SURGICAL APPROACH FOR THE TREATMENT OF SECONDARY AORTO-ENTERIC FISTULA

The incidence of secondary aortoenteric fistula (AEFs) in abdominal aorta reconstructed with a synthetic graft ranges from 1 to 2%.1 - 4 The conventional radicai therapy for AEFs: repair of the intestinal lesion, removal of the prosthetic graft, aortic stump ligature and extra-anatomie bypass, has a high mortality (14- 29%) and risk of limb loss (13-29%) due to reinfection or thrombosis of the extra-anatomie bypass.5 These discouraging results have led some groups to recommend more conservative operative management: removal of the infected prosthetic graft, and in situ replacement w i t h a prosthesis made of synthetic material (expanded polytetrafluorethylene, antibiotic-soaked Dacron), or autologous or homologous tissue.6"15 Whatever the operative technique chosen, apart from aortic stump blowout caused by the close anatomie proximity of the duodenum to the aortic stump or the proximal aorto-prosthetic anastomosis, one of the most feared complications is recurrent AEF, which has a mortality rate ranging from 17 to 100%.10 Another problem, especially in patients with profuse active gastrointestinal bleeding, is the need for prompt control of the proximal aorta. Attempting this manoeuvre conventionally through a transperitoneal median approach is labourious owing to the dense adhesions that the infectious process causes at this site. We have previously reported our experience of treating AEFs patients by in situ graft replacement17 and in this article we would like to focus attention on the techniques we * Please address ali correspondence to: F. Speziale, 1° Cattedra di Chirurgia Vascolare, Università di Roma "La Sapienza", Policlinico Umberto 1°, 00161 Roma, Italia. now use for repairing the involved bowel and for preparing and clamping the abdominal aorta.