Topical Ankaferd Application to Presacral Bleeding due to Total Mesorectal Excision in Rectal Carcinoma

Dear Editor,

We have read with great interest the article by Karakaya et al. [1] indicating the efficacy of Ankaferd Blood Stopper (ABS) in a rat model of liver injury. We would like to contribute our experience related to the hemostatic efficacy of ABS in a patient with presacral bleeding developed following the abdominoperineal resection (APR) for the treatment of low rectal carcinoma.

Resection of the rectum and various pelvic tumors is usually performed with minimal bleeding, which ranges from 4.6–9.4% [2]. However, it sometimes represents an unusual “difficult to manage” complication. Conventional hemostatic procedures, such as tamponing, suturing, and cauterization, occasionally do not resolve but just perpetuate the hemorrhage [3]. Hemostasis in this area is difficult to achieve because of the complex interlacing of the venous network both beneath and on the surface of the periosteum. Furthermore, those veins tend to retract beneath the anterior surface of the bony sacrum.

An 89-year-old female with T3N0M0 rectal carcinoma underwent APR in our surgery clinic. During the mesorectal excision, massive bleeding from the presacral fascia occurred in the patient. After the specimen was removed hemostatic sutures were used to control bleeding, and gauze tampons were placed into the pelvis. As we removed the gauze tampons after 15 min, major bleeding stopped but continued in the form of oozing, which could not allow homeostasis using electrocauter and gauze spunches. We decided to use ABS. Accordingly, ABS in spray form was applied topically to the oozing area and the bleeding stopped within seconds. A closed suction drain was placed in the perineal space and end colostomy was performed. The suction drain was removed on the fifth postoperative day and the patient was discharged on the 12th postoperative day. The postoperative course was uneventful and further rebleeding was not observed. In the present case, topical application of ABS to bleeding in the presacral area was very effective to stop oozing within seconds. This unique observation prompted us to suggest that topical ABS application, as a novel approach, is a practical, effective, and safe adjunctive hemostatic treatment modality, which can be used in many difficult hemorrhagic surgical states.