全肝游离技术在肾癌伴下腔静脉癌栓手术中的应用价值

The application of liver free technique in surgery of renal cell carcinoma with tumor thrombus

目的:探讨全肝游离技术在肾癌伴MayoⅡ~Ⅳ级下腔静脉癌栓手术中的应用价值。方法:回顾性分析2014年1月至2019年12月北京大学第三医院收治的25例肾癌合并MayoⅡ~Ⅳ级下腔静脉癌栓患者的病例资料。男20例,女5例。平均年龄(61±6)(45~74)岁。术前均行泌尿系CTU或MRU检查、腔静脉增强磁共振血管成像检查,肿瘤位于左侧8例,右侧17例。肿瘤长径中位值7(3.6~12.1)cm。癌栓Mayo分级:Ⅱ级1例,Ⅲ级7例,Ⅳ级17例。伴远处转移7例,分别为肺转移6例,骨转移1例。经多学科会诊(MDT)后制订手术方案,根治性肾切除术19例,减瘤性肾切除术6例,均行经腹腔开放手术入路下腔静脉癌栓切除术。术中采用全肝游离技术进行右半肝或肝门游离,即将肝脏周围的韧带完全游离,打开肝肾间隙,充分游离肝脏裸区,显露肝上下腔静脉、肝下下腔静脉以及肝后下腔静脉侧壁。对于MayoⅣ级癌栓,11例采用不开胸游离膈肌取栓法,6例联合心脏外科行开胸体外循环取栓法。结果:本组25例手术均顺利完成。手术时间中位值444(258~694)min,术中出血量中位值2000(250~10000)ml,输悬浮红细胞中位值1300(400~10400)ml。术后住院时间中位值10(4~25)d。术后并发症15例(60%),包括:肝损伤8例,呼吸系统并发症5例,肾损伤4例,贫血3例,感染3例,血栓形成1例。围手术期死亡3例。结论:在肾癌伴下腔静脉癌栓手术中采用全肝游离技术可以获得良好的手术视野,可有效控制下腔静脉出血,有助于安全切除肿瘤,保障手术安全。

Objective To disiuss the application of liver free technique in renal cell carcinoma patients with MayoⅡ-Ⅳtumor thrombus.Methods The clinical data of renal cell carcinoma patients with MayoⅡ-ⅣIVC tumor thrombus in our hospital from January 2014 to December 2019 were retrospectively analyzed.25 patients underwent right part of liver or hepatic portal part dissection via open abdominal approach.There were 20 males and 5 females,aged 45-74 years(mean 61±6 years).All patients underwent urinary tract CTU or MRU examination,vena cava enhanced magnetic resonance angiography.There were left 8 cases,right 17 cases;the median length of tumor was 7 cm(3.6-12.1 cm).There were 1 case of Mayo gradeⅡtumor thrombus,7 cases of Mayo gradeⅢtumor thrombus,and 17 cases of Mayo gradeⅣtumor thrombus.There were 7 cases of distant metastasis,including 6 cases of lung metastasis and 1 case of bone metastasis.After multi-disciplinary consultation(MDT),19 patients underwent radical nephrectomy and 6 patients underwent tumor reducing nephrectomy.During the operation,the ligaments around the liver were completely dissociated and the space between the liver and kidney was opened.The bare area of the liver was fully dissociated,to expose the inferior vena cava.For Mayo gradeⅣtumor thrombus,11 cases were treated with free diaphragmatic thrombus removal without thoracotomy,and 6 cases were treated with open chest cardiopulmonary bypass.Results The median operation time was 444(258-694)min,the median intraoperative blood loss was 2000(250-10000)ml,and the median value of suspended red blood cell transfusion was 1300(400-10400)ml.The median postoperative hospital stay was 10(4-25)days.15 patients(60%)had postoperative complications,including 8 cases of liver injury,5 cases of respiratory complications,4 cases of kidney injury,3 cases of anemia,3 cases of infection and 1 case of thrombosis.Three patients died during perioperative period.Conclusions The application of total liver free technique might obtain good exposure of surgical field,effectively control the hemorrhage of inferior vena cava,which is helpful for safe resection of tumor.