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Causes, diagnosis, and management of duodenal obstruction after aortic surgery
Causes, diagnosis, and management of duodenal obstruction after aortic surgery Deron J. Tessier, MD,a and Colleen M. Brophy, MD,b Scottsdale and Phoenix, Ariz While ileus is common after repair of abdominal aortic aneurysm, small bowel obstruction is uncommon and duodenal obstruction is rare. We report a case of high-grade, mechanical obstruction of the third and fourth portions of the duodenum that required operative intervention. A review of the literature is included, with emphasis on the causes, diagnosis, and management options for duodenal obstruction associated with aortic reconstructive surgery. (J Vasc Surg 2003;38:186-9.)
Gastrointestinal complications are estimated to occur in as many as 21% of patients after aortic reconstructive surgery.1 Most commonly these complications include ileus, bleeding, and Clostridium difficile–related colitis; and rarely, small bowel obstruction and colonic ischemia.1 Duodenal obstruction is rare after aortic surgery, with only 18 cases reported in the literature. The causes, diagnosis, and management of duodenal obstruction are poorly understood and form the basis of this review. CASE REPORT A 77-year-old man with a 3 cm abdominal aortic aneurysm (AAA) and bilateral common iliac artery aneurysms (right, 6 cm; left, 4 cm) underwent transabdominal aorta– bilateral iliac artery reconstruction. During the procedure the small bowel was packed into the right upper and lower quadrants and the duodenum was mobilized toward the midline with electrocautery. The midline retroperitoneum was exposed down to the aorta, and the circumference of the aorta was exposed just below the renal arteries to facilitate clamp placement. The aneurysm was repaired, and the retroperitoneum was closed with running Vicryl suture. The patient was discharged on postoperative day 4 tolerating a regular diet. He returned 2 weeks later with bilious vomiting. An upper gastrointestinal tract series demonstrated high-grade obstruction of the fourth portion of the duodenum (Fig 1). Computed tomography (CT) enabled confirmation of an obstruction of the third to fourth portion of the duodenum, with no sign of compression from hematoma (Fig 2). A nasogastric tube was placed, and the patient was observed for 5 days. High output from the nasogastric tube continued, with no indication of resolution of the obstruction. The patient was returned to the operating room. On entering the abdomen it was noted that the omentum had adhesed to the midline wound. After tedious dissection, the abdomen was carefully entered without iatrogenic enterotomy. The small bowel was inspected, and careful attention was directed at the duodenum. A From the Department of Surgery, Mayo Clinic Scottsdale,a and the Carl T. Hayden Veterans Affairs Medical Center.b Competition of interest: none. Reprint requests: Deron J. Tessier, MD, Department of Surgery, Mayo Clinic Scottsdale, 13400 E. Shea Blvd, Scottsdale, AZ 85259 (e-mail: [email protected]). Copyright © 2003 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2003/$30.00 ⫹ 0 doi:10.1016/S0741-5214(03)00145-9
186
Fig 1. Barium-enhanced gastrointestinal study demonstrates high-grade stenosis of the fourth portion of the duodenum. dense circumferential adhesion was obstructing the third and fourth portions of the duodenum, separate from the previous retroperitoneal closure. The band was lysed with both sharp and blunt dissection. Intraoperatively, air and contrast medium were instilled through the nasogastric tube, and plain films were obtained, which demonstrated resolution of the obstruction. The patient recovered uneventfully and was discharged on postoperative day 10 tolerating a regular diet. At 1-year follow-up, he is doing well with no sequelae.
DISCUSSION Mechanical obstruction of the small and large bowel have been associated with expanding aneurysms.2-4 Surgical resection of the aneurysm under these circumstances relieves the obstruction. Postoperative gastrointestinal complications are not uncommon after aortic surgery and include ischemia, gastritis, ulcer, enterocolitis, and ascites.1,5,6 The most common postoperative complication is ileus, which occurs in as many as 10% of patients.7 Postop-
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Tessier and Brophy 187
Fig 2. CT scan shows obstruction of the third to fourth portion of the duodenum, with collapsed distal small bowel. Note no retroperitoneal hematoma.
erative mechanical intestinal obstruction after abdominal aortic surgery is rare and poses a significant diagnostic and therapeutic dilemma.5 In a study of 1475 patients undergoing AAA repair, small bowel obstruction occurred in 2.9% of patients, 41% of which required adhesiolysis.8 Patients with obstruction lasting longer than 2 weeks almost always require operative relief of the obstruction. In general, early postoperative small bowel obstruction requiring surgical intervention carries significant morbidity, including abdominal and wound sepsis, fistula formation, wound disruption, and persistent obstruction.9 Therefore a 1-week to 2-week trial of conservative therapy in these patients is reasonable.8 Duodenal obstruction after AAA repair is rare, with only 16 cases reported in the English literature.10-19 Two of these patients had duodenal obstruction after aortic replacement because of occlusive disease.13,19 In patients with duodenal obstruction after aortic reconstructive surgery, symptoms are noted 8 to 60 days (mean, 13.3 days) after the operation, and include increased nasogastric tube output, nausea, bilious vomiting, and pain. Reported causes of duodenal obstruction after aortic repair include hematoma, sac seroma, superior mesenteric syndrome, bowel edema, and adhesions10-13,15-20 (Table).
Hematoma, seroma, and superior mesenteric artery syndrome are all characterized by external compression of the duodenum. Together these comprise 32% of the now 19 reported cases of duodenal obstruction after aortic surgery. Hematoma encasing the duodenum was reported by Reasbeck,11 and Burns and Bradbury18 used CT scans to document a seroma that was compressing the duodenum. Superior mesenteric artery syndrome is characterized by compression of the duodenum between the retroperitoneum and the superior mesenteric artery, usually from retroperitoneal hematoma.17 Some authors15 have used contrast material– enhanced studies to suggest hematoma or superior mesenteric artery syndrome as the cause of obstruction; however, contrast-enhanced studies only define the presence of obstruction, not its cause. Adhesions have been found in 7 patients (37%) and suggested in another 5 patients (26%). Conservative management was successful in all 5 patients with presumed adhesion formation. However, the only radiologic study obtained in these patients was an upper gastrointestinal series with barium, which cannot exclude all possible causes of obstruction. Therefore the incidence of duodenal obstruction secondary to adhesions may be overestimated.
JOURNAL OF VASCULAR SURGERY July 2003
188 Tessier and Brophy
Summary of reported cases of duodenal obstruction after aortic surgery
Reference
Pathologic Patient condition
No. of previous abdominal operations
Rijken and Butzelaar10
1
AAA
NS
Reasbeck11
1
AAA
NS
Sebesta et al12
1
AAA
Lord et al13
1
Budorick and Love14 Lamont et al15
Clyne and Kumar16 Campagnol et al17 Burns and Braddary18 Hans19
Current report
Diagnostic study Contrast swallow/ CT Contrast swallow Contrast swallow Contrast swallow Contrast swallow Contrast
Cause of obstruction Hematoma
30
21
Hematoma
14
5
SMA syndrome
12
3
Unknown
6
Unknown
Intervention
Days to resolution
Evacuation of hematoma
NS NS
66
Duodenojejunal bypass Gastrojejunal bypass Decompression
8
7
Decompression
7
Adhesion
7
10
NS
Contrast swallow Contrast swallow CT
Adhesion
8
7
Adhesion
8
0
Duodenojejunal bypass Duodenojejunal bypass Adhesiolysis
Adhesion
8
7
Contrast swallow Contrast swallow Contrast swallow Contrast swallow Contrast swallow Contrast swallow Contrast swallow CT Contrast swallow
Suggested SMA syndrome Suggested hematoma Unknown
10
2
Vagotomy, pyloroplasty Occlusion Aortobifemoral bypass AAA Multiple
3
AAA
NS
4
AAA
1
AAA
Aortobifemoral bypass NS
2
AAA
NS
1
AAA
NS
2
AAA
Aortic tube graft
1
AAA
2
AAA
1
AAA
Nephroureterectomy Cholecystectomy, appendectomy NS
1
AAA
NS
1
AAA
Cholecystectomy
2 3
AAA NS Pancreatitis Occlusion Cholecystectomy, Adhesion nephrectomy, adhesiolysis AAA None Contrast Adhesion swallow/ CT
1
Postoper- Days of conative day servative of diag- managenosis ment
NS 66
NS NS NS
12
Gastrojejunal bypass Decompression
9
13
Decompression
13
9
15
Decompression
NS
Unknown
9
17
Decompression
NS
Unknown
8
10
Decompression
10
Seroma
11
14
Decompression
14
Adhesion
35
6
Adhesiolysis
NS
24 19
32 NS
Decompression Adhesiolysis
32 NS
18
5
Adhesiolysis
NS
12
AAA, Abdominal aortic aneurysm; SMA, superior mesenteric artery syndrome, NS, not specified.
The most definitive way to diagnose adhesion as the cause of obstruction is laparotomy. Because of the close association of the aorta to the pancreas, postoperative pancreatitis after aortic repair is not uncommon.5 In 1989 Hans19 reported 3 patients in whom severe pancreatitis developed after emergent aneurysm repair (2 patients) and elective aortic reconstruction. Duodenal obstruction developed postoperatively in all 3 patients, due to thick adhesions in 2 patients and to external compression by edematous pancreas in the third patient. Elevated amylase and lipase concentrations, and CT findings confirmed the diagnosis of pancreatitis as the cause of duodenal obstruction. With time and adequate decompression of the proximal stomach, excellent results have been obtained with conservative management in some patients. Conservative man-
agement of postoperative duodenal obstruction after aortic surgery is successful in 47% of patients. Mean time until resolution of obstruction treated conservatively was 22 days (range, 7-66 days). However, in 83% (5 of 6 patients) the obstruction resolved in less than 2 weeks with conservative therapy. While conservative management is reasonable in the immediate postoperative period, in some cases the obstruction does not resolve spontaneously. Adequate radiologic evaluation should be performed, consisting of contrast-enhanced studies to determine extent of obstruction and CT scans to determine the cause. Patients who would benefit most from conservative management are those with compression due to hematoma, seroma, or pancreatitis. In patients in which these causes are not identified, the most likely cause of obstruction is adhesion, which is not likely to resolve spontaneously. A trial of
JOURNAL OF VASCULAR SURGERY Volume 38, Number 1
conservative management for 1 to 2 weeks is reasonable in most patients.8 Surgical therapy has been required in 53% of reported cases of postoperative duodenal obstruction. The median duration of conservative management in patients who ultimately required surgery was 10 days (range, 0-21 days). The most common finding at exploration was a tight adhesive band, found in 7 patients (70%). Superior mesenteric artery syndrome was found in 2 patients (20%), and a complicated hematoma in 1 patient (10%). Surgical therapy included duodenojejunal bypass grafting (3 patients, 30%), gastrojejunal bypass grafting (2 patients, 20%), adhesiolysis (4 patients, 40%), and evacuation of hematoma (1 patient, 10%). Combined postoperative mortality was 10%. Recurrent obstruction was not reported in any patients. CONCLUSION Postoperative duodenal obstruction poses a diagnostic and therapeutic dilemma after aortic surgery. Symptoms typically appear 2 weeks postoperatively. Determination of the cause of obstruction is instrumental in guiding the therapeutic approach. Contrast-enhanced upper gastrointestinal studies and CT scans will assist in determining the specific mechanism. Conservative management has produced excellent results in patients with obstruction secondary to superior mesenteric artery syndrome, hematoma, and seroma. However, duodenal obstruction secondary to an adhesive band will likely require operative intervention. The median duration of conservative management in patients ultimately requiring repeat operation is 10 days. In addition, there have been no reported complications from conservative management in these patients. Finally, in 83% of patients conservative treatment results in resolution of the obstructive by 2 weeks. Therefore repeat operation is indicated in patients with duodenal obstruction secondary to a presumed adhesive band or any cause that fails to resolve with 2 weeks of conservative management. REFERENCES 1. Valentine RJ, Hagino RT, Jackson MR, et al. Gastrointestinal complications after aortic surgery. J Vasc Surg 1998;28:404-11; discussion, 411-2.
Tessier and Brophy 189
2. Adair HM. Duodenal obstruction due to abdominal aortic aneurysm. BMJ 1975;2:727. 3. Hayashi T, Nagasue N, Chang YC, et al. Duodenal stenosis caused by ruptured aneurysms of the pancreaticoduodenal artery: a case report. Japn J Surg 1989;19:63-6. 4. Ozergin U, Vatansev C, Durgut K, et al. An internal iliac artery aneurysm causing a colonic obstruction: report of a case. Surg Today 2001;31:839-41. 5. Crowson M, Fielding JW, Black J, et al. Acute gastrointestinal complications of infrarenal aortic aneurysm repair. Br J Surg 1984;71:825-8. 6. Orr NW, Ware CC. Some gastrointestinal complications of adbominal aneurysm surgery. Proc R Soc Med 1968;61:342-3. 7. Sicard GA, Reilly JM, Rubin BG, et al. Transabdominal versus retroperitoneal incision for abdominal aortic surgery: report of a prospective randomized trial. J Vasc Surg 1995;21:174-81; discussion, 181-3. 8. Siporin K, Hiatt JR, Treiman RL. Small bowel obstruction after abdominal aortic surgery. Am Surg 1993;59:846-9. 9. Gersin K, Ponsky J, Fanelli R. Enteroscopic treatment of early postoperative small bowel obstruction. Surg Endosc 2002;16:115-6. 10. Rijken AM, Butzelaar RM. Compression of the descending duodenum after reconstruction of infrarenal aortic aneurysm. J Vasc Surg 1996;24: 178-9. 11. Reasbeck PG. Vascular compression of the duodenum following resection of an abdominal aortic aneurysm. N Z Med J 1980;92:198-9. 12. Sebesta P, Pirk J, Filipova H. Superior mesenteric artery syndrome following abdominal aortic aneurysm resection and replacement. Thorac Cardiovasc Surg 1987;35:378-81. 13. Lord RS, Nankivell C, Graham AR, Tracy GD. Duodenal obstruction following abdominal aortic reconstruction. Ann Vasc Surg 1987;1:58790. 14. Budorick NE, Love L. Duodenal obstruction after repair of abdominal aortic aneurysm. Radiology 1988;169:421-2. 15. Lamont PM, Clarke PJ, Collin J. Duodenal obstruction after abdominal aortic aneurysm repair. Eur J Vasc Surg 1992;6:107-10. 16. Clyne CA, Kumar AS. Duodenal obstruction following reconstruction of abdominal aortic aneurysm. Eur J Vasc Surg 1993;7:98-100. 17. Campagnol M, Di Giacomo M, Cruciani R, Cavallaro A. Duodenal obstruction following elective abdominal aortic aneurysm repair. Cardiovasc Surg 1996;4:843-5. 18. Burns P, Bradbury AW. Duodenal obstruction following aortic aneurysm repair caused by an aneurysm sac seroma. Eur J Vasc Endovasc Surg 2000;20:487-8. 19. Hans SS. Pancreatitis and duodenal obstruction after aortic surgery. Am Surg 1989;55:177-9. 20. Chaillou P, Patra P, Petiot JM, et al. Mechanical obstruction of the duodenum after surgery of the abdominal aorta. J Chir 1989;126:596-7. Submitted Oct 29, 2002; accepted Jan 20, 2003.
Gastrointestinal complications are estimated to occur in as many as 21% of patients after aortic reconstructive surgery.1 Most commonly these complications include ileus, bleeding, and Clostridium difficile–related colitis; and rarely, small bowel obstruction and colonic ischemia.1 Duodenal obstruction is rare after aortic surgery, with only 18 cases reported in the literature. The causes, diagnosis, and management of duodenal obstruction are poorly understood and form the basis of this review. CASE REPORT A 77-year-old man with a 3 cm abdominal aortic aneurysm (AAA) and bilateral common iliac artery aneurysms (right, 6 cm; left, 4 cm) underwent transabdominal aorta– bilateral iliac artery reconstruction. During the procedure the small bowel was packed into the right upper and lower quadrants and the duodenum was mobilized toward the midline with electrocautery. The midline retroperitoneum was exposed down to the aorta, and the circumference of the aorta was exposed just below the renal arteries to facilitate clamp placement. The aneurysm was repaired, and the retroperitoneum was closed with running Vicryl suture. The patient was discharged on postoperative day 4 tolerating a regular diet. He returned 2 weeks later with bilious vomiting. An upper gastrointestinal tract series demonstrated high-grade obstruction of the fourth portion of the duodenum (Fig 1). Computed tomography (CT) enabled confirmation of an obstruction of the third to fourth portion of the duodenum, with no sign of compression from hematoma (Fig 2). A nasogastric tube was placed, and the patient was observed for 5 days. High output from the nasogastric tube continued, with no indication of resolution of the obstruction. The patient was returned to the operating room. On entering the abdomen it was noted that the omentum had adhesed to the midline wound. After tedious dissection, the abdomen was carefully entered without iatrogenic enterotomy. The small bowel was inspected, and careful attention was directed at the duodenum. A From the Department of Surgery, Mayo Clinic Scottsdale,a and the Carl T. Hayden Veterans Affairs Medical Center.b Competition of interest: none. Reprint requests: Deron J. Tessier, MD, Department of Surgery, Mayo Clinic Scottsdale, 13400 E. Shea Blvd, Scottsdale, AZ 85259 (e-mail: [email protected]). Copyright © 2003 by The Society for Vascular Surgery and The American Association for Vascular Surgery. 0741-5214/2003/$30.00 ⫹ 0 doi:10.1016/S0741-5214(03)00145-9
186
Fig 1. Barium-enhanced gastrointestinal study demonstrates high-grade stenosis of the fourth portion of the duodenum. dense circumferential adhesion was obstructing the third and fourth portions of the duodenum, separate from the previous retroperitoneal closure. The band was lysed with both sharp and blunt dissection. Intraoperatively, air and contrast medium were instilled through the nasogastric tube, and plain films were obtained, which demonstrated resolution of the obstruction. The patient recovered uneventfully and was discharged on postoperative day 10 tolerating a regular diet. At 1-year follow-up, he is doing well with no sequelae.
DISCUSSION Mechanical obstruction of the small and large bowel have been associated with expanding aneurysms.2-4 Surgical resection of the aneurysm under these circumstances relieves the obstruction. Postoperative gastrointestinal complications are not uncommon after aortic surgery and include ischemia, gastritis, ulcer, enterocolitis, and ascites.1,5,6 The most common postoperative complication is ileus, which occurs in as many as 10% of patients.7 Postop-
JOURNAL OF VASCULAR SURGERY Volume 38, Number 1
Tessier and Brophy 187
Fig 2. CT scan shows obstruction of the third to fourth portion of the duodenum, with collapsed distal small bowel. Note no retroperitoneal hematoma.
erative mechanical intestinal obstruction after abdominal aortic surgery is rare and poses a significant diagnostic and therapeutic dilemma.5 In a study of 1475 patients undergoing AAA repair, small bowel obstruction occurred in 2.9% of patients, 41% of which required adhesiolysis.8 Patients with obstruction lasting longer than 2 weeks almost always require operative relief of the obstruction. In general, early postoperative small bowel obstruction requiring surgical intervention carries significant morbidity, including abdominal and wound sepsis, fistula formation, wound disruption, and persistent obstruction.9 Therefore a 1-week to 2-week trial of conservative therapy in these patients is reasonable.8 Duodenal obstruction after AAA repair is rare, with only 16 cases reported in the English literature.10-19 Two of these patients had duodenal obstruction after aortic replacement because of occlusive disease.13,19 In patients with duodenal obstruction after aortic reconstructive surgery, symptoms are noted 8 to 60 days (mean, 13.3 days) after the operation, and include increased nasogastric tube output, nausea, bilious vomiting, and pain. Reported causes of duodenal obstruction after aortic repair include hematoma, sac seroma, superior mesenteric syndrome, bowel edema, and adhesions10-13,15-20 (Table).
Hematoma, seroma, and superior mesenteric artery syndrome are all characterized by external compression of the duodenum. Together these comprise 32% of the now 19 reported cases of duodenal obstruction after aortic surgery. Hematoma encasing the duodenum was reported by Reasbeck,11 and Burns and Bradbury18 used CT scans to document a seroma that was compressing the duodenum. Superior mesenteric artery syndrome is characterized by compression of the duodenum between the retroperitoneum and the superior mesenteric artery, usually from retroperitoneal hematoma.17 Some authors15 have used contrast material– enhanced studies to suggest hematoma or superior mesenteric artery syndrome as the cause of obstruction; however, contrast-enhanced studies only define the presence of obstruction, not its cause. Adhesions have been found in 7 patients (37%) and suggested in another 5 patients (26%). Conservative management was successful in all 5 patients with presumed adhesion formation. However, the only radiologic study obtained in these patients was an upper gastrointestinal series with barium, which cannot exclude all possible causes of obstruction. Therefore the incidence of duodenal obstruction secondary to adhesions may be overestimated.
JOURNAL OF VASCULAR SURGERY July 2003
188 Tessier and Brophy
Summary of reported cases of duodenal obstruction after aortic surgery
Reference
Pathologic Patient condition
No. of previous abdominal operations
Rijken and Butzelaar10
1
AAA
NS
Reasbeck11
1
AAA
NS
Sebesta et al12
1
AAA
Lord et al13
1
Budorick and Love14 Lamont et al15
Clyne and Kumar16 Campagnol et al17 Burns and Braddary18 Hans19
Current report
Diagnostic study Contrast swallow/ CT Contrast swallow Contrast swallow Contrast swallow Contrast swallow Contrast
Cause of obstruction Hematoma
30
21
Hematoma
14
5
SMA syndrome
12
3
Unknown
6
Unknown
Intervention
Days to resolution
Evacuation of hematoma
NS NS
66
Duodenojejunal bypass Gastrojejunal bypass Decompression
8
7
Decompression
7
Adhesion
7
10
NS
Contrast swallow Contrast swallow CT
Adhesion
8
7
Adhesion
8
0
Duodenojejunal bypass Duodenojejunal bypass Adhesiolysis
Adhesion
8
7
Contrast swallow Contrast swallow Contrast swallow Contrast swallow Contrast swallow Contrast swallow Contrast swallow CT Contrast swallow
Suggested SMA syndrome Suggested hematoma Unknown
10
2
Vagotomy, pyloroplasty Occlusion Aortobifemoral bypass AAA Multiple
3
AAA
NS
4
AAA
1
AAA
Aortobifemoral bypass NS
2
AAA
NS
1
AAA
NS
2
AAA
Aortic tube graft
1
AAA
2
AAA
1
AAA
Nephroureterectomy Cholecystectomy, appendectomy NS
1
AAA
NS
1
AAA
Cholecystectomy
2 3
AAA NS Pancreatitis Occlusion Cholecystectomy, Adhesion nephrectomy, adhesiolysis AAA None Contrast Adhesion swallow/ CT
1
Postoper- Days of conative day servative of diag- managenosis ment
NS 66
NS NS NS
12
Gastrojejunal bypass Decompression
9
13
Decompression
13
9
15
Decompression
NS
Unknown
9
17
Decompression
NS
Unknown
8
10
Decompression
10
Seroma
11
14
Decompression
14
Adhesion
35
6
Adhesiolysis
NS
24 19
32 NS
Decompression Adhesiolysis
32 NS
18
5
Adhesiolysis
NS
12
AAA, Abdominal aortic aneurysm; SMA, superior mesenteric artery syndrome, NS, not specified.
The most definitive way to diagnose adhesion as the cause of obstruction is laparotomy. Because of the close association of the aorta to the pancreas, postoperative pancreatitis after aortic repair is not uncommon.5 In 1989 Hans19 reported 3 patients in whom severe pancreatitis developed after emergent aneurysm repair (2 patients) and elective aortic reconstruction. Duodenal obstruction developed postoperatively in all 3 patients, due to thick adhesions in 2 patients and to external compression by edematous pancreas in the third patient. Elevated amylase and lipase concentrations, and CT findings confirmed the diagnosis of pancreatitis as the cause of duodenal obstruction. With time and adequate decompression of the proximal stomach, excellent results have been obtained with conservative management in some patients. Conservative man-
agement of postoperative duodenal obstruction after aortic surgery is successful in 47% of patients. Mean time until resolution of obstruction treated conservatively was 22 days (range, 7-66 days). However, in 83% (5 of 6 patients) the obstruction resolved in less than 2 weeks with conservative therapy. While conservative management is reasonable in the immediate postoperative period, in some cases the obstruction does not resolve spontaneously. Adequate radiologic evaluation should be performed, consisting of contrast-enhanced studies to determine extent of obstruction and CT scans to determine the cause. Patients who would benefit most from conservative management are those with compression due to hematoma, seroma, or pancreatitis. In patients in which these causes are not identified, the most likely cause of obstruction is adhesion, which is not likely to resolve spontaneously. A trial of
JOURNAL OF VASCULAR SURGERY Volume 38, Number 1
conservative management for 1 to 2 weeks is reasonable in most patients.8 Surgical therapy has been required in 53% of reported cases of postoperative duodenal obstruction. The median duration of conservative management in patients who ultimately required surgery was 10 days (range, 0-21 days). The most common finding at exploration was a tight adhesive band, found in 7 patients (70%). Superior mesenteric artery syndrome was found in 2 patients (20%), and a complicated hematoma in 1 patient (10%). Surgical therapy included duodenojejunal bypass grafting (3 patients, 30%), gastrojejunal bypass grafting (2 patients, 20%), adhesiolysis (4 patients, 40%), and evacuation of hematoma (1 patient, 10%). Combined postoperative mortality was 10%. Recurrent obstruction was not reported in any patients. CONCLUSION Postoperative duodenal obstruction poses a diagnostic and therapeutic dilemma after aortic surgery. Symptoms typically appear 2 weeks postoperatively. Determination of the cause of obstruction is instrumental in guiding the therapeutic approach. Contrast-enhanced upper gastrointestinal studies and CT scans will assist in determining the specific mechanism. Conservative management has produced excellent results in patients with obstruction secondary to superior mesenteric artery syndrome, hematoma, and seroma. However, duodenal obstruction secondary to an adhesive band will likely require operative intervention. The median duration of conservative management in patients ultimately requiring repeat operation is 10 days. In addition, there have been no reported complications from conservative management in these patients. Finally, in 83% of patients conservative treatment results in resolution of the obstructive by 2 weeks. Therefore repeat operation is indicated in patients with duodenal obstruction secondary to a presumed adhesive band or any cause that fails to resolve with 2 weeks of conservative management. REFERENCES 1. Valentine RJ, Hagino RT, Jackson MR, et al. Gastrointestinal complications after aortic surgery. J Vasc Surg 1998;28:404-11; discussion, 411-2.
Tessier and Brophy 189
2. Adair HM. Duodenal obstruction due to abdominal aortic aneurysm. BMJ 1975;2:727. 3. Hayashi T, Nagasue N, Chang YC, et al. Duodenal stenosis caused by ruptured aneurysms of the pancreaticoduodenal artery: a case report. Japn J Surg 1989;19:63-6. 4. Ozergin U, Vatansev C, Durgut K, et al. An internal iliac artery aneurysm causing a colonic obstruction: report of a case. Surg Today 2001;31:839-41. 5. Crowson M, Fielding JW, Black J, et al. Acute gastrointestinal complications of infrarenal aortic aneurysm repair. Br J Surg 1984;71:825-8. 6. Orr NW, Ware CC. Some gastrointestinal complications of adbominal aneurysm surgery. Proc R Soc Med 1968;61:342-3. 7. Sicard GA, Reilly JM, Rubin BG, et al. Transabdominal versus retroperitoneal incision for abdominal aortic surgery: report of a prospective randomized trial. J Vasc Surg 1995;21:174-81; discussion, 181-3. 8. Siporin K, Hiatt JR, Treiman RL. Small bowel obstruction after abdominal aortic surgery. Am Surg 1993;59:846-9. 9. Gersin K, Ponsky J, Fanelli R. Enteroscopic treatment of early postoperative small bowel obstruction. Surg Endosc 2002;16:115-6. 10. Rijken AM, Butzelaar RM. Compression of the descending duodenum after reconstruction of infrarenal aortic aneurysm. J Vasc Surg 1996;24: 178-9. 11. Reasbeck PG. Vascular compression of the duodenum following resection of an abdominal aortic aneurysm. N Z Med J 1980;92:198-9. 12. Sebesta P, Pirk J, Filipova H. Superior mesenteric artery syndrome following abdominal aortic aneurysm resection and replacement. Thorac Cardiovasc Surg 1987;35:378-81. 13. Lord RS, Nankivell C, Graham AR, Tracy GD. Duodenal obstruction following abdominal aortic reconstruction. Ann Vasc Surg 1987;1:58790. 14. Budorick NE, Love L. Duodenal obstruction after repair of abdominal aortic aneurysm. Radiology 1988;169:421-2. 15. Lamont PM, Clarke PJ, Collin J. Duodenal obstruction after abdominal aortic aneurysm repair. Eur J Vasc Surg 1992;6:107-10. 16. Clyne CA, Kumar AS. Duodenal obstruction following reconstruction of abdominal aortic aneurysm. Eur J Vasc Surg 1993;7:98-100. 17. Campagnol M, Di Giacomo M, Cruciani R, Cavallaro A. Duodenal obstruction following elective abdominal aortic aneurysm repair. Cardiovasc Surg 1996;4:843-5. 18. Burns P, Bradbury AW. Duodenal obstruction following aortic aneurysm repair caused by an aneurysm sac seroma. Eur J Vasc Endovasc Surg 2000;20:487-8. 19. Hans SS. Pancreatitis and duodenal obstruction after aortic surgery. Am Surg 1989;55:177-9. 20. Chaillou P, Patra P, Petiot JM, et al. Mechanical obstruction of the duodenum after surgery of the abdominal aorta. J Chir 1989;126:596-7. Submitted Oct 29, 2002; accepted Jan 20, 2003.