A recent review and case report (AF Nita et al JPGN 2020; 71: 163-70) describe an anguishing outcome after an endoscopy.  This publication is a useful, cautionary tale. In my view, the associated editorial (“MacGyver and Rapunzel in the Pediatric Endoscopy Suite” by JR Lightdale, pg 147-8) tiptoes on the issue of safety concerns of the endoscopic approach described in the review.

Case report: The authors describe a 9 year old with trichobezoar/Rapunzel syndrome who underwent a 3 hour endoscopic procedure with APC to remove the trichobezoar which was found to be composed of both human hair and doll’s hair (the latter may have contributed to complications).  In addition, the child had undiagnosed celiac disease.  Subsequent to the procedure, the child required a laparotomy; she had 18 small intestinal perforations and a gastric perforation.  The child went on to need an extensive small bowel resection (107 cm) and a 3 month hospitalization.

The authors state that a previous review had indicated only a 5% success rate for trichobezoar endoscopic removal (RR Gorter et al. Pediatr Surg Int 2010; 26: 457-63). However, they claim increased success more recently by identifying 16 of 52 (30.7%) removal rate from recent case reports.  Interestingly, one of the successful endoscopic removals cited by the authors had a respiratory arrest during the procedure (Esmali et al).

Bad advice from this article:

• #1 The authors repeatedly suggest now that there is a >30% endoscopic success rate for endoscopic removal and thus they suggest that “it remains reasonable to attempt endoscopic retrieval” as long as a gastric trichobezoar occupies less than two-thirds of the stomach and has limited to no extension into the small bowel.
• #2 The authors believe that “the skill mix of the endoscopist” is an important issue.

My take on their ‘learning points’:

1. This 30% success rate should not be taken seriously due to publication bias (many unsuccessful cases are not reported) and due to treatment bias.  Many clinicians would never attempt to remove a very large trichobezoar.  Thus, the 30% success rate likely includes bezoars that may be more amenable to removal and by centers with more advanced endoscopists.
2. The second claim about endoscopist skill is also bad advice.  First of all, some of the authors of this study have extensive endoscopic experience and yet this did not preclude a bad outcome for this child.  Secondly, in my experience, ~85% of individuals (including GI doctors) consider themselves above average; thus, it may be difficult to know if the ‘skill mix’ of the endoscopist is suitable.  Large trichobezoars are rare and no individuals will have enough experience to be considered experts.
3. My advice: Don’t try to be MacGyver in the endoscopy suite.  Most trichobezoar cases are more suitable for surgical removal.  The most important skill of a good endoscopist is good judgement and the ability to identify cases in which an endoscopy is ill-advised.

Isle of Palms, SC