J Cardiovasc Surg (Torino). 2017 Aug;58(4):557-564. doi: 10.23736/S0021-9509.16.08201-X.

Abdominal aortic aneurysm treatment: minimally invasive fast-track surgery and endovascular technique in octogenarians.

Martelli M1, Renghi A2, Gramaglia L2, Casella F1, Brustia P3.

1 Division of Vascular Surgery, Department of Surgery, Ospedale Maggiore della Carità, Novara, Italy.
2 Department of Anesthesiology, Ospedale Maggiore della Carità, Novara, Italy.
3 Division of Vascular Surgery, Department of Surgery, Ospedale Maggiore della Carità, Novara, Italy – brustiapiero@aruba.it.

 

Abstract

BACKGROUND:

We conducted a retrospective study on patients aged over eighty who underwent elective surgery for an abdominal aortic aneurysm between January 2006 and December 2010. We compared our results with fast-track abdominal aortic surgery (OPEN group) and with endovascular aneurysm repair (EVAR group).

METHODS:

We followed 97 consecutive octogenarians affected by abdominal aortic aneurysm who underwent elective surgery. A total of 55 patients were enrolled in the OPEN group (56.7%) and 42 were enrolled in the EVAR group (43.3%).

RESULTS:

Eight patients (14.5%) in the OPEN group and six patients in the EVAR group (14.2%) received transfusions. None of the patients required admission to the intensive care unit. In total, 53 patients (98%) in the OPEN group and 34 patients (80%) in the EVAR group were able to get up and walk in the afternoon after the end of surgery. The recovery of intestinal transit was on day 2 in the OPEN group and on day 1 in the EVAR group. Patients in both groups were discharged on average on the fourth postoperative day. There were no perioperative mortalities in the OPEN and the EVAR groups.

CONCLUSIONS:

Minimally invasive treatment with the fast-track protocol and EVAR are both valid options in octogenarian patients because we obtained comparable results in terms of resumption of feeding, early ambulation, days of hospitalization, perioperative rate of mortality and morbidity.

PMID:25268073

 

 

Additional information 

Author: Brustia Piero and Cassatella Renato

 

At the end of last century health cost-effectiveness balance caught on with the purpose of optimizing resources and improving care level quality at the same time.

Kehelet1 and Carli2 were among the pioneers of new school of thought about all-accomplished patient management, that is multimodal approach. Showing encouraging results in colo-rectal surgery, the second step was the question of feasibility in other surgical specialties.

Taking on this challenge our vascular team has been tried to apply a fast-track protocol as clinical as managerial in major vascular surgery starting in April 2000.

Apart from seriousness of pathology, the surgical act seems only the epiphenomenon of a complex condition as perioperative disease is. This is due to surgical incision, catheter insertions, dread for operation, having a feeling to be a patient and no more a person, so that psycho-physical balance became imparied, if this is true for all patients, is more important in elderly and very elderly patients.

The aim of fast-track philosophy is limiting as better is possible, the perioperative stress, related to adverse effects as pain, ileus, nausea, vomiting, insulin-resistance and so on.

In our experience applying aortic fast-track required few years, challenging fears and scepticism.

Nevertheless the results were comfortable, considering an high risk surgery like abdominal aortic one, certyfied on over 1000 treated patients3

In the era of endovascular surgery that can treat near 60% of patients with an aortic aneurysm, we think that a vascular surgery unit must give optimal treatment also in the other 40% of patients with the better pathway for open surgery. In this way we may offer mininvasiveness to all patients.

 

Protocol

Vascular surgeons apply minimally invasive surgery:

Left sub-costal incision, involving less dermatomes

no evisceration, reducing water loss due to perspiration

avoidance or limited use of curare drug, ameliorating perioperative respiratory performance

no insertion of nasogastric tube, useless to surgeon as well as to anaesthesiologist

no insertion of drainage at the end of surgery, making intraoperative good homeostasis

limited oral bowel preparation, reducing preoperative dehydration

 

Vascular anaesthesiologist tried to reduce invasive manners and improve perioperative pain control:

inserting thoracic epidural catheter just before operation, followed by gradual 15-20 ml of Levobupivacaine 0,5% administration to obtain preoperative analgesia between T2 and L1 levels

using double seal laryngeal mask to decrease airwai invasiveness, being as safe as orotracheal tube and low anesthetic gas amount ( Sevoflurane MAC 0,7%)

avoiding central venous catheter and capitalizing two large peripheral cannulae (16G and/or 14G), enough for fluid and blood products infusions

managing fluid administration avoiding hypovolemia and hyperidratation at the same time with rational use of colloids (euvolemia)

following hemodynamic intraoperative performance by delta-up/delta-down analysis of radial artery catheter and, if necessary, by transoesophageal echoardiography for particular cases

optimizing postoperative analgesia after intensive nurse training

 

All the team was skilled for:

assess whole preoperative care pathway in outpatient regimen

reduce perioperative laboratory and instrumental tests following literature indications

use intraoperative blood rescue avoiding autologous bood infesion when possible

avoid postoperative care ubit and transfer patient directly to the vascular ward, basing on Ramsey Scale, ameriorating patient comfort

enhance rehabilitation based on early oral feeding and early ambulation, followed by nurses, in vascular ward in the same day of surgery

periodical updating with surgeons, anaesthesiologists, nurses and other specialists as cardiologists, physioterapists, dietitians, diabetologists and so on.

 

From the clinical point of view, fast-track surgery consists in the application of clinical pathways based on evidence-based medicine.

 

References:

1 Kehlet, H. (1997). Multimodal approach to control postoperative pathophisiology and rehabilitation. Br. J. Anaesth. 78(5), 606-617.
2 Carli, F. (1999). Perioperative factors influencing surgical morbidity: what the anesthesiologist need to know. Can. J. Anesth. 46(5): R70-R79.
3 Brustia P, Renghi A, Aronici M, Gramaglia L, Porta C, Musiani A, Martelli M, Casella F, De Simeis ML, Coppi G, Settembrini A, Mottini F, Cassatella R. Fast-track in abdominal aortic surgery: experience in over 1,000 patients. Ann Vasc Surg. 2015 Aug;29(6):1151-9.

 

 

Hemodynamic parameters. 

 

 

By-pass

End of surgery

 

Afternoon of surgery’s day ambulation