Comparison of Transperitoneal and Retroperitoneal Approach in Aorto Iliac Occlusive Disease

Abstract

Introduction: Despite the fact that the transperitoneal approach (TP) is most widely accepted approach to the aortic surgery because it is simple, fast, and provides good exposure of the abdominal cavity and vascular structures, lately have been increasingly advocated as an alternative retroperitoneal (RP) approach in order to avoid entering peritoneal sac, achieving lower physiological trauma and faster establishment of gastrointestinal function. Objective: The aim of this study was to compare the basic peri and postoperative results of TP and RP approaches in the surgical treatment of AIOD. Patients and Methods: The study included 114 patients with aortoiliac occlusive disease (AIOD) that underwent surgical treatment at the Department of Vascular Surgery, Clinical Center University of Sarajevo from January 2010 until December 2012 year. In view of the surgical technique used subjects were divided into two groups. Group A consisted of 57 patients on who had been used RP approach, and group B 57 subjects with TP used approach. Results: In patients from group A were observed significantly lower values: the length of operation (201.66 ± 43.9 minute vs. 267.36 ± 47.57 min, p <0.001), amount of postoperative drainage (56.14 ± 55.5 ml versus 130.71 ± 92.34 ml, p <0.001), length of stay in the intensive care unit (ICU) (1.10 ± 0.36 days versus 2.46 ± 1.25 days, p <0.001), time required for the restoration of gastrointestinal motility (4.38 ± 5.59 versus 1.05 days ± 1.19 days, p <0.001), length of hospitalization (9.26 ± 1, 95 ± 11 days versus 1.96 days, p <0.001), costs of hospitalization (2394.98 ± BAM 346.67 versus 2933.72 ± 428.10 BAM, p <0.001). Analysis of the incidence of postoperative complications (8 vs. 7 complication complications, p>0.05) and mortality (3 versus 3, p>0.05) showed no statistically significant difference between the analyzed groups. Conclusion: RP approach in vascular reconstructive surgery in AIOD offers better postoperative results when compared to TP approach.

Comparison of Transperitoneal and Retroperitoneal Approach in Aorto Iliac Occlusive Disease

DOI: 10.5455/medarh.2013.67.249-251

Med Arh. 2013 Aug; 67(4): 249-251Received: June 28th 2013 | Accepted: August 15th 2013

CONFLICT OF INTEREST: NONE DECLARED

ORIGINAL PAPER

Comparison of Transperitoneal and Retroperitoneal Approach in Aorto Iliac Occlusive Disease

Muhamed Djedovic1, Nedzad Rustempasic1, Samed Djedovic2, Dragan Totic1, Sid Solakovic1, Emir Mujanovic2, Aslani Ilijas1, Haris Vukas1, Alma Krvavac1, Dzejra Rudelija1, Alen Ahmetasevic1Department for Vascular Surgery, Clinical center of University of Sarajevo, Sarajevo, Bosnia and Herzegovina1BH Heart Center Tuzla, Tuzla, Bosnia and Herzegovina2

Introduction: Despite the fact that the transperitoneal approach (TP) is most widely accepted approach to the aortic surgery because it is simple, fast, and provides good exposure of the abdominal cavity and vascular structures, lately have been increasingly advocated as an alternative

retroperitoneal (RP) approach in order to avoid entering peritoneal sac, achieving lower physiological trauma and faster establishment of gastrointestinal function. Objective: The aim of this study was to compare the basic peri and postoperative results of TP and RP approaches in the surgical treatment of AIOD. Patients and Methods: The study included 114 patients with aortoiliac occlusive disease (AIOD) that underwent surgical treatment at the Department of Vascular Surgery,

Clinical Center University of Sarajevo from January 2010 until December 2012 year. In view of the surgical technique used subjects were divided into two groups. Group A consisted of 57 patients on who had been used RP approach, and group B 57 subjects with TP used approach. Results: In patients from group A were observed signicantly lower values: the length of operation (201.66 43.9 minute vs. 267.36 47.57 min, p <0.001), amount of postoperative drainage (56.14 55.5 ml versus 130.71 92.34 ml, p <0.001), length of stay in the intensive care unit (ICU) (1.10 0.36 days versus 2.46 1.25 days, p <0.001), time required for the restoration of gastrointestinal motility (4.38 5.59 versus 1.05 days 1.19 days, p <0.001), length of hospitalization (9.26 1, 95 11 days versus 1.96 days, p <0.001), costs of hospitalization (2394.98 BAM 346.67 versus 2933.72 428.10 BAM, p <0.001). Analysis of the incidence of postoperative complications (8 vs. 7 complication complications, p>0.05) and mortality (3 versus 3, p>0.05) showed no statistically signicant dierence between the analyzed groups. Conclusion: RP approach in vascular reconstructive surgery in AIOD oers better postoperative results when compared to TP approach. Key words: aorto-iliac disease, retroperitoneal approach, transperitoneal approach.

Corresponding author: Muhamed Djedovic, MD, Clinic for Vascular Surgery, Clinical Center of University of Sarajevo, Cekalusa 88, Sarajevo, Bosnia and Herzegovina. [email protected], Tel [phone].

1. INTRODUCTION

Aorto iliac occlusive disease (AIOD) and the atherosclerotic process begin at the terminal part of aorta and the initial part of iliac arteries. This process consists of two phases: the stenotic and then occlusive. The goal of revascularization in this disease is restoration of

blood ow which reduces symptoms in patients with claudication and prevents amputation in patients with critical limb ischemia. Transperitoneal (TP) approach is widely accepted in surgery of the abdominal aorta, as it is easy, fast and provides good exposure of the abdominal cavity and vascular structures.

Therefore, the TP approach is described as the gold standard to which other methods are compared. However, it has some disadvantages, especially long-term gastro-intestinal recovery after surgery. That is why as an alternative to TP is developed RP approach that avoids opening peritoneum, resulting in a lower physiological trauma and reduces postoperative morbidity.

This approach was rst described by John Abernathy 1796 (1). Charls Rob was the rst who reported on a large clinical trial with more than 500 procedures through the anterolateral RP approach (2). He concluded that this approach has several physiological advantages, such as less postoperative pain, shorter duration of ileus, shorter duration of hospitalization and earlier initiation of oral feeding. Although he suggested that it should be used whenever possible,technical difficulties associated with this approach led to the fact that it was used in only 25% of his patients. Later, Williams reported on the extended left posterolateral RP approach that further enhanced exposure of the proximal aorta and its branches (3). Other authors were able to nd other advantages of this approach such as lower hospital costs, decreased blood loss and a lower incidence of early complications (4). Although the RP approach eventually gained increasing

Med Arh. 2013 Aug; 67(4): 249-251 ORIGINAL PAPER

249

Comparison of Transperitoneal and Retroperitoneal Approach in Aorto Iliac Occlusive Disease

popularity among vascular surgeons still there are some of those who emphasize disadvantages of this approach, particularly hampered performance of the operation, i.e. poorer exposure and they are still strong supporters of TP approach.

In the literature, there are still not enough studies that give us answer to the question of the superiority of one over the other approach, i.e. favoring the use of one of them. In our country, till now have not been conducted similar studies that analyze the well-matched groups.

2. GOAL

The goal of this study was to compare the basic peri and postoperative results of TP and RP approach in the surgical treatment of AIOD.

3. PATIENTS AND METHODS

3.1. Respondents

The study involved patients with AIOD that underwent surgical treatment at the Department of Vascular Surgery, Clinical Center University of Sarajevo, from January 2010 until December 2012 year. Subjects were divided into two groups. Group A consisted of 57 patients in which RP approach had been used to access the aorto iliac segment, and group B with 57 patients in which TP approach had been used.

Following parameters were analyzed: Total operative time (time from the rst surgical incision to the nal stitch in minutes),

The amount of postoperative bleeding (total blood volume through drains from the exit from the operating room to the time of removal thereof, expressed in milliliters),

Time spent in the Intensive Care Unit (ICU) (time spent in ICU from leaving the operating room to the reallocation on the department, in days),

Total time required for the restoration of gastrointestinal motility in days (time to occurrence of stools in days),

Length of hospitalization (time from surgery to leaving home, ex-

pressed in days), Economic parameters (the total cost of treatment from admission to discharge in BAM),

The incidence of postoperative complications,

Mortality.3.2. Methods

The operations were performed under general anesthesia. TP approach was performed with medial laparotomy, i.e. longitudinal incision starting from the xiphoid processus up to pubic symphysis. RP approach is performed with incision on the lateral abdominal wall.

Statistical analysis was performed using SPSS. We used Students t-test for analysis of categorical variables and the X2 test for continuous variables. The dierence between samples was considered signicant if p <0,05.

4. RESULTS

Analysis of major perioperative results showed a statistically signicant dierence between the analyzed groups in the length of operation (201.66 43.9 min vs. 267.36 47.57 min, p <0.001), the amount of postoperative drainage (56.14 55.5 ml versus 130.71 92.34 ml, p <0.001), length of stay in the ICU (1.10 0.36 days versus 2.46 1.25 days, p <0.001), time required for the restoration of gastrointestinal motility (4.38 1.05 days versus 5.59 1.19 days, p <0.001), length of hospitalization (9.26 1. 95 days vs. 111.96 days, p <0.001), and total cost of treatment (2394.98 346.67 BAM vs. 2933.72 428.10 BAM; p <0.001) (Table 1).

Analysis of the incidence of postoperative complications between the two

groups indicates a smaller number of them in group A, but without statistical signicance (8 vs. 7 complications, p>0.05). An identical conclusion derived from the analysis of mortality rate between the analyzed groups that also was not statistically signicant (3 vs. 3 deaths, p>0.05) (Table 2).

5. DISCUSSION

TP approach is widely accepted surgical approach because it is simple, fast, and provides good exposure of intra-abdominal cavity and vascular structures. RP approach has advantages such as shorter intubations time, less postoperative blood loss and lower total cost of treatment (4,5). There are studies that showed no signicant dierence between the TP and RP approach (6). Main problem of these studies is that they included patients with AIOD and aneurismal disease which means that they were not homogeneous (7, 8, 9). There were only few studies that analyze two well-matched groups in which the operations was made with the two approaches (5, 6). While in some priority was given to RP approach (5), the other studies did not conclusively prove the superiority of one over the other approach (6, 10).

In this study, we have ana lysed a homogeneous group, i.e. in patients with isolated AIOD and came up with results that point toward advantages of RP approach. The results were very conclusive, starting with the shorter length of surgery (201.66 43.9 min vs. 267.36 47.57 min, p <0.001), which is not so common in the literature, primarily due to abundace of facts that this approach is technically demanding than classic TP approach (5,8,11). In addition, RP approach had smaller amount of postoperative drainage (56.14 55.5 ml versus 130.71 92.34 ml, p <0.001) (10 ).

One of the advantages of RP approach that has been proven in this study also is earlier restoration of intestinal motility. It is well known that as a result of repeated manual contact with intestines in TP approach leads to a longer du-

Group A Group B P Value SD Value SDSurgery (min) 201.6 43.9 267.3 47.5 <0.001 Drainage (mil) 56.1 55.5 130.7 92.3 <0.001 Staying in a ICU (days) 1.1 0.36 2.4 1.2 <0.001 Motility (days) 4.3 1.05 5.59 1.1 <0.001 Hospitalization (days) 9.2 1.9 11 1.9 <0.001

Cost price (BAM) 2394.9

346.7 2933.7 428.1 <0.001

Table 1. Perioperative results in our study

Group A (n )

Group B (n )

P

Bleeding Lymphorrhea Atrial Fibrilatrion Dehiscence Mortality

2 1 3 1 3

2 2 3 1 3

0,05 0,05 0,05 0,05 0,05

Table 2. Postoperative complications and mortality

250

Med Arh. 2013 Aug; 67(4): 249-251 ORIGINAL PAPER

Comparison of Transperitoneal and Retroperitoneal Approach in Aorto Iliac Occlusive Disease

ration of paralytic ileus, which leads to later establishment of gastrointestinal function (12). Appearance of stool was sign of established intestinal motility (4.38 5.59 versus 1.05 days 1.19 days, p <0.001), and once again results demonstrated the advantage of RP approach. Decreased ICU stay (1.10 0.36 days versus 2:46 1.25 days, p<0.001) and shorter hospitalization (9:26 1, 95 11 days versus 1.96 days, p<0.001) resulted in the above mentioned advantages of this approach. No statistically signicant dierence was noticed with regard to the incidence of postoperative complications (p>0.05). The price was statistically signicantly lower in patients who had RP approach (2394.98 346.67 vs. 2933.72 BAM BAM 428.10, p<0.001).

6. CONCLUSION

The results of this study show that RP approach in vascular reconstructive surgery in AIOD oers better postoperative results than TP approach. This can be argumeted by: shorter time of surgery, less postoperative drainage volume, faster restoration of intestinal

motility, shorter stay in ICU and shorter hospitalizations and lower total cost of treatment.

REFERENCES

1. Abernathy J. Surgical observations. London. Longman and ORees, 1804: 209-231.

2. Rob C. Extraperitoneal approach to the abdominal aorta. Surgery. 1963; 53: 87-89.

3. Williams GM, Ricotta J, Zinner M. The extended retroperitoneal approach for treatment of extensive atherosclerosis of the aorta and renal vessels. Surgery. 1980; 88: 846-855.

4. Hioki M, Iedokoro Y, Kawamura J, Yamashita Y, Yoshino N, Orii K, Masuda S, Yamashita K, Tanaka S. A left retroperitonealapproach using a retractor to repair abdominal aortic aneurysms :a comparison with the transperitoneal approach. Surg Today. 2002; 32(7): 577-580.

5. Kalko Y, Ugurlucan M, Basaran M, Nargileci E, Banach M, Alpagut U, Yasar T. Comparison of Transperitoneal and Retroperitoneal Approaches in Abdominal Aortic Surgery. Acta Chir Belg. 2008; 108: 557-562.

6. Sieunarine K, Lawrence-Brown MM, Goodman M.A. Acomparison of transperitoneal and retroperitoneal approaches for infrarenal aortic surgery : early and late results. Cardiovasc Surg.

1997; 5 (1) : 71-76.7. Cambria R, Brewster DC, Abbott WM, Freehan M, Megerman J, Lamuraglia G, Wilson R, Wilson D, Teplick R, Davison JK. Transperitoneal versus retroperito-neal approach for aortic reconstruction A randomised prospective study. J Vasc Surg. 1990; 11(2) : 314-324 ; discussion 324-325.

8. Basel H, Aydin U, Kutlu H. Comparison of retroperitoneal and transperitoneal procedures in aortoiliac occlusive diseases. Turkish Journal of Thoracic and Cardiovascular Surgery. 2009; 17(4): 249-253.

9. Solakovic E. Results of bypass in the aortoiliac region. Acta Chir Iugosl. 1989; 36(2): 691-693.

10. Wachenfeld-Wahl C, Engelhardt M, Gengenbach B, Bruijnen HK, Loeprecht H, Woele KD. The trans-peritoneal versus the retro-peritoneal approach for the treatment of infrarenal aortic aneurysms: is one superior ? Vasa. 2004; 33(2) : 72-76.

11. Q u i n o n e s - B a l d r i c h W J , G a r -ner C, Caswell D, Ahn SS, Gela-bert HA, Machleder HI, Moore WS. Endovascular,transperitoneal, and retroperitoneal abdominal aortic aneurysm repair: results and costs. J Vasc Surg.1999; 30(1): 59-67.

12. Nevelsteen A, Fourneau I, Daenens K. The retroperitoneal approach to the abdominal aorta. Acta Fac Med Naiss. 2005; 22(3): 115-119.

Med Arh. 2013 Aug; 67(4): 249-251 ORIGINAL PAPER

251