Perioperative anesthetic considerations in middle lobe torsion after a right upper lobectomy: Two case reports

Overview

Middle lobe torsion represents a rare but life-threatening postoperative complication following pulmonary lobectomy. This case series examines perioperative anesthetic management strategies in two patients who developed right middle lobe torsion following right upper lobectomy, with emphasis on diagnostic approaches and surgical airway management during reoperation.

Methods and approach

Two cases of postoperative middle lobe torsion were evaluated through clinical presentation, radiological investigation including contrast-enhanced computed tomography, bronchoscopic examination, and anesthetic management during reoperation. Diagnostic protocols involved assessment of persistent atelectasis patterns and selective imaging modalities to distinguish torsion from other postoperative complications. Anesthetic technique for reoperation incorporated double-lumen intubation with attention to airway mucosal characteristics, hemodynamic monitoring during detorsion procedures, and anticipation of vascular compromise sequelae.

Results

Initial presentation in both cases manifested as postoperative atelectasis with preserved oxygenation status, creating diagnostic ambiguity on preliminary bronchoscopy. Contrast-enhanced imaging and repeat bronchoscopic evaluation facilitated definitive diagnosis. In the first case, advanced parenchymal ischemia necessitated middle lobectomy. In the second case, viability assessment permitted detorsion with lobar fixation. Both patients demonstrated hemodynamic stability throughout anesthetic induction, lung isolation, and surgical intervention, with no reperfusion-related instability documented. Postoperative management included corticosteroid therapy and non-invasive positive pressure ventilation for airway secretion management and atelectasis prevention.

Implications

The presentation of persistent postoperative atelectasis with preserved oxygenation status warrants heightened diagnostic consideration of lobar torsion, necessitating systematic integration of cross-sectional imaging and repeat endoscopic evaluation rather than reliance on initial bronchoscopic findings alone. Perioperative anesthetic management requires anticipatory planning for airway mucosal edema, strategic double-lumen tube selection, and intensive hemodynamic surveillance during torsion release, particularly when viability assessment remains equivocal.