From Big Medical Encyclopedia

CRYOSURGERY (grech, kryos cold + surgery) — the surgical methods of topical treatment by cold applied in some fields of medicine (surgery, oncology, ophthalmology, dermatology, etc.).

Use of cold in medicine is known from an extreme antiquity. For 2500 BC in Egypt applied cold compresses to treatment of fractures of bones of a skull and wounds of a thorax. In Hippocrates's compositions is in detail described to lay down. effect of topical administration of cold for a stop of bleeding from wounds and at traumatic hypostasis. Widely N. I. Pirogov used cooling for treatment of wounds.

Topical administration of Aether chloratus causing cooling was offered apprx. the 100th lot ago for anesthesia.

In 1938. Fairies (T. Fay) for the first time made the general cooling of a body of the patient approximately to 30 ° within several days that allows to consider him the founder of a method of a hypothermia (see. Hypothermia artificial ). In the subsequent Fey applied local cooling in neurosurgery — at a craniocereberal injury, abscesses of a brain and so forth.

Technical progress of the middle of 20 century was an incentive of the increased interest in use of cold in biology and medicine that led to creation of new scientific discipline — the cryobiology which is a theoretical basis of a cryogenic method in a wedge, medicine. The saved-up actual materials on impact of low temperatures on various biol, objects (from seeds of plants, viruses, microbes and unicells to mammals) showed that living cell under the influence of low temperatures can turn into ice at a temperature much below 0 °. According to Masur (P. Mazur, 1968), living cells freeze completely at t ° — 20 °. It is possible to consider established that transition of living tissue to solid state of ice leads in the subsequent to her death.

Staging of process of freezing in biol, is presented to system by Rinfret (A. Rinfret, 1968) in the form of a curve (fig. 1).

Fig. 1. The curve characterizing four stages of process of freezing on Rinfreta: the first stage (a) — decrease in temperature is lower than a point of freezing (v), and the system remains in liquid state; the site of a curve below the specified point (the second stage) (would) reflect a stage of overcooling. Bystry raising of a curve to a point (v) testifies to the beginning of formation of ice (latent heat of crystallization); the third stage (g) — the plateau of a curve — shows transition of system to other phase; the fourth stage (d) — decrease in temperature when the system is in solid state. On abscissa axis — time, on ordinate axis — temperature.

Some reasons of irreversible destruction of living cells in the course of their freezing are established: dehydration with sharp strengthening of electrolytes; ruptures of cellular membranes acute crystals of ice; a denaturation of phospholipids in cellular membranes; the termination of blood circulation in a zone of freezing leading to development of an ischemic necrosis.

Importance in To. has the speed of freezing. There are bases to believe that for a cryolysis of living tissue snap-freezing with decrease in temperature with a speed about 50 ° in minute and slower thawing is preferably relative (10 — 12 ° in a minute).

The terms «bystry» and «slow» cooling often are treated in literature is contradictory. In this regard it is necessary to give the classification of cooling rate presented by L. K. Lozina-Lozinsky (1972) in the form of the table.

Table. CLASSIFICATION of COOLING RATE (according to L. K. Lozina-Lozinsky, 1972)

In pilot studies of W. Gill and soavt. (1968) established that recycles of freezing and thawing increase intensity of destructive impact of cold on cells, especially on more resistant by cold tumor cells.

The question of changes of blood vessels under the influence of low temperatures is important. Numerous experimental morfol. by researches it was shown that capillaries, small arteries and veins within the center of a cryolysis nekrotizirutsya completely. Walls of large arteries after thawing keep anatomical structure. At gistol. research E. I. Kandel and soavt. (1974) found only little changes of an inner elastic membrane.

Shalmen (S. Shulman, 1969), W. A. Soanes et al. (1970), E. Gursel et al. (1972), etc. after a cryolysis of adenocarcinomas of in situ of a prostate in some cases observed regress of the regional and remote metastasises. The mechanism of this phenomenon is explained immunol, reactions with formation of specific autoantibodies. Dzhantorno's experiments (S. Jantorno) and soavt. (1967), Shalmena (1969) on rabbits to some extent confirmed this assumption.

The main advantages of use of a cryosurgical method in clinic can be formulated in the following original positions.

1. Cryoinfluence allows to destroy completely set volume normal or patol, the fabric located both on a body surface and in the depth of any body.

2. Access to the deep-located fabrics can be provided with the minimum traumatization of fabric the thin cryosurgical tool.

3. Local cryosurgical impact on living tissues, as a rule, without serious consequences also does not demand anesthesia.

4. The arising center of a cryonecrosis possesses peculiar biol, inertness, causing minimum perifocal reaction of surrounding fabrics.

5. Local freezing of fabric can be made without any injury of the healthy cells surrounding the center of a cryonecrosis. This feature of a method allows to consider freezing fiziol, an extirpation.

6. Cold influence blocks small arterial and venous vessels that allows to make cuts and to delete the centers almost without blood even in richly vaskulyarizirovanny bodies (a brain, a liver, kidneys and so forth). The haemo static effect of freezing warns a possibility of secondary bleedings.

7. The high resistance of a wall of large vessels to low temperature causing recovery of a normal blood-groove even after their full freezing allows to make safely a cryolysis of normal or tumoral fabrics in close proximity to these vessels.

8. Decrease in temperature of fabric (first of all brain) allows to make temporary reversible switching off of functions of the cooled structure that serves funkts, the test before irreversible destruction.

9. The centers of a cryolysis quickly begin to live, without causing formation of rough hems, big cosmetic defects.

The cryosurgical method finds broad application in oncology, neurosurgery, ophthalmology, dermatology, urology, otorhinolaryngology, gynecology, pediatrics and a proctology.

The cryosurgery in oncology

the Cryosurgery in oncology is applied to destruction of benign and malignant tumors of various bodies and fabrics.

The beginning of use To. in oncology it is connected with a name of Arnott (J. M of Arnott), which in 1851 made freezing of the centers of cancer of neck of uterus and a breast cancer.

Numerous researches on freezing of cancer cells as in vitro, and in an experiment on animals was established that these cells have bigger resistance to low temperature, than normal cells of an organism. The reasons of this resistance still are completely not established. Nevertheless it is shown that. though after freezing to solid state the majority of cancer cells perishes, their small part can survive and be: source of further growth of a tumor. In this regard holding repeated sessions for achievement of a full necrosis of fabric of a malignant tumor is recommended. At the same time Cooper (G. Cooper, 1965) believes that during the freezing to t ° — 20 ° all cells of any tumor perish.

Use To. in the general oncology about two directions develop. The first — aspiration to a radical cryolysis of a tumor when it is supposed that the cryomethod is more effective, than usual surgical techniques and also when an operative measure for one reason or another cannot be applied.

The second direction — to use To. as palliative operation at inoperable or incurable malignant new growths with the purpose to reduce pains or to temporarily recover passability of hollow bodies.

There are messages on successful operations by a cryogenic method at vascular tumors, and also at a carcinoma cutaneum of the person, a pilar part of the head, oral cavity and nasopharynx.

With the purpose to recover passability of a gullet at inoperable cancer Gage (A. Gage, 1968) made a cryolysis of a tumor via the esophagoscope. After such operation patients had an opportunity during certain time to swallow of liquid food.

Separate attempts of cryosurgical impact on primary and metastatic tumors of bones are described. After freezing in some cases disappearance of bone tumors with the subsequent gradual substitution of the center of a cryonecrosis a normal bone tissue was observed.

A cryosurgery in neurosurgery

Indications: need of destruction of the deep-located brain structures, conduction paths, tumors of c. N of page, and also local cooling of certain zones of brain bark for the purpose of treatment of epilepsy, in particular the epileptic status. Local freezing is one of the main methods of destruction in stereotaxic neurosurgery (see). An object of a cryolysis are various subcrustal structures depending on nozol, forms of a disease.

The cryosurgical method can be applied in three options depending on localization and prevalence of a tumor of a brain.

Fig. 2. Cryolysis (freezing) of an intracerebral tumor cryogenic device.

The first option — a cryolysis of a tumor of in situ without the subsequent removal (fig. 2). The cryolysis is reasonable at inoperable deep subcrustal gliomas. Through a frezevy opening in a calvaria the cryosurgical device installed in stereotaxic the device is entered into the central part of a tumor. It is desirable that the volume of an ice sphere on the end of the device corresponded to the sizes of a tumor. After freezing and thawing the device is deleted. The frozen part of a tumor nekrotizirutsya and then resolves. The described technique is, as a rule, palliative as full destruction of the glioma which usually does not have a clear boundary with healthy tissue of a brain manages to be made only in isolated cases.

Fig. 3. Cryoextirpation (cryosurgical removal) of intracerebral and meningososudisty tumors: 1 — a tumor; 2 — a cannula of the cryosurgical device; 3 — dissect and klipirovanny vessels.

The second option called by a cryo-extirpation consists in freezing of a tumor of a brain to solid state with the subsequent its total removal (fig. 3). This option is shown at superficially located tumors — meningiomas and high-quality gliomas (so-called nodal forms of gliomas). In these cases make usual osteoplastic trepanation, bare a tumor on a small extent, enter the cryodevice into its central part and freeze ice before turning into. Then, using the device as the convenient handle, separate a tumor from brain fabric and delete.

The third option is a combination two previous. At the same time the main part of an intracerebral tumor is frozen and deleted, and its peripheral departments in the depth of a brain only freeze, counting on their subsequent destruction.

One more direction in To. the stereotaxic cryolysis of tumors of a hypophysis is transnasal approach. It is used also for destruction of a normal hypophysis at metastasises of hormonal and dependent cancer (a breast cancer, ovaries, a prostate gland and so forth), and also at a diabetic retinopathy.

The main indication to a cryohypophysectomy are the adenomas of a hypophysis growing preferential from the Turkish saddle in the main bosom. Most often it is the eosinophilic adenomas which are clinically shown a syndrome of an acromegalia. With the significant suprasellyarny growth in adenoma with existence of the expressed hiazmalny syndrome the transnasal cryohypophysectomy is not shown.

The cryohypophysectomy is made as follows: by means of the stereotaxic device enter a cannula for local freezing into the set subcrustal structure. Freezing time — about 2 — 2,5 min. The beginning of formation of the ice sphere on the active end of the cryodevice is determined by falling of degree of vacuum on the manometer of an aspirator. After a vykipaniye of liquid nitrogen and switching off of an aspirator it is required about 5 — the ice sphere, min. for full thawing. After that operation is finished and the cryocannula is deleted.

Cryosurgical removal of benign meningososudisty tumors of a brain — meningiomas make by means of special devices, in particular the device of Shalnikov allowing to turn a tumor of considerable volume into ice. After freezing blood circulation in a tumor stops that gives the chance to remove it quickly and almost without blood. It is more difficult to estimate results of a cryolysis of neuroectodermal tumors of a brain.

The transnasal cryohypophysectomy is made by means of the stereotaxic device which is installed on a special frame. Under an endotracheal anesthesia or a neyroleptanalgeziya enter the cannula trocar with the acute end fixed in the stereotaxic device into a nasal cavity. After the corresponding stereotaxic calculations under direct vision of the electron-optical converter enter a trocar into a pituitary pole of the Turkish saddle. Further through a trocar enter a cryogenic cannula into a tumor and depending on the sizes of a tumor make freezing, creating several centers blocking each other. At the same time it is necessary to aim to destroy as much as possible all tumor, but to keep a back share of a hypophysis (neurohypophysis).

After completion of freezing the cryodevice is taken. In the presence of small bleeding make a front tamponade of a nasal cavity. Complications after operation are observed seldom. The nasal Liquorrhea is noted in 1 — 4% of cases.

The cryohypophysectomy at most of patients gives considerable and lasting positive effect, first of all at adenomas of a hypophysis — the phenomena of an acromegalia decrease, there pass headaches, visual acuity improves, symptoms of not diabetes mellitus, etc. disappear. In parallel a wedge, to improvement hormonal and biochemical indicators are normalized. After a cryohypophysectomy concerning a diabetic retinopathy of R. W. Rand and soavt. (1968) note improvement of visual acuity and reduction of expressiveness of vascular disorders on an eyeground. Norrell (H. A. Norrell, 1970) at metastasises of a breast cancer after this operation noted long, quite often long-term, remission with disappearance of metastasises, especially in bones.

Results of stereotaxic operations at extrapyramidal diseases depend on the applied method of destruction of tissue of brain. Use of a cryosurgical method significantly increased efficiency of these operations. So, e.g., at parkinsonism permanent disappearance of a tremor, muscular rigidity and others the wedge, displays of a disease takes place in 80 — 85% of cases, and the postoperative lethality makes apprx. 1%.

The cryosurgery in ophthalmology

Use of low temperatures for treatment of eye diseases has more than semicentennial history. In the beginning Hartson (Hart son, 1911), S. V. Romanov (1914; etc. used opportunities to lay down. impacts of cold at trachoma, and Sheler (F. Schoeler, 1918), etc. — at amotio of a retina. After Byetti (1950) it was offered to G. Bietti to apply cryoapplication of a sclera at glaucoma.

However to the second half of 20 century use of cold in ophthalmology had sporadic character. Only after development by Krvavich (T. Krwawicz, 1961) a method of cryoextraction of a crystalline lens at to a cataract (see). To. gained bystry and universal distribution in ophthalmology.

Indications: depending on the nature of action of the cold agent the last can be used: 1) for the purpose of creation of temporary commissure between the tool (cryo-manipulator) and fabric — the most frequent route of administration of cold in a cryosurgery of an eye (a krioeketraktion of a crystalline lens, fixing of tumors of a choroid during their removal); 2) for receiving adhesive process between covers of an eyeglobe (at amotio of a retina, peripheral cysts, the equatorial atrophies, removal of intraocular foreign bodys, and also at cystous conjunctival small pillows after fistuliziruyushchy antiglaukomatozny operations); 3) for the purpose of the damaging and destroying influence on fabrics (at glaucoma for reduction of products of watery moisture by creation of the centers of an atrophy in a ciliary body, at spring Qatar, pterygiums, postoperative commissures of a vitreous with an endothelium of a cornea on afakichny eyes, an intraocular cysticercus, at Gippel's disease — Lindau, angiomas, papillomas, retinoblastomas, melanomas, etc.); 4) with the antiinflammatory purpose, for a rassasyvaniye of blood, strengthening of regenerative ability and for prevention of loss of a vitreous (at a hemophthalmia, Ils's disease, at infringement of an iris after operations, at a keratitis, helcomas, sclerites and other diseases, and also during the processing of wounds of an eyeglobe after extraction of a cataract and removal from an eye of nonmagnetic foreign bodys).

There are practically no contraindications for use of cryoinfluences in ophthalmology.

Techniques of use of cold are various: lotions, applications of snow of carbonic acid on a conjunctiva, a cornea, introduction to a conjunctival sac, cryoblowing; most often, however, applications are carried out by means of the cooled cryomanipulator. Extent of its cooling fluctuates ranging from 0 to — 79 — 190 ° depending on the used cooling medium.

Complications are connected with careless use of the cryomanipulator or with excessively long influence of very low temperature and are expressed in opacities of the vitreous body, hemorrhages in it, separations of an iris at its accidental primorazhivaniye during a kriofakiya. Prevention of complications consists in an exception of the specified reasons.

A cryosurgery in otorhinolaryngology

Indications: Menyer's disease, the raised bleedings during operation on a mastoid, various inflammatory diseases, and also tumors (high-quality and malignant) an ear, a throat and a nose.

A relative contraindication is that cryosurgical influence in some cases demands repeated use that treatment detains. E.g., for removal of almonds at hron, tonsillitis it is required two - or triple cryoinfluence for 1,5 months whereas after usual operation of the patient it is discharged from hospital most often on 5 — the 6th day. But in certain cases, when the patient has a disease of blood, the raised bleeding or the patient of old age, cryoinfluence is justified.

For cryosurgical influence in the depth of cavities of an ear, a nose, a throat, a throat, a trachea cryoprobes and cryoapplicators are created. The cryosurgical method is a little painful, during operation does not give bleeding.

Complications: late bleeding (on 5 — the 6th day) after removal of almonds, paresis of a soft palate, hypostasis of a mucous membrane, the sky and a uvula. These complications can be prevented if precisely to adhere to a technique of cryoinfluence and not to allow overdose it. To. in otorhinolaryngology won the strong place and it is widely applied both in policlinic, and in a hospital.

The cryosurgery in urology

the Cryosurgery in urology is for the first time used by Gonder (M. J. Gonder) with soavt, in 1964.

In a wedge, practice the most frequent indications for it are: adenoma, a prostate cancer, high-quality new growths of a bladder, profuse bleedings from the breaking-up tumors of a bladder, prostate and urethra.

The cryolysis of tumors of a bladder is shown in cases when radical operation (a resection, a cystectomy) is technically impracticable because of prevalence of blastomatous process or is contraindicated for other reasons.

Contraindications to To. in urology is not present.

Fig. 4. The diagrammatic representation of operation of a cryolysis of a tumor of a prostate (the zone of cryoinfluence is specified by shooters) with direct vision with the help a trocar cystoscope (entered into a bladder through a section in an abdominal wall) behind the provision of a cryoprobe; in a rectum — a finger for establishment of provision of a cryoprobe.

Technology of operation: the patient for operation for a prostate cancer is stacked in situation, as for a lithotomy. The bladder is emptied and filled with air for the purpose of reduction of cooling of its walls. On an urethra enter a cryoprobe and under control of the finger which is in a rectum establish it so that the freezing part was in a prostatic part of an urethra. Freezing is continued by 3 — 5 min. under control of feeling a finger of cold or the beginning fixing of a mucous membrane of a rectum. After freezing include a heater. After thawing the cryoprobe gains mobility and is easily taken. For direct vision over freezing it is possible to use special a trocar cystoscope (fig. 4). Along with a technique of an endovesical cryolysis with the help a trocar cystoscope many urologists carry out a cryolysis of tumors of a bladder on a «open» bubble, bringing a cryoprobe directly to a tumor.

Directly after cryoinfluence there is hypostasis of fabric. To 4 — to the 7th day the prostate begins to decrease in sizes, is especially strong by 21st day. At gistol, a research in the place of impact of cold strictly limited necrosis is defined. With 5 — the 7th day rejection of necrotic fabrics and regeneration which come to an end by the end of the 4th week begins. In a zone of a cryolysis the wide gleam of an urethra covered by an epithelium and surrounded with a zone of fibrosis is formed. The considerable duration of sloughing is an essential lack of a cryoprostatectomy, and also the reason of complications. Recommend to apply proteolytic enzymes to elimination of this shortcoming, and Molnar, Hashek (To. Haschek), Fidler (To. Fiedler), Mac-Doneld (J. N of McDonald) apply a transurethral electroresection to removal of necrotic masses.

The cryolysis of a prostate cancer is applied with the palliative purpose to improvement of a passage of urine. In certain cases after a cryolysis the termination of growth of a tumor, growth of metastasises and even cases of their involution is observed.

Complications: bleedings in the period of sloughing that demands repeated cryo-influence or electrothermic coagulation. The immediate and long-term results of a cryolysis encouraging.

A cryosurgery in gynecology

Indications: erosion, dysplastic processes after removal of polyps, endometriosis of a neck of uterus, a leukoplakia, the sharp-pointed condylomas which are not giving in to conservative treatment, dysfunctional uterine bleedings, the adenomyosis of a uterus which developed near an endometria.

Contraindications: acute and subacute inflammatory diseases of female generative organs.

Fig. 5. Schemes of provision of an active part of cryoprobes (are shaded) during the cryoprocessing (zones of cryoinfluence are outlined by a dotted line): and — a neck of uterus and the cervical channel — only the cervical channel, in — cavities of the uterus according to Kahane and Brokkunyer — cavities of the uterus across Grishchenko

Technique: cryoinfluence is preceded, as a rule, by a biopsy for clarification of nature of damage of a vagina, a neck or a body of the womb: in cases of cryoprocessing of walls of a cavity of the uterus the carried-out previously diagnostic scraping provides also removal of the most part of an endometria and deeper subsequent frost penetration in walls of a uterus. The technique of cryoinfluence developed by V. I. Grishchenko (fig. 5, h), unlike Kahane and Brokkunyer's recommendations (W. G. Cahan, A. Brockunier) (fig. 5, c), provides 3 — 4 applications of the probe without cryolysis of walls of the channel of a neck of uterus. Cryo-processing at erosion, displaziya of a neck of uterus is usually carried out by means of a cryoprobe (fig. 5, I), the cryo-manipulator to-rogo has the cone-shaped end entering into channel of a neck of uterus. and the round flat wide basis adjoining to a surface of a vulval part of a neck of uterus. In other cases cryoprobes with the cryomanipulator of a cylindrical form of different length and thickness are applied (fig. 5, b).

Advantage To. in gynecology the painlessness and the minimum injury especially important at treatment of diseases of a neck of uterus is during pregnancy.

Fig. 6. Microdrug of a wall of a uterus (after cryoprocessing): a hyalinosis, a thickening of walls, deformation and narrowing of gleams of vessels of a uterus (are specified by shooters) near an endometria; in the left upper corner not changed blood vessel (is specified by an arrow) which was not exposed to cryoinfluence.

The cryomethod in childbearing age is more preferable to patients in comparison with diathermocoagulation and because after its use there are less expressed cicatricial changes of fabrics which can break disclosure of a neck at childbirth. In cases of an adenomyosis the changed fabrics are exposed to a cryonecrosis and the subsequent demarcation patholologically. At women with dysfunctional uterine bleedings (see). preferential climacteric, the resistant amenorrhea sometimes is caused by treatment; as a rule, after short-term lack of monthly the menstrual cycle is recovered; the size of a uterus, usually fibromatous, decreases; monthly become less plentiful due to reduction of gleams of blood vessels of a uterus owing to their hyalinosis (fig. 6), substitution of a part of an endometria cicatricial fabric.

Complications: occasionally, at the insufficient accounting of contraindications, the aggravation of an inflammation in bodies of a reproductive system is observed; narrowing and closing of the channel of a neck of uterus at the expense of inflammatory hypostasis after a cryolysis of its walls. It promotes development in a uterus inf. process. The prevention of such complication consists in strict performance of a technique of the cryoprocessing excluding a deep cryolysis, and at pathology in a body of the womb — in cooling of the cervical channel. == A cryosurgery in a proctology ==

For the first time a method K. in a proctology it was used by G. Cooper in 1963 — 1965.

In a proctology To. has the following indications: as palliative intervention at cancer and sarcoma of a rectum, radical at high-quality (first of all fleecy) tumors of a rectum and perianal condylomas, hemorrhoids.

Contraindications: different types of nonspecific colitis, fistulas (especially difficult) a rectum, and also the hemorrhoidal nodes complicated by an inflammation.

Technique: freezing of fabrics is made by application of a tip of the cryodevice within 4 — 5 min., and in the subsequent the tip heats up and separates from the frozen fabrics. Usually the zone of a primorazhivaniye of fabrics extends to 1,5 — 2 cm from a surface of a tip. In need of broader impact on a large patol, the center repeated applications in one or several sessions are possible.

At hemorrhoids usually in one session freeze 1 — 2 main of a node in order to avoid circular hypostasis of an anus. The second session To. both at hemorrhoids, and at a tumor make after rejection of a cryonecrosis in 10 — 14 days from the moment of the previous session

of K. Gemorroidektomiya it is made through anoskop (usually in out-patient conditions) without preliminary anesthesia and is not followed by blood loss.

Usually cryoinfluence and the subsequent postoperative current are not followed by complications and the wound after sloughing heals quickly, without the expressed inflammatory changes.

Complications: early rejection of a cryonecrosis at the act of defecation and possible in this regard bleedings or infection of a wound. For the purpose of prevention it the delay of a chair within 3 — 4 days with the subsequent purpose of a diet and aperient means for providing a «soft» chair is recommended.

The long-term results To. in a proctology favorable.

A cryosurgery in pediatrics

Indications: intensively growing flat or small cavernous hemangiomas of various localization at children up to 6 — 7-months of age. At children of advanced age as the indication serve the cosmetic defects caused by existence of similar hemangiomas, warts, papillomas, a pigmental nevus. A.S. Doletsky (1974) used a cryolysis for destruction of varicose nodes of a stomach at a syndrome of portal hypertensia.

In children's otorhinolaryngology cryoinfluence is applied at hron, tonsillitis, at a papillomatosis of a throat, to therapy of hypertrophic rhinitis, hypertrophic pharyngitis and small knots of voice folds, and also for a stop of nasal bleedings.

Technique: patol, education is frozen from a surface in depth in the contact way (application of a coolant in the form of the created lump with a plain surface — «dry ice» of t ° — 79,5 ° or the special device).

Duration of application at treatment of hemangiomas «dry ice» from 20 to 40 sec. on skin twice less on mucous membranes. For the cryoapplicators using liquid nitrogen, this time respectively decreases twice.

Cryotherapy of warts and papillomas lasts from 60 to 180 sec.

According to D. G. Chireshkin (1974), the cryotonsilectomy demands 5 — 8-min. exposure and 3 — 4 sessions of a cryolysis. Optimum time of influence at a cryolysis of papillomas of a throat 180 sec., and the number of applications during one session from 2 to 5 depending on age of the child and prevalence of process.

The cryotonsilectomy is followed by formation of a necrotic plaque for the 1st days which in 2 — 3 days becomes thicker and gains grayish color. Plaques disappear to 8 — to the 10th a diya. Then there is a reduction of palatine tonsils continuing to 3 — 4 weeks. To. a papillomatosis of a throat, hypertrophic rhinitis and pharyngitis causes the small hypostasis which is not interfering breath. Due to pointed influences inflammatory reaction is minimum.

A cryosurgery in dermatology, cosmetology

Indications: vulgar and flat warts, papillomas; sharp-pointed condylomas, senile keratosis, hypertrophic hems, pigmental and vascular birthmarks.

Contraindications to cryoinfluence: hypertension, epilepsy, vasomotor spasms.

Technique: leather before the procedure is processed by 70% alcohol.

The applicator is put to the deleted element with exposure 10 — 30 sec., as necessary from two - triple repetition. The first minute after freezing there are a hyperemia, small hypostasis, and in 6 — 24 hours the epidermal bubble with serous or hemorrhagic contents is formed. On 3 — the 7th day the bubble dries up and turns into a dense box, edges in 8 — 10 days is torn away, leaving a pink spot.

At influence of liquid nitrogen easy burning, a pricking, pain is noted. Subjective feelings, as a rule, short-term that the specified method to apply in children's practice allows.

In the presence of big bubbles they should be opened at the basis with scissors and to process spirit solution of 1 — 2% of tetraethyl-diamino-triphenyl-carbohydride sulfate, Castellani's liquid and to apply an aseptic bandage for 3 — 5 days. During removal of periungual and bottom warts the specified procedures are repeated to 3 — 5 times at an interval of 3 — 5 days. At sharply expressed hyperkeratosis previously horny layer around a wart should be removed.

Flat warts are removed cryomassage with the easy surface pressure of skin. Sessions repeat 3 — 4 bucketed times 2 min.

Kriomassazh liquid nitrogen apply also at treatment of acne rash, seborrhea, gnezdny baldness. Continuous rotary motions May sir a cosiness the affected skin from 2 to 5 min. depending on the center of defeat. The procedure is repeated in 2 — 3 days. On a course of treatment of 15 procedures. Cryomassage can be carried out also using dry ice.

Devices for a cryosurgery

Devices for a cryosurgery represent the technical devices containing the tips or elements cooled by various coolants of the action directed and limited on the square at bodies and fabrics for implementation of methods K. (destructions and removals education). With receiving liquefied gases Whyte (A. S. White, 1889) used a liquid air for destruction of high-quality new growths. Pyyuz (W. And. Pusey, 1907) applied in dermatology of application by «dry ice». In the 30th 20 century there were first devices with the cooled metal tips. Lorta-Jacob's cryocauter with the hollow metal tips cooled by snow of carbonic acid which found application in dermatology was the most perfect of them.

Since 1960 almost at the same time fr. otorhinolaryngologists of Lemarye, Myule (A. Lemariey, N. Miller), polsk, the ophthalmologist Krvavich (T. Krwawicz, 1961), amer. the neurosurgeon Cooper (I. S. Cooper, 1961) and in the Soviet Union A. I. Shalnikov and soavt. (1962) devices were developed for

K. V 1969 by B. A. Komarov et al. offered the device of local cryoinfluence of autonomous type with vapor-liquid circulation of nitrogen for otorhinolaryngology, ophthalmology and other fields of medicine.

Designs of devices of local cryoinfluence received various names in which partially or their appointment is completely reflected: cryoapplicator, cryo-destructor, cryocauter, cryomanipulator, kriofak, cryoextractor.

The following coolants are applied to cryosurgical devices:

1. Dichlorodifluoro methane (temperature of boiling — 29,8 ° with a pressure of 1 atm) and freon-22 (temperature of boiling — 40,8 ° with a pressure of 1 atm); are stored and transported in liquid state in steel cylinders under pressure of 5,7 and 9,3 atm at 20 °.

2. CO carbon dioxide 2 (carbonic acid) in the form of dry ice or snow (temperature of evaporation — 78,48 ° at 1 atm), gases and liquid (temperature of boiling — 78,9 ° at 1 atm); it is stored and transported in liquid state in steel cylinders under pressure of 58,46 atm at 20 °.

3. Nitrous oxide N 2 O (temperature of boiling-89 hail. at 1 atm); it is stored and transported in liquid state in steel cylinders at 60 atm.

4. Liquid nitrogen N 2 (temperature of boiling — 195,76 ° at 760 mm of mercury.); it is stored and transported in vessels of the Dewar.

Fig. 7. Ways of cooling of fabrics at local cryoinfluence by various cryogenic devices (the cooled site of fabric is shown in the bottom of drawings by shading): and — a tip (1) through hladoprovod (2) from the cold accumulator (l); — a tip (1) through hladoprovod (2) from a coolant (3) in strong or liquid state; e — a hollow tip (1) through a cannula (2) from a coolant (3) in firm liquid state of a pla; — a firm coolant (1); d — a tip (1) without bottom from a coolant (2) in liquid state or moistened z it is mute cotton wool; e — a tip (1) without bottom from tsirkuliruyemy on a cannula (2) coolants in a liquid or vapor-liquid state; — a tip (1) through hladoprovod (2) from a thermopile (3); z — from a tip (1) under pressure a liquid or gaseous coolant (2); and — through a hollow tip (1) gas under pressure from a tube (2) — Thomson's effect — Joule and the gas circulating on a cannula (3); to — through a hollow tip (1) a liquid coolant under pressure from a tube (2) — with phase change of liquid in gas and to Thomson's effects — Joule and the coolant circulating on a cannula (3); l — through a hollow tip (1) the coolant in a vapor-liquid state circulating on a cannula (2); m — through a hollow tip (1) konvektsionno the coolant circulating on a cannula (2)., Shooters specified circulation of a coolant.

In cryogenic devices various ways of cooling of a tip and ways of direct giving of coolants on fabric are applied that is represented in the figure 7.

Usually I apply to local cryoimpact on open and easily accessible objects directly coolants (liquid nitrogen, snow or dry ice) or devices with cannulas without heat insulation, with partial and full heat insulation. For processing of the objects located in bodies or in hardly accessible cavities, usually use devices with the cannulas having the full heat insulation excluding cold impact on surrounding fabrics. The full heat insulation of cannulas is provided with existence of the vacuumized gap along its outside wall (the principle of the device of the Dewar), the electric heater etc.

Depending on refrigerating capacity of the device depth of the maximum promorazhivaniye of fabric under the influence of temperature from — 10 to — the 180th hail. varies over a wide range — from 1 — 3 mm to 3 — 5 cm. One of essential shortcomings of the devices working by the principle of a primorazhivaniye of fabric is that in fabric there are cracks from which after thawing bleeding is possible.

In All-Union research in-those medical instrument making (VNIIMP) both All-Union research and test in-those medical equipment (VNIIIMT) are developed devices on the basis of vapor-liquid circulation of nitrogen. Tips of these devices have temperature in contact with fabrics not above — 190 °. what causes condensation and decrease in an ambient air on a tip (temperature of decrease — 182 — 184 °) and excludes effect of a primorazhivaniye (wet ice).

Depending on designs and appointment devices can be divided into 4 classes.

Class I — cryoapplicators autonomous. Their characteristics: 1. Lack of any remote bonds during the operation of the device. 2. Time of continuous operation is limited to quantity of the filled coolant or mass of the cold accumulator. 3. The temperature schedule at cryoinfluence is not controlled. Belong to the class I:

Fig. 8. A set of the cryoprobes applied in otorhinolaryngology (shooters specified replaceable tips), is developed by VNIIIMT.

1. Krioapplpkatora autonomous with cold accumulators. The most known design of this type is Krvavich's cryoextractor for removal of a crystalline lens. The similar design of the cryoapplicator is developed for ophthalmology in Ying-those physical problems of Academy of Sciences of the USSR. In VNIIIMT "A set of cryoprobes for otorhinolaryngology" (fig. 8) is developed.

Fig. 9. The cryoapplicator eye KG-05 — 20, is developed by VNIIIMT: 1 — the plug with a rod, a spring and the piston for connection with the charger and for regulation of pressure of a coolant; 2 — the case (thermoisolating the cylinder) in which the snow briquette is formed; 3 — replaceable tips with various areas of contact with fabrics and with various temperature schedules.

2. Cryoapplicators autonomous with not circulating coolants. The cryoapplicator with the cooled tip is developed in VNIIIMT, the KG-65-20 type (fig. 9). in the thermoisolated case to-rogo in the metal cylinder the dry ice or the pressed snow of carbonic acid compressed the piston from a spring towards a tip is located.

Fig. 10. Advanced model of the cryosprayer of the Kharkiv FTINT of AN of USSR: 1 — a replaceable tip (syringe needle); 2 — a cannula; 3 - a rychazhok of the beginning and interruption in supply of liquid nitrogen in a tip; 4 — the case (filling capacity).

3. Cryoapplicators autonomous with direct circulation of coolants: coolants refuel in the case or a barrel placed in the case and move under pressure in liquid or gaseous state upon the processed object. The cryosprayer of liquid nitrogen is developed in the Kharkiv FTINT of AN of USSR (fig. 10). Liquid nitrogen from the case under pressure through a replaceable tip moves on the processed object.

Fig. 11. The scheme of the cryoapplicator with the vapor-liquid closed circulation of nitrogen: 1 — the case (filling capacity with liquid nitrogen); 2 — the tube giving liquid nitrogen to a tip: 3 — a tube (cannula) which is taking away vapor-liquid mix of nitrogen back in filling capacity; 4 — a tip in which vapor-liquid mix of nitrogen is formed: 5 — an opening for removal of gaseous nitrogen.
Fig. 12. The cryoapplicator eye KG-195, is developed by VNIIIMT: 1 — a replaceable tip; 2 — a cannula; 3 — the thermoisolated case from plastic; 4 — a cover for gas station of nitrogen.

4. Cryoapplicators autonomous with the closed circulation of coolants: the coolant in a liquid or vapor-liquid state moves in the cooled tip, and then vapor-liquid mix gets back to the filling capacity where exit gases separate and go to the atmosphere, but not evaporated liquid goes to a tip again. In the figure 11 the scheme of work and the device the cryoapplicator and with vapor-liquid circulation of nitrogen is shown. In VNIIIMT the krpoapplikator eye KG-195 (fig. 12), and in VNIIMP the cryoapplicator otorhinolaryngological nitric KAO-01 is developed.

Fig. 13. The cryoextractor eye rod KGF, is developed by VNIIIMT: 1 — the replaceable tip connected to a core (cold accumulator); 2 — the case plastic with a core (inside); 3 — the plug for fastening of a core and connection with the charger.

5. Cryoapplicators autonomous combined. In them signs of above-mentioned types are combined. In VNIIIMT the cryoextractor eye rod KGF (fig. 13) which releases the Leningrad production association «Krasnogvardeets» is developed. The cryoextractor is cooled with liquid carbonic acid with formation of snow.

Fig. 14. The cryodevice KDM-5m applied in otorhinolaryngology; it is developed at Institute of physical problems of Academy of Sciences of the USSR: 1 — a cryotip with the microelectric heater; 2 — the thermoisolated cannula; 3 — a vessel foam for filling with nitrogen; 4 — wires for a remote otogrev of a tip; 5 — a tube plastic for a suction of vapors of nitrogen from a tip an otsasyvatel of continuous action.

Class II. Devices with remotely connected independent cryoapplicators. Their characteristics: 1. Time of continuous operation is limited to quantity of a coolant in the cryoapplicator or the weight and cooling temperature of the cold accumulator. 2. The temperature schedule of a tip can remotely be registered and be regulated. 3. Circulation of a coolant in the cryoapplicator can remotely be carried out by a suction. In designs of a class various types of independent cryoapplicators are used. In Ying-those physical problems of Academy of Sciences of the USSR the K DM-5 cryodevice of m (fig. 14) with circulation of liquid nitrogen by means of a remote suction of vapors of nitrogen is developed. Frostbite of a tip is provided remotely with the microheater which is built in in it. In same in-those the similar cryodevice is developed for neurosurgery with the thermocouple in a tip for remote measurement of temperature. Similar devices are developed for treatment of tumors of the head and a neck in Kiev in-that physics of AN of USSR. In GDR the device is developed for ophthalmology of IKG-1 with the cryoapplicator without circulation of liquid nitrogen. The temperature schedule of a tip changes and measured remotely by the microheater and the thermocouple the control unit.

Class III. Devices with remote giving of coolants in cryoapplicators. Their characteristics:

1. Time of continuous operation is limited to the capacity of a vessel (cylinder), from to-rogo the coolant in the cryoapplicator moves remotely. 2. The temperature schedule of a tip is measured on the thermocouple and regulated by the microheater or change of pressure of giving of a coolant.

Fig. 15. The device for cryogenic treatment of gynecologic diseases of AKG-01 of the Kharkiv FTINT of AN of USSR: 1 — the cart mobile; 2 — a cylinder with a coolant; 3 — the cryoapplicator with a replaceable tip; 4 — the control unit; 5 — a hose for remote giving of a coolant from a cylinder via the control unit in the cryoapplicator.
Fig. 16. Thermoelectric Cryoextractor of a Cataract (TCC) of the Leningrad All-Russian Research Institute of sources of current: 1 — krionakonechnnk, cooled by the semiconductor battery; 2 — the case of the cryoapplicator; 3 — a hose for a supply of a current and cooling water; 4 — the control unit.

In the Kharkiv FTINT of AN of USSR the device of cryogenic treatment ginekol, diseases of AKG-01 (fig. 15) with supply of nitrous oxide from a cylinder via the control unit with manometers in the cryoapplicator is developed. Temperature of a tip in contact with fabric — 50 — 60 °. In Ying-those physical problems of Academy of Sciences of the USSR the device cooled by CO gas is developed 2 , for otorhinolaryngology with distance steering of supply of gases. Devices with replaceable cryoapplicators are developed in the Kharkiv FTINT of AN of USSR, Ying-those physical problems of Academy of Sciences of the USSR.

Class IV. Devices with the managed generators of cold. Their characteristics: 1. Time of continuous operation is almost not limited and depends only on existence of current in the power supply network. 2. The temperature schedule of a tip can remotely change and be stabilized on the thermocouple. In the Leningrad All-Russian Research Institute of sources of current the thermoelectric cryoextractor of a cataract of TKK (fig. 16) with the principle of cooling of a tip with the semiconductor battery was developed. From the control unit on a hose for heat removal water is brought. In the same hose conducting wires are built in. In GDR having developed a similar cryoprobe of «OKS-3» with the compressor car placed in the control unit.

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E. I. Kandel; V. G. Abramov (oft.), A. L. Akseldorf, L. I. Dunayevsky, A. F. Akhabadze (dermas.), V. I. Grishchenko (gin.), B. A. Komarov (tekhn.), I. I. Potapov (ENT specialist.), V. D. Fedorov (Abd. hir.), V. V. Shafranov (ped.).