IMAGES FOR SURGEONS ANZJSurg.com
Aortoenteric fistula due to endojunk In February 2013, an 86-year-old man presented to a regional hospital with haematemesis and associated abdominal pain. He was haemodynamically stable, with a background of: • Endovascular aortic repair (EVAR) of a 58-mm abdominal aortic aneurysm (AAA; May 2006) • Coil emobolization of a type I endoleak (October 2006) • Delayed closure of sternal wound following coronary artery bypass grafts because of enterobacter infection (April 2010) • Infected EVAR, resulting in laparotomy, excision of infected EVAR, oversewing of infrarenal aorta, right axillofemoral bypass and femoro-femoral bypass (January 2011); during this procedure, the embolization coils were not identified or removed. A gastroscopy showed metal protruding into the second segment of the duodenum (Fig. 1). Non-contrast computed tomography scan of the abdomen and pelvis showed the horizontal portion of the duodenum could not be clearly separated from the aorta (Fig. 2). Also, a loss of sharpness of the aorta was noted at the level of the duodenum with poorly defined infiltrate in the fat. The computed tomography illustrates how these two structures (infrarenal aorta and third segment of the duodenum) are closely abutting one another. The radiological findings were consistent with erosion into the duodenum or infection, or a combination of both. The patient was transferred to a major operating centre and taken to the theatre. Midline laparotomy incision was followed by adhesiolysis of small bowel. A loop of duodenum was exposed via Kocher manouver and a supracoeliac clamp was applied. Multiple coil embolization wires and prolene sutures were identified and
Fig. 1. Gastroscopy – protrusion in D2.
© 2014 Royal Australasian College of Surgeons
removed from the aortic stump, which was oversewn (Fig. 3). The duodenum was debrided, an end to end anastomosis was performed, followed by placing a portion of omentum between the anastomic site and aortic stump. Secondary aortoenteric fistulas (AEF) are more common than primary and occur in the setting of previous aortic reconstructive
Fig. 2. Abdominal computed tomography – aorta and D3 abutting one another.
Fig. 3. Infiltrated duodenum with coils and prolene.
ANZ J Surg 85 (2015) 983–990
984
procedures. Given that the anterior wall of the aneurysmal aorta is in close proximity to, and often adherent to the posterior wall of the duodenum, the third and fourth segments of the duodenum are the most likely sites for the formation of aortoenteric fistulae, occurring in 83% of both primary and secondary AEF.1 Secondary AEF is an infrequent, although serious complication of aortic aneurysmal repair (both open and endovascular). The incidence of secondary aortoenteric fistulae varies between 0.36 and 1.6% of aortic repair patients.1–4 Incidences of arterial tree embolization coil and guidewire erosion into adjacent viscera, although rare, have been previously documented.5–7 Based on our findings on gastroscopy as well as intraoperatively, this is the likely responsible mechanism for AEF in our patient. It has been previously postulated that a shrinking AAA, in combination with continual transmission of pressure from the aorta on the duodenum could cause embolization coils to erode into the bowel lumen.5 This may have been the case in our patient, given the resolution of endoleak post-coil embolization and reduction in aneurysmal sac size. Embolization coil erosion into bowel is an uncommon cause of secondary AEF. Long-term follow-up of AAA repair patients with endoleaks and subsequent coil embolization is required to assess the risk of developing complications such as AEF. Removal of the embolization coils at the time of aortic repair following infected EVAR could have prevented AEF formation in this patient. This case identifies the importance of removing foreign bodies which have the potential to erode into the duodenum.
Images for surgeons
References 1. Cronenwett JL, Johnson W. Chapter 42. Rutherford’s Vascular Surgery. Philadelphia: Elsevier Saundaers, 2010; 663–74. 2. Ruby BJ, Cogbill TH. Aortoduodenal fistula 5 years after endovascular abdominal aortic aneurysm repair with the Ancure stent graft. J. Vasc. Surg. 2007; 45: 834–6. 3. Hallett JW, Marshall DM, Petterson TM et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36 years population-based experience. J. Vasc. Surg. 1997; 25: 277–85. 4. Johnston KW. Nonruptured abdominal aortic aneurysm: six-year follow-up results from the multicentre prospective Canadian aneurysm study. J. Vasc. Surg. 1994; 20: 163–70. 5. Bertges DJ, Villella ER, Makaroun MS. Aortoenteric fistula due to endoleak coil embolisation after endovascular AAA repair. J. Endovasc. Ther. 2003; 10: 130–5. 6. Farres H, Gonzales AJ, Garrett HE. Aortoduodenal fistula after endograft repair of abdominal aneurysm secondary to a retained guidwire. J. Vasc. Surg. 2012; 56: 1413–5. 7. Onohara T, Okadome K, Mii S et al. Rupture of embolised coeliac artery aneurysm into the stomach: is coil embolisation an effective treatment for coeliac anastomotic pseudoaneurysm? Eur. J. Vasc. Surg. 1992; 6: 330–2.
Zacharia T. Bazzi, MBBS, GDAAD Raffi Qasabian, MBBS, BSc, FRACS (Vascular Surgery) Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12583
Rectal constriction secondary to metastatic micropapillary adenocarcinoma of the bladder In Australia, bladder cancer is one of the 10 most common cancers, responsible for 2217 new diagnosis of cancer as well as 925 deaths in 2007.1 While over 90% of bladder cancers are urothelial in origin, only 1–2% of them represent primary adenocarcinoma. They commonly metastasize to regional lymph nodes, liver, lung and bone.2 Although they may involve the distal gastrointestinal tract, this is usually through direct invasion and non-contiguous metastasis rarely happens.3 In the literature, rectal constriction secondary to transitional cell carcinoma of the bladder has been reported by different authors.4–6 We describe a case of metastatic micropapillary adenocarcinoma of the bladder resulting in rectal constriction. A 65-year-old man presents with an alteration of bowel habit on the background history of micropapillary adenocarcinoma of bladder. The patient’s bladder cancer was diagnosed 28 months earlier because of left flank pain. Ultrasound showed a large bladder mass causing left-sided ureteric obstruction. He subsequently underwent a radical cystoprostatectomy, bilateral pelvic lymph node dissection and ileal conduit formation. Histopathology from the operative specimen confirmed a pT3N0 micropapillary adenocarcinoma of bladder. The surgical margins were clear. Adjuvant chemotherapy with gemcitabine and cisplatin was given post-operatively. The patient recovered well from the operation.
Twenty-three months post-treatment, he described increasing constipation, faecal incontinence and tenesmus. Digital rectal examination found a fixed circumferential tumour. Magnetic resonance imaging scan (Fig. 1) confirmed extensive thickening of rectal submucosa extending through the lamina propria and muscularis mucosa, with extension beyond the wall from 1 o’clock to 6 o’clock. Several irregular lymph nodes were found in the mesorectal fascia. On colonoscopy (Fig. 2), there was circumferential rectal wall thickening with narrowing of the rectal and anal canal, while rectal mucosa appeared to be intact. The biopsy histopathology showed poorly differentiated infiltrative carcinoma of urothelial origin (positive for urothelial markers P53, CK34 and CK7). A defunctioning end colostomy was created prior to chemotherapy, from which he recovered quickly with relief of his presenting symptoms. He subsequently received pelvic radiotherapy for palliative management. In the literature, a 10% risk of rectal involvement by bladder cancer has been reported.5,7 In 1989, Stillwell et al. described two cases of rectal constriction secondary to direct invasion of transitional cell carcinoma (TCC) of the bladder.5 Although the mechanism of spread is different to our patient (non-contiguous metastasis), normal mucosa was observed on colonoscopy/proctoscopy in both studies. © 2014 Royal Australasian College of Surgeons
Aortoenteric fistula due to endojunk In February 2013, an 86-year-old man presented to a regional hospital with haematemesis and associated abdominal pain. He was haemodynamically stable, with a background of: • Endovascular aortic repair (EVAR) of a 58-mm abdominal aortic aneurysm (AAA; May 2006) • Coil emobolization of a type I endoleak (October 2006) • Delayed closure of sternal wound following coronary artery bypass grafts because of enterobacter infection (April 2010) • Infected EVAR, resulting in laparotomy, excision of infected EVAR, oversewing of infrarenal aorta, right axillofemoral bypass and femoro-femoral bypass (January 2011); during this procedure, the embolization coils were not identified or removed. A gastroscopy showed metal protruding into the second segment of the duodenum (Fig. 1). Non-contrast computed tomography scan of the abdomen and pelvis showed the horizontal portion of the duodenum could not be clearly separated from the aorta (Fig. 2). Also, a loss of sharpness of the aorta was noted at the level of the duodenum with poorly defined infiltrate in the fat. The computed tomography illustrates how these two structures (infrarenal aorta and third segment of the duodenum) are closely abutting one another. The radiological findings were consistent with erosion into the duodenum or infection, or a combination of both. The patient was transferred to a major operating centre and taken to the theatre. Midline laparotomy incision was followed by adhesiolysis of small bowel. A loop of duodenum was exposed via Kocher manouver and a supracoeliac clamp was applied. Multiple coil embolization wires and prolene sutures were identified and
Fig. 1. Gastroscopy – protrusion in D2.
© 2014 Royal Australasian College of Surgeons
removed from the aortic stump, which was oversewn (Fig. 3). The duodenum was debrided, an end to end anastomosis was performed, followed by placing a portion of omentum between the anastomic site and aortic stump. Secondary aortoenteric fistulas (AEF) are more common than primary and occur in the setting of previous aortic reconstructive
Fig. 2. Abdominal computed tomography – aorta and D3 abutting one another.
Fig. 3. Infiltrated duodenum with coils and prolene.
ANZ J Surg 85 (2015) 983–990
984
procedures. Given that the anterior wall of the aneurysmal aorta is in close proximity to, and often adherent to the posterior wall of the duodenum, the third and fourth segments of the duodenum are the most likely sites for the formation of aortoenteric fistulae, occurring in 83% of both primary and secondary AEF.1 Secondary AEF is an infrequent, although serious complication of aortic aneurysmal repair (both open and endovascular). The incidence of secondary aortoenteric fistulae varies between 0.36 and 1.6% of aortic repair patients.1–4 Incidences of arterial tree embolization coil and guidewire erosion into adjacent viscera, although rare, have been previously documented.5–7 Based on our findings on gastroscopy as well as intraoperatively, this is the likely responsible mechanism for AEF in our patient. It has been previously postulated that a shrinking AAA, in combination with continual transmission of pressure from the aorta on the duodenum could cause embolization coils to erode into the bowel lumen.5 This may have been the case in our patient, given the resolution of endoleak post-coil embolization and reduction in aneurysmal sac size. Embolization coil erosion into bowel is an uncommon cause of secondary AEF. Long-term follow-up of AAA repair patients with endoleaks and subsequent coil embolization is required to assess the risk of developing complications such as AEF. Removal of the embolization coils at the time of aortic repair following infected EVAR could have prevented AEF formation in this patient. This case identifies the importance of removing foreign bodies which have the potential to erode into the duodenum.
Images for surgeons
References 1. Cronenwett JL, Johnson W. Chapter 42. Rutherford’s Vascular Surgery. Philadelphia: Elsevier Saundaers, 2010; 663–74. 2. Ruby BJ, Cogbill TH. Aortoduodenal fistula 5 years after endovascular abdominal aortic aneurysm repair with the Ancure stent graft. J. Vasc. Surg. 2007; 45: 834–6. 3. Hallett JW, Marshall DM, Petterson TM et al. Graft-related complications after abdominal aortic aneurysm repair: reassurance from a 36 years population-based experience. J. Vasc. Surg. 1997; 25: 277–85. 4. Johnston KW. Nonruptured abdominal aortic aneurysm: six-year follow-up results from the multicentre prospective Canadian aneurysm study. J. Vasc. Surg. 1994; 20: 163–70. 5. Bertges DJ, Villella ER, Makaroun MS. Aortoenteric fistula due to endoleak coil embolisation after endovascular AAA repair. J. Endovasc. Ther. 2003; 10: 130–5. 6. Farres H, Gonzales AJ, Garrett HE. Aortoduodenal fistula after endograft repair of abdominal aneurysm secondary to a retained guidwire. J. Vasc. Surg. 2012; 56: 1413–5. 7. Onohara T, Okadome K, Mii S et al. Rupture of embolised coeliac artery aneurysm into the stomach: is coil embolisation an effective treatment for coeliac anastomotic pseudoaneurysm? Eur. J. Vasc. Surg. 1992; 6: 330–2.
Zacharia T. Bazzi, MBBS, GDAAD Raffi Qasabian, MBBS, BSc, FRACS (Vascular Surgery) Department of Vascular Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12583
Rectal constriction secondary to metastatic micropapillary adenocarcinoma of the bladder In Australia, bladder cancer is one of the 10 most common cancers, responsible for 2217 new diagnosis of cancer as well as 925 deaths in 2007.1 While over 90% of bladder cancers are urothelial in origin, only 1–2% of them represent primary adenocarcinoma. They commonly metastasize to regional lymph nodes, liver, lung and bone.2 Although they may involve the distal gastrointestinal tract, this is usually through direct invasion and non-contiguous metastasis rarely happens.3 In the literature, rectal constriction secondary to transitional cell carcinoma of the bladder has been reported by different authors.4–6 We describe a case of metastatic micropapillary adenocarcinoma of the bladder resulting in rectal constriction. A 65-year-old man presents with an alteration of bowel habit on the background history of micropapillary adenocarcinoma of bladder. The patient’s bladder cancer was diagnosed 28 months earlier because of left flank pain. Ultrasound showed a large bladder mass causing left-sided ureteric obstruction. He subsequently underwent a radical cystoprostatectomy, bilateral pelvic lymph node dissection and ileal conduit formation. Histopathology from the operative specimen confirmed a pT3N0 micropapillary adenocarcinoma of bladder. The surgical margins were clear. Adjuvant chemotherapy with gemcitabine and cisplatin was given post-operatively. The patient recovered well from the operation.
Twenty-three months post-treatment, he described increasing constipation, faecal incontinence and tenesmus. Digital rectal examination found a fixed circumferential tumour. Magnetic resonance imaging scan (Fig. 1) confirmed extensive thickening of rectal submucosa extending through the lamina propria and muscularis mucosa, with extension beyond the wall from 1 o’clock to 6 o’clock. Several irregular lymph nodes were found in the mesorectal fascia. On colonoscopy (Fig. 2), there was circumferential rectal wall thickening with narrowing of the rectal and anal canal, while rectal mucosa appeared to be intact. The biopsy histopathology showed poorly differentiated infiltrative carcinoma of urothelial origin (positive for urothelial markers P53, CK34 and CK7). A defunctioning end colostomy was created prior to chemotherapy, from which he recovered quickly with relief of his presenting symptoms. He subsequently received pelvic radiotherapy for palliative management. In the literature, a 10% risk of rectal involvement by bladder cancer has been reported.5,7 In 1989, Stillwell et al. described two cases of rectal constriction secondary to direct invasion of transitional cell carcinoma (TCC) of the bladder.5 Although the mechanism of spread is different to our patient (non-contiguous metastasis), normal mucosa was observed on colonoscopy/proctoscopy in both studies. © 2014 Royal Australasian College of Surgeons
