Volume 12 Number 4 October 1990
3. Montohu 1, Torras A, Revert L. Polycystic kidneys and abdominal aortic aneurysms. Lancet 1980;i: 1 I33-4. 4. Palmaz JC, Carson SN, Hunter G, Weinshelbaum A. Male hypoplastic infrarenal aorta and premamrc atherosclerosis. Surgery 1983;94:9I-4. 5. Roodvoets AP. Aortic aneurysms in presence of kidney disease. Lancet 1980;1:1413-4.
Transperitoneal versus retroperitoneal approach for aortic reconstruction: A randomized 13rospective study To the Editors:
Surgeons who frequently use the retroperitoneal approach for aortic surgery in community hospitals without the same tertiary anesthetic and intensive care unit sul ?ort as major academic centers provide may be confused by the article o f Cambria et al. (J VAse Suv.G 1990; 11:314-25). Ample data exist in comparative studies in the American as well as the European literature that report the advantage of the retroperitoneal approach in decreasing hospitalization, paralytic ileus, and blood loss, even though the mortality is similar with both surgical approaches3 -s In the report by Cambria et al. no statistically significant difference was found between the transperitoneal and retroperitoneal approach in aortic surgery as it refers to multiple intraoperative and postoperative parameters. My confusion whcn interpreting their data is the description by the authors of three maneuvers that are not commonly practiced by most vascular surgeons; "Eighty percent of all patients were anesthetized with a combination of continued epidural narcotics and inhalation agents," "Nasogastric tubes were always removed at the time ofendotracheal intubation and only reinserted if the clinical situation dictated," and "~saatotransfusion is now routine in our practice." Another randomized study by Nevelsteen et al,~ has been published, which addresses the benefits of the retroperitoneal approach over the transabdominal approach for aortic surgery. The results by this surgical group with extensive experience in both the transperitoneal 7 and retroperitoneal 8 approach to aortic surgery demonstrated a statistically significant improvement in pulmonary function parameters in the retroperitoneal group when compared to the transabdominal approach. A randomized mul.ricenter prospective trial addressing the use of a combination of general anesthetic and epidural anesthesia for pain control is needed to demonstrate if these two surgical approaches to aortic surgery are equivalent, as shown in the study by Cambria et al., or if only certain parameters are improved as was demonstrated in the study by Nevelsteen. Manuel Doblas, 21/119
Department of Surgery Hospital "Viegen de la Salud" Av. de Barber s/n Toledo, Spain
Letters to the Editors
505
REFERENCES
1. Rob C. Extraperitoneal approach to the abdominal aorta. Surgery 1963;53:86-89. 2. Helsby R, Moossa R. Aortoiliac reconstruction with special reference to the extraperitoneal approach. Br J Surg 1975; 62:596-600. 3. Willekens FGJ, Widdershoven GMJ, Kirk RS. The retroperitoneal approach to the aortoiliac vessels. Angiolog3~ 1985; 1:31-7. 4. Sicard GA, Freeman MB, VanderWoude JC, Anderson CB. Comparison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. J VAsc SUr,G 1987;5:I9-27. 5. Leather RP, Shah DM, Kaufman JL, Fitzgerald KM, Gahng BB, Feustel PI. Comparative analysis of retroperitoneal and transperitoneal aortic replacement for aneurysm. Surg Gynecol Obstet I989;I68:387-93. 6. Nevelsteen A, Smet G, Weyman S, Depre H, Suy R. Transabdominal or retroperitoneal approach to the aortoiliac track: pulmonary ffmction studies. Eur J Vase Surg 1988;2:229-32. 7. Nevelsteen A, Suy R, Daenen W, Boel A, Stalpaert G. Aortofemoral grafting: factors influencing late results. Surgep,z 1980;88:642-53. 8. Nevelsteen A, Boeckxstaens C, Smet G, Willikens FGJ, Suy R. Extensive aortoiliofemoral endarterectomy with LeVeen placque cracker. J Cardiovasc Surg 1988;29:441-8. Reply To the Editors:
Apparently Dr. DoNas is convinced of the superiority of the retroperitoneal approach over the transperitoneal approach for aotic surgery, yet much of the literature that he cites as "ample data" of the "advantage of the retroperitoneal approach" has been reviewed in our artide) ,s We noted that these reports suffer from the use of historical controls, and in our study we emphasized the necessity for controlling other variables in an era when a number of factors have improved the overall course of patients undergoing elective aortic surgery. Indeed, our study included a retrospectively reviewed group of patients in whom a number of perioperative parameters were significantly different from all randomized patients. Thus the differences were a function of the evolution of the care of the patient undergoing aortic surgery over time, but independent of retroperitoneal versus transperitoneal approach3 I believe wc demonstrated conclusively that there was no significant difference with the two approaches in either perioperative pulmonary dysfunction, length of hospital stay, or blood loss as claimed by Dr. DoNas. There was indeed in our patients, a significant advantage for the retroperitoneal approach with respect to recovery, of gastrointestinal fianction, but the clinical importance of these small differences is doubtful. I would disagree with Dr. DoNas' contention that early discontinuation o f nasogastric suction and autotransfusion are not commonly practiced by vascular surgeons after aortic surgery. With respect to the combined epidural and general anasthesia for aortic surgery this is now routine in our practice although cer-
3. Montohu 1, Torras A, Revert L. Polycystic kidneys and abdominal aortic aneurysms. Lancet 1980;i: 1 I33-4. 4. Palmaz JC, Carson SN, Hunter G, Weinshelbaum A. Male hypoplastic infrarenal aorta and premamrc atherosclerosis. Surgery 1983;94:9I-4. 5. Roodvoets AP. Aortic aneurysms in presence of kidney disease. Lancet 1980;1:1413-4.
Transperitoneal versus retroperitoneal approach for aortic reconstruction: A randomized 13rospective study To the Editors:
Surgeons who frequently use the retroperitoneal approach for aortic surgery in community hospitals without the same tertiary anesthetic and intensive care unit sul ?ort as major academic centers provide may be confused by the article o f Cambria et al. (J VAse Suv.G 1990; 11:314-25). Ample data exist in comparative studies in the American as well as the European literature that report the advantage of the retroperitoneal approach in decreasing hospitalization, paralytic ileus, and blood loss, even though the mortality is similar with both surgical approaches3 -s In the report by Cambria et al. no statistically significant difference was found between the transperitoneal and retroperitoneal approach in aortic surgery as it refers to multiple intraoperative and postoperative parameters. My confusion whcn interpreting their data is the description by the authors of three maneuvers that are not commonly practiced by most vascular surgeons; "Eighty percent of all patients were anesthetized with a combination of continued epidural narcotics and inhalation agents," "Nasogastric tubes were always removed at the time ofendotracheal intubation and only reinserted if the clinical situation dictated," and "~saatotransfusion is now routine in our practice." Another randomized study by Nevelsteen et al,~ has been published, which addresses the benefits of the retroperitoneal approach over the transabdominal approach for aortic surgery. The results by this surgical group with extensive experience in both the transperitoneal 7 and retroperitoneal 8 approach to aortic surgery demonstrated a statistically significant improvement in pulmonary function parameters in the retroperitoneal group when compared to the transabdominal approach. A randomized mul.ricenter prospective trial addressing the use of a combination of general anesthetic and epidural anesthesia for pain control is needed to demonstrate if these two surgical approaches to aortic surgery are equivalent, as shown in the study by Cambria et al., or if only certain parameters are improved as was demonstrated in the study by Nevelsteen. Manuel Doblas, 21/119
Department of Surgery Hospital "Viegen de la Salud" Av. de Barber s/n Toledo, Spain
Letters to the Editors
505
REFERENCES
1. Rob C. Extraperitoneal approach to the abdominal aorta. Surgery 1963;53:86-89. 2. Helsby R, Moossa R. Aortoiliac reconstruction with special reference to the extraperitoneal approach. Br J Surg 1975; 62:596-600. 3. Willekens FGJ, Widdershoven GMJ, Kirk RS. The retroperitoneal approach to the aortoiliac vessels. Angiolog3~ 1985; 1:31-7. 4. Sicard GA, Freeman MB, VanderWoude JC, Anderson CB. Comparison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. J VAsc SUr,G 1987;5:I9-27. 5. Leather RP, Shah DM, Kaufman JL, Fitzgerald KM, Gahng BB, Feustel PI. Comparative analysis of retroperitoneal and transperitoneal aortic replacement for aneurysm. Surg Gynecol Obstet I989;I68:387-93. 6. Nevelsteen A, Smet G, Weyman S, Depre H, Suy R. Transabdominal or retroperitoneal approach to the aortoiliac track: pulmonary ffmction studies. Eur J Vase Surg 1988;2:229-32. 7. Nevelsteen A, Suy R, Daenen W, Boel A, Stalpaert G. Aortofemoral grafting: factors influencing late results. Surgep,z 1980;88:642-53. 8. Nevelsteen A, Boeckxstaens C, Smet G, Willikens FGJ, Suy R. Extensive aortoiliofemoral endarterectomy with LeVeen placque cracker. J Cardiovasc Surg 1988;29:441-8. Reply To the Editors:
Apparently Dr. DoNas is convinced of the superiority of the retroperitoneal approach over the transperitoneal approach for aotic surgery, yet much of the literature that he cites as "ample data" of the "advantage of the retroperitoneal approach" has been reviewed in our artide) ,s We noted that these reports suffer from the use of historical controls, and in our study we emphasized the necessity for controlling other variables in an era when a number of factors have improved the overall course of patients undergoing elective aortic surgery. Indeed, our study included a retrospectively reviewed group of patients in whom a number of perioperative parameters were significantly different from all randomized patients. Thus the differences were a function of the evolution of the care of the patient undergoing aortic surgery over time, but independent of retroperitoneal versus transperitoneal approach3 I believe wc demonstrated conclusively that there was no significant difference with the two approaches in either perioperative pulmonary dysfunction, length of hospital stay, or blood loss as claimed by Dr. DoNas. There was indeed in our patients, a significant advantage for the retroperitoneal approach with respect to recovery, of gastrointestinal fianction, but the clinical importance of these small differences is doubtful. I would disagree with Dr. DoNas' contention that early discontinuation o f nasogastric suction and autotransfusion are not commonly practiced by vascular surgeons after aortic surgery. With respect to the combined epidural and general anasthesia for aortic surgery this is now routine in our practice although cer-
