Asymptomatic metalloptysis complicating lobectomy in pulmonary aspergilloma – An unusual complication

1. Introduction 

Surgical resection is considered to be the most definitive treatment for a symptomatic pulmonary aspergilloma presenting with recurrent haemoptysis.1 We report a very unusual complication of expectoration of titanium surgical clips through right lobectomy stump in a patient who underwent lobectomy several years prior for a symptomatic aspergilloma. We believe this to be first instance of metalloptysis in a case of pulmonary aspergilloma, following lobectomy.

2. Case report 

A 28 year-old man had undergone right upper lobe lobectomy for a pulmonary aspergilloma which was causing recurrent haemoptysis. He had developed pulmonary tuberculosis for which he was prescribed antitubercular therapy and was declared cured post treatment. Subsequently, after a gap of one year, he developed episodes of recurrent cough and haemoptysis and he was diagnosed as having an aspergilloma in right upper lobe, symptoms not being relieved by conservative management. A surgical opinion was sought and a right upper lobe lobectomy was performed. The surgery and postoperative period was uneventful and he recovered well with a good relief of his symptoms.

After a gap of seven years patient had a severe paroxysm of cough and he expectorated two surgical clips (Fig. 1). He also acquired vague discomfort over the right anterior chest region at this time. Patient had no fever, haemoptysis, dyspnea, or dysphagia. When the patient reported to us one week later, there were no signs or symptoms suggestive of a pleural space infection or pneumothorax. Laboratory investigations, including white blood cell count, were within normal limits. Chest radiography demonstrated stigmata of a right sided thoracotomy with radio-opaque shadows of surgical clips. There was no evidence of pleural effusion or a pneumothorax (Fig. 2). No previous X-ray films, other than one postoperative film, were available for comparison. Bronchoscopy demonstrated a healed lobectomy stump without evidence of an actual, open bronchopleural fistula but with no other clip visible within the lumen. As the patient was symptom free he was told that it might be likely that he may cough another clip at some point in the future, but that this was nothing about which he should be concerned as long as he remained asymptomatic.

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Fig. 1 Expectorated titanium surgical clips.

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Fig. 2 Post right upper lobe lobectomy chest radiograph; (A) post operative (B) recent film after metalloptysis. Arrows point to surgical clips.

3. Discussion 

Surgical resection of the cavity and removal of the fungus ball is usually indicated in patients with recurrent haemoptysis, if their pulmonary function is sufficient to allow surgery. Surgical treatment is associated with relatively high mortality rates, ranging from 7% to 23%. The most common causes of death post-operatively are severe underlying lung disease, pneumonia, acute myocardial infarction, and invasive pulmonary aspergillosis. Other postoperative complications include haemorrhage, residual pleural space, bronchoalveolar fistula, empyema, and respiratory failure.1 Technologic advances in the field of cardiothoracic surgery have brought considerable convenience and timesaving to a number of thoracic surgical procedures, such advances may also be the source of unusual complications. Bronchial arteries, which formerly would have been ligated, are now often controlled by electrocautery or the application of surgical clips. We report one such unusual complication of expectoration of a titanium surgical clip through a right lobectomy stump, the procedure having been performed six years previously for a symptomatic aspergilloma.

Dieter et al.2 were probably the first to report such a complication, in which patient expectorated 11 of the 12 clips, about 34 years back. Shamji and coworkers3 reported on surgical staple metalloptysis after apical bullectomy and placement of pericardial buttresses. They cited possible local inflammation as a cause for erosion. The article by Ahmed and colleagues4 describes a patient with cystic bronchiectasis who had undergone a right upper lobectomy followed by a completion pneumonectomy. The patient several years later had a coughing spell and expectorated a surgical clip without systemic signs. Ahmed and colleagues4 noted that they were unaware of any previous report of nonreactive commonly used titanium surgical clips eroding into the bronchial tree. Two of the previous reports concerned lung volume reduction surgery5, 6 and the expectorated materials in both consisted of staples and dry bovine pericardial strips used for staple line reinforcement. Inflammation initiated by the staples or more likely the buttressing material is speculated to have resulted in erosion of small bronchioles and the subsequent expectoration. Saunders and coworkers reported a case of bullet migration through pulmonary parenchyma and its spontaneous expulsion.7

Healed tuberculosis complicated with aspergilloma presenting with recurrent haemoptysis, by virtue of the severe inflammatory process that it creates, is accompanied by dilated bronchial arteries which are the most common source of haemoptysis. Ligation of all bronchial arteries in these circumstances with ties is time-consuming and tedious. Particularly in the vicinity of the bronchial stump, the use of cautery, with its risk of spreading heat injury, is ill-advised. Control of bleeders with titanium clips in these areas is technically easy and has been considered a relatively safe option. In the case presented here, the constant motion of the bronchial stump during respiratory cycle through the years appears to have resulted in the slow migration of these fairly sharp surgical clips from the small bronchial vessels in the vicinity of the right upper lobe bronchial stump into the airway. An inflammatory process does not appear to have contributed, because no signs indicative of inflammation were discovered locally during bronchoscopy, nor was there any systemic evidence of infection.

Although there was no associated haemoptysis or bronchopleural fistula permitting passage of air or microbes in the pleural cavity in our case, the occurrence of this event highlights that surgical clips should be used more judiciously in the vicinity of the bronchial stump and perhaps they should be redesigned such that their ends are blunt rather than sharp to prevent such possible unusual complications.

Conflict of interest statement 

We, the authors of the article confirm that none of us have a conflict of interest to declare in relation to this work.