CLINICAL IMAGING 1992;16:259-262
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MAGNETIC RESONANCE IMAGING OF RETAINED SURGICAL SPONGES CASE REPORT HIROSHI SUGIMURA, MD, SHOZO TAMURA, MD, YOSUKE KAKITSUBATA, MD, SACHIKO KAKITSUBATA, MD, OSAMU UWADA, MD, YASUSHI KIHARA, MD, MASANAO NAGATOMO, MD, AND KATSUSHI WATANABE, MD
The magnetic resonance imaging (MRI) features of sponges retained postsurgically in three patients are described. MRI depicted these as well-defined round masses, which were of low signal intensity on Tlweighted images and very high signal intensity on TZweighted images. We scrutinized these masses on T2-weighted images. MRI revealed the low-signalintensity structures to have wavy, striped, and/or spotted appearances, which raised the suspicion that they might be retained surgical sponges within mass lesions. KEY WORDS:
Foreign
body;
Surgical; Abscess; Magnetic
resonance
imaging
INTRODUCTION Retained surgical sponges can be discovered long after laparotomies and the preoperative diagnoses of retained sponges may be difficult (1,2).We performed magnetic resonance imaging (MRI) on three patients who had retained surgical sponges. The radiological features are described and their diagnostic implications are discussed. From the Department of Radiology, Miyazaki Medical College, Japan. Address reprint requests to: Hiroshi Sugimura, M.D., Department of Radiolonv, Mivazaki Medical College, 5200 Kihara. Kivo< take, Miyazaki f%9-16; Japan. Received January 1992; accepted March 2, 1992 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899/7071192/$5.00
New York, NY 10010
CASE REPORTS Case 1 A 57-year-old man was admitted with complaints of general fatigue, chest pain, and cough. He had undergone a left upper lobectomy for pulmonary tuberculosis at 32 years of age. A plain radiograph of his chest revealed an abnormal opacity in the area of the left lower lung field. Computed tomography (CT) depicted a mass lesion that had an irregular margin and contained small calcifications. With MRI, the mass showed low signal intensity on Tl-weighted images and high signal intensity on T%weighted images. Coronal MRI showed the mass to be above the diaphragm (Figure 1A). At surgery, the mass was found to include a foreign body consisting of gauze (Figure lB), which was tightly adherent to the diaphragm. Case 2 A i’l-year-old man had undergone a total gastrectomy 2 years prior to admission. This admission was for evaluation of a right subphrenic mass. A plain chest radiograph showed an abnormal opacity in the area of the right lower lung field. Ultrasonography demonstrated a mass in the right subphrenic region in which coarse irregular echoes with intense post acoustic shadowing were observed. The mass was of low signal intensity on Tl-weighted images (Figure 2A) and high signal intensity on T&weighted images (Figure 2B). Coronal MRI demonstrated the mass to be below the diaphragm. MRI revealed a low-signal-intensity
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spin echo image (TRITE = 500/35) easily demonstrates the mass above the FIGURE 1. Case 1. (A) Coronal Tl-weighted diaphragm (arrow). (B) Cross-section. The mass contained yellowish amorphous materials and had thick walls.
C FIGURE 2. Case 2. MRI shows a mass that is of low signal intensity on a Tl-weighted image (TR/TE = 500/30) (A) and high signal intensity on a T2-weighted image (TR/ TE = 2000/80) (B). Coronal MRI readily demonstrates the masses below the diaphragm (A). Note the low-signalintensity structure (arrowheads), which is suspected of being the retained surgical sponge, within the cystic mass on TX-weighted images (C).
OCTOBER-DECEMBER
FIGURE structure and high having a
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3. Case 3. (A) Longitudinal ultrasonogram of the midportion of the abdomen shows a spongiform echogenic in the mass. (B-D) MRI shows a mass that is of low signal intensity on Tl-weighted images (TRITE = 500/30) (B) signal intensity on a T&weighted image (TRITE = 2OOOi80) (C). Note the low signal intensity structures [arrows) wavy appearance within the cystic mass on the T2-weighted images (C, D).
structure within a cystic mass on T&weighted images (Figure zC). At laparotomy, the mass was found to be a surgical sponge adherent to the diaphragm. Case 3 A 65-year-old man was admitted complaining of general fatigue. Eleven years prior to admission he had undergone a right nephrectomy for a right renal calculus. Ultrasonography demonstrated a cystic mass in the right side of his midabdomen (Figure 3A). Highly coarse irregular echoes suggested the possibility of a retained surgical sponge within the mass. CT demonstrated a sharply demarcated round mass surrounded by a dense wall containing small calcifications. Tl-weighted images (Figure 3B) revealed a
low signal intensity mass in the right midabdomen, and T&weighted images (Figure 3C) showed a highsignal-intensity mass within the low intensity structure. Retained surgical sponges were suspected (Figure 3D). At laparotomy, a mass 10 cm in diameter with a thick wall was found containing yellowish pus and a surgical sponge tightly adherent to the peritoneum.
DISCUSSION Fistulae, erosions, and perforations of neighboring viscera caused by retained surgical sponges have been reported (3-5). However, many foreign bodies retained after surgery cause no symptoms (6) and
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they may be incidentally discovered many years after an operation. Radiologically, whirl-like appearances on plain radiographys have been described as characteristic of retained sponges (2). Ultrasonography reveals a mass with an echogenic center and a hypoechoic rim (7, 8). Parienty et al. (6) reported the CT pattern of retained sponges as the so called “spongioform pattern” caused by gas, which corresponds to that seen on plain radiography and is characteristic of retained sponges. Other reports of CT findings have described the foreign body as a round, sharply demarcated mass with a dense, enhanced wall (9). The advent of MRI has added to our capabilities in the diagnosis and evaluation of mass lesions. However, to our knowledge, the MRI patterns of retained surgical sponges have not yet been reported. In our cases MRI revealed well-defined round masses, which were of low signal intensity on Tl-weighted images and very high signal intensity on T2-weighted images, with or without thick walls. On T&weighted images, MRI showed lowsignal-intensity structures with wavy, striped, and/ or spotted appearances within the mass lesions, which were suspected of being retained surgical sponges. When there are retained sponges near the diaphragm, CT and ultrasonography cannot readily demonstrate the orientation of the masses. However,
the sagittal or coronal images provided by MRI afford us useful information about surrounding structures. The authors thank Dr. Walter J. Russell for his help in editing the manuscript.
REFERENCES 1. Williams RJ, Bragg DG, Nelson JM. Gossypiboma. The problem of retained surgical sponge. Radiology 1978;129:323-326. 2. OlnickHM, Weens HS. Radiological diagnosis of retained surgical sponges. JAMA 1955;159:1525-1527. 3. Robinson KB, Levin EJ. Erosion of retained into the intestine. AJR 1966;96:339-343.
surgical sponges
4. Mason LB. Migration of surgical sponge into small intestine. JAMA 1968;205:938-939. 5. Sturdy JH, Baird RM, Gerfin AN. Surgical sponges: A cause of granuloma and adhesion formation. Ann Surg 1967;165:128134. 6. Parienty RA, Pradel J, Lepreux JF, Nicodeme C, Dologa M. Computed tomography of sponges retained after laparotomy. J Comput Assist Tomogr 1981;5:187-189. 7. Chau WK, Lai KH, Lo KJ. Sonographic findings of intraabdominal foreign bodies due to retained gauze. Gastrointest Radio1 1984;9:61-63. 8. Sekiba K, Akamatsu N, Niwa K. Ultrasound Characteristics of abdominal abscess involving foreign bodies (Gauze]. JCU 1979;7:284-286. 9. Sheward SE, Williams AG, Mettler FA, Lacey SR. CT appearance of a surgically retained towel (Gossy-piboma). J Comput Assist Tomogr 1986;10:343-345.
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MAGNETIC RESONANCE IMAGING OF RETAINED SURGICAL SPONGES CASE REPORT HIROSHI SUGIMURA, MD, SHOZO TAMURA, MD, YOSUKE KAKITSUBATA, MD, SACHIKO KAKITSUBATA, MD, OSAMU UWADA, MD, YASUSHI KIHARA, MD, MASANAO NAGATOMO, MD, AND KATSUSHI WATANABE, MD
The magnetic resonance imaging (MRI) features of sponges retained postsurgically in three patients are described. MRI depicted these as well-defined round masses, which were of low signal intensity on Tlweighted images and very high signal intensity on TZweighted images. We scrutinized these masses on T2-weighted images. MRI revealed the low-signalintensity structures to have wavy, striped, and/or spotted appearances, which raised the suspicion that they might be retained surgical sponges within mass lesions. KEY WORDS:
Foreign
body;
Surgical; Abscess; Magnetic
resonance
imaging
INTRODUCTION Retained surgical sponges can be discovered long after laparotomies and the preoperative diagnoses of retained sponges may be difficult (1,2).We performed magnetic resonance imaging (MRI) on three patients who had retained surgical sponges. The radiological features are described and their diagnostic implications are discussed. From the Department of Radiology, Miyazaki Medical College, Japan. Address reprint requests to: Hiroshi Sugimura, M.D., Department of Radiolonv, Mivazaki Medical College, 5200 Kihara. Kivo< take, Miyazaki f%9-16; Japan. Received January 1992; accepted March 2, 1992 0 1992 by Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, 0899/7071192/$5.00
New York, NY 10010
CASE REPORTS Case 1 A 57-year-old man was admitted with complaints of general fatigue, chest pain, and cough. He had undergone a left upper lobectomy for pulmonary tuberculosis at 32 years of age. A plain radiograph of his chest revealed an abnormal opacity in the area of the left lower lung field. Computed tomography (CT) depicted a mass lesion that had an irregular margin and contained small calcifications. With MRI, the mass showed low signal intensity on Tl-weighted images and high signal intensity on T%weighted images. Coronal MRI showed the mass to be above the diaphragm (Figure 1A). At surgery, the mass was found to include a foreign body consisting of gauze (Figure lB), which was tightly adherent to the diaphragm. Case 2 A i’l-year-old man had undergone a total gastrectomy 2 years prior to admission. This admission was for evaluation of a right subphrenic mass. A plain chest radiograph showed an abnormal opacity in the area of the right lower lung field. Ultrasonography demonstrated a mass in the right subphrenic region in which coarse irregular echoes with intense post acoustic shadowing were observed. The mass was of low signal intensity on Tl-weighted images (Figure 2A) and high signal intensity on T&weighted images (Figure 2B). Coronal MRI demonstrated the mass to be below the diaphragm. MRI revealed a low-signal-intensity
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B
spin echo image (TRITE = 500/35) easily demonstrates the mass above the FIGURE 1. Case 1. (A) Coronal Tl-weighted diaphragm (arrow). (B) Cross-section. The mass contained yellowish amorphous materials and had thick walls.
C FIGURE 2. Case 2. MRI shows a mass that is of low signal intensity on a Tl-weighted image (TR/TE = 500/30) (A) and high signal intensity on a T2-weighted image (TR/ TE = 2000/80) (B). Coronal MRI readily demonstrates the masses below the diaphragm (A). Note the low-signalintensity structure (arrowheads), which is suspected of being the retained surgical sponge, within the cystic mass on TX-weighted images (C).
OCTOBER-DECEMBER
FIGURE structure and high having a
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261
3. Case 3. (A) Longitudinal ultrasonogram of the midportion of the abdomen shows a spongiform echogenic in the mass. (B-D) MRI shows a mass that is of low signal intensity on Tl-weighted images (TRITE = 500/30) (B) signal intensity on a T&weighted image (TRITE = 2OOOi80) (C). Note the low signal intensity structures [arrows) wavy appearance within the cystic mass on the T2-weighted images (C, D).
structure within a cystic mass on T&weighted images (Figure zC). At laparotomy, the mass was found to be a surgical sponge adherent to the diaphragm. Case 3 A 65-year-old man was admitted complaining of general fatigue. Eleven years prior to admission he had undergone a right nephrectomy for a right renal calculus. Ultrasonography demonstrated a cystic mass in the right side of his midabdomen (Figure 3A). Highly coarse irregular echoes suggested the possibility of a retained surgical sponge within the mass. CT demonstrated a sharply demarcated round mass surrounded by a dense wall containing small calcifications. Tl-weighted images (Figure 3B) revealed a
low signal intensity mass in the right midabdomen, and T&weighted images (Figure 3C) showed a highsignal-intensity mass within the low intensity structure. Retained surgical sponges were suspected (Figure 3D). At laparotomy, a mass 10 cm in diameter with a thick wall was found containing yellowish pus and a surgical sponge tightly adherent to the peritoneum.
DISCUSSION Fistulae, erosions, and perforations of neighboring viscera caused by retained surgical sponges have been reported (3-5). However, many foreign bodies retained after surgery cause no symptoms (6) and
262
CLINICAL IMAGING VOL. 16, NO. 4
SUGIMURA ET AL.
they may be incidentally discovered many years after an operation. Radiologically, whirl-like appearances on plain radiographys have been described as characteristic of retained sponges (2). Ultrasonography reveals a mass with an echogenic center and a hypoechoic rim (7, 8). Parienty et al. (6) reported the CT pattern of retained sponges as the so called “spongioform pattern” caused by gas, which corresponds to that seen on plain radiography and is characteristic of retained sponges. Other reports of CT findings have described the foreign body as a round, sharply demarcated mass with a dense, enhanced wall (9). The advent of MRI has added to our capabilities in the diagnosis and evaluation of mass lesions. However, to our knowledge, the MRI patterns of retained surgical sponges have not yet been reported. In our cases MRI revealed well-defined round masses, which were of low signal intensity on Tl-weighted images and very high signal intensity on T2-weighted images, with or without thick walls. On T&weighted images, MRI showed lowsignal-intensity structures with wavy, striped, and/ or spotted appearances within the mass lesions, which were suspected of being retained surgical sponges. When there are retained sponges near the diaphragm, CT and ultrasonography cannot readily demonstrate the orientation of the masses. However,
the sagittal or coronal images provided by MRI afford us useful information about surrounding structures. The authors thank Dr. Walter J. Russell for his help in editing the manuscript.
REFERENCES 1. Williams RJ, Bragg DG, Nelson JM. Gossypiboma. The problem of retained surgical sponge. Radiology 1978;129:323-326. 2. OlnickHM, Weens HS. Radiological diagnosis of retained surgical sponges. JAMA 1955;159:1525-1527. 3. Robinson KB, Levin EJ. Erosion of retained into the intestine. AJR 1966;96:339-343.
surgical sponges
4. Mason LB. Migration of surgical sponge into small intestine. JAMA 1968;205:938-939. 5. Sturdy JH, Baird RM, Gerfin AN. Surgical sponges: A cause of granuloma and adhesion formation. Ann Surg 1967;165:128134. 6. Parienty RA, Pradel J, Lepreux JF, Nicodeme C, Dologa M. Computed tomography of sponges retained after laparotomy. J Comput Assist Tomogr 1981;5:187-189. 7. Chau WK, Lai KH, Lo KJ. Sonographic findings of intraabdominal foreign bodies due to retained gauze. Gastrointest Radio1 1984;9:61-63. 8. Sekiba K, Akamatsu N, Niwa K. Ultrasound Characteristics of abdominal abscess involving foreign bodies (Gauze]. JCU 1979;7:284-286. 9. Sheward SE, Williams AG, Mettler FA, Lacey SR. CT appearance of a surgically retained towel (Gossy-piboma). J Comput Assist Tomogr 1986;10:343-345.
