Bronchial rupture following endobronchial blocker placement: a case report of a rare, unfortunate complication

Background Lung separation may be achieved through the use of double lumen tubes or endobronchial blockers. The use of lung separation techniques carries the risk of airway injuries which range from minor complications like postoperative hoarseness and sore throat to rare and potentially devastating tracheobronchial mucosal injuries like bronchus perforation or rupture. With few case reports to date, bronchial rupture with the use of endobronchial blockers is indeed an overlooked complication. Case presentation A 78-year-old male patient with a left upper lobe lung adenocarcinoma underwent a left upper lobectomy with a Fuji Uniblocker® as the lung separation device. Despite an atraumatic insertion and endobronchial blocker balloon volume within manufacturer specifications, an intraoperative air leak developed, and the patient was found to have sustained a left mainstem bronchus rupture which was successfully repaired and the patient extubated uneventfully. Unfortunately, the patient passed on in-hospital from sepsis and other complications. Conclusion Bronchial rupture is a serious complication of endobronchial blocker use that can carry significant morbidity, and due care should be exercised in its use and placement. Bronchoscopy should be used during insertion, and the volume and pressure of the balloon kept to the minimum required to prevent air leak. Bronchial injury should be considered as a differential in the presence of an unexplained air leak.

Surgical correction of postpneumonectomy syndrome with adjustable saline implants and transoesophageal echocardiography

Postpneumonectomy syndrome can have a significant clinical impact on a patient. It presents as progressive dyspnoea due to compression of the contralateral bronchus and/or pulmonary veins. Herein, we present a patient who over a 2-year period developed progressive dyspnoea on exertion and eventually also at rest, due to compression of her left mainstem bronchus and her left inferior pulmonary vein. Surgical correction with implantable adjustable saline implants was undertaken to ameliorate her symptoms. Concurrent use of intraoperative transoesophageal echocardiography permitted real-time adjustment of the implants. This allowed objective measurement and demonstration of normalization of pulmonary vein velocity, which resulted in complete symptom resolution.

Surgical Management of Primary Pulmonary Mucoepidermoid Carcinoma of the Proximal Left Mainstem Bronchus

A 29-year-old non-smoking female with a history of recurrent AML presented with worsening dyspnea. A CT scan revealed an 8 X 7 mm polypoid soft tissue nodule 8 mm distal to the carina in the left mainstem bronchus. She was brought to the operating room and a nearly obstructing soft fleshy tumor in the left mainstem bronchus just distal to the carina was removed with bronchoscopy. Pathology revealed a low grade mucoepidermoid carcinoma 0.8 cm in largest dimension with negative margins. The patient returned for a resection and was intubated with a right mainstem double lumen tube and placed in left lateral decubitus. After posterolateral thoracotomy, the azygos vein was divided to mobilize the esophagus and retract it laterally. Level 4 and 7 lymph node dissection were performed to obtain access to the anterior tracheal and subcarinal spaces. There was minimal dissection lateral to the trachea to minimize risk of ischemia. One centimeter of trachea just proximal to the carina was circumferentially isolated with umbilical tape for retraction. We bronchoscopically confirmed the location for transection and advanced a jet ventilator catheter distally. We resected one centimeter of left mainstem bronchus. We inspected the lumen of the airway to confirm no gross residual disease and confirmed negative pathologic margin before performing an end-to-end anastomosis with interrupted absorbable sutures under both jet and cross-table ventilation. Postoperatively, the patient had an uncomplicated course and was discharged without any supplemental oxygen on postoperative day 6. Final pathology was low grade mucoepidermoid carcinoma, T1aN0.

Endobronchial, laryngeal and mediastinal melanoma: a rare constellation of metastatic disease

A 45-year-old man presents with acute respiratory failure. Imaging revealed a left mainstem endobronchial mass with subcarinal lymphadenopathy, but no other evidence of a primary tumour. An incidental laryngeal nodule was found during bronchoscopy. Biopsies of this lesion by nasopharyngoscopy and subcarinal lymph nodes via mediastinoscopy were performed. Histopathological and immunohistochemical examination showed evidence of melanoma in both samples. Mutational analysis identified the presence of a BRAFV600E mutation. The patient underwent bronchoscopic ablation of the left mainstem endobronchial tumour with laser therapy followed by initiation of encorafenib and binimetinib combination therapy. The patient remains alive at 4 months after initial presentation of disease. This case adds to the body of literature highlighting the clinical heterogeneity and challenges of the management of metastatic pulmonary melanoma. To the best of our knowledge, this simultaneous constellation of metastasis has not been described before.

An Unusual Cardiac Cause of Unilateral Neonatal Wheezing

A neonate presented three days after birth with left-sided unilateral inspiratory wheezing, intermittent respiratory distress, and desaturations. She was found to have a large ductus arteriosus aneurysm that caused compression of her left mainstem bronchus and left pulmonary artery. This lesion was not identified prior to birth on routine prenatal screening, which included fetal ultrasonography. Diagnosis was made on day of life (DOL) 5 by a computed tomography with angiography scan. On DOL 7, she underwent cardiac surgery which included resection of the ductal aneurysm, patch reconstruction of the transverse aortic arch and descending aorta, patent ductus arteriosus excision, and atrial secundum septal defect repair. There were no postoperative complications, and she has been asymptomatic since.

Descending Aortic Translocation and Right Pulmonary Artery Reimplantation for Midline Descending Aorta and Crossed Pulmonary Arteries in an Infant

Left mainstem bronchial compression by a midline descending thoracic aorta is a rare anatomic variant. Translocation of the descending thoracic aorta to the ascending aorta has recently been described to treat this condition. We performed an aortic translocation and right pulmonary artery reimplantation in a 4-month-old infant with severe pulmonary hypertension secondary to right pulmonary artery stenosis and left bronchial compression by a midline descending thoracic aorta. The procedure was successful in ameliorating the patient’s left mainstem bronchial compression and pulmonary hypertension. Descending aortic translocation should be considered when the left bronchus is compressed causing respiratory symptoms.