腹部大動脈瘤術後吻合部仮性動脈瘤十二指腸穿破の1救命例  [in Japanese] A Case of Aortic Anastomotic False Aneurysm Associated with a Graft-Duodenal Fistula  [in Japanese]

症例は63歳,男性で8年前に施行された腹部大動脈瘤(AAA)に対する人工血管置換術中枢側吻合部の仮性動脈瘤に大量の下血を合併し緊急入院となった.腹部CTで中枢側吻合部に7.0cm大の仮性動脈瘤を認め,胃カメラでは十二指腸下行部までに出血源は認められず,仮性動脈瘤の十二指腸水平部への穿破と診断し緊急手術を施行した.Spiral positionとし,胸腹部大動脈瘤のapproachで仮性動脈瘤を露出した.中枢側吻合部が全周にわたり離断され仮性動脈瘤が形成されていた.新しい人工血管で腎動脈直下腹部大動脈と古い人工血管との間にinterpositionした.十二指腸水平部で仮性瘤と瘻孔を形成しており,穿孔部を小腸パッチにて修復した.術後経過は良好で,術後14カ月現在感染の所見なく経過している.本邦においては,AAA術後の中枢側仮性動脈瘤の十二指腸への穿破例に対する手術報告例は少なく報告した.

We report a case of successful surgical treatment for an aortic anastomotic false aneurysm associated with a graft-duodenal fistula after abdominal aortic aneurysm repair. A 63-year-old man was admitted with melena and an aortic anastomotic false aneurysm after prosthetic graft replacement 8 years previously. CT scan demonstrated an aneurysm with a maximum diameter of 70 mm at the proximal anastomosis of the prosthetic graft. Gastroduodenoscopy revealed no bleeding site in the stomach or the first and second portions of the duodenum. Therefore, we performed an emergency operation under a diagnosis of an aortic anastomotic false aneurysm associated with a graft-duodenal fistula. The aneurysm was replaced with interposition of a new prosthetic graft via a thoracoabdominal approach. The fistula was repaired by covering the duodenum with the jejunum through a left pararectal laparotomy. The postoperative course was uneventful, and there was no evidence of graft infection at 14 months after the operation.