Innovative Pleuroscopic Retrieval of an Intrathoracic Metallic Foreign Body- A Case Report

Innovative Pleuroscopic Retrieval of an Intrathoracic Metallic Foreign Body- A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Innovative Pleuroscopic Retrieval of an Intrathoracic Metallic Foreign Body- A Case Report Talha Mahmud, Namra Khalid, Muhammad Shah Nawaz, Kashif Ali Tarar This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7056863/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 3 You are reading this latest preprint version Abstract Background This case underscores the need to consider factitious disorder in patients with recurrent unexplained injuries. It showcases the efficacy of medical thoracoscopy (MT) in safely removing intrapulmonary foreign bodies, thereby avoiding thoracotomy. The successful retrieval of the foreign body (FB) using MT highlights the utility of minimally invasive techniques, especially in resource-constrained settings, offering a valuable alternative to surgical extraction and emphasizing the importance of innovative approaches in thoracic care. Case Presentation A 40-year-old woman from Pakistan presented with a metallic FB embedded in her right upper lung lobe. Despite previous attempts at removal, the object remained in place. Psychiatric evaluation revealed anxiety, oversensitivity, and self-inflicted injuries, raising concerns about a factitious disorder, possibly Munchausen syndrome. Intervention MT was performed under general anesthesia. One lung ventilation was achieved by selective intubation of left main bronchus (LMB). Right sided pleural space was explored after induction of an artificial pneumothorax, adhesions were lysed, and the FB, a 5.5 cm long sewing needle, was successfully removed from right upper lobe. Outcome The patient had an uneventful post-procedure course and was discharged. This case demonstrates the dual importance of clinical innovation and psychiatric consideration in managing complex cases. Conclusion MT is a safe and cost-effective approach for retrieving intrathoracic FBs, offering a valuable alternative to surgical extraction. This case highlights the dual importance of clinical innovation in thoracic care using innovative techniques like pleuroscopic retrieval, and the need for psychiatric consideration in managing complex cases with underlying factitious disorders. Innovative techniques intrathoracic foreign body medical thoracoscopy pleuroscopy psychiatric comorbidities Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Background Intrathoracic FBs are rare and often pose significant diagnostic and therapeutic challenges. 1 The majority of reported cases involve sharp objects, such as needles, which may represent iatrogenic complications. 2 According to a recent systematic review, Video-Assisted Thoracic Surgery (VATS) has been shown to be a safe and effective technique for removing intrathoracic FBs from various locations within the thorax, yielding favorable clinical outcomes in both elective and emergency settings. 3 , 4 We present a unique case of a 40-year-old woman with a 5.5 cm long sewing needle embedded in her right upper lobe, complicated by her psychiatric comorbidities, which posed additional challenges in diagnosis and management. Furthermore, the location and size of the needle made its removal a complex procedure. To our knowledge, only a handful of cases involving intrathoracic FBs have been reported in the literature. 2 , 5 This patient was managed in the interventional pulmonology department of a tertiary care public hospital. Our case report aims to contribute to the existing literature and provide insights into the management of such complex cases. 6 This case report also fills a knowledge gap by highlighting the utility of pleuroscopy as a safe and cost-effective alternative to thoracotomy for removing intrathoracic FBs, particularly in low-resource settings where access to advanced VATS/thoracic surgery may be limited. Case Report A 40-year-old Pakistani housewife, a nonsmoker, presented to our pulmonary clinic with a 3-month history of persistent, vague chest pain that failed to respond to analgesics prescribed by local general physicians. A chest radiograph (posteroanterior and right lateral views) revealed a wire-like metallic FB in the right upper zone (Fig. 1 ). Previous attempts at removal by a local surgeon via skin exploration were unsuccessful, and multiple hospital visits yielded recommendations for thoracotomy, which the patient and her husband declined. The patient's psychosocial history revealed that she had four healthy children and a mother with uncontrolled psychosis. Notably, she had undergone removal of 21 pins and needles from her arms, legs, and abdominal wall skin over the past two years. Despite this, she denied any knowledge of needle insertion, attributing the phenomenon to "supernatural forces." This unusual history raised concerns about potential factitious disorder. Psychiatric evaluation revealed normal cognition but identified anxiety, oversensitivity, and an over-caring personality. Her failure to recognize the self-inflicted nature of her repetitive traumatic injuries (needle insertions) and attribution to "black magic" raised concerns about Munchausen syndrome, a factitious disorder characterized by intentional production or feigning of illnesses or injuries. The psychiatrist prescribed escitalopram but also provided education to the patient and her family on addressing underlying psychological issues, aiming to reduce the risk of future factitious injuries and improve overall patient outcomes. Physical examination revealed an obese woman (BMI 30) with apparent anxiety, normal vital signs, and unremarkable physical examination findings. Imaging studies (Figs. 1 , 2 and 3 ) showed a needle in the right upper lobe, with the CT chest revealing the needle piercing obliquely below the second rib, traversing the right upper lobe, and extending into the right paratracheal area, without any evidence of penetration into the airways. Initial flexible fiberoptic bronchoscopy findings revealed clear airways and no visible evidence of needle entry into the airways (up to subsegmental level). To facilitate removal of the needle from the lung, we opted for MT under general anesthesia in the operation theater. We opted for MT due to its minimally invasive nature, which reduces complications and promotes faster recovery, making it a suitable alternative for this patient who had experienced unsuccessful removal attempts and was reluctant to undergo thoracotomy. The procedure commenced with blunt dissection using a hemostat in the 4th intercostal space, mid-axillary line, followed by pleural puncture with blunt dissection using the index finger. A suction catheter was then inserted to induce artificial pneumothorax during spontaneous breathing. Subsequent single portal rigid video pleuroscope (Karl Storz® Hopkins Telescope Optik 0 o , 10 mm) insertion for pleural evaluation revealed limited space due to thick inflammatory adhesions (induced by the FB) between the upper lung and parietal pleura (Figs. 4 A). Fluoroscopic evaluation (Fig. 5 ) performed on-site confirmed the presence of the needle in the right upper lobe region of the lung, embedded beneath thick pleural adhesions. To overcome this challenge, we achieved one-lung ventilation by intubating the LBM with an endotracheal tube (ETT, 7.0 mm) over a 5mm flexible fiberoptic video bronchoscope (Fujinon® EB-270-T). The bronchoscopy’s key advantage was enabling precise navigation and intubation of the LBM, thereby facilitating effective collapse of the right lung during the procedure. The patient was intubated after induction of general anesthesia with a regimen consisting of intravenous propofol, midazolam, fentanyl, and atracurium. This makeshift approach was necessitated by cost constraints, which precluded the use of a double-lumen ETT. Following successful intubation of the LMB with the ETT, the right lung collapsed thus allowing for unobstructed maneuverability of the pleuroscope and facilitating a more thorough evaluation of the right pleural cavity. Thick pleural adhesions were identified and meticulously lysed using rigid biopsy forceps, employing a blunt dissection technique followed by gentle retraction to the right side. After thorough apical/anterior pleural adhesiolysis, the proximal end of the metallic FB was successfully exposed, revealing its penetration into the lung parenchyma within the upper pleural zone (Figs. 4 B). FB was grasped with rigid biopsy forceps, and removed en-bloc with the forceps, pleuroscope, and metallic trocar. The extracted FB was a 5.5 cm long, slightly deformed sewing needle with a broken eye, which had remained in situ for 3 months (Fig. 6 ). Intraoperative challenges included a narrowed pleural space due to dense adhesions, which necessitated meticulous lysis using rigid biopsy forceps. Additionally, a makeshift one-lung ventilation technique was employed, using a single-lumen ETT and flexible fiberoptic bronchoscope to intubate the LMB, which successfully expanded the pleural space by collapsing the right lung, despite presenting technical difficulties. The procedure lasted approximately 2 hours, including setup and anesthesia. Mild self-settling oozing was observed, post-procedure, after which a 24 French chest drain was inserted. The patient was monitored closely post-procedure, with vital signs and oxygen saturation monitored in the recovery room. A chest radiograph was performed after chest drain insertion to confirm proper placement. The chest drain was removed the following day, and the patient was discharged from the hospital shortly after. The patient was scheduled for a follow-up appointment with the pulmonary physician and advised to attend regular monthly psychiatric consultations to closely monitor her mental health and address any ongoing psychological concerns. Conclusion Aspiration of scarf pins or sewing needles into the lung and retrieval using innovative techniques proves to be cost effective in the developing world where access to thoracic surgery and health care is costly. 1 Intrapleural FB is uncommon and is usually encountered in the setting of penetrating thoracic trauma, and can rarely complicate diagnostic thoracentesis. 2 Pleuroscopy, has emerged as a valuable tool in diagnosing and managing pleural FBs. 5 The patient's history of multiple needle removals and attribution of her condition to "supernatural forces" were consistent with Munchausen syndrome. 6 , 7 Patients with factitious disorders pose challenges in thoracic surgery due to potential self-inflicted injuries. Early psychiatric involvement and a multidisciplinary approach (interventional pulmonology, thoracic surgery, psychiatry, supportive care) are crucial for effective management and preventing future harm. In patients with pleural disease and dry pleural space requiring MT, induction of a рոеսmοthοrах before intercostal dissection is carried out to limit the risk of lung puncture, typically by using a Boutin needle. 8 In our set up, during such situations, we typically induce a pneumothorax using a 12 French suction catheter, as an alternative to the unavailable Boutin needle. In this case, our technique involved careful intercostal dissection using a hemostat, followed by blunt parietal pleura puncture with the operator's index finger, and suction catheter insertion. Air entry was verified by hissing sounds during spontaneous breathing, and partial lung deflation created space for introducing the blunt-tip trocar and pleuroscope, enabling safe pleural inspection. Although double-lumen ETTs are traditionally used for lung isolation, advancements in technology, such as fiberoptic video-bronchoscopy, have significantly enhanced intubation and lung isolation procedures in difficult airway cases. 9 In our patient, bronchoscopic-guided ETT placement in the LMB facilitated targeted lung deflation, expanding the right pleural space and exposing the impacted FB - a long sewing needle. The needle's proximal blunt end was grasped and carefully extracted from the upper lobe lung parenchyma. Subsequent en-bloc retrieval was achieved using the pleuroscope and trocar. Although surgical extraction using thoracotomy or VATS constitutes the primary management strategy, a pulmonary FB with its proximal end in the pleural cavity can also be retrieved using MT performed after ipsilateral lung collapse achieved by one lung ventilation with an ETT inserted using flexible bronchoscope. While direct comparisons between MT and VATS for intrathoracic FBs retrieval are lacking, both techniques offer safer alternatives to traditional thoracotomy. MT may be particularly advantageous in resource-constrained settings due to its potential cost-effectiveness. However, MT carries risks such as incomplete retrieval, bleeding, lung injury, and infection. 10 MT may be recommended as a first-line approach for patients with pleural-based FBs that can be safely and efficiently managed thoracoscopically, especially in cases with clear diagnoses, lysable adhesions, and accessible FBs. This case report demonstrates the successful management of a rare and complex case of intrapleural FB using innovative and cost-effective techniques. The use of MT and bronchoscopic-guided ETT placement facilitated the safe and effective removal of the FB, highlighting the importance of interventional pulmonology in managing such cases. The successful outcome highlights the potential of this minimally invasive approach in resource-constrained healthcare systems, where access to advanced surgical facilities may be limited. This approach can be a valuable addition to the clinical toolkit, offering a safe and cost-effective alternative to traditional thoracotomy or VATS. Further studies are needed to explore the full potential of medical thoracoscopy in similar cases, but our experience suggests that it can be a game-changer in the right clinical context. Abbreviations BMI Body mass index FB Foreign body MT Medical thoracoscopy ETT Endotracheal tube Declarations Authors’ contributions TM wrote the main manuscript text and NK, MSN and KAT provided details of the case including consent, history, figures and supporting data. All authors reviewed the manuscript. Funding The authors declare that there is no funding. Data availability No datasets were generated or analysed during the current study. Competing interests The authors declare no competing interests Patient’s Consent Written informed consent was obtained from the patient for publication and any accompanying images. Authors information Professor Dr Talha Mahmud FCPS. MD. PhD ( Corresponding author) Department of Pulmonology, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore Pakistan. [email protected] , Tel: +92-3014397549 Dr. Namra Khalid MBBS Email: [email protected] Department of Pulmonology, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore Pakistan. Dr. Muhammad Shah Nawaz MBBS Email: [email protected] Department of Pulmonology, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore Pakistan. Dr. Kashif Ali Tarar MBBS Email: [email protected] Department of Medicine, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore Pakistan. References Mahmud T, Shafiq A, Hafeez A, Saqib M, Farooq S (2016) Sewing machine needle retrieval from distal airways using flexible bronchoscope under fluoroscopy. Respir Med Case Rep 19:132–134. Narasimhan RL, Sehgal IS, Dhooria S, Aggarwal AN, Behera D, Agarwal R (2017) Removal of Intrapleural Foreign Body by Medical Thoracoscopy: Report of Two Cases and a Systematic Review of the Literature. J Bronchology Interv Pulmonol 24:244–249. doi: 10.1097/LBR.0000000000000393 . Kakamad FH, Ali RK, Amin BJH, Mohammed SH, Omar DA, Mohammed KK, et al (2023). The role of VATS in the removal of intrathoracic foreign bodies - a systematic review. Indian J Thorac Cardiovasc Surg. 39:125–136. doi: 10.1007/s12055-022-01445-9 . Manicum B, Hardcastle TC (2025). A retrospective review of the management and outcome of patients with retained intrathoracic foreign bodies. S Afr J Surg. 63:151–156. doi: 10.36303/SAJS.01341 . Get'man VG (1989) Diagnostika i udalenie inorodnykh tel grudnoĭ polosti pri torakoskopii. Grudn Khir 50–55. Russian. PMID: 2792880. Won HS, Cha YK, Kim JS, Jang SJ, Bak SH, Yoon HJ (2022) A Pictorial Review of Radiologic Findings of Foreign Bodies in the Thorax. Taehan Yongsang Uihakhoe Chi 83:293–303. doi: 10.3348/jksr.2021.0084 American Psychiatric Association (2022) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Boutin C, Cargnino P, Viallat JR (1980) Thoracoscopy in the early diagnosis of malignant pleural effusions. Endoscopy 12:155–160. doi: 10.1055/s-2007-1021674 Collins SR, Titus BJ, Campos JH, Blank RS (2018) Lung Isolation in the Patient With a Difficult Airway. Anesth Analg 126:1968–1978. doi: 10.1213/ANE.0000000000002864 . Roberts ME, Rahman NM, Maskell NA, Bibby AC, Blyth KG, Corcoran JP et al. (2023). BTS Pleural Guideline Development Group. British Thoracic Society Guideline for pleural disease. Thorax;78(Suppl 3):s1-s42. doi: 10.1136/thorax-2022-219784 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 20 Oct, 2025 Submission checks completed at journal 19 Oct, 2025 First submitted to journal 18 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7056863","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":532712578,"identity":"01216062-edf6-4768-b7b7-3c03c2674784","order_by":0,"name":"Talha 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1","display":"","copyAsset":false,"role":"figure","size":333959,"visible":true,"origin":"","legend":"\u003cp\u003eThe chest radiograph (PA and lateral views) shows a metallic foreign body in the right upper zone, with its proximal end above the 2nd rib and its distal end at the lower tracheal border on the right side.\u003c/p\u003e","description":"","filename":"image1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7056863/v1/6658689b98e49ee1a00c12cf.jpeg"},{"id":94135851,"identity":"7634e77d-3202-4bec-830b-a7edf4d5c35c","added_by":"auto","created_at":"2025-10-22 19:01:03","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":663323,"visible":true,"origin":"","legend":"\u003cp\u003eCT chest (at the level of aortic arch) revealing the needle piercing obliquely below the second rib, traversing the upper lobe, and extending into the right paratracheal part.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-7056863/v1/12041f9f967502122a986bc1.png"},{"id":94135850,"identity":"d7db76c3-7873-4e63-aec6-f87205de28ad","added_by":"auto","created_at":"2025-10-22 19:01:03","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1767641,"visible":true,"origin":"","legend":"\u003cp\u003eCT chest 3D volumetric reconstruction images (A and B) revealing a linear metallic FB (needle) in the right upper lobe, obliquely penetrating the lung parenchyma and traversing approximately two-thirds of the chest's anteroposterior diameter.\u003c/p\u003e","description":"","filename":"image3.png","url":"https://assets-eu.researchsquare.com/files/rs-7056863/v1/6dc0d90b9cb28b9fd2374c34.png"},{"id":94135856,"identity":"0ce7e4f1-9f71-47ef-86c4-4f43ee6785cb","added_by":"auto","created_at":"2025-10-22 19:01:03","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":2156580,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Intraoperative thoracoscopic view showing thick apical pleural adhesion (12 o’ clock position), adherent lung (3 o’ clock position) and rigid biopsy forceps (6 o’ clock position)-(B) Illustrating the metallic FB's trajectory: entering the apical pleural space (8 o'clock position) and penetrating the lung parenchyma (3 o'clock position).\u003c/p\u003e","description":"","filename":"image4.png","url":"https://assets-eu.researchsquare.com/files/rs-7056863/v1/2f34bca26a4d3925c22c2253.png"},{"id":94135849,"identity":"a3b8d1ec-c33b-4f80-a029-480441add7a9","added_by":"auto","created_at":"2025-10-22 19:01:03","extension":"jpg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":13872,"visible":true,"origin":"","legend":"\u003cp\u003eFluoroscopic imaging guided the needle search during pleural exploration, localizing the FB in the right upper zone.\u003c/p\u003e","description":"","filename":"image5.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7056863/v1/9a1c6fea9e087d9735e8199c.jpg"},{"id":94136492,"identity":"a379a239-3987-49c8-ba44-a9da387f88b8","added_by":"auto","created_at":"2025-10-22 19:09:03","extension":"jpg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":101060,"visible":true,"origin":"","legend":"\u003cp\u003eRetrieved metallic FB (deformed long sewing needle with broken eye).\u003c/p\u003e","description":"","filename":"image6.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7056863/v1/9abea1fd09f0e09ad66c42f4.jpg"},{"id":94136589,"identity":"76eb779d-5824-4f0b-a3a1-0a3be5bb2d53","added_by":"auto","created_at":"2025-10-22 19:17:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5772128,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7056863/v1/ee939e1f-afd0-486f-82be-cad735e15aac.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Innovative Pleuroscopic Retrieval of an Intrathoracic Metallic Foreign Body- A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eIntrathoracic FBs are rare and often pose significant diagnostic and therapeutic challenges.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The majority of reported cases involve sharp objects, such as needles, which may represent iatrogenic complications.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e According to a recent systematic review, Video-Assisted Thoracic Surgery (VATS) has been shown to be a safe and effective technique for removing intrathoracic FBs from various locations within the thorax, yielding favorable clinical outcomes in both elective and emergency settings.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e We present a unique case of a 40-year-old woman with a 5.5 cm long sewing needle embedded in her right upper lobe, complicated by her psychiatric comorbidities, which posed additional challenges in diagnosis and management. Furthermore, the location and size of the needle made its removal a complex procedure. To our knowledge, only a handful of cases involving intrathoracic FBs have been reported in the literature.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e This patient was managed in the interventional pulmonology department of a tertiary care public hospital. Our case report aims to contribute to the existing literature and provide insights into the management of such complex cases.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e This case report also fills a knowledge gap by highlighting the utility of pleuroscopy as a safe and cost-effective alternative to thoracotomy for removing intrathoracic FBs, particularly in low-resource settings where access to advanced VATS/thoracic surgery may be limited.\u003c/p\u003e"},{"header":"Case Report","content":"\u003cp\u003eA 40-year-old Pakistani housewife, a nonsmoker, presented to our pulmonary clinic with a 3-month history of persistent, vague chest pain that failed to respond to analgesics prescribed by local general physicians. A chest radiograph (posteroanterior and right lateral views) revealed a wire-like metallic FB in the right upper zone (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Previous attempts at removal by a local surgeon via skin exploration were unsuccessful, and multiple hospital visits yielded recommendations for thoracotomy, which the patient and her husband declined. The patient's psychosocial history revealed that she had four healthy children and a mother with uncontrolled psychosis. Notably, she had undergone removal of 21 pins and needles from her arms, legs, and abdominal wall skin over the past two years. Despite this, she denied any knowledge of needle insertion, attributing the phenomenon to \"supernatural forces.\" This unusual history raised concerns about potential factitious disorder. Psychiatric evaluation revealed normal cognition but identified anxiety, oversensitivity, and an over-caring personality. Her failure to recognize the self-inflicted nature of her repetitive traumatic injuries (needle insertions) and attribution to \"black magic\" raised concerns about Munchausen syndrome, a factitious disorder characterized by intentional production or feigning of illnesses or injuries. The psychiatrist prescribed escitalopram but also provided education to the patient and her family on addressing underlying psychological issues, aiming to reduce the risk of future factitious injuries and improve overall patient outcomes.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003ePhysical examination revealed an obese woman (BMI 30) with apparent anxiety, normal vital signs, and unremarkable physical examination findings. Imaging studies (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and \u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) showed a needle in the right upper lobe, with the CT chest revealing the needle piercing obliquely below the second rib, traversing the right upper lobe, and extending into the right paratracheal area, without any evidence of penetration into the airways. Initial flexible fiberoptic bronchoscopy findings revealed clear airways and no visible evidence of needle entry into the airways (up to subsegmental level). To facilitate removal of the needle from the lung, we opted for MT under general anesthesia in the operation theater. We opted for MT due to its minimally invasive nature, which reduces complications and promotes faster recovery, making it a suitable alternative for this patient who had experienced unsuccessful removal attempts and was reluctant to undergo thoracotomy. The procedure commenced with blunt dissection using a hemostat in the 4th intercostal space, mid-axillary line, followed by pleural puncture with blunt dissection using the index finger. A suction catheter was then inserted to induce artificial pneumothorax during spontaneous breathing. Subsequent single portal rigid video pleuroscope (Karl Storz\u0026reg; Hopkins Telescope Optik 0\u003csup\u003eo\u003c/sup\u003e, 10 mm) insertion for pleural evaluation revealed limited space due to thick inflammatory adhesions (induced by the FB) between the upper lung and parietal pleura (Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eA). Fluoroscopic evaluation (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e) performed on-site confirmed the presence of the needle in the right upper lobe region of the lung, embedded beneath thick pleural adhesions. To overcome this challenge, we achieved one-lung ventilation by intubating the LBM with an endotracheal tube (ETT, 7.0 mm) over a 5mm flexible fiberoptic video bronchoscope (Fujinon\u0026reg; EB-270-T). The bronchoscopy\u0026rsquo;s key advantage was enabling precise navigation and intubation of the LBM, thereby facilitating effective collapse of the right lung during the procedure. The patient was intubated after induction of general anesthesia with a regimen consisting of intravenous propofol, midazolam, fentanyl, and atracurium. This makeshift approach was necessitated by cost constraints, which precluded the use of a double-lumen ETT. Following successful intubation of the LMB with the ETT, the right lung collapsed thus allowing for unobstructed maneuverability of the pleuroscope and facilitating a more thorough evaluation of the right pleural cavity. Thick pleural adhesions were identified and meticulously lysed using rigid biopsy forceps, employing a blunt dissection technique followed by gentle retraction to the right side. After thorough apical/anterior pleural adhesiolysis, the proximal end of the metallic FB was successfully exposed, revealing its penetration into the lung parenchyma within the upper pleural zone (Figs.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003eB). FB was grasped with rigid biopsy forceps, and removed en-bloc with the forceps, pleuroscope, and metallic trocar. The extracted FB was a 5.5 cm long, slightly deformed sewing needle with a broken eye, which had remained in situ for 3 months (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Intraoperative challenges included a narrowed pleural space due to dense adhesions, which necessitated meticulous lysis using rigid biopsy forceps. Additionally, a makeshift one-lung ventilation technique was employed, using a single-lumen ETT and flexible fiberoptic bronchoscope to intubate the LMB, which successfully expanded the pleural space by collapsing the right lung, despite presenting technical difficulties. The procedure lasted approximately 2 hours, including setup and anesthesia. Mild self-settling oozing was observed, post-procedure, after which a 24 French chest drain was inserted. The patient was monitored closely post-procedure, with vital signs and oxygen saturation monitored in the recovery room. A chest radiograph was performed after chest drain insertion to confirm proper placement. The chest drain was removed the following day, and the patient was discharged from the hospital shortly after. The patient was scheduled for a follow-up appointment with the pulmonary physician and advised to attend regular monthly psychiatric consultations to closely monitor her mental health and address any ongoing psychological concerns.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAspiration of scarf pins or sewing needles into the lung and retrieval using innovative techniques proves to be cost effective in the developing world where access to thoracic surgery and health care is costly.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Intrapleural FB is uncommon and is usually encountered in the setting of penetrating thoracic trauma, and can rarely complicate diagnostic thoracentesis.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Pleuroscopy, has emerged as a valuable tool in diagnosing and managing pleural FBs.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e The patient's history of multiple needle removals and attribution of her condition to \"supernatural forces\" were consistent with Munchausen syndrome.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Patients with factitious disorders pose challenges in thoracic surgery due to potential self-inflicted injuries. Early psychiatric involvement and a multidisciplinary approach (interventional pulmonology, thoracic surgery, psychiatry, supportive care) are crucial for effective management and preventing future harm.\u003c/p\u003e\u003cp\u003eIn patients with pleural disease and dry pleural space requiring MT, induction of a рոеսmοthοrах before intercostal dissection is carried out to limit the risk of lung puncture, typically by using a Boutin needle.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e In our set up, during such situations, we typically induce a pneumothorax using a 12 French suction catheter, as an alternative to the unavailable Boutin needle. In this case, our technique involved careful intercostal dissection using a hemostat, followed by blunt parietal pleura puncture with the operator's index finger, and suction catheter insertion. Air entry was verified by hissing sounds during spontaneous breathing, and partial lung deflation created space for introducing the blunt-tip trocar and pleuroscope, enabling safe pleural inspection.\u003c/p\u003e\u003cp\u003eAlthough double-lumen ETTs are traditionally used for lung isolation, advancements in technology, such as fiberoptic video-bronchoscopy, have significantly enhanced intubation and lung isolation procedures in difficult airway cases.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e In our patient, bronchoscopic-guided ETT placement in the LMB facilitated targeted lung deflation, expanding the right pleural space and exposing the impacted FB - a long sewing needle. The needle's proximal blunt end was grasped and carefully extracted from the upper lobe lung parenchyma. Subsequent en-bloc retrieval was achieved using the pleuroscope and trocar. Although surgical extraction using thoracotomy or VATS constitutes the primary management strategy, a pulmonary FB with its proximal end in the pleural cavity can also be retrieved using MT performed after ipsilateral lung collapse achieved by one lung ventilation with an ETT inserted using flexible bronchoscope.\u003c/p\u003e\u003cp\u003eWhile direct comparisons between MT and VATS for intrathoracic FBs retrieval are lacking, both techniques offer safer alternatives to traditional thoracotomy. MT may be particularly advantageous in resource-constrained settings due to its potential cost-effectiveness. However, MT carries risks such as incomplete retrieval, bleeding, lung injury, and infection.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e MT may be recommended as a first-line approach for patients with pleural-based FBs that can be safely and efficiently managed thoracoscopically, especially in cases with clear diagnoses, lysable adhesions, and accessible FBs. This case report demonstrates the successful management of a rare and complex case of intrapleural FB using innovative and cost-effective techniques. The use of MT and bronchoscopic-guided ETT placement facilitated the safe and effective removal of the FB, highlighting the importance of interventional pulmonology in managing such cases. The successful outcome highlights the potential of this minimally invasive approach in resource-constrained healthcare systems, where access to advanced surgical facilities may be limited. This approach can be a valuable addition to the clinical toolkit, offering a safe and cost-effective alternative to traditional thoracotomy or VATS. Further studies are needed to explore the full potential of medical thoracoscopy in similar cases, but our experience suggests that it can be a game-changer in the right clinical context.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBMI Body mass index\u003c/p\u003e\u003cp\u003eFB Foreign body\u003c/p\u003e\u003cp\u003eMT Medical thoracoscopy\u003c/p\u003e\u003cp\u003eETT Endotracheal tube\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAuthors’ contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTM wrote the main manuscript text and NK, MSN and KAT provided details of the case including consent, history, figures and supporting data. All authors reviewed the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analysed during the current study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatient’s Consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eProfessor Dr Talha Mahmud FCPS. MD. PhD\u003c/strong\u003e (\u003cstrong\u003eCorresponding author)\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepartment of Pulmonology, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore Pakistan.\u0026nbsp;[email protected], Tel: +92-3014397549\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDr. Namra Khalid\u003c/strong\u003e MBBS\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003cp\u003eDepartment of Pulmonology, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore Pakistan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDr. Muhammad Shah Nawaz\u0026nbsp;\u003c/strong\u003eMBBS\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003cp\u003eDepartment of Pulmonology, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore Pakistan.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDr. Kashif Ali Tarar\u0026nbsp;\u003c/strong\u003eMBBS\u003c/p\u003e\n\u003cp\u003eEmail: [email protected]\u003c/p\u003e\n\u003cp\u003eDepartment of Medicine, Shaikh Zayed Hospital, Federal Postgraduate Medical Institute, Lahore Pakistan.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMahmud T, Shafiq A, Hafeez A, Saqib M, Farooq S (2016) Sewing machine needle retrieval from distal airways using flexible bronchoscope under fluoroscopy. Respir Med Case Rep 19:132\u0026ndash;134.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNarasimhan RL, Sehgal IS, Dhooria S, Aggarwal AN, Behera D, Agarwal R (2017) Removal of Intrapleural Foreign Body by Medical Thoracoscopy: Report of Two Cases and a Systematic Review of the Literature. J Bronchology Interv Pulmonol 24:244\u0026ndash;249. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/LBR.0000000000000393\u003c/span\u003e\u003cspan address=\"10.1097/LBR.0000000000000393\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKakamad FH, Ali RK, Amin BJH, Mohammed SH, Omar DA, Mohammed KK, et al (2023). The role of VATS in the removal of intrathoracic foreign bodies - a systematic review. Indian J Thorac Cardiovasc Surg. 39:125\u0026ndash;136. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s12055-022-01445-9\u003c/span\u003e\u003cspan address=\"10.1007/s12055-022-01445-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eManicum B, Hardcastle TC (2025). A retrospective review of the management and outcome of patients with retained intrathoracic foreign bodies. S Afr J Surg. 63:151\u0026ndash;156. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.36303/SAJS.01341\u003c/span\u003e\u003cspan address=\"10.36303/SAJS.01341\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGet'man VG (1989) Diagnostika i udalenie inorodnykh tel grudnoĭ polosti pri torakoskopii. Grudn Khir 50\u0026ndash;55. Russian. PMID: 2792880.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWon HS, Cha YK, Kim JS, Jang SJ, Bak SH, Yoon HJ (2022) A Pictorial Review of Radiologic Findings of Foreign Bodies in the Thorax. Taehan Yongsang Uihakhoe Chi 83:293\u0026ndash;303. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3348/jksr.2021.0084\u003c/span\u003e\u003cspan address=\"10.3348/jksr.2021.0084\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAmerican Psychiatric Association (2022) Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBoutin C, Cargnino P, Viallat JR (1980) Thoracoscopy in the early diagnosis of malignant pleural effusions. Endoscopy 12:155\u0026ndash;160. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1055/s-2007-1021674\u003c/span\u003e\u003cspan address=\"10.1055/s-2007-1021674\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCollins SR, Titus BJ, Campos JH, Blank RS (2018) Lung Isolation in the Patient With a Difficult Airway. Anesth Analg 126:1968\u0026ndash;1978. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1213/ANE.0000000000002864\u003c/span\u003e\u003cspan address=\"10.1213/ANE.0000000000002864\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRoberts ME, Rahman NM, Maskell NA, Bibby AC, Blyth KG, Corcoran JP et al. (2023). BTS Pleural Guideline Development Group. British Thoracic Society Guideline for pleural disease. Thorax;78(Suppl 3):s1-s42. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/thorax-2022-219784\u003c/span\u003e\u003cspan address=\"10.1136/thorax-2022-219784\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-bronchology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Bronchology](https://ejb.springeropen.com/)","snPcode":"43168","submissionUrl":"https://submission.nature.com/new-submission/43168/3","title":"The Egyptian Journal of Bronchology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Innovative techniques, intrathoracic foreign body, medical thoracoscopy, pleuroscopy, psychiatric comorbidities","lastPublishedDoi":"10.21203/rs.3.rs-7056863/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7056863/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis case underscores the need to consider factitious disorder in patients with recurrent unexplained injuries. It showcases the efficacy of medical thoracoscopy (MT) in safely removing intrapulmonary foreign bodies, thereby avoiding thoracotomy. The successful retrieval of the foreign body (FB) using MT highlights the utility of minimally invasive techniques, especially in resource-constrained settings, offering a valuable alternative to surgical extraction and emphasizing the importance of innovative approaches in thoracic care.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCase Presentation\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA 40-year-old woman from Pakistan presented with a metallic FB embedded in her right upper lung lobe. Despite previous attempts at removal, the object remained in place. Psychiatric evaluation revealed anxiety, oversensitivity, and self-inflicted injuries, raising concerns about a factitious disorder, possibly Munchausen syndrome.\u003c/p\u003e\u003cp\u003e\u003cb\u003eIntervention\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMT was performed under general anesthesia. One lung ventilation was achieved by selective intubation of left main bronchus (LMB). Right sided pleural space was explored after induction of an artificial pneumothorax, adhesions were lysed, and the FB, a 5.5 cm long sewing needle, was successfully removed from right upper lobe.\u003c/p\u003e\u003cp\u003e\u003cb\u003eOutcome\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe patient had an uneventful post-procedure course and was discharged. This case demonstrates the dual importance of clinical innovation and psychiatric consideration in managing complex cases.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusion\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMT is a safe and cost-effective approach for retrieving intrathoracic FBs, offering a valuable alternative to surgical extraction. This case highlights the dual importance of clinical innovation in thoracic care using innovative techniques like pleuroscopic retrieval, and the need for psychiatric consideration in managing complex cases with underlying factitious disorders.\u003c/p\u003e","manuscriptTitle":"Innovative Pleuroscopic Retrieval of an Intrathoracic Metallic Foreign Body- A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-22 19:00:58","doi":"10.21203/rs.3.rs-7056863/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-20T06:20:56+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-20T01:44:49+00:00","index":"","fulltext":""},{"type":"submitted","content":"The Egyptian Journal of Bronchology","date":"2025-10-18T07:47:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"the-egyptian-journal-of-bronchology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"","sideBox":"Learn more about [The Egyptian Journal of Bronchology](https://ejb.springeropen.com/)","snPcode":"43168","submissionUrl":"https://submission.nature.com/new-submission/43168/3","title":"The Egyptian Journal of Bronchology","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b5f16ff8-c24d-4e35-a770-9344bae92829","owner":[],"postedDate":"October 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T04:38:39+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-22 19:00:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7056863","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7056863","identity":"rs-7056863","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}