The case, published as a case report in the journal General Thoracic and Cardiovascular Surgery Cases, describes how surgeons found the rotated lobe during keyhole surgery, successfully untwisted it, and sent the patient home just four days later. The authors emphasize that pulmonary torsion is a potentially fatal complication that clinicians rarely suspect in this setting, even though the procedure that preceded it is among the most routine in emergency medicine.
Pulmonary torsion is defined as the rotation of lung tissue on its bronchovascular pedicle, the stalk that carries the bronchus and blood vessels to the lobe. When a lobe rotates, both the airway and the vessels can become obstructed or compromised, cutting off ventilation and blood flow. According to the report, the overall incidence is extremely low, ranging from 0.089 percent to 0.4 percent, and the condition most frequently occurs after pulmonary resection surgery. Its association with spontaneous pneumothorax, a spontaneous collapse of the lung, is described as very limited: before this report, only two cases had been documented in the literature. The authors classify pulmonary torsion as arising in three clinical circumstances, postoperative, spontaneous, and posttraumatic, and cite a systematic review in which 72.8 percent of cases occurred postoperatively, 21.6 percent spontaneously, and 5.6 percent after trauma.
The patient in this case had a history of chest tube drainage for right spontaneous pneumothorax seven months earlier. He presented to the emergency department with a one-day history of acute dyspnea and chest pain. Chest radiography revealed complete collapse of the right lung with a shift of the mediastinum toward the opposite side, the hallmark of a tension pneumothorax, in which accumulating air builds pressure that can be life-threatening. Emergency physicians performed immediate tube thoracostomy, and the patient was then referred to the thoracic department and admitted. On arrival his heart rate was 113 beats per minute, blood pressure 121 over 88 millimeters of mercury, respiratory rate 20 breaths per minute, oxygen saturation 95 percent on room air, and body temperature 36.8 degrees Celsius. Laboratory tests showed a white blood cell count of 13,400 per microliter, indicating leukocytosis, while his C-reactive protein was only 0.04 milligrams per deciliter, showing no significant inflammatory response.
The day after drainage, chest radiography confirmed that the lung had re-expanded adequately and there were no air leaks. A chest computed tomography scan performed to look for pulmonary cysts found no obvious bullae or blebs, the air-filled spaces often associated with spontaneous pneumothorax. What the scan did show, however, was atelectasis, or collapse, of the right middle lobe, with the middle lobe bronchus coursing posterior to the hilum, the central region where airways and vessels enter the lung. The indwelling chest tube was positioned dorsal to the torsed lobe. Crucially, at the time, this bronchial deviation was not recognized, and the atelectasis was attributed to the preceding pneumothorax. Because the patient had presented with a tension pneumothorax and faced a risk of recurrence, surgery was planned, but since torsion had not been suspected, the operation was scheduled electively on hospital day 3 rather than as an emergency.
The operation was performed under general anesthesia with one-lung ventilation in the left lateral decubitus position. Thoracoscopic examination revealed a complete pulmonary fissure, meaning the boundary between the lobes was fully developed, and the collapsed right middle lobe was found displaced dorsally behind the lower lobe and rotated approximately 90 degrees clockwise, consistent with lobar torsion. Importantly, the lung parenchyma retained a normal pink color without venous congestion or ischemic changes, indicating the lobe was still viable. The surgical team therefore performed detorsion alone, without resection. A leak test demonstrated no air leakage, and systematic inspection of the entire lung surface revealed no identifiable bullae or blebs. Pleural changes extending from the mediastinal surface to the lung apex were ablated using soft coagulation, and polyglycolic acid sheets were applied to the ablated areas and placed over the surfaces of the upper and middle lobes, which the authors describe as an adjunct intended to limit excessive mobility of the middle lobe and prevent retorsion.
The postoperative course was uneventful. Radiography confirmed resolution of the atelectasis and adequate lung re-expansion, the chest tube was removed on postoperative day 3, and the patient was discharged on day 4 without complications. The authors note that the outcome might easily have been different. If a torsed pulmonary lobe progresses to necrosis, lobectomy, or ligation of the pulmonary veins draining the torsed lobe before detorsion, is recommended. The rationale is that inflammatory mediators and thromboembolic substances released from necrotic tissue can spread throughout the body and potentially cause serious complications such as acute respiratory distress syndrome, multiple organ failure, and cerebral infarction. In this case, because the color of the lung parenchyma was preserved and no congestion was observed, detorsion alone was considered sufficient.
Why did the lobe twist in the first place? The report reviews several factors that contribute to the pathogenesis of pulmonary torsion, drawing on risk factors identified by Felson and colleagues: atelectasis, a long lobar pedicle, a complete interlobar fissure, pneumothorax or pleural effusion, and division of the pulmonary ligament. In this patient, complete fissures were confirmed intraoperatively, and the middle lobe was found rotated behind the lower lobe. The authors propose two possible mechanisms for the torsion. The first is direct physical displacement of the middle lobe caused by contact with the chest tube during its insertion. The second is mechanical obstruction of normal middle lobe re-expansion by the indwelling chest tube, preventing the lobe from returning to its anatomical position. The presence of a complete fissure, as confirmed at surgery, likely conferred increased mobility to the middle lobe and may have further predisposed it to torsion.
Diagnosis is the central challenge the authors highlight. Pulmonary torsion is often difficult to diagnose, and its typical symptoms and physical signs are frequently absent. According to previous reports cited in the paper, symptoms can include chest pain, fever, and cough, but 20 percent of patients are asymptomatic. In this case, lung expansion after drainage was adequate, blood tests showed no elevation in C-reactive protein, and the patient had no notable subjective symptoms. Chest radiography revealed only linear atelectasis in the right middle lung field, a subtle finding that could plausibly be dismissed as a remnant of the pneumothorax. It was the chest CT that showed the right middle lobe bronchus extending posterior to the hilum, the imaging sign that suggested torsion. The authors’ conclusion is direct: when lobar atelectasis is observed after chest tube insertion, clinicians should consider pulmonary torsion and promptly perform CT imaging, even when lung re-expansion appears satisfactory and the air leak has ceased.
The management decisions in this case also carry lessons. To prevent recurrent torsion after detorsion, fixation of the affected lobe to an adjacent lobe by suturing has been reported, mainly for postoperative pulmonary torsion. In this patient, however, the causative factors, the pneumothorax and the indwelling chest tube, had been eliminated, and the detorsed middle lobe remained viable and re-expanded well, so suture fixation was considered unnecessary. The authors are candid that coverage with polyglycolic acid sheets is not an established method of torsion prophylaxis and may be insufficient when used alone; the sheets were applied over the upper and middle lobes as an adjunct to limit excessive mobility of the middle lobe.
As a single case report, the study cannot establish how often torsion follows chest tube drainage, and the authors themselves note that its occurrence in association with spontaneous pneumothorax is very limited, with only two previously reported cases. The imaging findings were recognized only in retrospect, and the surgery was performed electively rather than emergently because torsion was not initially suspected. Nevertheless, the case illustrates a striking clinical point: chest tube drainage for primary spontaneous pneumothorax is a routine procedure widely performed in emergency medicine, yet pulmonary torsion, a potentially fatal complication, can occur unexpectedly in this context. For clinicians, the practical takeaway from this report is that unexplained lobar atelectasis after chest tube insertion warrants prompt CT imaging to exclude torsion, because early recognition, before the lobe loses viability, can allow simple detorsion and a full recovery rather than lobectomy and its systemic complications.
Subject of Research: A rare case of right middle lobe torsion following chest tube drainage for primary spontaneous pneumothorax
Article Title: Middle lobe torsion after chest tube drainage for primary spontaneous pneumothorax: a case report
Article References: Kohtake, H., Himuro, N., Seto, K., Endo, T., & Kobayashi, M. (2026). Middle lobe torsion after chest tube drainage for primary spontaneous pneumothorax: a case report. General Thoracic and Cardiovascular Surgery Cases, 5(1), Article 35. https://doi.org/10.1186/s44215-026-00268-z
Image Credits: AI Generated
DOI: 10.1186/s44215-026-00268-z
Keywords: pulmonary torsion, primary spontaneous pneumothorax, chest tube drainage, middle lobe atelectasis, tension pneumothorax, thoracic surgery, detorsion, chest CT, case report, complete pulmonary fissure, polyglycolic acid sheet, emergency medicine
News Source: Ophelia Keating. (October 30, 2026). Rare Lung Torsion Follows Routine Chest Tube Drainage in Young Man with Collapsed Lung. Scienmag.
