Diagnosis and treatment for postoperative lobar torsion

Abstract

To analyze retrospectively 8 cases of postoperative lobar torsion after thoracotomy. 8 cases of postoperative lobar torsion were collected (5 men and 3 women; median age, 55.0 +/- 7.7 years), including lobectomy 4 (left upper lobe of lung 2, right upper lobe of lung 2), esophageal carcinosectomy 2, resection of schwannoma in the right upper mediastinum 1, and descending aorta replacement 1. The postoperative lobar torsions were right middle lobe 2, right upper lobe 1, left upper lobe 3, left lower lobe 1, left lung 1. The median peak temperature was 38.4 degrees C (range, 37.8 - 40.2 degrees C) and the median white blood cell count was 10.6 x 10(9) cells/L (range, 9.3 - 14.9 x 10(9) cell/L) during the first 48 hours postoperatively. Postoperative radiographs demonstrated pulmonary infiltrates and volume loss in 6 patients and complete opacification in 2 patients. The diagnosis of lobar torsion was made a median of 4 days (range, 2 - 14 days) after the initial operation; 6 patients underwent resection of lung and recovered; 2 had the injured lobe or lung rotated and died. Complications after reoperation included respiratory failure in 2 patients, atrial arrhythmia in 2 patients. Median hospitalization was 24 days and range from 10 to 56 days. The mobilization of hilus of lung or residual pulmonary atelectasis is the main mechanism of the lobar torsion after thoracotomy. Lobar torsion represents a difficult diagnostic dilemma in the early postoperative period after thoracotomy. Exploratory thoracotomy must be performed without delay. The injured parenchyma should be sacrificed unless the diagnosis is obtained very early. When the injured lobe or lung is rotated back into normal position, simultaneous endotracheal suction is very important to prevent aspiration of fluid from the obstructed part of the bronchial tree to the uninvolved segments and dangerous postoperative hypoxia.