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(Radiographics. 2002;22:67-86.)
© RSNA, 2002

EDUCATION EXHIBIT

Radiographic and CT Findings in Complications Following Pulmonary Resection1

Eun A. Kim, MD, Kyung Soo Lee, MD, Young Mog Shim, MD, Jhingook Kim, MD, Kwanmien Kim, MD, Tae Sung Kim, MD and Po Song Yang, MD

1 From the Departments of Radiology (E.A.K., K.S.L., T.S.K., P.S.Y.) and Thoracic Surgery (Y.M.S., J.K., K.K.), Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea. Recipient of a Certificate of Merit award for an education exhibit at the 2000 RSNA scientific assembly. Received March 27, 2001; revision requested May 17 and received June 6; accepted June 6. Address correspondence to K.S.L. (e-mail: kslee@smc.samsung.co.kr).


   Abstract
Top
 Abstract
LEARNING OBJECTIVES FOR TEST...
 Introduction
 Pulmonary Resection Techniques
 Complications Following...
 Anastomotic Dehiscence
 Conclusions
 References
 
A variety of pulmonary resection techniques are currently available, including pneumonectomy (intrapleural, extrapleural, intrapericardial, and sleeve pneumonectomy), lobectomy, and limited resection (sleeve lobectomy, segmentectomy, nonanatomic parenchyma-sparing resection). However, pulmonary resection is often followed by postoperative complications that differ according to the type of surgery and the time elapsed since surgery was performed. The most common complications are bleeding, pulmonary edema, atelectasis, pneumonia, persistent air leak, bronchopleural fistula, and empyema. Other, less frequent complications include cardiac herniation, lung torsion, chylothorax, anastomotic dehiscence, wound infection, esophagopleural fistula, and recurrent tumor. The radiologist plays a major role in the diagnosis of various complications following pulmonary resection. Unfortunately, chest radiography has a relatively low diagnostic accuracy in the detection of these complications. When radiographic findings are subtle or equivocal, computed tomography frequently allows more accurate identification of the disease process. Several complications that follow pulmonary resection are life-threatening and require prompt management. Therefore, knowledge of the diverse radiologic appearances of these complications as well as familiarity with the clinical settings in which specific complications are likely to occur are vital for prompt, effective treatment.

© RSNA, 2002

Index Terms: Lung, consolidation • Lung, CT, 60.1211 • Lung, diseases, 60.21, 60.24, 60.4125, 60.4127, 60.71, 60.74, 60.76 • Lung, edema, 60.71 Lung, radiography, 60.11 • Lung, surgery, 60.452, 60.453 • Lung, torsion • Surgery, complications, 60.452, 60.453


   LEARNING OBJECTIVES FOR TEST 3
Top
 Abstract
 LEARNING OBJECTIVES FOR TEST...
Introduction
 Pulmonary Resection Techniques
 Complications Following...
 Anastomotic Dehiscence
 Conclusions
 References
 
After reading this article and taking the test, the reader will be able to:


   Introduction
Top
 Abstract
 LEARNING OBJECTIVES FOR TEST...
 Introduction
Pulmonary Resection Techniques
 Complications Following...
 Anastomotic Dehiscence
 Conclusions
 References
 
Complications following pulmonary resection differ according to the type of surgery and the time elapsed since surgery was performed. Early and late complications following pneumonectomy and lobectomy or sleeve lobectomy are shown in the Table.


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  		Complications Following Pulmonary Resection

 
Chest radiography and computed tomography (CT) are especially useful in the evaluation of complications related to pulmonary resection (1,2). The relatively low diagnostic accuracy of chest radiography in the detection of these complications can be improved with CT and with knowledge of the clinical settings in which specific complications are likely to occur. In this article, we describe the various surgical techniques used in pulmonary resection and discuss and illustrate the radiographic and CT features of a variety of postoperative complications.


   Pulmonary Resection Techniques
Top
 Abstract
 LEARNING OBJECTIVES FOR TEST...
 Introduction
 Pulmonary Resection Techniques
Complications Following...
 Anastomotic Dehiscence
 Conclusions
 References
 
Pulmonary resection techniques include pneumonectomy (intrapleural, extrapleural, intrapericardial, and sleeve pneumonectomy), lobectomy, and limited resection (sleeve lobectomy, segmentectomy, nonanatomic parenchyma-sparing resection).

Intrapleural pneumonectomy is the most frequently used procedure and involves resection of the lung and surrounding visceral pleura. Extrapleural pneumonectomy involves en bloc resection of the ipsilateral lung, parietal and mediastinal pleura, pericardium, and diaphragm (3). Intrapericardial pneumonectomy may be performed by opening the pericardium and dividing the vessels that are involved by a tumor within the pericardium (3). Sleeve pneumonectomy is an aggressive and extended procedure for resection of bronchial carcinoma involving the tracheobronchial angle, carina, or lower trachea and the ipsilateral lung. The airway is reconstructed with anastomosis of the proximal contralateral main stem bronchus to the lower trachea (4).

Limited resection of the lung and major airways refers to surgical procedures that preserve functioning lung tissues and provide adequate cancer treatment. Sleeve lobectomy, segmentectomy, and wedge resection are included in this category (5). Sleeve lobectomy has evolved into an alternative to pneumonectomy in carefully selected cases of bronchogenic carcinoma, especially for cancer in a lobar orifice. The lobe is resected en bloc, along with a portion of the common airway (Fig 1). Sleeve resection requires the following: (a) adequate resection of the primary tumor as documented with intraoperative frozen section, (b) reconstruction of the airway by means of a meticulous end-to-end technique with absorbable or monofilament suture, and (c) wrapping of the anastomosis with pleura or comparable vascularized tissue (5). The most common site for sleeve resection is the right upper lobe (75% of cases), which reflects the anatomic advantage of using the relatively long bronchus intermedius for airway reconstruction. The left upper lobe (16% of cases) and left lower lobe (8%) are less common sites of sleeve resection because of the proximity of the lobar orifices and pulmonary artery (5). Recently, extended sleeve lobectomy (atypical bronchoplasty) has been performed in patients with noncompromised lung function and large, centrally located tumors to avoid pneumonectomy (Fig 2) (6).



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  		Figure 1.   Schematic illustrates a sleeve right upper lobectomy. The right airway is resected proximally in the right main bronchus and distally in the bronchus intermedius (dotted lines). The airway is then reconstructed with anastomosis of the bronchus intermedius proximally to the right main bronchus (hatched line). RLL = right lower lobar bronchus, RML = right middle lobar bronchus, RUL = right upper lobar bronchus. (Adapted and reprinted, with permission, from reference 6.)

 


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  		Figure 2.   Schematic illustrates an extended sleeve lobectomy. Following right upper and middle bilobectomy, the airway is reconstructed with anastomosis of the right lower lobar bronchus (RLL) proximally to the right main bronchus. Following left lower lobectomy and lingular segmentectomy, the airway is reconstructed with anastomosis of the upper divisional bronchus of the left upper lobe (UD) proximally to the left main bronchus. BS = basal segmental bronchus of the right lower lobe, LLL = left lower lobar bronchus, LS = lingular segmental bronchus of the left upper lobe, LUL = left upper lobar bronchus, RML = right middle lobar bronchus, RUL = right upper lobar bronchus, SS = superior segmental bronchus of the right lower lobe.

 

   Complications Following Pulmonary Resection
Top
 Abstract
 LEARNING OBJECTIVES FOR TEST...
 Introduction
 Pulmonary Resection Techniques
 Complications Following...
Anastomotic Dehiscence
 Conclusions
 References
 
Hemothorax
Major hemorrhage following thoracotomy and resection is most commonly the result of inadequate hemostasis of a bronchial artery or systemic vessels in the chest wall. It infrequently results from the slipping of a ligature from a major pulmonary vessel or an unrecognized injury to a systemic vein. Bleeding related to a coagulation abnormality is rare. The overall mortality rate associated with uncontrolled bleeding is less than 0.1% (2).

Hemothorax often manifests as a rapidly enlarging pleural effusion. CT can demonstrate hemorrhagic pleural effusions as areas of high attenuation. CT findings in hemothorax include heterogeneously attenuating pleural fluid, hyperattenuating areas of debris within pleural fluid, and a fluid-hematocrit level (Fig 3). As the hemorrhagic pleural effusion begins to clot, loculations develop within the pleural fluid and fibrin balls emerge. These pleural pseudotumors can be distinguished from pleural-based masses by their high attenuation on unenhanced CT scans (7).



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  		Figure 3.   Hemothorax in a 38-year-old man who had undergone left lower lobectomy for squamous cell carcinoma of the lung. Intravenously administered contrast material-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the level of the inferior pulmonary vein shows a multiloculated fluid collection with heterogeneous attenuation in the left pleural space. The fluid had attenuation values of 12.4 HU and 44.1 HU in the posterior (*) and anterior (*) aspects, respectively.

 
Chylothorax
Chylothorax is defined as an accumulation of chyle in the pleural space caused by disruption of the thoracic duct or one of its major divisions. Sites of potential thoracic duct injury during pneumonectomy include (a) the inferior right hemithorax in the paravertebral area during extrapleural resection, (b) the pericarinal and subaortic areas during radical nodal dissection, and (c) the inferior pulmonary ligaments on either side during standard resection (8). Triglyceride concentrations greater than 110 mg/dL in the pleural fluid are considered diagnostic (8).

Rapid excessive filling of the postpneumonectomy space with fluid on chest radiographs is often the first sign suggesting a postpneumonectomy chylothorax (Fig 4). The attenuation of chylous effusions at CT is variable; it may be low due to the fat content of the fluid but more often is not because of the high protein content of the fluid. Lymphangiography may show leakage of contrast material into the pleural space, and even small amounts of contrast material can be detected in the pleural space at CT performed after lymphangiography (7).



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  		Figure 4a.   Chylothorax in a 63-year-old man who had undergone left pneumonectomy for adenocarcinoma of the lung. (a) Chest radiograph obtained 6 days after surgery shows a large fluid collection in the left pneumonectomy space with mediastinal shifting toward the right side. (b) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the level of the left atrium shows a large fluid collection with homogeneous low attenuation in the left pneumonectomy space. The fluid had an attenuation value of -6.4 HU and proved to be chylous at thoracentesis. Note also the cardiac displacement to the right side.

 


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  		Figure 4b.   Chylothorax in a 63-year-old man who had undergone left pneumonectomy for adenocarcinoma of the lung. (a) Chest radiograph obtained 6 days after surgery shows a large fluid collection in the left pneumonectomy space with mediastinal shifting toward the right side. (b) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the level of the left atrium shows a large fluid collection with homogeneous low attenuation in the left pneumonectomy space. The fluid had an attenuation value of -6.4 HU and proved to be chylous at thoracentesis. Note also the cardiac displacement to the right side.

 
Persistent Air Leak
Air leak following major pulmonary resection is a well-known problem. Nearly all patients undergoing lobectomy or segmentectomy can be expected to experience some degree of postoperative air leakage. This complication occurs more frequently when interlobar fissures are incomplete or absent. It is also common in pulmonary resection performed in older patients with emphysema. Chest radiography and CT show persistent pneumothorax, pneumomediastinum, or subcutaneous emphysema. Successful closure of the airway is mandatory when performing a major pulmonary resection. If bronchioles or alveolar spaces remain open, bronchioloalveolar leakage develops and an air leak results (9). Nearly all air leaks originating from the periphery of the lung stop within 24–48 hours after surgery when the remaining parenchyma completely fills the pleural cavity. By definition, persistent air leak continues beyond the normal hospital stay (usually 7 days). This condition usually leads to prolonged hospitalization and increased costs; however, it does not directly imply a higher morbidity and mortality rate.

Bronchopleural Fistula
BPF remains the most dreaded complication following thoracic surgery. Its prevalence is reported to range between 2% and 13%. Mortality rates for BPF range from 30% to 70% (10). The most common cause of death associated with this condition is aspiration pneumonia with subsequent adult respiratory distress syndrome (Fig 5). BPF is more common after right pneumonectomy than after left pneumonectomy. This is probably due to anatomic features of the right main bronchus including larger size, greater tendency to spring open, and less mediastinal coverage than the left main bronchus (10). BPF is frequently associated with postoperative mechanical ventilation (10). Predisposing factors are preoperative uncontrolled pleuropulmonary infection, trauma, and preoperative radiation therapy (10,11). BPF is the main cause of postpneumonectomy empyema. In the immediate postoperative period, bronchial leaks are rare and are usually due to faulty closure of the bronchus. Delayed BPF is much more common and is usually due to infection or recurrent tumor of the bronchial stump. An adequately short stump, a disease-free margin, and mainte-nance of bronchial vascularity by preserving the bronchial artery or peribronchial tissue have been strongly suggested as means of avoiding avascular necrosis of the stump (10). BPF usually develops in the bronchial stump after pneumonectomy or lobectomy and is usually diagnosed with bronchoscopy (12).



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  		Figure 5a.   BPF in a 60-year-old man with dyspnea who had undergone right lower lobectomy for adenocarcinoma of the lung. (a) Chest radiograph obtained 4 days after surgery shows a pleural effusion with newly developed multiple air-fluid levels in the right pleural space. A chest tube was subsequently inserted. (b) On a follow-up chest radiograph obtained 1 day later, the air-fluid levels in the right pleural space have disappeared; instead, newly formed small, nodular lesions are seen in the left middle and lower lung zones (arrows). These findings suggest aspiration pneumonia due to BPF. Endotracheal intubation was subsequently performed.

 


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  		Figure 5b.   BPF in a 60-year-old man with dyspnea who had undergone right lower lobectomy for adenocarcinoma of the lung. (a) Chest radiograph obtained 4 days after surgery shows a pleural effusion with newly developed multiple air-fluid levels in the right pleural space. A chest tube was subsequently inserted. (b) On a follow-up chest radiograph obtained 1 day later, the air-fluid levels in the right pleural space have disappeared; instead, newly formed small, nodular lesions are seen in the left middle and lower lung zones (arrows). These findings suggest aspiration pneumonia due to BPF. Endotracheal intubation was subsequently performed.

 
Radiologic findings in BPF consist of (a) a continuous increase in the residual intrapleural airspace, (b) the appearance of an air-fluid level, (c) changes in an already present air-fluid level, (d) development of tension pneumothorax, and (e) a drop in the air-fluid level exceeding 2 cm during the postoperative period or the reappearance of an air-fluid level in a patient who has undergone pneumonectomy (13). Movement of the mediastinum back toward its preoperative position, a finding that suggests volume enlargement of the resected hemithorax with leaked air, may be evidence of BPF (13). In a recent study, Westcott and Volpe (14) found CT to be useful in the diagnosis and management of peripheral BPF. CT findings in BPF include air and fluid collections in the pleural space and demonstration of a communication or tract from an airway or the lung parenchyma to the pleural space (Fig 6). In their study, BPF was directly visualized with standard or thin-section CT in 10 of 20 patients (50%) (14). In the remaining 10 patients, persistent localized air and fluid collections or a postoperative air leak suggested the presence of BPF.



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  		Figure 6a.   BPF in a 71-year-old man with cough who had undergone right lower lobectomy for adenocarcinoma of the lung. (a) CT scan (1-mm collimation, lung windowing) obtained at the subcarinal level 1 month after surgery shows a fistulous tract between the right main bronchus and the right pleural space (arrow). Note also the air-fluid level in the right lower lobectomy space (arrowhead). (b) Unenhanced CT scan (1-mm collimation, mediastinal windowing) obtained at the same level also shows the fistulous tract between the right main bronchus and the right pleural space (arrow).

 


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  		Figure 6b.   BPF in a 71-year-old man with cough who had undergone right lower lobectomy for adenocarcinoma of the lung. (a) CT scan (1-mm collimation, lung windowing) obtained at the subcarinal level 1 month after surgery shows a fistulous tract between the right main bronchus and the right pleural space (arrow). Note also the air-fluid level in the right lower lobectomy space (arrowhead). (b) Unenhanced CT scan (1-mm collimation, mediastinal windowing) obtained at the same level also shows the fistulous tract between the right main bronchus and the right pleural space (arrow).

 
Postpneumonectomy Empyema
Empyema is a serious but uncommon complication of pulmonary resection, occurring in 2%–16% of patients. It is associated with high mortality rates that range from 16% to 71% (12). Mortality is especially high when the empyema is associated with a large BPF (10). Postpneumonectomy empyema occurs more commonly with completion pneumonectomy (ie, pneumonectomy following previous lobectomy), right pneumonectomy, preoperative irradiation, gross contamination of the pleura, surgically caused sepsis, mediastinal lymph node dissection, and a long bronchial stump and in patients requiring postoperative mechanical ventilation (12).

Empyema usually occurs in the early postoperative period but can develop months or even years after surgery. Empyema that occurs shortly after surgery is due to residual infection in the pleural cavity. Empyema may also occur secondary to BPF or esophagopleural fistula. Staphylococcus aureus, Pseudomonas aeruginosa, Streptococcus species, and Aerobacter aerogenes are the most commonly cultured organisms in most reported series (13).

At radiography, postpneumonectomy empyema typically manifests as multiple air-fluid levels in the early postoperative period and as mediastinal shifting away from the surgical side in the late postoperative period (Fig 7). In demonstrating reversal of the normal concavity of the mediastinal pleura even without mediastinal displacement, CT shows the volume-expanding process within the postpneumonectomy space better than chest radiography (Fig 8).



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  		Figure 7a.   Postpneumonectomy empyema in a 64-year-old man who complained of chest wall pain after undergoing right pneumonectomy for squamous cell carcinoma of the lung. (a) Chest radiograph obtained immediately after surgery shows an air-fluid level in the right pneumonectomy space. Note also the subcutaneous emphysema and surgical wires in the right chest wall. (b) Follow-up chest radiograph obtained 63 days after surgery shows a large fluid collection with a persistent air-fluid level in the right hemithorax.

 


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  		Figure 7b.   Postpneumonectomy empyema in a 64-year-old man who complained of chest wall pain after undergoing right pneumonectomy for squamous cell carcinoma of the lung. (a) Chest radiograph obtained immediately after surgery shows an air-fluid level in the right pneumonectomy space. Note also the subcutaneous emphysema and surgical wires in the right chest wall. (b) Follow-up chest radiograph obtained 63 days after surgery shows a large fluid collection with a persistent air-fluid level in the right hemithorax.

 


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  		Figure 8.   Postpneumonectomy empyema in a 70-year-old man who developed fever 5 months after undergoing right pneumonectomy for squamous cell carcinoma of the lung. Intravenous contrast-enhanced CT scan (7-mm collimation) obtained at the level of the right main pulmonary artery shows a hydropneumothorax with diffusely enhancing parietal pleura in the right pneumonectomy space. Note also the inward convexity of the mediastinal pleura in the azygoesophageal recess (arrows), a finding that suggests mass effect.

 
Atelectasis
Atelectasis resulting from retained secretions and subsequent lack of aeration of various parts of the remaining pulmonary parenchyma is often seen after pulmonary resection. Atelectasis occurs in 5%–10% of sleeve resections and is the result of local edema at the anastomotic site, interruption of the ciliary epithelium and lymphatic vessels, or partial denervation of the reimplanted lobe (15). It is seen more often after the sleeve resection of lower lobes because anastomotic kinking is greater when securing the anastomosis between the upper lobar bronchus and the proximal main bronchus. Atelectasis is less common after the sleeve resection of upper lobes because the distal lumen of the lower lobar bronchus is made wider to accommodate the size of the proximal lumen (15). In some patients, infection may be superimposed on unresolved atelectatic areas or may result from unrecognized episodes of aspiration. CT shows ground-glass attenuation and consolidation in the atelectatic lobe (Fig 9).



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  		Figure 9a.   Atelectasis in a 71-year-old man who complained of cough after undergoing right lower lobectomy for adenocarcinoma of the lung. (a) Chest radiograph obtained 19 days after surgery shows poorly defined consolidation in the right middle and lower lung zones and left lower lung zone. Note also the fluid collection in the right lower lung zone with obliteration of the right costophrenic angle. (b) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the level of the left atrium shows consolidation posteriorly in the remaining right lung and a small collection of fluid and gas in the right pleural space.

 


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  		Figure 9b.   Atelectasis in a 71-year-old man who complained of cough after undergoing right lower lobectomy for adenocarcinoma of the lung. (a) Chest radiograph obtained 19 days after surgery shows poorly defined consolidation in the right middle and lower lung zones and left lower lung zone. Note also the fluid collection in the right lower lung zone with obliteration of the right costophrenic angle. (b) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the level of the left atrium shows consolidation posteriorly in the remaining right lung and a small collection of fluid and gas in the right pleural space.

 
Pneumonia
The reported prevalence of postthoracotomy pneumonia ranges from 2% to 22% (16). Approximately 30% of new pulmonary infiltrates in a surgical intensive care unit have proved to be caused by a disease process other than pneumonia (16). Lack of radiographic evidence of pneumonia does not rule out the possibility of postoperative pneumonia because there is often a time lag between clinical presentation and manifestation at radiography. Postoperative pneumonia is most common in patients requiring prolonged ventilatory support or who have ongoing difficulty in clearing tracheobronchial secretions (13). Postoperative pneumonia is most often caused by aspiration of gastric secretions and bacterial colonization of the atelectatic lobe (17). Intubation and mechanical ventilation may increase the size and prevalence of aspirations with a concomitant increase in the development of pneumonia (18,19). In hospitalized patients with colonies of highly virulent organisms, aspiration may overwhelm lung defenses, leading to the development of pneumonia.

Radiographic findings vary somewhat among the various species of gram-negative bacilli. Chest radiographs typically show patchy bronchopneumonic patterns. The lobar airspace consolidation pattern is much less common (Fig 10) (18). A prolonged disease course or large aspirations may result in severe necrotizing bronchopneumonia (Fig 11).



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  		Figure 10a.   Aspiration pneumonia in a 68-year-old man who developed productive cough after undergoing right upper lobectomy for squamous cell carcinoma of the lung. (a) Chest radiograph obtained 49 days after surgery shows reticulonodular lesions bilaterally in the middle lung zones. Note also the pleural fluid collection in the right lower lung zone. (b) Thin-section CT scan (1-mm collimation, lung windowing) shows ground-glass attenuation and consolidation in the left upper and right lower lobes. The abnormality is more severe in the left upper lobe. Note also the small amount of fluid and gas in the fissure in the right pleural space (arrow).

 


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  		Figure 10b.   Aspiration pneumonia in a 68-year-old man who developed productive cough after undergoing right upper lobectomy for squamous cell carcinoma of the lung. (a) Chest radiograph obtained 49 days after surgery shows reticulonodular lesions bilaterally in the middle lung zones. Note also the pleural fluid collection in the right lower lung zone. (b) Thin-section CT scan (1-mm collimation, lung windowing) shows ground-glass attenuation and consolidation in the left upper and right lower lobes. The abnormality is more severe in the left upper lobe. Note also the small amount of fluid and gas in the fissure in the right pleural space (arrow).

 


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  		Figure 11a.   Necrotizing pneumonia in a 39-year-old man who had undergone lingular segmentectomy of the left upper lobe for bronchiectasis. (a) Chest radiograph obtained 7 days after surgery shows consolidation in the remaining left upper lobe. Note also the air-fluid levels in the left midlung zone, a finding that indicates a collection of air and fluid in the segmentectomy space. (b) Thin-section CT scan (1-mm collimation, lung windowing) shows consolidation and ground-glass attenuation in the remaining left upper lobe. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) shows consolidation with volume expansion in the remaining left upper lobe. (d) Photograph of the gross pathologic specimen shows necrotizing hemorrhagic pneumonia (arrows). (e) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows suppurative inflammation and necrosis (arrows).

 


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  		Figure 11b.   Necrotizing pneumonia in a 39-year-old man who had undergone lingular segmentectomy of the left upper lobe for bronchiectasis. (a) Chest radiograph obtained 7 days after surgery shows consolidation in the remaining left upper lobe. Note also the air-fluid levels in the left midlung zone, a finding that indicates a collection of air and fluid in the segmentectomy space. (b) Thin-section CT scan (1-mm collimation, lung windowing) shows consolidation and ground-glass attenuation in the remaining left upper lobe. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) shows consolidation with volume expansion in the remaining left upper lobe. (d) Photograph of the gross pathologic specimen shows necrotizing hemorrhagic pneumonia (arrows). (e) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows suppurative inflammation and necrosis (arrows).

 


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  		Figure 11c.   Necrotizing pneumonia in a 39-year-old man who had undergone lingular segmentectomy of the left upper lobe for bronchiectasis. (a) Chest radiograph obtained 7 days after surgery shows consolidation in the remaining left upper lobe. Note also the air-fluid levels in the left midlung zone, a finding that indicates a collection of air and fluid in the segmentectomy space. (b) Thin-section CT scan (1-mm collimation, lung windowing) shows consolidation and ground-glass attenuation in the remaining left upper lobe. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) shows consolidation with volume expansion in the remaining left upper lobe. (d) Photograph of the gross pathologic specimen shows necrotizing hemorrhagic pneumonia (arrows). (e) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows suppurative inflammation and necrosis (arrows).

 


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  		Figure 11d.   Necrotizing pneumonia in a 39-year-old man who had undergone lingular segmentectomy of the left upper lobe for bronchiectasis. (a) Chest radiograph obtained 7 days after surgery shows consolidation in the remaining left upper lobe. Note also the air-fluid levels in the left midlung zone, a finding that indicates a collection of air and fluid in the segmentectomy space. (b) Thin-section CT scan (1-mm collimation, lung windowing) shows consolidation and ground-glass attenuation in the remaining left upper lobe. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) shows consolidation with volume expansion in the remaining left upper lobe. (d) Photograph of the gross pathologic specimen shows necrotizing hemorrhagic pneumonia (arrows). (e) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows suppurative inflammation and necrosis (arrows).

 


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  		Figure 11e.   Necrotizing pneumonia in a 39-year-old man who had undergone lingular segmentectomy of the left upper lobe for bronchiectasis. (a) Chest radiograph obtained 7 days after surgery shows consolidation in the remaining left upper lobe. Note also the air-fluid levels in the left midlung zone, a finding that indicates a collection of air and fluid in the segmentectomy space. (b) Thin-section CT scan (1-mm collimation, lung windowing) shows consolidation and ground-glass attenuation in the remaining left upper lobe. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) shows consolidation with volume expansion in the remaining left upper lobe. (d) Photograph of the gross pathologic specimen shows necrotizing hemorrhagic pneumonia (arrows). (e) Low-power photomicrograph (original magnification, x40; hematoxylin-eosin [H-E] stain) shows suppurative inflammation and necrosis (arrows).

 
Pulmonary Edema
Postoperative pulmonary edema is a life-threatening complication that develops 2–3 days after pulmonary resection, usually after pneumonectomy, lobectomy, or bilobectomy (20). The prevalence of postpneumonectomy pulmonary edema is generally reported to range from 2.5% to 5%, whereas that of postlobectomy pulmonary edema is less than 1% (21). Postpneumonectomy pulmonary edema is a clinical condition in which a patient experiences rapidly progressing dyspnea and hypoxemia and the remaining lung develops rapid infiltration, progressing to diffuse interstitial pulmonary edema, consolidation, and adult respiratory distress syndrome. When respiratory distress occurs after pneumonectomy, other causes must be excluded before a diagnosis of postpneumonectomy pulmonary edema is made. The most common cause of the edema is overhydration from excessive fluid replacement during surgery. Other causes are acute myocardial infarction with left heart failure, decreased serum protein concentration, capillary injury from sepsis or prolonged inspiration of gases with a high oxygen concentration, administration of fresh frozen plasma, arrhythmia, and interruption of lymphatic drainage related to extensive surgical dis-section (22,23). Patients who undergo right pneumonectomy are considered to be at a higher risk for postpneumonectomy pulmonary edema than those who undergo left pneumonectomy (21).

The most frequent radiologic findings in milder forms of postpneumonectomy pulmonary edema are similar to those in hydrostatic pulmonary edema without diffuse alveolar damage and include Kerley lines, peribronchial cuffing, and ill-defined vessels. These findings have a tendency to disappear within a few days. On conventional radiographs, severe postpneumonectomy pulmonary edema manifests as infiltrates with an appearance identical to that of adult respiratory distress syndrome (Fig 12)(22,24,25).



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  		Figure 12a.   Adult respiratory distress syndrome in a 40-year-old man who had undergone right pneumonectomy for squamous cell carcinoma of the lung. Postoperative CT scans obtained at the level of the left upper lobar bronchus (a) and inferior pulmonary vein (b) 30 days after surgery show extensive ground-glass attenuation in the left lung. The pneumonectomy space is filled with fluid and gas.

 


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  		Figure 12b.   Adult respiratory distress syndrome in a 40-year-old man who had undergone right pneumonectomy for squamous cell carcinoma of the lung. Postoperative CT scans obtained at the level of the left upper lobar bronchus (a) and inferior pulmonary vein (b) 30 days after surgery show extensive ground-glass attenuation in the left lung. The pneumonectomy space is filled with fluid and gas.

 
Gossypiboma
The term gossypiboma is used to describe a mass within the body that is composed of cotton matrix and most commonly refers to a retained surgical sponge (26). The pleural space is the most likely site for surgical swabs, but the swabs may become invaginated into the lung, mimicking an intrapulmonary lesion (27).

Early in the postoperative period, gossypiboma may be confused at radiology with lung abscess, loculated empyema, complicated hematoma, or seroma. Over time, atypical calcification and thick, irregular inflammatory lesion walls may mimic a chronic infectious or granulomatous process or a neoplasm (Figs 13, 14). Gas may be present in the sponge mesh and produce a whorllike pattern that is detectable at radiologic examination (Fig 13) (28).



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  		Figure 13a.   Gossypiboma in a 48-year-old man who had undergone tracheal resection and anastomosis for tracheal stenosis. (a) Unenhanced CT scan (5-mm collimation, mediastinal windowing) shows a soft-tissue mass with high attenuation centrally in the right paratracheal area (arrow). (b, c) Intravenous contrast-enhanced serial CT scans (7-mm collimation, mediastinal windowing) obtained at a level similar to a 26 months (b) and 42 months (c) later demonstrate the changing nature of the right paratracheal lesion with cavity formation. (d) Clinical photograph shows gauze that was removed through a defect in the right tracheal wall at bronchoscopy.

 


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  		Figure 13b.   Gossypiboma in a 48-year-old man who had undergone tracheal resection and anastomosis for tracheal stenosis. (a) Unenhanced CT scan (5-mm collimation, mediastinal windowing) shows a soft-tissue mass with high attenuation centrally in the right paratracheal area (arrow). (b, c) Intravenous contrast-enhanced serial CT scans (7-mm collimation, mediastinal windowing) obtained at a level similar to a 26 months (b) and 42 months (c) later demonstrate the changing nature of the right paratracheal lesion with cavity formation. (d) Clinical photograph shows gauze that was removed through a defect in the right tracheal wall at bronchoscopy.

 


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  		Figure 13c.   Gossypiboma in a 48-year-old man who had undergone tracheal resection and anastomosis for tracheal stenosis. (a) Unenhanced CT scan (5-mm collimation, mediastinal windowing) shows a soft-tissue mass with high attenuation centrally in the right paratracheal area (arrow). (b, c) Intravenous contrast-enhanced serial CT scans (7-mm collimation, mediastinal windowing) obtained at a level similar to a 26 months (b) and 42 months (c) later demonstrate the changing nature of the right paratracheal lesion with cavity formation. (d) Clinical photograph shows gauze that was removed through a defect in the right tracheal wall at bronchoscopy.

 


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  		Figure 13d.   Gossypiboma in a 48-year-old man who had undergone tracheal resection and anastomosis for tracheal stenosis. (a) Unenhanced CT scan (5-mm collimation, mediastinal windowing) shows a soft-tissue mass with high attenuation centrally in the right paratracheal area (arrow). (b, c) Intravenous contrast-enhanced serial CT scans (7-mm collimation, mediastinal windowing) obtained at a level similar to a 26 months (b) and 42 months (c) later demonstrate the changing nature of the right paratracheal lesion with cavity formation. (d) Clinical photograph shows gauze that was removed through a defect in the right tracheal wall at bronchoscopy.

 


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  		Figure 14a.   Gossypiboma in a 64-year-old woman who had undergone right upper lobectomy for squamous cell carcinoma of the lung. (a, b) Intravenous contrast-enhanced serial CT scans (10-mm collimation, mediastinal windowing) obtained at the level of the aortic arch (b obtained 12 months after a) demonstrate the change in a soft-tissue lesion from a wall-enhancing, cystlike lesion to a solid-looking lesion. (c) Axial T2-weighted MR image obtained 62 months after a shows an oval mass with low signal intensity, a finding that suggests a fibrotic lesion. (d) Coronal contrast-enhanced T1-weighted MR image obtained at the same time as c shows a heterogeneous, moderately enhancing soft-tissue lesion in the right paraspinal area.

 


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  		Figure 14b.   Gossypiboma in a 64-year-old woman who had undergone right upper lobectomy for squamous cell carcinoma of the lung. (a, b) Intravenous contrast-enhanced serial CT scans (10-mm collimation, mediastinal windowing) obtained at the level of the aortic arch (b obtained 12 months after a) demonstrate the change in a soft-tissue lesion from a wall-enhancing, cystlike lesion to a solid-looking lesion. (c) Axial T2-weighted MR image obtained 62 months after a shows an oval mass with low signal intensity, a finding that suggests a fibrotic lesion. (d) Coronal contrast-enhanced T1-weighted MR image obtained at the same time as c shows a heterogeneous, moderately enhancing soft-tissue lesion in the right paraspinal area.

 


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  		Figure 14c.   Gossypiboma in a 64-year-old woman who had undergone right upper lobectomy for squamous cell carcinoma of the lung. (a, b) Intravenous contrast-enhanced serial CT scans (10-mm collimation, mediastinal windowing) obtained at the level of the aortic arch (b obtained 12 months after a) demonstrate the change in a soft-tissue lesion from a wall-enhancing, cystlike lesion to a solid-looking lesion. (c) Axial T2-weighted MR image obtained 62 months after a shows an oval mass with low signal intensity, a finding that suggests a fibrotic lesion. (d) Coronal contrast-enhanced T1-weighted MR image obtained at the same time as c shows a heterogeneous, moderately enhancing soft-tissue lesion in the right paraspinal area.

 


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  		Figure 14d.   Gossypiboma in a 64-year-old woman who had undergone right upper lobectomy for squamous cell carcinoma of the lung. (a, b) Intravenous contrast-enhanced serial CT scans (10-mm collimation, mediastinal windowing) obtained at the level of the aortic arch (b obtained 12 months after a) demonstrate the change in a soft-tissue lesion from a wall-enhancing, cystlike lesion to a solid-looking lesion. (c) Axial T2-weighted MR image obtained 62 months after a shows an oval mass with low signal intensity, a finding that suggests a fibrotic lesion. (d) Coronal contrast-enhanced T1-weighted MR image obtained at the same time as c shows a heterogeneous, moderately enhancing soft-tissue lesion in the right paraspinal area.

 
Previous CT studies have described the foreign body as a sharply defined, round mass with a high-attenuation central portion and an enhancing wall (28,29). The absence of central enhancement is likely due to a trapped clot within the sponge, and the peripheral enhancement is due to inflammatory reaction. Cystic masses with an infolded pattern strongly suggesting towels have also been described (30).

Lung Torsion
In postoperative torsion, rapidly progressing signs and symptoms with resultant infarction (shock, sepsis, deterioration of the patient) may appear. The mortality rate is high if the torsion goes unrecognized and surgical fixation or excision of the involved lobe is delayed (31). The degree of rotation in pulmonary torsion is generally 180°, although on occasion, 90°or 360° torsion has been recorded. Torsion of hilar structures and especially of the pulmonary veins leads to impaired circulation with reflux into the venous pathways, resulting in interstitial edema and alveolar exudation. Depending on the severity of the condition, a hemorrhagic infarction may develop (32).

CT findings in postoperative lobar torsion include tapered obliteration of the proximal pulmonary artery and accompanying bronchus of the involved lobe and amorphous soft-tissue attenuation at the hilum. The torsed lobe demonstrates poorly enhancing consolidation with increased volume, ground-glass attenuation, interlobular septal thickening, and intralobular linear attenuation. Neofissure following lobectomy demonstrates bulging and an unusual orientation (Fig 15). Early recognition of a postoperative lobar torsion is vital, and CT may be helpful in making an early confirmatory diagnosis.



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  		Figure 15a.   Right upper lobe torsion in a 55-year-old woman who had undergone right middle lobectomy for bronchioloalveolar carcinoma. (a) Chest radiograph obtained immediately after surgery shows chest tubes in the right hemithorax, subcutaneous emphysema in the right chest wall, and an epidural catheter in the sternal area. No significant abnormality is seen in the lungs. (b) Chest radiograph obtained 1 day later shows rapidly developing consolidation with volume expansion in the right upper lobe. A neofissure is seen bulging downward (arrow), indicating a volume increase in the right upper lobe. A small amount of right pleural effusion is also noted. One chest tube was subsequently removed. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the carinal level at the same time as b shows airspace consolidation in the right upper lobe without enhancement of the parenchyma or pulmonary vessels. Note also the posterior bulging of the neofissure (arrow). (d) CT scan obtained at the level of the bronchus intermedius shows obstruction of the right upper lobar pulmonary artery (arrow) with surrounding soft-tissue attenuation. Note also the thickening of the posterior wall of the bronchus intermedius (arrowhead). (e) Thin-section CT scan (1-mm collimation) obtained at the level of the aortic arch shows ground-glass attenuation and consolidation and interlobular septal thickening with volume expansion in the right upper lobe. A chest tube has been inserted (arrow). (f) Photograph of the gross specimen shows hemorrhagic infarction with congestion (arrows). (g) Photomicrograph (original magnification, x100; H-E stain) shows a torsed pulmonary artery (arrows) and venous congestion (arrowheads). (h) Photomicrograph (original magnification, x100; H-E stain) shows intra-alveolar hemorrhage (arrowheads) and diffuse edematous thickening of the interlobular septa (arrow).

 


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  		Figure 15b.   Right upper lobe torsion in a 55-year-old woman who had undergone right middle lobectomy for bronchioloalveolar carcinoma. (a) Chest radiograph obtained immediately after surgery shows chest tubes in the right hemithorax, subcutaneous emphysema in the right chest wall, and an epidural catheter in the sternal area. No significant abnormality is seen in the lungs. (b) Chest radiograph obtained 1 day later shows rapidly developing consolidation with volume expansion in the right upper lobe. A neofissure is seen bulging downward (arrow), indicating a volume increase in the right upper lobe. A small amount of right pleural effusion is also noted. One chest tube was subsequently removed. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the carinal level at the same time as b shows airspace consolidation in the right upper lobe without enhancement of the parenchyma or pulmonary vessels. Note also the posterior bulging of the neofissure (arrow). (d) CT scan obtained at the level of the bronchus intermedius shows obstruction of the right upper lobar pulmonary artery (arrow) with surrounding soft-tissue attenuation. Note also the thickening of the posterior wall of the bronchus intermedius (arrowhead). (e) Thin-section CT scan (1-mm collimation) obtained at the level of the aortic arch shows ground-glass attenuation and consolidation and interlobular septal thickening with volume expansion in the right upper lobe. A chest tube has been inserted (arrow). (f) Photograph of the gross specimen shows hemorrhagic infarction with congestion (arrows). (g) Photomicrograph (original magnification, x100; H-E stain) shows a torsed pulmonary artery (arrows) and venous congestion (arrowheads). (h) Photomicrograph (original magnification, x100; H-E stain) shows intra-alveolar hemorrhage (arrowheads) and diffuse edematous thickening of the interlobular septa (arrow).

 


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  		Figure 15c.   Right upper lobe torsion in a 55-year-old woman who had undergone right middle lobectomy for bronchioloalveolar carcinoma. (a) Chest radiograph obtained immediately after surgery shows chest tubes in the right hemithorax, subcutaneous emphysema in the right chest wall, and an epidural catheter in the sternal area. No significant abnormality is seen in the lungs. (b) Chest radiograph obtained 1 day later shows rapidly developing consolidation with volume expansion in the right upper lobe. A neofissure is seen bulging downward (arrow), indicating a volume increase in the right upper lobe. A small amount of right pleural effusion is also noted. One chest tube was subsequently removed. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the carinal level at the same time as b shows airspace consolidation in the right upper lobe without enhancement of the parenchyma or pulmonary vessels. Note also the posterior bulging of the neofissure (arrow). (d) CT scan obtained at the level of the bronchus intermedius shows obstruction of the right upper lobar pulmonary artery (arrow) with surrounding soft-tissue attenuation. Note also the thickening of the posterior wall of the bronchus intermedius (arrowhead). (e) Thin-section CT scan (1-mm collimation) obtained at the level of the aortic arch shows ground-glass attenuation and consolidation and interlobular septal thickening with volume expansion in the right upper lobe. A chest tube has been inserted (arrow). (f) Photograph of the gross specimen shows hemorrhagic infarction with congestion (arrows). (g) Photomicrograph (original magnification, x100; H-E stain) shows a torsed pulmonary artery (arrows) and venous congestion (arrowheads). (h) Photomicrograph (original magnification, x100; H-E stain) shows intra-alveolar hemorrhage (arrowheads) and diffuse edematous thickening of the interlobular septa (arrow).

 


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  		Figure 15d.   Right upper lobe torsion in a 55-year-old woman who had undergone right middle lobectomy for bronchioloalveolar carcinoma. (a) Chest radiograph obtained immediately after surgery shows chest tubes in the right hemithorax, subcutaneous emphysema in the right chest wall, and an epidural catheter in the sternal area. No significant abnormality is seen in the lungs. (b) Chest radiograph obtained 1 day later shows rapidly developing consolidation with volume expansion in the right upper lobe. A neofissure is seen bulging downward (arrow), indicating a volume increase in the right upper lobe. A small amount of right pleural effusion is also noted. One chest tube was subsequently removed. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the carinal level at the same time as b shows airspace consolidation in the right upper lobe without enhancement of the parenchyma or pulmonary vessels. Note also the posterior bulging of the neofissure (arrow). (d) CT scan obtained at the level of the bronchus intermedius shows obstruction of the right upper lobar pulmonary artery (arrow) with surrounding soft-tissue attenuation. Note also the thickening of the posterior wall of the bronchus intermedius (arrowhead). (e) Thin-section CT scan (1-mm collimation) obtained at the level of the aortic arch shows ground-glass attenuation and consolidation and interlobular septal thickening with volume expansion in the right upper lobe. A chest tube has been inserted (arrow). (f) Photograph of the gross specimen shows hemorrhagic infarction with congestion (arrows). (g) Photomicrograph (original magnification, x100; H-E stain) shows a torsed pulmonary artery (arrows) and venous congestion (arrowheads). (h) Photomicrograph (original magnification, x100; H-E stain) shows intra-alveolar hemorrhage (arrowheads) and diffuse edematous thickening of the interlobular septa (arrow).

 


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  		Figure 15e.   Right upper lobe torsion in a 55-year-old woman who had undergone right middle lobectomy for bronchioloalveolar carcinoma. (a) Chest radiograph obtained immediately after surgery shows chest tubes in the right hemithorax, subcutaneous emphysema in the right chest wall, and an epidural catheter in the sternal area. No significant abnormality is seen in the lungs. (b) Chest radiograph obtained 1 day later shows rapidly developing consolidation with volume expansion in the right upper lobe. A neofissure is seen bulging downward (arrow), indicating a volume increase in the right upper lobe. A small amount of right pleural effusion is also noted. One chest tube was subsequently removed. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the carinal level at the same time as b shows airspace consolidation in the right upper lobe without enhancement of the parenchyma or pulmonary vessels. Note also the posterior bulging of the neofissure (arrow). (d) CT scan obtained at the level of the bronchus intermedius shows obstruction of the right upper lobar pulmonary artery (arrow) with surrounding soft-tissue attenuation. Note also the thickening of the posterior wall of the bronchus intermedius (arrowhead). (e) Thin-section CT scan (1-mm collimation) obtained at the level of the aortic arch shows ground-glass attenuation and consolidation and interlobular septal thickening with volume expansion in the right upper lobe. A chest tube has been inserted (arrow). (f) Photograph of the gross specimen shows hemorrhagic infarction with congestion (arrows). (g) Photomicrograph (original magnification, x100; H-E stain) shows a torsed pulmonary artery (arrows) and venous congestion (arrowheads). (h) Photomicrograph (original magnification, x100; H-E stain) shows intra-alveolar hemorrhage (arrowheads) and diffuse edematous thickening of the interlobular septa (arrow).

 


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  		Figure 15f.   Right upper lobe torsion in a 55-year-old woman who had undergone right middle lobectomy for bronchioloalveolar carcinoma. (a) Chest radiograph obtained immediately after surgery shows chest tubes in the right hemithorax, subcutaneous emphysema in the right chest wall, and an epidural catheter in the sternal area. No significant abnormality is seen in the lungs. (b) Chest radiograph obtained 1 day later shows rapidly developing consolidation with volume expansion in the right upper lobe. A neofissure is seen bulging downward (arrow), indicating a volume increase in the right upper lobe. A small amount of right pleural effusion is also noted. One chest tube was subsequently removed. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the carinal level at the same time as b shows airspace consolidation in the right upper lobe without enhancement of the parenchyma or pulmonary vessels. Note also the posterior bulging of the neofissure (arrow). (d) CT scan obtained at the level of the bronchus intermedius shows obstruction of the right upper lobar pulmonary artery (arrow) with surrounding soft-tissue attenuation. Note also the thickening of the posterior wall of the bronchus intermedius (arrowhead). (e) Thin-section CT scan (1-mm collimation) obtained at the level of the aortic arch shows ground-glass attenuation and consolidation and interlobular septal thickening with volume expansion in the right upper lobe. A chest tube has been inserted (arrow). (f) Photograph of the gross specimen shows hemorrhagic infarction with congestion (arrows). (g) Photomicrograph (original magnification, x100; H-E stain) shows a torsed pulmonary artery (arrows) and venous congestion (arrowheads). (h) Photomicrograph (original magnification, x100; H-E stain) shows intra-alveolar hemorrhage (arrowheads) and diffuse edematous thickening of the interlobular septa (arrow).

 


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  		Figure 15g.   Right upper lobe torsion in a 55-year-old woman who had undergone right middle lobectomy for bronchioloalveolar carcinoma. (a) Chest radiograph obtained immediately after surgery shows chest tubes in the right hemithorax, subcutaneous emphysema in the right chest wall, and an epidural catheter in the sternal area. No significant abnormality is seen in the lungs. (b) Chest radiograph obtained 1 day later shows rapidly developing consolidation with volume expansion in the right upper lobe. A neofissure is seen bulging downward (arrow), indicating a volume increase in the right upper lobe. A small amount of right pleural effusion is also noted. One chest tube was subsequently removed. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the carinal level at the same time as b shows airspace consolidation in the right upper lobe without enhancement of the parenchyma or pulmonary vessels. Note also the posterior bulging of the neofissure (arrow). (d) CT scan obtained at the level of the bronchus intermedius shows obstruction of the right upper lobar pulmonary artery (arrow) with surrounding soft-tissue attenuation. Note also the thickening of the posterior wall of the bronchus intermedius (arrowhead). (e) Thin-section CT scan (1-mm collimation) obtained at the level of the aortic arch shows ground-glass attenuation and consolidation and interlobular septal thickening with volume expansion in the right upper lobe. A chest tube has been inserted (arrow). (f) Photograph of the gross specimen shows hemorrhagic infarction with congestion (arrows). (g) Photomicrograph (original magnification, x100; H-E stain) shows a torsed pulmonary artery (arrows) and venous congestion (arrowheads). (h) Photomicrograph (original magnification, x100; H-E stain) shows intra-alveolar hemorrhage (arrowheads) and diffuse edematous thickening of the interlobular septa (arrow).

 


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  		Figure 15h.   Right upper lobe torsion in a 55-year-old woman who had undergone right middle lobectomy for bronchioloalveolar carcinoma. (a) Chest radiograph obtained immediately after surgery shows chest tubes in the right hemithorax, subcutaneous emphysema in the right chest wall, and an epidural catheter in the sternal area. No significant abnormality is seen in the lungs. (b) Chest radiograph obtained 1 day later shows rapidly developing consolidation with volume expansion in the right upper lobe. A neofissure is seen bulging downward (arrow), indicating a volume increase in the right upper lobe. A small amount of right pleural effusion is also noted. One chest tube was subsequently removed. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the carinal level at the same time as b shows airspace consolidation in the right upper lobe without enhancement of the parenchyma or pulmonary vessels. Note also the posterior bulging of the neofissure (arrow). (d) CT scan obtained at the level of the bronchus intermedius shows obstruction of the right upper lobar pulmonary artery (arrow) with surrounding soft-tissue attenuation. Note also the thickening of the posterior wall of the bronchus intermedius (arrowhead). (e) Thin-section CT scan (1-mm collimation) obtained at the level of the aortic arch shows ground-glass attenuation and consolidation and interlobular septal thickening with volume expansion in the right upper lobe. A chest tube has been inserted (arrow). (f) Photograph of the gross specimen shows hemorrhagic infarction with congestion (arrows). (g) Photomicrograph (original magnification, x100; H-E stain) shows a torsed pulmonary artery (arrows) and venous congestion (arrowheads). (h) Photomicrograph (original magnification, x100; H-E stain) shows intra-alveolar hemorrhage (arrowheads) and diffuse edematous thickening of the interlobular septa (arrow).

 
Postpneumonectomy Syndrome
Postpneumonectomy syndrome, which consists of intrathoracic major airway compression, results from an exaggerated response to some pulmonary compensatory mechanisms after pulmonary resection (Fig 16) (33). The mechanism in postpneumonectomy syndrome consists of stretching of the intrathoracic airways of the remaining lung against fixed mediastinal structures. Risk factors for postpneumonectomy syndrome include the age and sex of the patient and the side on which surgery was performed (33). The symptoms of airway compression are more likely to occur in infants and young children. Most reported cases of postpneumonectomy syndrome have occurred after right pneumonectomy. Several anatomic factors may represent causes of this right-sided predominance. For example, right lung volume may exceed left lung volume, so that right pneumonectomy results in more mediastinal shifting toward the right side with the heart being displaced into the right hemithorax; consequently, there is a greater chance of airway compression between the mediastinal structures. Another possible cause is the left aortic arch. With right pneumonectomy and the resultant mediastinal shifting, the left main bronchus is stretched and pushed down by the left aortic arch and is then compressed inferiorly between the left pulmonary artery and the descending aorta. Left pneumonectomy syndrome is occasionally seen in patients with a right aortic arch. A third possible cause is an elongated left main bronchus, which may be more prone to compression (33). CT and bronchoscopy provide excellent documentation of airway compression (Fig 16). CT also provides information on the status of the postpneumonectomy space; the position of the mediastinal blood vessels, bronchi, and thoracic spine; and the specific site of bronchial obstruction (33).



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  		Figure 16a.   Postpneumonectomy syndrome in a 26-year-old woman who complained of sudden dyspnea after undergoing right pneumonectomy. (a, b) Unenhanced CT scans (3-mm collimation, mediastinal windowing) obtained at slightly different levels 7 months after surgery show compression of the distal trachea and left main bronchus by the left pulmonary artery anteriorly and the descending thoracic aorta posteriorly. Mediastinal shifting is predominantly toward the right hemithorax. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained after corrective surgery for right pneumonectomy syndrome shows a silicone bag placed in the right hemithorax for volume expansion (arrows) and a patent left main bronchus with a normalized luminal diameter.

 


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  		Figure 16b.   Postpneumonectomy syndrome in a 26-year-old woman who complained of sudden dyspnea after undergoing right pneumonectomy. (a, b) Unenhanced CT scans (3-mm collimation, mediastinal windowing) obtained at slightly different levels 7 months after surgery show compression of the distal trachea and left main bronchus by the left pulmonary artery anteriorly and the descending thoracic aorta posteriorly. Mediastinal shifting is predominantly toward the right hemithorax. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained after corrective surgery for right pneumonectomy syndrome shows a silicone bag placed in the right hemithorax for volume expansion (arrows) and a patent left main bronchus with a normalized luminal diameter.

 


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  		Figure 16c.   Postpneumonectomy syndrome in a 26-year-old woman who complained of sudden dyspnea after undergoing right pneumonectomy. (a, b) Unenhanced CT scans (3-mm collimation, mediastinal windowing) obtained at slightly different levels 7 months after surgery show compression of the distal trachea and left main bronchus by the left pulmonary artery anteriorly and the descending thoracic aorta posteriorly. Mediastinal shifting is predominantly toward the right hemithorax. (c) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained after corrective surgery for right pneumonectomy syndrome shows a silicone bag placed in the right hemithorax for volume expansion (arrows) and a patent left main bronchus with a normalized luminal diameter.

 
Esophagopleural Fistula
Esophagopleural fistula is a devastating pathologic condition that occurs in 0.2%–1.0% of patients who undergo pneumonectomy (34,35). Patients with esophagopleural fistula represent a very heterogeneous group because the condition can result from at least three different mechanisms: surgically-caused injury, mediastinal cancer recurrence, and chronic infection (34). Large lesions appear during the immediate postoperative period. A diagnosis of esophagopleural fistula is obvious when food particles appear in the drainage fluid. Smaller leaks may be difficult to detect and tend to cause chronic empyema. Cancer recurrence causes about one-half of all esophagopleural fistulas. Most of these fistulas occur during the first 2 years following cessation of cancer treatment, as does cancer recurrence (34,35).

The diagnosis and therapeutic management of esophagopleural fistula continue to present major problems. Diagnosis is usually confirmed at thoracic radiography. However, conventional radiography has limitations. A fistulous tract cannot be diagnosed until the empyema space contains air. Esophagography is another useful imaging modality. However, because orally administered contrast material that the patient ingests while in the upright position may fail to opacify a tiny fistulous tract, it is recommended that the patient be placed in the lateral decubitus position with the pneumonectomy side down (34). Standard and high-resolution CT are also useful in the diagnosis and management of esophagopleural fistula or of any tumor recurrence that creates a fistula at the bronchial stump (Fig 17).



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  		Figure 17a.   Esophagopleural fistula in a 48-year-old man who had undergone left pneumonectomy and mediastinal lymph node dissection for squamous cell carcinoma. (a) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the level of the bronchus intermedius 2 weeks after surgery shows a fistulous tract (arrow) between the air-filled dilated esophagus (*) and the left pleural space. (b) Esophagogram obtained 2 days later also shows the fistulous tract between the distal esophagus and the left pleural space. (Courtesy of Seon Young Yoo, MD, Korean Veterans Hospital, Seoul, Korea.)

 


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  		Figure 17b.   Esophagopleural fistula in a 48-year-old man who had undergone left pneumonectomy and mediastinal lymph node dissection for squamous cell carcinoma. (a) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) obtained at the level of the bronchus intermedius 2 weeks after surgery shows a fistulous tract (arrow) between the air-filled dilated esophagus (*) and the left pleural space. (b) Esophagogram obtained 2 days later also shows the fistulous tract between the distal esophagus and the left pleural space. (Courtesy of Seon Young Yoo, MD, Korean Veterans Hospital, Seoul, Korea.)

 

   Anastomotic Dehiscence
Top
 Abstract
 LEARNING OBJECTIVES FOR TEST...
 Introduction
 Pulmonary Resection Techniques
 Complications Following...
 Anastomotic Dehiscence
Conclusions
 References
 
Extended lymph node dissection for lung cancer increases the risk of bronchial wall ischemia and anastomotic dehiscence. Extended resection may also result in excessive tension on the bronchial suture line, leading to anastomotic dehiscence or stricture (36). Anastomotic dehiscence may manifest as an early airway complication, especially after sleeve lobectomy (up to 6% of cases) (5), and may lead to BPF or bronchovascular fistula (37).

The CT appearance of anastomotic dehiscence was reported by Semenkovich et al (38) in a study of 21 patients in whom this disease was bronchoscopically proved. The most sensitive and specific CT finding for anastomotic dehiscence was a defect in the bronchial wall. Extraluminal air surrounding the anastomosis was an equally sensitive but less specific finding. Bronchial irregularity and narrowing were less commonly seen.

Bronchial Anastomotic Stenosis
Bronchial anastomotic stenosis is a potentially serious complication and the most common late complication following sleeve resection, occurring in up to 18% of cases (5). This complication is due to interruption of the bronchial blood supply to the distal bronchial segment and partial anastomotic dehiscence with granulation (39). Postoperative radiography and CT demonstrate bronchial narrowing at the anastomotic site.

Local Tumor Recurrence
Local tumor recurrence includes ipsilateral mediastinal node metastasis, recurrence in the chest wall or parietal pleura (Fig 18), and recurrence at the surgical margin (Fig 19) (40). In a report by Spjut and Mateo (41), recurrence at the bronchial stump was seen in 2.2% of all cases of resected lung cancer. CT is valuable in demonstrating the recurrent mass. There may be tumor recurrence at the bronchial stump, even when the resected margin is sufficiently distant from the tumor and the surgical margin of the resected specimen is negative for cancer. The recurrent mass is always outside the organized fluid and soft-tissue reaction in the postpneumonectomy space and is commonly located at the site of the bronchial stump. If the recurrent mass is small, not well defined, or does not displace adjacent structures, differentiation from postsurgical fibrosis is difficult. Correlation with bronchoscopic findings and positron emission tomographic findings is helpful in verifying the presence of a recurrent mass. Repeat CT may be performed to evaluate the growth of the mass.



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  		Figure 18a.   Local tumor recurrence in a 70-year-old man who developed cough after undergoing left pneumonectomy for squamous cell carcinoma of the lung. (a) CT scan (7-mm collimation, mediastinal windowing) obtained 1 month after surgery shows no evidence of tumor recurrence. (b) Follow-up CT scan obtained 2 years later shows an enhancing soft-tissue mass in the stump site of the left main bronchial resection (arrow).

 


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  		Figure 18b.   Local tumor recurrence in a 70-year-old man who developed cough after undergoing left pneumonectomy for squamous cell carcinoma of the lung. (a) CT scan (7-mm collimation, mediastinal windowing) obtained 1 month after surgery shows no evidence of tumor recurrence. (b) Follow-up CT scan obtained 2 years later shows an enhancing soft-tissue mass in the stump site of the left main bronchial resection (arrow).

 


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  		Figure 19a.   Local tumor recurrence in a 65-year-old woman who developed chest wall pain after undergoing left pneumonectomy for sarcoma of the pulmonary artery and vein. (a) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) shows a 3.5-cm mass in the left lower lobe with obliteration of the left lower lobar pulmonary artery. The tumor was located primarily in this artery. (b) Follow-up CT scan obtained 18 months later shows a recurrent mass in the left posterior chest wall (arrow).

 


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  		Figure 19b.   Local tumor recurrence in a 65-year-old woman who developed chest wall pain after undergoing left pneumonectomy for sarcoma of the pulmonary artery and vein. (a) Intravenous contrast-enhanced CT scan (7-mm collimation, mediastinal windowing) shows a 3.5-cm mass in the left lower lobe with obliteration of the left lower lobar pulmonary artery. The tumor was located primarily in this artery. (b) Follow-up CT scan obtained 18 months later shows a recurrent mass in the left posterior chest wall (arrow).

 
Cardiac Herniation with Torsion
Cardiac herniation with subsequent torsion is a very rare postpneumonectomy complication that requires urgent reduction. Most cases of cardiac herniation are the result of prolapse of the heart through the pericardial defect created at the time of surgery. The most common cause of cardiac herniation is an intrapericardial pneumonectomy without closure of the defect. A rare case that occurred after lobectomy has also been reported (42). Cardiac herniation occurs independent of the size of the surgically created pericardial defect and shows no side predilection. It occurs most often after pneumonectomy, which creates a large dead space with negative pressure for herniation. Cardiac herniation may involve acute angulation laterally with the apex touching the lateral chest wall, or there may be lateral posterior rotation, placing the apex in the region of the posterior costophrenic sulcus (13). Air may outline the empty pericardial space (2). On the right side, the heart comes out of the pericardial sac and rotates in a counterclockwise manner around the axis of the vena cava, which produces superior vena cava syndrome of the upper half of the body. On the left side, the ventricles come out through a medium-sized pericardial defect into the left pleural cavity and are strangulated by the edge of the pericardial sac.

In right-sided herniation, the shadow of the herniated heart can easily be seen in the vacant right pleural cavity at chest radiography and is easily recognizable and pathognomonic. In left-sided herniation, the ventricular mass lies horizontally across the diaphragm, giving the mass a "flattened boot" shape, and the cardiac shadow is not seen to the right of the spine (43).


   Conclusions
Top
 Abstract
 LEARNING OBJECTIVES FOR TEST...
 Introduction
 Pulmonary Resection Techniques
 Complications Following...
 Anastomotic Dehiscence
 Conclusions
References
 
The radiologist plays a major role in the diagnosis of various complications following pulmonary resection. The relatively low diagnostic accuracy of chest radiography may be improved by familiarity with the clinical settings in which specific complications are likely to occur. Knowledge of the diverse radiographic appearances of complications that follow pulmonary resection should lead to improved recognition of these complications, several of which may be life-threatening and require prompt management. When radiographic findings are subtle or equivocal, CT frequently allows more accurate identification of the disease process as well as prompt and appropriate treatment.


   Footnotes
 
Abbreviations: BPF = bronchopleural fistula, H-E = hematoxylin-eosin


   References
Top
 Abstract
 LEARNING OBJECTIVES FOR TEST...
 Introduction
 Pulmonary Resection Techniques
 Complications Following...
 Anastomotic Dehiscence
 Conclusions
 References
 

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