To study intraoperative blood loss and analyse average blood loss and number of transfusions in patients who underwent pelvic oncological surgeries in this oncology centre in South India from January 2012 – December 2018. A retrospective analysis of medical records of 257 patients who had undergone pelvic oncological surgeries in our institute from January 2012 and December 2018 was done and information regarding blood loss and transfusions was analysed with student’s T test. Out of 257 patients, 72 underwent pelvic exenteration of which 18 were operated for primary and 54 were operated for recurrences, 105 underwent Wertheim’s hysterectomy, 19 patients underwent APR, 8 underwent LAR, 5 underwent AR, 36 underwent surgical staging 8 underwent Cystectomy and 4 underwent sacrectomy. In our analysis we found that laparoscopic surgeries had less blood loss (average 354 ml) compared to open surgeries (average 811 ml) and upfront surgeries (531 ml) had less blood loss compared to surgeries done post chemoradiotherapy (668 ml) resulting in less number of transfusions, transfusion reactions, infections and early recovery in laparoscopic and upfront surgeries. Laparoscopic surgery in pelvic oncological surgeries has become a benefit to surgeons because of less intraoperative blood loss, reduced hospital stay and better outcomes. Though laparoscopic surgeries require a learning curve, extensive anatomical knowledge about the procedure during open surgeries made learning curve less steep. Blood loss in upfront cases is less than that of post chemoradiotherapy cases leading to less infection rates, better recovery and with increase in duration of surgery, blood loss is more.
2. Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years
Shanmugam et al. 037
Till few years back most of the surgeries used to be done
in open method with wound morbidity and prolonged bed
rest. With advances in laparoscopic surgery it became an
effective and economically efficient alternative to open
surgery. It is known that the laparoscopic approach is
associated with a shorter hospitalization, faster recovery,
lower risk of thromboembolic complications, and
postoperative infections.
In case of oncologic surgeries which need extensive
dissection, laparoscopic surgeries help in minimising the
morbidity compared to open surgeries. Further surgeries
done before giving chemoradiotherapy (upfront surgeries)
are associated with less morbidity compared to surgeries
done after giving chemoradiotherapy as there is distortion
of anatomy and fibrosis post chemoradiotherapy.
Intraoperative haemorrhage is the most frequent
complication of pelvic surgeries during dissection (Stolfi et
al., 1992). Appropriate preoperative planning, a meticulous
and consistent surgical technique and the appropriate
utilization of haemostatic adjuncts are potentially useful
strategies to minimize the risk of severe blood loss. Pelvic
haemorrhage is problematic due to the particular
anatomical arrangement of pelvic blood vessels within a
confined physical space. Injury to the presacral venous
plexus (PSVP) and the sacral basivertebral veins during
dissection in the retro-rectal plane may result in large
volume bleeding within a short time period (D’Ambra et al.
2009)
In this retrospective study the incidence of blood loss was
studied in patients who underwent major pelvic oncological
surgeries.
MATERIALS AND METHODS
The Intraoperative records of all 257 patients who
underwent Pelvic exenteration (PE), Surgical staging,
Interval cytoreduction (IC), Cystectomy, Hysterectomy,
Abdomino pelvic resection (APR), Anterior and Low
Anterior resection (AR & LAR) from January 2012 to
December 2018 in the age group of 25-80 years were
collected from the database of our institution and
information regarding blood loss and transfusions during
different procedures was analysed with student’s T test.
Out of 257 patients 145 had carcinoma cervix, 51 had
carcinoma rectum and anal canal, 24 had carcinoma
endometrium, 12 had carcinoma ovary, 10 had carcinoma
bladder, 4 had pelvic bone tumors, 6 had carcinoma
vagina and 5 had uterine sarcoma. Details of intra
operative blood loss measured from suction canisters and
gravimetric method (difference in preoperative and
postoperative weight of gauze used), transfusions
required, type of surgery, mean duration of surgery and
details of chemoradiotherapy are collected and analysed.
RESULTS
The patient characteristics and blood loss are tabulated in
table 1,2,3,4 respectively. The average age group of
patients included in this study were between 25- 80 years
with mean age of 51.05 years. Out of 257 patients 232
were female patients and 25 were male patients. Out of
257 patients 73 belong to performance status 1, 149
belong to status 2, 35 belong to status 3. (Table 1)
In the 257 patients included in our study 145 had
carcinoma cervix, 51 had carcinoma rectum and anal
canal, 24 had carcinoma endometrium, 12 had carcinoma
ovary, 10 carcinoma bladder, 4 pelvic bone tumors, 6
carcinoma vagina and 5 uterine sarcoma. (table 1)
In this analysis we found that the mean duration of surgery
for Pelvic exenteration surgery, Low anterior resection,
Abdominoperineal resection and Anterior resection was
240 minutes each, Surgical staging and Hysterectomy 180
minutes each, Cystectomy 210 minutes and sacrectomy
(anterior and posterior) 420 minutes.
Of the 257 patients 72 underwent PE; average blood loss
was 550 ml in 20 patients who underwent laparoscopic
surgery and 920 ml in 52 patients who had open surgery
(p value=0.7).Thirty six patients underwent surgical
staging; average blood loss was 250ml in 8 patients who
underwent laparoscopic surgery and 460 ml in 28 patients
who had open surgery (p value=0.6). Eight patients
underwent cystectomy; average blood loss was 450ml in 3
patients who underwent laparoscopic surgery and 850 ml
in 5 patients who had open surgery (p value=0.7). One
hundred and five patients underwent hysterectomy;
average
TABLE 1: PATIENT CHARACTERISTICS
No. of patients: 257
Sex: Male: 25 (9.7%)
Female: 232 (90.3%)
PERFORMANCE STATUS:
I : 73 (28.4%)
II : 149 (58%)
III : 35 (13.6%)
DIAGNOSIS: NO. OF PATIENTS
Carcinoma cervix 145 (56.4%)
Carcinoma rectum and anal canal 51 (19.8%)
Carcinoma endometrium 24 (9.3%)
Carcinoma ovary 12 (4.7%)
Carcinoma bladder 10 (3.9%)
Pelvic bone tumours 4 (1.5%)
Carcinoma vagina 6 (2.3%)
Uterine sarcoma 5 (1.9%)
PERIOPERATIVE MORTALITY:
OVERALL: 4(1.5%)
POST APR: 1(4%)
POST PELVIC EXENTERATION: 3(4.1%)
3. Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years
J. Cancer Clin. Oncol. 038
blood loss was 200ml in 50 patients who underwent
laparoscopic surgery and 450 ml in 55 patients who had
open surgery (p value=0.6). Since we had less number of
patients in each group to analyse separately we had
clubbed APR/LAR/AR together. Thirty two patients
underwent APR/LAR/AR; average blood loss was 320ml
in 20 patients who underwent laparoscopic surgery and
690 ml in 12 patients who had open surgery (p value=0.6).
Four patients underwent sacrectomy with average blood
loss of 1500 ml, with more blood loss in posterior approach
than anterior approach.
In our study there was 970 ml average blood loss in 45
patients who underwent surgery post chemo radiotherapy
when compared to 480ml in 27 upfront pelvic exenteration
cases (p value=0.6). There was 440ml blood loss in 30
patients who underwent surgery post chemoradiotherapy
cases when compared to 260 ml in 6 upfront cases of
surgical staging (p value=0.7).. There was 870ml blood
loss in 2 patients who underwent surgery post
chemoradiotherapy cases when compared to 420 ml in6
upfront cases of cystectomy (p value=0.6). There was 420
ml blood loss in 45 patients who underwent surgery post
chemoradiotherapy when compared to 220 ml in 60
upfront cases of hysterectomy (p value=0.6). There was
640 ml blood loss in 25 patients who underwent surgery
post chemoradiotherapy when compared to 310 ml in 7
upfront cases of APR/LAR/AR (p value=0.6). There was
1500 ml blood loss in 4 upfront cases of sacrectomy
laparoscopy was not used in sacrectomy cases.
TABLE 2: MEAN DURATION OF SURGERY
TYPE OF SURGERY MEAN DURATION
OF SURGERY
(minutes)
1. PELVIC EXENTERATION 240
2. LAR/APR/AR 240
3. SURGICAL STAGING/IC 180
4. HYSTERECTOMY 180
5. CYSTECTOMY 210
6. SACRECTOMY (ANTERIOR+
POSTERIOR )
2 staged procedure
420
TABLE 3: COMPARISON OF AVERAGE BLOOD LOSS BETWEEN LAP AND OPEN PELVIC PROCEDURES
TYPE OF SURGERY NO. OF
CASES
AVERAGE BLOOD LOSS in ml P VALUE* NO. OF
TRANSFUSIONS
LAP(no. of
patients)
OPEN(no. of
patients)
LAP OPEN
PELVIC EXENTERATION 72 550 (20) 920 (52) 0.7 5 29
SURGICAL STAGING/IC 36 250 (8) 460 (28) 0.6 1 6
CYSTECTOMY 8 450 (3) 850 (5) 0.7 0 3
HYSTERECTOMY 105 200 (50) 450 (55) 0.6 0 7
APR/LAR/AR 32 320 (20) 690 (12) 0.6 2 6
SACRECTOMY 4 1500(4) 4
*student’s t – test
TABLE 4: COMPARISON OF AVERAGE BLOOD LOSS BETWEEN UPFRONT AND POSTCHEMORADIOTHERAPY
CASES
TYPE OF SURGERY POST CRT
CASES
AVERAGE BLOOD
LOSS
POST CRT(ml)
UPFRONT
CASES
AVERAGE BLOOD
LOSS
UPFRONT(ml)
P VALUE*
PELVIC EXENTERATION 45 970 27 480 0.6
SURGICAL STAGING/IC 30 440 6 260 0.7
CYSTECTOMY 2 870 6 420 0.6
HYSTERECTOMY 45 420 60 220 0.6
APR/LAR/AR 25 640 7 310 0.6
SACRECTOMY Nil 4 1500
*student’s t – test
Number of transfusions required in patients who
underwent laparoscopic surgeries is less compared to
those who underwent open surgeries (8 vs 55). In our
retrospective analysis we found that surgeries done
laparoscopically had less average blood loss when
compared to open surgeries and upfront surgeries had
less average blood loss compared to surgeries done post
chemoradiotherapy (CRT).
DISCUSSION
The incidence of presacral haemorrhage during pelvic
dissection has been reported to be between 4.6 - 9.4 %.
The challenging anatomy is complicated by the
vasodilatory properties of anaesthetic drugs and the
lithotomy position frequently utilized in pelvic surgery,
resulting in sacral venous pooling and increased
hydrostatic pressure exacerbating blood loss (Hill et al.,
4. Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years
Shanmugam et al. 039
1994; Wang et al., 1985). Blood transfusions have been
associated with number of complications like transfusion
reactions, transfusion related lung injury and transfusion
associated circulatory overload, allergic reactions,
transmitted infections and coagulation abnormalities. The
transfusion rate correlated with the reported frequency of
allogenic blood transfusions in colorectal cancer surgery is
between 32 and 68 %. Transfusions during sacrectomies
and exenterations were associated with high risk of
morbidity (Harlaar et al., 2012, Melton et al., 2006; Bansal
et al., 2009).
Pelvic packing was shown to provide a simple and
effective tamponading technique. Care needs to be taken
on removal of the packing, which may disturb any clot
formed with resultant pooling of blood obscuring the
source of the bleed. In addition, packing may cause a rise
in intra-abdominal pressure or excessive inferior vena
cava (IVC) compression while repeated packing may
cause shearing of the delicate veins in the PSVP
(Timmons et al., 1991).
One case of recurrent uterine sarcoma died
intraoperatively due to severe blood loss, one case of APR
had secondary haemorrhage and collapsed before shifting
to operation theatre. One case of vault recurrence that
underwent open total pelvic exenteration with 800ml blood
loss and 1 intraoperative blood transfusion went into acute
renal failure. One case of carcinoma cervix post RT
recurrence that underwent total pelvic exenteration with
wet colostomy with 1000 ml intraoperative blood loss and
2 transfusions died in 1st post-operative day.
The emergence of laparoscopic surgery in pelvic
oncological surgeries is an important milestone of the
modern surgery. This revolution means the arrival of the
minimal invasive surgery. Compared with open procedure,
less intraoperative blood loss, less postoperative pain and
shorter hospital stay are the outstanding advantages of the
laparoscopic procedure.
Even though there is no statistical significance in blood
loss between laparoscopic and open, upfront and post
chemoradiotherapy cases in our study there is clinically
significant difference in less blood loss, less no. of
transfusions and early recovery in laparoscopic surgeries.
Kunlin Yang et al (2015) performed a study in 11 cases
that underwent laparoscopic total pelvic exenteration vs
open total pelvic exenteration which concluded that there
was less blood loss, early recovery time and shortened
duration of hospital stay. Comparing our results with above
study we found laparoscopic PE had lesser blood loss
hence early recovery. Atsushi Ogura et al (2016) also
concluded that blood loss was less and lesser number of
transfusions in laparoscopic pelvic exenteration surgeries
when compared to open surgeries.
Ling Hui Chu et al (2016) performed a study of
laparoscopic vs open surgical staging in 151 patients had
less intra operative blood loss in laparoscopic surgeries
(78 vs 248) ml. Tae Wook Kong et al (2010) also had
similar results when compared with our study.
Pedro T Ramirez et al (2018) study of minimally invasive
hysterectomy was associated with lower rates of blood
loss in laparoscopic surgery compared to open surgeries
(164+/-131 vs 595+/-284) ml. We had similar results when
compared with our study.
Nosov et al performed a prospective analysis of
laparoscopic vs open radical cystectomy in 42 patients
which concluded that intra operative blood loss is lower in
laparoscopic cystectomy when compared to open surgery
(285 vs 77) ml. Julien Guillotreau et al (2009) also had
similar results when compared to above study and our
study. In our study on radical hysterectomy (shanmugam
et al., 2018) we found that post chemo radiotherapy
patients had more blood loss compared to upfront
hysterectomy cases (350 vs 200) ml due to distorted
anatomical planes and fibrosis.
Andrea Petruzziello et al (2014) study on surgical results
of pelvic exenteration in the treatment of gynaecologic
cancer had a perioperative mortality rate of 4 out of 28
patients compared to 3 out of 72 patients in our study.
Rutegard M et al (2010-11) study on rectal cancers had a
mortality rate of 1.5% for APR surgeries compared to 4%
in our study.
Blood loss during surgery leads to decreased immunity,
hypotension leading to decreased perfusion of vital
organs, increased anastomotic leak rates, acute kidney
injury, increased infection rate, transfusion reactions,
transfusion related infections all of which can be minimised
by meticulous surgery with proper anatomic knowledge
and adequate control of intraoperative bleeding.
In our patients bleeding was controlled intraoperatively by
ligation of the bleeding vessel, cauterisation of the bleeder,
and by pelvic packing. In our hospital as a routine measure
we will do pelvic packing for all exenteration cases and
some cases of APR before closing abdomen which will be
removed after 48 hours through perineal wound.
Intraoperative bleeding in pelvic oncological surgeries can
be controlled by preoperative optimisation by prophylactic
tranexamic acid, preoperative optimisation of the patient,
preoperative embolization of the suspected vessel if
significant bleeding is anticipated.
CONCLUSION
Laparoscopic surgery in pelvic oncological surgeries has
become a benefit to surgeons because of less
intraoperative blood loss, reduced hospital stays and
better outcomes. Though laparoscopic surgeries require a
learning curve, extensive anatomical knowledge about the
procedure during open surgeries have made the learning
5. Retrospective Analysis of Intra Operative Blood Loss in Pelvic Oncological Surgeries - A Single Institution Experience in 7 Years
J. Cancer Clin. Oncol. 040
curve less steep leading to lesser morbidity. Blood loss in
upfront cases is less than that of post chemoradiotherapy
cases leading to less infection rates, better recovery and
with increase in duration of surgery, blood loss is more.
FUNDING SOURCES
No funding required
DISCLOSURE SECTION
None
CONFLICTS OF INTEREST
None
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