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Abstract
To document the postlobectomy radiographic and computed tomographic (CT) appearance of neofissures of the right lung.
Chest radiographs and CT scans from 25 patients who had undergone right lobectomy were assessed by two chest radiologists, and decisions on the findings were reached by consensus. Analyses included orientation of the neofissure and lobar reorientation of the remaining lobes.
Neofissure location after right upper lobectomy (n = 13) was superior and anterior compared with the location of the left major fissure on both lateral radiographs and CT scans. After right middle lobectomy (n = 4), the neofissure had less vertical orientation than the left major fissure (the highest posterior portion was lower and the lowest anterior portion was higher than the left major fissure) on both lateral radiographs and CT scans. After right lower lobectomy (n = 8), two types of lobar reorientation and, accordingly, two types of neofissure were observed in the right lower lung zone (posteriorly and anteriorly high, respectively, on lateral radiographs).
Analyses of neofissures on lateral radiographs and CT scans enable differentiation among various kinds of lobectomy.
Lung cancer is currently the most common malignancy in the world. A lobectomy is the gold standard of care for most patients with an operable lung cancer and accounts for 60-70% of lung resection. The chest radiograph may appear normal after a lobectomy, particularly in uncomplicated cases. However, lobectomy usually leaves the surgical staples at the bronchial stump and causes various changes in the intra- and extrapulmonary thoracic structures on plain radiographs. These changes may differ according to the resected lobe. We retrospectively evaluated the plain radiographic appearances of the post-lobectomy chest, free of postoperative complications or recurrent/metastatic lung cancer. Based on our observations, the changes that occur in pulmonary and extrapulmonary anatomy can differ according to the resected lobe. Recognition of these changes will make it easier to identify which lobe has been removed surgically.
To provide a quantitative analysis of postlobectomy chest radiographic changes and to evaluate whether the scarring from prior sternotomy affects the size of the hemithorax and the duration of air leak in patients with subsequent lobectomy.
In this retrospective case-controlled series, 10 consecutive patients who had a lobectomy after a prior sternotomy and 30 controls, 3 for each case, matched for lobectomy site were identified. Pre- and postoperative chest radiographs were quantitatively analysed for diaphragmic elevation, size of each hemithorax, mediastinal shift, and the presence of pneumothorax. Charts were reviewed for air-leak duration, surgical complications, and duration of hospitalization.
There was no difference between patients with lobectomy and with and without prior sternotomy for the following variables expressed as mean (SD): hemidiaphragm elevation (1.5 ± 2.5 vs 0.5 ± 2.0 cm; P = .2), change of hemithorax size (mean transverse, 0.99 ± 0.05 vs 0.97 ± 0.07; P = .5; craniocaudal, 0.93 ± 0.08 vs 0.91 ± 0.08; P = .4) and mediastinal shift (upper, 1.2 ± 0.4 vs 1.3 ± 0.6; P = .5; lower, 1.2 ± 0.4 vs 1.2 ± 0.3; P = .8), the latter 2 were expressed as the ratio of post- to preoperative measurements. These postlobectomy radiographic findings varied, depending on the resected lobe, and became progressively more pronounced during the first 12 months after surgery. There was no difference in pneumothorax duration (mean [SD]) (9.5 ± 21 days vs 6.4 ± 7.5 days; P = .5), air leak duration (mean [SD]) (0.7 ± 0.8 days vs 1.3 ± 3.9 days; P = .6), complication rate (20% vs 30%; P = .5), or hospital stay (mean [SD]) (6.0 ± 1.7 days vs 6.9 ± 4.7 days; P = .6).
There are specific patterns of volume loss, mediastinal shift, and hemidiaphragm displacement that can be quantified on postlobectomy chest radiographs. Prior sternotomy did not affect postlobectomy radiographic changes or patient outcome.
The purpose of this study was to evaluate postsurgical changes in the tracheal bifurcation angle on chest radiographs after upper lobectomy and to determine whether bronchial repositioning after upper lobectomy mimics that in upper lobe collapse.
The authors selected 81 patients who had undergone upper lobectomy with complete mediastinal and subcarinal lymph node dissection and in whom chest radiographs had been obtained before operation and at four postoperative intervals. The interbronchial angle and the subcarinal angle were measured on the preoperative and postoperative radiographs and compared statistically.
The average interbronchial angle and subcarinal angle during any postoperative period were significantly smaller than those before lobectomy (P < .001). These average angles decreased gradually during the postoperative periods.
The tracheal bifurcation angle was decreased on follow-up chest radiographs in most patients who underwent upper lobectomy with mediastinal lymph node dissection. This finding may be useful for establishing a history of this surgical procedure on the basis of chest radiographs.
Radiographic and computed tomographic (CT) examinations of the chest in four patients with collapse of the right middle lobe of the lung after lobectomy of the right upper lobe were reviewed. The diagnosis of collapse was made on the basis of findings of increased density in the right middle lobe and volume loss evidenced by displacement of the neofissure seen at CT. Plain radiographic findings included opacity in the right hilar and paramediastinal areas in all four patients, with smooth margination simulating mediastinal widening in three.
Following lobectomy of the right upper lobe of the lung, a single fissure, the neofissure, separates the right middle and lower lobes. In 25 patients in whom chest radiographs and computed tomographic (CT) scans were obtained after right upper lobectomy, the neofissure was identifiable to some extent on the radiographs in seven (28%) and on CT scans in 24 (96%). Among those patients in whom the neofissure was seen in its entirety, in 12 of 20 (60%) it was oriented predominantly in the coronal plane, paralleling the course of the original major fissure but displaced anteriorly and superiorly. In seven of 20 patients (35%) the superior aspect was coronal, rotated clockwise toward the sagittal plane inferiorly. In one of 20 patients (5%) the neofissure was oriented predominantly in the sagittal plane. The right middle lobe lies anterior and medial to the neofissure; the right lower lobe lies posterior and lateral.
The authors present a systematic review of the changes that occur in pulmonary and extrapulmonary anatomy as the result of lobar collapse or resection. Differences in the changes produced by lobectomy and lobar collapse are noted.
A case of middle lobe torsion occurring after a right upper lobectomy is described. The appearance of a wedge-shaped opacity with a characteristically positioned oblique fissure should alert the radiologist to the possibility of torsion. The combination of radiographic, bronchoscopic, and clinical findings should direct the clinician to the correct diagnosis.
The inferior pulmonary ligament is unfamiliar to most radiologists because it blends with the mediastinum and is not visualized on the normal chest roentgenogram. The thoracic surgeon, however, encounters this structure during operative procedures involving the lower part of the thorax. Although the ligament does not affect the normally functioning lung, it does exert a restrictive influence under certain pathological circumstances and can affect the resultant roentgen appearance of the chest. In these instances, the ligament itself may become visible. It is the purpose of this paper to clarify the anatomy of this structure and its appearance in various disease states. Anatomy The inferior pulmonary ligament (5) consists of a double serosal sheath connecting the visceral pleura on the medial surface of the lower lobe of each lung to the parietal pleura covering the mediastinum (Fig. 1). It extends downward in a sheet-like manner from the inferior margin of the pulmonary hilus to the diaphragm and loosely ...