Surgical treatment of aorto-enteric fistulas.

BACKGROUND: Our series of secondary aorto prosthetic fistulas (PEF) to identify if and how different surgical treatment affect outcome is reviewed.

METHODS: Between 1982 and December 1999, in the authors department, 42 patients were investigated for a secondary PEF. Mean age was 65 years: the mean time interval since the primitive aortic procedure was 49 months. Twenty patients were treated in emergency surgery: 29 presented evidence of gastrointestinal bleeding. The preoperative work-up included esophagogastroduodenoscopy, CT scan, and aortography. The vast majority of PEF were in a duodenal location. Surgical procedure carried out was graft excision, bowel suture or bowel resection, aortic stump closure and axillofemoral (AXF) bypass (11), new in situ revascularization by synthetic prosthesis (5), simple suture (9), graft excision without revascularization (1), in situ revascularization using arterial homograft (13).

RESULTS: The mean surgery duration was 4 hours and 53 minutes, the mean blood loss was 1845+/-1132. Two patients died shortly after proximal aortic control was obtained. Early overall mortality was 50%, the early overall bypass occlusion rate was 12.5%, the early overall amputation rate was 10%, and the early new PEF rate was 12.5%. Late overall mortality was 22.5%, the late overall bypass occlusion rate was 20%, the late overall amputation rate was 7.5%, and the late new PEF rate was 10%.

CONCLUSIONS: Bleeding of the gastrointestinal tract in patients with a history of intra-abdominal reconstructive vascular surgery must raise severe suspicion as to the certainty of existence of a PEF unless the diagnostic procedure excludes this possibility. All treatment methods resulted in catastrophic failure, related to recurrent PEF or septic complication. Perhaps, in the presence of PEF extra-anatomical bypass associated with aortic ligature remains an interesting surgical solution.