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Simultaneous Gastrointestinal Surgery in Patients With Elective Abdominal Aortic Reconstruction
An Additional Risk Factor?
Thomas Luebke, MD;
Ulrich Wolters, MD, PhD;
Michael Gawenda, MD;
Jan Brunkwall, MD, PhD;
Arnulf H. Hoelscher, MD, FACS, FRCS
Arch Surg. 2002;137:143-147.
ABSTRACT
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Hypothesis The management of simultaneously occurring intra-abdominal abnormalities and abdominal aortic aneurysms or aortoiliac occlusive disease is controversial. The aim of this retrospective study was to analyze whether gastrointestinal operations performed at the same time as aortic repair increase the postoperative morbidity and mortality rate.
Method Between January 1, 1989, and December 31, 1997, a total of 42 patients underwent open aortic tube (n = 33) or bifurcated grafting (n = 9) and simultaneous surgery of 1 or more gastrointestinal abnormalities. In a matched-pairs analysis for each of the aforementioned patients, a control patient with an exclusive aortic procedure was selected. For each matched pair the following aspects were noted: the type of operative procedure, time of execution, duration of the surgical procedure, the duration of postoperative ventilatory assistance, intensive care unit and hospital stays, the number of blood units transfused, the use of antibiotics, and the main postoperative complications.
Results The comparison between the matched pairs revealed no statistically significant difference for postoperative morbidity or mortality rate or length of intensive care unit and hospital stays. There were no operative or hospital deaths. None of the patients has (median follow-up, 68 months) shown evidence of graft infection.
Conclusion A 1-stage operation management is feasible if appropriate care is given to the technical details and if the rules of antisepsis are followed.
INTRODUCTION
PATIENTS considered for abdominal aortic surgery have been shown to have a high incidence of coexistent cardiac, vascular, and other diseases, that affect operative risk, perioperative complications, and survival. Aneurysms of the infrarenal abdominal aorta (AAA) and aortoiliac occlusive diseases are encountered in patients older than 60 years, at a rate of 2% to 5% of the population.1 The aneurysms are combined with a concomitant abdominal nonvascular disease in an incidence of 7% to 29%,2 with cholecystopathy at a rate of 4.9% to 19.2%,3 with neoplasia at a rate of 4% to 8%,4 and with other vascular anomalies at a rate of 2.3%.2
The concomitant occurrence of AAA and gastrointestinal diseases still remains a therapeutic dilemma, mainly with respect to the potential of prosthetic graft infection in cases of simultaneous surgery. The main controversy revolves around whether to treat the lesions simultaneously or as staged procedures, especially in cases of coexisting intra-abdominal malignant neoplasms. There is a scarcity of experience reported in the literature to assist in making an appropriate decision. Most surgeons3, 5 think that the lesion with the most dangerous or symptomatic complications should be operated on first and, thus, have elected to treat the majority of patients sequentially. Only small case series report the results of a policy of performing a combined procedure in cases of concurrent symptomatic malignancy.6-8 The goal of this study was to analyze whether gastrointestinal operations performed at the same time as aortic repair would increase the postoperative morbidity and/or mortality rate.
PATIENTS AND METHODS
From January 1, 1989, to December 31, 1997, a total of 851 patients having AAA and 379 patients with an aortoiliac occlusive disease were operated on electively (502 tube grafts; 728 aortoiliac-femoral bypasses) in the Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany. During the same period, 42 patients (4.9%), 35 men and 7 women, with a median age 67 years (age range, 49-84 years) underwent aortic surgery (33 because of AAA and 9 because of aortoiliac occlusive disease) and simultaneous surgery of 1 or more gastrointestinal abnormalities (1-stage operation). The nonvascular abnormality was diagnosed either in the preoperative period (ie, colorectal carcinoma, 5; sigmoid colon diverticulosis-diverticulitis, 5; gastric carcinoma, 2; and cholelithiasis, 10) or discovered at the time of surgery (ie, colonic infarction, 1; Meckel diverticulum, 5; small-bowel carcinoid, 1; adhesion-incomplete ileus, 3; inflammatory small-bowel tumor, 3; appendicitis, 2; and cholelithiasis, 5). All the aneurysms were located infrarenal and their median transverse diameter was 5.0 cm (diameter range, 3.5-16 cm) as measured by computed tomography.
The aortic graft surgery was performed through a transperitoneal approach. In all patients the aortic grafting was performed first and the peritoneum was closed over the prosthesis, followed by the completion of the second procedure. No retroperitoneal approach was used. In cases of coincidental intestinal abnormalities (eg, Meckel diverticulum), we performed bowel cleaning via "on the table lavage." All patients received 5000 IU of heparin sodium before aortic cross clamping, and heparin was not inactivated by giving protamine hydrochloride during the rest of the operative procedure. Thirty-three patients (78.6%) received open aortic tube grafts; 9 patients (21.4%) underwent a bifurcated graft.
In a matched-pairs analysis for each of the aforementioned patients, a control patient with an exclusive aortic procedure was selected and matched for the following variables: age, sex, American Society of Anesthesiologists' classification of the patient's health, and type of aortic surgery. The atherogenic risk factors, concomitant diseases, and American Society of Anesthesiologists' scores of the patient's health for the control group are given in Table 1. In the present investigation, for each matched pair the following aspects were analyzed: the type of operative procedures and the time of their execution, the duration of the surgical procedure, the duration of postoperative ventilatory assistance, the duration of intensive care unit and hospital stays, the number of units of blood transfused, the use of antibiotics, and the main postoperative complications.
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Table 1. Preoperative Risk Factors
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To analyze significant relations of the preoperative, intraoperative, and postoperative data, the Fisher exact test, or  2 test was used for the categorical parameters; the Mann-Whitney test was used for the continuous parameters. Results are expressed as medians; statistical significance was set at P<.05.
RESULTS
The operative procedures carried out are listed in Table 2. All concurrent gastrointestinal malignancies were symptomatic (Table 3). The most common symptoms relating to the carcinoma were anemia, weight loss, gastrointestinal tract bleeding, a recent change in bowel habit, and intestinal transit problems or obstruction. All 15 patients who had cholelithia sis had episodes of right upper quadrant pain, liver dysfunction, or both at the same time. At the time of their operation, they showed no signs of cholecystitis or cholangitis. Perioperative single-shot antibiotic prophylaxis (a second-generation cephalosporin and metronidazole) was administered routinely in all patients. In 5 patients who underwent simultaneous surgery and 4 patients who underwent aortic repair alone, antibiotic therapy was continued postoperatively.
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Table 2. Simultaneous Operative Procedures
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Table 3. Coexisting Intra-abdominal Disease Treated at the Same Time as Aortic Grafting in This Case Series
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SHORT-TERM RESULTS
The short-term results are given in Table 4. There were no hospital deaths. Five patients (11.9%) who underwent simultaneous surgery and 7 patients (16.6%) who underwent an aortic procedure alone suffered postoperative complications. The surgical and nonsurgical complications are shown in Table 5. No patient developed peritonitis after simultaneous operation. In the case of colonic surgery, no clinical anastomotic leaks were observed (tested by water-soluble iodinated [Gastrografin; Schering Germany GmbH, Berlin]–contrast medium enema in all those patients).
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Table 4. Short-term Results*
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Table 5. Surgical and Nonsurgical Complications
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LONG-TERM FOLLOW-UP
Of the 42 patients who underwent simultaneous procedures, 36 (85.7%) are still alive. The length of follow-up ranges from 18 to 126 months (median, 68 months). The causes of death of 6 patients were disseminated cancer (n = 2), myocardial infarction (n = 3), and renal failure (n = 1). Follow-up in the 42 patients who underwent an aortic procedure alone ranged from 16 to 112 months (median, 63 months). During the observation period, 7 patients died. The cause of death was renal failure (n = 1), myocardial infarction (n = 3), and pneumonia and respiratory failure (n = 3). There has been no clinical or ultrasonographic evidence of aortic graft infection in any of the patients during long-term follow-up.
COMMENT
In 1960 DeBakey et al9 first reported their experience with 640 aneurysmectomies, of which 51 were combined with other intra-abdominal operative procedures (eg, cholecystectomy or appendectomy). They reported no increase in the postoperative morbidity and mortality rate, and no increase in graft infection. Since then controversial views have evolved among authors.2-3,5, 10-12 Some consider the combination of the 2 procedures generally safe, especially in cases of asymptomatic cholecystolithiasis, as opposed to those13-16 who believe that such a combination significantly increases postoperative morbidity and mortality (Table 6). In String's11 case series, 9 of 17 patients with untreated, asymptomatic gallstones developed cholecystitis or biliary tract pain after aneurysm resection. String concluded that if there were no mitigating circumstances, cholecystectomy should be combined with the aortic procedure. Thomas et al18 reported the case series of 521 patients undergoing aortoiliac reconstructions. Eighty-five nonvascular procedures were performed in 76 patients. Overall, there were no significant differences in morbidity and mortality when nonvascular procedures were combined with aortic reconstruction. Authors who do not advocate concomitant procedures identify the potential of postoperative graft infection as a major disadvantage. Ouriel et al3 reported that of 18 patients who underwent concomitant procedures, 1 developed a prosthetic infection in the immediate postoperative period. This patient did not have the graft retroperitonealized before cholecystectomy, and in addition had a gastrostomy and drainage of the liver bed performed. Becker and Blundell17 reported the cases of 2 patients and Ouriel et al3 noted 1 patient who developed late graft infection after combined aneurysmectomy and cholecystectomy. Most of these data as well as our own suggest that cholecystectomy can safely be performed at the same time of aneurysmectomy in selected patients (Table 6). Because the potential benefit of preventing postoperative cholecystitis is arguable, cholecystectomy should be deferred if any difficulty is encountered during aneurysm repair. Of course, the 1-stage operation must be scheduled during the absence of cholecystitis or cholangitis, and cholecystectomy should be carried out carefully to prevent mechanical injury of the wall of the gallbladder.
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Table 6. Literature Review of Simultaneous Aortic Procedures With Coexistent Intra-abdominal Abnormality
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Tilson et al24 found a significantly higher incidence of concomitant malignancy with aneurysm repair in comparison with patients who had atherosclerotic occlusive disease. They proposed that this relation could be explained by immunologic damage to the epithelial connective tissue matrix causing both aneurysms and malignancy. However, this has never been reconfirmed. In 1967, Szilagyi et al25 were the first to report on concomitant malignancies and aneurysms. In case series published in the United States, the most common intra-abdominal malignancy identified in patients with aortic aneurysm involves the colon and rectum. The incidence of colorectal malignancy in these case series ranged from 1.7% to 3.8%.19, 26 Management of concomitant AAA and malignancy and especially colorectal malignancy causes the greatest dilemma, as there is no clear consensus on whether to treat the cancer or the aneurysm first, or, indeed, simultaneously. Szilagyi et al25 have classified the concomitant existence of aneurysm and intraperitoneal neoplasia in 4 groups depending on the initial presentation. They concluded that the symptomatic lesion should be treated first. When both lesions are asymptomatic then priority should be given to the aneurysm if it is large and to the cancer if the aneurysm is small. If metastases are present, an AAA should only be repaired if it is symptomatic or large (<6 cm). Velanovich and Andersen6 applied decision analysis to this therapeutic dilemma in an attempt to resolve the issue of treatment priority. Simultaneous procedures should be considered if the aneurysm is more than 5 cm in diameter and the cancer has a more than 75% to 80% chance of obstruction or perforation, provided that the operative mortality rate is likely to be less than 10%.6
Simultaneous surgery has many theoretical attractions. Single-stage management has the advantage of achieving complete treatment while exposing the patient to only one anesthesia and one recovery period. Simultaneous surgery removes the risk of a second major operation with its problems of adhesions, its potential opportunity for cardiac and pulmonary complications, and the risk of complications of the untreated lesion. Furthermore, the complications of the first operation may postpone the second operation, resulting in a delay in definitive treatment for the second disease. There is a real risk of tumor spread if a cancer is untreated at the first operation19, 27 especially if the second operation is delayed. There is, in total, the risk of the increased perioperative morbidity and mortality of the 2 procedures and aneurysm rupture5 if it is untreated.
The surgical management in cases of AAA or aortoiliac occlusive lesions and a second intraperitoneal operative procedure still remains a matter of debate. The theoretical increased risk of graft infection, despite little evidence in the literature, remains the main argument against simultaneous surgery and has made most surgeons reluctant to perform a second nonvascular procedure at the time of aortic surgery. Subsequent case series, although reporting few cases, have shown that there is no increase in morbidity and mortality when compared with elective aneurysm repair alone.4, 7-8,19-20,28-29 As a result, this procedure could be the preferred approach both for elective surgery or when colon cancer or another symptomatic or life-threatening intra-abdominal abnormality is found unexpectedly during aortic surgery. Our study reinforces this message and shows that nonvascular operations may be performed at the same time as elective AAA repair or aortoiliac reconstruction without an increase in the postoperative morbidity or mortality rate and the length of intensive care unit and hospital stay, and without any enormous increase in graft infection. Our study represents another case series reporting simultaneous surgery of the abdominal aorta and a second intra-abdominal disease. In the 1-stage operation, management is feasible if appropriate care is given to the technical details including the rules of antisepsis, and if the vascular surgeon is sufficiently experienced in gastrointestinal surgery to perform the second nonvascular procedure or if help by an experienced visceral surgeon is available.
AUTHOR INFORMATION
Corresponding author and reprints: Thomas Luebke, MD, Department of Visceral and Vascular Surgery, University of Cologne, Joseph-Stelzmann-Strasse 9, 50931 Cologne, Germany (e-mail: thomas_luebke{at}yahoo.de).
From the Department of Visceral and Vascular Surgery, University of Cologne, Cologne, Germany.
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