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Open Surgical Strategy for Abdominal Aortic Aneurysms:Should Open Repair Be Avoided in Cases of Extremely Old-Aged Patients or Patients with Previous Laparotomy?
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iDepartment of Surgery, Asahi General Hospital, Asahi, Japanj
| Takatoshi Furuya |
Hideo Kagaya |
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During the past 19.5 years, we performed open repairs of 666 non-ruptured abdominal aortic aneurysmsiAAAjand iliac artery aneurysms regardless of the patientfs age, previous abdominal surgery, or comorbidities. To evaluate our strategies, we reviewed octogenarians and patients with previous laparotomy, dividing them into several groups.i1jOctogenarians were divided into the EO-groupiextremely-old patients, 85 years old or older:n56jand the O-groupioctogenarians, younger than 85 years old:n113).i2jAll cases operated by transabdominal approachin661jwere divided into the A-groupiwith previous laparotomy:n164jand the B-groupiwithout laparotomy:n497).i3jA-group was also divided into subgroups according to the kind of previous surgery:M-groupistomach or gall bladder surgery:n120), C-groupicolorectal surgery:n20), Ao-groupiaortic surgery:n16), and S-groupicolonic or urinary stoma constructing surgery:n6). We introduced our clinical pathway in January 2000 and non-heparin technique in November 2000 for all AAA repairs. Non-heparin technique was revised in January 2003, excluding AAA with occlusive disease after several thrombotic complications. A comparison between EO-group and O-group proved that there was a significant difference only in aneurysmal diameter and frequency of renal impairment. Mean operation timei201}56min vs 210}52min), intraoperative blood lossi442}338ml vs 430}242ml), postoperative length of stayi9.4}5.0 days vs 8.2}2.8days), and hospital mortalityi0% vs 0.9%jwere the same in both groups. Analyses of the consequences of previous laparotomy showed that A-group needed significantly longer exposure timei74}27min vs 63}23min:p0.00001jand operation timei218}55min vs 204}53min:p0.004jthan B-group, but intraoperative blood lossi453}370ml vs 449}274mljand transfusion ratesi6.7% vs 8.5%jwere the same in both groups. Because the data of M-group and C-group were similar to each other as well as those of Ao-group and S-group, we compared the perioperative data between M{C-group and Ao{S-group. Concerning exposure time, M{C-group required 6 min more than B-group and Ao{S-group 37 min more than M{C-group. The operation time of M{C group was 8 min longer than B-group and that of Ao{S-group was 45 min longer than M{C-group. Although there were significant differences in intraoperative blood lossi396}247ml vs 820}701 ml:p0.009jand transfusion ratesi4.2% vs 22.7%:p0.001jbetween M{C-group and Ao{S-group, postoperative length of stayi8.1}2.2 days vs 10.2}7.5 daysjwas almost the same, and the majority of patientsi97.2% and 100% of respective groupsjwere discharged. Our experiences with clinical pathway and non-heparin technique suggest that open repair of AAA should not be refrained only for extremely old-aged patients or patients with previous laparotomies.
Jpn. J. Cardiovasc. Surg. 42:260-266i2013j
KeywordsFabdominal aortic aneurysm, octogenarian, previous laparotomy, clinical pathway, non-heparin
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