INTESTINAL FISTULAS (fistulae intestinales) — the openings isolated from an abdominal cavity in an intestinal wall through which the gleam of a gut is reported either with the environment, or with other hollow body.
To. pages are known from antiquity, however to the middle of 19 century in literature on them only single messages met that it was connected with a small number of operations on abdominal organs.
and convenient is considered the simplest classification To. page, offered by V. A. Oppel and N. I. Bobrikova (with P. D. Kolchenogov and B. A. Vitsyn's nek-ry additions, 1964, 1965). On this classification To. pages divide as follows: on an etiology — inborn, acquired (medical, traumatic, other); in the location of a fistular opening — outside and internal; on a structure of a fistular opening and the channel — labelloid, tubular and transitional; on number of openings — single (one-oral, two-oral) and multiple (next, remote); on localization — fistulas of a duodenum, a small bowel, a large intestine, rectum; on a passage of intestinal contents — full, incomplete; on the allocated ekskret — fecal, mucous, it is purulent - fecal, is purulent - mucous, other; on existence or lack of complications — uncomplicated and complicated with local (an abscess, fecal phlegmon, dermatitis, osteomyelitis etc.) and the general (exhaustion, sepsis and so forth) complications.
the Reasons of education To. pages are various. During wars frequency considerably increases To. page, especially fire origin. In peace time the most frequent reasons of formation To. pages are the inflammatory processes, malignant new growths closed and open damages. In some cases To. pages are imposed by surgeons for the purpose of unloading of a digestive tract or administration of liquid and nutrients in its gleam (see. Colostomy , Enterostomy ).
Patol, changes in an organism are defined first of all by localization and complications To. page. The above fistula, the more its negative influence on an organism is located. At the same time full fistulas or incomplete, but with considerable separated quicker lead to the expressed disturbances in an organism. Allocation outside of a large amount of liquid, enzymes, electrolytes and undigested foodstuff leads to the progressing exhaustion of an organism. The greatest changes consisting in the progressing dystrophy are observed in a liver and kidneys.
At outside To. the page, especially enteric, quickly enough comes a hypoproteinemia with a disproteinemia, the shown hypoalbuminemia, increase alpha and gamma globulinovykh fractions. Depending on height of fistula the water and electrolytic balance is in a varying degree broken, especially quickly there comes the hypopotassemia and a hypovolemia which, in turn, promote disturbance of electrolytic balance. These changes are less expressed at low enteric fistulas and fistulas of a large intestine. However at accession to the last it is purulent - septic complications the phenomena of a toxaemia which also lead to heavy dystrophic changes with development of hepatonephric insufficiency develop.
A cause of death at To. the village most of authors considers loss of digestive juices, electrolytes, sharp disturbance of protein metabolism, dehydration of an organism.
A clinical picture
the Main symptom outside To. page — allocation from a wound of a chyme, gases or a calla. At low fistulas, especially left half of a large intestine, allocation happen periodic. Weight of a clinical picture is defined by localization of fistula, quantity of the ekskret allocated from it, and also existence of complications. Complications To. pages proceed in the form of dermatitis, maceration of skin, formation of purulent cavities, phlegmons of hypodermic and retroperitoneal cellulose, osteomyelites. The heaviest oslozh a neniye — a septicopyemia and a septicaemia (see. Sepsis ).
Preliminary judgment of localization To. the page can be made by results of a usual cleansing enema. At an arrangement To. the page in a large intestine water, as a rule, pours out through a fistular opening outside. It usually is not observed if fistula proceeds from a small bowel. An approximate idea of location of fistula is given also by overseeing by the patient after meal. Allocation from a fistular opening of few changed food masses within the next hour after food demonstrates existence of duodenal or high enteric fistula. In doubtful cases it is possible to give to sick per os solution methylene blue, Carbolenum that facilitates ascertaining of allocation them from a fistular opening. Plays an important role in diagnosis rentgenol. research. At high fistulas of a small bowel a X-ray analysis of a stomach and intestines, and at colic fistulas irrigoskopiya (see) allow to define location of a fistular opening rather precisely. At internal To. the village rentgenol, a research of intestines allows to establish accurately the direction of the fistular course, and also to define body, about the Crimea is reported To. page. An important role at outside To. the page plays fistulografiya (see), allowing not only to specify localization of fistula, but also to define a condition of the bringing and taking away departments of a gut. The research of a condition of the taking-away department of a gut is obligatory, first of all, at full fistulas since at long existence To. pages are noted cases of a considerable atrophy and even an obliteration of the taking-away department. Endoscopic methods of a research, such, as gastroscopy (see), duodenoskopiya (see), intestinoskopiya (see), kolonoskopiya (see), matter generally for diagnosis of internal fistulas (e.g., gastrolic) since allow to specify localization of a fistular opening, a condition of an intestinal wall, to define expressiveness of inflammatory process or existence of a malignant tumor.
Types of intestinal fistulas
Inborn intestinal fistulas
Inborn intestinal fistulas result from disturbance of processes of an embryogenesis at early stages of fetation.
Enteric inborn fistulas are connected with disturbance of an obliteration of a vitelline and intestinal channel (ductus omphaloentericus). Normal the zapustevaniye of a vitelline and intestinal channel occurs by 3rd month of an antenatal life. At disturbance of its obliteration there are full or incomplete enteric fistulas or fistulas of a navel (fig. 1 and 2).
Full fistula of a navel arises when the vitelline and intestinal channel remains nezarashchenny throughout and the gleam of an ileal gut is reported with the environment through an umbilical ring. Outward To. page it is quite characteristic and does not represent special difficulties for diagnosis. After falling away of an umbilical cord the umbilical wound is not closed. In the field of an umbilical ring it is possible to find a mucous membrane of a gut of bright red color. Fabrics around fistula of an infiltrirovana. At a natuzhivaniye and shout of the child evagination (ectropion) of an adjacent piece of a gut through a fistular opening is possible that it can lead to disturbance of passability of intestines. In doubtful cases valuable diagnostic reception is the fistulografiya. A contrast agent through fistula gets to a small bowel. The continuous expiration of intestinal contents leads to maceration of skin of a front abdominal wall and exhaustion. Children lag behind in physical. development.
Treatment of full fistulas of a navel only operational. In order to avoid complications (evagination, infection of a front abdominal wall, an ulceration and bleeding) operation is made after establishment of the diagnosis at once. Operation consists in excision of the fistular course throughout. On defect of a gut put a one-row suture. Forecast, as a rule, favorable.
Incomplete fistulas are observed much more often than full and arise at disturbance of an obliteration of distal department of a vitelline and intestinal channel.
At incomplete To. the village among not plentiful granulations in the field of an umbilical wound is possible to find a dot fistular opening with small serous or serous and purulent separated. Course of such fistulas always long. Quite often the secondary inflammatory phenomena join. Make sounding of the fistular course for confirmation of the diagnosis. Usually the probe manages to be carried out on depth of 1 — 2 cm. In doubtful cases it is necessary to make a fistulografiya. It allows to specify the nature of fistula.
Treatment of incomplete fistulas of a navel needs to be begun with conservative actions. Are reasonable daily a gigabyte. bathtubs with weak solution of potassium permanganate. The umbilical wound after a toilet and processing by alcohol is cauterized by 5% spirit solution of iodine or 10% solution of silver nitrate. As a result of the carried-out conservative treatment in most cases incomplete fistulas independently are closed. At inefficiency of conservative treatment the operative measure consisting in excision of the fistular course is shown. It is reasonable to perform operation aged 6 months are more senior. Forecast, as a rule, favorable.
Developing of colic inborn fistulas is connected with incomplete short circuit of a vertical cloacal partition in early stages of embryonic development. As a result of it there is a message between anorectal and urogenital parts of primary foul place.
These fistulas are observed at normally created anus, and also at its atresia and a rectum. Fistulas can open in a reproductive system (a vagina, an entrance of the vagina, a uterus), in uric system (a bladder, an urethra) y to the area of a crotch.
At normally functioning opening of an anus the act of defecation happens in the natural way, but at the same time fecal masses partially departs through fistula in that body, about the Crimea there is a message. At boys fistula most often opens in an urethra, at girls — in an entrance of the vagina. In the presence of an anastomosis between a rectum and a bladder the effluence of muddy urine because of mixing it with a stake is constantly noted. At the same time through an urethra gases depart. Such fistulas often proceed hard owing to accession of the ascending infection of uric ways. At rektovestibulyarny fistula the incontience liquid a calla and gases is usually noted. Localization of fistula is established at external examination and overseeing by the act of an urination. Fistulografiya finally confirms the diagnosis.
The choice of a method of treatment and its terms depend on a type of fistula. At patients with fistula in uric system operation is shown right after the birth and establishment of the diagnosis. At fistulas in a reproductive system (at girls) the issue of treatment is resolved individually. The indication to early operation (6 — 8 months) the persistent locks which are followed by intoxication and lag in physical are. development. At fistula in a vagina or uric system performance of a belly and perineal proctoplasty is more reasonable.
The acquired intestinal fistulas
the Acquired intestinal fistulas are formed as a result of the complicated current acute and hron, inflammatory processes in an abdominal cavity or malignant new growths. The acute appendicitis, peritonitis, ulcer processes are the most frequent reasons of formation of fistulas in went. - kish. path, ginekol, diseases, tuberculosis of intestines, disease Krone. Fistulas can be also a consequence of complications of various surgeries on abdominal organs and retroperitoneal space. Quite often injuries of a stomach, especially getting wounds, lead to education To. page.
At labelloid fistulas the mucous membrane of a gut grows together with skin on all circle of a fistular opening (fig. 3). In labelloid fistula distinguish the following elements: an opening of fistula, front and back walls, the bringing and taking away sites of the gut bearing fistula. The bringing and taking away parts of an intestinal tube at most of patients with labelloid fistulas are separated from each other by the sticking-out back wall of a gut in the form of a so-called spur (fig. 4). The spur can be mobile (false) and motionless (true). The first freely plunges during the pressing by a finger into a gleam of a gut. Sometimes it occurs also at a postural change of the patient. The true spur is not set in an abdominal cavity neither at a postural change of the patient, nor during the pressing by a finger because of fixing by its hems and commissures.
Depending on the size of a corner, under the Crimea are fixed to each other bringing and taking away a knee кишки§ bearing fistula, distinguish acute and stupid (flat) spurs. The top of a spur is turned into a fistular opening, the basis — to an abdominal cavity. Any wall of a gut can take part in formation of a spur. The created true spur does not allow passing of intestinal contents to distal department that leads to formation full To. page.
At big fistulas protrusion of the bringing or taking away pieces of a gut can be observed, and on site such fistula big hernial protrusion is quite often formed. At full labelloid fistula in the taking-away knee there occur atrophic changes, and fistula in these cases is characterized by the short channel and a wide gleam. Labelloid fistulas happen one-oral (fig. 5) and two-oral, and two-oral fistulas always full (fig. 6).
Tubular To. pages (fig. 7) are characterized by existence of the channel covered by either cicatricial, or granulyatsionny fabric between an outside opening of fistula and an intestinal wall. In tubular fistula, except the channel, distinguish an outside and internal opening. Tubular fistulas, as a rule, incomplete also tend to independent closing.
Allocate still transitional forms of fistulas when symptoms of labelloid and tubular fistulas take place. D. P. Chukhriyenko describes so-called piogenic fistulas at which between internal and outside openings of tubular fistula there is a purulent cavity.
Conservative treatment always shall be complex. Only inefficiency, and sometimes and explicit hopelessness of conservative treatment forces to resort to operation. And persistent conservative treatment at tubular fistulas shall be especially visual.
Its complex joins first of all the actions directed to reduction or the termination of an effluence of intestinal contents, to elimination of exhaustion, dehydration, a toxaemia, prevention and elimination of irritant action of enzymes on surrounding fabrics. For reduction or the prevention of allocations from labelloid fistula drainage glass and rubber tubes, several types of obturators and gates, and also special devices are offered. Use of drainage glass tubes like Paul (fig. 8), rubber gates and the transporting devices is reasonable only at high enteric fistulas since dense intestinal contents quickly close a gleam of fistula. Obturators can be used at labelloid fistulas of any localization if there is no true spur.
At fistulas of a small bowel with a well-marked spur the devices aspirating intestinal contents from the bringing piece and transporting them in the taking-away piece of a gut (Maknoton's device, fig. 9) are used. I. M. Rokhkind for closing of a gleam of intestinal fistula used rubber drainage tubes, to-rymi the spur was at the same time pushed aside and the gleam of fistula (fig. 10) was closed. Hatskelevich (1938) offered the model of the rubber gate (fig. 11). Prost is also easy to use the obturator offered by P. B. Kolchenogov (fig. 12). The author managed to carry out full-fledged obturation at 44,2% of patients with labelloid To. page.
However any gates did not find broad application since they quite often squeeze an intestinal wall that causes frustration of its food with the subsequent development of complications.
For fight against maceration of skin there are methods which can be divided into means of mechanical protection (obturation of fistula) and means biol, protection (various buffer solutions, powders from powdered milk, acidophilic paste, a beef-infusion broth, meat juice, small plates from beef meat, ointment, etc.). From ointments Lassar's paste, Lauenstein's ointment (Dermatolum of 4 g, zinc oxide of 50 g, starch of 50 g, lanolin of 60 g, linseed oil of 36 g) and zinc oxide ointment are recommended. As powders apply also gypsum, talc, wood charcoal, a kaolin. Creation on skin of a protective film from the rubber adhesive dissolved in gasoline from BF-2, BF-6, VBK-14 glue is possible. Seldom apply water bathtubs and an open way with use of a framework with electrolamps. For topical treatment tubular To. villages use Potter's method: enter a thin rubber catheter into fistula and kapelno 0,1 N pour in solution salt to - you, instead of it it is possible to use also other buffer solutions.
At treatment of tubular fistulas of a large intestine sick appoint rest, a medicamentous delay of a chair, a rigid diet. Food shall be high-calorific, digestible, contain as little as possible cellulose. Food shall be fractional (5 — 6 times a day). At high fistulas reception of per os of liquid shall be limited to 500 ml. Strictly divide introduction of liquid and dense food. Meat dishes, liquid eggs, an omelet with milk, the wiped cottage cheese with sour cream, butter on 20 — 30 g, white loaf, crackers, biscuit, sugar, abrupt porridges (semolina, rice), vermicelli, jelly, mousses, kissels, vitamins are a part of a daily diet. In process of reduction and consolidation of allocations add cellulose in the form of gentle vegetables, puree potato, carrot, from a cauliflower. The patient shall lie preferential on the party opposite I whistle. In such situation the back wall of a gut droops and the gut becomes more passable for gases and a calla.
In the presence of local inflammatory processes (infiltration, abscesses, purulent flow) their adequate drainage is necessary. Along with topical treatment the events directed to the prevention of exhaustion and dehydration of an organism shall be held. For this purpose enter intravenously kapelno medicinal solutions (5% solution of glucose of 1 — 1,5 l, Ringer's solution of 1 — 1,5 l, etc.)» vitamins, proteinaceous drugs like casein, Aminopeptidum, plasma (see. Parenteral food ). Also hemotransfusion is shown.
Uncomplicated tubular fistulas under the influence of fortifying treatment, the corresponding diet and topical treatment in considerable number of cases heal. Therefore to operational treatment outside To. page it is necessary to resort not earlier than in 6 — 12 months
is Distinguished by extra peritoneal and intraperitoneal operations. During the doaseptichesky period treatment of intestinal fistulas was generally conservative, and rare operations were performed by an extra peritoneal method. At the same time much attention was paid to elimination of a spur, to-ruyu considered the main reason preventing healing of fistulas.
In 1815 Dyupyuitren designed the tool for crush of a spur — enterotrib. After implementation in surgical practice of an asepsis, antiseptics and improvement of the technology of operations on intestines big distribution was gained by intraperitoneal methods. However some extra peritoneal methods are occasionally applied also in sovr. wedge, practice. Operation Malgenya — Panasa (fig. 13) is shown at the small fistulas having a false spur. The section of skin is made on border of a mucous membrane. Then get into a layer between serous and muscular covers. For suture without tension allocate, otstupya from edges of defect of a gut, the site in 1,5-2 cm. After this edge of a fistular opening refresh. Put a catgut noose or continuous stitch through all layers of a wall of a gut, then impose the second row of gray and serous silk seams. The abdominal wall is not sewn up.
K. P. Sapozhkov offered at the small fistulas having a false spur, the following method of operation (fig. 14). The section is made on edge of a mucous membrane of fistula. Then on the finger entered into a gleam of a gut separate a mucous membrane in the form of a cuff 2 cm high. On the basis of a cuff put a purse-string stitch then it is set in a gleam of a gut and tighten a seam. The second row of seams is imposed on a muscular layer of a gut. Skin is not sewn up.
Nelaton's operation — Rangnielia — Rokitsky is shown at the labelloid fistulas having a wide flat spur and also when bringing and taking away a knee open separately. It consists in use of rags of skin which are rolled by epidermis inside and are sewn up (fig. 15). Passability of a gut is recovered at the expense of the tube created from skin rags. Under skin enter a drainage.
A. V. Melnikov developed the operation (fig. 16) which is in what on both sides of fistula from skin and hypodermic cellulose is found by two rags like wings of a butterfly. The basis of rags is located cross to a gleam of a gut. Width of the basis corresponds to the diameter of fistula. Rags immerse in depth of fistula that they adjoined the refreshed surfaces. As a result labelloid fistula turns into tubular and heals.
Distalny whistling for existence of a true spur and obturation of intestines is a contraindication for closing of fistula with an extra peritoneal way.
A transitional side between extra peritoneal and transabdominal methods is the operation offered by Brown (N. of Braun). The intestinal loop is otseparovyvat around fistula whenever possible without opening of an abdominal cavity. The bringing and taking away pieces are sewed among themselves gray and serous seams, then between these seams and fistula cut both knees and impose the second row of seams. Mending of the wide anastomosis received thus comes to an end with imposing of a two-row front seam. The sewn-up intestinal loop is lowered in a wound, and the abdominal wall is layer-by-layer sewn up tightly. According to P. T. Volkov, extra peritoneal operations give on average 3,7% of the next postoperative lethality. After similar operations often there is recurrence (35 — 40%) that causes the necessity of repeated operations. In this regard many surgeons give preference intraperitoneal to operations.
Intraperitoneal methods are subdivided into operations on switching off of fistula and the bowel resection bearing fistula.
At switching off of the intestinal loop bearing fistula, open with a bypass anastomosis (Mezonnev's operation) far from fistula an abdominal cavity, between the bringing and taking away loops impose an anastomosis on type a side sideways. Operation is applied seldom since she does not prevent hit of intestinal contents in fistula.
Modification of this operation is the unilateral switching off of fistula offered in 1871 by Hacken and N. Senn. The abdominal cavity is opened far from fistula, the bringing knee is crossed and its proximal end connect to the taking-away knee an anastomosis the end sideways. The distal piece of the bringing loop is sewn up tightly. According to some information, after this operation in 11% of cases fistulas do not heal; besides, a negative side of this operation is formation of fecal stones in the disconnected loop.
The method of bilateral switching off of a gut for the first time applied F. Trendelenburg in 1875. Far from fistula open an abdominal cavity, then cross the bringing and taking away loops both between them above and below fistula impose an anastomosis. The ends of the switched-off site process in the different ways: on the Dash, one end (any) is sewn up tightly and lowered in an abdominal cavity, another is sewed in a wound of an abdominal wall (whistle for Tiri); across Vella, both ends sew in a wound (Vella's fistula); on Holsteda — to Germann, the ends of the switched-off gut sew y a ring; across Bernstein — both ends sew up tightly and immerse in an abdominal cavity.
At bad outflow from the disconnected gut the break of contents in an abdominal cavity with development of peritonitis is possible. Therefore the best way is Vella's way as the first stage of treatment To. page. Then make either removal of the disconnected loop, or its demucosation on Boots at. At satisfactory condition of the patient these two phases are completed in one step. To demucosations (see) it is impossible to resort in the presence of tumors and inflammatory infiltrates.
V. Hacker in 1888 offered operation of bilateral switching off of a gut with evagination of both ends of the disconnected loop. This operation was executed for the first time by L. F. Lenevich (1889). V. Hacker's operation — Lenevich is made at the mobile loops of intestines having a mesentery at absence in an abdominal cavity of massive commissures and at single fistulas. In other cases when evagination is impossible, the switched-off sites of a gut sew in a wound of an abdominal wall across Vella and then delete.
Methods of the regional bowel resection bearing fistula are also various.
Operation of Half-ANO is shown at small single fistulas. Fistula is surrounded with an oval section then far from it get into an abdominal cavity. Excise all fistular course and separate the basis of the fistular course with a regional resection of an intestinal wall. The opening in a gut is taken in in transverse direction.
At Melnikov's operation the abdominal cavity is opened with an oval section, releasing fistula from unions. Then the gut is removed in a wound and cicatricial edges of fistula exsect. Defect in an intestinal wall is sewn up in transverse direction, imposing a so-called anastomosis in 3/4 (fig. 17). According to the author, such way can be used at fistulas of any sizes. At the same time it is necessary that on those and other sides from a mesentery the strip of an intestinal wall not less than 1,5 — 2 cm wide was kept.
The method of a circular single-step resection of the intestinal loop (fig. 18) bearing fistula was offered in 1888 by T. Billroth. Two semi-oval cuts around fistula cut layer-by-layer skin and hypodermic cellulose. These rags sew up with provisional seams over fistula. Then cut an aponeurosis and open an abdominal cavity. The intestinal loop bearing fistula is removed in a wound outside that to carry out a resection out of an abdominal cavity. Within not changed gut carry out a resection and passability recover an anastomosis the end in the end. At an arrangement of fistula on an intestinal loop with a mesentery this technique yields good results.
To W. Korte in 1896, and then the Soviet surgeon V. M. Mysh developed a circular resection of a loop of the gut bearing fistula with preliminary imposing of an anastomosis on type a side sideways (fig. 19).
Considering features of a large intestine, most of surgeons — supporters of intraperitoneal operations make them in two, and sometimes and at three moments. Founders of a method of step-by-step performance of operations on a large intestine in Russia are I. I. Grekov and A. A. Troyanov.
In modern conditions, despite considerable progress of an asepsis, antiseptics and methods of anesthesia, single-step operations it is necessary to apply only at good shape of the patient and the uncomplicated course of fistula. In all other cases it is more reasonable step-by-step operations.
Bibliography: Vicine B. A. Outside intestinal fistulas, Novosibirsk, 1965, bibliogr.; I. I. K Greeks to a question of treatment of fecal fistulas, Unusual effect of full switching off of a gut, Russian doctor, t. 2, No. 3, page 92, 1903; D au-letsky S Ya., Gavryushov V. V. and Akopyan B. G. Surgery of newborns, page 161, 194, M., 1976; To the Ephedra N about about in P. D. Outside intestinal fistulas and their treatment, M., 1964, bibliogr.; Lyonyushkin A. I. Proctology of children's age, page 231, M., 1976, bibliogr.; A. V. Klinik's millers and prevention of fistulas of a stomach and intestines at wounded in an abdominal cavity, M., 1947; Tobik S. Treatment of outside fistulas of intestines, the lane with polsk., M., 1977, bibliogr.; Chernyakhovsk M. G. Intestinal fistulas and their treatment, Kiev, 1893; Chukhriyenko D. P. and White And. C. Outside intestinal fistulas, Kiev, 1975, bibliogr.; S eg and N. J., Bacon H. E. a. Gennaro A.R. Surgical management of enterocutaneous fistulas of the small intestine and colon, Dis. Colon Rect., v. 11, p. 69, 1968.
B. D. Fedorov; A. F. Dronov (it is put, hir.).