Laparoscopic treatment for an unusual foreign body.

Sir,

Although foreign body (FB) passes spontaneously and uneventfully through the digestive tract, some FBs may become trapped and eventually lead to significant gastrointestinal tract injury. We recently encountered a case of a strange and uncommon FB ingestion.

A 29-year-old woman was admitted to the emergency medical centre of our hospital with the complaint of two FB ingestions. No information on the FB was available at that time. Computed tomography (CT) of the chest revealed a toothbrush in the oesophagus; however, the morphology and characteristics of another FB were not clearly identified on CT [Figure 1]. The on-call gastroenterologists decided to perform an emergency endoscopy to remove the FB. On flexible endoscopy, the ingested FB was confirmed to be a cleaner that is used to remove hair or waste from a sink drain. The ingested cleaner had multiple fishbone-like structures on its body to effectively open a drain. Unfortunately, the direction of the fishbone-like structures was opposite to that of the alimentary tract; therefore, the more they attempted to remove it, the more they injured the oesophageal mucosa. Finally, they abandoned the plan to extract the instrument and pushed it into the stomach. Subsequently, the on-call surgical team decided to perform laparoscopic surgery to remove the FB.

Figure 1

Chest computed tomography scan

Under a laparoscopic view, the peritoneal cavity was clear without gastric injury. First, we created a gastrostomy and found the cleaner in the stomach and removed it through the 5-mm trocar site [Figure 2]. Next, we removed the toothbrush via a 12-mm trocar site and closed gastrostomy site using Endo GIA™ Articulating Reload with Tri-Staple™ Technology (length, 60 mm; medium/thick; COVIDIEN™, Dublin, Ireland). The laparoscopic operation took 40 min and no complications occurred. After surgery, oral intake was well-tolerated, and she was discharged on the 8th postoperative day without complications, including oesophageal stricture.

Figure 2

Laparoscopic removal of the foreign bodies

Recently, the “less is more” concept has gained popularity and is widely performed in many individual centres. Most young physicians, managing patients who ingest a FB at the emergency medical centre, tend to opt for endoscopy without fully considering the nature of the ingested FB. It seems that endoscopy is generally indicated whenever possible and when the patient's clinical condition is stable.[12] Comparatively, surgery is believed to be restrictively performed with strict indications. Moreover, some authors reported that endoscopic intervention was successful in most cases including long or sharp FBs such as bones, toothpicks and dentures.[34] However, as shown in the aforementioned case, if the direction of thorn in the FB is cranial, endoscopic removal may worsen the oesophageal mucosal injury; therefore, we believe that the morphology of FB should be considered in the decision of treatment modality. Laparoscopic FB removal via gastrostomy is simple and easily performed. Therefore, it may be a good alternative when endoscopic FB removal is impossible.

We think that clinicians should carefully choose a treatment option when they cannot identify the ingested FB. In addition, when an unexpected clinical situation occurs during the procedure, clinicians should not hesitate to employ other treatment modalities.

Financial Support and Sponsorship

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Conflicts of Interest

There are no conflicts of interest.