Successful Repeated CT-Guided Drainage Of Rectal Mucocele After L

World Journal of Colorectal SurgeryVolume 6, Issue 3 2016 Article 2

Successful Repeated CT-Guided Drainage OfRectal Mucocele After Low Anterior

Resection For Rectal Prolapse

Aleksandr A. Reznichenko∗

∗University of Cincinnati, Cincinnati, Ohio, The United States Of America,[email protected]

Copyright c©2016 The Berkeley Electronic Press. All rights reserved.

Successful Repeated CT-Guided Drainage OfRectal Mucocele After Low Anterior

Resection For Rectal Prolapse

Aleksandr A. Reznichenko

Abstract

Rectal mucoceles are extremely rare with only a few cases reported. Most commonly they oc-cur after colorectal surgeries for inflammatory bowel disease. Clinically, rectal mucoceles presentwith symptoms of compression of surrounding organs, and are well visualized by computer to-mography (CT) or ultrasound (US). The treatment may involve drainage or surgical resection.We present a case of a rectal mucocele after low anterior resection for rectal prolapse which wassuccessfully treated with repeated CT-guided drainage.

KEYWORDS: Rectal mucocele, rectal prolapse, CT-guided drainage, rectal stump

Introduction

Rectal mucoceles most commonly occur after surgical interventions for

inflammatory bowel disease, usually as a result of distal stenosis, retraction or

chronic inflammation of the rectal stump post colectomy with end colostomy. The

clinical picture of rectal mucoceles is nonspecific and may include compression of

surrounding organs and infection. Treatment requires either drainage or removal of

the mucus-producing epithelium. Endoscopic ultrasound (EUS) has previously

been utilized for transanal drainage of rectal mucocele. The utilization of CT-

guided drainage for the treatment of rectal mucoceles so far has not been reported.

Case Report

An 81 year-old female with history of morbid obesity, Parkinson's disease, diabetes

mellitus, chronic heart failure, urinary tract infection (UTI), osteoarthritis,

hypothyroidism, peripheral vascular disease, hysterectomy, cholecystectomy,

appendectomy, hemorrhoidectomy and loop transverse colostomy. The transverse

colostomy had been remotely performed for rectal prolapse by another surgical

group. The patient presented with a long history of rectal prolapse and associated

severe rectal mucosal ulcerations causing lower gastrointestinal (GI) bleed.

Additionally, she had a large symptomatic parastomal hernia.

Based on the clinical presentation of two separate surgical problems (rectal prolapse

and parastomal hernia) and the patient request for a single surgery, we made a

decision to address both of these problems simultaneously. It was felt that perineal

approach (such as an Altemeier procedure) was not a suitable option, as it would

not allow repairing of a large parastomal hernia. We also considered abdomino-

peroneal resection and/or intersphincteric proctectomy. However, we felt that both

of these procedures could put our patient at considerable risk of perineal wound

infection and/or problems with perineal wound healing. After careful discussion

with the patient, we decided to proceed with low anterior resection and repair of

parastomal hernia. Acellular non-crosslinked porcine bladder submucosa

extracellular matrix (Acell Matristem® Acell Inc., Columbia Maryland, U.S.A.)

was chosen as a biologic graft for parastomal hernia repair. We made our choice

based on the availability of the hospital supplies and also on our prior experience

with Acell Matristem® for hiatal hernia repair.

1Reznichenko: Successful Repeated CT-Guided Drainage Of Rectal Mucocele After L

Produced by The Berkeley Electronic Press, 2016

Following cardiac clearance and medical optimization, patient was taken to the

operative room. During the procedure, we found a significant weakness of the

pelvic floor, with severe stretching and atrophy of the levator ani muscles and

suspensory ligaments of the rectum. The rectum was displaced anteriorly. Given

these intraoperative findings, in order to exclude the small bowel from the pelvic

floor, we decided to reinforce the pelvic floor with the biologic graft (Acell

Matristem®). Exploratory laparotomy, lysis of adhesions, low anterior resection,

relocation of the stoma with repair of parastomal hernia, repair of the pelvic floor

with biologic graft was performed.

The rectum was mobilized as low as possible and transected with a stapler (Echelon

Endopath® GIA stapler, Ethicon US LLC Cincinnati Ohio, U.S.A.).

Approximately 5 cm of rectal stump remained. The biologic graft was secured to

the lateral pelvic sidewalls and top of the sacrum with fascia stapler (Auto

Suture®). A 10 French Jackson-Pratt (JP) was inserted and left next to the rectal

stump.

Postoperatively, the patient had semi-clear discharge from the drain for five months

after the procedure. The amount of fluid varied from 5-40 ml daily. Biologic grafts

are well known stimulate fluid production, and we felt that the drainage in this

patient was related to the biologic graft which was used for the reinforcement of

the pelvic floor. The drain was removed after the drainage completely stopped. Four

weeks later, the patient started to have pressure in her pelvis which was

accompanied by symptoms of fever of 102oF and chills. A CT demonstrated an

oval collection 5.4 x 3.7 cm in size, located above rectal stump. The white blood

cell count (WBC) was 17,000. Patient was referred to Interventional Radiology and

underwent CT-guided transperineal drainage of the collection. Both transperineal

and transrectal approaches were considered, however it was felt that transperineal

route would be safer. Cultures showed Peptostreptococcus species and patient was

given antibiotics accordingly, with temporary resolution of symptoms.

One month later the patient returned with a fever of 100oF. A CT, showed

reaccumulation of same size pelvic collection (Figure 1). Clear fluid was drained

percutaneously by a transperineal approach under with CT-guidance. A 12-French

pigtail catheter was inserted (Figure 2). Cultures grew Enterococcus faecalis and

the patient again was treated with antibiotics. After five days, the drainage stopped

and the catheter was removed.

Six weeks later the patient presented with a UTI. CT demonstrated a smaller pelvic

collection at the same location (Figure 3). It was drained with the same CT-guided

2 World Journal of Colorectal Surgery Vol. 6, Iss. 3 [2016], Art. 2

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transperineal approach and 12-French pigtail catheter was again inserted (Figure

4). At this time, the fluid was clear and gelatinous, without bacterial growth. Based

on the location of the collection adjacent to the rectal stump, together with patient

history and gelatinous consistency of the fluid, we concluded that this collection

represented a rectal mucocele. After three days, there was no drainage, and the

catheter was removed. The patient had a complete recovery. She continues to be

closely followed and remains asymptomatic after six months.

Discussion

Rectal mucoceles are rare with only ten cases reported. They most commonly occur

after surgery for inflammatory bowel disease as a result of distal stenosis, retraction

or chronic inflammation of the rectal stump, after colectomy and end colostomy (1,

2, 3, 4, 5). Rectal mucoceles were also described as a result of perineal and pelvic

trauma (6), following surgical repair of imperforated anus (7), following

hemorrhoidectomy (8) and after pull-through surgery for Hirschprungs disease (9).

There is no gender predilection. There were two reported pediatric cases (7, 9).

Our patient had history of rectal prolapse with rectal mucosal ulcerations causing

lower GI bleed. Following low anterior resection there was a possible remnant of

rectal mucosa. This mucosal lining with chronic inflammation from rectal prolapse

continued to secrete mucus which accumulated over time and caused mucocele.

Rectal mucoceles can grow to a large size and cause compression of surrounding

organs, including bowel, ureter, bladder (2, 3, 5, 7). They also may have a septic

presentation (5), as it was in our case.

Rectal mucoceles are visualized by imaging studies as fluid filled structures close

to the rectal stump (3). Both US (5) and CT (1, 3, 7) were used successfully.

Treatment of rectal mucoceles require either drainage or removal of the mucus-

producing epithelium (3, 5, 10). Features of rectal mucoceles are presented in Table

1.

A rectal mucocele should be suspected when a fluid collection occurs close to the

rectal stump after pelvic surgery. It should be distinguished from the pelvic abscess.

It is also important to differentiate rectal mucoceles from appendiceal mucoceles



and ovarian mucus containing tumors (Table 2). We made a diagnosis of rectal

mucocele based on several factors, including: patient history, location of the

collection close to the rectal stump, and consistency of the draining fluid. Resection

is the most effective treatment, but it involves significant morbidity associated with

surgery. Our patient was not a candidate for another operation, therefore we used

an alternative approach. To the best of our knowledge, this is the only report where

CT-guidance was successfully and repeatedly utilized in the treatment of rectal

mucocele.

References

1. Appleton N, Day N, Walsh C. Rectal mucocele following subtotal

colectomy for colitis. Ann R Coll Surg Engl 2014; 96(6):13-4.

2. Witte JT, Harms BA. Giant colonic mucocele after diversion colostomy for

ulcerative colitis. Surgery, 1989; 106: 571-574.

3. Teoh AY, Lee JF, Chong CC, Tang RS. Endoscopic US-guided drainage

of a rectal mucocele after total colectomy for Crohn’s disease. Endoscopy, 2013:45

Suppl 2.

4. Creagh MF, Chan TY. Case report: rectal mucocele following Hartmann's

procedure. Clin Radiol 1991; 43:358-359.

5. Shunmugam PR Shivakumar P. Mucocele of the rectum. J Clin Case Rep

2012: Vol 2, Issue 11, p 170.

6. Nicosia JF, Abcarian H. Mucocele of distal colonic segment, a late sequela

of trauma to the perineum. Dis Colon Rectum. 1974; 17(4):536-9.

7. Panicek DM, Leeson SH, Hitch DC, Farrar FM. Perirectal mucocele after

imperforate anus repair. Pediatr Radiol. 1987; 17(1):73-4.

8. Hsu KF, Hsien CB, Yu JC, Chan DC, Wu CC, Jin JC, Chao PC. Rare rectal

mucocele mimic tumor following hemorrhoidectomy in an adult patient. Rev Esp

Enferm Dig. 2011; 103(5):276-7.

9. Hsu WM, Wang W, Chen CC. Enteric mucocele formation after endorectal

pull-through: report of a case. J Formos Med Assoc. 2000; 99(8):650-2.

10. Subhas G, Balaraman S, Mittal VK. Extraluminal rectal mucocele resulting

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TABLE 1: Summary table for rectal mucoceles

Etiology Most commonly occur after surgery for inflammatory bowel disease as a

result of distal stenosis, retraction or chronic inflammation of the rectal

stump after colectomy and end colostomy. Also described as a result of

perineal and pelvic trauma, of the surgical repair of imperforated anus,

following hemorrhoidectomy after pull-through surgery for Hirschprungs

disease.

Incidence Rare and limited to case reports. Only 10 cases reported

Gender ratio No predilection

Age predilection Mostly described in adults, only 2 cases reported in pediatric patients

Risk factors Pelvic and rectal surgery, Inflammatory bowel disease (IBD)

Treatment Drainage or surgical removal of the mucus- producing epithelium

Prognosis Depends on the etiology and early diagnosis

Findings on Imaging Fluid filled structure next to the rectal stump



TABLE 2: Differential diagnosis and imaging characteristics of rectal mucocele

Entity Presentation CT MRI US

Rectal mucocele History of rectal

surgery, pelvic

pain and pressure

Fluid filled mass in the

pelvis, distention of

rectal stump

N/A Dilated fluid filled

structure in the

pelvis

Pelvic abscess History of

abdominal or

pelvic

procedures,

pelvic pain,

fever

Thick walled fluid

collection, possible air

bubbles and multiple

loculations

Inhomogeneous areas of

low T1weighted signal

intensity, mural

enhancement, T2-

intermediate to high

Anechoic, cystic

structure to complex,

multi-loculated,

echogenic mass

Appendiceal

mucocele

Right lower

quadrant (RLQ)

pain, acute or

chronic

Well-circumscribed,

low-attenuation,

spherical or tubular

mass contiguous with

the base of the

cecum. Mural

calcification

Rounded right iliac

fossa mass. T1: signal

may be variably

hypointense to

isointense T2:

hyperintense

Cystic mass with

variable internal

echogenicity.

Onion sign

Ovarian

mucinous

cystadenoma

Pain in lower

abdomen,

menstrual cycle

irregularity,

vaginal bleeding

High attenuation in

some locules due to the

high protein content of

the mucoid material

Large multi-locular

cyst with gelatinous

material. Variable

signal intensities on

both T1 and T2

sequences

Large cystic adnexal

mass with septations



Successful Repeated CT-Guided Drainage Of Rectal Mucocele After L

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