Primary Aorto-Duodenal Fistula as a Late Complication of Radiotherapy: Report of a Case and Review of the Literature

Abstract

Primary aorto-duodenal fistula (PADF) is a rare condition that may result in rapid exsanguination if untreated. PADF due to radiotherapy appears to be extremely rare with only a few cases reported in the medical literature. We report the case of a 61-year-old man who presented with massive gastrointestinal bleeding 25 years after surgery and radiotherapy for seminoma of the testicle and was successfully treated at our institution. We also review the literature on this very uncommon condition. A Medline search was conducted for the period from 1966 to June 2006 to identify case reports of PADF following radiotherapy. Only 7 cases of PADF due to radiotherapy were identified in addition to our own, 4 males and 3 females, aged 40 to 73 years, all treated for various forms of abdominal malignancies. The latency period ranged from 2 weeks to 25 years. None of the aortas were aneurysmatic. One patient died before he could be taken to the operating room. 5 patients underwent surgical repair and 4 survived. 2 patients underwent endovascular treatment but did not survive. PADF may develop up to 25 years after radiotherapy. Diagnosis should be considered when massive upper gastrointestinal bleeding develops in a patient who had previous abdominal radiotherapy, no matter how long before the episode of bleeding. Prompt surgical repair offers a reasonable chance of cure. Endovascular procedures do not appear to be efficacious.

Endovascular Repair with a Stent Graft in a Patient with Aortoduodenal Fistula after Radiation Therapy

“…As described in the Introduction, primary ADF involving a normal-size aorta is rare [ 2 ]; furthermore, ADF related to radiation therapy is extremely rare. Puccio reviewed the research on this uncommon condition and reported that radiation related AEF was not associated with aneurysm in all eight cases, including their own case [ 3 ]. ADF typically occurs between the third and fourth portions of the duodenum (70%–90%) [ 4 ].…”

“…Several reports have mentioned acute or chronic radiation-induced damage to tissues as a potential cause for ADF and suggested that minor, but sustained, damage to either of or both the duodenal wall and aortic wall can result in tissue necrosis and perforation of these walls [ 3 , 8 – 12 ]. Histological changes related to radiotherapy include mucosal and submucosal damage due to obliteration of small vessels, telangiectasia, and new vessel formation, resulting in tissue damage and subsequent formation of fibrosis and chronic erosion (ulcer).…”

An aortoenteric and a graft-enteric fistulae - A severe acute abdominal event

“…Nejčastěji se vyskytuje sekundární aortoduodenální (respektive protézoduodenální) píštěl, tedy komunikace mezi cévní protézou a trávicím traktem, mnohem vzácněji pozorujeme tzv. primární aortoenterální píštěl, komunikaci mezi nativní aortou a trávicím traktem [2][3][4]. Stejně raritní je vzniklá komunikace mezi stentgraftem po předchozím endovaskulárním řešení aneurysmatu břišní aorty (EVAR) a trávicím traktem [5].…”

Primary aorto-enteric fistula

“…Primary aorto-enteric fistula (PAEF) is a life threatening complication, defined as a spontaneous erosion and communication of the abdominal aorta into the intestinal tract [1] . They are distinguished from secondary AEF, which occur following aortic surgery; the latter being far more prevalent [1] .…”

“…Primary aorto-enteric fistula (PAEF) is a life threatening complication, defined as a spontaneous erosion and communication of the abdominal aorta into the intestinal tract [1] . They are distinguished from secondary AEF, which occur following aortic surgery; the latter being far more prevalent [1] . Aorto-duodenal fistulae (ADF) are the most common type (∼60%) owing to the close relationship of the duodenum (in particular D3/4 which is tethered to the retroperitoneum), with the underlying abdominal aorta.…”