A modified technique for the laparoscopic management of large gastric bezoars

Discussion

Bezoars are divided into 5 groups according to their content; phytobezoar, tricobezoar, lactobezoar, medication bezoar, and bolus food. The incidence of bezoar is 0.4%.4 Decreased acid secretion, gastroparesis, and gastric outlet obstruction facilitate bezoar formation. Also, inadequate chewing of food, which is difficult to digest, may influence bezoar formation.5 Most common predisposing factors are diabetic gastroparesis and gastric dismotility after surgery.5 Mostly vagotomy, pyloroplasty, and in a lesser extent antrectomy may lead to bezoar formation. It can also occur without any predisposing factor by eating hair or too much palm.3 Some series reported prior abdominal surgeries and co-morbidities as the leading cause of bezoar formation, and some series proposed ineffective chewing of food in patients with dental problems as the key point in bezoar formation.6 Our patient did not have any prior abdominal surgery, but she had bad oral hygiene and dental problems. Stomach and small bowel ulcers and perforations, chronic GI bleeding, intussusceptions, obstruction, pancreatitis, cholangitis, anemia, and malnutrition are among their complications and can cause mortality up to 30%.6,7 The case we present had early satiety, vomiting, weight loss, anemia, hypoalbuminemia, and gastric ulcer. The diagnosis is established via GI endoscopy, GI contrast study, or computerized tomography.8 Enzymatic and gastric motility increasing agents are among the medical treatment options. As a medical treatment modality, some authors used Coca-Cola for small gastric phytobezoar and reported that up to 23-50% of bezoar can be dissolved.1 Gastrointestinal endoscopy is a golden standard in the diagnosis and treatment of small gastric bezoar. For this purpose, water jets, forceps, lithotripters, and baskets are used for gastroscopic fragmentation. This treatment depends on the composition and size of the bezoar and the experience of the clinician. In case of failure with medical and GI endoscopic treatment options, surgery is conceivable.3,5 Laparoscopy providing smaller incision, less postoperative pain, and better cosmetic results, is an alternative method to conventional open surgery. However, there is a risk of spillage and peritoneal contamination due to the use of endobag placed in the peritoneal cavity. In the technique we used, since the endobag is inserted through the gastrotomy and opened in gastric lumen, and the bezoar is put into the endobag inside the stomach, spillage and contamination of peritoneal cavity is expected to be negligible. Limitations of this technique for large gastric bezoars are, the need for experienced laparoscopic surgeons, location, and adhesions of the bezoar inside the stomach. The size of the endobag used, sets the limits for the size of bezoars, which can be removed by this technique. Hybrid techniques in which laparoscopy and laparotomy are used concomitantly with an aim to prevent peritoneal contamination have been reported in the literature. The modification suggested by Tudor and Clark9 is a technique in which stomach is sutured to the anterior abdominal wall and a device is used to minimize peritoneal contamination. Son et al,10 described a method where they used one port to make the gastrostomy and closed it extra corporeally by using staplers. They reported less contamination. There are some differences between authors in applying the technique, but there is no evidence supporting one technique to be better than the other. Gastrostomy can be closed either intra or extra corporeally and both with stapler or suture.2,3 These combined techniques are excellent for giant bezoars, which are very difficult to remove by the traditional laparoscopic technique. On the other hand, these techniques have more complications and the duration of the operation is longer than the technique we proposed (3.5 versus 2 hours). Therefore, we think that these hybrid techniques should be used only for the removal of giant bezoars. For the smaller bezoars, which are not suitable for GI endoscopic removal, our technique would be a better option.

In conclusion, we believe that laparoscopy is a safe and reliable procedure in bezoar treatment without the need of an additional abdominal incision, except for the giant bezoars. In the technique we used, contamination is expected to be less, since the bezoar is put into the endobag placed in the stomach instead of the peritoneal cavity. The main disadvantage of this technique is the inapplicability for giant bezoars. Furthermore, it is difficult to use it in the removal of intestinal bezoars. Prospective studies are necessary to determine optimal treatment strategies for different kinds of bezoars in different locations.