Migration of surgical clips through a right lobectomy stump mimicking an asthmatic syndrome
© Di Crescenzo et al; licensee BioMed Central Ltd. 2013
Published: 8 October 2013
The mechanical stapler is routinely used in thoracic surgery practice to attend resection of bronchus and vessels. Herein, we reported a very rare complication as the migration of a titanium surgical clip through a right lobectomy stump. One year after the procedure, the patient complained of persistent cough. A misdiagnosis of asthma was made and she treated for 6 months with bronchodilators, corticosteroid and antihistaminic without success. Thus, patient re-referred of our unit. No clinical signs of infection as fewer, productive cough, dyspnea were present. The laboratory exams were within normal value including white cells. CT scan revealed no abnormalities. Bronchoscopy demonstrated a healed upper bronchus stump without evidence of an actual, open bronchopleural fistula but with clips apparently working their way into the airway, with approximately half of the clip visible within the lumen. The side of the clips that would be open before closure by the surgeon formed the leading edge of the clips visible in the lumen. The clips were successfully removed during flexible bronchoscopy with a forceps usually used for biopsy. After the procedure, the cough disappeared. The endoscopy check after 3 months showed a normal bronchial stump without evidence of fistula.
The mechanical stapler is routinely used in thoracic surgery practice to attend resection of bronchus and vessels. Herein, we reported a very rare complication as the migration of a titanium surgical clip through a right lobectomy stump. One year after the procedure, the patient complained of persistent cough. A misdiagnosis of asthma was made and she treated for 6 months with bronchodilators, corticosteroid and antihistaminic. Symptoms disappeared after removing surgical clip with flexible bronchoscopy.
Foreign body erosion into the tracheobronchial tree is uncommon and its presentation is highly variable. In literature few reports reported the expectoration of staples and dry bovine pericardial strips used for staple line reinforcement after surgery for emphysema [2, 3]. Saunders and coworkers  reported a case of bullet migration through pulmonary parenchyma and its spontaneous expulsion. Only one paper from Ahmed et al  reported a migration of clips from pneumonectomy and spontaneously expectorated.
In the present case the persistent cough, appeared after 1 year from the lobectomy, was misdiagnosed as asthma disease. The patient was treated for 6 months with medical therapy including bronchodilators, corticosteroid and antihistaminic without success. Then, she was re-referred to our unit. Despite the presence of cough, the diagnosis of bronchopleural fistula was unlike due to lack of fewer, of productive cough and of other clinical and laboratory signs of infection. Bronchoscopy showed a healed upper bronchus stump without evidence of an actual, open bronchopleural fistula but with clips apparently working their way into the airway, with approximately half of the clip visible within the lumen. The side of the clips that would be open before closure by the surgeon formed the leading edge of the clips visible in the lumen. Thus, the persistent cough was due to chronic irritation of bronchial mucosa by clips. Conversely to Ahmed et al  who decided against to remove the clips, we decided to take away the clips because the patient was symptomatic. Despite rigid bronchoscopy is usually indicated for removing foreign body obstructing air way [6–16], in the present case the clips were successfully extracted with a flexible bronchoscopy. After the procedure, the persistent cough disappeared. Yet, the endoscopic view at 3 months showed a normal bronchial stump. In conclusion, in patient undergoing lung resection with persistent cough, bronchoscopy is mandatory in order to exclude the presence of bronchopleural fistula and/ or the migration of surgical clips used to attend bronchus or vessels ligation.
PL: Resident at of Thoracic Surgery - University of Salerno. FN: Resident at of Thoracic Surgery - University of Salerno. CC: Resident in Department of Clinical Medicine and Surgery -University of Naples. MD : acquisition of data, drafting the manuscript, given final approval of the version to be published. BA : acquisition of data, drafting the manuscript, given final approval of the version to be published. AG: Assistant Professor of Pediatric Surgery - University of Salerno. MV: Associate Professor of Endocrinology - University of Salerno. VDC: Assistant Professor of Thoracic Surgery - University of Salerno.
Funding for publication of this article was funded by a donation given by Merck Serono spa to the Department of Clinical Medicine and Surgery, University of Naples "Federico II", Italy.
This article has been published as part of BMC Surgery Volume 13 Supplement 2, 2013: Proceedings from the 26th National Congress of the Italian Society of Geriatric Surgery. The full contents of the supplement are available online at http://www.biomedcentral.com/bmcsurg/supplements/13/S2
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