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Weekly Chest CasesArchive of Old Cases

Case No : 1066 Date 2018-04-02

  • Courtesy of Hyun-ju Lim, MD, Kun Young Lim, MD, Soo Hyun Lee, MD, Hyae Young Kim, MD / National Cancer Center
  • Age/Sex 78 / M
  • Chief Complaintpost-operative status for lung cancer, increasing WBC and C-reactive protein level
  • Figure 1
  • Figure 2
  • Figure 3

Diagnosis With Brief Discussion

Diagnosis
Right Middle Lobe Torsion
Radiologic Findings
Fig 1. Chest radiograph taken immediately after right upper lobectomy shows no abnormal post-operative finding.
Fig 2. Abnormally increased opacity has developed in right upper to mid lung zone on follow-up chest radiograph taken after one week.
Figs 3. Chest CT demonstrates expanded, poorly enhancing right middle lobe with internal consolidation/ground glass attenuation. Abrupt cut-off of right middle lobar bronchus is seen.
Brief Review
The incidence of lobar torsion is rare, occurring in 0.089-0.3% of patients following lobectomy. Lobar torsion is most commonly observed after thoracic surgery, and torsion of the right middle lobe after right upper lobectomy is the most common. It may also occur in traumatic or spontaneous condition.
Clinical findings include fever, tachycardia, dyspnea, and decreased breathing sounds, but these findings are not specific enough to make a confirmative diagnosis. Radiologic and bronchoscopic findings may be specific to make a correct diagnosis. Specific radiographic findings include rapid opacification or serial position change of the affected lobe. Post-operative follow-up with chest radiograph is most important for the correct diagnosis of a lobar torsion. On CT scan, the lobe will typically enhance poorly and have either ground glass attenuation/consolidation. The affected lobe can expand or undergo complete collapse. The bronchi and hilar vessels supplying the torsed lobe may exhibit cut-offs. The hilum can be displaced due to abnormal rotation. Lobar air-trapping with expansion of the twisted lobe owing to hemorrhagic engorgement and infarction may also be observed. Bronchoscopy may reveal an abnormally tight and obstructed orifice of the affected lobe.
In most cases, resection is performed due to irreversible ischemic change of the distorted lobe. In a few patients, simple de-torsion is carried out. If lobar torsion is suspected, exploratory thoracotomy should be performed without delay to prevent serious morbidity and mortality. To reduce the risk of lobar torsion, the right middle lobe can be fixed to the right lower lobe, especially if the fissure is well developed.
References
1. Child L, Ellis S and Francies O. Pulmoanry lobar torsion: a rare complication following pulmonary resection, but one not to mss. BJR Case Rep 2017; 2:20160010
2. Crijns K, Jansen F, van Straten A and van den Borne B. A pulmonary shadow after lobectomy: an unexpected diagnosis. The Netherlands Journal of Medicine 2012;70:232-235.
3. Chen C, Hung T, Chen T and Liu H. Torsion of right middle lobe after a right upper lobectomy. Journal of Cardiothoracic Surgery 2009;4:16-17
Keywords
Lung, Postoperative complication,

No. of Applicants : 126

▶ Correct Answer : 31/126,  24.6%
  • - Ishikawa Matto Central Hospital , Japan MANABU AKIMOTO
  • - Showa university Northern Yokohama Hospital , Japan KOTA WATANABE
  • - Showa University Fujigaoka Hospital , Japan KYOKO NAGAI
  • - Higashi-Ohmi General Medical Center , Japan AKITOSHI INOUE
  • - The University of Tokyo Hospital , Japan Akifumi Hagiwara
  • - Chonbuk National University Hospital , Korea (South) MINGI SHIN
  • - McGill University Health Center , Canada Alexandre Semionov
  • - NIMS, HYDERABAD , India BHASKAR K
  • - Chonbuk National University Hospital , Korea (South) EUN HA JUNG
  • - Other , Korea (South) SEONGSU KANG
  • - Asan Medical Center , Korea (South) HYUN JUNG KOO
  • - The Jikei university , Japan TAKU GOMI
  • - university of montreal , Canada Andrei Bogdan Gorgos I
  • - Kyungpook national university hospital , Korea (South) Nari Jung
  • - Yeungnam University Medical Center , Korea (South) JONGSOO PARK
  • - Chungbuk National University Hospital , Korea (South) YOUNGHUN JEON
  • - The University of Tokyo Hospital , Japan RYO KUROKAWA
  • - Medicheck health care , Korea (South) Chae hun Lim
  • - Other , Korea (South) MARI A
  • - Chungbuk National University Hospital , Korea (South) LEE JUNG HWAN
  • - , Japan NAOMI YUASA
  • - Chonbuk National University Hospital , Korea (South) KUM JU CHAE
  • - Chonbuk National University Hospital , Korea (South) WEON JANG
  • - Korea University Guro Hospital , Korea (South) KYU-CHONG LEE
  • - Chonbuk National University Hospital , Korea (South) SOL KI KIM
  • - Teikyo University Hospital , Japan KAORU SUMIDA
  • - , Japan YUMI MAEHARA
  • - , Korea (South) SEOYOUNG PARK
  • - Chonnam National University Hwasun Hospital , Korea (South) JONG EUN LEE
  • - Samsung Medical Center , Korea (South) HYUN JUNG YOON
  • - Ajou University Hospital , Korea (South) YOO YOUNGJIN
▶ Correct Answer as Differential Diagnosis : 1/126,  0.8%
  • - Kinki University Faculty of Medicine, , Japan MITSURU MATSUKI
▶ Semi-Correct Answer : 48/126,  38.1%
  • - Hyogo Prefectural Amagasaki General Medical Center , Japan TOMOAKI OTANI
  • - King Abdulaziz University Hospital , Saudi Arabia Amr M. Ajlan
  • - Ajou University School of Medicine , Korea (South) JUNG YONG JUN
  • - Gifu University Hospital , Japan TOMOHIRO ANDO
  • - Chonbuk National University Hospital , Korea (South) AHN JI HOON
  • - , Korea (South) HANKYUL KIM
  • - Ajou university hospital , Korea (South) Pae Sun Suh
  • - Seoul National University Hospital , Korea (South) JAE WON CHOI
  • - MD , India DEEPANDER SINGH RATHORE
  • - Vita Hospital , Brazil DIOGO LAGO PINHEIRO
  • - Chungbuk National University Hospital , Korea (South) CHANGHOON OH
  • - 罹…stanbul , Turkey AYHAN YILMAZ
  • - Chonbuk National University Hospital , Korea (South) SANGJIN PARK
  • - Oita University, Faculty of Medicine , Japan Fumito Okada
  • - Beaulieu clinic Geneva , Switzerland gilles GENIN
  • - Ajou University Hospital , Korea (South) Taeyang Ha
  • - The University of Tokyo Hospital , Japan TOSHIHIRO FURUTA
  • - Myongji Hospital , Korea (South) KI EON KWON
  • - , Korea (South) KIM HAE JIN
  • - Asan Medical Center , Korea (South) JOOAE CHOE
  • - Gifu University Hospital , Japan Yo Kaneko
  • - Chonbuk National University Hospital , Korea (South) YOUNGKWANG LEE
  • - Samsung Medical Center , Korea (South) KYOWON GU
  • - Ewha Womans University Medical Center , Korea (South) YOUNGSUN KO
  • - , Korea (South) DAYOUNG KIM
  • - Other , Korea (South) JIN YOUNG KIM
  • - CLINIQUE STE CLOTILDE , Reunion PATRICK MASCAREL
  • - Diskapi Yildirim Beyazit Hospital, Ankara , Turkey MERIC TUZUN
  • - Centre Hospitalier Regional de Lanaudiere , Canada Matthieu Storme
  • - Soonchunhyang University Hospital Seoul , Korea (South) BODA NAM
  • - Yonsei University,Severance Hospital , Korea (South) KYUNGSUN NAM
  • - Ajou University Hospital , Korea (South) HYERIN KIM
  • - Chungbuk national university hospital , Korea (South) Miran Yeon Yeon
  • - Azienda Ospedaliera di Cremona , Italy Pietro Sergio
  • - Multimagem Diagn泥˜sticos , Brazil PEDRO PAULO TEIXEIRA E SILVA TORRES
  • - Wuhan Union Hospital , China QIGUANG CHENG
  • - The University of Tokyo Hospital , Japan TAKU TAJIMA
  • - Fortis hospital , Mohali , India SHALEEN RANA
  • - Kizawa Memorial Hospital , Japan Shoji Okuda
  • - Other , Korea (South) TAE SUN KANG
  • - Ichinomiya Nishi Hospital , Japan Takao Kiguchi
  • - , China TINGTING WANG
  • - Private sector , Greece VASILIOS TZILAS
  • - Hamamatsu university school of medicine , Japan YUKI HAYASHI
  • - the first affiliatited hospital of nanjing medical univercity , China HAI XU
  • - Chungbuk National University Hospital , Korea (South) HYEONMI RYU
  • - Ewha Womans University Hospital , Korea (South) YOOKYUNG KIM
  • - Jiangsu province hospital , China WANGJIAN ZHA
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