累及下腔静脉的右上腹肿瘤患者的外科治疗

Surgical treatment for right upper quadrant tumors with inferior vena cava involvement

目的：探讨累及下腔静脉的右上腹肿瘤患者外科手术治疗的安全性和疗效。方法回顾性分析2006年1月至2012年12月郑州大学第一附属医院肝胆胰外科收治的77例右上腹肿瘤患者临床资料。其中男36例，女41例；年龄22～71岁，中位年龄51岁；右肾癌20例，右肾错构瘤2例，右肾上腺肿瘤30例，腹膜后肿瘤25例。下腔静脉受侵犯55例，其中25例伴下腔静脉癌栓，包括Ⅰ型癌栓4例，Ⅱ型2例，Ⅲ型17例，Ⅳ型2例。所有患者均签署知情同意书，符合医学伦理学规定。行右上腹肋缘下切口或胸腹联合切口，游离、显露肿瘤及下腔静脉，术中根据情况阻断下腔静脉、肾静脉及第一肝门。对于Ⅰ、Ⅱ型癌栓，在切除肿瘤的同时取出癌栓。Ⅲ、Ⅳ型癌栓在体外循环辅助下先切除肿瘤再取出癌栓。观察患者围手术期情况，包括下腔静脉血流阻断时间、术中出血量、手术时间、术后住院时间，死亡和并发症发生等情况。结果77例患者均切除肿瘤及下腔静脉癌栓，手术顺利。下腔静脉血流阻断时间中位数为20（13～28）min，术中失血量800（200～1800）ml，手术时间156（120～180）min，术后住院时间15（10～18）d。围手术期死亡1例，死于窒息；围手术期无其他严重并发症发生。随访期间死亡10例，均死于肿瘤复发、转移。结论对于累及下腔静脉的右上腹肿瘤患者，选择合适的手术入路和方法行肿瘤及癌栓切除是安全、有效的。

Objective To assess the safety and effects of surgical treatment for the right upper quadrant tumors with inferior vena cava involvement. Methods Clinical data of 77 patients with right upper quadrant tumors in Department of Hepatobiliary and Pancreatic Surgery, the First Afifliated Hospital of Zhengzhou University from January 2006 to December 2012 were analyzed retrospectively. There were 36 males and 41 females with age ranging from 22 to 71 years old and a median age of 51 years old. The patients included 20 cases of right renal carcinoma, 2 cases of hamartoma of right kidney, 30 cases of right adrenal tumors, 25 cases of retroperitoneal tumors. Inferior vena cava involvement was observed in 55 cases, in which 25 cases were combined with tumor thrombus of inferior vena cava. Four cases were tumor thrombus typeⅠ, 2 cases were typeⅡ, 17 cases were typeⅢ, and 2 cases were typeⅣ. The informed consents of all patients were obtained and the ethical committee approval was received. Subcostal incisions in the right upper abdomen or thoracoabdominal incisions were made and the tumors and inferior vena cava were separated and exposed. The blood lfows of inferior vena cava, renal veins and the ifrst porta were excluded depending on circumstances during the operation. For tumor thrombus typeⅠandⅡ, it was removed at the same time as the tumors were resected. For tumor thrombus typeⅢandⅣ, it was removed after the tumors were resected under cardiopulmonary bypass. The perioperative situations of patients including duration of inferior vena cava blood exclusion, intraoperative blood loss, operation duration, postoperative hospital stay, death and complications were observed. Results All the 77 cases underwent tumor resection and removal of tumor thrombus of inferior vena cava successfully. The median of duration of inferior vena cava blood exclusion was 20 （13-28）min. The intraoperative blood loss was 800（200-1 800）ml. The operation duration was 156 （120-180）min. The postoperative hospital stay was 15（10-18）d. One case died of asphyxia during the perioperative period. No other severe complication was observed during the perioperative period. Ten cases died of tumor recurrence and metastasis during the follow up. Conclusion For the patients with right upper quadrant tumors with inferior vena cava involvement, resecting the tumor and tumor thrombus is safe and effective by choosing a proper surgical approach.