Abstract         Curriculum          Bibliografia 

Alberto Maria Raso

The therapeutic conduct of an abdominal aortic aneurysm (AAA) can vary, other than because of the presence of vascular disorders in other locations, where there are also local conditions of heightened surgical risk and, especially, where there is an association with non-vascular intra-abdominal disorders, whether neoplastic or not. 
The incidence rates in AAA carriers of concomitant malign neoplasia varies from 5.1% to 1.5% (personal finding), while non-malignant abdominal affections account for 5% (3.5% personal). The incidence for abdominal operations associated with AAA interventions varies according to the type of condition: for colecystectomies, it ranges from 3% (personal) to 7.5%; for nephrectomies, from 0.6% to 2% (personal); for hernioplasties, the values are around 0.6-0.7%. The mortality rates in the associated simultaneous operations, in response to Ochsner's figure of 8.6% for aortic surgery alone (1% personally), present, respectively, values of 5.8% and 0.9% in aortic surgery associated with another non-vascular operation.
In the case of synchronous lesions requiring surgery, the timing assumes special significance in the planning out of aggressive operations for the vascular disorder and the associated non-vascular affection respectively. Indeed, in this situation it is fundamental to determine if the simultaneous surgery would be truly beneficial for the patient of if, on the contrary, it might generate an importantly raised risk for the op. and/or of blood loss, or if an increased morbidity/mortality possibility might result. 

In the pre-op weighing up of options, it is undoubted that a significant indication lies in the evolution of the AAA, where a reliable signal of the risk of rupture is the caliber of the dilatation itself. In fact it has been shown that an AAA having a diameter greater than 6cm presents a complication risk of 46% compared to the 31% for narrower AAAs. More precisely, the AAAs may be subdivided into three categories reflecting the percentage burst risk: 9.5% for an AAA <5cm, 36% when the diameter is between 5 and 7cm and 76% if the dia. exceeds 7cm, and reaching 95% for the forms with a dia. broader than 10cm. And this in conformity too with the average rate of annual growth of the AAA, which is 5.29mm for the forms between 30 and 39mm dia., 6.88mm for those between 40 and 49mm, and 7.45mm for those greater than 50mm. Apart from the sac morphology, the evolution of these AAAs is conditioned by the presence of arterial hypertension, BPCO and the evolution of the transverse diameter compared to the anterolateral. 

Such conditions are usually represented by:
1 - extended viscerovisceral or visceroparietal adherences, secondary to abdominal surgery, peritonitis, traumas or irradiation. In such situations, a laparotomy may lead to an accidental opening of an ansa with subsequent bacterial contamination of the prosthesis;
2 - the presence of a hilo- or colostomy and from cutaneous urinary derivatives that, apart from the motive of technical difficulty, can be potential sources of bacterial contamination, moreover, it is necessary to consider that, in the majority of cases, these ostomies are carried out because of neoplasia, so it is essential to ascertain that the neoplastic picture is under control,
3 - anatomic changes linked to, or induced by, prior operations. 

All authors are nowadays agreed in the affirmation that operations on the gastrointestinal tract and bile ducts are never combined with surgery on the aorta, particularly if the procedures involve the loss of organic fluids. On the contrary, it is possible to perform surgery, such as vagotomy, whenever indicated. 
As regards AAAs and gastroduodenal ulcer, it will be the lesion characteristics that determine the therapeutic options, according to the algorithm in Table 1. 

JATAL HERNIA can provide for a combined surgical treatment, since this does not involve a septic risk. The simultaneous surgery indication seems justified whenever:
- the hernia is symptomatic and diagnosed pre-op.;
- the hernia has already been responsible for esophagitis with or without blood-loss, esophagitis whose significance has to be evaluated.
Depending on the type of hernia, the stance may be summarized as set out in Table 2.

Hernias and abdominal laparoceles are frequently found in AAA carriers and testify to the probable generalized deficiency of the connective tissues. The association varies from 1.2% to 5.9%, taking account of the fact that more than 12% of patients will have already undergone hernioplasty ops. by the time of discovering the AAA. 
The treatment may be contemporaneous since the contamination risk is almost zero, whereas the risk of a post-op. occlusion from hernial strangulation is not negligible and may represent a source of potential sepsis. In particular, inguinal hernia may be treated endoabdominally and contemporaneously, with usually modest outcomes, or else with a technique by Trabucco or Lichtenstein in the same session, especially if the hernial portal is narrow and therefore with a greater risk of complications.

The presence of a gallbladder lithiasis is not infrequent, given that, in patients over 50 years old, it appears in 20-25% of subjects affected by AAA, and it is not rare for a clinical picture, attributable to a biliary tree disorder, to mask the presence of an AAA.
The gallbladder stone's natural history differs according to whether it is symptomatic or not.

Cholecystectomy prior to AAA seems a therapeutically logical sequence in the event of the acute infective complication of a cholecystic lithiasis such as cholecystitis, angiocholitis or pancreatitis.
Moreover, cholecystectomy before AAA finds justification in the fact that the systematic bile cultures in patients affected by cholelithiasis were positive in 10-30% of cases, and that the mortality rate for cholecystitis after an AAA operation is still high. The awareness, therefore, of a pre-op cholecystopathy authorizes the intervention, possibly laparoscopically, in this case assessing the risk of an aneurysmatic rupture linked to the pneumoperitoneum, a rupture that can occur because of broad diameter AAA or with fragile walls or blisters. The intra-operative finding should, according to some, lead to a combined cholecystectomy in order to avoid potentially lethal complications. 
The diagnostic-therapeutic protocol of this association may follow the iters indicated in Table 4.

The presence of AAA and urolithiasis involves the differential diagnosis, in the acute phase, of the etiology of the pain symptoms. The concomitance of these two disorders can in anyhow give rise to doubts over the therapeutic options. In fact, extracorporeal soundblast lithotripsy is considered contraindicated for kidney stones, given the possibility of inducing or accelerating the abrupture of the AAA. It would seem more correct, whenever possible, to utilize endoscopic therapy. 
In the event of surgery that requires the opening up of the urinary tract, it would seem more precautionary not to carry out the two operations in the same session, but rather to postpone the urological procedure a few weeks. In any case, even for this sector, the principle of the presence or absence of urinary symptomology holds good; in the case of symptomatic urolithiasis, this is cooled down and, subject to the urocultures, an appropriate therapy is established for sterilizing the urine. 
As for the renal and vesical neoplasia, even though the Literature advises two operating sessions, we ourselves have recently performed nephrectomies for neoplasia in one session only with AAA, similarly to the derivations with neovesica, during the operation for which we first dealt with treating the AAA and then preparing the neovesica. 
Immediate outcomes were excellent and at 2 years too. Indeed, the operations over 2 separate sessions provide first for the treatment of the aneurysm, thus obviating possible damage from ligation of the vessels and other complications that could make preparation of the neovesica difficult. On the contrary, if the neovesica is prepared first, a fibrosis of the retroperitoneum will show up within a month, making the AAA operation more difficult, and keeping in mind too that the neovesica, anatomosurgically, remains anterior to the aorta.
In cases of non-neoplastic pancreatic lesions, it is necessary to assess both the risk of possible septic complications of pancreatic origin subsequent to treating the vascular disorder, and the chances of success, for the cysts, with an evacuative treatment through percutaneous drainage (CT- or ultrasound-guided). Moreover, should the pancreatectomy not necessitate derivations in the digestive channel, it is appropriate for it to be carried out in the same operative session, similarly to what we recently did in a case of neoplasm of the body and tail of the pancreas, associated with AAA.
In the event of acute pancreatitis, on the other hand, and especially if associated with a concomitant biliary lithiasis, simultaneousness of the two operations is contraindicated. The staging provides for treating the pancreatitis, and then that of the biliary calculosis and, with the condition stabilized, the deferred AAA surgery.

Prophylactic appendectomy for the "innocent" appendix has not any significance. On the contrary, the finding of an AAA during a motivated appendectomy induces a deferment, even if briefly, of the vascular op. The occasional finding of an appendicopathy called either "sub-acute" or "chronic", similarly with Meckel's diverticulum, makes one consider it less risky for the prosthetic aortic implant, an appendectomy with a sinking of the stump and omental protection, rather than leaving in place an appendix susceptible to insidious new acute phases. 
Analogous considerations may prevail for diverticulosis of the colon and its complications. Intestinal resections cannot be combined, in the one operating session, with prosthetic vascular surgery. 

AAA, preferring to manifest in the sixth and seventh decades of life, has rates of incidence and onset similar to those of neoplastic disorders, whose frequencies rise with the advancing of age. In a survey conducted by us on 1,219 patients who had died from vascular diseases, we found a 5.5% incidence of malign neoplasia, prevalently sited in the lungs (19.1%). 
The circumstances that drive the surgeon to an almost obligatory choice, elected surgery can encompass: 
- patients with intra- or extra-abdominal neoplastic disease diagnosed and treated before the AAA was discovered;
- patients in whom the diagnosis of the two affections is pre-operative;
- patients in whom, during an operation for intra-abdominal neoplasia, a previously missed AAA is found;
- patients in whom, during an operation for AAA, a previously undiagnosed intra-abdominal neoplasm is found.
In the general assessment, the following variables ought to be considered: 
- the degree of urgency of the treatment for asymptomatic, symptomatic or abruptured AAA;
- the acute or chronic character of the abdominal disorder;
- the benign or malignant character of such lesion and its short-term behavior;
- the diagnosis made in the pre- or intra-op phases;
- the various surgical and technical options for the two lesions, including the actual chances for an endoprosthetic placement in the AAAs;
- the degree of risk in simultaneous treatment.
There is thence the need to determine:
- the treatment order of priority;
- the ideal time to elapse between the two operations;
- the risk of early or delayed post-op complications of the deferred disorder;
- the morbidity and mortality rates of both operations, separately or simultaneously;
- awareness of any other treatments of the neoplastic disorder, not only surgical but also chemotherapy and radiation. 

In clinical practice, it is appropriate to set the therapeutic priorities on the basis of:
a - the lesion that is the most life-threatening to the patient;
b - the risk of septic contamination;
c - the extent of the neoplastic disease.
In digestive tract neoplasia, surgical simultaneous invokes suitable choice criteria, not excluding the a priori possibility of a combined operation by even following two different surgical access routes, especially whenever there is a chance of bacterial contamination. However, it is undoubtedly the case that the concomitance of two major surgical procedures can contribute to increasing the peri-op risk. 

It is appropriate and desirable that contemporaneous surgery should occur when at least two of the following conditions subsist:
- whether or not the patient's condition would allow two surgical sessions;
- there is an ascertained risk of aneurysm rupture;
- there is a risk of a short-term acute development of the neoplastic disease;
- there is a rapid development of the neoplasm, as can occur with gastric carcinoma;
- the patient's general condition would be found to be such as to support one surgical act, with the related prolonged narcosis over time.

In patients carrying an AAA, the concomitance of increased local surgical risk conditions and/or non-vascular disorders, especially neoplastic, ought to induce the surgeon to plan out the treatment rationally, scrupulously evaluating the risks/benefits deriving from the therapeutic choice. In the case of synchronous lesions, diagnosed at the same time and requiring surgery, then the timing assumes special importance in the planning and realization of the aggressive operations of the AAA and the non-vascular affection respectively. Account should be taken that, after the informed and comprehensive, well-specified consent from the psychological point of view for the patient, a single operation is the preferred option, unless contrary viewpoints are made known. 
Should it be decided to proceed with several deferred surgical sessions, it would be necessary to establish:
a - whether to treat the AAA first, or the associated condition;
b - how much time should separate the operations;
c - which disorder to treat first;
d - which surgical timing would improve the patient's prognosis, offering the best assurance of safety, both immediate and future.

In weighing up the pre-op decisions, the following should be particularly considered:
a - the risk of AAA rupture;
b - the prognosis linked to the presence of the neoplasm;
c - the risk of a prosthetic infection deriving from surgical treatment for the neoplasm associated with the AAA;
d - the cumulative surgical risk;
e - the presence or not of an emergency situation, whether vascular or to do with the neoplasm.

The conclusions of what has been said above are set out in Table 7. Table 8 summarizes the elective surgery conditions. 
Table 9 explains the three standard situations in which the surgeon may find himself. 
Finally, Table 10 gives an account of the reasons why one can and should operate in a single surgical session. 
 

Alberto Maria Raso
Direttore
Cattedra di Chirurgia Vascolare
Università degli Studi di Torino