Ann Thorac Surg 2004;78:2156-2157
© 2004 The Society of Thoracic Surgeons
Case report
Successful Removal of Bovine Pericardium by Bronchoscope After Lung Volume Reduction Surgery
Akinori Iwasaki, MDa,*,
Yasuteru Yoshinaga, MDa,
Takayuki Shirakusa, MDa
a Second Department of Surgery, School of Medicine, Fukuoka University, Fukuoka, Japan
Accepted for publication July 29, 2003.
* Address reprint requests to Dr Iwasaki, Second Department of Surgery, School of Medicine, Fukuoka University, 45-1, 7 Chome Nanakuma, Jonan-ku, Fukuoka 814-0180, Japan
akinori{at}fukuoka-u.ac.jp
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Abstract
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We report on a patient in whom, 10 months after lung volume reduction surgery, bovine material visibly migrated to the bronchial lumen. In this particular case, bronchoscopic treatment was successful. The patient remained well 12 months after such treatment. The report also suggests that the alternative use of absorbable material will reduce later postoperative complications.
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Introduction
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Currently, the National Emphysema Treatment Trial, a multicenter randomized trial, is under way to evaluate the benefits and useful therapy for lung volume reduction surgery (LVRS) [1]. In general, the LVRS procedure involves resection of the worst target area by thoracoscope or through a median sternotomy [2]. There have been many reports on survival, functions, mortality, and morbidity after LVRS [3]. Early morbidity for these procedures is mainly associated with prolonged air leakage. To protect against air leakage and to reduce complications, Cooper and colleagues [4] have reported on a technique in which bovine pericardium is used as a buttress for the staple line. After publication of this report, many patients with severe emphysema underwent resection of a target area relying on the described procedure. In these cases buttressing material contributed to reduced air leakage and early postoperative complications. Recently more long-term outcomes have been evaluated and a few late complications have been reported [5]. One such complication consists of chronic inflammation, especially related to the bovine pericardium (Peri-Strip). Yet none of these previous reports discussed direct treatment; instead, only measures such as antibiotic administration were used [6]. Several later reports reflected the same conservative therapy of antibiotics. Here we report on the first case of direct therapy, ie, removal with a bronchoscope.
According to our inclusion criteria, we selected a 73-year-old man who had undergone bilateral thoracoscopic LVRS. Both target areas were in the same basal lower lobe, and were resected using an ELC45 stapler (Ethicon, Cincinnati, OH) with a Peri-Strip (Biovascular, Minneapolis, MN). The patient experienced minor right air leakage lasting 6 days and displayed no remarkable postoperative change.
Subsequently the subject showed marked initial clinical and physiologic post-LVRS improvement. Six months later, the patient experienced cough and expectoration of sputum. He returned complaining of severe continuous cough and mild fever 10 months after LVRS surgery. A chest roentgenogram showed an infiltrative shadow in the right lower field of the lung. A computed tomographic scan showed consolidation in the same lesion (Fig 1). White blood cell counts and C-reactive protein levels, which were 13,400/mm3 and 56.25 mg/dL, respectively, suggested bronchopneumonia. After 1 week of treatment with antibiotics, the patient's symptoms persisted. Bronchoscopy was performed to obtain diagnosis. Investigation with the flexible bronchoscope revealed an endobronchial foreign body, located from the right lower bronchus to the carina, which appeared to be a Peri-Strip with staple (Fig 2). Initially we planned simply to observe the item, worried that attempts at removal could lead to complications such as bleeding, which we were unequipped to handle in the endoscopic examination room. After this bronchoscopic examination, it was decided that an endobronchial operation would be performed instead of a right thoracotomy in the operating room. This procedure was successful: the Peri-Strip with the staple was grasped and removed from the bronchus using the bronchoscope (Fig 3). One week later the patient was discharged from the hospital. The patient's postoperative course remained uneventful and without symptoms 1 year after the procedure.
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Fig 1. Computed tomographic scan demonstrating consolidation, with high metallic density in the right lower lobe.
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Fig 2. Flexible bronchoscopic finding. (A) Peri-Strip is located along the right bronchus. (B) Right lower subsegment after removal. Arrow shows the path of removal.
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Comment
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In thoracic surgery, bovine pericardium is a common material used to cover defects in the pericardium; it is also used in heart-valve replacement as well as to reinforce the pleura. This material is treated with glutaraldehyde to diminish antigenicity. Recently, the government suspended permission for its use because of the problem of the viral infection bovine spongiform encephalopathies in Japan. We report a case of visible migration of bovine material to the bronchial lumen and subsequent successful treatment by bronchoscopy. A number of previous reports have described cases of expectoration of surgical staples with Peri-Strip after LVRS [5]. All of these cases occurred within 20 months of LVRS, except in a single 5-year case. In the present case, the patient began coughing at 6 months and symptoms became marked at 10 months after LVRS. It is unclear why the material migrated directly into the endobronchus. Saunders and colleagues [7] reported a case of spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet. Therefore, we speculated that chronic inflammation close to the bronchus occurred to a significant extent and that one part of the foreign body penetrated the bronchial wall. After that, according to the process of expectoration of a foreign body, the item was separated from the surrounding tissue of the lung. Other reports have only rarely reported severe symptoms such as hemoptysis, and there was an absence of such symptoms in our case. Instead symptoms mainly consisted of a cough resulting from irrigation of the bronchial epithelium. We saw no endobronchial bleeding after removal of the Peri-Strip by the flexible bronchoscope. The possibility of such bleeding was an initial concern, but this proved unfounded. When LVRS is performed the Peri-Strip is rinsed many times for deletion in an antigenic solution (propylene oxide) before use. We speculate that in the reported cases the Peri-Strip caused a reaction in the lung, and that chemical treatment with a glutaraldehyde or propylene oxide may not be able to prevent this reaction. This mechanism may provide an explanation for reports that the use of bovine pericardium is characterized by early chronic inflammation and minimal fibroplasia [8]. We further speculated about what is encapsulating the tissue that easily led to inflammation, leading to possible expectoration of the Peri-Strip. Currently we have changed from the use of the bovine Peri-Strip to the use of absorbable polyglycolic acid sheets. Each side of a stapler was covered with polyglycolic acid felt, and this stapler was used to resect the target area. After use of this absorbable material in 10 cases, no complications such as that of the present case have been seen. We believe that the use of such absorbable material will reduce the later postoperative complications in cases of LVRS.
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References
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- The National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume–reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003;348:2059–2073[Abstract/Free Full Text]
- McKenna RJ, Brenner M, Fischel RJ, Gelb AF. Should lung volume reduction for emphysema be unilateral or bilateral? J Thorac Cardiovasc Surg. 1996;112:1331–1339[Abstract/Free Full Text]
- Koebe HG, Kugler C, Dienemann H. Evidence-based medicine: lung volume reduction surgery (LVRS). Thorac Cardiovasc Surg. 2002;50:315–322[Medline]
- Cooper JD, Patterson GA, Sundaresan RS, et al. Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg. 1996;112:1319–1330[Abstract/Free Full Text]
- Ahmed S, Marzouk KA, Bhuiya TA, Iqbal M, Rossoff L. Asymptomatic expectoration of surgical staples complicating lung volume reduction surgery. Chest. 2001;119:307–308[Abstract/Free Full Text]
- Shamji MF, Maziak DE, Shamji FM, Matzinger FRK, Parkins DG. Surgical staple metalloptysis after apical bullectomy: a reaction to bovine pericardium? Ann Thorac Surg. 2002;74:258–261[Abstract/Free Full Text]
- Saunders MS, Cropp AJ, Award MJ. Spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet: case report. Trauma. 1992;33:909–911[Medline]
- Vaughn CC, Vaughn PL, Vaughn CC III. Tissue response to biomaterials used for staple-line reinforcement in lung resection: A comparison between expanded polytetra- fluoroethylene and bovine pericardium. Eur J Cardiothorac Surg. 1998;13:259–265[Abstract/Free Full Text]
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Abstract
Introduction
