Abdalla Mustafa, Mian Jabbar, Muhammad Rashid, Martin Downey, Kawan Shalli
Wishaw General Hospital, NHS Lanarkshire, Scotland
Introduction: Stapled haemarrhoidopexy (SH) is a widely accepted procedure for treatment of symptomatic haemorrhoids and rectal mucosal prolapse. Less postoperative pain and less operative time were the main attractive features when compared to conventional treatment procedures. Rates of complication after SH range from 6.4% to 31%. Life threatening complications are very rare and include rectal perforation, sepsis, bleeding and rectal obstruction. We aim to describe our experience in managing acute rectal obliteration after this procedure and review current available literature.
Methods: SH was electively performed in a 60 year old lady using an Ethicon PPH to treat both circumferential haemorrhoids and partial thickness rectal prolapse. Standard precautions were taken during the procedure; however complete rectal obliteration was noticed at the end of the procedure. Therefore, laparoscopic loop colostomy was fashioned. Contrast study confirmed rectal mucosal obliteration. A new endoscopic technique was used to re-establish continuity of the bowel. A review of literature was performed using MEDLINE and Pubmed databases.
Results: To date only five cases of acute rectal obliteration following SH has been reported. In those cases, the complication had occurred either due to misplacement of a purse string or firing the stapler outside the purse string and catching redundant rectal mucosa. In some cases the cause was uncertain. Rectal obliteration was previously managed either by progressive dilatation using an initially inserted guide wire through the obstructed site, limited Delorme’s procedure performed internally followed by muscular and mucosal anastomosis, and manual removal of stapler punches followed by repair of mucosal defects. In our case rectal lumen was reopened after passing an endoscope via the colostomy. A cannula from PEG’s set was inserted rectally; this was used to pass a guide wire which was then snared by the endoscope. The wire was tied to the anvil of an EEA circular stapler and under endoscopic guidance it was passed through the obstructed site. The Stapler was then passed rectally and locked to the anvil, closed, fired with resulted complete circular luminal continuity. The patient had uneventful recovery and the stoma successfully reversed few weeks later.
Conclusions: Rectal obliteration following SH is a very rare complication but it could be under reported. In our case, rectal obliteration had occurred despite the standard steps taken during SH and a complete tissue doughnut on the stapler ring. The cause was uncertain in this case. Possible explanation could be due to excessive proximal rectal mucosa which was caught further above the purse string on firing the device. Therefore, extreme precautions are always advised when performing such procedure. Such complication was managed successfully using a new endoscopic technique. We suggest avoiding PPH as a treatment for combined circumferential haemorrhoids and prolapsed rectal mucosal disorder.
Session: Poster Presentation
Program Number: P603