*From the Thoracic Surgery Department (Drs. Granetzny and Boseila), Klinikum Niederrhein, Evangelisches Krankenhaus Duisburg Nord, Duisburg; and Department of Chest Medicine (Drs. Holtbecker and Thomas), St Elisabeth KH, Dorsten, Germany.
Correspondence to: Ahmad Boseila, MD, Thoracic Surgery Department, Evangelisches Krankenhaus Duisburg-Nord, Fahrner Str. 133, Duisburg 47169, Germany; e-mail: firstname.lastname@example.org
Intraoperatively retained foreign bodies are both medical and medico-legal problems. We report a patient who underwent a lower left lobectomy initially for nonresolving chronic organizing pneumonia. Rethoracotomy was performed due to a suspicious CT finding of a retained surgical sponge that turned out to be a GI anastomosis (GIA) staple line. Postoperatively, the situation was simulated using a surgical sponge adherent to the skin, to demonstrate the difference between the radioopaque marker of the surgical gauze and the GIA staple line. The facts of this case suggest the need for careful interpretation of such radiographic studies in the context of radioopaque materials intentionally employed during the first operation. If in doubt, digital magnification for more detailed and accurate inspection should be performed to avoid unnecessary rethoracotomy.
The appearance of retained surgical gauze varies widely, and its recognition by CT scan is useful. Air trapped within a sponge gives rise to a characteristic spongiform pattern. CT findings together with previous surgery permit the correct preoperative diagnosis of retained surgical gauze.1In any patient with an intrathoracic opacity who has previously undergone thoracotomy, textilloma, hematoma, abscess formation, and the recurrence of a primary tumor,2as well as lung infarction just adjacent to the staple line3 should be included in the differential diagnosis.
We report the case of a 58-year-old man who had undergone a left lower lobectomy for a nonresolving chronic organizing pneumonia. Intraoperatively, severe adhesions were encountered. Due to the absence of an interlobar fissure, three GI anastomosis (GIA) staple lines had to be applied. At the end of the operation, the sponge count was reported correct. The pathologic examination revealed chronic carnificated pneumonia.
Plain chest radiographs were done in the immediate postoperative phase and before discharge of the patient. In these plain radiographs, there was no suspicion of a retained foreign body.
Ten days postoperatively, the patient started to have recurrent attacks of fever up to 39°C. Laboratory investigations indicated the presence of an inflammatory process. No specific cause could be detected, and the patient was sent back to the referring lung physician. Due to further persisting fever, broad-spectrum antibiotics were administered, chest CT scan was performed, and retained surgical gauze with a 10-cm-long radioopaque thin line was interpreted as the cause of the persistent fever (Fig 1
The patient was readmitted to our clinic, and the postoperative plain chest radiographs and CT of the chest were presented at our multidisciplinary conference, and a retained foreign body could not be excluded. The exploration 5 weeks after the initial thoracotomy revealed marked adhesions. In the course of the thoracic cage exploration, the suspected retained surgical gauze was not found.
A further search was performed using a C-arm (Fig 2
), and surgical gauze was radiographed separately to compare with the intrathoracic findings. When the presence of surgical gauze was doubted, further dissection showed the staple suture row under thick adhesions. The suture line was marked with a needle; when inflated, the respiratory movement of the lung could be followed on the screen, identifying the staple line as the suspected foreign body, and the exploration was terminated at this point. The further course of the patient was uneventful.
The question was raised if this unnecessary rethoracotomy could have been avoided. Therefore, a staple was applied to surgical gauze parallel to the radioopaque marker integrated in the sponge, and radiography was performed. Clear differences could be detected with regard to the discontinuity and the regularity of the staple line in comparison to the marker in the surgical gauze (Fig 3
To simulate real circumstances, a radiograph was performed of this same surgical gauze taped to the chest wall of a volunteer, and here the difficulties in differentiation appeared. The differences with regard to the discontinuity and the regularity of the staple line in comparison to the marker in the sponge were no longer so obvious (Fig 4
Postoperative unresolving fever if associated with the nonspecific clinical picture of an infectious process, and a suspicious radiologic finding, raise the question of intraoperatively retained surgical gauze. In view of the medical and medico-legal issues involved,4 the surgeon must seriously consider that nothing short of re-exploration will totally rule out the presence of a foreign body. To our knowledge, there has been no previous report of a false interpretation of staple lines as a retained foreign body, and we therefore report it to be added to the various differential diagnoses in such a clinical setting.
In most cases, the differences between the staple line and the radioopaque marker in surgical gauze can be identified, showing an irregular structure of the surgical gauze in comparison with the regular arrangement of the staples in a stapler line. If in doubt, we recommend that the images be digitally magnified for more detailed and accurate inspection to avoid unnecessary rethoracotomy.
Although the patient recovered uneventfully, we report this as an unnecessary re-exploration. We believe it serves to remind physicians, surgeons, and radiologists of the need for thoughtful examination of postoperative chest radiographs, explaining all foreign bodies in the context of those intentionally left behind during the prior procedure.
Abbreviation: GIA = GI anastomosis
The authors have no conflicts of interest to disclose.
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