Stewart J R, Carey J A, McDougal W S, Merrill W H, Koch M O, Bender H W
Department of Cardiac and Thoracic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.
Ann Thorac Surg. 1991 May;51(5):717-21; discussion 721-2.
Of 29 patients with inferior vena caval tumor thrombus, 14 with supradiaphragmatic extension were deemed suitable for operation. Patients (age, 7.5 to 70 years) had renal cell carcinoma (n = 8), Wilms' tumor (n = 2), transitional cell carcinoma (n = 1), and adrenal carcinoma (n = 3). Seven patients had stage III disease, and 7 patients had stage IV disease. Two patients (group A) had unresectable disease at exploratory celiotomy, 4 patients (group B) underwent tumor thrombectomy without cardiopulmonary bypass, and cardiopulmonary bypass was employed in 8 patients (group C). Three of 8 group C patients had Budd-Chiari syndrome at diagnosis. Cardiopulmonary bypass with moderate hypothermia, and inferior vena caval interruption (clip or filter), was employed in all patients. There were no perioperative deaths. Transient neurological impairment was observed postoperatively in 2 patients. Coagulopathy developed in 1 patient who had hepatic encephalopathy and Budd-Chiari syndrome preoperatively and in another patient in whom protamine could not be administered. No patient had acute renal failure requiring hemodialysis. Median survival is 41 and 17 months in groups B and C, respectively. Some authors have advocated profound hypothermia and circulatory arrest in these patients. We find that satisfactory visualization and excision can be performed with cardiopulmonary bypass and moderate hypothermia, avoiding potential renal, hepatic, neurological, and septic complications associated with circulatory arrest.
在29例下腔静脉肿瘤血栓患者中，14例有膈上延伸者被认为适合手术。患者年龄为7.5至70岁，患有肾细胞癌（n = 8）、威尔姆斯瘤（n = 2）、移行细胞癌（n = 1）和肾上腺癌（n = 3）。7例患者为Ⅲ期疾病，7例患者为Ⅳ期疾病。2例患者（A组）在剖腹探查时发现无法切除，4例患者（B组）在未进行体外循环的情况下接受了肿瘤血栓切除术，8例患者（C组）采用了体外循环。C组8例患者中有3例在诊断时患有布加综合征。所有患者均采用中度低温体外循环及下腔静脉阻断（夹子或过滤器）。围手术期无死亡病例。术后2例患者出现短暂性神经功能障碍。1例术前患有肝性脑病和布加综合征的患者以及另1例无法使用鱼精蛋白的患者发生了凝血病。没有患者发生需要血液透析的急性肾衰竭。B组和C组的中位生存期分别为41个月和17个月。一些作者主张对这些患者采用深度低温和循环停止。我们发现，通过体外循环和中度低温可以实现满意的视野和切除，避免与循环停止相关的潜在肾、肝、神经和感染并发症。
