br Introduction Accidental ingestion of foreign bodies is co

Introduction Accidental ingestion of foreign bodies is common, and approximately 80–90% of ingested foreign bodies pass uneventfully through the gut within 1 week. In particular, <1% of patients who ingest a foreign body develop complications such as perforation or penetration of the gastrointestinal (GI) tract. Toothpick ingestion is a relatively rare event that may result in severe gut injuries with peritonitis, sepsis, or death. Ingested toothpicks have been removed through laparoscopy in only 9% of cases. We report a case of gastrojejunal fistula caused by the unintentional ingestion of a toothpick, which was treated through single-port laparoscopy.
Case report A 46-year-old man had a history of agenesis of the right kidney, low anterior resection of the rectum for treating rectal cancer, pacemaker Silvestrol for treatment arrhythmia, coronary artery bypass graft surgery for treating coronary artery disease, and anxiety for which he was under medication. He visited the emergency department of a teaching hospital for consultation because of dysuria with a fever of up to 40°C for 3 days. The patient did not experience nausea, vomiting, passage of bloody stools, melena, or change in bowel habits. However, for more than 2 weeks, he had experienced intermittent left upper quarter discomfort and left flank soreness. He denied foreign body ingestion, although he recalled having been drunk weeks before. On arrival at the emergency department, his vital signs were as follows: body temperature, 40°C; pulse rate, 96 beats/min; respiratory rate, 20 breaths/min; and blood pressure, 137/75 mmHg. Laboratory studies showed a white blood cell count of 16,850/mm3 with 92.4% being neutrophils; a blood urea nitrogen level of 42.6 mg/dL; and a creatinine level of 5.6 mg/dL. The urinary analysis revealed a white blood cell count of >100 per high power field. Therefore, under the impression of left acute pyelonephritits with hydronephrosis, he was prescribed an intravascular antibiotic with ceftriaxone for 2 days. Because a ward bed was unavailable, the patient was transferred to our hospital nephrology ward for further treatment. On arrival to our ward, his vital signs were stable, except for intermittent fever. Physical examination revealed epigastric and left upper quarter tenderness but no flank knocking pain. Laboratory studies showed a white blood cell count of 11,680/mm3 with 71% being neutrophils, a blood urea nitrogen level of 41 mg/dL, a creatinine level of 4.0 mg/dL, a C-reactive protein concentration of 57.8 mg/dL, and normal urinary analysis results. Chest and abdominal radiographs were unremarkable. Computed tomography of the abdomen revealed a radiodense linear object protruding from the posterior gastric wall to the proximal jejunum with adjacent peritoneal inflammation (Figure 1). Gastroduodenoscopy showed one tip of a toothpick protruding from the posterior gastric body wall (Figure 2). After consulting a gastroenterologist because of the perforation of the gastrojejunal fistula, endoscopic retrieval of the toothpick was not performed. A GI surgeon was consulted. Because he had a previous abdominal operation, an exploratory single-port laparoscopy was performed. An incision of approximately 4 cm was created over the midline upper umbilicus, and a single-port laparoscopic device was used. After performing careful enterolysis, the inflamed pseudotract was visible between the stomach and proximal jejunum (Figure 3). At that time, intraoperative gastroduodenoscopy equipment was unavailable; therefore, the stomach was opened and the 7-cm toothpick was successfully removed (Figures 4 and 5). The stomach was subsequently closed smoothly using an Endo-GIA stapler (Ethicon Endo-surgery, Inc, Cincinnati, OH, USA). No discharges were visible over the fistula area. The patient recovered uneventfully. He was discharged on Postoperative Day 6.
Discussion Toothpick ingestion is a medical emergency because it can lead to acute abdomen and gut perforation. Most patients swallow toothpicks while eating sandwiches, particularly when consuming an alcoholic beverage; they cannot recall or are even unaware of the ingestion. Our patient similarly did not remember swallowing a toothpick. Steinbach et al report that approximately 46% of patients are aware of ingesting a toothpick.