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Indian Journal of Cancer, Vol. 47, No. 3, July-September, 2010, pp. 349 Letter To Editor Surgical misadventure of transecting tumor infiltrated infrarenal vena cava in a patient of Wilms tumor Kanojia RP, Mishra A1, Rao KLN Departments of Pediatric Surgery, Cardiothoracic and 1 Vascular Surgery, Post Graduate Institute of Medical Education and Research (PGIMER) Chandigarh, India Code Number: cn10085 PMID: 20587920 DOI: 10.4103/0019-509X.64710 Sir, We had an unusual case of a patient with Wilms tumor who underwent surgery as an adjuvant treatment after primary chemotherapy. This 1-year-old male baby had a large right renal tumor with tumor thrombus extending up to the level of hepatic veins in the inferior vena cava (IVC). Doppler examination showed absence of blood flow in the IVC due to thrombus. He underwent 4 cycles of chemotherapy. There was a significant reduction in the size of the renal lump after chemotherapy. He was taken up for nephrectomy with the intent of removing the tumor thrombus from the IVC. Peroperatively, the IVC was densely adhered to the tumor and additionally, due to anatomical misjudgment, it was accidently transected during nephrectomy. Even after transection, there was no bleeding from both the cut ends of the IVC as they were filled with tumor thrombus. The upper end of the transected IVC was further explored to retrieve tumor thrombus, but it was densely adhered to the walls of the vessel. In the end, after ensuring that the opposite renal vein was intact, both ends were left ligated. Intraoperatively, after the transection, the patient did not show any evidence of hemodynamic instability. Postoperatively, the patient recovered well with no hemodynamic consequences in the lower limbs and has been undergoing chemo- and radiotherapy. It was analyzed in retrospect that the patient was having chronic IVC obstruction due to tumor and had already developed collaterals to bypass the infrarenal IVC obstruction. A review of cases where IVC was transected either accidently or deliberately revealed that renal cell carcinoma in adults is the most common instance where IVC is involved, where it is either ligated or resected as part of a tumor excision. [1],[2] Many times it has been left ligated or reconstructed using prosthetic grafts.[3] Although a few reports for pediatric cases exist, it is not advisable to perform a ligation. The presented experience made us aware that if the IVC is disrupted at the infrarenal level, the clinical consequences in terms of the venous return from the lower limbs is minimal as collateral circulation is established due to chronic obstruction. In one of the reports of a trauma victim, the IVC was ligated as a damage control measure for severe bleeding. [4] The patient recovered with some edema in postoperative period, which resolved completely in the follow-up. An obvious anatomical query arises as to where the collaterals form, which are able to facilitate the venous return from the lower extremity. Anatomically, collateral circulation develops via the retroperitoneal and vertebral venous plexuses, ascending lumbar veins, and paravertebral veins, which drain into the azygos and the hemi-azygos systems. Testicular and ovarian veins may also contribute as accessory pathways. [5] These collaterals may take some time to develop in trauma patients who had a good IVC flow prior to the ligation. It can be remarked that IVC ligation is a possible complication of renal tumor with tumor thrombus in the vena cava, and the operating surgeon should be aware of the possible consequences in the occurrence of such an event. Even if it is a chronic venous obstruction, it is unlikely that the patient will have any lower limb venous drainage problems. References
Copyright 2010 - Indian Journal of Cancer |
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