1. Gossypiboma (Textiloma)
2. Pilocytic astrocytoma WHO grade 1 (residual)
Given the histology findings, the operative notes from his first resection were reviewed and there was no report of missing patties or cotton balls. All swabs and patties were accounted for. Hemostasis at the initial surgery had been achieved with the use of FloSeal (Baxter Inc.), a bovine derived hemostatic matrix. The development of this gossypiboma is curious in the absence of gross macroscopic cotton fibres. Possible causes for the foreign body reaction include the hemostatic matrix used at the time of the first surgery or microscopic strands of cotton that may have been retained at the time hemostasis was being achieved.
Surgical hemostatic agents are divided into non-reabsorbable and reabsorbable, with the former group consisting of cotton, muslin and swabs that are removed prior to wound closure (4). Reabsorbable materials are left in intentionally and can cause a foreign body reaction as in the example of Surgicel (Ethicon Inc.), an oxidized cellulose material, commonly used in neurosurgical procedures. Other reabsorbable hemostatic agents in use are: gelatin compounds (Gelfoam- Pfizer), collagen compounds (Avitene- Bard Davol Inc.) and hemostatic matrix (FloSeal- Baxter Inc. or Surgiflo- Ethicon 360). Hemostatic matrix agents are thrombin-gelatin sealants used regularly in both cranial and spinal procedures (1). The gelatin and thrombin components are mixed together at the time of use and are activated, facilitating clotting, when in contact with blood. The median time for degradation for this product is 30 days in comparison to oxidized cellulose and collagen products that have median degradation of 60 days and 90 days respectively. Complications and adverse effects due to hemostatic matrix are rare. However, in general surgical literature, there have been reports of an inflammatory reaction to this agent causing adhesions that result in small bowel obstruction (2). In the neurosurgical literature, there have been reports of giant cell granulomas with gelatin based hemostatic products.
In rat neurosurgical models, matrix hemostatic sealant along with oxidized cellulose and collagen compounds were shown to have a propensity for inciting a granulomatous inflammatory reaction. Gelatin compounds are not polarizable on light microscopy and the same is true for hemostatic matrix. There are descriptions in the literature of granulomatous reactions to fine cotton fibres causing large intracranial lesions that mimic tumors or abscess. These fibres are derived from cotton pledgets, balls or cotton patties. Using wet cottonoids and copious irrigation reduces the risk of leaving microscopic fibres.
Radiological imaging of gossypiboma can mimic recurrent tumour or abscess in the acute setting. They appear as space occupying lesions and, in some cases, radio-opaque marker found on swabs is not always apparent (3). In our case, one of the differentials was a traumatic aneurysm as a result of traction from retractors at the first resection. Both angiography and histology ruled this out.
Gossypiboma in neurosurgery is a rare occurrence. Its lack of specific imaging properties means it is easily mistaken for other more commonly occurring intracranial lesions.
Contributed by Tafadzwa Mandiwanza MRCS, Chandrasekaran Kaliaperumal FRCS, Linda Mulligan FRCPath, Elizabeth Ryan FFR RCSI, Seamus Looby FFR RCSI, John Caird FRCS, Francesca Brett MD., FRCPath., MSc (FM),