Left Upper Lobe torsion Following L...

Left Upper Lobe torsion Following Lower Lobe Resection (*1)

Pulmonary torsion respects to parenchymal rotation on its bronchovascular pedicle. In the English literature, torsion following pulmonary resection has been described in the right middle lobe, [12] and in the left lower lobe [34] following resectional surgery Because torsion compromises the pulmonary vasculature, ready recognition and surgical intervention is required to avoid the attendant morbidity and mortality. [5] We report a surgically-proven case of left upper lobe torsion following left lower lobe resection for bronchogenic carcinoma.

CASE REPORT

A 51-year-old woman at handed with a left lower lobe mass forward routine chest roentgenogram (Fig 1) She was asymptomatic and her physical examination was normal. Bronchoscopy was normal. At thoracotomy, the anatomy was normal Frozen section of the mass revealed adenocarcinoma. Mediastinal lymph nodes were normal. Left lower lobe resection was performed without complication. The left upper lobe re-expanded to fill the chest prior to closure

forward the first postoperative day, the patient complained of left-sided chest pain. She had sinus tachycardia (120 beats for minute), tachypnea (24 breaths by minute), and diminished breath unmutilateds over the left hemithorax. Arterial line gas analysis on room air showed [PaO.sub.2], 72 mm Hg; [PaCO.sub.2], 45 mm Hg; and pH 747 Chest roentgenogram revealed perfect left hemithoracic opacification without tracheal deviation (Fig 2) Aggressive postural drainage, chest physiotherapy, and nasotracheal suctioning did not alter the patient's clinical status or the roentgenographic appearance. The patient was turn backed to surgery.

At surgery the left upper lobe had undergone a 360[degrees] counterclockwise torsion about its bronchovascular pedicle. Detorsion originateed in hemorrhage into the endotracheal tube, necessitating immediate cross-clamping of the left pulmonary hilus and completion pneumonectomy. Pathologic examination showed acute hemorrhagic infarction. Postoperatively, the patient make knowned aspiration pneumonia and ventilatory insufficiency. She was treated with antibiotics, extubated onward the tenth postoperative day, and discharged uneventfully

DISCUSSION

Pulmonary torsion may happen following blunt chest trauma, [6-11] nonpulmonary thoracic steps [12-14] and pulmonary resections. [1-415] Post-resectional torsion most numerous commonly occurs after right upper lobectomy when the right middle lobe is not sutur to the right lower lobe. Right lower lobe torsion after right upper lobe resection present itselfs next most frequently. [4] Schuler [2] reported that 18 of 31 cases of pulmonary gangrene "resulting from torsion or intraoperative injury" involved the upper lobes. Following pulmonary resection, torsion of the right middle lobe [12] and the left lower lobe [34] has been reported previously. This case demonstrates torsion of the left upper lobe after left lower lobe resection, and to our knowledge, is the first reported surgically-proven postresectional left upper lobe torsion.

Because torsion is usually associated with delayed regaining and is occasionally fatal, [3] an understanding of prevention, recognition, and management of torsion is important. Torsion is fancy to be due to increased mobility of a lobe. Traumatic or surgical disruption of intrathoracic attachments which stabilize the position of the lobe may allow lobar rotation forward its bronchovascular pedicle if there is a perfect interlobar fissure in the absence of pleural adhesions. [125] Torsion stops the airway in addition to compromising the two the bronchial and pulmonary vasculatures; atelectasis, retained secretions, and infection can complicate the resultant pulmonary infarction.

A high index of suspicion is necessary to diagnose postoperative pulmonary torsion. Chest pain, sometimes confused with incisional tendernes usually is of unanticipated onset and is often accompanied by means of tachycardia, tachypnea, and occasionally by means of hypotension. Breath sounds through the whole extent of the area are diminished. Pulmonary secretions can be copious and sometimes sanguinary An early air leak may cease unexpectedly as torsion occludes the airway. Arterial offspring gas analysis may demonstrate hypoxemia refractory to oxygen supplementation, [8] on the other hand as in our case, hypoxemia may not be abysmal because both ventilation and perfusion are impaired by dint of torsion. Early chest roentgenograms may point out to prominent reticular markings with lung compass larger than expected from compensatory expansion alone; this is consideration due to edema from venous obstruction. after films demonstrating consolidation and contortion loss associated with infarction may glance at acute atelectasis. [5] Bronchoscopy is indicated to hinder endobronchial obstruction by retained secretions. Engorgement of bronchial mucosal tubes from venous obstruction suggests torsion. Torsion may cause bronchial obstruction which admits the bronchoscope with hurry but recurs when the bronchoscope is withdrawn. [1] Although pulmonary angiography might be helpful, [16] the associated delay in definitive treatment can complicate regaining [15] or be fatal. [3]