Benefits of laparoscopic versus open aortobifemoral bypass surgery – focus on the surgical inflammatory reaction, humoral stress response and health economics

This dissertation concerns some of the possible advantages of totally laparoscopic aortobifemoral bypass surgery in the treatment of aortoiliac occlusive disease, with focus on the postoperative inflammatory reaction, the surgical stress response and cost-effectiveness. The scientific work consists of three substudies from an ongoing multicenter, randomized, controlled trial, the Norwegian Laparoscopic Aortic Surgery Trial (NLAST), comparing laparoscopic and open aortobifemoral bypass in patients suffering from symptomatic aortoiliac occlusive disease

Totally laparoscopic aortobifemoral bypass surgery in the treatment of aortoiliac occlusive disease or abdominal aortic aneurysms - A systematic review and critical appraisal of literature

Purpose: This systematic review aims to evaluate the published literature regarding totally laparoscopic aortobifemoral bypass (LABF) surgery in the treatment of aortoiliac occlusive disease (AIOD) or abdominal aortic aneurysms (AAA), compared with open aortobifemoral bypass surgery. Materials and methods: A systematic review of the medical literature between 1990 and 2016 was performed, searching the medical databases Cochrane Library, OVID Medline, Embase and PubMed. Studies concerning totally LABF with or without control group and containing more than 10 patients were included in the analysis. Operative and aortic cross-clamping times, blood loss, rate of conversion to open surgery, mortality and morbidity within the first 30 postoperative days, hospital stay and primary and secondary patency of the graft were extracted and compared with open surgery when possible. Results: Sixty-six studies were deemed eligible for inclusion in this review, 16 of them matched the inclusion criteria for quantitative synthesis. The patient material consisted of 588 patients undergoing totally LABF, 22 due to AAA, and the remaining 566 for AIOD. Five comparative studies regarding AIOD compared 211 totally LABF procedures with 246 open procedures. Only one study concerning AAA was eligible for inclusion, and this study did not provide a comparison against an open group. The operating and aortic cross-clamping times were shorter in the open group. Conversion rates ranged from 0% to 27%. There was no statistically significant difference in mortality between the two groups (p=0.64). Hospital stays ranged from 4.0 to 12.1 and 5.0 to 12.8 days in the laparoscopic group and open group, respectively. Most of the studies provided low levels of evidence, mainly due to lack of blinding, randomization and correction of bias. Conclusion: Totally laparoscopic aortoiliac surgery seems to be a feasible technique with unaffected mortality and trend toward benefits in hospital stay and possibly also in complication rates. The literature published this far is sparse and with inconsistent results. More randomized controlled trials are required before this method can be widely implemented

Cost-utility analysis comparing laparoscopic vs open aortobifemoral bypass surgery

Objectives: Laparoscopic aortobifemoral bypass has become an established treatment option for symptomatic aortoiliac obstructive disease at dedicated centers. Minimally invasive surgical techniques like laparoscopic surgery have often been shown to reduce expenses and increase patients’ health-related quality of life. The main objective of our study was to measure qualityadjusted life years (QALYs) and costs after totally laparoscopic and open aortobifemoral bypass. Patients and methods: This was a within trial analysis in a larger ongoing randomized controlled prospective multicenter trial, Norwegian Laparoscopic Aortic Surgery Trial. Fifty consecutive patients suffering from symptomatic aortoiliac occlusive disease suitable for aortobifemoral bypass surgery were randomized to either totally laparoscopic (n=25) or open surgical procedure (n=25). One patient dropped out of the study before surgery. We measured health-related quality of life using the EuroQol (EQ-5D-5L) questionnaire at 4 different time points, before surgery and for 6 months during follow-up. We calculated the QALYs gained by using the area under the curve for both groups. Costs were calculated based on prices for surgical equipment, vascular prosthesis and hospital stay. Results: We found a significantly higher increase in QALYs after laparoscopic vs open aortobifemoral bypass surgery, with a difference of 0.07 QALYs, (p=0.001) in favor of laparoscopic aortobifemoral bypass. The total cost of surgery, equipment and hospital stay after laparoscopic surgery (9,953 €) was less than open surgery (17,260 €), (p=0.001). Conclusion: Laparoscopic aortobifemoral bypass seems to be cost-effective compared with open surgery, due to an increase in QALYs and lower procedure-related costs. Keywords: laparoscopy, aortobifemoral bypass, cost-utility, quality-adjusted life years, QALYs, EQ-5D, health-related quality of life, HRQoL, cost-effectivenes

Patient-perceived health-related quality of life before and after laparoscopic aortobifemoral bypass

Background: In patients operated with laparoscopic aortobifemoral bypass (LABFB) for atherosclerotic obstruction in aortoiliac segment, the main focus of the reports published during the last two decades has been morbidity and mortality. The primary objective of this study was to examine the health-related quality of life (HRQL) in these patients before and after LABFB. Patients and methods: Fifty consecutive patients (27 females) with Trans-Atlantic Inter-Society Consensus II, type D lesions were prospectively included. Short-Form 36 (SF-36) questionnaire was used to get information about the HRQL before LABFB and at 1, 3 and 6 months after the operation. Main indication for LABFB was intermittent claudication. Linear mixed-effect models were used to assess changes in HRQL over time. Age, gender, smoking, blood loss, operation time, concomitant operation, the American Society of Anesthesiologists category, length of hospital stay, previous vascular procedures and aorta cross-clamping were used as fixed factors and their impact on the physical components of the SF-36, as well as the summary scores were determined with univariate analysis. Variables with P<0.2 were included in the multivariate regression analysis. P<0.05 was considered statistically significant. Results: Statistically significant improvement was found in all SF-36 domains as well as in the summary scores after LABFB compared to the preoperative scores. The improvement in scores was substantial already at 1 month and the effect was maintained at 3 and 6 months survey time points. Concomitant operations had a statistically significant negative impact on the physical components of SF-36. Data completeness of item questionnaires was 93% in the whole material. Reliability scale and homogeneity estimates for the eight domains had high internal consistency. Conclusion: Patients operated with LABFB for Trans-Atlantic Inter-Society Consensus II, type D lesions have reduced HRQL. LABFB leads to substantial and statistically significant improvement in the patients’ HRQL, when examined with SF-36. These results need to be replicated by a randomized clinical trial

Cost comparison analysis of laparoscopic versus open aortobifemoral bypass surgery: A randomized controlled trial

Background: Laparoscopic aortobifemoral bypass (LABFB) surgery has become an established treatment procedure for aortoiliac occlusive disease (AIOD), Trans-Atlantic Inter-Society Consensus II (TASC II), type D lesions. However, studies with an economic evaluation of this procedure are sparse. The main purpose of our study was to compare the costs of LABFB and open aortobifemoral bypass (OABFB) surgery. Patients and methods: This is a substudy of a larger randomized controlled prospective multicenter trial, Norwegian Laparoscopic Aortic Surgery Trial (NLAST). Perioperative data were collected on 70 patients undergoing surgery for AIOD, TASC type D lesions. Thirty-four patients were randomized to LABFB and 36 patients to OABFB. Treatment costs were calculated for the two operative treatments until 30 postoperative days. In addition to fixed and variable costs, direct and indirect costs were also included. Results: The mean total cost of LABFB was 19,798 € and for OABFB 34,016 € until 30 postoperative days. Laparoscopic procedure was 14,218 € less costly than the open procedure. The main factor leading to less cost of LABFB was shorter length of hospital stay (mean 5.3 days, 95% CI 4.1–6.5) as compared to OABFB (mean 10.1 days, 95% CI 7.5–12.6). Ten patients, three in the LABFB and seven in the OABFB group, had complications that resulted in reoperations within the 30 postoperative days. The mean cost of treatment for the complicated patients was 49,349 € and 82,985 €, respectively, for LABFB and OABFB. Conclusion: Laparoscopic aortobifemoral bypass procedure costs less than open aortobifemoral bypass for the treatment of advanced aortoiliac occlusive disease

Comparison of the acute-phase response after laparoscopic versus open aortobifemoral bypass surgery: a substudy of a randomized controlled trial

Purpose: Minimally invasive surgical techniques have been shown to reduce the inflammatory response related to a surgical procedure. The main objective of our study was to measure the inflammatory response in patients undergoing a totally laparoscopic versus open aortobifemoral bypass surgery. This is the first randomized trial on subjects in this population. Patients and methods: This is a substudy of a larger randomized controlled multicenter trial (Norwegian Laparoscopic Aortic Surgery Trial). Thirty consecutive patients with severe aortoiliac occlusive disease eligible for aortobifemoral bypass surgery were randomized to either a totally laparoscopic (n=14) or an open surgical procedure (n=16). The inflammatory response was measured by perioperative monitoring of serum interleukin-6 (IL-6), IL-8, and C-reactive protein (CRP) at six different time points. Results: The inflammatory reaction caused by the laparoscopic procedure was reduced compared with open surgery. IL-6 was significantly lower after the laparoscopic procedure, measured by comparing area under the curve (AUC), and after adjusting for the confounding effect of coronary heart disease (P=0.010). The differences in serum levels of IL-8 and CRP did not reach statistical significance. Conclusion: In this substudy of a randomized controlled trial comparing laparoscopic and open aortobifemoral bypass surgeries, we found a decreased perioperative inflammatory response after the laparoscopic procedure measured by comparing AUC for serum IL-6

Perioperative humoral stress response to laparoscopic vs open aortobifemoral bypass surgery

Minimally invasive surgery seems to reduce hormonal stress response to surgery, but has not previously been examined in major abdominal vascular surgery. Aortic cross-clamping time and operation time is known to be longer in the totally laparoscopic aortobifemoral bypass (LABF) as compared to open aortobifemoral bypass (OABF). The main objective of our study was to measure the hormonal stress response during surgery and aortic cross-clamping in patients undergoing a totally laparoscopic versus an open aortobifemoral bypass. This was a sub-study of a larger randomized controlled multicentre trial. Thirty consecutive patients with severe aortoiliac occlusive disease were randomized to either a laparoscopic (LABF) or an open (OABF) procedure. The surgical stress response was measured by perioperative monitoring of adrenocorticotropic hormone (ACTH), aldosterone, metanephrine and cortisol at eight different time-points. During surgery. there was an increase in all humoral stress markers in both groups. The analysis of covariance showed increased levels of cortisol and ACTH in open group at 24 h time-point as compared to the baseline and this difference was statistically significant between the two groups, which indicate an earlier return to baseline levels in the laparoscopic group. Results from the General Estimated Equations (GEE) model indicate that LABF generates a lower level of metanephrine and higher level of aldosterone as compared to OABF. In conclusion, although they have higher levels of ACTH, aldosterone and cortisol during surgery, the patients operated with a laparoscopic aortobifemoral bypass achieve earlier hormonal homeostasis after surgery compared to open aortobifemoral bypass. This is an Accepted Manuscript of an article published by Taylor & Francis, available online: http://www.tandfonline.co