EP498 - Concurrent Colorectal Pathology and Aortic Disease: Experience at a Tertiary Referral Center in the Philippines

Image or Table (Do Not add text here):

Purpose/Background: Concurrent colorectal pathology and aortic disease is uncommon, with its incidence in the range of 0.49 to 2.1%. Risk factors common to both conditions include smoking, obesity, and diabetes mellitus. Consensus regarding approaches to treatment is still lacking. Various options may be considered: staged vs synchronous approach, colorectal pathology vs aneurysm first, endovascular vs open repair of aneurysm. We aimed to describe treatment strategies employed utilizing a multidisciplinary team (MDT) approach for patients seen at our institution.

Methods/Interventions: Case series

Results/Outcomes: We managed four cases with these concomitant conditions. A summary is presented in Table 1.

Conclusion/Discussion: Several factors should be considered in treatment planning for such cases. There is a risk of perioperative aneurysmal rupture after colorectal resection if the colorectal pathology is addressed first. On the other hand, if aneurysm repair is prioritized, there is risk for tumor progression leading to obstruction, perforation, and upstaging. This potentially leads to delays in systemic treatment. If both are deemed equally life-threatening, a single-stage approach may be employed. However, the extent of surgery will largely be dictated by the intraoperative status of the patient. Also, for combined procedures, there may be a risk of aortic graft infection in cases where there may be contamination, such as gross spillage during colonic resection and leaks from colorectal anastomosis.

Often, the dictum ascribed to is that the more symptomatic and life-threatening condition is given priority—a symptomatic AAA should be addressed first followed by colon resection. If the colorectal mass is symptomatic, resection followed by aneurysm repair can be done. When neither is symptomatic, repair the AAA first if its size is  6cm. But if the AAA is < 6cm, colon resection may be done first. A single-stage procedure is a feasible option if both are symptomatic as it has been shown to carry a lower morbidity compared to a staged procedures and eliminates the risk for progression of the disease left untreated. If aortic anatomy permits, an EVAR is favored compared to open repair as EVAR has been shown to reduce operative mortality by two-thirds versus an open repair. Porcellini et al. (2007) demonstrated the benefit of EVAR over open repair among patients with concurrent malignant diseases and found that the EVAR group had shorter LOS (EVAR 12.8 days vs open 18.2 days), lower morbidity rate (EVAR 9.1% vs open 50%), and higher one- and two-year survival rates (EVAR 100% and 90.1% vs open 71.4% and 49%).

In patients presenting with concurrent colorectal pathology and aortic disease, surgical management is driven by the urgency of presentation. An MDT approach is essential in treatment planning. EVAR is favored over an open repair, but careful patient selection is of importance.