Gradual staple line disruption presenting with subtle multidiverticular pocket syndrome after STARR.

Abstract

A diverticulum of the rectum is a rare complication (2, 5 %) [1, 2] after trans-anal staple procedures, often resulting in faecal matter entrapment leading to the formation of a faecolyth which is likely to obstruct the internal orifice. This can cause local sepsis, eventually requiring reoperation [2]. A 28-year-old female operated on with stapled transanal rectal resection (STARR) for rectocele was referred to our Institution for severe chronic constipation, worsened in the last weeks with fever, abdominal and perineal pain, and rectal bleeding. Clinical examination and MRI revealed a rectal diverticulum with faecal impaction requiring removal under anaesthesia. Five days after stool disimpaction, she underwent MR-defecography which confirmed the presence of one posterior large diverticulum with incomplete elimination of enema. Endoscopy was carefully carried out showing multiple orifices (six) distributed circumferentially along the staple line; two retained agraphes were also identified (Fig. 1a; movie 1). The patient underwent transanal multiple diverticulectomy with direct reconstruction of the rectal wall (Fig. 1b; movie 2). At six months follow-up patient’s symptoms improved and proctoscopy showed good wound healing. The use of trans-anal stapling devices has gained popularity over the last years. Stapled techniques significantly reduce postoperative pain, which is the single most important reason why patients avoid surgery for proctological diseases [3]. However, higher rates of recurrences of symptomatic prolapsing haemorrhoids and obstructed defecation are observed [2, 4]. These may require repeated procedures [4, 5], sometimes technically demanding [5]. In addition, serious complications––unusual with conventional techniques––are reported with trans-anal staplers, also in experienced hands [1]. A iatrogenic rectal diverticulum, seldom observed after STARR [1, 2], may become inflamed with impacted faeces and progress to abscess formation and perforation, condition known as rectal pocket syndrome [1]. We suggest that its prevalence is underestimated because it is often asymptomatic in the short-term, but the effect of a longterm evolution is unknown. Treatment of this condition requires a trans-anal operation that involves experience to face complications that could rise from this relatively simple procedure. We believe that rectal anatomy after STARR is far to be a physiologic rectal anatomy; it produces a weak region (suture line) that is subjected to high pressures, exposing to the risk of complications. Our patient developed a pocket syndrome due to subtle, gradual disruption of the suture line resulting in multiple rectal diverticula formation. When combined with clinical examination, conventional imaging tools are extremely useful in detecting post-operative complications. Dynamic MRI-defecography is non-invasive imaging tool which has several advantages: it offers a clearer visualisation of Electronic supplementary material The online version of this article (doi:10.1007/s13304-014-0274-z) contains supplementary material, which is available to authorized users.