SESSION TYPE: Bronchology Cases
PRESENTED ON: Wednesday, October 24, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: A multidisciplinary effort including thoracic surgery, interventional pulmonology and hyperbaric oxygen therapy was used to successfully treat the post-surgical complications of a rare malignancy.
CASE PRESENTATION: An 18-year old male was diagnosed with hemangioendothelioma obstructing the left main bronchus. He was subsequently found to have metastasis to level 4L and 7 lymph nodes. The CT scan showed an atelectatic left lung that was suspected to be chronic post-obstructive pneumonia but he looked clinically well and only complained of dyspnea on exertion. He was presented at tumor board where surgical resection was recommended. A left pneumonectomy was completed; the left mainstem bronchus was stapled flush with the main carina and covered with mediastinal pleura after lymph node dissection. After discharge he developed a worsening hydropneumothorax and was suspected to have a bronchopleural fistula. Follow-up bronchoscopy revealed a 2 mm hole representing the orifice of a fistula allowing air to enter the chest with surrounding 5-6 mm zone of pale, scarred mucosa at the base of the left bronchial stump. A fibrin sealant (Tisseel®) was initially used to plug the tract. However, the bronchopleural fistula persisted. The lesion was treated as a compromised surgical flap and hyperbaric oxygen therapy was arranged. To avoid tension pneumothorax or dislodgement of the fibrin plug during compression and decompression, the left thorax was vented using a thoracostomy tube left open to ambient pressure. After completing 30 treatments, the bronchopleural fistula resolved. Repeated bronchoscopy showed stability of the plug and rejuvenation of the pale mucosa, and closure was confirmed using a fistulogram.
DISCUSSION: We present a unique case of rare malignancy requiring a creative multidisciplinary effort for management. To our knowledge, the combination of surgical intervention for metastatic hemangioendothelioma, interventional pulmonology placement fibrin sealant for bronchopleural fistula and involvement of hyperbaric oxygen therapy has not been previously reported.
CONCLUSIONS: Early, collaborative effort of surgical, pulmonary and hyperbaric medicine specialty services can be extremely effective in managing complications especially when they arise in rare clinical presentations.
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2) Rosengarten D, Kramer MR, Amir G, Fuks L, Berkman N. Pulmonary epithelioid hemangioendothelioma. Isr Med Assoc J. 2011 Nov;13(11):676-9.
DISCLOSURE: The following authors have nothing to disclose: Siavash Farshidpanah, Gregory Cheek, Jason Wallen, Claire McArthur
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