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Ann Thorac Surg 2002;74:258-261
© 2002 The Society of Thoracic Surgeons

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Case report

Surgical staple metalloptysis after apical bullectomy: a reaction to bovine pericardium?

^a Division of Thoracic Surgery, The Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
^b Department of Diagnostic Imaging, The Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada
^c Department of Pathology, The Ottawa Hospital, Civic Campus, Ottawa, Ontario, Canada

Accepted for publication February 17, 2002.

* Address reprint requests to Dr Maziak, The Ottawa Hospital, Civic Campus, 1053 Carling Ave, CPC Rm 162, Ottawa, Ontario K1Y 4E9, Canada
e-mail: dmaziak{at}ohri.ca

	Abstract

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Palliation of symptomatic emphysema may include bullous resection to improve function of the remaining lung. Buttressing staple lines with bovine pericardium partially alleviates postoperative air leak, but can promote inflammation and infection. We report a patient expectorating staples and pericardium 5 years after bilateral apical bullectomy. Previous reporting of this complication in lung volume reduction operation also involved both pericardium and staples, and we propose that an ongoing local inflammatory reaction to these materials may facilitate delayed erosion into airways.

	Introduction

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Surgical treatment of emphysema currently includes bullectomy and a lung volume reduction operation. The removal of large bullae allows for improved function of the remaining lung through decreased airway resistance, relief of compressive effect, and reduction of physiologic dead space. The latter technique reduces the work of breathing by resection of hyperinflated lung areas to allow for normal diaphragmatic function, increased recoil properties of the remaining lung tissue, and increased vital capacity [1]. With the residual functioning lung tissue, subjective factors of dyspnea and exercise tolerance, and objective measurements of forced expiratory volume in 1 second and PaO₂ are normally markedly improved [2]. Emphysematous lung is often unforgiving, and bovine pericardium buttressing of areas of stapling is used to reduce air leak. However one must address the question of whether this elicits inflammation and infection, thereby promoting erosion of materials into the larger bronchi. Two previous reports outline cases of metalloptysis, the asymptomatic expectoration of surgical staples accompanied by pericardium after lung volume reduction operation, and we report the first case of symptomatic expectoration of the same materials after bilateral apical bullectomy for major bullous disease.

A 35-year-old male and former 30 packs per year smoker presented with shortness of breath and anterior bilateral chest pain on exertion. Previously well, he worked in a steel factory where he was exposed to welding fumes. Chest radiography demonstrated bilateral upper lobe bullous cysts, flattened diaphragms, and a hyperinflated left chest that was confirmed by computed tomographic scan. He was found to be a good surgical candidate and underwent bilateral apical bullectomy through a median sternotomy. A bovine pericardium-reinforced PLC-55 staple line was applied to both apices and a similarly reinforced RL-30 staple line was used to excise bullous disease observed in the left lower lobe. Significant postoperative bleeding required reoperation to achieve hemostasis by figure of eight catgut stitches of two arterial bleeders from the staple line. The postoperative recovery was otherwise unremarkable. He returned 4 years later complaining of a cough, hemoptysis, and continued expectoration of staples. A computed tomographic scan of the right upper lobe showed a lesion consistent with an inflammatory process (Fig 1A). The cough specimen revealed a pale tan fibrinous fragment of tissue (the pericardial patch), multiple staples, and a blue Prolene suture (Ethicon, Somerville, NJ). Acute inflammatory cells (neutrophils) with colonies of mixed bacterial flora were also present (Fig 1B). Flexible bronchoscopy did not reveal any evidence of any retained staples and bronchial washings showed inflammatory cells. Needle biopsy sampling of the new right apical lung lesion revealed inflammatory cells around a small noncaseating granuloma. He was treated with ciprofloxacin for a suspected chest infection. He continued to cough up the foreign material for 3 months and has not had any recurrence as of 1 year.

View larger version (69K): [in this window] [in a new window]   Fig 1. (A) Computed tomographic scan of the chest (4 years postapical bullectomy). Note the inhomogenous infiltrative lesion in the right upper lobe, consistent with inflammatory changes. (B) Expectorated material with hematoxylin phloxine saffron stain at original magnification x250 showing bovine pericardium (upper arrow) and neutrophils (lower arrow).

	Comment

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Dense epicardial reactions can occur when bovine pericardium is used as a substitute to primary closure after coronary revascularization. Histology of the sample during reoperation demonstrated significant neovascularization, lymphocytic infiltration, fibroblastic reaction, and edema. Reported complications include high fever of otherwise unexplained origin and sterile abscess cavity formation that resolved only upon removal of the graft for resolution [7]. Though markedly atypical, these cases indicate the possibility of severe inflammatory reaction to the processed tissue and suggest that caution regarding the clinical use of bovine pericardium to be appropriate. Large studies demonstrating the frequency of such responses have yet to be reported.

Despite this case, the rare nature of this complication leads our institution to continue use of bovine pericardium buttress for lung volume reduction operations and bullectomies. There has been interest in the use of polytetrafluoroethylene in canine models with the findings of no focal inflammation, as well as significantly greater tissue coverage of the graft when compared with bovine pericardium [8]. A paucity of literature surrounding the phenomenon of metalloptysis exists, and no cases have been reported involving surgical staple expectoration when polytetrafluoroethylene buttresses have been used. A potential fear of bacterial colonization of this synthetic biomaterial [9] has thus far cautioned many against adopting its use, but definitive clinical trials are needed before conclusive comment can be made.

As mentioned, buttressing of staple lines has become common to attempt prevention of air leak after pulmonary resection. The application of this reinforcement reduces the duration of the tube thoracostomy as well as hospital length of stay [10]. However cost analysis was insignificantly changed because the benefit was offset by the material costs. There is much evidence suggesting a local inflammatory reaction to the bovine pericardium that may facilitate the materials’ erosion into the airways from which they could be expectorated. Cases in the literature all include surgical staple metalloptysis accompanied by pericardial patches, and there have been no reports of surgical staple expectoration unaccompanied by such material. Also, the combined staple and pericardium expectoration further reaffirms a likely ongoing local reaction to material with documented antigenicity. Whereas the surgical practice at our institution has not changed, and bovine pericardium buttressing is still used, we advise that surgeons be aware of this rare complication.

	References

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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): Donna E. Maziak Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shamji, M. F. Articles by Perkins, D. G. Search for Related Content PubMed PubMed Citation Articles by Shamji, M. F. Articles by Perkins, D. G. Related Collections Lung - other