CHAPTER VII
Management of Retained Intrathoracic ForeignBodies, Mediterranean (Formerly North African) Theater of Operations
Lyman A. Brewer III, M.D., and Thomas H. Bur ford, M.D.
INCIDENCE
Experience in the Mediterranean Theater of Operations, U.S. Army, duringWorld War II showed that, exclusive of those in the heart and pericardium, whichare discussed separately (p. 49), retained intrathoracic foreign bodies could beanticipated in approximately one out of every four penetrating chest wounds.
The remarkable paucity of recorded cases of retained foreignbodies after World War I leads to two possible assumptions, (1) that themajority of patients from whom missiles were not removed remained symptom-free,or (2) that they were unaware of their condition. In view of the generalapprehension known to be felt when casualties were aware that they wereharboring foreign bodies, the second assumption seems likely as the explanationof a considerable number of cases.
INDICATIONS FOR SURGERY
Experience with retained intrathoracic foreign bodies incivilian practice was not of great help to military surgeons because in civilianpractice, the patient could be observed and the object removed electively if itbecame symptomatic. In military practice, the surgeon had to decide withreasonable promptness whether the patient could be safely returned to duty withthe foreign body in situ, which meant that he had to predict the chances of thedevelopment of future complications, including infection.
Wounding agents-Generally speaking, if the foreignbody was a bullet, it was less likely to cause complications than if it were ashell fragment or rib fragments.
Bone fragments from fractured ribs furnished a special problem. Suchfragments, set in motion by the impact of the missile, were far more apt toproduce lung damage, because of their irregular, jagged surfaces, than metallicforeign bodies. They were more frequently found in the lung than were metal-
326
lic objects. They were not usually seen on preoperative roentgenograms, andunless they presented themselves on inspection or palpation, they were often notrecognized at operation. A prolonged search for them, such as might beundertaken for known metallic objects, was therefore seldom carried out. If,however, they were seen in the lung through the pleural defect after debridementhad been completed, particularly if there were extensive lacerations of thepulmonary parenchyma, it was best to remove the fragments and repair the damagewithout delay.
This was particularly true when the bone fragments were partly in theparenchyma and partly in the pleural space, a location in which they were likelyto produce considerable trauma as the lung reexpanded and came into contact withthe chest wall. The result was an air leak in some cases, and provision of anavenue of infection in others. Fortunately, bone spicules partly in the lung andpartly in the parenchyma were usually found and removed without difficulty.
Accessibility of objects-If it was necessary to explore the pleura inthe course of initial wound surgery in thoracic wounds, the obvious course wasto remove any accessible foreign objects, regardless of size. This course,however, was not justified if only debridement was required, nor was it employedin the emergency treatment of sucking wounds.
The majority of foreign bodies were located in the periphery of the lung,where their removal was often-though not always-simple becausethey were accessible (vol. I). The mere presence of an object in the parenchyma,however, was not in itself an indication for its removal.
Size of objects-The size of the object also played a part in thedecision for or against removal. Early in the war, and especially with theestablishment of the first thoracic surgery center in the North African theater,the policy was adopted of removing all shell fragments 0.8 cm. in diameter orlarger seen on posteroanterior roentgenograms. At this time, it was thought thatremoval would be simple because the location, by palpation, of objects of thissize would furnish no difficulty. Later, when the experience was evaluated, itwas found that it furnished a great deal, and the policy was therefore changed,so that only foreign bodies of 1.5 cm. in diameter or larger were removedroutinely. This policy, which avoided a great deal of pulmonary trauma, provedincreasingly satisfactory, and added experience furnished no reason to alterthis limit in the absence of other indications for surgery.
There was never any question that very large objects (over1.5 cm. in length) should be removed, either in the forward or the base area-thatis, during other procedures or electively-as soon as possible. Here,the question was one of timing, not of indication. If the objects were small,not more than 1 or 2 cm. in length, they could be let alone unless they werenear the heart, a large vessel, or the esophagus; then they were removed. Ifforeign bodies near vital structures were let alone until complications haddeveloped, their removal was hazardous.
327
Infection-It was recognized that the lung and pleura tolerate foreignbodies well and that many of these retained objects were sterile. Many of them,however, were not, for fragments of ribs, bits of clothing, and other debriswere often carried into the chest with the missile and furnished a nidus forinfection. Infection was particularly likely when the object was irregular. Onthe other hand, foreign material was not necessarily a source of infection. Inone series studied in the Mediterranean theater, a little over half of theforeign objects removed had bits of clothing about them, but in no instance,aside from 4 cases in which lung abscesses had already developed, could positivecultures be obtained from the missile cavity. Unfortunately, it was not possibleto predict, without surgical investigation, in which cases foreign materialother than the missiles was present and, if it were, in which cases infectionwould develop.
Pulmonary infection associated with a retained foreign body was also anindication for surgical intervention. Exploration of the chest and removal ofthe foreign body before infection developed practically always was followed by aspeedy recovery, whereas the delayed treatment of a pulmonary abscess about aforeign body was attended with grave risks.
It was necessary to consider the possible presence of aforeign body in any instance of prolonged pulmonary suppuration after wounding.In an occasional case, a drainage tube which had not been securely anchored andhad slipped into the chest might be the cause of the trouble. This possibilitymade it particularly important that the record state clearly the presence andlocation of all such tubes.1 2
Clinical considerations-Hemoptysis associated with a retained foreignbody was a positive indication for its removal (fig. 71).
Pain was a difficult symptom to evaluate. In most instances,it was connected with the wound in the chest wall and had no connection at allwith the presence of the object, though it was not always possible to convincesoldiers of this fact.
Psychic manifestations, in fact, played an extremelyimportant part in the decision for or against removal. Many men were seriouslydisturbed by the knowledge that they had one or more shell fragments in thechest. It was repeatedly observed that a patient who harbored a large foreignbody in the thigh, for instance, and a very much smaller one in the pulmonaryparenchyma, ignored the former and became lung-conscious because of the presenceof the latter. Reassurance by the surgeon that the pulmonary object was unlikelyto
1Loss of drainagetubes into the pleural cavity seems to be an important cause of chronic empyema.The exact number of such cases encountered in Veterans' Administrationhospitals is not clear, but one of the authors of this chapter has performedseveral operations for this cause. The experience suggests to him that it isimportant that the presence of a drainage tube be specifically recorded eachtime a dressing is changed; failure to find it on subsequent dressings wouldthen be an indication for roentgenologic study and an attempt to retrieve it,which is not a difficult matter if it is searched for immediately. Within 48hours or longer, the pleura may seal over it and surgery may be required for itsremoval.-L. A. B. III.
2The obvious solution of this problem is, of course, prophylactic-theattachment of a safety pin or other radiopaque marker to every drainage tube.-F.B. B.
328
give him trouble sometimes satisfied him, but in borderlinecases, of course, no honest guarantee could be given that he would be immunefrom late complications. In such cases, the policy was to remove the object.
It was also the policy to remove the object when the patientwith an intrathoracic foreign body complained of vague pains in the chest,shortness of breath, and other subjective symptoms. If these manifestationspersisted, his emotional attitude, quite aside from any physical considerations,would obviously interfere with his return to duty, and the proper course was toremove the retained missile.
Conclusions-The final decision concerning removal wasbased on a number of factors, including the size and shape of the foreign body;whether there were multiple or single objects; the location of the object orobjects; the presence or absence of symptoms which could be attributed to thepresence of the object; and the patient's ability to withstand surgery. Objectswhich had been retained from 10 to 14 days were unlikely to cause immediatetrouble, and individualization of each case was therefore possible. As a matterof fact, a theater policy regarding the removal of foreign bodies wasnecessarily tentative; whether retained objects would give future trouble was aquestion which could be answered only by followup in the future.
SURGICAL TIMING
Although there was eventually a fair amount of agreementconcerning the size of foreign bodies for which removal was indicated, theproper time for operation remained the subject of considerable discussion untilthe end of the war.
The removal of foreign bodies could seldom be justified as an indication forthoracotomy in forward areas, especially when immediate evacuation to the rearwas contemplated. Removal of the objects within 24 to 48 hours, unless they wereencountered in the course of initial wound surgery, was generally frowned upon.The surgical risk, the rate of infection, and the morbidity from other causeswere all increased when this practice was followed. Experience proved that onlya very few objects gave rise to any difficulty if they were left in situ untilthe patient was evacuated to a fixed hospital (vol. I). It was therefore thepolicy to leave them undisturbed when thoracotomy was done on some validindication in a field or evacuation hospital unless they were readilyaccessible. When the missile could be seen under the fluoroscope to be pointingagainst a large vessel and moving with each pulsation, prompt removal wasobviously indicated.
Very few experienced thoracic surgeons removed retained foreign bodies untilat least 14 days after wounding. By this time, pulmonary equilibrium had beenreestablished. Traumatic wet lung had been controlled, with reaeration ofalveoli, absorption of interstitial fluid, removal of extravasatedintrapulmonary blood, and reestablishment of normal tracheobronchial patency.
329
Technically, it was far easier to locate metallic fragments in crepitant,aerated pulmonary tissue than in the boggy, indurated tissue present soon afterinjury. The lung was better able to withstand lobotomy after it had recovered tosome extent from the original injury. Finally, secondary closure of debridedwounds had usually been accomplished within the period specified, and theabsence of granulating wounds in the chest wall greatly reduced the hazard ofinfection. The general policy was to close open wounds in the chest wall bydelayed primary wound closure at least 24 hours before thoracotomy for removalof retained foreign bodies. The incision for the thoracotomy was then so plannedthat these wounds were avoided. It was even better if the operation could bedeferred until the chest wound was solidly healed, especially if it had to betraversed in performance of the thoracotomy for removal of the foreign body.
The status of the wound in the chest wall played a part in the end results ofremoval of foreign bodies. In 102 operations in one series (p. 349), 3 of the 4empyemas which developed after operation were directly attributable to thepresence of an unhealed wound in the thoracic wall at the time of operation.
By the policy of delayed surgery, the patient was in a hospital toward therear, where more detailed study could be made and the decision for or againstremoval of the foreign body arrived at deliberately, and not under the stress ofcombat conditions in a forward hospital. Better preoperative and postoperativecare was also available in a fixed hospital, in which the patient could be keptas long as was necessary. All the circumstances, therefore, were more favorablefor success than they were after a hasty operation performed as an emergencybefore cardiorespiratory equilibrium was reestablished.
While foreign bodies were frequently removed without difficulty weeks andeven months after wounding, long delays were not desirable if it was clear thatthe objects must be removed. When more than 2 weeks had elapsed, the increasedfibrosis present around them sometimes made repair and closure of theparenchymal incision more difficult. Extensive intrapleural adhesions, composedof fibrous tissue, sometimes made it difficult to palpate the object within thelung, and separation of the adhesions was likely to be time consuming andassociated with considerable oozing. In addition, the fibrous tissue reactionwhich had usually developed around the object by this time itself resulted inthe creation of a space in the lung that was often difficult to obliterate.
Delay in the removal of the foreign body when its excision was clearlyindicated was sometimes necessary because of other wounds. One patient, forinstance, with a spinal injury, also harbored a large intrapleural foreign body6 by 3 by 2 centimeters. The size of the object furnished a clear indication forits removal, but the condition of the patient because of his spinal injury madeit impossible to operate on him until 20 days after wounding. By this time, themissile had produced so much erosion of lung tissue that a bronchopleuralfistula had formed; empyema had then developed; and a severe intrapleuralhemorrhage occurred and was a contributing cause of death. In retrospect, an
330
earlier attempt to remove the foreign body, in spite of the surgical riskpresented by the patient, might have been lifesaving.
The following case reports are not exceptional. They aretypical of the favorable results consistently obtained when retainedintrathoracic foreign bodies were correctly handled, according to the principlesof management standardized in the Mediterranean theater.
Case 1-AU.S. Army nurse, when struck by a bomb fragment on 29 March 1944, sustained apenetrating, sucking wound of the right chest and a right-sided hemopneumothorax.The bomb fragment lodged in the right upper lobe.
The wound of entry was debrided and thesucking wound closed, after which thoracentesis was instituted. Closure wascompleted by delayed primary wound closure 5 days later.
Fluoroscopic and roentgenologic localizationrevealed a fragment 1.5 cm. in its greatest diameter lying in the upper lobe ofthe right lung (fig. 124A). Thoracotomy, without costal section or resection,was done 4 weeks after injury, and the fragment was removed.
The patient made an uneventful recovery (fig. 124B). Hertransfer to the Zone of Interior for reassignment was for psychic rather thanphysical factors.
Case 2-This patient, who waswounded by a high-velocity missile, underwent thorough debridement at anevacuation hospital, after adequate resuscitation, and was evacuated to athoracic center 4 days after injury. The wound was closed on the fifth day andhealing per primam occurred. Aspiration of a hemothorax of moderate size, whichhad been begun in the evacuation hospital, was continued daily until the pleuralspace was empty.
Accurate localization of the missile to the posterior portionof the apex of the left lower lobe was accomplished by roentgenologicexamination in two planes (fig. 125A and B). Thoracotomy, without costal sectionor resection, was performed on the 12th day after wounding. The object wasremoved without difficulty.
Convalescence was entirely uneventful. Oneweek after thoracotomy, the lung was clear and well expanded (fig. 125C), andthe pleural space contained neither air nor fluid. Ten days after operation, thewound was solidly healed; the patient was progressively
331
332
ambulant; and he had a full range of arm andshoulder motion (fig. 125D). Within 22 days after injury, the reparative phaseof management was completed and, after a brief period of rehabilitation, returnto full duty was anticipated.
TECHNIQUES OF LOCALIZATION
Thoracotomy for the removal of foreign bodies retained in the pleural cavityand the lungs was a safe and rational procedure only when the preoperativelocalization of these objects had been sufficiently accurate for their removalwithout extensive manipulations and an extended search for them. Only by thepossession of reliable information concerning their location could there be alogical surgical approach.
General considerations-While all phases oflocalization were important, the first problem that concerned the thoracicsurgeon was whether the foreign body lay within the confines of the pleura or inthe extrapleural tissues. Many objects in the chest wall could be removed underlocal analgesia, and no specialized training was required for their propermanagement. The object which lay within the pleural cavity necessitated a verydifferent intellectual and technical approach from that which would be used foran entirely extrapleural foreign body in the chest wall. Once the pleuralboundary had been crossed, the surgeon was confronted with a host of problems,such as the management of open pneumothorax and the necessity for positivepressure anesthesia, which required specialized training for their solution.
In a war zone, there was frequently not at hand the equipmentcommonly employed in peacetime for the accurate localization of intrathoracicforeign bodies, such as stereoscopy, the parallax method, and electric locators.That did not mean, however, that accurate localization could not be accomplishedin almost every case if cognizance was taken of basic principles and if asystematized plan of study was followed. The plan to be described proved itsefficiency in the localization of several hundred foreign bodies in the chestobserved in the Mediterranean theater.
Physical examination-Careful palpation, if successful, was the mostaccurate possible method of determining the location of a foreign body.Palpation soon after wounding might be futile because of tenderness and spasm.When they had disappeared, palpation was frequently very useful.
Case 3-This patient received achest wound from an enemy machine pistol, the bullet coming to lie in the softtissues of the posterior thoracic cage. It was easily visualized (fig. 126) byposteroanterior and lateral films. When the patient was admitted to the chestcenter, the bullet could not be palpated. As spasm and tenderness subsided, itwas readily palpable. At operation, it was found lying in the erector spinaemuscles and was recovered without difficulty under local anesthesia.
Roentgenologic examination.-The study of a patient with a foreignbody in the chest began with routine posteroanterior and lateral roentgenograms.Although in numerous instances, these two views apparently sufficed
333
for accurate localization, in general, they were usuallyconsidered as little more than scout films, to indicate the direction thatsubsequent investigation should take. To rely solely upon them could easily leadto grief. That one view was worthless for localizing purposes seems almost tooobvious to mention, but occasionally, a patient was encountered whose chest hadbeen explored-fruitlessly-on the basis of a single film.
In the examination of the initial films, the chest wasdivided into sectors (fig. 127), which made it possible to determine certainfacts at once. If the object lay outside of these sectors, it was clear that itwas extrapleural. To illustrate:
Let it be assumed that a missile lies on the right side of the chest, insector B-B? (fig. 127). If only the posteroanterior film were examined, theobject could lie anywhere in the sagittal plane of the right mid hemithorax.Further examination of the lateral film clarified the matter. If the object layin the anterior chest wall, it would appear in sector A?. If it were in thetissues of the posterior chest wall, it would lie in sector C?. Since, in thelateral view, it lay in sector B?, it was assumed to lie in the midcoronalplane, and to be intrapulmonary, as it proved to be:
Case 4.-This patient wasstruck in the right side of the chest by a German rifle bullet. Examination ofposteroanterior and lateral films (fig. 127) showed that it lay in sector B-B?.At operation, the missile, which was the brass jacket of a rifle bullet, wasremoved from the right middle lobe.
334
Both suspected and unsuspected foreign bodies frequently cameto light after withdrawal of fluid or air or both from the chest, with resultingreexpansion of the lung and coincidental changes in position of the object (fig.128). Such evidence was always looked for on serial films. Foreign bodiesobserved in serial films to have dropped from apex to base were intrapleural andextrapulmonary. A characteristic positional change related to movement of theshoulder girdle or of large muscle group of the chest wall furnished prima facieevidence that the foreign body was extrapleural.
The following case history illustrates this situation:
Case 5-In this case, the foreignbody was found in sector B in the left side of the chest (fig. 129A). It seemedsuspended high in the center of a pneumothorax pocket, with no visible means ofsupport. Since it did not drop to the bottom of the pleural cavity, it could notpossibly lie free within it. When the lung was completely reexpanded (fig.129B), there was no significant positional change; the slight change in the axisof the metallic fragment was caused by elevation of the shoulders. Thisphenomenon was frequently helpful in localizing foreign bodies in and about thescapula and clavicle.
At operation, this shell fragment was removed from a locationdeep to the pectoralis major muscle, just inferior to the left clavicle.
The closer the foreign body lay to the pleural surface, themore difficult it was to be certain that it lay within the lung tissue. In fact,if it lay in sectors other than B-B?, posterolateral and anterior films wereinadequate, and recourse to supplemental procedures was necessary.
335
336
Fluoroscopy-If, during the examination under the fluoroscope, theretained missile was observed to move the distance of an interspace with therespiratory act, it was assumed to be intrapulmonary. If it moved synchronouslywith the cardiac pulsations, then it might be in the lung or in the mediastinum.
Case 6-Thispatient, an Italian prisoner of war, was struck in the left chest by a highexplosive fragment. On fluoroscopic examination, the object was seen to movesynchronously with the respiratory excursions. Posteroanterior and lateral films(fig. 130) showed it lying in sector C-C?.
At thoracotomy, it was removed without difficulty from deep inthe left lower lobe.
Case 7-This patient was struck inthe left chest by a high explosive fragment. Examination of the posteroanteriorand lateral films placed the object in sector A-C? (fig. 131). It was notpossible to determine, from the films alone, that the fragment did not lieoutside the bony cage. Fluoroscopy projected the missile within the arc of theribs and thus in lung tissue.
At thoracotomy, the missile was removed from the left lowerlobe.
Fluoroscopic examination was supplemented by spot films madeby a special technique whenever the missile was in a peripheral sector and hadnot been located by other means. Under fluoroscopic visualization, the patientwas rotated so that the foreign body was brought to the position apparentlynearest to the external thoracic surface. In this profile position, as thefollowing case shows, it was usually possible to determine whether the objectwas extrapleural, intrapleural, or intrapulmonary. Spot films were made for moredeliberate study:
337
Case 8.-This patient was wounded by a high explosive fragment. The foreign body lay in sector A-B? (figs. 132A and B). When objects were in this location, it was impossible, without supplemental studies, to be certain that they lay intrapleurally or extrapleurally. Utilizing fluoroscopy, with rotation of the patient, an additional roentgenogram (fig. 132C) showed that the object lay outside the lung surface. Since, furthermore, it was projected external to the inner margin of the rib, it necessarily lay in the thoracic wall and not within the pleural cavity. The straight line of increased density shown in the roentgenogram in this position was due, as in similar cases, to an extrapleural hematoma associated with the metallic object deep in the thoracic wall.
Diagnostic pneumothorax-If the issue was still in doubt, the matter could usually be promptly settled by diagnostic pneumothorax (fig. 133). When air was injected into the chest and the foreign body underwent positional changes coincidental with those observed in the lung, it was obviously intrapulmonary. If it remained in its original position, as in the following case, it was obviously extrapulmonary.
Case 9.-This patient sustainedmultiple penetrating chest wounds from high explosive fragments. Two objects layin the soft tissues of the lower lateral chest wall (fig. 134). The third objectlay in sector B-C?, in which supplemental studies are practically alwaysrequired. Diagnostic pneumothorax did not alter the position of the fragment.
The extrapulmonary location of the object, as indicated byfluoroscopy, was confirmed by operation, at which it was removed through asimple incision over the ninth interspace.
A combination of fluoroscopic examination and pneumothoraxalso settled the location of foreign bodies lying partly in the extrapleuraltissue and partly intrapleurally. This was a particularly important variety ofretained object
338
(p. 326). In the following case, the development of ahemopneumothorax served the purpose of an artificial pneumothorax and clarifiedthe position of the fragment:
Case 10-This patient was wounded by a penetrating high explosivefragment. Posteroanterior and lateral roentgenograms showed it lying in sectorB-B?. Since it was quite large, it was thought that accurate localization mightbe difficult. Later, when the patient developed a hemopneumothorax, the definiterotation of the object (fig. 135) showed that it must be within lung tissue.
The diagnosis was confirmed at operation.
Pneumothorax was never instituted until a competent thoracic surgeon or othermedical officer had stated that it could safely be used. Lung puncture andhemorrhage were always possibilities. The use of this method was limited.
339
340
341
A special technique was required, in which relatively few medical officerswere trained, because of the decreasing use of pneumothorax in the treatment oftuberculosis.
Diagnostic pneumoperitoneum-Foreign bodies about the diaphragm werenotoriously difficult to localize. It was frequently necessary to induce adiagnostic pneumoperitoneum to establish their exact location (figs. 136, 137,and 138). Once it had been induced, posteroanterior and lateral films were madein the upright position, sometimes supplemented by oblique films and films inthe lateral decubitus. If these studies produced even a single view showing
342
the foreign body above the diaphragm, it was evident that the location wasintrathoracic and not subdiaphragmatic, as the following cases show:
Case 11-This patient sustained awound of the left chest from a high explosive fragment. Posteroanterior andlateral views (fig. 137) showed it lying in sectors A-B?, in the vicinity ofthe diaphragm, a location in which accurate localization was always moredifficult. After pneumoperitoneum had been induced, additional films left thelocation still undecided. A third film (fig. 137C) definitely located the objectin the superior substance of the diaphragm.
343
344
In this case, as in a number of similar cases, the oblique view was decisive.
Case 12-In this case, as in the preceding case, it was necessary toinduce pneumoperitoneum to secure exact localization of three foreign bodies(fig. 138). Posteroanterior and lateral films showed one object to beextrapleural, lying in the soft tissues of the chest wall. The second object layin the anterior costophrenic region above the diaphragm, though whether it wasintrapulmonary or intrapleural was not clear. A profile view (fig. 138C)projected the missile in lung tissue, thus proving that it did not lie in theintercostal soft tissues. A third object lay outside the substance of the liver(fig. 138D).
At thoracotomy, the second object was found lying in the substance of themiddle lobe of the lung.
Pneumoperitoneum, like pneumothorax, had to be used with careand judgment. It was never employed in the presence of intra-abdominalinfection. If abdominal surgery had been performed recently, satisfactory aircaps, because of adhesions, were not usually seen over and around the liver. Ifthe object was on the left side, a 2-gm. dose of sodium bicarbonate given orally15 minutes before the films were made frequently produced enough gaseousdistention for a satisfactory outline of the left diaphragm. In an occasionalcase, both pneumothorax and pneumoperitoneum had to be employed diagnosticallyto achieve definitive localization of the object.
345
Localization of mediastinal foreign bodies.-Mediastinal foreign bodiessometimes offered difficulties of localization (figs. 139 and 140). They weremost often found in sector C-B? and in this location were frequently observedto move synchronously with the cardiac pulsations. On the left side, in thislocation, they might be either cardiac or pericardial problems. Differentialdiagnosis required careful study and consideration:
Case 13-This patient received multiple wounds of the extremities and theright side of the chest when a shell exploded close to him. Examination of theposteroanterior film (fig. 140A) showed two foreign bodies. The first lay insector B-B? and was clearly in the intrapulmonary substance. The second lay insector C-B?, which made it necessary again to differentiate between anintrapulmonary and a mediastinal location.
At operation, the second object was found in the mediastinum, just under themediastinal pleura.
The evaluation of mediastinal foreign bodies was also important from anotherstandpoint, the possibility of injury of the esophagus. If this suspicionexisted, operation was a matter of extreme urgency. Overlooked esophagealperforations were attended with a very high mortality. Moreover, the surgicalapproach was different from that employed in the removal of intrapleural,intrapulmonary, and other mediastinal foreign bodies. Patients were questionedexplicitly concerning any symptoms which might point to esophageal injury,particularly dysphagia.
It was difficult to differentiate some intrapulmonary missiles from missileslocated in the mediastinum, but, since the surgical approach was the same inboth instances, the differentiation was academic rather than practical.
346
SURGICAL TECHNIQUE
The fundamental surgical principle of adequate exposure was particularlyimportant in the removal of foreign bodies from the lungs. Skin and muscleincisions had to be wide enough to permit access to at least two interspaceswhen the bony thoracic cage was exposed. If precise localization had beenaccomplished and if the lung was adherent to the chest wall, it was sometimespossible to remove the object without entering the free pleural space.
When the object was deeply embedded in the lung, an opening into the pleurawas necessary and had to be large enough to permit palpation and adequateexposure.
A posterior incision was usually employed, without division or resection ofthe ribs. A short incision was made into the lung, at the point at whichlocalization procedures, confirmed by palpation, had indicated that the foreignbody was nearest the surface. When operation was performed soon after wounding(within 14 days), there was, as a rule, little or no reaction about it.
Localization was sometimes less accurate than desirable because the presenceof a clotted pneumothorax prevented the use of diagnostic pneumothorax (fig.141). Hemothorax or hemothoracic empyema sometimes complicated the situation atoperation also. Decortication, in some cases, had to be carried out before asearch for the object was undertaken, as it was not possible to palpate a
347
fragment through the inelastic rind. If the hemothorax involved only a singlelobe, decortication was also preferable to an extended and difficult search forthe foreign body. Associated abscesses were either curetted out or, if thelesion was peripheral, were managed by wedge resection.
Closure was by the silk technique throughout. The lung was closed in twolayers, the pleura being inverted with the second layer. Sutures were placed inthe intercostal muscles and tied after the ribs had been approximated.Pericostal sutures were avoided.
The chest was ordinarily drained with both anterior and posterior intercostalwater-seal tubes. The use of the anterior tube, which was usually removed within48 hours, insured prompt expansion of the upper lung. The posterior tube waskept in place for 3 or 4 days.
In the early experience, penicillin was used intrapleurally, but thispractice was subsequently discarded, and the antibiotic was used systemicallybefore and after operation.
The following case history illustrates the successful management of foreignbodies associated with massive empyema:
Case 14-This patient was struck in the right chest by a bomb fragment on26 March 1944, sustaining a severe penetrating wound, with hemothorax. Ametallic foreign body was retained in the affected area.
The wound was debrided, and repeated aspiration was employed. This procedure,at first effective, later ceased to be useful, and the patient developed feverand other symptoms and signs of sepsis. Roentgenograms revealed a right clottedhemothorax in addition to the retained foreign body (fig. 142A). Materialaspirated from the right chest became
348
progressively more purulent and more offensive in odor. Cultures grewproteolytic clostridia.
Under penicillin protection, a thoracotomy was done 21 days after injury,with removal of the foreign object and decortication of the lung.
Recovery was prompt and uneventful (fig. 142B). The patient was discharged tofull duty on 5 June 1944, about 10 weeks after injury.
ANALYSIS OF CASES
In a series of 1,058 penetrating wounds of the chest observedby surgeons of the 2d Auxiliary Surgical Group in the Mediterranean theater, anexperience which may be assumed to be typical, there were 291 retainedintrathoracic foreign bodies, exclusive of foreign bodies in the heart andpericardium. Of these, 39 were intrapleural and 252 intrapulmonary andmediastinal. Since the great majority of these patients were under observationin thoracic surgery centers for periods ranging from a week to 2 months afterinjury, this series offered an excellent opportunity to determine what happensto retained intrathoracic missiles within this period after wounding.
Preoperative Complications
The following complications, which developed during the periods ofobservation, represent the ill effects of retained foreign bodies:
In the 252 intrapulmonary and mediastinal foreign bodies,there were 4 delayed or recurrent hemoptyses; 2 secondary intrapleuralhemorrhages from the lung; 18 late or recurrent bronchopleural fistulas; 4 lungabscesses; 2 mediastinal abscesses associated with the retained objects; and 30empyemas.
In the 39 intrapleural foreign bodies, there were 15 empyemas.
The total complications in these 291 cases were thus 75 innumber, 25.8 percent; 60 were associated with the 252 intrapulmonary andmediastinal objects and 15 with the 39 intrapleural objects.
There was no correlation in this study between the incidence of complicationsand the size and configuration of the missiles. There was also no correlation asto location except in one regard, that missiles located in the periphery of thelung gave rise to a higher incidence of complications than those in the hilus.This observation was at variance with the popular concept that a missile lyingin close proximity to vascular or bronchial structures in the hilus was morelikely to give rise to complications than a missile in the periphery. Theexplanation may be that missiles that lodged at or near the hilus were missilesthat had lost their momentum. Those that tore through it usually lacerated themajor divisions of the pulmonary artery or vein, with rapid death byexsanguination. Surgeons who worked in field hospitals almost never saw acasualty with damage to a major pulmonary vessel. These casualties did not livelong enough to be hospitalized.
349
These figures are significant in view of the numerousdiscussions concerning the relative incidence of empyema in intrapleural versusintrapulmonary retained foreign bodies. In the 39 intrapleural cases, empyemaoccurred 15 times, an incidence of 38.5 percent. In the intrapulmonary group of252 objects it occurred 30 times, an incidence of 11.9 percent, which isstrikingly close to the overall incidence of empyema in chest wounds in theMediterranean theater. This observation corroborated the opinion generally heldby thoracic surgeons that intrapleural foreign bodies were far more likely togive rise to trouble than intrapulmonary missiles.
The majority of the complications, almost 75 percent, developed during thesecond and third weeks after injury. Aside from the empyemas, the earliestcomplication observed was a lung abscess which appeared a week after injury.Only 4 complications, none in the intrapleural group, developed earlier than 10days after wounding. The earliest complications were usually hemorrhage,atelectasis, pneumonitis, and pulmonary embolus. Lung abscess was extremelyuncommon (at all times), though in this series it was the first complication tobe observed, 7 days after wounding.
Results of Surgery
Surgery was carried out in 102 of these 291 retained foreign bodies, in 15instances for intrapleural objects and in 87 for objects in the intrapulmonaryor mediastinal tissues (fig. 143). In five instances, the object was notremoved, for various reasons, and in four instances, it was not found at thesite expected from the preoperative localization.
There were no deaths in the 102 operations and no instancesof permanent disability or deformity. The 13 postoperative complications weredistributed as follows: 3 wound infections; 4 empyemas (3 small, resulting fromsubjacent extension of the wound infection to the pleural cavity and 1 basal,unrelated to wound infection); 1 clotted hemothorax; 1 atelectasis; 1 secondaryhemorrhage; 2 bronchopleural fistulas; and 1 thrombophlebitis. None of thesecomplications resulted in prolonged disability.
About half of the retained objects, as previously mentioned,were found with associated cloth fragments at the site of lodgment, but, exceptin the four lung abscesses, no positive cultures were obtained from the missilecavities.
Conclusions
Although the series is small, these figures are important,since they overturn many misconceptions as to the innocuousness of retainedintrathoracic missiles. An incidence of 15 percent of significant complicationswithin the first 60 days after wounding points to the fact that the retainedmissile is, on the contrary, a real source of danger to the host and must beconsidered seriously in the reparative management of every case. On the otherhand, the fact that so few complications developed earlier than 10 days afterwounding justified
350
FIGURE 143.-Specimens of metallic foreignbodies removed from lungs and pleural cavity.
the policy of waiting until the patient had arrived in a fixed hospital toremove the missile.
This comparison definitely favors the removal of retainedforeign bodies, though not statistically. The incidence of postoperativecomplications, when surgery was done at the thoracic surgery center in thisseries was approximately 13.4 percent, while the incidence of complicationsencountered when the foreign bodies were not removed was 15 percent.Statistically, this is a totally insignificant difference, almost an argument,in fact, for leaving these objects in situ. Clinically, however, the balance isall in favor of their removal at the proper time and on the proper indications.The complications of retained foreign bodies are all debilitating, and many ofthem are potentially fatal. The properly staged removal of these objects,however, is attended with a minimal mortality-there were no deaths in thisseries-and with a low morbidity.
Much remains to be learned concerning the question of retained foreign bodiesin penetrating thoracic wounds. This analysis of a small series of cases
351
is not conclusive, and final statistics are not yet available. The analysis,however, does show the fallacy of the opinion that it can be confidentlyanticipated that such objects will do no harm, and it also vindicates theMediterranean theater policy of removing all objects larger than 1.5 cm. intheir greatest diameter, preferably within the first 14 days after injury, afterthe patient has been evacuated to the base.
Final appraisal must await long-term followup studies on both the group inwhich the object was retained and the group in which it was removed.3
3The reader is referred to chapter XI (p. 441) for long-term followupstudies on casualties with retained foreign bodies in the chest.
