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2020, vol. 77, br. 9, str. 992-999
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Aortoduodenalna fistula posle resekcije aneurizme abdominalne aorte
Aortoduodenal fistula after abdominal aortic aneurysm resection: Two case reports
aVojnomedicinska akademija, Klinika za vaskularnu i endovaskularnu hirurgiju, Beograd + Univerzitet odbrane, Medicinski fakultet Vojnomedicinske akademije, Beograd bUniverzitet odbrane, Medicinski fakultet Vojnomedicinske akademije, Beograd + Vojnomedicinska akademija, Klinika za opštu hirurgiju, Beograd cVojnomedicinska akademija, Klinika za opštu hirurgiju, Beograd dVojnomedicinska akademija, Klinika za anesteziologiju i intenzivnu terapiju, Beograd eVojnomedicinska akademija, Klinika za ortopedsku hirurgiju i traumatologiju, Beograd fVojnomedicinska akademija, Klinika za vaskularnu i endovaskularnu hirurgiju, Beograd
e-adresa: tomicdoc@gmail.com
Sažetak
Uvod. Aortoenterična fistula (AEF) je retka i izuzetno teška komplikacija operacije aorte. Prikazali smo dva bolesnika sa sekundarnom aortoduodenalnom fistulom (SADF) kao komplikacijom operacije aorte. Prikazi bolesnika. U prvom slučaju SADF je nastala 11 godina nakon resekcije aneurizme abdominalne aorte, sa znacima krvarenja iz gastrointestinalnog trakta (GIT). Posle negativnog ezofagogastroduodenoskopskog (EGDS) nalaza učinjena je multislajsna kompjuterizovana tomografija (MSCT) angiografija koja je otkrila curenje kontrasta u duodenum iz 10 cm široke aneurizme visceralne aorte. Bolesnik je hitno operisan, kada je izvađen graft, redukovana aneurizma sa prešivanjem proksimalnih i distalnih delova aorte, urađena je rekonstrukcija creva i aksilobifemoralni bajpas (AxFF). Bolesnik je otpušten 30. dana posle operacije. U drugom slučaju, SADF je nastala pet meseci nakon endovaskularne rekonstrukcije abdominalne aorte (EVAR) sa znacima krvarenja iz GIT i sepse. U sledećih osam dana učinjene su tri EGDS i viđen je normalan nalaz. Na MSCT aortografiji nađeni su znaci endoleak-a, partikule slobodnog gasa u aneurizmatskoj vreći i retroaortalno, kao i znaci prisustva krvi u crevima. Bolesnik je hitno operisan i odstranjen je stent graft, ušiveni proksimalni i distalni delovi aorte, učinjena reparacija crevnog zida i AxFF. Bolesnik je egzitirao prvog postoperativnog dana zbog sepse i sindroma multiorganske disfunkcije. Zaključak. Preporučeni tretman SADF podrazumeva ekstraanatomski AxFF sa kompletnom ekscizijom inficiranog grafta ili stent grafta, prešivanje aortnih bataljaka i reparaciju duodenuma. Zbog visoke smrtnosti, kod tih bolesnika neophodna je hitna dijagnostička procena i odluka o adekvatnom operativnom tretmanu. Iako su preporuke European Society of Vascular Surgery, kao vodiča, veoma korisne, ne postoji jedinstven stav o tretmanu AEF, tako da svaki bolesnik zahteva specifičan tretman.
Abstract
Introduction. Aortoenteric fistula (AEF) is rare and extremely difficult complication of aortic surgery. We presented two cases of secondary aortoduodenal fistula (SADF) as complication after aortic surgery. Case reports. In the first patient SADF happened 11 years after open abdominal aneurysmal resection with gastrointestinal tract (GIT) bleeding. After negative esophagogastroduodenoscopy (EGDS) we performed multislice computed tomography (MSCT) which revealed contrast leakage in duodenum from 10 cm wide visceral aortic aneurysm. The patient was treated with graft excision, aneurysmal reduction, sewing of proximal and distal aortal stumps, bowel repair followed by axillobifemoral bypass (AxFF). The patient dismissed on 30th postoperative day. The second case of ADF happened five months after endovascular reconstruction of abdominal aorta with GIT bleeding and fewer. During following 8 days, he had three negative EGDS. On MSCT we found signs of endoleak, free air in aneurysmal sac, and signs of blood in the intestine. On urgent operation we extracted stent graft, sewed proximal and distal aortal stumps, performed bowel repair and AxFF. The patient died a day after operation with signs of sepsis and multiple organ failure syndrome. Conclusion. Conventional treatment of ADF means extraanatomic AxFF with complete excision of infected graft or stent graft, with closure of aorta's proximal and distal stumps and duodenal repair. Because of high mortality, prompt diagnostic evaluation and quick decision of an adequate operative treatment is necessary. Although European Society of Vascular Surgery recommendations, as a guide, are very helpful, there is no unique attitude about management of AEF, so each patient should be specifically treated.
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