Combined Right Nephrectomy

Mehrdad Nikfarjam
1
, Niraj J Gusani
1
, Eric T Kimchi
1
,
Rickhesvar P Mahraj
2
, Kevin F Staveley-O’Carroll
1
Departments of
1
Surgery and
2
Radiology, Penn State Milton S. Hershey Medical Center,
Penn State College of Medicine. Hershey, PA, USA
ABSTRACT
Context Nephrectomy and pancreatico-
duodenctomy are operations often performed
for the treatment of malignancy. However, the
combination of both procedures is rarely
reported.
Objectives The indications and outcomes of
combined right nephrectomy and pancreatico-
duodenectomy were assessed.
Study design Patients were identified from a
prospective operative database between 2002
and 2008.
Setting A tertiary care center.
Patients One-hundred and 80 patients
undergoing pancreaticoduodenectomy. There
were 5 (2.8%) patients treated by combined
right nephrectomy and pancreaticoduodenal
resection.
Main outcome measure Description of these
5 patients.
Results Three patients had retroperitoneal
sarcomas adherent to the right kidney and
duodenum, one patient had a locally advanced
transitional-cell carcinoma and the remaining
patient presented with an ampullary
malignancy and concurrent right renal tumor
All patients underwent en bloc resection with
clear margins. Median operating time was 13
hours (range: 9-21 hours). There was no
perioperative mortality in this series.
Complications were noted in 3 (60%) patients
related to pancreaticoduodenal resection and
all were managed conservatively without
significant clinical impact. Median post-
operative hospital stay was 8 days (range: 7-
11 days). At a median follow-up of 14 months
(range: 3-36 months) all patients were alive
without evidence of disease recurrence.
Conclusion En bloc right nephrectomy
combined with pancreaticoduodenal resection
can be performed in selected patients with
malignant tumors with acceptable morbidity
to achieve clear resection margins.
INTRODUCTION
Nephrectomy is indicated for the treatment of
localized renal cell carcinoma and
uroepithelial malignancies. Pancreatico-
duodenectomy is the treatment of choice for
periampullary cancers. The indication for the
combination of both procedures is not well-
defined. As far as is known, there have been
no previous series reporting on patients
treated by combined right nephrectomy and
pancreaticoduodenal resection. Most of the
information on this combined procedure is
confined to isolated case reports [1, 2].
We report on a series of patients undergoing
en bloc
right nephrectomy and
pancreaticoduodenectomy. The indications
for surgery, the surgical approach, and

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outcomes of the patients undergoing this
combined procedure are described.
METHODS
Patients
One-hundred and 80 patients undergoing
pancreatic resection at Milton S. Hershey
Medical Center between January 2002 and
December 2007 were identified from a
prospectively maintained operative database.
Combined
right
nephrectomy
and
pancreaticoduodenal resection was performed
in 5 patients (2.8%).
Data Recording
Operative details, indications for combined
resection, the length of procedure, blood loss,
complications and outcomes were analyzed.
All patients underwent complete work-up for
evidence of metastatic disease by computed
tomography (CT) of the chest, abdomen and
pelvis. Tumors were considered potentially
locally resectable if there was no evidence of
major vessel encasement. All patients in this
series were well functioning and considered
fit for major surgery. Abdominal pain was the
most common presenting symptom.
Interventions
En bloc resection of the right kidney,
pancreas, and duodenum was performed to
minimize the risk of tumor disruption, with
the aim of obtaining a negative surgical
margin when tumors involved both the
periampullary and right perinephric regions.
Following a midline laparotomy, mobilization
of the right kidney from lateral to medial was
performed as the initial step. The renal vessels
were identified posteriorly, followed by
ligation and division. The adrenal gland was
separated from the kidney and retained, if
possible, when resection margins were not
being compromised. Otherwise the right
adrenal gland was mobilized along with the
kidney and vessels. In cases where there was
tumor extension inferiorly to involve the right
colon, the root of the small bowel mesentery
was completely mobilized and a right
hemicolectomy
performed.
Otherwise
following division of the right renal vessels,
further dissection was carried anterior to the
vena cava, until the left renal vein was
completely exposed, to achieve full
kocherization of the duodenum.
Pancreaticoduodenectomy was performed in
all cases in a conventional manner [3]. This
involved ligation of the gastroduodenal artery,
division of the distal bile duct followed by
exposure of the portal vein. The proximal
jejunum was divided and its mesenteric
vessels transected close to the intestinal wall.
The neck of pancreas was divided anterior to
the portal-superior mesenteric vein
confluence, clear of macroscopic tumor,
followed by division of uncinate process
adjacent to the superior mesenteric artery,
allowing the specimen to be removed.
Reconstruction following pancreaticoduodenal
resection proceeded in a standard manner as
previously described [3]. An end-to-side
pancreaticojejunal duct-to-mucosa anastomosis
was constructed. This was followed by a
single layer biliary anastomosis and a two
layered duodenojejunal or gastrojejunal
anastomosis. Abdominal drains were placed
adjacent to the biliary and pancreatic
anastomoses. Complications were defined
according to previously defined criteria [3, 4].
Postoperative Management
All patients were managed in a surgical
intensive care unit (SICU) for 24 hours post
operatively unless more prolonged monitoring
was subsequently indicated. Nasogastric tubes
were inserted at the time of operation and
removed at day 1 postoperatively. A liquid
diet was commenced day 2 post operatively
and progressed to a soft diet. Drain fluid
amylase measurements were performed after
day 5 post operatively. Octreotide was not
administered prophylactically in this series.
Erythromycin was commenced at day 2 post
operatively at 200 mg intravenously 8 hourly
for prevention of delayed gastric emptying.
No patients in this series had operative
feeding jejunostomy tubes inserted as they
were not considered malnourished
preoperatively. Patients not tolerating a diet
by day 7 post operatively, but otherwise
clinically well, were considered to have

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delayed gastric emptying. They were
commenced on total parenteral nutrition and
discharged home or to a rehabilitation facility
with outpatient follow-up.
ETHICS
Consent was obtained for each patient for
possible combined resection including
nephrectomy and pancreaticoduodenectomy.
Review of charts was performed with
institutional review committee approval. The
study protocol conforms to the ethical
guidelines of the Declaration of Helsinki.
STATISTICS
Frequencies, median, and range were used as
descriptive statistics.
RESULTS
Details of the 5 patients who underwent
combined
right
nephrectomy
and
pancreaticoduodenal resection during the
Table 1. Characteristics of patients undergoing combined right nephrectomy and pancreaticoduodenal resection.
Patient Age
(years)
Sex ASA
score
Malignancy
Staging (TNM)
Kidney status
#1
83 Female III
Transitional cell carcinoma
T4N0M0;
4 cm tumor
Arising from kidney attached to
duodenum
#2
67 Male III
Ampullary carcinoma and
oncocytomas (atypical features)
T1N0M0;
4 cm renal tumor
Concurrent tumors
#3
56 Male III
Retroperitoneal liposarcoma
20 cm tumor Attached to kidney and duodenum
#4
61 Male III
Retroperitoneal sarcoma
24 cm tumor Attached to kidney, colon, and
duodenum
#5
84 Female III
Retroperitoneal sarcoma
6 cm tumor Attached to kidney and duodenum
Table 1. (Continued).
Patient
Resection
Perioperative
course: EBL,
blood
transfusion,
operative time,
LOS
Complication
Chemotherapy/
radiotherapy
Outcome
#1
PPPD, right nephrectomy and
adrenalectomy, R0 (distal ureter
in situ cancer)
1,000 mL, 5 units,
13 h, 8 days
Grade A pancreatic fistula
None
Alive and
disease free
after 3 months
#2
PPPD, right nephrectomy, R0 200 mL, 0 units,
9 h, 7 days
None
None
Alive and
disease free
after 36 months
#3 Classic PD, right hemicolectomy,
right nephrectomy and
adrenalectomy, R0
900 mL, 2 units,
15.5 h, 7 days
Delayed gastric emptying,
ileus, intra-abdominal
collectiona
None
Alive and
disease free
after 14 months
#4 Classic PD, right hemicolectomy,
right nephrectomy and
adrenlectomy, R0
2,150 mL, 4 units,
20.5 h, 10 days
Grade A pancreatic fistula,
delayed gastric emptying
None
Alive and
disease free
after 3 months
#5
Classic PD, right nephrectomy
and adrenaletomy, R0
300 mL, 0 units,
10 h, 11 days
None
None
Alive and
disease free
after 20 months
2 weeks post operatively
ASA: American Society of Anesthesiologists
EBL: Estimated blood loss
LOS: length of stay (postoperative)
PD: pancreaticoduodenectomy
PPPD: pylorus preserving pancreaticoduodenectomy
R: resection status
TNM: tumor node metastases grading

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study period are shown in Table 1. There
were 3 male and 2 female patients. The
median age at the time of surgery was 67
years (range: 56-84 years). Primary
retroperitoneal sarcoma was the most
common tumor treated, occurring in three
patients. One patient had a locally advanced
transitional cell carcinoma, with surrounding
inflammatory changes and the remaining had
an ampullary adenocarcinoma coexisting with
a renal oncocytoma. On imaging,
retroperitoneal sarcomas were adherent to
kidney and duodenum/pancreas, without
direct tumor infiltration of these organs
(Figure 1). Nephrectomy and pancreatico-
duodenal resection was considered necessary
to ensure clear resection margins. Similarly,
in a case of transitional cell carcinoma,
adherence to the duodenal wall rather than
direct infiltration necessitated en bloc
resection to achieve tumor clearance.
The median operating time was 13 hours
(range: 9-20.5 hours). Median estimated
blood loss was 900 mL (200-2,150 mL).
Blood transfusions were required in 3
patients. Median postoperative intensive care
stay was 2 days (1-6 days). One or more
complications were noted in 3 cases (60.0%).
Two patients had low volume pancreatic
fistulae that were managed conservatively and
did not prolonged hospital stay. Median
length of post-operative hospital stay was 8
days (7-11 days). All radial resection margins
were clear of malignancy. One patient with
transitional cell carcinoma, had carcinoma in
situ at the ureteral cut margin. Median follow-
up in this series was 14 months (3-36
months), with all patients alive and disease
free at the time of the last review.
DISCUSSION
Nephrectomy and pancreaticoduodenal
resection are often performed for the
treatment of malignancy. The outcomes of
patients undergoing nephrectomy are well
document for both open and laparoscopic
procedures [5]. Similarly, outcomes of large
series of patients treated by pancreatico-
duodenal resection are increasingly reported
[6, 7]. However, reports of combined
nephrectomy and pancreaticoduodenal
resection are limited to isolated case reports
[2]. The indications for combined procedures,
surgical approach and outcomes are
essentially unknown.
The complication rate for nephrectomy is well
described in large series and varies somewhat
between laparoscopic and open approaches
[5, 8]. Generally nephrectomy is associated
with low major complication rates. In a series
of 98 patients undergoing open nephrectomy,
the overall complication rate was 31%, with a
median operating time of 3 hours [5]. There
was no perioperative mortality. Wound
related complications were most common,
followed by ileus. The estimated blood loss
was 216 mL with less than 10% of patients
requiring a blood transfusion. The median
length of hospital stay in this series was 6
days. The median blood loss in other recent
open nephrectomy series range from 216 to
371 mL and the median hospital stay range
Figure 1. Computed tomography (CT) images of two
cases showing adherence of retroperitoneal sarcomas to
the right kidney and duodenum/pancreas requiring
combined resection. a. Sagittal section showing tumor
(*) attached to the inferior pole of the kidney and
duodenum (Patient #4). b. Axial image depicting the
large size of the tumor, with surrounding inflammatory
change due to an episode of pancreatitis (Patient #4). c.
Coronal section showing tumor located adjacent to
hilum of the right kidney abutting the portal vein and
duodenum. An incidental abdominal aortic aneurysm is
demonstrated (Patient #5). d. Axial view more clearly
showing attachment of sarcoma to duodenum
anteriorly (Patient #5).

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from 4 to 16 days [9, 10, 11]. In our series
there were no specific complications related
to nephrectomy and all patients had preserved
renal function based on comparisons of
preoperative and postoperative serum
creatinine measurements.
The morbidity and mortality of pancreatico-
duodenal resection has been the subject of
numerous publications [6, 7, 12]. The
mortality rate with this procedure ranges from
1 to 5% in large series [6, 7, 13]. Morbidity
remains high, ranging from 30 to 50% [4, 6,
7, 12]. Delayed gastric emptying remains the
most common complication occurring in 15 to
45% of cases depending on the definition
used [14]. Pancreatic fistula is the next most
common complication of pancreaticoduodenal
resection ranging from 2% to more than 20%
[4, 6]. The median length of hospital stay is
quoted as 9 days in large volume pancreatic
centers [6, 15]. In our series, the observed
morbidity was related to pancreaticoduodenal
resection and reflects finding reported
elsewhere in literature [4, 6, 7, 12].
The morbidity observed in our cases is not
unexpected given the complexity of tumors
treated. Three patients had retroperitoneal
sarcomas attached to right kidney and
duodenum. One of these patients also had
attachment of tumor to the right colon. The
median operating time and estimated blood
loss was 13 hours and 900 mL, respectively.
Blood transfusions were required in 3 of 5
cases (60%). Pancreatic fistulas occurred in
two patients (40%). This is acceptable
particularly given that all pancreatic
anastomoses in this series involved high risk
cases, based on pancreas texture. Four
patients had a soft texture pancreas, with one
developing a fistula. The remaining patient
with a retroperitoneal sarcoma had patchy
necrosis of the pancreas due to a previous
episode of severe acute pancreatitis. In both
cases of pancreatic fistula, this did not have
significant clinical impact on patient
outcomes, resolving with conservative
treatment. Delayed gastric emptying was
noted in two patients, treated by a short period
of total parenteral nutrition. The median
length of hospital stay in this series was 8
days and reflects the low clinical impact of
complications observed. This also reflects our
early discharge policy, particularly in patients
that are otherwise well, but with delayed
gastric emptying. There are no other reports
of series of patients treated by en bloc right
nephrectomy and pancreaticoduodenectomy
to compare with our series. Although there
are no other such reports, the morbidity
associated with this procedure is similar, if
not better than other reports, where
multivisceral operations are performed, that
include pancreatic resection [1, 16, 17].
The indications and outcomes of patients
undergoing combined right nephrectomy and
pancreaticoduodenectomy
have
not
previously been defined. The only other
detailed report of combined right
nephrectomy and pancreaticoduodenectomy is
a case of a patient with colon cancer invading
into the pancreas and kidney [2]. Even in
large reviews of patients undergoing
pancreaticoduodenectomy or nephrectomy,
the combination of both procedures is rarely
reported. Renal malignancies very rarely
attach to the duodenum and pancreas, and in
most circumstances can be separated from
these organs. In our series, one patient with
transitional cell cancer had a locally advanced
tumor attached to duodenum and pancreas
with surrounding inflammatory change, not
allowing for a lesser resection. In another
patient with a concurrent renal tumor and
ampullary adenocarcinoma, for oncologic
reasons it was felt that en bloc resection
should be undertaken. Combined resection of
pancreas and right kidney appears most
applicable to retroperitoneal sarcoma attached
to both kidney and periampullary region. If
there is a small focus of tumor attachment to
the duodenum, partial duodenal resection with
appropriate repair should be contemplated.
More often, distinguishing tumor boundaries
can be very difficult and any breach of these
boundaries could equate to early tumor
recurrence. A combined en bloc resection in
these cases may ensure clear resection
margins and no recurrence has been observed
to this date. In our series 3% of
pancreaticoduodenal
resections
were

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454
combined with right nephrectomy. This is a
higher percentage than expected, but partly
reflects our interest and aggressive approach
to the management of advanced retro-
peritoneal malignancies.
Right nephrectomy combined with a
pancreaticoduodenal resection appears to be a
safe operative procedure for resection of
tumors invading the right kidney and
duodenum/pancreas, those located in close
proximity to both regions and in the cases of
concurrent tumors. En bloc resection can be
performed to minimize the risk of positive
margins without increased morbidity. The
morbidity of this procedure appears to be
related to pancreaticoduodenal resection
alone.
Received February 5
th
, 2008 - Accepted May
6
th
, 2008
Keywords Kidney; Nephrectomy; Pancreas;
Pancreatic Neoplasms; Pancreaticoduodenectomy;
Sarcoma
Conflict of interest The authors have no
potential conflicts of interest
Correspondence
Kevin F Staveley-O’Carroll
Penn State Milton S. Hershey Medical Center
Penn State College of Medicine
Department of Surgery, H070
500 University Drive
P.O. Box 850
Hershey, PA 17033-0850
USA
Phone: +1-717.531.5965
Fax: +1-717.531.3649
E-mail: kstaveleyocarroll@hmc.psu.edu
Document URL: http://www.joplink.net/prev/200807/23.html
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