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。     

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。     

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.     

Use of absorbable hemostatic gauze with medical adhesive is effective for achieving hemostasis in presacral hemorrhage

BackgroundManagement of presacral hemorrhage is always challenging. Herein we describe the use of an absorbable hemostatic gauze with α-cyanoacrylate medical adhesive to achieve hemostasis.MethodsIn this study, we conducted total mesorectal excision for the treatment of rectal cancer in 258 patients from March 2006 to May 2009. Intraoperative presacral hemorrhage developed in 5 (2%) patients during rectal mobilization.ResultsIn these 5 patients, massive bleeding could not be controlled by pressure and pelvic packing with gauze. An absorbable hemostatic gauze spread with medical adhesive was compressed onto the bleeding vessel for at least 20 minutes. Hemostasis was achieved successfully and was maintained during the surgery. Patients recovered uneventfully and no postoperative events were noted.ConclusionsThe use of an absorbable hemostatic gauze with medical adhesive is a simple and effective method for achieving hemostasis when massive presacral hemorrhage occurs. However, its effectiveness needs to be confirmed in a controlled study in a properly selected patient population.     

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.     

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.     

腹腔镜下骶前肿瘤切除术6例临床分析

目的:探讨腹腔镜下切除原发性骶前肿瘤的可行性、手术方法及安全性。方法:回顾分析6例原发性骶前肿瘤患者的临床资料,术前经直肠指诊、B超、CT和/或MRI做出诊断,均采用完全腹腔镜手术切除肿瘤。患者21~63岁,平均(40.8±13.5)岁;肿瘤直径平均(6.7±2.1)cm。结果:肿瘤均被顺利完整切除,术中未出现不可控制的出血,出血量200~1 100 ml,平均(350.2±118.3)ml;6例患者术后24~72 h肠道功能恢复并进食,未出现腹部并发症。随访3~24个月,平均(11.2±7.2)个月,随访期间患者均未出现肿瘤复发,排尿及性功能基本正常。术后标本病理类型:皮样囊肿2例,良性畸胎瘤1例,间质瘤1例(高风险),脂肪瘤1例,神经纤维瘤1例。结论:腹腔镜下切除骶前肿瘤是安全、可行的,与既往文献报道的开腹手术相比,具有出血少、创伤小、术后康复快、住院时间短等优点,是技术条件成熟的医院可选择的手术方式。     

Management of massive presacral bleeding during low pelvic surgery -- an alternative technique

Although massive presacral bleeding during rectal mobilization is uncommon, it can rapidly destabilize a patient. So, effective hemostasis is critical in severe presacral hemorrhage due to the fatal course of this complication. Among the reported methods are packing, thumbtacks, inflatable devices, muscle tamponade, muscle fragment welding and application of endoscopic staplers. Local hemostatic agents in conjunction with other methods such as diathermy, cyanoacrylate tissue adhesives and application of bone wax are among other alternatives which may help to treat this serious complication. The aim of this study is to describe the anatomic and physiologic basis of our mode of treatment, which is new in the literature approach, treating two patients with presacral bleeding during low anterior resection for rectal cancer. The technique is the early clamping of the infrarenal aorta and suture ligation of the bleeding points from the presacral plexus.     

Presacral retroperitoneal hematoma after blunt trauma presents with rectal bleeding — A case report

IntroductionWe present a case of a presacral hematoma, which penetrated into the rectum resulting in rectal bleeding. This is an unusual presentation of a presacral hematoma.Presentation of the caseA 76-year-old woman, using warfarin anticoagulant prophylaxis, presented with a rectal bleed two days after a fall. A sigmoidoscopy revealed that the source of bleeding was a presacral hematoma penetrating into the rectum. A Computed Tomography scan of the pelvis confirmed the presence of a hematoma measuring 10 × 9.4 cm in the presacral space, as well as a fracture of os coccygis. She was transferred to a highly specialized facility, where she was treated conservatively with blood transfusions and repeated endoscopic toilet of the presacral cavity. One month after her initial fall, the patient had fully recovered.DiscussionRectal bleeding usually causes suspicion of a bleeding in the gastrointestinal tract. In this report the patient’s anticoagulant treatment has likely contributed to bleeding and the formation of the hematoma. To our knowledge, this is the first case report of a presacral hematoma acutely penetrating into the rectum and causing lower gastrointestinal bleeding.ConclusionRectal bleed after trauma, in a patient receiving anticoagulant treatment, should raise suspicion of a penetrating hematoma, and such patients should be managed at highly specialized facilities.     

盆腔手术骶前静脉丛大出血临床分析

目的探讨盆腔手术术中骶前静脉丛大出血的防治方法。方法回顾性分析鞍山市中心医院普外科1998年1月-2013年1月发生的8例骶前静脉丛大出血的临床病例资料。结果8例骶前静脉丛大出血全部止血成功,出血量为1000～4000mL,平均2600mL。结论熟悉盆腔解剖结构,并按解剖层次正确操作,是预防出血的关键。发生大出血时可用直接电凝法止血,方法简便易行。     

Validating the use of rectus muscle fragment welding to control presacral bleeding during rectal mobilization

The incidence of presacral bleeding during rectal mobilization is low, but such bleeding may be massive and even fatal. Haemostasis can be difficult to achieve using conventional methods because of the complex interlacing of the venous network at the sacral periosteum. Historically, pelvic packing and metallic thumbtacks have been the more commonly used methods in our institution. However, the need for repeat surgery to remove the packs and the difficulties encountered in tack application have forced us to explore other methods. In 1994, the procedure termed muscle fragment welding, which uses electrocautery through a rectum muscle fragment, was introduced to control presacral bleeding. From January 1999 to February 2002, six of 416 patients undergoing pelvic surgery in our institution developed massive presacral haemorrhage and therefore, this technique was used. Haemostasis was immediate and permanent. No major untoward postoperative events such as re-bleeding or infection were noted. One cas developed a second-degree burn in the right elbow due to a misplaced ground conduction plate. Rectus muscle fragment welding is , in our experience, an effective and practical method of controlling presacral haemorrhage.     

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.     

The use of bonewax to control massive presacral bleeding

Massive presacral bleeding during retroperitoneal resection is unusual, and can be difficult to control. We describe a technique for managing this complication whereby bonewax is pushed through the presacral fascia and periosteum directly into the bleeding point in the sacrum, followed by abdominal packing. This maneuver proved successful for achieving hemostasis when we recently encountered this intraoperative complication. Received: September 27, 2001 / Accepted: May 7, 2002     

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.     

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.     

Hemostatic Step-by-Step Procedure to Control Presacral Bleeding During Laparoscopic Total Mesorectal Excision

Background  A new procedure of hemostasis during laparoscopic total mesorectal excision is described. Methods  In our surgical department, from January 2004 to December 2007, 128 patients underwent laparoscopic total mesorectal excision. Among them, 47 patients underwent laparoscopic anterior resection after preoperative radiotherapy, 68 patients underwent laparoscopic anterior resection without preoperative radiotherapy, and 13 patients underwent laparoscopic abdominal perineal amputation. Results  In seven laparoscopic rectal surgery cases, we encountered unstoppable presacral bleeding, not amenable by conventional hemostatic solutions. In these cases we applied a simple staging hemostatic procedure. We first performed local compression: tamponing with a small gauze or absorbable fabric hemostat. If bleeding did not stop, we localized an epiploic or omental scrap and excised it by using bipolar forceps and use it as a plug on the tip of a grasping forceps. This plug is then put on the bleeding source and monopolar coagulation is applied by electrified dissecting forceps through the interposed grasping forceps. If bleeding did not stop, we used a little scrap of bovine pericardium graft and tacked it to the bleeding site using endoscopic helicoidal protack. Conclusions  Our experience suggests that this hemostatic step-by-step procedure is a valid option to control persistent presacral hemorrhages.     

Endoscopic perineal approach to the presacral space: a feasibility study

Background  Currently, pathologies from the presacral space are explored primarily by using transabdominal approaches. Major complications may occur, including bowel and rectal perforation, or bleeding. To avoid and reduce these potentially severe risks, a new surgical approach to the presacral space, which permits exploration through the perineum with minimal invasive techniques, had already been developed and is now further elaborated in a cadaver and clinical study. Study design  A prospective study was performed using four cadavers with no history of pelvic or perineal disease. A minimally invasive exploration of the presacral retroperitoneum was performed to examine a potential new anatomical surgical space. After positioning the patients in the prone or supine position, a 1-cm vertical median incision was made in the ano-coccygeal ligament. Entry to the presacral space was first established through blunt-finger and balloon dissection. A 30° 10-mm laparoscope was inserted through a 12-mm trocar, and two additional 5-mm trocars were inserted to avoid injury to the sciatic nerve. A clinical pilot study was performed on three patients using this technique. Results  Under direct vision, a wide dissected cavity was observed, with the rectum and mesorectum retracted ventrally. Access and manipulation of posterior pelvic organs were simplified. Placing cadavers in the jack-knife position provided superior accessibility to the presacral space when compared with a supine position. Clear exposure of the sacrum, mesorectum, ureters and bladder, prostate region, iliac vessels (with its branches), and lymph nodes was achieved. Conclusion  Endoscopic perineal approach to the presacral space was considered.     

环形缝合控制骶前静脉丛出血临床观察(附10例报告)

目的总结环形缝合法对骶前静脉丛出血的止血效果。方法采用环形缝合处理骶前出血10例,其中复发性直肠癌行Miles手术6例,行Hartmann术3例;子宫平滑肌肉瘤术后复发行部分乙状结肠加直肠切除术1例。结果10例均止血满意,缝合完成后未再出血,痊愈出院。结论环形缝合能安全地控制骶前出血,适用于能明视出血点的无休克病人。     

Electrocoagulación sobre un fragmento de músculo recto anterior abdominal para el control de la hemorragia presacra durante la resección rectal

IntroductionPresacral venous haemorrhage during rectal movement is low, but is often massive, and even fatal. Our objective is the “in vitro” determination of the results of electrocoagulation applied to a fragment of muscle on the sacral bone surface during rectal resection due to a malignant neoplasm of the rectum.Material and methodSingle-pole coagulation was applied “in vitro” with the selector at maximum power on a 2 × 2 cms muscle fragment, applied to the anterior side of the IV sacral vertebra until reaching boiling point. The method was used on 6 patients with bleeding of the presacral venous plexus.ResultsIn the “in vitro” study, boiling point was reached in 90 seconds from applying the single-pole current on the muscle fragment.Electrocoagulation was applied to a 2 × 2 cm rectal muscle fragment in 6 patients with presacral venous haemorrhage, using pressure on the surface of the presacral bone, with the stopping of the bleeding being achieved in all cases.ConclusionsThe use of indirect electrocoagulation on a fragment of the rectus abdominis muscle is a straightforward and highly effective technique for controlling presacral venous haemorrhage.