Torsion of the Middle Lobe after Upper Lobectomy with Infarction of One Segment of the Lung
Sergei A. Plaksin*
E.A. Vagner Perm State Medical University, Perm, Permskiy krai, 614990, Russia, st. Petropavlovskaia, 26
*Corresponding author
*Sergei A. Plaksin*, E.A. Vagner Perm State Medical University, Perm, Permskiy krai, 614990, Russia, st. Petropavlovskaia, 26
DOI: 10.55920/JCRMHS.2025.09.001378
Figure 1: Chest X-Ray on postoperative Day 1 (A - lateral) and Day 3 (B – anteroposterrior) shows increased opacification in the right upper and middle lung fields
Figure 2: Contrast-enhanced CT on postoperative day 3 following surgery. Axial section with lung window (A), mediastinal window (B), sagittal section (C) and coronal section (D) demonstrates consolidation, ground-glass opacities with an interlobular septal thickening in the middle lobe.
Figure 3: During rethoracotomy intraoperative images demonstrated a hemorrhagic dark reddish surface of the lung parenchyma of the fifth segment (S5) of the middle lobe which is looking like infarct. Forth segment is good inflated with normal color (S 4). L LOBE – lower lobe.
On postoperative day 3 hemoptysis appeared in the amount of 30 ml per day. There were no signs of infection. The temperature was 36.6° C, SpO2 97%, in the blood test leukocytes 10.9, neutrophils 75.4%, lymphocytes 11.8%. CXR showed signs of middle lobe dyslectasis, and the mediastinum is slightly displaced to the right (Fig.1B). Computer tomography (CT) showed the middle lobe is displaced upwards in the anterior part of the hemithorax, its pneumatization is expressed unevenly, contoured compaction of the medial and lower parts of the lobe is determined as ground-glass opacities and consolidation with an interlobular septal thickening in the middle lobe, contrasting vessels and bronchi are traced, located more in the lateral part of the lobe (Fig.2). The surgical suture is visualized against the background of a compacted parenchyma near the mediastinal pleura, in the basal region there is a local prolapse of the pneumatized lower lobe. Bronchoscopy demonstrateda deformity and a hemorrhagic sputum in the middle lobar bronchus. A torsion of the middle lobe was suspected and an exploratory surgery was indicated. On postoperative day 4 a rethoracotomy was performed. A partial torsion of the middle lobe was revealed in a clockwise direction for 90 degrees. The middle lobe was raised with a hemorrhagic dark reddish surface of the lung parenchyma of the fifth segment which is looking like infarct. Forth segment was good inflated with normal color (Fig. 3). All vessels were normal with no signs of thrombosis. The middle lobe bronchus was open. Taking unviable changes in the lobe, a middle lobectomy was performed. The postoperative period was uneventful.
Histolopathology: The tissue of the fifth segment of the lung with marked congestion, according to the type of hemorrhagic infarction, the tissue of the fourth segment is intact. The infarction zone has a clear border, dark cherry color on the incision.
Microscopy: In the lung tissue, a site of infarction with infiltration and accumulation of unchanged and hemolysed red blood cells in the alveoli, with partial destruction of interalveolar kinks, with focal pronounced leukocyte infiltration. Microthrombi in the small pulmonary arteries. In the lung tissue outside of hemorrhagic infarction, there are purulent inflammation like acinar pneumonia.