Inferior vena cava resection and reconstruction: Technical considerations in the surgical management of renal cell carcinoma with tumor thrombus

Impact of Left Renal Vein Ligation on Renal Function Following En Bloc Resection of Segmental Inferior Vena Cava and Right Kidney

BACKGROUND

Renal function after left renal vein (LRV) ligation following en bloc resection of segmental inferior vena cava (IVC) and right kidney is understudied. We assessed the impact of LRV ligation on postoperative renal function following en bloc resection of segmental IVC and right kidney.

METHODS

We retrospectively reviewed 28 patients who underwent LRV ligation during en bloc resection of segmental IVC and right kidney. Patient demographics, tumor characteristics, intraoperative factors, complications, length of hospital and intensive care unit (ICU) stay, and patient survival were collected. Pre- and postoperative renal function was retrospectively analyzed.

RESULTS

Twenty patients underwent robot-assisted surgery and eight patients underwent open surgery. The median operative time was 162 min and estimated blood loss was 350 mL. Ten patients had normal renal function and 12 patients had an initial increase in creatinine but improved gradually. Six patients developed acute renal failure; five patients gradually recovered in 5-32 days after temporary hemodialysis. Renal replacement therapy significantly correlated with maximal anterior-posterior diameter of the LRV (p = 0.001). Complications were observed in 11 cases, four of which were Clavien-Dindo grades I-II. Thirteen patients were alive with no recurrence, nine patients were alive with metastasis, and six cases died during the follow-up period.

CONCLUSIONS

LRV ligation following en bloc resection of segmental IVC and right kidney is feasible, with no significant long-term impact on renal function. The maximum anterior-posterior diameter of the LRV is a reliable method for predicting renal replacement therapy in the absence of collateral circulation.

Circumferential Inferior Vena Cavectomy Without Caval Replacement in the Management of Renal Cell Carcinoma with Tumor Thrombus

PURPOSE OF REVIEW

Renal cell carcinoma presents a unique proclivity for vascular involvement giving rise to a peculiar form of locally advanced disease so-called tumor thrombus. To date, the only curative strategy for these cases remains surgery, which should aim to remove every vestige of macroscopic disease. Most of the preexisting literature advocates opening the vena cava to allow tumor thrombus removal and subsequent venous suture closure. However, inferior vena cava circumferential resection (cavectomy) without caval replacement is possible in the majority of cases since progressive occlusion facilitates the development of a collateral venous network aimed at maintaining cardiac preload.

RECENT FINDINGS

Radical nephrectomy with tumor thrombectomy remains a surgical challenge not exempt of operative complications even in experienced hands. In opposition to what traditional cavotomy and thrombus withdrawal can offer, circumferential cavectomy without caval replacement would provide comparable or even better oncologic control, decrease the likelihood of operative bleeding, and prevent the development of perioperative pulmonary embolism. This review focuses on the rationale of circumferential IVC resection without caval replacement and the important technical aspects of this approach in cases of renal cell carcinoma with vascular involvement. We also include an initial report on the surgical outcomes of a contemporary series of patients managed under this approach at our center.

The feasibility of contrast-enhanced CT to identify the adhesive renal venous tumor thrombus of renal cell carcinoma

OBJECTIVE

To identify adhesive renal venous tumor thrombus (RVTT) of renal cell carcinoma (RCC) by contrast-enhancement CT (CECT).

MATERIALS AND METHODS

Our retrospective study included 53 patients who underwent preoperative CECT and pathologically confirmed RCC combined with RVTT. They were divided into two groups based on the intra-operative findings of RVTT adhesion to the venous wall, with 26 cases in the adhesive RVTT group (ARVTT) and 27 cases in the non-adhesive group (NRVTT). The location, maximum diameter (MD) and CT values of tumors, the maximum length (ML) and width (MW) of RVTT, and length of inferior vena cava tumor thrombus were compared between the two groups. The presence of renal venous wall involvement, renal venous wall inflammation, and enlarged retroperitoneal lymph node was compared between the two groups. A receiver operating characteristic curve was used to analyze the diagnostic performance.

RESULTS

The MD of RCC and the ML and MW of the RVTT were all larger in the ARVTT group than in the NRVTT group (p = 0.042, p < 0.001, and p = 0.002). The proportion of renal vein wall involvement and renal vein wall inflammation were higher in the ARVTT group than in NRVTT groups (both p < 0.001). The multivariable model including ML and vascular wall inflammation to predict ARVTT could achieve the best diagnostic performance with the area under the curve, sensitivity, specificity, and accuracy of 0.91, 88.5%, 96.3%, and 92.5%, respectively.

CONCLUSION

The multivariable model acquired by CECT images could be used to predict RVTT adhesion.

CLINICAL RELEVANCE STATEMENT

For RCC patients with tumor thrombus, contrast-enhanced CT could noninvasively predict the adhesion of tumor thrombus, thus predicting the difficulty of surgery and contributing to the selection of an appropriate treatment plan.

KEY POINTS

• The length and width of the tumor thrombus could be used to predict its adhesion to the vessel wall. • Adhesion of the tumor thrombus can be reflected by inflammation of the renal vein wall. • The multivariable model from CECT can well predict whether the tumor thrombus adhered to the vein wall.

Surgical treatment of massive pulmonary thromboembolism due to renal cell carcinoma

While renal cell carcinomas frequently invade the renal vein and inferior vena cava, the right atrial extension or formation of bilateral pulmonary massive embolism is quite unusual. A 65-year-old male patient underwent bilateral pulmonary tumor endarterectomy and total thrombectomy of the inferior vena cava combined with left nephrectomy under total circulatory arrest with antegrade cerebral perfusion. Both mediastinal and abdominal approaches facilitated the complete removal of the caval thrombus under the guidance of transesophageal echocardiography. The patient is still under follow-up for six months without metastasis. In conclusion, pulmonary thromboembolism due to renal cell carcinoma is rare, surgical treatment is possible.

En Bloc Resection of Right Renal Cell Carcinoma and Inferior Vena Cava Tumor Thrombus Without Caval Reconstruction: Is It Safe to Divide the Left Renal Vein?

Introduction

It has been suggested that inferior vena cava (IVC) reconstruction following resection of retroperitoneal tumors with IVC tumor thrombus (TT) is not required when adequate collateral circulation is present. There are no reports evaluating mid-term effects on renal function in these patients. The purpose of this study was to assess renal function after en bloc resection of right renal cell carcinoma (RCC) with obstructing IVC TT and the possible risks that may arise after left renal vein division.

Materials and Methods

A bi-institutional retrospective review was performed over a 15-year period, assessing patients with right RCC and obstructing level II–IV TT. All patients underwent extensive evaluation and cardiology clearance, and informed consent was obtained for right radical nephrectomy and thrombectomy with or without IVC reconstruction with possible cardiopulmonary bypass (CPB). Patient demographics, tumor characteristics, intraoperative factors, complications, length of stay, and patient survival were evaluated. Preoperative creatinine was recorded, as was creatinine on the day of discharge and at 6 and 12 months postoperatively.

Results

Twenty-two patients were included in the study. Median age at surgery was 62.5 (range: 45–79) years, and 19 (86%) of the patients were men. One patient (5%) had a level II thrombus, 14 patients (64%) had a level III thrombus (IIIa, n = 3; IIIb, n = 6; IIIc, n = 3; IIId, n = 2), and seven patients (32%) had a level IV thrombus. Intraoperatively, median estimated blood loss was 1.35 (range: 0.2–25) L. The median length of hospital stay was 11 (range: 5–50) days. Median preoperative creatinine was 1.20 (range: 0.40–2.70) mg/dl, and postoperatively, median creatinine was 1.3 (range: 0.86–2.20) mg/dl. Median creatinine levels at 6 months and 12 months postoperatively were 1.10 (range: 0.5–1.8) mg/dl and 1.40 (range: 0.6–2.0) mg/dl, respectively. Four patients died (range: 0.1–1.3 years), and median postoperative follow-up among the 18 ongoing survivors (at last follow-up) was 1.5 (range: 0.5–7.0) years.

Conclusions

Resection of right RCC with an obstructing level II–IV TT without reconstruction of the IVC appears to not have a significant adverse effect on mid-term renal function after division of the left renal vein.

Progressive Obstruction of Inferior Vena Cava by Ameroid Constrictor: The Canine Model of Revealing Hemodynamic and Compensatory Patterns of Tumor Thrombus Formation at The Renal Hilus Level

BACKGROUND

To develop an efficient and stable canine model of IVC progressive obstruction at the renal hilus level.

METHODS

The model was established in two beagles by encircling an ameroid constrictor on the IVC at renal hilus level. Abdominal wall varicosity and animal weight variations were observed weekly after operation. Ultrasound examination was performed weekly after surgery to observe the AC position, the diameter and the velocity in the IVC. Six weeks after surgery, IVC angiography and CT scan were performed to observe the collateral circulation establishment and internal organ variation. Blood samples were taken regularly to monitor for variation in critical biochemical parameters. Renal biopsy was performed at 0, 2, 4, and 6 weeks after surgery.

RESULTS

Superficial varicose veins were observed on the abdominal wall at 2 weeks after surgery. Four weeks after operation, the IVC diameter increased by approximately 30%, whereas the IVC velocity decreased by more than 50%. Collateral circulation was observed by IVC angiography at 6 weeks through multiple dilated veins along with neovascularization. CT scan showed congestive alteration in the kidney. The body weight, kidney, and liver function were not significantly affected. Chronic congestive renal injury was detected in the renal tubular epithelium by kidney biopsy after surgery.

CONCLUSIONS

A canine model of IVC progressive obstruction at renal hilus level was stably and safely established for the first time by using an AC, which may be helpful for preserving pivotal collateral circulation and non-tumor side kidney function in the IVC thrombus surgery.

Influence of Deep Invasive Tumor Thrombus on the Surgical Complexity and Prognosis of Patients With Non-Metastatic Renal Cell Carcinoma Combined With Venous Tumor Thrombus

BACKGROUND

To evaluate the impact of deep invasive tumor thrombus (DITT) on the surgical complexity and prognosis of patients with renal cell carcinoma with venous tumor thrombus.

METHODS

We retrospectively reviewed clinical data of 138 patients with non-metastatic renal cell carcinoma combined with venous tumor thrombus, who underwent surgical treatment in Peking University Third Hospital from January 2015 to June 2020. Patients were divided into the DITT group (84 patients) and non-invasive tumor thrombus (NITT) group (54 patients). Chi-square, t-test and Mann-Whitney U test were used for categorical and continuous variables, respectively. Kaplan-Meier plots were performed to evaluate the influence of DITT. Univariable and multivariable Cox regressions were conducted to determine independent prognostic factors and then assembled to make a nomogram to predict the survival. The performance of the nomogram was evaluated by Harrell's consistency index (C-index) and calibration plot.

RESULTS

Deep invasive tumor thrombus significantly increased the difficulty of surgery for patients with renal cell carcinoma with venous tumor thrombus, which is mainly reflected in longer operation time (p < 0.001), more surgical bleeding (p  < 0.001), a higher proportion of perioperative blood transfusion (p  = 0.006), a higher proportion of open surgery (p = 0.001), a longer postoperative hospital stay (p = 0.003), and a higher proportion of postoperative complications (p = 0.001). DITT (hazard ratio [HR] = 2.781, p = 0.040) was one of the independent risk factors for worse prognosis. Multivariate analysis showed that sarcoma-like differentiation (p = 0.040), tumor thrombus invasion (p = 0.040), low hemoglobin (p = 0.003), and pathological type (p < 0.001) were independent prognostic factors. The nomogram, combining all these predictors, showed powerful prognostic ability with a C-index of 78.8% (CI: 71.2%-86.4%). The predicted risk closely matches the observed recurrence probability.

CONCLUSION

Deep invasive tumor thrombus significantly increased the difficulty of surgeries for patients of renal cell carcinoma with venous tumor thrombus, and may lead to poor prognosis.

Renal cell carcinoma with tumor thrombus growing against the direction of venous return: an indicator of complicated surgery and poor prognosis

PURPOSE

To explore the effect of tumor thrombus growing against the direction of venous return (GADVR) tumor thrombus on the choice of surgical approach, the impact on the complexity of the surgery and the prognosis.

METHODS

We retrospectively analyzed the clinicopathological data of 213 patients, who underwent surgery in a single center of Peking University Third Hospital between January 2016 and June 2020. For right renal cell carcinoma (RCC) and venous tumor thrombus (VTT), imaging revealed a filling defect in the left renal vein, which was significantly enhanced in enhanced imaging, suggesting that the tumor thrombus grew against the direction of venous return into the left renal vein. For left RCC and VTT, at least one of the left renal vein branches has tumor thrombus. The branches include the left adrenal vein, the left gonadal vein (testicular vein or ovarian vein), and the left ascending lumbar vein. The patients were divided into two groups according to whether they were GADVR tumor thrombus, and we compare the clinicopathological characteristics of GADVR tumor thrombus and non-GADVR tumor thrombus. Univariate and multivariate Cox regression analyses were performed to explore the risk factors that affect the prognosis of patients with RCC and VTT. Kaplan-Meier plots were conducted to evaluate the effect of GADVR on progression-free survival (PFS).

RESULTS

Compared with non-GADVR tumor thrombus, patients with GADVR tumor thrombus had a higher proportion of open surgery (76.2% vs. 52.1%, P = 0.035), a higher proportion of tumor thrombus adhering to the inferior vena cava (IVC) vessel wall (81% vs. 45.8%, P = 0.002), a higher proportion of segmental resection of the IVC vessel wall (61.9% vs. 15.6%, P < 0.001); higher preoperative serum creatinine value (110.0 μmol/L vs. 91.0 μmol/L, P = 0.015), a higher proportion of tumor thrombus combined with bland thrombus (non-tumor thrombus) (57.1% vs. 19.8%, P < 0.001). In terms of surgical complexity, patients with GADVR tumor thrombus had a longer median operation time (379 min vs. 308 min, P = 0.038), more median surgical blood loss (1400 mL vs. 600 mL, P = 0.018), and more postoperative complications (52.4% vs. 30.7%, P = 0.045). Multivariate Cox regression analysis showed that GADVR tumor thrombus, symptoms, postoperative serum creatinine, distant metastasis, sarcomatoid feature, pathological type, lymph node dissection were independent risk factors for PFS. Patients with GADVR tumor thrombus's median survival time was 14.0 months, while patients with non-GADVR tumor thrombus were 32.0 months (P = 0.016). GADVR tumor thrombus is an independent risk factor for PFS in patients with RCC and VTT.

CONCLUSION

GADVR tumor thrombus is a characteristic feature of tumor thrombus, with an incidence of 9.9%. It has a higher proportion of open surgery and higher surgical complexity, which is an independent risk factor for PFS.

Inferior vena cava interruption in renal cell carcinoma with tumor thrombus: surgical strategy and perioperative results

Background

To analyze the influence of inferior vena cava (IVC) interruption for perioperative and oncological results in patients with renal cell carcinoma and tumor thrombus and summarize the surgical strategies of IVC interruption for different situations.

Methods

We retrospectively analyzed the clinical and pathological data of 103 patients in our center. Patients were divided into two groups with 32 cases (31.1%) underwent IVC interruption (Group 1) while 71 cases (68.9%) did not. For comparison of continuous variables, the Mann–Whitney U test was used. For comparison of categorical variables, Chi-square tests were used. A propensity score based matching method was used to eliminate possible bias. Kaplan–Meier plots were performed to evaluate the influence of IVC interruption on overall survival and cancer specific survival. All the statistical analyses were performed using SPSS 24. A P value < 0.05 was considered statistically significant.

Results

Among the 32 patients who underwent IVC interruption, the median age was 61 years and the median tumor size was 7.7 cm. There were 28 males and 23 tumors were on the right side. We successfully matched 29 patients who underwent IVC interruption to 29 patients without this procedure in 1:1 ratio. No significant differences existed in baseline characteristics between the groups. The comparison of perioperative data showed that patients who underwent IVC interruption had significantly longer median postoperative hospital stays (13 vs 9 days, P = 0.022) and a higher overall postoperative complication rate (79.3 vs 51.7%, P = 0.027). According to the side and shape of tumor thrombus, it could be divided into four categories. There were 15 cases (46.9%) with right filled-type tumor thrombus (RFTT), 8 cases (25.0%) with right non-filled-type tumor thrombus (RNFTT), 1 case (3.1%) with left filled-type tumor thrombus (LFTT) and 8 cases (25.0%) with left non-filled-type tumor thrombus (LNFTT). According to different categories, different surgical procedures were adopted.

Conclusions

IVC interruption will increase the incidence of overall postoperative complications, but not the risk of major postoperative complications. Tumor thrombus should be divided into four categories, and different sides and shapes of renal tumor thrombus need different operative procedure of IVC interruption.

Retrohepatic inferior vena cava control through an anterior approach in cases of renal cell carcinoma with level IIIa tumor thrombus: Step-by-step description

OBJECTIVE

To evaluate the safety and efficacy of the retrohepatic inferior vena cava control through an anterior approach (RIVCA) technique in renal cell carcinoma (RCC) with level IIIa tumor thrombus.

PATIENTS AND METHODS

Initial series of 6 cases presenting RCC and level IIIa tumor thrombus who underwent radical nephrectomy and tumor thrombectomy using the RIVCA technique between 2018-2019. RIVCA technique aims to gain complete control of the retrohepatic inferior vena cava above the cranial end of the tumor thrombus, but excluding the major hepatic veins in order to preserve the natural hepato-caval shunt. A step-by-step description of the procedure is provided. Disease features, operative characteristics, and surgical outcomes were registered prospectively.

RESULTS

Radical nephrectomy and tumor thrombectomy were completed in all cases. RIVCA technique did not increase operative time significantly (range: 14-22 min). Mean estimated blood loss was 325 cc (range: 250-400). Blood transfusion was not required intraoperatively in any of the cases. Mean postoperative transfusion rate was 1.3 red blood cells packed units (range: 0-2). There were no cases of intraoperative pulmonary embolism or major complications (Clavien-Dindo III-V) in the period of 30 days postoperatively. Median postoperative length of stay was 8 days (range: 5-11).

CONCLUSIONS

The RIVCA technique applied to cases of RCC and level IIIa tumor thrombus provides complete control of the retrohepatic inferior vena cava above the tumor thrombus cranial end, while prevents intraoperative hemodynamic instability by maintaining cardiac preload through the porto-caval shunt. This technique may limit operative morbidity (intraoperative pulmonary embolism and massive hemorrhage), thus becoming a helpful adjunct to be used in cases of RCC with level IIIa tumor thrombus.

[Influence of deep invasive tumor thrombus on the surgical treatment and prognosis of patients with non-metastatic renal cell carcinoma complicated with venous tumor thrombus]

OBJECTIVE

To evaluate the impact of deep invasive tumor thrombus on the surgical complexity and prognosis of patients with renal cell carcinoma complicated with inferior vena cava tumor thrombus.

METHODS

We retrospectively reviewed the clinical data of 94 patients with non-metastatic renal cell carcinoma complicated with inferior vena cava tumor thrombus, who underwent surgical treatment in Peking University Third Hospital from January 2017 to June 2020. The patient's general condition, clinicopathological characteristics, surgery and survival information were collected. The patients were divided into two groups based on the intra-operative findings of tumor thrombus adhesion to the venous wall, of which 64 cases were in the deep invasive tumor thrombus (DITT) group and 30 cases were in the non-invasive tumor thrombus (NITT) group. Chi-square, t test and Mann-Whitney U test were used for categorical and continuous variables respectively. Kaplan-Meier plots and multivariable Cox regressions were performed to evaluate the influence of DITT on the prognosis of the patients with renal cell carcinoma with inferior vena cava tumor thrombus.

RESULTS

DITT significantly increase the difficulty of surgery for the patients with renal cell carcinoma with venous tumor thrombus, which was mainly reflected in the longer operation time (362.5 vs. 307.5 min, P=0.010), more surgical bleeding (1 200 vs. 450 mL, P=0.006), more surgical blood transfusion (800 vs. 0 mL, P=0.021), more plasma transfusion (200 vs. 0 mL, P=0.001), a higher proportion of open surgery (70.3% vs. 36.7%, P=0.002), a longer post-operative hospital stay (9.5 vs. 8 days, P=0.036), and a higher proportion of post-operative complications (46.9% vs. 13.8%, P=0.002). DITT was associated with worse overall survival of the patients with renal cell carcinoma with inferior vena cava tumor thrombus (P=0.022). Even in the multivariate analysis, DITT was still a poor prognostic factor for the overall survival of these patients [HR: 4.635 (1.017-21.116), P=0.047].

CONCLUSION

For patients with non-metastatic renal cell carcinoma with inferior vena cava tumor thrombus, DITT will significantly increase the difficulty of surgery, and may lead to poor prognosis.

Inferior Vena Cava Reconstruction Using a Ringed Polytetrafluoroethylene Interposition Graft and Inferior Vena Cava Filter Placement Following Resection of Renal Cell Carcinoma With a Tumor Thrombus Directly Infiltrating the Inferior Vena Cava

BackgroundRenal cell carcinoma (RCC) with tumor thrombus (TT) may extend into and, in rare cases, actually invade the inferior vena cava (IVC). Techniques of IVC reconstruction after removal of the RCC, TT, and infiltrated portion of the IVC have not been well documented. Methods A ringed polytetrafluoroethylene (PTFE) interposition graft along with an IVC filter placed within the graft (to prevent the development of pulmonary emboli) was used for patients who underwent surgical resection of RCC with TT extending into and directly invading the wall of the IVC. Demographic information about these patients along with their pathology reports, surgical procedures, and patency of the PTFE graft was obtained and described. Results Four male patients were identified as having RCC and TT with histologic invasion of the IVC requiring IVC dissection and replacement with a PTFE graft (as described above); their TT levels were II, IIIa, IIIc, and IV, respectively. Patient ages were 58, 65, 58, and 51 years and tumor sizes were 7.5, 7.5, 15.0, and 6.5 cm, respectively. These patients were followed for 36, 24, 32, and 48 months, respectively. At last follow-up, each patient had a patent IVC graft, and none of them developed any pulmonary emboli post-operatively. Conclusions Ringed PTFE interposition graft along with an IVC filter deployed inside the graft appears to be a safe vascular conduit for IVC reconstruction after surgical resection of RCC with TT directly invading the IVC.

Retrohepatic inferior vena cava control through an anterior approach in cases of renal cell carcinoma with level iiia tumor thrombus: Step-by-step description

OBJECTIVE

To evaluate the safety and efficacy of the retrohepatic inferior vena cava control through an anterior approach (RIVCA) technique in renal cell carcinoma (RCC) with level iiia tumor thrombus.

PATIENTS AND METHODS

Initial series of 6 cases presenting RCC and level iiia tumor thrombus who underwent radical nephrectomy and tumor thrombectomy using the RIVCA technique between 2018-2019. RIVCA technique aims to gain complete control of the retrohepatic inferior vena cava above the cranial end of the tumor thrombus, but excluding the major hepatic veins in order to preserve the natural hepato-caval shunt. A step-by-step description of the procedure is provided. Disease features, operative characteristics, and surgical outcomes were registered prospectively.

RESULTS

Radical nephrectomy and tumor thrombectomy were completed in all cases. RIVCA technique did not increase operative time significantly (range: 14-22min). Mean estimated blood loss was 325cc (range: 250-400). Blood transfusion was not required intraoperatively in any of the cases. Mean postoperative transfusion rate was 1.3 red blood cells packed units (range: 0-2). There were no cases of intraoperative pulmonary embolism or major complications (Clavien-Dindo III-V) in the period of 30 days postoperatively. Median postoperative length of stay was 8 days (range: 5-11).

CONCLUSIONS

The RIVCA technique applied to cases of RCC and level iiia tumor thrombus provides complete control of the retrohepatic inferior vena cava above the tumor thrombus cranial end, while prevents intraoperative hemodynamic instability by maintaining cardiac preload through the porto-caval shunt. This technique may limit operative morbidity (intraoperative pulmonary embolism and massive hemorrhage), thus becoming a helpful adjunct to be used in cases of RCC with level iiia tumor thrombus.

Controversies in the diagnosis of renal cell carcinoma with tumor thrombus

Diagnosis and treatment of renal cell carcinoma with venous tumor thrombosis remains a challenge today, requiring multidisciplinary teams, mainly in tumor thrombus levels III-IV. Our objective is to present the various diagnostic techniques used and its controversies. A review of the most relevant related articles between January 2000 and August 2020 has been carried out in PubMed, EMBASE and Scielo. Continuous technological development has allowed progress in its detection, in the approximation of the histological subtype, and in the determination of tumor thrombus level. Regardless of the imaging technique used for its diagnosis (CT, MRI, TEE, ultrasound with contrast), the time elapsed until treatment is vitally important to reduce the risk of complications, some of them fatal, such as pulmonary thromboembolism.

Renal Cell Carcinoma with or without Tumor Thrombus Invading the Liver, Pancreas and Duodenum

Simple Summary

Renal cell carcinoma rarely invades the surrounding visceral structures. While surgical extirpation has been the mainstay of treatment for the localized disease, the role of surgery in cases of venous involvement, adjacent invasion or distant metastasis remains controversial. Furthermore, the surgical option may represent a challenge. A large series of locally advanced renal cancer with involvement of the liver, pancreas, and/or duodenum, sometimes in conjunction with tumor thrombus extending inside the inferior vena cava is herein reported. Our series establishes the technical feasibility of this complex surgical procedure with acceptable complication rates, no perioperative death, and potential for durable response. With the use of new systemic therapy schedules, these patients will probably have a better opportunity of survival extension.

Abstract

Background: The purpose of this study is to report the outcomes of a series of patients with locally advanced renal cell carcinoma (RCC) who underwent radical nephrectomy, tumor thrombectomy, and visceral resection. Patients and methods: 18 consecutive patients who underwent surgical treatment in the period 2003-2019 were included. Neoplastic extension was found extending into the pancreas, duodenum, and liver in 9(50%), 2(11.1%), and 7(38.8%) patients, respectively. Seven patients (38.8%) presented also inferior vena cava tumor thrombus level I (n = 3), II (n = 2), or III (n = 2). The resection was tailored according to the degree of invasiveness. Demographics, clinical presentation, disease characteristics, surgical details, 30-day postoperative complications, and overall survival (OS) were analyzed. Results: Median age was 56 years (range: 40–76). Median tumor size was 14.5 cm (range, 8.8–22), and 10 cm (range: 4–15) for those cases with pancreatico-duodenal and liver involvement, respectively. Median estimated blood loss (EBL) was 475 mL (range: 100–4000) and resulted higher for those cases requiring thrombectomy (300 mL vs. 750 mL). Nine patients (50%) required transfusions with a median requirement of 4 units (range: 2–8). No perioperative deaths were registered in the first 30 days. Overall complication rate was 44.4%. Major complications were detected in 6/18 patients (33.3%). Overall median follow-up was 24 months (range: 0–108). Five-year OS (actuarial) rate was 89.9% and 75%, for 9/11 patients with pancreatico-duodenal involvement and 6/7 patients with liver invasion, respectively. Conclusion: Our series establishes the technical feasibility of this procedure with acceptable complication rates, no deaths, and potential for durable response.

Clinicopathological and radiological significance of the collateral vessels of renal cell carcinoma on preoperative computed tomography

This study aimed to investigate the clinicopathological and radiological significance of the collateral vessel of renal cell carcinoma (RCC) on preoperative computed tomography (CT). Preoperative contrast-enhanced CT of 236 consecutive patients with pathological documented RCC were retrospectively reviewed during the period of 2014. The associations of the presence of collateral vessels with perioperative clinicopathological and radiological features, as well as long term survival outcomes were analyzed. Totally, collateral vessels were detected by contrast-enhanced CT in 110 of 236 patients. The presence of collateral vessels was significantly associated with higher pathologic T stage, higher Fuhrman grade, higher overall RENAL scores, greater tumor size and enhancement, and more tumor necrosis (all P < 0.05). In patients with clear cell RCC, those harboring collateral vessels had significantly higher SSIGN scores (P < 0.001) and shorter overall survival (P = 0.01) than those without collateral vessel. The incidence of intraoperative blood loss, blood transfusion, radical nephrectomy (RN) and open surgery were also significantly higher in patients with collateral vessels (all P < 0.05). In multivariate analysis, the presence of collateral vessels was significantly associated with RN (P = 0.021) and open surgery (P = 0.012). The presence of collateral vessels was significantly associated with aggressive clinicopathological parameters and worse prognosis. It is worth paying attention to its association with the choice of RN and open surgery in clinical practice.

Ex Vivo Resection and Autotransplantation for Conventionally Unresectable Tumors - An 11-year Single Center Experience

BACKGROUND AND AIMS

Ex vivo surgery may provide a chance at R0 resection for conventionally unresectable tumors. However, long-term outcomes have not been well documented. In this study, we analyze our 11-year outcomes to define its role.

STUDY DESIGN

We retrospectively analyzed 46 consecutive patients who underwent ex vivo surgery at our institution 2008-2019.

RESULTS

The types of tumors were: carcinoma (n = 20), sarcoma (n = 20) and benign to low grade tumor (n = 6). The type of ex vivo surgery was chosen based on tumor location and vascular involvement. The most commonly performed procedure was ex vivo hepatectomy (n = 18), followed by ex vivo resection and intestinal autotransplantation (n = 12), ex vivo Whipple procedure and liver autotransplantation (n = 8) and multivisceral ex vivo procedure (n = 7). Twenty-three patients (50%) are currently alive with median follow-up of 4.0-years (11 months-11.8 years). The overall survival was 70%/59%/52%, at 1-/3-/5-years, respectively. Patient survival for benign to low grade tumors, sarcoma, and carcinoma was 100%/100%/100%, 65%/60%/50%, and 65%/45%/40%, at 1-/3-/5-years, respectively. Ninety-one percent patients had R0 resection, and 57% had no recurrence to date with median follow-up of 3.1-years. Two patients (4.3%) died within 30 days due to sepsis and gastroduodenal artety (GDA) stump blowout. Two additional patients died between 30 and 90 days due to sepsis. Perioperative mortality in the last 23 consecutive cases was limited to 1 patient who died of sepsis between 30 and 90 days.

CONCLUSIONS

For a selected group of patients with conventionally unresectable tumors, ex vivo surgery can offer effective surgical removal with a reasonably low perioperative mortality at experienced centers.

Tumor Thrombus Into the Inferior Vena Cava After Resection of Renal Cell Carcinoma: Recurrence or Tumor Thrombus Left Behind?

OBJECTIVE

To describe a series of 3 cases of renal cell carcinoma that developed a metachronic recurrence in the form of inferior vena cava tumor thrombus after a first attempt of curative intent by means of radical nephrectomy.

METHODS

A complete work-up consisting of total body computed tomography and transesophagic echocardiography was performed in all cases. After extensive counseling a decision for surgical excision was made. We used a transplant-based approach to eliminate every vestige of visible neoplastic tissue including the tumor thrombus in all cases. Three different approaches, including tangential and circumferencial excision of the inferior vena cava with or without caval replacement by prosthetic vascular graft were used for caval management after thrombectomy.

RESULTS

Estimated blood loss ranged between 500 and 2000 cc. Transfusion requirements varied from 1-9 red blood cell packed units. Complete thrombectomy along with excision of all visible neoplastic lesions was achieved in all cases. One of the patients experimented a cardiac arrest on postoperative day 7 without fatal consequences that increased de length of stay (range 7-30 days). No other major complications were registered. None of the patients died in the first 30 days after the procedure.

CONCLUSION

The transplant-based surgical approach to thrombectomy in these cases provides for excellent exposure and vascular control, thus minimizing the complication rate and resulting a safe treatment option for the patient.

Surgical Tips for Inferior Vena Cava Thrombectomy

PURPOSE OF REVIEW

The aim of this review is to describe the preoperative evaluation, surgical techniques, and postoperative management of patients with renal cell carcinoma (RCC) undergoing radical nephrectomy (RN) and inferior vena cava (IVC) thrombectomy.

RECENT FINDINGS

RN and IVC thrombectomy remains the standard management option in non-metastatic RCC patients with IVC thrombus. A comprehensive preoperative workup, including high-quality imaging, blood works, and appropriate consultations are required for all patients. The aim of the surgery is complete resection of all tumor burden, which requires a skillful surgical team for such a challenging procedure and is inherently associated with a high rate of perioperative morbidity and mortality. Preoperative CT or MRI is essential for surgical planning. The surgical approach is mainly determined by the level of the tumor thrombus. The open approach has been the standard, though minimally invasive and robotic techniques are emerging in selected cases by experienced surgeons.

Imaging predictors for assessment of inferior vena cava wall invasion in patients with renal cell carcinoma and inferior vena cava tumor thrombus: a retrospective study

Background

Renal cell carcinoma (RCC) has the propensity to lead to venous tumor thrombus (VTT). Nephrectomy with tumor thrombectomy is an effective treatment option but is a technically challenging surgical procedure that is accompanied by a high rate of complications. The aims of this study were to investigate pre-operative imaging parameters for the assessment of inferior vena cava (IVC) wall invasion due to a tumor thrombus in patients with RCC and to identify predictors from the intra-operative findings.

Methods

Clinical and imaging data were collected from 110 patients who underwent nephrectomy with IVC tumor thrombectomy (levels I–IV) for RCC and IVC tumor thrombus at the Peking University Third Hospital between May 2015 and March 2018. Univariable and multivariable logistic regression and receiver operating characteristic curves were used to assess the correlations between pre-operative imaging features and intra-operative macroscopic invasions of the IVC wall by tumor thrombus.

Results

Among the 110 patients, 41 underwent partial or segmental resection of IVC. There were univariate associations of pre-operative imaging parameters that could be used to predict the need for IVC resection, including those of the Mayo classification, maximum anterior-posterior (AP) diameter of the renal vein at the renal vein ostium (RVo), maximum AP diameter of the VTT at the RVo and IVC occlusion. For the multivariable analysis, the AP diameter of the VTT at the RVo and IVC occlusion were associated with a significantly increased risk of invasion of the IVC wall by tumor thrombus. The optimum imaging thresholds included an AP diameter of the VTT at the RVo larger than 17.0 mm and the presence of IVC occlusion, with which we predicted invasions of the IVC wall requiring IVC resection. The probabilities of intra-operative IVC resection for patients without both independent factors, with an AP diameter of the VTT at the RVo larger than 17.0 mm, with IVC occlusion, and with both concurrent factors were 5%, 23%, 56%, and 66%, respectively.

Conclusion

An increase in the AP VTT diameter at the RVo and the presence of complete occlusion of the IVC are independent risk factors for a high probability of IVC wall invasion by tumor thrombus.

The influence of venous tumor thrombus combined with bland thrombus on the surgical treatment and prognosis of renal cell carcinoma patients

Objective

To describe the clinical characteristics of renal cell carcinoma (RCC) with venous tumor thrombus (VTT) and bland thrombus (BT), and to evaluate the influence of BT on surgical treatment and cancer‐specific survival (CSS) of RCC with VTT.

Methods

We retrospectively reviewed clinical data of 123 patients with RCC and VTT, who underwent surgical treatment in our center between February 2015 and May 2018. Patients were divided into the BT group (21 patients) and non‐BT group (102 patients). Chi‐square and Mann‐Whitney U test were used for categorical and continuous variables respectively. Univariable log‐rank tests and multivariable Cox regressions were conducted to evaluate the prognostic significance of each variable. Kaplan‐Meier plots were performed to evaluate the influence of BT.

Results

In the delayed phase of enhanced magnetic resonance imaging (MRI), BT and VTT had difference. Patients were divided according to the relative position of BT: proximal end BT (one patients), contralateral renal vein BT (two patients), distal end BT (12 patients), and multiple BT (six patients). The average length of BT was 8.4 ± 5.8 cm (range: 0.6‐20.0 cm). Patients with BT had longer operative time (P = .001), more surgical blood loss (P = .004), higher proportion of open surgery (P = .006), more postoperative complications (P = .011). BT (hazard ratio [HR] = 3.323, P = .007) were independent risk factors for poor prognosis.

Conclusions

In the delayed phase of enhanced MRI, BT showed no obvious enhancement, while VTT usually showed enhancement. This was an important basis for preoperative imaging diagnosis of BT. The presence of BT increases the difficulty of surgery, and is correlated with adverse survival outcomes in patients with RCC and VTT.

A Multidisciplinary Approach to Oncological Resections with Vascular Surgeons Improves Patient Outcomes

OBJECTIVE

Oncological resections have become more radical in pursuit of disease free margins. Consequently, vascular structures may be injured inadvertently or purposely resected, with or without subsequent reconstruction. Thus, vascular surgeons have an increasing role in oncological surgery. The present authors sought to review their experience and examine the effect of timing of referral to a Vascular Surgeon (VS) on patient and surgical outcomes following tumour resection.

METHODS

A retrospective review was conducted of a prospectively maintained database at a public hospital network in Adelaide, Australia. All cases of collaboration between a VS and other surgeons for resection of cancer or non-malignant tumour were included. Medical records and operative, pathological, and transfusion data were reviewed, with particular attention to referring team, timing of VS referral (pre- or intra-operative), and the operative role of the VS.

RESULTS

Seventy-two cases were identified from January 2004 to June 2018. The most common collaborators were General Surgery and Urology. Of the cases, 86% were elective and 71% were referred to the VS pre-operatively. Pre-operative referral was associated with a predominant VS role of dissection and exposure. Pre-operative referral was associated with lower odds of vessel repair and reconstruction compared with intra-operative referral (adjusted OR = 0.20; 95% CI 0.04-0.93; p = .040) and a lower incidence of positive surgical margins (35% vs. 80%, p = .028). The rate of blood product units required was lower among pre-operative referrals relative to intra-operative referrals, but the effect of timing was not significant after adjustment for potential confounders (IRR = 0.80, 95% CI 0.26-2.44; p = .70).

CONCLUSION

Pre-operative planned involvement of vascular surgery in oncological operations can improve surgical outcomes, with additional expected benefits for surgical training and cross specialty collaboration.

Initial Series of Robotic Segmental Inferior Vena Cava Resection in Left Renal Cell Carcinoma With Caval Tumor Thrombus

OBJECTIVE

To present our preliminary experience of robotic left radical nephrectomy (LRN) and segmental inferior vena cava (IVC) resection without caval replacement for left renal cell carcinoma (RCC) with inferior vena cava tumor thrombus.

MATERIALS AND METHODS

Between 2017 and 2018, 7 patients underwent segmental IVC resection and LRN robotically. All patients underwent preoperative cavography, demonstrating complete IVC occlusion. Computed tomography-based 3-dimensional reconstruction revealed sufficient collateralization of the IVC and right renal vein (RRV). The cephalic IVC was circumferentially resected and ligated just below the second porta hepatis. The caudal IVC was circumferentially resected above the RRV with preservation of the major collaterals. The RRV was not dissected during the procedure to avoid compromising its neocollaterals. The IVC portion between the RRV and the second porta hepatis was removed en bloc with the tumor thrombus, and the LRN was performed.

RESULTS

All cases were successfully performed by robotic surgery without conversion. Median operative time was 420 minutes. Median intensive care unit stay was 3 days. Four grade Ⅱ complications occurred in 2 patients. One patient had mild LEE postoperatively and recovered without special medication. Median preoperative and 3-6 months follow-up serum creatinine was 118.7 μmol/L and 135.2 μmol/L, respectively. No patient needed dialysis postoperatively. One case occurred disease progression. No patient died during the follow-up period.

CONCLUSION

Robotic segmental IVC resection for left RCC with inferior vena cava tumor thrombus is feasible in well-selected cases. Three-dimensional reconstruction and cavography are helpful in the preoperative evaluation of neocollaterals in patients with suprarenal IVC occlusion.

Perioperative Outcome of Suprarenal Resection of Vena Cava Without Reconstruction in Urologic Malignancies: A Case Series and Review of the Literature

OBJECTIVE

To describe the feasibility and perioperative outcome of suprarenal resection of inferior vena cava (IVC) in urologic neoplasms without reconstruction.

METHODS

We retrospectively reviewed the patients who underwent suprarenal resection of IVC without reconstruction for urologic neoplasms in our institution between September 2010 and October 2019. Patients' demographic, clinical, radiologic, and 90-day perioperative complications were recorded.

RESULTS

Twenty-eight (79% male) patients with a median age of 59 (25-75) years were included in the study. Twenty-five (89%) of patients had renal cell carcinoma, 1 had renal leiomyosarcoma, and 2 had metastatic testicular teratoma. Twenty-two patients had Mayo level 3 thrombus, 3 had level 2, and 3 had level 4. The mean radiologic thrombus length was 12.6 cm. Eleven patients had radiologic bland thrombosis in the infrarenal IVC. Twenty-seven patients underwent open, and 1 robotic surgery. The median operating time was 411 (range 240-808) minutes, median blood loss was 3750 cc, and all but 1 patient received perioperative transfusion (median 11 units of packed red blood cells). Median hospital stay was 5 (3-50) days. Ninety-day complication rate was 35% (Clavien-Dindo grade I/II and III/IV were 21% and 14%, respectively). Four patients (14%) developed transient nondisabling leg edema. The 90-day mortality rate was 7%.

CONCLUSION

Suprarenal inferior vena cava resection without reconstruction is feasible, yet high-risk operation that should be performed in experienced centers in selected patients with urologic malignancies.

Vascular Injury During Urologic Surgery: Somebody Call My Mother

PURPOSE OF REVIEW

To provide the critical elements to effectively manage hemorrhage from vascular injuries sustained during planned urological interventions.

RECENT FINDINGS

The frequency of intraoperative vascular injuries is increasing. However, literature concerning the management of iatrogenic operative vascular injuries is scarce. Although rare, intraoperative vascular injuries may be associated with potential catastrophic complications and death. The decision-making process following a potential life-threatening intraoperative vascular injury occurs in a very short time frame. Appropriate knowledge of the critical elements to identify the source of bleeding, initiate first-line hemostatic measures, select the candidate for damage control strategies, and perform the indicated operative repairing maneuvers and techniques have been proved crucial to ensure hemodynamic stability and bleeding cessation. The key surgical principles to counteract the impact of exsanguinating bleeding, and the aim to obtain the best achievable outcomes after definitive repair, are described in detail in this review.

Body mass index as an independent risk factor for inferior vena cava resection during thrombectomy for venous tumor thrombus of renal cell carcinoma

Objective

To define preoperative clinical and radiographic risk factors for the need of inferior vena cava (IVC) resection in patients with renal cell carcinoma (RCC) and IVC tumor thrombus.

Methods

We reviewed data of 121 patients with renal cell carcinoma and venous tumor thrombus receiving radical nephrectomy and thrombectomy at our institution between 2015 and 2017, and 86 patients with Mayo I–IV level tumor thrombus were included in the final analysis. Clinical features, operation details, and pathology data were collected. Preoperative images were reviewed separately by two radiologists. Univariable and multivariable logistic regression analyses were applied to evaluate clinical and radiographic risk factors of IVC resection.

Results

Of the 86 patients, 44 (51.2%) received IVC resection during thrombectomy. In univariate analysis, we found that body mass index (BMI) (odds ratio [OR] = 1.22, P = 0.003), primary tumor diameter (OR = 0.84, P = 0.022), tumor thrombus width (OR = 1.08, P = 0.037), tumor thrombus level (OR = 1.57, P = 0.030), and IVC occlusion (OR = 2.67, P = 0.038) were associated with the need for resection of the IVC. After adjusting for the other factors, BMI (OR = 1.18, P = 0.019) was the only significant risk factor for IVC resection. Multivariable analysis in Mayo II–IV subgroups confirmed BMI as an independent risk factor (OR = 1.26, P = 0.024). A correlation between BMI and the width (Pearson’s correlation coefficient [PCC] = 0.27, P = 0.014) and length (PCC = 0.23, P = 0.037) of the tumor thrombus was noticed.

Conclusion

We identified BMI as an independent risk factor for IVC resection during thrombectomy of RCC with tumor thrombus in a Chinese population. More careful preoperative preparation for the IVC resection and/or reconstruction is warranted in patients with higher BMI.

Adult Wilms tumor with inferior vena cava thrombus and distal deep vein thrombosis - a case report and literature review

BACKGROUND

Adult Wilms tumor (WT, nephroblastoma) is a rare, but well-described renal neoplasm. Although inferior vena cava tumor thrombosis is present in up to 10% of Wilms tumors in childhood, only few cases of this clinical manifestation in adults have been reported. To the best of our knowledge, this is the first case of adult WT infiltrating into inferior vena cava (IVC) with concomitant distal deep vein thrombosis.

CASE PRESENTATION

A 28-year-old male patient with gross hematuria and right flank pain was diagnosed with right kidney tumor penetrating to IVC. Preoperatively, acute distal thrombosis in inferior vena cava and lower extremities veins occurred. Right radical nephrectomy with tumor thrombectomy via cavotomy was performed. In order to prevent pulmonary embolism, IVC was ligated below left renal vein level. Histopathological examination revealed a triphasic nephroblastoma without anaplastic features. Postoperatively, patient was diagnosed with metastatic liver disease, which was treated with two lines of chemotherapy followed by radiotherapy with achievement of complete response.

CONCLUSIONS

Adult WT occurs usually in young patients, under 40 years of age. Neoadjuvant chemotherapy proved to be effective in children, resulting with tumor shrinkage and venous tumor thrombus regression. Therefore, percutaneous biopsy should be always considered in young patients presenting with renal tumor invading venous system. IVC ligation is a safe treatment option in the event of complete inferior vena cava occlusion due to distal thrombosis concomitant to tumor thrombus, provided collateral venous pathways are well-developed.

Feasibility of Pure Conventional Retroperitoneal Laparoscopic Radical Nephrectomy With Level II Vena Caval Tumor Thrombectomy

OBJECTIVE

To report our surgical outcomes and experiences with pure conventional retroperitoneal laparoscopic nephrectomy and tumor thrombectomy for patients with right renal tumors and level II inferior vena caval tumor thrombus.

MATERIALS AND METHODS

From February 2012 to June 2014, five patients underwent pure conventional retroperitoneal laparoscopic nephrectomy and tumor thrombectomy. After the inferior vena cava was blocked using tourniquet loops above and below the thrombus with the contralateral renal vein being clamped, the inferior vena cava was opened, and the tumor thrombus was fully extracted.

RESULTS

The mean patient age was 57 years (43-71 years) and the mean body mass index was 22.44 kg/m(2) (20-25 kg/m(2)). The mean operative time was 241 minutes (180-300 minutes) and the mean estimated blood loss was 290 ml (50-1000 mL). The mean tumor size was 6.9 cm (3.5-9 cm) and the mean tumor thrombus length was 5.5 cm (4-10 cm). One patient needed an intraoperative transfusion, and the patient encountered bilateral lower limb deep vein thrombus. With a mean follow-up of 11.5 months (5-30 months), one patient was identified with lung metastasis 4 months postoperatively.

CONCLUSION

Although pure conventional laparoscopic nephrectomy and tumor thrombectomy for level II tumor thrombus are challenging, they are feasible in carefully selected patients. More studies are needed to confirm their superiority and oncologic outcomes.

Clinical and radiographic predictors of the need for inferior vena cava resection during nephrectomy for patients with renal cell carcinoma and caval tumour thrombus

OBJECTIVE

To evaluate the clinical and radiographic predictors of the need for partial or circumferential resection of the inferior vena cava (IVC) requiring complex vascular reconstruction during venous tumour thrombectomy for renal cell carcinoma (RCC).

PATIENTS AND METHODS

Data were collected on 172 patients with RCC and IVC (levels I-IV) venous tumour thrombus who underwent radical nephrectomy with tumour thrombectomy at the Mayo Clinic between 2000 and 2010. Preoperative imaging was re-reviewed by one of two radiologists blinded to details of the patient's surgical procedure. Univariable and multivariable associations of clinical and radiographic features with IVC resection were evaluated by logistic regression. A secondary analysis was used to assess the ability of the model to predict histological invasion of the IVC by the tumour thrombus.

RESULTS

Of the 172 patients, 38 (22%) underwent IVC resection procedures during nephrectomy. Optimum radiographic thresholds were determined to predict the need for IVC resection based on preoperative imaging included a renal vein diameter at the renal vein ostium (RVo) of 15.5 mm, maximum anterior-posterior (AP) diameter of the IVC of 34.0 mm and AP and coronal diameters of the IVC at the RVo of 24 and 19 mm, respectively. On multivariable analysis, the presence of a right-sided tumour (odds ratio 3.3; P = 0.017), an AP diameter of the IVC at the RVo of ≥24.0 mm (odds ratio 4.4; P = 0.017), and radiographic identification of complete occlusion of the IVC at the RVo (odds ratio 4.9; P < 0.001) were associated with a significantly increased risk of IVC resection. The c-index for the model was 0.81.

CONCLUSIONS

We present a multivariable model of the radiographic features associated with the need for IVC resection during tumour thrombectomy. Pending external validation, this model may be used for preoperative planning, patient counselling and planned involvement of vascular surgical colleagues in anticipation of the need for complex vascular repair.

Surgical resection and inferior vena cava reconstruction for treatment of the malignant tumor: technical success and outcomes

OBJECTIVE

The purpose of this study was to review patients who underwent inferior vena cava (IVC) resection with concomitant malignant tumor resection and to consider the operative procedures and the outcomes.

MATERIALS AND METHODS

Between 2000 and 2012, 41 patients underwent resection of malignant tumors concomitant with surgical resection of the IVC at our institute. The records of these patients were retrospectively reviewed.

RESULTS

Primary tumor resections included nephrectomy, hepatectomy, retroperitoneal tumor extirpation, lymph node dissection, and pancreaticoduodenectomy. The IVC interventions were partial resection in 23 patients and total resection in 18 patients. Four patients underwent IVC replacement. Operation-related complications included pulmonary embolism, acute myocardial infarction, deep vein thrombosis, leg edema and temporary hemodialysis. There were no operative deaths. The mean follow-up period was 24.9 months (range: 2-98 months). The prognosis depended on the type and stage of the tumor.

CONCLUSION

Resection and reconstruction of the IVC can be performed safely if the preoperative evaluations and surgical procedures are performed properly. The IVC resection without reconstruction was permissive if the IVC was completely obstructed preoperatively, but it may also be considered in cases where the IVC is not completely obstructed.