AAA v bowel cancer

53yo male for right hemicolectomy.


  • Laparoscopic appendicectomy 12/12 ago, no issues.
  • Mass found in Right Colon due appendicectomy
  • ETOH binge drinker


  • 5cm AAA, asymptomatic
    • Incidental finding in workup for bowel cancer
    • Now 5.5cm, requires treatment
  • HCV
    • Patient reported having HBV previously
    • On further investigation, diagnosed with HCV in 2015, with low titres. 
    • FibroScan – no cirrhosis. Planned for no active treatment but advised to await new treatments in the very near future. 
    • Lost to follow up after that.


EVAR v. Open repair AAA

  • Concerns about longer recovery with open procedure, may delay cancer treatment
  • Neurohumoral responses to major open abdominal surgery may accelerate cancer spread/progression
  • On a population level, Uptodate suggests:
    • Randomized trials comparing open AAA repair with EVAR have found significantly improved 30-day M&M for EVAR but no significant differences in long-term outcomes up to 10 years.
    • A pooled analysis of these trials identified a 69% reduction in the risk for perioperative mortality for endovascular compared with open repair (odds ratio [OR] 0.33, 95% CI 0.17-0.64).
    • EVAR appears to be associated with the need for more secondary procedures and an ongoing future risk of aortic rupture. 

Surgical considerations

  • If bowel surgery was more urgent (e.g. obstruction) would open or laparoscopic procedure be preferable with known large AAA? – unclear
  • Abdominal CT often ordered by surgeons in suspected appendicitis in older age group, due to possibility of cancer

Role for HCV RNA PCR (BMJ best practice)

  • Negative result confirms no current infection (whereas antibodies will always be +)
  • Recommended 1st line test if immunocompromised, as antibody testing may be negative due to failed/delayed seroconversion 
  • Used to detect reinfection
  • 15-45% of people will clear the virus spontaneously, so PCR tells you if they are viraemic.


  • Proceed with EVAR
  • HCV PCR – no need for titres. If PCR + will need treatment for HCV.
  • Proceed with bowel cancer surgery regardless of requirement for HCV Rx.
  • Check alpha-fetoprotein level to screen for liver cancer