Life threatening complications after PPH are usually associated with anastomotic leakage or pelvic sepsis [
22,
100‐
102]. Their frequency was 0.08 and 0.09% in two large series [
20,
32]. Anastomotic dehiscence after PPH, which may lead to pelvic sepsis in case of full-thickness rectal stapling, was reported in 3.2% of 654 patients [
26].
In a recent systematic review, McCloud et al. [
103] reported 7 cases of life-threatening pelvic sepsis in 4 years, and 6 cases of pelvic sepsis after manual hemorrhoidectomy in 20 years. Of the 7 cases after PPH, 4 were associated with anastomotic dehiscence, 5 had perineal debridement (including the external sphincter in 2 cases), 4 required temporary fecal diversion and 2 required permanent fecal diversion. After permanent fecal diversion, one patient died of septic shock. Patients typically presented with urinary difficulties, fever, severe pain, septic shock and leukocytosis, usually within the first week after surgery but in one case after 39 days. It is unclear if an eighth case (a patient who died after perineal debridement and fecal diversion) reported by Herold in a one-year German survey of 4635 PPH [
103] is the same case as reported by Bonner et al. [
104] and included in McCloud et al.’s series [
103]. The same German survey reported three rectal perforations requiring one permanent and two temporary stomas [
53]. A case of pelvic sepsis leading to vena cava thrombosis and eventually requiring nephrectomy has also been reported [
105]. Between 1999 and 2007 the FDA CDRH website [
16] listed 38 cases of rectal perforation or staple line dehiscence during stapled hemorrhoidopexy (Table
1). In one case perforation was attributed to a too deep purse string while in 8 of the 10 cases where no error or device malfunctioning was noted the diagnosis was delayed. Ninenteen (50%) of patients required an abdominal operation and 13 (34%) patients required fecal diversion including one patient who underwent an abdomino perineal resection and one death from sepsis. None of these cases has been reported in the scientific literature. So, numerous life-threatening complications after PPH in a few years and a small number of pelvic sepsis after manual hemorrhoidectomy in a much longer period of time have been described. Considering that manual operations are more frequently used than PPH, with a 4:1 ratio in Italy [
106] where stapled hemorrhoidopexy is extremely popular, we may conclude that the rate of life-threatening complication is much lower after manual hemorrhoidectomy. The reason for this difference may well be the learning curve [
53] and, if this is the case, the frequency of such serious complications should diminish as was the case for bile duct injury after laparoscopic cholecystectomy. Nevertheless, the gravity of these adverse events seems to be greater after PPH, since pelvic sepsis frequently requires a stoma while this is very rare after manual procedure [
103].
Rectal perforation may be facilitated by a too deep insertion of the purse string, which causes a full-thickness transection of the rectal wall, prone to dehiscence, or by the fact that, in hemorrhoidal surgery, the rectum is not often mechanically cleansed. The staple line after PPH should be systematically checked and anastomotic defects should be promptly repaired. Use of perioperative antibiotic coverage seems to be justified.
Retroperitoneal and rectal hematoma causing intestinal obstruction and requiring a stoma have been reported [
102,
107]. On the other hand, even massive rectal wall hematoma diffusing to the whole pelvis and reaching the cecum may respond to transanal drainage by rectotomy.
Intestinal perforation and bleeding with hemoperitoneum due to an undiagnosed enterocele may occur [
108]. In case of a patient with enterocele and a prolapsed Douglas pouch due to a previous hysterectomy, the surgeon should be alerted. PPH experts published a consensus article which suggests that enterocele is to be a contraindication to stapled haemorrhoidopexy [
109].