Thorax, 1977, 32, 501-504

Postoperative lobar torsion and gangrene

MICHAEL V. KELLY II, E. ROSS KYGER, AND WARREN C. MILLER

From the Departments of Surgery and Medicine, University of Texas Medical School at Houston,Hous!on, Texas 77030, USA

Kelly, M. V., Kyger, E. R., and Miller, W. C. (1977). Thorax, 32, 501-504. Postoperative lobartorsion and gangrene. Following left upper lobectomy for a pulmonary nodule, complete180-degree torsion of the left lower lobe with haemorrhagic infarction occurred. Despitere-exploration within 24 hours of the initial procedure the patient died. Postoperative torsionrequires early diagnosis and resection of the gangrenous tissue.

Torsion of the lung, or one of its lobes, with thedevelopment of gangrene is fortunately a rareevent. It has occurred spontaneously in an acces-sory lobe and after chest trauma, hiatal hernior-rhaphy, and resection of pulmonary segments orlobes (Schuler, 1973). We have recently observedsuch a complication after a left upper lobectomyin a patient with impressively rapid clinicaldeterioration.Case report

A 65-year-old woman with essential hypertensionwas admitted to hospital because of syncopalepisodes associated with antihypertensive therapy.Adjustment of her drug regime eliminated thepresenting complaint. However, a routine chestradiograph showed a small density in the leftupper lobe (Fig. 1). No previous chest radiographswere available for comparison. Tomography con-firmed the presence of a non-calcified nodule andrevealed a smaller adjacent nodule. There wasslight fibronodular streaking in the lung andscattered hilar calcification suggestive of previousgranulomatous disease. Skin reactivity to inter-mediate strength PPD was negative. Fibreopticbronchoscopy showed no abnormality. Pulmonaryfunction studies indicated adequate reserve forlobectomy. There were no malignant cells in thesputum, but the lack of calcification and indistinctmargins of the mass were suspicious of malig-nancy. During thoracotomy two well-delineatedmasses were readily palpable deep within the pul-monary parenchyma, precluding wedge resection.Left upper lobectomy was accomplished withoutdifficulty. Histological examination showedmultiple granulomata. No organisms were seen.

The initial postoperative course was uneventful.A chest radiograph showed good expansion of theleft lower lobe (Fig. 2). Vital signs were stable. On40% inspired oxygen, arterial blood gases werePao2 187 mmHg (24 9 kPa) and Paco2 38-5 mmHg(5X1 kPa). The next morning moderate hypotensionand tachycardia developed but responded favour-ably to fluid therapy. A radiograph showed com-plete opacification of the left chest (Fig. 3). Breathsounds were diminished on the left. The chesttubes were functioning, and there was no air leakor blood loss. A diagnostic thoracentesis failed toobtain fluid. Bronchoscopy revealed the left upperlobe suture line to be intact. The orifice to theleft lower lobe was oedematous, distorted, andnarrowed. No evidence of aspiration of gastriccontents was seen. Despite these marked changes,arterial blood gases on 40% inspired oxygen werePao2 163 mmHg (21-7 kPa) and Paco2 36-8 mmHg(4 9 kPa). Her clinical condition progressivelydeteriorated, and so vasopressor drugs were ad-ministered. Because of the suspicion of lobartorsion, she underwent a second exploratorythoracotomy within 24 hours of the first procedureand within 12 hours of the appearance of tachy-cardia. A foul odour was apparent as the incisionwas re-opened. Complete 180-degree torsion ofthe left lower lobe was present with occlusion ofthe bronchovascular bundle at the hilum. The lungtissue was heavy and boggy with a blue-blackhaemorrhagic appearance (Fig. 4). The lobe wasrapidly removed. As the chest was being closed,cardiac arrest occurred. Despite open-chest cardiacmassage and drug therapy she could not beresuscitated and was pronounced dead in theoperating room.

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Fig. 1 Preoperative chest radiographshowing a left upper lobe nodule.

Fig. 2 Immediate postoperative chestradiograph showing good expansion ofthe left lower lobe.

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Postoperative lobar torsion and gangrene

Fig. 3 Chest radiograph takenapproximately 12 hours after operationshowing complete opacification of theleft chest.

Fig. 4 Intraoperative illustration of the infarcted gangrenous lobe as a result of torsion.

Discussion

Torsion of the lung results in haemorrhagic in-farction and eventually gangrene. Most experi-mental studies have shown that interruption ofboth the bronchial and pulmonary circulations is

required to produce infarction. Ligation of thepulmonary artery alone, or the artery and vein,does not cause pulmonary infarction (Liebow etal., 1950). Blood flow is restored through bronchialcollateral circulation to the pulmonary artery. Inhis description of two-stage pneumonectomy,

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Rienhoff (1938) reported that, in his clinical ex-perience, ligation of the pulmonary artery andveins resulted in wet gangrene only if the bron-chial circulation was inadvertently interrupted.

Torsion of the lung produces striking deteriora-tion of the patient, air leak and sepsis frequentlycompounding the problem (Mullin et al., 1972).Most reported cases demonstrate a slower down-hill course than ours. Because of its rarity, delayin diagnosis may occur. The process may be pro-gressive as retrograde thrombosis and spillage ofcontaminated sputum affect adjacent lobes andthe opposite lung.

Diagnosis is aided by chest radiography, whichshows sudden complete opacification of the rotatedlobe. Arterial blood gases were deceptive in thecase presented. This may be explained by theabsence of any blood flow to the infarcted lobewith perfusion shunted to uninvolved areas.Despite what appeared to be adequate oxygena-tion, the patient's condition deteriorated remark-ably. Bronchoscopy may not be diagnosticalthough it is helpful in ruling out other disorders,such as aspiration pneumonia.

Prevention of a fatal outcome requires earlydiagnosis and resection of the infarcted area.Vigorous endotracheal suction is hampered by thepossibility of damage to the bronchial stump.However, all attempts should be made to aspirate

the contaminated sputum from the bronchial treebefore reoperation in order to protect the remain-ing uninvolved segments. Antibiotics, fluids, andsupplemental oxygen may be of temporary benefit.Treatment is speedy resection of the gangrenouslobe.

References

Liebow, A. A., Hales, M. R., Bloomer, W. E.,Harrison, W., and Lindskog, G. E. (1950). Studieson the lung after ligation of the pulmonary artery:2. Anatomical changes. American Journal ofPathology, 26, 177-185.

Mullin, M. J., Zumbro, G. L., Jr., Fishback, M. E.,and Nelson, T. G. (1972). Pulmonary lobargangrene complicating lobectomy. Annals of Sur-gery, 175, 62-66.

Rienhoff, W. F., Jr. (1938). A two-stage operation fortotal pneumonectomy in the treatment of carcinomaof the lung, demonstrating a new technique forclosure of the bronchus. Journal of ThoracicSurgery, 8, 254-271.

Schuler, J. G. (1973). Intraoperative lobar torsionproducing pulmonary infarction. Journal of Thorac.cand Cardiovascular Surgery, 65, 951-955.

Requests for reprints to: Dr. W. C. Miller, Director,Pulmonary Division, Department of Internal Medicine,John H. Freeman Building, Texas Medical Center,6400 West Cullen Street, Houston, Texas, 77025, USA.

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