Laparoscopic Treatment of Gastric Bezoar.

2010·0.33 MB·English

by  Sharma, Deborshi

C R
ASE EPORT
Laparoscopic Treatment of Gastric Bezoar
Deborshi Sharma, MS, MRCS(Ed), Manish Srivastava, MBBS, MS, Raghavendra Babu, MBBS, MS,
Rama Anand, MD, Anurag Rohtagi, MD, Shaji Thomas, MD, DNB, FAIS
ABSTRACT INTRODUCTION
A seventeen-year-old female presented with a symptom- Gastric bezoars are foreign bodies in the stomach that
atic abdominal mass that was diagnosed by barium meal increase in size due to accumulation of nonabsorbable
and computed tomography to be a gastric bezoar. She foodorfibers.Morethan90%ofcasesareinchildrenand
underwent laparoscopic removal of the bezoar, through young females.1 Traditionally, bezoars are removed by
an anterior wall gastrostomy in an endobag, which was laparotomy; however, because of recent reports, laparo-
extracted piecemeal through a 4-cm upper midline inci- scopic removal is slowly growing as the choice of inter-
sion. vention.
The technique is described with a review of a few previ-
ous laparoscopic-assisted cases. CASE REPORT
Key Words: Trichobezoar, Management, Laparoscopy, A 17-year-old female came to our outpatient surgery de-
Surgical technique. partment with a lump and dragging pain in her upper
abdomen.Shewasmalnourishedwiththinbrittlehairand
was mildly pale. A well-defined, nontender mass was
palpated in the epigastrium, which was tubular in shape
extendingfromtheleftsubcostalmargintotherightlum-
bar region. The upper margin of the lump was extending
below the left costal margins and could not be appreci-
ated. The patient had no history of vomiting, hemateme-
sis, or melena. The rest of her general and abdominal
examinationwasunremarkable.Abdominalultrasonogra-
physhowedanechogenicmassinthestomach;however,
nodefinitediagnosiscouldbemade.Thepatient’sbarium
meal showed a mottled filling defect with entrapped air
predominantly in the body and antrum with minimal ex-
tension into the pylorus and duodenum suggesting a Tri-
chobezoar(Figure1).Sheunderwentcontrastenhanced
computed tomography of the abdomen (CECT), which
showed a nonenhancing mixed density intraluminal gas-
tric mass with foci of air and oral contrast. The mass was
circumscribed by oral contrast, suggesting a trichobezoar
(Figure 2). An endoscopy was also done to confirm the
Department of Surgery, Lady Hardinge Medical College, New Delhi, India (Drs diagnosis. The endoscopist tried to fragment and remove
Sharma,Srivastava,Babu,Thomas). it, which was not successful.
DepartmentofRadiology,LadyHardingeMedicalCollege,NewDelhi(DrAnand).
DepartmentofRadiology,LadyHardingeMedicalCollege,NewDelhi,Divisionof
Laparoscopic Removal Technique
Medical Endoscopy, Lady Hardinge Medical College, New Delhi, India (Dr
Rohtagi).
Thepatientunderwentlaparoscopic-assistedtrichobezoar
Addresscorrespondenceto:Dr.DeborshiSharma,MS,MRCS(Ed),DepartmentofSurgery, removalfromherstomach.Shewasoperatedonwhilein
LadyHardingeMedicalCollege,NewDelhi,110001,INDIA.Telephone:[phone],
theLloyd-Davispositionwitha300reverseTrendelenburg
0091-9971539797,Fax:[phone],E-mail:[email protected]
tilt.A6-mminfraumbilicalcameraportwasestablishedfor
DOI:10.4293/108680810X12785289144566
a5-mm300telescopealongwith2more6-mmportsatthe
©2010byJSLS,JournaloftheSocietyofLaparoendoscopicSurgeons.Publishedby
theSocietyofLaparoendoscopicSurgeons,Inc. leftlumbarregionattheleveloftheumbilicusand11mm
JSLS(2010)14:263–267 263
LaparoscopicTreatmentofGastricBezoar,SharmaDetal.
attherightlumbarregion.Afterreleasingafewadhesions,
a gastrostomy was done over the anterior wall of the
stomach by using ultrasonic scissors (Figure 3). The
stomach contents were aspirated, and the bezoar mobi-
lized inside the stomach by using the 5-mm suction can-
nula. The apex of the gastric rent was elevated with a
grasper through the left port while the bezoar was mobi-
lized from the fundus holding it with a 10-mm claw for-
ceps (Figure 3). Once the proximal end of the bezoar
cameoutofthestomach,thehardbezoarwasagainlifted
withtheclawforceps(Figure3)tototallyremoveitfrom
the stomach and insert it into the endobag. The stomach
was irrigated, and both ends were examined for any
residue. The laparoscope could be inserted through the
gastricrentproximallyintothefundusofthestomachand
distallyintothefirstpartoftheduodenumthroughtheleft
lumbar port, which seemed to be a distinct advantage
over conventional open surgery. This procedure con-
firmedtheabsenceofanysmallresidues.Thebezoarwas
removedthrougha4-cmuppermidlineincisioninpieces
and the anterior gastric wall sutured extracorporeally
through it.
Theabdominalretrievalincisionwasclosedandpneumo-
peritoneum was re-achieved, which allowed us to check
thesuturedgastricrentandcopiouslyirrigatetherightand
left subphrenic and paracolic spaces. The patient had a
prolonged ileus in her postoperative period, and on her
Figure1.BariumMealUpperGIseriesshowingmottledfilling third postoperative day a mild discharge was seen from
defectwithentrappedairinthestomach. her main retrieval wound, which subsided within 2 days.
DISCUSSION
Bezoars are classified into 4 main types, according to the
materialsofwhichtheyarecomposed:Phytobezoars,Tri-
chobezoars, medication bezoars, and lactobezoars. Most
common are phytobezoars that consist of indigestible
fruits, vegetable fibers, skin, or seeds.2 Phytobezoars are
classically found in adults with a history of previous gas-
tric surgery, conditions of reduced gastric acidity, poor
gastricmixing,ordelayedmotility.Trichobezoars,orhair-
balls,areamassofhairs,decayingfoodmaterialorboth.
Medication bezoars consist of undigested tablets or semi-
liquid drugs. Lactobezoars are frequently found in low-
birth-weight or premature neonates fed with a highly
concentrated formula within the first weeks of life.2
Bezoars usually (90%) are found in children and young
females1 with pica, psychiatric disorders, or mental retar-
Figure 2. Axial CECT image shows a nonenhancing mixed dation, but rarely a severe psychiatric disorder is seen.3
density intraluminal gastric mass with foci of air and oral con- Usually there are no symptoms until the trichobezoar
trast.Massiscircumscribedbyoralcontrast. reachesasubstantialsize.3Anindentableabdominalmass
264 JSLS(2010)14:263–267
Figure 3. Intraoperative images: (A) Dis-
tended stomach with trichobezoar; (B) Tri-
chobezoarseeninsidethestomachaftergas-
trostomy with ultrasonic scissors; (C) Bezoar
ismobilizedinsidethestomachwithclawand
graspingforceps;(D)Trichobezoarbeingre-
moved from the stomach with claw forceps
beforeputtingintotheendobag.
is the commonest presentation,4 with other features like trast enhancement precludes a neoplastic lesion.4 Endos-
alopeciacircumscriptaandsignsofgastricoutletobstruc- copy confirms the diagnosis and often the offending
tion.3 Gastric bezoar formation occurs in patients with bezoarcanberemovedbythisroute.3Trichobezoarhasa
altered gastric physiology, impaired gastric emptying, re- black color that is seen due to denaturation of proteins
duced acid production, or all of these together. This is and gives a foetid odor due to entrapment of undigested
usuallycausedbypreviousgastricsurgery,suchaspartial fat in the hair mesh with bacterial colonization.3
gastrectomy, vagotomy, or pyloroplasty, but may be
causedbygastroparesisorgastricoutletobstruction.Con- Currentlyacceptedtreatmentofbezoars,includeobserva-
tributing factors can include dysmotility of the gastroin- tion,dissolution,fragmentation,andlaparotomyandgas-
testinaltract,dehydration,malnutrition,anddiabetesmel- trotomy.1 Beyond these other modalities, gastroscopic
litus. After antrectomy, the incidence is as high as 10% to fragmentation, nasogastric lavage or suction, and enzy-
25%.2Poormasticationandingestionoflargequantitiesof matic therapy with cellulose and papain have been
indigestiblesolidsmayalsoprecipitatebezoarformation.2 tried.6,7 Endoscopy is also known to have a therapeutic
Trichobezoar can be associated with Me´ne´trie`r’s disease potential.4Endoscopycanbedifficultandriskywithafew
and pancreatitis.3 casesofesophagealperforationreportedintheliterature.3
EndoscopicirrigationwithCocaCola(NaHCO3)canhave
Ultrasound features are not confirmatory; however, an amucolyticeffectinremovingtrichobezoars.2Othermin-
arc-like surface echo casting a clear posterior acoustic imally invasive modalities like extracorporeal lithotripsy,
shadow with dilated lumen can suggest the diagnosis.3 endoscopiclithotripsy,andlaserfragmentationareemerg-
Barium can show a cast of the stomach. CECT scan has a ing. Their role, success rates, and complications need to
high accuracy rate and differentiates it from any neo- be defined.4,7
plasms.4,5 CECT scan shows a well-circumscribed ovoid
intraluminal lesion, composed of concentric whorls of Therapeutic laparoscopy is fast emerging and has been
differentdensitieswithpocketsofairenmeshedwithinit, demonstrated to be feasible, though difficult in the man-
appearing in the stomach region. Beyond the lesion, the agement of gastric bezoars.1,5-10 Theoretically, 80% of ab-
bowel collapses.3 Oral contrast fills the more peripheral dominal operations could be performed laparoscopi-
interstices of the lesion, and a thin band of contrast cir- cally.1 Laparoscopy is associated with minimal incision,
cumscribesit.Absenceofsignificantpostintravenouscon- less pain, reduced hospital stay, excellent cosmetic out-
JSLS(2010)14:263–267 265
LaparoscopicTreatmentofGastricBezoar,SharmaDetal.
come, and fewer complications compared with the open withlaparoscopyandopensurgery8alongwithanecdotal
procedure.8,10 Authors have described their techniques reports of single cases.5,11 It can present as an isolated
with 3 to 5 ports (Table 1). Controversy exits regarding massorwithsatellitenodulescausinginterruptedobstruc-
themethodofretrieval.Mostauthorsadvocatepiecemeal tion.5 The ideal recommended procedure is to milk the
removal over in to-to removal. The greatest risk of con- bezoar beyond the ileo-cecal valve into the cecum; how-
tamination is at the time of gastrostomy and during its ever,laparoscopic-assistedproceduresarealsocommonly
transferintotheendo-bag.9Disadvantagesoflaparoscopy applied. Distention of proximal bowel can hamper visi-
couldbeoflongeroperatingtime,highercosts,andprob- bility, and occasionally locating the intestinal bezoar is
lems with retrieval.1,7 Retrieval should always be in an difficult in laparoscopy.11
endo-bagandpiecemeal,orinto-toremovaldependson
The association of pregnancy merits special mention, as
thesizeandweightofthebezoar.Imperviousendobagis
bezoars are commonly seen in young females in the re-
absolutely essential to prevent spillage and infection.
productive age group. Laparoscopy during pregnancy is
Comparisons have been made in small intestinal bezoars never without the fear of harm, including spontaneous
Table1.
ComparingVariousAvailableReportsofLaparoscopicGastricBezoarRemoval
Authorsand Technique Gastrostomy Retrieval Sizeof Recovery Follow-up
Year Closure Bezoar/
Time
Nirasawaetal 4ports, Intracorporealtwo Direct 11cm, Uncomplicated PsychiatryOPD
1998 Gastrostomy layeredclosure 185g, followup
with 300min
electrocautery
Yaoetal2000 3Ports, Intracorporealtwo Surgicalgloves, - Oralintake -
Anterior layers Piecemeal POD3,
longitudinal Uneventful
gastrostomy recovery
Shamietal Supine,3ports, Intracorporeal Endobag, 17cm, Oralintake 1yr,Uneventful
2007 Anterior Vicryl2-0 Piecemeal 720g, POD1,
gastrostomy 220min Discharge
usingultrasonic POD3,Wound
scalpel infection
Palaniveluet Anterior Throughabdominal Endobag - Oralintake 2yrs,
al2007 gastrostomy retrievalincision POD3, Uneventful
withstay Discharge
sutures POD5
Songetal 4Ports, Endo-GIAstaplers Endobag, 7cm,-, Oralintake -
2007 Anterior Piecemeal 50min POD3,
gastrostomy, Discharge
Monopolar POD6,
cautery Uncomplicated
Meyer-Rochow LloydDavis Intracorporealtwo Endobag, 180min Oralintake Pregnancy
etal2007 position,5 layers Piecemeal POD2, clinic
ports, Discharge
Gastrostomy POD3,
with Uneventful
electrocautery
Sharmaetal LloydDavis,3 Throughabdominal Endobag, 20cm, Oralintake 21months,
2010 ports,Anterior retrievalincision Piecemeal 450g, POD5, Uneventful.
gastrostomy 150min Discharge
withultrasonic POD7,Wound
scissors Infection
266 JSLS(2010)14:263–267
abortion of the developing fetus; however, increasing 5. Palanivelu C, Rangarajan M, Senthilkumar R, Madankumar
cumulative worldwide experience suggests that there is MV.Trichobezoarsinthestomachandileumandtheirlaparos-
no significant difference in fetal morbidity with laparos- copy-assisted removal: a bizarre case. Singapore Med J. 2007;
48(2):e37–e39.
copy compared with laparotomy.9
6. Yao CC, Wong HH, Chen CC, Wang CC, Yang CC, Lin CS.
CONCLUSION Laparoscopicremovaloflargegastricphytobezoars.SurgLapa-
roscEndoscPercutanTech.2000;10(4):243–245.
Thelaparoscopicapproachtoremovegastricbezoarshas
7. ShamiSB,JararaaAA,HamadeA,AmmoriBJ.Laparoscopic
abetteroutcomewithmanybenefitsoverlaparotomyand
removal of a huge gastric trichobezoar in a patient with tricho-
is slowly becoming the treatment of choice. Randomized
tillomania. Surg Laparosc Endosc Percutan Tech. 2007;17(3):
trialsarenotpossibleduetothepaucityofcases.Oncethe
197–200.
underlying disease is dealt with surgically, the cause
should be looked into with a multidisciplinary approach 8. Yau KK, Siu WT, Law BK, Cheung HY, Ha JP, Li MK.
to prevent further episodes. Laparoscopic approach compared with conventional open ap-
proachforbezoar-inducedsmall-bowelobstruction.ArchSurg.
2005;140(10):972–975.
References:
9. Meyer-RochowGY,GrunewaldB.Laparoscopicremovalof
1. Nirasawa Y, Mori T, Ito Y, Tanaka H, Seki N, Atomi Y.
a gastric trichobezoar in a pregnant woman. Surg Laparosc
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10. SongKY,ChoiBJ,KimSN,ParkCH.Laparoscopicremoval
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outletobstruction.JChinMedAssoc.2008;71(1):49–52. 11. Kan JY, Huang TJ, Heish JS. Laparoscopy assisted manage-
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3. O’SullivanMJ,McGrealG,WalshJG,RedmondHP.Tricho-
cutanTech.2005Sep;15(5):297–298.
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