Body packer syndromeVM Kulkarni1, JA Gandhi1, RA Gupta1, RB Deokar2, ND Karnik3, MY Nadkar3
1 Department of General Surgery, Seth G. S. Medical College, Acharya Donde Marg, Parel, Mumbai, India
2 Department of Forensic Medicine, Seth G. S. Medical College, Acharya Donde Marg, Parel, Mumbai, India
3 Department of Medicine, Seth G. S. Medical College, Acharya Donde Marg, Parel, Mumbai, India
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0022-3859.101646
Source of Support: None, Conflict of Interest: None
A 42 years old man was found unconscious at Mumbai airport. At local hospital he needed ventilator support for disordered breathing. Urine analysis revealed benzodiazepines and opiates. On 6 th day, patient passed a drug packet per rectum. It revealed cocaine. X-ray abdomen showed multiple packets [Figure 1]. Patient was referred to our center.
At our center, eleven packets were removed per rectum; each was a plastic pouch of 3×2 cm concealed with electrical tape. CT scan abdomen ruled out perforation and located the sites of remaining packets. Decision for emergency laparotomy was taken for prolonged retained packets beyond 5 days of ingestion.
On laparotomy, four gastric packets were removed via distal gastrotomy. Endoscope was passed through gastrotomy to confirm complete clearance of stomach and down to proximal jejunum. One packet found in second part of duodenum [Figure 2] which was removed via gastrotomy. Scattered packets in small intestine were milked and removed via a single ileotomy. The large intestinal packets were milked and removed per rectum. The endoscope was passed through the ileotomy and per rectally to inspect the bowel and the missed packets were removed. The small bowel that was not reachable by the endoscope was seen against its light to locate missed out packets. Of total 35 packets removed [Figure 3], 3 had ruptured outer tape. Patient recovered and had superficial wound infection.
The sensitivity of X-ray abdomen in detecting drug packets is 88%.  Positive urine toxicology screening does not indicate packet rupture because drug seepage is known phenomenon and some are active drug abusers. 
The risks to the body packer depend upon
Surgery is reserved for patients with complications like drug intoxication, ,, gastrointestinal obstruction, ,, peritonitis,  perforation  or delayed passage beyond 5 days of conservative treatment. 
Aim of surgery is complete exploration and total intestinal clearance in drug overdose and relieve obstruction when intestines are obstructed. There are different methods to conduct surgery like gastrotomy, , multiple enterotomies,  single enterotomy , and packet removal per anus after milking packets distally. ,, Colonic non obstructing, unruptured packets may be left to be expulsed per anus naturally.  Resection with primary anastomosis and/or stoma is done when indicated. , Palpation during surgery does not exclude remaining packets and can cause complications leading to reoperation. , Postoperative mortality is reported due to pelvic abscess,  DIC. 
Before discharge, two normal packet free stools and a normal plain X-ray abdomen is recommended to confirm total clearance. ,
We did not come across any report that used intraoperative endoscopy to confirm complete clearance. Used via the mouth, rectum, enterotomy and gastrotomy it directly visualizes the complete length of the bowel and can identify a packet mixed in stools or hidden at turns, unless colon is totally loaded. It can also detect missed packets. Enteroscopy can help identify intact packets which could be safely milked to the enterotomy and ruptured packets which need to be removed without milking via separate overlying enterotomy. The packet should not be retrieved via the endoscope with any kind of grasping instrument. As use of intraoperative endoscopy prolongs operative time and should be used cautiously in hemodynamically unstable patient.
In our case, use of intra operative endoscopy helped in complete clearance, minimized the number of enterotomies and avoided post-operative investigations.
[Figure 1], [Figure 2], [Figure 3]