A.J. Arvelakis

Bickerstaff

E.A. Bastounis

E.L. Papalambros

E.S. Felekouras

J. Griniatsos

Komori

Lobbato

S.E. Georgopoulos

Sigler

Szilagyi

Takeuchi

PubMed

Crossref

Abdominal aortic aneurysm and hepatocellular carcinoma: a one‐stage approach

BackgroundThe operative management of abdominal aortic aneurysm (AAA) and co‐existing intra‐abdominal malignancy has been a long‐standing controversy. It is unclear whether a single‐stage or a two‐stage approach is the more appropriate therapeutic option and also which lesion should be treated first.Case outlineAn 82‐year‐old man with a 4 × 5‐cm mass in the left liver (segment IV), suspected to be a hepatocellular carcinoma (HCC), had a concomitant 6‐cm infrarenal AAA. At the same operation he underwent a left hepatectomy followed by repair of the aneurysm. He was discharged on the 17th postoperative day. To the best of our knowledge, this is the third report in the world literature of a patient who underwent a successful simultaneous resection of an AAA and HCC and the first in which the liver resection was performed first.DiscussionWe recommend liver resection and AAA repair in a single‐stage procedure, regardless of the time sequence of the procedures. This approach can be considered safe, and the theoretical risk of graft infection can be kept to a minimum

Bastounis, E.A.

Felekouras, E.S.

Arvelakis, A.J.

Georgopoulos, S.E.

Griniatsos, J.

Papalambros, E.L.

Elsevier - Publisher Connector 

Abdominal aortic aneurysm and hepatocellular carcinoma: a one‐stage approach 

195
Case Report
Abdominal aortic aneurysm and hepatocellular 
carcinoma: a one-stage approach
EA Bastounis, ES Felekouras,AJ Arvelakis, SE Georgopoulos, J Griniatsos and 
EL Papalambros 
First Department of Surgery, University of Athens Medical School, Athens, Greece
Background
The operative management of abdominal aortic aneurysm
(AAA) and co-existing intra-abdominal malignancy has
been a long-standing controversy. It is unclear whether a
single-stage or a two-stage approach is the more appro-
priate therapeutic option and also which lesion should be
treated first.
Case outline
An 82-year-old man with a 435-cm mass in the left liver
(segment IV), suspected to be a hepatocellular carcinoma
(HCC), had a concomitant 6-cm infrarenal AAA. At the
same operation he underwent a left hepatectomy followed
by repair of the aneurysm. He was discharged on the 17th
postoperative day. To the best of our knowledge, this is the
third report in the world literature of a patient who
underwent a successful simultaneous resection of an AAA
and HCC and the first in which the liver resection was
performed first.
Discussion
We recommend liver resection and AAA repair in a single-
stage procedure, regardless of the time sequence of the
procedures. This approach can be considered safe, and
the theoretical risk of graft infection can be kept to a
minimum.
Key words
hepatocellular carcinoma, abdominal aortic aneurysm
Correspondence to: J Griniatsos , Flat 2, 1B Oak Road, Ealing
Broadway, London W5 3SS, UK (e-mail: johngrin@hotmail.com)
HPB 2002 Volume 4, Number 4 195–197
© 2002 Martin Dunitz Ltd.
Martin Dunitz Taylor&Francishealthsciences
Introduction
The management of abdominal aortic aneurysm (AAA)
and co-existing intra-abdominal malignancy remains
controversial. These lesions can be resected in either a one-
stage or a two-stage operation, and the best order of pro-
ceeding is uncertain [1]. Existing data mainly concern
AAA and neoplasms of the gastrointestinal tract or urinary
system; only two cases of hepatocellular carcinoma (HCC)
and AAA have been reported previously [2].
We describe case of simultaneous liver resection and
AAA repair.
Case report
An 82-year-old Greek Orthodox priest was admitted with a
mass in the left liver and an AAA, which were seen on an
ultrasound scan performed for upper abdominal discomfort.
Abdominal CT scan revealed a tumour in segment IV of
the liver, measuring 435 cm in size, plus an infrarenal
abdominal aortic aneurysm (AAA) that was 6 cm in diam-
eter (Figure 1A). An elevated AFP (647 ng/ml) was con-
sidered diagnostic for hepatocellular carcinoma (HCC).
The history and physical examination did not reveal any
previous liver or cardiovascular disease, except for moder-
ate chronic obstructive pulmonary disease. A complete
preoperative metastatic work-up was negative.
The patient initially underwent left hepatectomy
(Figure 1B), followed by aneurysmectomy and aorto-bi-iliac
bypass, due to occlusive disease of the proximal common
iliac arteries (Figure 1C). He remained stable throughout
the procedure. The operative time was 240 minutes, and
three units of blood were transfused. After a 2-day stay in
the intensive care unit, he recovered uneventfully and was
discharged from hospital on the 17th postoperative day.
Liver histology revealed well-differentiated HCC. The
patient refused any additional treatment for the HCC and
was still alive at 3–year follow-up. 
Discussion
The timing of repair of an AAA and a concurrent malig-
nancy is a difficult problem. Delay in the surgical treatment
of either lesion carries inherent risks (aneurysmal rupture or
cancer spread), while resection of both lesions carries an
increasing peri-operative risk and a likelihood of graft
contamination.
When gastrointestinal cancer is associated with AAA,
treatment of the symptomatic disease comes first [3, 4]. If
there is no absolute indication for treatment of either
lesion, the decision regarding the order and timing of the
two operations can be difficult.
There is no clear consensus in the literature. Szilagyi
and colleagues [3] recommend a two-stage approach,
whereas other authors perform a one-stage procedure [4].
Lobbato and co-authors [5] surveyed the opinions of 46
specialists in general and vascular surgery in the USA on
this matter. One third of the responders favoured excision
of the carcinoma followed later by AAA repair, one third
favoured excision of the aneurysm followed later by resec-
tion of the carcinoma, and the remaining one third stated
that they would withhold a decision until laparotomy was
performed. Only two responders reported that they would
perform simultaneous resection of both lesions. Yet some
authors have suggested that operation for gastrointestinal
malignancy and AAA repair may be performed safely at the
same time provided that the retroperitoneum is closed
before tumour surgery is started [6, 7].
The co-existence of an AAA larger than 5 cm in
diameter and HCC is extremely rare. The present case is
the first we have encountered in the last 20 years with a
workload of more than 60–80 cases of AAA per year. In
Japan, where the incidence of HCC is higher than the rest
of the world, Komori et al. [7] have reported one case in 229
AAAs (0.4%). 
Takeuchi and colleagues [2] have recommended that
AAA repair should precede liver resection. According to
the principles of liver surgery, cholecystectomy should be
performed in any case of major hepatectomy for cancer.
In the absence of gall bladder pathology, liver resection
plus cholecystectomy is considered to be a ‘clean’ surgical
procedure. Mainly for that reason, we think that hepatic
resection could precede aneurysmectomy. This option
permits better monitoring of the general status of the
patient, especially the coagulation profile, and thus inser-
tion of an arterial graft can be performed safely. It also
gives more time for inspection of bile duct integrity and
control of any bile leakage, which should be corrected
intraoperatively.
In conclusion, combined liver resection and AAA
repair in either order appears to be safe and carries a low
risk of graft infection.
EA Bastounis et al.
196
Figure 1. (a) CT scan of the abdomen showing the liver tumor (white arrow) and the AAA (black arrow). (b) Intra-operative images of the liver resection (black
arrow) and the aneurysm (white arrow). (c) Intra-operative images of the liver resection (black arrow) and aorto-bi-iliac graft (white arrow).
cba
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197
Abdominal aortic aneurysm and hepatocellular carcinoma


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Abdominal aortic aneurysm and hepatocellular carcinoma: a one-stage approach

Abdominal aortic aneurysm and hepatocellular carcinoma: a one-stage approach

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