Definition and etymology.
Gossypiboma is a non-medical term that refers to all nonabsorbable material,
which has been left behind in some body cavity, after a surgical procedure. The matrix is composed of cotton,
and is associated with tissue inflamatory reaction.(12)
The term Gossypiboma derives from the Latin ¨gossypium¨ meaning "cotton," and from the Swahili ¨boma¨ meaning "place where it is hidden"(1)(2).
Also, the suffix ¨oma¨ means tumor or growth(2). For some English-speaking authors the designation of gossypiboma means a tumor that gives rise to gossip,
as it gives rise to comments on the ability of the surgeon(9).
This term must be used exclusively for any mass that is formed in the body from retained cotton.
There are other different synonyms that refer to foreign bodies of textile origin,
forgotten in the body,
such as gasoma,
cottonoid,
compresoma,
textiloma,
oblite,
pseudotumor of gauze(3).
The real incidence of the textilomas,
and the true magnitude of the problem are difficult to determine,
because there are serious legal issues involved,
which are the reason why these surgical situations are finally hidden and rarely reported,
leading to unrealiable statistics.
Three important risk factors have been identified that lead to the retention of foreign bodies: emergency surgery,
unplanned changes in the procedure and body mass index(3)(4)(8).
The number of gauzes during,
or at the end of the surgery,
avoids in many cases its occurrence. When the results of the intraoperative count are incomplete,
and the suspicion of forgetting is established,
it is necessary to carry out imaging studies; however,
these studies may be false negative,
and do not exempt the surgical team from legal responsibility.
When a gossybipoma is discovered,
it generates shame to the responsible parties,
and contempt by the medical community.
It is considered an offense that is denied,
covered and forgotten.
(9)
The gossypibomas can be diagnosed after any type of surgery,
being more frequent in the ones of the digestive system (52%) (appendectomies and cholecystectomies),
followed by gynecological (22%) (hysterectomies,
caesarean sections),
urological ( 10%),
vascular (10%),
thoracic (7.4%) and trauma (6%).(9)(12) (Fig.
2)
Pathophysiology.
The non-absorbable material of the Gossypiboma does not decompose.
The cotton matrix forms a nest,
which is surrounded by an area of fibrosis and retraction,
leading to two types of reactions in the body(1)(2).
The first is the aseptic fibrinous response, in which multiple adhesions develop,
and the cottonoid is encapsulated,
resulting in a foreign body granuloma,
generating a space-occupying mass that simulates clinical tumors.
The exudative response is given by bacterial contamination of the cotton matrix,
with the subsequent formation of abscesses and fistulas,
which drain the infectious content. (Fig.
3).
Clinic and complications.
The gossypibomas have variable clinical symptoms ranging from completely asymptomatic patients discovered as incidental findings,
to those that generate symptoms in the immediate postoperative period,
or some decades after the initial surgery. For this reason,
the entity is known as "the great simulator".
In symptomatic cases,
the clinical presentation is nonspecific due to several signs and symptoms that depend on location,
size of the gauze,
inflammatory reaction and time of evolution.
When the Gossypiboma is located in the abdominal cavity,
it can be presented as a palpable mass with abdominal pain,
distension,
nausea,
vomiting or intestinal occlusion,
as well as signs of sepsis(2).
The diagnosis should be based on the clinical suspicion as well as the surgical history of the patient.
In the immediate postoperative period,
the patient can develop an acute inflammatory condition due to infection of the surgical material, with inflammatory symptoms and the ocurrence of fistulas,
presenting drainage either to the cutaneous level or towards an adjacent organ,
or hematoma.(1)(2) (Fig.
4).
Furthermore,
in those patients who present clinical obstruction,
gossypiboma can be produced by migration of surgical material through the intestinal loops,
that can reach the ileocecal valve,
giving obstructive symptoms or achieving passage through it,
and can be eliminated by the anus.(12)
Patients with gossypibomas in the thoracic cavity present a clinical picture of chest pain that radiates to the shoulder,
cough,
hemoptysis,
fever and bilious expectoration.
The most frequent sites for the location of the textiloma are the pleural and pericardial cavities.
A gossypiboma located in the paraspinal muscles,
after a spinal surgery,
can cause low back pain,
while if they are located at the level of the extremities,
they can cause edema,
pain,
periosteal reaction and an increase of the local vascularization simulating tumor lesions.
For those asymptomatic patients (6-30%) the diagnosis is more delayed,
given the absence of signs and symptoms(5).
The initial suspicion usually comes from an imaging study in the immediate or delayed postoperative period.
Radiological Findings.
The radiological findings of the forgotten surgical material are variable,
however there are characteristic findings in the different imaging methods that lead to the diagnosis of gossypiboma.
Conventional Radiology.
Simple X-ray projections are the simplest method used to identify foreign bodies (Gossypiboma)(1),
with a sensitivity of around 76% to 90%. The radiopaque marker is undoubtedly a finding that demonstrates the existence of the textiloma within the cavity.(1) (Fig.5)
The material that does not present a radiopaque marker can be identified by the visualization of a heterogeneous,
radius lucid,
ill-defined mass with air bubbles inside,
a fibrotic capsule generating a radiological pattern in honeycomb or bread crumb. (5)(12)
Ultrasonography
Ultrasonography is useful in the evaluation of gossypibomas at the abdominal level. The image can adopt two types of patterns: Type I,
where an anterior linear echogenic image is observed with extensive posterior acoustic shadow,
(Fig.
6,7,8) and Type II,
a predominantly cystic mass with undulating or angulated internal echogenic images,
and with defined acoustic shadow(2)(4). (Fig.
9,10,11,12).
Both types present posterior acoustic shadow,
being a characteristic of the entity and its relation with a former surgery.
(6)
Computed tomography.
The CT scan is the method of choice for the identification of gossypiboma because of its high sensitivity,
and specificity,
because the surgical material is well delineated.
(Fig.
13)
The characteristic findings are a low-density mass with a thin enhancing capsule or wall (1)(2),
after the administration of intravenous contrast (Fig.
14)(1).
Also ,
a CT scan can show a thick spongiform aspect with gas bubbles(11), which adopt an appearance of twist or swirl ("whirlwind" pattern)(1) due to the gas trapped inside the fibers of the textile material(2). Calcifications along the network architecture of a surgical sponge, or at the Wall,
are clearly identifiable on CT and are an indicators of chronicity. The radiopaque marker can be seen as a linear image of metallic density adjacent to the mass.
(Fig.
15,
16,
17,18,
19,
20)
The forgotten gossypibomas in the thoracic cavity that are inside the pleural space do not show air bubbles in their interior,
due to the reabsorption of the air by the pleura.
(Fig.
21.) (5)
Magnetic resonance.
In Magnetic Resonance,
the characteristics of the signaling depend on the liquid within the material,
the time of evolution,
and the histological composition.
Characteristically, a mass of soft-tissue density is observed,
with thick walls with spiral content inside, which presents a low T1 signal presentation, with a low T2 signal with verticillated stripes in the central portion.
Magnetic resonance can also show enhancement, and in some cases,
a serrated border to the inner wall in the T1 sequence with contrast (Gadolinium)(4).
Differential diagnostics.
In front of the variable clinical and imaging findings,
it is the surgical background,
which finally gives the diagnosis.
However, it is important to establish some differential diagnosis according to the location of the Gossypiboma.
(Fig.
22)
At the level of the abdominal cavity,
the Gossypiboma can be indistinguishable from tumours or abscesses.
In acute intestinal obstructions,
the diagnosis of textilomas should be ruled out as one of the first options in all patients with a history of previous abdominal surgery(3).
Fecalomas may present irregular contours and poorly defined limits at CT,
but are located inside colon loops and do not present a well defined and thick capsule.
(4)
Hematomas are seen in the early postoperative period and in general present progressive resorption.(4)
At the intracranial level it is necessary to make a differential diagnosis with tumor recurrence,
radiation necrosis and intracerebral abscess according to the patient's background,
since the imaging behavior is very similar in all cases.
In the thoracic cavity,
there are no pathognomonic images of gossybipomas leading to confusions with other lesions such as abscesses,
bruises,
bronchiectasis or neoplasia.
This diagnosis should be considered in all patients with atypical mass in chest,
or with former surgeries at this level.
In the extremities,
the gossybipomas imitate malignant neoplasms such as osteosarcomas or fibrous malignant histiocytomas.