JRSM >
Volume 96, Number 4 >
Pp. 188-189
Department of General Surgery, Hillingdon Hospital, Pield Heath Road, Middlesex UB3 3NN, UK
Correspondence to: Mr T Paes E-mail: trevor.paes{at}btinternet.com
Hospitals near international airports are increasingly exposed to the surgical mule or body packer, who tries to smuggle narcotics by an intracorporeal route. Hillingdon Hospital is one of those serving London Heathrow.
CASE HISTORIES
Case 1
A man of 33, just off a flight from the West Indies, was referred by
Customs & Excise officials when he began vomiting and complaining of lower
abdominal pain. Urine was positive for cocaine and he admitted to having
swallowed seventy packages of the drug; at least fifty were visible on a plain
abdominal X-ray and were presumed to be in his distal colon. There were no
signs of drug toxicity; the rectum was empty. He was admitted for observation
and routine purging of the packs. The pain and vomiting settled and he
tolerated full diet and Picolax (sodium picosulphate). By the eighth day of
admission no package had been passed and, having consented to an examination
under anaesthesia and possible laparotomy, he was taken to theatre.
Sigmoidoscopy revealed an empty bowel to 25 cm. A lower midline laparotomy was
performed. A hugely distended stomach was found to contain eighty-three
packages of cocaine (weighing 1.02 kg) which were removed through a small
gastrotomy.
Case 2
A man of 38 was detained by Customs & Excise on suspicion of drug
trafficking. While in custody he had a single episode of haematemesis and was
referred to the accident and emergency department, where he admitted to having
ingested at least forty packages of cocaine about 72 hours previously. There
was no clinical evidence of drug toxicity. The only positive clinical finding
was a midline abdominal scar, the result of a laparotomy 10 years previously
for perforated peptic ulcer. The urine contained traces of cocaine. He was
admitted under the medical team for observation. Next day his scrotum became
acutely swollen and painful. Obstructive symptoms were absent. Clinically he
had a strangulated right inguinal hernia, and packages were palpable within
the scrotum. On exploration through a right groin incision the hernia sac
contained transverse colon with a single perforation
(Figure 1). A colotomy was
performed and eighteen packages were delivered. A laparotomy allowed reduction
of the large bowel, and after delivery of a further twenty-two packages the
colotomy was converted to a formal colostomy within the right iliac fossa. The
hernial defect was repaired by Bassini's technique. A total of 485 g of
cocaine was retrieved.
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COMMENT
Body packers usually swallow their packages, hoping to retrieve them after natural passage through the gut; the rectum and vagina offer other means of concealment.1,2,3 Surgeons should exercise special vigilance in patients with acute surgical conditions who have recently arrived in the UK. Fortunately, package leakage (with drug overdose) is rare. Conservative management with oral purgation is the treatment of choice even in patients with mild abdominal symptoms.4,5 The commonest surgical presentation for body packers is intestinal obstruction, and a plain abdominal radiograph is all that is needed to confirm the diagnosis since these packages are invariably radio-opaque.
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