肝癌合并下腔静脉癌栓的外科治疗

目的总结7例肝癌合并下腔静脉（inferior vena cava,IVC）癌栓患者的手术方法及治疗经验。方法自2003年7月至2005年5月,我们为7例肝癌合并IVC癌栓的患者实施了肝癌切除及右心房和（或）IVC切开取栓手术。所有患者均采用全肝血流阻断来控制IVC血流。根据癌栓上极位置的不同,分别采用5种不同术式：（1）静脉转流,心脏停搏,右心房及下腔静脉切开取栓1例;（2）静脉转流,心脏不停搏,心包内高位阻断下腔静脉,右心房和（或）下腔静脉切开取栓2例;（3）经腹部切口切开膈肌,心包内高位阻断下腔静脉,下腔静脉切开取栓1例;（4）经腹部切口,经膈肌腔静脉裂孔小切口,心包外高位阻断肝上下腔静脉,下腔静脉切开取栓1例;（5）经腹部切口,肝上阻断下腔静脉,下腔静脉切开取栓2例。结果所有手术均获成功,术后并发症包括胸腔积液2例,右膈下积液1例,切口感染1例。7例患者的生存时间为2周～26个月,平均9．8个月。已死亡的6例患者术后生存时间分别为13、9、11、2、17个月和2周,尚生存的1例患者已无瘤生存26个月。结论对合适病例实施肝癌切除和IVC切开取栓手术是安全可行的。手术治疗可以避免右心流人道阻塞和肺动脉栓塞造成的猝死,并有可能获得相对提高的生存时间和生活质量。     

Tumor Thrombectomy Without Bypass for Low-Grade Malignant Tumors Extending into the Inferior Vena Cava: Report of Two Cases

Endometrial stromal sarcoma (ESS) rarely extends into the inferior vena cava (IVC). Two cases of ESS extending into the IVC were encountered. In the first case a low-grade sarcoma and cavography revealed the tumor thrombus to extend to just below the left renal vein from the right internal iliac vein, and the IVC was patent. A tumor thrombectomy was accomplished to prevent pulmonary embolism (PE) and to achieve a good prognosis. The second case was also a low-grade sarcoma. Abdominal computed tomography scanning revealed a large thrombus extending into the IVC just below the hepatic vein. A tumor thrombectomy with an IVC resection was performed. The postoperative course was uneventful for both cases. Aggressive surgical treatment is thus recommended to excise a tumor thrombus with or without an IVC resection in patients with ESS of low-grade malignancy extending into the IVC to prevent sudden death due to PE.     

Renal arteriovenous malformation with thrombus in the inferior vena cava

BACKGROUND: Thrombus formation in the inferior vena cava (IVC) is usually seen in cases with malignancy. In contrast, vascular anomalies hardly ever accompany this disorder. Herein, a case of thrombus formation in the IVC associated with renal arteriovenous malformation (AVM) is reported. METHODS/RESULTS: A 50-year-old woman who received transarterial embolization (TAE) for AVM in the right kidney noticed right flank pain with macrohematuria 12 months later. Because radiographic evaluation could not rule out malignancy in the kidney, nephrectomy was performed. During nephrectomy, a palpable thrombus was found in the IVC, so thrombectomy was performed simultaneously. Histopathologic examination revealed an old infarction due to the TAE, circumferential arteriovenous thrombi and a large organized thrombus up to the IVC, but neither renal cell carcinoma nor transitional carcinoma in the kidney. CONCLUSIONS: Careful observation may be required, even after treatment for renal AVM, such as TAE, to avoid the formation of an IVC thrombus.     

Antegrade balloon occlusion of inferior vena cava during thrombectomy for renal cell carcinoma

Nephrectomy with inferior vena cava (IVC) thrombectomy for advanced renal cell carcinoma (RCC) is a challenging and morbid surgical case. We describe the use of a simple endoluminal technique to occlude the suprahepatic IVC during thrombectomy. A 60-year-old male presented with a large right-sided RCC and IVC tumour thrombus. The tip of the thrombus, which was non-adherent to the caval wall, extended to the level of the hepatic veins. After complete dissection of the kidney, we obtained suprahepatic control of the IVC by a large compliant balloon, introduced through the right internal jugular vein and inflated just below the level of the diaphragm. The IVC thrombectomy was performed in a bloodless field. Mean blood pressure remained stable during IVC balloon inflation with a total occlusion time of 10 minutes. Intraprocedural completion cavogram and postoperative Doppler ultrasonography showed no residual IVC clot. Blood loss during the thrombectomy portion of the case was scant. The patient’s postoperative course was uncomplicated and, at the last follow-up, he had stable metastatic disease on sunitinib therapy. For the surgical treatment of RCC with retrohepatic IVC tumour extension, transjugular balloon occlusion of the suprahepatic IVC offers an alternative to extensive hepatic mobilization to obtain suprahepatic thrombus control. Advantages over traditional surgical methods may include decreased surgical time, lower risk of liver injury and tumour embolism. We suggest this method for further evaluation.     

Recidive of renal cell carcinoma tumor thrombus in inferior vena cava via lumbar vein

Renal cell carcinoma (RCC) develops tumor thrombus in the renal vein and inferior vena cava (IVC) in 10% of cases. Surgical treatment is radical nephrectomy and thrombectomy of the IVC. Local recidive can develop in the lumbar fossa, lymph nodes, and the IVC. We report a 58-year-old patient admitted to the Clinic for Urology at the Military Medical Academy, Belgrade, Serbia, in February 2009 with RCC of the left kidney and tumor thrombus in the IVC. After ultrasonography exam and multislice computed tomography scan, we performed radical nephrectomy and thrombectomy of the IVC (level II). Four months after the operation, ultrasound exam and cavography showed intracaval and paracaval recidive tumor masses in the renal part of the IVC. On operation we removed intraluminal IVC thrombus, which arises from the lumbar vein on the IVC posterior wall, with paracaval thrombus in the lumbar vein. We conclude that RCC tumor thrombus can spread from the kidney to the IVC through the lumbar vein.     

单一体位机器人腹腔镜肝后下腔静脉癌栓取出术的初步体会

目的:探讨单一体位机器人辅助腹腔镜肝后下腔静脉癌栓取出术的可行性和安全性。方法:回顾性分析2015年12月至2020年8月郑州大学第一附属医院收治的6例行单一体位机器人辅助腹腔镜肝后下腔静脉癌栓取出术患者的临床资料。男5例,女1例;平均年龄58(46~74)岁。平均体质指数24.6 (20.6~28.2) kg/m ...     

Intraoperative transesophageal echocardiography for inferior vena caval tumor thrombus in renal cell carcinoma

BACKGROUND: We investigated the advantages of intraoperative transesophageal echocardiography (TEE) during inferior vena caval tumor thrombectomy in renal cell carcinoma (RCC). METHODS: Five patients with RCC that extended into the inferior vena cava (IVC) underwent radical nephrectomy. To remove the tumor thrombus in the IVC, an inflated Fogarty balloon catheter was used to pull the thrombus below the level of the hepatic veins with real-time TEE monitoring. RESULTS: In all cases, TEE monitoring during surgery provided an accurate and excellent view of the IVC thrombus. TEE was particularly helpful for the thrombectomy to minimize hepatic mobilization by using occlusion balloon catheter in two patients whose thrombus extended to the intrahepatic IVC. CONCLUSIONS: Intraoperative real-time TEE monitoring is a safe, minimally invasive technique that can provide accurate information regarding the presence and extent of IVC involvement, guidance for placement of a vena caval clamp, confirmation of complete removal of the IVC thrombus and intervention using catheters to assist in thrombectomy.     

肝细胞癌合并下腔静脉癌栓的手术治疗

目的 探讨肝细胞癌(简称肝癌)合并下腔静脉癌栓的手术治疗方法。方法 采用肝切除 腔静脉取栓治疗4例肝癌合并下腔静脉癌栓患者,取栓方法包括经荷栓肝静脉取栓(1例)和下腔静脉切开取栓(3例),后者又分在全肝血流阻断下取栓(2例)和在萨氏钳局部血管阻断下取栓(1例)。结果 4例肝癌及下腔静脉癌栓均得到成功切除,术中无明显并发症发生;术后除l例发生中等量胸水外,无其他并发症发生;随访中3例已死亡,分别生存30、10和14个月;1例尚存活,已生存7个月。结论 肝癌合并下腔静脉癌栓的手术治疗安全可行,其基本术式为肝切除 下腔静脉切开取栓。     

后腹腔镜肾癌根治性切除并下腔静脉癌栓取出术的麻醉管理

目的探讨后腹腔镜肾癌根治性切除并下腔静脉癌栓取出术的麻醉管理要点。方法回顾性分析2010年12月一2014年6月3例后腹腔镜肾癌并下腔静脉癌栓根治术患者的围术期临床资料。I型癌栓2例,Ⅱ型癌栓1例。气管插管全身麻醉,Ⅱ型癌栓术中行短暂下腔静脉阻断。结果3例均顺利完成取栓,无中转开腹,手术时间244、333、289rain,1例下腔静脉完全阻断时间10rain,术中均未发生肺栓塞及其他严重麻醉并发症。l例术后拔管返回普通病房,2例转入ICU后24h内拔气管导管并转回普通病房。结论后腹腔镜肾癌根治性切除并下腔静脉癌栓取出术是新型、高危但可行的手术方式,麻醉医师应当熟知具体手术操作步骤,以制定相关麻醉计划并密切配合,密切关注下腔静脉阻断期间循环波动,严防大出血、肺栓塞等严重并发症的发生。     

Combined resection of a tumor and the inferior vena cava: report of two cases

Tumor resection and caval tumor thrombectomy, with or without cavotomy and inferior vena cava (IVC) replacement are sometimes performed in patients with renal cell carcinoma (RCC) extending into the IVC or liver tumors invading the IVC. Two such cases were treated. Case 1: a 68-year-old female was transferred with a diagnosis of right RCC with tumor thrombus extending into the IVC. A plication was performed to prevent extension into the right atrium before the nephrectomy and cavotomy with removal of the tumor thrombus was accomplished, because the IVC was almost completely obstructed and the hemodynamics were stable during cross-clamping of the IVC. Case 2: a 37-year-old female was transferred with a diagnosis of a giant metastatic liver tumor. A trisegmentectomy with resection of the invaded IVC and IVC replacement was performed while the abdominal aorta was cross-clamped to maintain the hemodynamics. Therefore, abdominal aortic cross-clamping was convenient to maintain the hemodynamics when the IVC replacement was performed during IVC cross-clamping.     

Positron emission tomography enhancing tumor thrombus in patient with renal cell carcinoma

A 65-year-old man underwent computed tomography (CT) of the abdomen during evaluation for anemia which showed a 10 cm right renal mass and inferior vena cava (IVC) thrombus. Positron emission tomography (PET)/CT revealed uptake of flurorodeoxyglucose (FDG) within only the tumor mass and thrombus. Right radical nephrectomy and IVC thrombectomy with IVC patch graft reconstruction were performed. Final pathology showed pT3bNxMx renal cell carcinoma (RCC) with IVC thrombus composed of poorly differentiated RCC. There is no evidence of recurrence at one year follow-up. We discuss the role of PET in RCC.     

Living donor liver transplantation with extensive caval thrombectomy for acute-on-chronic Budd-Chiari syndrome

The key consideration when performing living donor liver transplantation (LDLT) in patients with Budd-Chiari syndrome (BCS) is careful management of a stenotic or occluded inferior vena cava (IVC), because it is not possible to replace the recipient stenotic or occluded IVC with donor IVC as in cadaver donor transplantation. We describe how we performed LDLT with extensive thrombectomy in a patient with acuteon-chronic BCS with a totally thrombosed retrohepatic IVC. The operation was successful and the patient remains well, with follow-up images showing a patent IVC and hepatic veins. To our knowledge, LDLT for a BCS patient with severe extensive caval thrombus has never been reported before. We consider that the successful outcome of this patient clearly demonstrates the feasibility of our technique of extensive thrombectomy, without a vessel graft, to manage a stenotic or occluded IVC in LDLT in patients with BCS.     

Case of bilateral renal cell carcinoma with the tumor thrombus in the inferior vena cava

We describe a case of bilateral renal cell carcinoma with the tumor thrombus in the inferior vena cava. A 71-year-old male was admitted to our department for, careful examination of bilateral renal tumors. Abdominal computed tomography (CT) revealed bilateral solid enhanced renal masses with the tumor thrombus in the inferior vena cava (IVC) and the left renal vein. The renal tumor did not reveal distant metastatic lesions. We enforced two-term operation for bilateral renal tumor. First, right nephrectomy and tumor thrombectomy in the IVC were performed. On the 32th day after the first operation, we performed left nephrectomy. On the second day after the last operation, the patient received hemodialysis. The histopathological diagnosis revealed bilateral renal cell carcinomas. At 9 months after the last operation, the patient had multiple bone metastases, multiple liver metastases and multiple lung metastases.     

Thrombectomy before hepatic resection for hepatocellular carcinoma with a tumor thrombus extending to the inferior vena cava

Tumor thrombi of hepatocellular carcinoma occasionally invade into the inferior vena cava (IVC) through the hepatic vein. Once the tumor thrombus is dislodged, severe and lethal complications, such as pulmonary infarction, can develop. We successfully operated on a hepatocellular carcinoma (HCC) patient with a tumor thrombus extending to the IVC through the right hepatic vein. To avoid dislodging the thrombus during surgery, a thrombectomy using selective hepatic vascular exclusion was performed before a hepatic resection, which is the most dangerous procedure to dislodge the thrombus.     

Surgical resection combined with chemotherapy for advanced hepatocellular carcinoma with tumor thrombus: report of 19 cases

BACKGROUND: Prognosis of hepatocellular carcinoma (HCC) with tumor thrombus in the main portal vein (MPV), inferior vena cava (IVC), or extrahepatic bile duct (EBD) treated by conventional therapies has been considered poor. This study aimed to evaluate the efficacy of hepatic arterial infusion chemotherapy after surgical resection as an adjuvant therapy or as a treatment for intrahepatic recurrence of HCC with tumor thrombus in MPV, IVC, or EBD. METHODS: Nineteen patients with HCC and tumor thrombus in the MPV, IVC, or EBD who underwent hepatectomy with thrombectomy were reviewed retrospectively. RESULTS: The overall 3-year survival rate was 48.5%. Two patients with postoperative residual tumor thrombus died within 6 months owing to rapid progression of the residual tumor thrombus. Five patients survived more than 5 years after their operations. Tumors disappeared completely in 3 patients after hepatic arterial infusion chemotherapy with a combination of cisplatinum and 5-fluorouracil, and the longest survival period was 17 years and 11 months in a patient with EBD thrombus. CONCLUSIONS: If hepatic reserve is satisfactory, an aggressive surgical approach combined with chemotherapy seems to be of benefit for patients having HCC with tumor thrombus in the MPV, IVC, or EBD.     

Solitary floating vena caval thrombus as a late recurrence of renal cell carcinoma

We report an unusual case of solitary thrombus floating in the inferior vena cava (IVC) in a patient who underwent radical nephrectomy for a renal cell carcinoma (RCC) of the right kidney extended into the renal vein with no capsular and perinephric tissue invasion (pT3b). Twenty months after surgery, a routine computed tomography scan identified an intraluminal mass floating in the IVC. Cavotomy and thrombectomy with no caval resection were successfully performed. A review of the literature showed only three previous published cases of RCC recurring in the IVC only, with no local recurrence or distant metastases. We outline the possible etiology of these unusual and solitary recurrences in the IVC and we emphasize the need for a strict surveillance for all patients with RCC and especially for those with pT1b, pT2 and pT3 disease. An early diagnosis of this rare recurrence can permit an easy removal of the thrombus with no caval resection and graft replacement, making this disease potentially curable by surgery.     

Surgical treatment of renal cell carcinoma with right atrial thrombus: early experience and description of a simplified technique

Operative management of patients presenting renal cell carcinoma's (RCC) with right atrial tumor thrombus extension is a technical challenge. It requires the use of cardiopulmonary bypass (CPB). The aim of this study was to report our early experience and to describe a simplified CPB technique. 5 consecutive patients underwent surgical resection by a joint cardiovascular and urological team. The ascending aorta was canulated. The venous drainage was achieved using a proximal canula inserted in the superior vena cava and a distal canula inserted in the IVC below the renal veins. Right atrium thrombus extension was extracted under normothermic CPB without cross clamping or cardioplegic arrest. A cavotomy was performed at the ostium of the renal vein and an endoluminal occlusion catheter was introduced. The thrombectomy and the radical nephrectomy were then performed. The occurrence of gaseous or tumor embolism, operative time, perioperative bleeding, and post-operative complications were assessed. Mean patients age was 62.9 years. Atrial and caval thrombectomy were achieved successfully in all patients. Mean operative time was 206 min. Mean CPB time was 62 min. Mean hospital stay was 18.8 days. One death occurred, due to respiratory failure. An asymptomatic early thrombosis of the IVC was diagnosed by CT scan in 1 patient. The four remaining patients were alive 6 months after the surgical procedure. Minimally invasive CPB technique can be used to treat intra atrial thrombus tumor extension arising from renal cell carcinoma. It can be performed safely with acceptable complications rate.     

Tumor renal con trombo en la vena cava inferior. Manejo quirúrgico y pronóstico

ObjectivesThe aim of this study was to evaluate strategies used for surgical management of renal cell carcinoma with tumoral thrombus extension in the inferior vena cava (IVC) and evaluate patient’s prognosis.MetodsFifteen patients with renal tumor and IVC thrombus, underwent radical nephrectomy and thrombectomy, and were retrospectively evaluated. Patients were followed for 0 to 36 months (mean of 9.5 months). Computed tomography (CT) scan with three-dimensional reconstruction was used to define IVC thrombus level.ResultsThe mean age was 54 years, range from 16 to 79. The thrombus was classified as level I - 13.5%, level II – 40%, level III – 26.5% and level IV – 20%. Surgery was performed with cardiopulmonary bypass (CPB) in six (40%) cases, three (50%) without sternotomy. There was one (13%) death during the intraoperative period; this patient presented extensive metastatic tumor, with the thrombus reaching the right atrium. Patients with lymph node or metastatic disease at initial presentation had poorer overall survival in Kaplan-Meier curve. Both, tumor stage (p = 0.380), and thrombus extension (p = 0.174) were not related to survival.ConclusionsDespite its morbidity and mortality, radical nephrectomy with thrombectomy should be performed in case of renal cell carcinoma with tumoral thrombus, because it can offers the possibility of local control. Patients with lymph node and distant metastatic disease have poor prognoses.     

Surgical strategy for treating renal cell carcinoma with thrombus extending into the inferior vena cava

OBJECTIVE: A surgical strategy for treating malignant renal tumors with thrombus extending into the inferior vena cava (IVC) was assessed. METHODS: We retrospectively reviewed the records for all patients with renal cell carcinoma (RCC; n=30) or Wilms tumor (n=1) with tumor thrombus extending into the IVC who underwent surgical intervention at our institution between January 1980 and December 2001. Tumors were classified preoperatively according to the cephalad extension of thrombus, and intraoperative procedures were selected on the basis of degree of extension. Patients with RCC underwent radical nephrectomy and removal of thrombus with (n=11) or without (n=19) IVC resection. Partial normothermic cardiopulmonary bypass without cardiac arrest was used in 4 patients. The Pringle maneuver was performed in 8 patients. Infrarenal abdominal aortic cross-clamping was used in 8 patients to maintain systemic blood pressure. IVC cross-clamping and the Pringle maneuver were performed in 5 patients with suprahepatic thrombus extension. Temporary placement of a filter in the IVC or plication of the IVC above the hepatic vein was performed before hepatic mobilization, to decrease the risk for pulmonary embolism. RESULTS: One patient died intraoperatively of pulmonary embolism. Postoperative complications occurred in 11 patients; all resolved with conservative therapy. The postoperative duration of survival in patients with RCC was 37 +/- 44 months (range, 4-180 months); the 5-year survival rate was 42%. CONCLUSION: Aortic cross-clamping during IVC occlusion prevented hypotension and maintained hemodynamic stability that has required bypass in other series. This surgical treatment with the less extensive approach could result in long-term survival of patients with RCC in whom tumor thrombus extends into the IVC. We recommend that radical nephrectomy and tumor thrombectomy, with or without caval resection, be performed in these patients, with less invasive additional maneuvers.     

Renal cell carcinoma: management of venous thrombus

Radical nephrectomy with vena cava thrombectomy remains the treatment of choice in patients with renal cell carcinoma and inferior vena cava involvement. Surgery is performed with curative intent in patients without evidence of metastases or for cytoreduction, followed by possible immunotherapy in patients with distant metastases. The role of magnetic resonance imaging for evaluating the renal vein and/or IVC to detect thrombus and the proximal extent of thrombus is fully established. Surgical removal of these cancers through a transabdominal approach, even in patients with a level 2 thrombus (involving the retrohepatic IVC with close proximity to the main hepatic veins) is possible, avoiding the potential added morbidity of a throacoabdominal approach or median sternotomy. The application of liver transplant techniques and liver mobilization procedures not generally familiar to urological surgeons facilitates wide exposure and proximal control of the IVC for tumors cephalad to the confluence of the hepatic veins. As an initial step we believe that cephalad retraction of the liver with mobilization of the IVC by securing the lumbar, small hepatic and other unnamed venous collaterals may be tried to gain exposure of the retrohepatic IVC. Overall survival in patients with IVC involvement after complete surgical removal in the absence of metastatic disease justifies aggressive surgical management.