EP241 - Rectal Ischemia After Emborrhoid Procedure … A Real Pain In The Butt

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Purpose/Background: Hemorrhoids are the most common disorder of the anal canal, with up to 10% of the population affected. Colon and Rectal Surgeons have multiple tools available to them in the management of this disease. First described in 2014, the Emborrhoid procedure performed by Interventional Radiology, has gained popularity in some medical centers recently. It involves the embolization of the superior hemorrhoidal artery branches, as well as the branches of the middle hemorrhoidal artery that appear to be feeding the hemorrhoidal complex on angiogram. While the procedure is marketed as “safe and effective”, the data to support this is limited with very few studies, and most with no long-term follow-up. We present a case of post-procedure rectal ischemia.

Methods/Interventions: The patient is a 43-year-old man who was initially seen in our clinic with bleeding per rectum. He was diagnosed with internal hemorrhoids and was offered a hemorrhoidectomy. He opted to have a rubber band ligation in the clinic as he wanted the shortest post-procedure recovery time and desired an immediate return to work. 4 weeks later, he returned with persistent symptoms. Again, he was offered surgical intervention but declined. Ultimately, he presented to an Interventional Radiology clinic that was marketing the Emborrhoid procedure, and he underwent an angiogram and embolization of the superior rectal artery.

Results/Outcomes: Post operatively, he had ongoing pelvic pain, constipation, and occasional bleeding per rectum. At his clinic follow up three weeks later, he was diagnosed with “suspected levator spasms” and treated with Valium. Two weeks after that, his persistent symptoms prompted a pelvic floor physical therapy referral, as well as a psychiatry referral for presumed anxiety around this pelvic pain. Anoscopy was unremarkable, though he had elevated resting tone on digital rectal exam. CT scan showed “segmental wall thickening of the distal sigmoid and superior rectum”. A colonoscopy was performed four months post-Emborrhoid which demonstrated a sigmoid stricture which could not be traversed with the colonoscope, even with balloon dilatation. Eventually a pediatric EGD scope was used, which traversed the stricture and noted some proximal ischemic ulceration. Two days later, the patient underwent a planned robotic low anterior resection. With the significant pelvic fibrosis encountered, along with decreased perfusion on examination with Indocyanine green, a primary anastomosis was not performed and the patient was given an end colostomy. Four months later he underwent a successful robotic colostomy takedown.

Conclusion/Discussion: Embolization of hemorrhoids by interventional radiology is a new procedure that is becoming more popular across the US. While it is being marketed to the public and to primary care physicians as a “safe and effective” procedure with minimal post-procedure down time, they should exercise caution as the long-term data is very limited. Rectal ischemia is a potential complication which can be quite morbid for affected patients. With many safe in-office and surgical treatment options for hemorrhoids, the Emborrhoid procedure should be reserved for a very select patient population, after consultation with Colon and Rectal Surgery.