Single-Incision Laparoscopic-Assisted Segmental Small-Bowel Resection for Small-Bowel Obstruction Caused by a...

Small-bowel obstruction (SBO) caused by a bezoar is uncommon. We report a case of SBO due to a persimmon phytobezoar (diospyrobezoar) in a patient with a history of distal gastrectomy, treated by single-incision laparoscopic-assisted surgery (SILS) with segmental small-bowel resection.

An 83-year-old woman with a history of distal gastrectomy (Billroth I reconstruction) and habitual consumption of dried persimmons presented with abdominal pain and vomiting. Initial non-contrast CT showed small-bowel dilatation without a definitive intraluminal mass. A subsequent ileus-tube contrast study demonstrated a 50-mm oval filling defect with complete obstruction. Ultrasonography revealed an intraluminal mass with heterogeneous echoes and posterior acoustic shadowing, and repeat non-contrast CT identified a gas-containing intraluminal mass consistent with a bezoar. After adequate decompression via an ileus tube, SILS was performed on day 6 of admission. Intraoperatively, the bezoar was firmly impacted and immobile; therefore, segmental small-bowel resection with functional end-to-end anastomosis was performed. Histopathology showed submucosal edema, congestion, hemorrhage, and inflammatory cell infiltration, indicating pressure-related circulatory impairment.

Firmly impacted persimmon bezoars may cause microscopic bowel-wall injury even without macroscopic necrosis. Segmental small-bowel resection can be a reasonable surgical option when bezoar impaction is severe and prolonged. SILS is a feasible minimally invasive approach in selected cases following adequate decompression.