Department of Surgery, Division II, Kobe University School of Medicine, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe 650, Japan
Abstract. The therapeutic approach to a patient who has an abdominalaortic aneurysm (AAA) and an intraabdominal nonvascular surgicaldisorder simultaneously remains controversial. To establish guidelinesfor the management of those patients, a retrospective review of patientswho had concomitant AAA and intraabdominal nonvascular surgicaldisorders was undertaken. During the period January 1988 to December1997 a series of 162 patients underwent surgical repairs of AAA in ourhospital. Among them 16 patients (9.9%) had several kinds of intraab-dominal nonvascular surgical disorders, and 13 underwent one-stageoperation for both diseases. That is, cholelithiasis coexisted in fivepatients, inguinal hernia in four, gastric cancer in two, and retroperito-neal tumor and renal tumor in one each. All AAAs were the infrarenaltype, and there were no inflammatory or ruptured aneurysms. In cases ofcholelithiasis coexistent with AAA, aneurysmectomy was performed first.After tight closure of the retroperitoneum, cholecystectomy was done. Incases of cholelithiasis coexistent with AAA, aneurysmectomy was per-formed first. After tight closure of the retroperitoneum, cholecystectomywas done. In cases of inguinal hernia coexistent with AAA, the AAA wasfirst replaced with a prosthetic vascular graft and a residual piece of thegraft was used as a patch for hernioplasty. This procedure was similar tolaparoscopic hernioplasty. In two cases of gastric cancer concomitant withAAA, the AAA was first replaced. Subtotal gastrectomy with D2 lymphaticdissection was done after tight closure of the retroperitoneum. A drainwas inserted into the epiploic foramen to detect anastomotic leakage. Aretroperitoneal tumor coexisting with AAA was dissected and resected enbloc with the aneurysmal wall because the tumor firmly adhered to theaneurysm. The abdominal aorta was then replaced with a prosthetic graft.In a case of renal tumor concomitant with AAA, nephrectomy was donefirst to perform a complete lymphatic dissection around the renal artery.Then AAA repair was performed with a conventional procedure. Therewere no fatal complications, such as pneumonitis, hemorrhage, anasto-motic leakage, or graft infection. All 13 patients were discharged from ourhospital and are currently free from recurrence of malignancy or hernia.In summary, properly selected one-stage operations for intraabdominalnonvascular surgical disorders and AAA may be safe and bring physicaland economic benefit to the patient.
With the westernized changes of life style in Japan, the number ofpatients with atherosclerotic disease including abdominal aorticaneurysm (AAA) has been increasing. As a result, patients with an
AAA and a coexisting surgical disorder are also increasing [1–5].When surgical disorders coexist in the abdominal or retroperito-neal cavity, the surgeon must decide whether to select a one-stageoperation with the same incision or a two-stage operation.
The frequency of the one-stage operation for both diseases hasbeen increasing in our institute, because elective repair of AAAbecomes progressively safer [6, 7]. Our clinical experience withthe one-stage operation for AAA and concomitant intraabdomi-nal nonvascular surgical disorders is reviewed herein and thesurgical strategy for those patients discussed.
Patients and Methods
During the period from January 1988 to December 1997 a seriesof 162 patients underwent surgical repair of AAA in our hospital(Table 1). Among them, 34 patients (21.0%) had another surgicaldisorder simultaneously. Seven patients had concomitant coro-nary artery disease, and six of them underwent coronary bypassgrafting simultaneously. One, who had severe unstable angina,underwent AAA reconstruction 6 months after coronary bypassgrafting. Ten patients had peripheral arterial occlusive disease,and all of them underwent peripheral arterial bypass graftingsimultaneously. One patient who had a lung cancer underwentlung resection 37 days after AAA repair. Altogether 16 patientshad several kinds of intraabdominal nonvascular surgical disorder,and 13 of them underwent a one-stage operation to correct bothdiseases. One patient with gastric cancer and one with inguinalhernia chose to have desired a two-stage operation. A patient withrectal cancer underwent a two-stage operation for fear of graftcontamination.
The 13 patients who underwent the one-stage operation forAAA and a nonvascular intraabdominal surgical disorder arereviewed in Table 2. There were nine men and four women withan average age of 71.8 years (range 62–80 years). Cholelithiasiscoexisted in five of them, inguinal hernia in four, gastric cancer intwo, and retroperitoneal tumor and renal tumor in one each.
All five patients who had cholelithiasis simultaneously hadepisodes of right hypochondralgia, liver dysfunction, or both. Atthe time of their operation, they had no signs of cholecystitis orcholangitis. Four patients had inguinal hernia simultaneously:
This International Society of Surgery (ISS)/Societe Internationale deChirurgie (SIC) article was presented at the 37th World Congress ofSurgery International Surgical Week (ISW97), Acapulco, Mexico, August24–30, 1997.
Correspondence to: Y. Tsuji, M.D.
external inguinal type in two and femoral hernia and internalinguinal type in one each.
Two patients had concomitant gastric cancer. The first was a69-year-old woman who visited her local hospital with a complaintof upper abdominal pain. Gastrofiberscopy revealed a small ulcerin the antrum, and atypical cells (moderately differentiated tubu-lar adenocarcinoma) were detected in the biopsy specimen.Echography and computed tomography (CT) scanning were donefor a differential diagnosis of her abdominal pain and revealed anAAA 50 mm in diameter. She was referred to our hospital for thetreatment of both diseases. The other patient, a 65-year-old man,visited our hospital with a complaint of abdominal pulsatiletumor. An AAA 52 mm in diameter was detected on an echogramand a CT scan. Gastrofiberscopy was performed preoperativelybecause he had had a history of gastric ulcer; it revealed earlygastric cancer (moderately differentiated tubular adenocarci-noma) in the middle part of stomach.
The retroperitoneal and renal tumors were easily detected onechogram and CT scan because they existed near the AAA. Bothpatients were referred to our hospital for treatment.
Results
Surgical Details
The AAAs were of the infrarenal type in all 13 cases, and themaximum diameter of the AAAs was 53 mm on average, rangingfrom 43 to 75 mm. There was no inflammatory or rupturedaneurysm. The replaced prosthetic vascular grafts were eight ofthe bifurcated type and five of the tubular type; six were wovenDacron and seven were albumin-coated woven double-velourDacron. Reconstruction of the inferior mesenteric artery wasadded in 3 (23.1%) of 13 cases.
In the case of cholelithiasis coexistent with AAA, a midlineincision was made and the peritoneal cavity entered. Afteropening the retroperitoneum and applying systemic hepariniza-tion, the AAA was replaced with a prosthetic graft. After neutral-ization of systemic heparinization and tight closure of the retro-peritoneum, cholecystectomy was performed. To avoid graftinfection, dissection of the gallbladder had to be performedcarefully. There was no mechanical injury on the wall of gallblad-der, and no intraperitoneal drain was placed.
In the case of inguinal hernia coexistent with AAA, a lowermidline incision was made, and the retroperitoneum was opened.
The AAA was replaced with a bifurcated- or tubular-type pros-thetic graft. The longitudinal incision was made on a residualpiece of the graft, and the opened graft was used as a patch forhernioplasty. After neutralization of heparinization and tightclosure of retroperitoneum, a curved peritoneal incision was madearound the inguinal ring. The peritoneum was reflected, and thehernia sac, vas deferens, spermatic vessels, and Cooper’s ligamentwere carefully dissected and exposed in this peritoneal opening. Apatch was placed in the preperitoneal space and then firmlysutured to Cooper’s ligament, the pubic ramus, iliopubic tract, andtransversus abdominis arch. These procedures were similar tolaparoscopic hernioplasty. After closure of the peritoneal incision,the abdomen was closed with no drainage.
In the case of gastric cancer concomitant with AAA, the AAAwas replaced first in both cases. After neutralization of hepa-rinization and tight closure of the retroperitoneum, subtotalgastrectomy with D2 lymphatic dissection was done (Fig. 1).Paraaortic lymph nodes and lymph nodes around the superiormesenteric artery were not dissected to keep the discontinuity ofboth surgical fields. A drain was inserted into the epiploic foramento detect anastomotic leakage.
A retroperitoneal tumor was strongly adherent to the aorticaneurysm. After opening the retroperitoneum and systemic hep-arinization, aortic cross-clamping was done at the proximal anddistal sides of the tumor and the AAA. The tumor was dissectedand resected en bloc with the aneurysmal wall; the abdominalaorta was then replaced with a prosthetic graft (Fig. 2). No drainwas inserted to the retroperitoneal space.
In the case of a renal tumor concomitant with AAA, a rightnephrectomy was done first because of complete lymphatic dis-section around the renal artery. AAA repair was then performedwith a conventional procedure. No drain was inserted into theretroperitoneal space.
Perioperative Course and Prognosis
GOI (nitrogen oxide, oxygen, and isoflurane) with fentanyl anes-thesia was used in all 13 cases. The operating time was 341minutes on average (range 290–470 minutes). The intraoperativebleeding amounted to 537 ml on average (range 267–664 ml),except for 3000 ml during the operation for retroperitonealtumor. One patient who underwent AAA repair and cholecystec-tomy suffered from adhesive intestinal obstruction 30 days afterthe operation and required surgical treatment. There were nofatal complications, such as pneumonitis, hemorrhage, anasto-motic leakage, or graft infection.
Pathologically, both gastric cancers were tubular adenocarci-noma in an early stage (cancer within submucosal invasion)without lymph node metastasis. The retroperitoneal tumor wasnon-Hodgkin’s malignant lymphoma (diffuse, large-cell type, B-cell type), and no neoplastic lesion was detected in other intraab-dominal lymph nodes. The renal tumor pathologically was renalcell carcinoma (clear-cell subtype, grade 1); extrarenal invasion,tumor thrombus, and lymph node metastasis were not detected.
The hospitalization period was 32.4 days on average (range15–66 days). All 13 patients were discharged from our hospitaland are now free from recurrence of malignancy or inguinalhernia.
Table 1. Surgical management for patients with AAA and othersurgical disorders simultaneously.
The incidence of patients with AAA and coexistent intraabdomi-nal surgical disorders is increasing, and the surgical strategy forthose patients remains controversial [1–5, 8–13]. The indicationsfor surgical repair for AAA in such patients are basically thoughtto be same as those for patients who have only AAA. Perko et al.[14] investigated the natural history of patients with nontreatedAAA. Their cumulative 5-year survival rate was only 15%, and themost frequent cause of death was aneurysmal rupture. Based onthese poor prognoses, the authors concluded that AAAs .6 cm indiameter should be treated surgically soon after detection. On theother hand, some reports have issued a special warning about
surgical indications for AAA in the patients who have intraab-dominal nonvascular diseases simultaneously. Swanson et al. [15]reported 10 asymptomatic AAAs that had ruptured within 36 daysof a primary laparotomy, and they suspected that collagen lysisinduced by laparotomy [16, 17], nutritional depletion, and localinflammation weakened the aneurysmal wall. Trueblood et al. [18]also indicated a high frequency of aneurysmal rupture followingresection of an abdominal malignancy, and they suspected that thedissecting maneuver during the operation for abdominal malig-nancy weakened the aneurysmal wall.
For these reasons we believe that the AAA should be treatedfirst or simultaneously if concomitant intraabdominal disordersexist and if the situation permits it. Another optional treatment ofAAA for those patients may be intraluminal stenting [19, 20].Although the long-term results of this practice are unknown, thisnew endovascular technique may become the standard method ofAAA repair for those patients.
In the case of cholelithiasis coexistent with AAA, many reportsrecommend a one-stage operation for the two diseases [8, 11, 12,21]. Ouriel et al. [21] reviewed the surgical prognosis of patientswith AAA and cholelithiasis. Most patients who underwentaneurysmectomy without cholecystectomy experienced an episodeof acute cholecystitis during their follow-up, two of which oc-curred during the immediate postoperative period. Based onthese findings, they recommended a one-stage operation for bothdiseases. They also reported one case of graft infection after theone-stage operation, when cholecystectomy was done beforeclosure of the retroperitoneum. It is important to perform AAArepair first, followed by cholecystectomy after tight closure of theretroperitoneum. Of course, this one-stage operation must bescheduled during the absence of cholecystitis or cholangitis, andcholecystectomy should be carried out carefully to prevent me-chanical perforation.
Recently, a technique of laparoscopic hernioplasty has beendeveloped, clinically applied, and evaluated for its curability; andit has become a standard treatment for inguinal hernia [22, 23].Hence we attempted simultaneous transabdominal preperitonealpatchplasty of the inguinal hernia during transperitoneal AAArepair. Using this technique, inguinal hernia can be repaired freeof tension in the same wound as for AAA repair. Furthermore, apatch for hernioplasty can be constructed of a residual piece ofthe prosthetic graft used for the AAA.
When retroperitoneal tumors, such as renal cell carcinoma ormalignant lymphoma, coexist with AAA, there is no doubt aboutselecting a one-stage operation [13, 24–26]. Because these retroper-itoneal tumors exist near the AAA, there is almost no anxiety aboutgraft infection. In our case of malignant lymphoma, it was indispens-able to resect the aneurysmal wall en bloc for curative operation.
Table 2. Intraabdominal nonvascular surgery operated with AAA repair concomitantly.
Other surgicaldisorder Operation No. of cases Postoperative course Prognosis
Fig. 1. Gastric cancer combined with AAA. A. Macroscopic findings of anearly gastric cancer in the antrum resected from a 69-year-old woman,with AAA repair. B. Macroscopic findings of an early gastric cancer in thebody resected from a 65-year-old man, with AAA repair.
Tsuji et al.: Intraabdominal Surgery Plus AAA Repair 471
In the case of gastrointestinal malignancies combined withAAA, the surgical strategy must be chosen with considerations ofthe estimated prognosis of the malignancy, the risk of aneurysmalrupture, and the degree of contamination during gastrointestinalsurgery. When gastric cancer coexists with AAA, some reportsrecommend a one-stage operation because there is a low risk ofgraft contamination [1, 3, 5]. Komori et al. [2] recommendedsimultaneous resection using segregated approaches: retroperito-neal approach for the AAA and transperitoneal approach for thegastric cancer. We now consider that a one-stage operation forAAA and gastric cancer in the early stage may be safely per-formed from a standpoint of the low morbidity and mortality ratesassociated with gastrectomy in Japan. In these cases, a segregatedapproach may not be necessary, considering the low risk of graftinfection. For advanced gastric cancer that needs paraaorticlymph node dissection, a one-stage operation with separateapproaches or a staged operation may be commendable.
When colorectal cancer coexists with an AAA, the decisionabout the surgical approach is difficult [10, 27–30]. Lobbato et al.[27] summarized the opinions of professors of general andvascular surgery concerning the treatment of such cases. One-third favored excision of the carcinoma first; one-third selectedexcision of the AAA first; and the remaining one-third said theywould make the decision when laparotomy was performed. Vela-novich and Andersen [28] reported that they decide on surgicalstrategy using the parameters of aneurysm size and the chances ofobstruction or perforation of the colorectal cancer. Robinson etal. [29] reported 10 cases of aneurysm rupture immediately aftercolorectal cancer resection, and they concluded that a large AAA(.6 cm in diameter) should either be given preferential treatmentor be resected simultaneously in view of the high risk of rupture.Nora et al. [30] also concluded that if the colorectal carcinoma isnot symptomatic and localized, the AAA should be resected first.In this series, we came across only one case of rectal cancercombined with AAA. For fear of graft contamination, Miles’operation was performed 3 weeks after AAA repair. However,because there are no reports of graft infection after a one-stageoperation, we now consider that simultaneous operation has a riskof fatal complications, such as sepsis or massive bleeding, follow-ing graft infection.
Conclusions
We have had 13 cases of successful one-stage operations for AAAand various kinds of intraabdominal nonvascular surgical disor-ders. To decide on the surgical approach for patients who haveAAA and intraabdominal nonvascular diseases, many factorsmust be taken into consideration: (1) whether the coexistentsurgical disorder is benign or malignant; (2) whether it is inflam-matory for benign diseases; (3) the estimated prognosis formalignant diseases; (4) the risk of aneurysmal rupture; (5) thedegree of contamination during the operation; and (6) if patient’scondition is good enough tolerate a one-stage operation. In ourhands, properly selected one-stage operations for intraabdominalnonvascular diseases and AAA were safe and brought physicaland economic benefits to the patients.
Fig. 2. Retroperitoneal tumor combined with AAA. A. Operativefindings of a retroperitoneal tumor coexisted with AAA. The tumorwas firmly adhered to the aneurysmal wall. B. Macroscopic findings of theretroperitoneal tumor. The tumor was resected with the aneurysmal wall.
472 World J. Surg. Vol. 23, No. 5, May 1999
Resume
La prise en charge therapeutique simultanee d’un patient ayantun anevrysme de l’aorte abdominale (AAA) associe a une pa-thologie intra-abdominale non-vasculaire reste controversee. Afind’etablir des recommandations pour ce tye de prise en charge, ona entrepris une revue retrospective des patients ayant un AAAassocie a une pathologie intra-abdominale non-vasculaire. Entrejanvier 1988 et decembre 1997, 162 patients ont ete traites pourAAA dans notre hopital. Parmi ceux-ci, 16 patients (9.9%)avaient egalement une pathologie intra-abdominale non-vascu-laire dont 13 ont ete operes dans un meme temps operatoire. Plusspecifiquement, cinq patients avaient une lithiase vesiculaire,quatre, une hernie inguinale, deux un cancer gastrique, un patient,une tumeur retroperitoneale et un autre, une tumeur du rein.Tous les AAA etaient sous-renaux, et aucun n’etaient inflamma-toire ou rompu. Dans les cas de lithiase vesiculaire, la cure del’AAA a ete pratiquee en premier. La cholecystectomie a eterealisee apres fermeture hermetique de l’espace retroperitoneal.Chez les patients ayant une hernie inguinale concommitante,l’AAA a ete replace d’abord par une prothese vasculaire et uneportion de la prothese a ete utilisee pour la reparation de lahernie, d’une maniere tres similaire a la cure de la hernie souslaparosopie. Chez les deux patients ayant un cancer gastrique, ona d’abord fait la cure de l’AAA. Ensuite on a realise unegastrectomie subtotale avec lymphadenectomie de type D2 apresfermeture hermetique de l’espace retroperitoneal. Un drain a eteinsere dans l’hiatus de Winslow pour eventuellement aider adetecter une fistule. Chez le patient avec tumeur retroperitoneale,celle-ci a ete dissequee en premier, et ensuite resequee en blocavec la paroi de l’AAA car la tumeur y etait extremementadherente. L’aorte abdominale a ensuite ete replacee par uneprothese. Chez le patient presentant la tumeur renale, la nephrec-tomie a ete accomplie en premier pour completer la dissectionlymphatique autour de l’artere renale. La cure de l’AAA a etefaite ensuite. On n’a observe aucune complication menacant lepronostic vital, telle l’infection pulmonaire, une hemorragie, unefistule anastomotique ou l’infection de la prothese. Parmi les 13patients sortis de notre hopital aucun n’a recidive ni leur cancer,ni, le cas echeant, leur hernie. En conclusion, chez des patientsselectionnes, on peut faire en un seul temps la cure d’un AAA etd’autres pathologies intra-abdominales non vasculaires, de faconsure, apportant a ces patients, de facon economique, une amelio-ration physique.
Resumen
El enfoque terapeutico de pacientes con aneurisma aorticoabdominal (AAA) coincidente con otras alteraciones, no vas-culares, intraabdominales sigue siendo polemico. Con objetode establecer directrices para el tratamiento de estos pacientesse efectuo una revision retrospectiva de enfermos con AAAasociado a procesos patologicos quirurgicos, no vasculares, delabdomen. Desde enero de 1988 a diciembre de 1997, 162pacientes fueron tratados en nuestro hospital por AAA. Entreellos, 16 (9,9%) presentaban lesiones graves, no vasculares,intraabdominales; en 13 casos se resolvio su patologıa en elmismo acto quirurgico. Ası, al AAA se asociaron 5 casos decolelitiasis, 4 hernias inguinales, 2 canceres gastricos, un tumorretroperitoneal y otro renal. Todos los AAA fueron infrarre-
nales y no hubo ningun caso de aneurisma inflamatorio ni deruptura aneurismatica. En casos de colelitiasis asociadadespues de la aneurismectomıa y del cierre hermetico delretroperitoneo, se efectuo una colecistectomıa. En los casos enque el AAA coexistıa con hernia inguinal se trato inicialmenteel AAA mediante colocacion de un injerto protesico, utilizandoun fragmento del mismo para la realizacion de una herniorrafiacon protesis; la tecnica utilizada fue similar a la empleada en eltratamiento laparoscopico de las hernias inguinales. En los doscasos de carcinoma gastrico, despues de tratar el AAA ysuturar hermeticamente el retroperitoneo, se procedio a efec-tuar una gastrectomıa subtotal con linfadenectomıa D2; seinserto un tubo de drenaje, a traves del foramen epiploico, parala deteccion precoz de cualquier dehiscencia anastomotica. Eltumor retroperitoneal fue resecado en bloque con el aneurismaa cuyas paredes estaba ıntimamente adherido; la aorta abdo-minal fue sustituida por una protesis vascular. En el caso deltumor renal concomitante con el AAA, se efectuo primero unanefrectomıa, con diseccion y extirpacion total de las adenopa-tias situadas alrededor de la arteria renal; se procedio acontinuacion a la reparacion convencional del AAA. No seregistraron complicaciones mortales tales como neumonıas,hemorragias, dehiscencias anastomoticas ni infeccion de lasprotesis. Los 13 pacientes fueron dados de alta hospitalaria yen la actualidad se encuentran bien sin recidivas cancerosas niherniarias. Conclusion: en pacientes seleccionados, en los quejunto al AAA coexisten otras patologıas quirurgicas, no vascu-lares, pueden tratarse simultaneamente ambos procesos en unsolo acto quirurgico, lo que es mas beneficioso para el paciente,reduciendo, ademas, los costos economicos.
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6. Poulias, G.E., Doundoulakis, N., Skoutas, B., Haddad, H., Karkanias,G., Lyberiades, D.: Abdominal aneurysmectomy and determinants ofimproved results and late survival: surgical considerations in 672operations and 1–15 year follow-up. J. Cardiovasc. Surg. 35:115, 1994
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Invited Commentary
John J. Bergan, M.D.
Department of Vascular Surgery, Loma Linda University MedicalCenter, Loma Linda, California, USA
This presentation argues for one-stage treatment of an abdominalaortic aneurysm (AAA) and concomitant surgical problems.There would be little disagreement with the repair of inguinalhernia following successful, uncomplicated AAA surgery withgraft replacement. Both surgical procedures are relatively free ofbacterial contamination. Interestingly, there are a number ofreported cases of ruptured AAA presenting as symptomaticinguinal hernia, and the argument could be made for earlydetection of aortic aneurysms before rupture and simultaneoushernia repair [1].
The question of simultaneous cholecystectomy during abdom-inal aneurysm surgery has been raised since the earliest days ofaortic surgery. Recently, the question has been asked in French[2] and answered in Italian [3], with the consensus being that thetwo operations can be done together safely. Interestingly, it isacalculous cholecystitis that presents the greatest threat. Ouriel etal. reported 50% mortality in acalculous cholecystitis complicatingAAA resection [4].
Concomitant surgical resections for malignancy present a morecomplex problem, although the tendency is to report successful
surgical experience [5, 6]. The Mayo Clinic experience [7] re-vealed a 2.6% mortality rate for 335 individuals with elective AAAsurgery and a 6.0% mortality rate in a group of 113 patients withaortic aneurysm resection and a concomitant nonvascular proce-dure. Morbidity rates were 12.8% for the first group of patientsand 18.5% for the latter. The morbidity and mortality in the groupwith combined surgery were largely due to the nonvascularprocedure, and cholecystectomy during abdominal aortic surgerywas implicated strongly.
Although it has always been my preference to do one surgicalprocedure per patient per day, Weinstein et al. [8] summarizedthe prevailing surgical thought saying, “If both conditions areasymptomatic, the relative risk and benefits of treatment must bebalanced against the probability that one or both of the conditionswill become symptomatic.”
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