Sponge-Induced Granuloma ("Gauzoma") as a Complication of Posterior Lumbar Surgery-Case Report-

A 45-year-old woman presented with complaints of low back pain and sciatica on the left persisting for 2 years. She had undergone left hemilaminectomy and discectomy for L4-5 intervertebral disc herniation at another medical center. Spinal computed tomography and magnetic resonance (MR) imaging revealed a mass lesion in the posterior paravertebral region. The mass was hypointense with ring enhancement on the T(1)-weighted images and hyperintense on the T(2)-weighted images. Surgery found a retained sponge within the paraspinal mass cavity which was removed totally. Foreign-body granuloma ("gauzoma") induced by forgotten sponge material is not an unusual complication of posterior lumbar surgery and should be considered as a potential cause in cases of surgical wound infections. MR imaging is essential to achieve the correct differential diagnosis.

Surgical counts can be risky business!

The surgical count plays a vital role in enabling perioperative nurses to provide a safe environment to surgical patients. Counting errors are preventable. Although national standards of care provide excellent guidelines for developing effective count protocols, counting procedures are often modified according to individual health care policy. This article will discuss the risk factors for retained items, rate of occurrence, what objects are being left in patients, role of x-rays and consequences of leaving an object in a patient. It will also highlight points to be considered when implementing new count policies.

Imaging of Transmural Migration of A Retained Surgical Sponge: A Case Report

A 61-year-old woman who had undergone a hysterectomy 15 years before this presentation had suffered from intermittent abdominal pain and a palpable lower abdominal mass for 3 months. Plain roentgenography revealed a radiopaque mass with serpiginous density in the pelvic region. Sonography showed curvilinear hyperechogenicity with an acoustic shadow. A small-bowel series revealed a huge amorphous filling defect inside the ileum. Computed tomography showed that the mass was a spongiform object with a whirl-like appearance mixed with air and with peripheral calcification.

A New Pitfall on Abdominal PET/CT: A Retained Surgical Sponge

Positron emission tomography (PET)/computed tomography (CT) and multidetector CT findings of an abdominal retained surgical sponge (RSS) are presented. A PET/CT study performed for evaluation of a suspected abdominal tumor demonstrated the inconclusive finding of a hypometabolic area surrounded by increased 2-[fluorine-18] fluoro-2-deoxy-D-glucose uptake. Follow-up contrast-enhanced multidetector CT suggested the correct diagnosis of an RSS. This is the first known report of the PET/CT appearance of an RSS.

Foreign body granulomas secondary to retained sponge fragment following mitomycin C trabeculectomy

BACKGROUND

Bleb related inflammation following trabeculectomy is usually seen in the late post operative period and is unusual in the first 6 months after surgery We report the clinical findings and course of two patients with early bleb related inflammation secondary to retained cellulose sponge fragments used to apply mitomycin C on the scleral surface.

METHODS

Retrospective review of medical records of two patients and pathology from one patient.

RESULTS

Both patients developed bleb related inflammation four months after a combined fornix based trabeculectomy and cataract procedure in which mitomycin C was applied using filter paper discs (Whatman filter paper #1). Material suggestive of cellulose fragments was noted in the filtering bleb in both patients. Patient 1 had a bleb leak at time of presentation and pathologic examination of foreign body material obtained from the site of the leak demonstrated a granulomatous reaction surrounding cellulose fibers. The foreign body material was removed in both patients. This led to resolution of the bleb leak in the first patient and at one year following the procedure both patients had functioning blebs in the affected eye.

CONCLUSIONS

Retention of sponge fragments is rare but may be a cause of bleb inflammation as a result of a foreign body granulomatous reaction. The choice of sponge material that does not shred may help in avoiding this unusual complication.

Modulating angiogenesis: the yin and the yang in ginseng

BACKGROUND

Ginseng is a commonly used nutraceutical. Intriguingly, existing literature reports both wound-healing and antitumor effects of ginseng extract through opposing activities on the vascular system. To elucidate this perplexity, we merged a chemical fingerprinting approach with a deconstructional study of the effects of pure molecules from ginseng extract on angiogenesis.

METHODS AND RESULTS

A mass spectrometric compositional analysis of American, Chinese and Korean, and Sanqi ginseng revealed distinct "sterol ginsenoside" fingerprints, especially in the ratio between a triol, Rg1, and a diol, Rb1, the 2 most prevalent constituents. Using a Matrigel implant model and reconstituting the extracts using distinct ratios of the 2 ginsenosides, we demonstrate that the dominance of Rg1 leads to angiogenesis, whereas Rb1 exerts an opposing effect. Rg1 also promoted functional neovascularization into a polymer scaffold in vivo and the proliferation of, chemoinvasion of, and tubulogenesis by endothelial cells in vitro, an effect mediated through the expression of nitric oxide synthase and the phosphatidylinositol-3 kinase-->Akt pathway. In contrast, Rb1 inhibited the earliest step in angiogenesis, the chemoinvasion of endothelial cells.

CONCLUSIONS

The present study explains, for the first time, the ambiguity about the effects of ginseng in vascular pathophysiology based on the existence of opposing active principles in the extract. We also unraveled a speciogeographic variation impinging on the compositional fingerprint that may modulate the final phenotype. This emphasizes the need for regulations standardizing herbal therapy, currently under the Dietary Supplement and Health Education Act. Furthermore, we propose that Rg1 could be a prototype for a novel group of nonpeptide molecules that can induce therapeutic angiogenesis, such as in wound healing.

Retained surgical textilomas occur more often during war

Retained surgical textile foreign bodies are a problem despite precautions taken by surgeons. Computed tomography (CT) is a method of choice in diagnosing the cases of retained textilomas. Over 12 years, we diagnosed 11 acute textilomas in 10 patients in the early postoperative period within 3 months after abdominal surgery. The presence of considerable amount of air bubbles within textile fibers was the most representative sign. A 3-10 mm wide peripheral rim was present in all textilomas. In additional 3 cases, chronic, encapsulated foreign body granulomas were found, two were mimicking renal neoplasms. All granulomas contained discrete or coarse calcifications. The period between surgery and CT diagnosis was from 6 months to 14 years in chronic lesions. It is important to emphasize that 9 textilloma in 8 patients were associated with the years of war in Croatia (1991 and 1992), in hospitals on battle fronts, where surgeons worked under extremely strenuous conditions and with great inflow of wounded soldiers and civilians.

Detection of retained surgical sponge by transthoracic and transesophageal echocardiography

We describe an unusual case of extracardiac mass in a patient who was assymptomatic and submitted to an open-chest coronary artery bypass operation 5 years previously. Transthoracic and transesophageal echocardiography revealed a rounded mass compressing the right atrium with a thick contour surrounding a heterogeneous center, suggestive of foreign body. Magnetic resonance imaging identified the mass as a pericardial cyst. Operation revealed a fibrinous cyst encapsulating a sponge. This case illustrates the central role of echocardiography for the diagnosis and treatment of patients with suspected retained surgical sponges.

Epitheloid angiosarcoma of the splenic capsula as a result of foreign body tumorigenesis. A case report

A case of an epitheloid angiosarcoma of the splenic capsula is reported. This tumour developed in close relation to a gauze sponge, which was accidentally left behind 38 years earlier during a left-sided nephrectomy. The tumour probably arose from pluripotential mesothelial stem cells within the splenic capsula, with subsequent mesothelial to endothelial metaplasia and neoplastic transformation. Clinical, radiological, peroperative and pathological features of this angiosarcoma add to the validity of the concept of inert foreign body tumorigenesis.

Teflon pledget reinforced fundoplication causes symptomatic gastric and esophageal lumenal penetration

BACKGROUND

Nissen fundoplication has become the standard operative procedure for the treatment of severe gastroesophageal reflux disease. The use of Teflon pledgets in Nissen fundoplications by our unit has been associated with a number of complications that has led to a change of technique in performing these operations.

METHODS

We reviewed our database of all patients who had fundoplications that involved the use of pledgets and identified those who had represented with postoperative complications related to pledget erosion/migration.

RESULTS

We identified 11 patients to date from a total of 1,175 fundoplications who had symptomatic pledget erosion occurring between 2 and 85 months after surgery (mean time 33.3 months). Symptoms included dysphagia, recurrent symptomatic gastroesophageal reflux, chest pain, and melaena, and in some cases significant morbidity was associated with the erosion. No common factor predisposing these patients to pledget erosion was identified. In the majority of cases removal of the pledget was associated with resolution of the symptoms. A review of the literature does not reveal any similar studies but problems associated with the erosion and migration of Teflon prostheses are described.

CONCLUSIONS

The use of Teflon pledgets in fundoplication is associated with a small but significant risk of complications that has led to our unit abandoning this technique.

Retained sponge after abdominal surgery

OBJECTIVE

To study the cause and clinical presentation along with clinical course (cooperative and postoperative) of retained abdominal sponge.

DESIGN

Observational case series.

PLACE AND DURATION OF STUDY

Surgical Department, Bahawal Victoria Hospital, Bahawalpur, from April 1, 2000 to August 31, 2002.

MATERIALS AND METHODS

The study included 12 patients. All the patients, who presented to surgical department during the stated period with retained abdominal sponge postoperatively, were included in the study. Retained abdominal foreign bodies, other than the surgical sponge, were excluded.

RESULTS

A total of 12 patients presented with retained abdominal sponge. Out of these, 33.33% were males and 66.66% females. Modes of presentation were intestinal obstruction, 58.33%, discharging sinus, 41.67%, intraabdominal abscess, 16.67%, peritonitis, 16.67% and mass abdomen, 8.33%. One death followed despite provision of due care.

CONCLUSION

Retained surgical sponge is a potentially lethal condition and all preventive measures should be taken to avoid this condition.

Double-blind randomised controlled trial comparing Merocel with Rapid Rhino nasal packs after routine nasal surgery

INTRODUCTION

Nasal packing after routine nasal surgery is commonly practiced in the UK. The most popular pack appears to be Merocel, however this can be associated with significant pain on its removal.

AIM

To test the efficacy of a relatively new nasal pack--the Rapid Rhino Goodman pack--introduced to our department, which claims to reduce pain and bleeding after nasal surgery.

METHODS

Fourteen patients undergoing routine nasal surgery were recruited into a randomised controlled trial. One nasal cavity was packed with a Merocel pack and the other with a Rapid Rhino Goodman pack. Patients were asked to record pain levels on each side using a visual analogue scale.

RESULTS

We found no difference between packs whilst in-situ, with all patients recording low to moderate pain scores. There were significantly higher pain levels associated with Merocel pack removal than with Rapid Rhino pack removal (average pain scores 5.64 vs 1.64, p < 0.001) and less bleeding overall.

CONCLUSIONS

Rapid Rhino (Goodman pack) is associated with significantly less pain on removal than Merocel pack, causes less bleeding and is not more painful whilst in-situ. We therefore recommend its use in routine nasal surgery.

Surgical swab foreign bodies--observations on 7 cases in Lagos

Foreign bodies inadvertently left in body cavities are a rare complication of abdominal and other surgeries. The true incidence of this condition is not known. The author reports on 7 such cases occurring over a 16-year period and comments on preventive measures, early diagnosis, tactful handling and the need for damage control when dealing with this unwelcome issue in a surgical setting.

Intrarenal foreign body presenting as a solid tumor

A 45-year-old man underwent radical nephrectomy for an asymptomatic solid renal mass radiographically interpreted as a tumor. The pathologic examination revealed an intrarenal sponge forgotten during nephrolithotomy performed 5 years previously. The sponge was surrounded by a thick fibrous capsule. This case suggests that foreign body should be included in the differential diagnosis of a suspected renal mass in patients with a history of previous surgery.