原位重建治疗移植物主动脉肠瘘和侵蚀的辅助方法。

Adjuncts to the Management of Graft Aorto-Enteric Erosion and Fistula with in situ Reconstruction.

机构信息

Vascular and General Surgery Department, Bordeaux University Hospital, Bordeaux, France.

Infectious Disease Department, Bordeaux University Hospital, Bordeaux, France.

出版信息

Eur J Vasc Endovasc Surg. 2021 Nov;62(5):786-795. doi: 10.1016/j.ejvs.2021.06.018. Epub 2021 Nov 1.

DOI:10.1016/j.ejvs.2021.06.018

PMID:34736846

Abstract

OBJECTIVE

The objective of this retrospective single centre study was to determine whether different enteric reconstruction methods and adjuncts confer a benefit after in situ reconstructions (ISRs) of graft aorto-enteric erosion (AEnE) and fistula (AEnF).

METHODS

Primary endpoints were in hospital mortality and AEnE/F recurrence. Survival was estimated using the Kaplan-Meier method and explanatory factors were searched for using uni- ± multivariable Cox regression analysis. In 2013, a multidisciplinary team meeting was convened and since then the primary operator has always been a senior surgeon.

RESULTS

Sixty-six patients were treated for AEnE (n = 38) and AEnF (n = 28, 42%) from 2004 to 2020. All patients with AEnF presented with gastrointestinal bleeding (vs. 0 for AEnE; p < .001). Signs of infection were seen in 50 patients (76% [37 for AEnE vs. 13 for AEnF]; p < .001). Referrals for endograft infection increased over time (n = 15, 23%; one before 2013 vs. 14 after; p = .002). Most patients underwent complete graft excision (n = 52, 79%) with increasing suprarenal cross clamping (n = 21, 32%; four before 2013 vs. 17 after; p = .015). Complex visceral reconstructions decreased over time (n = 31, 47%; 17 before 2013 vs. 14 after; p = .055), while "open abdomens" (OAs) increased (one before 2013 vs. 22 after; p < .001), reducing operating time (p = .012). In hospital mortality reached 42% (n = 28). Estimated survival reached 47.6% (95% confidence interval [CI] 35.0 - 59.1) at one year and 45.6% (95% CI 33.0 - 57.3) at three years and was higher for AEnE than for AEnF (log rank p = .029). AEnE/F recurrence was noted in 12 patients (18%). Older age predicted in hospital mortality in multivariable analysis (p = .034). AEnE/F recurrence decreased with the presence of a primary senior surgeon (vs. junior; p = .003) and OA (1 [4.4%] vs. 11 [26%] for primary fascial closure; p = .045) in univariable analysis.

CONCLUSION

Mortality and recurrence rates remain high after ISR of AEnE/F. Older age predicted in hospital mortality. Primary closure of enteric defects ≤ 2 cm in diameter reduced operating time without increasing the recurrence of AEnF.

摘要

目的

本回顾性单中心研究的目的是确定不同的肠重建方法和辅助手段是否能在原位重建（ISR）移植物肠-主动脉侵蚀（AEnE）和瘘（AEnF）后获益。

方法

主要终点为住院死亡率和 AEnE/F 复发。使用 Kaplan-Meier 法估计生存率，并使用单变量和多变量 Cox 回归分析寻找解释因素。2013 年，召集了一个多学科团队会议，自那时以来，主要手术医生一直是一名资深外科医生。

结果

2004 年至 2020 年，66 例患者因 AEnE（n=38）和 AEnF（n=28，42%）接受治疗。所有 AEnF 患者均有胃肠道出血（AEnE 为 0；p<0.001）。50 例患者有感染迹象（76%[37 例 AEnE 与 13 例 AEnF]；p<0.001）。用于内植物感染的转诊呈上升趋势（n=15，23%；2013 年之前 1 例，之后 14 例；p=0.002）。大多数患者行全移植物切除（n=52，79%），并增加了肾上极交叉夹闭（n=21，32%；2013 年之前 4 例，之后 17 例；p=0.015）。随着时间的推移，复杂的内脏重建减少（n=31，47%；2013 年之前 17 例，之后 14 例；p=0.055），而“开放腹部”（OA）增加（2013 年之前 1 例，之后 22 例；p<0.001），从而缩短了手术时间（p=0.012）。住院死亡率达到 42%（n=28）。估计的生存率在一年时达到 47.6%（95%置信区间[CI]35.0-59.1），在三年时达到 45.6%（95%CI33.0-57.3），AEnE 高于 AEnF（对数秩检验 p=0.029）。12 例（18%）患者出现 AEnE/F 复发。多变量分析显示，年龄较大预测住院死亡率（p=0.034）。单变量分析显示，初级主治外科医生（与初级外科医生相比；p=0.003）和 OA（初级筋膜闭合为 1[4.4%]，而初级筋膜闭合为 11[26%]；p=0.045）的存在降低了 AEnE/F 的复发率。