ACA App
Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
Home | About us | Editorial Board | Search | Ahead of print | Current Issue | Archives | Submission | Subscribe | Advertise | Contact | Login 
Users online: 963 Small font size Default font size Increase font size Print this article Email this article Bookmark this page
 


 

 
     
    Advanced search
 

 
 
     
  
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Email Alert *
    Add to My List *
* Registration required (free)  


    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures

 Article Access Statistics
    Viewed1378    
    Printed59    
    Emailed0    
    PDF Downloaded103    
    Comments [Add]    

Recommend this journal

 


 
Table of Contents
CASE REPORT  
Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 137-139
Technology: An aid to clinical judgement


1 Consultant Department of Anesthesia, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, India
2 Consultant Department of Urology, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, India
3 Consultant Department of Cardiac Surgery, G. Kuppusamy Naidu Memorial Hospital, Coimbatore, India

Click here for correspondence address and email

Date of Submission09-Nov-2012
Date of Acceptance04-Jan-2013
Date of Web Publication29-Mar-2013
 

   Abstract 

Complete removal of renal cell tumor with thrombus which extends above the diaphragm often necessitates use of cardiopulmonary bypass. Transesophageal echocardiography (TEE) can play an important role in delineating the extent of tumor growth. We describe a patient with renal cell carcinoma with thrombosis invading into the right ventricle and its complete removal with the aid of TEE.

Keywords: Cardiopulmonary bypass, Renal cell carcinoma, Right atrial thrombus, Transesophageal echocardiography

How to cite this article:
Govindasamy R, Manickam P, Gopalakrishnan G, Muralidharan S. Technology: An aid to clinical judgement. Ann Card Anaesth 2013;16:137-9

How to cite this URL:
Govindasamy R, Manickam P, Gopalakrishnan G, Muralidharan S. Technology: An aid to clinical judgement. Ann Card Anaesth [serial online] 2013 [cited 2019 Sep 17];16:137-9. Available from: http://www.annals.in/text.asp?2013/16/2/137/109771



   Introduction Top


Cochrane review showed that perioperative monitoring with pulse oximetry does not improve the outcome, effectiveness, and efficacy. [1] Apparently, it is very difficult to demonstrate that any monitoring device improves patient outcome. [2],[3] On the contrary, transesophageal echocardiography (TEE) has improved the patient outcome in many situations. Non-cardiac surgery has been increasingly identified as a potential valuable indication for TEE. [4] TEE, a minimal-risk, semi-invasive imaging procedure is increasingly becoming an indispensable part of an anesthesiologist's armamentarium. It provides a unique and well-documented diagnostic advantage in certain clinical scenarios. We describe a case where the technology (TEE) aided clinical judgment improved the patient outcome.


   Case Report Top


A 55-year-old, 64-kg gentleman was admitted with abdominal swelling of 2 months duration with decreased urine output and bilateral pedal edema. The diagnostic work-up revealed stage IV right renal cell carcinoma (RCC) with no co-morbidity. Pre-anesthetic evaluation revealed heart rate of 110/min, a blood pressure of 110/80 mmHg, and diminished air entry in the basal areas of right chest. His laboratory investigations showed a hemoglobin 8.3 gm% and a marginally raised serum creatinine of 1.7 mg%; the other laboratory results were within the normal limits.

Ultrasound examination of the abdomen revealed a large right renal mass measuring 21 × 15.2 cm with extension of the tumor mass in to the inferior vena cava (IVC). Transthoracic echocardiography (TTE) revealed a right atrial mass protruding in to the right ventricle with a suspicious entry in to the pulmonary artery. X-ray chest showed a right pleural effusion. The computed tomographic imaging findings were complimentary to the ultra-sonogram and echocardiogram. Magnetic resonance imaging and lung perfusion scan were not performed. The patient was scheduled for a right radical nephrectomy and removal of the right atrial mass under cardiopulmonary bypass (CPB). The multidisciplinary team consisted of an anesthesiologist, an urologist, a cardiac surgeon, and a perfusionist. The patient was premedicated with intramuscular morphine sulfate 7.5 mg and glycopyrrolate 0.2 mg. In the operating room, monitoring commenced with standard 5-lead electrocardiogram with ST segment analysis, pulse oximetry, capnography, nasopharyngeal temperature, and urine output. Before anesthesia induction, right radial artery and right internal jugular vein (Arrow 8.5F Quadri-lumen Catheter, Reading PA, USA) was cannulated under local anesthesia for direct arterial and central venous pressure monitoring. Two large bore, 14G, peripheral intravenous cannulae were placed in both the forearms. Anesthesia was induced with 200 μg of fentanyl and 100 mg of thiopentone sodium and endotracheal intubation was facilitated with 8 mg of vecuronium. The airway was secured with an 8.5 mm tracheal tube, (Smiths Medical, Kent, UK). Anesthesia was maintained with 50:50 air: Oxygen mixture, 1-1.5 MAC (minimum alveolar concentration) isoflurane, and intermittent boluses of fentanyl and vecuronium. An X Matrix iE 33 (Philips, Bothel, USA) TEE probe was inserted; TEE imaging showed a right atrial mass flipping in to the right ventricle. There was no extension of the tumor in to the pulmonary artery [Figure 1].
Figure 1: Wrap around view showing the tumor thrombus in right atrium and right ventricle

Click here to view


A bilateral sub-costal roof-top incision was first performed by the urologist and the abdomen opened. A large right lower pole renal mass with a thrombus occupying the entire IVC was noted. The renal mass was mobilized and right nephrectomy was performed after ligation of the renal vessels. The apex of the sub costal incision was then extended in the midline upward, toward the suprasternal notch to facilitate a mid-line sternotomy (Mercedes Benz incision). Throughout the surgical procedure, at critical points, TEE monitoring was performed and a close communication with the surgeons was maintained. Following sternotomy and systemic heparinization, ascending aorta and superior vena cava were cannulated in the standard way, but the IVC was cannulated in the abdomen well below the renal vein and CPB was established. The patient was cooled to 30°C. Red blood cells were added to the CPB prime to maintain hematocrit above 25%. After cardioplegic arrest, the right atrium was opened and the tumor mass occupying the IVC, right atrium, and the right ventricle was removed en-bloc without leaving behind any remnants. The patient was then rewarmed to 36°C and preparations were made to wean the patient from CPB. However, the TEE examination before separation from CPB revealed two more pieces of small tumor mass attached to the IVC near the site of entry of the hepatic vein [Figure 2]. Attempts at removal by Fogarty catheter and Foley balloon inflation were unsuccessful. Then, it was decided to maintain CPB and the supra-hepatic part of the IVC was opened after mobilizing the liver and the tumor mass was removed under vision. The IVC was then closed and the patient weaned from CPB. The subsequent TEE examination showed a clear IVC [Figure 3]. A complete TEE examination was performed to check for any remnant tumor bits in the IVC, right atrium, right ventricle, and the pulmonary artery. There were no remnant tumor bits. After ensuring complete tumor removal, the patient was weaned from CPB, heparin was neutralized with protamine sulfate, hemostasis was secured, and sternum was wired and the chest and the abdomen were closed in layers. Intraoperatively, the patient received about 3000 ml of crystalloids and five units of whole blood, two packed cells, and four units of fresh frozen plasma . At the end of procedure lasting about six and half hours, the patient was transferred to intensive care unit (ICU) with stable hemodynamics for postoperative ventilation. He was extubated the following morning. In the ICU, he received two units of whole blood and two units of platelet-rich plasma. He maintained good urine output in the postoperative period. He was discharged on the 14 th postoperative day in a stable condition. At discharge, his serum creatinine was 1.2 m%. Abdominal ultrasound examination performed in the follow-up did not reveal any residual tumor.
Figure 2: Tumor bits in the inferior vena cava and at hepatic vein junction

Click here to view
Figure 3: Inferior vena cava free from tumor thrombus

Click here to view



   Discussion Top


RCC is the most common malignancy of the kidney. When RCC progresses, it is known to form tumor thrombus in the renal vein and/or the vena cava. Historically, up to 10% of patients with RCC have tumor thrombus involving the renal vein or vena cava and 1% have tumor thrombus extending in to the right atrium. [5] Non-metastatic RCC with extension into the vena cava is potentially curable.

In recent times, with the introduction of improved imaging and monitoring techniques and adoption of advanced surgical and vascular bypass techniques for stage III and IV tumors, the incidence of early surgical complications and operative deaths have decreased. Aggressive surgical resection of these extensive lesions can produce a long-term freedom from disease. It has been shown that the extent of the tumor thrombus does not determine the outcome or survival. As tumors in the vena cava enlarge rapidly, reliance only on recent radiographic imaging, when surgery is being contemplated is emphasized. RCC extending into the IVC or the right atrium present a surgical challenge and calls for multidisciplinary management. Improvements in cross-sectional imaging, the introduction of dynamic monitoring with TEE, and the adoption of vascular bypass techniques have improved the safety and completeness of these operations. Intraoperative TEE allows early assessment of the tumor thrombus characteristics that predict a free-floating and easily extractable thrombus either in the supra-diaphragmatic vena cava or the right atrium. Intraoperative TEE also monitors the thrombus during mobilization phase of the operation during which the thrombus can potentially embolize. Our patient had a free-floating thrombus extending in to the right ventricle and it could be extracted very easily. But for the presence of TEE monitoring, the assessment of completeness of the surgical procedure may not have been possible as the TEE demonstrated adherent tumor bits in the IVC while preparation were made to wean the patient from CPB. Although attempts to extract tumor bits by Foley catheter were unsuccessful and necessitated hepatic mobilization to expose the supra-diaphragmatic part of the vena cava for the removal of tumor bits, it was worth the effort in achieving a complete removal of the thrombus which was demonstrated by TEE imaging. These advances have led to decreased mortality and perioperative morbidity, and overall improved surgical outcome for patients who present with the most challenging tumor treatment in genitourinary oncology.

 
   References Top

1.Pedersen T, Dyrlund Pedersen B, Møller AM. Pulse oximetry for perioperative monitoring. Cochrane Database Syst Rev 2003;(3): CD002013.  Back to cited text no. 1
    
2.Moller JT, Pedersen T, Rasmussen LS, Jensen PF, Pedersen BD, Ravlo O, et al. Randomized evaluation of pulse oximetry in 20,802 patients: I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology 1993;78:436-44.  Back to cited text no. 2
    
3.Moller JT, Johannessen NW, Espersen K, Ravlo O, Pedersen BD, Jensen PF, et al. Randomized evaluation of pulse oximetry in 20,802 patients: II. Perioperative events and postoperative complications. Anesthesiology 1993;78:445-53.  Back to cited text no. 3
    
4.American Society of Anesthesiologists and Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Practice guidelines for perioperative transesophageal echocardiography. An updated report by the American Society of Anesthesiologists and the Society of Cardiovascular Anesthesiologists Task Force on Transesophageal Echocardiography. Anesthesiology 2010;112:1084-96.  Back to cited text no. 4
    
5.Blute ML, Leibovich BC, Lohse CM, Cheville JC, Zincke H. The Mayo Clinic experience with surgical management, complications and outcome for patients with renal cell carcinoma and venous tumour thrombus. BJU Int 2004;94:33-41.  Back to cited text no. 5
    

Top
Correspondence Address:
Palaniappan Manickam
79, 10th Cross Street, Thirumagal Nagar, Pelamedu Pudur, Coimbatore - 641 004
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.109771

Rights and Permissions


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top