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a Departments of Cardiothoracic and Vascular Surgery, All India Institute of Medical Sciences, New Delhi 110029, India
b Department of Urology, All India Institute of Medical Sciences, New Delhi 110029, India
(Email: ujjwalchow{at}rediffmail.com; ujjwalchowdhury{at}gmail.com).
We thank Drs Ciancio and Salerno [1] for their interest in our article [2] and the editor for giving us the opportunity to reply. We are aware of the new classification and "piggyback liver transplantation techniques" introduced by them to aid in the surgical management of renal cell carcinoma (RCC) [3, 4].
Although level I and level II tumor thrombi have standardized management protocol, optimal operative approach for suprahepatic, supradiaphragmatic (level IIID and level IV) tumor thrombi is debatable [2–6]. Prevention of major bleeding, embolism from the tumor thrombus, and hepatic and renal dysfunction during dissection has required the development of different techniques to manage these problems [2–6].
We performed tumor thrombectomy in a total of 67 patients of RCC with inferior vena cava (IVC) thrombus (level I, 19 patients; level II, 40 patients; and level III, 8 patients) between January 1996 and June 2007 at All India Institute of Medical Sciences [5, 6]. We published the technical details of intrahepatic IVC dissection for tumor thrombectomy on 8 patients with nonadherent level III IVC thrombus as an alternative to veno-venous bypass [5, 6]. In 2 patients with level IIID tumor thrombus, we had performed a modified thoracoabdominal approach controlling IVC at the cavoatrial junction intrapericardially [7].
Therefore, we concur with the observations of Ciancio and Salerno [1] that cardiopulmonary bypass (CPB) can be avoided for the majority of cases of RCC with IVC thrombus. However, we believe that there is no foolproof formula for choosing an optimal surgical approach in selecting a patient for level IV tumor thrombectomy with or without CPB. The management strategy does depend on the cranial extent of IVC thrombus and the degree of vessel and right atrial (RA) wall invasion.
The cohort of 6 patients described in this publication underwent radical nephrectomy with tumor thrombectomy from the IVC and RA under mild hypothermic CPB and intermittent cross-clamping of the supraceliac abdominal aorta [2].
All patients had varying degrees of IVC and RA wall invasion and 1 patient required partial excision of IVC and pericardial patch reconstruction. The tumor thrombus was extended almost half the RA cavity in 2 patients and required pulmonary artery (PA) clamping to protect from pulmonary embolism during mobilization. Any attempt at milking the tumor down would have resulted in a tear of the IVC and RA wall or left behind residual tumor material, or both. All patients demonstrated varying degrees of tumor permeation within the hepatic veins that were removed under direct vision using Russian forceps and suckers.
Despite the usefulness of magnetic resonance imaging and intraoperative transesophageal echocardiography in detecting adherence of caval thrombus, the feasibility of tumor thrombectomy with or without excision of IVC and RA wall is best assessed during surgery [2].
In the series described by Ciancio and associates [4] between 1997 and 2005, 66 patients underwent nephrectomy with vena caval thrombectomy. The extent of tumor thrombus reported was renal in 13 patients, infrahepatic in 7, retrohepatic in 38, and intra-atrial in 8. Tumor thrombectomy was performed in 63 patients without using CPB. Out of 8 patients with level IV intra-atrial tumor, 5 patients underwent thrombectomy by the "piggyback liver mobilization technique," and 3 patients required CPB assistance for tumor involvement of the RA wall [4].
For level IV tumors, the reported mean blood loss was 6,100 ± 2,162.6 mL (range, 500 to 20,000 mL). One patient with level III tumor who underwent surgery died on postoperative day 7 possibly due to massive pulmonary embolism. This patient incidentally had an unresectable tumor and was treated by a non-CPB approach [4]. One patient with level IV tumor undergoing tumor thrombectomy using CPB and circulatory arrest had 20,000 mL blood loss and died of coagulopathy [3].
In our study the mean intraoperative blood loss was only 492 ± 73.6 mL (range, 400 to 600 mL). There was no hospital death. At a mean follow-up of 43 ± 24.6 months (range, 10 to 70 months), all patients are active and remain disease-free [2].
These data further support our approach of using CPB, mild hypothermia, and intermittent supraceliac abdominal aortic occlusion for level-IV IVC thrombus. This provided an adequate bloodless field and allowed complete removal of intracardiac and vena caval tumor thrombi with or without vena caval reconstruction.
We conclude that the CPB and non-CPB approaches should be treated as complementary rather than rival techniques. Appropriate case selection should guide the proper technique to be adopted in an individual patient.
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