The management of aortoenteric and paraprosthetic fistulae

Aortoenteric and aortic paraprosthetic fistulae are devastating complications. Most authors recommend total excision of the graft and revascularization of the lower extremities by extra-anatomic bypass. We reviewed the University of Pittsburgh experience with these fistulae in 15 patients between 1977 and 1987. There were 9 aortoenteric fistulae (AEF) and 6 paraprosthetic fistulae (PPF). Seven of the 9 AEF had no abscess surrounding the graft, but communication of the intestine with the aortic anastomosis. One patient died during operation. Six patients underwent a local repair or in situ replacement of the graft. All 6 of those patients survived operation without limb loss. Two of the 9 patients with AEF had evidence of graft infection and underwent total excision of the graft and extra-anatomic reconstruction. Both patients died, one of sepsis and one of aortic stump rupture. All 6 patients with PPF had clinical and operative evidence of overt graft infection and underwent total graft excision and extra-anatomic bypass. Two of these patients died secondary to sepsis. We conclude that AEF, without evidence of graft infection, were safely treated by local repair. Patients with PPF had infected grafts requiring graft removal with significant morbidity and mortality.     

Primary aortoenteric fistulae: the challenges in diagnosis and review of treatment

Primary aortoenteric fistula (PAEF) is a potentially fatal condition which poses a considerable diagnostic challenge because of its infrequency and the nonspecific presentation. We report the case of a 61-year old woman who presented to her general practitioner with nonspecific and intermittent rectal bleeding, hematemesis, and weight loss. Four days later, she presented to the emergency department with worsening symptoms. The investigations revealed a new small 3.8-cm abdominal aortic aneurysm on computed axial tomography (CT), however, no evidence of a fistula was observed either on CT scan or endoscopy. Two days later, she became unstable requiring an emergency laparotomy and was taken to the operation theater for an en bloc resection of a segment of the aorta and duodenum with exclusion of the duodenum with an inline reconstruction of the aorta using a Dacron graft for a PAEF. The published data were reviewed to address the issues of optimal diagnostic methods and management of PAEF.     

Lessons learnt from the 4D trial

Renal dysfunction alters the pathogenesis of cardiovascular disease (CVD) profoundly conferring a very high-risk to the patients. Currently strategies are developed to combat CVD and clinical studies test a number of hypothesis. In this setting the results of the 4D study, comparing atorvastatin with placebo on cardiovascular outcomes in 1255 type 2 diabetic patients on maintenance hemodialysis, came as a great and unsuspected surprise. After a median follow-up of 4 years atorvastatin (20 mg/d) decreased the relative risk by 8% (95% confidence interval, 0.77-1.10; P=0.37) despite a high number of cardiovascular events and an overall 24% cardiovascular mortality. This indicates, that the risk in type 2 diabetic patients on hemodialysis origins from factors other than an atherogenic lipoprotein phenotype alone. Due to non-significant effects of atorvastatin on the primary endpoint and the different quality of such endpoints in dialysis patients as well as an unexplained higher rate of fatal strokes in atorvastatin treated patients we do not recommend to initiate statin treatment in patients with type 2 diabetes mellitus undergoing hemodialysis therapy at the present time. Statin therapy should be implemented earlier during the course of progressive vascular damage.     

Diagnostic lessons learnt from a series of enterovesical fistulae

Objective An enterovesical fistula (EVF) is an uncommon condition requiring careful and sometimes extensive preoperative investigation. Our experience over a 10‐year period has been reviewed with emphasis on the diagnostic investigations performed. Patients and method Forty‐two patients (30 male) have been studied. Presenting symptoms, diagnostic investigations, and subsequent treatment have been reviewed. Results The site of the fistulae were; 37 colonic, 2 rectal, and 3 ileal. The commonest presenting symptoms were; pneumaturia 75%, faecaluria 63% and urinary tract infections 57%. The positivity rate of the investigations performed were; cystoscopy 89%, urine cytology 86%, barium enema 65%, computerized tomography (CT) scanning 55%, IVP 35%, and cystography 27.5%. The causes of the fistula were; diverticular disease 71%, carcinoma 20%, Crohn's disease 7%, and radiotherapy 2%. Conclusions We recommend cystoscopy and urine cytology for faecal material as the first‐line investigations in all patients with a suspected enterovesical fistulae. CT scanning and barium enema should not be first line investigations but may be performed subsequently to help determine the aetiology and planning of surgery.     

Lessons learnt from carotid artery trials

The objective of the authors is to assess the natural history of carotid artery disease and the role of carotid intervention in preventing ipsilateral stroke. The development of endovascular techniques for correction of carotid artery stenoses made this less invasive technique very popular, with an inherent risk of unregulated overuse by a variety of medical specialists, who are not always well informed on the natural history of carotid artery disease. It re-opened the discussion on the value of carotid endarterectomy for stroke prophylaxis. This ongoing debate offers the opportunity to distil evidence-based guidelines for the management of extracranial carotid artery stenoses. In recent papers, some authors expressed doubts on the validity and general applicability of the results of the pivotal randomised trials of carotid endarterectomy. The excellent results in terms of operative outcome and long term stroke prevention would, according to certain comments, not be attainable in routine practice. Another criticism of carotid endarterectomy is its higher operative morbidity in terms of cranial nerve lesions and myocardial infarctions, compared to endovascular procedures. This consideration is, for some authors, the main reason to espouse carotid artery stenting as a better alternative to carotid endarterectomy. Any evidence supporting this point of view is missing. The supposed equivalence or non-inferiority of carotid artery stenting is purely speculative. The aim of this review paper is to summarize the crude data of carotid surgery trials. The authors aim to answer four questions. For which lesions is carotid endarterectomy most beneficial ? Are the results of randomised carotid surgery trials biased by the selection of patients ? Is operative morbidity, other than stroke, under-estimated ? Is carotid artery stenting safe and efficacious ? An in-depth review with a critical analysis is made of recently published and on-going trials, comparing carotid surgery with percutaneous carotid angioplasty.     

Improvements in the diagnosis and management of aortoenteric fistula

To assess the impact of an aggressive approach (early operation, graft removal, and extraanatomic bypass) adopted by us 5 years ago in patients with aortic synthetic grafts and gastrointestinal bleeding, we reviewed our 15 year experience with aortoenteric fistula in 13 patients. The courses of six patients from the recent series (1979 through 1984) were contrasted with those of seven patients from our earlier series (1968 through 1978). Twelve of 13 patients presented with gastrointestinal bleeding (usually low volume), and no patient presented in shock. Six of seven patients in Series I (earlier series) had positive blood cultures, whereas only two of six in Series II (recent series) had this finding. Of the 13 patients, 10 underwent preoperative endoscopy. It was only with consistent visualization of third and fourth portions of the duodenum that a diagnosis of aortoenteric fistula was established (three of four patients 75 percent). Although the upper gastrointestinal series was abnormal more frequently (five of seven patients, 71 percent) than arteriograms (three of nine patients, 33 percent), the latter was more specific for a predisposing lesion. At surgery, nine (70 percent) patients had an anastomotic fistula and four (30 percent), a false aneurysm. Although only one of seven patients in Series I survived (14 percent), four of six patients in Series II were alive at last follow-up in September 1984 (67 percent). Early diagnosis followed by prompt operation with removal of the synthetic graft and extraanatomic bypass is associated with an improved survival for patients with aortoenteric fistula, but the degree of preoperative sepsis as indicated by positive blood cultures appears to be an important prognostic sign.     

Improved outcomes in the recent management of secondary aortoenteric fistula

OBJECTIVE: We reviewed the presentation, management, and late events in a recent experience with aortic graft-enteric communications (secondary aortoenteric fistula) to identify variables associated with poor outcomes. METHODS: Since 1991, 29 patients (19 men, 10 women; mean age, 70) presented with a secondary aortoenteric fistula. The duration from aortic graft implantation to aortoenteric fistula development ranged from 8 months to 180 months (mean, 47 months). Presenting symptoms included gastrointestinal bleeding (n = 25), sepsis and retroperitoneal abscess (n = 3), and ruptured para-anastomotic aneurysm (n = 1). One third (10/29) of patients were hypotensive at presentation. Repair was accomplished by graft excision with axillobifemoral bypass (17 simultaneous, 8 staged), graft excision with in situ deep vein replacement (n = 2), or graft excision with rifampin-treated prosthetic replacement (n = 2). Mean follow-up was 51 months, and the incidence of late events was reported by life table methods. RESULTS: The operative (< or = 30-day) mortality rate was 21%, with shock at presentation (P < .01), the need for preoperative transfusion (P < .01), and use of suprarenal aortic clamping during aortoenteric fistula repair (P = .03) associated with lethal outcome. Cumulative mortality related to aortoenteric fistula management was only 24% within an overall 5-year survival rate of 61%. Freedom from recurrent infection or amputation was 86% and 88% at 5 years, respectively, and assisted graft patency was 79%. Presence of staphylococcal species in 22% of patients and occasional operative findings of adjacent perigraft "biofilm" suggests that underlying indolent graft infection may contribute to the development of aortoenteric fistula in some cases. CONCLUSION: Outcomes associated with aortoenteric fistula repair were surprisingly favorable in the absence of preoperative hemodynamic instability.     

Diagnosis and management of aortoenteric fistulas.

Development of an aortoenteric fistula (AEF) is a devastating and life-threatening condition, which is as difficult to diagnose as it is to treat. Fortunately, it is rare, most commonly seen as a delayed complication of aortic reconstruction. Two types are recognized: primary and secondary. Primary fistulas occur de novo between the aorta and bowel, most commonly duodenum. Secondary fistulas occur between an aortic graft and segment of bowel. Diagnosis of AEF requires a high index of suspicion in patients who present with either signs of infection or gastrointestinal hemorrhage. Early diagnosis is essential for a successful outcome because of the lethal nature of AEF. Symptomatology can be varied but most often includes signs of infection and of gastrointestinal bleeding. Esophagogastroduodenoscopy (EGD) and computed tomography (CT) scans are the most useful tests to diagnose AEF. Treatment almost always requires excision of the infected graft and revascularization. Placement of an extra anatomic bypass, followed by graft excision, has been the usual treatment. Recent experience with in situ revascularization has shown that a variety of materials can be use for in situ reconstruction with good results. Morbidity and mortality rates still are high even in contemporary series. The mortality rate still is approximately 33%, but amputation rates have been reduced to less then 10%. Care of patients with AEF requires timely control of bleeding and infection followed by vascular reconstruction performed in a manor to minimize physiological stress.     

Diagnosis and management of spontaneous aortoenteric fistulas.

Spontaneous aortoenteric fistulas are rare but appear to be increasing. They may occur anywhere from the esophagus to the rectum but most often between the duodenum and an infrarenal abdominal aortic aneurysm. Four patients (two with aortoesophageal, one with aortoduodenal, and one with aortocolic fistulas) are presented. The patient usually presents with the clinical triad of aortic aneurysm, pain suggesting aortic disruption, and gastrointestinal hemorrhage. The final exsanguinating hemorrhage is usually preceded by prodomal hemorrhages of varying severity which may be present for weeks to months. Endsocopy is the most helpful diagnostic procedure. Prompt aggressive surgical therapy is the only hope for survival. Successful reconstruction requires placement of the graft in uninfected tissue--often in an extraanatomic position--and interposition of healthy tissues between the graft and the repaired enteric tract.     

Fibrin glue in the management of anal fistulae

OBJECTIVE: Fibrin glue has been used as a sphincter sparing approach for the treatment of anal fistulae for two decades. However, there is uncertainty about its short and long-term efficacy. The objective of this review was to ascertain the role of fibrin glue in the management of anal fistulae, including assessment of recurrence rates, continence disturbance and other complications. METHODS: We searched Medline (January 1966 to February 2004), the Cochrane database, and EMBASE using the terms anal fistulae, fistula-in-ano, and fibrin glue. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. A systematic review of all articles relating to the use of fibrin glue in the treatment of anal fistulae was performed. This included 19 studies. Reviewers performed data extraction independently. Outcomes evaluated included recurrence rates, continence disturbance, septic complications, adverse drug reactions, and duration of follow-up. Heterogeneity of the clinical trials made direct comparisons difficult and meta-analysis impossible. RESULTS: The success rates reported in published studies range from 0% to 100%. Differences in patient selection (including fistula aetiology and type), treatment protocols, and follow-up duration may contribute to such diverse results. CONCLUSIONS: Fibrin glue is simple to use, has a minimal morbidity and should not affect later treatment options in the event of its failure. It is therefore theoretically attractive as a first line treatment in the management of those types of anal fistula in which it has been shown to work. However, further research into 'biological' glues is merited and these subject to randomised controlled study.     

NHSLA litigation in hip fractures: Lessons learnt from NHSLA data

Hip fractures are a major cause of trauma related death, usually occurring in vulnerable elderly patients. There are an estimated 70,000 hip fractures in the UK per year with numbers set to rise. The estimated annual cost to the healthcare economy is in the region of £2 billion. A 17-year review examining litigation related to hip fractures was undertaken.Under a freedom of information request, data was obtained relating to all orthopaedic claims made to the NHS Litigation Authority (NHSLA) between 1995 and 2012. Data was filtered to identify cases involving hip fractures examining litigation trends related to this specific area.10263 NHSLA orthopaedic cases were identified, of which 13.3% (n = 1364) cases related to the hip and femur. Hip fractures made up 16.7% (n = 229). The total cost of hip fracture litigation was over £7 million with an average cost per case of £32,700. The commonest reasons for litigation were diagnostic errors (30.6%), issues with care (24.9%) alleged incompetent surgery (15.7%) and development of pressure sores (5.7%).This study highlights the main causes of litigation in patients sustaining hip fractures, with diagnosis in the emergency department and ward presenting a significant problem. In addition, the data identifies a range of care related issues, as well as several surgical factors and highlights the importance of pressure area care. We discuss these and make suggestions on how to improve practice in this area with the aim of improving patient care and reducing litigation.