History
A 50-year-old Mexican woman presented with abdominal pain to the emergency department of a hospital in the United States of America 12 months after a successful gastric surgery in her native land. She reported that 6 months after her surgery she developed epigastric discomfort and underwent treatment for what she was told was a suture granuloma. She did well for a short time but has had recurrent infection at the site marked by pain, a foul discharge from the site of surgery, subjective fever, nausea and vomiting – the same group of complaints that sent her to the emergency room this time. Except for hypothyroidism adequately treated with synthroid, past cesarean section and bilateral tubal ligation, her medical record was unremarkable. On examination, there was a dermal sinus in her epigastrium, bound by red inflamed tenderness and from which issued a foul discharge. She was afebrile and except for borderline leucocytosis, was fine. She had contrast-enhanced CT scan of the abdomen and latter an upper gastrointestinal series, the findings of which prompted a laparoscopic intervention. She did well afterward.
Radiologic findings
CT scan (top panel):
There is a round thick-walled mass ( arrowed red on all 3 CT images) anterior to the stomach, collapsing it. It has a spongiform matrix of bubbles of air mixed with unenhancing soft tissue and at its 8:00 position on the coronal view (the middle image), exhibits a radiodense non-metallic structure. Its 11:00 position on the axial view (the first image) is continuous with a midline thickening of the abdominal wall that proved to be a sinus at laparoscopy.
Upper gastrointestinal series (bottom panel):
There is a massive filling defect external to the stomach that markedly diminishes its capacity and corresponds in location to the mass seen on the CT scan. The red arrow on the first 2 images identifies radio-contrast in the collapsed stomach, the blue arrow identifies the extra-gastric mass, while the brown arrow identifies the radiopaque foreign body seen within the mass on the CT scan, which at surgery and pathology belonged to a surgical sponge. The 3rd image is a panoramic view of the upper midgut showing the mass, the stomach, and the proximal small bowel, demonstrating absence of gastric outlet obstruction. The topography of the gastric lumen is normal as shown on the double-contrast images (image not shown) and there is no communication between the mass and the stomach.
Surgico-Pathologic finding
The resected track of tissue between the mass and the skin at histology proved to be a fistula surrounded by “fibroadipose tissue and skeletal muscle with hemorrhage and focal chronic inflammation.” The mass was removed in fragments of friable foul tissue in the midst of which was a “blood-stained yellow gauze-like sponge measuring 16 cm x 10.9 cm x 3 cm.”
Final diagnosis: Gossypiboma.
Discussion
Medical errors are common. Among them, though not as frequent as others but equally important, is the problem of unintentional retention of foreign objects in opened body cavities. Although our patient had her surgery outside USA, estimates suggest that every year in the USA foreign objects are unintentionally left in 1500 patients and it is believed that these estimates may be low because such occurrences attract embarrassing press attention and punitive legal sanction that perpetrators are unwilling to report all. What is left in a patient varies: a surgical instrument such as needle, staple, forceps, scissors, or a surgical sponge. The term gossypiboma describes a forgotten sponge and derives from Gossypium, Latin for cotton and boma, Swahili for a place of concealment. Textiloma is another term for lost surgical sponge since some surgical sponges are made from synthetic textile.
When a foreign object disappears in a patient there is a 50% chance that knowledge of the loss occurs within 3 weeks of surgery and 26% likelihood of such knowledge more than 2 months afterward. In all, 40% of gossypibomas are found within 1 year of their culprit surgery and 50% within 5 or more years. One of two things happens following unintentional retention of a foreign object in the body: an acute suppurative reaction may supervene as the body aggressively reacts to the foreigner or a more insidious accommodative granulomatous containment occurs as the foreign object is walled off into a calcified mass. The former is intense, with telltale features of acute infection – pain, fever, localized tenderness, diminished use of the affected area, etc – as the body attempts to destroy and expel the object. It may cause peritonitis, bowel perforation or obstruction, fistularization, septic shock syndrome and even death. The second form of reaction is relatively quiet and smoldering and may go undetected for many years. Walled-off foreign bodies have masqueraded as tumors in the body, being found serendipitously many years after they were forgotten. Our case exemplifies an intermediate type having smoldered for 12 months, its vigor blunted by intercurrent surgical interventions in Mexico and its vim diminished by the continuous emptying of its foul contents through an epigastric sinus.
There are other unsavory consequences of such error. In 69% of patients re-operation is inevitable. Legal adjudication is almost certain to incur a hefty penalty because negligence is obvious and its consequences on the patient self-evident. The press is gleeful in its exposition and decrying of wanton ineptitude and lack of care, attracting unwanted institutional public scrutiny and spot light with potential pocket book downsizing. The Centers for Medicare and Medicaid Services (CMS) currently does not pay for the treatment of errors caused by recent hospitalization, so the hospital will swallow the cost of clearing its mess – that is, if the patient returns to the original hospital. A visit from The Joint Commission on Accreditation of Health Care Organizations is every administrator’s nightmare. And, of course, there is the embarrassment to the surgeon responsible for the occurrence.
Foreign body retention can occur in any operation that involves opening of the body. Not surprisingly it does not occur with minimally invasive or laparoscopic surgeries. A majority occur with abdominal and gynecological surgeries with a few reported with cardiothoracic, neurosurgical, and other operations.
Research has shown that the following are risk factors or conditions that increase the likelihood of retaining a foreign body in a patient after surgery:
The urgency and nature of a procedure: Procedures performed emergently are 8.8 times more likely to be associated with retention of a foreign object in a patient than those done electively. Such procedures are often associated with speed and some measure of chaos that may lead to poor attention to instrument counting. In addition, procedures that are long, involve multiple operators or change of guards, or that are complicated have higher chance of being associated with foreign object retention. Under these circumstances, there is more blood loss and so more use of sponges and instruments with greater chance of losing some due to increase in number and reduced visibility from bleeding. Further, personnel may tire and be less attentive to detail and more likely to fail to fully communicate information to succeeding colleagues during shift changes. Thus, surgeons and nurses confronted with scenarios like these should be more vigilant to the possibility of unintentional retention of a foreign object and guard against it.
Unplanned change in a procedure: When there is an unscheduled change in the performance of a procedure, there is a 4.1 increased risk of leaving a foreign body behind in a patient. The reason is the confusion that such change may introduce to the procedure which makes foreign body retention more likely. In a sense it is an urgent or emergent surgery, not elective, and so prone to the vagaries of the former.
A patient’s body habitus: The size of a patient expressed as their body mass index has been shown to be associated with higher risk of postsurgical foreign body retention; the risk increases by 1.1 for each unit of increase in the patient’s body mass index. It is believed that a larger body mass provides more areas of concealment of surgical instruments and sponges and, to some degree, the tedium inherent in surgery on such patients may sap any remaining vigilance against losing foreign objects in them.
Poor counting discipline: Second only to not operating on a patient in the prevention of unintentional foreign body retention is the counting of surgical instruments and sponges. The importance of this exercise in reducing the risk of foreign body retention is underscored by the standards set for it by the Association of periOperative Room Nurses (AORN) – I refer the reader to the association’s web site, www.aorn.org, for details of its recommendations – and for this reason most preventive efforts aimed at unintentional foreign body retention have to do with instrument counting. Strict adherence to AORN’s standards significantly, but not completely, reduces the incidence of postoperative foreign body retention in patients. Disciplined accounting for every sponge or surgical instrument that makes a trip into a surgical field is the beginning of efforts to prevent leaving such in a patient.
Imaging problems: Most surgical instruments are radiopaque and so are easily identifiable when lost. Further, in USA since 1933, surgical sponges have been impregnated with barium in some form to enhance their visibility when lost. Thus, the principal mode of searching for a missing object in a patient in the operating room is radiography. But obtaining, interpreting, and transmitting the findings of a radiograph is not as seamless as it sounds. First, image acquisition is usually directed by the operating surgeon who may or may not be the final interpreter of the study. This can be problematic if the study fails to show the missing item and is interpreted by a radiologist unfamiliar with what the missing item looks like and who may be befuddled by the many surgical instruments that clutter the imaged surgical field. Clear instructions to the interpreting radiologist from the operating surgeon as to where and what to look for may help. Second, image acquisition may be suboptimal because it is portable and the operating field sterile and pregnant with many instruments; in addition the patient may be obese, reducing x-ray penetration. Interpreting such poor-quality image either by the surgeon or a radiologist may be unrewarding. Attention to detail during image acquisition or the use of fluoroscopy under the direction of the surgeon or an invited radiologist may assist in this regard. It may be necessary to use CT scan ( I do not recommend other imaging modalities like sonography and MRI because they have less utility in this regard) to search for the missing object when the patient is out of the operating room. Third, the communication of the findings of a radiograph to the operating surgeon may be suboptimal especially if the study is interpreted after the patient is out of the operating room. Clear documentation of the findings of a study and the methods of communicating them to the requesting surgeon may help in this situation.
In summary, forgetting foreign objects in patients after surgery is a medical error with far-reaching consequences for the patient, health care providers, and health care institutions. Its avoidance requires combined individual vigilance and institutional supervision.