ELSEVIER
Surgical Oncology
journal homepage: http://www.elsevier.com/locate/suronc
S urgical nicology
Adrenal tumors of different types with or without tumor thrombus invading the inferior vena cava: An evaluation of 33 cases*
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Gaetano Ciancio a,b,c,”, Ahmed Farag a,c,e, Javier Gonzalezª, Jeffrey J. Gaynor a, c
a Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
b Department of Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
” Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
d Department of Urology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
e Department of Surgery, Zagazig University School of Medicine, Zagazig, Egypt
ARTICLE INFO
Keywords:
Adrenocortical carcinoma Tumor thrombus Inferior vena cava Transplant-based
ABSTRACT
Background and objectives: Adrenal tumors with/out tumor thrombus (TT) in the inferior vena cava (IVC) pose a challenge to the surgeon due to the potential of massive hemorrhage and tumor thromboembolism. We report our experience in managing different types of adrenal tumors.
Methods: From 11/1996-5/2015, 33 patients underwent resection of adrenal tumors with/without TT/IVC in 8 and 25 patients, respectively. Transplant-based (TB) techniques were utilized to resect the tumors. Intra- operative as estimated blood loss (EBL) and cardiopulmonary bypass (CPB) use; post-operative as length of hospital stay (LOS); and actuarial survival outcomes were recorded.
Results: Median EBL was 200 cc (10-8,000), tumor size was 9.0 cm (4-25), and LOS was 7days (5-60). Adre- nocortical carcinoma (ACC,11/33) was the commonest type. Three ACC/level IV TT/IVC underwent CPB to extract TT from the right atrium(n = 1), right atrium and right ventricle(n = 1), and right atrium and right pulmonary artery(n = 1), respectively. A complete resection of the adrenal tumors was achieved in all patients, and no deaths were observed in the immediate postoperative period. With a median follow-up of 60 (range: 18-120) months, 4/11 ACC patients have died of their disease. Actuarial survival for ACC patients at 60 months was 57.1 ± 16.4%.
Conclusions: An aggressive surgical approach is the only hope for curing large adrenal tumors with/without TT/ IVC. TB techniques provide excellent exposure to the retroperitoneal space and safe removal of large adrenal masses.
1. Introduction
Adrenal tumors infrequently extend into the inferior vena cava (IVC), although the risk of such occurrence is higher among patients having malignant adrenal tumors [1,2]. Adrenal tumors may also present themselves as large urological malignant disease hosted in the upper abdomen with or without tumor thrombus (TT). Surgery offers the only potential cure for these patients [1,2], and surgeons would agree that the types of surgeries performed to remove these tumors are complex
and require an excellent understanding of the anatomy [1-4].
At our center we developed and currently use an organ transplant- based (TB) approach to help in removing large urological tumors safely and with fewer post-operative complications including estimated blood loss (EBL) and the requirement for blood transfusions [3,4]. The TB approach is based on the use of i) a modified chevron incision extending out laterally to the mid-axillary line, ii) self-retaining re- tractors specifically designed for hepatobiliary and liver transplant surgery, and iii) a variety of maneuvers commonly used in organ
Abbreviations: ACC, Adrenocortical carcinoma; BCS, Budd-Chiari syndrome; CPB, Cardio-pulmonary bypass; CT, Computed tomography; DVT, Deep vein thrombosis; EBL, Estimated blood loss; IVC, Inferior vena cava; MRI, Magnetic resonance imaging; PRBCs, Packed red blood cells; TB, Transplant-based; TEE, Transesophageal echocardiography.
* University of Miami Miller School of Medicine/Jackson Memorial Hospital, Miami, FL, USA.
* Corresponding author. University of Miami Miller School of Medicine, Department of Surgery and Urology, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami Fl., Miami Transplant Institute 1801 NW 9th Ave, 7th Floor Miami, FL 33136, USA. E-mail address: gciancio@med.miami.edu (G. Ciancio).
procurement and transplantation including visceral mobilization, vascular isolation and control, and TT handling when present. A modi- fied chevron incision is made in order to gain better access to the upper abdomen. A self-retaining (Rochard) retractor is used to elevate and evert the costal margins, enabling the diaphragm to be flattened for easier liver mobilization and to provide adequate exposure of the ret- rohepatic IVC. For large right adrenal tumors, i.e., those behind the retrohepatic IVC, conventional liver mobilization, which involves en-bloc mobilization of the liver and IVC off the posterior body wall, provides excellent exposure of the retrohepatic IVC, allowing the pri- mary tumor to be accessed more easily. The stomach, pancreas, spleen, and liver (if needed) are mobilized for large left adrenal tumors by applying the same surgical techniques used to retrieve the pancreas and liver for transplantation.
In dealing with the TT inside the IVC, the liver is further mobilized off the IVC so that it becomes only attached to the IVC by the major hepatic veins (the “piggyback” technique of liver transplantation). Small hepatic veins are ligated and divided to allow maximum liver mobili- zation and exposure of the IVC. A plane between the IVC and posterior abdominal wall is then created to achieve circumferential vascular control of the IVC. This step is crucial, especially if the TT is adherent to the IVC wall and requires excision and graft placement [1-4].
The proper surgical technique has to provide both adequate exposure and vascular control in order to avoid massive hemorrhage and death, and the TB approach facilitates its use in patients having adrenal tumors with or without TT. We need to provide a measure of safety, with decreased blood loss and cancer control in our commitment to bring no harm to the patient. Here, we describe our experience in the manage- ment of 33 patients with different types of adrenal tumors with and without IVC TT utilizing a transabdominal approach and TB approach, applying surgical principles from the fields of urologic oncology and transplantation maneuvers.
2. Materials and methods
From November 1996 to May 2015, 33 patients underwent resection of adrenal tumors. The study was performed in accordance with the ethical standards of the University of Miami Institutional Review Board and the Helsinki Declaration (as revised in 2013). Informed consent was given, including the complexity of the surgery and emphasizing the risks associated with bleeding and tumor embolization to the pulmonary arteries.
Initial diagnosis was made by computed tomography (CT). Cardiac, renal, and respiratory status were evaluated pre-operatively. The level of the thrombus was confirmed in 4 patients with magnetic resonance imaging (MRI). The cranial extent of the tumor was defined per our own classification for adrenal tumors with TT [2]. Clinical and pathological staging were performed using the TNM classification. Preoperative embolization was not performed in any of the patients [5].
Eight patients had extension of TT into IVC; classified as level IV (atrial) TT in 4 patients, level IIIb (Supradiaphragmatic Infra-atrial) TT in 1 patient, level IIIa (Suprahepatic Infradiaphragmatic) TT in 1 pa- tient, level II TT (Intrahepatic) in 1 patient, and level Ia (renal vein) TT in 1 patient [2]. Twenty-five patients had no TT in IVC. All patients were managed by a transabdominal approach, and only 3 patients had bypass maneuvers (each of these 3 patients had a level IV TT). The tumor was on the right side in 23 patients, on the left side in 9 patients, and bilateral in 1 patient.
Transesophageal echocardiography (TEE) was used to monitor TT in the 8 patients having adrenal tumors with TT. TEE helps in delineating the cranial extent of TT and is therefore critically helpful in the surgical management of these patients [6]. Cell saver was used in 2 patients with atrial tumor thrombus.
2.1. Operative technique
The surgical technique, for both right and left adrenal tumors, has been described previously [1-3,7]. First, a sub-costal incision was made commencing approximately 2 fingerbreadths below the right or left costal margin (according the tumor location), extending out laterally to the mid-axillary line. A Rochard self-retaining retractor was then placed, elevating the costal margins and splaying them laterally toward the axillae.
We pursued early intraoperative ligation of the involved adrenal arteries (Fig. 1A). The adrenal gland was mobilized medially with the liver or en bloc with the spleen and pancreas until the adrenal artery (including, in some instances, the renal artery) was identified and ligated using the same principles in dealing with large renal tumors with or without TT [8]. Arterial ligation resulted in decompression of collateral circulation, decreasing blood loss, which is very important in order to avoid the need for blood transfusions.
With the transabdominal approach, exposure of the left adrenal gland begins by mobilization of the descending colon. The spleen is dissected off the diaphragm and mobilized en bloc with the pancreas toward the midline. This exposes the entire upper retroperitoneal space from the diaphragm to the superior border of the left kidney.
Exposure of the right adrenal gland starts with liver mobilization, beginning with dissection of the ligamentum teres, which is divided. The falciform ligament is divided with cautery, and this incision is carried around the right superior coronary ligament, bypassing the left side, and dividing the left triangular ligament. The visceral peritoneum to the right of the hepatic hilum and the infrahepatic vena cava is incised in conjunction with the right inferior coronary and hepato-renal ligaments. The liver is gradually rolled to the left [9]. Liver mobilization allows adequate exposure of the upper abdomen and retroperitoneum and fa- cilitates removal of large urological masses [1-4]. For a Level III-IV TT, an opening in the lesser omentum allows the porta hepatis to be controlled with a Rummel tourniquet; a Pringle maneuver can then be carried out (temporarily occluding the portal venous and arterial inflow to the liver) as required. We then proceed with the “piggyback” liver transplant technique. The term “piggyback” is used, because the re- cipient’s vena cava is left in situ and the liver is mobilized off the IVC [1-4]. Small hepatic veins passing from the right and caudate lobe are ligated and divided. The liver is dissected off the IVC until it lies in a “piggyback” fashion, attached to IVC only by the major hepatic veins.
In this fashion, the infrahepatic, intrahepatic, and suprahepatic portions of the IVC are completely exposed. In addition to mobilizing the liver off the cava, creating a plane between the IVC and the posterior abdominal wall is important, because it permits circumferential vascular control of the IVC. In particular, small tributaries can become engorged to look like lumbar vessels, and they need to be identified and ligated.
A useful technique, which we have applied for a thrombus located above the hepatic veins, is to milk the thrombus below the major hepatic veins and then apply a vascular clamp just below the major hepatic veins [1-4,9]. This “milking” maneuver is often feasible to perform, since ligation of the adrenal arteries reduces the blood supply to the TT. It serves a dual function. First, it allows the liver to drain into the IVC avoiding hypotension from decreased venous return. Second, by not clamping the major hepatic veins or porta hepatis, liver congestion and postoperative hepatic dysfunction are avoided.
The surgeon must be careful when touching the TT to avoid dis- lodging it. The Pringle maneuver is then performed to temporarily occlude the vascular inflow to the liver. The infrarenal cava is controlled, a Satinsky clamp is placed across the suprahepatic IVC, and for a left adrenal tumor with TT, the right adrenal vein is clamped. The IVC is incised from the major hepatic veins to the right adrenal vein, and the tumor is sharply dissected off the IVC. The three major hepatic veins can be directly visualized, their orifices inspected, and tumor is then removed if it is invading them. Following removal of the TT and closure of the upper IVC, the clamp is repositioned below the hepatic veins, the
3
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RV
A
TT
A
AT
TTMHV
C
B
Pringle is released, and normal liver blood flow is reestablished [1-5]. The remaining IVC below the hepatic veins is sutured closed. Fig. 1B shows an adrenal tumor and the TT going into the right atrium and ventricle, and major hepatic veins.
In the other 25 adrenal tumors without TT, the size of the tumor was a major problem (Fig. 1C). For a right or left side adrenal tumor, the liver or en bloc pancreas-spleen [1-4,7-9] was mobilized, respectively, as a first step to increase exposure of the retroperitoneal space. This allowed for the tumor to be more easily mobilized and visualized, and to facili- tate access to the adrenal artery or arteries as a second step. Once the adrenal artery or arteries were ligated and divided, the surgery was then easier to perform and with minimal blood loss. Evicel® was used over the remnant of the renal hilum, renal fossa, and along the cavotomy of the IVC.
2.2. Intraoperative and postoperative variables
The intraoperative variables including operative time, EBL as well as whether the cell-saver was used, the use of cardio-pulmonary bypass (CPB), and whether or not Budd-Chiari syndrome (BCS) developed were recorded. Postoperatively, cardio-pulmonary complications, deep vein thrombosis (DVT), extended ileus, length of hospital stay, and tumor histology were noted.
2.3. Statistical methods
Medians and ranges for selected baseline characteristics were re- ported as descriptive statistics in this study. For the subset of 11 patients having adrenocortical carcinoma (ACC), actuarial survival following surgery was estimated using the Kaplan-Meier technique.
3. Results
Thirty-three patients underwent radical adrenalectomy with a me- dian age of 52.6 (range:15.9-80.3) years. Females comprised 57.6% (19/33). Median tumor size was 9.0 (range: 4.0-25.0) cm. Eight of the 33 patients had radical adrenalectomy along with resection of tumor/ blood thrombus from the IVC (tumor characteristics and intraoperative/ postoperative outcomes for the 8 patients having an adrenal mass and TT are displayed in Table 1). For these 8 patients having an adrenal mass and TT, the level of TT on CT/MRI correlated well with the intra- operative findings. One of these patients was a female with virilizing testosterone producing ACC with level IV TT and pulmonary emboli in the right pulmonary artery. All 8 patients underwent complete extrac- tion of TT from the IVC, with no newly detectable pulmonary emboli by TEE.
Median EBL (available in 31/33 patients) was 200 (range: 10-8,000) cc. Twenty-seven patients (81.8%) did not require blood transfusions. Two patients required 2 units (U) of packed red blood cells (PRBCs) during surgery, and one patient received 2 U PRBCs immediately before surgery. Three patients with adrenocortical carcinoma (ACC) and level IV TT underwent CPB to extract the TT from the right atrium and right pulmonary artery (due to pulmonary emboli detected prior to surgery) in one patient, from the right atrium and right ventricle in another pa- tient, and from the right atrium in the third patient. As shown in Table 1, EBL for these 3 patients was 6000, 8000, and 4500 ml, respectively. All 3 patients received cell saver blood (600 cc, 650 cc, 900 cc, respectively) and 10 U, 12 U and 16 U of PRBCs during surgery, respectively. For one additional patient with an infarcted adrenal adenoma and level IV TT, the thrombus was removed from the right atrium without the need of CPB [10]. Median length of hospital stay for the 33 patients was 7 (range: 5-60) days. None of the patients developed DVT or pulmonary emboli in the immediate post-operative period.
| ID | Pathology | TT Cranial Level | Tumor Laterality | Tumor Size (cm) | EBL (ml) | Blood transfusions | OR time (min) | LOS (d) |
|---|---|---|---|---|---|---|---|---|
| #1 | ACC (T4N0) | IV | Right | 20 | 4500 | 10U PRBCs; 2U FFP; 600 cc cell saver | 330 | 60 |
| #2 | ACC (T4N0) | IIIa | Left | 18 | 750 | 0 | 216 | 8 |
| #3 | ACC (T4N0) | Ia | Left | 25 | 500 | 0 | 252 | 7 |
| #4 | ACC (T4N0) | IIIb | Right | 11 | 800 | 0 | 234 | 8 |
| #5 | ACC (T4N1) | IV | Left | 18 | 6000 | 12U PRBCs; | 360 | 15 |
| 100U FFP; 4U Platelets; | ||||||||
| #6 | ACC (T4N0) | IV | Right | 9.7 | 8000 | 650 cc cell saver; 1U Cryoprecipitate 16U PRBCs; 2U Platelets; 9U FFP; 900 cc cell saver; 2U Cryoprecipitate | 395 | 14 |
| #7 | Pheochromocytoma | II | Right | 6 | 300 | 0 | 252 | 7 |
| #8 | Infarcted Adenoma | IV | Right | 5 | 500 | 2U PRBCs | 325 | 7 |
Abbreviations: ACC, Adrenocortical Carcinoma; TT, Tumor Thrombus; ESL: estimated blood loss; U: Unit; PRBCs, Packed Red Blood Cells; FFP, Fresh Frozen Plasma; OR, Operative Time; LOS, Length of Hospital Stay.
a Of note, all patients were advised to start ambulation on the day immediately following surgery. In addition, oral intake for these patients began at approximately 40 h following surgery.
3.1. Budd-Chiari syndrome (BCS)
Three patients had BCS, two with ACC and level IV TT, and one with ACC and level IIIb TT. In one of the 2 patients with ACC level IV TT, the patient necessitated the replacement of IVC with a Gore-Tex® vascular graft; the other patient had IVC filter placement. The last patient just required removal of the TT from the IVC.
3.2. Involvement of other organs
Three patients with large ACC, 9.7 cm/level IV TT, 11 cm/level IIIb, and 15 cm/no IVC TT, respectively, required a right-sided nephrectomy en bloc with the right adrenal tumor. A left-sided nephrectomy was performed in a patient with an 18 cm ACC/level IV TT. Splenectomy was performed in another patient with an 18 cm ACC/level IIIa suprahepatic infradiaphragmatic TT.
Two ACC patients, one with level IIIb TT and the other patient with a 5 cm tumor but no IVC TT, required removal of the right hepatic vein that was full of tumor thrombus. Another patient with a recurrent ACC required replacement of the IVC with a Gore-Tex® vascular graft.
One patient with a 9.5 cm pheochromocytoma required a right ne- phrectomy, and another patient with a 17 cm right myelolipoma required a right nephrectomy with a partial liver resection. In both pa- tients, there was no plane of dissection between the tumor and adjacent kidney; thus, a nephrectomy was required. Of note, the latter patient had bilateral myelolipomas, with the tumor on the left side being 5 cm; a partial adrenalectomy was performed on the left side in the attempt to preserve adrenal tissue.
3.3. Adrenocortical carcinoma (ACC)
There were 11 patients with ACC of which 6 had TT. Two patients had T4N0 with level IV atrial TT, 1 had T4N1 ACC with level IV TT, 1 had T4N0 with level IIIb supradiaphragmatic and infra-atrial, and 1 had T4N0 with IIIa suprahepatic infradiaphragmatic TT. One additional patient had T4N0 with a 25 cm tumor and level Ia adrenal vein TT going into the left renal vein; two surgical attempts at an outside institution had previously been performed on this patient without success to remove the ACC. Despite the size of the adrenal mass, the left kidney was spared during the resection. Complete surgical resection of the ACC tumors was achieved in each of these 11 cases.
Among the 5 patients with ACC and no IVC TT, 2 patients had T2N0,
and 1 had T4N0 with TT extending into one of the hepatic veins of the right lobe; this tumor was resected en bloc with the adrenal mass. Two patients had T4N1 with 3/4 and 4/4 positive lymph nodes, respectively. The fifth patient had a recurrence of ACC after six years of a 5 cm ACC resection.
Of note, one of the ACC patients was a Jehovah’s witness having an 18 cm left ACC with level IIIa suprahepatic infradiaphragmatic TT. This patient’s blood loss was 750 cc, and no cell saver was used.
Post-surgical follow-up was available for each of the 11 ACC patients. Four of these patients died of their disease (at 24, 36, 40, and 48 months post-surgery, respectively); median follow-up among the 7 ongoing survivors was 60 (18-120) months post-surgery. Estimated actuarial survival at 60 months post-surgery for the ACC subgroup was 57.1% ± 16.4% (Fig. 2). Patient survival appeared to be poorer for the 6 ACC patients with TT, as 4 of these patients died of their disease. No deaths have been observed among the 5 patients with ACC and no TT.
One of the patients with ACC and level IV TT had a complicated post- operative course including prolonged intubation, candidemia, acute kidney injury (pre-operative creatinine was 2.0 mg/dl), bilateral pleural effusions, and atrial fibrillation. He was discharged after 60 days with a recovering renal function (creatinine on discharge was 2.2 mg/dl).
1
0.9
0.8
Proportion Alive
0.7
0.6
0.5
0.4
Actuarial Survival at 60mo for 11 Patients having Adrenocortical Carcinoma: 57.1% +/- 16.4%.
0.3
0.2
Patient Survival (N=11, 4 Events)
0.1
0
0
10
20
30
40
50
60
Months since Surgery
Another patient, with ACC and level IV TT including TT in the right pulmonary artery, was left with an open abdomen due to severe edema of the small bowel. The previously mentioned patient had CPB and BCS, and on post-operative day 5 the abdomen was closed; this patient was discharged on post-operative day 15.
Two additional patients developed ileus that resolved with the placement of a nasogastric tube.
3.4. Pathology report
Upon pathological examination, the 33 patients were categorized with the following adrenal tumor types: (1) adrenocortical carcinoma in 11 patients (2/11 were of oncocytic type); (2) pheochromocytoma in 8 patients; (3) myelolipoma in 5 patients (1/5 had a bilateral myeloli- poma); (4) poorly differentiated recurrent ACC in 1 patient; (5) large metastatic renal cell carcinoma in 1 patient (probably, the right adrenal gland was not resected during the original right nephrectomy); (5) low grade lymphoma in 1 patient; (6) adrenal gland with pseudocyst and hemorrhage in 1 patient; (7) angiomyelolipoma in 1 patient; (8) lip- osarcoma in 1 patient; (9) adrenal oncocytic neoplasm in 1 patient; (10) glioneuroblastoma in 1 patient; (11) infarcted adenoma in 1 patient who had a blood thrombus extending all the way into the right atrium.
One patient with ACC level Ia TT had a right temporal metastasis removed at 1 year following the original surgery.
One patient with malignant pheochromocytoma had metastatic pheochromocytoma to the right femoral head and the thoracic vertebrae spine (T1) at 4 and 4.5 years after the initial tumor resection, respectively.
4. Discussion
The surgical procedures for patients presenting with a large adrenal tumor with possible extension into the IVC are high-risk, complex, and challenging due to the association of such tumors with difficult to reach exposures, multiple venous collaterals, risk of developing pulmonary emboli, and major perioperative blood loss. Although these procedures are difficult to perform, and with high risk, surgery is the only viable option that exists today for attempting a cure in any patient having one of these complex adrenal tumors.
We describe in this report a variety of adrenal tumors which are not very common. For instance, ACC is a rare urological malignancy, and the surgical approach is very demanding as often the tumors present as large invasive masses adherent to surrounding tissues and organs, carrying a poorer prognosis [11]. All 11 patients in our cohort having ACC tumors, including 6 patients with TT (level IIIa in 1, IIIb in 1, and IV in 3, with one of these patients also having pulmonary emboli in the right pul- monary artery), had complete surgical resection of their tumors. The presence of IVC TT made the surgery more demanding and complex, and the use of an organ TB approach allowed for safe removal of the TT in each case. While Laan at el justified their attempt of complete resection in 28 patients having ACC with IVC TT, survival beyond 36 months was limited [12].
Pheochromocytoma is a rare neuroendocrine tumor, and one of the 8 patients in our cohort with this tumor type had a level II TT. Bai at el [13] reported their experience with a large series of 262 patients with pheochromocytoma, and none had a TT. Five patients in our cohort had adrenal myelolipomas, which is a benign non-functional neoplasm with both fatty and myeloid tissue [14]; none of these patients had a TT. Thus, the occurrence of TT in patients with one of these two adrenal tumor types is quite rare.
When dealing with adrenal tumors that include TT, the critical part of the operation is the management of the IVC [1-3]. Two important goals are to minimize bleeding and to prevent the development/lodging of pulmonary emboli from the TT during surgery, either of which can lead to fatal consequences. At the same time, another goal is to minimize the use of the cell saver, especially for patients having more aggressive
malignant tumors.
Patients with renal cell carcinoma (RCC) and a more proximal level TT, particularly those having level IV TT who require CPB, are known to be at higher risk of experiencing major bleeding during surgery [4]. A similar phenomenon was observed here for the 3 ACC patients with a level IV TT that required CPB. In that RCC study [4], the organ transplant-based approach was shown to significantly reduce major bleeding in the more proximal level tumors and was also associated with minimizing the use of CPB [4].
Over the years, we have developed several approaches to aid in the safe removal of these tumors. The improvements in surgical technique have often been achieved due to the application of surgical principles from different disciplines. We blended lessons learned in the fields of liver transplant surgery and urologic oncology to deal with large renal tumors and TT extending into the IVC. The concept of resorting to an entirely intra-abdominal approach without CPB or veno-venous bypass is the byproduct of this approach [4,15,16].
An important principle of our surgical approach includes mobiliza- tion of the adrenal mass with early ligation of the arterial supply to the adrenal gland/tumor. The adrenal mobilization begins laterally and proceeds posteriorly paying special attention to ligate perirenal collat- eral circulation. With the posterior approach, fewer varices are encountered as opposed to dissection anterior to the adrenal. Once the adrenal gland is mobilized medially, the arterial supply is identified, ligated and divided. The collateral circulation quickly collapses, making the rest of the dissection easier. In fact, this approach has the same effect as performing preoperative embolization but without its known morbidity risks [8].
Our experience affirms the safe use of an organ TB approach for resection of adrenal tumors without/with TT extending into the IVC [4]. The organ TB approach also helps facilitate the resection of large adrenal tumors by increasing exposure of the retroperitoneal space. The current study is the largest series reporting a variety of adrenal tumors with- out/with TT resected safely and without the use of large amounts of blood products in an almost bloodless field due to early ligation of the adrenal arteries.
5. Conclusions
A trans-abdominal surgical incision using a TB approach to adrenal tumors with or without tumor thrombus in the IVC can provide the surgeon with good exposure of the retroperitoneal space with minimal blood loss during surgery and the development of fewer post-operative complications. The use of liver and IVC mobilization techniques helps achieve additional exposure and enables the surgeon to have excellent control of the IVC for safe resection of these tumors. Early ligation of the adrenal artery/arteries help decrease blood loss and avoids the need for arterial embolization.
Authorship
Gaetano Ciancio,1,2,3 Ahmed Farag,1,2,3 Javier Gonzalez,1,2,3 and Jeffrey J. Gaynor1,2,3
1The conception and design of the study, or acquisition of data, or analysis and interpretation of data.
2Drafting the article or revising it critically for important intellectual content.
3Final approval of the version to be submitted.
Authorship contributions
Gaetano Ciancio: Conceptualization, Methodology, Investigation, Writing - Original Draft, Visualization, Supervision, Formal analysis; Ahmed Farag: Conceptualization, Methodology, Investigation, Writing - Original Draft, Visualization, Supervision, Formal analysis; Javier
Gonzalez: Conceptualization, Methodology, Investigation, Visualiza- tion; Jeffrey J. Gaynor: Conceptualization, Methodology, Investigation, Writing - Original Draft, Visualization, Supervision, Formal analysis.
Declaration of competing interest
None.
Acknowledgment
There were no funding nor personal resources to declare for the performance of this study.
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