Anesthetic Approach to a Case of Hepatoblastoma With Right Atrial Spread for Simultaneous Resection of Both

Hepatoblastoma is the most common primary liver tumor in childhood. However, cases involving age >5 years are extremely rare. Invasion of the inferior vena cava and right atrium in hepatoblastoma places the patient in a high-risk group, and due to the rarity of such presentation, the preferred surgical approach is not clear. We present the perioperative anesthetic management of hepatoblastoma in an eight-year-old child with right atrial invasion at diagnosis, with no regression in size of the tumor after chemotherapy, treated subsequently with combined cardiac and liver surgery. Due to the possibility of impingement of the tumor thrombus onto the tricuspid valve or superior vena cava, or systemic embolization from the right atrium, access for the cardiopulmonary bypass was kept ready at the start of surgery. Intraoperative evidence of fragmentation of a small part of the right atrial tumor was noted in trans-esophageal echocardiography midway during left hepatectomy. This necessitated the emergency institution of cardiopulmonary bypass and en-bloc removal of the tumor thrombus with the remaining left hepatectomy specimen. The anesthetic management was further compounded by the risk of peri-operative pulmonary embolization, coagulopathy, blood loss and hemodynamic instability, ischemia-reperfusion injury, and post-operative hepatic, renal and pulmonary complications inherent in hepatectomies. The case presented a unique set of challenges to both surgeons and anesthetists. What was most evident from the successful management of such a case was the need for a team approach, with adequate communication between teams managing the patient.