Unique solution to the difficult problem of an aorto‐duodenal fistula in a regional centre

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Excerpt

A 75‐year‐old man presented to his local regional emergency department following an episode of haematemesis and associated presyncope. He was noted to be hypotensive and bradycardic during the transfer into the hospital. His past medical history was significant for an open abdominal aortic aneurysm repair in 2005.
On arrival the patient was resuscitated and his condition stabilized. Peptic ulcer disease was initially the suspected diagnosis. The patient was commenced on a proton pump inhibitor infusion and admitted to the hospital. His condition remained stable overnight. An upper gastrointestinal endoscopy the next morning failed to identify any cause for the bleeding episode.
Later that day, the patient had a massive episode of melaena. An urgent abdominal computed tomography (CT) angiogram was performed which identified a graft enteric fistula (GEF) as the source of bleeding (Fig. 1). Shortly after the completion of the study, the patient passed further melaena and became haemodynamically unstable. While administering simultaneous massive blood product transfusion and inotropic support, the patient was transferred emergently to the theatre.
A midline laparotomy was performed and the supraceliac aorta was exposed and clamped. The retroperitoneum was opened to expose the D3 segment of the duodenum overlying the infra‐renal aorta. The duodenum was displaced anteriorly and caudally and, using a 30‐mm EndoGIA Stapler (Covidien, Mansfield, MA, USA), was divided longitudinally in a ‘sleeve duodenectomy’ fashion. Doing this left a short cuff of duodenum as a temporizing autologous patch transversely over the aorta. The supraceliac clamp was then removed, and the patch was assessed as effectively achieving haemostasis. There was a total clamp time of 21 min. The ‘Bogata bag’ technique was employed for temporary abdominal closure to facilitate urgent air transfer to the nearest tertiary referral centre for definitive vascular surgical management.
On arrival to the tertiary vascular surgical centre, the patient was transferred directly to the operating theatre. Formal laparotomy proceeded. The longitudinally stapled duodenum was deemed viable and in continuity. The infra‐renal aorta and distal aortic graft were exposed and clamped. The Dacron graft was excised and the remaining stump of infra‐renal aorta was oversewn. Infection appeared to be localized to the graft material. Following exposure and clamping distally, the common iliac arteries were spatulated and anastomosed in continuity. A size four Fogarty embolectomy catheter was passed down both legs prior to closure and clot was extracted. The abdomen was then irrigated thoroughly and closed. The right axillary artery was then dissected out and an axillo‐uni‐femoral bypass graft was performed using 8‐mm polytetrafluoroethylene reinforced graft to the right common femoral artery (Fig. 2). The patient was transferred intubated, ventilated and sedated to the intensive care unit (ICU).
The patient remained in the ICU for the following 13 days. Post‐operatively, the patient's recovery was slowed by acute kidney and lung injury. A CT scan excluded bowel obstruction and enteral feeding was gradually introduced. The patient was eventually transferred to a nearby rehabilitation facility and returned home fully mobile and functionally independent. He remains well and independent at 12‐month follow‐up.
The patient's condition in our case warranted urgent laparotomy for life‐threatening haemodynamic instability. The general surgeon, through the use of a gastrointestinal stapler, achieved haemorrhage control without compromising the duodenal lumen or attempting a complex vascular repair outside his specialty of training. This technique is novel and cannot be recommended as routine practice; however, it may be a useful option to have in the surgical armamentarium for the management of the unstable patient.
The management goals for GEF are to control haemorrhage, eradicate infection and maintain lower limb perfusion.
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