title: Intraoperative bleeding and haemostasis during pelvic surgery for locally advanced or recurrent rectal cancer: a prospective evaluation.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Colorectal Surgery, Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK, victoriabonello@gmail.com.
authors.forename: V A
authors.initials: VA
authors.lastname: Bonello
authors.forename: A
authors.initials: A
authors.lastname: Bhangu
authors.forename: J E F
authors.initials: JE
authors.lastname: Fitzgerald
authors.forename: S
authors.initials: S
authors.lastname: Rasheed
authors.forename: P
authors.initials: P
authors.lastname: Tekkis
mesh_terms: D016063:Blood Loss, Surgical / Q000706:statistics & numerical data; D001803:Blood Transfusion / Q000706:statistics & numerical data; D005260:Female; D006488:Hemostasis, Surgical / Q000379:methods* / Q000706:statistics & numerical data; D006801:Humans; D007430:Intraoperative Care / Q000379:methods; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000601:surgery*; D010388:Pelvis / Q000601:surgery; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000601:surgery*; D013630:Tampons, Surgical / Q000706:statistics & numerical data