Open Surgical Strategy for Abdominal Aortic Aneurysms:Should Open Repair Be Avoided in Cases of Extremely Old-Aged Patients or Patients with Previous Laparotomy?

iDepartment of Surgery, Asahi General Hospital, Asahi, Japanj

Takatoshi Furuya Hideo Kagaya
During the past 19.5 years, we performed open repairs of 666 non-ruptured abdominal aortic aneurysmsiAAAjand iliac artery aneurysms regardless of the patientfs age, previous abdominal surgery, or comorbidities. To evaluate our strategies, we reviewed octogenarians and patients with previous laparotomy, dividing them into several groups.i1jOctogenarians were divided into the EO-groupiextremely-old patients, 85 years old or older:n56jand the O-groupioctogenarians, younger than 85 years old:n113).i2jAll cases operated by transabdominal approachin661jwere divided into the A-groupiwith previous laparotomy:n164jand the B-groupiwithout laparotomy:n497).i3jA-group was also divided into subgroups according to the kind of previous surgery:M-groupistomach or gall bladder surgery:n120), C-groupicolorectal surgery:n20), Ao-groupiaortic surgery:n16), and S-groupicolonic or urinary stoma constructing surgery:n6). 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 timei201}56min vs 210}52min), intraoperative blood lossi442}338ml vs 430}242ml), postoperative length of stayi9.4}5.0 days vs 8.2}2.8days), and hospital mortalityi0% vs 0.9%jwere the same in both groups. Analyses of the consequences of previous laparotomy showed that A-group needed significantly longer exposure timei74}27min vs 63}23min:p0.00001jand operation timei218}55min vs 204}53min:p0.004jthan B-group, but intraoperative blood lossi453}370ml vs 449}274mljand transfusion ratesi6.7% 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 lossi396}247ml vs 820}701 ml:p0.009jand transfusion ratesi4.2% vs 22.7%:p0.001jbetween M{C-group and Ao{S-group, postoperative length of stayi8.1}2.2 days vs 10.2}7.5 daysjwas almost the same, and the majority of patientsi97.2% and 100% of respective groupsjwere 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. 42:260-266i2013j

KeywordsFabdominal aortic aneurysm, octogenarian, previous laparotomy, clinical pathway, non-heparin