Case Study: Surgical Oncology

Renal Retroperitoneal Mass Adherent to the Inferior Vena Cava with Blood Conservation by Cell Saver and Intraoperative Normovolemic Hemodilution (IANH)

A 68-year old woman who is one of Jehovah’s Witnesses presented with general malaise and some left upper quadrant pain and nausea. Her history was significant for a right nephrectomy for renal cell carcinoma 15 years ago. A CT scan revealed a heterogeneous mass located in the right-sided retroperitoneal space measuring 8 by 11 cm with compression of the inferior vena cava (IVC) and effacement of the gallbladder. In addition, she had a pacemaker implant 3 years prior, for the treatment of sick sinus syndrome. 

Two surgeons, Dr. James Black from vascular surgery, and Dr. Mohamed Allaf from Urology as well as Dr. Steven Frank, the Medical Director of the Center for Bloodless Medicine and Surgery  were consulted. Drs. Frank and Allaf saw her at the same time together, along with her family members, to map out an intraoperative plan. On reviewing the CT scans, the three physicians decided that a surgical resection would be high-risk, given the involvement of the vena cava, and that the risk of bleeding was significant. The risks and benefits of the procedure, as well as the available blood conservation techniques were discussed with the patient and her family. It was decided that by using autologous blood salvage (Cell Saver), along with a special leukoreduction filter, the risks would be minimized and the planned procedure could be accomplished. Intraoperative autologous normovolemic hemodilution (IANH) was also discussed as a blood conservation technique and the patient agreed this was acceptable to minimize risks.

The preoperative hemoglobin level was 14.7 g/dL, which was thought to be adequate for this surgical procedure. The anesthesia plan was developed by Dr. Frank, which included a thoracic epidural to minimize both postoperative pain and the requirement for narcotic pain medications. Large bore venous access was placed after induction of general anesthesia, using three 8.5 French introducers, 2 in the right and 1 in the left internal jugular veins. An intra-arterial catheter was also placed in the radial artery for continuous blood pressure monitoring. This degree of venous access would allow for veno-veno bypass from the iliac vein to the right atrium, if a vena cava cross clamp was necessary to remove the tumor. Prior to incision, 2 units of fresh whole blood were removed into CPDA anticoagulant bags, but remained in continuity with the patient’s circulation (via IV tubing) at all times. A volume expander (albumin) along with 2 liters of crystalloid solution were given for the hemodilution technique. Phenylephrine was given to maintain blood pressure during the IANH phlebotomy to allow the safe removal of autologous blood. 

The surgery was performed through a right-sided thoraco-abdominal incision, and the diaphragm was taken down to provide access to the tumor. The tumor was identified and was adherent to the vena cava, but appeared to be resectable. A sidebiting cross clamp was applied to the cava, the tumor was removed, and the cava was repaired. There was no need for veno-veno bypass as the patient tolerated the partial cross clamp with hemodynamic stability. The blood loss was substantial (1,200 mLs) which for her body mass (50kg) was about 1/3 of her entire blood volume (calculated as 70 mL per kg or 3,500 mLs). The shed blood was processed through the Cell Saver and returned to the patient using the leukoreduction filter to minimize and chances of spreading tumor cells. The 2 units of autologous whole blood were given back to her near the end of the procedure. The closure included repair of the diaphragm and no chest tube was required. 

On postoperative day #1 she was sitting up in a chair and on postoperative day #2 she was walking. A duplex ultrasound exam of the vena cava and iliac veins revealed good blood flow, and no narrowing or thrombosis. Pain scores and narcotic requirements were minimal due to the thoracic epidural. The pathology report came back as recurrent papillary renal cell carcinoma, with clean margins, indicating the tumor was completely resected. She was discharged to home on postoperative day #7 to be followed up by Oncology.