Gossypiboma: Contrast-enhanced computed tomography for detection and foolproof management

Shivi Jain; Shuchi Jain; Vaibhav Jain; Madhu Jain

doi:10.4103/0972-4958.135228

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CASE REPORT

Year : 2014 | Volume : 28 | Issue : 1 | Page : 40-42

Gossypiboma: Contrast-enhanced computed tomography for detection and foolproof management

Shivi Jain¹, Shuchi Jain², Vaibhav Jain³, Madhu Jain²
¹ Department of Radio diagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
² Department of Obstetrics and Gynecology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
³ Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication

24-Jun-2014

Correspondence Address:
Prof. Madhu Jain
G-11, Lal Bahadur Shastri Nagar Colony, Karaundi, Varanasi - 221 005, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0972-4958.135228

Abstract

The word 'gossypiboma' or 'textiloma' is used to describe a retained surgical sponge in the body after an operation. If it is left in the abdomen, it may cause serious morbidity and mortality of the patient as well as medico-legal problems. It varies between 1 out of 1,000-1,500 intra-abdominal operations and 1 out of 300-1,000 of all operations. Herein, we report two cases, the first presenting 1.5 years after cesarean section with fever and purulent vaginal discharge and the second, two years after with abdominal swelling and pain. The contrast-enhanced computed tomography (CECT) proved to be diagnostic and guided towards proper management. Imaging detected trans-visceral migration of the sponge in the first case and improved the prognosis. High degree of suspicion raised by imaging and correlation with clinical picture are the cornerstone for a good outcome.

Keywords: Gossypiboma, retained surgical sponge, textiloma, trans-visceral migration

How to cite this article:
Jain S, Jain S, Jain V, Jain M. Gossypiboma: Contrast-enhanced computed tomography for detection and foolproof management. J Med Soc 2014;28:40-2

How to cite this URL:
Jain S, Jain S, Jain V, Jain M. Gossypiboma: Contrast-enhanced computed tomography for detection and foolproof management. J Med Soc [serial online] 2014 [cited 2023 Apr 1];28:40-2. Available from: https://www.jmedsoc.org/text.asp?2014/28/1/40/135228

Introduction

Gossypiboma is a word derived from " gossypium" (means cotton in Latin) and " boma" (means place of concealment in Swahili). It is a rare complication of surgery. Also known as textiloma or cottonoid, it describes a mass in the body that comprises retained surgical sponge and reactive tissue. Gossypibomas may appear even years after surgery with non-specific clinical features. Herein, we present two such cases where early diagnosis with contrast-enhanced computed tomography (CECT) saved the life of the patients, along with a brief review of literature.

Case Reports

Case 1

A 21-year-old female with history of cesarean section done outside 1.5 years back presented with fever for one month, weight loss, and purulent discharge per vagina. Per abdomen, uterus was 20 weeks size with localized tenderness and rigidity. Per speculum examination revealed purulent discharge. Per vaginal examination showed a tender soft and fluctuant swelling anterior to uterus. Per rectal examination showed no evidence of collection in pouch of Douglas.

X-Ray abdomen was not informative. Trans-vaginal sonography (TVS) revealed an echogenic structure lying anterior to uterus with dense posterior shadow raising suspicion of a foreign body. Associated rent of size 1.8 cm was seen in anterior uterine wall, through which air foci in the uterine cavity were observed communicating with those in the echogenic structure.

CECT abdomen demonstrated a thick-walled cavity lying anterior to uterus that contained multiple air locules with typical spongiform appearance [Figure 1]a and b and surrounding fat stranding favoring presence of retained sponge with walled-off inflammation. Additionally, air locules in the cavity were clearly delineated to communicate with air of the cecum raising possibility of focal cecal perforation (trans-visceral migration of the sponge).

Figure 1: (a and b) (Case 1): Coronal and axial CECT abdominal sections show air locules of the cavity containing sponge (asterisk) communicating with cecal air (arrow) raising the suspicion of trans-visceral migration of sponge. Fat planes with the uterus are ill-defined supporting possibility of uterine perforation (c and d) (Case 2): Axial and sagittal CECT abdominal sections show a well-defined cavity with anteriorly placed air-fluid level (arrow) indicating abscess formation with the nidus being retained sponge (asterisk), which is identified by its characteristic mottled air/spongiform appearance

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Laparotomy showed dense adhesions on anterior surface of uterus. Adhesiolysis revealed a swab, which was removed [Figure 2]a. The pus-filled cavity showed communication with uterus on one hand and with cecum on the other. While the 2 cm rent present on anterior surface of uterus was stitched, the rent on cecum was converted into a temporary cecostomy, which was closed subsequently in follow-up.

Figure 2: (a) (Case 1): Per-operative photograph reveals the retained surgical sponge (asterisk) within a pus-filled cavity (arrow) (b) (Case 2): Per-operative photograph reveals large amount of intra-peritoneal pus (arrow) as the surgical sponge (asterisk) is being pulled out

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Case 2

A 30-year-old female presented with a swelling in central abdomen for three months and associated off and on pain and swelling. She had cesarean section done two years back. The abdominal skin was red, tender, and had a fluctuating mass.

Ultrasound (not shown) showed gas shadows underlying the skin surface hampering proper assessment. CECT abdomen revealed a well-defined thick-walled hetrodense intra-peritoneal lesion of size 11.0 × 15.3 × 14.0 cm showing air-fluid level anteriorly and multiple small air locules in characteristic spongiform appearance centrally unveiling presence of a retained sponge inciting formation of an abscess ([Figure 1]c and d). Surrounding significant fat stranding was also noted. The lesion showed ill-defined fat planes with anterior abdominal wall muscles and was seen compressing the jejunal loops posteriorly.

Laparotomy revealed a swab of about 15 × 11 cm and was removed. Two liters of pus present in a walled-off cavity was drained following the removal of the swab [Figure 2]b.

Discussion

The problem of retained foreign body is old and will perhaps remain as a hazard in every operative procedure if utmost care is not exercised. The most frequent type of foreign body left inside the abdomen during surgery is laparotomic gauze (69%), followed in the order of frequency by artery clamps, other smaller instruments, irrigation material etc.

The first reported and published case of "foreign body left in the abdomen" was by Crossen and Crossen in 1940. ^[1] Retained sponges are most frequently observed in patients with obesity, during emergency operations, and following laparoscopic interventions. Although most frequently found in the intra-abdominal cavity, they can also be seen in paraspinal muscles, intrathoracic region, legs, shoulders, and pericardial space.

The gossypiboma cases can lead to embarrassment, humiliation, loss of job, and law suit worldwide. Data concerning the actual incidence is difficult to estimate because of a low reporting rate due to medico-legal implications. It varies between 1 out of 1,000-1,500 intra-abdominal operations and 1 out of 300-1,000 of all operations. ^[2] It is difficult to recognize a gossypiboma by using simple radiological screening as the cotton sponge commonly used does not have any radiological marker. Moreover, the cotton can simulate hematoma, granulomatous process, abscess formation, cystic mass, or even a neoplasm.

The possibility of a retained foreign body should be considered in the differential diagnosis of any patient post-operatively presenting with pain, infection, or palpable mass. The low index of suspicion is due to rarity of the condition and latency in the manifestation. If the diagnosis is made early, laparoscopic retrieval may be feasible. As per an article, gossypibomas were commonly found in the abdomen (56%), pelvis (18%), and thorax (11%). The most common method of detection was computed tomography (61%), radiography (35%), and ultrasound (34%). Pain/irritation (42%), palpable mass (27%), and fever (12%) were the leading signs and symptoms, but 6% of cases were asymptomatic. Complications included adhesion (31%), abscess (24%), and fistula (20%). Average time of its discovery was 6.9 years with a median (quartiles) of 2.2 years (0.3-8.4 years). ^[3] The longest time for gossypiboma to remain in the body has been reported as 23 years following cesarean section. ^[4]

Migration of retained sponge in bowel is rare compared to abscess formation and occurs as a result of inflammation in the intestinal wall that evolves to necrosis. The intestinal loop closes after complete migration of sponge. Detection of trans-visceral migration of swab into cecum in our first case was possible only with CT. The unique feature in this patient was that she did not have any complaint suggesting involvement of the bowel. Simple removal of the sponge without paying any attention to the cecal rent would have resulted into dreadful morbidity.

The inflammatory granulomatous reaction is the most likely cause of the extra-osseous accumulation of technetium-99m-methylene diphosphonate (Tc-99m MDP) in gossypibomas as studied by nuclear medicine study. ^[5] On CT, a gossypiboma may manifest as a cystic lesion with internal spongiform appearance with mottled shadows as bubbles, hyperdense capsule, concentric layering, or mottled mural calcifications. ^[6] When no radiopaque marker is seen on x-ray or CT, the characteristic internal structure of the gauze granuloma is best revealed on magnetic resonance imaging (MRI). MRI features of gossypiboma in the abdomen and pelvis include the delineation of a well-defined mass with a peripheral wall of low signal intensity on T1- and T2-weighted imaging, with whorled stripes seen in the central portion and peripheral wall enhancement after intravenous gadolinium administration on T1-weighted imaging.

Gossypibomas are thus uncommon, mostly asymptomatic, and difficult to diagnose. Particularly chronic cases do not show specific clinical signs. Proper imaging and surgical management play significant role.

Acknowledgements

We are thankful to Dr. M. A. Ansari, Associate Professor in Department of General Surgery, and Dr. Ashish Verma, Asst. Professor in the Department of Radio diagnosis and Imaging, Institute of Medical Sciences, Banaras Hindu University, Varanasi for their expert advice and supervision.

References

1.	Crossen HA, Crossen DF. Foreign bodies left in the abdomen. St. Louis: CV Mosby Co. Publishers; 1940. p. 49.
2.	Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained foreign bodies after surgery. J Surg Res 2007;138:170-4.
3.	Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: A systematic literature review of retained surgical sponges. CurrOpinAnaesthesiol 2009;22:207-14.
4.	Sümer A, Carparlar MA, Uslukaya O, Bayrak V, Kotan C, Kemik O, et al. Gossypiboma: Retained surgical sponge after a gynecologic procedure. Case Report Med 2010;2010. pii: 917626.
5.	Thomas BG, Silverman ED. Focal uptake of Tc-99m MDP in a gossypiboma. ClinNucl Med2008;33:290-1.
6.	Murphy CF, Stunell H, Torreggiani WC. Diagnosis of gossypiboma of the abdomen and pelvis. AJR Am J Roentgenol 2008;190:W382.