Five-year survival after retroperitoneal oncologic resection with and without vascular surgeon intervention

Abstract

Objectives

Retroperitoneal tumor resection commonly disturbs major vessels; therefore, surgical teams can recruit vascular surgeons to prevent injuries and improve the prognosis of oncologic patients. The objective of the present study is to establish long-term survival after retroperitoneal tumor resection surgery with an emphasis on the potential impact of preventing or repairing major vessel injuries when tumors are adjacent to the aorta or vena cava.

Methods

Retrospective case series including all cases of surgical removal of retroperitoneal tumors between 2007 and 2020 in a highly specialized hospital in Mexico City. Long-term survival was defined as 5 years after surgical intervention. Descriptive statistics, group-comparison tests, and regression analysis were performed using Stata 16.

Results

From a total of 70 cases, vascular injury occurred in 30 (42.8%) and the vascular surgeon intervened in 19 (27.1%) of them, 4 (21%) were performed by a vascular surgeon with planned intervention, and in 9 (47.3%) cases the vascular surgeon was called to join the surgery due to emergency. Intraoperative bleeding was 2-fold greater in the group with an emergent participation of vascular surgery in contrast with the planned intervention group (4, 235 mL vs 2, 035 mL, p = 0.04). The regression model revealed a significant association between the intervention of a vascular surgeon and long-term survival (OR 59.3, p = 0.03) after adjusting for sociodemographic and characteristics of oncologic nature.

Conclusions

Planned intervention of vascular surgeons in retroperitoneal tumor resection may have a positive impact not only in trans-operatory period, but also on long-term survival.

Keywords

Retroperitoneal neoplasms retrospective studies vascular system injuries Mexico biometry vascular surgical procedures

Highlights

1. Iatrogenic vascular injuries are not uncommon complications in the context of retroperitoneal oncologic resections.

2. The Vascular Surgeon should be an important part of any surgical unit to reduce morbidity.

3. Planned surgical interventions of Vascular Surgeons in retroperitoneal tumor resection may increase long-term survival and reduce morbidity and mortality.

Background

Technological and biomedical advances in surgical techniques have been able to reduce the incidence of intraoperative vascular complications, but they are still common in tumor resection surgeries.^2,5,6 Furthermore, hemorrhagic complications have been reported as one of the most prevalent, comprising 33–47% of intraoperative cardiac arrests and deaths.^4,6,7 Retroperitoneal oncologic resections may affect vessels such as the aorta or vena cava, increasing the risk of massive bleeding; therefore, planning vascular surgeon intervention may be an effective preventative measure to reduce incidence of hemorrhagic complications. Even when vascular surgeons are involved in the trans operative period, it may not be successful, because their performance may not be based on whether the surgeon has a complete knowledge of the case, but on their assistance in an emergency situation. Delays in contact-time with the vascular surgeon, when needed, worsens post-operative prognosis.¹ Among the reported causes of a delay in the contact-time with the vascular surgeon, hesitancy may be the leading barrier.^2,4

The vascular surgeon may have a relevant role when it comes to complex oncological resections; hence, their intervention in a planned or an emergent context is desirable, ideally from the first instance of surgery planning.^2,8–10 Vascular injuries may affect a patient´s prognosis not only in the short term, but also in the long term; therefore, it is necessary to improve efforts and propose strategies in order to reduce their incidence.^6,11,12

The objective of the present study is to establish the long-term survival in patients after a retroperitoneal tumor resection surgery, with and without vascular surgeon intervention, with an emphasis on the potential impact of preventing or repairing major vessel injuries.

Material and methods

The data were derived from retrospective clinical series including all cases of retroperitoneal tumor resection where tumors were adjacent to the vena cava or aorta in a highly specialized hospital between 2007 and 2020 in Mexico City. Long-term survival was defined as over a 5-year period after surgery.

The information source constituted of the clinical records of each patient, including the surgical notes, trans and postchirurgic complications and clinical manifestations, evolution, and routine evaluations after 5 years. An ad hoc dataset was generated, and each criterion was transformed as variable for further processing using Stata 16 software.

Intervention of vascular surgeons was considered a nominal variable, where no intervention was compared to planned and emergency intervention.

Quantitative variables such as age, surgery duration, and bleeding were presented as means and standard deviations. Qualitative variables are presented in frequencies, proportions, and percentages. Classical group-comparison tests were performed to identify differences within groups of vascular intervention (none or planned/emergency). A logistic regression model for binary dependent variables was performed to predict the 5-year survival after the intervention, where clinical variables along with trans surgery outcomes and vascular surgeon intervention were included. Post estimations to ensure goodness of fit were performed using Pearson test; pseudo R2 was also assessed for the model and residual plots.

All data was anonymized. The institutional review board, ethics and research committees from the “Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán” approved the present study; registration number: 3513.

Results

A total of 70 (100%) surgical interventions were performed on 61 patients during our study period. Regarding demographic characteristics of patients, 41 (58.5%) surgeries were performed on 35 (57.3%) men with a mean age of 50.47 years (SD ± 16.82) at the time of surgery. In terms of comorbidities, the patient had a history of obesity in 7 (10%) of the surgical interventions; in addition, patients had a history of chemotherapy, radiotherapy and a previous abdominal intervention in 23 (32.8%), 10 (14.2%), and 48 (68.5) surgeries, respectively. Most of the surgical interventions were programmed by Surgical Oncology (67%), followed by Urology and Vascular Surgery. Mean intraoperative bleeding was 1815.6 mL (±2020) and mean surgical time was 276 min (±128). Table 1 summarizes clinical and demographic data in our patient series. When it comes to the different types of tumors encountered, the most common one was liposarcoma, found in 28 surgeries (40%), followed by teratomas in 7 (10%) and carcinomas in 5 (7.1%). Among other tumors resected, there were: leiomyosarcomas, germinal cell tumors, yolk sac tumors, and undifferentiated tumors. Vascular injuries were reported in 30 (42.8%) surgical interventions during the study period, 89% of them related to surgeries planned by urology and surgical oncology. Vascular surgeons intervened in 19 (27.1%) of these surgeries; 6 (31.5%) of them were planned interventions, 4 (21%) were scheduled by a vascular surgeon, and 9 (47.3%) were emergent. The mean Length of Stay (LOS) was 14.94 days (±14.94) with a median of 11 days. In addition, 33 (47.1%) patients with had LOS greater than 11 days, 5 (7.1%) required the use of vasopressors for more than 3 days after surgery and 5 (7.1%) were admitted into the Intensive Care Unit (ICU) for more than 3 days. Additionally, when evaluating long-term survival, 59 (85%) of these cases survived at least 5 years after surgery.

Table 1.

Demographics and clinical variables.

	N (%)	SD
Men	41 (58)
Mean age (years)	50	±16.8
Intraoperative vascular injury occurrence	30 (43)
Vascular surgeons intervention	19 (27)
Previous radiotherapy	10 (14)
Previous chemotherapy	23 (33)
Previous abdominal surgery	48 (68)
LOS greater than 11 days	33 (47)
Trans operative bleeding greater than 750 mL	45 (64)
Lymphadenectomy	15 (21)
Surgical time (minutes)	276	±128.2
Intraoperative bleeding (ml)	1816	±2020.2

LOS: length of stay.

When comparing average intraoperative bleeding between the groups with or without a vascular surgeon intervention, it was found that the group were the vascular surgeons intervened had a greater mean intraoperative bleeding (3077 (±2753) vs 1, 336 (±1, 423), p = <0.001), respectively. Comparing intraoperative bleeding between planned and emergent interventions, the mean intraoperative bleeding was 2-fold greater in the emergent intervention group (2138 mL (±2368) vs 4368 mL (±2861), p = 0.04), respectively. Additionally, we found that the proportion of vascular injuries in the emergent intervention group (88%; n = 8) was significantly higher when compared to the planned intervention group (50%; n = 5) (p = 0.034). Furthermore, no statistically significant difference was found regarding LOS (20 days (±4.8) vs 21 days (±6.5), p = 0.88) or surgical time (348.1 (±137.2) vs 303.7 (±45.4) minutes, p = 0.48) between groups.

When performing a univariate analysis, previous radiotherapy correlated with 5-year mortality after surgery (OR 0.17 (±0.04–0.73), p = 0.01). In contrast, after performing a multivariate analysis, intervention of vascular surgeons showed a statistically significant association with a 5-year survival (OR 59.3 (±1.4–2467.9), p = 0.03), even after adjusting for clinical and sociodemographic variables. Post estimation test results supported the goodness of fit in the model, including Pseudo R2 (0.40) and Pearson Goodness of fit and constant term with p > 0.05 with congruent residual q-q plotting (Table 2).

Table 2.

Long term survival multivariate analysis.

Pseudo R2: 0.40; log likelihood: −19.07; Pearson: 0.053
Patients characteristics	OR	Standard error	z	p value
Men	1.18	1.40	0.14	0.886
Age (years)	0.94	0.04	−1.26	0.209
Intraoperative vascular injury	0.35	0.46	−0.79	0.432
Complications/other	0.03	0.07	−1.74	0.081
Vascular surgeons intervention	59.32	112.84	2.15	0.032
Previous radiotherapy	0.01	0.03	−2.17	0.030
Previous chemotherapy	10.94	17.49	1.59	0.134
Previous abdominal surgery	1.40	1.58	0.30	0.761
LOS greater than 11 days	2.07	2.31	0.65	0.515
Trans operative bleeding >750 mL	92.86	194.59	2.16	0.031
Lymphadenectomy	0.02	0.04	−2.06	0.039
Surgical time (minutes)	1.00	0.00	0.05	0.959
Intraoperative bleeding (ml)	0.99	0.00	−2.16	0.031

OR: odds ratio; ML: milliliters; LOS: length of stay

Discussion

Retroperitoneal tumors are rare entities, commonly presented as asymptomatic until reaching a considerable size that affects adjacent structures, including major vessels. In the present study, we identified liposarcomas as being the most prevalent tumor which coincides with existing literature.^13–15 In addition, we found males to be more commonly affected than females, which is congruent with what has been previously reported in some clinical series of up to 63 patients.^13,14

In a study by Yoo T and colleagues², the incidence of intraoperative vascular injures was 58.7% (27/46) in a 3-year period whilst Giswold et al.¹⁶ reported an incidence of 27.1% (23/85) in an 8-year period; however, it is worth mentioning that the first study analyzed vascular injuries in non-vascular procedures while the second one was centered on iatrogenic arterial injuries. In the present study, vascular injuries were reported in 30 (42.8%) surgeries in a 14-year period.

In contrast with previous studies,¹⁶ most vascular injuries took place during surgical interventions by oncologic surgeons, followed by urologists (56.6% vs 33.3%), the latter being consistent with previous reports, such as Yoo and colleagues.²

Prompt diagnosis and treatment are essential to address and resolve vascular injuries. Hence, as previously described^7,8 these lesions often require expertise in vascular surgical techniques and arterial and venous site interventions; all of which are an essential part in the curriculum of vascular surgery residency programs, which makes the vascular surgeon an essential part of any surgical unit.^2,7,16 Even though vascular surgeons may not be available at all hospitals⁸ they may still be considered during the initial planning of tumor resections involving major vessels. Previously, Powell et al.⁸ have reported a perceived need for improving the worldwide ratio of vascular surgeons and Mexico may not be an exception as there are currently only 0.48 vascular surgeons per 100 000 inhabitants.⁹

Even though multidisciplinary treatment is now a common practice, many of the interventions conducted by the vascular surgery team, in the context of these tumors, are in response to intraoperative complications, with some studies reporting a greater prevalence at midnight.^17,18 The latter is consistent with our findings in the present study, where 47% of all vascular surgery interventions were unplanned leading to adverse outcomes in up to 60% of these.

Regarding long-term survival, Woldu and colleagues¹⁹ indicated that survival can be achieved if these interventions are performed by an experienced surgeon; these findings are consistent with those reported by Schwarzbach et al.²⁰ Furthermore, Danczyk and colleagues³ reported a mean survival of 4.3 years after surgery while Mogannam et al.¹⁰ reported an estimated 80% 5-year survival in their case control study; which is consistent with the findings of our present case series. To our knowledge no previous study has analyzed the clinical variables as predictors of long-term survival yet.

Certain limitations can be attributed to our analysis, first, it is important to mention that the significant variables in the model did not imply individual associations, thus, it is a combination of factors such as intraoperatively bleeding, previous medical and surgical history, sociodemographic characteristics among others that mediate the association between the intervention of the vascular surgery team and long-term survival. Tjeertes and colleagues²¹ reported that the occurrence of cardiovascular post-operative complications was significantly associated with a decreased long-term survival; even after eliminating high risk surgeries from their analysis. In addition, Khuri et al.²² reported, in their analysis of over 100 000 patients, that a decreased long-term survival was not associated with the pre-operative risk; which should make us consider looking into other factors that could explain long-term survival in these patients. Furthermore, Han and colleagues²³ emphasized that the surgeon’s experience is paramount to the 10-year survival after cardiac surgery and Yuan et al.²⁴ reported that post-operative complications resulting from surgical intervention, worsen long-term prognosis in oncologic patients. Hence, the results in the present study are in accordance with what has been previously described in the literature; highlighting the importance of preventing intraoperative complications by considering a planned interdisciplinary approach which should include a vascular surgeon. Oncovascular surgery is a relatively new field, which emphasizes that major vascular involvement is not an impediment for tumor resection, therefore, as Woo et al.²⁵ have reported, vascular surgeons should be an essential player when it comes to oncologic surgery, as they have been showed to allow for an optimal tumor resection and vascular dissection, helping to prevent complications when properly involved while surgical planning.

We have presented one of the largest single-center retroperitoneal tumor series, which contributes to enhance our understanding of the later and the importance of a multidisciplinary approach in challenging situations. Limitations of this study are those characteristics of a retrospective patient-series. Thus, our inclusion criteria only included tumor location, regarding of pathological nature.

Conclusions

As vascular injuries may occur in surgical resections of retroperitoneal tumors, it may be pertinent to involve the vascular surgeon since the initial planning of any tumor resection with major vessel involvement. Vascular surgeon planned intervention may reduce complications and improve the probability of survival after 5 years, even after adjusting for clinical and sociodemographic characteristics of the patients, nature of the tumor, and previous therapeutic approaches.

Footnotes

Author contributions

Luis O. Bobadilla-Rosado: Conceptualization, Methodology, Validation, Formal Analysis, Investigation, Writing-Original Draft, Writing Review-Editing, Visualization, and Supervision. Gabriel Lopez-Pena: Methodology, Validation, Formal Analysis, Investigation, Writing Review-Editing, and Visualization. Ana T. Verduzco-Vazquez: Investigation. Hugo Laparra-Escareno: Validation, Writing Review-Editing, Visualization. Javier E. Anaya-Ayala: Validation, Writing Review-Editing, Visualization, and Supervision. Hugo Azcorra: Data curation, Data Validation, Formal Analysis, and Statistical Software Analysis. Nina Mendez-Dominguez: Methodology, Validation, Formal Analysis, and Supervision. Carlos A. Hinojosa: Conceptualization, Methodology, Visualization, and Supervision. All authors approve the manuscript.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Luis O. Bobadilla-Rosado

Gabriel Lopez-Pena

Ana T Verduzco-Vazquez

Hugo Laparra-Escareno

Javier E Anaya-Ayala

Hugo Azcorra

Nina Mendez-Dominguez

Carlos A Hinojosa

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