HOW I DO IT DIFFERENTLY
|Year : | Volume
| Issue : | Page :
Multimodal minimally invasive management of retained impacted denture in duodenum
Deepa Kizhakke Veetil, Randeep Wadhawan, Naveen Kumar Verma, Muneendra Gupta, Shamsu Rehman Tanai
Department of Minimal Access Surgery, Bariatric and Gastrointestinal Surgery, Manipal Hospital, New Delhi, India
|Date of Submission||15-Feb-2022|
|Date of Acceptance||23-Mar-2022|
|Date of Web Publication||08-Jul-2022|
S-18, Greater Kailash-1, New Delhi - 110 048
Source of Support: None, Conflict of Interest: None
Introduction: Accidental ingestion of dentures can lead to certain life-threatening complications. Duodenal impaction is particularly a challenging situation. Minimally invasive procedures can help when done as a combined approach.
Our Modification: Endoscopy is the first-line management of retained foreign bodies. However, in difficult locations, a combined endoscopy and laparoscopy can help prevent complications and associated morbidity and improve outcome for the patient.
Benefit: Decreased post-operative morbidity and better outcome for the patient.
Keywords: Denture, endoscopy, laparoscopy, minimally invasive surgery, oesophageal perforation
|How to cite this URL:|
Veetil DK, Wadhawan R, Verma NK, Gupta M, Tanai SR. Multimodal minimally invasive management of retained impacted denture in duodenum. J Min Access Surg [Epub ahead of print] [cited 2022 Aug 14]. Available from: https://www.journalofmas.com/preprintarticle.asp?id=350273
| ¤ Introduction|| |
Denture use is common in elderly people, and the accidental ingestion of both the fixed and removable ones has been reported. Most of the ingested foreign bodies pass out through the rectum, but in very few percentage of cases (1%–3%), they can lead to complications. Denture dislodgement and ingestion has been reported to cause specific complications related to obstruction, bleeding and perforation of the intestine.
The most common sites of complication are at the oesophagus, and the ileocecal junction. Duodenal retainment of the denture is particularly rare. Even when reported to have caused complications in the duodenum, the management is difficult as if they cannot be removed endoscopically, then it resulted in laparotomy, kocherisation of the duodenum and enterotomy.
Minimally invasive surgery has better patient recovery outcomes and lesser morbidity as proven through various studies. The management of this case of accidental denture ingestion is particularly interesting as it reflects the advantages of multidisciplinary minimally invasive management of a difficult case that enabled a better recovery for the patient.
| ¤ Case Presentation|| |
As shown in [Figure 1] a 49-year-old woman with no known medical comorbidities presented with complaints of sudden-onset pain and something stuck in her throat after taking her routine medications orally at night. The patient developed difficulty in breathing and was taken to a nearby hospital where she was initially managed.
Imaging in the form of X-ray done revealed a foreign body in the oesophagus. The patient was taken up for an upper gastrointestinal endoscopy. During the procedure, there was an oesophageal perforation which was managed with endoscopic hemoclip-assisted closure of the oesophageal perforation, and intercostal drainage of the bilateral pneumothorax which had developed was done. The patient required intubation and mechanical ventilation and was managed in the intensive care unit initially.
Once the patient improved clinically, the patient was extubated and shifted to the ward. The intercostal drainage tubes were removed, and the patient was discharged. She was referred to a higher centre for further management of the retained foreign body.
On presentation to our centre, the patient was detected to have retained denture in the duodenum, as shown in [Figure 2].
|Figure 2: X-ray abdomen showing the denture in the region of the duodenum. The yellow arrow is pointing to the denture|
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| ¤ Our Modification|| |
The patient was planned for a combined endoscopy and laparoscopy procedure in view of the partially impacted nature of the denture in the duodenum.
Intraoperatively, laparoscopy ports were placed and pneumoperitoneum was created. Endoscopy was then done which identified the denture in the duodenal mucosal wall with no perforation of the wall. The denture was stabilised using a snare, as shown in [Figure 3], but could not be pulled back across the pylorus. Laparoscopic gastrostomy was then done and the pylorus was dilated using the laparoscopic bowel grasper. This enabled the retrieval of the denture across the pylorus and into the abdominal cavity, as shown in [Figure 4] and [Figure 5]. The dimensions of the ingested denture are shown in [Figure 6]. The gastrostomy was closed using a V-Loc absorbable suture.
|Figure 3: Therapeutic endoscopy images showing stabilisation of the denture using a snare|
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|Figure 4: Intraoperative picture showing the laparoscopic view and through the gastrostomy the endoscope can be seen|
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|Figure 5: Laparoscopic view showing the retrieval of the stabilised denture through the gastrostomy|
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|Figure 6: Retrieved denture by the combined endoscopy and laparoscopy modalities|
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Intra-abdominal drain was placed and port sites were closed. The patient was extubated and shifted to the ward. The drain was removed on post-operative day 2. The patient was discharged on post-operative day 3 when she was tolerating liquids orally and was comfortable.
On follow-up at post-operative day 7 of the definitive procedure, the patient was comfortable and tolerating orally and there was a superficial surgical site infection of one of the port sites. This was managed by dressings and the wound healed.
| ¤ Discussion|| |
The benefits of the modification (combined laparoscopy and endoscopy)can be elaborated further as
- Enabling the intraluminal identification of the foreign body
- Stabilisation of the the foreign body to prevent the distal movement and migration
- Retrieving the FB to the pylorus area enable the gastrotromy at the antrum and not a duodenotomy. This in turn reduced the postoperative morbidity for the patient.
Accidental foreign body ingestion getting retained can lead to life-threatening complications. In this case, the patient developed an oesophageal perforation following an upper gastrointestinal endoscopy done to retrieve the denture, following which the patient required ventilatory management in the intensive care unit. The two-tooth denture which was partially fixed got displaced and retained in the duodenum. As it was impacted, it required a combined management. Endoscopic stabilisation followed by laparoscopic gastrostomy and removal of the denture was required.
Duodenal retained dentures are best dealt with endoscopy first. Moreover, as the denture would cause more traumas while being removed through that route, a combined procedure using laparoscopy was anticipated and planned. Minimally invasive combined laparoscopy and endoscopic management of this patient helped the faster recovery of this patient and with minimal post-operative morbidity.
Management of this case reflects the advances in the treatment modalities and a collaborative effort across the various departments of the hospital. Multidisciplinary team management is the way forward for the future to have improved patient outcomes.
| ¤ Conclusion|| |
Combined endoscopy and laparoscopy is a better option for difficult retained foreign bodies of the gastrointestinal tract as this helps reduce the morbidity for the patient. Collaborative multidisciplinary management of difficult cases helps in the better recovery of the patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
We would like to thank the Department of Medical Gastroenterology and Anaesthesiology and Operation Theatre staff at Manipal Hospital.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| ¤ References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]