Oncovascular Surgery: There Would Be No Such Thing without Vascular Surgeons.

One of the appeals of vascular surgery is being “surgeons’ surgeon”. When other surgeons get in trouble with bleeding in the operating room, it is the vascular surgeons who come to their rescue. Whether we like it or not, emergent intraoperative consultations for iatrogenic vascular injuries are underappreciated and undervalued part of vascular surgical practice. Complex oncologic resections requiring vascular control and reconstructions are often performed by oncologic surgeons, without preoperative evaluation by vascular surgeons, potentially resulting in intraoperative emergencies associated with poor outcome. Things can be better.

In this issue of Vascular Specialist International, Dr. Ahram Han and colleagues from Seoul National University illustrate the important contributions that vascular surgeons provide in the care of patients undergoing complex oncological resections [1]. Starting with a clear definition of the term “oncovascular surgery”, the authors provide an overview of surgical resection of several tumor types including angiosarcoma, caval leiomyosarcoma, intravenous leiomyomatosis, and retroperitoneal soft tissue sarcoma with major vascular involvement. With this framework, different roles that vascular surgeons can play are described as primary surgeons, consultants, rescue surgeons, or both.

Most of us in the field of vascular surgery would wholeheartedly agree with the authors’ conclusion that “Vascular surgeons need to show leadership in cancer surgery for the sake of the patients with complex advanced disease ….” What that leadership should look like may be debated. The authors suggest, “… vascular surgeons should teach every oncologic surgeon about the basic vascular surgical technique. There are lots of ways of hand-on training of surgical skills for the surgical residents and fellows, including lectures, dry lab, wet lab and cadaveric dissection. After learning basic vascular technics, the oncologic surgeons can repair the vessel injury by themselves or are less likely to injure the vessels by crude handling with traumatic instruments or clips.”

Unfortunately, even at a tertiary academic center in the United States of America where I practice, general surgical training, albeit utilization of lectures, dry lab, wet lab, and cadaver sessions, remains inadequate to teach the technical expertise and knowledge base for complex vascular reconstructions in these cases. Oncovascular surgeries most likely constitute a minority of daily practices of most oncologic surgeons. As such, these vascular reconstructions are better performed in the hands of vascular surgeons. We have previously reported that unplanned intraoperative consultations, particularly involving caval injuries, result in significantly higher blood loss, compared to planned multidisciplinary resections [2]. At our center, we have adopted a systematic multidisciplinary team approach to treatment of complex retroperitoneal sarcoma. With early consultation and evaluation by the vascular surgeons, we saw more planned, combined operations and better outcomes, as indicated by lower blood loss and hospital length of stay. Additionally, with increasing collaboration, our oncologic surgeons gained better respect for vasculature and tissue handling skills leading to fewer unanticipated emergent consults.

Undoubtedly, with continued advances in medical and surgical oncology, the indications for surgical resectability will expand in the future, and with it, the value of vascular surgical expertise. I thank the authors for highlighting the essential roles of vascular surgeons in oncovascular surgeries.