Duodenocaval fistula: A life-threatening condition of various origins

Abstract

We report on two cases of duodenocaval fistula. The first patient, a 73-year-old man, had sepsis and occult digestive bleeding. We diagnosed a fistula that resulted from a right nephrectomy and subsequent radiotherapy for a urothelial tumor 20 months earlier. The second patient, a 60-year-old woman, complained of right abdominal pain. A duodenocaval fistula that was caused by duodenal perforation by a migrating caval filter placed 10 years earlier was revealed by means of endoscopy. Both patients had a successful operation to treat the condition. An extensive review of the literature disclosed 35 other cases and identified two factors of good prognosis: duodenocaval fistulas caused by migrating caval filters and early surgery.

Caval Penetration by Inferior Vena Cava Filters

“…16,37 In patients with organ/structure injury, surgery may be indicated, especially for symptomatic patients in whom conservative management or endovascular retrieval has failed. 38 For example, formal laparotomy is recommended for patients with filter-related gastric bleeding, small bowel volvulus, small bowel obstruction, or life-threatening retroperitoneal hemorrhage. 23,38,39 Additionally, patients with vascular injury may require endovascular embolization, stent placement, or laparotomy and surgical ligation.…”

“…38 For example, formal laparotomy is recommended for patients with filter-related gastric bleeding, small bowel volvulus, small bowel obstruction, or life-threatening retroperitoneal hemorrhage. 23,38,39 Additionally, patients with vascular injury may require endovascular embolization, stent placement, or laparotomy and surgical ligation. 40 In high-risk patients, penetrations involving the abdominal aorta have been treated successfully with endovascular stent-grafts, 22,41 and penetration-induced obstructive nephropathy has been treated successfully with percutaneous nephrostomy and antegrade ureteral stenting.…”

Duodenocaval Fistula After Irradiation and Resection of a Retroperitoneal Sarcoma

“…The frequent association of a duodenal ulcer with these fistulae suggests that the fistula is related to fibrosis and post-irradiation mucosal damage. 2 Patients with DCF classically present with septicemia and gastrointestinal tract bleeding. 3 Nearly 70% of patients with DCF have noted at least one of these symptoms but only 45% present both septicemia and digestive tract hemorrhage.…”

“…The mortality rate of DCF approaches 40%. 2 From a literature review of 35 patients who developed DCF, the most common etiology of DCF was trauma followed by resection of a retroperitoneal tumor combined with adjuvant postoperative irradiation. Two patients in this review had tumor resection without postoperative irradiation.…”

“…3 Nearly 70% of patients with DCF have noted at least one of these symptoms but only 45% present both septicemia and digestive tract hemorrhage. 2 Other presentations include non-specific complaints as abdominal pain, weight loss, fever of unknown origin, diarrhea, small bowel obstruction, hemorrhagic shock, respiratory distress, and stroke secondary to cerebral air embolism after gastroduodenoscopy 1 . Regardless of clinical symptoms or signs, the diagnosis of DCF is particularly difficult.…”