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ORIGINAL ARTICLE
Year : 2017  |  Volume : 5  |  Issue : 1  |  Page : 1-8

Computed tomography of retained intra-abdominal sponges: Eight-year experience at a tertiary care center


1 Department of Radiology, SKIMS, Srinagar, Jammu and Kashmir, India
2 Department of general and minimally Invasive surgery, SKIMS, Srinagar, Jammu and Kashmir, India

Date of Web Publication12-Apr-2017

Correspondence Address:
Naseer Ahmed Choh
Department of Radiology, SKIMS, Srinagar, Jammu and Kashmir
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2320-3846.204417

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  Abstract 

Objectives: To describe the clinical profile and imaging appearances of retained intra-abdominal sponges in a tertiary care center of a developing country over an 8-year period. Such cases are usually described as isolated case reports in literature, and case series on this subject are rare in literature.
Materials and Methods: Seventeen cases are described with reference to the type of surgery, time between the surgery and diagnosis, computed tomography (CT) appearances, operative findings, and final outcome. The patients were traced from the imaging findings and clinical records and were followed until their discharge from the hospital.
Results: The most common surgeries were cesarean section (five cases - 29%) and cholecystectomy (four cases - 23%). The time interval between surgery and diagnosis varied between 3 days and 9 months and most cases were diagnosed within 3 months. CT suggested the correct diagnosis in all but one patient. There were two fatalities in the cases; four patients required segmental small gut resection and one required partial gastrectomy. Ten cases followed elective surgeries and rest followed emergency procedures.
Conclusion: Retained surgical sponges continue to be an embarrassing iatrogenic complication with devastating medicolegal implications and carry significant morbidity and mortality. Radiologists need to be familiar with this entity for a correct early diagnosis.

Keywords: Computed tomography, intra-abdominal, sponges


How to cite this article:
Choh NA, Jabeen S, Ashraf O, Khan A, Shaheen F, Wani GM, Shera TA, Wani M, Shah M, Gojwari T, Robbani I. Computed tomography of retained intra-abdominal sponges: Eight-year experience at a tertiary care center. Saudi Surg J 2017;5:1-8

How to cite this URL:
Choh NA, Jabeen S, Ashraf O, Khan A, Shaheen F, Wani GM, Shera TA, Wani M, Shah M, Gojwari T, Robbani I. Computed tomography of retained intra-abdominal sponges: Eight-year experience at a tertiary care center. Saudi Surg J [serial online] 2017 [cited 2017 Aug 23];5:1-8. Available from: http://www.saudisurgj.org/text.asp?2017/5/1/1/204417


  Introduction Top


Gossypiboma (also called as textiloma) refers to a surgical sponge or gauze which is inadvertently retained in the abdominal cavity (or thorax) following surgery (Latin Gossypium: Cotton; boma: Place of concealment).[1] This leads to an aseptic granuloma which may encapsulate and remain asymptomatic for many years or provoke an exudative reaction with superadded infection causing abscesses and internal fistulas.[2] Even though they may occur in the chest, extremities, central nervous system, breast or spine, they are most frequently found in an intra-abdominal location.[1],[3],[4],[5],[6],[7] Retained sponges often present as a diagnostic dilemma. The diagnosis can be facilitated by ultrasound and computed tomography (CT) provided a high index of suspicion is maintained, and the radiologist is familiar with various imaging appearances of the same.

We report a series of seventeen cases of gossypibomas encountered during radiological investigations of patients from 2008 to 2015 in a busy tertiary care hospital with emphasis on their CT features. We believe that the actual incidence is higher and many of these cases are either reexplored without a CT scan on mere strong clinical and sonographic suspicion, and some cases are probably asymptomatic and go unnoticed.


  Materials and Methods Top


The study was carried out in two tertiary care hospitals from 2007 to 2015, and all cases with a CT diagnosis of retained surgical sponge were analyzed for radiological and clinical features and ultimate surgical outcome. We encountered 17 cases of retained intra-abdominal sponges that were referred for CT scan of the abdomen for a clinical complaint (pyrexia, palpable lump) and a sonographic suspicion. Seven patients were scanned using a single slice CT scanner (GE Medical systems) while ten patients were scanned on multi-slice 64 detector row scanner (Somatom, Sensation, Siemens medical systems). Intravenous contrast was given in nine patients while no contrast was thought necessary in eight patients. One patient was administered rectal contrast to confirm the presence of an extraluminal sponge which was not clear on the noncontrast study.

Observations

Nine patients (53%) had a history of pelvic surgery - Five patients (29.4%) of cesarean section, one patient of myomectomy, mesh placement for solitary rectal ulcer, hysterectomy, and vaginal reconstruction each. Four cases (23%) were seen following cholecystectomy, one after splenectomy, appendicectomy, hepatic hydatid cystectomy, and choledocholithotomy each. Surprisingly, ten cases (59%) were seen after elective procedures and seven cases (41%) were encountered after emergency surgery [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]. Two deaths were noted (approximately 12%); one in a patient who was asymptomatic and kept under observation and one who succumbed to sepsis even after the sponge was surgically removed. Four patients (23.5%) required segmental resection of small gut because of dense adhesions, and one patient required a partial gastrectomy.
Figure 1: Patient had undergone splenectomy and presented with pyrexia and abdominal discomfort. Contrast-enhanced computed tomography abdomen shows a well-circumscribed, thick-walled mass with air loculi and dense ill-defined foci with surrounding adherent gut loops. A large retained surgical sponge was found at laparotomy

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Figure 2: A well-circumscribed, encapsulated mass with mottled air lucencies is seen in right iliac fossa anterior to the cecum in this patient who had undergone surgery for a rectal ulcer. The computed tomography was done on the 3rd postoperative day

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Figure 3: A wavy spongiform structure is seen within a large well-circumscribed collection showing an air-fluid level. This patient had originally been operated for choledocholithiasis, deteriorated in the postoperative period and eventually succumbed due to comorbid cardiac problems

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Figure 4: An encapsulated organized collection is seen with a small central sponge, 4 months after an appendicectomy

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Figure 5: A large intraperitoneal collection is seen with a central spongiform structure representing a retained surgical towel. The patient presented in the 2nd week following a cesarean section

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Figure 6: The contrast-enhanced computed tomography shows a sponge with mottled air lucencies in the left hypochondrium anterolateral to contrast-filled splenic flexure and descending colon. The patient was asymptomatic and on follow up until she suffered a catastrophic lower gastrointestinal hemorrhage

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Figure 7: Axial image from pelvic computed tomography demonstrate a heterogeneous mass with mottled air lucencies within uterine cavity suggestive of a retained sponge

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Figure 8: Sagittal reformatted image from pelvic computed tomography demonstrate a heterogeneous mass with mottled air lucencies within uterine cavity suggestive of a retained sponge

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Figure 9: Axial contrast-enhanced computed tomography of the abdomen shows a large encapsulated collection with multiple air lucencies in it. A retained sponge was suggested and confirmed on reexploration

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Figure 10: Computed tomography reveals an encapsulated collection in subhepatic space with central air foci, consistent with a sponge

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Figure 11: Contrast-enhanced computed tomography pelvis reveals a heterogeneous attenuation lesion with central dense wavy structure and adjacent adherent dilated gut loops. No air lucencies were noted in this case

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Figure 12: Contrast-enhanced computed tomography upper abdomen shows a sponge eroding into gastric antrum and duodenum. Partial gastrectomy was required in this case

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Figure 13: Sagittal reformatted image shows a sponge eroding into gastric antrum and duodenum. Partial gastrectomy was required in this case

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Figure 14: Contrast-enhanced computed tomography abdomen shows features of small gut obstruction with a well-defined sponge underneath the abdominal wall (postcesarean section)

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Figure 15: A well-defined sponge with mottled air foci within the small gut loops that had fistulized into an ileal loop

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[Table 1] summarizes the clinical, radiological, and postoperative outcomes in these patients [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15].
Table 1: Summary of clinical, radiological, and postoperative outcome in patients with gossypiboma

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  Discussion Top


Retained surgical sponge is a rare but serious iatrogenic complication which often goes underreported and underpublished because of medicolegal issues.[8] In this paper, we have published our experience of retained intra-abdominal sponges in a busy tertiary care hospital over 8 years (2007–2015). We encountered a total of 17 cases with an approximate incidence of two cases per year which is slightly higher than that quoted by other authors.[9] It is pertinent to mention that seven patients (41%) were operated in peripheral hospitals and private nursing homes but eventually were referred to the central referral hospital for evaluation and management.

Surgical sponges are made of cotton which is inert and does not cause any specific chemical reaction within the body except adhesion and granuloma formation.

Thus, they can induce an aseptic fibrinous response with encapsulation and adhesion formation with surrounding structures resulting in a foreign body granuloma. Sometimes, a sinus tract or a fistula can form (which may open either externally on skin or internally into gut) in an attempt to extrude the foreign body.[2] Not uncommonly, an exudative type of response can be seen with abscess formation. The patients with an exudative or wet type of reaction are more likely to present earlier and frequently present with features of infection and sepsis.[7],[8],[10] In our series, four patients (approximately 24%) presented with an exudative type of reaction with collections of varying sizes suggesting that this is an uncommon pattern. In addition, only two of these patients were febrile. The dry encapsulated sponges were the predominant type (11 patients-approximately 65%). A longer interval between surgery and diagnosis predisposed to dense adhesions necessitating small gut resection in four patients and partial gastrectomy in one case. Fistulization into stomach was observed in one case and into small gut in one patient; one patient expelled the gauze per rectum 3 months after surgery which was presumed to have internally fistulized into the gut from an intraperitoneal location. Surprisingly, the patient had mild symptoms (pelvic discomfort, altered bowel habits) and a subsequent CT showed mild stranding of pelvic fat without any collection. Similar cases have earlier been reported in the literature.[11],[12]

All patients underwent sonography, and the diagnosis was suggested by ultrasound in all but one patient. However, sonographic findings are nonspecific and not sufficiently characteristic in some cases. CT shows specific findings, internal fistulization, adhesions, and collections and always adds confidence to the diagnosis. Ultrasound features include primarily a hyperechoic appearance with sharply delineated acoustic shadowing in the absence of air or calcification (most common feature in our experience); other sonologic appearances include a cystic mass with highly irregular internal echoes as well as a hypoechoic complex mass.[13],[14],[15] All types of appearances were seen in our cases.

CT findings of gossypibomas are described as a well-circumscribed, thick-walled mass which may show enhancement following administration of contrast. The mass may show gas, speckled calcification, or wall calcification. The internal structure may appear spongiform or whirl-like due to the gas trapped in the mesh of sponges; it may be low density or complex with both low-density and spotted or striped high-density foci.[13],[15],[16],[17],[18] Magnetic resonance imaging (MRI) is rarely used for evaluation of retained sponges. Magnetic resonance findings include a hypointense capsule, hypointense signal on T1-weighted images and hyperintense signal on T2-weighted images with a central hypointense wavy irregular structure corresponding to the folded gauze.[1],[7],[19] We did not do MRI in any of our cases. The combination of two imaging modalities (ultrasound and CT) provided a confident diagnosis. We noted mottled air lucencies in all except one patient (who had undergone hysterectomy 9 months before diagnosis and in whom an adnexal tumor was suggested on CT).

The time interval from the initial surgery to the diagnosis of gossypiboma has varied in our study from 3 days to 9 months, and the majority of patients were diagnosed between 3 and 4 months. The different clinical features included a palpable lump, fever, small gut obstruction, gastric outlet obstruction, and wound discharge. Two patients (approximately 12%) were asymptomatic and the sponge was diagnosed on routine sonography, thereby suggesting that some asymptomatic patients may go unnoticed. Most of the cases followed cesarean sections (29.5%) and cholecystectomies (23.5%), presumably because these are the most common surgeries performed on the basis of number. Unlike in other series where retained sponges have been discovered years after the initial operation, all of our cases were diagnosed within the 1st year, with the majority being diagnosed 1–3 months following surgery.

We saw internal gas bubbles on CT scans in all but one of our cases. The gas bubbles within the sponge possibly get resorbed with time; there was an inverse relation between the amount of mottled gas and the time elapsed since surgery. The exceptional case of a sponge without air foci was a female in whom an ovarian tumor was diagnosed preoperatively and who had undergone hysterectomy 9 months ago.

There were two deaths in our series underscoring the importance of emergent intervention. One patient who had cardiac and respiratory comorbidities and who had been operated for choledocholithiasis succumbed to sepsis and multi-organ failure within a week after the sponge was removed. The other patient, who had a retained sponge after a hepatic hydatid cystectomy, was being observed until she presented with a fulminant lower gastrointestinal hemorrhage, possibly, due to the erosion of a major vascular structure. Observation of asymptomatic gossypibomas may thus not be a prudent approach. Four patients had to undergo segmental small gut resection and one patient required partial gastrectomy, highlighting the technical difficulty of operative management because of adhesions and gut fistulization.

Surprisingly, ten of our cases were seen after elective surgeries, while in seven patients, the complication occurred after emergency room operative procedures. This underscores the importance of human error in the genesis of this complication in addition to other factors such as time-consuming surgery, operation in a difficult anatomic location, and change of theatrical staff during the procedure. Even though this complication is due to an inherent human error, the adherence to better practices and standards such as performing preoperative sponge counts, use of radiopaque sponges, and continuing medical education for the theater personnel cannot be overemphasized.[8]

The chief differential diagnosis to be considered in case of a gossypiboma includes a chronic organized abscess, bezoar, or organized hematoma. An abscess usually has air fluid levels but may coexist with a gossypiboma. Abscesses may also show interspersed mottled air lucencies and may be indistinguishable from retained sponges.[16],[20] One helpful feature in such cases will be dense acoustic shadowing in case of sponges and dirty acoustics in case of air containing collections. Hematoma usually shows resolution with serial CT scans and can also be distinguished more easily by its characteristic MRI appearance.[15] Bezoars may exactly mimic gossypibomas if their intraluminal position is not ascertained and may be reported as retained foreign bodies; however, an intraluminal bezoar may represent a sponge that has eroded into the gut lumen and may be suggested by inflammatory stranding and history of previous surgery. We encountered one case of small gut obstruction following a cesarean section, in which a large bezoar was misinterpreted as a retained sponge. We did not notice any calcified sponge in our cases because calcification requires a longer time and all our cases were <9 months old.

As retained intra-abdominal sponges are still seen in developing nations, plain radiographs may give a clue to the diagnosis. Some sponges have radiopaque markers which make them visible on plain X-ray. Sponges which are not radiopaque may be visible due to entrapped air seen as mottled radiolucencies.[21],[22]


  Conclusion Top


Gossypiboma is a serious iatrogenic complication which carries significant morbidity and mortality. A high index of suspicion should be maintained in postoperative symptomatic patients (persistent fever, palpable lump, collection). Adherence to better theatrical practices and adequate training of theatrical staff are mandatory as prevention is always better and easier than cure. Ultrasound and CT features are characteristic, and the two modalities if used together should avoid misdiagnosis. MRI is not required in a majority of cases. Initially, plain radiograph may provide a clue to the diagnosis if the sponge has a radiopaque marker or in a radiolucent sponge with entrapped air.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Manzella A, Filho PB, Albuquerque E, Farias F, Kaercher J. Imaging of gossypibomas: Pictorial review. AJR Am J Roentgenol 2009;193 6 Suppl: S94-101.  Back to cited text no. 1
    
2.
Niederkohr RD, Hwang BJ, Quon A. FDG PET/CT detection of a gossypiboma in the neck. Clin Nucl Med 2007;32:893-5.  Back to cited text no. 2
    
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Madan R, Trotman-Dickenson B, Hunsaker AR. Intrathoracic gossypiboma. AJR Am J Roentgenol 2007;189:W90-1.  Back to cited text no. 3
    
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Lo CP, Hsu CC, Chang TH. Gossypiboma of the leg: MR imaging characteristics. A case report. Korean J Radiol 2003;4:191-3.  Back to cited text no. 5
    
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Mathew JM, Rajshekhar V, Chandy MJ. MRI features of neurosurgical gossypiboma: Report of two cases. Neuroradiology 1996;38:468-9.  Back to cited text no. 6
    
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O'Connor AR, Coakley FV, Meng MV, Eberhardt SC. Imaging of retained surgical sponges in the abdomen and pelvis. AJR Am J Roentgenol 2003;180:481-9.  Back to cited text no. 7
    
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Bani-Hani KE, Gharaibeh KA, Yaghan RJ. Retained surgical sponges (gossypiboma). Asian J Surg 2005;28:109-15.  Back to cited text no. 8
    
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Kiernan F, Joyce M, Byrnes CK, O'Grady H, Keane FB, Neary P. Gossypiboma: A case report and review of the literature. Ir J Med Sci 2008;177:389-91.  Back to cited text no. 9
    
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Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: The need to count sponges. World J Surg 2000;24:521-7.  Back to cited text no. 10
    
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Godara R, Marwah S, Karwasra RK, Goel R, Sen J, Singh R. Spontaneous transmural migration of surgical sponges. Asian J Surg 2006;29:44-5.  Back to cited text no. 11
    
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Choi JW, Lee CH, Kim KA, Park CM, Kim JY. Transmural migration of surgical sponge evacuated by defecation: Mimicking an intraperitoneal gossypiboma. Korean J Radiol 2006;7:212-4.  Back to cited text no. 12
    
13.
Yamato M, Ido K, Izutsu M, Narimatsu Y, Hiramatsu K. CT and ultrasound findings of surgically retained sponges and towels. J Comput Assist Tomogr 1987;11:1003-6.  Back to cited text no. 13
    
14.
Sugano S, Suzuki T, Iinuma M, Mizugami H, Kagesawa M, Ozawa K, et al. Gossypiboma: Diagnosis with ultrasonography. J Clin Ultrasound 1993;21:289-92.  Back to cited text no. 14
    
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Choi BI, Kim SH, Yu ES, Chung HS, Han MC, Kim CW. Retained surgical sponge: Diagnosis with CT and sonography. AJR Am J Roentgenol 1988;150:1047-50.  Back to cited text no. 15
    
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Kokubo T, Itai Y, Ohtomo K, Yoshikawa K, Iio M, Atomi Y. Retained surgical sponges: CT and US appearance. Radiology 1987;165:415-8.  Back to cited text no. 16
    
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Malik A, Jagmohan P. Gossypiboma: US and CT appearance Indian J Radiol Imaging 2002;12:503-4.  Back to cited text no. 17
    
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Sahin-Akyar G, Yagci C, Aytaç S. Pseudotumour due to surgical sponge: Gossypiboma. Australas Radiol 1997;41:288-91.  Back to cited text no. 18
    
19.
Kim CK, Park BK, Ha H. Gossypiboma in abdomen and pelvis: MRI findings in four patients. AJR Am J Roentgenol 2007;189:814-7.  Back to cited text no. 19
    
20.
Apter S, Hertz M, Rubinstein ZJ, Zissin R. Gossypiboma in the early post-operative period: A diagnostic problem. Clin Radiol 1990;42:128-9.  Back to cited text no. 20
    
21.
Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained surgical sponge. Ann Surg 1996;224:79-84.  Back to cited text no. 21
    
22.
Barriga P, García C. Ultrasonography in the detection of intra-abdominal retained surgical sponges. J Ultrasound Med 1984;3:173-6.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
 
 
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