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Gossypiboma – the Retained Surgical Swab: an Enduring Clinical Challenge

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Gossypiboma – the Retained Surgical Swab: an Enduring Clinical Challenge REVIEW Gossypiboma – the retained surgical swab: An enduring clinical challenge R Naidoo, FCS (SA), MMed (Surgery); B Singh, FCS (SA), MD Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa Corresponding author: R Naidoo ([email protected]) Retained abdominal swabs remain a difficult problem. This review highlights the risk factors and index pathology, as well as markers that raise clinical suspicion, of a condition that may be elusive in presentation on account of its otherwise nonspecific signs and symptoms. A review of the English literature reporting retained abdominal swabs between 1992 and 2012 revealed 100 cases. Fifty-six percent of patients presented with pain, most commonly coupled with an abdominal mass or symptoms of bowel obstruction; 6% of patients presented with a fistula or a sinus; and 6% presented with extrusion of the swab; only 7% presented with signs indicative of sepsis. The most common initial surgery was obstetric and gynaecological (in 44% of cases); the second most common was general surgery (36%), most commonly following cholecystectomy. Plain abdominal X-ray was done in 45% of patients, followed by ultrasound, computed tomography (CT) scan or both. CT scan is the best preoperative diagnostic tool currently. The varying presentations exhibited by this postsurgical entity will continue to perplex the attendant practitioner. Clinical suspicion assisted by ultrasound and CT scan will improve definitive diagnosis. While there are many checkpoints to prevent this rare yet significant complication, human error and the unpredictability of surgery may make elimination impossible. The challenges presented with a retained swab, although rare, will persist, and with it the devastating consequences for both patient and clinician. Because of this, especially in the era of a litigious mindset, surgical vigilance and pre-emptive measures cannot be emphasised enough. S Afr J Obstet Gynaecol 2016;22(1):29-32 DOI:10.7196/SAJOG.2016.v22i1.1052 The term ‘gossypiboma’ is used to describe a retained surgical swab following any Literature search using keywords surgical procedure. Although a rela- undertaken using the Google Scholar, Pubmed/Medline, EBSCO host Titles of all results were tively rare occurrence, it has been noted research databases and Science Direct screened for relevance since the beginning of surgical practice databases between 1990 and 2012 and continues to date, despite advances in operative theatre practice. The con- sequences of a retained swab can be life-altering or even fatal. The myriad of Reports of retained swabs outside the clinical presentations often mimic other abdomen and pelvis were excluded Patients under the age of 18 were excluded Of the relevant results, foreign- clinical entities, making the diagnosis language publications were excluded difficult. Non-human subjects were excluded and abstracts of relevant articles were Studies reporting three or more cases were not evaluated for suitability added to the cohort as these results were used Epidemiology to compare conclusions Accurate incidence of gossypiboma is hampered by the reluctance to report these cases, as well as the confidentiality agreements following legal settlements.[1] This complication may sometimes remain asymptomatic, being discovered many years The number of case reports satisfying all criteria was 95, later or diagnosed at a different institution, which reported 100 cases. and these factors impact on the accuracy of Each article was then used to its incidence. The most common retained ll in a proforma foreign body is the surgical swab, probably because of its frequent use, small size and Fig. 1. Search strategy and data collection methods. being easily missed when blood soaked.[1] The most common site involved is the abdominal cavity followed by the thoracic cavity.[1] Data abstraction and was quantified under the following For this review on the challenges analysis headings: clinical presentation, radiological presented by a retained swab, the search The content from the literature was imaging, initial surgery and time between strategy and data collection were based on reviewed by a single author to eliminate bias surgery and presentation. Descriptive data the review of published literature (Fig. 1). in extracting information. The information analysis was conducted. SAJOG • September 2016, Vol. 22, No. 1 29 Ethical approval exudative pathological process is less Limitations to the study included the Ethical approval was sought and obtained common. reliance on reported data only, the sole from the University of KwaZulu-Natal Only 6% of patients presented with a use of electronic sources for the literature Biomedical Research and Ethics Committee. fistula, which underscores the remarkable search and exclusion of literature prior way in which the body seals off the swab to 1990, as well as exclusion of foreign- Results without allowing a loss in gastrointestinal language publications. The study looked at There were 95 case reports deemed suitable continuity. Remarkably, 6% of patients reported cases only, which is biased towards for analysis, and these reported 100 cases of also presented with complete extrusion more unusual cases. gossypiboma. of the swab via a normal orifice, which The pathogenesis of a gossypiboma has further amplifies the pathological processes been attributed to two types of foreign- Clinical presentation outlined. body reactions which, between them, Table 1 lists case data. Pain was the most help to explain the variety of associated common presenting system; 56% of patients Index surgical procedure clinical presentations. The first type is complained of severe pain as part of their The most common specialty predisposed an aseptic fibrous tissue reaction that presenting symptom complex but only to gossypiboma was obstetric and gynae- involves fibroblast reaction, adhesion 22% complained of isolated pain. Pain cological surgery (n=44, 44%) (Table 1). formation (resulting in either complete or was usually coupled with one of the other The most common operation performed incomplete encapsulation) and granuloma common symptoms, such as an abdominal was caesarean section (n=21), which formation.[2] The second type is an exudative mass or symptoms of vomiting and/or comprised 48% of the obstetric and gynae- inflammatory response which results in constipation, which were considered as cological procedures performed, and abscess formation or chronic internal or obstructive symptoms. These findings abdominal hysterectomy (n=13) comprising external fistulae, which may eventually are consistent with the pathogenesis 30%. The general surgery procedure that result in transmural migration. The of the foreign body being walled off, commonly predisposed to gossypiboma was inflammatory reaction elicited by the with fibrosis creating a mass exerting open cholecystectomy (n=19), comprising swab initiates a process of self-extrusion, external compression, or the foreign body 53% of the total number of general surgery because the human body has the capability migrating into the lumen to cause luminal procedures. to recognise the sponge as a foreign obstruction. body and its instinct is to eliminate it.[3] Seven percent presented with signs Radiological investigations Extrusion may be external and occur of abdominal sepsis, suggesting that an Since the diagnosis is elusive, a range of via a sinus or the abdominal incision investigations may have to be undertaken. itself; alternatively, it may be internal by Table 1. Case data of reported cases of Plain X-ray of the abdomen is the most basic eroding and perforating a hollow viscus retained abdominal swabs (N=100) investigation for abdominal com plaints. and then migrating into the viscus aided Of the 45% of patients who had a plain by peristalsis. When complete, the swab % abdominal X-ray, only 8% of patients required may be extruded. If the migration is Clinical presentation no further investigations, suggesting that incomplete, it may obstruct the viscus.[3] Pain 56 plain X-ray may not be helpful in confidently Clinical manifestation shows vast vari- Mass 32 diagnosing a gossypiboma. Abdominal ation which relates to the location of the Obstructive symptoms 20 ultrasound appears to be a valuable tool, with material within the abdomen.[4] The clinical Fistula or sinus 6 21% of patients being successfully diagnosed presentation is dictated by the type of with ultrasound and X-ray only; 64% of foreign-body reaction. The presentation Sepsis 7 patients had a computed tomography (CT) may be acute and severe or chronic and Extrusion 6 scan. vague. Some of the most common presenting Other 40 symptoms are abdominal masses, fistulas Surgical discipline Discussion or sinuses, intestinal obstruction, intra- General surgery 36 Retained abdominal swabs remain a abdominal abscesses and pain. The septic Obstetrics and gynaecology 44 difficult problem to eradicate even though complications may also be influenced by Trauma surgery 6 tremendous strides in surgical practice the degree of intra-abdominal spillage and have been made. Despite many advances, contamination during the index surgery.[2] Urology 10 human error will always remain a variable An array of radiological investigations Other 4 that cannot be controlled; it is likely that has been described in the investigation of Radiological investigations this problem, although rare, will persist, patients with a gossypiboma. The reason for X-ray 45 and with it the devastating
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