Nicholette Goh, MBBS, Sunder Balasubramaniam, Wee Ming Tay, Mui Heng Goh. Tan Tock Seng Hospital
Instroduction: Gastrointestinal perforation from foreign bodies can lead to life threatening sepsis, and pose a significant challenge given the need to drain the septic source as well as safely extract the offending object.
Case Description: A 71-year-old Chinese lady presented with abdominal pain and constitutional symptoms without peritonitis or fever. A computed tomographic (CT) scan of the abdomen revealed two retroperitoneal abscesses with a 4 cm fishbone within (Image 1). The cavities were (5.8 by 2.4cm) and (10 by 7 cm) in size, one of which was surrounding the right external iliac artery. There was a visible connection from the third portion of the duodenum to the superior abscess cavity.
She underwent radiology-guided drainage of the collections, followed by a gastrograffin swallow which did not demonstrate an ongoing leak. Retrieval of the fishbone was first attempted endoscopically. This was done by placing a 5 mm laparoscopic port into the cavity to insufflate it with gas, followed by introduction of a flexible choledochoscope. Unfortunately, the bone could not be visualised, and the procedure was hence converted to open retroperitoneal approach via a 4 cm incision. The bone was successfully retrieved (Image 2), and a repeat CT done post-operatively showed near resolution of the abscess and complete removal of the fishbone. The patient was fit for discharge on the 4thpost-operative day.
Discussion: Intestinal perforation from the ingestion of a foreign body most commonly affects the colon and terminal ileum. If the perforation is intra-peritoneal, peritonitis usually results; however retroperitoneal perforations may seal off and hence present in a more insidious fashion.
To our knowledge, this is the first such report of retroperitoneal abscess due to a foreign body managed by minimally invasive techniques. Fluoroscopic extraction by the radiologist was considered in this case but deemed unsuitable due to the risk of fragmentation and having pieces left behind. The retroperitoneal approach combined with interventional radiology allowed us to avoid the morbidity of laparotomy and speed the patient’s recovery.
As expertise develops further, it is hoped that minimally invasive techniques like those used in retroperitoneoscopic adrenalectomy or pancreatic debridements can be used in such cases in the future. These can also be considered for trauma patients with projectile injuries who face a similar problem.
Conclusion: Multidisciplinary collaboration allowed for a novel method of extraction of a fishbone, and hence faster recovery than would be expected with traditional laparotomy and extraction.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94226
Program Number: P002
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster