腹主动脉球囊临时阻断技术在骨盆及骶骨肿瘤切除术的应用进展

骨盆和骶骨肿瘤由于其解剖复杂,周围毗邻重要的血管、神经、内脏器官,且肿瘤发病相对隐蔽,早期症状不明显,发现时肿瘤体积巨大,肿瘤血供丰富。因此手术切除和重建的难度大,最主要的困难仍是大出血的问题,在某些情况下,失血量会危及生命,巨大的手术风险使很多骨肿瘤大夫望而却步。受到战伤腹主动脉球囊成功发挥"血管内止血带"的启示,国内外逐步将其应用于非战伤躯干部位创伤出血救治和外科手术中。北京大学人民医院自2003年开始将低位腹主动脉球囊临时阻断技术应用于骨盆及骶骨肿瘤切除术,至今有超过1500例使用经验,为全世界应用球囊最多的医疗机构。腹主动脉球囊阻断技术的使用主要是针对预计术中出血量较多的患者,参考因素包括患者年龄、肿瘤血供、肿瘤体积大小、肿瘤累及范围、血管条件等。腹主动脉球囊临时阻断的应用大大减少了术中出血,缩短手术时间,增加了手术安全性。但腹主动脉球囊的使用也带来了相应的并发症,如穿刺点血肿、急性动脉血栓形成、假性动脉瘤、动脉闭塞等。本文旨在通过文献回顾,并总结十余年的腹主动脉球囊应用经验,对腹主动脉球囊在骨盆及骶骨肿瘤切除术中的适应证、操作流程、安全性、有效性、并发症预防措施及研究进展进行综述,以期腹主动脉球囊更好的临床推广应用。

Abdominal aortic balloon occlusion in the pelvic and sacral tumor resection:An updated review

Surgical treatment for bone and soft tumors of pelvis and sacrum presents a big challenge,because of the complex anatomy of sacropelvic region,large tumor volume at presentation,rich blood supply to the tumor and visceral involvemen,et al.Therefore,surgical excision and reconstruction are technically difficult for sacropelvic tumors.Extensive intraoperative haemorrhage could be life-threatening,and this issue remains a major concern.How to effectively control bleeding during surgery is critical for successful operation and patient's favorable prognosis.Some previous attempts,such as interventional selective internal iliac artery embolization or manual ligation through an additional anterior approach,were tested to be ineffective.Inspired by the success of resuscitative endovascular balloon occlusion of the aorta(REBOA)which resemble an endovascular tourniquet for traumatic hemorrhagic shock,some researchers have applied this techinique to control surgical bleeding during pelvic or sacral tumor resection.The authors have performed REBOA for more than 1500 sacropelvic tumr surgeries since 2003 in Peking University People's Hospital.The patient age,the diameter of femoral artery and aorta,atherosclerosis,as well as tumor location,volume and expansion and blood suppy,have to be thoroughly evaluated prior to REBOA administration.Admittedly,the application of REBOA do reduce intraoperative bleeding,shorten the operation duration,improve the safety of surgery,yet some complications were observed including local hematoma at the puncture site,acute arterial thrombosis,femoral artery pseudoaneurysm or occlusio,et al.The purpose of this study is to review the literature on REBOA administration in pelvic and sacral tumors excision,with the focus on its indications,performing procedure,the safety and efficacy,and complications.Moreover,in order to popularize the clinical application of aortic balloon occlusion in the future,we summarize our experience of abdominal aortic balloon occlusion over 10 years.