应用前侧皮瓣的半骨盆截肢术

The application of anterior flap hemipelvectomy in the treatment of pelvic tumors

目的探讨应用前方带股血管蒂的股四头肌肌皮瓣覆盖臀后部创面的半骨盆截肢术（前侧皮瓣半骨盆截肢术）的手术适应证、手术方法、患者预后和并发症情况。方法自2009年4月至2010年10月，北京积水潭医院骨肿瘤科对10例患者采用前侧皮瓣半骨盆截肢术，男9例，女1例；年龄30-62岁，平均45岁。软骨肉瘤7例、上皮样肉瘤1例、多形性脂肪肉瘤1例、梭形细胞肉瘤1例。结果9例患者获得随访，随访时间12-30个月，平均21．5个月。术后仅1例出现轻度皮缘坏死，无伤口感染者。局部复发3例（33-3％），2例软骨肉瘤、1例上皮样肉瘤。死亡3例（33．3％），包括复发的2例、另1例软组织脂肪肉瘤患者因肺转移死亡；1例复发患者带瘤存活；2例患者肺转移带瘤存活；余3例未见复发和转移。结论前侧皮瓣半骨盆截肢术适用于：（1）臀后部软组织肿块侵及皮肤皮下或反应区到达皮下；（2）骨盆恶性肿瘤复发需行半骨盆截肢，原手术切口污染臀部软组织，无法使用常规后侧皮瓣；（3）臀部皮肤软组织因放疗等原因影响后侧皮瓣血运。此手术的必要条件是髂外血管到股血管通畅良好，可顺利游离且不在肿瘤反应区内。适应证明确的情况下，前侧皮瓣覆盖较常规后侧半骨盆截肢更便于操作和覆盖，便于获得更好的外科边界，术后并发症少。

Objective To investigate indications, technique, prognosis and complications of anterior flap hemipelvectomy （hemipelvectomy using a quadriceps femoris muscle flap with superficial femoral artery） in the treatment of pelvic tumors. Methods From April 2009 to October 2010, 10 patients with pelvic tumors underwent anterior flap hemipelvectomy in our department. There were 9 males and 1 female, aged from 30 to 62 years （average, 46 years）. There were 7 cases of chondrosarcoma, 1 case of epithelioid sarcoma, 1 case of pleomorphic liposarcoma and 1 case of spindle cell sarcoma. Results Nine patients were followed up for 12 to 30 months （average, 21.5 months）. Superficial skin necrosis occurred in 1 patient, while there was no wound infection. Local recurrence （33.3%） occurred in 3 patients, including 2 cases of chondrosareoma and 1 case of epithelioid sarcoma. Three patients died at last, including 2 patients with local recurrence and 1 with pulmonary metastasis from liposarcoma. Two patients survived with pulmonary metasta- sis, and remaining 3 patients survived without recurrence and metastasis. Conclusion Anterior flap hemipelvectomy is indicated for： （1） patients with extensive soft tissue sarcoma in the buttock, and the tumor or reaction zone involve the subcutaneous tissue; （2） patients with recurrent pelvic tumors, and the conventional posterior flap can＇t be used due to contamination by the original incision; （3） patients whose posterior flap has poor blood supply due to radiotherapy or other factors. The prerequisite of the surgery is that the blood stream between external iliac artery and femoral artery is unobstructed; moreover the blood vessels are not in the tumor reaction zone. Compared with conventional posterior flap, the anterior flap hemipelvectomy is an easier procedure, which not only can easily cover surgical defect and obtain better surgical margin, but also has less complications.