Case Reports Retroperitoneal Air After Routine Hemorrhoidectomy Report of a Case BRITA D. KRISS, M.D., JOEL A. PORTER, M.D., FREDRICKA. SLEZAK, M.D.
Kriss BD, Porter JA, Slezak FA: Retroperitoneai air after routine hemorrhoidectomy: report of a case. Dis Colon Rectum 1990; 33:971-973. Retroperitoneal air as a complication after routine hemorrhoidectomy has not been reported in the literature. This occurred recently after hemorrhoideetomy in a 34-year-old patient receiving glucoeorticoid therapy for rheumatoid arthritis. Adverse steroidal effects of wound healing have been well documented. It is believed that steroid-induced tissue changes contributed to the development of this unique complication. [Key words: Complications of hemorrhoidectomy; Retroperitoneal air; Pneumomediastinum
HEMORRHOIDECTOMY IS A frequently performed operation with many known complications. Review of the literature, however, reveals no reports of retroperitoneal air after hemorrhoidectomy.1--4 Much attention has been focused on the adverse metabolic tissue effects of glucocorticoids. 5 The association between steroid use and gastrointestinal ulceration and perforation is well accepted. 6 We present the case of a patient with steroid-dependent rheumatoid arthritis in whom retroperitoneal air was found after hemorrhoidectomy.
Report of a Case A 34-year-old woman with rheumatoid arthritis aud symptomatic external hemorrhoids was admitted to the hospital for hemorrhoidectomy. Prior office evaluation included a rigid sigmoidoscopy to 15 cm, which was normal. The patient had been receiving 10 mg of prednisone daily, but was weaned from her steroids two weeks before elective surgery. A routine closed clamp hemorrhoidectomy was performed in the left lateral, right anterior, and right Address reprint requests to Dr. Porter: 55 Arch Street, Suite 3D, Akron, Ohio 44304
971
From the Department of General Surgery, Akron City Hospital, Akron, Ohio, and the Northeastern Ohio Universities College of Medicine, Rootstown, Ohio
posterior quadrants. No intraoperative difficulties were encountered. Stress doses of hydrocortisone were administered preoperatively and postoperatively, followed by a tapered regimen of oral prednisone. The patient required Foley catheterization for urinary retention on the first postoperative evening. The following day she was preoccupied with frequent efforts to pass flatus and stool. On the second postoperative day, the patient complained of flulike symptoms including myalgias, fever, chills, and nausea. She denied emesis and had passed flatus but no stool. Aside from a temperature of 102.3 ~ F, there was no change in the patient's physical examination. Abdominal examination revealed a soft, nontender abdomen. Laboratory evaluation disclosed a white blood cell count of 10,900 with 83 percent segmented neutrophils and 8 percent band forms. Blood and urine cultures were obtained. Urinalysis revealed 5 to l0 white blood cells in the urine. Trimethaprim/sulfamethoxazole was begun empirically for presumed urinary tract infection. To complete the fever evaluation, the patient had chest radiographs performed, which revealed pneumomediastinum and retroperitoneal air (Fig. 1). The patient was given nothing by mouth and begun on intravenous ticarcillin and metronidazole. Abdominal radiographs revealed retroperitoneal air, abundant fecal matter throughout the colon, and probable soft tissue gas within the true pelvis (Fig. 2). A Gastrografin| swallow was obtained to rule out a perforated peptic ulcer and was normal. Digital examination demonstrated the expected tenderness without masses or fluctuance. Anoscopy was performed and demonstrated no abnormal findings. All suture lines were noted to be intact. Over the next 48 hours, the patient's symptoms, fever, and leukocytosis all resolved. Blood and urine cultures were negative. Her diet was gradually advanced, intravenous antibiotics were discontinued, and oral Vibramycin was introduced. On postoperative day six, the patient moved her bowels and was discharged on oral Vibramycin, bulk laxatives, and stool softeners. She did well at home and had no unusual problems or complaints at her postoperative follow-up visits. Specifically, the suture lines healed well and there was no evidence of suppuration.
972
KRISS, PORTER, AND SLEZAK
FIC. 1. Chest radiograph revealing pneumomediastinum.
Discussion
Ever since "Compound F" was given to patients with rheumatoid arthritis in 1949, a number of steroids have been shown to be therapeutically effective against a variety of medical illnesses. Along with their anti-inflammatory properties, numerous complications of these medications have become apparent. It was only one year after their discovery that Beck et al.7 warned of an increased risk of colonic perforation in patients receiving steroids. The connective tissue response to glucocorticoids is basically catabolic with decreased synthesis and increased degradation of protein, RNA, and DNA, and decreased uptake of glucose and amino acids. Clinically, this results in a profoundly negative effect on wound healing due to decreased hyperplasia and collagen formation. We have considered two reasons for the presence of retroperitoneal air in a routine posthemorrhoidectomy patient. During the operative dissection, it is plausible that air may have been introduced into the
Dis. Col. & Rect,
November1990
FIC. 2. Abdominal radiograph showing retroperitoneal air.
fragile tissues and dissected cephalad. Alternatively, the patient's persistent Valsalva maneuvers may have forced air into the retroperitoneum via the suture line. Both the hospital evaluation and the patient's postoperative course rule out an intra-abdominal catastrophe. High morbidity and mortality are associated with gastrointestinal perforation in steroid-treated patients. ~ Avoiding prolonged delay before diagnosis and treatment of glucocorticoid-related complications may be challenging but cannot be overemphasized. Since abdominal and chest radiographs are not routinely obtained after hemorrhoidectomy, we believe that it is important to note this occurrence of retroperitoneal air after seemingly uneventful hemorrhoidectomy. This complication may occur more frequently but has escaped diagnosis. It may even require no treatment. With no precedent to follow, this patient was successfully treated conservatively with observation and antibiotics, without untoward effects. The role of steroids in this complication, as well as the need for treatment, is still a matter of speculation.
Volume33 Number11
RETROPERITONEAL AIR
References 1. Bautista LI. Hemorrhoidectomy--how I do it: Complications of closed hemorrhoidectomy (symp). Dis Colon Rectum 1977;20:183-5. 2. Crystal RF, Hopping RA. Early postoperative complications of anorectal surgery. Dis Colon Rectum 1974;17:336-41. 3. Menda RK. An experience in Bombay with postoperative complications of hemorrhoidectomy. Dis Colon Rectum 1966; 9:176-8.
9 73
4. Miller H. Postoperative complications of hemorrhoidectomy. Am J Proct 1966;17:361-70. 5. Baxter JD, Forsham PH. Tissue effects of glucocorticoids. Am J Med 1972;53:573-90. 6. Remine SG, Millrath DC. Bowel perforation in steroid treated patients. Ann Surg 1980; 192:581-6. 7. Beck JC, Brown JS, Johnson LG, et al. Occurrence of peritonitis during ACTH administration. Can Med Assoc J 1950; 62:426-6.
Kriss BD, Porter JA, Slezak FA: Retroperitoneai air after routine hemorrhoidectomy: report of a case. Dis Colon Rectum 1990; 33:971-973. Retroperitoneal air as a complication after routine hemorrhoidectomy has not been reported in the literature. This occurred recently after hemorrhoideetomy in a 34-year-old patient receiving glucoeorticoid therapy for rheumatoid arthritis. Adverse steroidal effects of wound healing have been well documented. It is believed that steroid-induced tissue changes contributed to the development of this unique complication. [Key words: Complications of hemorrhoidectomy; Retroperitoneal air; Pneumomediastinum
HEMORRHOIDECTOMY IS A frequently performed operation with many known complications. Review of the literature, however, reveals no reports of retroperitoneal air after hemorrhoidectomy.1--4 Much attention has been focused on the adverse metabolic tissue effects of glucocorticoids. 5 The association between steroid use and gastrointestinal ulceration and perforation is well accepted. 6 We present the case of a patient with steroid-dependent rheumatoid arthritis in whom retroperitoneal air was found after hemorrhoidectomy.
Report of a Case A 34-year-old woman with rheumatoid arthritis aud symptomatic external hemorrhoids was admitted to the hospital for hemorrhoidectomy. Prior office evaluation included a rigid sigmoidoscopy to 15 cm, which was normal. The patient had been receiving 10 mg of prednisone daily, but was weaned from her steroids two weeks before elective surgery. A routine closed clamp hemorrhoidectomy was performed in the left lateral, right anterior, and right Address reprint requests to Dr. Porter: 55 Arch Street, Suite 3D, Akron, Ohio 44304
971
From the Department of General Surgery, Akron City Hospital, Akron, Ohio, and the Northeastern Ohio Universities College of Medicine, Rootstown, Ohio
posterior quadrants. No intraoperative difficulties were encountered. Stress doses of hydrocortisone were administered preoperatively and postoperatively, followed by a tapered regimen of oral prednisone. The patient required Foley catheterization for urinary retention on the first postoperative evening. The following day she was preoccupied with frequent efforts to pass flatus and stool. On the second postoperative day, the patient complained of flulike symptoms including myalgias, fever, chills, and nausea. She denied emesis and had passed flatus but no stool. Aside from a temperature of 102.3 ~ F, there was no change in the patient's physical examination. Abdominal examination revealed a soft, nontender abdomen. Laboratory evaluation disclosed a white blood cell count of 10,900 with 83 percent segmented neutrophils and 8 percent band forms. Blood and urine cultures were obtained. Urinalysis revealed 5 to l0 white blood cells in the urine. Trimethaprim/sulfamethoxazole was begun empirically for presumed urinary tract infection. To complete the fever evaluation, the patient had chest radiographs performed, which revealed pneumomediastinum and retroperitoneal air (Fig. 1). The patient was given nothing by mouth and begun on intravenous ticarcillin and metronidazole. Abdominal radiographs revealed retroperitoneal air, abundant fecal matter throughout the colon, and probable soft tissue gas within the true pelvis (Fig. 2). A Gastrografin| swallow was obtained to rule out a perforated peptic ulcer and was normal. Digital examination demonstrated the expected tenderness without masses or fluctuance. Anoscopy was performed and demonstrated no abnormal findings. All suture lines were noted to be intact. Over the next 48 hours, the patient's symptoms, fever, and leukocytosis all resolved. Blood and urine cultures were negative. Her diet was gradually advanced, intravenous antibiotics were discontinued, and oral Vibramycin was introduced. On postoperative day six, the patient moved her bowels and was discharged on oral Vibramycin, bulk laxatives, and stool softeners. She did well at home and had no unusual problems or complaints at her postoperative follow-up visits. Specifically, the suture lines healed well and there was no evidence of suppuration.
972
KRISS, PORTER, AND SLEZAK
FIC. 1. Chest radiograph revealing pneumomediastinum.
Discussion
Ever since "Compound F" was given to patients with rheumatoid arthritis in 1949, a number of steroids have been shown to be therapeutically effective against a variety of medical illnesses. Along with their anti-inflammatory properties, numerous complications of these medications have become apparent. It was only one year after their discovery that Beck et al.7 warned of an increased risk of colonic perforation in patients receiving steroids. The connective tissue response to glucocorticoids is basically catabolic with decreased synthesis and increased degradation of protein, RNA, and DNA, and decreased uptake of glucose and amino acids. Clinically, this results in a profoundly negative effect on wound healing due to decreased hyperplasia and collagen formation. We have considered two reasons for the presence of retroperitoneal air in a routine posthemorrhoidectomy patient. During the operative dissection, it is plausible that air may have been introduced into the
Dis. Col. & Rect,
November1990
FIC. 2. Abdominal radiograph showing retroperitoneal air.
fragile tissues and dissected cephalad. Alternatively, the patient's persistent Valsalva maneuvers may have forced air into the retroperitoneum via the suture line. Both the hospital evaluation and the patient's postoperative course rule out an intra-abdominal catastrophe. High morbidity and mortality are associated with gastrointestinal perforation in steroid-treated patients. ~ Avoiding prolonged delay before diagnosis and treatment of glucocorticoid-related complications may be challenging but cannot be overemphasized. Since abdominal and chest radiographs are not routinely obtained after hemorrhoidectomy, we believe that it is important to note this occurrence of retroperitoneal air after seemingly uneventful hemorrhoidectomy. This complication may occur more frequently but has escaped diagnosis. It may even require no treatment. With no precedent to follow, this patient was successfully treated conservatively with observation and antibiotics, without untoward effects. The role of steroids in this complication, as well as the need for treatment, is still a matter of speculation.
Volume33 Number11
RETROPERITONEAL AIR
References 1. Bautista LI. Hemorrhoidectomy--how I do it: Complications of closed hemorrhoidectomy (symp). Dis Colon Rectum 1977;20:183-5. 2. Crystal RF, Hopping RA. Early postoperative complications of anorectal surgery. Dis Colon Rectum 1974;17:336-41. 3. Menda RK. An experience in Bombay with postoperative complications of hemorrhoidectomy. Dis Colon Rectum 1966; 9:176-8.
9 73
4. Miller H. Postoperative complications of hemorrhoidectomy. Am J Proct 1966;17:361-70. 5. Baxter JD, Forsham PH. Tissue effects of glucocorticoids. Am J Med 1972;53:573-90. 6. Remine SG, Millrath DC. Bowel perforation in steroid treated patients. Ann Surg 1980; 192:581-6. 7. Beck JC, Brown JS, Johnson LG, et al. Occurrence of peritonitis during ACTH administration. Can Med Assoc J 1950; 62:426-6.
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