Hepatic tumour resection with profound hypothermia and circulatory arrest

Cardiopulmonary bypass as an adjunct for the noncardiac surgeon

The use of cardiopulmonary bypass (CPB) in noncardiac surgical settings has been increasingly developed and has greatly benefited noncardiac surgeon. A few years after the advent of CPB as well as profound hypothermic circulatory arrest in the early years, it was employed by neurosurgeons in cerebrovascular surgery and by general thoracic surgeons in carinal tumor resection. Indications for CPB were extended and modified year after year. It has facilitated not only the surgical management by surgeons of lesions that cannot be managed safely and effectively by conventional techniques, or conventional techniques carry significant risks to the patient, but also the preservation of the viability of multiple organ procurement, the practice of isolated limb perfusion for the treatment of malignancies of the extremities, and emergent cardiopulmonary resuscitation. Owing to the complications arising from CPB and profound hypothermic circulatory arrest, such as postoperative bleeding, coagulopathy, and neurologic deficits, efforts have been made to avoid these common hazards. Thus, innovative techniques including extracorporeal membrane oxygenation, percutaneous cardiopulmonary support, venovenous bypass, normothermic CPB, and minimally invasive approaches have emerged and played an important role as alternatives of standard CPB in decreasing morbidity and mortality and improving survival.

Continuing Experience with Liver Resection and Vena Cava Reconstruction using Cardiopulmonary Bypass and Hypothermic Circulatory Arrest

When the suprahepatic vena cava or the hepatic vein confluence with the inferior vena cava (IVC) is obscured by tumor or a clot in the IVC extends above the liver, cross-clamping the IVC during liver or retroperitoneal resection is hazardous. This report describes a 10-year experience with ten patients who had liver (seven) or retroperitoneal (three) resections with vena cava reconstruction using cardiopulmonary bypass and hypothermic circulatory arrest. There were no perioperative deaths. Morbidity consisted of prolonged bile leak (one), pulmonary embolism (one), and stroke (one). Control of the liver was secured in six of seven patients who had a liver resection. There were three significant advantages to this technique. First, the median sternotomy provided superior exposure to the suprahepatic IVC. Second, the bypass technique avoided the risks of hemodynamic instability and prevented air embolism and sudden uncontrolled hemorrhage incurred by resection or IVC cross-clamping. Third, hypothermia provided a method of protection for residual liver function especially in the face of chronic liver disease induced by infection or chemotherapy.

Surgical treatment for recurrent hepatocellular carcinoma with tumor thrombi in right atrium: using cardiopulmonary bypass and deep hypothermic circulatory arrest

Tumor in the right atrium creates a life-threatening condition and should be removed immediately. A cirrhotic patient who had recurrent hepatocellular carcinoma (HCC) over remnant liver with tumor thrombi extending to inferior vena cava (IVC) and right atrium presented with impending congestive heart failure. The recurrent tumor and its thrombi were successfully resected en-bloc using cardiopulmonary bypass and hypothermic circulatory arrest. Although the patient's disease-free and actual survival time were only 6 months and 14 months, respectively, he was rescued from heart failure. This aggressive surgical strategy creates further possibility to treat such advanced HCC cases. Further investigations regarding adjuvant therapies in these circumstances, however, are necessary.

Cardiopulmonary bypass, profound hypothermia, and circulatory arrest for neurosurgery

Six female and 4 male patients (age, 23 to 75 years) underwent operation for difficult intracranial lesions. Preoperative diagnoses included four giant intracranial aneurysms, three base of skull glomus jugulare tumors, two arteriovenous malformations, and one cerebellar hemangioblastoma. All lesions were inoperable or nearly so by standard neurosurgical techniques. All patients were placed on total bypass via groin cannulations. Bypass times ranged from 111 to 269 minutes (mean, 174 minutes) with cooling times of 26 to 83 minutes (mean, 48 minutes) and warming times of 68 to 110 minutes (mean, 83 minutes). Circulatory arrest times ranged from 1.25 to 60 minutes with 1 patient not requiring arrest. The lowest core temperatures recorded varied from 8.4 degrees to 13.7 degrees C. There was one postoperative death and one major complication, both in patients with arteriovenous malformations. Eight patients (80%) have achieved an excellent result. Profound hypothermia with the option of circulatory arrest and exsanguination has been an indispensable adjunct to the safe management of intracranial aneurysm, glomus jugulare tumor, and hemangioblastoma.