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| CASE REPORT |
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| Ahead of print publication |
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Clinical Spectrum of Gossypiboma: Case Series and Review of Literature
Priya Ranjan1, Vijay Chetan Jha2, Vipin Venugopal Nair3, Sibi Eranki4, Onkar Singh5
1 Department of GI Surgery, Command Hospital, Northern Command, Udhampur, Jammu and Kashmir, India
2 Department of Surgery, 92 Base Hospital, Srinagar, India
3 Department of Surgery, Armed Forces Medical College, Pune, Maharashtra, India
4 Department of Pathology, Command Hospital Northern Command, Udhampur, Jammu and Kashmir, India
5 Department of Plastic and Reconstructive Surgery, Command Hospital, Eastern Command, Kolkata, West Bengal, India
| Date of Submission | 19-May-2021 |
| Date of Decision | 30-Aug-2021 |
| Date of Acceptance | 20-Sep-2021 |
| Date of Web Publication | 01-Apr-2022 |
Correspondence Address:
Priya Ranjan,
Department of GI Surgery, Command Hospital Northern Command, Udhampur, Jammu and Kashmir
India
 Source of Support: None, Conflict of Interest: None DOI: 10.4103/jmms.jmms_75_21
Gossypiboma is a term used to describe retained surgical sponge after surgery. This is an avoidable clinical condition causing significant morbidity and mortality. The clinical presentation is variable and often a diagnostic enigma. The consequences of gossypiboma are undesirable, disappointing, and have medicolegal implications for the surgical team. We report three cases of gossypiboma with varying clinical spectrums. The first case had gastric outlet obstruction due to retained surgical sponge after open cholecystectomy. It had eroded both into the first part of the duodenum and transverse colon. Endoscopic and radiological evaluation helped to establish the diagnosis of duodenocolic fistula with gastric outlet obstruction. The second patient was treated for penetrating abdominal wound and presented with persistent fever with discharging sinus at the wound site. The third patient had undergone exploratory laparotomy for recurrent hydatid cyst of the liver and, in addition to recurrent hydatid cyst, a surgical sponge was also found. All these patients had retained surgical sponges but different clinical presentations. These patients underwent exploratory laparotomy and surgical removal of the retained surgical item (RSI) followed by a successful recovery. Gossypiboma should be considered as a differential diagnosis in all unexplained postoperative sepsis, intestinal obstruction, and intra-abdominal mass. Standard surgical safety measures in the operative room help to prevent the incidence of RSIs.
Keywords: Duodenocolic fistula, gastric outlet obstruction, gossypiboma, retained surgical items
| Introduction | |  |
Retained surgical item (RSI) is an avoidable clinical condition causing significant morbidity and mortality. The clinical presentation is variable and often a diagnostic dilemma. The consequences of RSI are undesirable and disappointing for the surgical team and it can lead to medicolegal problems.[1] We present three cases of intra-abdominal retained surgical sponges in postoperative patients who presented with different clinical features at varying postoperative intervals. Our first case presented with pain abdomen and features of gastric outlet obstruction, the second case had recurrent fever and purulent discharge from the surgical site, while our third case was asymptomatic. The symptomatic cases underwent clinical evaluation and preoperative radiological evaluation which detected a retained surgical sponge. They underwent exploratory laparotomy and surgical removal of RSI and had a successful recovery. The surgical sponge was incidentally found in an asymptomatic case.
| Case Report | | |
Case I
A 64-year-old lady had undergone open cholecystectomy for calculous cholecystitis 2 months back. She was admitted with persistent nonbilious vomiting, pain in the upper abdomen, and unquantified weight loss since the surgery. She denied a history of fever, hematemesis, bleeding per rectum, or distension of the abdomen. Her physical examination revealed features of dehydration, tachycardia, low-grade fever, and fullness in the right upper quadrant with mild tenderness. Clinically, she was diagnosed as a case of gastric outlet obstruction. She was resuscitated and further evaluated.
Ultrasonography (USG) of the abdomen detected a soft dense area around the gastroduodenal aspect. Upper gastrointestinal endoscopy initially detected only food particles; however, on repeat endoscopy, a surgical sponge was seen in the second part of the duodenum (D1) causing gastric outlet obstruction [Figure 1]. To delineate the location of the surgical sponge and relation with intra-abdominal organs, a contrast-enhanced computed tomography (CECT) of the abdomen was done. CECT abdomen (coronal multiplanar reconstruction image) revealed grossly dilated stomach filled with large amount of air and soft tissue density contents suggestive of food residue and gastric outlet obstruction. [Figure 2]. The first part of the D1 was also dilated with well-defined soft-tissue density mass with small foci of air within [Figure 2]. The lesion was extending beyond the confines of D1 anteriorly and was seen within hepatic flexure and proximal transverse colon [Figure 2] and [Figure 3].
On exploratory laparotomy, intraoperative findings were (1) dense adhesion in the right upper quadrant with stomach and colon adhered to parities and (2) large surgical sponge (gossypiboma) eroding into the hepatic flexure of the colon and first part of D1 causing duodenocolic fistula, gastric outlet obstruction, and colonic obstruction [Figure 4]. Adhesiolysis, removal of gossypiboma, distal gastrectomy, gastrojejunostomy, segmental colectomy, and ileocolic anastomosis were performed. The patient had a gradual and uneventful postoperative recovery.
Case II
A 25-year-old person sustained penetrating injury abdomen and had hypotension on presentation. He was initially resuscitated and evaluated. Initial imaging of the abdomen (USG & CECT scan) detected hemoperitoneum with liver lacerations. He underwent exploratory laparotomy, hemostasis, perihepatic packing, and peritoneal wash. He was re-explored and perihepatic packings were removed. The patient had an uneventful recovery; however, he again presented after 6 weeks with recurrent fever and purulent discharge from the penetrating entry wound site. CECT of the abdomen revealed a retained perihepatic abdominal swab. The retained swab was removed surgically and the patient had an uneventful recovery.
Case III
A 47-year-old lady, known cases of hydatid cyst liver operated on 9 years back, presented with dull aching pain in the right upper quadrant. She was evaluated and imaging suggested recurrent hydatid cyst liver Segment V and VI. She underwent open cystopericystectomy and an abdominal swab found incidentally in the right subhepatic region was removed.
| Discussion | | |
Definition
RSI after any surgical procedure is an avoidable error. The earliest incidence of RSI was reported in 1859 when a sea sponge was lost in the operative wound.[1] The term “Gossypiboma” is used to describe RSI which is cotton or cottonoid in nature.[2] Gossypiboma is derived from the Latin word Gossypium (cotton) and Swahili boma (enclosure). It causes immense biological reactions leading to significant morbidity and mortality.
Incidence
The actual incidence of RSIs including gossypiboma is not known due to low clinical reporting and associated medicolegal issues. The estimated incidence of a retained surgical sponge is 1/8801–18760 per abdominal operation.[1],[3] RSI is more common in abdominal and pelvis surgeries and a surgical sponge is more misplaced or missing than needles and instruments.
Risk factors
The risk factors for retained foreign bodies including surgical sponges have not been studied much. Gawande et al. analyzed several factors of surgical procedure that could affect the incidence. These were emergency surgery, unexpected change in surgical plan, prolonged surgery with more than one surgical team involved, change in nursing staff during surgery, increased body mass index, the volume of blood loss, female sex, and surgical counts.[3] In their study, only three factors were statistically significant by matched multivariate logistic regression. These were emergency surgery (33% vs. 7%, P < 0.001), an unexpected change in a surgical procedure (34% vs. 9%, P < 0.001), and higher mean body mass index.[3],[4]
Biological response of gossypiboma
A retained surgical sponge may have a variable biological response such as inflammatory, septic, and aseptic response. The septic inflammatory response has an exudative, acute inflammatory reaction with the formation of an abscess close to the retained surgical sponge. These patients present in the early postoperative period and are potentially detected and treated early.[1],[5] The aseptic fibrotic type of response leads to the development of mass in relation to the retained sponge. This leads to mass and pressure effect on adjacent abdominal viscera leading to the development of abdominal mass, erosion of bowel loops, and fistula formation.[5],[6],[7] These patients have delayed clinical presentation with an abdominal mass, malabsorption, pain abdomen, vomiting, and weight loss.[1],[5],[6] Sometimes, patients present after a prolonged interval with the suspicion of abdominal tumor.
Clinical features
These patients may have an immediate, acute, or delayed clinical presentation. The location of the foreign body in the abdomen, its relation to the bowel, and tissue reaction determine the formation of adhesions, erosions, and/or formation of internal or external fistulae.[1],[5],[6] Presence of a foreign body should be suspected in all patients who present with unexplained sepsis, intestinal obstruction, and palpable abdominal mass on a background of previous laparotomy. The patient may present with unrelated symptoms and a gossypiboma incidentally detected on radio-imaging. Most of the patients present with intra-abdominal abscess, fistula, and intestinal obstruction in postoperative period.[6],[7],[8] A few patients have very dormant sequelae and the present after years of the index surgery, with suspected intra-abdominal tumors.
Imaging
Plain X-ray of the abdomen helps to detect metallic foreign bodies such as surgical instruments and needles. Surgical sponges with radiopaque markers can also be detected in the early postoperative period.[1] CECT of the abdomen is the investigation of choice for detecting retained surgical instrument as well as gossypiboma.[9] It can detect the position of foreign bodies in relation to intra-abdominal organs. It can also detect complications such as fistula or perforation of bowel. On CECT scan, the gossypiboma has a characteristic spongiform pattern with gas bubbles.[9] This appears as a low-density mass with peripheral wall enhancement with air bubbles inside. Sometimes, it is very difficult to differentiate this appearance from a loaded colon. If gossypiboma has eroded into the bowel, it appears stretched due to drag and peristaltic movement. This appearance has been called “stretched faeces sign.”[10] A long-standing gossypiboma may have calcification of wall and fibers of surgical sponge which can be detected as a calcified reticulate ring. CECT scan of the abdomen can usually detect surgical sponges, but on many occasions, magnetic resonance imaging may be required to differentiate from soft tissue tumors. A surgical sponge appears as a soft tissue-density mass with a thick well-defined capsule. The mass appears hypointense on T1-weighted images and has whorled an internal configuration on T2-weighted images.[9] Researchers have also used barium studies to delineate bowel erosions and fistula caused by gossypiboma.[1]
Management
All foreign bodies including surgical sponges once detected need surgical removal. Initial resuscitation for sepsis, obstruction, or fistula should be followed by surgical exploration.[1] A surgical sponge is walled off by dense adhesions with bowel loops and omentum. Hence, meticulous dissection is needed to remove surgical sponges or foreign bodies. Eroded bowel and fistula may require resection, diversion, or reconstruction of the affected bowel segment. Minimally invasive and percutaneous extraction of foreign bodies has been successful in a few cases.[11] Metallic small foreign bodies, where removal caries more risk of damage, should be left inside.[1]
Medicolegal status
In RSIs, the doctrine of Res ipsa loquitur, or “the thing speaks for itself,” applies. Here, an expert witness for proof of negligence is not required and this leads to the indefensible medicolegal condition.[1] The litigation has a detrimental effect on the surgeon's professional reputation as well as his social and financial life. The reason to sue the surgical team is also determined by poor communication and insensitive handling of the incident.[12] Apart from seeking compensation for pain and suffering, the other reason for litigation is a concern for standard care, explanation of the incident, fixing the accountability, and lesson for future improvement in care.[12]
Prevention
RSI is an avoidable and unwarranted condition for surgical team as well as for patients. Most incidents occur following emergency and prolonged surgery.[3],[13] The surgical team should be extra vigilant for prevention. It is a safe practice to examine the operative field and the peritoneal cavity thoroughly after the surgery.[4] The use of radiographically detected surgical sponge (barium impregnated thread or radiopaque markers) has been recommended.[1] These sponges can be detected on a plain radiograph in case of postoperative surgical count mismatch; however, in few cases, it is difficult to detect it. Multiple intraoperative (preoperative and postoperative) surgical count checks are most effective preventive measure for RSIs.[1],[13]
| Conclusion | | |
RSI is an inadvertent surgical error which causes significant morbidity, mortality, and medicolegal issues. The biological response, location of surgical sponge, and time of detection of RSIs determine the clinical feature and surgical management. Possibility of gossypiboma should be considered in all postoperative patients presenting with unexplained sepsis, intestinal obstruction, and intra-abdominal mass. Standard surgical safety measures in the operative room can help to prevent this complication.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 9. | Manzella A, Filho PB, Albuquerque E, Farias F, Kaercher J. Imaging of gossypibomas: Pictorial review. AJR Am J Roentgenol 2009;193 Suppl 6:S94-101. |
| 10. | Yadav MK, Lal A, Nagi B. Gossypiboma: Stretched feces sign. AJR Am J Roentgenol 2010;195:W375. |
| 11. | Nosher JL, Siegel R. Percutaneous retrieval of nonvascular foreign bodies. Radiology 1993;187:649-51. |
| 12. | Vincent C, Young M, Phillips A. Why do people sue doctors? A study of patients and relatives taking legal action. Lancet 1994;343:1609-13. |
| 13. | Greenberg CC, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The frequency and significance of discrepancies in the surgical count. Ann Surg 2008;248:337-41. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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