目的

探讨累及重要血管的腹膜后盆底肿瘤切除术中出血风险的预防与管理，总结腹膜后盆底肿瘤累及重要血管时的处理经验。

方法

回顾性分析2020年1月至2024年5月于广东省中医院收治的27例累及重要血管（包括腹主动脉、下腔静脉、髂血管、肠系膜动静脉）的腹膜后盆底肿瘤患者的临床资料，包括一般临床诊治资料（患者年龄、性别、BMI、既往腹部手术史以及是否原发肿瘤等）、手术相关资料（ASA分级、手术时间、术后住院时间以及术后并发症等）、出血预防及处理的相关措施资料（出血风险术前处理方式、术中输注血液制品及输血量、累及重要血管的处理方式等）以及重建3D影像资料。

结果

27例累及重要血管的腹膜后盆底肿瘤患者中，男13例，女14例，年龄中位数64.0（51.0，68.0）岁，肿瘤最大径中位数10.5（6.5，20.0）cm，原发肿瘤15例（55.6%），复发肿瘤12例（44.4%），平均术前HGB（112.9±3.7）g/L。所有病例中累及腹主动脉5例（18.5%），下腔静脉2例（7.4%），髂动脉6例（22.2%），髂静脉2例（7.4%），髂动静脉2例（7.4%），脾动脉1例（3.7%），左肾静脉1例（3.7%），左肾动静脉1例（3.7%），肠系膜下动静脉1例（3.7%），联合累及下腔静脉及髂动脉2例（7.4%），联合累及下腔静脉及右肾静脉1例（3.7%），联合累及下腔静脉及左髂总动脉1例（3.7%）；联合累及胃网膜左静脉及左肾静脉1例（3.7%），直肠上动脉1例（3.7%）。根据不同的具体情况，分别采用钝性分离、血管间断阻断及悬吊、血管结扎或者联合脏器切除等处理手段，均成功地实现了肿瘤的完整切除。术中出血量中位数为300.0（100.0，700.0）ml，术中输血10例（37.0%），主要成分为红细胞及新鲜冰冻血浆。术后入住ICU有8例（29.6%），术后住院时间中位数为15.0（12.0，25.0）d。最常见的病理类型为脂肪肉瘤，共9例（33.3%）。

结论

对于累及重要血管的腹膜后盆底肿瘤切除术，术前应备好足够的血制品，充分做好各种手术预案，除备好血管置换相关措施外，更要在手术剥离肿瘤与血管间隙之前做好血管预阻断带的放置，预防重要血管的突发大出血，全面重视出血风险的有效预防和控制。

Objective

To explore the prevention and management of hemorrhage risks during resection of pelvic retroperitoneal tumor involving major blood vessels, and to summarize the experience in managing retroperitoneal pelvic tumors involving major blood vessels.

Methods

A retrospective analysis was conducted on the clinical data of 27 patients with pelvic retroperitoneal tumor involving major vessels(including the abdominal aorta, inferior vena cava, iliac vessels, and mesenteric arteries and veins) who were treated at Guangdong Provincial Hospital of Traditional Chinese Medicine between January 2020 and May 2024. The data included general clinical information (such as patient age, gender, body mass index, history of previous abdominal surgery, and whether the tumor was primary or recurrent), surgery-related information(ASA classification, operative time, postoperative hospital stay, and major postoperative complications),data related to hemorrhage prevention and management (preoperative strategies to mitigate bleeding risks,intraoperative transfusion of blood products and transfusion volume, and management of major vessels involved by the tumor), and three-dimensional reconstruction images.

Results

Among the 27 patients with pelvic retroperitoneal tumor involving major blood vessels, there were 13 males and 14 females, with a median age of 64.0 (51.0, 68.0) years. The median maximum tumor diameter was 10.5 (6.5, 20.0) cm, with 15 cases (55.6%) being primary tumors and 12 (44.4%) being recurrent tumors. The average preoperative hemoglobin level was 112.9±3.7 g/L. In terms of vascular involvement, the abdominal aorta was involved in 5 cases (18.5%), inferior vena cava in 2 (7.4%), iliac artery in 6 (22.2%), iliac vein in 2 (7.4%), both iliac artery and vein in 2 (7.4%), splenic artery in 1 (3.7%), left renal vein in 1 (3.7%), both left renal artery and vein in 1 (3.7%), inferior mesenteric arteries and veins in 1 (3.7%), both inferior vena cava and iliac artery in 2 (7.4%), both inferior vena cava and right renal vein in 1 (3.7%), both inferior vena cava and left common iliac artery in 1 (3.7%), both left gastroepiploic vein and left renal vein in 1 (3.7%), and superior rectal artery in 1 (3.7%). Depending on the specific circumstances, treatment strategies included blunt dissection,intermittent vascular occlusion and suspension, vascular ligation, or combined organ resection, all of which successfully achieved complete tumor resection. The median intraoperative blood loss was 300.0 (100.0,700.0) ml, and 10 patients (37.0%) required intraoperative blood transfusions, mainly red blood cells and fresh frozen plasma. Postoperatively, 8 patients (29.6%) were admitted to the intensive care unit, and the median postoperative hospital stay was 15.0 (12.0, 25.0) days. The most common pathological type was liposarcoma, accounting for 9 cases (33.3%).

Conclusion

For resection of pelvic retroperitoneal tumor involving major blood vessels, it is crucial to prepare sufficient blood products preoperatively and formulate comprehensive surgical plans. In addition to preparing for vascular replacement, preoperative placement of vascular occlusion bands before tumor dissection is essential to prevent sudden massive hemorrhage from major vessels. Full attention should be given to effective prevention and control of bleeding risks.