Case Study
Right upper lobe torsion following middle lobectomy: a rare complication
Asian Cardiovascular & Thoracic Annals 21(6) 739–740 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312469518 aan.sagepub.com
Mohammed W Khalil, Matthew de Hoest and Mahmoud Loubani
Abstract Middle lobe torsion is a known complication of right upper or lower lobectomy, whereas torsion of the upper or lower lobe is extremely rare. We report our experience with torsion of the right upper lobe following a middle lobectomy in a 74-year-old man with non-small-cell lung cancer.
Keywords Lung neoplasms, pneumonectomy, reoperation, torsion abnormality
Case report A 74-year-old man presented to our unit with nonsmall-cell lung cancer of the right middle lobe, confirmed by bronchial washings and demonstrated to be respectable on positron-emission tomography. The patient underwent a right middle lobectomy through a right thoracotomy. Intraoperatively, the tumor was found to be central and adherent to the continuation of the right pulmonary artery to the lower lobe. Dissection of the middle lobe, mobilization of the tumor off the hilum, and sleeve resection of the pulmonary artery invaded by the tumor were performed, with extensive pulmonary artery reconstruction. The upper lobe appeared to be very mobile at the end of the procedure, but on reinflation of the lungs, the upper and lower lobes were in the correct orientation and well apposed at the fissure; therefore, it was not felt necessary to anchor the upper lobe to the lower one. A postoperative chest radiograph (Figure 1) revealed full reexpansion of the right lung with normal vascular markings. On the following day, a chest radiograph revealed what appeared to be partial atelectasis of the right upper lobe. The patient was asymptomatic, and physiotherapy was advised because a mucus plug was suspected. However, the chest radiograph on the second postoperative day was worse despite intensive physiotherapy. The patient remained asymptomatic with no production of sputum or shortness of breath. Torsion was suspected and an urgent computed tomography scan was performed. This revealed torsion of the right
upper lobe with blockage of the pulmonary artery branch to the right upper lobe and narrowing of the continuation of the artery to the lower lobe (Figure 2). The patient was taken to the operating room, and preoperative bronchoscopy suggested torsion of the right upper lobe bronchus. The thoracotomy was reopened and 180-degree clockwise torsion of the right upper lobe was confirmed. The lobe was dusky in the lower third and generally edematous but viable. The torsion was corrected and the upper lobe was anchored to the lower lobe with Prolene stitches and Teflon pledgets. The patient did well postoperatively with daily improvements in the chest radiographs. He was discharged home on the 7th postoperative day.
Discussion Lobar torsion following pulmonary resection is a very rare complication with a reported incidence of less than 0.4%, and it could lead to gangrene or necrotizing pneumonitis of the affected lobe.1 It usually involves the right middle lobe after right upper or lower
Department of Cottingham, UK
Cardiothoracic
Surgery,
Castle
Hill
Hospital,
Corresponding author: Mohammed W Khalil, Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham HU16 5NR, UK. Email: [email protected]
740
Asian Cardiovascular & Thoracic Annals 21(6)
Figure 1. Immediately postoperative radiograph showing the fully expanded right lung with normal vascular markings.
Figure 2. Computed tomography scan showing blockage of the right upper lobe pulmonary artery branch and narrowing of the artery to the lower lobe, and right upper lobe atelectasis.
lobectomy, especially in the presence of a complete fissure, and necessitates anchoring of the middle lobe to the remaining lobe to prevent its torsion.2 However, it has also been reported to occur to the left upper lobe following lower lobectomy, to the left lower lobe following upper lobectomy, and even to the lingula after left upper segmentectomy.3–5 The potential danger is gangrene of the lobe if not detected early enough. In that case, urgent repeat thoracotomy must be carried out with excision of the necrotic lobe. In our case, the lobe was viable because of prompt early recognition and a high index of suspicion. The nutritional blood supply to the lung comes from the bronchial arteries, not the pulmonary artery. So even though the pulmonary blood supply was cut off in this case, we suspect that there was still some blood supply from the bronchial artery, and especially that the torsion was 180 degrees and not 360 degrees. After the initial operation, the 2 lobes came together nicely, and it was thought that this should prevent torsion. However, the likely mechanism of the torsion in this case was a mucus plug causing partial collapse of the upper lobe, making it more mobile and allowing the torsion postoperatively. Thus we wish to emphasize the importance of ensuring adequate pulmonary toilet postoperatively to avoid mucous plug obstruction. Good pain control to enable coughing, nebulizers, use of humidified oxygen if needed, and adequate physiotherapy must be ensured.2 We also recommend that fixation of the lobes should be performed if there is any concern about increased mobility of either of the lobes left behind. This is most important in patients
with inadequate pulmonary function who will not tolerate further resection of a gangrenous lobe. A high index of suspicion is necessary for early diagnosis, and rethoracotomy and correction of the problem should be performed without delay.5 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Hennink S, Wouters MW, Klomp HM and Baas P. Necrotizing pneumonitis caused by postoperative pulmonary torsion. Interact Cardiovasc Thorac Surg 2008; 7: 144–145. 2. Schamaun M. Postoperative pulmonary torsion: report of a case and survey of the literature including spontaneous and posttraumatic torsion [Review]. Thorac Cardiovasc Surg 1994; 42: 116–121. 3. Kucich VA, Villarreal JR and Schwartz DB. Left upper lobe torsion following lower lobe resection. Early recognition of a rare complication. Chest 1989; 95: 1146–1147. 4. Demir A, Akin H, Olcmen A, Melek H and Dincer SI. Lobar torsion after pulmonary resection: report of two cases. Ann Thorac Cardiovasc Surg 2006; 12: 63–65. 5. Eguchi T, Kato K, Shiina T, Kondo R, Yoshida K and Amano J. Pulmonary torsion of the lingula following a segmentectomy of the left upper division. J Gen Thorac Cardiovasc Surg 2008; 56: 505–508.
Right upper lobe torsion following middle lobectomy: a rare complication
Asian Cardiovascular & Thoracic Annals 21(6) 739–740 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312469518 aan.sagepub.com
Mohammed W Khalil, Matthew de Hoest and Mahmoud Loubani
Abstract Middle lobe torsion is a known complication of right upper or lower lobectomy, whereas torsion of the upper or lower lobe is extremely rare. We report our experience with torsion of the right upper lobe following a middle lobectomy in a 74-year-old man with non-small-cell lung cancer.
Keywords Lung neoplasms, pneumonectomy, reoperation, torsion abnormality
Case report A 74-year-old man presented to our unit with nonsmall-cell lung cancer of the right middle lobe, confirmed by bronchial washings and demonstrated to be respectable on positron-emission tomography. The patient underwent a right middle lobectomy through a right thoracotomy. Intraoperatively, the tumor was found to be central and adherent to the continuation of the right pulmonary artery to the lower lobe. Dissection of the middle lobe, mobilization of the tumor off the hilum, and sleeve resection of the pulmonary artery invaded by the tumor were performed, with extensive pulmonary artery reconstruction. The upper lobe appeared to be very mobile at the end of the procedure, but on reinflation of the lungs, the upper and lower lobes were in the correct orientation and well apposed at the fissure; therefore, it was not felt necessary to anchor the upper lobe to the lower one. A postoperative chest radiograph (Figure 1) revealed full reexpansion of the right lung with normal vascular markings. On the following day, a chest radiograph revealed what appeared to be partial atelectasis of the right upper lobe. The patient was asymptomatic, and physiotherapy was advised because a mucus plug was suspected. However, the chest radiograph on the second postoperative day was worse despite intensive physiotherapy. The patient remained asymptomatic with no production of sputum or shortness of breath. Torsion was suspected and an urgent computed tomography scan was performed. This revealed torsion of the right
upper lobe with blockage of the pulmonary artery branch to the right upper lobe and narrowing of the continuation of the artery to the lower lobe (Figure 2). The patient was taken to the operating room, and preoperative bronchoscopy suggested torsion of the right upper lobe bronchus. The thoracotomy was reopened and 180-degree clockwise torsion of the right upper lobe was confirmed. The lobe was dusky in the lower third and generally edematous but viable. The torsion was corrected and the upper lobe was anchored to the lower lobe with Prolene stitches and Teflon pledgets. The patient did well postoperatively with daily improvements in the chest radiographs. He was discharged home on the 7th postoperative day.
Discussion Lobar torsion following pulmonary resection is a very rare complication with a reported incidence of less than 0.4%, and it could lead to gangrene or necrotizing pneumonitis of the affected lobe.1 It usually involves the right middle lobe after right upper or lower
Department of Cottingham, UK
Cardiothoracic
Surgery,
Castle
Hill
Hospital,
Corresponding author: Mohammed W Khalil, Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham HU16 5NR, UK. Email: [email protected]
740
Asian Cardiovascular & Thoracic Annals 21(6)
Figure 1. Immediately postoperative radiograph showing the fully expanded right lung with normal vascular markings.
Figure 2. Computed tomography scan showing blockage of the right upper lobe pulmonary artery branch and narrowing of the artery to the lower lobe, and right upper lobe atelectasis.
lobectomy, especially in the presence of a complete fissure, and necessitates anchoring of the middle lobe to the remaining lobe to prevent its torsion.2 However, it has also been reported to occur to the left upper lobe following lower lobectomy, to the left lower lobe following upper lobectomy, and even to the lingula after left upper segmentectomy.3–5 The potential danger is gangrene of the lobe if not detected early enough. In that case, urgent repeat thoracotomy must be carried out with excision of the necrotic lobe. In our case, the lobe was viable because of prompt early recognition and a high index of suspicion. The nutritional blood supply to the lung comes from the bronchial arteries, not the pulmonary artery. So even though the pulmonary blood supply was cut off in this case, we suspect that there was still some blood supply from the bronchial artery, and especially that the torsion was 180 degrees and not 360 degrees. After the initial operation, the 2 lobes came together nicely, and it was thought that this should prevent torsion. However, the likely mechanism of the torsion in this case was a mucus plug causing partial collapse of the upper lobe, making it more mobile and allowing the torsion postoperatively. Thus we wish to emphasize the importance of ensuring adequate pulmonary toilet postoperatively to avoid mucous plug obstruction. Good pain control to enable coughing, nebulizers, use of humidified oxygen if needed, and adequate physiotherapy must be ensured.2 We also recommend that fixation of the lobes should be performed if there is any concern about increased mobility of either of the lobes left behind. This is most important in patients
with inadequate pulmonary function who will not tolerate further resection of a gangrenous lobe. A high index of suspicion is necessary for early diagnosis, and rethoracotomy and correction of the problem should be performed without delay.5 Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Hennink S, Wouters MW, Klomp HM and Baas P. Necrotizing pneumonitis caused by postoperative pulmonary torsion. Interact Cardiovasc Thorac Surg 2008; 7: 144–145. 2. Schamaun M. Postoperative pulmonary torsion: report of a case and survey of the literature including spontaneous and posttraumatic torsion [Review]. Thorac Cardiovasc Surg 1994; 42: 116–121. 3. Kucich VA, Villarreal JR and Schwartz DB. Left upper lobe torsion following lower lobe resection. Early recognition of a rare complication. Chest 1989; 95: 1146–1147. 4. Demir A, Akin H, Olcmen A, Melek H and Dincer SI. Lobar torsion after pulmonary resection: report of two cases. Ann Thorac Cardiovasc Surg 2006; 12: 63–65. 5. Eguchi T, Kato K, Shiina T, Kondo R, Yoshida K and Amano J. Pulmonary torsion of the lingula following a segmentectomy of the left upper division. J Gen Thorac Cardiovasc Surg 2008; 56: 505–508.
