e-ISSN 1941-5923 © Am J Case Rep, 2018; 19: 812-819 DOI: 10.12659/AJCR.910060 Received: Accepted: Published: Practical Suggestions for Prevention of Complications Arising from Oxidized Cellulose Retention: A Case Report and Review of the Literature 2018.03.19 2018.04.26 2018.07.11 Authors’ Contribution: Study Design A Data Collection B Statistical Analysis C Data Interpretation D Manuscript Preparation E Literature Search F Funds Collection G ABCDEF 1 AE 1 BCD 2 BCD 3 CD 2 BCE 2 ABCD 2,4 Guglielmo Niccolò Piozzi Elisa Reitano Valerio Panizzo Barbara Rubino Davide Bona Domenico Tringali Giancarlo Micheletto Corresponding Author: Conflict of interest: Guglielmo Niccolò Piozzi, e-mail: guglielmopiozzi@gmail.com None declared Patient: Final Diagnosis: Symptoms: Medication: Clinical Procedure: Specialty: Male, 51 Oxidised cellulose retain Abdominal pain • nausea • vomiting — Laparoscopic abdominal exploration and drainage Surgery Objective: Background: Case Report: Conclusions: MeSH Keywords: Full-text PDF: Challenging differential diagnosis Bleeding is a major intraoperative complication during surgical procedures. When conventional methods such as ligature and diathermocoagulation are inefective for bleeding management, hemostatic agents should be used. Oxidized cellulose is one of the major hemostatic agents used worldwide. Oxidized cellulose is often left in situ after hemostasis because of its high level of reabsorption that lasts up to 8 weeks. However, 38 cases of retaining-associated complications are reported in the literature. A 51-year-old male patient presented in our emergency department with acute abdominal pain, nausea, and vomiting. The patient had been admitted in our department for laparoscopic cholecystectomy for acute cholecystitis 25 months previously. Abdominal ultrasound and CT scan showed the presence of a cystic circular mass, with homogeneous luid content, close to the surgical clips of the previous surgery, resembling a “neogallbladder”. Laparoscopic abdominal exploration and drainage were performed. Histological examination reported protein-based amorphous material with rare lymphocytes and macrophages. Culturing was negative for bacterial growth. The patient was discharged uneventfully on the 4th postoperative day. The primary surgical report was evaluated with evidence of application of Gelita-Cel® Standard for hemostatic purposes. Results of 12-month follow-up were normal. Herein, we report the irst case of a complication associated with the use of Gelita-Cel® Standard. We reviewed the literature to better deine the purpose and limits of oxidized cellulose use as a hemostatic agent. Despite the fundamental role of oxidized cellulose as a hemostatic agent, we provide some practical suggestions to prevent the reported severe complications and surgical overtreatments. Cellulose, Oxidized • Cholecystectomy, Laparoscopic • Diagnosis, Differential • Hemostasis, Surgical • Postoperative Complications https://www.amjcaserep.com/abstract/index/idArt/910060 2261 812 1 Department of General Surgery, University of Milan, Milano, Italy 2 Department of General Surgery, Istituto Clinico Sant’Ambrogio, Milano, Italy 3 Department of Pathology, IRCCS Policlinico San Donato Hospital, San Donato Milanese, Italy 4 Department of Medical and Surgical Pathophysiology and Transplantation, Policlinico Hospital, Milano, Italy 3 This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) 2 57 Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] Piozzi G.N. et al.: Oxidized cellulose-retaining complications: Prevention tips © Am J Case Rep, 2018; 19: 812-819 Background Successful hemostasis has always been fundamental in all surgical procedures. Ligature and diathermocoagulation are the main hemostatic methods; however, since 1909, with the use of ibrin [1], numerous hemostatic agents (HA) have become available. In 1945, oxidized cellulose (OC) was introduced in surgery and it has become one of the major HAs because of its ease of use, favorable biocompatibility, and bactericidal properties [2–4]. Several OCs are available and classiied in regenerated oxidized cellulose (ROC; e.g. Surgicel® – Johnson and Johnson, Somerville, NJ, USA) and non-regenerated oxidized cellulose (nROC; e.g., Oxycell® – Becton Dickinson, Franklin Lakes, NJ, USA). Although the manufacturers recommend the OC removal after its use, it is generally left in situ because of its high level of reabsorption that lasts up to 8 weeks. However, several cases of retained OC with severe complications have been reported in the literature. Here, we describe a complication that was associated with the use of Gelita-Cel® Standard (ROC; Gelita Medical, Eberbach, Germany) and we review the literature to better deine the purpose and limits of OC as a hemostatic agent. Case Report A 51-year-old male patient presented in our emergency department with acute abdominal pain, nausea, and vomiting. Laboratory test results were normal with no evidence of inlammation markers (white blood cells: 8.03×103/µl; neutrophils: 68.2%; C reactive protein: 3 mg/l). He had been admitted to our department for laparoscopic cholecystectomy for acute cholecystitis 25 months previously. The patient complained of moderate abdominal pain since his irst operation; therefore, he had abdominal CT scan at 6 months, showing evidence of A Figure 1. Cystic lesion with homogeneous luid content close to surgical clips resembling a “neo-gallbladder” (white arrow). a circular mass (39×34 mm) with luid content (density 35– 45 HU). In addition, an abdominal US at 24 months showed a non-vascularized mass in the liver bed that was suspected to be a granuloma. The patient was admitted for an abdominal CT scan and the results conirmed a circular cystic mass with homogeneous luid content, close to the surgical clips of the previous surgery, resembling a “neo-gallbladder” (Figure 1). Although the patient had no signs of inlammation or infection, a hepatic abscess was suspected based on imaging results and previous surgical history. To better deine the patient’s unclear clinical condition, we chose to perform a surgical drainage instead of a percutaneous (US- or CT-guided). Therefore, the patient underwent laparoscopic abdominal exploration, incision of the hepatic bed mass, and drainage of amorphous, brown, dense material (Figure 2). A drain was left in the liver bed and B Figure 2. (A) Intraoperative image of “neo-gallbladder”; (B) drainage of amorphous material. This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] 813 Piozzi G.N. et al.: Oxidized cellulose-retaining complications: Prevention tips © Am J Case Rep, 2018; 19: 812-819 Table 1. Imaging features of OC retention. Technique patterns being less efective than thicker tight-knit patterns against antibiotic-resistant microorganisms [9]. Main characteristics US – – – – – Complex mass Well-encapsulated hypoisoechoic lesion Circumscribed margins Internal hyperechoic nodules (“ile-lottante”) Perilesional vascularization (Doppler) CT scan – – – – – Mixed-/low-attenuation mass Focal central collection of gas Absence of air-luid levels Peripherical faint enhancement Proximity to the surgical site MRI – Nonspeciic – Hypointense stripes inside cystic-like cavity on T2 PET/CT – Image with high glucose uptake – False-positive was removed on the 2st postoperative day. Histological examination reported protein-based amorphous material with rare lymphocytes and macrophages. Culturing was negative for bacterial growth. After antibiotic prophylaxis with extended spectrum B-lactam, the patient was discharged without symptoms on the 4th postoperative day. The primary surgical report was evaluated for evidence of use of Gelita-Cel® Standard for hemostatic purposes. The 12-month follow-up was uneventful. Oxidized regenerated cellulose (ROC) is a re-absorbable material that can be intentionally left in the surgical ield. In vivo studies on rats were performed to analyze the tissue reaction to locally implanted hemostatic agents [10]. ROC absorption starts after 24–48 h; at day 7 the gauze is surrounded by inlammatory granulation tissue, and complete degradation occurs between 4–8 weeks [6,10,11]. However, absorption is not always complete, with consequent gauze retention as irst described by Vanderhoof et al. [12]. Therefore, it is common for ROC to appear as a mass during the immediate postoperative period, mimicking a postoperative abscess [13], tumor [14], or hematoma [15], posing a serious challenge in diferential diagnosis [16]. On CT scan, a retained OC may appear as a mixed- or low-attenuation mass containing a focal central collection of gas, located inside or near the operative site, with a faint enhancement at the mass periphery and absence of air-luid levels [13,17,18] (Table 1). Over time, the central collection of air is completely replaced by soft tissue, leading to the formation of a foreign-body granuloma [13]. MRI indings are nonspeciic, but the presence of hypointense stripes inside a cystic-like cavity on T2-weighted images is considered to be a characteristic sign of ROC-associated granuloma [19]. Discussion Bleeding can be a major intraoperative complication during surgical procedures. When conventional methods such as ligature and diathermocoagulation are inefective for bleeding management, hemostatic agents (HA) can be used. In 1909, ibrin was described as an efective HA [1] and since then numerous hemostatic devices have been used such as topical thrombin, porcine collagen, and OC [5]. OC was irst used for medical purposes in 1945 [2,3], and since then it has been widely used in surgery, with several forms available. OC is easy to use and has good biocompatibility and bactericidal properties [4]. OC is made of cellulose, which is a homopolysaccharide of glucopyranose polymerized through b-glucosidic bonds [6,7]. Cellulose can be either regenerated to form organized ibers or non-regenerated with unorganized ibers prior to oxidation. When cellulose ibres are oxidized, conversion of hydroxyl groups to carboxylic acid groups occurs, yielding polyuronic acid [6,7]. The low pH of the carboxylic acid groups is responsible for several actions: primary local hemostyptic action, secondary platelet activation to form a temporary platelet plug [6,7], and hostile acidic environmental conditions for bacterial survival [8]. Moreover, the knit structure and thickness of the gauge is responsible for bactericidal properties, with thinner loose-knit 814 This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) PET/CT images may produce false-positive results in case of foreign body granuloma as a consequence of localized inlammation, mimicking malignant tissue glucose uptake [20–22]. Retained OC is frequently found in ultrasound imaging (US) as a complex mass or well-encapsulated hypo-isoechoic lesion with circumscribed margins and internal hyperechoic nodules at the surgical site [23]. The presence of hyper-isoechoic nodules within a complex cystic mass can be explained as typical granulomatous foreign body reaction induced by the presence of ROC and was described by Giuliani et al. as “ilelottante” [23,24]. Moreover, the use of color/power Doppler should be considered as part of the ultrasound procedure. A perilesional vascularization is probably indicative of compression exerted by OC on neighboring tissues or connected to the presence of granulation tissue around the surgical site [25,26]. Nevertheless, imaging can be useful and clinical evaluation is fundamental in conirming diagnostic suspicion. We reviewed the literature and retrieved a total of 28 papers comprising 38 cases of OC retention. The details of cases are shown in Table 2. Surgical sites included: brain (6), cervical spine (1), thoracic spine (1), thorax (10), abdomen (12), and Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] Piozzi G.N. et al.: Oxidized cellulose-retaining complications: Prevention tips © Am J Case Rep, 2018; 19: 812-819 Table 2. Reported cases of OC retaining complications in the literature. Author Year Age Sex Device Surgical Site Primary diagnosis Primary surgery Time (days) Symptoms Suspect Removal Dutton et al. [32] 1983 35 M Surgicel Brain Head injury Frontotemporal skull and lacerated left frontal lobe repair 2,5 h Vision Hematoma impairment Yes Perez-Guerra et al. [31] 1984 59 F Surgicel Thorax Squamous cell carcinoma Left pneumonectomy 2h Paraplegia Cord compression Yes Ito et al. [39] 1989 n.a. n.a. OC Brain Intracranial meningioma Intracranial meningioma removal 390 Incidental Large granuloma Yes Ito et al. [39] 1989 n.a. n.a. OC Brain Intracranial meningioma Intracranial meningioma removal 630 Incidental Large granuloma Yes Ito et al. [39] 1989 n.a. n.a. OC Brain Anterior Vascular treatment communicating artery aneurysm n.a. Incidental Large granuloma Yes Short [28] 1990 72 F OC Thorax Bronchogenic carcinoma few days Paraplegia Cord compression Yes Short [28] 1990 49 M OC Thorax Lung Right upper lobectomy adenocarcinoma 2 Paraplegia Cord compression Yes Short [28] 1990 59 M OC Thorax Bronchogenic carcinoma Right lower lobectomy 3,5 h Paraplegia Cord compression Yes Bradley et al. [40] 1991 58 M Oxycel Abdomen Cholecystitis Cholecystectomy 120 Incidental Abscess/ Hematoma No Deger et al. [41] 1995 71 F Surgicel Abdomen Ovary serous Ovariectomy adenocarcinoma 150 Abdominal discomfort Tumor recurrence Yes Sandhu et al. [42] 1996 n.a. n.a. Surgicel Brain Intracranial meningioma Intracranial meningioma removal 60 Incidental Tumor recurrence Yes Sandhu et al. [42] 1996 n.a. n.a. Surgicel Brain Intracranial meningioma Intracranial meningioma removal 360 Incidental Tumor recurrence Yes Iwabuchi et al. [43] 1997 46 F Surgicel Thorax n.a. Right lower lobectomy 1 Paraplegia n.a. Yes Concha et al. [37] 1997 41 F Surgicel Abdomen Kidney failure Kidney transplant 570 Fever, Granuloma/ abdominal neoplasia pain, renal function impairment Yes, allograft extirpation Banerjee et al. [44] 1998 28 M Surgicel Spinal Disk degeneration, spinal stenosis Spinal decompression 2 Cauda equina syndrome Cord compression Yes Lovstad et al. [29] 1999 56 F Surgicel Thorax Lung tumor Left lower lobectomy 2,5 h Paraplegia Cord compression Yes Azmy [35] 2001 2 M Surgicel Abdomen Neuroblastoma Right adenectomy 4 Incidental Tumor recurrence Yes Ibrahim et al. [45] 2002 53 F Surgicel Thorax Aortic root aneurysm Aortic root replacement 42 Incidental Abscess Yes Gao et al. [46] 2002 37 F Surgicel Pelvic HemopeHysterectomy, right ritoneum, salpingo-oophorectomy ruptured corpus luteum 30 Abdominal Granuloma pain, vaginal discharge Brodbelt et al. [27] 2002 37 F Surgicel Thorax Metastatic sarcoma 1 Paraplegia This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Right upper/middle lobectomy Lung lobectomy Yes Extradural mass No Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] 815 Piozzi G.N. et al.: Oxidized cellulose-retaining complications: Prevention tips © Am J Case Rep, 2018; 19: 812-819 Table 2 continued. Reported cases of OC retaining complications in the literature. Author Year Age Sex Device Surgical Site Primary diagnosis Primary surgery Time (days) Symptoms Suspect Removal Brodbelt et al. [27] 2002 50 M Surgicel Thorax Thoracic trauma Thoracic surgery 3 Weakness/ numbness right leg Brodbelt et al. [27] 2002 15 (m) M Surgicel Thorax n.a. Cardiac surgery 2 Flaccid Extradural mass Yes paraparesis, extradural mass Farina Perez et al. [47] 2004 63 F Surgicel Abdomen Renal cell carcinoma Laparoscopic partial necrectomy 8 Incidental Somani et al. [34] 2005 62 F Surgicel Abdomen Myeloibrosis Splenectomy 540 Renal tumor Kidney tumor suspect Yes, necrectomy Arnold et al. [38] 2007 55 M Surgicel Abdomen n.a. Cholecystectomy 4 Abdominal pain Postoperative abscess No Salmo et al. [48] 2009 n.a. M Oxycel Abdomen Rectal cancer Colon resection 90 Incidental Tumor recurrence Yes Agarwal et al. [49] 2010 47 M Surgicel Abdomen Renal cyst Laparoscopic nephronsparing surgery 90 Incidental Kidney mass No Royds et al. [36] 2012 56 F Surgicel Cervical Total thyroidectomy 30 Wound swelling Suture abscess Yes Teik et al. [50] 2012 50 F Surgicel Abdomen Cystic papillary renal cell carcinoma Laparoscopic nephronsparing surgery 180 Incidental Heterogeneous Yes mass Wang et al. [51] 2013 83 M Surgicel Abdomen GIST Recurrent GIST 120 GIST recurrence Heterogeneous Yes mass Behbehani et al. [52] 2013 47 F Surgicel Pelvic Uterine leiomyoma Laparoscopic total hysterectomy, bilateral salpingo-oophorectomy 21 Pelvic pain, Postoperative fever abscess No Behbehani et al. [52] 2013 46 F Surgicel Pelvic Uterine leiomyoma and adenomyosis Laparoscopic total hysterectomy 10 Abdominal pain, fever Postoperative abscess Yes Tam et al. [53] 2014 50 F Surgicel Pelvic Endometriosis Laparoscopic hysterectomy 6 Pelvic pain Gas collection No Tam et al. [53] 2014 45 F Surgicel Pelvic Endometriosis Robotic-assisted 10 laparoscopic hysterectomy, left salpingo-oophorectomy, right salpingectomy, appendectomy Abdominal Abscess pain, vaginal discharge No Tam et al. [53] 2014 43 F Surgicel Pelvic Endometriosis Laparoscopic hysterectomy, 4 left oophorectomy, bilateral salpingectomy Malaise Abscess No Zhang et al. [54] 2015 21 F Surgicel Pelvic Symptomatic ovarian cyst Ovarian cystectomy Pelvic pain Heterogeneous No mass Cormio et al. [55] 2016 67 F Surgicel Pelvic Cystocele, anterior genital prolapse Pubovaginal sling, cystocele 180 repair Irritative voiding symptoms Ovarian cancer Yes Singh et al. [56] 2016 71 M Surgilo Abdomen Clear cell carcinoma Left robotic partial nephrectomy Nodular lesion Recurrence/ residual tumor No 816 Multinodular goiter This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) 7 30 Extradural mass Yes Gas collection Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] No Piozzi G.N. et al.: Oxidized cellulose-retaining complications: Prevention tips © Am J Case Rep, 2018; 19: 812-819 pelvis (8). Twenty-nine patients received Surgicel ®, 2 received Oxycel®, 1 received Surgilo® (Johnson and Johnson, Somerville, NJ, USA), and 6 received non-speciied OC (Table 2). Here, we report the irst case of complications due to Gelita-Cel® retention. In circumstances requiring extensive dissection in the costovertebral angle, precise technique is imperative. Uncontrolled or poorly controlled bleeding in an intervertebral foramen should be an indication for consultation of a neurological surgeon. The preoperative diagnosis and surgical procedure are described in Table 2. The times from primary surgery to detection of retained OC ranged between 2 hours and 630 days. Twelve cases were incidental and the others were symptomatic. Various symptoms were described, ranging from malaise and fever to paraplegia, cauda equina syndrome, and vision impairment. Diagnostic suspicion was tumor recurrence (6), abscess (7), cord compression (6), granuloma (4), extradural mass (3), heterogeneous mass (3), gas collection (2), kidney tumor (2), ovarian cancer (1), hematoma (1), abscess/hematoma (1), granuloma/neoplasm (1), and non-speciied lesion (1). Gauze removal was performed in 27 cases. In 2 patients, removal of the gauze required a major procedure: 1 patient underwent nephrectomy and another had allograft extirpation that resulted in need for dialysis. Dutton et al. [32] reported a case of compressive optic neuropathy after OC migration from the anterior cranial fossa into the orbital apex through an orbital roof fracture. Banerjee et al. [33] reported a case of cauda equina syndrome treated with OC removal and consequent severe impairment of quality of life. To avoid major complications, particular attention must be paid to hemostatic control in rigid inextensible anatomical structures such as the skull and spinal cord. Despite the fundamental importance of OC as an essential hemostatic agent in surgery, some precautions are needed to avoid future complications. Although 38 cases, in addition to our reported case, are very few compared to all surgical procedures performed with OC use with no associated complication, complications may also be severe and associated with risky surgical procedures. Our review of the literature found that 8 patients experienced paraplegia, which occurred between 2 hours and 2 days after thoracic surgery [27–29]; cord compression was suspected and urgent laminectomy was performed, revealing a mass of Surgicel® in the extradural space. A surgical report showed the use of OC to control diicult bleeding from the posterior angle of the thoracotomy incision. The posterior end of the rib adjacent to the gaping thoracostomy is usually a bleeding site that is hard to manage. During thoracostomy closure, the rib approximation may produce a compressive force on the OC, forcing it to migrate into the adjacent foramen. The established negative pressure of the intravertebral subdural space can enhance this pressure gradient and cause OC herniation with consequent symptomatology [26]. Product information warns against leaving OC in situ next to foramina after hemostasis due to swelling, which can result in nerve damage due to pressure in a bony conined area [30]. However, there is no report regarding the potential of material migration. Five out of 6 patients presented with total motor and sensory deicit, with extension according to the cord compression site [27–29]: one had spastic monoplegia involving the right leg [28], one patient has to use a cane to walk [27], and one has walking impairment requiring leg braces and obligatory catheterization [27]. This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) In 9 cases, tumor mass or neoplasm recurrence was suspected, with consequent resective treatment. Somani et al. [34] reported a case of clinically/radiologically suspected renal cell carcinoma in a patient who previously underwent splenectomy for myeloibrosis, evidenced as an heterogenous kidney mass formation on abdominal CT scan with paraortic lymphadenopathy. Nephrectomy was performed, but histology did not show a neoplasm and instead found a foreign-material granuloma. This is an important case of retained OC mimicking a neoplasm. Azmy et al. [35] reported a case of OC removal in a patient suspected to have a recurrence of neuroblastoma. Royds et al. [36] documented the irst case of local tissue reaction associated with Surgicel® in head and neck surgery, with removal and resolution conirming its cause. Concha et al. [37] reported a case of xanthogranulomatous pyelonephritis caused by OC retention in a renal allograft, with consequent extirpation of the allograft and return to dialysis in a 41-year-old patient. Arnold et al. [38] documented an abscess mimicking a mass following cholecystectomy and liver biopsy. Among all 38 cases described, plus our reported case, 11 patients were treated conservatively due to suspicion of an OCretaining lesion after surgical history evaluation and multidisciplinary analysis by surgeons and radiologists. Although retained OC has been described by many authors [27–29,31,32,34–56], we believe it is important to focus on the cases in which there were severe complications in order to form some conclusions and recommendations The manufacturers recommend OC removal after hemostasis is obtained. If the surgeon decides to leave an OC gauze in situ, it should be used sparingly, as many problems have been attributed to excessive use [45]. If OC is left in situ, the surgical report and the discharge document should state it in order to correctly inform the patient in detail about this condition. In surgical procedures in rigid inextensible anatomical structures as the skull, spinal cord, and pleural cavity (in proximity Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] 817 Piozzi G.N. et al.: Oxidized cellulose-retaining complications: Prevention tips © Am J Case Rep, 2018; 19: 812-819 Table 3. Practical suggestions for safe use of OC. Practical suggestion – Remove OC after hemostasis – If left in situ, use it sparingly – Report the use of OC in the surgical report – Inform the patient about OC retention – Use extreme care in rigid non-extensive anatomical structures (eventual neurosurgical aid) – Accurate surgical history evaluation to the spine), OC should be used with extreme care and, if possible, neurosurgical support should be used for better and safer hemostasis [32] (Table 3). Moreover, when a mass is observed, accurate imaging evaluation and surgical history are required to assess a possible retained granulomatous lesion and to provide the best medical/surgical treatment. Further studies are needed to determine if layer versus coiled disposal of oxidized cellulose may have a role in complications and to assess whether ibrillar oxidized cellulose is safer than the gauze form. Our surgical case report is fully compliant with the SCARE criteria [57]. Conclusions Bleeding is a major intraoperative complication during surgical procedures. OC is an efective aid in hemostasis when ligature and diathermocoagulation are inefective. Despite biocompatibility and reabsorption, cases of retained OC complications have been described in the literature. OC should be removed when hemostasis is obtained. If necessary, only a small quantity of OC should be placed in situ and it should be documented in the surgical report and the discharge document in order to correctly inform the patient. Accurate surgical history evaluation should always be performed, and multidisciplinary case evaluation between surgeons and radiologists should be done to achieve a more accurate diagnosis and prevent unnecessary revision surgery or further medical and/or surgical interventions. In case of surgical procedures with hemostatic control in rigid inextensible anatomical structures such as the skull and spinal cord, OC should be used with extreme care in order to avoid major complications and, if possible, neurosurgical support should be used for better and safer hemostasis. We also presented the irst case of a complication following Gelita-Cel® retention in a case of “neo-gallbladder”. Our aim here is not to criticize the use of OC as hemostatic agent – it has well-documented efectiveness in surgery – but rather to provide some practical suggestions on how to avoid the severe complications reported in the literature. Conflicts of interest None. References: 1. Hong YM, Loughlin KR: The use of hemostatic agents and sealants in urology. J Urol, 2006;176: 2367–74 2. Frantz VK, Lattes R: Oxidized cellulose-absorbable gauze (cellulosic acid). JAMA, 1945; 129: 798–801 11. Mayank M, Agarwal MM, Mandal AK et al: Surgicel granuloma: Unusual cause of recurrent mass lesion after laparoscopic nephron-sparing surgery for renal cell carcinoma. Urology, 2010; 76: 334–35 3. Frantz VK: Absorbable cotton, paper and gauze: (Oxidized cellulose). Ann Surg, 1943; 118: 116–26 12. Vanderhoof ES, Merendino KA: Unfavorable reactions to oxidized cellulose in the bed of the gallbladder; the retained Oxycel sponge syndrome. Arch Surg, 1949; 58: 182–88 4. Lewis KM, Spazierer D, Urban MD et al: Comparison of regenerated and non-regenerated oxidized cellulose hemostatic agents. Eur Surg, 2013; 45: 213–20 13. Young ST, Paulson EK, McCann RL, Baker ME: Appearance of oxidized cellulose (Surgicel) on postoperative CT scans: Similarity to postoperative abscess. Am J Roentgenol, 1993; 160: 275–77 5. Spotnitz WD, Burks SG: Hemostats, sealants, and adhesives II: Update as well as how and when to use the components of the surgical toolbox. Clin Appl Thromb Hemost, 2010;16: 497–514 14. Sandhu GS, Elexpuru-Camiruaga JA, Buckley S: Oxidized cellulose (Surgicel) granulomata mimicking tumour recurrence. Br J Neurosurg, 1996; 10: 617–19 6. Pierce AM, Wiebkin OW, Wilson DF: Surgicel: Its fate following implantation. J Oral Pathol, 1984; 13(6): 661–70 7. Miller JM, Jackson DA, Collier CS: An investigation of the chemical reactions of oxidized regenerated cellulose. Exp Med Surgery, 1961; 19: 196–201 15. van Gelderen F, Swinnen J: Appearance of oxidized cellulose (Surgicel) on abdominal radiographs. Am J Roentgenol, 1996; 167: 1593 16. Kim SR, Baik HK, Park YW: Retained surgical sponge presenting as a pelvic tumor after 25 years. Int J Gynaecol Obstet, 2003; 82: 223–25 8. Dineen P: The efect of oxidized regenerated cellulose on experimental infected splenotomies. J Surg Res, 1977; 23: 114–16 17. O’Connor AR, Coakley FV, Meng MV, Eberhardt SC: Imaging of retained surgical sponges in the abdomen and pelvis. Am J Roentgenol, 2003; 180: 481–89 9. Spangler D, Rothenburger S, Nguyen K et al: In vitro antimicrobial activity of oxidized regenerated cellulose against antibiotic-resistant microorganisms. Surg Infect, 2003;4: 255–62 18. Mausner EV, Yitta S, Slywotzky CM, Bennett GL: Commonly encountered foreign bodies and devices in the female pelvis: MDCT appearances. Am J Roentgenol, 2011; 196: W461–70 10. Alpaslan C, Alpaslan GH, Oygur T: Tissue reaction to three subcutaneously implanted local hemosatic agents. Br J Oral Maxillofac Surg, 1997; 35: 129–32 19. Oto A, Remer EM, O’Malley CM et al: MR characteristics of oxidized cellulose (Surgicel). Am J Roentgenol, 1999; 172: 1481–84 818 This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) 20. Yuh-Feng T, Chin-Chu W, Cheng-Tau S, Min-Tsung T: FDG PET CT features of an intraabdominal gossypiboma. Clin Nucl Med, 2005; 30: 561–63 Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] Piozzi G.N. et al.: Oxidized cellulose-retaining complications: Prevention tips © Am J Case Rep, 2018; 19: 812-819 21. Ghersin E, Keidar Z, Brook OR et al: A new pitfall on abdominal PET/CT: A retained surgical sponge. J Comput Assist Tomogr, 2004; 28: 839–41 40. Bradley M, Singh G: Case report: An oxidized cellulose granuloma – another hepatic pseudotumour? Clin Radiol, 1991; 44(3): 206–7 22. Vertechy L, di Francesco L, Musella A et al: Nonabsorbable suture granuloma mimicking ovarian cancer recurrence at combined positron emission tomography/computed tomography evaluation: A case report. J Med Case, 2014; 8: 202 41. Deger RB, LiVolsi VA, Noumof JS: Foreign body reaction (gossypiboma) masking as recurrent ovarian cancer. Gynecol Oncol, 1995; 56(1): 94–96 23. Giuliani M, Fubelli R, Patrolecco F et al. Mammographic and ultrasonographic indings of oxidized regenerated cellulose in breast cancer surgery: A 5-year experience. Clin Breast Cancer, 2015; 15(5): e249–56 24. Kwag H: Imaging indings of implanted absorbable mesh in patients with breast partial resection. Yonsei Med J, 2008; 49: 111–18 25. Bäz E, Madjar H, Reuss C et al: The role of enhanced Doppler ultrasound in diferentiation of benign vs. malignant scar lesion after breast surgery for malignancy. Ultrasound Obstet Gynecol, 2000; 15: 377–82 26. Stuhrmann M, Aronius R, Schietzel M: Tumor vascularity of breast lesions: Potentials and limits of contrast-enhanced Doppler sonography. Am J Roentgenol, 2000; 175: 1585–89 42. Sandhu GS, Elexpuru-Camiruaga JA, Buckley S: Oxidized cellulose (Surgicel) granulomata mimicking tumour recurrence. Br J Neurosurg, 1996; 10(6): 617–19 43. Iwabuchi S, Koike K, Okabe T et al: Iatrogenic paraplegia caused by surgicel used for hemostasis during a thoracotomy: Report of a case. Surg Today, 1997; 27(10): 969–70 44. Banerjee T, Goldschmidt K: ‘Surgiceloma’ manifested as cauda equina syndrome. South Med J, 1998; 91(5): 481–83 45. Ibrahim MF, Aps C, Young CP: A foreign body reaction to Surgicel mimicking an abscess following cardiac surgery. Eur J Cardiothorac Surg, 2002; 22(3): 489–90 46. Gao HW, Lin CK, Yu CP et al: Oxidized cellulose (Surgicel) granuloma mimicking a primary ovarian tumor. Int J Gynecol Pathol, 2002; 21(4): 422–23 27. Brodbelt AR, Miles JB, Foy PM, Broome JC: Intraspinal oxidized cellulose (Surgicel) causing delayed paraplegia after thoracotomy – a report of three cases. Ann R Coll Surg Engl, 2002; 84(2): 97–99 47. Fariña Pérez LA, Delgado C, Dos Santos J: Oxidized cellulose (Surgicel) mimics an abscess after laparoscopic partial nephrectomy. Actas Urol Esp, 2004; 28(1): 54–56 28. Short HD: Paraplegia associated with the use of oxidized cellulose in posterolateral thoracotomy incisions. Ann Thorac Surg, 1990; 50(2): 288–89 48. Salmo E, Bisset R, Aldean I: Oxidized cellulose mimicking a recurrent colorectal cancer: Report of a case and review of the literature. Colorectal Dis, 2010; 12(4): 381–82 29. Løvstad RZ, Steen PA, Forsman M: Paraplegia after thoracotomy – not caused by the epidural catheter. Acta Anaesthesiol Scand, 1993; 43(2): 230–32 30. Ordell, NJ: Physician’s desk reference. Medical Economics Company, Inc., 1989; 1058 31. Perez-Guerra F, Holland JM: Epidural hematoma as a cause of postpneumonectomy paraplegia. Ann Thorac Surg, 1985; 39(3): 282 32. Dutton JJ, Tse DT, Anderson RL: Compressive optic neuropathy following use of intracranial oxidized cellulose hemostat. Ophthalmic Surg, 1983; 6: 487–89 33. Banerjee T, Goldschmidt K: ‘Surgiceloma’ manifested as cauda equina syndrome. South Med J, 1998; 91(5): 481–83 34. Somani BK, Kasthuri RS, Shave RM, Emtage LA: Surgicel granuloma mimicking a renal tumour. Surgery, 2006; 139(3): 451 35. Azmy AF: Oxidized cellulose haemostat mimicking a possible recurrence of neuroblastoma. BJU Int, 2001; 88(3): 295–96 36. Royds J, Kieran S, Timon C: Oxidized cellulose (Surgicel) based reaction post thyroidectomy mimicking an abscess: A case report. Int J Surg Case Rep, 2012; 3(7): 338–39 37. Concha A, Esteban RJ, Talavera P et al: Xanthogranulomatous pyelonephritis caused by Surgical in a renal allograft. Nephrol Dial Transplant, 1997; 12(7): 1509–11 38. Arnold AC, Sodickson A: Postoperative Surgicel mimicking abscesses following cholecystectomy and liver biopsy. Emerg Radiol, 2008; 15(3): 183–85 39. Ito H, Onishi H, Shoin K, Nagatani H: Granuloma caused by oxidized cellulose following craniotomy. Acta Neurochir, 1989; 100(1–2): 70–73 This work is licensed under Creative Common AttributionNonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) 49. Agarwal MM, Mandal AK, Agarwal S et al: Surgicel granuloma: unusual cause of “recurrent” mass lesion after laparoscopic nephron-sparing surgery for renal cell carcinoma. Urology, 2010; 76(2): 334–35 50. Teik T, Sanli O, Oktar T et al: Oxidized regenerated cellulose granuloma mimicking recurrent mass lesion after laparoscopic nephron sparing surgery. Int J Surg Case Rep, 2012; 3(6): 227–30 51. Wang H, Chen P: Surgicel® (oxidized regenerated cellulose) granuloma mimicking local recurrent gastrointestinal stromal tumor: A case report. Oncol Lett, 2013; 5(5): 1497–500 52. Behbehani S, Tulandi T: Oxidized regenerated cellulose imitating pelvic abscess. Obstet Gynecol, 2013; 121(2 Pt 2 Suppl. 1): 447–49 53. Tam T, Harkins G, Dykes T et al: Oxidized regenerated cellulose resembling vaginal cuf abscess. JSLS, 2014; 18(2): 353–56 54. Zhang F, Bonidie MJ, Ventrelli SM, Furlan A: Intraovarian oxidized cellulose (Surgicel) mimicking acute ovarian pathology after recent pelvic surgery. Radiol Case Rep, 2015; 10(4): 39–41 55. Cormio L, Cormio G, Di Fino G et al: Surgicel® granuloma mimicking ovarian cancer: A case report. Oncol Lett, 2016; 12(2): 1083–84 56. Singh A, Jai S, Ganpule S, Ganpule A: Bolster material granuloma masquerading as recurrent renal cell carcinoma following partial nephrectomy. Indian J Radiol Imaging, 2016;26(3): 352–55 57. Agha RA, Fowler AJ, Saetta A et al., SCARE Group: The SCARE statement: Consensus-based surgical case report guidelines. Int J Surg, 2016; 34: 180–86 Indexed in: [PMC] [PubMed] [Emerging Sources Citation Index (ESCI)] [Web of Science by Clarivate] 819