Ann Thorac Surg 2008;85:2116-2118. doi:10.1016/j.athoracsur.2007.12.026
© 2008 The Society of Thoracic Surgeons
Case Reports
Bronchial Obstruction Due to Teflon Pledgets Migration 13 Years After Lobectomy
Lisa M. Precht, MD,
Eric Vallières, MD*
Section of Thoracic Surgery, Surgical Services, Swedish Cancer Institute, Seattle, Washington
Accepted for publication December 6, 2007.
* Address correspondence to Dr Vallières, Thoracic and Foregut Surgery, 1101 Madison, Ste 850, Seattle, WA 98104 (Email: eric.vallieres{at}swedish.org).
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Abstract
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Bronchopleural fistula is a major cause of morbidity and mortality after pulmonary resection. Different techniques of reinforcing the bronchial stump to prevent this complication have been described. Pledgeted sutures have been suggested for this purpose but have the potential to erode into the bronchus years after resection. We report an unusual case of airway obstruction 13 years after lung resection where pledgeted sutures had been used to reinforce a lobectomy stump. Bronchoscopic management of this rare complication consisted of endobronchial débridement and placement of a silicon stent to allow remodeling of the stenotic airway.
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Introduction
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Bronchopleural fistula is a rare but dreaded complication after pulmonary resections that is, unfortunately, associated with high morbidity and mortality rates. Risk factors for the development of bronchopleural fistula include advanced cancer stage, preoperative chemotherapy or radiation therapy, or both, previous steroid therapy, a residual carcinomatous stump, postoperative mechanical ventilation, chronic obstructive pulmonary disease, diabetes mellitus, and malnutrition [1, 2]. The use of Teflon pledgets (DuPont, Wilmington, DE) has been reported to reinforce the bronchial stump to potentially reduce the incidence of bronchopleural fistula, especially in patients at increased risk [3]. We report a case of bronchial obstruction caused by erosion of Teflon pledgets into the airway 13 years after resection.
In 1994 a 65-year-old man underwent right upper lobectomy for a central squamous cell carcinoma (pT2 N2 M0 R1). The patient subsequently received adjuvant chemoradiation therapy to a dose of 59 Gy in view of positive bronchial resection margins (R1) and extensive N2 mediastinal involvement.
He had been doing well for 13 years after completion of therapy, until the age of 78, when he presented with mild dyspnea, a new cough, and a wheeze. A chest roentgenogram was unremarkable. A computed tomography (CT) scan showed a partially calcified mass surrounding his right mainstem bronchus with endobronchial extension causing significant narrowing of the bronchus (Fig 1). Flexible bronchoscopy confirmed the presence of a mass completely obstructing the right mainstem bronchus (Fig 2), and analysis of biopsy specimens revealed a dense lymphoplasmacytic infiltrate without evidence of malignancy. Subsequent positron emission tomography and CT imaging demonstrated abnormal 2-[fluorine-18]fluoro-2-deoxy-D-glucose uptake in the mass, with a maximum standardized uptake value of 11 but no suggestion of disease elsewhere (Fig 3).
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Fig 1. Chest computed tomography scan shows a right hilar mass that partially surrounds the right mainstem bronchus. Endobronchial extension is suspected.
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Fig 2. (A) Bronchoscopic view of the distal trachea, main carina, the open left main bronchus and occluded right main bronchus. (B) The proximal right main bronchus is completely occluded by a fleshy mass.
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Fig 3. A 2-[fluorine-18]fluoro-2-deoxy-D-glucose positron-emission tomography computed tomography fusion scan shows high uptake in the right hilar mass with a maximum standard uptake value measured at 11.
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The patient was referred for further management. Rigid bronchoscopy allowed endoscopic débridement, and after multiple biopsies, a polypropylene suture was noted in the area. Upon further inspection, it became apparent that we had uncovered sutured foreign material that appeared to be firmly attached to the bronchial wall, which was causing the obstruction. Patency of the airway was reestablished just enough to allow placement of a 10-mm posted silicon stent.
The foreign material was later confirmed to be Teflon. A copy of the 1994 operating report indicated that the right upper lobe bronchus had been taken flush with the main bronchus and that the stump had been closed with 4-0 interrupted polypropylene sutures reinforced on the outside with 8 Teflon pledgets (DuPont). This and our findings at endoscopy confirmed that the bronchial obstruction was secondary to the endobronchial migration of Teflon pledgets that had eroded through the bronchial wall.
The stent was up-sized 6 weeks later, and additional Teflon was removed. The stent was removed 6 months later. The patient has remained asymptomatic, without recurrence of his respiratory symptoms, 1 year since removal.
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Comment
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Although the incidence of bronchopleural fistula has decreased in recent decades, it still remains a major cause of morbidity and mortality after pulmonary resection. Different techniques of reinforcing the bronchial stump to prevent this complication have been described. The use of Teflon pledgets has been suggested for this purpose. As demonstrated in this case, Teflon has the potential to erode into the bronchus years after resection, although probably rarely.
A review of the literature reveals several reports of erosion of Teflon pledgets in surgery. Dally and colleagues [4] reported a series of 11 patients who underwent Teflon pledget-reinforced Nissen fundoplication and presented with symptomatic pledget erosion between 2 and 85 months after the operation. Conn and colleagues [5] described the extrusion of aortic pledgets from a sternal wound 6 years after a cardiac operation. The reports of Teflon erosion in gastric, cardiac, urologic [6], and now pulmonary operations demonstrate the universality of this occurrence.
One has to acknowledge as well that it is possible that the adjuvant radiation therapy the patient received may have contributed to the erosion and migration of the foreign material in our case, a situation not described in the other reports. Patients undergoing lung resection with increased risk for development of bronchopleural fistula may be better served with tissue reinforcement of the bronchial stump using pericardium, pleura, omentum, or muscle flaps [7, 8].
Bronchoscopic management of this rare complication consisted of endobronchial débridement and placement of a silicone elastomer stent to allow remodeling of the stenotic airway. Given our experience with this case and with other benign airway conditions that share similarities with this case, we believe that such conservative management should allow excellent results in most instances and avoid the need for reoperation in such situations.
Another issue this case highlights is the importance of obtaining a tissue diagnosis before embarking on treatment for suspected primary or recurrent lung cancer. This patient was assumed to have a local recurrence of his cancer. He presented with a new cough, and imaging was extremely suggestive of recurrence at the site of the previous incomplete resection. Following the principle to always confirm malignancy before embarking on potentially morbid treatments, we repeated bronchoscopic sampling, which eventually led to the benign diagnosis, thus confirming the axiom that tissue is the issue.
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References
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- Sirbu H, Busch T, Aleksic I, Schreiner W, Oster O, Dalichau H. Bronchopleural fistula in the surgery of non-small cell lung cancer: incidence, risk factors, and management Ann Thoracic Cardiovasc Surg 2001;7:330-336.
- Algar FJ, Alvarez A, Aranda JL, Salvatierra A, Baamonde C, Lopez-Pujol FJ. Prediction of early bronchopleural fistula after pneumonectomy: a multivariate analysis Ann Thorac Surg 2001;75:1662-1667.
- Sato M, Saito Y, Nagamoto N, et al. An improved method of bronchial stump closure for prevention of bronchopleural fistula in pulmonary resection Tohuku J Exp Med 1992;168:507-513.[Medline]
- Dally E, Falk GL. Teflon pledget reinforced fundoplication causes symptomatic gastric and esophageal luminal penetration Am J Surg 2004;187:226-229.[Medline]
- Conn KS, Dunning JJ, Pillai R. Extrusion of Teflon aortic pledgets from a sternal wound six years after cardiac surgery Eur J Cardiothorac Surg 1997;12:150-153.[Abstract]
- Cholhan HJ, Stevenson KR. Sling transaction of urethra: a rare complication Int Urogynecol J Pelvic Floor Dysfunct 1996;7:331-334.[Medline]
- Taghavi S, Marta GM, Lang G, et al. Bronchial stump coverage with a pedicled pericardial flap: an effective method for prevention of postpneumonectomy bronchopleural fistula Ann Thorac Surg 2005;79:284-288.[Abstract/Free Full Text]
- Cerfolio RJ, Bryant AS, Yamamuro M. Intercostal muscle flap to buttress the bronchus at risk and the thoracic esophageal-gastric anastomosis Ann Thorac Surg 2005;80:1017-1020.[Abstract/Free Full Text]
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Abstract
Introduction
