Granulomatous Peritonitis Due to Cellulose Fibers From Disposable Surgical Fabrics:Laboratory Investigation and Clinical Implications

Abstract

Two patients with postoperative granulomatous peritonitis were found to have lesions with a distinctive type of foreign body. Laboratory investigation revealed this foreign body to be cellulose, morphologically identical with fibers derived from disposable surgical gowns and drapes, and cotton. The same type of foreign body granulomas was produced experimentally by introducing lint prepared from these gowns and drapes into the peritoneal cavities of rats. Since disposable gowns and drapes are being used with increasing frequency, cellulose lint derived from these sources should be added to the list of hazardous foreign materials which are potential wound contaminants.

Postoperative granulomatous peritonitis mimicking abdominal tuberculosis

“…At explorative laparoscopy or laparotomy, the peritoneum and omentum are mostly studded with multiple small nodules …”

“…Furthermore, multinucleate Langhans or foreign‐body‐typed giant cells containing foreign material particles, surrounded by eosinophils and lymphocytes, can be detected. Mononuclear macrophages and areas of interstitial focal fibrosis may also be traceable …”

“…In the literature, a few cases of peritoneal granulomatous reaction to cellulose fibers are described . They mostly followed bowel perforation and also clinically mimicked tuberculosis in some cases .…”

“…It is assumed that accidental intraperitoneal introduction of foreign material (eg, cellulose fibers after intestinal perforation or cornstarch from surgical glove powder) induces a delayed cell-mediated hypersensitive inflammatory response with the formation of foreign body granulomas in susceptible individuals. 1,2,8,11,12 Because of the variable clinical presentation, the diagnosis of postoperative granulomatous peritonitis represents a challenge for clinicians. In order to find the right diagnosis in due time, all patients, presenting to the hospital with unclear abdominal pain, abdominal tenderness, and fever, should be asked for abdominal surgery performed during the past weeks or months.…”

The role of surgical gowns, drapes, and masks in the generation of airborne particulates

“…As controversial as the role that airborne contamination may have on the outcome of a surgical procedure, the pathogenicity of wood pulp fibers has been identified in the literature on numerous occasions. Complications after surgery attributable to wood pulp fibers from nonwoven materials first was reported in the literature on several occasions more than 25 years ago 4 …”