Secondary aortoduodenal fistula without gastrointestinal bleeding directly detected by CT and endoscopy

Secondary aortoenteric fistula: a narrative review of the view of the surgeon

Aortoenteric fistula (AEF) is defined as the abnormal communication between the aorta and the gastrointestinal tract. AEFs are divided into primary and secondary usually after abdominal aortic aneurysm (AAA) recovery and are a rare but quite dangerous cause of gastrointestinal bleeding that the general surgeon may face during his/her career. Secondary AEF was first described in 1953 to a 44-year-old woman 3 months after an AAA operation. This review presents the role of the surgeon in the management of secondary aortoenteric fistulas. AEFs are a rare but fatal gastrointestinal bleeding cause that the general surgeon may be asked to manage. Diagnosis requires the combination of strong clinical suspicion and the presence of a history of AAA surgery. Although a vascular surgery case, general surgeons play a role in choosing the technique of restoring the intestinal tract, which seems to be significantly related to subsequent morbidity and mortality.

Necrotizing fasciitis of the thigh due to a secondary aortoduodenal fistula

Background: Secondary aortoenteric fistula is an iatrogenic complication after aortic reconstructive surgery presenting with gastrointestinal bleeding and/or infectious symptoms. Infrequently, it may manifest with nonspecific and atypical clinical signs. We present a case of necrotizing fasciitis of the thigh complicating secondary aortoduodenal fistula, diagnosed with CT-scan. Case presentation: A 67-year-old man with a history of an open aortic-bifemoral bypass 6 years ago was admitted for a progressively swollen and painful right thigh for the last month. Through laboratory and morphological (CT-scan) investigations, a secondary aortoduodenal fistula associated with necrotizing fasciitis of the right thigh was discovered. After general supportive care and empiric antibiotherapy, the patient underwent a prosthetic explantation, a resection of the perforated bowel with end-to-end anastomosis, and extensive debridement of the necrotic tissue of the thigh. No revascularization has been attempted. The patient died the next day of multiple organ failure. Conclusion: Secondary aortoenteric fistula is rare but with a poor prognosis. Clinical presentation is not always typical. A high index of suspicion is the most important factor for improving outcomes. There is not a consensus about optimal management. Axillo-bifemoral revascularization and subsequent graft removal seem to be the best therapeutic option.

Aortoduodenal fistulas after endovascular abdominal aortic aneurysm repair and open aortic repair

OBJECTIVE

In the present study, we have reported and compared aortoduodenal fistulas (ADFs) after endovascular abdominal aortic aneurysm repair (EVAR) vs after open aortic repair (OAR).

METHODS

We retrospectively analyzed the data from patients treated for ADFs from January 2015 to May 2020 in our hospital. The clinical data, diagnostic procedures, and surgical options were evaluated. The primary endpoints of the present study were 30-day and 1-year mortality. The secondary endpoints were major postoperative complications.

RESULTS

A total of 24 patients (20 men; median age, 69 years; range, 53-82 years) were admitted with ADFs after EVAR (n = 9) or OAR (n = 15). These patients accounted for ∼4.3% of all abdominal aortic aneurysm repairs in our hospital. The median interval from the initial aortic repair and the diagnosis of ADF was 68 months (range, 6-83 months) for the ADF-EVAR group and 80 months (range, 1-479 months) for the ADF-OAR group. Three patients in the ADF-EVAR group had refused surgical treatment owing to their high surgical risk. One patient in the ADF-OAR group had undergone removal of the aortic prosthesis without replacement. Of the remaining 20 patients, 12 (ADF-EVAR group, n = 4; ADF-OAR group, n = 8) had undergone in situ replacement of the aorta and 8 (ADF-EVAR group, n = 2; ADF-OAR group, n = 6) had undergone extra-anatomic reconstruction with aortic ligation. After a mean follow-up of 26 months, no patient had experienced early limb loss. However, one case of rupture of the venous graft (ADF-EVAR), one case of aortic stump blowout (ADF-OAR), and one case of a ureteroarterial fistula with a homograft (ADF-OAR) had occurred. Overall, the incidence of postoperative complications was significantly greater after ADF-OAR (93% vs 33%; P = .036). The most frequent bacteria involved in the blood cultures were Escherichia coli (25% of patients), and Candida spp. (61%) were the predominant pathogens found on intra-abdominal smears. The in-hospital mortality rates for the ADF-EVAR and ADF-OAR group were 22% and 13%, respectively. The corresponding 1 -year mortality rates were 22% and 33%.

CONCLUSIONS

Patients with ADFs after EVAR or OAR have limited overall survival. In addition to the similar therapeutic approaches, we found no significant differences in postoperative mortality between these two uncommon pathologic entities. In our study, the overall postoperative morbidity seemed greater for the ADF-OAR group.

Complete Erosion of an Aortobifemoral Bypass Graft Limb into Duodenum

A 67-year-old male with a history of aortobifemoral bypass graft (ABF) for critical limb ischemia 10 months prior at a regional hospital was transferred to our center with 1 week history of rigors and 3 months of a chronic discharging left groin sinus. Two months prior he had a right-sided ureteric stent inserted for ureteric obstruction. Routine bloods revealed an acute-on-chronic renal injury and subsequent noncontrast computed tomography (CT) demonstrated left-sided hydroureter and hydronephrosis suggestive of extrinsic compression by the left bypass graft limb. A new left-sided ureteric stent was inserted and the right exchanged with no gross signs of infection. His impaired renal function precluded intravenous contrast and so a CT with oral contrast showed circumferential oral contrast and gas surrounding the right limb of his ABF. Urgent gastroscopy revealed periprosthetic erosion with the ABF limb traversing the distal third part of the duodenum. He underwent bilateral axillofemoral bypass grafts, laparotomy with explantation of the ABF, and primary duodenojejunostomy. Bilateral ureters were compressed by overlying graft limbs. Bilateral groins were infected with frank pus on exploration and were associated with impending anastomotic disruption of his previous ABF distal anastomoses. His postoperative course was complicated by colonic ischemia with perforation leading to irreversible multiorgan failure. This patient was remarkably well on presentation with life-threatening pathology. He had no abdominal symptoms or gastrointestinal bleeding. This case demonstrates the diagnostic and management difficulties of periprosthetic erosions and the consequences of graft tunneling superficial to ureters.

Perigraft Abscess Subsequent to Aortoesophageal Fistula

A 79-year-old man with appetite loss and nausea for 1 month was admitted to our hospital. His thoracic aortic aneurysm had gradually increased in size due to perigraft endoleak after the previous aneurysm repair surgery. Although he showed no hematemesis, melena, or a fever, gastrointestinal endoscopy and contrast-enhanced computed tomography (CT) revealed an aortoesophageal fistula (AEF). He developed septic shock due to a perigraft abscess and eventually died, although aortic graft replacement and esophageal transection were performed. Clinical suspicion is the most important factor for obtaining an accurate diagnosis and improving the prognosis in cases of AEF.

Asymptomatic Secondary Aortoduodenal Fistula Incidentally Diagnosed During a Health Check-up: A Case Report

Secondary aortoenteric fistulas (AEFs) are an uncommon but fatal complication of abdominal aortic reconstructive surgery. Aortoduodenal fistulas (ADFs) are the most frequent secondary AEFs (80%). The incidence of secondary AEFs is increasing because of the increasing number of individuals undergoing aortic aneurysm repairs with prosthetics. In most cases of secondary AEFs, surgical repair is performed with the patient in a poor condition, owing to late diagnosis. Thus, an early diagnosis is crucial. We report a case of an asymptomatic secondary ADF that was incidentally diagnosed using esophagogastroduodenoscopy (EGD) and computed tomography during a health check-up and was successfully repaired, with the patient in a stable condition even after the development of life-threatening symptoms. Based on our case, we suggest that noticing unexplained leukocytosis in regular hematological examination and performing surveillance EGD in an asymptomatic individual who has undergone abdominal aortic reconstructive surgery may aid in the early diagnosis of secondary AEFs before fatal complications manifest.