Bronchobiliary fistula in fibrolamellar hepatocellular carcinoma with anesthetic challenges during living donor liver transplantation: A case report.

BACKGROUND

Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare malignancy that may lead to complex postoperative complications, including brochobiliary fistula (BBF).

CASE SUMMARY: We report a 21-year-old patient with pulmonary metastatic FL-HCC, previously treated with multiple liver ablations, left lung wedge resections, and thoracic radiation, who subsequently developed a right-sided BBF. The patient presented for living donor liver transplantation after persistent bilioptysis and recurrent infections despite biliary drainage and prior surgical repair. Intraoperative management was challenging. A left-sided double-lumen tube was used to isolate the left lung and avoid positive-pressure ventilation of the fistulized right lung. However, one-lung ventilation resulted in hypoxia requiring return to two-lung ventilation with continuous suctioning. Surgical dissection was prolonged due to dense adhesions between the liver, right hemidiaphragm, and lung, causing major blood loss and necessitating rapid, high-volume transfusion of blood products.

CONCLUSION

This case underscores the significant airway, ventilation, and hemorrhage challenges encountered during liver transplantation in patients with persistent BBF and extensive thoracoabdominal adhesions.