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Case Reports  |   July 1997
Whole Lung Torsion after a Thoracoabdominal Esophagogastrectomy 
Author Notes
  • (Fisher) Fellow in Cardiothoracic Anesthesiology.
  • (Ammar) Assistant Professor of Anesthesiology.
  • (Silvay) Professor of Anesthesiology.
  • Received from the Department of Anesthesiology, Mount Sinai School of Medicine, New York, New York. Submitted for publication October 1, 1996. Accepted for publication January 13, 1997.
  • Address reprint requests to Dr. Fisher: Department of Anesthesiology, Box 1010, Mount Sinai Medical Center, One Gustave L. Levy Place, New York, New York 10029–6574.
Article Information
Case Reports
Case Reports   |   July 1997
Whole Lung Torsion after a Thoracoabdominal Esophagogastrectomy 
Anesthesiology 7 1997, Vol.87, 162-164. doi:
Anesthesiology 7 1997, Vol.87, 162-164. doi:
Although torsion of a lobe is not uncommon during lung surgery, torsion of the whole lung during a nonpulmonary procedure is rare. Torsion of the lung is defined as the parenchymal rotation of the whole lung on its bronchovascular pedicle. [1 ] Rotation occurs with equal frequency in the left and right lungs. [2 ] Predisposing factors include transection of the inferior pulmonary ligament, pleural space adhesions, pneumothorax, and pleural effusion. [2 ] Pulmonary torsion is most often a consequence of trauma or a complication of thoracotomy. Oddi et al. [3 ] and Chan et al. [4 ] reported cases of torsion after a transthoracic esophageal surgery. We report a third such case of intraoperative torsion of the left lung during an esophagogastrectomy.
Case Report 
A 52-yr-old white man (weight, 70 kg; height, 170 cm) with a well-documented benign esophageal stricture was admitted to the hospital for an elective thoracoabdominal esophagogastrectomy. The patient's past medical history was significant for a large hiatal hernia, duodenitis, depression, and factor V deficiency. He had smoked one half a pack of cigarettes per day for 20 yr and reported occasional use of alcohol. He had no significant history of cardiovascular or pulmonary disease. His symptoms included severe progressive dysphagia with the intake of solid foods. His medications were omeprazole and diazepam. On physical examination he was well developed, well nourished, and in no acute distress. Results of his laboratory tests were significant only for a mild elevation of the prothrombin time of 14.7 s. Results of his preoperative chest radiograph and electrocardiogram were normal.
In addition to basic American Society of Anesthesiologist routine monitors, a catheter was placed in the left radial artery for systemic blood pressure monitoring and in the right internal jugular vein for central venous pressure monitoring. Anesthesia was induced with thiopental, fentanyl, and midazolam. Pancuronium was used for muscle relaxation, and the patient's trachea was intubated with an 8.0-mm single-lumen cuffed endotracheal tube. Anesthesia was maintained with oxygen, nitrous oxide, isoflurane, fentanyl, and pancuronium. The patient was placed in the right lateral decubitus position and a left thoracoabdominal incision was made. Exposure of the thoracic esophagus was complicated by adhesions from chronic pleuritis and mediastinitis and required extensive dissection of the lung from the parietal pleura. In addition, the inferior pulmonary ligament was divided and the lung retracted and reflected anteriorly for adequate exposure. With retraction of the left lung there were multiple episodes of oxygen desaturation to 80–82% that required occasional reexpansion of the compressed lung under direct vision. The intraoperative course was otherwise uncomplicated.
After the operation, the patient was admitted to the postanesthesia care unit. Mechanical ventilation was continued. The patient was hemodynamically stable with appropriate oxygenation, although his chest radiograph revealed a left upper lobe infiltrate. On the first postoperative day, the patient was awake, alert, moving all extremities, and following verbal commands. He was weaned from mechanical ventilation and his trachea was extubated. After extubation the patient was in no respiratory distress with good arterial blood gases and arterial oxygen saturation, but there were no breath sounds over the left hemithorax. The postextubation chest radiograph (Figure 1) revealed complete opacification of the left hemithorax, and chest tube drainage was minimal. It was decided to reintubate the patient for aggressive suctioning and bronchoscopy. Fiberoptic bronchoscopy revealed concentric narrowing of the left mainstem bronchus with edema and erythema. A chest radiograph after bronchoscopy and aggressive suctioning showed no improvement in the lung fields, and the patient was sedated and remained connected to the ventilator.
Figure 1. Postextubation chest radiograph showing complete opacification of the left hemithorax.
Figure 1. Postextubation chest radiograph showing complete opacification of the left hemithorax.
Figure 1. Postextubation chest radiograph showing complete opacification of the left hemithorax.
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On the second postoperative day, the patient became acutely hypoxic; the pH of the arterial blood gas was 7.52, the partial pressure of carbon dioxide was 35 mmHg, the partial pressure of oxygen was 58 mmHg, and the oxygen saturation rate was 90% while he was ventilated with a fractional inspired oxygen tension of 1.0, and a blood pressure of 70/40 mmHg. Bloody secretions were suctioned from the tracheal tube. Despite aggressive tracheal suctioning, oxygenation did not improve and the patient was taken emergently to the operating room for reexploration of the left hemithorax. In the operating room, after general anesthesia was induced, the single-lumen endotracheal tube was removed and rigid bronchoscopy was performed. This revealed bleeding and total occlusion of the left main bronchus. A right-sided 41-French double-lumen endobronchial tube (Mallinckrodt Medical, St. Louis, MO) was placed. Oxygenation improved with isolated right lung ventilation. Exploration of the left hemithorax via a left thoracotomy revealed bloody pleural fluid and a distended hemorrhagic lung. Further examination revealed torsion of the left lung, which required three counter-clockwise rotations to return the lung to its anatomic position. To determine the viability of the lung, a wedge resection of the left upper lobe was examined. This revealed hemorrhagic necrosis, and a left pneumonectomy was performed.
The patient's postoperative course was complicated by pneumonia, sepsis, acute respiratory distress syndrome, respiratory failure requiring tracheostomy, bronchopleural fistula requiring a muscle flap, and a left empyema. The patient eventually recovered and was discharged home.
Discussion 
Torsion of the whole lung during a nonpulmonary procedure occurs only rarely. Pulmonary torsion leads to compromise of the pulmonary and bronchial circulations with eventual hemorrhagic infarction and pulmonary necrosis. Therefore, during surgery, it is imperative that torsion of the lung is prevented by careful reinflation of the collapsed lung under direct vision; whenever this condition is considered in the postoperative period, a prompt diagnosis with immediate surgical intervention is essential to preserve lung viability, to decrease complications, and to prevent death.
Whole lung torsion occurs with nonspecific signs and symptoms, and thus the physician must maintain a high index of suspicion to make this diagnosis. Presenting features include deterioration of the patient's condition; cessation of bubbling from the chest tube drains, which may reflect a lack of ventilation to the twisted lung; a clinical picture of shock or sepsis; and hypoxemia. Physical examination may reveal absent or diminished breath sounds over the affected lung. Several modalities may help in early diagnosis and intervention. Felson [2 ] describes many radiographic signs that are usually observed with pulmonary torsion. Classically there is opacification of the twisted pulmonary tissue and a change in the position of an opacified lobe or pulmonary vasculature on serial chest radiographs. Other radiographic findings include lobar air trapping, bronchial cutoff, or distortion. Nonradiographic procedures that may aid in the diagnosis include bronchoscopy, angiography, and thoracentesis. Bronchoscopy is usually nonspecific but can show varying degrees of bronchial obstruction, edema, and increased secretions. Pulmonary arteriography can reveal distortion of the pulmonary vascular tree. Thoracentesis can be negative or the fluid can be bloody or chocolate colored, as described by Moser and Proto. [5 ] Results of ventilation-perfusion scans are usually nonspecific.
Prevention of torsion requires an understanding of the factors that contribute to rotation of the lung on its bronchovascular pedicle. Intraoperative factors include avoidance of direct injury to the hilar vessels during dissection and inadvertent torsion during retraction. Other mechanisms of torsion can include transection of the inferior pulmonary ligament that anchors the lower lobe, absence of a parenchymal bridge between contiguous lobes, presence of a long and slender hilar pedicle, an airless lobe, and pneumothorax. In the two reported cases, [3,4 ] the authors suggested that division of the inferior pulmonary ligament was the contributing factor that made torsion possible. We think that contributing factors in this case were dissection of extensive pulmonary adhesions and transection of the inferior pulmonary ligament.
Pulmonary torsion is a rare complication associated with significant complications and death. The diagnosis should be entertained whenever opacification of a hemithorax appears on chest radiographs after operation. Early surgical intervention is recommended.
References 
References 
Kucich VA, Villarreal JR, Schwartz DB: Left upper lobe torsion following lower lobe resection. Early recognition of a rare complication. Chest 1989; 95:1146-7.
Felson B: Lung torsion: Radiographic findings in nine cases. Radiology 1987; 162:631-8.
Oddi MA, Traugott RC, Will RJ, Simmons RA, Treasure RL, Schuchmann GF: Unrecognized intraoperative torsion of the lung. Surgery 1981; 89:390-3.
Chan MC, Scott JM, Mercer CD, Conlan AA: Intraoperative whole-lung torsion producing pulmonary venous infarction. Ann Thorac Surg 1994; 57:1330-1.
Moser ES, Proto AV: Lung torsion: Case report and literature review. Radiology 1987; 162:639-43.
Figure 1. Postextubation chest radiograph showing complete opacification of the left hemithorax.
Figure 1. Postextubation chest radiograph showing complete opacification of the left hemithorax.
Figure 1. Postextubation chest radiograph showing complete opacification of the left hemithorax.
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