1. World Journal of Colorectal Surgery
Volume 6, Issue 3 2016 Article 2
Successful Repeated CT-Guided Drainage Of
Rectal Mucocele After Low Anterior
Resection For Rectal Prolapse
Aleksandr A. Reznichenko∗
∗
University of Cincinnati, Cincinnati, Ohio, The United States Of America,
areznik9@yahoo.com
Copyright c 2016 The Berkeley Electronic Press. All rights reserved.

2. Successful Repeated CT-Guided Drainage Of
Rectal 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 present
with 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 was
successfully treated with repeated CT-guided drainage.
KEYWORDS: Rectal mucocele, rectal prolapse, CT-guided drainage, rectal stump

3. 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.
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4. 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 102o
F 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 100o
F. 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
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5. 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
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6. 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
from bowel sequestration at the anastomotic site after sigmoidectomy. Am Surg.
2010; 76(1):107-8.
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7. 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
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8. 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
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