Annals of the Royal College of Surgeons of England (1990) vol. 72, 215-217
ortic aneurysms V Vella
who
A Shandall
do
them?
MCh
MB BCh Senior House Officer
Senior Surgical Registrar
G Duthie FRCSEd Surgical Registrar
Consultant Surgeon
K Shute
should
MS
Department of Surgery, Royal Gwent Hospital, Newport, Gwent
Key words: Abdominal aortic
aneurysm;
Mortality
All patients undergoing abdominal aortic aneurysm repairs in a district general hospital between 1 January 1983 and 31 December 1987 were reviewed. Of the 76 cases, 53 were planned and 23 were ruptured aneurysms. The male:female ratio was 4.4:1, and the age range was 47-84 years (mean 67.7 ± 6.97 years). Half underwent an ultrasound scan, showing a maximum diameter range of 3-12 cm. Fifty-seven (75%) had tube grafts, and 19 (25%) bifurcation grafts. The 30-day mortality was 3.7% for planned cases, and 26% for ruptured cases. The principal operator in 55 (72.5%) cases was a consultant; consultant anaesthetists were involved in 61.3% cases.
We conclude that aneurysm surgery can safely be performed in a district general hospital by a general surgeon -.ith an interest in vascular surgery
It has been claimed that aortic aneurysm repairs should only be performed in major centres by specialist vascular surgeons (1). This view has recently been strengthened by the CEPOD report (2) which showed deficiencies in the care of such patients. Although this view may reflect the ideal situation, at present it is not entirely realistic. Nevertheless, the CEPOD report has stimulated surgeons to take a greater interest in the mortality rates for certain procedures, including aneurysm surgery. We have reviewed the results of aortic aneurysm repair carried out by one surgical team in a district general hospital, in order to assess the safety of performing such surgery in small centres without a specialist vascular surgeon.
Patients and methods This study reviewed all cases of abdominal aortic aneurysm repair carried out by a general surgical team with an
Correspondence to: Mr K Shute, Department of Surgery, Royal Gwent Hospital, Newport, Gwent NP9 2UB
interest in vascular surgery, during the 5-year period 1 January 1983 to 31 December 1987 inclusive. Planned and ruptured cases were included. The cases were obtained from a record book of all vascular surgery undertaken, and the case notes retrieved from the medical records department. The patients were divided by age, sex and presentation (planned or ruptured), with any risk factor notedhypertension, diabetes mellitus, cardiovascular, pulmonary or renal disease and smoking habit. The type of graft inserted (tube or bifurcation) was recorded, and the diameter of the aneurysm according to ultrasound scan (where available) was also recorded. The grade of surgeon and anaesthetist involved in each of the operations was noted. Deaths attributed to surgery were defined as those occurring within 30 days of operation.
Results During the 5-year period
a
total of 76 abdominal aortic
aneurysm repairs were undertaken. Of these, 53 (70%) were planned procedures, and 23 (30%) were emergencies for ruptured aneurysms. The ruptured cases
included one aortocaval fistula and one aortoduodenal fistula. Fifty-seven (75%) had tube grafts inserted and 19 (25%) bifurcation grafts. The male:female ratio was 4.4:1, and the age range was 47-84 years with a mean age of 67.7 ± 6.97 years (mean ± 2 SD). The majority of the patients fell into the 65-74 years age group. Of the risk factors noted, 22 (35.5%) were hypertensive; 20 (32.25%) had known cardiac disease; 5 (8%) pulmonary disease; 4 (6.47%) cerebrovascular disease; and 3 (4.8%) were diabetic. None had a known history of renal disease. The majority were smokers (Fig. 1). Half of the patients had ultrasound scans, with a maximum diameter range of 3-12 cm (mean 6.16+ 1.6 cm).
216
V Vella
et
al.
80-
60
% of
cases
40
20
Hypertensive
Cardiac Pulmonary
C.V.A.
Renal
Diabetic
Smokers
Figure 1. Known risk factors.
Table I shows the most senior grade of surgeon and anaesthetist involved in the operations. The consultant was the principal operator in 72.7% of planned, and 72.2% of ruptured cases; the senior registrar in 11.4% of planned and 27.8% of ruptured cases, and the registrar in 15.9% of planned cases. Registrars were never the principal surgeon in ruptured cases. A consultant anaesthetist was involved in 63.6% of planned and 55.6% of ruptured cases, with the senior registrar in the majority of the remainder. Registrars were only principally involved in 7% of planned cases, and never in ruptured cases.
The mortality rates are shown in Table II; 2 (3.7%) of planned cases and 6 (26%) of ruptured cases died. Of the planned cases, one died of congestive cardiac failure, and the other from a myocardial infarction. Of the ruptured cases, one aneurysm had a large suprarenal extension and was deemed inoperable, one died from congestive cardiac failure, two of acute renal failure, and two from myocardial infarction.
Discussion The true incidence of abdominal aortic aneurysm is difficult to determine as a large number remain undiagnosed. An incidence of 3% in the over-50 years age group, or 2-4% of the total population has been suggested (3, 4). The incidence appears to be rising (5),
Table I. Grade of principal this study
surgeon
and anaethetist in
Planned
Ruptured
72.7 11.4 15.9
72.2 27.8 0
63.6 29.5 6.9
55.6 44.4 0
Surgeon Consultant Senior Registrar
Registrar Anaesthetist
Consultant Senior Registrar
Registrar
whether due to the ageing population, or to an increased diagnostic accuracy. Ruptured abdominal aortic aneurysms have been shown to be responsible for 0.6% of all deaths. Abdominal aortic aneurysms are therefore common and account for a large number of deaths, a proportion of which may be avoidable. The CEPOD report (2) suggested that there are major deficiencies in the treatment of patients with aortic aneurysms, and this has prompted us to review our own mortality rate and assess our shortcomings. Table II shows some operative mortality figures published during the last 10 years with a range of 3-10% for planned procedures and a range of 23-81% for emergency operations for ruptured aneurysms. There has been little change in the mortality over this time. The best results available in this country are those of Ruckley et al. (14) from Edinburgh and it should be the aim of all units carrying out such surgery to attain comparable results. The CEPOD report (2) attempted to explain why results may be poor in some areas. Of the cases they studied, one had been operated upon by a senior house officer, 16 by registrars, 30 by senior registrars and 93 by consultants. It is inexcusable for SHOs to operate on aneurysms unsupervised and we believe that registrars also should not be operating without supervision. All patients in this study were under the care of a general surgeon with an interest in vascular surgery. We operate a completely non-selective policy on ruptured aneurysms, ie all patients presenting to the hospital with a ruptured aneurysm are given the chance of surgery. Morriston Hospital, Swansea (5), has a similar policy, with a mortality rate of 45%. When this, and our mortality of 26% are compared with that of Budd (16), where only 65% of emergency cases receive surgery with a mortality rate of 68%, it can be seen that a selection procedure does not offer any increase in survival. The patients who are not offered surgery have a 100% mortality, and we therefore believe that surgery should Table II. Reported mortality rates for aneurysm repairs Reporter
Date
Planned
Rupture
Gordon-Smith (7) Crawford (8) Fielding (9) Makin (10) Jenkins (1) Fielding (11) Castledon (12) Ingoldby (5) Hollier (13) Johansson (6) Ruckley (14) Thomas (15) Budd (16) Shute
1978 1981 1981 1983 1984 1984 1985 1986 1986 1986 1987 1988 1988 1988
10 5 8 9 NR 8 4 5 5.7 NR 3 8
55 23 43 50 32 42 31 48 NR 62 24 81 68 26
All figures are % of mortalities NR= results not recorded
3.5 3.7
Aortic aneurysms-who should do them? Table III. Guidelines for aortic aneurysm surgery 1 Non-selection policy for ruptured aneurysms. 2 Immediate transfer to operating theatre. 3 Resuscitation and anaesthesia with surgical team in attendance. 4 All cases operated upon by consultant or senior registrar (with vascular training), and senior anaesthetist.
be carried out in all cases. In order to achieve this, any patient presenting with a possible rupture is directed immediately to the operating theatre, where resuscitation and induction of anaesthesia are carried out. Results published from major vascular units are generally those with the lowest mortality rates. It is likely that this reflects the expertise of the surgeons involved, but may also reflect a degree of patient selection, ie the patients who survive the long journey to the centre are the most stable patients, and are therefore those most likely to survive surgery. In local hospitals, patients who may well have died in transit to a major centre undergo operation for ruptured aortic aneurysm, and in this respect surgery performed locally may even offer a survival advantage. On the other hand, patients unlikely to survive may undergo surgery in a local hospital merely because they reach the hospital alive. These factors may account for the poor mortality figures reported from many district general hospitals compared with those from major centres. We consider it essential that there is close consultant supervision of all junior staff performing aneurysm surgery whether planned or ruptured. We believe that our results show that aneurysm surgery can be safely performed in district general hospitals without a specialist vascular service, with results comparable to those of major centres. This is only possible if strict guidelines are adhered to (Table III).
References I Jenkins AMcL, Ruckley CV, Nolan B. Ruptured abdominal aortic aneurysm. Br J Surg 1986;73:395-8.
217
2 Buck N, Devlin HB, Lunn JN. Report of the Confidential Enquiry into Peri-operative Deaths. London: Nuffield Provincial Hospitals Trust and the King's Fund, 1987. 3 Turk KAD. The post-mortem incidence of abdominal aortic aneurysm. Proc R Soc Med 1965;58:869-70. 4 Schilling FJ, Hempel HF, Becker WH, Clinstalus G. Asymptomatic aortic aneurysms detected on the abdominal roentgenogram. Circulation 1966;23 (suppl. III):209-12. 5 Ingoldby CJH, Wejanto R, Mitchell JE. Impact of vascular surgery on community mortality from ruptured aortic aneurysms. BrJ7 Surg 1986;73:551-3. 6 Johansson G, Swedenborg V. Ruptured abdominal aortic aneurysms: a study of incidence and mortality. Br J Surg 1986;73: 101-3. 7 Gordon-Smith IC, Taylor EW, Nicolaides AN, Golcman L, Kenyon JR, Eastcott HHG. Management of abdominal aortic aneurysm. Br J Surg 1978;65:834-8. 8 Stanley Crawford E et al. Infra-renal abdominal aortic aneurysms. Factors influencing survival after operation performed over a 25 year period. Ann Surg 1981;193:699709. 9 Fielding JWL, Black J, Ashton F, Slaney G, Campbell DJ. Diagnosis and management of 528 abdominal aortic aneurysms. Br Med J 1981;283:355-9. 10 Makin GS. Changing fashions in surgery of aortic aneurysms. Ann R Coll Surg Engl 1983;65:308-10. 11 Fielding JWL, Black J, Ashton F, Slaney G. Ruptured aortic aneurysms: post-operative complications and their aetiology. Br 7 Surg 1984;71:487-91. 12 Castledon WM, Mercer JC, and members of the West Australian Vascular Service. Abdominal aortic aneurysms in Western Australia: descriptive epidemiology and patterns of rupture. BrJI Surg 1985;72:109-12. 13 Holler LH, Reigel MM, Kazmier FJ, Pairolero PC et al. Conventional repair of abdominal aortic aneurysm in the high risk patient: a plea for abandonment of non-resective treatment. J Vasc Surg 1986;3:712-17. 14 Ruckley CV, Jenkins AMcL, Nolan B, Webb JAG. Aortic aneurysms in Scotland 1971-83. 2nd International Vascular Symposium. Programme and Abstracts. London: September 1986. 15 Thomas PRS, Stewart RD. Abdominal aortic aneurysm. Br J Surg 1988;75:733-6. 16 Budd JS, Finch DR. Management of abdominal aortic aneurysm. Br Med J 1988;297:484. Received 9 November 1989
ortic aneurysms V Vella
who
A Shandall
do
them?
MCh
MB BCh Senior House Officer
Senior Surgical Registrar
G Duthie FRCSEd Surgical Registrar
Consultant Surgeon
K Shute
should
MS
Department of Surgery, Royal Gwent Hospital, Newport, Gwent
Key words: Abdominal aortic
aneurysm;
Mortality
All patients undergoing abdominal aortic aneurysm repairs in a district general hospital between 1 January 1983 and 31 December 1987 were reviewed. Of the 76 cases, 53 were planned and 23 were ruptured aneurysms. The male:female ratio was 4.4:1, and the age range was 47-84 years (mean 67.7 ± 6.97 years). Half underwent an ultrasound scan, showing a maximum diameter range of 3-12 cm. Fifty-seven (75%) had tube grafts, and 19 (25%) bifurcation grafts. The 30-day mortality was 3.7% for planned cases, and 26% for ruptured cases. The principal operator in 55 (72.5%) cases was a consultant; consultant anaesthetists were involved in 61.3% cases.
We conclude that aneurysm surgery can safely be performed in a district general hospital by a general surgeon -.ith an interest in vascular surgery
It has been claimed that aortic aneurysm repairs should only be performed in major centres by specialist vascular surgeons (1). This view has recently been strengthened by the CEPOD report (2) which showed deficiencies in the care of such patients. Although this view may reflect the ideal situation, at present it is not entirely realistic. Nevertheless, the CEPOD report has stimulated surgeons to take a greater interest in the mortality rates for certain procedures, including aneurysm surgery. We have reviewed the results of aortic aneurysm repair carried out by one surgical team in a district general hospital, in order to assess the safety of performing such surgery in small centres without a specialist vascular surgeon.
Patients and methods This study reviewed all cases of abdominal aortic aneurysm repair carried out by a general surgical team with an
Correspondence to: Mr K Shute, Department of Surgery, Royal Gwent Hospital, Newport, Gwent NP9 2UB
interest in vascular surgery, during the 5-year period 1 January 1983 to 31 December 1987 inclusive. Planned and ruptured cases were included. The cases were obtained from a record book of all vascular surgery undertaken, and the case notes retrieved from the medical records department. The patients were divided by age, sex and presentation (planned or ruptured), with any risk factor notedhypertension, diabetes mellitus, cardiovascular, pulmonary or renal disease and smoking habit. The type of graft inserted (tube or bifurcation) was recorded, and the diameter of the aneurysm according to ultrasound scan (where available) was also recorded. The grade of surgeon and anaesthetist involved in each of the operations was noted. Deaths attributed to surgery were defined as those occurring within 30 days of operation.
Results During the 5-year period
a
total of 76 abdominal aortic
aneurysm repairs were undertaken. Of these, 53 (70%) were planned procedures, and 23 (30%) were emergencies for ruptured aneurysms. The ruptured cases
included one aortocaval fistula and one aortoduodenal fistula. Fifty-seven (75%) had tube grafts inserted and 19 (25%) bifurcation grafts. The male:female ratio was 4.4:1, and the age range was 47-84 years with a mean age of 67.7 ± 6.97 years (mean ± 2 SD). The majority of the patients fell into the 65-74 years age group. Of the risk factors noted, 22 (35.5%) were hypertensive; 20 (32.25%) had known cardiac disease; 5 (8%) pulmonary disease; 4 (6.47%) cerebrovascular disease; and 3 (4.8%) were diabetic. None had a known history of renal disease. The majority were smokers (Fig. 1). Half of the patients had ultrasound scans, with a maximum diameter range of 3-12 cm (mean 6.16+ 1.6 cm).
216
V Vella
et
al.
80-
60
% of
cases
40
20
Hypertensive
Cardiac Pulmonary
C.V.A.
Renal
Diabetic
Smokers
Figure 1. Known risk factors.
Table I shows the most senior grade of surgeon and anaesthetist involved in the operations. The consultant was the principal operator in 72.7% of planned, and 72.2% of ruptured cases; the senior registrar in 11.4% of planned and 27.8% of ruptured cases, and the registrar in 15.9% of planned cases. Registrars were never the principal surgeon in ruptured cases. A consultant anaesthetist was involved in 63.6% of planned and 55.6% of ruptured cases, with the senior registrar in the majority of the remainder. Registrars were only principally involved in 7% of planned cases, and never in ruptured cases.
The mortality rates are shown in Table II; 2 (3.7%) of planned cases and 6 (26%) of ruptured cases died. Of the planned cases, one died of congestive cardiac failure, and the other from a myocardial infarction. Of the ruptured cases, one aneurysm had a large suprarenal extension and was deemed inoperable, one died from congestive cardiac failure, two of acute renal failure, and two from myocardial infarction.
Discussion The true incidence of abdominal aortic aneurysm is difficult to determine as a large number remain undiagnosed. An incidence of 3% in the over-50 years age group, or 2-4% of the total population has been suggested (3, 4). The incidence appears to be rising (5),
Table I. Grade of principal this study
surgeon
and anaethetist in
Planned
Ruptured
72.7 11.4 15.9
72.2 27.8 0
63.6 29.5 6.9
55.6 44.4 0
Surgeon Consultant Senior Registrar
Registrar Anaesthetist
Consultant Senior Registrar
Registrar
whether due to the ageing population, or to an increased diagnostic accuracy. Ruptured abdominal aortic aneurysms have been shown to be responsible for 0.6% of all deaths. Abdominal aortic aneurysms are therefore common and account for a large number of deaths, a proportion of which may be avoidable. The CEPOD report (2) suggested that there are major deficiencies in the treatment of patients with aortic aneurysms, and this has prompted us to review our own mortality rate and assess our shortcomings. Table II shows some operative mortality figures published during the last 10 years with a range of 3-10% for planned procedures and a range of 23-81% for emergency operations for ruptured aneurysms. There has been little change in the mortality over this time. The best results available in this country are those of Ruckley et al. (14) from Edinburgh and it should be the aim of all units carrying out such surgery to attain comparable results. The CEPOD report (2) attempted to explain why results may be poor in some areas. Of the cases they studied, one had been operated upon by a senior house officer, 16 by registrars, 30 by senior registrars and 93 by consultants. It is inexcusable for SHOs to operate on aneurysms unsupervised and we believe that registrars also should not be operating without supervision. All patients in this study were under the care of a general surgeon with an interest in vascular surgery. We operate a completely non-selective policy on ruptured aneurysms, ie all patients presenting to the hospital with a ruptured aneurysm are given the chance of surgery. Morriston Hospital, Swansea (5), has a similar policy, with a mortality rate of 45%. When this, and our mortality of 26% are compared with that of Budd (16), where only 65% of emergency cases receive surgery with a mortality rate of 68%, it can be seen that a selection procedure does not offer any increase in survival. The patients who are not offered surgery have a 100% mortality, and we therefore believe that surgery should Table II. Reported mortality rates for aneurysm repairs Reporter
Date
Planned
Rupture
Gordon-Smith (7) Crawford (8) Fielding (9) Makin (10) Jenkins (1) Fielding (11) Castledon (12) Ingoldby (5) Hollier (13) Johansson (6) Ruckley (14) Thomas (15) Budd (16) Shute
1978 1981 1981 1983 1984 1984 1985 1986 1986 1986 1987 1988 1988 1988
10 5 8 9 NR 8 4 5 5.7 NR 3 8
55 23 43 50 32 42 31 48 NR 62 24 81 68 26
All figures are % of mortalities NR= results not recorded
3.5 3.7
Aortic aneurysms-who should do them? Table III. Guidelines for aortic aneurysm surgery 1 Non-selection policy for ruptured aneurysms. 2 Immediate transfer to operating theatre. 3 Resuscitation and anaesthesia with surgical team in attendance. 4 All cases operated upon by consultant or senior registrar (with vascular training), and senior anaesthetist.
be carried out in all cases. In order to achieve this, any patient presenting with a possible rupture is directed immediately to the operating theatre, where resuscitation and induction of anaesthesia are carried out. Results published from major vascular units are generally those with the lowest mortality rates. It is likely that this reflects the expertise of the surgeons involved, but may also reflect a degree of patient selection, ie the patients who survive the long journey to the centre are the most stable patients, and are therefore those most likely to survive surgery. In local hospitals, patients who may well have died in transit to a major centre undergo operation for ruptured aortic aneurysm, and in this respect surgery performed locally may even offer a survival advantage. On the other hand, patients unlikely to survive may undergo surgery in a local hospital merely because they reach the hospital alive. These factors may account for the poor mortality figures reported from many district general hospitals compared with those from major centres. We consider it essential that there is close consultant supervision of all junior staff performing aneurysm surgery whether planned or ruptured. We believe that our results show that aneurysm surgery can be safely performed in district general hospitals without a specialist vascular service, with results comparable to those of major centres. This is only possible if strict guidelines are adhered to (Table III).
References I Jenkins AMcL, Ruckley CV, Nolan B. Ruptured abdominal aortic aneurysm. Br J Surg 1986;73:395-8.
217
2 Buck N, Devlin HB, Lunn JN. Report of the Confidential Enquiry into Peri-operative Deaths. London: Nuffield Provincial Hospitals Trust and the King's Fund, 1987. 3 Turk KAD. The post-mortem incidence of abdominal aortic aneurysm. Proc R Soc Med 1965;58:869-70. 4 Schilling FJ, Hempel HF, Becker WH, Clinstalus G. Asymptomatic aortic aneurysms detected on the abdominal roentgenogram. Circulation 1966;23 (suppl. III):209-12. 5 Ingoldby CJH, Wejanto R, Mitchell JE. Impact of vascular surgery on community mortality from ruptured aortic aneurysms. BrJ7 Surg 1986;73:551-3. 6 Johansson G, Swedenborg V. Ruptured abdominal aortic aneurysms: a study of incidence and mortality. Br J Surg 1986;73: 101-3. 7 Gordon-Smith IC, Taylor EW, Nicolaides AN, Golcman L, Kenyon JR, Eastcott HHG. Management of abdominal aortic aneurysm. Br J Surg 1978;65:834-8. 8 Stanley Crawford E et al. Infra-renal abdominal aortic aneurysms. Factors influencing survival after operation performed over a 25 year period. Ann Surg 1981;193:699709. 9 Fielding JWL, Black J, Ashton F, Slaney G, Campbell DJ. Diagnosis and management of 528 abdominal aortic aneurysms. Br Med J 1981;283:355-9. 10 Makin GS. Changing fashions in surgery of aortic aneurysms. Ann R Coll Surg Engl 1983;65:308-10. 11 Fielding JWL, Black J, Ashton F, Slaney G. Ruptured aortic aneurysms: post-operative complications and their aetiology. Br 7 Surg 1984;71:487-91. 12 Castledon WM, Mercer JC, and members of the West Australian Vascular Service. Abdominal aortic aneurysms in Western Australia: descriptive epidemiology and patterns of rupture. BrJI Surg 1985;72:109-12. 13 Holler LH, Reigel MM, Kazmier FJ, Pairolero PC et al. Conventional repair of abdominal aortic aneurysm in the high risk patient: a plea for abandonment of non-resective treatment. J Vasc Surg 1986;3:712-17. 14 Ruckley CV, Jenkins AMcL, Nolan B, Webb JAG. Aortic aneurysms in Scotland 1971-83. 2nd International Vascular Symposium. Programme and Abstracts. London: September 1986. 15 Thomas PRS, Stewart RD. Abdominal aortic aneurysm. Br J Surg 1988;75:733-6. 16 Budd JS, Finch DR. Management of abdominal aortic aneurysm. Br Med J 1988;297:484. Received 9 November 1989
