Brooks M J, Bradbury A, Wolfe H N
Regional Vascular Unit, St Mary's Hospital, London, U.K.
Eur J Vasc Endovasc Surg. 1999 Oct;18(4):290-3. doi: 10.1053/ejvs.1999.0830.
preoperative pulmonary function has been shown by univariate analysis to be an independent predictor of outcome following Crawford Type IV thoraco-abdominal aortic aneurysm repair. The aim of this study was to determine if outcome had been improved by the introduction of a subcostal approach for the elective repair of these aneurysms.
39 patients studied (19 subcostal, 20 thoracolaparotomy) all operated on between 1993 and 1998 by a single surgeon using a standard technique. No significant difference in median age (69 years) or weight (64 kg vs. 69 kg) between the two groups.
preoperative co-morbidities, pulmonary function and predictors of respiratory failure did not vary significantly between the two groups, despite a trend towards greater respiratory, cardiac and renal disease in the subcostal group. Preoperative median pulmonary function in both groups was 80% of that predicted for age, sex and height. The subcostal approach did not significantly reduce blood loss (3500 ml vs. 4500 ml) or anaesthetic time (255 min vs. 253 min). Overall 30 day mortality was 10.2%. The rate of re-operation was significantly higher in the subcostal group (21% vs. 0%, p=0.05). No differences were observed in intensive care unit stay, total hospital stay or respiratory complications, despite earlier extubation of the subcostal group (47% vs. 10% extubated at 12 h, p=0.01).
the introduction of a subcostal approach for type IV thoraco-abdominal aneurysm repair in selected "high risk" patients has been associated with an unacceptably high rate of complications requiring early re-operation. We feel that this relates to the problems inherent in the introduction of a new technique and reduced exposure in patients of inappropriate body habitus. The predicted benefit to pulmonary function is realised in shorter intubation times, but has not translated into earlier recovery or improved outcome. Operation duration and blood loss have not been significantly reduced. Based on these outcomes, we do not currently recommend the general adoption of this approach in all type IV repairs. We will continue to evaluate this approach in patients with poor pulmonary function and a suitable body habitus.
单因素分析显示，术前肺功能是克劳福德IV型胸腹主动脉瘤修复术后预后的独立预测因素。本研究的目的是确定采用肋下入路选择性修复这些动脉瘤是否改善了预后。
研究了39例患者（19例采用肋下入路，20例采用胸腹联合切口），均于1993年至1998年间由同一外科医生采用标准技术进行手术。两组患者的中位年龄（69岁）或体重（64kg对69kg）无显著差异。
尽管肋下入路组的呼吸、心脏和肾脏疾病有增加趋势，但两组患者术前的合并症、肺功能及呼吸衰竭预测因素并无显著差异。两组术前肺功能中位数均为根据年龄、性别和身高预测值的80%。肋下入路并未显著减少失血量（3500ml对4500ml）或麻醉时间（255分钟对253分钟）。总体30天死亡率为10.2%。肋下入路组再次手术率显著更高（21%对0%，p=0.05）。尽管肋下入路组拔管时间更早（12小时时47%对10%，p=0.01），但在重症监护病房停留时间、总住院时间或呼吸并发症方面未观察到差异。
在选定的“高危”患者中采用肋下入路进行IV型胸腹主动脉瘤修复，与需要早期再次手术的并发症发生率高得令人无法接受有关。我们认为这与引入新技术所固有的问题以及不适合体型的患者暴露减少有关。对肺功能的预期益处体现在插管时间缩短，但并未转化为更早恢复或改善预后。手术时间和失血量并未显著减少。基于这些结果，我们目前不建议在所有IV型修复中普遍采用这种方法。我们将继续在肺功能差且体型合适的患者中评估这种方法。
