AAA v bowel cancer

53yo male for right hemicolectomy.

Background:

Issues:

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.

Discussion:

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 1^st 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.

Plan:

Perioperative Talk