Long-Term Outcomes of Surgical Treatment with In Situ Graft Reconstruction for Secondary Aorto-Enteric Fistula

Abstract

Objectives:The optimal surgical management for secondary aorto-enteric fistula (sAEF) is controversial. Here, we report the long-term outcomes of a surgical treatment with in situ graft reconstruction for sAEF that was performed at our hospital. Methods: Between 2009 and 2012, 10 consecutive patients (8 males, 2 females, mean age 75.9 years) with sAEF were surgically treated with in situ graft reconstruction. Perioperative and long-term outcomes were reviewed retrospectively by medical records. Results: Clinical manifestations, including gastrointestinal bleeding, shock, sepsis, and back and abdominal pain, were observed during the treatment of the patients. In all the cases, the fistula was found between the duodenum or small intestine and the graft anastomosis, the graft itself, or pseudoaneurysm. Total graft excision and in situ graft reconstruction with omental coverage and digestive tract reconstruction was performed for all cases. There were two operative deaths because of multiple organ dysfunction syndrome and sepsis. The other patients showed no sAEF related complications, such as graft infection, and were alive during the 54-month mean follow-up period (33-76 months). Conclusion: According to our study, the long-term outcomes of surgical treatment with in situ graft reconstruction for sAEF were considered satisfactory. (This article is a translation of Jpn J Vasc Surg 2016; 25: 1-6.)

Surgical Management of Aortoenteric Erosion Due to Pulsatile Stress After Aneurysm Repair: A Case Report

“…6) Some reports have suggested the existence of herald bleeding, which is a characteristic warning sign of this disease. 1,7) Song et al suggested that the frequency of herald bleeding was an average of 3.6 episodes and that the time between the initial herald bleeding and massive exsanguination ranged from 5 h to 5 months (median, 4 days, with over 50% of cases being longer than 3 days). 8) The management of SAEFE varies and is dependent on the patient s condition, with complete resection of the fistula being a standard treatment option.…”

Imaging work-up and endovascular treatment options for aorto-enteric fistula

“…Recent estimates of early post-operative mortality for these open surgical techniques vary widely, but remain high, in the range of 18-54% (8,9). As a result of these high mortality rates, endovascular interventions have grown in popularity to manage AEF patients.…”

“…These massive hemorrhages may be life threatening. However, between 27% and 60% of SAEFs do not present with GI bleeding (1,6,8). The most common presentation for SAEF without GI bleeding is sepsis, which occurs in up to 80% of SAEF patients (some of these may have concomitant GI bleeding) (16,17).…”

“…While SAEFs are frequently diagnosed intraoperatively during laparotomy, and are occasionally detected pre-operatively with endoscopy, CT angiography is the diagnostic modality of choice (3,7,8,21,22). CT angiography has a relatively high sensitivity (approximately 94%) and specificity (approximately 85%) for the diagnosis of SAEF (23)(24)(25).…”

“…CT findings that strongly suggest SAEF include periaortic foci of gas, periaortic inflammatory changes including fat stranding, periaortic edema, thickening and close proximity of the graft to the adjacent bowel wall, graft thrombosis, perigraft fluid, and extravasation of contrast agent into the GI lumen (6,8,21,26). Several of these findings are nonspecific and can be within normal limits within the first weeks post aortic graft placement, such as foci of gas and perigraft edema.…”