Common operation, uncommon complication. Bleeding from superior haemorrhoidal artery after minimally invasive procedure for hemorrhoids – a case report

Abstract

Minimally invasive procedure for hemorrhoids is one of the commonest new wave operations done for prolapsed hemorrhoids. The diameter of the stapled tissue is critical in this operation, and an increase in the same could include more tissue in the anvil, with disastrous results. This is a case report of a post minimally invasive procedure for hemorrhoids bleed, which was refractory to two local oversewing attempts. When the bleeding was massive, an angiogram was obtained. This revealed a pseudo aneurysm of the left superior haemorrhoidal artery, which was embolized, stopping the bleed. The stapler dimensions were studied and the possible cause of the event was arrived at. The specific stapler used had a diameter of 2 mm more than the regular Medtronic and Ethicon staplers, possibly including more of the rectal wall, and the superior haemorrhoidal artery as well. This case report documents a rare and potentially fatal complication of a simple procedure.

Perirectal Hematoma and Intra-Abdominal Bleeding after Stapled Hemorrhoidopexy and STARR—A Proposal for a Decision-Making Algorithm

“…Seven studies were excluded based on reasons listed in Table 1 [12][13][14][15][16][17][18]. Cumulatively, 17 articles (15 case reports and two case series) were considered relevant, and 38 patients were included ( Figure 1, Seven papers reported perirectal hematoma [3,17,18,[20][21][22][23][24][25][26][27]. In seven articles, intraabdominal bleeding was described [28][29][30][31][32][33][34], two reported retroperitoneal hematoma [19,25].…”

“…Seven studies were excluded based on reasons listed in Table 1 [ 12 , 13 , 14 , 15 , 16 , 17 , 18 ]. Cumulatively, 17 articles (15 case reports and two case series) were considered relevant, and 38 patients were included ( Figure 1 , Table 2 ) [ 3 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”

“…Other rare causes of late bleeding can be the pseudoaneurysms of the superior rectal artery [24,27,32]. Another, but not well studied and reported cause can be overlooked blood clotting disorders.…”

“…In hemodynamically stable or stabilizable patients, the contrast CT is the primary diagnostic modality, which can identify the bleeding source. In the case of active bleeding throughout the hematoma, the selective angiography of the lower mesenteric artery with super-selective embolization of the upper rectal artery is the method of choice [24,25,27,28]. The colonoscopy and rectoscopy are of only minimal value.…”

“…The most worrying complication this approach is re-bleeding, which can occur in up to 34% [38]. It is a late and unpredictable event, often as a consequence of the development and rupture of a pseudoaneurysm of one of the branches of the upper rectal artery [24,27,32].…”