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. 2023 Feb 6;36(2):ivad038.
doi: 10.1093/icvts/ivad038.

Middle lobe suffering due to malposition and 180° tilt of the 2 remaining lobes after right upper lobectomy

Aurelie Janet-Vendroux  1 , Charbel Al Zreibi  1 , Guillaume Reverdito  2 , Alex Arame  1 , Alain Badia  1 , Hicham Masmoudi  1 , Houssem Messaoudi  1 , Francoise Le Pimpec-Barthes  1   3
Affiliations

Middle lobe suffering due to malposition and 180° tilt of the 2 remaining lobes after right upper lobectomy

Aurelie Janet-Vendroux et al. Interdiscip Cardiovasc Thorac Surg. .

Abstract

Middle lobe (ML) suffering after right upper lobectomy (RUL) is rare but represents a major complication usually due to lobar torsion. We report 3 atypical consecutive cases of ML suffering due to malposition of the 2 remaining right lobes with a 180° tilt. All 3 female patients had surgery for non-small-cell carcinoma including RUL associated with radical hilar and mediastinal lymph node removal. Postoperative chest X-ray abnormalities appeared at days 1-3 respectively. The diagnosis of malposition of the 2 lobes was done on contrast-enhanced chest CT scan at days 7, 7 and 6, respectively. A reoperation for suspected ML torsion was required in all patients. Three repositionings of the 2 lobes and 1 middle lobectomy were performed. The postoperative courses were then uneventful, and the 3 patients were alive at a mean follow-up of 12 months. Before thoracic approach closure after RUL, systematic check of good positioning of the 2 reinflated remaining lobes is indispensable. It may prevent ML suffering secondary to 180° lobar tilt leading to whole pulmonary malposition.

Keywords: Lobar malposition; Lung cancer; Middle lobe suffering; Morbidity; Postoperative; Right upper lobectomy.

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Figures

Figure 1:
Figure 1:
Case no 1: chest CT scan at day 7 with coronal view (A) and sagittal views (B and C). A middle and lower lobe malposition with a 180° lobar tilt were revealed. Middle lobe was in back position. Diaphragmatic face of right lower lobe was close to back part of anterior chest wall and Fowler’s segment was in extreme lower part of the pleural cavity.
Figure 2:
Figure 2:
Case no 2: chest CT scan at day 6 with axial view (A) and sagittal views (B and C). A middle and lower lobe malposition with a 180° lobar tilt were revealed. Middle lobe positioned in the back part of pleural cavity presented signs of infarction. Diaphragmatic face of right lower lobe was close to back part of the anterior chest wall and Fowler’s segment was in extreme lower part of the pleural cavity. The diameter of pulmonary artery for right lower lobe was also reduced (A).
See this image and copyright information in PMC

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