CAJ | 학술논문

目的探讨左肾癌伴下腔静脉癌栓的手术治疗方法.方法回顾性分析2009年12月至2014年12月收治的25例左肾癌合并下腔静脉癌栓患者的临床资料,男15例,女10例.年龄37～72岁,平均58岁.术前行磁共振血管成像检查明确癌栓的上、下极位置.下腔静脉癌栓分级:Ⅰ级9例(36％),Ⅱ级9例(36％),Ⅲ级4例(16％),Ⅳ级3例(12％).25例均于全麻下行根治性左肾切除+下腔静脉癌栓取出术.术中根据癌栓的分级采用不同的手术方式:≤Ⅱ级癌栓(肝下癌栓)在暴露并控制癌栓上、下方下腔静脉和右肾静脉后切开取栓;Ⅲ级癌栓(肝后癌栓)在肝胆外科协助下行背驮式肝脏游离术后充分游离肝后下腔静脉段,依次控制癌栓上、下方下腔静脉、右肾静脉和第一肝门后切开取栓;Ⅳ级癌栓(膈上癌栓)在心胸外科协助下,对癌栓未入右心房者采用胸腹联合切口,在胸腔内控制癌栓上方下腔静脉切开取栓,如癌栓进入右心房则需在体外循环下完成取栓.结果本组25例手术无术中死亡病例,所有癌栓均被完全清除;1例Ⅲ级癌栓术中发生肺动脉栓塞,联合心胸外科在体外循环下完成取栓术抢救成功.手术时间130 ～ 300 min,平均180 min;术中失血量200～3000ml,平均500 ml.随访3～60个月,平均47个月.13例(52％)无瘤生存,3例(12％)复发转移带瘤生存,9例(36％)死于肝转移、肺转移和多器官衰竭.各级癌栓的5年生存例数分别为:Ⅰ级8例(50％),Ⅱ级6例(37％),Ⅲ级2例(13％),Ⅳ级0例.结论左肾癌合并下腔静脉癌栓患者行根治性肾切除+下腔静脉癌栓取出术仍是目前唯一可达到治愈的治疗方法,术中癌栓脱落引起肺动脉栓塞时紧急行体外循环下取栓术是有效的处理方式.
목적 탐토좌신암반하강정맥암전적수술치료방법.방법 회고성분석2009년12월지2014년12월수치적25례좌신암합병하강정맥암전환자적림상자료,남15례,녀10례.년령37～72세,평균58세.술전행자공진혈관성상검사명학암전적상、하겁위치.하강정맥암전분급:Ⅰ급9례(36％),Ⅱ급9례(36％),Ⅲ급4례(16％),Ⅳ급3례(12％).25례균우전마하행근치성좌신절제+하강정맥암전취출술.술중근거암전적분급채용불동적수술방식:≤Ⅱ급암전(간하암전)재폭로병공제암전상、하방하강정맥화우신정맥후절개취전;Ⅲ급암전(간후암전)재간담외과협조하행배타식간장유리술후충분유리간후하강정맥단,의차공제암전상、하방하강정맥、우신정맥화제일간문후절개취전;Ⅳ급암전(격상암전)재심흉외과협조하,대암전미입우심방자채용흉복연합절구,재흉강내공제암전상방하강정맥절개취전,여암전진입우심방칙수재체외순배하완성취전.결과 본조25례수술무술중사망병례,소유암전균피완전청제;1례Ⅲ급암전술중발생폐동맥전새,연합심흉외과재체외순배하완성취전술창구성공.수술시간130 ～ 300 min,평균180 min;술중실혈량200～3000ml,평균500 ml.수방3～60개월,평균47개월.13례(52％)무류생존,3례(12％)복발전이대류생존,9례(36％)사우간전이、폐전이화다기관쇠갈.각급암전적5년생존례수분별위:Ⅰ급8례(50％),Ⅱ급6례(37％),Ⅲ급2례(13％),Ⅳ급0례.결론 좌신암합병하강정맥암전환자행근치성신절제+하강정맥암전취출술잉시목전유일가체도치유적치료방법,술중암전탈락인기폐동맥전새시긴급행체외순배하취전술시유효적처리방식.
Objective To investigate the outcome of surgical treatment for patients with left renal carcinoma associated with inferior vena cava (IVC) tumor thrombus.Methods Data from 25 consecutive patients (15 male cases and 10 female cases) with left renal carcinoma and IVC thrombus were retrospectively reviewed in our hospital from December 2009 to December 2014.The patients were classified according to location of the upper extent of the tumor thrombus,including level Ⅰ (or renal) in 9 cases (36％),level Ⅱ (or retrohepatic) in 9 cases (36％),level Ⅲ (or suprahepatic) in 4 cases(16％) and level Ⅳ (or atrial) in 3 cases (12％).Magnetic resonance angiography was applied in each patient to determine the accurate location of tumorous embolus.All patients accepted radical nephrectomy and caval thrombectomy under the general anesthesia.For cases with the level Ⅰ and l thrombus (the sub-hepatic thrombus type),caval thrombectomy was not performed until the bilateral renal veins and sub-hepatic IVC were well-exposed and controlled by tourniquets.For cases with level Ⅲ thrombus (the post-hepatic thrombus type),sub-thrombus IVC,bilateral renal veins,first hilus hepatis and retrohepatic IVC should be exposed and controlled sequentially through piggyback technique assisted by specialist before caval thrombectomy.For the cases with level Ⅳ thrombus (the supra-diaphragm type),the thrombectomy was performed under control of superior vena cava through thoracotomy if embolus was found near the right atrium.Otherwise,extracorporeal circulation should be considered.Results All patients received radical nephrectomy and caval thrombectomy successfully with the lesions extirpated.No death occurred during hospital stay.The average operation duration was 180 min(range 130-300 min)and blood loss was 500 ml(range 200-3 000 ml) One patient (level Ⅲ tumor thrombus) complicated by pulmonary embolism and rescued via thrombectomy by the cardiovascular specialists under extracorporeal circulation.The mean duration of follow-up was 47 months,ranged from 3 months to 60 months.The disease-free survival rate was 52％ (13 cases) and the survival with tumor rate was 12％ (3 cases).The rest 9 patients (36％) died due to liver or lung metastasis and multiple organ failure.The 5-year survival rate in the individual level were as follows:level Ⅰ in 8 cases (50％),level Ⅱ in 6 cases (38％) and level Ⅲ in 2 cases (13％).Conclusions Radical nephrectomy and caval thrombectomy is a viable and definitive treatment for left renal carcinoma associated with tumor embolus in the IVC.Extracorporeal circulation and atriotomy should be considered in the cases of acute pulmonary embolism caused by tumor thrombus.