Retroperitoneal approach for aortic surgery: is it worth it?

Background: Previous reports suggest that earlier hospital discharges and r educed postoperative complications occur when a retroperitoneal approach is used for aortic surgery. Other publications refute this concept. In an eff ort to determine the most cost efficient method for aortic surgery in our i nstitution, while maintaining high standards of care and outcome, we compar ed the retroperitoneal approach to the conventional transperitoneal aortic operation. Patients and methods: Between December 1995 and April 1998, 120 patients un derwent aortic surgery by either the transperitoneal (n = 60) or retroperit oneal approach (n = 60). All patients were enrolled prospectively in a vasc ular registry and retrospectively reviewed. Patients were randomly assigned to one of three vascular surgeons, A clinical pathway for elective aortic surgery was developed and applied to both groups. Patients were evaluated w ith respect to demographics, comorbidities, preoperative risk stratificatio n, conduct of the operative procedure, length of stay, complications, cost, clinical outcomes and patient satisfaction. The indications for aortic sur gery were similar in both groups - 64% for aneurysm disease and 36% for occ lusive disease. Both symptomatic and asymptomatic aneurysms were included a nd size ranged from 4.4 to 14 cm. All aortic reconstructions were done in t he standard manner using knitted Dacron velour prostheses in either the aor tic tube, bi-iliac or bi-femoral configuration. Statistical analysis of mea ns and medians was accomplished using the Wilcoxin Rank-sum test and percen tages were compared using Fisher's Exact test. P values less than 0.05 indi cate statistical significance. Results: There were no statistically significant differences in patient dem ographics. The incidence of atherosclerotic coronary artery disease, obstru ctive pulmonary disease, diabetes, hyperlipidemia, tobacco abuse, distal lo wer extremity occlusive disease and the results of chemical myocardial stre ss evaluations were similar in both groups. Comorbidities of pre-existing r enal insufficiency/failure and morbid obesity were increased in the retrope ritoneal group. Five patients in the retroperitoneal group represented redo aortic surgery and there were no redo procedures in the transperitoneal gr oup. Length of operative procedures and blood replacement requirements for both groups were similar. The transperitoneal group required 2-31 more intr aoperative intravenous (IV) crystalloid than the retroperitoneal group (P < 0.0001). Statistically significant reductions in ICU days, postoperative i leus and total lengths of stay were observed in the retroperitoneal group ( P < 0.0001), This resulted in substantial reductions in hospital costs for the retroperitoneal group (P < 0.01). Postoperative complications were simi lar for both groups except for statistically significant increases in pulmo nary edema (P < 0.01) and pneumonia (P < 0.001) in the transperitoneal grou p. Cardiac arrhythmias, primarily atrial dysrhythmias, were more frequent i n the transperitoneal group but this failed to reach statistical significan ce (P < 0.16). Combined thirty day mortality was 0.9%. Time of recovery to full activity and patient satisfaction substantially favored the retroperit oneal group. Conclusion: Our clinical pathway and algorithm for aortic surgery was easil y followed by those patients in the retroperitoneal approach group and resu lted in decreases in ICU time, postoperative ileus, volume of intraoperativ e crystalloid and total length of stay. The patients in the transperitoneal group often failed to progress appropriately on the pathway. Reduced hospi tal costs associated with aortic surgery using the retroperitoneal approach has increased the profitability for this surgery in our institution by an average of $4000 per case and has increased the Value (quality/cost) of thi s surgery to our patients and our institution. (C) 2001 The International S ociety for Cardiovascular Surgery. Published by Elsevier Science Ltd. All r ights reserved.