DOI: https://doi.org/10.36347/sjmcr.2026.v14i07.021

Pages: 1696-1702

Venous thromboembolism is one of the leading causes of preventable death after abdominal cancer surgery, and its simultaneous occurrence with a massive pneumothorax is exceptional, confronting the clinician with a difficult therapeutic dilemma. We report the case of an 81-year-old man, classified as American Society of Anesthesiologists (ASA) physical status III, who underwent right hemicolectomy and liver metastasectomy for a caecal adenocarcinoma with a synchronous hepatic metastasis, under general anaesthesia with orotracheal intubation. Preanaesthetic assessment identified an elderly oncological patient at very high thromboembolic risk, with no renal impairment and no coagulation disorder. The anaesthetic strategy aimed at airway protection, controlled mechanical ventilation with protective targets, maintenance of adequate tissue perfusion, and structured monitoring of emergence and extubation. A left subclavian central venous catheter was inserted intraoperatively, and thromboprophylaxis with enoxaparin was started from the eighth postoperative hour. On the third postoperative day, in a context of haemodynamic instability and an intense inflammatory response, acute dyspnoea developed; computed tomography pulmonary angiography demonstrated a bilateral proximal pulmonary embolism associated with a large left pneumothorax and a residual pneumoperitoneum. Despite intensive care management, the outcome was fatal. This observation illustrates the occurrence of a fatal thromboembolic event despite guideline-concordant thromboprophylaxis in a patient at very high risk. It highlights the exceptional nature of the pulmonary embolism–pneumothorax association, the diagnostic pitfall of postoperative dyspnoea with several possible simultaneous causes, and the central importance of prevention. It also underlines the need to report perioperative anaesthetic data in a structured manner, since positive-pressure ventilation, subclavian catheterisation and post-extubation surveil