ARTICLE IN PRESS
doi:10.1510/icvts.2006.144683
Interactive CardioVascular and Thoracic Surgery 6 (2007) 92–93
www.icvts.org
Negative results - Thoracic general
Intraoperative migration of a nail from the left B10b to the main
bronchus
Ryutaro Kikuchia, Noritaka Isowaa,*, Hirokazu Tokuyasub, Yuji Kawasakib
Divisions of Thoracic Surgery, Matsue Red Cross Hospital, 200 Horomachi, Matsue, Shimane 690-8506, Japan
b
Respiratory Medicine, Matsue Red Cross Hospital, Shimane, Japan
a
Received 12 September 2006; received in revised form 4 November 2006; accepted 6 November 2006
Abstract
Objective: We report a rare case in which an intrapulmonary foreign body underwent a large intraoperative migration. Method: A 57year-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 B10 b 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.
䊚 2007 Published by European Association for Cardio-Thoracic Surgery. All rights reserved.
Keywords: Bronchus; Foreign-body migration; Thoracotomy
1. Introduction
Aspiration of a foreign body into the airway is a common
problem in children and elderly people w1–4x. Nowadays
most aspirated foreign bodies are removed by a flexible or
rigid bronchoscope, and a thoracotomy with a bronchotomy
andyor resection of the affected lung segment is required
only in 1–3% of all aspiration cases w2,4x. Although a wealth
of literature exists describing the benefits and pitfalls of a
flexible or rigid bronchoscope w1,3x, 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.
*Corresponding author. Tel.: q81-852-24-2111; fax: q81-852-31-9783.
E-mail address: [email protected] (N. Isowa).
䊚 2007 Published by European Association for Cardio-Thoracic Surgery
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 doublelumen 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 w1–3x. 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,
ARTICLE IN PRESS
R. Kikuchi et al. / Interactive CardioVascular and Thoracic Surgery 6 (2007) 92–93
Fig. 1. (a) Chest roentgenogram shows a nail in the left lower lung field. (b)
A three-dimensional computed tomography shows the nail (arrow) lodged in
the periphery of the left B10b.
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 w1x. 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 w3x. Some
organic foreign bodies can absorb water and swell, resulting
in total occlusion of the airway w1,3x. 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 w3x. The aforementioned means that
93
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 w1,2x. Injury to surrounding structures due to migration, which leads to pneumothorax,
pyothorax, hemothorax, bronchopleural fistula, massive
hemoptysis, etc., is another possible late complication w2x.
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
Fig. 2. (a) An intraoperative fluoroscope shows that the nail (arrow) has
already moved into the double-lumen endotracheal tube (arrowheads indicate the radiopaque line of the endotracheal tube). (b) The extracted rusty
nail is shown.
w1x Ludemann JP, Hughes CA, Holinger LD. Management of foreign bodies
of the airway. In Shields TW, LoCicero J, 3rd, Ponn RB, editors. General
thoracic surgery, Edition 5th. Philadelphia: Lippincott Williams & Wilkins, 2000:853–862.
w2x Doody DP. Foreign body aspiration. In: Grillo HC, editor. Surgery of the
trachea and bronchi. Hamilton: BC Decker, 2004:707–718.
w3x Rafanan AL, Mehta AC. Adult airway foreign body removal. What’s new?
Clin Chest Med 2001;22:319–330.
w4x Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin
N Am 2001;11:861–872.