56例盆腔巨大肿瘤的外科治疗

目的探讨盆腔巨大肿瘤患者的外科治疗。方法回顾性分析2005年2月至2012年1月河南省肿瘤医院收治的56例盆腔肿瘤患者的临床资料。通过术前增强cT检查或数字医学三维重建技术对肿瘤的可切除性进行评估，术中联合多种手术入路，对肿瘤进行游离和切除。术后通过电话和门诊随访，了解患者肿瘤复发转移情况。寿命表法计算患者生存率。结果56例患者中，50例术前进行CT检查，6例进行数字医学三维重建。49例患者术前评估需行联合脏器切除；5例术前评估为仅行肿瘤切除；2例术前评估为肿瘤不可切除。14例患者术前确诊，8例术中通过快速冷冻切片病理检查确诊，其余34例患者术后通过病理检查确诊。手术入路：21例患者采用骶前正中入路联合经会阴尾骨前人路，11例采用骶前正中入路，8例采用闭孔入路，8例采用耻骨后入路，8例采用闭孔入路联合经会阴尾骨前入路。手术方式：18例行肿瘤＋直肠切除，12例行肿瘤＋膀胱部分切除，12例行肿瘤＋子宫、卵巢切除，10例行肿瘤＋部分小肠、结直肠切除，4例行肿瘤十全盆腔脏器切除。53例患者达到R。切除，2例为肉眼未见肿瘤残留，1例有肿瘤残留。平均手术时间为100min。50例患者术后恢复顺利，6例患者出现术后并发症，其中3例出现肠梗阻（2例经保守治疗痊愈、1例经手术治疗痊愈），2例出现盆腔感染，1例出现结肠造口瘘口旁疝，经通畅引流及营养支持治疗后均痊愈。56例患者中1例因术后突发心肌梗死死亡。术后病理检查：腺癌25例、胃肠问质瘤15例、肉瘤16例。随访至2012年12月，56例患者失访9例，腺癌患者5年生存率为26．7％，肉瘤患者5年生存率为18．9％，胃肠道间质瘤患者5年生存率为52．6％。结论盆腔巨大肿瘤术前的可切除性评估能减少不必要的剖腹探查，提高手术的安全性。

Surgical management of huge pelvic tumor： a report of 56 cases

Objective agement of huge pelvic tumor To investigate the surgical man- Methods The clinical data of 56 patients with huge pelvic tumor who were admitted to the Cancer Hospital of Henan Province from February 2005 to January 2012 were retrospectively analyzed. Tumor resectability was assessed via enhanced computed tomography or three-dimensional reconstruction, and the tumors were freed and resected by combi- nation of multiple surgical approaches. All the patients were followed up via telephone or re-examination at the out-patient department to learn the recurrence and metastasis of tumor. The survival rate was calculated using the life table. Results Fifty patients received preoperative computed tomography examina- tion, and the imaging data of 6 patients were three-dimensionally reconstructed. Preoperative evaluation showed that 49 patients needed combined multivisceral resection, 5 needed tumor resec- tion, and the tumors of 2 patients were unresectable. Fourteen patients were diagnosed preoperatively, and 8 patients were diag- nosed by intraoperative rapid frozen section examination, and the rest 34 patients were diagnosed by postoperative pathological examination. The surgical approaches including anterior median sacral approach combined with transperineal coccyx anterior approach （21 patients）, anterior median sacral approach （11 patients） , obturator approach （8 patients）, retropubic approach （8 patients） and obturator approach combined with transperineal approach of coccyx （8 patients）. Tumor and rectum resection was carried out on 18 patients, tumor and partial bladder resec- tion on 12 patients, tumor, uterus and ovariectomization on 12 patients, tumor, part of the small intestine and colorectal resec- tion on 10 patients, tumor and total pelvic exenteration on 4 patients. In all the 56 patients, 53 achieved R0 resection, 2 cases reached naked eye clean, 1 case had residual tumor. The mean operation time was 100 minutes. Fifty patients recovered uneventfully. Six patients had postoperative complications, including 3 patients with intestinal obstruction （2 patients were cured by conservative treatment, and 1 patient was cured by surgery）, 2 patients with pelvic infection and 1 patient with co- lostomy hernia, and they were cured by drainage and nutritional support. One patient died of postoperative myocardial infarction. The results of postoperative pathologic study showed that 25 patients were with adenocarcinoma, 16 with sarcoma and 15 with gastrointestinal stromal tumor. Forty-seven patients were follow- up to December 2012, and the 5-year survival rate was 26.7% for patients with adenocarcinoma, 18.9% for patients with sarco- ma, and 52.6% for patients with gastrointestinal stromal tumor. Conclusion Preoperative assessment of resectability of huge pelvic tumor can reduce unnecessary laparotomy and improve the safety of operation.