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Transabdominal Approach Associated With Increased Long-term Laparotomy Complications After Open Abdominal Aortic Aneurysm Repair
Charles DeCarlo, MD, Christina Manxhari, Jahan Mohebali, MD, Samuel I. Schwartz, MD, Matthew J. Eagleton, MD, Mark F. Conrad, MD, MMSc.
Massachusetts General Hospital, Boston, MA, USA.

Objectives - While transabdominal (TA) and lateral approaches (LA) to open abdominal aortic aneurysm repair (OAR) are both acceptable and widely used, there is a paucity of data evaluating subsequent post-operative laparotomy-associated complications (LC). The aim of this study was to establish the incidence of LC after OAR and determine if approach was associated with long-term LC.
Methods - Institutional data for OAR (2010-2019) was queried, excluding urgent and emergent cases. The primary endpoint was long-term LC defined as any complication related to entry into the abdomen. LA included retroperitoneal and thoracoabdominal approach. Kaplan-Meier analysis estimated freedom from LC and Fine-Gray method for competing risk determined predictors of LC with death as a competing risk.
Results - There were 241 patients who underwent OAR; 91 via TA and 150 via LA (mean age 70.09.1 year; 71.7% men). Patients who underwent TA were significantly younger (66.78.9 vs 72.18.7 years; p-value<0.001), more likely to be male (83.5% vs 64.7%;p-value 0.002), and more likely to have a history of small-bowel obstruction (SBO) (3.3% vs 0%: p-value=0.025). Patients who under LA where more likely to require a supraceliac clamp (20.7% vs 1.1%; p-value<0.001). There was no difference in perioperative complications or long-term mortality. The most common LC were hernia (TA: 26.4%, LA: 11.3%; p-value=0.003), small bowel obstruction (TA: 8.8%, LA: 1.3%; p-value=0.005), and other LC (TA: 13.2%, LA: 2.0%; p-value=0.001) which included evisceration, bowel ischemia, splenic injuries requiring reintervention, enterocutaneous fistula, internal hernia, and retrograde ejaculation. Operative LC complications were more common in the TA group (17.6% vs. 2.7%; p-value<0.001). Unadjusted 1, 3, and 5-year freedom-from-LC was 77.7% (95% CI: 66.0%-85.8%), 60.5% (46.5%-71.9%), and 54.0% (38.8%-67.0%) for TA vs. 94.8% (88.8%-97.7%), 82.2% (72.2%-88.9%) and 79.1% (68.4%-86.5%) for LA, respectively (Figure, logrank p-value<0.001). Predictors of LC were history of SBO (p-value=0.001), increasing BMI (p-value=0.005), and TA approach (p-value<0.001).
Conclusion - TA approach was an independent predictor of long-term LC after OAR along with increasing BMI and history of SBO. In patients with amenable anatomy, LA may be favorable for preventing long-term LC, especially in high-risk patients.


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