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

Background 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. Case presentation 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. Conclusion 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.


Background
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][2][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.

Case presentation
A 61-year-old Han Chinese man presented with intermittent epigastric pain for the last 10 months. The pain was mild and non-radiating, without specific relieving or aggravating factors. The patient had no history of nausea, vomiting, general weakness, poor appetite or body weight loss. He had undergone laparoscopic cholecystectomy conversion to open cholecystectomy for acute gangrenous cholecystitis 10 months ago at another hospital. Gauze retention in the peritoneal cavity with migration into the duodenum was noted after upper gastrointestinal (UGI) endoscopy ( Figure 1). An abdominal X-ray examination showed the retained material was a surgical sponge ( Figure 2). Abdominal computed tomography (CT) scan showed transmural migration of the gauze into the duodenum ( Figure 3). Endoscopic intervention failed to remove the entire gauze, and intractable duodenal ulcer caused by the gauze persisted. Surgical intervention was then performed. During the operation, a gossypiboma, about 2 cm in size, was noted between the supra-duodenal region and round ligament (Figure 4), with penetration into the anterior wall of the duodenal bulb, resulting in a penetrated duodenal ulcer about 1.5 cm in diameter ( Figure 5). The gauze was embedded in the granulation tissue surrounding the gossypiboma ( Figure 6). The gauze was removed successfully, and the penetrated ulcer was repaired with duodenorrhaphy. The postoperative period was uneventful.

Literature search
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.

Results
Our PubMed search yielded seven reports of transmural migration of retained surgical sponge into the duodenum. Relevant data are shown in Table 1. Three patients were male and four patients were female, with ages ranging from 26 to 62 years. The time from the causative operation to presentation with a retained surgical sponge ranged from 2 months to 2 years. Initial surgical procedures included cholecystectomy in 4 patients [5 patients, if the  present case is included], laparotomy in 1, hemicolectomy in 1, and removal of hydatid cyst in 1 patient. Including our case, 3 cases were scheduled for open surgery. The other 4 patients were scheduled for endoscopy to remove the gossypiboma. One patient received endoscopy but the gauze could not be retrieved using biopsy forceps and a polypectomy snare. As there was no free perforation, conservative treatment was applied, and proton pump inhibitors and liquid diet were recommended. The patient had a stable clinical course and was endoscopically followed up at 5-day intervals.

Discussion
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][10][11][12][13][14][15][16][17][18]. There are no national or local registers, and the reluctance of medical institutions to publish matters that may have medicolegal 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 Figure 3 Abdominal CT scan. The CT-scan reveals transmural migration of the gauze into the duodenum (white arrow).

Figure 4
The intra-operative finding before removing the gossypiboma. Gossypiboma, about 2 cm in size, was noted between the supra-duodenal region and round ligament.
According to the literature, transmural migration of gossypiboma into the duodenum is rare. To date, only 7 cases have been published [2,[4][5][6][7][8]26]. Other reported sites of migration include seven sponges into the jejunum, five into the stomach, five into the colon, one into the ileocolic region, one into the ileojejunal region, and one into both the jejunum and colon. In three patients, the surgical sponge passed spontaneously through the rectum. The small intestine is the most common part of the intestine into which migration takes place ( Table 2). The most common initial surgery for removal of gossypiboma in the gastrointestinal system was cholecystectomy (15 cases), followed by caesarian section (9 cases), hysterectomy (7 cases), laparotomy (5 cases), appendectomy (3 cases), splenectomy (1 case), distal gastrectomy (1 case), hemicolectomy (1 case), cystectomy + myomectomy (1 case), hydatid cyst (1 case), nephrectomy (1 case) and anterior resection (1 case) ( Table 3).
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 Figure 6 The removed specimen. The gauze was embedded in the granulation tissue surrounding the gossypiboma. 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 [17]. 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.
Gossypibomas should be removed as soon as diagnosed. Surgery is the preferred method of treatment for gossypiboma. Various techniques, including percutaneous techniques, such as laparoscopy and laparotomy, are used for the removal of gossypiboma, depending on the clinical presentation and medical equipment available [4,6,26,30,46]. In cases with migration of gossypiboma into the digestive tract, nonsurgical approaches such as endoscopic retrieval of foreign bodies have been reported. According to the literature, gastrostomy, segmental resection, and endoscopic extraction were used for removal of gossypibomas that migrated into the stomach, intestine and colon, and duodenum, respectively. For patients with gossypiboma transmurally migrated into duodenum, endoscopic removal could be attempted if there was no emergent conditions such as active GI bleeding, obstruction, or free perforation. Of the eight cases of gossypiboma migrated into duodenum, including our case, surgical intervention was necessary in three patients for persistent fistula or intractable ulcer. If the endoscopy fails to retrieve the gossypiboma and the patient is asymptomatic, conservative treatment with close observation can be considered. A therapeutic scheme is proposed for the treatment of gossypiboma transmurally migrated into the digestive tract (Figure 7).

Conclusion
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.  Cystectomy + Myomectomy 1 [41] Hydatid cyst 1 [5] Nephrectomy 1 [28] Anterior resection 1 [28] Figure 7 Scheme of the therapeutic approach proposed for transmural migration of gossypiboma into gastrointestinal system. For patients with gossypiboma transmurally migrated into gastrointestinal system, endoscopic removal could be attempted if there was no emergent conditions such as active GI bleeding, obstruction, or intra-abdominal sepsis. If the endoscopy fails to retrieve the gossypiboma and the patient is symptomatic, surgical intervention is indicated. For asymptomatic patients after unsuccessful endoscopic extraction, conservative treatment with close observation can be considered.