Control of blood loss during giant upper extremity tumor resection by interventional methods

doi:10.21203/rs.3.rs-1609030/v1

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Control of blood loss during giant upper extremity tumor resection by interventional methods

https://doi.org/10.21203/rs.3.rs-1609030/v1

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Background:

The purposes of this retrospective study were to determine the efficacy of interventional methods in control of intraoperative blood losses and investigate the perioperative complications.

Methods:

The cases of 44 patients in whom a giant upper extremity tumor had been operated between 2008 and 2022 were analyzed retrospectively. Twenty-nine patients were treated with interventional methods(Group A)compared with fifteen patients treated without the interventional methods(Group B).According to the different intervention methods, group A was further broken down into Group C(the combination of the balloon occlusion and transarterial embolization(TAE),n=11) and Group D(the TAE group,n=18).According to the days of TAE prior to the surgery, Goup D was broken into Group E(the same day of TAE prior surgery) and Group F(more days of TAE prior to surgery).The demographic features ,the blood loss and ICU(intensive care unit) admission rate and the application of vasopressors during the surgery were kept and compared.

Results:

Clinical records of 44 cases who were diagnosed with giant upper extremity tumor and underwent surgery were collected. The number of groups A,B,C,D,E and F were 29, 15, 11,18,7,11.The maximum diameter of the tumor(cm) in Group B(without interventional group) was significant larger than that of o the Group A(with interventional group)(12.61±4.47 vs 9.78±3.71,P=0.031<0.05).The transfusion of blood plasma(ml) of Group B is also higher than that of Group A(425.33±476.20 vs 425.33±476.20,P=0.021<0.05).Although the blood loss(ml) didn’t differ significantly between Group A and Group B(467.93±302.08 vs 1150±1424.15,p=0.087>0.05 ).But when we defined massive bleeding as the blood loss over 1000 mls,we found that the massive bleeding rate in Group A is lower than that in Group B(6.9% vs 46.47%,p=0.004<0.05).The rate of minors(patient’s age less than 18) in Group C was also significantly higher than that in Group D(27.7% vs 0.00%,p=0.045<0.05).The amount of transfusion of RBC(ml) in Group C was also significantly higher than that of Group D(458.18±292.22 vs 164.44±224.03,p=0.021<0.05). We didn’t find obvious perioperative complications in our patients.

Conclusions:

Interventional methods decrease the size of the tumor, and decrease the blood loss and the amount of blood transfusion in patients with giant upper extremity tumor. For senile patients with primary vessel problems, the placement of endovascular balloon should be more cautious.There exits no obvious complications perioperatively.

giant upper extremity tumor

resection

interventional methods

anesthesia

Since the first reported cases in the 1970s, the role of transarterial embolization(TAE) in the treatment of primary or metastatic bone tumors has gradually been accepted.Preoperative embolization can effectively reduce the risk of intraoperative bleeding and the incidence of complications, and has a greater effect for tumors with abundant blood supply[1].Arterial embolization combined with abdominal aortic balloon block has been widely used in lower extremity surgery, such as pelvic and sacral tumors, and plays an important role in reducing perioperative bleeding and complications[2–4].

Similarly,when it comes to the giant upper extremity bone tumors,we might face the resembling problems,such as bleeding,limb preservation and rapid perioperative rehabilitation. Previous cases have been reported that preoperative arterial embolization is an effective neoadjuvant treatment for surgery for upper extremity bone tumors, especially for large tumors with joint involvement[5].For hypervascular bone tumors, TAE could be considered as preoperative measures to reduce the blood loss during the upper extremity tumor resection[6].

It has also been reported in the literature that the administration of subclavian artery balloon can reduce the perioperative bleeding and complications at the time of trauma[7].Subclavian balloon occlusion may bring some related complications, including subclavian artery stenosis, stroke, limb ischemia, spinal cord ischemia and so on.It has also been reported in the literature that the placement of an infra clavicular balloon can reduce the occurrence of perioperative stroke[8].

However, the impact of the interventional methods on the hemodynamics and the occurrence of perioperative complications for upper extremity tumor is still unclear.Our study aims to explore the effects of interventional methods on hemodynamic and perioperative complications during surgery for giant bone tumors of the upper extremity.

The study protocol was approved by the Ethics Committee of Peking University People’s Hospital (Approval No.2022PHB084-001).And the research adhered to the tenets of the Declaration of Helsinki.As shown in Fig. 1, we retrospectively analyzed the history data of 44 patients with retinoblastoma who were admitted to our hospital during 1st March 2008 and 1st March 2022 by searching our electronic medical record database using the key word “giant upper extremity tumor”. The inclusion criteria were as follows: (1) giant upper extremity tumor ready for surgery; (2) all the information related to the patients’features are available for analysis. The patients with missing clinical data and the cases without operation were excluded from our study. The demographic and clinical information were recorded from the electronic anesthetic documentation system. Based on the foregoing criteria, 44 patients were included into statistical analysis. According to the acceptance of interventional methods, the patients were divided into an interventional group (Group A; n = 29) and an un-interventional group (Group B; n = 15).The demographic data was collected including age, BMI (body mass index), American Society of Anesthesiologists (ASA) physical status,the size of the tumor(calculated by the maximum diameter of the tumor).

The procedure for the management of transarterial embolization(TAE) and subclavian artery balloon were as follows. On the day of surgery or some days before surgery, the patient was first transferred to the interventional operating room for TAE.After finding the tumor where the blood supply was abundant,gelfoam or microspring ring was appled to occlude the blood supply of the tumor.On the day of surgery ,the subclavian artery balloon was placed for insertion under fluoroscopic guidance. The procedure was performed by interventional physicians. Catheters were inserted via the femoral arteries under local anesthesia, and the tips were placed into the subclavian artery. The balloon was briefly inflated, and contrast was injected to verify occlusion of the artery. After placement of the catheters, the patient was transferred to the operating room.

According to the different intervention methods, group A was further broken down into Group C(the combination of the balloon occlusion and TAE,n = 11) and Group D(the TAE group,n = 18).According to the days of TAE prior to the surgery, Goup D was broken into Group E(the same day of TAE before surgery) and Group F(more than one day of TAE prior to surgery).The clinical data included the operation times,the anesthesia time, the estimated blood loss, the transfusion of red blood cell and plasma, the application of the vasopressors, the admission of ICU(intensive care unit) and the postoperative hospital stay.The possible perioperative complications were also kept,including stroke,the ischemia of remote limbs and the disturbance of the spinal functions.The TAE days ahead of surgery,and the balloon occlusion time were also kept.

Statistical analysis

SPSS 21.0 statistical software was used for data description and analysis. Continuous variables were expressed as mean ± standard deviation. The independent sample t test was employed for measurement data, and Chi-square or Fisher’s exact tests were used for categorical data. A value of P < 0.05 was considered significant.

The rate of utilization of the technique of inventional methods was 65.91% (29/44) among the patients diagnosed with giant upper extremity tumors. The rate of subclavian balloon occlusion in inventional patients was 37.93%(11/29). And the average overall balloon occlusion time was 22.73 min (Table 2). According to the acceptance of interventional methods, the patients were divided into an interventional group (Group A; n = 29) and an un-interventional group (Group B; n = 15).According to the different intervention methods, group A was further broken down into Group C(the combination of the balloon occlusion and TAE,n = 11) and Group D(the TAE group,n = 18).According to the days of TAE prior to the surgery, Goup D was broken into Group E(the same day of TAE prior to surgery) and Group F(more days of TAE prior to surgery)(Fig. 1).

Table 1

Demographic characteristics of patients with giant upper extremity tumor
	Group A(n = 29)	Group B(N = 15)	P
Age(years old)	48.76 ± 22.84	42.33 ± 15.64	0.279
Height(cm)	166.07 ± 9.31	167.60 ± 7.24	0.582
Weight(kg)	60.17 ± 13.72	65.20 ± 11.16	0.228
BMI(kg/m2)	22.07 ± 3.38	23.56 ± 3.06	0.157
The maximum diameter of the tumor(cm)	9.78 ± 3.71	12.61 ± 4.47	0.031*
The operation time(min)	147.07 ± 78.96	141.67 ± 58.12	0.816
The anesthesia time(min)	177.07 ± 78.84	171.00 ± 58.29	0.794
The blood loss(ml)	467.93 ± 302.08	1150 ± 1424.15	0.087
The transfusion of RBC(ml)	275.86 ± 286.37	466.67 ± 532.74	0.128
The transfusion of blood plasma(ml)	155.90 ± 269.67	425.33 ± 476.20	0.021*
The POD(days)	9.35 ± 7.36	10.47 ± 7.36	0.641
ASA classification			0.441
Ⅰ	6	2
Ⅱ	22	11
Ⅲ	1	2
Massive bleeding	2/29(6.90%)	7/15(46.67%)	0.004*
The application of vasopressor	9/29(31.03%)	3/15(20.00%)	0.500
The admission of ICU	2/29(6.90%)	1/15(6.67%)	1.000

Table 2

Demographic characteristics of patients with different kind of interventional methods
	Group C(n = 11)	Group D(N = 18)	P
Age(years old)	33.81 ± 20.47	57.89 ± 19.49	0.004*
Height(cm)	170.55 ± 8.25	163.33 ± 9.04	0.041*
Weight(kg)	63.18 ± 16.14	58.33 ± 12.14	0.365
BMI(kg/m2)	21.54 ± 3.91	22.39 ± 3.08	0.519
the maximum diameter of the tumor(cm)	10.64 ± 3.42	9.25 ± 3.87	0.337
The operation time(min)	151.82 ± 54.14	144.17 ± 92.31	0.249
The anesthesia time(min)	183.64 ± 52.21	144.17 ± 92.31	0.805
Balloon occlusion time(min)	22.73 ± 34.67
The blood loss(ml)	513.64 ± 357.14	440.00 ± 270.36	0.534
The transfusion of RBC(ml)	458.18 ± 292.22	164.44 ± 224.03	0.005*
The transfusion of blood plasma(ml)	216.36 ± 324.57	120.56 ± 232.64	0.363
The POD(days)	6.73 ± 2.28	10.94 ± 8.89	0.070
ASA classification			0.216
Ⅰ	4	2
Ⅱ	7	15
Ⅲ	0	1
Massive bleeding	1/11(9.09%)	1/17(5.88%)	1.000
The application of vasopressor	4/11(36.36%)	5/18(27.78%)	0.512
The admission of ICU	0/11(0)	2/18(11.11%)	0.512
The minors(patient’s age less than 18)	3/11(27.27%)	0/18(0.00%)	0.045*

Data on the perioperative hemodynamic control, the perioperative clinical outcome and complications were also observed.

The maximum diameter of the tumor(cm) in Group B(without interventional group) was significant larger than that of o the Group A(with interventional group)(12.61 ± 4.47 vs 9.78 ± 3.71,P = 0.031 < 0.05).The transfusion of blood plasma(ml) of Group B is also higher than that of Group A(425.33 ± 476.20 vs 425.33 ± 476.20,P = 0.021 < 0.05).Although the The blood loss(ml) didn’t differ significantly between Group A and Group B(467.93 ± 302.08 vs 1150 ± 1424.15,p = 0.087 > 0.05 ).But when we defined massive bleeding as the blood loss over 1000 mls,we found that the massive bleeding rate in Group A is lower than that in Group B(6.9% vs 46.47%,p = 0.004 < 0.05)(Table 1).

According to the different intervention methods, group A was further broken down into Group C(the combination of the balloon occlusion and TAE,n = 11) and Group D(the TAE group,n = 18).The average balloon occlusion time(min) was 22.73.The patients in Group C were more younger than that of Group D(33.81 ± 20.47 vs 57.89 ± 19.49,P = 0.004 < 0.05).The rate of minors(patient’s age less than 18) in Group C was also significantly higher than that in Group D(27.7% vs 0.00%,p = 0.045 < 0.05).The amount of transfusion of RBC(ml) in Group C was also significantly higher than that of Group D(458.18 ± 292.22 vs 164.44 ± 224.03,p = 0.021 < 0.05).But there didn’t exist any difference in the amount of blood loss between Group C and Group D(513.64 ± 357.14 vs 440.00 ± 270.36,p = 0.534 )(Table 2).

According to the different pre-operative embolization days, Group D was further broken down into the Group E(the same day of TAE before surgery) and Group F(more than one day of TAE prior to surgery).The blood loss(ml) in these two Groups didn’t differ significantly(357.14 ± 229.91 vs 492.73 ± 291.00,p = 0.314).Upon the operation time(min),we didin’t observe significant difference between Group E and Group F(128.57 ± 28.97 vs 154.09 ± 117.06,p = 0.583).The postoperative ICU(intensive care unit) admission,the application of vasopressors between the different two groups were not significantly differential(Table 3).

Table 3

Demographic characteristics of patients with different days of TAE
	Group E(n = 7)	Group F(N = 11)	P
Age(years old)	52.86 ± 18.47	61.09 ± 20.30	0.399
Height(cm)	165.29 ± 8.40	162.09 ± 9.61	0.482
Weight(kg)	59.71 ± 11.29	57.45 ± 13.10	0.712
BMI(kg/m2)	21.25 ± 3.02	23.11 ± 3.03	0.221
the maximum diameter of the tumor(cm)	9.43 ± 5.12	9.14 ± 3.11	0.881
The operation time(min)	128.57 ± 28.97	154.09 ± 117.06	0.583
The anesthesia time(min)	158.57 ± 28.97	182.27 ± 117.72	0.612
The blood loss(ml)	357.14 ± 229.91	492.73 ± 291.00	0.314
The transfusion of RBC(ml)	291.43 ± 234.91	83.64 ± 183.70	0.052
The transfusion of blood plasma(ml)	161.43 ± 276.43	94.55 ± 210.35	0.583
The POD(days)	12.14 ± 11.23	10.18 ± 7.56	0.662
Massive bleeding	0/7(0)	1/11(9.09%)	1.000
The application of vasopressor	3/7(42.86%)	2/9(22.22%)	0.326
The admission of ICU	0/7(0)	2/11(18.18%)	0.497

We didn’t witness the occurrence of the subclavian artery stenosis, stroke, limb ischemia, spinal cord ischemia in all of the patients.

Interventional methods have been applied for the tumor therapy or perioperative methods for operation.For visceral tumors,such as hepatic tumors and renal tumors, interventional methods could help to decrease the tumor size,the blood loss,preserve the function of the organ,and at the same time have little complications[9–10].For bone tumors, interventional methods could also be feasible and safe in reducing the intraoperative blood loss and facilitate tumor resection,especially for tumors with abundant vascular supply[11–12].Previous study has introduced the application of interventional methods in upper extremities,but in very small sample size[13].To our knowledge, this is the first report that concretely assess the control of blood loss during giant upper extremity tumor resection by interventional methods.

One previous study has indicated that preoperative and therapeutic embolization are feasible in extremities of bone and soft tissue tumors.The blood loss of the scapular Ewing sarcoma is 1800 ml,and the devascularization rate is 70%[14].In our study,we compared the maximum diameter of the tumor(cm) in different groups.In Group B(without interventional group), the maximum diameter of the tumor(cm) was significant larger than that of the Group A(with interventional group)(12.61 ± 4.47 vs 9.78 ± 3.71,p = 0.031 < 0.05). Although the blood loss(ml) didn’t differ significantly between Group A and Group B(467.93 ± 302.08 vs 1150 ± 1424.15,p = 0.087 > 0.05 ).But the massive bleeding rate in Group A is lower than that in Group B(6.9% vs 46.47%,p = 0.004 < 0.05).And the transfusion of blood plasma(ml) of Group B is also higher than that of Group A(425.33 ± 476.20 vs 425.33 ± 476.20,p = 0.021 < 0.05).Preoperative embolization of primary or metastatic bone tumors is an effective method in shrinking the tumor size and reducing blood loss.

TAE could provide feasible blood control in operations.But,there also exist some problems,such as the impulse intervention of TAE for tumor might not provide longlasting devascularization of the tumor.Not all the tumors could receive the complete percent of TAE,and as time goes by,the revascularization of the tumor might increase[15].There are also flexible addition of invertional methods,such as the subclavian balloon occlusion.The subclavian balloon has been applied in subclavian artery avulsion following blunt trauma.Subclavian balloon can be feasible to control bleeding and allow an surgery of open repair[16].In an case of Subclavian artery laceration following clavicle fracture,endovascular balloon was also used while the fixation of the clavicle was completed[17].In our research,according to the different intervention methods, group A was further broken down into Group C(the combination of the balloon occlusion and TAE,n = 11) and Group D(the TAE group,n = 18).The difference in the amount of blood loss between Group C and Group D(513.64 ± 357.14 vs 440.00 ± 270.36,p = 0.534) was not significant.But the amount of transfusion of RBC(ml) in Group C was significantly higher than that of Group D(458.18 ± 292.22 vs 164.44 ± 224.03,p = 0.005 < 0.05).Because the rate of minors(patient’s age less than 18) in Group C was significantly higher than that in Group D(27.7% vs 0.00%,p = 0.045 < 0.05).And the minors were more intolerable to blood loss and ischemia,so the blood transfusion was more active.

The possible complications accompanied by endovasclular balloon could occur in all stages including positioning, inflation, during occlusion, deflation, and removal of the sheath[18]. We should learn about these complications before we act.To decrease the compliactions,we should try to minimize the occlusion time ,lessen the time the balloon remains in our body.In our study ,we didn’t observe the relative complications associate with the endovascular balloon,such as subclavian artery stenosis, stroke, limb ischemia, spinal cord ischemia in all of the patients.In our study,the balloons were all inserted the day of the surgery, the average balloon occlusion time(min) was 22.73,and the sheath was immediately removed after the surgery was ended.What’s more,the patients in balloon occlusion group were younger than that of placebo group(33.81 ± 20.47 vs 57.89 ± 19.49,p = 0.004 < 0.05) in our study.For senile patients with primary vessel problems, we should be more cautious of the complications of endovasular balloon.Communication with the anesthesia team is of vital importance to guarantee the safety perioperatively.

In patients with fracture,delayed hemorrhage might increase a patient’s perioperative death rate; early embolization intervention might improve the patients’ outcomes[19–20].Shorter doortoembolization time(DTE) time was associated with better clinical outcomes in patients with complex pelvic fracture[21]. For patients with bone tumors,the embolization time before surgery also arouses great interests for researchers.One previous study investigated the difference of embolization time of intraoperative blood loss for renal cell carcinoma bone metastases.The results may suggest that it is beneficial to perform the surgery < 1 day after TAE[22].The optimal time of embolization has been in debate.Some researchers suggest that the operation should be undertaken as quickly as possible,because there exists the risk of revascularization[23–25].In our research,according to the different pre-operative embolization days, Group D was further broken down into the Group E(the same day of TAE before surgery) and Group F(more than one day of TAE prior to surgery).The blood loss in these two Groups didn’t differ significantly(357.14 ± 229.91 vs 492.73 ± 291.00,p = 0.314).Upon the operation time(min),we didin’t observe significant difference between Group E and Group F(128.57 ± 28.97 vs 154.09 ± 117.06,p = 0.583).Resemblingly,the postoperative ICU admission,the application of vasopressors between these groups were not significantly differential.

Limitations

The main limitation of our study is its retrospective characteristics. Because subjects were not randomly allocated, selection bias may exist. The number of cases is also small in our study, and this study could not be adequately powered statistically. And the medical intervention (such as the choice of patients to receive TAE or balloon occlusion) cannot be made on a blinded base. As a result, a large multicenter and randomized controlled study is needed to verify the findings.

TAE: transarterial embolization,

BMI :body mass index,

ASA：American Society of Anesthesiologists,

ICU:intensive care unit,

POD:postoperative day,

RBC:red blood cell,

DTE:door‑to‑embolization time

Acknowledgements

We thanks Xu Guo for his designing of data retrieval program.We also thank the surgeons and interventional doctors from our hospital for their cooperations.

Authors’ contribution

Study conception: HL and YF.

Study design: All authors.

Study conduct: FH.

Data analysis: FH.

Data interpretation: FH.

Drafting of the manuscript: FH.

All authors approved the final version of the manuscript.

Funding

No funding was obtained for this study.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

Ethical approval has been confirmed from the Ethics Committee of Peking University People’s Hospital (ref approval number: Approval No.2022PHB084-001).

Consent for publication

Not Applicable.

Competing interests

There exists no financial and non-financial competing interests.

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Control of blood loss during giant upper extremity tumor resection by interventional methods

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Materials And Methods

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Discussion

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