ABSTRACT
Resumo A fístula aortoentérica é uma grave condição clínica, e seu manejo permanece sendo um grande desafio técnico aos cirurgiões. A abordagem por cirurgia convencional nesses casos está relacionada a altos índices de morbimortalidade. A cirurgia endovascular apresenta-se como uma ótima alternativa nesses casos; contudo, por não se tratar de aorta nativa, a anatomia pode não ser compatível com os dispositivos endovasculares comercialmente disponíveis, fazendo-se necessário, em casos de urgência, a utilização de dispositivos modificados pelo cirurgião. O caso relatado reporta uma fístula aortoentérica secundária, tratada em situação de urgência por técnica endovascular com dispositivo modificado.
Abstract Aortoenteric fistula is a severe clinical condition and its management remains a major technical challenge for surgeons. In these cases, the conventional surgical approach is associated with high rates of morbidity and mortality. Endovascular surgery is an excellent option in these cases, but considering that the aorta has been treated previously, anatomy may not be compatible with commercially available endovascular devices and so physician-modified endografts may be needed in urgent cases. The case reported involves a secondary aortoenteric fistula, treated on an emergency basis with endovascular techniques, using a physician-modified endograft.
Subject(s)
Humans , Male , Aged , Prostheses and Implants , Vascular Fistula/surgery , Endovascular Procedures/instrumentation , Aortic Aneurysm/surgery , Emergencies , Endovascular Procedures/methodsABSTRACT
RESUMEN Introducción: Las fístulas aorto-entéricas son una causa infrecuente de hemorragia digestiva. El pronóstico, generalmente ominoso, depende de una alta sospecha clínica y diagnóstico oportuno. Objetivo: Presentar el caso de una hemorragia digestiva por una fístula Aortoentérica diagnosticada y tratada. Presentación del caso: Se reporta el caso de un hombre de 72 años intervenido con el diagnóstico hemorragia digestiva masiva en el preoperatorio; sin embargo, el diagnóstico de la fístula se hizo en el intraoperatorio, sin observar dilatación aneurismática, pero si una aorta ateromatosa y un proceso inflamatorio hacia la fístula. Se realizó reparación quirúrgica urgente con reparación cara anterior aorta infrarrenal cercana a la bifurcación y resección del íleo terminal con ileoascendentostomía termino-lateral. Discusión: Las fístulas aorto-entéricas es una causa potencialmente fatal de hemorragia digestiva. El diagnóstico continúa siendo un desafío debido a su presentación inespecífica y siempre debiese ser considerado frente a una hemorragia digestiva sin causa aparente. Existen varias opciones para el enfrentamiento quirúrgico que deben ser analizadas caso a caso, sin retrasar la reparación. Conclusiones: La fístula aorto-entérica primaria es una causa poco frecuente de hemorragia digestiva, que todo médico y cirujano debe tener en cuenta frente a un paciente con sangrado digestivo de causa no precisada(AU)
ABSTRACT Introduction: Aortoenteric fistulas are a rare cause of gastrointestinal bleeding. The generally ominous prognosis depends on high clinical suspicion and timely diagnosis. Objective: To present a case of gastrointestinal hemorrhage for aortoenteric fistula diagnosed and treated. Case presentation: The case is reported of a 72-year-old man who received surgery after the diagnosis of massive gastrointestinal bleeding during the preoperative period. However, the diagnosis of the fistula was made intraoperatively, without observing aneurysmal dilation, but an atheromatous aorta and an inflammatory process leading to the fistula instead. Urgent surgical repair was performed with repair of anterior infrarenal aorta near the bifurcation and resection of the terminal ileum with end-to-side ascending ileostomy. Discussion: Aortoenteric fistulas are a potentially fatal cause for gastrointestinal bleeding. Diagnosis continues to be a challenge due to its nonspecific presentation and should always be considered for any case of unexplained gastrointestinal bleeding. There are several options for surgical management that must be analyzed case by case, without delaying repair. Conclusions: Primary aortoenteric fistula is a rare cause for gastrointestinal bleeding, which every doctor and surgeon must take into account when dealing with a patient with digestive bleeding of an unspecified cause(AU)
Subject(s)
Humans , Male , Aged , Fistula/surgery , Gastrointestinal Hemorrhage/diagnostic imaging , Ileum/surgeryABSTRACT
La fístula aortoentérica (FAE) es la solución de continuidad entre la arteria aorta y una porción del sistema digestivo; su incidencia va del 0.04 al 0.07% y su mortalidad alcanza hasta 79%, lo que la convierte en un verdadero reto a la hora de establecer su manejo por la efectividad con la cual se debe efectuar su manejo. Existen diversas manifestaciones de la enfermedad que pueden distraer su diagnóstico, sin embargo es común el dolor abdominal y el sangrado digestivo acompañado o no de signos de inestabilidad hemodinámica. Actualmente, no existe un consenso para el manejo de las FAE; sin embargo, los pilares fundamentales son: control de la infección, reparación vascular y reconstrucción entérica; para esto es indispensable un equipo multidisciplinario de gran experiencia. Se presenta el caso de una paciente de 76 años con varias comorbilidades, portadora de bypass aorto-bi-femoral por enfermedad aterosclerótica de la aorta. Acudió por dolor abdominal, sangrado digestivo alto e inestabilidad hemodinámica. Luego de la valoración inicial fue diagnosticada de FAE y sepsis. Tomando en cuenta las recomendaciones mundiales, se realizó un procedimiento en 2 tiempos que incluían: a) reparo vascular: bypass extra-anatómico, exéresis de prótesis y cierre del muñón aórtico y, b) reparo entérico (por la magnitud anatómica de la lesión intestinal y luego de haber descartado la factibilidad de una rafia o derivación intestinal): como último recurso un procedimiento de Whipple
Aortoenteric fistulas are defined as a communication between the aorta and a portion of the digestive system. This pathology has a 0.04-0.07% incidence with a mortality rate of up to 79% making it's management a true challenge. Clinical manifestations vary thus common symptoms include abdominal pain and digestive bleeding and may or may not include signs of hemodynamic instability. Until now there is no consensus regarding the management of FAE hence the pillars of treatment include: infection control, vascular reparation and enteric reconstruction. A multidisciplinary team is imperative. We are presenting the case of a 76-year-old female with various comorbidities and a history of an aortic bifemoral bypass reconstruction due to aortic sclerosis disease; that presented with abdominal pain, upper digestive bleeding and hemodynamic instability. She was diagnosed with a FAE and sepsis. Taking into consideration international recommendations she was treated with a single procedure in two times. For the vascular correction: an extra-anatomical bypass; removal of previous prosthetic aortic implant and closure of the aortic stump. Due to the magnitude of the intestinal damage simple closure and intestinal derivation were discarded as options for enteric repair and a Whipple procedure was used as a last resource.
Subject(s)
Humans , Female , Aged , Aortic Diseases , Gastric Bypass , Digestive System Fistula , Intestinal Fistula , Abdominal Pain , Sepsis , Gastrointestinal HemorrhageABSTRACT
A 92 year-old-female with melena was admitted to our hospital. She underwent Y-graft replacement of the abdominal aorta at the age of 65. Gastroduodenal fiberscopic examination and computed tomography (CT) confirmed the diagnosis of aortoduodenal fistula. The fistula in the proximal anastomotic site was occluded with a suture ligature and omentopexy was performed. On the 15th post-operative day she developed high-grade fever. CT revealed a pseudoaneurysm formation at the proximal anastomosis site. She underwent emergency endovascular aneurysmal repair (EVAR). Her postoperative course was uneventful. She is doing well without symptoms of recurrent infection.
ABSTRACT
Primary aortoenteric fistula (PAEF) is a rare but catastrophic cause of massive gastrointestinal bleeding. Diagnosis of PAEF is difficult to make and is frequently delayed without strong clinical suspicion. Timely surgical intervention is essential for patient's survival. We report on a case of an 86-year-old woman with no history of abdominal surgery, who presented with abdominal pain. Initially, computed tomography scan showed an intra-abdominal abscess, located anterior to the aortic bifurcation. However, she was discharged without treatment because of spontaneous improvement on a follow-up computed tomography scan, which showed a newly developed right common iliac artery aneurysm. One week later, she was readmitted due to recurrent abdominal pain. On the second day of admission, sudden onset of gastrointestinal bleeding occurred for the first time. After several endoscopic examinations, an aortoenteric fistula bleeding site was found in the sigmoid colon, and aortography showed progression of a right common iliac artery aneurysm. We finally concluded that intra-abdominal abscess induced an infected aortic aneurysm and enteric fistula to the sigmoid colon. This case demonstrated an extremely rare type of PAEF to the sigmoid colon caused by an infected abdominal aortic aneurysm, which has rarely been reported.
Subject(s)
Aged, 80 and over , Female , Humans , Abdominal Abscess/diagnosis , Aorta, Abdominal/diagnostic imaging , Aortic Aneurysm, Abdominal/diagnosis , Bacteroides/isolation & purification , Bacteroides fragilis/isolation & purification , Colon, Sigmoid/diagnostic imaging , Colonoscopy , Enterococcus/isolation & purification , Fistula/diagnosis , Tomography, X-Ray ComputedABSTRACT
A 71-year-old man who had undergone repair of a ruptured abdominal aortic aneurysm with a tube graft 3 months ago was transferred from another hospital with an Aortoenteric Fistula (AEF) for surgical treatment. Computed tomographic (CT) angiography revealed pseudoaneurysm formation at the proximal anastomotic site. Waiting for the elective operation, he developed massive hematemesis with shock. Endovascular stent-graft repair was emergently performed because of high risk for conventional open surgery. Gastrointestinal bleeding was successfully controlled. The psuedoaneurysm disappeared, which was confirmed by postoperative CT angiography. At 1-year follow-up, he has shown no clinical and radiographic evidence of recurrent infection or bleeding. For the case with shock, Endovascular repair could be a bridge to open surgery because it is fast and minimally invasive. Endovascular repair of AEF is technically feasible and may be the definitive treatment in selected patients without signs of infection and gastrointestinal bleeding.
ABSTRACT
Aortoenteric fistula (AEF) developed after treatment for an abdominal aortic aneurysm (AAA) is a rare but usually fatal complication. We report a rare case of AEF bleeding after endovascular stent grafting for AAA which was managed angiographically. An 81-year-old man presented with hematochezia and acute abdominal pain for 1 day ago. Four years ago, an aortic stent was implanted in the infrarenal aorta for AAA. Endoscopies were performed to evaluate the hematochezia. Evidence of gastrointestinal bleeding was observed, but a clear bleeding point was not detected on upper endoscopy and colonoscopy. Contrast-enhanced computed tomography performed subsequently showed that the bleeding point was located in the fourth portion of the duodenum as an AEF caused by an inflammatory process in the stent-graft. Intra-arterial angiography showed a massive contrast leakage into the bowel via a small fistula from around the aortic stent graft site. Embolization was successfully performed by injecting a mixture of glue and lipiodol into the AEF tract. The patient was discharged with no evidence of gastrointestinal bleeding after the embolization.
Subject(s)
Aged, 80 and over , Humans , Male , Angiography , Aortic Aneurysm, Abdominal/therapy , Aortic Diseases/etiology , Embolization, Therapeutic , Endoscopy, Gastrointestinal , Fistula/etiology , Gastrointestinal Hemorrhage/therapy , Stents/adverse effects , Tomography, X-Ray ComputedABSTRACT
A secondary aortoenteric fistula (AEF) is a direct communication between the gastrointestinal tract and the aorta in a patient who has undergone major surgery on the aorta, often an aorta graft operation. We experienced a patient who had undergone graft interposition for abdominal aortic aneurysm and was admitted due to three episodes of hematemesis and following hamatochezia. Gastroscopy, colonoscopy, and radioactive iodine scan failed to identify the bleeding site in the patient. He was diagnosed with AEF by double balloon enteroscopy and recovered after surgical intervention.
Subject(s)
Humans , Aorta , Aortic Aneurysm, Abdominal , Colonoscopy , Double-Balloon Enteroscopy , Fistula , Gastrointestinal Tract , Gastroscopy , Hematemesis , Hemorrhage , Iodine , Lymphokines , TransplantsABSTRACT
We report a case of secondary aortoenteric fistula (SAEF). A 76-year-old man who had undergone bifurcated graft replacement for an abdominal aortic aneurysm 18 years previously was admitted to our hospital on 2008. Since the patient was in hemorrhagic shock and had several comorbidities, he first underwent emergency endovascular aneurysmal repair (EVAR). The patient recovered from shock, and then the duodenal fistula was closed and a temporary tube enterostomy was made on the next day. The patient's recovery was uneventful and he was discharged 34 days after EVAR without any sign of infection. However, the patient was admitted for a recurrent SAEF 16 months after the procedure. Although emergency surgery was performed, he died due to sepsis 11 days after surgery. EVAR could be useful to control bleeding associated with SAEF ; however, it would be necessary for a long-term results to perform additional radical surgery subsequently to ensure the patients' hemodynamic recovery.
ABSTRACT
La hemorragia digestiva alta es un síndrome frecuente que aparece como complicación de enfermedades, no sólo digestivas, sino también sistémicas. Aunque 85-90% de los episodios hemorrágicos se interrumpen de forma espontánea o gracias a medidas conservadoras, entre 10 y 25% de los pacientes requieren una intervención quirúrgica urgente. Actualmente, la mortalidad ha descendido hasta 4 ó 9% en pacientes menores de 60 años y, en los mayores de 60 años oscila entre 14 y 30%, teniendo gran valor la gastroduodenoscopía fibro-óptica como exploración de rutina. No obstante, la creciente proporción de pacientes mayores de 60 años con este síndrome ha hecho que estas cifras permanezcan estacionarias. A continuación exponemos la Historia clínica de un paciente de la tercera edad que presentó una hemorragia digestiva alta, resultado de una fístula aorto-entérica secundaria, quien falleciera antes de ser intervenido de urgencia. Se exponen actualizados los aspectos más importantes de dicha entidad nosológica y su tratamiento.
Upper digestive hemorrhage is a common sindrome that appears not only secondary to digestive diseases but also a systemic too. Although 85 to 90% of those episode stop spontaneously or with medical treatment, mortality rate, nowdays has been decreased to 4 or 9% in patients below sixty years old and in patients over 60 years old, mortality rate, are between 14 to 30%. Fiberoptic endoscopy has become the optimal diagnostic procedure. Nevertheless the increase of life rate had become a cause that these mortality rate state stationary. The objective of this report is to presents the history of a geriatric patient with an upper digestive bleeding due to a secondary aortoenteric fistula, who died before an attempt to surgical stop the bleeding and to review this subject.
Subject(s)
Humans , Male , Aged , Duodenoscopy , Gastrointestinal HemorrhageABSTRACT
The present study aimed to experimentally evaluate the protection role of glycerin preserved bovine peritoneum (BP) against intestinal adhesions to a vascular graft. Experiments were performed on 24 adult rabbits, randomly dived into two groups. All animals were submitted to a vascular graft over the infra-renal aorta and vena cava. Group 1(12 animals ) was submitted to a BP patch on the retroperitoneal opening, between the vascular prosthetic graft and the intestinal loops. Group II (12 animals ) had the retroperitoneal opening sutured. After 7, 14, 28 and 60 days, 3 animals of each group were randomly killed and the retro peritoneum, with or without the BPpatch, was removed for histological analysis. The histological analysis showed that the BP stimulated a moderate to intense inflammatory reaction at the beginning of the experiments and on the 60-day evaluation, the inflammatory reaction was mild, limited to the BP border with its histological structure preserved. In conclusion, the BP is a safe and cheap interposition material to be used between vascular grafts and intestinal loops, presenting a protection role against adhesions between them.
El objetivo de este estudio fue evaluar experimentalmente el rol protector del peritoneo bovino (PB) preservado en la glicerina en contra de las adherencias intestinales de un injerto vascular. Los experimentos se realizaron en 24 conejos adultos, randomizados aleatoriamente en dos grupos. Todos los animales fueron sometidos a un injerto vascular sobre la aorta infra-renal y la vena cava. Grupo I (12 animales), fue sometido a un parche PB en una apertura retroperitoneal suturada, entre el injerto vascular y el intestino. Grupo II (12 animales) con la apertura retroperitoneal suturada. Después de 7, 14, 28 y 60 días, 3 animales de cada grupo fueron sacrificados al azar y el retro peritoneo, con o sin el parche de PB, se retiró para el análisis histológico. El análisis histológico mostró que la PB estimuló una moderada a intensa reacción inflamatoria al inicio de los experimentos y en la evaluación de 60 días, la reacción inflamatoria fue leve, limitada a los bordes de la PB con su estructura histológica preservada. En conclusión, la PB es una forma segura y barata de material de interposición para ser utilizada entre injertos vasculares e intestinales, presentando un rol de protección contra adherencias entre ellos.
Subject(s)
Cattle , Animals , Rabbits , Blood Vessel Prosthesis , Aortic Diseases/surgery , Aortic Diseases/pathology , Vascular Fistula/surgery , Vascular Fistula/pathology , Peritoneum/transplantation , Bioprosthesis , Postoperative Complications/prevention & control , Intestinal Diseases/prevention & control , Time Factors , Tissue PreservationABSTRACT
Primary aortoenteric fistulae (AEFs) are extremely rare vascular disease entities, with a mortality ranging from 33 to 85%. Only two cases of Salmonella mycotic aortic aneurysms causing primary AEFs have been reported. We experienced a rare case of a 57-year-old man with intermittent gastrointestinal bleeds and who was diagnosed as having primary aortoenteric fistula with abdominal aortic aneurysm, confirmed by CT. In the operation room, the fistula was closed and a temporary proximal duodenojejunostomy was created. The aneurysm was replaced with an aorto-biiliac bypass using Dacron Graft with an inter-positioning omental flap. The microbiology report of aneurysm wall, blood and periaortic tissue showed infection with group D salmonella. He was treated with ciprofloxacin and discharged in good general condition on the 21st post-operative day.