Transabdominal approach associated with increased long-term laparotomy complications after open abdominal aortic aneurysm repair

Effect of two surgical approaches on the lung function and prognosis of patients with combined esophagogastric cancer

BACKGROUND

Adenocarcinoma of the esophagogastric junction has a center of origin within 5 cm of the esophagogastric junction. Surgical resection remains the main treatment. A transthoracic approach is recommended for Siewert I adenocarcinoma of the esophagogastric junction and a transabdominal approach is recommended for Siewert III adenocarcinoma of the esophagogastric junction. However, there is a need to determine the optimal surgical approach for Siewert II adenocarcinoma of the esophagogastric junction to improve lung function and the prognosis of patients.

AIM

To investigate and compare the surgical effects, postoperative changes in pulmonary function, and prognoses of two approaches to treating combined esophagogastric cancer.

METHODS

One hundred and thirty-eight patients with combined esophagogastric cancer treated by general and thoracic surgeries in our hospital were selected. They were divided into group A comprising 70 patients (transabdominal approach) and group B comprising 68 patients (transthoracic approach) based on the surgical approach. The indexes related to surgical trauma, number of removed lymph nodes, indexes of lung function before and after surgery, survival rate, and survival duration of the two groups were compared 3 years after surgery.

RESULTS

The duration of surgery, length of hospital stay, and postoperative drainage duration of the patients in group A were shorter than those of the patients in group B, and the volume of blood loss caused by surgery was lower for group A than for group B (P < 0.05). At the one-month postoperative review, the first second, maximum ventilation volume, forceful lung volume, and lung volume values were higher for group A than for group B (P < 0.05). Preoperatively, the QLQ-OES18 scale scores of the patients in group A were higher than those in group B on re-evaluation at 3 mo postoperatively (P < 0.05). The surgical complication rate of the patients in group A was 10.00%, which was lower than that of patients in group B, which was 23.53% (P < 0.05).

CONCLUSION

Transabdominal and transthoracic surgical approaches are comparable in treating combined esophagogastric cancer; however, the former results in lesser surgical trauma, milder changes in pulmonary function, and fewer complications.

Open Retroperitoneal Repair for Complex Abdominal Aortic Aneurysms

Background  Open surgical repair (OSR) of complex abdominal aortic aneurysms (CAAAs) can be challenging. We frequently utilize the retroperitoneal (RP) approach for such cases. We audited our outcomes with the aim of establishing the utility and safety of this approach.

Methods  Retrospective analysis was performed of all patients undergoing OSR of an unruptured CAAA via a RP approach in our center over a 7-year period. Data on repairs via a transperitoneal (TP) approach were collected to provide context. Demographic, operative, radiological, and biochemical data were collected. The primary outcome measure was 30-day/inpatient mortality. Secondary outcomes included the need for reoperation, incidence of postoperative chest infection, acute kidney injury (AKI) and length of stay (LOS). All patients received aortic clamping above at least one main renal artery.

Results  One hundred and three patients underwent OSR of an unruptured CAAA; 55 via a RP approach, 48 TP. The RP group demonstrated a more advanced pattern of disease with a larger median maximum diameter (65 vs. 61 mm, p = 0.013) and a more proximal extent. Consequently, the rate of supravisceral clamping was higher in RP repair (66 vs. 15%, p  < 0.001). Despite this there were no differences in the observed early mortality (9.1 vs. 10%, NS); incidence of reoperation (10.9 vs. 12.5%, NS), chest infection (32.7 vs. 25%, NS), and AKI (52.7 vs. 45.8%, NS); or median LOS (10 vs. 12 days, NS) following RP and TP repair.

Conclusion  OSR of CAAAs carries significant 30-day mortality. In patients unsuitable for fenestrated endovascular aortic repair or those desiring a durable long-term solution, OSR can be performed through the RP or TP approach. This study has demonstrated that in our unit RP repair facilitates treatment of more advanced AAA utilizing complex proximal clamp zones with similar perioperative morbidity and mortality compared with TP cases utilizing more distal clamping.

Retroperitoneal versus Transperitoneal Approach for Open Repair of Complex Abdominal Aortic Aneurysms

OBJECTIVES

Several studies have demonstrated advantages of the retroperitoneal approach (RP) over the transperitoneal approach (TP) for infrarenal abdominal aortic aneurysm (AAA) repair. We performed a retrospective analysis comparing the outcomes of TP versus RP surgical approach for open complex AAA (cAAA) repair and evaluated their relative use over time.

METHODS

Patients undergoing open repair for intact cAAA (juxtarenal, suprarenal, or type-IV thoracoabdominal aortic aneurysms) between 2011-2019 were identified in the National Surgical Quality Improvement Program (NSQIP). The primary outcome was perioperative death. Secondary outcomes included perioperative complications and approach usage over time. We performed multivariable adjustment by creating propensity scores and using inverse probability-weighted logistic regression.

RESULTS

Among 1,195 patients identified, 729 (61%) underwent cAAA repair via a TP approach and 466 (39%) underwent repair via an RP approach. Compared with a TP approach, RP patients more frequently had a supracoeliac clamp position (32% vs. 20%, p<.001) and concomitant renal revascularization (30% vs. 18%, p<.001). After adjustment, an RP approach was associated with lower odds of perioperative mortality (4.0% vs. 7.2%; OR:0.54; 95%CI:0.32-0.91; p=.022). Furthermore, an RP approach was associated with lower odds of any major complication (24% vs. 30%; OR:0.73; 95%CI:0.56-0.94), cardiac complications (4.9% vs. 8.2%; OR:0.60; 95%CI:0.37-0.96), wound complications (2.1% vs. 6.0%; OR:0.34; 95%CI:0.17-0.64), and postoperative sepsis (0.8% vs. 2.4%; OR:0.37; 95%CI:0.12-0.99). The proportion of repairs using an RP approach decreased from 2011-2015 to 2016-2019 (42% vs. 35%, p=.020), particularly for supra-renal and type-IV thoracoabdominal aneurysms (49% vs 37%, p=.023).

CONCLUSION

In open cAAA repair, the RP approach may be associated with lower perioperative mortality and morbidity compared with the TP approach. However, we found that the relative usage of the RP approach is decreasing over time, even in suprarenal/type-IV TAAA's, and repairs utilizing a supracoeliac clamping site. Increased utility of the RP approach, when appropriate, may lead to improved outcomes following open cAAA repair.