The surgery of the long-term central venous accesses in oncology.

The implantation of Long-Term Central Venous Catheters (LTCVC) in cancer patients has been essential to conduct the oncological treatments of today. The complexity of the protocols requires accuracy on the management of such devices in order to keep them long-functioning. The article focuses on such subject from an oncological perspective, pointing out threats of the disease to the central venous system (CVS) and the ways to face them successfully. The most salient points related to surgical techniques and the insights to follow-up long-term inserted catheters are discussed. An anatomical classification is suggested to help understand occurrence of malpositions and to north the necessary maneuvers of repositioning. Such matters are based on 3000 LTCVC-placements performed by the author at the Brazilian National Cancer Institute (INCA) between 1999 and 2011. As nearly 30% of the patients presented some sort of anatomical disorder at the moment of the surgery, it was judged worthy to address such experience to those young surgical oncologists willing to tackle LTCVCs in Cancer Units.

A modified internal jugular vein access for long-term catheter placement in cancer patients.

BACKGROUND: Placement, handling, and maintenance of indwelling central venous access devices may be difficult due to anatomical, clinical, or hematologic conditions in many cancer patients needing chemotherapy. An alternative approach technique is suggested joining surgical dissection to venipuncture, assisted by fluoroscopy, as a secure way to avoid complications of long-term indwelling catheters. Although ultrasound guided puncture is a safe procedure, it is not always available or familiar to most surgeons. METHODS: At the National Cancer Institute (INCA) in Rio de Janeiro, Brazil, 1750 long-term catheter placements were performed between the years 1997 and 2005. Among those, 160 were done through an alternative technical procedure consisting of an anterior cervical cutdown approach to the internal jugular vein (IJV) followed by percutaneous visual puncture of the vein. This modified internal jugular vein access (MIJVA) was employed when other access techniques were not feasible or if other underlying conditions increase the risk of bleeding complications. RESULTS: The MIJVA procedure was successful in all 160 patients. Although it was used only as an exceptional option in difficult venous accesses, further prospective trials must be conducted, however, for comparison with other technical approaches. CONCLUSION: The MIJVA is an option that provides successful IJV dissection and safe percutaneous visual puncture overcoming anatomical pitfalls in placement of long-term venous access for chemotherapy in cancer patients.

Cirurgia dos cateteres de longa permanência (CLP) nos centros de transplante de medula óssea / Surgery of long-term catheters (LTC) in a bone marrow transplantation center

O capítulo disserta sobre a utilização de Cateteres de Longa Permanência (CLP) num Centro de Transplante de Medula Óssea (CTMO), abordando seus aspectos cirúrgicos com o objetivo de preparar cirurgiões para o enfrentamento de pacientes hematológicos graves, seja no preparo para um TMO ou em situações complexas durante ou após o transplante. Baseado numa experiência de 2.000 cateterismos executados pelo autor no Instituto Nacional de Câncer (INCA) é intencionado, numa narrativa didática para jovens cirurgiões, a dar orientação de prática cirúrgica necessária para o sucesso da implantação destes cateteres em pacientes de CTMOs. São mostrados e discutidos aspectos inerentes ao cateter em si, como escolha de tipos e modelos, suas indicações, as técnicas cirúrgicas a serem adotadas normalmente (com a descrição detalhada do acesso jugular interno), as situações difíceis com questões relevantes à anatomia do mediastino com seus possíveis obstáculos e a forma de vencê-los, e finalmente, os resultados e as complicações advindas do uso destes sistemas especificamente em pacientes de um CTMO.