From Big Medical Encyclopedia

BILIOUS FISTULAS — pathological or artificially created it is long the existing courses (channels) through which bile from biliary tract is emitted outside or comes to the next hollow bodies or cavities.

Depending on where bile follows. pages divide on outside, internal and combined.

Outside bilious fistulas

Outside bilious fistulas are most important in the practical relation. Among them on the mechanism of education distinguish: 1) spontaneously arisen (spontaneous); 2) posttraumatic (fire and not fire origin); 3) postoperative (connected with the postponed operative measure on the bilious ways and the bodies, next to them); 4) imposed with to lay down. purposes. Outside. pages can be full — all bile arrives through fistula outside, and incomplete — a part of bile gets into intestines. If to the bile arriving through fistula intestinal contents, then such fistula naz are added. mixed. Depending on a configuration of the fistular course outside. pages happen direct, twisting or chetkoobrazny. Existence of inflammatory processes in a liver, in an abdominal cavity or in fabrics of an abdominal wall demonstrates development of the complicated outside. page. Periodically closed and opening again outside. villages received the name of recurrent.

Most often postoperative outside meet. pages which main reason of education disturbance of an integrity of bilious channels unnoticed by the surgeon is or, more rare, a gall bladder at operative measures, especially if the obstacle to outflow of bile on extrahepatic bilious channels remains.

Outside. the pages which resulted from damage of the general bilious or hepatic channels during liver operations and bilious ways or other abdominal organs, as a rule, are the most dangerous to patients and happen full and constant, i.e. functioning until their elimination by an operative measure.

Outside. the page can arise and independently as a result of inflammatory process, napr as a complication of acute cholecystitis perforation through an abdominal wall. Usually outside. pages open on a front abdominal wall.

Outside. the page can be created and is artificial as a palliative surgical grant at mechanical jaundice in connection with inoperable cancer of biliary tract or heads of a pancreas with a prelum of the general bilious channel; at an atresia of bilious ways at children and in some other cases this fistula is the first stage of radical operation for elimination of obturatsionny jaundice and its effects.

With to lay down. purpose outside. the page depending on indications can be imposed on a gall bladder — cholecystostomy (see), on the general bilious canal — choledochostomy (see), on the general, right or left hepatic canals — a hepaticostomy (see. Bilious channels ) or on one of intra hepatic bilious channels — a gepatokholangiostomiya (see. Liver, operations ). Most often the cholecystostomy is shown at acute cholecystitis — when cholecystectomia (see) it is dangerous because of a serious general condition of the patient or considerable technical difficulties. For a temporary decompression at radical operation on the bilious ways the choledochostomy is used.

Clinical picture at patients with outside. the page depends on the nature of fistula (full or incomplete, etc.) and duration of its existence. Full fistulas when all bile is given vent outside are especially dangerous. Long outpouring of bile outside causes considerable fluid losses and electrolytes (potassium, calcium, phosphorus, chlorine, magnesium) and leads to serious violations of water-salt balance and process of digestion. This symptom complex received the name of an acholia. The acholia is characterized by a lose of weight, a loss of appetite, the vomiting raised by bleeding, hypochromia anemia, osteoporosis, a hair loss, trophic skin frustration, avitaminosis of A, B, D, E, K.

The general condition of patients with spontaneously arisen incomplete outside. the page usually does not happen heavy; in such cases through fistula together with bile pus, and sometimes and concrements is often emitted. At posttraumatic (fire) outside. the page amount of the emitted bile is usually small, transformation is quite often observed. the page in is purulent - bilious, and then in purulent. If at the same time purulent complications in a liver or in subphrenic space do not develop, then such wounded quickly recover.

Fig. 1. Fistulogramma of incomplete outside bilious fistula: 1 — the fistular channel (the rest of a vesical channel) contrasted through a drainage tube (in the drawing a tube at the left); 2 — a stone in the general bilious channel.

Diagnosis outside. the page usually is established without effort on the basis of the expiration from fistula bile (see), however to define with reliability from where fistula proceeds, it is possible after rentgenol, researches (fig. 1). One of the simplest and informative methods is fistulografiya (see), allowing to obtain the valuable data.

Conservative treatment . the page can provide only temporary effect. Long existence of outside. the page always demonstrates existence serious patol, changes in bile-excreting system — most often impassability of hepatic or general bilious channels therefore overwhelming number of patients with. the page is subject to operational treatment. Nature of operation on an occasion of outside. the page depends on a type of an obstacle to normal outflow of bile (a stricture, stones, a tumor and so forth). The purpose of operation is creation or recovery of a way for free intake of bile to intestines by means of various type of an internal biliodigestivny anastomosis, excisions of a stricture or a tumor with anastamosing of a bilious channel the end in the end, plastics on a submersible drainage and other receptions. The choice of an operative measure at outside. the page depends on a condition of bilious channels at the patient. If accidental damages of the bilious courses during the previous operation did not cause big defect of the general bilious channel, then it is necessary to aim at recovery of its integrity on the hidden drainage. Recovery of passability of the general bilious channel by sewing together the end in the end admits many surgeons by the best method of treatment outside. page (see. Bilious channels, damages, operations ).

If outside. by page it was formed as a result of damage of the general bilious channel during a resection of a stomach and recovery of its integrity is complicated, technically the simplest operation of elimination of outside. the page will be creation of an anastomosis between a gall bladder and a loop of a small bowel. In some cases at a remote gall bladder and at an obliteration of a distal piece of the general bilious channel it is necessary to resort to imposing of an anastomosis between hepatic channels and various departments went. - kish. path. Among similar operations are the most widespread hepaticoduodenostomy (see) and a hepaticoenterostomy (see. Bilious channels, operations).

Fig. 2. Diagrammatic representation of some stages of operation of a hypodermic holefistuloenterostomiya: and — mobilization of the site of a «free» segment of a jejunum with the kept feed vessels after imposing of an anastomosis the end sideways between proximal department of a jejunum and its free site; on the right above — the first stage of operation; — the mobilized site of a jejunum is prepared for introduction to the hypodermic tunnel for outside bilious fistula; at the left below — suture between the otseparovanny mouth of the fistular course and the free site of a jejunum; on the right above — operation is complete; 1 — the line of the section bordering outside bilious fistula; 2 — the line of a verkhnesredinny section; 3 — an outside opening of fistula; 4 — the mobilized site of a jejunum; 5 — the proximal site of a jejunum; 6 — an interintestinal anastomosis; 7 — a mesentery with the kept blood vessels; 8 — a stomach; 9 — an anastomosis between the mobilized site of a jejunum and the bilious fistular course.

In some cases imposing of an intraperitoneal anastomosis of bilious channels with the digestive channel for the purpose of elimination of outside. the page becomes absolutely impracticable, and then at patients with resistant full outside. pages make a hypodermic holefistuloenterostomiya by Smirnov's (fig. 2) method.

Technology of operation. From an upper median laparotomy mobilization of the site of a jejunum of 35 — 40 cm with preservation of feed vessels is made. The mobilized loop is crossed and carried out via the prepared hypodermic tunnel towards. page. The hypodermic anastomosis on type the end sideways between the otseparovanny fistular course and the free site of a small bowel is imposed. The continuity of intestines is recovered by an anastomosis the end sideways between oral department of a jejunum and its free site.

Internal bilious fistulas

Internal bilious fistulas can report among themselves bilious ways (bilio-biliary), bilious ways with a stomach or nearby sites of intestines (biliodigestivny), with bronchial tubes (bilious and bronchial). Spontaneous internal. pages are usually formed owing to destruction patol, process of walls of the hollow bodies soldered to bilious channels or a gall bladder. This complication can develop at cholelithiasis, echinococcosis, malignant tumors, an actinomycosis of a large intestine and other diseases. They can be formed at a peptic ulcer as a result of a penetration and perforation of an ulcer in bilious ways. The most often internal. pages arise between a gall bladder and a duodenum (holetsistoduodenalny. page), general bilious channel and duodenum (holedokhoduodenalny. page), between a gall bladder and a cross colon.

With to lay down. purpose internal. pages are imposed, as a rule, for creation of a bypass outflow tract of bile in the presence of unremovable obstacles: cicatricial narrowing of distal department of the general bilious channel, cancer of a big nipple of a duodenum (a faterov of a nipple), at indurative pancreatitis, cancer of a head of a pancreas, etc.

Most often impose an anastomosis between a gall bladder and a duodenum — cholecystoduodenostomy (see), a gall bladder and a stomach — cholecystogastrostomy (see), and also between the general bilious channel and a duodenum — choledochoduodenostomy (see) or the general bilious channel and a jejunum — a choledochojejunostomy.

Clinical manifestations internal. pages usually mask at patients with symptoms of a basic disease. As complication of internal. the page in connection with throwing of contents of intestines or stomach to hepatic canals often arises cholangitis (see), abscesses of a liver are more rare (see the Liver, diseases). As a result patol, messages of a gall bladder with intestines can get to guts large stones of a gall bladder that in turn can be the cause of development of obturatsionny intestinal impassability (see. Impassability of intestines ).

Fig. 3. The survey roentgenogram of area of a gall bladder at internal bilious fistula: 1 — air in the bilious courses; 2 — a gas bubble in a duodenum.

Internal. pages are easily diagnosed at emergence of impurity of bile where she normal is not, napr, impurity of bile to a phlegm at formation of bilious and bronchial fistulas. But the main method allowing to establish existence of internal. page and its localization, the research — survey roentgenoscopy and a X-ray analysis of area of a liver and bilious ways (fig. 3) at which gas in bilious ways, a duodenografiya in a condition of artificial hypotonia (can be defined see is rentgenol. Duodenografiya relaxation ); at bilious and bronchial fistulas the diagnosis facilitates bronchography (see). The intravenous holangiografiya not always reveals internal. page since dumping of a contrast agent through a wide fistular opening interferes with its concentration in bilious channels (see. Holegrafiya ). Allows to specify character and

localization. page a holangiografiya on the operating table (see. Holangiografiya ).

Operational treatment internal. the page is necessary only when they are complicated by development of a cholangitis, hepatitis, abscess of a liver and at bilious and bronchial fistulas. When adequate dumping of bile into intestines is provided, in the absence of the ascending infection of bilious ways their elimination is inexpedient. Operation on an occasion of internal. the page consists in dissociation of the bodies forming. page, sewing up of their walls if on the nature of a disease removal or a resection of these bodies is not required.

See also Cholelithiasis , Bilious channels , Liver .

Bibliography: Bregadze I. L. and Ivanov P. A. Outside bilious fistulas, M., 1965, bibliogr.; 3edgenidze G. A. and Lindenbraten L. D. Urgent radiodiagnosis, page 295, L., 1957; Kochiashvili V. I. The atlas of surgical interventions on the bilious ways, M., 1971; Napalkov P. N., At the h in and t to and V. G. and Artemyev's N of H. H. Fistulas of bilious ways, L., 1976, bibliogr.; P e of t r about in B. A. and Galperin E. I. Hirurgiya of extrahepatic bilious channels, M., 1971, bibliogr.; H and l of and N about in A. I. Naruzhnye bilious fistulas, Owls. medical, No. 10, page 113, 1976; Shalimov A. A. and d river. Hirurgiya of a liver and bilious channels, Kiev, 1975, bibliogr.

A. B. Galitsky, A. I. Chalganov.