Laparoscopic intragastric removal of giant trichobezoar.

Abstract

Gastric bezoars are a rare clinical entity, most commonly observed in patients with mental or emotional illness. Large bezoars can be difficult to remove laparoscopically without extending a port incision.
We report the case of a large symptomatic trichobezoar with Rapunzel syndrome that occurred in a 17-year-old girl who had trichotillomania.
The bezoar was removed laparoscopically, in piecemeal fashion, through a gastrotomy port. This procedure did not require an extension of any incision, nor did it require the contents of the stomach to directly touch the incision, thereby reducing the risk of infection. The patient was discharged home, on the fourth postoperative day, free of any complications.
This case illustrates the safety of the laparoscopic approach in the removal of large gastric bezoars. In considering use of this approach, the potentially long operative time must be weighed against the benefits of both minimal risk of infection and minimal incisions.

Full text

Page 1

Laparoscopic Intragastric Removal
of Giant Trichobezoar
Harry F. Dorn, MD, John L. Gillick, BS, Gustavo Stringel, MD
ABSTRACT
Background and Objectives: Gastric bezoars are a rare
clinical entity, most commonly observed in patients with
mental or emotional illness. Large bezoars can be difficult
to remove laparoscopically without extending a port inci-
sion.
Methods: We report the case of a large symptomatic
trichobezoar with Rapunzel syndrome that occurred in a
17-year-old girl who had trichotillomania.
Results: The bezoar was removed laparoscopically, in
piecemeal fashion, through a gastrotomy port. This pro-
cedure did not require an extension of any incision, nor
did it require the contents of the stomach to directly touch
the incision, thereby reducing the risk of infection. The
patient was discharged home, on the fourth postoperative
day, free of any complications.
Conclusion: This case illustrates the safety of the laparo-
scopic approach in the removal of large gastric bezoars. In
considering use of this approach, the potentially long
operative time must be weighed against the benefits of
both minimal risk of infection and minimal incisions.
Key Words: Trichobezoar, Gastric outlet obstruction, Ra-
punzel syndrome, Trichotillomania.
INTRODUCTION
Trichobezoars are a rarely encountered late complication
of trichotillomania, a disease characterized by the uncon-
trollable urge to pull out one’s hair. Occasionally, patients
with this disease also have trichophagia, resulting in hair
accumulation within the stomach and intestine. They can
present with abdominal pain, loss of appetite, weight loss,
and vomiting. After long periods of time, these patients
can present with trichobezoar-induced bowel or gastric
outlet obstruction. In the present report, we describe the
case of a large gastric trichobezoar that was successfully
removed laparoscopically and review the findings that led
to this course of treatment.
CASE REPORT
A 17-year-old girl presented with a sharp, epigastric
pain. She said she had the pain for 3 weeks, and that it
had gotten especially worse during the 5 days prior to
admission. The patient denied any nausea, vomiting, or
hematemesis. She also denied fever, chills, or any sick
contacts. She said that she had been having normal
bowel movements. However, she had noticed a de-
creased frequency over the past 3 weeks. She also
complained of decreased appetite with weight loss of
approximately 10 pounds during this time. Review of
systems was otherwise unremarkable. Her past medical
history was only remarkable for migraines, for which
she took sumatriptan as needed. Her surgical history
included a distal pancreatectomy in 2000 after a bicycle
accident. She denied any psychiatric history and had no
known history of mental illness.
On physical examination, she did not demonstrate obvi-
ous hair loss. Her abdomen was mildly tender in the
epigastric region with more pain in the left upper quad-
rant than the right. She also displayed mild guarding in the
left upper quadrant. Laboratory values were all within
normal limits. Abdominal computed tomography (CT) re-
vealed heterogeneous material in the lumen of the stom-
ach, suspicious for a bezoar, measuring over 10cm within
the lumen (Figures 1 and 2). An ultrasound revealed
gastric outlet obstruction caused by a large echogenic
mass.
Division of Pediatric Surgery, Department of Surgery, Maria Fareri Children’s
Hospital, Westchester Medical Center, New York Medical College, Valhalla, New
York, USA (all authors).
Address correspondence to: Gustavo Stringel, MD, Division of Pediatric Surgery,
Department of Surgery, Maria Fareri Children’s Hospital, Westchester Medical
Center, New York Medical College, Valhalla, NY 10595, USA.
DOI: 10.4293/108680810X12785289144520
© 2010 by JSLS, Journal of the Society of Laparoendoscopic Surgeons. Published by
the Society of Laparoendoscopic Surgeons, Inc.
JSLS (2010)14:259–262
259
CASE REPORT

Page 2

The patient was first brought to the operating room for an
upper endoscopy, where the bezoar was visualized. The
mass extended to the pylorus with possible obstruction of
the gastric outlet. Over a 6-hour period, ?10% of the
bezoar was removed. Pediatric surgery was then con-
sulted. The patient returned to the operating room on the
second day of admission. Three laparoscopic ports were
created: 5mm (umbilical), 5mm (left lower quadrant), and
12mm (left upper quadrant). The adhesions between the
stomach and peritoneum were lysed, and 2 stay sutures
were applied to the stomach through the greater curva-
ture. A gastrotomy was then performed by inserting a
blunt trochar into the stomach, inflating a gastric balloon,
and pulling the balloon against the stomach wall, creating
a 10-mm intragastric port (Blunt Tip Trocar, United States
Surgical, Tyco, Norwalk, Connecticut (Figure 3). Carbon
dioxide was then pumped into the stomach to create 4mm
Hg pressure. Dark hair was found in the stomach in many
clumps (Figure 4). Using the working scope, the hair was
removed in pieces (Figure 5). The duodenum was then
entered, demonstrating Rapunzel syndrome. After com-
plete removal of the bezoar, the gastrotomy was closed
with an endostapling device. Total operation time was
approximately 6 hours.
Postoperatively, the patient was placed on a nasogastric
tube and fed nothing by mouth. On the fourth postoper-
ative day, the patient tolerated a regular diet and was
discharged home. The patient’s postoperative course was
free of complications. An inpatient psychiatric evaluation
revealed only a guarded and hesitant patient who denied
any hair eating. She admitted only to hair-biting, nail-
biting, and some insomnia. She admitted to seeing a
psychologist 1 to 2 times per week over the last 2 years. It
was recommended that she see an outpatient clinician on
an intensive basis, and subsequently she was diagnosed
with nonspecific anxiety disorder “NOS.”
Figure 1. Axial computed tomography demonstrating bezoar
obstructing entire lumen of stomach.
Figure 2. Axial computed tomography demonstrating gastric
bezoar in lumen of stomach with extension to duodenum.
Figure 3. Intraoperative photograph demonstrating gastrotomy
with stomach apposed to abdominal wall.
Laparoscopic Intragastric Removal of Giant Trichobezoar, Dorn HF et al.
JSLS (2010)14:259–262
260

Page 3

DISCUSSION
Trichobezoars are most commonly associated with tricho-
tillomania. In this psychiatric disorder, patients recurrently
pull out their own hair. The patients experience an in-
creasing sense of tension immediately before pulling out
the hair or when attempting to resist the behavior. The
feeling of tension is followed by a sense of gratification
after pulling out the hair. This behavior cannot be ac-
counted for by another disorder, and causes significant
impairment.1Trichotillomania affects about 1% of the
population. One third of these patients have trichophagia,
and 1% of these patients eat enough hair to require sur-
gery.2The first reported case of trichobezoar was de-
scribed by Baudamant in 1779,3and the first successful
surgical removal was performed by Schonborn in 1885.4
The clinical presentation of a trichobezoar is usually that
of a gastric outlet or bowel obstruction, although most are
found in the stomach. Patients experience epigastric pain,
nausea, vomiting, and loss of appetite. Obstruction can
result if the mass is allowed to enlarge. Uncommonly,
Rapunzel syndrome can occur in which a tail of hair
extends from the stomach to the small intestine, or from
the small intestine in the colon.5Past accepted treatment
modalities have included observation, dissolution, frag-
mentation, or surgery. The surgical approach could either
be laparoscopic or open.
In a retrospective study conducted by Yau et al,6the
laparoscopic approach was shown to have better post-
operative outcomes. The authors took all patients with
bezoar-induced small bowel obstruction and divided
them based on either open or laparoscopic surgery. The
patients treated laparoscopically had fewer complications,
shorter hospital stays, and shorter times for return of
bowel function. Therefore, if possible, the laparoscopic
approach should be pursued.
Several authors have described a laparoscopic approach.
Nirasawa et al7described using an 8-cm laparoscopic
gastric incision, placing the bezoar in a plastic bag, and
then removing it through a suprapubic minilaparotomy.
However, the authors acknowledged that hair and gastric
juice were spilled and retrieved. This method poses 2
risks. First, spillage of the bag contents could lead to an
intraabdominal infection; and second, the incision itself
could be contaminated, leading to wound infection. In
addition, an 8-cm incision is a sizeable incision within the
gastric wall.
Kanetaka et al8used a 2-channel laparoscopic approach,
in which a gastric incision of 1cm was made, and the
bezoar was then fragmented using laparoscopic scissors.
The fragments were then retrieved using gastroscopy. As
Song et al9pointed out, it is difficult to fragment the
bezoar with laparoscopic scissors. Setting up gastroscopy
in the same operating room also poses a logistical chal-
lenge.
Shami et al10described making 3 laparoscopic ports fol-
lowed by a longitudinal anterior gastrotomy. The bezoar
Figure 4. Intraoperative photograph demonstrating tricho-
bezoar in lumen of stomach.
Figure 5. Total gastric trichobezoar removed. Ruler shown is
15 cm.
JSLS (2010)14:259–262
261

Page 4

was then placed in a tissue retrieval bag. The bag was
brought to the exterior through a 4-cm extension of one of
the ports. The bezoar was fragmented within the bag, and
retrieved in piecemeal fashion. The abdominal cavity was
then washed out. Song et al9described a similar approach
in which a gastric incision was made laparoscopically. The
bezoar was then placed in a laparoscopic retrieval Endo-
bag. The opening of the bag was then externalized so the
bezoar could be fragmented within the bag. Once frag-
mented, the bezoar was then extracted within the bag
through the incision.
Both of these techniques attempt to minimize the possi-
bility for contamination of the field by gastric contents.
However, as described in Shami’s case, wound infections
can still occur. Although the contact is minimized, there is
still a risk of gastric spillage and contamination. Moreover,
with respect to all of these approaches, the efficacy is
limited by the size of the bezoar. We surmise that it would
be difficult to manipulate a large bezoar into a bag and
then fragment it.
CONCLUSION
Our approach involved a completely laparoscopic resec-
tion and removal of the bezoar, without exposing the
abdominal cavity to the stomach contents. By securing the
stomach to the abdominal wall, then creating an intragas-
tric port, the risk for contamination was minimized. How-
ever, this approach too is limited by size. Since the bezoar
was so large, and only piecemeal removal was possible,
operating time was long. In choosing an approach, the
anesthesia time and the patient’s ability to tolerate it, in
addition to possible surgeon fatigue, must be weighed
against the benefits of both minimal risk of infection and
minimal incisions in the abdomen and stomach.
References:
1.
Washington, DC: American Psychiatric Association, 2000.
Diagnostic and statistical manual of mental disorders. 4th ed.
2.
punzel syndrome. Am J Psychiatry. 2005;162:242–248.
Frey AS, McKee M, King RA, Martin A. Hair apparent: Ra-
3.
l’estomac et dans les intestines gre ˆles. J Med Chir Pharm. 1779;
52:507–514.
Baudamant WW. Memoire sur des cheveux trouves dans
4.
unusual complication of trichobezoar. Mt Sinai J Med. 1972;39:
293–299.
Beck AR, Kim SK. Multiple small bowel perforations: an
5.
Simultaneous gastric and small intestinal trichobezoars—a hairy
problem. J Pediatr Surg. 2006;41:1495–1497.
Hoover K, Piotrowski J, St. Pierre K, Katz A, Goldstein AM.
6.
Laparoscopic approach compared with conventional open ap-
proach for bezoar-induced small-bowel obstruction. Arch Surg.
2005;140:972–975.
Yau KK, Siu WT, Law BK, Cheung HY, Ha JP, Li MK.
7.
Laparoscopic removal of a large gastric trichobezoar. J Pediatr
Surg. 1998;33:663–665.
Nirasawa Y, Mori T, Ito Y, Tanaka H, Seki N, Atomi Y.
8.
K, Kanematsu T. Two-channel method for retrieval of gastric
trichobezoar: report of a case. J Pediatr Surg. 2003;38:e7.
Kanetaka K, Azuma T, Ito S, Matsuo S, Yamaguchi S, Shirono
9.
of gastric bezoar. Surg Laparosc Endosc Percutan Tech. 2007;
17:42–44.
Song KY, Choi BJ, Kim SN, Park CH. Laparoscopic removal
10. Shami SB, Jararaa AA, Hamade A, Ammori BJ. Laparoscopic
removal of a huge gastric trichobezoar in a patient with
trichotillomania. Surg Laparosc Endosc Percutan Tech. 2007;
17:197–200.
Laparoscopic Intragastric Removal of Giant Trichobezoar, Dorn HF et al.
JSLS (2010)14:259–262
262