RECTAL PERFORATION AFTER STAPLED HEMORRHOIDECTOMY : A CASE REPORT

...................................................................................................................... Introduction:Most patients with hemorrhoidal disease are treated conservatively Surgical stapling is a simple and effective treatment for thirdand fourth-degree hemorrhoids. It has a shorter hospitalization period and causes less discomfort than conventional operations. However, this procedure is associated with severe adverse effects, such as rectal bleeding, pelvic sepsis, and rectal perforation, which can be life-threatening [2–4]. Rectal free perforation after stapled hemorrhoidectomy is extremely rare, and most patients are treated with laparotomy and stoma formation for fecal diversion.

Case Report:-A 45-year-old man presented to the emergency department with sudden-onset diffuse perianal pain and hematochezia. He had undergone stapled hemorrhoidectomy 13 days earlier and was discharged after an uneventful postoperative course. He was a known case of seropositive status since 10 years on treatment for the same and was on anti-kochs treatment since the past 2 months. Digital rectal examination revealed hematochezia with a perforation of the rectum 5cm from the anal verge. On per abdominal examination his abdomen was soft with no signs of perforation. Laboratory findings were unremarkable. X ray abdomen standing was normal. Ct scan was done which showed a rectal perforation 5cm from the anal verge[ Figure 1].
The patient was posted for emergency laparotomy under general aneasthesia. On opening the abdomen there was minimal contamination and the rectal tear identified. Washes were given and the rectal tear suture with 3.0 silk. Drain was kept and the abdomen closed in layers. The patient had an uneventful postoperative course and discharged on the 10 th postoperative day.

Discussion:-
Stapled hemorrhoidectomy is a widely accepted surgical technique for prolapsed internal hemorrhoids because of advantages, including shorter hospital stay and less discomfort, compared with conventional hemorrhoidectomy [2,3]. However, this procedure for prolapsed hemorrhoids (PPH) is associated with adverse effects, collectively referred to as "PPH syndrome," consisting of proctalgia, tenesmus, urgency, and rectovaginal fistula [1]. Furthermore, studies have reported major complications requiring fecal diversion, such as retroperitoneal sepsis and intraperitoneal rectal perforation, which are potentially life-threatening [4][5][6][7]. The most common early complication is rectal bleeding; its incidence ranges from 4% to 8%, and approximately 5% of minor rectal bleeding requires early reintervention [8].
In the laparoscopic era, colorectal surgeons may agree to attempt laparoscopic management of colorectal perforation following colonoscopy, diverticulitis, and anastomotic leakage [9][10][11][12]. The SCANDIV trial showed that laparoscopic lavage for perforated diverticulitis is no better than conventional operations; laparoscopic lavage did not reduce morbidity and had worse outcomes, such as high reoperation rate and missing carcinoma [9]. Another randomized controlled trial, however, reported that laparoscopic lavage may be an appropriate treatment option, though the condition in question was different [10]. Lee et al. reported that laparoscopic reintervention for anastomotic leakage was associated with shorter hospitalization and fewer complications [12]. The choice of treatment should be determined after considering the state of the patient.

Conclusion:-
Stapled hemorrhoidectomy is widely used for treatment of pro-lapsed hemorrhoids because of certain advantages. However, it can have severe adverse effects, such as rectal bleeding, pelvic sep-sis, and rectal perforation, which are potentially life-threatening. Unexpected abdominal pain after stapled hemorrhoidectomy can be due to associated rectal perforation; therefore, immediate evaluation should be performed. Emergency divertion procedures have to 873 be performed. Laparoscopic primary repair without stoma can be performed successfully in select patients with rectal perforation following stapled hemorrhoidectomy