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Gossypiboma- a Rare Cause of Gastric Outlet Obstruction Advanced Research in Gastroenterology & Hepatology Case Report Adv Res Gastroentero Hepatol Volume 1 Issue 2 - November 2015 Copyright © All rights are reserved by Parveen Malhotra Gossypiboma- A Rare Cause of Gastric Outlet Obstruction Parveen Malhotra*, Vani Malhotra, Naveen Malhotra, Ajay Chugh, Abhishek Chaturvedi, Parul Chandrika and Ishita Singh Department of Medical Gastroenterology, PGIMS, India Submission: October 04, 2015; Published: November 10, 2015 *Corresponding author: Parveen Malhotra, Head and Department of Medical Gastroenterology, Obstetrics & Gynecology and Anesthesiology, PGIMS, Rohtak 124001, Haryana, India, Tel: 9215372663; Email: Abstract Introduction: Gossypiboma is a surgical instrument or sponge left inside patient’s body post operatively. It has varied manifestations from being asymptomatic to severe complications like vomiting, pain abdomen, obstruction, perforation, peritonitis and even death. Rarely it ileum or colon. Very few cases have been reported in literature till now. We report the largest transmural migrated gossypiboma to date which wascan havea surgical transmural mop measuring migration 26 and × 23leads cm to and bowel was orsuccessfully visceral perforation, removed endoscopically. obstruction or fistula formation which usually occurs in stomach, Our Case: A fifty eight year-old man who was symptomatic for gallstones underwent open cholecystectomy six months back at andsome duodenum private hospital. which gave He wassuspicion asymptomatic of malignancy. for one On month upper post-operativelygastrointestinal endoscopy,but later on a surgicaldeveloped mop pain that abdomen, had totally dyspepsia, migrated anorexia into the stomachand intermittent and duodenum vomiting. was On seen. investigating, The surgical barium mop swallow was successfully and abdominal removed ultrasonogram by endoscopy revealed and patient a filling recovered defect at completely antrum of afterstomach the procedure. Conclusion: migration of gossypiboma Gossypiboma occurs should into the not stomach. be missed in any postoperative patient with unexplained pain abdomen and vomiting. Endoscopy is both diagnostic as well as therapeutic modality but surgery becomes definitive treatment in endoscopically failed cases or when incomplete Keywords: Migratory gossypiboma; Pain abdomen; Vomiting; Endoscopy Introduction operatively he developed pain abdomen and persistent vomiting. Persistent abdominal pain was mainly in the epigastrium and Gossypiboma is the term used to describe a retained right hypochondrium. He was symptomatically treated by various private practitioners but in vain. In between he had a bout of fever which was associated with rigor and chills and patientnon-absorbable and surgeon surgical [1 material that is composed of cotton abdominalmatrix which gossypiboma leads to serious may varysurgical from complications mild abdominal for bothpain antibiotics treatment but pain abdomen and vomiting persisted. to major complications including]. Clinical bowel symptoms or visceral related perforation, to intra- Patientremained had for features one week. of Hecomplete became gastric afebrile outlet after fiveobstruction days of oral for 2]. Despite its rarity, last three weeks, before he reported to our department. He transmural migration of gossypiboma is one of the possible was not able to accept anything orally and was on intravenous causesobstruction, of these fistula gastrointestinal formation or sepsis complications. [ Transmural function tests were normal. The barium swallow (Figure 1) and reported to occur in stomach, ileum, colon, bladder, vagina and fluids. On investigating, he had mild anemia, but liver and renal diaphragmmigration [of3 an intra-abdominal gossypiboma has been of stomach and duodenum which was suggestive of gastric of transgastric migration of a gossypiboma but all of them were carcinoma.abdominal Thusultrasonogram endoscopy revealed was done a for filling proper defect diagnosis, at antrum after surgical sponges]. As of per smaller literature, size and this three is the of themsixth werereported removed case obtaining written informed consent from the patient including endoscopically [3,4]. surgical risks. Endoscopy revealed a large surgical sponge which Case Report totally migrated and was found partially in pyloric antrum and rest half was stuck in duodenum (Figure 2). The surgical sponge forceps was pulled into the stomach (Figure 3). The sponge was A fifty eight year-old man underwent open cholecystectomy was loosened with normal saline and then with saw-tooth for cholelithiasis, six months back but four weeks post- Adv Res Gastroentero Hepatol 1(2): ARGH.MS.ID.55556 (2015) 0029 Advanced Research in Gastroenterology & Hepatology then removed with gentle round motions from the mouth. The prolonged sticking of surgical sponge lead to huge dilatation of pyloric antrum (Figure 4). The removed surgical sponge was 26 removed endoscopically, till date (Figure 5). The procedure cm x 23 cm and is of the largest size which has been successfully sonogramwas completed were foundwithout to beany normal. complications The patient .The was next started day; onall laboratory parameters, check endoscopy and abdominal ultra- under hemodynamically normal condition after two days of observation.per- oral feeds which he accepted well, hence was discharged Figure 3: Gossypiboma being removed with help of Snare. Figure 1: Barium swallow revealing mass like lesion at An- tro-duodenal area. Figure 4: Dilated Pyloric Antrum after removal stucked Gos- sypiboma. Figure 2: Large Gossypiboma which migrated into stomach. Figure 5: The removed surgical sponge of size 26 cm x 23 cm. How to cite this article: Parveen M, Vani M, Naveen M, Ajay C, Abhishek C. Gossypiboma- A Rare Cause of Gastric Outlet Obstruction. Adv Res 0030 Gastroentero Hepatol. 2015;1(2): 555556. Advanced Research in Gastroenterology & Hepatology Discussion whenPatients fixed reaction undergoing and/or emergency partial migration surgery, have those occurred. with high potentially dangerous and it is encountered more commonly thanGossypiboma is reported following[5]. Gossypiboma an intra-abdominal leads to two surgery types ofis forbody retained mass index, surgical lengthy materials operations, [1,8]. Simple inexperienced precautions staff like or 6,7 educatingunexpected the change staff, in taggingsurgical procedurethe sponges are withmajor markers risk factors or asymptomaticforeign body orreactions; gives rise aseptic to painless fibrinous abdominal response mass, whereasand an preoperative multiple counts of sponges and materials should exudative reaction [ ]. The aseptic fibrinous response can be reduce the incidence of gossypiboma [8]. In addition, new technologies like electronic tagging of sponges may be helpful in [exudative8]. Retained reactions sponge migratescan lead rarelyto severe and ismanifestations bodily response like to decreasing the incidence [11]. intestinal perforation, obstruction, fistula formation or sepsis or into a hollow viscus. Transmural migration occurs as a result Conclusion extrude the foreign material by developing a fistula externally Transmural migration of gossypiboma should be considered to necrosis [9]. Later on, necrotic area closes after complete in the differential diagnosis of any postoperative patient with migrationof inflammation of the insurgical the intestinal sponge. wall The whichsmall ultimatelyintestine isleads the most affected site due to its thin wall and large outer surface. diagnostic as well as therapeutic modality but surgery may be Compared with the intestines, the stomach is an unusual site unexplained pain abdomen and vomiting. Endoscopy is both for transmural migration due to its higher localization and of incomplete migration of gossypiboma. thick wall [9]. The same thing occurred in our case as patient considered in endoscopically failed/ refractory cases or in cases developed gradually progressive features of obstruction and had References an episode of fever associated with rigor and chills which may 1. Sozutek A, Karabuga T, Bozdag AD, Derici H (2010) Asymptomatic have been due to mild peritonitis, at the time of migration of surgical sponge into gastrointestinal tract. The patient developed 2. gossypibomaGawande AA, mimicking Studdert aDM, liver Oravmass. EJ,Turk Brennan J Surg 26(4): TA, Zimmer225-228. MJ (2003) Risk factors for retained instruments and sponges after Untilfeatures now, of thiscomplete condition gastro-duodenal has been previously outlet obstruction, reported onlydue to complete sticking of sponge at pyloric antro-duodenal level. 3. surgery.Erdil A, Kilciler N Eng JG, Med Ates 348(3): Y, Tuzun 229-235. A, Gulsen M, et al. (2008) Transgastric 3,4,6,9]. Interestingly, all of them occurred after migration of retained intraabdominal surgical sponge: gossypiboma acute open cholecystectomy operations, as occurred in our case. Hence,in five caseswe emphasize [ that acute cholecystectomy is a major 4. inMentes the bulbus. BB, InterYilmaz Med E, 47(7): Sen 613-615.M, Kayhan B, Gorgul A, et al. factor that leads to this kind of complication. (1997) Transgastric migration of a surgical sponge. J Clin magnetic resonance (MR) may usually be helpful for diagnosis. 5. GastroenterolCheng TC, Chou 24(1): AS, Jeng55-57. CM, Chang PY, Lee CC (2007) Computed In addition,Imaging imagingprocedures of a hyperechogenicsuch as plain X-ray, mass USG,with hypoechoicCT and/or 569. rim on USG or a rounded mass with a dense central part and tomography findings of gossypiboma. J
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