经皮球囊导管阻断技术在下腔静脉瘤栓切除术中的应用

目的 探讨经皮球囊导管阻断技术在下腔静脉瘤栓切除术中的应用价值. 方法 经CT、MRI及彩色多普勒超声等检查确诊为肾或肾上腺肿瘤合并肝后型或肝下型下腔静脉瘤栓患者12例.男7例,女5例.年龄20～76岁,平均51岁.右侧肿瘤11例,左侧1例.肾肿瘤11例,肾上腺肿瘤1例.12例均于术前经皮穿刺右侧颈内静脉,于瘤栓近心端下腔静脉内预置一球囊导管,术中经导管充盈球囊阻断下腔静脉后,再行下腔静脉瘤栓切除术. 结果 12例肿瘤合并下腔静脉瘤栓的根治性切除术全部完成.手术时间210～670 min,平均324 min.术中出血量600～7960 ml,平均2563 ml.无手术或围手术期死亡.术后患者恢复良好,肝肾功能正常,无并发症发生.术后平均12(9～15)d出院.术后病理报告:肾细胞癌9例,转移性肝细胞癌1例,良性血管平滑肌脂肪瘤1例,肾上腺平滑肌肉瘤1例.肾癌术后TNM分期:T3b N0M08例,T3bNxM11例.术后平均随访(21±10)个月,中位随访时间24个月.4例分别于术后6、9、15、22个月死于肺转移、肝转移及肝癌复发,其余8例术后已存活6～35个月,平均26个月.9例肾癌患者术后1、3年肿瘤特异生存率分别为78%和67%. 结论 经皮球囊导管阻断技术在低位肝后型或肝下型下腔静脉瘤栓的根治性切除术中是一种安全、简便、有效的方法,具有重要的临床应用价值.     

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.     

Right hepatic lobectomy and removal of inferior vena caval tumor embolus in a patient with hepatocellular carcinoma, using veno-venous bypass while preserving perfusion in the remnant liver: A case report

We describe a successful hepatectomy and the removal of a tumor embolus in a 43-year-old woman with hepatocellular carcinoma occupying the right lobe extending to the right branch of the portal vein and the inferior vena cava (IVC). Intraoperative echography revealed the tumor embolus in the IVC to originate from the main tumor via the right inferior hepatic vein, which extended cephalad from the confluence of the right hepatic vein to the IVC. Right hepatc lobectomy was performed via the anterior approach. Using femoro-axillary veno-venous bypass, we opened the IVC at the root of the inferior right hepatic vein to remove the tumor embolus after oblique clamping of the IVC between the right and middle hepatic veins was carried out to preserve perfusion in the remnant liver. Preserving perfusion in the remmant liver in radical hepatectomy for hepatocellular carcinoma with tumor embolism in the IVC appears to be a safe and advantageous technique in patients with poor liver reserve.     

Pedunculated hepatocellular carcinoma suspected of right adrenal tumor: a case report]

We report a rare case of extrahepatic growing hepatocellular carcinoma which was clinically diagnosed as right adrenal tumor. A 61-year-old woman was admitted for further examination of right flank pain and hypertension. Abdominal computed tomographic scan and echogram revealed a suprarenal mass. Hypercatecholaminemia was suspected from urinary analysis. Preoperative diagnosis was right adrenal tumor; suspected pheochromocytoma. On operation, we found the tumor was pedunculated from right lobe of liver and compressing normal right adrenal gland. Its clinical diagnosis was hepatocellular carcinoma. Ten months after operation she is still alive. We discuss the difficulty of differential diagnosis between extrahepatic growing hepatocellular carcinoma and adrenal tumor.     

Extension incision for renal carcinoma including invaded vena cava and right lobe of liver.

We report on a thirty-five-year-old woman with renal cell carcinoma who successfully underwent right radical nephrectomy and extended right hepatic lobectomy with resection and reconstruction of inferior vena cava (IVC). A temporary bypass was placed between the infrarenal IVC and right atrium using a heparin-coated synthetic tube. The tumor was resected en bloc including right kidney, adrenal gland, hepatic lobe, and IVC. The IVC was reconstructed using an expanded polytetrafluoroethylene (EPTFE) graft. Her postoperative course was uneventful with no signs of recurrence four years after surgery.     

Bilateral adrenal masses from renal cell carcinoma: a case report

We report a case of bilateral adrenal metastasis from renal cell carcinoma. A 65-year-old man was referred to our hospital for a right renal mass. A computed tomography revealed a 9 cm right renal tumor and bilateral adrenal masses (3.5 cm on the right side and 4.5 cm on the left). A right radical nephrectomy and bilateral adrenalectomy demonstrated renal cell carcinoma with metastasis to bilateral adrenal glands. The pathological findings of the right renal tumor showed clear cell carcinoma, G3 > G2 and both adrenal tumors showed the same pathology as the right renal tumor. The patient is alive with lung metastasis after 15 months postoperatively treated with interferon-alpha.     

A case of exohepatic pedunculated hepatocellular carcinoma suspected of adrenal tumor

A case of exohepatic pedunculated hepatocellular carcinoma that was clinically diagnosed as nonfunctioning adrenal tumor is reported. A 66-year-old man was admitted to our hospital for further examination of unstable angina pectoris. Abdominal echogram and CT scan revealed a large tumor in the right retroperitoneal space. Selective right renal arteriography demonstrated that the tumor was fed by the capsular branch of right renal artery and the right adrenal artery. Adrenal function was normal. Preoperative diagnosis of right nonfunctioning adrenal tumor was made. On operation we found that the tumor was pedunculated from the liver and adhered massively to both right kidney and vena cava. The tumor and right kidney were removed. A histopathological examination demonstrated well differentiated hepatocellular carcinoma (Edmondson's grade II type).     

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。     

Renal cell carcinoma with an infrarenal vena caval tumor thrombus

Extension of renal cell carcinoma (RCC) along venous drainage pathways is a well-recognized entity. All previously reported cases of inferior vena cava (IVC) involvement by RCC have been with tumor thrombus in the suprarenal IVC. We report a 45-year-old man who had RCC arising from the lower pole of the right kidney with a tumor thrombus totally occluding the infrarenal IVC. The patient underwent radical nephrectomy with successful ligation and resection of the infrarenal IVC.     

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.     

Hepatocellular carcinoma with a solitary adrenal metastasis and poor hepatic functional reserve: Report of a case

A 54-year-old man with a 15-year history of liver disease, was found by his family physician to have multiple tumors in the right lobe of the liver and a large right retroperitoneal tumor. He was referred and admitted to our institute where a preoperative diagnosis of liver cirrhosis complicated by hepatocellular carcinoma and probable right adrenal metastasis was made. Because his hepatic functional reserve was so poor, only resection of the right adrenal tumor with a splenectomy for hypersplenism and a cholecystectomy for the prevention of cholecystitis secondary to the scheduled transcatheter arterial embolization was performed. The patient was discharged in good clinical condition 5 weeks after surgery.     

Resection of the inferior vena cava for hepatic malignancy.

Involvement of the inferior vena cava (IVC) by hepatic tumors, although uncommon, is considered to be unresectable by standard surgical techniques. Recent advances in hepatic surgery have made combined hepatic and vena caval resection possible. The purpose of this study is to describe the surgical techniques and early results of combined resection of the liver and IVC. From 1997 to 2000, 11 patients underwent resection of the IVC along with four to seven liver segments. Resections were carried out for hepatocellular carcinoma (four); colorectal metastases (four); and hepatoblastoma, gastrointestinal stromal tumor metastases, and squamous cell carcinoma in one patient each. Ex vivo procedures were performed twice, and total vascular isolation was used in the nine other cases. The IVC was reconstructed with ringed Gore-Tex tube graft (five), primarily (five), or with Gore-Tex patches (one). There were two early deaths: one from liver failure at 3 weeks and one from sepsis secondary to a perforated segment of small bowel 4 months postresection. One patient with a gastrointestinal stromal tumor died at 32 months of recurrent tumor and one patient with hepatocellular carcinoma is alive with recurrent tumor at 16 months. The remaining patients are alive and disease free with follow-up ranging from 3 to 40 months without evidence of IVC occlusion. Combined resection of the liver and IVC is a formidable undertaking with substantial surgical risk. However, this aggressive surgical approach offers a chance for cure in patients with tumors involving the IVC that would otherwise have a dismal prognosis.     

Intracaval endovascular ultrasonography for large adrenal and retroperitoneal tumors

BACKGROUND: An accurate diagnosis of inferior vena cava (IVC) invasion is important in deciding the surgical strategy for a large adrenal tumor. We investigated the diagnostic value of intracaval endovascular ultrasonography (ICEUS) for invasion of the IVC by a large adrenal tumor. METHODS: Nine of 163 patients with adrenal and retroperitoneal tumors underwent ICEUS between 1993 and 2002. Intravascular ultrasonography was performed through the right femoral vein with the use of an 8Fr, 20-MHz transducer. The diagnostic criterion for detecting IVC invasion with ICEUS was identification of destruction of a single echogenic layer of the IVC wall or identification of an intracaval tumor mass. The ICEUS finding was confirmed by pathologic examination. RESULTS: The mean diameter of the tumors in 9 patients undergoing ICEUS and resection was 12.6 cm (range, 8.6-16 cm). Pathologic diagnosis varied: adrenocortical carcinoma, 4; malignant pheochromocytoma, 1; leiomyosarcoma, 1; metastatic lung cancer, 1; paraganglioma, 1; and neurilemmoma, 1. Vascular invasion was identified in 2 patients by ICEUS and confirmed by examination of resected specimens. The sensitivity, specificity, and positive predictive values of ICEUS for the diagnosis of the IVC invasion were 100%, 100%, and 100%, respectively. However, these values for computed tomography were 100%, 14%, and 25%, respectively; and for cavography, 100%, 57%, and 40%, respectively. CONCLUSIONS: ICEUS provides confirmatory information regarding tumor invasion of the IVC. This modality also can assist in formulating an operative strategy for large adrenal or retroperitoneal tumors.     

Simultaneous radical surgical treatment for membranous obstruction of the inferior vena cava and the coincident hepatocellular carcinoma —the first successful case—

To our knowledge, this is the first report of a patient for whom a successful radical treatment for both membranous obstruction of the inferior vena cava (MOVC) and coincident hepatocellular carcinoma (HCC) were simultaneously carried out. A 36 year old Japanese man with Budd-Chiari syndrome due to MOVC was found to have HCC in the right hepatic lobe during a shunt operation between the inferior vena cava (IVC) and the right atrium (RA), using a vascular prosthetic graft. He was referred to us from another institute for further operative procedures. Both the mediastinum and the abdomen were entered through a long midline incision with longitudinal splitting of the sternum. The graft that had been occluded by thrombus was removed. Transcardiac membranotomy was achieved by manual manipulation and then by Tubb's dilator. The hepatic tumor with an abundant surgical margin of the liver was resected. The tumor of 2.5×2.5×2.0 cm was a well differentiated clear cell type HCC associated with congestive liver cirrhosis. Postoperative contrast and pressure studies through IVC showed satisfactory results. Serum alfa-fetoprotein levels decreased from 503 to 12 ng/ml. The patient is well at least for 44 months after the surgery without any recurrence at the time of completion of this writing.     

Inferior vena cava reconstruction using fresh inferior vena cava allograft following caval resection for leiomyosarcoma: midterm results

We present a 56-year-old woman affected by a large leiomyosarcoma originating from the suprarenal inferior vena cava (IVC). A computed tomography (CT) scan revealed near obstruction of the IVC and involvement of the right renal vein. The patient underwent successful en bloc resection of the tumor, right kidney, right adrenal gland, and IVC. Caval reconstruction was performed using a non-type specific allograft, followed by left renal vein re-implantation. The patient tolerated the procedure well without any complications. The use of an IVC allograft allowed for continued graft patency, without the need of immunosuppression or long-term anticoagulation. However, local recurrence did occur.     

Resection of recurrent inferior vena cava tumor after radical nephrectomy for renal cell carcinoma

Management of recurrent tumor in the inferior vena cava (IVC) after radical nephrectomy is surgically challenging. We report 3 cases of recurrent renal cell carcinoma within the IVC managed by three different surgical techniques. One patient was treated with tumor thrombus removal and primary cavotomy closure. The second patient was treated with IVC ligation and removal without vascular reconstruction. A third patient was treated with IVC wall excision and placement of a bovine pericardium graft. Although technically difficult, repeat resection of IVC tumor recurrence after nephrectomy for renal cell carcinoma is an acceptable method of treatment.     

Simultaneous radical surgical treatment for membranous obstruction of the inferior vena cava and the coincident hepatocellular carcinoma--the first successful case

To our knowledge, this is the first report of a patient for whom a successful radical treatment for both membranous obstruction of the inferior vena cava (MOVC) and coincident hepatocellular carcinoma (HCC) were simultaneously carried out. A 36 year old Japanese man with Budd-Chiari syndrome due to MOVC was found to have HCC in the right hepatic lobe during a shunt operation between the inferior vena cava (IVC) and the right atrium (RA), using a vascular prosthetic graft. He was referred to us from another institute for further operative procedures. Both the mediastinum and the abdomen were entered through a long midline incision with longitudinal splitting of the sternum. The graft that had been occluded by thrombus was removed. Transcardiac membranotomy was achieved by manual manipulation and then by Tubb's dilator. The hepatic tumor with an abundant surgical margin of the liver was resected. The tumor of 2.5 X 2.5 X 2.0 cm was a well differentiated clear cell type HCC associated with congestive liver cirrhosis. Postoperative contrast and pressure studies through IVC showed satisfactory results. Serum alfa-fetoprotein levels decreased from 503 to 12 ng/ml. The patient is well at least for 44 months after the surgery without any recurrence at the time of completion of this writing.     

Rare case of left adrenal cortical carcinoma with level 3 inferior vena cava thrombus via adrenal vein

Introduction

Adrenocortical carcinoma (ACC) is a rare malignancy with an incidence of 0.7–2.0 cases/million habitants/year. It shows a bimodal pattern of age distribution with a higher incidence in the first decade and then between 40 and 50 years. Women are most frequently affected (55–60%).

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。