Abnormal advanced hemorrhoidal disease: the need of a staged resection

We present an unusual case of advanced hemorrhoidal disease in an 57-year-old man presenting with anemia, persistent bleeding, anal protrusion. Conventional hemorrhoidectomy was not feasible because of the risk of a massive hemorrhage caused by hypertrophic protruded vascular anal cushions. A two-stage resection was then undertaken. The aim of the first procedure was to reduce the vascularization of the protruded mucosa by a circular series of interrupted mass stitches. This approach was successful and an important reduction of vascularization was obtained. The operation was then completed two weeks later, requiring a radical circular removal of the giant anal cushions and anal canal epithelium with subsequent mucocutaneous anastomosis. A careful submucosal dissection was performed to identify and preserve the anal sphincters. No normal perianal skin was available to preserve bridges between the resected cushions. At the end of the operation, an ectopic mucosa was apparent but gradual reduction was observed in subsequent postoperative days along with recovery of anal sphincter function, and the patient was uneventfully discharged on the seventh postoperative day. On the 30th postoperative day a normal anal canal closure was observed with no ectopic mucosa. Normal continence with no functional disorder was reported and digital examination demonstrated the presence of a mild asymptomatic stenosis. (See Video, Supplemental Digital Content 1, http://links.lww.com/DCR/A1).