Perirectal hematoma after stapled surgery for hemorrhoidal prolapse and obstructed defecation syndrome: case series management to avoid panic-guided treatment

**Background:** Stapled surgical techniques for hemorrhoidal prolapse and obstructed defecation syndrome (ODS) are widely used and generally safe, but rare severe complications can occur. Perirectal hematoma (PH) is one such complication, with a reported incidence of 0.5–1%. The literature on PH consists mostly of isolated case reports with heterogeneous management approaches, and there is little guidance on optimal treatment. The authors note that aggressive surgical interventions are often driven by a 'panic approach' rather than evidence.

**Methods:** This retrospective case series analyzed a prospective database from three high-volume Italian proctology units ('Sapienza' University of Rome; University of Rome 'Tor Vergata'; Cisanello University Hospital Pisa) between January 2008 and December 2018. All surgeons had performed at least 100 stapled operations before the study period. All patients who developed PH after stapling for hemorrhoidal disease or ODS with internal prolapse were included. PH was defined as severe extra-visceral bleeding with massive symptomatic blood collection in the pelvis around the rectum. Diagnostic workup, treatment, and clinical evolution were recorded for each case.

**Key Results:** Among 3,058 patients who underwent stapled procedures, 14 (0.46%) developed large PHs. All 14 patients were female, aged 41–70 years (mean 56 years). None had prior proctologic or gynecologic surgery or were on antiplatelet/anticoagulant medication. Ten patients underwent stapled procedures for internal rectal prolapse and rectocele with ODS; four for hemorrhoidal prolapse. PH onset was intraoperative in 1 case, immediately postoperative in 7, within the first 3 postoperative days in 4, and after hospital discharge in 2. The main symptom was anal pain (14/14, 100%). Postoperative peritonism occurred in 6 cases (43%). Notably, 8 of 14 patients (57%) had no rectal bleeding. Digital rectal examination raised suspicion in all 14 patients. Pelvic contrast CT was performed in all cases; endoluminal ultrasound in 5. PH size ranged from 35×40 mm to 90×75 mm. Location was posterior in 10 cases, anterior in 2, and circumferential in 2. All patients received IV fluids and antibiotics (metronidazole + ciprofloxacin). Four patients required blood transfusions. Six patients with abdominal tenderness received a bladder catheter. Two patients with sudden hypotension underwent urgent angio-CT and arteriography with embolization of active bleeding sources. No patients required abdominal surgery. Eight cases underwent anorectal evaluation under anesthesia. Transanal spontaneous drainage occurred in 9 cases (64%). One patient with late-onset hematoma was managed as an outpatient. Three patients were discharged before Day 5; nine between Day 6 and Day 14. No clinical sequelae were detected at 1-year follow-up.

**Clinical Implications:** This study demonstrates that most PHs after stapled proctologic surgery are hemodynamically stable and can be managed conservatively with IV fluids, antibiotics, clinical monitoring, serial blood counts, and CT imaging. Spontaneous transanal drainage through the suture line is the most common and favorable outcome (64% in this series). The authors propose a classification system based on localization (posterior vs. anterior), time of onset (intraoperative, early postoperative, late-onset), and evolution (stable vs. progressive). For progressive PHs with active bleeding, arteriography with embolization is effective and should be performed promptly to avoid major abdominal surgery. Aggressive surgical interventions (laparotomy, colostomy, rectal resection, internal iliac artery ligation) should be reserved only for cases where embolization fails. The key message is that a structured, non-panic approach can prevent catastrophic surgical outcomes. Study limitations include the small number of PH cases, inability to perform statistical analysis, and retrospective design.