J Thorac Cardiovasc Surg 2003;126:303
© 2003 The American Association for Thoracic Surgery
Acute postoperative lobar torsion associated with pulmonary arterial rupture
J. Mark Jones, AFRCSa,
L. Doug Paxton, FFARCSIa,
Alastair N. J. Graham, FRCSa
a Department of Thoracic Surgery, Royal Victoria Hospital, Belfast, United Kingdom
To the Editor
We read with interest the review "Lobar Torsion After Pulmonary Resection: Presentation and Outcome."1 Lobar torsion is indeed a rare complication of elective lobectomy. Most cases of lobar torsion manifest in a delayed fashion, often from pulmonary venous congestion, when the twisted lobes are often considered nonviable.1,2
In contrast to these studies, we report a case of pulmonary arterial rupture associated with acute postoperative lobar torsion. A 62-year-old man underwent elective left upper lobectomy for squamous cell carcinoma (pT2 N0) with routine division of the inferior pulmonary ligament. Surgery was unremarkable, and the patient was extubated in the operating room. On transfer to the recovery room, however, a dramatic increase in bleeding of more than 2 L from the underwater seal chest drains was noted, accompanied by systemic hypotension. The patient was reanesthetized, intubated, and transferred for emergency reopening of the thoracotomy. During thoracotomy, which revealed a significant volume of blood in the pleural cavity, the patient sustained a ventricular fibrillatory cardiac arrest. After the pericardium was opened, intracardiac adrenaline was administered, and internal cardiac massage and defibrillation were performed. Lobar torsion was diagnosed, with the diaphragmatic surface of the lower lobe facing in an anterosuperior orientation. A laceration at the junction of the main pulmonary artery with the apical branch of the lower lobe was detected, in keeping with the line of torsion. There had been no dissection around this branch at the initial operation. The laceration was repaired with 4-0 Prolene suture (Ethicon, Edinburgh, United Kingdom), and subsequent recovery was uneventful.
It had been our standard practice to divide the inferior pulmonary ligament during upper lobectomy. However, it is possible that this is more likely to allow torsion, in a similar manner to an unfixed middle lobe after right upper lobectomy.3 We therefore changed practice after this event. We no longer divide the inferior pulmonary ligament during upper lobectomy, because, in theory, this could reduce the risk of torsion.2 This would be difficult to prove, however, because of the rare occurrence of this complication. It is, however, interesting that there has been no increase in the incidence of problems as a result of a residual space in the apex of the pleural cavity, since this decision not to divide the inferior pulmonary ligament was taken. We are interested to hear the comments of other surgeons who may have seen cases of this previously unreported presentation of lobar torsion and would appreciate their views on division of the inferior pulmonary ligament.
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References
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- Cable DG, Deschamps C, Allen MS, Miller DL, Nichols FC, Trastek VF, et al. Lobar torsion after pulmonary resection: presentation and outcome. J Thorac Cardiovasc Surg. 2001;122:1091–1093[Abstract/Free Full Text]
- Wagner RB, Nesbitt JC. Pulmonary torsion and gangrene. Chest Surg Clin North Am. 1992;2:839–852
- Wong PS, Goldstraw P. Pulmonary torsion: a questionnaire survey and a survey of the literature. Ann Thorac Surg. 1992;54:286–288[Abstract/Free Full Text]
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