Totally tubeless simultaneous bilateral VATS for pulmonary fungal granulomas following solid organ transplantation

Radiologically differentiating opportunistic pulmonary fungal infections from lung malignancies after solid organ transplantation (SOT) is difficult. Although a surgical biopsy is often required for definitive diagnosis, conventional intubated general anesthesia and routine chest tube drainage increase the risk of nosocomial infections and complications in immunosuppressed patients. Simultaneous bilateral completely tubeless video-assisted thoracoscopic surgery (VATS)—performed without endotracheal intubation or postoperative chest drains—is an advanced Enhanced Recovery After Surgery (ERAS) approach that could mitigate these risks. However, clinical experience with this technique in SOT recipients remains scarce. A 64-year-old male liver transplant recipient on long-term sirolimus presented with incidental pulmonary nodules. He had a limited 5-year smoking history (10 cigarettes/day), and his routine antiplatelet therapy (aspirin) was held preoperatively. Chest CT revealed a solid right upper lobe nodule and a cavitary left upper lobe nodule. Both lesions displayed spiculated margins and pleural indentation, raising high suspicion for malignancy (synchronous primary lung cancers and/or pulmonary metastases). The patient underwent simultaneous bilateral tubeless VATS wedge resections. Surgery was performed under regional anesthesia with spontaneous ventilation via a laryngeal mask airway (LMA). Estimated blood loss was 20 mL. After bilateral resection and negative water-seal tests, the temporary chest tubes were removed directly on the operating table. Final pathology confirmed chronic fungal granulomatous inflammation. A postoperative day (POD) 1 chest radiograph showed near-complete bilateral lung expansion with a minimal left pneumothorax and mild localized atelectasis. The patient remained asymptomatic, requiring no pleural interventions. Managed under standard ERAS protocols, he recovered uneventfully and was discharged on POD 4. Chronic immunosuppression can induce local fibrosis that causes pulmonary fungal infections to radiologically mimic malignancies. For high-risk solid organ transplantation (SOT) recipients, simultaneous bilateral tubeless VATS may represent a potential diagnostic and therapeutic strategy. Avoiding chest tubes minimizes potential pathways for nosocomial infection. Concurrently, preserving spontaneous ventilation may facilitate physiological recovery, allowing for the safe, conservative observation of minor postoperative radiological abnormalities.