|Year : 2018 | Volume
| Issue : 3 | Page : 447-450
Textiloma discovered 22 years after splenectomy: a case report
Department of General Surgery Mansoura, Faculty Medicine, Mansoura University, Egypt
|Date of Submission||09-Apr-2016|
|Date of Acceptance||11-Jul-2017|
|Date of Web Publication||07-Jan-2019|
Dr. Hesham Elgendy
8th DDep of Surgery, 2nd Floor, Main Building, Mansoura University Hospital, Elgomhoryia Strret, Mansoura, 35516, 35511
Source of Support: None, Conflict of Interest: None
Background Retained foreign body after laparotomy is not uncommon. Surgical sponge is considered the most common retained foreign body and this is called textilomas or gossypibomas. Retained sponge induces a severe foreign body reaction, which usually leads to serious complications. Although the complications induced by retained foreign bodies are known, only a few cases can be found in the literature because of medicolegal aspects.
Case presentation This case report focuses on a 50-year-old male farmer with a history of splenectomy, who presented to us with a picture of acute small bowel obstruction and toxemic shock. Laboratory investigations indicated marked leukocytosis, and elevated serum bilirubin and creatinine levels. Computedtomography scan of the abdomen showed a heterogeneous round object in the left upper quadrant of the abdomen. Upon exploratory laparotomy, a textiloma was discovered with intestinal loops coiled round it. Resection of the diseased bowel loops was performed with ileostomy. The patient was admitted to the ICU as his condition continued to deteriorate; he developed hepatorenal syndrome, followed by hepatic encephalopathy and died.
Conclusion Gossypiboma is not a straightforward diagnosis; accidentally retained sponges are not usually suspected clinically, but subsequently recognized on computed tomography imaging studies. The delay in the detection of RFO leads to serious complications that may cost the patient his/her life, which is why it must be suspected in any patient with a history of operative intervention.
Keywords: acute abdomen, foreign body, gossypiboma, retained sponge, textiloma
|How to cite this article:|
Elgendy H. Textiloma discovered 22 years after splenectomy: a case report. Benha Med J 2018;35:447-50
| Background|| |
Accidental retention of a foreign body (FB) inside the patient’s abdomen after laparotomy is a well-known surgical complication and is called retained foreign object (RFO). Gossypiboma is a type of RFO, derived from the Latin word ‘gossypium,’ which means cotton. Gossypiboma means an FB granuloma surrounding a cotton matrix . Textiloma is another RFO derived from the word ‘textile’ and it has the same definition as gossypiboma, except for synthetic materials instead of cotton. Wilson reported the first case of a gossypiboma in 1884 .
Gossypiboma carries serious medicolegal squeal, which is why in many cases gossypiboma is not reported, making it difficult to estimate the real incidence of this problem . However, the registered incidence is one in 1500 after laparotomy and one in 3000 in all types of operative interventions ,.
Two types of FB reactions are induced by gossypiboma . The first type is a sterile fibrinous reaction forming a granuloma, which is usually asymptomatic. The second type induces an exudative inflammatory reaction, leading to abscess formation, associated with clinical symptoms . This pathogenesis explains why some gossypibomas remain unnoticed for many years and others present with serious outcomes such as bowel obstruction, intestinal fistula, septic peritonitis, and bleeding because of erosion into a nearby blood vessel . The estimated mortality rate of this condition can reach up to 10% . Clinically, gossypiboma can present as an abdominal mass with repeated biopsy attempts, which is why computed tomography (CT) scan is the cornerstone in the diagnosis of gossypibomas and its related complications .
Several methods have been used to reduce the incidence of this condition. These methods include introduction of laparoscopy, usage of radio-opaque surgical sponges, counting the number of sponges twice before closure of the abdominal wall, and use of radiography to detect any missing sponge. Unfortunately, in developing countries with financial constraints, these methods are hardly utilized and the incidence of gossypiboma and its complications is still considerable .
| Case presentation|| |
In this report, we focus on a case of gossypiboma discovered 22 years following splenectomy and describe the presenting features, risk factors, and outcome of this condition. The names of surgeons and places of previous surgical procedures are not reported for ethical reasons.
A 50-year-old male farmer was admitted to the Mansoura University Emergency Hospital complaining of acute pain in the left hypochondrium, generalized abdominal distention, vomiting, and constipation for the past 3 days. In terms of surgical history, the patient reported that he had undergone a splenectomy 22 years ago in a rural hospital for the treatment of portal hypertension and hypersplenism. The patient also reported having a prolonged history of abdominal discomfort, nausea, and recurrent attacks of left hypochondrial colicky pain of mild intensity that did not interfere with his lifestyle.
On general examination, the patient appeared ill and cachectic. Vital signs indicated low-grade fever (38°C), tachypnea (26/min), and tachycardia (110 bpm). On abdominal examination, the patient’s abdomen was diffusely tender and rigid, with an evident scar of the left paramedian incision from previous splenectomy.
A series of investigations were ordered for the patient including blood picture, which indicated marked leukocytosis (white blood cells=40.5 K/Ul) and severe anemia (hemoglobin=7.3 g/dl). Other laboratory tests showed a low serum albumin level (1.9 g/dl), high serum bilirubin level (1.5 mg/dl), elevated serum creatinine level (2.5 mg/dl), and normal levels of liver enzymes.
Plain radiography on the abdomen and pelvis was completely normal, except for some gaseous distension. Abdominal ultrasonography showed a coarse cirrhotic liver with mild bilharzial periportal fibrosis, and no free or localized fluid collections; yet, there was an ill-defined mass in the left hypochondrium composed of thick-walled intestinal loops with a rim of fluid in between.
On the basis of the sonographic findings, a pelviabdominal CT scan was ordered. The CT scan showed a round heterogeneous mass in the left upper quadrant of the abdomen with multiple central lucencies ([Figure 1] and [Figure 2]). On the basis of these findings, a strong suspicion of an intestinal tumor or lymphoma was raised and a decision to perform an exploratory laparotomy was made.
|Figure 1 Pelviabdominal computed tomography scan indicating a round heterogeneous mass in the left upper quadrant with multiple central lucencies.|
Click here to view
Upon surgical exploration, there were dense adhesions between the splenic flexure and the small bowel that were meticulously divided. The continuity of the colonic wall was found to be intact. After dissection, we found the jejunal and ileal loops coiled together as one mass, wrapped around a hard blackish object ([Figure 2]). Multiple perforations were also detected in the bowel wall. Dissection of the healthy bowels was performed, followed by resection of about 70 inches of unhealthy intestine along with FB. An anastomosis was not feasible owing to the poor general condition of the patient; thus, a double-barrel ileostomy was performed. The FB retrieved from the abdomen was discovered to be a retained surgical sponge that was missed after the previous splenectomy ([Figure 3]).
The patient was admitted to the ICU postoperatively because of his critical condition. Despite rigorous attempts to combat toxic shock, hepatorenal failure supervened as the serum creatinine and bilirubin levels continued to increase, with evident oliguria and decompensated liver functions. Unfortunately, 5 days after surgery, the patient developed hematemesis and melena and then entered a state of hepatic encephalopathy that lasted for 2 days before died.
| Discussion|| |
Retention of surgical sponges does not only increase the morbidity of patients but also leads to serious negative sequelae for the surgeons involved. Such cases usually receive wide media coverage, which can destroy the reputation of the operating surgeon .
Despite continuous improvements in surgical procedures and the technical advancements, the problem of postoperative RFO is still unresolved. RFO is not acceptable at any level and its consequences are too adverse and costly to be tolerated . Female sex, obesity, obstetric, and emergent operations are documented risk factors for gossypiboma .
Sometimes, gossypiboma are incorrectly diagnosed preoperatively, which can lead to unwanted invasive procedures or interventions. Interaction between the clinician and the radiologist, on the one hand, and between the clinician and the patient on the other increases the possibility of an accurate diagnosis of RFO . This serious complication can be prevented using standard sponge packing systems, accurate counting of surgical instruments and sponges, and use of sponges with radio-opaque markers. Radiofrequency detectors and radiofrequency-labeled surgical sponges have been introduced recently. However, despite all these precautions, RFO still remains a frequently encountered complication .
| Conclusion|| |
Gossypiboma is not a straightforward diagnosis; accidentally retained sponges are not usually suspected clinically, but subsequently recognized on CT imaging studies. The delay in the detection of RFO leads to serious complications that may cost the patient his/her life, which is why it must be suspected in any patient with a history of operative interventions.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]