NECROSIS. GANGRENE

NECROSIS

Necrosis is an area mortification of the tissue. The explanation for native mortification of the tissue could be direct harm to tissue by any traumatic issue, inadequate vitamin of the tissue on account of infringement of blood circulation, metabolic illnesses, harm to the nervous system.

Exterior elements, which injure tissues, could be the next:

mechanical elements (blows, compression, ruptures, wounds, and so forth.);

thermal elements (burns and frostbite);

electrical elements (electrotrauma);

chemical elements (concentrated acids and alkalis, different caustics and organ secretions);

poisonous elements (microbic toxins);

radiation vitality (burns by X-ray radiation and radioactive burns).

Vitamin insufficiency of tissue may cause such infringements of blood circulation:

acute cardiac failure;

embolism of vessels;

lengthy spasms or obliteration of blood vessels (Raynaud’s illness, Buerger’s illness, obliterating endarteritis, obliterating atherosclerosis, nonspecific aortoarteritis);

rupture and compression of vessels (wound to the principle vessels, their compression whereas squeezing within the hernial gates or any kind of strangulated intestinal obstruction, compression by laborious plaster bandages or long-term tourniquet utility);

infringement of the coagulation system of blood by hypercoagulation and rheological properties of the blood;

infringement of the integrity and construction of the intima of the blood vessels (thromboses and inflammations of the arterial and venous partitions, atherosclerosis).

Insufficiency of tissue vitamin could be noticed with metabolic illnesses, for instance, diabetes, scorbutus. Infringements of tissue vitamin and trophics are noticed with harm to the nervous system (tumor, neurosyphilis, syringomyelia), and likewise with damages to the top and spinal wire and peripheral nerves.

Within the prevalence, growth and progress of necrosis massive position is performed each by the overall anatomic and physiological options of an organism and native ones. The diploma of the organism’s reactance, hypovitaminosis, and accompanying illnesses belong to common options of an organism. The native ones embody the construction kind of the vascular system (most important or collateral), kind of growth of infringements of blood circulation, presence of pathological modifications within the vessels, presence of microbes and their toxins on the necrosis space.

Necroses can develop in several organs and tissues; they’re categorized by their aetiology, depth of damage and the scientific course:

in accordance with aetiology — particular and nonspecific;

in accordance with the depth of the broken tissue — superficial, deep, complete;

in accordance with the scientific course — dry, humid.

Nonspecific necrosis is the results of wounds or lengthy compression of blood vessels and tissues, intensive burns, surgical an infection, trophic modifications (mattress sores, ulcers), thromboses and embolisms. Particular necrosis is the results of atherosclerosis, obliterating endarteritis, syphilis, endocrinal pathologies (diabetes).

Necrosis could be coagulational (dry), as noticed with burns by concentrated acids, and liquefactive (humid), noticed with radiation burns. Apparent attributes of necrosis come up 4–6 h after the tissue dies. Useless tissue, underneath the affect of proteolytic enzymes rejects. If the necrotic plenty are situated on the physique floor after rejection, an ulcer is shaped. With intensive and deep necrosis, tissue disintegration and diffusion of poisonous merchandise can result in acutely pronounced intoxication, the event of poisonous shock and the dying of the affected person.

GANGRENE

Gangrene is likely one of the types of necrosis, predetermined by infringement of blood circulation and the event of lifeless tissue. Probably the most usually cause for the event of gangrene is acute or continual arterial insufficiency. Dry, or coagulative, and humid gangrene are distinguished.

Dry Gangrene

Dry gangrene impacts the extremities extra usually. It’s characterised by quick drying of lifeless tissue with out an infection and it seems mummification of lifeless tissue. The tissue rapidly turns into dehydrated and dries up, turning brown or blue-black.

The necrosis course of is restricted and often doesn’t progress. Histologically within the tissue coagulative necrosis with the disintegration of the mobile nucleus, erythrocytes, leukocytes and settlement of protein within the plasma is marked. Clinically within the preliminary stage, robust ischemic pains within the extremities extra distal from the harm, as a rule, are noticed. The extremity turns into pale and is chilly to the contact; the pores and skin regularly will get a marble look.

Superficial and deep sensitivity turns into boring after which fully disappears; the perform of the extremities is damaged. Pulse on the peripheral arteries isn’t decided. If on the similar time with occlusion of the principle vessel there’s resistant spasm of the collaterals, the necrosis zone turns into extra intensive. Additional a demarcation shaft, which limits the dwelling tissue from the lifeless ones, develops. The lifeless tissue comes off, and on the demarcation line the connective tissue cells a number of, the leukocytes accumulate and granulations type. The border between the alive and lifeless tissue goes deeper, untill the necrotic space rejects, after which there’s a granulating wound, which slowly heals. Because of the mummification of lifeless tissue throughout dry gangrene, absorption of poisonous substances of tissue disintegration isn’t important and intoxication doesn’t happen. The overall situation of the affected person is sweet. With a purpose to forestall the prevalence of native problems, the an infection of lifeless tissue and the transition of dry gangrene into humid throughout redressing, it’s essential to strictly observe the principles of aseptics. The extremity is immobilized, dry bandages are utilized, physiotherapeutic procedures (quartz irradiation) are performed. Necrectomy, i.e. surgical removing of necrotic tissue, in addition to amputation of the extremity is important to postpone till the prevalence of a demarcation shaft is in full view. If gangrene is brought on by direct harm of tissue, necrectomy is important to conduct behind the demarcation line. If gangrene developed on account of infringement of arterial blood circulation, the amputation of the extremity is performed significantly extra proximal, i.e. throughout the borders of completely viable tissue with good blood provide. With a purpose to forestall the event of dry gangrene, early prognosis and therapy of blood vessels illnesses, which may result in the event of necrosis and gangrene (thromboses, obliterating endarteritis and atherosclerosis) have essential significance. It’s essential to enhance blood circulation, promote the event of collaterals, and liquidate the spasm of blood vessels. It’s essential to conduct in due time reconstructive operations on vessels to normalize the blood provide of the extremities.

Humid gangrene

Humid gangrene can be a form of necrosis. It develops primarily in overweight, pastous sufferers on account of acute infringement of blood circulation. Purulent or putrefactive an infection regularly accompanies humid gangrene. The event of humid gangrene can be promoted by hypostases, which ends from cardiac failure, renal illnesses and diabetes.

With humid gangrene, the lifeless tissue doesn’t dry up and turn into a very good nutrient medium for an infection. Putrefactive (protruding) disintegration of tissue develops, which is very often accompanied by anaerobic an infection (fuel gangrene).

When the lifeless tissue breaks up, it turns right into a moist soiled mass of grayish-green colour with an disagreeable odour. Intensive absorption of the disintegration merchandise, which rapidly leads to extreme intoxication resulting in the dying of the affected person, is noticed. With humid gangrene the demarcation line isn’t shaped, the method spreads rapidly to the exterior tissue. The extremities turn into pale, chilly to the contact after which cyanotic-red dots seem; the dermis exfoliates and blisters, stuffed with bloody, stinking exudate, type; hypostasis of tissue sharply will increase. Extreme ache happens within the broken extremity. The talked about above native phenomena are accompanied by systematic intoxication. The affected person’s face turns into gray; tongue is dry; pulse is of weak filling and strain; the arterial strain is low, full apathy and excessive temperature of hectic origin is noticed.

The course of diabetic gangrene is particularly extreme. Sufferers with diabetes have decreased resistancy and tissue regenerative properties and elevated susceptibility of an organism to pathogenic organisms of pyo-septic an infection. Due to this, sufferers with diabetes simply get secondary inflammations, and the injuries regenerate very badly. Humid gangrene can harm totally different organs and in consequence the scientific image is various. It relies upon upon the kind of tissue, the character and localization of the broken organ. Gangrene of inner organs happens solely as humid gangrene and is accompanied by signs of peritoneal irritation and peritonitis growth. Pulmonary gangrene has its personal scientific indicators.

The therapy for humid gangrene is directed on quick elimination of broken cells, wrestle in opposition to intoxication and an infection, correction of metabolism infringement.

Necrectomy with humid gangrene isn’t efficient as a result of it doesn’t enhance the affected person’s situation, doesn’t liquidate the supply of intoxication. With gangrene of the belly organs, emergency laparotomy, the removing of the broken organ and sanitation of the belly cavity, is finished. Broad-spectrum antibiotics, sulfamidin and nitrofuran preparations, antiseptics, vaccines and serum, immunomodulators are utilized to wrestle in opposition to an infection. For wrestle in opposition to intoxication all of the accessible strategies of intra- and extracorporal cleansing are used: introduction of large amount of crystalloids (isotonic answer of sodium chloride, 5–10% answer of glucose), haemotransfusion, plasma, albumin, haemodesum and different blood substitutes, lactosol, low-molecular polyglucin together with cardiac and diuretic substances (strategy of pressured diuresis). It’s essential to use additionally haemosorption, plasmosorption, ultra-violet irradiation of blood (UVIB). Together with the therapist-endocrinologist, correction of the carbohydrate metabolism problems are performed for sufferers with diabetes.

DECUBITUS

Decubitus is a model of necrosis. That is dystrophic, ulcer-necrotic modifications on the pores and skin, fatty hypodermis and gentle tissue right down to the bones, which develop on account of infringement of microcirculation brought on by compression.

Compression happens on areas of the coccygeal bone, scapula, heals, and so forth. Decubitus happens in weakened sufferers, particularly with damages to the spinal wire, within the postoperative interval when sufferers are motionless in mattress for a very long time. Decubitus types regularly, imperceptibly. First, the sufferers complain of feeling of compression and ache. The primary attributes of decubitus is pale pores and skin with redness following. Then it’s joined by cyanosis; hypostasis develops; the dermis exfoliates; blisters, stuffed with serous-hemorrhagic exudate, type. Comfortable tissue dies right down to the periosteum. The pores and skin dies; necrotic tissue separates and types a deep purulent wound, the underside which is the periosteum of the following bone. An an infection can result in the event of sepsis and the affected person’s dying.

Preventive measures in opposition to decubitus have essential significance. Such sufferers needs to be turned over each 2 h and left in that place for some minutes. It’s essential to look at and alter often mattress linen and underwear; there needs to be no wrinkles within the mattress linen. It’s essential to re-make the mattress 2–3 instances a day. It’s essential to look at every day the cleanliness of the integuments, wash areas the place decubitus type usually with heat water, then wipe it with a tampon moistened in a ten% answer of camphor spirit, with rotary actions rub and therapeutic massage them. The pores and skin on the maceration websites needs to be washed with chilly water and cleaning soap, diligently dried, wiped with spirit and powdered. Underneath the pelvis and sacrum they put a rubber circle lined with a movie, and underneath heals and elbows — cotton-gauze circles. Critically ailing sufferers are placed on particular porolon or mattresses, that are stuffed with water or air.

Typically within the medical apply it’s attainable to look at a socalled inner decubitus, for instance, lifeless vein partitions on account of the presence of dense catheter in it for a very long time for intravenous introduction of medicines or lifeless inner organ physique partitions, which underwent compression by a dense drainage tube. Preventive measures for the above-stated inner decubitus consists in that dense catheters and drainage tubes shouldn’t stay in affected person’s organs for a very long time.

It’s far more troublesome to deal with decubitus, which shaped, than forestall its formation. Decubitus are handled with a concentrated answer of potassium permanganate, powder with streptocide and rubbed with sensible inexperienced or water answer of methylene blue. The floor of the decubitus needs to be lined with aseptic bandage and a ten% streptocide ointment or a 1% streptocide emulsion. It’s essential to use physiotherapy (UV-rays, quartz). When necrosis is restricted, the road of demarcation types; the lifeless tissue is surgically eliminated, i.e. necrotomy is performed, or they’re melted with proteolytic enzymes (trypsin, chymotrypsin). This therapy is joined with making use of bandages with hypertonic options (10% answer of sodium chloride). After cleaning the wound, numerous ointment bandages are used with antiseptics, stimulating remedy (hemotransfusion, plasma, protein blood substitutes), and if essential — surgical therapy — pores and skin transplantation (autodermoplastic).

ULCERS

Ulcer is a defect of the pores and skin or mucous membrane, shaped on account of necrosis tissue. After the lifeless tissue rejection, the defect takes a very long time to heal, which ends up in the formation of an ulcer. The principal reason behind ulcers is a pointy lower in regeneration processes, predetermined by the overall situation of the affected person or the accompanying illnesses or metabolism sicknesses. Tissue anemia and trophic modifications in tissue play an vital position of their formation.

The explanations for ulcers are the next:

Infringement of arterial blood circulation (thromboses, embolism, extreme angiospasm), venous blood circulation (varicose dilation, superficial and deep thrombophlebitis, arteriovenous fistulas), in addition to lymph circulation problems.

Adjustments within the vessel partitions throughout atherosclerosis, obliteratingendarteritis, the Raynaud’s illness, and syphilitic aortitis.

Traumatic damages of assorted genesis — mechanical, thermal, chemical, electrical, radiation.

Infections — purulent, putrefactive, particular (tuberculosis, syphilis, leprosy) and mycotic (actinomycosis, blastomycosis, epidermomycosis).

Problems of metabolism processes (diabetes, scurvy, blood illnesses, anemia).

Neurotrophic problems (with traumatic damages and radicular tumours of the spinal and peripheral nerves, syringomyelia and progressive paralysis).

Benign and malignant tumours, that are inclined to be coveredby ulcers (sarcoma, lymphogranulomatosis).

First, necrotic cells with lifeless tissue, microbes are shaped with purulent discharge. Round this cell, a granulation shaft develops, which modifications into dense connective tissue, and across the ulcer nonspecific irritation is noticed. The formation of an ulcer happens in opposition to a background of indicators of pronounced trophic infringement. Its look and sizes could be various, the shape — from spherical or prolonged to any form. The sides of the ulcer could be each clean and even or uneven, jagged, pale or cyanotic. The underside of the ulcer often is raised or crateriform, stuffed with a muddy liquid, granulation tissue and necrotic cells. Ulcers, which border a dense layer of connective tissue, are known as callous ulcers. Ulcers can generally be lined by fungoid hypergranulations.

Ulcers may cause totally different problems, for instance: secondary bleeding from erosive blood vessels, accompanied by an infection, penetration, i.e. germination of an ulcer into adjoining organs, or perforation of an ulcer into the cavity or a neighboring hole organ. With the therapeutic of in depth ulcers, scars can type, which deform the organ and break its perform. Malignant regeneration, a so-called malignancy of ulcers, which sharply change the scientific shows, medical coverage and the prognosis of every particular person case, is feasible. Healed ulcers are inclined to recur.

Remedy of ulcers needs to be complicated, directed on the elimination of the fundamental illness, i.e. etiologically directed. Conservative means are utilized extra usually for therapy of exterior ulcers: mattress routine, immobilization of the extremity within the raised place, cautious skincare, physiotherapeutic actions (ultra-violet irradiation). It’s essential to observe all aseptic guidelines. Within the preliminary stage, bandages with hypertonic options are utilized on the ulcer; proteolytic enzymes are used for full cleaning of the ulcer from pyo-necrotic mass and an infection. After the ulcer is cleansed, bandages with ointments and antiseptics are utilized. Hypergranulations are cauterized with a ten% answer of silver nitrate (argentum nitricum); delete with the assistance of a pointy Volkmann’s curette; the extremity is immobilized with a zinc-gelatinous bandage, consisting of zinc-gelatinous glue and bandage. Zinc-gelatinous glue comprises 3 components of zinc oxide and three components of gelatin, 5 components of glycerin and 9 components of water. Earlier than the utilization, the combination is warmed, placed on the extremity, and dressed with a gentle bandage.

Apart from of native therapy of ulcers, it’s essential to conduct common remedy, directed on the stimulation of immune-biological and reparation processes in an organism. With this goal they apply full-volume, wealthy in nutritional vitamins meal, immunomodulating elements, protein preparations and blood substitutes, physiotherapy workouts, and so forth.

When conservative actions fail, they apply operative strategies of therapy, which offer the cleaning of an ulcer from pathologically modified granulations and round scars. If the tissue defect is shaped, it’s lined with a pores and skin transplant or regional pores and skin grafting on a large pedicle is performed.

Atherosclerotic ulcers come up in aged individuals. They’re principally situated within the decrease third of the shin and on the ft. They’re small, spherical or oval. The granulations are languid, pale; the perimeters of the ulcer are flat, dense, and uneven. Pronounced indicators of continual arterial insufficiency are noticed.

Varicose-trophic ulcers are massive and extra usually situated on the interior space of the bone. The ulcers are often deep, the neighboring tissue is dense and sclerotic, the pores and skin has darkish spots, throughout palpation — not very painful. Ulcers are at all times integrated with varicose dilation of superficial veins on the legs, that are the fundamental diagnostic attributes for the formation of ulcers. Ulcers which seem in opposition to a background of continual venous insufficiency after thrombophlebitis of deep veins on the legs, are known as post-thrombophlebitic. They are often of big sizes, situated on the interior floor of the shin or round as a cuff surrounding the entire shin. The pores and skin of the shin across the ulcer is pigmented, swollen, dense, acute sclerotic (indurative cellulitis).

For therapy of varicose-trophic ulcers — their sooner cleaning and shutting — together with hypertonic and proteolytic enzymes, vacuuming with the assistance of particular vacuum-devices, in addition to remedies in particular aerotherapeutic installations (ATI) have been efficiently utilized in our clinic. Remedy of ulcers in ATI happens underneath sure situations — temperature, humidity and sterile air, which move by means of particular antibacterial filters.

With varicose-trophic ulcers after their closing, surgical therapy is important — removing of the delated superficial veins and suturing the perforated veins, normalizing venous circulation within the legs. Whether it is unattainable to conduct surgical therapy, the varicose nodes are thrombosed by coming into phlebosclerotic substances (66% answer of glucose, varicocidum).

Radiation ulcers consequence from the motion of ionizing irradiation — throughout radiation remedy or informal irradiation. The formation of necrosis is preceded by modifications on the pores and skin — pigmentation, shiny pink teleangiectasia, hair loss, atrophy. Then necrosis with the formation of a trophic ulcer, occurring deep with a spherical or oval type and twisting edges, happens. Across the ulcer, the zone of sclerotic hypodermis and atrophied pores and skin is discovered. If the ulcers cowl a tumour, a dense infiltrate, which enters the depth, is discovered, isn’t displaced throughout palpation, soldered with the encircling tissues and organs, the place the ulcer is situated. The ulcer is thickened, dense, tuberous, uneven edges; the underside is roofed with necrotic tissue; websites of growths on the perimeters of the ulcer, which testify to the persevering with lively progress of the tumour, are regularly noticed. With suspicion of malignancy, i.e. malignant regeneration of the ulcer, it’s essential to conduct a biopsy — incision of the sting of the ulcer for following histologic examination, that can decide subsequent medical coverage.

For efficient therapy, it’s essential to know and take note of the ulcer formation pathogenesis. Remedy needs to be pathogenetic, i.e. directed on the trophic normalization of tissue and the fundamental pathological processes, which entails the ulcer formation. Fortifying remedy additionally has nice worth within the complicated therapy of ulcers: vitamin remedy, full-value vitamin, the usage of anabolics and normalization of metabolism processes. For fixing a optimistic impact within the affected person, it’s essential to advocate sanatorium therapy. Using hydrosulphuric, radonic mineral baths, and dirt baths improves the tissue trophic and normalizes blood and lymph circulation, which is efficient preventive measures of ulcer relapses.

FISTULA

Fistula is an irregular pathological duct in tissues, a slim channel lined with epithelium or granulations, and which connects an organ, a pure or pathological cavity with the organ’s floor or with one another. If the channel connects a hole organ or whith any cavity with the superficial covers, it’s an exterior fistula. If the pathological duct connects hole organs, it’s an inside fistula. The latter needs to be distinguished from anastomosis, utilized artificially with medical goal.

Fistulae are divided into congenital, ensuing from infringement of embryogenesis (defects of growth), and bought, ensuing from trauma, tumours, inflammatory illnesses. Fistulae are additionally a results of operative intervention which ended with the factitious formation of an exterior fistula and is an intermediate or closing stage of the surgical therapy. For instance, imposing gastrostomy, enteroand colostomy, cystostomy.

After the construction fistulae are divided into tubular, the partitions of that are lined with granulations, and labia-shaped  — the partitions are lined with epithelium. Tubular, or granulating, fistulae are lined with granulation tissue from the within alongside the entire size of the channel; they generally tend to shut independently. Labia-shaped, or epitheliated, fistulae are lined with epithelium, which straight move into the dermis of the encircling integument. Such fistulae aren’t inclined to shut independently and require surgical therapy.

Fistulae are additionally distinguished in accordance with the kind of discharge: mucous, purulent, uric, biliary, feces, salivary, liquor. Within the fistula’s secretion pathological parts, which assist decide the prognosis (microbacteria tuberculosis, actinomycosis, bone sequestrations, malignant cells) could be discovered. The secretion from the fistula, getting on the pores and skin, may cause its irritation, maceration and formation of ulcers, noticed with duodenal, small intestinal and pancreatic fistulae.

Each exterior fistula has exterior pores and skin orifice, channel and an inner orifice. Some fistulae haven’t any channel, as a result of the wall of the organ can attain the extent of the pores and skin and even to stay above it, forming a lip.

Labia-shaped fistulae could be full if the contents of the organ, for instance the intestines, discharges outdoors, and incomplete if the contents of the organ solely partly discharge by means of the fistula opening. For the event of labia-shaped fistula and its functioning, the eperon, which types on account of the posterior again wall of the gut falling into the opening of the fistula, has essential significance. The size of the fistula duct relies upon upon the thickness of the tissue by means of which the fistula passes, mobility of the organ, its displacement by the pathological course of, presence of accretions between organs. The pores and skin orifice of the exterior fistula could be of assorted dimension and type. Most frequently exterior fistulae are single, however could also be plural. The formation mechanism of plural fistulae is the next: close to the already current single fistula quite a few paths containing the pus, which ends up in the formation of a number of abscesses, which then break to the surface and type plural fistula. Actinomycosis is a illness the place primarily-plural fistulae are extra usually shaped.

The fistula scientific course consists of native and common signs. Native signs are the presence of the fistula, its localization, character of discharge, pores and skin maceration across the exterior orifice, construction of the channel. Basic signs are these of the fundamental illness which is the explanation for fistula, similar to trauma, defects of growth, sickness.

A affected person with a fistula is examined by the overall plan: complaints of the affected person on the presence of the fistula, character and quantity of discharge, dependence on meal, defecation and urination. It’s essential to take note of anamnestic information — the fistula prevalence time (congenital or acquired) and cause for its prevalence (trauma or results of an operation). It’s essential to look at rigorously the fistula, discover its localization, construction (tubular or labia-shaped), kind and quantity of discharge. Laboratory and instrumental research of the fistula is performed. It’s essential to make use of colour indicators to ascertain the prognosis. The affected person is given an answer of dye to drink, for instance, methylene blue, and the time of its appearence within the fistula needs to be marked. This methodology of prognosis helps to find out the peak of the fistula, which is particularly vital with a fistula of the esophagus, abdomen, and duodenum.

Whereas inspecting a affected person with a fistula, “X-ray” strategies — fistulography — are vital. The liquid distinction substance is entered to the fistula by means of a skinny catheter; the X-ray footage are taken. On the roentgenograms they decide the localization and course of the fistula path, presence of discharge, detect the organ that the fistula, its degree, and attainable pathological modifications in its wall.

With the suspicion of the inside fistula, i.e. fistula of the interior organs, it’s essential to conduct radiopaque research of the esophagus, abdomen, small and huge intestines. With this goal, barium or the opposite radiopaque substance is entered into the organ cavity and its overflow by means of the organ’s wall into the encircling tissue, cavities or outdoors is set.

At this time for prognosis of fistulae, specification of their localization, and sizes, endoscopic strategies of research, similar to gastroscopy, colonoscopy, bronchoscopy, cystoscopy, and so forth., primarily based on the utilization of fiber optics and optical paths, are broadly used. Endoscopes could also be entered by means of pure apertures inside any hole organ and to rigorously look at its wall. In some circumstances, an inside fistula could be discovered throughout an operation, carried out for this or that illness.

Remedy of sufferers with exterior fistula relies on the next rules:

— native remedy;

— common remedy;

— operative remedy.

Native remedy — the therapy of a wound, defending the encircling tissue from the motion of the fistula discharge. For this goal bodily means — ointments, pastes, powder (Lassar’s paste, glues BF-2, BF-6, polymerized movie, silicone pastes), that are utilized close to the exterior apertures of the fistula to stop contact with the pores and skin and to advertise discharge adsorption are used. Chemical means, prevention of pores and skin irritation by neutralizing the enzymes secreted from the fistula, are used. With this goal inhibitors of proteolytic enzymes (contrical, Gordoxum, Trasylolum, zymophren, and so forth.) are used. Mechanical methods of defending the pores and skin are directed on important discount or termination of fistula discharge with the assistance of particular diversifications, similar to pelotives, obturators or vacuums-devices. The sanitation of purulent fistulae is performed with the assistance of fixed washing with antiseptic options. Granulating tubular fistula could be closed independently after eliminating the reason for its arising — eradicating the ligatures, bone sequestration, and terminating the fistula discharge. The epitheliated fistulae by no means shut independently and require surgical therapy — suturing the organ entrance, and generally resections of the given organ. Synthetic fistulae are shaped for bettering the affected person’s situation with the aim of feeding him or discharge of the contents or secretion from the organ. These fistulae could be non permanent or everlasting. The non permanent fistulae are closed surgically after the development of the affected person’s situation. The inside synthetic fistulae are interorgan anastomosis and are utilized for a very long time or for the entire life.