Surgicel® packing remnants mimicking mediastinitis after adult cardiac surgery

Surgicel® packing remnants mimicking mediastinitis after adult cardiac surgery Abstract Surgicel® is one of the most commonly used bioabsorbable topical haemostatic agents. Some articles have reported that Surgicel® remnants might be misdiagnosed as an abscess. However, the number of reports in the cardiothoracic surgical field is limited. Herein, we report a 65-year-old woman who was suspected of having mediastinitis on computed tomography after redo-Bentall operation. Reoperation revealed that internal accumulation of Surgicel® remnants mimicked mediastinitis. It is important to share the use and location of Surgicel® with radiologists. If mediastinitis cannot be ruled out, the next step of reoperation or magnetic resonance imaging should be promptly taken. Mediastinitis, Postsurgical complications, Aortic surgery INTRODUCTION Oxidized regenerated cellulose (Surgicel®, Johnson and Johnson Medical, Arlington, TX, USA) is an absorbable local haemostatic gauze used to control bleeding during surgery. Some published articles have reported that Surgicel® remnants can mimic an abscess [1]. In the cardiothoracic surgical field, there have been only two case reports involving the misdiagnosis of Surgicel® remnants [2]. Herein, we report a patient who underwent redo-Bentall operation with Surgicel® packing around the aortic graft and was erroneously diagnosed with mediastinitis on computed tomography (CT). CASE REPORT A 65-year-old woman underwent total aortic arch replacement for acute aortic dissection 16 years ago and Bentall operation for aortic root dilatation 11 years ago. Follow-up CT revealed aortic root pseudoaneurysms. During that period, her renal function decreased, and maintenance dialysis was required since 4 years. Redo-Bentall operation for the aortic pseudoaneurysms was planned. Because of dense adhesion around the aortic root graft, right atriotomy was performed to approach the aortic annulus. Some sutures in non-coronary cusps for the redo-Bentall procedure were placed from inside the right atrium. Persistent bleeding around the new aortic root graft was controlled with Surgicel® packing. The postoperative course was uneventful, with dialysis until the 9th postoperative day, at which point the white blood cell count and C-reactive protein level were elevated to 9500/μl and 18.8 mg/dl, respectively, without any symptoms, including fever. On the 13th postoperative day, although she was still asymptomatic and afebrile, the white blood cell count and C-reactive protein level increased to 22 900/μl and 29.4 mg/dl, respectively. Enhanced CT revealed a hypodense mediastinal mass encircling the aortic root graft with scattered air bubbles (Fig. 1). Considering the elevation of inflammatory markers and the CT findings, the possibility of mediastinitis could not be excluded. We decided to perform an emergency reoperation on the same day. Haematoma and retained Surgicel® were recovered. The location was consistent with the location of the suspected abscess on preoperative CT. Figure 1: View largeDownload slide Computed tomography of the chest on the 13th postoperative day. Hypodense mediastinal collection and air bubbles without any hydroaeric level or central/peripheral contrast enhancement are seen around the ascending aortic graft. Figure 1: View largeDownload slide Computed tomography of the chest on the 13th postoperative day. Hypodense mediastinal collection and air bubbles without any hydroaeric level or central/peripheral contrast enhancement are seen around the ascending aortic graft. Intravenous antibiotics were administered until culture of the intraoperative specimens revealed no organisms. Postoperative CT confirmed disappearance of the occupied space around the aortic graft. She had an uneventful recovery, and she remains well 3 years after the surgery. COMMENT Surgicel®, a local haemostatic gauze, consists of oxidized regenerated cellulose. Several published articles have reported that Surgicel® remnants can mimic an abscess [1]. It is challenging to differentiate between Surgicel® remnants and an abscess only with radiography or sonography. With regard to CT, Frati et al. [3] reported that an irregular air-bubble-trapped image, without any hydroaeric level or central and peripheral contrast enhancement, is the usual presentation of Surgicel® remnants. However, it is unclear whether these typical findings could be adapted to cardiothoracic surgery with median sternotomy, as free gas bubbles and localized mediastinal fluid collection in the mediastinum are common CT findings and thus are not valuable, particularly during the early postsurgical period [4]. In contrast, magnetic resonance imaging might be helpful as it can demonstrate hypointensity for Surgicel® remnants and hyperintensity for an abscess in T2-weighted images [5]. It is crucial to share information on the use and location of Surgicel® with radiologists on a request for postoperative CT. Prospective blind reading studies by Frati et al. [3] found that radiologists with information on the use of Surgicel® could more accurately identify the Surgicel® location and prevent misdiagnosis as an abscess or haematoma than radiologists without such information. Apart from image findings, diagnosis of mediastinitis using laboratory tests is also challenging because inflammatory markers could be elevated during normal healing process or as a reaction to Surgicel®. In addition, reoperation by itself can increase the risk of mediastinitis. Therefore, the difficulty of diagnosing mediastinitis and the risk of re-exploration should be considered; however, if the possibility of a mediastinitis is not ruled out, timely intervention should be performed. CONCLUSION In conclusion, radiologists should be informed about the presence and location of Surgicel® to ensure appropriate evaluation of CT findings and avoid unnecessary treatment. Although postoperative mediastinitis could be catastrophic, it is difficult to establish an accurate diagnosis just based on CT or laboratory findings. Therefore, the decision to perform a reoperation or magnetic resonance imaging should be taken without delay, considering the risk of intervention. Conflict of interest: none declared. REFERENCES 1 Young ST , Paulson EK , McCann RL , Baker ME. Appearance of oxidized cellulose (Surgicel) on postoperative CT scans: similarity to postoperative abscess . AJR Am J Roentgenol 1993 ; 160 : 275 – 7 . Google Scholar CrossRef Search ADS PubMed 2 Alves Junior L , Vicente WV , Ferreira CA , Manso PH , Arantes LR , Pinheiro KS. Surgicel packing and an erroneous diagnosis of mediastinitis in a neonate . Tex Heart Inst J 2010 ; 37 : 116 – 8 . Google Scholar PubMed 3 Frati A , Thomassin-Naggara I , Bazot M , Daraï E , Rouzier R , Chéreau E. Accuracy of diagnosis on CT scan of Surgicel® Fibrillar: results of a prospective blind reading study . Eur J Obstet Gynecol Reprod Biol 2013 ; 169 : 397 – 401 . Google Scholar CrossRef Search ADS PubMed 4 Yamashiro T , Kamiya H , Murayama S , Unten S , Nakayama T , Gibo M et al. . Infectious mediastinitis after cardiovascular surgery: role of computed tomography . Radiat Med 2008 ; 26 : 343 – 7 . Google Scholar CrossRef Search ADS PubMed 5 Oto A , Remer EM , O'Malley CM , Tkach JA , Gill IS. MR characteristics of oxidized cellulose (Surgicel) . AJR Am J Roentgenol 1999 ; 172 : 1481 – 4 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

Surgicel® packing remnants mimicking mediastinitis after adult cardiac surgery

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Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1569-9293
eISSN
1569-9285
D.O.I.
10.1093/icvts/ivy006
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Abstract

Abstract Surgicel® is one of the most commonly used bioabsorbable topical haemostatic agents. Some articles have reported that Surgicel® remnants might be misdiagnosed as an abscess. However, the number of reports in the cardiothoracic surgical field is limited. Herein, we report a 65-year-old woman who was suspected of having mediastinitis on computed tomography after redo-Bentall operation. Reoperation revealed that internal accumulation of Surgicel® remnants mimicked mediastinitis. It is important to share the use and location of Surgicel® with radiologists. If mediastinitis cannot be ruled out, the next step of reoperation or magnetic resonance imaging should be promptly taken. Mediastinitis, Postsurgical complications, Aortic surgery INTRODUCTION Oxidized regenerated cellulose (Surgicel®, Johnson and Johnson Medical, Arlington, TX, USA) is an absorbable local haemostatic gauze used to control bleeding during surgery. Some published articles have reported that Surgicel® remnants can mimic an abscess [1]. In the cardiothoracic surgical field, there have been only two case reports involving the misdiagnosis of Surgicel® remnants [2]. Herein, we report a patient who underwent redo-Bentall operation with Surgicel® packing around the aortic graft and was erroneously diagnosed with mediastinitis on computed tomography (CT). CASE REPORT A 65-year-old woman underwent total aortic arch replacement for acute aortic dissection 16 years ago and Bentall operation for aortic root dilatation 11 years ago. Follow-up CT revealed aortic root pseudoaneurysms. During that period, her renal function decreased, and maintenance dialysis was required since 4 years. Redo-Bentall operation for the aortic pseudoaneurysms was planned. Because of dense adhesion around the aortic root graft, right atriotomy was performed to approach the aortic annulus. Some sutures in non-coronary cusps for the redo-Bentall procedure were placed from inside the right atrium. Persistent bleeding around the new aortic root graft was controlled with Surgicel® packing. The postoperative course was uneventful, with dialysis until the 9th postoperative day, at which point the white blood cell count and C-reactive protein level were elevated to 9500/μl and 18.8 mg/dl, respectively, without any symptoms, including fever. On the 13th postoperative day, although she was still asymptomatic and afebrile, the white blood cell count and C-reactive protein level increased to 22 900/μl and 29.4 mg/dl, respectively. Enhanced CT revealed a hypodense mediastinal mass encircling the aortic root graft with scattered air bubbles (Fig. 1). Considering the elevation of inflammatory markers and the CT findings, the possibility of mediastinitis could not be excluded. We decided to perform an emergency reoperation on the same day. Haematoma and retained Surgicel® were recovered. The location was consistent with the location of the suspected abscess on preoperative CT. Figure 1: View largeDownload slide Computed tomography of the chest on the 13th postoperative day. Hypodense mediastinal collection and air bubbles without any hydroaeric level or central/peripheral contrast enhancement are seen around the ascending aortic graft. Figure 1: View largeDownload slide Computed tomography of the chest on the 13th postoperative day. Hypodense mediastinal collection and air bubbles without any hydroaeric level or central/peripheral contrast enhancement are seen around the ascending aortic graft. Intravenous antibiotics were administered until culture of the intraoperative specimens revealed no organisms. Postoperative CT confirmed disappearance of the occupied space around the aortic graft. She had an uneventful recovery, and she remains well 3 years after the surgery. COMMENT Surgicel®, a local haemostatic gauze, consists of oxidized regenerated cellulose. Several published articles have reported that Surgicel® remnants can mimic an abscess [1]. It is challenging to differentiate between Surgicel® remnants and an abscess only with radiography or sonography. With regard to CT, Frati et al. [3] reported that an irregular air-bubble-trapped image, without any hydroaeric level or central and peripheral contrast enhancement, is the usual presentation of Surgicel® remnants. However, it is unclear whether these typical findings could be adapted to cardiothoracic surgery with median sternotomy, as free gas bubbles and localized mediastinal fluid collection in the mediastinum are common CT findings and thus are not valuable, particularly during the early postsurgical period [4]. In contrast, magnetic resonance imaging might be helpful as it can demonstrate hypointensity for Surgicel® remnants and hyperintensity for an abscess in T2-weighted images [5]. It is crucial to share information on the use and location of Surgicel® with radiologists on a request for postoperative CT. Prospective blind reading studies by Frati et al. [3] found that radiologists with information on the use of Surgicel® could more accurately identify the Surgicel® location and prevent misdiagnosis as an abscess or haematoma than radiologists without such information. Apart from image findings, diagnosis of mediastinitis using laboratory tests is also challenging because inflammatory markers could be elevated during normal healing process or as a reaction to Surgicel®. In addition, reoperation by itself can increase the risk of mediastinitis. Therefore, the difficulty of diagnosing mediastinitis and the risk of re-exploration should be considered; however, if the possibility of a mediastinitis is not ruled out, timely intervention should be performed. CONCLUSION In conclusion, radiologists should be informed about the presence and location of Surgicel® to ensure appropriate evaluation of CT findings and avoid unnecessary treatment. Although postoperative mediastinitis could be catastrophic, it is difficult to establish an accurate diagnosis just based on CT or laboratory findings. Therefore, the decision to perform a reoperation or magnetic resonance imaging should be taken without delay, considering the risk of intervention. Conflict of interest: none declared. REFERENCES 1 Young ST , Paulson EK , McCann RL , Baker ME. Appearance of oxidized cellulose (Surgicel) on postoperative CT scans: similarity to postoperative abscess . AJR Am J Roentgenol 1993 ; 160 : 275 – 7 . Google Scholar CrossRef Search ADS PubMed 2 Alves Junior L , Vicente WV , Ferreira CA , Manso PH , Arantes LR , Pinheiro KS. Surgicel packing and an erroneous diagnosis of mediastinitis in a neonate . Tex Heart Inst J 2010 ; 37 : 116 – 8 . Google Scholar PubMed 3 Frati A , Thomassin-Naggara I , Bazot M , Daraï E , Rouzier R , Chéreau E. Accuracy of diagnosis on CT scan of Surgicel® Fibrillar: results of a prospective blind reading study . Eur J Obstet Gynecol Reprod Biol 2013 ; 169 : 397 – 401 . Google Scholar CrossRef Search ADS PubMed 4 Yamashiro T , Kamiya H , Murayama S , Unten S , Nakayama T , Gibo M et al. . Infectious mediastinitis after cardiovascular surgery: role of computed tomography . Radiat Med 2008 ; 26 : 343 – 7 . Google Scholar CrossRef Search ADS PubMed 5 Oto A , Remer EM , O'Malley CM , Tkach JA , Gill IS. MR characteristics of oxidized cellulose (Surgicel) . AJR Am J Roentgenol 1999 ; 172 : 1481 – 4 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

Journal

Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Jan 19, 2018

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