CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 72 (2020) 59–62 Contents lists available at ScienceDirect International Journal of Surgery Case Reports journal homepage: www.casereports.com Lower gastrointestinal bleeding due to colonic fistula caused by a gossypiboma: Case report and literature review María José Gómez-Jurado a , Anna Curell a , Rocío Martín a , Amador García Ruiz de Gordejuela a,b,∗ , Manel Armengol a,b a Department of General and Digestive Surgery, Hospital Universitari Vall d’Hebron, Barcelona, Spain b Universitat Autonoma de Barcelona, Spain a r t i c l e i n f o a b s t r a c t Article history: INTRODUCTION: Even in modern surgery, human mistakes cannot be totally avoided. Retained surgical Received 4 April 2020 items are among the most feared ones. Forgotten sponges inside patients can cause a wide range of Received in revised form 15 May 2020 complications due to the foreign body reaction, called gossypiboma. The incidence of gossypibomas Accepted 16 May 2020 in the literature is probably underreported due to its legal implications; however, we must know its Available online 29 May 2020 consequences and highlight the importance of the prevention strategies. We present a case where only preventive measures would have avoided its fatal outcome. Keywords: PRESENTATION OF CASE: An 85-year-old male, previous left nephrectomy 12 years before, came to the Gossypiboma Retained surgical item emergency room with hematochezia and hemodynamic instability. An emergent angio-CT revealed a 12 Foreing body cm mass due to a gossypiboma near the descending colon; the presence of air suggested an infection Lower gastrointestinal bleeding and/or fistulization to the bowel. It was decided not to perform invasive procedures, resulting in the Colonic fistula patient’s death. Complication DISCUSSION: Gossypibomas can remain asymptomatic for years, being diagnosed when causing an obstruction, malabsorption, septic symptoms or even spontaneously. This may lead to high morbidity and mortality rates. In order to prevent it, different strategies have been described, with the objective to intensify surveillance. When diagnosed, laparotomy, laparoscopic and even endoscopic procedures have been performed successfully. CONCLUSION: We suggest putting all our efforts in identifying high risk patients and surgeries, training the OR team and enhancing protocols and checklists to minimize any preventable errors. © 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). 1. Introduction abdominal gossypiboma has been reported to occur in the stomach, duodenum, ileum, colon, bladder, vagina and diaphragm [3]. Intraabdominal surgery can sometimes lead to human errors. We aim to present a case where only accurate prevention would One of them is leaving surgical items inside patients’ bodies. Specif- have avoided its fatal ending. This paper is presented in line with ically, forgetting a sponge inside a patient can cause a foreign body the SCARE criteria [4]. reaction surrounding the textile matrix [1,2]. This reaction is called “gossypiboma”, with an estimated incidence of 1/1000 to 1/1500 of intraabdominal operations. Real incidence of gossypibomas is 2. Case presentation probably underreported, mostly due to the legal implications of their detection, but also because many patients remain asymp- An 85-year-old male, with history of left nephrectomy 12 years tomatic [2]. Such incidents may result in major injury. In a report before due to a renal carcinoma, came to the emergency room of 24 cases of foreign bodies retained after intraabdominal surgery, (ER) by ambulance with hematochezia and hemodynamic instabil- complications observed included perforation of the bowel, sepsis, ity. Patient’s comorbidities included hypertension, type 2 diabetes, and death in two patients [1]. Transmural migration of an intra- chronic obstructive pulmonary disease and congestive heart fail- ure. Patient was fully dependent for basic daily activities. During the follow-up of his renal malignancy, a foreign body was ∗ Corresponding author. Permanent address: Hospital Universitari Vall d’Hebron, identified at the first control CT scan. The patient was informed and Servicio de Cirugía General, Passeig Vall d’Hebron 119-129, 08035 Barcelona, Spain. E-mail addresses: Mariajosegomezjurado@gmail.com (M.J. Gómez-Jurado), declined a new surgery because of the high risk the new interven- annacurell2@gmail.com (A. Curell), rociomartin3004@gmail.com (R. Martín), tion would entail. A conservative management with radiological gordeju@icloud.com (A. García Ruiz de Gordejuela). surveillance was decided. https://doi.org/10.1016/j.ijscr.2020.05.053 2210-2612/© 2020 IJS Publishing Group Ltd. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/). CASE REPORT – OPEN ACCESS 60 M.J. Gómez-Jurado et al. / International Journal of Surgery Case Reports 72 (2020) 59–62 Fig. 1. Lower gastrointestinal bleeding due to a colonic fistula caused by a gossypiboma A) Coronal view. B) Sagittal view. The physical examination revealed left-side abdominal tender- and intraoperative changes in nursing staff, didn’t appear to have a ness, associated to anemization, that required blood transfusion, significantly risk for RSI [5]. and septic parameters in blood-test. An emergent angio-CT Obesity is a controversial item, being a significant risk factor revealed a 12 cm mass due to a gossypiboma near the descend- in some studies [1,6], without reaching statistical significance in ing colon (Fig. 1). The presence of air inside the mass suggested others [7]. Nevertheless, in all these studies patients with higher an infection and/or fistulization to the bowel. No signs of active mean BMI were found in the RSI group, having similar anatomic bleeding were observed. Due to the patient’s age and comorbidi- locations for the RSI. ties, it was decided not to perform any aggressive procedures. The Lu et al. published two types of reaction secondary to gossypi- decision was discussed and accorded with the patient’s relatives bomas [3]. The first one is an aseptic fibrous response to the foreign because the patient was quite disorientated. We initiated full-dose material that creates adhesions and encapsulation. This may take a wide-spread intravenous antibiotics and basic support measures. silent clinical course which can be asymptomatic. A gossypiboma After 8 days of conservative treatment, the patient developed sep- may undergo calcification, disruption, partial absorption, and even tic shock related to perforation of the sigmoid colon and pulmonary diffusion. In the abdomen, the sponge can get surrounded by omen- and heart failure, resulting in the patient’s death. tum and intestines, which attempt to encapsulate it [8,9]. The second type of foreign body reaction is exudative, and produces an inflammatory reaction that ends with an abscess for- 3. Discussion mation [3]. The body may attempt to extrude the foreign material, which can lead to complications such as erosion, external fistula The case we present represents a fatal and even unexpected formation and perforation of an adjacent viscera and migration. evolution of an already known complication. The patient had been The small intestine is the most common viscera into which migra- properly informed of the complication and non-surgical manage- tion takes place. This type of response often causes symptoms like ment was decided due to high comorbid condition of the patient. abdominal pain, nausea, vomiting, anorexia and weight loss, result- During evaluation of the patient at the ER, we considered that ing from obstruction or a malabsorption-type syndrome caused laparotomy and colectomy were the only surgical options for the by multiple intestinal fistulas or intraluminal bacterial overgrowth patient. We found that no other less invasive approaches were eli- [3,8,9]. gible. Some studies suggest that the gold standard should be a CT scan Several studies have tried to identify the risk factors of retained [8]. A characteristic sign of this pathology is the curved or banded surgical items (RSI). All the following items are related to greater radiopaque lines on plain X-ray or CT scan, which represent the propensity for disorganization and team communication break- radiopaque markers of the surgical swabs [8,10]. Nevertheless, this downs, being more difficult to keep track of materials and having radiographic finding may not be seen in some cases, like in calci- an increased likelihood of RSI [5]: fication depositions. Some surgical swabs used long time ago may not have radiopaque markers. We can find a rounded mass with a • Unplanned or unforeseen changes dense central part and an enhancing wall [10–12]. Gibbs et al. sug- • More than one subprocedure with or without multiples surgical gested that the spongiform pattern with entrapped gas bubbles, similar to what we found in our case (Fig. 1, is the most specific CT teams • Unplanned intraoperative events finding for gossypibomas, with an incidence of 54% [8]. • Multiple surgeons on various surgical teams Lu et al. described in their work a novel imaging feature called • Use of temporizing maneuvers, such as cavitary packing with sur- the “calcified reticulate rind”, consisting in a gradual deposition of calcifications along the fiber network of the surgical gauze [11]. gical sponges, temporary vascular shunting, leaving in situ clamps Gossypibomas on MRI may appear as low-signal-intensity lesions and other surgical instruments during patient transfers • Diverting team’s attention to items such as non-functioning on T2 weighed images with wavy, stripped or spotted appearances [8,10,12]. equipment Gossypibomas should be removed as soon as diagnosed, being the gold standard method for treatment [3]. Different techniques, On the other hand, Moffat-Bruce et al. showed in their meta- using laparoscopy and laparotomy, are used depending on the clin- analysis that performing surgeries at dawn, emergency procedures CASE REPORT – OPEN ACCESS M.J. Gómez-Jurado et al. / International Journal of Surgery Case Reports 72 (2020) 59–62 61 ical presentation, localization and medical equipment available. the initial symptoms, their removal may be associated with a high According to the literature, gastrostomy and segmental resection, complication and mortality rate. Overall, prevention is the key to laparoscopic or laparotomy were used to remove gossypibomas turn this condition into a real “never event”. that had migrated intraluminary. In those scenarios, endoscopic retrieval of foreign bodies has been reported [1] and may be indi- Author contribution cated. Gossypiboma-associated mortality is as high as 11–35% [13], María José Gómez-Jurado: Managed the case, Writed the orig- stressing the importance of preventing this complication. However, inal manuscript, Got informed consent. every case must be evaluated individually, and a tailored balance Anna Curell: Managed the case, Reviewed and edited the should be considered [1,2]. manuscript, Got informed consent. Prevention of these potentially harmful events is critical to Rocío Martín: Managed the case, Reviewed and edited the avoid the so called “never events”. The goal is to make that name manuscript, Got informed consent. come true. Training directed at increasing situational awareness Amador García Ruiz-de-Gordejuela: Managed the case, and improved team communication should be in the first line of Reviewed and edited the manuscript. prevention. It would help to prepare operative teams to approach Manel Armengol Carrasco: Reviewed and edited the more effectively such unplanned events [5,6]. manuscript, Supervised the process. One of the most important strategies consists on enhancing careful and thorough swabs and material counting, and in cases of Funding discrepancy, a thorough cavitary exploration and/or radiographic imaging of the surgical field must be performed [1,2,9,14,15]. This research did not receive any specific grant from funding Besides, there are some studies that encourage us to classify the agencies in the public, commercial, or not-for-profit sectors. patients into high or low risk. Using this tool would heighten awareness and understanding of the entire operating room, so to Ethical approval eliminate the occurrence of this unwanted events [1,5,14,15]. Gawande et al. showed that, among the many cases of retained The study was exempted from ethical approval. foreign bodies in which counts were performed, 88% involved a final count that was erroneously thought to be correct [1]. In the same line, when radiographic imaging is performed, Stawicki et al. Informed consent highlighted the fact that nearly half of all RSI were missed on ini- tial interpretation of such “foreign body films”, giving the surgical Relatives were contacted and signed informed consent for the team a false sense of security [6]. It is described that false-negative publication. intraoperative radiographies (IOR) have resulted from poor quality films, multiple known radiopaque densities, and the radiologists Registration of research studies being unaware of the concern about a foreign body [6,14]. More recently, different devices have been introduced to help NA. detecting RSI using radiofrequency and other forms of electronic tagging [16]. The use of radiofrequency identification systems has Guarantor a number of inherent disadvantages and has never come into gen- eral usage, probably because it is expensive, time consuming and Amador García Ruiz de Gordejuela. involves radiation, albeit a minimal amount. Moreover, other for- eign bodies that are nonmetallic and do not contain a radiopaque Provenance and peer review marking will not be imaged on a radiograph. The results of the testing described by Fabian et al. suggest Not commissioned, externally peer-reviewed. that electronic technology could reduce the incidence of retained items [16]. This system would have the added advantages of being Declaration of Competing Interest portable and quick, not using radiation, and discovering retained sponges while the wound is still open. 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