Wang G L, Bi H, Ye J F, Zhang H X, Ma L L
Department of Urology, Peking University Third Hospital, Beijing 100191, China.
Beijing Da Xue Xue Bao Yi Xue Ban. 2016 Aug 18;48(4):729-732.
To describe a feasible surgical technique for patients with renal cell carcinoma associated with a supradiaphragmatic tumor thrombus that avoids cardiopulmonary bypass procedure.
We retrospectively analyzed 2 cases with right kidney tumor and tumor thrombus above the diaphragm treated in April and August, 2015. The two patients were both female, aged 73 and 67 years. The tumor sizes of right kidneys were 7.0 cm×6.3 cm×5.7 cm and 8.7 cm×7.0 cm×5.2 cm, and the tumor thrombuses were 1.3 cm and 1.8 cm above the diaphragm. The second patient had synchronous metastasis in right adrenal gland , and the tumor thrombus arose from the adrenal vein but not the renal vein. Intraoperative transesophageal echocardiography (TEE) was used to assess real-time mobility of the thrombus. A modified chevron incision was used, the right kidney was mobilized laterally and posteriorly, and the renal artery was identified, ligated, and divided. The infradiaphragmatic inferior vena cava (IVC) was exposed and isolated by mobilizing the liver off the diaphragm or to the left (piggyback liver mobilization, case 2). The central diaphragm tendon was dissected or incised in the midline until the supradiaphragmatic intrapericardial IVC was identified and gently pulled beneath the diaphragm and into the abdomen. The tumor thrombus was then "milked" downward out of the intrapericardial IVC under the guidance of TEE. The distal and proximal IVC to the tumor thrombus, porta hepatis, and left renal vein were clamped. Tumor thrombus was removed from the IVC. The IVC was sutured and vascular clamps were placed below the major hepatic veins. Pringle's maneuver was then released and hepatic blood drainage was permitted during closure of the remaining IVC. Related literature was reviewed.
Complete resection was successful through the transabdominal approach without CBP in both patients. Estimated blood loss was 1 500 mL and 2 000 mL, and 1 200 mL and 800 mL of blood were transfused. The postoperative courses were uneventful. Both patients subsequently underwent tyrosine-kinase inhibitor therapy. Both patients were alive without tumor recurrence or new metastasis during the follow-up of 6 months and 9 months.
In selected cases, renal cell carcinoma extending into the IVC above the diaphragm can be resected without sternotomy, CBP or DHCA.
描述一种适用于肾细胞癌合并膈上肿瘤血栓患者的手术技术，该技术可避免体外循环手术。
回顾性分析2015年4月和8月收治的2例右肾肿瘤合并膈上肿瘤血栓的患者。2例均为女性，年龄分别为73岁和67岁。右肾肿瘤大小分别为7.0 cm×6.3 cm×5.7 cm和8.7 cm×7.0 cm×5.2 cm，肿瘤血栓位于膈上1.3 cm和1.8 cm处。第2例患者右肾上腺有同步转移，肿瘤血栓起源于肾上腺静脉而非肾静脉。术中采用经食管超声心动图（TEE）评估血栓的实时活动情况。采用改良人字形切口，将右肾向外侧和后方游离，识别、结扎并切断肾动脉。通过将肝脏从膈下向左侧游离（背驮式肝脏游离，病例2）暴露并分离膈下下腔静脉（IVC）。在中线切开或分离中央膈肌腱，直至识别出膈上心包内IVC，并将其轻柔地拉至膈下并放入腹腔。然后在TEE引导下将肿瘤血栓从心包内IVC向下“挤出”。夹闭肿瘤血栓上下两端的IVC、肝门和左肾静脉。从IVC中取出肿瘤血栓。缝合IVC，并在主要肝静脉下方放置血管夹。然后松开Pringle手法，在关闭剩余IVC时允许肝血流。查阅相关文献。
2例患者均通过经腹途径成功完成切除，未进行体外循环。估计失血量分别为1500 mL和2000 mL，输血分别为1200 mL和800 mL。术后病程顺利。2例患者随后均接受了酪氨酸激酶抑制剂治疗。在6个月和9个月的随访中，2例患者均存活，无肿瘤复发或新的转移。
在特定病例中，延伸至膈上IVC的肾细胞癌可不进行胸骨切开、体外循环或深低温停循环而切除。
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