Sacral Tumor Resection Research Articles

Prevention and nursing on perioperative complications of sacral tumor resection and reconstruction

Objective To investigate the measures of prevention and care on perioperative complications of sacral tumor resection and reconstruction. Methods Enhanced the awareness of the common complications before surgery and strengthen measures of prevention and care including psychological care, intraoperative bleeding prevention, bowel sphincter function training and skin preparation. The postoperative care including closely monitoring the vital signs, observing the spinal cord nerve function, strengthen nursing care containing the posture care, wound and drainage tube care, early stage rehabilitation guidance and limb functional training were carried out. Results During the perioperative period, without complications occurred. Conclusions Emphasis the prevention and care on complications and carrying out the proper treatment and nursing measures are essential to successful surgeries and the recovery of patients. Key words: Sacral reconstruction; Complication; Prevention; Perioperative; Nursing

Use of Aortic Balloon Occlusion to Decrease Blood Loss During Sacral Tumor Resection

Aortic balloon occlusion has been introduced into sacral tumor surgery to reduce extensive hemorrhage. The purposes of this retrospective study were to determine the efficacy of aortic balloon occlusion in decreasing intraoperative and postoperative blood losses and to analyze the complications of this technique. The cases of 215 patients in whom a sacral tumor had been treated surgically between 1997 and 2009 were studied retrospectively. Ninety-five patients who had had sacral tumor resection without aortic balloon occlusion were compared with 120 patients in whom aortic balloon occlusion had been carried out during the tumor resection. The demographic data, possible factors influencing hemorrhage, and total blood loss volume (including intraoperative and postoperative volumes) were determined with a review of the medical records and compared between the two groups. There were no significant differences between the two groups in terms of the demographic data, grade of malignancy, tumor blood supply, location of the tumor, percentage of patients who had a recurrent tumor or preoperative radiation, surgical approach, or type of resection. The patients with aortic balloon occlusion had a larger mean tumor volume, more frequently had a sacral reconstruction, and had a longer mean operative time; however, their mean total (2963 mL) and intraoperative (2236 mL) blood loss volumes were lower than those of the patients without occlusion (4337 and 3935 mL, respectively) (p < 0.001). Complications related to aortic balloon occlusion included femoral artery embolism in three patients and hematoma formation at the puncture site in five. Aortic balloon occlusion decreases the total and intraoperative blood loss volumes in patients treated with sacral tumor surgery who require extensive dissection. There is a low rate of balloon-related complications.

Midsacral Amputation for En Bloc Resection of Chordoma

En bloc resection, with adequate surgical margins, of primary malignant bone tumors of the sacrum is associated with long term disease control and potential cure. Resection of sacral tumors is difficult due to the proximity of neurovascular and visceral structures, and complete, or even partial, sacrectomy often results in functional loss for the patient. We describe the technique for en bloc resection of a sacral chordoma through a mid-sacral amputation. We demonstrate successful removal of a large sacral tumor with wide surgical margins while preserving neurologic function. This technique for midsacral amputation to remove a sacral tumor en bloc minimizes local recurrence and maximizes neurovascular function.

The Surgical Management of Sacral Chordomas

Retrospective case series. The purpose of this study was to evaluate factors that contribute to improved local control and survival. In addition, we sought to define the expected morbidity associated with treatment. Sacral chordomas are rare tumors presumed to arise from notochordal cells. Local recurrence presents a major problem in the management of these tumors and it has been correlated with survival. Resection of sacral tumors is associated with significant morbidity. Forty-two patients underwent resection for sacral chordoma between 1990 and 2005. Twelve patients had their initial surgery elsewhere. There were 12 female and 30 male patients. The proximal extent of the sacrectomy was at least S2 in 32 patients. Median survival was 84 months, and 5-year disease-free (DFS) and disease-specific survival (DSF) were 56% and 77%, respectively. Local recurrence (LR) and metastasis occurred in 17 (40%) and 13 (31%) patients, respectively. Local recurrence (P=0.0001), metastasis (P=0.0001), prior resection (P=0.046), and higher grade (P=0.05) were associated with a worse DSF. Prior resections (P=0.0001) and intralesional resections (P=0.01) were associated with a higher rate of LR. Intralesional resections were associated with a lower DSF (P=0.0001). Wide contaminated margins treated with cryosurgery and/or radiation were not associated with a higher LR rate. Rectus abdominus flaps were associated with decreased wound complications (P=0.01). Thirty-one (74%) patients reported that they self catheterize; and 16 (38%) patients required bowel training, while an additional twelve (29%) patients had a colostomy. Twenty-eight (67%) patients reported sexual dysfunction. Two (5%) patients died due to sepsis. Intralesional resection should be avoided as it is associated with a higher LR rate and worse survival. Rectus abdominus flaps ought to be considered as they lower the wound complication rate. Sacral resection is associated with significant morbidity.

Strategy of Surgical Treatment of Sacral Neurogenic Tumors

Assessment of different surgical approaches and procedures to remove different types of neurogenic tumors (Types I-IV). To aid surgeons faced with operating on a sacral neurogenic tumor by providing guidelines for determining the best surgical approach to use based on the way a neurogenic tumor presents. It is often difficult to determine the best surgical approach to use when operating on sacral neurogenic tumors. This retrospective study reports on the outcomes of patients with sacral neurogenic tumors and the surgical approach used in each case in order to better assess the most appropriate surgical approach and procedure to use with each tumor type. Between July 1998 and July 2006, 48 cases (18 males) with sacral neurogenic tumors were admitted and treated. Average age was 47 years old (range, 17-75). The average period of follow-up was 47 months. There were 41 cases with benign tumors and 7 cases of malignant tumors. Depending on how the tumor presented, 1 of 3 surgical approaches was used, an anterior approach (7 patients), a posterior approach (22 patients), or a combined anterior-posterior approach (19 patients). For the cases of Type I and the cases of Type II and III in which tumors grew forward but were lower than S1 level, surgical resection of tumors required a simple posterior approach. The cases of Type II and III in which tumors grew forward and expanded higher than S1 level required a combined anterior-posterior approach. For cases of Type IV, a simple anterior approach for resection of tumors was used. In surgical resection of sacral neurogenic tumors, surgical approach depends on the location and size of the tumors. Intraspinal tumors should be excised from a posterior approach. For giant neurogenic tumors that arise from the sacrum and involve the spinal canal, surgical resection should be done by a combined anterior-posterior approach. Giant presacral neurogenic tumors located below the S1 level can be removed by a posterior approach. The anterior surgical approach should be used for giant presacral neurogenic tumors that are located above S1 and do not involve the spinal canal.

Reconstruction of bony defect after resection of malignant pelvic tumor involvement of sacrum

To review the patients with malignant pelvic tumors involving sacrum treated surgically and to discuss the methods of resection of tumors and reconstruction of defects. Nineteen patients with malignant pelvic tumors involving the sacrum were treated surgically in People's Hospital between July 1999 and July 2007. The series comprised 12 males and 7 females. Five patients were diagnosed with chondrosarcoma, 4 with Ewing sarcoma, 4 with osteosarcoma, 1 with malignant fibrohistiocytoma (MFH), 1 with giant cell tumor (GCT), and 4 with metastatic bone tumors. Acetabulum was preserved after resection of the iliac and sacral tumor and reconstructed with screw and rod system in 10 patients. Among this 10 patients, 5 of them were also done bone graft. Acetabulum was not preserved after resection of the iliac and sacral tumor and the defect was reconstructed with modular hemipelvic prosthesis in 9 patients. Oncology result: 7 patients (7/19, 36.9%) had local relapse, including of 2 osteosarcoma, 2 chondrosarcoma, 2 Ewing sarcoma and 1 metastatic tumor. Two of 4 osteosarcoma, 2 of 4 Ewing sarcoma, 1 of 5 chondrosarcoma and 1 MFH patients died of lung metastasis. Two patients with metastatic lung cancer died of the disease 1 year after surgery. One patient with kidney carcinoma and 1 with thyroid carcinoma alive without of disease. Functional result: 8 patients with acetabular reconstruction after resection of pelvic and sacral tumors could walk with a cane 2 months after surgery. Average ISOLS function score was 20, including good in 3, fair in 5 and poor in 1 patient. One of the patient with modular hemipelvic prosthetic reconstruction occurred dislocation treated with 1 month after surgery and experienced open reduction. Hemipelvic prosthesis was took out in 1 patient because of the deep infection. For patients with acetabulum preserved after resection of the iliac and sacral tumor, reconstructed with screw and rod system combining with bone graft is an ideal method for restoration. Bone graft with resected femoral head and neck on residual sacrum and modular hemipelvic prosthetic reconstruction after resection of the pelvic tumor involving of the secrum is a good choose.

Polyaxial screws for lumbo-iliac fixation after sacral tumor resection: experience with a new technique for an old surgical problem

Background Although numerous reports have been published about various methods for reconstruction after sacrectomies, there are still biomechanical and technical dilemmas that are unaddressed. This report describes the experience at authors' institution of five cases in which polyaxial pedicle screws construct has been successfully used for lumbo-iliac fixation after sacral tumor resection. Methods Five cases of sacral tumors, two of Ewing's sarcoma and three of giant cell tumor (GCT) underwent surgical resection and then reconstruction was done with hardware using vertical rods placed alongside the spine bilaterally, transfixing monoaxial and polyaxial pedicle screws in lower lumbar levels and polyaxial screws into the ilium bilaterally. Cross links were also used to connect the two vertical members, thus enhancing biomechanical stability of the construct. Use of autologous bone grafts was relied upon to fill the gap created by sacral resection. Results No instrumentation failure was noted and the continuity of the spine and pelvis was well established with the instrumentation and auto grafts. In follow up of these patients (1–3 years), no complications were seen. Conclusion Polyaxial pedicle screws fixation is an effective technique to transmit axial load from spine to the appendicular bone and can be used safely in patients in whom sacral integrity is compromised after surgical resection. However, the long term benefits of this technique need to be evaluated.

Evaluation of factors associated with postoperative infection following sacral tumor resection

Resection of sacral tumors has been shown to improve survival, since the oncological prognosis is commonly correlated with the extent of local tumor control. However, extensive soft-tissue resection in close proximity to the rectum may predispose patients to wound complications and infection. To identify potential risk factors, a review of clinical outcomes for sacral tumor resections over the past 5 years at a single institution was completed, paying special attention to procedure-related complications. Between 2002 and 2007, 46 patients with sacral tumors were treated with surgery. Demographic data, details of surgery, type of tumor, and patient characteristics associated with surgical site infections (SSIs) were collected; these data included presence of the following variables: diabetes, obesity, smoking, steroid use, previous surgery, previous radiation, cerebrospinal fluid leak, number of spinal levels exposed, instrumentation, number of surgeons scrubbed in to the procedure, serum albumin level, and combined anterior-posterior approach. Logistic regression analysis was implemented to find an association of such variables with the presence of SSI. A total of 46 patients were treated for sacral tumor resections; 20 were male (43%) and 26 were female (57%), with an average age of 46 years (range 11-83 years). Histopathological findings included the following: chordoma in 19 (41%), ependymoma in 5 (11%), rectal adenocarcinoma in 5 (11%), giant cell tumor in 4 (9%), and other in 13 (28%). There were 18 cases of wound infection (39%), and 2 cases of repeat surgery for tumor recurrence (1 chordoma and 1 giant cell tumor). Factors associated with increased likelihood of infection included previous lumbosacral surgery (p = 0.0184; odds ratio [OR] 7.955) and number of surgeons scrubbed in to the operation (p = 0.0332; OR 4.018). Increasing age (p = 0.0864; OR 1.031), presence of complex soft-tissue reconstruction (p = 0.118; OR 3.789), and bowel and bladder dysfunction (p = 0.119; OR 2.667) demonstrated a trend toward increased risk of SSI. Patients undergoing sacral tumor surgery may be at greater risk for developing wound complications due to the extensive soft-tissue resections often required, especially with the increased potential for contamination from the neighboring rectum. In this study, it appears that previous lumbosacral surgery, number of surgeons scrubbed in, patient age, bowel and bladder dysfunction, and complex tissue reconstruction may predict those patients more prone to developing postoperative SSIs.

Risk factors for blood loss during sacral tumor resection.

Extensive hemorrhage is a serious complication during sacral tumor resection. Identifying the risk factors predicting the possibility of extensive hemorrhage would be important to predict which patients would need large amounts of transfused blood intraoperatively and postoperatively and which patients would need blood control by vascular occlusion. We retrospectively reviewed 173 patients who underwent sacral tumor resection performed at our institute between 2003 and 2007. Patients with an estimated total blood loss greater than 3000 mL were classified as having a large amount of blood loss. Sixty-nine (39.88%) patients had blood loss greater than 3000 mL. Male gender, excessive tumor blood supply, tumors involving the S2 body and cephalad to the S2 body, tumor volume greater than 200 cm(3), aorta occlusion, surgical approach, reconstruction, and operative time were associated with a large amount of blood loss. Tumors cephalad to the S2-S3 disc space (odds ratio, 3.840), tumor volume greater than 200 cm(3) (odds ratio, 3.381), and excessive blood supply (odds ratio, 2.281) independently predicted a large amount of blood loss. Sacral tumors that invaded cephalad to the S2-S3 disc space with a volume greater than 200 cm(3) and an excessive blood supply were likely to have a large amount of blood loss during resection. Level III, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Computer-Assisted Sacral Tumor Resection

Resection of sacral tumors is one of the most difficult operations in orthopaedic oncology because complex anatomy and important internal organs in the pelvic area make it difficult to achieve wide surgical margins1. Wide resection of sacral tumors may lead to serious functional impairments due to injury to important internal organs and/or the lumbosacral nerve roots or through the disruption of load-bearing through the sacroiliac joint. Recent advances in diagnostic modalities facilitate better surgical planning and can help in the performance of surgeries as planned. Computer-assisted surgery has been used in orthopaedic operations such as cruciate ligament reconstruction, hip and knee arthroplasty, and pedicle screw placement. The main advantage of computer-assisted navigation over other imaging modalities is that intraoperative identification can increase the accuracy of surgical resection. We report a case of sacral chondrosarcoma in which computer-assisted surgery provided intraoperative real-time imaging, thereby allowing us to achieve adequate surgical margins while preserving the sacral nerve roots. Additionally, the tumor resection was carried out through a posterior approach only. The patient was informed that data concerning the case would be submitted for publication, and he consented. A fifty-two-year-old man was referred to us with a longer than five-month history of a dull pain in the lower back. There was no evidence of a neurologic deficit in the lumbosacral nerve roots. Systemic symptoms, such as fever or weight loss, were absent. Plain radiographs of the pelvis showed an osteolytic lesion at the right sacral ala. Magnetic resonance imaging revealed that the tumor was located in the right sacral ala, between the sacroiliac joint and the first and second sacral foramina (Fig. 1). Computed tomography revealed cortical destruction of the sacral side of the sacroiliac joint, but there was no evidence of involvement of the ilium. Further evaluation, including computed tomography …

Appling the abdominal aortic‐balloon occluding combine with blood pressure sensor of dorsal artery of foot to control bleeding during the pelvic and sacrum tumors surgery

To investigate the feasibilities of reducing intraoperative hemorrhage and improving the safety of pelvic and sacrum tumor surgery using sizing balloon occluding abdominal aorta. From May 2001 to May 2007, 18 patients were diagnosed as sacrum or pelvic tumor and underwent surgery in our institution. Balloon catheters were placed via femoral artery to occlude the abdominal aorta of pelvic tumor and sacrum region undergoing the sacrum resection or half pelvis resection and replacement operation in 12 patients. A sizing balloon was used to occlude the abdominal aorta for 60 min in assisting with resection of pelvic and sacral tumors. After the abdominal aorta was occluded, much less intraoperative hemorrhage was found, and the average blood loss was only 280 ml (range 200-600 ml). This procedure assisted the surgeon in identifying clearly the surgical margin and neurovascular structure surrounded by the tumors. The blood pressure remained stable during the operation. And the function of the kidney, the pelvis organs and the lower extremities were normal. Intraoperative abdominal aorta occluding may effectively control intraoperative hemorrhage, thus assisting the surgeon in the complete and safe resection of pelvic and sacrum tumors.

Control of Blood Loss During Sacral Surgery by Aortic Balloon Occlusion

Radical sacral surgery can be associated with life-threatening blood loss. Effective and safe methods for controlling this blood loss remain elusive. We here report the use of an inflatable sizing balloon to intermittently occlude the distal abdominal aorta and control blood loss during sacral tumor resections. The balloon catheter was introduced into the abdominal aorta via the femoral artery. Pulse oxygen saturation signals from bilateral toes and ultrasonography were used to guide and confirm the location of the balloon in the abdominal aorta and distal to the renal arteries. The balloon was deflated for 10 min after each 60 min occlusion period. In five patients undergoing sacral tumor resection, the estimated blood loss when using balloon occlusion was <300 mL, and surgical duration was <2 h. No significant change in kidney, pelvic organ, and lower extremity function was found after the surgeries. Percutaneous aortic balloon occlusion can provide safe and effective control of blood loss during sacrococcygeal tumor resection.

Surgical Excision of Sacral Tumors Assisted by Occluding the Abdominal Aorta with a Balloon Dilation Catheter: A Report of 3 Cases

A report of 3 cases of upper sacral tumors excised by occluding the abdominal aorta with a balloon dilation catheter (BDC). To investigate the feasibilities of reducing intraoperative hemorrhage and improving the safety of surgical excision of sacral tumors assisted by occluding the abdominal aorta with a BDC. Surgical excision of upper sacral tumors has been considered a high-risk and difficult operation, with multiple complications because of its massive and uncontrollable intraoperative hemorrhage. However, until now and to our knowledge, no report on resection of sacral tumors assisted by occluding the abdominal aorta with a BDC is available. A BDC was used to occlude the abdominal aorta for 40-65 minutes in assisting with resection of upper sacral tumors in 3 cases. After the abdominal aorta was occluded, much less intraoperative hemorrhage was found, and the volume of blood loss was only 100-200 mL. This procedure assisted the surgeon in identifying clearly the surgical margin and sacral nerves surrounded by the tumors. In addition, intraoperative contamination was also minimized. The blood pressure remained stable during the operation. To occlude the abdominal aorta with a BDC may effectively reduce intraoperative hemorrhage, thus assisting the surgeon in the complete and safe resection of upper sacral tumors.

En bloc resection of primary sacral tumors: classification of surgical approaches and outcome

En bloc resection with adequate margins is associated with the highest probability of long-term tumor control or cure in most cases of primary sacral malignancies. The authors present their experience with a systematic approach to these lesions. They provide a novel classification of surgical techniques based on the level of nerve root sacrifice and evaluate the functional and oncological outcomes. Seventy-eight consecutive patients underwent 94 resections of sacral neoplasms at The University of Texas M. D. Anderson Cancer Center in Houston between August 1993 and June 2002. The records of 29 consecutive patients who underwent en bloc resection of primary sacral tumors were retrospectively reviewed. The median follow-up period was 55 months (range 1-103 months). Chordoma was the most frequent tumor type (16 cases). Midline sacral amputation was performed in 25 patients (eight low, four middle, seven high, and five total sacrectomies; one hemicorporectomy). Lateral sacrectomy was undertaken in four patients (two unilateral excisions of the sacroiliac joint and two hemisacrectomies). The surgical margins were wide in 19 cases, marginal in nine, and contaminated in one. The type of sacrectomy correlated with characteristic outcomes with respect to bladder, bowel, and ambulatory functions. Duration of hospital stay was related to the extent of sacrectomy (p = 0.003, Wilcoxon signed-rank test). The median Kaplan-Meier disease-free survival for patients with chordoma was 68 months (95% confidence interval 46-90 months). Classification of en bloc sacral resection techniques by the level of nerve root transection is useful in predicting postoperative function and the potential for morbidity. Adequate surgical margins should not be compromised to preserve function when they are necessary to affect tumor control.

Role of autologous blood transfusion in sacral tumor resection: patient selection and recovery after surgery and blood donation

AbstractWe carried out sacral en-bloc resection in six patients (three with chordoma; one with pheochromocytoma; one with malignant schwannoma; and one with giant cell tumor) using preoperatively collected autologous blood, to avoid homologous blood transfusion. An average of 3200 ml was collected preoperatively, with patients receiving recombinant human erythropoietin (r-HuEPO), at a total dose of 130 000 units on average. In four patients, we were able to accomplish the surgery without homologous blood transfusion. Postoperatively, the hemoglobin level in these four patients recovered to the pre-collective level in 4.5 weeks, on average. These clinical results indicate that en-bloc sacrectomy, which requires a large volume of blood transfusion, can be accomplished with preoperatively collected autologous blood alone.

A CASE OF GIANT MUCINOUS CYST ADENOMA IN THE SACROCOCCYGEAL REGION

We present a case of giant mucinous cyst adenoma which occurred in the sacrococcygeal region and developed evacuational disturbance. A 41-year-old woman, who underwent sacral tumor resection on her birth, noticed a slowly growing mass in the perianal region and developed evacuational disturbance. She was referred to our hospital for the evaluation of tumor. Image studies suggested a recurred sacrococcygeal teratoma.The well-defined tumor was 1070 gm in weight and contained large amount of mucinous fluid. Histologically, it was mucinous cyst adenoma without any malignancy. There is no previous report of mucinous cyst adenoma occurred in the sacrococcygeal region, although it is common in the ovary and a few in the retroperitoneum. Histogenesis of sacrococcygeal cyst adenoma is unclear. We applied a technique of posterior gluteal thigh faciocutaneus flap because of a large amount of tissue and skin defect. This was proved to be useful from cosmetic and functional standpoint to cover the tissue defect as well as to reinforce the vulnerability of the pelvic floor after the resection of the tumor and some part of the levator ani muscle.

Sacral Resection

Tumors involving the sacrum are difficult to treat. These include both primary tumors of the sacrum and locally invasive colorectal carcinomas. Sacral resection is often the only effective alternative for meaningful palliation or cure of sacral tumors. A review of 20 cases of sacral resections for primary sacral tumors (8) and locally invasive anorectal cancers (12) is presented. The mortality (0%) and morbidity (35% urinary complications, 25% wound disruptions, 1600-mL median blood loss) compare favorably with reports in the literature. Long-term survival was achieved with primary tumors of the sacrum. Local control of disease was achieved in the majority of patients with rectal cancer, with good palliation of preoperative pain. Long-term survival, however, is rare in this group. Surgical resection of sacral tumors can be undertaken with acceptable morbidity and mortality in selected patients.