Enteric repair in aortoduodenal fistulas: a forgotten but often lethal player.
BACKGROUND
An aortoenteric fistula is an abnormal communication between the aorta and the bowel lumen. It is usually caused by previous aortic surgery and involves the duodenum (ADF) in most cases. The treatment of this high-mortality condition is based on the correction of enteric and vascular defects. However, enteric repair indications and impact are unknown.


OBJECTIVE
We sought to characterize the surgical procedures available for duodenal repair in ADF and estimate their impact in mortality.


METHODS
A literature search was conducted, between the years 1951-2010. Cases (791 from 614 references) were individually registered and analyzed to demography, enteric location, type and cause of fistula, type of surgical procedure, mortality, and cause of death. Risk factors to outcome were estimated by univariate and multivariate analysis.


RESULTS
The enteric procedure was described in 331 cases: duodenorrhaphy (with or without omentum interposition; with or without enterostomy) in 266 cases, duodenal resection/reconstruction in 54 cases, antibiotic or abdominal drainage alone in 4 cases, and nothing was done in 7 cases. Vascular treatment was described in 515 cases: extra-anatomic bypass in 207 cases, in situ graft in 197 cases, direct closure of the aortic defect in 52 cases, endovascular procedures in 32 cases, and others arterial reconstructions in 27 cases. Univariate analysis revealed that mortality caused by ADF is directly associated with primary ADF type, direct closure of the aortic defect, and is inversely associated with recent publications, omentum interposition, use of an in situ graft, and endovascular prosthesis. Multivariate analysis revealed that omentum interposition and the use of an in situ graft were independent factors to the outcome, and that omentum use was the strongest factor related to survival. The most common cause of death was ADF recurrence (41.8%), which was significantly high (P = 0.036) in the patients who underwent simple duodenorrhaphy.


CONCLUSIONS
The literature supports the use of omentum interposition and suggests that duodenal derivation is preferable to the simple closure of fistula. Delayed or avoided enteric repair after endovascular treatment emerged as an option, but needs additional supporting research.
Department of Surgical Oncology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal; Faculdade de Medicina de Lisboa, Lisbon, Portugal. Electronic address: cgfonseca@ipolisboa.min-saude.pt.
Catarina
C
Rodrigues dos Santos
Department of Surgical Oncology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal; Faculdade de Medicina de Lisboa, Lisbon, Portugal.
Rui
R
Casaca
Department of Surgical Oncology, Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal; Faculdade de Medicina de Lisboa, Lisbon, Portugal.
José Crespo
JC
Mendes de Almeida
Department of Vascular Surgery, Centro Hospitalar Lisboa Norte, Lisbon, Portugal; Faculdade de Medicina de Lisboa, Lisbon, Portugal.
Luis
L
Mendes-Pedro
D001018:Aortic Diseases / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D013505:Digestive System Surgical Procedures / Q000009:adverse effects / Q000401:mortality; D004378:Duodenal Diseases / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007412:Intestinal Fistula / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D015999:Multivariate Analysis; D016017:Odds Ratio; D012008:Recurrence; D012307:Risk Factors; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D014656:Vascular Surgical Procedures / Q000009:adverse effects / Q000401:mortality