Phytobezoars are retained concretions of indigestible food particles from fruits and vegetables that accumulate and conglomerate in the gastrointestinal tract and are most commonly found in the stomach.1–7 Etymologically, the word bezoar comes from the Persian word ‘padzahr’, meaning to expel poison.6
The first series published on gastrointestinal bezoars was based on patients who had not undergone any previous stomach surgery;8 however, after Norberg’s revision in 1956, the appearance of bezoars was reported more frequently in patients who had undergone previous surgery for gastroduodenal peptic ulcers and, thus, phytobezoars became a recognized sequela of this type of surgery.8
Historically, those with symptomatic bezoars tended to be post-vagotomy or -gastrectomy patients. Owing to the demographic change in gastric surgery (a decrease in vagotomies and an increase in bariatric surgery), we may see a shift in the type of patient who develops gastric bezoars.9
To our knowledge, bezoars that occur following sleeve gastrectomy are rare and have not been reported in the literature. However, owing to the rapid increase in the popularity of this operation, we expect more cases to be reported in the future.
We report the case of a 40-year-old man who underwent laparoscopic, vertical sleeve gastrectomy along the greater curve of the stomach as a result of morbid obesity (he had a body mass index of 42 kg/m2). He did not experience complications during the postoperative period, except for an initial bout of heartburn, but this responded to medical treatment with proton pump inhibitors and Gaviscon® (Reckitt Benckiser, Slough, UK).
The patient had a history of gastro-oesophageal reflux disease and the result of histopathological tests from the resected part of the stomach showed chronic non-active gastritis but was negative for Helicobacter pylori. However, after 90 days, the patient returned with a persistent heartburn and epigastric pain, for which he was admitted to hospital and an upper gastrointestinal endoscopy examination revealed a phytobezoar that was stuck in the antroduodenal area. This was treated by dismantling the phytobezoar and moving it towards the stomach (Figure 1), from which it was then removed piecemeal by snaring and using biopsy forceps for smaller fragments.
The postoperative period was uncomplicated and the epigastric pain faded, at which time the patient was discharged in a good condition and his follow-up results were normal.
The incidence of phytobezoars after gastric and bariatric operations is rare; however, it is a well-recognized entity. Bezoars are documented to occur after intragastric balloon insertions, adjustable gastric bandings and Roux-en-Y gastric bypasses, but bezoars of the small bowel are very rare2,7,13 and, to our knowledge, this is the first documented case of antroduodenal phytobezoar following laparoscopic sleeve gastrectomy.
Possible causative factors include a reduction in gastric acidity, peptic activity, poor gastric mixing and delayed emptying.4,14 Baunmann et al.15 studied motility changes after sleeve gastrectomy in a small group of patients using MRI and reported that the sleeve part of the stomach lacked propulsive peristalsis after the operation.15 However, another study with nuclear medicine techniques has demonstrated that gastric emptying remains unchanged following laparoscopic sleeve gastrectomy when the antrum is preserved.16 Another factor that affects gastric emptying is dietary changes, such as consuming more vegetable- and fruit-based food items, which is desirable for those who seek good results from their bariatric procedure. Some theories assume the need for a nidus for the bezoar to form and grow (e.g. a non-absorbable stitch); however, no such sutures were added to the line of stapling in our case.
The stomach is the most common site of bezoars in general,5 but they can occur in other parts of the gastrointestinal tract, such as the small bowel.2,17–19 Bezoars in the small bowel of patients with a history of gastric operations are mentioned in the literature19,20 and a history of previous gastric operations is one of the most common risk factors for the development of bezoars.2,6,21,22 Bariatric procedures may increase the incidence of bezoars in the small bowel owing to altered anatomy and physiology, which, in turn, may allow the progress of inadequately digested gut contents from the stomach to the small bowel.
The clinical manifestations of bezoars vary from asymptomatic to acute abdominal syndromes, e.g. epigastric distension, abdominal pain and acid regurgitation, depending on the location of the mass. In our case, the phytobezoar was found in the pyloric opening, with the greater part in the duodenum. The symptoms included heartburn and pain; however, it did not cause obstructive symptoms. Absence of obstructive symptoms could be partly due to the fluid nature of the diet consumed or the retractile (mobile) nature of the mass as it may have occasionally returned to the more spacious, triangular remnant of antrum.
Owing to the rarity of bezoars, it is usually an unexpected and surprising diagnosis. However, it must be emphasized that recurrent abnormal symptoms after bariatric operations should be investigated via endoscopy or imaging studies, e.g. contrast computed tomography (CT) or Gastrografin® (Bracco Diagnostics Inc., NJ, USA) meal, and followed up to rule out any mechanical problems. A study by Oh et al.18 reported that the use of abdominal CT was becoming more frequent and led to more accurate diagnoses and, therefore, earlier surgery for bezoar-induced small bowel obstructions, thereby reducing the rate of complications.18
Management of bezoars depends on their size, consistency, location and presentation. Some studies describe conservative methods to manage smaller phytobezoars, including changing to a liquid diet, gastric irrigation, chemical or enzyme dissolution [e.g. by using cellulase, acetylcysteine, papain or Coca-Cola® (Atlanta, GA, USA)];5,23–25 however, the success rates are variable. For larger bezoars, active intervention is advised and the aim should be to treat using the least invasive mode and to avoid surgery, if possible. Examples of such techniques include endoscopic fragmentation and removal, which can be combined with use of various types of snares, Dormia basket, mouse-teeth clamp, biopsy forceps or suction (endoscopic dissolution),5 or a minimally invasive method such as a laparoscopic approach, or a combination of both endoscopic and laparoscopic approaches, if necessary. Son et al.26 used a hybrid access surgery combining intragastric and single port surgery to avoid contamination of the peritoneal cavity.26
A Chinese study described a method of treatment that incorporated a laser mini-explosive technique through an endoscope which resulted in a high cure rate.27 Lithotripsy to fragment the bezoar has been mentioned in the literature5 but laparotomy should be reserved for patients presenting with complications such as perforation, bleeding or unresolved obstruction as well as significantly large, non-fragmental or inaccessible bezoars and used only if all other methods have failed.4,5,23,28 Recently, more gastroenterologists and surgeons have been able to deal with bezoar-related complications endoscopically or laparoscopically.
Coexisting bezoars can occur and, consequently, when a gastric or intestinal bezoar is diagnosed, the possible presence of coexisting bezoars elsewhere should be cautiously investigated.6