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

Abstract

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.

Key Words: Fibrolamellar hepatocellular carcinoma; Bronchobiliary fistula; Liver transplantation; Anesthetic management; One-lung ventilation; Airway management; Hypoxic pulmonary vasoconstriction; Hepatopulmonary syndrome; Case report

Core Tip: Bronchobiliary fistula in a patient with fibrolamellar hepatocellular carcinoma creates major anesthetic challenges during liver transplantation, particularly when one-lung ventilation is not tolerated. In this case, despite successful lung isolation with a double-lumen tube, one-lung ventilation resulted in hypoxemia, likely due to impaired pulmonary physiology related to chronic liver disease, prior lung surgery, and thoracic radiation. Ventilation therefore had to be transitioned to two-lung ventilation with continuous airway suctioning to control persistent biliary contamination. The operation was further complicated by extensive thoracoabdominal adhesions and significant blood loss, requiring early vascular access planning and rapid, high-volume transfusion. This case highlights the importance of understanding altered hypoxic pulmonary vasoconstriction and ventilation-perfusion mismatch in liver disease, anticipating potential failure of one-lung ventilation, and preparing flexible airway, ventilation, and transfusion strategies to maintain oxygenation and hemodynamic stability during complex liver transplantation.

INTRODUCTION

Brochobiliary fistula (BBF) is a rare complication involving the formation of abnormal interconnection between the biliary tract and bronchial trees[1]. Most patients with BBF present with bilioptysis, characterized by scant bile-stained sputum, and may also exhibit other clinical features such as an irritating cough, fever, and jaundice[1,2]. BBF can be classified as congenital or acquired. Acquired cases arise from a wide range of etiologies, including benign hepatic masses, hepatic malignancies, trauma, biliary obstruction, and complications following interventions such as transcatheter arterial chemoembolization or radiofrequency ablation of the liver[3]. The development of BBF is closely associated with hepatobiliary disease as well as surgical and interventional procedures involving these anatomical structures. Fibrolamellar hepatocellular carcinoma (FL-HCC) is a rare primary liver cancer that significantly varies from classical hepatocellular carcinoma (HCC)[4]. It is predominantly found in adolescents and young adults without underlying liver disease[5]. Surveillance, Epidemiology, and End Results (SEER) data report an incidence of 0.2 cases per million person-years (< 5% of primary liver tumors), whereas recent computational analyses integrating electronic medical records with national payer data estimate the true United States incidence of FL-HCC at 18.5 cases per million person-years, five to eight times higher than the SEER estimate[6,7]. FL-HCC reported a higher stage at diagnosis, a higher rate of lymph node metastases, and a greater rate of major hepatectomy, when compared with conventional HCC[8]. Liver resection is considered the primary potentially curative treatment. However, liver-directed therapies such as chemoembolization, radioembolization, radiofrequency ablation, and microwave ablation, as well as systemic therapy, may also be used depending on the stage of FL-HCC and the extent of metastasis[9].

We present a case of a patient with FL-HCC complicated by BBF. The patient ultimately underwent living donor liver transplantation as possible curative treatment. To our knowledge, there are no prior reports of patients with BBF undergoing living donor liver transplantation as a curative treatment. Liver transplantation is a highly complex procedure performed in critically ill patients, requiring precise and sophisticated anesthetic management. We aim to describe the anesthetic considerations and intraoperative challenges encountered during the procedure and provide a focused discussion based on this experience.

CASE PRESENTATION

Chief complaints

A 21-year-old female with metastatic FL-HCC complicated by BBF presented for living donor liver transplantation.

History of present illness

The patient presented with worsening bilioptysis (approximately 150 mL/day) and decreased output from her biliary drains in the setting of a known BBF. She had a history of FL-HCC diagnosed in 2020 with a complex subsequent course.

History of past illness

Given the extensive and multifaceted nature of her prior treatments and complications, the detailed clinical timeline is summarized in Table 1.

Table 1 Timeline of the patient’s clinical course.

Time	Clinical event	Intervention	Outcome/note
2020 (5 years prior)	Diagnosis of FL-HCC	Two cycles of nivolumab	Discontinued due to immune-related type 1 DM and thyroiditis
Within first year	Extensive hepatic tumor burden	Ex vivo hepatic tumor resection with Roux-en-Y hepaticojejunostomy	Major alteration of biliary anatomy
Following years	Tumor recurrence	Microwave ablation and radioembolization	Progressive hepatic injury
4 years after diagnosis	Pulmonary metastasis	Left lung wedge resection and stereotactic radiation to both lungs	Radiation exposure to lung parenchyma
Subsequent course	Development of hepatic bilomas, intrahepatic abscesses, polymicrobial cholangitis	Internal–external biliary drainage	Recurrent sepsis and chronic biliary complications
Later period	Development of BBF	Surgical repair with diaphragmatic reconstruction	Recurrent fistulae and persistent bilioptysis
Preoperative period	Drain malfunction and persistent BBF	IR exchange and repositioning of chest tube, biloma drain, biliary drain	Multiple drains present in right hemithorax and RUQ
Preoperative status (2025)	Dyspnea on exertion, bilioptysis, poor nutritional status (BMI: 16)	Evaluation for surgery	Compromised pulmonary and systemic condition
Final stage	Persistent BBF with metastatic FL-HCC	Referral for living donor liver transplantation	Considered as potential curative option

FL-HCC: Fibrolamellar hepatocellular carcinoma; BMI: Body mass index; DM: Diabetes mellitus; BBF: Brochobiliary fistula; RUQ: Right upper quadrant.

Personal and family history

The patient had no personal history of cancer or underlying liver disease. Her family history was notable for a maternal grandmother with breast cancer, with the patient’s mother testing negative for BRCA mutations, and a maternal grandfather with lung cancer.

Physical examination

The patient appeared chronically ill and jaundiced, reporting notable pruritus, decreased appetite, malaise, and fatigue; her body mass index was 16. Preoperative vital signs were blood pressure 114/65 mmHg, heart rate 99 beats/minute, respiratory rate 16 breaths/minute, oxygen saturation 97% on room air, and temperature 36.4 °C. Airway evaluation revealed a Mallampati class I view, normal cervical range of motion, adequate mouth opening and intact dentition. She endorsed dyspnea on exertion, abdominal pain, and intermittent episodes of coughing up bile.

Laboratory examinations

No special notes.

Imaging examinations

Chest computed tomography (CT) showed a right lung mass and fluid along the right major fissure, secondary to BBF (Figure 1A and B). Abdomen CT showed significant hepatomegaly, splenomegaly, and multiple liver masses (Figure 1C).

Figure 1 Preoperative imaging examinations of thoracic and abdominal structure with chest radiography A: Chest computed tomography (CT) with manifesting right lung mass; B: Chest CT with contrast showed right lung mass and fluid along right major fissure; C: Abdominal CT with contrast showed significant hepatomegaly with multiple liver masses and splenomegaly; D: Radiography confirming a right pleural pigtail catheter within the right hemithorax and the presence of a biloma drain and internal-external drains in the right upper quadrant.

Recent imaging confirmed drain malfunction and persistent BBF. Interventional radiology exchanged and repositioned the right-sided chest tube and biliary drains, with preoperative radiography confirming their placement in the right hemithorax and upper quadrant (Figure 1D).

FINAL DIAGNOSIS

A diagnosis of pulmonary metastatic FL-HCC with persistent BFF was established. She was subsequently referred for living donor liver transplantation as a potential curative treatment option.

TREATMENT

Intra-operative management

The patient was brought to the operating room with standard ASA monitors, along with a 20-gauge left radial arterial line and peripheral IV in place. Given the risk of aspiration and anticipated airway complexity, a rapid sequence induction was performed. The trachea was intubated with a 37 Fr left-sided double-lumen tube (DLT), and correct positioning was confirmed with flexible bronchoscopy. Bile was observed draining from the right mainstem bronchus, consistent with the known BBF. To prevent airway contamination and prevent exacerbation of the fistula, the right lung was isolated, and ventilation was maintained to the left lung. Shortly after initiating one-lung ventilation (OLV), the patient’s oxygen saturation decreased to 93%-94%. Notably, peak airway pressure, which had been approximately 19 cmH₂O during two-lung ventilation (TLV), increased to 25 cmH₂O during OLV. After maintaining OLV for approximately one hour, oxygen saturation did not improve, and airway pressure continued to rise. Recruitment maneuvers and intermittent TLV were used judiciously when oxygenation could not be maintained. Given the persistent desaturation, continuation of OLV was deemed unsafe, and ventilation was transitioned back to TLV. TLV was resumed, resulting in stable oxygenation with SpO₂ maintained above 99%. However, continuous bile drainage from the right main bronchus required frequent suctioning while maintaining TLV. Inhalational anesthesia was maintained with isoflurane. Changes in ventilation parameters, oxygenation, and arterial blood gas analysis during the surgical procedure are summarized in Table 2.

Table 2 Ventilation parameters, oxygenation status, and arterial blood gas analysis during the procedure.

	Baseline after anesthesia	After resumed TLV	After native liver out	5 minutes after reperfusion	90 minutes after reperfusion
Ventilation	OLV	TLV	TLV ± OLV	TLV	TLV
FiO2 (%)	100	89	67	70	70
SpO2 (%)	94	99	100	100	99
PIP (cmH2O)	24	20	23	19	18
ABP (mmHg)	137/57	114/54	137/62	125/58	108/58
pH	7.33	7.35	7.42	7.36	7.44
PaCO2 (mmHg)	49	43	52	43	44
PaO2 (mmHg)	83	140	220	202	161
HCO3- (mmol/L)	26	24	33	25	29
Base excess/deficit	-0.1	-1.7	7.9	-0.9	4.6
Hb (g/dL)	8.2	7.8	7.2	8.9	10.6
K+ (mmol/L)	3.6	3.5	4.9	3.5	3.4
Lactate (mmol/L)	1.10	1.10	4.60	4.80	4.00

OLV: One-lung ventilation; TLV: Two-lung ventilation; PIP: Peak inspiratory pressure; ABP: Arterial blood pressure; Hb: Hemoglobin.

Due to anatomic variation, the left internal jugular vein could not be cannulated; therefore, the right internal jugular vein was used for placement of both an 8 Fr Swan-Ganz catheter and a 9 Fr central venous catheter. An additional radial arterial line was placed in the contralateral side, and a 7 Fr rapid infusion catheter was inserted into the left antecubital vein. Although veno venous bypass was requested, no additional right-sided access was available due to existing large-bore catheters.

The surgical procedure was technically challenging due to dense perihepatic adhesions, extensive liver adherence to the diaphragm and inferior vena cava, and complex biliary reconstruction. Operative exploration revealed two percutaneous biliary stents in situ, as well as a biliary-bronchial fistulous tract extending into the right bronchus, correlating with the patient’s continuous bile-laden cough. Intraoperative inspection further demonstrated that one of the percutaneous biliary drainage catheters traversed the diaphragm and entered the liver. This abnormal tract was believed to be the direct source of her bilioptysis. At the time of native hepatectomy, all pre-existing percutaneous biliary drainage tubes were removed. Following explanation of the native liver and elimination of the biliary source, bile entry into the bronchial tree ceased, resulting in decreased bile drainage from the right bronchus and allowing stable TLV without the need for frequent suctioning.

Estimated blood loss was approximately 4 liters. A massive transfusion protocol was activated, including administration of 17 units of packed red blood cells, 8 units of fresh frozen plasma, 3 platelet units, 3 units of cryoprecipitate, 10 liters of crystalloid, and 600 mL of 5% albumin. Hemodynamic stability was primarily maintained through early and aggressive volume and blood product resuscitation. A norepinephrine infusion was initiated transiently at the time of reperfusion to support systemic vascular tone and was required only for a short duration. The infusion was gradually tapered and discontinued by the end of the procedure, allowing most of the operation to be completed with minimal vasopressor support. Calcium supplementation and methylene blue were administered per institutional protocol to correct electrolyte abnormalities and address vasoplegia. Urine output remained robust, totaling 5.6 liters throughout the procedure. At the surgeon’s request, an octreotide infusion was initiated to modulate portal venous flow through the newly implanted liver, and intraoperative Doppler ultrasonography confirmed adequate graft perfusion.

Transfer to intensive care unit

At the end of surgery, the DLT was exchanged for an 8.0 mm single-lumen tube. The patient was transferred intubated to the transplant intensive care unit, hemodynamically stable and no longer requiring vasoactive support. Sedation and analgesia were titrated to ensure ventilator synchrony and minimize coughing.

OUTCOME AND FOLLOW-UP

The patient was extubated on postoperative day 1 by the critical care team and maintained stable respiratory status on 4 L/minute of oxygen via nasal cannula. Her subsequent inpatient course was uncomplicated, with steadily improving liver enzymes, good tolerance of a gastrointestinal-soft diet, and independent ambulation. She was discharged on postoperative day 12. She has since required brief interval admissions for close monitoring but has continued to do well, and at her 6-month outpatient follow-up she reported full return to normal daily activities.

DISCUSSION

Management of BBF can be very difficult and is often associated with a high rate of morbidity and mortality. There has been no widely accepted management strategy in this condition[1]. In the absence of established treatment guidelines, management of BBF is typically individualized according to the underlying etiology and hepatobiliary pathology. Recent advances have broadened therapeutic options through minimally invasive and endoscopic techniques, including endoscopic sphincterotomy, biliary stent placement, and percutaneous transhepatic biliary drainage for biliary decompression[10].

Our case may be considered unique in several respects. Firstly, liver transplantation was undertaken as a potential curative treatment for BBF associated with hepatic malignancy. Although living donor transplantation is a complex decision involving surgical, ethical, and donor-related considerations, this case highlights that transplantation may serve as a definitive treatment option in selected patients, as it addresses both the BBF and the underlying hepatic disease contributing to its development.

Secondly, this case highlights important anesthetic challenges related to airway and ventilation management in patients with BBF. Airway management is particularly crucial when bilioptysis because of a BBF is present, as it isolates the non-affected lung, preventing its contamination.

Chronic biliary contamination of the respiratory tract can lead to recurrent pneumonitis, progressive respiratory compromise from airway irritation, and systemic complications such as malnutrition and sepsis[11]. The literature on anesthetic management in BBF is limited and consists primarily of case reports, which emphasize strategies aimed at preventing positive-pressure ventilation before lung isolation to avoid contamination of the contralateral lung with bile[12,13]. The summary of published case reports describing anesthetic management of BBF is provided in Table 3. In most reported cases, DLT with fiberoptic bronchoscopy was successfully performed, and OLV was maintained throughout surgery. DLTs are generally preferred because they facilitate reliable lung isolation and allow continuous suctioning of bile-stained secretions[12-14]. In a combined liver-kidney transplant in which BBF was discovered intraoperatively, emergent selective lung isolation using a Fogarty catheter was necessary to control a massive air leak and prevent cross-contamination prior to surgical repair[15]. Only one case had underlying pulmonary infection with poor lung function, in which repeated saline suctioning of biliary spillage from the affected lung was required until fistula ligation[14].

Table 3 Comparative review of anesthetic strategies in literatures.

	Sex/age	Primary disease	Biloptysis	Fistula affected lung	Pre-existing pulmonary disease	Surgery	Surgical position	Anesthesia	Endotracheal tube	Ventilation mode	Anesthetic challenge
1	Male/44	BBF after pancreaticoduodenectomy	Yes	Right	Pneumonia	Resection of fistula and bilobectomy	Left lateral decubitus position	GA	Left-sided DLT	OLV	Initially saturation decreased but gradually increased. Repeated bronchial lavage
2	Female/64	BBF with thrombosed hepatic artery aneurysm	Yes	Right	No	Deceased donor liver retransplantation	Supine position	GA	37-Fr left-sided DLT	OLV with CPAP in the right lung	After skin closure, approximately 500 mL/minute air leak from a suspected residual right bronchopleural fistula was detected during TLV, so OLV was resumed
3	Male/58	BBF with prior hepatic hydatid cyst resection	Yes	Right	No	Thoracotomy and resection of fistula and lobectomy	Left lateral decubitus position	GA	37-Fr left-sided DLT	OLV	-
4	Male/61	Intrahepatic cholangiocarcinoma	Yes	N/A	No	ERCP	N/A	GA	8.0 mm SLT	TLV	A spontaneous bronchobiliary fistula to the right bronchial tree was identified intraoperatively, and the patient was reintubated with a DLT
5	Male/20	BBF with prior exploratory laparotomy for grade 4 liver injury due to a blunt abdominal trauma	Yes	Right	No	ERCP and placement of a biliary stent	Prone and slight head-up position	MAC	N/A	SV	Temporarily hypotensive initially and thereafter remained hemodynamically stable
6	Male/66	Polycystic kidney disease and ESLD	Yes	NA	No	Combined liver-kidney transplantation	Supine position	GA	SLT and using a fogarty catheter	TLV	Identified intraoperative BBF with significant air leak; selective segmental isolation using a fogarty catheter

BBF: Bronchobiliary fistula; ESLD: End-stage liver disease; ERCP: Endoscopic retrograde cholangiopancreatography; GA: General anesthesia; MAC: Monitored anesthesia care; N/A: Not applicable; DLT: Double-lumen tube; SLT: Single-lumen tube; OLV: One-lung ventilation; CPAP: Continuous positive airway pressure; SV: Spontaneous ventilation.

In our case, OLV using DLT was initially planned and successfully achieved with isolation of the affected right lung. However, OLV could not be maintained intraoperatively, necessitating conversion to TLC with frequent airway suctioning. This failure of OLV can be better understood by considering both pulmonary physiology and the patient’s underlying conditions. Hypoxic pulmonary vasoconstriction (HPV) is a regional pulmonary vascular response in which arterioles constrict in hypoxic or atelectatic lung segments, increasing local pulmonary vascular resistance and diverting blood flow toward better-ventilated regions to minimize right-to-left shunt. During OLV, effective oxygenation depends on this mechanism in the nonventilated lung, together with relative vasodilation and low vascular resistance in the ventilated lung, to facilitate redistribution of perfusion[16]. In patients with chronic liver disease, however, this compensatory response may be impaired by hepatopulmonary syndrome (HPS). HPS is characterized by intrapulmonary vascular dilatations and arteriovenous shunting that produce baseline ventilation-perfusion mismatch and may attenuate HPV[12,17]. This condition has been reported in approximately 10% of liver transplant candidates and is most commonly associated with cirrhosis and portal hypertension although it can also occur in non-cirrhotic chronic liver disease[12,18]

The patient described in this case report had a five-year history of FL-HCC with pulmonary metastases, treated with multiple surgeries and ablations, resulting in chronic liver disease with ongoing hepatocellular injury, as reflected by a high model for end-stage liver disease-sodium (MELD-Na) score of 25. Such injury is known to trigger overproduction of potent vasodilators, including nitric oxide and carbon monoxide, leading to precapillary and capillary dilatation and the formation of intrapulmonary arteriovenous shunts[18]. This pathophysiology likely produced a pre-existing ventilation-perfusion mismatch and attenuated HPV, thereby compromising a key compensatory mechanism required to maintain oxygenation during OLV, which may partly explain the difficulty encountered in our patient.

Another possible cause of the failure of OLV can be explained by the fact that the patient had prior left lung wedge resection and radiation therapy on both lungs. Radiation-induced lung injury refers to pulmonary damage following thoracic radiation caused by destruction of alveolar epithelial and endothelial cells and disruption of the alveolar-capillary barrier[19,20]. This injury initiates an inflammatory cascade with increased vascular permeability, macrophage activation, and release of reactive oxygen and nitrogen species and profibrotic cytokines, resulting first in radiation pneumonitis and later in chronic pulmonary fibrosis[19]. These structural and inflammatory changes lead to progressive deterioration in lung function. The patient’s history of recurrent pneumonitis and pneumonia requiring antibiotic treatment suggests that her baseline pulmonary function was likely already compromised. This may also have contributed to the inability to maintain OLV in our patient. In addition, the patient had several other factors known to predict hypoxemia during OLV, including a history of prior contralateral lung surgery, which may have reduced functional pulmonary reserve, and the supine surgical position rather than the lateral decubitus position, resulting in less gravitational redistribution pulmonary perfusion[21].

Because TLV was required to maintain oxygenation, vigilant anesthetic management was essential, including frequent suctioning of bile from the right bronchus to limit contamination of the contralateral lung. Continuous airway clearance and serial arterial blood gas monitoring enabled dynamic ventilatory adjustments and physiological stability despite ongoing biliary contamination. This experience emphasizes the importance of anticipating potential OLV failure based on preoperative pulmonary status and the previously described physiologic mechanisms expected in a patient with chronic liver disease, rending preparation for an alternative ventilation strategy in advance a key for anesthetic management.

Extensive intra-abdominal adhesions significantly prolonged the hepatectomy phase, which lasted 435 minutes. A key intraoperative finding was the percutaneous biliary drain tract, with one catheter traversing the diaphragm into the liver and directly communicating with the right pleural cavity, likely representing the main pathway for bile entry into the bronchial system and the cause of persistent bilioptysis. The dense perihepatic adhesions and adherence of the liver to the diaphragm and inferior vena cava contributed to prolonged operative time and substantial blood loss. Regarding fluid and transfusion management, the patient required massive transfusion. Massive transfusion is defined as intraoperative transfusion of ≥ 10 units of packed red blood cells[22]. Although the evidence indicates that intraoperative blood transfusion is linked to worse postoperative outcomes in liver transplant recipients[23], transfusion remains frequently unavoidable during liver transplantation for intraoperative blood loss due to coagulopathy and surgical blood loss. In our case, massive transfusion was required, and hemodynamic support stability was maintained with norepinephrine, and calcium and methylene blue were administered to address electrolyte disturbances and vasoplegia. Recurrent laboratory assessments allowed timely correction of coagulopathy, acid-base derangements, and hyperglycemia. Prior studies have demonstrated that massive transfusion during orthotopic liver transplantation is independently associated with factors such as previous right-sided abdominal surgery, low preoperative hemoglobin, elevated model for end-stage liver disease score, prolonged cold and warm ischemia times, and extended operative duration. These variables serve as important predictors of substantial intraoperative blood loss in complex transplant cases[22]. Our patient exhibited several established predictors of perioperative complexity, including a history of extensive prior abdominal surgery, a high MELD-Na score of 25, preoperative anemia with a hemoglobin of 9.2 g/dL, prolonged cold ischemia time of 237 minutes, and an extended operative duration of 13.3 hours. Regarding vascular access, veno venous bypass was not feasible because an anatomic variation of the left internal jugular vein precluded cannulation, limiting central venous access to the right internal jugular vein. In anticipation of potential massive transfusion, a 7-Fr rapid infusion catheter was placed via antecubital access for blood product administration, highlighting the importance of proactive vascular access planning in liver transplant anesthetic management.

CONCLUSION

This case illustrates the complexity of anesthetic and surgical challenges during liver transplantation in a patient with BBF and FL-HCC with pulmonary metastases. The inability to sustain OLV was not due to technical difficulty with lung isolation, but rather to impaired pulmonary physiology related to HPS, prior lung resection, and radiation-induced lung injury. Transition to TLV with frequent airway clearance and close physiologic monitoring allowed adequate oxygenation until removal of the native liver eliminated the source of bile entry into the bronchial tree. The operation was further complicated by dense intra-abdominal adhesions, prolonged hepatectomy, and substantial blood loss requiring massive transfusion, highlighting the importance of early vascular access planning, coordinated transfusion strategy, and vigilant hemodynamic management in complex transplant cases. This experience underscores the need to anticipate potential failure of OLV in patients with BBF and compromised pulmonary reserve, and to prepare alternative ventilation and resuscitation strategies tailored to the patient’s underlying physiology and surgical complexity.

ACKNOWLEDGEMENTS

The authors extend their gratitude to the patient and her family for consenting to share this case. We also acknowledge the contributions of the perioperative, surgical, and critical care teams who coordinated efforts made this work possible.