title: Extraperitoneal approach reduces neutrophil activation, systemic inflammatory response and organ dysfunctionin aortic aneurysm surgery.
abstract: OBJECTIVE
  to compare the effects of transperitoneal and extraperitoneal approaches on systemic inflammatory response, neutrophil activation and organ dysfunction in elective abdominal aortic aneurysm (AAA) repair.
  
  
  METHODS
  twenty patients admitted for elective infrarenal AAA repair were prospectively randomised into transperitoneal (n =10) or extraperitoneal ( n =10) groups. 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/alpha(1)-anti-trypsin complexes were significantly higher in the transperitoneal group at 6 h after surgery compared to the 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) and 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 <0.01), 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 and 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 in the extraperitoneal approach.
authors.affiliation: Vascular Surgery Unit, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, Northern Ireland.
authors.forename: L L
authors.initials: LL
authors.lastname: Lau
authors.forename: K R
authors.initials: KR
authors.lastname: Gardiner
authors.forename: L
authors.initials: L
authors.lastname: Martin
authors.forename: M I
authors.initials: MI
authors.lastname: Halliday
authors.forename: R J
authors.initials: RJ
authors.lastname: Hannon
authors.forename: B
authors.initials: B
authors.lastname: Lee
authors.forename: C V
authors.initials: CV
authors.lastname: Soong
mesh_terms: D018806:APACHE; D000368:Aged; D000704:Analysis of Variance; D017544:Aortic Aneurysm, Abdominal / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000517:prevention & control*; D018375:Neutrophil Activation / Q000502:physiology*; D011183:Postoperative Complications / Q000517:prevention & control*; D011446:Prospective Studies; D018709:Statistics, Nonparametric; D018746:Systemic Inflammatory Response Syndrome / Q000517:prevention & control*; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures / Q000379:methods*