He recovered uneventfully and was discharged on day 5 after surgery. At follow-up, he was progressing well without complication, his liver function is normal and resumes full-time work 1 month after the surgery. He denied the recurrence of any of his preoperative symptoms 4 months after the surgery in the follow-up.
Accidental ingestion of foreign bodies is not rare and the vast majorities (80–90%) of ingested foreign bodies spontaneously pass through the gastrointestinal tract uneventfully within 1 week.[3,4] In fact, less than 1% of patients who ingested a foreign body become symptomatic, it is usually secondary to obstruction or perforation of the gastrointestinal tract.[2,4] Development of liver abscess secondary to ingested foreign body migration is even more uncommon, and the first case was reported by Lambert and colleagues in 1898. Since then, literature regarding this disease have increased, especially in the past 4 decades. In the present study, we just focus on the enterohepatic migration of ingested foreign body and aim at summarizing its characteristics and the proper way of management.
A systematic PUBMED survey of all English language literatures published since 1980 was finished by using the keywords “liver mass,” “hepatic abscess,” “inflammatory pseudotumor,” “foreign body,” “toothpick,” “fishbone,” “chicken bone,” or“needle.” All literature collected from the search were reviewed carefully and only cases with an ingested foreign body that penetrated directly into the liver were included in the present study. The following variables were analyzed: gender; age; type hepatic lesion; site of liver involved; type and size of foreign body; treatment performed (endoscopy, surgery, intervention, and autopsy); and duration of hospitalization. Cases with insufficient quality or incomplete data were excluded. Finally, 80 papers[3,4,7–83] with 86 cases were selected for analysis in the present study. All statistical analyses were performed using commercially available software (SPSS, version 18.0 for Windows). Data were expressed as mean ± SD. The Student t test was used for comparison of 2 different sets of continuous values. Differences were considered statistically significant when P < .05.
Of the reviewed 86 cases, there are 48 male and 38 female patients. The mean age of these patients is 51 ± 19 years (ranging from 5 months to 86 years). With regard to the risk factors of foreign body ingestion, numerous groups “at risk” of ingested foreign body perforation have been identified in the literature, including prison inmates, psychiatric patients, alcoholics, children, elderly peoples, selected professions (carpenters and dressmakers). Other conditions include eating quickly, hot or cold beverages, cognitive impairment, and people who wear dentures.[71,84] The wearing of dentures is a well-described risk factor because they can eliminate the tactile sensation of the palatal surface. This palatal sensory feedback is a protective mechanism for identifying small, sharp, or hard textured objects included in the food bolus.[5,90] Dental factors also have been reported in up to 80% of foreign body ingestion cases especially in elderly peoples who have hypopselaphesia of the palatal surface and degradation of palatal sensory feedback with age.[84,90] Wearing dentures and the usage of toothpicks are also reported to be risk factors for a foreign body-related hepatic abscess. In the present review, 3 cases are reported with psychiatrics or cognitive impairment patients with a mean age of 30.5 years old. Meanwhile, these patients usually ingest foreign body intentionally and this behavior has a tendency to be repeated. There are 6 cases in the present study with patients under the age of 17 and all of them had ingested a foreign body of the metallic needle by accident. Needle seems to be the most common foreign body causing perforation and boys are more frequently involved than girls. It may be attributed to their carelessness and immature palatal sensory feedback, especially in child and infant.
Theoretically perforation can occur anywhere along the gastrointestinal tract, however, it usually occurs at areas of angulation or narrowing such as the pylorus and ileocecal junction. Actually, the most common sites of perforation of the gut are ileocecal junction and rectosigmoid region.[2,75] However, the common perforation sites of enterohepatic migrated foreign body reported are the stomach (pylorus included) and duodenum. In the present review, 44 cases have a gastric perforation (pylorus included) while 18 cases get duodenal perforation, agreeing with previous studies.[33,37] Colon takes the third place of the most common site of perforation reported (6 cases).[19,42,55–57,70] A proposed hypothesis stated that a thicker gut wall (stomach and colon) can make the foreign body to perforate more gradually, and the close proximity of the omentum and adjacent organs, such as the liver assists in “sealing” the perforation site without gross intra-peritoneal spillage of gastrointestinal contents.[84,85] Moreover, the surrounding inflammatory adhesion might form even before the perforation sealed. This hypothesis can explain the considerable asymptomatic period of time between foreign body ingestion and appearance of overt symptoms as well as regional rather than diffuse peritonitis in these cases. With regard to the source of migrated foreign body, foreign bodies penetrating the left lobe of liver usually come from the proximal 2 parts of duodenum, pylorus, and gastric antrum while foreign bodies penetrating the left lobe of liver may also come from the ascending colon, hepatic flexure of the colon, and transverse colon. The predominant location of hepatic involvement induced by foreign body penetration is the left lobe which is in contrast to cryptogenic hepatic abscesses that often affect the right lobe. In the present review, foreign bodies penetrating the left lobe of liver directly through stomach are identified in 36 cases (including 23 cases in left lateral lobes), right unilobular involved in only 1 case, bilobular involved in 2 cases; while foreign bodies penetrating the left lobe of liver directly through duodenum are identified in 10 cases (including 6 cases in left lateral lobes), right unilobular involved in 7 case, bilobular involved in 1 case. Caudate lobe involvement is diagnosed in 3 cases from stomach and 1 case from duodenum. In the 6 cases with colon perforation, left unilobular involvement is detected in 1case as right unilobular involvement is detected in 5 cases (Table 1). According to the review, foreign bodies piercing through the stomach are more likely to involve the left lobe especially the lateral lobe than that of the “duodenal perforation group” (P = .002) while the “colon perforation group” is more frequent to appear right lobe involvement which is in contrast to that of the “stomach perforation group” (P < .001).
Ingested foreign bodies vary from countries and depend on dietary habits. Reported foreign bodies include metallic or plastic objects such as needle, coin,[87,91] metallic wire, pen, dental plate, and toothbrush; organic objects such as animal bones (fish chicken, and rabbit), or shell; wooden objects such as toothpick, clothespin or some plan, and other objects. With regard to penetrated foreign bodies, objects that cause perforation are usually sharp, pointed, or elongated, yet all of the aforementioned foreign bodies have been reported for penetration. The incidence rate of foreign body enterohepatic migration in the present reviewed 86 cases are fishbone (45.3%), toothpick (23.2%), needle (14.0%), chicken bone (8.1%), clothespin (2.3%), toothbrush (2.3%), rosemary twig (1.2%), pen (1.2%), lobster shell (1.2%), and metal wire (1.2%). However, some previous studies hold that the shape or size of objects cannot predict the risk of perforation as opposed to the spontaneous passage, such as elongated blunt head objects can perforate the mucosa after erosion due to pressure from longstanding impaction. The size of migrated foreign bodies in reviewed papers varies from 1 cm (fishbone) to 20 cm (toothbrush) and their shape varies from sharp (sewing needle) to blunt (toothbrush). It is reasonable that the longer the foreign body is the higher possibility the perforation happens. Hence perforation and migration of small-sized foreign body is less reported and more difficult to detect than that of the longer foreign body. Thus it is rational to pay more attention to the diagnosis and treatment of these patients. In our reported case, the size of the migrated fishbone is 1.7 cm. Though it is not the shortest migrated foreign body ever reported, but to the best of our knowledge, it is the shortest enterohepatic migrated foreign body removed by laparoscopy. Moreover, how such a short foreign body penetrates and embedded deeply into the liver remains unclear.
Imaging techniques such as X-ray, BUS or CT scan are optional. The choice depends on not only the symptom of the patient but also the nature and size of the foreign body. As the degree of radio-opacity of the foreign body varies with the different type, and even with bony radiopacity, because of the masking effect of the soft tissue mass, fluid collection around the penetrated foreign body and the absence of free gas in the abdomen, plain radiograph is unreliable in this rare condition. Ultrasound is useful in detecting the presence of hyperreflective foreign bodies regardless of their orientation and even if it is radiotransparent. Nowadays, BUS is treated as an alternative screening technique for its noninvasion, convenience, and radiation-free.
However, it is not always reliant due to factors such as the patient's body habitus, the operator's performance and the site of perforation. CT scan is now the golden standard for the diagnosis of foreign body migration owing to its high resolution and accuracy. Foreign body usually appearing as a hyperdense linear object under CT. CT scan in cases of foreign body ingestion can also determine the presence of a perforation, the extent of intra-abdominal inflammation either with or without abscess formation and adjacent organ impairment. On account of tomographic angle and the thickness of cuts, linear foreign body lying between adjacent CT cuts maybe barely visible. Moreover, signs of resultant bowel perforation, however, may not always be evident on an ordinary CT scan. As a consequence, coronal or sagittal reconstructive or repeated CT scan and a high index of suspicion are necessary for the diagnosis. magnetic resonance imaging (MRI) is usually contraindicated for its relatively low accuracy and in condition when metallic objects cannot be completely ruled out. Endoscopy (gastroduodenoscopy and colonoscopy) is the preferred choices for the assessment and management of objects lodged in upper or lower gastrointestinal tract because of their capacity of visualization of areas involved in the perforation. Unfortunately, the accuracy may reduce in some chronic cases of perforation or migration with healed mucosa and endoscopy does not allow examination of the mid-gut. The decision of operation before clear diagnosis establishment is always hard arduous to make. Despite advances in imaging quite a few diagnoses are still made during the operation. Laparoscopy may be a choice when the patient with severe agnogenic acute abdomen.
Minimally invasive hepatectomy and gastrectomy have been expanded over the past 2 decades. Although majority of major hepatectomies are still performed as an open surgical procedure in the regional hospital, laparoscopic approach is considered the gold standard treatment for lesions located in the left lateral lobe of the liver (segment II and III).[94,95] In patients with prior abdominal surgery and resultant adhesions, laparoscopic surgery may be a technical challenge, with an increased risk of organ or vessel injury if extensive adhesiolysis is required. With recent advances of endoscopic instruments, transluminal therapies can be performed via the gastrointestinal tract when there is a sinus tract between the liver abscess and the intestine. In case the foreign body partly remains in the lumen of gastrointestinal tract, endoscopy is particularly appropriate. It can also be performed in combination with percutaneous interventional procedure in selected cases. However, both of the procedures can be technically demanding. What needs to be emphasized is that no matter which procedures adopted, make sure there is no foreign body residual and the perforation site is sealed firmly if possible.
With respect to the prognosis, the mean postoperational hospitalization duration (POD) after the foreign body removal laparotomy is 8.7 ± 3.2 days (ranging from 3 days to 14 days) whilst the laparoscopic group has significantly shorter mean POD of 4.5 ± 3.1 days (ranging from 1 day to 12 days) (P < .001). In the papers reviewed there are 4 cases of death reported, 2 of the victims[11,17] received medications only, 1 died of a heart attack 8 days after a successful percutaneous interventional removal of a fish bone, the last victim died of pre-/intraoperative misdiagnosis of fish bone induced hepatic abscesses. These reported cases underline the lifesaving effect of early diagnosis and proper way of treatment for this potentially lethal condition.
In summary, we report a rare case of enterohepatic migration of an ingested fish bone mimicking liver neoplasm and is successfully removed by laparoscopy. To the best of our knowledge, it is the shortest (1.7 cm) enterohepatic migrated foreign body removed by laparoscopy ever reported. A review of the literature highlights the crucial role of CT scan in this rare condition. The key to make this potentially difficult diagnosis is to have a high index of clinical suspicion. As employed in our case, the minimally invasive procedure of laparoscopy is technically feasible and safe for both diagnosis and treatment of patients with foreign body ingestion, particularly when the gastrointestinal tract perforation and/or abscess formation is suspected. Conservative observation of an asymptomatic ingested foreign should be treated with caution. Early diagnosis and decisive treatment in time are vital in patients with life-threatening conditions.
Chao Wang and Jun Chen writed the original draft and edited it. Jianyong Zhuo, Xue Wen participated in the specimen and data collection. Qi Ling, Haijun Guo and Zhikun Liu searched the library and found the resource. Xiao Xu, Shusen Zheng conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final manuscript.
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