Description of Event or Problem · 1
A PHYSICIAN REPORT WAS REC'D FROM A LITERATURE ARTICLE INVOLVING A 28-YR-OLD PT WHO REQUIRED THE USE OF GELFOAM STERILE SPONGES DURING AN ORTHOTOPIC LIVER TRANSPLANT. THE PT REQUIRED THE LIVER TRANSPLANT AS A RESULT OF END-STAGE LIVER DISEASE SECONDARY TO HEPATITIS C. DURING THE SURGERY, LACERATIONS DEVELOPED WHICH RESULTED IN SIGNIFICANT HEMORRHAGE FOLLOWING REVASCULARIZATION. THE BLEEDING WAS REDUCED TO A SLOW OOZE AFTER PROLONGED PACKING AND REPLACEMENT WITH BLOOD PRODUCTS. THREE LARGE GELFOAM WAFERS WERE PLACED BETWEEN THE DOME OF THE LIVER AND THE DIAPHRAGM. AN ADD'L WAFER WAS PLACED BETWEEN THE UNDERSURFACE OF THE RIGHT HEPATIC LOBE AND THE RIGHT KIDNEY. THE ABDOMEN WAS CLOSED, LEAVING THE WAFERS IN SITU. BECAUSE OF THE DEGREE OF TRANSPORT INJURY, THE PT WAS SLOW TO RECOVER FROM THE TRANSPLANT AND DID HAVE SOME MODERATE REJECTION ON POSTOPERATIVE DAY 16. ON POSTOPERATIVE DAY 19, THE PT COMPLAINED OF EPIGASTRIC PAIN. ABDOMINAL ROENTGENOGRAMS SHOWED EXTRAINTESTINAL AIR UNDER THE RIGHT HEMIDIAPHRAGM AND A COLLECTION OF LOCULATED GAS IN THE RIGHT SUBHEPATIC SPACE. BASED ON THIS EVIDENCE OF POSTOPERATIVE FREE AIR COUPLED WITH EPIGASTRIC PAIN, A DECISION WAS MADE TO DO EXPLORATORY SURGERY TO SEE IF THERE WAS ANY INFECTION, ABSCESS, OR PERFORATION. EXPLORATION IN THE OR FAILED TO IDENTIFY INTRA-ABDOMINAL PATHOLOGY. HOWEVER, THE GELFOAM WAFERS WERE CLEARLY IDENTIFIABLE AND WERE RETRIEVED FROM BOTH LOCATIONS. IT WAS SUSPECTED THAT THESE WAFERS CONTAINED FREE AIR. ALL INTRAOPERATIVE CULTURES FAILED TO DEMONSTRATE ORGANISMS. THE PT'S POSTOPERATIVE COURSE WAS UNCOMPLICATED, AND SHE WAS DISCHARGED ONE WEEK LATER. IT WAS CONCLUDED BY THE PHYSICIANS THAT KNOWLEDGE OF THE ASSOCIATION BETWEEN AN ABSORBABLE GELATIN SPONGE (GELFOAM) AND POSTOPERATIVE GAS COLLECTIONS MAY PREVENT MISDIAGNOSIS OF AN ABSCESS OR PERFORATION AND HELP AVOID AN UNNECESSARY OPERATION.