Świętokrzyskie Centrum Onkologii informuje, że przeprowadza nowe zabiegi z zakresu chirurgii rekonstrukcyjnej z wykorzystaniem odległych przeszczepów tkankowych z zespoleniami mikronaczyniowymi. Operacje wykonywane są u pacjentów z zaawansowanymi nowotworami jamy ustnej i gardła.
Specjaliści w Klinice Otolaryngologii, Chirurgii Głowy i Szyi Świętokrzyskiego Centrum Onkologii z pomocą nowych zabiegów ratują życie pacjentom z nowotworami w rejonie głowy i szyi, u których konieczne są rozległe amputacje i rekonstrukcje. Prof. Stanisław Góźdź, dyrektor Świętokrzyskiego Centrum Onkologii, wyjaśnia, że radykalne leczenie nowotworów wiąże się z okaleczeniem, w tym przypadku widocznym – obejmującym rejon twarzy i szyi. Narzędzia i działania, które wdrożono w ŚCO pozwalają jednak uzupełnić tę radykalność.
W ŚCO odbyły się już pierwsze zabiegi rekonstrukcyjne
Specjaliści ŚCO w przeciągu dwóch miesięcy przeprowadzili cztery operacje rekonstrukcji z pomocą odległych przeszczepów z zespoleniami mikronaczyniowymi.
2 lutego br. zabieg odbył się u pacjenta z rakiem dna jamy ustnej naciekającym żuchwę po lewej stronie z przerzutami do węzłów chłonnych. Dr n.med. Sławomir Okła, specjalista otorynolaryngolog, kierownik Kliniki Otolaryngologii, Chirurgii Głowy i Szyi ŚCO, podkreśla, że u pierwszego chorego konieczne było usunięcie ponad połowy żuchwy, a także bardzo dużej części dna jamy ustnej i błony śluzowej policzka oraz wargi dolnej.
Drugą operację przeprowadzono 18 lutego br. u pacjentki z rakiem migdałka podniebnego prawego ze wznową po radio-chemioterapii. Podczas zabiegu usunięto migdałek wraz z całą boczną ścianą gardła środkowego i fragmentem podniebienia miękkiego. Nieuniknione było również radykalne usunięcie węzłów chłonnych na szyi po prawej stronie z zaoszczędzeniem wszystkich nerwów, naczyń i mięśnia mostkowo- obojczykowo-sutkowego. Chirurdzy wskazują, że ich działania dodatkowo utrudniało osłabienie tkanek po przebytych naświetleniach. Dr Okła wyjaśnia, że zabieg był bardzo rozległy, jednak dał chorej o wiele lepszą jakość życia.
Metoda rekonstrukcji z pomocą odległych przeszczepów daje chorym szansę na powrót do prawidłowej funkcji i wyglądu. Pierwszy zoperowany pacjent opuścił szpital po 3 tygodniach, a pacjentka – po 10 dniach. Pacjenci mogą normalnie funkcjonować.
Wycięcie nowotworu nie musi wiązać się z maksymalnym zaoszczędzeniem tkanek
W obu przypadkach, ze względu na rozmiar ubytków tkanek, rekonstrukcja z użyciem uszypułowanego płata piersiowego (skórno-mięśniowego płata pobranego wraz z zachowanymi własnymi naczyniami krwionośnymi) była niemożliwa. Dlatego, jak wyjaśnia dr Okła, użyty został płat udowy, czyli fragment skóry z powięzią uszypułowanego na naczyniach krwionośnych: tętnicy i dwóch naczyniach żylnych.
– Te naczynia poprzez połączenie na szyi do tętnicy i żyły twarzowej pozwoliły na przywrócenie ukrwienia dla płata i zapewniły dobre gojenie. U pacjenta zastosowano również płytę tytanową do odtworzenia kości żuchwy – podkreśla ekspert.
Podczas zabiegów rekonstrukcji specjaliści wykorzystali mikroskop z możliwością obrazowania naczyń użyciem fluorescencji oraz z równoległym podłączeniem podglądu asystenckiego, tak by w jednym mikroskopie mogły operować dwie osoby siedzące po dwóch stronach stołu. Operacja trwa około 12 godzin i angażuje dwa zespoły chirurgów, instrumentariuszy i zespół anestetyczny.
– Tutaj mamy najlepszą zasadę w onkologii: jedna osoba resekuje, a druga rekonstruuje. Jest zespół dwóch liderów. Chirurg, który wycina nowotwór, nie musi iść na kompromis, żeby zaoszczędzić jak najwięcej tkanek, a więc wziąć mniejszy margines czyli ryzykować nieradykalność. Ponieważ możemy dobrać więcej pasujących tkanek z miejsc odległych, wzrasta szansa na radykalność. Wtedy też szanse na wyleczenie pacjenta są dużo większe – zaznacza dr Okła.
Przygotowanie zespołu do wykonywania rekonstrukcji z odległym przeszczepem trwało 3 lata
Pacjenci, którzy wymagali rekonstrukcji z pomocą przeszczepu tkankowego pobranego z miejsc odległych, do tej pory nie mogli być leczeni w ŚCO ze względu na brak odpowiednich narzędzi i specjalistów z dziedziny chirurgii naczyniowej. W Polsce funkcjonuje tylko kilka ośrodków, które zajmują się rekonstrukcjami tego typu, co sprawia, że pacjenci długo czekają na zabieg. Dr Okła podkreśla, że w ŚCO udało się jednak wyszkolić ludzi, a dzięki władzom województwa zakupić sprzęt.
Przygotowanie zespołu trwało około 3 lata – lekarze zagłębiali wiedzę na temat rekonstrukcji z wykorzystaniem zespoleń mikronaczyniowych w Samodzielnym Publicznym Szpitalu Klinicznym w Lublinie, pod okiem wybitnych specjalistów. Dr Okła wyjaśnia, że tego typu zabiegi wymagają perfekcyjnej znajomości anatomii miejsca, z którego pobierany jest fragment tkanek do późniejszej rekonstrukcji. Istotne naczynia muszą zostać zachowane, by zaopatrzyć dany region.
– Musimy też wiedzieć, który region da się w ten sposób pobrać, jakie są jego granice i jak znaleźć naczynia krwionośne, które trzeba bezwzględnie zaoszczędzić. Bo inaczej, nawet jeśli podłączymy te naczynia, a one będą gdzieś uszkodzone, te tkanki nie będą odżywiane i nie mają szans na przeżycie. Jest to ogromne wyzwanie – tłumaczy dr Okła.
Ekspert dodaje, że do połączenia wypreparowanych naczyń niezbędny jest również ogrom sprzętu, narzędzia mikrochirurgiczne. Wdrożenie nowych technik w ŚCO było możliwe dzięki dofinansowaniu zakupu narzędzi przez Urząd Marszałkowski Województwa Świętokrzyskiego na kwotę ponad 435 tys. zł, w tym dofinansowanie UE wyniosło ponad 373 tys. zł. Wartość całego sprzętu do operacji z mikrozespoleniami naczyniowymi to ponad 1,2 mln zł, w tym sam mikroskop kosztował 750 tys. zł.
Źródło: Świętokrzyskie Centrum Onkologii
Przeczytaj także: GUMed: operacja korekty przedramienia z wykorzystaniem wirtualnego modelowania i druku 3D
Przeczytaj bezpłatnie pokrewny artykuł w czasopiśmie „Chirurgia Plastyczna i Oparzenia”:
Zastosowanie autogenicznych przeszczepów skórnych w pełnym ubytku. Opis przypadku
Very nice post. I just stumbled upon your blog and wanted to say that I’ve really enjoyed browsing your blog posts. In any case I’ll be subscribing to your feed and I hope you write again soon!
quetiapine cipro denk 750 Medical Director of the Irish Heart Foundation and Consultant Cardiologist, Dr Angie Brown said Cholesterol has become a household word and one which is often associated with a need to keep it as low as possible buy cialis online us
My husband and i have been really relieved when Raymond managed to do his preliminary research while using the ideas he acquired when using the site. It is now and again perplexing to just continually be making a gift of things which often the rest have been making money from. We consider we need you to thank for that. These explanations you made, the easy web site navigation, the friendships you assist to create – it’s everything awesome, and it’s really assisting our son and the family believe that the idea is pleasurable, and that is pretty mandatory. Thanks for everything!
I have to voice my respect for your generosity supporting people that actually need guidance on in this theme. Your very own commitment to passing the message across had become exceptionally helpful and have truly allowed ladies like me to realize their desired goals. Your own insightful instruction indicates this much to me and even more to my fellow workers. Best wishes; from all of us.
I want to show some thanks to you just for rescuing me from this trouble. After browsing through the internet and meeting concepts which were not pleasant, I assumed my entire life was well over. Existing devoid of the answers to the issues you’ve sorted out by means of your guideline is a serious case, and the kind which may have adversely affected my entire career if I hadn’t encountered your web site. Your skills and kindness in maneuvering all the details was tremendous. I don’t know what I would’ve done if I hadn’t come upon such a subject like this. I am able to at this time look ahead to my future. Thank you very much for your expert and result oriented help. I will not be reluctant to recommend your web sites to any person who wants and needs support about this subject matter.
I really wanted to jot down a simple message to be able to appreciate you for some of the fabulous solutions you are giving on this website. My time-consuming internet search has at the end been honored with reliable content to go over with my best friends. I would tell you that many of us readers are definitely endowed to exist in a notable community with very many outstanding professionals with helpful concepts. I feel quite blessed to have discovered your website page and look forward to really more fun minutes reading here. Thanks once again for everything.
I in addition to my buddies were found to be checking the excellent tips and tricks from the blog while unexpectedly developed a horrible suspicion I never thanked the blog owner for those strategies. My young boys were so passionate to read all of them and already have actually been using those things. Appreciate your being very kind and also for obtaining this form of good topics millions of individuals are really desirous to discover. Our own honest regret for not saying thanks to earlier.
Thanks for all of your effort on this site. Betty delights in participating in internet research and it is easy to understand why. We learn all about the lively way you convey useful items through your web site and even inspire participation from some others on the point and my girl is actually being taught a whole lot. Take advantage of the rest of the new year. You are doing a splendid job.
I have to show appreciation to the writer for bailing me out of this incident. Because of exploring throughout the the net and finding proposals that were not pleasant, I figured my life was gone. Existing without the presence of strategies to the problems you’ve sorted out by means of this article is a critical case, and the ones which might have in a wrong way affected my entire career if I hadn’t noticed your site. Your good training and kindness in handling all things was very helpful. I don’t know what I would’ve done if I hadn’t discovered such a step like this. I’m able to at this moment look forward to my future. Thanks very much for the expert and amazing help. I won’t think twice to refer your web sites to anyone who should receive recommendations about this subject.
My husband and i have been really lucky Albert managed to finish up his preliminary research through the entire ideas he got in your site. It is now and again perplexing to simply continually be giving away thoughts that some other people might have been making money from. So we understand we’ve got the writer to thank because of that. These illustrations you’ve made, the simple web site menu, the relationships your site give support to promote – it’s got all spectacular, and it is leading our son and the family do think this subject is satisfying, and that’s seriously mandatory. Thank you for the whole lot!
I simply needed to appreciate you once more. I am not sure the things that I could possibly have gone through without these recommendations documented by you relating to such question. It was an absolute frightening matter in my position, nevertheless finding out the very well-written manner you handled the issue made me to leap for fulfillment. I am thankful for your work as well as sincerely hope you realize what a powerful job that you are getting into instructing people today using a site. I am sure you have never met any of us.
Can I just say what a aid to search out somebody who actually knows what theyre speaking about on the internet. You positively know the best way to deliver an issue to mild and make it important. Extra folks have to read this and understand this aspect of the story. I cant consider youre no more fashionable because you positively have the gift.
I and also my buddies ended up reading through the nice procedures found on the blog and the sudden came up with a terrible suspicion I never thanked the blog owner for them. The guys were for this reason joyful to learn them and have now actually been tapping into these things. Thanks for simply being so kind and then for deciding upon this kind of important topics millions of individuals are really desirous to be informed on. Our sincere apologies for not expressing appreciation to you sooner.
My husband and i have been very excited when Peter managed to carry out his reports via the ideas he came across using your web pages. It’s not at all simplistic to just find yourself giving away tips and tricks many people might have been trying to sell. So we take into account we have got the blog owner to give thanks to because of that. The explanations you made, the simple blog navigation, the relationships you aid to foster – it is most sensational, and it’s really assisting our son and the family reckon that that topic is excellent, which is rather important. Thank you for all!
I am glad for commenting to make you be aware of of the great experience my girl encountered going through your web page. She noticed several issues, which included what it’s like to have an awesome teaching character to get many others smoothly gain knowledge of specified advanced subject areas. You truly surpassed her expected results. I appreciate you for giving such warm and friendly, healthy, explanatory not to mention cool tips on that topic to Janet.
I and also my buddies came looking through the good tips on your website while immediately developed a terrible feeling I never thanked the website owner for those secrets. My men are actually as a result very interested to study all of them and have in effect in fact been taking advantage of those things. Thank you for actually being quite considerate and then for obtaining varieties of fabulous topics millions of individuals are really wanting to be aware of. My honest regret for not expressing gratitude to earlier.
I simply wanted to develop a brief message to say thanks to you for these nice information you are giving out on this site. My incredibly long internet search has finally been rewarded with useful information to go over with my guests. I 'd admit that we readers actually are extremely fortunate to be in a superb site with so many special people with insightful advice. I feel really happy to have discovered your entire website and look forward to some more amazing moments reading here. Thank you again for all the details.
I enjoy you because of all your hard work on this web page. My mother delights in participating in investigation and it’s really easy to understand why. Most people know all regarding the dynamic manner you give simple secrets via your website and as well as encourage response from other ones on this area of interest while our own child is undoubtedly starting to learn a great deal. Have fun with the rest of the year. You are performing a very good job.
I wanted to write a note to say thanks to you for some of the magnificent concepts you are writing here. My rather long internet search has at the end of the day been compensated with high-quality concept to talk about with my great friends. I 'd assert that many of us readers are really endowed to dwell in a fine place with so many special professionals with good basics. I feel very happy to have seen your entire weblog and look forward to tons of more cool moments reading here. Thanks once again for everything.
I just wanted to construct a quick note to be able to appreciate you for some of the fantastic strategies you are sharing at this website. My prolonged internet look up has at the end of the day been compensated with useful suggestions to exchange with my pals. I would suppose that many of us readers actually are unquestionably blessed to be in a fine place with so many brilliant professionals with valuable methods. I feel very much fortunate to have seen your web pages and look forward to tons of more awesome minutes reading here. Thanks a lot again for everything.
I enjoy you because of your entire hard work on this web site. My aunt enjoys working on research and it is easy to see why. My partner and i notice all regarding the powerful mode you offer good items by means of this web blog and as well as attract contribution from other people on this subject then my daughter has always been learning so much. Have fun with the rest of the new year. You’re the one performing a really good job.
Thank you so much for providing individuals with remarkably marvellous possiblity to read from this website. It’s always very pleasurable and also stuffed with amusement for me and my office peers to search your web site nearly 3 times every week to study the newest items you have. And indeed, I’m just at all times fascinated considering the cool information served by you. Certain 3 facts in this posting are particularly the most suitable I’ve ever had.
333 15, plus 60 x before and after viagra use Alternatively, GDNF might enhance the neuronal activity either afferent or efferent of both ears, protecting both the treated and the contralateral cochlear function
Thanks a lot for giving everyone an exceptionally wonderful possiblity to read from this site. It’s usually so fantastic and also packed with a great time for me personally and my office co-workers to visit your blog no less than three times a week to learn the newest items you have got. And lastly, I’m actually fulfilled with all the brilliant tactics you serve. Some 3 ideas in this post are undoubtedly the very best we have all ever had.
I am writing to make you know what a wonderful experience my princess experienced reading through yuor web blog. She realized some details, including how it is like to have an excellent giving heart to have the mediocre ones effortlessly learn about a variety of advanced matters. You undoubtedly surpassed her expected results. Thank you for showing these great, trusted, revealing and in addition easy thoughts on this topic to Jane.
Thanks a lot for providing individuals with an extraordinarily spectacular chance to check tips from this site. It is often very fantastic and packed with a lot of fun for me personally and my office acquaintances to visit the blog a minimum of three times in one week to learn the new guidance you have got. Not to mention, I’m just usually fulfilled considering the beautiful methods you serve. Certain 2 points in this article are in truth the most impressive I have ever had.
I simply had to thank you so much all over again. I do not know what I could possibly have used without these information discussed by you regarding such topic. It became a very difficult circumstance in my circumstances, nevertheless noticing a new expert strategy you managed that took me to leap over happiness. Now i am happy for your assistance and trust you find out what a powerful job you were carrying out teaching the rest through the use of a blog. I’m certain you’ve never encountered any of us.
I want to point out my affection for your kindness in support of visitors who absolutely need help on your concern. Your personal dedication to passing the solution all-around ended up being especially productive and has truly made ladies like me to achieve their ambitions. Your own invaluable tutorial means so much a person like me and substantially more to my mates. With thanks; from all of us.
Thank you for all your valuable effort on this web page. Kate really likes going through investigations and it is easy to understand why. I notice all concerning the powerful form you produce helpful ideas by means of your blog and therefore inspire response from some others about this area plus our own daughter is truly becoming educated a great deal. Take advantage of the rest of the new year. You’re the one carrying out a wonderful job.
I needed to create you that little word to help say thanks a lot as before for your personal marvelous suggestions you have contributed above. It was simply remarkably open-handed with people like you to offer openly exactly what a lot of folks would have offered for sale for an ebook to help with making some profit on their own, certainly now that you might well have done it if you considered necessary. These creative ideas likewise served as a great way to fully grasp that the rest have similar zeal the same as mine to know a little more with respect to this condition. I’m sure there are some more pleasurable moments in the future for people who take a look at your site.
Usama Basit, MD, MBBS propecia ireland
I am just commenting to make you be aware of what a amazing experience my friend’s girl experienced visiting your webblog. She noticed several things, including how it is like to have a marvelous giving spirit to make a number of people without difficulty master several extremely tough subject areas. You actually exceeded visitors’ expectations. Many thanks for showing these powerful, trusted, explanatory not to mention fun thoughts on this topic to Ethel.
Thank you a lot for giving everyone such a marvellous possiblity to read from this site. It really is so superb plus jam-packed with a great time for me personally and my office fellow workers to visit your blog on the least three times in 7 days to find out the newest guidance you will have. Of course, I’m always satisfied for the cool solutions you serve. Selected 2 facts on this page are in reality the most impressive we have had.
I enjoy you because of your entire effort on this site. Gloria takes pleasure in participating in internet research and it’s really easy to understand why. A lot of people know all of the dynamic manner you make vital tricks through this web blog and in addition increase response from the others on that subject matter so our own girl is always becoming educated a lot. Take advantage of the remaining portion of the new year. You are doing a first class job.
My wife and i ended up being so excited that Michael managed to finish up his reports through your precious recommendations he gained using your blog. It’s not at all simplistic just to be offering techniques that a number of people have been making money from. And we consider we have the writer to be grateful to because of that. All of the explanations you’ve made, the straightforward blog menu, the relationships you will help foster – it’s got many astounding, and it’s making our son in addition to the family recognize that this content is brilliant, and that is exceedingly fundamental. Thanks for the whole lot!
I in addition to my buddies were looking at the great advice from the blog then all of the sudden developed a terrible feeling I never thanked the site owner for those tips. Those ladies are already totally glad to see all of them and have in effect extremely been making the most of them. We appreciate you really being indeed accommodating and then for getting some beneficial themes millions of individuals are really needing to understand about. Our sincere regret for not expressing appreciation to sooner.
I just wanted to type a quick word to be able to express gratitude to you for some of the nice concepts you are sharing at this website. My prolonged internet lookup has at the end been paid with beneficial suggestions to write about with my pals. I would assume that most of us visitors actually are undeniably endowed to dwell in a really good site with so many marvellous professionals with beneficial suggestions. I feel rather grateful to have used your weblog and look forward to so many more cool minutes reading here. Thank you once again for everything.
I and my guys ended up looking through the excellent helpful tips from your web site and suddenly developed a horrible suspicion I never expressed respect to the web blog owner for those strategies. The men ended up as a result excited to learn them and have in truth been making the most of these things. Many thanks for indeed being really helpful and also for choosing this form of tremendous topics millions of individuals are really desperate to learn about. Our honest apologies for not expressing appreciation to sooner.
Thanks for all your labor on this web site. Kate delights in getting into research and it’s really easy to understand why. A lot of people notice all of the dynamic mode you provide worthwhile strategies via this web site and in addition attract response from visitors on this concern and our favorite simple princess is undoubtedly becoming educated a lot. Take pleasure in the rest of the new year. You have been performing a terrific job.
I am just commenting to make you know what a brilliant discovery my cousin’s princess enjoyed reading through your webblog. She mastered too many things, including how it is like to have a very effective giving mindset to have the others without difficulty thoroughly grasp a variety of complex subject areas. You undoubtedly surpassed visitors’ desires. Thank you for showing the good, safe, educational and also easy tips about the topic to Lizeth.
Thanks a lot for giving everyone an extremely breathtaking chance to discover important secrets from this website. It’s usually very brilliant and full of a great time for me and my office fellow workers to search your website minimum thrice in 7 days to read through the new guides you have. Of course, I’m just at all times motivated with your beautiful hints you serve. Selected 3 tips in this posting are surely the very best we have had.
I must show appreciation to the writer for bailing me out of such a predicament. Just after browsing through the internet and meeting basics which were not helpful, I thought my life was gone. Existing without the presence of approaches to the difficulties you’ve resolved through the short article is a crucial case, and the ones which could have badly damaged my entire career if I hadn’t come across your web page. Your ability and kindness in handling a lot of stuff was tremendous. I’m not sure what I would have done if I had not come upon such a stuff like this. I’m able to at this moment relish my future. Thanks for your time so much for your skilled and result oriented help. I will not be reluctant to refer the website to anybody who should have support on this situation.
Thanks so much for giving everyone a very splendid opportunity to read articles and blog posts from this web site. It really is very ideal plus jam-packed with fun for me and my office mates to visit your site minimum 3 times every week to study the newest stuff you have. Not to mention, we are always motivated with all the unique things you give. Selected 4 tips in this article are easily the simplest I have had.
My husband and i have been now thrilled Ervin managed to do his inquiry with the ideas he discovered from your very own web page. It’s not at all simplistic to just always be giving away things that many people have been selling. And now we fully grasp we have got you to be grateful to for this. The most important explanations you made, the simple blog navigation, the friendships you can help to engender – it’s mostly fantastic, and it’s facilitating our son in addition to us feel that the topic is thrilling, and that’s exceptionally indispensable. Thank you for the whole lot!
Thank you a lot for providing individuals with an exceptionally pleasant opportunity to read in detail from here. It can be very sweet and packed with fun for me personally and my office mates to search your web site at a minimum three times a week to see the newest stuff you have. Of course, I’m so actually amazed considering the mind-boggling points served by you. Selected 3 facts in this article are basically the most impressive we have ever had.
Щ‚Ш§Щ„ШЄ Щ„Щ‡ Ш§Щ…Ш±ШЈШЄЩ‡ Щ…Ш§ ШШЁШіЩѓ Ш№Щ† ШЈШ¶ЩЉШ§ЩЃЩѓ Щ‚Ш§Щ„ ШЈЩ€ Щ…Ш§ Ш№ШґЩЉШЄЩ‡Щ… Щ‚Ш§Щ„ШЄ ШЈШЁЩ€Ш§ ШШЄЩ‰ ШЄШ¬ЩЉШЎ Щ€Щ‚ШЇ Ш№Ш±Ш¶Щ€Ш§ Ш№Щ„ЩЉЩ‡Щ… Щ‚Ш§Щ„ ЩЃШ°Щ‡ШЁШЄ ШЈЩ†Ш§ ЩЃШ§Ш®ШЄШЁШЈШЄ ЩЃЩ‚Ш§Щ„ ЩЉШ§ ШєЩЏЩ†Ш«Ш± ЩЃШ¬ШЇШ№ Щ€ШіШЁ Щ€Щ‚Ш§Щ„ ЩѓЩ„Щ€Ш§ Щ„Ш§ Щ‡Щ†ЩЉШ¦Щ‹Ш§ Щ€Ш§Щ„Щ„Щ‡ Щ„Ш§ ШЈШ·Ш№Щ…Щ‡ ШЈШЁШЇЩ‹Ш§ Щ‚Ш§Щ„ Щ€Ш§ЩЉЩ… Ш§Щ„Щ„Щ‡ Щ…Ш§ ЩѓЩ†Ш§ Щ†ШЈШ®Ш° Щ…Щ† Щ„Щ‚Щ…Ш© ШҐЩ„Ш§ Ш±ШЁШ§ Щ…Щ† ШЈШіЩЃЩ„Щ‡Ш§ ШЈЩѓШ«Ш± Щ…Щ†Щ‡Ш§ ШШЄЩ‰ ШґШЁШ№Щ€Ш§ Щ€ШµШ§Ш±ШЄ ШЈЩѓШ«Ш± Щ…Щ…Ш§ ЩѓШ§Щ†ШЄ Щ‚ШЁЩ„ Ш°Щ„Щѓ ЩЃЩ†ШёШ± ШҐЩ„ЩЉЩ‡Ш§ ШЈШЁЩ€ ШЁЩѓШ± ЩЃЩ‚Ш§Щ„ Щ„Ш§Щ…Ш±ШЈШЄЩ‡ ЩЉШ§ ШЈШ®ШЄ ШЁЩ†ЩЉ ЩЃШ±Ш§Ші Щ…Ш§ Щ‡Ш°Ш§ Щ‚Ш§Щ„ШЄ Щ„Ш§ Щ€Щ‚Ш±Ш© Ш№ЩЉЩ†ЩЉ Щ„Щ‡ЩЉ Ш§Щ„ШўЩ† ШЈЩѓШ«Ш± Щ…Щ†Щ‡Ш§ Щ‚ШЁЩ„ Ш°Щ„Щѓ ШЁШ«Щ„Ш§Ш« Щ…Ш±Ш§ШЄ generic cialis 5mg Storage The capsules should be stored in manufacturer s original foil package at 20 to 25 C 68 to 77 F see USP Controlled Room Temperature
Glad to be one of the visitors on this awe inspiring web site : D.
I’m really impressed with your writing skills and also with the layout on your weblog. Is this a paid theme or did you customize it yourself? Anyway keep up the nice quality writing, it is rare to see a nice blog like this one today..
Right now it appears like BlogEngine is the best blogging platform available right now. (from what I’ve read) Is that what you’re using on your blog?
I am so happy to read this. This is the type of manual that needs to be given and not the accidental misinformation that’s at the other blogs. Appreciate your sharing this greatest doc.
Nice read, I just passed this onto a friend who was doing a little research on that. And he just bought me lunch as I found it for him smile Therefore let me rephrase that: Thank you for lunch!
Magnificent goods from you, man. I have understand your stuff previous to and you are just extremely magnificent. I actually like what you’ve acquired here, really like what you are stating and the way in which you say it. You make it entertaining and you still take care of to keep it sensible. I cant wait to read far more from you. This is really a terrific website.
soothing relaxation
deep sleep
F*ckin¦ amazing things here. I am very glad to peer your article. Thanks a lot and i’m looking forward to touch you. Will you kindly drop me a e-mail?
You are my inspiration, I possess few blogs and sometimes run out from brand :). „Yet do I fear thy nature It is too full o’ the milk of human kindness.” by William Shakespeare.
Bossa Nova jazz
stress relief
gym
Hello, Neat post. There’s an issue with your site in internet explorer, would check this?K IE still is the marketplace chief and a large section of folks will leave out your wonderful writing because of this problem.