MQJ8Tll14eCKll1M
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0AHaKO B03MO)f(HO 111 peTporpaAHOe fllllM·
ct>oreHHoe MeTacTaJ111poeaH111e. 0 peTporpaA-
HblX n111MQ:ioreHHblX MeTacTa3aX rosops:iT np111 111x
Bbls:IBneHlt1111 Ha 2 CM All1CTanbHee Hll1)f(Hero Kpas:i
onyxon111 . 3To npo1..1cxoA111T np111 6noK~posaH111111
MHO)f(eCTBOM MeTaCT830B oprnrpaAHblX (npH-
MblX) nyTeilJ OTTOKa m1M¢bl.
P111c. 75. MeTacTaJHpoeaH111e paKa npH-
MOM KHWKH
A. MH0>1<ecTBeHHb1e MeTacTaJbl e ne-
'-!eHb (KT); 6. MeTacTa3bl e nerK111e (KT)
f eMamo2eHHOe Memacm03Up08GHUe
leMaToreHHoe MerncTa3111posaH111e npo1t1c-
XO.Qll1T np111 nonaAaH111111 onyxoneBblX KneToK s se-
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pe3 cpe,QHll1e 111 Hll1)f(Hll1e npHMOKll1WeYHble BeHbl -
B nerK1t1e, ronOBHOIA M03r, H8Afl04e4H111Kll1, KOCTll1
111 Apyrne opraHbl 1t1 TKaH111 (P111c . 75).
P111c. 76. PacnpocTpaHeHHblM Kap~H­
HOMaTo3 6plOWlllHbl
MMnflaHmat,woHHble Memacma3bl KnACClll<t>lllKAUlllfl PAKA
lllMnnaHTa41110HHoe MeTacTa3111posaH111e nPflMOlll KlllWK"1
npOlllCXOAlllT np111 l/IMnnaHTa4111111 , «nplll)l{lllBne-
Hl/ll/I)} )1{1113Hecnoco6HblX KJleTOK 3flOKaYeCTBeH- Me>KoyHapoaHaR 1<f1accuc/JuKau,uR TNM
HOll1 onyxon111 s 3AOPOBblX TKaH51X, pacnono)l{eH- Me>KoyHapooH020 npomuaopaKoao20
HblX BAan1.1 OT nepB1.1YHOro oYara. Kap41.1H0Ma- C0/030 no MKG-10, 1997 2000
T03 6pl0Wli1Hbl (P1.1c. 76) . 3TO Han1.141.1e MHOro- 6yKsb1 o6o3Ha4al0r T - tumor, N - nodus,
1.rncneHHblX MenK1.1x MeTacTarn4ecK1.1x onyxone- M - metastasis
BblX y3nos Ha s111c4epanbHOll1 111 nap1.1eTanbHoll1 T - nep81114Has:i onyxonb
6piow1.1He np1.1 npopacTaHl.1111 onyxon111 cepo3Holl1 T is - in situ npe111H0a3111sHas:i aAeH0Kap4111-
o6ono4Klil opraHa. HOMa, carcinoma in situ, onyxonb B npeAenax
3n111ren1.151 111n111 c lllH883111et1 TOilbKO CI11113l-1CTOVI
namOfl02ULfeCKOR OHOmOMUR paKO npRMOU o6ono4Kl.1
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T 1 - onyxonb 111Hcp111nbTp111pyeT cni.-t3111CTYIO
J70KQJ1U30U,UR onyxoflU o6onOYKY Ill nOACfilll3111CTYIO OCHOBy Kl.1WKlll
- AHanbHb1!11 KaHan . LJacToTa Bbl51sneHlll51 - T 2 - onyxonb 111Hcpi.-tnbTp111pyeT Mb1We4HYIO
1% o6ono4KY
- H111)1{He-aMnyn51pHblll1 OTAen (Ao 6cM). T 3 - onyxonb npopacTaeT noAcepo3Hyio
l.JaCTOTa Bbl518neHl.151 -26% ocH00y 111 Henep111roH1113111po0aHHb1e y4acTKlll KlllW-
- CpeAHe-aMnyn51pHblll1 OTAen (6-12cM). Kiii
l.JaCTOTa Bbl51BneHlll51 48%
T 4 - 111Hsa311151 s nep1.1peKTanbHb1e TKaH111 111
COCeAHllle opraHbl.
- BepxHe-aMnyn51pHblll1 111 peKToc1.1rM011tAHblll1 N pernoHapHble n111Mcparn4ecK111e y3nb1 :
OTAefibl (12-18 CM). LJacTOTa Bbl51BneHlll51 -25% Nx - HeAOCTaT04HO AaHHblX Ami 04eHK111
- AHanbHblVI paK (1 %) per1.10HapHblX MeTaCT830B
NO - Her np1113HaKOB nopa:>1<eH1115I pernoHap-
rucmoflo2uLtecKoe cmpoeHue onyxoflu HblX n111MtjJaTlllY6CKlllX y3nos
N 1 - Bbl51BneHo Meracrarn4ec1<oe nopa)l{e-
• )f{ene3111CTblll1 (BblCOKO- ,yMepeHHO-, Ill
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y3nos
• Cn11131.1cTa5I a,[\eH0Kap4111HoMa, N2 - 8bl518neHo Merncrnrn4ecKoe nopa)l{e-
• nepcTHeBli1AHOKJleT04Hblill, H111e 4 111 6onee per1110HapHblX n111MtjJar111YecK111x
y3.no0
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N3 - MeTacTaT111YecKoe nopa)l{eH111e perno-
• nnoCKOKJleTOYHbli/1 , HapHblX n111McpaT1114eCKlllX y3nos BAOnb Marncr-
• HeA111¢cpepeH41.1posaHHb1t1 paK panbHblX cocyAOB np51Mot1 1<111w1<111
M 0TAaneHHble Meracra3bt :
<:/JopMbl pocma onyxoflu Mx - HeAOCTaT04HO A8HHblX AI151 04eHKlll
OT,[\aneHHblX M6T8CT830B
PaK np51MOll1 Kl.1WKl.1 M0)1{€T li1MeTb 3K30cpli1T-
MO - oT,QaneHHblX MeracTa3oB HeT
Hblll1, 3HA0¢1i1TH0-1i1Hcpli1nbTPli1PYIOl.J..lli11/1 li1!1V. nepe- M1 - OTAaneHHble MeTacTa3bl ecrb
XOAHble cpopMbl poem. 3K30cp1.1THble onyxon111 G creneH111 A111¢cpepeH4111pos1<111 onyxon111:
li1MelOT rp1.160Bl.1AHYIO QJOPMY 111n1.1 HanoMli1H8IOT G1 - xopowo ,Q111cpcpepeH4111posaHHble,G2 -
4serHyio Kanycry, pacryuwio B npocseT np51Moill yMepeHHOAV1cf:>cpepeH4i.-tpo0aHHb1e, G3 - Hlll3KO-
Kl.1WKlll (Piiie. 77) A111QJcpepeH41.1posaHHb1e, G4 - HeA111¢cpepeH4111-
po0aHHb1e.
P111c. 77. 3K30cpMTHblM pocT onyxom1.
A. rncT011orn"lecK111ill MaKponpenapaT. no pacnpocmpaHeHHOCmU
6.PeKTOPOMaHOCKOnM~
(K11accuc/JuKau,uR MuH3apaaa CCCP, 1980)
3HAOQJlllTHble onyxom1 npopacraior 0 rny- 1 cTaAMH onyxonb 111n1.1 51388 noKan1113yeTC5I
61.1Hy KlllWe4HOll1 CTeHKl-1 1.1 l.1M€IOT 8111A orpaHlll- 8 CilVl3VICTOt1 o6on04Ke Ill no,QC!llll3111CTOM cnoe
4eHHblX 111n111 o6wi.-tpHblX 5138 c Hep08HblM l-1H- KlllWKlll . Per1.10HapHblX Meracra3os HeT.
cp1.1nbTp1t1p088HHblM AHOM 111 c nnoTHblMlll 0an111-
2 cTaAMH A) onyxonb 111n1.1 513Ba 3aH1.1MaeT
AO 1\2 oKpy>KHocrn Kl.1WKl.1. PernoHapHblX Mera-
Koo6pa3Hb1M1.1 Kpa51Ml.1 . K nepexoAHblM tjJopMa
CTa30B H6T.
ornoc51TC51 6nio,Q4eo6pa3Hb1e onyxon1.1 c yMe-
2 cTaAMH 6) onyxonb 111n1.1 513Ba 3aH111Maer
peHHO np111nOAH5!TblMlll Kpa51Mlll (3K30QJl.1THblill
AO 1\2 OKPY>KHOCTlll Kl.1WKlll . E,a111Hlll4Hble Perno-
pocT) 111 nonoro 3anaAa10lJ..11t1M1.1 4eHTpanbHblMlll HapHble MeTaCT83bl.
OTAenaMlll (3HAOQJlllTHblli1 lllHQJlllnbTplllpylOlJ..llllill
pocr).
247
 3 cTa.QM,St A) onyxonb 111m1 Sl3Ba 38H111Maer 4 cTa.QMR 06w111pHaS1 pacnaAa10U\as:ics:1 He-
6onee 1\2 0Kpy)l{HOCTV1 KVIWKll1. npopacraeT naAB111)1{Has:i onyxonb, npopacra10U\8s:I OKpy)l{alO-
CTeHKY Kf!IWKlll nfll6o cna51Ha c oKpy>KalOU\lllMlll op- U\Vle opraHbl c MHO}f(eCTBeHHblM£11 pernoHapHblMtil
raHaM111. PernoHapHblX Meracra30B HeT. VI OT.AeneHHblMVI MeTacra3aMV1.
3 CTa.Ql.llR 6)
onyxonb mo6b1X pa3Mepos c B 1929 roAy C .E.Dukes (C.E AblOKc) npeA-
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TOpas:i ,D,O ClllX nop VICnonb3YSTCs:I 3a py6e)l{OM.

CooTBeTCTBHe KJiacc1uf>HKa~uu MnHJpaea CCCP, TNM, Dukes

CTaAlll5l T TNM TNM Dukes
0 Tis NO MO
T1 NO MO
I T2 NO MO A
T3 NO MO
II T4 NO MO B
T n106as:1 N1 MO
111 T rno6as:1 N2 MO c
IV T n106as:i N n106a51 M1
KflUHUKG pat<a npRMOU KUWKU sepXHlllX OTAenos nps:iMoi.:1 KlllWKlll B n03AHlllX CTa-
Kn1.1Hl.1YecKa51 KaprnHa paKa npS'IMOM J<l.1WKl.1 Alil51X 3a6onesaH1115l (Ill 6 111n111 IV) . Conpoao>K,l\a-
HaXOAVITC51 a npS1MoLil 3as111cV1Mocr111 or yposHs:1 ercs:i TVlnlll4HblMll1 CVIMnTOMaMlll ocrpoill TOJ1CTO-
pacnono)l{eHVISI onyxom1, xapaJ<Tepa ee poem , Kll!We4HOH HenpoXOA111MOCTlt1 - np111crynoo6pa3-
cra,D,111111 3a6onesaHlllS'I . 8b1,D,en5!10T 5 rpynn Cl.4M- Hbl€ 60!1111 B }f(ll180Te, 83,D,YTVle >K111BOTa, TOWHOTa,
moMos paKa np51MOLil KVIWKlll: psora.
1. naronor1114ecK111e BblAeneH111S1 1113 nps:iMoVI
KlllWKlll b017b
2. Paccrpoi::icrna cpyHKLIVIVI roncroill KVIWKVI 5onb s:ism:1ercs:i paHHVIM 111 xapaKTepHblM
3. HapyweH111e npoxo,D,VIMOCTVI K11tWeYHV1Ka ClllMnTOMOM nlllWb npltl aHanbHOM paKe (1%).
4.6onb 8b1we aHopeJ<TaJlbHOH m1H111111 6onesbrx pel(en-
5. HapyweH111e 06U\ero COCT051HVls:I . Topos B cn1113VICTOH o6onoYKe nps:iMoVI K111WKll1
H€T. no:noMy nplll aMnyns:ipHOM paKe 60ilb no-
namofTOZU!.feCKUe BbfOefleHUfl U3 npFIMOU 5'1Bm~eTC5l B n03AHlllX CT8AlllflX, nplll npopaCT8Hl/llll
l<UWl<U onyxonblO Bcei::i TOnll\111 MblWeYHOVl cTeHK111 , a
Kposb TeMHoro L\Bera co crycrKaMVI BblAe- TalOl<e COC8AHVIX opraHOB. 6onb B03HVIKaeT Ill np111
ns:iercs:i AO Kana, BO speMs:t TeHe3MOB, Vlnl/I BHe sosneYeH11111 s npo4ecc KpecTL\OBOro cnnereH1115l .
aJ<Ta ,D,eQ:>eKaUVll-1 . no3TOMY 3H,[\Ocp111THblS, onyxon111 C 111HQJlllJ1bTpll1-
KpoMe KpOBlll np111 paKe nps:iMoVI KVIWKVI 1113 pylOU\VIM pocTOM Bb13blBalOT 6onV1 Yall\e, 4eM
38AHero npoxo,D,a MO)l{eT Bb1Aen51TbCSI CJ11113b 111 3K30cp111THble , paCtyll\llle B npocseT KlllWKlll . 0
rHoLil. CIH13b 111 rHoi1 Bbl,D,ens:1iorcri aMecre c 1<po- 6om1x B )Kl/IBOTe np111 HapyweH1111i1 npOXO,!llllMOCTJ.1
Bb10 . KlllWKVI ynOMl/IHanoCb BblWe .

HapyweHue <jJyH1<u,uu moncmou Kuw1<u HapyweHue 06w,e20 cocmoRHUR

BeCbMa xapaJ<TepHbl no>KHb1e no3b1Bbl K CH111>KeHV1e Maccbl rena , Vl3MeHeHV1e u,sera
Ae¢eK8L\llllll - TeHe3Mbl 3-4 pa3a 8 cyTKlll. np111 KO>KHblX noKpOBOB (6ne,D,Hb1H, 3eMnlllCTbllll , 111HO-
TeHe3M8X BM€CTO Kana BblAens:iercs:i KPOBb, r,[la YYTb >KenTyWHb1lll) cs~3aHo c xpoH111Yec1<oi;1
Cnlll3b. np111 n03.QHlllX CT8A11151X p8381.188€TC51 38- onyxonesoi::i 111HTOKC1t1Kau,111eVI. AHeMl/151 pa3BVIBa-
nop. lll3M€H51eTC51 8111,IJ, Kana - neHTOBlll,IJ,HblVl 11111111 ercs:i Vl3-3a An111renbHOLil, noYTlll e)Ke,D,HeBHolll
«OBS4111VI». XOTb ti! H83H84VIT8J1bHO~ KposonorepVI. 0AH8KO
np111 8H8JlbHOM VI HllDl<HeaMnyns:1pHOM paKe 3Tll1 ClllMnTOMbl pa3BVIBalOTC51 B n03,[\HVIX CT8,[\11151X
np111 lllHBa3111111 CcplllHKTepOB MO)f(eT pa3Bll1TbC51 onyxonesoro npou,ecca . Bo3HVIKHoseHV1e per1110-
He,D,ep>KaH111e Kana 111 ra3os np111 sosneYeH111111 s H8PHblX Ill OTAaneHHblX MeTaCT830B, KaK npaBVl-
npo1..1ecc aHaJ1bHblX cQ:>111HKrepos 111 cH11t)l{eH111111 111x no, 1113MeHeHlt1e KnlllHlllYeCKOVl KapTVIHbl He conpo-
roHyca. BO)f{,l\alOTCS1 VI cneu,VlanbHOlll CVIMnTOMaH1Klll He
lllMelOT.
HapyweHue npoxoouMocmu moncmoiJ
l<UWl<U ,D,ua2Hocmu1<a pa1<a npRMDiJ 1<uw1w
HapyweH111e npoXOA111MOCTlll roncrnlll KlllWKlll PaK nps:iMoVI K111WKlll OTHOCVITCfl K 3nOKaYeCT-
OAHO Vl3 ocno>KH8HVIH paKa nps:iMoJ/J KVIWKVI . Pa3- aeHHblM HOaoo6pa3oaaH111s:iM Hapy)KHOlll no1<an111-
BlllBaeTC51 48ll.18 np111 CTeH03111PYIOU\eM paKe 3a4V1111. Y 70% 6oJlbHblX onyxonb pacnonaraercs:i

248
Ha pacCTOs:IHl/ll/I AO 9-10 CM OT Kpas:i 3a,LJ,Hero npoMe)f{HOCTl/I Ha4111H81-0T c Bbls:ICHeHl/ls:I )f(ano6,
npoxoAa, 111 MO>KeT 6b1Tb o6Hapy}!{eHa np111 nanb- c6opa aHaMHe3a 111 06L11ero ocMoTpa. BeAYLl.llllMlll
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BOTa, OCMOTp Ill nanbn8L\llls:I npOMe>KHOCTlll , naxo-
PaHHee BbtRB/1eHue pa1<a npRMoiJ l<UWJ<U BblX o6nacTelil, nanbl\e8oe 111ccneA08aH111e nps:1-
UflU Cl<pUHUH2 Moill KlilWKlil, aHOCKOnJ/151, peKTOPOMaHOCKOn1t15!.
PaHHee Bbls:l8IleH111e 111n111 cKp111H111Hr (om AHocKomtff aHocKonoM (npoKTOCKonoM).
aHan. screening - npoceusaHue) paKa nps:iMolil npol/l3BOAl/ITC51 OCMOTp aHailbHOfO KaHana Ill
KlllWKl/I npOBOAlllTCs:I c noMOLl.lbl-0 reMOKKYnbTHOro H1.u1<HeaMnyn5!pHoro OTAena np111 noMOLl.llll aHo-
TecTa Ill 3H,[lOCKOnlll'-leCKl/IX MeT0,[\08, lllCCJle,qosa-
c1<ona. nplllMeHeHllle peKTailbHOro 3epKaITa Ma-
Hl/ls:I paKOB0-3M6plllOHaJlbHOro aHT111reHa (P3A) B
JlOlllHcpopMaTlllBHO Ill 5one3HeHHO.
nna3Me KP081/1. V1Mel-OTCs:I MeTOAbl Bbls:IBJleHl/ls:I B
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Ils:lpHblX MapKepos onyxon111. 3rn MoneKYilbl ,[!HK MaHOCKon11151 n0380Jl51eT 81113yanbHO OL\eHlllTb
onyxon111 , KOTOpb1e 111Me1-0T reHHb1e MYTal\1111/1, on- BHyTpeHHl-01-0 no8epXHOCTb np51MOVl lt1 AlllCTaJlb-
peAens:1eMble COOTBeTCTBYl-Oll.llllMl/I na6oparnp- HOlit TpeTlll ClllfMOBlllAHOVt Kl/IWKl/I AO ypo8H51 20-
HblMl/I MeTOAlllK8Mlll. 25 CM OT 3aAHero npoxoAa . 8 HacT051Ll.lee 8peM51
see w111pe lllCnOilb3Yl-OTC51 r1116K1t1e ClllfMOCKOnbl.
06CfleaoaaHue na4ueHmoa c pa1<0M noJlO}f(eHllle 60ilbHQrO -KOJleHHO-JlOKTe80e l/IJll/I
npRMOU l<UWl<U KoneHo- nneyesoe (P111c. 78).
06cne,o,08aH111e naL1111eHTOB c 3a6oneaa-
HV15!MVI TOJlCTOill KVIWl<VI , aHaJlbHOro l<aHana VI

A 5
Puc. 78. nono>KeHue naL!UeHma npu peKmopoMaHocKonuu.
A. KoneHHo-noKmesoe . E. KoneHHo-nnel/esoe

np111 8blnOJlHeHllllll peKTOpOMaHOCKOnllll/I l/IJllll L.(111TOAl/l8fHOCTlllKa , L\lllTOJl0fl/l4eCKOe 111ccne-

rn6Koi:1 Cl/lfMOCKOnllll/I OL\eHl/IBaeTC51 L\8eT, 6necK, AOB8Hl/le OTAens:1eMoro c nosepxHoCTl/I onyxon~
BJ18}f(HOCTb , 3Jl8CTlllYHOCTb I/I penbeQ:> CJ11/131/1CTOi:1 no csoeill 111HcpopMaT1t1BHocrn YCTYnaeT rncrono-
o6onoYKlll , xapaKTep ee cKilaA4arncrn, oco6eH- rw-iecKoMy MeTOAY. HO 8 KOnonpoKTOJ10flll4eCKO~
HocT111 cocyAltfCTOro PlllCYHKa ; HanltfYltfe narnno- npaKTltfKe cnoco6 nplllo6peTaer oco6yto L\eH-
fl/l4ecK111x o5pa308aH111V!; a TaK)f{e ToHyc 111 A8111ra- HOCTb , ecn111 Heso3MO)f{HO nposecTlll 6111onc~t0.
TenbHY1-0 <PYHKL\1/11-0 OCMaTp1t18aeMblX OTAeil08 .
Pi..tc. 80. PeKTopoMaHocKon1.1'-!ecKas:t
6MonCMff. 5111onc1111-0 np01113BOA51T nplll Bbl-
KapTMHa
nonHeHllll/I peKTopoMaHOCKOnllllll l/IJllll aHOCKon111111
(P111c. 79, 80). A. HopMaJlbHast cni..t3MCTas:t nps:iMoH
KHWKM. 6. nonMn peKTOClr1fMOM,QHOro OT,D,e-
P1.1c. 79. }l{ecTKr.1M peKropoMaHocKon B na. B. 3K30cPMTHblM paK peKToc1.1rMOM,D,Horo
co6paHHOM 01.1p,e. 1. Ty6yc. 2.06ryparop. or,Qe11a
3. rpywa ,D,flff 88e,D,eHHSI 803,D,yxa. 4. 0Ky-
PeHrreHonorn4ecKa71 A111arHocT1111<a. (P~c . 81 ).
.nstp. 5. ~l-m~bl p,.nsw 6paw-6i..toncH1r1. 6. "1c-
TO'-IHMK CBeTa. 7. rM6KMM ceeTOBOA P1.1c. 81. "1p1r1rorpa<PMR. 3K30cPHTHblM
Ans:i 1113y4eH111s:1 3noKa4eCT8eHHOVI onyxon111
paK npRMOH KHWKH (A), CHfMOBHAHOH KHW-
TKaHb 6epeTcs:i 1113 ee Kpas:i Ha rpaH111L1e c He1113-
Kr.1 (6). Crpe.nKaMH yKa3aHbl rpaHH4bl ,Qe-
MeHeHHOVt CJll/l31/1CTOi:1 o6onOYKOVt . <PeKT08 Hano.nHeHHs:t

249
 np111 111pp111rocKon111111 AOn>KHbl o6s:t3aTenbHO
111cnonb30BaTbC5l cneAYtoll.lllle MeTOAlllKVi: TYroe
3anonHeH111e KVIWKVI (KOHTpacrHas:t Kn1113Ma), Vi3Y-
48Hllle penbecpa cn1113111cToil1 o6ono4Klll nocne
onop0>KH8Hlll5l KlllWKVI OT KOHTpaCTHOill MaCCbl ,
ABOillHoe KOHTpacrnpoBaHllle (KOHTpacTHoe Be-
ll.leCTBO-cepHOKlllCfiblill 6ap111i11 Vi B03Ayx).
<l>1116pOKOilOHOCKOnliU:I - B8)1(Hbll'.4 M8TOA
A1118rHOCTlllKlt1 3a6onesaH1t1!'.4 TOnCTOl'.4 KlllWKlll OT
np5lMOil1 AO cnenol'.4 (P1-1c 164). Y Ka}l<Aoro Kono-
npoKTonor1114ecKoro 6onbHOro cneAyeT Bbinon-
Hs:tTb KOfiOHOCKOnlllto np111 nommax nps:tMOill KlllWKlll
1-1 TeM 6onee np1-1 paKe AL-1CTanbHbiX OTAenos
Puc. 164. r:/Ju6poKonoHocKon «0/y(npus»
Ynbmpa3ayKoeoe uccneiJoeaHue (Y3t1) (Puc. 165).
P111c.82. 8HyTp111npocseTHoe 3H.QopeK-
TallbHOe Y3111 ceKTopHblM poTa4MOHHblM
,QaT'-IMKOM 1.1acTOTOH 7,5 MHz. A. HopMallb·
Haff CTeHKa npffMOH KlllWKlll. CTpe11KaM111 (1,
2, 3) yKa3aHbl CllOlll CTeHKlll npffMOH KlllWKlll .
6. Onyxo11b (T) c 111Hsa3111eLll AO no,Qc111113111-
CToro CllOff(T1). Cpe,QHlllH CllOH, yKa3aH-
HblH cTpenKoLil, pacno110>1<eH Me>1<,qy onyxo-
llbl-0 Ill Mb1We4HOH 0601104KOH
Y3111 - MeTOA AlllarHOCTlllKL-1 paKa nps:tMol'.4
KlllWKlll, era pacnpocTpaHeHHOCTlll , MeTaCT8308 B
Apyrne opraHbl 6ptowHoi4 nonocrn, a TaK)f(e on-
peAeneH111s:t creneH111 1-1Hsa3111111 onyxon111 Toncroi/1
KlllWKlll B CT8HKY :noro opraHa Ill Afis:I o6Hapy:>Ke-
Hlt1s:t nopa:>KeHHblX pernoHapHblX fi111Mcp8Tlll48CKlllX
y3nos. Bb1c0Ka5l creneHb cosnaAeH111s:t AaHHblX
Y3111 111 nocneonepa41110HHoro 111ccne,D.0BaH111s:t
YAaneHHblX npenapaTos CB1t1AeTenbcTsyer o
WlllpOKlllX B03MO:>KHOCT5lX 3TOl'.4 M8TOAlllKlll.
Ila6opaTopHaH AMarHOCTMKa - 06ll.l111e
aHanlll3bl KpOBlll Ill M04111 , 61110XlllMlll48CKJlle aHa-
JH13bl.
JlanapocKon111st. ,O.ns:i AlllarHocT111K111 MeTa-
cTa3oB B ne48Hb , Bbls:tBneHL-18 Kap4111HOMaT03a
6ptowHoil1 nonocrn.
V1ccneA0BaH111e M048BblX nyTel'.4 111 reH111Ta-
m1il1 Ans:t 111cKnto4eH1115l npopacTaH111s:t onyxom1 so
s.nara.nlllll.le, MOYeeol1 ny3blpb, npe~cTarenbHYIO
:>Kene3y.
250
TOfiCTOill KL-1WK1t1, o6Hapy)f(eHHblX np1t1 peKTopoMa-
HOCKOn111111 . Heo6XOAVIMO o6cneAOB8Tb BCIO TOn-
CTYIO KlllWKY, 4T06b1 He nponycrnTb c1-1HxpoHHb1e
onyxonesb1e 111n1-1 socnan1-1TenbHb1e 1t13MeHeH111s:t ,
pacnono)f(eHHb1e BblWe ypoBHs:t, AOCTL-1)f(L-1Moro
)f(eCTK1t1M peKTocKonoM . CneAyeT 3H8Tb, 4TO 6a-
p1.1esas:1 Knlt13Ma (111pp111rocKon111s:t) Ill KOfiOHOCKOnllls:t
He KOHKYPL-1PYIOT, a AOnonHs:tlOT APYf Apyra . Ko-
noHOCKonvis:i He3aMeH111Ma ,D.ns:t AlllCnaHcepHoro
Ha6ntoAeH111s:t 3a 6onbHblMlll nocne YAaneHL-15l no-
n111nos, Afis:t peryns:tpHblX OCMOTpOB TOfiCTOill
KlllWKlll y 6onbHblX, onep111posaHHblX no nOBOAY
paKa TOfiCTOill KlllWKl.1.
KoMnbJOmepHOR moM02pacjJuR (KT)
u RoepHo - Ma2HumHb1iJ pe3oHaHc (flMP)
KT np111 paKe np5lMOl'.4 KlllWKlll (P111c. 83). np111-
MeHs:teTcs:t no Cfi8AYIOL14111M noKa3aHllls:tM :
- no,D.03p8Hlt18 Ha paK nps:iMoi/1 KlllWKlll np1t1
H8803MO)f(HOCTlll 111p111rocKon111111 111n111 KOnOHOCKO-
n111111.
- Heo6XOAlllMOCTb 04eHKlll creneH111 pacnpo-
crpaHeHHOCTlll Ha COC8AHVie opraHbl
-OnpeAeneH111e pe3eKTa6enbHOCTlt1 o6pa3o-
eaHlll51.
- 8b1s:isneH111e nopa:>KeH1M1 n111Mcpoy3nos, ne-
4eH111 , nerK111x 111 APYrlllX opraHos
P111c. 83. PaK npflMOH KlllWKlll c MeTacTa-
3aM111 e pernoHapHble 11111M<j:>aT1111.1ecK111e y3-
11b1 (KT)
/1,ucjJcjJepeH4ua11bHOR oua2Hocmw<a paKa
npRMOU KUWKU
npolll3BOAlllTCSl c APYrlllMlll 3a6oneBaHlll5lMlll
nps:iMol'.4 KlllWKlll Ill opraHOB, HaXOAs:tll.lL-1XCSl B Heno-
cpeACTB8HHOil1 6nlll30CTlll OT nps:IMOll1 KlllWKl/i . .
1. leMoppol/1 , aHanbHas:t TP8Ll.4111Ha , 6one3Hb
KpoHa , aKT1t1HOM1t1K03.
2. ,O.o6poKa4ecrseHHble onyxon111 nps:tMoiil
KlllWKlll - non1t1nb1 , sopc111H48Tb1e onyxon111 .
3. Onyxon111 Manora Ta3a MeTacTa3
WH1114nepa (paK )f(€fiYAKa), OKononps:tMOKlliLUe4-
Hble repaTOlllAHble o6pa30BaH1t1s:i .
 4 . PaK M04esoro ny3bip51 111 reH111Tan1111ii c
npopacrnH111eM B np51MYIO KlllWKY (MaTKa, snara-
nm11e, npeACTaTenbHas:i )f{ene3a) .
Jle4eHue pa1<a npRMOU J<UWJ<U
P8,L:l111KanbHOe ne4eH111e paKa np51Molii KlllWKlll
- oneparnsHoe BMewaTenbCTBO . Bb16op MeTOAa
onepa4111111 3as111c111T OT n0Kan1113a411151 onyxon111,
BlllA8 pocra (3HAO- 111n111 3K30QJlllTHbilii), CTeneHl/I
pacnpocTpaHeH111s:i onyxonesoro npo4ecca, 06-
ll.lero COCTOS'IHl/le 6onbHOro.
,D,ns:i paA111KanbHoro yAaneH111s:i onyxon111
npHMOlii KlllWKlll np111 ee pe3eKL\llllll He06XOAlllMO
OTcrynaTb OT sepxHero Kpa51 HOB006pa30B8HlllSl
Ha 12-15CM, OT Hl/l)f{Hero Kpa51 AO 2- 5CM. TaKlllM
o6pa30M , rnaBHblM Kp111Tep111eM Bb16opa cnoco6a
onepa4111111 51sns:ieTcs:i paccT051Hllle OT KP8H 38AHe-
ro npoxoAa AO Hlll)f{Hero nonioca onyxom-1. np111
3HAOQJlllTHOM lllHQJlllnbTPlllPYIOll.leM pocTe Heo6-
XOAlllMO Y4111TblB8Tb , 4TO 111Hsa311151 cTeHKlll MO)f{eT
pacnpocTpaHHTbCSl AO 2 CM Hl/l)f{e BltlAlllMOro
Hlll)f{Hero Kpas:i onyxonltl Ill AO 10 CM Bbl We BlllAlll-
MOro sepxHero Kpas:i onyxon1t1
OcHOBHbte BUObl onepau,uiJ npu paKe
npRMOU l<UWl<U
Pa3nw-1atoT paA111KanbHb1e onepal.\111111 , yc-
nosHo-paA111KanbHb1e, nann111aT111BHb1e 111 c111Mmo-
MaT1114eCK1t1e.
1. PaA111KanbHble onepau,111111 06ecne\.1111satoT
OTCYTCTBllle OCT8TKOB onyxon111 Ill MeTaCT830B c
BblCOKolii seposnHOCTbto nonHoro 1113ne\.leH111s:i.
2. np111 ycnOBHO-p8AlllK8nbHblX onepa4111s:ix
AOCTlllraeTCSl OTCYTCTBl/le OCT8TKOB onyxonltl , HO
OCTaeTC51 sepOHTHOCTb Hani/1411151 MeTaCT830B.
B r
Puc. 84. 3manb1 HanoJKeHUR nnocKoi1 KonocmoMbl npu 6piowHo-npoMeJKHocmHoi1 3Kcmupnau,uu npRMOi1 KUWKU.
A. <PopMupoeaHue omeepcmuR e KOJKe. 5. KoJKHo-cepo3HO-MblWe4Hble web1. B. noawueaHue cnu3ucmoi1 o6ono4KU
KUWKU K KOJKe . /. 06UjUU eua nJJOCKOU KOJJOCmOMbl.
6) C coxpaHeH111eM 3aMblKarenbHoro anna-
para nps:iMOC1 KlllWKt.1
251
3. nannlllaTlllBHble onepaL.J,111111 OCT8Bn5llOT
sepOSlTHOCTb Hanlll4lt1Sl OCT8TKOB onyxon1t1 lt1 Me-
TaCT830B. L!enb nann1t1aTlllBHblX onepau,1111ii:
• npeAynpe)f{AeHl/le KpOBOTe4eHlllSl 1113 ony-
xon111 ;
• npeAOTBpall.leH1t1e ocTpolii Kt.1We4Holii He-
npoxoA1.1Mocrn;
• V1cKnl04eHt.1e pacnaAa onyxon1.1.
4. C1.1MnTOMarn4ecK1.1e onepa41111.1 yny4wa-
10T Ka4eCTBO )f{t.13Ht.1 60JlbHOro npt.1 HeB03MO)f{H0-
CTlll YAaneH1.1s:i onyxon1.1
I. PaA111KanbHb1e
A) C YAaneH1.1eM 3aMblKaTenbHOro annapa-
Ta nps:iMolii Kt.1WKt.1
6plOWHo-npoMe)f{HOCTH8Sl 3KCrnpnau.111s:i
nps:iMolii Kt.1WKlll no KeHIO - Maliincy c OAHO-
CTBOnbHolii KOJlOCTOMOlii Ha nepeAHelii CTeHKe
}f(lllBOTa (E. Quenu 1896; W. Miles, 1908). np1.1-
MeHs:ieTcs:i np1.1 onyxons:ix, pacnono}f(eHHblX Hlll>Ke
6 CM or Kpas:i 3aAHero npoxoAa . YAan51eTcs:i
nps:iMas:i Kt.1WK8 c onyxonblO, \.18CTb Ct.1rMOBt.1AHOlii
Kt.1WKlll BMeCTe c 6pb1>KeliiKOC1 , pernoHapHble
m1M¢arn4ecK1.1e y3nbl.
np1.1 3TOC1 onepau,1111.1 BMecre c nps:iMoi.:1 Kt.1W-
KoC1 YAans:ilOTC51 see KOMnoHeHTbl 3an1.1paTenbHO-
ro annapaTa nps:iMoi.:1 KlllWKt.1. V13-3a 6onbworo
o6beMa yAans:ieMblX TKaHelii 06pa3yercs:i o6wL4p-
Has:i paHesas:i nosepxHOCTb c 6onbwoC1 Kposono-
repei.:1 111 Tp8BM8Tlll38L.J,llleC1 WOKOreHHblX 30H.
Onepa4111s:i Taf()f{e npo1113BOAlllTC51 ABYM51 6p111ra-
.QaM1.1 x111pypros a6AOMll1HanbHOC1 111 npoMe)f{HOCT-
HOC1 . 3asepwaeTcs:i onepa411151 ¢opM1.1posaH111eM
O,[lHOCTBOnbHOro npOTlllBOeCTeCTBeHHOro 38,QHe-
ro npoxoAa 1113 c111rMOBlllAHorC1 KlllWKlll B nesolii
nOAB3AOWHOJA 06nacT111 (Piiie. 84) .
6plOWHO-aHanbH851 pe3eKL\11151 np51MOJA
KlllWKlll c Hlll3BeAeHl/leM Cll1fMOBlllAHOC1 Klt1WKlll .
np111MeH5!eTC5! nplll onyxons:ix, pacnonO)f(eHHblX B
lt1HTepsane 6 - 12 CM OT Kpa51 3a,r\Hero npoXOAa.
Y,o,an51eTc51 np51Ma51 K1t1W1<a, Ho aHailbHb1ill KaHan
111 aHaJlbHble ccj:l1t1HKTepb1 coxpaHsitoTCS'I . H1t13BO-
Alt1TC51 o6oA04Ha51 K1t1w1<a s aHanbHblill KaHan .
<t>opM111pyeTC5I KOilOpeKTaJlbHblill aHaCTOM03 KO-
HeL\-B-KOHeL\ Me>K,D,y Hlt13BeA8HHOill Klt1WKOIA lt1
eepxH1t1M KpaeM aHanbHoro KaHana. Onepal.\11151
npolt13BOAlt1TCSl ABYM5l 6p1t1raAaM1t1 x111pyproB 1113
a6,D,OMlt1HanbHOfO 111 npoMe)f(HOCTHOfO ,D,ocrynoe
(P111c. 85).

A E
Puc. 85. 5plOWHO-BHaJ1bHBR pe3eKLJ,UR npRMOLJ KUWKU. A. flupoo6pa3Hb/U pa3pe3 6pJOWUHbl. 5. OmCeL/eHue KUWKU
npOKCUMan bHee onyxonu . B. Pa3pe3 Ha npoMe>KHocmu . / . OmceL/eHue KLIWKU oucmanbHee onyxonu . .a.
Hu3eeoeHue
CUZM06U0HOU KUWKLJ LJ c/JOpMUp06BHLJe CLJZMO-peKmOaHaCmOM03a. E. Cc/JOpMUp06BHHb/U CLJZMO-peKmOaHacmOM03.

- nepe,[1HSl51 pe3eKL\1!15l np51MOllJ J<lt1Wl<lt1 C WL1HHOMY .£10Cryny, B 0Tnlil41!1e OT npoMe)f(HOCT-

Cll1fMO-peKTOaHaCTOM030M KOHet..i-B-KOH8L\. np1t1- HblX. YAansieTc5l nopa)f(eHHblill cerMeHT npS'IMOill
MeH5leTCS'I np111 onyxomix, pacnono)l{eHHblX Bbl- Iii Clt1fMOBL1)J,HOill KL1Wl<lt1 c onyxonblO (P1t1c. 86) .
we 12 CM OT 1<pas:i 3aAHero npoxo,D,a . HaaeaH111e 3aTeM HaKna)J,blBaeTCs:l c111rMopeKTOaHaCTOM03
3Ta onepal\1!151 nony4111na 6naro,D,apsi 4pe36pto- KOHel\-B-KOHel\.

Puc. 86. HU3KBR nepeOHRR pe3eKLJ,LJR npRMOU KUWKU c cpopMupoeaHLJeM KOMnpecCLJOHHOao

aHacmoMo3a annapamoM AKA.

np1t1 BblCOKlt1X nepe,D,HL1X p838KL\lt151X BblnOJ1- - Onepal\1!151 rapTMaHa. Pe38KL\1115l npHMOIA

H5leTCSl pyYHoi:1 woe, np1t1 Hlt13Klt1X 111cnonb3YtoTcsi K111WKll1 c yw1t1BaH1t1eM AlilCTailbHoro orpe3Ka K1t1W-
cw111saiou.i111e annapaTbl. 1<111 Hamyxo 111 Q:>opM1!1poBaH!-1eM OAHOCTBOilbHOill

252
Cl11rMOCTOMbl Ha nepeAHel/1 CTeHKe )f(JABOTa 1113
npoKCJAManbHOfO 0Tpe3Ka l<lllWK!.1. np111MeHHeTCS'I
np111 onyxom1x, pacnoJlo)f(eHHblX Bb1we 12 CM or
KpaH 38AHero npoxo,qa s cnyYae BbrnonHeHIAH
onepaLl,1111.1 no cpo4HblM no1<a3aH!.1HM np111 ocno)f(-
HeHHOM paKe npHMOlli Kli1WKlll : OCTpoVI TOJ1CTOKlll-
We\.JHOll1 HenpOXOAlllMOCTlll li1nlll np111 nepcpopau,111111
CTeHK!.1 Kli1WKll1. B nocneAylO~eM B03MO)f(H0 BOC-
CTaHOBJ1eH111e Ll,eJ10CTHOCH1 TOJlCTOIA KlllWKlll (\.le-
pe3 3 MeCHLl,a nocne onepau,1.11.1) .
8) . Pacw111peHHb1e onepaLl,111111. BMewaTenb-
crna, np111 KOTOpblX BMecre c nps:iMOlA KlllWK0171
A 5
Puc. 87. A Bua onepau,uoHH020 peKmocKona u UHcmpyMeHmoe anfl mpaHcaHanbHOO
3HaoMuKpoxupypcu4ecKoD pe3eKu,uu. E. Onepau,uoHHbtO peKmocKon eeeaeH e npRMYJO KUWKY (T C.
oaap10K, 2005).
npVIMeHHeTCS'I np111 npelllHB83111BHblX onyxo-
JlS'IX (TisNOMO) 111 onyxons:ix c 111Hsa3111elll AO nop,-
cn1113111croro cnos:1 (T1 NOMO), pacnono)f(eHHbJX
HM)l{e 6 CM or KpaH 3ap,Hero npoxop,a.
E). ~111ropep,yKT111BHb1e onepau,111111. Onepa-
4111111, np111 KoropblX YAam1ercs:1 nepB1114HaH 111n111
peLl,li1A111BHas:i onyxonb c OAHOBpeMeHHblM non-
HbJM 111n111 "laCTVl\.JHbJM yAaneH111eM or,QaneHHblX
Meracra3os. 4a~e scero - 3TO yp,aneH111e Mera-
cra3os e ne4eH111 nyreM pa3nVl4Horo BVIAa 111
06beMa pe3eKu,11111l 3Toro opraHa . Pe)f(e - y.Qane-
HVle MeTaCT830B B HV14HlllKaX, 60J1bWOM canbHli1-
1<e, OT,QenbHblX VIMnnaHT8Ll,1110HHblX MeTaCT830B
Ha nap1.1eTaJ1bHOll1 1.1 BVICLl,epanbH0171 6pt0WV1He.
PHC. 88. neTneeaR, ABYXCTBOnbHaR
CMrMOCTOMa
11 . C111MnTOMarn4ec1<111e onepaLl,~1111. Hano>1<e-
H111e AByxcrnonbHOIA KonocroMbl - c111rMocToM111s:1,
TpaHCBep30CTOMli1S:I. np111MeHS'leTCS'I np111 onyxo-
IlHX, KOTOpble HeB03MO>KHO pe3eLl,111pOB8Tb (P111c.
88).
XuMuonyYeaoe neYeHue paKa npRMOU
l<UWKU
nepsli14Has:i onyxonb np111 paKe nps:iMo1711<111w-
K111 y,QanHeTCH x111pyprn\.leC1<V1. 3To cny)f(ll1T OCHO-
B8Hli1eM ,D,nH nposep,eHlils:l a,QblOBaHTHOro (,D,0-
nonHlilTeJlbHOro) x111M111onyYesoro ne4eHVIH nocne
253
YAam110T nopa)f(eHHbJe mnMcpoy3nbJ I, II, Ill no-
PHAKa - aopTO-Ta3oso-noAB3AOWHaH n111McpaAe-
H3KTOMlllH.
r). KoM6111HlllposaHHble onepa4111111. BMewa-
TenbCTBa , np111 KOTOpblX 0.D,HOBpeMeHHO yp,am:llOT
npHMYIO Kll1WKY Ill p,pyrne opraHbl , BOBne\.leHHble
B onyxonesb111l npou,ecc. 3rn - aMnyra4111H 111n1A
3KCT111pnaLl,11111 MaTKli1, pe3eKLl,111H Mo4esoro ny3b1-
ps:1, TOHKOIA Kli1WKV1, ne4eH111 Ill np.
,D.). TpaHcaHanbHOe 111cce4eH111e onyxon111
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muo~eM Y111cne cnyYaee 6btBalOT sap1i1KD3Ha51
(90% Ha6nt0AeH1111A) 111 nocnpoM6ocpne6111rnl.fe-
cKa5I (10%) 6one3H111. PeAKas:i np1.14"1Ha XBH -
epo)l(AeHHOe HapyweH111e paas111rns:1 BeH03Hoi)!
c1.1cTeMbl (cpne60A1t1cnna3111s:1) .
PHC. 89. 8HeWHHW BH~ HH}f{HHX KOHe'f-
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XpoH1t14eCKas:i seH03Ha71 HeAOCTaT04HOCTb
80 MHOroM CB513aHa c B03AelACTB111eM rpaBl/ITa-
1..11111.1, 3aTPYAH5llOL1\elA OTTOK BeH03HOi/I KpOBL-1 1113
Hor e ycnos1.,u:1x npflMOXO)f{,l:leHIAfl mo,.qew. XBH
4pe3Bb14al1Ho pacnpocTpaHeHa B cospeMeHHOM
Mll1pe. 8n111AeM111onorns:i 111ccneAoeaH111s:1 , npose-
AeHHoe Ha npoMb1wneHHb1x npeAnpills:irni;ix Bb1-
s:1s111no np1t13HaK111 aroro naronor1114ecKoro co-
cros:iH111s:i y 60% pa60Ta10ll\ll1X.
Ka>KYLl\ai;ics:i 6e306illAHOCTb sap111K03HblX BeH
illfllt1 OTeKa KOHe4HOCTll1, cyll\eCTBYIOL1\111X y na1..1111-
eHTa B TeYeHJlle MHOfJllX neT, He Bbl3blBaS'I era
6ecnoKol1cTsa, secbMa 06MaH41110a. T5l)l(enb1e
ocno)f(HeHf..151 XBH , raK111e KaK rpocp1114ecK111e 513-
Bbl, npl.1BO,Q51T MHOrfllX 6onbHblX K lllHBan111AHOCTIA
li1 BblKnl04eHllllO 1113 aKTll1BHOi:.1 co~111anbHOIA )f(ll13Hlll .
5onee TOro, np111 XBH B03MO)f(Ha 111 CMepTb na-
L..\illeHTa B pe3ynbTaTe KpOBOTe4eHll1S'I "13 0ap111-
K03HOro yana 111n111 B03HillKHOBeH111111 111 nporpecc111-
posaHillll1 0ap111KoTpoM6ocpne6111ra, nepexoAe
TPOM603a Ha Cll1CTeMy rny6oKVIX BeH 111 nocne-
AYIOLl\eM pa3s111r111111 aM6or1111111 nero4HblX apTep1111A .
AHamoMUR, c/JU3UOf102UR u
namoc/JU3UOf102UR eeH03H020 ommoKa
06Ll\e 11138 ecrno, 4rn c1t1cTeMa Kposoo6pa-
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111T 111 3 Tpex OTAenos: apTep1t1anbHOro, BeHOJHOro
Ill M1t1Kpou,111peyns:iropHoro. Aprep111anbHYIO CIAC-
TeMy Ha3blBalOT TpaHcnopTHOi:.1 , TaK KaK OHa
06ecne41t1BaeT np1t1TOK K1t1cnopoAa 111 n1.1raTenb-
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BeHo3HYKJ c111cTeMy Haab1Ba10r 3 saKYaTopHol1, 8
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AeH111eM 111 AeaaKT111sau.111ei:.1 TKaHeBblX Mera6on111-
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Ha yposHe M111KPOL.lillPKYns:irnpHoro pycna . BeHbl
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cso!A npocseT y>t<e np111 npocToi/I nepeMeHe no-
no>t<eHll171 Tena. Hall16onee Bblpa)f(eHHoe, 2-3
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He4HOCTet1 npo1.1cxoA1t1T 8 sepTll1KanbHOM nano-
255
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HOM opTOCTa3e. BOT no4eMy BeHbl npi1106peTalOT
B03MO)l(HOCTb AenoH111posarb 3Ha4111renbHble
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YacTo Ha3bJBalOT eMKOCTHblM111 cocyAaM111. TKa-
Hesoi/I MeTa6om13M ocyll\eCTsm1ercs:i 3a c4eT
COCYAOB Mll1KPOL..\111PKYm1TOpHoro pycna, KOTOpble
t-tMelOT OYeHb TOHf<YIO cpeHecrp1-1poBaHHYIO CTeH-
Ky. nepcpy3111s:i M111KpOL..\111pKyns:iTOpHoro pycna
ocyll\eCTBmleTCS'I B OCHOBHOM 3a C4eT rpaAt.1eHTa
JJ,asneHi1151 Me)l(Ay aprepillanbHblM ill seH03HblM
OTAenaMill cOCYAll1CTOro pycna.
BeHo3Has:i CillCTeMa HVl)l(HlllX KOHe4Hocrei/I
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ro OTTOKa 1113 Hll1)f(Hll1X KOHe4HOCTei/I illMelOT nep-
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noAKO)f(Hble BeHbl.
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L..\eHTpocTpeM111TenbHb111l TOK Kpos111 . B nepcpopatt-
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lllMelOT.
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cpeA111 KOTOPblX 3aH1t1MaeT pa6ora Mb1We4HO -
aeH03Hoi1 n0Mnb1. CaMas:i 6onbWaf! <PYHKL..\ll10-
HanbHas:i Harpy3Ka nO)f(ll1TCS'l Ha Mb1We4HO - Be-
H03HYIO noMny roneH111 , KOTopa51 nepeKa4111saeT
AO 75% KpOBll1 HOr.
5onbWYIO 48CTb )f(lt13Hll1 cospeMeHHbli/I 4eno-
aeK npoBOA1t1T s sepT1t1KanbHOM nono:>KeH1.-11t1 . To
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111cnblTb1saer Afllt1TenbHYKJ HarpyaKY AaBneH111eM,
aenll14l.1Ha KOTOporo np51MO nponopl..\lllOHanbHa
pocry lt1 B cpe,o,HeM cocrasns:ier 99 MM .pr.er.
noMillMO aroro, s HenOABlll)f(HOM oprocTaae
3a C4er no31ttl(1ttOHHoro pacw1ttpeH1tts:i aeH yaem1-
4111Baercs:i ill 06beM AenOHlllPOBaHll151 KpOBf..1. np111
HOpManbHOi:.1 cpyHKL..\1111.1 Mb1We4HO - BeH03HblX
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CHill>KaeTCS'I 6onee 4eM B 3 pa3a.
KpoMe Mb1we4HO - BeH03Holll noMnbl B
o6ecne4eHilllll seH03Horo oTToKa 1113 Hlll)f(Hll1X Ko-
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3KCKYPCill51 nerK1.1x, coKpall\eH111e npasoro npeA-
cepAl.151 , a Ta10Ke nponynbClllBHa51 aKTlllBHOCTb KOTOpble lllMelOT 6onee 3naCT111'-lHYIO MeM6paHy Ill
nesoro >KenyAO'-lKa. 3proHaMlll'-lHYIO cj:JopMy, OTTeCHSllOT 1113 1...1€HTpa
COCYAa nelilKOLllllTbl , KOTOpble KaK 6bl nepeK8Tbl-
B8IOTCSl no 111HT111Me. 3AeCb s c1.1ny noKa ell.\e
nnoxo 1113y'-leHHblX nplll'-llllH , 3HAOTenlllOL\l.1Tbl Ha-
'-ll.1H810T Cl.1HTe31.1pOB8Tb Ill BbfBOAlllTb Ha nosepx-
HOCTb MoneKyJlbl 8):\re3111111 , KOTOpble CHa'-lana
«np111Kne1.1Ba10T» , a 38TeM aKTl/IBl.131.1PYIOT nelilKO-
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pys:1 no BeH03HOMY pycny , Ha'-ll.1H8IOT l.1Hcj:JlllnbT-
p1.1posaTb Ill pa3pywaTb KapKac BeH03HOlll CT8HKlll
111 KnanaHbl BeH , BblXOASlT B napaB838IlbHOe npo-
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socnan1.1TeilbHble peaKL\111111, lllTOfOM KOTOpblX S'IB-
Jl51eTCSl 06pa3osaH1t1e TpOcjJlll'-leCKlllX 5138 .

OcHOBHbte npoRBfleHuR namo1102uu

C111HAPOM xpoHlll'-leCKOlll BeH03HOlll HeAOCTa-
TO'-lHOCTltl BbJ3bfB8eT Tp.1.1 3a6o.nesaHJ.151 .
BapMK03Ha~ 6oneJHb xapaKTep1113yeTcsi
nopa)f(eH1.1e nosepxHOCTHblX seH , pacnono>KeH-
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pa3s111T111111 3a6onesaH1115I cTeHKa seHbl noAsepra-
eTC7i y3nosarnL1 TpaHccj:JopMa1...1111111. Bap1.1K03Has:i
Puc. 90. BeH03HBfl cucmeMa HU>KHUX 6one3Hb - non1113TlllOnor111'-lHoe 3a6onesaH111e , B
KoHe4Hocmeu.
era pa3Bllffllllll 111rpaeT ponb HecKOflbKO cpaKTopos .
1. Ko>Ka OnpeAeneHHoe 3Ha'-leH111e 111rpaeT reHern'-lecKa51
2. 06ll.\8Sl 6eApeHH8S'I BeHa npeApacnono>KeHHOCTb. no HacneACTBY nepe-
3. MblWL.lbl A8eTC51 spo}l\.QeHHas:i c.na6ocTb seH03Holll cTeH-
4. an0Hespo3 Klll. V'lccneAOBaHlllSlMlll nocneAHlllX neT AOKa3aHo
5. 6onbwas:i noAKO>KHas:i seHa CHlll)f(eH111e Cl.1HTe3a KonnareHa 3 rnna y 6onbHblX
6. BeHa - nepcpopaHT c BaplllK03HOL1 6one3Hbl0. V1MetOT 3HaYeHl/le rop-
7. nosepXHOCTHaS'I 6eApeHHaS1 BeHa MOHanbHbl8 B03AelilcTBlllSl (6epeMeHHOCTb , np111-
8. nOAKOneHHa51 BeHa eM 3CTporeH-recToreHoB} , 3Ha'-l1t1TenbHb1e cTaT111-
9. Manasi nOAKO>KH851 BeHa '-lecK111e Harpy3Kl.1 (An111TenbHOe npe6b1saH111e Ha
10. cypanbHbll.1 BeHbl Horax), perym:rpHbllli nOAbeM Ts:l}f(ecrnfli , nonosas:i
11 . rny60Kas:1 c111cTeMa KOMMyH111KaHTHblX seH np111HaAne>KHOCTb ()f(8Hll.\111Hbl 6onet0T B 2-3 pa3a
12. BeHbl - nepcf:JopaHTbl Me>KAy Manolll noA- Yall.\e) . y Ka>KAOfO naL1111eHTa MO>KHO Bbl71BlllTb
KO>KHolil 111 rny6oKlllMlll seH8Mlll O,[\lllH 1.1n111 HeCKOnbKO nplll'-llllH- cj:JaKTopoB sap111-
K03HOll1 6one3Hlll .
A111ccpyHKL11t1Sl MblWe'-lHO- seH03HOl.1 n0Mnb1 nocrrpoM6oq>ne6MTM'fecKa.R 6one3Hb
nplllBOAlllT K 1113Bpall.\8HllllO BeH03HOro OTTOKa, KO- (nT<bC) pa3BlllB88TCSl y 6onbHblX nepeHeCWlllX
rAa nplll X0Ab6e lllHTpaBeH03HOe A8BneH111e He TpoM6o3 rny60K111x seH. nocne npeKpall.\eH1.1~
CHlll)f{88TC51, a B03p8CTaeT B HeCKOnbKO pa3. np1.1 TPOM6oopa3osaHl.151 Ha'-l1t1HaeTcs:1 peKaHan1113al..llll71
Tsi>KenblX cj:JopMax XBH B AlllCTanbHblX OTAenax TpOM6111poBaHHOlll B8Hbl , B npo1...1ecce KOTopoll1
roneH111 lllHTpaseHo3HOe AasneH111e np111 XOAb6e npovtCXOAlllT pa3pyweHvte BeH03HblX KflanaHOB ,
MO>KeT AOCTl.1raTb 200-300 MM.pT.CT. 3TO TaK n11160 cj:JopM111pyt0TCSl y'-laCTKlll OKKnl03111111 cocyAa,
Ha3b1saeMoe A1t1HaM1.1'-lecKoe seH03Hasi rnnep- o6ycnosneHHble C08Al.1HvtTenbHO-TK8HHO!l1
TeH3111Sl , KOTOpy10 C'-ll.1TalOT OCHOBHblM nospe>K- TpaHccj:JopMa4111elll TPOM60Tlll'-leCKlllX Mace. Bap111-
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TaKlllX ycnOBl.151X rpaAllleHT A8BneHlll51 B MlllKpo- BTOp111'-lHb1!11 xapaKTep 111 no51Bn51eTC51 '-lepe3 He-
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ll.\8eTCSl. To ecTb nepcpy3111si TKaHelA 111 MeTa6on111- Hlll'-lecKolll BeH03HOC1 HeAOCTaTO'-lHOCTlll 6blBalOT
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256
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BeHym1pHble WYHTbl. np1113H8Klll XBH B 3TlllX c11y-
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3muonamo2eHe3
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np1114111Hbl , Bbl3Baswellr XBH, naTOreHe3
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,QeH. V1HlllL\111111pyeT KacKaA naT0110rlll4eCKlllX peaK-
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3Jl8CTl/l4eCKlllX B0110KOH CTeHKlll nO,QKO>KHblX
nep¢opaHTHblX BeH , 4TO nplllBOAlllT K VIX pacwvr-
peHllllO . 803Hl/IKaer OTHOClllTeJlbH851 He,QOCT8T04-
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coxpaHHOCTlll CTBOpKlll VIX CMblKalOTCs:I He nOJlHO-
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111 peKaHan1113al.\llllll TpoM6orn4eCKlllX Mace.
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eT pecj:>moKC KpOBlll no nep¢opaHTHblM BeHaM
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COCTOs:!Hlll51.
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K0Mnpecc111H .
3. 3¢¢eKTIABHOCTb ¢apMaKOTepan111111.
4 . CeoespeMeHHoe x1,1pypr111YecKoe ne4eH1.-1e .
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L\eccoM B BeH03HOM pycne ,QOJl)f(8H 6b1Tb cp04HO
rocn1t1TaJllt131ApOBaH B OT,[\8Jl8Hl/le cocy,QlllCTOV!
111nt1 06111e1A x111pypmw . 5onbHoro c ocTpbrM se-
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pac4eHl/IB8Tb KaK KaH,[\lllAaTa Ha TpOM6oaM6o-
IlllllO nero4Holll aprep111111 .
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p1t1H (cTapToBaH A03a OT 5 AO 10 Mr) H841AH8IOT
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6 MeCf!L..\eB (yposeHb MHO cocrnsns:1er 2-3 np1r1
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pa3a B .QeHb) , Ae3arperaHTbl (acn111p111H 0,5 x l'4
Ta6) , peononHrmOKMH 200 Mil BIB KaneflbHO ,
neHTOKClll<J>HnnMH 10,0 Ha 200 Mfl . cp11!3. p-pa
ala KanenbHO . .0,nfl npocp11111aKTL1KV1 rpoM6o3M60-
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Kaea-<J>HnbTpa (p111c. 98 .)
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CVIMnTOM8Mlll xpoHlll4eCKOIA BeH03HOIA HeAOCTa-
TOLIHOCTVI (YTOMJlSleMOCTb, OTeKIA, TSl}l{eCTb B
Horax snnoTb AO HeB03MO}l{HOCTlll B TeL1eH111e
1<a1<oro-m160 6onee l-1n1t1 MeHee npo,.qom1<111renb-
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no}f<eHllllll) lt1 6blCTpO 803Hlt1K810UJ,lt1Mlll lt1 T5l)!(eno
nporeKa10UJ,lllM1t1 rpocp11t4eCK11tM11t paccrpoi:1-
creaM11t .

Puc. 98. KacfJa - cfJunbmp

ctJopMb1 nrcpe:
1. Bap1t11<03Has:i
Kaea-qwnbmp - ycTpolllcTso, ynasm1sa10- 2 . Ore4Ho-s:i3BeHHas:i
L11ee rpoM6bl 111 cso6oAHO nponycKa10L11ee o6bl4- 3. CMeWaHHas:i .
HYIO 1<posb, npe,llcTasm1er 1113 ce6s:i " 30HTlllK ",
KOTOPbllll pacKpb1saeTcs:1 s seHe nocne ere no- Ile'-leHMe
craHOBKlll s HY:>t<Hoe MeCTo 111 YAaneH111s:1 ¢111Kca- OnepaTlllBHoe - noKa3aHo n111wb He6onb-
Topa . YcTaHasn111saeTcs:1 3HAOBact<yns:ipHo np111 woi/1 rpynne naL11t1eHros - wyHT111py10w,111e onepa-
yrpo3e TpoM603M6on111111 . 4111vi np111 OKKJll03111111 nOAB3,QOWHOro cerMeHTa,
noK838Hlll51 K ycTaHOBKe K8Ba-¢1t1nbTpa: no- YAaneH1t1e sapVIK03Ho-pacw111peHHblX seH 1t1n1t1
Ka38Hlll8M Ami 111MnnaHraL1111111 nocneAHero cny- nepeB513Ka nep¢opaHTOB no 536KOt<y Ill nviHTOHy.
}l{aT :;in11130Ab1 T3nA s aHaMHe3e, rpoM6o3 rny-
60K111x BeH nOAKOneHHOro Ill VIIll.'10¢eMopanbHOro KoHcepeamueHoe neYeHue:
cerMeHTOB Ha ¢oHe V15C , CH, Mep4arenbHOll1 ll13MeHeHIASI 06pa3a >KIA3HIA:
aplllTMlllJ1L • np111 Manono,.qs.11D1<HOM o6pa3e )f{lt13Hltl 1-2
YcraHOBKa: B Hacrns:1L11ee speMs:t Havi6onee pa3a B 48C 10-12 nOAbeMOB Ha HOCOLIKlll;
w111p0Ko 111cnonb3yercs:i YpecKO}f<Has:i 111MnnaHra4111s:1 • n<t>K (cnopTlllBHas:! XO,Qb6a, nnaBaH1t1e) ;
1<asa-¢111nbTpos. TexH111Ka 4pecKO)!(HOll1 111MnnaH- • ne4e6Hb1Jll M8CCa)!(;
ra4111111 KaBa-ct>111nbTpOB pa3nlll4HblX KOHCTpyK41111/1 • L1111pt<yns:tpHbli-1 AYW ;
V1Meer MHoro o6w,ero. V1MnnaHT8L\11151 1<asa- • HoweH111e KOM¢opTHOi-1 06ys111 ;
¢111nbrpos npoBOAlllTC51 B peHneHoonepa41110H- • CH111}f<eH111e Maccbl rena ;
HO~. JJ,ns:i ol..(eHKfll cocros:iH111s:t HnB 111 nony1..1eH111s:i
• YMeHbWeHvie norpe6neH1t1s:1 nosapeHHOl/1
lllH¢0pM8L\Vllll 0 3M6onoreHHOCTlt1 TpOM6a BH848- con1t1 lt1 )!(lt1AKOCTlll ;
ne npo1113BOAlllTCS'I perporpaAHas:i 111n111 aHrerpaA- • Bo3BblWeHHoe nono}f<eH111e Hlll}l{HVIX KO-
Has:i vineo1<asarpacpvis:1 . Bb16op ,.qocryna (peTpo-
He4HOCTelA Ha H04b.
rpaAHbllll - s:ipeMHbli.1, nOAKnl041t14Hblli1; aHTerpaA-
Hbllll -6eApeHHb1il1) 3asvic111r or npeAnonaraeMolll KoHcepeaTHBHOe 11el.feH11te:
noKanvi3aL11t11t1 TpoM6a: npoBeAeH111e KaTerepa L1e- - 3naCTl.1YHas:I KOMnpeCCltlfl (3D8CTl.14eCKOe
pe3 rpoM6111posaHHb1e seHbl Ypesaro ¢parMeH-
61t1HTOBaH1t1e, KOMnpecc1110HHbllli Tplt1KOT8)!()
ra41t1ei/1 rpoM6a c pa3svirneM T3nA. Kasa- - HopMan1113a4111si pe>Kl'1Ma TPYAa 111 OT.QblXa,
¢1t1nbTp lllMnnaHTlt1PYIOT HenocpeACTBeHHO Hlll}f<e ycTpaHeH1t1e CT8Tlll4Hb1X Harpy30K
yCTb€B no4e4HbfX BeH. npvi Hlll3KOM nonO}f(eHllllll
- ¢ne60TOHlt1Klll:
Kasa-cpvinbrpa o6pa3osasweecs:i Me>K.Qy Hlt1M 111
• ,QerpaneKc 100 Mr no 1ra6. x 2 pa3a s
ycTb5lMlll noYe4HblX seH "Meprnoe" npocrpaHcrno
AeHb;
nosb1waeT p1t1c1< TpoM6006pa3oaaHV1S1 111 T3nA
• 3Ct<y3aH no 16 Kanenb (rpaHyn) x 4 pa3a
nocnpoM6ocpne6MTM'-leCKMM B AeHb;
CMH.qpOM • aHTlllCTaKC 2 Kancynbl YTPOM.
nocnpoM6ocf:>ne6111T1114eCKlllM ClllHAPOM - npenapaTbl yKpennfl10lJ.111te cocy,ll1t1Cry10
npeAcTaBns:teT co6oi/1 Clt1MnTOMOKOMnneKC, pa3- CTeHt<y:
BlllB810ll\lllli1Cs:! y 6onbHblX, nepeHeCWlllX OCTpblilt • TpoKcesa31ttH no 2 Kancynbl x 2 pa3a s
rpoM603 rny6ot<lllX BeH, Ill .flBnRIOUJ,ltleiCR cne,D,CT- ,lleHb.
Bl/leM 41t1pt<ynsiTOpHblX paccrpoiltcTB B KOHe4HO- - ,Qe3arperaHTbl
CTlll 1113-Ja HecocrmnenbHOCTlll KnanaHHoro an- • acn1t1p1t1H 0,5xY.i Ta6. Be4epoM.
napaTa rny60K111x seH B y4acr1<ax peKaHan1t13a- - MeCTHble npenapaTbl (renltl , Ma3111):
4111111, OTCYTCTBVls:I npOXOAlllMOCTlll rny60KlllX BeH B • «AHaseHon»;
Hepe1<aHan1113oBaHHblX cerMeHrax 111 KJlanaHHOilt • rpvi6eHo3111A;
He,QOCTaTOLIHOCTlll nOAKO}f<HblX Ill nep¢opaHTHblX • «BeHopyTOH»;

277