First case report of gastric outlet obstruction due to aortofemoral bypass Dacron graft erosion of the duodenum treated with neo aortoiliac system procedure

INTRODUCTION: Gastric outlet obstruction is an uncommon complication of surgical treatment of aortoiliac occlusive disease with aortofemoral bypass. The most frequent presenting feature of duodenal erosion due to aortic synthetic graft is upper gastrointestinal bleeding, which can range from a minor “herald” bleed to exsanguinating hemorrhage. CASE PRESENTATION: A 64-year-old male patient with an aortofemoral Dacron bypass due to aortoiliac occlusive disease TASC II D with a chronic graft infection required emergency resection of the right limb of the Dacron graft two years ago. The patient developed abdominal pain, postprandial vomiting and progressive weight loss with an upper gastrointestinal endoscopy that showed Dacron graft material eroding into the fourth portion of the duodenum generating a gastric outlet obstruction without aortoenteric fistula and ulceration in the duodenal mucosa. CLINICAL DISCUSSION: The treatment goals of aortoenteric fistula are to control hemorrhage, treat infection, maintain adequate distal perfusion, graft explantation and aortic reconstructions like in this case. Traditional treatment of aortoenteric fistula is graft excision and establishing an anatomic autologous or an extra-anatomic synthetic bypass. Neo aortoiliac system procedure has shown to be the most effective and safest emerging technique today. CONCLUSION: Aortoenteric fistula is a life-threatening condition associated with high morbidity and mortality and it can also pose a diagnostic dilemma. There are many presentations of aortoenteric fistula including gastric outlet obstruction syndrome. The neo aortoiliac system procedure is the ideal curative surgical approach in stable patients.