ARTICLE IN PRESS doi:10.1510/icvts.2007.158378
Interactive CardioVascular and Thoracic Surgery 7 (2008) 144–145 www.icvts.org
Negative results - Pulmonary
Necrotizing pneumonitis caused by postoperative pulmonary torsion Simon Henninka,*, Michel W.J.M. Woutersa, Houke M. Klompa, Paul Baasb Department of Surgical Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands b Department of Thoracic Oncology, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands a
Received 26 April 2007; received in revised form 31 October 2007; accepted 31 October 2007
Abstract Pulmonary torsion is an adverse event with a reported incidence of 0.089–0.4%. It may occur spontaneously, after trauma but most often as a rare complication after pulmonary surgery. We describe a case of lobar torsion of the left upper lobe after lobectomy of the left lower lobe, which resulted in a necrotizing pneumonitis with fever, hemoptysis and weight loss. A completion pneumonectomy was performed after which the patient recovered well. A review of the literature shows that a delay in diagnosis and treatment of this rare complication can have catastrophic consequences. Surgery is the treatment of choice since sparing of the lobe is hardly ever possible due to the irreversible ischemic changes. Detorsion, instead of resection, may lead to fatal complications. Although infrequent, one should be aware of lobar torsion and the necessity for immediate re-intervention. 䊚 2008 Published by European Association for Cardio-Thoracic Surgery. All rights reserved. Keywords: Lung; Torsion; Postoperative complications
1. Introduction Pulmonary torsion is a rare event, which is described most frequently as a complication following pulmonary surgery. The risk for torsion is highest in the right middle lobe (RML), after resection of the right upper lobe (RUL). Recognition of this complication may be difficult, especially if signs of infarction as shock, sepsis and interstitial pulmonary edema are lacking. Conventional chest radiography may show atelectasis, but chest computed tomography (CT) and bronchoscopy are more helpful to confirm the diagnosis. Obliteration of the pulmonary artery and kinking of the bronchus are alarming signs. Generally, the degree of torsion is 1808, but lesser displacements may occur and signs can be mitigated, as described in the following case. 2. Case report A 47-year-old woman presented with hemoptysis and coughing and was diagnosed with a cT2N0M0 bronchioloalveolar cell carcinoma of the left lower lobe (LLL). A lobectomy was performed under 48 h antibiotic prophylaxis (cefuroxim 3 dd 1500 mg) and with a double lumen endobronchial tube. Thoracotomy was performed by a posterolateral incision, without using VATS (video assisted thoracoscopic surgery). Inspection of the lung showed a complete interlobular fissure. The pulmonary artery accessory branches to the lower lobe were identified and ligated. *Corresponding author. Tel.: q31-20-512 9111; fax: q31-20-512 2508. E-mail address:
[email protected] (S. Hennink). 䊚 2008 Published by European Association for Cardio-Thoracic Surgery
The inferior pulmonary ligament was transected and subsequently the veins were explored and litigated. The main left lower bronchus was transected using a stapler and the LLL was removed. Extensive lymph-node sampling was performed at stations 5, 6, 9, 10 and 11. The remaining left upper lobe (LUL) was inflated under inspection before closure of the thorax. The patient was discharged from the hospital after nine days, free of any symptoms or signs after hemoptysis and coughing. The initial symptoms, hemoptysis and coughing, recurred within a few days after discharge. A bronchoscopy showed an intact bronchial stump and an anterior rotation of LUL orifices (fish mouth) eleven days after primary surgery. CT after eighteen days confirmed the diagnosis, showing a necrotizing pneumonitis of the LUL with torsion of the left pulmonary artery and the left main bronchus (Fig. 1). CT-angiography the same day showed complete obstruction of the left pulmonary artery (Fig. 2). A completion pneumonectomy was performed on day 25, because of persistent sub-febrile temperature (over 38 8C) and deterioration of the patient. A gangrenous upper lobe was resected. The postoperative period was uneventful and the patient was discharged on the 57th day after primary surgery. Histopathologic examination showed massive hemorrhagic necrosis and infarction of the lung with an organized thrombus in a large artery branch. 3. Discussion Pulmonary torsion is a rare complication with an incidence ranging from 0.089% to 0.4% w1–3x. The pathophysiology of
ARTICLE IN PRESS S. Hennink et al. / Interactive CardioVascular and Thoracic Surgery 7 (2008) 144–145
Fig. 1. CT-scan with intravenous contrast showing torsion of the left pulmonary artery and the left main bronchus (arrow).
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refractory to oxygen supplementation, persistent fever, hemoptysis and productive coughing. Other symptoms are air-leak, shock, sepsis, and deterioration of the patient that may progress rapidly. However, presentation can also be very discrete. The median time to diagnosis is ten days after surgery, as in our patient w1, 3x. Failure to recognize LT postoperatively will result in death caused by lobar infarction. Radiographic findings are crucial in the diagnosis. Routine serial chest radiographs made after surgery may show different abnormalities: a collapsed or consolidated lobe in an unusual position, hilar displacement in an inappropriate direction for the atelectatic lobe, alteration in the normal position of pulmonary vasculature, rapid opacification of an ipsilateral lobe, bronchial cut-off or distortion, lobar air trapping and pneumothorax w5x. Lobar torsion is suspected on plain chest radiography, CT evaluation can confirm the diagnosis w4x. In our patient, the CT was very indicative (Fig. 1, arrow). In general bronchoscopic examination should be the next diagnostic step. This may show partial or complete obstruction of the bronchus to the affected lobe, caused by edema or distortion (fish mouth sign) w3x. However, non-specific findings in chest radiographs, CT and bronchoscopy and incorrect interpretation of these findings may lead to a delay in diagnosis and treatment w5x. Surgical resection of the afflicted lobe is the only treatment option for LT. Detorsion has proven to be unsuccessful and even dangerous treatment because derotation of the affected lobe may result in trombo-embolic or vascular complications, aspiration, sepsis and shock. In previous reports none of the torsioned lobes was considered viable w2, 3, 5x. Completion pneumonectomy should be performed cautiously. During surgery, lateral position of the patient causes gangrenous tissue and fluids to cross the tracheal bifurcation and flow into the unaffected lung. Double lumen endotracheal tubes or bronchus blockers should therefore be used w1–3, 5x. 4. Conclusion
Fig. 2. Three-dimensional reconstruction of the pulmonary arteries, dorsal view. On the right the normal arteries of the right lung are visible, on the left no arteries can be found due to torsion (arrow).
lobar torsion (LT) remains unclear. Predisposing factors for LT are: a complete interlobar fissure, absence of adhesions, a narrow middle lobe hilum and extensive mobilization at surgical dissection of intrathoracic attachments and the inferior pulmonary ligament w1x. Of all LTs, 70% develop after a RUL resection and 15% after a LUL resection. Other causes for LT could be a heavy compact lobe, pneumothorax or pleural effusion w4x. The degree of rotation in pulmonary torsion is generally 1808, although 908 or 3608 torsions have been reported and can occur in both directions w4x. LT may present with a variety of signs and symptoms. Suspicion of LT is raised by sudden and unexplained dyspnea
Surgeons should be aware of this rare complication of pulmonary surgery. Early diagnosis and surgical intervention are crucial to avoid the catastrophic consequences of LT. Prevention of LT, by fixation of the remaining lobes to each other or to the thoracic wall, could be helpful measures. References w1x Apostolakis E, Koletsis EN, Panagopoulos N, Prokakis C, Dougenis D. Fatal stroke after completion pneumonectomy for torsion of left upper lobe following left lower lobectomy. J Cardiothorac Surg 2006;1:25. w2x Cable DG, Deschamps C, Allen MS, Miller DL, Nichols FC, Trastek VF, Pairolero PC. Lobar torsion after pulmonary resection: presentation and outcome. J Thorac Cardiovasc Surg 2001;122:1091–1093. w3x Demir A, Akin H, Olcmen A, Melek H, Dincer SI. Lobar torsion after pulmonary resection; report of two cases. Ann Thorac Cardiovasc Surg 2006;12:63–65. w4x Felson B. Lung torsion: radiographic findings in nine cases. Radiology 1987;162:631–638. w5x Velmahos GC, Frankhouse J, Ciccolo M. Pulmonary torsion of the right upper lobe after right middle lobectomy for a stab wound to the chest. J Trauma 1998;44:920–922.
