R a d i o l o g y Ca s e R e p o r t s 1 7 ( 2 0 2 2 ) 3 7 0 9 – 3 7 1 2 Available online at www.sciencedirect.com journal homepage: www.elsevier.com/locate/radcr Case Report Unintentionally retained pelvic drainage tube found on Imaging; A case report✩, ✩ ✩ Klenam Dzefi-Tettey, Bsc., MBCHB, FWACS, a ,∗ FGCP , Emmanuel Kobina Mesi Edzie, MBCHB, MBA, FGCPb, Edmund Kwadwo Kwakye Brakohiapa, MBCHB, FWACS, FGCPc , Juliana Labi, MBCHBa , Eunice Sena Aku Nyamuame, Bsc., MBCHBa, Nana Yaa Fredua Agyeman, MBCHBa , Jerry Coleman, MBCHB, FWACS , FGCSd a Department of Radiology, Korle Bu Teaching Hospital, 1 Guggisberg Avenue, Accra, Ghana b Department of Medical Imaging. School of Medical Sciences, College of Health and Allied Sciences, University of Cape Coast, Cape Coast, Ghana c Department of Radiology, University of Ghana Medical School, Accra, Ghana d Department of Obstetrics and Gynaecology, University of Ghana Medical School, Accra, Ghana a r t i c l e i n f o a b s t r a c t Article history: A retained drainage tube after surgery is rare and patients may be asymptomatic if it occurs. Received 5 July 2022 The presence of a retained drainage tube may be first recognized on imaging and this re- Accepted 9 July 2022 quires a high index of suspicion by radiologists. In this case report, we described an inciden- Available online 2 August 2022 tal finding of an asymptomatic retained fractured drainage tube in the pelvis of a 32-year-old female on ultrasonography for renal evaluation. This highlighted the need for radiologists to Keywords: have a high index of suspicion when performing ultrasonography on postoperative patients Retained drainage tube and surgeons should be meticulous when removing drainage tubes postsurgery. The possi- Laparotomy bility of a foreign body should be considered when unfamiliar findings are encountered on Ultrasonography imaging. Surgeons should inspect drainage tubes after removal to ensure the full length of Computed tomography scan the tube is removed. Pelvis © 2022 The Authors. Published by Elsevier Inc. on behalf of University of Washington. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ) Introduction Retained intraperitoneal drains are an uncommon finding but when they occur, are associated with increased risk of morbidity and mortality for the patient as well as legal✩ Competing Interests: None to declare. ✩✩ Funding: No external funding secured for this manuscript. ∗ Corresponding author. E-mail address: k.dzefittey@kbth.gov.gh (K. Dzefi-Tettey). https://doi.org/10.1016/j.radcr.2022.07.049 1930-0433/© 2022 The Authors. Published by Elsevier Inc. on behalf of U CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4implications for the healthcare professionals involved [1] . In- struments and drains left in the abdomen following surgery may present with complications including adhesion forma- tion, intestinal obstruction, abscesses, and erosion into the gastrointestinal tract. Patients may also be asymptomatic with no clinical findings [2] . niversity of Washington. This is an open access article under the .0/ ) 3710 R a d i o l o g y Ca s e R e p o r t s 1 7 ( 2 0 2 2 ) 3 7 0 9 – 3 7 1 2 Fig. 1 – Pelvic Ultrasound images acquired using (A) curvilinear and (B) Linear probes showing the tubular structure (red arrows) with the associated heterogeneous subcutaneous collection. Case presentation A 32-year-old female was referred for an abdominal ultra- sonography to evaluate her kidneys after a history of acute kidney injury. Ultrasonography of the abdomen and pelvis was performed using C5-2D curvilinear array probe (2-5 MHz) of Edan Acclarix LX4 ultrasound machine. The abdominal ul- trasound findings were bilateral echogenic but normal sized kidneys suggestive of renal parenchymal disease. The rest of the intra-abdominal organs were unremarkable. A pelvic ul- trasonography was done although not requested and this re- vealed a tubular structure with parallel echogenic walls within the pelvis and an enlarged uterus with a calcified fibroid. An L12-5D linear probe of Edan Acclarix LX4 with frequencies of 5-12 MHz was used to properly delineate the findings. This showed the distal end of a tubular structure surrounded by an ill-defined heterogeneous minimal collection within the sub- cutaneous tissues anterior to the urinary bladder, Figure 1 . A Suggestion of a retained foreign body postsurgery likely a frac- tured drainage tube was made. A complimentary unenhanced abdominal and pelvic Com- puted Tomography (CT) scan was done with Canon 32 slice CT scan machine with multiplanar reconstruction and the fol- lowing images were acquired in 3D, axial, coronal and sagit- tal planes. This confirmed the initial ultrasound findings of a curvilinear tubular hyperdense structure extending from the right iliac fossa coursing anterior to the uterus to the lower an- terior abdominal wall. Also seen was associated surrounding granulation tissue formation with micro abscesses in the an- terior abdominal wall with fat stranding and a calcified uter- ine fibroid, Figure 2 . Further history revealed that the patient, at a gestational age of 23 weeks had abruptio placentae, intrauterine foetal death, pre-eclampsia and disseminated intravascular coagu- lation. Emergency hysterotomy was performed after failure of induced labor at that time. Intraoperative findings were male fresh still birth, a couvelaire uterus, retro-placental clots and hemorrhagic ascites. A pelvic drain was inserted duringthe surgery to monitor postoperative bleeding which was re- moved by the attending doctor seven days after surgery, af- ter it had drained less than approximately 45 ml in 24 hours. Thirty-five days into the patient’s admission, and after seven sessions of dialysis, an abdominal ultrasound was requested to evaluate the state of the kidneys after a diagnosis of acute kidney injury. Following the diagnosis of the fractured retained drainage tube, the patient went on to have an exploratory laparotomy. Remnant of the drainage tube measuring approximately 8cm was seen embedded in the peritoneum surrounded by pus, Figure 3 . Patient had a normal recovery after surgery with contin- uing improvement of her renal function and was discharged postoperative day 8 after the exploratory laparotomy. Discussion The incidence of retained intra-abdominal foreign bodies is unknown but it is estimated to occur in 1 of every 1000-1500 intra-abdominal operations [2] . The aim of this case report is to highlight the importance of a radiologist being thorough in the examination of the postoperative patient and not only focus on the history provided by the clinician. This was the case in our patient where an abdominal ultrasound was re- quested but evaluation of the pelvis found a retained fractured drainage tube. Fractured drains are rare but probably under- estimated because they may go unnoticed due to it being re- tracted intraperitoneally possibly from being over stretched if excessive force is used during removal, curled, or sutured loosely with an unsecured knot [2] . In a postoperative pa- tient, radiologists should remember that unintentionally re- tained surgical instruments are often clinically unsuspected and may be first recognized on imaging [3] . Thus when strange findings cannot be corroborated, the likelihood of a retained foreign body should be considered. Radiologists need to ac- R a d i o l o g y Ca s e R e p o r t s 1 7 ( 2 0 2 2 ) 3 7 0 9 – 3 7 1 2 3711 Fig. 2 – Unenhanced Abdominal & Pelvic CT scan, MPR images (A) 3D, (B) sagittal, (C) coronal and (D) axial views showing the retained fractured drainage tube (red arrows). Fig. 3 – Retained drainage tube with fractured edge after laparotomy. quaint themselves with imaging findings of surgical mate- rials in order to have a high index of suspicion of uninten- tionally retained foreign bodies in the context of a postop- erative patient [4] . Proper communication of the findings in a clinically relevant time to the surgeon through phone calls and appropriate documentation in the radiology report is im- portant to ensure the appropriate action is taken as soon as possible [5] as done for our patient. In the case of our pa- tient, a laparotomy was performed to remove the fractureddrainage tube. For the surgeon, when a decision is made to remove a drainage tube, it should be measured and the tip should be inspected to ensure it is smooth and intact after removal [6] . It is also recommended that the drainage tube should be intentionally cut before insertion during surgery in order to have a consistent number of holes each time. The holes should be counted at the time of removal to ensure there are no re- tained fragments [7] . Retained foreign bodies lead to unin- 3712 R a d i o l o g y Ca s e R e p o r t s 1 7 ( 2 0 2 2 ) 3 7 0 9 – 3 7 1 2 tended surgeries which is an unpleasant experience for both the patient and the surgeon. In this case report, we highlighted the possibility of sur- gically placed foreign bodies being retained and the need for high index of suspicion among radiologists if any patient is brought in postoperatively for imaging irrespective of the du- ration of the surgery. Conclusion Though a rare event, retained surgical drains can occur and may be asymptomatic or symptomatic. By thoroughly exam- ining both the abdomen and pelvis of postoperative patients brought for ultrasonography whilst maintaining a high index of suspicion, accidentally left foreign bodies can be detected. Inspection of drainage tubes after removal would draw the at- tention of the surgeon to the possibility of a retained fractured drainage tube leading to prompt action being taken to reduce morbidity. Patient Consent Informed consent was obtained from the patient. The patient was also ensured of complete anonymity and confidentiality. R E F E R E N C E S [1] Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348(3):229–35. doi: 10.1056/nejmsa021721 . [2] Klein J, Farman J, Burrell M, Demeter E, Frosina C. The forgotten surgical foreign body. Gastrointest Radiol 1988;13(2):173–6. doi: 10.1007/BF01889051 . [3] Ahn JH , Kang CH , Choi SJ , Park MS , Jung SM , Ryu DS , et al. CT findings of foreign body reaction to a retained endoloop ligature plastic tube mimicking acute appendicitis: a case report. Korean J Radiol 2016;17(4):541–4 doi: 10.3348%2Fkjr.2016.17.4.541 . 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