Surgery of retrohepatic and supraphrenic vena cava tumor thrombus

According to the extension length of the tumor thrombus in the inferior vena cava, it can be divided into the following 4 types: 1 renal vein surrounding type, the tumor thrombus does not exceed 2 cm above the renal vein opening; 2 the sub-hepatic type, the tumor thrombus exceeds 2 cm above the renal vein opening, However, in the third hepatic inferior vena cava; 3 post-hepatic type, the tumor thrombus reaches the posterior inferior vena cava, but below the diaphragm; 4 upper type, the tumor thrombus exceeds the transverse sputum, and sometimes reaches the right atrium. Preoperatively, the extent of vena cava tumor thrombus can be determined by CT or MRI. Sometimes it is necessary to undergo transesophageal ultrasound examination. Patients who cannot accurately determine the extent of tumor thrombus need to undergo antegrade and retrograde inferior vena cava angiography. For patients with renal cell carcinoma with inferior vena cava tumor, the prognosis depends on the stage of the tumor, pathological grade, local lymph node invasion and distant metastasis, and whether the tumor thrombus is removed during operation, and there is no significant relationship between the length of the tumor and the tumor in the inferior vena cava. . Therefore, patients with renal cancer with inferior vena cava tumor thrombus can still be actively treated. The operation of the posterior hepatic and superior iliac vein thrombosis was performed by a chest-abdominal incision, and the chest was cut into a happy bag. The traditional surgical procedure is to temporarily block the inferior vena cava on the iliac crest. To overcome the excessive congestion of the portal venous return system, it is necessary to simultaneously block the hilar and superior mesenteric artery. However, the operation time can only be limited to 20 minutes, which is obviously not enough to complete complicated surgical operations, and is not suitable for right atrial cancer. Treating diseases: kidney cancer Indication The operation of the posterior hepatic and superior vena cava tumor thrombus is applicable to: Regardless of whether a distant metastasis occurs in a malignant renal tumor, radical nephrectomy should be considered unless the patient's condition does not allow it or is unwilling to bear the risk of surgery. If the distant metastasis is an isolated resectable lesion, the lesion can be removed simultaneously or in stages. If the distant metastases cannot be removed, or the adjacent organs cannot be completely removed, radical nephrectomy can be used as a palliative operation to alleviate local symptoms caused by the tumor, such as pain, bleeding, etc., or as a kind of comprehensive treatment such as biological therapy. Auxiliary treatment. Contraindications 1, advanced tumors have dyscrasia. 2, there is a serious bleeding tendency, blood disease. 3, there are serious heart, lung and other organ diseases can not tolerate surgery. 4. Extensive transfer of multiple organs. Preoperative preparation 1, the tumor volume is too large, or blood, preoperative renal artery embolization, so that the tumor shrinks for surgical removal, and can reduce intraoperative bleeding. 2, a large renal embryonic tumor before the operation of short-term (not more than 2 weeks) deep X-ray radiation therapy. 3, patients with vena cava tumors, MRI before surgery to determine the extent of tumor thrombus, if necessary, through esophageal ultrasound or vena cava angiography, to understand the upper and lower boundaries of the tumor thrombus and collateral circulation. 4, mitomycin 20mg for intraoperative soaking wounds. 5, leaving the stomach tube and catheter before surgery. 6, clean the enema before surgery. 7, preparing blood. 8. Prepare blood vessel suture instruments and blood vessel sutures. 9, the need for vena cava cancer plug removal, should be central venous cannulation. Surgical procedure At present, the use of deep hypothermia, cardiac arrest, cardiopulmonary bypass surgery. Free kidney, ligation and severing of renal artery ureter as described above, free tumor thrombus distal vena cava and contralateral renal vein, cut off the lumbar vein. Then, the chest doctor cuts the chest and cuts the happy bag, exposes the heart and the large blood vessels, and heparinizes the whole body. Ascending aorta and right atrium cannula, open cardiopulmonary shunt. The cardiac arrest is used to stop the heart from beating, and the temperature of the fluid in the ascending aorta is lowered to lower the core temperature of the body to 15-20 ° C, and 95% of the blood in the body is discharged into the extracorporeal circulation pump to stop the circulation in the body. At this time, the operation is performed in a substantially blood-free environment. The vena cava at the entrance of the renal vein is cut along the sleeve around the tumor. At the same time, the right atrium is opened, the tumor thrombus is removed, the kidney tumor is removed, and the vena cava lumen is carefully examined. No tumor thrombus remains, suture the vena cava and right atrial incision. After the thrombectomy is completed, the body cycle is restarted and gradually warms up, so that the core temperature of the body rises to 35 ° C, the cardiopulmonary bypass is terminated, the electric defibrillation is resumed, the heartbeat is restored, and heparin is neutralized with protamine sulfate. If the wall of the vena cava has a tumor thrombus infiltration, segmental vena cava resection or partial resection of the vena cava wall below the hepatic vein opening is feasible. Compared with traditional surgical methods, the advantages of this method are: 1 does not require extensive separation of the posterior hepatic or pericardial vena cava; 2 does not need to block the hilar and mesenteric artery; 3 intraoperative bleeding less, distal tumor thrombus shedding The risk of embolization is small; 4 stop circulation time can reach 40 ~ 60min; 5 can perform lobectomy and hepatectomy. complication 1. After the operation, the blood was often leaked due to small blood vessels, and the intraoperative blood pressure was low. Therefore, the operation should be carefully performed, and the cut small blood vessels should be carefully ligated, especially the distal end of the lumbar vein. Pay attention to the neovascularization of the tumor. 2, chyle ascites is generally leaked into the lymphatics of the chyle in the systemic lymph node dissection. 3, postoperative pneumonia and atelectasis due to long incision, the patient is caused by pain and restricted breathing. In addition to encouraging deep breathing after surgery, nebulization can be given. 4, incision infection and incision splitting occur in poor overall condition. Anemia and hypoproteinemia should be corrected before operation. When the peritoneal wound is soaked with mitomycin, the abdominal wall incision should be avoided and postoperative support treatment should be strengthened. Patients with concurrent chyluria and pancreatic leakage should be promptly explored for drainage and given high parenteral nutrition. 5, functional intestinal obstruction caused by colonic contact with the kidney fossa wound, generally can relieve themselves, if necessary, gastrointestinal decompression to intestinal peristalsis recovery. Patients with longer recovery time should be given intravenous high nutrition therapy. 6, renal failure after segmental vena cava resection, contralateral renal venous return disorder caused. Left renal failure can gradually recover with the establishment of collateral circulation, which can be temporarily treated by hemodialysis. Right renal failure may require timely reconstitution of renal venous return.

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