Discussion
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,