RU2759129C1 - Method for prevention of postoperative pulmonary thromboembolism in case of tumor thrombosis of the inferior vena cava - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely surgery and oncology, and can be used for the prevention of postoperative pulmonary tromboembolism in the surgical treatment of patients with kidney cancer complicated by tumor thrombosis of the inferior vena cava (VCI). A median laparotomy is performed, the duodenum is mobilized by Kocher and displaced medially. The mobilization of the kidney with a tumor is performed. The renal artery is isolated and ligated. There are suprarenal, renal and infrarenal sections of the inferior vena cava, renal venous entries. During the revision, the height of the tip of the tumor thrombus is determined. Blood flow through the inferior vena cava is stopped. Unfractionated heparin is injected, 5000 units. After that, vascular clamps are applied above the level of the thrombus, to the contralateral renal vein and the infrarenal part of the inferior vena cava. Longitudinal venotomy of the inferior vena cava is performed in the suprarenal region. Thrombectomy of a tumor thrombus is performed. The kidney with a tumor thrombus and a renal vein is removed. Antegrade and retrograde blood flow is monitored. A venotonic incision is sutured with a 4/0 winding suture, the inferior vena cava is stitched 1 cm below the renal veins with transversely U-shaped sutures at a distance of 1 cm. Blood flow is restored, hemostasis is carried out. The wound is sutured tightly in layers.

EFFECT: extension of the range of methods for prevention of postoperative pulmonary thromboembolism.

1 cl, 2 dwg, 1 ex

Description

The invention relates to medicine, namely to surgery, oncology, and can be used for the prevention of postoperative thromboembolism of the pulmonary arteries in the surgical treatment of patients with kidney cancer complicated by tumor thrombosis of the inferior vena cava (IVC) (T3b-4Nx-1Mx-1).

About 210,000 new cases of malignant neoplasms (MNO) of the kidney are detected annually in the world. In the structure of the incidence of cancer in Russia in 2018, kidney tumors accounted for about 4% (13,500 cases). The Southern Federal District accounts for more than 2500 cases. In 35-40% of newly diagnosed cases of kidney malignant neoplasm, a locally advanced stage or the presence of distant metastases is diagnosed (see State of cancer care for the population of Russia in 2019. Kaprin A.D., Starisky V.V., Shazadova A.O.).

During surgical interventions in this group of patients, there is a high risk of pulmonary embolism (PE), which is associated with many factors:

1) the presence of a tumor thrombus in the lumen of the IVC leads to impaired blood flow or obstruction of the lumen;

2) compression of the IVC by enlarged paraaortic, paracaval lymph nodes;

3) the presence of a hypercoagulable state in cancer patients with a locally advanced stage or the presence of distant metastases.

Extravasal compression of the IVC and the presence of a tumor thrombus in the lumen due to impaired blood flow causes the occurrence of venous hypertension distal and promotes the formation of venous thrombosis.

The need for the use of anticoagulant prophylaxis in cancer patients, at present, is beyond doubt. However, in this category of patients, the early postoperative period is accompanied by a high risk of hemorrhagic complications, which leads to a delay in the onset of anticoagulant prophylaxis.

Therefore, anticoagulant prophylaxis of PE is possible only after a preliminary assessment of the state of the hemostasis system, the severity of the patient's condition, the volume of the operation, control of renal function, under constant dynamic observation.

In a study by Park H. et al. it was shown that the presence of a tumor thrombus 8 times increases the risk of postoperative PE in patients with renal cell carcinoma of the kidney compared with similar patients without a tumor thrombus. The increased risk of venous thrombosis persists not only in the postoperative period, but also in the long term. (see Park H. et al., Influence of Tumor Thrombus on Occurrence of Distant Venous Thromboembolism and Survival in Patients With Renal Cell Carcinoma After Surgery. Clin Appl Thromb Hemost. Jan-Dec 2019; 25.doi: 10.1177 / 1076029618823288). Similar results are presented in a Canadian study (see Yokom DW, Ihaddadene R, Moretto P, Canil CM, Reaume N, Le Gal G, Carrier M. Increased risk of preoperative venous thromboembolism in patients with renal cell carcinoma and tumor thrombus. J Thromb Haemost 2014; 12: 169–71. Doi: 10.1111 / jth.12459).

All of the above indicates the need to develop additional methods for preventing the development of PE in patients with renal cancer and IVC tumor thrombosis.

To date, various ways of solving this problem have been proposed.

The least invasive method of preventing pulmonary embolism is endovascular, which consists in implanting a cava filter distal to the orifices of the renal veins under X-ray control (see patent for invention RU 2040278 C1, publ. 25.07.1995). However, the installation of a cava filter in the surgical area and the IVC suture has a high risk of injury and rupture of the vein wall. The operation requires the introduction of a contrast agent, which can lead to the development of acute renal failure with a single-stage nephrectomy. The presence of a foreign body in the lumen of the vessel can be a source of thrombosis and thromboembolism.

There is a possibility of migration of the cava filter proximal with the development of various complications. The implantation of a cava filter also requires specially equipped X-ray operating rooms, specialists in X-ray surgeons, and expensive instrumentation.

Also, the known "Method of surgical treatment of patients with thrombosis, with lesions of veins in the ileocaval and femoral segments, using a device for removing blood clots and foreign bodies from vessels and hollow organs - a thromboextractor (TREX)" (see patent for invention RU 2716510 C1 , publ. 03/12/2020. Bul. No. 8), which consists in the introduction of a thromboextractor through the internal jugular vein into the lumen of the IVC, performing venotomy of the common femoral vein, thrombectomy through the femoral access. The main disadvantages of this approach are:

- high risk of acute renal failure associated with the use of contrast media in nephrectomy conditions;

- high risk of trauma to the IVC suture zone after removal of a tumor thrombus during a thromboextractor;

- additional access at the hip.

This method can be used to prevent PE only with thrombosis of one limb.

The invention "A device for removing blood clots and foreign bodies from vessels and hollow organs" (see patent for invention RU No. 2152757 C1, publ. 20.07.2000. Bulletin No. 20) has similar disadvantages: the need to use contrast, trauma to the IVC in the area operations.

The method of plication of the inferior vena cava from the laparotomic (see Phlebology: A guide for physicians. V.S.Saveliev. - M .: Medicine, 2001, p. 236-237) or retroperitoneal access (see patent RU 2189786 C1, publ. 27.02 .2002. Bull. No. 27) with the use of manual or mechanical suture can reduce the number of postoperative thrombosis of the inferior vena cava and pulmonary embolism. These methods are less expensive compared to endovascular, have better long-term results (patency of the plication zone compared to the patency of the cava filter). However, IVC plication is not performed preventively, but only when venous thrombosis develops in the IVC system, which accordingly requires repeated surgery.

The known method of regional thrombolysis, which consists in administering a thrombolytic agent through a catheter directly to thrombomass (see EP Kokhan, IK Zavarzin "Selected lectures on angiology". Second edition, revised and supplemented. Moscow, Nauka, 2006, ISBN 5 -02-033969-5, p. 273).

Nevertheless, the use of thrombolytics is absolutely contraindicated in the first 10 days of the postoperative period, therefore, this method cannot be used in patients with kidney cancer in the postoperative period.

Foreign oncologists suggest IVC ligation during thrombectomy from the latter (see R. Ayyathurai et al., Bland thrombus association with tumor thrombus in renal cell carcinoma: analysis of surgical significance and role of inferior vena caval interruption.BJU International; Volume 110, Issue 11b ; p. E 449-E455. https://doi.org/10.1111/j.1464-410X.2012.11128.x) (see Blute ML, Boorjian SA, Leibovich BC, Lohse CM, Frank I., Karnes RJ Results of inferior vena caval interruption by greenfield filter, ligation or resection during radical nephrectomy and tumor thrombectomy. J. Urol. 2007; 178: 440-5).

However, IVC ligation is possible only with chronic IVC obstruction and the presence of well-developed collaterals preserved after nephrectomy and lymphadenectomy. Otherwise, IVC ligation is fraught with serious complications.

IVC plication is a well-known and long-used method of surgical prevention of PE in acute embolic venous thrombosis in the IVC system (see Russian clinical guidelines for the diagnosis, treatment and prevention of venous thromboembolic complications, 2015. Phlebology, vol. 9, issue 2, no. 4 , 2015).

The difference between our proposed method lies in the fact that during subsequent treatment (postoperative period and chemotherapeutic treatment), the implementation of preventive IVC plication will allow patients to avoid the threat of PE in the event of venous thrombosis in the IVC system, additional surgical treatment of VTEC in the postoperative period for urgent indications (installation of kava filters, thrombectomy, IVC plication), will provide time for assessing the hemostasis system and selecting an adequate dose of anticoagulants.

The objective of the present invention is to improve the results of surgical treatment of patients with renal cancer and IVC tumor thrombosis due to surgical prevention of pulmonary embolism.

The technical result of the invention is the development of a method to prevent the development of venous thrombosis, which will subsequently improve the results of treatment of patients with locally advanced renal cancer.

The technical result is achieved by performing a median laparotomy, the duodenum is mobilized according to Kocher and displaced medially, the kidney with a tumor is mobilized, the renal artery is isolated and ligated, the suprarenal, renal and infrarenal sections of the inferior vena cava, the renal vein orifice are determined, when apex of a tumor thrombus; stop blood flow through the inferior vena cava, inject unfractionated heparin 5000 U, then apply vascular clamps above the thrombus level, on the contralateral renal vein and infrarenal inferior vena cava, perform a longitudinal venotomy of the inferior vena cava in the suprarenal section, perform thrombectomy, remove the neoplastic thrombus with a tumor thrombus and a renal vein, antegrade and retrograde blood flow is monitored, the venotomy incision is sutured with a 4/0 twist suture, the inferior vena cava 1 cm below the renal veins is sutured transversely with U-shaped sutures at a distance of 1 cm, blood flow is restored, hemostasis is performed, the wound is sutured tightly in layers.

Consequently, performing reventive plication of IVC after thrombectomy of a tumor thrombus and nephrectomy in patients with renal malignant neoplasm can reduce the incidence of pulmonary embolism, avoid repeated surgical interventions, and is not costly in terms of both time and surgical trauma.

The novelty of the invention lies in the fact that all patients with locally advanced malignant neoplasm of the kidney during the main surgical intervention simultaneously perform IVC plication, regardless of the available data on the presence or absence of venous thrombosis in its system, by imposing U-shaped sutures 1 cm below the confluence renal veins.

The main advantages of this method are:

1) decrease in the frequency of PE in the postoperative and long-term period;

2) a decrease in the frequency of repeated surgical interventions in the development of venous thrombosis in the IVC system;

3) there is no likelihood of trauma to the IVC suture after thrombectomy of a tumor thrombus;

4) no need to use a contrast agent;

5) low cost of performing IVC plication;

6) does not significantly lengthen the operation time (takes no more than 10 minutes) and does not increase the surgical trauma.

The method is illustrated by the figures.

Figure 1 shows a CT scan of the abdominal cavity, in which a thrombus is visualized in the lumen of the common iliac veins, the right renal vein, IVC 3 cm cranial to the right renal vein.

Figure 2 shows the performance of the operation: right nephrectomy, IVC thrombectomy, IVC plication.

The method is performed as follows.

A median laparotomy is performed; the duodenum is mobilized according to Kocher and displaced medially. A kidney with a tumor is mobilized. The renal artery is isolated and ligated. Allocate the suprarenal, renal and infrarenal parts of the inferior vena cava, the mouth of the renal veins.

During the revision, the height of the apex of the tumor thrombus is determined. Before stopping the blood flow through the IVC, unfractionated heparin 5000 U is injected intravenously, then vascular clamps are applied above the thrombus level, on the contralateral renal vein and infrarenal IVC. A longitudinal IVC venotomy is performed in the suprarenal section, a tumor thrombus is thrombectomy, and the drug is removed (a kidney with a tumor thrombus and a renal vein).

Antegrade and retrograde blood flow is monitored. The venotomy incision is sutured with a 4/0 twist suture. The inferior vena cava 1 cm lower under the renal veins is stitched transversely with U-shaped sutures at a distance of 1 cm. Blood flow is restored. Hemostasis. The wound is sutured tightly in layers.

We give a clinical example of the application of the method.

Patient S., 57 years old, was admitted to the hospital with a diagnosis of cancer of the right kidney pT3bN1M1 (metastatic lesion of the adrenal glands from 2 sides, intrathoracic lymph nodes. According to CT of the abdominal cavity in the lumen of the common iliac veins, the right renal vein, IVC at 3 cm a thrombus is cranial to the right renal vein (see Fig. 1).

The operation was performed: nephrectomy on the right, thrombectomy from the IVC, plication of the IVC (see Fig. 2). The duration of the vascular stage was 14 minutes.

On the 3rd day of the postoperative period, the patient developed phlebothrombosis of the left lower extremity with flotation of the thrombus tip 10 cm.

Considering the performed preventive IVC plication, the patient was treated conservatively. Due to the high hemorrhagic risk, a reduced dose of anticoagulants (Fraxiparin 0.4 mg 2 times a day) was prescribed, followed by an increase in the dose to the therapeutic dose (0.8 mg 2 times a day) with a decrease in the risk of bleeding.

The patient was discharged from the clinic in satisfactory condition on the 16th day after the operation. After the operation, the patient was repeatedly examined. 6 months after the surgical stage of treatment, the patient's condition is satisfactory, no data for the progression of the disease have been identified.

According to the ultrasound examination, the patency of the IVC plication zone was preserved, no signs of chronic venous insufficiency of the lower extremities were revealed.

In total, 6 people were operated on in the clinic. All patients had surgery without complications. Postoperative PE was not observed in any patient. Ultrasound examination of the IVC system in the late postoperative period revealed phlebothrombosis of the lower extremities in 4 patients. The episode of venous thrombosis was arrested conservatively, taking into account the previously performed IVC plication.

Thus, the use of the proposed method reduces the risk of PE in the postoperative period.

The developed method makes it possible to significantly improve the immediate and long-term results of treatment of patients with renal cancer and IVC tumor thrombus.

The technical and economic efficiency of the method lies in the fact that the preventive plication of IVC after thrombectomy of a tumor thrombus and nephrectomy in case of kidney malignant nephrectomy allows, without special material costs, to reduce the frequency of PE and to avoid repeated surgical interventions in the postoperative period.

The introduction of the proposed method of surgical prevention of PE in patients with kidney cancer will significantly reduce the frequency of postoperative PE and the cost of treatment.

Claims (1)

A method for the prevention of postoperative pulmonary embolism in tumor thrombosis of the inferior vena cava, which consists in performing a median laparotomy, the duodenum is mobilized according to Kocher and displaced medially, the kidney with the tumor is mobilized, the renal artery is isolated and ligated, the inferior renal renal is isolated and ligated. the inferior vena cava, the mouth of the renal veins, during the revision, the height of the apex of the tumor thrombus is determined; stop blood flow through the inferior vena cava, inject unfractionated heparin 5000 U, then apply vascular clamps above the thrombus level, on the contralateral renal vein and infrarenal inferior vena cava, perform a longitudinal venotomy of the inferior vena cava in the suprarenal section, perform thrombectomy, remove the neoplastic thrombus with a tumor thrombus and a renal vein, antegrade and retrograde blood flow is monitored, the venotomy incision is sutured with a 4/0 twist suture, the inferior vena cava 1 cm below the renal veins is sutured transversely with U-shaped sutures at a distance of 1 cm, blood flow is restored, hemostasis is performed, the wound is sutured tightly in layers.

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