Ralph W. DeNatale, M.D., E. Stanley Crawford, M.D., Hazim J. Sail, M.D., and Joseph S. Coselli, M.D., Houston, Tex.

Transcription

1 Graft reconstruction to treat disease of the abdominal aorta in patients with colostomies, ileostomies, and abdominal wall urinary stomata Ralph W. DeNatale, M.D., E. Stanley Crawford, M.D., Hazim J. Sail, M.D., and Joseph S. Coselli, M.D., Houston, Tex. Abdominal aortic reconstruction combined with colon or urinary tract operations is generally not acceptable because of a supposed greater incidence of graft infection. Similar fears exist regarding aortic reconstruction in the presence of colostomies, ileostomies, and permanent urinary diversion stomata. In fact, the presence of a colostomy has been reported to be a contraindication for abdominal aortic reconstruction. This report is concerned with vascular operations in 13 such patients with aortic disease referred to us for fear of these complications. Eleven patients had abdominal aortic aneurysms and two had atherosclerotic occlusion of the aorta and iliac arteries. Twelve patients had colostomies, ileostomies, or both and one patient had permanent tube cystostomy. All had good renal function and the disease for which the diversion procedure was performed was either cured or under good control. All patients survived the vascular reconstructive procedures without significant complications and long-term follow-up revealed that late graft infection did not occur. ( J VASe SURG 1987;6:240-7.) Graft reconstruction for aortic disease generally is not combined with colon resection for fear of graft site contamination and subsequent graft infection. A similar cautious approach is taken in patients with infected urinary tract disease. The usual manner of managing this combination of diseases is staging operation by treating the most life- or limb-threatening condition first and then performing operative treatment of the other at a later date when the patient is fully recovered and the operative site is healed. Abdominal wall colostomies and ileostomies performed for fecal diversion are also considered to be sources of contamination. When these structures are permanent, they may be permanent sources of contamination and some surgeons have expressed the opinion that they are contraindications for reconstructive operation in the treatment of aortic disease. 1,2 Aversion to aortic reconstruction also has been taken in patients with permanent cutaneous urinary diversion stomata for fear of contamination. Additional concerns include injury to altered urinary From the Department of Surgery, Baylor College of Medicine and The Methodist Hospital. Presented at the Eleventh Annual Meeting of the Southern Association for Vascular Surgery, Scottsdale, Ariz., Jan , Reprint requests: E. Stanley Crawford, M.D., 6535 Fannin St. MS B-405, Houston, TX Table I. Type, duration, and disease requiring diversion procedures (n = 13) No. of Duration Type of divenion ~ses (yr) Original disease End colostomy (fecal) Cancer--rectum Ileostomy (fecal) 1 1 Ulcerative colitis Ileostomy (urinary) Cancer--bladder Ileostomy (urinary) 1 3 Cancer--pros- Colostomy (fecal) tate Tube cystostomy 1 7 Neurogenic bladder tract anatomy in patients with urinary diversion procedures and sources of colon blood supply in patients with colostomies who had previous multiple operations for large bowel disease. Finally, since both fecal and urinary diversion procedures are usually performed in the adult for malignant disease, a conservative approach to the vascular disease is assumed, usually on the basis that the malignant disease may run its fatal course ahead of the vascular disease. Regardless of these appropriate cautious attitudes based primarily on principles established in the treatment of combined intra-abdominal malignancy and aortic disease, certain clinical situations appear to warrant abdominal aortic reconstruction in patients previously subjected to diversion procedures. There-

2 Volume 6 Number 3 September 1987 Aortic graft reconstruction in presence of colostomy, ileostomy, and urina~ stoma 241 Fig. 1. Drawings show position of patient and location of incision used in treatment of thoracoabdominal aortic aneurysms and infrarenal abdominal aortic aneurysms that were approached retroperitoneally. fore the purpose of this article is to present an experience in the treatment of 13 patients during the past 21 years with these conditions because the resuits suggest that the previously established principles of treatment of coincidental intra-abdominal malignancy and abdominal aortic aneurysms may be modified to allow combining treatment in certain selected cases with both abdominal wall fecal or urinary diversion and abdominal aortic disease, s PATIENTS There were 12 men and one woman in this group of patients whose ages ranged from 48 to 77 years. Eleven patients had aneurysms varying in size from 8 to 10 cm--three thoracoabdominal, one juxtarenal infrarenal, and seven infrarenal in location. The predominant symptom in these patients was either pain or tenderness related to the aneurysm. Two patients had aortoiliac occlusive disease: one had complete bilateral aorto-iliac artery obstruction and the other had occlusion of the left iliac limb of a bilateral aortocommon femoral artery bypass graft. Both patients had rest and night pain in the affected extremities. The type, duration, and disease requiring diversion procedures in these patients are shown in Table I. All of the patients were in good general health and disease requiring diversion was either cured or under good control. The midline abdominal incision employed for the original operation was well healed and the skin around the ostomy sites was in good condition. The aortic disease was confirmed by aortography and excretory urography showed the condition of the kidneys and position of the ureters and ileal loops. The kidneys appeared normal and the ureters were not obstructed. Renal function was good in all cases. TREATMENT The patients bathed twice daily for 2 days before operation and broad-spectrum antibiotics considered appropriate during the period of treatment were given parenterally every 8 hours beginning 8 hours before operation, during operation, and for 5 days after operation. In addition, patients with fecal diversion were purged 48 hours before operation, limited to liquid diet, and given oral antibiotics (neomycin i gin, erythromycin base I gm, at i VM, 2 VM, 9 VM, and 11 VM the day before operation) to diminish enteric flora. After anesthetization, endotracheal and nasogastric tube insertion, the clean ostomy bags that had been attached in the patients' rooms on the day of operation were removed and the abdominal wall and upper thighs were thoroughly washed and dried. Soft rubber catheters of appropriate size were inserted into the stomata and attached to the side of the patient and inserted into a container attached to the side of the operating table. A plastic adhesive drape was then attached to the upper thighs, abdomen, and chest excluding the stoma from the prospective line of incision. Operation was then performed through incisions made 2 cm or more from the ostomy site and usually included excision of old midline scars made at the previous operation. The three thoracoabdominal aneurysms were treated through thoracoabdominal incisions, with

3 242 DeNatale et al. Journal of VASCULAR SURGERY,/ / Y Fig. 2. Drawings show method ofthoracoabdominal aortic replacement of aneurysm in patients with sigmoid colostomies. A, The descending thoracic and upper abdominal aorta is replaced and the visceral arteries are reattached above the transverse colon. B, The transverse colon is then retracted upward, the infrarenal abdominal aorta exposed, and then replaced by the distal end of graft. the abdominal segment being made in the midline (Fig. 1). The suprarenal abdominal segment of aneurysm in two of three patients was exposed retroperitoneauy by incising the peritoneum along the left gutter and mobilizing the descending colon from near the colostomy site upward, including the splenic flexure, the left kidney, spleen, stomach, and tail of pancreas. These structures were reflected upward and to the right exposing the posterolateral aspect of the aneurysm from above downward to just below the renal arteries (Fig. 2, A). These organs were then replaced to their original position, the small bowel retracted to the right, and the infrarenal aortic segment exposed in the midline medial to the colostomy limb of the colon in the conventional manner. The upper exposure was repeated and the descending thoracic and upper abdominal segment of aneurysm was replaced as previously described. 4 After visceral vessel reattachment, the graft was damped below the renal arteries and circulation restored into these arteries.

4 Volume 6 Number 3 September 1987 Aortic graj~ reconstruction m presence of colostomy, ileostomy, and urina~ stoma 243 Fig. 3. Graft replacement of abdominal aortic aneurysm and preservation of residual colon circulation in a patient who had first abdominoperineal resection of rectum for cancer and later right and hepatic flexure resection for a second cancer. A, Drawing made before operation shows location and extent of aneurysm and blood supply of residual colon. B, Drawing made of operation shows location and aortic graft and reattachment of inferior mesenteric artery. Operation was then shifted to the lower midline exposure and the infrarenal abdominal aortic segment replaced (Fig. 2, B). The third patient with a thoracoabdominal aneutysm had a low midline tube cystotomy. This patient was treated in the conventional manner after the cystotomy site was excluded by drapes as described. Six patients with infrarenal abdominal aortic aneurysms were treated by midline abdominal incisions. Five of these had left lower quadrant colostomies. In four patients, aneurysmal exposure and replacement was performed in the usual manner. The residual colon in the fifth case was dependent on the inferior mesenteric artery for its blood supply (Fig. 3). The aneurysm was replaced as in the former cases and the inferior mesenteric artery was reattached to the graft as previously reported, s One patient had a right lower quadrant stoma for ileal loop urinary diversion and another had a left lower quadrant colostomy as well as a right lower quadrant ileostomy for ileal loop urinary diversion (Fig. 4). The intra-abdominal ileal loop and its mesentery were easily identified overlying the peritoneum covering the aneurysm. The ureters had been connected to the loop respective to their original locations and were thus not intimately related to the aneurysm. The ileal loop in these cases was first separated from the peritoneum coveting the aneurysm and retracted downward. The anterior surface of the aneurysm was exposed in the conventional manner. The aorta and iliac arteries were clamped and the aneurysm incised anteriorly. The graft was inserted in the usual fashion. Retroperitoneal extraperitoneal exposure was employed in two patients with abdominal aortic aneurysms who had right-sided ileal loop urinary diversion stomata (Fig. 5). Both patients had had three previous attempts at aneurysm resection through midline transabdominal exposure, but operation had been abandoned either because of adhesions or because the ureteral diversion anatomy was not clear. Transabdominal retroperitoneal exposure allowed

5 244 DeNatale et al. Journal of VASCULAR SURGERY B Fig. 4. Graft replacement for abdominal aortic aneurysm in patient who had both right-sided ileal loop urinary diversion and left-sided end sigmoid colostomy. A, Drawing made before operation shows location of ureters and ileum and extent of aneurysm. B, Drawing shows method of treatment. displacement of the left kidney, ureter, and ileal loop upward and to the right with the left colon and other viscera. The aneurysm was then replaced from behind those structures. Both patients with occlusive disease had ileostomy stomata, one for fecal diversion and the other for urinary diversion. One limb of an aorto-bilateral femoral artery bypass graft that had been previously inserted was obstructed in the patient with the stoma for fecal diversion and this was treated by femorofemoral artery bypass graft. Obstruction was complete and involved the aorta and renal and iliac arteries in the latter case. This patient was treated by proximal endarterectomy of the aorta, superior mesenteric, right renal, and distal aorto-common femoral artery bypass grafts performed through midabdominal and bilateral groin incisions with the graft being placed alongside and behind the ileal loop (Fig. 6). Management after operation. The incisions were dressed separately with an adhesive bandage after a new bag was firmly secured to the skin around the ostomy site or sites. This or a similar bag was maintained in place until the wound had healed and sutures or clips were removed. Broad-spectrum antibiotics were given, as indicated earlier, for 5 days. RESULTS All of the patients survived operation with successful restoration of circulation. The thoracic and abdominal wounds healed without complications. One femoral wound in the patient who had femorofemoral artery bypass developed a superficial wound infection that did not involve the deeper layer surrounding the graft. This wound was treated by opening the superficial layers, frequent local wound dressing, and secondary closure. Infection was due to Staphylococcus epiderrai~, which was treated by cefazolin (Kefzol) (1 grn) given intramuscularly every 8 hours for 2 weeks followed by cephalexin (Keflex) (1 gin) taken orally every 6 hours for 3 months. Late results. All patients have been followed up and no patient had either wound or graft infection after discharge from the hospital. Three patients have died, one at 9 years of rupture of thoracic aortic aneurysm, one at 8 years of myocardial infarction, and one at 3 years of renal failure. Ten patients are still alive, two less than 6 months, six from 6 months

6 Volume 6 Number 3 September 1987 Aortic graft reconstruction in presence of colostomy, ileostomy, and urina~ stoma 245 w" ~.~ ~ii ~ ~ ~-'~ ', ~\\~ Fig. 5. Method of graft replacement of infrarenal aortic aneurysm with the transperitoneal retroperitoneal approach. With the use of the incision shown in Fig. 1, the chest is entered through the bed of the ninth or tenth rib to expose the upper surface of the diaphragm and lower thoracic aorta. The peritoneum is either stripped from the undersurface of diaphragm and abdominal wall (completely retroperitoneal) or the peritoneum is entered anteriorly and then the retroperitoneum is entered lateral to the descending colon. Regardless, the aorta is exposed laterally and behind by retracting the viscera upward and to the right. The aorta is clamped above the diaphragm, the aneurysm opened, the proximal segment flushed, and the graft is damped below the renal arteries. Visceral arterial blood flow is restored by removal of the lower thoracic aortic clamp while the distal anastomosis is being made. to 2 years, one at 30 months, and one at 8 years. Cancer has not recurred and peripheral circulation has remained good either to the time of death or follow-up. DISCUSSION The results obtained in this small group of patients suggest that elective abdominal aortic operation may be considered in certain patients with abdominal wall fecal and urinary diversion. Guidelines of management may be employed in this type of patient as previously outlined in patients with coincidental intra-abdominal malignancy and abdominal aortic aneurysm, s These guidelines include the following: (1) An absolute indication for consideration of aortic reconstruction for abdominal aortic aneurysm is rupture or pain and tendemess of aneurysm. An absolute indication for consideration of aortic or arterial reconstruction for aortoiliac occlusive disease is impending gangrene or rest pain in the lower extremities, especially when the lesion is not susceptible to balloon dilatation treatment. Another absolute indication is when the vascular lesion is associated with other complications such as bowel or great vein erosion, infection, embolization, and disseminated intravascular coagulation. (2) A reasonable indication for elective operation in a patient with a mature stoma with healthy surrounding skin and controlled bowel or urinary tract disease is a large asymptomatic aneurysm, more than 5 cm in diameter, or an enlarging aneurysm, and in a patient with worsening symptoms of claudication when dilatation

7 246 DeNutule et al. Journal of VASCULAR SURGERY Fig. 6. Proximal endarterectomy of aorta, superior mesenteric, and right renal artery and aortobilateral common femoral artery bypass graft in treatment of patient with total aortic obstruction occurring after left nephrectomy, total cystectomy, and right-sided ileal loop urinary diversion. A, Drawing shows extent of occlusive disease and position of ileal loop urinary diversion procedure. B, Drawing of treatment used in this case. is not possible. (3) A conservative watchful approach would appear indicated in patients with small asymptomatic aneurysms, less than 5 cm, or aortoiliac occlusion that produces only mild to moderate intermittent daudication. (4) Contraindications to elective vascular operations may include uncontrolled or advanced cancer; immature stomata or stomal complications including abscesses, sinuses, skin rashes, and ulcerations; and hydronephrosis, pyelonephritis, and uremia complicating malfunctioning urinary diversion procedures. Prophylaxis. The aortic problem in the 13 patients reported here occurred after the operations that resulted in fecal or urinary diversion. Therefore preventive measures were not possible. When the diseases requiring aortic reconstruction and fecal or urinary diversion coexist, management (frequently by proper staging) may avoid the necessity of aortic reconstruction in the presence of diversion stomata. For example, elective operations requiring urinary tract diversion or proctocolectomy may be delayed several weeks, during which time aortic reconstruc- tion may be safely and effectively performed in routine fashion. Moreover, the presence of a healed graft site should not impose problems for the subsequent bowel or urinary tract operation. Preferred method of aortic reconstruction. The opportunities for contamination are the same regardless of routes of exposure and methods of reconstruction. It is therefore recommended that conventional procedures that produce the best immediate and long-term results be employed. In general, this includes graft replacement of aneurysms and aortoiliac Or aortofemoral bypass in patients with aortoiliac occlusive disease. Simple unilateral iliac artery occlusion may be effectively treated by femorofemoral bypass. The placement of incision and the route of exposure are selected for the advantages of exposure in the individual case and not simply to dodge the location of the ostomy site. The retroperitoneal approach to the abdominal aorta is preferred in patients with thoracoabdominal aneurysms and in other patients regardless of the origin of aortic disease when it is known from pre-

8 Volume 6 Number 3 September 1987 A orticgraft reconstruction in presence of colostomy, ileostomy, and urinao, stoma 247 vious operations that the patient has extensive adhesions and in those patients with history of complicated ureteral reconstructions. These indications are absent in most patients; consequently, standard approaches depending on the preference of the surgeon are advised. We prefer midline abdominal incisions. Percutaneous balloon dilatation was successfully used in three patients with iliac artery obstruction and in one patient with renal artery obstruction in addition to those reported here. Open abdominal operation was avoided in these cases. Extra-anatomic bypass (femorofemoral artery bypass) was successfully employed in one patient in this series. Axillobilateral femoral artery bypass was not used because the procedure was considered inferior to those em- ployed and would not have reduced the possibility of contamination. REFERENCES 1. Dale WA. Management of vascular surgical problems. New York: McGraw-Hill, 1985: Rutherford RB. Infrarenal aortic aneurysms. In: Rutherford RB, ed. Vascular surgery, 2rid ed. Philadelphia: WB Saunders, 1984; Szilagyi DE, Elliott JP, Berguer R. Coincidental malignant, and abdominal aortic aneurysm. Arch Surg 1967;95: Crawford ES. Thoracoabdominal and abdominal aortic aneurysms involving renal, superior mesenteric, and celiac arteries. Ann Surg 1974;179: Crawford ES. Symposium: prevention of complications of abdominal aortic reconstruction. Introduction. Surgery 1983; 93:91-6.