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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 28  |  Issue : 3  |  Page : 185-187

A rare cause of unclosed abdominal wall wound: Swallowed suture needles


Department of Plastic, Reconstructive and Aesthetic Surgery, Bagcilar Training and Research Hospital, Istanbul, Turkey

Date of Submission02-Mar-2019
Date of Acceptance31-Aug-2019
Date of Web Publication26-May-2020

Correspondence Address:
Dr. Percin Karakol
Department of Plastic, Reconstructive and Aesthetic Surgery, Bagcilar Training and Research Hospital, Istanbul, Ankara
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/tjps.tjps_23_19

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  Abstract 


Foreign body ingestion that is mostly seen in children, may also seen in adults with psychiatric disorders. Many foreign bodies are excreted with feces; otherwise, they may perforate abdominal organs and cause peritonitis. Sometimes, they can migrate organs and penetrate the abdominal wall. We report, in this report, a 33-year-old unemployed tailor woman with her sister with Munchausen syndrome by proxy disorder. The patient has an unclosed wound after having swallowed multiple suture needles in attempt of suicide. Foreign body ingestion may present with various symptoms. Abdominal nonhealing wounds can occur, and after several attempts of treatment, if there are recurrent dehiscence, psychiatric disorders should be considered.

Keywords: Foreign body, migration, Munchausen syndrome by proxy


How to cite this article:
Karakol P, Tatar BE, Uslu C, Sezgic M. A rare cause of unclosed abdominal wall wound: Swallowed suture needles. Turk J Plast Surg 2020;28:185-7

How to cite this URL:
Karakol P, Tatar BE, Uslu C, Sezgic M. A rare cause of unclosed abdominal wall wound: Swallowed suture needles. Turk J Plast Surg [serial online] 2020 [cited 2020 Jul 10];28:185-7. Available from: http://www.turkjplastsurg.org/text.asp?2020/28/3/185/284955




  Introduction Top
Foreign body ingestion is generally seen in children over 4 years old, but it can also be seen in adults with mental retardation or psychiatric disorders. Patients can swallow needles for attempting suicide. In the United States, approximately 1500 people die yearly from ingestion of foreign bodies.[1] Foreign bodies are usually excreted in the stool without causing any complications by passing through the gastrointestinal tract. The rate of perforation at any place varies between 15% and 35% if it is not excreted from the gastrointestinal tract.[1] The rate of peritonitis is low when perforation occurs (1%–2%). Foreign body ingestion is known to trigger duodenal stenosis and web formation.[2]

Swallowing objects, such as suture needles, toothpicks, or turban needles, are seen frequently. Patients with psychiatric disorders can swallow foreign bodies. In this report, we present a 32-year-old tailor woman who swallowed multiple suture needles for attempting suicide; her sister has Munchausen syndrome by proxy disease.


  Case Report Top


A 33-year-old female patient presented with an abdominal open wound which had been closed at least a year ago. In her history, it was revealed that she was a tailor and had Von Willebrand disease. When she was 18 years old, she applied to an emergency department because of swallowing needles after her father's funeral. Physical examination and screenings showed that there was an open wound approximately 20 cm with reek and exudate from umbilicus to pubis [Figure 1]. On abdominal and pelvic X-ray examination, innumerable suture needles were demonstrated [Figure 2].
Figure 1: Preoperative view of unclosed abdominal wall wound

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Figure 2: Preoperative X-ray showing multiple needles in abdominal and pelvic regions

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The patient was hospitalized, and intravenous treatment was started. Swab culture was taken, and she was sent for radiography examination. There were no alterations in her blood parameters. The patient was consulted to the general surgery for evaluation of fascia defects. General surgery unit evaluated the patient for any fistula tract or fascial rupture, and they decided to put prolene mesh on the defect that was on the left side of the umbilicus.

After two sessions of negative pressure wound treatment, the patient was taken to the operation room. Under general anesthesia, reconstructive total abdominoplasty was planned for the defect. Above the deep fascia of rectus muscle, the dissection was continued to the base of the xiphoid process. Two needles were removed from the flaps which were elevated [Figure 3]. Hernia of the abdominal organs and rectus diastasis were seen near the umbilical area. Prolene mesh was placed on the herniated area and fixed with sutures by general surgeons. Necrotic tissues were excised, and new belly button was reconstructed. Two Hemovac drains were placed, and the skin was sutured. After the operation, there were no complications [Figure 4]. The patient was seen in her routine controls, and the wound was totally closed. Two months after the last control day, the patient presented to the emergency service for dehiscence of her abdominal wound. She claims that the dehiscense occurred during defecation. The patient was operated for dehiscence after the emergency service arrival. On the postoperative first day, there was dehiscence again but suture materials were absent which were sutured one day previously. We consulted the psychiatry department about the situation. After their examination, the sister of the patient was diagnosed with Munchausen syndrome by proxy disease. She confessed that her stitches were cut by her sister because her sister did not want to take care of her at home. She was dependent on her sister as she was unemployed. The patient's sister was hospitalized in the psychiatry clinic, and our patient was discharged after closure of the wound. The patient was seen 6 weeks after her discharge and wound healing was observed.
Figure 3: Intraoperative view of the surgical procedure, needles can be seen on flaps elevated

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Figure 4: Postoperative view of the patient

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In our case, the sister of our patient is the caregiver, and she deliberately produces illness in our patient so that the proxy will receive medical care that gratifies the caregiver. Hence, the sister of our patient has this psychiatric disorder, Munchausen syndrome by proxy (MSBP).


  Discussion Top


The most common cause of ingestion of foreign bodies is accidental swallowing. If they are not excreted with stool, conservative treatment may be required often. Twenty percent of the cases required endoscopy, which is a noninvasive examination, and only 1%–2% of patients require surgery.[1]

There are several cases in the literature about foreign body swallowing. Foreign bodies can cause mediastinitis, cardiac tamponade, and pericarditis. Mediastinal access is through the esophagus.[1] There are cases of peritonitis, in which cholecystectomy is required due to gallbladder perforation by migration of ingested bodies.[3]

Intrahepatic foreign bodies are rare. There are three theories about migration of foreign bodies to the liver: migration from gastrointestinal tract, direct penetration of the abdominal wall or through bloodstream.[4]

In literature, there is a case about esophageal fish bone migration which induced thyroid abscess.[5]

A foreign body was seen coincidentally near L3 (lumbar) spine on computed tomography (CT) of a patient, 33-year-old, who was treated for tuberculosis. He said that he swallowed a toothpick when he was 18.[6] There are different opinions about the path of foreign body migration from the gastrointestinal tract to vertebrae such as transarterial, transvenous, or transmesenteric. Due to the foreign body located perpendicular to L3 spine, transaortic route was more sensible than the other theories. Aorta is closer to esophagus in some specific areas such as T6–T11 (thoracic vertebra), T11–L2, and L2–L3 levels.

Even clinical presentations of foreign body ingestion show variability. General symptoms are abdominal pain, nausea, vomiting, and tenderness. Some blood parameters such as liver enzymes and C-reactive protein may rise.[7]

Since the foreign bodies are mostly radiopaque, direct radiography is sufficient for diagnosis.[8] It is more useful to screen with magnetic resonance imaging or CT in patients with clinical signs such as peritonitis and mediastinitis.[1]

In our case, a 33-year-old tailor woman who has Von Willebrand disease applied to ER with abdominal wound that has not been closed or healed by any medical intervention. There had not been any complication throughout weeks after the operation. After 2 months, the patient applied with dehiscence, and as soon as we saw the wound, we reoperated the patient. On postoperative 1st day, we saw that there was dehiscence again. Hence, her sister was responsible for removing the sutures.

MSBP, is formerly defined in the Diagnostic and Statistical Manual of Mental Disorders-5 as factitious disorder on others. This disorder is about feigning of physical and psychological signs and symptoms; also induction of injury associated with identified fraud on a victim. Although well-documented in the pediatric literature, several cases of MSBP with adult proxy have been reported. Diagnostic criteria for factitious disorder imposed on others (previously named “factitious disorder by proxy”) are as follows:

  1. Psychological and physical signs and symptoms, or induction lesion or disease on others are feigned in association with identified fraud
  2. Individual presents the other (victim) as ill, impaired, or injured
  3. Fraudulent behavior is evident even with the absence of obvious external rewards
  4. Individual's behavior is no longer well-explained by a disorder, such as delirium or other psychotic conditions.


The inducement of removing sutures after 2 months and yielding hospitalization of the patient is related to meeting her own psychological need and receiving praise from medical staff.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.


  Conclusion Top


Foreign body ingestion is usually seen in pediatric patients, but can also be seen in adults, especially in patients who are convicts and patients with psychiatric disorders. Foreign bodies in the abdomen may cause wounds which are resistant to be closed. In case of a dehiscent wound, which is operated recently and had an optimal dressing, every doctor should be alert to psychiatric diseases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ozkan Z, Kement M, Kargı AB, Censur Z, Gezen FC, Vural S, et al. An interesting journey of an ingested needle: A case report and review of the literature on extra-abdominal migration of ingested foreign bodies. J Cardiothorac Surg 2011;6:77.  Back to cited text no. 1
    
2.
Klingler PJ, Seelig MH, DeVault KR, Wetscher GJ, Floch NR, Branton SA, et al. Ingested foreign bodies within the appendix: A 100-year review of the literature. Dig Dis 1998;16:308-14.  Back to cited text no. 2
    
3.
Dogan H, Caglayan K, Isler B.F., Arslan H, Ozucelık D.N. Perforation of the gallbladder due to a swallowed sewing needle: Case report. J Emerg Med Case Rep 2017;8:7-10.   Back to cited text no. 3
    
4.
Avcu S, Unal O, Ozen O, Bora A, Dülger AC. A swallowed sewing needle migrating to the liver. N Am J Med Sci 2009;1:193-5.  Back to cited text no. 4
    
5.
Chen CY, Peng JP. Esophageal fish bone migration induced thyroid abscess: Case report and review of the literature. Am J Otolaryngol 2011;32:253-5.  Back to cited text no. 5
    
6.
Ozsunar Y, Tali ET, Kilic K. Unusual migration of a foreign body from the gut to a vertebral body. Neuroradiology 1998;40:673-4.  Back to cited text no. 6
    
7.
Nishimoto Y, Suita S, Taguchi T, Noguchi S, Ieiri S. Hepatic foreign body a sewing needle in a child. Asian J Surg 2003;26:231-3.  Back to cited text no. 7
    
8.
Bakal U, Tartar T, Kazez A. A rare mode of entry for needles observed in the abdomen of children: Penetration. J Indian Assoc Pediatr Surg 2012;17:130-1.  Back to cited text no. 8
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