TITLE:
Comparative Effectiveness of Median Sternotomy vs Minimal Access Cardiopulmonary Bypass and Circulatory Arrest for Resection of Renal Cell Carcinoma with Inferior Vena Caval Extension
AUTHORS:
William C. Faust, Richard S. D’Agostino, John Libertino
KEYWORDS:
Renal Cell Cancer, Kidney Cancer, Inferior Vena Cava, Caval Thrombus
JOURNAL NAME:
Journal of Cancer Therapy,
Vol.7 No.10,
October
17,
2016
ABSTRACT: Introduction: The use of
cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest (DHCA) is
an adjunctive surgical technique that can be employed for the resection of
renal cell carcinoma (RCC) with venous thrombus extension superior to the level
of the
hepatic veins. Median Sternotomy (MS) or Minimal Access (MA)
incisions may be used to establish CPB during the resection of these extensive
tumors. We review our experience with both incisional approaches and
compareoperative details, perioperative complications, and recurrence free
survival. Materials
and Methods: From
1986 to 2012, 70 radical nephrectomies with concomitant inferior
vena cava (IVC) thrombectomies were performed at our
institution using MS (23 patients)
and MA (47 patients) techniques. Preoperative
patient characteristics, pathologic data, and organ specific postoperative
complications and follow-up data were compared between groups.
Estimates of overall and recurrence-free
survival were constructed using
Kaplan-Meier curves and compared using log-rank testing. Results: There were
no significant differences with respect to patient demographics
or preoperative comorbid conditions between the MA and MS groups. The MA group
showed a significant reduction (p 0.05) in
the duration of postoperative
mechanical ventilation, length of stay, operative time, and number of
blood transfusions compared to MS patients. Overall and organ-system specific complications
demonstrated a decreased incidence of wound infection (37.9% v. 12.5%, p = 0.0135)
and sepsis (14.3% v. 0%, p = 0.0137) in
patients undergoing MA approach.
Perioperative mortality was significantly reduced in the MA group (30.4% v.
8.5% p = 0.0179).
Recurrence-free
survival in the MS group was 0.59 years and 1.2 years in the MA group
(p = 0.06). Conclusions: Minimal
access surgical approaches for CPB and DHCA during the resection of RCC with extensive
tumor thrombus provide similar oncologic control with decreased duration of
mechanical ventilation, length of stay and infection related complications. Our
findings suggest that MA techniques provide significant advantages over MS.