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J Thorac Cardiovasc Surg 2007;134:1090-1091
© 2007 The American Association for Thoracic Surgery
Brief Communication |
Department of Thoracic Surgery, Soouth Nassau Communities Hospital, Oceanside, NY.
Received for publication May 16, 2007; accepted for publication May 30, 2007. * Address for reprints: Charles C. Sticco, DO, General Surgery Resident, South Nassau Communities Hospital, One Healthy Way, Oceanside, NY 11572. (Email: csticco{at}numc.edu).
The incidence of postlobectomy lobar torsion is rare. The literature states that lobe torsion occurs in 0.089% to 0.3% of patients after lung resection.1
Traditionally, treatment includes re-exploratory thoracotomy with affected lobe resection.2 We present a case of right middle lobe torsion with surgical treatment through a video-assisted thoracoscopic (VATS) approach after thoracotomy and right upper lobectomy.
A 59-year-old male patient had chest pain and cough for 10 days. A chest radiograph revealed a small round nodular density in the right upper lobe of the lung. An outpatient computed tomographic (CT) scan confirmed the presence of a 1.7-cm speculated tumor with no significant mediastinal lymphadenopathy. Medical history was significant for Crohn disease, hypertension, and a 45 pack-year history of smoking. Home medications included valsartan (Diovan), mesalamine (Asacol), and methotrexate.
The patient initially underwent a right VATS with wedge resection followed by a right thoracotomy and formal right upper lobe lobectomy. Pathologic examination revealed moderately differentiated adenocarcinoma without lymph node involvement staged as a T1 N0 tumor.
On postoperative day 2, the patient became tachypneic, tachycardic, and reported having a cough with dark red sputum. Oxygen saturation was 90% on 50% supplemental oxygen.
Arterial blood gases revealed a carbon dioxide tension of 36 mm Hg and an oxygen tension of 54 mm Hg. A chest radiogram demonstrated a large opacity occupying the medial right hemithorax most likely representing a collapsed right middle lobe (Figure 1).
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The true incidence of lobar torsion has been difficult to determine. Published reports have documented torsion developing in 0.089% to 0.3% of patients who have had lobectomy.1 The exact pathophysiology of lobar torsion remains controversial. Early articles have shown that bronchial occlusion produces ischemia of lobar bronchi, whereas other studies describe venous outflow obstruction and blood flow interruption causing parenchymal congestion and ischemia seen in lobar torsion.1
The clinical presentation of lobar torsion is varied. Cable and associates1 described how signs and symptoms may present dramatically with fever, tachycardia, and loss of breath sounds over the affected lung field. Other patients may exhibit these characteristics to a lesser degree. Respiratory distress usually coincides with radiographs showing opacification of the affected lung. It has been suggested that suturing the middle lobe to the lower lobe after a right upper lobectomy may prevent lobar torsion.1 Although this was preformed in our case, middle lobe torsion still occurred. Previous case reports have described this presentation immediately after surgery as well as several days postoperatively.1-3 This report illustrates how a high degree of awareness and prompt treatment ensures a satisfactory outcome through a minimally invasive procedure.
Current treatment of lung torsion is thoracotomy with lung resection of the nonviable lobe.2 The indications for thoracoscopic lobectomy have been expanding with increasing surgeon experience. VATS lobectomy may offer a second option with possible benefits over the open technique. McKenna, Houck, and Fuller4 have noted a decrease in blood loss, less postoperative pain, and better pulmonary function after surgery in patients undergoing VATS lobectomy. As minimally invasive thoracic surgery becomes more readily available, the literature is mounting that shows reduced rates of complications and better survival.4
Our patient’s uneventful course postoperatively may indicate a suitable alternative to open thoractomy for treating lobar torsion. This case occurred after open thoracotomy; however, as VATS lobectomy becomes more prevalent for non–small cell lung cancer and other indications, the occurrence of lobar torsion after VATS should be investigated. Additional reporting is necessary to determine if this less invasive technique results in quicker recovery and in a better overall outcome.
References
This article has been cited by other articles:
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  Y. Tanaka, W. Nishio, D. Hokka, S. Kawamura, E. Shimada, and S. Okumura Acute torsion of the left lower lobe caused by chronic traumatic hernia of the diaphragm J. Thorac. Cardiovasc. Surg., February 1, 2010; 139(2): e4 - e6. [Full Text] [PDF]
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