Scientific Letter
Renal-Appendicular Fistula of the Renal Graft in a Transplanted Patient: An Uncommon Form of Lower Gastrointestinal Hemorrhage
Fistula reno-apendicular del injerto renal en paciente trasplantado: forma infrecuente de hemorragia digestiva baja
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"referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Guillermo" "apellidos" => "Marín-Hargreaves" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Marta" "apellidos" => "Ramírez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Pedro" "apellidos" => "Moya" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Antonio" "apellidos" => "Arroyo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Cirugía General y Aparato Digestivo, Hospital General Universitario, Elche, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio Cirugía Vascular, Hospital General Universitario, Elche, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Fistula reno-apendicular del injerto renal en paciente trasplantado: forma infrecuente de hemorragia digestiva baja" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1696 "Ancho" => 800 "Tamanyo" => 195672 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a and b) Inflammatory mass in the right iliac fossa (RIF) encompassing the appendix with an orifice that corresponds with the appendix-graft fistula.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Primary aortoenteric fistula (PAEF) is defined as an abnormal communication between the aorta and a segment of the gastrointestinal tract. It differs from secondary aortoenteric fistula, in which there is previous aortic surgery.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Most PAEF occur in the duodenum (83%), mainly in the third and fourth portion, although it may occasionally occur in other segments of the gastrointestinal tract, such as the small intestine, colon or even appendix, although there are very few cases reported of this location in the literature.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case report of a kidney transplant recipient who developed a fistula between the donor renal artery (which presented aneurysmal dilatation) and the appendix, causing symptoms of abdominal pain and lower gastrointestinal bleeding that required emergency surgical intervention.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient was a 70-year-old male with a history of renal transplantation (1994) who came to our Emergency Department complaining of abdominal pain and fever for several hours. In the ER, he presented with symptoms of anal bleeding and hypovolemic shock, which responded to fluid therapy. Once the patient was stabilized, abdominal CT revealed the renal graft in the right liac fossa (RIF), and a lesion at the iliac bifurcation that seemed to correspond with a false aneurysm of the graft, measuring 3<span class="elsevierStyleHsp" style=""></span>cm with gas in its interior. In the proximity, a probable loop of the small intestine or thickened appendix was visualized. The findings suggested an inflammatory process in the donor renal artery area, complicated with possible fistulization to a small intestinal loop or appendix.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Angiography demonstrated a leak of contrast from the aneurysmal dilatation of the donor arterial anastomosis to the intestine. A covered prosthesis was positioned, excluding the aneurysm of the renal artery. Having resolved the arterial leak, a laparotomy was performed, revealing an inflammatory phlegmon in the right iliac fossa that encompassed the appendix with an orifice that corresponded with the appendix-graft fistula (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>a and b), and an appendectomy was performed. The patient had an uneventful postoperative course and was discharged on the 10th post-op day.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">PAEF is defined as an abnormal communication between the aorta and a segment of the gastrointestinal tract, with no previous aortic surgery. It is a rare disease, with few cases published in the medical literature, and was first described in 1817.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3,4</span></a> The main etiology is abdominal aortic aneurysm (AAA). Our patient developed an aneurysm, but in the donor renal artery. Other possible though very uncommon causes are septic aortitis, TBC, cancer or radiation.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The diagnosis and treatment of PAEF is difficult, and only 33%–50% of cases are diagnosed preoperatively. In the series published, gastrointestinal bleeding is the most frequent symptom (61%–94%), followed by signs of infection (20%–30%) and symptoms of acute ischemia (20%–30%).<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> Normally, the initial episodes of melenas or hematemesis resolve spontaneously, forming a kind of “sentinel bleeding” that tends to recur in periods of hours or days before the final massive bleeding. There is no diagnostic technique of choice; the combination of ultrasound and imaging tests (CT or MRI) can be a good option, although there are no published studies to support this. It is important to have a high index of suspicion based on the patient's medical history and physical examination for a correct diagnosis. It must be remembered that there are reports of mortality rates above 75% in cases of late diagnosis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">In kidney transplants, vascular complications represent 5%–10% of all complications, especially renal artery and vein thrombosis (1.7%), renal stenosis (1.5%), lymphoceles (12%) and renal artery aneurysms. The latter is a very rare complication of renal transplantation that can lead to loss of the graft. Generally, these aneurysms are easily diagnosed by follow-up CT in kidney transplant recipients and Doppler ultrasound provides the differential diagnosis with hematomas, urinomas and lymphocele.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Traditionally the technique of choice for treatment has been open surgery with repair of the aorta using a prosthesis (Dacron or PTFE) or extra-anatomical bypass. Endovascular procedures have increased in recent years, fundamentally in secondary aortoenteric fistulas, while in PAEF there are few cases described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The main complication of endovascular treatment is infection, although this also occurs in open surgery. On occasion, these patients present silent infections with no fever or leukocytosis. The probability of infection can be decreased if the local infection is eliminated first and the endovascular prosthesis is implanted later. These patients present high perioperative morbi-mortality. A recent review about PAEF concluded that around 2/3 of the patients died during surgery or in the first 30 days post-op.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, we can state that endovascular treatment of primary aortoenteric fistula is an effective alternative to open surgery, especially in high-risk patients, but treating this type of patients requires adequate training and experience.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0055" class="elsevierStylePara elsevierViewall">Foundation grant, <span class="elsevierStyleGrantSponsor" id="gs0005">Hospital General in Elche, Spain</span>.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Pérez-Legaz J, Marín-Hargreaves G, Ramírez M, Moya P, Arroyo A. Fistula reno-apendicular del injerto renal en paciente trasplantado: forma infrecuente de hemorragia digestiva baja. Cir Esp. 2013;91:397–399.</p>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1696 "Ancho" => 800 "Tamanyo" => 195672 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">(a and b) Inflammatory mass in the right iliac fossa (RIF) encompassing the appendix with an orifice that corresponds with the appendix-graft fistula.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Primary aortoenteric fistula and endovascular repair" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "S. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 3 | 5 |
| 2024 October | 6 | 8 | 14 |
| 2024 September | 21 | 15 | 36 |
| 2024 August | 16 | 17 | 33 |
| 2024 July | 16 | 12 | 28 |
| 2024 June | 9 | 1 | 10 |
| 2024 May | 9 | 8 | 17 |
| 2024 April | 13 | 4 | 17 |
| 2024 March | 12 | 0 | 12 |
| 2024 February | 15 | 3 | 18 |
| 2024 January | 11 | 1 | 12 |
| 2023 December | 17 | 2 | 19 |
| 2023 November | 23 | 1 | 24 |
| 2023 October | 26 | 2 | 28 |
| 2023 September | 9 | 4 | 13 |
| 2023 August | 9 | 3 | 12 |
| 2023 July | 28 | 5 | 33 |
| 2023 June | 30 | 1 | 31 |
| 2023 May | 22 | 3 | 25 |
| 2023 April | 17 | 0 | 17 |
| 2023 March | 12 | 1 | 13 |
| 2023 February | 8 | 7 | 15 |
| 2023 January | 12 | 5 | 17 |
| 2022 December | 7 | 3 | 10 |
| 2022 November | 22 | 7 | 29 |
| 2022 October | 28 | 10 | 38 |
| 2022 September | 15 | 10 | 25 |
| 2022 August | 19 | 9 | 28 |
| 2022 July | 9 | 7 | 16 |
| 2022 June | 9 | 5 | 14 |
| 2022 May | 14 | 4 | 18 |
| 2022 April | 11 | 7 | 18 |
| 2022 March | 11 | 7 | 18 |
| 2022 February | 13 | 7 | 20 |
| 2022 January | 17 | 6 | 23 |
| 2021 December | 11 | 10 | 21 |
| 2021 November | 10 | 6 | 16 |
| 2021 October | 22 | 7 | 29 |
| 2021 September | 10 | 10 | 20 |
| 2021 August | 18 | 11 | 29 |
| 2021 July | 11 | 11 | 22 |
| 2021 June | 10 | 6 | 16 |
| 2021 May | 8 | 7 | 15 |
| 2021 April | 21 | 4 | 25 |
| 2021 March | 18 | 11 | 29 |
| 2021 February | 10 | 11 | 21 |
| 2021 January | 16 | 7 | 23 |
| 2020 December | 5 | 7 | 12 |
| 2020 November | 9 | 7 | 16 |
| 2020 October | 9 | 6 | 15 |
| 2020 September | 20 | 6 | 26 |
| 2020 August | 12 | 5 | 17 |
| 2020 July | 5 | 3 | 8 |
| 2020 June | 8 | 6 | 14 |
| 2020 May | 17 | 8 | 25 |
| 2020 April | 8 | 3 | 11 |
| 2020 March | 12 | 4 | 16 |
| 2020 February | 7 | 2 | 9 |
| 2020 January | 10 | 6 | 16 |
| 2019 December | 23 | 5 | 28 |
| 2019 November | 11 | 7 | 18 |
| 2019 October | 9 | 7 | 16 |
| 2019 September | 18 | 4 | 22 |
| 2019 August | 12 | 1 | 13 |
| 2019 July | 17 | 13 | 30 |
| 2019 June | 52 | 27 | 79 |
| 2019 May | 127 | 27 | 154 |
| 2019 April | 47 | 16 | 63 |
| 2019 March | 3 | 2 | 5 |
| 2019 February | 10 | 10 | 20 |
| 2019 January | 4 | 4 | 8 |
| 2018 December | 4 | 1 | 5 |
| 2018 November | 7 | 1 | 8 |
| 2018 October | 7 | 3 | 10 |
| 2018 September | 21 | 4 | 25 |
| 2018 August | 3 | 1 | 4 |
| 2018 July | 5 | 1 | 6 |
| 2018 June | 4 | 0 | 4 |
| 2018 May | 7 | 5 | 12 |
| 2018 April | 8 | 2 | 10 |
| 2018 March | 3 | 0 | 3 |
| 2018 February | 5 | 1 | 6 |
| 2018 January | 5 | 7 | 12 |
| 2017 December | 11 | 4 | 15 |
| 2017 November | 7 | 2 | 9 |
| 2017 October | 8 | 1 | 9 |
| 2017 September | 8 | 2 | 10 |
| 2017 August | 8 | 2 | 10 |
| 2017 July | 15 | 1 | 16 |
| 2017 June | 9 | 4 | 13 |
| 2017 May | 20 | 1 | 21 |
| 2017 April | 12 | 2 | 14 |
| 2017 March | 21 | 4 | 25 |
| 2017 February | 21 | 3 | 24 |
| 2017 January | 20 | 4 | 24 |
| 2016 December | 15 | 8 | 23 |
| 2016 November | 21 | 5 | 26 |
| 2016 October | 24 | 6 | 30 |
| 2016 September | 21 | 11 | 32 |
| 2016 August | 15 | 10 | 25 |
| 2016 July | 10 | 2 | 12 |
| 2016 June | 19 | 6 | 25 |
| 2016 May | 21 | 27 | 48 |
| 2016 April | 17 | 14 | 31 |
| 2016 March | 18 | 28 | 46 |
| 2016 February | 20 | 17 | 37 |
| 2016 January | 18 | 6 | 24 |
| 2015 December | 10 | 6 | 16 |
| 2015 November | 20 | 3 | 23 |
| 2015 October | 34 | 6 | 40 |
| 2015 September | 27 | 7 | 34 |
| 2015 August | 12 | 9 | 21 |
| 2015 July | 6 | 1 | 7 |
| 2015 June | 5 | 1 | 6 |
| 2015 May | 24 | 0 | 24 |
| 2015 April | 18 | 8 | 26 |
| 2015 March | 20 | 7 | 27 |
| 2015 February | 8 | 2 | 10 |
| 2015 January | 26 | 0 | 26 |
| 2014 December | 42 | 12 | 54 |
| 2014 November | 16 | 3 | 19 |
| 2014 October | 16 | 4 | 20 |
| 2014 September | 16 | 1 | 17 |
| 2014 August | 11 | 6 | 17 |
| 2014 July | 19 | 2 | 21 |
| 2014 June | 9 | 2 | 11 |
| 2014 May | 13 | 3 | 16 |
| 2014 April | 13 | 2 | 15 |
| 2014 March | 10 | 2 | 12 |
| 2014 February | 6 | 2 | 8 |
| 2014 January | 8 | 3 | 11 |
| 2013 December | 8 | 3 | 11 |
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