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Year : 2002  |  Volume : 12  |  Issue : 1  |  Page : 137-139
Spontaneous transmural migration of a retained surgical sponge into the intestinal lumen - a rare cause of Intestinal obstruction


Department of Radiodiagnosis and GI Surgery, GB Pant Hospital, New Delhi-110002, India

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How to cite this article:
Puri S K, Panicker H, Narang P, Chaudhary A. Spontaneous transmural migration of a retained surgical sponge into the intestinal lumen - a rare cause of Intestinal obstruction. Indian J Radiol Imaging 2002;12:137-9

How to cite this URL:
Puri S K, Panicker H, Narang P, Chaudhary A. Spontaneous transmural migration of a retained surgical sponge into the intestinal lumen - a rare cause of Intestinal obstruction. Indian J Radiol Imaging [serial online] 2002 [cited 2019 Nov 19];12:137-9. Available from: http://www.ijri.org/text.asp?2002/12/1/137/28436
Sir,

Recognition of a post-operatively retained foreign body is essential but is often delayed either because of medico legal implications or because of confusing clinical presentation and non-specific imaging features[1]. We wish to present an unusual case of a retained surgical sponge which had migrated into the intestinal lumen leading to intestinal obstruction eight months after the operation.

A thirty-two years old woman presented with recurrent episodes of subacute intestinal obstruction of two months duration. She had undergone cholecystectomy elsewhere eight months ago. On examination she was moderately anaemic and had an ill-defined, firm, mildly tender and mobile mass in the epigastric and umbilical regions.

Blood examination was unremarkable except for hemoglobin level of 8 gm.%. Plain radiographs of abdomen revealed an ill-defined radiodensity suggestive of a mass in the centre of abdomen with no evidence of any abnormal luminal of extra luminal bowel gas pattern. US examination revealed a densely echogenic lesion in the region of mass with strong posterior acoustic shadowing [Figure - 1]. The mass was separate from major abdominal organs which were otherwise normal. CT Scan showed a dilated jejunal loop with an intra-luminal mass showing mottled air densities suggestive of a sponge. Walls of the jejunal loop were thickened with inflammatory streaking in the surrounding mesentry [Figure - 2] A pre-operative small bowel enema examination confirmed a large, well defined, intra-luminal mass inside a dilated jejunal loop with barium coating and permeating the interstices of the mass [Figure - 3].

Patient was subjected to surgery which revealed the affected loop of jejunum and a surgical sponge inside. A small portion of the sponge was still protruding out of the wall representing the fistulous site through which it would have migrated into the lumen. Inflammatory adhesions were noticed in the surrounding mesentry and bowel loops. The involved segment of jejunum was resected and end-to-end anastomosis performed. Post-operative recovery was uneventful. Histopathological examination was consistent with surgical sponge.

A post-operatively retained cotton surgical sponge, although clinically inert, may serve as a nidus for catastrophic complications. Two types of foreign body reactions may result. One is an aseptic fibrinous response that creates adhesions and encapsulations resulting in a granuloma or pseudotumor formation, also referred euphemistically as "Gossypiboma" [1],[2]. The other is an exudative type of response leading to abscess formation with or without bacterial superinfection and fistula formation. Septic complications are likely to present in the early post-operative period, while aseptic encapsulations may go undetected for years. Commonly the body tries to extrude such retained foreign bodies along the path of least resistance which could be either through the wound, sinus tract or rarely into a hollow viscus like intestine, urinary bladder or vagina. Retained surgical sponge may also be expelled per-rectum without any problem after as long as five years of surgery [3],[4]. During migration, surgical sponge may also cause erosion of a vessel leading to serve haemorrhage. With passage of time, if undetected, such foreign bodies may undergo calcification, disruption an even complete resorption[4].

Radiological diagnosis of retained surgical foreign bodies without radio-opaque markers may be extremely difficult. Coupled with clinical suspicion of retained surgical sponge, there are various signs which can help in making the correct diagnosis of these foreign bodies. Plain radiographs of abdomen may be normal or may show a soft tissue mass with entrapped gas bubbles. US shows a mass with hypoechoic rim and a central echogenic area with intense acoustic shadowing representing either the foreign body itself or entrapped air [1],[2]. Barium studies commonly show distorted and adherent bowel loops whereas an intraluminal sponge, as seen in our case, would be seen as a filling defect. Delayed films may show retention of barium entrapped within the sponge mesh, resembling a bezoar. CT findings of the retained sponge are a well circumscribed mass with or without gas bubbles, enhancement of wall after contrast injection and calcification. A "spongiform pattern" and a "whirl pattern" have been described as a result of air trapping between the synthetic fibres of a sponge [1],[2],[4].

However, all these features might not be seen in a number of cases and differentiation from an abscess or hematoma with fistulous communication may be extremely difficult. In conclusion, timely surgical intervention is possible only if there is awareness of such a condition and its radiological features, while investigating abdominal masses in patients with a history of previous surgery either recent or remote[5].

 
   References Top

1.Prasad S, Krishnan A, Limdi J and Patankar T. Imaging features of Gossypiboma: Report of two cases. J Posgrad Med 1999; 45:18-19  Back to cited text no. 1    
2.Sahin - Akyar G, Yagci C and Aytac S. Pseudotumor due to surgical sponge: Gossypiboma. Australasian Radiology 1997; 41:288-291  Back to cited text no. 2    
3.Wig JD, Goenka MK, Suri S, Sudhakar PJ and Vaiphei K. Retained surgical sponge: An unusual cause of intenstinal obstruction. J Clin Gastroenterol 1997; 24:57-58  Back to cited text no. 3    
4.Robinson KB and Levin EJ. Erosion of retained surgical sponges into the intestine. AJR 1966;96:339-343  Back to cited text no. 4    
5.Kalovidouris A, Kehagias D, Moulopoulos L, Gouliamos A, Pentea S, and Vlahos. Abdominal retained surgical sponges: CT appearance. Eur Radiol 1999;9:1407-1410.  Back to cited text no. 5    

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Correspondence Address:
S K Puri
Department of Radiodiagnosis and GI Surgery, GB Pant Hospital, New Delhi-110002
India
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Source of Support: None, Conflict of Interest: None


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[Figure - 1], [Figure - 2], [Figure - 3]

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