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Phytobezoars Following Gastric Surgery for Duodenal Ulcer
Symposium on Unexpected Presentations of Surgical Disease
Phytobezoars Following Gastric Surgery for Duodenal Ulcer
Ransom R. Buchholz, M.D., and Arnold S. Haisten, M.D.
During the last 50 years, most of the complications seen after partial gastric resection have been repeatedly reported and vigorously discussed. Also, the occurrence of small bowel obstruction by foodstuffs is known to occur with some frequency.H. 39 Little emphasis, however, has been directed to the occurrence of an entity that is being reported with increasing frequency, namely, the occurrence of small bowel obstruction by a phytobezoar in the patient who had previously been subjected to partial gastric resection. Moreover, another entity to be recently reported with increasing frequency has been the occurrence of gastric phytobezoars with outlet obstruction following antrectomy-vagotomyand pyloroplasty-vagotomy. Szemes and Amberg37 reported 5 such bezoars in a 3 year period in patients who had Billroth I gastroduodenostomy and truncal vagotomy. Moseley23 has reported an instance of pyloric obstruction by phytobezoar following pyloroplasty-vagotomy. Cain et al5 added 2 cases of gastric phytobezoar following gastric surgery for duodenal ulcer and reviewed the literature and recorded 97 cases of both small bowel and gastric bezoars following gastric surgery. Cohen and HeunB recently recorded the first reported case of obstruction by phytobezoar at the ligament of Trietz.
LITERATURE The first case of intestinal obstruction by phytobezoar after gastric resection was reported by Seifert33 from Germany in 1930. The offending foodstuff was sauerkraut. Prior to 1955, only 5 additional cases had been reported. These single case reports were by Smithwick and Allen,34 Baumeister and Darling,! Fleming and Ward-McQuaid,!5 Stalker and Gotham,36 and Elfving and Scheinin.14 In 1955 Norberg25 described 7 patients in whom bezoars caused intestinal obstruction after gastric resection for duodenal ulcer. Since From the Surgical Service, Veterans Administration Center, Temple, Texas Surgical Clinics of North America- Vol. 52, No.2, April 1972
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Norberg's report in 1955, there have been over 150 cases reported. It is of interest that in 1961, Norberg26 recorded 21 more cases, making a total of 28 cases from one institution in Sweden. Also, Powley29 reported 9 cases from a single hospital in England. Six of his cases occurred within a 2 year period. Thus, while Spurzem and Dresser15 were able to find only 13 cases in the world literature in 1957, Schlang and McHenry,32 in 1963, collected 84 cases of intestinal obstruction following gastric resection in which the bolus was composed of orange pulp alone. During the last 2 years, 31 unreported cases of intestinal obstruction by phytobezoar in the postgastrectomy patient have been documented by personal communications. 28 Our experience with this entity consists of 10 instances of phytobezoar formation in 9 patients following gastric surgery. Six patients presented with the clinical findings of small bowel obstruction. All these patients required surgical intervention for the relief of obstruction. The phytobezoars in the 3 other patients were gastric in location. Two of these phytobezoars were removed by surgical procedures. Since these phytobezoars that are retained in the gastric pouch are usually of small food particles encased in a gel-like membrane, it may be feasible to disintegrate the mass by gastroscopic manipulation in some cases. Case No.1 A 50 year old man had subtotal gastric resection (anterior Polya) in 1962. He experienced no difficulty until 1967, when he was admitted with a history of nausea, vomiting, and abdominal cramping pain of 18 hours' duration. An abdominal series revealed distended loops of small bowel. Exploration of the abdomen revealed distended loops of small bowel to 50 cm. from ileocecal valve. An intraluminal mass was palpated at this level, and attempts to "milk" this mass into the cecum were unsuccessful. Enterostomy was performed and segments of orange pulp (Fig. 1) were removed. Recovery was uneventful. Condition of the chewing mechanism in this patient was poor. Case No.2 A 50 year old man had subtotal resection (anterior Hofmeister) in 1951, for massive bleeding from a gastric polyp. In 1957, he was admitted to the hospital with a 24-hour history of nausea, vomiting, and cramping abdominal pain. An abdominal x-ray series revealed many distended loops of small bowel and fluid levels. Operative intervention revealed an intraluminal mass 45 cm. from the ileocecal valve. A phytobezoar composed of orange segments was removed by enterostomy. Recovery was uneventful. The patient was edentulous. Case No.3 A 44 year old white man was subjected to subtotal gastric resection (Billroth II-antecolic) in 19:;>8, for an intractable duodenal ulcer. Four years later he was admitted with symptoms and signs of small bowel mechanical obstruction. X-ray films revealed distended loops (Fig. 2). An intraluminal mass was causing complete small bowel obstruction 30 cm.
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Figure 1. Phytobezoar composed of orange segments.
Figure 2. Flat plate of abdomen, Case 3.
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proximal to the ileocecal valve. Attempts at "milking" were unsuccessful. Enterostomy was accomplished, and a phytobezoar composed of segments of orange was removed. Recovery was uneventful. The patient was edentulous.
Case No.4 A 62 year old man was admitted to the hospital in 1959, complaining of nausea, vomiting, and cramping abdominal pain. X-ray films revealed diffuse small bowel distention. Exploration of the abdomen revealed an intraluminal mass approximately at the junction of jejunum and ileum. An orange segm.ent phytobezoar was removed by enterostomy. Recovery was uneventful. The patient was edentulous.
Case No.5 A 36 year old man had subtotal gastric resection (anterior Hofmeister) in 1950 for massive bleeding from duodenal ulcer. In 1957, he was suspected of having a marginal ulcer. Exploration elsewhere did not reveal a marginal ulcer, and vagotomy was done. Six weeks later, he was admitted to our hospital with symptoms and signs of small bowel obstruction. Twenty-four hours prior to onset of symptoms, he had eaten a large number of figs. At operation, a large intraluminal mass, composed of fig fibers, was removed by enterotomy, 50 cm. from the ileocecal valve. Many adhesions were present. Recovery was uneventful. The patient's chewing mechanism was poor.
Case No.6 This 43 year old man had closure of perforated duodenal ulcer in 1945. In 1950, a subtotal gastrectomy (anterior Hofmeister) was done for intractable duodenal ulcer. He was admitted in 1958, with symptoms, signs, and x-ray findings of small bowel obstruction. Forty hours prior to onset of symptoms, the patient had eaten several baked apples. At the time of surgery, an intraluminal obstructing mass was found 15 cm. from the ileocecal valve. This mass was "milked" into the cecum with relief of obstruction. A second mass was palpated in the gastric pouch and gastrotomy was performed. A phytobezoar composed of apple peel was removed. Recovery was without complications. The patient had excellent teeth. Case No.7 A 57 year old man with a long history of duodenal ulcer was found to have partial pyloric obstruction. On March 20, 1968, antrectomy and vagotomy (Billroth II) were performed. His postoperative course was excellent, and he was discharged from the hospital on his tenth postoperative day. One week after discharge, he had onset of recurrent nausea and vomiting. He was readmitted on April 15, 1971. An upper gastrointestinal series (Fig. 3) revealed a large barium-coated mass in the gastric pouch which was thought to represent a phytobezoar. Patient denied intake of oranges, figs, sauerkraut, or other similar foods. Findings were confirmed by cinefiuoroscopy. On gastroscopic examination (Fig. 4), a large
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Figure 3. Upper gastrointestinal series showing barium-coated mass.
Figure 4. troscopy.
Gastric camera photograph of bezoar as seen during gas-
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congealed mass of foreign material in the gastric pouch was visualized. The stoma was patent and of average size. After a 5 day trial of enzymes (Adolph's Meat Tenderizer), a gastrointestinal series revealed no change in the size or configuration of the mass. On April 30, 1968, gastrotomy was performed, and a large white mass with a thin-walled membrane was removed. This phytobezoar measured 5 x 7 cm. The content of the mass was not accurately determined. The patient's postoperative course was excellent, and he has had no further difficulty. He is edentulous. Case No.8 A 48 year old man who had had subtotal gastric resection in 1959, was admitted to this hospital in 1969, with mild digestive symptoms. A phytobezoar was visualized in the gastric stump on gastroscopic examination. After 5 days of therapy with Adolph's Meat Tenderizer via naso gastric tube, he was reexamined with the gastroscope, and no bolus was present. He was readmitted in 1971, complaining of postprandial epigastric pain. A gastrointestinal series and gastroscopic visualization confirmed the presence of another phytobezoar. Intake of the usual foodstuffs causing phytobezoar was denied. He was again treated with meat tenderizer. Two weeks later, another gastroscopic examination revealed that the bezoar was smaller, but still present. The patient refused surgical removal of bezoar. Case No.9 A 63 year old man had subtotal gastric resection in another hospital for "intractable" duodenal ulcer in 1965. Eighteen months later, because of a diagnosis of marginal ulcer and "high acid," a transthoracic vagotomy was done. The patient continued to have epigastric discomfort. In 1968, he was admitted to the hospital, complaining of epigastric pain and vomiting on occasion. A Hollander test revealed evidence of complete vagotomy. An upper gastrointestinal series revealed stomal stenosis and a questionable intragastric mass. At time of exploration, a 5 x 5 cm. phytobezoar was removed from the gastric pouch. It was composed of orange pith, apple peels, and pecans. He remembered eating fruit salad several weeks previously. The stomal stenosis was revised. His postoperative course was excellent.
FACTORS IN THE ETIOLOGY OF OBSTRUCTION The following factors influence the development of obstruction. Physical Characteristics of the Bolus In almost all instances the foods have been pulpy fruits or vegetables. These normally contain a large proportion of undigestible material, even after passage through a normal digestive tract. After an orange segment is broken and the juice is pressed out, there remains a fibrous mass similar to the original form and consisting mainly of segmented septa. A seg-
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ment in this state is easily swallowed. It is suggested that this segment moves rapidly through the stoma, progresses into the small intestine, and is reconstituted with intestinal juices and pectin. This probably accounts for the normal-appearing segments that are found as the obstructing mass in patients who have been operated upon.
Condition of the Chewing Mechanism As one studies the reported cases, the condition of the chewing mechanism was noted in only 46 patients. In approximately half the cases, the teeth were either in poor condition or the patients were edentulous and had ill-fitting dentures. Norberg,26 discussing this factor in his 28 cases, believed that the condition of the chewing mechanism was not as important as the eating habits. In our 9 cases, the chewing mechanism was considered adequate in 3 and poor in 6 cases. It would seem fair to conclude that incomplete mastication of the foodstuff would favor the formation of the bolus. This would seem to be especially true in the case of oranges.
Anatomy and Mobility of the Small Bowel Most surgical anatomists20 agree that the circumference of the small bowel is smallest at a site 50 to 75 cm. proximal to the ileocecal valve. Peristaltic waves are less forceful at this level. 19 This corresponds to the site of obstruction by the phytobezoar in most of the reported cases. It should be emphasized, however, that on occasions the phytobezoars are multiple; thus, the proximal bowel and stomach should be examined at time of surgery to rule out the possibility of another bolus being in transit. Loss of Pyloric Function Perhaps the most important factor in the occurrence of food bolus obstruction following gastric resection is the loss of pyloric function. The current concept 13 of the function of the pylorus envisions a mechanism that is different from that of the usual sphincter. There is evidence that the diameter of the pyloric aperture is directly related to the diameter of the antrum. Vigorous contraction of the antrum and simultaneous decrease of the pyloric aperture occur in response to a waye of gastric peristalsis.9 As the antrum contracts, the simultaneous decrease in the diameter of the pyloric aperture sharply limits the size of the food particles squeezed into the duodenum. This concept17 of pyloric control of the size of food masses passed from the stomach can explain why in most instances, in the intact stomach, masses of food large enough to obstruct the small bowel do not traverse the pylorus.
Interval Between Gastric Resection and Obstruction by Phytobezoar In the collected series of Schlang and McHenry,32 the greatest number of cases appeared in the interval of 5 to 10 years following gastrectomy. Norberg, in his series of 28 cases, found that the longest interval between gastric resection and obstruction by phytobezoar was 21
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years. 25 • 26 The shortest interval was 9 months. The average interval in Norberg's patients was 8.3 years. In the 9 cases presented here, the average interval was 5.8 years. Nature of Foodstuff Involved The orange has been by far the most frequent offending foodstuff. The obstructing bolus has been composed of orange segments in approximately 90 per cent of the documented cases. Other vegetable foodstuffs that have been involved are figs, apples, grapefruit, coconuts, beans, Brussels sprouts, potato peel, berries, and cabbage. With the exception of one macaroni bolus, the offending foods have been high in fiber content. Foods consisting largely of protein and carbohydrate have not formed bezoars. Presumably, the pancreatic and intestinal secretions reduce these materials to a digested state. It is of significance that in the comprehensive review by Ward-McQuaid39 of obstruction by phytobezoar in 178 patients who had not previously been subjected to gastric resection, the orange was the offending foodstuff in only 11 per cent of the cases. Citrus fruit (orange) was the offending foodstuff in 5 of the 9 cases presented here. In other cases, figs and apple peels were the foodstuff involved. In the remaining 2 cases, the mass was conglomerate, and it was impossible to accurately denote the involved fibers.
INCOMPLETE OBSTRUCTION It is interesting to speculate that there are perhaps varying degrees of obstruction due to food in the postgastrectomy state. Several authors1o • 32 suggest that such a situation does occur. These cases vary from transient colic to the impacted complete obstruction demonstrated by the 6 cases presented. It is significant that 2 patients in the collected series required surgery a second time because of obstruction due to food (orange), and in one of the presented cases, there was reformation of a phytobezoar after the initial one had been dissolved by enzymes. It is suggested that perhaps on occasions the bizarre symptoms of the post gastrectomy patient are the result of transient obstruction of the small bowel by incompletely digested food material.
DISCUSSION AND SUMMARY Although the clinical reports indicate that the diagnosis of acute intestinal obstruction in the post gastrectomy patient is not always simple, most of the patients with this disorder are readily determined to have obstruction and are properly managed. Norberg 26 stated that the preoperative diagnosis of phytobezoar obstruction was properly made in 6 of his 28 cases. Powley29 indicated that the correct preoperative diagnosis was entertained in 4 of the 9 cases that he reported. Preoperative diag-
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nosis was correctly made in 2 of our 6 cases of small bowel obstruction, and in the 3 cases of bezoars in the gastric pouch. This particular complication following gastric surgery should be a preventable cause of late morbidity. That this complication does occur is worthy of wide recognition. It would appear that insufficient attention has been given to the possibility of this complication after gastric surgery. The suggested sequence of events in the formation of phytobezoars has been indicated (Fig. 5). The patient cannot be expected to be aware of its possible occurrence unless he has been given clear and adequate instructions by his medical advisors. This increasing problem of food obstruction in patients who have had gastrectomy and in persons who have had vagotomy and drainage procedures should bring into sharp focus the necessity for clear and emphatic instructions to such patients to avoid fibrous foods, especially oranges, unless these foods can be finely chewed or mechanically minced prior to ingestion. The total elimination of oranges from the diet of these patients would eliminate 90 per cent of the instances of this late complication following gastric surgery. Printed and illustrated instructions (Fig. 6) are given to all patients who have been subjected to gastric surgery. These instructions denote to the patients the foods that they should avoid in the future.
GASTRIC SURGERY BILLROTH I AND II VAGOTOMY AND GASTROJEJUNOSTOMY VAGOTOMY AND ANTRAL RESECTION VAGOTOMY AND PYLOROPLASTY GASTROENTEROSTOMY
~
LOSS OF NORMAL PYLORIC FUNCTION LOW GASTRIC ACIDITY
+
INADEQUATE CHEWING MECHANISM
~
BOLUS OBSTRUCTION Figure 5.
Sequence of events in the formation of phytobezoars.
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o0
o 0
YOU HAVE RECENTLY HAD A SURGICAL PROCEDURE PERFORMED ON YOUR STOMACH.
YOU SHOULD SOON BE ABLE TO INCLUDE NEARLY ALL THE
FOODS YOU DESIRE IN YOUR DIET. HOWEVER, IT IS IMPORTANT THAT YOU SHOULD NOT EAT CERTAIN FOODS THAT YOU HAVE PERHAPS EATEN IN THE PAST.
EATING THE FOODSTUFFS
THAT ARE LISTED BELOW HAS BEEN FOUND TO RESULT IN BOWEL OBSTRUCTION (LOCKED BOWELS) AFTER ONE HAS HAD STOMACH SURGERY. ORANGES SHOULD BE ELIMINATED FROM YOUR DIET ENTIRELY. JUICE ONLY.
USE ORANGE
OTHER FOODS SUCH AS GRAPEFRUIT, FIGS, APPLES, STRING
BEANS, BRUSSEL SPROUTS, CABBAGE, BERRIES AND BAKED POTATO PEEL SHOULD BE AVOIDED UNLESS THEY ARE PROPERLY CHEWED OR MECHANICALLY MINCED . DIETETIC SERVICE, VA CENTER, TEMPLE, TEXAS Figure 6.
Instructions given to postgastrectomy patients.
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REFERENCES 1. Baumeister, C. F., and Darling, D. D.: Acute intestinal obstruction due to orange pulp bezoar. Ann. Surg., 126:251-252 (Aug.) 1947. 2. Binns, P. M.: Orange-bolus obstruction. Brit. Med. J., 2:710 (Sept. 9) 1961. 3. Bowen, F. H.: Obstruction of the small bowel due to boli of ingested coconut. A report of two cases. Amer. Surgeon, 22:1076-1078 (Nov.) 1956. 4. Butler, M. F.: Orange-pith ileus after partial gastrectomy. Brit. Med. J., 2:549-550 (Sept. 28) 1959. 5. Cain, G. D., Moore, P., and Patterson, M.: Bezoars-A complication of the post-gastrectomy state. Amer. J. Dig., Dis., 13:801-809 (Sept.) 1968. 6. Chenilleau and Laffitte: Deux cas d'occlusion gastrectomie. Bordeaus Chir., 2:87-88 (April) 1953. 7. Chun, J. J., and Dinan, j. J.: Small bowel obstruction due to phytobezoars in gastrectomized subjects. Canad. J. Surg., 8:272-275 (July) 1965. 8. Cohen, Y., and Heun, S. W.: Phytobezoar after gastrectomy. Brit. J. Surg., 58:236-239 (Mar.) 1971. 9. Davenport, H. W.: Physiology of the Digestive Tract. Chicago, Yearbook Medical Publishers, Inc., pp. 50-51,1961. 10. Davies, D. G., and Lewis, R. H.: Food obstruction of the small intestine. A review of 15 cases. Brit. Med. J., 2:545-548 (Sept. 26) 1959. 11. DeBakey, M., and Ochsner, A.: Bezoars and concretions; comprehensive review of literature with analysis of 303 collected cases and presentation of 8 additional cases. Surgery, 4:934-963 (Dec.) 1938. 12. Edelmann, G.: L'ileus alimentaire chez les gastrectomises. Arch. mal Appar. Dig., 50:657-661 (June) 1961. 13. Edwards, D. A. W.: Physiological aspects of the pylorus. Proc. Roy. Soc. Med., 54:930-933 (Nov.) 1961. 14. Elfving, G., and Scheinin, T. M.: Intestinal obstruction caused by ingested vegetables. Ann. Chir. Gynaec. Fenniae,42:178-183, 1953. 15. Fleming, J. P., and Ward-McQuaid, J. N.: Four unusual complications of partial gastrectomy. Australian New Zealand J. Surg., 20:73-78 (Aug.) 1950. 16. Hansbrough, E. T., and Lipin, R. J.: Intestinal obstruction due to food bolus following gastrectomy. Amer. Surgeon, 24:80-83 (Jan.) 1958. 17. Johnson, H. D.: The pylorus: Its functions and some surgical considerations. Proc. Roy. Soc. Med., 54:938-940 (Nov.) 1961. 18. Kott, I., and Urca, I.: Intestinal obstruction after partial gastrectomy due to orange pith. Arch. Surg., 100:79-81 (Jan.) 1970. 19. Latchmore, A. J. C.: Stomach-ache. Lancet, 1 :1153-1155 (June 29) 1940. 20. MacCarthy, D. F.: Intestinal obstruction by food. Lancet, 2:998-999, (Nov. 10) 1956. 21. McCabe, R., and Knox, W. G.: Phytobezoar in gastrectomized patients. Cause of small bowel obstruction. Arch. Surg., 86:264-266 (Feb.) 1963. 22. Manier, j. W.: Intestinal obstruction due to phytobezoar following gastric resection. Amer. J. Gastro., 39:48-51 (Jan.) 1963. 23. Moseley, R. V.: PylOriC obstruction by a phytobezoar following pyloroplasty and vagotomy. Arch. Surg., 94:290-291 (Feb.) 1967. 24. Nagel, G. W., and Bergera, J. J.: Phytobezoars occluding the smallintestine following subtotal gastrectomy. Amer. J. Surg., 99:318-319, (Mar.) 1960. 25. Norberg, P. B.: Intestinal obstruction due to citrus fruits after partial gastrectomy. Acta. Chir. Scandinav., 109:43-47, 1955. 26. Norberg, P. B.: Intestinal obstruction due to food. Surg. Gynec. Obstet., 113:149-152, (Aug.) 1961. 27. Oppolzer, R.: Phytobezoarileus nach Magen-resektion. Klin. Med., (Wien), 15:306-310 (July) 1960. 28. Personal communications. 29. Powley, P. H.: Bolus obstruction after partial gastrectomy. Brit. Med. J., 2:1392-1393 (Nov. 25) 1961. 30. Ribet, M., Fovet, A., and Guerrin, F.: Occlusion of the small intestine due to phytobezoars after gastrectomy (3 cases). Presse Med., 69:2610-2612 (Dec.) 1961. 31. Rigler, R. C., and Grininger, D. R.: Phytobezoars following partial gastrectomy. SURG. CLIN. N. AMER., 50:381-386 (Apr.) 1970. 32. Schlang, H. A., and McHenry, L. E.: Obstruction of the small bowel by orange in the postgastrectomy patient. Ann. Surg., 159:611-622 (April) 1964. 33. Seifert, E.: Ueber Krautileus. Deutsche Ztschr. f. Chir., 224:96-98,1930. 34. Smithwick, R. H., and Allen, A. W.: Presentation of a case. New Eng. J. Med., 226 :864-866 (Mar 21) 1942.
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35. Spurzem, R R, and Dresser, P. L.: Intestinal obstruction due to phytobezoar following gastric resection; report of 2 cases. Surgery, 42:493-495 (Sept.) 1957. 36. Stalker, L. K., and Gotham, I. J., Jr.: Small bowel obstruction due to a phytobezoar. New York State J. Med., 50:1614 (July) 1950. 37. Szemes, G. C., and Amberg, J. R: Gastric bezoars after partial gastrectomy. Radiology, 90:765-768 (Apr.) 1968. 38. Turney, J. P.: Orange-bolus obstruction. Brit. Med. J., 2:893-894 (Sept. 30) 1961. 39. Ward-McQuaid, N.: Intestinal obstruction by food. Lancet, 2:359 (Aug. 18) 1956. 40. Wee, G. E., Bond, L. F., and Calman, C. H.: Acute intestinal obstruction due to orange section bezoars following subtotal gastrectomy. Missouri Medicine, 60:437-439 (May) 1963. 41. Wilde, W. L.: Potato skin phytobezoars in edentulous gastrectomized patients: A growing clinical syndrome. Amer. J. Surg., 109:649-651 (May) 1965. Veterans Administration Center Temple, Texas 76501
Phytobezoars Following Gastric Surgery for Duodenal Ulcer
Ransom R. Buchholz, M.D., and Arnold S. Haisten, M.D.
During the last 50 years, most of the complications seen after partial gastric resection have been repeatedly reported and vigorously discussed. Also, the occurrence of small bowel obstruction by foodstuffs is known to occur with some frequency.H. 39 Little emphasis, however, has been directed to the occurrence of an entity that is being reported with increasing frequency, namely, the occurrence of small bowel obstruction by a phytobezoar in the patient who had previously been subjected to partial gastric resection. Moreover, another entity to be recently reported with increasing frequency has been the occurrence of gastric phytobezoars with outlet obstruction following antrectomy-vagotomyand pyloroplasty-vagotomy. Szemes and Amberg37 reported 5 such bezoars in a 3 year period in patients who had Billroth I gastroduodenostomy and truncal vagotomy. Moseley23 has reported an instance of pyloric obstruction by phytobezoar following pyloroplasty-vagotomy. Cain et al5 added 2 cases of gastric phytobezoar following gastric surgery for duodenal ulcer and reviewed the literature and recorded 97 cases of both small bowel and gastric bezoars following gastric surgery. Cohen and HeunB recently recorded the first reported case of obstruction by phytobezoar at the ligament of Trietz.
LITERATURE The first case of intestinal obstruction by phytobezoar after gastric resection was reported by Seifert33 from Germany in 1930. The offending foodstuff was sauerkraut. Prior to 1955, only 5 additional cases had been reported. These single case reports were by Smithwick and Allen,34 Baumeister and Darling,! Fleming and Ward-McQuaid,!5 Stalker and Gotham,36 and Elfving and Scheinin.14 In 1955 Norberg25 described 7 patients in whom bezoars caused intestinal obstruction after gastric resection for duodenal ulcer. Since From the Surgical Service, Veterans Administration Center, Temple, Texas Surgical Clinics of North America- Vol. 52, No.2, April 1972
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Norberg's report in 1955, there have been over 150 cases reported. It is of interest that in 1961, Norberg26 recorded 21 more cases, making a total of 28 cases from one institution in Sweden. Also, Powley29 reported 9 cases from a single hospital in England. Six of his cases occurred within a 2 year period. Thus, while Spurzem and Dresser15 were able to find only 13 cases in the world literature in 1957, Schlang and McHenry,32 in 1963, collected 84 cases of intestinal obstruction following gastric resection in which the bolus was composed of orange pulp alone. During the last 2 years, 31 unreported cases of intestinal obstruction by phytobezoar in the postgastrectomy patient have been documented by personal communications. 28 Our experience with this entity consists of 10 instances of phytobezoar formation in 9 patients following gastric surgery. Six patients presented with the clinical findings of small bowel obstruction. All these patients required surgical intervention for the relief of obstruction. The phytobezoars in the 3 other patients were gastric in location. Two of these phytobezoars were removed by surgical procedures. Since these phytobezoars that are retained in the gastric pouch are usually of small food particles encased in a gel-like membrane, it may be feasible to disintegrate the mass by gastroscopic manipulation in some cases. Case No.1 A 50 year old man had subtotal gastric resection (anterior Polya) in 1962. He experienced no difficulty until 1967, when he was admitted with a history of nausea, vomiting, and abdominal cramping pain of 18 hours' duration. An abdominal series revealed distended loops of small bowel. Exploration of the abdomen revealed distended loops of small bowel to 50 cm. from ileocecal valve. An intraluminal mass was palpated at this level, and attempts to "milk" this mass into the cecum were unsuccessful. Enterostomy was performed and segments of orange pulp (Fig. 1) were removed. Recovery was uneventful. Condition of the chewing mechanism in this patient was poor. Case No.2 A 50 year old man had subtotal resection (anterior Hofmeister) in 1951, for massive bleeding from a gastric polyp. In 1957, he was admitted to the hospital with a 24-hour history of nausea, vomiting, and cramping abdominal pain. An abdominal x-ray series revealed many distended loops of small bowel and fluid levels. Operative intervention revealed an intraluminal mass 45 cm. from the ileocecal valve. A phytobezoar composed of orange segments was removed by enterostomy. Recovery was uneventful. The patient was edentulous. Case No.3 A 44 year old white man was subjected to subtotal gastric resection (Billroth II-antecolic) in 19:;>8, for an intractable duodenal ulcer. Four years later he was admitted with symptoms and signs of small bowel mechanical obstruction. X-ray films revealed distended loops (Fig. 2). An intraluminal mass was causing complete small bowel obstruction 30 cm.
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Figure 1. Phytobezoar composed of orange segments.
Figure 2. Flat plate of abdomen, Case 3.
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proximal to the ileocecal valve. Attempts at "milking" were unsuccessful. Enterostomy was accomplished, and a phytobezoar composed of segments of orange was removed. Recovery was uneventful. The patient was edentulous.
Case No.4 A 62 year old man was admitted to the hospital in 1959, complaining of nausea, vomiting, and cramping abdominal pain. X-ray films revealed diffuse small bowel distention. Exploration of the abdomen revealed an intraluminal mass approximately at the junction of jejunum and ileum. An orange segm.ent phytobezoar was removed by enterostomy. Recovery was uneventful. The patient was edentulous.
Case No.5 A 36 year old man had subtotal gastric resection (anterior Hofmeister) in 1950 for massive bleeding from duodenal ulcer. In 1957, he was suspected of having a marginal ulcer. Exploration elsewhere did not reveal a marginal ulcer, and vagotomy was done. Six weeks later, he was admitted to our hospital with symptoms and signs of small bowel obstruction. Twenty-four hours prior to onset of symptoms, he had eaten a large number of figs. At operation, a large intraluminal mass, composed of fig fibers, was removed by enterotomy, 50 cm. from the ileocecal valve. Many adhesions were present. Recovery was uneventful. The patient's chewing mechanism was poor.
Case No.6 This 43 year old man had closure of perforated duodenal ulcer in 1945. In 1950, a subtotal gastrectomy (anterior Hofmeister) was done for intractable duodenal ulcer. He was admitted in 1958, with symptoms, signs, and x-ray findings of small bowel obstruction. Forty hours prior to onset of symptoms, the patient had eaten several baked apples. At the time of surgery, an intraluminal obstructing mass was found 15 cm. from the ileocecal valve. This mass was "milked" into the cecum with relief of obstruction. A second mass was palpated in the gastric pouch and gastrotomy was performed. A phytobezoar composed of apple peel was removed. Recovery was without complications. The patient had excellent teeth. Case No.7 A 57 year old man with a long history of duodenal ulcer was found to have partial pyloric obstruction. On March 20, 1968, antrectomy and vagotomy (Billroth II) were performed. His postoperative course was excellent, and he was discharged from the hospital on his tenth postoperative day. One week after discharge, he had onset of recurrent nausea and vomiting. He was readmitted on April 15, 1971. An upper gastrointestinal series (Fig. 3) revealed a large barium-coated mass in the gastric pouch which was thought to represent a phytobezoar. Patient denied intake of oranges, figs, sauerkraut, or other similar foods. Findings were confirmed by cinefiuoroscopy. On gastroscopic examination (Fig. 4), a large
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Figure 3. Upper gastrointestinal series showing barium-coated mass.
Figure 4. troscopy.
Gastric camera photograph of bezoar as seen during gas-
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congealed mass of foreign material in the gastric pouch was visualized. The stoma was patent and of average size. After a 5 day trial of enzymes (Adolph's Meat Tenderizer), a gastrointestinal series revealed no change in the size or configuration of the mass. On April 30, 1968, gastrotomy was performed, and a large white mass with a thin-walled membrane was removed. This phytobezoar measured 5 x 7 cm. The content of the mass was not accurately determined. The patient's postoperative course was excellent, and he has had no further difficulty. He is edentulous. Case No.8 A 48 year old man who had had subtotal gastric resection in 1959, was admitted to this hospital in 1969, with mild digestive symptoms. A phytobezoar was visualized in the gastric stump on gastroscopic examination. After 5 days of therapy with Adolph's Meat Tenderizer via naso gastric tube, he was reexamined with the gastroscope, and no bolus was present. He was readmitted in 1971, complaining of postprandial epigastric pain. A gastrointestinal series and gastroscopic visualization confirmed the presence of another phytobezoar. Intake of the usual foodstuffs causing phytobezoar was denied. He was again treated with meat tenderizer. Two weeks later, another gastroscopic examination revealed that the bezoar was smaller, but still present. The patient refused surgical removal of bezoar. Case No.9 A 63 year old man had subtotal gastric resection in another hospital for "intractable" duodenal ulcer in 1965. Eighteen months later, because of a diagnosis of marginal ulcer and "high acid," a transthoracic vagotomy was done. The patient continued to have epigastric discomfort. In 1968, he was admitted to the hospital, complaining of epigastric pain and vomiting on occasion. A Hollander test revealed evidence of complete vagotomy. An upper gastrointestinal series revealed stomal stenosis and a questionable intragastric mass. At time of exploration, a 5 x 5 cm. phytobezoar was removed from the gastric pouch. It was composed of orange pith, apple peels, and pecans. He remembered eating fruit salad several weeks previously. The stomal stenosis was revised. His postoperative course was excellent.
FACTORS IN THE ETIOLOGY OF OBSTRUCTION The following factors influence the development of obstruction. Physical Characteristics of the Bolus In almost all instances the foods have been pulpy fruits or vegetables. These normally contain a large proportion of undigestible material, even after passage through a normal digestive tract. After an orange segment is broken and the juice is pressed out, there remains a fibrous mass similar to the original form and consisting mainly of segmented septa. A seg-
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ment in this state is easily swallowed. It is suggested that this segment moves rapidly through the stoma, progresses into the small intestine, and is reconstituted with intestinal juices and pectin. This probably accounts for the normal-appearing segments that are found as the obstructing mass in patients who have been operated upon.
Condition of the Chewing Mechanism As one studies the reported cases, the condition of the chewing mechanism was noted in only 46 patients. In approximately half the cases, the teeth were either in poor condition or the patients were edentulous and had ill-fitting dentures. Norberg,26 discussing this factor in his 28 cases, believed that the condition of the chewing mechanism was not as important as the eating habits. In our 9 cases, the chewing mechanism was considered adequate in 3 and poor in 6 cases. It would seem fair to conclude that incomplete mastication of the foodstuff would favor the formation of the bolus. This would seem to be especially true in the case of oranges.
Anatomy and Mobility of the Small Bowel Most surgical anatomists20 agree that the circumference of the small bowel is smallest at a site 50 to 75 cm. proximal to the ileocecal valve. Peristaltic waves are less forceful at this level. 19 This corresponds to the site of obstruction by the phytobezoar in most of the reported cases. It should be emphasized, however, that on occasions the phytobezoars are multiple; thus, the proximal bowel and stomach should be examined at time of surgery to rule out the possibility of another bolus being in transit. Loss of Pyloric Function Perhaps the most important factor in the occurrence of food bolus obstruction following gastric resection is the loss of pyloric function. The current concept 13 of the function of the pylorus envisions a mechanism that is different from that of the usual sphincter. There is evidence that the diameter of the pyloric aperture is directly related to the diameter of the antrum. Vigorous contraction of the antrum and simultaneous decrease of the pyloric aperture occur in response to a waye of gastric peristalsis.9 As the antrum contracts, the simultaneous decrease in the diameter of the pyloric aperture sharply limits the size of the food particles squeezed into the duodenum. This concept17 of pyloric control of the size of food masses passed from the stomach can explain why in most instances, in the intact stomach, masses of food large enough to obstruct the small bowel do not traverse the pylorus.
Interval Between Gastric Resection and Obstruction by Phytobezoar In the collected series of Schlang and McHenry,32 the greatest number of cases appeared in the interval of 5 to 10 years following gastrectomy. Norberg, in his series of 28 cases, found that the longest interval between gastric resection and obstruction by phytobezoar was 21
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years. 25 • 26 The shortest interval was 9 months. The average interval in Norberg's patients was 8.3 years. In the 9 cases presented here, the average interval was 5.8 years. Nature of Foodstuff Involved The orange has been by far the most frequent offending foodstuff. The obstructing bolus has been composed of orange segments in approximately 90 per cent of the documented cases. Other vegetable foodstuffs that have been involved are figs, apples, grapefruit, coconuts, beans, Brussels sprouts, potato peel, berries, and cabbage. With the exception of one macaroni bolus, the offending foods have been high in fiber content. Foods consisting largely of protein and carbohydrate have not formed bezoars. Presumably, the pancreatic and intestinal secretions reduce these materials to a digested state. It is of significance that in the comprehensive review by Ward-McQuaid39 of obstruction by phytobezoar in 178 patients who had not previously been subjected to gastric resection, the orange was the offending foodstuff in only 11 per cent of the cases. Citrus fruit (orange) was the offending foodstuff in 5 of the 9 cases presented here. In other cases, figs and apple peels were the foodstuff involved. In the remaining 2 cases, the mass was conglomerate, and it was impossible to accurately denote the involved fibers.
INCOMPLETE OBSTRUCTION It is interesting to speculate that there are perhaps varying degrees of obstruction due to food in the postgastrectomy state. Several authors1o • 32 suggest that such a situation does occur. These cases vary from transient colic to the impacted complete obstruction demonstrated by the 6 cases presented. It is significant that 2 patients in the collected series required surgery a second time because of obstruction due to food (orange), and in one of the presented cases, there was reformation of a phytobezoar after the initial one had been dissolved by enzymes. It is suggested that perhaps on occasions the bizarre symptoms of the post gastrectomy patient are the result of transient obstruction of the small bowel by incompletely digested food material.
DISCUSSION AND SUMMARY Although the clinical reports indicate that the diagnosis of acute intestinal obstruction in the post gastrectomy patient is not always simple, most of the patients with this disorder are readily determined to have obstruction and are properly managed. Norberg 26 stated that the preoperative diagnosis of phytobezoar obstruction was properly made in 6 of his 28 cases. Powley29 indicated that the correct preoperative diagnosis was entertained in 4 of the 9 cases that he reported. Preoperative diag-
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nosis was correctly made in 2 of our 6 cases of small bowel obstruction, and in the 3 cases of bezoars in the gastric pouch. This particular complication following gastric surgery should be a preventable cause of late morbidity. That this complication does occur is worthy of wide recognition. It would appear that insufficient attention has been given to the possibility of this complication after gastric surgery. The suggested sequence of events in the formation of phytobezoars has been indicated (Fig. 5). The patient cannot be expected to be aware of its possible occurrence unless he has been given clear and adequate instructions by his medical advisors. This increasing problem of food obstruction in patients who have had gastrectomy and in persons who have had vagotomy and drainage procedures should bring into sharp focus the necessity for clear and emphatic instructions to such patients to avoid fibrous foods, especially oranges, unless these foods can be finely chewed or mechanically minced prior to ingestion. The total elimination of oranges from the diet of these patients would eliminate 90 per cent of the instances of this late complication following gastric surgery. Printed and illustrated instructions (Fig. 6) are given to all patients who have been subjected to gastric surgery. These instructions denote to the patients the foods that they should avoid in the future.
GASTRIC SURGERY BILLROTH I AND II VAGOTOMY AND GASTROJEJUNOSTOMY VAGOTOMY AND ANTRAL RESECTION VAGOTOMY AND PYLOROPLASTY GASTROENTEROSTOMY
~
LOSS OF NORMAL PYLORIC FUNCTION LOW GASTRIC ACIDITY
+
INADEQUATE CHEWING MECHANISM
~
BOLUS OBSTRUCTION Figure 5.
Sequence of events in the formation of phytobezoars.
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o0
o 0
YOU HAVE RECENTLY HAD A SURGICAL PROCEDURE PERFORMED ON YOUR STOMACH.
YOU SHOULD SOON BE ABLE TO INCLUDE NEARLY ALL THE
FOODS YOU DESIRE IN YOUR DIET. HOWEVER, IT IS IMPORTANT THAT YOU SHOULD NOT EAT CERTAIN FOODS THAT YOU HAVE PERHAPS EATEN IN THE PAST.
EATING THE FOODSTUFFS
THAT ARE LISTED BELOW HAS BEEN FOUND TO RESULT IN BOWEL OBSTRUCTION (LOCKED BOWELS) AFTER ONE HAS HAD STOMACH SURGERY. ORANGES SHOULD BE ELIMINATED FROM YOUR DIET ENTIRELY. JUICE ONLY.
USE ORANGE
OTHER FOODS SUCH AS GRAPEFRUIT, FIGS, APPLES, STRING
BEANS, BRUSSEL SPROUTS, CABBAGE, BERRIES AND BAKED POTATO PEEL SHOULD BE AVOIDED UNLESS THEY ARE PROPERLY CHEWED OR MECHANICALLY MINCED . DIETETIC SERVICE, VA CENTER, TEMPLE, TEXAS Figure 6.
Instructions given to postgastrectomy patients.
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REFERENCES 1. Baumeister, C. F., and Darling, D. D.: Acute intestinal obstruction due to orange pulp bezoar. Ann. Surg., 126:251-252 (Aug.) 1947. 2. Binns, P. M.: Orange-bolus obstruction. Brit. Med. J., 2:710 (Sept. 9) 1961. 3. Bowen, F. H.: Obstruction of the small bowel due to boli of ingested coconut. A report of two cases. Amer. Surgeon, 22:1076-1078 (Nov.) 1956. 4. Butler, M. F.: Orange-pith ileus after partial gastrectomy. Brit. Med. J., 2:549-550 (Sept. 28) 1959. 5. Cain, G. D., Moore, P., and Patterson, M.: Bezoars-A complication of the post-gastrectomy state. Amer. J. Dig., Dis., 13:801-809 (Sept.) 1968. 6. Chenilleau and Laffitte: Deux cas d'occlusion gastrectomie. Bordeaus Chir., 2:87-88 (April) 1953. 7. Chun, J. J., and Dinan, j. J.: Small bowel obstruction due to phytobezoars in gastrectomized subjects. Canad. J. Surg., 8:272-275 (July) 1965. 8. Cohen, Y., and Heun, S. W.: Phytobezoar after gastrectomy. Brit. J. Surg., 58:236-239 (Mar.) 1971. 9. Davenport, H. W.: Physiology of the Digestive Tract. Chicago, Yearbook Medical Publishers, Inc., pp. 50-51,1961. 10. Davies, D. G., and Lewis, R. H.: Food obstruction of the small intestine. A review of 15 cases. Brit. Med. J., 2:545-548 (Sept. 26) 1959. 11. DeBakey, M., and Ochsner, A.: Bezoars and concretions; comprehensive review of literature with analysis of 303 collected cases and presentation of 8 additional cases. Surgery, 4:934-963 (Dec.) 1938. 12. Edelmann, G.: L'ileus alimentaire chez les gastrectomises. Arch. mal Appar. Dig., 50:657-661 (June) 1961. 13. Edwards, D. A. W.: Physiological aspects of the pylorus. Proc. Roy. Soc. Med., 54:930-933 (Nov.) 1961. 14. Elfving, G., and Scheinin, T. M.: Intestinal obstruction caused by ingested vegetables. Ann. Chir. Gynaec. Fenniae,42:178-183, 1953. 15. Fleming, J. P., and Ward-McQuaid, J. N.: Four unusual complications of partial gastrectomy. Australian New Zealand J. Surg., 20:73-78 (Aug.) 1950. 16. Hansbrough, E. T., and Lipin, R. J.: Intestinal obstruction due to food bolus following gastrectomy. Amer. Surgeon, 24:80-83 (Jan.) 1958. 17. Johnson, H. D.: The pylorus: Its functions and some surgical considerations. Proc. Roy. Soc. Med., 54:938-940 (Nov.) 1961. 18. Kott, I., and Urca, I.: Intestinal obstruction after partial gastrectomy due to orange pith. Arch. Surg., 100:79-81 (Jan.) 1970. 19. Latchmore, A. J. C.: Stomach-ache. Lancet, 1 :1153-1155 (June 29) 1940. 20. MacCarthy, D. F.: Intestinal obstruction by food. Lancet, 2:998-999, (Nov. 10) 1956. 21. McCabe, R., and Knox, W. G.: Phytobezoar in gastrectomized patients. Cause of small bowel obstruction. Arch. Surg., 86:264-266 (Feb.) 1963. 22. Manier, j. W.: Intestinal obstruction due to phytobezoar following gastric resection. Amer. J. Gastro., 39:48-51 (Jan.) 1963. 23. Moseley, R. V.: PylOriC obstruction by a phytobezoar following pyloroplasty and vagotomy. Arch. Surg., 94:290-291 (Feb.) 1967. 24. Nagel, G. W., and Bergera, J. J.: Phytobezoars occluding the smallintestine following subtotal gastrectomy. Amer. J. Surg., 99:318-319, (Mar.) 1960. 25. Norberg, P. B.: Intestinal obstruction due to citrus fruits after partial gastrectomy. Acta. Chir. Scandinav., 109:43-47, 1955. 26. Norberg, P. B.: Intestinal obstruction due to food. Surg. Gynec. Obstet., 113:149-152, (Aug.) 1961. 27. Oppolzer, R.: Phytobezoarileus nach Magen-resektion. Klin. Med., (Wien), 15:306-310 (July) 1960. 28. Personal communications. 29. Powley, P. H.: Bolus obstruction after partial gastrectomy. Brit. Med. J., 2:1392-1393 (Nov. 25) 1961. 30. Ribet, M., Fovet, A., and Guerrin, F.: Occlusion of the small intestine due to phytobezoars after gastrectomy (3 cases). Presse Med., 69:2610-2612 (Dec.) 1961. 31. Rigler, R. C., and Grininger, D. R.: Phytobezoars following partial gastrectomy. SURG. CLIN. N. AMER., 50:381-386 (Apr.) 1970. 32. Schlang, H. A., and McHenry, L. E.: Obstruction of the small bowel by orange in the postgastrectomy patient. Ann. Surg., 159:611-622 (April) 1964. 33. Seifert, E.: Ueber Krautileus. Deutsche Ztschr. f. Chir., 224:96-98,1930. 34. Smithwick, R. H., and Allen, A. W.: Presentation of a case. New Eng. J. Med., 226 :864-866 (Mar 21) 1942.
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35. Spurzem, R R, and Dresser, P. L.: Intestinal obstruction due to phytobezoar following gastric resection; report of 2 cases. Surgery, 42:493-495 (Sept.) 1957. 36. Stalker, L. K., and Gotham, I. J., Jr.: Small bowel obstruction due to a phytobezoar. New York State J. Med., 50:1614 (July) 1950. 37. Szemes, G. C., and Amberg, J. R: Gastric bezoars after partial gastrectomy. Radiology, 90:765-768 (Apr.) 1968. 38. Turney, J. P.: Orange-bolus obstruction. Brit. Med. J., 2:893-894 (Sept. 30) 1961. 39. Ward-McQuaid, N.: Intestinal obstruction by food. Lancet, 2:359 (Aug. 18) 1956. 40. Wee, G. E., Bond, L. F., and Calman, C. H.: Acute intestinal obstruction due to orange section bezoars following subtotal gastrectomy. Missouri Medicine, 60:437-439 (May) 1963. 41. Wilde, W. L.: Potato skin phytobezoars in edentulous gastrectomized patients: A growing clinical syndrome. Amer. J. Surg., 109:649-651 (May) 1965. Veterans Administration Center Temple, Texas 76501