There is no ‘hard and fast right answer’. Every situation is different and must be carefully individualized. This type of question is a favorite for board examiners both in General Surgery as well as those sitting for the Special Certificate in General Vascular Surgery. The important thing is to be able to justify your actions in a conservative and logical way and be prepared to handle complications appropriately. The one truism that seems to echo throughout these dual diagnosis problems is to generally address the most immediate and life thretening problem first.
Example: Impacted CBD stone with acute cholecystitis leads to operation. Asymptomatic 5cm AAA noted at surgery.
Correct Procedure: Cholecystectomy + CBD exploration. Followed by elective w/u + Rx of AAA.
EXAMPLE: SBO with severe abd pain. 8cm AAA noted at lap. No evidence of leak.
Correct Procedure: Treat SBO as indicated. AAA resection as soon as patient is able to tolerate it in post op period.
EXAMPLE: Abd pain and mass. Suspected carcinoma confirmed by Colonoscopy, No Sx of bowel obstruction or overt GI bleeding. 6.5cm AAA noted on pre op CT.
- Option#1: AAA resection followed by interval Colon resection
- Option#2: Colon resection followed by interval AAA resection
- Option#3: Combined Procedure==>’GO TO JAIL’ (almost always)
#1 and #2 Options both have supporters. It’s really a toss up. I generally would favor #2 but I’ve done it both ways.
EXAMPLE: Unexplained very sudden + severe abd + back pain ?peritoneal signs X rays + and all Labs including Amylase nl. Patient is 65 yo male in ‘good health’ Exp Lap.Performed at 2AM. Exploration shows only 2 findings: 4cm AAA found with no evidence of leak. Sigmoid colon reveals 4-6 cm hard mass which is very consistent with a malignancy although an inflammatory mass cannot be ruled out. Here I would resect the AAA because the symptoms point to an unstable, albeit ‘small’ aneurism. I would deal with the sigmoid mass later.However the same findings in an asymptomatic patient would prompt me to deal with the colonic lesion and probably watch the AAA with routine survelience.
There are hundreds of permutations on this ‘dual diagnosis’ theme. Major factors to consider include: General Health of the patient, including CV status (CHF, MI’s, Angina) Size of the aneurism. Emergency vrs elective operation Concomitant pathology: Example: Is it severe chloecystitis or is it mildly symptomatic biliary colic. Is the surgeon comfortable with watching an AAA and is he able to assess the patient frequently and accurately in the post op period. (The latter is VERY difficult to do even for the experienced General or Vascular surgeon)
Fortunately these problems aren’t too common. But unfortunately they aren’t rare either I see some variant of it at least 3-4 times per year.
As always if the patient survives most people will say you acted correctly. If the patient doesn’t do well your decision willl probably be loudly questioned by your colleagues. (And you may even get a letter from one of those friendly personal injury attornies who pollute the land.)