Case Study
Intrathoracic gossypiboma presenting 52 years later as a chest mass
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 596–598 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314557181 aan.sagepub.com
Marcelo Parra1, Federico Oppliger2, Rau´l Berrı´os1 and Giancarlo Schiappacasse3
Abstract We describe the rare case of a 71-year-old man with a chest mass that was found to be an intrathoracic gossypiboma left 52 years earlier during an emergency lung bilobectomy. This mass was complicated by extension across the chest wall. There are no reports in the literature of a patient carrying a thoracic gossypiboma for such a long period of time, let alone with extension across the chest wall.
Keywords Foreign bodies, surgical sponges, thoracic wall
Introduction Gossypiboma (or textiloma) refers to a retained sponge or swab in any body cavity. The word comes from the Latin gossypium which means cotton and boma from Swahili, meaning place of concealment.1 The first description of a gossypiboma, which was left in the abdomen, was in 1884. Since then, gossypibomas have been described mainly in case reports.2
Case report A 71-year-old man had undergone an emergency right bilobectomy (inferior and middle lobes) 52 years earlier after presenting with massive hemoptysis secondarily to tuberculosis. He suffered no further events for 51 years when he noticed an anterior chest mass (Figure 1). One year later, he reported that the mass had grown bigger and more painful during the previous 2 months. A chest radiograph showed a cystic lesion in the right upper lobe. Subsequently, chest computed tomography indicated an intrathoracic gossypiboma (Figure 2). The patient underwent elective surgery through a transverse incision in the second right intercostal space. The pectoralis major muscle was detached and retracted inferiorly from the clavicle, draining 300 mL of pus. Between the first and second costal cartilages, a fistula was found communicating with a cavity where another 400 mL of pus and a partially destroyed surgical pad
were found. The textiloma was retrieved completely with video assistance through the same incision (Figure 3). The cavity was washed with saline solution. No connection to the airway was noticed, and good lung expansion was achieved. A drain was placed in the cystic cavity and a 24 F pleurotomy was made. Ceftriaxone and clindamycin were started empirically until the culture results were obtained; these were negative for bacteria, fungus, and tuberculosis, thus the antibiotics were suspended. The patient’s postoperative course was uneventful and he was discharged on the 6th day. Long-term follow-up revealed no complications.
Discussion The occurrence of gossypiboma is related to various factors including long operations with different teams, emergencies, and material counting errors. It carries not only serious complications such as abscesses, 1
Thoracic Surgery Department, Hospital Padre Hurtado, Santiago, Chile Clı´nica Alemana-Universidad del Desarrollo School of Medicine, Santiago, Chile 3 Imaging Department, Hospital Padre Hurtado, Santiago, Chile 2
Corresponding author: Marcelo Parra, MD, Esperanza 2150, San Ramo´n, 8880465 Santiago, Chile. Email: [email protected]
Downloaded from aan.sagepub.com at FLORIDA INTERNATIONAL UNIV on August 31, 2015
Parra et al.
597
Figure 1. Preoperative photograph showing the right pectoral mass.
Figure 2. Axial computed tomography image with intravenous contrast, showing the oval-shaped mass in the superior lobe with a high-density zone in its interior and a metallic marker anteriorly. The mass extends through the intercostal muscle to the subpectoral region.
fistula, perforation, migration, and adhesions but also important legal consequences. In the USA, hospitalizations involving lost medical objects cost more than USD 60,000 and related malpractice suits cost USD 150,000–500,000 per case to health institutions.3 Prevention of gossypiboma can be ensured simply by counting in a consistent sequence by two similar people, with immediate radiography if there are any doubts raised by the counts. Newer technologies for detection
include bar codes and a radiofrequency detector; the first prevents double counting, and radiofrequency detects marked sponges. Williams and colleagues3 demonstrated how hospitals could significantly save money with less use of x-rays and less time spent in the operating room, and moreover, avoid the potential cost of readmission for surgery as well as legal costs. The most common sites of gossypiboma are the abdomen, pelvis, and thorax, with an estimated global
Downloaded from aan.sagepub.com at FLORIDA INTERNATIONAL UNIV on August 31, 2015
598
Asian Cardiovascular & Thoracic Annals 23(5)
Figure 3. The pad fragments in the tray.
incidence of 1/1000–1/10,000 overall, but these numbers might be underestimated.1 The thorax is the least frequent site; thoracic gossypibomas have been described in no more than 40 published cases. Pathologically, a foreign object can produce an aseptic fibrotic response with consequent adhesion, encapsulation, and formation of a granuloma or an exudative reaction leading to a localized abscess. Clinically, the patients may present with cough, pain, nausea, vomiting, fever, or a palpable mass, and they may remain asymptomatic for a long period of time. The average time from the first surgery to diagnosis is 6.9 years.1 The longest period described previously was 40 years by Szarf and colleagues,4 but our case took 52 years for presentation. The diagnosis is challenging and almost never considered early among the hypotheses because of its rare occurrence. Computed tomography is the imaging of choice because it can better characterize the lesion and evaluate the surrounding structures and complications. It may show a well-encapsulated mass with an enhanced rim, calcified deposits along its architecture, air bubbles, and a radiopaque wire marker, if present. A lung abscess, hematoma, aspergilloma, or lung sequestration should be kept in mind in the differential diagnosis.5 Surgery is the treatment of choice to avoid further complications. Usually an open approach is necessary if the foreign object has been inside the body for a long time, due to the chronic reaction and adhesions to surrounding structures; but if diagnosed early, it might be retrieved in a lass invasive way. No lung resection was performed in this case because a right completion pneumonectomy in a possibly infected
scenario would have carried high morbidity and probable mortality. The most important lesson is to take preventative measures in the operating room to avoid these types of cases.6 Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Hameed A, Naeem A, Azhar M, Fatimi SH. Intrathoracic gossypiboma. BMJ Case Rep 2014 Jan 8;2014. pii: bcr2013201814. doi: 10.1136/bcr-2013-201814. 2. Mir R and Singh V. Retained intra-thoracic surgical pack mimicking as recurrent aspergilloma. J Clin Diag Res 2012; 6: 1775–1777. 3. Williams TL, Tung DK, Steelman VM, Chang PK and Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg 2014; 219: 354–364. 4. Szarf G, Mussi de Andrade TC, Nakano E, et al. Fortyyear-old intrathoracic gossypiboma after cardiac valve surgery. Circulation 2009; 119: 3142–3143. 5. Ridene I, Hantous-Zannad S, Zidi A, et al. Imaging of thoracic textiloma. Eur J Cardiothorac Surg 2011; 39: e22–e26. 6. Wan W, Le T, Riskin L and Macario A. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 2009; 22: 207–214.
Downloaded from aan.sagepub.com at FLORIDA INTERNATIONAL UNIV on August 31, 2015
Intrathoracic gossypiboma presenting 52 years later as a chest mass
Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(5) 596–598 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314557181 aan.sagepub.com
Marcelo Parra1, Federico Oppliger2, Rau´l Berrı´os1 and Giancarlo Schiappacasse3
Abstract We describe the rare case of a 71-year-old man with a chest mass that was found to be an intrathoracic gossypiboma left 52 years earlier during an emergency lung bilobectomy. This mass was complicated by extension across the chest wall. There are no reports in the literature of a patient carrying a thoracic gossypiboma for such a long period of time, let alone with extension across the chest wall.
Keywords Foreign bodies, surgical sponges, thoracic wall
Introduction Gossypiboma (or textiloma) refers to a retained sponge or swab in any body cavity. The word comes from the Latin gossypium which means cotton and boma from Swahili, meaning place of concealment.1 The first description of a gossypiboma, which was left in the abdomen, was in 1884. Since then, gossypibomas have been described mainly in case reports.2
Case report A 71-year-old man had undergone an emergency right bilobectomy (inferior and middle lobes) 52 years earlier after presenting with massive hemoptysis secondarily to tuberculosis. He suffered no further events for 51 years when he noticed an anterior chest mass (Figure 1). One year later, he reported that the mass had grown bigger and more painful during the previous 2 months. A chest radiograph showed a cystic lesion in the right upper lobe. Subsequently, chest computed tomography indicated an intrathoracic gossypiboma (Figure 2). The patient underwent elective surgery through a transverse incision in the second right intercostal space. The pectoralis major muscle was detached and retracted inferiorly from the clavicle, draining 300 mL of pus. Between the first and second costal cartilages, a fistula was found communicating with a cavity where another 400 mL of pus and a partially destroyed surgical pad
were found. The textiloma was retrieved completely with video assistance through the same incision (Figure 3). The cavity was washed with saline solution. No connection to the airway was noticed, and good lung expansion was achieved. A drain was placed in the cystic cavity and a 24 F pleurotomy was made. Ceftriaxone and clindamycin were started empirically until the culture results were obtained; these were negative for bacteria, fungus, and tuberculosis, thus the antibiotics were suspended. The patient’s postoperative course was uneventful and he was discharged on the 6th day. Long-term follow-up revealed no complications.
Discussion The occurrence of gossypiboma is related to various factors including long operations with different teams, emergencies, and material counting errors. It carries not only serious complications such as abscesses, 1
Thoracic Surgery Department, Hospital Padre Hurtado, Santiago, Chile Clı´nica Alemana-Universidad del Desarrollo School of Medicine, Santiago, Chile 3 Imaging Department, Hospital Padre Hurtado, Santiago, Chile 2
Corresponding author: Marcelo Parra, MD, Esperanza 2150, San Ramo´n, 8880465 Santiago, Chile. Email: [email protected]
Downloaded from aan.sagepub.com at FLORIDA INTERNATIONAL UNIV on August 31, 2015
Parra et al.
597
Figure 1. Preoperative photograph showing the right pectoral mass.
Figure 2. Axial computed tomography image with intravenous contrast, showing the oval-shaped mass in the superior lobe with a high-density zone in its interior and a metallic marker anteriorly. The mass extends through the intercostal muscle to the subpectoral region.
fistula, perforation, migration, and adhesions but also important legal consequences. In the USA, hospitalizations involving lost medical objects cost more than USD 60,000 and related malpractice suits cost USD 150,000–500,000 per case to health institutions.3 Prevention of gossypiboma can be ensured simply by counting in a consistent sequence by two similar people, with immediate radiography if there are any doubts raised by the counts. Newer technologies for detection
include bar codes and a radiofrequency detector; the first prevents double counting, and radiofrequency detects marked sponges. Williams and colleagues3 demonstrated how hospitals could significantly save money with less use of x-rays and less time spent in the operating room, and moreover, avoid the potential cost of readmission for surgery as well as legal costs. The most common sites of gossypiboma are the abdomen, pelvis, and thorax, with an estimated global
Downloaded from aan.sagepub.com at FLORIDA INTERNATIONAL UNIV on August 31, 2015
598
Asian Cardiovascular & Thoracic Annals 23(5)
Figure 3. The pad fragments in the tray.
incidence of 1/1000–1/10,000 overall, but these numbers might be underestimated.1 The thorax is the least frequent site; thoracic gossypibomas have been described in no more than 40 published cases. Pathologically, a foreign object can produce an aseptic fibrotic response with consequent adhesion, encapsulation, and formation of a granuloma or an exudative reaction leading to a localized abscess. Clinically, the patients may present with cough, pain, nausea, vomiting, fever, or a palpable mass, and they may remain asymptomatic for a long period of time. The average time from the first surgery to diagnosis is 6.9 years.1 The longest period described previously was 40 years by Szarf and colleagues,4 but our case took 52 years for presentation. The diagnosis is challenging and almost never considered early among the hypotheses because of its rare occurrence. Computed tomography is the imaging of choice because it can better characterize the lesion and evaluate the surrounding structures and complications. It may show a well-encapsulated mass with an enhanced rim, calcified deposits along its architecture, air bubbles, and a radiopaque wire marker, if present. A lung abscess, hematoma, aspergilloma, or lung sequestration should be kept in mind in the differential diagnosis.5 Surgery is the treatment of choice to avoid further complications. Usually an open approach is necessary if the foreign object has been inside the body for a long time, due to the chronic reaction and adhesions to surrounding structures; but if diagnosed early, it might be retrieved in a lass invasive way. No lung resection was performed in this case because a right completion pneumonectomy in a possibly infected
scenario would have carried high morbidity and probable mortality. The most important lesson is to take preventative measures in the operating room to avoid these types of cases.6 Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
References 1. Hameed A, Naeem A, Azhar M, Fatimi SH. Intrathoracic gossypiboma. BMJ Case Rep 2014 Jan 8;2014. pii: bcr2013201814. doi: 10.1136/bcr-2013-201814. 2. Mir R and Singh V. Retained intra-thoracic surgical pack mimicking as recurrent aspergilloma. J Clin Diag Res 2012; 6: 1775–1777. 3. Williams TL, Tung DK, Steelman VM, Chang PK and Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg 2014; 219: 354–364. 4. Szarf G, Mussi de Andrade TC, Nakano E, et al. Fortyyear-old intrathoracic gossypiboma after cardiac valve surgery. Circulation 2009; 119: 3142–3143. 5. Ridene I, Hantous-Zannad S, Zidi A, et al. Imaging of thoracic textiloma. Eur J Cardiothorac Surg 2011; 39: e22–e26. 6. Wan W, Le T, Riskin L and Macario A. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 2009; 22: 207–214.
Downloaded from aan.sagepub.com at FLORIDA INTERNATIONAL UNIV on August 31, 2015
