Lung torsion after tracheoesophageal fistula repair in an infant
A 30-year-old pregnant woman was transferred to our institution at 32 weeks' gestation due to polyhydramnios. At 41 weeks of gestation, a 3.7 kg boy was delivered by misoprostol induction. After birth, the baby had mild respiratory distress and copious secretions. An attempt to pass a nasogastric tube failed, and chest radiographs showed a pouch in front of the first thoracic vertebra. The baby was diagnosed with esophageal atresia with distal TEF and underwent esophagoesophagostomy and fistula ligation on the first day of birth. The posterolateral thoracotomy using a transpleural approach was performed. The pleura dissection was carried superiorly to the apex of the chest and inferiorly for a couple of intercostal spaces. Pulmonary lobes were retracted to expose the esophagus as usual manner. During the operation, abnormal anatomic features were not found, except for esophageal atresia with distal TEF. A chest tube was placed in the thoracic cavity.\nOn the first postoperative day, the patient had aggravated respiratory distress with tachypnea and bloody secretions from the endotracheal tube. Chest radiographs showed opacification of the right upper lobe (RUL) (). Despite repeated efforts of endotracheal suctioning and physiotherapy, serial chest radiographs on the second postoperative day revealed rapidly progressed consolidation with volume expansion of the right hemithorax (). A computed tomographic (CT) scan was performed and showed abrupt narrowing of the right upper lobar bronchus and no visible right middle lobar bronchus, with extensive consolidation (). Immediately, the baby underwent an emergency operation on day 3 from birth. Intraoperative findings revealed 180° torsion of the RUL and right middle lobe (RML) in a clockwise direction. Both lobes appeared dark red and were engorged. After detorsion of both lobes, there was some immediate improvement in the color of the RUL, but improvement was uncertain in the RML (). Although viability of the RML could not be proven, pexy of both lobes was performed.\nIn spite of emergency rethoracotomy, respiratory distress signs and symptoms did not improve. Chest radiographs showed persistent opacification of the right hemithorax. A CT scan on the seventh day after reoperation showed consolidation in the RML (). Bronchoscopy was performed and revealed a patent airway for the RUL but not for the RML. On the eighth day of second operation, the third operation was performed. Intraoperative findings revealed that the pexy of both lobes were secure, and the RUL had improved with regards to color, congestion and edema. On the other hand, RML appeared dark red and was still congested without any improvements from before. The RML was surgically removed. After the third surgery, respiratory distress signs and symptoms and radiologic examinations were improved. The baby was discharged on the 42nd day after birth. On follow-up at 6 months of age, the baby's growth and development were normal, and radiologic findings were improved, except for evidence of resection of the RML ().