Resection of hypernephromas with vena caval or right atrial tumor extension using extracorporeal circulation and deep hypothermic circulatory arrest: a multidisciplinary approach.

OBJECTIVE: Among retroperitoneal tumors, renal cell carcinoma most often invades the retrohepatic inferior vena cava or the right atrium. Even in these cases, radical nephrectomy may be performed with curative intention. The aim of this retrospective study was to elucidate the impact of cardiopulmonary bypass and hypothermic circulatory arrest on surgical complications, primary mortality, and long-term survival. PATIENTS AND METHODS: From Jan. 1981 till Aug. 1996, 44 patients were operated upon for renal cell carcinoma with advanced vena caval extension. The patients were divided into two groups. In 19 cases (Cardiopulmonary Bypass Group), extracorporeal circulation and deep hypothermic circulatory arrest was used. The Conventional Technique Group comprised 25 patients who had radical nephrectomy, paraaortic lymphadenectomy and extirpation of the intracaval tumor thrombus applying common principles in vascular surgery. The median age was 59 years with a range from 42 to 78 years in the Cardiopulmonary Bypass Group, and 60 years, ranging from 22 to 72 years, in the Conventional Technique Group. In addition, both groups did not differ in gender, UICC TNMG staging classification, and perioperative risk factors. A review of the patient charts was done and surveys were sent to survivors or nearest of kin. Wilcoxon test and log-rank test were used as appropriate.
RESULTS: A lower intraoperative complication rate was found in patients who had surgery using cardiopulmonary bypass. This was especially true with embolization of the tumor thrombus into the pulmonary arteries: 0.0% in Cardiopulmonary Bypass Group and 16.0% in Conventional Technique Group (P < 0.05). Severe hemorrhage occurred in 10.5% (Cardiopulmonary Bypass Group) and 16.0% (Conventional Technique Group). This translated into a significantly lower perioperative mortality in the Cardiopulmonary Bypass Group when compared to the Conventional Technique Group (5.6 and 16.0%, respectively). In spite of these results, differences in long-term survival did not reach statistical significance. But, a trend to superior long-term survival was apparent. The mean survival was 1289 +/- 278 days in the Cardiopulmonary Bypass Group and 746 +/- 166 days in the Conventional Technique Group.
CONCLUSIONS: Due to acceptable long-term results, the resection of hypernephromas showing extensive vena caval invasion seems to be justified. The use of cardiopulmonary bypass and hypothermic circulatory arrest is able to decrease primary morbidity and mortality. However, the influence on long-term survival remains to be proven.