(Chest. 2001;119:307-308.)
© 2001
American College of Chest Physicians
Asymptomatic Expectoration of Surgical Staples Complicating Lung Volume Reduction Surgery*
Shahid Ahmed, MD;
Kamel A. Marzouk, MD;
Tawfiqul Alam Bhuiya, MD;
Mobeen Iqbal, MD and
Leonard J. Rossoff, MD
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Abstract
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Lung volume reduction surgery (LVRS) has recently been introduced
as a palliative treatment for patients with severe emphysema. The most
common postoperative complication is persistent air leak requiring
prolonged tube thoracostomy. We describe a unique case of a patient
with severe emphysema who underwent LVRS and presented, about a year
later, with the repeated expectoration of surgical staples.
Key Words: lung volume reduction • reduction pneumoplasty • surgical staples
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Introduction
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Lung volume reduction surgery (LVRS)
has recently reemerged as a surgical option for the treatment of
end-stage emphysema in selected patients.1
The encouraging
results of smaller trials have resulted in an ongoing large multicenter
trial to evaluate the efficacy of LVRS.
The complication rate of LVRS has been reported to be low. Persistent
air leak, respiratory failure, pneumonia, and reexploration are the
commonly reported complications.2
We report a unique case
of asymptomatic expectoration of surgical staples subsequent to LVRS.
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Case Report
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A 61-year-old man and former smoker, with a total of 30
pack-years, presented with severe emphysema and home-oxygen dependency.
A CT scan of the chest demonstrated upper-lobe- predominant
centriacinar emphysema. He underwent bilateral LVRS via median
sternotomy. A bovine pericardium-reinforced staple suture line
(Peristrips; Biovascular; St. Paul, MN) was applied on the right,
predominantly over the anterior segment of the right upper lobe and
middle lobe and on the left anteriorly, predominantly above the
lingula. His postoperative course was unremarkable.
He clinically improved but remained oxygen dependent. One year after
surgery, he reported expectoration of metallic staples covered with
yellow material (Fig 1
). He was treated
with antibiotics for several episodes of purulent bronchitis/pneumonia.
He coughed several staples attached by strips of bovine pericardium
without evidence of hemoptysis, dyspnea, or chest pain. A repeat CT
scan did not detect any significant abnormalities, and he continued to
improve with a diminishing oxygen requirement.
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Discussion
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LVRS has recently reemerged as a possible surgical option for the
treatment of severe emphysema in selected patients.1
3
4
Proposed mechanisms of improvement include increased elastic recoil,
decreased airway resistance, and improved respiratory muscle
function.5
6
The procedure can be performed using several
surgical approaches, including video-assisted thoracoscopic surgery,
median sternotomy, and, less commonly, lateral
thoracotomy.2
LVRS usually, as in our case, entails the
resection of 20 to 30% of the lung unilaterally or bilaterally.
Mortality rates vary among series, and reported early and late
mortality rates range from 2.4 to 7% and 4 to 17%,
respectively.2
3
4
The more common postoperative morbidity
includes persistent air leak (chest tube for > 5 days) with a
prevalence of 30 to 40% in reported series.3
4
7
Other
significant reported complications include pneumonia (9 to 12%), GI
disturbance (2 to 15%), respiratory failure (2.5 to 13%), and the
need for surgical reexploration (2.5 to 10.5%).2
3
4
7
Rarer complications even include development of a giant
bulla.8
We believe that this represents a previously
unreported complication of this surgery. Interestingly, enough repeated
radiographic studies did not reveal any untoward findings and no
evidence of air leak. Furthermore, the patient remained asymptomatic
and even showed gradual clinical improvement. The mechanism of the
staple expectoration is unclear. We speculate that relatively larger
bronchi were traversed by the reinforced suture line. Subsequently
small sections of bovine pericardium and attached staple(s) may have
eroded into these bronchi and separated, allowing their expectoration.
This may have been facilitated by a local infectious inflammatory
reaction. Fortunately, enough healing apparently had taken
place to obviate the development of a bronchopleural
fistula.
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Footnotes
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Abbreviation: LVRS = lung volume reduction surgery
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References
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Cooper, JD, Trulock, EP, Triantafillou, AN, et al (1995) Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 109,106-119[Abstract/Free Full Text]
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Sciurba, FC (1997) Surgical approaches to end-stage disease: lung transplantation and volume reduction. Clin Chest Med 18,259-276[CrossRef][ISI][Medline]
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McKenna, RJ, Jr, Brenner, M, Mullin, M, et al (1996) A randomized, prospective trial of stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 111,317-321[Abstract/Free Full Text]
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Cooper, JD, Patterson, GA, Sundaresan, RS, et al (1996) Result of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg 112,1319-1329[Abstract/Free Full Text]
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Sciurba, FC, Rogers, RM, Keenan, RJ, et al (1996) Improvement in pulmonary function and elastic recoil after lung reduction surgery for diffuse emphysema. N Engl J Med 334,1095-1099[Abstract/Free Full Text]
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Gelb, AF, McKenna, RJ, Brenner, M, et al (1996) Contribution of lung and chest wall mechanics following emphysema resection. Chest 110,11-17[Abstract/Free Full Text]
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Keenan, RJ, Sciurba, FC, Landreneau, RJ, et al (1996) Superiority of bilateral versus unilateral thoracoscopic approaches to lung reduction surgery [abstract]. Am J Respir Crit Care Med 153,A268
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Iqbal, M, Rossoff, L, McKeon, K, et al (1999) Development of a giant bulla after lung volume reduction surgery. Chest 116,1809-1811[Abstract/Free Full Text]
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Abstract
Introduction
