Clinical results of surgery for retroperitoneal sarcoma with major blood vessel involvement

A three-decade experience of radical open endvenectomy with pericardial patch graft for correction of Budd-Chiari syndrome

BACKGROUND

We previously reported the value of our operative procedure for Budd-Chiari syndrome (BCS) that comprised reconstruction of the occluded or severely stenosed inferior vena cava (IVC) using an autologous pericardium patch and reopening as many occluded hepatic veins as possible. Here, we present the long-term durability and efficacy of the autologous pericardium patch for reconstruction of the IVC in BCS.

METHODS

We retrospectively analyzed a series of 53 consecutive patients (mean age, 48.4 +/- 12.8 years; range, 24-76 years; 34 men) who underwent surgical treatment for BCS at our institution from 1979 to 2008. Patency of the IVC and hepatic veins was examined by venography at discharge. Patients attended an outpatient clinic every 1 or 2 months for follow-up. The reconstructed IVC was evaluated by enhanced computed tomography every 1 or 2 years.

RESULTS

Two in-hospital (operative mortality, 3.7%) and 15 late deaths occurred. During a mean follow-up of 7.6 +/- 6.5 years (range, 0.08-24.1 years), the reconstructed IVC became totally obstructed in three patients, of whom two underwent reoperation, and severely stenosed in two patients, who required percutaneous transvenous balloon venoplasty (PTV). The 5- and 10-year patency rates without reoperation or PTV for the reconstructed IVC were 90.5% and 84.3%, respectively. The cumulative 5- and 10-year survival rates were 89.8% and 70.7%, respectively.

CONCLUSION

The autologous pericardium patch is effective and durable for reconstructing a diseased IVC in BCS.

A cylindrical femoral vein panel graft for caval reconstructions

This report describes a simple venous reconstructive technique that results in an autogenous vascular graft with sufficient luminal diameter for replacing the vena cava. The majority of vena caval reconstructions are performed using prosthetic grafts; however, graft infection is a concern in clean-contaminated hepatobiliary and retroperitoneal resections.

The role of surgical margin status in retroperitoneal sarcoma

Retroperitoneal sarcomas (RPS) represent approximately 15% of all soft tissue sarcomas (STS). Clinical and prognostic features as well as oncologic outcomes are well known in this group of patients. Post-operative margin status specifically, is a major predictor of local and distant recurrence and survival. The purpose of this review is to define complete resection as it applies to RPS and evaluate its effect on future outcomes in these patients.

Pancreatic and multiorgan resection with inferior vena cava reconstruction for retroperitoneal leiomyosarcoma

BACKGROUND

Inferior vena cava (IVC) leiomyosarcoma is a rare tumor of smooth muscle origin. It is often large by the time of diagnosis and may involve adjacent organs. A margin-free resection may be curative, but the resection must involve the tumor en bloc with the affected segment of vena cava and locally involved organs. IVC resection often requires vascular reconstruction, which can be done with prosthetic graft.

CASE PRESENTATION

We describe a 39-year-old man with an IVC leiomyosarcoma that involved the adrenal gland, distal pancreas, and blood supply to the spleen and left kidney. Tumor excision involved en bloc resection of all involved organs with reimplantation of the right renal vein and reconstruction of the IVC with a polytetrafluoroethylene graft. The patient recovered without renal insufficiency, graft infection, or other complications. Follow-up abdominal imaging at 1 year showed a patent IVC graft and no locally recurrent tumor. Prosthetic graft provides a sufficient diameter and length for replacement conduit in extensive resection of IVC leiomyosarcoma.

CONCLUSION

To our knowledge, this is the first case of resection of an IVC sarcoma with prosthetic graft reconstruction in combination with pancreatic resection. Aggressive surgical resection including vascular reconstruction is warranted for select IVC tumors to achieve a potentially curative outcome.

Current concepts in the management of retroperitoneal soft tissue sarcoma

Soft tissue sarcomas (STS) in the retroperitoneum are usually diagnosed at the late stages. Surgery is the mainstay of treatment. The technique of resection is standardized. After dissection of the retroperitoneal blood vessel, a retroperitoneal plane of dissection adjacent to the spinal foramina is established in between the layers of the abdominal wall. Complete resection with tumor-free resection margins is the primary goal in retroperitoneal sarcoma surgery. Preoperative assessment of pathoanatomical growth patterns with respect to retroperitoneal vascular structures--as well as to visceral and retroperitoneal organs--influences surgical strategies and thus the surgical outcome. Blood vessel replacement and a multivisceral en bloc approach improve the quality of resection. Blood vessel involvement is stratified in type I (arterial and venous involvement), type II (arterial involvement), type III(venous involvement), and type IV (no vascular involvement). Adjuvant and neoadjuvant treatment options (chemotherapy, targeted therapy, and radiation therapy) are currently being investigated. A prospective randomized phase III trial has shown a positive effect of neoadjuvant chemotherapy combined with regional hyperthermia in disease-free survival, response rate, and local control. Subsets of liposarcomas (myxoid and round cell type) are selectively responsive to novel drugs, such as trabectedin, a DNA-binding agent. Radiotherapy is applied in higher-grade locally advanced retroperitoneal STS. The optimal technique of delivering radiotherapy remains to be determined. The restricted number of patients with retroperitoneal STS and unsatisfying results in local tumor control and long-term survival indicate the need for multi-institutional cooperative studies. An international effort is required to improve the evidence level on multimodal treatment algorithms.

Repair of the inferior vena cava with autogenous peritoneo-fascial patch graft following abdominal trauma: a case report

Abdominal vascular injuries are among the most challenging and lethal injuries in traumatized patients. Inferior vena cava is the most frequently injured vein during the blunt or penetrating trauma. The primary repair, end to end anastomosis, endovascular stenting, or graft interposition with autogenous or synthetic materials should be considered in selected cases. However, in cases the synthetic graft was preferred, intestinal contaminations due to small or large bowel perforation accompanying the trauma have been cited as a limiting factor for the use of such grafts as in the current case. However, a previous history of lower leg variceal surgery prevents the use of great saphenous vein as a graft. So in the present case, the authors report a patient with inferior vena cava injury repaired with autogenous peritoneo-fascial graft. The authors have used APF graft in traumatic inferior vena cava injury for the first time.

Resection of malignant tumors invading the vena cava: perioperative complications and long-term follow-up

OBJECTIVE

Invasion of the vena cava by malignant tumors is generally considered an absolute contraindication for surgery as a result of high surgical risk. Surgical treatment with resection of the vena cava may be beneficial for selected patients. This study was performed to evaluate our experiences with resection of the vena cava for malignant tumors, with a special focus on secondary tumors involving the inferior caval vein.

METHODS

A total of 35 patients underwent extended resection of malignant tumors invading the vena cava. Prosthetic repair was performed in 13 patients by using a ringed polytetrafluoroethylene graft. Preoperative risk factors, mortality and morbidity, and long-term follow-up and graft patency rates were examined.

RESULTS

The operative mortality rate was 6%. Minor complications occurred in 12 patients (34%). The graft patency rate was 85%, and there was no graft-related perioperative morbidity. The 1-, 3-, and 5-year survival rates were 76%, 32%, and 21%, respectively, with a median survival of 29 months. Incomplete resection and cardiopulmonary risk have a significant negative effect on survival.

CONCLUSIONS

Radical resection of the vena cava is a feasible procedure in highly selected patients, with low morbidity and mortality and acceptable survival rates, especially in patients with complete resection of the tumor.

Surgical management of 143 patients with adult primary retroperitoneal tumor

AIM: To analyze the surgical management of adult primary retroperitoneal tumors (APRT) and the factors influencing the outcome after operation.

METHODS: Data of 143 cases of APRT from 1990 to 2003 in the First Affiliated Hospital of China Medical University were evaluated retrospectively.

RESULTS: A total of 143 cases of APRT were treated surgically. Among them, 122 (85.3%) underwent complete resection, 16 (11.2%) incomplete resection, and 3 (3%) surgical biopsies. Twenty-nine (20.2%) underwent tumor resection plus multiple organ resections. Ninety-five malignant cases were followed up for 1 mo to 5 years. The 1-year, 3-year, and 5-year survival rates of the patients subject to complete resection was 94.9%, 76.6% and 34.3% and that of patients with incomplete resection was 80.4%, 6.7%, and 0%, respectively (P < 0.001). The Cox multi-various regression analysis showed the completeness of tumor, sex and histological type were associated closely with local recurrence.

CONCLUSION: Sufficient preoperative preparation and complete tumor resection play important roles in reducing recurrence and improving survival.

Vascular reconstruction with the superficial femoral vein following major oncologic resection

INTRODUCTION

Involvement of critical vascular structures has historically been considered a contraindication to tumor resection. This study describes outcomes following radical oncologic resection with concomitant resection of critical vascular structures and reconstruction with the superficial femoral vein (SFV).

METHODS

All patients undergoing radical oncologic resection requiring resection of major vascular structures and concomitant reconstruction using the SFV as conduit were retrospectively reviewed. Primary outcomes were surgical morbidity and mortality; secondary measures included long-term patency and oncologic outcomes.

RESULTS

Seven patients were included. There were three retroperitoneal and two groin sarcomas, and two squamous cell carcinomas metastatic to groin lymph nodes. No perioperative mortality occurred. Five patients experienced minor morbidity. One vein graft in a patient with pre-existing chronic deep venous thrombosis (DVT) occluded post-operatively. No subsequent long-term venous or arterial graft occlusions occurred (median 20.2 months, range 9.0-49.7). Two patients died of tumor recurrence during follow-up.

CONCLUSIONS

Resection of tumors involving critical vascular structures is feasible. The SFV conduit is a versatile option for major vascular reconstruction, providing good long-term patency rates with acceptable morbidity and mortality. Vascular resection and reconstruction with the SFV offers another technique to provide limb-sparing surgery in patients traditionally offered only amputation, while providing favorable oncologic outcomes.

Magnifying endoscopic observation of the gastric mucosa, particularly in patients with atrophic gastritis

The gastric mucosal surface was observed using the magnifying fibergastroscope (FGS-ML), and the fine gastric mucosal patterns, which were even smaller than one unit of gastric area, were examined at a magnification of about 30. For simplicification, we classified these patterns by magnifying endoscopy in the following ways; FP, FIP, FSP, SP and MP, modifying Yoshii's classification under the dissecting microscope. The FIP, which was found to have round and long elliptical gastric pits, is a new addition to our endoscopic classification. The relationship between the FIP and the intermediate zone was evaluated by superficial and histological studies of surgical and biopsy specimens. The width of the band of FIP seems to be related to the severity of atrophic gastritis. Also, the transformation of FP to FIP was assessed by comparing specimens taken from the resected and residual parts of the stomach, respectively. Moreover, it appears that severe gastritis occurs in the gastric mucosa which shows a FIP. Therefore, we consider that the FIP indicates the position of the atrophic border.