Challenging Surgery for Retroperitoneal Tumors and Liver Transplant Surgeons

Abstract

Resection of tumors in the retroperitoneum, surrounding, invading, or growing into the inferior vena cava (IVC), presents challenges to most surgeons. Of the uncommon tumors that present in this way, the most common is renal cell carcinoma (RCC), which has the unique propensity to grow into the lumen of the IVC via the renal vein. Other retroperitoneal tumors, such as adreno-cortical carcinomas and primary sarcomas arising in the retroperitoneum, may invade the IVC and/or other surrounding structures, such as the liver or the diaphragm. The article published in this issue of World Journal of Surgery by Facciuto et al. [1] describes the application of surgical techniques used in liver transplantation for the resection of these tumors. Safe and complete resection of these lesions requires familiarity with mobilization of the liver and the dissection and control of the infrahepatic, intrahepatic, and suprahepatic IVC. Liver transplant surgeons are uniquely placed in possessing the experience and skills required for such exposure and dissection. Other critical facilities and expertise available to these surgeons are the routine availability of intraoperative ultrasound, venovenous bypass, specialist anesthetic assistance with the intraoperative management of patients undergoing this type of surgery, and the ability to resect involved liver segments simultaneously. If resection and replacement of the IVC is also required, liver transplant units will have access to a bank of allogeneic venous grafts from deceased organ donors. The rationale for surgical excision even for locally advanced neoplasms with tumor thrombus in the IVC, shortand long-term outcomes, and the effect of other treatment modalities have been published mostly for RCCs [2, 3]. The remarkably low morbidity and zero mortality achieved by Facciuto and colleagues compares favorably with previously published results in this area. In describing the Mayo Clinic experience during a 30-year period since 1970, Blute et al. [4] reported two intraoperative and two perioperative deaths (14.2%) in 28 patients who had level III (TNM classification: pT3B) RCC tumor thrombus in the IVC. Our own unpublished experience mirrors that of the New York group with no intraoperative or perioperative mortality in the resection of pT3b RCCs in more than 30 patients. All of our cases were initially referred to a specialist urological surgeon and involved multidisciplinary discussion on the management approach. Patients with tumor thrombus extending into the intrahepatic and suprahepatic IVC were selected for surgery to be jointly performed by a urologist and a liver transplant surgeon in the liver transplant unit. An important technical consideration is the gradual obstruction to flow in the IVC from the tumor thrombus, which results in the development of collateral venous circulation in the retroperitoneum. Even after clamping proximal and distal IVC as well as the contralateral renal vein, these venous collaterals cause significant blood loss when the isolated segment of the IVC is opened. One of the key maneuvers in avoiding blood loss from these collateral veins is complete mobilization and retraction of the liver and full exposure of the intrahepatic IVC to the level of the hepatic veins. Placement of the surgeon’s (left) hand posterior to the IVC and pressing it anteriorly is then adequate to minimize blood loss when the IVC is incised for the extraction of the contained tumor thrombus. Collaboration between urologists and liver transplant surgeons has been one of the key developments in the M. Akyol (&) Scottish Liver Transplant Unit, The Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, Scotland, UK e-mail: murat.akyol@ed.ac.uk