Surgery: Current Research

A Uncommon Side Effect of Stapled Hemorrhoidopexy: Mucocele

Shalu Pandey^{* *}Correspondence: Shalu Pandey, Department of Biomedical Sciences, University of Delhi, India, Email:

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Introduction

The most prevalent anorectal problem is haemorrhoids, which affects 50% of those over the age of 50, according to estimates. In addition, many surgeons are attempting to use Stapled Hemorrhoidopexy (SH) due to reported advantages over open variants of hameorrhoidectomy, which include a shorter operating time, less postoperative pain, better wound healing, and an earlier return to work. Traditional open hemorrhoidectomy remains the gold standard in the surgical management of circumferential prolapsed haemorrhoids. In comparison to conventional open hemorrhoidectomy, SH generally raised the relative risk of hemorrhoid recurrence. A rare but distinct collection of procedural problems have been brought on by the stapled approach to the hemorrhoid-bearing mucosa, with postoperative Rectal Mucocele (RM) being one such instance. Patients with RM often appear clinically later, with some asymptomatic cases being identified incidentally. Tenesmus and soreness in the lower abdomen are two signs of a post-SH RM, which in certain circumstances can exacerbate an evacuatory problem that already existed. We speculate that it may be due to a specific technical effect of the stapled technology brought on by improper positioning of the resected rectal mucosa under the stapled line. In this case, a portion of the rectal mucosa has either been torn away from the purse-string or has not been fully included into the suture. The epithelium eventually became submucosally implanted, either with or without a luminal link. We present many instances of symptomatic RM that developed after a SH operation.

The goal of the retrospective study is to identify the potential causes of RM by analyzing the clinical traits, treatment, and outcomes of this uncommon condition.

Results

Since 2013, seven patients—five of whom are male and ranging in age from 20 years to 75 years-were found to have an RM after a SH operation. These cases first surfaced 6 months on average (range 2 months-84 months) following SH operation. One of the patients had an additional condition (Type II diabetes mellitus). All of the patients complained of varying anal discomfort, with 5/7 experiencing intermittent anal pain and 2 having trouble urinating. None of the patients had intermittent fevers or rectal bleeding when they first arrived. Digital rectal examination revealed pararectal masses in every case, which were palpable in two patients and were anterior in one, anteroventral in three, posterolateral in two, and posterior in one. The majority of the cystic components in these morphologically diverse masses, which ranged in size from 0.5cm to 0.8 cm to 3.3cm to 4.5 cm, were present. Even when there was no luminal link, the bulk was always closely correlated with discernible residual staples. The mucus' cytology was unremarkable. Each case's histology revealed normal rectal mucosa with only little fibrosis around it. The postoperative course of all patients was uneventful, and all cases remained asymptomatic at a one-year follow-up. Only two patients were evaluated with a repeat MRI test one week following surgery.

Discussion

The first type of SH, Prolapse and Haemorrhoids (PPH), was developed by Longo in 1998 and is advised for patients with Grade II–IV haemorrhoids. The relatively rare RM treatment after SH operation accounts for only 2.5% of problems. When there hasn't been a prior stapled anorectal operation, RM is especially uncommon (SH or STARR transanal rectal resection).

In the original description of the rectal pocket syndrome, secretory pieces of the rectal mucosa became isolated and entrenched in the submucosa. The connexion of RM with a SH surgery reflects a special form of this condition. There is a luminal link associated with rectal pocket syndrome that allows for the accumulation and concretion of a faecolith and any associated possible problems. In contrast, there is no direct luminal connexion in a postoperative RM, leading to mucus buildup and the development of a pararectal mass. Incorporating all mucosal folds is the aim of SH so that the mucosa is evenly drawn up as the gun is closed. In order for a rectal pocket or RM to form following a stapled excision and anastomosis, there often needs to be a separation of a portion of the mucosal edge such that the mucosa is retained beneath the stapled line. First off, if a double purse string suture is used, portion of the tissue in between widely spaced sutures might not be fully retracted into the stapler cabin housing, resulting in closed cavities forming once the stapler is fired. Second, accidentally incorporating more mucosa between the stapler jaws while the purse string suture is tightened and knotted around the shaft of the opening stapler head results in the creation of RM. Thirdly, RM can occur when a single purse-string procedure is performed with too much space between the two stitches or when the purse-string slips and bites the tissue too superficially. We do not, however, believe that RM will result from the third condition occurring by itself. Generally speaking, it appears that purse string sutures that have significant gaps between the threads may omit some of the circumferential mucosal edge. And once the stapler has fired, a purse-string suture that was inserted too superficially may rip through, leaving a piece of the mucosa that was not included into the anastomosis. Tissue-selecting approach, which is a partial or segmental stapled hemorrhoidopexy, is a modified SH procedure that our group originally reported on in terms of safety and feasibility. Another name for it is Partial Stapled Hemorrhoidopexy (PSH). Because the anastomotic loop created by the stapler is linear and perpendicular to the rectal wall, a parallel anastomotic line is not created. To put it another way, RM formation cannot be brought on by suture that is just too much or too superficial. Along with stapler-related factors, poor surgical manipulation can also result in cyst development. The patient may occasionally receive silk sutures for hemostasis during or following surgery. We hypothesized that using a nonabsorbable suture made matters worse and may have contributed to the embedding of islands of mucosa. The distance between the sutures and the loose rectal mucosa, which was unable to be entirely pushed into the stapled chamber, determines how these various proposed mechanisms of RM development develop. The mucosa could discharge mucus continuously to develop cysts because there was no opening or direct link between the mucosa and the rectal lumen. Last but not least, abscesses may develop as a result of germs or leftover faeces aggravating the condition. Despite the fact that most of these mucoceles are believed to be asymptomatic, if the rectal epithelium is buried submucosally, a cycle of mucus retention, faecal contamination, and bacterial overgrowth will begin, with the possibility of abscess (and perhaps fistula) formation. When a pararectal mass is present on clinical examination (or with specialized imaging), symptomatic cases outside of a septic presentation would often complain of tenesmus and even partial evacuation, where each has its own differential diagnosis. This may include endometriotic deposits, cystic developmental retrorectal lesions (rectal duplication, epidermoid and dermoid cysts), benign neoplasms (lipoma, leiomyoma, GIST), malignant tumors (mesenchymal, neural, neuroendocrine, carcinoid, lymphoma), benign tumors (lipoma, leiomyoma, GIST), and rectal diverticula. The characteristics of any pararectal mass's contents and its connection to the central rectal lumen are defined through the use of MR imaging. High signal intensity on T2-weighted sequences, entrapped faecal waste, and surrounding cyst wall oedema are characteristics of cystic masses, as are inflammatory alterations.

Surgery is the preferred course of treatment for RM when symptoms call forit. The surgical alternatives include mucocele excision, or more commonly, evacuation of the mucocele contents, marsupialization, which involve cutting a hole through the cyst to access the rectal lumen and removing any unnecessary staples. The size and location of the mucocele determine the best surgical option, and mucocele excision is frequently the best option for smaller mucocele found in the superficial area. In some cases, surgical combinations are employed, depending on the location and extent of the mucocele. In the experience, if regular stapled hemorrhoidopexy is performed with a few tactics, the incidence of RM can be decreased. We still think that incorrect purse sutures are the primary cause of RM. We focus mostly on purse-sewing technique. If a double purse-string is used, there shouldn't be much space between the two purse rows. The purse-string traction line needs to be continuously tightened before the staple cartridge is fully closed to ensure that the sutured mucosa enters the staple cartridge evenly. To prevent hematoma formation and lessen postoperative suture hemostasis, the closed stapler should be thoroughly squeezed for 20 seconds to 30 seconds. A good disinfection procedure might also lessen the chance of bacterial retention during suturing.

This study's drawback is that it is retrospective in nature. Considering that RM is a relatively uncommon complication, we intend to gather further evidence to support the notion we put up regarding the causes of RM following SH surgery.

Conclusion

Multiple methods are suggested via which isolated and submucosally embedded mucosal fragments can generate RM following a SH treatment. These relatively uncommon mucoceles can be controlled quite successfully by deflation and fenestration into the rectal lumen, but they can be avoided with a few surgical techniques.