摘要
目的评估以肝移植切口结合肝脏游离技巧处理右肾中上极巨大肿瘤及下腔静脉内癌栓的安全性和有效性,总结其优越性。方法 2007年5月—2011年7月间共有8例患者行肝脏游离后的右肾癌根治术,年龄32～83岁,平均年龄为(56.8±17.6)岁。肿瘤直径9.5～15.0cm,平均直径为(11.4±2.5)cm。磁共振成像(MRI)评估癌栓所处静脉水平后,采用MayoClinic的五级分类法进行腔静脉内癌栓分级。合并腹膜后及肾门旁淋巴结转移3例;合并0级癌栓2例,合并Ⅱ级癌栓2例,合并Ⅲ级癌栓1例。术中采用背驮式肝移植技巧游离翻转肝脏,尝试应用Pringle技术短暂阻断肝脏血流以获取较清晰的手术视野,切除患肾后取尽下腔静脉内癌栓并重建下腔静脉。手术当天及术后第1天,所有患者入外科重症监护病房,监测术后患者肝、肾功能情况。结果 3例合并下腔静脉内癌栓的患者均成功取尽癌栓,重建下腔静脉。术中见患者的癌栓范围与MRI提示的癌栓范围相符。所有患者术中失血量200～900mL,平均术中失血量为(387.5±299.7)mL;0级癌栓患者术中失血量为300、200mL,Ⅱ级癌栓患者为400、500mL,Ⅲ级癌栓患者为900mL。所有患者手术时间为137～309min,平均手术时间为(210.1±67.0)min;其中Ⅰ级癌栓患者手术时间为212、137min,Ⅱ级癌栓患者为249、278min,Ⅲ级癌栓患者为309min。所有患者术中及术后均未发生严重并发症。患者术后第1天血清肌酐水平86～113μmol/L,平均为(99.3±8.7)μmol/L;丙氨酸转氨酶水平为22～35U/L,平均为(29.3±5.1)U/L;天冬氨酸转氨酶为14～38U/L,平均为(24.1±8.1)U/L。应用Pringle技术暂时阻断肝脏血流后无1例患者产生肝功能损害。结论翻肝技术可充分显露右侧腔静脉-膈肌角,暴露其间的肿瘤侧支血管、膈下血管、肝后下腔静脉及因肿瘤压迫而向上推移的右肾上腺,适用于右肾巨大占位和下腔静脉内Ⅰ～Ⅲ级癌栓的根治性切除。与此同时,放弃传统的胸腹联合切口而使用单纯经腹途径,可降低麻醉风险,减小手术创伤,同时也可避免术后留置胸腔闭式引流,为术后患者的护理和早期活动提供有利条件。
[Abstract] Objective To evaluate the safety and efficacy of liver dissection technique combined with liver transplant incision on very huge tumor in upper pole of right kidney and tumor thrombus in the inferior vena cava. Methods From May 2007 to July 2011, right radical nephrectomy was carried out in 8 patients with liver dissection technique. The average age of the patients was （56.8 ＋ 17.6） years （range, 32 - 83 years）. The average diameter of tumor was （11.4-＋ 2.5） cm （range, E9.5-- 15] cm）. Mayo Clinic five taxonomy was applied for tumor thrombus in the vena cava after MRI assessment. Three patients presented with renal hilum and retroperitoneal lymph node metastasis, 2 with grade 0 tumor thrombus, 2 with grade II tumor thrombus and 1 with grade III tumor thrombus. The piggyback liver transplantation was used to dissect the liver, and Pringle maneuver was tried to get a clearer operative field by briefly blocking the hepatic blood flow. After radical nephrectomy and thrombectomy, the inferior vena cava was reconstructed. All patients were sent to intensive care unit （ICU） postoperatively and stayed there for one day. Liver and kidney function were measured. Results The total thrombectomy and reconstruction of the inferior vena cava were successfully carried out in 3 patients with tumor thrombus. The range of tumor thrombus was correlated to MRI results. The average blood loss was （387.5 ±299.7） mL （range, [200- 900] mL）. Intraoperative blood loss was 300, 450 and 900 mL in the patients with grade 0, II and III tumor thrombus, respectively. The average operative time was （210.1±67.0） min （range, [37-309] min）. Mean operative time was 212, 263.5 and 309 min in the patients with grade I, II and III tumor thrombus, respectively. No patients had severe complications during and after surgery. The levels of serum creatinine, alanine transaminase and aspartate transaminase were （99. 3 ± 8. 7） μmol/L （86 - 113μmol/L）, （29.3 ± 5.1 ） U/L （22 - 35 U/L） and （24.1 ± 8.1 ） U/L （ 14 - 38 U/L）, respectively. No patients presented with liver dysfunction related to Pringle maneuver. Conclusion The right superior vena cava-diaphragmatic angle, tumor collateral vessels, inferior vena cava, subdiaphragmatic blood vessels and right adrenal gland can be easily revealed by liver ligament dissection and liver mobilization. This technique can be applied in the huge tumor of right kidney with inferior vena cava I --III grade tumor thrombus. Transabdominal approach may not only reduce the risk of anesthesia and surgical trauma, but also avoid the thoracic drainage after surgery, which offers favorable conditions for postoperative care and early activities. （Shanghai Med J, 2013, 36.. 239-242）
出处
《上海医学》
CAS
CSCD
北大核心
2013年第3期239-242,共4页
Shanghai Medical Journal
关键词
翻肝
背驮式肝移植
右肾上极占位
下腔静脉内癌栓
Liver mobilization
Piggyback liver transplantation
Upper pole mass in right kidney
Inferior vena cava cancer embolus
