Available via license: CC BY-NC-ND 4.0
Content may be subject to copyright.
j coloproctol (rio j). 2019;39(1): 70–73
www.jcol.org.br
Journal of
Coloproctology
Case Report
Common operation, uncommon complication.
Bleeding from superior haemorrhoidal artery after
minimally invasive procedure for hemorrhoids – a
case report
Janavikula Sankaran Rajkumar, Aluru Jayakrishna Reddy∗, Ravikumar Radhakrishnan,
Anirudh Rajkumar, Syed Akbar, Dharmendra Kollapalayam Raman
Life Line Institute of Minimal Access Surgery, Kilpauk, India
article info
Article history:
Received 7 August 2018
Accepted 5 September 2018
Available online 5 October 2018
Keywords:
MIPH
Embolized: pseudoaneurysm
abstract
Minimally invasive procedure for hemorrhoids is one of the commonest new wave opera-
tions 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 disas-
trous 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 mas-
sive, 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.
© 2018 Sociedade Brasileira de Coloproctologia. Published by Elsevier Editora Ltda. This
is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Operac¸ão comum, complicac¸ão incomum. Sangramento de artéria
hemorroidária superior após PMIH – um relato de caso
Palavras-chave:
PMIH
Embolizadas: pseudoaneurisma
resumo
O procedimento minimamente invasivo para as hemorroidas (PMIH) é uma das novas
operac¸ ões mais comuns para ao tratamento de hemorroidas prolapsadas. O diâmetro do
tecido grampeado é crítico nessa operac¸ ão; um aumento nesse diâmetro poderia colocar
mais tecido na bigorna do grampeador, com resultados desastrosos. Este relato de caso
descreve o desfecho de uma hemorragia após PMIH, refratária a duas tentativas locais de
∗Corresponding author.
E-mail: doc jk@yahoo.in (A.J. Reddy).
https://doi.org/10.1016/j.jcol.2018.09.005
2237-9363/© 2018 Sociedade Brasileira de Coloproctologia. Published by Elsevier Editora Ltda. This is an open access article under the CC
BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
j coloproctol (rio j). 2019;39(1): 70–73 71
sobressutura. Um angiograma foi realizado quando a hemorragia foi considerada intensa.
O exame revelou um pseudoaneurisma da artéria hemorroidária superior esquerda, que foi
embolizada, interrompendo o sangramento. As dimensões do grampeador foram estudadas
e descobriu-se a possível causa do evento.O grampeador específico usado tinha um diâmetro
2 mm maior do que os grampeadores regulares da Medtronic e da Ethicon e possivelmente
captou uma área maior da parede retal e a artéria hemorroidária superior. Este relato de caso
documenta uma complicac¸ão rara e potencialmente fatal de um procedimento simples.
© 2018 Sociedade Brasileira de Coloproctologia. Publicado por Elsevier Editora Ltda. Este
´
e um artigo Open Access sob uma licenc¸a CC BY-NC-ND (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Introduction
The minimally invasive procedure for hemorrhoids or MIPH
has made significant strides in the field of proctology.
The principle of this operation is to remove a doughnut of
haemorrhoidal tissue from an area above the dentate line, and
reposit the anal columns in such a way that the staple line is
above the dentate line. This supradentate hemorrhoidopexy is
of proven immediate postoperative benefit in the treatment of
grade 4 hemorrhoids,1doughnut pattern of hemorrhoids, etc.
This case report is one of a 27-year old male who underwent
the MIPH and had severe postoperative bleeding, found to be
pseudo aneurysmal in origin. Emergency angioembolisation
was therapeutic.
Case report
A 27-year old had MIPH for Grade 3 hemorrhoids, in a circum-
ferential presentation. He underwent the procedure using a
newer version of the MIPH gun, available in the Indian mar-
ket. Made in China, the gun looked identical to the standard
guns from Ethicon, and functioned identically ex vivo.
The procedure was straightforward, with a purse string up
to the internal sphincter, but excluding it and the final staple
line was 3 cm above the dentate line.
On the second post-operative day, along with the stools,
there was a large bleed per rectum. Conservative management
was adopted, but on the third post operative day, there was
a massive bleed, and a drop of hemoglobin of 3g, necessi-
tating transfusion of three units of packed red cells, and an
exploration of the staple line, which was found to have a brisk
arterial spurter. This was oversewn, along with the stapler line,
using 2/0 polyglactin sutures (vicryl). After 48h, he had one
more bout of bright red blood issuing from the anus, and once
more had transfusions and exploration. The staple line bleed
was at the same spot, in the 3-o’clock position. Deep sutures of
2/0 vicryl were again deployed. For the next 48 h he was stable,
and consequently discharged.
He was readmitted; barely 12h later, with a massive
rebleed, and was hypotensive.
After aggressive resuscitation with intravenous fluids,
packed cells, and fresh frozen plasma, a decision was taken
to study the vascular anatomy locally in a more detailed
manner. To this end, an angiogram of the internal iliac artery
LIGHT BULB
SIGN
Fig. 1 – Superior rectal artery – light bulb sign.
Fig. 2 – Inferior mesenteric artery (IMA) angiogram.
was obtained, which showed a pseudo aneurysm of the left
superior haemorrhoidal artery, with active leak of contrast,
signifying an ongoing bleed, known as the light bulb sign
(Fig. 1). Immediate embolization was completed, with seal-
ing of the contrast leak immediately demonstrated (Figs. 2–4).
Thereafter, the patient had a smooth postoperative course,
with no further complications.
72 j coloproctol (rio j). 2019;39(1): 70–73
Fig. 3 – Super selective angiogram-active extravasation
contrast.
POST COILING
Fig. 4 – Superior rectal artery embolization using microcoil
(2 mm ×2cm).
Discussion
The crucial step in the MIPH is the stapler excision of the anal
columns above the dentate line, resulting in repositioning of
the hemorrhoids into a more proximal site. This involves a
purse string that invaginates the wall of the anorectum into
the shaft of the stapler.2If the stapler head is larger, a cor-
respondingly larger portion of the wall is included, and this
would result in perirectal tissues being within the firing sta-
pling position.3,4 The superior haemorrhoidal artery runs very
close to the wall of the rectum, and inclusion of a part of its
wall would cause a pseudo aneurysm, which did not respond
Fig. 5 – Stapler.
to conventional oversewing of staple line. Angio embolization
is the final port of call for a bleeding pseudo aneurysm, and
this proved effective. Pseudoaneurysms arise from a disrup-
tion in arterial wall, with blood dissecting into the tissues
around the damaged artery creating a perfused sac that com-
municates with the arterial lumen. They may be traumatic,
iatrogenic (from surgical, endoscopic or radiological interven-
tional procedures).4,5
When examined later, the Chinese stapler gun had an
external diameter of 34.5 mm (Figs. 5 and 6), vis-a-vis the
33 mm of the standard guns. This could have resulted in
inclusion of the wall of the vessel, and caused the pseudo
aneurysm. It has been reported that if the size of stapler is
more than 33 mm, the complication of bleeding is higher.1
Factors that may help to minimize the risk of bleeding:
manual overstitching of the staple line; use of the 33mm gun,
which has a smaller staple closure and is more hemostatic;
tightening the gun to the absolute limit; and use of a post-
operative endoanal sponge. The bleeding rate decreased from
12.9% to 4.4% with the increasing experience of the performing
surgeon.1,6,7
Only in one case have we encounteredpseudo aneurysm, in
a series of 28 MIPH cases done with the Chinese stapler guns.
Although these are still very popular in India, in our unit we
have given up the low cost stapler for MIPH.
Pseudo aneurysm of the superior rectal artery has been
reported,5Pseudo aneurysm of the cystic artery or right
hepatic artery after cholecystectomy and inadvertent lateral
wall injury to the vessel, is well documented.2,8 So is splenic
artery or left gastric arterial pseudo aneurysm secondary
to pancreatic pseudocyst or pancreatic necrosis. But to our
Fig. 6 – View of the circumference of the stapler.
j coloproctol (rio j). 2019;39(1): 70–73 73
knowledge, there are only few reported till now, on supe-
rior haemorrhoidal pseudo aneurysm, a rare complication of
MIPH.
Conclusion
This case report, of post MIPH pseudo aneurysmal bleeding, is
being published as it is uncommon, and to highlight techni-
cal considerations in choice of stapler, etc., to avoid rare but
deadly complications of an otherwise simple procedure.
Conflicts of interest
The authors declare no conflicts of interest.
references
1. Pescatori M, Gagliardi G. Postoperative complications after
procedure for prolapsed hemorrhoids (PPH) and stapled
transanal rectal resection (STARR) procedures. Tech
Coloproctol. 2008.
2. Ravo B, Amato A, Bianco V, Boccasanta P, Bottini C, Carriero A,
et al. Complications after stapled hemorrhoidectomy: can they
be prevented? Tech Coloproctol. 2002.
3. Ho YH, Seow-Choen F, Tsang C, Eu KW. Randomized trial
assessing anal sphincter injuries after stapled
haemorrhoidectomy. Br J Surg. 2001;88:1449–55.
4. Oughriss M, Yver R, Faucheron JL. Complications of stapled
hemorrhoidectomy: a French multicentric study. Gastroenterol
Clin Biol. 2005;29:429–33.
5. Janmohamed A, Noronha L, Saini A, Elton C. An unusual cause
of lower gastrointestinal haemorrhage. BMJ Case Rep.
2011.
6. Angelone G, Giardiello C, Prota C. Stapled hemorrhoidopexy.
Complications and 2-year follow-up. Chir Ital. 2006;58:
753–60.
7. Tebala GD, Khan AQ, Keane S. Major pelvic bleeding following
a stapled transanal rectal resection: use of laparoscopy as a
diagnostic tool. Ann Coloproctol. 2016;32:195–8.
8. Fondran JC, Porter JA, Slezak FA. Inflammatory polyps: a cause
of late bleeding in stapled hemorrhoidectomy. Dis Colon
Rectum. 2006;49:1910–3.
