Asian Cardiovasc Thorac Ann 2003;11:3-6
© 2003 Asia Publishing EXchange Ltd
Gastrointestinal Complications After Transperitoneal Abdominal Aortic Surgery
Ufuk Alpagut, MD,
Yusuf Kalko, MD,
Enver Dayioglu, MD
Department of Cardiovascular Surgery, University of Istanbul Medical Faculty, Istanbul, Turkey
For reprint information contact: Ufuk Alpagut, MD Tel: 90 212 635 2921 Fax: 90 212 534 2232 email: alpagutu{at}usa.net Department of Cardiovascular Surgery, University of Istanbul Medical Faculty, Çapa, Istanbul 34390, Turkey.
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ABSTRACT
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A major gastrointestinal complication after transperitoneal aortic surgery, though unusual, may be disastrous. We determined retrospectively the risk factors, associated events, and outcomes of gastrointestinal complications that developed after transperitoneal aortic revascularization to treat aneurysmal or occlusive disease over a 10-year period. Among 750 patients reviewed, gastrointestinal complications developed postoperatively in 65 of them (8.6%), including paralytic ileus in 35 patients, gastrointestinal bleeding and mechanical ileus in 6 patients each, colonic necrosis in 2, ischemic colitis and diarrhea in 10, acute cholecystitis in 2, ascites in 1, as well as aortoduodenal fistula, which developed about 2 months postoperatively in 3 patients. Five of the patients died of multiorgan failure. Mean stay in the intensive care unit was 3 days, and hospital stay ranged from 15 to 60 days. No risk factors were identified for the occurrence of gastrointestinal complications. These results show that gastrointestinal complications after transperitoneal aortic surgery prolong hospital stay and may have serious consequences.
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INTRODUCTION
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Gastrointestinal (GI) complications after abdominal aortic surgery can lead to serious outcomes and even death. GI complications have been reported in 2% of patients after cardiac surgery (with 25% mortality), 7% after neurosurgical operations, 20% after cardiac transplantation, and 50% after orthotopic lung transplantation, while the reported incidence after abdominal aortic surgery is 20% and the mortality rate is between 16% and 67%.1–4 The rate may increase after transperitoneal aortic operations, possibly due to visceral hypoperfusion, in patients with volume loss and who are in shock, as in ruptured abdominal aneurysm.5 Specific complications include GI bleeding, intestinal ischemia, ileus, and aortoduodenal fistula.6 Although GI complications occur infrequently after abdominal aortic surgery, they can seriously affect postoperative outcome. In this study, our aim was to evaluate retrospectively the frequency of GI complications, the predisposing factors, and the types of treatment in patients who underwent transperitoneal aortic surgery for occlusive or aneurysmal disease.
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PATIENTS AND METHODS
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We reviewed retrospectively 750 patients who underwent abdominal aortic surgery transperitoneally to treat abdominal aortic aneurysm or aortoiliac occlusion between 1990 and 2001. The patients were evaluated in terms of age, sex, atherosclerotic and cardiac risk factors, previous history of GI diseases and laparotomy, the type of aortic operation, nasogastric drainage time, intestinal motility recovery time, the type of postoperative GI complication, and the duration in the intensive care unit and the hospital.
Nasogastric drainage was installed in all the patients. After surgery, drainage was terminated when active bowel sounds were heard on auscultation, when the patient had passed gas, or when drainage was less than 500 mL•h-1. Drainage was restarted if the stomach became dilated. Urgent surgery was performed if intestinal ischemia, mechanical ileus, or aortoduodenal fistula developed. All the patients were given a first-generation cephalosporin prophylactically as well as prophylaxis of gastroduodenal ulcers. Colonic blood supply was assessed after aortic surgery.
Comparisons between parameters were made with the chi-squared test and group comparisons with the Student t test. A p value < 0.05 is considered significant.
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RESULTS
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Aortobifemoral or aortoiliac bypass was performed in 600 patients (80%) with aortoiliac occlusive disease; and aneurysmectomy and reconstruction were carried out in 150 patients (20%) with abdominal aortic aneurysm, 140 of them (93%) electively and 10 (7%) urgently because of rupture. The mean age of the patients was 65 years, and 98% of them were male. Atherosclerotic risk factors and prior GI disease and laparotomy are shown in Table 1
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The types of postoperative complications and their mortality rates are listed in Table 2. GI complications developed in 65 patients (8.6%). Intestinal motility recovery time was 18 ± 6 hours. Mean nasogastric drainage time was 72 hours. Drainage was restarted in 35 patients because of paralytic ileus, vomiting, and stomach dilatation. Ileus resolved after nasogastric tube replacement for persistent gastric distention and, in 25 patients with electrolyte imbalance, appropriate electrolyte replacement.
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Table 2. Morbidity and Mortality Rates of Different Types of Complications After Transperitoneal Aortic Surgery (n = 750)
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Mechanical ileus was detected by radiological examination in 6 patients, who were operated on immediately. Three of them had prior laparotomy. Short-segment intestinal infarction was detected by exploration in 3 of these patients, and resection was performed. Adhesions were found in the other 3 patients and were separated.
GI bleeding occurred in 6 patients with a history of gastritis and/or ulcer. They underwent nasogastric aspiration, antiulcer treatment, and blood transfusion. Two patients developed colonic necrosis and perforation; they died of sepsis and multiorgan failure following surgery. A patient with cirrhosis, which was detected in a previous laparotomy, died of postoperative multiorgan failure. There were 2 cases of acute cholecystitis, one of which needed cholecystectomy.
The inferior mesenteric artery (IMA) was found to be patent in 25 patients who were operated on for aortic aneurysm. The IMA orifice was ligated in the aneurysmal sac in 15 of them; 10 of these patients developed temporary ischemic colitis and diarrhea, 2 of whom underwent reoperation because of severe stomach dilatation and decreased hematocrit. As much as 1.5 L of free blood was drained from the peritoneal cavity of these patients. The other 10 patients underwent IMA reimplantation and did not have diarrhea.
A duodenal fistula (Figure 1) developed in 3 patients about 2 months after operation for ruptured abdominal aortic aneurysm, juxtarenal aortic aneurysm, and juxtarenal aortic occlusion, respectively. They underwent urgent surgery, but 2 of them died of sepsis and multiorgan failure. The surviving patient was healthy during follow-up and remained under observation.
Mean stay in the intensive care unit was 3 days, and total hospital stay ranged from 15 to 60 days. No meaningful statistical relationship was found between age or preoperative risk factors and the frequency of GI complications.
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DISCUSSION
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The reported incidence of colonic ischemia after abdominal aortic surgery is between 0.2% and 10%.7,8 Progression to necrosis and perforation can be fatal. Prediction and prevention of this complication is possible by monitoring blood supply sufficiency in the colon through simple inspection, measurement of IMA perfusion pressure, Doppler ultrasonography, routine sigmoidoscopy, or the measurement of intramural pH in the sigmoid colon.9
Division of a patent IMA is frequently required after abdominal aortic surgery, especially in cases of aneurysm. This is one of the main causes of ischemic colitis. The vessel should be tied or the orifice closed within the aneurysmal sac. Temporary ischemic colitis may develop because of pressure on the intestine exerted by an intraabdominal hematoma.
Aortoduodenal fistula is a late complication due to low-grade infection of the prosthesis or to mechanical erosion, and it occurs in 0.4% to 4% of cases.10,11 It should be repaired as soon as it is diagnosed. Notwithstanding urgent intervention, its mortality rate remains high. However, younger age, early recognition of the symptoms, and using the saphenous vein for reconstruction could improve the chance of success, as was the case in our surviving patient.
In contrast to the transperitoneal approach, several studies found that the retroperitoneal approach produced more favorable results, including decreased nasogastric decompression time and intestinal motility recovery time, less discomfort, lower incidence of GI complications, as well as shorter intensive care unit stay.12–14 This approach facilitates infrarenal abdominal aortic surgery.
Our review shows that transperitoneal aortic surgery may lead to serious GI complications, but no risk factors were identified. The retroperitoneal approach needs to be further evaluated as an alternative to the transperitoneal approach in terms of reducing postoperative complications and the associated mortality, especially if there is a history of abdominal surgery.
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ABSTRACT
INTRODUCTION
