Chronic Nonhealing Wound Due To Iatrogenic Foreign Body— A Case Report

ABSTRACT

A 5-year-old male child presented with nonhealing wound on the left scapular region. He had a history of multiple abscesses 8 months back. Incision and drainage were done for all abscesses in the same sitting at another hospital. All wounds healed except one of the scapular regions. The wound was explored and there was large cotton gauze inside the wound. The common causes of nonhealing of wound are tuberculosis, malignancy, and immunodeficiency. However, iatrogenic foreign body is also an important cause and should be considered in differential diagnosis. Careful history, wound examination, and radiological investigations are an important tool for diagnosis of retained foreign bodies. The scientific term for the retained foreign body is gossypiboma or textiloma.

INTRODUCTION

Chronic nonhealing wound leads to stress for parents and doctors. Any nonhealing wound should be examined carefully, proper history taking, details of previous surgery, and any systemic disorders. Foreign bodies can be found in the abdomen, solid organs, and soft tissue.[1,2] The gossypiboma in soft tissue most commonly present as nonhealing wound. The presenting symptoms depend on site of retained foreign body. The incidence of surgical retained foreign body is 0.001%–0.01%.[3]

CASE REPORT

A 5-year-old male child presented with chronic wound on the left scapular region. He had a history of multiple abscesses with fever 8 months back. He was admitted to another hospital for this problem. There were total four abscesses, two on both lower limb, one in abdominal wall, and one at scapular region. He was operated for these abscesses under general anesthesia. Incision and drainage of all abscesses were done in the same sitting. He was on regular dressing of all wounds. Three wounds healed over the time except of scapular region. He was on oral antibiotics and regular dressing. Wound swab culture was also done and showed no growth. Parents were very apprehensive regarding nonhealing of wound.

We examined the child very carefully and took a thorough history. There was no significant birth history. Initially, the child was worked up for tuberculosis (TB) as this is very prevalent in our area. No family history of TB was present. His weight was according to his age. Monteux test along with TB gold was done and found negative. There was no history of any malignancy. There was no history of diabetes mellitus. On examination, wound had small sinus opening with granulation tissue on top [Figure 1]. It was just lateral to medial border of the left scapula. There was puckering of skin mimicking osteomyelitis. Then we planned for radiological investigations such as X-ray chest and ultrasound of wound.[4] X-ray chest was normal with normal rib spaces and lung shadow. Ultrasound of local region showed acoustic shadow with strong suspicion of foreign body [Figure 3]. Then, contrast-enhanced computed tomography (CT) chest was done to look for any intrathoracic extension of foreign body [Figure 4]. There was no intrathoracic extension with normal ribs and normal lung shadow on CT scan chest. Then planning of re-exploration of wound was done.[5] A routine hemogram along with viral markers was done. Hemoglobin was 10.8 g, total white blood cells counts were 10,000 and platelets were within normal limits. Viral markers were negative. Under general anesthesia with intubation patient was placed in semiprone position. A transverse incision was over the wound including the top of a wound. On deeper dissection, we found large cotton gauze was deep to muscular plane. It was densely adhered to surrounding structures. Whole cotton gauze along with surrounding chronically inflamed tissue was excised and wound was cleaned thoroughly. Primary closure of wound was done. A small corrugated drain was kept and was removed after 48 h. The patient was kept on oral antibiotics for 7 days. The wound healed without any complications. Stitches were removed on 10^th postoperative day.

Figure 1.

Small wound with granulation tissue on top

Figure 3.

Ultasound of local region

Figure 4.

CECT Chest

DISCUSSION

Surgical site infection is affected by multiple factors such as the infecting organisms, local wound environment (foreign body and dressing of wound), and systemic host defense mechanism (diabetes, carcinoma, and chemotherapy).[6] Foreign bodies having tendency to cause inflammatory reaction in the body.[7] It can be metal implant, shunt tubes, or any cotton gauze.[8] It can be found in any part of the body such as abdominal cavity, solid organs (liver, spleen, kidney, and bones), and soft tissue. The presentation depends upon the sites and nature of foreign body [Figure 2].[9] The foreign body in soft tissue mostly present as sinus or nonhealing ulcer. The scientific term for retained foreign body is gossypiboma that is derived from two words Gossypium (cotton) and Boma (place of concealment). Earlier it was termed as textiloma. The surgical cotton gauge is the commonest retained foreign body. Gossypiboma in our case was packing cotton gauze deep to muscular plane. Hence, it presented as nonhealed wound with small sinus opening and granulation tissue on top of a wound. As it was inside for about 8 months, so surrounding structures were chronically inflamed and adhered. Therefore, excision of cotton gauze along with surrounding chronically inflamed tissue was done. As the patient was on continuous treatment at different hospitals, antibiotics were given on and off along with regular dressing. Any nonhealed wound should be examined carefully. Radiological investigation is very useful to rule out any suspected foreign body. Any child operated for multiple abscesses the counting of cotton gauze is of utmost important. Preferably one end of gauze should be brought outside the wound. Although retained foreign body is rare, it should be considered as an important differential diagnosis in nonhealing chronic wound.

Figure 2.

Excised foreign body

Medico legally when a patient dies due to medical negligence doctor is made liable to civil law for paying compensation in Tort if proven. However, if there is gossypiboma, it comes under the doctrine of res ipsa loquitur[10] means that the thing speaks for itself. As it comes under gross negligence the doctor is made criminally liable for the offence under 304-A IPC.

To prevent gossypiboma cotton gauge or sponges should be counted by hand before and after surgeries. The Association of Perioperative Registered Nurses recommended guideline in 1970. Four separate counts are recommended – (a) at the time of unpacking and set up, (b) before the beginning of surgery, (c) when closure starts, and (d) at the time of final skin closure. The WHO recommended that count should always be done separately in a consistent sequence by two similar persons with their names being noted in the count sheet or nursing record.

CONCLUSION

Retained foreign body (gossypiboma) is a rare cause of chronic nonhealing wound but is an important differential diagnosis that’s often missed. It is completely avoidable and rarely documented. Radiological investigation like ultrasonography of local region and CT scan is an important tool to make diagnosis.[11] Counting of packing gauze, proper dressing, and keeping one end of gauze outside the wound can prevent such type of complications in children.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed

Financial support and sponsorship

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Conflicts of interest

There are no conflicts of interest.