Surgical Management of Intestinal Obstruction from Phytobezoar

Abstract

Purpose: Phytobezoar is the most common type of bezoar, which can occasionally present as an intestinal obstruction. In this study, the surgical experience and outcome in the management of intestinal obstruction caused by bezoars are described. Methods: A retrospective analysis of all operative cases of bezoars (n = 36) at Khoo Tech Puat hospital between 2011-2017 was performed. Patient demographics, imaging and operative findings, characteristics of bezoars and related morbidities were analyzed. The study population was subdivided into 2 groups based on operative intervention (fragmentation and milking of bezoars, versus enterotomy and/or bowel resection). Results: There were 36 cases of bezoars in 35 patients that were included in this study. Computed tomography scans were diagnostic of bezoars in 27 cases (75%). There were 20 cases (55.6%) that underwent fragmentation and milking of bezoars. The remaining 16 cases (44.4%) required an enterotomy or bowel resection. Bezoars that required enterotomy / bowel resection were more likely to be distally located in the ileum (75% vs 40%, p = 0.01), larger in volume (86.5 mL vs 63 mL, p = 0.04), with significant increase in morbidity rates (43.8% vs 5%, p < 0.01) compared with all other cases of bezoars. Conclusion: Risk factors for enterotomy / bowel resection in bezoar bowel obstruction include, nondiagnostic computed tomography scans, distally located, and larger volumes of bezoars. Fragmentation and milking should be attempted first as it has lower morbidity rates than enterotomy / bowel resection surgery.

Small bowel obstruction secondary to phytobezoar in a patient with myotonic dystrophy

“…Treatment of bezoars is dependent on their location within the GI tract. For gastric bezoars, these include chemical dissolution of the bezoar with coca-cola, endoscopic removal or surgery 9 11 12 28. Historically, surgery for gastric bezoars has been via laparotomy,28 however recent literature describes successful laparoscopic surgical techniques to remove gastric bezoars 11…”

“…Intestinal bezoars causing obstruction require surgery for removal 9 28 29. Paschos et al describe a case series including four patients, all with SBO from ileal bezoars, who underwent laparotomy and successful removal of bezoar 29.…”

Bezoar-induced small bowel obstruction: a rare cause of a common problem

“…demonstrated that those with large volume bezoars (5.3 cm length and 3.7 cm length) and those with higher density bezoars on CT scan were independent risk factors for requiring surgical intervention [ 2 ]. When surgery is needed, the most common operations performed are partial small bowel resection if there is concern for bowel compromise, enterotomy with bezoar extraction, or milking the stone toward the ileocecal valve [ 2 , 10 ]. Furthermore, it is possible to fragment the stone while it remains intraluminal and milk the fragments forward [ 6 ].…”

Shiitake Mushroom as a Cause of Bowel Obstruction

“…Surgery is the standard treatment for small bowel obstruction due to bezoar (10). Generally, the bezoar is impacted in the narrowest segment of the small bowel, which is at the terminal ileum, just proximal to the ileocecal valve.…”