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Annals of Vascular Surgery Apr 2024Information regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes...
BACKGROUND
Information regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes and presenting comprehensive patient details through a structured treatment approach are necessary to establish a treatment strategy for this rare, complex, and fatal condition.
METHODS
We performed a single-center retrospective review of consecutive sAEF managed based on our in situ revascularization and intestinal repair strategy. The primary endpoint of this study was all-cause mortality, and secondary endpoints were the incidence of in-hospital complications and midterm reinfections.
RESULTS
Between 2007 and 2020, 16 patients with sAEF, including 13 men (81%), underwent in situ revascularization and digestive tract repair. The median follow-up duration for all participants was 36 (interquartile range, 6-62) months. Among the participants, 81% (n = 13), 13% (n = 2), and 6% (n = 1) underwent aortic reconstruction with rifampin-soaked grafts, unsoaked Dacron grafts, and femoral veins, respectively. The duodenum was the most commonly involved site in enteric pathology (88%; n = 14), and 57% (n = 8) of duodenal breaks were repaired by a simple closure. Duodenum's second part-jejunum anastomosis was performed in 43% of patients (n = 6), and 19% of the patients (n = 3) died perioperatively. In-hospital complications occurred in 88% patients (n = 14), and the most frequent complication was gastrointestinal. Finally, 81% patients (n = 13) were discharged home. Oral antibiotics were administered for a median duration of 5.7 months postoperatively; subsequently, the participants were followed up carefully. Reinfection was detected in 6% of the patients (n = 1) who underwent reoperation without any complications. The 1-year and 3-year overall survival rates of participants were 75% (n = 12) and 75% (n = 9), respectively, and no sAEF-related deaths occurred, except perioperative death.
CONCLUSIONS
Surgical intervention with contemporary management based on our vascular strategy and digestive tract procedure may be a durable treatment for sAEF.
Topics: Male; Humans; Treatment Outcome; Blood Vessel Prosthesis; Intestinal Fistula; Aortic Diseases; Blood Vessel Prosthesis Implantation; Retrospective Studies; Duodenum; Vascular Fistula
PubMed: 38159719
DOI: 10.1016/j.avsg.2023.10.028 -
VideoGIE : An Official Video Journal of... Dec 2023Video 1A 51-year-old woman underwent orthotopic liver transplant with duct-to-duct anastomosis for primary biliary cholangitis 8 months prior to presentation. Two months...
Video 1A 51-year-old woman underwent orthotopic liver transplant with duct-to-duct anastomosis for primary biliary cholangitis 8 months prior to presentation. Two months postoperatively, she presented with clinical biliary pancreatitis. An MRCP performed on admission demonstrates dilated donor biliary tree and a severe stricture at the anastomosis. An index ERCP shows an indwelling surgical biliary "stent" exiting the duodenal papillae and anastomotic stricture. The surgical stent was removed, a sphincterotomy was performed, and there was an inability to traverse the anastomotic stricture. A representative cholangiogram shown here demonstrates the presence of a severe stricture completely obstructing the biliary tree. ERCP was done the next day, placing a 10-mm × 8-cm fully covered metal stent throughout the anastomosis. Three months later, the stent was removed because there was recurrent stricture at the site of anastomosis. Four months after stent removal, the patient again presented with clinical and laboratory obstructive biliary disease. A follow-up MRCP showed a severe anastomotic biliary stricture with an upstream stone. Several attempts were made to pass ERCP antegrade through the stenosis. However, they were unsuccessful. The rate-limiting step for successful recanalization was guidewire passage across the stricture. In this case, there was complete obliteration of the lumen by fibrosis. Efforts to pass 0.025-inch and 0.035-inch angled hydrophilic guidewires were unsuccessful. Recurrent stricturing was believed to be because of ischemia or inadequate recanalization. Our approach was to attempt antegrade recanalization and biliary decompression through an EUS-guided hepatogastrostomy. However, antegrade recanalization was unsuccessful and led to retrograde cholangioscopy using a single-use endoscope (SpyScope DS-2; Boston Scientific, Marlborough, Mass, USA) 4 weeks later. This video shows the cholangioscopic recanalization process. There was no passage of contrast antegrade or retrograde. During the cholangioscopy, there was no visible lumen. The area of suspected anastomosis based on the pearly white appearance of scar tissue was approached using mini-forceps (SpyBite; Boston Scientific) and a bite-on-bite approach to re-establish a lumen for stent placement. We used the pearly scar tissue as a guide to ensure the correct site for recanalization. We felt comfortable doing this because a hepatogastrostomy and sphincterotomy were thought to be protective against any bile leak if tunneling had dissected out of the duct. Moreover, contrast injection was used periodically to monitor progression into the duct. Eventually, the forceps were advanced into the proximal biliary tree under cholangioscopic direction, re-establishing a lumen. Bile is seen flowing through the identified lumen. While a rendezvous approach with antegrade transillumination and a percutaneous SpyScope DS-2 might be safer for recanalization of complete obstruction, the process would require multiple admissions and procedures for percutaneous access and fistula maturation. This might increase morbidity for this patient with no difference in outcome. We propose that cholangioscopic recanalization along with protection from bile leakage would be a reasonable approach in this case and similar cases with altered anatomy, hepatogastrostomy in place, or unavailability for follow-up or multiple procedures. This is an intraoperative radiographic representation. On the left, the cholangiogram is seen in place and the mini-forceps are passing through it into the proximal biliary tree. On the right, passage of the guidewire with balloon dilation of the stricture is shown. The stone previously seen on MRCP passed spontaneously. A follow-up cholangiogram showed luminal patency. A 10-mm × 10-cm fully covered metal stent (Viabil; W.L. Gore, Flagstaff, Ariz, USA) was placed across anastomosis.
PubMed: 38155823
DOI: 10.1016/j.vgie.2023.08.001 -
ACG Case Reports Journal Dec 2023
PubMed: 38125872
DOI: 10.14309/crj.0000000000001244 -
International Journal of Surgery Case... Jan 2024Bouveret's syndrome is an uncommon condition characterized by the impaction of a gallstone in the pylorus or duodenum via a cholecysto-enteric fistula causing gastric...
INTRODUCTION AND IMPORTANCE
Bouveret's syndrome is an uncommon condition characterized by the impaction of a gallstone in the pylorus or duodenum via a cholecysto-enteric fistula causing gastric outlet obstruction. We report two unusual cases of Bouveret's syndrome causing gastric outlet obstruction in two elderly patients.
CASE PRESENTATION
Two elderly female patients presented to the surgical assessment unit with features of gastric outlet obstruction. In both cases, an urgent computed tomography (CT) of the abdomen showed pneumobilia, gastric distension, and gallstones impaction at the duodenal bulb. In Patient 1, endoscopic removal of the impacted gallstones was done successfully. She was discharged three days following an uneventful recovery. In Patient 2, an endoscopic removal of a single large gallstone was attempted, which was unsuccessful. She underwent robotic gastrotomy with extraction of the large gallstone with primary repair. She was discharged on 8th postoperative day.
CLINICAL DISCUSSION
Treatment options for Bouveret's syndrome include endoscopic management and surgery. The selection of treatment options depends upon factors like the degree of obstruction, the impaction site, number, type or size of gallstones, patient co-morbidities and clinical parameters at presentation, as well as expertise available, both endoscopic and surgical.
CONCLUSIONS
Bouveret's syndrome is one of the rare complications of gallstone. Endoscopic management can be effective at removing the impacted gallstones, which is particularly helpful for those elderly patients who have multiple medical co-morbidities, as in our first patient. Surgical management like minimal invasive surgery (robotic) can be beneficial in failed endoscopic attempt of removal of stone like in the second patient.
PubMed: 38113565
DOI: 10.1016/j.ijscr.2023.109134 -
Archive of Clinical Cases 2023Pancreatic injury post blunt abdominal trauma is exceedingly rare. When complete major pancreatic duct (MPD) disruption occurs, a disconnection between the pancreas and...
Pancreatic injury post blunt abdominal trauma is exceedingly rare. When complete major pancreatic duct (MPD) disruption occurs, a disconnection between the pancreas and the duodenum can take place, ultimately leading to fistula formation. We describe a case of MPD disruption following blunt abdominal trauma, complicated by a fistula between the pancreas and an open abdomen (pancreatico-atmospheric fistula). Although the fistula was managed using standard methods for treating pancreatic fistulas, wound care was a significant challenge in this case where the fistula exteriorized into an open abdomen.
PubMed: 38098696
DOI: 10.22551/2023.41.1004.10270 -
Medicine Dec 2023The management of bile duct injury (BDI) remains a considerable challenge in the department of hepatobiliary and pancreatic surgery. BDI is mainly iatrogenic and mostly...
RATIONALE
The management of bile duct injury (BDI) remains a considerable challenge in the department of hepatobiliary and pancreatic surgery. BDI is mainly iatrogenic and mostly occurs in laparoscopic cholecystectomy (LC). After more than 2 decades of development, with the increase in experience and technological advances in LC, the complications associated with the procedure have decreased annually. However, bile duct injuries (BDI) still have a certain incidence, the severity of BDI is higher, and the form of BDI is more complex.
PATIENT CONCERNS
We report the case of a patient who presented with bile duct injury and formation of a right hepatic duct-duodenal fistula after LC.
DIAGNOSES
Based on the diagnosis, a dissection was performed to relieve bile duct obstruction, suture the duodenal fistula, and anastomose the right and left hepatic ducts to the jejunum.
INTERVENTION
Based on the diagnosis, a dissection was performed to relieve bile duct obstruction, suture the duodenal fistula, and anastomose the right and left hepatic ducts to the jejunum.
OUTCOMES
Postoperative recovery was uneventful, with normal liver function and no complications, such as anastomotic fistula or biliary tract infection. The patient was hospitalized for 11 days postoperatively and discharged.
LESSONS
The successful diagnosis and treatment of this case and the summarization of the imaging features and diagnosis of postoperative BDI have improved the diagnostic understanding of postoperative BDI and provided clinicians with a particular clinical experience and basis for treating such diseases.
Topics: Humans; Hepatic Duct, Common; Bile Ducts; Cholecystectomy; Liver; Cholecystectomy, Laparoscopic; Cholestasis; Abdominal Injuries
PubMed: 38065856
DOI: 10.1097/MD.0000000000036565 -
Clinical Case Reports Dec 2023Brucella aortitis should be one of the differential diagnoses of inflammatory aortic aneurysms. In situ repair of intermittent aortoenteric fitulae and repair of...
KEY CLINICAL MESSAGE
Brucella aortitis should be one of the differential diagnoses of inflammatory aortic aneurysms. In situ repair of intermittent aortoenteric fitulae and repair of infrarenal aortic aneurysm with synthetic graft can be used in clean scarred fistulae.
ABSTRACT
Arterial aneurysms are very rare complications of Brucella infection. The purpose of this case report is to document a case of abdominal aortic aneurysm and primary aorto-duodenal fistula as a complication of Brucella infection, along with the management of brucella induced aortoenteric fistula with insitu synthetic graft. We report a 53-year-old man with a complaint of abdominal pain and melena. Radiological evaluation revealed an inflammatory abdominal aortic aneurysm and a primary aorto-duodenal fistula was identified during surgery. The patient underwent laparotomy, and surgical repair of the aneurysm with a bifurcated Dacron graft, while the entry of the aorto-duodenal fistula was closed with intra-aortic sutures. One month later, the patient tested positive for the Wright agglutination test (1:80) and Coomb's test (1:640) for brucella, and was treated with doxycycline, rifampicin, and ciprofloxacin for brucellosis. Though rare, brucella aortitis should be considered as one of the differential diagnoses of inflammatory aortic aneurysms. In situ repair of intermittent aortoenteric fistula and repair of the infrarenal aortic aneurysm with synthetic graft could be considered in a clean scarred fistula.
PubMed: 38054195
DOI: 10.1002/ccr3.8269 -
Journal of Inflammation Research 2023Necrotizing pancreatitis (NP) complicated by gastrointestinal fistula is challenging and understudied. As the treatment of necrotizing pancreatitis changed to a step-up...
PURPOSE
Necrotizing pancreatitis (NP) complicated by gastrointestinal fistula is challenging and understudied. As the treatment of necrotizing pancreatitis changed to a step-up strategy, we attempted to evaluate the incidence, risk factors, clinical outcomes and treatment of gastrointestinal fistulas in patients receiving a step-up approach.
METHODS
Clinical data from 1274 patients with NP from 2014-2022 were retrospectively analyzed. Multivariable logistic regression analysis was conducted to identify risk factors and propensity score matching (PSM) to explore clinical outcomes in patients with gastrointestinal fistulas.
RESULTS
Gastrointestinal fistulas occurred in 8.01% (102/1274) of patients. Of these, 10 were gastric fistulas, 52 were duodenal fistulas, 14 were jejunal or ileal fistulas and 41 were colonic fistulas. Low albumin on admission (OR, 0.936), higher CTSI (OR, 1.143) and invasive intervention prior to diagnosis of gastrointestinal fistula (OR, 5.84) were independent risk factors for the occurrence of gastrointestinal fistula, and early enteral nutrition (OR, 0.191) was a protective factor. Patients who developed a gastrointestinal fistula were in a worse condition on admission and had a poorer clinical outcome (p<0.05). After PSM, both groups of patients had similar baseline information and clinical characteristics at admission. The development of gastrointestinal fistulas resulted in new-onset persistent organ failure, increased open surgery, prolonged parenteral nutrition and hospitalization, but not increased mortality. The majority of patients received only conservative treatment and minimally invasive interventions, with 7 patients (11.3%) receiving surgery for upper gastrointestinal fistulas and 11 patients (26.9%) for colonic fistulas.
CONCLUSION
Gastrointestinal fistulas occurred in 8.01% of NP patients. Independent risk factors were low albumin, high CTSI and early intervention, while early enteral nutrition was a protective factor. After PSM, gastrointestinal fistulas resulted in an increased proportion of NP patients receiving open surgery and prolonged hospitalization. The majority of patients with gastrointestinal fistulas treated with step-up therapy could avoid surgery.
PubMed: 38026251
DOI: 10.2147/JIR.S433682 -
World Journal of Clinical Cases Oct 2023Primary aortoduodenal fistula is a rare cause of gastrointestinal (GI) bleeding consisting of abnormal channels between the aorta and GI tract without previous vascular...
BACKGROUND
Primary aortoduodenal fistula is a rare cause of gastrointestinal (GI) bleeding consisting of abnormal channels between the aorta and GI tract without previous vascular intervention that results in massive intraluminal hemorrhage.
CASE SUMMARY
A 67-year-old man was hospitalized for coffee ground vomiting, tarry stools, and colic abdominal pain. He was repeatedly admitted for active GI bleeding and hypovolemic shock. Intermittent and spontaneously stopped bleeders were undetectable on multiple GI endoscopy, angiography, computed tomography angiography (CTA), capsule endoscopy, and Tc-labeled red blood cell (RBC) scans. The patient received supportive treatment and was discharged without signs of rebleeding. Thereafter, he was re-admitted for bleeder identification. Repeated CTA after a bleed revealed a small aortic aneurysm at the renal level contacting the fourth portion of the duodenum. A Tc-labeled RBC single-photon emission CT (SPECT)/CT scan performed during bleeding symptoms revealed active bleeding at the duodenal level. According to his clinical symptoms (intermittent massive GI bleeding with hypovolemic shock, dizziness, dark red stool, and bloody vomitus) and the abdominal CTA and Tc-labeled RBC SPECT/CT results, we suspected a small aneurysm and an aortoduodenal fistula. Subsequent duodenal excision and duodenojejunal anastomosis were performed. A 7-mm saccular aneurysm arising from the anterior wall of the abdominal aorta near the left renal artery was identified. Percutaneous intravascular stenting of the abdominal aorta was performed and his symptoms improved.
CONCLUSION
Our findings suggest that Tc-labeled RBC SPECT/CT scanning can aid the diagnosis of a rare cause of active GI bleeding.
PubMed: 37946757
DOI: 10.12998/wjcc.v11.i29.7162 -
Case Reports in Gastroenterology 2023The case is about an 87-year-old female. While staying at a facility, she had a fever and abdominal pain and visited our hospital for an up-close examination and...
The case is about an 87-year-old female. While staying at a facility, she had a fever and abdominal pain and visited our hospital for an up-close examination and treatment. An abdominal CT scan revealed gallstones, gallbladder enlargement, and common bile duct stones. Endoscopic retrograde cholangiopancreatography was performed to confirm the presence of common bile duct stones, which were extracted. At that time, she was diagnosed with a duodenal fistula of the gallbladder and underwent surgery in our department. The gallbladder and duodenum were firmly adhered, and gallstones were palpated between the gallbladder and duodenum. The gallbladder was incised at the fundus to check the lumen, and gallstones were lodged in the fistula with the duodenum. After the removal of gallstones, the gallbladder was dissected, and a fistula with the duodenum was identified. After treating the cystic duct, the fistula was removed, and the gallbladder was removed. Because the duodenal wall was fragile due to inflammation and the fistula was large and difficult to close simply, the duodenal bulb was separated with a linear stapler, and the stomach and jejunum were reconstructed with a 25-mm CDH using the Roux-en-Y technique. The patient's postoperative course was good, and she was discharged from the hospital.
PubMed: 37928966
DOI: 10.1159/000531486