Internal hemorrhoids are one of the most common diseases causing hematochezia. However, other severe diseases such as colorectal cancer and inflammatory bowel disease can also cause rectal bleeding. In most hemorrhoid cases, patients will not have rectal cancer. From the point of view of colorectal cancer diagnosis, comorbidity of hemorrhoids is the most common cause of missed opportunity for diagnosis of cancer . Therefore the guidelines for the management of hemorrhoids published from the American Society of Colon and Rectal Surgeons recommend complete endoscopic evaluation of the colon in selected patients with symptomatic hemorrhoids and rectal bleeding, such as patients over 50 years old without complete examination within 10 years or those with positive fecal immunochemical testing [8, 9].
Therefore, it is extremely important to exclude the possibility that the patients with internal hemorrhoids also have a rectal tumor, both of which could be causes of hematochezia. However, even if patients do not have rectal tumors when treated with ALTA sclerotherapy, they could develop rectal tumors afterwards that require surgical treatment. Although little is known about the long-term pathological changes within the rectum after ALTA injection, the long-lasting success rate of ALTA sclerotherapy suggested that sclerosis after ALTA injection would be persistent . In such cases, we have to pay close attention to dissect the sclerosed retcum. We routinely use Gutclamper before transection of the rectum for irrigation from anus to remove exfoliated tumor cells. In our case, the Gutclamper also helped to compress the distal side of the tumor, where ALTA injection caused sclerosis. The SmartClamp function of the da Vinci Xi system was very useful in achieving enough compression before dissection of the sclerosed rectum. It was reported that precompression or slow firing is important for secure stapling with a linear stapler [11, 12]. We applied this theory for DST anastomosis with a circular stapler, and a total of 4 min waiting time was employed to achieve sufficient compression with sclerosed rectum. Histological examination of the resected specimen revealed dramatic fibrosis in the muscularis propria layer at the stump even though ALTA was probably injected into the submucosal layer.
We previously reported 3 cases of laparoscopic rectal surgery for rectal cancer after ALTA therapy . All of the 3 cases were planned to perform laparoscopic LAR with DST. However, only one case was successful with a diverting ileostomy. The other two cases were unsuccessful for DST anastomosis because of the difficulty to transect the sclerosed rectum with laparoscopic linear staplers. One of them had transanal hand-sewn anastomosis with a diverting ileostomy, and the other had Hartmann’s procedure. This case is the 4th case we experienced, and to our knowledge, it is the first reported case of Rob-LAR after ALTA sclerosing therapy. The patient in this case unfortunately suffered portal vein thrombosis after surgery, but in terms of anastomosis, the postoperative course was satisfactory and his diverting ileostomy was closed 12 weeks after primary surgery as scheduled without any complication.