Eur J Cardiothorac Surg 2008;33:937-938. doi:10.1016/j.ejcts.2008.01.037
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Pseudotumor associated with polytetrafluoroethylene sleeves
Esther Fernándeza,*,
Pedro López de Castroa,
Gustavo Tapiab,
Julio Astudilloa
a Thoracic Surgery Department, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
b Pathology Department, University Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
Received 12 October 2007;
received in revised form 26 December 2007;
accepted 16 January 2008.
* Corresponding author. Address: Carretera de Canyet s/n, 08916 Badalona, Barcelona, Spain. Tel.: +34 934978921. (Email: esther_med2000{at}yahoo.es).
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Abstract
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We report the case of a patient who was operated on in February 2001. We performed a wedge resection of the upper right lobe. The pathologic examination demonstrated a lung adenocarcinoma (pT2N0M0, R0). We used staple line reinforcement material (ePTFE) during the operation because the patient had an important emphysema. We re-operated in January 2005 because during follow-up we observed a suspicious image that suggested a tumoral relapse. Histopathological study showed extrinsic material compatible with the one used in the original resection.
Key Words: Complications of surgery • Emphysema • Glue biologic
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1. Introduction
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The most frequent complications we find when operating an emphysematous patient are air leaks that can last for several weeks [1–4] and increase the hospital stay. In order to minimize these air leaks several techniques that reinforce the staple line using different materials have been developed: strips of bovine pericardium [1,4], absorbable polydioxanone ribbon (PDS-ribbon) [2], Teflon [5], polytetrafluoroethylene (ePTFE) sleeves [3], and biologic glue.
The material used to reinforce the staple line must be supple, thin enough to allow overlapping staple lines, easy to cut, non-porous to prevent air leakage, strong so that it can resist the tension when the lung expands again, degradable and absorbable [1,3]. It is important to avoid application of the stapler too near the hilum because of the risk of vascular injury [3]. With these techniques, a decrease or absence of air leaks have been observed through the staple line when we re-expand the lung again [1].
We report the case of a patient who was operated on in February 2001 and who underwent a wedge resection (FEV1 0’97 cc) in the upper right lobe with a pathology of lung adenocarcinoma (pT2N0M0, R0). Associated with this surgery we performed lung volume reduction surgery with pleural abrasion. We used ePTFE to reinforce the staple line. We took a follow-up CT scan in February 2002 and detected a new lesion in the upper right lobe that seemed to be close to the anterior resection. We decided to observe the lesion and we performed another CT scan in November 2003 (Fig. 1a) and another in October 2004. In the last CT scan the lesion seemed to be growing and suggested tumoral relapse (Fig. 1b). New functional respiratory tests showed: FEV1 1390 cc (48%) and a perfusion scan showed a 43% right lung perfusion and a 57% left lung perfusion (FEV1 ppo 946 cc). We did not perform other studies such as PET-CT or CT-PAAF because we observed that the lesion was growing and suspected the relapse. In January 2005 we re-operated on the patient. First we performed two biopsies of the lesion in the upper right lobe that was reported as an extrinsic material compatible with the material used in the original resection with fibrosis and chronic inflammation (Fig. 2
) but without evidence of tumoral relapse. We did not perform the lobectomy because one of the biopsies was performed deep into the lesion so we were sure we had enough material for a diagnosis. The postoperative course was excellent without complications.
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Fig. 1. (a) CT November 2003. (b) CT October 2004: image suggestive of tumoral relapse in the upper right lobe.
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2. Comment
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The use of different materials to reinforce the staple line has been very frequent in the last years and it has also been used in lung volume reduction surgery and other resection surgery in emphysematous patients. The use of these materials is recent so we do not know what complications can appear. We introduce a case of a patient with an image of pseudotumor that was suspicious of a tumoral relapse. Perhaps, now with the more frequent use of PET-CT we can avoid the re-operation of such patients. Definitely the interpretation of such lesions with image techniques is difficult but we must keep in mind this possibility. Wassef et al. [5] described the injection of Teflon used in a vocal cord paralysis that simulated a thyroid neoplasm that was resected and informed as a teflonoma. Iwasaki et al. [4] have reported complications such as endobronchial displacement of this material 6 months after being removed by bronchoscope [4] because of the patient's symptoms (cough, expectoration and fever).
We think that patients may benefits from using these materials in the early postoperative period but they could develop complications later. We hope that the benefit is greater than the number of complications.
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References
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- Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038-1039.[Abstract]
- Juettner FM, Kohek P, Pinter H, Klepp G, Fiehs G. Reinforced staple line in severely emphysematous lungs. J Thorac Cardiovasc Surg 1989;97:362-363.[Abstract]
- Vaughn CC, Wolner E, Dahan M, Grunenwald D, Vaughn 3rd CC, Klepetko W, Filaire M, Vaughn PL, Baratz RA. Prevention of air leaks after pulmonary wedge resection. Ann Thorac Surg 1997;63:864-866.[Abstract/Free Full Text]
- Iwasaki A, Yoshinaga Y, Shirakusa T. Successful removal of bovine pericardium by bronchoscope after lung volume reduction surgery. Ann Thorac Surg 2004;78:2156-2157.[Abstract/Free Full Text]
- Wassef M, Achouche J, Guichard JP, Tran Ba Huy P. A delayed teflonoma of the neck simulating a thyroid neoplasm. J Otorhinolaryngol Relat Spec 1994;56:352-356(128).
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Abstract
1. Introduction
