Pulmonary Procedures |

Bronchomediastinal Fistula From Erosion of Surgical Pledgets Into the Airway FREE TO VIEW

Ali Sadoughi, MD; Bryan Meyers, MD; Praveen Chenna, MD
Author and Funding Information

Barnes Jewsih Hospital, Washington University in St. Louis, Saint Louis, MO

Chest. 2015;148(4_MeetingAbstracts):838A. doi:10.1378/chest.2261266
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SESSION TITLE: Procedures Case Report Posters

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 27, 2015 at 01:30 PM - 02:30 PM

INTRODUCTION: Surgical pledgets may erode into neighboring airways many years after their original placement.

CASE PRESENTATION: A 55 years old female with a resection of a cystic abnormality in the mediastinum about 5 years ago, presented with cough, dyspnea and recurrent respiratory infections. PET/CT scan revealed an abnormality in the subcarinal area and an endobronchial lesion in bronchus intermedius (BI). Bronchoscopy showed granulation tissue and a foreign body, consistent with erosion of the sutures and surgical pledgets into the BI. A subcarinal mass was seen by endobronchial ultrasound, and its cytopathology exam showed cystic features with mucoid-like material. The patient was then taken to the operating room. An inevitable bi-lobectomy of the right middle and lower lobes was performed due to extensive necrosis and instability of BI. There were significant adhesions around the right lower lobe and BI with purulent secretions and pledgets in the airway. There was also a cavity in the subcarinal space that was holding pledgets and purulence. One month following surgery the patient noticed significant improvement in her symptoms.

DISCUSSION: This case represents erosion of surgical pledgets into the airway, causing chronic inflammation, narrowing of the airway with a bronchomediastinal fistula. Pledgeted sutures and repair stitches had been placed during a prior resection of a benign mediastinal mass years ago. Pledgeted sutures are usually used for reinforcing the bronchial stump during lung surgeries. There are several reports of erosion of Teflon pledgets in different surgeries. Successful endoscopic ablation of migrated pledgets into major airways have been reported. A very thorough evaluation of the involved anatomic structures before any endoscopic intervention is necessary in order to avoid major events such as massive bleeding, bronchopleural fistula, or spread of infection to the mediastinal area. In this case, erosion of the pledgets into the airways and associated recurrent infections caused extensive purulent and necrotic injury of the BI and right lower lobe, making surgical resection of the right middle and lower lobes inevitable for a successful operative outcome.

CONCLUSIONS: Broncho-pleural/mediastinal fistula still remains a major cause of morbidity and mortality after thoracic surgery. Teflon pledgets have been used for reinforcement of the anastomosis and stitches, however they may erode into the airway years after resection.

Reference #1: Aboudara M, et al. Teflon haemoptysis. BMJ case reports 2012

DISCLOSURE: The following authors have nothing to disclose: Ali Sadoughi, Bryan Meyers, Praveen Chenna

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