Br. J. Surg. 1992, Vol. 79, October, 1017- 1018

Synchronous aortic and gastrointestinal surgery

T. H. Brown and J. F. Kelly Department of General Surgery, Royal Lancaster Infirmary, Ashton Road, Lancaster LA4 lRP, UK Correspondence to: Mr T. H. Brown, Unit 10 Secretaries, Manchester Royal Infirmary, Oxford Road, Manchester MI 3 9WL, U K

The synchronous performance of aortic and gastrointestinal surgery may hold an increased risk of aortic graft infection. The experience of one surgeon who performed 32 such synchronous operations over a period of I 1 years is reviewed. No graft infection occurred and it is concluded that such combined operations may be safer to perform than staged surgery in elderly patients.

It is generally held that the synchronous performance of aortic graft and gastrointestinal tract surgery should be avoided because of the risk of subsequent graft infection. Some authors suggest caution is needed if a concomitant procedure is contemplated, and that the gastrointestinal operation can usually be deferred’. However, the risk of graft infection following synchronous surgery varies in different reports2 and some feel that cholecystectomy combined with aortic graft surgery may be preferable to the possibility of postoperative acute chole~ystiris~. There are some patients in whom concomitant disease of the gastrointestinal tract is discovered at the time of aortic surgery; this includes benign or malignant gastric or duodenal ulcers, cholecystitis or common bile duct (CBD ) stones, diverticulitis and colonic carcinoma. There are two possible approaches: one procedure (usually the vascular) is carried out at that time and the second operation deferred to a later date, or both procedures are performed under the same anaesthetic. The former approach requires two major operations within the space of a few weeks, whereas the latter requires only one general anaesthetic but with a theoretically increased risk of aortic graft infection. This paper reviews a series of patients under the care of one surgeon (J.F.K. ) who have been managed with synchronous aortic graft and gastrointestinal surgery. Patients who needed gastrointestinal surgery for a life-threatening condition have been excluded and only those for whom synchronous surgery was indicated, but not imperative, are discussed.

Patients and methods Between 1980 and 1991, 32 patients underwent synchronous aortic graft and gastrointestinal surgery. There were 23 men and nine women with a median age of 70 (range 55-86) years. During the study period three patients underwent emergency colectomy for an ischaemic or perforated colon along with aortic surgery. These were life-threatening conditions for which treatment could not have been delayed; they have been excluded from this study. Of the 32 patients, 2 0 had biliary surgery. All those who underwent cholecystectomy had a severely diseased gallbladder, evidence of acute cholecystitis, an obstructed gallbladder or had suffered recurrent episodes of biliary pain before their aneurysm operation. Two of these patients also underwent exploration of the CBD for stone removal. None of these patients had simple asymptomatic gallstones. Nine patients had gastric surgery: seven truncal vagotomy and pyloroplasty for benign peptic ulcer disease, one total gastrectomy for an operable carcinoma, and one excision of a gastric ulcer. The final three patients underwent bowel surgery: right hemicolectomy for a bleeding diverticulum, anterior resection for carcinoma, and small bowel resection for jejunal diverticulitis.

Results There was only one postoperative death, which occurred in a 78-year-old man who had an aortic graft for aneurysm and truncal vagotomy and pyloroplasty for a scarred duodenum with active ulceration. Following surgery, urine output was poor and renal failure and a necrotic buttock developed. The


0 1992 Butterworth-Heinemann


patient died 6 days after surgery from renal failure due to trash embolization into the renal arteries. Four patients required a second laparotomy. This second procedure was respectively for ischaemic ileum, intraabdominal bleeding, oversewing of an acute gastric erosion, and drainage of a subphrenic abscess following cholecystectomy. Two patients developed wound infection and two had pyrexia for which no cause was found (one had a haematoma drained); a further patient had a pneumonia. Limb ischaemia required lower-limb amputation (below- and through-knee respectively) in two patients. No patient developed evidence of any form of graft sepsis in the immediate postoperative period and none has subsequently developed evidence of graft infection. Long-term follow-up revealed two patients who required further surgery. In one an operation was performed for retained stones in the CBD 9 years after the original surgery; this patient required a further operation for incisional hernia 6 months later. In the second patient a suprarenal aortic aneurysm developed and ruptured 7 years after the first procedure. A further two patients developed an incisional hernia.

Discussion There are a number of patients with large ( > 5 3 cm) aortic aneurysms who also have serious gastrointestinal pathology. It is often policy to treat these by staged operations because of the theoretical risk of infecting a vascular prosthesis by synchronous surgery. However, the gastrointestinal pathology or its serious nature may be discovered only at laparotomy. A decision must then be made whether to deal with the two conditions synchronously or to stage the procedures, dealing with the greater perceived threat first. Although two general surgical procedures may be carried out synchronously, surgeons are cautious about performing gastrointestinal tract surgery at the same time as introducing a foreign body into the abdomen, especially a vascular graft’. The main reason for this is the increased chance ofgraft infection with its risk of serious sequelae. However, there are also risks involved with leaving a surgically correctable condition, especially the danger of postoperative cholecystitis”6 or haemorrhage from a peptic ulcer, and synchronous surgery should at least be considered. Occasionally, as in the patients discussed with jejunal diverticulitis or acute gallbladder pain, abdominal pain in the presence of a large aneurysm is misdiagnosed as an aortic rupture. In the present series there was a high morbidity rate, as reported elsewhere’, but only one death. All the patients who underwent further surgery while in hospital (laparotomy in three, laparotomy with amputation in one, amputation alone in one) survived to be discharged. There was no indication that the performance of two procedures simultaneously significantly increased the risks over those of a single procedure, although in a series from the Mayo Clinic’ there was an unexpected increase in morbidity attached to two operations. The majority of the synchronous procedures involved operations on the


Aortic and gastrointestinal surgery: T.

H. Brown and J. F. Kelly

biliary tract. In several series of combined biliary and aortic surgery6-' there were no deaths attributed to cholecystectomy, although there was one graft infection. It is unlikely that recent developments in biliary surgery, such as laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography, will make much difference to the management of patients with acute gastrointestinal and aortic pathologies, although where staged procedures are acceptable they may reduce the severity of one of them. In conclusion, this small series has not shown any increased risk of graft infection after synchronous aortic and gastrointestinal surgery. Synchronous operations should be given consideration when faced with dual bowel and vascular pathology in the abdomen.

References 1.

Bickerstaff LK, Holier LH, Van Peenen HJ, Melton LJ, Pairolero PC, Cherry KJ. Abdominal aortic aneurysm repair combined with a second surgical procedure. Morbidity and


2. 3.

4. 5.




mortality. Surgery 1984; 95: 487-91. Thomas JH. Abdominal aortic aneurysmorrhaphy combined with biliary or gastrointestinal surgery. Sury C/in Nor/h A m 1989; 69: 807- 15. Calligaro KD, Veith FJ. Diagnosis and management of infected prosthetic aortic grafts. Surgery 1991; 110: 805-13. Ottinger LW. Acute cholecystitis as a postoperative condition. An7 Surg 1976; 184: 162-5. Devine RM, Farnell MB, Mucha P. Acute cholecystitis as a complication in surgical patients. Arch Sury 1984; 119: 1389-93. Ouriel K, Ricotta JJ, A d am JT, DeWeese JA. Management of acute cholecystitis in patients with abdominal aneurysm surgery. A m Surg 1983; 198: 717-19. Temaur WG, Baird RN. Second intra-abdominal pathology: concomitant or sequential surgery. In: Greenhalgh RM, Mannick JA, eds. The Cause and Management of Aneurysms. London: WB Saunders, 1990: 321-6. Schirmer BD, Edge SB, Dix J e / a/.Laparoscopic cholecystectomy. Treatment of choice for symptomatic cholelithiasis. Ann Surg 1991; 213: 665-71.

Paper accepted 9 June 1992

Br. J. Syrg., Vol. 79, No. 10. October 1992

Synchronous aortic and gastrointestinal surgery.

The synchronous performance of aortic and gastrointestinal surgery may hold an increased risk of aortic graft infection. The experience of one surgeon...
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