Rectum: Management of the Urgent APR and Dissecting the “Frozen” Pelvis




© Springer International Publishing Switzerland 2017
Jose J. Diaz and David T. Efron (eds.)Complications in Acute Care Surgery10.1007/978-3-319-42376-0_15


15. Rectum: Management of the Urgent APR and Dissecting the “Frozen” Pelvis



Rao R. Ivatury1  


(1)
Department of Surgery, Virginia Commonwealth University, Richmond, VA, USA

 



 

Rao R. Ivatury

Email:


Keywords
Rectal cancerFrozen pelvisRecurrent rectal cancerBleeding rectal cancer



Problem Analysis


Continued bleeding PR, presumably of a significant degree, requiring multiple transfusions of blood and blood products and invasive interventions in a clinical scenario of recurrent, advanced cancer with very limited palliation.


Therapeutic Interventions


These must be planned with a consideration of


  1. 1.


    Recurrent, fixed (inoperable for cure) cancer that makes total resection extremely difficult and dangerous.

     

  2. 2.


    Postoperative, postradiation frozen pelvis with dense adhesions that make iatrogenic injury to vital structures very likely and massive intra-operative blood loss and intra-operative mortality a distinct possibility.

     

Even though the editors give me the suggestion of an emergent abdomino-perineal resection, I consider it a last resort. My steps for a therapeutic solution will involve the following:


Preoperative [1]





  1. 1.


    Since this is a palliative and not a curative approach with a very limited scope for meaningful palliation, what are the patient’s and family’s approach to end-of-life decision?

     

  2. 2.


    If their decision is to do whatever is necessary, after a thorough discussion with them I will consider any of these following ancillary measures to control or diminish the bleeding:




    1. (a)


      Correction of all bleeding diatheses and correction of coagulopathy;

       

    2. (b)


      Preoperative angiography and embolization of bleeding vessels;

       

    3. (c)


      Preoperative angiography and occlusion of internal iliac arteries (may not succeed if the bleeding is from the anal verge and the branches of external iliac artery);

       

    4. (d)


      Endoscopy in the lithotomy position, debridement of the tumor with or without fulguration, and application of pressure packs with or without hemostatic substances (e.g., quick clot);

       

    5. (e)


      Cryoablation to stop bleeding; and

       

    6. (f)

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Nov 18, 2017 | Posted by in Uncategorized | Comments Off on Rectum: Management of the Urgent APR and Dissecting the “Frozen” Pelvis

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