Bronchial fistula is the pathology of a bronchial tree which is characterized by existence of the pathological message of a bronchial tube with the external environment, a cavity of a pleura or a gleam of internals. The clinical picture is defined by relationship of a bronchial tube with other anatomical structures. The general signs are short wind, cyanosis, cough with allocation of contents of the drained bodies (pus, food masses, bile impurity and so forth). The diagnosis of bronchial fistula is confirmed by data of radiodiagnosis (a X-ray analysis of lungs, a fistulografiya, a bronchography, KT), endoscopies (bronkhoskopiya, EGDS), a pleural puncture with a manometriya. Tactics concerning bronchial fistulas can be conservative or surgical.
Bronchial fistula – the fistula causing the abnormal message of a bronchial tube with any cavity, body or the surface of skin. Bronchial fistulas are one of the most complex problems of pulmonology and thoracic surgery as will difficult respond to conservative treatment, support chronic purulent processes, significantly burden the postoperative forecast. Frequency of formation of bronchial fistulas is closely connected with their etiology. So, congenital esophageal and esophageal and bronchial messages occur at 0,03% of newborns. In structure of the acquired bronchial fistulas postoperative defects prevail – 2-30% of complications of a resection of a lung fall to their share.
Formation of congenital bronchial fistulas happens vnutriutrobno. Developing of bronkhopishchevodny and trakheopishchevodny fistulas is caused by incomplete division of respiratory and digestive systems at a certain stage of an embryogenesis under the influence of various factors influencing a fruit (avitaminosis, pre-natal infections, injuries, radiation and so forth). In most cases at such malformation there is svishchevy a course between the main bronchial tube (usually right) and a gullet. The etiology of the acquired bronchial fistulas can be various:
- Postoperative defects. Most often the postoperative fistulas caused by insolvency of a stump of a bronchial tube or its necrosis, an empiyemy pleura, prevalence of tumoral process on a bronchial tube wall and so forth meet. As show statistical data, postoperative bronchial fistulas twice more often are formed after the pnevmonektomiya executed concerning lung cancer than after other rezektsionny interventions (lobectomy, a bilobektomiya, etc.).
- Infections of lungs and bronchial tubes. Among the reasons of the acquired bronchial fistulas specific are on the second place and nonspecific it is purulent - destructive processes of lungs: actinomycosis, tuberculosis, lung abscess, bacterial destyoruktion of lungs. Less often to formation of defect in a wall of a bronchial tube spontaneous pheumothorax, disintegration of a cancer tumor, lung echinococcosis, perforation bring into a bronchial tree of diverticulums of a gullet, a cyst or abscess of a liver.
- Traumatic damages. The third group of the factors leading to formation of bronchial fistulas is connected with the closed thorax injuries, lung wound and so forth.
In the beginning bronchial fistula represents the pathological message which walls are covered by necrotic masses. In process of rejection of impractical fabrics the channel covered with granulyatsionny or epitelialny fabric is formed. This channel can connect a bronchial tube to a chest wall, a pleural cavity, nearby bodies, causing a specific clinical picture. Over time walls of the svishchevy course become rigidny, interfering with independent closing of defect. Any infectious process in a bronchial tree, a cavity of a pleura, pulmonary fabric supports the course of bronchial fistula.
Except division into the congenital and acquired, bronchial fistulas are subdivided on single (62%) and multiple (38%, including "a trellised lung"). Taking into account an etiologichesky factor they can have a post-traumatic, post-infectious, postoperative origin. Depending on the level of localization distinguish fistulas of the main, share, segmentary, subsegmentary bronchial tubes and alveolar fistulas. In clinical practice anatomic classification within which allocate is of the greatest value:
1. External (torakobronkhialny) fistulas:
- bronkhokozhny and bronkhoplevrokozhny - open on a surface of a chest wall in the form of gubovidny (with one opening) or kanalovidny (with two openings - external and internal) messages.
2. Internal fistulas:
- bronchopulmonary – represent the message of a bronchial tube with a nagnoitelny cavity in pulmonary fabric (a cavity at tuberculosis, lung abscess, the gangrenous center, etc.)
- bronkhoplevralny – are characterized by direct contact of a bronchial tube with a pleural cavity
- bronkhoorganny (bronkhopishchevodny, bronkhozheludochny, bronkhokishechny, bronkhozhelchny, etc.) meet seldom; are formed in the presence of the pathological channel tying a bronchial tube with a gleam of a gullet, stomach, intestines, gall bladder.
Symptoms of bronchial fistulas
Their anatomic features, diameter, terms of formation of defect, existence or lack of infectious process act as the criteria defining symptomatology of bronchial fistulas. Symptoms of intoxication (fever about oznobam, weakness, weakness, a headache, small appetite) and respiratory insufficiency (cyanosis, short wind, thorax pains) belong to number of the general symptoms accompanying development of pathology. Besides, the specific manifestations are characteristic of different types of bronchial fistulas.
External (bronkhokozhny, bronkhoplevrokozhny) fistulas are characterized by existence of visible defect on skin of a chest wall from which periodically departs mucous or mucopurulent separated, and at cough and a natuzhivaniye air can be emitted. Hit in svishchevy the course of water provokes developing of sharp pristupoobrazny cough and an attack of suffocation. Sometimes removal of an okklyuzionny bandage causes strengthening of cough, short wind and cyanosis, violation of a voice up to an aphonia.
The bronchial fistulas which are reported with Sukhoi a pleural cavity are shown by dry cough or an expectoration of insignificant quantity of a mucous phlegm. At the bronkhoplevralny fistulas which developed against the background of purulent pleurisy, the general condition of patients is burdened is purulent-rezorbtivnoy fever, intoxication, exhaustion. The otkhozhdeniye of large volume of a purulent, fetid phlegm at cough is noted, the expressed short wind, release of air from a pleural drainage, hypodermic emphysema. The clinic of bronchopulmonary fistulas is defined subfebrilitt, cough with allocation of a mucopurulent phlegm, perspiration, weakness.
The expectoration is the main sign of bronkhoorganny fistulas to patients of contents of that body with which the bronchial tube is reported: the eaten food, bile, gastric or intestinal contents. Congenital trakheo-and bronkhopishchevodny fistulas can be suspected soon after the child's birth on the basis of a poperkhivaniye when feeding, swellings of a stomach, development of aspiration pneumonia. As the main display of the acquired fistulas serves the cough connected with reception of liquid and food, sometimes – suffocation.
The long course of bronchial fistulas can lead to developing of pneumonia and a chronic empiyema of a pleura. Complications in the form of a blood spitting or pulmonary bleeding, aspiration pneumonia of other lung are possible. System consequences are presented by sepsis, massive internal bleeding, a visceral amiloidoz.
At survey of the patient with the estimated diagnosis "bronchial fistula" cyanosis of skin and mucous, short wind, tachycardia, characteristic deformation of trailer phalanxes of fingers ("drum sticks", "hour glasses") pays attention. Auskultation reveals scattered mixed rattles.
The Bronkhokozhny fistulas opening on a surface of a chest wall are found visually. With the diagnostic purpose sounding of fistula with introduction of water solution of methylene blue can be carried out. Developing of cough with allocation of the painted phlegm confirms existence of bronchial fistula. The fistulografiya with contrast substances is made for obtaining information on extent and a configuration of the svishchevy course. In some cases to specify localization, the quantity, the sizes of the svishchevy courses allows the diagnostic torakoskopiya which is carried out through a svishchevy opening in a chest wall.
At internal fistulas the bronkhoskopiya allowing to estimate a condition of a bronchial tree, and also radiological methods of diagnostics has important diagnostic value: survey X-ray analysis and KT of lungs, bronchography. Bronkhoplevralny fistulas can be revealed by means of data of a pleural puncture with a manometriya – at the message of a bronchial tree with a pleura cavity in the last it is not possible to create negative pressure by air aspiration. In case of suspicion on existence of bronkhopishchevodny or bronkhozheludochny fistula the ezofagogastroskopiya is shown.
Treatment of bronchial fistulas
In most cases bronchial fistulas demand expeditious treatment. At the same time, conservative tactics can be applied to some fistulas of bronchial tubes. The thoracic surgeons owning all arsenal of methods of maintaining patients with bronchial fistulas have to be engaged in treatment of this pathology. Conservative treatment of bronchial fistulas assumes holding actions for sanitation of purulent cavities: drainage of a pleural cavity, washing by antiseptic solutions, introduction of proteolytic enzymes and antibiotics, removal of foreign matters, imposing of the device of active aspiration, etc. After an obliteration of residual cavities perhaps samostrelny closing of small bronchial fistulas.
There is a positive experience of elimination of fistulas by means of the chemical cauterization or electrothermic coagulation of a fistula allowing to destroy an epitelialny vystilka and to stimulate growth of connecting fabric in the channel. At large fistulas temporary endoscopic closure of a svishchnesushchy bronchial tube can be applied by a special porolonovy seal – such tactics allows to carry out an unleavened wheat cake of a purulent cavity and to create favorable conditions for expeditious elimination of bronchial fistula.
Conservative treatment of bronchial fistulas is successful only in 10-12% of cases therefore expeditious closing of defect is shown to most of patients. For expeditious elimination of torakobronkhialny fistula its excision with the subsequent ushivaniye, muscular plasticity a rag on a leg can be carried out. At postoperative fistulas performance of a reamputation of a stump of a bronchial tube is shown. Elimination of esophageal and bronchial fistulas demands an ushivaniye of defects from a gullet and a bronchial tube, it is possible – resections of the changed part of a lung. Closing of bronkhoplevralny fistula can be made by means of an intraplevralny torakoplastika or a decortication of a lung.
Forecast and prevention
The outcome and the prospects of recovery depend on the reason which led to formation of bronchial fistula, completeness, adequacy and timeliness of medical actions. The most serious forecast and a high lethality (30-70%) is noted at the postoperative fistulas complicated an empiyemy pleura. When developing bronchial fistula waiting tactics is inadmissible; earlier beginning of conservative actions, carrying out surgical intervention after necessary preparation is necessary. Prevention of the acquired bronchial fistulas consists in observance of the technology of processing of a stump of a bronchial tube, timely therapy is purulent - destructive diseases of lungs, the prevention of injuries of thorax.