Apostolakis Efstratios, Koletsis Efstratios N, Panagopoulos Nikolaos, Prokakis Christos, Dougenis Dimitrios
Department of Cardiothoracic Surgery, University of Patras School of Medicine, Greece.
J Cardiothorac Surg. 2006 Sep 12;1:25. doi: 10.1186/1749-8090-1-25.
The lobar torsion after lung surgery is a rare complication with an incidence of 0.09 to 0.4 %. It may occur after twisting of the bronchovascular pedicle of the remaining lobe after lobectomy, usually on the right side. The 180-degree rotation of the pedicle produces an acute obstruction of the lobar bronchus (atelectasis) and of the lobar vessels as well. Without prompt treatment it progresses to lobar ischemia, pulmonary infarction and finally fatal gangrene.
A 62 years old female patient was admitted for surgical treatment of lung cancer. She underwent elective left lower lobectomy for squamous cell carcinoma (pT2 N0). The operation was unremarkable, and the patient was extubated in the operating room. After eight hours the patient established decrease of pO(2) and chest x-ray showed atelectasis of the lower lobe. To establish diagnosis, bronchoscopy was performed, demonstrating obstructed left lobar bronchus. The patient was re-intubated, and admitted to the operating room where reopening of the thoracotomy was performed. Lobar torsion was diagnosed, with the diaphragmatic surface of the upper lobe facing in an anterosuperior orientation. A completion pneumonectomy was performed. At the end of the procedure the patient developed a right pupil dilatation, presumably due to a cerebral embolism. A subsequent brain angio-CT scan established the diagnosis. She died at the intensive care unit 26 days later.
The thoracic surgeon should suspect this rare early postoperative complication after any thoracic operation in every patient with atelectasis of the neighboring lobe. High index of suspicion and prompt diagnosis may prevent catastrophic consequences, such as, infarction or gangrene of the pulmonary lobe. During thoracic operations, especially whenever the lung or lobe hilum is full mobilized, fixation of the remaining lobe may prevent this life threatening complication.
肺手术后肺叶扭转是一种罕见的并发症，发生率为0.09%至0.4%。它可能发生在肺叶切除术后剩余肺叶的支气管血管蒂扭转之后，通常发生在右侧。蒂部180度旋转会导致肺叶支气管急性梗阻（肺不张）以及肺叶血管梗阻。若不及时治疗，病情会发展为肺叶缺血、肺梗死，最终导致致命的坏疽。
一名62岁女性患者因肺癌入院接受手术治疗。她因鳞状细胞癌（pT2 N0）接受了择期左下肺叶切除术。手术过程顺利，患者在手术室拔管。八小时后，患者的pO₂下降，胸部X线显示下叶肺不张。为明确诊断，进行了支气管镜检查，显示左肺叶支气管梗阻。患者重新插管，并被送入手术室进行开胸手术。诊断为肺叶扭转，上叶的膈面朝前上方。遂行全肺切除术。手术结束时，患者出现右侧瞳孔散大，推测是由于脑栓塞。随后的脑部血管CT扫描确诊。26天后，她在重症监护病房死亡。
胸外科医生应对任何胸部手术后出现邻近肺叶肺不张的每位患者怀疑这种罕见的术后早期并发症。高度的怀疑指数和及时的诊断可预防灾难性后果，如肺叶梗死或坏疽。在胸部手术期间，尤其是在肺或肺叶肺门完全游离时，固定剩余肺叶可预防这种危及生命的并发症。
