Ann Thorac Surg 2008;86:958-961. doi:10.1016/j.athoracsur.2008.05.036
© 2008 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Foreign Bodies in Pleura and Chest Wall
Dov Weissberg, MDa,b,*,
Dorit Weissberg-Kasav, MDa,b
a Department of Thoracic Surgery, Tel Aviv University Sackler School of Medicine, Tel Aviv, Israel
b E. Wolfson Medical Center, Holon, Israel
Accepted for publication May 9, 2008.
* Address correspondence to Dr Weissberg, 11 Be'eri Street, Rehovot, 76352, Israel (Email: dovw{at}post.tau.ac.il).
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Abstract
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Background: In contrast to other locations, foreign bodies in pleura and chest wall have been rarely reported and there is no consensus with regard to treatment.
Methods: Between 1971 and 2001, 22 patients with foreign bodies in pleura or chest wall were admitted to our department. Their charts were reviewed for preoperative diagnosis, history, kind and location of the foreign bodies, length of retention, management of patients, and complications.
Results: Three etiologic groups were identified: iatrogenic (11 patients), traumatic-intentional (10), and accidental (1). Foreign bodies were extracted in 21 patients: at thoracotomy in 6, direct pleuroscopy in 6, video-thoracoscopy in 4, and simple incision in 5. One foreign body was left behind because of objection of parents. There were no complications and no deaths. Follow-up lasted from one year to 7 years in 15 patients (68.2%). Seven patients did not show for follow-up.
Conclusions: Foreign bodies should be removed from pleura and chest wall, when possible. Small, blunt, peripherally located foreign bodies may be left behind if difficulties at extraction are anticipated. Thoracotomy may be needed for treatment of associated injuries, and for removal of materials used in plombage, because of adhesions. In others the use of videothoracoscopy is preferable. Physicians performing diagnostic and therapeutic procedures in anatomic proximity of pleura should exert utmost care to avoid iatrogenic introduction of a foreign body.
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Introduction
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Retained foreign bodies (FBs) in the tracheobronchial tree, gastrointestinal tract, peritoneal cavity, and in various other locations have been the subject of many reports and reviews. In contrast, pleural cavity and chest wall have been rarely mentioned in this association, usually as case reports, and there is no consensus with regard to treatment [1–6]. Over a 30-year period we encountered 22 patients with FBs retained in the pleural cavity or in the chest wall. Our experience with these patients is summarized in this report.
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Patients and Methods
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Approval for this study was obtained from our Institutional Review Board, and individual consent was waived. Between July 1971 and December 2001, 22 patients with FBs in the pleural cavity or in the chest wall were hospitalized in the Wolfson Medical Center. Their charts were reviewed for patient demographics, preoperative diagnosis, etiology, kind and location of the FB, timing of the procedure (emergency versus elective), type of the procedure, and complications.
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Results
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There were 14 male and 8 female patients from 2 to 73 years old, average 38.3. Three etiologic groups were identified (Table 1).
Iatrogenic
This group comprises 11 patients. In 4 instances the FB was retained accidentally; in 7 it was placed in the chest as part of a therapeutic procedure, plombage in the treatment of pulmonary tuberculosis.
Traumatic-intentional
Ten patients were identified. This group includes 5 instances of altercation or aggressive intent, and 5 patients with unstable personalities who caused damage to themselves.
Accidental
One patient was identified.
All FBs except one were extracted. This was accomplished at direct pleuroscopy using mediastinoscope in six patients, with help of videothoracoscopy in 4, at full thoracotomy or minithoracotomy in 6, and with the aid of a simple incision and various grasping instruments in 5. There were no complications and no deaths related to the procedure. In one pediatric patient the parents had not consented to treatment and the FB was left behind.
The follow-up lasted from one year to 7 years in 15 instances. Of these, 10 patients were doing well at their latest follow-up, although one was later admitted to another hospital because of a repeated intentional insertion of another FB. In one patient there was a residual draining sinus after extraction of Lucite (polymerized methyl methacrylate) balls. Four patients died at ages from 64 to 73 years. Their deaths occurred from 2 years to 7 years after the FB extraction, from causes unrelated to the procedure.
Seven patients did not show for follow-up. This group includes 4 patients involved as victims in bellicose or aggressive activity, one prisoner, the child whose parents did not cooperate, and the girl with the ball-point pen penetrating pleura, who did not keep her appointment (patient 22 in Table 1).
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Comment
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In the era of treatment of pulmonary tuberculosis by plombage, various FBs were placed in the chest in order to compress the lung and "keep it at rest." The efficacy and usefulness of this method of treatment is beyond the scope of this paper, although it appears that in a considerable proportion of patients the tuberculous process had been arrested. However, leaving the FB in the chest (either in the pleural cavity or extrapleurally) predisposed the patient to a potential infection at some future time. Indeed, a certain proportion of the FBs became infected, resulting in some of the patients in a full-blown empyema; in others, in smaller collections of pus or in draining sinuses [7, 8]. In other patients, migration of paraffin blocks or Lucite balls into the mediastinum, muscles of the chest wall, or the subcutaneous tissue has been observed. This was often accompanied by compression or erosion of vital organs [7, 9] or by infection at the new location [8, 10–12]. Among our patients, the infections and migrations had occurred many years (sometimes decades) after the initial treatment, and numerous patients had changed their country of residence. Thus it is impossible to determine in what proportion of patients these complications had occurred. Because of infections, these FBs must be extracted. While the best way of extraction from the pleural cavity would be either thoracotomy or videothoracoscopy, it is the authors conviction that adhesions and severe scarring after the past tuberculosis and therapeutic procedures, point to thoracotomy as the better approach in this group of patients [7, 8].
Another subgroup consists of 5 patients who placed needles and pins intentionally in their chest. The reasons for their deeds ranged from plain stupidity and psychopathic personalities to intentionally introduced pneumothorax by a prisoner who wished to spend some time in the hospital; a welcome respite from his jail term. For extraction of the needles either direct pleuroscopy or videothoracoscopy are sufficient. As this series started in 1971, before videothoracoscopy was available, it is heavy-weighted in favor of pleuroscopy. At present, the advantages of the video method with its much improved visualization of the pleural cavity would be chosen, rather than pleuroscopy. Indeed, in recent years we used the videothoracoscopy in patients with penetrating trauma, such as the next subgroup.
The third subgroup consists of 5 patients, victims of an aggressive attack, such as stabbing or intentional explosion. In 2 of these, thoracotomy was unavoidable for treatment of associated injuries; in 3 others videothoracoscopy was used to rule out intrathoracic injuries. Video-assisted thoracic surgery (VATS) is both safe (2% of procedure-related complication rate) and effective (0.8% missed injury rate), and should be used if feasible [3, 5, 13]. Even if conversion to an open thoracotomy is eventually necessary, initial exploration with VATS may determine the size, shape, and extent of the incision [5]. In 6 patients the FBs were removed by a simple "cut down" incision and a variety of forceps [5, 13].
Some of the FBs may be difficult to diagnose, causing delay of treatment, as exemplified by the surgical sponge in patient 1 (Table 1). This patient had been treated in the era preceding computerized tomography (CT). Had the CT been available, this FB would have been diagnosed earlier, with earlier referral for treatment.
Although no complications occurred in relation to extracting any of the FBs, one case was caused by us, while extracting a nut fragment from the left bronchus in a child. At the moment of grasping, one jaw of the extracting forceps broke off and by force of expansion was shot off to the pleura (patient 4, Table 1; Fig.1). Consequently, the child's parents refused any further cooperation, including follow-up examinations. This brings up the question whether all pleural FBs should be routinely extracted. Massard and colleagues [7] recommended routine ablation of any residual plombage material whenever operative risk is acceptable because of high incidence of infection and migration. This is particularly applicable to FBs located in the immediate proximity of major vessels, heart, or esophagus, and to all sharp FBs, lest they penetrate and cause bleeding or damage to organs [7, 9, 11]. It is also applicable to all large FBs introduced traumatically, particularly if they contain potentially contaminated material, such as parts of clothing and dirt. However, most of the small and clean objects located in the periphery are fairly well-tolerated and can be left behind [14, 15].
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Fig 1. Chest roentgenogram shows complete left-sided pneumothorax and metallic foreign body (jaw of forceps) near the pericardiophrenic angle.
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Only 15 of our patients (68.2%) were followed regularly. Others did not keep their appointments due to the social composition of our group. Patients involved in bellicose activity, mentally compromised and psychopaths, do not usually care for their well being unless considerable suffering is involved.
We conclude the following. (1) FBs in pleura and chest wall should be removed whenever possible. Small, blunt, and peripherally located FBs may be left behind, if difficulties at extraction are anticipated. (2) Thoracotomy may be necessary after treatment of tuberculosis by plombage; because of excessive adhesions, and for treatment of associated injuries after trauma. In others, treatment by VATS is preferable and recommended. (3) Physicians involved in diagnostic and therapeutic procedures in close proximity to pleura should exert utmost care to avoid iatrogenic introduction of FBs.
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References
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Abstract
Introduction
