二次性大動脈十二指腸瘻に対する一期的ステントグラフト内挿術および十二指腸再建術

Secondary Aorto-duodenal Fistula Successfully Treated With One-stage Endovascular Aortic Repair and Duodenal Reconstruction

大動脈十二指腸瘻（aorto-duodenal fistula：ADF）はまれな疾患ではあるが，発症すると出血性ショックをきたすこともあり，また無治療の場合の致死率は13～70％と報告される，非常に重篤な疾患である1）．本邦のガイドラインでは侵襲的治療として人工血管置換術が推奨されており，ステントグラフト内挿術（endovascular aortic repair：EVAR）はbridge therapyとしての立ち位置である2）．われわれは一期的なEVARおよび十二指腸切除・再建術で良好な転帰を得た症例を経験したので，文献的考察をふまえて報告する．

Secondary aorto-duodenal fistula （ADF） is a rare but fatal complication following aortic reconstruction, with a high risk of massive gastrointestinal bleeding and infection. Although open graft replacement combined with intestinal resection has been the standard treatment, it is associated with considerable perioperative mortality. Recently, endovascular aortic repair （EVAR） has been increasingly used as a less invasive alternative in selected patients. We report a case of a 58-year-old man who developed secondary ADF three years after open abdominal aortic graft replacement. The patient presented with bloody stools and progressive anemia, suspected to have herald bleeding. Upper gastrointestinal endoscopy and contrast-enhanced computed tomography （CT） revealed fistula formation of the duodenum to the proximal anastomosis of the aortic graft. Emergency one-stage surgery was performed. EVAR was first undertaken to achieve rapid hemostasis and prevent intraoperative hemorrhage, followed by partial duodenectomy, duodenojejunal reconstruction, and omentoplasty. No obvious graft rupture or abscess formation was observed intraoperatively. The postoperative course was uneventful, and long-term antibiotic therapy was administered. No recurrence or infectious complications were observed during 11 months of follow-up. This case suggests that one-stage EVAR combined with duodenal reconstruction and omentoplasty can be an effective and less invasive treatment option for carefully selected patients with secondary ADF.