대한흉부영상의학회 Weekly Chest Cases

Case No : 171 Date 2001-02-03

Courtesy of Joon Beom Seo, M.D. Han Kyung Lee, M.D. / Gachon Medical School, Gil Medical Center
Age/Sex 58 / F
Chief ComplaintS/P right upper lobectomy due to solitary pulmonary nodule. The first chest radiograph is an immediate postoperative image. The second one is one day later.

Figure 1

Diagnosis With Brief Discussion

Diagnosis: Torsion of RML after RULobectomy
Radiologic Findings: Chest radiograph obtained after operation shows increased opacity in right upper zone.
The surgeon, however, thought that it was probably pleural fluid collection.
The radiograph obtained at the next day shows markedly increased opacity of the right upper lung with bulging nature of lower margin.
When the radiologist saw both of the radiographs, he thought the possibility of loculated pleural effusion, pneumonia and lobar torsion, and he telephoned the operator.
The operator told him that the clinically the patient was unremarkable without any signs of infection, and the recalled that the major fissure was complete on operation!

The radiologist, therefore, told it could be torsion of right middle lobe.
Another finding that raises the possibility of the diagnosis of lobar torsion is the unusual location of the surgical suture material at the midst of the right lung, which was used to divide the incomplete minor fissure.
Usually the suture material is seen at the hilar area.

Chest CT was done immediately, and it shows consolidation of the right middle lobe with increased volume, obstruction of proximal right middle lobar bronchus, and abnormal orientation of pulmonary arteries.

Under the impression of the lobar torsion with subsequent infarction, operation was done.
Intraoperative bronchoscopy showed narrowing of the bronchus with swelling of the mucosa.

The operator found that the right middle lobe was twisted about 180 degrees,
and the drained pulmonary vein was twisted and obstructed.

Right middle lobectomy was done, because the lobe was severely congested and partially infracted.
Pathology revealed hemorrhagic infarction.
Brief Review: Torsion of a lobe or lung occurs most commonly as a complication of blunt chest trauma or of thoracic surgery (usually lobectomy or lingulectomy).
It has also been described after lung transplantation, after fine-needle aspiration biopsy, and in patients with spontaneous pneumothorax.

The radiologic findings consist of atelectasis due to airway obstruction, abnormal positioning and orientation of pulmonary vessels and bronchi within the atelectatic lobe, abnormal position of the hilum in relation to the atelectatic lobe, and rapid expansion of an abnormally located consolidated lobe.

CT demonstrates twisting and narrowing or occlusion of the bronchus as well as abnormal orientation of the pulmonary vessels and delayed opacification following intravenous administration of contrast.
References: 1. Fraser RS, Muller NL, Colman N, Pare PD. Fraser and Pare's diagnosis of diseases of the chest, 4th ed. Philadelphia: W.B. Saunders, 1999:2622-2623, 2671-2672
2. Felson B. Lung torsion: radiographic findings in nine cases. Radiology 1987; 162: 631-638
Keywords: Lung, Iatrogenic lung disease, Postoperative complication,

No. of Applicants : 38

▶ Correct Answer : 21/38, 55.3%

- 媛由蹂瑜
- 嫄곗갹
- 嫄닿뎅
- 寃쏀щ
- 怨
- 怨源吏
- 怨
- 怨
- 源吏
-
- 源
- 源誘쇱＜
- 諛
-
- 諛
- 吏二쇨
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- 11th Air Force Hospital Byung-June Jo
- Seoul City Boramae Hospital Jae-Woo Song
- Seoul National University Hospital Tae Jung Kim
- Stedelijk OLV Ziekenhuis Mechelen, Belgium Ivan Pilate

▶ Semi-Correct Answer : 10/38, 26.3%

- 怨
- 源
-
- 議곗誘
- 怨
- 源
- Matsuyama Red Cross Hospital, Matsuyama, Japan Shunya Sunami
- Ospedale di Fabriano, Italy Giancarlo Passarini
- Pol. S.Orsola-Malpighi, Bologna, Italy Maurizio Zompatori
- Santa Maria delle Grazie Hospital-Pozzuoli, Naples, Italy Bianca Cusati

대한흉부영상의학회 Korean Society of Thoracic Radiology

Archive of Old Cases

Case No : 171 Date 2001-02-03

Discussion

No. of Applicants : 38