Objective. To propose and introduce a diagnostic-treatment algorithm for the inferior vena cava (IVC) leiomyosarcoma into clinical practice. Materials and methods. During last 30 years in Zakarpattya Regional Clinical Hospital Named After Andriy Novak and Zakarpattya Antitumoral Centre were operated 8 patients, suffering the IVC leiomyosarcoma - 7 (87.5%) women and 1 (12.5%) man. Median of the patients' age have constituted 57 yrs old. For characterization of the affection localization in accordance to own views on the subject the classification of the IVC division into 7 segments was applied: infrarenal, іnterrenal, suprarenal, retrohepatic, іnfradiaphragmatic, supradiaphragmatic,іntracardial. Іntravasal localization of the tumor was observed in 3 (37.5%), extravasal - in 1 (12.5%), mixed - in 4 (50%) patients. In all the patients the open laparotomy approach was applied: in 1 (12.5%) patient median laparotomy was performed, and in 7 (87.5%) - bilateral subcostal laparotomy of a «Chevron» type. For the IVC alloprosthesis in 6 (75%) patients a politetrafluoroethylene prosthesis was applied, while in 2 (25%) - Gore-tex prosthesis of 18-22 mm in diameter. In 5 (62.5%) patients circular resection with the IVC alloprosthesis was done, in 2 (25%) - circular resection, the IVC alloprosthesis and іmplantation of right and left renal veins into the prosthesis, and in 1 (12.5%) - circular resection, alloprosthesis of IVC and implantation of left renal vein into prosthesis. Results. The operation median duration have constituted 215 (160 - 320) min, while the average volume of the blood loss - 305 (250 - 500) ml. The Degree II postoperative complications in accordance to classification of Clavien-Dindo were registered in 2 (25%) patients. Pulmonary thromboembolism, venous thrombosis, thrombosis of prosthesis, as well as intraoperative or immediate postoperative lethality were not observed. In 7 (87.5%) patients a radical intervention was performed. In 3 (37.5%) patients a remote hepatic and pulmonary metastases have been developed, leading to their death in terms from 10 to 34 mo. General one-, two- and a three-ear survival have constituted 87.5, 75 and 62.5%, accordingly. Conclusion. Surgical approach of a «Chevron» type and the staged dissection of IVC guarantees an adequate visualization of its іnfra-, іnter- and suprarenal segments. The «piggyback» procedure of hepatic mobilization and Pringle maneuver constitute necessary parts on the stage of dissection in retrohepatic, infradiaphragmatic and supradiaphragmatic segments of IVC. Radical tumoral excision with the IVC prosthesis and implantation, when needed, of renal or hepatic veins - is the only one possibility for improvement of the patients' quality of life in the IVC leiomyosarcoma.
Objective. To determine the volume of surgical intervention on vena cava inferior in renal cancer, complicated by invasion of tumoral thrombus into the vein wall. Materials and methods. Into the investigation were included 147 patients, suffering renal cancer, complicated by tumoral venous thrombosis, who were treated surgically in the Zakarpattya Regional Clinical Hospital named after Andriy Novak or in the Zakarpattya Antitumoral Centre in 2005 - 2020 yrs. The patients’ age varied from 27 to 79 yrs old, their average age have constituted 58 yrs old. There were 97 (66%) men and 50 (34%) women. The null level of venous spread of tumoral thrombus was diagnosed in 55 (37.4%), І – in 32 (21.8%), ІІ – in 30 (20.4%), ІІІ – in 22 (15.0%), and IV - in 8 (5.4%) patients. The tumor was localized in right kidney in 51 (34.7%) patients. Surgical treatment in all the patients was performed - nephrectomy and various interventions on the vein. Longitudinal resection of the vein was performed in 55 (37.4%), resection with suturing of alloflap - in 5 (3.4%), circular resection with prosthesis “end-to-end” - in 4 (2.7%) patients. In the tumoral thrombus localization, including a renal vein, the uxtaosteum resection was performed in 100% of the patients. Results. Average duration of the operation was 165 (102 - 292) min, average volume of the blood loss - 780 (240 - 2250) ml. Mild and moderate postoperative complications in accordance to classification of Clavien-Dindo (Degree I - II) was registered in 38 (21.8%), and the severe (Degree ІІІ - V) - in 6 (4.1%) patients. Surgical complications of Degree III or complications, which demanded urgent relaparotomy, were not observed. In early postoperative period 1 patient died. General postoperative lethality have constituted 0.7%. In all the patients a laminar blood flow was preserved. In no one patient the prosthesis thrombosis, recurrence of the prosthesis thrombus, recurrence of tumoral venous thrombus or pulmonary thromboembolism. Conclusion. Radical method of surgical treatment of renal cancer, complicated by tumoral thrombosis of vena cava inferior, must include nephrectomy, cavatomy, thrombectomy, various variants of resection and prosthesis of the vein. In the null level of the tumoral thrombus venous spread the performance of uxtaosteum resection of renal vein is obligatory.
Введение. На сегодняшний день, несмотря на наличие огромного арсенала иммунохимиотерапевтических средств и современных источников радиационного облучения, основным методом лечения локализованных и местнораспространенных форм рака почки остается хирургический. Хирургическое лечение неосложненных форм рака почки практически решенная проблема и не вызывает сомнений, но при раке почки с имплантационным тромбом системы нижней полой вены (НПВ) возникает целый ряд вопросов, которые нуждаются в решении. Цель. Предложить и внедрить в клиническую практику тактические приемы и очередность хирургических манипуляций при опухоли левой почки с имплантационными тромбами супраренальной части НПВ.Материалы и методы. В исследование включено 144 пациента с раком почки, осложненным опухолевым тромбозом НПВ. Все пациенты находились на лечении в Закарпатской областной клинической больнице им. А. Новака в период с 2005 по 2019 г. Возраст пациентов варьировал от 27 до 79 лет, средний – 58,4 года. Мужчин было 95 (66%), женщин – 49 (34%). Уровень распространения опухолевого тромба по НПВ определяли согласно классификации клиники Мэйо. Поражение левой почки опухолью имело место у 49 (34%) пациентов, из которых у 16 (32,7%) пациентов был 0 уровень тромба, у 17 (34,7%) – I уровень, у 10 (20,4%) – II уровень, у 4 (8,2%) – III уровень и у 2 (4,1%) – IV уровень. Все пациенты прооперированы из трансабдоминального доступа по типу «шеврон» или «мерседес» с применением техники мобилизации органов en block в правых и левых отделах брюшной полости и забрюшинного пространства. При III и IV уровнях опухолевого тромба во время каватромбэктомии использовали методику piggyback мобилизации печени, маневр liver-hanging и прием Pringle. При IV уровне опухолевого тромба выполняли полуовальную или Т-образную диафрагмотомию в сухожильном центре диафрагмы над НПВ.Результаты. Ни в одном случае при раке левой почки с имплантационными тромбами НПВ мы не зафиксировали эпизодов периоперационной тромбоэмболии легочной артерии или послеоперационной летальности.Заключение. Предложенная этапность трансабдоминальной хирургической тактики при удалении опухолевых тромбов II–IV уровней с первоначальной каватромбэктомией и восстановлением кровотока по НПВ предопределяет успех и радикальность лечения пациентов при опухоли левой почки с имплантационными тромбами супраренальной части НПВ. Introduction. Today, despite the presence of a great arsenal of immunochemotherapeutic agents and modern sources of radiation exposure, the main method of treating localized and locally advanced forms of renal cancer is surgical. Surgical treatment of uncomplicated forms of renal cancer is practically a solved problem and is beyond doubt, but in renal cancer with an implantation thrombus of the inferior vena cava (IVC) system, a number of questions arise that need to be resolved. Purpose. To propose and introduce into clinical practice the tactical techniques and the sequence of surgical procedures for a tumor of the left kidney with implantation thrombi of the suprarenal IVC.Materials and methods. The study included 144 patients with RC complicated by IVC tumor thrombosis. All patients were treated at the Transcarpathian Regional Clinical Hospital named afterA. Novak in the period from 2005 to 2019. The age of the patients varied from 27 to 79 years, the average age was 58.4 years. There were 95 men (66%) and 49 women (34%). The level of extension of tumor thrombus by IVC was determined according to the classification of the Mayo clinic. The lesion of the left kidney with a tumor took place in 49 (34%) patients, of which 16 (32.7%) patients had 0 level thrombus, 17 (34.7%) – I level, 10 (20.4%) – II level, 4 (8.2%) – III level, and 2 (4.1%) – IV level. All patients underwent surgery with the “chevron” or “mercedes” transabdominal approach using the “en block” organ mobilization technique in the right and left abdominal and retroperitoneal regions. At the levels III and IV of the tumor thrombus during cavatrombectomy, the piggyback technique of liver mobilization, the liver-hanging maneuver, and Pringle were used. For the level IV tumor thrombus, the semi-oval or T-shaped diaphragmotomy was performed in the tendon center of the diaphragm above the IVC.Results. There were no cases of left renal cancer with implantable IVC thrombi with the episodes of perioperative pulmonary embolism or postoperative mortality.Conclusion. The proposed staging of transabdominal surgical tactics for the removal of the level II–IV tumor thrombi with initial cavathrombectomy and restoration of blood flow through the IVC predetermines the success and radicalism of treatment in patients with the left kidney tumors with implantation thrombi of the suprarenal IVC.
Введение. На сегодняшний день единственным радикальным методом лечения рака почки (РП), осложненного опухолевым тромбом нижней полой вены (НПВ), считается хирургический. Применение агрессивной хирургии, которая предусматривает выполнение радикальной нефрэктомии и тромбэктомии с НПВ, приводит к возникновению целого ряда осложнений, предотвратить которые можно путем совершенствования хирургической техники.Цель. Улучшить результаты хирургического лечения рака левой почки, осложненного имплантационным тромбом НПВ, путем разработки дифференцированного подхода к выполнению доступа и этапности хирургических манипуляций.Материалы и методы. В исследование включено 144 пациента с РП, осложненным опухолевым тромбозом НПВ. Все пациенты находились на лечении в Закарпатской областной клинической больнице им. А. Новака в период с 2005 по 2019 г. Возраст пациентов варьировал от 27 до 79 лет, средний составил 58,4 года. Мужчин было 95 (66%), женщин – 49 (34%). Уровень распространения опухолевого тромба по НПВ определяли согласно классификации клиники Мэйо. Поражение левой почки опухолью имело место у 49 (34%) пациентов, из которых у 16 (32,7%) пациентов был 0 уровень тромба, у 17 (34,7%) – I уровень, у 10 (20,4%) – II уровень, у 4 (8,2%) – III уровень и у 2 – IV уровень. Все пациенты прооперированы из трансабдоминального доступа по типу «шеврон» или «мерседес» с применением техники мобилизации органов «en block» в правых и левых отделах брюшной полости и забрюшинного пространства.Результаты. Использование представленной этапности при хирургическом лечении опухолей левой почки с имплантационным тромбом НПВ позволило во всех случаях выполнить радикальное вмешательство: каватромбэктомию и нефрэктомию, без возникновения эпизодов тромбоэмболии легочной артерии, без значимых кровотечений и без повторных тромбозов. Заключение. Трансабдоминальный доступ по типу «шеврон» или «мерседес» с применением техники мобилизации органов «en block» в правых и левых отделах брюшной полости и забрюшинного пространства, полный контроль над НПВ обеспечивают успешное радикальное хирургическое лечение пациентов с опухолью левой почки и имплантационным венозным тромбом. Introduction. Today, the only radical treatment for renal cancer (RC) complicated by a tumor thrombus of the inferior vena cava (IVC) is the surgical one. The use of aggressive surgery, which involves implementation of radical nephrectomy and thrombectomy with IVC, leads to a number of complications that can be prevented by improving the surgical techniques.Purpose. To improve the results of surgical treatment of the left renal cancer complicated by implantation thrombus of IVC by developing a differentiated approach to the access and stages of surgical procedures.Materials and methods. The study included 144 patients with RC complicated by IVC tumor thrombosis. All patients were treated at the Transcarpathian Regional Clinical Hospital named after A. Novak in the period from 2005 to 2019. The age of the patients varied from 27 to 79 years, the average age was 58.4 years. There were 95 men (66%) and 49 women (34%). The level of dissemination of tumor thrombus on IVC was determined according to the classification of the Mayo clinic. The lesion of the left kidney with a tumor took place in 49 (34%) patients, of which 16 (32.7%) patients had 0 level thrombus, 17 (34.7%) – level I, 10 (20.4%) – level II, in 4 (8.2%) – level III, and in 2 – level IV. All patients underwent surgery with a “chevron” or “mercedes” transabdominal approach using the “en block” organ mobilization technique in the right and left abdominal and retroperitoneal regions.Results. The use of the presented stages in the surgical treatment of the left kidney tumors with implantation IVC thrombus let to perform radical intervention in all cases: cavathrombectomy and nephrectomy, without episodes of pulmonary embolism, significant bleeding, and repeated thrombosis.Conclusion. Transabdominal “chevron” or “mercedes” access with the use of the “en block” organ mobilization technique in the right and left parts of the abdominal cavity and retroperitoneal space, full control over the IVC ensure successful radical surgical treatment of patients with the left kidney tumor and implantation venous thrombus.
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