- Email: [email protected]
Intraoperative endoscopic removal of a duodenal bezoar in a patient with intestinal malrotation
AT THE FOCAL POINT Lawrence J. Brandt, MD, Associate Editor for Focal Points
Intraoperative endoscopic removal of a duodenal bezoar in a patient with intestinal malrotation
A 72-year-old woman presented with abdominal pain. She had a history of intestinal malrotation and had undergone a laparoscopic Ladd operation. She was diagnosed with a bezoar in the third portion of the duodenum after abdominal CT scan, EGD, and upper GI series (A and B, arrows), and acute angulation was found at the junction between the third and fourth portions of the duodenum. Duodenotomy was attempted but failed because of multiple adhesions and distorted anatomy. The patient was referred to our hospital after gastrojejunostomy had been performed. EGD revealed the bezoar and a huge circumferential ulcer, but we were not able to pass the endoscope through because of luminal obstruction (C). We decided to perform a combined surgical and endoscopic procedure. At laparotomy, the endoscope was introduced through a gastrotomy performed on the gastric antrum. Surprisingly,
www.giejournal.org
the bezoar was not detected in the duodenal third portion and was not even palpable, presumably because of adhesions. After extensive adhesiolysis, the bezoar was palpated in the fourth portion of the duodenum. An enterotomy was created approximately 10 cm distal to the Treitz ligament, through which the endoscope was passed (D). The bezoar was fragmented by snare and mechanical lithotripsy with a basket, and the crushed bezoar was retrieved (D). The histopathologic diagnosis was phytobezoar.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
Volume
-,
No.
-
: 2014 GASTROINTESTINAL ENDOSCOPY 1
At the Focal Point
Eun Jeong Gong, MD, Hwoon-Yong Jung, MD, PhD, AGAF, Do Hoon Kim, MD, Hyun Lim, MD, Department of Gastroenterology, Ki Byung Song, MD, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery,
University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea http://dx.doi.org/10.1016/j.gie.2014.02.028
Commentary William Edwards Ladd (1880-1967), one of the fathers of pediatric surgery, described so-called Ladd’s bands and the Ladd procedure. Ladd’s bands are fibrous extensions of peritoneum that attach the cecum to the abdominal wall, but may cross the duodenum, thereby creating an obstruction. Presentations of Ladd’s bands include acute and chronic duodenal obstruction and obstruction because of an internal hernia. The Ladd procedure is performed to alleviate adverse events of intestinal malrotation and involves surgical division of Ladd’s bands, widening of the small intestine mesentery, appendectomy, and positioning the bowel such that the colon will permanently reside on the left side of the abdomen and the small bowel on the right side, thereby precluding any torsion about each other and the SMA. As many as 40% of patients with malrotation present within the first week of life, 75% by age 1 year, and 25% after the first year and into adulthood. It is critical when one looks at an upper GI series to determine whether the duodenum crosses the midline from the right to the left side; if it stays on the right, the patient has a malrotation. With so many adhesions and acute angulation of the proximal GI tract, I cannot imagine that this patient was symptom-free until the current presentation, and I assume she must have known of certain foods that just were not “digested right.” Stasis is key to the formation of bezoars, a word that derives from the Persian pad-zahr, meaning counter-poison and that originally referred to an antidote given to counteract a noxious and potentially fatal ingestant. Whether this was an enterolith or a bezoar, however, will not be resolved absent chemical analysis, but unless the anatomic derangements that fostered its formation are permanently corrected, the authors will likely get another chance at removing a similar obstruction. Lawrence J. Brandt, MD Associate Editor for Focal Points
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2014
www.giejournal.org
Intraoperative endoscopic removal of a duodenal bezoar in a patient with intestinal malrotation
A 72-year-old woman presented with abdominal pain. She had a history of intestinal malrotation and had undergone a laparoscopic Ladd operation. She was diagnosed with a bezoar in the third portion of the duodenum after abdominal CT scan, EGD, and upper GI series (A and B, arrows), and acute angulation was found at the junction between the third and fourth portions of the duodenum. Duodenotomy was attempted but failed because of multiple adhesions and distorted anatomy. The patient was referred to our hospital after gastrojejunostomy had been performed. EGD revealed the bezoar and a huge circumferential ulcer, but we were not able to pass the endoscope through because of luminal obstruction (C). We decided to perform a combined surgical and endoscopic procedure. At laparotomy, the endoscope was introduced through a gastrotomy performed on the gastric antrum. Surprisingly,
www.giejournal.org
the bezoar was not detected in the duodenal third portion and was not even palpable, presumably because of adhesions. After extensive adhesiolysis, the bezoar was palpated in the fourth portion of the duodenum. An enterotomy was created approximately 10 cm distal to the Treitz ligament, through which the endoscope was passed (D). The bezoar was fragmented by snare and mechanical lithotripsy with a basket, and the crushed bezoar was retrieved (D). The histopathologic diagnosis was phytobezoar.
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
Volume
-,
No.
-
: 2014 GASTROINTESTINAL ENDOSCOPY 1
At the Focal Point
Eun Jeong Gong, MD, Hwoon-Yong Jung, MD, PhD, AGAF, Do Hoon Kim, MD, Hyun Lim, MD, Department of Gastroenterology, Ki Byung Song, MD, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery,
University of Ulsan College of Medicine, Asan Medical Center, Asan Digestive Disease Research Institute, Seoul, Korea http://dx.doi.org/10.1016/j.gie.2014.02.028
Commentary William Edwards Ladd (1880-1967), one of the fathers of pediatric surgery, described so-called Ladd’s bands and the Ladd procedure. Ladd’s bands are fibrous extensions of peritoneum that attach the cecum to the abdominal wall, but may cross the duodenum, thereby creating an obstruction. Presentations of Ladd’s bands include acute and chronic duodenal obstruction and obstruction because of an internal hernia. The Ladd procedure is performed to alleviate adverse events of intestinal malrotation and involves surgical division of Ladd’s bands, widening of the small intestine mesentery, appendectomy, and positioning the bowel such that the colon will permanently reside on the left side of the abdomen and the small bowel on the right side, thereby precluding any torsion about each other and the SMA. As many as 40% of patients with malrotation present within the first week of life, 75% by age 1 year, and 25% after the first year and into adulthood. It is critical when one looks at an upper GI series to determine whether the duodenum crosses the midline from the right to the left side; if it stays on the right, the patient has a malrotation. With so many adhesions and acute angulation of the proximal GI tract, I cannot imagine that this patient was symptom-free until the current presentation, and I assume she must have known of certain foods that just were not “digested right.” Stasis is key to the formation of bezoars, a word that derives from the Persian pad-zahr, meaning counter-poison and that originally referred to an antidote given to counteract a noxious and potentially fatal ingestant. Whether this was an enterolith or a bezoar, however, will not be resolved absent chemical analysis, but unless the anatomic derangements that fostered its formation are permanently corrected, the authors will likely get another chance at removing a similar obstruction. Lawrence J. Brandt, MD Associate Editor for Focal Points
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2014
www.giejournal.org