Shadi Al-Bahri, MD, Esther Cha, MD, Gregory B Burgoyne, MD. MedStar Union Memorial Hospital
Introduction:
With any abdominal surgery in a difficult abdomen, the procedure is filled with potential hazards. In addition to a prolonged operative time, there is a risk of enterotomy or damage to blood vessels and ureters. An irradiated pelvis increases this risk and may cause additional morbidity such as delayed healing. An impacted foreign body can also be a challenging problem to deal with alone but when combined with a difficult abdomen can make the problem impossible.
Case report:
A 67 year-old male presented with a small bowel obstruction and CT scan imaging revealed a foreign body impacted in the ileum approximately 20 cm proximal to the ileocecal valve. The patient had a history of prostate cancer with radiation to the pelvis and thereafter developed perforated diverticulitis, requiring Hartmann’s colostomy. Later he underwent a colostomy take-down but developed wound infection and dehiscence resulting in an incisional hernia which was repaired. The patient was treated conservatively with NGT decompression but the foreign body did not move and operative intervention was undertaken. Due to the extensive scarring of his midline abdomen, a right sided transverse incision was used to retrieve the foreign body. An appendectomy was performed to avoid return into the abdomen and an attempt was made to insert the colonoscope was inserted through the appendostomy but this was unsuccessful. An enterotomy was made in the terminal ileum and the endoscope was advanced to the foreign body which was retrieved with a snare. The foreign body was found to be a 3.5 cm piece of bone. There was mucosal ulceration but no evidence of perforation. The patient tolerated the procedure well, and diet was resumed upon return of bowel function. There were no post-operative complications.
Discussion:
Foreign body ingestion is a rare cause of small bowel obstruction, and exploration and retrieval is recommended if the obstruction does not resolve or if the bowels perforate. The method of retrieval depends on the site of the foreign body. Upper endoscopy can be used proximally. Colonoscopy can be used for colonic foreign bodies. Fortunately, in the small bowel, the terminal ileum is the narrowest part and most likely the site of impaction. Operative retrieval is easier if there are no prior abdominal interventions. An irradiated pelvis or abdomen, multiple prior procedures and a frozen abdomen warrant an alternative approach. As it can be difficult or impossible to access the ileum using a colonoscope transanally, a limited right-sided transverse incision can be employed through virgin territory allowing immediate access to the cecum and terminal ileum through which endoscopic retrieval could be performed. A review of the literature to date did not yield any other descriptions of this approach for foreign body retrieval, however, an appendostomy and endoscopy to rule out malignancy in patients with right sided diverticulitis has been documented.
Conclusion:
Consideration should be given to foreign body retrieval through an appendostomy or ileostomy if a midline laparotomy is considered too high risk in the setting of pelvic irradiation and multiple prior abdominal surgeries.