Management of Lobar Torsion Following Lung Transplantation
Redha Souilamas, MD,
Sophie Couchon, MD1,
Anne Hernigou, MD1,
Romain Guillemain, MD2,
Véronique Boussaud, MD2,
Joshua Sonnett, MD3
Department of Thoracic Surgery
1 Department of Radiology
2 Department of Cardiovascular Reanimation European Hospital Georges Pompidou Paris, France
3 Presbyterian Hospital Columbia University New York, NY, USA
Redha Souilamas, MD, Tel: +33 1 56092475, Fax: +33 1 56093380, Email: redha.souilamas{at}egp.aphp.fr, Department of Thoracic Surgery, European Hospital Georges Pompidou, 20 rue Leblanc 75015, Paris, France.
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ABSTRACT
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We report 4 cases of acute lobar torsion in patients who had undergone bilateral lung transplantation. Bronchoscopy showed complete obstruction in only 2 of them. Torsion was confirmed by computed tomography in coronal minimal and maximal intensity projections with reconstruction. At operation, 1 detorsion and 3 lobectomies were carried out. Early diagnosis and rapid surgical intervention can save the affected lobe.
Key Words: Lung Transplantation • Pneumonectomy • Postoperative Complications
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INTRODUCTION
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Lobar torsion after bilateral lung transplantation is not well recognized: to our knowledge, there have been only 3 previous reports.1–3 We describe 4 cases of left lobar torsion following bilateral lung transplantation. These cases accounted for 2.9% of 137 bilateral lung transplant procedures performed in both centers during the same 3-year period.
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CASE REPORTS
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All 4 patients were male. The first 3 suffered from end-stage cystic fibrosis and were treated in the European Georges Pompidou Hospital, Paris. The 4th had idiopathic pulmonary fibrosis and was treated in the Presbyterian Hospital, New York. Their characteristics and follow-up data are summarized in Table 1
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CASE 1
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This patient presented with significant bleeding on the 1st postoperative day and required reoperation for hemostasis. Bronchoscopy revealed complete obstruction of the left lower lobe bronchus. Computed tomography (CT) in coronal minimal and maximal intensity projections with reconstruction showed dense consolidation of the left lower lobe, acute cut-off of the left lower bronchus and left lower lobe artery, and left pleural effusion. Reoperation confirmed left lower lobe torsion with 180° rotation in a clockwise fashion, and hemorrhagic infarction of the entire left lower lobe. After detorsion, the lobe was nonviable, so a left lower lobectomy was performed. The patient was not extubated and had a tracheostomy. Eight months later, he was living at home, and the tracheotomy had been closed.
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CASE 2
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Post-transplant chest radiography on the 4th postoperative day indicated left lower lobe infiltration. Bronchoscopy showed complete obstruction of the left lower lobe bronchus. CT in coronal minimal and maximal intensity projections revealed dense consolidation of the left lower lobe and acute cut-off of the left lower bronchus. Reoperation confirmed complete torsion of the entire left upper lobe. After detorsion, the lobe was nonviable, and a left lower lobectomy was performed. The patient was in a good condition 2 years later.
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CASE 3
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This patient presented with unequal bilateral auscultation, with complete left upper lobar silence 4 h after transplantation and before extubation. Bronchoscopy showed complete obstruction of the left upper lobe bronchus. CT in coronal minimal and maximal intensity projections confirmed lobar torsion. A thoracotomy was performed 6 h post-transplantation, detorsion was easily achieved, and the lobe was saved. The patient had an uneventful recovery in the 1st year of follow-up.
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CASE 4
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Primary graft dysfunction immediately after transplantation and required arterial-to-venous extracorporal membrane oxygenation. Extensive blood product use necessitated reexploration and evacuation of hemothorax, with termination of membrane oxygenation on postoperative day 1. Chest radiography on postoperative day 2 showed significant improvement except for increasing opacification of the left lower lobe. Bronchoscopy revealed no acute obstruction of the lobe but significant hemorrhagic secretions isolated to the left lower lobe. CT in coronal minimal and maximal intensity projections confirmed consolidation of the lung with probable torsion. Reoperation confirmed the torsion, and a left lower lobectomy was performed. Postoperative recovery was prolonged but otherwise uneventful, and the patient was doing well 5 years post-transplant.
Pathologic examination of the 3 lobectomy specimens revealed severe passive congestion, thrombotic occlusion of medium-sized pulmonary arteries, and pulmonary infarction.
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DISCUSSION
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The surgical complexity of lung transplantation, division of the pulmonary ligament of the donor, complete fissure, and an undersized donor lung theoretically increase the potential mobility of the adjacent lobe within the chest cavity.2,3 It has been postulated that ischemia-reperfusion injury and the consequent increase in lung water/weight may also contribute to the development of torsion.3 However, it has not been suggested that repeated checking for hemostasis and reoperation for bleeding could fail to recognize a twisted lobe.4 Two of our patients and one reported by Grazia and colleagues3 underwent reoperation for bleeding.
The clinical presentation of lung torsion is usually acute, yet the rarity of this condition commonly results in a significant delay in diagnosis. Clinical presentation may vary depending on whether the torsion is partial or complete.1 Partial torsion can present more insidiously with obstructive pneumonia or partial collapse of the affected lobe(s). Complete torsion usually presents acutely with chest pain, hemoptysis, hypoxemia, bronchorrhea, and persistent air leak.2 In our experience, the patients presented with variable symptoms. The time delay to diagnosis is significant: undiagnosed complete lung torsion often leads to fulminant pulmonary necrosis. Imaging plays an important role in diagnosis.2,5 Usually the sequence in diagnosis is radiography, bronchoscopy, CT, and pulmonary angiography.5,6 Angiography was not needed in our cases. CT with thin slices (0.6 mm) allows multiplanar reformats and precise description of the vessels and bronchi (position, orientation, course, and strictures). Minimal and maximal intensity projection CT produces angiographic and bronchographic views with various angles of rotation and limited superposition. CT is currently used to diagnose pulmonary embolism and has progressively replaced pulmonary angiography for this indication. It also allows early postoperative evaluations in the same acquisition of both transplanted lungs’ parenchyma, bronchi, and vessels, avoiding the need for conventional angiography (Figures 1 and 2).
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Figure 1. Computed tomography in maximal intensity projection, sagittal view, showing left upper lobe pulmonary artery torsion.
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Figure 2. Computed tomography in axial view, in lung window, showing left lower lobe bronchial narrowing.
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When a diagnosis of complete torsion has been made, treatment must be carried out immediately because the time to pulmonary necrosis is short.3 Options include simple detorsion or resection of the involved pulmonary segment(s). With an early diagnosis, surgical detorsion is possible if the lobe is apparently healthy, as in one of our patients. In a reported case of incomplete torsion, surgical correction was unnecessary.2,7 However, lobectomy is required in most cases to avoid the development of sepsis. It has been suggested that detorsion should be avoided if possible before isolation and occlusion of the hilar structures for lobectomy because of systemic release of toxic substances produced in the ischemic lung segment.3,8 In our first 2 cases, detorsion before lobectomy was performed 5 days after bilateral lung transplantation, without postoperative complications.
This experience suggests that early diagnosis is greatly dependent on the degree of clinical suspicion. CT with reconstruction may lead to early thoracotomy and surgical detorsion. Lobectomy is indicated when the lobe is nonviable. Simple detorsion may be tried even in cases of late diagnosis. We recommend checking anatomical structures carefully before thoracotomy closure, especially during a second thoracotomy for hemostasis, at the start of a single center learning curve, and when the graft has a complete fissure as in our 4 cases.
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REFERENCES
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- Collins J, Kuhlman JE, Love RB. Acute, life-threatening complications of lung transplantation. Radiographics 1998; 18:43–7.
- Gilkeson RC, Lange P, Kirby TJ. Lung torsion after lung transplantation: evaluation with helical CT. AJR Am J Roentgenol 2000;174:1341–3.[Free Full Text]
- Grazia TJ, Hodges TN, Cleveland Jr JC, Sheridan BC, Zamora MR. Lobar Torsion Complicating Bilateral Lung Transplantation. J Heart Lung Transplant 2003;22:102–6.[Medline]
- Oddi MA, Traugott RC, Will RJ, Simmons RA, Treasure RL, Schuchmann GF. Unrecognized intraoperative torsion of the lung. Surgery 1980;89:390–3.
- Felson B. Lung torsion: radiographic findings in nine cases. Radiology 1987;162:631–8.[Abstract/Free Full Text]
- Spizarny DL, Shetty PC, Lewis Jr JW. Lung torsion: preoperative diagnosis with angiography and computed tomography. J Thorac Imaging 1998;12:42–4.
- Schamaun M. Postoperative pulmonary torsion: report of a case and survey of the literature including spontaneous and posttraumatic lesions. Thorac Cardiovasc Surg 1994;42:116–21.[Medline]
- Velmahos GC, Franhouse J, Ciccolo M. Pulmonary torsion of the right upper lobe after right middle lobectomy for a stab wound to the chest. J Trauma 1998;44:920–2.[Medline]
Asian Cardiovasc Thorac Ann 2009;
17:196-198
© 2009 by SAGE Publications
DOI: 10.1177/0218492309103322
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ABSTRACT
INTRODUCTION
