FISTULAS (fistula, singular; synonym fistulas) — the pathological courses covered by granulyatsionny fabric or an epithelium, connecting the pathological center in soft tissues or bones, hollow body or a cavity of an organism to the environment or among themselves.
S.'s emergence is connected with malformations of various bodies, pathological processes (inflammatory, tumoral), injuries and operations. Depending on etiol. a factor distinguish S. inborn and acquired, in relation to the environment — outside (reported with the environment) and internal (not reported with the environment). On character of separated distinguish C. mucous, purulent, salivary (see. Sialosyrinxes ), with the expiration of cerebrospinal liquid, milk, bilious (see. Bilious fistulas ), fecal, uric; the mixed S., napr, slizistognoyny are sometimes observed, it is purulent - milk, etc. S. designate as well on body, burrowing, napr, gastric S., esophageal S. is connected with pathology to-rogo, intestinal fistulas (see), bronchial fistulas (see), urinogenital fistulas (see).
Inborn S. are a consequence of malformations — full or partial not fusion of embryonal channels and cracks. They are covered by an epithelium (the epithelized S.). Median and side Pages are most widespread. necks (see) and S. of a navel (see. Navel, umbilical area ). Median S. necks are more often connected with anomalies of development thyroid gland (see) disturbances of involution of a thyroid and lingual channel are also result. In cases of full not fusion median S. are formed (precisely on a midline at the level of a hypoglossal bone), at a partial obliteration — median cysts, to-rye, abscessing, are opened and too form Page. Side (branchyogenic) S. of a neck develop at disturbance of an obliteration of channels of a thymus, from the remained remains of embryonal branchial apertures or as a result of opening of suppurated branchyogenic cyst (see); they are located on a side surface of a neck of a kpereda from grudino - a clavicular and mastoidal muscle. Umbilical S. result from not fusion of the embryonal umbilical and intestinal course or not fusion uric channel (see). So, at poltsy not fusion of the pu-pochno-intestinal course intestinal S. between an ileal gut and a navel is formed, at not fusion only of the outside end of the course — umbilical (mucous) S., and at not fusion only of the internal end of the course — a diverticulum of an ileal gut (see. Mekkelya diverticulum ). At full not fusion of an uric channel fistula between a bladder and a navel is formed, the obliteration only of its internal end leads to umbilical (mucous) S.'s formation, and an obliteration only of its outside end — to emergence of a diverticulum of a bladder.
The acquired fistulas are connected by the origin with various processes. So, the inflammatory centers in soft tissues, bones, joints, bodies (see. Abscess , Osteomyelitis , Phlegmon ) can break outside, forming if there is no full otkhozh-deniye of nekrotizirovanny fabrics, outside S. (purulent, bilious, etc.). Abscesses, breaking in surrounding fabrics and bodies, form internal S. — between the centers in soft tissues, between the center in soft tissues and hollow body (e.g., rekto-pararectal S.), between hollow body and a serous cavity (e.g., bronchopleural S.), between two hollow bodies — interorgan S. (e.g., esophageal and tracheal S.) etc.
S.'s emergence at new growths is explained by disintegration sprouted in the next bodies and fabrics of a malignant tumor. In these cases there can be matochnopuzyrny, vulval pryamokishechnye, interintestinal, bronchopleural and other Pages.
At an injury and operations S.'s education can be caused directly by damage of hollow body or a necrosis of its wall owing to disturbance of blood circulation, emergence and break of a suppurative focus outside, insolvency of seams of a wall of hollow body or the infected foreign body left in fabrics — a gauze napkin, a ligature (so-called alloyed S.), etc.
On S.'s structure can be granulating and epithelized. The typical granulating so-called tubular S. (see fig. 7 to St. Intestinal fistulas ) represents rather long, narrow, gyrose, sometimes with many branches the course having one internal and one or several outside openings. In S.'s walls perifocal inflammatory and cicatricial changes are found. Such it is long the existing S. sometimes consider as the defect of fabrics not inclined to healing i.e. as a narrow and deep ulcer. From the patologoanatomychesky point of view similar S. is incomplete, not created as its walls are covered not with an epithelium, and granulyatsionny fabric (see).
Healing of the granulating S. is interfered the mechanical impact on fabrics of the continuous current separated, destroying action on granulation of reactive substances (e.g., digestive enzymes), by destruction of granulations and oppression of reparative processes in surrounding S. fabrics microbic toxins. The condition of reactivity of an organism of the patient is of great importance. The same factors with a considerable length of S. interfere with epithelization of its walls, i.e. transformation of the granulating S. into epithelized. At constant damage of granulations conditions for penetration of microflora into S.'s walls and maintenance in them hron are created. inflammations with education in surrounding S. soft tissues of a set of ubts. The systematic in-itsirovaniye during the weakening of protective forces of an organism can lead it to an aggravation of local pyoinflammatory process and even to its generalization. The infection with causative agents of a pyogenic infection of a tuberculous focus which is observed at S. of a tubercular etiology is especially dangerous (see. Tuberculosis extra pulmonary, tuberculosis of bones and joints ).
Independent healing of the granulating S. unlike epithelized perhaps at elimination patol. the center (e.g., an otkhozhdeniye or removal of the sequester or a foreign body), the permanent termination of current of contents from hollow body (e.g., from a bladder at recovery of passability of an urethra). The granulating S. can be closed also at suppression, but not complete elimination patol. the center, at the temporary termination of current of contents from hollow body, but in these cases the slightest deterioration in a course of a disease leads to S.'s recurrence, is frequent with formation of new fistular branchings and cavities (see. Osteomyelitis , Paraproctitis ).
The epithelized S. have no the expressed fistular channel. As in them there is no defect of an epithelial cover, from the pathoanatomical point of view they are completed, created and independently are not closed. The epithelized S. * in some cases can develop from very short and wide, is long the existing granulating fistula under conditions, especially favorable for epithelization. Option of the epithelized S. is labelloid S. (see fig. 3 and 4 to St. Intestinal fistulas ), in Krom the mucous membrane of hollow body directly grows together with skin (as lips).
In clinic outside S. are shown first of all by emergence of an outside opening of fistula and allocation from it in various quantities and various character of liquid contents. The outside opening of S. can be small (e.g., inborn S. of a neck) or wide (e.g., labelloid intestinal S.). At long existence of S. its discharge irritates surrounding skin, causing dermatitis (see). Especially sharp and painful changes of skin are observed around gastric S., S. duodenal or a jejunum in connection with the corroding effect of enzymes of digestive juices, around uric S. where dense hypostasis of surrounding skin is quite often formed, and then develops elephantiasis (see). For S. of a tubercular etiology, S. at actinomycosis (see) pallor and puffiness of granulations around a fistular opening, specific character of separated is characteristic. The general condition of patients with outside S. is broken first of all in connection with the basic disease which caused S.'s emergence (tuberculosis, a malignant tumor, long purulent process, etc.). Further deterioration in the general state can be connected with the plentiful expiration through S. of separated. So, at S. of a stomach and especially a jejunum big loss of digestive juices, proteins, electrolytes, waters leads to sharp disturbance of all types of exchange, acid-base equilibrium, weight reduction (weight) of a body; at the plentiful expiration of bile processes of digestion of food, coagulability of blood, etc. are broken.
The most expressed a wedge, manifestations are observed at internal, interorgan Pages. Big danger is constituted by such interorgan S., at to-rykh contents unusual for it get into body through fistula. So, at bronchoesophageal S. the food getting into bronchial tubes can cause acute asphyxia (see), and in the subsequent aspiration pneumonia (see); at enterovesical S. intestinal contents, getting into a bladder, can lead to development of an urosepsis (see. Sepsis ) etc.
Outside S.' diagnosis usually comes easy. It is based on the characteristic complaints given the anamnesis, existence of an outside opening of S. and characteristic separated. For specification of the direction of the fistular course, its length, width, quantity and character of branches, communication with patol. the center apply sounding, a contrast X-ray analysis (see. Fistulografiya ). The discharge is investigated on presence salt to - you (at suspicion on gastric S.), urate salts (at suspicion on uric S.), etc. Emergence of the painted phlegm at administration of dye (e.g., methylene blue) in a pleural cavity testifies to bronchopleural S.; administration of dye in S. allows to establish to area of an anus on coloring of contents of a rectum existence of the message of S. with a gleam of a gut.
Diagnosis of internal fistulas is based on a wedge, and a lab. the functions of appropriate authorities given about disturbances, and also on data rentgenol. researches. With the advent of fibroendoskop of small diameter value of a fistuloskopiya increased (see. Endoscopy ).
Treatment is defined by a form and a stage of formation of Page. It can be conservative, operational, more often combined. At the disturbance of the general condition of the patient which in some cases is sharply expressed napr, at intestinal, esophageal, bronchial and other similar S., appoint parenteral food, carry out correction of disturbances of a homeostasis, disintoxication, antibacterial therapy, etc. that has big, sometimes crucial importance.
At treatment of the granulating S. elimination of the center of an inflammation in the depth of fabrics is carried out by conservative methods (antibacterial agents, physical therapy, etc.) and operational way. At an operative measure delete sequesters of a bone, dead soft tissues, foreign bodys, etc., create good outflow of separated, passing the fistular course. Bilious S. after establishment of natural outflow of bile in a duodenum, S. of a bladder at recovery of a normal urination begin to live independently. The granulating intestinal S. usually close in the operational way since their healing can be interfered by continuous infection of fabrics on the course of Page. At the narrow granulating salivary S. sometimes there is enough closing of the fistular course with a purse-string seam. At the nek-ry granulating S. formed after operative measures, napr as a result of insolvency of seams of a stump of a bronchial tube, went. - kish. an anastomosis, etc., a certain value is had endoscopic to lay down. the procedures (removal of ligatures, granulations, sealing of defect medical glue, temporary endobronchial occlusion a porolonovy sponge etc.) which are quite often allowing to avoid traumatic operation.
Treatment of the epithelized S. operational, it consists in elimination patol. the center which caused S.'s emergence and in radical excision of the fistular course together with the epithelium covering it. Destruction of an epithelium by other methods (chemical, thermal, electric) is ineffective.
At labelloid S. only radical operation — mobilization of walls of hollow body and mending of an opening in it or, napr is shown, at cicatricial changes of walls, a resection of a part of body.
In outside S.' treatment the nosotrophy is especially important (see. Leaving ). Any separated S. which is especially containing digestive enzymes, elements of urine, etc. promotes infection and renders irritant action on skin up to development of heavy dermatitis. At each bandaging the skin surrounding S. is cleared and greased with sterile vaseline, a sintomitsinovy emulsion or Lassar's paste. It is necessary to adjust collecting allocations that they irritated surrounding skin as little as possible and did not soil linen. For this purpose at S. of hollow bodies apply drainage (see) with removal of bile, urine, etc. in a large bottle, and for collecting intestinal contents adapt a kalopriyemnik. Skin around S., through to-rye gastric or pancreatic juice separates, cover with pieces of crude meat or ovalbumin. Good results are yielded by also frequent bathtubs and S.'s treatment without bandage under a framework that allows the most sick to drain as required a discharge gauze tampons.
Artificial fistulas form special group C., created in purposely operational way for the purpose of recovery of passability of hollow body, assignment in the necessary direction of its contents or a secret, and also for providing food of an organism through it. Of hollow body it is accepted to call artificially created outside S. an ostomy, artificially created internal interbody-ny of S. — an anastomosis, an anastomosis (see. Anastomosis ), and operations on their creation — a stomiya. Treat operations on creation of an ostomy gastrostomy (see), colostomy (see), pyelostomy (see), tracheostomy (see), cholecystostomy (see), enterostomy (see), etc.; to operations for formation of an anastomosis — gastroenterostomy (see), cholecystogastrostomy (see), an enteroenterostomiya (see. Enteroenteroanastomoz ), etc. Depending on indications create temporary ostomies counting upon a possibility of their independent subsequent fusion (on a minovaniya of need for them) and constants — necessary for a long time (in such cases create labelloid S., hemming a mucous membrane of body to skin). During the formation of an anastomosis create the epithelized S., sewing with each other mucous membranes of both bodies.
Bibliography: Askerkhanov R. P. and M and x and t and l about in M. M. Treatment of intestinal fistulas, Surgery, No. 9, page 44, 1981; Borisov A. I. and Alikov V. B. Surgical treatment of high intestinal fistulas, there she, page 54; D about l e c cue S. Ya., Gavryushov V. V. and Akopyan V. G. Surgery of newborns, page 103, 198, M., 1976; Zakharov S. N., etc. Treatment of outside fistulas of a digestive tract, Surgery, No. 9, page 51, 1981; Outside and internal fistulas in surgical clinic, under the editorship of E. N. Wangqiang, M., 1982; V. I Pods. General surgery, page 497, M., 1978.
V. Y. Struchkov.