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Endoscopic management of gossypiboma

Open AccessPublished:July 26, 2018DOI:https://doi.org/10.1016/j.vgie.2018.06.006
      A 30-year-old woman presented because of abdominal pain, vomiting, and low-grade fever for the previous 2 weeks. She had undergone a complicated cholecystectomy (laparoscopic procedure to open conversion) at a different institution 3 weeks earlier. On clinical examination, an ill-defined, firm, tender lump was palpable in the epigastrium. Her laboratory evaluation showed leukocytosis (total leukocyte count, 12,300/μL; polymorphs, 80%).
      Contrast-enhanced CT of the abdomen showed a large, well-defined lesion in the gastrohepatic region with an internal reticular pattern with gastric communication (Fig. 1A). She was given broad-spectrum antibiotics. Gastroscopy showed the cylindrical projection of a surgical gauze pad visible in the gastric antrum (Fig. 1B). Another part of the gauze protruded through the anterior wall of the duodenal cap. Endoscopic removal of the gauze was performed with the patient under conscious sedation (Video 1, available online at www.VideoGIE.org).
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      Figure 1A, Contrast-enhanced CT view showing large well-defined lesion in gastrohepatic region with an internal reticular pattern with gastric communication. B, Gastroscopic view showing large gauze piece in stomach protruding through antrum. C, Proximal end of gauze piece is firmly grasped with a snare and removed with slight traction. D, Removal of entire gauze piece from esophagus through oral cavity. E, Entire piece of gauze pad. F, Recheck endoscopic view showing large fistulous opening in antrum. G, Recheck endoscopic view on day 3 showing healing fistulous opening in antrum. H, Endoscopic view at 3 months showing scarring at previous fistulous site in antrum.
      The projecting proximal part of the gauze was encircled with a large-diameter braided snare (SnareMaster, 25 mm, Olympus, Kuroishi, Aomori, Japan) reaching close toward the gastric wall (Fig. 1C). Slowly and firmly, the entire gauze was pulled into the stomach.
      The snare was disentangled, and a rat-tooth forceps was used to grasp the edge. An attempt to withdraw the endoscope, along with the gossypiboma held with forceps, failed because of significant resistance at the upper esophageal sphincter. The braided snare was used again, replacing the rat-tooth forceps, to firmly grip the proximal segment of the gossypiboma in the esophagus. The whole unit was then gradually but firmly pulled out (Figs. 1D and E).
      After the procedure, endoscopy showed a mild mucosal tear at the upper esophagus and large fistulous openings draining pus in the antral region and duodenal cap (Fig. 1F). A nasogastric tube was placed for continuous aspiration. Subcutaneous emphysema was observed in the neck after 4 hours and gradually subsided. The patient remained fasting for the next 48 hours. On day 3, gastroscopy showed significant healing of the gastric fistulous opening (Fig. 1G). The patient was discharged in stable condition on oral antibiotics and antacids. Follow-up endoscopy at 3 months showed scarring in the antrum and normal mucosa in the duodenal cap (Fig. 1H).
      Complete endoscopic management is technically feasible in the patient with gossypiboma eroding into the GI lumen. Gossypiboma is a rare, serious adverse event that requires surgery. Endoscopic removal can be attempted for a gossypiboma having an extension into the GI lumen.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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