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

Middle lobe torsion following pulmonary lobectomy is an uncommon but potentially life-threatening postoperative complication that poses significant challenges for perioperative anesthetic management. We report two cases of right middle lobe torsion after right upper lobectomy in which persistent postoperative atelectasis and equivocal initial bronchoscopic findings prompted repeated bronchoscopy and contrast-enhanced computed tomography examinations, leading to early diagnosis and timely surgical intervention. Anesthetic planning for reoperation focused on appropriate lung isolation with carefully selected double-lumen tubes, anticipation of airway mucosal edema, and vigilant hemodynamic monitoring when releasing lung torsion. In the first case, irreversible torsion and compromised perfusion necessitated middle lobectomy, whereas in the second case, preserved parenchymal enhancement permitted detorsion with lobar fixation. Both patients maintained acceptable oxygenation and stable hemodynamics during anesthesia, with no evidence of reperfusion-related instability. Postoperative management involved corticosteroid administration and non-invasive positive pressure ventilation to address airway secretions and recurrent atelectasis. These cases underscore the need for heightened clinical consideration of lobar torsion in patients with persistent atelectasis despite preserved oxygenation, systematic use of imaging modalities, and anesthetic strategies tailored to dynamic airway and vascular challenges. Awareness of lobar torsion's diagnostic subtleties and perioperative risks, coupled with close multidisciplinary coordination, are essential for optimizing perioperative outcomes in this rare but critical condition.