J Thorac Cardiovasc Surg 2003;126:2104
© 2003 The American Association for Thoracic Surgery
Foreign bodies expectorated through the pneumonectomy stump
Raymond A. Dieter, Jr, MD
Dupage Medical Group, General Surgery, Glen Ellyn, IL 60137, USA
To the Editor:
The article by Ahmed and colleagues1 in the November 2002 issue, "Benign Expectoration of a Surgical Clip Through a Pneumonectomy Stump," was of interest to me. Certainly all of us performing pulmonary surgery, especially lobectomy and pneumonectomy surgery, are concerned regarding the potential for healing of the bronchial stump and possible breakdown with fistula formation. Various possible causes for such concern include the type of suture (such as silk), the length of the bronchial stump, and the closeness of any tumor or acute infectious process to the line of resection. In addition, the vascularity of the remaining bronchus is certainly important in the healing. More recently, the use of staples and surgical clips in the performance of thoracic surgery has become frequent to reduce the time of the surgical procedure, the amount of air leakage, and the prolonged comorbidity.
The article by Ahmed and colleagues1 describes a patient with cystic bronchiectasis who had undergone a right upper lobectomy followed by a completion pneumonectomy. The patient several years later had a coughing spell and expectorated a surgical clip without systemic signs. Ahmed and colleagues1 noted that they were unaware of any previous report of nonreactive commonly used titanium surgical clips eroding into the bronchial tree.
Shamji and coworkers2 reported on surgical staple metalloptysis after apical bullectomy and placement of pericardial buttresses. They cited possible local inflammation as a cause for erosion. All of us performing pulmonary surgery over a long period have had unusual postoperative occurrences develop. I was among the authors of an article in 1974 entitled "Unusual Expectoration,"3 in which we reported a number of interesting and unusual items coughed up by patients. These included a bullet and shrapnel. One patient after right lung surgery coughed up 11 of 12 titanium surgical clips. This particular patient brought the clips to us on a routine postoperative visit in an envelope and asked what he should do with them. Chest radiography and physical examination demonstrated no adverse effects from expectoration of these metallic clips. Radiography showed that he retained only 1 surgical clip. A letter was sent to the manufacturing company, inquiring as to the incidence of such an occurrence. No response was ever received from the manufacturer.
I appreciate the article, and I also would suggest that when any foreign body is used in thoracic surgery, particularly in the lung, there is a possibility that the patient will expectorate that foreign body and bring it to the attention of the physician. Ahmed and colleagues’ article1 was not the first such report, as demonstrated by our report of 27 years before.
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References
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- Ahmed Z, Kaiser LR, Shrager JB. Benign expectoration of a surgical clip through a pneumonectomy stump. J Thorac Cardiovasc Surg. 2002;124:1025–1026[Free Full Text]
- Shamji MF, Manjiak DE, Shamji FM, Matzinger FR, Perkins DG. Surgical staple metalloptysis after apical bullectomy: a reaction to bovine pericardium? Ann Thorac Surg. 2002;74:258–261[Abstract/Free Full Text]
- Dieter RA Jr, Cornell R, Hasbrouck P. Unusual expectoration. Am Fam Physician. 1974;10:112–116
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