Duodenocaval Fistula After Irradiation and Resection of a Retroperitoneal Sarcoma

Abstract

Duodenocaval fistulae (DCF) are rare with only 38 previously reported cases in English literature 1 . This often lethal condition typically arises as a complication from trauma, peptic ulcer disease, or transmural migration of ingested foreign bodies. Twelve patients have developed duodenocaval fistulae after resection of retroperitoneal tumors, and ten of these patients also have had post-operative external beam irradiation 1 . We present a case of DCF occurring 1 month after completion of pre-operative external beam irradiation and resection of a retroperitoneal myxofibrosarcoma. Report of a CaseA 69-year-old man completed a course of external beam irradiation of 45 cGy delivered in 25 fractions over 35 days and 2 weeks subsequently underwent resection of a retroperitoneal myxofibrosarcoma. The patient's recovery was complicated by a superficial wound infection, which was treated with open wound packing and intravenous cefazolin for 7 days. Seventeen days after hospital discharge, his recovery was interrupted further by fever of 39°C and rigors. Upon readmission, he appeared ill and anorexic. He denied nausea, vomiting, hematemesis, melena, dysuria, and hematuria. He was normotensive with a heart rate of 64 and a temperature of 37.8°C. His abdominal examination was unremarkable except for a focal area of suppuration along the inferior aspect of his incision, which was treated by incision and drainage. Broadspectrum antibiotic coverage was started. Laboratory findings revealed hemoglobin of 10.1 g/dl, white blood cell count of 3.56×10 9 /l, and INR of 1.1. Computed tomography (CT) of his chest, abdomen, and pelvis with enteric and intravenous contrast revealed a small sterile peri-aortic fluid collection confirmed by aspirate cultures.During his first evening of hospitalization, a recurrent episode of septicemia (tachycardia, hypotension, rigors, chills, and fever of 40°C) occurred. His antimicrobial therapy was broadened with fluconazole and metronidazole. Blood cultures obtained during this episode revealed a methicillin resistant Staphylococcus aureus and Enterobacter cloacae bacteremia, and Candida glabrata fungemia. His septicemia recurred nightly despite modifications of his broad-spectrum antibiotic and antifungal therapy. Transesophageal echocardiography and an indium-labeled white blood cell scan failed to localize a source for his septicemia. On his seventh hospital day, a repeat abdominal CT scan with enteric and intravenous contrast suggested a duodenocaval fistula (Fig. 1).To confirm the suspected diagnosis before attempting resection of the involved duodenum and IVC in an irradiated field, an upper gastrointestinal endoscopy was performed cautiously. Despite confirmation of the diagnosis by the presence of fresh clot in the third portion of the duodenum, intraluminal hemorrhage and hemodynamic instability prompted termination of the endoscopy without attempts at temporary endoscopic control before definitive operation. Even with immediate cardiopulmonary resuscitation, the patient died. Postmortem ...

Inferior vena cava graft-enteric fistula after extended hepatectomy with caval replacement

“…The subsequent adherence of the jejunal loop to the PTFE graft in an irradiated field predisposed the bowel to ulceration, transmural penetration, fistula formation, sepsis, and secondary graft thrombosis. 7,8,18 Alternatively, formation of a thick neointima 4 and the characteristics of the PTFE graft could have been the cause of the thrombosis, and fistula formation could have been delayed, as suggested by the presence of dense fibrous tissue at the upper anastomotic end of our graft.…”

“…Because of the small size and the short follow-up of the series that have been previously reported, little is known about long-term infectious complications after such an extreme surgery. 4,[6][7][8] Herein, we describe the case of an enteric-IVC graft fistula after an extended liver resection with caval replacement performed 11 years earlier. We discuss the diagnostic challenges, possible etiology, and therapeutic implications of this case.…”

Successful percutaneous thrombectomy of an infected vena-caval thrombus due to a toothpick

“…[3][4][5] This typically arises as a complication from trauma, peptic ulcer disease, or migration of ingested foreign bodies. 6 Guillem et al 4 reported 37 cases of DCF with literature review. Half of the DCF were traumatic in origin, caused by a penetrating abdominal injury or the migration of an ingested foreign body (toothpick, chicken bone, or fish bone) or caval filter penetration.…”

Duodenocaval fistula as a result of a fish bone perforation

“…1 This highly lethal condition characteristically arises as a complication from trauma, resection of a retroperitoneal tumor with adjuvant radiotherapy, or peptic ulcer disease. 1,2 Trauma can result from a penetrating abdominal injury, an IVC filter, or the transmural migration of an ingested foreign body.…”

“…2 Toothpicks and chicken bones have been reported as causative swallowed items of DCF, yet this case is the first to be described consecutively with a fish bone perforation. 1,3,4 Digestive tract perforation from an ingested foreign body is rare. It has been estimated that 80% to 90% will pass uneventfully, and only less than 1% will result in perforation.…”