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My Toughest CaseRemoving a Tumor by Taking Multiple Organs Out of the Body

Tomoaki Kato, Transplant Surgeon, New York–Presbyterian Hospital/Columbia University Medical Center

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The patient was a 63- year-old woman who had a rare malignancy called a leiomyosarcoma. Chemotherapy worked a little, but radiation really didn’t do anything. Her only option was surgery, but she had been told her tumor was inoperable, at least by conventional methods. The tumor wasn’t especially large; it was about as big as a baseball. But it happened to be in a very bad location. It was sitting on the abdominal aorta, the biggest artery of the abdomen, and wrapping around two other major arteries. Basically, the blood vessels that supply every major abdominal organ—stomach, pancreas, spleen, liver, small bowel, large bowel—were involved. Going to the tumor directly wasn’t possible because every one of those organs was in the way. Even if you could get to the tumor, there was no way to cut it out without cutting sections of the arteries involved. That would mean cutting off the blood supply to the attached organs, causing them to die.

As a transplant surgeon, I knew that organs can survive outside the body for up to ten hours before going into a recipient. My idea was to use transplant techniques with this patient. We’d clamp the arteries and take out her abdominal organs, and put them in a cold-preservation solution. Then we’d cut out the tumor in the arteries, reconstruct her blood vessels using synthetic materials, replace the organs, and reconnect the arteries. It would be like an organ transplant with the same person as donor and recipient.

I’ve done a number of multiple-organ transplants, but this exact surgery had never been done before. I told the patient there would be unknown risks involved, and that the procedure would be very dangerous. Because we would be disconnecting the abdominal aorta, which goes to the spine, there was a chance of paralysis. Blood connections could leak or clot. What if you take all the organs out, then find that you can’t reconstruct the blood vessels?

The initial part of the surgery took six hours. We were trying to create a situation where the entire organ block is “up in the air,” meaning all the connections are cut and it’s ready to move. First, I divided the esophagus from the stomach. The large bowel had to be cut in the middle portion. Part of the colon came out. After we cut the arteries, we moved the organ block into preservation solution on the back table. Even though organs can survive in the ice box for up to ten hours, the patient can’t survive without organs for that long. Our assumption was probably six hours, but we didn’t want to reach that point. That was the final limit.

Altogether, we numbered seven surgeons and two anesthesiologists. The team on the back bench had the organ block and was cutting out the tumor and building the grafts needed to reconnect the arteries to the organs. I was working in the patient’s abdomen. She was lying there on the table under anesthesia, with nothing in her body cavity. I’m used to seeing the empty abdomen, but many surgeons, when they see it, are in awe.

To get the tumor out, we had to remove four inches of vena cava and three inches of aorta, which we replaced with more synthetic grafts. The organs were out for nineteen minutes. It took about an hour to sew them back in. Altogether it took about two hours to reestablish blood flow. With all the reconnecting we still had to do—the stomach to the esophagus, and the rest—the total surgery took fifteen hours. She went home in three weeks.


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