ObjectiveTo evaluate the clinical efficiency of balloon occlusion of the lower abdominal aorta in blood loss control during resections of pelvic or sacral tumor. MethodsFrom April 2006 to April 2010, 24 patients diagnosed as pelvic or sacral tumor in this hospital were collected. Balloon occlusion of the lower abdominal aorta to control blood loss was used in these cases. Balloon catheters were placed via femoral artery to occlude the abdominal aorta before operation. Resections of pelvic or sacral tumors were performed after occlusion of abdominal aorta, duration no longer than 60 min per occlusion, if repeated occlusions needed, 10－15 min release in between. Results Average operative time was 153 min (range 40－245 min) and average blood loss was 310 ml (range 200－650 ml) in this series, and the procedure helped in clearly identifying the surgical margin, neurovascular structures, and adjacent organs. The blood pressure were stable in all the cases. No postoperative renal function impairment was found in all the cases, no side injuries to adjacent organs was identified. One case complicated with thrombosis in iliac artery at same puncture side was successfully treated with catheter thrombectomy. ConclusionIntraoperative abdominal aorta balloon occluding in pelvic and sacral tumor surgical operation could reduce blood loss, and improve the safety of operation.
ObjectiveTo investigate the clinical efficiency of pelvic and sacrum tumor surgery using sizing balloon occlusion of the lower abdominal aorta. MethodsFrom January 2005 to June 2011, 156 patients were diagnosed to have sacrum or pelvic tumor and underwent surgery in our institution. Temporary balloon occlusion of abdominal aorta was used in 51 patients during the resection of sacrum and pelvic tumors (balloon group). Another 105 patients received the traditional surgery resection (control group). The results of the whole operation time, the volume of blood loss and transfusion, the complication and the total days of stay in hospital in the two groups were compared with each other. ResultsAfter the abdominal aorta was occluded, 92.2% of the patients in the balloon group had holistic resection or edge resection, while the number was 86.7% for the control group. In the balloon group, the average operation time was (171.96±65.16) minutes, the average intraoperative blood loss was (746.86±722.73) mL, and the blood transfusion was (411.76±613.73) mL. The postoperative lead flow was (294.50±146.09) mL, and the postoperative tube removal was within (2.98±1.07) days. Improvement of patients'condition was significantly better than the control group (P<0.05). No significant difference was found in the total days of stay in hospital and the postoperative complications between the two groups (P>0.05). ConclusionUsing abdominal aorta occlusion can effectively control intraoperative hemorrhage, and show the operation field clearly. It also can reduce operation time and control the blood transfusions. Appropriately extended balloon blocking time can obviously improve the tumor removal rate and the safety of the operation.
ObjectiveTo study the value of CT angiography (CTA) in the surgical treatment of bone tumors with the temporary balloon blocking technique. MethodsA retrospective analysis was made on the clinical data of 36 bone tumor patients between April 2008 and October 2013. There were 22 males and 14 females, aged from 25 to 83 years (mean, 46 years). The tumor located at the sacrococcygeal region in 17 cases, at the ilium in 12 cases, at the pubis in 5 cases, and at the proximal femur in 2 cases. Before surgery, CTA was performed to measure the external diameter of aortaventralis and arteria iliac communis, and the distance between the low renal artery and the abdominal aortic bifurcation as well as mark the anatomical relationship between the low renal artery, the abdominal aortic bifurcation and bony landmarks of vertebral body. According to these data, suitable balloon was chosen and the balloon positioning was guided in the surgery to completely excise tumor assisted by balloon blocking technique. ResultsThe CTA results showed that the external diameter of aortaventralis and arteria iliaca communis was (1.545±0.248) cm and (1.060±0.205) cm respectively, and the distance between the low renal artery and the abdominal aortic bifurcation was (10.818±1.165) cm. The three-dimensional reconstruction showed that the opening of the low renal artery was mainly located at L1 (16/36, 44.4%) and the abdominal aortic bifurcation mainly located at L4 (22/36, 61.1%). Effective block of abdomial aorta was performed; the blood pressure obviously increased in 3 cases after balloon inflation, and pulse of the left dorsal artery of the foot decreased in 1 case after removal of balloon, which were relieved after expectant treatment. The operation time was 118-311 minutes; the intraoperative blood loss was 200-1 800 mL, 21 patients were given blood transfusion, and the amount of blood transfusion was 400-1200 mL; and the aortic clamping time was 40-136 minutes. All patients were followed up 5-44 months (mean, 21 months). According to Enneking standard, the results were excellent in 9 cases, good in 20 cases, fair in 5 cases, and poor in 2 cases at 3 months after operation. There were 10 cases of dysfunction of urination and defecation, 2 cases of tumor recurrence, and 3 cases of death after surgery. ConclusionCTA and three-dimensional reconstructions technique can accurately measure the external diameter of aortaventralis and arteria iliaca communis and the distance between low renal artery and abdominal aortic bifurcation and offer great help to choose appropriate balloon and locate the balloon during surgery. The balloon blocking technique under the assistance of CTA can obviously reduce intraoperative blood loss and tumor recurrence, supply a clear view in surgery and shorten the operation time.
ObjectiveTo investigate the short-term effectiveness of allogeneic bone transplantation for pelvic reconstruction of large skeletal defects after tumor resection. MethodsBetween January 2008 and November 2009, 9 patients with pelvic tumor were treated, and the clinical data were retrospectively analyzed. There were 1 male and 8 females with an average age of 36.1 years (range, 18-44 years). There were 5 cases of giant cell tumor of bone, 2 cases of chondrosarcoma, 1 case of malignant giant cell tumor of bone, and 1 case of Ewing sarcoma. According to the Enneking system for staging musculoskeletal tumors, the lesion involved ilium (region I) in 4 cases, acetabulum (region II) in 6 cases, pubis and ischium (region III) in 3 cases, and sacrum (region IV) in 1 case. The average disease duration was 6.8 months (range, 1-36 months). After accurate resection of the tumor, allograft ilium with or without acetabulum was used in 6 cases and 2 cases respectively, and allogenous bone plate in 1 case for pelvic reconstruction; total hip arthroplasty was performed in 6 cases; sacrum screw was used in 1 case. ResultsInfection of incision and abdominal distention occurred in 1 case, and was cured after debridement; primary healing of incision was obtained in the other cases, without infection, lower limb deep venous thrombosis, or dislocation. The average follow-up was 11.8 months (range, 8-15 months). The X-ray films showed breakage of plate in 1 case at 8 months after operation and partial bone resorption in 2 cases; good position of the prosthesis, plate, and transplanted bone was observed in the other cases. No local recurrence was found. At last follow-up, the average musculoskeletal tumor score (MSTS) was 23 (range, 18-29). ConclusionAllogeneic bone transplantation for pelvic reconstruction of large skeletal defects after tumor resection can achieve satisfactory short-term surgical and functional effectiveness.
ObjectiveTo explore the value of the long time lower abdominal aorta balloon block technology in the pelvis or sacrum tumor surgery. MethodsFrom January 2005 to June 2013, the sacrum or pelvic tumor patients underwent the long time lower abdominal aorta balloon block technology in the Orthopedics Department of West China Hospital of Sichuan University were enrolled. According to the balloon blocking time, patients were divided into A (<90 mins), B (90 to 180 mins), and C (>180 mins) groups. The intraoperative blood loss, blood transfusion amount, average lengths of hospital stay, postoperative volume of drainage, and postoperative complications were compared among the three groups. ResultsA total of 78 patients were included, of which 21 were in group A, 38 were in group B and 19 were in group C. All patients received en bloc resection, and did not experience intraoperative balloon shift and abdominal aorta flow leakage. Comparing the three groups, there were significant differences in intraoperative blood loss (P=0.026) and average lengths of hospital stay (P=0.021). Further pairwise comparison showed the intraoperative blood loss and average lengths of hospital stay in group C were significantly higher than those in group A and group B. In addition, there were no statistical differences among the three groups in blood transfusion amount, postoperative volume of drainage and postoperative complications. ConclusionIn the pelvis and sacrum tumor surgery, extending the time of abdominal aorta balloon block can reduce bleeding, save blood, increase the safety of surgery without increasing in postoperative complications.
ObjectiveTo investigate the clinical feasibility of optical surface imaging (OSI) system in guiding thermoplastic body film to fix radiotherapy of pelvic tumors.MethodsFrom January to May in 2019, 20 pelvic tumor patients fixed with thermoplastic films were selected. After the first treatment, cone beam CT (CBCT) was performed to verify and correct the setup errors. OSI was used to collect the patient’s image information as the reference image for the later treatment setup. The later treatment was performed by traditional three-point setup, and OSI was used to record the setup data and monitor the treatment. CBCT scan results were taken as the standard, to calculate the system error (Σ), random error (σ) and margin of three-point and OSI setup. The result of CBCT scan was defined as three-point setup error.ResultsIn lateral-medial, superior-inferior, and anterior-posterior directions, the OSI system errors were 0.14, 0.37, and 0.14 cm, respectively, the random errors were 0.20, 0.57, and 0.23 cm, respectively, and the corresponding margins were 0.49, 1.32, and 0.51 cm, respectively; the three-point setup system errors were 0.13, 0.39, and 0.12 cm, respectively, the random errors were 0.15, 0.43, and 0.13 cm, respectively, and the corresponding margins were 0.43, 1.28, and 0.39 cm, respectively. If the target coverage rate was counted at the 0.8 cm outward margin, the proportions of the three-point setup in lateral-medial, superior-inferior and anterior-posterior were 100.00%, 80.65%, and 100.00%, respectively, and those of the OSI setup were 100.00%, 95.48%, and 99.35%, respectively. Pearson analysis showed that the weakly correlation of lateral-medial, superior-inferior directions had statistical significance (P<0.05), and there was no statistical significance in the other directions (P>0.05).ConclusionsCompared with the traditional three-point setup, OSI cannot improve the setup precision of thermoplastic body film fixation in pelvic tumor radiotherapy. OSI acquired the image of thermoplastic phantom, which is quite different from the actual target location of the patient. OSI application method should be improved in clinical application.
Objective To explore the surgical skills of modified Gibson combined with modified ilioinguinal (MGMII) approach in the treatment of Enneking Ⅱ+Ⅲ pelvic malignant tumors in the three-dimensional (3D) printed customized integrated hemipelvic prosthesis, and to evaluate the convenience and accuracy of the surgical approach and the short-term effectiveness. Methods Between January 2017 and March 2019, 7 patients with Enneking Ⅱ+Ⅲ pelvic malignant tumors were treated with tumor resection and 3D printed hemipelvic prosthesis replacement via MGMII approach. There were 6 males and 1 female. The age ranged from 23 to 68 years, with an average of 43.7 years. There was 1 chondrosarcoma, 1 Ewing’s sarcoma, 1 osteosarcoma, 1 malignant Schwannoma, 2 metastatic renal clear cell carcinoma, and 1 metastatic hepatocellular carcinoma. The Enneking stage of 4 cases of primary malignant tumor was stage ⅡB. The disease duration was 6-12 months, with an average of 9.5 months. The preoperative Harris hip score (HHS) was 82.1±1.4 and the Musculoskeletal Tumor Society (MSTS) score was 21.4±1.1. The tumor size by imaging examination was 5.1-9.1 cm, with an average of 6.9 cm. The operation time, intraoperative blood loss, postoperative blood transfusion volume, and postoperative complications were recorded. Postoperative pathological examination confirmed tumor residue according to R classification criteria. The lower limb length, acetabular height, acetabular eccentricity, abduction angle, and anteversion angle were measured and the bone integration was observed by imaging review. Bilateral abductor muscle strengths were measured, and joint function was evaluated by MSTS score and HHS score. Results All operations were successfully completed. The operation time was 210-360 minutes (mean, 280.0 minutes); the intraoperative blood loss was 1 300-2 500 mL (mean, 1 785.7 mL); the postoperative blood transfusion volume was 0-11 U (mean, 6.1 U). Postoperative pathological examination confirmed R0 resection assisted by osteotomy guide plate. All incisions healed by first intention. All patients were followed up 30-48 months (mean, 41.3 months). At last follow-up, the imaging review showed the good osseointegration in all 7 cases. There was no significant difference in the lower limb length, acetabular height, acetabular eccentricity, abduction angle, and anteversion angle between the affected side and the healthy side (P>0.05), all of which met the requirements of anatomical reconstruction. At 3 months after operation, the ratios of muscle strength between the affected side and the healthy side was 68.29%±7.41% at 3 months and 89.86%±2.79% at 12 months, showing a significant difference between the two time points (t=8.242, P=0.000). At last follow-up, the MSTS score and HHS score were 27.3±0.8 and 96.6±1.4, respectively, which significantly improved when compared with those before operation (P<0.05). None of the patients had assisted walking at last follow-up. There was no recurrence, death, or complications such as deep infection, dislocation of the prosthesis, or fracture of the prosthesis or screw. Conclusion MGMII approach can expose the posterior column of the acetabulum, especially the ischial tubercle, which is helpful to avoid tumor rupture during tumor resection and preserve the muscle functions such as gluteus medius and iliac muscle while ensuring the resection scope.
Objective To investigate the effectiveness of three-dimensional (3D)-printed hemi-pelvic prosthesis for revision of aseptic loosening or screw fracture of modular hemi-pelvic prosthesis. MethodsBetween February 2017 and January 2020, 11 patients with aseptic loosening or screw fracture of modular hemi-pelvic prosthesis were revised using 3D-printed hemi-pelvic prostheses. There were 7 males and 4 females with an average age of 44 years (range, 25-60 years). In the first operation, all patients underwent total tumor resection, modular hemi-pelvic prosthesis reconstruction, and autologous femoral head transplantation. According to the Enneking pelvic partition system, 8 cases were resected in zones Ⅰ+Ⅱ and 3 cases in zones Ⅰ+Ⅱ+Ⅲ. The interval from the initial operation to this revision ranged from 14.3-66.2 months, with an average of 35.8 months. The operation time, the amount of intraoperative bleeding, and the occurrence of complications were recorded. At 6 months after the first operation, before revision, and at last follow-up, the American Musculoskeletal Tumor Society (MSTS) score and Harris score were used to evaluate the recovery of lower limb function. The pain-free walking distance of patients without brace assistance was recorded at last follow-up. X-ray films were taken at 1 month after the first operation, before revision, and at 1 month after revision, the acetabulum position was assessed by the differences in weight arm and cup height between bilateral hip joints. At last follow-up, the digital X-ray tomography was taken to evaluate the prosthesis-bone integration and the occurrence of aseptic loosening. Results The operation time was 182.6-238.0 minutes (mean, 197.4 minutes). The amount of intraoperative bleeding was 400-860 mL (mean, 550.0 mL). All incisions healed by first intention with no infection, hip dislocation, nerve damage, or vascular-related adverse events. The MSTS score and Harris score at last follow-up were significantly higher than those at 6 months after the first operation and before revision (P<0.05), while the score before revision was significantly lower than that at 6 months after the first operation (P<0.05). At last follow-up, the patients were able to walk more than 1 000 meters painlessly without brace assistance. Imaging review showed that the difference of cup height at 1 month after revision was significantly lower than that at 1 month after the first operation and before revision, and at 1 month after the first operation than before revision operation, and the differences were significant (P<0.05). There was no significant difference in the difference of weight arm among three time points (P>0.05). All prostheses were well integrated, and no aseptic loosening of the prosthesis or screw fracture occurred. Conclusion Revision with 3D-printed hemi-pelvic prostheses benefited in reconstructing stable pelvic ring and natural bodyweight transmission for patients encountering the aseptic loosening or screw fracture of modular hemi-pelvic prosthesis. Early postoperative rehabilitation training can maximize the recovery of patient limb function, reduce pain during walking, and reduce the incidence of complications.
The simultaneous objectives of destroying tumor cells while protecting normal pelvic organs present a dual clinical and technical challenge within the realm of pelvic tumor radiotherapy. This article reviews the latest literatures, focusing on technological innovations in key aspects of radiotherapy such as positioning, planning, and delivery. These include positioning fixation techniques, organ-at-risk avoidance irradiation, non-coplanar irradiation techniques, as well as organ displacement protection and image-guided adaptive techniques. It summarizes and discusses the research progress made in the protection of critical organs during pelvic tumor radiotherapy. The paper emphasizes technological advancements in the protection of critical organs throughout the processes of radiotherapy positioning, planning, and implementation, aiming to provide references for further research on the protection of critical organs in the external irradiation treatment of pelvic tumors.