Pulmonary lobar torsion: a rare complication following pulmonary resection, but one not to miss

Abstract

Lobar torsion is an uncommon phenomenon but a crucial diagnosis to consider in any patient undergoing lobectomy, as the clinical findings and radiographic appearances are non-specific. This case report documents the clinical and radiological evolution of middle lobe torsion in a patient who underwent right upper lobectomy for Stage 1 adenocarcinoma of the lung. The diagnosis of lobar torsion is most often made on CT scanning of the chest, which is frequently performed in order to distinguish this from multiple other more frequently encountered post-operative complications. Contrast-enhanced CT scan is the recommended imaging modality in suspected cases. If features of lobar torsion are identified, the findings must be communicated immediately to cardiothoracic surgeons owing to the potentially life-threatening consequences of delay. Management of lobar torsion is predominantly surgical, with several techniques currently in use; however, video-assisted thoracoscopic surgery is emerging as an increasingly favoured approach.

Figure 1.

Axial lung window reformat of original diagnostic CT image demonstrating a small soft tissue nodule in the right upper lobe.

Figure 2.

The first post-operative chest radiograph performed within hours of upper lobectomy. There is increased density adjacent to the right hilum but no lobar parenchymal consolidation. A right central venous catheter, endotracheal tube and right chest drain are also demonstrated. AP, anteroposterior.

Figure 3.

Chest radiograph performed 48 h postoperatively. There has been an increase in the right perihilar opacification, with well-defined superior and inferior margins formed by the boundaries of the torted right middle lobe; the diagnosis could have been suspected at this point. Surgical emphysema is seen throughout the soft tissues of the right chest wall. AP, anteroposterior.

Figure 4.

Chest radiograph on post-operative day 3 confirms further deterioration, with more extensive opacification projected over most of the hemithorax but sparing the costophrenic angle and apex. AP, anteroposterior.

Figure 5.

Axial images from the post-operative contrast-enhanced CT scan. (a) Soft tissue window shows an expanded, poorly enhancing right middle lobe, which tapers towards the hilum. (b) Lung window demonstrates extensive ground-glass opacity, consolidation and interlobular septal thickening.

Figure 6.

Coronal reformat of the post-operative contrast-enhanced CT scan. (a) Lung window setting. The middle lobe is expanded and superiorly located with extensive ground-glass consolidation. (b) Soft tissue window setting. The middle lobe is expanded and superiorly located with extensive ground-glass consolidation.

Figure 7.

Sagittal reformat of the post-operative contrast-enhanced CT scan on soft tissue window. The middle lobe can be seen tapering towards the hilum and hilar surgical clips. There is interlobular septal thickening and expansion of the poorly enhancing superiorly positioned middle lobe.