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© 2004 European Association of Cardio-Thoracic Surgery
Migration of surgical sponge retained at mediastinoscopy into the trachea
Department of Surgery, Faculty of Medicine and Division of Thoracic Surgery, Thoracic Diseases Institute, Federal University of Rio de Janeiro (UFRJ), Av. Brig. Trompowski S/n, Hospital Universit * Corresponding author. Address: Rua Baráo de Lucena 48 - Suite 03, Rio de Janeiro, RJ 22260-020, Brazil. Tel./fax: +55-21-253-73499. (E-mail: haddad{at}ufrj.com). Received April 5, 2004; received in revised form July 14, 2004; accepted July 23, 2004
It is uncommon to find an iatrogenic foreign body after thoracic surgery. We present a case of migration of a surgical sponge left inadvertently in the mediastinum during a troublesome mediastinoscopy, that migrated into the trachea 6 years later with airway obstruction. The foreign body was extracted through rigid bronchoscopy and the patient had a full recovery.
It is very uncommon to find surgical instruments, sponges, towels and gauze left inadvertently in the thoracic cavity or mediastinum postoperatively. Possible predisposing factors are higher mean body-mass index, emergency surgery, more than one surgical team involved or an unexpected change in the surgical procedure [1].
A 62-year-old lady was submitted in another Institution to a mediastinoscopy for diagnosis of an anterior mediastinal mass with superior vena cava obstruction syndrome. During the operation, the innominate artery was injured and repaired through a partial median sternotomy. The diagnosis was malignant thymoma. The patient was submitted to chemotherapy and radiotherapy with complete response, except for a 3-cm solid residual mass anterior to the mid third of the trachea (Fig. 1A). She was asymptomatic and refused any kind of surgical exploration and did not return to surgical follow up. Six years later she presented to our service complaining of productive cough, dyspnea and fever. A CT scan showed that the pre-tracheal residual tumor was partially empty, and an intra-tracheal mass was present, as well as post-radiotherapy residual changes in the paramediastinal lung fields (Fig. 1B). A rigid bronchoscopy under general anesthesia showed a gauze ulcerating the anterior wall of the trachea and obstructing 80% of its lumen (Fig. 1C). There was a 2.5-cm defect in the anterior wall of the trachea and purulent material in the tracheobronchial tree (Fig. 1D). The gauze was extracted, the airway was aspirated, antibiotics were given and the patient became asymptomatic and was discharged on the fourth post-operative day. The follow up was done with CT scans (with virtual bronchoscopy) each 6 months until complete healing of the tracheal defect (Fig. 2A and B). The patient refused a control bronchoscopy.
Surgical sponges are usually made of inert cotton, but they can provoke an aseptic reaction with foreign body granuloma, fibrosis, adhesions, calcification and ulceration. They can also become infected with abscess formation and fistulization to adjacent structures. They have been named textiloma or gossypiboma. Although many surgical sponges and towels have some radiopaque wire markers, these markers are sometimes absent and they are not seen on plain radiography as occurred with this case. CT has proven to be very valuable in suggesting the presence of this type of problem [2]. An inhomogeneous hypo-attenuating mass is usually seen. A typical whirl-like aspect due to the presence of gas is sometimes identified [3,4]. Gauze or towel left inside the patient may not be recognized on a radiograph. This will usually be due to poor observation, but errors may result from unfamiliarity with the patterns of the markers when present [5]. It is recommended that the surgeons and radiologists are familiar and aware of this type of images. This patient had a retained gauze in the mediastinum after a troublesome operation undergone 6 years earlier, with an unexpected complication represented by an arterial injury. Because of this complication she never returned to surgical follow up. The retained gauze migrated and obstructed the main airway 6 years later. She had previous surgery (for correction of the arterial lesion at mediastinoscopy), chemotherapy and radiotherapy (for the malignant thymoma). Therefore, any kind of tracheal resection and reconstruction under this environment could be a high-risk operation. The treatment first outlined in our service was the bronchoscopic removal of the obstructing foreign body with posterior stenting of the airway if necessary. The patient had a full recovery and stenting was not necessary. It has been 18 months since the procedure and the patient continues to be asymptomatic.
A retained intra-thoracic foreign body is a rare occurrence in clinical practice with isolated cases published in the literature. The case presented here is very unusual and had a simple solution outlined by the kind of environment around the lesion aggravated by previous existence of a malignant tumor plus emergency surgery, chemotherapy, radiotherapy and an irregular ulcerating lesion in the anterior wall of the trachea. This environment could make any open surgical approach a very difficult and risky procedure. We preferred to make an endoscopic approach to solve the airway obstruction and follow the tracheal lesion with CT scans (virtual bronchoscopy) until complete healing.
Author: Dr. Luciano Solaini, Thoracic Surgery Unit, Department of Surgery, V.le Randi, 5, Ravenna, 48100 Italy Date: 27-Aug-2004 Message: I have some comments for this paper: 1. From the title it seems that a retained sponge is a complication of mediastinoscopy. Actually it is because of the procedure of repair of a iatrogenic injured innominate artery which occured during mediastinoscopy. 2. Malignant thymomas arise between the sternum and the ascending aorta; it is very rare to find a thymoma localized between the aorta and the trachea. 3. Invasive tumors like malignant thymomas have a severe prognosis when the resection is not performed, but in this case, with also a sponge included in the area, radiotherapy and chemotherapy were effective. 4. After bronchoscopic removal of the sponge, the patient had a very likely course with a tracheal cartilagineous healing favourable and a very short hospital stay. In conclusion I believe the reported case very very exceptional. Response Author: Dr. Rui Haddad, Department of Surgery, Rua Barao de Lucena 48 - Suite 03, Rio de Janeiro - RJ, 22260-020 Brazil Date: 02-Sep-2004 Message: Dr. Solaini is right in his skeptical comments only when he states that this is a "very very exceptional case". In fact, it is really exceptional and that is why it deserves to be reported. It is necessary anyway to reply to his comments. 1. We really don't know if the sponge was put at mediastinoscopy or at partial sternotomy. Both procedures were done at the same time and the procedure itself is not a big deal. The main subject of this report is related to the foreign body, the respiratory obstruction six years later, the simple solution adopted for this complex case and the unexpected excellent result. 2. This patient had a SVC obstruction (we didn't have access to the preoperative films). Thus, it is right to suppose that the ideal access for biopsy because of the usual location of thymomas, as stated by him, is an anterior mediastinotomy or a VATS approach rather than a cervical mediastinoscopy. The procedure (mediastinoscopy) was done in another hospital 6 years before the consultation in our service, and besides the complication, it was effective in providing tissue for diagnosis including complete immunohistochemistry analysis. 3. The treatment, done 6 years ago, without surgery, was effective and we know from the literature that a few lucky patients can be cured without surgery [1, 2, 3]. This patient refused any surgical procedure after his initial CT/RT treatment mainly because she was angry with the complication that occurred at mediastinoscopy. She underwent radical RT (6.0 cGy) and 6 cycles of cisplatin based chemotherapy. The residual mass (actually the foreign body) was reported in the first CT scan after the treatment. 4. In relation to the treatment and outcome of the tracheal defect it was a big surprise to me that this patient did so well. At the 3rd post-procedure day, she was completely asymptomatic and was discharged in the next day with oral antibiotics only. But we did a closed follow-up on this patient with weekly consultations, virtual bronchoscopy every 6 months or earlier if necessary (she refused flexible bronchoscopy and was completely asymptomatic). Nine months after the procedure we had the proof of the healing of the tracheal wall with the virtual bronchoscopy that is shown in this case report. Our first planned treatment was to stent the airway if there were some clinical related healing problems. But she was very lucky again. We believe that Dr. Solaini unfortunately missed the chief points of this case report. It is not important the kind of initial procedure, or the access for biopsy, or even the miraculous cure of the malignant thymoma. The important points are the migration of the foreign body six years after a mediastinal surgical procedure, the respiratory obstruction treated with rigid bronchoscopy and the spontaneous healing of the 2.5 cm irregular anterior tracheal wall defect. These facts are the real objective for this publication. References [1] Loehrer PJ, Chen, M, Kim K, Aisner SC, Einhorn LH, Livingston R , Johnson D. Cisplatin, doxorubicin and cyclophosphamide plus thoracic radiation therapy for limited-stage unresectable thymoma: an intergroup trial. J Clin Oncol 1997;15(9):3093–9. [2] Mornex F, Resbeut M, Richaud P, Jung GM, Mirabel X, Marchal C, Lagrange JL, Rambert P, Chaplain G, Nguyen TD: Radiotherapy and chemotherapy for invasive thymomas: a multicentric retrospective review of 90 cases. International J Rad Oncol Biol Phys 1995;32(3):651–9. [3] Giaccone G, Ardizzoni A, Kirkpatrick A, Clerico M, Sahmoud T, van Zandwijk N: Cisplatin and etoposide combination chemotherapy for locally advanced or metastatic thymoma: a phase II study of the European Organization for Research and Treatment of Cancer Lung Cancer Cooperative Group. J Clin Oncol 1996;14(3):814–20.
doi:10.1016/j.icvts.2004.07.015
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Abstract
1. Introduction
