原发性肝癌合并右心房和下腔静脉癌栓的手术治疗

Surgical treatment of hepatocellular carcinoma combined with tumor thrombus in right atrium and inferior vena cava

目的：探讨在体外循环常温心脏不停跳下行右心房和下腔静脉切开取栓＋部分肝切除术治疗原发性肝癌合并右心房和下腔静脉癌栓的临床疗效。 方法：采用回顾性描述性研究方法。收集2014年12月北京大学人民医院收治的1例原发性肝癌合并右心房和下腔静脉癌栓患者的临床资料。联合心脏外科在体外循环常温心脏不停跳下，行右心房和下腔静脉切开取栓＋部分肝切除术。观察指标：（1）术中和术后情况：术中所见、手术时间、体外循环时间、术中出血量、术中输血情况、术后并发症情况、术后住院时间。（2）术后病理学检查情况。（3）随访情况：患者生存及肿瘤复发、转移情况。采用门诊方式进行随访，了解患者生存及肿瘤复发、转移情况。随访时间截至2016年9月。 结果：（1）术中和术后情况：术中见右心房内癌栓大小为3.0 cm×4.0 cm。手术时间为630 min，体外循环时间为85 min，术中出血量为 4 000 mL，术中输入压积RBC 1 820 mL，血浆2 200 mL。术后早期患者出现一过性肝、肾功能指标异常，但均快速恢复至正常水平。患者术后出现右侧胸腔积液及肺部感染，经积极治疗后，于术后第5天脱离呼吸机支持，术后第15天拔除胸腔闭式引流管。无出血、胆汁漏、切口感染等并发症发生。患者于术后第25天出院。（2）术后病理学检查情况：肿瘤位于肝右后叶，边界不清晰，剖面呈灰白色；右心房和下腔静脉癌栓呈灰白色，质地糟脆，大小为4.0 cm×4.0 cm×2.0 cm。免疫组织化学染色检测结果示肝细胞、磷脂酰基醇蛋白聚糖-3、CD34阳性，AFP阴性，Ki-67阳性指数为15%。病理学诊断为中分化肝癌。（3）随访情况：患者出院后恢复顺利，未诉明显不适。术后第45天行肝动脉造影检查结果示：肝动脉肝静脉瘘形成，行奥沙利铂＋吉西他滨预防性灌注化疗，采用明胶海绵行肝右动脉栓塞术。随访期间，患者定期复查腹部CT和胸部X线片，未见下腔静脉癌栓和肿瘤复发。 结论：对于原发性肝癌合并右心房和下腔静脉癌栓患者，联合心脏外科在体外循环常温心脏不停跳下，行右心房和下腔静脉切开取栓＋部分肝切除术安全可行。

Objective：To explore the clinical effect of embolectomy through incision of right atrium and inferior vena cava under normothermia cardiopulmonary bypass with beating heart ＋ partial hepatectomy for hepatocellular carcinoma （HCC） combined with tumor thrombus in right atrium and inferior vena cava. Methods：The retrospective and descriptive study was conducted. The clinical data of 1 patient with HCC combined with tumor thrombus in right atrium and inferior vena cava who were admitted to the Peking University People′s Hospital in December 2014 were collected. The patient underwent embolectomy through incision of right atrium and inferior vena cava under normothermia cardiopulmonary bypass with beating heart＋partial hepatectomy. Observation indicators： （1） intra and postoperative situations： intraoperative findings, operation time, cardiopulmonary bypass time, volume of intraoperative blood loss, intraoperative blood transfusion, postoperative complication and duration of hospital stay; （2） postoperative pathological examination; （3） followup situation： survival of patient and tumor recurrence or metastasis. Followup using outpatient examination was performed to detect survival of patient and tumor recurrence or metastasis up to September 2016. Results：（1） Intra-and post-operative situations：size of tumor thrombus in right atrium, operation time, cardiopulmonary bypass time, volume of intraoperative blood loss, volumes of intraoperative red blood cell and blood plasma transfusions were 3.0 cm× 4.0 cm, 630 minutes, 85 minutes, 4 000 mL, 1 820 mL and 2 200 mL, respectively. The abnormal and transient liver and renal functions in early stage after surgery recovered quickly to the normal level. Patient with pleural effusion and pulmonary infection received active treatment, and then ventilator treatment was stopped at 5 days postoperatively and closed thoracic drainagetube was removed at 15 days postoperatively. There was no occurrence of hemorrhage, bile leakage and wound infection. Patient was discharged from hospital at 25 days postoperatively. （2） Postoperative pathological examination： tumor with unclear boundary and graywhite section located in the right posterior lobe of the liver. Tumor thrombus in right atrium and inferior vena cava was graywhite, with a rough texture and size of 4.0 cm×4.0 cm×2.0 cm. Immunohistochemical staining dectection showed that liver cells, glypican 3 and CD34 were positive and alphafetoprotein was negative, with a positive index of Ki-67 of 15%. The moderatedifferentiated HCC was confirmed by pathologic examination. （3） Followup situation： patient had a smooth recovery after discharge, without obvious discomfort. Hepatic arterialvenous fistula was confirmed at 45 days postoperatively by hepatic arterial angiography. Patient underwent preventive infusion chemotherapy with oxaliplatin and gemcitabine, and right hepatic arterial embolization with gelatin sponge. During the followup, patient received regular reexaminations of abdominal computed tomography and chest Xray, without tumor thrombus in inferior vena cava and tumor recurrence. Conclusion：Embolectomy through incision of right atrium and inferior vena cava under normothermia cardiopulmonary bypass with beating heart and partial hepatectomy are safe and feasible for patient with HCC combined with tumor thrombus in right atrium and inferior vena cava.