Yanagihara Takahiro, Ichimura Hideo, Kobayashi Keisuke, Sato Yukio
Department of Thoracic Surgery, Hitachi General Hospital, Japan.
Department of Thoracic Surgery, Hitachi General Hospital, Japan; Department of Thoracic Surgery, Faculty of Medicine, University of Tsukuba, Japan.
Int J Surg Case Rep. 2017;41:86-88. doi: 10.1016/j.ijscr.2017.10.013. Epub 2017 Oct 16.
Atelectasis of the right middle lobe following right upper lobectomy may result from lobar torsion, bronchial kink, or impacted mucus plug. Although clinical consequence of lobar torsion could be serious, differentiating it from bronchial kink is occasionally challenging.
A 39-year old man with non-small cell lung cancer of cT1aN0M0 stage IA underwent right upper lobectomy. On postoperative day 1, we identified middle lobe atelectasis on the chest X-ray and performed bronchoscopy, which showed an obstruction of the right middle lobe bronchus without mucoid impaction. We injected air using a bronchoscope to the middle lobe, which re-expanded it. However, on postoperative day 2, chest X-ray showed a slightly collapsed and opacified middle lobe. Although enhanced computed tomography showed a patent middle lobe pulmonary artery, we noticed that a staple placed in the horizontal fissure was in contact with the lower lobe, implying the possibility of lobar torsion. Rethoracotomy on postoperative day 2 revealed a 240° clockwise rotation of the congested middle lobe. Therefore, we performed simple detorsion. The patient was discharged 10days after rethoracotomy without further adverse events.
In our case, patency of the pulmonary artery and temporary improvement of the atelectasis using a bronchoscopic aeration maneuver could not rule out the possibility of lobar torsion.
The position of the staple placed on the interlobar fissure should be evaluated using computed tomography in postoperative middle lobe atelectasis. If the aeration maneuver for middle lobe atelectasis using bronchoscope fails, rethoracotomy should be considered.
右上肺叶切除术后右中叶肺不张可能由肺叶扭转、支气管扭结或黏液栓堵塞引起。尽管肺叶扭转的临床后果可能很严重，但将其与支气管扭结区分开来有时具有挑战性。
一名39岁的男性，患有cT1aN0M0期IA的非小细胞肺癌，接受了右上肺叶切除术。术后第1天，我们在胸部X光片上发现中叶肺不张，并进行了支气管镜检查，结果显示右中叶支气管阻塞，无黏液样物质堵塞。我们用支气管镜向中叶注入空气，使其重新扩张。然而，术后第2天，胸部X光片显示中叶略有塌陷和模糊。尽管增强计算机断层扫描显示中叶肺动脉通畅，但我们注意到放置在水平裂中的吻合钉与下叶接触，这意味着存在肺叶扭转的可能性。术后第2天再次开胸手术发现充血的中叶顺时针旋转了240°。因此，我们进行了简单的扭转复位。患者在再次开胸手术后10天出院，没有出现进一步的不良事件。
在我们的病例中，肺动脉通畅以及使用支气管镜通气操作使肺不张暂时改善并不能排除肺叶扭转的可能性。
对于术后中叶肺不张，应使用计算机断层扫描评估放置在叶间裂上的吻合钉的位置。如果使用支气管镜对中叶肺不张进行通气操作失败，应考虑再次开胸手术。
