Piggyback liver transplant techniques in the surgical management of urological tumors with inferior vena cava tumor thrombus

Background An important characteristic of renal cell carcinomas and adrenal tumors is that these tumors may expand into the renal vein and inferior vena cava, and transform into tumor thrombi. This study was to evaluate the use of piggyback liver transplant techniques for surgical management of urological tumors with inferior vena cava tumor thrombus.Methods Nineteen patients with renal cell carcinomas or adrenal tumors with inferior vena cava tumor thrombus were treated from November 1995 to April 2008. Their ages ranged from 29 years to 76 years (mean 54 years). The extent of tumor thrombus was infrahepatic (level Ⅰ) in 2, retrohepatic (level Ⅱ) in 7, suprahepatic (level Ⅲ) in 6, and intra-atrial (level Ⅳ) in 4 patients. We used cardiopulmonary bypass with deep hypothermic circulatory arrest to remove the thrombi in 3 cases of level Ⅳ and in 2 cases of level Ⅲ. In all level Ⅱ, 4 level Ⅲ, and 2 level Ⅳ cases, we used piggyback liver transplant techniques to mobilize the liver off of the inferior vena cava and to separate the inferior vena cava from the posterior abdominal wall.Results Mean operative time was 5.1 hours, mean estimated blood loss was 2289 ml and mean blood transfusion was 12.84 U. One patient with adrenal cortical carcinoma and level Ⅳ thrombus died in the immediate postoperative period. Three patients were lost to follow up, and the other 15 survivors were followed from 5 months to 56 months. Eight of these 15 patients died due to metastasis; however 7 were still alive at the last follow-up.Conclusions An aggressive surgical approach is the only hope for curing patients diagnosed with urological tumors combined with inferior vena cava tumor thrombus. The use of piggyback liver transplant techniques to mobilize the liver off of the inferior vena cava provides excellent exposure of the inferior vena cava. Patients with a level Ⅱ or level Ⅲ inferior vena cava thrombus may be treated without using cardiopulmonary bypass.