European Journal of Cardio-Thoracic Surgery, Vol 12, 127-132, Copyright © 1997 by European Association for Cardio-thoracic Surgery
Resection of hypernephromas with vena caval or right atrial tumor extension using extracorporeal circulation and deep hypothermic circulatory arrest: a multidisciplinary approach
A Welz, N Schmeller, C Schmitz, B Reichart and A Hofstetter
Department of Cardiac Surgery, Grosshadern Clinics, Ludwig-Maximilians- University Munich, Germany.
OBJECTIVE: Among retroperitoneal tumors, renal cell carcinoma most often
invades the retrohepatic inferior vena cava or the right atrium. Even in
these cases, radical nephrectomy may be performed with curative intention.
The aim of this retrospective study was to elucidate the impact of
cardiopulmonary bypass and hypothermic circulatory arrest on surgical
complications, primary mortality, and long-term survival. PATIENTS AND
METHODS: From Jan. 1981 till Aug. 1996, 44 patients were operated upon for
renal cell carcinoma with advanced vena caval extension. The patients were
divided into two groups. In 19 cases (Cardiopulmonary Bypass Group),
extracorporeal circulation and deep hypothermic circulatory arrest was
used. The Conventional Technique Group comprised 25 patients who had
radical nephrectomy, paraaortic lymphadenectomy and extirpation of the
intracaval tumor thrombus applying common principles in vascular surgery.
The median age was 59 years with a range from 42 to 78 years in the
Cardiopulmonary Bypass Group, and 60 years, ranging from 22 to 72 years, in
the Conventional Technique Group. In addition, both groups did not differ
in gender, UICC TNMG staging classification, and perioperative risk
factors. A review of the patient charts was done and surveys were sent to
survivors or nearest of kin. Wilcoxon test and log-rank test were used as
appropriate. RESULTS: A lower intraoperative complication rate was found in
patients who had surgery using cardiopulmonary bypass. This was especially
true with embolization of the tumor thrombus into the pulmonary arteries:
0.0% in Cardiopulmonary Bypass Group and 16.0% in Conventional Technique
Group (P < 0.05). Severe hemorrhage occurred in 10.5% (Cardiopulmonary
Bypass Group) and 16.0% (Conventional Technique Group). This translated
into a significantly lower perioperative mortality in the Cardiopulmonary
Bypass Group when compared to the Conventional Technique Group (5.6 and
16.0%, respectively). In spite of these results, differences in long-term
survival did not reach statistical significance. But, a trend to superior
long-term survival was apparent. The mean survival was 1289 +/- 278 days in
the Cardiopulmonary Bypass Group and 746 +/- 166 days in the Conventional
Technique Group. CONCLUSIONS: Due to acceptable long-term results, the
resection of hypernephromas showing extensive vena caval invasion seems to
be justified. The use of cardiopulmonary bypass and hypothermic circulatory
arrest is able to decrease primary morbidity and mortality. However, the
influence on long-term survival remains to be proven.
