Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3711_Библиотеки_им_академика_М_И_Перельмана

If one could predict which patients would develop a s­tula, different surgical techniques might be utilized. When repairing aortic aneurysms or performing aortoiliac grafts, one needs to avoid the possibility of entering the bowel during dissection. We have closed the abdomen and awak­ened the patient upon inadvertently entering the bowel in elective patients—to return another day to perform the vascular surgery—in hopes of avoiding graft infections. Further, vascular grafts under tension should be avoided to prevent erosion of the contiguous tissue—such as the ure­ter or bowel [20]. Also when closing, the abdomen, the synthetic graft should be protected from direct contact with the surface of the bowel, to prevent or reduce the pos­sible formation of pressure necrosis and a stula. Placing the synthetic aortic bifurcation graft limbs beneath the ure­ters and covering the graft with aneurysmal wall, perito­neum and omentum should reduce the chance of stula formation. When urgency dictates, we have utilized a transthoracic or a subdiaphragmatic approach for proximal control of the aorta as temporizing blood-sparing approaches in the critical patient. Each of these methods however may add other potential complications and thus are avoided when possible. We abandoned suture closure of the distal aortic stump as we developed the current tech­nique and have had no aortic or iliac vessel disruptions since utilizing this approach.

0.8% of the patients (32 of 3932) developed an aortoenteric stula within 18.5 months of aneurysm treatment, espe­cially when EVAR was utilized for pseudo- aneurysm or emergency therapy [22]. Whether the spiral saphenous vein reconstruction of the infected aorta by Heyligers and Vriens will prove superior to the endograft will require further evaluation [23]. Similarly, other research, such as litho­plasty, will require time for analysis [24]. All of the studies will be observed for the restrictive value in blood transfu­sion and, in morbidity, mortality, and cost [25].

Unfortunately, many of these patients have multiple simultaneous disease processes which require concomitant treatment. Amputation of an extremity, renal failure, pro­longed intubation, bowel concerns, and long-term respirator care are all considerations. With the current aggressive mul­tidisciplinary therapy programs, the mortality rate has been reduced, and long-term survival may be available to a large percentage of these patients [26, 27]. Infections, a challenge of vascular surgery, and other potential complications con­tinue to be monitored [26].

Along with medical therapy, the expense of treatment of these patients continues to rise, unfortunately placing an additional burden on the patient, the family, and the treating medical team. These stulae are an uncommon but life- threatening process requiring diagnosis and treat­ment on an urgent basis—many within minutes or hours. The associated age and medical condition of these patients have a great impact on their potential outcome. Another possible stula might be an aortoappendiceal communica­tion. We have never seen one of these, but literature review has demonstrated a few articles regarding aortoappendi­ceal stula formation (A-A-F). Rectal bleeding seems to be a major sign of the A-A-F.As a result, colonoscopic examination has been used in the diagnosis of such a s­tula [28]. These stulas may also arise from the chronic, infected, and contained rupture of an abdominal aortic aneurysm [29].

In the elective prior planned surgery in a patient with an aortic lesion, preoperative planned programs progress at a different speed and utilization. In these patients, when pos­sible, an anesthetic consultation before procedure should clarify some of the desired steps to be utilized. In these patients, preoperative antibiotics, blood typing and screen­ing, and the possible requirement for a central venous access are all determined. In the OR or special procedure room, the requirement for or not of an arterial line or TEE (transesoph­ageal echo) may be assessed along with the possibility of an epidural (including possible bleeding considerations).

Of note, more recently, an increase in deaths due to abdominal malignancy have been reported following aortic endograft procedures for abdominal aortic aneurysm ther­apy. These malignancy deaths are presumably due to the increased radiation dosage received during endograft implan­tation and the post procedure serial studies of the endovascu­lar implanted aortic aneurysm grafts.