Management of synchronous retroperitoneal and nonretroperitoneal disease

It is not uncommon to have postchemotherapy residual disease at multiple sites within and outside the retroperitoneum. Presurgical planning is individualized and may require coordination with multiple surgical specialties based on tumor location, including urology, general and thoracic surgery, and otolaryngology. To minimize the number of surgical procedures, resection of residual disease at multiple sites under one anesthetic seems appropriate if there is no significant increase in complications. Some earlier reports described multiple sequential surgeries to excise all residual masses [9,24]. These retrospective series demonstrated few major perioperative complications. In 1983, Mandelbaum and colleagues [23] described the first one-stage procedure for simultaneous thoracic and retroperitoneal residual disease in 24 patients. Eighteen patients underwent median sternotomy and 6 had thoracotomy for residual thoracic disease, followed by RPLND under the same anesthetic. There were no perioperative deaths or major complications. When compared with the entire cohort of 72 patients who underwent resection of residual thoracic disease, the subset undergoing combined excision only had a slightly prolonged ileus without other additional morbidity. Long-term survival was similar in the overall and combined groups (74% and 83%, respectively).

In 1996, investigators from MSKCC reviewed their experience with 24 patients who underwent simultaneous retroperitoneal and thoracic resection of postchemotherapy residual masses [20]. In addition, 3 of these patients also underwent formal neck dissection to remove an anterior cervical mass. Three patients were excluded from the single-stage operative approach because of poor pulmonary function. All patients had midline abdominal incisions for the RPLND, and the incision was extended to a thoracoabdominal approach in 2 patients. The other 22 patients received separate thoracic incisions. More than half of the patients received high-risk or salvage chemotherapy, 5 had undergone previous RPLND, and 2 demonstrated elevated a-fetoprotein levels before surgery. Fourteen patients underwent modified rather than complete RPLND because the frozen section demonstrated only necrosis. The overall 5-year survival was 79%. This study demonstrated that simultaneous resection of abdominal, thoracic, and cervical residual masses was a feasible and safe alternative to multiple staged procedures. A retrospective study from Indiana University reviewed 143 patients who underwent resection of residual retroperitoneal and chest disease under the same anesthetic [25]. Fifty of the 143 cases (35%) were classified as having a complicated postoperative course. When compared with the overall group who underwent postchemotherapy RPLND at Indiana University during the same time period, major and minor complications were significantly higher in the subset of 143 patients who underwent the combined approach. No single major or minor complication was more likely in the patients who underwent the combined procedure. The investigators concluded that a combined removal of retro-peritoneal and thoracic disease was reasonable based on morbidity. The possibility of added complications was offset by the elimination of additional surgical procedures.

Patients who have residual hepatic lesions frequently undergo synchronous resections. Hahn and colleagues [12] reviewed the Indiana University experience with resection of residual hepatic disease in 57 patients. Concomitant procedures were performed in 53 of 60 (87%) liver resections, including 37 RPLNDs. Complications occurred in 18 procedures (30%), 15 (83%) of which entailed synchronous resections at multiple sites. Chylous ascites is a well-known complication associated with synchronous liver resection [13].

The above studies demonstrate that a combined approach under the same anesthetic for retroper-itoneal and non-retroperitoneal lesions is acceptable based on morbidity in this relatively young and healthy patient population. Appropriate patient selection is imperative, and preoperative evaluation must reveal adequate pulmonary function. The combined procedure must be technically feasible with acceptable blood loss and reasonable time constraints. Because of the nature of the combined procedure, a multidisciplinary approach must be coordinated with surgeons from various specialties.

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