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Role of Epiaortic Ultrasound Probe Intraoperatively to Give Clamp over Inferior Vena Cava while Removing Renal Cell Carcinoma from IVC along with Nephrectomy |
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Vipin kumar singh, Sandeep sahu, Rajee V Ratan 1. Assistant Professor, Department of Anaesthesia and Critical Care, KGMU, Lucknow (UP), India. 2. Associate Professor, Department of Anaesthesia and Critical Care, SGPGIMS, Lucknow (UP), India. 3. Assistant Professor, Department of Anaesthesia and Critical Care, RMLIMS, Lucknow (UP), India. |
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Correspondence Address : Dr. Vipin Kumar Singh, Department of Anaesthesiology and Critical Care, KGMU, Lucknow-226003, UP, India. E-mail: vipintheazad@gmail.com |
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| ABSTRACT |  | ||||||||||||||||||
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| Keywords : Intraoperative USG probe, IVC extension, Radical nephrectomy | |||||||||||||||||||
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| DOI and Others : 10.7860/IJARS/2016/16501:2102 | |||||||||||||||||||
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| INTRODUCTION |
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Sir, Renal cell carcinoma has got some unique features like its intracaval extension as a tumor thrombus without involvement of vena cava wall in majority of cases (1),(2). Extension in vena cava is seen in 4-10% of cases (3),(4). Radical nephrectomy along with vena caval thrombectomy is the only treatment strategy for those patients who do not have metastasis (5),(6). The distal end of the tumor thrombus in the inferior vena cava (IVC) is the basis of classification for the level of thrombus. The level I thrombus is defined as when the distal end of thrombus extend below the liver (infra hepatic), level II thrombus are those lying behind the liver (retro-hepatic) and level III thrombus are supra diaphragmatic with or without extension to the right atrium (7). It is essential to know the cephalad extension of the tumor thrombus in the IVC because the surgical techniques for thrombectomy are decided by the distal end of thrombus and it will affect the immediate surgical outcome also (7),(8). By means of CT scan or MRI and color doppler ultrasound we can determine the distal end of tumor thrombus as well as patency of the hepatic veins. But intraoperatively due to manipulation of renal tumor and adhesiolysis, extension of tumor in vena cava could be changed. At this point of time, clamp over vena cava without knowing the present status of extension might be disastrous due to embolisation of some part of tumor to heart. To know the extension of tumor intraoperatively, we used epiaortic ultrasound probe (5to12 MHz) over vena cava, after that clamp applied. This approach might be beneficial in case of level I and level II tumor thrombus to avoid tumor embolisation. A case of 23 yrs old male presented to Urology Department with chief complaint of haematuria with passage of clots for last 2 months, pain in right flank region for 2 months and fever off and on for 2 months. On inspection, there was diffuse abdominal swelling involving right hypochondrium, epigastrium and right lumbar region. On palpation, a 25×25 cm non tender, globular, firm mass detected. Investigations showing haemoglobin 7.6 g/dl, total leucocyte count 7700/ mm3, platelet count 2.15×105/mm3. Serum sodium 141 mEq/L, serum potassium 5.0mEq/L and serum creatinine 0.7 mg/dl. On MRI report, right kidney was totally replaced by a well defined heterogeneously enhancing large mass with invasion of perirenal fascia noted (Table/Fig 1). Right renal vein was thrombosed with thrombus seen extending upto the infrahepatic portion and retro- hepatic portion of IVC (approximately 3.2 cm below the hepatic vein in confluence draining into IVC). The IVC was focally expanded in the renal segment and non enhancing hypointense thrombus was seen filling the IVC for 6.3 cm with a thin rim of peripheral contrast (Table/Fig 2). Multiple small retroperitoneal lymph nodes were observed. He is diagnosed a case of renal cell carcinoma with level II tumor thrombus. After anesthetizing the patient, we put central line and arterial line for beat to beat hemodynamic monitoring. After proper painting and draping, Chevron incision was made over abdomen. Adhesiolysis around the tumor was done, after mobilization of intestine. Renal artery and vein ligated and kidney removed with minimal disturbance of IVC (Table/Fig 3). To know the exact extension of tumor in IVC, intraoperatively we used epiaortic ultrasound probe (5 to 12 MHz) over vena cava. Upper extension of tumor in IVC is seen and we applied clamp there. Then inferior vena cava opened and thrombus removed in toto with excision of IVC wall at points of invasion with tissue margin then repaired again with prolene. During intraoperative period, hemodynamics was stable. After surgery, extubation was done. In the postoperative recovery room , patient was hemodynamically stable. We observed him intensively for next 24 hrs. In this way, by using epiaortic ultrasound probe intraoperatively we can assure extension of tumor inside IVC and then clamping site accordingly. Otherwise tumor embolisation could lead to increase in morbidity and mortality of renal cell carcinoma patients. | |||||||||||||||||||
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