title: Laparotomy during endovascular repair of ruptured abdominal aortic aneurysms increases mortality.
abstract: OBJECTIVE
  Subset analyses from small case series suggest patients requiring laparotomy during endovascular repair of ruptured abdominal aortic aneurysms (REVAR) have worse survival than those undergoing REVAR without laparotomy. Most concomitant laparotomies are performed for abdominal compartment syndrome. This study used data from the American College of Surgeons National Surgical Quality Improvement Program to determine whether the need for laparotomy during REVAR is associated with increased mortality.
  
  
  METHODS
  Data were obtained from the 2005 to 2013 National Surgical Quality Improvement Program participant user files based on Current Procedural Terminology (American Medical Association, Chicago, Ill) and International Classification of Diseases-9 Edition coding. Patient and procedure-related characteristics and 30-day postoperative outcomes were compared using Pearson χ2tests for categoric variables and Wilcoxon rank sum tests for continuous variables. A backward-stepwise multivariable logistic regression model was used to identify patient- and procedure-related factors associated with increased death after REVAR.
  
  
  RESULTS
  We identified 1241 patients who underwent REVAR, and 91 (7.3%) required concomitant laparotomy. The 30-day mortality was 60% in the laparotomy group and 21% in the standard REVAR group (P < .001). The major complication rate was also higher in the laparotomy group (88% vs 63%; P < .001). Multivariable analysis showed laparotomy was strongly associated with 30-day mortality (odds ratio, 5.91; 95% confidence interval, 3.62-9.62; P < .001).
  
  
  CONCLUSIONS
  Laparotomy during REVAR is a commonly used technique for the management of elevated intra-abdominal pressure and abdominal compartment syndrome development. The results of this study strongly confirm findings from smaller studies that the need for laparotomy during REVAR is associated with significantly worse 30-day survival.
authors.affiliation: Duke University School of Medicine, Durham, NC.
authors.forename: Shaunak S
authors.initials: SS
authors.lastname: Adkar
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC. Electronic address: ryan.turley@dm.duke.edu.
authors.forename: Ryan S
authors.initials: RS
authors.lastname: Turley
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Ehsan
authors.initials: E
authors.lastname: Benrashid
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Mitchell W
authors.initials: MW
authors.lastname: Cox
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Leila
authors.initials: L
authors.lastname: Mureebe
authors.affiliation: Department of Surgery, Duke University Medical Center, Durham, NC.
authors.forename: Cynthia K
authors.initials: CK
authors.lastname: Shortell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D001019:Aortic Rupture / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000401:mortality*; D016009:Chi-Square Distribution; D016208:Databases, Factual; D057510:Endovascular Procedures / Q000009:adverse effects / Q000401:mortality*; D005260:Female; D006801:Humans; D059325:Intra-Abdominal Hypertension / Q000209:etiology / Q000401:mortality / Q000601:surgery; D007813:Laparotomy / Q000009:adverse effects / Q000401:mortality*; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D012189:Retrospective Studies; D012307:Risk Factors; D018709:Statistics, Nonparametric; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States