Ying Wei Lum

Graft Reconstruction of Inferior Vena Cava for Renal Cell Carcinoma Stage pT3b or Greater

OBJECTIVES To review the methods and outcomes for simultaneous radical nephrectomy and inferior vena cava (IVC) graft reconstruction at our institution. Renal cell carcinoma has the potential to propagate and invade the IVC, requiring resection and/or reconstruction of the IVC concurrently with radical nephrectomy. METHODS A prospective database of patients undergoing simultaneous radical nephrectomy with IVC reconstruction for renal cell carcinoma was queried. The data were collected and analyzed for patients who had undergone IVC graft reconstruction. RESULTS A total of 17 patients were identified from 1999 to 2010, with a median age of 61 years (range 36-77). The tumor was right sided in 14 patients. The median tumor size was 12 cm (range 7.5-23), 15 tumors had clear cell histologic findings, and 16 were high grade. Seven patients had clinical metastasis found on imaging preoperatively, with another 4 having lymph node metastasis on pathologic examination. Of the 17 patients, 11 underwent patch grafting (3 expanded polytetrafluoroethylene and 8 bovine pericardium) and 6 underwent IVC interposition (3 Dacron and 3 expanded polytetrafluoroethylene). Also, 5 and 3 patients underwent cardiopulmonary and venovenous bypass, respectively. The mean estimated blood loss was 4 L, and the mean hospitalization was 7 days (range 5-16). Six patients experienced perioperative complications, with 1 perioperative mortality. Two patients overall developed graft thrombosis. Of the 6 patients initially without metastasis, the recurrence-free and overall survival rate was 50% and 83%, respectively, at a mean of 55 months. Of the 11 patients initially with metastasis, the recurrence-free and overall survival rate was 18% and 45%, respectively, at a mean of 13 months. CONCLUSIONS For selected patients with advanced renal cell carcinoma and extensive IVC thrombus, resection with patch or interposition grafting of the IVC yields acceptable patency rates, minimal complications related to the graft, and reasonable oncologic results in a high-risk patient population.

Outcomes of Bypass Support Use during Inferior Vena Cava Resection and Reconstruction

BACKGROUND The safety and effectiveness of using venovenous and cardiopulmonary bypass for resection of the inferior vena cava (IVC) is not well studied. The goal of this study was to compare outcomes following IVC resection with and without bypass support. METHODS We analyzed all patients undergoing IVC resection at our institution (September 1999 to June 2014) and compared the use of bypass support with cross-clamp alone using univariable and Kaplan-Meier analyses. The outcomes included perioperative complications and survival. RESULTS Sixty-three patients underwent IVC resection (mean age 58 ± 2 years, mean follow-up 21 ± 3 months). Bypass patients (32%) were similar to non-bypass patients (68%) in age, gender, tumor size, type, and grade (P = nonsignificant [NS]). Bypass patients were more likely to undergo complete IVC reconstruction (55% vs. 24%, P = 0.01) at the suprarenal level (62% vs. 35%, P = 0.05), and had higher intraoperative blood loss (9.6 ± 2.1 vs. 3.2 ± 1.4 L, P = 0.01). Complete R0 resection was similar between groups (50% vs. 52%, P = NS). There were more overall perioperative complications in bypass patients (P = 0.0005), with a trend toward more frequent venous thromboembolic events (40% vs. 21%, P = 0.13). The incidence of acute kidney injury (10% vs. 9%) and renal failure requiring dialysis (10% vs. 2%) was similar (P = NS). Length of stay was longer following bypass (12.2 ± 1.2 vs. 8.0 ± 0.1 days, P = 0.004). There were no differences in overall mortality (15% vs. 14%, P = NS) or tumor recurrence (50% vs. 47%, P = NS). Bypass patients had a nonsignificant trend toward longer disease-free survival (20.7 ± 5.2 vs. 10.4 ± 3.8 months, P = 0.12). CONCLUSIONS The use of bypass support for IVC resection is associated with more complex operations and higher rates of perioperative complications. However, the overall mortality and morbidity of bypass, including renal complications, is similar to cross-clamping alone. Thus, the need for bypass should not preclude attempts at complete tumor resection.

Herpes simplex virus following stab phlebectomy.

Herpes simplex virus infection following surgery is an unusual postoperative phenomenon. Many mechanisms have been suggested, with the most likely explanation related to latent virus reactivation due to a proinflammatory response in the setting of local trauma. Here, we present a case of herpes simplex virus reactivation in an immunocompetent female following a conventional right lower extremity stab phlebectomy. Salient clinical and physical examination findings are described, and management strategies for herpes simplex virus reactivation are outlined. This is the first known case report of herpes simplex virus reactivation following lower extremity phlebectomy.

Surgical Updates on Thoracic Outlet Syndrome

Purpose of ReviewThoracic outlet syndrome is a widely recognized, yet highly disputed, syndrome mostly affecting structures of the thoracic outlet, including the brachial plexus, subclavian artery, and subclavian vein. Surgical decompression in the form of first rib resection with scalenectomy remains the mainstay of treatment particularly for venous and arterial thoracic outlet syndrome. This review serves as an update of recent publications/updates in the literature.Recent FindingsApproaches to operative management continue to evolve as minimally invasive techniques have increased in popularity. Diagnostic techniques continue to evolve, particularly with regard to neurogenic thoracic outlet syndrome, to allow for more timely and accurate diagnosis. Conservative management strategies, such as anterior scalene muscle blocks, are utilized with increasing frequency, although their long-term outcomes remain unclear.SummaryThe aim of the present work is to review updates in the diagnosis and management of thoracic outlet syndrome over the last decade, and discuss utility and outcomes of various strategies.