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Abstract

Important issues are raised in your letter. Our report of 47 patients with retroperitoneal tumors, the majority of which were sarcomas, undergoing radical resection with vena cava reconstruction specifically excluded patients with renal cell carcinoma.1Quinones-Baldrich W. Alktaifi A. Eilber F. Eilber F. Inferior vena cava resection and reconstruction for retroperitoneal tumor excision.J Vasc Surg. 2012; 55 (discussion: 1393): 1386-1393Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Renal cell carcinomas with involvement of the inferior vena cava most often can be resected with limited inferior vena cava excision and extraction of unattached intraluminal tumor thrombus. Retroperitoneal sarcomas with inferior vena cava origin or invasion on the other hand, require more extensive resection. Reconstruction of the inferior vena cava after resection as noted by our experience can be performed with minimal morbidity and mortality. Operative time is not significantly increased (averages 4 hours for the entire case) and no graft infections have occurred in our series. As mentioned in our report, we do not routinely anticoagulate patients postoperatively even when circumferential resection and reconstruction have been performed. The main benefit of inferior vena cava reconstruction is the avoidance of venous hypertension and its clinical manifestations. Venous collaterals are often removed during radical tumor excision. In the experience reported by Dylami et al2Daylami R. Amiri A. Goldsmith B. Troppmann C. Schneider P.D. Khatri V.P. Inferior vena cava leiomyosarcoma: is reconstruction necessary after resection?.J Am Coll Surg. 2010; 210: 185-190Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar with routine vena cava ligation after resection in six patients, three patients developed lower extremity edema (reported as “well tolerated”), three patients developed acute renal failure with recovery, and two patients developed a chylous leak (potentially secondary to venous hypertension). The technique for retrohepatic inferior vena cava exposure, control and resection as described by Ciancio et al3Ciancio G. Livingstone A.S. Soloway M. Surgical management of renal cell carcinoma with tumor thrombus in the renal and inferior vena cava: the University of Miami experience in using liver transplantation techniques.Eur Urol. 2007; 51: 988-994Abstract Full Text Full Text PDF PubMed Scopus (116) Google Scholar, 4Ciancio G. Gonzalez J. Shirodkar S.P. Angulo J.C. Soloway M.S. Liver transplantation techniques for the surgical management of renal cell carcinoma with tumor thrombus in the inferior vena cava: step-by-step description.Eur Urol. 2011; 59: 401-406Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar and referred to as the “piggyback” method includes control of the portal triad (Pringle maneuver), mobilization of the retrohepatic inferior vena cava and ligation of the smaller hepatic veins draining the caudate lobe. In our cases, more cephalad inferior vena cava involvement requiring resection and reconstruction (as opposed to removal of tumor thrombus) of the portion where the main hepatic veins drain, does require control of the infra- and suprahepatic vena cava. We refer to this method as “hepatic vascular isolation.” Both methods involve some degree of liver ischemia and avoid individual control of the main hepatic veins which are easily injured and difficult to repair. Management of tumors involving the inferior vena cava will differ according to the type of tumor and the degree of invasion of the vessel wall. Caval reconstruction after resection is associated with excellent clinical outcomes. We appreciate the opportunity to clarify these issues. Regarding “Inferior vena cava resection and reconstruction for retroperitoneal tumor excision”Journal of Vascular SurgeryVol. 56Issue 4PreviewThe authors report their surgical experience of inferior vena cava (IVC) resection and reconstruction for patients with retroperitoneal tumor excision.1 Of the 47 patients included in the study, 27 patients underwent circumferential resection of the IVC and replacement with polytetrafluoroethylene (PTFE) graft after en bloc tumor resection. Eighteen of these patients underwent extensive resection and replacement of the IVC. We would like to commend the authors for their excellent surgical technique and the postoperative results. Full-Text PDF Open Archive