不开胸处理肾癌并膈上瘤栓

Surgery for renal carcinoma with supradiaphragmatic tumor thrombus: avoiding sternotomy and cardiopulmonary bypass

目的:探讨不开胸处理肾癌伴膈上下腔静脉瘤栓的可行性和安全性。方法:回顾性分析2015年4月和8月北京大学第三医院收治的2例右肾癌伴膈上下腔静脉瘤栓患者的临床资料,2例患者均为女性,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,瘤栓分别达膈上1.3 cm和1.8 cm,病例2伴同侧肾上腺转移,瘤栓起源于右肾上腺静脉而非肾静脉。手术全程在经食道心脏超声(transesophageal echocardiography,TEE)监测下进行,取改良Chevron切口,游离右肾外侧及背侧,游离并断扎肾动脉,将肝自膈肌向下游离(病例1),或向左侧行背驮式游离(病例2),显露并游离出膈下的下腔静脉,分离或沿中线切开膈肌中心腱,显露膈上心包段下腔静脉,并将其轻柔下拉至膈下。手术在TEE监测下将瘤栓轻柔推至膈下。阻断瘤栓下方和上方下腔静脉、第一肝门和左肾静脉,切开静脉壁,完整取出瘤栓,缝合关闭腔静脉切口,将瘤栓上方腔静脉阻断钳移至肝静脉开口以下,开放第一肝门以缩短肝血供阻断时间,继续缝合至完全关闭腔静脉切口。结果:两例手术均顺利完成,术中出血量分别为1 500和2 000 m L,分别输悬浮红细胞1 200和800 m L,术后均恢复顺利,且均辅助酪氨酸激酶抑制剂治疗,分别随访9个月和6个月,患者均存活,未见肿瘤复发和新发转移。结论:部分肾癌伴膈上瘤栓病例可不开胸取膈上瘤栓,无需体外循环(cardiopulmonary bypass,CPB)和深低温心脏停跳(deep hypothermic circulatory arrest,DHCA)。

Objective： To describe a feasible surgical technique for patients with renal cell carcinoma associated with a supradiaphragmatic tumor thrombus that avoids cardiopulmonary bypass procedure. Methods ： We retrospectively analyzed 2 cases with right kidney tumor and tumor thrombus above the dia- phragm 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 pos- teriorly, and the renal artery was identified, ligated eava （IVC） was exposed and isolated by mobilizing , and divided. The infradiaphragmatic inferior vena 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. Resuits： 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. Conclusion： In selected cases, renal cell carcinoma extending into the IVC above the diaphragm can be resected without sternotomy, CBP or DHCA.