Transgastric migration of gossypiboma remedied with endoscopic removal: a case report

Abstract

BackgroundRetained surgical instrument or sponge following an intra-abdominal surgery is a potentially dangerous medico-legal problem. The condition may manifest either as asymptomatic or severe gastrointestinal complications. Transmural migration of gossypiboma is a rare entity that may lead to bowel or visceral perforation, obstruction and/or fistula formation. Transmural migration of an intra-abdominal gossypiboma has been reported to occur in stomach, ileum, colon, bladder, vagina and diaphragm. To our knowledge, this is the fifth case reported in the medical literature. However, we report the first case of the largest gossypiboma to date: a surgical gas compress measuring 20 × 20 cm which was successfully treated endoscopically.Case presentationA 52-year-old woman with obstructive jaundice was referred to our clinic. She had a medical history of cholecystectomy and T-tube drainage for choledocholithiasis a year previously. Abdominal ultrasonography and computed tomography revealed a mass located into the stomach which was compatible with gastric carcinoma. On the gastroscopy, a surgical gas compress that had totally migrated into the stomach was observed. The compress was successfully removed by gastroscopy through the esophagus. The recovery of the patient was uneventful.ConclusionTransmural migration of gossypiboma into the stomach should be considered in the differential diagnosis of any postoperative patient with obstructive jaundice symptoms. Endoscopy may be feasible for both diagnosis and treatment even though the size of gossypiboma is large. However, surgery should be considered in case of fixed reaction or incomplete migration of gossypiboma located into the stomach.

Intra-abdominal Gossypiboma Revisited: Various Clinical Presentations and Treatments of this Potential Complication

“…b MRI of gossypiboma which was misdiagnosed as liver cancer or hydatid cyst. c Endoscopy imaging of gossypiboma which was migrated into the stomach reported from first postoperative day to 43 years [1][2][3][4][5][6][7][8][9][10][11][12][13][14]. This interval period was found to be 14 days to 12 years in our study.…”

“…Patients usually remain asymptomatic; however, they may suffer of nonspecific gastrointestinal symptoms like mild abdominal pain or painless abdominal mass, as well. On the other hand, exudative reaction leads to abscess formation; thus, it may manifest as a severe clinical course resulting in intestinal perforation, obstruction, external-internal fistula formation, or sepsis, which is likely due to the transmural migration of retained surgical sponges [2,3,10,16]. Transmural migration occurs as a result of inflammation in the intestinal wall that evolves into necrosis [17].…”

“…The clinical presentation of gossypiboma is variable and usually depends on the tissue reaction and localization of gossypiboma. Gossypiboma induces two types of biological responses, aseptic fibrinous response or exudative reaction [2,6,15]. Aseptic fibrinous response usually creates adhesions and encapsulation that result in a foreign body granuloma (pseudotumor) in the abdomen.…”

“…Gossypiboma is the term used to describe a retained nonabsorbable surgical material that is composed of cotton matrix which leads to serious surgical complications for both patient and surgeon [1,2]. Its incidence is not precisely known probably due to medico-legal importance of this potential complication.…”

“…Its incidence is not precisely known probably due to medico-legal importance of this potential complication. Gossypiboma induces two types of tissue reaction which consisted of aseptic fibrinous response and exudative response [1][2][3]. Clinical presentation is strongly associated with the type of foreign body reaction which may manifest itself in various clinical presentations ranging from mild abdominal pain to major surgical complications including bowel or visceral perforation, obstruction, fistula formation, or sepsis, although it may remain asymptomatic for many years [1][2][3][4][5][6].…”