title: Staged surgery for chronic primary aortoduodenal fistula in a septic patient.
abstract: Aortoenteric fistula is one of the most challenging problems that confront the vascular surgeons. Controversy remains over the optimal treatment because of the continued publication of series with high mortality, amputation, and aortic disruption rates. A positive preoperative blood culture is the best predictor of mortality with increased amputation rates due to infection of the extra-anatomic bypass. Therefore, in selected cases with sepsis, a prudent management protocol is required. We report a 68-yr-old male presenting with a chronic primary aortoduodenal fistula extensively involving the duodenum and Gram-negative sepsis. We planned a staged operation. Initially, an emergency laparotomy and control of the aorta allowed stabilization of the patient, identification of the fistula, and direct in situ placement of the prosthetic graft followed by an en bloc resection of the aneurysm and the surrounding structures. After he recovered from sepsis and had been stabilized, a staged extra-anatomic bypass followed by transabdominal removal of the temporarily placed graft was done. This management plan will allow the highest success rate and may be a prudent management protocol for these difficult cases.
authors.affiliation: Department of Surgery, University of Ulsan College of Medicine, Gangneung Asan Hospital, Gangneung, Korea. ypcho@gnah.co.kr
authors.forename: Yong Pil
authors.initials: YP
authors.lastname: Cho
authors.forename: Gil Hyun
authors.initials: GH
authors.lastname: Kang
authors.forename: Myoung Sik
authors.initials: MS
authors.lastname: Han
authors.forename: Hyuk Jai
authors.initials: HJ
authors.lastname: Jang
authors.forename: Yong Ho
authors.initials: YH
authors.lastname: Kim
authors.forename: Je-ho
authors.initials: JH
authors.lastname: Ryu
authors.forename: Chang Kyun
authors.initials: CK
authors.lastname: Park
authors.forename: Sung Gyu
authors.initials: SG
authors.lastname: Lee
mesh_terms: D000368:Aged; D017544:Aortic Aneurysm, Abdominal / Q000150:complications / Q000473:pathology* / Q000601:surgery*; D002908:Chronic Disease; D013505:Digestive System Surgical Procedures; D004386:Duodenum / Q000473:pathology; D006801:Humans; D007412:Intestinal Fistula / Q000150:complications / Q000473:pathology* / Q000601:surgery*; D008297:Male; D018805:Sepsis / Q000150:complications*; D014057:Tomography, X-Ray Computed