Sonography and computed tomography of a gossypiboma and in vitro studies of sponges by ultrasound. Case report

Gauze for concern: A Case Report and systematic review of delayed presentation of paraspinal textiloma

Textilomas, gossypibomas, muslinomas and gauzomas, otherwise collectively known as Retained Non-absorbable Hemostatic Material (RNHM), are surgical materials such as cotton or gauze pads that are accidentally retained in the surgical bed post-operatively. They may present acutely with signs of infection or may rarely remain chronic and asymptomatic; the latter posing a significant challenge to clinical and imaging diagnosis. Textilomas are not routinely reported due to their medicolegal implications and are usually encountered fortuitously. Here, we report a case of an individual who presented with a non-specific lower backache, had a remote history of lumbar discectomy and in whom a textiloma at the postoperative site was seen to mimic a soft-tissue mass on imaging. In addition, we review current, up-to-date literature on delayed presentations of such retained materials after surgery of the lumbar spine.

Case report

A 43-year-old male presented with pain in his right lower back and gluteal region. He had undergone an L4-L5 discectomy 11 years ago, remained asymptomatic since, and noticed an insidious, worsening pain a week before presentation. Mild tenderness was elicited over the region of pain. A clinical diagnosis of L4-L5 extraforaminal disc prolapse with deep surgical site infection was made. Ultrasound showed an iso-to-hyperechogenic lesion in the right lower paraspinal region. MRI showed a very well-defined, ovoid T1-hypointense and T2-iso-hypointense lesion in the deep posterior paraspinal region of the L4/5 level adjacent to right laminar process of L4 vertebra. The lesion caused scalloping and chronic erosion of the laminar process. No obvious air pockets were present. The features of infection, like soft tissue oedema and collection, were absent. Based on imaging, differentials of nerve sheath tumour and gossipybomas was made. Open wound exploration was performed, which showed a wad of gauze within the right L4-L5 interlaminar space, with thin surrounding granulation tissue. The L4-L5 disc and exiting nerve root were normal. The mass was removed, local washing was done and wound was closed.

Conclusion

Though unfortunate and relatively rare, the possibility of a textiloma must be considered among the differential diagnoses of a mass in the spinal region in the event of prior surgery, no matter how remote the history. Clinical presentation may vary, but the imaging appearance is largely consistent and can be relied upon to prevent unnecessary investigation and facilitate early surgical removal of the offending retained material.

Retention of Nonabsorbable Hemostatic Materials (Retained Surgical Sponge, Gossypiboma, Textiloma, Gauzoma, Muslinoma) After Spinal Surgery: A Systematic Review of Cases Reported During the Last Half-Century

OBJECTIVE

Retention of nonabsorbable hemostatic materials (RNHMs), that is, retained surgical sponge, gauzoma, gossypiboma, muslinoma, or textiloma, is a rarely seen surgical complication after spinal surgery that may remain asymptomatic for many years and may represent a diagnostic difficulty with associated medicolegal implications.

METHODS

We performed a systematic review of the English-language literature published between 1965 and 2017, accessed through 4 popular databases. We found a total of 37 articles (24 case reports; 7 image presentations; 5 clinical series, and 1 letter to editor) containing 58 cases of RNHMs located within the spinal canal or around the spinal column after surgery.

RESULTS

In this study, there were 29 female and 29 male patients from 13 countries, ages ranging from 17 years to 87 years, with initial diagnoses of lumbar or cervical disc herniation, spinal stenosis, or spondylolisthesis (n = 54), or spinal tumor (n = 4). The interval from the initial surgery to the presentation of RNHMs ranged from 13 days to 40 years, with a mean of 75.9 months. Various imaging techniques such as computed tomography and magnetic resonance imaging were used with histologic study, confirming the presence of RNHMs in the majority of patients with a complete recovery resulting in 93% of patients.

CONCLUSIONS

RNHMs is an overreported entity in underdeveloped or developing countries, including Turkey and Morocco, with progression occurring over years. RNHMs should be considered in the differential diagnosis of any patient who presents with back pain, spinal cord, or nerve roots symptomatology after spinal surgery.

What type of imaging work-up will help to confirm the diagnosis of gossypiboma in the limb? Review of literature

Gossypiboma imaging features are not well known and are often confused with soft tissue tumours. Publications on this topic mainly consist of case reports and small cohorts. Its appearance on various imaging modalities is not well defined. This led us to carry out a review of literature to determine specifically: (1) which imaging modalities should be used in cases of suspected gossypiboma, (2) what are the most common imaging findings that contribute to the diagnosis of gossypiboma. An exhaustive review of literature was carried out in June 2015 in the Medline, PubMed and Cochrane databases using the keywords "gossypiboma/textiloma/foreign body". We found 205 articles describing one or multiple cases of gossypiboma in various locations. Of these, the 32 articles that had imaging data were chosen - 16 for the limbs and 16 for other locations. The type of imaging carried out, description of the gossypiboma and circumstances of the discovery and occurrence were recorded. Descriptive statistics were generated to define the type of imaging used and the various findings. Imaging consisted of X-rays in 21/32 cases (66%), computed tomography (CT) in 14/32 cases (43%), magnetic resonance imaging (MRI) in 21/32 cases (65%) and ultrasonography in 14/32 cases (43%). On X-rays, bone involvement was found in 9/15 cases (60%); there was peripheral contrast product uptake on the CT scans in 9/14 cases (64%), a hypointense signal on T1-weighted sequences on MRI in 6/13 cases (46%) and lack of vascularisation in 8/13 cases (62%) and a acoustic shadow on ultrasonography in 9/14 cases (64%). In a patient presenting with a soft tissue lump and history of surgery, an imaging work-up including X-rays, ultrasonography and MRI must be performed. Bone involvement on X-rays, acoustic shadowing on ultrasonography and hypointense signal on T1-weighted MRI sequences with lack of vascularisation in combination with a history of surgery can bring up the possibility of gossypiboma. If there is a possibility of soft tissue tumour, the case should be discussed in a multidisciplinary meeting and a biopsy should be performed first.

LEVEL OF EVIDENCE

IV - systematic analysis of published retrospective studies.

Retained foreign bodies: a serious threat in the Indian operation room

Retained foreign bodies (RFBs) are a surgical complication resulting from foreign materials accidently left in a patient's body. This review attempts to give an overview of different types of RFBs, problems related to them and their management after the surgical operation. The internet was searched using the Google and Google scholar. In addition, relevant electronic journals from the University's library such as Entrez (including PubMed and PubMed central), Since Direct, Scirus, NIH.gov, Medknow.com, Medscape.com, Scopus, MedHelp.org, Cochrane library, WebMD.com, and World Health Organization Hinari. It shows that the major reasons of RFBs are emergency surgical operation with unplanned changes, patient high body mass index, and poor communication. To prevent this textile material should be radiopaque marked and must be counted once at the start and twice at the conclusion of all surgical procedures. If the count is incorrect, then radiography or manually re-exploration should be performed. Ultrasonography, computerized tomography, magnetic resonance imaging and radio frequency identification are also used in the proper identification of RFBs. Safety practice should be robust and simple enough to protect patient under the most chaotic of circumstances. Proper communication among the personnel participating in surgery aimed at preventing this medical negligence would help in mitigating such errors. Finally, the surgeon should not only follow the standard recommended procedure, but also report cases of RFBs.

Foreign body reaction to a retained surgical sponge (gossypiboma) mimicking an implant associated sarcoma in a dog after a tibial plateau levelling osteotomy

A dog was presented with the complaint of an acute onset left pelvic limb lameness three years after a right tibial plateau levelling osteotomy had been performed. Radiographs taken at the time of presentation showed signs that were consistent with a diagnosis of an implant associated sarcoma. At revision surgery, a retained surgical sponge was identified, leading to a diagnosis of a gossypiboma. This is the first reported case of a gossypiboma as a complication of a tibial plateau levelling osteotomy surgery.

A serious medicolegal problem after surgery: gossypiboma

After surgery, the most common foreign bodies retained in the abdominal cavity are the surgical sponges. The aim of the present study was to emphasize the importance of gossypiboma, which is a serious and medicolegal problem. The records of 12 patients with a confirmed diagnosis of gossypiboma after abdominal surgery at Dicle University Hospital were retrospectively reviewed between January 1994 and December 2009. Eight of the 12 patients were females, and 4 were males. Previously, 7 patients had been operated on electively, and 5 had undergone operations on an emergency basis. Abdominal ultrasonography clearly demonstrated gossypibomas in 5 patients, and computed tomography demonstrated a more precise image of retained surgical sponges in 3 patients. One patient died because of ventricular fibrillation; the other 11 patients were discharged in good health. To eliminate the risk of gossypibomas, all sponges should be counted at least twice (once preoperatively and once postoperatively); use of small sponges should be avoided during laparotomy, and only sponges with radiopaque markers should be used. The surgeon should explore the abdomen before closure. In cases in which the sponge count is uncertain, an abdominal x-ray should be performed before closure.

Cystoscopic removal of an intravesical gossypiboma mimicking a bladder mass: a case report

Background

Intravesical retained surgical sponges are very rare and only a few cases have been removed by minimally invasive techniques.

Case presentation

We report a case of an intravesical gossypiboma in a 71-year-old man from western Nepal, who presented with urinary retention and persistent lower urinary tract symptoms one year after open cystolithotomy. He was diagnosed with an intravesical mass using ultrasonography. The retained surgical sponge was found during cystoscopy and removed through endoscopy.

Conclusion

Intravesical gossypibomas are rare and can mimic a bladder mass. This is one of the few reported cases of cystoscopic removal.

Gossypiboma after mandibular contouring surgery

BACKGROUND

Gossypiboma is derived from the Latin word gossypium, meaning cotton, and it means a postoperatively retained foreign body used in operations. Several cases of gossypiboma have been reported especially after abdominal surgery, but there has not been any reported case in plastic surgery. Mandibular contouring surgery cannot ensure a view wide enough to avoid injury to surrounding structures such as a facial artery and a retromandibular vein. In addition, many surgeons pack the sponge into the operative field to prevent bleeding, and surgeons may neglect remnant surgical materials. Recognition of gossypiboma is essential but is often considerably delayed and cause medicolegal problems. Therefore, it is important to ensure that every effort is made to prevent such occurrences. We had a chance to evaluate and treat gossypiboma, and in this paper, we want to share our experiences.

MATERIALS AND METHODS

In circa 1999 to 2007, there were 3 cases diagnosed as gossypiboma after a mandible angle surgery. All patients were female, and some had signs of fever, swelling, tenderness, and purulent discharge of an oral wound. We performed a computed tomographic scan and blood test, and foreign body removal was done under general anesthesia. Intraoperatively, the diagnosis of gossypiboma was confirmed.

RESULTS

All symptoms were reduced or subsided after surgery. It was noted that no postoperative infection remained.

CONCLUSIONS

Gossypiboma must be considered when fever, unilateral swelling, tenderness, or unhealed oral wound is sustained despite an antibiotics therapy and a drainage procedure after a mandible angle surgery. In that case, a computed tomographic scan can be recommended as an effective method for detection of gossypiboma.

Focal uptake of Tc-99m MDP in a gossypiboma

A 51-year-old Korean woman with a history of breast cancer underwent screening bone scintigraphy, which revealed minimal soft tissue uptake of Tc-99m methylene diphosphonate (MDP) in the right lower quadrant. CT and plain films confirmed that the uptake was due to a retained surgical sponge or gossypiboma. The incidence of gossypibomas has been reported at high as 1 in 1000 to 15,000 intra-abdominal operations. The natural progression of an aseptic gossypiboma is a foreign body reaction and granuloma formation. This inflammatory granulomatous reaction is the most likely cause of the extraosseous accumulation of Tc-99m MDP. This entity should be added to the already extensive list of etiologies of extraosseous MDP accumulation.

18F-FDG PET/CT findings of a right subphrenic foreign-body granuioma

We report a case of an 85-year-old woman with a foreign-body granuloma which accumulated 18F-fluorodeoxyglucose (FDG). Unenhanced computed tomography showed a hyperdense mass with a hypodense rim in the right subphrenic space. FDG PET/CT images showed intense FDG uptake in the hypodense rim and little FDG uptake in the center of the mass, showing a ring-shaped appearance. The fusion imaging of FDG PET/CT represented the metabolic features of the foreign-body granuloma. When a ring-shaped FDG uptake is noted in the abdomen of a patient with a history of abdominal surgery, a foreign-body granuloma should be included in the differential diagnosis.

Role of CT-guided core needle biopsy in the diagnosis of a gossypiboma: case report

A 66-year-old woman with previous hysterectomy had dysuria and vaginal spotting for 1 month. Computed tomography showed a heterogeneous presacral mass with eccentric calcification. Biopsies of the bladder and vagina and transrectal biopsy of the pelvic mass yielded only inflammation. T2-weighted magnetic resonance images revealed a heterogeneous mass with wavy hypointensities. Computed tomographically guided biopsy targeting at the calcified area disclosed thread-like materials, thus confirming the diagnosis of gossypiboma.

An unusual cause of small bowel obstruction: gossypiboma--case report

BACKGROUND

The term "gossypiboma" denotes a mass of cotton that is retained in the body following surgery. Gossypiboma is a medico-legal problem especially for surgeons. To the best of our knowledge, the patient presented herein is the second reported patient in whom the exact site of migration of a retained surgical textile material into the intestinal lumen could be demonstrated by preoperative imaging studies.

CASE PRESENTATION

A 74-year-old woman presented with symptoms of small bowel obstruction due to incomplete intraluminal migration of a laparotomy towel 3 years after open cholecystectomy and umbilical hernia repair. Plain abdominal radiography did not show any sign of a radio-opaque marker in the abdomen. However, contrast enhanced abdominal computerized tomography revealed a round, well-defined soft-tissue mass with a dense, enhanced wall, containing an internal high-density area with air-bubbles in the mid-abdomen. A fistula between the abscess cavity containing the suspicious mass and gastrointestinal tract was identified by upper gastrointestinal series. The presence of a foreign body was considered. It was surgically removed with a partial small bowel resection followed by anastomosis.

CONCLUSIONS

Although gossypiboma is rarely seen in daily clinical practice, it should be considered in the differential diagnosis of acute mechanical intestinal obstruction in patients who underwent laparotomy previously. The best approach in the prevention of this condition can be achieved by meticulous count of surgical materials in addition to thorough exploration of surgical site at the conclusion of operations and also by routine use of surgical textile materials impregnated with a radio-opaque marker.

Ultrasonographic appearance of intra-abdominal granuloma secondary to retained surgical sponge

This report describes two animals (one dog and one cat) with a retained surgical sponge. Both had nonspecific clinical signs. Clinical examination, ultrasonography and cytologic examination were used to identify an abdominal mass compatible with a granuloma. The lesions were surgically removed and confirmed histologically as granulomas secondary to a retained sponge. The ultrasonographic appearance was very similar in both animals.

Radiographic and ultrasonographic features of retained surgical sponge in eight dogs

The radiographic and ultrasonographic signs in eight dogs with a surgical or pathologic diagnosis of retained surgical sponge were reviewed. The most frequent previous surgery was ovariohysterectomy, either as an elective procedure or to treat pyometra. The median elapsed time between surgery and diagnosis of retained surgical sponge was 9.5 months (range 4 days to 38 months). Five dogs had a draining sinus; four had a palpable abdominal mass. Radiologic signs included localized, speckled or whirl-like gas lucency, abdominal mass, and non-focal soft tissue swelling. Survey radiography and sinography were considered diagnostic for retained surgical sponge in 4/7 (57%) and 3/5 (60%) dogs, respectively. The combined use of survey radiography and sinography enabled detection of 6/7 (86%) sponges. In each dog that had ultrasonography, a hypoechoic mass was found that had an irregular hyperechoic centre. The possibility of retained surgical sponge should be considered in animals with a history of previous surgery and a sinus or abdominal mass.