Lung and lobe torsion: a narrative review

Introduction

Lobar torsion is an uncommon but potentially life-threatening complication that can arise following lobectomy. Lobar torsion is thought to result from anatomical or surgical disruptions within the thoracic cavity, leading to the rotation of a lung lobe and subsequent obstruction of the pulmonary vessels and bronchi (1,2). This obstruction impairs pulmonary arterial, venous, and bronchial circulation, potentially resulting in pulmonary infarction. If undiagnosed, complete lung torsion can progress to fatal outcomes (1-3). An increased intrathoracic space following segmentectomy or lobectomy is believed to heighten the risk of torsion by allowing greater mobility of the remaining lung or lobes (1,2).

Lung and lobar torsion predominantly occur in three clinical scenarios: postoperative, spontaneous, and post-traumatic. Most reported cases involve the right middle lobe, commonly following right upper lobectomy (1). The condition carries a significant mortality rate, estimated at approximately 8.3%, and is associated with considerable morbidity, often necessitating emergent surgical intervention, such as completion pneumonectomy (1,2). This article aims to summarize the current literature on pulmonary torsion, assess existing knowledge, and identify areas requiring further investigation. We present this article in accordance with the Narrative Review reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-880/rc).

Methods

A comprehensive narrative review was conducted by searching multiple online databases, including PubMed, Google Scholar, Cochrane Library, Scopus, and Embase, to identify relevant articles on pulmonary torsion. The search was restricted to articles published between 1985 and 2024 (Table S1). Keywords used in the search included pulmonary torsion, lobe torsion, lobectomy, lung necrosis, emergency thoracotomy, left upper lobe, left lower lobe, right upper lobe, right middle lobe, right lower lobe, pediatric lobectomy, idiopathic torsion, traumatic torsion, and thoracotomy complications (Table S2). A total of 92 articles were initially identified as potentially relevant, and 61 were included in the final review (Figure S1).

Inclusion criteria required that articles clearly described, referenced and/or documented cases of lobe torsion with identifiable clinical details. Articles were excluded if the cases mentioned were either not traceable, had imprecise anatomical location or were deemed redundant across multiple sources. Studies published in English, French, Spanish, German, and Japanese were considered; for articles in Japanese, Google Translate was used for translation purposes.

Results

A total of 125 cases of lung or lobar torsion were identified across 61 published articles. Key findings include:

Etiology

Ninety-one cases (72.8%) occurred in postoperative settings, with 71 (56.8%) specifically following thoracotomy procedures (Table 1).

Anatomical distribution

The right middle lobe was the most frequently affected site, involved in 38 cases, most commonly following right upper lobectomy, which accounted for 33 of these cases. In contrast, torsion of the right upper lobe was rare, with only four cases documented since 1989, all of which occurred in the postoperative setting. Notably, each case of upper lobe torsion followed a lower lobectomy (Table 2).

Detorsion outcomes

We identified 19 cases of successful lobar detorsion (Table 3). Of these:

• 13 following upper lobectomy;
• 4 followed spontaneous torsion;
• 1 post-lung transplantation;
• And 1 was identified and managed intraoperatively.

Among the 13 post-upper lobectomy cases, intraoperative macroscopic findings were available in 12. In all of these, the affected lobe appeared viable, with no reported signs of necrosis, infarction, or congestion.

Additionally, two cases of partial detorsion success were reported in infants. In both instances, the right lower lobe was salvaged, but the right middle lobe required resection due to irreversible ischemic damage.

Narrative review

Physiopathology and etiology

Pulmonary torsion is characterized by the rotation of a lung or its lobe around the bronchovascular pedicle. This pathological rotation can lead to obstruction of the bronchovascular structures, resulting in severe complications if not promptly diagnosed and managed.

The underlying mechanism of pulmonary torsion is thought to involve disruptions within the thoracic cavity. These disruptions may arise secondary to trauma, intrathoracic procedures, or other thoracic interventions. Reported causes include lung transplantation, lung resection via video-assisted thoracic surgery (VATS) or thoracotomy, surgeries involving the esophagus, mediastinum, or aorta, such as esophageal resections, mediastinal tumor excisions, and aortic repairs (1-10). Additionally, spontaneous lung torsion has been reported, often in association with underlying intrapulmonary pathologies. These include massive pleural effusion, hemothorax, atelectasis, pneumothorax, pulmonary sequestration, diaphragmatic hernia, pneumonia (with or without abscess formation), and neoplasms (11-26).

Such conditions can exert compressive forces on the lung, airways, or pulmonary vessels, predisposing the affected lobe to rotation and subsequent vascular obstruction.

Procedures such as segmentectomies and lobectomies can increase the intrathoracic space, thus creating conditions that facilitate torsion of the residual lung parenchyma. In the context of lung transplantation, additional risk factors include resection of the pulmonary ligament, volume mismatches between the donor lung and the recipient hemithorax, technical challenges during transplantation, and complex anastomoses. Anatomical variations, such as the division or absence of the inferior pulmonary ligament, elongated bronchovascular pedicles, and the presence of complete interlobar fissures, may further predispose individuals to lung torsion (5-7,27-35). In the pediatric population, lung torsion has been documented following blunt thoracic or abdominal trauma, tracheoesophageal repairs, and cardiac surgeries, including ductus arteriosus closure and modified Blalock-Taussig shunts (1,27,36-42).

As the tracheobronchial tree twists during torsion, the pulmonary arterial, venous, and bronchial circulation may become compromised. This disruption can result in pulmonary infarction and, if complete lung torsion remains undiagnosed, may lead to fatal outcomes (28).

Epidemiology

The incidence of pulmonary torsion is reported to range from 0.089% to 0.4% (1). In our literature review, 72.8% of reported cases occurred in postoperative patients, most frequently following upper thoracotomy (Tables 1,2). Due to its rarity, pulmonary torsion poses significant diagnostic challenges, with misdiagnosis rates as high as 18% (1).

Analysis of postoperative lung torsion incidence reveals that its frequency varies depending on the type of surgical procedure. The postoperative setting is the most common context for pulmonary torsion, accounting for approximately 62% to 73% across various reviews. This is consistent with our literature review, which found an incidence rate at the higher end of this range (1,9). Case series consistently identify the right middle lobe (n=39) as the most frequently affected site, typically occurring after a right upper lobectomy. In contrast, torsion of the left upper lobe (n=9) is considerably less common. The rarest form of torsion involved the right upper lobe (n=4). Notably, all cases of upper lobe torsion occurred exclusively in postoperative settings (Table 2).

Diagnosis: clinical presentation, imaging and bronchoscopy

The diagnosis of lung torsion is challenging due to the absence of specific clinical signs. Common nonspecific symptoms include fever, chest pain, dyspnea, tachycardia, and hypoxia, with dyspnea, fever, and chest pain being the most frequently observed. The onset typically occurs 4 to 14 days following thoracic procedures, trauma, or other precipitating events. It is important to note that some patients may remain asymptomatic and present without any clinical signs (1). Furthermore, a case of intraoperative pulmonary torsion during the repair of post-traumatic aortic disruption was reported in 1997, identified by a sudden rise in peak inspiratory pressure (43).

Upon clinical suspicion of pulmonary torsion, radiological imaging is pivotal in diagnosing lung torsion (1,5,44-49). Chest X-rays may reveal worsening consolidation, abrupt interruption of the pulmonary artery, anatomical irregularities, or pulmonary opacities (1,31,49). Computed tomography (CT) imaging and CT angiography offer more detailed insights, frequently demonstrating abrupt truncation and pulmonary artery obstruction, interlobular septal thickening in the displaced lobe, venous congestion, and abnormal lobe displacement. A hallmark radiographic finding is the “antler sign”, characterized by narrowed, blocked, or inverted vascular and bronchial structures (48). Although the degree of lung rotation varies, it most commonly approaches 180 degrees. In cases involving necrotic lung tissue, imaging highlights the loss of parenchymal integrity and pulmonary vascular architecture (1,5,50). While chest X-ray is valuable for monitoring patients after lobectomy or thoracic trauma, CT imaging is essential for the non-invasive diagnosis of lobar torsion.

Bronchoscopy is a valuable adjunct in the evaluation of lung torsion. It may reveal obstructive findings, such as bronchial narrowing, extrinsic compression, or a stenotic “fish mouth” appearance at the bronchial orifice. Resistance encountered during bronchoscopy is another suggestive finding. However, bronchoscopy alone does not always yield a definitive diagnosis (1,5,6,28,43,50,51). Even though bronchoscopy can be a valuable diagnostic tool when readily available, it does not replace the need for thoracic CT imaging.

Differential diagnosis

The differential diagnoses for lung torsion include hemothorax, pneumonia, pulmonary contusion (particularly following sublobar resection), lung gangrene, atelectasis, empyema, pulmonary edema, inadvertent hilar ligation, diaphragmatic herniation, and anastomotic site leakage (1,32,45,46) (Table 4).

Treatment and prognosis

Early intervention in lung torsion is critical to preserving viable tissue. Detorsion procedures, aimed at restoring lung function, often involve securing the lung to surrounding structures with sutures or staples (5,40,49).

If detorsion proves impossible or unsuccessful, lobectomy becomes necessary. Successful detorsion should ideally occur within hours of diagnosis to prevent irreversible ischemic damage. In cases where detorsion is delayed, resection becomes a safer alternative, as it minimizes the systemic release of inflammatory markers and thus reducing the risk of multiorgan failure (52,53).

For cases involving severely damaged tissue, maintaining the lung rotated until the pulmonary veins are clamped is crucial to prevent the systemic dissemination of inflammatory markers and stroke in case of clot formation in the vein. Once clamping is achieved, a decision regarding detorsion or resection is made based on the viability of the affected tissue. Prolonged ischemia, abscess formation, perforation, or underlying malignancy often necessitate resection (11,49). Delayed treatment increases the risk of clot formation, potentially leading to pulmonary embolism or stroke. Prophylactic heparinization is sometimes employed to reduce these risks (5). Conservative management is associated with recurrent pneumonia, which may eventually lead to fatal outcomes (1,49).

After fixation of the remaining lobe, complications such as pneumonia, air leaks, or emphysema are relatively rare, with most procedures proceeding without significant intraoperative or postoperative issues (5,54,55).

The prognosis of lung torsion is poor when management is delayed or when complications such as sepsis or sepsis-like syndromes arise due to ischemia or necrosis of nonviable lung tissue (5,52). Mortality rates vary depending on the underlying etiology and the patient’s comorbidities, with complete lung torsion carrying a higher risk than lobar torsion. Among affected populations, trauma patients have the highest mortality rate at 22.2%, followed by those undergoing thoracic surgery at 8.8%, and patients with spontaneous lung torsion at 3.1% (1). Addressing lung torsion requires meticulous planning and management to minimize potential complications (Table 5) (32,44,56-58).

Prophylaxis

Preventive strategies for postoperative pulmonary torsion include creating pleural flaps, suturing or stapling the lobes, or securing them with adhesive substances such as Bio-Glue (CryoLife Inc.) (40,59,60). Another interesting method, used following right upper lobectomy, is to use an absorptive sheet (Neoveil) soaked in fibrinogen over the contiguous lobes in a bridging manner (54). Keeping in mind that these sheets, as well as other adhesives, must be used when the lung is inflated (1,54,60).

Indication for fixation of a lobe may be recommended in the setting of increased thoracic space. As noted in our results, right middle lobe torsion was the most frequent, primarily occurring after right upper lobectomy. Our findings underscore the potential indication for prophylactic measures, particularly during upper lobectomy, as 80% of torsion cases occurred following upper lobe resection.

However, given the rarity of this condition, no consensus exists regarding the effectiveness of these techniques, warranting further investigation into prevention strategies (59,60).

Limitations

The primary limitation of our study is the limited amount of existing research on the topic, most of which consists of case reports. Furthermore, this article is subject to the inherent limitations of narrative reviews, including selection and publication bias. The use of Google Translate to interpret Japanese-language articles also presents a limitation, potentially affecting the accuracy and reliability of our analysis of those sources.

Discussion

In this review, we identified 125 published cases of lobar torsion, more than any previously reported series. When comparing our findings to the existing literature, several consistent patterns emerged. Most notably, lobar torsion commonly occurs following upper lobectomies, underscoring the importance of appropriate prophylactic strategies. A questionnaire-based survey from 1992 reported that 63% of surgeons routinely fixed the middle lobe following a right upper lobectomy (61). However, we found no robust data evaluating the effectiveness of such prophylactic measures in preventing torsion.

Given that detorsion is a key component of lung torsion management, we examined the conditions associated with successful outcomes. As outlined in our results, in cases where intraoperative macroscopic assessment was documented, the affected lobe showed no evidence of necrosis, infarction, or congestion. This finding underscores the importance of prompt diagnosis and intervention.

Due to the limited number of reported detorsion cases—particularly unsuccessful ones—we are unable to determine a definitive success rate. However, based on the available data, successful detorsion appears to occur only when there are no macroscopic signs of lung damage. An exception to this observation was noted in the pediatric population, where two cases involving detorsion of infarcted right middle and lower lobes resulted in partial success—specifically, preservation of the right lower lobe in both instances (37,42).

Given the limited data on the management and prevention of lung torsion, we propose the establishment of a centralized reporting system—such as an online database—to facilitate future research. As a rare clinical entity, lung torsion is subject to significant publication bias, which hinders accurate assessment of incidence, outcomes, and best practices. A dedicated database could help clarify conditions associated with successful detorsion and better evaluate the effectiveness of prophylactic measures, particularly following upper lobectomies. Such a resource would be highly valuable in advancing understanding and guiding consensus in this underreported area.

Conclusions

Pulmonary torsion, while rare, is a serious complication that can result from lobectomy, thoracic trauma, or spontaneously. It occurs when a lung lobe rotates, obstructing vital bronchovascular structures, which can lead to infarction. The most common cause of torsion is postoperative, particularly following right and left upper lobectomies. The cornerstone of diagnosis is CT angiography, while chest X-ray and bronchoscopy can provide valuable complementary information. Delayed diagnosis significantly heightens both mortality and morbidity. Timely intervention, often requiring lobectomy, is crucial to prevent irreversible lung damage. In this review, successful detorsion is observed only when the lobe shows no visible signs of necrosis or infarction. Additionally, the risk of thrombosis following torsion should not be overlooked. Further research into effective prophylactic measures for high-risk surgical patients is essential. Clinicians should maintain a high index of suspicion for torsion, particularly in the postoperative setting, to optimize patient outcomes.

Acknowledgments

We thank Dr Sarah Hennen and Dr Nunzia Tacelli for their mentoring throughout the writing process.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-880/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-880/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-880/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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