Treatment Strategies for Massive Presacral Bleeding

An 84-year-old male patient was complaining of constipation and rectal bleeding for 6 months. Colonoscopy and rigid sigmoidoscopy showed a posterior upper rectal mass (13 cm from anus). Histopathology confirmed moderately differentiated adenocarcinoma. A CT scan of the thorax, abdomen, and pelvis, as well as pelvic magnetic nuclear resonance imaging, revealed midrectal cancer cT3N0M0 with clear predicted circumferential margin. The patient underwent anterior resection with tumor-specific total mesorectal excision and end colostomy. During the posterior rectal dissection, dilated fragile varicose presacral veins were damaged, and severe bleeding was observed. Initial pelvic packing was ineffective, as well as bone wax and clips. Internal iliac arteries were ligated, and additional packing was finally successful and the bleeding stopped. The patient was resuscitated with a total blood loss of 4.2 L. The bleeding did not recur, and the packs were removed on postoperative day 2. The postoperative course was uneventful, and the patient was discharged on postoperative day 13 from the initial operation and postoperative day 5 from packing removal.