Year : 2013  |  Volume : 16  |  Issue : 2  |  Page : 137--139

Technology: An aid to clinical judgement


Radhika Govindasamy1, Palaniappan Manickam1, Ganesh Gopalakrishnan2, S Muralidharan3,  
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

Correspondence Address:
Palaniappan Manickam
79, 10th Cross Street, Thirumagal Nagar, Pelamedu Pudur, Coimbatore - 641 004
India

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.



How to cite this article:
Govindasamy R, Manickam P, Gopalakrishnan G, Muralidharan S. Technology: An aid to clinical judgement.Ann Card Anaesth 2013;16:137-139


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 2020 Apr 6 ];16:137-139
Available from: http://www.annals.in/text.asp?2013/16/2/137/109771


Full Text

 Introduction



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



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}

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}{Figure 3}

 Discussion



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.

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