432 Case Reports
Three Cases of Intrathoracic Gossy-
piboma with Varying Morbidities
Depending on the Time of Detection
H. K. Okur, E. Okur, R. Baran
Sureyyapasa Chest Diseases and Thoracic Surgery Teaching Hospital,
Istanbul, Turkey
Abstract
!
An intrathoracic gossypiboma (surgical sponge retained within
the thoracic cavity during surgery) is rare but causes serious sur-
gical complications and presents with difficulties in the differen-
tial diagnosis. In this article, we describe three cases of intra-
thoracic gossypiboma identified with the help of exploratory
surgery 22, 10 and 3 years after they had been retained after sur-
gery. The radiological findings varied in these cases and were in-
sufficient for an accurate preoperative diagnosis. Marked deteri-
oration in the neighboring lung tissue was observed over time,
and the patients who had gossypibomas for 22, 10 and 3 years
required pneumonectomy, lobectomy and partial decortication,
respectively.
Key words
Surgical sponge · thoracic surgery · pneumonectomy · thora-
cotomy
Introduction
! Since the cyst wall had extended and invaded the hilum, hilar
A surgical sponge retained in the thoracic cavity, also known as a
gossypiboma, can lead to serious surgical complications.
Although intrathoracic gossypibomas are rare compared to in-
tra-abdominal ones, they are more difficult to identify because
they tend to lose their characteristic radiological appearance
over time. Over the last 12 years, we encountered 3 cases of in-
trathoracic gossypiboma which were identified with the help of
exploratory thoracotomy at 22, 10 and 3 years after the primary
surgery.
Case 1
! lier and thoracotomy for bilateral hydatidosis 10 years earlier.
A 43-year-old male patient referred to our clinic presented with
the complaints of cough, sputum expectoration and hemoptysis
that had persisted for 1 week. The patient had developed para-
plegia as a result of a traffic accident he had been involved in 22
years earlier. He had also been operated through a right thora-
cotomy after this accident, but we could not obtain the records
on the details of the thoracotomy. The right hemithorax seemed
smaller than the left and appeared to be poorly involved in res-
piration. Additionally, decreased breathing sounds were noted
on the right side during auscultation. Digital clubbing was noted.
Posteroanterior radiography of the chest revealed a round non-
homogenous mass-like lesion, occupying most of the right lung
field. Computed tomography (CT) revealed a decrease in the
right hemithorax volume, with a heterogeneous soft tissue den-
sity (11 × 10 cm) with gas bubbles along the chest wall around
the middle lobe (l " Fig. 1). Fiberoptic bronchoscopy revealed se-
Okur HK et al. Three Cases of … Thorac Cardiov Surg 2009; 57: 432 – 440
Fig. 1 CT scan showing a soft tissue mass with gas bubbles (case 1).
verely purulent secretions coming from the right middle lobe.
The culture of the secretions showed no pathogenic growth.
Treatment with antibiotics was initiated with a preliminary di-
agnosis of abscess formation, but the condition of the patient
did not improve; therefore surgery was subsequently per-
formed. Exploration of the hemithorax through a right thoracot-
omy revealed a thick-walled cyst-like lesion compressing the
right lung. The right lung was almost completely destroyed and
had very poor ventilation. The cyst wall, which was approxi-
mately 2 cm thick, was cut open and very thick purulent materi-
al removed along with a semisolid foreign body. Irrigation of the
foreign body revealed it to be cotton gauze or a small towel.
dissection was impossible. Pneumonectomy was necessary for
the non-ventilating dysfunctional lung.
Case 2
!
A 68-year-old female patient was admitted to hospital with the
complaints of cough, dyspnea and back pain that had persisted
for 4 months. During previous evaluations by other physicians,
she was considered to have developed pneumonia in the left
lung and had received antibiotic treatment for the same. She
had undergone orthopedic surgery on her right leg 15 years ear-
The results of a physical examination were normal. A CT scan
showed a lesion (5 × 5.5 cm) with heterogeneous hypodense
areas in the latero-basal segment of the left lower lobe
(l" Fig. 2). A left thoracotomy was performed and a foreign body
was recovered from the cavity of the cystic lesion in the lower
lobe. A lower lobectomy was performed because the lower lobe
was totally destroyed.
Case 3
!
A 58-year-old male patient was admitted to our hospital for the
complaint of chest pain on the left side which had persisted for 5
months. He had undergone surgery for occlusion of the abdomi-
nal aorta 3 years earlier, followed by drainage of the left pleural
effusion with the aid of a chest tube. Dullness to percussion and
decreased breathing sounds were noted in the left lower lobe

Fig. 2 CT view of a 5 × 5.5-cm lesion with heterogeneous density in the
left lower lobe (case 2).
during auscultation. A CT scan showed a 10 × 8-cm thin-walled
septated cystic lesion above the left hemidiaphragm. The results
of a bronchoscopic evaluation were normal. A left thoracotomy
was performed after a preliminary diagnosis of lung abscess.
During exploration a piece of gauze enclosed in a cyst was de-
tected between the lung and the diaphragm and this foreign
body was found to have given rise to the infection. The gauze
was removed and partial decortication was performed.
Discussion
!
Previous reports have described the incidence of foreign body
retention (sponges or instruments) during surgical procedures
as varying from 1 in 1000 cases to 1 in 18 000 cases [1]. The inci-
dence is considered to be closer to 1 in 1000 cases, because not
all cases are reported to avoid bad publicity and insurance
claims. Eighty percent of the retained foreign bodies are gossypi-
bomas, three-fourths of which are found after abdominal or pel-
vic surgery and two-thirds after an uncomplicated scheduled
surgical intervention [1]. A retained cotton matrix can rapidly
lead to local inflammation on the first day after the surgery, fol-
lowed by a granulomatous reaction after approximately 1 week,
and fibrosis after a fortnight. If infection develops around the
side of retained material, it may result in the formation of an ab-
scess, whose contents may subsequently drain through a cuta-
neous fistula. Nonspecific clinical manifestations such as fever
or pain develop long after the initial surgical procedure [2]. Sec-
ondary infection around the cotton matrix mimics a nonspecific
inflammatory reaction. Organ compression, migration of the
cotton matrix or fistula formation may occur during later stages.
In rare cases, gossypibomas may be asymptomatic. The pre-
ferred method for the differential diagnosis of suspected gossy-
pibomas is CT. CT findings for gossypibomas may vary depend-
ing on the type of reaction these foreign bodies elicit. A gossypi-
boma may appear as a heterogeneous, low-density cystic mass
with a thin high-density wall, following contrast enhancement
[3]. Wavy or striped high-density areas may be found within
the mass representing the retained sponge. However, this find-
ing may often be misinterpreted as an abscess or hematoma.
The differential diagnosis is facilitated by the presence of a ra-
dio-opaque marker and/or gas bubbles reflecting a spongiform
pattern; these are the most characteristic CT findings for gossy-
pibomas [3, 4]. Previous studies have shown that the spongiform
Case Reports 433
appearance can be attributed to the entrapment of air bubbles
between the gauze fibers [3, 4].
Most published reports describing CT findings of gossypibomas
concerned intra-abdominal gossypibomas, and only a few have
dealt with gossypibomas in the thoracic cavity [4, 5]. In the thor-
ax, the pleural space is the most likely location in which a sponge
may be retained; however this sponge may subsequently appear
as an intrapulmonary gossypiboma due to enfolding by the lung
tissue around the lesion [5, 6].
In our first case, the patient had undergone a thoracotomy 22
years earlier, at which time the sponge or towel had been re-
tained within the surgery site. Owing to the long delay in detec-
tion, the foreign body had destroyed the whole lung through the
formation of a very thick capsule that compressed and invaded
the hilar structures. A right pneumonectomy was warranted for
complete removal of the infected cyst capsule and the dysfunc-
tional lung.
In the second case, the sponge had been retained during hydatid
cyst resection performed 10 years earlier. During thoracotomy,
the lobe was noted to have been destroyed by the reaction eli-
cited by the foreign body. In this case also, the cyst wall was very
thick and warranted lobectomy.
The third patient had undergone vascular grafting via laparoto-
my. However, a left phrenetomy must have been performed dur-
ing this operation for some reason, because there was no other
explanation for the presence of a foreign body in the left pleural
space. In this case, partial decortication was sufficient, and lung
resection was not required.
Conclusion
!
In conclusion, symptoms of hemoptysis, blood-stained sputum,
chest or back pain, cough or dyspnea and a medical history of
thoracic surgery should alert the physician to the possibility of
an intrathoracic gossypiboma. In our case series, the lesions vi-
sualized by CT exhibited various morphologies, but they mostly
resembled intrapulmonary cysts. In case 1, the gossypiboma was
present for the longest duration (22 years) and this patient had
the worst outcome necessitating a pneumonectomy. In case 2,
the gossypiboma had been present for 10 years and this patient
required a lobectomy for treatment. The best prognosis was
noted in case 3, where the gossypiboma was detected 3 years
after it had been retained. Our series suggests that the damage
to neighboring lung tissue induced by gossypiboma increases
with time. Therefore, we recommend that gossypibomas be re-
moved immediately after detection even in the absence of overt
clinical symptoms.
References
1 Buy JN, Hubert C, Ghossain MA et al. Computed tomography of retained
abdominal sponges and towels. Gastrointest Radiol 1989; 14: 41 – 45
2 Kuwashima S, Yamato M, Fujioka M, Ishibashi M, Kogure H et al. MR
findings of surgically retained sponges and towels: report of two
cases. Radiat Med 1993; 11: 98 – 101
3 Choi BI, Kim SH, Yu ES, Chung HS, Han MC et al. Retained surgical
sponge: diagnosis with CT and sonography. AJR Am J Roentgenol
1988; 150: 1047 – 1050
4 Sheehan RE, Sheppard MN, Hansell DM. Retained intrathoracic surgical
swab: CT appearances. J Thorac Imaging 2000; 15: 61 – 64
5 Suwatanapongched T, Boonkasem S, Sathianpitayakul E, Leelachaikul P.
Intrathoracic gossypiboma: radiographic and CT findings. Br J Radiol
2005; 78: 851 – 853
6 Topal U, Gebitekin C, Tuncel E. Intrathoracic gossypiboma. AJR Am J
Roentgenol 2001; 177: 1485 – 1486
Okur HK et al. Three Cases of … Thorac Cardiov Surg 2009; 57: 432 – 440
434 Case Reports
received May 19, 2008
Bibliography
DOI 10.1055/s-2008-1038962
Thorac Cardiov Surg 2009; 57: 432 – 434
© Georg Thieme Verlag KG Stuttgart · New York ·
ISSN 0171‑6425
Correspondence
Dr. Erdal Okur
Sureyyapasa Chest Diseases and Thoracic Surgery Teaching Hospital
Maltepe
34758 Istanbul
Turkey
Phone: + 90 53 27 96 16 00
Fax: + 90 21 64 21 42 65
erdalokur@hotmail.com
Central Large Pulmonary
Arteriovenous Malformation
with Aneurysmal Dilatation
P.-K. Hsu, W.-H. Hsu, Y.-C. Wu
Division of Thoracic Surgery, Department of Surgery, Taipei Veterans
General Hospital, Taipei, Taiwan – Republic of China
Abstract
! artery and drainage to the left superior pulmonary vein
A centrally located large pulmonary arteriovenous malformation
(PAVM) with aneurysmal formation is uncommon and the opti-
mal treatment remains unclear. Here we report a 63-year-old fe-
male with a large PAVM located in the pulmonary hilum pre-
senting with dyspnea and a brain abscess. A muscle-sparing
thoracotomy with lobectomy of the left upper lobe was success-
fully performed under the guidance of three-dimensional recon-
struction imaging of the thoracic vasculature.
Key words
Thoracic surgery · computed tomography · vascular malfor-
mation
Introduction
! course was smooth and the dyspnea improved. So far, she con-
Pulmonary arteriovenous malformations (PAVM) are a direct
communication between the pulmonary arteries and veins.
Most PAVM are congenital, whereas acquired PAVM caused by
trauma, surgery, and malignancy form the minority of cases [1].
The pathogenesis of PAVM remains unclear. Proposed mecha-
nisms include a defect in the terminal arterial loops, a failure of
capillary development during the fetal stage, and progressive di-
lation of favored limbs of the smaller plexus [2, 3]. The clinical
significance is that PAVMs are the cause of not only right-to-left
shunt, leading to pulmonary symptoms, but also of paradoxical
embolism resulting in neurological complications [3].
A PAVM typically ranges from 1 to 5 cm in size, and most are
found in the lower lobes [3]. A centrally located large PAVM is
very uncommon. Here we report a case of a large PAVM located
in the pulmonary hilum with an initial presentation of brain ab-
scess.
Hsu P-K et al. Central Large Pulmonary … Thorac Cardiov Surg 2009; 57: 432 – 440
Case Description
!
A 63-year-old woman suffering from dyspnea on exertion for
years was admitted with the complaint of dizziness, repeat epi-
staxis and muscle weakness for 2 weeks. Her past history in-
cluded cervical spondylolithesis and pyelonephritis for more
than 5 years. Physical examination revealed disoriented con-
sciousness, bruits over the left parasternal area, telangiectasia
on the oral mucosa and tongue, clubbing fingers, and weakness
of four limbs. Laboratory work-up was normal except for polycy-
themia (hemoglobin of 17.0 g/dl and hematocrit of 50.8 %). Arte-
rial oxygen saturation was 79% with a PO2 value of 43 mmHg in
room air (21 % oxygen). A cerebrovascular accident was sus-
pected and magnetic resonance imaging of the brain was ar-
ranged. A large ring enhanced mass lesion at the bilateral supe-
rior parietal lobule with perifocal edema and internal marked re-
stricted diffusion, which was compatible with abscesses, was
found. The abscess was aspirated stereotactically and treated
with antibiotics. Clinically, the patientʼs consciousness recov-
ered and she regained her muscle power, but dyspnea persisted.
Thus she was referred to the thoracic department for further
evaluation.
Chest X‑ray and contrast-enhanced chest CT scan depicted one
enhanced mass lesion at the left pulmonary hilum (l " Fig. 1 a, b).
The three-dimensional reconstruction images showed a pulmo-
nary arteriovenous malformation with aneurysmal formation at
the left upper lobe, occupying the left pulmonary hilum, with a
supplying artery from the anterior branch of the left pulmonary
(l" Fig. 1 c). Based on the clinical presentation and imaging find-
ings, the diagnosis of hereditary hemorrhage telangiectasia
(HHT) with PAVM complicated with brain abscess caused by par-
adoxical embolism was made.
To relieve the dyspnea and prevent the neurological complica-
tions of PAVM, the patient underwent a left posterolateral
muscle-sparing thoracotomy. One 9 × 5 × 4-cm pulsating oval
cystic lesion was found at the left pulmonary hilum. The ectatic
anterior branch of the left pulmonary artery and the superior
pulmonary vein were divided. The apical, posterior, and lingular
branches of the pulmonary artery were also divided and a LUL
lobectomy was completed. Arterial blood gas data showed a dra-
matic improvement from baseline after resection (l " Table 1).
Pathologically, a cystic structure with an irregular contour and
anastomosing vascular channels was noted. The postoperative
tinues to do well at three months after operation.
Discussion
!
Churton et al. was the first to report on PAVM in 1897 [4] and
Bosher et al. analyzed the pathologic anatomy of PAVM in 1959
[5]. The etiology is unknown, but changes in endoglin have been
postulated as the genetic basis [6]. Previous works have indi-
cated that females are affected twice as often as males and the
majority of patients developed symptoms between the fourth
and sixth decades [3, 5]. Approximately 70% of PAVM are associ-
ated with HHT, which is characterized by arteriovenous malfor-
mations of the skin, mucous membranes and visceral organs [1,
3]. The clinical manifestations include recurrent epistaxis, mu-
cosal telangiectasia, and gastrointestinal bleeding [1, 3]. The
most common lung complaint with PAVM is dyspnea, which re-
sults from right-to-left shunt. On physical examination, typical
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