Clinical analysis of modified radical nephrectomy and inferior vena cava thrombectomy with deep hypothermic circulatory arrest

Abstract

Objective To evaluate the safety and efficacy of modified radical nephrectomy and high level inferior vena cava thrombectomy with deep hypothermic circulatory arrest.Methods From March 1997 to February 2013,36 patients,diagnosed as renal cell carcinoma (RCC) associated with level Ⅲ-Ⅳ inferior vena cava (IVC) tumor thrombi,were accepted radical nephrectomy and IVC thrombectomy using cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA).Among them,24 patients were male and 12 patients were female.Their age ranged from 19 to 72 years old (mean 53.8± 13.1 years old).Level Ⅲ IVC tumor thrombi was found in 29 cases and level Ⅳ IVC tumor thrombi was found in 7 cases.Eight radical nephrectomies with IVC thrombectomies were performed according to the classic surgical procedures,including 7 cases with level Ⅲ IVC tumor thrombi and one case with level ⅣV IVC tumor thrombus.Twenty-eight radical nephrectomies with IVC thrombectomies were performed using modified techniques,including 22 cases with level Ⅲ IVC tumor thrombi and 6 cases with level Ⅳ IVC tumor thrombi.The mean size of tumor was 10.2±4.3 cm.There were no significant differences in patient and pathological characteristics,including age,sex gender,body mass index (BMI),Eastern Cooperative Oncology Group (ECOG) performance status,tumor size and thrombus levels (P＞0.05).The main modifications techniques included as follow:①Taking the 4th right intercostal incision and right inguinal incision to establish CPB in order to avoid the need of median sternotomy.Meanwhile,the right subcostal and lateral rectus incision was considered as the approach for nephrectomy; ②Applying the laparoscopic ultrasound probe to monitoring the thrombus level during the procedures ; ③Delaying the maximal mobilization of kidney tumor after thrombectomy.The operation time,CPB time,circulatory arrest time,estimated blood loss,intraoperative blood transfusions,postoperative hospital stays,perioperative complications and mortality were compared between the two groups.Results The mean operation time (580.0± 31.0 min vs.438.2 ± 87.1 min),CPB time (190.0±11.4 min vs.160.4±30.2 min),postoperative ICU stays (74.0±11.8 h vs.38.7±17.2 h) and postoperative hospital stays (12.9± 1.6 d vs.9.6± 1.9 d) were siguificantly shorter in the technique modified group than those in the traditional group (P＜0.05).At the same time,the estimated blood loss (4 166.7± 871.0 ml vs.2 547.1 ± 1 363.4 ml),intraoperative blood transfusions (3 133.3±575.0 ml vs.1 894.1±956.9 ml) and perioperative mortality (2/8 vs.0,i.e 25.0％ vs.0) were also significantly lower in the technique modified group than those in the traditional group (P＜0.05).The circulatory arrest duration (27.3±5.9 min vs.24.4±8.2 min),resuscitation time (4.6±0.9 h vs.3.8± 1.7 h) and perioperative complication rates (2/ 8 vs.4/28,i.e 25.0％ vs.14.3％)didn't show significantly different between the two group (P＞0.05).Conclusions Radical nephrectomy and level Ⅲ-Ⅳ tumour thrombectomy using CPB combined with DHCA is relatively safe and with low morbidity and mortality rate.The technical modifications may facilitate the operation,help minimize surgical trauma and improve perioperative outcomes. Key words: Renal cell carcinoma; IVC thrombus; Deep hypothermic circulatory arrest; Technical modifications