Lobar Torsion Following Bilateral Lung Transplantation

Abstract

Torsion of lobes of the lung is a rare complication following lung transplantation. We present a case of counterclockwise torsion of the right lung allograft and review of nine additional cases in the literature of lobar torsion following lung transplantation. A high degree of suspicion is needed for early diagnosis with rapid surgical intervention to preserve lung viability.

Left Lung Torsion: Complication of Lobar Resection for an Early Stage Lung Adenocarcinoma

“…Lung torsion is the rotation of a pulmonary lobe around the hilar pedicle resulting in bronchovascular compromise. It is a rare event seen mainly in the postoperative setting following thoracic surgery [ 1 , 2 ]. Fewer cases described its occurrence spontaneously or secondary to blunt trauma and pleural effusion [ 1 , 3 , 4 ].…”

“…The underlying pathophysiology remains controversial with reports delineating few predisposing factors [ 1 , 2 , 10 ]: (i) increased mobility secondary to inferior pulmonary ligament transection [ 11 , 12 ]; (ii) complete interlobar fissures resulting in loss of parenchymal bridge between contiguous lobes; (iii) an easily displaceable milieu of air or fluid in cases of pneumothorax or pleural effusion [ 4 ]; (iv) a heavy compact airless lobe in cases of atelectasis and consolidations; (v) a relatively longer left lobar pedicle [ 2 , 11 ]; (vi) pedicle skeletonisation during hilar lymph node removal [ 13 ].…”

“…The clinical picture of lung torsion varies depending on whether the torsion is partial or complete. Partial torsion has an insidious course presenting with partial collapse or obstructive pneumonia [ 2 ]. On the other hand complete torsion predisposes to a more dramatic presentation characterized by fever, tachycardia, hemoptysis, chest pain, hypoxemia, and loss of breath sounds at the affected side [ 1 , 2 ].…”

“…Plain radiography can raise early suspicion for postoperative torsion if certain findings are delineated including inappropriate hilar displacement away from the collapsed lobe, collapsed lobe in an unusual location, ipsilateral lobe opacification following surgery, and bronchial cutoff ( Figure 2 ) [ 10 ]. CT findings are more specific including lobar consolidation with ground glass attenuation and interlobular septal thickening associated with tapered obliteration of the proximal bronchus and artery of the involved lobe ( Figure 3 ) [ 2 , 14 ]. Direct visualization through bronchoscopy can be diagnostic, revealing an occluded bronchus of the involved segment without evidence of a mucous plug or endobronchial lesion ( Figure 4 ).…”

Post-operative imaging of pulmonary vessels

“…Imaging findings suggestive of this complication include collapsed or consolidated lung in an atypical position after surgery on conventional radiograph. CT better demonstrates rotation, tapering and obliteration of the proximal pulmonary artery and bronchus of the affected lobe or lung with pulmonary venous obstruction and amorphous soft-tissue attenuation of the hilum with poorly enhancing peripheral pulmonary parenchyma (22,23) (Figure 8).…”