Video-Assisted Excision of a Giant Bronchogenic Cyst in a Patient with CAD and Chronic Respiratory Failure

A 56-years-old patient visited Max Super Speciality Hospital, Mohali with a history of shortness of breath and chest pain since he was one month-old. The patient was a chronic smoker for over 30 years with a history of Chronic Respiratory Failure and Obstructive Sleep Apnea for the past seven years. 

The respiratory failure had required intermittent non-invasive ventilatory support and hospitalisation seven years back. The patient also had Coronary Artery Disease (CAD), requiring a Percutaneous Angioplasty and stenting of all three coronary arteries five years back and repeated stenting of the LAD and RCA three years back.

The patient’s CXR revealed a mediastinal widening with increased Bronchiovascular markings in the bilateral basal bones. In the same evaluation, a 2-D Echocardiography showed no regional wall motion anomaly, and pulmonary artery systolic pressure was 24 mmHg, with a grade I dysfunction. The left ejection fraction was 45%. The CECT chart revealed a large sub-cardial non-enhancing cyst near the midline but towards the right, abutting the oesophagus and splaying the carina with indentation of the left atrium. The soft tissue attenuation was 40 HU, suggestive of a Bronchogenic Cyst. The blood gas analysis revealed a pO2 saturation of 62% and a pCO2 concentration of 40%.

The patient was taken up for video-assisted Thoracoscopic Excision of his Bronchogenic Cyst. The right lung was densely adherent to the cyst, overlying chest wall as well as adjacent to the pericardium which was carefully separated. There was a large 71 x 72 x 9.1 cm cyst filled with 300 ml dirty white material with a putty-like consistency. Azygos vein adherent to the chest wall started bleeding during an attempt to separate it from the cyst wall and was thus ligated. The cyst wall abutting the left atrium was carefully separated.

The inferior pulmonary ligament was adherent to the cyst wall and needed to be repaired with a 4-0 prolene suture. The pericardium was opened to check for any intra-pericardial extension of cyst or bleeding. Hemostasis was done, and the patient was shifted to ICU in hemodynamically stable condition. After 12 hours of mechanical ventilation, he was extubated but required intermittent non-invasive ventilatory support as he had carbon dioxide retention. As his carbon dioxide levels started rising to more than 50, a Pulmonologist was consulted, and he was put on oral steroids. 

The patient's condition improved after the initiation of steroids and was discharged the next day. On his first follow-up after one week, he was recovering well, and his steroids were tapered off gradually within a week. The histopathology report showed fibro collagenous cyst wall lined by respiratory epithelium with mild chronic inflammation in the wall consistent with a Bronchogenic Cyst.

This case has the unique distinction of being the largest Bronchogenic Cyst reported so far in our knowledge from the literature review. The cyst was abutting vital structures, including the left atrium, oesophagus, superior vena cava, was densely adherent to Azygos vein and right inferior pulmonary vein.

Moreover, this patient also had underlying Coronary Disease post-PTCA as well as a history of Respiratory Failure, which further increased the operative risk. However, despite all difficulties, the doctors performed video-assisted thoracoscopic resection of the giant Bronchogeinc Cyst without any complications and were able to achieve uneventful post-operative recovery despite several associated comorbidities.