Intraoperative migration of a nail from the left B10b to the main bronchus
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《血管的通路杂志》
a Divisions of Thoracic Surgery, Matsue Red Cross Hospital, 200 Horomachi, Matsue, Shimane 690-8506, Japan
b Respiratory Medicine, Matsue Red Cross Hospital, Shimane, Japan
Abstract
Objective: We report a rare case in which an intrapulmonary foreign body underwent a large intraoperative migration. Method: A 57-year-old man with an intrapulmonary nail in the left S10 was admitted into our hospital. Since the removal by a flexible bronchoscopy was unsuccessful, a thoracotomy was performed. Result: Preoperative chest roentgenograms and a bronchoscopy after an endotracheal intubation confirmed that the nail had not migrated. During the operation, however, the nail moved from the periphery of B10b to the main bronchus. Conclusion: It is mandatory to confirm the precise location of a foreign body even during an operation to avoid unnecessary pulmonary resections.
Key Words: Bronchus; Foreign-body migration; Thoracotomy
1. Introduction
Aspiration of a foreign body into the airway is a common problem in children and elderly people [1–4]. Nowadays most aspirated foreign bodies are removed by a flexible or rigid bronchoscope, and a thoracotomy with a bronchotomy and/or resection of the affected lung segment is required only in 1–3% of all aspiration cases [2,4]. Although a wealth of literature exists describing the benefits and pitfalls of a flexible or rigid bronchoscope [1,3], there are few publications describing the problems with a thoracotomy when it is used to remove an airway foreign body. We herein describe a rare case of an intrapulmonary foreign body, which insidiously migrated intraoperatively from the periphery of the left B10b to the left main bronchus.
2. Case report
A 57-year-old man was referred to our hospital because of an intrapulmonary foreign body in the left lower lobe. He had aspirated a nail through the mouth during a carpentry accident twelve days before arriving at our hospital. A chest roentgenogram revealed a nail in the left lower lung field (Fig. 1a). The subject was admitted to the hospital for a flexible bronchoscopy to remove the nail. We tried to remove the foreign body using several kinds of forceps through a fluoroscope because the nail was beyond the bronchoscopic vision, but all attempts were unsuccessful.
A three-dimensional computed tomography showed that the nail was at the periphery of the left B10b (Fig. 1b). A rigid bronchoscope was unsuitable for removal of the foreign body because of its peripheral position, and a thoracotomy was performed five days after hospital admission. Preoperative diurnal chest roentgenograms and a bronchoscopy performed after a double-lumen endotracheal tube intubation confirmed that the nail had not migrated until the start of the operation. A segmentectomy of the left S10 was planned because it was impossible to identify the nail by palpations. After dividing the pulmonary ligament and exposing of A10 and B10, an intraoperative fluoroscope was performed to identify the precise position of the nail. At that time, the nail had already moved into the double-lumen endotracheal tube inserted into the left main bronchus (Fig. 2a). Therefore, the segmentectomy was halted and the nail was extracted from the endotracheal tube by a flexible bronchoscope with a magnet. Fig. 2b shows the extracted rusty nail. The postoperative course was unremarkable and the patient was discharged without any sequelae.
3. Discussion
It is well recognized that airway foreign bodies located in the central tracheobronchial tree often dislodge and move during the removal procedure [1–3]. However, to our knowledge no published English literature exists describing such a large migration of an airway foreign body lodged deep into the lung periphery during a thoracotomy. Therefore, the present case is quite instructive for general thoracic surgeons.
Shape and chemical nature are two important factors that may have increased the possibility of migration. First, irregularly shaped objects and sharply pointed objects have a tendency to stick to the mucosa of the tracheobronchial tree and become fixed [1]. Second, airway foreign bodies are classified into organic and inorganic substances. Generally, an organic foreign body results in more severe mucosal inflammation, and within a few hours, causes the development of granulation tissue around it [3]. Some organic foreign bodies can absorb water and swell, resulting in total occlusion of the airway [1,3]. Therefore, organic foreign bodies have a tendency to readily immobilize. On the other hand, inorganic foreign bodies are generally inert, and sometimes may be tolerated for many years without prominent symptoms [3]. The aforementioned means that inorganic foreign bodies may migrate even when they have been aspirated a long time previously.
Some inorganic foreign bodies do not result in any clinical symptoms for many years and stay without migration. However, it is impossible to distinguish, shortly after aspiration, which airway foreign body will be clinically indolent for many years and observation is more suitable than intervention. Late complications of aspirated foreign bodies are reported to be bronchial stenosis, recurrent pneumonia, lung abscess formation, and bronchiectasia, which may result in lung destruction [1,2]. Injury to surrounding structures due to migration, which leads to pneumothorax, pyothorax, hemothorax, bronchopleural fistula, massive hemoptysis, etc., is another possible late complication [2]. These complications do not always happen, but once developed, they tend to be serious and intractable. Therefore, airway foreign bodies diagnosed shortly after aspiration should be removed as soon as possible, in case of a patient without considerable comorbidity and a high operative risk.
In the present case, the nail was simply-shaped, not sharp enough to stick to the mucosa, and the nail was made of metal, resulting in no inflammation or granulation of the bronchial mucosa. Although twelve days had passed since the aspiration, the nail was mobilized from the periphery of the tracheobronchial tree. The elevation and palpation of the left lower lobe after pulmonary ligament dissection were probably the main cause of the foreign body migration, and the positive pressure ventilation had little effect to mobilize the nail. However, intraoperative manipulation does not always mobilize the bronchoscopically irremovable foreign body. An excessive manipulation may result in injuries around the foreign body. Accordingly, routine intraoperative squeezing of the lung is not recommended.
In conclusion, in order to avoid unnecessary pulmonary resections, it is mandatory to confirm the precise location of an intrapulmonary foreign body frequently with a fluoroscope and bronchoscope even during a thoracotomy; the aforementioned especially holds true in the case of inorganic and simple-shaped airway foreign bodies, because of the possibility of an unexpected migration. The presumption that a bronchoscopically irremovable airway foreign body is firmly fixed in the bronchial tree and does not migrate intraoperatively is incorrect.
References
Ludemann JP, Hughes CA, Holinger LD. Management of foreign bodies of the airway. In: Shields TW, LoCicero 3rd J, Ponn RB. editors General thoracic surgery 5th 2000;Philadelphia: Lippincott Williams & Wilkins 853–862. In.
Doody DP. Foreign body aspiration. In: Grillo HC. editor Surgery of the trachea and bronchi2004;Hamilton: BC Decker 707–718. In:.
Rafanan AL, Mehta AC. Adult airway foreign body removal. What's new Clin Chest Med 2001; 22:319–330.
Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am 2001; 11:861–872.(Ryutaro Kikuchia, Noritaka Isowaa,, Hiro)
b Respiratory Medicine, Matsue Red Cross Hospital, Shimane, Japan
Abstract
Objective: We report a rare case in which an intrapulmonary foreign body underwent a large intraoperative migration. Method: A 57-year-old man with an intrapulmonary nail in the left S10 was admitted into our hospital. Since the removal by a flexible bronchoscopy was unsuccessful, a thoracotomy was performed. Result: Preoperative chest roentgenograms and a bronchoscopy after an endotracheal intubation confirmed that the nail had not migrated. During the operation, however, the nail moved from the periphery of B10b to the main bronchus. Conclusion: It is mandatory to confirm the precise location of a foreign body even during an operation to avoid unnecessary pulmonary resections.
Key Words: Bronchus; Foreign-body migration; Thoracotomy
1. Introduction
Aspiration of a foreign body into the airway is a common problem in children and elderly people [1–4]. Nowadays most aspirated foreign bodies are removed by a flexible or rigid bronchoscope, and a thoracotomy with a bronchotomy and/or resection of the affected lung segment is required only in 1–3% of all aspiration cases [2,4]. Although a wealth of literature exists describing the benefits and pitfalls of a flexible or rigid bronchoscope [1,3], there are few publications describing the problems with a thoracotomy when it is used to remove an airway foreign body. We herein describe a rare case of an intrapulmonary foreign body, which insidiously migrated intraoperatively from the periphery of the left B10b to the left main bronchus.
2. Case report
A 57-year-old man was referred to our hospital because of an intrapulmonary foreign body in the left lower lobe. He had aspirated a nail through the mouth during a carpentry accident twelve days before arriving at our hospital. A chest roentgenogram revealed a nail in the left lower lung field (Fig. 1a). The subject was admitted to the hospital for a flexible bronchoscopy to remove the nail. We tried to remove the foreign body using several kinds of forceps through a fluoroscope because the nail was beyond the bronchoscopic vision, but all attempts were unsuccessful.
A three-dimensional computed tomography showed that the nail was at the periphery of the left B10b (Fig. 1b). A rigid bronchoscope was unsuitable for removal of the foreign body because of its peripheral position, and a thoracotomy was performed five days after hospital admission. Preoperative diurnal chest roentgenograms and a bronchoscopy performed after a double-lumen endotracheal tube intubation confirmed that the nail had not migrated until the start of the operation. A segmentectomy of the left S10 was planned because it was impossible to identify the nail by palpations. After dividing the pulmonary ligament and exposing of A10 and B10, an intraoperative fluoroscope was performed to identify the precise position of the nail. At that time, the nail had already moved into the double-lumen endotracheal tube inserted into the left main bronchus (Fig. 2a). Therefore, the segmentectomy was halted and the nail was extracted from the endotracheal tube by a flexible bronchoscope with a magnet. Fig. 2b shows the extracted rusty nail. The postoperative course was unremarkable and the patient was discharged without any sequelae.
3. Discussion
It is well recognized that airway foreign bodies located in the central tracheobronchial tree often dislodge and move during the removal procedure [1–3]. However, to our knowledge no published English literature exists describing such a large migration of an airway foreign body lodged deep into the lung periphery during a thoracotomy. Therefore, the present case is quite instructive for general thoracic surgeons.
Shape and chemical nature are two important factors that may have increased the possibility of migration. First, irregularly shaped objects and sharply pointed objects have a tendency to stick to the mucosa of the tracheobronchial tree and become fixed [1]. Second, airway foreign bodies are classified into organic and inorganic substances. Generally, an organic foreign body results in more severe mucosal inflammation, and within a few hours, causes the development of granulation tissue around it [3]. Some organic foreign bodies can absorb water and swell, resulting in total occlusion of the airway [1,3]. Therefore, organic foreign bodies have a tendency to readily immobilize. On the other hand, inorganic foreign bodies are generally inert, and sometimes may be tolerated for many years without prominent symptoms [3]. The aforementioned means that inorganic foreign bodies may migrate even when they have been aspirated a long time previously.
Some inorganic foreign bodies do not result in any clinical symptoms for many years and stay without migration. However, it is impossible to distinguish, shortly after aspiration, which airway foreign body will be clinically indolent for many years and observation is more suitable than intervention. Late complications of aspirated foreign bodies are reported to be bronchial stenosis, recurrent pneumonia, lung abscess formation, and bronchiectasia, which may result in lung destruction [1,2]. Injury to surrounding structures due to migration, which leads to pneumothorax, pyothorax, hemothorax, bronchopleural fistula, massive hemoptysis, etc., is another possible late complication [2]. These complications do not always happen, but once developed, they tend to be serious and intractable. Therefore, airway foreign bodies diagnosed shortly after aspiration should be removed as soon as possible, in case of a patient without considerable comorbidity and a high operative risk.
In the present case, the nail was simply-shaped, not sharp enough to stick to the mucosa, and the nail was made of metal, resulting in no inflammation or granulation of the bronchial mucosa. Although twelve days had passed since the aspiration, the nail was mobilized from the periphery of the tracheobronchial tree. The elevation and palpation of the left lower lobe after pulmonary ligament dissection were probably the main cause of the foreign body migration, and the positive pressure ventilation had little effect to mobilize the nail. However, intraoperative manipulation does not always mobilize the bronchoscopically irremovable foreign body. An excessive manipulation may result in injuries around the foreign body. Accordingly, routine intraoperative squeezing of the lung is not recommended.
In conclusion, in order to avoid unnecessary pulmonary resections, it is mandatory to confirm the precise location of an intrapulmonary foreign body frequently with a fluoroscope and bronchoscope even during a thoracotomy; the aforementioned especially holds true in the case of inorganic and simple-shaped airway foreign bodies, because of the possibility of an unexpected migration. The presumption that a bronchoscopically irremovable airway foreign body is firmly fixed in the bronchial tree and does not migrate intraoperatively is incorrect.
References
Ludemann JP, Hughes CA, Holinger LD. Management of foreign bodies of the airway. In: Shields TW, LoCicero 3rd J, Ponn RB. editors General thoracic surgery 5th 2000;Philadelphia: Lippincott Williams & Wilkins 853–862. In.
Doody DP. Foreign body aspiration. In: Grillo HC. editor Surgery of the trachea and bronchi2004;Hamilton: BC Decker 707–718. In:.
Rafanan AL, Mehta AC. Adult airway foreign body removal. What's new Clin Chest Med 2001; 22:319–330.
Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am 2001; 11:861–872.(Ryutaro Kikuchia, Noritaka Isowaa,, Hiro)