Extraperitoneal approach reduces neutrophil activation, systemic inflammatory response and organ dysfunction in aortic aneurysm surgery

Objectives: to compare the effects of transperitoneal and extraperitoneal approaches on systemic inflammatory response neutrophil activation and organ dysfunction ill elective abdominal aortic aneurysm (AAA) repair. Patients ann methods: twenty patients admitted for elective intrarenal AAA repair were prospectively randomised into transperitoneal (n=10) or extraperitoneal (n=10) group. Neutrophil activation was assessed by measuring the plasma levels of neutrophil elastase/alpha (1)-anti-trypsin complexes before surgery, intraoperatively and at 6 h, 12 h, 24 h and then daily after surgery. Venous blood samples for estimation of liver function tests, full blood counts, urea and electrolytes and arterial samples for blood gas analysis were taken daily from preoperatively to day 5 after surgery. Multiple organ dysfunction (MOD) and systemic inflammatory response (SIR) scores were calculated daily. Results: the concentrations of neutrophil elastase/alpha1-anti-trypsin complexes were significantly higher in the transperitoneal group at 6 12 after surgery compared to thr extraperitoneal group (799(455-921) ng/ml (median(i.q.r.)) vs 307(171-395) ng/ml, p <0.005), and at 12 h (397(364-936) ng/ml vs 319(134-352) ng/ml, p <0.05). The MOD scores were significantly higher in the transperitoneal group in comparison to the extraperitoneal group at day 1 (2.5(2-3.3) vs 1(0-1), p <0.001) ann day 2 (2.5(2-3.3) vs 1(0-1), p <0.001). The SIR scores were also significantly higher at day 1 (1(0-2) vs 0, p <0.001), day 2 (1.5(0-2.3) vs 0, p <0.01), and day 3 (1(0-1) vs 0, p <0.05). Conclusions: neutrophil activation, systemic inflammatory response anf organ dysfunction are increased in elective AAA repair when a transperitoneal approach is used. This may be related to intestinal manipulation and mesenteric traction which are reduced ill the extraperitoneal approach.