Emerg Radiol (2008) 15:183–185 DOI 10.1007/s10140-007-0665-2
CASE REPORT
Postoperative Surgicel mimicking abscesses following cholecystectomy and liver biopsy Alicia C. Arnold & Aaron Sodickson
Received: 29 June 2007 / Accepted: 8 August 2007 / Published online: 25 September 2007 # Am Soc Emergency Radiol 2007
Abstract In postoperative patients presenting with abdominal pain or fever, a computed tomography (CT) finding of gas in the operative site raises concern for abscess but can be mimicked by the normal postoperative appearance of oxidized regenerated cellulose (Surgicel). Information about the operative use of Surgicel and its location is important for accurate CT interpretation of postoperative studies. This case illustrates a scenario in which knowledge of the use of Surgicel offered an explanation for the CT findings, resulting in successful conservative management.
when unexplained gas is found in the surgical bed. The postoperative appearance of Surgicel can mimic an abscess, and it is important to consider as a potential cause of the imaging findings. The utilization of the electronic medical record or discussion with the patient’s surgeon can inform the radiologist that Surgicel was used during the operation. Appropriate inclusion of the postoperative appearance of Surgicel in the differential diagnosis is essential to ensure that the patient is managed appropriately.
Keywords Surgicel . Oxidized regenerated cellulose . Hemostatic agents . Abscess . Computed tomography
Case report
Introduction Surgicel (Ethicon, Somerville, NJ), oxidized regenerated cellulose, is one of several bioabsorbable surgical hemostatic agents, which are used in a variety of operations in instances where hemostasis is difficult to achieve. While it is often removed prior to surgical closure, it may be left in place in certain circumstances. In this setting, the radiologist may expect to encounter Surgicel on postoperative imaging studies. In postsurgical patients with abdominal pain or fever, abscess is high on the differential diagnosis, especially A. C. Arnold (*) : A. Sodickson Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA e-mail:
[email protected] A. Sodickson e-mail:
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A 55-year-old man with a history of end stage renal disease on hemodialysis presented to the emergency department with right upper quadrant pain and abdominal distension. Four days earlier, he underwent laparoscopic converted to open cholecystectomy and concomitant wedge liver biopsy for question of cirrhosis. He was discharged on the second postoperative day in stable condition. On the day of presentation to the emergency department, he underwent hemodialysis and subsequently complained of abdominal pain and emesis. Upon presentation, he was afebrile and had a normal white blood cell count of 5.3 K/μl but was hypotensive, with blood pressure 60/43. A computed tomography (CT) scan performed with oral and intravenous contrast demonstrated two foci of mixed soft tissue density and gas, one measuring 3.4×2.5 cm within the gallbladder fossa (Fig. 1) and the other measuring 1.8×1.7 cm along the left hepatic margin (Fig. 2). There was initial concern that these might represent postoperative abscesses. However, detailed review of the patient’s operative report revealed that Surgicel was placed both in the gallbladder fossa and at the left hepatic lobe biopsy site. As the Surgicel was thought to explain the CT findings,
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Fig. 1 Contrast enhanced CT image shows a low attenuation mass in the gallbladder fossa. Inset in a wider display window demonstrates peripheral punctuate and linear foci of gas
he was treated conservatively for presumed ileus or partial small bowel obstruction and did not manifest signs of progressive intra-abdominal infection through his hospital course. Proper identification of the postoperative appearance of Surgicel led to appropriate conservative management. A follow-up CT scan performed 4 days later demonstrated unchanged appearance of the Surgicel material.
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similar to findings expected in an abscess with gas forming organisms [8]. On magnetic resonance imaging, Surgicel has a short T2 relaxation time leading to a hypointense mass on T2-weighted images, a feature that may be helpful in differentiating it from abscess, which is more typically T2 hyperintense [2]. Contained signal voids may suggest the presence of gas. Misidentifying retained hemostatic material as an abscess may result in unnecessary aspiration attempts, drainage procedures, or even reoperation. While Surgicel is a sterile and bactericidal agent, in appropriate clinical situations aspiration or other evaluation may be necessary, as cases of superinfection have been described [8]. Retained Surgicel is gradually resorbed by the body, reportedly within 7–14 days [9]. However, its continued presence on imaging has been described up to postoperative day 35 by ultrasound [8]. A recent study of a different agent, Gelfoam, showed gas retained in the absorbable gelatin sponge up to 38 but not exceeding 56 days [10]. Absorbable hemostatic agents should thus be considered as possible sources of gas in the surgical bed for approximately one month postoperatively. Postoperative patients frequently present with complaints of abdominal pain and fever, raising concern for the presence of an abscess. It is important for radiologists to be aware of the existence and imaging characteristics of Surgicel and similar surgical hemostatic agents, particularly by CT. Correlation with the patient’s surgical history either by review of the operative note or discussion with the
Discussion Surgicel is a sterile bioabsorbable thrombogenic agent used adjunctively in surgical procedures to assist in the control of capillary, venous, and small arterial hemorrhage when ligation or other conventional methods of control are impractical or ineffective [1]. One of its uses is in hepatobiliary surgery where bleeding from small hepatic vessels may be challenging to control [2]. Surgicel is composed of a gauze-like material that is placed dry onto a bleeding site, and when saturated with blood, swells into a mass to promote hemostasis. It is frequently removed after hemostasis is achieved but may occasionally be left in place. In these cases, foci of gas trapped within the gauze as it became saturated with blood may be seen on postoperative imaging. Prior reports have described the imaging features of hemostatic agents in the postoperative patient, particularly when their appearance may mimic abscess [3, 4, 5, 6]. On CT, retained Surgicel most commonly appears as a low attenuation, nonenhancing mass containing linear and central gas collections [7]. By ultrasound, Surgicel appears as an echogenic mass with posterior reverberation artifact,
Fig. 2 Contrast enhanced CT image demonstrates a rounded low attenuation mass in the anterior aspect of segment III of the liver, corresponding to the wedge biopsy site. Inset in a wider display window demonstrates contained punctate foci of gas
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patient’s surgeon can prevent misinterpretation and aid in successful patient management. References 1. Surgicel (2005) Surgicel fibrillar and Surgicel Nu-Knit absorbable hemostats (oxidized regenerated cellulose) package insert. Somerville, NJ: Johnson and Johnson 2. Oto A, Remer EM, O’Malley CM, Tkach JA, Gill IS (1999) MR characteristics of oxidized cellulose (Surgicel). Am J Roentgenol 172 (6):1481–1484 3. Elkof O, Lebowitz RL (1981) Localized intra- and retroperitoneal gas collections following intraoperative use of surgical gelatine sponge. Pediatr Radiol 11(1):1–4 4. Turley BR, Taupmann PL, Johnson PL (1994) Postoperative abscess mimicked by surgicel. Abdominal Imaging 19:345–346
185 5. Ibrahim MF, Aps C, Young CP (2002) A foreign body reaction to Surgicel mimicking an abscess following cardiac surgery. Eur J Cardiothorac Surg 22(3):489–490 6. Stringer MD, Dasgupta D, McClean P, Davidson S, Ramsden W (2003) “Surgicel abscess” after pediatric liver transplantation: a potential trap. Liver Transpl 9(2):197–198 7. Young ST, Paulson EK, McCann RL, Baker ME (1993) Appearance of oxidized cellulose (Surgicel) on postoperative CT scans: similarity to postoperative abscess. Am J Roentgenol 160 (2):275–277 8. Melamed JW, Paulson EK, Kliewer MA (1995) Sonographic appearance of oxidized cellulose (Surgicel): pitfall in the diagnosis of postoperative abscess. J Ultrasound Med 14(1): 27–30 9. Ethicon, Inc. (2005) Wound closure manual. Somerville, NJ 10. Sandrasegaran K, Lall C, Rajesh A, Maglinte DT (2005) Distinguishing gelatin bioabsorbable sponge and postoperative abdominal abscess on CT. Am J Roentgenol 184(2):475–480