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Lingular Torsion Presenting as Progressive Hypoxia
Cardiothoracic Surgery SESSION TITLE: Fellow Case Report Slide: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Slide PRESENTED ON: Wednesday, October 26, 2016 at 11:00 AM - 12:15 PM
Lingular Torsion Presenting as Progressive Hypoxia Svetlana Kotova MD* Providence Cancer Center, Portland, OR INTRODUCTION: Pulmonary torsion after lung resection is rare (1-3). Only a few reports describe lingular torsion (2-3) after a segmentectomy and diagnosis is a challenge.
CARDIOTHORACIC SURGERY
CASE PRESENTATION: 63 male, prior smoker but with excellent PFT’s, underwent bilateral thoracoscopy with wide excision on the right and a lingula sparing segmentectomy the left. Immediate postoperative course was complicated by subcutaneous emphysema. He developed dyspnea and required supplemental oxygen on day 3. CXR showed bilateral opacities. Despite diuresis, dyspnea and hypoxia worsened. Exam was showed stable subcutaneous crepitus and coarse breath sounds. Bilateral opacities progressed and non-contrast CT chest was obtained. Overall clinical picture of consolidation localized to lingula were worrisome for torsion. Bronchoscopy showed blood in the left main bronchus, and inability to enter lingular bronchus. Thoracoscopy showed congested and necrotic lingula and completion lobectomy was performed. DISCUSSION: Pulmonary torsion is seen in <1% of lung resection (1,2) with only few reports of lingular torsion (2-3). The main challenge is timely diagnosis as atelectasis, pneumonitis, intraparenchymal hemorrhage can appear the same and will resolve with non-operative strategies. Perhaps, the most common early sign is demonstration of pulmonary infiltrate and volume loss (1). Bronchoscopy can show narrowing or inability of enter the bronchus of the involved segment, likely most specific finding (1). CT chest may show abrupt bronchus cut off and consolidation. However, both studies need to be actively considered before patient deteriorates. CONCLUSIONS: Worsening clinical status despite patient’s participation in prescribed therapy prompted additional investigation leading to diagnosis. This case serves as a reminder of a vague nature of this complication and that the lack of expected progress should be actively investigated to exclude this complication. Reference #1: Cable DG, Deschamps C, Allen MS, Miller DL, Nichols FC, Trasteck VF, Pairolero PC. Lobar torsion after pulmonary resection: Presentation and outcome. J Thorac Cardiovasc Surg 2001;122:1091-3. Reference #2: Gossot D, Zaimi R, Fournel L, Grigoroiu M, Brian E, Neveu C. Totally thoracoscopic pulmonary anatomic segmentectomies: technical considerations. J of thoracic disease 2013;5 (S3):S200-6. Reference #3: Eguchi T, Kato K, Shiina T, Kondo R, Yoshida K, Amano J. Pulmonary torsion of the lingula following a segmentectomy of the left upper division. Gen Thorac Cardiovasc Surg 2008;56:505-8. DISCLOSURE: The following authors have nothing to disclose: Svetlana Kotova No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.051
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
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150#4S CHEST OCTOBER 2016
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Lingular Torsion Presenting as Progressive Hypoxia Svetlana Kotova MD* Providence Cancer Center, Portland, OR INTRODUCTION: Pulmonary torsion after lung resection is rare (1-3). Only a few reports describe lingular torsion (2-3) after a segmentectomy and diagnosis is a challenge.
CARDIOTHORACIC SURGERY
CASE PRESENTATION: 63 male, prior smoker but with excellent PFT’s, underwent bilateral thoracoscopy with wide excision on the right and a lingula sparing segmentectomy the left. Immediate postoperative course was complicated by subcutaneous emphysema. He developed dyspnea and required supplemental oxygen on day 3. CXR showed bilateral opacities. Despite diuresis, dyspnea and hypoxia worsened. Exam was showed stable subcutaneous crepitus and coarse breath sounds. Bilateral opacities progressed and non-contrast CT chest was obtained. Overall clinical picture of consolidation localized to lingula were worrisome for torsion. Bronchoscopy showed blood in the left main bronchus, and inability to enter lingular bronchus. Thoracoscopy showed congested and necrotic lingula and completion lobectomy was performed. DISCUSSION: Pulmonary torsion is seen in <1% of lung resection (1,2) with only few reports of lingular torsion (2-3). The main challenge is timely diagnosis as atelectasis, pneumonitis, intraparenchymal hemorrhage can appear the same and will resolve with non-operative strategies. Perhaps, the most common early sign is demonstration of pulmonary infiltrate and volume loss (1). Bronchoscopy can show narrowing or inability of enter the bronchus of the involved segment, likely most specific finding (1). CT chest may show abrupt bronchus cut off and consolidation. However, both studies need to be actively considered before patient deteriorates. CONCLUSIONS: Worsening clinical status despite patient’s participation in prescribed therapy prompted additional investigation leading to diagnosis. This case serves as a reminder of a vague nature of this complication and that the lack of expected progress should be actively investigated to exclude this complication. Reference #1: Cable DG, Deschamps C, Allen MS, Miller DL, Nichols FC, Trasteck VF, Pairolero PC. Lobar torsion after pulmonary resection: Presentation and outcome. J Thorac Cardiovasc Surg 2001;122:1091-3. Reference #2: Gossot D, Zaimi R, Fournel L, Grigoroiu M, Brian E, Neveu C. Totally thoracoscopic pulmonary anatomic segmentectomies: technical considerations. J of thoracic disease 2013;5 (S3):S200-6. Reference #3: Eguchi T, Kato K, Shiina T, Kondo R, Yoshida K, Amano J. Pulmonary torsion of the lingula following a segmentectomy of the left upper division. Gen Thorac Cardiovasc Surg 2008;56:505-8. DISCLOSURE: The following authors have nothing to disclose: Svetlana Kotova No Product/Research Disclosure Information DOI:
http://dx.doi.org/10.1016/j.chest.2016.08.051
Copyright ª 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.
44A
[
150#4S CHEST OCTOBER 2016
]