ABSTRACT
Primary aortoenteric fistulas (AEF) are rare. The majority of these are due to atherosclerotic aortic aneurysms. Mycotic aortic aneurysms leading to primary AEF are exceedingly uncommon. Here we report a rare case of primary AEF secondary to Salmonella-related mycotic aneurysm and discuss the diagnostic and therapeutic issues.
Subject(s)
Aneurysm, Infected , Intestinal Fistula , Salmonella typhi , Vascular Fistula , Humans , Aneurysm, Infected/diagnosis , Aneurysm, Infected/microbiology , Intestinal Fistula/microbiology , Intestinal Fistula/diagnosis , Intestinal Fistula/etiology , Salmonella typhi/isolation & purification , Vascular Fistula/diagnosis , Vascular Fistula/microbiology , Male , Typhoid Fever/diagnosis , Typhoid Fever/complications , Middle Aged , Salmonella Infections/diagnosis , Salmonella Infections/complicationsABSTRACT
Background: Tsukamurella species were first isolated in 1941. Since then, 48 cases of Tsukamurella bacteremia have been reported, a majority of which were immunosuppressed patients with central venous catheters.A case is described and previous cases of Tsukamurella bacteremia are reviewed. Patients and Methods: A 70-year-old total parenteral nutrition (TPN)-dependent female with recurrent enterocutaneous fistula (ECF), developed leukocytosis one week after a challenging ECF takedown. After starting broad-spectrum antibiotic agents, undergoing percutaneous drainage of intra-abdominal abscess, and subsequent repositioning of the drain, her leukocytosis resolved. Blood and peripherally inserted central catheter (PICC) cultures grew Tsukamurella spp. The patient was discharged to home with 14 days of daily 2 g ceftriaxone, with resolution of bacteremia. Conclusions: Tsukamurella spp. are a rare opportunistic pathogen predominantly affecting immunocompromised patients, with central venous catheters present in most cases. However, there have been few reported cases in immunocompetent individuals with predisposing conditions such as end-stage renal disease and uncontrolled diabetes mellitus.
Subject(s)
Actinomycetales Infections , Anti-Bacterial Agents , Bacteremia , Humans , Aged , Female , Bacteremia/microbiology , Bacteremia/drug therapy , Anti-Bacterial Agents/therapeutic use , Actinomycetales Infections/microbiology , Actinomycetales Infections/drug therapy , Intestinal Fistula/microbiology , Intestinal Fistula/surgery , Immunocompromised HostSubject(s)
Blood Vessel Prosthesis Implantation/adverse effects , Dyspepsia/surgery , Graft Occlusion, Vascular/surgery , Intestinal Fistula/surgery , Prosthesis-Related Infections/surgery , Aorta/diagnostic imaging , Aorta/surgery , Blood Vessel Prosthesis/adverse effects , Computed Tomography Angiography , Dyspepsia/diagnosis , Dyspepsia/microbiology , Femoral Artery/diagnostic imaging , Femoral Artery/surgery , Graft Occlusion, Vascular/diagnosis , Graft Occlusion, Vascular/microbiology , Humans , Intestinal Fistula/diagnosis , Intestinal Fistula/microbiology , Male , Middle Aged , Prosthesis-Related Infections/complications , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/microbiology , Time Factors , Time-to-Treatment , Treatment OutcomeABSTRACT
Colocutaneous fistula is a rare entity in colorectal disease. We present a case of colocutaneous fistula in a patient whose postoperative course following a laparoscopic anterior resection for sigmoid cancer was complicated by Clostridioides difficile colitis. During the follow-up period, it was found that his bowel contents were preferentially discharging through this fistula which had taken up the role of an 'autocolostomy'. Given the physiological impact of an additional surgical procedure, a definitive repair of the fistula was deferred and instead the patient was taught to manage it in keeping with general principles of stoma care. Over the subsequent follow-up period, he has now developed a large parastomal hernia and is being considered for definitive repair.
Subject(s)
Clostridium Infections , Intestinal Fistula , Clostridium Infections/complications , Humans , Intestinal Fistula/diagnosis , Intestinal Fistula/microbiology , Intestinal Fistula/surgery , MaleABSTRACT
Primary aortoduodenal fistula is a rare, life-threatening pathology that is difficult to diagnose and manage. We present the case of a 64-year-old male with a primary aortoduodenal fistula. Our patient initially underwent an endovascular aneurysm repair at an outside institution before being transferred to our tertiary care center, where he ultimately had definitive management with an extra-anatomic bypass, aortic ligation, duodenal resection with primary anastomosis, and gastrojejunostomy tube placement. His surgical cultures grew Candida albicans, and he was discharged with a 6-week course of intravenous antibiotics with subsequent antibiotic suppression for 1 year. He died 14 months postoperatively from tongue squamous cell carcinoma. We also review the current literature regarding epidemiology, pathology, diagnostics, management, and case reports from 2015 to present. Overall, timely diagnosis and treatment is imperative for reducing mortality from primary aortoduodenal fistula, and although formal consensus is lacking regarding most clinical aspects, an increasing number of case reports has helped describe options for management.
Subject(s)
Aneurysm, False/surgery , Aneurysm, Infected/surgery , Aortic Aneurysm, Abdominal/surgery , Aortic Diseases/surgery , Digestive System Surgical Procedures , Duodenal Diseases/surgery , Intestinal Fistula/surgery , Vascular Fistula/surgery , Vascular Surgical Procedures , Adult , Aged , Aged, 80 and over , Aneurysm, False/diagnostic imaging , Aneurysm, False/microbiology , Aneurysm, Infected/diagnostic imaging , Aneurysm, Infected/microbiology , Anti-Bacterial Agents/therapeutic use , Aortic Aneurysm, Abdominal/diagnostic imaging , Aortic Aneurysm, Abdominal/microbiology , Aortic Diseases/diagnostic imaging , Aortic Diseases/microbiology , Duodenal Diseases/diagnostic imaging , Duodenal Diseases/microbiology , Female , Humans , Intestinal Fistula/diagnostic imaging , Intestinal Fistula/microbiology , Male , Middle Aged , Treatment Outcome , Vascular Fistula/diagnostic imaging , Vascular Fistula/microbiologyABSTRACT
Aortoenteric fistula after endovascular aortic repair for an abdominal aortic aneurysm is a rare but severe complication. Particularly, a case of inflammatory abdominal aortic aneurysm is extremely rare and there are only 3 reported cases. A 70-year-old man underwent endovascular aortic repair for impending rupture of an inflammatory abdominal aortic aneurysm and was medicated steroids for approximately 2 years. Four years after endovascular aortic repair, he developed endograft infection with an aortoduodenal fistula and a left psoas abscess. He underwent total endograft excision, debridement, in situ reconstruction of the aorta using prosthetic grafts with omental coverage, and digestive tract reconstruction to prevent leakage. Pseudomonas aeruginosa was detected in the infected aortic sac. The patient has not experienced recurrence of infection in the 35 months since his operation.
Subject(s)
Aortic Aneurysm, Abdominal/surgery , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis/adverse effects , Duodenal Diseases/microbiology , Endovascular Procedures/adverse effects , Intestinal Fistula/microbiology , Prosthesis-Related Infections/microbiology , Pseudomonas Infections/microbiology , Psoas Abscess/microbiology , Vascular Fistula/microbiology , Aged , Aortic Aneurysm, Abdominal/diagnostic imaging , Blood Vessel Prosthesis Implantation/instrumentation , Debridement , Device Removal , Duodenal Diseases/diagnostic imaging , Duodenal Diseases/surgery , Endovascular Procedures/instrumentation , Humans , Intestinal Fistula/diagnostic imaging , Intestinal Fistula/surgery , Male , Omentum/surgery , Prosthesis-Related Infections/diagnostic imaging , Prosthesis-Related Infections/surgery , Pseudomonas Infections/diagnostic imaging , Pseudomonas Infections/surgery , Psoas Abscess/diagnostic imaging , Psoas Abscess/surgery , Treatment Outcome , Vascular Fistula/diagnostic imaging , Vascular Fistula/surgeryABSTRACT
A 52-year-old woman presented with fever and a persisting calf abscess ten years after she had received an aorta-bifemoral bypass. Her infection parameters were increased and she had anaemia. CT of the abdomen revealed air surrounding the proximal anastomosis of the bypass suggesting bypass graft infection. The diagnosis of an aorta-duodenal fistula was confirmed by gastroduodenoscopy showing migration of the bypass through the wall of the duodenum into the intestinal lumen. The bypass was resected and reconstructed using the superficial femoral vein. The patient recovered uneventful.
Subject(s)
Abscess/microbiology , Aorta, Abdominal/surgery , Blood Vessel Prosthesis/microbiology , Postoperative Complications/microbiology , Vascular Grafting/adverse effects , Anastomosis, Surgical/adverse effects , Aorta, Abdominal/microbiology , Duodenal Diseases/microbiology , Female , Femoral Vein/microbiology , Femoral Vein/surgery , Humans , Intestinal Fistula/microbiology , Leg/blood supply , Leg/microbiology , Middle Aged , Vascular Fistula/microbiologySubject(s)
Aneurysm, Infected/diagnostic imaging , Aortic Aneurysm, Abdominal/diagnostic imaging , Gastrointestinal Hemorrhage/diagnostic imaging , Intestinal Fistula/diagnostic imaging , Aneurysm, Infected/microbiology , Aneurysm, Infected/surgery , Aortic Aneurysm, Abdominal/microbiology , Aortic Aneurysm, Abdominal/surgery , Coma/complications , Computed Tomography Angiography , Duodenum/diagnostic imaging , Duodenum/pathology , Endoscopy , Endoscopy, Digestive System , Fistula/surgery , Gastrointestinal Hemorrhage/microbiology , Gastrointestinal Hemorrhage/surgery , Humans , Intestinal Fistula/microbiology , Intestinal Fistula/surgery , Male , Melena/complications , Middle Aged , Salmonella Infections/blood , Shock/complications , VomitingSubject(s)
Antitubercular Agents/therapeutic use , Biological Therapy/adverse effects , Crohn Disease/drug therapy , Intestinal Fistula/pathology , Latent Tuberculosis/drug therapy , Tuberculosis, Gastrointestinal/drug therapy , Crohn Disease/complications , Crohn Disease/microbiology , Humans , Intestinal Fistula/etiology , Intestinal Fistula/microbiology , Latent Tuberculosis/chemically induced , Male , Middle Aged , Remission, Spontaneous , Treatment Outcome , Tuberculosis, Gastrointestinal/chemically inducedABSTRACT
In situ reconstruction using femoral veins is emerging as one of the acceptable options for aortic reconstruction in patients with aortoduodenal fistula. We report a 35-year young male who presented with secondary aortoenteric fistula. His infected aortic graft was removed and was successfully managed by neo-aortic reconstruction, using both femoral veins in a 'pantaloon' fashion. He had smooth postoperative recovery and did not have graft re-infection. He did not show signs of chronic venous insufficiency on long-term follow-up.
Subject(s)
Aorta, Abdominal/pathology , Aortic Diseases/diagnosis , Blood Vessel Prosthesis/adverse effects , Endovascular Procedures/adverse effects , Femoral Vein/transplantation , Intestinal Fistula/diagnosis , Intestinal Fistula/surgery , Vascular Fistula/diagnosis , Vascular Fistula/surgery , Adult , Aorta, Abdominal/surgery , Biopsy , Device Removal , Duodenal Diseases/surgery , Humans , Intestinal Fistula/microbiology , Male , Postoperative Complications , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/microbiology , Prosthesis-Related Infections/surgery , Reoperation , Treatment Outcome , Vascular Fistula/diagnostic imaging , Vascular Fistula/microbiologyABSTRACT
PURPOSE:: To increase awareness of the clinical presentation, diagnostic workup, and treatment options for endograft infections. CASE REPORT:: A 75-year-old male patient was admitted with suspected endograft infection 4 years after endovascular aortic aneurysm repair (EVAR). Although preoperative diagnostics showed no definitive signs of endograft infection, eventual surgical exposure of the endograft revealed signs of advanced inflammation, including the unexpected finding of an aortoduodenal fistula. CONCLUSION:: A detailed evaluation of patient history and clinical examination, performed as a part of routine follow-ups, may be beneficial in identifying possible severe complications after EVAR early on. Regarding options for aortic reconstruction in case of endograft infection, bovine pericardium deserves consideration as a promising, feasible, and easily available graft material.
Subject(s)
Aortic Aneurysm, Abdominal/surgery , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/instrumentation , Blood Vessel Prosthesis/adverse effects , Device Removal , Endovascular Procedures/adverse effects , Endovascular Procedures/instrumentation , Intestinal Fistula/surgery , Prosthesis-Related Infections/surgery , Vascular Fistula/surgery , Aged , Aortic Aneurysm, Abdominal/diagnosis , Biopsy , Humans , Intestinal Fistula/diagnostic imaging , Intestinal Fistula/microbiology , Male , Prosthesis Design , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/microbiology , Reoperation , Treatment Outcome , Vascular Fistula/diagnostic imaging , Vascular Fistula/microbiologyABSTRACT
OBJECTIVE: After primary infection with Coxiella burnetii, patients may develop acute Q fever, which is a relatively mild disease. A small proportion of patients (1%-5%) develop chronic Q fever, which is accompanied by high mortality and can be manifested as infected arterial or aortic aneurysms or infected vascular prostheses. The disease can be complicated by arterial fistulas, which are often fatal if they are left untreated. We aimed to assess the cumulative incidence of arterial fistulas and mortality in patients with proven chronic Q fever. METHODS: In a retrospective, observational study, the cumulative incidence of arterial fistulas (aortoenteric, aortobronchial, aortovenous, or arteriocutaneous) in patients with proven chronic Q fever (according to the Dutch Chronic Q Fever Consensus Group criteria) was assessed. Proven chronic Q fever with a vascular focus of infection was defined as a confirmed mycotic aneurysm or infected prosthesis on imaging studies or positive result of serum polymerase chain reaction for C. burnetii in the presence of an arterial aneurysm or vascular prosthesis. RESULTS: Of 253 patients with proven chronic Q fever, 169 patients (67%) were diagnosed with a vascular focus of infection (42 of whom had a combined vascular focus and endocarditis). In total, 26 arterial fistulas were diagnosed in 25 patients (15% of patients with a vascular focus): aortoenteric (15), aortobronchial (2), aortocaval (4), and arteriocutaneous (5) fistulas (1 patient presented with both an aortocaval and an arteriocutaneous fistula). Chronic Q fever-related mortality was 60% for patients with and 21% for patients without arterial fistula (P < .0001). Primary fistulas accounted for 42% and secondary fistulas for 58%. Of patients who underwent surgical intervention for chronic Q fever-related fistula (n = 17), nine died of chronic Q fever-related causes (53%). Of patients who did not undergo any surgical intervention (n = 8), six died of chronic Q fever-related causes (75%). CONCLUSIONS: The proportion of patients with proven chronic Q fever developing primary or secondary arterial fistulas is high; 15% of patients with a vascular focus of infection develop an arterial fistula. This observation suggests that C. burnetii, the causative agent of Q fever, plays a role in the development of fistulas in these patients. Chronic Q fever-related mortality in patients with arterial fistula is very high, in both patients who undergo surgical intervention and patients who do not.
Subject(s)
Aneurysm, Infected/microbiology , Arteriovenous Fistula/microbiology , Bronchial Fistula/microbiology , Bronchial Fistula/surgery , Cutaneous Fistula/microbiology , Endocarditis, Bacterial/microbiology , Intestinal Fistula/microbiology , Prosthesis-Related Infections/microbiology , Q Fever/microbiology , Aged , Aged, 80 and over , Aneurysm, Infected/diagnosis , Aneurysm, Infected/mortality , Aneurysm, Infected/surgery , Arteriovenous Fistula/diagnosis , Arteriovenous Fistula/mortality , Arteriovenous Fistula/surgery , Bronchial Fistula/diagnosis , Bronchial Fistula/mortality , Cutaneous Fistula/diagnosis , Cutaneous Fistula/mortality , Cutaneous Fistula/surgery , Endocarditis, Bacterial/diagnosis , Endocarditis, Bacterial/mortality , Endocarditis, Bacterial/surgery , Female , Humans , Incidence , Intestinal Fistula/diagnosis , Intestinal Fistula/mortality , Intestinal Fistula/surgery , Male , Middle Aged , Netherlands/epidemiology , Prognosis , Prosthesis-Related Infections/diagnosis , Prosthesis-Related Infections/mortality , Prosthesis-Related Infections/surgery , Q Fever/diagnosis , Q Fever/mortality , Q Fever/surgery , Registries , Retrospective Studies , Risk Factors , Time FactorsABSTRACT
BACKGROUND: Selective digestive decontamination is commonly used to decrease lumenal bacterial flora. Preoperative bowel decontamination may be associated with a lower wound infection rate but has not been shown to decrease risk of intra-abdominal abscess or lower leak rate for enteric anastomoses. Alternatively, the decontamination disrupts the normal flora of the gastrointestinal tract and may affect normal physiology, including immunologic function. This study reports complication rates of an intestine transplant program that has never used bowel decontamination. METHODS: All adult patients who underwent intestine transplant from 2003 to 2015 at a single center were reviewed. Posttransplant complications included intra-abdominal abscess, enteric fistula, and leak from the enteric anastomosis. Viral, fungal, and bacterial infections in the first year after transplant are reported. RESULTS: There were 184 adult patients who underwent deceased donor intestine transplant during the study period. Among these patients, 30% developed an infected postoperative fluid collection, 4 developed an enteric fistula (2%), and 16 had an enteric or anastomotic leak (8%). The rate of any bacterial infection was 91% in the first year, with a wound infection rate of 25%. Fungal infection occurred in 47% of patients. Rejection rates were 55% at 1 y for isolated intestine patients and 17% for multivisceral (liver inclusive) patients. CONCLUSIONS: Among this population of intestine transplant patients in which no bowel decontamination was used, rates of surgical complications, infections, and rejection were similar to those reported by other centers. Bowel decontamination provides no identifiable benefit in intestine transplantation.
Subject(s)
Gastrointestinal Microbiome/immunology , Graft Rejection/epidemiology , Intestinal Diseases/surgery , Intestines/transplantation , Postoperative Complications/epidemiology , Preoperative Care/methods , Abdominal Abscess/epidemiology , Abdominal Abscess/immunology , Abdominal Abscess/microbiology , Adult , Aged , Anastomosis, Surgical/adverse effects , Female , Graft Rejection/immunology , Graft Rejection/microbiology , Humans , Intestinal Fistula/epidemiology , Intestinal Fistula/immunology , Intestinal Fistula/microbiology , Intestines/immunology , Intestines/microbiology , Male , Middle Aged , Postoperative Complications/immunology , Postoperative Complications/microbiology , Preoperative Care/adverse effects , Retrospective Studies , Transplants/microbiology , Treatment Outcome , Young AdultSubject(s)
Bacterial Infections/therapy , Drainage/instrumentation , Endoscopy, Digestive System/instrumentation , Pancreatitis, Acute Necrotizing/therapy , Stents , Adult , Bacterial Infections/diagnostic imaging , Bacterial Infections/microbiology , Duodenal Diseases/diagnosis , Duodenal Diseases/microbiology , Duodenal Diseases/therapy , Endosonography , Humans , Intestinal Fistula/diagnostic imaging , Intestinal Fistula/microbiology , Intestinal Fistula/therapy , Male , Pancreatic Fistula/diagnostic imaging , Pancreatic Fistula/microbiology , Pancreatic Fistula/therapy , Pancreatitis, Acute Necrotizing/diagnostic imaging , Pancreatitis, Acute Necrotizing/microbiology , Tomography, X-Ray Computed , Treatment Outcome , Ultrasonography, InterventionalABSTRACT
BACKGROUND: The aim of this study was to compare outcomes and identify factors related to increased mortality of open surgical and endovascular aortic repair (EVAR) of primary mycotic aortic aneurysms complicated by aortoenteric fistula (AEF) or aortobronchial fistula (ABF). METHODS: Patients with primary mycotic aortic aneurysms complicated by an AEF or ABF treated by open surgery or endovascular repair between January 1993 and January 2014 were retrospectively reviewed. Outcomes were compared between the open surgery and endovascular groups, and a Cox's proportional hazard model was used to determine factors associated with mortality. RESULTS: A total of 29 patients included 14 received open surgery and 15 received endovascular repair. Positive initial bacterial blood culture results included Salmonella spp., oxacillin-resistant Staphylococcus aureus, and Klebsiella pneumoniae. Mortality within 1 month of surgery was higher in the open surgery than in the endovascular group (43 vs. 7%, respectively, p = 0.035). Shock, additional surgery to repair gastrointestinal (GI) or airway pathology, and aneurysm rupture were associated with a higher risk of death. Compared with patients without resection surgery, the adjusted hazard ratio of death within 4 years in patients with resection for GI/bronchial disease was 0.25. Survival within 6 months was better in the endovascular group (p = 0.016). CONCLUSION: The results of this study showed that EVAR/thoracic EVAR (TEVAR) is feasible for the management of infected aortic aneurysms complicated by an AEF or ABF, and results in good short-term outcomes. However, EVAR/TEVAR did not benefit long-term survival compared with open surgery.
Subject(s)
Aneurysm, Infected/surgery , Aortic Aneurysm/surgery , Blood Vessel Prosthesis Implantation , Bronchial Fistula/surgery , Endovascular Procedures , Intestinal Fistula/surgery , Vascular Fistula/surgery , Aged , Aneurysm, Infected/diagnostic imaging , Aneurysm, Infected/microbiology , Aneurysm, Infected/mortality , Aortic Aneurysm/diagnostic imaging , Aortic Aneurysm/microbiology , Aortic Aneurysm/mortality , Blood Vessel Prosthesis Implantation/adverse effects , Blood Vessel Prosthesis Implantation/mortality , Bronchial Fistula/diagnostic imaging , Bronchial Fistula/microbiology , Bronchial Fistula/mortality , Endovascular Procedures/adverse effects , Endovascular Procedures/mortality , Feasibility Studies , Female , Humans , Intestinal Fistula/diagnostic imaging , Intestinal Fistula/microbiology , Intestinal Fistula/mortality , Kaplan-Meier Estimate , Male , Middle Aged , Proportional Hazards Models , Retrospective Studies , Risk Factors , Time Factors , Treatment Outcome , Vascular Fistula/diagnostic imaging , Vascular Fistula/microbiology , Vascular Fistula/mortalitySubject(s)
Digestive System Fistula/etiology , Duodenal Diseases/etiology , Intestinal Fistula/etiology , Liver Abscess/etiology , Liver Diseases/etiology , Liver Neoplasms/secondary , Melena/etiology , Neuroendocrine Tumors/secondary , Aged , Anti-Bacterial Agents/therapeutic use , Digestive System Fistula/diagnosis , Digestive System Fistula/drug therapy , Digestive System Fistula/microbiology , Duodenal Diseases/diagnosis , Duodenal Diseases/drug therapy , Duodenal Diseases/microbiology , Duodenoscopy , Humans , Intestinal Fistula/diagnosis , Intestinal Fistula/drug therapy , Intestinal Fistula/microbiology , Liver Abscess/diagnosis , Liver Abscess/drug therapy , Liver Abscess/microbiology , Liver Diseases/diagnosis , Liver Diseases/drug therapy , Liver Diseases/microbiology , Liver Neoplasms/microbiology , Liver Neoplasms/therapy , Male , Neuroendocrine Tumors/microbiology , Neuroendocrine Tumors/therapy , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
BACKGROUND: Perigraft hygromas or seromas are an unusual finding and/or complication after open aortic repair. METHODS AND RESULTS: We present a case of an 82-year-old man with a previous urgent aortic bifurcated graft for abdominal aortic aneurysm rupture. He received several treatments due to abdominal compartment syndrome, requiring a Bogota Bag and colostomy derivation. He was finally discharged home and lost on follow-up. Eight years after this procedure, he presented to the urgency department with an abdominal mass and pain. Urgent computed tomography (CT) scan revealed a giant bilobed aortic sac, corresponding with a huge hygroma. A 3-stage minimally invasive procedure was scheduled due to hostile abdomen. Six months after successful treatment, patient came with fever and abdominal pain. He was diagnosed with graft infection and aortoenteric fistula and was treated with explantation and silver in situ repair. CONCLUSIONS: Aortic hygroma or seromas after open repair should be treated by open means whenever possible. Endovascular techniques could be a valid option in selected patients; however, further evidence is needed.