Aorto-enteric Fistula After Endovascular Abdominal Aortic Aneurysm Repair for Behcet's Disease Patient: A Case Report

Introduction

A 42 year old male with Behcet's disease (BD) had endovascular treatment of a symptomatic infrarenal abdominal aortic aneurysm (AAA). Thirteen months later he developed haematemesis and melaena.

Methods

Computed tomography (CT) and angiography showed an aorto-enteric fistula with migration and kinking of the stent graft. Explantation of the infected graft and axillobifemoral bypass, aneurysm sac debridement, and jejunal repair with omental interposition was performed on this severely contaminated patient.

Discussion

There are no reports of an aorto-enteric fistula secondary to endovascular repair in the literature and this case describes the potential consequences of endovascular repair of AAA in BD. The aorto-enteric fistula was associated with persistent inflammatory aortitis, stent graft kinking, and infection. Five cases of secondary aorto-enteric fistulas following open AAA repair in BD patients have been reported including this case resulting from endovascular repair.

Incidence and Risk Factors of Venous Thromboembolism Following Major Abdominal Surgery

OBJECTIVE

Objective: Venous thromboembolism (VTE) has been recognized as a common surgical complication in Western populations more than in Asian populations. Guidelines recommend the routine use of pharmacological prophylaxis for high-risk general surgical patients to prevent VTE. However, the necessity of routine pharmacological prophylaxis for major abdominal surgery in Thai patients has not been clearly determined. The purpose of the study was to determine the incidence and risk factors of VTE in Thai patients undergoing major abdominal surgery.

MATERIAL AND METHOD

A prospective cohort study was conducted between January and September 2014 in our institution. One hundred sixty seven patients that underwent major abdominal operation were analyzed. For the diagnosis of deep vein thrombosis (DVT), a duplex Doppler ultrasonography was performed in all patients five to seven days following surgery and in patients suspected of DVT until four weeks after surgery. CT angiography of pulmonary vasculature was carried out in patients suspected of pulmonary thromboembolism (PE). All patients were divided into two groups, non-VTE and VTE groups. The Student t-test was used to compare all continuous variables between both groups. Fisher’s exact test was used to compare all categorical variables. The risk factors of VTE were identified by stepwise backward regression analysis and reported with risk ratio (RR) and 95% confidence interval (CI). A p-value of <0.05 was regarded as statistically significant.

RESULTS

VTE was diagnosed in six patients (an incidence of 3.6%, 95% CI 3.39-3.81), three patients for proximal DVT (1.8%) and three patients for PE (1.8%). All cases were symptomatic. By multivariable analysis, risk factors of VTE could not be identified. However, higher BMI and postoperative longer rest on bed trended to increase the risk for VTE.

CONCLUSION

The incidence of VTE in Thai patients that underwent major abdominal operation is low (3.6%), even in the context of risk factors typically regarded as high risk. Further studies into this area are warranted, especially well-designed large studies to develop an accurate risk stratification model specific for the Asian population.

Surgical venous thrombectomy for phlegmasia cerulea dolens and venous gangrene of the lower extremities

OBJECTIVE

Phlegmasia cerulea dolens (PCD) and venous gangrene are limb and life-threatening conditions of iliofemoral acute deep vein thrombosis (DVT).

MATERIAL AND METHOD

The authors retrospectively evaluated surgical management of 15 patients from 125 patients with acute iliofemoral DVT (6 PCD and 9 venous gangrene) between January 1991 and August 2002 with long-term follow-up.

RESULTS

All of our 15 patients underwent surgery within 10 days of the onset of symptoms. Six patient with impending gangrene and failure for initial management with bed rest, extremity elevation, fluid resuscitation, and systemic anticoagulation for six to 12 hours underwent iliofemoral venous thrombectomy and distal arteriovenous fistula (AVF) can preserve limbs. In nine patients with venous gangrene that underwent iliofemoral thrombectomy below knee had transmetatarsal amputation done after decreasing leg edema. All patients underwent caval filter insertion before venous thrombectomy. There was no pulmonary embolism (PE) or immediate mortality. Anticoagulation treatment was given for at least six months. The distal arteriovenous fistula was closed as a secondary operation six weeks after initial operation. On the follow-up, 10-year period, seven patients died from the advanced carcinomas 7, 9, 9, 12, 14, 18, and 20 months after an operation. The remaining eight patients have regularly followed-up over 120 months. Three patients (37.5%) had recurrence of DVT; the rate of recanalization in common iliac veins on duplex scan was 100%. Three patients (37.5%) developed reflux in at least one deep venous segment without signs and symptoms of postphlebitic syndrome.

CONCLUSION

Surgical venous thrombectomy with distal AVF are safe method and should be reserved to treat PCD and venous gangrene patients with contraindications to thrombolysis or in condition that thrombolytic therapy is not available. There is no postphlebitic syndrome on the long-term follow-up (> 120 months) of all surviving patients.

Management of the infected aortoiliac aneurysms

PURPOSE

We have reviewed ruptured and nonruptured infected aortoiliac aneurysms to study the clinical presentation, management and eventual outcome of patients managed with in situ prostheses, axillofemoral prostheses grafts and endovascular reconstruction.

DESIGN

A retrospective chart review of 16 cases treated at a single institution.

METHODS

From January 2007 to March 2008, a total of 93 patients with aortoiliac aneurysms underwent surgical repair at our institution. Among these, 16 patients (17.2%) were shown to be infected aneurysms of the infrarenal (n = 6), juxtarenal (n = 2), and pararenal aorta (n = 1); the others were 5 common, 1 external, and 1 internal iliac arteries. Fourteen patients were male and 2 were female with the mean age of 66 years (range, 45-79). In all cases, the diagnosis was confirmed by abdominal computed tomography and empirical parenteral antibiotics were administered at least 1 week, unless in patients need emergency operations. At the time of an operation, all were saccular and were classified as primary infected aortoiliac aneurysms. Thirteen patients had surgical debridement with in situ graft interposition and omental wrapping, 2 underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass, 1 underwent aneurysmectomy of left external iliac artery and polytetrafluoroethylene (PTFE) graft interposition, and 1 underwent endovascular exclusion. The parenteral antibiotics were continued in the postoperative period for 4-6 weeks. Chronic renal disease was present in 37.5% (6/16), with diabetes mellitus present in 31.25% (5/16). The most common pathogen was Salmonella sp. (n = 6) and E. coli (n = 5). Thirty-seven percent (6/16) of the patients presented late, with a 37.5% (6/16) incidence of ruptured (4 contained, 2 free ruptured) that needed emergency surgery.

RESULTS

Disease-specific mortality was 31.25% (5/16). The 30-day mortality rate of ruptured cases is high 67% (4/6), because patients present late in the course of the disease. One patient who underwent aneurysm exclusion and extra-anatomic (axillo-femoral) bypass died 6 months later from burst aortic stump. Salmonella and E. coli are the most common pathogens.

CONCLUSIONS

Early diagnosis followed by surgical intervention with proper antibiotic coverage provides the best results. Mortality rate was still high in patients with sepsis and rupture. An in situ graft interposition and omental wrapping is a safe option for revascularization of infected aneurysms of the iliac arteries and infrarenal aorta.

Mycotic abdominal aortic aneurysm due to Streptococcus suis: a case report

BACKGROUND

Streptococcus suis is a common infection of pigs. Human infection is often related to accidental inoculation through skin injuries during occupational exposure to pigs and pork. The disease may present as meningitis, bacteremia, and less commonly endocarditis, arthritis, or bronchopneumonia.

METHODS

Case report and review of the literature.

RESULTS

We report a case of bacteremia and severe sepsis caused by S. suis serotype 2 complicated by septic arthritis in a 56-year-old male with history of a prior contact with unprocessed pork. The causative agent was isolated from blood cultures and aspirated synovial fluid. The patient's condition improved after treatment with penicillin, but he was found subsequently to have an abdominal aortic aneurysm, confirmed by computed tomography (CT) scan. The mycotic aneurysm was successfully repaired using an in situ graft reconstruction. Tissue samples analyzed using polymerase chain reaction identified S. suis serotype 2 as the causative organism. After completion of two weeks of parenteral antibiotics, an oral form of ciprofloxacin (0.25 g twice a day) was continued for one month. The patient was discharged from our institution after uncomplicated recovery. Clinical review, a CT scan, and inflammatory markers nine months after surgery revealed no evidence of infection.

CONCLUSION

This is the first report of mycotic aneurysm caused by S. suis, which may be an etiologic agent of mycotic aneurysms, especially when complicated by bacteremia in adults with a recent history of contact with pigs or unprocessed pork.

Vascular Pythiosis in a Thalassemic Patient

Pythium insidiosum is a fungus that causes disease in both animals and humans. Human pythiosis is an emerging disease in the tropical, subtropical, and temperate regions of the world, occurring in localized and systemic or vascular forms. Most patients with arterial pythiosis have an underlying hemoglobinopathy, such as thalassemia. A case is presented of a thalassemic horse stable worker who developed an ulcerative cutaneous lesion on the lower left leg followed by progressive ascending involvement of the arteries of that extremity with a necrotizing arteritis with aneurysm formation. P. insidiosum was not isolated from the ulcer by culture or wet potassium hydroxide preparations but was diagnosed by histopathologic study of a biopsy. P. insidiosum infection was quickly confirmed by immunoblot method, aiding in preoperative decision making. Many systemic antibiotics or antimycotics have not been effective in the treatment of systemic pythiosis, and radical surgical removal of all infected tissue is the only method to ensure patient survival. An orally administered saturated solution of potassium iodide, amphotericin B-oral solution, and terbinafine has succeeded only in the cutaneous form but had no favorable effect on vascular pythiosis. It is likely that immunotherapy, successfully used in animal pythiosis, may be beneficial in the treatment of human vascular pythiosis.

Application of immunoblot assay for rapid diagnosis of human pythiosis

OBJECTIVE

Pythiosis, a life-threatening infectious disease, has been reported from Maharaj Nakorn Chiang Mai hospital since 2001. Delayed diagnosis, due to difficulty in obtaining an appropriate specimen and in timely identification, causes delayed treatment resulting in a high mortality rate. To address this problem, a previously developed immunoblot has been evaluated and objected as an effective diagnostic tool for human pythiosis in this hospital.

MATERIAL AND METHOD

The immunoblot assay was evaluated using human sera with culturally proven fungal infection. Sera from humans with a variety of other fungal infections, pooled healthy human sera including Cryptococcus neoformans-, Penicillium marneffei-, and Histoplasma capsulatum-immunized rabbit antisera were used as controls. The assay was applied to evaluate twenty-six sera of suspected pythiosis patients. Moreover, in appropriate cases, a combination of immunoblot, culturing and polymerase chain reaction (PCR) were also performed in order to determine the accuracy of the immunoblot assay.

RESULTS

The presented immunoblot assay was not reactive with any sera of the controls or those of the other fungal-infected patients used in the present study. Pythiosis could be differentiated from other fungal infections with similar symptoms in sixteen of twenty-six samples of suspected patients. The positive ones showed the proper reactive pattern as shown in P. insidiosum-immunized rabbit serum. The present study provided evidence that the 40 to 35-kDa antigens were reactive specifically with all sera from both treated and active pythiosis patients. Culturing and PCR results were consistent with the immunoblot finding.

CONCLUSION

The immunoblot assay developed in the present study is specific to P. insidiosum-infection and suitably applied as an effective tool for human pythiosis diagnosis.

An Unusual Complication of EVAR, Spontaneous Rectus Sheath Hematoma: A Case Report

OBJECTIVE

To report a successful conservative management in a case of spontaneous rectus sheath hematoma (SRSH) after Endovascular Aneurysmal Repair (EVAR) of infrarenal Abdominal Aortic Aneurysm (AAA).

CASE PRESENTATION

An 84-year-old woman with a 6 cm in diameter infrarenal AAA underwent EVAR at our hospital. During the procedure, intravenous heparin was administered to keep the activated clotting time around 300 seconds. One hour after the procedure, the patient complained of pain on her right side abdomen. Physical examination revealed a tender mass in the right lower abdominal wall. Laboratory studies showed a fall in hemoglobin from 12.7 g/dl to 9.3 g/dl. Ultrasound (US) examination demonstrated an 8 × 5 cm hematoma within the right rectus muscle. Follow-up US examination revealed that the hematoma had enlarged and a computed tomography (CT) examination of the lower abdomen was performed. CT scan showed a smooth-shaped mass within the layers of the anterolateral abdominal wall leading to enlargement of the right rectus abdominis muscle without signs of active bleeding. A conservative management was considered.

RESULT

The clinical course was uneventful with a stable hemodynamic state. The patient was discharged 12 days later and was doing well at the 2 week follow-up.

CONCLUSION

Spontaneous rectus sheath hematoma is an unusual complication of a patient on anticoagulant therapy during EVAR. A prompt radiological investigation may prevent unnecessary surgical procedures in this unusual complication.

Decrease in the Incidence of Buerger's Disease Recurrence in Northern Thailand

PURPOSE

Buerger's disease is a peripheral arterial occlusive disease (PAOD), which occurs mainly in young male smokers. It is common in Asia, the Middle East, and Eastern European countries, but rare in North America and Western European countries. We investigated the changes in the prevalence and recurrence of Buerger's disease at a referral hospital in northern Thailand.

METHODS

We conducted a retrospective study of patients with Buerger's disease admitted to Chiang Mai University Hospital between January 1988 and December 2002. Buerger's disease was diagnosed according to Shionoya's clinical criteria.

RESULTS

We evaluated 78 patients with Buerger's disease, with a collective total of 108 admissions. Forty-one patients were admitted for initial treatment, and 37 patients had a history of treatment and were admitted for worsening of Buerger's disease. Between 1988 and 1995, 23 patients were admitted with newly diagnosed Buerger's disease, 52 were admitted because of Buerger's disease exacerbation, and 372 were admitted for a PAOD; whereas between 1996 and 2002, the respective numbers were 18, 15, and 632 (2.9 +/- 1.9/year vs 2.6 +/- 1.3/year, P = 0.25; 6.5 +/- 1.1/year vs 2.1 +/- 1.1/year, P = 0.001; 54.1 +/- 6.7/year vs 81.6 +/- 5.2/year, P < 0.0001). Of the 78 patients with Buerger's disease, 76 were men and 2 were women, with a mean age at onset of 34.1 +/- 5 years. The predominant symptom on admission was burning pain in the feet and hands in 75%, digital gangrene in 74%, and a digital ulcer in 43.5%.

CONCLUSIONS

The incidence of recurrence of Buerger's disease seems to be decreasing in our institution, whereas the incidence of this disease and its recurrence both seem to be decreasing in Western countries and Japan.

Mini-laparotomy for repair of infrarenal abdominal aortic aneurysm

AIM

In this study, we evaluated the surgical results of minimal incision aortic surgery (MIAS) compared with the transabdominal approach (TPA) and the retroperitoneal approach (RPA) to repair non-ruptured infrarenal abdominal aortic aneurysm (AAA).

METHODS

Three different surgical techniques were studied prospectively in 72 consecutive patients with non-ruptured infrarenal AAA. These patients were randomized into 3 groups of 24 patients each. Group I comprised of patients who underwent MIAS repair. They were compared with group II patients, who underwent the traditionally long midline TPA, and group III patients, who underwent the left RPA to repair non-ruptured infrarenal AAA. All surgery was performed between January 2000 and December 2004. Demographic characteristics, including age, sex, body weight, aneurysm size, previous abdominal operations and comorbid factors of the three groups studied, were compared using the Fischer's exact test. Parameters including operative time, intraoperative fluid administration, and transfusion requirements were compared using the 2-tailed Student t test. Length of stay in the Intensive Care Unit (ICU), time to resumption of regular dietary feeding, and hospital length of stay were recorded and compared using the Wilcox rank sum test. The incidence of 30 day postoperative complications and mortality were compared between the three groups. All 72 patients who entered this study had informed consent.

RESULTS

There was no significant difference between group I (MIAS), group II (TPA), and group III (RPA) with regard to age, sex distribution, aneurysm size, or body weight. There was male sex prevalence in all three groups. Surgical exposure of the common femoral arteries was more commonly required in group III (RPA) than in the other groups. Although the length of incision tended to be longer in group III (RPA) than in group II (TPA) and I (MIAS), there was no significant difference in intraoperative time, or aortic cross-clamped time among the three groups. There was a significant difference in the need for intraoperative fluid, the most being in group II (TPA) and the least in group I (MIAS). There was significantly less blood loss in group I (MIAS), as compared with the other 2 groups, but intraoperative blood transfusion for all groups was not significantly different. ICU stay, return to general dietary feeding, and hospital length of stay for group I (MIAS) and III (RPA) were significantly lower than in group II (TPA), which had a higher incidence of postoperative ileus.

CONCLUSIONS

MIAS is as safe as retroperitoneal repair and standard transabdominal repair in the treatment of non-ruptured infrarenal AAA, and also more costefficient than retroperitoneal and standard transabdominal repair.

Left retroperitoneal versus midline transperitoneal approach for abdominal aortic aneurysms (AAAs) repair

OBJECTIVE

The purpose of this prospective randomized study was to compare the left retroperitoneal approach (RPA) with the midline transperitoneal approach (TPA) for infrarenal abdominal aortic aneurysms (AAAs) repair with operative details, postoperative complications, and total cost comparision.

MATERIAL AND METHOD

Between January 2000 and December 2003, 36 patients undergoing elective surgery for infrarenal AAAs were included in the prospective comparison of transperitoneal approach (TPA) with retroperitoneal approach (RPA). Thirty-six patients were analyzed, with 18 in group 2 (TPA) and 18 in group I (PRA). There was no significant differences between the groups in patient demographics. (p value > 0.05)

RESULTS

There was no significant differences in the aortic cross clamp time, operative time, estimated blood loss and intraoperative blood transfusion between the two groups (p value > 0.05); however, significantly more intraoperative fluid needs and bowel function onset had a statistically longer return in group 11 (TPA) than in group I (RPA). Statistically reduction in postoperative ileus (>4 days) and total length of hospital stay was observed in group I (RPA) (p value < 0.05). Postoperative cardiopulmonary complications were statistically significantly more increased in group II (TPA) than in group I (RPA). Wound complications were more in group I (RPA) (1 hematoma, 4 abdominal wall hernia, and 4 chronic wound pain) than in group II (TPA) (2 chronic wound pain). Total cost payment was not significantly different in both groups.

CONCLUSION

The left retroperitoneal approach for infrarenal AAAs repair, with fewer cardiopulmonary complications and shorter hospital stay has more unsatisfactory postoperative wound complications than the midline transperitoneal approach.

Seasonal variation of Buerger's disease in Northern part of Thailand

OBJECTIVES

Buerger's disease is a common peripheral arterial occlusive disease in Asia, Middle East, and eastern European countries. This study was undertaken to investigate the seasonal variation in admission pattern of with patients Buerger's disease at our institution which is a referral hospital in the Northern Thailand.

MATERIAL AND METHODS

Patients with Buerger's disease admitted to Chiang Mai University Hospital between January 1987 and December 2002 were studied retrospectively. Data are reported as mean+/-SD. Statistical significance was analyzed by Chi-square test.

RESULTS

Eighty-four patients (82 men and two women) with Buerger's disease were evaluated on 121 admissions. Forty-five were newly diagnosed cases, who were admitted for initial treatment, and 39 were known cases who experienced worsening of the disease. Sixty-three admissions (52%) took place during winter (November to February), 44 admissions (34.6%) during the rainy season (June-October) and only 14 admissions (11.6%) occurred during the summer (March-May). There was a significant difference in the monthly admission rates during the three seasons (p<0.05).

CONCLUSION

Admission for Buerger's disease showed a significant seasonal variation, with a peak in the winter followed by the rainy and summer season, respectively. Further research is needed to confirm our findings and evaluate the underlying mechanisms.

Abdominal incisional endometrioma following cesarean section: a case report

A 34 year old woman underwent a cesarean section for placenta previa when she was 25 years old, after that she took oral contraceptives regularly for 8 years and remained asymptomatic. Upon entering our hospital, the patient stopped taking the oral contraceptives and had a one year history of cyclic bleeding from the lower midline abdominal incision scar. Surgical excision was done and pathological findings revealed endometrioma.

Management of celiac artery aneurysm: a case report

A case of CAA in a 68-year-old male patient is reported. The patient had vague abdominal pain for 1 year. Physical examination revealed a pulsatile abdominal mass on the epigastrium. Abdominal ultrasonography and visceral arteriography confirmed the diagnosis of CAA. Aneurysmectomy with direct implantation was performed transabdominally.

The retroperitoneal approach for abdominal aortic aneurysms

Graft replacement has become the reliable and effective form of treatment for abdominal aortic aneurysms (AAA). Operative therapy remains the major undertaking with significant rates of postoperative morbidity and mortality. The use of retroperitoneal approach has been proposed as an alternative to standard midline transabdominal approach. Over a 5 year period, 43 consecutive nonrandomized infrarenal AAA patients underwent elective surgical correction by the authors. 32 patients with the mean age of 75 underwent transabdominal reconstructive procedures for AAA. The average size of AAA was 5.9 cm and operative time was 3 hours and 25 minutes. The mortality rate was 6.25 per cent (2 of 32). The cause of death was myocardial infarction 1, and acute renal failure 1. There are many complications in the transabdominal group. 11 had prolonged ileus, 2 MI, 2 wound dehiscence, 2 atelectasis, 1 acute renal failure and 1 chylous ascites. In 11 patients with retroperitoneal approach, the average size of AAA was 5.6 cm and operative time was 3 hours and 29 minutes. No operative mortality, the only 1 complication was retroperitoneal hematoma. The most notable difference between the retroperitoneal group and transabdominal group was the speed and ease of postoperative recovery. The patients in the retroperitoneal group needed a shorter period of intubation, nasogastric drainage, stay in the intensive care unit and hospital. Patients in the retroperitoneal group also resumed oral alimentation sooner, shorter and smoother postoperative course. The patients in the retroperitoneal group had less blood loss and fewer transfusions than in the transabdominal group. Findings from our experience using the left retroperitoneal approach for a reconstructive procedure of AAA indicate that it results in fewer overall physiologic disturbances of the patients. We believe that the left retroperitoneal approach is a useful surgical access of choice for the elective repair of AAA.

Esophageal conduit in nearly hopeless corrosive esophageal stricture patient

The case report of a 28 year old woman with strictured esophagus from corrosive esophagitis for 4 months is presented. Barium swallowing showed a strictured esophagus extending from T2 to the aortic knob and needed frequent dilatations. The patient had a perforated thoracic esophagus and mediastinitis on last dilatation. Cervical esophagostomy, transabdominal esophageal bandaging and jejunostomy feeding were done along with intravenous broad spectrum antibiotics. On esophagoscopy, there was complete stenosis of the cervical esophagus 2 cm from the postcricoid area. The large intestine from the caecum, transverse colon and descending colon was chosen as the esophageal conduit because of adequate length to pass subcutaneously. The caecum was anastomosed to the cervical esophagus and descending colon to the stomach. Seven days postoperatively, the patient could take liquids and soft porridge orally. There was a small leakage from the cervical anastomosed, spontaneous closure was achieved 3 weeks postoperatively. We chose the right side colon as the esophageal conduit because of adequate length to pass subcutaneously. Mediastinal and transhiatal routes could not be passed because of previous mediastinitis from thoracic esophageal perforation. This may be an alternative choice of operation for high cervical esophageal stenosis with previous mediastinitis.

A simple tunneler for extra-anatomical bypass grafts and interposition arteriovenous hemodialysis fistulas

A simple and inexpensive tunneler has been employed in arterial grafting encompassing femoropopliteal, aortofemoral, axillo femoral bypass and vascular access procedures. This is fashioned from a disposable Argyle thoracostomy tube. This technique is recommended because of its simplicity, ready availability, lack of expense, and relative safety.