Bonello V A, Bhangu A, Fitzgerald J E F, Rasheed S, Tekkis P
Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK,
Tech Coloproctol. 2014 Oct;18(10):887-93. doi: 10.1007/s10151-014-1150-z. Epub 2014 Jun 3.
This study aimed to prospectively quantify the frequency of serious bleeding during pelvic surgery for locally advanced or recurrent rectal cancer and review the surgical methods used to control this.
Consecutive cases of pelvic surgery for curative resection of locally advanced or recurrent rectal cancer were prospectively evaluated over a nine-month period. The procedures undertaken included multivisceral resections, sacrectomies or ultra-low anterior resections. Multivisceral resections were defined as pelvic exenterations, extra-levator abdominoperineal resections (ELAPER) and recurrent anterior resections. The primary endpoint was the proportion of patients sustaining major blood loss, defined as ≥1,000 ml. The secondary endpoint was the blood transfusion rate. Haemostatic adjunct use was recorded.
Twenty-six patients underwent surgery, comprising 11 pelvic exenterations, 3 ELAPERs, 1 recurrent anterior resection, 5 abdominosacral resections and 6 ultra-low anterior resections. The median intraoperative blood loss was 1,250 ml with 53.8 % of the patients sustaining a loss ≥1,000 ml. Fifty per cent of patients required a blood transfusion within 24 h, and one or more haemostatic adjuncts were necessary in 50 % of the cases. Adjuncts used included a fibrinogen/thrombin haemostatic agent in 38.5 % of patients, temporary intraoperative pelvic packing in 11.5 % of patients and preoperative internal iliac artery embolization in 7.7 % of patients.
This patient group is at a high risk of intraoperative haemorrhage, and such patients are high consumers of blood products. Haemostatic adjunct use is often necessary to minimize blood loss. We describe our local algorithm to assist in the assessment and intraoperative management of these challenging cases.
本研究旨在前瞻性地量化局部晚期或复发性直肠癌盆腔手术期间严重出血的发生率，并回顾用于控制出血的手术方法。
在九个月的时间里，对连续进行的局部晚期或复发性直肠癌根治性切除盆腔手术病例进行前瞻性评估。所进行的手术包括多脏器切除、骶骨切除或超低位前切除术。多脏器切除定义为盆腔脏器清除术、经肛提肌外腹会阴联合切除术（ELAPER）和复发性前切除术。主要终点是发生大出血（定义为≥1000 ml）的患者比例。次要终点是输血率。记录止血辅助措施的使用情况。
26例患者接受了手术，包括11例盆腔脏器清除术、3例ELAPER、1例复发性前切除术、5例腹骶联合切除术和6例超低位前切除术。术中失血量中位数为1250 ml，53.8%的患者失血量≥1000 ml。50%的患者在24小时内需要输血，50%的病例需要一种或多种止血辅助措施。使用的辅助措施包括：38.5%的患者使用纤维蛋白原/凝血酶止血剂，11.5%的患者术中临时盆腔填塞，7.7%的患者术前行髂内动脉栓塞。
该患者群体术中出血风险高，是血液制品的高消耗者。通常需要使用止血辅助措施以尽量减少失血。我们描述了我们当地的算法，以协助评估和处理这些具有挑战性的病例。
