Delayed Presentation of Rectal Ischaemia Following Aortic Surgery: Rectal Stricture, Local Perforation and Graft Infection

Abstract

We report a case of ischa-emic rectal stricture following emergency repair ofa leaking abdominal aortic aneurysm, complicatedby a delayed local perforation, and secondary graftinfection.Case HistoryA 71-year-old male underwent emergency aortobi-femoral repair for a leaking abdominal aortic aneur-ysm with iliac aneurysmal dilatation. He sustained aprolonged period of hypotension during the proced-ure, and the patent inferior mesenteric artery wasligated. The common iliac arteries were oversewn attheir origin.His recovery was complicated by a prolonged per-iod of ventilation, wound haematoma in the left groin(which was managed conservatively) and post-operative diarrhoea without bleeding. Symptoms ofintractable diarrhoea persisted after discharge for sev-eral weeks. Multiple stool samples failed to identifyany pathogenic organism and Clostridium difficiletoxin could not be identified in the bloodstream.Rigid sigmoidoscopy revealed a smooth upper rectalstricture, though the rectal mucosa appeared normal;biopsies revealed patchy acute inflammatory cell infil-trate in the lamina propria. A gastrograffin enema(Fig. 1) confirmed this, and identified a very smallleak of contrast into the pararectal tissues, as well assigmoid diverticular disease. Dilatation of the stricturewas planned.Before this could be done he presented acutely tocasualty with a painful swelling in the left iliac fossaand groin. He gave a two months history of nightsweats, progressive anorexia, malaise, lethargy, andchronic diarrhoea. He was pyrexial and there was atender, erythematous, non-pulsatile 8cm diameterswelling in the left iliac fossa above the scar from theprevious groin incision. Digital rectal examination wasnormal. An urgent CT scan of the aorta confirmed thediagnosis of graft infection, with a gas/fluid filledcollection visible around the left limb of the graft(Fig. 2).At laparotomy the trunk and right limb of the graftwere well incorporated; the left limb of the graft waspoorly incorporated and surrounded by pus. It wasexcised and a left axillo-popliteal bypass constructedwith a silver-coated graft. The remainder of the lapar-otomy appeared normal, and there was no evidenceof colonic perforation. However seven days post-operatively faeces discharged from the left groinwound. The patient underwent emergency re-laparot-omy; a perforation of the upper rectum was nowobvious, and a Hartmann’s procedure performed.Examination of the specimen revealed a smoothbenign stricture of the upper rectum with a localperforation.