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© 2004 European Association of Cardio-Thoracic Surgery
Combined procedures using the extracorporeal circulation and urologic tumor operation – experiences in six cases
a Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University, Moorenstrasse 5, D-40225 Dusseldorf, Germany
* Corresponding author. Tel.: +49-211-8118331; fax: +49-211-8118333 Received September 9, 2003; received in revised form October 20, 2003; accepted October 22, 2003
We investigated the question whether combined open heart surgery and urologic tumor operations may be helpful for patients with coincident diseases. From 8/1989 to 8/2000 six patients underwent combined open heart surgery and urologic tumor operation. (61–76 years). Two patients suffered from aortic valve stenosis, four patients from ischemic heart disease. Concerning the kidney five patients had an adenocarcinoma, one patient a non-Hodgkin's lymphoma. In two patients we performed an aortic valve replacement and tumor nephrectomy (partial resection of the kidney), respectively. Four patients underwent myocardial revascularization and the corresponding tumor operation. The immediate postoperative course shows satisfactory results. In long-term follow-up one patient reported a low level of loading capacity, however, without typical ischemic symptoms. A clue for a tumor recidivism has not yet been observed. Two patients died 2.5 years after the operation, but the underlying reasons remain speculative because of missing autopsy. Patients suffering from both cardiovascular and kidney disease can be treated in only one setting with low risk. Remembering critically the limited number of cases, we conclude that combined procedures should take preference of operations in two settings, which is in agreement with the current data from the literature.
Key Words: Simultaneous procedure; Open heart surgery; Renal cell carcinoma
The management of patients with coexisting diseases who undergo cardiac surgery is subject to debate as the operative mortality in such patients is increased. Traditionally the surgical procedures have been staged with the cardiac surgery performed first followed by the general operation at a later date. Especially with the approach of tumor resection (e.g. pulmonary or abdominal tumor) the curative goal is delayed and the additional costs of two settings have to be considered [1]. Besides that the immunosuppressive effects of cardiopulmonary bypass (CPB) may have a deleterious effect on tumor growth and dissemination [2]. In recent times, however, in both, tumor surgery as well as other coexisting surgical diseases, such as abdominal aneurysm or carotid stenoses, the attempt has been made to perform the cardiac as well as the non-cardiac disease in only one setting. Satisfactory results have been reported concerning simultaneous pulmonary tumor resection, carotid endarterectomy or abdominal aneurysm repair [3–5]. However, little is known concerning further coexisting non-cardiac diseases, which are scheduled for surgical therapy. In some cases renal tumors are known to extend into the right atrium and then have to be treated radically using CPB. In our study we present a series of six patients who underwent simultaneous urologic tumor operation without contact to the heart and cardiac surgery using the extracorporeal circulation as a two-cavity performance in only one setting. The immediate perioperative results and the long-term follow-up are reflected and compared to the current view out of the literature in the following course.
The clinical records of all patients who underwent simultaneous cardiac surgery and urologic tumor operation between 8/89 and 8/00 were reviewed. In total there were six patients (four male, two female) with a mean age of 69 years (age span from 61 to 76 years). All patients presented themselves with distinct symptoms of dyspnoe according at least to NYHA II and/or with anginous complaints according at least to CCS II. The kidney lesion was already known and had been identified during the preoperative assessment as an incidental finding. Two patients had primarily consulted the urologist because of hematury and the accompanying cardiac disease was evaluated in the frame of this examination. 2.1. Cardiac pathology Four patients suffered from ischemic heart disease (in all cases as a triple vessel disease, which could not be treated interventionally, i.e. using a PTCA due to the underlying morphology of the stenosis), the other two patients had a valvular aortic stenosis with a maximal pressure gradient of 55, respectively 70 mmHg, as estimated by catheterization. The underlying pathology was confirmed by histologic examination afterwards and showed degenerative findings in both cases.Left ventricular function was determined by ventriculography and echocardiography and was in all instances normal or just moderately impaired. 2.2. Kidney pathology Pathology consisted of primary renal cell tumor (adenocarcinoma) in five patients, one patient suffered from a renal manifestation of a non-Hodgkin's disease. Standard preoperative investigations consisted of sonography and computerized axial tomography (CT). Fig. 1 shows the CT-scan of one patient with a renal cell carcinoma with central necrosis on the right side. In two patients it was possible to establish a tissue diagnosis using a CT guided fine needle aspiration biopsy. Further diagnostics concerning eventual filiarization had run uneventful.
2.3. Operative details After induction of anesthesia at first a median sternotomy was performed. After pericardiotomy the management of extracorporeal circulation was prepared in order to be able to perform an emergent cannulation at any time. Under conditions of stable hemodynamics the urologist was consulted and performed tumor resection using a subcostal approach or a median laparatomy. After removing either the entire kidney or only a part accompanied by an extensive lymph node dissection, a drainage was placed and the abdominal cavity was closed again. In case of ischemic heart disease the left internal thoracic artery (LITA) was harvested. After application of 300 IU heparin/kg body wt. and an ACT level >400 s the extracorporeal circulation was established and the corresponding procedures [coronary artery bypass grafting (CABG) or aortic valve replacement (AVR)] were performed. In no case was a cell-saver employed. CABG was carried out using the technique of intermittent cross-clamping, AVR employing selective application of Bretschneider's cardioplegia via coronary ostium access. Three patients suffering from coronary artery diseases received a LITA-graft and two additional venous grafts (V. saphena magna), one patient received three additional venous grafts. In case of aortic valve replacement in both patients a mechanical bileaflet heart valve—according to the patient's age or on their special request—was employed. After decannulation sternal closure was carried out in typical manner. Table 1 summarizes the main subjects of all six patients.
There was no operative mortality. The patients were electively ventilated postoperatively and extubated, if oxygenation and vigilance were satisfactory. In no case was a prolonged ventilatory support necessary. A catecholamine therapy was not required after extubation. Blood loss was considered to be moderate both via the chest tubes and the abdominal drainage (below 750 ml during the first 24 h). No patient required reexploration because of massive bleeding and no massive transfusion therapy had to be performed. Tables 2 and 3 show the main aspects concerning the immediate post- and perioperative course.
All patients could be misplaced to the normal ward at the first postoperative day. Discharge from hospital was performed at the 7th postoperative day with further maintenance in their home hospital. Further follow-up (data available from 5 month to 11 years postoperatively) shows three patients without any complaints. One patient after CABG mentioned no typical ishemic symptoms, showed, however, a low level of loading capacity. Two patients died 2.5 years after operation, but the underlying reasons remain speculative, because of missing autopsy. A clue for a tumor recidivation was not observed in any case.
Traditionally patients suffering from coexisting diseases other than cardiac origins have been treated operatively in different settings. However, in recent years many attempts have been made in order to avoid one more operation and anesthesia with the aim to fulfill two operations in only one setting. The accompanying non-cardiac diseases are various: The method of simultaneous carotid endarterectomy combined with open heart surgery has been reported by different authors, yet, and has become a routine procedure nowadays. Evagelopulos and colleagues report on a series of 313 patients who underwent such a performance [5]. Besides the fact that it has become an accepted concept to treat patients with cardiac disease and concomitant pulmonary cancer in the same setting as a simultaneous operation, Danton and colleagues report on a series of 13 patients [3] with an acceptable perioperative risk and long-term follow-up. This is in agreement with other authors, some of them perform such combined procedures not only as open heart surgery but also as an off-pump operation [6]. Additionally, a review throughout the literature shows singularly other origins of combined cardiac with general or vascular surgical procedures, such as repair of abdominal aneurysm [7], correction of pectus malformations in case of replacement of the ascending aorta [8], or resection of a retrosternal goiter [9]. Our current series represents a population of two different basic diseases with no underlying substantial connection. In case of pulmonary cancer many successful attempts have been made to treat both diseases in one operation. The aim of our study was to prove this concerning renal carcinoma too. The advantage has to be seen in avoiding a second procedure and hence anesthesia. Besides that a delayed tumor resection may increase the risk of filialirization and additionally the doubling of costs has to be considered. Furthermore, exposure to the immunosuppressive effects of cardiopulmonary bypass may have a deleterious effect on tumor growth and dissemination [2]. In contrast, possible disadvantages, such as systemic heparinization in a two cavity-operation with an increased risk of bleeding have to be considered. Besides that the immediate perioperative burden may be more intensive and impair the outcome. To our knowledge, currently no data concerning combined renal tumor resection and open heart surgery as two different origins are available from the literature. However, there are many reports concerning tumor thrombus of a renal cancer into the inferior vena cava, in some cases even with extension to the right atrium, such as Willms tumor. In those cases the use of extracorporeal circulation is absolutely indispensable. Franke and colleagues [15] report on a 68-year-old man suffering from combined ischemic heart disease and malignant tumor of the right kidney with continuous growth of a tumor cone into the subdiaphragmal vena cava, which could be resected in deep hypothermia and circulatory arrest. This performance emphasizes the possibly higher risk of such surgery. Table 3 reflects the recent results of different centers. The results of our current series—remembering the relatively low number of patients—are in agreement with many other studies from the literature where a satisfactory long-term survival is demonstrated. These results are congruent to investigations concerning other simultaneous approaches, such as cardiac surgery and carotid endarterectomy or pulmonary tumor resection. Thus we conclude that two-cavity performance for open heart surgery and tumor resection of the kidney is a save and cost spearing procedure as demonstrated by the immediate perioperative results. doi:10.1016/S1569-9293(03)00236-6
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Abstract
1. Introduction
