腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓

目的探讨腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓的临床经验和文献分析。 方法女性患者,61岁,临床诊断：右肾癌合并高位肝后下腔静脉癌栓。术前全面评估手术风险,组织多学科会诊为患者制定详尽的围手术期治疗与护理方案,拟行腹腔镜下右侧肾癌根治性切除+高位肝后下腔静脉癌栓取出+腹膜后淋巴结清扫术。术后医护密切配合严密观察患者病情变化,进行围手术期观察处理与护理。 结果手术顺利完成,手术时间390 min,无中转开放手术。术中完全游离右侧和左侧肾静脉、肝后下腔静脉直达第二肝门水平远端,近右肾静脉处下腔静脉内侧壁剪开静脉壁,癌栓下部小灶性侵犯静脉壁,切除部分腔静脉壁完整取出癌栓,恢复左侧肾静脉、腔静脉血流回流无障碍。术后病理提示符合透明细胞癌,癌组织侵犯肾窦脂肪,腹膜后淋巴结（-）。术后随访6个月未见肿瘤复发。 结论腹腔镜下微创手术治疗肾癌合并高位肝后下腔静脉癌栓安全可行,多学科协助模式为疑难复杂病例提供了一种新的选择,值得临床进一步推广。     

Suprarenal vena caval occlusion. Principles of operative management.

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.     

Ӧ�ø�����ǻ����ǰ��·�������г��޴�Ĥ��֬������10���ٴ�����

??Modified anterior approach to the inferior vena cava in large retroperitoneal liposarcoma??A report of 10 patients QIU Hui??LI Cheng-peng??WU Jian-hui??et al. Sarcoma Center??Peking University Cancer Hospital &Institute??Key Laboratory of Carcinogenesis and Translational Research (Ministry of Education)??Beijing 100142??China
Corresponding author??HAO Chun-yi??E-mail??haochunyi@vip.sina.com
Abstract Objective To explore the safety and feasibility of modified anterior approach to the inferior vena cava in large retroperitoneal liposarcoma. Methods The clinical data of 10 patients performed extended resection with the modified anterior approach applied from August 2015 to February 2016 in Sarcoma Center of Peking University Cancer Hospital were analyzed retrospectively. Results Totally complete resection and the modified anterior approach were successfully performed in all 10 patients, combined with 2 right hepatectomy, 6 pancreaticoduodenectomy, 10 right colectomy, 10 right nephrectomy and 2 partial resection and reconstruction of inferior vena cava. The R0 resection rate was 100%. The operation time and blood loss was 540-1000 min and 800-6000 mL respectively. One pancreatic fistula??two intra-abdominal abscess and one prosthetic vascular graft thrombosis were observed. One patient was treated operatively??and no patient died in hospital. Conclusion Modified anterior approach is safe and feasible in resection of large retroperitoneal liposarcoma.     

Leiomyosarcoma of the inferior vena cava involving the renal veins: a simple method of right renal vein reimplantation

In this report we describe a case of leiomyosarcoma of the inferior vena cava involving the renal veins. The abdominal computed tomography scan showed a tumor in the infrahepatic portion of the inferior vena cava and the confluence of the renal veins. After resection of the tumor, venous reconstruction involved the replacement of the inferior vena cava with a prosthetic graft and the implantation of the right renal vein into the portal vein. The left renal vein was ligated distally, with preservation of collateral pathways. To our knowledge, no other reports of such venous reconstruction have been published. After a follow-up of 30 months, the patient has shown no further symptoms, and the abdominal computed tomography scan demonstrates patency of the renal portal anastomosis. Tests indicated normal renal and hepatic function, suggesting good tolerance of the renal portal anastomosis. We believe that the technique described in this report should be adopted routinely for tumors located in the renal veins, provided complete resection of the tumor with a comfortable resection margin is possible.     

THE MANAGEMENT OF RENAL CELL CARCINOMA WITH INFERIOR VENA-CAVAL INVOLVEMENT

Seven patients with renal cell carcinoma involving the inferior vena cava underwent surgical resection between 1975 and 1991. Pre-operative staging defined five patients with stage T3bNoMo disease, one patient with stage T3bN₁Mo, and one patient with stage T3bNoM 1 disease.¹ At operation one patient had tumour thrombus filling the right atrium. Two patients had tumour thrombus within the intrahepatic vena cava and four infrahepatic tumour thrombus. The mean follow-up is 34.4 months (median 40 months). Four patients have been followed for over 4 years. Three of these patients are survivors, two have remained disease-free since their initial surgery. The other patient had a liver resection at 49 months for a solitary metastases; he is currently disease free. One patient died at 38 months from a gastrointesinal haemorrhage. Three patients are 12 months or less postoperation. Operative mortality was zero. The mean postoperative hospital stay was 14.7 days. Data suggests that 3–10% of renal cell carcinomas will involve the inferior vena cava.² The small number of patients in this series suggests that many patients with renal cell carcinoma involving the inferior vena cava are not referred for surgical assessment. These patients are potential surgical candidates. Their survival after surgical resection, excluding the group with extension of tumour thrombus into the hepatic cava or above, is not reduced when compared with other patients with renal carcinoma.^3,4     

Total replacement of the suprarenal inferior vena cava with an expanded polytetrafluoroethylene tube graft in 2 patients with tumor thrombi from renal cell carcinoma

Total replacement of the suprarenal inferior vena cava using an expanded polytetrafluoroethylene vascular graft was successful in 2 renal cell carcinoma patients with extended tumor thrombi densely adherent to the vena caval wall. Right radical nephrectomy in 1 patient and enucleation of the tumor in the solitary right kidney were performed concomitantly. Both patients are well without tumor recurrence and with good vena caval patency 14 and 6 months postoperatively. This procedure could be a safer mode of operation in cases of extended vena caval involvement by malignant tumors. Total reconstruction of the inferior vena cava enables more radical resection of the tumor.     

Robot-assisted laparoscopic retroperitoneal leiomyosarcoma resection with inferior vena cava graft replacement: a case report

The aim of the present study was to report the initial clinical experience of robot-assisted laparoscopic retroperitoneal leiomyosarcoma resection with inferior vena cava graft replacement. The patient was a 45-year-old female with abdominal pain. She was referred to our hospital and found to be with a retroperitoneal mass (46 mm × 45 mm). The inferior vena cava and the distal part of left renal vein were invaded by the tumor and compression was obviously seen from magnetic resonance imaging. The serum level of potassium, epinephrine, norepinephrine, cortisol, adrenocorticotropic hormone and renin angiotensin aldosterone system were all in normal ranges before the surgery. The operation was performed via a six port, robot assisted, transperitoneal laparoscopic approach. The tumor was completely resected and adherent part of inferior vena cava (approximately 5 cm) was dissected. Considering severe impairment of the great vessel, we decided to replace excised caval segment with an extended polytetrafluoroethylene graft and undertook the inferior vena cava reconstruction. The patient was discharged 11 days postoperatively with embolus in the graft. Anticoagulants were routinely administrated and the thrombus seemed to be smaller 3 months after operation. Abdominal pain was resolved and pathological examination finally confirmed that the tumor was leiomyosarcoma with negative margins free from tumor. Leiomyosarcoma of inferior vena cava present a technical challenge to surgeons. Comprehensive preparation should be made preoperatively to facilitate tumor resection and vascular management. In specific cases, robotic resection of leiomyosarcoma from great vessels and vascular repairment might be feasible options in experienced hands.     

Resection and reconstruction of the great vessels for lung cancer and mediastinal tumor

Between January 1994 and December 1997, 17 patients with lung cancer and 5 patients with mediastinal tumor underwent extensive resection and reconstruction of the great vessels. In patients with lung cancer, the aorta was resected under cardiopulmonary bypass in 4 patients, the superior vena cava in 12, and the left main pulmonary artery with combined resection of the left atrium in 1 and the aorta in 1. In five patients who underwent resection of the superior vena cava, subcarinal resection and reconstruction were also performed. Three patients died within 30 days after surgery. Six patients died of cancer between 3 months and 2 years after surgery. Two patients who underwent aortic resection for node negative lung cancer have survived more than 3 years after surgery. Six patients have survived between 6 months and 2 years after surgery. The histologic type of mediastinal tumor was thymic cancer in 3 patients, invasive thymoma in 1 and malignant lymphoma in 1. In patients who underwent resection of the superior vena cava for mediastinal tumor, bilateral brachiocephalic vein reconstruction was performed in 4 patients and the left brachiocephalic vein reconstruction in 1. One patient underwent resection of the right atrium. The patient with invasive thymoma has survived for more than 3 years. Two of 3 patients with thymic cancer died within 2 years. When complete resection is achieved with combined resection of the great vessels, survival may be anticipated in patients with N0 lung cancer or in those with invasive thymoma.     

累及重要血管的腹膜后肿瘤切除术

目的总结合并重要血管切除重建的腹膜后肿瘤切除经验。方法对16例累及重要血管的腹膜后肿瘤患者均采用合并重要血管切除重建的肿瘤切除术。血管重建方式：人工血管移植16例次，下腔静脉部分切除及修补3例次；其中动静脉联合重建6例次，合并其它脏器切除重建5例次。结果无手术死亡。随访14例，随访期3~71个月，平均30个月。随访期间死亡5例，其中12个月内死亡3例， 64个月内死亡1例，71个月死亡1例；随访期无血管阻塞。结论合并重要血管切除重建的腹膜后肿瘤切除术对累及重要血管的腹膜后肿瘤是安全有效的。     

Should the inferior vena cava be reconstructed after resection for malignant tumors?

BACKGROUND: Caval replacement after circumferential resection of the inferior vena cava remains controversial. The aim of the current study is to determine whether or not inferior vena cava replacement should be performed. METHODS: We reviewed 36 cases undergoing resection of the inferior vena cava concomitant with resection of malignant neoplasms. Our criteria for circumferential resection of the inferior vena cava were half or more of the circumference of the vessel wall invaded by tumor, a primary tumor of the caval wall, or massive intraluminal tumor thrombus suspected of adhering to the caval wall. We detailed 10 patients undergoing circumferential resection of the inferior vena cava. RESULTS: Most of patients who did not undergo replacement of the inferior vena cava showed no sign of swelling of the lower limbs, but one showed persistent leg edema with oliguria. This patient had poor development of collateral circulation and mild obstruction of the inferior vena cava before surgery. Two patients who underwent replacement of inferior vena cava had no venous sequelae, although they had poor development of collateral circulation before surgery. CONCLUSION: Caval replacement after circumferential resection of the inferior vena cava may be necessary in patients who have preoperative poor development of collateral circulation or who have oliguria or unstable hemodynamics intraoperatively.     

Prosthetic replacement of the inferior vena cava and the iliofemoral vein for urologically related malignancies

OBJECTIVE: To evaluate the feasibility and results of prosthetic venous replacement, as inferior vena cava (IVC) and iliofemoral vein resection and replacement are sometimes necessary when they are extensively involved by a large and fixed tumour thrombus from renal cell carcinoma (RCC) or other urological malignancies. PATIENTS AND METHODS: Five men and two women (age range 41-75 years) were treated over a 10-year period (1991-2001) by aggressive venous surgery to achieve complete tumour resection, with prosthetic graft replacement to re-establish venous flow. The tumours included RCC of the right kidney (two), retroperitoneal liposarcoma (two), bladder cancer (one), retroperitoneal fibrosarcoma (one) and inguino-pelvic lymphoma (one). Two patients had a vena caval replacement, of whom one had a circular reinforced PTFE and one a Dacron silver graft; five patients had either an iliofemoral or an ilio-iliac circular reinforced PTFE graft. The prosthetic diameter was 18-20 mm for the IVC grafts and 8-10 mm for the iliac grafts. In all the patients, graft patency was evaluated during the follow-up by colour flow duplex imaging, and in one it was determined by angio-computed tomography scan and venography. RESULTS: One patient died 30 days after surgery; of the remaining six patients one had no evidence of regional recurrence or metastatic disease at 12 months, and five died from recurrent tumour 8-30 months after surgery. The mean time to death was 23 months. At 3 months all six prosthesis were patent; at 6 months four were patent and at 12 months three of five prostheses were patent. CONCLUSION: Resecting and replacing the IVC allows complete tumour resection and avoids renal failure, providing durable relief from the symptoms of venous obstruction. Iliofemoral prosthetic reconstruction for urological-related malignancies represents a viable option to avoid venous engorgement and lower extremity swelling, at least in the early postoperative period. The mean time to death for the present patients must be considered the limit for these aggressive operations.     

Resection of advanced stage malignant retroperitoneal neoplasms with tumor thrombus extending into the right atrium: Report of four cases

Surgery for retroperitoneal neoplasms with a tumor thrombus extension into the right atrium is challenging. This study reviewed four surgical cases of advanced stage malignant neoplasms with the tumor thrombus extending into the right atrium. The malignant neoplasms involved the kidney in two patients, and the liver and adrenal gland in one each. The tumor thrombus was removed through a longitudinal cavotomy and right atriotomy in all cases. The inferior vena cava reconstruction was performed by directly closing it in one patient and by pericardial patch suturing in another. Cardiopulmonary bypass was used for all procedures and a Pringle maneuver was used to reduce bleeding from the liver in three. There was no perioperative or hospital death. Two of the four with renal cell carcinoma were alive 7 and 13 months after the surgery. One with hepatocellular carcinoma died of recurrent malignancy after 4 months, while the patient with an adrenal carcinoma remained disease free after surgery. These cases indicate the safety of the present procedure. Although the long-term results are still unknown, there were favorable early results and a lack of perioperative complications. Surgical challenges in resecting an intracardiac extension of retroperitoneal malignancy require close cooperation among the attending urologist, and both gastrointestinal and cardiovascular surgeons.     

累及气管下段右侧壁和上腔静脉的右上肺癌的外科治疗

目的：探讨累及气管下段右侧壁和上腔静脉的右上肺癌外科治疗策略及其疗效。方法累及气管下段右侧壁和上腔静脉的T4期肺癌外科治疗患者4例，采用“左主支气管延长”法气道重建，2例采用腔外分流法置换上腔静脉，2例行上腔静脉侧壁切除术。1例同时行肺动脉侧壁部分切除术。结果4例患者均顺利完成手术，无围手术期死亡。术后均给予低分子肝素抗凝治疗2周，之后改为阿司匹林抗凝治疗。术后声音嘶哑合并肺部感染1例，1例房颤。无其他严重并发症，术前上腔静脉阻塞综合征的2例患者术后无上腔静脉阻塞表现，胸部增强CT提示上腔静脉通畅。2例患者分别生存34个月和36个月，仍在随访中；另2例术后病理N2的患者分别生存30个月和31个月，已死亡。结论左主支气管根部延长术和腔外分流法上腔静脉置换或侧壁切除用于治疗累及气管下段右侧壁和上腔静脉的右上肺癌，安全有效。     

Testicular carcinoma with inferior vena cava thrombosis extending into the right atrium treated with chemotherapy and anticoagulation.

A 34-year-old male with pulmonary emboli and thrombosis of the inferior vena cava extending into the right atrium was found at presentation to have a mixed seminoma and embryonal cell testicular carcinoma with high-volume retroperitoneal disease and visceral metastases. The patient was free of disease 19 months after treatment with combination chemotherapy and anticoagulation followed by resection of the residual mass. We could not find any previous report of a patient with bulky retroperitoneal disease and vena cava thrombosis successfully treated with chemotherapy without vena cava resection.     

Vena caval resection in bulky metastatic germ cell tumors

We describe the operative management and followup of vena caval resection in 12 patients with thrombosis of the inferior vena cava secondary to bulky metastatic (stage B3 or IIC) germ cell tumors. All patients received induction chemotherapy (10 platinum-based) followed by retroperitoneal lymph node dissection. The inferior vena cava was resected from just below the renal veins to the bifurcation of the iliac veins. Complete resection of retroperitoneal disease was accomplished in all patients. Five patients had postoperative complications, including 2 small bowel obstructions, 1 prolonged ileus and 2 persistent lymphatic leaks. Mean hospital stay was 37 days (range 27 to 49 days) versus 12 days (range 8 to 16 days) for noncomplicated recoveries. No long-term sequelae related to the vena caval resection have occurred with followup of 24 to 80 months. Seven patients are without disease, with a mean followup of 36 months (range 24 to 60 months). We conclude that en bloc vena caval resection for thrombosis of the vena cava allows for complete resection and simplifies the procedure with acceptable morbidity.     

应用改良下腔静脉前入路法完整切除巨大腹膜后脂肪肉瘤10例临床分析

目的 探讨改良下腔静脉前入路法在腹膜后脂肪肉瘤根治切除手术中应用的安全性和可行性。方法　回顾性分析北京大学肿瘤医院暨北京市肿瘤防治研究所软组织与腹膜后肿瘤中心2015年8月至2016年2月应用改良前入路法行肿瘤根治切除术治疗10例腹膜后巨大脂肪肉瘤病人的术中及术后资料。结果 10例病人均完整切除肿瘤。手术时间540～1000 min,术中出血800～6000 mL,联合右半肝切除2例,胰十二指肠切除术6例,右半结肠、右肾切除10例,下腔静脉切除重建5例。均达到R0切除,术后发生B级以上胰瘘1例,Clavien-DindoⅢ级以上腹腔感染2例,人工血管血栓形成1例,二次手术1例,无围手术期死亡。结论 应用改良前入路法切除右侧腹膜后巨大脂肪肉瘤安全、可行,值得开展进一步研究。     

Renal cell carcinoma with a huge solitary metastasis to the contralateral adrenal gland: A case report

Renal cell carcinoma (RCC) is capable of metastasizing to several organs. Synchronous isolated contralateral adrenal metastasis of the primary RCC is, however, very rare. Herein we report a case of RCC with a huge solitary metastasis to the contralateral adrenal gland that was surgically treated. We scheduled nephrectomy for the left primary RCC and adrenalectomy for the right adrenal tumor. However, at surgery we found a huge right adrenal tumor that had invaded the right kidney, right renal vein, and inferior vena cava. Therefore right nephrectomy was performed simultaneously with resection and reconstruction of the inferior vena cava. Pathological findings demonstrated that the left renal tumor and right adrenal tumor had the same histology. Although the patient required hemodialysis, he remains well at six months postoperatively. So far, there have been only two cases of a solitary contralateral metastatic adrenal tumor that was larger than the primary RCC, thus the present case is the third one.     

原发性下腔静脉平滑肌肉瘤的手术治疗

目的 探讨原发性下腔静脉平滑肌肉瘤的手术治疗.方法 回顾性分析山东大学附属省立医院血管外科2009年10月-2011年5月收治的5例原发性下腔静脉平滑肌肉瘤患者,均行手术治疗,采用肿瘤及受累下腔静脉切除、人工血管重建双肾静脉及远端下腔静脉血流的术式.结果 本组5例患者平均手术时间为166.6 min,术中平均失血量为1...     

医源性下腔静脉损伤的预防和处理

目的探讨医源性下腔静脉损伤的预防和紧急处理。方法回顾性分析7例医源性下腔静脉损伤,原发病为右肾上腺肿瘤1例,右肾肿瘤3例,右脓肾1例,右上腹膜后肿瘤1例,胰头癌1例。损伤后致大出血立即压迫止血,原右腰部切口者重新改行腹部切口,入腹后用手向右推挤下腔静脉立即止血,吸净积血看清腔静脉破口,取辛氏钳夹闭破口,以3-0丝线或聚丙烯不吸收线连续缝合损伤处。结果本组7例中1例抢救不力,致出血性休克死亡,6例止血效果良好,其他合并伤均积极治疗获愈,仅1例双下肢轻度浮肿。结论医源性下腔静脉损伤只要紧急抢救方法得当均可获得成功。术中仔细操作,此种损伤是完全可预防的。     

Treatment of colorectal liver metastasis with biliary and portal vein tumor thrombi by hepatopancreatoduodenectomy

We present a case of a large colorectal liver metastasis with portal vein and biliary tumor thrombi and duodenal and jejunal direct invasion that required hepatopancreatoduodenectomy. A 38-year-old woman presented to her local hospital with right back pain and jaundice. She had undergone transverse colectomy and limited liver resection for transverse colon cancer with a synchronous liver metastasis in September 1991, and low anterior resection for rectal carcinoma in January 1996. She was diagnosed as having colorectal liver metastasis and was referred to our hospital for possible surgery. Radiologic and endoscopic examinations revealed a large liver tumor occupying the right lobe, biliary dilation in the left lateral section, and a portal vein tumor thrombus. Invasion of the inferior vena cava and the right renal vein were also suspected. Intraoperative findings revealed a large liver tumor that occupied the right lobe and invaded the duodenum and jejunum. The tumor was resected successfully by right trisectionectomy, caudate lobectomy, pancreatoduodenectomy, partial resection of the jejunum, and combined portal vein resection and reconstruction. The inferior vena cava, right kidney, and renal vein could be detached from the tumor. The patient has enjoyed an active life without recurrence for 2 years since the operation.