Successful Surgical Treatment of Aortoenteric Fistula

In order to establish optimal management for aortoenteric fistula (AEF) the records of five patients treated for AEF (four aortoduodenal and one aortogastric fistula) were retrospectively reviewed. The arterial reconstruction procedures were selected according to the surgical findings, underlying cause, and patient status. In situ aortic reconstructions with prosthetic grafts were performed on three patients who had no gross findings of periaortic infection, whereas axillo-bifemoral bypass was carried out in the other two patients with periaortic purulence. In all patients, after retroperitoneal irrigation a pedicled omentum was used to cover the aortic graft or aortic stump. In the preoperative abdominal computed tomography (CT) scan there was a periaortic air shadow in four out of five patients. There was no surgical mortality or graft infection observed during a mean follow-up period of 40 months (range, 24-68 months). Therefore, the treatment results of an AEF can be improved using intravenous contrast-enhanced abdominal CT for rapid diagnosis and selection of an appropriate surgical procedure based on the surgical findings and underlying cause.

Lymphangioma of the Small Intestine with Chronic Gastrointestinal Bleeding

A lymphangioma of the small bowel is a rare benign tumor of the lymphatic system, which generally is non-symptomatic but can develop some complications such as gastrointestinal obstruction or bleeding. A 40-year-old female was admitted to our hospital due to chronic gastrointestinal bleeding of 17 months duration. Endoscopic evaluation, computed tomographic examination of the abdomen and pelvis, angiography and enteroclysis were performed, but no abnormal findings were found. A red blood cell (RBC) scan demonstrated the presence of active bleeding in the upper abdominal area; however, the precise location of the bleeding could not be determined. An exploratory laparotomy was performed, with an approximately 0.4 cm sized polypoid mass detected in the proximal jejunum just distal to the Treitz ligament on an intraoperative endoscopic examination through the incision in the mid-jejunum. A segmental resection of the jejunum containing the bleeding mass and primary anastomosis was performed. The final pathological diagnosis was a lymphangioma of the jejunum. In patients with a non-localized bleeding lesion in the small intestine, an intraoperative endoscopic examination could be a useful diagnostic method.

Lessons from Successful Surgical Treatment of Aortoenteric Fistula

Aorto-enteric fistula (AEF) is a rare cause of gastrointestinal (GI) bleeding but has a high mortality rate. PURPOSE: To find a better way to manage this rare vascular condition, we reviewed our series of surgical treatment for AEF. METHOD: We retrospectively reviewed the medical records of 5 patients with AEF. For the diagnosis of AEF, a contrast-enhanced abdominal CT scan was performed for all patients but conventional aortography was not performed. The surgical procedures for the AEF were determined by the operatvie findings. For 3 patients with no evidence of periaortic infection, enteric fistula closure and aortic aneurysm repair with prosthetic grafts were performed while the other 2 patients revealing periaortic infection underwent resection of infected aorta (or infected aortic graft), aortic suture closure, retroperitoneal coverage with omental pedicle and axillo-bifemoral bypass were performed. In a patient who underwent abdominal aortic resection, concomitant left colectomy was required due to colonic ischemia. RESULT: The underlying causes and features of AEF were 4 primary and 1 secondary AEF; 4 aorto-duodenal and 1 aorto-gastric fistula; 4 infrarenal and 1 type IV thoracoabdominal aneurysm, and 4 true and 1 paraanastomotic pseudoaneurysm. Episodes of herald bleeding and periaortic air bubble on CT scan was noted in 4/5 (80%) of patients. There was no operative mortality or graft infection during the follow up period (mean, 23 months, range 3~50 months). CONCLUSION: For the early diagnosis of AEF, periaortic air bubble shadow on abdominal CT scan in a patient with pulsating abdominal mass or previous history of aortic surgery was an important diagnostic clue. Prompt surgical treatment according to the operative finding resulted in good surgical outcomes.