肾癌并肝段和肝以上下腔静脉癌栓的诊治体会

Diagnosis and treatment of renal cell carcinoma complicated with inferior vena cava tumor thrombus in hepatic segment and upper hepatic segment

外科手术是可能治愈肾癌并肝段和肝以上下腔静脉癌栓患者的唯一治疗方式。术前对肝段和肝以上下腔静脉癌栓的准确诊断至关重要。术前影像学检查中，腹部CT增强扫描和下腔静脉MRI扫描是诊断和评价肝段和肝以上下腔静脉癌栓的最佳方法。与肝以下癌栓相比，肝内和肝以上下腔静脉癌栓延伸范围广，手术难度增大。对于简单的肝段下腔静脉癌栓（癌栓顶端刚达到肝静脉水平者）可尝试采用后腹腔镜联合经腹途径腹腔镜手术方式。对于其他的肝段和肝以上癌栓患者，开放手术成为标准手术方式。术中除游离肝下的下腔静脉外，还需要充分游离、暴露肝脏及第一肝门，显露肝后下腔静脉及肝静脉。对于进入心房的癌栓，首选纵行切开膈肌，用＂Milking＂技术挤压癌栓至下腔静脉，用＂导尿管法＂取出癌栓。对于其他较高难度的心房内癌栓，需建立体外循环，取肋缘下切口和胸部正中切口开胸并打开心包，取出癌栓。肝段和肝以上下腔静脉癌栓患者应尽早诊断，积极采取手术治疗。

Surgical treatment is the only cure treatment for patients with inferior vena cava tumor thrombus in hepatic segment and upper hepatic segment. The accurate diagnosis of tumor thrombus is very important. In preoperative imaging examination, the abdominal enhanced CT scan and the inferior vena cava MRI scan were the best methods for the diagnosis and evaluation of the tumor thrombus in hepatic segment and upper hepatic segment. Compared with the tumor thrombus below the liver, the tumor thrombus in hepatic segment or above hepatic segment extend widely, and the operation are more difficult. For simple inferior vena eava tumor thrombus （the top of the thrombus has reached the level of hepatic vein ）, Retroperitoneal approach combined with transperitoneal approach should be used. Open surgery is the standard procedure for other tumor thrombus in hepatic segment and upper hepatic segment. In addition to exposure of inferior vena cava below the hepatic vein, the liver and the first hepatic hilum should be exposed. For tumor thrombus in the atrium, after the longitudinal incision of diaphragm, we use ＂Milking＂ technology to squeeze thrombus into inferior vena cava. Then we use ＂catheterization＂ technology to remove thrombus. For difficult atrial tumor thrombus, an extracorporeal circulation should be performed. The median incision in the chest should be performed to open the chest and open the pericardium and remove the tumor thrombus. Patients with tumor thrombus in hepatic segment or upper hepatic segment should be diagnosed as early as possible and they need actively treated by operation.