The call came through our transfer center. At the time this patient was transferred, one of the chairmen emeriti of the clinic, called my cell phone with the story. It was still my first year at the clinic and pleasant to be talking to one of the giants of vascular surgery. The patient was suffering from upper gastrointestinal hemorrhages, and not responding to EGD. He was taken to the operating room by his local general surgeon, who soon found that he was bleeding from a primary aortoduodenal fistula. He was able to control the bleeding by putting his finger on the hole but his institution was not set up for vascular surgical care. After a brief conversation, our quarterback decided the patient needed to come rapidly by helicopter with his surgeon maintaining hemostasis –like the proverbial Dutch boy with his finger in the dike. The patient was prepared for transport by placing drapes over his open abdomen with the surgeon maintaining finger pressure on the duodenal fistula, and they arrived like that into the operating room for emergency surgery. The operation was made difficult by inflammation, but I was able to get a clamp on the aorta infrarenally and dismiss the real hero of the day, the patient’s first surgeon who got a helicopter ride home. The aorta was focally necrotic and this was sent for culture which came back MRSA, but otherwise it was normal. I repaired with a bovine pericardial patch and after repair of the duodenum by our general surgeon, omentum was laid down and secured over the aorta and beneath the bowel.
The patient had a history of sarcoidosis and aortic valvular endocarditis, but it was relatively remote. There was no significant atherosclerotic plaque nor aneurysm to account for the development of the aortoduodenal fistula. The patient survived and is doing better now over a year after his rescue by his flying surgeon. The other hero, of course, is the pedicled omental flap. The omentum is a mysterious organ to me and without adequate study or explanation from a functional, developmental, or evolutionary point of view.