Value of a systematic operative protocol for cocaine body packers

Digestive endoscopic removal of cocaine pellets: Safety evaluation

Background and study aims

Removal of cocaine pellets by endoscopy is the subject of much debate, due to the supposed risk of rupture. This study aimed to evaluate the safety of digestive endoscopic removal of cocaine pellets.

Patients and methods

This was a single-center, observational, retrospective study conducted at the Cayenne Hospital in French Guiana from July 2015 to May 2023. We included patients in whom digestive endoscopy was performed for delayed evacuation despite conservative treatment defined by persistence of pellets on imaging from the third day of hospitalization. Endoscopy was performed only if the pellets present were at low risk of rupture (type 4 according to the classification by Pidoto in 2002). We collected demographic, imaging, endoscopic and follow-up data.

Results

We included 111 patients, 75% of whom were male. Median age was 25 years (range, 20-33). Imaging was performed in 99% of cases. On imaging prior to endoscopy, pellets were found mainly in the stomach (28%), right colon (28%), left colon (30%), and sigmoid (31%). Median time to endoscopy was 3 days (range, 2.5-4). Median number of pellets extracted endoscopically was one (range, 1-4). The material used was mainly endoscopic baskets (60%). No patient presented any per or post-endoscopic complications. No pellets ruptured during extraction. There was no sign of cocaine intoxication during or after endoscopy. The success rate for pellet removal was 92% during the first endoscopy and 100% during the second endoscopy.

Conclusions

Endoscopic removal of micro-industrially-produced cocaine pellets seems to be a safe and effective method. Therefore, endoscopy has a place in management of these patients.

International Smuggling of Illicit Drugs by Body Concealment at a Tertiary Hospital in Istanbul

ABSTRACT

Smuggling of illicit substances by internal concealment has recently become a preferred method of international drug trade. The drug carriers are known as body packers. This study aimed to assess the demographic features and outcomes of body packers admitted to a referral center in Istanbul. Data were retrospectively evaluated from January 2017 to December 2019 from suspected body packers who were referred to the emergency department of a tertiary-care university by Istanbul Airport narcotics police due to suspected concealment of illicit drugs. Eighty-one cases were identified and included in this study. Of these, 71 subjects were confirmed to be body packers by radiological methods. The 15 women and 56 men had a mean age of 35 years. The most common nationality of the body packers was Nigerian, followed by Turkish and South African. Cocaine was the most commonly smuggled packet, followed by hashish, and heroin. All body packers were conservatively managed using laxatives or watchful waiting. No cases required surgical retrieval of packets. Abdominal radiography and computed tomography are useful tools for the evaluation of suspected body packers. The use of improved packaging material by smugglers and complications due to surgery and endoscopy make the conservative approach preferred.

H. Prise en charge des body-packers

>Aujourd’hui, le body-packing ou transport in corpore de substances illicites est le mode de transport de drogues le plus répandu en Europe. Il porte essentiellement sur la cocaïne et l’héroïne, bien que toute autre substance puisse être concernée dans une moindre mesure. Les passeurs (« mules ») sont identifiés par les services de police et de douane sur la base de plusieurs indices permettant de les suspecter, comme l’origine des vols long-courriers, l’abstinence alimentaire, etc. La sensibilité du dépistage urinaire et le diagnostic reposent essentiellement sur l’imagerie abdominale, de préférence l’examen tomodensitométrique lorsqu’il est disponible. Les passeurs sont ensuite placés sous surveillance médicale. Celle-ci n’est pas standardisée, mais devrait durer au moins six heures, avec une attention particulière aux paramètres hémodynamiques et neurologiques. Le risque de rupture des paquets est principalement lié à la qualité de l’emballage. Le traitement est essentiellement conservateur. Les complications restent rares, et le recours à la chirurgie s’avère nécessaire en cas de signes d’intoxication et/ou d’occlusion digestive.

The role of radiology in diagnosis and management of drug mules: an update with new challenges and new diagnostic tools

Emergency physicians and radiologists have been increasingly encountering internal concealment of illegal drugs. The packages commonly contain powdered solid drugs such as cocaine, heroin, methamphetamine and hashish, but they may also contain cocaine in the liquid form. The second type of package has recently been more commonly encountered, and poses a greater diagnostic challenge. As clinical evaluation and laboratory tests frequently fail to make the correct diagnosis, imaging examination is typically required. Imaging methods assume a vital role in the diagnosis, follow-up and management. Abdominal X-ray, ultrasonography, CT and MRI are used for the imaging purposes. Among the aforementioned methods, low-dose CT is state-of-the-art in these cases. It is of paramount importance that radiologists have a full knowledge of the imaging characteristics of these packages and accurately guide physicians and security officials.

Assessment of the management outcomes of body packers

BACKGROUND

The constant need for rapid financial gain drives the international illegal drug industry, which encourages healthy individuals to smuggle drugs through internal concealment. The aim of this study was to evaluate our practice of the management of body packers using a hospital-based protocol in order to validate it.

METHODS

Electronic hospital data were retrospectively reviewed between 2000 and 2013 of all patients that were admitted to Hillingdon Hospital with a history of internal drug concealment. Demographic as well as clinical data including investigations and management were collected.

RESULTS

One hundred and twenty patients were admitted over the study period to our surgical unit. This included 86 male and 34 female patients with a mean age of 38 (range 19-64) years. Three per cent (n = 4) underwent surgery for either cocaine toxicity or obstruction. The rest of the patients were managed conservatively with bowel cleansing preparations to encourage the natural passage of drug packages.

CONCLUSION

Conservative treatment is safe and effective for drug body packers. We therefore recommend conservative management to be the mainstay for body packers with surgery only being indicated on clinical grounds.

The role of surgery in the management of "body packers"

INTRODUCTION

The concealment of packets of illegal substances within body cavities is a common technique for drug smuggling worldwide. The goal of our study was to analyze the results of conservative treatment of "body packers", indications for surgical intervention, and postoperative morbidity.

METHODS

This is a retrospective study of patients admitted to our hospital and diagnosed as body packers. The diagnostic protocol included an abdominal X-ray and urinalysis for toxic substances. Only patients with gastrointestinal symptoms, signs of intoxication, or a positive urinalysis were admitted for observation. Conservative management included bowel rest and serial abdominal radiographs to confirm the passage per rectum of all foreign bodies. Asymptomatic patients were given laxatives in the emergency department (ED) to promote bowel movements and were not admitted to the hospital.

RESULTS

A total of 763 body packers were admitted to the hospital, all of whom were initially treated conservatively. Of these patients, 47 (6 %) developed complications: 28 with bowel obstruction, three with bowel perforation, and 16 with substance intoxication. In patients developing complications, urinalysis for toxic substances was negative in 19 (40 %). Sixteen (34 %) patients who developed complications were successfully managed nonoperatively. Three (6 %) other patients died before surgery: two deaths resulted from acute toxicity (one of them with an acute onset and a negative urinalysis) and the third patient died of bowel perforation. Laparotomy was required in 28 (3.5 %) body packers admitted for observation. Enterotomy and/or gastrotomy to remove the packets were the most frequently performed procedures. Postoperative morbidity occurred in 57 % of patients, with wound infection being the most frequent complication.

CONCLUSIONS

Conservative management was effective in 94 % of symptomatic patients. A laparotomy was required in only 3.5 % of cases. The mortality rate in this series was low, resulting from either severe cocaine poisoning from ruptured packets or bowel perforation.

Detection of residual packets in cocaine body packers: low accuracy of abdominal radiography-a prospective study

OBJECTIVE

To evaluate the accuracy of abdominal radiography (AXR) for the detection of residual cocaine packets by comparison with computed tomography (CT).

METHODS

Over a 1-year period unenhanced CT was systematically performed in addition to AXR for pre-discharge evaluation of cocaine body packers. AXR and CT were interpreted independently by two radiologists blinded to clinical outcome. Patient and packet characteristics were compared between the groups with residual portage and complete decontamination.

RESULTS

Among 138 body packers studied, 14 (10 %) had one residual packet identified on pre-discharge CT. On AXR, at least one reader failed to detect the residual packet in 10 (70 %) of these 14 body packers. The sensitivity and specificity of AXR were 28.6 % (95 % CI: 8.4-58.1) and 100.0 % (95 % CI: 97.0-100.0) for reader 1 and 35.7 % (95 % CI: 12.8-64.9) and 97.6 % (95 % CI: 93.1-99.5) for reader 2. There were no significant patient or packet characteristics predictive of residual portage or AXR false negativity. All positive CT results were confirmed by delayed expulsion or surgical findings, while negative results were confirmed by further surveillance.

CONCLUSION

Given the poor performance of AXR, CT should be systematically performed to ensure safe hospital discharge of cocaine body packers.

KEY POINTS

• Both abdominal radiography and computed tomography can identify gastrointestinal cocaine packets. • Ten per cent of body packers had residual packets despite two packet-free stools. • Seventy per cent of these residual packets were missed on AXR. • No patient or packet characteristics predicted residual packets or AXR false negativity. • CT is necessary to ensure safe medical discharge of body packers.

Prevalence and medical risks of body packing in the Amsterdam area

AIM

Body packing is a way to deliver packets of drugs across international borders by ingestion. The aim of the study was to provide an estimate of the medical risks of body packing, describe predictors for hospital referral in detained body packers and provide an estimate for the prevalence of body packing in the Amsterdam area.

METHODS

From May 2007 to December 2008, we studied medical records of body packers immediately detained after arrival at Amsterdam Schiphol airport, hospital records of both detained body packers and self-referrers at two emergency departments of hospitals in Amsterdam and records kept by forensic physicians in charge of post-mortem examinations of all unnatural deaths in the area (years 2005-2009).

RESULTS

In airport detainees, the hospital referral rate was 4.2% (30 out of 707 detained body packers), the surgery rate was 1.3%. Significant predictors of hospital referral were delayed production of drug packets after arrest, cigarette smoking and country of departure. The surgery rate in self-referrers was comparable to the rate observed in those referred from the detention centre to hospital (30% vs. 31%). In addition, from 2005 to 2009, 20 proven cases of lethal body packing were identified. Based on our data, it is estimated that minimally 38% of all incoming body packers were missed by airport controls.

CONCLUSION

The risk for lethal complications due to body packing is low on a population basis and comparable to other studies. This also applies for the hospital referral and surgery rates found in this study. Cigarette smoking has not yet been described in the literature as a potential predictor for hospital referral in detained body packers and therefore deserves attention in future research. A substantial fraction of body packers manages to remain undiscovered.

[Surgical complications in drug body-packers: an uncommon but potentially lethal emergency]

INTRODUCTION

Drug trafficking by means of introducing packets of illegal substances in body cavities carries a risk of suffering from a gastrointestinal obstruction and/or severe poisoning in the person who transports them. Spain is considered as the port of entry to Europe for drugs, and some Spanish hospitals have experience in managing these types of patients. Two hospitals in Madrid, including the Gregorio Marañón University General Hospital (HGUGM), received these potential patients from the Madrid Barajas airport.

OBJECTIVE

To analyse the results of the conservative treatment and the need for surgery in "body-packers".

MATERIAL AND METHODS

A retrospective, observational study of patients diagnosed as a body-packer between January 2000 and December 2008. Those with gastrointestinal symptoms, signs of poisoning, or positive for drugs of abuse, were admitted to the Custodial Unit of our hospital. The conservative treatment consisted of digestive rest and imaging studies until expulsion from the body. Asymptomatic patients were discharged from the Emergency Department.

RESULTS

A total of 549 patients, with a median age of 31 years, and of whom 81% were males, were hospitalised during this period. Less than half (40%) showed positive for drugs in the urine, with cocaine in 80% of the cases. Of the 549 patients with initial conservative treatment, 27 (4.9%) had serious complications (16, bowel obstruction, and 11 with signs of poisoning). Of these, 23 required surgery (the 16 obstructions and 7 of the poisonings); 2 were successfully treated in ICU, and 2 died before surgery (0.4%) of the cases. The most frequent surgical treatment was enterotomy and/or gastrostomy to extract the packets. Thirteen (56%) of those operated on had associated morbidity (11 abdominal infections and 2 nosocomial infections).

CONCLUSIONS

Conservative treatment is safe in 95% of the patients. A small percentage required surgical treatment, basically for gastrointestinal obstruction or severe poisoning.

Gastrointestinal decontamination in the acutely poisoned patient

Objective

To define the role of gastrointestinal (GI) decontamination of the poisoned patient.

Data Sources

A computer-based PubMed/MEDLINE search of the literature on GI decontamination in the poisoned patient with cross referencing of sources.

Study Selection and Data Extraction

Clinical, animal and in vitro studies were reviewed for clinical relevance to GI decontamination of the poisoned patient.

Data Synthesis

The literature suggests that previously, widely used, aggressive approaches including the use of ipecac syrup, gastric lavage, and cathartics are now rarely recommended. Whole bowel irrigation is still often recommended for slow-release drugs, metals, and patients who "pack" or "stuff" foreign bodies filled with drugs of abuse, but with little quality data to support it. Activated charcoal (AC), single or multiple doses, was also a previous mainstay of GI decontamination, but the utility of AC is now recognized to be limited and more time dependent than previously practiced. These recommendations have resulted in several treatment guidelines that are mostly based on retrospective analysis, animal studies or small case series, and rarely based on randomized clinical trials.

Conclusions

The current literature supports limited use of GI decontamination of the poisoned patient.

Body packers: a plea for conservative treatment

Background

The incidence of smuggling and transporting of illegal drugs by internal concealment, also known as body packing, is increasing in the Western world. The objective of this study was to determine the outcome of conservative and surgical approaches in body packers.

Materials and methods

Clinical data on body packers admitted to our hospital from January 2004 until December 2009 were collected. The protocol for body packers required surgery when packets were present in the stomach for >48 h. Outcomes of the conservative and surgical group were assessed and analyzed. Morbidity and mortality were assessed in body packers with drug packets present in the stomach for <48 h and in those with gastric packets for >48 h.

Results

During the study period, more body packers were treated conservatively. Mortality was 2% in all patients and was due to intoxication. There were no significant differences of mortality, hospital admission time, and ICU admission time in the compared groups with drug packets in the stomach for less or >48 h. In 24% (4/17) of the patients with bad package material, a ruptured drug packet was found during surgery. This resulted in death in only one patient.

Conclusion

Drug packets in the stomach for >48 h are not an indication for surgery. We recommend that surgery should only be performed in body packers with signs of intoxication or ileus and reserve conservative treatment for all other patients.

Collection of biological samples in forensic toxicology

Forensic toxicology is the study and practice of the application of toxicology to the purposes of the law. The relevance of any finding is determined, in the first instance, by the nature and integrity of the specimen(s) submitted for analysis. This means that there are several specific challenges to select and collect specimens for ante-mortem and post-mortem toxicology investigation. Post-mortem specimens may be numerous and can endow some special difficulties compared to clinical specimens, namely those resulting from autolytic and putrefactive changes. Storage stability is also an important issue to be considered during the pre-analytic phase, since its consideration should facilitate the assessment of sample quality and the analytical result obtained from that sample. The knowledge on degradation mechanisms and methods to increase storage stability may enable the forensic toxicologist to circumvent possible difficulties. Therefore, advantages and limitations of specimen preservation procedures are thoroughfully discussed in this review. Presently, harmonized protocols for sampling in suspected intoxications would have obvious utility. In the present article an overview is given on sampling procedures for routinely collected specimens as well as on alternative specimens that may provide additional information on the route and timing of exposure to a specific xenobiotic. Last, but not least, a discussion on possible bias that can influence the interpretation of toxicological results is provided. This comprehensive review article is intented as a significant help for forensic toxicologists to accomplish their frequently overwhelming mission.

Blood cocaine and metabolite pharmacokinetics after cardiac arrest in a body-packer case

Introduction: Cocaine body packing, the internal concealment of cocaine for transportation between countries, may expose to life-threatening intoxications. No data is currently available on the pharmacokinetics of cocaine and its metabolites when a packet rupture occurs in a body packer. Case report: We report the first pharmacokinetic data associated with a severe cocaine intoxication in a body packer, resulting in cardiac arrest. Massive concentrations of cocaine (observed maximal concentration: 1.66 mg/L, 1 hour after the cardiac arrest) were measured in plasma up to about 15 hours, suggesting a prolonged absorption due to a slow-release in the gastrointestinal tract despite surgical extraction of the packets. Apparent cocaine elimination half-life was 7.6 hours. Conclusion: A prolonged apparent cocaine elimination half-life has been observed. Further pharmacokinetic studies are needed to understand better the pathophysiology of acute cocaine intoxication in body packers.

Surgical approach to body packing

PURPOSE

Body packers, i.e. individuals carrying illegal drug packages in their bodies, are usually managed medically. For the minority, surgical intervention is needed.

METHODS

We review our experience to compare surgical and nonsurgical approaches for treating symptomatic body-packing patients.

RESULTS

From April 2004 to March 2007, 45 patients were referred to our hospital. Nine of them underwent surgical intervention. The number of packets and total swallowed drugs were more among surgically-treated patients (P = 0.003, 0.004 respectively). The mean duration between drug swallowing and admission to the hospital was longer among surgically-treated patients (P = 0.001). Surgically-treated patients were more symptomatic. Resistant toxicity and symptomatic cocaine and heroin mixture packing were the most common indications for surgery. Surgery was usually performed without any complication.

CONCLUSION

Surgical intervention is indicated for body packers with persistent nonresponsive toxicity, gastrointestinal obstruction or perforation, and symptomatic cocaine packers.