Howard Ryan, Kurz Sarah, Sherman Matthew A, Underhill Joshua, Eliason Jonathan L, Coleman Dawn M
Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
Ann Vasc Surg. 2015 Nov;29(8):1614-8. doi: 10.1016/j.avsg.2015.06.090. Epub 2015 Aug 28.
Secondary aortoduodenal fistula (SADF) is a rare, life-threatening complication of abdominal aortic reconstruction. Clinical presentation varies and treatment requires complex surgical repair associated with considerable morbidity and mortality. This retrospective study examines the contemporary management of SADF at a tertiary vascular surgical practice.
Thirteen patients were managed for SADF between 2004 and 2014. Vascular and duodenal reconstructions were considered. Primary end points included bile leak, major complications, and mortality.
Of the 13 patients presenting with SADF, 6 presented with luminal blood loss. During mean follow-up (632 days), the rate of major complication was 77%. Overall, 38% developed duodenal leak. All leaks occurred after graft explantation with extra-anatomic bypass, and the majority of these patients (80%) had no preceding history of acute gastrointestinal (GI) bleed. There were no leaks identified after duodenal exclusion with gastrojejunostomy. Patients that developed duodenal leak had longer mean intensive care unit length of stay (LOS; 7.0 vs. 2.3 days, P = 0.004), longer mean overall hospital LOS (36.6 vs. 18.5 days, P = 0.012), and greater late mortality (40% vs. 13%). There were 2 SADF-related deaths. Overall mortality trended higher in females (67% vs. 20%, P = 0.125) and those that presented without acute GI bleed (43% vs. 17%, P = 0.308).
Surgical reconstruction for SADF results in major morbidity. Those presenting with acute GI bleed trended toward better outcomes than those without. Duodenal leak remains a serious complication. Duodenal exclusion may represent a more appropriate and conservative approach for management of the duodenal defect in select patients.
继发性主动脉十二指肠瘘（SADF）是腹主动脉重建术后一种罕见的、危及生命的并发症。临床表现各异，治疗需要复杂的手术修复，且伴有较高的发病率和死亡率。本回顾性研究探讨了在一家三级血管外科中心对SADF的当代治疗方法。
2004年至2014年间，对13例SADF患者进行了治疗。考虑进行血管和十二指肠重建。主要终点包括胆漏、主要并发症和死亡率。
13例SADF患者中，6例出现腔内失血。在平均随访期（632天）内，主要并发症发生率为77%。总体而言，38%的患者发生十二指肠漏。所有漏均发生在解剖外旁路移植术后移植物取出后，且这些患者中的大多数（80%）既往无急性胃肠道（GI）出血史。胃空肠吻合术十二指肠旷置术后未发现漏。发生十二指肠漏的患者平均重症监护病房住院时间更长（7.0天对2.3天，P = 0.004），平均总住院时间更长（36.6天对18.5天，P = 0.012），晚期死亡率更高（40%对13%）。有2例与SADF相关的死亡。总体死亡率在女性（67%对20%，P = 0.125）和无急性GI出血的患者中（43%对17%，P = 0.308）有升高趋势。
SADF的手术重建会导致严重的发病率。有急性GI出血的患者预后比无急性GI出血的患者更好。十二指肠漏仍然是一种严重的并发症。对于部分患者，十二指肠旷置可能是处理十二指肠缺损更合适、更保守的方法。
