Endoscopic treatment of rectal pocket syndrome
05. September 2013 (online)
A 70-year-old woman was admitted with rectal pain and soiling 3 years after a Longo’s stapled hemorrhoidopexy . Physical examination and laboratory tests were negative. Colonoscopy showed a 30-mm bulge with a 3-mm orifice in the lower rectum. Stools could be observed through the orifice ([Fig. 1]). A pelvic magnetic resonance imaging scan highlighted a stool-laden diverticulum of the mesorectal region, 35 × 20 × 25 mm in size ([Fig. 2]). An endoscopic ultrasound color-Doppler examination showed poor vascularization of the septum between the diverticulum and the rectal lumen.
Endoscopic incision of the cavity wall was performed using a biliary pre-cut needle, with incisions at 3, 6, and 9 o'clock ([Fig. 3]). Stools were then evacuated by digital squeezing. The procedure was complicated by bleeding, which was successfully treated by endoscopic clipping.
The patient was discharged after a brief observation period. At 1-month follow-up she was asymptomatic, and lower endoscopy showed a fully opened diverticulum with no residual stool ([Fig. 4]).
The “rectal pocket syndrome,” caused by entrapment of the tied purse string by fired staples, is a rare complication (2.5 %) of stapled hemorrhoidopexy and usually requires surgical opening of the pocket . Only two case reports have been published previously in the literature, one of which was managed by releasing the tied suture and the other by creating a diverting stoma  . To our knowledge the present case is the first report of endoscopic treatment for rectal pocket syndrome. The procedure appears to be feasible, safe, and effective. The idea was taken from experience of treatment of esophageal rings by means of sagittal incision .
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