Surgical management of adrenal tumours extending into the right atrium

Abstract

This paper discusses the surgical approach for the treatment of adrenal tumours extending into the right atrium (RA), using a cardio-pulmonary bypass (CPB) associated with deep hypothermic circulatory arrest (DHCA). Pre-operative planning and surgical steps are described in details. The association of CPB with hypothermic circulatory arrest (HCA) provides a bloodless operating field, direct intra-vascular vision, reduces the risk of embolization and allows extensive inferior vena cava (IVC) or RA repair in cases of infiltration of the vascular wall. Establishing a dedicated multidisciplinary team with experience in managing these challenging cases is fundamental to offer treatment to patients with advanced disease, who would otherwise risk being turned down for surgery. A close collaboration between general and cardiac surgeons and a deep understanding of the surgical procedure steps are fundamental to safely performing these procedures. We advocate centralising adrenal surgery in a small number of units with adequate multidisciplinary support.

Surgery for advanced adrenal malignant disease: recommendations based on European Society of Endocrine Surgeons consensus meeting

“…As R0 surgical resection is the only curative option, IVC resection should be discussed in a referral centre. A recent publication 45 detailed the technical aspects of such operations and the support provided by cardiac surgeons. The multicentre ESES survey 46 published in 2012 reported favourable outcomes in patients with IVC invasion.…”

Adrenalektomide endikasyonlar ve cerrahi seçenekler

“…Tumours of the right adrenal gland frequently involve the IVC due to the right adrenal vein directly draining into it. [31] In the presence of tumor thrombus in the inferior vena cava, it has to be removed with the tumor. The technique used for intra-operatory venous control depends on the location and extension of the tumour/thrombus in the venous circulation; the extension of the thrombus should be detected with the preoperative imaging studies.…”

“…The technique used for intra-operatory venous control depends on the location and extension of the tumour/thrombus in the venous circulation; the extension of the thrombus should be detected with the preoperative imaging studies. [31] Cross clamping of the IVC is sufficient if the upper limit of the tumour/thrombus is below the hepatic veins. Hepatic vascular exclusion (HVE) is needed if the tumour/thrombus extends into the hepatic veins or into the retro-or supra-hepatic IVC.…”

“…In case of subdiaphragmatic tumor thrombus, venous control is provided by cardiopulmonary bypass and hypothermic circulatory arrest (HCA). [31] If there is any question of local invasion into the kidney parenchyma or renal hilar vessels, partial nephrectomy or total nephrectomy should be performed to ensure an R0 resection. In some cases, the kidney may be able to be spared if the renal hilar vasculature is not involved, and the renal capsule can be included as part of the inferior margin.…”