Interactive Cardiovascular and Thoracic Surgery 2:268-269(2003)
© 2003 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Multiple pellets expectoration: bronchial repair by using a costal cartilage graft
Fahri O uzkayaa,* and
Yigit Akçal b
a Department of Thoracic Surgery, Erciyes University Faculty of Medicine, 38039 Kayseri, Turkey
b Department of Cardiovascular Surgery, Erciyes University Faculty of Medicine, 38039 Kayseri, Turkey
* Corresponding author. Tel.: +90-532-585-5343; fax: +90-352-437-5285
foguzkaya{at}erciyes.edu.tr
Received August 25, 2002;
received in revised form January 9, 2003;
accepted February 26, 2003
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Abstract
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Foreign body expectoration resulting from penetrating thoracic injury is an extremely rare condition. It requires bronchoscopy for diagnosis, and if there is a bronchial wound with a large tissue defect, costal cartilage grafting covered with a vascularized muscle flap is suggested as a good alternative for the treatment.
Key Words: Pellet expectoration; Bronchial repair
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1. Introduction
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Foreign bodies resulting from penetrating thoracic injury rarely cause symptoms such as bullet expectoration in early post-traumatic period [1]. To our knowledge we report the first case in which intrathoracic multiple pellets penetrated into bronchus, located, and eventual expectorated by coughing.
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2. Case report
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A 19-year-old man was admitted to emergency room because of shot-gun injury. He had a wound of approximately 5x5 cm in left anterior axillary line on 3th–5th intercostal space. Wound contained a full-thickness tissue defect and multiple fractures of ribs, and it was also ‘sucking wound’ type. Blood pressure was 90/60 mmHg, and heart rate was 100 per minute. Respiration rate was 38/min. On oscultation, respiratory sounds had been diminished on him left hemithorax. Chest X-ray revealed a left hemopneumothorax, and multiple pellets which were scattered in left hemithorax. We performed wound debridement, and closed it. The lung was re-expanded after a chest tube was inserted. There was no air-leak. He was stabilized medically. The broncoscopy was not performed as an initial procedure because the patient had no finding of bronchial injury. Sixteen hours after the injury, bronchoscopy was performed because of the pellet expectoration.
It was seen a wad which penetrated anteriorly the left lower lobe bronchus just below secondary carina and obstructed nearly the bronchial lumen, and also seen multiple pellets throughout left main bronchus. The pellets were removed, and then, a left posterolateral thoracotomy was performed. It was found that wad penetrated anterolaterally the upper lobe, went towards the hilum, and eventual lodged in the secondary carina partially. When the wad was extracted, a 15x10 mm sized bronchial defect, which extended toward the secondary carina, was seen in the left lower lob bronchus. There was no vascular injury.
The sixth costal cartilage was removed through the thoracic cavity. The removed cartilage was split in thickness of 2 mm for use as a patch-graft. Then, this graft was sutured interruptedly with 4-0 polydiaxonone sutures to close the bronchial defect. Also the cartilage graft was covered with a vascularized, pedicled intercostal muscle flap. Blood clots and secretions were cleaned by bronchoscopy at the 1st day after the operation. He discharged at postoperative 7th day.
The patient was asymptomatic during the follow-up period (however, he expectorated postoperatively three pellets 1st week), and there was no pulmonary complication and there were still the pellets were on roentgenogram in postoperative 9th month (Fig. 1). He was controlled bronchoscopically 1 year after the operation. It was found that the bronchial lumen was open in spite of mild granulation tissue at the operation field (Fig. 2). The patient who had no symptom refused the treatment for bronchial granulation.
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3. Conclusion
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Expectoration of any intrathoracic foreign body resulting from penetrating chest injury is seen very rarely. This is associated with bronchopulmonary injuries. Especially, the expectoration of metallic objects is extremely rare. Saunders et al reported an expectorated bullet 3 months after the injury [1]. Surgical exploration should be performed in the probability of a bronchopleural fistula. In our case, we demonstrated that the patient expectorated some pellet at each period of coughing. To our knowledge, a similar case has not been reported previously.
A foreign body expectoration is a bronchoscopy indication for the evaluation of tracheobronchial injury and the exploration of the other foreign bodies.
In the treatment of lobar bronchial injuries, especially, which include vascular injury and parenchymal damage, lobectomy may be recommended [2]. However, parenchyma-sparing procedures should be chosen as possible [3]. We preferred a parenchyma-sparing procedure in our case. We did not prefer a primary repair or a bronchial sleeve resection because the length of defect was 15 mm, and its width was less than a half of bronchial circumference.
We used free costal cartilage graft, which has been suggested for repairing of congenital tracheal strictures [4,5], and covered the graft with pedicled, vascularized intercostal muscle flap. We found bronchial continuity with reasonable granulation tissue at the end of the 1st year.
In conclusion, a foreign body expectoration resulting from penetrating thoracic injury requires bronchoscopy for diagnosis, and costal cartilage grafting covered with vascularized muscle flap is suggested as a good alternative for the treatment of such a bronchial defect.
doi:10.1016/S1569-9293(03)00052-5
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References
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- Saunders MS, Cropp AJ, Awad M. Spontaneous endobronchial erosion and expectoration of a retained intrathoracic bullet: case report. J Trauma. 1992;33:909–911[Medline]
- Battistella FD, Benfield JR. Blunt and penetrating injuries of the chest wall, pleura, and lungs. Shields TW, LoCicero III, Ponn RB. General thoracic surgery. Philadelphia, PA: Lippincott Williams & Wilkins; 2000. p. 815–831
- Rocco G, Allen M. Bronchial repair with pulmonary preservation for severe blunt trauma. Thorac Cardiovasc Surg. 2001;49:231–233[Medline]
- Oue T, Kamata S, Usui N, Okuyama H, Nose K, Okada A. Histopathologic changes after tracheobronchial reconstruction with costal cartilage graft for congenital tracheal stenosis. J Pediatr Surg. 2001;36:329–335[CrossRef][Medline]
- Hartley BE, Gustafson LM, Liu JH, Hartnick CJ, Cotton RT. Duration of stenting in single-stage laryngotracheal reconstruction with anterior costal cartilage grafts. Ann Otol Rhinol Laryngol. 2001;110:413–416[Medline]
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Abstract
1. Introduction
