Surgical Treatment of Inferior Vena Cava Leiomyosarcoma

Vol. 211, No. 1, July 2010

3. Sancho A, Gavela E, Avila A, et al. Risk factors and prognosis for proteinuria in renal transplant recipients. Transplant Proc 2007; 39:2145–2147. 4. Meier-Kriesche HU, Arndorfer JA, Kaplan B. The impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. Transplantation 2002;73:70–74.

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Ultrasound-Guided Percutaneous Cholecystostomy in Pregnancy Jay Requarth, MD, FACS Winston-Salem, NC I read with great interest the evidence-based review on the management of biliary tract disease during pregnancy by Neumayer and colleagues.1 Treatment options for cholecystitis were limited to laparoscopic cholecystectomy and observational management. Unfortunately, another therapeutic option, ultrasound guided percutaneous cholecystostomy (UGPC), was not listed. Described by Radder in 1980, a percutaneous drainage catheter can be placed with local anesthesia utilizing 2-dimensional B-mode ultrasound, without ionizing radiation, with excellent results.2-5 Furthermore, UGPC has been used successfully in patients with acute cholecystitis during pregnancy.6,7 UGPC will not treat common bile duct stones or gallstone pancreatitis, but bile leakage is rare (approximately 3%).5

REFERENCES 1. Neumayer L, Marcaccio M, Visser B, et al. Management of biliary tract disease during pregnancy. J Am Coll Surg 2010; 210:367–369. 2. Rader RW. Ultrasonically guided percutaneous catheter drainage for gallbladder empyema. Diagn Imaging 1980;49:330–333. 3. Welschbillig-Meunier K, Pessaux P, Lebigot J, Lermite E, Aube C, Brenhant O, et al. Percutaneous cholesystostomy for high-risk patients with acute cholecystitis. Surg Endosc 2005;19:1256–1259. 4. Spira RM, Nissan A, Zamir O, Cohen T, Fields SI, Freund HR. Percutaneous transhepatic cholecystostomy and delayed laparoscopic cholecystectomy in critically ill patients with acute calculus cholecystitis. Am J Surg 2002;183:62–66. 5. Leveau P, Anderson E, Carlgren I, Willner J, Anderson R. Percutaneous cholecystostomy: a bridge to surgery or definite management of acute cholecystitis in high-risk patients. Scand J Gastroenterol 2008;43:593–596. 6. Tseng JY, Yang MJ, Yang CC, Chao KC, Li HY. Acute cholecystitis during pregnancy: what is the best approach? Taiwan J Obstet Gynecol 2009;48:305–307.

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7. Allmendinger N, Hallisey MJ, Ohki SK, Straub JJ. Percutaneous cholecystostomy treatment of acute cholecystitis in pregnancy. Obstet Gynecol 1995;86:653–654.

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Surgical Treatment of Inferior Vena Cava Leiomyosarcoma Andrea Mingoli, MD, FACS Paolo Sapienza, MD Gioia Brachini, MD Barbara Tarantino, MD Bruno Cirillo Rome, Italy We read with great interest the paper by Daylami and colleagues1 reporting their experience on inferior vena cava (IVC) leiomyosarcoma treatment. Six patients affected with a leiomyosarcoma arising from segments I and II were operated on. The IVC was already occluded in 4 patients. In all cases a neoadjuvant radiation treatment was performed 6 weeks before surgery. A radical resection was achieved in 4 cases, and in the two R1 cases, a focal area of tumor was observed at the retroperitoneum and the abdominal aorta. Postoperative complications included a transient acute renal failure (3 cases), a chylous leak (2) and a well-controlled lower limb edema (3). The authors reported encouraging results with no evidence of local recurrence at a 30-month median follow-up and suggested a positive role of preoperative external-beam radiation on mass reduction and tumor-free margin resection. Given the low incidence of severe and definitive postoperative complications, they think that IVC reconstruction can be avoided when tumor arises below the hepatic veins. In 1992 the International Registry of IVC Leiomyosarcoma was established at Sapienza University of Rome.2 At present more than 400 patients have been enrolled and for the majority of them additional clinical, pathologic, and therapeutic data, lacking in the original manuscript, and the up-to-date follow-up were obtained by personal correspondence. During the past 18 years several data analyses have been conducted to investigate pathogenesis and natural history of this tumor and support the most rational treatment.3-5 In 1997 we published the results of a Registry data analysis performed to determine the influence of the extent of venous resection (caval wall vs segmental resection) on survival and local recurrence rates.5 We analyzed 120 patients who had

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undergone an IVC tumor radical resection. An up-to-date follow-up was available for 102 patients. A caval wall resection was performed in 53 patients and a segmental caval resection in 67. Fifty of these 67 patients had a ligature of the IVC, and the remaining 17 patients had a caval reconstruction. In spite of similar long term survival and incidence of local recurrence, the resection of a caval segment was responsible for all early postoperative deaths (3), seven major complications including one renal insufficiency, one IVC syndrome, and 21 cases of lower limb deep venous thrombosis (DVT) without longterm sequelae. IVC leiomyosarcoma is a slow-growing tumor arising from the smooth muscle cells of the caval wall and enlarging by intra- or extraluminal growth rather than by infiltration. The retroperitoneal mass, often very large, is loosely adherent to the adjacent structures, thus permitting its dissection up to the IVC, where it results firmly attached, usually with a small pedicle. Given the lack of lymphatic drainage in the IVC wall, the tumor is usually limited to the site of origin and its radical resection does not require more than a 1-cm margin of free caval tissue. Extended local resection, which is technically more demanding, should be avoided. It can be justified when an intracaval neoplastic thrombus not otherwise removable is present, in rare cases of intramural tumor growth, or to overcome technical difficulties. If an IVC resection is deemed necessary, a prosthetic reconstruction is not mandatory: the rich retroperitoneal venous collateral pathways allow caval ligation without major complications. If the right kidney can be preserved, its vein can be re-anastomosed to the proximal or distal caval stumps. As suggested by Daylami et al., the avoidance of venous reconstruction may reduce operative time, prevent pulmonary embolism from lower limb DVT, and avoid possible complications such as graft infection, high output heart failure, and lifelong anticoagulation. Registry data analysis did not confirm Daylami’s observations about the positive role of adjuvant therapy on easier tumor-free resection, and radiation therapy resulted ineffective on local recurrence rate. However, results of our analysis on adjuvant therapy are still limited by the small number of treated patients and the lack of consistent protocol.

REFERENCES 1. Daylami R, Amiri A, Goldsmith B, et al. Inferior vena cava leiomiosarcoma: is reconstruction necessary after resection? J Am Coll Surg 2010;210:185–190. 2. Mingoli A, Cavallaro A, Stipa S, Feldhaus RJ. Inferior vena cava leiomyosarcoma. J Vasc Surg 1993;17:451. 3. Mingoli A, Feldhaus RJ, Cavallaro A, Stipa S. Leiomyosarcoma of the inferior vena cava: analysis of a world series of 141 patients and report of three new cases. J Vasc Surg 1991;14:688–699.

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4. Mingoli A, Cavallaro A, Sapienza P, et al. International Registry of Inferior Vena Cava Leiomyosarcoma: analysis of a world series of 218 patients. Anticancer Res 1996;16:3201–3205. 5. Mingoli A, Sapienza P, Cavallaro A, et al. The effect of extent of caval resection in the treatment of inferior vena cava leiomyosarcoma. Anticancer Res 1997;17:3877–3882.

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Collaborations between Surgeons and Industry Are Productive and Beneficial to Patients Don Nakayama, MD, FACS Macon, GA Dr Schwarze1 proposes that a tax be assessed on surgical device makers and pharmaceutical companies that would fund a central independent entity to educate and instruct physicians on new drugs and devices. Her goal is to “disentangle the message”—presumably evidenced-based assessments of devices and drugs— “from the marketing.” The Association of Clinical Researchers and Educators has recently been organized to present important arguments that counter those posited by Dr Schwarze and the restrictive policies that are under consideration at her home institution, the University of Wisconsin, and elsewhere. There are several problems with her analysis. First is that marketing per se reflects devious intentions. Device manufacturers and pharmaceutical companies want to produce a product that benefits patients, has acceptably low risks, and makes a profit. This is little different from any clinical practice in academic medical centers. One only needs to watch a Pittsburgh Steelers football game to see the UPMC [University of Pittsburgh Medical Center] logo on the end zone score board or on the top of the tallest skyscraper in the skyline to recognize that marketing is pervasive in all medical endeavors. Not all, or even the thinnest minority, of it is bad. Marketing is a way to get the message out that a product, be it an endovascular device or a specialty university practice, has value and should be used. Second is her proposal for a centrally pooled educational fund financed by industry to eliminate bias in surgical instruction. The interposition of this central source itself would introduce the bias of the council of wise leaders redistributing funds, itself an example of the “magical thinking” that Dr Schwarze decries among surgeons who presumably are being manipulated by industry. Industry groups representing the pharmaceutical industry (PhARMA) and device manufacturers (AdvaMed) have