|Year : 2015 | Volume
| Issue : 1 | Page : 34-36
Gossypiboma: A cause of iatrogenic fecal entero-cutaneous fistula
Olabode P Oluwole1, Akinbola Michael F Akinnagbe1, Edmund Joseph C Nwana1, Idoko Pius Ogolekwu2, Monday G Yilkudi2
1 Department of Pathology/Forensic Medicine, University of Abuja Teaching Hospital, Gwagwalada, Abuja, F.C.T, Nigeria
2 Department of Surgery, General Surgery Unit, University of Abuja Teaching Hospital, Gwagwalada, Abuja, F.C.T., Nigeria
|Date of Web Publication||7-Jan-2015|
Olabode P Oluwole
Department of Pathology/Forensic Medicine, University of Abuja Teaching Hospital, Gwagwalada, Abuja,
Source of Support: None, Conflict of Interest: None
Gossypiboma or textiloma is used to describe a retained surgical swab in the body after an operation. Inadvertent retention of a foreign body in the abdomen often requires another surgery. Foreign bodies forgotten in the abdomen include towels, artery forceps, pieces of broken instruments or irrigation sets, and rubber tubes. The most common surgically retained foreign body is the laparotomy sponge. Such materials cause foreign body reaction in the surrounding tissue. The complications caused by these foreign bodies are well known, but cases are rarely published because of medico-legal implications. We report a case of 36-year-old teacher who was admitted with 1-week complaints of colicky abdominal pain, postprandial vomiting and entero-cutaneous fistula following caesarean section performed 6 months prior to her referral to our hospital. Clinicians and Pathologists must have a high index of suspicion of this entity and its proper reporting, as the cases are liable to go to court.
Keywords: Fecal entero-cutaneous fistula, foreign body granuloma, gossypiboma, iatrogenic, laparotomy sponge
|How to cite this article:|
Oluwole OP, Akinnagbe AF, Nwana EC, Ogolekwu IP, Yilkudi MG. Gossypiboma: A cause of iatrogenic fecal entero-cutaneous fistula. J Med Trop 2015;17:34-6
|How to cite this URL:|
Oluwole OP, Akinnagbe AF, Nwana EC, Ogolekwu IP, Yilkudi MG. Gossypiboma: A cause of iatrogenic fecal entero-cutaneous fistula. J Med Trop [serial online] 2015 [cited 2020 Jan 19];17:34-6. Available from: http://www.jmedtropics.org/text.asp?2015/17/1/34/148694
| Introduction|| |
Forgotten or missed foreign bodies, such as cotton wool sponges, gauze, or instruments, after any surgical procedure are considered as misadventure and is associated with several medico-legal problems.  The term "gossypiboma" denotes a mass of cotton retained in the body after any intervention.  This term is derived from the Latin word Gossypium or "cotton" and the Swahili word boma for a "place of concealment". Other terms used for gossypiboma include "texiloma", "cottonoid", "cottonballoma", "muslinoma" and "gauzeoma".
The first reported malpractice suit on gossypiboma was in 1933,  since that period data concerning the incidence of gossypiboma tend to fluctuate and difficult to estimate due under-reporting because of medico-legal implications.
However, it is now estimated that gossypiboma may occur in 1 out of 300-1000 of all surgical interventions and 1 out of 1000-1500 of intra-abdominal operations. 
| Case Report|| |
A 36-year-old woman who was referred from to us from a Military Hospital with a week history of fever, colicky abdominal pain, abdominal distension, vomiting and 6 months history of a discharging wound on the lower abdomen.
She has been on daily dressing of the discharging wound on the lower abdomen over the scar of a caesarean section she had 6 months prior to referral to our center.
While on this conservative dressing of the discharging wound she developed this features of intestinal obstruction for 1-week necessitating her referral to the teaching hospital.
On presentation at our center she was found to be dehydrated, febrile (39.4°C) with a blood pressure of 100/60 mmHg. The abdomen was moderately distended with an ill-defined mass felt midway between the umbilicus and pubic symphysis. A fistulous opening at the mid part of a pfannenstiel incision was seen draining a feculent material. There were increased bowel sounds but no rebound tenderness.
We made a diagnosis of an entero-cutaneous fistula with subacute intestinal obstruction.
She had nasogastric tube, urinary catheter and intravenous fluid for resuscitation. Her packed cell volume was 32%. Abdominal ultrasound and plain abdominal X-ray revealed dilated loops of bowel with centrally placed air-fluid levels.
At laparotomy a complex mass of jejunum held together with the ileum, sigmoid colon and uterus with fibrous attachment to the anterior abdominal wall. There was a single jejunal opening in continuity with the fistulous opening on the scar. The dilated jejunum had an indentable mass within it.
The sigmoid colon and uterus were separated from the jejunum and the segment of the jejunum containing the mass and the fistulous opening was resected and an end to end anastomosis was carried out.
The mass in the jejunum was found at histology to be a surgical sponge measuring 35 cm × 15 cm which had migrated into the jejunum.
The patient had an uneventful postoperative period and was discharged 10 days after surgery [Figure 1].
| Discussion|| |
Retained foreign body after surgery is an avoidable surgical misadventure. It has serious professional and medico-legal consequences to the surgeon, the involved health services and associated significant morbidity and mortality for the patient. , Moreover, Dakubo et al.  noted that not only the mortality from retained sponges ranges from 15% to 22%, the retained foreign body in the abdomen often requires another surgery to recover it and this increases the morbidity and mortality.
The incidence is generally underestimated due to several factors; under-reporting because of medico-legal implications, some patients remain asymptomatic and never present to the hospital, and the estimated incidence is calculated with the denominator that includes a large number of procedures with very low incidence of retained gauze. ,
A Surgeon working alone in a peripheral hospital, where most of the misadventure of retained foreign bodies occurs in our environment is most unlikely to report himself and it is easy for him to cover up. Local data on incidence of retained foreign materials are not available, it is in the light of the facts stated above, that most authors hypothesizes that the incidence of retained instruments would be higher here than quoted in the literature. 
Gossypiboma is the commonest foreign material retained. It accounts for 70% of retained foreign materials.  Qamar et al.  and Sushel et al.  reported, five and nine cases of gossypibomas in their review of 11 and 15 cases respectively, the reasons they deduced were common usage, small size and amorphous structure of the surgical sponge.
The most common site of surgical sponge retention is intraperitoneal following laparatomy; however, it has been reported virtually in all operations in every part of the body, including limbs, brain, tooth canal and in the scrotum. ,
The common presentation of gossypiboma in the literature include, abdominal mass, intestinal obstruction, peritonitis, perforation, extrusion of the sponge and rarely fistula. 
Our index patient presented with abdominal mass, abscess formation, entero-cutaneous fistula with fecal discharge and symptoms of intestinal obstruction. There are two types of fistula, internal (between digestive tract and other abdominal viscera) and external (includes skin or other epithelial surfaces). About 80% of external fistulas are caused by either medical errors or diseases such as Crohn disease and cancers.  Our findings in this report are similar to the report by Govarjin et al.,  as their patient also presented with entero-cutaneous fistula and fecal discharge following caesarean section.
Non-radio-opaque impregnated towels are used as surgical sponge in many operating rooms in poor resource countries. The surgical mop retained in our patient was a face towel which lacked a radio-opaque marker, thus, it can't be diagnosed by radiologic screening and may mimic radiographic patterns of hematoma, neoplasm, granulomatous process, abscess formation, cystic masses, calcification and air bubbles as well. The exact modalities of granuloma due to gauze are best seen in contrast enhanced magnetic resonance imaging. 
This case presents an example of some of the complications that can arise from use of improvised surgical facilities in the place of conventional and acceptable surgical materials.
Concerning complete migration of gossypiboma into the intestine, Gencosmanoglu et al.  reported abscess formation and severe intraluminal adhesions due to migration of laparotomy towel into mid-abdomen 2 years after open cholecystectomy and hernia repair in a 74-year-old woman presented as small bowel obstruction. They concluded that gossypiboma should be considered as a cause for intestinal mechanical obstruction.
Except for FRIENDS (foreign body in fistula duct, radiation, infection, inflammation in origin of fistula, epithelialization of fistula duct, neoplasia of fistula and distal obstruction of fistula) most of entero-cutaneous fistulas are closed spontaneously.  In our patient, the entero-cutaneous closed after surgical intervention.
Concerted efforts by all theatre users are needed to prevent this unfortunate complication of abdominal exploration. The time honored simple task of sponge count is subject to human error and exploration of the surgical site at the conclusion of surgery may not be fool-proof either. The traditional surgical mop is impregnated with radio-opaque markers that make radiological screening easy when necessary. Though this is practiced in many standard centers, and is highly encouraged, it may still not be conclusive as the risk of false positive count is not completely eliminated.
However, in our environment, especially in rural areas where trained staffs are few, attempt should be made to procure radio-opaque materials that can be viewed by X-rays. In addition, counting of surgical material before and after surgery should be attended to by the surgeons, and nurses to reduce human error instead of allowing the nurses alone to do the counting.
New trends to prevent retention of surgical materials involve multi-level checks, automated counting systems using bar-codes and counters, radio-frequency beacon and reader with base station and the radio-frequency identification system which focus mainly on detection. 
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