直肠癌术中骶前大出血的防治

目的 探讨直肠癌根治术中骶前静脉丛大出血的预防和处理方法.方法 回顾性分析本院2001年1月至2007年12月收治的42例直肠癌术中骶前静脉丛大出血的临床资料.结果 42例骶前静脉丛大出血中40例止血成功,2例死亡,Miles术35例,Dixon术7例,30例出血量为900～8000 mL.结论 手术操作不当是导致骶前大出血的主要原因,按盆腔解剖结构正确操作是预防出血的关键,术中压迫法和术后纱布填塞法是处理骶前大出血最有效的方法.     

直肠癌术中盆壁出血的预防和处理

直肠癌1280例根治术中合并骶前及盆腔出血30例(2．3％)，掌握盆腔脏器、血管筋膜解剖，操作熟练，解剖层次正确是预防盆腔大出血的关键。解剖直肠后壁时，务必要注意保护好骶前筋膜．钝锐性分离相结合。分离直肠前壁时，注意勿损伤前列腺或阴道后壁的静脉丛。骶前静脉丛大出血，可以采取缝扎．大纱布充填压迫；骶椎静脉出血，可以用图钉按压止血，髂内动静脉损伤可以结扎髂内动脉，缝扎或止血海绵压迫止血，前列腺及阴道后壁出血．可以用“8”字缝合打包压迫止血。     

直肠癌根治术骶前静脉大出血的原因及处理对策

目的 探讨直肠癌根治术中骶前大出血的原因及纱布填塞压迫法治疗骶前大出血的临床应用价值。方法 对我院2001年1月-2006年9月的直肠癌患者术中发生的5例骶前静脉大出血的原因及纱布填塞法压迫止血治疗的经验进行回顾性分析。结果本组患者1例因用手指分离至骶尾部时撕破骶前筋膜致骶前静脉破裂出血，2例为未进入正常解剖层次盲目钝性分离骶前筋膜而引起出血，2例因术中骶前静脉出血处理不当致大出血，均使用纱布填塞压迫法后很快止血成功，顺利完成手术。术后72小时去除纱布，无再次继发性出血发生，患者恢复好，随访无不良反应。结论 直肠癌根治术中未能掌握正确的解剖层次或操作方法失当是骶前静脉丛大出血主要原因．纱布填塞压迫止血是处理骶前静脉破裂大出血可靠的方法。     

直肠癌术中盆腔大出血的预防和处理

目的　介绍直肠癌根治手术中防止盆腔大出血的经验与紧急处理措施。方法　 1993年 8月至 2 0 0 0年 4月我科完成直肠癌根治手术 687例。术者掌握盆腔解剖 ,沿间隙操作 ,保护好骶前静脉丛 ;沿髂内动脉内侧镰状筋膜处理侧韧带 ,有时结扎直肠中动脉 ;肿瘤浸润阴道或前列腺可边切除边缝合 ;盆腔侧壁中度浸润者可在侧方淋巴结清除的同时 ,合并髂内动、静脉分支和肿瘤切除。发生盆腔大出血 ,根据大出血部位及肿瘤情况可采用骶丛止血钉按压法 ,纱布压迫止血法 ,缝扎止血法或血管修补术止血。结果　发生术中大出血仅 14例 ,术中失血量 <40 0ml 5例 ,40 0～ 80 0ml 8例 ,>80 0ml 1例。止血后未发生再次大出血。行Miles手术 8例 ,保肛手术 6例 ,无手术中死亡。结论　直肠癌根治手术中按解剖层次正确操作 ,阻断直肠周围血流可防止盆腔大出血。发生盆腔大出血可用骶丛止血钉、纱布压迫、缝扎止血或血管修补术止血。     

直肠癌术中盆腔大出血的预防和处理

目的：介绍直肠癌根治手术中防治盆腔大出血的处理经验。方法：１９９３年８月～２０００年４月,共完成直肠癌根治手术６２７例。术中因血管损伤而发生大出血者１２例,计骶前静脉丛６例、骶椎静脉１例、前列腺静脉丛２例、髂内动静脉分支２例,髂总静脉１例。防治方法：术者应掌握盆腔解剖,力求沿间隙操作,保护好骶前静脉丛,沿髂内动脉内侧镰状筋膜处理侧韧带。肿瘤浸润阴道或前列腺时可边切除边缝合,盆腔侧壁轻度浸润者可在侧方淋巴结清除的同时,合并髂内动静分支结扎。发生盆腔大出血时,应根据出血部位和肿瘤情况,分别选用骶丛止血钉按法、纱布压迫止血法、缝所止血法或血管修补术。结果：本组出血率１．９１％,失血量〈１５０ｍｌ者５例,１５０～５００ｍｌ１６例,〉５００ｍｌ者１例。应用骶丛止血钉按压止血４例,纱布压迫止血法３例,髂内动脉分支缝扎２例,     

直肠癌术中骶前静脉丛破裂大出血的防治探讨

目的:探讨直肠癌根治术中骶前静脉丛破裂大出血的常见原因和防治方法。方法:对我科进行的直肠癌根治术患者进行系统性分析，术中发生骶前静脉丛破裂大出血7例，术中按出血部位和手术进展情况分别采取止血钉钉压、碘仿纱条填塞法止血。结果:6例止血成功并痊愈出院，1例因止血失败出血死亡。结论:手术操作不当是导致术中骶前静脉丛破裂大出血的主要原因，实行全直肠系膜切除(TME)是预防骶前静脉丛破裂大出血的关键。止血钉钉压和碘仿纱条填塞是治疗术中骶前静脉丛破裂大出血的有效方法。     

纱布填塞治疗骶前静脉丛大出血

目的探讨骶前静脉丛大出血的治疗。方法回顾性分析12例骶前静脉丛大出血的患者,原发病为直肠癌9例,骶前肿瘤2例,右盆腔化学感受器瘤1例。出血时可用纱布填塞压迫止血。结果本组12例中1例用一般止血无效,致出血性休克死亡,其余11例用纱布填塞压迫均治愈。结论骶前静脉丛损伤大出血用纱布填塞压迫,止血效果好,最适合基层医院,值得推荐。     

直肠癌根治术中骶前静脉丛大出血防治探讨

目的:探讨直肠癌根治术中骶前静脉丛大出血的常见原因和防治方法. 方法:术中发生骶前静脉丛大出血5例,分别采取图钉钉压、碘仿纱条填塞止血. 结果:全部病例止血成功并痊愈出院.结论:手术操作不当是导致术中骶前静脉丛大出血的主要原因,实行全直肠系膜切除(TME)是预防骶前静脉丛破裂大出血的关键,图钉钉压和碘仿纱条填塞是治疗术中骶前静脉丛大出血的有效方法.     

24例骶前静脉丛大出血的处理体会

各种盆腔内手术引起的骶前静脉丛破裂大出血,来势凶猛,止血有一定困难。如处理不当往往给病人带来严重后果。本文综合4组计24例,其中23例在直肠癌或骶前肿瘤切除术中,发生骶前静脉丛破裂大出血,1例因脱肛行肛周注射药物造成直肠肠壁及其周围间隙感染而致大出血,均采用了髂内动脉结扎等不同止血方法。现将4组的止血经验综合分析报道如下。临床资料(见表)     

Foley尿管气囊压迫治疗骶前静脉丛大出血的评价(附6例报告)

目的:评价直肠癌根治术中用Foley尿管气囊压迫治疗骶前静脉丛大出血(MPVP)的临床价值。方法:分析1995~2005年用Foley尿管气囊压迫治疗骶前静脉丛大出血6例的临床资料。结果:6例骶前大出血中全部用Foley尿管气囊压迫控制出血,术中出血量为800~1700mL,Foley尿管于术后4d拔除3例,5d1例,6d2例,均无再出血,会阴切口均一期愈合。结论:Foley尿管气囊压迫治疗骶前静脉丛大出血是一种简单安全有效的治疗方法。     

New concepts in severe presacral hemorrhage during proctectomy

In the past, surgeons thought that severe presacral hemorrhage during proctectomy was caused by damage of the presacral venous plexus. By studying the anatomy and clinical data, we found that injury of the sacral basivertebral vein also caused this serious complication. Presacral hemorrhage is seen as massive bleeding from the distal pelvic surface of sacrum or from one to several large-caliber foramina of sacral basivertebral veins in that area. This type of presacral hemorrhage is more dangerous than that from simple injury of presacral venous plexus and sometimes it is fatal. We describe the anatomic features of the vertebral venous system and its close relationship with severe presacral hemorrhage. We also propose some new concepts about cause, hemostatic measures, and principles of prevention.     

高频电凝治疗骶前大出血

目的 评价高频电凝治疗骶前大出血的临床价值.方法 回顾性分析2005年2月至2008年3月用高频电凝治疗的8例骶前大出血患者的临床资料.当发生骶前大出血时,先以纱布或手指压迫出血部位,再充分暴露术野,快速吸去积血,然后慢慢松开手指看清出血点.将高频电刀功率凋至80-100 W,直接电凝出血点,电凝范围较出血点稍大;对出血点缩至骶孔内者,先电凝出血处周围骶前筋膜或骶骨骨膜,使用时电刀对骨膜施加一定压力,持续一定时间,使骨膜破坏塌陷,再电凝出血处.结果 8例骶前大出血患者使用高频电凝获得即时止血,并顺利完成手术,无相关并发症发生.结论 高频电凝治疗骶前大出血是一种简单、快速、安全、有效的治疗方法.     

Circular Suture Ligation of Presacral Venous Plexus to Control Presacral Venous Bleeding During Rectal Mobilization

Background

Presacral venous bleeding during rectal mobilization is uncommon but potentially life-threatening. Various methods have been proposed for controlling the bleeding, but each has some obvious limitations in clinical practice. We report a simple technique that was designated as circular suture ligation. This technique was efficient in controlling presacral venous bleeding encountered during rectal mobilization.

Methods

The key point of circular suture ligation was to control the bleeding by suture ligating the venous plexus in one or more circles in the area with intact presacral fascia that surrounds the bleeding site while the bleeding site was temporarily controlled with fingertip pressure. From September 2007 to December 2011, 258 patients underwent rectal surgery in our department because of rectal cancer. Uncontrolled presacral venous bleeding with traditional methods was encountered in eight patients (3 %) with estimated blood loss from 300 to 5,000 ml.

Results

Bleeding was successfully controlled in all eight patients with the circular suture ligation. None of the patients required reoperation for bleeding or other issues. No patients developed chronic pelvic pain after the operation.

Conclusions

Our experience suggests that circular suture ligation of venous plexus in the area with intact presacral fascia that surrounds the bleeding site is an effective and simple technique to control presacral venous bleeding when traditional techniques fail.     

The use of spray electrocautery to control presacral bleeding: a report of four cases

Bleeding originating from the presacral venous plexus during pelvic operations is difficult to control, constituting a potentially life-threatening complication. Although suture ligatures, packing, and placement of tacks are established hemostatic techniques, they are often proved to be ineffective. We report a simple novel technique using spray diathermy for managing this severe complication. We have applied our method in four patients, two undergoing low anterior resection, and the others undergoing abdominoperineal resection for rectal cancer, that manifested severe presacral bleeding during rectal mobilization. Electrocautery at spray setting was applied slightly above the target bleeders at the presacral fascia, delivering a high-frequency electrical current in combination with drainage suction. In all cases, the method resulted in successful hemostasis. Applying spray electrocautery is a simple and effective method for controlling presacral bleeding. The advantages of using such a method instead of conventional hemostatic techniques include the option of varying the degree of haemostatic effect by altering the frequency and the volume of electric current.     

Surgical management of presacral bleeding

Introduction

Presacral venous bleeding is an uncommon but potentially life threatening complication of rectal surgery. During the posterior rectal dissection, it is recommended to proceed into the plane between the fascia propria of the rectum and the presacral fascia. Incorrect mobilisation of the rectum outside the Waldeyer’s fascia can tear out the lower presacral venous plexus or the sacral basivertebral veins, causing what may prove to be uncontrollable bleeding.

Methods

A systematic search of the MEDLINE^® and Embase™ databases was performed to obtain primary data published in the period between 1 January 1960 and 31 July 2013. Each article describing variables such as incidence of presacral venous bleeding, surgical approach, number of cases treated and success rate was included in the analysis.

Results

A number of creative solutions have been described that attempt to provide good tamponade of the presacral haemorrhage, eliminating the need for second operation. However, few cases are reported in the literature.

Conclusions

As conventional haemostatic measures often fail to control this type of haemorrhage, several alternative methods to control bleeding definitively have been described. We propose a practical comprehensive classification of the available techniques for the management of presacral bleeding.     

Anwendung der Beckenzwinge beim polytraumatisierten Patienten mit instabilem Becken

BACKGROUND: Unstable fractures of the posterior pelvic ring are frequently combined with severe hemorrhage. In 80% of cases the bleeding originates in the ruptured presacral venous plexus or the fracture itself. Arterial bleeding is less common. The pelvic clamp introduced by Ganz can make it possible to stabilise the pelvis, with subsequent compression of the fracture planes and reduction of the intrapelvic volume in such cases, so improving the prognosis. Use of the pelvic clamp can be integrated into the management in the emergency room with no problem. METHODS: This paper presents the authors' own modification of the technique for using the pelvic clamp in the emergency situation when only a clinical examination of the patient has been possible and also analyses specific problems that arise in this situation. To this end, the data relating to 29 polytraumatised patients with unstable posterior pelvic ring fractures were analysed in a retrospective study. RESULTS: In all, 8 complications were seen in 6 patients. There were 2 cases of pin malposition and 2 of over-compression of the ossa coxae and local wound problems. Secondary pin dislocation was observed in 1 case. In all these cases it was possible to correct the pelvic clamp, so that emergency stabilisation was practicable without further surgical intervention. Minor complications were found in 2 patients. These took the form of bleeding at the pin-insertion site. In 1 case an unstable transiliacal fracture was found, and in this case it was not possible to stabilise the posterior pelvic ring with the pelvic clamp. No iatrogenic lesions were detected following application of the pelvic clamp. CONCLUSION: In the hands of an experienced and practised user application of the pelvic clamp is a safe method for emergency stabilisation of the posterior pelvic ring in polytraumatised patients, even without blood volume control. Problems can be solved and do not generally mean the pelvic clamp cannot be used. The immediate radiological check (e.g. during the emergency CT -scan performed for primary diagnosis) is a must, however.