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Stopping a Heart to Remove a Tumor
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Dr. Jessica J. Kandel treats children with Wilms tumor |
In most cases, Wilms tumor, a relatively rare kidney tumor found in children from birth to about 10 years of age, is treated by removing the tumor through an abdominal incision.
However, a few months ago, surgeons at Morgan Stanley Children's Hospital of New York (CHONY) were confronted with a much more complicated case of Wilms tumor in an eight-year-old girl.
She was referred to Jessica J. Kandel, MD Irving Assistant Professor of Pediatric Surgery at CHONY, because her tumor had spread from her left kidney into the inferior vena cava (IVC), the large vein that travels through the diaphragm and drains into the heart.
Simply put, the tumor had extended directly into the girl's heart.
Dr. Kandel drew on the resources of Morgan Stanley Children's Hospital of New York to assemble a multidisciplinary treatment team to plan a dramatic, literally heart-stopping operation to remove the tumor.
The child was taken to her pediatrican because of a distended stomach and constipation, symptoms that led the doctor to suspect Wilms tumor.
She was then referred to Dr. Kandel, a recognized expert on Wilms, who detected the tumor's spread.
"If we had simply removed the tumor from her left kidney, the tumor tissue would have remained in the girl's vascular system," Dr. Kandel says.
"The problem is that the IVC carries an enormous supply of blood to the heart—all the blood from the bottom half of the body."
The first step was to administer chemotherapy to shrink the tumor as much as possible—standard procedure in treating Wilms tumor.
The CHONY team tracked the tumor by echocardiograms and CT scans.
In the meantime, Dr. Kandel called on Ralph S. Mosca, MD Director of Pediatric Cardiac Surgery at CHONY to plan the surgery.
"We devised a two-part operation," she says.
"Dr. Mosca came into the OR first to prepare the patient to go on a heart bypass machine.
When he left, Dr. [Allan M.] Goldstein and I dissected the tumor and actually removed it, and then closed its connection with the IVC." Dr. Goldstein is a postdoctoral pediatric surgical residency fellow at CHONY.
ALL SYSTEMS ARE STOP!
With the meter ticking, the team stopped the girl's heart.
"We had about 40 minutes from start to finish for the operation—otherwise complications would have set in," Dr. Kandel says.
First, they gradually allowed the bypass machine to take over for her heart function, while cooling her body temperature to about 18 degrees Celsius.
"We actually packed her head in ice and then turned off the pump so her heart would stop when it was cold," Dr. Kandel says.
"We've all heard of children who have been in cold water for an hour and are presumed to have drowned, and who are then resuscitated—this is the same principle.
The cold is actually protective—it stops all body systems."
However, after 40 minutes the slowed metabolic rate that results from the cold can have serious consequences.
Once the pump was off, the surgeons drained the blood from the inferior vena cava and then cut the vein open, from the kidney all the way to the heart.
With Dr. Mosca working from the top and Drs. Kandel and Goldstein working from the bottom, they dissected the tumor from the vein and heart and then sewed everything back up.
"By shutting everything off, we decreased the metabolic rate in the brain and other essential tissue," Dr. Kandel says.
Fortunately, the team removed all tumor tissue within the 40-minute window.
"Once we had it all, we put her back on bypass and warmed her up, a process that took less than an hour," Dr. Kandel says.
"When her heart started to beat everything came alive.
Then we closed the incisions and went home."
A POST-OP CANDY BAR
The young girl was able to eat a Snickers bar the day after surgery, when she was still in the ICU, Dr. Kandel says. "Children are remarkable.
It's astonishing to think about shutting someone off like that.
This was very scary for the child and her family.
She did beautifully. She's continuing with chemotherapy and she's doing very well.
We anticipate that she has a 90 percent chance of being cured."
The kind of comprehensive care available at Morgan Stanley Children's Hospital of New York can provide creative treatment options for complex childhood illnesses.
In addition to Dr. Kandel and the other surgeons, this child's caregivers included pediatric oncologist Darrell Yamashiro;
pediatric internist Charles Schleien; pediatric cardiologist David E. Solowiejczyk; and specially trained pediatric surgical and medical nurses and social service staff.
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