Post hemorrhoidectomy complications: CT imaging findings

Journal Pre-proof Post hemorrhoidectomy complications: CT imaging findings

Eyal Klang, Tamer Sobeh, Marianne Michal Amitai, Sara Apter, Yiftach Barash, Noam Tau PII:

S0899-7071(19)30283-9

DOI:

https://doi.org/10.1016/j.clinimag.2019.12.015

Reference:

JCT 8807

To appear in:

Clinical Imaging

Received date:

16 June 2019

Revised date:

15 December 2019

Accepted date:

20 December 2019

Please cite this article as: E. Klang, T. Sobeh, M.M. Amitai, et al., Post hemorrhoidectomy complications: CT imaging findings, Clinical Imaging(2019), https://doi.org/10.1016/ j.clinimag.2019.12.015

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© 2019 Published by Elsevier.

Journal Pre-proof Post hemorrhoidectomy complications: CT imaging findings Eyal Klang MD a , Tamer Sobeh MD a , Marianne Michal Amitai MD a , Sara Apter MD a , Yiftach Barash MD M.Sc a , Noam Tau MD a a

– Department of Diagnostic Imaging, Chaim Sheba Medical Center, Ramat Gan,

Israel, affiliated to the Sackler School of Medicine, Tel-Aviv University, Israel

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Keywords: hemorrhoidectomy, hemorrhoids, complications, CT.

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Corresponding author: Noam Tau, MD

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Department of Diagnostic Imaging, Chaim Sheba Medical Center, Tel Hashomer,

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Sackler Faculty of Medicine, Tel Aviv University, 52621, Ramat Gan, Israel.

Declarations of interest: none

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E-mail: [email protected]

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This research did not receive any specific grant from funding agencies in the public,

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commercial, or not-for-profit sectors.

Journal Pre-proof

Post hemorrhoidectomy complications: CT imaging findings Introduction: We aimed to describe computed tomography (CT) findings of early complications after interventional hemorrhoid treatments in emergency department (ED) patients.

Materials and Methods:

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We identified all ED patients requiring abdominal and/or pelvic CT between February 2012 and February 2019, and included only patients who underwent CT for

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suspected early (up to 30 days) post hemorrhoidectomy procedure complications.

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Presenting symptoms, salient CT findings and clinical outcomes were collected.

Results:

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Overall, 48,425 abdominal and/or pelvic CTs were performed. Of these, we identified

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12 patients (8 male, 4 female) who underwent CT in our ED following

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hemorrhoidectomy procedures. At presentation, peri-anal or abdominal pain was the most common symptom. One patient presented with hemodynamic instability. CT findings included proctitis (4/12), rectal perforation (2/12), peri-anal abscess (1/12) and peri-anal fistula (1/12). Two of the patients with proctitis presented with significant submucosal edema. On follow-up, three patients required intensive care hospitalization, and two of those underwent emergent laparotomy. The third patient died due to secondary infection during his hospitalization.

Conclusion:

Journal Pre-proof Hemorrhoidectomy procedures may result in severe complications which should be recognized by ED radiologists. These complications carry a potential risk for significant clinical consequences. Both clinicians and radiologists should be aware of the possibility of such complications when patients present to the ED early after hemorrhoid procedures.

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Keywords: CT; hemorrhoids; hemorrhoidopexy; complications

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1. Introduction

Hemorrhoids are a common anorectal condition, affecting 4.4% - 39% of the adult population in developed countries [1-3].

Multiple treatment options are available. These include non-invasive methods, such

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as dietary and lifestyle modifications, topical and systemic medications. When these fail, invasive outpatient procedures are sometimes required, including rubber band

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ligation (RBL), sclerotherapy, hemorrhoidal artery ligation and laser procedures. In

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more severe cases, surgical interventions including stapled hemorrhoidopexy, open

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hemorrhoidectomy and closed hemorrhoidectomy may be used [4-7].

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Post-procedural complications are usually mild and non life-threatning. These

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complications include local pain, urinary retention, mild bleeding and perianal

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abscess, with varying incidence, depending on the specific technique used. Lifethreatening complications such as rectal perforation, sepsis, excessive bleeding, retroperitoneal and pelvic abscesses are rare [8-14].

To the best of our knowledge, computed tomography (CT) findings of severe post hemorrhoidectomy complications have only been rarely described [15-16]. We aimed to present the CT findings of complications after various interventional treatments of hemorrhoids, in patients requiring imaging in the emergency department (ED).

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2. Materials and methods This institutional review board approved retrospective study was performed in a major tertiary teaching hospital, and included all patients presenting to the ED

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between February 2012 and February 2019. Informed consent was waived. We have

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conducted a search for all patients presenting with any clinical complaints after

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hemorrhoid treatment who underwent abdominal and/or pelvic CT scans in the ED.

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We searched radiology reports in our radiology information system for the following

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terms: “hemorrhoids” or “hemorrhoidectomy”. The final patient cohort included only patients who presented to the ED up to 30 days post hemorrhoidectomy

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procedure [17].

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CT scans were performed on 1 of 2 different CT platforms: GE Discovery 64 (General

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Electric Healthcare, Waukesha, WI) or Philips Brilliance 64 (Philips Medical System, Cleveland, OH). All CT protocols included intravenous contrast administration (iohexol 350 mg/mL up to 2 mL/kg). One patient also ingested oral contrast (iohexol 350 mg/mL 52 mL diluted in 2 L water) prior to the CT examination.

Computerized medical records provided clinical data, which included: age; gender; prior history of hemorrhoidectomy procedures; type of hemorrhoidectomy procedure; time from procedure; and presenting symptoms on ED admission. We also collected data regarding findings on initial physical examination (including peri anal and rectal tenderness, rectal discharge and signs of peritonitis); ED vital signs

Journal Pre-proof and laboratory results (including white blood count and C-reactive protein level); and clinical follow-up (including duration of hospital stay, antibiotic use, subsequent surgeries, intensive care unit hospitalization and clinical outcome).

Each of the CT scans were retrospectively read in consensus by 2 board-certified abdominal radiologists with 7 and 9 years' experience, who evaluated the examinations for imaging features of abdominal and / or pelvic post-operative

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complications. All CT evaluations were then reviewed by a third radiologist with 32 years of experience to resolve possible discrepancies. Main imaging findings of

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interest were: rectal submucosal edema and proctitis; rectal perforation;

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3. Results

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abdominal, pelvic or peri-anal abscesses; and abdominal or pelvic free fluid.

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Between February 2012 and February 2019 there were 48,425 abdominal and/or

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pelvic CT scans performed in our ED. Of these, 13 patients were referred to CT (5 abdominal-pelvis, 8 pelvis) with the clinical question including post hemorrhoidectomy procedure complications. One patient was excluded as his CT was performed more than 30 days after the hemorrhoidectomy procedure. Therefore, our final cohort included 12 patients (8 males and 4 females); with a mean age at the time of the procedure was 43 ± 10.9 years (range, 28 – 66 years). Table 1 presents patients' demographic data and hemorrhoidectomy procedure information.

Journal Pre-proof On presentation, peri-anal or abdominal pain was present in 11/12 (91.67%) cases and fever was present in 3/12 patients (25.0%). Mean CRP was 56.5 ± 41 mg/L (normal range <3 mg/L) and leukocytosis (defined as > 11 × 10 9/L) was present in 6/12 cases (50.0%). One patient presented with hemodynamic instability (blood pressure of 60/40 mmHg). The mean time between the hemorrhoid procedure and

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ED presentation was 11 ± 9 days (range, 1-30 days).

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On CT, the most common abnormal finding was proctitis with submucosal edema,

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found in 4/12 (33.3%) patients (Figures 1, 2 and 3), followed by rectal perforation,

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found in 2/12 (16.7%) patients (Figures 4, 5 and 6). One patient had a small

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ischiorectal fossa abscess (Figure 7), likely secondary to anal perforation, and another patient had a peri-anal fistula. Free fluid was found in 2/12 patients (16.7%).

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Four patients had an unremarkable CT. The presenting symptoms, physical

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examination findings, laboratory results and CT findings of the 12 included patients

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are summarized in Table 2.

Three patients required emergent surgery. Of these, one patient underwent emergent laparotomy due to massive amount of free abdominal gas due to suspected bowel perforation (Figures 5 and 6). One patient had emergent surgery due to severe submucosal rectal edema, suspected to represent rectal ischemia, as well as large amount of free peritoneal fluid (Figure 3). Both patients did not require bowel resection, but were treated with a diverting colostomy and had prolonged intensive care hospitalization. The third patient underwent peri-anal abscess drainage with good clinical results.

Journal Pre-proof One patient died of cryptococcal meningitis, most probably as a complication of spinal anesthesia rather than directly related to the hemorrhoid procedure. The remaining patients were treated conservatively with complete subsequent symptom resolution.

Patients remained in hospital for a median of 3 days (range, 1 – 57 days). Three

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patients were treated in the intensive care unit (ICU) for a median of 7 days (range,

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4-11 days).

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Total hospital and ICU stay, surgeries performed, treatments received and final

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outcome are summarized in Table 3.

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4. Discussion

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Our study aimed to describe the radiological findings of early complications following

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hemorrhoidectomy procedures Only a few case reports in non-radiology literature presented the CT findings of severe post hemorrhoidectomy procedure complications, mainly in the surgical literature [15-16]. Hemorrhoidectomy is a common procedure, mostly performed in an outpatient setting. These procedures are generally considered safe, and the most prevalent post-procedural complications of non-surgical interventions are local pain and bleeding reported in in 8%-100%, with a mild trend towards lower complication rates after sclerotherapy [13]. As with non-surgical treatments, local pain and mild bleeding have similar prevalence following surgical interventions. Stapled

Journal Pre-proof hemorrhoidopexy is associated with less post-operative pain and quicker recovery compared to conventional hemorrhoidectomy [19, 20]. Other complications of open and closed surgical hemorrhoidectomy include: urinary retention or urinary infection (20.1%), delayed hemorrhage (2.4%), impaired continence (33%) and anal strictures (3.8%) [19]. Severe life-threatening complications such as rectal perforation, sepsis, excessive bleeding, retroperitoneal

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and pelvic abscesses are rare, and should be readily recognized by radiologists [8-

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14].

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Over a period of 7 years, we identified 12 patients who have undergone abdominal

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or pelvic CT exams in the ED with suspected post hemorrhoidectomy procedure

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complications out of 48,425 CT abdominal or pelvic scans performed. We evaluated patients by CT, as it is an accurate diagnostic tool to detect intra and retroperitoneal

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bleeding, abscess formation and rectal perforation.

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Peri-anal or abdominal pain was the most common presenting symptom, present in

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11/12 (91.67%) patients. Most patients had elevated inflammatory markers, including CRP and WBC. One patient presented with hemodynamic instability. The most common abnormal CT finding was submucosal edema and proctitis (4/12), and the second most common finding was rectal perforation (2/12). Consequently, two patients required emergent laparotomy and another patient underwent perianal drainage, while all other patients were treated conservatively. Of 12 patients, three required intensive care hospitalization.

The exact pathophysiology of post hemorrhoidectomy proctitis is unknown, and several possible mechanisms may be proposed. First, these changes may represent

Journal Pre-proof infectious or inflammatory processes. Second, one may suggest a pathway in which decreased or impaired post-procedural venous flow may result in bowel wall edema and eventually venous ischemia, similar to the mechanism behind stercoral colitis [7, 18]. This hypothesis is supported by our findings of severe rectal submucosal edema with mucosal hyperemia observed in two patients. It should be noted, that as hemorrhoid procedure is mostly performed on an outpatient basis, and as CT is not

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routinely performed after these procedures, the actual frequency of bowel wall

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edema is unknown, and as venous return is impaired as part of the procedure, some

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degree of rectal wall edema may be more common than clinically apparent, without

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significant consequences.

Our study has a few limitations: The current study is a retrospective, single center

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study, and alongside the rarity of post- hemorrhoidectomy procedural complications,

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our study includes a small number of patients. Moreover, as the majority of

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hemorrhoidectomy procedures are performed in an outpatient setting, a future large-scale prospective cohort study should be performed to assess the rate of complications, and especially severe complications. As mentioned above, as CT is not used for post procedural follow-up in patients undergoing hemorrhoidectomy procedures, we cannot compare our findings with the normal, expected post procedural appearance of the rectum.

In conclusion, hemorrhoidectomy procedures may rarely cause severe complications which should be recognized by ED radiologists. Although uncommon, these complications carry a potential risk for significant clinical consequences. Both

Journal Pre-proof clinicians and radiologists should be aware of the possibility of such complications

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when patients present to the ED early after hemorrhoid procedures.

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Figure legends Figure 1: Axial contrast enhanced CT shows minimal submucosal rectal wall edema and mild perirectal fat stranding. No evidence of perforation (patient 7). Figure 2: Moderate submucosal rectal wall edema with significant perirectal fat stranding. No evidence of perforation (patient 6). Figure 3: Severe submucosal rectal wall edema and mucosal hyperemia,

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accompanied by large amount of free fluid, later identified as pus on surgery. No evidence of perforation was found on CT as well as during surgery (patient 2).

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Figure 4: Posterior rectal wall perforation with gas seen between the pelvic floor

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muscles (patient 1).

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Figures 5 and 6: Rectal perforation with large amount of free peritoneal fluid and gas, as well as severe pre-peritoneal and subcutaneous emphysema (patient 4).

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Figure 7: Small left sided ischio-rectal fossa abscess (patient 12).

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References

[1] Johanson J, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. Gastroenterology. 1990;98(2):380-386.

[2] Lee JH, Kim HE, Kang JH, Shin JY, Song YM. Factors associated with hemorrhoids

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in korean adults: korean national health and nutrition examination survey. Korean J

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Fam Med. 2014;35(5):227-36.

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Colorectal Dis. 2011;27(2):215-220.

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[3] Riss S, Weiser F, Schwameis K et al. The prevalence of hemorrhoids in adults. Int J

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[4] Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist's view. World J

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Gastroenterol. 2015;21(31):9245-52.

[5] van Tol RR, van Zwietering E, Kleijnen J, et al. Towards a core outcome set for hemorrhoidal disease-a systematic review of outcomes reported in literature. Int J Colorectal Dis. 2018;33(7):849-856.

[6] Giamundo P, Salfi R, Geraci M, Tibaldi L, Murru L, Valente M. The Hemorrhoid Laser Procedure Technique vs Rubber Band Ligation: A Randomized Trial Comparing 2 Mini-invasive Treatments for Second- and Third-degree Hemorrhoids. Diseases of the Colon & Rectum. 2011;54(6):693-698.

Journal Pre-proof [7] Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol. 2012;18(17):2009-17.

[8] Albuquerque A. Rubber band ligation of hemorrhoids: A guide for complications. World J Gastrointest Surg. 2016;8(9):614-620.

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[9] Ratto C, Campennì P, Papeo F, Donisi L, Litta F, Parello A. Transanal hemorrhoidal

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dearterialization (THD) for hemorrhoidal disease: a single-center study on 1000

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consecutive cases and a review of the literature. Tech Coloproctol. 2017;21(12):953-

Pr

e-

962.

[10] Yeo D, Tan KY. Hemorrhoidectomy - making sense of the surgical options. World

rn

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J Gastroenterol. 2014;20(45):16976-83.

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[11] Brown SR, Tiernan JP, Watson AJM, et al. Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and thirddegree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial. Lancet. 2016;388(10042):356-364.

[12] Faucheron J, Voirin D, Abba J. Rectal perforation with life-threatening peritonitis following stapled haemorrhoidopexy. British Journal of Surgery. 2012;99(6):746-753.

[13] Cocorullo G, Tutino R, Falco N, et al. The non-surgical management for hemorrhoidal disease. A systematic review. G Chir. 2017;38(1):5-14.

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[14] Cirocco WC. Life threatening sepsis and mortality following stapled hemorrhoidopexy. Surgery. 2008;143(6):824-9.

[15] Greensmith S, Ip B, Vujovic Z. Rectal perforation secondary to transanal

oo

f

haemorrhoidal dearterialisation. Ann R Coll Surg Engl. 2017;99(5):e154-e155.

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[16] Sturiale A, Cafaro D, Fabiani B, Ferro U, Naldini G. Rectal perforation after

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Doppler-guided hemorrhoidal dearterialization treated with diverting

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sigmoidostomy. Tech Coloproctol. 2018;22(7):553-554.

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[17] Morris MS, Deierhoi RJ, Richman JS, Altom LK, Hawn MT. The Relationship

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2014;149(4):348–354.

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Between Timing of Surgical Complications and Hospital Readmission. JAMA Surg.

[18] Serpell J, Nicholls R. Stercoral perforation of the colon. British Journal of Surgery. 1990;77(12):1325-1329.

[19] Hardy A, Chan CLH, Cohen CRG. The Surgical Management of Haemorrhoids – A Review. Dig Surg. 2005;22:26–33.

Journal Pre-proof [20] Gravié JF, Lehur PA, Huten N, et al. Stapled hemorrhoidopexy versus milliganmorgan hemorrhoidectomy: a prospective, randomized, multicenter trial with 2-year

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rn

al

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postoperative follow up. Ann Surg. 2005;242(1):29–35.

Journal Pre-proof Table 1 - Patient demographic data and procedure information. Patient

Age

Gender

(years)

Prior

Current

Time to

hemorrhoidectomy

hemorrhoidectomy

presentation (days)

procedures

procedures and perianal procedures Open

1

42

Female

None

3

2

34

Female

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hemorrhoidectomy None

Rubber band ligation

1

3

28

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Unspecified

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Unspecified

Male

28

Female

6

48

53

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5

Male

9 Lateral anal sphincterotomy. Stapled

None

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4

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hemorrhoidectomy

hemorrhoidectomy.

11 hemorrhoidectomy Hemorrhoidal artery

None

26 ligation

Previous sclerotherapy

Sclerotherapy

injections

(8th injection)

Female

3

Unspecified 7

40

Male

None

hemorrhoidectomy.

17

Anal fissure surgery. Hemorrhoid laser 8

42

Male

None

5 procedure

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39

Male

RBL (recent)

Rubber band ligation

8

Unspecified 10

48

Male

None

13 hemorrhoidectomy Stapled

11

66

Male

None

10 hemorrhoidectomy Unspecified hemorrhoidectomy.

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None

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Male

Lateral anal

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sphincterotomy.

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51

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12

30

Journal Pre-proof Table 2 - Signs and symptoms of patient in ED presentation

Patient

Presentin

Physical

BP (mmHG),

Oral

WBC

g

examination

Pulse (BPM)

temperature,

(10 /

symptom

findings

Blood

L)

s

CRP

9

CT findings

Main finding

(mg/L)

saturation Posterior rectal perforation 120/80 Peri-anal

36.5c

11

tenderness

100%

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pain.

with subcutaneous gas.

53

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86

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Pelvic 1

Pr

Pelvic

Perforation

Small amount of free peritoneal fluid. Severe rectal submucosal edema with mucosal hyperemia.

36.8c

pain,

Diffuse

91/62

3.7

100%

rectal

peritonitis

127

Proctitis density free fluid (>20 HU). Diffuse small and large

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bleeding

Large volume of high 29

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2

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bowel wall thickening, likely reactive.

Peri-anal Pelvic

tenderness.

pain,

Tender

rectal

prolapsed

bleeding

internal

122/77 101

36.4c

13

3

6.5

No pathologic findings.

Normal

99%.

hemorrhoid Diffuse

Large volume perirectal, Not

4

abdomina

NA

NA

NA

NA

retroperitoneal, pre-

documented l pain,

peritoneal and

Perforation

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subcutaneous gas.

fever

Rectal perforation Peri-anal

Peri-anal 5

mass with

116/79

36.7c

pus

71

98%

9.5

pain and

57

No pathological findings.

Normal

mass. discharge. Moderate rectal submucosal

pain, fever.

112/74

38c

112

97%

24

of right

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6

tenderness

131

anterior

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Peri-anal

edema with mucosal

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Swelling and

Peri-anal

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rectal wall

Anal fissure, 99/60

7

pain and

38.3c

pus 108

Mild periPeri-anal 8

115/73 anal

68

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pain.

Proctitis

stranding. Suspected perirectal phlegmonous reaction.

Minimal rectal submucosal

17.6 81

edema.

Proctitis

Mild perirectal fat stranding.

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discharge

Perirectal and presacral fat

98%

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fever.

hyperemia.

36.6c

9

Minimal rectal submucosal 36

98%

Proctitis edema

tenderness Peri-anal

Peri-anal

9

37.7c

10

NA

pain.

tenderness

15

No pathologic findings

Normal

NA

Tender Peri-anal hemorrhoids pain, 10

Inter-sphincteric peri-anal 119/79

36.5c

80

99%

16

, rectal constipati

NA

purulent

fistula / sinus tract.

Fistula

Fecal impaction

on. discharge General

Peri-anal

141/74

39c

weakness,

tenderness

74

89%

11

100 15

No pathologic findings

Normal

Journal Pre-proof fever. Small ischiorectal fossa Peri-anal 125/77

36.3c

tenderness

63

99%

4.9

abscess with gas and fluid,

pain.

NA

Abscess likely due to anal perforation

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CRP – C-reactive protein. WBC – white blood count

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12

Peri-anal

Journal Pre-proof Table 3 - Patient management and outcome Patient

Total

Intensive

hospital stay (days)

Subsequent

Antibiotics or

Final

care unit stay Surgeries

anti-fungal

outcome

(days)

treatment (Yes/No)

3

0

None

Yes

Resolved

2

37

11

Diverting

Yes

Discharged

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1

with

Presacral

colostomy.

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colostomy.

0

4

47

4

6

0

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2

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5

Pr

1

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3

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drainage None

No

Resolved

Diverting

Yes

Lost to

colostomy Peri-anal

follow up Yes

Resolved

abscess drainage

5

0

None

Yes

Resolved

7

5

0

None

Yes

Resolved

8

1

0

None

Yes

Resolved

9

1

0

None

No

Resolved

10

3

0

None

Yes

Resolved

11

57

7

None

Yes

Death

12

1

0

None

Yes

Resolved

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Highlights

1. Data on the radiologic findings of post hemorrhoidectomy complications is limited. 2. Complications include rectal submucosal edema, proctitis and rectal perforation. 3. Patients may even require urgent surgery and intensive care hospitalization.

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4. Although uncommon, these complications carry a risk for significant

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consequences.

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7