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Minimal Access versus Median Sternotomy for Cardiopulmonary Bypass in the Management of Renal Cell Carcinoma with Vena Caval and Atrial Involvement
William C. Faust, MD, John A. Libertino, MD.
Lahey Clinic, Burlington, MA, USA.

BACKGROUND:
Cardiopulmonary Bypass (CPB) with Deep Hypothermic Cardiac Arrest (DHCA) is a surgical technique used in the management of renal cell carcinoma (RCC) with venous thrombus extension at and above the level of the hepatic veins. Traditional Median Sternotomy (TMS) or Minimal Access (MA) approaches may be used to perform CPB during the resection of these tumors. We aim to review our experience with both approaches and compare operative details, perioperative complications, and recurrence free survival.
METHODS:
From 1986-2012, 70 radical nephrectomies with IVC thrombectomies were performed at our institution using TMS (23 patients) and MA (47 patients) techniques. Preoperative patient characteristics, pathologic data, postoperative complications and follow-up data were compared between groups. Estimates of overall and recurrence free survival were constructed using Kaplan-Meier curves and compared using log-rank testing.
RESULTS:
There were no significant differences with respect to patient demographics or co-morbidities between the MA and TMS group. In the MA vs. TMS group there were significant decreases (p <0.05) in duration of postoperative mechanical ventilation, length of stay, operative time, and number of blood transfusions. Overall and organ system specific complications revealed a decreased rate of wound infection (37.9% v. 12.5%, p=0.0135) and sepsis (14.3% v. 0%, p=0.0137) in patients undergoing MA approach. Perioperative mortality defined as death within 30 days of surgery was significantly reduced in the MA group (30.4% v. 8.5% p=0.0179). Recurrence free survival in the TMS group was 0.59 years and 1.2 years in the MA group (p=0.06)
CONCLUSIONS:
Minimal Access surgical techniques in conjunction with circulatory arrest for the removal of RCC with extensive tumor thrombus provides similar oncologic control with decreased duraiton of mechanical ventilation and length of stay. In addition there were decreased rates of infectious complications. Our findings suggest that MA techniques provide significant advantages over TMS.


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