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J Thorac Cardiovasc Surg 2006;132:720-721
© 2006 The American Association for Thoracic Surgery

Brief Communication

Clinical and radiographic signs lead to early detection of lobar torsion and subsequent successful intervention

^a Department of Cardiothoracic Surgery, University of Southern California, Los Angeles, Calif
^b Department of Radiology, University of Southern California, Los Angeles, Calif
^c Department of Surgery, Division of Thoracic and Foregut, University of Southern California, Los Angeles, Calif

Received for publication April 11, 2006; accepted for publication May 17, 2006.

^_* Address for reprints: Samer Kanaan, MD, 1520 San Pablo St, Suite 4300, Los Angeles, CA 90033 (Email: skanaan{at}earthlink.net).

Lobar torsion occurs rarely after pulmonary resection, with an incidence of approximately 0.1%.^1-3 Most cases of lobar torsion are detected late, usually require resection, and are associated with significant mortality.^1-4 We describe a case of lobar torsion and the clinical and radiographic signs that led to early detection and successful operative intervention.

Clinical Summary

A 61-year-old man presented with a left upper lobe nodule that had increased in size over 6 months from 1.2 cm to 2.1 cm, as determined by means of computed tomographic (CT) scanning. Positron emission tomographic scanning showed this lesion to have increased metabolic activity. The patient underwent a left thoracotomy and wedge resection of the nodule, revealing adenocarcinoma. Completion left upper lobectomy was performed, the chest was closed with 2 chest tubes, and on closure, the lung was visualized to expand fully.

The patient's postoperative course was initially unremarkable. He had a postoperative chest radiograph revealing an expanded left lower lobe with chest tubes in place. On postoperative day 1, his chest radiograph showed slight volume loss on the left, as well as a slight change in the position of the chest tubes. The next morning, his lung was completely opaque on the left (Figure 1). Clinically, he was not hypoxic, and bronchoscopy revealed a near-complete occlusion of the left lower bronchus with substantial bronchorrhea. In addition, his chest tube output had increased from a total of 300 mL to more than 1600 mL of serous fluid over 24 hours. CT scan (Figure 2) showed a twist in the left pulmonary vein and left main bronchus.

View larger version (90K): [in this window] [in a new window]   Figure 1. Chest radiograph demonstrating opacification of the left lung field on postoperative day 2.

View larger version (134K): [in this window] [in a new window]   Figure 2. Computed tomographic scan showing torsion of the left pulmonary vein, consolidation of the left lower lobe, and upward orientation of the left pulmonary vessels compared with the right.

Discussion

Diagnosis of lobar torsion can be difficult, and when it occurs, it is usually too late to salvage the affected lung parenchyma, contributing to significant morbidity and mortality. This case illustrates lobar torsion detected early in the postoperative period, allowing successful operative intervention to reduce the torsion.

Left lower lobe torsion is uncommon compared with right middle or lower lobe torsion.^1,5 Wagner and Nesbitt⁵ stated that lobar torsion occurs 70% of the time after right upper lobectomy and only 15% of the time after left upper lobectomy. Likewise, Cable and colleagues¹ described 7 cases of torsion of 7887 resections with none involving the left lower lobe, and Yamane and associates³ had 2 cases of 1002 resections with no left lower lobe torsion. All torsion cases in both studies required pulmonary resection.

This case had several clinical signs and radiographic findings that pointed to the diagnosis of torsion. First, the patient had opacification of the affected lung without hypoxia. Opaqueness of the lung is commonly described in the literature, but no comment is made in regard to the associated lack of hypoxia.^1-3 One would expect that opacification caused by mucous plugging would cause hypoxia that improved with mucous removal, but torsion appears to cause opacification and no hypoxia because the lung is completely shunted, receiving no oxygen and no blood flow.

Second, torsion is suggested by narrowing or occlusion of the bronchus on bronchoscopy with associated bronchorrhea. Cable and associates¹ described bronchoscopic narrowing or occlusion in all 7 of their patients, but bronchorrhea is not described. This case illustrated the possibility that lobar torsion leads to parenchymal congestion and associated fluid egress in the airway that can be detected on bronchoscopy.

Third, the patient had voluminous serous chest tube output. We believe that this sign, not described in the literature, is related to the pulmonary congestion mentioned above and to associated fluid shifts in the lung with torsion, leading to increased chest tube output.

Lastly, we noted a subtle change in the position of the chest tubes on radiography. The literature also does not describe this finding, but lobar torsion could shift the location of the chest tubes slightly, which might raise the level of suspicion that torsion has occurred.

Most studies describe fever on presentation, which is likely a late finding and related to ischemic or necrotic lung parenchyma, which requires resection.^1,3 Our patient did not have fever, reflecting early detection of the torsion.

The clinical and radiographic findings are subtle but, if identified, can suggest lobar torsion and mandate further workup, which should include a CT scan and early operative intervention. If performed early, successful reduction of the torsion and salvage of the affected lung parenchyma are possible.

References

1. 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]
   
2. Larsson S, Lepore V, Dernevik L, Nilsson F, Selin K. Torsion of a lung lobe. diagnosis and treatment. Thorac Cardiovasc Surg 1988;36:281-283.[Medline]
   
3. Yamane N, Sano Y, Nagahiro I, Aoe M, Date H, Shimizu N. Lobar torsion after pulmonary resection for lung cancer. Kyobu Geka 2005;58:1153-1157.[Medline]
   
4. Kelly MV, Kyger ER, Miller WC. Postoperative lobar torsion and gangrene. Thorax 1977;32:501-504.[Abstract/Free Full Text]
   
5. Wagner RB, Nesbitt JC. Pulmonary torsion and gangrene. Chest Surg Clin North Am 1992;2:839-852.
   

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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Samer Kanaan Jeffrey A. Hagen Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kanaan, S. Articles by Hagen, J. A. Search for Related Content PubMed PubMed Citation Articles by Kanaan, S. Articles by Hagen, J. A. Related Collections Lung - other