LOBAR TORSION AFTER ELECTIVE RIGHT UPPER LOBECTOMY

Abstract

IntroductionLobar torsion is a rare entity, with an incidence between 0,09 an 0,3 %, but with a high mortality rate if not treated early, Postoperative middle lobe torsion following right upper lobectomy is the most common form of pulmonary torsion.Clinical caseA 72-year-old man who was a smoker and suffered from arterial hypertension and dilated cardiomyopathy, presented with a right upper lobe nodule and underwent elective right upper lobectomy. We used a 37Fr left double-lumen tube to manege one-lung ventilation and a thoracic epidural catheter was inserted to manage postoperative pain. The patient remained hemodynamically stable during the operation and right lung was re-expanded, so he was extubated in the operating room and transferred to the ICU during the first 24 hours.On postoperative day-1 chest radiography showed decreased clarity of the right middle fields, so had adopted a wait and see approach because the patient whas asymptomatic. But on postoperative day 2 chest radiography showed worsening being compatible with lobar torsion, so he was brought to the operating room emergently.DiscussionTorsion of the right middle lobe was observed without vascular or bronchial involvement. A lobe detorsion was carried out and it was fixed to the lower right lobe. Postoperative recovery was uneventful and patient was discharged 12 days after operation.In lobar torsion a delay in diagnosis and/or an improper treatment strategy can lead to serious complications. So that, the key to the patient management is an early diagnosis.The clinical presentation varies from asymptomatic to sudden dyspnea and chest pain with acute respiratory failure and hemoptysis. It can also associate serohematic debit in chest tube drainage.Radiologic findings are almost mandatory for the diagnosis. In plain radiography, we can identify a rapid opacification, collapsed lobe or positional change of the affected lobe. Computed tomography (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. Intraoperative bronchoscopy is also a very useful tool when postoperative lobar torsion is suspected.The treatment is controversial. In torsions of < 180° with incomplete obstruction of the pedicle, correction with lobar preservation (detorsion) can be considered but many authors recommend lobectomy as the treatment of choice. Lobar torsion is a rare entity, with an incidence between 0,09 an 0,3 %, but with a high mortality rate if not treated early, Postoperative middle lobe torsion following right upper lobectomy is the most common form of pulmonary torsion. A 72-year-old man who was a smoker and suffered from arterial hypertension and dilated cardiomyopathy, presented with a right upper lobe nodule and underwent elective right upper lobectomy. We used a 37Fr left double-lumen tube to manege one-lung ventilation and a thoracic epidural catheter was inserted to manage postoperative pain. The patient remained hemodynamically stable during the operation and right lung was re-expanded, so he was extubated in the operating room and transferred to the ICU during the first 24 hours. On postoperative day-1 chest radiography showed decreased clarity of the right middle fields, so had adopted a wait and see approach because the patient whas asymptomatic. But on postoperative day 2 chest radiography showed worsening being compatible with lobar torsion, so he was brought to the operating room emergently. Torsion of the right middle lobe was observed without vascular or bronchial involvement. A lobe detorsion was carried out and it was fixed to the lower right lobe. Postoperative recovery was uneventful and patient was discharged 12 days after operation. In lobar torsion a delay in diagnosis and/or an improper treatment strategy can lead to serious complications. So that, the key to the patient management is an early diagnosis. The clinical presentation varies from asymptomatic to sudden dyspnea and chest pain with acute respiratory failure and hemoptysis. It can also associate serohematic debit in chest tube drainage. Radiologic findings are almost mandatory for the diagnosis. In plain radiography, we can identify a rapid opacification, collapsed lobe or positional change of the affected lobe. Computed tomography (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. Intraoperative bronchoscopy is also a very useful tool when postoperative lobar torsion is suspected. The treatment is controversial. In torsions of < 180° with incomplete obstruction of the pedicle, correction with lobar preservation (detorsion) can be considered but many authors recommend lobectomy as the treatment of choice. Bibliography•Moreno Asencio MT, Rivo Vázquez E, Quiroga Martínez J, Moldes Rodriguez M, García Prim JM. Left upper lobar torsion after video-assisted thoracoscopic lower lobectomy. Cir Esp. 2017; 95(7):406–8.•Mansour W, Moussaly E, Abou Yassine A, Nabagiez J, Maroun R. Left Lung Torsion: Complication of Lobar Resection for an Early Stage Lung Adenocarcinoma. Case Rep Crit Care. 2016;2016:9240636. doi: 10.1155/2016/9240636. Epub 2016 May 17.