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© 2003 American Society for Clinical Oncology
Diagnostic Challenges in Patients With TumorsCASE 1. GOSSYPIBOMA (FOREIGN BODY) MANIFESTING 30 YEARS AFTER LAPAROTOMYRoswell Park Cancer Institute and the State University of New York at Buffalo, Buffalo, NY
A 48-year-old woman presented to her primary care physician complaining of abdominal pain and weight loss. Her work-up included a computed tomography (CT) scan of the abdomen and pelvis, which showed an intra-abdominal mass. The patient was therefore referred to our institution for further management and treatment. Her past medical and surgical history was significant for a total abdominal hysterectomy and bilateral salpingo-oophorectomy 30 years ago at an outside institution for chronic pelvic inflammatory disease. On physical examination, she was obese. Her abdominal examination was significant for tenderness over an underlying mass in the left mid abdomen. Initially, the differential diagnosis included lymphoma, retroperitoneal sarcoma, or gastrointestinal stromal cell tumor. The CT scans ordered by the referring facility and transported by the patient were carefully reviewed. Subsequently, the diagnosis of gossypiboma (foreign body) was made. Figure 1
The patient underwent an exploratory laparotomy and a mass was excised from the adherent small bowel and its mesentery (Fig 3  ). No bowel resection was required. Pathologic evaluation confirmed the presence of a foreign body consistent with a sponge with surrounding inflammation and fibrosis. The patient had an uneventful postoperative course and was discharged home on the fifth postoperative day. She has been seen in follow-up and is doing well.
The term gossypiboma is derived from the Latin word gossypium, meaning cotton, and the Kiswahili word boma, meaning place of concealment. There are numerous case reports of retained foreign bodies in the literature, but the true incidence is thought to be underreported secondary to the possible legal ramifications of this technical oversight.1 A patient with a retained laparotomy sponge presents either acutely or in a delayed fashion, as the patient above.2,3 Those patients who present acutely usually have an episode of sepsis and abscess formation. This is an exudative response that may lead to the complications of fistulae, perforation, or endoluminal erosion with subsequent obstruction and even extrusion. Those who present in a delayed fashion, such as the patient presented, have a fibrinous response. This is usually an aseptic process that creates adhesions and a thick capsule around the retained sponge. Most nonmetallic equipment used in the operating room today contains a radio-opaque marker. Awareness of the radiographic appearance of these markers is required for detection and diagnosis. There are reports in the literature of the appearance of a retained sponge on plain radiographs, CTs, magnetic resonance images, and ultrasound.2–8 Cases of retained sponges with no radio-opaque markers are also reported in the literature and can make the preoperative definitive diagnosis difficult, if not impossible.9 The case of a retained sponge or instrument raises the issue of human fallibility. There is a growing body of literature analyzing human factors in the study and prevention of medical accidents.10 This field has grown out of an effort to reduce the human contribution in potentially catastrophic high-risk enterprises such as road, sea, and air travel, in addition to nuclear, chemical, and other industrial enterprises. Research from the aviation industry has shown that with implementation of measures to improve team management and the quality of communication between team members, there is a significant impact on human performance.11 Swiss researchers have examined these team issues in the operating rooms of a teaching institution.12 They found that "interpersonal and communication issues are responsible for many inefficiencies, errors, and frustrations in this psychologically and organizationally complex environment." Thus one of the goals of effective risk management should be to enhance human performance at all levels of an organization.13 Despite all the technologic advances of the 21st century, human fallibility remains. The possibility of a gossypiboma exists even in modern medicine. The importance of correct sponge and instrument counts cannot be overstated. When counts are off, patience is required. If a thorough search does not find the missing item(s), then a radiograph is necessary. Ironically, in most cases of a retained sponge, the final sponge count is seemingly correct.3 To avoid the complication of a gossypiboma, there must be thorough attention to detail by the operating room team and a careful inspection of the abdomen before closure even in the face of correct counts. AUTHORS’ DISCLOSURES OF POTENTIAL CONFLICTS OF INTEREST The authors indicated no potential conflicts of interest.
REFERENCES 1. Zbar AP, Agrawal A, Saeed IT, et al: Gossypiboma revisited: A case report and review of the literature. J R Coll Surg Edinb 43:417–418, 1998[Medline]
2. Olnick HM, Weens HS, Rogers JV: Radiological diagnosis of retained surgical sponges. JAMA 159:1525–1527, 1955
3. Moyle H, Hines OJ, McFadden DW: Gossypiboma of the abdomen. Arch Surg 131:566–568, 1996 4. Roumen RMH, Weerdenburg HPG: MR features of a 24-year old gossypiboma: A case report. Acta Radiol 39:176–178, 1998[Medline]
5. Rappaport W, Haynes K: The retained surgical sponge following intra-abdominal surgery. Arch Surg 125:405–407, 1990 6. Williams RG, Bragg DG, Nelson JA: Gossypiboma: The problem of the retained surgical sponge. Radiology 129:323–326, 1978[Abstract] 7. Skheward SE, Williams AG, Mettler FA, et al: CT appearance of a surgically retained towel (gossypiboma). J Comput Assist Tomogr 10:343–345, 1986[Medline] 8. Prasa S, Krishana A, Limd J, et al: Imaging features of gossypiboma: Report of two cases. J Postgrad Med 45:18–19, 1999[Medline] 9. Bhat HS, Mahesh G, Ramgopal KS: Gossypiboma: An unusual cause of perinephric abscess. J R Coll Surg Edinb 42:272–282, 1997[Medline] 10. Reason JT: Understanding adverse events: The human factor, in: Vincent C (ed): Clinical Risk Management. London, United Kingdom, BMJ Publications, 1995, pp 9–30 11. Helmreich RL, Butler RA, Taggart WIZ, et al: Behavioral markers in accidents and incidents: Reference list. Austin, Texas, Univesity of Texas, 1994 (Technical report 94-3; NASA/University of Texas FAA Aerospace Crew Research Project) 12. Helmreich RL, Schaefer H-G: Team performance in the operating room, in: Bogner MS (ed): Human Errors in Medicine. Hillsdale, NJ, Erlbaum, 1994 13. Cook RI, Woods DD: Operating at the sharp end: The complexity of human error, in: Bonger MS (ed): Human Errors in Medicine. Hillsdale, NJ, Erlbaum, 1994, pp 255–310
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Copyright © 2003 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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