대한흉부영상의학회 Weekly Chest Cases

Case No : 943 Date 2015-11-23

Courtesy of Geewon Lee / Pusan National University Hospital
Age/Sex 69 / M
Chief ComplaintAbnormal postoperative radiographic findings and laboratory results

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Diagnosis With Brief Discussion

Diagnosis: Lung (RML) torsion
Radiologic Findings: Chest radiograph obtained immediately after operation demonstrates a chest tube in the right hemithorax and no significant abnormality in the lungs.
Serial postoperative chest radiographs show a large increased density occupying the right upper and middle lung zones with bulging nature of the lower margin. However, the surgeon thought the increased density as pneumonia due to increased CRP.
Contrast-enhanced chest CT scan was performed 6 days after the operation. At lung window view, there was diffuse ground-glass attenuation and consolidation with increased volume in the RML. At mediastinal window view, abnormal soft-tissue attenuation at superior aspect of the right inferior pulmonary vein, wall thickening along the right middle lobar bronchus, stretching of the pulmonary artery, and acute obliteration of the vein draining from the RML was seen.
Under the impression of lobar torsion and subsequent infarction, operation was performed. The operator found RML torsion with intact RML bronchus and artery, but narrowing of the RML vein with severe congestion, thus, right middle lobectomy was performed.
Brief Review: Lung torsion most commonly occurs as a complication of thoracic surgery with reported incidences of 0.1% of pulmonary resection. Majority of lung torsions occur after right upper lobe lobectomy (70%) followed by left upper lobe lobectomy (15%). The middle lobe is particularly vulnerable after upper lobectomy because its small size expands to occupy a potentially large free space.
Radiographic findings consist of reoriented major fissure which may extend below the hilum and rapid postoperative lobar opacification.
CT findings include tapered obliteration of the proximal pulmonary artery and accompanying bronchus of the involved lobe and amorphous soft-tissue attenuation at the hilum. The torsed lobe demonstrates poorly enhancing consolidation with increased volume, ground-glass attenuation, interlobular septal thickening, and intralobular linear attenuation.
Mortality is high (10-20%) if lung torsion is unrecognized and surgical fixation is delayed.
Please refer to
References: 1. Rosado-de-Christenson et al. Diagnostic Imaging: Chest. Second edition. 2012
2. Kim EA et al. Radiographic and CT Findings in complications following pulmonary resection. Radiographics. 2002;22:67-86
Keywords: Lung, Iatrogenic lung disease, Postoperative complication,

No. of Applicants : 90

▶ Correct Answer : 42/90, 46.7%

- Kyoto University , Japan Akihiko Sakata
- Juntendo University Hospital , Japan Akifumi Hagiwara
- Daejin Medical Center Bundang Jesaeng General Hospital , Korea (South) Donghwan Kim
- McGill University Health Center , Canada Alexandre Semionov
- University of Tsukuba Hospital , Japan Hiroaki Takahashi
- Yokohama-asahi-chuo-general hospital , Japan Kyoko Nagai
- radiologist, aditya imaging centre , India vivek patel
- Deptt of Radiodiagnosis & Imaging, PGIMER chandigarh , India Ram Galwa
- Kyungpook national university , Korea (South) Chungeun Lim
- Ishikawa Matto Central Hospital , Japan Manabu Akimoto
- Osaka Rosai Hospital , Japan Hiromitsu Sumikawa
- University of Tsukuba Hospital , Japan Sodai Hoshiai
- Niigata City General Hospital , Japan Takao Kiguchi
- Okayama University Hospital , Japan Toshiyuki Komaki
- Shiga University of Medical Science , Japan Akitoshi Inoue
- CHRU Lille , France Paul Lebert
- CHU Poitiers , France CHAN paul
- Asan Medical Center , Korea (South) Jooae Choe
- Otsu Red Cross Hospital , Japan Hirotsugu Nakai
- Severance hospital , Korea (South) Suyon Chang
- Asan Medical Center , Korea (South) Soyeoun Lim
- university of montreal , Canada Andrei Gorgos I
- Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
- Asan Medical Center , Korea (South) , Korea (South) Han Na Lee
- Ondokuz Mayis University , Turkey Cetin Celenk
- ROKAF 10th Fighter Wing , Korea (South) Kun Woo Kang
- Kinki University Faculty of Medicine, , Japan Mitsuru Matsuki
- IRSA La Rochelle , France Denis Chabassiere
- the first affiliatited hospital of nanjing medical univercity , China Hai Xu
- 異⑸ , Korea (South) Yunhee Jang
- Diskapi Yildirim Beyazit Hospital, Ankara , Turkey Meric Tuzun
- Pusan National University Hospital , Korea (South) LEE YOU JIN
- Asan Medical Center, Ulsan University , Korea (South) Mi Young Kim
- Okinawa Kyodo Hospital , Japan Shoko Iraha
- Gifu Central Hospital , Japan Haruo Watanabe
- CLCC Rennes , France nicolas gautier
- National Center hospital of Neurology and Psychiatry , Japan Kaoru Sumida
- Seirei Hamamatsu General Hospital , Japan Kenichi Mizuki
- The University of Tokyo Hospital , Japan Toshihiro Furuta
- Pneumologia Universitaria, Policlinico di Bari , Italy Mario Damiani
- Niigata University , Japan Atsushi Uehara
- Medicheck health care , Korea (South) Chae Lim

▶ Correct Answer as Differential Diagnosis : 4/90, 4.4%

- Ajou University Hospital , Korea (South) Taeyang Ha
- chungbuk national university hospital , Korea (South) lee jung hwan
- chungbuk national university hospital , Korea (South) jeehye kim
- The University of Tokyo Hospital , Japan Takeyuki Watadani

▶ Semi-Correct Answer : 8/90, 8.9%

- Armed Forces Seoul Hospital , Korea (South) Eui Jin Hwang
- University of British Columbia , Canada Amr Ajlan
- Oita University, Faculty of Medicine , Japan Fumito Okada
- Teikyo University Mizonokuchi Hospital , Japan Noriko Kobayashi
- DAYA General Hospital,Thrissur,Kerala , India Raveendran TK
- Wuhan Union Hospital , China Qiguang Cheng
- Kizawa Memorial Hospital , Japan Shoji Okuda
- stanley medical college , India yazhini v

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 943 Date 2015-11-23

Discussion

No. of Applicants : 90