Trattamento in situ extranatomico delle fistole protesicoenetriche. Nostra esperienza

Extranatomic or «in situ» treatment of enteric-prosthetic fistulas. Personal experience. - There are two types of prosthetic enteric fistula: anastomotic and paraprosthetic. In the former, the duodenum invol­ves aortic anastomosis of the graft. Usually false aneurysm develops and compresses the duodenum; but as it expands, it ruptures into the organ with cataclismic bleeding. Paraprosthetic fistula present with in­dolent gastrointestinal blood loss. The source of bleeding appears to be erosion of vessels within the bowel wall itself.
Between December I988 and October I 994, 8 cases of enteric-prosthetic fistulas (EPF) on 270 dacron aor­tic-anastomosis were observed. Twenthy months (range 6-36) after the graft, symptoms occurred: cephalo­sporine and teicoplanine were routinely administered before and after the operation.
Three patients, with anastomotic prosthetic-enteric fistula, were treated by conventional procedure: the in­fected graft was removed and aortic stump was ligated and an axillobifemoral bypass was performed. 2 po­stoperative death were observed after severe RIC and sepsis. One patient is still alive at 10 months.
Five patients, with paraprosthetic enteric fistula, were treated by «in situ» procedure. Three patients requi­red an intestinal resection with clearance of the graft and omentopexy in 2 cases and resection of the graft and prosthetic (PTFE) aorto-bifemoral bypass anastomosed proximally to dacron stump. One patient was treated by intestina! suture and prosthesis was protected by polipropilene mesh. In the last patient, the aor­to-aortic dacron graft was substituted by PTFE prosthesis. All patients are still alive at follow-up of 5-15 months without infection signs.
In conclusion, the «in situ» procedure reduces surgical trauma and anesthesia: is a valid alternative to ex­tranatomic treatment. For the prevention of fistulas the omentopexy is recommended.