Rare case of Intrathoracic gossypiboma presenting 47 years later as a purulent fistula: A report

Intrathoracic gossypiboma is a consequence of retained sponge/swap, gauzoma, muslinoma, textiloma, or cottonoid in the thoracic cavity during surgery. The thoracic cavity is of the rarest place for gossypiboma as these entities most occur after abdominal surgery.

According to history, a 62-year-old male patient was admitted to our department with a purulent fistula at the site of previous surgery in the right posterolateral thoracic area. The fistula was painful, warm, and erythematous with induration and continuous milky purulent drainage. He had a past medical history of diabetes mellitus from 20 years ago, which was treated with insulin injections. He also had two previous surgeries, the first was right posterolateral thoracotomy and pneumonectomy for the management of chronic tuberculosis about 47 years ago, and the other one was abdomino-pelvic resection for the management of colorectal cancer. The patient had developed a purulent lesion from two years ago, but mentioned no other symptoms. He also mentioned that his diabetes mellitus was severe in these 2 years. On physical examination, he had a 3*3 cm lesion with purulent secretion in the right posterolateral thoracic area. The surrounding tissue was red and tender.

His Chest X-ray showed opacities covering the whole right hemithorax and radiopaque strip (Fig. 1). The patient was investigated with a chest computed tomography (CT) scan without contrast, which showed a giant lesion within the right thoracic cavity with thread-like calcifications (Fig. 2). With suspicion of gossypiboma, right video-assisted thoracoscopic surgery was planned. Preoperative lab testing showed a white blood cell count of 10,600/μL with 81.6% polymorphonuclear neutrophils and 7.9% lymphocytes. C-reactive protein was in the upper limit of normal. Other blood examinations were normal. Microbial examination of the lesion showed infection with E. coli, which was resistant to ceftriaxone and ampicillin sulbactam. An infected surgical sponge was detected in the surgery. Due to severe adhesion to thoracic structures and mediastinum, we had to convert the operation to a right posterolateral thoracotomy. And it was removed from the thoracic cavity without any complications (Fig. 3).

Several factors contribute to patient morbidity and mortality during surgery. Retained sponge/swap, gauzoma, muslinoma, textiloma, or cottonoid are examples of these, and they all lead to gossypiboma. Gossypiboma can occur in any cavity, although the abdomen, pelvis, and thorax are the most common. In unresolved situations, they frequently lead to major complications that result in rehospitalization, reoperation, and even death. In the case of an intrapleural opacity following surgery, a differential diagnosis of gossypiboma should always be explored. A thorough clinical history, such as the onset of mass development, can provide a clue to its origin, which can then assist the treatment. The gossypiboma rate of occurrence varies between 1 in 1000 and 1 in 10,000 cases. Nonetheless, determining the exact incidence of gossypiboma is difficult due to widespread underreporting due to the risk of medicolegal repercussions. In general, thoracic gossypiboma is not a common diagnosis. A recent analysis found only 40 cases in the English literature. Clinically, patients may be asymptomatic for a long period or present with discomfort, nausea, vomiting, or a palpable lump, which can take anywhere from a few hours to years to diagnose. Here, they report a case of intrathoracic gossypiboma that was missed for a long period of time with no symptoms.

Thus, the researchers concluded that the rarity of gossypiboma necessitates a high index of suspicion for correct diagnosis. Gossypiboma is often difficult to diagnose, leading to misdiagnosis and unnecessary interventions. It is important to consider this entity as a diagnosis in any case with an unexplained or unusual presentation during the postoperative period.

Reference:

Rafieian, S., Vahedi, M., Sarbazzadeh, J. et al. Intrathoracic gossypiboma presenting 47 years later as a purulent fistula: a case report. surg case rep 8, 123 (2022). https://doi.org/10.1186/s40792-022-01479-6