Asymptomatic gossypiboma with complete intramural migration and ileoileal fistula

Abstract

Retained gossypiboma is a rare and under-reported complication of surgery, which can present in a variety of ways. Thus, a very high index of suspicion is required by the clinician to clinch the diagnosis in a postoperative patient. A 45-year-old woman, who was otherwise asymptomatic, presented to the General Surgery outpatient department (OPD) with a contrast-enhanced CT suggestive of a retained intra-abdominal foreign body from previous surgery. An exploratory laparotomy was planned on elective basis. Intraoperatively, dense inter-bowel adhesions were found in the upper abdomen. After a meticulous adhesiolysis, an ileoileal fistula and an intraluminal surgical sponge were discovered. Resection and anastomosis of the involved ileal segment was done. An asymptomatic patient with a migrated intramural gossypiboma with an ileoileal fistula is an extremely rare occurrence. In these circumstances, it becomes almost impossible for the surgeon to clinch the diagnosis of a gossypiboma in an otherwise asymptomatic patient, without the aid of radiological investigations.

Background

Out of the millions of operations performed every year, it is reported that a foreign body is left behind in about 0.001%–0.01% of patients. Out of these foreign bodies, about 80% are reported to be surgical sponges.¹ Furthermore, a foreign body is left behind in approximately 1 of every 550 major operations performed.² This unfortunate complication has been described in all types of surgical procedures; including those of abdomen, head and neck and thoracic regions.³

An accidental retention of a surgical sponge in the abdomen following a difficult procedure is an avoidable, unfortunate but a frequently reported incident. The real incidence of such complications is difficult to estimate due to under reporting of such cases to avoid medico-legal complications and embarrassment for the surgical team.^{4 5} The retained surgical sponges can lead to events which could be devastating for both, the patient and the surgeon who operated. Several factors contribute to such an occurrence. These include untrained nursing and surgical team, inexperienced surgeon, long and complex procedures and inadequate operating facilities.⁶ Terms that are used to describe these retained sponges include textiloma, cottonoid, cottonballoma and gauzeoma.⁷ The most prevalent terminology used for retained surgical sponge is ‘Gossypiboma’, which has been coined from the merger of two words, ‘gossypium’ and ‘boma’. ‘Gossypium’ is a latin word, which means cotton; whereas, ‘boma’ is a Swahilli word which means place of concealment.⁸

A retained sponge can lead to two pathological reactions: aseptic or exudative. The aseptic response leads to a fibrotic reaction which leads to development of a mass. Exudative reaction leads to an inflammatory reaction leading to abscess formation. Intraluminal migration of a gossypiboma is a rare but reported complication.⁹

Patients with gossypiboma can have various presentations, ranging from mild abdominal discomfort to symptoms of intestinal obstruction like abdominal distention, vomiting, non-passage of faeces and flatus or may even lead to malabsorptive states leading to weight loss.^{10 11} Therefore, although rare, a possibility of gossypiboma should be considered in a postoperative patient presenting with even mild abdominal discomfort. Radiological investigations like abdominal X-ray and contrast- enhanced CT (CECT) abdomen can be used to confirm the diagnosis. Complications like bowel perforation, visceral perforation, fistula formation and intestinal obstruction can occur. We present in this report, the case of an asymptomatic female patient with retained surgical sponge post hysterectomy with complete transmural migration of the gossypiboma.

Case presentation

A 45-year-old obese woman presented to the surgery OPD of our hospital, 2 years after undergoing a total abdominal hysterectomy for carcinoma of left ovary in a private hospital. The surgical procedure was done on elective basis. She had also received six cycles of taxane-platinum-based chemotherapy. Patient presented with mild abdominal discomfort for 2 months after the procedure, for which an ultrasound and subsequently, a CECT abdomen was done and a diagnosis of a retained sponge or a gossypiboma was made. The patient had been informed of the diagnosis of a retained surgical mop in her abdomen by the radiologist who reported her CECT scan. Patient remained asymptomatic for the next 2 years and was symptom-free even at the time of presentation to our hospital. She had been counselled by a private practitioner, regarding the requirement of another surgery to remove the gossypiboma from the abdomen. She had type II diabetes mellitus since the past 10 years and had been taking oral medications for the same. On physical examination, the heart rate and blood pressure were normal. She was obese and had a body mass index (BMI) of 34. Abdominal examination revealed a lower midline healthy vertical scar. The abdomen was soft, non-tender, non-distended and no palpable lump or organomegaly was present. There was no visible or expansile cough impulse. We could not retrieve any information regarding the surgical sponge count during the prior surgical procedure. The discharge summary of the prior admission for hysterectomy from the private medical centre did not document any information about the surgical sponge count during the procedure.

Investigations

The radiograph of the abdomen (figure 1) showed a radio-opaque curvilinear shadow in the central abdomen. The CECT of the abdomen showed a hypodense area with multiple mottled air foci and a curvilinear hyperdense opacity with minimal peripheral ring enhancement in the supraumbilical region suggestive of a gossypiboma (figures 2–4).

Figure 1.

Radiograph of the abdomen showing radio-opaque marker (black solid arrow).

Figure 2.

Contrast-enhanced CT abdomen coronal section showing the gossypiboma (white solid arrow) with a radio-opaque marker within.

Figure 3.

Contrast-enhanced CT abdomen sagittal section showing the gossypiboma with air foci within (white solid arrow).

Figure 4.

Contrast-enhanced CT abdomen axial section showing the gossypiboma (white solid arrow), linear radio-opaque marker (white pointed arrow) and the presence of oral contrast proximally and distally.

Differential diagnosis

Diseases or conditions which may have a similar presentation to abdominal gossypiboma and are more likely to be erroneously diagnosed include:

1. Intra-abdominal abscess.

2. Intra-abdominal tumour.

3. Intestinal obstruction.

Treatment

Patient was planned for an exploratory laparotomy on elective basis. Intraoperatively, dense interbowel adhesions and clumped bowel loops were visualized in the upper abdomen. An ileal segment was coiled in an inverted ‘C-shaped’ manner with a firm mass palpable within the ‘C loop’ (figure 5). No foreign body or gossypiboma was visible in the peritoneal cavity. After adhesiolysis, resection of the involved ileal segment was done. On straightening the resected bowel loop, an ileoileal fistulous communication was identified within the loop (figures 5 and 6) and an intraluminal retained surgical sponge was found distal to the fistula (figure 7). Hand-sewn anastomosis of the healthy ileal ends was done and a pelvic drain was placed. A meticulous surgical sponge count was done by the nursing staff and re-confirmed by the surgeon. Thereafter, the abdomen was closed in layers.

Figure 5.

Diagrammatic representation of the intraoperative findings.

Figure 6.

Resected gross specimen of affected small bowel showing small bowel ends (black solid arrows) and dismantled ileoileal fistula (white pointed arrow).

Figure 7.

Extracted gossypiboma or surgical sponge from the lumen of small bowel.

Outcome and follow-up

Postoperative recovery was smooth and uneventful. She was allowed orally on postoperative day 3 and discharged on postoperative day 7. The histopathology examination report revealed a 24 cm resected small bowel segment on gross examination. Microscopic examination of the proximal resected end showed submucosal oedema and the distal end showed serositis. Sections from intervening mucosa showed ulceration of lining mucosa with hypertrophy of muscularis propria. Six lymph nodes were isolated; all of which showed reactive changes. Patient is on regular follow-up and is doing fine.

Discussion

Literature review shows that the first case of a retained foreign body after laparotomy was reported by Wilson in 1884.¹² The reported incidence of a retained foreign body ranges from 1 in 100 to 1 in 3000 for all types of surgical procedures.¹³ However, it is believed that this number is an underestimation of the actual incidence; as a lot of cases of gossypiboma go unreported due to fear of medico-legal complications and embarrassment for the surgical team¹⁴ and adversely affecting the self-esteem of the surgeon.

The incidence of leaving behind a foreign body after a procedure in the abdomen is maximum and ranges from 1 in 100 to 1 in 300.¹³ Gossypiboma retention in the abdomen accounts for about 56% of all cases, followed by pelvis in 8% cases and thorax in 11% cases.³

Highest incidence has been seen after open cholecystectomy followed by caesarean section procedures and hysterectomy.¹⁵ The retained gossypiboma, most commonly affects the small intestines, predominantly the ileum.¹³

Certain risk factors have been incriminated for such a disastrous error. These include emergency procedures, long procedures, unplanned change of operating room staff, high BMI of the patient and female gender.^{6 16}

The clinical presentation of such a patient can be varied. The patient may be asymptomatic and is incidentally diagnosed with a retained gossypiboma; as was in this case. They may also present with just mild abdominal discomfort or with severe abdominal pain, abdominal distension or septic shock because of intra-abdominal abscess, intestinal obstruction or bowel perforation. The signs and symptoms depend on the site and size of the offending foreign body and inflammatory reaction produced by the host.^{17 18}

Abdominal radiograph is the most common primary imaging tool used for investigation. It can help detect intestinal obstruction, bowel perforation and can even diagnose a gossypiboma if a radio-opaque marker has been impregnated in the foreign body. Radio-opaque material impregnated surgical sponges have been in practice since 1929, after they were introduced by Cahn.² However, this advantage can also be lost over time as the radio-opaque material tends to disintegrate with time.¹⁹

On ultrasonography, a gossypiboma is usually visualised as a well-defined or cystic mass with linear or wavy internal echogenic area or as a complex hypoechoic region with posterior acoustic shadowing.^{20 21} MRI shows a well-defined mass with low intensity peripheral wall on T1 and T2 weighted images. Peripheral wall enhancement and central stripes are seen with gadolinium contrast.²² However, the investigation modality of choice is a CECT scan. A classical spongiform or mottled pattern due to air bubbling is a pathognomonic characteristic feature. A well-defined mass with a capsule with variable density and calcification is suggestive of a gossypiboma on a CECT scan.^{3 23}

Despite the available investigation modalities, diagnosis can often become difficult to establish as the surgical sponge is made from cotton. Cotton produces an inflammatory reaction, that can mimic a haematoma, abscess, granulomatous process or even a cystic mass or a neoplasm.²⁴

The response of the human body to a foreign substance depends on certain factors, like the antigenicity of the foreign substance and the intensity of the inflammatory reaction it incites.

Classically, two types of host responses have been described:

1. Transudative response—is generated by a gossypiboma of low antigenicity, which elicits a mild inflammatory response. A chronic process ensues, which leads to encapsulation of the gossypiboma resulting in a mass formation followed by adhesions and calcification. Migration of the gossypiboma is a rare feature. The patient usually presents late.^{21 25}

2. Exudative response—generated by a gossypiboma of high antigenicity, eliciting a more severe inflammatory response leading to formation of abscess. Patients usually become symptomatic earlier.

In the exudative response, high pressure is exerted by the gossypiboma on the surrounding structures. If the bowel is in close proximity, it leads to necrosis and breach of the bowel wall. A fold of the sponge may enter the lumen and with the help of continuous bowel peristalsis, the complete mop can enter the lumen and can even migrate distally into the bowel. Eventually, the migrating gossypiboma might get stuck somewhere distally in the small bowel or at the ileo-caecal junction leading to intestinal obstruction.^{25 26} In rare instances, the gossypiboma may negotiate beyond the ileo-caecal junction and be evacuated by defecation.²⁷

A hypothesis of transluminal migration of a gossypiboma has been suggested with the following four stages:

1. Stage of foreign body reaction—the sponge gets walled off by the omentum and intestines.

2. Stage of secondary infection—the cotton filaments reach the lumen of bowel and cytolysis takes place.

3. Stage of invasion into the lumen—mass formation takes place.

4. Stage of remodelling—fibrotic scar formation takes place at the site of breach of bowel wall.²⁶

Once the diagnosis has been confirmed, the treatment of choice, in most cases, is surgery. The procedure involves exploration, release of adhesions and drainage of any abscess, if present, and finally removal of the foreign body. If the gossypiboma is densely adhered to the bowel, a resection and anastomosis of the affected bowel segment may become necessary. Rarely, endoscopic techniques can be used to remove the sponge if it is completely intraluminal.²⁸

A gossypiboma can be a life-threatening complication for the patient and have serious consequences for the operating surgeon. The most effective way to decrease its incidence is to prevent such a catastrophe. The onus of preventing such an event lies not only on the nursing staff but on the operating surgeon as well. Relative ease of communication should exist between the operating team and the nursing staff during any surgical procedure.

Rigorous compliance with procedures and checklists should be followed preoperatively, intraoperatively and postoperatively. Use of sponges impregnated with radio-opaque substances must be encouraged.^{6 29} In an attempt to prevent the incidence of gossypiboma, the association of operating room nurses in 2015 proposed recommendations that consisted of counting of surgical sponges in use at various specified times during the procedure. Counts are performed before beginning the procedure, whenever additional items are brought into operative field, before the body cavity is closed, just before the wound is closed and the final count is done before the surgeon closes the skin.^{29 30}

Although a meticulous counting procedure, such as the one proposed above, can prevent retention in majority of the cases; it has been seen that 88% cases of gossypiboma have taken place in spite of correct counts. This astounding fact suggests that even such a painstaking procedure does not ensure total prevention of gossypiboma. Manual errors in counting, even after a documented correct count, can lead to retention of a sponge.⁶ Therefore, multiple checks and employment of newer methods like automated counting systems with bar codes and counters, radiofrequency labelled sponges and radio frequency readers can be helpful.^{31 32} Although used rarely, an intraoperative abdominal radiograph just before the closure has been shown to be of benefit.³³

A clear and effective communication between the surgical team, operating room nurses and anaesthetists is a sine qua non in reducing the incidence of retained surgical foreign bodies.

Learning points.

• Gossypiboma is an avoidable, unfortunate but reported surgical complication which can have devastating consequences for the surgeon and the patient.

• Presentation of a patient can range from being asymptomatic to one with frank signs of intestinal obstruction and even perforation peritonitis.

• Radiological investigations like abdominal radiograph, ultrasonography and abdominal contrast-enhanced CT scan together with a high index of suspicion in a previously operated patient help in making an accurate diagnosis

• An asymptomatic patient with a migrated intraluminal/intra bowel gossypiboma with an ileoileal fistula is a rare occurrence.

• Surgery remains the treatment of choice. The best way to prevent such a complication is to prevent it by being thorough with the mop count, using bar codes and radio frequency scanners and even an intraoperative radiograph, wherever feasible.