Department of Surgery, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
Miami Transplant Institute, University of Miami Miller School of Medicine, Jackson Memorial Hospital, Miami, FL, USA.
World J Surg Oncol. 2024 Mar 7;22(1):76. doi: 10.1186/s12957-024-03355-z.
The gold standard treatment for renal cell carcinoma (RCC) with tumor thrombus (TT) is complete surgical excision. The surgery is complex and challenging to the surgeon, especially with large tumor thrombus extending into the inferior vena cava (IVC) and right atrium. Traditionally, these difficult cases required the use of cardiopulmonary bypass (CPB) with or without deep hypothermic cardiac arrest, but in recent years, different surgical techniques derived from the field of liver transplantation have been used in efforts to avoid CPB.
We present a case of RCC with TT level IIIc (extending above major hepatic veins) that "uncoiled" intraoperatively into the right atrium after division of the IVC ligament, transforming into a level IV TT. Despite the new TT extension, the surgery was successfully completed exclusively through an abdominal approach without CPB and while using intraoperative transesophageal echocardiography (TEE) monitoring and a cardiothoracic team standby.
This case highlights the need for a multidisciplinary approach and the utility of intraoperative continous TEE monitoring which helped to visualize the change of the TT venous extension, allowing the surgical teamto modify their surgical approach as needed avoiding a catastrophic event.
肾细胞癌（RCC）合并肿瘤血栓（TT）的金标准治疗方法是完全手术切除。该手术复杂且对外科医生具有挑战性，尤其是对于延伸至下腔静脉（IVC）和右心房的大肿瘤血栓。传统上，这些困难的病例需要使用心肺旁路（CPB），无论是否伴有深低温心脏停搏，但近年来，源自肝移植领域的不同手术技术已被用于避免 CPB。
我们报告了一例 RCC 合并 TT Ⅲ c 级（延伸至肝静脉上方）的病例，在 IVC 韧带分离后，肿瘤“解开”并进入右心房，转化为 IV 级 TT。尽管新的 TT 延伸，但手术仅通过腹部途径成功完成，无需 CPB，并在术中使用经食管超声心动图（TEE）监测和心胸团队待命。
该病例强调了多学科方法的必要性和术中连续 TEE 监测的实用性，它有助于观察 TT 静脉延伸的变化，使手术团队能够根据需要修改手术方法，避免灾难性事件的发生。
