Ministry of health of Ukraine
Congenital cysts light, hypoplastic lungs. Congenital partial emphysema
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Congenital cysts light, hypoplastic lungs. Congenital partial emphysema. 1.Actualness of topic. Congenital malformations of the respiratory system in children is one of the most difficult problems of modern children's pulmonology. Congenital defects of the respiratory system often is the basis for chronic nonspecific inflammatory bronchopulmonary diseases. Over the last decade there has been growth of lung diseases, including the fate of congenital malformations accounted 9,7-34,1% of cases, and 5% of them require surgical treatment of the causes of these anomalies. Despite the large number of studies of lung hypoplasia, lifetime diagnosis of up to 80%. Lung cysts in children are from 3.5 to 5.5% of the total number of patients with nonspecific lung diseases. Chastist complications that arise in this pathology, necessitating knowledge malformations of respiratory system. 2. Specific objectives: 1. To analyze the frequency and structure of congenital lung cysts, hypoplastic lungs, partial emphysema in children. 2. Classify congenital lung cysts, hypoplastic lungs, partial emphysema. 3. Master the embriopatohenez congenital cystic lung hypoplasia pulmonary emphysema lobarnoyi. 4. Recognize the major symptoms of congenital cystic pulmonary hypoplasia pulmonary emphysema lobarnoyi in children. 5. Develop the skills of physical examination of the patient: inspection, palpation and other clinical examination of patients with impaired lung development. 6. Propose and justify methods for diagnosis of congenital lung cysts, hypoplastic lungs, partial emphysema in children. 7. Interpret auxiliary diagnostic methods (laboratory tests, ultrasound, x-ray). 8. Differentiate defects depending on the clinic. 9. Identify indications for conservative and surgical treatment of this pathology. 10. Offer medical tactic in the presence of defects of the lungs. 11. Formulate a complete clinical diagnosis, according to the classification of the disease. 12. To interpret the general principles of treatment of malformations. 13. Establish psychological contact with patients and parents to improve preparedness for treatment (including surgery) and awareness of the negative consequences of the disease in the event of failure of medical advice. 4.2 Theoretical question for the class: 1. Define the concept of malformations of respiratory system, classification and location hypoplastic lungs, lung cysts, congenital emphysema lobarnoyi in this structure. 2. Master the classification of malformations of the lung. 3. Embriopatohenez malformation of the lung. 4. Classification of congenital lung cysts. 5. Classification of partial congenital emphysema. 6. The main clinical symptoms malformations of respiratory system. 7. Symptomatology malformation of the lungs. 8. The main clinical symptoms of partial congenital emphysema. 9. Methods of diagnosis of pulmonary hypoplasia. 10. Methods for diagnosing congenital partial emphysema. 11. Differential diagnosis of lung malformations in children. 12. Differential diagnosis of congenital emphysema partial 13. Indications for surgical treatment of malformations of the lung, congenital partial emphysema 14. Major surgery with malformation of the lungs. 15. Surgical treatment of congenital partial emphysema. 16. Forecast treat lung malformations in children. 4.3 Practical tasks used in class. 1. Installing psychological contact with patients, parents. Compilation of complaints, history of life and disease. 2. The Plan examination of the patient with hypoplasia of the pulmonary cysts pulmonary emphysema lobarnoyu. 3. Examination of the patient with congenital pulmonary cysts, hypoplasia of pulmonary emphysema lobarnoyu: inspection, palpation, percussion, auscultation. 4. Mounting system for drainage of the chest cavity. 5. Interpretation of the data X-ray, CT research and study of the diagnosis. 6. Definition of indications and contraindications to conservative or operative treatment of malformations of respiratory system. 7. The Plan preoperative preparation of the patient with congenital pulmonary cysts, hypoplasia of pulmonary emphysema lobarnoyu 8. Demonstration video scenes surgeries in this pathology. 9. The Plan postoperative management of patients with congenital cysts pulmonary hypoplasia pulmonary emphysema lobarnoyu. 10. Propose a plan of rehabilitation after surgery, performed in connection with developmental disabilities. Contents subject. Pulmonary hypoplasia Pulmonary hypoplasia is the underdevelopment of all elements of the lung structures (bronchi, blood vessels and lung parenchyma). Major and equity bronchi ending functionally imperfect rudiments. Pulmonary hypoplasia is associated with impaired formation of primary buds. Primary laryngeal-tracheal outgrowth appears on four Sundays development (Figure 1). First, it has a round shape and connects the ventral-caudal part of the pharynx. At the distal end there are two outgrowths thickening, called lung buds. Endo buds that make up part of the tab Broch and parenchymal lung start their development within the parenchyma that surrounds them and forms the stroma of lung dolok, cartilaginous plates, smooth muscle and connective tissue. Stages of formation of the bronchial tree presented in Figure 1-5. The Newborn. Stopping of laryngeal-tracheal germ causes lung aplasia. Stop the development of one of the kidneys leads to the development of unilateral aplasia (Fig. 6). The reason hypoplasia (Fig.7), light may be a violation of embryogenesis at each posliduyuschyh stages (Figure 2, 3, 4). Considering that cystic lung hypoplasia (Fig. 8) often appears as a result of stopping development phase digit branching bronchial tree branches after 05.04 order. Formation of solitary cysts (Fig. 10), and lobarnoyi emphysema (Fig. 9) also appears as a result of water forming lung tissue. Unlike previous states they may not show up immediately after birth, so that their display to a term pulmonary respiration. In the pathogenesis hipoplaziy combined impaired bronchial patency, supporting lung tissue hypoxia and desolation pulmonary vasculature, accompanied by bronchitis and obstructive emphysema development. Pathogenesis of pulmonary hypoplasia is closely associated with the occurrence of congenital diaphragmatic hernia. Simple pulmonary hypoplasia (PGL) (at NO Putov) is characterized by a uniform reduction in lung volume reduction by bronchial tree. The lumen is narrowed bronchi, lung volume (split) decreased, blood supply depleted. These changes are confirmed Bronhografiya - revealed deformation and convergence bronchi may be moderate their expansion. Hipoplazovana fate characterized by pallor and "doughy" consistency. Cystic lung hypoplasia (KGL) - decrease volume or absence of lung parenchyma in the affected areas, while expanding cystic segmental or subsegmental bronchi. II Platov (1971) identifies two types of cystic hypoplasia: a) with hypoplasia of the pulmonary parenchyma and cystic changes of the bronchi; b) with hypoplasia of the bronchi and cystic lesions of the lung. This form is called polycystic and usually observed in older children and adult patients. Pulmonary hypoplasia can be combined with other disabilities: diaphragm hernia defects of the skeletal system, urinary tract, heart, central nervous system, the digestive system. Clinical manifestations of PGL and KGL depend mainly on the amount of underdeveloped lungs and accession infection. Possible asymptomatic course hipoplaziy. Very often for extended periods observed respiratory syndrome in children, due to bronchitis, acute respiratory infections, pneumonia. Children behind in physical development, complaining of chest pain. When viewed noteworthy deformity of the chest retraction of her side of the process. In many cases marked acrocyanosis and "drumsticks." Joining infection leads to the formation of so-called secondary chronic pneumonia. Children complain of cough with discharge of purulent sputum, low-grade fever. During physical research methods appears the following changes. Auscultation listen weakened breathing or lack of it over the affected area, dry, wet and mixed wheezing. Myocardial dysfunction mainly exchange character. Sometimes meet hypertrophy of the heart, myocardial degeneration, pulmonary heart. In the diagnosis of pulmonary hipoplaziy crucial renthenobronholohichni methods. Optimal timing of bronchographic survey in all age groups is the period of sustained remission. In simple hypoplasia characteristic is to reduce the volume of the chest on the affected side with heavy shading in the area marked high standing dome diaphragm, lung volume reduction, depending on the amount of damage. Heart and mediastinal organs are biased towards underdeveloped lungs may prolapse healthy lungs through the anterior mediastinum into the second half of the chest ("pulmonary hernia"). Identify changes in the root of the lungs - its expansion and loss of definition of anatomical elements, which are caused by blood circulation and lymph circulation due to inflammation, characterized by abdominal lesions, depletion of pulmonary pattern, narrowing of the intercostal spaces. Common signs of lung malformations include bronchoconstriction I-II procedure bronchiectasis IV-V order, absence or drastic reduction of peripheral bronchi. Therefore, when Bronhografiya filled large bronchi, shallow bronchial branching absent. In polycystic radiological picture is visualized in the form of tender, explicit prosvitlin the background unchanged lung tissue, it resembles honeycomb. Depending on the presence of acute inflammation, transparency sick lungs can be reduced, cystic cavities in the parenchyma may have fluid levels. In bronhohramah displays rounded cavity, similar to grapes, bronchiectasis and deforming bronchitis in patients who underwent pyo-inflammatory exacerbation with a progressive course. Survey bronchoscopy defines catarrhal catarrhal-purulent, purulent endobronchites. The degree of ventilation depends on the activity of inflammation and worsening of bronchial patency. The method of treatment depends on the lesion, presence of complications, the characteristics of the disease, pulmonary function status respiration. Conservative treatment is more common in children with unilateral lesions within the fate in the absence of secondary changes and recurrent course of disease. Along with medication and antibacterial therapy are important Sanatsiyno bronchoscopy. Along with conservative methods used and surgical treatment. Thus the question of whether the operation is decided depending on the nature of the defects, the volume of lesions, severity of lung infection, the functional state of the lungs and cardiovascular system, compensatory ability of pulmonary respiration and pulmonary circulation, results of examinations of other organs and systems. Setting developmental disorders or functions associated with the risk of the next surgery. Absolute indications for surgical treatment are local and mosaic forms of lesion volume defects up to 12 segments with progressive recurrent pyo-inflammatory type of course. The operation is performed outside the aggravation phase, 1-2 months after and 1-2 weeks after bronchographic survey. Angiographic examination is essential to the time of the transaction. Surgical treatment is contraindicated in bilateral lesions (up to 12-15 segments) in severe respiratory failure, pulmonary hypertension, the evils and diseases of other organs (heart, kidney, liver, and malignant formations and diseases of the CNS, blood). Method of surgical treatment depends on the amount of damage. Typical anatomical resection of the affected lung zones apply if damage is localized within the fate of two fractions or whole lung. Economical (atypical) resection of the affected area is shown at local and mosaic lesions. Segmental resection of lung indicated for cavitary formations established as within the bronchus and parenchyma in segment. Combined resection should be performed to patients who had lesions along with one or two fractions cavity formation in the adjacent areas of the lungs. When saving and combined operations stored pneumatization plays a positive role in preventing inflection left bronchus and filling the remaining volume of the chest cavity. Postoperative complications in the treatment of HL: sputum bronchial obstruction, empyema, pleural cavity, suppurating wounds, pneumonia, acute cardiovascular failure. Congenital lung cysts Their emergence is associated with impaired development of the bronchi and alveoli in the prenatal period. If it occurs in the early stages of embryogenesis, then there are rare cysts of large size, and in later periods - multiple, small, called polycystic lungs. Their formation promotes growth properly developed bronchial rudiments of mechanical stretching their accumulated ¬ vanym mucus. The inner surface is covered with a cyst epithelium and in the leg sometimes find items and bronchial smooth muscle fibers. Congenital bronchogenic cyst on location may be central or peripheral. The central cyst sometimes combined with bronchus. Cysts can be filled with air or fluid. The clinical course distinguish between uncomplicated and complicated cysts. Uncomplicated congenital cysts from asymptomatic pe ¬ rebihom usually found accidentally during radiologist ¬ tion is very poorly research. These cysts must be differentiated from those Nabu ¬ air cysts and lung abscesses that occur after acute purulent destructive pneumonia. Such cysts after 6 months appears epi ¬ telialna pad, clinically and radiologically they differ ¬ ing to birth. In such cases, helps conduct morphological studies. Complications of congenital cysts are distributed as follows: suppurating cyst - 60%, tense cyst - 20% breakthrough player ¬ vralnu cavity 5%. At cysts from asymptomatic falls 15%. Suppuration cysts occur at any age and is accompanied by deterioration of general condition, improving ¬ tion of body temperature to high numbers, intoxication, fever, leukocytosis. On radiographs (Fig.12) show a circular cavity with fluid level. On CT scan clearly defined CBSA ¬ la cysts no perifocal inflammatory reaction that helps to distinguish congenital cyst of abscess in intrapulmonary form HHDP. Paraezofahealni diaphragmatic hernia in which part of the stomach is in the chest cavity and during the X-ray detected in a cavity with fluid level can stimulate picture suppurating cyst. In such cases it is necessary to conduct radiological investigations ¬ tion of contrast medium. Diagnostic puncture does not hold in order to prevent infection of the pleural cavity. In that same volume of research conducted in the case of polycystic lung for suspected cell picture of intestinal loops with left-sided diaphragmatic hernia.
Clinic. When screening children exhibit lag part of the chest in breathing on the affected side. Percussion over the lung field is determined tympanitis, borders shifted heart in a healthy way. These objective studies do not allow to exclude pneumothorax busy, but during radiologic studies reveal the contours of the cysts, sometimes a presence of membranes. Tense pneumothorax is a pulmonary ¬ hydrogen pleural form of acute purulent destruction of the lungs with prolonged severe and severe intoxication. Differential diagnosis. Strained lung cyst must be distinguished from congenital partial emphysema, which is characterized radiographically depletion pulmonary pattern, increased transparency pulmonary parenchyma, often in the region of the upper lobe of the left lung and severe mediastinal shift and flattening of the dome of the diaphragm. Break complicated cysts leads to pneumothorax, or piotoraksu pneumoempyema. Differential diagnosis of pulmonary pleural forms HHDP in this case is difficult. Therefore necessary to consider the history, clinical course of the disease. Treatment of congenital cysts with surgery alone after diagnosis. If a hard cyst before operation shown holding puncture and drainage of the cyst to reduce intrathoracic pressure. The volume of surgical interventions determined by the size and distribution of cystic formation. When cysts do tsystoektomiyu small diameter, medium - segmental resection of the lung, and if the cyst diameter exceeds the transverse size air lobe, lobectomy shows, sometimes with resection reed segments of the lungs. Congenital partial emphysema. The emergence of this rare congenital valve associated with the presence of the bronchi due to underdevelopment of cartilaginous rings or hypertrophy of the mucous membrane of the bronchus or its stenosis. Pathomorphological studies reveal smooth muscle aplasia of terminal respiratory bronchioles lack of intermediate generations of small bronchi or aplasia of all respiratory lobe with having mikropolikistozu. All this leads to disruption of the elastic properties of the lungs. Obstructive bronchial compression factor is abnormally located vessels - arterial duct, ligament or enlarged vein. Clinic lobarnoyi congenital emphysema depends on the performance of intrathoracic pressure and shift of the mediastinum. According to clinical manifestations and terms of partial congenital emphysema divided into asthma, subcompensated and compensated form. Clinically, asthma, or acute localized congenital emphysema seen in infants in the first days of life. It is characterized by classic symptoms syndrome intrapulmonary tension: acute progressive respiratory failure, increasing shortness of breath, bouts of coughing and cyanosis, tachycardia. Children are restless, body position forced on the patient side, while there is breath involvement mizhrebrovyh intervals, drink ¬ ment of the affected part of the chest, its lag in breathing. Bodies mediastinum shifted sharply to the healthy side, percussion - on the affected side tympanitis, auscultatory - breaths ¬ tion is missing. On radiographs (Mal.14.) Determine the enhanced transparency pulmonary pattern on the affected side, showing eclipse triangular adjacent to mediastinum and caused by di ¬ Leanca ousted, kolabovanoyi pulmonary parenchyma. The dome diaphragm flattened. The affected lobe in healthy prolabiruyut ¬ tion toward the formation mezhystynalnoyi hernia. For subcompensated form clinical signs appear aged 1-3 months, gradually increase respiratory disorders, but assaults ¬ dy intermittent cyanosis. Radiological findings show greater transparency and lack of pulmonary pattern, along with bloated lobe visible shadow kolabovanoyi healthy share, a moderate shift of the mediastinum. Compensated form seen in children older than 1 year, when emerging infectious diseases or flu. During exercise there is an easy and fast dyspnea vtomlyuva ¬ ness. Children behind in physical development, the affected part of the chest explodes, maybe scoliosis. Localized congenital emphysema may have accidentally discovered during fluorography or radiological examination. The differential diagnosis of pneumothorax hold tight, tense cyst lungs, diaphragm hernia, emphysema due to the presence of foreign bodies in the bronchi, emphysema compensated with pneumonia. Additional methods used bronchoscopy, Bronhografiya especially when compensated forms of congenital localized emphysema. Computed tomography (CT) is used in certain cases where a simple and minimally invasive methods are not informative for diagnosis. Treatment of acute localized congenital emphysema neonatal surgery. A must is to determine the ventilation-perfusion parameters. Shown urgent thoracotomy, removal of the affected lobe. Segmental resection of the lung may, if necessary, combined with the removal of the vascular component anomalies (intersection arterial duct or ligament). If the conditions and experience of the surgeon not guarantee adequate safety radio operators ¬, then reduce growing tension can intrapulmonary through bronchoscopy and temporary occlusion of the affected lobe bronchus seal. Radical surgery performed with perednobichnoho access the fifth mizhrebrovomu gap. Autopsy pleural cavity spend cautiously because pereroztyahnena parenchyma affected lobe may suffer damage. The operation is complicated by the fact that the inflated lobe occupies the entire pleural cavity and prevent manipulation ¬ modulation at the root of the lung. When subcompensated form urgency of surgery determined by the patient, with the compensated form of operation is performed routinely. Materials for self-control. Situational tasks: Task 1. In newborn patient's condition heavy, wheezing, breathing left sharply weakened, percussion - box sound. In plain film chest - left lung tissue increased transparency with subtle pulmonary picture. Moderate mediastinal shift to the right. In the lower part of the left - a triangular shadow adjacent to the shadow of the heart. 1. Your diagnosis? 2. What form of the disease? 3. Surgical tactics of another doctor. Task 2. The child's first year of life when tested on bronhohrami on the background of increasing transparency of lung tissue are thinned, vidryvchasti upper lobe bronchi and reed segments thickened, collected tassel bronchi of the lower lobe. 1. What kind of pathology talking about? 2. What diseases should conduct a differential diagnosis? 3. Tactics treatment. Problem 3. The child's first year, amid complete clinical care, X-ray examination of the lungs revealed cystic formation up to 1 cm in diameter. Condition is satisfactory, no respiratory distress. 1. Your diagnosis? 2. What is your tactic? 3. What diseases should conduct a differential diagnosis? Problem 4. In newborn patient's condition heavy, growing signs of respiratory failure: dyspnea, respiratory left sharply weakened, percussion - box sound. In plain film chest - left lung tissue increased transparency with subtle pulmonary picture. Moderate mediastinal shift to the right. Exhibited diagnosed congenital lobarna emphysema. 1. What surgical tactics? 2. What form of the disease? 3. What diseases have to conduct a differential diagnosis? Problem 5. In children 1 year the patient's condition moderate moderately severe respiratory failure: dyspnea, respiratory left weakened, percussion - box sound. In plain film chest - left lung tissue increased transparency with subtle pulmonary picture. In the lower part of the left - a triangular shadow adjacent to the shadow of the heart. The diagnosis: congenital lobarna emphysema. Displaying radical surgery. 1. How much surgery? 2. What form lobarnoyi emphysema? 3. What time of surgery? Problem 6. In the two-year boy in X-ray examination revealed the top share of the right lung cyst formation up to 5 cm in diameter, without signs of inflammation. When examining the control dynamics absent. Condition is satisfactory, no respiratory distress. 1. What kind of pathology talking about? 2. What time of surgery? 3. How much surgery? Problem 7.V boy 6 years old within two years after the parents refused surgical treatment, X-ray examination revealed the top share of the right lung rounded education to 9cm in diameter with a fluid level. Severe inflammation: fever to 39oS, shortness of breath, respiratory failure. Upon further examination confirmed the diagnosis: congenital cyst upper-lobe of the right lung, with difficulty. Condition heavy. 1. What complication cysts arose in this case? 2. What time of surgery? 3. How much surgery? Task 8. A child of 3 days after birth severe respiratory failure. Examination revealed syndrome intrapulmonary tension on the left, while crying child rozovishaye. Established diagnosis of congenital emphysema lobarna left. 1. What is the fate of this pathology is most often affected? 2. Timing of surgery? 3. Volume surgery? Problem 9. The child is 5 months in the survey revealed: in the middle of fate right lung rounded cystic formation, with effects of inflammation. The patient's condition was satisfactory. Respiratory disorders have been identified. 1. What kind of pathology should consider? 2. What complication cysts most likely? 3. What medical tactics? Problem 10.U children aged 1 year marked by a protracted course of pneumonia. According Review radiographs of the chest-enhanced pnevmotyzatsiya lung, mediastinal shift to the right lower lobe atelectasis left. 1. What is the likely diagnosis? 2. What medical tactics? 3. Volume surgery? Tests:
A. Surgical B. Clinical observation S. Surgical treatment is contraindicated D. Conservative treatment E. spa treatment 2. Newborn in distress syndrome with respiratory failure in children hospitalized surgical department. An examination of the diagnosis: congenital lobarna emphysema. The method of treatment for congenital emphysema lobarniy are: A. expectantly tactics V. Conservative treatment C. Radical surgery D. Puncture formation E. Thoracostomy 3. The boy 3 months of the survey diagnosed congenital lung cyst, complications and stress subplevralno located within a single segment. What is expedient to perform the operation in this case? A. lobectomy V. Cystectomy S. pulmonectomy D. Segmentectomy E. Marsupializatsiyu cysts 4. In infants with respiratory distress syndrome diagnosed congenital lobarnu emphysema. After preoperative preparation performed surgery - lobectomy. The most common complication after this operation are: A. Suppuration wound B. Prolonged malignant hyperthermia S. Pneumothorax, residual pleural cavity, atelectasis, pneumonia D. Deformation of the chest E. pleural effusion, empyema, hemothorax 5. In infants with a syndrome of respiratory disorders after a survey revealed: congenital upper-lobe emphysema lobarnu left lung. The most frequent localization lobarnoyi congenital emphysema are: A. upper lobe of the right lung B. The upper lobe of the left lung C. The lower lobe of right lung D. The lower lobe of the left lung E. The average share of the right lung 6. As a boy of 4 months, received by the surgical hospital for examination detected syndrome intrathoracic tension left. Which of these anomalies does not lead to the syndrome of intrathoracic tension? A. Lobarna emphysema V. lung cyst C. This diaphragm hernia D. False diaphragm hernia E. Agenesis lungs 7. Newborn found: not pronounced respiratory syndrome disorders. The examination found: partly straightened plot lungs. When there is a complete smoothing of the lungs after birth in newborns? A. Immediately C. After 1 hour C. After 6 hours D. A day E. Within a few days 8. A child of 3 days after birth severe respiratory failure. Examination revealed syndrome intrapulmonary tension on the left, while crying child rozovishaye. Most likely diagnosis: A. diaphragm hernia V. Atresia choanae C. Cyst lungs D. Lobarna emphysema E. Pneumothorax 9. In children 6 months showed symptoms of respiratory failure. The examination revealed: congenital lung cyst complicated by stress and subplevralno located within a single segment. What kind of operation is expedient to perform this child? A. lobectomy V. Cystectomy S. pulmonectomy D. Segmentectomy E. Marsupializatsiyu cysts 10. In the surgical ward hospitalized boy 3 years old with severe respiratory failure. After examination the diagnosis: congenital cyst intense upper-lobe of the right lung. What type of treatment indicated the child? A. Radical surgery V. Conservative treatment S. puncture the cyst D. Draining the cyst E. expectantly tactics List of theoretical issues. 1. Classification of pulmonary hypoplasia. 2. Embryogenesis lungs. 3. The main clinical symptoms of pulmonary hypoplasia. 4. Methods of diagnosis of pulmonary hypoplasia. 5. Differential diagnosis of pulmonary hypoplasia 6. Surgical management of pulmonary hypoplasia 7. Methods of surgical interventions in hypoplastic lungs. 8. Classification of congenital lung cysts. 9. The main clinical symptoms of congenital lung cysts. 10. Diagnosis of congenital lung cysts. 11. Differential diagnosis of congenital lung cysts. 12. Type of anesthesia during surgical intervention. 13. Methods surgery of congenital lung cysts. 14. Postoperative complications. 15. Classification lobarnoyi congenital emphysema. 16. The main clinical symptoms of congenital lobarnoyi emphysema. 17. Methods of diagnosis of congenital emphysema 18. Indications for surgical intervention. 19. Types of surgery of congenital emphysema Practical tasks 1. Analysis of survey radiographs of the chest cavity. 2. Mounting system for drainage of the chest cavity. Recommended Reading. Basic Books: 1. Ashkraft KU, Holder TM Children's surgery. St. Petersburg, 1996, 384p. 2. Isakovi YF Hyrurhycheskye disease of child age. - Moscow: Medicine, 2004 - 1t, 567s. 3. Sushko VI Surgery childhood. - Kyiv, HEALTH, 2009. - 704 p. 4. Isakovi JF, Dronov. Children's surgery. (Of the National MANUAL)-M "HЭOTAR-Media", 2008.-809s. Further Reading: 1. Resnick BJ, Zaporozhan VN, Minkov IP Vrozhdennыe development defects in children. - Odessa: AO: BAKHVA, 1994. - 448p. 2. Soloviev AE Neotlozhnaya Surgery of child age. - Zaporozhye, 2000. - 421s 3. Surgical Pathology. / Pod.red. Hrubnyka V. - Odessa, 2003. - 447s. 4. Shunko EE, Hanes GS, Lakshya O.T.Perynatalnыy sepsis. Teaching and method. Handbook. Kiev. Rutenyya, 2002 5. Diagnostic Radiology / Ed. by C.A.Gooding. - J.B. Lippincott Company, Philadelphia, 1990. - 552p. Yüklə 0,88 Mb. Dostları ilə paylaş:
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