CAJ | 학술논문

目的探讨CT引导下肾癌冷冻消融术后出血的预防与止血措施.方法回顾性分析8例肾透明细胞癌患者资料,所有患者均行氩氦刀冷冻消融治疗.冷冻基本模式为10 min冷冻,复温3 min,重复循环1次.冷冻探针穿刺前均行CT增强扫描,观察肿瘤边界与肾皮质、肾盂的位置关系以及肿瘤内血供情况,尽量选择减少正常肾皮质及肾盂损伤的路径,在保证治疗疗效的情况下采取适型冷冻减少探针数量以减少肾包膜的损伤.术中间断行CT扫描观察冰球覆盖病灶情况、监测冷冻范围及肾周有无出血.术后行心电监护观察血压变化及术后24 h复查CT或血常规观察有无活动性叶血.结果 8例在CT引导下成功将冷冻探针适形置入病灶,按冷冻基本模式完成冷冻消融.术中适时CT扫描下可清晰地观察到低密度冰球完全包裹病灶而无累及肾盂和肾周围正常组织.冷冻消融过程中均无出血.探针拔出后CT扫描显示,3例无肾周出血,其中1例因冷冻后穿刺活检出现较大量出血,约150 ml,经介入栓塞治疗止血;2例分别有5根和6根冷冻探针拔针后只有肾被膜外极少量出血,约10 ml;1例3根冷冻探针的患者经多次氦气复温后只有少量被膜外出血,约30 ml;1例有8根冷冻探针的患者出现拔针后中等量被膜内外出血,约60 ml;1例有7根冷冻探针的患者出现拔针后较大量肾被膜内外出血,约200 ml,经积极采取出血动脉栓塞治疗后出血停止.少量及中等量出血者,经静脉输注2 IU凝血酶和严格卧床休息,24h后复查CT,未见明显活动性出血,复查血常规提示血红蛋白及红细胞数未见明显变化.结论穿刺前行增强CT扫描,有助于确定进针路径,减少损伤,从而预防和减少术中出血的风险.对于术中及术后较大量出血者应立即给予介入栓塞治疗,少量及中等量出血者可先行保守治疗.
목적 탐토CT인도하신암냉동소융술후출혈적예방여지혈조시.방법 회고성분석8례신투명세포암환자자료,소유환자균행아양도냉동소융치료.냉동기본모식위10 min냉동,복온3 min,중복순배1차.냉동탐침천자전균행CT증강소묘,관찰종류변계여신피질、신우적위치관계이급종류내혈공정황,진량선택감소정상신피질급신우손상적로경,재보증치료료효적정황하채취괄형냉동감소탐침수량이감소신포막적손상.술중간단행CT소묘관찰빙구복개병조정황、감측냉동범위급신주유무출혈.술후행심전감호관찰혈압변화급술후24 h복사CT혹혈상규관찰유무활동성협혈.결과 8례재CT인도하성공장냉동탐침괄형치입병조,안냉동기본모식완성냉동소융.술중괄시CT소묘하가청석지관찰도저밀도빙구완전포과병조이무루급신우화신주위정상조직.냉동소융과정중균무출혈.탐침발출후CT소묘현시,3례무신주출혈,기중1례인냉동후천자활검출현교대량출혈,약150 ml,경개입전새치료지혈;2례분별유5근화6근냉동탐침발침후지유신피막외겁소량출혈,약10 ml;1례3근냉동탐침적환자경다차양기복온후지유소량피막외출혈,약30 ml;1례유8근냉동탐침적환자출현발침후중등량피막내외출혈,약60 ml;1례유7근냉동탐침적환자출현발침후교대량신피막내외출혈,약200 ml,경적겁채취출혈동맥전새치료후출혈정지.소량급중등량출혈자,경정맥수주2 IU응혈매화엄격와상휴식,24h후복사CT,미견명현활동성출혈,복사혈상규제시혈홍단백급홍세포수미견명현변화.결론 천자전행증강CT소묘,유조우학정진침로경,감소손상,종이예방화감소술중출혈적풍험.대우술중급술후교대량출혈자응립즉급여개입전새치료,소량급중등량출혈자가선행보수치료.
Objective To explore the methods of the hemorrhage prevention and the measures of hemostasis by CT guided after renal cancer cryoablation.Methods Retrospective analysis of 8 patients of renal cell carcinoma patienthave been done,all the patients were underwent cryoablation.The basic model included 10 min frozen,3 min thawed and 1 cycle were repeated.Before the cryoprobe puncture,a CT scan was taken to observe the blood supply of the tumor and the relationship between the border of the tumor and renal cortex,renal pelvis.Besides,the path of reducing the injury of normal renal cortex and renal pelvis was chosen,and the decreased number of probes was adopted by taking conformal cryoablation to reduce the damage to the renal capsule,in theensurance of the treatment efficacy.Intraoperative CT scan was performed discontinuously,to observe the covering status of the range of ice ball on the lesion and to monitor the perirenal bleeding.Postoperative ECG and blood pressure changes was observed 24 h after operation.Besides,CT scan or blood routine examination is necessary to monitor whether active bleeding happened.Results According enhanced CT image positioning puncture path,the path of probes were selected in the shortest path between the tumor margins and the renal cortical which avoid the renal pelvis.Probes were CT-guided conformal puncture into the lesion successfully for 8 patients,according to freezing basic mode to complete cryoablation.Timely intraoperative CT scan can clearly observe that a low-density ice ball wrapped lesion completely without involving the renal pelvis and normal tissue surrounding the kidney.There was no bleeding in the procedure of cryoablation.After the probe was pulled,CT scan showed:3 of the 8 patients didn't show any sign of henorrhage,in which 1 patient had heavily bleeding,about 150 ml due to the biopsy after cryoablation.The bleeding was stopped by interventional embolization.A little hemorrhage was found in two patients,about 10 ml outside renal capsule.Medium hemorrhage took place in two patients,30 nl in one patient which underwent several cycles of thawing and 60 ml in another.The patients of mild and medium hemorrhage was treated with intravenous injection of Reptilase and strict bed rest.There was a great hemorrhage in one patient,about 200 ml.The bleeding was stopped by interventional embolization.A small and moderate bleeding,it necessary to execute intravenous infusion 2 IU reptilase and strict bed rest.There was no significant active bleeding from the CT scan after 24 h operation and no change in the blood routine examination of blood hemoglobin and red blood cell count.Conclusions Before the puncture,it is necessary to perform an enhanced CT scan to understand the position,which can determine the path of the puncture.It can reduce the damage of renal cortex,renal capsule and surrounding tissue and prevent and reduce the risk of bleeding.For larger amounts of intraoperative and postoperative bleeding subjects,the embolization should be given immediately,as for the small or moderate amount of bleeding,the conservative treatment may be given firstly.