Spontaneous aortoenteric fistula involving the sigmoid: A case report and review of literature.

INTRODUCTION: Primary aortoenteric fistula (PAEF) is a pathological communication between the aorta and any portion of the gastrointestinal tract. The pathology is very rare and easily overlooked during the diagnostic process. PRESENTATION OF CASE: We report the exceptional case of an 86-year-old man with episodes of abdominal pain and rectal bleeding of unknown cause over a period of 1,5 months due to a PAEF to the sigmoid. A sigmoidectomy was performed and a rifampicin-soaked aortic graft was placed. The patient had an uneventful post-operative recovery. The duration of symptoms, the anatomic location of the fistula and the outcome after surgery makes this case unique. DISCUSSION: With an incidence of 0.04-0.07% in all patients with aortic aneurysms a PAEF is very rare. Only 2% of PAEF's involves the sigmoid. The most common cause is an atherosclerotic aortic aneurysm. Patients with PAEF can present with a triad of symptoms including gastrointestinal bleeding, abdominal pain and a pulsating mass. A contrast-enhanced computer-tomography scan (CTa) is the most accurate tool to demonstrate a PAEF. Without a strong clinical suspicion, diagnosing a PAEF is hard and frequently delayed. The overall PAEF-related mortality is high (61-100%) and decreases after surgery (30-40%). CONCLUSION: A primary aortoenteric fistula involving the sigmoid is very rare. Clinical presentation can vary, diagnosis can be difficult and surgical options may differ. Even with low suspicion of PAEF, we recommend performing a CTa. With a high overall mortality of more than 60% due to exsanguinating, surgical treatment is always indicated.

[Centralisation of treatment of ruptured aneurysm]. / Centraliseren van behandeling geruptureerd aneurysma.

In the future, patients with a ruptured aneurysm will be treated at fewer hospitals in the Netherlands. Although there is a search for scientific support for this, the reason for centralisation is obvious: reduction of costs and reduction of workload for vascular surgeons during night and weekend shifts. Already there are a number of examples of regionally organised vascular surgeons who treat their patients with a ruptured aneurysm with great satisfaction and with good results.

A systematic review of endovascular treatment of extensive aortoiliac occlusive disease.

OBJECTIVES: Current multidisciplinary guidelines recommend to treat extensive aortoiliac occlusive disease (AIOD) by surgical revascularization. Surgery provides good long-term patency, but at the cost of substantial perioperative morbidity. Development of new technologies and techniques has led to increased use of endovascular therapy for extensive AIOD. We performed a systematic review of the literature to determine contemporary short- and long-term results of endovascular therapy for extensive AIOD. METHODS: The Medline, Embase, and Cochrane databases were searched to identify all studies reporting endovascular treatment of extensive AIOD (TransAtlantic Inter-Society Consensus (TASC) type C and D) from January 2000 to June 2009. Two independent observers selected studies for inclusion, assessed the methodologic quality of the included studies, and performed the data extraction. Outcomes were technical success, clinical success, mortality, complications, long-term primary, and secondary patency rates. RESULTS: Nineteen nonrandomized cohort studies reporting on 1711 patients were included. There was substantial clinical heterogeneity between the studies considering study population and interventional techniques. Technical success was achieved in 86% to 100% of the patients. Clinical symptoms improved in 83% to 100%. Mortality was described in seven studies and ranged from 1.2% to 6.7%. Complications were reported in 3% to 45% of the patients. Most common complications were distal embolization, access site hematomas, pseudoaneurysms, arterial ruptures, and arterial dissections. The majority of complications could be treated using percutaneous or noninvasive techniques. Four- or 5-year primary and secondary patency rates ranged from 60% to 86% and 80% to 98%, respectively. CONCLUSIONS: Endovascular treatment of extensive AIOD can be performed successfully by experienced interventionists in selected patients. Although primary patency rates are lower than those reported for surgical revascularization, reinterventions can often be performed percutaneously, with secondary patency comparable to surgical repair.

Juxtarenal aortic aneurysm repair.

OBJECTIVES: Juxtarenal aortic aneurysms (JAA) account for approximately 15% of abdominal aortic aneurysms. Despite advances in endovascular aneurysm repair, open repair requiring suprarenal aortic cross-clamping is still the treatment of choice for JAA. We performed a systematic review of the literature to determine perioperative mortality and postoperative renal dysfunction after open repair for non-ruptured JAA. METHODS: The Medline, Embase, and Cochrane databases were searched to identify all studies reporting non-ruptured JAA repair published between January 1966 and December 2008. Two independent observers selected studies for inclusion, assessed the methodologic quality of the included studies, and performed the data extraction. Study heterogeneity was assessed using forest plots and by calculating the between-study variance. Outcomes were perioperative mortality, postoperative renal dysfunction, and new onset of dialysis. Summary estimates with 95% confidence interval (95% CI) were calculated using a random effects model based on the binomial distribution. RESULTS: Twenty-one non-randomized cohort studies from 1986 to 2008, reporting on 1256 patients, were included. Heterogeneity between the studies was low. The mean perioperative mortality was 2.9% (95% CI, 1.8 to 4.6). The mean incidence of new onset of dialysis was 3.3% (95% CI, 2.4 to 4.5). Incidence of postoperative renal dysfunction could be derived from 13 studies and ranged from 0% to 39% (median, 18%). In seven studies, cold renal perfusion during suprarenal clamping was performed in order to preserve renal function; however, based upon the included data, definitive conclusions regarding its efficacy could not be drawn. CONCLUSIONS: Open repair of non-ruptured JAA using suprarenal cross-clamping can be performed with acceptable perioperative mortality; however, postoperative deterioration of renal function is a common complication. Preservation of renal function after JAA repair requires further investigation.

Chyloperitoneum following abdominal aortic surgery.

Chyloperitoneum is an uncommon but serious complication following abdominal aortic surgery. As there seems to be no uniformity concerning the treatment, we performed a literature search to evaluate the best treatment results. All Medline-cited articles on chyloperitoneum after abdominal aortic surgery were assessed and analyzed. Thirty-eight cases of chyloperitoneum following abdominal aortic surgery were found. Patients developed symptoms after a median of 16 days (range 2-120 days) and were asymptomatic after 68 days (mean, range 27-93 years). All patients underwent diagnostic paracentesis, which confirmed the diagnosis. In 26 cases (68%), paracentesis was part of the treatment. The use of diuretics (24%) as therapeutic value was abandoned. Total parenteral nutrition, used in 21 patients (55%), provides the possibility of an extended period of oral starvation that reduces the lymphatic flow from the leaking duct. Medium-chain triglyceride, used in 28 cases (76%), is generally accepted as reducing lymphatic flow. When all conservative measures fail, surgical exploration is indicated. Two surgical interventions were mentioned: placing a peritoneovenous shunt or transfixing the damaged lymph vessel; both were described with different outcomes. This review supports conservative treatment of chyloperitoneum following abdominal aortic surgery.

Carcinoid tumor in a Meckel's diverticulum: hypothesis on mutual embryological origin.

Congenital defects presenting at an adult age are subject to diagnostic errors because of their relative rarity and often odd clinical presentation. We illustrate a 63-year-old male patient with multiple ileal carcinoid tumors along with a carcinoid tumor in Meckel's diverticulum. The Meckel's diverticulum is a congenital abnormality arising from a patent vitelline duct and is found at the anti-mesenteric side of the ileum. In the Meckel's diverticulum, ectopic tissue or neoplasms are sometimes found, which may lead to intussusception, hemorrhage, or inflammation. The carcinoid tumor is a neuroendocrine neoplasm originating from the neural crest and is diagnosed at virtually all ages. It may exhibit malignant behavior but generally has a mild clinical course. It is most often found in endodermally derived organs, especially the digestive and pulmonary tracts, and coexists frequently with malignant tumors, predominantly of endodermal origin such as colorectal carcinoma. The carcinoid tumor and Meckel's diverticulum are known to coincide, whereas the carcinoid is not really considered to be an embryologically determined defect. We hypothesize that both lesions are derived from local erroneous interaction among the neural crest and the endoderm.