Gossypiboma- a Rare Cause of Gastric Outlet Obstruction

Advanced Research in Gastroenterology & Hepatology

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 surgical developed mop pain that abdomen, had totally dyspepsia, migrated anorexiainto 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 vary surgical 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 sepsiscomplications. [ 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 Thus ultrasonogram endoscopy revealedwas 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 found without to be any normal. complications The patient .The was next started day; on all 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 of is 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 or reactions; gives rise asepticto painless fibrinous abdominal response mass, whereas and 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 migrates can lead rarely to severe and is manifestations 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. wallThe whichsmall ultimatelyintestine is leads 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 this complete condition gastro-duodenal has been previously outlet obstruction, reported only due 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 imaging procedures of a hyperechogenic such as plain X-ray, mass USG,with hypoechoic CT and/or 569. rim on USG or a rounded mass with a dense central part and tomography findings of gossypiboma. J Chin Med Assoc 70(12): 565- enhancing wall on CT are the basic signs of gossypiboma [5,10]. 6. Erbay G, Koc Z, Caliskan K, Araz F, Ulusan S (2012) Imaging and or neoplasm which leads to unnecessary radical surgical It is misdiagnosed as intra-abdominal hematoma, abscess clinical findings of a gossypiboma migrated into the stomach. Turk J interventions. 7. Gastroenterol 23(1): 54-57. sponge with migration into the duodenum and persistent duodenal Gossypiboma should be removed as soon as possible to avoid Düx M, Ganten M, Lubienski A, Grenacher L (2002) Retained surgical further surgical complications and legal problems [1]. Although 8. fistula.Patil KK, Eur RadiolPatil SK, 12(Suppl Gorad 3): KP, 74-77. Panchal AH, Arora SS, et al. open surgery is the most common approach in the treatment (2010) Intraluminal migration of surgical sponge: gossypiboma. of gossypiboma, removal can be easily performed by minimally invasive techniques such as endoscopy or laparoscopy [1,4,6]. 9. SaudiSarda J GastroenterolAK, Pandey D,16(3): Neogi 221-222. S, Dhir U (2007) Postoperative Although successful removals of surgical sponges by endoscopy complications due to a retained surgical sponge. Singapore Med have been reported before, the feasibility of endoscopy in removal of such a large surgical sponge compress was 10. JKopka 48(6): L, e160-164. Fischer U, Gross AJ, Funke M, Oestmann JW, et al. (1996) CT the largest gossypiboma published till date successfully treated endoscopically.challenging. To ourHence, knowledge, we emphasize herein wethat report endoscopy the first may case be of a of retained surgical sponges (textilomas): pitfalls in detection and 11. Fabian CE (2005) Electronic tagging of surgical sponges to prevent good option in the removal of such a large sponge located in the evaluation. J Comput Assist Tomogr 20(6): 919-923. stomach and duodenum. However, surgery should be considered their accidental retention. Surgery 137(3): 298-301.

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 0031 Gastroentero Hepatol. 2015;1(2): 555556.