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Volume 25 |
October - December 2009 (Part-I) |
Number 5 |
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Published by : PROFESSIONAL MEDICAL PUBLICATIONS |
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ORIGINAL ARTICLE- |
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Volume 25 |
October - December 2009 (Part-I) |
Number 5 |
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Comparision of retroperitoneal and transperitoneal
procedures in aortoiliac occlusive diseases
Halil Basel1, Unal Aidin2, Aysenur
Dostbil3,
Sinasi Manduz4, Nurkay Kantarcioglu5, Abdussamed Hazar6
ABSTRACT
Objective: Comparision of transperitoneal (TP) and retroperitoneal procedures at the surgical treatment of aortiliac occlusive diseases (AIOD) was aimed in this study. Advantages and disadvantages of the procedures were also evaluated.
Methodology: From October 2003 to March 2009, 110 patients underwent aortic surgery. TP technique was performed to 50 patients and retroperitoneal(RP) technique was performed to 60 patients. Demographic datas, risk factors, peroperative and postoperative medical datas (24 parameters) were analyzed and compared between two groups. No statistically significiant difference was observed in demographic datas and risk factors. Five of eight operative parameters resulted in favor of RP procedure. Length of intensive care unit ( ICU) stay (p<0.01) length of hospital stay (p<0.01), return of bowel functions (p<0.01), time of beginning oral feding (p<0.01), effort pain score (p<0.01) were significiantly different in RP group and, results were better than TP group. Pulmonary complications were analyzed as lesser in RP group (p=0.02) There was no statistically significant difference at the rest of complication datas (wound complications p=0.09, paralitic ileus p=0.14, re-operation p=0.46, 30 day mortality p=0.30).
Conclusion: Comparision of Medical datas showed that RP procedure is more advantegous than TP procedure at the surgical treatment of AIOD.
KEY WORDS:
Aortic surgery, Retroperitoneal approach, Transperitoneal approach.Pak J Med Sci October - December 2009 (Part-I) Vol. 25 No. 5 723-727
How to cite this article:
Basel H, Ayidin U, Dostbil A, Manduz S, Kantarcioglu N, Hazar A. Comparision of retroperitoneal & transperitoneal procedures in aortoiliac occlusive diseases. Pak J Med Sci 2009;25(5):723-727.
1. Halil Basel MD.
2. Unal Aydin MD.
1.2 Cardio Vascular Surgery Clinic of
Education Research Hospital of Van
Edremit / VAN TURKEY
3. Aysenur Dostbil MD.
Anesthesia Clinic of Education Research Hospital of Van
Edremit / VAN TURKEY
4. Sinasi Manduz MD.
5. Nurkay Kantarcioglu MD.
4.5 Cardio Vascular Surgery Clinic of Cumhuriyet University,
Faculty of Medicines Sivas
Edremit / VAN TURKEY
6. Abdussamed Hazar MD.
Cardio Vascular Surgery Clinic of Harran University,
Faculty of Medicines Sanli Urfa Edremit / VAN TURKEY
Correspondence:
Halil Basel MD.
Cardio Vascular Surgery Clinic of Education &
Research Hospital of Van
Edremit / VAN TURKEY
E mail: hbasel@mynet.com
* Received for Publication: June 4, 2009
* Revision Received: September 5th 2009
* Revision Accepted: September 7th 2009
INTRODUCTION
Aortoiliac occlusive disease (AIOD) is the result of atherosclerotic and obliterative plaques in the infrarenal aorta an iliac arteries. The natural history of this pathology is characterized by increased mortality and morbidity, if not treated. Surgical treatment of AIOD has been well standardized for many years and the outcomes are quite good. The most widely used exposure of the infrarenal abdominal aorta is the transperitoneal (TP) approach, however there is an increasing popularity of the retroperitoneal (RP) approach too.
1-5 The studies comparing these two procedures report significiantly lower percentages of pulmonary.6 cardiac5,7 and gastrointestinal complications5 when retroperitoneal approach was used. However there are various studies reporting no significiant differences between RP and TP approaches.8 This study aims to compare the RP and TP approaches in a patient population consisting of only AIOD, to find out the optimal surgical technique .METHODOLOGY
One hundred ten patients who had undergone aortic surgery between October 2003 and March 2009, were studied retrospectively. Demographic datas and risk factors of the patients are listed in Table-I. All patients were operated for AIOD, abdominal aorta aneurysms, previous RP or TP operations, re-operations were excluded from the study. Sixty patients were operated with RP approach and 50 patients were operated with TP approach. Aortofemoral bypas was performed in 18 patients from RP group and 10 patients from TP group (Table-II).
Operations were performed under general anesthesia. The transperitoneal approach was performed through Standard midline laparotomy. Laparotomy incision varied 12-20 cm through midline. The retroperitoneal approach was performed with an oblique 10-12 cm incision from the left subcostal magrin to the rectus abdominis mýuscle margin. It was reached to the retroperitoneal cavity by dissecting the aponeurosis of abdominal muscles. The aorta was exposed from bifurcation to the renal artery level and aortotomy for anastomosis was performed. Aortoiliac occlusions were treated by bypasssing the stenotic segments as end-to-side proximal anastomosis and end-to-side fashion to common femoral arteries in groins. The patients were transported to intensive care unit (ICU) after the operation.
Eight parameters were monitored in both groups (Table-III). Duration of operation, aortic cross clamp time, blood loss in 24 hours, legth of ICU stay (hours), length of hospital stay (days), return of bowel functions (hours), time of beginning oral feding (days), effort pain score. Effort pain score was achieved by asking the patient to cough strongly 6 hours after the extubation and attributing a score of between 1-10 for the pain patient felt. (0: no pain, 10: highest pain) Post oprative complications were also compared in both groups. Complications compared are (Table-IV): pulmonary complications wound complications, paralytic ileus, re-operation, 30 day mortality rate.
When democraphic datas and risk factors were evaluated, retroperitonel and transperitoneal groups were similar to each other . Consequently procedures were performed acccording to surgeon’s preference, familitary and desire to use the method. All surgical procedures were peformed by three senior surgeons however every surgeon performed the technique which is familiar to himself.
All parameters were evaluated in both groups. Continuous variables were tested by Student t test and Mann Whitney U test. Variables in categoric forms were tested with Z test . Statistical significiance rate was assumed as 5 % and 1%. Statistical analyses were performed with SPSS.
RESULTS
Both groups were compared for demographics and risk factors (Table-I). A significiant difference couldn’t be determined in the groups. Aortofemoral [RP 18 (30%), TP 10(20%)] and aortobifemoral [RP 42(70%), TP 40(80%)] procedures were performed. (Table-II) Statistically significiant difference wasn’t established in operative procedures between groups (p<0.818).
Eight parameters containing operative and postoperative datas were compared in each group. In comparision, five of eight parameters were established statistically different. These parameters were length of intensive care unit stay, length of hospital stay, return of bowel functions, time of beginning oral feeding and effort pain score. There was no statistically significiant difference in the rest of eight parameters. These were operation time, aortic cross clamp time and blood loss.
In the RP group the length of ICU stay (RP 7.93 hours vs TP 18.22 hours, p<0.01) and length of hospital stay (RP 3.36 days vs TP 5.39 days, p<0.01) were shorter than the TP group. In the comparision of return of bowel functions (RP 13.32 hours vs TP 23.78 hours, p<0.01) and time of beginning oral feeding (RP 1.43 days vs TP 2.61 days, p<0.01) a significiant difference was observed in RP group. Significiant difference was also observed in the comparision of effort pain score. In RP group mean pain score was 4.14 however in TP group pain score was 5.61 and p value was <0.01. In TP group coughing was more painful.
Operation complications were also compared in both groups. (Table-IV) There was no pulmonary complication in RP group but four were assessed in TP group p=0.02). Wound complications (infection, bulging, incisional hernia, incisional pain) were observed in 10 (20%) patients in TP group but observed in four (8%) in RP group (p=0.09). In TP group paralitic ileus was observed in four (8%) patients however no paralitic ileus occured in RP group (p=0.14). Patients undergoing re-operation were more in TP group (TP four (8%) vs RP two (3%), p=0.46). Two patient (TP n:1) underwent re-operation for graft thrombosis and four patients (RP n:2, TP n:2) for anastomotic bleeding The operative mortality was only two (1.53 %) in 30 day follow up period. Mortality occured in TP group because of myocardial infarction. Statistical analyzes were performed for the comparision of complications. Only two parameters (pulmonary complications) were significiantly lower in RP group. Other complications were also lower in RP group neverthless significiant difference wasn’t analyzed.
DISCUSSION
There are many studies criticizing the superiority of retroperitoneal versus transperitoneal approach at the surgical treatment of AIOD.
9-12 Several authors have reported that no difference was seen between the procedures.11,13 However these studies were heterogenous, containing aortic aneurysms and AIOD. Surgical treatment of aortic aneurysms is completely different procedure therefor outcomes are also different from AIOD. In our series aneuryms were excluded to form unique groups. Sienaurine compared with aneurysm an AIOD seperately.10 This study reported no significiant difference between two procedures. However Darling concluded in his study that RP approach provided advantages associated with minimal effects on the gastrointestinal and respiratory functions and reduced ICU and hospital stay.12 The results of our study is consistent with the conclusions of Darling. Because return of bowel functions (p<0.01), time of beginning oral feeeding (p<0.01), effort pain score (p<0.01)were better and length of hospital (p<0.01) and ICU (p<0.01) stays were shorter in RP group. The outcomes of RP procedure were more physiological in gastrointestinal and pulmonary functions.Peroperative findings of our study didn’t show a significiant difference between procedures. Operation time and aortic cross clamp time was a little longer in RP group On the other hand blood loss in 24 hours was slightly higher in TP group. The medical datas were consistent with previous studies.
10,14Complications that have occured in both procedures showed that pulmonary complications were significiantly less in RP group. (p=0.02) This outcome is supported with the reports of Darling and Buckley.
12,15 Paralitic ileus was not recorded in RP group however four patients with paralitic ileus were observed in TP group. (p=0.14) A statistical significiant difference wasn’t analyzed neverthless studies proving less gastrointestinal complication had been reported.1,12 Four patients from TP group and two patient from RP group underwent re-operation(p=0.46) No certain difference was analyzed.Thirty day mortality was 4%. Mortality occured in TP group (n:2) originating from myocardial infarction. Wound complications were regarded as infection, incisional hernia, incisional pain, bulging. In our study wound complications were more common in TP group (p=0.09) but p value didn’t reach statistical significiance. However Sienaurine et al. reported higher incidence of wound complications with RP procedure.
10 We prefer a short left flank incision 10-12cm and muscle dissecting instead of muscle incisionfor reaching to the retroperitoneal area. These surgical preferences might cause the post operative outcomes.In our study we didn’t evaluate the economic proceeds of RP procedure. However RP approach resulting in less operative complication and shorter ICU and hospital stay, reduces hospital costs and increases the profitability of aortic surgery.
15CONCLUSION
At the surgical treatment of AIOD better surgical outcomes were achieved with RP approach. Better gastrointestinal and pulmonary functions, lesser pain and shorter hospital stay were obtained with RP technique. Consequently RP procedure increases operative success and provides better recovery course.
REFERENCES
1 Tosenovsky P, Janousek L, Lipar K, Moravec M. Left retroperitoneal versus transperitoneal approach for abdominal aortic surgery-retrospective comparison of intraoperative and postoperative data. Bratisl Lek Listy 2003;104(11):352-5.
2 Arko F0R, Bohannon WT, Mettauer M, Lee SD, Patterson DE, Manning LG, et al. Retroperitoneal approach for aortic surgery: is it worth it? Cardiovascular Surg 2001;9(1):20-26.
3 Bernd MM, Rainer M, Matthias T, Gisela B, Alexander O, Karl HO, et al. The retroperitoneal approach combined with epidural anesthesia reduces morbidity in elective infrarenal aortic aneurysm repair. Interact CardioVasc Thorac Surg 2009;8:35-39.
4 Masae Haga, Masashi Inaba, Hiroshi Yamamto. Comparision of Transperitoneal and Retroperitoneal Approach for Aortic Aneurysm Repair. Japanese J Cardiovascular Surgery 2000;29(5)305-308.
5 Kirby LB, Rosenthal D, Athkins CP, Brown GA, Matsuura JH, Clark MD, et al. Comparision between the transabdominal and retroperitoneal approaches for aortic reconstructionin patients at high risk. J Vasc Surg. 1999;30(3):400-5.
6 Quinose-Balbrich WJ, Garner CH, Caswell D. Endovascular, transperitoneal and retroperitoneal abdominal aortic aneurysms repair: Results and costs. J Vasc Surg 1999; 30:59-67.
7 Carrel T, Niederhauser U, Laske A, Bauer E, von Segesser LK, Turina M. Retroperitoneal approach in selective surgery of infrarenal aorta. Helv Chir Acta 1992; 58(4):583-588.
8 Kimihiro K, Jin O, Katsumi K, Sosei K, Daihiko E, Kyotaro M, et al. Comparison of Retroperitoneal and Transperitoneal Approach for Reconstruction of Abdominal Aortic Aneurysm in Patients with Previous Laparotomy International J angiology 1997;6(4)230-233.
9 Sicard GA, Reilly JM, Picus DD, Allen BT. Transperitoneal versus retroperitoneal incision for abdominal aortic surgery: report of a prospective study randomised trial. J Vasc 1995;21:174-183.
10 Sienaurine K, Lawrence-Brown MD, Goodman MA. Comparision of transperitoneal and retroperitoneal approaches for infrarenal aortic surgery: early and late results. Cardiovasc Surg 1997;5(1):71-76.
11 Cambria RP, Brewster DC, Abbot WM, Freehan M, Megerman J, LaMuraglia G, et al. Transperitoneal versus retroperitoneal approach for aortic reconstruction: A randomised prospective study. J Vasc Surg, 1990;11(2):314-25.
12 Darling C, Shah DM, Chang BB, Paty PS, Leather RP. The current status of the use of a retroperitoneal approach for reconstruction of the aorta and its branches. Ann Surg 1996; 224(4):501-6 506-8.
13 Wachenfeld-Wahl C, Engelhardt M, Gengenbach B, Bruijnen HK, Loeprecht H, Woelfle KD. Transperitoneal versus retroperitoneal approach for treatment of infrarenal aortic aneurysms: is one superior? Vasa 2004;33(2):72-6.
14 Hioki M, Iedokoro I, Kawamura J, Yamashita Y, Yoshino N. A left retroperitoneal approach using a retractor to repair abdominal aortic aneurysms: a comparision with transperitoneal approach. Suurg Today 2002;32(7):577-80.
15 Buckley CJ, Lee SD, Arko FR, Bohannon WT, Mettauer M, Patterson DE, et al. Economic considerations for aortic surgery: Retroperitoneal approach-is it worth it? Acta Chir Belg 2000;100(6):247-50.
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