普外心外联合手术治疗合并膈上下腔静脉及右心房瘤栓的小儿肿瘤

Combined general and cardiac surgery for the treatment of pediatric tumors with supradiaphragmatic inferior vena cava and right atrium tumor thrombus

目的探讨普外心外联合手术治疗合并膈上下腔静脉及右心房瘤栓的小儿肿瘤的可行性及效果。方法回顾性分析2015年6月至2019年5月首都儿科研究所附属儿童医院普外心外联合手术治疗的合并膈上下腔静脉及右心房瘤栓的8例肿瘤患儿的临床治疗过程。手术取胸腹联合正中切口,心外科先行打开心包,备体外循环,然后普外科上台切除腹部原发肿瘤,切开膈下下腔静脉并取出膈下瘤栓,同时尝试自下腔静脉开口处取出膈上瘤栓,若瘤栓无法自膈下完整取出,则收紧预制的肺动脉阻断带,建立体外循环,心外科切除膈上部分瘤栓或打开右心房切除右心房内瘤栓。结果8例患儿中,肝母细胞瘤4例,肾母细胞瘤3例,肾上腺皮质癌1例。其中瘤栓进入右心房4例,均在体外循环下切开右心房取栓;1例在体外循环下切除膈上下腔静脉瘤栓;3例未行体外循环,在膈下完整取出瘤栓。8例患儿中,7例完整切除瘤栓,1例残留髂静脉瘤栓,8例患儿均未出现肺栓塞。8例患儿术后规律化疗,中位随访时间22.5个月(10~57个月),6例存活,1例死亡,1例失访。结论普外心外联合手术,在减少患者痛苦的前提下,可以一次完整切除原发肿瘤及膈上瘤栓,提高了肿瘤的完整切除率,同时避免了肺栓塞发生的风险。使得以往痛苦大、风险高的手术变得更加安全、有效、人性化。

Objective To investigate the feasibility and efficacy of combined general and cardiac surgery in the treatment of pediatric tumors with supradiaphragmatic inferior vena cava(IVC)and right atrium(RA)tumor thrombus.Methods Retrospective analysis was performed on the clinical treatment of 8 pediatric tumor patients with supradiaphragmatic IVC and RA tumor thrombus treated by combined general and cardiac surgery in Children′s Hospital,Capital Institute of Pediatrics from June 2015 to May 2019.The operation was performed through a combined thoracoabdominal median incision.Cardiac surgeon opened the pericardium for cardiopulmonary bypass(CPB).Subsequently,general surgeon resected the primary abdominal tumor,cut open the subphrenic IVC,removed the subphrenic tumor thrombus,and made an attempt to remove the supradiaphragmatic tumor thrombus through the same incision of IVC.If the tumor thrombus cannot be completely removed through this incision,cardiac surgeon shall tighten the prefabricated pulmonary artery blocking band,establish CPB,and remove the supradiaphragmatic tumor thrombus in IVC or open RA to remove the atrial tumor thrombus.Results In the 8 cases,there was hepatoblastoma in 4 cases,nephroblastoma in 3 cases,and adrenocortical carcinoma in 1 case.Among them,there was RA tumor thrombus in 4 cases,which was removed by right atrial thrombectomy under CPB;tumor thrombus in supradiaphragmatic IVC in 1 case,which was removed under CPB;subphrenic IVC in 3 cases,which was completely removed without the adoption of CPB.Among those 8 cases,7 cases had complete resection of the tumor thrombus and 1 case had residual iliac vein tumor thrombus,and none of them developed pulmonary embolism.All the 8 cases underwent regular postoperative chemotherapy,and median follow-up time was 22.5 months(10-57 months),with 6 survived cases,1 case died,and 1 case losing follow-up.Conclusions Combined general and cardiac surgery can allow complete resection of the primary tumor and supradiaphragmatic and right a trial tumor thrombus in a single operation with reduced pain in patients,which could not only improve the rate of complete tumor resection but also reduce the risk of pulmonary embolism,thereby making the previously painful and risky surgery safer,more effective and more humane.