Complete Lobar Torsion Simulating Hemorrhagic Shock After Left Upper Lobectomy
Chang Chen, MD,
Hui Zheng, MD1,
Liang Duan, MD,
Xue-fei Hu, MD
Department of Thoracic Surgery
1 Department of Pathology, Tongji University Affiliated Shanghai Pulmonary Hospital Shanghai, China
Chang Chen, MD, Tel: +86 21 65115006, Ext. 2074, Fax: +86 21 65111298, Email: changchenc{at}hotmail.com, Zhengmin Rd. 507, Shanghai 200433, China.
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ABSTRACT
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Lung torsion is a rare but serious complication after thoracic operations. We describe an unusual case of left lobar torsion after video-assisted thoracoscopic upper lobectomy. The profound symptom was impending hemorrhagic shock, which masqueraded as postoperative bleeding. The differentials between these 2 entities and treatment options for lung torsion are discussed.
Key Words: Acute Lung Injury • Pneumonectomy • Postoperative complications • Pulmonary infarction
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INTRODUCTION
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Lung torsion is a rare but potentially lethal complication after pulmonary resection.1,2 Early recognition with prompt reoperation is the only option for salvaging the diseased lung.3,4 However, difficulty may be experienced in determining whether severe blood loss indicates intrathoracic bleeding. We describe a case of hemorrhagic shock in a patient with lobar torsion after video-assisted thoracoscopic left upper lobectomy.
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CASE REPORT
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A 44-year-old normally developed male was admitted with left upper lobe bronchiectasis and hemoptysis. Physical examination was unrevealing. A thoracoscopic left upper lobectomy was accomplished despite marked adhesions and evident bronchial vessel formation at the upper mediastinum. At the end of the operation, the pulmonary ligament was routinely dissected in the hope of achieving complete pulmonary expansion. On the 1st postoperative day, the patient complained of dizziness and vomiting, which were considered to be side effects of epidural analgesia. Chest drainage showed 750 mL of dark bloody fluid. His hemoglobin concentration was 11 g · dL–1. Chest radiography revealed mild infiltration in the left lower field, suspicious of operative contusion (Figure 1A
). However, in the next 2 days, the dizziness progressed, and the patient was unable to sit up. Severe anemia developed, and his hemoglobin level abruptly dropped to 5 g · dL–1. Chest radiography showed total opacity of the left thorax and contralaterally shifted mediastinum (Figure 1B). The chest tube was still functioning and had released 700 and 650 mL of serous fluid during the previous 48 h. Bedside bronchoscopy was refused. Hemothorax with instant coagulation was highly suspected from the finding of abnormal bronchial vessels formation. Following a transfusion of 800 mL of red blood cells, the hemoglobin only increased to 6 g · dL–1. The patient now appeared seriously ill and manifested predisposing symptoms of hemorrhagic shock, with tachycardia (140 beats s–1) and hypotension (80/60 mm Hg). Central venous pressure was 4 cm H2O. With suspected postoperative bleeding, the patient underwent an emergency thoracotomy. An engorged blue-black lung was seen occupying the whole left thorax. When the hilum was exposed, a 180-degree counterclockwise twist of the left lower lobe was discovered. Because the pulmonary tissue was nonviable, completion pneumonectomy was performed. Postoperative chest radiography showed mild infiltration in the right upper field and minor effusions, both of which resolved a week later. The patient was discharged on the 12th postoperative day. The final pathology demonstrated pulmonary infarction that on histological examination manifested as a vast amount of passive congestion and diminishment of normal pulmonary structures.
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Figure 1. (A) Chest radiograph on 1st postoperative day, showing good expansion of the left lower lung. Mild infiltration can be seen in the lower field. (B) Hypertensive opacity occupying the whole left chest cavity, which appears to displace the mediastinum. Note the convex pulmonary margin next to the chest tube (arrow).
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DISCUSSION
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The overall incidence of lung torsion has been reported as 0.089%–0.2%, and is equally rare after thoracic surgery.1,2 The case described here is the first case in our institution, among 18,000 pulmonary operations and over 13,000 lobectomies performed over the last 50 years. The pathophysiological mechanisms of torsion development were previously postulated as an airless lobe, incision of the inferior pulmonary ligament, pleural effusion, a long slim lobar pedicle, and lack of pleural adhesions.1
Only meticulous observations of both clinical and radiological manifestations, although uncharacteristic, can provide an indication of torsion development. Thereafter, bronchoscopy, contrast chest computed tomography, or angiography can be diagnostic in finding the distorted or occluded bronchi or tapered pulmonary artery.5,6 There is dramatic deterioration in the patient’s general condition, which can manifest as high fever, severe chest pain, massive hemoptysis, bronchorrhea, and sepsis, seen radiographically as abrupt consolidation and abnormal location of the collapsed lung.7 The lesson we learned from this case is that severe anemia may result from lung torsion, and it should alert surgeons to this unusual complication. Subsequent maneuvers, such as contrast computed tomography, would have been diagnostic and prompted reoperation. However, the differential between postoperative bleeding and lung torsion in the present case was slight. Intrathoracic bleeding was suspected considering the history of extensive mediastinal adhesions, voluminous drainage, and blood loss. The distinguishing features were: the chest opacity appeared hypertensive, and the resultant huge tension markedly shifted the mediastinum; the serous fluid drainage, albeit a large amount, was inconsistent with the severity of the anemia; and radiographically, there was a convex pulmonary margin around the chest tube.
Options for surgical intervention include simple detorsion or resection of the involved pulmonary segments.1 Detorsion alone is advocated only in patients who undergo re-intervention within a few hours of the primary procedure; while in the majority of patients, pulmonary resection is mandatory due to pulmonary gangrene. Embolisms to other vital organs are the main complications after surgery, which should therefore be carefully monitored.8
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REFERENCES
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Asian Cardiovasc Thorac Ann 2009;
17:191-193
© 2009 by SAGE Publications
DOI: 10.1177/0218492309103313
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ABSTRACT
INTRODUCTION
