Foreign-body excretion through the bronchial stump after extrapleural pneumonectomy

Abstract

Foreign-body excretion is a bioresponse of the human body. Bronchial foreign bodies commonly occur through aspiration or inhalation. We present a rare case of the excretion of a foreign body through the bronchial stump 19 months after pneumonectomy. A 52-year-old man had a high fever and chest discomfort. He underwent a left extrapleural pneumonectomy for malignant pleural mesothelioma 19 months earlier. He received postoperative chemotherapy, which consisted of 4 cycles of cisplatin, doxorubicin, and cyclophosphamide, and sequential radiation therapy for the entire hemithorax of 56 Gy in total.1Sugarbaker D.J. Strauss G.M. Lynch T.J. Richard W. Mentzer S.J. Lee T.H. et al.Node status has prognostic significance in the multimodality therapy of diffuse malignant mesothelioma.J Clin Oncol. 1993; 11: 1172-1178Crossref PubMed Scopus (200) Google Scholar, 2Sugarbaker D.J. Grarcia J.P. Richards W.G. Harpole Jr, D.H. Healy-Baldini E. DeCamp Jr, M.M. et al.Extrapleural pneumonectomy in the multimodality therapy of malignant pleural mesothelioma Result in 120 consecutive patients.Ann Surg. 1996; 224: 288-294Crossref PubMed Scopus (196) Google Scholar Blood count showed luekocytosis, and chemistry showed an increased C-reactive protein level. Chest radiography showed no abnormal lesions except for left-side opacity after pneumonectomy. Computed tomography of the chest and the abdomen showed no evidence of recurrence of malignant pleural mesothelioma. Culture of thoracentesis fluid showed no growth of microorganisms. Bronchoscopic examination revealed a foreign body, a whitish cottony material, at the left main bronchial stump (Figure 1). Endoscopic extraction with forceps identified a hemostat of oxidized cellulose (Figure 2). After the extraction, a blue suture was translucently identified in the mucosa of the bronchial stump. Bronchopleural fistula was not seen during or after the extraction. Culture of the material revealed Haemophilus species. After the removal of the infected foreign body, the patient recovered quickly and has been doing well for 3 years.Figure 2Oxidized cellulose extracted with forceps broncho-scopically.View Large Image Figure ViewerDownload (PPT) The bronchial stump at the left extrapleural pneumonectomy was hand sutured with interrupted polypropylene sutures (3-0 Prolene; Ethicon Inc, Somerville, NJ) and reinforced with a pedicled intercostal muscle by using the same polypropylene sutures for bronchus. On the next day, the patient underwent a re-exploration of the thorax as a result of the excessive blood loss. After hemostasis was obtained, cotton-type oxidized cellulose (Oxycel; Sankyo Co, Tokyo, Japan) was inserted into the mediastinum as a hemostat. Bronchoscopic examination 4 weeks after the pneumonectomy showed normal findings at the bronchial closure. For 19 months of postoperative follow-up, the patient had been without any symptoms of bronchopleural fistula, and chest radiography had never shown an air-fluid level in the left thorax. The bronchial stump should have been airtight since the extrapleural pneumonectomy. In the literature most foreign bodies found in the airway are the result of aspiration or inhalation. On the other hand, several bronchial foreign bodies that were not inhaled have been reported. Migration of shrapnel from the pulmonary parenchyma into a bronchus 64 years after the injury was reported.3Bogedain W. Migration of shrapnel from lung to bronchus.JAMA. 1984; 251: 1862-1863Crossref PubMed Scopus (11) Google Scholar Two foreign bodies with uncommon ways of entry were removed with a bronchoscope: one was a bullet that eroded in the right lower bronchus after having penetrated through a wound in the chest wall, and the other was a fragment of circular saw lodged in the right main bronchus after penetration through a wound in the neck.4Aprigliano F. Bronchial foreign bodies: an uncommon way to entry.Ann Otol Rhinol Laryngol. 1990; 99: 695-697PubMed Google Scholar Recent literature also described expectoration of titanium staples in 3 patients many months after volume-reduction surgery for pulmonary emphysema.5Oey I. Waller D.A. Metalloptysis: a late complication of lung volume reduction surgery.Ann Thorac Surg. 2001; 71: 1694-1695Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar Jackson and Jackson6Jackson C. Jackson C.L. Bronchoesophagology. WB Saunders, Philadelphia (PA)1950Crossref Google Scholar mentioned that foreign bodies, especially metallic ones that cause little specific reaction, can reach the bronchi through penetration of the chest wall. However, few nonmetallic foreign bodies migrating into the airway have been reported. Our patient appeared to have excreted a hemostat of oxidized cellulose from the thoracic cavity into the endobronchial lumen through the sutures of the bronchial stump. The foreign-body reaction of cellulose has been known to be mild in in vivo experiments.7Miyamoto T. Takahashi S. Ito H. Inagaki H. Noishiki Y. Tissue biocompatibility of cellulose and its derivatives.J Biomed Mater Res. 1989; 23: 125-133Crossref PubMed Scopus (304) Google Scholar Although the mechanisms of the migration remain unknown, we would provide evidence of a rare nonmetallic foreign body in the airway through the bronchial stump.