Transhepatic chest tube malposition complicated by delayed hepatic hemorrhage following tube removal: A case report and literature review

Chest tube thoracostomy is a routine procedure for the management of pneumothorax and pleural effusions. Although generally considered safe, it may be associated with potentially life-threatening complications, including injury to adjacent thoracic and abdominal organs. Hepatic perforation secondary to chest tube insertion is exceptionally rare, with only a limited number of cases reported in the literature. We report the case of a 62-year-old chronic smoker admitted for a secondary spontaneous pneumothorax who underwent multiple chest tube insertions after accidental tube dislodgement. Following accidental dislodgement of the initial chest tube, reinsertion resulted in inadvertent intrapulmonary placement complicated by pulmonary abscess formation. After removal and repeat insertion, contrast-enhanced computed tomography (CT) demonstrated transdiaphragmatic migration of the chest tube into the hepatic parenchyma, involving the junction of segments VII and VIII. The intrahepatic tract measured approximately 30 mm in length and 12 mm in maximal diameter, without active contrast extravasation or significant hemoperitoneum. After multidisciplinary evaluation, the transhepatic chest tube was removed under close monitoring. Twenty-four hours later, the patient developed delayed clinical bleeding from the drain insertion site associated with a decrease in hemoglobin from 10 g/dL to 8 g/dL. Emergency CT revealed a hepatic laceration along the previous drain tract without active contrast extravasation or significant hemoperitoneum. Because the patient remained hemodynamically stable and bleeding ceased spontaneously, conservative management with close clinical and radiological surveillance was successfully undertaken. This case highlights the indispensable role of multidetector CT in diagnosing chest tube malposition, assessing hepatic injury, guiding therapeutic decision-making, and supporting non-operative management in selected patients. It also illustrates the risk of delayed clinical bleeding following loss of the temporary tamponade effect exerted by the retained chest tube.