A Successfully Treated Surgical Case of Graft Duodenal and Colonic Fistula with Cardio- pulmonary Arrest after Abdominal Aortic Graft Replacement

Toshihiko Ichihara

Michio Sasaki and Tomonobu Abe

（Department of Cardio-vascular Surgery, Tosei General Hospital, Seto, Japan, and Department of Cardiac Surgery, Nagoya University School of Medicine, Nagoya, Japan）

A secondary aorto-enteric fistula can directly communicate with the gastroduodenal tract, colonic tract and the aorta in patients undergoing major surgery on the aorta, and this phenomenon is observed particularly often in patients who have undergone abdominal aortic graft replacement. We encountered a case of secondary aortoduodenal fistula and colonic fistula. The patient was a 60-year-old man who had previously undergone a graft replacement for an infra-renal abdominal aortic aneurysm. His present admission was due to episodes of gastro-intestinal hemorrhaging and he had also undergone an abdominal aortic graft replacement 2 months previously. The patient’s bleeding was managed conservatively. A scar was observed in the duodenum based on the endoscopic findings. At 10 days after admission, abdominal computed tomography（CT）showed active bleeding from the graft in the third portion of the duodenum. We therefore diagnosed secondary aorto-duodenal fistula. Since this pathogenic state may lead to serious massive gastroduodenal hemorrhaging, both an accurate diagnosis and emergency operation are therefore essential to successful treatment. We immediately inserted an intra-aortic occlusion balloon catheter（IABO). Thereafter, another aorto colonic fistula was detected after laparotomy, for the first time. First, the old graft was removed and the direct closure of the duodenum was performed, followed by omentopexy, colostomy, colostoma and then the extra-anatomical revascularization between the left axillary and bilateral femoral arteries was carried out. Finally, an intestinal feeding tube was inserted. The patient fell into a state of cardiac arrest during the operation due to the uncontrolled active bleeding in spite of the presence of IABO. An emergency thoracotomy was thus performed in the left 4th intercostal region. The descending aorta was clamped, and then all of the planned procedures were performed in order. The postoperative course was eventful, however, the patient’s lower thigh eventually had to be amputated due to ischemia of the clamped descending aorta. We encountered a case of graft duodenal and colonic fistula with cardio pulmonary arrest due to delayed diagnosis based on the endoscopic findings after abdominal aortic graft replacement. This case was successfully treated despite various difficulties in making a timely and accurate diagnosis.

 

Jpn. J. Cardiovasc. Surg. 43:224-229（2014）

Keywords：post replacement of abdominal aortic aneurysm;prosthetic graft duodenal fistula;prosthetic graft colonic fistula;cardio pulmonary arrest