O-118
INTRATHORACIC GIANT DESMOID TUMOUR: DECISION-MAKING INTRAOPERATIVE STRATEGY TO AVOID CATASTROPHIC INTRAOPERATIVE COMPLICATIONS

Objectives: Here we present a failed surgical challenge for a life-threatening giant intrathoracic desmoid tumour. Decision-making steps during the perioperative period and their consequences were addressed.

Case description: An 18-year-old male presented with severe dyspnoea, orthopnoea, stridor and signs of SVC obstruction. He was oxygen-bound at rest with severe exercise limitation, and was found to have a huge intrathoracic mass occupying the entire right pleural cavity with marked displacement of the heart, great vessels and the trachea. Preceding histology of open biopsy was reported as malignant soft tissue sarcoma of unknown origin. Two previous removal attempts within the last year via right postero-lateral thoracotomy had been unsuccessful. A consensus was achieved, after a multidisciplinary meeting, that there was no alternative treatment better than a surgical challenge to relieve his life-threatening symptoms. The patient was prepared for arterious-venous extracorporeal membrane oxygenation (ECMO) support and a wide clam-shell incision was utilised for better access to the great vessels and protection of the heart from further compression during dissection. Although the tumour appeared encapsulated, separation from the chest wall was difficult due to dense adhesions from previous thoracotomies resulting in continuous troublesome bleeding and haemodynamic instability, necessitating ECMO support and he was heparinized. After tumour excision, the mediastinum returned back to nearly midline position and the right lung expanded fairly well to fill almost all pleural space. However, intractable haemodynamic instability did not allow successful weaning from ECMO, thus, prohibiting us to achieve a satisfactory haemostasis. Unfortunately, he developed severe hypovolemic low cardiac output syndrome and coagulopathy and died of uncontrollable bleeding despite massive blood transfusion. Final histology revealed a desmoid tumour.

Conclusion: Late diagnosed giant intrathoracic tumours can be life-threatening due to severe compression to vital organs. ECMO support facilitates dissection manoeuvres considerably during operation; however, its undesired consequences relating to anticoagulation should be handled cautiously.

Disclosure: No significant relationships.