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Enteric Fistula To Inferior Vena Cava Following Pelvic Leiomyosarcoma Resection, Nephrectomy, And Caval Reconstruction
Saranya Sundaram, MD MSCR, William Hawkins, Lindsey Korepta, MD.
Medical University of South Carolina, Charleston, SC, USA.
DEMOGRAPHICS: Inferior vena cava (IVC) enteric fistulas are an uncommon phenomenon that occur following abdominal surgery. There are few published reports with no clear guidelines on management. We present a 50-year-old female with prior sarcoma resection now with pain, bacteremia, and new abscess on abdominal imaging.
HISTORY: Five-years prior, the patient underwent leiomyosarcoma resection with en-bloc right nephrectomy, oophorectomy, and 20mm ringed-PTFE IVC interposition graft. She developed several days of fevers and malaise, with imaging concerning for fistulous connection between duodenum and interposition graft. With persistent bacteremia and downtrending hematocrit, she was taken to an operating room by general and vascular surgery for urgent repair.
PLAN: A midline laparotomy incision was used to expose the prior surgical bed. Control was obtained of retrohepatic IVC and distal native IVC and aorta mobilized, allowing complete resection of infected PTFE graft. A 14mm cryovein conduit was sewn in an end-to-end fashion to healthy native proximal/distal IVC. A short segment duodenal resection and primary anastomosis with omental flap was performed. The remaining abdominal fascia and skin were then closed in standard fashion. The patient had no immediate peri-operative complications. She continued intravenous heparin during hospitalization and transitioned to oral anticoagulation on postoperative day 10. She had slow progression to oral intake but tolerated a regular diet at discharge. No symptom recurrence of was reported at six-months.
DISCUSSION: IVC enteric fistulas are a life-threatening pathology that can occur following extensive prior abdominal dissection, especially after vascular graft reconstruction. Urgent repair with resection of the involved graft and reconstruction with autologous or semi-autologous tissue may be necessary to treat systemic infection or bleeding and, ultimately, prevent death.
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