INTRODUCTION: We describe a patient who underwent esophagectomy and gastric interposition, which was complicated post-operatively by mediastinitis and vertebral osteomyelitis. He developed cough and was found to have an endobronchial inflammatory polyp due to migration of a surgical staple into the airway.
CASE PRESENTATION: A 62 year old man, who recently underwent esophagectomy and gastric interposition for esophageal cancer, presented with a 10-day history of fever, back pain and cough. The cough was productive of yellow sputum. There was no hemoptysis. Physical exam revealed fever and tenderness over the thoracic spine. Chest computed tomography (CT) revealed evidence of mediastinitis, thoracic spine osteomyelitis and a 5 mm polypoid mass with a central focus of high attenuation in the left mainstem bronchus that was not present on prior study (figure 1). Flexible bronchoscopy showed a friable, smooth, mobile, polypoid mass partially obstructing the left mainstem bronchus (figure2). Forceps biopsies of the mass were obtained and sent for histopathology. After biopsy, a metallic foreign body (FB) was seen in the center of the polyp. The FB was removed using biopsy forceps. The mass was not completely excised and was still partially obstructing the left mainstem bronchus at the end of bronchoscopy. Pathology demonstrated squamous epithelium and acute on chronic inflammation consistent with fibro-connective tissue, surrounding a surgical staple. Patient’s cough resolved within 2 weeks after removal of FB without additional treatment. Follow-up Chest CT 3 weeks later showed complete resolution of the left mainstem bronchus mass.
DISCUSSIONS: The patient’s esophagectomy and gastric pull-up surgery was complicated by mediastinal-esophageal fistula and mediastinitis that led to tissue breakdown and migration of the surgical staple into the airway. Staple line breakdown from chronic infection and local tissue invasion had been reported in the literature. Chest CT 1 week prior to bronchoscopy showed findings suggestive of mediastinitis with no evidence of endobronchial lesion. The patient’s cough began around the time of this CT, persisted for 1 week, and a follow-up CT demonstrated an endobronchial mass. A FB was suggested on CT. The FB, but only a small part of the polyp, was successfully removed via bronchoscopy. This case is unusual in that the surgical staple migrated into the airway within 1 week and it was associated with the formation of an inflammatory polyp. Prior case reports have suggested that the use of inhaled and systemic corticosteroids (CS) after removal of the FB may help in resolution of the polyp and its mass effect (1, 2). In our case, CS was not used due to concern that this may interfere with healing of the esophageal fistula. In our case, removal of the FB itself resulted in disappearance of the inflammatory polyp and the patient’s cough (2).
CONCLUSION: Development of an endobronchial inflammatory polyp due to surgical staple migration is a potential post-operative airway complication in esophagectomy and gastric interposition. Removal of the FB via flexible bronchoscopy, as in this case, may lead to resolution of the polyp and symptoms, without addition of CS. The role of CT and flexible bronchoscopy in evaluation of cough after mediastinal intervention is also key.
DISCLOSURE: Abdulilah Arafeh, No Financial Disclosure Information; No Product/Research Disclosure Information