eP465 - Extensive Subcutaneous Emphysema of the Neck and Retropharyngeal Space, Pneumomediastinum, and Pneumoretroperitoneum After Hemorrhoidectomy: A Case Report

Purpose/Background: The rise of transanal procedures has led to improvement in morbidity for patients for early stage rectal cancer, polyps, and hemorrhoids. One rare complication is rectal perforation that can present as ectopic air seen commonly in the retroperitoneum, mediastinum, or soft tissues of the neck.Methods/Interventions: A 33-year-old female who underwent outpatient hemorrhoidectomy and transanal polypectomy presented with vocal changes and dyspnea on postoperative day one. She had CT findings of extensive subcutaneous emphysema from the perineum up to the neck with operative exploration without evidence of necrotizing infection or perforation. Sutures were removed and wounds were allowed to heal with secondary intention.Results/Outcomes: A healthy 33F was referred to our colorectal surgery clinic with longstanding symptomatic hemorrhoids refractory to medical management. After physical examination and review of recent colonoscopy, we decided to proceed with excision hemorrhoidectomy and transanal excision of the anal polyp, undergoing 3 column hemorrhoidectomy and partial thickness trans anal excision of rectal polyp with ligature. On POD1, patient presented to the ER with diffuse crepitus of neck, chest, and abdomen; shortness of breath, and hoarseness. She states that she smoked a cigarette and the shortness of breath started one hour after that. She was having intractable burping, flatus, abdominal bloating, diffuse abdominal pain, neck and chest pain. On presentation, her vital signs were within normal limits and she was room air. Chest X-ray was concerning subdriaphragmatic air and small right lateral chest wall subcutaneous emphysema extending into the right subclavicular space and base of neck. CT demonstrated findings of extensive subcutaneous emphysema from the perineum up to the neck and retropharyngeal spaces, pneumomediastinum, and pneumoretroperitoneum. Patients WBC was 16.6 and lactate was normal. Patient was admitted for broad spectrum empiric antibiotics and taken for exam under anesthesia. Operative findings yielded no crepitus by perianal region, no bleeding or erythema, suture lines intact. Sigmoidoscopy to 25cm from anal verge showed no evidence of perforation with normal appearing mucosa. No inflammation or gangrene. All hemorrhoidectomy sutures were removed to evaluate deeper tissue space with no evidence of infection or necrosis. Wounds were left open for drainage and healing by secondary intention. After 24hours of antibiotics, they were discontinued. Repeat CT on POD3 demonstrated decrease in subcutaneous emphysema and patient was discharged after tolerating regular diet.She followed up in clinic with outpatient CXR on POD 18 with resolution of chest and neck emphysema and pneumomediastinum. Patient had improvement in chest pain and no SOB at the time, endorsed no abdominal pain, no fecal incontinence, improving anal discomfort, and anorectal exam with well healing hemorrhoidectomy wounds.Conclusion/

Discussion: There are few case reports documenting ectopic air after transanal procedures, usually presenting with sepsis due to iatrogenic rectal perforation requiring surgical repair or with findings that support diagnosis of malignancy. Further studies are needed to guide management of extensive emphysema without intraabdominal exploration for nonmalignant pathologies of the anorectum in hemodynamically stable patients who continue to improve clinically."CT abdomen with emphysema

Emphysema: perirectal soft tissue, retroperitoneum, mediastinum
Emphysema CT Chest

Emphysema: retroperitoneum, mediastinum, soft tissue neck"