Middle lobe torsion after right upper lobectomy

Lung torsion is a rare but life-threatening complication and occurs in 0.09–0.4 % of cases after lung resections and in 4 % of postoperative complications due to lung tumors. Partial torsion is a 90–degree rotation of the lung, while complete torsion is 180 degrees or more. Torsion is caused by excessive mobility and a long bronchovascular pedicle of the lobe. Pulmonary torsion generally involves hilar structures and may cause ischemia, infarction, and necrosis of the lung. 70 % of all lung torsions are middle lobe torsions after right upper lobectomy. On the chest X-ray, opacities of the upper lung field appears from 1-3 days after surgery. Signs of torsion according to computed tomography are ground glass opacities and consolidation, interlobular septal thickening, devascularization of the middle lobe, obliteration of the middle lobe bronchus. Bronchoscopy can show of unusually angled and obstructed middle lobe bronchus. Suspected lung torsion requires immediate surgical reintervention. If the torsion lobe is congested but viable with no necrosis, lung detorsion without resection is possible. The danger of detorsion of the twisted lobe is associated with the risk of thromboembolism on the background of pulmonary vein thrombosis, pulmonary edema during reexpansion, vascular complications, acute respiratory distress syndrome, multiple organ dysfunction and sepsis due to ischemic necrosis of the remaining lung. If the middle lobe is not viable due to infarction, necrosis and gangrene, it must be removed. In case of high risk, to prevent torsion, it is proposed to use collagen film with fibrin glue, synthetic polymer glue Coseal, hemostatic plates TachoSil, Hemopatch, fix with nodal or stapler sutures to the other lobe. Timely repeated operation for torsion of the lobe provide a favorable outcome.

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