肝静脉和下腔静脉血流控制在高难度肝肿瘤切除中的应用

目的评估肝静脉主干和(或)下腔静脉血流控制在高难度肝切除术中的作用和意义。方法对33例位于Ⅳ、Ⅶ、Ⅷ段和左半肝、右半肝、右三叶的肝肿瘤进行了游离下腔静脉和肝静脉主干并加以控制的肝切除术。其中肝细胞性肝癌26例;胆管细胞性肝癌2例;转移性肝癌2例;肝血管瘤3例。32例患者在术中成功预置了下腔静脉和肝静脉的阻断带,必要时控制肝静脉和下腔静脉血流。1例患者预置肝静脉阻断带失败。结果33例全部成功切除肿瘤,术中输血0-1600ml,其中7例没有输血。全组无术中死亡病例。结论熟练掌握和合理控制肝静脉主干和下腔静脉血流,可以提高复杂肝肿瘤切除的安全性和减少输血,有助于完成高难度肝肿瘤的切除。     

肝移植中肝脏左旋显露手法对血流动力学的影响

目的:通过观察肝移植中切肝阶段采用肝脏左旋显露手法时下腔静脉压力及其他循环指标的变化,探讨该术式的安全性和有效性。方法:选择择期行原位肝移植的手术病人18例,分别记录进腹后左侧旋转肝脏时的下腔静脉压、中心静脉压、平均动脉压等循环指标;测定病人术前至术后肾功能指标。结果:18例肝移植均顺利进行,所有病人术后愈合良好,无明显术后并发症。病人心率和下腔静脉压在肝脏旋转后显著升高(P<0.01)。肾灌注压则在旋肝后显著降低(P0.05),但旋转后2阶段(第2次左旋)出现了显著变化(P0.05)。结论:无论是经典式还是背驮式肝移植术,术中采用肝脏左旋显露手法是一种安全、有效的显露右半肝及肝后下腔静脉的方法。该法可避免传统手法对肝后下腔静脉的机械性损伤,不会引起术中全身血流动力学剧烈波动,对术后肾功能具有保护作用。     

An anatomical study of short hepatic veins,with special reference to delineation of the caudate lobe for hanging maneuver of the liver without the usual mobilization

Abstract. Background/Purpose: The present study was designed to anatomically assess a very recently reported hanging maneuver of the liver without mobilization, in which forceps are inserted blindly between the inferior vena cava (IVC) and liver parenchyma. Methods: We dissected 56 formalin-fixed livers (1) to determine whether preservation of the caudate vein (the largest vein draining Spiegel's lobe) and inferior right hepatic vein (IRHV) was possible and (2) to identify the territories drained by other, non-preserved short hepatic veins. Results: A potential space for insertion of the forceps was found between the openings of the caudate vein and IRHV; however, if preservation of both veins is absolutely necessary, we recommended protecting the IRHV, such as by taping and retracting it. We classified the other short hepatic veins into two categories, i.e., those draining the left portal vein territory and those draining the right territory. The distributions of the openings of the veins in these territories overlapped. Conclusions: Clear delineation of the left caudate lobe according to the drainage veins appeared to be difficult when the liver was divided along a straight line in front of the IVC. Received: March 22, 2001 / Accepted: August 21, 2001     

Right inferior phrenic vein indicating the right hepatic vein confluence into the inferior vena cava

BACKGROUND: Limiting backflow bleeding from the hepatic veins is a priority when performing hepatectomy. However, hepatic vein encirclement is difficult, especially in re-resection. We verified the presence and trajectory of the right inferior phrenic vein (RIPV), which could be a useful anatomic landmark to guide surgeons in targeting the extrahepatic right hepatic vein (RHV) before dissection. METHODS: Between May 2001 and January 2005, 100 consecutive patients with liver tumors were enrolled and underwent hepatectomy: 77 patients underwent surgery for tumors located in the right hemiliver. RESULTS: RIPV was detected in all but 1 patient (99%), and its trajectory was always guided toward the extrahepatic RHV. The only patient in whom RIPV was not detected had undergone prior liver resection and interstitial therapies for colorectal cancer liver metastases. CONCLUSIONS: Apart from exceptional conditions, detection of the RIPV is always feasible and allows safe surgical dissection while approaching the extrahepatic RHV before hepatic resection.     

Compressive stenosis of the inferior vena cava due to localized ascites after living-donor liver transplantation

A 54-year-old woman was admitted to our hospital following the diagnosis of decompensated liver cirrhosis with hepatitis C. She underwent living-donor liver transplantation, performed using the left hepatic lobe with the middle hepatic vein donated by her husband. After the transplantation, the patient suffered from massive ascites with liver dysfunction. Computed tomography demonstrated stenosis of the suprahepatic inferior vena cava (IVC) with focal collection of fluid. A second laparotomy was performed 19 days after the transplantation. When the encapsulated localized ascites on both sides of the IVC was opened, the ascites was flushed away. Subsequently, the grafted liver was easily mobilized and it was placed in the natural position without any tension, and the pressure gradient of the IVC was improved. Herein, we report a very rare case of compression stenosis of the IVC resulting in Budd-Chiari syndrome caused by localized encapsulated ascites.     

血管腔内技术治疗下腔静脉综合征

目的 探讨血管腔内技术治疗下腔静脉综合征的疗效。方法 2002年6月～2004年11月对17例下腔静脉综合征进行下腔静脉腔内扩张、腔内支架植入术,术后常规抗凝治疗。结果 下腔静脉压力梯度从治疗前（16.8±4.3）mmHg下降到治疗后（2.6±0.6）mm Hg（t=13.280,P=0.001）。IVCS症状评分从治疗前（4.4±1.6）分下降到治疗后（2.1±1.7）分（t=6.880,P=0.010）。下肢肿胀、阴囊或外阴浮肿、腹水和全身浮肿于术后1～4 d后减轻。结论 血管腔内技术治疗下腔静脉综合征疗效可靠。     

切除累及下腔静脉肝癌的体会

目的探讨累及下腔静脉肝癌切除的可能性。方法复习近三年中我科切除的累及下腔静脉的原发性肝癌２６例。结果手术经过顺利，术后无严重并发症，无手术死亡。结论良好的麻醉、熟练的切肝技术和控制大出血的能力，切除累及下腔静脉的肝癌是可行的     

Preoperative placement of retreivable inferior vena cava filters in bariatric surgery

BACKGROUND: Postoperative pulmonary embolism (PE) is a major source of mortality after bariatric surgery. In conjunction with pharmacologic thromboprophylaxis, lower extremity pneumatic compression devices, and early ambulation, preoperative placement of a retrievable inferior vena cava (IVC) filter may reduce the risk of thromboembolic complications. METHODS: From June 2003 to October 2005, 652 patients underwent mini-open Roux-en-Y gastric bypass. Of the 652 patients, 557 were women and 95 were men. The mean patient age was 40.7 +/- 3.6 years (range 18-67), mean body mass index was 44.7 +/- 4.6 kg/m(2) (range 35-78), and mean operative time was 60.2 +/- 5.3 minutes (range 42-79). The high-risk PE group consisted of 27 patients (4.1%; 9 men and 18 women) who received preoperative retrievable IVC filters placed by the interventional radiology staff 2 hours before bypass surgery. Their mean age was 47 +/- 4.4 years (range 31-66) and mean body mass index 48.7 +/- 4.2 kg/m(2) (range 38-75). The indications for filter placement were previous deep vein thrombosis/PE, thrombophlebitis, a hypercoagulable state, pulmonary hypertension, an inability to ambulate, a body mass index >65 kg/m(2), and the presence of severe sleep apnea. The filters were removed 18.2 +/- 2 days (range 15-21) postoperatively. RESULTS: All 27 patients who received a prophylactic IVC filter tolerated the procedure well, without major complications. One retrievable filter was not removed because of prolonged hospitalization secondary to small bowel obstruction. No thromboembolic complications occurred in this high-risk group. CONCLUSION: Preoperative placement of retrievable IVC filters is a safe measure for the prophylaxis of PE in high-risk bariatric patients. The filters can be placed efficiently just before surgery, and most filters can be removed 2-3 weeks postoperatively. Additional investigation is necessary to prove the effectiveness of retrievable IVC filters in bariatric surgery.     

下腔静脉内平滑肌瘤病诊治分析

目的 总结下腔静脉内平滑肌瘤病的诊治经验.方法 回顾性分析1998年3月至2007年4月收治的8例下腔静脉内平滑肌瘤病患者的临床资料,并随访观察其疗效.结果 8例患者中4例术前经下腔静脉造影同时取活检术前诊断为下腔静脉内平滑肌瘤病.8例患者中有1例拒绝手术治疗,14个月后猝死.接受手术治疗的7例患者术后病理示IVL,其中除1例死于术中大出血,1例术后2年复发外,其余5例无严重并发症,术后随访7～65个月,平均随访29个月,已恢复正常生活.结论 下腔静脉内平滑肌瘤病多源于子宫平滑肌瘤,是一种雌激素依赖性肿瘤.下腔静脉造影的同时取活组织检查是术前诊断下腔静脉内平滑肌瘤病的有效方法.手术切除肿瘤是惟一有效的治疗方法,同时应进行抗雌激素治疗,近期疗效满意.     

Resection and reconstruction of the inferior vena cava for neoplasms

AIM: To evaluate the results of an aggressive surgical approach of resection and reconstruction of the inferior vena cava (IVC). METHODS: The approach to caval resection depends on the extent and location of tumor involvement. The supraand infra-hepatic portion of the IVC was dissected and taped. Left and right renal veins were also taped to control the bleeding. In 12 of the cases with partial tangential resection of the IVC, the flow was reduced to less than 40% so that the vein was primarily closed with a running suture. In 3 of the cases, the lumen of the vein was significantly reduced, requiring the use of a polytetrafluoroethylene (PTFE) patch. In 2 of the cases with segmental resection of the IVC, a PTFE prosthesis was used and in 1 case, the IVC was resected without reconstruction due to shunting the blood through the azygos and hemiazygos veins. RESULTS: The mean operation time was 266 min (230-310 min) with an average intraoperative blood loss of 300 mL (200-2000 mL). The patients stayed in intensive care unit for 1.8 d (1-3 d). Mean hospital stay was 9 d (7-15 d). Twelve patients (66.7%) had no complications and 6 patients (33.3%) had the following complications: acute bleeding in 2 patients; bile leak in 2 patients; intra abdominal abscess in 1 patient; pulmonary embolism in 2 patients; and partial thrombosis of the patch in 1 patient. General complications such as pneumonia, pleural effusion and cardiac arrest were observed in the same group of patients. In all but 1 case, the complications were transient and successfully controlled. The mortality rate was 11.1% (n = 2). One patient died due to cardiac arrest and pulmonary embolism in the operation room and the second one died 2 d after surgery due to coagulopathy. With a median follow-up of 24 mo, 5 (27.8%) patients died of tumor recurrence and 11 (61.1%) are still alive, but three of them have a recurrence on computed tomography. CONCLUSION: There are a variety of options for reconstruction after resection of the IVC that offers a higher resectable rate and better prognosis in selected cases.     

紧贴下腔静脉肝血管瘤的手术治疗

目的探讨紧贴下腔静脉（inferior vena cava,IVC）的肝血管瘤的手术治疗。方法回顾性分析2003年1月至2005年9月手术切除的30例紧贴IVC的肝血管瘤的临床资料,利用第三肝门解剖法、肝静脉结扎阻断法、半肝血流阻断法3种方法,切除紧贴IVC的肿瘤。结果30例肝血管瘤均安全切除,IVC修补5例,术中出血量100～5000ml。术后无明显并发症发生。随访至今,1例血管瘤复发,其余均良好。结论把肿瘤的流入、流出道在肝外预先处理,可以减少手术的风险。术中注意肿瘤的显露,力争肿瘤的完整切除,避免流出道梗阻,肝脏创面渗血不止等紧急情况下压纱布也是一种有效的选择。     

Feasibility of hanging maneuvers in orthotopic liver transplantation with inferior vena cava preservation and in liver surgery

Background/Purpose The aim of this work was to study the feasibility and complication rates of liver hanging maneuvers: the Belghiti liver hanging maneuver (BLHM) in liver resection and the modified liver hanging maneuver (MLHM) in orthotopic liver transplantation (OLT) with inferior vena cava (IVC) preservation.Methods From January 2001 to August 2003, BLHM was planned in 26 consecutive right hepatectomies and MLHM in 28 consecutive OLTs with IVC preservation.Results BLHM was performed in 24/26 patients (92%). In the 2 remaining patients, chronic biliary infection (n = 1) and intraparenchymal hemorrhagic hepatocellular carcinoma (n = 1) did not allow BLHM to be achieved. Bleeding during the BLHM procedure occurred in 1 patient (4%), with no need for interruption. MLHM was performed in all 28 patients, and in none of them was bleeding observed during the maneuver.Conclusions BLHM and MLHM are important technical refinements with several advantages. Feasibility rates were 92% and 100%, respectively. Bleeding risk remained low (4%) for BLHM and was 0% for MLHM. The rate of BLHM failure suggests that the feasibility rate may be higher in normal liver parenchyma.     

Leiomyosarcoma of the infra-renal inferior vena cava

Leiomyosarcoma of the inferior vena cava (IVC) is a rare slow-growing retroperitoneal tumor. Two percent of leiomyosarcomas are vascular in origin, and tumors of the IVC account for the majority of the cases. The diagnosis is frequently delayed, because affected patients remain asymptomatic for a long period. It has an extremely poor prognosis, with 5-year actuarial malignancy-free survival rates of 30% to 50% after a wide surgical resection. The authors present the case of a patient with IVC leiomyosarcoma who underwent en bloc resection of the tumor along with the involved segment of the infrarenal IVC without caval reconstruction. Complete surgical resection offers the only potential of long-term survival, but survival of unresected patients is generally measured in months. Palliative resections may temporarily improve symptoms but do not offer long-term survival.     

达芬奇机器人手术系统辅助下腔静脉滤器取出术的临床疗效

目的达芬奇机器人手术系统辅助下下腔静脉滤器取出术的临床疗效。 方法采用回顾性描述性研究方法,收集2019年7月陆军军医大学西南医院血管外科收治的亚洲首例行达芬奇机器人手术系统辅助下下腔静脉滤器取出术患者的临床资料。患者下腔静脉滤器置入术后2个月余,血管腔内技术无法取出下腔静脉中的滤器,在达芬奇机器人手术系统辅助下取出下腔静脉滤器。观察指标：术中及术后情况;随访及生存情况。采用门诊进行随访,了解患者术后生存情况。随访时间截至2019年8月。 结果患者成功行达芬奇机器人手术系统辅助下下腔静脉滤器取出术。手术时间326 min,术中出血量100 ml,完成下腔静脉滤器取出术后,下腔静脉切口吻合良好,无出血及狭窄,无术中并发症发生。患者术后住院时间3 d。随访及生存情况：患者术后随访1个月,腹部穿刺套管孔愈合良好,患者生存良好。 结论达芬奇机器人手术系统辅助下下腔静脉滤器取出术安全可行。     

肝癌合并下腔静脉癌栓的外科治疗

肝癌合并下腔静脉癌栓的治疗仍是医学难题,一直被视为手术禁忌证.患者主要接受非手术治疗或放弃治疗,其生存率较低.近年来随着医学的进步,手术治疗肝癌合并下腔静脉癌栓的成功率逐年增高.201 1年5月哈尔滨医科大学附属第二医院为1例肝癌合并下腔静脉癌栓患者行肝脏Ⅴ、Ⅶ、Ⅷ段切除＋下腔静脉癌栓取出术.术前CT检查示肝Ⅴ、Ⅶ、Ⅷ段占位性病变,下腔静脉内癌栓充盈,三维重建测算左半肝体积489 cm^3,低于最小存活肝脏体积.为了最大限度保留剩余肝脏,拟行保留肝Ⅵ段的右半肝切除术,于全肝血流阻断下腔静脉癌栓取出术.患者术后恢复良好,术后18个月复查未见明显复发转移症状.     

Surgical treatment of retroperitoneal leiomyosarcoma invading the inferior vena cava: report of three cases

Retroperitoneal leiomyosarcoma is a rare neoplasm for which complete surgical removal provides the only effective treatment, as local recurrence adversely affects prognosis. However, invasion of major vessels may occur, making complete resection difficult. This report describes the cases of three patients who required concomitant resection of parts of the inferior vena cava because of direct tumor invasion. The major vessels should be isolated in preference to the tumor capsule during surgery to prevent sudden exsanguination or incomplete tumor resection. Resection of a recurrent sarcoma or a solitary metastasis can be effective in selected patients. Received: September 20, 2001 / Accepted: May 7, 2002     

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...     

Replacement of the retrohepatic vena cava in segmental liver transplantation

Reduced grafts represent an important technical development in paediatric liver transplantation. The use of a left lateral segment graft has required preservation of the native inferior vena cava to “piggy-back” the graft onto it. We report four children who underwent left lateral segment transplantation with caval replacement using the donor iliac vein because the native retrohepatic inferior vena cava was small, friable or difficult to preserve. There were no caval or hepatic vein complications post-transplant and the donor iliac vein proved to be a satisfactory interpositional graft. The technique offers the advantages of a wider retrohepatic cava avoiding venous outflow or caval obstruction, provides good tissue to suture and is well suited for the triangulation technique of the left hepatic vein. Received: 24 January 1997 Received after revision: 20 June 1997 Accepted: 30 June 1997     

Intrapericardial control of the inferior vena cava from the abdominal cavity

Vascular isolation of the liver is a useful technique in major hepatic surgery that involves hepatic veins and the inferior vena cava. In some patients, exposure of the suprahepatic inferior vena cava is suboptimal from the abdominal cavity, and extension into the chest is required. This report details technical considerations of the control of the inferior vena cava within the pericardium from the abdominal cavity, through a vertical incision in the diaphragm, and without the need for a thoracic incision. We review the clinical situations when a transdiaphragmatic, intrapericardial access of the inferior vena cava should be considered.     

High dorsal drainage routes of Spiegel's lobe

Abstract. Background/Purpose: The venous drainage from Spiegel's lobe to the terminal portion of the hepatic veins has been described in the literature, but its morphology remains unclear. Methods: We examined 42 dissected liver specimens and 38 cast specimens. Results: In 8 of the 42 dissected liver specimens and 5 of the 38 cast specimens we found atypical but thick (over 3 mm) caudate veins that drained Spiegel's lobe and emptied into the terminal portion (along the most proximal 5-mm course) of the middle hepatic vein (MHV) or the inferior vena cava (IVC) near the MHV terminal (less than 10 mm from the MHV). We termed these the superior caudate vein. This vein ran upward between the caudate portal branches of the left and hilar bifurcation origins or through the territory of the left origin. The superior caudate vein, consistently coexisted with the typical vein(s). We also found several analogues of the superior caudate vein, such as the cranially shifted opening of the typical caudate vein and relatively thick proximal tributaries of the MHV from Spiegel's lobe. Conclusions: Although the superior caudate vein, if present, seemed to have a large role in the venous drainage of the lobe, its incidence seemed to be too low for clinical relevance. Received: May 11, 2001 / Accepted: August 1, 2001