Intractable duodenal ulcer caused by transmural migration of gossypiboma into the duodenum - a case report and literature review
© Lv et al.; licensee BioMed Central Ltd. 2014
Received: 24 December 2013
Accepted: 5 June 2014
Published: 10 June 2014
Gossypiboma 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.
A 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.
Transmural 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.
KeywordsGossypiboma Duodenal ulcer Transmural migration Surgical complication Duodenorrhaphy Endoscopy Endoscopic extraction
Gossypiboma 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 stomach, duodenum, ileum, colon, bladder, vagina and diaphragm [1–3]. 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 gossipyboma successfully treated by duodenorrhaphy. We systematically reviewed the literature on transmural migration of gossypiboma into duodenum and present an overview of published cases. A scheme of the therapeutic approach is also proposed.
We searched the PubMed (2000–2013) database for case reports about transmural migration of gossypiboma into the duodenum. The abstracts of all articles published in Dutch, English, French, German, and Spanish were screened. The full texts of articles published in other languages but with an abstract in English were analyzed. Articles were selected for review if they included the following patient data: age, sex, initial surgery, interval, clinical presentation, diagnostic methods, location, and surgical procedures.
Transmural migration of gossypiboma into the duodenum: review of the selected literature (2000–2013)
Interventions (Surgical indication)
Erdil et al. 
Sinha et al. 
US, CT, endoscopy
Alis et al. 
Peyrin-Biroulet et al. 
Sarda et al.7
Abdominal pain, vomiting
Dux et al. 
Abdominal pain, vomiting
Surgical drainage (Persistent duodenal fistula)
Manikyam et al. 
Abdominal pain, vomiting
Right hemicolectomy, Duodenorraphy (Gastric outlet obstruction and duodeno-ileo-colic fistula)
Lv et al. (present study)
Endoscopic extraction, Duodenorrhaphy (Intractable duodenal ulcer)
The term “gossypiboma” denotes a cotton sponge that is retained inside a patient during surgery. The reported incidence of gossypiboma varies between 1/100 and 1/3000 for all surgical interventions and from 1/1000 to 1/1500 for intra-abdominal operations [9–18]. There are no national or local registers, and the reluctance of medical institutions to publish matters that may have medico-legal implications probably leads to underreporting of diagnosed cases. Furthermore, some patients remain asymptomatic and in such cases gossypibomas may never be found.
As a consequence of gossypiboma, two types of foreign body reactions can occur. The first type is an aseptic fibrous response to the foreign material that creates adhesions and encapsulation. The result is a foreign body granuloma which may take a silent clinical course which dose not produce any clinical symptoms. A gossypiboma may undergo calcification, disruption, partial absorption, and even diffusion. The second type of foreign body reaction is exudative in nature and produces an inflammatory reaction with abscess formation. The body attempts to extrude the foreign material, which may lead to post-surgical complications such as external fistula formation or erosion and perforation into adjacent viscera. This may then result in migration of the foreign body into the gut, intestinal obstruction, or extrusion of the sponge through the rectum. The exudative type of response often causes symptoms in the early postoperative period, but the extrusion process may take years and the clinical symptoms are unspecific [7–9, 19–25]. Wattanasirichaigoon describes 4 stages in the process of migration: foreign body reaction, secondary infection, mass formation, and remodeling .
Reported cases of transmural migration of gossypiboma into the gastrointestinal organs according to the impacted gastrointestinal organs: review of the selected literature (2000–2013)
Reported cases of transmural migration of gossypiboma into the gastrointestinal organs according to the initial procedures: review of the selected literature (2000–2013)
No. of patients
Cystectomy + Myomectomy
Many risk factors, such as duration and complexity of surgery, excessive blood loss in trauma patients, surgery under emergency conditions, unplanned procedural changes, a change in operating room teams during the course of the operation, and a failure to count surgical instruments and sponges, were identified. The three most important risk factors are emergency surgery, unplanned change in the operation, and body mass index [2, 15, 18, 33].
Nonspecific clinical symptoms may preclude an accurate diagnosis. The clinical presentation of gossypiboma is variable. According to the literature, common symptoms and signs of transmural migration of gossypiboma into the duodenum may include abdominal pain, vomiting, and bleeding [7, 9, 30]. The most frequently reported symptom was abdominal pain. The main complications of abdominal gossypiboma were bowel or viscera perforation, obstruction, peritonitis, adhesion, abscess development, fistula formation, sepsis, and migration of the sponge into the lumens of the gastrointestinal tract [9, 30].
The diagnosis of gossypiboma is difficult because the clinical symptoms are nonspecific and the imaging findings are often inconclusive. In imaging studies, they are mostly seen as radio-opaque material, yet radiolucent material like sponges can cause diagnostic problems. However, plain radiography, barium studies, endoscopy, ultrasonography (US), CT, and magnetic resonance imaging (MRI) are useful for diagnosis . Plain radiographs may disclose the presence of gossypiboma if the surgical sponge is calcified or when a characteristic “whirl-like” pattern is evident. In the literatures, endoscopy played an important role in the diagnosis and treatment of intraluminal gossypiboma cases.
In conclusion, gossypiboma should be considered in the differential diagnosis of any postoperative patient who presents with pain, infection, or a palpable mass. Plain radiography, barium studies, endoscopy, ultrasonography, CT scan, and MRI are useful for diagnosis. Transmural migration of gossypiboma into the duodenum is a rare surgical complication. The treatment strategies include endoscopic removal and surgical intervention. Prompt surgical intervention should be considered for emergent conditions such as active bleeding, GI obstruction, or intra-abdominal sepsis. For non-emergent conditions, surgical intervention could be considered in intractable cases if endoscopic extraction failed.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent form is available for review by the Editor of this journal.
Magnetic resonance imaging
Endoscopic retrograde cholangiopancreatography.
The authors thanks the Department of Medical Research, Taichung Veterans General Hospital for providing the funding for English language editing.
- Zantvoord Y, Weiden RM, van Hooff MH: Transmural migration of retained surgical sponges: a systemic review. Obstet Gynecol Surv. 2008, 63 (7): 465-471. 10.1097/OGX.0b013e318173538e.View ArticlePubMedGoogle Scholar
- Erdil A, Kilciler G, Ates Y, Tuzun A, Gulsen M, Karaeren N, Dagalp K: Transgastric migration of retained intraabdominal surgical sponge: gossypiboma in the bulbus. Inter Med. 2008, 47 (7): 613-615. 10.2169/internalmedicine.47.0391.View ArticleGoogle Scholar
- Lin TY: Chuang CK:Gossypiboma: migration of retained surgical gauze and spontaneous transurethral protrusion. BJU Int. 1999, 84 (7): 879-880.View ArticlePubMedGoogle Scholar
- Sinha SK, Udawat HP, Yadav TD, Lal A, Rana SS: Bhasin DK:Gossypiboma diagnosed by upper-GI endoscopy. Gastrointest Endosc. 2007, 65: 347-349. 10.1016/j.gie.2006.06.077.View ArticlePubMedGoogle Scholar
- Alis H, Soylu A, Dolay K, Kalacyci M, Ciltas A: Surgical intervention may not always be required in gossypiboma with intraluminal migration. World J Gastroenterol. 2007, 13 (48): 6605-6607. 10.3748/wjg.13.6605.View ArticlePubMedPubMed CentralGoogle Scholar
- Peyrin-Biroulet L, Oliver A: Bigard MA:Gossypiboma successfully removed by upper-GI endoscopy. Gastrointest Endosc. 2007, 66 (6): 1251-1252.View ArticlePubMedGoogle Scholar
- Dux M, Ganten M, Lubienski A, Grenacher L: Retained surgical sponge with migration into the duodenum and persistent duodenal fistula. Eur Radiol. 2002, 12 (suppl 3): S74-S77.PubMedGoogle Scholar
- Manikyam SR, Gupta V, Gupta R, Gupta NM: Retained surgical sponge presenting as a gastric outlet obstruction and duodeno-ileo-colic fistula: report of a case. Surg Today. 2002, 32: 426-428. 10.1007/s005950200068.View ArticlePubMedGoogle Scholar
- Yildirim S, Tarim A, Nursal TZ, Yildirim T, Caliskan K, Torer N, Karagulle E, Noyan T, Noyan T, Moray G, Haberal M: Retained surgical sponge (gossypiboma) after intraabdominal or retroperitoneal surgery: 14 cases treated at a single center. Langenbecks Arch Surg. 2006, 391 (4): 390-395. 10.1007/s00423-005-0581-4.View ArticlePubMedGoogle Scholar
- Bani-Hani KE, Gharaibeh KA, Yaghan RJ: Retained surgical sponges(gossypiboma). Asian J Surg. 2005, 28: 109-115. 10.1016/S1015-9584(09)60273-6.View ArticlePubMedGoogle Scholar
- De Campos FF, Franco F, Maximiano LF, Martines JA, Felipe-silva AS, Kunitake TA: An iron deficiency anemia of unknown cause: a case report involving gossypiboma. Clinics (Sao Paulo). 2010, 65 (5): 555-558. 10.1590/S1807-59322010000500014.View ArticlePubMed CentralGoogle Scholar
- Akbulut S, Sevinc MM, Basak F, Aksory S, Cakabay B: Transmural migration of a surgical compress into the stomach after splenectomy: a case report. Cases J. 2009, 2: 7975-10.4076/1757-1626-2-7975.View ArticlePubMedPubMed CentralGoogle Scholar
- Patil KK, Patil SK, Gorad KP, Panchal AH, Arora SS, Gautam RP: Intraluminal migration of surgical sponge: gossypiboma. Saudi J Gastroenterol. 2010, 16 (3): 221-222. 10.4103/1319-3767.65195.View ArticlePubMedPubMed CentralGoogle Scholar
- Agarwal AK, Bhattacharya N, Mukherjee R: Intraluminal gossypiboma. Pak J Med Sci. 2008, 24 (3): 461-463.Google Scholar
- Cruz RJ, Poli De Figueiredo LF, Guerra L: Intracolonic obstruction induced by a retained surgical sponge after trauma laparotomy. J Trauma. 2003, 55 (5): 989-991. 10.1097/01.TA.0000027128.99334.E7.View ArticlePubMedGoogle Scholar
- Gupta S, Mathur AK: Spontaneous transmural migration of surgical sponge causing small intestine and large intestine obstruction. ANZ J Surg. 2010, 80 (10): 756-757.View ArticlePubMedGoogle Scholar
- Govarjin HM, Talebian M, Fattahi F, Akbari ME: Migration of retained long gauze from abdominal cavity to intestine. JRMS. 2010, 15 (1): 54-57.PubMedPubMed CentralGoogle Scholar
- Dakubo J, Clegg-Lamptey J, Hodasi W, Obaka H, Toboh H, Asempa W: An intra-abdominal gossypiboma. Ghana Med J. 2009, 43 (1): 43-45.PubMedPubMed CentralGoogle Scholar
- Tiwary SKR, Khanna R, Khanna AK: Transmural Migration of Surgical Sponge Following Cholecystectomy: An unusual cause of gastric outlet obstruction. Internet J Surg. 2006, 7: 2-Google Scholar
- Gwande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ: Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003, 348 (3): 229-235. 10.1056/NEJMsa021721.View ArticleGoogle Scholar
- Mentes BB, Yilmaz E, Sen M, Kayhan B, Gorgul A, Tatlicioglu E: Transgastric migration of a surgical sponge. J Clin Gastroenterol. 1997, 24 (1): 55-57. 10.1097/00004836-199701000-00013.View ArticlePubMedGoogle Scholar
- Cheng TC, Chou AS, Jeng CM, Chang PY, Lee CC: Computed tomography findings of gossypiboma. J Chin Med Assoc. 2007, 70 (12): 565-569. 10.1016/S1726-4901(08)70063-7.View ArticlePubMedGoogle Scholar
- Erbay G, Koc Z, Caliskan K, Araz F, Ulusan S: Imaging and clinical findings of a gossypiboma migrated into the stomach. Turk J Gastroenterol. 2012, 23 (1): 54-57.View ArticlePubMedGoogle Scholar
- Kundan KK, Patil SK, Gorad KP: Intraluminal migration of surgical sponge: gossypiboma. Saudi J Gastroenterol. 2010, 16 (3): 221-222. 10.4103/1319-3767.65195.View ArticleGoogle Scholar
- Wattanasirichaigoon S: Transmural migration of a retained surgical sponge into the intestinal lumen: an experimental study. J Med Assoc Thai. 1996, 79: 415-422.PubMedGoogle Scholar
- Sarda AK, Pandey D, Neogi S: Dhir U:Postoperative complications due to a retained surgical sponge. Singapore Med J. 2007, 48: 160-164.Google Scholar
- Alegre-Salles V, Saba E, Dias-Soares P: Clinical images in gastroenterology: Textiloma (Gossypiboma) in the gastric lumen. Rev Gastroenterol Mex. 2010, 75 (1): 77-PubMedGoogle Scholar
- Keymeulen K, Dillemans B: Epitheloid angiosarcoma of the splenic capsula as a result of foreign body tumorigenesis. Case report Acta Chir Belg. 2004, 104 (2): 217-220.PubMedGoogle Scholar
- Sozutek A, Yormaz S, Kupeli H, Saban B: Transgastric migration of gossypiboma remedied with endoscopic removal: a case report. BMC Res Notes. 2013, 14 (6): 413-View ArticleGoogle Scholar
- Kansakar R, Thapa P, Adhikari S: Intraluminal migration of gossypiboma without intestinal obstruction for fourteen years. JNMA J Nepal Med Assoc. 2008, 47 (171): 136-138.PubMedGoogle Scholar
- Yeung KW, Chang MS, Huang JF: Imaging of transmural migration of a retained surgical sponge: a case report. Kaohsiung J Med Sci. 2004, 20 (11): 567-571. 10.1016/S1607-551X(09)70260-8.View ArticlePubMedGoogle Scholar
- Uluçay T, Dizdar MG, Sunay Yavuz M: The importance of medicolegal evaluation in a case with intra-abdominal gossypiboma. Forensic Sci Int. 2010, 198 (1–3): 15-18.View ArticleGoogle Scholar
- Sumer A, Carparlar MA, Uslukaya O, Bayrak V, Kotan C, Kemik O, Llikerden U: Gossypiboma: retained surgical sponge after a gynecoogic procedure. Case Report Med. 2010, 917626-Google Scholar
- Sarker M, Kibra G, Haque M, Sarker KP: Spontaneous transmural migration of the retained surgical mop into the small intestinal lumen causing sub-acute intestinal obstruction: a case report. TAJ. 2006, 19 (1): 34-37.Google Scholar
- Turan M, Kibar Y, Karadayi K: Intraluminal migration of retained surgical sponge without sign of peritonitis — report of a case. Chir Gastroenterol. 2003, 19 (2): 181-183. 10.1159/000072126.Google Scholar
- Sharma D, Pratap A, Tandon A, Shukla RC, Shukla VK: Unconsidered cause of bowel obstruction- gossypiboma. Can J Surg. 2008, 51 (2): 34-35.Google Scholar
- Grassi N, Cipolla C, Torcivia A, Bottino A, Fiorentino E, Ficano L, Pantuso G: Trans-visceral migration of retained surgical gauze as a cause of intestinal obstruction: a case report. J Med Case Rep. 2008, 2: 17-10.1186/1752-1947-2-17.View ArticlePubMedPubMed CentralGoogle Scholar
- Gencosmanoglu R, Inceoglu R:An unusual cause of small bowel obstruction: gossypiboma— case report. BMC Surg. 2003, 3: 6-10.1186/1471-2482-3-6.View ArticlePubMedPubMed CentralGoogle Scholar
- Puri SK, Panicker H, Narang P: Spontaneous transmural migration of a retained surgical sponge into the intestinal lumen-a rare cause of Intestinal obstruction. Indian J Radiol Imag. 2002, 12 (1): 137-139.Google Scholar
- Silva CS, Caetano MR, Silva EA, Falco L, Murta EF: Complete migration of retained surgical sponge into ileum without sign of open intestinal wall. Arch Gynecol Obstet. 2001, 265 (2): 103-104. 10.1007/s004040000141.View ArticlePubMedGoogle Scholar
- Disu S, Wijesiriwardana A, Mukhtar H, Eben F: An ileal migrationof a retained surgical swab (gossypiboma): a rare cause of an epigastric mass. J Obstet Gynaecol. 2007, 27 (2): 212-213. 10.1080/01443610601157778.View ArticlePubMedGoogle Scholar
- Kato T, Yamaguchi K, Kinoshita K, Sasaki K, Kagaya H, Meguro T, Morita T, Takahashi T: Intestinal Obstruction due to Complete Transmural Migration of a Retained Surgical Sponge into the Intestine. Case Rep Gastroenterol. 2012, 6 (3): 754-759. 10.1159/000346285.View ArticlePubMedPubMed CentralGoogle Scholar
- Malhotra MK: Migration surgical gossypiboma-cause of iatrogenic perforation: case report with review of literature. Niger J Surg. 2012, 18 (1): 27-29.PubMedPubMed CentralGoogle Scholar
- Ogundiran T, Ayandipo O, Adeniji Sofoluwe A, Ogun G, Oyewole O, Ademola A: Gossypiboma: complete transmural migration of retained surgical sponge causing small bowel obstruction. BMJ Case Rep. 2011, doi:10.1136/bcr.04.2011.4073Google Scholar
- Rappaport W, Haynes K: The retained surgical sponge following intra-abdominal surgery. Continuing Problem Arch Surg. 1990, 125 (3): 405-407.PubMedGoogle Scholar
- Hinrichs C, Methratta S, Ybasco AC: Gossypiboma treated by colonoscopy. Pediatr Radiol. 2003, 33 (4): 261-262.View ArticlePubMedGoogle Scholar
- Ozyer U, Boyvat F: Imaging of a retained laparotomy towel that migrated into the colon lumen. Indian J Radiol Imaging. 2009, 19 (3): 219-221. 10.4103/0971-3026.54889.View ArticlePubMedPubMed CentralGoogle Scholar
- Choi JW, Lee CH, Kim KA, Park CM, Kim JY: Transmural migration of surgical sponge evacuated by defecation: mimicking an intraperitoneal gossypiboma. Korean J Radiol. 2006, 7: 212-214. 10.3348/kjr.2006.7.3.212.View ArticlePubMedPubMed CentralGoogle Scholar
- Reichelt A, Buchholz G, Schülke C: Migration of a retained intra-abdominal foreign body into the colon. Chirurg. 2011, 82 (11): 1027-1030. 10.1007/s00104-011-2086-8.View ArticlePubMedGoogle Scholar
- Tandon A, Bhargava SK, Gupta A, Bhatt S: Spontaneous transmural migration of retained surgical textile into both small and large bowel: a rare cause of intestinal obstruction. Br J Radiol. 2009, 82 (976): 72-75. 10.1259/bjr/32683906.View ArticleGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2482/14/36/prepub
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.