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Control of presacral venous bleeding during rectal surgery

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Abstract

Background

Presacral venous hemorrhage is an uncommon but potentially life-threatening complication of rectal surgery. It is difficult to control presacral venous hemorrhage with conventional hemostatic measures and several alternative methods for hemostasis have been proposed. We described our experience of using the combination of a hemostatic matrix and an absorbable hemostat as an alternative method of hemostasis.

Methods

From September 2007 to March 2009, 83 patients underwent rectal surgery for cancer, ulcerative colitis, or familial adenomatous polyposis. Three patients (3.6%) had severe presacral hemorrhage, which was controlled by the combined use of a hemostatic matrix (FloSeal; Baxter, USA) and an absorbable hemostat (Surgicel Fibrillar; Ethicon, USA).

Results

Intraoperative blood transfusion was required in 1 patient. Postoperative blood loss was minimal and drain was removed on day 4 in all 3 patients.

Conclusions

The use of synthetic hemostatic agents is an effective and simple way to arrest presacral bleeding where conventional methods fail.

Section snippets

Patients and Method

A retrospective review of 83 patients who underwent rectal surgery from September 2007 to March 2009 was performed. All the patients who sustained intraoperative presacral bleeding during mobilization of the rectum and methods of hemostasis were noted. Fifty-eight patients had a low anterior resection for rectal cancer and 25 patients had proctocolectomy and ileal anal pouch anastomosis for ulcerative colitis or familial adenomatous polyposis. Three patients (3.6%) with a previous ileorectal

Results

In the first patient, initially we tried to arrest bleeding by cauterization, which exacerbated the bleeding. As an alternative, the pelvis was packed with swabs which resulted in recurrent bleeding as soon as they were removed. Following this, we tried to insert a metallic thumbtack into the sacrum which unfortunately failed to penetrate the bone and bended. The patient continued to bleed when we attempted the combined use of a hemostatic sealant and an absorbable hemostat followed by gauze

Comments

Presacral venous bleeding is an uncommon but potentially life-threatening complication of rectal surgery with an incidence of 3% to 9.4%.3 It is more frequent in patients who undergo preoperative radiotherapy for rectal cancer3 or in patients who have had previous rectal surgery. Our percentage of 3.6 is in line with literature reports and also all 3 patients had a previous low ileorectal anastomosis for ulcerative colitis.

Traditional methods for stopping bleeding include pelvic packing and the

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