title: Contemporary Management of Secondary Aortoduodenal Fistula.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors: Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
authors: Ryan
authors: R
authors: Howard
authors: Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
authors: Sarah
authors: S
authors: Kurz
authors: Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
authors: Matthew A
authors: MA
authors: Sherman
authors: Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
authors: Joshua
authors: J
authors: Underhill
authors: Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI.
authors: Jonathan L
authors: JL
authors: Eliason
authors: Section of Vascular Surgery, University of Michigan Cardiovascular Center, Ann Arbor, MI. Electronic address: dawnbarn@umich.edu.
authors: Dawn M
authors: DM
authors: Coleman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects*; D004378:Duodenal Diseases / Q000175:diagnosis / Q000209:etiology* / Q000601:surgery*; D005260:Female; D015390:Gastric Bypass; D006801:Humans; D007412:Intestinal Fistula / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016896:Treatment Outcome; D016157:Vascular Fistula / Q000175:diagnosis / Q000209:etiology / Q000601:surgery*