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Abstract
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Background and Aims Hemipelvectomy and reconstruction with limb salvage stands as the primary treatment for periacetabular pelvic sarcomas. Anesthetic management is challenging due to highly aggressive surgery and the complex pelvic anatomy (figure 1). Intraoperative bleeding management, coagulation disturbances and postoperative pain are particularly relevant. We describe our clinical practice in these surgeries.
Methods A case series of 10 patients with periacetabular pelvic sarcomas that underwent hemipelvectomy and pelvic reconstruction with custom prosthesis between 2016 and 2022 was analyzed. Approval by IRB was requested (IIBSP-COO-2024-72).
Results All patients underwent combined epidural and intravenous general anesthesia. Monitoring included arterial pressure waveform for hemodynamic parameters and goal-directed fluid therapy, alongside thromboelastometry for coagulopathy correction guidance. Two patients underwent preoperative arterial embolization. A pre-incisional bolus of 10-15mg/kg tranexamic acid followed by an infusion of 10-15mg/kg over 8 hours was administered. Median blood loss was 2375 ml (1500 – 4500 ml). Intraoperative fluid and transfusion therapy are detailed in table 1. Four patients required plastic surgical reconstruction. Median surgical time was 7 hours (6.5 – 13.5), ICU stay 2.5 days (1 – 10) and hospital stay 36 days (18 – 116). Epidural infusion of 2mg/ml ropivacaine with 2mcg/ml fentanyl achieved optimal pain control. Two accidental catheter dislodgements were registered (figure 2).
Periacetabular pelvic sarcoma and reconstruction with custom prosthesis
Intraoperative fluids, blood and blood component therapy
Days with epidural catheter
Conclusions Pelvic reconstruction with custom prosthesis after large oncologic resection is a long-lasting painful procedure associated with high morbidity. Perioperative management of major bleeding and optimal pain management with epidural analgesia are primary goals for the anesthesiologist. Subcutaneous tunnelling of epidural catheters should be considered to prevent accidental dislodgement.