J Korean Med Sci.  2004 Apr;19(2):302-304. 10.3346/jkms.2004.19.2.302.

Staged Surgery for Chronic Primary Aortoduodenal Fistula in a Septic Patient

• Cho YP
• Kang GH
• Han MS
• Jang HJ
• Kim YH
• Ryu JH
• Park CK
• Lee SG

• KMID: 1733495
• DOI: http://doi.org/10.3346/jkms.2004.19.2.302

Abstract

Aortoenteric fistula is one of the most challenging problems that confront the vascular surgeons. Controversy remains over the optimal treatment because of the continued publication of series with high mortality, amputation, and aortic disruption rates. A positive preoperative blood culture is the best predictor of mortality with increased amputation rates due to infection of the extra-anatomic bypass. Therefore, in selected cases with sepsis, a prudent management protocol is required. We report a 68-yr-old male presenting with a chronic primary aortoduodenal fistula extensively involving the duodenum and Gram-negative sepsis. We planned a staged operation. Initially, an emergency laparotomy and control of the aorta allowed stabilization of the patient, identification of the fistula, and direct in situ placement of the prosthetic graft followed by an en bloc resection of the aneurysm and the surrounding structures. After he recovered from sepsis and had been stabilized, a staged extra-anatomic bypass followed by transabdominal removal of the temporarily placed graft was done. This management plan will allow the highest success rate and may be a prudent management protocol for these difficult cases.

Keyword

Aortic Aneurysm; Fistula; Duodenum; Sepsis; Surgery

MeSH Terms

Aged
Aortic Aneurysm, Abdominal/complications/*pathology/*surgery
Chronic Disease
Digestive System Surgical Procedures
Duodenum/pathology
Human
Intestinal Fistula/complications/*pathology/*surgery
Male
Sepsis/*complications
Tomography, X-Ray Computed

Figure

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  Fig. 1 Preoperative contrast-enhanced axial computed tomography demonstrates a 9.5-cm wide abdominal aortic aneurysm (A) tightly attached to the duodenum (D).

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  Fig. 2 The gross pathology of the resected aortoduodenal specimen shows ruptured abdominal aortic aneurysm (A) with a thrombus encroaching the duodenal wall (D). Note the absence of a muscle layer and serosa in the duodenal wall.

Reference

1. Martinez R, Garces D, Podeur L, Abdel Aal K, Laffon M, Castellani L. Ruptured abdominal aortic aneurysm. A ten year experience. J Cardiovasc Surg. 1997. 38:1–6.

2. Bunt TJ. Synthetic vascular graft infections. II. Graft-enteric erosions and graft-enteric fistulas. Surgery. 1983. 94:1–9.

3. Moulton S, Adams M, Johansen K. Aortoenteric fistula: a 7 year urban experience. Am J Surg. 1986. 151:607–611.

4. Peck JJ, Eidemiller LR. Aortoenteric fistulas. Arch Surg. 1992. 127:1191–1194.

5. Kleinman LH, Towne JB, Bernhard VM. A diagnostic and therapeutic approach to aortoenteric fistulas: clinical experience with twenty patients. Surgery. 1979. 86:868–880.

6. Taheri SA, Kulaylat MN, Grippi J, Ricotta JJ, Kale J, Bernhard H. Surgical treatment of primary aortoduodenal fistula. Ann Vasc Surg. 1991. 5:265–270.

7. Sweeney MS, Gadacz TR. Primary aortoduodenal fistula: manifestation, diagnosis, and treatment. Surgery. 1984. 96:492–497.

8. Lee OJ, Kim SH. Aortoesophageal fistula associated with tuberculous mediastinitis, mimicking esophageal Dieulafoy's disease. J Korean Med Sci. 2002. 17:266–269.

9. Reynolds JV, Galloway JM. Primary aortoduodenal fistula: a case report and review of the literature. Ir J Med Sci. 1991. 160:381–384.

10. Pagni S, Denatale RW, Sweeney T, McLaughlin C, Ferneini AM. Primary aorto-duodenal fistula secondary to infected abdominal aortic aneurysms: the role of local debridement and extra-anatomic bypass. J Cardiovasc Surg. 1999. 40:31–35.

11. Lemos DW, Raffetto JD, Moore TC, Menzoian JO. Primary aortoduodenal fistula: a case report and review of the literature. J Vasc Surg. 2003. 37:686–689.

12. Daugherty M, Shearer GR, Ernst CB. Primary aortoduodenal fistula: extra-anatomic vascular reconstruction not required for successful management. Surgery. 1979. 86:399–401.