An Intra-abdominal Foreign Body Presenting as a Colonic Tumor" Review o f Literature and Report o f a Case*

ALFRED EDINBURGH, M . D .

A RETAINED FOREIGN BODY within the peritoneal cavity can and does h a p p e n , and should be discussed from the standpoint o f prevention, diagnosis, clinical course, and treatment. It usually occurs in the face of a correct sponge and needle c o u n t . 9' ~5

Historical

Rego Park, ,Veu, York

Background

T h e use o f nonabsorbable materials in the manufacture o f surgical gauzes and pads has always presented a potential nightmare to the practicing surgeon. Despite the d e v e l o p m e n t o f protective measures such as r a d i o p a q u e threads woven into gauze pads, sponge and pad and even instrument counts, the a t t a c h m e n t o f metallic rings or instruments to pads, and the f r e q u e n t use of postoperative x-rays in the operating suite, there are still episodes of retained gauzes, pads, a n d / o r instruments. T h e r e is an extreme paucity o f reports on the subject in the American literature, for obvious reasons, but there are a great many reports in the foreign literature. One Of the earliest and most c o m p r e h e n s i v e reports in o u r literature was in I901 by Dr. August S c h a c h n e r -~a entitled " F o r e i g n Bodies Accidentally Left in the Abdominal Cavity: With Report o f One H u n d r e d and Fifty-Five Cases" f r o m c o r r e s p o n d e n c e with dozens o f p r o m i n e n t surgeons. T h e i r replies indicated the practice for many years of prophylactic measures such as sponge, pad, and i n s t r u m e n t counts by one, two, and even three operating room personnel including the surgeon's assistant; and the attachments o f long tapes a n d / o r instruments to pads and to sponges, ta T h e mortality from this oversight was very high, and usually the result o f peritonitis a n d / o r o t h e r sepsis. Dr. Schachner also reviewed cases, discussed pathologic changes, symptomatology, prevention, and medicolegal aspects o f this clinical entity. T h e next significant r e p o r t i n g was a review in 1940 by Crossen and Crossen 4 of the world literature from * Read at the annual Members Night o f t h e New York Society of Colon and Rectal Surgeons, New York, New York, September 14, I978. Address reprint requests to Dr. Edinburgh: 98-51 Queens Boulevard, Rego Park, New York, 11374.

F16. 1. Plain roentgenogram of abdomen preliminary to a barium enema. Notice metallic ring, ribbon type radiopaque insert in a surgical gauze, a whorl-like configuration characteristic of gas trapped between fibers, and the outline of a mass--all diagnostic features of a retained laparotom~ pad.

1859 to 1940 with r e p o r t i n g of 307 cases, including 14 retained m o r e than five years; the longest intervals to discovery were _94 and 30 years. T h e y correlated the pathologic changes s u r r o u n d i n g the sponge with the duration o f its retention: d u r i n g the first two m o n t h s there was little reaction, and these were incidental findings at autopsy; from two months to two years infective inflammation and abscess f o r m a t i o n o c c u r r e d with extrusion via a fistulous tract or internally into the r e c t u m , l'a'~7"2~'e~ vagina, bladder, or in-

00 I2-3706/79/0700/0324/$00.70 ~ American Society of Colon and Rectal Surgeons

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INTRA-ABDOMINAL FOREIGN BODY

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FIG. 2. A (above). Barium enema study of cecum and terminal ileum. Notice the defect in the cecum. Defects also in terminal ileum represent portion of a laparotomy pad within the small intestine. Metallic ring and ribbon type radiopaque insert also present. B (right). Barium enema study, full view': showing features described above and apparent extravasation of barium to area of metal ring.

testinal lumen21; by nine m o n t h s 80 per cent o f cases showed intestinal erosion; sponges in two to three years showed aseptic encapsulation with f o r m a t i o n of a distinct fibrous capsule. After five years the sponge t e n d e d to disintegrate and occasionally calcification o c c u r r e d in or a b o u t the sponge.

Pathology T h e body reacts to nonabsorbable substances either bv inflammation o f an aseptic fibrinous type p r o d u c ing adhesions a n d encapsulation, or by e x u d a t i o n with abscess formation. Either case may lead to the f o r m a t i o n of a mass, immediately postoperatively, m o n t h s , or even m a n y years later. T h e reticular spaces o f the sponge may be filled with fluid or with gas, and later may b e c o m e organized into a solid mass, with or without calcification. 2~

Clinical Features T h e s e foreign bodies may remain a s y m p t o m a t i c a n d n o t be d i s c o v e r e d f o r m a n y years, tl'x4'1s'~9" 23"24--Zawadzki and T r u e m n e r 2s r e p o r t e d cases after 23 and 28 years, Rymer and McCarthy 22 reported an acute abdomen after 33 years, and Devgan and Tucker s

reported a right lower quadrant mass associated with weight loss and anorexia, a n d with the preoperative diagnosis o f a carcinoma o f the colon, 55 years after a s p o n g e was left in at the time of an a p p e n d e c t o m y . T h e r e f o r e , a retained foreign body in the peritoneal cavity nmst be consideed in the differential diagnosis of a patient with an abdominal mass, and thus one needs a careful history even of the remote past. Most r e t a i n e d f o r e i g n bodies are in the lower a b d o m e n , 7 a n d they may be a s y m p t o m a t i c , cause intestinal p e r f o r a t i o n with p e r i t o n i t i s o r abscess f o r m a t i o n , fecal fistula, o r e x t r u d e into the lum e n ; a p p r o x i m a t e l y 10 p e r cent h a v e b e e n rem o v e d f r o m the r e c t u m . T h e r e are r e p o r t s o f a n u m b e r o f bizarre f o r e i g n bodies with u n u s u a l presentations.2, 4, 6-s, 10,1c,~9 R a d i o p a q u e threads were first i n t r o d u c e d into surgical sponges by Cahn in 1929, but were not in use in the U n i t e d States u n t i l 1 9 4 0 . l a ' 2 2 ' ' < ~ r I n 1931 Levene 12 indicated that a roentgenologist was rarely called u p o n to locate a surgical sponge because the markers, such as lead discs, metal staples, and b a r i u m i m p r e g n a t e d strips were inadequate for good, consistent visualization, and therefore r e c o m m e n d e d a r a d i o p a q u e e l e m e n t v u l c a n i z e d into the s p o n g e .

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A. EDINBURGH

Dis. Col. & Rect.

July~-August i979

Fro. 3. A view at laparotomy of abscess cavity outlined by terminal ileum on one side, and containing laparotomy pad with attached metal ring.

Careful studies "6 d e m o n s t r a t e d that barium sulfatecoated monofilaments were most easily visualized.

Diagnosis Olnick et al., tr in 1955, discussed the signs that were the r o e n t g e n o l o g i c e v i d e n c e o f r e t a i n e d f o r e i g n bodies. T h e most i m p o r t a n t is the demonstration o f the r a d i o p a q u e insert in the surgical gauze. This presents as one o f two types: the m o n o f i l a m e n t or thread type which may be distorted by' folding, twisting, and disintegration; and the ribbon type. A gauze pad may also be recognizable by the presence of gas t r a p p e d between the fibers, g M n g a characteristic whorl-like configuration. T h e gas is either of intestinal origin, or

F~G. 5. R e t a i n e d l a p a r o t o m y pad with a t t a c h e d r i n g - demonstrating "pseudopod" of pad on left from lumen of ileum, and a smaller "pseudopod" on the right which had extended into the cecum.

it is f o r m e d by bacteria in an abscess. A palpable mass c o r r e s p o n d i n g to the foreign body and the s u r r o u n d ing tissue reaction is often sharply' outlined on the r o e n t g e n o g r a m . Rarely', there may be calcifications. If a sinus tract is present, the sponge may be visualized indirectly by the injection of iodized oil. B a r i u m in a gastrointestinal x-ray examination may outline the silhouette and interstices o f a l a p a r o t o m y pad within the small intestine. Finally, the presence of a metallic ring or clacnp which is attached to a pad may be seen. T h u s , there are surgeons who even r e c o m m e n d the

FIG. 4. A view at laparotomy showing sites of perforation into ileum (upper clamp) and into cecum (lower clamp). Also wall of abscess ca~i D on ileum.

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INTRA-ABDOMINAL FOREIGN BODY

routine postoperative abdominal film in the surgical suite? The patient described below showed many of the f:atures we have been discussing.

Report of a Case A 64-~ear-old man was first seen in January 1978 after noticing that his right lower abdomen was higher than his left while lying in bed in November 1977. His appetite had been poor for approximately one and one-half months. There had been a 20pound weight loss during the four to six weeks prior to admission. He noted tiredness and weakness, and was found, by his local physician, to be slightly anemic with hemoccuh negative stools. He v,as sent to the hospital for a barium enema. When I saw the preliminar} roentgenogram, I made the diagnosis (Fig. 1). However, the barium enema was completed and interpreted as a possible cecal carcinoma (Fig. 2). A review of his past history revealed that nine years earlier, following a stab wound of the abdomen, the patient had u n d e r g o n e an exploratory laparotomy, with ~egative findings. I admitted the patient to the hospital and palpated a 4 • 4 inch tender, firm. fixed mass in the right lower quadrant of the abdomen. Subsequently, I performed a colonoscopy revealing extrinsic pressure on the cecum, indenting it and thus obscuring a full view of the cecum which was markedly distorted, but the mucosa was grossly normal. At laparotomy there was a fecal abscess in the right lower quadrant containing a laparotomy pad with an attached ring (Fig. 3). The ring had eroded into the terminal ileum approximately two feet from the ileocecal valve. A six-inch long pseudopod of the pad had perforated into the lumen of the terminal ileum 10 inches from the ileocecal valve, and another pseudopod of pad had perforated into the caput cecum for four inches adjacent to the ileocecaI ~al~e (Figs. 4 and 5). More than two feet of terminal ileum were resected ~ith an end-to-end anastomosis, and the cecum was closed in three layers with drainage. The postoperative course included a cecal fistula onset seven days postoperatively, which was treated with hyperalimentation for three weeks with complete closure.

Summary A c a s e is r e p o r t e d i n w h i c h a p a t i e n t s e e m e d t o show the clinical picture of a colonic tumor, but was f o u n d to h a v e a r e t a i n e d l a p a r o t o m y p a d f r o m a n exploratory operation which had been performed nine years earlier. This case of an intra-abdominal foreign body demonstrated many interesting and instructive clinical, radiologic, and surgical features w i t h a p p r o a c h e s to t h e d i a g n o s i s a n d m a n a g e m e n t of this condition.

References 1. Akcakoyunlu I: Spontaneous expulsion through the rectum of a Kocher forceps left in the abdomen 14 months. Br Med J 2: 182, 1944

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2. Batts JA Jr, Chimis SV, Alleyne GL: An unusual foreign body in the pelvic cavity a f t e r laparotomy. Obstet Gynecol 48: 369, 1976 3. Benjamin HB, Klamecki B, HaftJS: Removal of exotic foreign body objects from the abdominal orifices. Am J Proctol 20: 413, 1969 4. Crossen HS, Crossen DF: Foreign Bodies Left in the Abdomen: T h e Surgical Problems, Cases, Treatment, Prevention; the Legal Problems, Cases, Decisions, Responsibilities. St Louis, C V Mosby Company, 1940, 762 pp 5. Devgan M, Tucker EF: Post-appendectomy cotton swabs retained for 55 years: Case report. Mo Med 74: 23, 1977 6. Fisher TL: Lost instruments. Can Med AssocJ 66: 399, 1952 7. Forbes RD: T h e retained abdominal sponge. West J Surg 56: 588, 1948 8. Hilton JH: Mislaid foreign bodies during surgery. I. Sponges. lI. Packing. III. Instruments. Can Med AssocJ 73: 414; 495; 578, 1955 9. jones SA: The foreign body problem after laparotomy: Personal experiences. Am J Surg 122: 785, 1971 10. Kanter AH: Removal of glass drinking tube from abdominal cavity: Case report. Ohio State M e d J 39: 1008, 1943 11. L e h m a n EP: Challenges of the foreign body. Arch Surg 63: 663, 1951 12. Levene G: New design of radiopaque element for surgical sponges. JAMA 146: 1320, 1951 13. Lewison EF: Radio-opaque t h r e a d - - a guide to the "lost" sponge. Mod Hosp 58:67 (Apr) 1942 14. Ligdas E: Lrber die diagnostischen u n d t h e r a p e u t i s c h e n Sehwierigkeiten nach Zurficklassen yon Fremdk6rpern in der Bauchh6hle. Zanbralbl Chir 84: 408, 1959 15. Nelson OA: Sponge count d u r i n g operation. Am J Surg 90: 680, 1955 16. Nicholson NJ: Foreign body in the abdomen. B r J Surg 36: 98, 1948 17. Olnick HM, Weens HS, R o g e r s J V J r : Radiological diagnosis of" retained surgical sponges. JAMA 159: 1525, 1955 18. Ott G: Twenty-two years' intra-abdominal retention of gauze sponge. Beitr Kiln Chir 198: 2, 1959 19. Ranson FT, Blumenfeld M: Removal of forceps from the abdominal cavity. Lancet 1: 159, 1950 20. Reinhardt R: Calcification of gauze pad left in the body during surgery. Monatsschr Rongenstrahl 88: 487, 1958 21. Robinson KB, Levin EJ: Erosion of retained surgical sponges into the intestine. Am j Roentgenol Radium T h e r Nucl Med 96: 339, 1966 29. Rymer CA, McCarthy JD: A silent sponge speaks. Am J Surg 198: 103, 1974 23. Schachner A: Foreign bodies accidentally" left in the abdominal cavity': With report of one h u n d r e d and fifty-five cases. Ann Surg 34: 499, 1901 94. Symmers D: T h e clinical significance of f o r e i g n body granulomas: A review. J SC Med Assoc 47: 14; 66, 1951 25. Techakampuch S, Talalak P: Migration of Kirschner's wire into abdominal cavity and transrectal removal. J Med Assoc Thai 60: 572, 1977 26. T h o m p s o n TM: X-ray visualization of surgical sponges. Surgery 37: 455, 1955 P7. Walker MA, Coburn CE: Gauze sponge in abdomen 27 years. J Kans Med Soc 42: 107, 1941 28. Zawadzki ES, T r u e m n e r KM: Postoperative foreign bodies in the abdomen. J Mich Med Soc 47: 630, 1948

An intra-abdominal foreign body presenting as a colonic tumor: review of literature and report of a case.

An Intra-abdominal Foreign Body Presenting as a Colonic Tumor" Review o f Literature and Report o f a Case* ALFRED EDINBURGH, M . D . A RETAINED FOR...
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