Gossypiboma transduodenal migration causing partial gastric outlet obstruction

Rajesh Sharma; Vishal Bodh; Brij Sharma; RS Jhobta; Rajesh Kumar; Ajay Ahluwalia

doi:10.4103/cjhr.cjhr_124_20

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CASE REPORT

Year : 2021 | Volume : 8 | Issue : 4 | Page : 276-278

Gossypiboma transduodenal migration causing partial gastric outlet obstruction

Rajesh Sharma¹, Vishal Bodh¹, Brij Sharma¹, RS Jhobta², Rajesh Kumar¹, Ajay Ahluwalia³
¹ Department of Gastroenterology, IGMC, Shimla, Himachal Pradesh, India
² Department of Surgery, IGMC, Shimla, Himachal Pradesh, India
³ Department of Radiodiagnosis, IGMC, Shimla, Himachal Pradesh, India

Date of Submission	31-Aug-2020
Date of Acceptance	25-Sep-2020
Date of Web Publication	27-May-2022

Correspondence Address:
Vishal Bodh
Department of Gastroenterology, IGMC, Shimla, Himachal Pradesh
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/cjhr.cjhr_124_20

Abstract

The term “gossypiboma” denotes a mass of cotton that is retained in the body following surgery. It is a rare but serious complication which is seldom reported because of the medicolegal implications. Gossypiboma usually has varied and vague presentation and is also difficult to detect on radiological investigations. It can even remain silent and present years after the operation. We report a case of a 46-year-old female who presented with vague upper abdominal pain associated with postprandial fullness and occasional vomiting. She had a history of open cholecystectomy 16 years ago. Abdominal X-ray and ultrasonogram examination of the abdomen were inconclusive. Her contrast-enhanced computed tomography of the abdomen revealed thickening of the wall of the pyloric antrum with air containing thick-walled structure in relation to the pyloric antrum and the first part of the duodenum possibility of the duodenal diverticulum with inflammatory/neoplastic thickening was suggested. Her esophagogastroduodenoscopy revealed large cotton sponge embedded in the anterior wall of the first part of the duodenum. On exploratory laparotomy, she was found to have a large gossypiboma embedded in the first part of the duodenum with dense adhesions to surrounding structures. Although rare, gossypiboma should be kept in mind as a differential diagnosis in postoperative cases presenting as vague pain even years after the operation.

Keywords: Contrast enhanced computed tomography, esophagogastroduodenoscopy, exploratory laparotomy

How to cite this article:
Sharma R, Bodh V, Sharma B, Jhobta R S, Kumar R, Ahluwalia A. Gossypiboma transduodenal migration causing partial gastric outlet obstruction. CHRISMED J Health Res 2021;8:276-8

How to cite this URL:
Sharma R, Bodh V, Sharma B, Jhobta R S, Kumar R, Ahluwalia A. Gossypiboma transduodenal migration causing partial gastric outlet obstruction. CHRISMED J Health Res [serial online] 2021 [cited 2023 Mar 28];8:276-8. Available from: https://www.cjhr.org/text.asp?2021/8/4/276/346096

Introduction

The term “gossypiboma” denotes a cotton foreign body that is retained inside the patient during surgery.^[1] The term is derived from a combination of Latin words “Gossypium” (cotton) and Swahili word “boma” (place of concealment). Other surgical materials may similarly be forgotten in the body, such as artery forceps, pieces of broken instruments or irrigation sets, scissors, needles, and rubber materials, but textile materials are the most commonly forgotten. Gossypiboma can occur after virtually any type of operation: It has been reported after intrathoracic, orthopedic, intraspinal, and neurological operations as well as breast surgery, but the most common is after intraabdominal or pelvic surgery.^[2] Most gossypiboma cases are discovered during the first few days after surgery; however, they may remain undetected for many years.^[3] Nonspecific clinical symptoms and inconclusive imaging findings may preclude an accurate diagnosis.^[4] Imaging modalities including plain radiography, ultrasonography, computed tomography (CT), and magnetic resonance imaging may help to have exact diagnosis preoperatively in many cases.^[5] Surgery is the recommended treatment option in these cases. Gossypiboma that presents late may pose a serious diagnostic dilemma. The development of a fistula to neighboring organs such as the stomach, duodenum, or intestine occurs infrequently.^[6],[7] The longer the retention time, the higher is the fistulization risk. We report a case of a 46-year-old female who was diagnosed to have gossypiboma 16 years after surgical procedure (open cholecystectomy) with partial migration into the duodenal lumen causing partial gastric outlet obstruction and symptoms of upper abdominal pain, postprandial fullness, and recurrent vomitings.

Case Report

A 42-year-old female presented to our gastroenterology outpatient department with complaints of pain upper abdomen, postprandial fullness, nausea, and occasional vomiting for the past 10 years. The pain was insidious in onset, dull aching, mainly confined to the epigastric and right hypochondriac region, and radiating to the back with no relation to meals. History of postprandial fullness, nausea, and recurrent vomiting was present. She had no history of hematemesis, Malena, loss of weight, and loss of appetite. There was no history of jaundice, fever, and abdominal distension. Her bowel and urinary habits were normal. She gave a history of open cholecystectomy in 2004. Her physical examination and systemic examination was normal. Her complete hemogram, liver, and renal biochemistry were normal. Her abdominal X-ray and ultrasound of the abdomen examination were normal multiple times in the past 10 years. She had visited multiple doctors and was prescribed multiple courses of oral proton pump inhibitors, antacid syrups, antispasmodics, antihistaminics, and prokinetics but she had no relief. In view of persistent complaints with recent exacerbation of symptoms in the past 1 month, contrast-enhanced computed tomography (CECT) of the abdomen was performed. Her CECT of the abdomen showed irregular thickening of the wall of the pyloric antrum with air containing thick-walled structure in relation to the pyloric antrum and first part of duodenum with regional lymphadenopathy possibility of the duodenal diverticulum with inflammatory/neoplastic thickening [Figure 1]a and [Figure 1]b. Her esophagogastroduodenoscopy examination revealed a deeply embedded large gauge piece in the anterior wall of the first part of the duodenum [Figure 1]c and [Figure 1]d. Endoscopic removal was not attempted in view of possible risk of perforation and the surgeon opinion was taken.

Figure 1: (a and b) Contrast-enhanced computed tomography – image irregular thickening of the wall of pyloric antrum with air containing thick-walled structure in relation to the pyloric antrum and the first part of the duodenum possibility of the duodenal diverticulum with inflammatory/neoplastic thickening. (c) Small arrow showing the pyloric opening, long arrow showing gauge in the first part of the duodenum. (d) Arrow showing gauze peace embedded in the first part of the duodenum

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Her exploratory laparotomy showed a large gauge piece adherent to the first part of the duodenum and making dense adhesion between the stomach, duodenum transverse colon, and omentum with duodenocolic fistula [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d. Adhesiolysis, distal gastrectomy, removal of foreign body with Billroth II gastrojejunostomy, and repair of fistula were performed. Broad-spectrum antibiotics were started and the patient was discharged after 7 days.

Figure 2: (a and b) Intraoperative picture showing gauge piece embedded in the 1^st part of the duodenum. (c) Surgeon removing gauge piece from the resected necrosed part of the duodenum. (d) White arrow shows a necrosed part of the duodenum. Moreover, black arrow shows the retrieved gauge piece

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Discussion

Gossypiboma actual incidence is difficult to ascertain because of low reporting rate due to medicolegal implications. The reported incidence is between 1 in 1000 and 1500 abdominal operations.^[8] Gossypiboma is most commonly seen in cases of emergency surgery, the unexpected change in the surgical procedure, disorganization (e.g., poor communication), change in surgical team or scrub nurses, hurried sponge counts, long operations, unstable patient, inexperienced staff, inadequate staff numbers, and obesity.^[9]

The retained surgical sponge trigger two biological responses: aseptic fibrinous response due to foreign body granuloma or exudative reaction leading to abscess formation.^[10] The symptoms depend upon the location, size of swab, and the type of reaction that occurs. Gossypiboma may present early with pain with or without lump formation or may remain asymptomatic for a long time with only vague symptoms as seen in our case. Patients may present with abdominal mass or subacute intestinal obstruction. Patients may rarely also present with fistula, perforation, or even extrusion per anus. In our case, the gossypiboma caused vague symptoms for quite some time before diagnoses are made.

Plain abdominal radiography is not helpful in diagnosing gossypiboma when radioopaque marker is not used in the sponges or disintegrated or fragmented over time.^[11] On ultrasonogram presence of brightly echogenic wavy structures in a cystic mass showing posterior acoustic shadowing that change in parallel with the direction of the ultrasound beam has been reported as a diagnostic feature of gossypiboma by Zbar et al.^[11] CT findings of gossypiboma, particularly in long-standing cases, may be indistinguishable from the intraabdominal abscess.^[11] Gossypiboma may be misdiagnosed as a malignant tumor and lead to unnecessary invasive diagnostic procedures,^[11] as is seen in our case. In our case, the abdominal X-ray and ultrasonogram were not able to formulate the diagnosis and CECT abdomen suggested the possibility of the duodenal diverticulum with inflammatory/neoplastic thickening. The diagnosis was made on upper gastrointestinal endoscopic examination performed to rule out the possibility of the duodenal diverticulum with inflammatory/neoplastic thickening as suggested on radiological imaging.

Once gossypiboma is diagnosed, it should be removed. Surgery had been the mainstay for the removal of retained foreign bodies, especially from the abdomen, since the greater omentum, small intestine, and large intestine usually wall off foreign bodies. In addition, it has been shown that there may be several dense adhesions between intraabdominal organs and foreign bodies at laparotomy, as seen in our case. Moreover, if the initial surgery had been performed a long time before the diagnosis of gossypiboma, there may be a fistula between the cavity containing the foreign body and the gastrointestinal tract as seen in our case. In this situation, resection of the affected segment is mandatory

Prevention is the best treatment and could be possible by the implementation of three measures: (1) meticulous count of all surgical materials, (2) thorough exploration of the surgical site at the conclusion of the procedures, and (3) routine use of surgical textile materials impregnated with a radioopaque marker

Conclusion

Gossypiboma should be included in the differential diagnoses of localized abdominal pains in patients with a history of a prior operation even many years after the surgery. Gossypiboma generally has nonspecific radiological findings and hence the diagnosis is often delayed. Gossypiboma can cause a wide variety of complications such as perforation, obstruction, fistula formation, and adhesion to the adjacent structures.

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

Nil.

Conflicts of interest

There are no conflicts of interest.

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