Double rectal perforation after stapled haemorrhoidectomy

Abstract

Dear Editor: In the last 10 years, in addition to the conventional haemorrhoid-resection techniques (Milligan & Morgan, Ferguson, Parks, etc.) the technique described by Longo rapidly spread into surgical practice, thanks to the reported advantages of less postoperative pain, reduced need of analgesics, earlier return to work or normal activity, shorter recovery and operative time and earlier pain-free first defecation. This treatment is based on the concept that haemorrhoidal prolapse is not just a venous disease but a disease of the whole haemorrhoidal complex, including the connective tissue, the rectal wall, the Treitz muscle and all other muscles involved in the structure, very important for anal continence. Many studies have compared Longo’s stapled anopexy with conventional methods and some complications were reported. The most common described early complication was bleeding (5–8%), followed by severe anal pain, thrombosis, urinary retention (anaesthesia could be involved) and suture dehiscence. After 1 week from the intervention, later complications noted were: recurrence of haemorrhoids, residual prolapse or persistence of symptoms(the most common), occurring in about 5% of the patients, chronic anal pain (2%), stenosis, anal fissure, faecal urgency, incontinence and anal sepsis (fistulas and abscesses). Rectal perforation was rarely reported. We treated a female patient, 27 years old, who came to our attention from a local hospital with an acute abdomen condition and a CT diagnosis of a rectal perforation. She had been previously treated for third-degree prolapsed haemorrhoids in the same hospital, where she received a Longo’s stapled haemorrhoidopexy using the Ethicon Endo Surgery PPH set. She was discharged on the second day after intervention, and she complained of diffused abdominal pain, she has no passed gas and mild temperature. Before the discharge, an enema was performed. The woman had a negative general and gynaecological anamnesis. She was nulliparous and never previously operated or hospitalised. She performed a colonoscopy before the intervention that was negative. No defecography or other diagnostic exams were performed before the intervention. On a fifth postoperative day, she was readmitted; a CT was performed and she was transferred to the emergency room of our hospital. CT examination showed a double rectal perforation, the first at the staple line level and the second further up in the rectum, with a faecal peritonitis and pneumoperitoneum. She presented tachycardia, high temperature (>38°C) and 100/60 of blood pressure. At physical examination, a severe diffuse abdominal pain was found. At rectal digital exploration a small dehiscence of the staple line was noted, about 5 cm above the anal verge, with no external signs of abscess. The exploration caused intense pain, but no stenosis of faecal impact was detected. No other endoanal procedures were performed. Laboratory data showed a white blood cell count of 20,300/mm. An emergency intervention was performed. At laparotomy, generalised faecal peritonitis was found and a rectal posterior perforation at the rectal–sigmoid junction was noted. The hole was closed with a discontinue suture and a left colostomy was performed. Her recto-sigmoid tract was not redundant and there were no diverticula or something else notable. Two suction drains were put in place. No specimens were sent to pathology. The patient was Int J Colorectal Dis (2009) 24:1113–1114 DOI 10.1007/s00384-009-0665-7