A 69-year-old female presented as an emergency with atrial fibrillation, which was treated with warfarin. She subsequently developed fresh rectal bleeding and after further investigations a Dukes B adenocarcinoma of the rectum was found. She subsequently underwent a low anterior resection, coloanal anastamosis and a defunctioning ileostomy. Three sterile surgical metallic tacks (pins) were inserted into the sacrum to stop brisk bleeding from the presacral venous plexus. Following discharge, she was readmitted with septic shock and a CT scan revealed a presacral fluid collection in the area surrounding the sacral tacks (pins) and an anastamotic dehiscence. The patient was not fit for further pelvic surgery to remove the tacks, so an alternative minimally invasive cystoscopic procedure was performed. The sacral tacks (pins) were removed by the urologist using a rigid cystoscope and cold cup biopsy forceps. To our knowledge, this is the first reported case in the literature.
A 69-year-old Caucasian female presented as an emergency in November
2006 with atrial fibrillation, which was treated with warfarin. Within one
month, she developed fresh rectal bleeding. Her international normalised ratio (INR) was 2.4. Her past medical history
included, type 2 diabetes, left renal calculi, and an anterior myocardial
infarction in 2001 (followed by a coronary angio-bypass graft). Subsequent
inpatient investigations revealed a Dukes B adenocarcinoma of the rectum 5 cm
from the anal verge. She underwent a low anterior resection, coloanal
anastamosis and a defunctioning ileostomy.
The procedure was complicated by presacral venous plexus haemorrhage. Attempts
to control the bleeding with packing and suturing were unsuccessful; three
sterile surgical metallic tacks (pins) were inserted into the sacrum to
compress the veins and stop the bleeding (Figure
Computerised tomography (CT) scout film showing the placement of the surgical tacks in the sacrum.
After discharge
she was referred back to the surgical team with hypotension and a temperature of
She was admitted to the Intensive Care Unit (ICU) for haemofiltration for acute renal failure and management of her septic shock. Intravenous cefuroxime and metronidazole antibiotics were started. A CT of her abdomen and pelvis revealed a large 9.0 cm by 3.5 cm presacral collection with flecks of gas. Her abdominal drain wound swab cultured methicillin-resistant staphylococcus aureus (MRSA); linozolid was added to her antibiotic regimen.
Her discharge from ICU was followed by a transfer to the Coronary Care Unit (CCU) for palpitations and increasing shortness of breath. An echocardiogram showed moderate to severe left ventricular function and mitral regurgitation.
She continued to be treated conservatively for her pelvic collection and sepsis in CCU. Within one month she became hypotensive and was readmitted to ICU for inotropic support. Her worsening sepsis was treated with tazocin, ciprofloxacin, and metronidazole, and the presacral collection was drained under CT guidance. A rigid sigmoidoscopy showed pus around the anastamosis, and a gastrografin enema revealed an anastamotic leak. A colostomy was considered but cancelled due to her poor cardiac function and breathlessness on minimal exertion. Other contraindications to invasive surgery and a general anaesthetic included a weight loss of 3.5 stone (24.5 Kg), ongoing sepsis and recurrent urinary tract infections (UTI's). A CT Urogram (CT-IVU) was organised to investigate her renal tract and recurrent urinary tract infections, this revealed left-sided hydronephrosis and 3 cm by 1 cm presacral thick-walled collection around the region of the surgical tacks (pins) in the sacrum. Attempts were made to optimise her nutritional status and improve her sepsis prior to surgical removal of the tacks, as it was felt they may be the underlying cause of her sepsis.
After a month she
was still unfit for major invasive surgery or a general anaesthetic. A decision
was made to remove the tacks through the rectum by passing a rigid cystoscope through
the anastamotic defect and removing these from the sacrum. She underwent an
examination under spinal anaesthesia. The sacral tacks (pins) were removed by
the urologist using a Storz 22 French standard rigid cystoscope with a
This is an illustration of the cold cut biopsy forceps passing through the anastamotic defect, and removing the tacks in the sacrum.
The patient made an
excellent recovery postprocedure, with improving infective and inflammatory
markers confirming resolution of the inflammatory response. The patient had a
follow-up CT scan of her abdomen on 24/10/2007 and although the presacral collection
improvement was minimal from a previous CT scan 4 months earlier (Figure
(a) CT precystoscopic tack removal. Note the thick walled presacral collection. (b) CT post cystoscopic tack removal. Although the improvement in pre-sacral soft tissue thickening and fluid collection is minimal, the patient was clinically much improved.
The use of the
rigid cystoscope in the anus and rectum has been described previously for closure
of genitourinary fistulae [