Intractable duodenal ulcer caused by transmural migration of gossypiboma into the duodenum - a case report and literature review

Abstract

BackgroundGossypiboma is a term used to describe a mass that forms around a cotton sponge or abdominal compress accidentally left in a patient during surgery. Transmural migration of an intra-abdominal gossypiboma has been reported to occur in the digestive tract, bladder, vagina and diaphragm. Open surgery is the most common approach in the treatment of gossypiboma. However, gossypibomas can be extracted by endoscopy while migrating into the digestive tract. We report a case of intractable duodenal ulcer caused by transmural migration of gossypiboma successfully treated by duodenorrhaphy. A systemic literature review is provided and a scheme of the therapeutic approach is proposed.Case presentationA 61-year-old Han Chinese man presented with intermittent epigastric pain for the last 10 months. He had undergone laparoscopic cholecystectomy conversion to open cholecystectomy for acute gangrenous cholecystitis 10 months ago at another hospital. Transmural migration of gossypiboma into the duodenum was found. Endoscopic intervention failed to remove the entire gauze, and duodenal ulcer caused by the gauze persisted. Surgical intervention was performed and the gauze was removed successfully. The penetrated ulcer was repaired with duodenorrhaphy. The postoperative period was uneventful.We systematically reviewed the literature on transmural migration of gossypiboma into duodenum and present an overview of published cases. Our PubMed search yielded seven reports of transmural migration of retained surgical sponge into the duodenum. Surgical interventions were necessary in two patients.ConclusionTransmural migration of gossypiboma into the duodenum is a rare surgical complication. The treatment strategies include endoscopic extraction and surgical intervention. Prompt surgical intervention should be considered for emergent conditions such as active bleeding, gastrointestinal obstruction, or intra-abdominal sepsis. For non-emergent conditions, surgical intervention could be considered for intractable cases in which endoscopic extraction failed.

Massive upper and lower gastrointestinal bleeding due to intra-abdominal gossypiboma

“…The first one leads to adhesions and encapsulation, and has generally a long silent clinical course. The second one leads to abscess formation, and generally occurs in early postoperative period [3]. In some cases, migration of the gossypiboma into the gut may be seen.…”

“…One of them is an aseptic fibrous response and other one is exudative reaction [3]. The first one leads to adhesions and encapsulation, and has generally a long silent clinical course.…”

“…In some cases, migration of the gossypiboma into the gut may be seen. The most common migration part of the intestine is the small bowel [3]. The migration can cause perforation, fistula formation, abscess formation, obstruction or bleeding.…”

“…The incidence of gossypiboma after intra-abdominal operations varies between 1 in 1000 to 1 in 1500 [3]. Risk factors are emergency operations, high body mass index, unplanned changes in the procedure, long operation time, inexperienced and inadequate staff and unstable condition of the patient [4,5].…”

Retained Surgical Gauze Swab Migration in a Paraplegic Patient: A Case Report and Literature Review

“…The second type triggers an exudative inflammatory reaction and abscess formation, attempting to extrude the foreign material. It is this type of reaction that might produce postsurgical complications such as fistula formation or migration of the retained material, and therefore lead to erosion and perforation into adjacent viscera [7][8][9]. The exudative type of response can cause symptoms in the early postoperative period, but the extrusion process can take years and clinical symptoms are often unspecific [7].…”