How to treat pelvic sepsis after stapled hemorrhoidopexy?

In the last decade, stapled hemorrhoidopexy has become increasingly popular and is indicated for the treatment of symptomatic hemorrhoids grade 3 and 4. Stapled hemorrhoidopexy does not remove the hemorrhoids, but it is rather a strip of mucosa and submucosa at the top of the hemorrhoids. Stapled hemorrhoidopexy is a safe, effective and time-efficient procedure in hands of experienced colorectal surgeons. However, life threatening complications occur occasionally.

An article to be published on October 14, 2008 in the World Journal of Gastroenterology addresses this case. The research team led by Prof. Koop Bosscha from the Jeroen Bosch Hospital of Netherlands, reported this case and reviewed the literature for managing major septic complications after stapled hemorrhoidopexy showing that it seems that no standardized treatment is available.

Septic complications after stapled hemorrhoidopexy are rare. The cause of severe (retroperitoneal) sepsis and its teatment including both surgical and non-surgical treatment of hemorrhoids remain uncertain. Many different types of treatment have been installed varying from surgical interventions such as debridement with end-colostomy to applying intravenous antibiotics only. When the staple line is intact, a conservative approach seems to be sufficient. Surgery seems to be mandatory when a rectal tear is diagnosed or the staple line seems not to be intact. To authors'opinion, it is allowed to compare the latter with a rectal perforation.

Many different types of treatment have been noted for rectal perforations too. Some other authors tried to standardize the treatment of rectal perforations. They noted that intraperitoneal rectal perforations should be considered as colonic or sigmoid perforations. These patients should undergo surgical treatment by diverting the fecal material. They also suggested a surgical treatment for severely ill and older patients with extraperitoneal rectal perforations. In all other cases of extraperitoneal rectal perforations, some authors preferred primary closure of the rectal wound with a diverting colostomy. The authors' opinion is not to close perforations primarily. In case of an intraperitoneal perforation, they always prefer to do a resection of the injured rectum with an anastomosis and with or without a diverting (loop) colostomy or ileostomy. In case of extraperitoneal perforations the treatment depends on the extent of the perforation. Antibiotics and bowel rest as sole therapy can be allowed in small perforations. Large perforations and/or severe sepsis require a diverting (loop) colostomy or ileostomy.

In conclusion, stapled hemorrhoidopexy is a safe, effective and time-efficient procedure. However, life-threatening complications can occur. In case of pelvic sepsis, no standardized treatment is available. Van Wensen et al suggested that experienced colorectal surgeons, who are familiar with the technique and its complications, should perform such procedures. Further studies are needed to investigate and classify the best treatment for pelvic sepsis after stapled hemorrhoidopexy.

Reference: van Wensen RJA, van Leuken MH, Bosscha K. Pelvic sepsis after stapled hemorrhoidopexy. World J Gastroenterol 2008; 14(38): 5924-5926 http://www.wjgnet.com/1007-9327/14/5924.asp

Correspondence to: Dr. Koop Bosscha, MD, PhD, Department of Surgery, Jeroen Bosch Hospital, location Groot Ziekengasthuis, Nieuwstraat 34, 's-Hertogenbosch 5211 NL, Netherlands. k.bosscha@jbz.nl Telephone: +31-73-6992708 Fax: +31-73-6992163

World Journal of Gastroenterology (WJG), a leading international journal in gastroenterology and hepatology, has established a reputation for publishing first class research on esophageal cancer, gastric cancer, liver cancer, viral hepatitis, colorectal cancer, and H pylori infection and provides a forum for both clinicians and scientists. WJG has been indexed and abstracted in Current Contents/Clinical Medicine, Science Citation Index Expanded (also known as SciSearch) and Journal Citation Reports/Science Edition, Index Medicus, MEDLINE and PubMed, Chemical Abstracts, EMBASE/Excerpta Medica, Abstracts Journals, Nature Clinical Practice Gastroenterology and Hepatology, CAB Abstracts and Global Health. ISI JCR 2003-2000 IF: 3.318, 2.532, 1.445 and 0.993. WJG is a weekly journal published by WJG Press. The publication dates are the 7th, 14th, 21st, and 28th day of every month. WJG is supported by The National Natural Science Foundation of China, No. 30224801 and No. 30424812, and was founded with the name of China National Journal of New Gastroenterology on October 1, 1995, and renamed WJG on January 25, 1998.

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