前列腺切除术后深静脉血栓形成26例分析

目的：预防前列腺切除术后深静脉血栓形成，减少肺栓塞等严重并发症。方法：通过对26例下肢深静脉血栓形成患者的分析，讨论前列腺切除术后深静脉血栓形成因素，提出预防措施。结果：保守治疗18例，15例痊愈，3例好转；行髂股静脉取栓术2例痊愈；表现为肺栓塞6例，4例死亡，2例治愈。结论：前列腺切除术后患者是高血凝状态和血管收缩是形成深静脉血栓的内因，而围手术期处理不当是促使血栓形成的外因。围手术期采用抗高血凝和血管收缩措施，进行正确的围手术期处理可较好预防深静脉血栓形成。     

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。     

下腔静脉平滑肌肉瘤的诊断及外科治疗

目的 了解下腔静脉平滑肌肉瘤的临床特点，总结下腔静脉平滑肌肉瘤的诊治经验。方法 对1986—2006年中国人民解放军总医院普外科收治的14例下腔静脉平滑肌肉瘤病人的临床资料进行回顾性分析。结果 12例病人实施手术，其中11例行肿瘤及相应的下腔静脉切除和必要的下腔静脉重建，1例仅行剖腹探查肿瘤活检；2例因远处转移而未手术。结论 肿瘤整块切除及必要的下腔静脉重建是治疗下腔静脉平滑肌肉瘤的有效方法。     

Temporary vena cava filters in the prevention of pulmonary embolism during total hip arthroplasty

Thromboembolism constitutes one of the most dangerous complications during the immediate postoperative period of prosthetic surgery. Pharmacological prophylaxis and mechanical vascular compression are not always sufficient to protect from this surgical complication. In patients at greatest risk for thromboembolism, often with a positive history for pulmonary embolism, temporary vena cava filters may be used to reduce the incidence of vascular and pulmonary complications. However useful, these filters cannot be routinely used in orthopedic surgery. We present our results with the use of Filcard RFO2 vena cava filters in an open, randomized study of 30 patients. Received: 5 November 2001/Accepted: 30 November 2001     

Hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with inferior vena caval thrombus

PURPOSE: To our knowledge we present the initial clinical report of hand assisted laparoscopic radical nephrectomy for renal cell carcinoma with tumor thrombus extending into the inferior vena cava. MATERIALS AND METHODS: A 76-year-old man was referred to our medical center with a 12.5 x 10 cm. stage T3b right renal tumor extending into the inferior vena cava. The caval thrombus was limited and completely below the level of the hepatic veins. After preoperative renal embolization via the hand assisted transperitoneal approach the right kidney was completely dissected with the renal hilum. Proximal and distal control of the inferior vena cava was obtained with vessel loops and a single lumbar vein was divided between clips. An endoscopic Satinsky vascular clamp was placed on the inferior vena cava just beyond its juncture with the right renal vein, thereby, encompassing the caval thrombus. The inferior vena cava was opened above the Satinsky clamp and a cuff of the inferior vena cava was removed contiguous with the renal vein. The inferior vena cava was repaired with continuous 4-zero vascular polypropylene suture and the Satinsky clamp was then removed. A literature search failed to reveal any similar reports of laparoscopic radical nephrectomy for stage T3b renal cell cancer. RESULTS: Surgery was completed without complication with an estimated 500 cc blood loss. Pathological testing confirmed stage T3b grade 3 renal adenocarcinoma with negative inferior vena caval and soft tissue margins. CONCLUSIONS: The introduction of vascular laparoscopic instrumentation and the hand assisted approach enabled us to extend the indications for laparoscopic radical nephrectomy to patients with minimal inferior venal caval involvement.     

Immediate skin-sparing mastectomy reconstruction with deep inferior epigastric perforator (DIEP) flap. Technical aspects and outcome

Although breast reconstruction with deep inferior epigastric perforator (DIEP) flap is a well-described technique, few publications have specifically reported the technical aspects and the outcome following skin-sparing mastectomy (SSM). The aim of this study is to analyse the feasibility of its immediate application and to describe the operative planning, outcome and complications after SSM. 27 patients underwent 30 DIEP flap breast reconstructions with all immediate and 3 bilateral. Mean time of follow-up was 29 months. Breast skin, DIEP Flap and donor-site complications were evaluated. Information on patient satisfaction was collected. 70% had tumors measuring 2 cm or less (T1) and 74% were stage 0 and I according to American Joint Committee on Cancer. Breast skin complications occurred in 7.4%, all represented by small areas of skin necrosis. Partial losses were observed in two (7.4%) patients (less than 15% of total area) and total DIEP loss in 1 (3.7%). Donor-site complications represented by bulging occurred in only one patient (3.7%). The majority of patients were either very satisfied or satisfied. One local recurrence was observed. All complications except 2 were treated by a conservative approach. The DIEP flap is a reliable technique for SSM reconstruction. Success depends on patient selection, coordinated planning with the oncologic surgeon and careful intraoperative and postoperative management. The main advantage is that patients can safely undergo dual procedures with the added aesthetic benefits in breast and abdominal donor site.     

Clinical outcome of surgical management for patients with renal cell carcinoma involving the inferior vena cava

BACKGROUND: The objective of this study was to evaluate the clinical outcome after surgical management of renal cell carcinoma (RCC) extending to the inferior vena cava (IVC). METHODS: This study included a total of 55 patients (41 men and 14 women; mean age, 59.3 years) with RCC (39 right- and 16 left-sided tumors) involving the IVC, who underwent radical nephrectomy and tumor thrombectomy between 1983 and 2005 at a single institution in Japan. The level of thrombus was classified as follows: level I, infrahepatic; level II, intrahepatic; level III, suprahepatic; and level IV, extending to the atrium. Clinicopathological data from these patients were retrospectively reviewed to identify factors associated with survival. RESULTS: There were 11 and 18 patients who were diagnosed as having lymph node and distant metastases, respectively. Twenty-two patients had tumor thrombus in level I, 20 in level II, 10 in level III, and 3 in level IV. Pathological examinations demonstrated that 34 and 21 patients had clear cell carcinoma and non-clear cell carcinoma, respectively, 42, 9 and 4 were pT3b, pT3c and pT4, respectively, and 6, 35 and 14 were Grades 1, 2 and 3, respectively. Cancer-specific 1-, 3- and 5-year survival rates of these 55 patients were 74.5%, 51.4% and 30.3%, respectively. Among several factors examined, clinical stage (P = 0.047), lymph node metastasis (P = 0.016), histological subtype (P = 0.034) and tumor grade (P < 0.001) were significantly associated with cancer-specific survival by univariate analysis. Furthermore, multivariate analysis demonstrated clinical stage (P = 0.037) and tumor grade (P < 0.001) as independent predictors of cancer-specific survival irrespective of other significant factors identified by univariate analysis. CONCLUSIONS: In patients with RCC involving the IVC, biological aggressiveness characterized by tumor grade rather than tumor extension would have more potential prognostic importance; therefore, more intensive multimodal therapy should be considered in patients with high grade RCC with tumor thrombus extending into the IVC.     

包括腔静脉旁部的肝尾叶切除术

目的：探讨并总结包括腔静脉旁路肝尾叶切除的方法和经验。方法：分别采用右后途径和左侧途径行肝右尾叶和全尾叶切除;前者附加部分右后叶切除,后者可为单独全尾叶切除或附加左外叶或左半肝切除。结果：成功施行包括腔静脉旁部的肝尾叶切除13例,其中右尾叶切除7例,全尾叶切除6例;全组无手术死亡,术中,术后均无严重并发症发生;术中平均失血量为896.15ml,平均肝门阻断时间为25.4min,术后平均住院12d。结论：虽然肝门部解剖关系复杂,但手术切除包括腔静脉旁部的肝尾叶仍是安全可行的。     

Evaluation of tumor thrombi in the inferior vena cava with intraoperative ultrasound

To report and discuss four cases of renal cell carcinoma (RCC) in which preoperative investigations yielded contradictory results regarding the cranial extension of propagation of the tumor thrombus into the vena cava. An intraoperative ultrasound scan (IOU) was performed in all cases to identify the exact level of the tumor thrombus. We have performed an IOU of the vena cava in four patients with RCC propagation into the inferior vena cava. Preoperative investigations were performed in all patients and consisted of abdominal Ultrasound scan (USS), contrast enhanced CT scan and gadolinium enhanced MRI scan. Intraoperative ultrasound has identified correctly the cranial extension and the absence of tumor thrombus infiltration in all patients. The thrombus reached the suprahepatic vena cava in two cases and was confined to the infrahepatic vena cava in the remainder. Preoperative imaging investigation had failed to determine the correct cranial extension of the tumor thrombus in two patients.IOU is a very useful tool to accurately assess the precise extent of tumor thrombus and eventually the presence of vein wall infiltration. These data are of paramount importance to plan the optimal surgical approach. According to our experience this type of investigation identifies the cranial extent of a tumor thrombus inside the vena cava better than standard imaging techniques.     

Results of inferior vena caval interruption by greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy

PURPOSE: Surgical resection for patients with renal cell carcinoma and venous tumor thrombus may require interruption of the inferior vena cava using a Greenfield filter, ligation or resection. We describe the indications, technique, complications and outcomes of vena caval interruption during nephrectomy with tumor thrombectomy. MATERIALS AND METHODS: We identified 160 patients treated for level II-IV tumor thrombus at our institution between 1970 and 2004. Operative reports were reviewed to establish vena caval interruption. All patients who underwent interruption were assessed for postoperative disability according to the American Venous Forum International Consensus Committee. RESULTS: Vena caval interruption was performed in 40 of 160 cases (25%), including 14 level II, 10 level III and 16 level IV thrombi. A total of 34 patients (85%) were symptomatic at presentation. A Greenfield filter was deployed before cavotomy closure in 4 of 160 patients (2.5%) for bland thrombus of the infrarenal vena cava. Vena caval ligation was used for bland thrombus that completely occluded the infrarenal vena cava in 23 of 160 patients (14.4%), while segmental vena caval resection was performed for tumor thrombus growing into the wall of the vena cava or for tumor thrombus that interfaced with bland thrombus in 13 of 160 (8.1%). Postoperatively no case was class 3 disability, 12 of 40 (30%) were class 2, 12 of 40 (30%) were class 1 and 16 of 40 (40%) showed no disability. CONCLUSIONS: The need to interrupt the inferior vena cava is not infrequent in patients undergoing radical nephrectomy and tumor thrombectomy, and it may be well tolerated postoperatively. Management should be based on the degree of venous occlusion and the presence of bland thrombus.