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Forty-Year-Old Intrathoracic Gossypiboma After Cardiac Valve Surgery

2009; Lippincott Williams & Wilkins; Volume: 119; Issue: 24 Linguagem: Inglês

10.1161/circulationaha.109.849794

1524-4539

Gilberto Szarf, Thaís Caldara Mussi, Edson Nakano, Denis Szjenfeld, Altair Silva Costa, Erica Rymkiewicz, Renato de Oliveira, Sérgio Ajzen, Luiz Eduardo Villaça Leão, Henrique Manoel Lederman,

Vascular Procedures and Complications

HomeCirculationVol. 119, No. 24Forty-Year-Old Intrathoracic Gossypiboma After Cardiac Valve Surgery Free AccessReview ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessReview ArticlePDF/EPUBForty-Year-Old Intrathoracic Gossypiboma After Cardiac Valve Surgery Gilberto Szarf, MD, PhD, Thais Caldara Mussi de Andrade, MD, Edson Nakano, MD, Denis Szjenfeld, MD, Altair Silva CostaJr, MD, Erica Rymkiewicz, MD, Renato de Oliveira, MD, Sergio Aron Ajzen, MD, PhD, Luiz Eduardo Villaca Leao, MD, PhD and Henrique M. Lederman, MD, PhD Gilberto SzarfGilberto Szarf From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. , Thais Caldara Mussi de AndradeThais Caldara Mussi de Andrade From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. , Edson NakanoEdson Nakano From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. , Denis SzjenfeldDenis Szjenfeld From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. , Altair Silva CostaJrAltair Silva CostaJr From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. , Erica RymkiewiczErica Rymkiewicz From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. , Renato de OliveiraRenato de Oliveira From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. , Sergio Aron AjzenSergio Aron Ajzen From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. , Luiz Eduardo Villaca LeaoLuiz Eduardo Villaca Leao From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. and Henrique M. LedermanHenrique M. Lederman From Thoracic Magnetic Resonance Imaging (G.S.) and Cardiovascular Magnetic Resonance Imaging (G.S., E.N., D.S.), Department of Radiology (T.C.M.d.A., S.A.A., H.M.L.), and Department of Thoracic Surgery (A.S.C., E.R., R.d.O., L.E.V.L.), UNIFESP, Sao Paulo, Brazil. Originally published23 Jun 2009https://doi.org/10.1161/CIRCULATIONAHA.109.849794Circulation. 2009;119:3142–3143A 59-year-old asymptomatic man, who had undergone cardiac valve surgery 40 years earlier, demonstrated a paracardiac mass on routine chest x-ray (Figure 1). Subsequently, a chest computed tomography scan was performed, which showed a 14.0×9.5 cm heterogeneous lesion, with lobulated contours, along the inferior aspect of the left and right ventricles (Figure 2). It was possible to identify areas of low density as well as high-density areas. Peripheral calcification was also present. There was mild peripheral enhancement after iodinated intravenous contrast injection. It was not possible to exclude cardiac invasion because this lesion had extensive contact with the cardiac ventricles. Download figureDownload PowerPointFigure 1. A, Posteroanterior chest radiograph showing an ill-defined opacity at the left pericardic region. B, This is better identified in the lateral projection (white arrows).Download figureDownload PowerPointFigure 2. Chest computed tomography before (A and B) and after (C and D) intravenous iodinated contrast injection, showing a heterogeneous lesion with peripheral calcifications and areas of high and low attenuation in close contact with the right and left ventricles.Cardiac magnetic resonance imaging was performed to examine the relation of this lesion to the cardiac chambers. The imaging revealed that the lesion was located below the left ventricle with a distinct cleavage plane with this chamber. On the other hand, the right ventricle had broad contact with this lesion. The lesion was heterogeneous, with fluid and solid areas (Figure 3 and online-only Data Supplement Movies I and II). Differential diagnoses included gossypiboma, calcified hematoma, and malignant tumor. Download figureDownload PowerPointFigure 3. Cardiac magnetic resonance in the (A) vertical long-axis and (B) short-axis planes, using steady-state free precession sequences, demonstrates that the lesion has solid and fluid areas and is located below the left and right ventricles, with a distinct cleavage plane with the former chamber (white arrow) and in broad contact with the latter (black arrow).At surgery, a mass with adhesions to the right ventricular wall was found in the pleural space. En bloc resection was performed followed by repair of the right ventricle, which was injured during dissection. Gross examination showed a predominantly cystic mass, in which 1 piece of retained gauze was found (Figure 4). The condition of the left ventricle and lung adjacent to the lesion were unremarkable. Download figureDownload PowerPointFigure 4. Surgical specimen of the resected mass (A) with a piece of retained gauze, which is best seen in greater detail (B).Gossypiboma (also called textiloma) is a term used to describe a mass in the body that is composed of a cotton matrix surrounded by a foreign-body reaction. It can have severe medical consequences, such as infection or abscess formation, and medicolegal consequences involving liability of the surgeon. The radiologist is often the first medical investigator confronted with the problem of retained surgical material, and its low incidence, variety of symptoms, and nonspecific radiologic findings can make it difficult to formulate a correct preoperative diagnosis (especially if a radiopaque marker is not present).1 Two frequent sites of intrathoracic gossypiboma are the pleural and pericardial cavities. Computed tomographic features of gossypibomas include a spongiform appearance with gas bubbles, a low-density mass with a thin enhancing capsule, and calcifications deposited along the network architecture of a surgical sponge.2,3 The features of the signal in magnetic resonance were matched with a predominantly cystic mass, as already described.4 It is important to remember that gossypibomas left within the pleural space can show no gas lucencies because of resorption of the air by the pleura.1In the present case, a central aspect was the importance of magnetic resonance imaging to define absence of clear invasion of the left ventricle by the mass, making the diagnosis of tumor less likely and allowing better preoperative planning.The online-only Data Supplement is available with this article at http://circ.ahajournals.org/cgi/content/full/119/24/3142/DC1.AcknowledgmentsThe authors would like to thank Andrea Puchnick for photographic and editing assistance.DisclosuresNone.FootnotesCorrespondence to Gilberto Szarf, Rua Sergipe, 605 ap. 73, Sao Paulo, Brazil 01243–001. E-mail [email protected]References1 Sheehan RE, Sheppard MN, Hansell DM. Retained intrathoracic surgical swab: CT appearances. J Thorac Imaging. 2000; 15: 61–64.CrossrefMedlineGoogle Scholar2 Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P. Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol. 2005; 78: 851–853.CrossrefMedlineGoogle Scholar3 Kopka L, Fischer U, Gross AJ, Funke M, Oestmann JW, Grabbe E. CT of retained surgical sponges (textilomas): pitfalls in detection and evaluation. J Comput Assist Tomogr. 1996; 20: 919–923.CrossrefMedlineGoogle Scholar4 Vayre F, Richard P, Ollivier JP. Intrathoracic gossypiboma: magnetic resonance features. Int J Cardiol. 1999; 70: 199–200.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Debaibi M, Sghair A, Gabsi S, Nejib F, Sridi A and Chouchen A (2022) A 34‐year‐old asymptomatic gossypiboma: A fortuitous diagnosis revealed by appendicular peritonitis: A case report, Clinical Case Reports, 10.1002/ccr3.5444, 10:2, Online publication date: 1-Feb-2022. Pyo W, Kim W and Kim J (2020) A Huge Pericardial Gossypiboma Causing Severe Cardiac Dysfunction, The Annals of Thoracic Surgery, 10.1016/j.athoracsur.2019.06.040, 109:3, (e167-e169), Online publication date: 1-Mar-2020. Kumar A, Paswan S, Prashad R, Kumari R and Kumar B (2018) Intrapericardial gossypiboma: Rare cause of intrathoracic mass, International Journal of Surgery Case Reports, 10.1016/j.ijscr.2018.04.024, 47, (75-79), . Yakar A, Atacan S, Yakar F, Ziyade N and Gündoğmuş Ü (2016) Medicolegal consequences of thoracic gossypiboma: A case report, Journal of Forensic and Legal Medicine, 10.1016/j.jflm.2016.05.010, 42, (65-67), Online publication date: 1-Aug-2016. Parra M, Oppliger F, Berríos R and Schiappacasse G (2014) Intrathoracic gossypiboma presenting 52 years later as a chest mass, Asian Cardiovascular and Thoracic Annals, 10.1177/0218492314557181, 23:5, (596-598), Online publication date: 1-Jun-2015. Machado D, Zanetti G, Araujo Neto C, Nobre L, Meirelles G, Pereira e Silva J, Guimarães M, Escuissato D, Souza Jr A, Hochhegger B and Marchiori E (2014) Thoracic textilomas: CT findings, Jornal Brasileiro de Pneumologia, 10.1590/S1806-37132014000500010, 40:5, (535-542), Online publication date: 1-Oct-2014. Boutayeb A, Marmade L, Laaroussi M, Bensouda A and Moughil S (2012) Textiloma mimicking a pericardial hydatid cyst: A case report, Heart, Lung and Circulation, 10.1016/j.hlc.2012.01.005, 21:5, (278-280), Online publication date: 1-May-2012. Nemati M (2012) Mediastinal gossypiboma simulating a malignant tumour, Interactive CardioVascular and Thoracic Surgery, 10.1093/icvts/ivs260, 15:4, (783-785), Online publication date: 1-Oct-2012. Rajković Z, Altarac S and Papeš D (2010) An Unusual Cause of Chronic Lumbar Back Pain: Retained Surgical Gauze Discovered after 40 Years, Pain Medicine, 10.1111/j.1526-4637.2010.00969.x, 11:12, (1777-1779), Online publication date: 1-Dec-2010. Sologashvili T, Kalangos A, Tissot C and Myers P (2013) Incidental Gossypiboma Discovered during Tricuspid Valve Re-Repair 11 Years after Ebstein Anomaly Repair, The Heart Surgery Forum, 10.1532/HSF98.20131015, 16:4, (216) June 23, 2009Vol 119, Issue 24 Advertisement Article InformationMetrics https://doi.org/10.1161/CIRCULATIONAHA.109.849794PMID: 19546397 Originally publishedJune 23, 2009 PDF download Advertisement SubjectsCardiovascular SurgeryComputerized Tomography (CT)