Image of the Month—Diagnosis | Congenital Defects | JAMA Surgery | JAMA Network
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Special Feature
Sep 2011

Image of the Month—Diagnosis

Arch Surg. 2011;146(9):1102-1103. doi:10.1001/archsurg.2011.215-b

The patient underwent an esophagogastroduodenoscopy to identify the source of the gastrointestinal bleeding, and graft material was seen at the base of a duodenal diverticulum with no active bleeding, indicating an aortoduodenal fistula (Figure 1). Understanding the risks, the patient refused any surgery. She was treated with a nasogastric tube and intravenous vancomycin hydrochloride and Zosyn (piperacillin sodium and tazobactam sodium; Wyeth, Madison, New Jersey). Her peritonitis resolved within 4 days. She then agreed to a palliative repair of the endoleak (Figure 2A and C). She was treated with an Excluder bifurcated endograft (W. L. Gore & Associates, Inc, Flagstaff, Arizona). A second Excluder bifurcated endograft was inserted into the first endograft, with the orientation such that the second device was rotated 180° compared with the first device, ensuring complete overlap of the 2 main bodies and converting the bifurcated device into an aorto-uni-iliac endograft. A completion angiogram showed complete resolution of the type IIIb endoleak (Figure 2B). The patient tolerated the procedure well without any complications and with complete resolution of the melanotic stool and endoleak confirmed by a computed tomographic angiographic scan with 3-dimensional reconstruction (M2S Inc, West Lebanon, New Hampshire). The patient was discharged from the hospital with oral antibiotics. At 1-year follow-up, the patient was doing well, without any complaints of abdominal pain or gastrointestinal bleeding, and tolerating a normal diet. There is no evidence of an endoleak or an expansion of the aneurysm on the 1-year follow-up computed tomographic scan with 3-dimensional reconstruction (Figure 2D).