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EJSO 33 (2007) 239-242
EJSO the Journal of Cancer Surgery www.ejso.com
Technical Note
Intrapericardial isolation of the inferior vena cava through a transdiaphragmatic pericardial window for tumor resection without sternotomy or thoracotomy
T.W. Chen ª, C.H. Tsai b, S.J. Chou, C.Y. Yud, M.L. Shih ª, J.C. Yu ª, C.B. Hsieh ª,*
a Department of Surgery, Division of General Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Sec 2, Cheng-kung Rd, Taipei 114, Taiwan, ROC
b Division of Cardiovascular Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Sec 2, Cheng-kung Rd, Taipei 114, Taiwan, ROC ” Department of Surgery, Division of General Surgery, Cardinal Tien’s Hospital, Taipei, Taiwan, ROC
d Department of Radiology, Tri-Service General Hospital, National Defense Medical Center, 325, Sec 2, Cheng-kung Rd, Taipei 114, Taiwan, ROC
Accepted 9 November 2006 Available online 15 December 2006
Abstract
Aims: The prognosis for patients with advanced tumors invading the inferior vena cava (IVC) is dismal and surgical treatments for these tumors are challenging. A surgical approach that avoids sternotomy and thoracotomy for tumors invading the IVC even to the level of the hepatocaval junction would be extremely helpful.
Methods: The intrapericardial IVC was isolated via a transdiaphragmatic pericardial window using a transabdominal approach. Hepatec- tomy was then applied via an anterior approach until the IVC was seen. Total hepatic vascular exclusion was achieved by clamping the portal triad, intrapericardial IVC and infrahepatic IVC. We removed the primary tumor, the liver portion involved and the tumor thrombi, with segmental resection of the IVC. Vascular continuity was reestablished using a 20-mm-diameter polytetrafluoroethylene graft. Results: Four patients with tumors invading the IVC were treated with this method. All underwent gross en-bloc tumor resections and all survived. Conclusion: This method for the resection of IVC tumors could avoid emboli dislodging from the tumor thrombi, prevent the complications of sternotomy, cardiopulmonary bypass and shorten operative times. @ 2006 Elsevier Ltd. All rights reserved.
Keywords: Inferior vena cava isolation; Tumor; Transdiaphragmatic pericardial window
Introduction
Involvement of the inferior vena cava (IVC) has long been considered a limiting factor for the curative resection of advanced tumors; the surgical risks are high and the prognosis for the patient is generally poor because of inad- equate tumor-free margins, and the need to consider the possible combinations of multi-organ resection, IVC recon- struction, sternotomy, thoracotomy and cardiopulmonary bypass (CPB). The difficulty of surgery varies according to the tumor type and the region of IVC involved. The
resection of tumors invading the junction of hepatic veins and the IVC (Fig. 1) is especially challenging. When the tu- mor thrombi extend above the diaphragm, cardiopulmonary bypass with or without hypothermic circulatory arrest is of- ten suggested.1,2 Traditionally, sternotomy or thoracotomy is also necessary to perform intrapericardial IVC isolation, achieve adequate tumor-free margin and prevent any em- boli forming from the tumor thrombi. Combining these ap- proaches with total hepatic vascular exclusion has made such resection possible. However, the postoperative pain and wound adhesion caused by sternotomy, coagulopathy and central nervous complications inherent to the cardio- pulmonary bypass and circulatory arrest1,3 have led us to search for an alternative technique.
* Corresponding author. Tel .: +886 2 8792 7191; fax: +886 2 8792 7372. E-mail address: albert0920@yahoo.com.tw (C.B. Hsieh).
Here we introduce a technique of transdiaphragmatic in- trapericardial IVC isolation for the resection of IVC tu- mors, even those reaching the hepatocaval junction. This method can achieve gross tumor en-bloc resection easily and avoids the need for sternotomy, thoracotomy and CPB.
Patients and methods
Four patients with IVC tumors-two suffering from he- patocellular carcinoma, one with a leiomyosarcoma and one with an adrenocortical carcinoma-underwent surgical resection with the technique “intrapericardial IVC isolation through a transdiaphragmatic pericardial window” without cardiopulmonary or venovenous bypass. All patients had tumors extending near or to the hepatocaval junction and none of them extended above the diaphragm.
Technique
After the induction of general anesthesia, a large-bore central venous line is inserted by the anesthesiologist. A bi- lateral subcostal incision with upward extension is made and the abdominal cavity is inspected. Transesophageal echocardiography is performed at the same time to delin- eate the cranial extent of the thrombus.
Intra-pericardial IVC isolation through transdiaphragmatic approach
The left lateral segment of the liver is mobilized first, and then a plane between the liver and the diaphragm is developed carefully. A transdiaphragmatic pericardial
window, about 5 x 5 cm, is made using an electrocautery pen (Fig. 2A). Through this window, the intrapericardial IVC is isolated with an umbilical tape by blunt and sharp dissection (Fig. 2B).
Hepatectomy
Intraoperative ultrasound is used to define the liver re- section line and the line is marked accordingly. Then an an- terior approach hepatectomy proceeds using the Pringle maneuver. After separating the liver parenchyma, the IVC is exposed. At this point, rapid blood transfusion pump and inotropic agents are prepared before the next proce- dure. No autotransfusion device is utilized in fear of tumor seeding. Generally, the central venous pressure will be maintained around 5-10 cm H2O and the mean arterial pressure kept above 60 mmHg before proceeding total he- patic vascular exclusion (TVE).
A
B
Intrapericardial IVC (to be isolated)
Vena caval foramen
Right atrium
Heart
Tumor of IVC
Diaphragm
New-made transdiaphragmatic pericardial window
Liver
ETBlue 醫學內容工作餐
ETBlue 2006.06
Resection of IVC under TVE and reconstruction
TVE is achieved by clamping the portal triad and the intra- pericardial and infrahepatic IVC. The patient’s hemody- namic condition is aggressively treated with inotropic agents and large volume fluid or blood supplements, when necessary. After stabilization of hemodynamic status, re- moval of the primary tumor, tumor-involved liver, tumor thrombi and segmental resection of the IVC are performed. The cut end of the IVC is carefully inspected to see if there is any residual tumor thrombus and is trimmed for anastomo- sis. Another vascular clamp is then applied below the hepato- caval-IVC junction, and the intrapericardial IVC and portal triad clamps are removed to allow reperfusion of the liver and decrease blood loss from the phrenic veins. Finally, con- tinuity of the IVC is reestablished using a 20-mm-diameter polytetrafluoroethylene (PTFE) graft (Fig. 3). The total dura- tion of the Pringle maneuver is about 30 min and the total vas- cular exclusion time is about 10 min.
Results
All patients underwent gross en-bloc tumor resections and survived the operation. The amounts of bleeding were 630 and 850 ml in the hepatocellular carcinoma patients, 1850 ml in the leiomyosarcoma patient and 3900 ml in the adrenocortical carcinoma patient. Although major bleeding and large amount of blood transfusion oc- curred in the leiomyosarcoma and adrenocortical carci- noma patients, both of them recovered smoothly.
The hepatocellular carcinoma patients died nine and 15 months after the operation because of tumor recurrences and subsequent liver failure. The patient with leiomyosar- coma developed lung metastases three months after the op- eration and died six months later. The patient with an adrenocortical carcinoma was alive and disease-free six months after surgery.
Discussion
The long-term prognosis for patients with tumors invad- ing IVC without curative resection is dismal. The IVC ob- struction syndrome and repeated pulmonary emboli frequently endanger patients’ lives. Surgical resection of these tumors not only prevents the risk of pulmonary emb- olisms, but also reduces the clinical effects of hormonal hy- persecretion and relieves the symptomatic compression of surrounding organs by large tumors.4
Transdiaphragmatic intrapericardial IVC isolation is simple and effective
For patients with IVC tumors, even those with tumor thrombi extending to the junction of hepatic veins, this trans- diaphragmatic intrapericardial IVC isolation method can avoid sternotomy, achieve a better length for gross tumor en-bloc resection and prevent tumor emboli. It thus facilitates mobilization and tumor resection. More importantly, this transdiaphragmatic pericardial window approach is simple to perform and can be done within 5 to 10 min. On the con- trary, the set-up time for CPB exceeds half a hour5 and the procedure of sternotomy needs additional twenty minutes or so. Not to mention the time spent on closure of the sternum wound. Besides, looping of the supradiaphragmatic IVC be- longs to part of the set-up procedures of CPB while perform- ing certain types of heart surgery. Other groups also have described different techniques to gain access to the supra- diaphragmatic IVC either by making a central radial incision through the diaphragm and the caval foramen6 or by dissect- ing off central diaphragm tendon circumferentially7 if infra- diaphragmatic caval clamping is impossible. Nevertheless, we think their techniques take greater skills and are more time-consuming.
The role of TVE
Total hepatic vascular exclusion, including clamping of the portal triad, the inferior vena cava above and below the liver, is beneficial for the resection of tumors involving both IVC and liver by decreasing bleeding and air emboli.8,9 A bloodless operative field allows easy, precise dissection and reconstruction, and therefore helps in short- ening the operation time. Meanwhile, for patients with long-standing obstruction of the IVC, the development of collateral drainage of the IVC through the ascending lum- bar veins and the azygous/hemiazygous system helps to avoid hemodynamic instability during TVE 0 and the need for cardiopulmonary or venovenous bypass. However, application of rapid transfusion system and full support of the anesthesiology team are important for maintaining sta- ble hemodynamic status while performing this technique. Once hemodynamic status is under control, bypass is not necessary; otherwise, venovenous bypass should be established.
The role of transesophageal echocardiography
Intraoperative transesophageal echocardiography is im- portant for delineating the cranial extent of the IVC tumors and mobility of the thrombus in our experience. Confirma- tion of a large intra-atrial thrombus may require CPB, but a small non-adherent thrombus may not. The present tech- nique is also helpful in the latter condition.
For hepatocellular carcinoma patients with tumor involving IVC and receiving only supportive treatment, their survivals are expected less than 3 months. For patients with leiomyosar- coma involving IVC without resection, their median survival is only one month. The survivals of our comparative three patients are better in comparison with those without resection. We recognize that the small sample size and various tumor his- topathologic types preclude conclusions on survival benefit; but this simple approach certainly provides hope for those who could not tolerate sternotomy and CPB.
In conclusion, this technique appears to be beneficial in the surgical treatment of IVC tumors, by providing a longer tumor- free margin of the IVC, shortening the operative time and avoiding the needs for sternotomy and CPB. However, more experience is necessary to validate the benefits of this approach.
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