Renal cell carcinoma metastatic to the duodenum treated with the Whipple operation: Case report of a patient with long-term survival and a review of the literature

Background: Venous thromboembolism is an important complication in patients carrying a long-term central venous access, particularly cancer patients; peripherally inserted central cather (PICC) lines have recently shown a higher incidence of thrombosis than classic central venous catheters (CVC), and a slightly different pattern of onset and risk factors. The aim of our study was early identification of thrombosis in patients carrying a PICC line to prevent complications related to asymptomatic deep venous thrombosis (DVT); we then performed a close follow-up of patients with PICC-related deep vein thrombosis (PRDVT) treated with low-molecular-weight heparin (LMWH). Methods: This prospective observational study included 200 patients who had a PICC-line positioned at our Department between 31 May and 29 October 2010; all PICCs were 4 Fr, sylicone and valvulated, positioned under ultrasound guidance; all patients were controlled weekly after positioning with a compressive ultrasound complete examination of the upper limb and neck vessels; in case of thrombosis, LMWH therapy according to the 2008 American College of Chest Physicians (ACCP) guidelines was initiated, and the patient was re-evaluated weekly with ultrasound examination; no catheter was removed because of thrombosis. Results: Of the 199 patients recruited, 150 were regularly followed; 26 cases of PRDVT in were diagnosed (17% of patients), mostly asymptomatic. When we examined the delay between catheter positioning and the detection of a catheter-related thrombosis, we noted a peak of thrombosis onset during the first 2 weeks after catheter placement (77% of all PRDVT; plus another 11% during the third week); 17/26 (65%) patients had complete recanalization of the vein within 4-42 days (mean 30, median 17); 4/26 (15%) patients had partial recanalization, and PICC removed after 20-76 days of anticoagulation, as it was no longer needed. Conclusions: The majority of recent-onset PRDVT resolved rapidly with LMWH therapy, underscoring the importance of early diagnosis and treatment of PRDVT to prevent further thromboembolic complications (pulmonary embolism and the post-phlebitic syndrome) and to increase the probability of complete resolution of the thrombosis. That said, PICC lines were found to be the easiest CVC to control for thrombotic complications, as ultrasound examination is cheap, noninvasive and available for any PICC team (unlike CT angiography, which is necessary for classical CVC). Renal cell carcinoma metastatic to the duodenum treated with the Whipple operation: Case report of a patient with long-term survival and a review of the literature S. Vaccarisi, E. Bonaiuto, N. Spadafora, V. Crocco, A.N. Garrini, V. Pellegrino, G. Cavallari, B. Nardo* 1 Hepato-Biliary-Pancreatic and Transplant Organs Unit, Department of Surgery, Annunziata Hospital, Cosenza, Italy 2 Department of Surgery and Transplantation, S.Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy * Corresponding author: Prof. Bruno Nardo MD, PhD, Hepato-BiliaryPancreatic and Transplant Organs Unit, Department of Surgery, Annunziata Hospital, Via F. Migliori 1, 87100 Cosenza, Italy. Phone: +39 0984 681214, Fax: +39 0984 23625. E-mail address: b.nardo@libero.it (B. Nardo).