Abstract
Introduction: The use of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA) is an adjunctive surgical technique that can be employed for the resection of renal cell carcinoma (RCC) with venous thrombus extension superior to the level of the hepatic veins. Median Sternotomy (MS) or Minimal Access (MA) incisions may be used to establish CPB during the resection of these extensive tumors. We review our experience with both incisional approaches and compareoperative details, perioperative complications, and recurrence free survival. Materials and Methods: From 1986 to 2012, 70 radical nephrectomies with concomitant inferior vena cava (IVC) thrombectomies were performed at our institution using MS (23 patients) and MA (47 patients) techniques. Preoperative patient characteristics, pathologic data, and organ specific postoperative complications and follow-up data were compared between groups. Estimates of overall and recurrence-free survival were constructed using Kaplan-Meier curves and compared using log-rank testing. Results: There were no significant differences with respect to patient demographics or preoperative comorbid conditions between the MA and MS groups. The MA group showed a significant reduction (p < 0.05) in the duration of postoperative mechanical ventilation, length of stay, operative time, and number of blood transfusions compared to MS patients. Overall and organ-system specific complications demonstrated a decreased incidence of wound infection (37.9% v. 12.5%, p = 0.0135) and sepsis (14.3% v. 0%, p = 0.0137) in patients undergoing MA approach. Perioperative mortality was significantly reduced in the MA group (30.4% v. 8.5% p = 0.0179). Recurrence-free survival in the MS group was 0.59 years and 1.2 years in the MA group (p = 0.06). Conclusions: Minimal access surgical approaches for CPB and DHCA during the resection of RCC with extensive tumor thrombus provide similar oncologic control with decreased duration of mechanical ventilation, length of stay and infection related complications. Our findings suggest that MA techniques provide significant advantages over MS.
Highlights
The use of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA) is an adjunctive surgical technique that can be employed for the resection of renal cell carcinoma (RCC) with venous thrombus extension superior to the level of the hepatic veins
Between 1986 and 2012, 70 radical nephrectomies and inferior vena cava (IVC) thrombectomies were performed at our institution for patients with renal cell carcinoma with either level 3 or level 4 venous thrombus involvement according to the Neves Classification [5]
Some investigators have removed Neves level 4 tumor thrombii without the aid of cardiopulmonary bypass, our experience has been that CPB allows for better overall exposure and control of supradiaphragmatic caval and atrial thrombii and allows for caval reconstruction as needed for caval wall invasion utilizing pericardium
Summary
The use of cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA) is an adjunctive surgical technique that can be employed for the resection of renal cell carcinoma (RCC) with venous thrombus extension superior to the level of the hepatic veins. Conclusions: Minimal access surgical approaches for CPB and DHCA during the resection of RCC with extensive tumor thrombus provide similar oncologic control with decreased duration of mechanical ventilation, length of stay and infection related complications. Two approaches have been developed to accomplish this: median sternotomy (Figure 1 and Figure 2) and a minimal access technique (Figure 3), as we have previously described [4] The objective of this current study is to review our current experience with both techniques, and compare perioperative complications, perioperative mortality, and recurrence-free and overall survival
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