Method of ligation of the external carotid artery. How to act in case of carotid injury. Indications for surgery

Ligation of the common carotid artery

Content

• Anamnesis witae
• 7. Pain relief
• 8. Online access
• 9. Operational reception
• 11. Postoperative treatment

Animal registration details

Anamnesis witae

The cow is kept in a typical barn for 200 heads. The content system for this period is pasture. Milking is carried out on the farm in the milk pipeline. Animal care is satisfactory. Drinking from autodrinkers ad libitum. The diet consists of plenty of green mass and concentrated feed - 1.5 kg per day.

1. Indications and contraindications for surgery

Indications for surgery:

Aneurysms

Damage to the common carotid artery and its branches;

To prevent bleeding

During surgery in the area of ​​its large branches.

Contraindications for surgery:

Late pregnancy;

The state of sexual hunting;

Two weeks before and after vaccinations;

Quarantine on the farm;

Exhaustion.

2. General training animal for surgery

Preparing the animal for surgery

For a favorable outcome of the operation, the preparation of the animal for it is important. Before surgery, the animal is clinical researches, in particular, measure body temperature, respiration, pulse rate. Do not operate on animals with elevated temperature, it is also not recommended to carry it out in the presence of infectious diseases, in malnourished animals. If the operation is not carried out urgently, then before it the animal is reduced to feed and, if possible, then a starvation diet is prescribed for no more than 12 hours.

When performing an operation under anesthesia, it should be borne in mind that some drugs, such as rometar, in the second half of pregnancy can cause fetal death.

animal operation carotid artery

With a favorable outcome in these cases, surgery can be performed under local anesthesia, since it has been established that it does not affect the development of the fetus.

Before the operation, the animals are walked in order to free the large intestine, clean or partially anesthetize.

3. Private preparation of the animal for surgery

Processing of the surgical field includes four main points: removal of hair, mechanical cleaning with degreasing, disinfection (asepticization) of the surface with tanning and isolation from surrounding areas of the body.

The hairline is trimmed or shaved. The latter has a great advantage, since skin asepticization can be done with greater care. It is most convenient to use a regular safety razor with a broken blade. Such processing is easier to carry out already on a fixed animal.

During mechanical cleaning and degreasing, the surgical field is wiped with a swab or a napkin moistened with a 0.5% solution of ammonia or alcohol-ether (equally), it is possible with clean gasoline, only after a dry shave. There are many ways of asepticization and tanning of the surgical field.

So, according to the Filonchikov method, tanning is carried out by double treatment of the surgical field with a 5% alcohol solution of iodine, and the interval between treatments should be at least 3 minutes.

According to the method of Borchers - double treatment with a 5% alcohol solution of formalin. This method is best used on skin with increased sweating.

According to Lepsha, the operating field is treated three times with 5% aqueous solution potassium permanganate (for dermatitis), and according to the Bokkal method - with a 1% alcohol solution of brilliant green. Skin can be aseptic and tanned with a solution of Altin, 1% solution of degmin or 3% degmicide.

An effective remedy for these purposes is a 1-3 solution of surfactant antiseptics patanol and atony.

The processing of the surgical field with a solution of furatsilina is as follows, mechanical cleaning and degreasing of the skin is carried out with an aqueous solution of furatsilin at a dilution of 1: 5000, asepsis and tanning - with an alcohol solution of furatsilin at a concentration of 1: 5000 - 500.0

Recipe: Solutions Furacilini 1: 5000 - 500.0

Miss. Da. signa. For mechanical cleaning and degreasing of the surgical field.

Recipe: Solutionis Furacilini spirituosae 1: 5000 - 300.0

Miss. Da. signa. External. For disinfection and tanning of the skin of the surgical field.

When processing the surgical field, the skin surface is wiped and lubricated in a certain order - from the central part to the periphery. The exception is the presence of an open purulent focus. In this case, they process from the periphery to the center.

Modern antiseptics for the preparation of the surgical field: Septocid K-1 (colored, used for pigmented skin areas); septocid k-2 (not colored); assipur (contains iodine); altin (1% alcohol solution. Disadvantage - slippery field after processing); aseptol (2% solution. The field is treated for 3 minutes); iodonate (1% solution. Process the field twice).

4. Preparation of the surgeon's hands, instruments, suture and dressing material

There are three main methods of modern hand preparation for surgery:

a) mechanical cleaning;

b) chemical asepticization;

c) leather tanning.

Mechanical cleaning consists in cutting nails, processing burrs. All unnecessary items are removed from the hands, the sleeves are bitten no lower than to the elbow. Hands are washed in soapy water alkaline solutions or in 0.5% ammonia solution. Hands are washed with a brush or in several trays in succession.

Wash until the water runs clear. Then the hands are dried with a coarse sterile towel.

Chemical asepticization - hands are treated from fingertips to elbows with a cotton-gauze swab, smeared with an antiseptic.

Tanning is achieved by treating the hands with alcohols or alums. There is a compaction of the upper layers of the skin and the excretory ducts of the glands are closed. Additionally, fingertips and nails are treated with a 5% alcohol solution of iodine. Most antiseptics at the same time.

Alfeld method. Wash your hands first with soap warm water, brush, wipe with a towel and then wipe the hands for 3-5 minutes with a cotton-gauze swab moistened with 96 0 alcohol.

Additionally, the fingertips are treated with a 55% alcohol solution of iodine.

Method of Spasolukotsky - Kochergin. Hands are washed for 3-5 minutes in a 0.5% solution of ammonia, then wiped with a towel and disinfected and tanned with 70-96 0 alcohol. Fingertips - alcohol solution of iodine 5%.

Oliveov's method. Hands are washed for 5-10 minutes in a 0.5% solution of ammonia, then wiped and wiped twice with a cotton-gauze swab moistened with iodized alcohol (1: 1000).

If the hands are conditionally clean, then iodized alcohol is used at a concentration of 1: 3000. Fingertips are not processed.

Kiyanov's method. Hands are washed for 5 minutes in a 0.5% solution of ammonia, wiped and treated for 3 minutes. Under a fluid jet with a 3% solution of zinc sulfate. The fingertips are treated with a 5% alcohol solution of iodine.

The method of solutions of furacilin. Hands are washed with soap, wiped and treated with a swab moistened with an iodine solution of furatsilina (1: 5000) and then treated with a swab moistened with an alcohol solution of furatsilina (1: 1500). The fingertips are treated with a 5% alcohol solution of iodine.

Modern antiseptics for hands.

Chlorhexidine bigluconate (gibitan) is available as a 20% concentrate. Before use, it is diluted with 70 0 alcohol to a concentration of 0.5-1%.

Hibisent (the active principle of gibitans).

Plivasept (the active principle of gibitan) is used 5%. The fingertips are not treated with an alcohol solution of iodine, since their combination with iodine causes irritation.

Also used is a 1% solution of Demin, a 3% solution of degmicide, a 1-3% solution of Novosept, atony tincture (sterility lasts up to 120 minutes), Rokkal 0.1-0.3%, tserigel (with drying, a protective film is formed that can be removed with ethyl alcohol), a polyalcoholic hand antiseptic, pervomur streptocide (active ingredient H 2 O 2 + formic acid), 0.25-0.5% solution of chloramine B. Hands can be treated with ultrasound, passing it through an antiseptic liquid for 30 seconds.

During this operation, the following method of processing hands is used: hands are washed in a 0.5% solution of ammonia, wiped with a rough towel. Then, within 5 minutes, they are treated twice with a poly-alcoholic antiseptic for hands using a cotton-gauze swab.

Recipe: Solutionis Ammonii caustic 0.5% -5000.0

D. Signa. External. Hand washing and degreasing.

Recipe: Polyalcoholic hand sanitizer 400.0

Da. signa. External. For the treatment of the surgeon's hands.

Tool preparation

When ligating the common carotid artery, the following instruments are used: scalpel, tweezers, wound hooks: sharp and blunt, simple and automatic, button probes, hemostatic, surgical spoons, curettes, hemostatic clamp, surgical needles, needle holder.

Still needed cotton-gauze swabs.

All metal instruments are sterilized in water with the addition of alkalis: 1% sodium carbonate, 3% sodium tetracarbonate (borax), 0.1% sodium hydroxide.

Alkalis increase the effect of sterilization, precipitate salts present in ordinary water, and prevent corrosion and discoloration of instruments. Before boiling, the tools are cleaned of the lubricant covering them, large and complex tools are disassembled.

The liquid is boiled in special metal vessels - simple and electronic sterilizers. Sterilizers have a volume lattice. The grate is removed with special hooks and instruments are placed on it, which are then lowered into the sterilizer after boiling the liquid for 3 minutes. During this period, the water is freed from the oxygen dissolved in it and neutralized with alkali. After boiling, the grate with instruments is removed from the sterilizer and the instruments are transferred to the instrument table. If the instruments need to be prepared in advance, then after sterilization they are wiped with sterile swabs, wrapped in 2-3 layers of a sterile sheet or towel, and then in a film; store and transport instruments in the sterilizer.

Other methods of sterilization are used depending on the circumstances and the type of instruments. In emergency cases, metal instruments can be flambéed; they are placed in a basin, doused with alcohol and burned. However, cutting and stabbing tools become blunt and lose their luster from firing.

If there are no conditions for sterilization by boiling, the instruments are sterilized chemically, dipping them for a certain time in an antiseptic solution: in an alcohol solution of furacilin at a concentration of 1: 500 for 30 minutes.

You can lower the instruments for 15 minutes. in Karepnikov's liquid: 20 g of formalin, 3 g of carboxylic acid, 15 g of sodium carbonate and 1000 ml of distilled water or in a 5% formalin alcoholic solution, 1% brilliant green alcoholic solution.

Suture preparation

The suture material must have a smooth, even surface, be elastic, sufficiently extensible and biologically compatible with living tissues, while having minimal reactogenicity and having an allergenic effect on the body.

Before sterilization, they are loosely wound on glass rods or glasses with polished edges, and then boiled for up to 30 minutes with the lid ajar so that the water temperature does not exceed 100 0 C, otherwise the threads will break. You can also use cotton and linen threads. They are sterilized according to the Sadovsky method: the threads in the skeins are washed in hot water with soap, then rinsed thoroughly, wound on glass slides and dipped for 15 minutes in 1.5% ammonia, then for 15 minutes in a 2% solution formalin, prepared on 65 0 alcohol.

Can be immersed for 24 hours in 4% formalin solution.

Re-sterilize in an alcohol solution of furacilin 1: 1500, septocide.

Sterilization of cotton-gauze swabs is carried out by autoclaving. Before autoclaving, swabs are placed (loosely) in bixes. The openings on the side wall are opened before loading the autoclave and closed after sterilization. Several biks are put into the autoclave at the same time. The duration of sterilization depends on the pressure gauge readings: at 1.5 atm. (126.8 0) - 30 min., at 2 atm. (132.9 0) - 20 min. Sterilization control in an autoclave - they look at test tubes with sulfur, how it melted, then sterilization was carried out reliably. After the required time has passed, heating is stopped, the release valve is carefully opened, steam is released and the pressure is brought to atmospheric (to zero), only after that the autoclave lid is carefully opened and the material is removed.

Swabs can also be sterilized with flowing steam, either in a special Koch flowing steam sterilizer, or using a saucepan or bucket with a lid.

Sterilization starts from the moment when steam begins to come out from under the lid for a while in a continuous stream. The steam temperature reaches 100 0 ; duration of sterilization is at least 30 minutes.

5. Fixation of the animal during the operation

The main thing when fixing animals is to apply the necessary technique that calms them, create conditions for safe research and operations.

Fixation in a standing position. In a group examination, closely spaced animals are tied to a hitching post or to a rope tightly stretched at the fence. In this position, they fix each other. This makes it possible to examine the area of ​​the head, neck, pelvis, external genital organs, vaccinate, examine rectally for pregnancy, castrate bulls in a standing position, etc.

The head of the animal is firmly tied to the post, thereby limiting its movement.

Fixation major horned livestock.

6. Anatomical and topographic data of the operated area

The ventral region of the neck extends downward from the cervical vertebrae. Borders: anterior - a line connecting the corners of the lower jaw and running along the contour of the external maxillary vein; the back is the handle of the sternum, the upper is the contour of the brachiocephalic muscle and the lower is the free edge of the neck. The composition of the ventral region of the neck includes: the larynx and trachea, esophagus, thyroid gland, surrounding muscles and fascia. The mutual arrangement of these organs and the layers covering them is not the same in different thirds of the neck, which should be taken into account when performing the operation (Fig. 1). Layers and organs. The skin is thin, mobile, in a large cattle hangs down on the free edge of the neck in the form of a fold. Under it is the subcutaneous tissue with the ventral branches of the skin cervical, nerves, skin blood and interfascial vessels branching in it. The superficial two-layered fascia of the neck is relatively loosely connected to the underlying layer, and fuses along the midline with the outer leaf of the deep fascia. In the middle and caudal third of the neck there is a subcutaneous muscle of the neck, which merges with the upper edge of the brachiocephalic muscle, and below covers the jugular groove.

The neurovascular bundle of the neck includes the common carotid artery, the vagus and sympathetic nerves, and the recurrent nerve. The latter gives off tracheal, esophageal and thyroid branches and ends in the larynx.

In cattle, the sympathetic trunk, entering the chest cavity, enters the caudal cervical ganglion or stellate ganglion.

Fig.2. Cross section of the ventral region of the neck in cattle at the level of the 3rd vertebra: 1 - skin; 2 - superficial fascia; 3 - brachiocephalic muscle; 4 - sternomaxillary muscle; 5 - external jugular muscle; 6 - own fascia of the brachiocephalic, sternomaxillary muscles and jugular vein; 7 - sternomastoideus muscle; 8 - deep fascia of the necks and from the plate (a - prevertebral, b - retrotracheal, c - pretracheal); 9 - fascia of the trachea; 10 - trachea; 11 - esophagus; 12 - internal jugular vein; 13 - carotid artery; 14 - vagosympathetic trunk; 15 - recurrent nerve; 16 - sternum hyoid to 17 - sternothyroid muscle; 18 - long muscle of the neck; 19 - white line of necks.

7. Pain relief

Anesthesia and infiltration anesthesia along the incision line, and an antipsychotic is also injected.

8. Online access

A skin incision is made in the caudal third of the jugular groove 8-10 cm long along the lower edge of the brachiocephalic muscle, along and above the jugular vein. After that, the superficial fascia and subcutaneous muscle are dissected. Stop bleeding. Wound hooks expand the wound. Two surgical tweezers grab the fascia into the fold and dissect it. Having determined the location of the artery by palpation of the pulse, the deep fascia of the neck is pulled up with tweezers and also dissected with scissors.

9. Operational reception

With the expansion of all layers of the wound, the neurovascular bundle is clearly visible. Later, the own fascia of the artery is cut with scissors, it is isolated with tweezers for 2-3 cm, a ligature is brought under it with a Deschen needle, without capturing the nerves, and bandaged. The operation is completed by applying a knotted suture to the deep catgut fascia, to the silk skin.

In case of accidental injuries of the artery, it is exposed at the site of injury in such a way that it is possible to tie up the central and peripheral ends of the vessel.

10. The final stage operations

Blood clots are removed from the wound cavity and powdered with antibiotic powder.

Recipe: Benzylpenicillin sodium 100000 ED

Streptocidi 20.0

Misce, fiat pulvis.

Da. signa. Powder on the wound.

11. Postoperative treatment

After ligation of the common carotid artery, the animal is monitored. If suppurative processes occur, the wound is cleaned and treated with an antiseptic solution.

12. Feeding, care and maintenance of the animal

After the operation, the animals are placed in a separate machine. Special feeding is not required. There should be no drafts. They put on a diet, exclude dusty feed.

13. List of used literature

1. Veremey E.I., Semenov B.S. Operative surgery workshop with pines topographic anatomy animals: Proc. allowance. - Minsk: Urajay, 2001. - 204 pages.

2. Eltsov S.G., Itkin B.Z., Sorokova I.F. et al. Operative surgery with the basics of topographic anatomy of domestic animals Ed. S.G. Yeltsov. - M.: State publishing house of agricultural literature, 1958.

3. Magda I.I. Operative surgery with the basics of topographic anatomy of domestic animals. - M.: Selkhozizdat, 1963.

4. Operative surgery / I.I. Magda, B.Z. Itkin, I.I. Voronin and others; Ed. I.I. Magda. - M.: Agrpromizdat, 1990. - 333 p.

5. Plakhotin M.V. Handbook of veterinary surgery. - M.: Kolos, 1977. - 256 p.

6. Lecture notes on operative surgery.

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Ligation of the common carotid artery
(a. carotis communis)

The indication is usually the injury of these vessels, as well as the consequences of injuries - aneurysms carotid vessels. The best place to expose all three carotid vessels is the carotid triangle (trigonum caroticum.). The incision is made along the anterior edge of the sternocleidomastoid muscle. The skin, subcutaneous tissue, superficial fascia with subcutaneous muscle and the second fascia of the neck are dissected. The muscle is retracted outwards (Fig. 57). The fiber and the sheath of the neurovascular bundle, which is formed by the parietal leaf of the fourth fascia, are bluntly stratified. The vessel is isolated and a ligature is brought under it on the Deschamps needle and then a ligation is performed. It must be remembered that the internal jugular vein (v. jugularis interna) is located outward from the common carotid artery, and the vagus nerve (n. vagus) is located between the vessels and behind them.
Ligation of the external and internal carotid arteries
(aa. carotis externa et interna)

For this operation, the same incision is used as for ligation of the common carotid artery (Fig. 57), only extended upwards from the hyoid bone. If we push the edges of the upper half of the wound with hooks and trace the trunk of the carotid artery upward, then at the level of the notch of the thyroid cartilage (incisura rhyreoidea) we get to the place of division. The latter is usually covered by a rather thick deep vein of the face (v. faciei profunda). If it lies just at the site of division, then in order to completely expose both trunks of the carotid artery, it has to be tied up in two places and cut between ligatures. From the place of division of the common carotid artery, the external carotid artery is directed inward and anteriorly. It is best recognized by the fact that immediately after division, it gives off several branches inward. The internal carotid artery goes deep and at first lies somewhat outward from the external carotid artery. Here, immediately above the place of division, both trunks can be tied up, and here, when they are exposed, it is necessary to dissect the common vagina.
Ligation of the common, internal and external carotid arteries is carried out no closer than 1 cm to the bifurcation site.
Despite the fact that ligation of the common and internal carotid arteries gives a large number of complications, until now, in order to stop bleeding, a ligature of vessels has been used.

Rice. 57. Exposure of the common and external carotid arteries.
1 - hypoglossal nerve; 2 - vagus nerve; 3 - internal jugular vein; 4 - deep cervical vein; 5 - descending branch of the hypoglossal nerve; 6 - sternocleidomastoid muscle; 7 - scapular-hyoid muscle; 8 - common carotid artery; 9 - thyroid gland; 10 - external carotid artery; 11 - superior thyroid artery; 12 - lingual nerve; 13 - digastric muscle.
Ligation of the lingual artery
(a. lingualis).

The large horn of the hyoid bone and the lower edge of the horizontal branch of the lower jaw are groped, and a slightly convex downward incision is made parallel to the latter by at least a transverse finger below the edge of the jaw and below the large horn of the hyoid bone. After dissection of the skin and subcutaneous muscle of the neck, the external jugular vein becomes visible in the posterior corner of the wound. The bottom of the wound stretched with hooks is formed by the submandibular gland covered with cervical fascia. After dissection of the cervical fascia, the gland is isolated along its entire lower circumference and pulled upward so that its excretory duct, which is directed into the depths, is tightly stretched. The digastric muscle and its tendon attachment to the hyoid bone are now clearly visible. The stylohyoid muscle (m. stylohyoideus) is immediately attached, passing along with the posterior belly of the digastric muscle. In the anterior corner of the wound, the jaw-hyoid muscle (m. mylohyoideus) extending from the hyoid bone to the lower jaw is stretched, which stands out especially clearly if the hyoid bone between the abdomens of the digastric muscle is grabbed with a thin sharp hook and pulled downward. Then the hypoglossal nerve (n. hypoglossus) is very clearly detected, running approximately parallel to the hyoid bone. This nerve lies directly on the hyoid-lingual muscle (m. hyoglossus), the longitudinally extending fibers of which serve as a background for the nerve passing here.
Within the described deep triangle of the neck, the fibers of the hyoid-lingual muscle are stupidly pushed apart with two anatomical tweezers and a transversely running artery is found under it and ligated (Fig. 58).

Rice. 58. Exposure of the lingual artery.
1 - subcutaneous muscle of the neck; 2 - jaw-hyoid muscle; 3 - hyoid-lingual muscle; 4 - lingual artery; 5 - digastric muscle; 6 - lingual vein; 7 - hypoglossal nerve; 8 - submandibular salivary gland.

Indications:

Wound of an artery or its large branches.

Traumatic aneurysm.

Preliminary stage in the removal of malignant tumors of the maxillofacial region (upper jaw, lower jaw, tongue), removal of metastases in the lymph nodes of the neck (Kraile operation), some benign tumors (arterial cavernous hemangiomas of the jaws and soft tissues of the maxillofacial region, huge adamantinomas of the lower jaws that have grown into the deep lateral parts of the face).

Position of the patient: on the back with a roller placed under the shoulders. The head is thrown back and slightly turned in the opposite direction.

Anesthesia- infiltration anesthesia with a 0.5% solution of novocaine with adrenaline, general anesthesia.

Operation steps:

An incision along the anterior edge of the sternocleidomastoid muscle from the level of the angle of the lower jaw to the level of the thyroid cartilage.

Dissection of the skin, subcutaneous tissue and subcutaneous muscle.

Ligation and intersection or retraction of the external jugular vein lying under the platysma in the upper section of the wound.

Opening along the grooved probe of the anterior wall of the vagina of the sternocleidomastoid muscle, releasing its anterior edge. After that, the muscle is pulled outward with a blunt hook. Dissect the posterior wall of the vagina. For orientation, a pulsation of the carotid artery is probed with a finger.

Stratification of the fiber and fascia that covers the vessels, the allocation of the common facial vein located above the carotid artery with venous trunks flowing into it. The vein is ligated and crossed.

Detection of a bifurcation and the external carotid artery departing from it at the level of the thyroid cartilage. The external carotid artery is recognized by the vessels departing from it. No vessels depart from the internal carotid artery.

Separation of the artery from the internal jugular vein and vagus nerve. The artery is ligated between the superior thyroid and lingual arteries. A thick silk ligature with a Duchamp needle is carefully brought under the artery from the side of the vein, leaving the vagus nerve aside.

When ligating an artery, it is more reliable to apply 2 ligatures to each end (especially to the central end).

INFECTIOUS-INFLAMMATORY COMPLICATIONS

With non-gunshot fractures of the jaws, three types of infectious and inflammatory complications should be distinguished: suppuration of soft tissues, suppuration of a bone wound, traumatic osteomyelitis.

Suppuration of soft tissues. The presence of a rich network of blood vessels and nerves in the area of ​​the jaws and the perimaxillary muscular sheath predetermines their frequent damage in gunshot and non-gunshot fractures. Therefore, jaw fractures are accompanied by bruises, rupture of soft tissues, in which hemorrhages occur. As a result of infection with hematomas, suppuration of soft tissues occurs. With late treatment of victims in medical institutions and inadequate therapy, abscesses and phlegmon of the maxillary tissues develop.

The clinical picture of soft tissue suppuration is characterized by an acute onset, the manifestation of local and general symptoms of inflammation (intense pain, infiltration and swelling of the maxillary tissues, skin hyperemia, fever, leukocytosis, increased ESR, etc.)

Suppuration of soft tissues with untimely treatment may be a factor predisposing to the development of traumatic osteomyelitis.

Suppuration of a bone wound- an inflammatory process localized only in the area of ​​the primary bone lesion, easily eliminated by draining the purulent focus. With suppuration of a bone wound, the main sign of traumatic osteomyelitis is absent - bone necrosis and sequestration do not occur. The duration of this period is 7-10 days.

When a bone wound suppurates, a limited inflammatory process usually occurs in the area of ​​the fracture. The mucous membrane of the alveolar process is often damaged, infiltrated, edematous, subperiosteal abscess is formed. Often there is swelling of the periorbital tissues. Removal of a tooth from the fracture gap, an incision at the site of the greatest infiltration of tissues, providing good drainage of the bone wound, usually leads to an abortive course of the inflammatory process.

With untimely and insufficiently active therapy, suppuration of a bone wound can transform into traumatic osteomyelitis.

Traumatic osteomyelitis- purulent-necrotic process in the zone of damage to the jaw, accompanied by bone necrosis with the formation of sequesters and regeneration bone tissue.

Traumatic osteomyelitis develops more often gradually, without a pronounced acute phase, if it was not preceded by suppuration of soft tissues. This feature of the course of the disease is due to the possibility of free outflow of wound discharge and purulent exudate from the area of ​​bone damage.

Initially, the clinical manifestations may be the same as with suppuration of a bone wound, but later in the area of ​​​​the surgical incision, the hole of the extracted tooth, in other areas of the skin or mucous membrane, a persistent fistula is formed, supported by a purulent-necrotic process in the bone and not prone to self-healing . Often, purulent discharge persists for many months after damage to the jaw.

X-rays are of great importance in the diagnosis of traumatic osteomyelitis of the jaws. Already on the 3rd week after the fracture of the jaw, limited foci of bone tissue destruction, small sequesters are formed. Repeated radiography reveals the growth of not only purulent-necrotic, but also reparative processes in the bone.

Based on clinical and radiological data, three forms of chronic traumatic osteomyelitis of the lower jaw are distinguished:

focal purulent-destructive process in the bone during the consolidation of fragments;

focal purulent-destructive process of wound surfaces of the bone without consolidation of fragments;

diffuse purulent-destructive process in the bone with the formation of large sequesters, without signs of fragment fusion.

Prevention of complications is:

in timely and correct delivery medical care sick. In case of jaw fractures, after repositioning of bone fragments, timely, reliable and sufficiently long-term immobilization of the jaw is necessary;

in deciding the "fate" of a tooth located in the fracture gap and surgical sanitation of the oral cavity. At the same time, they must be removed from the fracture line;

all teeth with complicated caries and with marginal periodontitis;

dislocated and broken teeth;

teeth and rudiments of teeth that interfere with the reposition of bone fragments.

All teeth remaining in the fracture line (intact teeth) are checked for pulp viability. If necessary, they are trepanated and sealed (often single-rooted) or removed. After removing the tooth from the fracture line, in the absence of purulent inflammation, the hole should be sutured tightly;

in meticulous oral care (oral hygiene). To this end, after each meal, the patient should use toothpicks and then rinse or irrigate the oral cavity with antiseptic solutions;

in the appointment of anti-inflammatory (antibacterial) therapy. It is only important that it does not replace other, the above methods of preventing inflammation;

in carrying out the whole complex of measures aimed at accelerating the regeneration of bone tissue (physiotherapy, physiotherapy, balanced diet, vitamin therapy, early functional loading, immunotherapy).

Traumatic sinusitis of the maxillary sinus develops with zygomatic-maxillary fractures, gunshot wounds of the upper jaw in those cases when, during the primary surgical treatment, a sinus revision is not performed with the subsequent removal of foreign bodies, bone fragments, hematomas from it with the obligatory imposition of an anastomosis in the lower nasal passage.

Salivary fistulas occur with non-gunshot and gunshot injuries of the salivary glands and their ducts. There are complete and incomplete salivary fistulas.

Ankylosis- persistent reduction of the jaws, caused by the fusion of the surface of the head of the lower jaw with the glenoid cavity of the temporal bone. According to the type of tissue that forms ankylosis, fibrous and bone are distinguished. The disease often occurs in childhood. But due to gunshot wounds of the maxillofacial region, fibrous ankylosis (articular contracture) can form. Treatment - surgical.

Persistent contracture of the masticatory muscles should be differentiated from unstable contractures, which are more correctly referred to as “jaw reduction”, which occurs when the masticatory muscles are involved in the inflammatory process. Contractures of masticatory muscles are also subdivided into extra-articular and articular, which should be differentiated from ankylosis of the lower jaw. Treatment of contractures is usually surgical.

Under false joint should be understood as an ununited fracture with persistent pathological mobility of fragments. A false joint occurs with imperfect reposition and immobilization of fragments of the lower jaw in cases of interposition of soft tissues, the lower alveolar nerve, in the event of traumatic osteomyelitis with extensive sequestration of bone tissue. Especially often, a false joint occurs with gunshot fractures of the lower jaw with extensive destruction of bone tissue and gunshot osteomyelitis. Treatment of a false joint of the lower jaw is surgical. In cases of large bone defects, bone grafting is used.

Dissertation abstractin medicine on the topic Clinical and functional aspects of ligation of the external carotid artery in tumors of the oropharyngeal zone

Gamilovskaya Yulia Vladimirovna

CLINICAL AND FUNCTIONAL ASPECTS OF LANGING THE EXTERNAL CAROTID ARTERY IN TUMORS OF THE OROPHARYNGEAL ZONE

14.00.04 - diseases of the ear, nose and throat 14.00.14 - oncology

Moscow - 2009

The work was done in the State educational institution higher professional education "Yaroslavl State Medical Academy of the Federal Agency for Health and Social Development" and at the Federal State Institution "Scientific - clinical center otorhinolaryngology" FMBA.

Scientific supervisors:

Official opponents:

doctor medical sciences, professor doctor of medical sciences, professor

Klochikhin Arkady Lvovich Trofimov Evgeny Ivanovich

Antoniv Vasily Fedorovich Reshetov Igor Vladimirovich

Leading organization: Moscow Regional Scientific Research Clinical Institute. M.F. Vladimirsky.

The defense will take place on March 31, 2009 at 13:00 at a meeting of the Council for the Defense of Doctoral and Candidate's Dissertations D208.059.01 at the Federal State Institution "Scientific and Clinical Center of Otorhinolaryngology" FMBA. Address: 123098, Moscow, st. Gamalei, 15, in the conference hall of the polyclinic of clinical hospital No. 86.

The dissertation can be found in the library of F1U "Scientific - Clinical Center of Otorhinolaryngology" FMBA.

Scientific Secretary of the Council for the Defense of Doctoral and Candidate's Dissertations, Doctor of Medical Sciences

E. M. Zelenkin

GENERAL DESCRIPTION OF WORK

Relevance of the problem

Malignant tumors in the head and neck region account for about 20% in the overall structure of oncological morbidity. Despite recent achievements in the diagnosis of neoplasms of the head and neck and carrying out activities aimed at identifying initial stages malignant neoplasms, including external localizations, 70 - 80% of patients are admitted for special treatment in III - IV stages of the disease. In this case, the treatment is combined or complex, and the operation is its main stage [Paches AI, 2000; Shah J., 2003].

One of the common stages of surgical treatment of such patients is the ligation of the external carotid artery in order to reduce blood loss during the operation and reduce the risk of bleeding in the postoperative period. However, a number of authors believe that with the radical removal of tumors of the oropharyngeal zone, bleeding can be controlled by ligation of vessels in the wound [Khodzhaev VG, 2000; Lyubaev B.JL, 2006; Ampil F., 2001].

There are many supporters of ligation of the external carotid artery on the side of the lesion during electrosurgical resections of the tongue and oropharynx. At the same time, in addition to a significant reduction in intraoperative blood loss, the reduction in the risk of delayed bleeding in the postoperative period is emphasized. Therefore, despite the introduction into practice of modern surgical technologies, such as a radio scalpel, a laser, ligation of the external carotid artery remains relevant [Kononuchenko V.P., 1967; Prokofiev V.E., 2004; Jahnke V., 1985; Ampil F.L., et al. 2001].

A thorough analysis of the literature showed that at present there is no consensus among physicians regarding possible influence external carotid artery to the blood supply to the brain and organ of vision. A number of authors believe that this vessel does not have any effect on these vital organs, so this operation can be successfully used in different categories of patients [Bragina LK, 1974; Anzola G.P., 2000].

carotid arteries, the influence of the external carotid artery in the blood supply to the brain and organ of vision is significant. This effect is enhanced with stenosis of the internal carotid artery, which greatly worsens functional state these organs during ligation of the external carotid artery and can lead to a number of serious consequences, such as: the development of ischemic cysts of the brain, the phenomena of transient amaurosis or retinal infarction [Zavgorodnyaya NG, 1997; Roen J.V., 2003; Stepanov O.P., 2006; Mcln-tyre K.E. et al., 1985; Feam S.J. et ah, 2000].

The question of the effect of ligation of the external carotid artery on the frequency of regional metastasis in patients with tumors of the oropharyngeal zone remains debatable. According to some authors, when applying ligation of the external carotid artery before starting radiation treatment tumor metastasis to the lymph nodes of the neck occurs less frequently [Hessen E.H., 1964]. However, there is also an opposite point of view, according to which operations on the main neurovascular bundle lead to traumatization of the regional lymph drainage pathways, which contributes to the development of metastases in the lymph nodes of the neck [Gremilov V.A., 1982; Duditskaya T.K., 1984; Tsentilo V.G., 2005].

The question of the time of onset of restoration of blood supply along the distal segment of the external carotid artery above the ligation site also remains relevant. In the available literature, we did not meet reports of possible recanalization through a section of the external carotid artery tied with two ligatures in the immediate and late postoperative period [Umrikhina ZA, 1963; Wacker A.B., 1965; Shotemore Sh.Sh. et al., 2001].

Thus, the analysis of the literature data showed the ambiguity of opinions on the advisability of performing the operation of ligation of the external carotid artery in head and neck surgery, which proves the necessity and timeliness of this study.

Purpose of the study

Improvement of functional and oncological results of treatment of patients with oropharyngeal cancer.

Research objectives

1. To identify possible changes in the brain according to ultrasound, transcranial duplex Dopplerography, electroencephalography, in the study of the neurological status and on the organ of vision by static quantitative perimetry in patients who underwent ligation of the external carotid artery.

4. To study the effect of external carotid artery ligation surgery on continued growth and recurrence of the primary tumor, regional and distant metastasis in patients with oropharyngeal cancer in the immediate and long-term period after surgical treatment.

5. To assess the feasibility of performing preventive ligation of the external carotid artery in patients with oropharyngeal cancer when planning radical treatment.

Scientific research

1. For the first time in a complex application modern techniques The effect of ligation of the external carotid artery on the functional state of the brain and organ of vision was studied.

2. Using Doppler ultrasound, the possibility of restoring blood flow in the distal segment of the external carotid artery above the ligation site was assessed.

3. For the first time, the effect of ligation of the external carotid artery on the degree of intraoperative blood loss, calculated by the formula for determining the volume of circulating blood during operations for oropharyngeal cancer, was determined.

4. The effect of ligation of the external carotid artery on the healing of a postoperative wound in the oropharynx, as well as on recurrence, regional and distant metastasis in patients with oropharyngeal cancer was studied.

5. The expediency of ligation of the external carotid artery in patients with tumors of the oropharyngeal zone during radical treatment was assessed.

Basic provisions for defense

1. Ligation of the external carotid artery will worsen the functional state of the brain and organ of vision, fixed by EEG readings, static and quantitative perimetry and in the study of neurological status in patients operated on for oropharyngeal cancer, while not affecting the oncological results of treatment.

2. Performing preventive ligation of the external carotid artery does not reduce intraoperative blood loss during radical surgery in patients with oropharyngeal cancer.

Practical significance

Refusal to perform preventive ligation of the external carotid artery in patients undergoing radical surgery for cancer of the oropharynx and oral cavity improves the functional results of this category of patients without changing the oncological results and reduces the duration of surgery.

Theoretical provisions and practical recommendations of the study can be used in the work of otorhinolaryngologists and oncologists. They can be included as educational material for students of medical universities and for the system of postgraduate professional education of doctors.

Thesis structure

The dissertation consists of an introduction, 4 chapters, conclusions, practical recommendations, a list of references, including 181 works, including 86 by foreign authors. The material is presented on 119 printed pages, contains 11 tables and 26 figures.

Work implementation

The main provisions of the dissertation have been introduced into the practice of the thoracic department (head-neck department) of the Yaroslavl Regional Clinical Oncology Hospital. They are used

when teaching students, interns and residents at the Department of ENT diseases and oncology of the Yaroslavl State medical academy.

The main provisions of the dissertation were presented at the international conference of young scientists - otorhinolaryngologists (ENT Research Institute, St. Petersburg, 2004), the All-Russian scientific and practical conference "New medical technologies in otorhinolaryngology" (Moscow, 2004), the Russian scientific - practical conference of young scientists of otorhinolaryngologists ( St. Petersburg, 2005), International Conference "Tumors of the Head and Neck" (Anapa, 2006), at the conference of young scientists of the Yaroslavl State Medical Academy (2007).

The work was performed at the Department of Otorhinolaryngology (Head - Doctor of Medical Sciences, Professor A.L. Klochikhin).

MAIN PROVISIONS OF THE WORK

Characteristics of clinical observations

The paper analyzes the results of treatment of 65 patients with advanced oropharyngeal cancer who were treated at the ENT clinic of the Yaroslavl Medical Academy on the basis of the head and neck tumor department of the regional clinical oncological hospital in the period from 2004 to 2007. All patients were aged 40 to 79 years.

All patients underwent radical antitumor treatment, as a rule, according to a combined or complex program. Radical surgery was the main component of special treatment. Depending on the characteristics of the surgical intervention, all patients were divided into two groups. The comparison group included 32 people who underwent preventive ligation of the external carotid artery. In patients of the main group (33 people), ligation of the external carotid artery was not performed. By gender, age, stage of cancer, the nature of metastatic lesions, the degree of tumor differentiation, concomitant pathology, as well as the volume and nature of surgical treatment, the compared groups are statistically comparable.

The study included patients with stages III and IV of oropharyngeal cancer, which corresponds to Ts^o-hMg according to the international classification. Metastasis to the lymph nodes of the neck

nostalgized with ultrasound, as well as on the basis of a puncture biopsy of the affected node under ultrasound control with further cytological confirmation of the diagnosis. According to the histological structure, keratinizing squamous cell carcinoma prevailed (57.1% - the main group; 52.5% - the comparison group), the non-keratinized form was present in 22.9% and 18.4 cases, respectively. The remaining patients (20% - the main group; 25% - the control group) had moderately differentiated squamous cell carcinoma. 53 patients (87%) were diagnosed with concomitant somatic pathology, including coronary heart disease, hypertonic disease, chronic bronchitis and other diseases of the main vital organs and systems.

Given the prevalence of the tumor, most patients, namely, 75% of patients in the comparison group and 84.8% of patients in the main group, received combined or complex antitumor treatment, which corresponds to modern standards treatment of patients with advanced oropharyngeal cancer. At the same time, 13 patients of the main group and 18 patients of the comparison group had radical surgical intervention on the primary focus, it was supplemented with a preventive or therapeutic operation on the lymphatic tracts of the neck: Crile's operation or sheath-fascial excision of the lymph nodes and tissue of the neck.

Research methods

All patients underwent a conventional clinical examination, including a detailed survey with the collection of patient complaints, anamnesis of the disease, examination of all JIOP - organs. Each patient underwent rigid endoscopy of all parts of the pharynx and nasal cavity with optical rhinoscopes "Azimuth", according to the indications, patients underwent fiber-optic endoscopy using a fibronaso-pharyngolaryngoscope of the company "Pentax" FNL - 15P2, a halogen illuminator "Pentax" LH - 150 PC. In addition, all patients underwent stomatopharyngoscopy using the Krasnogvardeets 1534 and Heine light sources. In doubtful cases, to determine the boundaries of the spread of the tumor, a fourfold magnification system was applied to the Krasnogvardeets 1534 illuminator. To assess the possible effect of ligation of the external carotid artery on the volume of blood loss in patients, the severity of intraoperative blood loss was calculated according to the formula of A.T. Staroverova with co-authors

(1979), which assesses the correlation between actual globular volume, hematocrit, hemoglobin, and patient weight.

GO fact. \u003d 11.08 + 0.615 Ht + 0.354 Hb -0.254Р, Where Ht is hematocrit in%, Hb is hemoglobin in g% P is the patient's weight in kg,

GO - actual globular volume in ml/kg, GO deficit = GO due - GO actual GO due = Body weight in kg x 40 ml/kg for men, or

Body weight in kg x 35 ml/kg for women, where 40 and 35 are the average normal values ​​of GO. If the globular volume deficit is up to 20% of the proper globular volume, then the blood loss is mild, not more than 500 ml. With a deficit of globular volume from 20% to 30%, blood loss is average, up to 1000 ml. With a globular volume deficit of more than 30%, severe blood loss, up to 1500 ml or more [Vilyansky MP, 1984].

To determine the possible effect of ligation of the external carotid artery on cerebral blood flow, the functions of the brain and the organ of vision, the following criteria were used: ultrasonic dopplerography of extracranial carotid arteries (USDG), electroencephalography (EEG), determination of visual fields by performing static quantitative perimetry. In addition, to evaluate the so-called "cerebro-cerebral" symptoms, we examined neurological status patients.

Statistical processing of the results of the study was carried out using the programs Microsoft Excel and Statistic 6.0. Shapiro-Wilk test was used to determine whether the obtained data obeyed the normal distribution law. With a normal distribution, the comparison of indicators was carried out using Student's t-test. In its absence, the nonparametric Kruskal-Wallis test was used at a significance level of differences within 0.05 (p<0,05) [Петри А., Сзбин К., 2003]. Проведен корреляционный анализ полученных результатов с определением силы связей с помощью коэффициента Спирмена (R).

RESULTS OF OUR RESEARCH AND THEIR DISCUSSION

Patients of the main group were not treated with ligation of the external carotid artery. Hemorrhage was stopped by ligation of vessels in the wound, as well as by bipolar coagulation.

In the study of blood loss in patients using the globular volume measurement formula, we considered it possible to divide the patients of the studied groups depending on the volume of the operation into three main subgroups, since these three options for surgical interventions were performed on patients. These subgroups are represented by: a) surgery on the primary lesion and ligation of the external carotid artery, b) surgery on the primary lesion with ligation of the external carotid artery and cervical lymphadenectomy, c) surgery on the primary lesion with ligation of the external carotid artery and cervical lymphadenectomy with reconstruction of the lower and / or the middle zone of the face with flaps with axial circulation.

When assessing blood loss in patients of the comparison group, the lowest values ​​of this indicator were noted in patients of the 1st subgroup, i.e. during surgery on the primary focus and ligation of the external carotid artery. Intraoperative blood loss in this category of patients was 282.5±35.2 ml. In the group of patients who, in addition to surgery on the primary lesion and ligation of the external carotid artery, underwent cervical lymphadenectomy, blood loss was 644.7 ± 45.5 ml. The greatest blood loss was observed in patients with the largest volume of surgery, namely, during surgery on the structures of the oral cavity and/or oropharynx with ligation of the external carotid artery, accompanied by cervical lymphodenectomy and reconstruction of the defect with a displaced musculoskeletal pectoral flap, and amounted to 850.2 ± 65.3 ml (p 0.05).

This fact is natural, since the stage of taking the flap from the chest is accompanied by bleeding from the edges of the resected muscle. The maximum volume of blood loss was no more than 1000 ml, which is moderate blood loss.

When assessing blood loss in patients of the main group, the same patterns were noted as in patients of the control group, namely, the lowest values ​​of this indicator were noted in patients of the 1st subgroup, i.e. during operations on the primary focus. Intraoperative blood loss in these patients was 302.5±.45.2 ml. In

In the second subgroup, namely, in patients after surgery on the primary focus and cervical lymphadenectomy, blood loss was 680.3±48.5 ml. Obviously, the greatest blood loss was observed in patients of the main group with the largest volume of surgery, namely, during surgery on the structures of the oral cavity and / or oropharynx, accompanied by cervical lymphadenectomy and reconstruction of the defect with a displaced pectoral musculoskeletal flap, and amounted to 861.2 ± 60, 3 ml (r<0,05), что иллюстрирует рис. 1.

blood loss, ml

Rice. 1. The volume of blood loss in patients of the studied groups.

The figures obtained correlate with the data obtained in the study of blood loss in patients of the control group. The maximum volume of blood loss in patients of the control group, as well as in patients of the main group, was no more than 1000 ml, which does not exceed blood loss of moderate severity. At the same time, there was no significant difference in the degree of blood loss in patients of both groups (p<0,05).

It should be noted that when conducting ultrasound Dopplerography of the vessels of the head and neck, 85% of patients in the control group and 78% of patients in the main group revealed concomitant pathology of the studied vessels of an atherosclerotic nature,

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types of transactions

1st subgroup 2nd subgroup 3rd subgroup

□ Control group

I am the main group

which is associated with the age characteristics of the study group of patients. At the same time, no hemodynamically significant vascular lesions were detected in patients at the preoperative stage.

When examining patients in the control group in the postoperative period by ultrasound examination of the vessels of the head and neck, an increase in the linear velocity of blood flow was revealed in almost all the main vessels of the neck and the main cerebral arteries. The most significantly increased blood flow velocity in the internal carotid artery, namely, from 48.7 cm/s to 56.7 cm/s, which amounted to 20.5% of the initial values. At the same time, the values ​​of blood flow velocity in the internal carotid artery slightly decreased during the year after the operation. However, we did not observe a complete recovery of the original values.

At the same time, there was an increase in the velocity of blood flow through the main vessels and from the opposite side, although to a much lesser extent. To a greater extent, the blood flow velocity increased in the common and external carotid arteries from the contralateral side. Only the blood flow through the anterior cerebral artery did not undergo significant dynamics. Natural, in our opinion, is the dynamics of the Purcelot index (III). The only significant increase in this indicator occurred in the internal carotid artery on the side of the ligation, which indicates an increase in the cross-sectional area of ​​the vessel and leads to hyperperfusion of the blood supply zone of this vessel.

It should be emphasized that the blood flow in the ligated external carotid artery was not located during all periods of observation in patients of the control group in the postoperative period. During the operation 1 year after the previous radical surgical intervention, accompanied by ligation of the external carotid artery, the old ligature was clearly visualized, while the blood flow distal to the dosing zone was not determined. Thus, we did not observe recanalization of the external carotid artery up to 1 year. We associate this fact with the use of a non-absorbable suture material such as lavsan or polyester when ligating this vessel.

The dynamics of the visual field often serves as an important criterion for assessing the course of the disease and the effectiveness of treatment, and also has a prognostic value. Identification of visual field disorders provides significant assistance in the topical diagnosis of the lesion.

of the brain due to characteristic visual field defects in case of damage to different parts of the visual pathway. Changes in the visual field in brain damage are often the only symptom on which topical diagnosis is based. The study of visual fields also provides significant assistance in the diagnosis of circulatory disorders of the main structures of the eyeball, such as the optic nerve and retina.

In this work, computer perimetry was performed in patients in the preoperative period and after surgery at 1, 6, and 12 months. Considering that ligation of the external carotid artery could indirectly affect the blood supply to such structures of the eyeball as the retina and optic nerve, we can assume the possibility of developing peripheral vision disorders.

Such violations are detected by computer perimetry in the form of narrowing of the peripheral boundaries of the visual field or the appearance of scotomas. In the control group, 15 patients with visual acuity of at least 0.03 with correction without concomitant ocular pathology were examined. According to computer perimetry performed in the early and late postoperative period, there were no visible changes in the visual fields of both eyes.

Only in two clinical cases, which accounted for 13.3% of cases, was the appearance of relative scotomas in the upper half of the visual field of both eyes in the early postoperative period, which did not manifest itself clinically. However, already 6 months after the operation, we observed a complete normalization of this indicator. To illustrate this fact, we present below the results of static perimetry in a patient with impaired visual fields after surgery accompanied by ligation of the external carotid artery.

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Rice. 2. Normal parameters of the study of visual fields in the patient before radical surgery with ligation of the external carotid artery.

Figure 2 shows the normal values ​​of static perimetry in a patient before surgery, accompanied by ligation of the external carotid artery. The study revealed only absolute scotomas corresponding to the anatomical zones of the exit of the optic nerve.

Rice. 3. Indicators of the study of visual fields in a patient on the 30th day after surgery, accompanied by ligation of the external carotid artery.

Figure 3 clearly shows visual field disturbances in a patient 1 month after surgery with ligation of the external carotid

artery. These changes were manifested by the appearance of relative scotomas in the upper parts of the visual fields, more on the side of the ligated external carotid artery, i.e. on right. The change in visual fields on the opposite side, in our opinion, is reflex in nature and does not have a functional effect on the organ of vision.

Rice. Fig. 4. Indicators of the study of visual fields in a patient 6 months after surgery, accompanied by ligation of the external carotid artery.

Figure 4 illustrates the normalization of static perimetry, while the presence of relative scotomas is not determined. Complete stabilization of the values ​​of the visual fields can also be traced a year after the operation.

Computer perimetry was performed in the patients of the main group in the preoperative period and after surgery at the same time as in the patients of the control group. In this group, 14 patients with visual acuity of at least 0.03 with correction without concomitant ocular pathology were examined. According to computer perimetry performed in the early and late postoperative period, there were no visible changes in the visual fields of both eyes, including even the absence of relative scotomas.

To assess the functional state of the brain, we used electroencephalography. Electroencephalogram - a curve obtained by registering fluctuations in electrical potential

ciala of the brain through the integument of the head. An indication for electroencephalography is vascular, dyscirculatory changes (assessment of the severity of disorders and the dynamics of restoration of brain function).

Electroencephalography revealed changes in three out of fifteen patients (20%) of the control group on the 30th day after the operation with ligation of the external carotid artery. These changes are characterized by an increase in diffuse changes in the bioelectrical activity of the brain and the appearance or increase in the amplitude of a peaked spindle-shaped alpha rhythm. Such changes completely disappeared six months after the study.

For the purpose of illustration, we present the types and characteristics of the patient's electroencephalograms, with EEG changes that appeared on the 30th day after surgery with ligation of the external carotid artery.

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Rice. 5. Normal EEG parameters in a patient of the control group before radical surgery.

Figure 5 shows the normal parameters of the electroencephalogram in a patient before the operation, accompanied by

by ligation of the external carotid artery. On the presented EEG, performed in the background recording, in response to afferent stimuli, moderately pronounced diffuse changes in the bioelectrical activity of the brain are determined according to the type of stimulation of the cortex with an emphasis on the fronto-central sections against the background of bursts of stem paroxysmal activity according to the type of interest of the hypothalamic-diencephalic structures. These changes are characterized as a variant of the norm.

Rice. Fig. 6. EEG parameters in a patient on the 30th day after radical surgery with ligation of the external carotid artery.

Figure 6 illustrates EEG changes in a patient one month after surgery with ligation of the external carotid artery. The increase in the bioelectrical activity of the brain is determined by the type of increase in the amplitude of biorhythms in the parietal regions, mainly due to the peaked spindle-shaped alpha rhythm. At the same time, single flashes of the spike type are asynchronously recorded in the frontal and central regions, without a tendency to increase in response to afferent stimuli. There is a suppression of the reaction of activation and assimilation of the rhythm. In comparison with the previous

The next study showed a pronounced asymmetry in the form of an appearance on the right, i.e. on the side of the ligation of the external carotid artery, pronounced paroxysmal activity with high-amplitude alpha-rhythm discharges in large numbers, generalized in areas in the right hemisphere.

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Rice. Fig. 7. EEG parameters in a patient 6 months after radical surgery with ligation of the external carotid artery.

However, the above-described changes in the patient's EEG were completely leveled by the sixth month after the operation, which is shown in Figure 7. A decrease in the bioelectrical activity of the brain is clearly seen in the form of a decrease in the amplitude of alpha rhythms. At the same time, it should be noted that the reactions of activation and assimilation of rhythms are enhanced.

When performing electroencephalography in patients of the main group, in contrast to the results of examination of patients in the control group, we did not reveal significant changes after a radical operation without ligation of the external carotid artery. In general, the bioelectrical activity of the brain remained in the pre-

affairs of the norm without the appearance or increase in the amplitude of the peaked spindle-shaped alpha rhythm.

Taking into account the fact that a violation of the main blood flow in the branches of the aorta can cause neurological disorders, we assessed the neurological status at the same time intervals as other methods of special examination of patients.

In patients in the early postoperative period, there was an increase in the intensity of headaches in the parietal-occipital region, more on the side of the operation. The dizziness detected before the operation increased, but there were no gait disturbances. Patients performed coordination tests satisfactorily. It should be emphasized that these disorders were transient and normalized by the sixth month after the operation.

In patients after ligation with the external carotid artery in the early postoperative period, there was a decrease in the sensitivity of half of the face corresponding to the side of the operation. However, these disturbances were transient. The sensitivity of the face was fully restored by the sixth month after the operation.

The highest mortality in patients of the control group was noted in the first year after treatment and amounted to a total of 10 patients (31.3%). At the same time, the vast majority of patients died from local recurrence - 5 clinical observations (15.6%), from regional metastasis - 1 patient (3.1%), one patient (3.1%) from generalization of the process with metastasis to the lungs , liver. Three patients (9.4%) died from concomitant diseases, 2 of them - from cardiovascular insufficiency (6.3%), 1 - from ischemic cerebrovascular accident (2.3%).

During the second year of follow-up, four patients (12.5%) died. Of these, 1 patient (3.1%) from local recurrence. Three patients died from other causes: one patient (3.1%) died from brain metastases, one patient (3.1%) from pneumonia, and one patient from pulmonary tuberculosis (3.1%), which is theoretically may be associated with adverse effects of external carotid ligation.

The lowest mortality rates were noted in the third year of observation. Only one patient (3.1%) died from a local recurrence.

Thus, out of 30 patients of the control group, followed up for more than three years, 16 people are alive, i.e. three-year survival was 46.7%. At the same time, 6 patients (18.8%) developed

local recurrences and metastases to the lymph nodes of the neck. All these patients were re-operated.

When evaluating the oncological results of treatment of patients of the main group, the following results were obtained. Within one year after treatment, we followed up 30 patients out of 33 patients. At the same time, 5 patients died during this period, which amounted to 16.7%. 2 patients (6.6%) died from local recurrence and continued tumor growth, 1 patient (3.3%) died from regional metastasis. Two patients (6.6%) died from concomitant diseases, of which 1 - from cardiovascular insufficiency (3.3%), 1 - from cerebrovascular accident of hemorrhagic type during the first week after surgery (3.3%).

Within two years, 14 patients were followed up, 3 patients died (21.4%). Of these, 2 patients (14.3%) from local recurrence. One patient (7.2%) died of acute cardiovascular failure.

Within three years, five patients were followed up, of which two (40%) died of relapse. One - from acute cerebrovascular accident (20%). Thus, among the patients of the main group, the three-year survival rate was 40%.

1. In patients with oropharyngeal cancer after a radical operation with ligation of the external carotid artery, transient functional brain disorders are possible, fixed during electroencephalography, neurological status examination. Also, after performing this operation, patients in 13.3% of cases had functional disorders of the organ of vision in the form of the appearance of relative scotomas, mainly on the side of the dressing, recorded by the method of static quantitative perimetry.

2. Ligation of the external carotid artery does not significantly affect the degree of intraoperative blood loss during radical surgery in patients with oropharyngeal cancer.

3. Ligation of the external carotid artery does not significantly affect the healing of the postoperative wound, as well as the frequency of postoperative complications.

4. Preventive ligation of the external carotid artery does not have a significant effect on the continued growth and recurrence of the primary tumor, regional and distant metastasis in patients with oropharyngeal cancer in the immediate and long-term period after surgical treatment.

5. When planning and performing a radical operation for oropharyngeal cancer, preventive ligation of the external carotid artery is not advisable.

The results of our research allow us to offer the following recommendations:

When performing radical operations in patients with cancer of the oropharynx and oral cavity, preventive ligation of the external carotid artery is not advisable, since in the postoperative period this leads to transient functional disorders of the brain and organ of vision, while the degree of intraoperative blood loss does not decrease. Also, ligation of the external carotid artery does not affect the oncological results, but objectively increases the duration of the surgical benefit in this severe category of patients.

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7. Modern clinical aspects of ligation of the external carotid artery in oropharyngeal cancer. // ready, for printing (Co-authors A.L. Klochikhin, E.I. Trofimov, E.M. Zelenkin).

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LIST OF ABBREVIATIONS.

INTRODUCTION

Chapter 1

CAROTID ARTERY (literature review).

1.1 Operation - ligation of the external carotid artery in the clinic, indications for it.

1.2 Side effects of ligation of the external carotid artery.

1.3 Summary.

Chapter 2. CHARACTERISTICS OF CLINICAL OBSERVATIONS,

METHODS OF TREATMENT AND EXAMINATION OF PATIENTS.

2.1 General characteristics of patients.

2.2 Characteristics of therapeutic measures.

2.2.1 The nature and technique of surgical intervention for oropharyngeal cancer with ligation of the external carotid artery.

2.2.2 The nature and technique of surgical intervention for oropharyngeal cancer without ligation of the external carotid artery.

2.3 Methods of examination of patients.

Chapter 3. TREATMENT OF PATIENTS WITH CANCER OF THE OROPHARYNGEAL REGION WITH THE APPLICATION OF LANGING OF THE EXTERNAL CAROTID ARTERY AS A STAGE OF RADICAL SURGICAL INTERVENTION.

Chapter 4. IMMEDIATE AND LONG-TERM RESULTS OF THE TREATMENT OF PATIENTS WITH CANCER OF THE OROPHARYNGEAL REGION WITH INTRAOPERATIVE LIGATING OF THE EXTERNAL CAROTID ARTERY AND WITHOUT PEREVY-YAZKA.

Dissertation Introductionon the topic "Oncology", Gamilovskaya, Yulia Vladimirovna, abstract

The urgency of the problem.

Malignant tumors in the head and neck region account for about 20% in the overall structure of oncological morbidity. Despite the latest advances in the diagnosis of head and neck tumors and the implementation of measures aimed at identifying the initial stages of malignant neoplasms, including external localizations, 70-80% of patients are admitted for special treatment in III-IV stages of the disease. In this case, the treatment is combined or complex, and the operation is its main stage [Paches AI, 2000; Shah J., 2003].

One of the common stages of surgical treatment of such patients is the ligation of the external carotid artery in order to reduce blood loss during the operation and reduce the risk of bleeding in the postoperative period. However, there is also a point of view according to which there is no need for ligation of this vessel during radical removal of tumors of the oropharyngeal zone, since bleeding can be controlled by ligation of vessels in the wound [Gremilov V.A., 1962; Wacker A.V., 1965; Khodzhaev V.G., 1978; 1983, 1997, 2000; Prokofiev V.E., 2004; Lyubaev V.L., 2006; Ampil F. L. et al., 2001; Shah J., 2003].

In the palliative treatment of patients with widespread tumors of the oropharyngeal zone, ligation of the external carotid artery is used as a prophylaxis for bleeding from a decaying tumor during radiation or chemotherapy [Zimont DI, 1953; Ogoltsova E.S., 1984; Kozlova A.V., 1971; Aleksandrov N.M., 1998; Sokolenko S.M., 2003].

At the same time, there are controversies regarding the possible effect of ligation of the external carotid artery on the state of the brain. So many authors deny the role of the external carotid artery in the blood supply to the brain and thus believe that it is possible to fearlessly ligate this artery even from 2 sides [Kozlova AV, 1971; Prokofiev V.E., Lebedev S.N., 2004; Martis S., 1978]. However, other researchers emphasize the significant role of the external carotid artery in the blood supply to the brain, which obviously increases with occlusion of the internal carotid artery [Stepanov O.P., 2006; Daihes N.A. et al., 2005; Mclntyre K.E. et al., 1985; Feam S J. et al., 2000].

The opinion of clinicians regarding the possible effect of ligation of the external carotid artery on the organ of vision is ambiguous. Some authors do not attach importance to the role of the external carotid artery in the blood supply to the organ of vision [Mayat G.E., 1968; Anzola G.P. et al., 2000]. At the same time, others, relying on anatomical information, emphasize the significant role of this vessel in the blood supply to the tissues of the orbit [Kuntsevich GI, 1992; Stepanov O.P., 2006; Mclntyre K.E. et al., 1985; Feam S.J. et al., 2000].

The question of the time of the onset of restoration of blood supply along the distal segment of the ECA above the ligation site also remains relevant. According to Umrikhina Z.A., with bilateral ECA ligation, tissue blood supply is restored in 30-45 days. According to Vakker A.V., with unilateral ligation of the ECA, blood supply to tissues is restored by 5-7 days, with bilateral ligation by 15-18 days. However, these studies were carried out on a small clinical material and using rather subjective methods. Therefore, we consider it necessary to evaluate the possibility of restoring blood flow along the ECA using modern methods of visualizing blood flow in the vessels. In the available literature, we did not find reports on the study of possible recanalization through the site of the ECA tied with two ligatures in the immediate and long-term postoperative period [Umrikhina Z.A., 1963; Wacker A.V., 1965; Shotemore Sh.Sh. et al., 2001].

In the literature available to us, there are different points of view on the effect of ligation of the external carotid artery on regional metastasis. Thus, according to the data of Ye.N. According to other authors, the ligation of this vessel, on the contrary, contributes to regional metastasis [Gremilov V.A., 1962; Duditskaya T.K., 1984; Centillo V.G., 1998]. The latter justify this by traumatizing the lymphatic outflow tracts during access for ECA ligation and the occurrence of implantation metastases in the intervention area. Given the above and different opinions of researchers on the issue of postoperative wound healing and distant metastasis, there is an urgent need to clarify a number of data on this issue.

Objective: Evaluation of the effectiveness of ligation of the external carotid artery in patients with oropharyngeal cancer.

Research objectives:

1. To study possible changes in the brain according to ultrasound, transcranial duplex Doppler, electroencephalography, in the study of neurological status and on the organ of vision by static quantitative perimetry in patients who underwent ligation of the external carotid artery.

2. To assess the possible effect of ligation of the external carotid artery on the degree of intraoperative blood loss in patients with oropharyngeal cancer.

3. To study the possible effect of ligation of the external carotid artery on postoperative wound healing and the incidence of postoperative complications.

4. To study the effect of ECA ligation on continued growth and recurrence of the primary tumor, regional and distant metastasis in patients with oropharyngeal cancer in the immediate and long-term period after surgical treatment.

5. To study the feasibility of ECA ligation in patients with oropharyngeal cancer when planning radical treatment.

Scientific novelty: For the first time, the effect of ligation of the external carotid artery on the functional state of the brain and organ of vision was studied in a comprehensive manner using modern techniques.

The possibility of restoring blood flow in the distal segment of the ECA above the ligation site was assessed using Doppler ultrasound technique.

For the first time, the effect of ECA ligation on the degree of intraoperative blood loss, calculated by the formula for determining the volume of circulating blood during operations for cancer of the oropharynx and oral cavity, was determined.

The effect of ligation of the external carotid artery on the healing of a postoperative wound in the oral cavity and oropharynx, as well as on recurrence, regional and distant metastasis in patients with oropharyngeal cancer was studied.

The expediency of ligation of the external carotid artery in patients with oropharyngeal cancer during radical treatment was assessed.

Provisions for defense: 1) Ligation of the external carotid artery worsens the functional state of the brain and organ of vision, fixed by EEG readings, static quantitative perimetry and in the study of neurological status in patients operated on for oropharyngeal cancer, while not affecting the oncological results of treatment .

3) Performing preventive ligation of the external carotid artery does not reduce intraoperative blood loss during radical surgery in patients with oropharyngeal cancer.

Practical significance: Refusal to perform preventive ligation of the external carotid artery in patients undergoing radical surgery for cancer of the oropharynx and oral cavity improves the functional results of treatment of this category of patients without changing the oncological results and reduces the duration of surgery.

Implementation of the results: The results of the study were implemented in the clinic of the Yaroslavl Oncological Center "Head-Neck" on the basis of the Yaroslavl Regional Clinical Oncological Hospital, the Department of Otorhinolaryngology of the Yaroslavl State Medical Academy. The dissertation materials are used in the educational process when conducting practical classes, seminars, lecturing at the Department of Otorhinolaryngology of the Yaroslavl State Medical Academy, conducting advanced training courses for otorhinolaryngologists and oncologists.

The work was carried out at the Department of Otorhinolaryngology (Head - Doctor of Medical Sciences, Professor A.JI. Klochikhin), supervisors - Doctor of Medical Sciences, Professor A.JI. Klochikhin, Doctor of Medical Sciences, Professor E.I. Trofimov.

Conclusion of the dissertation researchon the topic "Clinical and functional aspects of ligation of the external carotid artery in tumors of the oropharyngeal zone"

1. In patients with oropharyngeal cancer after a radical operation with ligation of the external carotid artery, transient functional brain disorders are possible, fixed during electroencephalography, neurological status examination. Also, after performing this operation, patients in 13.3% of cases had functional disorders of the organ of vision in the form of the appearance of relative scotomas, mainly on the side of the dressing, recorded by the method of static quantitative perimetry.

2. Ligation of the external carotid artery does not significantly affect the degree of intraoperative blood loss during radical surgery in patients with oropharyngeal cancer.

3. Ligation of the external carotid artery does not significantly affect the healing of the postoperative wound, as well as on. the frequency of postoperative complications.

4. Ligation of the external carotid artery does not have a significant effect on the continued growth and recurrence of the primary tumor, regional and distant metastasis in patients with oropharyngeal cancer in the immediate and long-term period after surgical treatment.

5. Refusal to ligate the external carotid artery during radical operations in patients with oropharyngeal cancer preserves the functional state of the brain and organ of vision.

1. When performing radical operations in patients with oropharyngeal cancer, ligation of the external carotid artery worsens the functional parameters of the brain and organ of vision, while the degree of intraoperative blood loss does not decrease.

2. Ligation of the external carotid artery does not affect the oncological results, but objectively increases the duration of the surgical intervention in patients of this severe category of patients.

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