Tuesday, November 13, 2007

no, doc. here's what happened

It all started out simply enough. Middle aged guy with some right lower quadrant abdominal pain and acute appendicitis on CT scan. It was going on for a little longer than one would expect for appendicitis -- 3-5 days -- but CT scans don't lie with appendicitis, right? He had a white count, but no fever. This semi-confusing picture wasn't enough to convince my attending to come in and take this guy's appendix out in the middle of the night. Admit for observation and serial exams were my instructions.

The next morning, the white count had improved thanks to a little Vitamin Z (zosyn) but he had point tenderness with rebound in the right lower quadrant. Surgical abdomen = surgery. I'm a big fan of the laparoscopic approach in men or women just because of the better field of vision, so we started there.

Once we had the camera intraperionteally, it seemed like his *entire* omentum was simply plastered to the cecum. No 15 minute appy for me. Oh well. So I gingerly start trying to peel away all this fat from the inflamed area. I'm working slowly, because the last thing I want is a hole in the bowel or some bleeding. A few minutes later, I see what looks like a piece of hay sticking right out of the colon.

"Sh*t. Is that really what I think it is? I'm not sure. Best not to say anything yet."

I keep working, and the piece of hay gets bigger and bigger. Except it's not a piece of hay. It's a freaking toothpick.

"Uh, Dr. Jones, I think there is a toothpick sticking out of the cecum. We should open."

"Let's pull it out first!"

I was screaming "NO!" in my head, while simultaneously having visions of feces come flooding out of the hole where the toothpick once was. But instead, I managed to suggest that we open first and then remove the foreign body under more controlled circumstances.

I won, thank goodness. So we made an extended Rocky-Davis incision and pulled up the cecum. The appendix was normal, of course. But about 3cm distal to the ileocecal valve was a *whole* toothpick. We removed it and inspected the damage. The cecostomy was only about 3mm wide, so we closed it with a few stitches, tacked a piece of epiploic fat over it and called it a day.

When I checked on the patient later, I asked him how it came to pass that he had swallowed a whole toothpick and when he thought it might have happened.

"No, Doc. Here's what happened," was how he began his story. Three weeks before the surgery, he was with his buddy and they were doing some fishing. They had reeled in some catfish earlier and his friend had cooked some and made little sandwiches out of it. He was ravenous and started wolfing down the sandwiches, probably not chewing much since he only had like 5 teeth to call his own. In the middle of his sandwich, his buddy informs him that there were toothpicks in the sandwich to hold it all together. Let me tell you, he was mighty pissed at his friend at that point.

After his story, I tried to find some other case reports involving ingestion of toothpicks and GI perforation. They usually perforate in the pylorus or duodenum. The amazing thing about this case was that it not only got past that area, but it made it through all 30 feet of small intestine, *through the ileocecal valve* and perforated in the cecum, which is the largest diameter structure in the alimentary tract aside from the stomach.


surg resident said...

Just saw a case of a jejunal perforation from a toothpick. I agree that is amazing that it got so far in.

Jeffrey said...

very interesting, but a lil wierd.
pleas submit this to SurgeXperiences.

the theme this week is "the wierd..." and i think your article fits it exactly. :)

Bongi said...

i have twice removed chicken bone fragments from the rectum. can't seem to get past the anal sphincter

Sid Schwab said...

Mine was a chicken bone in the sigmoid, presenting like a perforated 'tic. People with dentures are at increased risk, being less able to sense the presense until it's too late.

When I admitted r/o appy-type patients, I usually didn't begin antibiotics until I felt I knew more about what was going on. Muddies the waters, I think, at least sometimes.

Buckeye Surgeon said...

I had a toothpick in jejunum last year. Question: Why did you have to open? No fecal contamination. Potentially could have did everything laparoscopically, no?

lights n steel said...

We could have, and I would have loved to. But my attending was barely comfortable doing a lap appy, let alone something else more complicated. He's pretty old school and is primarily a vascular surgeon. I could have probably closed the hole primarily laparoscopically, but we didn't have access to an endo-stitch device that I'm used to using. I don't tie knots with a knot pusher all that well. Plus, we were worried that if we pulled out the toothpick a whole lotta fecal material would be quick to follow...

Kellie said...

I had a toothpick in the sigmoid presenting as a perforated tic.

It was interesting in that I, for some unknown reason, asked the woman if she used toothpicks much PRIOR to her surgery. She said no. At this time I worked in NC and everyone it seemed walked around with toothpicks hanging out of their mouths.

When it was a toothpick, the woman asked me if I was psychic or something, LOL.