The most frequent complication after a thoracic surgical procedure for a patient with emphysema is a prolonged air leak that increases the length of their hospital stay.1 Standard therapy for treating air leaks after lung resection involves surgical stapling or suturing techniques and electrocautery. To minimize air leaks, several preventive techniques that reinforce the staple line using different materials have been developed, ie, strips of bovine pericardium,2 expanded polytetrafluoroethylene (ePTFE) sleeves,3 absorbable reinforcement felt (polyglycolic acid, Neoveil, Gunze, Kyoto, Japan), and biological glue. We report a rare case of the migration of staple line reinforcement materials found as an endobronchial foreign body and its successful removal using a flexible bronchoscope.
A 60-year-old man underwent an right upper lobe lobectomy and lymph nodal dissection for a poorly differentiated adenocarcinoma T1N0M0 lung cancer in December 2002 at an outside institution. On the basis of the surgical records, there was a complete fissure between the right upper and middle lobes, whereas it was incomplete between the upper and lower lobes. An EndoGIA II 45 mm-3.5 staple cartridge (United State Surgical, Norwalk, CT) covered with artificial reinforcement material, that is, ePTFE (Seamguard W.L.Gore & Associates, Inc., Flagstaff, AZ) was fired twice to separate the incomplete interlobar fissure between the upper and lower lobes. To resect the right upper lobe bronchus, an EndoGIA II 45 mm-3.5 staple cartridge (United State Surgical, Norwalk, CT) was used. For 3 years, until November 2005, the patient's postoperative course remained uneventful and then he missed follow-up visits.
In February 2008, during the 50th month, the patient developed a severe productive cough. During flexible bronchoscopy, a staple-line reinforcement material was found protruding into the right main stem bronchus (RMB) lumen from its membraneous wall (Fig. 1A). Three-dimensional computed tomographic (3D-CT) scanning of the chest (Fig. 1B) revealed that the main body of the staple-line reinforcement material was located in the right mediastinum with one of its ends migrating into the RMB.
Under general anesthesia, the migrated portion of the reinforcement material was severed using endobronchial scissors through the flexible bronchoscope and removed (Figs. 1C–E), leaving its mediastinal portion untouched. The patient experienced a significant improvement in his symptomatology.
After 1 year, in March 2009, the patient developed a recurring productive cough. A repeat chest 3D-CT scanning and a flexible bronchoscopy (Fig. 2A–C) revealed a residual staple line protruding into the RMB. Once again, under general anesthesia, using a flexible bronchoscope, we tried to trim the neck of the staple-line reinforcement material; however, our attempts were unsuccessful due to difficulty in manipulation of the instruments. Eventually, we tightly grasped the staple line with a biopsy-forceps through the flexible bronchoscope and pushed it into a peripheral bronchus; once it was totally extracted out of the mediastinum, it was pulled out from the endobronchial tree (Fig. 2D). A follow-up chest CT scan revealed no residual material either in the thorax or mediastinum, and the patient has remained symptom free ever since.
A postoperative air leak is a common complication after standard lung surgery. When a prolonged air leak occurs, it can result in increased morbidity and longer hospital stay.1 Studies from the mid 1990s to the present have shown the benefit of routinely buttressing pulmonary staple lines in patients at-risk for postoperative air leaks.3,4
The virtues of a reinforcement material are ease of use, biocompatibility, flexibility, strength, air tightness, and cost-effectiveness.4 A variety of reinforcement materials are used in thoracic surgery, such as nonsynthetic bovine pericardium (Peri-Strips, Synovis); other nonabsorbable materials, such as ePTFE (Seamguard, W.L.Gore & Associates, Inc., Flagstaff, AZ) or a bioabsorbable polymer (Duet TRS, Covidien, Tokyo, Japan).
In past clinical practices, the 2 most used reinforcements were the bovine pericardium [Peri-Strips Dry (Biovascular, Inc, Saint Paul, MN)] and expanded ePTFE [Seamguard (W.L.Gore Associates, Inc, Flagstaff, AZ)].5
Complications of lung volume reduction surgery have lately included the asymptomatic expectoration of surgical staples linked by bovine pericardium,6 coughing up of a Peri-strip with titanium staples,7 and the need for bronchoscopic removal of the bovine pericardium with staples.8,9 Postoperative complications of lung cancer surgery have included bronchial obstruction due to Teflon pledget migration10 and a pseudotumor associated with ePTFE sleeves.11 In addition, the other kinds of late postoperative complications such as a migrated foreign body have included the need for bronchoscopic removal of an endobronchial gauze that migrated from the mediastinum after mediastinoscopy,12 rigid bronchoscopical removal of iatrogenic surgical gauze after tracheal surgery,13 open thoracotomic surgery of lung abscess from the transdiaphragmatic migration of a forgotten gauze sponge after a cholecystectomy and choledochotomy,14 need for lobectomy and thoracoplasty for gauzeoma from a 30-year-old patient who underwent pulmonary tuberculosis surgery,15 and sudden suffocation by a surgical sponge retained after a 23-year-old patient underwent lung cancer surgery.16
In the past, nonabsorbable materials such as ePTFE reinforcement materials for lung surgery have been used. More recently, however, absorbable materials, such as the Duet TRS Reload with preloaded tissue reinforcement material composed of a synthetic polymer (Covidien, Tokyo, Japan) or an absorbable polyglycolic acid reinforcement sheet (Neoveil, Gunze, Kyoto, Japan) with biological glue after staple-firing are being used. The use of an absorbable material is indeed attractive as there is a low risk-to-benefit ratio and ease of placement.
The etiology for this migration of the reinforcement material was considered as follows. Five years ago, staple lines were used for a lobectomy located in the right mediastinum, which had settled in the backside of the RMB. This foreign object continued to stimulate and form a granulation reaction of a foreign body, which resulted in this endobronchial migration. Eventually, the patient's severe productive cough let us identify the endobronchial migration.
A bronchoscope may be successfully used for the diagnosis and removal of foreign bodies in patients with suspected endobronchial foreign bodies. The possible presence of endobronchial foreign bodies should be remembered in patients with persistent symptoms in patients with lung cancer or other chronic respiratory diseases.
We experienced migration of a staple-line reinforcement material into the endobronchial tree several months after a lobectomy. Our case highlights the importance of using a bioabsorbable material over the nonabsorbable one. Nevertheless, if endobronchially migrated, the material can be excised and removed with the help of a flexible scope, thus avoiding a thoracotomy. A 3D-CT scan of the chest is very helpful to detect the exact anatomic location of the foreign body and its relation to the surrounding vital structures.
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