A 58-year-old man presented with postprandial pain that radiated to the right shoulder
and right flank. He had undergone a laparoscopy-assisted distal gastrectomy with Billroth
II anastomosis 2 months previously for Borrmann type III advanced gastric cancer.
The operation had been uneventful and he had been discharged without any complications.
However, about a week after being discharged he developed abdominal discomfort that
worsened after eating. Because of the progressive postprandial abdominal pain, which
was unrelated to gastric dumping syndrome or blind loop syndrome, his oral intake
had reduced and he had lost 6 kg since the time of the operation.
When he was seen again, his physical examination revealed mild epigastric tenderness.
His chest and abdominal radiographs were normal and an abdominal ultrasound was also
unremarkable. His laboratory tests were all normal except for mild anemia.
An upper gastrointestinal endoscopy was therefore performed to evaluate the cause
of his abdominal pain. During this procedure, a remnant nylon thread that looked quite
taut was seen leading into the efferent loop from the site of the anastomosis ([Fig. 1 a]). When the thread was pulled back into the gastric lumen using biopsy forceps, food
material was found stuck to the end ([Fig. 1 b]). Linear ulceration was noted along a line where the thread had compressed and eroded
the mucosa of the efferent loop ([Fig. 1 c]). The thread was detached from the site of the anastomosis using biopsy forceps
and the bezoar was then removed with a net ([Fig. 1 d]). After the thread and attached bezoar had been removed, the patient no longer complained
of postprandial pain.
Fig. 1 Endoscopic views in a 58-year-old man who had recently undergone laparoscopy-assisted
distal gastrectomy with Billroth II anastomosis showing: a a tense nylon surgical thread leading towards the efferent loop at the site of the
anastomosis; b a bezoar that was found dangling at the end of the thread when it was pulled back
into the gastric lumen; c a linear compression ulcer that had been induced by the thread in the efferent loop;
d the bezoar being successfully removed using a net after the thread had been detached
from the site of the anastomosis.
Endoscopy_UCTN_Code_CPL_1AH_2AK
