Size of abdominal aneurism governs best treatment choice
DEAR DR. ROACH — I just found out that my dad has an abdominal aortic aneurism that measures 4.7 centimeters. I know you’ve covered the relationship between size of an aneurism and treatment, but can you go over that again? Also, he has stage 4 COPD. If the size of his aneurism makes him a candidate for surgery, how would the COPD affect that decision? How worried should we be? — A.A.
ANSWER — The aorta, the largest blood vessel in the body, is subject to dilation and weakening in some people, especially men with a history of smoking. Rupture of the aneurism is a feared complication because it is almost always fatal. Elective repair is considered when an aneurism is found.
Discussions about all medical procedures should include as clear as possible answers to these two questions: What are the likely outcomes if I do the procedure, and what are the likely outcomes if I don’t do the procedure?
At 4.7 cm, your father’s aneurism is considered “medium-sized,” and has a low risk of rupture. Only 1.6% of aneurisms this size rupture. In older studies, which used open repair, the 30-day mortality rate from the difficult and dangerous surgery was 5.5%. AAA repair is generally not considered until the aneurism is greater than 5.5 cm. At this size, there is a benefit to surgery because the risk of rupture exceeds the risk of surgery. However, the individual characteristics and preferences of the patient must be considered — patients at higher risk might benefit only when the aneurism is larger, while a few otherwise healthy patients might elect for surgery even if the aneurism wasn’t quite 5.5 cm.
Because of your dad’s severe COPD, his risk is higher than the average person. A prudent surgeon would be slow to recommend surgery. Moreover, a surgeon would be very likely to recommend endovascular repair. The 30-day mortality is much lower. Death rates with endovascular surgery are in the 1% to 2% range, compared with 4% to 5% in the open surgery group.
Even at this point, medical management can reduce the risk of the aneurism enlarging or at least slow progression. If your dad still smokes, quitting would be by far the most important thing he could do for his health. Regular moderate exercise is highly recommended, but he should avoid heavy weightlifting.
Control of elevated blood pressure and cholesterol is probably of benefit as well.
DEAR DR. ROACH — My wife is 65, and I am 62. We have the same gastroenterologist. Several years ago, my wife was diagnosed with diverticulosis. The doctor told her to refrain from eating hard-to-digest foods such as nuts, corn and seeds. A year ago, the doctor told me that I have diverticulosis. He informed me that the recommendation to stay away nuts and seeds is no longer needed. The doctor did not explain why his recommendation had changed.
Can you provide some guidance on dietary recommendations for patients who have diverticulosis
but are not currently experiencing problems with it? — S.O.
ANSWER — Diverticulosis is the presence of small pouches in the colon. These can become inflamed, causing pain and fever, a condition called diverticulitis. Nuts and seeds were once thought to precipitate diverticulitis by becoming lodged in the pouches.
There was never good evidence to support the recommendation against eating seeds and nuts, and the recommendation has changed because nuts and seeds are generally a healthy addition to diet, and because there is some evidence that eating these may actually reduce the risk of developing diverticulitis.