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Duodenal obstruction from a secondary aortoduodenal fistula An 88-year-old man presented through the emergency department in December 2012 with a 6-day history of central abdominal pain. The pain was of moderate severity and radiated to the back. There was associated bilious vomiting and constipation but no melaena or haematemesis. The patient had an endoluminal graft (Gore Excluder bifurcated graft, W. L. Gore & Associates, Belrose, NSW, Australia) inserted for a 4.5-cm abdominal aortic aneurysm (AAA) in March 2007. Post-operative groin infection was treated with antibiotics, and endoleaks in 2009 and 2010 were embolized by interventional radiologists with Onyx glue (ev3 Endovascular, Inc., Plymouth, MN, USA). Other past medical history included an acute myocardial infarction, atrial fibrillation, hypertension and dyslipidaemia. On examination the patient was alert and oriented, with hypotension (87/53 mmHg), heart rate of 88 and temperature of 36.7. Abdominal examination revealed a distended abdomen with hypoactive bowel sounds and tenderness in the right flank. There was no evidence of peritonitis. Laboratory investigations showed haemoglobin of 129 g/L and white cell count of 9.2 × 109/L. Liver function tests and lipase levels were normal. Computed tomography of the abdomen revealed duodenal obstruction, with gross dilatation of the stomach and first two segments of the duodenum (Fig. 1). There was an abrupt transition at the mid-part of the third segment of the duodenum (D3) (Fig. 2). At this level, there was a large thrombus within the aneurysmal sac adherent to D3, at the point of duodenal obstruction.
The patient was kept nil by mouth, administered intravenous fluids and an in-dwelling catheter and nasogastric tube were inserted. Without clinical resolution despite gastric decompression, an explorative laparotomy was performed. The operative findings were extrinsic compression of D3 by the intraluminal thrombus of the aneurysmal sac, clear fistulous holes in the aneurysmal wall and the duodenum, periduodenal necrosis and inflammation at D3 consistent with the fistulous communication, and an intact aortic graft beneath the thrombus without evidence of bleeding from the proximal end of the endoluminal graft. The aneurysmal sac was debrided, the duodenal side of the fistula was resected, and a side-to-side duodenojejunostomy was created. Graft cultures of the aneurysmal wall yielded Propionibacterium acnes; the patient was thus commenced on Timentin (GlaxoSmithKline, Abbotsford, VIC, Australia). Post-operative pyrexia required the ongoing use of antibiotics, with a plan to continue amoxicillin for life. At 6- and 12-month reviews postoperatively, the patient has been well, tolerating a full diet and maintaining a steady weight. Although primary aortoenteric fistulas (AEFs) are due to a spontaneous communication of the lumen of an aortic aneurysm with an intestinal loop, secondary AEFs occur in patients who have undergone surgical repair of aortic aneurysms with prosthetic implants.1 With the increasing use of prosthetic graft materials, the incidence of secondary AEFs has exceeded primary AEFs. Secondary AEFs are thought to arise from the combination of friction between the proximal anastomotic sutures and the bowel,
Fig. 1. Dilatation of the stomach and first part of duodenum, proximal to the bowel obstruction.
Fig. 2. Large thrombus within the aneurysmal sac, with this section adherent to the third part of duodenum, causing the bowel obstruction.
© 2014 Royal Australasian College of Surgeons
ANZ J Surg •• (2014) ••–••
2
persistent bowel trauma caused by pulsations of the aortic graft, and intraoperative bowel wall injury.2 These causes are typically associated with prior open repair of AAAs. The use of endoluminal techniques to repair AAAs increased during the 1990s, with the goal of minimizing the invasiveness of conventional open repairs, and its use is also beneficial in reducing the incidence of secondary AEFs.3,4 This is achieved through the absence of anastomotic suture lines and the lack of damage involved in incorporating adjacent organs in the periaortic inflammatory process.3,4 However, complications of endoluminal repairs have been noted, including endoleaks and infection, and these can assist in the formation of AEFs. Endoleaks can lead to endotension causing pressure necrosis of the aneurysm against the intestinal wall.5 It has also been suggested that repeated sac embolizations after endoluminal repair, as occurred in this case, can lead to AEF formation.6 Furthermore, risk factors for the development of a graft infection in this case include the aortic thrombus acting as a nidus, prior groin infection following the endoluminal repair and potential contamination from additional procedures for the endoleaks.7 An underlying graft infection promotes inflammatory changes and bowel wall erosion leading to fistula formation. This process likely occurred in our case. We hypothesize that these factors forming the fistula, together with the large intraluminal thrombus that was compressing against the duodenum, led to the bowel obstruction. Specifically, the fistula, at one point of the compression, provided the fulcrum for the duodenal compression to be persistent. This is a rare phenomenon and supports the notion that a clinical suspicion of an AEF is essential in patients who present with acute abdominal symptoms or upper gastrointestinal bleeding and have a history of surgical repair of aneurysms with prosthetic implants.
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2. Chari A, Bratby M, Anthony S et al. Endovascular treatment of a secondary aortoenteric fistula: a temporary solution? Br. J. Hosp. Med. 2011; 72: 288–9. 3. Abou-Zamzam A, Bianchi C, Mazraany W et al. Aortenteric fistula development following endovascular abdominal aortic aneurysm repair: a case report. Ann. Vasc. Surg. 2003; 17: 119–22. 4. Parry DJ, Waterworth A, Kessel D, Robertson I, Berridge DC, Scott DJ. Endovascular repair of an inflammatory abdominal aortic aneurysm complicated by aortoduodenal fistulation with an unusual presentation. J. Vasc. Surg. 2001; 33: 874–9. 5. Saratzis N, Saratzis A, Melas N, Ktenidis K, Kiskinis D. Aortoduodenal fistulas after endovascular stent-graft repair of abdominal aortic aneurysms: single centre experience and review of the literature. J. Endovasc. Ther. 2008; 15: 441–8. 6. Bertges DJ, Villella ER, Makaroun MS. Aortoenteric fistula due to endoleak coil embolization after endovascular AAA repair. J. Endovasc. Ther. 2003; 10: 130–5. 7. Laser A, Baker N, Rectenwald J, Eliason JL, Criado-Pallares E, Upchurch GR Jr. Graft infection after endovascular abdominal aortic aneurysm repair. J. Vasc. Surg. 2011; 54: 58–63.
Aviv Pudipeddi,* MBBS (Hons) Ross Calopedos,† Anthony Grabs,‡ MBBS, FRACS Douglas Fenton-Lee,§ MBBS, FRACS Rohan Gett,¶ MBBS, BSc (Med), FRACS, MS *St Vincent’s Hospital, §Upper GI Surgery Unit, Departments of ‡Vascular Surgery and ¶Colorectal Surgery, St Vincent’s Hospital, and †University of New South Wales, Sydney, New South Wales, Australia doi: 10.1111/ans.12718
References 1. Quílez Ivorra C, Massa Domínguez B, Amillo Marques M, Moya Garcia MI, Arenas Jimenez J, Gomez Andres A. Aortoenteric fistulas: clinical presentation and helical computed tomography findings. Gastroenterol. Hepatol. 2005; 28: 378–81.
© 2014 Royal Australasian College of Surgeons
Duodenal obstruction from a secondary aortoduodenal fistula An 88-year-old man presented through the emergency department in December 2012 with a 6-day history of central abdominal pain. The pain was of moderate severity and radiated to the back. There was associated bilious vomiting and constipation but no melaena or haematemesis. The patient had an endoluminal graft (Gore Excluder bifurcated graft, W. L. Gore & Associates, Belrose, NSW, Australia) inserted for a 4.5-cm abdominal aortic aneurysm (AAA) in March 2007. Post-operative groin infection was treated with antibiotics, and endoleaks in 2009 and 2010 were embolized by interventional radiologists with Onyx glue (ev3 Endovascular, Inc., Plymouth, MN, USA). Other past medical history included an acute myocardial infarction, atrial fibrillation, hypertension and dyslipidaemia. On examination the patient was alert and oriented, with hypotension (87/53 mmHg), heart rate of 88 and temperature of 36.7. Abdominal examination revealed a distended abdomen with hypoactive bowel sounds and tenderness in the right flank. There was no evidence of peritonitis. Laboratory investigations showed haemoglobin of 129 g/L and white cell count of 9.2 × 109/L. Liver function tests and lipase levels were normal. Computed tomography of the abdomen revealed duodenal obstruction, with gross dilatation of the stomach and first two segments of the duodenum (Fig. 1). There was an abrupt transition at the mid-part of the third segment of the duodenum (D3) (Fig. 2). At this level, there was a large thrombus within the aneurysmal sac adherent to D3, at the point of duodenal obstruction.
The patient was kept nil by mouth, administered intravenous fluids and an in-dwelling catheter and nasogastric tube were inserted. Without clinical resolution despite gastric decompression, an explorative laparotomy was performed. The operative findings were extrinsic compression of D3 by the intraluminal thrombus of the aneurysmal sac, clear fistulous holes in the aneurysmal wall and the duodenum, periduodenal necrosis and inflammation at D3 consistent with the fistulous communication, and an intact aortic graft beneath the thrombus without evidence of bleeding from the proximal end of the endoluminal graft. The aneurysmal sac was debrided, the duodenal side of the fistula was resected, and a side-to-side duodenojejunostomy was created. Graft cultures of the aneurysmal wall yielded Propionibacterium acnes; the patient was thus commenced on Timentin (GlaxoSmithKline, Abbotsford, VIC, Australia). Post-operative pyrexia required the ongoing use of antibiotics, with a plan to continue amoxicillin for life. At 6- and 12-month reviews postoperatively, the patient has been well, tolerating a full diet and maintaining a steady weight. Although primary aortoenteric fistulas (AEFs) are due to a spontaneous communication of the lumen of an aortic aneurysm with an intestinal loop, secondary AEFs occur in patients who have undergone surgical repair of aortic aneurysms with prosthetic implants.1 With the increasing use of prosthetic graft materials, the incidence of secondary AEFs has exceeded primary AEFs. Secondary AEFs are thought to arise from the combination of friction between the proximal anastomotic sutures and the bowel,
Fig. 1. Dilatation of the stomach and first part of duodenum, proximal to the bowel obstruction.
Fig. 2. Large thrombus within the aneurysmal sac, with this section adherent to the third part of duodenum, causing the bowel obstruction.
© 2014 Royal Australasian College of Surgeons
ANZ J Surg •• (2014) ••–••
2
persistent bowel trauma caused by pulsations of the aortic graft, and intraoperative bowel wall injury.2 These causes are typically associated with prior open repair of AAAs. The use of endoluminal techniques to repair AAAs increased during the 1990s, with the goal of minimizing the invasiveness of conventional open repairs, and its use is also beneficial in reducing the incidence of secondary AEFs.3,4 This is achieved through the absence of anastomotic suture lines and the lack of damage involved in incorporating adjacent organs in the periaortic inflammatory process.3,4 However, complications of endoluminal repairs have been noted, including endoleaks and infection, and these can assist in the formation of AEFs. Endoleaks can lead to endotension causing pressure necrosis of the aneurysm against the intestinal wall.5 It has also been suggested that repeated sac embolizations after endoluminal repair, as occurred in this case, can lead to AEF formation.6 Furthermore, risk factors for the development of a graft infection in this case include the aortic thrombus acting as a nidus, prior groin infection following the endoluminal repair and potential contamination from additional procedures for the endoleaks.7 An underlying graft infection promotes inflammatory changes and bowel wall erosion leading to fistula formation. This process likely occurred in our case. We hypothesize that these factors forming the fistula, together with the large intraluminal thrombus that was compressing against the duodenum, led to the bowel obstruction. Specifically, the fistula, at one point of the compression, provided the fulcrum for the duodenal compression to be persistent. This is a rare phenomenon and supports the notion that a clinical suspicion of an AEF is essential in patients who present with acute abdominal symptoms or upper gastrointestinal bleeding and have a history of surgical repair of aneurysms with prosthetic implants.
Images for surgeons
2. Chari A, Bratby M, Anthony S et al. Endovascular treatment of a secondary aortoenteric fistula: a temporary solution? Br. J. Hosp. Med. 2011; 72: 288–9. 3. Abou-Zamzam A, Bianchi C, Mazraany W et al. Aortenteric fistula development following endovascular abdominal aortic aneurysm repair: a case report. Ann. Vasc. Surg. 2003; 17: 119–22. 4. Parry DJ, Waterworth A, Kessel D, Robertson I, Berridge DC, Scott DJ. Endovascular repair of an inflammatory abdominal aortic aneurysm complicated by aortoduodenal fistulation with an unusual presentation. J. Vasc. Surg. 2001; 33: 874–9. 5. Saratzis N, Saratzis A, Melas N, Ktenidis K, Kiskinis D. Aortoduodenal fistulas after endovascular stent-graft repair of abdominal aortic aneurysms: single centre experience and review of the literature. J. Endovasc. Ther. 2008; 15: 441–8. 6. Bertges DJ, Villella ER, Makaroun MS. Aortoenteric fistula due to endoleak coil embolization after endovascular AAA repair. J. Endovasc. Ther. 2003; 10: 130–5. 7. Laser A, Baker N, Rectenwald J, Eliason JL, Criado-Pallares E, Upchurch GR Jr. Graft infection after endovascular abdominal aortic aneurysm repair. J. Vasc. Surg. 2011; 54: 58–63.
Aviv Pudipeddi,* MBBS (Hons) Ross Calopedos,† Anthony Grabs,‡ MBBS, FRACS Douglas Fenton-Lee,§ MBBS, FRACS Rohan Gett,¶ MBBS, BSc (Med), FRACS, MS *St Vincent’s Hospital, §Upper GI Surgery Unit, Departments of ‡Vascular Surgery and ¶Colorectal Surgery, St Vincent’s Hospital, and †University of New South Wales, Sydney, New South Wales, Australia doi: 10.1111/ans.12718
References 1. Quílez Ivorra C, Massa Domínguez B, Amillo Marques M, Moya Garcia MI, Arenas Jimenez J, Gomez Andres A. Aortoenteric fistulas: clinical presentation and helical computed tomography findings. Gastroenterol. Hepatol. 2005; 28: 378–81.
© 2014 Royal Australasian College of Surgeons
