Total sacrectomy with a combined antero-posterior surgical approach for malignant sacral tumours

Unfolding the Art of Methodical Approach for Total Sacrectomy

BACKGROUND

Total sacrectomy is a technically demanding surgery with substantial risks, including high morbidity and mortality due to the likelihood of exsanguination.1-3 Despite the evolution of surgical techniques,4,5 the incidence of postoperative complications remains significant.1 This study presents a systematic approach to total sacrectomy, with a particular focus on a modified technique for isolating the iliac vessels, aimed at effective management of complex sacrococcygeal masses and the reduction of operative complications.

PATIENTS AND METHODS

Employing our approach, a 45-year-old male patient presenting with a sacrococcygeal mass involving the lower S1 bone and sacroiliac joint underwent total sacrectomy. A meticulous preoperative workup, including magnetic resonance imaging (MRI), was followed by precise surgical steps: sigmoid colon and rectal mobilization, isolation of the iliac vessels,2,6 lumbosacral nerve trunk preservation, and strategic anterior and posterior osteotomies. The procedure concluded with reconstruction using mesorectal fat and bilateral gluteus maximus flaps.5-7 RESULTS: The patient's operation was conducted successfully without any perioperative complications, culminating in a chordoma resection with clear margins. Postoperative recovery was swift, allowing for discharge on the seventh day.

CONCLUSIONS

The application of our systematic sacrectomy method, with particular emphasis on the isolation of the external iliac veins, significantly minimized intraoperative bleeding risks and other perioperative complications. Our technique offers a reproducible and effective strategy for the surgical management of sacrococcygeal masses.

Soft-tissue reconstruction with pedicled vertical rectus abdominis myocutaneous flap after total or high sacrectomy for giant sacral tumor

BACKGROUND

The large soft-tissue defect after total or high sacrectomy for giant sacral tumor induces high incidence of wound complications. It remains a huge challenge to reconstruct the soft-tissue defect and achieve the preferred clinical outcome.

METHODS

A total of 27 patients undergoing one-stage total or high sacrectomy for giant sacral tumors between 2016 and 2021 in a tertiary university hospital were retrospectively reviewed. Participants were divided into two groups. Thirteen patients underwent a pedicled vertical rectus abdominis myocutaneous (VRAM) flap reconstruction, whereas 14 patients underwent a conventional wound closure. Patient's clinical characteristics, surgical duration, postoperative complications, and outcomes were compared between the two groups.

RESULTS

Patients in VRAM and non-VRAM groups were similar in baseline characteristics. The mean tumor size was 12.85 cm (range: 10-17 cm) in VRAM group and 11.79 cm (range: 10-14.5 cm) in non-VRAM group (P = 0.139). The most common giant sacral tumor is chordoma. Patients in VRAM group had a shorter length of drainage (9.85 vs 17.14 days), postoperative time in bed (5.54 vs 17.14 days), and total length of stay (19.46 vs 33.36 days) compared with patients in non-VRAM group. Patients in the VRAM group had less wound infection and debridement than patients in non-VRAM group (15.4% vs 57.1%, P < 0.001).

CONCLUSIONS

This study demonstrates the advantages of pedicled VRAM flap reconstruction of large soft-tissue defects after high or total sacrectomy using the anterior-posterior approach. This choice of reconstruction is better than direct wound closure in terms of wound infection, length of drainage, and total length of stay.

Sacrectomy with Posterior-Only Approach in Sacral Tumors: An Analysis of 26 Cases and Review of Literature

BACKGROUND

Sacral masses can be removed using anterior, posterior, or combined approaches. Achieving total sacrectomy through a posterior-only approach results in a shorter procedure time, minimal tissue damage, and a reduced risk of complications. In this study, we aimed to share our experience with performing total sacrectomy using a posterior-only approach in 26 patients and to assess their clinical outcomes at our center.

MATERIALS AND METHODS

This retrospective study examines the clinical progression, surgical response, and outcomes of 26 patients with various sacral mass pathologies. We accessed patient information from our hospital records.

RESULTS

The study included 14 men (54%) and 12 women (46%), with an average age of 49.8 years. Most cases had a normal body mass index, while 6 were overweight. Sacrectomy was performed at a high level in 12 patients and at a middle level in 14 patients. In addition to pain, motor deficits were observed in 9 patients, and sphincter dysfunction was found in 5. Preoperative embolization was conducted for 11 patients. The most prevalent lesions were chordoma (8 patients), malignant peripheral nerve sheath tumor (4 patients), giant cell tumor (3 patients), and solitary plasmacytoma (3 patients). Only 1 patient experienced a temporary partial motor deficit after surgery. There were no instances of cerebrospinal fluid leakage. Five patients experienced local recurrence, and 1 had distant metastasis.

CONCLUSIONS

Performing sacrectomy for large or giant sacral tumors through a posterior approach is both feasible and safe, resulting in reduced morbidity and no significant change in overall survival.

Characteristics, survivals and risk factors of surgical site infections after En Bloc sacrectomy for primary malignant sacral tumors at a single center

INTRODUCTION

For prolonged survival, primary malignant sacral tumors (PMST) are treated by En Bloc sacrectomy. Few studies analyzed specifically the surgical site infections (SSI) for this condition and whether they impact on the patients' survivals.

OBJECTIVES

The objectives were to (1) describe their characteristics; (2) compare the survivals of infected and non-infected patients; (3) identify patients- and surgery-related risk factors.

METHODS

We conducted a retrospective single center study on 51 consecutive patients with PMST who underwent an En Bloc sacrectomy. Mean follow-up was 89±68months (range, 13-256months). Histology consisted of 46 chordoma, 3 chondrosarcoma, 1 Ewing tumor, 1 malignant peripheral nerve sheet tumor. Mean age was 57.4±13.7years with 26 (51%) male. Approaches were mainly anterior-and-posterior with, for the anterior approach, 18 laparotomy and 32 laparoscopy. Other surgical characteristics included 39 (76%) sacrectomy above S3; 7 (14%) instrumented cases; 8 (16%) colostomy. A pedicled omental flap with artificial mesh was used for posterior wall reconstruction. Overall and disease-free survivals were compared between infected and non-infected patients using Kaplan-Meier curves and log-rank test.

RESULTS

A total of 29 (57%) patients developed a SSI (7 deep, 22 organ/space) at mean 13.2±7.7days. One patient had also an infected intraperitoneal hematoma at day 150. SSIs were polymicrobial in 26 (90%) cases with Enterococcus sp. (27%) and E. coli (24%) as predominant organisms. Overall and disease-free survivals were not statistically different between infected and non-infected patients. Factors associated with increased likelihood of SSI included age>65years (OR=3.64; 1.06-12.50; p=0.04) and an elevated ASA score (OR=3.28, 1.05-10.80; p=0.046). Neoadjuvant radiotherapy (OR=2.86; 0.97-9.37; p=0.08) demonstrated a trend towards increased risk of SSI. Tumor volume, sacrectomy level, operating time, laparoscopy, colostomy, instrumentation, bowel incontinence were not associated to an increased risk of SSI.

CONCLUSION

En Bloc sacrectomy for PMST led to frequent and early SSI which, however, did not seem to impact survivals. Preoperative frailty was the predominant risk factor found in this series. Further studies are required to identify protective measures.

LEVEL OF EVIDENCE

III, case-control study.

Reconstruction With 3D-Printed Prostheses After Sacroiliac Joint Tumor Resection: A Retrospective Case-Control Study

Background

Sacroiliac joint tumor is rare, and the reconstruction after tumor resection is difficult. We aimed to analyze and compare the clinical effects of three-dimensional (3D) printed prostheses and bone cement combined with screws for bone defect reconstruction after sacroiliac joint tumor resection.

Methods

Twelve patients with sacroiliac joint tumors who underwent tumor resection and received 3D-printed prostheses to reconstruct bone defects in our hospital from January 2014 to December 2020 were included in the study group Twelve matched patients who underwent sacroiliac joint tumor resection and reconstruction with bone cement and screws in the same time period were selected as the control group.

Results

In the 3D-printing group, six cases were extensively excised, and six cases were marginally excised. All patients were followed up for 6–90 months, and the median follow-up time was 21 months. Among them, nine patients had disease-free survival, two survived with tumor recurrence, and one died due to tumor metastasis. The MSTS-93 score of the surviving patients was 24.1 ± 2.8. The operation time was 120.30 ± 14.50 min, and the intraoperative bleeding was 625.50 ± 30.00 ml. In the control group, seven cases were extensively excised, and five cases were marginally excised. All patients were followed up for 6–90 months, with a median follow-up time of 20 months. Among them, nine patients had disease-free survival, one survived with tumor recurrence, and two died due to tumor metastasis. The MSTS-93 score of the patients was 18.9 ± 2.6. The operation time was 165.25 ± 15.00 min, and the intraoperative bleeding was 635.45 ± 32.00 ml. There was no significant difference in survival status, intraoperative blood loss, or complications between the two groups (P>0.05). However, there were statistically significant differences in operative time and postoperative MSTS-93 scores between the two groups (P<0.05).

Conclusions

After resection of the sacroiliac joint tumor, reconstruction using 3D printed prostheses was shorter and resulted in better movement function.

Sacral insufficiency fractures are a risk of massive bleeding during sacrectomy: patient series

BACKGROUND

Sacrectomy carries significant risk of bleeding; however, specific risk factors, apart from medical comorbidities and tumor type, for this life-threatening complication remain unclear. This study describes two cases of massive bleeding, including one death during sacrectomy attributable to adherence of the internal iliac vein (IIV) and its neuroforaminal tributaries from sacral insufficiency fractures.

OBSERVATIONS

The authors presented two cases involving patients who received sacrectomy for a chordoma and experienced massive bleeding from the IIV due to adherence of the IIV and its neuroforaminal tributaries around sacral insufficiency fractures. They assessed their institution’s previous two decades’ experience of sacrectomies to determine risk factors for massive bleeding and performed anatomical dissection of 20 hemipelvises, which revealed the close proximity of the IIV to the sacral foraminae and the consistency of neuroforaminal tributaries arising from the foraminae.

LESSONS

Sacral insufficiency fractures may cause scarring that adheres to the IIV and its neuroforaminal tributaries, which risks massive bleeding during sacrectomy.