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

Abstract

A case of an inferior vena cava (IVC) graft-enteric fistula manifesting with recurrent sepsis 11 years after a right hepatectomy extending to segments I and IV, the extrahepatic bile duct, and IVC followed by chemotherapy and external-beam radiation therapy is described. A preoperative workup revealed graft thrombosis with air bubbles inside the lumen. Laparotomy found a chronic fistula between the graft and the enteric biliary loop. Removal of the graft without further vascular reconstruction, a take-down of the biliary loop, and a redo hepaticojejunostomy were performed successfully. The diagnostic challenges, possible etiology, and therapeutic implications of this case are discussed.

Duodenocaval Fistula in a Patient with Inferior Vena Cava Leiomyosarcoma Treated by Surgical Resection and Caval Polytetrafluoroethylene Prosthesis

“…First of all, DCF represents a relatively rare clinical manifestation and only 37 cases have been described [ 9 ]. The occurrence of DCF has been reported in different oncological settings, such as retroperitoneal metastatic cholangiocarcinoma [ 11 ], renal cell carcinoma [ 10 ], urothelial tumor [ 9 ], and uterine adenocarcinoma [ 13 ]. However, to the best of the authors' knowledge, this represents the first case of a DCF in a patient previously treated for an IVC leiomyosarcoma.…”

“…Because symptoms are nonspecific, diagnosis is mainly based on the results of radiologic and endoscopic studies [ 9 ]. CT allows a noninvasive evaluation of the IVC and the adjacent structures [ 12 ] and is capable of detecting thrombus, air bubbles in the IVC, or infectious fluid collection around the IVC itself and duodenum [ 11 , 12 ]. Endoscopy generally demonstrates ulcer of the duodenum, along with visible bleeding, but cannot properly rule out the effective extent of penetration [ 10 , 14 ].…”

“…Finally, it should be highlighted that the occurrence of DCF represents a lethal event and prompt laparotomy is mandatory [ 11 , 15 ]. Since the IVC was chronically obstructed, no gastrointestinal hemorrhage occurred.…”

“…Thus, no further emergency surgical intervention was required in this patient. Conversely, other literature's series showed that palliative endovascular stent graft [ 13 ], prosthesis ablation [ 11 ], digital control of bleeding, suturing of the duodenum and IVC, and the placement of an epiploic or jejunal patch to prevent recurrence [ 16 ] were necessary.…”

“…Duodenocaval fistula (DCF) is a rare [ 9 ] but lethal postsurgical complication [ 10 , 11 ]. Trauma is the most common etiology (50%) but DCF might also arise following migration of IVC filters (27%), transmural migration of ingested foreign bodies (16%), or peptic ulcer disease related to retroperitoneal tumor resection in association with radiotherapy (19%) [ 9 ].…”