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微创泌尿外科杂志  2018, Vol. 7 Issue (4): 230-234    DOI: 10.19558/j.cnki.10-1020/r.2018.04.004
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下腔静脉瘤栓切除术中下腔静脉离断的术前决策及影响因素分析
杜松良1, 2, 黄庆波1, 史涛坪1, 顾良友1, 李宏召1, 王保军1, 沈诞1, 彭程1, 刘凤永3, 熊江4, 马鑫1, 张旭1
1 中国人民解放军总医院泌尿外科 中国人民解放军总医院肾脏疾病国家重点实验室 100853 北京;
2 南开大学医学院;
3 中国人民解放军总医院介入放射科;
4 中国人民解放军总医院血管外科
Preoperative decision-making and analysis of influence factors for inferior vena cava transection during inferior vena cava thrombectomy
Du Songliang1, 2, Huang Qingbo1, Shi Taoping1, Gu Liangyou1, Li Hongzhao1, Wang Baojun1, Shen Dan1, Peng Chen1, Liu Fengyong3, Xiong Jiang4, Ma Xin1, Zhang Xu1
1 Department of Urology/State Key Laboratory of Kidney Diseases, Chinese PLA General Hospital, Beijing 100853, China;
2 School of Medicine, Nankai University;
3 Department of Interventional Radiology, Chinese PLA General Hospital;
4 Department of Vascular Surgery, Chinese PLA General Hospital
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摘要 目的: 探讨下腔静脉瘤栓切除术中下腔静脉离断的术前决策制定及其影响因素。方法: 回顾性分析中国人民解放军总医院泌尿外科2016年7月~2017年8月对8例下腔静脉瘤栓患者行下腔静脉离断术的临床资料。原发肾肿瘤7例,腹膜后恶性孤立性纤维肿瘤1例。左侧1例,右侧7例。Mayo分级Ⅱ级7例,Ⅲ级1例。301分级Ⅱ级7例,Ⅲ级1例。术前下腔静脉完全阻塞7例,5例合并远心端长段血栓。术前行下腔静脉造影示侧支循环充分建立。下腔静脉离断的方式包括完全离断和部分离断。对于右侧肿瘤,瘤栓高度在第二肝门以下,下腔静脉离断后不需要重建。对于高度达第二肝门以上的右侧瘤栓,可部分离断腔静脉。对于左侧下腔静脉瘤栓合并远心端长段血栓,手术方法为离断右肾静脉水平以下的下腔静脉,重建右肾静脉水平以上的下腔静脉。结果: 所有手术均采用机器人辅助腹腔镜下腔静脉瘤栓切除术。其中下腔静脉完全离断7例,部分离断加腔静脉重建1例。中位手术时间290 min(250~470 min),中位术中出血1 600 ml(700~6 000 ml),所有患者均给予术中输血,中位输血量1 025 ml(450~3 880 ml)。术后均转入ICU监护治疗,ICU中位住院天数4 d(1~6 d)。术后病理类型肾细胞癌5例,肉瘤2例,恶性孤立性纤维性肿瘤1例。术前肌酐中位值95.8 μmol/L(58.7~174.5 μmol/L),术后3~6个月中位血肌酐99.7 μmol/L (70.0~162.3 μmol/L)。术后3例患者出现暂时性双下肢水肿。所有患者均顺利出院,无围手术期死亡病例。术后中位住院天数8.5 d(5~30 d)。术后随访,4例患者出现远处转移,其中2例死亡,中位随访时间11个月(4.5~15.0个月)。结论: 下腔静脉离断在腔静脉瘤栓切除术中安全可行。术前下腔静脉造影有助于判断侧支循环建立情况以及离断决策的制定。根据瘤栓高度,肿瘤侧别,腔静脉阻塞及侵犯程度,侧支循环建立情况制定不同的离断策略。
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杜松良
黄庆波
史涛坪
顾良友
李宏召
王保军
沈诞
彭程
刘凤永
熊江
马鑫
张旭
关键词 机器人肾癌静脉瘤栓瘤栓切除术下腔静脉离断    
AbstractObjective: To explore preoperative decision-making and influencing factors for inferior vena cava (IVC) transection during inferior vena cava thrombectomy. Methods: Eight patients with venous tumor thrombus underwent IVC transection from July 2016 to August 2017. There were 7 cases at right side and 1 case at left side. Primary tumor type was renal cell carcinoma in 7 patients and retroperitoneal malignant solitary fibrous tumor in 1. There were 7 cases of Mayo level Ⅱ and 1 case of level Ⅲ thrombus. Cases of level Ⅱ and level Ⅲ thrombus according to the "301" classification were 7 and 1, respectively. Preoperative imaging study revealed that the IVC was completely occluded in 7 cases and distal bland thrombus in 5 cases. Preoperative venography demonstrated robust collateral veins were established. For right cases with Mayo level Ⅰ-Ⅱ thrombus, the IVC was ligated and transected without reconstruction. For the cases of Mayo level Ⅲ-Ⅳ thrombus, the IVC was ligated and transected below the second porta hepatis; The IVC above the second porta hepatis was cut and then sutured after removal of the thrombus. For left cases, the IVC was ligated and transected at infra-renal vein level; the IVC above the right renal vein was cut and reconstructed after removal of the thrombus. Results: All cases were given the robotic surgery. Median operation time was 290 min. Median blood loss was 1600 mL. Median blood transfusion was 1025 mL. Median intensive care unit stay was 4 days. Median preoperative serum creatinine was 95.8 μmol/L (58.7-174.5). Median serum creatinine at 1st to 3rd month during the follow up period was 99.7 μmol/L (70.0-162.3 μmol/L). The mild transient lower extremity edema occurred in 3 patients and recovered within one month. No perioperative death occurred. Distant metastasis occurred in 4 patients postoperatively, resulting in 2 deaths. Median follow-up time was 11 months. Conclusions: IVC transection is safe and feasible during robotic venous thrombectomy. Venography is essential to ide.pngy the collateral vessels and help in preoperative decision making. According to tumor thrombus extent, primary tumor side, vena cava obstruction, venous wall invasion, establishment of collateral circulation, different strategies could be developed preoperatively.
Key wordsrobotics    renal tumor    venous tumor thrombus    venous tumor thrombectomy    inferior vena cava transection
收稿日期: 2018-05-15     
ZTFLH:  R737.11  
基金资助:国家高技术研究发展计划(863计划)(2014AA020607, 2012AA021101)
通讯作者: 张旭,xzhang@foxmail.com;马鑫,urologist@foxmail.com   
引用本文:   
杜松良, 黄庆波, 史涛坪, 顾良友, 李宏召, 王保军, 沈诞, 彭程, 刘凤永, 熊江, 马鑫, 张旭. 下腔静脉瘤栓切除术中下腔静脉离断的术前决策及影响因素分析[J]. 微创泌尿外科杂志, 2018, 7(4): 230-234.
Du Songliang, Huang Qingbo, Shi Taoping, Gu Liangyou, Li Hongzhao, Wang Baojun, Shen Dan, Peng Chen, Liu Fengyong, Xiong Jiang, Ma Xin, Zhang Xu. Preoperative decision-making and analysis of influence factors for inferior vena cava transection during inferior vena cava thrombectomy. JOURNAL OF MINIMALLY INVASIVE UROLOGY, 2018, 7(4): 230-234.
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