Manual Complications in Cardiothoracic Surgery: Avoidance and Treatment

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The venous obstruction predisposes to gangrene of the lobe, but the time required for this to occur, is not well known. The coexisted obstruction of the bronchial arterial circulation produces lobar infarction [ 4 ]. Factors predisposing to lobar torsion are considered to be the following: a complete interlobar fissure, the absence of adhesions [ 10 ], a narrow middle lobe hilum [ 4 ] and an overzealous mobilization of the lobe after surgical disruptions of its intrathoracic attachments [ 11 ] including the routine division of inferior pulmonary ligament [ 12 ]. In the presence of a complete interlobar fissure, prevention of middle lobe torsion following upper lobectomy could be achieved by fixating the middle to the lower lobe with the use of TachoCombl, as recently described [ 13 ].

Early diagnosis is based on the high index of suspicion, which should be raised postoperatively when a patient suffers from: a sudden and unexplained dyspnea, tachypnea refractory to oxygen supplementation, with or without deterioration of arterial blood gases, b persistent high fever, hemoptysis and productive cough consisting of massive hemorrhagic or copious bronchial secretions [ 4 , 8 , 11 ].

More specifically, radiological signs in plain chest X-rays which could allow further confirmation of the suspicion of lobar torsion include: a a sudden opacification and absence of expansion of the remaining and previously normal lobe, particularly if the opacificated lobe is in an unusual anatomic position, with or without a bronchial cut-off sign, b the absence of mediastinal shift to the ipsilateral side and no intercostal narrowing [ 9 , 14 ]. Furthermore, if any early previous air leak ceases suddenly and if expansion of the collapsed lobe after vigorous tracheobronchial suction does not occur, although some copious and bloody secretions are aspirated, one should suspect the presence of lobar torsion and should proceed with a prompt bronchoscopy [ 15 , 16 ].

Bronchoscopy may reveal a compressed or occluded lobar bronchus appearing like a "fish mouth" [ 4 ]. It should be noted that although the instrument may be passed through the site of obstruction, the bronchus could collapse again after the bronchoscope is withdrawn [ 11 ]. Thoracic CT scanning, although not characteristic, it may help in establishing the diagnosis. It could show an increased opacification, occupying the remaining lobe.


The absence of bronchogram in the consolidated area suggests the complete obstruction — "cut-off" sign — of the bronchus [ 17 ]. The site of rotation may be seen as obliteration [ 18 ]. Contrast-pulmonary arteriography during helical CT scanning has the advantage of direct evidence of stenosis or complete obstruction of kinking vessels [ 1 , 18 , 19 ]. The transesophageal echocardiography TEE may reveal the turbulent flow in the pulmonary vein and the presence of a potentially lethal thrombus. The lung-ventilation scan shows poor or no perfusion and minimal ventilation of the distorted lobe [ 14 , 20 ].

The benefits for a surgeon to be watchful, to diagnose and subsequently re-operate a patient with lobar torsion are the following: a salvage of the lobe before it develops infarction or gangrene, especially for patients with critical preoperative pulmonary function unable to tolerate pneumonectomy, b reduction of the risk of infection and sepsis, c prevention of thrombosis in the obstructed pulmonary vein, which could be a catastrophic complication [ 14 ].

However, despite clinical and laboratory signs, lobar torsion may not be diagnosed early enough. According to the Mayo Clinic's experience, the median time for the diagnosis of a lobar torsion is 10 days postoperatively, ranging from 2 to 14 days [ 1 ]. Similarly, the two reported cases by Parambil were diagnosed 5 and 10 days after the initial operation [ 20 ].

In our case, a prompt diagnosis of this complication was definitely established and the patient underwent an emergency re-operation, approximately 16 hours after the initial thoracotomy. However, a thrombus had already been established in the occluded pulmonary veins. It should be noted that, it was taken into consideration that during re-operation and untwisting of the lobe, to assess its viability, an already existing thrombus may be embolized. Our plan was to perform a completion pneumonectomy.

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However, just before clamping the hilum, the contorted lobe was suddenly untwisted to resume its physiological position lobe repositioning , causing fatal cerebral embolism. Upon retrospective analysis of this case, we concluded that we should have reopened the thoracotomy carefully in a stepwise manner and meticulously keep the lobe in place until intrapericardial clamping of the pulmonary veins is placed. Also, if a TEE had been done, pulmonary vein thrombus might have definitely been diagnosed prior to reoperation and therefore efforts could have been done to avoid untwisting. To the best of our knowledge, only two cases of this rare complication have been described in the literature.

The first-one was reported by Inoue et al. They reported a year old man, who, after a left lower lobectomy, had developed torsion of the upper lobe, on the 2 nd postoperative day. During re-operation, the patient developed right hemiplegia after repositioning of the upper lobe. The second-case referred to a patient who after an initial left upper lobectomy underwent a completion lobectomy of the contorted lower lobe.

A massive cerebral infarction complicated the re-operation [ 22 ]. Treatment of lobar torsion consists of two options: either completion lobectomy or repositioning and fixation [ 4 , 10 ]. Sacrifice of the lobe is indicated whenever pulmonary infarction or gangrene has been suspected [ 4 , 5 ].

This is easily recognized upon inspection of the lobe which appears "blue-black". It is proposed that in any other case the lobe should be repositioned and fixated with a suture to the other lobe if it exists, or fixated with a pleural flap to the thoracic wall, to prevent torsion re-occurrence [ 4 ].

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In summary, we have described a case of left-upper lobe torsion following left-lower lobectomy. Despite prompt diagnosis, fatal cerebral emboli unfortunately occurred. In agreement with the literature available and our experience, we are of the opinion that in all re-operations, the surgeon should always keep in mind the possibility of pulmonary vein thrombosis and therefore, the lobe should be kept contorted intentionally, until pericardial clamping of the pulmonary veins has been applied.

The lobe can be repositioned, and afterwards surgical decisions can be taken whether lobectomy should be performed, which, based on the accumulated knowledge, we consider the most appropriate procedure, or lobar salvage and fixation. J Thorac Cardiovasc Surg. Ann Thorac Surg. Wagner R, Nesbitt J: Pulmonary torsion and gangrene. Chest Surg Clin Norht Am. Schamaun M: Postoperative pulmonary torsion: report of a case and survey of the literature including spontaneous and posttraumatic torsion.

Thorac Cardiovasc Surg. J Trauma. Burke S, Faber P: Complications of pulmonary resection. Complications in Cardiothoracic Surgery-Avoidance and Treatment. Edited by: Little AG. J Heart Lung Transplant. Wong P, Goldstraw P: Pulmonary torsion: a questionnaire survey and a survey of the literature. Schuler J: Intraoperative lobar torsion causing pulmonaryinfarction.

Ponn R: Complications of pulmonary resection. General Thoracic Surgery. Inter CardioVasc Thorac Surg. Louis J, Daffner R: Torsion of the lung causing refractory hypoxemia. Kucich V, Villarreal J, Schwartz D: Left upper lobe torsion following lower lobe resection: early recognition of a rare complication. Mil Med.

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J Thorac Imaging. Evaluation with helical CT. Kyobu Geka.

Complications in Cardiothoracic Surgery: Avoidance and Treatment

Download references. Correspondence to Efstratios N Koletsis. Reprints and Permissions. Search all BMC articles Search. Abstract Background The lobar torsion after lung surgery is a rare complication with an incidence of 0. Case Presentation A 62 years old female patient was admitted for surgical treatment of lung cancer. Conclusion The thoracic surgeon should suspect this rare early postoperative complication after any thoracic operation in every patient with atelectasis of the neighboring lobe.

Open Peer Review reports. Clinical Instructorships Current Clinical Instructors. Lung Cancer. Why Choose Stanford.

Complications in Cardiothoracic Surgery: Avoidance and Treatment, 2nd Edition

We consider excellence in surgery for lung cancer to be at the core of the mission of the Thoracic Surgery service at Stanford, located in the San Francisco Bay Area. Several studies have now demonstrated that risks are lower and cure rates higher when lung cancer procedures are performed by surgeons, such as those at Stanford, who are specialized in these techniques. We count among our surgeons some of the most experienced lung cancer surgeons in the San Francisco Bay Area and the country. Patients with lung cancer usually have a history of cigarette smoking. They may complain of persistent cough, recent weight loss, or other symptoms, but they may be totally without symptoms at an early stage.

Such a finding in a smoker, in the absence of signs of infection, should prompt early referral to a thoracic surgeon. This approach often prevents unnecessary delay in providing what we hope will be curative surgical therapy. At Stanford, we feel strongly that it is critical to completely assess the stage or extent of spread of the cancer to other parts of the body before therapy is initiated. In some patients, we will recommend performing biopsies of the lymph nodes in the chest. Knowledge about lymph node involvement is important, because if the lymph nodes in the chest contain a tumor, we may recommend giving chemotherapy or chemoradiation prior to surgery.

Once the diagnosis of lung cancer is made and the staging process is completed, cancer therapy can begin. This is the most common operation and has very low complication and mortality rates.

Cardiothoracic Surgery

This more complex procedure may avoid the need for pneumonectomy. Although sometimes required, one would like to avoid this if a complete removal of the cancer can be performed without pneumonectomy.