Department of Surgery, Division of Transplantation, University of Miami Miller School of Medicine, Miami, Florida, USA.
Eur Urol. 2011 Mar;59(3):401-6. doi: 10.1016/j.eururo.2010.07.028. Epub 2010 Aug 3.
Renal cell carcinoma (RCC) with tumor thrombus in the inferior vena cava (IVC) poses a challenge to the surgeon given the operative difficulty, potential for massive hemorrhage, and possibility of tumor thromboemboli.
To determine the applicability of a self-developed technique based on orthotopic liver transplantation procedures for safe resection of these tumors.
DESIGN, SETTING, AND PARTICIPANTS: From August 1997 to February 2008, 68 consecutive patients underwent resection of RCC with suprahepatic and/or retrohepatic (level 3 and 4) tumor thrombus in a single referral institution.
A triradiate incision over the upper abdomen permits the placement of a Rochard retractor. Early vascular control of the renal artery is achieved by creating a posterior plane of dissection. Venous collateral decompression permits development of a bloodless anterior plane by mobilizing the liver in a "piggy-back" fashion and the spleen-pancreas en bloc to the midline. Thrombus extraction requires circumferential control at the renal veins, hepatic hilum, and IVC before cavotomy. The central tendon of the diaphragm may be opened for cranial control and gentle traction over the right atrium performed. Repositioning of the proximal clamp and Pringle release avoid veno-venous bypass and cardiopulmonary bypass (CPB) in most cases.
The extent of the tumor thrombus was retrohepatic in 56 patients and suprahepatic/intra-atrial in 12 patients.
Mean operative time was 5 h 32 min. Mean estimated blood loss (EBL) was 2112±3834 ml (range: 100-25 000), with a mean transfusion being 4.2±4.1 U (range: 0-30). Five patients (7.3%) required CPB. Three patients (4.4%) died in the immediate postoperative period. All had complete tumor resection. No patient developed intraoperative thromboembolism.
This surgical approach provides excellent exposure and control of the IVC in cases with level 3 and 4 tumor thrombus, avoiding CPB except in rare circumstances.
肾细胞癌（RCC）合并下腔静脉（IVC）肿瘤栓子给外科医生带来了挑战，因为手术难度大、大出血的可能性大、肿瘤栓子脱落的可能性大。
确定基于原位肝移植手术的自创技术在安全切除这些肿瘤中的适用性。
设计、地点和参与者：1997 年 8 月至 2008 年 2 月，在一家转诊机构中，连续 68 例 RCC 患者接受了肝上和/或肝后（3 级和 4 级）肿瘤栓子切除术。
上腹部三叶形切口可放置 Rochard 牵开器。通过创建后平面解剖来实现早期肾动脉血管控制。静脉侧支减压允许通过将肝脏以“背驮式”方式和脾-胰整块向中线移动来发展无血的前平面。血栓提取需要在腔静脉切开前在肾静脉、肝门和 IVC 处进行环形控制。膈肌中心腱可以打开以进行颅侧控制，并轻柔地在右心房上方进行牵引。重新定位近端夹和松开 Pringle 可避免大多数情况下的静脉-静脉旁路和心肺转流（CPB）。
56 例患者肿瘤栓子位于肝后，12 例患者位于肝上/心房内。
平均手术时间为 5 小时 32 分钟。平均估计失血量（EBL）为 2112±3834ml（范围：100-25000），平均输血 4.2±4.1U（范围：0-30）。5 例（7.3%）需要 CPB。3 例（4.4%）患者在术后即刻死亡。所有患者均行完全肿瘤切除术。无术中血栓栓塞发生。
这种手术方法为 3 级和 4 级肿瘤栓子提供了极好的 IVC 暴露和控制，除了极少数情况下外，避免了 CPB。
