继发性腹主动脉瘤肠瘘的诊治分析

目的总结继发性腹主动脉瘤肠瘘的诊治经验,提高治疗效果。 方法回顾性分析本院2000年1月至2014年12月接诊的6例腹主动脉瘤开放及腔内修复术后继发肠瘘患者的资料。2例初次手术方式为腹主动脉瘤切除+人工血管置换,4例为腹主动脉瘤腔内修复术。本次均以反复发热就诊,发热距初次手术中位时间11个月（1~27个月）,2例伴有"预兆性消化道出血"。再次手术前确诊3例,其中2例放弃治疗。4例患者经充分准备后施行腋动脉-双侧股动脉人工血管旁路、移植物取出及肠修补,其中1例伴有主动脉膀胱瘘的患者同时行膀胱修补。 结果肠瘘位于十二指肠水平段2例,空肠上中段4例。4例接受再次手术的患者均痊愈出院,随访3~48个月,1例人工血管旁路闭塞但无下肢严重缺血,无其他严重并发症。 结论继发性腹主动脉瘤肠瘘是腹主动脉瘤术后罕见的严重并发症,经充分的抗炎准备后建立解剖外旁路并及时移除植入物是有效的治疗手段。     

膀胱肠瘘诊断治疗12例报告

目的探讨膀胱肠瘘的诊断与治疗方法。方法回顾性分析12例膀胱肠瘘患者的临床资料。男10例，女2例。平均年龄57岁。膀胱回肠瘘3例、膀胱结肠瘘7例、膀胱直肠瘘2例。病因为肠道恶性肿瘤7例、Crohn病3例、膀胱癌和肠道憩室炎各1例。临床表现粪尿10例、反复尿路感染6例、腹痛4例、气尿3例。CT确诊5例（5／9）、膀胱镜确诊3例（3／6）、膀胱造影确诊2例（2／5）、钡剂灌肠确诊1例（1／5）。行手术治疗10例，其中病变肠段切除一期吻合加膀胱部分切除术4例，病变肠段切除一期吻合加瘘修补术或单纯膀胱引流术各1例，一期横结肠造口、二期结肠癌根治加膀胱部分切除术1例，姑息性近端结肠造口术3例。保守治疗2例。结果1例于入院后第10天死于感染性休克。9例随访3个月～16年，平均6．5年。肠瘘1例复发，再次手术后治愈；1例保守治疗者及1例姑息性手术者死于肿瘤转移，1例术后2年死于脑血管意外，此前随访肠瘘无复发；余5例手术治疗者生存良好，无明显术后并发症。结论膀胱肠瘘多继发于肠道恶性肿瘤，主要临床表现为粪尿和反复尿路感染，CT和膀胱镜为首选的检查方法，治疗以手术为主。     

肠外瘘12例治疗体会

肠外瘘是腹部外科常见而严重的并发症及危重症。笔者在过去 16年中对 12例肠外瘘患者采取早期手术治疗 ,均获得成功 ,现报告如下。临床资料本组 12例患者中 ,男 9例 ,女 3例。年龄 13～ 67岁 ,平均 34岁。 12例肠瘘共有瘘口 14个。复杂瘘 1例 ,十二指肠瘘 1例 ,小肠瘘 9例 ,结肠瘘 2例。致瘘因素 :十二指肠残端瘘 1例 ,胃大部切除毕Ⅱ式术后横结肠梗阻近端瘘 1例 ,出血坏死性肠炎术后小肠、结肠复杂瘘 1例 ,小肠外伤、梗阻肠切除吻合口瘘 3例 ,阑尾残端瘘 2例 ,肠伤寒穿孔修补术后瘘 2例 ,妇产科刮宫术后小肠瘘 1例 ,女性结扎术后小肠瘘 1例…     

感染性腹主动脉瘤诊疗体会

目的 总结感染性腹主动脉瘤的诊疗体会.方法 回顾性分析我院2009年6月～2012年5月收治的8例感染性腹主动脉瘤患者的临床资料.2例采用外科手术治疗,行原位血管重建;3例采用腔内修复术,3例未行手术.结果 成功手术5例,随访6～12个月,中位随访时间10个月.原位血管重建2例:1例术后2个月出现吻合口破裂大出血致死;1例出现人工血管-肠瘘,切除左髂支人工血管,两端缝扎,随访1年,未出现不良事件.腔内治疗3例,随访期间均未出现复发、支架再感染、支架移位、内漏等不良事件.未手术3例,均因感染性腹主动脉瘤破裂死亡.结论 感染性腹主动脉瘤罕见,术前诊断率低,死亡率极高.按照其特有的症状、体征及影像学和病原学检查,明确诊断后,应先抗生素治疗,并根据不同情况选择个体化治疗方案.     

感染性腹主动脉瘤的诊治经验

目的总结感染性腹主动脉瘤(infected abdominal aortic aneurysm,IAAA)的诊治经验。方法回顾性分析2010年7月至2018年12月哈尔滨医科大学附属第一医院血管外科收治的10例IAAA患者的临床资料。结果 5例动脉瘤破裂行急诊手术(4例腔内手术、1例开放手术),5例择期手术。6例细菌培养阳性,4例阴性。3例开放手术患者均为原位血管重建,其中1例术后26 d死于腹主动脉消化道瘘,术后1年生存率为66.7%(2/3)。5例腔内修复患者围术期无死亡。随访期内死亡2例,术后1年生存率为60.0%(3/5)。2例复合手术患者围术期和随访期均无死亡和严重并发症发生,术后1年生存率为100.0%(2/2)。结论 IAAA治疗的关键在于控制感染、手术时机把握以及动脉重建方式的选择,临床工作中应根据患者的具体情况选择最佳的治疗方案。     

一站式杂交手术治疗复杂胸腹主动脉疾病

目的总结应用Hybrid技术,腹主动脉去分支化联合降主动脉腹主动脉腔内修复术治疗复杂胸腹主动脉疾病的经验及效果。方法 2016年10月～2020年10月我院收治胸腹主动脉病变病人10例,其中胸腹主动脉瘤1例,胸腹主动脉夹层9例。根据主动脉疾病累及范围,先行相应累及部位的内脏动脉旁路手术,再一期或二期行主动脉腔内覆膜支架修复。随访3～48个月,中位随访时间24.5个月。结果所有手术均成功完成,其中9例一期腔内修复,1例二期腔内修复。同期手术平均手术时间8.5小时,平均腔内手术时间2.0小时。术后30天无死亡病例,围术期5例急性肾损伤,5例急性肝损伤,3例肠梗阻,1例肠漏。其中肠漏瘘病人术后3个月出院。至随访结束时,所有病人无内漏、截瘫,随访期间所有旁路血管通畅,无狭窄。结论杂交技术治疗复杂胸腹主动脉病可行,近中期疗效满意,长期效果有待进一步随访。     

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目的 探讨慢性放射性肠炎的手术适应证及手术方式。方法 回顾性分析1995～2002年南京医科大学第一附属医院经手术治疗的5例慢性放射性肠炎的临床资料。结果 5例慢性放射性肠炎因狭窄伴穿孔、肠梗阻、直肠阴道瘘、出血分别行肠切除吻合、旁路手术、结肠造口及Miles手术。5例手术均获成功。随访6个月至2年，效果满意。结论 慢性放射性肠炎出现肠梗阻、肠瘘、出血、肠穿孔等并发症宜行手术治疗，肠切除吻合是较理想的术式。     

肠浆膜覆盖术治疗肠瘘12例报告

我院外科自1975年4月以来,采用肠浆膜覆盖术治疗肠瘘12例,效果满意。报告如下。一、临床资料12例均为腹部术后并发肠瘘。其中发生在蛔虫性肠穿孔修补术后3例,外伤性肠穿孔修补术后3例,肠梗阻肠减压口瘘4例,右半结肠切除术后吻合口瘘1例,肝脓肿切开引流术后引流管压迫致肠瘘1例。空肠中段瘘5例,回肠中上段瘘6例,横结肠瘘1例。瘘口直径0.5～1.5cm例,直径1.5cm以上8例。瘘发生后12小时以内手术5例,30天内手术2例,70天内手术5例。经肠浆膜覆盖术治愈的最短时间为14天,最长30天,平均22天。无1例再发肠瘘,12例均获治愈。二、治疗方法及手术操作1.腹膜炎不重,全身情况尚可,12小时以内者,则立即剖腹,找到瘘口,进行修剪,全层间断缝合修补,再行肠浆膜覆盖。2.腹膜炎重,全身情况差,则先行腹腔充分引流,于瘘口旁放置两根多孔橡胶管,负压吸引,并抗炎,纠正水电解质失衡,静脉高价营养等治疗,待全身情况明显改善,腹膜炎症局限后,再行手术补瘘并     

手术联合介入栓塞治疗动静脉瘘

目的 探索动静脉瘘的治疗方法及影响效果的因素。方法 复习1999～2003年收治5例动静脉瘘病人的临床资料。男3例，女2例。5例病人均行栓塞和，或手术治疗。结果 3例先天性动静脉瘘。1例股部刀刺伤致股动静脉瘘。1例因椎间盘手术致腹主动脉下腔静脉瘘。5例病人均有症状。腹主动脉下腔静脉瘘病人进行性加重的心衰、血尿、蛋白尿。股动静脉瘘病人持续性高血压，左心扩大。5例病人术前全部确诊。2例病人术中主要瘘口缝扎切断，加周围血管栓塞，1例术前周围血管栓塞，术中结扎主要瘘口，1例单纯行栓塞治疗，1例瘘口修补加入造血管包被。术后2例患肢肿胀，治疗后痊愈。结论 手术联合介入栓塞疗法对先天性及后天性动静脉瘘效果满意。     

腋动脉真性动脉瘤的手术治疗

目的总结腋动脉真性动脉瘤的诊断和手术治疗体会。方法回顾分析1995年1月至2006年6月收治的16例腋动脉真性动脉瘤的临床资料,收集其病因、临床表现、辅助检查、手术中资料以及术后随访资料等。结果均表现为腋窝搏动性肿物,影像学检查均提示腋动脉瘤,均在全身麻醉下行动脉瘤切除,自体静脉移植腋动脉重建,结果均获得近期临床治愈。随访3~10年,平均5年5个月,1例术后2年出现吻合口狭窄,1例术后3年吻合口闭塞,1例手术后5年死于急性脑出血,余13例无复发或并发症出现。结论腋窝搏动性肿物是腋动脉真性动脉瘤的主要临床表现,无创性超声检查有助于明确诊断,真性动脉瘤切除、血管重建是一种可靠的理想的治疗方法。     

In Situ Repair of a Secondary Aortoappendiceal Fistula with a Rifampin-Bonded Dacron Graft

Secondary aortoenteric fistulas remain challenging diagnostic and therapeutic problems. Although the duodenum is most frequently involved, other intestinal segments are possible sites for fistulization. We report here a case of graft-appendiceal fistula revealed by recurrent gastrointestinal bleeding 11 years after abdominal aortic aneurysm replacement. The preoperative diagnosis was not achieved by endoscopy or imaging assessment. Despite recommended principles of total graft excision and extraanatomic bypass, appendectomy and in situ rifampin-bonded graft reconstruction were performed because of the advanced age and poor arterial runoff. The postoperative course was uneventful and the patient remains well 17 months after operation.     

Primary aorto/iliac-enteric fistula-report of 6 new cases

The management of patients with vascular-enteric fistulas remains a challenging diagnostic and therapeutic problem for the vascular surgeon. Although fortunately quite a rare cause of gastrointestinal bleeding, reported mortality and amputation rates are very high. Fistulas between major vascular structures and the gastrointestinal tract are classified as either primary or secondary. Primary fistulas occur most commonly between an aortic aneurysm and the distal duodenum, while secondary fistulas occur following erosion of prosthetic material into the bowel following aortic reconstruction. The authors report 6 new cases of primary aortoenteric fistula: A malignant aortoenteric fistula in a patient with advanced metastatic squamous cell carcinoma involving the infrarenal aorta and duodenum, 4 cases of primary aortoenteric fistulas in patients with abdominal aortic aneurysms, and 1 iliac-enteric fistula secondary to a common iliac aneurysm. The diagnosis is often difficult to make, and although it was considered in 4 patients preoperatively, the diagnosis was not made until the time of laparotomy in all of these patients. Three patients were treated with an in-situ vascular graft, 2 others had the distal abdominal aorta oversewn and axillobilateral femoral bypass performed, and in the case involving the malignancy, the patient underwent primary aortic repair owing to the extent of the tumor process prohibiting aortic reconstruction. Three patients had primary closure of the intestine performed, and 3 required bowel resection and primary anastomosis. The overall 30-day mortality rate was 50% as 3 patients died in the early postoperative period and the remaining 3 patients survived to be discharged from hospital. One patient (17%) required bilateral above-knee amputations. Treatment of patients with vascular-enteric fistulas is a difficult problem, often associated with delayed diagnosis and high morbidity and mortality rates. Successful surgical management can be achieved with primary closure of the intestinal tract and an in-situ vascular graft or extraanatomic bypass.     

Primary aortoduodenal fistula complicated by abdominal aortic aneurysm

A 74-year-old male patient was operated in Vakif Gureba Hospital for aortoduodenal fistula developing from abdominal aortic aneurysm. The patient was diagnosed as abdominal aortic aneurysm after physical examination and computed tomography in another center. Appearing of melena and hematemesis gastroduodenoscopy and radionuclide scanning was performed as diagnosis. After 6 days gastrointestinal bleeding recurred in massive haemorrhage and the patient was operated with a diagnosis of aortoenteric fistula as emergency. A midline laparotomy was performed. There was a fistula between infrarenal abdominal aortic aneurysm (with diameter 8x10 cm) and the 3rd portion of the duodenum. The duodenum was resected segmental and the fistula was disconnected. Following aneurysmotomy a prosthetic graft was placed in the aortobiiliac position. The patient was discharged at the 42nd postoperative day. Primary aortoenteric fistula is a very rare consequence of untreated abdominal aortic aneurysm. The segments of intestine most frequently involved in aortoenteric fistula are the 3rd and 4th portions of the duodenum. Clinical presentation is recurrent episodes of gross gastrointestinal haemorrhage. These cases have high mortality and morbidity unless evaluated as quickly as possible and appropriate surgical intervention performed.     

Aortic sepsis: is there a role for in situ graft reconstruction?

Conventional extraanatomic reconstruction for aortic sepsis is associated with a significant risk of operative death, as well as frequent late complications. We evaluated in situ aortic grafting in the treatment of primary or graft-related aortic infection. Eleven selected patients underwent in situ aortic graft reconstruction in the setting of mycotic aneurysm (n = 5), secondarily infected aortic aneurysm (n = 1), primary aortoenteric fistula (n = 1), and secondary aortoenteric fistula (n = 4). All patients survived: follow-up from 10 to 130 months reveals no evidence for graft thrombosis, pseudoaneurysm, new or recurrent aortoenteric fistula, or subsequent aortic operations in any patient. A literature review produced 110 cases of aortic sepsis managed by in situ aortic reconstruction during the last decade. Thirty-two patients (29%) either died in the operative period or suffered a lethal late complication associated with their aortic reconstruction. This mortality rate declined to 21% if patients undergoing incomplete removal of a contaminated graft were excluded, and to 19% with the addition of our 11 patients. Both our experience and that described in the literature suggest that, in properly-selected patients, in situ aortic graft replacement may be a rational treatment option for localized or circumscribed aortic sepsis.     

Aortoenteric fistula to the sigmoid colon-case report

Aortoenteric fistula is defined as a communication between the aorta and any adjacent segment of the bowel. It may be primary or secondary. The former occurs de novo in patients with intestinal or vascular diseases, whereas secondary aortoenteric fistula is a rare and dreadful complication of aortic reconstruction with vascular prosthesis. We report a case of a 62-year-old man who presented to the emergency department with acute rectal bleeding. The patient had previous aortoiliac surgery with the utilization of an aorto-bifemoral vascular graft. Diagnosis of secondary aortoenteric fistula was made between the aortoiliac graft and sigmoid colon. After exploratory laparotomy, Hartmann's procedure, excision of the graft, oversewing of the aortic stump, and axilobifemoral bypass were successfully performed. This study reports a rare type of secondary aortoenteric fistula to the left colon, and it describes an unusual and successful surgical treatment.     

Primary aortoduodenal fistula in a patient with pararenal abdominal aortic aneurysm

Primary aortoenteric fistula is a rare and extremely serious condition. In most cases, it is caused by an abdominal aortic aneurysm presenting with symptoms of gastrointestinal bleeding. Diagnosis is difficult owing to its rarity and the fact that diagnostic tests are not definitive in many cases. Surgery is performed urgently in most cases and is associated with high mortality. We report a case of a 65-year-old man presenting with symptoms of abdominal pain and massive rectal hemorrhage. Computed tomography revealed a pararenal abdominal aortic aneurysm and suspected aortoenteric fistula. The patient underwent an emergency surgery, confirming the suspected diagnosis. The surgery performed was the traditionally recommended extra-anatomical bypass with aortic ligation and repair of the intestinal defect. We describe the clinical condition and provide an up-to-date overview of diagnosis and treatment by reviewing the literature. We believe the therapeutic decision should be personalized by assessing the anatomy of the aneurysm, the patient's clinical status, the degree of local contamination, and the surgeon's experience with each of the techniques.     

腹主动脉肠瘘六例的诊治体会

目的探讨腹主动脉肠瘘的临床表现特征和治疗经验。方法对我院６例腹主动脉肠瘘进行回顾性分析。结果６例病人,男女各３例,年龄２５～７０岁;４例病理检查为动脉粥样硬化性腹主动脉瘤,年龄均６０岁以上,２例动脉中层发育不良,年龄为２５岁和３２岁;４例术前有小量多次上消化道“信号性出血”,２例突发大出血,术前诉腰部背部疼痛４例;５例为肾下型腹主动脉瘤,１例为胸腹主动脉瘤;瘘口部位３例在十二指肠第三段,２例空肠上段,１例横结肠;４例手术,２例行人造血管移植,均生存至今,１例双侧腋股动脉旁路,１例术中未找到出血部位,后２例术后死亡;另２例未来得及手术死亡。结论术前确诊腹主动脉肠瘘不容易,凡患者腹部有搏动性动脉瘤,腹部或背部剧烈疼痛,上消化道少量多次出血,应积极手术治疗。     

Lessons learnt in the management of aortoenteric fistulae

Secondary aortoenteric fistula may be treated directly by local repair or by excision of all prosthetic material with extra-anatomic revascularisation. We have reviewed our experience with 14 aorto-enteric fistulae encountered between 1960 and 1984. Two patients who were not treated surgically died. Direct repair was attempted in seven patients, two of whom had no prosthetic material present and survived. Five patients had prosthetic grafts which were not removed and four died from recurrent aortic haemorrhage. There were five other patients who had prosthetic grafts which were removed prior to extra-anatomic reconstruction. Three of these died in the peri-operative period, two from sepsis but only one from aortic stump bleeding. The operative mortality was 58%. The overall survival was only 36% (5 of 14 patients) but there was less chance of recurrent aortic haemorrhage when all prosthetic graft material was removed and direct repair avoided.     

Secondary arterio-enteric fistulae: a surgical challenge

Ten cases of secondary arterio-enteric fistulae are described. There were nine graft enteric fistulae and one fistula involving the aortic suture line following elective resection of an infected graft. Only four of the patients initially received prophylactic antibiotics (single dose) at the original aortic reconstruction, and the vascular suture line had only been protected in two. Eight patients presented with bleeding and two with groin abscesses. One patient died before operation. Graft resection was undertaken in all patients and organisms were grown from six of eight grafts cultured. No patient died during operation but one died after 3 days. Axillofemoral bypass grafts were constructed in seven patients (four immediately after resection of prosthetic grafts and three within 4 days of operation). Only three of the eight patients who survived operation are still alive; two died of a ruptured aorta and one from a recurrent fistula. Two patients died of other causes. Four of five axillofemoral grafts in surviving patients subsequently occluded.     

New computed tomographic signs of aortoenteric fistula

Successful preoperative diagnosis of aortoenteric fistula is often difficult. Clinical findings, roentgenography, angiography, and endoscopy have been used in diagnosis with only partial success. Newer techniques of gallium citrate Ga 67 scanning, ultrasonography, and computed tomographic (CT) scanning have been used in recent years to establish the diagnosis of aortic graft infection or aortoenteric fistula. In two cases, the CT scan clearly established the diagnosis of secondary aortoenteric fistula, as well as two previously unreported signs of aortoenteric fistula: intraluminal aortic gas and paraprosthetic extravasation of contrast medium.