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Ann Thorac Surg 2001;71:1694-1695
© 2001 The Society of Thoracic Surgeons

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Case report

Metalloptysis: a late complication of lung volume reduction surgery

^a Department of Thoracic Surgery, Glenfield Hospital, Leicester, England, United Kingdom

Accepted for publication July 10, 2000.

Address reprint requests to Dr Oey, Thoracic Department, Glenfield Hospital, Leicester LE3 9QP, England

	Abstract

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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.

	Introduction

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Foreign 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.

	Case reports

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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 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.

View larger version (209K): [in this window] [in a new window]   Fig 1. Mass that was expectorated containing Peri strip with titanium staples.

	Comment

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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

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1. Saunders M.S., Cropp A.J., Awad M.J. Spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet: case report. Trauma 1992;33:909-911.[Medline]
2. Cooper J.D., Trulock E.P., Triantafillou A.N., et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106-119.[Abstract/Free Full Text]
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;67:815-817.[Abstract/Free Full Text]
4. Vaughn C.C., Vaughn P.L., Vaughn C.C., 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;13:259-265.[Abstract/Free Full Text]
5. Hazelrigg S.R., Boley T.M., Naunheim K.S., et al. Effect of bovine pericardial strips on air leak after stapled pulmonary resection. Ann Thorac Surg 1997;63:1573-1575.[Abstract/Free Full Text]
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;52:477-480.[Medline]
7. Nguyen H., Nguyen H.V., Barra J.A., Raut Y., Morinaga S., Suemasu K. Absorbable synthetic clips and pulmonary excision. Our clinical experience. Chir (Paris) 1987;124:113-118.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): David A. Waller Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Oey, I. Articles by Waller, D. A. Search for Related Content PubMed PubMed Citation Articles by Oey, I. Articles by Waller, D. A. Related Collections Lung - other