Anna Paprocka-Lipińska, Beata Dytkowska, Elżbieta Sobolewska, Jarosław Skokowski, Janusz Zdzitowiecki
Postoperative pulmonary torsion: a case report
Chair and Department of Anaesthesiology and Intensive Therapy,
Head: prof. J. Suchorzewska Chair and Dept of Thoracic Surgery,
Head: Prof. J. Skokowski Chair and Dept of Oncological Surgery,
Head: prof. A. Kopacz. Medical Academy of Gdańsk, Poland
Pulmonary torsion is an uncommon event and may occur after surgery or trauma or spontaneously. We present a case of postoperative torsion of upper and middle right pulmonary lobe following esophagectomy. Both lobes were resected and patient eventually recovered.
The torsion of a lobe, or the entire lung, is a very infrequent complication of thoracic surgery (with or without pulmonary tissue resection), blunt trauma or a spontaneous event [1, 2, 3].
In Great Britain in 1992 a questionnaire survey of 140 thoracic surgery centres reported on 39 patients with pulmonary torsion. In 36 cases the complication was a consequence of thoracic surgical procedures (28 pulmonary tissue resections, 3 cardiosurgical paediatric procedures, 2 repairs of diaphragmatic hiatus hernia and 3 following oesophagectomy). In only 2 patients the torsion occurred following closed thoracic trauma, and in only one no evident cause was found .
The clinical picture of pulmonary torsion is not characteristic. Haemoptysis increased volume of bronchial secretion or otherwise inexplicable worsening of a postoperative patient's general condition may be observed. Chest X-rays demonstrate usually the uniform opacification of the lung/lobe, increasing with time. No radiological signs, characteristic for atelectasis are, however, noted. This picture results from haemorrhagic pulmonary infarction. Bronchoscopy, bronchography and thoracic CTscan may be also helpful in confirming the diagnosis. Arterial blood gases analysis may be normal, as the perfusion/ventilation ratio of the lungs (as a whole) remains unchanged (the affected segment is neither perfused, nor ventilated) [1, 2, 3].
The treatment requires an emergency thoracotomy. Restoring of normal anatomical conditions, by a simple derotation of the affected part of the lung is, however, possible only during the first few hours. When this delay is longer, irreversible necrotic changes with secondary multiple abscesses usually develop, requiring surgical resection of the affected pulmonary parenchyma . Non diagnosed cases may result in fatal sepsis.
A case of this unusual complication is presented.
The 58-year old patient with oesophageal squamous-cell carcinoma after preoperative chemo- and radiotherapy was scheduled to oesophagectomy according to Akiyama technique by thoracic and abdominal approach . The patient was in good general condition - ASA grade II. General anaesthesia with thiopentone 5mg/kg, pipecuronium 0.1mg/kg, nitrous oxide/oxygen 65/35%, isoflurane 0.2-0.6% and fentanyl was uneventful. After the procedure, which lasted 6 hours, the patient was transferred to the Intensive Care Unit, where controlled ventilation was maintained until the full return of consciousness and skeletal muscle function (i.e. 25 hours). The control chest X-ray, before extubation, revealed discrete subcutaneous emphysema on the neck and widened right lung hilus, with suspicion of the presence of fluid in this region [Fig.1]. The general condition of the patient was stable. Both clinical and laboratory tests of spontaneous respiratory function where also normal. During the next postoperative night the general condition of the patient suddenly deteriorated. Psychomotor agitation, disturbances of consciousness, dyspnoea and a drop in SpO2 (monitored by pulsoximetry) from 97% to 89% were noted.
The patient was reintubated and controlled ventilation restarted. Chest X-ray revealed the opacification of the right lung with a mediastinal shift to the left [Fig.2]. During bronchofiberoscopy, the abundant mucous-bloody secretions was found and suctioned from the right-side bronchi.
On the next postoperative day, a control chest X-ray demonstrated the increase of the right lung opacification, concerning mainly the median and upper lobes [Fig. 3] The results of acid-base balance tests were satisfactory: pH 7.41; pCO2 35 mmHg (4.7 kPa); pO2 137.2 mmHg (18.2 kPa); HCO3 22.5 mM/L at FiO2 0.4.
An oesophageal anastomosis desuturation was excluded during fiberoscopy.
The progressive deterioration of the patients' general condition was observed, manifested by cardiovascular instability (hypotonia requiring dopamine and norepinephrine infusion). This, together with the unclear radiological picture led to a decision of rethoracotomy and revision of the right pleural cavity. After its opening, a maximally inflated lung, "bulging" out on inspiration was seen, without visible deflation at expiration. The segments 1 and 3 were completely rotated 180° counter-clockwise and the costal surface of the median lobe was completely displaced to the mediastinum, as the effect of complete vascular pedicle torsion. At this stage of the procedure the problems consisted of massive bloody secretion flow from the endotracheal tube and a drop in periferal haemoglobin oxygen saturation to 90%. Selective intubation of the left bronchus was performed with the aid of a broncho-fiberoscope, and the selective left-lung ventilation was started. After the derotation manoeuvre of both lobes an attempt of their inflation was unsuccessful, so bilobectomy (upper and median lobe resection) was performed. Postoperative chest X-ray did not demonstrate the changes described preoperatively [Fig. 4].
The postoperative course was complicated by acute renal failure, treated successfully with haemodialysis. The patient, at good general condition, left the Intensive Therapy Clinic 16 days after rethoracotomy.
Pulmonary torsion is a very rare, life-threatening complication. If undiagnosed and untreated it may lead to death from developing sepsis . Clinical diagnosis is difficult, as no characteristic symptoms exist [1, 2, 3, 4]. Most frequently the pulmonary torsion is a complication of thoracosurgical procedures, especially of resection of the right upper or lower lobe. Some authors state, that fixation of the median lobe to the lobe remaining after resection, eliminates the risk of this complication [1, 2].
In the case described pulmonary torsion most probably occurred shortly after thoracotomy, and was a consequence of great mobility of the upper and median lobes. Haemorrhagic infarction (manifested on chest X-rays as opacification) occurred after the beginning of spontaneous ventilation and the resulting changes of intrathoracic pressures. The diagnosis might be delayed by the fact that no experienced surgeon, thoracic surgeon or anaesthesiologist have ever dealt with such a complication. This delay might have implicated the necessity of extended pulmonary tissue resection.
Originally published in Anestezjologia Intensywna Terapia 31; (3), 187-189, 1999.
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