Video Assisted Thoracoscopy for Spontaneous Lung Torsion

Spontaneous lobar or whole-lung torsion is a rare clinical phenomenon with only a handful of case reports published in the literature (1–5). Most instances are associated with a postoperative or post-trauma setting or in the setting of other pathology such as cancer or pleural effusion. Previous reports have described detorsion and/or surgical resection because of the concern for post-torsion pulmonary infarction. This video presents the case of a right lobar torsion causing symptoms of dyspnea with hypoxia and subsequent successful detorsion via thoracoscopy.

The Patient

A sixty-nine-year-old woman with past medical history notable for metastatic infiltrating ductal breast carcinoma was referred to the thoracic surgery clinic for newly worsening hypoxia, dyspnea, and radiographic findings of right upper lobar torsion. Prior to diagnosis the patient had no respiratory symptoms, and she had no previous thoracic operations. The patient’s hypoxia and dyspnea were treated with two liters of continuous supplemental oxygen via nasal cannula. The patient had attempted weaning from supplemental oxygen but was unsuccessful and she continued to have persistent symptoms. After a thorough discussion in clinic, she wished to pursue surgical intervention for her lung torsion with the goal of no longer requiring supplemental oxygen and to improve her quality of life. 

The Surgery

In the operating room, a dual lumen endotracheal tube was inserted and a pre-incision bronchoscopy, which revealed a collapsed right upper lobe bronchus with no apparent intrabronchial lesions, was performed. The team then proceeded with a right-sided video assisted thoracoscopy using three port sites. Next, isolated left lung ventilation commenced. Upon entrance into the right hemithorax, the initial lobar anatomy was confusing; however, all pulmonary tissue appeared viable. The right upper lobe appeared more posteromedial, and the right fissures were misaligned, thus, what initially appeared to be the middle lobe was actually the displaced upper lobe. Using atraumatic graspers, the right lobes were repositioned in the anatomically correct orientation. During this, an enlarged and cobblestone appearing lymph node in the horizontal fissure was discovered and biopsied. The middle lobe was also noted to be tethered anteriorly to the superior vein. The exact significance of this is unknown, but the tethered middle lobe may have prompted the spontaneous upper lobe torsion. At the conclusion of the surgery a chest tube was inserted. Completion bronchoscopy confirmed widely patent right upper lobe and segmental bronchi. 

The patient recovered quickly postoperatively and no longer required supplemental oxygen at hospital discharge. Final pathology demonstrated metastatic breast carcinoma within the lymph node specimen. Postoperative radiographic imaging confirmed proper right upper lobe alignment and improved aeration. The patient continues to do well. 

Conclusions

Spontaneous lung torsion is a rare clinical presentation but when it does occur, video assisted thoracoscopy may be performed for successful detorsion without the need for pulmonary resection, which may improve patients’ symptoms. 

References

1. Felson B. Lung torsion: radiographic findings in nine cases. Radiology 1987; 162(3):631-8.
2. Ekstein SF, McCambridge A, Edel ES, Wan Koo C, Blackmon SH. Case of spontaneous whole-lung torsion with literature review. J Thorac Dis 2018; 10(9): E690-693.
3. Kita Y, Go T, Nii K, Matsuura N, Yokomise H. Spontaneous torsion of the right upper lung lone: a case report. Surg Case Rep 2017; 3(37).
4. Moser ES and Proto AV. Lung torsion: case report and literature review. Radiology 1987; 162(3): 639-43.
5. Chrysou K, Gioutsos K, Filips A, Schmid R, Schmid RA, Kocher GJ. Spontaneous right whole-lung torsion secondary to bronchial carcinoma: a case report. J Cardiothoracic Surg 2016; 11(107).

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