Aust. N.Z. J . Surg. (1994) 64,415-418 415

ABDOMINAL AORTIC ANEURYSM AND ASSOCIATED COLORECTAL CARCINOMA: A MANAGEMENT PROBLEM

GREGORY ROBINSON, WALTER HUGHES, ERIC LIPPEY Department of Surgery, Repatriation General Hospital Concord, Sydney, New South Wales, Australia

The increasing age of the population has led to the more common occurrence of multi-organ disease. Colorectal cancer (CRC) and abdominal aortic aneurysm (AAA) in the same patient is a difficult management problem. Over 10 years, 23 patients with CRC and AAA were treated at Concord Hospital. The management and outcome of these patients was reviewed to identify an optimum plan for patients with both conditions. The average age of patients was 71 years, ranging from 52 to 90 years. There was only one female patient in the series. In 19 of the patients, the AAA and CRC were synchronous, while in the other four patients the AAA and CRC were remote events. Within the group of patients with synchronous AAA and CRC, 12 had the diagnosis of both conditions made pre-operatively. However, in seven cases an unexpected AAA or CRC was found at operation for the other condition. Sixteen patients underwent resection of the CRC, while only eight underwent repair of the AAA. There were three deaths following CRC resection, two following AAA resection, and one following simultaneous CRC resection and AAA repair. Two of 10 patients with large (> 6cm) AAA, who underwent CRC resection, ruptured the AAA in the postoperative period. A further patient ruptured 10 months following CRC resection. Colorectal cancer was given priority over AAA when these conditions were found simultaneously. The present study suggests that a large AAA (> 6cm) should be either given preferential treatment, or resected simul- taneously, in view of the high risk of rupture.

Key words: abdominal neoplasms, aneurysm, aorta abdominal, aortic aneurysm, aortic rupture, colon and rectal surgery, colonic neoplasms, colorectal neoplasms, rectal neoplasms, vascular surgery.

INTRODUCTION

Both abdominal aortic aneurysms (AAA) and colorectal carcinomas (CRC) are challenging surgical problems in their own right. As these diseases occur in a similar age group it is inevitable that cases of concomitant AAA and CRC will be encountered. When this occurs a surgical dilemma is apparent. Attempts have been made to estab- lish management guidelines. Some guidelines have been based on retrospective studies, although patient numbers remain small. Other studies have based their guidelines on polling surgical opinion and performing decision analysi~.~.~ It is the view of the present authors that aneurysmal disease has been overshadowed by the pres- ence of a carcinoma. The experience of the Repatriation General Hospital Concord, Sydney, is presented.

METHODS

Records of patients with concomitant AAA and CRC were reviewed over a 10 year period. The long-term outcome of each patient was obtained.

Correspondence: Gregory Robinson, Department of Surgery, Second Floor Multi Building, Repatriation General Hospital Concord, Hospital Road, Concord, NSW 2139, Australia.

Accepted for publication 8 December 1993.

RESULTS

Over the 10 year period studied, 1337 AAA were treated. There were 23 cases in which an AAA was associated with a CRC. Only one patient was female. The age group ranged from 52 to 90 years, with the mean age being 71 years.

There were 24 cases of CRC in 23 patients. The sites of the CRC were right colon (three), transverse colon (one), descending colon (one), sigmoid colon (seven) and rectum ( 12). Using the Australian Clinico-Pathological Staging System the tumour stages were four stage A cases, nine stage B cases, eight stage C cases, and three stage D cases. The CRC was suspected clinically in 21 of 23 cases, and confirmed by barium examination in nine, by endoscopy in six, and rectal examination in six. The other two cases were incidental findings at laparotomy for AAA.

The size of the AAA was 6cm or greater in 14 cases. Ony two aneurysms were less than 4 cm. The AAA were diagnosed clinically in 1 1 patients, while the other 12 cases were incidental findings. Six cases were detected on computed tomography (CT) scanning for assessment of the CRC, one on ultrasound examination and five at operation for CRC.

Twenty patients underwent resection of their CRC. Only eight patients underwent an operation for the AAA. The reason for non-operative treatment of the AAA in- cluded the presence of metastatic disease in five, medical

476 ROBINSON ET AL.

Table 1. Group 1 : CRC treated before diagnosis of AAA (four patients)

Period CRC treated before

Case, age, sex CRC site, stage, treatment AAA (years)

1 (69, M) Right colon, C 1 , resection 2

2 (52, M) Recto-sigmoid. B 1, 4

3 (54, M) Rectum, B 1 , resection 7

4 (68. M) Sigmoid, C 1 , resection 0.3

resection

Size of AAA, Status of cancer treatment

Local recurrence 4 cm, nil

Hepatic Large, nil metastases Disease free Large, graft

Disease free 3.5 cm, nil

Results

Died at 2'/2 years, cardiogenic shock Died at 2 years, metastatic disease Died day 4 after AAA repair, stroke Alive at 5% years, recurrent cancer

Table 2. Group 2: Synchronous AAA and CRC

Case, age, sex CRC site, stage, treatment AAA size, treatment Results

CRC and AAA diagnosed pre-operatively 5 (68, F) Rectum, B 1 , resection 6 (72, M) Rectum, C 1, resection 7 (77, M) Sigmoid, B 2, resection 8 (66, M) Rectum, D, diathermy 9 (79, M) Rectum, B 1 , resection 10 (68, M) Rectum, D, colostomy 1 1 (69, M) Sigmoid, B 1, right colon, A 3,

staged resection 12 (68, M) Rectum, A 3, resection 13 (72, M) Right colon, C 1, resection 14 (81, M) Rectum, A 3, resection 15 (90, M) Transverse colon, B 2,

resection 16 (88. M) Rectum, C 1 , resection

17 (60, M) Sigmoid, C 1 , resection 18 (78. M) Rectum, B 1 , resection 19 (82. M) Rectum, C 1 , resection 20 (69. M) Rectum, A 2, resection 21 (77. M) Left colon, C 1 , resection

AAA diagnosed at operation for CRC

CRC diagnosed at operation for AAA 22 (74. M) 23 (70, M)

Sigmoid, D 1 , resection Sigmoid, B 2, nil

Small, nil 4 cm, nil 5.7 cm, graft 5 months later 5.5 cm, nil 6 cm, simultaneous graft 6.3 cm, nil 10 cm, nil

7 cm, graft 2 months later 5 cm, graft 6 weeks later 7 cm, nil 6 cm, nil

5.7 cm, nil

6 cm, nil 6.8 cm, graft 4 months later 4 cm, nil Large, nil 6 cm, graft 2 days later, following rupture

9.3 cm, simultaneous graft 8 cm, graft for rupture AAA

Alive at 9% years Alive at 4 months Died 13 days after AAA repair, gastric bleed Died at 2 months, metastatic disease Died at 21 days, pulmonary embolus Died at 1.8 years, metastatic disease Died at 8 months, ruptured AAA

Died at 1 year, lung cancer Alive at 5% years Died at 1 month, pulmonary oedema Died at 6 months, pneumonia

Died at 18 months, local recurrence

Died at 5 days, ruptured AAA Alive at 5% years Died at 21 days, sepsis Died at 2 years, pulmonary failure Alive at 3% years

Died at 18 months, metastatic disease Died intra-operatively

condition in two, small size of the AAA in three and death prior to treatment of the AAA in five.

The cases were placed into two groups. Group 1 con- tained those cases where the AAA and CRC were not synchronous. There were four such cases, in all of which the aneurysms were diagnosed after treatment of the CRC. Group 2 contained the remaining cases in which there was coexistence of the AAA and CRC.

Group 1 non-synchronous AAA and CRC Four patients were diagnosed as having an AAA some time after treatment of a CRC (Table 1). Only one of these patients underwent repair of the AAA. Metastatic disease precluded treatment in the other three patients. Two of these four patients have died from causes un- related to the AAA at 2 and 2l/2 years following diagnosis

of the AAA. The third patient is living to date at 5 % years following AAA diagnosis. The patient who under- went repair of the AAA suffered a stroke and died postoperatively.

Group 2 synchronous CRC and AAA Nineteen patients had synchronous AAA and CRC. These were subdivided as follows: (i) AAA and CRC diagnosed pre-operatively in 12 patients; (ii) AAA diagnosed at operation for CRC in five patients; and (iii) CRC diag- nosed at operation for AAA in two patients.

Sixteen of the 19 patients in Group 2 underwent treat- ment of the CRC as the primary event, with two others undergoing simultaneous resection of the CRC and AAA. Five patients had the AAA resection some time following surgery for the CRC. Twelve patients in Group 2 had

AORTIC ANEURYSM AND COLORECTAL CANCER 471

large AAA (6cm or greater). Two of these underwent simultaneous resection of the AAA and CRC. Nine patients had their CRC treated initially, either because of metastatic disease (one), acute obstruction (one), stenos- ing lesion (two), age and medical condition (two) or unexpected finding of AAA at operation, and CRC resec- tion proceeded as planned (three). The twelfth patient presented with rupture of a known AAA and died intra-operatively .

Fourteen of 19 patients from group 2 died. Death resulted from metastatic disease in five, medical condition in three, ruptured AAA in three, sepsis following CRC resection in one, respiratory failure following AAA resec- tion in one, and pulmonary embolus following combined resection in one.

In the series, four ruptured AAA occurred. All were 6 cm or greater in diameter. Two of these cases followed CRC resection (day 2 and day 5 postoperatively). Only one survived this event. In neither case was the CRC obstructing. In a third patient AAA rupture occurred 8 months after initial surgery for the CRC. Abdominal aortic aneurysm surgery for this patient was delayed due to the finding of a second CRC and abdominal septic complications following its resection. The fourth patient presented with rupture of a known AAA, and died intra- operatively.

In Group 2 there were seven aneurysms resected. Two of these were resected simultaneously with the CRC, and five were resected some period following CRC resection (2 days, 6 weeks, 2 months, 4 months and 5.5 months, respectively). Of those patients who underwent resection of the AAA, two died of postoperative complications, two died of metastatic disease (15 and 18 months, respec- tively, following AAA resection), and three are surviving (two at 5.5 years and one at 3.5 years, respectively, following AAA resection).

Twelve patients in Group 2 did not undergo resection of their AAA, and only two are surviving (5 months and 9.5 years), both of these having small AAA. The other 10 patients died due to: AAA rupture in three (5 days, 10 months and 21 months following AAA diagnosis, respec- tively); metastatic disease in three; medical condition in three; sepsis in one patient as a post-operative complica- tion of CRC resection. Of the patients who died from ruptured AAA, two were medically fit with a prospect of a 50% 5 year survival from the stage of their cancers.

DISCUSSION The occurrence of AAA and CRC in the same patient is uncommon. In this study the incidence was 1.72% of all AAA treated. Of 1040 cases of CRC treated surgically, 23 had an AAA(2.2%).

Risk of rupture The rupture of an AAA following unrelated abdominal procedures has been reported el~ewhere.~.~ In one study 10 patients developed rupture of AAA within 36 days of a prior laparotomy.' It has been suggested that increased collagenase activity post-laparotomy weakens the aneu-

rysmal wall, and increases the predisposition for rup t~ re .~ This theory has been investigated with equivocal results.s-'o

In the present study, two of the 10 patients with large (> 6 cm) AAA who underwent CRC resection developed rupture in the postoperative period. A third patient died of ruptured AAA 10 months following CRC resection. On the other hand, in the six patients with small (C 6 cm) AAA who underwent CRC resection, no rupture occurred.

The authors of the present study conclude that when the size of the AAA is 6cm or greater, CRC resection alone carries a very high risk of rupture. Consideration should therefore be given either to preferential treatment of the aneurysm, or simultaneous resection of the AAA and CRC.

In this study there were two cases of simultaneous AAA and CRC resection with one postoperative death. Other successes with simultaneous AAA and CRC resec- tion have been reported.2 The theoretical risk of graft infection remains.".l2 Graft infection rates following AAA resection alone vary from 1 to 3%," and survival follow- ing graft infection of between 35 to 78%." Combined AAA resection with non-vascular procedures have dem- onstrated no increased incidence of graft

Other authors have shown successful AAA resection combined with other procedures, especially cholecystec- tomy. 12-14.17.18 H owever, in other studies mortality re- mained higher than for AAA resection a l ~ n e . ' ~ * ' ~ Recently it has been reported that grafts soaked in rifampicin gave satisfactory results in contaminated fields. 19-20

In one-third of the present cases of simultaneous CRC and AAA, the presence of the other pathology was not diagnosed until laparotomy, leaving an unexpected and difficult decision for the surgeon. Selective pre-operative screening may reduce the incidence of unexpected AAA in those undergoing colonic resection. Males above the age of 60, or patients with a first degree relative with AAA, and patients with occlusive peripheral vascular disease or peripheral aneurysmal disease are groups with a high incidence of AAA.21-24 These groups would justify abdominal ultrasound before CRC resection. Similarly, patients with known AAA who have risk factors for colonic carcinoma would also clearly benefit from pre- operative colonoscopy.

Prognosis In their series of synchronous AAA and CRC, Nora et al. reported only 23.5% alive at follow-up, with only one 5 year survivor.2 In the present study, 14 of 19 patients with synchronous AAA and CRC have died, with the longest survivor being 5 years from the date of diagnosis of the synchronous pathology. Three of the five surviving patients have had both the AAA and CRC resected. .The other two patients had small AAA and these are being observed.

CONCLUSION This study suggests that in patients with a known large (> 6 cm) AAA and a synchronous CRC, either the AAA be given preferential treatment, or resected simultaneously,

478 ROBINSON ET AL.

in view of the high risk of rupture. The judicious use of screening for the other condition in high risk patients will hopefully reduce the incidence of unexpected findings at laparotomy .

REFERENCES 1. Szilagyi DE, Elliott MD, Berluer R. Coincidental malig-

nancy and abdominal aortic aneurysm: Problems of man- agement. Arch. Surg. 1967; 95: 402- 12.

2. Nora JD, Pairolero PC, Nivatvongs S, Cherry KJ, Hallett JW, Gloviczki P. Concomitant abdominal aortic aneurysm and colo-rectal carcinoma: Priority of resection. J. Vasc. Surg. 1989; 9: 630-6.

3. Hugh TB, Masson J, Graham AR, Tracy GD. Combined gastrointestinal and abdominal aortic aneurysm operations. Aust. N.Z. J. Surg. 1988; 58: 805-10.

4. Velanovich V, Anderson CA. Concomitant abdominal aor- tic aneurysm and colorectal cancer: A decision analysis approach to a therapeutic dilemma. Ann. Vasc. Surg. 1991; 5: 449-55.

5 . Lobbato VJ, Rothenberg RE, Laraja RD, Georgiou J. Coexistence of abdominal aortic aneurysm and carcinoma of the colon: A dilemma. J. Vasc. Surg. 1985; 2: 724-6.

6. Trueblood HW, Williams DK, Gustafson JR. Aneurysmal rupture following resection of abdominal malignancy. Am. Surg. 1976; 42: 535-7.

7. Swanson RJ, Littooy FN, Hunt TK, Stoney RJ. Laparotomy as a precipitating factor in the rupture of intra-abdominal aneurysms. Arch. Surg. 1980; 115: 299-304.

8. Busuttil RW, Abou-Zamzam AM, Machleder HI. Collagen- ase activity of the human aorta. Arch. Surg. 1980 115:

9. Menashi S, Campa JS, Greenlagh RM, Powell JT. Collagen in abdominal aortic aneurysm: Typing, content and degra- dation. J. Vasc. Surg. 1987; 6 578-82.

10. Cohen JR, Perry MO, Hariri R, Holt J, Alvarez D. Aortic collagenase activity affected by laparotomy, caecal resec- tion, aortic mobilisation and aortotomy in rats. J. Vasc. Surg. 1984; 1: 562-5.

11. Bemhard VM. Management of graft infections following abdominal aortic aneurysm replacement. World J. Surg.

1373-8.

1980 4: 679-86.

12. Tompkins WC, Chavez CM, Conn JH, Hardy JD. Combin- ing intra-abdominal arterial grafting with gastrointestinal or biliary tract procedures. Am. J . Surg. 1973; 126: 598-60.

13. Stoll WM. Surgery for intra-abdominal lesions associated with resection of aortic aneurysms. Wis. Med. J. 1966; 65:

14. Oschner JL, Cooley D, Debakey ME. Associated intra- abdominal lesions encountered during resection of aortic aneurysms. Dis. Colon Rectum 1960; 3: 485-90.

15. Thomas JH, McCroskley BL, Illiopoulos JI, Harion CA. Hermreck AS, Pierce GE. Aortoiliac reconstruction com- bined with nonvascular operations. Am. J. Surg. 1983; 146:

16. Bickerstaff LK, Hollier LH, Vanpeenen HJ, Melton LJ, Pairolero PC, Cherry KJ. Abdominal aortic aneurysm re- pair combined with a second surgical procedure: Morbidity and mortality. Surgery 1984; 95: 487-9 1.

17. Ouriel K, Ricotta JJ. Adams JT, Deweese JA. Management of cholelithiasis in patients with abdominal aortic aneu- rysm. Ann. Surg. 1983; 198 717-19.

18. String ST. Cholelithiasis and aortic reconstruction. J. Vasc. Surg. 1984; 1: 664-9.

19. Strachan CJL. Newsom SWB, Ashton TR. The clinical use of an antibiotic-bonded graft. Eur. J. Vasc. Surg. 1991; 5:

20. Avramovic JR, Fletcher JP. Rifampicin impregnation of a protein-sealed Dacron graft: An infection-resistant pros- thetic vascular graft. Aust. N.Z. J. Surg. 1991; 61: 436-40.

21. Nicholls EA, Norman PE, Lawrence-Brown MMD, Good- man MA, Pedersen B. Screening for abdominal aortic aneurysms in Western Australia. Aust. N.Z. J. Surg. 1992;

22. Bengtsson H, Norrgard 0, Angquist KA, Ekberg 0, Oberg L, Bergqvist D. Ultrasonographic screening of the abdomi- nal aorta among siblings of patients with abdominal aortic aneurysms. Br. J. Surg. 1989; 76: 589-91.

23. Cheatle TR, Scurr JH. Abdominal aortic aneurysms: A review of current problems. Br. J. Surg. 1989; 76: 826-9.

24. Taylor LM, Porter JM. Basic data related to clinical deci- sion making in abdominal aortic aneurysms. Ann. Vasc. Surg. 1986; 1: 502-4.

89-90.

784-7.

627-32.

62: 858-61.