Incidental Mediastinal Gossypiboma : Interpretative Medico-Legal Difficulties In A Case Of Malpractice Happened 14 Years Before Death

Introduction : the presence of a gauze retained in the thoracic cavity is a rare complication of a previous surgery and occurs more frequently in paediatric field, representing conversely an unusual occurrence among the adults. This report regards the accidental finding of a gauze in mediastinum, “forgotten” 14 years before the death of a woman, carrier of valvulopathy, whose death would have occurred for reasons not imputable to the intrathoracic foreign body. The case: A fifty-three-year-old woman, Jehovah’s Witness, underwent surgery of aortal and mitral replacement and plastic operations on a tricuspid valve. 14 years later, for the appaearance of new symptoms, she had a further successful operation. The postoperative course was marked mostly by rehabilitative therapies, until the onset of respiratory failure, bilateral pleural effusions and fever, complicated by heart failure, which culminated in the death, due to hematemesis. At first, a not medico-legal autopsy was performed, straight afterwards suspended for the finding of a 5 cm tumefaction in the mediastinum, consisting of surgical gauze. The Judicial Authority was informed and ordered the medio-legal post-mortem examination, three day later. Results: The judicisl autopsy, in addition to the signs of previous necropsy, showed findings on heart (globose and hypertrophic), lungs (hepatised) and stomach (ulcers), thereby identifying the cause of death in the Multi Organ failure (MOF) complicated by gastro-enterorrhagia for cardial ulcer. The madiastinal mass, consisting of partially digested and flaked surgical gauze free from active inflammation, was radiographically compared whit a sample of gauze in use at the last division of heart Surgery where the patient was hospitalised, appearing completely different in kind. Histopatological examination of the viscera showed an acute generalized infectious involvement of multiple organs, which was quite consistent with the proposed cause of death, whereas that of garzoma, with no signs of acute and subacute inflammation, confirmed the initial macroscopic evaluation, indicative of a dated retention in the thorax of the foreign body. Discussions: The case of malpractice, here reported, highlights the diagnostic and interpretative difficulties, regarding the incidental finding of a foreign body in the mediastinum, if the radiographic investigations, performed for chronic non-specific symptoms, should not be conclusive. In particular, it is difficult to identify the role played by the intrathoracicforeign body, as primum movens in the genesis of sepsis responsible for the death, lacking post-mortem signs of active inflammation. Thereby, the histopathological investigation confirmed their essential importance in proper comprehension of a case.