Anaesthesia, 2009, 64, pages 11301133 doi:10.1111/j.1365-2044.2009.05988.x .....................................................................................................................................................................................................................

CASE REPORT

Lobar torsion following thoraco-abdominal oesophagogastrectomy

V. Felmine1 and M. Zuleika2
1 Specialist Trainee 4, Department of Anaesthesia, St Georges Hospital, Tooting, London, UK 2 Consultant in Anaesthesia and Intensive Care, Department of Anaesthesia and Intensive Care, Royal Surrey County Hospital, Guildford, Surrey, UK Summary

Following thoraco-abdominal oesophagogastrectomy for an adenocarcinoma of the lower oesophagus, an 81-year-old female with no pre-existing respiratory disease could not be weaned from mechanical ventilation. Right upper and middle lobe torsion were found at thoracotomy on the 14th postoperative day. Both lobes were resected. The patient was discharged from hospital after several postoperative complications. Pulmonary torsion is a rare, potentially life-threatening complication of thoraco-abdominal oesophagogastrectomy. Differentiation from the more common postoesophagectomy pulmonary complications can be difcult. Early post-thoracotomy lung opacication, in the absence of the expected degree of hypoxaemia, should trigger a suspicion of pulmonary torsion.
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Correspondence to: Dr Vinita Felmine E-mail: vfelmine@hotmail.com Accepted: 6 April 2009

The development of pulmonary complications is the most important contributor to morbidity and mortality after oesophageal resection [1]. Pulmonary torsion is a rare complication. Torsion is dened as the act or process of twisting, turning or rotating about an axis [2]. Pulmonary torsion can occur spontaneously, following trauma or after thoracic surgery [3]. One or more lobes or an entire lung may undergo torsion. We describe a case of lobar torsion following a thoracoabdominal oesophagogastrectomy. It was only recognised at thoracotomy after 14 postoperative days on the intensive care unit. This case report aims to increase awareness of pulmonary torsion as a potential complication of non-pulmonary thoracic surgery and to identify issues in its diagnosis and management.
Case report

An 81-year-old female with cerebrovascular disease and mild stable Alzheimers disease but no pre-existing respiratory disease was diagnosed with an adenocarcinoma of the oesophagus. A two phase subtotal oesophagectomy with two eld lymph node dissection was performed
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through a right thoracotomy with laparoscopic gastric mobilisation under general anaesthesia and a thoracic epidural. At induction of general anaesthesia, placement of a double lumen endobronchial tube was difcult due to the apparent small size of the left main bronchus on bronchoscopy. A microlaryngoscopy tube (ID 5.0 mm) was used to intubate the left main bronchus and enable one lung ventilation. However, one-lung ventilation was difcult during the procedure and the right lung had to be re-inated several times. The patients trachea was extubated at the end of surgery. Within an hour of extubation, the patients trachea was re-intubated due to hypoventilation and desaturation. The immediate postoperative chest radiograph (Fig. 1) showed that all lung zones were aerated. The patient again failed extubation on the rst postoperative day. The chest radiograph done after re-intubation showed a normal left lung but homogenous opacication of the right lung with no volume loss and no tracheal shift (Fig. 2). Since tracheal extubation was not imminent a percutaneous tracheostomy was performed. Bloodstained secretions were noted both before and after the
2009 The Authors Journal compilation 2009 The Association of Anaesthetists of Great Britain and Ireland

Anaesthesia, 2009, 64, pages 11301133 V. Felmine and M. Zuleika Lobar torsion following thoraco-abdominal oesophagogastrectomy . ....................................................................................................................................................................................................................

Figure 3 3 CT chest showing right middle (RML) and upper

(RUL) lobes, bronchial cut-off (BC) and the right pulmonary artery (RPA).
Figure 1 Immediate postoperative chest radiograph.

Figure 2 Postoperative

day 1 chest radiograph showing homogenous opacication of the right lung.

tracheostomy but it was unclear if the source was the oropharynx or the tracheobronchial tree. All three intercostals drains were removed by day 7. The patient continued to produce variable amounts of blood-stained sputum. While both the neutrophil count and C-reactive protein were persistently elevated, the patient remained afebrile and microbiology reports on sputum and pleural uid were negative. Failure to wean from respiratory support prompted several investigations. Serial chest radiographs showed persistent opacication
2009 The Authors Journal compilation 2009 The Association of Anaesthetists of Great Britain and Ireland

of the right lung. Bronchoscopy identied oedema and hyperaemia of the carina and copious tenacious mucoid secretions but no mention was made of partial or complete obstruction of the right main bronchus. A CT scan of the chest showed a thickened rim around the right upper lobe and part of the right middle lobe (Fig. 3). The loculated uid collection in the right hemithorax was suspected to be an empyema of the right chest but only a small amount of dark transparent uid was drained. As the patient continued to deteriorate (requiring vasopressors), a right thoracotomy was done on the 14th postoperative day. Since previous attempts at double lumen endobronchial intubation had been unsuccessful, the patients lungs were ventilated through a single lumen tracheostomy. The bronchi and vascular pedicles of the right upper and middle lobes were found to be torted to 180 with the middle lobe at the apex. The deep oblique ssure extended down to the bronchus. This lack of bridging tissue between the lobes suggests an increased risk of torsion [4]. While the right lower lobe was normal in appearance, the right upper and middle lobes were tense and haemorrhagic. The affected lobes (upper and middle) were untwisted and then resected. Extensive haemorrhagic infarction of the upper and middle lobes of the right lung was conrmed on microscopic examination. Complete disruption of the normal pulmonary architecture and blood vessel thrombosis were also noted. There was no evidence of primary or metastatic malignancy in the resected tissue. Bronchoscopy on the day following pulmonary resection found copious blood-stained secretions in the left main bronchus and both lobes of the left lung. A postoperative chest radiograph showed widespread patchy consolidation of the left lung (Fig. 4).
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V. Felmine and M. Zuleika Lobar torsion following thoraco-abdominal oesophagogastrectomy Anaesthesia, 2009, 64, pages 11301133 . ....................................................................................................................................................................................................................

Figure 4 Postpulmonary resection chest radiograph showing

widespread patchy consolidation of the left lung.

Postlobectomy, the patients multi-organ dysfunction improved. During the 110 days spent on the intensive care unit following lobectomy her recovery was complicated by several lower respiratory tract infections. She was discharged from hospital 145 days after oesophagogastrectomy.
Discussion

Pulmonary torsion is a rare complication of non-pulmonary thoracic surgery. We have found only three reported cases of pulmonary torsion following transthoracic oesophageal surgery [57]. However, pulmonary torsion is probably both under-diagnosed and under-reported [8]. It carries a high mortality and early diagnosis requires a high index of suspicion. In this patient, repeated intraoperative reination of the collapsed right lung and the lack of bridging parenchyma between lobes may have contributed to torsion. Clinical ndings can be related to the pathophysiology of pulmonary torsion. The affected lung is neither perfused nor ventilated. Hypoxaemia is not a prominent nding as the ventilation and perfusion defects are matched [9, 10]. Bronchial occlusion, if partial, can result in overination of the distal lung but if complete leads to accumulation of secretions. Vascular obstruction leads to haemoptysis and pleural effusions. Venous occlusion results in pulmonary congestion whereas arterial occlusion can lead to infarction and gangrene of lung. Ischaemic and necrotic lung parenchyma can result in the systemic inammatory response syndrome (SIRS) [9]. Radiographic signs suggestive of pulmonary torsion are rapid opacication of the ipsilateral lobe following
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thoracic surgery (which may be mistaken for pleural blood or effusion), a collapsed or consolidated lobe that occupies an unusual position on a plain radiograph, a change in position of an opacied lobe on serial chest radiographs, hilar displacement in a direction inappropriate for the atelectatic lobe and alteration in the normal position and sweep of the pulmonary vasculature. Bronchial cutoff or distortion may be seen on a plain radiograph but are best seen on CT scan [3]. Bronchoscopy alone cannot exclude a diagnosis of pulmonary torsion [9] since the bronchoscope may pass distal to a partial obstruction as it did in our patient. Excessive secretions, bronchial hyperaemia and oedema may be seen. The aims of treatment are to preserve viable lung and to resect infarcted tissue. Options include resection of affected lung (with or without untorsion) and untorsion without resection. There have been reports of untorted lung being salvaged [10, 11]. Untorting lung that is ischaemic may release inammatory factors and thrombi into the circulation and infected secretions and or blood into the bronchial tree. A double lumen endobronchial tube can protect the unaffected lung from contamination and allow differential ventilation. Intra-operative Trendelenburg position and intravenous steroids have been suggested to be benecial [11]. Banki and Velmahos [9] have proposed a diagnostic and therapeutic algorithm for pulmonary torsion. In our patient, an awareness of pulmonary torsion as a complication of non-pulmonary thoracic surgery would have resulted in earlier diagnosis and management. Despite clinical and radiological ndings suggestive of pulmonary torsion, it was only recognised at thoracotomy. Since the torted lobes were macroscopically infarcted and unsalvageable, untorting them prior to resection led to soiling of the left lung with pooled secretions and blood. Once the diagnosis of pulmonary torsion was made, the left lung should have been protected with a right bronchial blocker or intubation of the left main bronchus with a microlaryngoscopy tube. Knowledge of rare, potentially life-threatening complications of common procedures can prevent morbidity and mortality. Early post-thoracotomy lung opacication in the absence of the expected degree of hypoxemia should trigger a suspicion of pulmonary torsion.
Acknowledgements

Consent for publication was granted by the patient. We would like to commend the exemplary dedication of the surgical and intensive care teams which resulted in this patients successful outcome.
2009 The Authors Journal compilation 2009 The Association of Anaesthetists of Great Britain and Ireland

Anaesthesia, 2009, 64, pages 11301133 V. Felmine and M. Zuleika Lobar torsion following thoraco-abdominal oesophagogastrectomy . ....................................................................................................................................................................................................................

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