Pulmonary lobar torsion: a rare complication following pulmonary resection, but one not to miss

Abstract

Lobar torsion is an uncommon phenomenon but a crucial diagnosis to consider in any patient undergoing lobectomy, as the clinical findings and radiographic appearances are non-specific. This case report documents the clinical and radiological evolution of middle lobe torsion in a patient who underwent right upper lobectomy for Stage 1 adenocarcinoma of the lung. The diagnosis of lobar torsion is most often made on CT scanning of the chest, which is frequently performed in order to distinguish this from multiple other more frequently encountered post-operative complications. Contrast-enhanced CT scan is the recommended imaging modality in suspected cases. If features of lobar torsion are identified, the findings must be communicated immediately to cardiothoracic surgeons owing to the potentially life-threatening consequences of delay. Management of lobar torsion is predominantly surgical, with several techniques currently in use; however, video-assisted thoracoscopic surgery is emerging as an increasingly favoured approach.

Long‐term survival after treatment of idiopathic lung lobe torsion in 80 cases

“…The treatment of LLT is surgical, with lung lobectomy considered the gold standard in animals, whereas controversy still exits regarding the optimal treatment in human medicine. Resection of the nonviable tissue avoiding a reperfusion insult is the typical treatment in both dogs and human patients, but repositioning, with or without pexy, seems to represent a feasible option according to the findings in some studies in man . Mortality associated with LLT in human patients ranges from 8.3% to 16% .…”

Successful video-assisted thoracoscopic management of the right middle lobe torsion: A rare complication of right upper lobectomy – A report of two cases

“…[ 3 ] Predisposing factors are complete interlobar fissures, heavy consolidated lobes with long vascular pedicle, large pleural effusions, massive pneumothorax and division/transaction of inferior pulmonary ligament after surgery or trauma. [ 4 ] Few authors also reported that VATS lobectomy can be a contributory factor in the development of lung torsion because of repetitive manipulation and rotation of the residual lobe during hilar and lymph node dissection. [ 3 ] In our experience, in both cases, middle lobe torsion happened after VATS right upper lobectomy.…”

“…Cutoff of the bronchi and hilar vessels supplying the malrotated lobe is the characteristic sign. [ 4 ] Bronchoscopy shows bronchial occlusion with unusual orientation. [ 6 ] Infection, postoperative lobar atelectasis, aspiration pneumonia, and necrotizing pneumonia contribute to the close differential diagnoses.…”

Post-lobectomy airways complications

“…Median time to diagnosis is four days (3) ranging from the day of operation up to three weeks (5,17). A number of factors predispose a lobe to torsion by increasing its mobility, including a long, narrow or skeletonised bronchovascular pedicle (1,3), complete oblique fissure (1), division of the inferior pulmonary ligament (1,18), pleural air or fluid (1), an atelectatic or congested remaining lobe (2,19) and the absence of adhesions (20).…”

“…Symptoms include dyspnoea (3), atypical chest pain (3,21), cough (4), haemoptysis (6) or bronchorrhoea (22). Sudden cessation of previous air leak, lobar collapse, together with tachypnoea (15), fever (15), hypoxaemia refractory to oxygen therapy (8,19), and leucocytosis should alert clinicians to consider lobar torsion (3,4). Complete torsion may rapidly progress to sepsis and shock.…”