JOURNAL OF NEW MEDICINE >

2021 , Vol. 52 >Issue 9: 666 - 671

DOI: https://doi.org/10.3969/j.issn.0253-9802.2021.09.005

Original Research

Application of segmental excision of inferior vena cava and/or external iliac vein without vascular reconstruction in complex surgeries for abdominal and pelvic tumors

  • Yuan Xiaoxu ,
  • Zhong Wenwen ,
  • Qu Hu ,
  • Ye Lei ,
  • Yao Bing ,
  • Ma Bo ,
  • Wang Dejuan ,
  • Qiu Jianguang
Expand
  • Department of Urology, Zhuhai People's Hospital （Zhuhai Hospital Affiliated to Jinan University）, Zhuhai 519000, China
Qiu Jianguang, E-mail:

Received date: 2021-05-28

  Online published: 2021-10-28

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Copyright reserved © 2021
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Abstract

Objective To summarize the experience of segmental excision of the inferior vena cava and/or external iliac vein without vascular reconstruction in complex surgeries for abdominal and pelvic tumors. Methods Clinical data of 11 patients undergoing complex surgeries for abdominal and pelvic tumors and segmental excision of the inferior vena cava and/or external iliac vein without vascular reconstruction were retrospectively analyzed. Results Among 11 cases, 3 patients developed postoperative metastases of colorectal cancer, 2 cases of renal pelvic cancer complicated with tumor thrombus and lymph node metastases, 1 case of renal pelvic cancer complicated with lymph node metastasis, 1 case of ureteral cancer complicated with lymph node metastasis, 1 case of abdominal implantation after surgery for renal pelvic cancer, 1 case of postoperative metastasis of cervical cancer, 1 case of retroperitoneal leiomyosarcoma and 1 case of bladder cancer. The surgeries involving blood vessels were performed including 5 cases of segmental resection of the inferior vena cava, 1 case of segmental resection of the right external iliac vein + segmental resection of the internal iliac artery and vein, 1 case of segmental resection of the right internal iliac artery and vein + segmental resection of the left external iliac vein, 1 case of segmental resection of the inferior vena cava + segmental resection of bilateral common iliac veins + prosthetic vessel bypass between the right common iliac artery and external iliac artery, 1 case of segmental resection of the inferior vena cava + segmental resection of the right external iliac artery and vein + prosthetic vessel replacement of the right external iliac artery and 2 cases of segmental resection of the external iliac vein, respectively. All patients successfully completed the surgeries. The median operation time was 570 （390 ~ 900） min. The median volume of intraoperative red blood cell infusion was 4 （2 ~ 15） units. The median volume of plasma transfusion was 600 （150 ~ 1800） ml. The median length of postoperative ICU stay was 0 （0 ~ 517） h. Postoperatively, venous embolism occurred in 5 cases. After conservative treatment, edema was gradually mitigated in 4 patients and international thrombolysis was delivered in 1 case. Conclusions For complex abdominal and pelvic tumors, such as tumor encasement, invasion or adhesion and of the inferior vena cava and external iliac vein, segmental resection of the involved major vein combined with ligation without vascular reconstruction can be considered. Although there is a risk of venous embolism of the lower limbs after surgery, it seldom causes severe adverse events.

Key words： Inferior vena cava; External iliac vein; Segmental resection of major vein; Complex abdominal and pelvic tumor

Cite this article

Yuan Xiaoxu , Zhong Wenwen , Qu Hu , Ye Lei , Yao Bing , Ma Bo , Wang Dejuan , Qiu Jianguang . Application of segmental excision of inferior vena cava and/or external iliac vein without vascular reconstruction in complex surgeries for abdominal and pelvic tumors[J]. JOURNAL OF NEW MEDICINE, 2021 , 52(9) : 666 -671 . DOI: 10.3969/j.issn.0253-9802.2021.09.005

随着医疗技术的发展,越来越多的中晚期肿瘤、复发转移肿瘤可采用手术治疗。中晚期肾盂癌、妇科肿瘤、肠道转移肿瘤常侵犯下腔静脉、髂内外动静脉,为达到根治性零级切除（R0切除）,外科医师不得不切除肿瘤侵犯的动静脉。髂内动静脉切除在临床较为常见,因一侧髂内动静脉的血供可以由另一侧髂内动静脉及体循环的血供代偿,所以切除髂内动静脉的安全性已得到外科医师的肯定。但切除下腔静脉、髂外静脉可导致下肢循环障碍及血栓,使得外科医师对于下腔静脉、髂外静脉节段性切除的实施较为担忧。我中心对11例涉及复杂腹盆腔肿瘤患者的下腔静脉和/或髂外静脉实施了节段性切除术,现总结经验如下。

对象与方法

一、研究对象

以2019年5月至2021年4月在中山大学附属第六医院泌尿外科接受手术并于术中节段性切除下腔静脉、髂外静脉且不重建血管的11例复杂腹盆腔肿瘤患者为研究对象。所有患者对手术知情同意,并签署知情同意书。本研究经中山大学附属第六医院医学伦理委员会批准。

二、研究方法

收集11例患者的临床资料,记录术中切除累及血管情况、手术时间、输血种类及量、术后病理检查结果、术后下肢血栓情况、下肢腿围等。回顾术前CT及MRI结果,分析血管受累情况及下肢侧支循环等。

三、手术方法

采用腹部正中+患侧横切口,进入腹盆腔后,按照层面外科的方法沿消化道与泌尿生殖系统之间的平面将结肠、小肠向前翻转,再沿血管平面将腹主动脉、下腔静脉及其分支、属支裸化,沿骨骼肌肉平面游离使其裸化,将肿瘤及所累及的肾脏、输尿管、肠管、血管切除[1]。下腔静脉、髂外静脉断端予以结扎或缝合,髂外动脉予以人工血管置换。动脉予以人工血管置换后,用彩色多普勒超声检查（彩超）证实下肢动脉血流通畅。吻合肠管、彻底止血后关腹。术前晚、术中离断大血管后、术后均给予那曲肝素钙抗凝,可进食后口服利伐沙班,终生予抗凝治疗（有1例未执行）。术后双下肢予以肢体气压治疗。术后监测下肢腿围、血清D-二聚体、下肢动静脉彩超。

结果

一、一般资料

11例患者一般资料见表1。
表1 11例腹盆腔复杂肿瘤患者一般资料
病 例 性别 年龄（岁） 身高（cm） 体质量（kg） ICU住院时间（h） 肿瘤情况
患者1 男 52 180 85 0 直肠癌术后转移
患者2 男 61 166 64 58 肾盂癌并癌栓、淋巴结转移
患者3 男 33 172 79 517 直肠癌术后转移
患者4 女 67 150 52 42 输尿管癌并淋巴结转移
患者5 女 44 156 56 108 宫颈癌术后转移
患者6 女 55 152 51 0 腹膜后平滑肌肉瘤
患者7 男 55 170 66 11 肾盂癌并淋巴结转移
患者8 女 52 157 48 0 肾盂癌术后种植
患者9 男 54 168 63 0 肾盂癌并癌栓、淋巴结转移
患者10 女 31 165 61 0 肠癌术后转移
患者11 男 65 168 55 0 膀胱癌

二、术中情况

术中血管切除、手术时间、输血等情况见表2,手术过程见图1及视频（扫描文末二维码即可观看）。
表2 11例腹盆腔复杂肿瘤患者术中血管切除、手术时间及输血情况
病 例 术中血管切除情况 手术时间（min） 输血种类及量
患者1 右侧髂外静脉节段性切除+右侧髂内动静脉节段性切除 570 4单位红细胞,150 ml血浆
患者2 下腔静脉节段性切除 900 4单位红细胞,1000 ml血浆
患者3 右侧髂内动静脉节段性切除+左侧髂外静脉节段性切除 780 30.5单位红细胞,5单位血小板,3600 ml血浆
患者4 下腔静脉节段性切除+双侧髂总静脉节段性切除+右侧
髂总动脉与髂外动脉人工血管搭桥术		 570 6单位红细胞,1800 ml血浆
患者5 下腔静脉节段性切除+右侧髂外动脉静脉节段性切除+
右侧髂外动脉人工血管置换		 750 9.5单位红细胞,600 ml血浆
患者6 下腔静脉节断性切除 420 2单位红细胞,200 ml血浆
患者7 下腔静脉节段性切除 420 2单位红细胞,600 ml血浆
患者8 右侧髂外静脉节段性切除 500 1.5单位红细胞
患者9 下腔静脉节段性切除 675 15单位红细胞,1200 ml血浆,10单位冷沉淀
患者10 下腔静脉节段性切除 390 无
患者11 左侧髂外静脉节段性切除 630 无
图1 下腔静脉节段性切除手术过程

A：游离髂外静脉下缘;B：建立髂外动静脉之间平面;C：结扎并离断脐内侧韧带;D：游离远端髂外静脉下缘;E：结扎髂外静脉远端;F：结扎髂外静脉近端;G、H：节段性切除下腔静脉

表3 11例腹盆腔复杂肿瘤患者下肢血栓及血管评估相关情况
病 例 下肢血栓情况 术前CT/MRI了解血管情况 下肢侧支循环
患者1 术后右侧髂外静脉远心段、股总静脉、股静脉近段、股深静脉近段、小腿肌间静脉血栓 肿瘤压迫、粘连右髂内、外动静脉 可能未建立
患者2 双下肢静脉血流通畅,未见血栓 肿瘤包绕、压迫下腔静脉 可能已建立
患者3 术后下肢静脉急性血栓形成（右侧肌间静脉、左侧股总静脉、左侧腘静脉、左侧胫后静脉其中1支、左侧腓静脉完全闭塞,左侧股静脉不完全闭塞） 肿瘤侵犯左髂外静脉可能 可能未建立
患者4 术后第3日彩超未见血栓。术后第4周经彩超发现血栓：右侧股总静脉血栓形成（不完全闭塞） 肿瘤包绕、压迫右髂外静脉 可能已建立
患者5 术后右下肢大隐静脉血栓后改变（部分再通）, 术前已有血栓 肿瘤包绕下腔静脉、右髂外动静脉 可能已建立
患者6 出院后未继续服用抗凝药物,术后1月余因下肢水肿发现下肢静脉血栓（髂静脉远心端及股总静脉、股深静脉、胫前、胫后静脉及部分肌间静脉闭塞）,水肿难以消退、予以介入溶栓治疗 肿瘤包绕并累及下腔静脉 可能已建立
患者7 双侧下肢静脉血流缓慢,未见血栓 局段性压迫下腔静脉 可能未建立
患者8 双下肢静脉血流通畅,未见血栓 肿瘤局部压迫、粘连右髂外静脉 可能未建立
患者9 双下肢静脉血流通畅,未见血栓 癌栓几乎完全堵塞下腔静脉 可能已建立
患者10 双下肢静脉血流通畅,未见血栓 肿瘤包绕下腔静脉 可能已建立
患者11 左侧下肢静脉急性血栓形成（左髂外静脉至左侧股总静脉静脉完全闭塞） 肿瘤压迫、粘连左髂外静脉 可能未建立

三、术后下肢血栓及血管评估相关情况

5例患者术前CT/MRI显示下腔或髂外静脉被肿物包绕或压迫严重,侧支循环可能已经建立,但仍有2例出现下肢静脉血栓,其中1例可能为出院后未继续服用抗凝药物所致,由于下肢水肿严重,予以介入溶栓治疗,另1例予保守治疗后水肿逐渐消退。
6例患者术前CT/MRI显示肿物轻微压迫或粘连下腔或髂外静脉,侧支循环可能未建立。其中仅3例发生下肢静脉血栓,予以保守治疗后水肿逐渐消退。

讨论

对肿瘤受累器官积极进行多脏器切除是必要的,以便实现完整根治性根除、阴性切缘,从而获得最大的治愈机会[2]。主要的血管结构如下腔静脉、髂外静脉受累会使手术更具挑战性[3]。虽然累及血管的肿瘤切除增加了手术的复杂性,但是有研究显示同时切除恶性肿瘤和受累大血管的患者生存率与无切除受累血管者类似,手术切除实现阴性切缘可使部分恶性肿瘤患者长期生存[3]。在不切除邻近受累脏器（包括下腔静脉）的情况下很难达到R0切除[4,5]。对于泌尿外科医师来说,需要联合切除下腔静脉或髂外静脉的手术主要见于肾癌癌栓侵犯静脉壁,肾盂、输尿管癌侵犯大血管,腹膜后肉瘤侵犯大血管,盆腔尿漏或粪漏导致复杂脓肿等情况。
主干静脉切除后重建的方法中人工血管置换最常见,约占10% ~ 80%,缝合修复约占12% ~ 33%,补片修补约占5% ~ 27%,切除后单纯结扎不重建约占10% ~ 52%[6,7,8,9,10,11]。下腔静脉切除后血管的处理方式存在争议,有学者主张单纯结扎即可[12,13]。在慢性下腔静脉梗阻的情况下,体内可能已形成大量侧支循环,因此下腔静脉切除后单纯结扎的患者术后恢复情况良好[13]。Daylami等[13]报道,在下腔静脉切除并结扎的患者中,50%发生四肢水肿,50%发生急性肾衰竭,肾衰竭可自行缓解,因此认为这些并发症常见,而且结扎下腔静脉后患者对下肢水肿的耐受性良好。在本组患者中约一半出现血栓、下肢水肿,但仅1例较严重需予以介入溶栓治疗,因此我们也认为下腔静脉或者髂外静脉切除后单纯结扎而不重建是可行的。
有学者认为下腔静脉切除后需要选择性或常规重建[7, 14]。但是目前的人工血管支架置换仍有较多缺点：例如延长手术时间,需血管外科医师协助,增加费用支出,还会存在发生人工血管血栓的风险,尤其是恶性肿瘤相关的有血栓倾向的患者。考虑到支架感染和肠漏的风险,当恶性肿瘤侵犯肠道需要切除肠管时,血管支架污染的风险增高,在这类患者中应尽量避免进行血管重建手术。在本中心也曾见术区感染导致血管腐蚀、大出血的病例,因此,我们更倾向选择单纯血管切除且不重建的策略以减少相关并发症。
髂外静脉切除或结扎后,股静脉的血液可经过多条属支回流,比如经腹壁下静脉回流至腹壁上静脉,经旋髂深静脉、髂腰静脉回流至腰升静脉,经耻静脉、闭孔静脉回流至髂内静脉,经大隐静脉、旋股内侧静脉、臀上静脉、臀下静脉回流至髂内静脉。因此一些血管修复手术常切取髂外静脉作为修补的材料,且无明显并发症[15]。可见髂外静脉的离断或结扎是安全的,大可不必担心由此引发严重并发症。
综上所述,对于复杂腹盆腔肿瘤,如肿瘤包绕、侵犯或粘连下腔静脉、髂外静脉,可考虑节段性切除受累主干静脉,单纯结扎且不予重建。本组的结果显示,虽然术后有发生下肢静脉血栓的风险,但因此而导致的严重不良后果并不常见。

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