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Metalloptysis: a late complication of lung volume reduction surgery
1694
CASE REPORT OEY AND WALLER METALLOPTYSIS: A LATE COMPLICATION OF LVRS
Ann Thorac Surg 2001;71:1694 –5
2. Evander A, Little AG, Ferguson MK, Skinner DB. Diverticula of the mid- and lower esophagus: pathogenesis and surgical management. World J Surg 1986;10:820– 8. 3. LeCount ER. Epibronchial pulsion diverticula of the esophagus. Chicago Pathol Soc Trans 1915;10:35–7. 4. Billiard, Decoulare´-Delafontaine. Gros diverticule intrathoracique de l’oesophage. J Radiol (Paris) 1926;10:508–10. 5. Barrett NR. Diverticula of the thoracic oesophagus. Lancet 1933;1:1009–11. 6. Cassou R, Raymond P. Diverticule ge´ant de l’oesophage thoracique simulant un hydropneumothorax enkyste´, avec me´gaoesophage. Arch Mal Digest (Paris) 1950;39:611–14. 7. Shaw HJ. Diverticula of the thoracic oesophagus. J Laryngol Otol 1954;68:70– 81. 8. Jonasson OM, Gunn LC. Midesophageal diverticulum with hemorrhage. Arch Surg 1965;90:713–15. 9. Etherington RJ, Clements D. Giant mid-oesophageal diverticulum: a rare cause of dysphagia. Br J Radiol 1990;63:221–2. 10. Arana E, Latorre FF, Diaz C. Diverticulos gigantes de eso´fago medio apareciendo como masas mediastinicas en radiografias de to´rax. Arch Bronconeumol 1995;31:44–5. 11. Trempe F. Large pulsion diverticulum of the middle third of the thoracic oesophagus. Can Med Assoc J 1955;73:38–9.
Fig 1. Mass that was expectorated containing Peri strip with titanium staples.
Metalloptysis: A Late Complication of Lung Volume Reduction Surgery Inger Oey, FRCS, and David A. Waller, FRCS (C-Th) Department of Thoracic Surgery, Glenfield Hospital, Leicester, England
We describe three cases where patients expectorated titanium staples many months after lung volume reduction surgery (LVRS). The possible mechanisms and technical implications of this rare complication are discussed. (Ann Thorac Surg 2001;71:1694 –5) © 2001 by The Society of Thoracic Surgeons
F
oreign bodies have been found to migrate in lung tissue. A case has been described where a bullet eroded a bronchus [1]. The patient developed hemoptysis 3 months after his injury and finally expectorated the bullet. We report three cases out of our total experience of 48 patients, where clips, from staple cartridges applied on the periphery of the lung, have migrated and finally have been expectorated.
dry bovine pericardial strips (Peri Strips, Bio-Vascular, St. Paul, MN). Eight months after surgery she started to cough up staples. In a period of 6 months, she had 7 episodes during which she coughed up 2 to 14 staples, with a total of 71 staples. She remains otherwise well. Her forced expiratory volume in one second (FEV1) increased from 25% pred before surgery to 33% pred at 1 year post surgery. Her SF36 scores showed an improvement in 2 of the 8 health domains.
Patient 2 The second patient is a 58-year-old patient who underwent bilateral VAT LVRS. Lung reduction was performed using the EZ45 stapling gun on both sides, again all buttressed with dry bovine Peri strips. Postoperative stay was uneventful. Twenty months later she started to cough up staples. She had 3 episodes during which she coughed up a mass containing Peri strip with staples (Fig 1). A computed tomography (CT) scan showed an inflammatory mass at the site of the staple line. During one of these episodes she was admitted to hospital with a chest infection.
Case Reports Patient 1 A 55-year-old patient underwent video-assisted thoracoscopic (VAT) LVRS without immediate complications. Bilateral upper lobe lung reduction was performed using both the EZ45 stapling gun (Ethicon Endo-Surgery, Cincinnati, OH) and the endoGIA 30 stapling gun (Autosuture, Norwalk, CT). All staple lines were buttressed with Accepted for publication July 10, 2000. Address reprint requests to Dr Oey, Thoracic Department, Glenfield Hospital, Leicester LE3 9QP, England.
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Patient 3 The last case is a 57-year-old patient who underwent bilateral LVRS. The EZ45 stapling gun was used with dry bovine Peri strips to buttress the staple lines. Postoperatively he spent three weeks in the intensive therapy unit (ITU) due to respiratory failure. For an increasing air leak, a second drain was inserted which was not removed until 4 weeks post surgery. Five months later, he required readmission to ITU with an infective exacerbation of chronic obstructive pulmonary disease. At nine months post surgery, he coughed up a small amount of phlegm containing a few staples. 0003-4975/01/$20.00 PII S0003-4975(00)02303-1
Ann Thorac Surg 2001;71:1695–7
Comment Cooper reintroduced the idea of LVRS in patients with severe emphysema [2]. To reduce postoperative air leaks, he buttressed his staples with bovine pericardium, which is frequently used in surgery due to its biocompatibility. However, Iwasaki and colleagues describe two patients who developed interstitial pneumonia at the bovine pericardial patches 3 months after LVRS [3]. They therefore, modified their technique to a fold plication technique obviating the need for buttressing. It would be interesting to know whether synthetic buttresses cause the same degree of interstitial pneumonitis. In an animal study, the tissue response to polytetrafluoroethylene (PTFE) and bovine pericardium for staple-line reinforcement was compared. After 30 days, only the pericardial specimens showed focal chronic inflammation [4]. In some centers unbuttressed staples are used in LVRS. However, in a prospectively randomized study comparing buttressed with unbuttressed staples, the postoperative air leak was 2.5 days longer in the group without buttresses [5]. It may be that the staples rather then the buttresses are the cause of the inflammation. Horio and associates described a patient who developed hemoptysis 3 months after a VAT bullectomy [6]. The staples were found to have caused a hematoma with resulting inflammation. Therefore, biodegradable staples may be a solution [7]. However, total disappearance occurs only after 6 to 7 months, which may not be soon enough to prevent this type of complication. Other techniques, such as laser ablation, have been developed to avoid the use of staples. Ultrasonic dissection has not been used routinely in LVRS but may be an alternative. In line with the introduction of a new surgical technique, we have coined a new term for a new complication; “metalloptysis,” coughing up of metal.
References 1. Saunders MS, Cropp AJ, Awad MJ. Spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet: case report. Trauma 1992;33:909–11. 2. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109: 106–19. 3. Iwasaki M, Nishiumi N, Kaga K, Kanazawa M, Kuwahira I, Inoue H. Application of the fold plication method for unilateral lung volume reduction in pulmonary emphysema. Ann Thorac Surg 1999;67:815–7. 4. Vaughn CC, Vaughn PL, Vaughn CC 3rd, Sawyer P, Manning M, Anderson D. Tissue response to biomaterials used for staple-line reinforcement in lung resection: a comparison between expanded polytetrafluoroethylene and bovine pericardium. Eur J Cardiothorac Surg 1998;13:259– 65. 5. Hazelrigg SR, Boley TM, Naunheim KS, et al. Effect of bovine pericardial strips on air leak after stapled pulmonary resection. Ann Thorac Surg 1997;63:1573–5. 6. Horio H, Nomori H, Fuyuno G, Kobayashi R, Castel-Dupont S. Intrapulmonary hematoma surrounding the stapled line after video-assisted thoracoscopic bullectomy for spontaneous pneumothorax. Kyobu Geka 1999;52:477– 80. 7. Nguyen H, Nguyen HV, Barra JA, Raut Y, Morinaga S, © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT TSENG ET AL RECONSTRUCTION OF THE ESOPHAGUS
1695
Suemasu K. Absorbable synthetic clips and pulmonary excision. Our clinical experience. Chir (Paris) 1987;124:113– 8.
Redoing Reconstruction of the Esophagus Using Remnants of the Ileo-Left Colon Aided by Microvascular Anastomosis Yau-Lin Tseng, MD, Ming-Ho Wu, MD, Mu-Yen Lin, MD, and Jing-Wei Lee, MD Divisions of Thoracic Surgery and Plastic Surgery, Department of Surgery, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.
Theoretically, the jejunum, fasciocutaneous or myocutaneous flap is recommended as an esophageal substitute in redoing reconstruction of the esophagus after a second incidence of corrosive injury. However, other esophageal substitutes should also be considered. We present a case of a 42-year-old woman who underwent esophageal reconstruction using an ileocolon graft for corrosive esophageal stricture ten years before. The patient ingested caustic drain cleaner again and underwent resection of the ileocolon graft secondary to corrosive necrosis. Two and a half months after the second incidence of corrosive injury, reconstruction of the esophagus was again performed using a graft of remnant ileo-left colon aided by microvascular anastomosis. The patient was able to swallow a regular diet after the procedure. Remnant ileo-left colon is a good alternative esophageal substitute in cases of repeated corrosive injury. (Ann Thorac Surg 2001;71:1695–7) © 2001 by The Society of Thoracic Surgeons
T
he substitutes most commonly used for replacement of the esophagus include portions from the stomach, colon, and jejunum [1, 2]. On patients with corrosive injury in which the stomach is also frequently injured, the colon or jejunum is the best choice of graft material [3]. However, in cases involving failure of the colon graft or injury to the neoesophagus, surgeons may choose pedicled intestine, extended jejunum, or other flaps for reconstruction [4, 5]. We present a case in which we used remnant ileo-left colon for a second reconstruction of the esophagus. Although severe adhesions in the abdominal cavity may be present, reconstruction of the esophagus can be performed with available remnant alimentary tract with the aid of microvascular surgery. A 42-year-old female patient had a history of substernal ileocolon reconstruction for corrosive esophageal stricture ten years before (Fig 1). She was referred to our hospital ten days after drinking Drano drain cleaner for Accepted for publication July 15, 2000. Address reprint requests to Dr Tseng, Department of Surgery, National Cheng Kung University Hospital, 138 Sheng-Li Rd, Tainan, Taiwan; e-mail: [email protected].
0003-4975/01/$20.00 PII S0003-4975(00)02306-7
CASE REPORT OEY AND WALLER METALLOPTYSIS: A LATE COMPLICATION OF LVRS
Ann Thorac Surg 2001;71:1694 –5
2. Evander A, Little AG, Ferguson MK, Skinner DB. Diverticula of the mid- and lower esophagus: pathogenesis and surgical management. World J Surg 1986;10:820– 8. 3. LeCount ER. Epibronchial pulsion diverticula of the esophagus. Chicago Pathol Soc Trans 1915;10:35–7. 4. Billiard, Decoulare´-Delafontaine. Gros diverticule intrathoracique de l’oesophage. J Radiol (Paris) 1926;10:508–10. 5. Barrett NR. Diverticula of the thoracic oesophagus. Lancet 1933;1:1009–11. 6. Cassou R, Raymond P. Diverticule ge´ant de l’oesophage thoracique simulant un hydropneumothorax enkyste´, avec me´gaoesophage. Arch Mal Digest (Paris) 1950;39:611–14. 7. Shaw HJ. Diverticula of the thoracic oesophagus. J Laryngol Otol 1954;68:70– 81. 8. Jonasson OM, Gunn LC. Midesophageal diverticulum with hemorrhage. Arch Surg 1965;90:713–15. 9. Etherington RJ, Clements D. Giant mid-oesophageal diverticulum: a rare cause of dysphagia. Br J Radiol 1990;63:221–2. 10. Arana E, Latorre FF, Diaz C. Diverticulos gigantes de eso´fago medio apareciendo como masas mediastinicas en radiografias de to´rax. Arch Bronconeumol 1995;31:44–5. 11. Trempe F. Large pulsion diverticulum of the middle third of the thoracic oesophagus. Can Med Assoc J 1955;73:38–9.
Fig 1. Mass that was expectorated containing Peri strip with titanium staples.
Metalloptysis: A Late Complication of Lung Volume Reduction Surgery Inger Oey, FRCS, and David A. Waller, FRCS (C-Th) Department of Thoracic Surgery, Glenfield Hospital, Leicester, England
We describe three cases where patients expectorated titanium staples many months after lung volume reduction surgery (LVRS). The possible mechanisms and technical implications of this rare complication are discussed. (Ann Thorac Surg 2001;71:1694 –5) © 2001 by The Society of Thoracic Surgeons
F
oreign bodies have been found to migrate in lung tissue. A case has been described where a bullet eroded a bronchus [1]. The patient developed hemoptysis 3 months after his injury and finally expectorated the bullet. We report three cases out of our total experience of 48 patients, where clips, from staple cartridges applied on the periphery of the lung, have migrated and finally have been expectorated.
dry bovine pericardial strips (Peri Strips, Bio-Vascular, St. Paul, MN). Eight months after surgery she started to cough up staples. In a period of 6 months, she had 7 episodes during which she coughed up 2 to 14 staples, with a total of 71 staples. She remains otherwise well. Her forced expiratory volume in one second (FEV1) increased from 25% pred before surgery to 33% pred at 1 year post surgery. Her SF36 scores showed an improvement in 2 of the 8 health domains.
Patient 2 The second patient is a 58-year-old patient who underwent bilateral VAT LVRS. Lung reduction was performed using the EZ45 stapling gun on both sides, again all buttressed with dry bovine Peri strips. Postoperative stay was uneventful. Twenty months later she started to cough up staples. She had 3 episodes during which she coughed up a mass containing Peri strip with staples (Fig 1). A computed tomography (CT) scan showed an inflammatory mass at the site of the staple line. During one of these episodes she was admitted to hospital with a chest infection.
Case Reports Patient 1 A 55-year-old patient underwent video-assisted thoracoscopic (VAT) LVRS without immediate complications. Bilateral upper lobe lung reduction was performed using both the EZ45 stapling gun (Ethicon Endo-Surgery, Cincinnati, OH) and the endoGIA 30 stapling gun (Autosuture, Norwalk, CT). All staple lines were buttressed with Accepted for publication July 10, 2000. Address reprint requests to Dr Oey, Thoracic Department, Glenfield Hospital, Leicester LE3 9QP, England.
© 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
Patient 3 The last case is a 57-year-old patient who underwent bilateral LVRS. The EZ45 stapling gun was used with dry bovine Peri strips to buttress the staple lines. Postoperatively he spent three weeks in the intensive therapy unit (ITU) due to respiratory failure. For an increasing air leak, a second drain was inserted which was not removed until 4 weeks post surgery. Five months later, he required readmission to ITU with an infective exacerbation of chronic obstructive pulmonary disease. At nine months post surgery, he coughed up a small amount of phlegm containing a few staples. 0003-4975/01/$20.00 PII S0003-4975(00)02303-1
Ann Thorac Surg 2001;71:1695–7
Comment Cooper reintroduced the idea of LVRS in patients with severe emphysema [2]. To reduce postoperative air leaks, he buttressed his staples with bovine pericardium, which is frequently used in surgery due to its biocompatibility. However, Iwasaki and colleagues describe two patients who developed interstitial pneumonia at the bovine pericardial patches 3 months after LVRS [3]. They therefore, modified their technique to a fold plication technique obviating the need for buttressing. It would be interesting to know whether synthetic buttresses cause the same degree of interstitial pneumonitis. In an animal study, the tissue response to polytetrafluoroethylene (PTFE) and bovine pericardium for staple-line reinforcement was compared. After 30 days, only the pericardial specimens showed focal chronic inflammation [4]. In some centers unbuttressed staples are used in LVRS. However, in a prospectively randomized study comparing buttressed with unbuttressed staples, the postoperative air leak was 2.5 days longer in the group without buttresses [5]. It may be that the staples rather then the buttresses are the cause of the inflammation. Horio and associates described a patient who developed hemoptysis 3 months after a VAT bullectomy [6]. The staples were found to have caused a hematoma with resulting inflammation. Therefore, biodegradable staples may be a solution [7]. However, total disappearance occurs only after 6 to 7 months, which may not be soon enough to prevent this type of complication. Other techniques, such as laser ablation, have been developed to avoid the use of staples. Ultrasonic dissection has not been used routinely in LVRS but may be an alternative. In line with the introduction of a new surgical technique, we have coined a new term for a new complication; “metalloptysis,” coughing up of metal.
References 1. Saunders MS, Cropp AJ, Awad MJ. Spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet: case report. Trauma 1992;33:909–11. 2. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109: 106–19. 3. Iwasaki M, Nishiumi N, Kaga K, Kanazawa M, Kuwahira I, Inoue H. Application of the fold plication method for unilateral lung volume reduction in pulmonary emphysema. Ann Thorac Surg 1999;67:815–7. 4. Vaughn CC, Vaughn PL, Vaughn CC 3rd, Sawyer P, Manning M, Anderson D. Tissue response to biomaterials used for staple-line reinforcement in lung resection: a comparison between expanded polytetrafluoroethylene and bovine pericardium. Eur J Cardiothorac Surg 1998;13:259– 65. 5. Hazelrigg SR, Boley TM, Naunheim KS, et al. Effect of bovine pericardial strips on air leak after stapled pulmonary resection. Ann Thorac Surg 1997;63:1573–5. 6. Horio H, Nomori H, Fuyuno G, Kobayashi R, Castel-Dupont S. Intrapulmonary hematoma surrounding the stapled line after video-assisted thoracoscopic bullectomy for spontaneous pneumothorax. Kyobu Geka 1999;52:477– 80. 7. Nguyen H, Nguyen HV, Barra JA, Raut Y, Morinaga S, © 2001 by The Society of Thoracic Surgeons Published by Elsevier Science Inc
CASE REPORT TSENG ET AL RECONSTRUCTION OF THE ESOPHAGUS
1695
Suemasu K. Absorbable synthetic clips and pulmonary excision. Our clinical experience. Chir (Paris) 1987;124:113– 8.
Redoing Reconstruction of the Esophagus Using Remnants of the Ileo-Left Colon Aided by Microvascular Anastomosis Yau-Lin Tseng, MD, Ming-Ho Wu, MD, Mu-Yen Lin, MD, and Jing-Wei Lee, MD Divisions of Thoracic Surgery and Plastic Surgery, Department of Surgery, College of Medicine, National Cheng Kung University, Tainan, Taiwan, R.O.C.
Theoretically, the jejunum, fasciocutaneous or myocutaneous flap is recommended as an esophageal substitute in redoing reconstruction of the esophagus after a second incidence of corrosive injury. However, other esophageal substitutes should also be considered. We present a case of a 42-year-old woman who underwent esophageal reconstruction using an ileocolon graft for corrosive esophageal stricture ten years before. The patient ingested caustic drain cleaner again and underwent resection of the ileocolon graft secondary to corrosive necrosis. Two and a half months after the second incidence of corrosive injury, reconstruction of the esophagus was again performed using a graft of remnant ileo-left colon aided by microvascular anastomosis. The patient was able to swallow a regular diet after the procedure. Remnant ileo-left colon is a good alternative esophageal substitute in cases of repeated corrosive injury. (Ann Thorac Surg 2001;71:1695–7) © 2001 by The Society of Thoracic Surgeons
T
he substitutes most commonly used for replacement of the esophagus include portions from the stomach, colon, and jejunum [1, 2]. On patients with corrosive injury in which the stomach is also frequently injured, the colon or jejunum is the best choice of graft material [3]. However, in cases involving failure of the colon graft or injury to the neoesophagus, surgeons may choose pedicled intestine, extended jejunum, or other flaps for reconstruction [4, 5]. We present a case in which we used remnant ileo-left colon for a second reconstruction of the esophagus. Although severe adhesions in the abdominal cavity may be present, reconstruction of the esophagus can be performed with available remnant alimentary tract with the aid of microvascular surgery. A 42-year-old female patient had a history of substernal ileocolon reconstruction for corrosive esophageal stricture ten years before (Fig 1). She was referred to our hospital ten days after drinking Drano drain cleaner for Accepted for publication July 15, 2000. Address reprint requests to Dr Tseng, Department of Surgery, National Cheng Kung University Hospital, 138 Sheng-Li Rd, Tainan, Taiwan; e-mail: [email protected].
0003-4975/01/$20.00 PII S0003-4975(00)02306-7