Abdominal Aneurysm with Aortoduodenal Fistula Masaaki MORIYAMA,Naokata OKA, Akira KUSABA,Takashi K~YOSE, Masato FURUYAMA,Kenichiro OKADOMEand Kiyoshi INOKUCHI A B S T R A C T : Two patients having the abdominal aneurysm with aortoduodenal fistula were treated surgically, but graft infection occurred. One patient died about 6 months after and the other about one year after the operation due to massive hemorrhage from the postoperative aortointestinal fistula. The difficulties in the treatment of the aortoduodenal fistula were discussed. K E Y W O R D S : abdominal aortic aneurysm, aortoduodenal fistula, synthetic graft, graft infection, axillo-femoral synthetic bypass, ligation of aortic stump, aneurysmal dilation, aortointestinal fistula, modified Roux-Yjejunal plasty. INTRODUCTION I n vascular surgery, graft infection is the most formidable complication which often ]cads to the loss of extremities or even death. The most effective means are the prevention of contamination during the operation, which is often difficult to accomplish in reconstructive surgery of an abdominal aneurysm with aortoduodenal fistula. In fact in two cases of abdominal aneurysm with aortoduodenal fistula treated with the synthetic grafts, the infection occurred in both cases in the implanted grafts. One patient died six months after and the other one year after the operation. The purpose of the present communication is to analyse the difficulties involved in the treatment.

CASEREPORTS Case 1. S.M. A 63 year old man was first admitted to our clinic on Dec. 23, 1969 with severe abdominal pain and collapse following melena. He had a previous history of lumbar vertebral fracture. Two days before the admission, he developed fainting, which was treated by a local physician. Next day, he regained his consciousness with blood pressure rising to 120/80 m m Hg. But in midnight, he fell into collapse associated with melena again, and was referred to us. On admission, blood pressure was 120/80 m m Hg and a pulsating abdominal mass, 10x 10 cm in size, was palpated. Laboratory examination revealed RBC 188x 104, WBC 6900, Hb 5.9 g/dl and Ht 21 per cent. The patient was diagnosed to have a ruptured abdominal aneurysm and an emergency operation was performed. Operative findings : A fusiform aortic aneurysm was noted distal to the renal arteries extending to the bilateral common iliac arteries, which penetrated into the 3rd portion of the duodenum. However, no hematoma in the peritoneal and retroperitoneal space was noted. The aneurysm was resected and a Dacron bifurcation graft was inserted. The fistula of the duodenum was repaired with interrupted mattress nylon sutures and covered

2rid Department of Surgery, Kyushu University, Faculty of Medicine, Fukuoka 812, Japan. JAPANESEJOURNALOF SURa~RY, VOL. 6, No. 1, pp. 29-34, 1976

30

Mor~yama et al.

Jap. J. Surg. March 1976

J

/ Fig. 1.

A B Case 1. First operation; Operative findings and procedures. A: Aortic aneurysm penetrated into the 3rd portion of the duodenum. B : Duodenal fistula closed by interrupted mattress nylon sutures and covered by remnant aneurysmal wall.

with the remnant aneurysmal wall. A silicon drain was placed adjacent to the proximal suture line (Fig. 1). His postoperative course was complicated with the episode of purulent discharge through the drain lasting 7 weeks, being treated successfully with local wound irrigation and systemic administration of antibiotics. He was discharged on April, 24, 1970 and was again hospitalized on June 12, 1970 with a pulsating mass at the left lower,quadrant of the abdomen and the enterocutaneous fistula. A fistulogram revealed a fistulous tract to the duodenum and a culture from the discharge through the fistula grew the staphylococcus aureus. On June 24, 1970, massive bleeding occurred suddenly from the abdominal fistula. The fistula was stuffed with the insertion of a Nelaton catheter (No. 10) slightly larger than the fistula. The massive bleeding ceased spontaneously. The translumbar aortogram revealed a ruptured false aneurysm of the right common iliac artery localizing at the site of the distal suture line of the synthetic graft. An elective operation was performed on June 29, 1970. The bilateral axillofemoral bypass was performed with 10 mm Dacron graft. The aorta was ligated distal to the renal arteries and bilateral external iliac arteries were also ligated. One month later, the infected synthetic graft was removed (Fig. 2). His postoperative course was uneventful until November 1970, when his occult blood in the feces became positive. At midnight on December 20, 1970 he suddenly collapsed and died. Autopsy showed aneurysmal dilatation of the ligated stump of the aorta which perforated into the jejunum. Case 2. Y.F. A 51 year old man was admitted to our clinic on December 24, 1973 with collapse following melena. A pulsating abdominal mass gradually growing in size was noted since 3 months before the admission. His blood pressure was 102/76 m m Hg and pulse rate was 102/min.. A 10 • 10 cm pulsating mass was present in the abdomen. The laboratory examination revealed Hb 8.5 g/dl, Ht 23 per cent, serum protein 6.0 g/dl and left ventricular hypertrophy in ECG. On his second hospital day, he fell into shock following massive melena. He was diagnosed to have the ruptured abdominal aneurysm

Volume 6

Number 1

31

Aortoduodenal .fistula.

I

I

bypass A

Nelaton catheter

c F i g . 2.

\

Case 1. Second operation; Operative findings and procedures. A: Massive hematoma caused by the rupture at the right distal suture line due to infection. B: Massive bleeding through the cutaneous fistula ceased after insertion of a Nelaton catheter. C: Abdominal aorta and bilateral external iliac arteries tied and axillo-femoral synthetic bypass undertaken.

with a o r t o i n t e s t i n a l fistula a n d an i m m e d i a t e o p e r a t i o n was u n d e r t a k e n on D e c e m b e r 25, 1973. O p e r a t i v e findings: No h e m a t o m a was present in the p e r i t o n e a l a n d r e t r o p e r i t o neal space. H o w e v e r , massive b l o o d clot was seen in the small intestine. A fusiform a o r t i c a n e u r y s m o r i g i n a t i n g distal to the r e n a l arteries e x t e n d i n g to the b i l a t e r a l c o m m o n iliac arteries was recognized. A n d an a o r t o d u o d e n a l fistula was found b e t w e e n the a n e u r y s m a n d the 3rd p o r t i o n of the d u o d e n u m . T h e a n e u r y s m was r e m o v e d a n d a D a c r o n bifurcation graft was inserted. T h e d u o d e n a l fistula was closed in two layers a n d R o u x - Y j e j u n a l loop was p l a c e d onto it to cover the d u o d e n a l closure (Fig. 3). His clinical course was u n c o m p l i c a t e d until the 79th p o s t o p e r a t i v e day, when he d e v e l o p e d low g r a d e fever on M a r c h 14, 1974. O n the 100th p o s t o p e r a t i v e day, occult b l o o d in the feces b e c a m e positive a n d it persisted. O n the 115th p o s t o p e r a t i v e day, he s u d d e n l y fell into shock following massive melena. O n exploration, an a r t e r i o s i g m o i d a l fistula was found at the distal suture line o f the synthetic graft to the left c o m m o n iliac artery. T h e left l i m b of the synthetic Y graft w i t h left c o m m o n iliac a r t e r y was resected (Fig. 4). T h e culture of the graft g r e w E. coli. O n M a y 26, 1974, he fell into shock again.

~loriyama et al.

32

Jap. J. Surg. 3/[arch 1976

.i , t t

i i \

:

.,i

,

,'

,",ta+~

A

! r I'

\,

{ C

D

!' [

F i g . 3.

\

E

t P~ i"

Case 2. First operation; Operative findings and procedures. A and B: Aorta-duodenal fistula closed after aortic grafting. C: J e j u n u m transected and the anal stump closed in two layers. D: Oral stump of the j e j u n u m anastomosed to the anal loop in end-to-side fashion. E : Site of duodenal closure covered with the arm of the jejunum. Submucous exposure obtained after seromuscular incision in place onto the closure site.

Volume 6 Number 1

33

Aortoduodenal fistula.

/ .-- closure of fistula

f ""

A Fig. 4.

Case 2. Second operation; Operative findings and procedures. A" Arterio-sigmoidal fistula occurring at left distal suture line. B : The infected left limb of the implanted synthetic graft resected and sigmoidal fistula was closed in two layers. DiscussioN

Emergency laparotomy was performed. However, he died in the operating room. The new aortoduodenal fistula was found at the proximal suture line of the synthetic graft inserted previously. However, the duodenal fistula repaired with the Roux-Y jejunal plasty on December 25, 1973, was completely healed. The postoperative infection of the implanted synthetic graft, especially in the aortic grafting, is one of the most serious complication in vascular reconstructive surgery. The incidence of these fatal complications of the implanted synthetic graft has been reported to be from 1.1 to 6.0 per cent and the mortality rate from 25 to 75 per cent.*,6,8,9,12 The infection of the implanted aortic graft is likely to be caused by imperfect sterilization, contamination by the intestinal fluid during the operative procedure and the bowel erosion elicited by the foreign body reaction between the implanted synthetic graft and the involved segment of the bowel. 11 Therefore, during the vascular surgery using the synthetic graft, great c a r e must be taken to prevent the infection by thorough sterilization of the graft, the sufficient protection of the aortic suture line and the synthetic graft by covering with the other synthetic material, surrounding tissues,a greater omentum 7 or the remnant aneurysmal wall. However, with the presence of the aortointestinal fistula caused by perforation of the abdominal aortic aneurysm into the intestinal tract, it is very difficult to avoid contamination with the intestinal contents during the management of the intestinal fistula. In our two cases presented here, it was thought that the graft infection was caused by contamination with duodenal juice during or after the management of the fistula. Evans 5 listed 56 cases of the aortoduodenal fistula reported sirme 1957. O f those, twenty cases were operated. Ten survived three months or more and only 5 survived one year or more following the operation. T h e causes of death were hemorrhage, renal failure, gangrene of sigmoid colon and pulmonary embolism. Generally, the most effective management for the infected synthetic grafts is their immediate removal. I f ischemia at the distal aspect occurs, the establishment of the bypass grafting away from the infected field is essential. For the infected aortic grafts, the axillo-femoral synthetic bypass graft in both side and subsequent removal of the infected graft with the closing of the aortic stump is recommended.2,4, 6. However, in our first case, the removal of the infected graft following

34

Mo@ama et al.

Jap. J. Surg. March 1976

the axillo-femoral bypass resulted in t h e a n e u r y s m a l d i l a t a t i o n o f the sown s t u m p o f the a o r t a a b o u t 5 m o n t h s after the o p e r a t i o n w h i c h r u p t u r e d into the small intestine w i t h the fatal consequence. As V e l l a r 10 p o i n t e d out, the ligation or sewing of the sclerotic a o r t a in the infected field is c o u r t i n g the disaster. Obviously, the a v o i d a n c e o f the c o n t a m i n a t i o n of the graft d u r i n g the o p e r a t i o n is most i m p o r t a n t . A l t h o u g h this is very difficult to accomplish in a c t u a l p r a c t i c e w h e n the a n e u r y s m is c o m p l i c a t e d with t h e a o r t o d u o d e n a l fistula, special care m u s t be taken to the following two points: u t m o s t c a r e to m i n i m i z e c o n t a m i n a t i o n of the o p e r a t i v e field a n d c o m p l e t e closure o f the d u o d e n a l fistula. Before the dissection n e a r the fistula, it is r e c o m m e n d e d to a p p l y a p a i r o f c l a m p s p r o x i m a l a n d distal to the site o f the fistula after squeezing out the bowel content. A d m i n i s t r a t i o n o f antibiotics into the bowel is also r e c o m m e n d e d . Special care m u s t be taken in closing the fistula. Since the tissue a r o u n d the fistula is g e n e r a l l y inflamed w i t h scar formation, it is r e c o m m e n d e d to excise the scar tissue as m u c h as possible. L a y e r to l a y e r a d a p t a t i o n a n d c o m p l e t e inversion of the mucosal layer of the d u o d e n a l w a l l is preferable. W h e n necessary, R o u x - Y j e j u n a l loop is a p p l i e d onto the site of the fistula closure. I n the first case, it was considered t h a t i n c o m p l e t e closure of t h e fistula led to the graft infection. I n the second case, the d u o d e n a l fistula was r e p a i r e d a n d reinforced b y the m o d i f i e d R o u x - Y j e j u n a l plasty. A l t h o u g h this p a t i e n t finally died from the massive b l e e d i n g t h r o u g h the newly f o r m e d a o r t o d u o d e n a l fistula, closure o f the fistula at the first' o p e r a t i o n was effected satisfactorily. (Received for publication on February 9, 1976) References 1. Blaisdell, F.W., DeMattei, G.A. and Gauder, P.J.: Extraperitoneal thoracic aorta to femoral bypass graft as replacement for an infected aortic bifurcation prosthesis, Am. J. Surg., 102: 583-585, 1961. 2. Blaisdell, F.W. and Hall, A.D. : Axillofemoral artery bypass for lower extremity ischemia, Surgery, 54: 563-568, 1963. 3. Cerny, J.C., Fry, W.L., Gambee, J. and Koyangyi, T.: Aortoduodenal fistula, J. Urol., 107: 12-24, 1972. 4. Corm, J.H., Hardy, J.D~ Chavez, C.M. and Fain, W.R.: Infected arterial grafts: Experience in 22 cases with emphasis on unusual bacteria and technics, Ann. Surg., 171: 704-714, 1970. 5. Evans, D.M. and Webster, J.H.H.: Spontaneous aortoduodenal fistula, Brit. J. Surg., 59: 368-372, t972. 6. Fry, W.J. and Lindenauer, S.M.: Infection complicating the use of plastic arterial implants, Arch. Surg., 94: 600-609, 1967. 7. Goldsmith, H.S., Santos, R.d.1., Vanamee, P. and Beat'tie, E.J. : Experimental protection

8. 9.

10.

11.

12. 13.

of vascular prosthesis by omentum, Arch. Surg., 97: 872-878, 1968. Hoffert, P.W., Gensler, S. and Haimovici, H. : Infection complicating arterial grafts, Arch. Surg., 90: 427-435, 1965. Szilagyi, D.E., Smith, R.F., Elliott, J.P. and Vrandecic, M.P.: Infection. in arterial reconstruction with synthetic grafts, Ann. Surg., 176: 321-333, 1972. Vellar, I.D.A. and Doyle, J.C.: Axillofemoral bypass in the management of infected aortic bifurcation dacron graft, Aust. N.Z.J. Surg., 40: 58-60, 1970. Wiermann, W.H., Strahan, R.W. and Spencer, J.R.: Small bowel erosion by synthetic aortic grafts, Am. J. Surg., 112: 791-797, 1966. Willwerth, B.M. and Waldhausen, J.A.: Infection of arterial prostheses, Surg. Gynec. Obst., 139: 446-452, 1974. Wolma, F.J., Derrick, J.R. and McCoy, J.: Management of infected arterial grafts, Am. J. Surg., 126: 798-802, 1973.

Abdominal aneurysm with aortoduodenal fistula.

Abdominal Aneurysm with Aortoduodenal Fistula Masaaki MORIYAMA,Naokata OKA, Akira KUSABA,Takashi K~YOSE, Masato FURUYAMA,Kenichiro OKADOMEand Kiyoshi...
339KB Sizes 0 Downloads 0 Views