Lobar torsion after pulmonary resection: presentation and outcome

Differentiating Imaging Features of Post-lobectomy Right Middle Lobe Torsion

PURPOSE

The purpose of this study was to identify differences in imaging features between patients with confirmed right middle lobe (RML) torsion compared to those suspected yet without torsion.

MATERIALS AND METHODS

This retrospective study entailing a search of radiology reports from April 1, 2014, to April 15, 2021, resulted in 52 patients with suspected yet without lobar torsion and 4 with confirmed torsion, supplemented by 2 additional cases before the search period for a total of 6 confirmed cases. Four thoracic radiologists (1 an adjudicator) evaluated chest radiographs and computed tomography (CT) examinations, and Fisher exact and Mann-Whitney tests were used to identify any significant differences in imaging features (P<0.05).

RESULTS

A reversed halo sign was more frequent for all readers (P=0.001) in confirmed RML torsion than patients without torsion (83.3% vs. 0% for 3 readers, one the adjudicator). The CT coronal bronchial angle between RML bronchus and bronchus intermedius was larger (P=0.035) in torsion (121.28 degrees) than nontorsion cases (98.26 degrees). Patients with torsion had a higher percentage of ground-glass opacity in the affected lobe (P=0.031). A convex fissure towards the adjacent lobe on CT (P=0.009) and increased lobe volume on CT (P=0.001) occurred more often in confirmed torsion.

CONCLUSION

A reversed halo sign, larger CT coronal bronchial angle, greater proportion of ground-glass opacity, fissural convexity, and larger lobe volume on CT may aid in early recognition of the rare yet highly significant diagnosis of lobar torsion.

Analysis of the unplanned reoperation following surgical treatment of pulmonary tumor

BACKGROUND

In this study, we aimed to summarize the extremely important lesson and experience in the whole process of surgical treatments of lung tumors for the benefit of steps taken to prevent against unplanned reoperation.

METHODS

Demographical and clinical information of 7732 patients were retrospectively retrieved and reviewed, who were diagnosed with pulmonary tumor and underwent surgical treatments from January 2016 to March 2021. Those patients who underwent unplanned reoperation for the treatment of severe complications were focused carefully and analyzed meticulously.

RESULTS

A total of forty-one patients (41/7732) received 44 unplanned reoperations. Among them, eight and thirty-three patients were diagnosed with benign and malignant tumor, respectively. The incidence of unplanned reoperations seemed to be similar on both sides (Left vs. Right: 12/3231 vs. 29/4501, p = 0.103). Lobectomy plus segmentectomy is prone to reoperation (2/16, 12.5%) as compared to the other types of surgery. The complications leading to reoperation was hemothorax, including active hemorrhage (23/44, 52.3%) and clotted hemothorax (6/44, 13.6%), chylothorax (8/44, 18.2%), and the others (7/44, 15.9%) including bronchopleural fistula, torsion, or injury of right middle bronchus and pulmonary bulla rupture. The morbidity and mortality after unplanned reoperation were 17.1% (7/41) and 12.2% (5/41), respectively.

CONCLUSIONS

Bronchi or vessel stumps, the surgical edges of the lung parenchyma, and pleural adhesions should be checked to avoid postoperative bleeding. Prophylactic ligation of the thoracic duct should be recommended in case of the suspected oily-like exudation in the lymph node bed. Smooth expansion of the middle lobe is important to avoid narrowing and torsion before transection of the bronchus.

Dislocation of a middle lobe torsion-preventing bridging structure with an absorptive sheet and fibrin glue: a case report

Background

Middle lobe torsion is a rare complication of right upper lobectomy. Middle lobe torsion can be critical; thus, various preventive measures are used.

Case presentation

A 77-year-old man underwent thoracoscopic right upper lobectomy with partial middle resection and S6 segmentectomy for right upper lobe lung cancer located at the confluence of the three lobes and lower lobe lung cancer. Inversion of the middle lobe was observed during lung expansion before chest closure. A bridging structure with an absorptive sheet and fibrin glue was placed in the basal section of the middle lobe under lung expansion to prevent torsion. On postoperative day 1, the patient was tachycardic and was found to have decreased lung field permeability. The patient underwent emergency surgery for suspected middle lobe torsion. Dislocation of the bridging structure between the basal segments of the middle lobe was confirmed, and the middle lobe was deviated cephalad. In addition, pulmonary congestion in S4 due to pressure stenosis of V4 caused by the deviation of the middle lobe was observed, and middle lobe resection was performed. The postoperative course was uneventful.

Conclusions

This case suggested that the reinforcement method with an absorptive sheet and fibrin glue lacked sufficient strength to prevent middle lobe torsion. Stronger fixation should be considered if the middle lobe rotation is thought to be sufficiently strong when the lung is reinflated before chest closure.

Impact of counterclockwise rotation of the right middle lobe following right upper lobectomy

OBJECTIVES

Following right upper lobectomy, the right middle lobe may shift towards the apex and rotate in a counterclockwise direction with respect to the hilum. This study aimed to investigate the incidence and clinical impact of middle lobe rotation in patients undergoing right upper lobectomy.

METHODS

From January 2014 to November 2018, 82 patients underwent right upper lobectomy at our institution for lung cancer using a surgical stapler to divide the minor fissure. Postoperative computed tomography scans evaluated the counterclockwise rotation of the middle lobe, in which the staple lines placed on the minor fissure were in contact with the major fissure of the right lower lobe (120° counterclockwise rotation). Clinicoradiological factors were evaluated and compared between patients with and without middle lobe rotation. We also reviewed surgical videos in patients with middle lobe rotation to evaluate the position of the middle lobe at the end of surgery.

RESULTS

Nine patients had a middle lobe rotation (11%), where 1 patient required surgical derotation. Patients with middle lobe rotation were significantly associated with more frequent right middle lobe atelectasis and severe postoperative complications compared with those without rotation. A surgical video review detected potential middle lobe rotation at the end of the surgery.

CONCLUSIONS

Middle lobe rotation without torsion following right upper lobectomy is not rare, and it is associated with adverse postoperative courses. Careful positioning of the right middle lobe at the end of surgery is warranted to improve postoperative outcomes.

[The role of the intensive care unit after thoracic surgery]

Lung (bronchial) cancer is the leading cause of cancer-related death in Western countries today. Thoracic surgery represents a major therapeutic strategy and the various advances made in recent years have made it possible to develop less and less invasive techniques. That said, the postoperative period may be lengthy, post-surgical approaches need to be more precisely codified, and it matters that the different interventions involved be supported by sound scientific evidence. To date, however, there exists no evidence that preventive postoperative admission to intensive care is beneficial for patients having undergone lung resection surgery without immediate complications. A stratification of the risk of complications taking into consideration the patient's general state of health (e.g., nutritional status, degree of autonomy, etc.), comorbidities and type of surgery could be a useful predictive tool regarding the need for postoperative intensive care. However, serious post-operative complications remain relatively frequent and post-operative management of these intensive care patients is liable to become complex and long-lasting. In the aftermath of the validation of "enhanced recovery after surgery" (ERAS) in thoracic surgery, new protocols are needed to optimize management of patients having undergone pulmonary resection. This article focuses on the main postoperative complications and more broadly on intensive care patient management following thoracic surgery.

Massive hemoptysis in a post-operative patient with recurrent lung cancer successfully treated by the combination therapy of Endobronchial Watanabe Spigot and bronchial artery embolization

A 76-year-old woman who was treated with lorlatinib for postoperative recurrent anaplastic lymphoma kinase-positive lung adenocarcinoma visited our hospital with massive hemoptysis. Chest computed tomography showed massive bleeding from the right upper lobe; however, the cause of bleeding was unclear. After bronchial artery embolization (BAE), bronchial occlusion was performed using an Endobronchial Watanabe Spigot (EWS) that was easily placed because BAE had reduced the bleeding volume. Treatment with BAE alone was inadequate; however, additional therapy with EWS after BAE successfully controlled the massive hemoptysis, especially in this patient who underwent lobectomy to prevent respiratory dysfunction.

Pearls and Pitfalls in Postsurgical Imaging of the Chest

A variety of surgical procedures are utilized to treat a spectrum of cardiopulmonary diseases. In the imaging of patients in the post-operative period, it is important to have an understanding of surgical techniques including invasive and minimally invasive procedures and the expected postsurgical findings. Knowledge of certain patient risk factors, various complications associated with specific surgical procedures, and a keen attention to detail are essential to avoid misinterpretation and delay diagnosis. Prompt detection of potential complications allows timely intervention, thereby, optimizing patient outcomes in the post-operative period.

Risk factors for atelectasis of the middle lobe after right upper lobectomy: preoperative bronchial diameter and stapling of the fissure

Background

Atelectasis of the middle lobe after right upper lobectomy is often seen. However, the risk factors for atelectasis are uncertain. Therefore, we assessed cases in our institution and investigated risk factors for atelectasis of the middle lobe following right upper lobectomy.

Methods

We identified 354 cases in which right upper lobectomy had been performed in our institution between January 2009 and December 2018, and 342 were included in this retrospective analysis. We divided patients into two groups according to the presence of postoperative atelectasis of the middle lobe, and then preoperative clinical variables and perioperative variables were compared between the two groups. Multivariable analyses for postoperative atelectasis of the middle lobe were performed using the logistic regression model.

Results

Middle lobe atelectasis was detected in 59 cases (17.3%). Multivariable analysis demonstrated that the preoperative diameter of the middle lobe bronchus [P=0.012; confidence interval (CI), 0.525–0.930] and stapling of the fissure between the upper and middle lobes (P=0.004; CI, 1.997–37.050) were independent risk factors for postoperative atelectasis of the middle lobe.

Conclusions

A small preoperative diameter of the middle lobe bronchus and stapling of the fissure between the upper and middle lobes are risk factors for middle lobe atelectasis following right upper lobectomy.

Management of Complications Following Lung Resection

Lung resections are associated with a variety of potential postoperative complications. Not surprisingly, pulmonary complications are most frequent after lung surgery. Cardiac and thromboembolic complications are also important. It is essential that surgeons anticipate the possibility of these complications and take preventative measures whenever possible. When complications do occur, prompt recognition and treatment is required to assure optimal patient outcomes.

Pulmonary torsion after resuscitative thoracotomy: a case report

We report a rare case of pulmonary torsion after nonpulmonary thoracotomy. A 38-year-old woman with schizophrenia committed suicide by a self-infliction of sharp force into the chest and abdomen. During emergent abdominal damage control surgery, a left-sided resuscitative thoracostomy was also performed due to hemorrhagic shock. Although abnormal shadow was detected on postoperative chest roentgenogram and computed tomography, the diagnosis of pulmonary torsion was delayed. Seven days after initial surgery, pulmonary torsion was diagnosed and managed by left upper lobectomy. To our knowledge, this is the first report of pulmonary torsion after resuscitative thoracotomy.

The postoperative chest in lung cancer

Most of the complications following lung cancer surgery occur in the early postoperative period and can result in significant morbidity and mortality. Delayed complications can also occur. Diagnosing these complications can be challenging because clinical manifestations are non-specific. Imaging plays an important role in detecting these complications in a timely manner and facilitates prompt interventions. Hence, it is important to have knowledge of the expected anatomical alterations following lung cancer surgeries, and the spectrum of post-surgical complications and their respective imaging findings to avoid misinterpretations or delay in diagnosis.

Middle lobe preservation and fixation after right upper and lower lobectomy for synchronous lung cancer

The incidence of multiple lung cancer has been steadily increasing worldwide. Although cases of patients with lung cancers in the right upper and lower lobe have also become more frequently reported in clinical work, simultaneous right upper and lower lobectomy reports with the middle lobe preservation are still quite rare. A total of three patients with lung cancers in the right upper and lower lobe were included in the study. The patients underwent simultaneous right upper and lower lobectomy, whereas the remaining middle lobe was sutured and fixed to the intercostal muscle of the incision to prevent postoperative lobe torsion. There was no procedure to reduce residual space，such as phrenic nerve crush or thoracoplasty. All patients were discharged from the hospital 7 days after the operation. The chest tube was removed 5 days after the operation in two patients. One patient was discharged with the tube because of slight pulmonary leakage, and the tube was removed 2 weeks after the operation. Six months after the operation, the chest computer tomography showed that the middle lobe expanded well and no obvious cavity or pleural effusion was found. The suture of the remaining middle lobe and intercostal muscle of the incision is a simple and effective method that can be used to successfully avoid middle lobe torsion. This strategy is safe and can be used as the first choice for eligible patients.

Lobar Torsion After Thoracoscopic Esophagectomy, and Prevention Method to Detect Its Incidence During the Operation

Lobar torsion is a rare but fatal complication, with such cases being mostly treated with pulmonary resection. Only a few cases of pulmonary torsion following esophagectomy have thus far been reported, and all cases occurred subsequent to transthoracic esophagectomy. We herein present the case of a patient with the right middle lobe torsion after thoracoscopic esophagectomy in a 64-year-old male. As the patient exhibited a hemodynamically unstable condition immediately after surgery and bronchoscopy and computed tomography revealed right middle lobe torsion, urgent surgery was performed. As torsion of right middle lobe was confirmed during a second operation, repositioning for torsion was performed. Fortunately, right middle lobe was aerated and exhibited a good complexion immediately after repositioning; therefore, pneumonectomy was not performed. Because it is difficult to observe the process of reinflation of a collapsed lung under direct vision in order to prevent lobar torsion when performing thoracoscopic esophagectomy, it is imperative to confirm the patency of the proximal bronchi during the operation using bronchoscopy.

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

Middle lobe torsion is an uncommon complication after right upper lobectomy. Clinical features are non-specific. CECT chest and diagnostic bronchoscopy are the essential investigations for the diagnosis. The treatment of choice is urgent re-exploration with either lobectomy or de-rotation with pneumopexy through thoracotomy or video assisted thoracoscopic approach based on the viability of lobe. Strong clinical suspiscion and early surgical intervention are the key points for success. This report highlights the role of video assisted thoracoscopic approach in the management of this rare complication.

Endobronchial valve therapy for severe emphysema: an overview of valve-related complications and its management

INTRODUCTION

Bronchoscopic lung volume reduction treatment with one-way valves is an effective guideline treatment option for patients with severe emphysema. However, important challenges and adverse reactions may occur after treatment.

AREAS COVERED

This review summarizes the complications after endobronchial and intrabronchial valve treatment that have been described by the currently published randomized controlled trials and other relevant papers regarding the complications and its management. In case there was no relevant literature regarding these subjects, recommendations are based on expert opinion. Complications include pneumothorax, post-obstruction pneumonia and hemoptysis. Also, the treatment may not be effective due to the presence of collateral ventilation or misplaced valves. Furthermore, an initial beneficial effect may vanish due to granulation tissue formation, valve dysfunction or valve migration. Careful follow-up after treatment with valves is important. Evaluation with a CT-scan and/or bronchoscopy is needed if there is no improvement after treatment, loss of benefit, or occurrence of important adverse events during follow-up.

EXPERT OPINION

Treating severe emphysema patients with one-way valves requires continuous dedication and expertise, especially to achieve an optimal outcome and elegantly deal with the various complications after treatment.

Postoperative complications of pulmonary resection

Thoracic surgery has seen a resurgence in recent years with increasing numbers of cases taken on since the mid-2000s. There has been a paradigm shift in how we manage lung cancer with more emphasis on surgical resection, and this has been aided by minimally invasive video-assisted thoracic surgery (VATS) techniques. As a result, the prevalence of postoperative findings and complications is also increasing, and it is increasingly important for the general radiologist to recognise and diagnose these conditions as thoracic surgical patients may present acutely to non-thoracic surgical institutions. This review will cover both the early and late complications following a variety of lung resection surgeries.

A pictorial review of lung torsion using 3D CT cinematic rendering

Lung torsion is the abnormal rotation of a lobe or lung around its bronchovascular pedicle. It most commonly occurs in the setting of pulmonary resection, though it has also been described after large-volume thoracentesis and video-assisted thoracic surgery, as well as spontaneously. Resulting ischemia can lead to infarction, making this an emergent diagnosis. As findings are often nonspecific, a high index of suspicion is required, especially in the postsurgical setting. 2D CT angiography findings are subtle and include direct signs of pedicle rotation on CT as well as indirect findings including loss of normal parenchymal enhancement, atelectasis of torsed lobe/lung, and abnormal fissure position. These direct and indirect findings are often appreciated on different window presets and upon review of images in multiple planes, with need to collate the information subsequently. 3D cinematic rendering (CR) using multi-planar light sources can readily highlight spatial relationships of vasculature in the chest and may be able to assist in the confident diagnosis of this sometimes subtle but life-threatening pathology. We have provided the first characterization of common lung torsion findings on 3D CR.

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

OBJECTIVE

To report outcomes of dogs treated for lung lobe torsion (LLT) and to determine prognostic factors for survival.

STUDY DESIGN

Retrospective multicenter study from four veterinary teaching hospitals.

ANIMALS

Dogs (n = 80) with LLT.

METHODS

Medical records were reviewed for clinical and histopathological findings. Long-term outcome was assessed with an owner questionnaire. Lung lobe torsion was classified as idiopathic or secondary on the basis of the etiology.

RESULTS

The most represented breeds were pugs (47.5%) and sighthounds (16.2%). The cause of the LLT was considered primary in 77%, secondary in 21%, and unknown in 2% of dogs. Postoperative complications were recorded in 14% of dogs. Overall, 95% of dogs survived to discharge, and median follow-up was 1095 days (range, 7-3809). Owners assessed outcomes and quality of life as excellent in 93% and 89% of dogs, respectively. Primary LLT was associated with a longer survival (median not reached in the study) compared with secondary LLT (921 days; range, 7-2073; P = .001).

CONCLUSION

Overall long-term survival after lung lobectomy for LLT was excellent. Primary LLT was associated with longer survival compared with secondary LLT. Long-term owner evaluation of clinical outcome for dogs undergoing lung lobectomy for LLT was considered excellent.

CLINICAL IMPACT

Dogs with primary LLT undergoing lung lobectomy have a longer survival time compared with dogs with secondary LLT and have an excellent postoperative outcome.

Postsurgical residual lung complications following left upper trisegmentectomy

OBJECTIVES

Segmentectomy has become an increasingly popular surgical procedure for small-sized lung lesions. Left upper trisegmentectomy (LUTS) is one of the most common segmentectomies performed because of its relative ease and simplicity; however, limited information is currently available on the specific postoperative complications associated with this procedure.

METHODS

Among 2060 surgically resected cases in our institute between 2009 and 2016, 129 (6.2%) underwent LUTS. Postoperative chest X-rays and/or thoracic computed tomography (CT) scans were retrospectively assessed for all cases to assess postsurgical residual lung complications following LUTS. We categorized cases into 4 groups: type A (atelectasis of the lingular segment), type B (lung torsion of the lingular segment), type C (necrosis of the 'isolated segment') and type D (haematoma along stapling lines).

RESULTS

Postsurgical lung complications following LUTS were observed in 17 (13.1%) patients (type A: n = 7, type B: n = 1, type C: n = 4 and type D: n = 5). Three patients (2.3%) required surgical intervention because of type B (n = 1) and type C (n = 2), namely, decreased permeability and remaining ground glass opacities in the residual lung, showing an exacerbated systemic inflammatory response. In contrast, type A and D cases were successfully observed by chest CT without any surgical intervention, and patients recovered within a few months of surgery.

CONCLUSIONS

We identified several postoperative residual lung complications following LUTS. Lung torsion or necrosis of the residual segment may require intensive care, including reoperation. Potentially serious complications always need to be ruled out after LUTS when radiological consolidation is detected postoperatively.

Fatal Stroke After Reoperation for Lobar Torsion

Lobar torsion is an extremely rare complication after elective lung surgery. Rotation of the bronchovascular pedicle results in airway obstruction and vascular compromise with lobar ischemia and pulmonary infarction. Rapid reoperation with untwisting of the pedicle is usually proposed. We report a case of an upper lobe torsion occurring at postoperative day one after a full thoracoscopic combined middle lobectomy and S⁶ segmentectomy. Lung detorsion resulted in a fatal cerebral infarction.

Right Upper Lobe Torsion after Right Lower Lobectomy: A Rare and Potentially Life-Threatening Complication

An 84-year-old woman was referred to our institution with suspected right lung cancer. Subsequently, she underwent thoracoscopic right lower lobectomy without mediastinal lymph node dissection. Postoperatively, she complained of dyspnea and developed arterial oxygen desaturation after 12 h and acute respiratory failure (ARF). An emergency chest computed tomography revealed the right upper bronchial stenosis with hilar peribronchovascular soft tissue edema because the middle lung lobe had been pushed upward and forward and the right upper lung lobe had twisted dorsally. Emergency bronchoscopy revealed severe right upper bronchial stenosis with an eccentric rotation and severe edema. The bronchia stenosis was successfully treated with glucocorticoids and noninvasive positive pressure ventilation for ARF.

Left upper lobe torsion in pneumothorax

We report a case of left upper lobe torsion in a patient who had a pneumothorax as a complication of subclavian venous access for an elective neurosurgical operation. Despite appropriate management of the pneumothorax, the patient's chest radiograph did not improve. Computed tomography of the chest was concerning for left upper lobe torsion. Fiberoptic bronchoscopy revealed near complete obstruction of the left upper lobe bronchus. Review of computed tomography imaging before and after bronchoscopy and subsequent thoracotomy confirmed lobar torsion. Consideration of lobar torsion in the differential diagnosis of patients with persistently abnormal chest imaging despite appropriate management after complications of routine procedures is important for early recognition and intervention of a potentially life-threatening problem.

Ipsilateral pulmonary infarction after major lung resection

Background

Lung infarction is a rare complication of lung resection, developing mainly because of technical errors. In some cases, a specific reason cannot be identified. This study aimed to investigate the occurrence, characteristics, and outcome of this pathology in a series of patients.

Methods

The medical records of patients who underwent reoperation for lung infarction without an apparent cause (based on imaging, reoperation findings, and histopathology) after major lung resection at our institution from 2006 to 2015, were investigated.

Results

Seven patients were identified. The mean age was 62.2 years (range 51–75 years), and 5 were male. Copious dissection or adverse events during surgery were recorded in all but 2 cases. The main presenting symptom was unsettling frank hemoptysis (4 cases) with a variable time of onset of symptoms (4–164 h). All reoperations necessitated further lung resection (4 patients had a further lobectomy and 3 had a completion pneumonectomy). During reoperation, all vessels and bronchi were intact. No apparent cause of infarction could be identified according to the histopathology report. Morbidity after reoperation was atrial fibrillation in 3 cases and bronchopleural fistula in 2, one of which required a transsternal pneumonectomy and this was the only mortality. Length of stay ranged from 8 to 90 days.

Conclusion

Ipsilateral lung infarction after lobectomy is a rare complication and the reason may not be identifiable. Treatment usually requires reoperation. Extensive manipulation or adverse events during surgery could induce this rare complication.

Postoperative Lung Torsion With Retained Viability: The Presentation and Surgical Indications

BACKGROUND

We review our experience with postoperative lung torsion with retained viability.

METHODS

A total of 2165 patients underwent pulmonary resection (lobectomy or segmentectomy) at our institution between 1 January, 1986, and 31 March, 2017. Eight (0.3%, six males and two females: median age, 68 years) had lung torsion with retained viability.

RESULTS

The right upper lobe was resected in seven patients, while the left upper segment was resected in one patient. The lung torsion with retained viability was the right middle lobe in seven patients and the left lingular segment in one patient. A bronchoscopic examination was performed in four patients to diagnose the pulmonary torsion; however, it demonstrated no specific findings. Subsequently, computed tomography (CT) was performed in all the patients, and lung torsion was diagnosed in all the patients based on the CT findings. None of the patients showed any symptoms when lung torsion was diagnosed in them. The diagnosis of pulmonary torsion was made at a median of 4 days (range, 1-22 days) after the initial surgery. Six patients underwent detorsion of the affected lung, while one patient had a lobectomy, and one patient received conservative management. The lungs of all patients in which detorsion was performed adequately re-expanded. Frequent pneumonia in the viable torsed lung was diagnosed as a cause of death in the one patient who received conservative management.

CONCLUSION

The timely decision to follow a surgical approach for lung torsion with retained viability can lead to a satisfactory outcome.

Lingular segment torsion following a left upper division segmentectomy

•

Torsion of the remaining segment after segmentectomy is extremely rare.

•

If there are no symptoms but lung torsion was suspected, prompt exploratory surgery can lead to a satisfactory outcome.

•

Physicians should consider the possibility of lung segment torsion when performing segmentectomy.

Introduction

Numerous publications regarding lung torsion have reported lobar torsion after lobectomy. On the other hand, torsion of the remaining segment after segmentectomy is extremely rare. We herein report a rare case of lingular segment torsion following a left upper division segmentectomy.

Case

A 68-year old female underwent thoracoscopic segmentectomy of the left upper division. She underwent chest radiography immediately after the initial surgery, which revealed complete expansion on the operated side. Routine chest radiograph findings on postoperative day 1 demonstrated atelectasis on the operated side, although she did not have any symptoms. Chest computed tomography was conducted because a follow-up chest radiograph on postoperative day 5 showed no improvement, and she was diagnosed with torsion of the lingular segment. We performed an exploratory thoracotomy. Based on intraoperative findings, the lingular segment was found to have a 90° clockwise torsion along the pedicle axis, although the segment was viable. We straightened the kinked lingular segment and affixed the lingular segment to the left lower lobe. The postoperative course was uneventful.

Conclusion

Although lobectomy is the most common cause of lung torsion, physicians should check for lung segment torsion when performing segmentectomy.

Idiopathic spontaneous pulmonary torsion of the lingula: A case report

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Spontaneous pulmonary torsion is an extremely rare event occurring as a complication of thoracic surgery and traumatic injuries.

•

Pulmonary torsion of a segment has been reported to occur only after segmentectomy.

•

This is the first case of spontaneous pulmonary torsion of lingula of unknown etiology.

Introduction

Spontaneous pulmonary torsion is an extremely rare event and is known to occur as a complication of thoracic surgery and traumatic injuries.

Presentation of case

An 18-year-old man presented to our hospital with pain in the left back region. Clinical examination, computed tomography and bronchoscopy are crucial for diagnosis of pulmonary torsion. During thoracotomy, the lingula segment was observed to be bent on the head side and turned 180° counterclockwise; subsequently, lingulectomy was performed.

Discussion

Spontaneous pulmonary torsion may occur in pulmonary conditions such as pneumothorax, atelectasis, infection, pleural effusion, congenital defect, or tumor. Furthermore, it can be speculated that torsion of the segment is possible only in the patients with an accessory fissure or those who have undergone a segmentectomy.

Conclusion

We have reported an extremely rare case with respect to the fact that the pulmonary torsion occurred spontaneously in an unseparated segment, and that the etiological factor could not be identified.

Intensive care in thoracic oncology

The admission of lung cancer patients to intensive care is related to postprocedural/postoperative care and medical complications due to cancer or its treatment, but is also related to acute organ failure not directly related to cancer.

Despite careful preoperative risk management and the use of modern surgical and anaesthetic techniques, thoracic surgery remains associated with high morbidity, related to the extent of resection and specific comorbidities. Fast-tracking processes with timely recognition and treatment of complications favourably influence patient outcome. Postoperative preventive and therapeutic management has to be carefully planned in order to reduce postoperative morbidity and mortality.

For patients with severe complications, intensive care unit (ICU) mortality rate ranges from 13% to 47%, and hospital mortality ranges from 24% to 65%. Common predictors of in-hospital mortality are severity scores, number of failing organs, general condition, respiratory distress and the need for mechanical ventilation or vasopressors. When considering long-term survival after discharge, cancer-related parameters retain their prognostic value.

Thoracic surgeons, anesthesiologists, pneumologists, intensivists and oncologists need to develop close and confident partnerships aimed at implementing evidence-based patient care, securing clinical pathways for patient management while promoting education, research and innovation. The final decision on admitting a patient with lung to the ICU should be taken in close partnership between this medical team and the patient and his or her relatives.

Prophylactic middle lobe fixation for postoperative pulmonary torsion

Background To prevent postoperative middle lobe torsion after a right upper lobectomy, we introduced a novel technique of interlobar fixation using collagen fleece coated with fibrin. In this study, the prophylactic effects of this method on the incidence of postoperative pulmonary torsion were analyzed. Methods Between April 2001 and December 2015, 3786 pulmonary resection procedures (excluding total pneumonectomy) were performed in our institution, and prophylactic interlobar fixation was selectively applied when intraoperative examination indicated that the patient was at high risk of postoperative pulmonary lobe torsion. As a control group, 842 patients who underwent pulmonary resection procedures between January 1996 and April 2001 were reviewed. Results During the study period, 10 (0.3%) patients underwent prophylactic middle lobe fixation (to the lower lobe after a right upper lobectomy in 9, and to the upper lobe after a right lower lobectomy in one). Pulmonary lobar (middle lobe) torsion occurred in only one patient (after right upper lobectomy); thus the incidence of this complication was 0.1% among patients who underwent a right upper lobectomy and 0.03% among all pulmonary resection procedures. The rates during the study period were marginally significantly lower than those in the control period (1.3% and 0.24%, respectively; p = 0.071 and p = 0.087, respectively). Conclusion Prophylactic middle lobe fixation might be useful for preventing postoperative pulmonary middle lobe torsion.

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

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.

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

Lobar torsion is a fatal but fortunately rare occurrence following lung resection. Early clinical signs and radiographic features may be nonspecific resulting in diagnostic delay. A high index of suspicion is vital for early diagnosis and intervention to avoid further parenchymal necrosis and deadly gangrene. We report a case of left lower lobe torsion in a 76-year-old female following elective upper lobectomy for underlying lung adenocarcinoma. Diagnosis was made following highly suggestive radiographic findings prompting bronchoscopy and revision thoracotomy. An emergency detorsion failed to restore lung viability and was followed by completion pneumonectomy. The patient recovered and was discharged on the seventh postoperative day.

Predictors of survival in lung torsion: A systematic review and pooled analysis

OBJECTIVE

Lung torsion (LT) is a rare but life-threatening event. The objective of this study was to systematically review the natural history and clinical outcome of LT in published studies.

METHODS

A review of publications on LT from January 1950 to December 2014 was performed using 3 databases (PubMed, EMBASE, and Web of Science). The primary efficacy outcome was LT-related mortality. Intervention was classified as direct resection (resection without detorsion), indirect resection (resection after detorsion), and reposition. Univariate comparisons of survival were performed using a logistic regression model.

RESULTS

There were 109 patients from 91 studies identified in this analysis. LT was frequently reported after upper lobectomy (74.4%) and the middle lobe was the most vulnerable lesion (29.4%). The main clinical presentations were dyspnea (38.4%), fever (23.3%), and chest pain (17.4%). Radiologic findings suggestive of LT included worsening consolidation and abrupt truncation/tapering of the pulmonary artery. The overall mortality was 8.3%. Univariate analysis showed that the extent of torsion (whole LT vs lobar torsion) was significantly associated with survival (odds ratio, 5.867; P = .017). No significant difference was found between patients receiving direct resection and those receiving reposition; a trend was observed for worsening outcomes in patients treated with indirect resection (odds ratio, 5.300; P = .060).

CONCLUSIONS

The systematic review reveals the prevalence, key diagnostic tests, and optimal treatment methods for lung torsion. Whole LT is associated with higher mortality rates than lobar torsion. If the tortuous part is viable, reposition and direct resection have similar survival rates; otherwise, direct resection should be performed.

Middle lobe preserving right lower lobectomy with a serratus anterior hammock flap in a patient with previous right upper lobectomy

Increasingly, many patients are diagnosed with a second lung cancer after curative thoracotomy. It is very difficult to manage such patients surgically due to the significant loss of pulmonary function. Especially on the right side, avoiding a completion pneumonectomy may contribute to reducing postoperative functional loss and surgical complications as well as the morbidity of post-pneumonectomy syndrome. A technique is needed to prevent torsion of the preserved middle lobe. Following recently published cases utilizing a latissimus dorsi muscle flap, in this case report, we describe the use of the serratus anterior muscle flap as an alternative.

Interlobar fixation using TachoSil(®): a novel technique

BACKGROUND

We evaluated the use of TachoSil(®) for anchoring middle lobe to lower lobe after upper right lobectomy.

METHODS

The fixation of middle lobe to lower lobe was required in 39/213 consecutive upper lobectomies. In 19/39 (49%) cases, it was performed with suturing and/or stapler (standard group) and in 20 cases (TachoSil group) with Tachosil(®) alone.

RESULTS

The operative time, complications, length of chest drain and hospital stay were similar between two groups. However, standard compared to TachoSil(®) group presented a higher incidence of atelectasis (5% vs. 0%, P=0.4) and air leaks (5% vs. 0%, P=0.4) but it did not reach significant difference. Our technique was safe, easy, and quick.

CONCLUSIONS

Upon contact with pleura, the clotting factors of TachoSil(®) dissolved and formed a fibrin network which glued the collagen sponge to the pleura surface. It allowed to fix the middle lobe to lower lobe without restricting lung re-expansion and/or injuring the parenchyma.

Detorsion of the Pulmonary Torsion: A Rare Post-thoracotomy Complication

Pulmonary torsion is a rare but serious condition. Without prompt treatment it progresses to lobar ischaemia, pulmonary infarction and finally fatal gangrene. We present a case of this rare complication in a 61-year-old woman following thoracic operation without involving any lung resection. Careful post-operative clinical observation, chest X-ray and CT scans are crucial for precise diagnosis of lobar torsion. The bedside radiograph provided initial evidence of torsion. Computed tomography scans revealed the presumptive diagnosis of right upper lobe torsion. On exploration, a 70° rotation of the right upper lobe in a clockwise direction was found. The lobar torsion was carefully relieved, and lobar fixation was performed as a prophylaxis against recurrence of this complication. The post-operative period was uneventful. Early recognition and prompt intervention is imperative in order to save the affected lung. Patients with well-developed interlobar fissures may benefit from pulmonary lobe fixation.

Uniportal thoracoscopic management of middle lobe torsion after upper lobectomy

Lobar torsion is a rare but potentially life-threatening complication following pulmonary resection. Surgical management usually entails an exploratory thoracotomy and resection of the involved lobe if nonviable. We present the case of a 67-year-old woman diagnosed with right middle lobe torsion 5 days after thoracotomy and right upper lobectomy for squamous carcinoma of the lung. A thoracoscopic right middle lobectomy was successfully performed utilizing a single 4-cm port placed along the midaxillary line in the 5th intercostal space.

Focus on treatment complications and optimal management surgery

Thoracic surgery comprises major procedures which may be challenging, not only from a technical point of view but also regarding anesthetic and postoperative management. Complications are common occurrences which are also related to the comorbidity of the patients. After major lung resections pulmonary and pleural complications are often encountered. In this overview more surgically related complications are discussed, focusing on postpneumonectomy pulmonary edema, thromboembolic disease including pulmonary embolism, prolonged air leak, lobar torsion, persistent pleural space, empyema and bronchopleural fistula. Prevention, timely recognition, and early adequate treatment are key points as complications initially considered to be minor, may suddenly turn into life-threatening events. To this end multidisciplinary cooperation is necessary. Preoperative smoking cessation, adequate pain control, attention to nutritional status, incentive spirometry and early mobilization are important factors to reduce the incidence of postoperative complications.

[Prevention and treatment of intraoperative complications of thoracic surgery]

In order to achieve a minimal complication rate there is a need for a comprehensive strategy. This means in the first line preventive steps which include patient positioning, suitable approaches and access, an appropriately qualified surgical team as well as a carefully planned dissection and preparation. Furthermore, a supply of additional instrumentation, such as thrombectomy catheters, special vascular clamps and even extracorporeal membrane oxygenation (ECMO) and a heart-lung machine (HLM) in cases of centrally located lesions should be on stand-by. Control instruments, such as a bronchoscope and esophagoscope should not be forgotten. In selected cases a preoperative embolization (vascular malformation) or cream swallow (thoracic duct injury) can be helpful. Special interventions to overcome complications arising are described for the chest wall, lung parenchyma, pulmonary vessels, great vessels, bronchial arteries, trachea and bronchi, esophagus, thoracic duct, heart, vertebral column and sternum corresponding to the topography.