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Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Rectal arteriovenous fistula resected laparoscopically after laparoscopic sigmoidectomy: A case report Hajime Ushigome, Tetsushi Hayakawa, Mamoru Morimoto, Hidehiko Kitagami & Moritsugu Tanaka Department of Surgery, Kariya Toyota General Hospital, Kariya, Japan
Keywords Iatrogenic; laparoscopic surgery; rectal arteriovenous fistula Correspondence Hajime Ushigome, Department of Surgery, Kariya Toyota General Hospital, 5-15 Sumiyoshi-cho, Kariya, Aichi 448-0852, Japan. Tel/Fax: +81 566 25 2902 Email: [email protected] Received: 19 September 2013; revised 19 October 2013; accepted 6 November 2013 DOI:10.1111/ases.12079
Abstract We report a very rare case of rectal arteriovenous fistula following sigmoidectomy and discuss this case in the context of the existing literature. In April 2011, the patient, a man in his 60s, underwent laparoscopic sigmoidectomy with lymph node dissection for sigmoid colon cancer. Beginning in February 2012, he experienced frequent diarrhea. Abdominal contrast-enhanced CT revealed local thickening of the rectal wall and rectal arteriovenous fistula near the anastomosis site. Rectitis from the rectal arteriovenous fistula was diagnosed. No improvement was seen with conservative treatment. Therefore, surgical resection was performed laparoscopically and the site of the lesion was confirmed by intraoperative angiography. The arteriovenous fistula was identified and resected. Postoperatively, diarrhea symptoms resolved, and improvement in rectal wall thickening was seen on abdominal CT. No recurrence has been seen as of 1 year postoperatively.
Introduction Arteriovenous fistula in the region of the inferior mesenteric artery (IMA) is very rare, with few reported cases. No previous reports have described onset following laparoscopic surgery or treatment with laparoscopic surgery. We report a case of rectal arteriovenous fistula that developed after laparoscopic sigmoidectomy with lymph node dissection. This arteriovenous fistula could be resected laparoscopically.
Case Presentation The patient was a man in his 60s with no medical history of note, except for hypertension. In April 2011, laparoscopic sigmoidectomy with D3 dissection was performed for treatment of sigmoid colon cancer. The left colic artery was preserved and the IMA peripheral to this was excised. A mechanical anastomosis was made using a double stapling technique. The postoperative course was good and the patient left the hospital after 9 days. Beginning in February 2012, the patient began to experience frequent diarrhea. No abnormalities were
56
seen on either abdominal examination or hematological findings. Fecal culture also yielded negative results for potential causative organisms of diarrhea. Colonoscopy revealed the rectal mucosa to the anal side of the anastomosis site was edematous, and engorged blood vessels were apparent (Figure 1a). CT showed that the wall of the entire circumference of the rectum to the anal side of the anastomosis site had thickened (Figure 2a). On 3-D CT, a blood vessel thought to be the superior rectal vein (SRV) was depicted alongside the superior rectal artery in the arterial phase (Figure 3a). When the internal pudendal artery was selectively enhanced from the left internal iliac artery, the SRV was depicted with contrast agent flowing into the SRV from the superior rectal artery near the anastomosis site (Figure 3b). Based on these findings, rectal arteriovenous fistula was diagnosed. Conservative treatment with fasting and intravenous drip was performed, but no improvement in symptoms was seen. The IMA had been severed in the previous surgery and the approach to the abnormal vessel was difficult. Embolization was therefore not considered feasible, and a strategy of resecting either the arteriovenous fistula or the colon was adopted. Surgery
Asian J Endosc Surg 7 (2014) 56–59 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Rectal arteriovenous fistula
H Ushigome et al.
a
b
Figure 1 Colonoscopy. (a) Preoperative. Capillaries are increased and rectal mucosa has become edematous at the margin of the anastomosis site. (b) Postoperative. Capillaries remain, but edematous changes in the rectal mucosa have disappeared.
a
Engorged vessels were apparent on colonoscopy, but edematous changes to the mucosa were no longer apparent (Figure 1b,2b).
Discussion
b
Figure 2 Abdominal CT. (a) Preoperative. Edematous wall thickening is seen around the entire circumference of the rectum at the margin of the anastomosis site. (b) Postoperative. Edematous wall thickening has disappeared.
was performed laparoscopically. Angiography was used to confirm the location of the arteriovenous fistula as needed intraoperatively. The mesorectal fascia was separated near the anastomosis site, and the abnormal vessel that formed the arteriovenous fistula was identified. On angiography, the SRV disappeared with blockage of this site, and the abnormal vessel was resected (Figure 4). The postoperative course was good, and the patient left the hospital after 11 days. As of 1 year after this surgery, no recurrence of the diarrhea has been reported.
The cause of arteriovenous fistula in the portal circulation is iatrogenic in the majority of cases (60%). In about 25% of cases, it is caused by congenital anomalies, including arteriovenous malformation and Osler-RenduWeber disease (1). Other causes are idiopathic or traumatic, and associated with events such as aneurysm rupture. These fistulas occur most commonly in the celiac artery region. Occurrence in the IMA region is exceedingly rare (1–3). The most common symptoms on initial examination in cases of arteriovenous fistula in the IMA region include abdominal pain, diarrhea, and abdominal masses (2,4), but patients occasionally present with portal hypertension symptoms (5,6). The mechanism for these symptoms involves stolen arterial blood from the arteriovenous fistula that flows directly into a vein, leading to venous hypertension. A state of relative congestion/ischemia then occurs due to obstruction of local venous circulation, causing ischemic enterocolitis. Frequent diarrhea is thought to have occurred in the present patient due to this mechanism. Bruit is useful in the diagnosis of arteriovenous fistula, but it cannot be heard in all cases. Angiography has previously been considered essential for diagnosis, but the utility of MRI and 3-D CT has been widely indicated in recent years (2,4,7). The present case could have also been diagnosed with 3-D CT. Reported causes of iatrogenic arteriovenous fistula include direct arteriovenous injury during surgery, infection/necrosis of vessel walls, arteriovenous consolidated ligation, and suture ligation (8,9). Given the course of the present case, iatrogenic onset seems the most likely possibility. However, because the superior rectal artery and SRV were each separated intraoperatively, ligated
Asian J Endosc Surg 7 (2014) 56–59 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
57
Rectal arteriovenous fistula
H Ushigome et al.
a
b
Figure 3 (a) On 3-D CT, a blood vessel thought to be SRV (blue arrows) appears alongside the SRA in the arterial phase. (b) Selective angiography from the left internal pudendal artery. Only the left branch of the SRA (red arrow) appears. Contrast agent flows into the SRV (blue arrows) near the anastomosis site and the SRV are shown. SRA, superior rectal artery; SRV, superior rectal vein.
a
b
c
Figure 4 Laparoscopic views and intraoperative angiography. (a) On angiography, arteriovenous fistula was identified (red arrow). (b) The SRV disappeared with blockage of this fistula. (c) The abnormal vessel was resected. SRV, superior rectal vein.
with absorbable sutures, and then cut using an ultrasonically activated scalpel, other causes should also be considered. Laparoscopic surgery is a widely used procedure that is performed with specialized instruments including ultrasonically activated scalpels, which cut and coagulate tissue simultaneously, and techniques, such double stapled anastomosis. In the present patient, nearly all tissue was cut with an ultrasonically activated scalpel and a double stapled anastomosis was performed. It is possible that these instruments and techniques, which are frequently used in laparoscopic procedures, affected the occurrence of arteriovenous fistula in the present case. Reported methods of treating arteriovenous fistula include interventional radiology, arteriovenous fistula resection, and colectomy, but no consensus has been reached on a preferred method (2,10). In the present case, conservative treatment proved ineffective and interventional radiation was contraindicated, so arteriovenous fistula resection, including bowel resection, was scheduled. Because the site of the arteriovenous fistula was near the peritoneal reflection, where securing a visual field is
58
difficult, we selected laparoscopic surgery. Although there have been no reported cases of laparoscopic surgery under such circumstances, it was thought that the arteriovenous fistula could be safely identified because laparoscopic surgery is minimally invasive and extends the visual field. Because the blood vessels were ligated rather than clipped, concurrent intraoperative angiography was used to ensure there were no objects for marking and to reliably identify the arteriovenous fistula. With this procedure, the arteriovenous fistula could be identified within the adhesive and consolidated mesorectum. After it was confirmed that the SRV was no longer compressed, only the abnormal vessels that formed the arteriovenous fistula could be excised. Laparoscopy effectively expanded the view in the narrow, deep pelvis, while angiography enabled reliable identification of the arteriovenous fistula. Both modalities thus proved extremely useful. Despite the success of this case, the possibility exists that arteriovenous fistula may occur due to the surgical implements and techniques unique to laparoscopic surgery, the indications for which have increased for gastrointestinal diseases in recent years. In the future,
Asian J Endosc Surg 7 (2014) 56–59 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Rectal arteriovenous fistula
H Ushigome et al.
accumulating and analyzing additional cases similar to the present one will be necessary. 5.
Acknowledgment The authors have no conflicts of interest to report. 6.
References 1. Pietri J, Remond A, Reix T et al. Arterioportal fistulas: Twelve cases. Ann Vasc Surg 1990; 4: 533–539. 2. Matui A, Iwai K, Kawasaki R et al. Transcatheter embolization of an inferior mesenteric arteriovenous fistula with frequent mucous diarrhea. Nihon Shokakibyo Gakkai Zasshi 2007; 104: 194–199. (in Japanese with English abstract). 3. Kamo M, Huwa S, Ishiyama M et al. A case of ischemic colitis caused by inferior mesenteric arteriovenous fistula. Rinsyouhousyasenn 2012; 57: 309–313. (in Japanese). 4. Türkvatan A, Ozdemir Akdur P, Akdog˘an M et al. Inferior mesenteric arteriovenous fistula with ischemic colitis:
7.
8.
9. 10.
Multidetector computed tomographic angiography for diagnosis. Turk J Gastroenterol 2009; 20: 67–70. Capron JP, Gineston JL, Remond A et al. Inferior mesenteric arteriovenous fistula associated with portal hypertension and acute ischemic colitis: Successful occlusion by intraarterial embolization with steel coils. Gastroenterology 1984; 86: 351–355. Dan R, Santhat N, James C. Ischemic colitis: An unusual case of inferior mesenteric arteriovenous fistula causing venous hypertension. Report of a case. Dis Colon Rectum 2008; 51: 1422–1424. Okada K, Furusyo N, Sawayama Y et al. Inferior mesenteric arteriovenous fistula 8-years after sigmoidectomy. Intern Med 2002; 41: 543–548. (in Japanese). Sumitomo K, Nakagawa T, Kobayashi H et al. Superior mesenteric arteriovenous fistula: Report of a case and review of the literature. Jpn J Surg 1993; 23: 73–77. Rossi P, Carillo FJ, Alfidi RJ et al. Iatrogenic arteriovenous fistulas. Radiology 1974; 111: 47–51. Donell ST, Hudson MJ, Lynn K. Iatrogenic superior mesenteric arteriovenous fistula. Report of a case and review of the literature. J Vasc Surg 1998; 8: 335–338.
Asian J Endosc Surg 7 (2014) 56–59 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
59
Asian J Endosc Surg ISSN 1758-5902
C A S E R E P O RT
Rectal arteriovenous fistula resected laparoscopically after laparoscopic sigmoidectomy: A case report Hajime Ushigome, Tetsushi Hayakawa, Mamoru Morimoto, Hidehiko Kitagami & Moritsugu Tanaka Department of Surgery, Kariya Toyota General Hospital, Kariya, Japan
Keywords Iatrogenic; laparoscopic surgery; rectal arteriovenous fistula Correspondence Hajime Ushigome, Department of Surgery, Kariya Toyota General Hospital, 5-15 Sumiyoshi-cho, Kariya, Aichi 448-0852, Japan. Tel/Fax: +81 566 25 2902 Email: [email protected] Received: 19 September 2013; revised 19 October 2013; accepted 6 November 2013 DOI:10.1111/ases.12079
Abstract We report a very rare case of rectal arteriovenous fistula following sigmoidectomy and discuss this case in the context of the existing literature. In April 2011, the patient, a man in his 60s, underwent laparoscopic sigmoidectomy with lymph node dissection for sigmoid colon cancer. Beginning in February 2012, he experienced frequent diarrhea. Abdominal contrast-enhanced CT revealed local thickening of the rectal wall and rectal arteriovenous fistula near the anastomosis site. Rectitis from the rectal arteriovenous fistula was diagnosed. No improvement was seen with conservative treatment. Therefore, surgical resection was performed laparoscopically and the site of the lesion was confirmed by intraoperative angiography. The arteriovenous fistula was identified and resected. Postoperatively, diarrhea symptoms resolved, and improvement in rectal wall thickening was seen on abdominal CT. No recurrence has been seen as of 1 year postoperatively.
Introduction Arteriovenous fistula in the region of the inferior mesenteric artery (IMA) is very rare, with few reported cases. No previous reports have described onset following laparoscopic surgery or treatment with laparoscopic surgery. We report a case of rectal arteriovenous fistula that developed after laparoscopic sigmoidectomy with lymph node dissection. This arteriovenous fistula could be resected laparoscopically.
Case Presentation The patient was a man in his 60s with no medical history of note, except for hypertension. In April 2011, laparoscopic sigmoidectomy with D3 dissection was performed for treatment of sigmoid colon cancer. The left colic artery was preserved and the IMA peripheral to this was excised. A mechanical anastomosis was made using a double stapling technique. The postoperative course was good and the patient left the hospital after 9 days. Beginning in February 2012, the patient began to experience frequent diarrhea. No abnormalities were
56
seen on either abdominal examination or hematological findings. Fecal culture also yielded negative results for potential causative organisms of diarrhea. Colonoscopy revealed the rectal mucosa to the anal side of the anastomosis site was edematous, and engorged blood vessels were apparent (Figure 1a). CT showed that the wall of the entire circumference of the rectum to the anal side of the anastomosis site had thickened (Figure 2a). On 3-D CT, a blood vessel thought to be the superior rectal vein (SRV) was depicted alongside the superior rectal artery in the arterial phase (Figure 3a). When the internal pudendal artery was selectively enhanced from the left internal iliac artery, the SRV was depicted with contrast agent flowing into the SRV from the superior rectal artery near the anastomosis site (Figure 3b). Based on these findings, rectal arteriovenous fistula was diagnosed. Conservative treatment with fasting and intravenous drip was performed, but no improvement in symptoms was seen. The IMA had been severed in the previous surgery and the approach to the abnormal vessel was difficult. Embolization was therefore not considered feasible, and a strategy of resecting either the arteriovenous fistula or the colon was adopted. Surgery
Asian J Endosc Surg 7 (2014) 56–59 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Rectal arteriovenous fistula
H Ushigome et al.
a
b
Figure 1 Colonoscopy. (a) Preoperative. Capillaries are increased and rectal mucosa has become edematous at the margin of the anastomosis site. (b) Postoperative. Capillaries remain, but edematous changes in the rectal mucosa have disappeared.
a
Engorged vessels were apparent on colonoscopy, but edematous changes to the mucosa were no longer apparent (Figure 1b,2b).
Discussion
b
Figure 2 Abdominal CT. (a) Preoperative. Edematous wall thickening is seen around the entire circumference of the rectum at the margin of the anastomosis site. (b) Postoperative. Edematous wall thickening has disappeared.
was performed laparoscopically. Angiography was used to confirm the location of the arteriovenous fistula as needed intraoperatively. The mesorectal fascia was separated near the anastomosis site, and the abnormal vessel that formed the arteriovenous fistula was identified. On angiography, the SRV disappeared with blockage of this site, and the abnormal vessel was resected (Figure 4). The postoperative course was good, and the patient left the hospital after 11 days. As of 1 year after this surgery, no recurrence of the diarrhea has been reported.
The cause of arteriovenous fistula in the portal circulation is iatrogenic in the majority of cases (60%). In about 25% of cases, it is caused by congenital anomalies, including arteriovenous malformation and Osler-RenduWeber disease (1). Other causes are idiopathic or traumatic, and associated with events such as aneurysm rupture. These fistulas occur most commonly in the celiac artery region. Occurrence in the IMA region is exceedingly rare (1–3). The most common symptoms on initial examination in cases of arteriovenous fistula in the IMA region include abdominal pain, diarrhea, and abdominal masses (2,4), but patients occasionally present with portal hypertension symptoms (5,6). The mechanism for these symptoms involves stolen arterial blood from the arteriovenous fistula that flows directly into a vein, leading to venous hypertension. A state of relative congestion/ischemia then occurs due to obstruction of local venous circulation, causing ischemic enterocolitis. Frequent diarrhea is thought to have occurred in the present patient due to this mechanism. Bruit is useful in the diagnosis of arteriovenous fistula, but it cannot be heard in all cases. Angiography has previously been considered essential for diagnosis, but the utility of MRI and 3-D CT has been widely indicated in recent years (2,4,7). The present case could have also been diagnosed with 3-D CT. Reported causes of iatrogenic arteriovenous fistula include direct arteriovenous injury during surgery, infection/necrosis of vessel walls, arteriovenous consolidated ligation, and suture ligation (8,9). Given the course of the present case, iatrogenic onset seems the most likely possibility. However, because the superior rectal artery and SRV were each separated intraoperatively, ligated
Asian J Endosc Surg 7 (2014) 56–59 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
57
Rectal arteriovenous fistula
H Ushigome et al.
a
b
Figure 3 (a) On 3-D CT, a blood vessel thought to be SRV (blue arrows) appears alongside the SRA in the arterial phase. (b) Selective angiography from the left internal pudendal artery. Only the left branch of the SRA (red arrow) appears. Contrast agent flows into the SRV (blue arrows) near the anastomosis site and the SRV are shown. SRA, superior rectal artery; SRV, superior rectal vein.
a
b
c
Figure 4 Laparoscopic views and intraoperative angiography. (a) On angiography, arteriovenous fistula was identified (red arrow). (b) The SRV disappeared with blockage of this fistula. (c) The abnormal vessel was resected. SRV, superior rectal vein.
with absorbable sutures, and then cut using an ultrasonically activated scalpel, other causes should also be considered. Laparoscopic surgery is a widely used procedure that is performed with specialized instruments including ultrasonically activated scalpels, which cut and coagulate tissue simultaneously, and techniques, such double stapled anastomosis. In the present patient, nearly all tissue was cut with an ultrasonically activated scalpel and a double stapled anastomosis was performed. It is possible that these instruments and techniques, which are frequently used in laparoscopic procedures, affected the occurrence of arteriovenous fistula in the present case. Reported methods of treating arteriovenous fistula include interventional radiology, arteriovenous fistula resection, and colectomy, but no consensus has been reached on a preferred method (2,10). In the present case, conservative treatment proved ineffective and interventional radiation was contraindicated, so arteriovenous fistula resection, including bowel resection, was scheduled. Because the site of the arteriovenous fistula was near the peritoneal reflection, where securing a visual field is
58
difficult, we selected laparoscopic surgery. Although there have been no reported cases of laparoscopic surgery under such circumstances, it was thought that the arteriovenous fistula could be safely identified because laparoscopic surgery is minimally invasive and extends the visual field. Because the blood vessels were ligated rather than clipped, concurrent intraoperative angiography was used to ensure there were no objects for marking and to reliably identify the arteriovenous fistula. With this procedure, the arteriovenous fistula could be identified within the adhesive and consolidated mesorectum. After it was confirmed that the SRV was no longer compressed, only the abnormal vessels that formed the arteriovenous fistula could be excised. Laparoscopy effectively expanded the view in the narrow, deep pelvis, while angiography enabled reliable identification of the arteriovenous fistula. Both modalities thus proved extremely useful. Despite the success of this case, the possibility exists that arteriovenous fistula may occur due to the surgical implements and techniques unique to laparoscopic surgery, the indications for which have increased for gastrointestinal diseases in recent years. In the future,
Asian J Endosc Surg 7 (2014) 56–59 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Rectal arteriovenous fistula
H Ushigome et al.
accumulating and analyzing additional cases similar to the present one will be necessary. 5.
Acknowledgment The authors have no conflicts of interest to report. 6.
References 1. Pietri J, Remond A, Reix T et al. Arterioportal fistulas: Twelve cases. Ann Vasc Surg 1990; 4: 533–539. 2. Matui A, Iwai K, Kawasaki R et al. Transcatheter embolization of an inferior mesenteric arteriovenous fistula with frequent mucous diarrhea. Nihon Shokakibyo Gakkai Zasshi 2007; 104: 194–199. (in Japanese with English abstract). 3. Kamo M, Huwa S, Ishiyama M et al. A case of ischemic colitis caused by inferior mesenteric arteriovenous fistula. Rinsyouhousyasenn 2012; 57: 309–313. (in Japanese). 4. Türkvatan A, Ozdemir Akdur P, Akdog˘an M et al. Inferior mesenteric arteriovenous fistula with ischemic colitis:
7.
8.
9. 10.
Multidetector computed tomographic angiography for diagnosis. Turk J Gastroenterol 2009; 20: 67–70. Capron JP, Gineston JL, Remond A et al. Inferior mesenteric arteriovenous fistula associated with portal hypertension and acute ischemic colitis: Successful occlusion by intraarterial embolization with steel coils. Gastroenterology 1984; 86: 351–355. Dan R, Santhat N, James C. Ischemic colitis: An unusual case of inferior mesenteric arteriovenous fistula causing venous hypertension. Report of a case. Dis Colon Rectum 2008; 51: 1422–1424. Okada K, Furusyo N, Sawayama Y et al. Inferior mesenteric arteriovenous fistula 8-years after sigmoidectomy. Intern Med 2002; 41: 543–548. (in Japanese). Sumitomo K, Nakagawa T, Kobayashi H et al. Superior mesenteric arteriovenous fistula: Report of a case and review of the literature. Jpn J Surg 1993; 23: 73–77. Rossi P, Carillo FJ, Alfidi RJ et al. Iatrogenic arteriovenous fistulas. Radiology 1974; 111: 47–51. Donell ST, Hudson MJ, Lynn K. Iatrogenic superior mesenteric arteriovenous fistula. Report of a case and review of the literature. J Vasc Surg 1998; 8: 335–338.
Asian J Endosc Surg 7 (2014) 56–59 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
59
