Lobar torsion after video-assisted thoracoscopic lobectomy: 2 case reports

Differentiating Imaging Features of Post-lobectomy Right Middle Lobe Torsion

PURPOSE

The purpose of this study was to identify differences in imaging features between patients with confirmed right middle lobe (RML) torsion compared to those suspected yet without torsion.

MATERIALS AND METHODS

This retrospective study entailing a search of radiology reports from April 1, 2014, to April 15, 2021, resulted in 52 patients with suspected yet without lobar torsion and 4 with confirmed torsion, supplemented by 2 additional cases before the search period for a total of 6 confirmed cases. Four thoracic radiologists (1 an adjudicator) evaluated chest radiographs and computed tomography (CT) examinations, and Fisher exact and Mann-Whitney tests were used to identify any significant differences in imaging features (P<0.05).

RESULTS

A reversed halo sign was more frequent for all readers (P=0.001) in confirmed RML torsion than patients without torsion (83.3% vs. 0% for 3 readers, one the adjudicator). The CT coronal bronchial angle between RML bronchus and bronchus intermedius was larger (P=0.035) in torsion (121.28 degrees) than nontorsion cases (98.26 degrees). Patients with torsion had a higher percentage of ground-glass opacity in the affected lobe (P=0.031). A convex fissure towards the adjacent lobe on CT (P=0.009) and increased lobe volume on CT (P=0.001) occurred more often in confirmed torsion.

CONCLUSION

A reversed halo sign, larger CT coronal bronchial angle, greater proportion of ground-glass opacity, fissural convexity, and larger lobe volume on CT may aid in early recognition of the rare yet highly significant diagnosis of lobar torsion.

Right middle lobe syndrome after upper lobectomy: Role of the bronchial angle

BACKGROUND

Right middle lobe syndrome is part of a spectrum of relatively rare but serious conditions that may occur following right upper lobectomy. We aimed to assess whether the preoperative middle lobe bronchial angle on CT predicted patients at risk of developing middle lobe syndrome.

METHOD

All patients who had a complete upper lobectomy over 4 years were retrospectively reviewed for clinical and imaging findings of middle lobe syndrome. Patients with previous lung surgery, preoperative chemo- or radiation therapy, or more extensive surgical resection were excluded. Patient demographics and symptoms, the surgical, pathologic and bronchoscopy reports, and pre- and post-operative chest imaging, to include 3D CT reconstructions and measurements of the middle lobe angles in a subset of patients, were retrospectively reviewed.

RESULT

One hundred and twenty-eight patients met inclusion criteria. Ten (8%) had middle lobe syndrome based on symptoms and imaging features. Eight had severe middle lobe consolidation. Two had postoperative onset of wheezing, with middle lobe bronchial abnormality on CT. The pre- and postoperative middle lobe bronchial angles of 14 patients without middle lobe syndrome were compared to 10 patients with middle lobe syndrome. The middle lobe bronchus was completely obliterated postoperatively and could not be determined in 1 patient. There was no significant difference between the pre- and postoperative angles in patients with or without middle lobe syndrome.

CONCLUSION

Middle lobe syndrome occurred in 8% of patients with right upper lobectomy. The preoperative middle lobe bronchial angle did not predict patients at risk for developing middle lobe syndrome.

Successful video-assisted thoracoscopic management of the right middle lobe torsion: A rare complication of right upper lobectomy - A report of two cases

Middle lobe torsion is an uncommon complication after right upper lobectomy. Clinical features are non-specific. CECT chest and diagnostic bronchoscopy are the essential investigations for the diagnosis. The treatment of choice is urgent re-exploration with either lobectomy or de-rotation with pneumopexy through thoracotomy or video assisted thoracoscopic approach based on the viability of lobe. Strong clinical suspiscion and early surgical intervention are the key points for success. This report highlights the role of video assisted thoracoscopic approach in the management of this rare complication.

A pictorial review of lung torsion using 3D CT cinematic rendering

Lung torsion is the abnormal rotation of a lobe or lung around its bronchovascular pedicle. It most commonly occurs in the setting of pulmonary resection, though it has also been described after large-volume thoracentesis and video-assisted thoracic surgery, as well as spontaneously. Resulting ischemia can lead to infarction, making this an emergent diagnosis. As findings are often nonspecific, a high index of suspicion is required, especially in the postsurgical setting. 2D CT angiography findings are subtle and include direct signs of pedicle rotation on CT as well as indirect findings including loss of normal parenchymal enhancement, atelectasis of torsed lobe/lung, and abnormal fissure position. These direct and indirect findings are often appreciated on different window presets and upon review of images in multiple planes, with need to collate the information subsequently. 3D cinematic rendering (CR) using multi-planar light sources can readily highlight spatial relationships of vasculature in the chest and may be able to assist in the confident diagnosis of this sometimes subtle but life-threatening pathology. We have provided the first characterization of common lung torsion findings on 3D CR.

Lung Lobe Torsion in an Adult Male Common Marmoset (Callithrix jacchus)

A 6-y-old, intact, pair-housed male common marmoset (Callithrix jacchus) presented with acute onset dyspnea and tachypnea immediately after sedation with alfaxalone; a history of gradual weight loss initiated the examination under sedation. Thoracic radiographs revealed significant right-lung consolidation, with a vesicular gas pattern in the right caudodorsal lung field, pleural effusion, and dorsal displacement of the heart. The marmoset was euthanized due to his unstable condition and poor prognosis. At necropsy, the cranial and middle lobes of the right lung were homogenously dark red-brown, enlarged, edematous, and twisted around the longitudinal axis at the hilus. The left lung lobes were pale pink and slightly edematous. In light of the clinical and gross necropsy findings, acute torsion of the right cranial and middle lung lobes was diagnosed. Predisposing conditions for lung lobe torsion include trauma, neoplasia, pulmonary disease, previous thoracic surgery, and diaphragmatic hernia, but none of these applied to this case. Initial therapy for lung lobe torsion is to stabilize the patient and treat for underlying conditions, with prompt surgical resection as the treatment of choice. To our knowledge, this report is the first description of lung lobe torsion in an experimentally unmanipulated New World NHP.

[Troubleshooting Common Unexpected Situations during Thoracoscopic Anatomical Pulmonary Resection]

The history of modern thoracoscopic pulmonary surgery could date back to the 1990s, and the related surgical technique has been matured after 20 years' development. Meanwhile, large amount of clinical data has been collected. Minimally invasive thoracic surgery represented by the thoracoscopic approach has been universally accepted as the preferred choice for the surgical treatment of early-staged non-small cell lung cancer and pulmonary benign diseases, and for the diagnosis of pulmonary diseases. With the generalization of thoracoscopic anatomical pulmonary resection, some unexpected situations during clinical practice has been reported in literatures, with issues involving anatomical variation, pathological factors, and surgical techniques. However, the systemic summary of the unexpected situations during thoracoscopic anatomical pulmonary resection is lacking until now. The present review, therefore, aims to summarize accidental issues and troubleshooting these unexpected situations on the basis of our own clinical practice and literature reports.

Interlobar fixation using TachoSil(®): a novel technique

BACKGROUND

We evaluated the use of TachoSil(®) for anchoring middle lobe to lower lobe after upper right lobectomy.

METHODS

The fixation of middle lobe to lower lobe was required in 39/213 consecutive upper lobectomies. In 19/39 (49%) cases, it was performed with suturing and/or stapler (standard group) and in 20 cases (TachoSil group) with Tachosil(®) alone.

RESULTS

The operative time, complications, length of chest drain and hospital stay were similar between two groups. However, standard compared to TachoSil(®) group presented a higher incidence of atelectasis (5% vs. 0%, P=0.4) and air leaks (5% vs. 0%, P=0.4) but it did not reach significant difference. Our technique was safe, easy, and quick.

CONCLUSIONS

Upon contact with pleura, the clotting factors of TachoSil(®) dissolved and formed a fibrin network which glued the collagen sponge to the pleura surface. It allowed to fix the middle lobe to lower lobe without restricting lung re-expansion and/or injuring the parenchyma.

VATS right upper lobectomy

Standard thoracotomy has been considered as the classic approach and only choice for the diagnosis and treatment of certain thoracic diseases especially in patients with peripheral lung cancer. Video-assisted thoracic surgery (VATS) is a new minimally invasive thoracic surgery through small incisions in the intercostal muscle of chest wall by using modern camera technology, high-tech equipment and surgical instrument. Consequently, VATS has become the preferred main method for peripheral lung cancer in the last two decades. The aim of the present paper is to describe and discuss the operative techniques of VATS for right upper lobectomy (RUL).

Re-thoracoscopic surgery for middle lobe torsion after right upper lobectomy

After pulmonary resection, lobar torsion is a rare but potentially serious complication. The reported occurrence rate is 0.089-0.3%. Generally, management for this condition is exploration through 'open technique' thoracotomy with the resection of the affected lobe. A 68-year old male was diagnosed with right middle lobe torsion 1 day after a video-assisted thoracoscopic (VATS) right upper lobectomy. A second VATS right middle lobectomy was successfully performed through the same incisions. The careful follow-up and the prompt detection of lobar torsion using the VATS approach lead to a satisfactory outcome.