侵犯下肢主要血管恶性肿瘤的保肢手术治疗

目的：探讨肿瘤侵犯下肢主要血管的保肢手术治疗。方法：将受肿瘤侵犯，无法解剖出来的血管作节段切除以彻底切除肿瘤，然后以直接吻合或进行血管移植桥接来重建下肢血循环以达到保肢目的。涉及髂血管节段切除和股血管节段切除各2例，切除后血管的重建，动脉采用直接吻合1例次，以自体大隐静脉倒置移植重建2例次，静脉以自体大隐静脉移植重建2例次，结果：4例病人获保肢切除后随访10个月－4年，患肢无疼痛和肿胀。结论：肿瘤侵犯了下肢主要血管，采用血管重建技术，仍可进行保肢手术治疗，使病人术后的生活质量 于截肢。     

带血管腓骨复合灭活瘤骨修复节段性骨缺损

目的探讨用带血管腓骨复合自体灭活瘤骨用于四肢长骨恶性肿瘤切除后节段性缺损重建临床结果。方法 2013～2018年间对8例(股骨远端4例,胫骨近端4例)长骨恶性骨肿瘤进行保肢手术,术时患者平均年龄(14±3.6)(10～21)岁。对肿瘤切除后肢体的节段性骨缺损用带血管自体腓骨复合自体灭活瘤骨进行重建。通过骨扫描评估移植腓骨的成活情况,通过X线片评估骨结合部的愈合情况。对患者随访进行肿瘤学和影像学结果的评估。国际保肢骨与软组织肿瘤学会93评分标准用于保肢后功能评估。结果术后平均随访42 (15～51)个月。4例采用游离腓骨瓣与自体灭活瘤骨复合,4例胫骨缺损采用同侧带蒂腓骨瓣局部转移与自体灭活瘤骨复合。肿瘤切除后平均骨缺损长度为(16.25±4.1) cm,移植腓骨平均长度为(18.8±3.8) cm。骨扫描结果证实所有移植腓骨均成活,自体灭活瘤骨和宿主骨之间的平均愈合时间分别为:股骨:(7.6±0.4)个月,胫骨:(8.4±1.5)个月。最终随访时的MSTS平均得分为95.5%。无感染和骨不连病例。4年以上随访患者肿瘤学结果:6例CDF (confinuous disease free),2例DOD (died of disease)。结论带血管的自体腓骨复合自体灭活瘤骨可用于长骨恶性肿瘤切除后节段性骨缺损的重建,带血管腓骨促进了自体灭活瘤骨与宿主骨之间的愈合,是复合生物重建获得良好功能结果的基础。     

以闭经为首发症状的髓母细胞瘤一例

该文例 2介绍了在切除肿瘤和受侵节段的股动、静脉后 ,倒置移植对侧大隐静脉重建股动脉 ,而股静脉断端予以结扎 ,术后患肢功能正常 ,无水肿。作者没有介绍该手术的理论依据及类似的文献报道。结扎股静脉是否能引起下肢水肿甚至坏死 ?该方法是否适合于所有的股静脉受累的肿瘤患者 ?编者认为尚有待进一步商榷。欢迎有关专家就此问题进行讨论     

大腿上段巨大淋巴瘤手术切除联合人造血管移植一例报告

侵犯股动、静脉的软组织肿瘤要求在彻底切除肿瘤的前提下尽可能保全肢体,具有一定难度和风险.我们报道1例采用人工血管移植重建肿瘤切除后血管缺损的成功病例.     

游离腓骨移植重建胫骨骨纤维结构不良病灶切除后骨缺损

目的 探讨吻合血管的游离腓骨移植重建胫骨骨纤维结构不良病灶切除后骨缺损的疗效。方法 对27例胫骨骨纤维结构不良患，行病灶彻底切除，所遗骨缺损以吻合血管的游离腓骨移植重建。移植腓骨长6cm～26cm，平均14．2cm。术后随访2年～12年，平均6．6年。结果 移植的腓骨术后平均4．2个月(3～8个月)达到骨性愈合，双下肢等长，功能接近正常。结论 吻合血管的游离腓骨移植重建胫骨骨纤维结构不良病灶切除后骨缺损，可最大限度地恢复患肢功能，是行之有效的方法。     

血管移植在肿瘤切除术中的应用

探讨血管移植在重要血管切除重建的肿瘤切除术中的临床应用。总结13例累及重要血管的恶性肿瘤切除及血管重建的经验,并与10例同期行剖腹探查术的患者对比。血管重建的方式人合移植7例。围手术期均无死亡,所有患者全部随访,实验组随访时间3～25个月,平均18.3个月,所有工血管移植13例,其中腹主动脉移植1例,腹主动脉联合下腔静脉移植1例,髂动脉移植2例,髂静脉移植2例,髂动静脉联患者在随访期间无重建血管感染、血栓形成等并发症,有2例于术后14、16个月复发,有1例于术后18个月死亡。对照组随访5～16个月平均9.2个月,有5例分别于术后5、7、9、9、11个月死亡。初步研究结果提示,累及重要血管的恶性肿瘤切除及血管重建安全、有效和可行,大大提高了患者的生活质量及生存质量,提高肿瘤切除率。     

大段异体皮质骨联合吻合血管自体腓骨结构性修复下肢骨肿瘤切除后骨缺损

目的探讨骨肿瘤保肢中应用大段异体皮质骨联合吻合血管自体腓骨结构性修复下肢骨肿瘤切除后大段骨缺损的临床效果。方法2001年1月～2005年12月,对17例患者下肢骨肿瘤切除后骨缺损采用大段异体皮质骨联合吻合血管自体腓骨进行结构性修复。其中男10例,女7例。年龄6～34岁。骨缺损部位:股骨8例,胫骨9例。骨缺损范围12～25cm,平均16.6cm。采用自体腓骨15～28cm,平均18.3cm;异体骨11～24cm,平均16.1cm。自体腓骨干14例,腓骨近段3例,均携带监测皮岛;捆绑式复合移植3例,嵌套式14例。结果所有患者随访6～48个月,平均20.2个月,供、受区创口均I期愈合,监测皮岛成活并与周围组织正常愈合,无明显排斥反应,无供区肢体功能障碍。Mankin评分:优8例,良5例,可2例,差2例,优良率76.47%。结论大段异体皮质骨联合吻合血管自体腓骨结构性修复下肢骨肿瘤切除后大段骨缺损效果满意。     

血管重建在软组织肉瘤累及肢体主要血管时的应用

目的:探讨人工血管重建对肢体软组织肉瘤累及大血管的保肢手术的临床意义。方法:收集2012年至2022年间我院所做的5例人工血管重建保肢手术案例资料,并结合文献进行分析。结果:所纳入5例患者均行肉瘤整体切除联合人工血管重建。其中平滑肌肉瘤2例,未分化多形性肉瘤1例,去分化脂肪肉瘤1例,侵袭性纤维瘤病1例;累及股动脉3例,股静脉3例,锁骨下动脉1例;累及臂丛神经1例,股神经1例。随访期间出现局部复发2例,远处转移2例,其中1例因多次复发转移行3次手术治疗;出现血管闭塞1例,行血管内介入手术后开通,余4例通畅;1例患者随访4月后死亡,最长随访时间10年。结论:肉瘤的生物学行为特征是影响血管重建的关键因素,同时对周围神经的保护也需要重视。     

肘关节周围骨肿瘤的保肢手术方法

目的探讨不同的治疗方法在肘关节周围骨肿瘤保肢中的应用价值。方法分析比较16例肘关节周围骨肿瘤患者分别进行各种保肢手术后的效果、生存质量、并发症及处理。本组骨肉瘤患者均采用新辅助化疗即:术前化疗 手术 术后化疗。在肿瘤切除后,采用人工关节置换6例,大段异体骨移植3例,骨水泥填充3例,单纯切除无重建者3例,短缩融合1例。结果16例骨肿瘤患者术后出现远处转移的共3例,为肺转移,2例骨巨细胞瘤行刮除骨水泥填塞局部复发而行瘤段切除假体置换术,1例复发恶变行瘤段切除短缩融合术。2例骨肉瘤软组织复发而截肢。3例行瘤段切除无重建者均为尺骨近端恶性骨肿瘤,术后肘关节功能恢复较好。结论在肘关节周围骨肿瘤保肢手术中,肿瘤广泛切除后、骨重建技术的进步是增加保肢手术范围、改善功能效果、降低手术并发症的关键。尺骨近端的恶性骨肿瘤采用瘤段切除局部旷置不失为一种较好的保肢治疗方法。     

胰腺癌术中门静脉/肠系膜上静脉重建材料的研究进展

随着外科技术的发展和围术期管理水平的提升,以往认为无法手术的侵犯大血管的腹部肿瘤,在血管重建技术的加持下,使得手术切除肿瘤成为可能。联合血管切除手术的应用使肿瘤切除范围扩大,提高了肿瘤的R0切除率,延长了患者生存期。门静脉（portal vein,PV）/肠系膜上静脉（superior mesenteric vein,SMV）系统,对于包括胰腺癌在内的肝胆胰及十二指肠肿瘤的手术至关重要,是上述肿瘤常累及的主要血管结构。联合PV/SMV系统切除重建技术的安全应用,为这类患者带来了新的希望。PV系统两端均为毛细血管网,血流速度慢,血液黏稠易凝,重建失败将严重影响肝脏血供,甚至引起肝功能衰竭。血管重建材料是影响手术效果和预后的重要因素,目前在静脉修复中,自体静脉、自体其他组织、同种异体静脉与人工材料均可作为供选择的修复材料,选择合适的材料对手术至关重要。本综述阐述了PV/SMV修复重建材料的研究进展,并说明了各种材料的特点与临床应用。      

Revascularization after segmental resection of lower extremity soft tissue sarcomas

BACKGROUND AND OBJECTIVES: Limb salvage surgery combined with vascular reconstruction has replaced amputation as the preferred treatment of soft tissue sarcomas involving major vascular structures of the extremities. We describe our experience with soft tissue sarcomas involving major vascular structures and examine outcomes according to the type of graft selected for arterial reconstruction. We also examine the effect of venous reconstruction on post-operative edema. METHODS: This retrospective review includes 14 patients with lower extremity soft-tissue sarcomas that encased major vessels, requiring combined limb-preserving tumor resection and revascularization with a synthetic or autogenous saphenous vein graft. Edema in patients with and without venous reconstruction was compared. The incidence of infection, wound dehiscence, and graft thrombosis were compared according to arterial graft type. RESULTS: There was no significant difference in edema in patients with venous reconstruction and those without. There was also no significant difference in infection and graft thrombosis in patients with synthetic grafts and those with autogenous saphenous vein grafts. Wound dehiscence occurred more often in patients with synthetic grafts (P = 0.029). CONCLUSIONS: Although this study was small, these results suggest that further studies are needed to determine the roles that vascular graft selection and venous reconstruction play in clinical outcome.     

Results of limb-salvage surgery with vascular reconstruction for soft tissue sarcoma in the lower extremity: comparison between only arterial and arterovenous reconstruction

BACKGROUND: Reports on vascular reconstruction in conjunction with limb salvage techniques for soft tissue sarcomas in the lower extremity have been published. The aim of this study was to investigate the necessity for venous reconstruction by comparing the results of arterial reconstruction alone and those of arteriovenous reconstruction. METHODS: Twenty-five (6.7%) of 373 patients underwent vascular resections for lower limb soft tissue sarcomas. Only arterial reconstruction was performed for 12 patients. Arteriovenous reconstruction was performed for 13 patients. The clinical results, complications, and postoperative function were compared between only arterial reconstruction group and arteriovenous reconstruction group. RESULTS: Limb salvage was achieved in 92% of all cases. No local recurrence has been observed. Nineteen patients (76%) are continuously free of disease. Histopathologic examination of the specimens showed that blood vessels had been infiltrated in 24%. The mean Musculoskeletal Tumor Society score was 70%. There were no significant differences in complication rate and postoperative function between two groups. CONCLUSIONS: Wide resection with vascular reconstruction for patients of soft tissue sarcomas involving major vessels in the lower limb provide long term local control and limb salvage. This study could not indicate the usefulness of additional venous reconstruction after vascular resection in the lower extremity.     

Results of surgery and multimodal therapy for patients with soft tissue sarcoma invading to vascular structures

BACKGROUND: The aim of this study was to analyze the impact of resection and reconstruction of major vessels on the limb salvage rate, local disease free survival, and overall survival for patients with soft tissue sarcomas invading to neurovascular bundles. METHODS: Twenty patients were treated in a 7-year period by one surgical team. Preoperative therapy consisted of isolated limb perfusion (n = 6), systemic chemotherapy (n = 4), systemic chemotherapy combined with regional hyperthermia (n = 2), and external beam irradiation (n = 1). All patients underwent resection of the sarcoma monobloc together with the neurovascular bundle invaded. Vessels were replaced by an autologous vein transplant or an allograft, and, in six patients, a myocutaneous flap or skin graft had to be used for soft tissue coverage. RESULTS: Histologic examination revealed negative histologic margins (R0-resection) and infiltration of the neurovascular bundle in all patients. In four patients, a local recurrence was observed, and, in three of them, reresection with negative margins was achieved. The mean local recurrence free survival was 54 months (confidence interval [CI], 42-66 months), and the mean overall survival was 48 months (CI, 32-57 months). Limb salvage was achieved in 19 of 20 patients. Eleven patients developed distant metastases after a mean survival time of 30 months. CONCLUSIONS: Extended sarcoma resection, including vessel replacement after preoperative multimodal therapy, provides long term local control and limb salvage. Amputation of extremity sarcoma can hardly be justified, even in cases of tumor invasion to neurovascular bundles. However, efforts to achieve better control over systemic spread are required for long term disease free survival.     

How much is a leg worth following radical tumor resection in bone sarcomas? Literature review

Bone sarcomas of the lower extremities are rare malignancies occurring mostly amongst adolescents and young adults. Necessarily, the therapy conducted in sarcoma centers is multimodal and multidisciplinary. In certain cases, in a metastasis free situation with adequate therapy, an overall survival rate of 90% can be achieved. Two principal surgical procedures exit for the local control of the malignancy: 1. Limb salvage with biological with/or endoprosthetic reconstruction; and, 2. amputation with restoration of the function with exoprosthesis or endo-exoprosthesis. Currently, limb salvage procedures are performed in up to 95% of cases. In contrast, amputation is performed when the disease has reached an advanced stage or limb salvage has failed. Both of the surgical options have their risks and possible complications.According to the literature, there should be no significant difference between limb salvage and amputation with respect to long-term overall survival, overall quality of life, psycho-socio-economic outcomes, or patient satisfaction. An important advantage of limb salvage is greater everyday functionality.With the expanded indication of limb salvage and great survival rates, the cases of late complications in patients expecting to maintain their own leg continues to increase.In some cases, it requires multiple interventions, ranging from minor up to the most complex revisions, to maintain the functionality of the extremity. Despite the great costs, personal effort, and the possible complications, limb salvage could be a suitable method to achieve functionally beneficial outcomes and patient satisfaction in bone sarcomas of the lower extremities over the long-term even in cases involving complications.     

Vascular reconstruction after retroperitoneal and lower extremity sarcoma resection

Purpose

Soft tissue sarcomas (STS) of the retroperitoneum and the lower limb with invasion of major blood vessels are very rare malignancies. This study analyses the outcome of patients with vascular replacement during resection of STS of the retroperitoneum and the lower extremity with either arterial or concomitant arterial and venous infiltration.

胰腺癌累及肠系膜上动脉外科手术切除的应用价值探讨

目的:探讨肠系膜上动脉局部切除在胰腺癌外科治疗中的应用,并评估其可行性.方法:回顾分析2例胰腺癌局部广泛侵润病例,行部分肠系膜上动脉、门静脉和肠系膜上静脉联合切除并重建的手术方法及术后恢复情况,评价其临床效果.结果:2例胰腺癌患者手术过程顺利,病例1SMA部分切除,消化道重建采用child吻合法.病例2行全胰切除,将受侵的SMV、PV、SMA联同胰体癌、全胰、十二指肠、部分空肠及相应区域和腹膜后脂肪组织及淋巴结整块切除,应用脾动脉与肠系膜上动脉端端吻合.肠系膜上动脉分别阻断45min和67min,门静脉阻断31min和55min.术后行B超检查血管通畅,门静脉血流为1550mL/min和1620mL/min,术后6个月随访,显示血管重建(脾动脉和肠系膜上动脉)吻合通畅,l例无瘤生存3年2个月,另1例无瘤生存11月.结论:在胰腺癌肿瘤局部侵润肠系膜上静脉、门静脉和肠系膜上动脉时联合切除并行血管修复或脾动脉和肠系膜上动脉重建是一种有效的手术方法.     

Vascular reconstruction with the superficial femoral vein following major oncologic resection

INTRODUCTION: Involvement of critical vascular structures has historically been considered a contraindication to tumor resection. This study describes outcomes following radical oncologic resection with concomitant resection of critical vascular structures and reconstruction with the superficial femoral vein (SFV). METHODS: All patients undergoing radical oncologic resection requiring resection of major vascular structures and concomitant reconstruction using the SFV as conduit were retrospectively reviewed. Primary outcomes were surgical morbidity and mortality; secondary measures included long-term patency and oncologic outcomes. RESULTS: Seven patients were included. There were three retroperitoneal and two groin sarcomas, and two squamous cell carcinomas metastatic to groin lymph nodes. No perioperative mortality occurred. Five patients experienced minor morbidity. One vein graft in a patient with pre-existing chronic deep venous thrombosis (DVT) occluded post-operatively. No subsequent long-term venous or arterial graft occlusions occurred (median 20.2 months, range 9.0-49.7). Two patients died of tumor recurrence during follow-up. CONCLUSIONS: Resection of tumors involving critical vascular structures is feasible. The SFV conduit is a versatile option for major vascular reconstruction, providing good long-term patency rates with acceptable morbidity and mortality. Vascular resection and reconstruction with the SFV offers another technique to provide limb-sparing surgery in patients traditionally offered only amputation, while providing favorable oncologic outcomes.     

腹膜后肿瘤术中重大血管的切除及重建

目的提高切除侵及腹部重大血管的腹膜后肿瘤的手术技能。方法总结近年来本院收治的腹膜后肿瘤中２５例侵及重大血管的手术切除及血管重建方面的经验。结果经过术前准备和术前评估,精心设计手术方案,对２５例患者成功实施了腹膜后肿瘤（包括受累血管）完整切除和相应的重大血管重建,无手术死亡病例。结论侵及重大血管的腹膜后肿瘤已不是手术禁忌证,应尽可能将受累血管及肿瘤完整切除,再行必要的血管重建,从而达到减少术后局部复发以及延长存活时间的目的。     

Surgical management of malignant bone tumours

Limb-salvage surgery has proved adequate in the management of malignant bone tumours. The goal of radical resection is to achieve local control with an appropriate surgical margin. Sixty-five cases of bone tumours have been managed by radical resection and suitable reconstruction by autologous fibular strut grafting. Single fibular grafting was attempted in the upper extremity and dual fibular grafting in the lower extremity. None had obvious evidence of secondary metastases at the time of surgery. out of 65 cases, 39 were sarcomatous lesions. Biplane Angiography had proved extremely useful in the exact delineation and appropriate resection of such lesions. Twenty two patients had complications - eight had local recurrence, three had deep infection needing amputation and eleven had multiple secondaries and died. It is suggested that in an Oncologically sound limb, salvage procedure with biological reconstruction should be attempted.     

Custom prosthetic reconstruction for proximal tibial osteosarcoma with proximal tibiofibular joint involved

BACKGROUND: The therapeutic results of managing proximal tibial osteosarcoma have been dramatically improved because of the recent advancements in imaging, chemotherapy, and surgical techniques. Further, the prognosis of patients with proximal tibial osteosarcoma is improved and the chance of survival with limb salvage surgery is increased. Among the limb salvage procedures, endoprosthetic reconstruction is now preferred to other methods such as allograft, composite allograft prosthesis, or arthrodesis. However, the treatment for proximal tibial osteosarcoma with proximal tibiofibular joint involved has not been reported. OBJECTIVE: The report of the preliminary results of custom prosthetic reconstruction for proximal tibial osteosarcoma with proximal tibiofibular joint involved following the primary tumor resection. The oncological results, functional outcomes, and complications were assessed in this present study. MATERIALS AND METHOD: Eleven patients with osteosarcoma of the proximal tibia and proximal tibiofibular joint were studied in 1995-2005, at Qilu Hospital of the Shandong University. Seven cases were males and four cases were females, with a mean age of 17 years (range 14-23). The surgical stage of all of the patients was Stage IIB, according to the Enneking Surgical Staging System. After neo-adjuvant chemotherapy, all of the patients underwent en bloc resection. This procedure included the proximal tibiofibular joint and the upper end of the fibula, followed by custom prosthetic replacement. The extensor mechanism was repaired by reattachment of the patellar tendon to the slot in the tibial component, with reinforcement by autologous bone-graft and suturing of the patellar tendon to a medial gastrocnemius rotation flap. The medial gastrocnemius rotation flap was then used to cover the implants. RESULTS: During the mean follow-up time of 47 months (range 12-96), six patients lived free of the disease, and five patients experienced various complications. One patient was still alive yet affected by the disease; one patient had an amputation due to local recurrence; and three died of pulmonary metastases. Several early complications had occurred amongst those five patients: one developed skin necrosis; two experienced transient palsy of the common peroneal nerve; and two developed deep vein thrombus of the lower limb. The mean Musculoskeletal Tumor Society score was 70% (range 55-86%), the mean postoperative range of motion was 85 degrees (range 0-120 degrees ), and the mean extension lag was 11 degrees (range 0-20 degrees ). CONCLUSION: Custom prosthetic reconstruction could yield as much satisfactory results as neoadjuvant chemotherapy and limb salvage surgery, for patients with osteosarcoma in proximal tibia and proximal tibiofibular joint. During the present study, most patients had good or excellent motor functioning with few incidences of complications. However, more attention should have been given to both the quality of function and long-term survival of patients.