Retained Sponge After Open Cholecystectomy Causing Gastric Outlet Obstruction: Case Report And Literature Review

摘要

Gastric outlet obstruction (GOO) is not considered a single entity; rather it is the clinical consequence of any disease process that produces blockade to gastric emptying. A study shows that only 37% of patients with GOO have benign disease and the remaining patients have obstructions due to malignancy. Gossypibomas most commonly occur following abdominal and gynecological surgery and generally require re-operation as soon as they are diagnosed as complications and morbidity are high. We report a case of retained surgical sponge after open cholecystectomy causing gastric outlet obstruction. Introduction Gastric outlet obstruction (GOO) is not considered a single entity; rather it is the clinical consequence of any disease process that produces blockade to gastric emptying. A study shows that only 37% of patients with GOO have benign disease and the remaining patients have obstructions due to malignancy.Gossypibomas most commonly occur following abdominal and gynecological surgery and generally require re-operation as soon as they are diagnosed as complications and morbidity are high. We report a case of retained surgical sponge after open cholecystectomy causing gastric outlet obstruction. We report a case of a patient with a retained sponge. Case report A 42-year-old woman presented to our university hospital with intractable repeated vomiting for 5 months. It was progressive and not responding to any medications. There were intermittent attacks of fever at the start of the complaint. Loss of weight was noted by the patient but there was no anorexia, hematemesis, dyspepsia or melena. Open cholecystectomy had been done 6 months ago and the patient remained unwell even after the operation, with vomiting from 2 weeks postoperatively until now.Physical examination revealed a thin build and an emaciated look. There was no fever, tachycardia or jaundice. Abdominal examination revealed a scar of the right Kocher incision of the cholecystectomy operation, but there were no palpable organs or masses in the epigastrium or right hypochondrium.Laboratory investigations showed a hemoglobin of 9.5 gm/dl, leucocytes of 7500/ml, normal blood sugar, urea, creatinine and liver functions. Imaging investigation by ultrasonography of the abdomen was unremarkable. Upper GIT endoscopy was planned to verify the cause of vomiting. Surprisingly, we found a big foreign body in the form of towels protruding from the pyloric canal towards the body of the stomach causing complete obstruction of the gastric outlet. Attempts at removal through the endoscope failed.Laparoscopy was decided to evaluate the abdominal cavity and to see any evidence of peritonitis. We found only marked adhesions at the site of the previous cholecystectomy operation, with the stomach and duodenum adherent to the abdominal wall.Laparotomy was performed for better assessment and management. It consisted of freeing the adhesions between the stomach, duodenum, and abdominal wall using sharp dissection. The scissor encroached upon the abdominal wall to avoid injury to the stomach and duodenum. Importantly, there was no evidence of perforation, fistula, hemorrhage or peritonitis on examining the gastroduodenal wall during laparotomy. A gastrotomy incision made on the anterior wall of the stomach revealed a large surgical towel emerging from the pyloric opening, obstructing the gastric outlet completely. Gentle removal of this towel was successfully achieved, followed by closure of the gastrotomy incision with Vicryl? 2/0 sutured in two layers. A nasogastric tube was left in the stomach for 3 days postoperatively. Closure of the laparotomy wound was performed, leaving a drain in the peritoneal cavity.The patient showed a smooth and uneventful postoperative course with marked and dramatic improvement in her condition. Vomiting ceased completely after one week, followed by normal enteral feeding.