A Novel Approach to Intractable Rectal Stump Drainage

Abstract

Purpose: Achieving safe and effective ablation of rectal tissue is a problem encountered when treating radiation proctopathy. We present a unique clinical scenario in which rectal tissue ablation reduced discharge from a rectal stump in a patient with a blast injury to his gluteal region. A 24 yearold active duty male with history of a blast injury to the buttocks from a rocket-propelled grenade suffered while serving in Iraq was referred to the gastroenterology service for bothersome rectal discharge. His initial injuries led to multiple surgeries including a right biceps femoris flap, urethra repair, colonic repair with placement of a colostomy, and other reconstructive surgeries. He was left disconnected with a rectal stump due to the absence of anal sphincter function and a difficult-to-reach rectal stump. Ten months after the injury, a flexible sigmoidoscopy was performed to evaluate rectal discharge and revealed a 10cm rectal stump with erythematous mucosa and copious, foul-smelling exudate. Biopsies were consistent with diversion proctitis. The patient was ineffectively treated with topical hydrocortisone foam and mesalamine enemas. A second endoscopy was performed with the intent of ablating rectal tissue using a radiofrequency ablation (RFA) electrode (HALO 90 system by BARRX Medical). Several weeks later, the patient noted a significant reduction in the amount of rectal discharge. Repeat endoscopy was performed 5 weeks later using argon plasma coagulation (APC), but he noted negligible improvement over the first ablative procedure. Another endoscopy was performed 8 weeks later using a combination of RFA and cryoablation, which resulted in a modest decrease in the amount of rectal discharge. One month later, he reported a decrease in the amount of discharge. The patient did not follow up in our clinic further due to discharge from the Army; however, he reported via phone continued improvement one year later. This is a unique case of a patient with diversion colitis and rectal stump drainage in the setting of an absent anal sphincter. Many of the topical therapies considered may have limited effect with absence of sphincter function. Using ablative procedures such as RFA and cryoablation had surprising effect. Although APC is considered the most helpful therapy for radiation proctopathy, it was difficult to use in this case due to the large surface area involved and the technical difficulty of the procedure. RFA and cryoablation seemed to be most effective and had a durable effect.