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Right Mainstem Obstruction Because of Erosion of a Retained Surgical Pledget

Chen, Alexander MD; Driscoll, James A. MD; Mayse, Martin L. MD

doi: 10.1097/LBR.0b013e31817afcec
Case Reports
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Airway foreign bodies may be discovered after aspiration, or less commonly, after erosion into the airway. Surgical pledgets may erode into neighboring anatomic structures, often many years after the original surgery. In this case, we describe a patient who developed chronic symptoms of dyspnea and cough and then developed an acute pneumonia because of obstruction of her right mainstem bronchus from a pledget placed 7 years earlier to control a bleeding mediastinal arteriovenous malformation. She was treated successfully with antibiotics followed by bronchoscopic removal of the pledget.

Department of Internal Medicine, Division of Pulmonary and Critical Care, Washington University School of Medicine, St Louis, MO

Reprints: Alexander Chen, MD, Division of Pulmonary and Critical Care Medicine, 660 South Euclid Avenue, Campus Box 8052, St Louis, MO 63110 (e-mail: achen@im.wustl.edu).

Received for publication March 31, 2008; accepted April 8, 2008

There is no conflict of interest.

Erosion of foreign bodies into the airway occurs rarely, and may result in airway obstruction, hemoptysis, or respiratory tract infection. Surgical pledgets are occasionally required to buttress sutures in cardiothoracic surgical cases. We report a case of a surgical pledget eroding into the right mainstem bronchus 7 years after a surgery to control a bleeding mediastinal arteriovenous malformation (AVM).

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CASE HISTORY

In April 2007, a 65-year-old white woman presented for evaluation of a mass in the right mainstem bronchus recently discovered by computed tomography (CT) and confirmed by flexible bronchoscopy. She had initially presented to her primary care physician for evaluation of a several month history of progressive shortness of breath, cough, and exercise limitation. Chest x-ray revealed right lower lobe pneumonia, and she was treated with oral levofloxacin. After she failed to improve with several days of antibiotics, CT scan of the chest was performed that revealed a mass in the right mainstem bronchus. Flexible bronchoscopy subsequently confirmed the right mainstem mass, which seemed to contain suture material. Gentle attempts at removal of the mass using biopsy forceps were unsuccessful. Cultures obtained during the bronchoscopy grew Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. Antibiotics were tailored toward these organisms, resulting in significant improvement after 1 week of therapy, whereupon she presented to the Interventional Pulmonology clinic.

Her past medical history was notable for a spontaneous right-sided hemothorax, occurring 7 years earlier requiring emergent thoracotomy. An actively bleeding subcarinal AVM was discovered intraoperatively, and “multiple pledgeted 4-0 prolene sutures” were placed to achieve hemostasis. Postoperative bronchoscopic evaluation revealed a segment of suture visible in the right mainstem bronchus, suggesting inadvertent bronchial injury during the case. The patient recovered from her surgery, and after a prolonged hospital course was discharged home in good condition. Over the ensuing several years, she did well from a respiratory standpoint until her most recent illness.

On presentation to the Interventional Pulmonology clinic, she was afebrile with normal vital signs and an SpO2 of 97% on room air. She was chronically ill seeming, but not acutely distressed. Breathing was unlabored, with a rate of 16 breaths/min. Chest auscultation revealed rhonchi throughout the right lung. The left lung was clear and there was no stridor or wheezing. Spirometry revealed a moderate obstructive ventilatory defect. The CT scan from the referring hospital (2 wk before her clinic visit) revealed a right lower lobe pneumonia and a mass in the right mainstem bronchus. A small amount of mediastinal air was seen just posterior to the proximal mainstem bronchus, near where the mass was located. A repeat CT scan performed on the day of her clinic visit revealed the presence of the right mainstem mass, but resolution of the mediastinal air (Fig. 1). The patient was prescribed an additional 1 week of oral antibiotics. Upon completion of this antibiotic course, rigid bronchoscopy was performed.

FIGURE 1.

FIGURE 1.

The patient was taken to the operating room and was intubated in standard fashion using a Bryan-Dumon rigid bronchoscope with an outer diameter of 12 mm. The rigid bronchoscope was advanced to the midtrachea where a foreign body was readily visible occluding 90% of the proximal right mainstem bronchus (Figs. 2, 3). The flexible bronchoscope was passed through the rigid barrel and was advanced to the foreign body that seemed to be a surgical pledget, containing tangled suture material. Gentle suction was applied to the foreign body to assess its mobility and bleeding tendency. No bleeding was noted, and upon attempted mobilization, the pledget seemed to be tethered medially to the proximal right mainstem bronchus just inferior to the main carina. The flexible bronchoscope was removed and 5-mm endoshears were advanced through the rigid bronchoscope and used to divide the pledget into smaller pieces to facilitate removal and cut sutures, thereby freeing the pledget from the medial wall of the right mainstem bronchus. Further debulking and removal of foreign body material was accomplished using cupped forceps. After debulking, residual granulation tissue was noted along the medial wall of the right mainstem bronchus and the degree of obstruction was <10% (Fig. 4). The patient tolerated the procedure and was discharged home the same day feeling well. She continued to do well on follow-up several weeks after the procedure.

FIGURE 2.

FIGURE 2.

FIGURE 3.

FIGURE 3.

FIGURE 4.

FIGURE 4.

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DISCUSSION

The patient in this case presented with partial obstruction of her right mainstem bronchus by a mass that was subsequently identified as a surgical pledget. Pledgets are small pads, often made of teflon, used to buttress sutures lines and to prevent suture from cutting into delicate tissues, such as vascular structures. In this patient, a nonabsorbable pledget and segment of suture had been used to control a bleeding subcarinal AVM 7 years before her presentation. Over time, the pledget and suture eroded into her right mainstem bronchus, resulting in subacute respiratory symptoms and predisposing her to an acute pneumonia. An inadvertent bronchial injury at the time of her initial surgery may have contributed to the process of erosion and migration into the airway.

On rare occasion, foreign bodies may erode into the airway and cause respiratory symptoms. Broncholithiasis most commonly results from erosion of a calcified intrathoracic lymph node into a neighboring airway.1 Intrathoracic foreign bodies that have been described to erode into the tracheobronchial tree include epicardially placed implantable cardioverter defibrillator leads,2–5 retained surgical sponges,6 arterial prosthetic grafts,7 and even a CardioSEAL device used to close an anomalous systemic to pulmonary venous channel.8 To our knowledge, there are no reported cases of surgical pledgets eroding into the tracheobronchial tree, though these objects have been seen to erode into other structures. Dally and Falk9 reported a series of 11 cases of teflon pledgets that had been placed during Nissen fundoplication eroding into the stomach, esophagus, or cardioesophageal junction. These complications were rare overall (occurring 11 times out of 1175 fundoplications) and arose on average 33.3 months after the procedure (range: 2 to 85 mo). Other cases that have been reported include erosion of surgical pledgets into the bladder (6 mo after bladder neck suspension surgery)10 and out of the chest wall (6 y after coronary artery bypass graft surgery).11

Erosion of foreign bodies into the airway can result in wheezing, cough, dyspnea hemoptysis, or predisposition to respiratory tract infection. Our patient experienced several months of dyspnea and cough and then developed a pneumonia that led to the discovery of the pledget in her right mainstem bronchus.

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CONCLUSION

Though airway foreign bodies are typically because of aspiration, they may occasionally erode into the airway from the surrounding structure. The clinical presentation because of erosion into the airway may be insidious, as seen in this case, where a partial obstruction of the right mainstem bronchus by a surgical pledget resulted in chronic respiratory complaints punctuated by an acute pneumonia. Treatment with antibiotics followed by delayed bronchoscopic removal of the pledget resulted in resolution of symptoms.

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REFERENCES

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10. Nabi G, Hemal AK, Khaitan A. Endoscopic management of an unusual foreign body in the urinary bladder leading to intractable symptoms. Int Urol Nephrol. 2001;33:351–352.
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Keywords:

airway obstruction; surgical pledget; rigid bronchoscopy

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