Introduction
A trichobezoar is a rare medical condition that is often difficult to treat medically.
In particular, giant gastric bezoars may be treated by highly invasive therapy, such
as open surgery [1]. We describe our experience with a patient in whom we successfully extracted a giant
gastric trichobezoar in a minimally invasive fashion by laparoscopic and endoscopic
cooperative surgery (LECS), performed in accordance with the principles of LECS [2], and we discuss the related literature.
Case report
A 32-year-old woman presented with abdominal pain. The patient had received oral medical
therapy for a diagnosis of schizophrenia since the age of 20 years. Since the diagnosis
of schizophrenia, the patient had had a habit of eating her hair. Abdominal pain persisted
for several months, and the patient consulted a local physician. A mass was palpated
in the abdomen, and computed tomography of the abdomen revealed a giant foreign mass
in the stomach. The patient was referred to our hospital for further evaluation and
treatment. With the exception of schizophrenia, her medical history was not relevant
to the current disorder.
Considering her family history, the patient’s mother had a history of gastric cancer.
With regard to her lifestyle history, as mentioned above, the patient had a habit
of eating her own hair since the diagnosis of schizophrenia. At initial presentation,
her height was 150 cm, and body weight was 40 kg. The palpebral conjunctivae were
not anemic. The abdomen was flat and soft. A mass was palpated in the lower abdomen.
There was no spontaneous pain or tenderness.
Blood biochemical examinations showed no clinically significant abnormal findings.
An upper gastrointestinal series ([Fig. 1]) revealed a giant mass composed of foreign matter, measuring about 290 × 100 mm,
and associated with calcification. The mass occupied a large portion of the stomach.
The flow of contrast media into the duodenum was good. Upper gastrointestinal endoscopy
([Fig. 2]) confirmed the presence of a giant gastric trichobezoar extending from the gastric
cardia to the gastric angle.
Fig. 1 Upper gastrointestinal series, showing a giant mass consisting of foreign matter,
measuring about 290 × 100 mm. The mass was associated with calcification and occupied
the entire stomach.
Fig. 2 Upper gastrointestinal endoscopic images. a A giant trichobezoar was present in the stomach. b A giant gastric trichobezoar was confirmed in the region extending from the gastric
cardia to the gastric angle.
Clinical course
A giant gastric trichobezoar was diagnosed on the basis of the findings described
above. The giant gastric trichobezoar occupied the entire stomach, and endoscopic
removal was considered difficult. We consulted a surgeon in our hospital and decided
to perform laparoscopic and endoscopic cooperative surgery (LECS) to remove the gastric
bezoar as shown in [Supplementary Video 1]. An incision was made in the umbilical region, and a Lap Protector Type S wound
retractor (Hakko Medical, Nagano, Japan) was inserted. After the gastric wall had
been incised, the Lap Protector S was removed. The gastric wall and skin of the abdominal
wound were secured with four supporting sutures, and the Lap Protector S was reinserted
to secure the area between the intra-stomach and the skin after incision of the anterior
of the stomach within the wound. An access port (E·Z Access, Hakko Medical) was mounted
on the Lap Protector and three 5-mm ports were placed in the E·Z Access to allow laparoscopic
and endoscopic examinations. The Lap Protector Type S is a small-type wound retractor
that requires a skin incision of 20 to 30 mm, and the E·Z Access is a silicon port
for the Lap Protector that makes it possible to insert multiple trocars without air
leakage.
Supplementary Video 1 Video illustrating laparoscopic and endoscopic cooperative surgery (LECS) to extract
a giant gastric trichobezoar.
The entire gastric trichobezoar was examined by both oral endoscopy (GIF-Q260 J, Olympus
Corporation, Tokyo, Japan) and laparoscopy, and the mass was sliced thinly using grasping
forceps and a scalpel for laparoscopic use that were inserted via the endoscope port.
After the gastric trichobezoar had become somewhat smaller, it was pulled out through
the Lap Protector S after removing the E·Z Access port. The absence of a remnant bezoar
was confirmed, and the incision in the gastric wall was sutured to complete the operation
([Fig. 3]).
Fig. 3 Intraoperative endoscopic findings. a A gastric trichobezoar was confirmed on endoscopy. b An E·Z Access was mounted on the Lap Protector, and three 5-mm ports were placed
in the E·Z Access to allow laparoscopy and endoscopy. c The use of endoscopic insufflation allowed the field of surgical vision to be secured.
d The bezoar was resected laparoscopically with the support of endoscopic forceps.
e The absence of remnant bezoars was confirmed, and the incision in the gastric wall
was sutured to complete the operation.
Discussion
A gastric bezoar is a foreign body resulting from the accumulation of orally ingested
food, hair, and other materials in the stomach. Bezoars can be broadly classified
as phytobezoars (fruit, etc.), trichobezoars, drug bezoars, and mixed bezoars according
to their main components [3]. Gastric trichobezoars are particularly common in adolescent women who have a habit
of eating their hair and should be removed because they carry the risks of gastric
ulceration and intestinal obstruction. Treatment options for gastric trichobezoars
include medical therapy (non-endoscopic treatments such as Coca-Cola dissolution therapy
[4], electrohydraulic lithotripsy [5], laser irradiation [6], extracorporeal shock wave lithotripsy, and endoscopic treatments in which stones
are crushed mechanically using a forceps and other instruments) and surgical therapy
(open abdominal surgery and laparoscopic surgery to remove gastric bezoars [7]
[8]
[9]). Medical therapy, particularly endoscopic treatment, has the drawbacks of difficulty
in securing a working space and treating giant gastric bezoars. On the other hand,
surgery carries the risks of scattering the gastric contents in the peritoneal cavity
and is a relatively invasive procedure, associated with a large surgical wound and
other negative factors.
To overcome the disadvantages of conventional treatments, we simultaneously performed
laparoscopic and endoscopic surgery in accordance with the principles of LECS to treat
the gastric bezoar. We searched PubMed, and found no study documenting the removal
of gastric bezoars by laparoscopic and endoscopic surgery in accordance with the principles
of LECS. Only one such patient was described in Gastroenterological Endoscopy, the official journal of the Japan Gastroenterological Endoscopy Society [10]. That report described a gastric bezoar measuring about 100 mm in diameter that
was attempted to be treated by endoscopic lithotripsy and Coca-Cola dissolution therapy,
but did not respond. LECS was therefore performed to remove the gastric bezoar. The
concurrent use of endoscopy is useful in patients who undergo laparoscopic surgery
to treat giant gastric bezoars.
In our case, the use of endoscopy allowed the entire gastric bezoar to be viewed and
the supportive use of insufflation and forceps allowed the gastric bezoar to be removed
more safely and reliably than was previously possible. LECS is therefore considered
to be a useful treatment for giant gastric bezoars and is likely to become a treatment
option in the future.
