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Rey J, Bornak A, Montoya C, Polania C, Kenel-Pierre S, Kang N, Sussman M, Gonzalez K, Erben Y. Aortoenteric Fistulas Following Endovascular Aortic Aneurysm Repair: A Review. Vasc Endovascular Surg 2025:15385744251339966. [PMID: 40340624 DOI: 10.1177/15385744251339966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2025]
Abstract
BackgroundSecondary aortoenteric fistulas (SAEF) following endovascular aortic repair (EVAR) is an extremely rare event but life threatening. Our review offers comprehensive knowledge on pathophysiology, clinical presentation, diagnosis, and treatment options.AimTo summarize the current literature regarding pathophysiology, clinical, diagnostic and therapeutic approach of aortoenteric fistulas secondary to EVAR.MethodsWe performed a literature search in Pubmed/MEDLINE to identify the literature published about SAEF after EVAR. Cases were summarized in a table and prevalences. Other relevant literature was included in the results sections.ResultsA total of 35 reports (single cases and small series) with 45 patients were included. SAEF after EVAR can result from infection, inflammation, or mechanical factors. Clinical presentation is often non-specific, ranging from a gastrointestinal herald bleed to hemorrhagic shock, or malaise and general infection-related symptoms. Cross-sectional imaging plays a critical role in diagnosing SAEF. The treatment approach involves a multidisciplinary team approach and requires broad-spectrum intravenous antibiotics, endovascular intervention for urgent hemorrhage control, and open surgical intervention for definitive repair. Long-term antimicrobial therapy is essential to avoid reinfection.ConclusionsSAEF following EVAR represents a complex, life-threatening condition with limited evidence-based management strategies. Given the growing prevalence of endovascular procedures, comprehensive knowledge of SAEF is crucial for all health care providers to improve early diagnosis and outcomes.
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Affiliation(s)
- Jorge Rey
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Arash Bornak
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Christopher Montoya
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Camilo Polania
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Stefan Kenel-Pierre
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Naixin Kang
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Matthew Sussman
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Kathy Gonzalez
- DeWitt Daughtry Family Department of Surgery, Division of Vascular Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL, USA
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Masuda H, Yamamoto Y, Ae R. Recurrent Hematochezia Due to a Rectal Fistula Caused by a Left Internal Iliac Artery Aneurysm. Cureus 2025; 17:e79483. [PMID: 40135012 PMCID: PMC11933728 DOI: 10.7759/cureus.79483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2025] [Indexed: 03/27/2025] Open
Abstract
Arterio-enteric fistulas (AEFs) are a rare cause of gastrointestinal bleeding involving direct communication between an artery and the intestinal tract. The duodenum is the most common fistula site for AEFs, but none of the rectal cases are known. We present the case of an elderly man with hematochezia due to a rectal fistula caused by a left internal iliac artery aneurysm, which was detected on contrast-enhanced computed tomography (CT), showing typical fistula formation and ectopic gas images. This case highlights the importance of considering the occurrence of rare but potentially fatal AEFs in elderly patients with hematochezia and that the timely performance of contrast-enhanced CT is critical for an accurate diagnosis.
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Affiliation(s)
- Hiroya Masuda
- Department of General Medicine, Sunagawa City Medical Center, Sunagawa, JPN
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Shimotsuke, JPN
| | - Yu Yamamoto
- Division of General Medicine, Jichi Medical University, Shimotsuke, JPN
| | - Ryusuke Ae
- Division of Public Health, Center for Community Medicine, Jichi Medical University, Shimotsuke, JPN
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Suzuki S, Saito M, Uno K, Asano N, Koike T, Akamatsu D, Mizuma M, Kamei T, Unno M, Masamune A. The usefulness of gel immersion endoscopy in identifying herald bleeding from an infectious aortoenteric fistula: a case report. Clin J Gastroenterol 2024; 17:871-875. [PMID: 39039400 DOI: 10.1007/s12328-024-02020-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 07/09/2024] [Indexed: 07/23/2024]
Abstract
A 62-year-old male with a history of stent graft replacement for an infectious aortic aneurysm, followed by multiple interventions for postoperative complications, was admitted with melena and anemia. Enhanced computed tomography (eCT) demonstrated fluffing and hyperdensities surrounding the graft, despite no evidence of an aortoenteric fistula (AEF). Emergency esophagogastroduodenoscopy (EGD) showed a massive bleeding in the reconstructed tract and the protruding lesion of postoperative granulation tissue with clots at the end of the blind pouch. Thereafter, hemorrhage temporarily reoccurred several times; however, the source could not be identified using eCT or EGD. Finally, on the third attempt, we performed gel immersion endoscopy (GIE) with manual injection of VISCOCLEARⓇ, and it showed purulent blood flowing from one side of the protruding lesion in the pouch. Based on the eCT findings showing exudation of the contrast agent from the graft into the pouch, we made a diagnosis of an AEF. However, radical surgery was not performed because of the patient's poor general condition. During conservative management, he died of uncontrolled bleeding from the AEF on the 5th day of hospitalization. This is the first case in which the GIE might provide tips to identify herald bleeding from a lethal AEF.
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Affiliation(s)
- Suguo Suzuki
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Miyagi, Sendai, 981-8574, Japan
| | - Masahiro Saito
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Miyagi, Sendai, 981-8574, Japan
| | - Kaname Uno
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Miyagi, Sendai, 981-8574, Japan.
| | - Naoki Asano
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Miyagi, Sendai, 981-8574, Japan
| | - Tomoyuki Koike
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Miyagi, Sendai, 981-8574, Japan
| | - Daijirou Akamatsu
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Masamichi Mizuma
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Takashi Kamei
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University Graduate School of Medicine, Miyagi, Japan
| | - Atsushi Masamune
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, 1-1 Seiryo-cho, Aoba-ku, Miyagi, Sendai, 981-8574, Japan
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4
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Mulita F, Leivaditis V, Verras GI, Pitros C, Dimopoulos P, Katsakiori PF, Dafnomili D, Tchabashvili L, Tasios K, Kehagias D, Antzoulas A, Papadoulas S, Koletsis E. Secondary aortoenteric fistula: a narrative review of the view of the surgeon. Arch Med Sci Atheroscler Dis 2024; 9:e66-e71. [PMID: 38846053 PMCID: PMC11155463 DOI: 10.5114/amsad/186358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 03/21/2024] [Indexed: 06/09/2024] Open
Abstract
Aortoenteric fistula (AEF) is defined as the abnormal communication between the aorta and the gastrointestinal tract. AEFs are divided into primary and secondary usually after abdominal aortic aneurysm (AAA) recovery and are a rare but quite dangerous cause of gastrointestinal bleeding that the general surgeon may face during his/her career. Secondary AEF was first described in 1953 to a 44-year-old woman 3 months after an AAA operation. This review presents the role of the surgeon in the management of secondary aortoenteric fistulas. AEFs are a rare but fatal gastrointestinal bleeding cause that the general surgeon may be asked to manage. Diagnosis requires the combination of strong clinical suspicion and the presence of a history of AAA surgery. Although a vascular surgery case, general surgeons play a role in choosing the technique of restoring the intestinal tract, which seems to be significantly related to subsequent morbidity and mortality.
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Affiliation(s)
- Francesk Mulita
- Department of Surgery, General University Hospital of Patras, Patras, Greece
| | - Vasileios Leivaditis
- Department of Cardiothoracic and Vascular Surgery, WestpfalzKlinikum, Kaiserslautern, Germany
| | | | - Christos Pitros
- Department of Vascular Surgery, General University Hospital of Patras, Patras, Greece
| | - Platon Dimopoulos
- Department of Interventional Radiology, General University Hospital of Patras, Patras, Greece
| | | | - Danai Dafnomili
- Department of Surgery, General University Hospital of Patras, Patras, Greece
| | - Levan Tchabashvili
- Department of Surgery, General University Hospital of Patras, Patras, Greece
| | - Konstantinos Tasios
- Department of Surgery, General University Hospital of Patras, Patras, Greece
| | - Dimitrios Kehagias
- Department of Surgery, General University Hospital of Patras, Patras, Greece
| | - Andreas Antzoulas
- Department of Surgery, General University Hospital of Patras, Patras, Greece
| | - Spyros Papadoulas
- Department of Vascular Surgery, General University Hospital of Patras, Patras, Greece
| | - Efstratios Koletsis
- Department of Cardiothoracic Surgery, General University Hospital of Patras, Patras, Greece
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Li J, Hu Y, Liu W, Tang J, Zhu S, Zeng C. A successful endovascular aortic repair of aortoesophageal fistula following esophagectomy: a case report and literature review. J Cardiothorac Surg 2024; 19:70. [PMID: 38326831 PMCID: PMC10848545 DOI: 10.1186/s13019-024-02540-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 01/28/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND Aortoesophageal fistula (AEF) is an extremely rare and highly fatal complication leading to a high risk of morbidity and mortality. Successful management of AEF after esophagectomy for esophageal carcinoma has rarely been reported in the literature. CASE PRESENTATION Here we present a rare case of a 44-year-old female with complications of AEF after esophagectomy for esophageal carcinoma, mainly presented as vomiting of blood. Both computed tomographic and computed tomography angiography of the chest showed bilateral pleural effusion and atelectasis, while gastroscopy showed large gastrointestinal bleeding. Emergency surgery was performed that included the removal of the mediastinal abscess, left lower pulmonary wedge resection, and thoracic endovascular aortic repair (TEVAR), followed by supportive treatment. The surgery went successful, and the patient was followed up for 1 year after discharge and showed good recovery. We also reviewed previous literature on the history, causes, pathophysiology, clinical presentation, diagnosis, and treatment of AEF after esophagectomy for esophageal adenocarcinoma. CONCLUSIONS In our case, thoracotomy combined with TEVAR was effective in treating AEF after esophagectomy for esophageal adenocarcinoma. This case provides successful experiences for clinical diagnosis and treatment of AEF after esophagectomy for esophageal carcinoma.
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Affiliation(s)
- Jina Li
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Yan Hu
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Wenliang Liu
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Jingqun Tang
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Song Zhu
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
- Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China
| | - Chao Zeng
- Department of Thoracic Surgery, The Second Xiangya Hospital, Central South University, Changsha, Hunan, People's Republic of China.
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Narayanan A, Hanna J, Okamura-Kho A, Tesar J, Lim E, Peden S, Dean A, Taumoepeau L, Katib N, Lyons O, Khashram M. Management of secondary aorto-enteric fistulae: a multi-centre study. ANZ J Surg 2023; 93:2363-2369. [PMID: 37012584 DOI: 10.1111/ans.18441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 03/12/2023] [Accepted: 03/19/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Secondary aorto-enteric fistulae (SAEF) are a rare, complex and life-threatening complication following aortic repair. Traditional treatment strategy has been with open aortic repair (OAR), with emergence of endovascular repair (EVAR) as a potentially viable initial treatment option. Controversy exists over optimal immediate and long-term management. METHODS This was a retrospective, observational, multi-institutional cohort study. Patients who had been treated for SAEF between 2003 and 2020 were identified using a standardized database. Baseline characteristics, presenting features, microbiological, operative, and post-operative variables were recorded. The primary outcomes were short and mid-term mortality. Descriptive statistics, binomial regression, Kaplan-Meier and Cox age-adjusted survival analyses were performed. RESULTS Across 5 tertiary centres, a total of 47 patients treated for SAEF were included, 7 were female and the median (range) age at presentation was 74 years (48-93). In this cohort, 24 (51%) patients were treated with initially with OAR, 15 (32%) with EVAR-first and 8 (17%) non-operatively. The 30-day and 1-year mortality for all cases that underwent intervention was 21% and 46% respectively. Age-adjusted survival analysis revealed no statistically significant difference in mortality in the EVAR-first group compared to the OAR-first group, HR 0.99 (95% CI 0.94-1.03, P = 0.61). CONCLUSION In this study there was no difference in all-cause mortality in patients who had OAR or EVAR as first line treatment for SAEF. In the acute setting, alongside broad-spectrum antimicrobial therapy, EVAR can be considered as an initial treatment for patients with SAEF, as a primary treatment or a bridge to definitive OAR.
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Affiliation(s)
- Anantha Narayanan
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Department of Vascular Surgery, Wellington Hospital, Wellington, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Joseph Hanna
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
| | - Amy Okamura-Kho
- Department of Vascular Surgery, Auckland Hospital, Auckland, New Zealand
| | - Joshua Tesar
- Department of Vascular Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Eric Lim
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
| | - Sam Peden
- Department of Vascular Surgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Anastasia Dean
- Department of Surgery, University of Auckland, Auckland, New Zealand
- Department of Vascular Surgery, Auckland Hospital, Auckland, New Zealand
| | - Lupe Taumoepeau
- Department of Vascular Surgery, Wellington Hospital, Wellington, New Zealand
| | - Nedal Katib
- Department of Vascular Surgery, Prince of Wales Hospital, Sydney, New South Wales, Australia
| | - Oliver Lyons
- Department of Vascular Surgery, Christchurch Hospital, Christchurch, New Zealand
- Department of Surgery, University of Otago, Otago, New Zealand
| | - Manar Khashram
- Department of Vascular Surgery, Waikato Hospital, Hamilton, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
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7
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Azzopardi M, Wallace T, Khaled YS. Aortoiliac graft-enteric fistula presenting as gastrointestinal hemorrhage: A report on a complex case management. Clin Case Rep 2023; 11:e7801. [PMID: 37593341 PMCID: PMC10427754 DOI: 10.1002/ccr3.7801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 07/18/2023] [Accepted: 07/31/2023] [Indexed: 08/19/2023] Open
Abstract
Key Clinical Message Iliac artery-enteric fistula is a rare cause of lower GI bleeding and can cause life-threatening consequences. A high degree of clinical suspicion is needed in patients with previous aortic surgery to allow early multidisciplinary intervention. Abstract This case study discusses the staged management of a 78-year-old patient presenting with life-threatening lower gastrointestinal (GI) bleeding secondary to an aortoiliac graft-enteric fistula (GEF) into the sigmoid colon on the background of an adenocarcinoma and diverticular disease. The patient had an aorto bi-iliac synthetic dacron graft repair of an abdominal aortic aneurysm (AAA) some 20 years ago. Here, we present a case of successful endovascular treatment of massive hemorrhage as a bridge to definitive second-stage dacron graft explant and autologous vein reconstruction with a simultaneous anterior resection.
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Affiliation(s)
- Michael Azzopardi
- Department of Academic Surgery, Leeds Institute of Medical ResearchSt James's University HospitalLeedsUK
| | - Tom Wallace
- Department of Vascular Surgery, Leeds Vascular InstituteLeeds General InfirmaryLeedsUK
| | - Yazan S. Khaled
- Department of Academic Surgery, Leeds Institute of Medical ResearchSt James's University HospitalLeedsUK
- School of MedicineUniversity of LeedsLeedsUK
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Rosianu CG, Hoara P, Achim F, Birla R, Bolocan A, Mohssen A, Copca N, Constantinoiu S. The Use of Esophageal Stents in the Management of Postoperative Fistulas-Current Status, Clinical Outcomes and Perspectives-Review. Life (Basel) 2023; 13:life13040966. [PMID: 37109495 PMCID: PMC10144597 DOI: 10.3390/life13040966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 03/31/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
Esophageal fistula remains one of the main postoperative complications, with the treatment often requiring the use of stents. This article reviews the updates on the use of endoscopic stents for the treatment of postoperative esophageal leakage in terms of indications, types of stents used, efficiency, specific complications and perspectives. MATERIALS AND METHODS We searched the PubMed and MEDLINE databases for the keywords postoperative esophageal anastomotic leak and postoperative esophageal anastomotic leak stent, and retrieved relevant papers published until December 2022. RESULTS The endoscopic discovery of the fistula is usually followed by the insertion of a fully covered esophageal stent. It has an efficiency of more than 60% in closing the fistula, and the failure is related to the delayed application of the method, a situation more suitable for endo vac therapy. The most common complication is migration, but life-threatening complications have also been described. The combination of the advantages of endoscopic stents and vacuum therapy is probably found in the emerging VACstent procedure. CONCLUSIONS Although the competing approaches give promising results, this method has a well-defined place in the treatment of esophageal fistulas, and it is probably necessary to refine the indications for each individual procedure.
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Affiliation(s)
- Cristian Gelu Rosianu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Petre Hoara
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Florin Achim
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Rodica Birla
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Alexandra Bolocan
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Ahmed Mohssen
- Gastroenterology Department, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Narcis Copca
- Second Department of Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
| | - Silviu Constantinoiu
- Department of General Surgery, "Carol Davila" University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Centre of Excelence in Esophageal Surgery, "Sfanta Maria" Clinical Hospital, 011172 Bucharest, Romania
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9
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Muacevic A, Adler JR. Primary Aortoesophageal Fistula Presenting as Upper Gastrointestinal Bleed. Cureus 2022; 14:e30018. [PMID: 36348888 PMCID: PMC9637265 DOI: 10.7759/cureus.30018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2022] [Indexed: 11/18/2022] Open
Abstract
Aortoenteric fistula is a rare condition that can be primary or secondary. The primary type is less common than the secondary. The secondary aortoenteric fistula is an uncommon fatal complication after reconstructive surgery for an aortic aneurysm or other aortic diseases. Here we present a case of a 59-year-old man who presented to our emergency department with sudden onset of massive hematemesis. Imaging studies were done and the patient was diagnosed to have aortoesophageal fistula. Upper gastrointestinal endoscopy showed an intraluminal bulge in the posterior wall of the esophagus with an ulcer and hematoma. The patient was planned for emergency surgical intervention, but the patient had recurrent bouts of hematemesis and, unfortunately, expired. Hence patients presenting with massive hematemesis, aortoenteric fistula can be the underlying cause, and all surgeons should be aware of such conditions and the need for emergent surgical intervention.
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10
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Yagi M, Aiboshi J, Kojima M, Yoshikawa S, Morishita K, Kaji M, Otomo Y. Life‐saving case of cardiopulmonary arrest by secondary aortoenteric fistula formed in the anastomotic site between the inferior mesenteric artery and aortic graft. Acute Med Surg 2022; 9:e2744. [PMID: 35356485 PMCID: PMC8948498 DOI: 10.1002/ams2.744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Revised: 02/19/2022] [Accepted: 03/03/2022] [Indexed: 11/10/2022] Open
Abstract
Background Secondary aortoenteric fistula is a fatal cause of gastrointestinal bleeding after aortic reconstructive surgery with a prosthesis. In most cases, the proximal suture line is involved. We herein report a rare case in which the fistula formed between the suture line of inferior mesenteric artery reimplantation and the jejunum. Case Presentation An 82‐year‐old man was transferred to our hospital due to hematemesis with severe hypovolemic shock. Although he fell into cardiopulmonary arrest, immediate resuscitation achieved return of spontaneous circulation. As his surgical history of aortic reconstruction and computed tomography findings suggested potential secondary aortoenteric fistula, emergency surgery was carried out. The anastomosis between the inferior mesenteric artery and aortic graft was communicating with the jejunum. Partial jejunal resection was undertaken, and the aortic graft was replaced. Conclusion The anastomosis between the inferior mesenteric artery and aortic graft in the previous aortic replacement can become the site of secondary aortoenteric fistula.
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Affiliation(s)
- Masayuki Yagi
- Trauma and Acute Critical Care Medical Center Tokyo Medical and Dental University Hospital of Medicine Tokyo Japan
| | - Junichi Aiboshi
- Trauma and Acute Critical Care Medical Center Tokyo Medical and Dental University Hospital of Medicine Tokyo Japan
| | - Mitsuaki Kojima
- Trauma and Acute Critical Care Medical Center Tokyo Medical and Dental University Hospital of Medicine Tokyo Japan
| | - Shunsuke Yoshikawa
- Trauma and Acute Critical Care Medical Center Tokyo Medical and Dental University Hospital of Medicine Tokyo Japan
| | - Koji Morishita
- Trauma and Acute Critical Care Medical Center Tokyo Medical and Dental University Hospital of Medicine Tokyo Japan
| | - Masahito Kaji
- Trauma and Acute Critical Care Medical Center Tokyo Medical and Dental University Hospital of Medicine Tokyo Japan
| | - Yasuhiro Otomo
- Trauma and Acute Critical Care Medical Center Tokyo Medical and Dental University Hospital of Medicine Tokyo Japan
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11
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A Rare Case of Aortoenteric Graft Erosion Presenting as Candida glabrata Fungemia. Case Rep Vasc Med 2021; 2021:9002143. [PMID: 34824875 PMCID: PMC8610657 DOI: 10.1155/2021/9002143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 11/05/2021] [Indexed: 11/18/2022] Open
Abstract
Background An aortoenteric fistula (AEF) describes a communication of the aorta or aortic graft with an adjacent loop of the bowel. Aortic graft erosion is a rare complication of abdominal aortic aneurysm repair. We describe a case of a patient presenting with sepsis from Candida glabrata fungemia secondary to aortoenteric erosion without any symptoms or signs of gastrointestinal bleeding. This is a unique case of Candida glabrata fungemia from aortoenteric graft erosion. Case Summary. This patient is a 75-year-old male with a history of a prior aortobifemoral bypass graft in 2005. He presented with complaints of right paraspinal pain and chills. He had no symptoms of gastrointestinal bleeding or abdominal pain. His white blood cell count was 25,600/mcl (4,000–11,000/mcL) with left shift. The erythrocyte sedimentation rate was 11 mm/hr (0-38 mm/hr), and C-reactive protein was 95.5 mg/L (<=10.0 mg/L). Blood cultures were obtained and eventually grew Candida glabrata. A computed tomography angiogram (CTA) of abdomen and pelvis demonstrated inflammation surrounding the graft concerning for graft infection with additional inflammatory changes tracking down both femoral limbs. He underwent staged bilateral femoralaxillary bypass followed by the excision of aortobifemoral bypass. Conclusion Patients with aortoenteric erosion can present with sepsis in absence of gastrointestinal bleeding. Emergent computed tomography angiogram (CTA) of abdomen and pelvis should be performed to assess for aortic graft erosion or fistula. Empiric treatment with antibiotics should include antifungal agent like micafungin until the final culture is reported. The definite management is an extra anatomic bypass, followed by graft excision.
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12
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Wang DQ, Liu M, Fan WJ. Secondary aortoesophageal fistula initially presented with empyema after thoracic aortic stent grafting: A case report. World J Clin Cases 2021; 9:8938-8945. [PMID: 34734078 PMCID: PMC8546808 DOI: 10.12998/wjcc.v9.i29.8938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 07/07/2021] [Accepted: 09/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Massive upper gastrointestinal (GI) bleeding is usually urgent and severe, and is mostly caused by GI diseases. Aortoesophageal fistula (AEF) after thoracic aortic stent grafting is a rare cause of this condition, and has a poor prognosis with a high mortality rate. The clinical symptoms of AEF are usually nonspecific, and the diagnosis is often difficult, especially when upper GI bleeding is absent. Early identification, early diagnosis, and early treatment are very important for improving prognosis.
CASE SUMMARY A 74-year-old man was admitted to the infectious disease department with > 10-d fever and 10-mo prior history of thoracic aortic stent grafting for thoracic aortic penetrating ulcers. Blood tests revealed elevated inflammatory indicators and anemia. Chest computed tomography (CT) showed postoperative changes of the aorta after endovascular stent graft implantation, pulmonary infection and pleural effusion. Pleural effusion tests showed empyema. After 1 wk of anti-infective treatment, temperature returned to normal and chest CT indicated improvement in pulmonary infection and reduction of pleural effusion. Esophageal endoscopy was performed because of epigastric discomfort, and showed a large ulcer with blood clot in the middle esophagus. However, on day 11, hematemesis and melena developed suddenly. Bleeding stopped temporarily after hemostatic treatment and bedside endoscopic hemostasis. Thoracic and abdominal aortic CT angiography confirmed AEF. Later that day, he suffered massive hemorrhage and hemorrhagic shock. Eventually, his family elected to discontinue treatment.
CONCLUSION AEF should be strongly considered in patients with a history of aortic intervention who present with fever, especially with empyema.
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Affiliation(s)
- De-Qiong Wang
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Mei Liu
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
| | - Wen-Juan Fan
- Department of Gastroenterology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, Hubei Province, China
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13
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Surgical approach to recurrent secondary aortoenteric fistulas: A case report. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2021; 29:399-403. [PMID: 34589261 PMCID: PMC8462110 DOI: 10.5606/tgkdc.dergisi.2021.21518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 04/12/2021] [Indexed: 11/29/2022]
Abstract
The increasing number of abdominal aortic grafts due to abdominal aortic aneurysms has caused secondary aortoenteric fistulas to be seen more frequently as a cause of gastrointestinal bleeding. High index of suspicion plays a significant role in the diagnosis in patients having clinical symptoms ranging from fecal occult blood to massive gastrointestinal bleeding, accompanied by hemorrhagic shock. A 65-year-old male patient developed two secondary aortoenteric fistulas consecutively. The first one was aortic graft-jejunal and the second one was aortic graft-duodenal in a short period. Secondary aortoenteric fistula developed after aortobifemoral bypass. The patient underwent graft revision and jejunal repair. He was reoperated three months later due to the newly developed aortic graft-duodenal fistula. The duodenal defect was closed, and an extra-anatomic aortoiliac bypass was performed to avoid graft-related enteric fistula. The patient was discharged uneventfully and was free from any complication at nine months after surgery.
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14
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Islam S, Ramnarine M, Harnarayan P, Maughn A, Naraynsingh V. Local Repair of a Secondary Aortoenteric Fistula in an Unstable Patient in a Resource-Poor Setting: A Case Report and Literature Review. Cureus 2021; 13:e14291. [PMID: 33968505 PMCID: PMC8096706 DOI: 10.7759/cureus.14291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The presentation of a massive upper gastrointestinal bleed (UGIB) due to an aortoenteric fistula (AEF) is a rare occurrence. A high index of suspicion is required to rapidly make the diagnosis and execute prompt surgical management. Despite the many surgical options described, the survival rate continues to be low. Conventional surgical management is associated with a high morbidity and mortality. However, in emergencies, patients are unsuitable for major vascular surgery and may benefit from the less invasive staged procedure. This is a case report of a secondary aortoenteric fistula (SAEF) presenting as a massive UGIB, two years after an abdominal aortic aneurysm repair using a Dacron graft. Due to a lack of endovascular service in our setting, we proceeded with an upper gastrointestinal endoscopy followed by exploratory laparotomy. A damage control approach was chosen for our patient, i.e., local repair of the graft and aorta, as our patient was on double inotropes on the table. The patient died within 24 hours as a result of massive blood volume loss.
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Affiliation(s)
- Shariful Islam
- Department of General Surgery, San Fernando General Hospital, San Fernando, TTO.,Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, TTO
| | - Malini Ramnarine
- Department of General Surgery, San Fernando General Hospital, San Fernando, TTO
| | - Patrick Harnarayan
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, TTO.,Department of General Surgery, San Fernando General Hospital, San Fernando, TTO
| | - Anthony Maughn
- Department of General Surgery, San Fernando General Hospital, San Fernando, TTO
| | - Vijay Naraynsingh
- Department of Clinical Surgical Sciences, University of the West Indies, St. Augustine, TTO.,Surgery, Medical Associates Hospital, St. Joseph, TTO
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15
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Luo J, Tang W, Wang M, Xiao Y, Tan M, Jiang C. Case series of aortoenteric fistulas: a rare cause of gastrointestinal bleeding. BMC Gastroenterol 2021; 21:49. [PMID: 33530944 PMCID: PMC7856786 DOI: 10.1186/s12876-021-01629-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 01/26/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Aortoenteric fistula (AEF) is a rare cause of gastrointestinal bleeding and is often misdiagnosed in clinical practice. Herein, a case series of AEFs are presented and the clinical characteristics, diagnosis, and management strategies are summarized. METHODS A retrospective analysis was performed on consecutive hospitalized patients with a final diagnosis of AEF at Beijing Friendship Hospital, Capital Medical University, between January 1, 2007 and March 31, 2020. The clinical data including diagnostic and management procedures as well as outcomes were collected and summarized. RESULTS A total of nine patients were included in this study, five with primary AEF and four with secondary AEF. Eight of the patients were male, and the median age was 63 years. The fistulas were located in both the small intestine and the colon. All patients presented with gastrointestinal bleeding and pain, followed by weight loss, anorexia, and fever. A typical abdominal triad was found in only two cases. Seven patients experienced complications with preoperative abdominal infections and sepsis, and multiple organ failure occurred in four of these patients. All patients were assessed by computed tomography and five underwent abdominal and/or iliac aorta angiography. Two of these patients showed contrast agent leakage from the abdominal aorta into the intestine. Two cases were diagnosed with AEF by endoscopy before the operation. Eight patients received surgery and six patients survived. CONCLUSIONS AEF is a rare cause of gastrointestinal bleeding that is associated with high mortality. Gastrointestinal bleeding and pain are the most common presentations. Timely diagnosis and multidisciplinary management are crucial to achieve a positive outcome.
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Affiliation(s)
- Jia Luo
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong' an Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Wen Tang
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong' an Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Mengran Wang
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong' an Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Yao Xiao
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong' an Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Manhong Tan
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong' an Road, Xicheng District, Beijing, 100050, People's Republic of China
| | - Chunyan Jiang
- Department of Internal Medicine and Geriatrics, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong' an Road, Xicheng District, Beijing, 100050, People's Republic of China.
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16
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Farquharson BJ, Erete L, Morgan-Rowe L, Metcalfe M. Roles of endovascular aneurysm repair in management of secondary aorto-enteric fistulas. J Surg Case Rep 2021; 2020:rjaa520. [PMID: 33391649 PMCID: PMC7765711 DOI: 10.1093/jscr/rjaa520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/19/2020] [Indexed: 12/28/2022] Open
Abstract
Secondary aorto-enteric fistulas (AEFs) are an uncommon but serious complication of abdominal aortic aneurysm (AAA) repair. Case review of two cases of secondary AEF are as follows: the first case involved a 75-year- old male who presented with AEF 1 year post-emergency open AAA repair, successfully managed with endovascular aortic aneurysm repair (EVAR) without complication. The second case involved a 75-year-old male patient 14 months post open AAA repair for an inflammatory aneurysm who presented with an iliac-enteric fistula. The previous repair was relined with a bifurcated EVAR with subsequent laparotomy and resection of the affected portion of the small bowel. Both patients on lifelong antibiotics without further episodes of sepsis, recurrence of AEF or mortality at 12 months follow up. EVAR can be successful in the management of secondary AEF. Careful patient selection, accurate image interpretation, and expedient management are key factors to successful short- and long-term outcomes.
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Affiliation(s)
- Barnaby Jmc Farquharson
- Correspondence address. Lister Hospital, Stevenage, East and North Hertfordshire NHS Trust, 114D Stapleton Hall Road, London N4 4QA, UK. E-mail:
| | - Leanna Erete
- Lister Hospital, Stevenage, East and North Hertfordshire NHS Trust, London, UK
| | - Luke Morgan-Rowe
- Lister Hospital, Stevenage, East and North Hertfordshire NHS Trust, London, UK
| | - Matthew Metcalfe
- Lister Hospital, Stevenage, East and North Hertfordshire NHS Trust, London, UK
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17
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Yadav A, Shrestha UK, Shrestha KR, Gurung D. Thoracic aortic aneurysm causing aorto-esophageal fistula-our experience with a rare disease. J Surg Case Rep 2020; 2020:rjaa242. [PMID: 32728417 PMCID: PMC7378018 DOI: 10.1093/jscr/rjaa242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/14/2020] [Accepted: 06/22/2020] [Indexed: 12/15/2022] Open
Abstract
Aorto-esophageal fistula is a life-threatening condition, accounting for a small number of cases of upper gastrointestinal bleeding where patients present with one or more features of Chiari's triad. We present the case of a 43-year-old woman, referred to us with symptoms of central chest pain, sudden onset dysphagia followed by massive hemoptysis. She was diagnosed with an aorto-esophageal fistula due to a ruptured thoracic aortic aneurysm and rushed for an emergency endovascular thoracic aortic stent and feeding jejunostomy with intravenous antibiotics and supportive care. After 6 weeks of surgery, the patient was re-evaluated to plan for an esophageal stent if required. The purpose of this presentation is to make the surgical fraternity aware of the gravity of this disease and novel techniques to manage it.
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Affiliation(s)
- Aakriti Yadav
- Department of General Surgery, Tribhuvan University Teaching Hospital, Institute of Medicine, Kathmandu, Nepal
| | - Uttam Krishna Shrestha
- Department of Vascular Surgery, Manmohan Cardio Thoracic Vascular and Transplant Center, Institute of Medicine, Kathmandu, Nepal
| | - Kajan Raj Shrestha
- Department of Vascular Surgery, Manmohan Cardio Thoracic Vascular and Transplant Center, Institute of Medicine, Kathmandu, Nepal
| | - Dinesh Gurung
- Department of Vascular Surgery, Manmohan Cardio Thoracic Vascular and Transplant Center, Institute of Medicine, Kathmandu, Nepal
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18
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Bhatti S, Endashaw O, Short J. The Herald Bleed: A Case Report of an Aortoenteric Fistula causing an Acute Lower Gastrointestinal Bleed. Cureus 2020; 12:e6966. [PMID: 32190513 PMCID: PMC7067570 DOI: 10.7759/cureus.6966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Aortoenteric fistula (AEF) is a rare life-threatening condition. Secondary AEF (SAEF) occurs in patients with abdominal aortic aneurysm (AAA) repair and has a high mortality rate. We present a case of a 66-year-old female who presented to the emergency room with hematochezia and hemodynamic instability. Emergent esophagogastroduodenoscopy (EGD) was negative. Colonoscopy revealed a 5 cm, pulsatile, bleeding, submucosal mass. A stat computed tomography (CT) angiogram of the abdomen and pelvis revealed a large left external iliac artery (LEIA) pseudoaneurysm. Vascular surgery emergently placed a LEIA stent. It appeared the patient had an aorto-bi-iliac (ABI) common iliac artery (CIA) bypass, 15 years ago, for a large AAA that had resulted in a SAEF, with the rare finding of communication with the colon. She had a complicated course involving surgical and medical management but with successful outcomes.
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Affiliation(s)
- Sundus Bhatti
- Internal Medicine, University of Louisville School of Medicine, Louisville, USA
| | - Omer Endashaw
- Gastroenterology, University of Louisville, Louisville, USA
| | - Jacolby Short
- Radiology, University of Louisville, Louisville, USA
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19
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Saito H, Nishikawa Y, Akahira JI, Yamaoka H, Okuzono T, Sawano T, Tsubokura M, Yamaya K. Secondary aortoenteric fistula possibly associated with continuous physical stimulation: a case report and review of the literature. J Med Case Rep 2019; 13:61. [PMID: 30871625 PMCID: PMC6419421 DOI: 10.1186/s13256-019-2003-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/31/2019] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Secondary aortoenteric fistula is a rare but fatal complication after reconstructive surgery for an aortic aneurysm characterized by abdominal pain, fever, hematochezia, and hematemesis, and the mortality rate is high. It has been suggested that it arises due to either continuous physical stimulation or prosthesis infection during primary surgery. We describe an aortoenteric fistula following reconstructive surgery for an abdominal aortic aneurysm together with postmortem pathological findings. CASE PRESENTATION A 59-year-old Japanese man who had undergone reconstructive surgery for an abdominal aortic aneurysm 20 months earlier presented with the chief complaint of hematochezia and malaise. Esophagogastroduodenoscopy and total colonoscopy revealed only colon diverticula with no bleeding. Contrast-enhanced computed tomography revealed gas within the aneurysm sac and adhesion between the replaced aortic graft and intestinal tract, suggesting a graft infection. After 18 days of antibiotic treatment, he suddenly went into a state of shock, with massive fresh bloody stool and hematemesis, followed by cardiac arrest. An autopsy revealed communication between the artery and the ileum through an ulcerative fistula at the suture line between the left aortic graft branch and the left common iliac artery. Pathological analysis revealed tight adherence between the arterial and intestinal walls, but no marked sign of infection around the fistula, suggesting that the fistula had arisen due to physical stimuli. CONCLUSIONS Pathological analysis suggested that the present secondary aortoenteric fistula arose due to physical stimuli. This reaffirms the importance of keeping reconstructed aortas isolated from the intestine after abdominal aortic aneurysm surgery.
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Affiliation(s)
- Hiroaki Saito
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Miyagi Japan
| | - Yoshitaka Nishikawa
- Department of Internal Medicine, Hirata Central Hospital, Fukushima, Ishikawa Japan
- Department of Health Informatics, Kyoto University School of Public Health, Kyoto, Kyoto Japan
| | - Jun-ichi Akahira
- Department of Pathology, Sendai Kousei Hospital, Sendai, Miyagi Japan
| | - Hajime Yamaoka
- Sendai Gastrointestinal Endoscopy Clinic, Sendai, Miyagi Japan
| | - Toru Okuzono
- Department of Gastroenterology, Sendai Kousei Hospital, Sendai, Miyagi Japan
| | - Toyoaki Sawano
- Department of Surgery, Minamisoma Municipal General Hospital, Minamisoma, Fukushima Japan
- Department of Public Health, Fukushima Medical University School of Medicine, Fukushima, Fukushima Japan
| | - Masaharu Tsubokura
- Department of Public Health, Fukushima Medical University School of Medicine, Fukushima, Fukushima Japan
| | - Kazuhiro Yamaya
- Department of Cardiovascular Surgery, Sendai Kousei Hospital, Sendai, Miyagi Japan
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20
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Karhof S, van Roeden SE, Oosterheert JJ, Bleeker-Rovers CP, Renders NHM, de Borst GJ, Kampschreur LM, Hoepelman AIM, Koning OHJ, Wever PC. Primary and secondary arterial fistulas during chronic Q fever. J Vasc Surg 2019; 68:1906-1913.e1. [PMID: 29685511 DOI: 10.1016/j.jvs.2018.01.044] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 01/18/2018] [Indexed: 12/25/2022]
Abstract
OBJECTIVE After primary infection with Coxiella burnetii, patients may develop acute Q fever, which is a relatively mild disease. A small proportion of patients (1%-5%) develop chronic Q fever, which is accompanied by high mortality and can be manifested as infected arterial or aortic aneurysms or infected vascular prostheses. The disease can be complicated by arterial fistulas, which are often fatal if they are left untreated. We aimed to assess the cumulative incidence of arterial fistulas and mortality in patients with proven chronic Q fever. METHODS In a retrospective, observational study, the cumulative incidence of arterial fistulas (aortoenteric, aortobronchial, aortovenous, or arteriocutaneous) in patients with proven chronic Q fever (according to the Dutch Chronic Q Fever Consensus Group criteria) was assessed. Proven chronic Q fever with a vascular focus of infection was defined as a confirmed mycotic aneurysm or infected prosthesis on imaging studies or positive result of serum polymerase chain reaction for C. burnetii in the presence of an arterial aneurysm or vascular prosthesis. RESULTS Of 253 patients with proven chronic Q fever, 169 patients (67%) were diagnosed with a vascular focus of infection (42 of whom had a combined vascular focus and endocarditis). In total, 26 arterial fistulas were diagnosed in 25 patients (15% of patients with a vascular focus): aortoenteric (15), aortobronchial (2), aortocaval (4), and arteriocutaneous (5) fistulas (1 patient presented with both an aortocaval and an arteriocutaneous fistula). Chronic Q fever-related mortality was 60% for patients with and 21% for patients without arterial fistula (P < .0001). Primary fistulas accounted for 42% and secondary fistulas for 58%. Of patients who underwent surgical intervention for chronic Q fever-related fistula (n = 17), nine died of chronic Q fever-related causes (53%). Of patients who did not undergo any surgical intervention (n = 8), six died of chronic Q fever-related causes (75%). CONCLUSIONS The proportion of patients with proven chronic Q fever developing primary or secondary arterial fistulas is high; 15% of patients with a vascular focus of infection develop an arterial fistula. This observation suggests that C. burnetii, the causative agent of Q fever, plays a role in the development of fistulas in these patients. Chronic Q fever-related mortality in patients with arterial fistula is very high, in both patients who undergo surgical intervention and patients who do not.
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Affiliation(s)
- Steffi Karhof
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sonja E van Roeden
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands.
| | - Jan J Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Chantal P Bleeker-Rovers
- Division of Infectious Diseases, Department of Internal Medicine, Radboud University Medical Center and Radboud Expertise Center for Q Fever, Nijmegen, The Netherlands
| | - Nicole H M Renders
- Department of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Gert J de Borst
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda M Kampschreur
- Department of Internal Medicine and Infectious Diseases, Medical Center Leeuwarden, Leeuwarden, The Netherlands
| | - Andy I M Hoepelman
- Department of Internal Medicine and Infectious Diseases, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Olivier H J Koning
- Department of Surgery, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Peter C Wever
- Department of Medical Microbiology and Infection Control, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
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21
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Lirici MM, Tierno SM, Giudice R, Coscarella C, Graziani MG, Pogany G. Secondary aortoenteric fistula successfully treated with staged endovascular repair and duodenal resection without graft removal. MINIM INVASIV THER 2019; 29:114-119. [PMID: 30848980 DOI: 10.1080/13645706.2019.1581623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Secondary aorto-enteric fistulae (SAEF) are rare life-threatening complications that occur after abdominal aortic graft implant to treat aortic aneurysm or occlusive disease. Conventional treatments such as extra-anatomic bypass grafting with aortic ligation and subsequent graft removal with bowel repair are associated with a 25% to 90% operative mortality rate. In the emergency setting, patients unsuitable for major arterial surgery may benefit from a staged, less invasive approach. We present a case of SAEF treated with endoluminal deployment of a stent graft followed by duodenojejunal resection and anastomosis without further aortic reconstruction and graft removal.
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Affiliation(s)
- Marco Maria Lirici
- Department of General Surgery, San Giovanni Hospital Complex, Rome, Italy
| | | | - Rocco Giudice
- Department of Vascular Surgery, San Giovanni Hospital Complex, Rome, Italy
| | - Carlo Coscarella
- Department of Vascular Surgery, San Giovanni Hospital Complex, Rome, Italy
| | | | - Gabriele Pogany
- Department of Vascular Surgery, San Giovanni Hospital Complex, Rome, Italy
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22
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Wanhainen A, Verzini F, Van Herzeele I, Allaire E, Bown M, Cohnert T, Dick F, van Herwaarden J, Karkos C, Koelemay M, Kölbel T, Loftus I, Mani K, Melissano G, Powell J, Szeberin Z, ESVS Guidelines Committee, de Borst GJ, Chakfe N, Debus S, Hinchliffe R, Kakkos S, Koncar I, Kolh P, Lindholt JS, de Vega M, Vermassen F, Document reviewers, Björck M, Cheng S, Dalman R, Davidovic L, Donas K, Earnshaw J, Eckstein HH, Golledge J, Haulon S, Mastracci T, Naylor R, Ricco JB, Verhagen H. Editor's Choice – European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms. Eur J Vasc Endovasc Surg 2019; 57:8-93. [DOI: 10.1016/j.ejvs.2018.09.020] [Citation(s) in RCA: 1724] [Impact Index Per Article: 287.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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23
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Köklü H, Dinçer A, Kumbasar U, Doğrul AB, Purnak T. An unusual cause of gastrointestinal bleeding in an elderly patient. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 29:610-612. [PMID: 30260785 DOI: 10.5152/tjg.2018.18264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Hayretdin Köklü
- Division of Gastroenterology, Department of Internal Medicine, Hacettepe
| | - Anıl Dinçer
- Department of General Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ulaş Kumbasar
- Department of Cardiovasculer Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Ahmet Bülent Doğrul
- Department of General Surgery, Hacettepe University School of Medicine, Ankara, Turkey
| | - Tuğrul Purnak
- Division of Gastroenterology, Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
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24
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Jiang C, Chen X, Li J, Li H. A case report of successful treatment of secondary aortoenteric fistula complicated with gastrointestinal bleeding and retroperitoneal abscess in an elderly patient. Medicine (Baltimore) 2018; 97:e11055. [PMID: 29901606 PMCID: PMC6024772 DOI: 10.1097/md.0000000000011055] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
RATIONALE The treatment of secondary aortoenteric fistula (SAEF) involves maintaining hemodynamic stability, infection control, revascularization, and surgical repair. Conventional open repair is associated with high mortality, whereas endovascular stent-graft repair is associated with recurrent infection or bleeding. PATIENT CONCERNS We report the case of an 85-year-old man with SAEF who presented with gastrointestinal bleeding and retroperitoneal abscess. DIAGNOSES He was misdiagnosed for 5 months. SAEF was eventually diagnosed by CT and gastroduodenoscopy. INTERVENTIONS The patient underwent hybrid open surgery: extraanatomic left axillofemoral bypass graft reconstruction, exploratory laparotomy, aortic stent graft excision, infrarenal abdominal aortic suture, left common iliac artery ligation, extensive surgical debridement, and retroperitoneal abscess resolution and drainage, along with duodenal defect repair and jejunal feeding tube placement. OUTCOMES He survived the complicated surgery and several life-threatening complications with multidisciplinary management. He has kept well for 15 months. LESSONS Elderly SAEF patients can undergo open repair when circumstances permit, but multidisciplinary management is crucial.
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Affiliation(s)
| | | | - Jianshe Li
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, P. R. China
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25
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Yamazato T, Nakamura T, Abe N, Yokawa K, Ikeno Y, Koda Y, Henmi S, Nakai H, Gotake Y, Matsueda T, Inoue T, Tanaka H, Kakeji Y, Okita Y. Surgical strategy for the treatment of aortoesophageal fistula. J Thorac Cardiovasc Surg 2018; 155:32-40. [DOI: 10.1016/j.jtcvs.2017.09.047] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 08/24/2017] [Accepted: 09/09/2017] [Indexed: 02/08/2023]
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26
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Cohen N, Lyons R, Weireter L. Internal Iliac- Enteric Fistula: A Rare Cause of Hemorrhagic Shock. Am Surg 2017. [DOI: 10.1177/000313481708300812] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nina Cohen
- Department of Surgery Eastern Virginia Medical School Norfolk, Virginia
| | - Robert Lyons
- Department of Surgery Eastern Virginia Medical School Norfolk, Virginia
| | - Leonard Weireter
- Department of Surgery Eastern Virginia Medical School Norfolk, Virginia
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27
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Bondurri A, Zampino L. A rare but life-threatening complication of aortic surgery: iliac appendiceal fistula. Eur Surg 2017. [DOI: 10.1007/s10353-017-0486-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Kulikovsky VF, Shevtsov YN, Karpachev AA, Soloshenko AV, Yarosh AL, Lopin AV, Mukhachev DL, Kas'yanov BV. [Gastrointestinal bleeding caused by false symptomatic infrarenal abdominal aortic aneurysm]. Khirurgiia (Mosk) 2017:102-103. [PMID: 28374721 DOI: 10.17116/hirurgia20173102-103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- V F Kulikovsky
- Belgorod State National University, Saint Joasaph Belgorod Regional Hospital
| | - Yu N Shevtsov
- Belgorod State National University, Saint Joasaph Belgorod Regional Hospital
| | - A A Karpachev
- Belgorod State National University, Saint Joasaph Belgorod Regional Hospital
| | - A V Soloshenko
- Belgorod State National University, Saint Joasaph Belgorod Regional Hospital
| | - A L Yarosh
- Belgorod State National University, Saint Joasaph Belgorod Regional Hospital
| | - A V Lopin
- Belgorod State National University, Saint Joasaph Belgorod Regional Hospital
| | - D L Mukhachev
- Belgorod State National University, Saint Joasaph Belgorod Regional Hospital
| | - B V Kas'yanov
- Belgorod State National University, Saint Joasaph Belgorod Regional Hospital
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Schappert A, Thompson D, Coome G, Hussain N. Elderly Man with Syncope. Ann Emerg Med 2016; 69:e3-e4. [PMID: 27993311 DOI: 10.1016/j.annemergmed.2016.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Andrew Schappert
- Department of Medicine, Division of Emergency Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada; Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Drew Thompson
- Department of Medicine, Division of Emergency Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada; Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Grant Coome
- Department of Medicine, Division of Emergency Medicine, Western University, London Health Sciences Centre, London, Ontario, Canada; Western University, London Health Sciences Centre, London, Ontario, Canada
| | - Nadeem Hussain
- Division of Gastroenterology, Western University, London Health Sciences Centre, London, Ontario, Canada; Department of Medicine, Division of Gastroenterology, Western University, St. Joseph's Health Care, London, Ontario, Canada
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Nazarewicz GV, Jain R. Upper Gastrointestinal Bleeding Caused by Aortoesophageal Fistula. Clin Gastroenterol Hepatol 2016; 14:A22. [PMID: 27546580 DOI: 10.1016/j.cgh.2016.08.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 08/13/2016] [Indexed: 02/07/2023]
Affiliation(s)
| | - Rajeev Jain
- Department of Medicine, Texas Health Dallas, Dallas, Texas; Texas Digestive Disease Consultants, Dallas, Texas
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Antunes AG, Peixe B, Guerreiro H. Fever and haematochezia: an unusual association. BMJ Case Rep 2016; 2016:bcr-2016-216655. [PMID: 27481263 DOI: 10.1136/bcr-2016-216655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Artur Gião Antunes
- Gastroenterology Department, Centro Hospitalar do Algarve, Faro, Portugal
| | - Bruno Peixe
- Gastroenterology Department, Centro Hospitalar do Algarve, Faro, Portugal
| | - Horácio Guerreiro
- Gastroenterology Department, Centro Hospitalar do Algarve, Faro, Portugal
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Efficacy of endoscopic management of leak after foregut surgery with endoscopic covered self-expanding metal stents (SEMS). Surg Endosc 2016; 31:612-617. [PMID: 27317034 DOI: 10.1007/s00464-016-5005-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Accepted: 05/23/2016] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Anastomotic or staple-line leak after foregut surgery presents a formidable management challenge. In recent years, with advancement of endoscopy, self-expanding covered stents have been gaining popularity. In this study, we aimed to determine the safety and effectiveness of self-expanding covered stents in management of leak after foregut surgery. METHODS Consecutive patients who received a fully covered self-expandable metal stent (SEMS) due to an anastomotic leak after upper gastrointestinal surgery between 2009 and 2014 were retrospectively reviewed. Demographic data, stent placement and removal, clinical success, time to resolution, and complications were collected. Predictive factors for clinical success rate were assessed. RESULTS A total of 20 consecutive patients underwent placement of fully covered SEMS for anastomotic leak, following esophagectomy (n = 5), esophageal diverticulectomy (n = 1), gastric sleeve (n = 4), gastric bypass (n = 3), partial gastrectomy (n = 4), and total gastrectomy (n = 3). All the stents were removed successfully, and clinical resolution was achieved in 18 patients (90 %) after a median of two (range 1-3) procedures and a mean of 6.2 weeks (range 0.4-14). Complications presented in 12 patients (60 %), including stent migration (n = 8), mucosal friability (n = 4), tissue integration (n = 2), and bleeding (n = 2). Two (10 %) patients' treatment was complicated by aorto-esophageal fistula formation resulting in one death. Demographic factors, comorbidities, and type of surgery were not predictive of clinical success rate or time to resolution. CONCLUSION SEMS are effective tools for the management of leaks after foregut surgery. The biggest challenge with this approach is stent migration. Caution is warranted due to the risk of fatal complications such as aorto-esophageal fistula formation. No type of surgery or particular patient factor, including age, sex, BMI, albumin, history of radiation, malignancy, and comorbid diabetes or coronary artery disease, appeared to be correlated with success rate. Larger studies are needed to determine factors predictive of clinical success.
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