The traditional method of tamponade includes packing with multiple laparotomy pads [22]. Pelvic packing effectively controls massive presacral bleeding. However, the need for a second operation within 24–48 h and the risk of pelvic sepsis are important disadvantages of this procedure [22]. Modified packing techniques have been described in which a bowel-isolation bag filled with gauzes or a sterile normal saline bag are placed in the presacral space with the neck brought out through a perineal wound [23, 24]. Two to four days later, the bag can be removed at the bedside, without the need for further surgery. Another advantage of using the bag compared with traditional packing is that it can be removed without disrupting the clot because its surface is less adherent. As this technique requires a perineal wound, it is especially useful for patients who have abdominoperineal resection and a permanent stoma. Even expandable breast implant sizers have been used successfully [25], but leaving such a device close to a fresh colorectal anastomosis can lead to anastomotic disruption.

Remzi and colleagues recently described a technique that may be considered in cases of problematic hemorrhage when other techniques have failed or are inapplicable [26]. A 4×2×1-cm piece of rectus abdominis muscle is harvested as a free flap and sewn over the bleeding area to tamponade the presacral bleeding. Although this is an option that requires no special equipment, it can be technically difficult and time consuming in a patient with a deep and narrow pelvis. Another technique that may provide a durable tamponade is to fix a hemostatic sponge or expanded polytetrafluoroethylene (PTFE) pledgets with endoscopic helical tackers to the sacrum [13, 27]. The advantage of this technique is the possibility of shooting the helical tacks precisely, even in a deep and narrow pelvis, with minimal obstruction of visibility. Nevertheless, the tacks may shift, causing damage, and their fixation in the sacrum may be responsible for chronic pain.

Many are the means of occlusion, including local hemostatic agents, argonbeam coagulators, thumbtacks, bone wax or cement, and indirect coagulation through muscle or epiploic appendix fragment [11, 14, 20, 28–35]. Although direct suture of the bleeding point often proves ineffective and is in most cases responsible of worsening the bleeding, Jiang and colleagues [36] reported that circular suture ligation of the venous plexus in the area with intact presacral fascia surrounding the bleeding site is an effective and simple technique to control presacral venous bleeding. The suture should include the presacral fascia, presacral veins, and deep connective tissues. However, it is difficult to perform if bleeding occurs at the bottom of a narrow pelvis; moreover, fibrosis of the presacral area as a result of previous rectal surgery increases the difficulty of identifying presacral vein distribution and suture ligation. Perhaps the most widely used method of occlusion is the insertion of stainless steel or titanium thumbtacks into the sacrum. This technique, described for the first time by Wang et al. in 1985, is often the only successful method of controlling massive presacral bleeding [20, 36–38]. However, the application of thumbtacks is difficult at the S3 and S4 levels because of the anatomical curvature of the sacrum; also, the device is not readily available in all operating rooms [39, 40]. Implantation of such pins into the sacrum is often associated with chronic pain, and their displacement increases the risk of anastomotic disruption [39, 40]. Finally, diffuse hemorrhage is difficult to control even if a number of thumbtacks are used, because they cannot be overlapped [41]. To tamponade a profusely bleeding area, a larger thumbtack was proposed, called “table fixation staple” because it has four feet like a table. It is usually used for knee-ligament repair and can vary in size to fit the different bleeding holes [42].

Many local hemostatic agents are currently readily available for use at several different bleeding sites. They are reabsorbed by the body within weeks, so there is no risk of infection or secondary complications from foreign bodies. They should be used from the start to treat presacral hemorrhage [11, 14, 28–30]. Even the combination of several hemostatic agents has been used with success in treating this severe intraoperative complication [14, 28, 30]. A patch, obtained by combining a layer of cyanoacrylate glue and one of gelatin sponge or absorbable hemostatic gauze, is placed over the lesion and compressed for several minutes to ensure adequate contact with the presacral fascia and polymerization of the adhesive. If bleeding continues beneath the edge of the patch, another piece can be glued over the bleeding point in the same manner.

A simple alternative technique it to apply electrocautery spray over the bleeding vessel at a 3- to 5-mm distance using a 90˚ angle of approach [43]. It can effectively reach and coagulate the nonvisible bleeding points that originate from the basivertebral veins [43]. The possible complication arising from this technique is sacral pain caused by thermal damage to spinal nerve roots in the sacral foramina; treatment requires analgesics orally for 3–6 months postoperatively [43].

Using an argon-beam coagulator (ABC) is reported to quickly arrest bleeding [31]. The eschar that is formed is nonfloating, and consequently, the risk of postoperative bleeding is low. Moreover, the argon gas prevents oxidation, which results in less charring and formation of necrotic tissue [31, 44]. The most significant complication is venous argon embolism; however, it has been reported mostly with direct application of the argon beam to a large venous structure or following direct contact of the tip of the ABC electrode with the tissue surface. Clinical argon gas embolism should not occur if ABC is used correctly and for small presacral veins [31, 44].

Another simple and very effective method of controlling profuse presacral hemorrhage is the use of bone wax, which is pushed into the bleeding point in the sacrum [33]. Another substance, borrowed from orthopedic surgery and used also in presacral bleeding, is polymethyl methacrylate cement [34]. Mixing the components creates a cement that can be applied on the bleeding surface, and cement hardening is characterized by substantial heat production, which provides excellent hemostasis.

Rectus abdominis muscle welding to control presacral bleeding was first described by Xu and Lin in 1994 [45]. A 2-cm-square segment of rectus abdominis muscle, harvested from the incision, is held in place with a forceps over the bleeding area while electrocautery, at a high setting (100 Hz), is applied to the forceps and energy transmitted to the muscle fragment. The result is welding of the bleeding site [35]. The muscle-welding method works by using the muscle fragment as an electrode for indirect coagulation [35]. It can be used with multiple bleeding sites, and all the necessary equipment is already on the operative field. In addition, no foreign bodies requiring removal remain in the patient, reducing the risk of secondary hemorrhage or anastomotic disruption [35]. Similarly, Lou and colleagues proposed using an epiploic appendix in place of the piece of muscle. Compared with the technique of muscle fragment welding, epiploic appendix is easier to remove, and due to its round shape, is easier to fill in the sacral neural foramen [21].

According to Lou and colleagues, massive presacral bleeding can be divided into two different types based on presacral venous system anatomy [21]. The first type of bleeding arises from the presacral venous plexus; it may be massive, but it can be stopped by using suture ligation. The other type is massive, highpressure bleeding that originates from the sacral neural foramen where the basivertebral vein is injured. This type of bleeding can be effectively controlled using electrocautery applied through the epiploic appendices pressed with a long Kelly clamp over the bleeding vessel [21]. However it is not always easy to distinguish between the two types of bleeding. Moreover, the combined use of different techniques may be more efficient than using single method to control the bleeding.

D’Ambra and colleagues described a sensible and simple algorithm for managing presacral bleeding. It provides for the initial use of bipolar cautery and suture followed by local compression using small-tampon gauze or absorbable hemostatic gauze, then cautery through a taenia epiploica or piece of omentum, and finally, the use of a little scrap of bovine pericardium graft fixed into the sacrum with endoscopic helicoidal ProTack [46]. In the authors’ experience in seven cases of unstoppable presacral bleeding not amenable to conventional hemostatic solutions during laparoscopic rectal surgery, the last hemostatic step was required in two cases only, because in the other five cases, hemorrhaging stopped after the second step.

In our experience over the past 15 years, we encountered uncontrolled presacral venous bleeding in one of 500 patients who underwent rectal resection for primary and recurrent adenocarcinoma (0.2%). This occurred in a 52-year-old woman with low rectal cancer (cT3N + M0) who underwent standard neoadjuvant chemoradiotherapy. During posterior dissection of the rectum, extensive bleeding from the presacral venous plexus was encountered. An attempt to obtain hemostasis was first performed with compression of local hemostatic agents, without bleeding arrest. Next, bone wax was used unsuccessfully. We then swiftly proceeded to resect the rectum to obtain a better view of the pelvic cavity. The bleeding continued even after isolation and transient closure of the common iliac vessels. In an attempt to reduce blood flow in the sacral region, selective embolization of arterial lumbar and hypogastric branches was performed, but bleeding persisted. Blood loss was estimated to be about 2000mL. To decrease further bleeding, five large abdominal packs were insert, the laparotomy wound was closed, and a colostomy was performed. The patient received nine units of packed red blood cells. After 72 h, relaparotomy was performed to remove the packs, and no further blood loss occurred. The perineal proctectomy was completed, and the patient recovered uneventfully with no postoperative complications.

Georgiou and colleagues demonstrated that a minimum of 14 cases is required for a surgeon to acquire the necessary experience to enhance the overall perioperative complication rate of exenterative pelvic surgery [48]. Furthermore, authors deem that the best results recorded in the final part of their experience are due not only to their improved technical skills but also to the most appropriate selection of patients for surgery, particularly the exclusion of cases with a higher risk of morbidity and unfavorable oncological outcome as those with involvement of external iliac vessels, sciatic nerve, and sacrum above S3. Other predictors of postoperative complications are neoadjuvant therapy, patient age and nutritional status, type of surgery, magnitude of intraoperative bleeding, and use and type of plastic reconstruction. In most studies, radiotherapy is considered one reason for a high complication rate, and in a recent series, neoadjuvant therapy was the only factor that increases the risk of complications on multivariate regression analysis [48–53]. On the other hand, Alberda and colleagues evaluated the influence of radiotherapy for the primary tumor on outcomes in a series of 93 patients with LRRC who underwent neoadjuvant (chemo)radiotherapy and resection [6]. The primary tumor was treated with total mesorectal excision (TME) in all patients and with neoadjuvant radiotherapy in 28. There was more blood loss in patients who received radiotherapy for the primary tumor, which is probably due to the extensive postradiation fibrosis after previous radiotherapy and reirradiation. Nevertheless, the authors reported no significant difference in mortality and morbidity rates and severity grade according to Dindo-Clavien classification between groups.

Malnutrition has been associated with an increased incidence of postoperative morbidity in cancer patients [54, 55]. There is little work on the relationship between patient nutritional status and morbidity and mortality rates after pelvic surgery for LRRC. Beaton and colleagues evaluated the effect of body mass index (BMI) in 31 recurrent and locally advanced rectal cancer patients and found no correlation between preoperative BMI and surgical and medical complications [56]. However, the average length of hospital stay was significantly longer in patients who were underweight compared with those who were of normal weight (p = 0.006) and those who were overweight and obese (p = 0.007).

Morbidity is also influenced by the extent of pelvic and perineal defect. LRRC may occur as a mobile recurrence or a huge mass fixed to local regional pelvic structures. In nonfixed recurrent tumors, complete resection can be achieved with limited surgery, and the outcomes are relatively favorable [57]. Nevertheless, in the era of TME, the most prevalent pattern of LRRC is extraluminal, with infiltration of anterior structures (bladder, prostate, seminal vesicles, uterus adnexa, vagina), pelvic sidewall, and sacrum. To obtain a radical resection, pelvic exenteration (PE) or abdominosacral resection is necessary. In these cases, morbidity rate is extremely high, even in experienced centers [5]. The Mayo Clinic group published their results on 304 patients who underwent multimodality therapy and resection for LRRC [58]. Higher complication rates were observed in those undergoing extended resections, including sacrectomy and PE (32% vs. 21%; p = 0.04) and in patients whose recurrence was fixed in more than two sites in the pelvis (20% no or one fixation vs. 35% two fixations vs. 32% three or more fixations, p = 0.05). Similar results from other institutions [48, 59, 60] reported the complication rate was higher in patients with sacrectomy than in those without (50% vs. 33%; p = 0.017) in a cohort of 52 patients who underwent resection of LRRC [60]. Multivariate analysis revealed partial sacrectomy as the only independent predictor of surgical morbidity (odds ratio [OR] 5.85; 95% confidence interval [CI] 1.72–17.79; p = 0.004) and major complications (OR 3.80; 95% CI 1.11–13.00; p = 0.034) in a series of 100 resection for LRRC [48]. Nevertheless, Heriot and colleagues compared the results of 63 radical resection with those of 90 radical extended resections (including anterior and posterior exenteration) for LRRC [8]. They showed that, although the rate of postoperative complications was higher in the latter group (24% vs. 31%), morbidity was independent of the extent of resection (p = 0211). In a pooled analysis of 100 cases operated on for LRRC in three Italian university hospitals, patients who underwent extended resection had longer mean length of hospital stay compared with those operated on using radical resection (14 ± 9.3 vs. 11 ± 9.5 days, p = 0.02) [61]. However, no difference concerning morbidity rate and severity grade according to Dindo-Clavien classification was found between groups. The authors suggested that these advanced procedures may be safely performed by experienced teams.

Morbidity is generally high after pelvic exenteration (PE) and, according to a recent systematic review, ranges between 37% and 100%, with a median value of 57% [47]. After extended resections for LRRC, the empty pelvic space is associated with many complications, including abscess, bowel obstruction, fistulas, wound breakdown, and — later — perineal hernia [15]. Septic complications are the most frequent. When infection does occur, some simple rules must be followed. Adequate drainage must be started early at diagnosis and removal of all devitalized tissue planned. Nowadays, percutaneous drainage of pelvic abscesses with computed tomography (CT) scan guidance is the most common form of drainage performed. The widespread utilization of interventional radiological procedures has decreased complication-associated morbidity, helped to avoid reoperation, and shortened hospital stays. In the experience of Llaguna and colleagues concerning a series of 101 patients undergoing resection for locally advanced and recurrent rectal cancer, 90% of complications amenable to radiological treatment were effectively managed via an interventional radiological procedure, whereas the remaining 10% required reoperation, none of which were secondary to failure of the interventional procedure [62]. The overall reoperation rate was 3%, nine times lower than that reported in studies performed in previous periods in which interventional radiological procedures were not widespread [63].

Septic pelvic complications can be reduced by filling the pelvic dead space with transposition of a myocutaneous flap. A series from MD Anderson Cancer Center reported significantly fewer complications in the 108 patients closed by tissue transfer compared with the 67 in whom primary closure was used following pelvic surgery (51.9% vs. 65.7%) [64]. Similarly, in more recent studies, flap reconstruction was found to be a protective factor against perineal morbidity after pelvic surgery [5, 65–67]. Davidge and colleagues, using multivariable regression methods, found a trend toward lower odds of perineal complications in patients receiving flaps (p = 0.065) compared with primary closure after PE for locally advanced or recurrent rectal cancer [67]. However there is debate in the literature regarding the advantage of pelvic reconstruction over primary closure, because perineal wound complications are frequent also after complex reconstruction of the large pelvic defect [68]. These complication rates, estimated to be ~40–50%, include wound dehiscence, flap necrosis, wound infection, and chronic perineal sinus. In a study comparing pelvic reconstruction with a vertical rectus abdominis myocutaneous flap for patients who underwent PE vs. primary closure, Chokshi and colleagues found no significant difference between groups. In particular, one of the most common complications was flap dehiscence [69]. When a large perineal defect is present from a wound breakdown, vacuum-suction dressings may be beneficial. They help keep a dressing in place, control excessive fluid drainage from the perineum, prevent perineal excoriation, and promote faster healing times, even in patients who have received extensive radiation [16, 68].

Complications associated with construction of the urinary conduit (ileourethral anastomotic leakage, ureteral injury, small-bowel leakage, stenosis of the ureter, and reduced renal function) are common (6–45%) [7, 51, 70]. Ureteric obstruction may necessitate placement of stents or nephrostomy tubes, endoscopic treatment of strictures, or surgical revision of ureteroenteric anastomoses. Continent urinary diversions involve multiple suture lines compared with ileal conduits and are therefore subject to a higher incidence of urinary leaks in the early postoperative period. They may also be subject to pouch rupture at any time, which may be treated initially with conservative measures, such as catheter drainage. If the urinary stream needs to be diverted further, nephrostomy tubes can be placed. If these measures still prove insufficient, surgical revision of the urinary diversion can then be performed [71].

Patients who experience serious morbidities generally have prolonged and repeated hospitalizations, and most of these patients spend their residual lives in the hospital. Moreover, patients with postoperative complications have less chance of gaining benefit from chemotherapy because the treatment can only be started after patients recover from surgery.

Late complications of PE may include incisional, perineal, and peristomal hernias; renal failure; venous thrombosis and pulmonary embolus; and pressure ulcers [47].

The perioperative mortality rate ranges from 0% to 25% (median 2.2%) [47]. Although the mortality rate is substantially acceptable in the majority of series, high mortality values are shown in some studies, confirming the need for careful patient selection and treatment centralization [72, 73].

In selected cases of large tumors involving the sacrum, sacropelvic resection may be required. This procedure is even more demanding and challenging than PE, and morbidity and mortality rates are higher. In 1981, Wanebo and Marcove described the first series of 11 patients who underwent abdominosacral resection for LRRC; about 20 years later, the group reviewed outcomes of 53 patients who underwent abdominosacral resection with curative intent [74, 75]. High amputation of the sacrum (S1–S2) was performed in 32 cases (60%). All patients had been irradiated previously. Operative mortality rate was 8%, mean blood loss >8000 mL, and mean operative time 20 hours. Major complications included prolonged intubation (20%), sepsis (34%), and posterior wound infection or flap separation (38%) [75].