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 Table of Contents  
IMAGES IN ACADEMIC MEDICINE
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 106-108

Gossypiboma: A clinical vignette and summary of radiologic characteristics


1 Department of Surgery, St. Luke's Hospital, Bethlehem, PA, USA
2 Department of Family Medicine, St. Luke's Hospital, Bethlehem, PA, USA
3 Department of Internal Medicine, St. Luke's Hospital, Bethlehem, PA, USA

Date of Submission01-Oct-2015
Date of Acceptance28-Nov-2015
Date of Web Publication2-Jun-2016

Correspondence Address:
Sudip Nanda
Department of Internal Medicine, St. Luke's Hospital, 801 Ostrum Street, Bethlehem, PA 18015
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-5568.183318

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  Abstract 

Gossypibomas are rare in modern surgery; however, present a significant medico-legal dilemma when they do arise. Treatment is surgical retrieval after identification. When seen years after the original procedure, a diagnostic dilemma arises. Diagnosis via radiologic means is often unreliable, thus, diagnosis involves excision or core needle biopsy. In this unique case, we were forced to make a diagnosis without tissue confirmation due to patient request. Gossypibomas have been described as having highly variable appearance on computed tomography, and thus, radiologic diagnosis is considered unreliable. Often, the characteristic spongiform appearance typically used to describe chronic gossypibomas is not observed. In our case, matching the radiodensity of surgical gauze with that of the gossypiboma helped to make a correct diagnosis, suggesting that radiologic diagnosis is possible in certain cases.
The following core competencies are addressed in this article: Medical knowledge, Patient care, Practice based learning and improvement, Systems based practice.

Keywords: Gossypiboma, hounsfield units, radiodensity


How to cite this article:
Lin A, Fegley M, Singh A, Nanda S. Gossypiboma: A clinical vignette and summary of radiologic characteristics. Int J Acad Med 2016;2:106-8

How to cite this URL:
Lin A, Fegley M, Singh A, Nanda S. Gossypiboma: A clinical vignette and summary of radiologic characteristics. Int J Acad Med [serial online] 2016 [cited 2020 Jan 29];2:106-8. Available from: http://www.ijam-web.org/text.asp?2016/2/1/106/183318


  Introduction Top


Gossypibomas are increasingly rare with advances of modern surgery. However, they do occur from time to time, in general surgery or specialties such as cardiothoracic surgery or neurosurgery.[1],[2],[3] The rate of retained surgical foreign bodies has been published in literature to be 0.3–1.0/1000 surgeries in the case of abdominal surgery.[4] However, given the medico-legal challenges that this problem presents, this number may be underestimated due to under-reporting. Risk factors for retained surgical objects include high intraoperative blood loss, duration of operation, sub-procedures, unexpected intraoperative factors, and incorrect or lack of surgical counts.[5] Sequelae of retained foreign bodies have been reported to include, in severe cases, intestinal obstruction, urinary retention, fistula formation, perforated viscous, abscess formation, sepsis, and transmural migration (most commonly intestinal).[6],[7],[8] However, because of nonspecific symptoms and presentation that can occur years after surgery, a high index of suspicion is necessary in any patient with surgical history who presents with subacute or acute abdominal pain. Usually, the diagnosis is straightforward, if anticipated, and is made either by excision or core needle biopsy.[9] This was a unique situation where the diagnosis was made without tissue confirmation.

Generally, gossypibomas present variably on computed tomography (CT) scan which makes radiologic diagnosis difficult. The characteristic appearance that has been described in literature is a spongiform pattern that occurs when air becomes trapped in the object.[10] However, only a minority of gossypibomas have this appearance on imaging. They can otherwise present either as low density, high density, or heterogeneous structures on CT scan.


  Case Report Top


A 61-year-old Caucasian female with a known history of ovarian tumor that had been successfully treated previously, presented with lower gastrointestinal bleeding. Colonoscopy revealed normal colon with grade I hemorrhoids in the rectum. However, CT scan of the abdomen revealed a soft tissue mass with hyperdense content in the right lower abdomen [Figure 1]. She had a history of portal and splenic vein thrombosis with an extensive collateral formation that involved the abdominal wall. Comorbidities included asthma, diabetes mellitus, left hemiparesis, hypertension, congestive heart failure, atrial fibrillation, hypothyroidism, lower limb deep vein thrombosis with pulmonary embolism, anemia, and portal hypertension with massive splenomegaly. The patient refused any invasive diagnostic or therapeutic procedures unless the incidentally discovered mass was a tumor. A preprocedure diagnosis was imperative.
Figure 1: Sagittal and axial cross section computed tomography images displaying mass. Arrows showing the sponge – gossypiboma with tissue reaction forming a cystic structure. The sponge is the gossypiboma and not the entire cystic mass formed by tissue reaction

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Incomplete tumor resection and recurrent ovarian tumor were discussed despite the fact that she was considered cured from her ovarian tumor. The possibility of gossypiboma with surrounding tissue reaction was entertained in view of the regular circumscribed nature of the mass and the uniform nature of its hyperdense content. The radiodensity of the hyperdense material within the intra-abdominal mass was similar to that of surgical gauze as measured in Hounsfield units, confirming the diagnosis of gossypiboma. The patient did not undergo any procedure and is still alive 3 years after her diagnosis suggesting that the mass does not represent a malignancy, and the diagnosis of gossypiboma was correct.


  Discussion Top


Gossypiboma is derived from the Latin word “gossypium”-cotton and boma-place of concealment.[4] The risk of retention of a foreign body after surgery significantly increases with high intraoperative blood loss, long operations, multiple sub-procedures, incorrect or lack of surgical counts, unexpected intraoperative events, or cases involving multiple surgical teams.[5] Recent meta-analysis did not identify increased body mass index or emergency surgery as statistically significant risk factors.[5] Gauzes account for two thirds of retained surgical items while instruments account for the rest.[1] Although most commonly detected in the abdomen and pelvis, it has been associated with all types of procedures,[4] including cardiothoracic surgery [2] and neurosurgery.[3] Because gossypiboma is not anticipated, it is frequently misdiagnosed and oftentimes radical surgical procedures erroneously follow.[4],[5],[6],[7] However, while they are not often anticipated, gossypibomas are theoretically completely preventable. Because of nonspecific symptoms and presentation that can occur years after surgery, a high index of suspicion is necessary in any patient with surgical history who presents with subacute or acute abdominal pain. Sequelae of retained foreign bodies have been reported to include, in severe cases, intestinal obstruction, urinary retention, fistula formation, perforated viscous, abscess formation, sepsis, and transmural migration (most commonly intestinal).[5],[6],[7]

Definitive diagnosis and treatment is determined by retrieval of the foreign body. Previous reports have usually used excision or core needle biopsy to obtain tissue, which on histopathology had revealed gauze and confirmed the diagnosis.[9] Laparoscopic retrieval of the retained foreign body has been described in cases of early detection.[11] However, diagnosis of gossypibomas is often delayed, and the foreign body may not be detected until years following the initial surgery.[12] Endoscopic retrieval has been described in cases of transmural migration into the lumen; however, surgical retrieval of the foreign body is the “gold standard”. In the literature, radiologic diagnosis alone has not been shown to be reliable due to the nonspecificity of retained surgical sponges on imaging and the variability in appearance depending on the location and qualitative characteristics of the sponge itself.[7]

In the current case, we were faced with an extraordinary situation where the patient refused all procedures unless her abdominal mass was a tumor. After counseling, the patient about the potential for mistake with such an approach, the diagnosis of gossypiboma was made based only on CT findings. In our case, we identified the foreign body by matching the Houndsfield units on imaging to that of a surgical sponge. The patient is still alive 3 years after the diagnosis. An abdominal CT done recently for a different indication revealed that the mass has remained approximately the same. In the situation of this particular patient, our experience suggests that in the appropriate situation, radiological diagnosis can be made without other confirmatory correlation.

Because of the medico-legal implications associated with retained surgical objects, vigilance and prevention is paramount.[4] Strategies that have been suggested in literature for prevention include radiography at the completion of any complex procedure prior to wound closure, thorough inspection of the cavity prior to closure, more conservative use of sponges and avoiding the use of small sponges, consistent adherence to counting procedures, and proper attention to the operating room environment.[1], 4, [6],[7],[8],[9] Maintaining a high index of suspicion can be invaluable in this setting.[4]


  Conclusions Top


Surgical retrieval remains the gold standard for definitive diagnosis and treatment of retained surgical foreign objects; however, in certain cases, when the patient refuses surgery, alternative methods must be considered. This was a suboptimal situation where surgical retrieval was not possible, and as such, a radiologic diagnosis was made and the patient was treated with observation. Very rarely in the literature is radiologic diagnosis alone suggested to be adequate for the diagnosis of gossypibomas (in particular, surgical sponges). This is because retained surgical sponges can present such a variable appearance on imaging.

Even in the case of adequate diagnosis, refusal of surgery presents an additional treatment dilemma. There are no studies demonstrating the safety or efficacy of observation or conservative treatment of retained surgical foreign bodies; thus, there are no established recommendations or guidelines regarding observation of retained objects. Fortunately for the current patient, she remained asymptomatic after the standard of care (e.g., surgery) was taken off the table as an option. However, by declining surgery the patient placed herself at risk for a variety of adverse events such as intestinal obstruction, urinary retention, transmural migration, fistula formation, perforated viscous, abscess formation, and sepsis. Even with surgical retrieval being available, prevention remains the best solution for reducing the risk for gossypibomas or other retained surgical objects.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229-35.  Back to cited text no. 1
    
2.
Topal U, Gebitekin C, Tuncel E. Intrathoracic gossypiboma. AJR Am J Roentgenol 2001;177:1485-6.  Back to cited text no. 2
    
3.
Mathew JM, Rajshekhar V, Chandy MJ. MRI features of neurosurgical gossypiboma: Report of two cases. Neuroradiology 1996;38:468-9.  Back to cited text no. 3
    
4.
Stawicki SP, Evans DC, Cipolla J, Seamon MJ, Lukaszczyk JJ, Prosciak MP, et al. Retained surgical foreign bodies: A comprehensive review of risks and preventive strategies. Scand J Surg 2009;98:8-17.  Back to cited text no. 4
    
5.
Moffatt-Bruce SD, Cook CH, Steinberg SM, Stawicki SP. Risk factors for retained surgical items: A meta-analysis and proposed risk stratification system. J Surg Res 2014;190:429-36.  Back to cited text no. 5
    
6.
Lata I, Kapoor D, Sahu S. Gossypiboma, a rare cause of acute abdomen: A case report and review of literature. Int J Crit Illn Inj Sci 2011;1:157-60.  Back to cited text no. 6
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7.
Lv YX, Yu CC, Tung CF, Wu CC. Intractable duodenal ulcer caused by transmural migration of gossypiboma into the duodenum – A case report and literature review. BMC Surg 2014;14:36.  Back to cited text no. 7
    
8.
Cruz RJ Jr., Poli de Figueiredo LF, Guerra L. Intracolonic obstruction induced by a retained surgical sponge after trauma laparotomy. J Trauma 2003;55:989-91.  Back to cited text no. 8
    
9.
Wan YL, Ko SF, Ng KK, Cheung YC, Lui KW, Wong HF. Role of CT-guided core needle biopsy in the diagnosis of a gossypiboma: Case report. Abdom Imaging 2004;29:713-5.  Back to cited text no. 9
    
10.
Kalovidouris A, Kehagias D, Moulopoulos L, Gouliamos A, Pentea S, Vlahos L. Abdominal retained surgical sponges: CT appearance. Eur Radiol 1999;9:1407-10.  Back to cited text no. 10
    
11.
Uranüs S, Schauer C, Pfeifer J, Dagcioglu A. Laparoscopic removal of a large laparotomy pad forgotten in situ. Surg Laparosc Endosc 1995;5:77-9.  Back to cited text no. 11
    
12.
Rajagopal A, Martin J. Gossypiboma – “A surgeon's legacy”: Report of a case and review of the literature. Dis Colon Rectum 2002;45:119-20.  Back to cited text no. 12
    


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