Journal of Chest Surgery

The Korean Society for Thoracic and Cardiovascular Surgery (대한심장혈관흉부외과학회)
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Clinical Study of the Treatments for Abdominal Aortic Aneurysm; Comparison between the Retroperitoneal and Transperitoneal Approaches

복부대동맥류 치료의 임상적 고찰; 후복막 접근법과 경복막 접근법의 비교

  • Son, Bong Soo (Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University) ;
  • Chung, Sung Woon (Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University) ;
  • Lee, Sang Kwon (Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University)
  • 손봉수 (부산대학교 의학전문대학원 흉부외과학교실) ;
  • 정성운 (부산대학교 의학전문대학원 흉부외과학교실) ;
  • 이상권 (부산대학교 의학전문대학원 흉부외과학교실)
  • Received : 2008.07.25
  • Accepted : 2008.11.14
  • Published : 2009.02.05
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Abstract

Background: The principal surgical technique for treating an abdominal aortic aneurysm since the 1960s has been the transperitoneal approach, yet there have been some recent studies that have reported improved surgical results with using the retroperitoneal approach. However, there are only limited clinical Korean studies that have, compared between the transperitoneal and retroperitoneal approaches. Material and Method: This study included 36 patients who had been diagnosed as having an aneurysm of the abdominal aorta and they were surgically treated between January 2001 and July 2007. The patients were subdivided into the retroperitoneal approach group (n=17) and the transperitoneal approach group (n=19), and they were compared in terms of the preoperative risk factors, the postoperative complications and the operative mortality. The risk factors of operative mortality risk and long-term survival for the 36 patients were assessed by the Kaplan-Meier method. Result: There were no significant differences between the groups in terms of gender, age, the underlying disease, a history of smoking, rupture of aneurysm, the preoperative symptoms, the operation time and the incidence of postoperative complications. However, the duration of postoperative fasting, the number of days of having an indwelling nasogastric tube and the length of the stay in the intensive care unit were significantly short for the retroperitoneal approach group (p<0.05). There was a 16.7% rate of operative mortality (6/36) and five of the deaths were attributed to preoperative ruptured aneurysm. On univariate analysis, a higher preoperative serum creatinine level (SCr ${\geq}$1.8 mg/dL, p=0.016) and ruptured aneurysm (p<0.001) were the significant risk factors of operative mortality. As assessed by the Kaplan-Meier method, the long-term survival was comparable between the groups and the five-year survival rate of all the patients was 57.5%. Conclusion: In the present study, a retroperitoneal approach has several advantages such as a shorter intensive care unit stay, a shorter duration of postoperative fasting and a shorter duration of an indwelling nasogastric tube. Therefore, unless there is any contraindication for a retroperitoneal approach, it could be considered as a primary surgical access for repairing an abdominal aortic aneurysm.

배경: 1960년대 이래로 복부 대동맥류의 주된 수술적 접근 방법은 경복막 접근법이나, 최근에는 후복막 접근법을 이용한 향상된 수술 성적들이 보고되고 있다. 하지만 후복막 접근법과 경복막 접근법의 비교에 대한 국내 연구는 제한적이다. 대상 및 방법: 2001년 1월부터 2007년 7월까지 복부대동맥류로 진단 받고 수술적 대동맥 치환술을 받은 36명 중 후복막 접근법을 이용한 17명과 경복막 접근법을 이용한 19명의 수술 전 위험인자, 술 후 합병증, 수술 사망률을 비교 분석하였다. 전체 36명의 환자에서 수술사망의 위험인자를 조사하고 Kaplan-Meier 생존 분석을 이용한 술 후 장기 생존율 조사하였다. 결과: 대상 환자 중 두 군간에 성별, 연령, 동반 질환의 유무, 흡연력, 파열 유무, 술 전 증상간의 유의한 차이는 없었으며, 대동맥 재건술식, 수술시간 및 술 후 합병증의 발생빈도에서도 유의한 차이가 없었다. 그러나 후복막 접근법 군에서 술 후 금식 기간 및 비위관 제거 기간이 짧았으며(p<0.05), 중환자실 재실 기간에서도 경복막 접근법 군에 비하여 유의하게 짧았다(p<0.05), 수술 사망은 총 6명(16.7%)이었으며 그 중 5명이 술 전 파열된 경우로, 단변량 분석에서 수술 전 1.8 mg/dL 이상의 혈중 크레아티닌 수치를 보이는 경우(p=0.016)및 파열된 복부 대동맥류(p<0.001)가 유의한 수술 사망의 위험 인자로 조사되었다. Kaplan-Meier 생존율 조사에서는 두 군간의 장기생존율의 차이는 없었으며 전체 환자의 5년 생존율은 57.5%였다. 결론: 본 연구 결과 후복막 접근법이 경복막 접근법에 비하여 중환자실 재실 기간이 짧고 술 후 금식 기간 및 비위간 거치 기간이 짧은 장점이 있었다. 따라서 후복막 접근법에 대한 특별한 금기가 없다면 후복막 접근법을 일차적으로 고려하는 것이 좋을 것으로 사료된다.

Keywords

References

  1. Dubost C, Allary M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: reestablishment of the continuity by a preserved human arterial graft, with results after five months. Arch Surg 1952;64:405-8 https://doi.org/10.1001/archsurg.1952.01260010419018
  2. Ricotta JJ, Williams GM. Endarterectomy of the upper abdominal aorta and visceral arteries through an extra-peritoneal approach. Ann Surg 1980;192:633-8 https://doi.org/10.1097/00000658-198011000-00009
  3. Lee HK, Lee YK. Abdominal aortic aneurysm. J Korean Surgical Society 1963;5:491-9
  4. Davies MJ. Aortic aneurysm formation: lessons from human studies and experimental models. Circulation 1998;98:193-5 https://doi.org/10.1161/01.CIR.98.3.193
  5. Ailawadi G, Eliason JL, Upchurch GR Jr. Current concepts in the pathogenesis of abdominal aortic aneurysm. J Vasc Surg 2003;38:584-8 https://doi.org/10.1016/S0741-5214(03)00324-0
  6. Sicard GA, Allen BT, Munn JS, Anderson CB. Retroperitoneal versus transperitoneal approach for repair of abdominal aortic aneurysm. Surg Clin North Am 1989;69: 795-806 https://doi.org/10.1016/S0039-6109(16)44885-1
  7. Lacroix H, Van Hemelrijk J, Nevelsteen A, Suy R. Transperitoneal versus extraperitoneal approach for routine vascular reconstruction of the abdominal aorta. Atca Chir Belg 1994;94:1-6
  8. Johnson JN, McLoughlin GA, Wake PN, Helsy CR. Comparison of extraperitoneal and transperitoneal methods of aorto-iliac reconstruction. Twenty years experience. J Cardiovasc Surg (Torino) 1986;27:561-4
  9. Cina B, Goksel O, Kut S, et al. Abdominal aortic aneurysm surgery: retroperitoneal or transperitoneal approach? J Cardiovasc Surg (Torino) 2006;47:637-41
  10. Sicard GA, Freeman MB, Vanderwoude JC, Anderson CB. Comparison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. J Vasc Surg 1987;5:19-27 https://doi.org/10.1067/mva.1987.avs0050019
  11. Steyerberg EW, Kievit J, de Mol Van Otterloo JC, van Bockel JH, Eijkemans MJ, Habbema JD. Perioperative mortality of elective abdominal aortic aneurysm surgery: a clinical prediction rule based on literature and individual patient data. Arch Intern Med 1995;155:1998-2004 https://doi.org/10.1001/archinte.155.18.1998
  12. Treska V, Certik B, Cechura M, Novak M. Ruptured abdominal aortic aneurysms - university center experience. Interact Cardiovasc Thorac Surg 2006;5:721-3 https://doi.org/10.1510/icvts.2006.135475
  13. Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993;328:1167-72 https://doi.org/10.1056/NEJM199304223281607
  14. Johansen K, Kohler TR, Nicholls SC, Zierler RE, Clowes AW, Kazmers A. Ruptured abdominal aortic aneurysm: the harborview experience. J Vasc Surg 1991;13:240-7 https://doi.org/10.1067/mva.1991.25530
  15. Scott RA, Tisi PV, Ashton HA, Allen DR. A 7-year follow-up of the entire abdominal aortic aneurysm population detected by screening. J Vasc Surg 1998;28:124-8 https://doi.org/10.1016/S0741-5214(98)70207-1
  16. Katz DA, Littenberg B, Cronenwtt JL. Manangement of small abdominal aortic aneurysms: early surgery vs watchful waiting. JAMA 1992;268:2678-86 https://doi.org/10.1001/jama.268.19.2678
  17. Norman PE, Semmens JB, Lawrence-Brown MM. Long-term relative survival following surgery for abdominal aortic aneurysm: a review. Cardiovasc Surg 2001;9:219-24 https://doi.org/10.1016/S0967-2109(00)00126-5