腹膜后肿瘤伴下腔静脉癌栓的外科处理

目的：探讨腹膜后肿瘤伴下腔静脉癌栓患者的分期和分型及外科处理。方法：2例右肾癌伴下腔静脉癌栓和1例右肾上腺皮质癌伴下腔静脉癌栓，分别行右肾癌或右肾上腺皮质癌根治性下腔静脉部分切除或切开取栓术。结果：2例术后分别存活48个月和12个月，1例术中死亡。结论：根据患者的分期和分型采用不同的手术方法，是治疗本病的有效途径。     

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     

Renal pelvis squamous cell carcinoma with inferior vena cava infiltration: Case report and review of the literature

INTRODUCTION

Renal squamous cell carcinoma (RSCC) is a rare tumor that is usually diagnosed late as a locally advanced malignancy with adjacent structure involvement. Radical surgical resection with negative margins is the mainstay of treatment, as it is correlated with improved survival, while other modalities of treatment have been shown to have limited efficacy.

PRESENTATION OF CASE

We report a case of a 56 year old gentleman with right RSCC with tumor encasing the inferior vena cava (IVC), treated successfully with surgical resection.

DISCUSSION

The surgical management of vascular involvement of similar tumors has not been discussed in-depth in the literature. Surgical resection of the IVC without reconstruction can be done successfully in the circumstance of good collateral circulation; otherwise IVC resection with reconstruction will be necessary.

CONCLUSION

Radical resection with clear margins of RSCC tumors with vascular involvement is feasible in selected circumstances.     

Adrenocortical carcinoma extending into the inferior vena cava in a patient with right kidney agenesis: Surgical approach and review of literature

INTRODUCTIONAdrenocortical carcinoma (ACC) is a rare malignancy with a poor prognosis and the association with tumor thrombus into the inferior vena cava (IVC) is not common. The best treatment is represented by radical surgery.PRESENTATION OF CASEWe describe a case of a large ACC of the left adrenal gland extending into the IVC through the left renal vein in a young patient with agenesis of the right kidney and signs of acute renal failure. A midline laparotomy was performed, subsequently extended by a left thoracophrenotomy through the 7th intercostal space in order to control the proximal surface of the mass and the thoracic aorta. The tumor was completely excised preserving the kidney, and thrombectomy was performed by a cavotomy with a temporary caval clamping, without cardiopulmonary by-pass (CPB).DISCUSSIONWe discuss surgical approaches reported in literature in case of ACC with intracaval extension. The tumor must be completely resected and the thrombectomy can be performed by different approaches: cavotomy with direct suture, partial resection of caval wall without reconstruction, resection of vena cava with graft reconstruction. These procedures could require a CPB, with an increased mortality. In our case we preserved the kidney and a thrombectomy without CPB was performed.CONCLUSIONIntracaval extension of ACC does not represent a contraindication to surgery. The best treatment of intracaval thrombus should be the cavotomy with direct suture. The CPB is not always required. In presence of renal agenesis, the preservation of the kidney is mandatory.     

Post traumatic inferior vena cava thrombosis: A case report and review of literature

IntroductionPost traumatic inferior vena cava (IVC) thrombosis is a rare and not well described entity with nonspecific clinical presentation. It remains a therapeutic challenge in traumatic context because of haemorrhagic risk due to anticoagulation.Presentation of caseWe report a case of IVC thrombosis in an 18 year-old man who presented with liver injury following a traffic crash. The thrombosis was incidentally diagnosed on admission by computed tomography. The patient was managed conservatively without anticoagulation initially considering the increasing haemorrhagic risk. IVC filter placing was not possible because of the unusual localization of the thrombus. Unfractionated heparin was started on the third day after CT scan control showing stability of hepatic lesions with occurrence of a pulmonary embolism. The final outcome was good.DiscussionThe management of post traumatic IVC thrombosis is not well described. Medical approach consists in conservative management with anticoagulation which requires the absence of active bleeding lesions. Surgical treatment is commonly based on thrombectomy under extracorporeal circulation. Interventional vascular techniques have become an important alternative approach for the treatment of many vessel lesions. Their main advantages are the relative ease and speed with which they can be performed.ConclusionPost traumatic IVC thrombosis is a rare condition. Its management is not well defined. Early anticoagulation should be discussed on a case-by-case basis. Other alternatives such IVC filter or surgical thrombectomy may be used when the bleeding risk is increased. The most serious risk is pulmonary embolism. Outcome can be favorable even with non surgical approaches.     

Ante situm liver resection with inferior vena cava replacement under hypothermic cardiopolmunary bypass for hepatoblastoma: Report of a case and review of the literature

IntroductionHepatoblastoma with tumour thrombi extending into inferior-vena-cava and right atrium are often unresectable with an extremely poor prognosis. The surgical approach is technically challenging and might require major liver resection with vascular reconstruction and extracorporeal circulation. However, which is the best surgical technique is yet unclear.Presentation of caseA 11-months-old boy was referred for a right hepatic lobe mass(90 × 78 mm) suspicious of hepatoblastoma with tumoral thrombi extending into the inferior-vena-cava and the right atrium, bilateral lung lesions and serum alpha-fetoprotein level of 50.795 IU/mL. After 8 months of chemotherapy (SIOPEL 2004-high-risk-Protocol), the lung lesions were no longer clearly visible and the hepatoblastoma size decreased to 61 × 64 mm. Thus, ante situm liver resection was planned: after hepatic parenchymal transection, hypothermic cardiopulmonary bypass was started and en bloc resection of the extended-right hepatic lobe, the retro/suprahepatic cava and the tumoral trombi was performed with concomitant cold perfusion of the remnant liver. The inferior-vena-cava was replaced with an aortic graft from a blood-group compatible cadaveric donor. The post-operative course was uneventful and after 8 months of follow-up the child has normal liver function and an alpha-fetoprotein level and is free of disease recurrence with patent vascular graft.ConclusionsWe report for the first time a case of ante situ liver resection and inferior-vena-cava replacement associated with hypothermic cardiopulmonary bypass in a child with hepatoblastoma. Herein, we extensively review the literature for hepatoblastoma with thumoral thrombi and we describe the technical aspects of ante situm approach, which is a realistic option in otherwise unresectable hepatoblastoma.     

Liver transplantation in a patient with complex anomaly of the inferior vena cava

Background

After the introduction of noninvasive imaging exams, congenital anomalies of the inferior vena cava (IVC) have become more commonly recognized. We report the first successful orthotopic liver transplantation (OLT) performed in an asymptomatic adult with complex IVC anomaly: duplication of the infrarenal IVC, azygos continuation of the IVC, agenesia of the hepatic portion of the IVC and presence of several anomalous veins communicating the common iliac vein and the IVC of one side with the contralateral side.

Methods

This complex anomaly was diagnosed with a venous abdominal angio CT.

Results

At liver transplantation, the short suprahepatic portion of the IVC was identified and clamped. The right, middle, and left hepatic veins were sectioned and joined in a single, wide cuff, using venoplasty. This single orifice was anastomosed to the suprahepatic IVC of the new liver. No venovenous bypass was employed. The patient had an uneventful postoperative course. A post transplantation venous abdominal angio CT showed normal blood flow at the anastomosis of the hepatic veins of the receptor and the IVC of the new liver.

Conclusions

This report is important to alert liver transplant teams of the possibility of complex IVC in asymptomatic adult individuals. Identification of these anatomical anomalies is vital to reduce the risk of serious hemorrhage and other operative complications during OLT.     

Evaluation of the inferior vena cava in potential pediatric renal transplant recipients

Vascular anomalies due to occlusion or thrombosis of the inferior vena cava (IVC) may be hazardous to renal transplantation, and preoperative vascular evaluation is important for safe and successful surgery. The purpose of this study was to assess the utility and accuracy of two-dimensional time-of-flight (2D-TOF) magnetic resonance venography (MRV) as an alternative to conventional angiography for evaluating the IVC and iliac vein in potential pediatric renal transplant recipients. Four children with chronic renal failure were evaluated with 2D-TOF MRV by superior presaturation pulse and target maximum intensity projection. The whole MRV examination and filming required less than 30 min. All four patients had a normal IVC and iliac vein. Two of the patients underwent renal transplantation, and the MRV findings were in total agreement with the final anatomy revealed intraoperatively. MRV is accurate for evaluating the condition of the IVC and iliac vein. It is a reliable, noninvasive and rapid technique that can be considered as an alternative to invasive angiography for evaluation of children scheduled for transplantation. We recommend the use of this noninvasive procedure to ascertain the patency of the IVC in all infants and children with a history of indwelling catheters in the IVC or those with a propensity to thrombosis, i.e., all recipients with nephrotic syndrome. The insertion of catheters in the femoral vein in children who may become candidates for renal transplantation should be discouraged.     

Superior vena cava resection with prosthetic replacement for non-small cell lung cancer: long-term results of a multicentric study

Objectives: Superior vena cava (SVC) resection with prosthetic replacement for non-small cell lung cancer (NSCLC) is infrequently performed and oncological results are unclear. To establish a historical benchmark for this extended surgery, we have updated and reviewed data from four international centers. Methods: Data were obtained through retrospective chart review. Prognostic factors were analyzed using first univariate techniques and subsequently multiple regression (logistic regression). Kaplan–Meier overall survival was calculated and prognostic factors examined by log–rank test and the estimation of hazard ratios using Cox regression. Results: From 1985 to 2000, 28 patients underwent SVC resection with prosthetic replacement for NSCLC. During the same period, 65 patients underwent partial SVC resection. Induction treatment was performed in 25% of patients. The resection was done for T involvement in 22 patients (79%), and for N2 involvement in the remaining. There were 12 tracheal sleeve resections, four pneumonectomies, and 12 lobar or sublobar resections with or without bronchoplasty. The median clamping time was 40 min. The median diameter of the prosthesis used was No. 14. Pathological examination showed direct SVC invasion (T4) in 79% of patients, whereas N2 disease was present in 50% of patients. Median intensive care unit and hospital stay were 3 and 20 days, respectively. The postoperative morbidity and mortality were 39 and 14%, respectively. The overall 5-year probability of survival was 15% (median of 9 months, range 0–105 months). Patients who underwent partial SVC resection during the same period had a significantly higher probability of survival (P=0.03). Induction chemotherapy was associated with a significant increase of postoperative morbidity in multivariate analysis. None of the potential prognostic factors analyzed in multivariate analysis were associated with survival, but the type of resection (sleeve pneumonectomy/pneumonectomy) were borderline significant. Conclusions: SVC resection with prosthetic replacement should not be considered an absolute contraindication in patients with NSCLC; however, the poor oncological results suggest more restrictive and severe criteria of patient selection (mediastinoscopy, induction treatment, no pneumonectomy, no N2 disease).     

Acute pyelonephritis with renal vein and inferior vena cava thrombosis in a case of hyperhomocysteinemia

Acute pyelonephritis is not considered a common cause of renal vein (RVT) and inferior vena caval thrombosis (IVCT). Apart from malignancy, RVT is not an uncommon condition amongst patients with nephrotic syndrome, most commonly seen in patients with membranous glomerulonephritis. However, RVT occurring in association to acute pyelonephritis is rare. Clinically, it is difficult to distinguish between acute pyelonephritis and RVT because both present with fever, flank pain, and hematuria. We report a case of acute pyelonephritis with RVT and IVCT with underlying hyperhomocysteinemia. The patient was treated with systemic anticoagulation, antibiotics, and B complex therapy. At 3 months follow-up, there was complete resolution of thrombus but the left kidney was nonfunctioning.     

Nine-year experience with insertion of vena cava filters in the intensive care unit

BACKGROUND: Vena cava filter insertion (VCF) is traditionally performed in a radiology suite or in the operating room. We reviewed our experience of bedside VCF insertion in the intensive care unit (ICU) performed by general surgeons. METHODS: A prospective, observational study of bedside VCF insertion in the ICU was performed by general surgeons between February 1996 and June 2005. Demographic data and procedural complications were recorded. RESULTS: Four hundred three patients underwent bedside VCF insertion. Complications included 1 groin hematoma, 2 misplacements, and a right ventricular perforation from a dilator requiring surgical repair. DVT occurred in 38 patients (8.5%); 14 occurred at the insertion site. There were 2 pulmonary embolisms (<1%) after VCF. Contrast-related renal failure occurred in 2 of the first 35 patients; carbon dioxide gas is now used for contrast in high-risk patients. CONCLUSIONS: Bedside insertion of VCF in the ICU by surgeons is safe and effective.     

腹膜后肿瘤术中腹主动脉及下腔静脉的切除与重建

目的 探讨累及腹主动脉及下腔静脉的腹膜后肿瘤切除时,受累血管的切除与重建的最佳方法。方法回顾性总结1990年1月至2003年6月33例累及腹主动脉及下腔静脉的腹膜后肿瘤的手术切除及血管重建的临床资料。结果全部病人均成功实施了肿瘤完整切除,包括受累血管的切除与重建,无手术死亡。随访29例,其3、5年存活率分别为60,1％和40．6％,平均存活期为53．9个月。结论累及腹主动脉及下腔静脉的腹膜后肿瘤不是根治性切除的手术禁忌证,腹主动脉及下腔静脉的切除与重建术,安全、有效、可行;重建腹主动脉及下腔静脉可以提高肿瘤的切除率,降低局部复发率,延长病人存活时间。     

Experimental replacement of the thoracic inferior vena cava with a high-porosity expanded polytetrafluoroethylene graft wrapped in an omental pedicle flap

We examined the patency and healing of a highporosity expanded polytetrafluoroethylene (ePTFE) graft implanted as an interposition graft in the thoracic inferior vena cava (IVC) and wrapped in an omental pedicle flap. High-porosity ePTFE grafts of 60 μ fibril length, with an internal diameter of 10 mm and a length of 4 cm, were implanted in 12 mongrel dogs. In 6 dogs, the grafts were wrapped in omental pedicle flap, and in the remaining 6 the grafts were unwrapped. The animals were killed 4 weeks after the replacement and the grafts were removed for examination. Patency of the graft in both groups was 100%; however, the thrombusfree area in the omentum-wrapped group was significantly larger (P<0.05) than that in the unwrapped group. Light microscopy revealed the marked infiltration of cells and capillaries within the graft interstices in the omentum-wrapped group. These findings suggest that encapsulation of the highporosity ePTFE graft is promoted by an omental pedicle flap.     

Deep venous thrombosis caused by congenital absence of the inferior vena cava: Report of a case

Although anomalies of the inferior vena cava (IVC) are seen frequently in a clinical setting, congenital absence of the IVC (AIVC) is rare. However, anomalies of the IVC should be considered in young patients suffering from recurrent and idiopathic DVT. We report a case of DVT possibly caused by AIVC in a 27-year-old man, and discuss the clinical features, diagnosis, and treatment of this unusual entity.     

Double superior vena cava: presentation of two cases and review of the literature

Introduction: Various anomalies in the development of the great thoracic veins of the embryo can be incidentally discovered in the normal adult. Duplication of superior vena cava (SVC) is a rare abnormality, but the most common thoracic venous congenital anomaly.

Case reports-methods: We present two cases in the intensive care unit of our hospital, of asymptomatic patients who underwent an uneventful central line placement in the left subclavian vein. The track of the catheter, as shown in the X-ray, was misplaced to the left of the aorta and further investigation with computed tomography angiography confirmed a persistent left SVC. In both cases the vein drained into the coronary sinus and then to the right atrium. In the second case the echocardiography revealed a dilated coronary sinus.

Conclusions: Double SVC can be fortuitously discovered during catheter insertion, thoracic or cardiac imaging and surgery. In most cases it drains into the right atrium, through the coronary sinus. This entity is significant to the physician because of its importance in differential diagnosis as a cause of a widened mediastinum, as well as any difficulty that can occur in the placement of a central venous catheter or a pace maker.     

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。     

肾静脉上结扎大鼠下腔静脉的心脏血流动力学改变和川芎嗪对其的影响

目的 探讨肾静脉平面以上结扎大鼠下腔静脉及应用川芎嗪后的心脏血流动力学改变。方法 在肾静脉平面以上结扎大鼠下腔静脉及川芎嗪治疗，术后1、6、24、48h检测心率、射血分数、心输出量、每搏输出量、鼠尾动脉压等心脏血流动力学指标。结果 单纯结扎大鼠下腔静脉后心输出量减少、血压下降，但至术后48h可完全代偿，动物全部存活。结扎下腔静脉并川芎嗪治疗术后心输出量减少、血压下降，但术后24h即可完全代偿，动物全部存活。结论 肾静脉平面以上结扎大鼠下腔静脉可使回心血量急骤减少而影响心功能，但术后48h即可完全代偿。若结扎下腔静脉同时加用川芎嗪治疗，可明显改善心功能状况。建议当腹膜后肿瘤侵及肾静脉平面以上的下腔静脉时，切除肿瘤及其累及下腔静脉段后，可直接结扎下腔静脉，同时加用川芎嗪治疗，无需附加健康右肾切除。术后早期应注意经上肢浅静脉补充液体以增加回心血量。     

经皮肾镜术中误入下腔静脉伴血栓形成一例并文献复习

目的探讨经皮肾镜碎石取石术（percutaneous nephrolithotomy, PCNL）中穿刺误入下腔静脉,留置肾造瘘管后出现下腔静脉血栓的处理办法。 方法结合文献复习,回顾性分析2017年5月我院收治的1例左肾铸型结石患者的临床资料。患者男,59岁,于全麻下行左PCNL。术中穿刺建立通道后出血汹涌,视野不清,中止手术,留置并夹闭肾造瘘管。术后第3日复查CT提示肾造瘘管经左肾静脉、下腔静脉至肝脏,下腔静脉内血栓形成。行经皮下腔静脉及左肾动脉造影,置入下腔静脉滤器及溶栓导管,透视监视下拔出左肾造瘘管。 结果拔出肾造瘘管后,患者无不良反应,血流动力学状态稳定,反复经导管造影,未见造影剂外溢。经溶栓治疗后,术后第11日再次行下腔静脉造影未见充盈缺损,顺利回收滤器。 结论PCNL术中穿刺误入下腔静脉,留置肾造瘘管伴下腔静脉血栓形成时,在血管造影辅助下分步缓慢拔出肾造瘘管并行溶栓治疗的方法安全、可靠,可避免外科手术的二次伤害及血栓相关并发症的发生。