Lobar Torsion After Lung Transplantation—A Case Report and Review of the Literature

Lobar torsion is a rare complication following lung transplantation. Early detection and immediate therapeutic intervention can lead to a favorable outcome. We report an unusual case of left lingular torsion following single lung transplantation performed for idiopathic pulmonary fibrosis. The patient experienced severe ventilatory compromise immediately after leaving the operating room, and a chest X-ray revealed a well-demarcated area of consolidation involving the left mid- and lower lung zones. Lingular torsion was promptly diagnosed and corrected surgically. The possibility of acute lobar torsion should be considered in lung transplant recipients who experience acute respiratory compromise in the early postoperative period. Early diagnosis and correction can avoid pulmonary infarction and the need for lobar resection.     

Lobar torsion after pulmonary resection for lung cancer

We reviewed our experience on postoperative lobar torsion. From January 1994 to December 2003, 1002 patients underwent lobectomy for lung cancer. Two (0.2%) patients with postoperative lobar torsion required surgical reintervention. The first case was that of a 79-year-old man who underwent left lower lobectomy for pulmonary adenocarcinoma. Based on the postoperative course, lobar torsion was highly suspected with progressive respiratory dysfunction and the chest X-ray showed complete opacification of the residual lobe. Rethoracotomy was performed on postoperative day 4. The left upper lobe was rotated clockwise, and completion pneumonectomy was carried out. The patient died 16 days after the second surgery because of respiratory failure due to severe pneumonia. The second case was that of a 24-year-old man with a diagnosis of metastatic lung cancer in the right upper lobe arising from pharyngeal cancer. The patient underwent right upper lobectomy and developed hemoptysis and persistent high fever. A chest computed tomography (CT) and bronchoscopy findings revealed lobar torsion of the middle lobe, and a reoperation was performed. The middle lobe was resected and the patient was discharged 8 days after the rethoracotomy. Pulmonary lobar torsion poses a difficult diagnostic dilemma in the early postoperative period after the pulmonary resection. Since late reoperation for postoperative lobar torsion sometimes results in poor prognosis, careful observation with bronchial fiberscopy as well as chest radiography is necessary for accurate diagnosis. Rethoracotomy should be carried out without any delay in cases of lobar torsion following pulmonary resection.     

Torsion of the middle lobe after right upper lobectomy of the lung; report of a case and the review of the Japanese literatures

We report a case of torsion of the residual right middle lobe of the lung, following right upper lobectomy for lung cancer. A 71-year-old man who had medical treatment for emphysema was admitted with a lung tumor on chest computed tomography. The tumor was diagnosed as pulmonary adenocarcinoma by transbronchial biopsy. Right upper lobectomy with mediastinal lymph node dissection, and partial resection of the right lower lobe were performed. On the following day, chest X-ray showed an opacification in the right upper lung field, which gradually increased. Bronchoscopic examination revealed a stenotic middle lobe bronchus. Torsion of the middle lobe was suspected, and rethoracotomy was performed on the second postoperative day. The middle lobe was torsed 90-degree counterclockwise around its bronchovascular pedicle. A middle lobectomy was performed secondary to severe congestion. The patient was discharged in good condition on the 11th postoperative day. In reviewing the literatures including this case, 13 of 16 torsions occurred after right upper lobectomy of the lung. Thirteen patients had rethoracotomy, 10 of them underwent resection of the rotated lung. Simple detorsion was carried out in 3 patients, and 1 of them developed cerebral infarction. Lung torsion was reported to be potentially life-threatening. Therefore, fixation of a remaining lobe should be performed. Exploratory thoracotomy should be performed without delay, if lung torsion is suspected.     

Case of lung torsion after esophagectomy

A 77-year-old man underwent esophagectomy for esophageal cancer. Chest radiograph just after the operation showed opacification of the right lung. Although chest radiograph still showed a marked opacification of almost whole right lung in the ICU in spite of multiple bronchoscopy examination and suctioning of pulmonary secretions, he showed no dyspnea. On the second postoperative day, his respiratory symptoms deteriorated unexpectedly. Computed tomography showed torsion of the right upper and middle lobes, and urgent surgery was scheduled. Following double-lumen endotracheal intubation, thoracotomy was performed under one lung ventilation. The lung was found rotated. The surgeons tried to reduce the torsion to preserve the viable lung, but failed. Bleeding from infarcted lung was observed (approximately 150 ml). Accordingly, stapled lobectomy was performed. After the second surgery, he fortunately recovered without any complications. Although lung torsion is a rare complication, not only thoracic surgeons, but also we, anesthesiologists, should be aware of this disease.     

Lobar torsion complicating bilateral lung transplantation.

We report a case of left lower lobe torsion in a patient who had undergone bilateral lung transplantation for alpha(1)-antitrypsin deficiency. The patient experienced acute pulmonary hypertension and hypoxemia on post-operative Day 3 and the chest X-ray showed bilateral alveolar infiltrates and a new focal consolidation of the left lower lobe. Fiberoptic bronchoscopy showed complete obstruction of the left lower lobe bronchus and abnormal rotation of the left upper lobe bronchus suggesting torsion, which was confirmed by pulmonary angiography and ultimately at thoracotomy. The possibility of acute lobar torsion should be considered in lung transplant recipients who demonstrate evidence of acute respiratory insufficiency in the early post-operative period.     

Video-assisted thoracoscopic lobectomy in the treatment of intralobar pulmonary sequestration

Pulmonary sequestration is a congenital malformation characterised by cystic, non-functioning embryonic lung tissue with vascularisation of an abnormal systemic artery. They are classified as intralobar (75%) and extralobar (25%) and are more common in the left lung and lower lobes (60-90%). We report two cases of intralobar pulmonary sequestration located in the lower lobe of the left lung which were subjected to video-assisted thoracoscopic surgery (VATS). Both patients had recurrent infections for which, after performing imaging tests, they were diagnosed with intralobar pulmonary sequestration in the left lower lobe, with an afferent arterial branch to the malformation from the aorta. A lower lobectomy was performed by video-assisted surgery, dividing the aberrant aortic artery with an endostapler. A single thoracic chest tube was placed and removed on postoperative day 2 and the patients were discharged on the same day. In both cases, the pathology examination revealed intralobar pulmonary sequestration. Pulmonary sequestrations are uncommon malformations that can be operated on using minimally invasive techniques, thereby permitting early discharge and a low rate of complications.     

Lobar torsion following thoraco-abdominal oesophagogastrectomy

Following thoraco-abdominal oesophagogastrectomy for an adenocarcinoma of the lower oesophagus, an 81-year-old female with no pre-existing respiratory disease could not be weaned from mechanical ventilation. Right upper and middle lobe torsion were found at thoracotomy on the 14th postoperative day. Both lobes were resected. The patient was discharged from hospital after several postoperative complications. Pulmonary torsion is a rare, potentially life-threatening complication of thoraco-abdominal oesophagogastrectomy. Differentiation from the more common postoesophagectomy pulmonary complications can be difficult. Early post-thoracotomy lung opacification, in the absence of the expected degree of hypoxaemia, should trigger a suspicion of pulmonary torsion.     

Computed tomography detection of stapled interlobar fissure facilitates diagnosing postoperative lobar torsion: A case report

IntroductionAtelectasis of the right middle lobe following right upper lobectomy may result from lobar torsion, bronchial kink, or impacted mucus plug. Although clinical consequence of lobar torsion could be serious, differentiating it from bronchial kink is occasionally challenging.Presentation of caseA 39-year old man with non-small cell lung cancer of cT1aN0M0 stage IA underwent right upper lobectomy. On postoperative day 1, we identified middle lobe atelectasis on the chest X-ray and performed bronchoscopy, which showed an obstruction of the right middle lobe bronchus without mucoid impaction. We injected air using a bronchoscope to the middle lobe, which re-expanded it. However, on postoperative day 2, chest X-ray showed a slightly collapsed and opacified middle lobe. Although enhanced computed tomography showed a patent middle lobe pulmonary artery, we noticed that a staple placed in the horizontal fissure was in contact with the lower lobe, implying the possibility of lobar torsion. Rethoracotomy on postoperative day 2 revealed a 240° clockwise rotation of the congested middle lobe. Therefore, we performed simple detorsion. The patient was discharged 10 days after rethoracotomy without further adverse events.DiscussionIn our case, patency of the pulmonary artery and temporary improvement of the atelectasis using a bronchoscopic aeration maneuver could not rule out the possibility of lobar torsion.ConclusionThe position of the staple placed on the interlobar fissure should be evaluated using computed tomography in postoperative middle lobe atelectasis. If the aeration maneuver for middle lobe atelectasis using bronchoscope fails, rethoracotomy should be considered.     

Lung torsion after tracheoesophageal fistula repair: a case report and review of literature

Lung torsion is a very rare event that has been described after trauma, spontaneously, and post-thoracic surgery, with only 8 cases reported in the pediatric literature. We present the first case report of lung torsion complicating tracheoesophageal fistula repair. The diagnosis was suggested on chest ultrasonogram and Doppler and confirmed by computed tomographic scans. On exploration, a 90° rotation of the right middle and lower lobes in a clockwise direction was found. A complete interlobar fissure and an absent inferior pulmonary ligament were identified as predisposing factors. The lobes were untwisted, and lobar fixation was performed to prevent retorsion. Postoperatively, the patient recovered complete lung function, and the patient's chest radiologic and ultrasonographic examination results normalized. Lung torsion is an extremely uncommon event. It causes clinical deterioration in the face of normal arterial blood gases and requires a high index of suspicion for diagnosis. Resection of the twisted lung or lobe may be unnecessary if diagnosis is made early and vascular occlusion is partial. Patients with complete interlobar fissures may benefit from pulmonary lobe fixation as a prophylaxis against occurrence or recurrence of this complication.     

Pericardial reconstruction using a pedicle flap of the diaphragmatic central tendon

A 46-year-old woman was referred to our hospital for further evaluation of an abnormal shadow on a chest X-ray. Chest computed tomography and magnetic resonance imaging revealed a lobulated tumor arising from the left lower lobe. At operation, the tumor tissue was found to have invaded the lingula and pericardium, involving the left phrenic nerve. Resection of the left lower lobe, lingula and pericar-dium including the phrenic nerve was performed for extended pulmonary malignancy. A pedicle flap of the diaphragmatic central tendon was used as a pericardial patch for pericardial reconstruction with satisfactory results. The patient’s postoperative course was uneventful. The postoperative histological diagnosis was pulmonary adenocarcinoma with sarcomatous elements [pT3N2M0]. At present, 43 months after the operation, the patient is receiving chemotherapy after having undergone cyberknife radiotherapy for brain metastasis of the tumor. The use of a pedicle diaphragmatic flap was effective in repairing a pericardial defect after extensive resection of pulmonary malignancy.     

Anomalous V2 of the left pulmonary vein detected using three-dimensional computed tomography in a patient with lung cancer: A case report

We report one of the rare anatomical variations of the pulmonary vein wherein the left V2 drained into the inferior pulmonary vein. A 63-year-old man was referred to our hospital because of an abnormal shadow in the left lower lung field that was noted on chest X-ray. Computed tomography (CT) revealed a tumor in the left lower lobe. A biopsied tumor specimen was diagnosed as an adenocarcinoma, and thus, left lower lobectomy was performed. Preoperative three-dimensional CT revealed that an anomalous V2 of the left lung drained from the superior segment into the inferior pulmonary vein. This variation type was confirmed during thoracoscopic left lower lobectomy. We were able to perform left lower lobectomy with the preservation of the anomalous V2. The postoperative course was uneventful, and the patient was discharged on postoperative day 12. It is important to identify anatomical variations of the pulmonary vein and reliably preserve and process the affected area to prevent postoperative complications.     

Pulmonary torsion following right upper lobectomy.

We report on a case of postoperative lobar torsion in a 51-year-old woman following right upper lobectomy. A right middle lobar torsion was diagnosed by postoperative observation with chest X-ray and bronchofiberscopy. An emergency rethoracotomy was performed and a middle lobectomy was carried out. The postoperative course was uneventful and the patient was discharged on the 17th day after rethoracotomy. Careful postoperative observation with chest radiography and bronchofiberscopy is important for the precise diagnosis of a lobar torsion. In a case of lobar torsion following lobectomy, rethoracotomy should be immediately carried out.     

Evaluation of postoperative pulmonary complications and remaining pulmonary arterial flow of lobectomized lung cancer patients using pulmonary digital subtraction angiography]

Postoperative pulmonary complications cause the decrease of the flow of remaining pulmonary circulation. We examined the effects of the difference of resected lobes on the postoperative course and remaining pulmonary circulation of the lobectomized lung cancer patients using a pulmonary digital subtraction angiography. In all cases with preoperative pulmonary complications, circulatory flow of the remaining lung on the operated side significantly decreased. In the cases without preoperative pulmonary complications, only the cases performed left upper lobectomy developed the decrease of the circulatory flow on the operated side. This seemed to be chiefly caused by a postoperative continual atelectasis of the remaining lower lobe due to kinking of the bronchus. On the other hand, the postoperative decrease of the residual pulmonary circulatory flow on the operated side was not developed in the cases undergoing a segmentectomy, even with pulmonary complications. Therefore, for any case requiring a left upper lobectomy or the case with an impaired lung requiring any type of lobectomy, contralateral pulmonary function should be exactly evaluated preoperatively.     

Non-tuberculous mycobacterial infection along the staple-suture line after segmentectomy for small peripheral lung cancer; report of a case

A 60-year-old non-immunocompromised man who had undergone right upper lobectomy and subsequent left superior segmentectomy for small peripheral lung cancers (stage I well-differentiated adenocarcinomas) 2 years earlier, was referred to us for further investigation of an asymptomatic abnormal shadow observed on a chest radiograph. Chest computed radiography showed air-space consolidation along the staple-suture line associated with the left superior segmentectomy, the abnormality was 4 x 5 x 5 cm. Completion lower lobectomy was performed because transbronchial biopsy did not provide for a definite diagnosis. Pathological examination revealed a large granuloma infected by Mycobacterium intercellulare. The lung parenchyma may be exposed along the staple-suture line and somewhat vulnerable to infection in cases of partial pulmonary resection. We should be aware of this possibility after lesser pulmonary resection for small peripheral lung cancer.     

Pulmonary vein thrombosis after lower lobectomy of the left lung

Pulmonary vein thrombosis is a known complication after lung transplantation but has rarely been reported after lobectomy or bilobectomy. We report the case of a left upper pulmonary vein thrombosis following an uneventful left lower lobectomy for bronchial carcinoma. Postoperative arterial blood gas values and chest radiographs were normal. On postoperative day 5, the patient became progressively dyspneic, developed hemoptysis and showed total opacification of the left lung without mediastinal shift on chest radiography. The patient remained dyspneic despite intravenous antibiotic therapy for suspected pneumonia and absence of obstruction at bronchoscopy. Diagnosis of left upper pulmonary vein thrombosis was finally made by contrast-enhanced multislice computed tomography followed by pulmonary angiography. Further clinical deterioration under conservative treatment forced us to remove the remnant left upper lobe that already showed gangrenous alterations. Pulmonary vein thrombosis following lobectomy or bilobectomy is very rare. Only 7 cases have been reported in the literature so far. Conservative treatment with antibiotics and anticoagulants may be successful but in case of clinical deterioration the affected lobe has to be resected. The mechanism of thrombosis remains unclear although intraoperative torsion and injury of vessels seem to be most likely since pulmonary vein thrombosis occurred in the operated hemithorax only.     

A case of lung cancer with extensive pleural adhesion, which could be resected by a thoracoscopic middle lobectomy

A thoracoscopic middle lobectomy was performed for a 78-year-old male with lung cancer associated with extensive pleural adhesion. After peeling off the area of pleural adhesion surrounding the surgical ports by finger, the thoracoscope was inserted into the thorax and then the area of adhesion in the other area was also peeled off under thoracoscope. A pulmonary vein was resected using a stapler. Due to adhesion at the fissures between the lobes, a pulmonary artery and bronchus of the middle lobe were cut from the front of the lung hilum. After that, the fissures between the lobes were also cut using a stapler thus resulting in a complete middle lobectomy. The operation time was 5 hours and 28 minutes, and the intraoperative bleeding was 200 ml. There was no postoperative air leakage, and the chest drain could be removed the day after surgery. In conclusion, even for lung cancer with extensive pleural adhesion, a thoracoscopic lobectomy can still be successfully performed. When a fissure between the lobes is found to adhere, the approach to pulmonary artery and bronchus from the front of the lung hilum is useful for performing a thoracoscopic middle lobectomy.     

Lobar torsion after pulmonary resection; report of two cases.

Lobar torsion is a rare complication after pulmonary resection. We report a case of right middle lobe torsion following a right upper lobectomy, and left lower lobe torsion following a left upper lobectomy. Careful postoperative clinical observation, chest radiography, fiberoptic bronchoscopy (FOB), and computed tomography (CT) are crucial for precise diagnosis of lobar torsion following pulmonary resection. Both patients underwent re-thoracotomy; a middle lobectomy and completion pneumonectomy were performed. In the clinical management of lobar torsion urgent diagnosis and conclusive surgical resection is needed to avoid mortality and morbidity.     

Unilateral pulmonary fibrosis following ipsilateral single-lung ventilation and anesthesia]

We experienced a rare case of unilateral pulmonary fibrosis following ipsilateral single-lung ventilation and anesthesia. A 75-year-old man with a 1-pack a day smoking history for 50 years was scheduled for right upper and middle lobectomy for lung cancer. The trachea and left bronchus were intubated with a 37-Fr double-lumen endobronchial tube, and anesthesia was maintained with oxygen, nitrous oxide, isoflurane, and epidural lidocaine. Left single-lung ventilation was maintained for 3.5 hours with FIO2 at 0.8-1.0, vital capacity at 10 ml.kg-1, and peak inspiratory pressure at 25 cmH2O. On postoperative day 55, reticular nodular density in chest roentogenography appeared only in the left lung while right lung showed pleural fluid and pneumonia. On postoperative day 105, a high-resolution computed tomographic scan revealed honeycomb pattern in the left lung and organized pneumonia in the right lung. The patient died from respiratory failure on postoperative day 155, and autopsy was not performed. Although the causative mechanisms of unilateral pulmonary fibrosis in this case was unclear, the patient had not been exposed to any drugs and inhalation agents known to induce pulmonary fibrosis. We speculate that high oxygen concentration, high peak inspiratory pressure, and overdistension of the left lung during the left single-lung ventilation and anesthesia were likely major initiating and contributing factors.     

Idiopathic spontaneous pulmonary torsion of the lingula: A case report

IntroductionSpontaneous pulmonary torsion is an extremely rare event and is known to occur as a complication of thoracic surgery and traumatic injuries.Presentation of caseAn 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.DiscussionSpontaneous 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.ConclusionWe 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.     

Large clear cell tumor of the lung mimicking malignant behavior

An 18-year-old man presented with a large (12 x 10 cm) cystic mass involving the lower lobe and lingula of the left lung on computed tomography. Intraoperatively a large cystic mass was seen densely adherent to the left lung and the chest wall. A left pneumonectomy was performed because of the dense adhesions and extreme vascularity. Pathologic examination revealed a benign sugar cell tumor of the lung. We believe this is the first case report of such a large, clear cell tumor of the lung, mimicking malignant behavior in terms of vascularity and local invasion and requiring pneumonectomy.