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Laparoscopic aortic surgery
1. J.-B Ricco, J. Cau, A. Valagier, G Régnault de la Mothe
University hospital, Poitiers, France
XV. ULUSAL VASKÜLER CERRAHi KONGRESİ
No conflict of interest to declare
LAPAROSCOPIC AORTIC SURGERY
AORTOiLiAK TIKAYICI HASTALIKLAR iÇiN
LAPAROSKOPiK CERRAHi
A Failed Innovation ?
2. PURPOSE
The purpose of laparoscopic vascular surgery
is to replicate the good and durable results of
the classical open approach in patients with
TASC D lesions or with AAA not amenable to
endovascular treatment
3. FEASIBILITY
1993: Dion et al. in Surg Laparosc Endosc
First laparoscopy-assisted aortobifemoral bypass
1993-2011: 45 publications (29 from EU)
• 1244 patients
830 for occlusive disease
414 for aneurysm
4. STUDY QUALITY
• All studies were observational, no RCT’s
• Heterogeneity of the studies
• Inadequate description of the study population
• Suspected selection bias of patients
Nio et al. Eur J Vasc Endovasc Surg 2007
16. CLINICAL STUDY
This study was planned by a group of vascular
surgeons trained in laparoscopic aortic surgery
to identify potential differences in the 30-day
complication rate of total laparoscopic vs. open
approach for aortic surgery.
Cau J, Ricco JB et al. Total laparoscopic aortic repair for occlusive and aneurysmal disease:
first 95 cases. Eur J Vasc Endovasc Surg. 2006
Cau J, Ricco JB. Laparoscopic aortic surgery: Techniques and results. J Vasc Surg 2008
Cau J, Ricco JB. Total laparoscopic renal artery bypass. J Vasc Surg. 2011
17. METHODS
January 2006 to December 2009
228 consecutive patients with AAA or occlusive disease
Total laparoscopic aortic surgery =83
open repair =145
Prospective study with propensity scoring
Endpoint : composite adverse event at 30-day:
Death, bleeding, graft thrombosis, MI, respiratory failure,
colon ischemia, evisceration.
18.
19. VARIABLES OPEN REPAIR
(n=145)
LAPAROSCOPY
(n=83)
p
Female gender 19 (13.1) 11 (13.3) 0.97
Body mass index 25.6±4.1 25.1±4.4 0.38
COPD 45 (31.0) 24 (28.9) 0.74
Diabetes 12 (8.3) 7 (8.4) 0.97
Dyslipidemia 96 (66.2) 55 (66.3) 0.99
Coronary disease 54 (37.2) 26 (31.3) 0.39
Values in parentheses are percentages
BASELINE CHARACTERISTICS
23. RESULTS IN OVERALL SERIES
End-point: 30-day mortality
• Logistic regression showed that ASA class was the only
independent predictor [OR 8.5, 95%CI 1.3-54.2].
Laparoscopic repair showed a tendency toward higher
mortality risk [OR 7.9, 95%CI 0.76-83.5]
• The small number of patients with AAA prevented
sensitivity analysis in subgroups of patients (AAA vs.
PAOD)
24. RESULTS IN OVERALL SERIES
End-point: Composite adverse events
• Logistic regression showed that laparoscopic repair was
the only independent predictor of composite adverse
events [OR 7.1, 95%CI 2.9 - 17.6]
25. PROPENSITY SCORE
The treatment groups differed markedly to
some variables
Need to develop a propensity score by logistic
regression
The calculated propensity score was employed
for a one-to-one matching as well as to adjust
for other variables
26. MATCHING BASED ON PROPENSITY SCOREMATCHING BASED ON PROPENSITY SCORE
PS Trt A vs. Trt B
Compare treatments based on matched pairs
This methodology simulates a RCT
PS1
PS2
PSm
29. PROPENSITY SCORE
LOGISTIC REGRESSION
• Patient’s age, indication for surgery and suprarenal
clamping were independent predictors for assigning
patients to laparoscopic or open repair group
• Laparoscopic repair was associated with a higher risk of
30-day composite adverse events [OR 6.5, 95%CI 2.7-
15.5]
• Laparoscopic repair was not associated with lower risk of
respiratory complications [OR 0.76, 95%CI 0.28 – 2.04]
30. CONCLUSIONS
This study suggests that total laparoscopic
aortic surgery even in well trained hands is not
as safe as open surgery to treat abdominal
aortic aneurysms and TASC D aortic disease.
This forum of the World federation for vascular surgery is for us a unique opportunity to present the European Union contribution to laparoscopic vascular surgery and our experience with this technique.
No comment
Since the seminale paper form Yves Marie Dion describing in 1993 the first laparoscopic-assisted aortobifemoral bypass, only 33 clinical studies mainly from Europe have been published on the subject
A careful review of these 33 studies shows some important deficits in many of them with incomplete description of the study population and a suspected selection bias of the patients. All these studies were observational and no RCT was done.
By avoiding large abdominal incision, thus decreasing pain and respiratory complications. Laparoscopic aortic surgery is certainly a less invasive procedure !
In contrast to the revolutionary changes coming from the endovascular pipeline and largely supported by the Industry, adoption of laparoscopy is aortic surgery is hampered by the steep learning curve and the fear of exposing patients to excessive morbidity.
For all the procedures that you will see, the patient Is placed in dorsal decubitus position with an inflatable bolster under the left flank. when the table was titled to the right (45°) and the bolster was inflated (35°). the patient Is in complete right lateral decubitus position.
The patient Is placed in dorsal decubitus position with an inflatable bolster under the left flank. Two supports were placed on the right thorax and flank in order to retain the patient when the table was titled to the right (45°) and the bolster was inflated (35°). After these maneuvers, i.e., tilting and inflation, the patient Is in complete right lateral decubitus position.
The firs case is a TASC D aortoiliac occlusive disease with severe calcifications not amenable to endovascular treatment.
To be done
In this second case, laparocopy was used to treat a severe left renal artery restenosis after stent failure.
This case is interesting , the AAA was large with a very short neck., same laparoscopic approach.
This case is interesting , the AAA was large with a very short neck., same laparoscopic approach.
One difficulty of totally laparoscopic aortic aneurysm surgery are the hemostasis of the lumbar arteries that decide us to work on a plug that coiuld also be useful in open surgery
In conclusion, Laparoscopic vascular techniques are certainly challenging, they need a new surgical expertise! But our fellows are doing the easy cases after 3 years of training and they like it, patients too that ask for. But indications should be selective
No comment
.
Laparoscopic repair was associated with significantly higher risk of composite adverse event (27.7% vs. 5.5%, p<0.0001) and of repeated surgery (15.7% vs. 4.1%, p=0.002) compared with open repair (Tab. 2). Furthermore, a tendency toward higher mortality risk was observed as well (4.1% vs. 0.7%, p=0.14). On the other hand patients who underwent laparoscopic repair had a significantly shorter in-hospital stay (mean, 8.9 vs. 11.1 days, p<0.0001) and a tendency toward lower risk of respiratory complications (8.4% vs. 15.9%, p=0.11).
Need to develop a propensity score that was estimated by logistic regression with backward selection by including clinical and operative variables with a difference (*) between the study groups (p<0.20)
The calculated propensity score was employed for one-to-one matching as well as to adjust for other covariates in estimating their impact on the postoperative outcome at multivariable analysis. We did not perform stratification analysis of propensity score because of the small size of the present series.
One-to-one propensity score matching between study groups was done according to a difference in the propensity score of less than 0.005 between each patient in the open and laparoscopic study groups. Logistic regression with the help of backward selection was used to adjust the effect of treatment method for propensity score as well as other variables in evaluating immediate postoperative outcome. A p < 0.050 was considered statistically significant.
One-to-one propensity score matching resulted in 49 pairs with similar preoperative characteristics. This table 2 summarizes the main outcome end-points in these matched pairs. Laparoscopic repair was associated with a significantly higher risk of composite adverse event (p<0.0001). This was likely due to significantly higher risk of reintervention after laparoscopic repair (p<0.008). Thirty-day mortality was somewhat higher after laparoscopic repair, but the difference was not statistically significant. No marked differences were observed in the other outcome end-points
But our interest towards less invasive surgery remains intact and we turned towards minimally invasive surgery