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Right middle lobe torsion after right upper lobectomy in a patient with an undiagnosed middle lobe syndrome
ARTICLE IN PRESS
Right middle lobe torsion after right upper lobectomy in a patient with an undiagnosed middle lobe syndrome Luis Gorospe, MD,a Alberto Caba~ nero-Sanchez, MD,b Gemma Marıa Mu~ noz-Molina, MD, PhD,b Ana Patricia Ovejero-Dıaz, MD,b and Percy Carvajal-Serrano, MD,b Madrid, Spain
From the Departments of Radiologya and Thoracic Surgery,b Ramo n y Cajal University Hospital, Madrid, Spain
WE DESCRIBE THE IMAGING FINDINGS OF A CASE OF A RIGHT MIDDLE LOBE (RML) torsion after a right upper lobectomy in a 60-year-old man with lung cancer. On postoperative day 2, the patient experienced chest pain and dyspnea, and 2 consecutive chest radiographs revealed a progressive consolidation of the RML. Thoracic computed tomography (CT) confirmed a poorly enhancing, low-attenuation consolidation of the RML (Fig, A) and obliteration of the RML artery and accompanying bronchus. RML torsion was diagnosed, and the patient underwent emergent operation, confirming a hemorrhagic infarction of the RML that was resected. Interestingly, review of the preoperative CT study performed at another institution already showed an obliteration of the RML bronchus and artery, as well as a very thin, chronic-looking atelectasis of the RML that was misinterpreted as a thickened fissure (Fig, B). A preoperative bronchoscopic biopsy of the patient’s right upper lobe nodule only revealed a “benign-looking narrowing of the RML bronchus.”
Postoperative lobar torsion is a rare, lifethreatening complication that occurs when a lobe rotates (or kinks) around its pedicle, producing an acute obstruction of the lobar bronchus, artery, and vein and causing lobar hemorrhagic infarction that usually requires lobectomy.1,2 Our case is interesting because a review of the preoperative CT images already showed an obliteration of the RML bronchus and artery as well as a very thin collapse of the RML that mimicked a thickened fissure. We speculate that forced re-expansion of an unnoticed, chronically collapsed RML after a right upper lobectomy may have triggered the RML torsion in our patient. REFERENCES 1. Ziarnik E, Grogan EL. Postlobectomy early complications. Thorac Surg Clin 2015;25:355-64. 2. Chen CH, Hung TT, Chen TY, Liu HC. Torsion of right middle lobe after a right upper lobectomy. J Cardiothorac Surg 2009;4:16.
All authors claim no conflicts of interest or disclosures. Accepted for publication August 26, 2016. Reprint requests: Luis Gorospe, MD, Department of Radiology, Ram on y Cajal University Hospital, Ctra. de Colmenar Viejo Km 9.100, Madrid 28034, Spain. E-mail: [email protected]. Surgery 2016;j:j-j. 0039-6060/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2016.08.037
SURGERY 1
ARTICLE IN PRESS 2 Gorospe et al
Surgery j 2016
Fig. (A) Axial contrast-enhanced thoracic CT maximum intensity projection image performed 24 hours after operation confirms a poorly enhancing, low-attenuation consolidation of the RML (asterisk). Note the surgical sutures in the posterior aspect of the consolidation (arrows). (B) Retrospective review of the preoperative CT images reveals a very thin collapse of the RML mimicking a thickened fissure (arrow).
Right middle lobe torsion after right upper lobectomy in a patient with an undiagnosed middle lobe syndrome Luis Gorospe, MD,a Alberto Caba~ nero-Sanchez, MD,b Gemma Marıa Mu~ noz-Molina, MD, PhD,b Ana Patricia Ovejero-Dıaz, MD,b and Percy Carvajal-Serrano, MD,b Madrid, Spain
From the Departments of Radiologya and Thoracic Surgery,b Ramo n y Cajal University Hospital, Madrid, Spain
WE DESCRIBE THE IMAGING FINDINGS OF A CASE OF A RIGHT MIDDLE LOBE (RML) torsion after a right upper lobectomy in a 60-year-old man with lung cancer. On postoperative day 2, the patient experienced chest pain and dyspnea, and 2 consecutive chest radiographs revealed a progressive consolidation of the RML. Thoracic computed tomography (CT) confirmed a poorly enhancing, low-attenuation consolidation of the RML (Fig, A) and obliteration of the RML artery and accompanying bronchus. RML torsion was diagnosed, and the patient underwent emergent operation, confirming a hemorrhagic infarction of the RML that was resected. Interestingly, review of the preoperative CT study performed at another institution already showed an obliteration of the RML bronchus and artery, as well as a very thin, chronic-looking atelectasis of the RML that was misinterpreted as a thickened fissure (Fig, B). A preoperative bronchoscopic biopsy of the patient’s right upper lobe nodule only revealed a “benign-looking narrowing of the RML bronchus.”
Postoperative lobar torsion is a rare, lifethreatening complication that occurs when a lobe rotates (or kinks) around its pedicle, producing an acute obstruction of the lobar bronchus, artery, and vein and causing lobar hemorrhagic infarction that usually requires lobectomy.1,2 Our case is interesting because a review of the preoperative CT images already showed an obliteration of the RML bronchus and artery as well as a very thin collapse of the RML that mimicked a thickened fissure. We speculate that forced re-expansion of an unnoticed, chronically collapsed RML after a right upper lobectomy may have triggered the RML torsion in our patient. REFERENCES 1. Ziarnik E, Grogan EL. Postlobectomy early complications. Thorac Surg Clin 2015;25:355-64. 2. Chen CH, Hung TT, Chen TY, Liu HC. Torsion of right middle lobe after a right upper lobectomy. J Cardiothorac Surg 2009;4:16.
All authors claim no conflicts of interest or disclosures. Accepted for publication August 26, 2016. Reprint requests: Luis Gorospe, MD, Department of Radiology, Ram on y Cajal University Hospital, Ctra. de Colmenar Viejo Km 9.100, Madrid 28034, Spain. E-mail: [email protected]. Surgery 2016;j:j-j. 0039-6060/$ - see front matter Ó 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.surg.2016.08.037
SURGERY 1
ARTICLE IN PRESS 2 Gorospe et al
Surgery j 2016
Fig. (A) Axial contrast-enhanced thoracic CT maximum intensity projection image performed 24 hours after operation confirms a poorly enhancing, low-attenuation consolidation of the RML (asterisk). Note the surgical sutures in the posterior aspect of the consolidation (arrows). (B) Retrospective review of the preoperative CT images reveals a very thin collapse of the RML mimicking a thickened fissure (arrow).