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北京大学学报（医学版） ›› 2024, Vol. 56 ›› Issue (4): 631-635. doi: 10.19723/j.issn.1671-167X.2024.04.014

• 论著 • 上一篇    下一篇

经食管超声心动图在肾切除术联合Mayo Ⅲ~Ⅳ级静脉瘤栓取栓术不同手术方式中的临床作用

杨捷1,冯杰莉1,*(),张树栋2,马潞林2,郑清3   

  1. 1. 北京大学第三医院心血管内科, 北京 100191
    2. 北京大学第三医院泌尿外科, 北京 100191
    3. 北京大学第三医院麻醉科, 北京 100191
  • 收稿日期:2024-03-13 出版日期:2024-08-18 发布日期:2024-07-23
  • 通讯作者: 冯杰莉 E-mail:jielifengtt@163.com
  • 基金资助:
    海淀创新转化专项科创研发项目(2022Y78475-06)

Clinical effects of transesophageal echocardiography in different surgical methods for nephrectomy combined with Mayo Ⅲ-Ⅳ vena tumor thrombectomy

Jie YANG1,Jieli FENG1,*(),Shudong ZHANG2,Lulin MA2,Qing ZHENG3   

  1. 1. Department of Cardiology, Peking University Third Hospital, Beijing 100191, China
    2. Department of Urology, Peking University Third Hospital, Beijing 100191, China
    3. Department of Anesthesiology, Peking University Third Hospital, Beijing 100191, China
  • Received:2024-03-13 Online:2024-08-18 Published:2024-07-23
  • Contact: Jieli FENG E-mail:jielifengtt@163.com
  • Supported by:
    the Haidian Innovation and Transformation Special Science and Technology Innovation Research and Development Program(2022Y78475-06)

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摘要：

目的: 比较经食管超声心动图(transesophageal echocardiography，TEE)在肾切除术联合下腔静脉Mayo Ⅲ~Ⅳ级瘤栓取栓术不同手术方式中的临床作用。方法: 纳入2022年1月至2024年2月在北京大学第三医院行根治性肾切除联合Mayo Ⅲ~Ⅳ级瘤栓取栓手术的患者28例，其中，机器人手术16例，腹腔镜手术2例，开腹手术10例，收集患者的各项临床资料进行分析比较。结果: 机器人手术的患者中有9例采用TEE，其中7例术中TEE影像结果较术前发生变化，包括2例术中TEE提示瘤栓进入右心房，2例显示下腔静脉瘤栓由Mayo Ⅲ级升至Ⅳ级，3例提示瘤栓与下腔静脉粘连，及时调整了手术方案；开腹手术的患者中有6例采用TEE，其中4例术中TEE提示Mayo分级较术前发生变化，包括3例提示瘤栓与下腔静脉粘连，1例提示瘤栓伴血栓形成，调整了手术方案，旷置或节段性切除瘤栓；腹腔镜手术的2例患者未采用术中TEE。术中采用TEE的作用包括开腹手术术中探查结合TEE监测瘤栓切除过程，机器人手术完全通过TEE监测瘤栓脱出，术中TEE还实时监测患者循环状态和心脏功能变化。结论: 肾切除术联合Mayo Ⅲ~Ⅳ级瘤栓取栓术的不同术式中，术中TEE均可再次确定瘤栓分级、粘连程度，并实时动态跟踪取栓过程，监测患者循环状态和心脏功能变化，具有重要的辅助作用，但其临床应用仍不足，建议这类手术均采用术中TEE。

关键词: 经食道超声心动图, Mayo Ⅲ~Ⅳ级瘤栓, 肾切除术, 血栓切除术

Abstract:

Objective: To analyze the clinical effects of intraoperative transesophageal echocardiography (TEE) in different surgical methods for nephrectomy combined with Mayo Ⅲ-Ⅳ inferior vena cave (IVC) tumor thrombectomy. Methods: In the study, 28 patients who did surgery of nephrectomy and Mayo Ⅲ-Ⅳ IVC thrombectomys in Peking University Third Hospital from 2022 January to 2024 February were included. Of the 28 patients, 16 patients did robotic surgery, 2 patients did laparoscopic surgery, and 10 patients did open surgery. All patients' clinical data were collected. Results: Intra-operative TEE was used in 9 robotic surgeries, of which 7 cases showed image changes compared with preoperative image results. Intraoperative TEE indicated that tumor thrombus entered the right atrium in 2 cases, showed that tumor thrombus grade rose from Mayo Ⅲ to Mayo Ⅳ in 2 cases, and indicated that tumor thrombus adhered to IVC wall in 3 cases. All of these surgical plans were timely adjusted. Intra-operative TEE was used in 6 cases of open surgery, and 4 cases of them showed Mayo grade changes compared with preoperative image results. Intraoperative TEE indicated that tumor thrombus adhered to the IVC wall in 3 cases, and tumor thrombus adhered to the IVC wall with thrombus in one case. The surgical plans were adjusted, and the tumor thrombus was left or segmentally removed. Laparoscopic surgery did not use intraoperative TEE. The effects of intraoperative TEE included: the combination of exploration and TEE monitoring was used in open surgery, and tumor thrombus removal process was fully monitored by intraoperative TEE in the robotic surgery. Intraoperative TEE real-time monitored circulatory status and cardiac function changes. Conclusion: In different surgical methods for nephrectomy combined with Mayo Ⅲ-Ⅳ tumor thrombectomy, intraoperative TEE can re-determine the tumor thrombus grade and degree of tumor thrombus adhered to IVC, track the tumor thrombus removal process in real-time, and monitor circulatory status and cardiac function changes. Intraoperative TEE plays an important role in different surgical methods, but its clinical application is still insufficient. Intraoperative TEE is recommended to such type of surgeries.

Key words: Transesophageal echocardiography, Mayo Ⅲ-Ⅵ tumor thrombus, Nephrectomy, Tumor thrombectomy

中图分类号: 

  • R737.11

表1

28例肾切除联合下腔静脉Mayo Ⅲ~Ⅳ级瘤栓取栓术患者的临床资料"

Items Robotic operation (n=16) Laparoscope urgery (n=2) Open surgery (n=10)
Age/years 58 (30-77) 71 (64-78) 57 (41-73)
Male 10 (62.5) 1 (50.0) 5 (50.0)
Left kidney removal 4 (25.0) 0 (0) 2 (20.0)
Time of surgery/min 249 (118-549) 219 (150-287) 350 (128-616)
Operative bleeding volume/mL 823 (50-3 000) 300 (200-400) 2 460 (400-12 000)
IVC obstrustion time/min 18 (7-28) 21 (19-23) 28 (12-50)
IVC tumor thrombus adhesion 7 (43.8) 0 (0) 6 (60.0)
IVC reconstruction method
  Incise and stitch 10 (62.5) 2 (100.0) 5 (50.0)
  Segmental resection 6 (37.5) 0 (0) 3 (30.0)
  Left/segmental removed 0 (0) 0 (0) 2 (20.0)
IVC tumor thrombectomy method
  Incise removal 10 (62.5) 2 (100.0) 5 (50.0)
  Foley draging 6 (37.5) 0 (0) 2 (20.0)
  Milking 0 (0) 0 (0) 1 (10.0)
Tumor thrombus falling off during operation 1 (6.3) 0 (0) 0 (0)
ARHF during operation 1 (6.3) 0 (0) 0 (0)
Mayo Ⅲ tumor thrombus 11 (68.8) 2 (100.0) 9 (90.0)
Mayo Ⅳ tumor thrombus 5 (31.2) 0 (0) 1 (10.0)
Intraoperative TEE 9 (56.3) 0 (0) 6 (60.0)
Intraoperative Mayo grade change by TEE diagnose 7 (43.8) 0 (0) 4 (40.0)

图1

术中TEE提示IVC瘤栓进入右心房"

图2

肾肿瘤及瘤栓"

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ISSN 1671-167X
CN 11-4691/R
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