Unusual complication of Ivor Lewis oesophagectomy

Clinical History

A 47-year-old previously healthy female patient underwent Ivor Lewis oesophagectomy for benign achalasia requiring a right thoracotomy incision. 48 hours after the operation she had an unsuccessful extubation attempt as she developed absence of air entry into the right lung, type-2 respiratory failure and required urgent re-intubation.

Imaging Findings

Initial AP semi-erect chest radiograph showed extensive opacification of the right lung with superior displacement of the horizontal fissure (Fig. 1).

Subsequent contrast enhanced CT chest revealed an abrupt tapering of the right main pulmonary artery and right main bronchus, best highlighted on the axial view (Fig. 2-3).
The abnormal positions of the right interlobar fissures are appreciable on all views (Fig. 3-6). The sagittal reconstruction best demonstrates the extent of the abnormal rotation of the interlobar fissures, with the highlighted curved arrow indicating the direction of torsion (Fig. 6).

Furthermore, there is extensive ground glass opacification in combination with interlobar smooth septal thickening forming a crazy-paving pattern, with patches of consolidation within the ground glass opacities. An important note is the absence of enhancement within the consolidation in the right lung when compared to the contralateral lung, in keeping with inadequate perfusion of the right lung secondary to torsion (Fig. 2–6).

Discussion

Lung torsion (LT) is defined as the rotation of pulmonary lobe(s) around the hilar pedicle resulting in bronchovascular compromise [1, 2, 3]. The torsion does not have to be complete.

In the literature, LT is described following three contexts- thoracic surgery, blunt trauma or spontaneously. Mortality rate is 12%-16% when complicated [4, 5]. Predisposing factors include pneumothorax, neoplasm, pleural effusion and complete lung fissures leading to freedom of movement of the lung [6]. Reported incidence is 0.09-0.4%, making it a rare event [1, 2, 3]. However, it may be more common than is realised following thoracic surgery, with up to 30% of UK thoracic surgeons encountering at least one case [6]. LT is more frequent following pulmonary resection, especially torsion of the middle lobe after upper or lower lobectomy.

Clinical features include rapid cessation of air entry to the affected lung and respiratory failure. If unrecognised, it can progress to haemorrhagic infarction and fatal lung gangrene. Early recognition and prompt intervention are essential in preventing potentially fatal complications.

Radiological imaging plays a crucial role in diagnosis. It is fast, non-invasive and guides the clinician to the correct management.

Chest radiograph is the first line radiological investigation. It may reveal a combination of hilar displacement, bronchial distortion or cut-off, collapsed or consolidated lobe/lung [2]. A further suggestive feature is progressive lobar consolidation on repeat radiographs, as highlighted in Fig. 1.

CT can better demonstrate the relations of the twisted structures. The hallmark features are luminal obstruction of the proximal pulmonary vasculature and bronchus at the level of the torsion, along with lobar malposition. Furthermore, features of a congested lung including septal thickening, ground-glass opacification and bronchial wall thickening are well demonstrated on CT. All of which are due to the impedance of venous return. Contrast-enhanced scans demonstrate absence of intrapulmonary vessels [7].

Usually CT is sufficient to confirm the diagnosis. This is made easier with post-processing techniques such as MIP, minIP and Virtual Bronchoscopy; demonstrating vasculature and bronchoscopic views, aiding the radiologist in making the diagnosis and supporting patient care [8].

Once diagnosed, LT is a surgical emergency. Therapeutic options include explorative thoracotomy to confirm and assess viability of the twisted lung allowing for one of two options; detorsion or pneumonectomy [2, 8].

Teaching points:
1.Whole LT is rare, however there should be a high index of suspicion in acutely unwell patients following surgery involving a thoracotomy.
2.Imaging plays an essential role in identifying the hallmark features of lung torsion.

Differential Diagnosis List

Final Diagnosis

Right lung torsion following Ivor Lewis oesophagectomy.

URL:	https://www.eurorad.org/case/15520
DOI:	10.1594/EURORAD/CASE.15520
ISSN:	1563-4086