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Ann Thorac Surg 1996;61:1092-1098
© 1996 The Society of Thoracic Surgeons
Departments of Surgery, Medicine, and Anesthesiology, Saint Louis University Health Sciences Center, St. Louis, Missouri
Accepted for publication December 23, 1995.
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Abstract |
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 TopFootnotes Abstract IntroductionPatients and MethodsResultsCommentReferences |
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Methods. Unilateral video-assisted thoracic surgical lung reduction was performed on 50 patients for the treatment of end-stage emphysema. There were 34 men and 16 women with a mean age of 61.5 years (range, 31 to 78 years). Emphysema was secondary to smoking in 45 patients (90%), and 
1-antitrypsin deficiency in 5 patients (10%), 4 of whom had smoked in the past. Lung reduction was performed unilaterally using a thoracoscope and a stapled resection without the routine use of bovine pericardium. The side to be operated on and site of resection were determined preoperatively by examination of the perfusion and computed tomographic scans of the lungs. The average amount of lung removed was 59 ± 15 g (range, 29 to 111 g).
Results. Morbidity included prolonged air leak in 15 patients (30%), bleeding in 3 (6%), pneumonia requiring reintubation in 3 (6%), myocardial infarction in 1 (2%), and perforated ulcer in 1 (2%). Seven patients (14%) required a second thoracic procedure for management of these complications. Two patients died, for an operative mortality of 4%. Follow-up obtained between 1 and 3 months in 25 patients revealed significant improvement in forced expiratory volume in 1 second (0.71 to 0.95 L; p < 0.001), forced vital capacity (2.24 to 2.58 L; p < 0.01), and oxygen tension (59 to 67 mm Hg; p < 0.01). The improvement in functional capacity as measured by 6-minute walk approached statistical significance (771 to 923 ft; p = 0.06).
Conclusions. Significant subjective improvement in dyspnea has been noted in 41 of 48 hospital survivors (85%). For patients with end-stage emphysema, unilateral video-assisted thoracic surgical lung reduction appears to be a preferable alternative to standard medical management.
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Introduction |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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In 1959, Brantigan and colleagues [5] reported yet another surgical approach for emphysema. This entailed multiple small resections, which reduced the overall size of the lung. Brantigan and colleagues thought that the remaining lung would re-expand to fill the enlarged chest cavity, and in doing so help to prevent the early collapse of the terminal airways, which results in obstructive disease. Although patients enjoyed significant subjective improvement, the tools to measure enhanced lung function were not yet available, lung transplantation appeared to be on the horizon, and this procedure was not widely adopted. More recently, the thoracoscopic application of laser energy to the surface of the lung has been used to ``shrink'' the lungs for patients with bullous emphysema, and thus improve respiratory function. Although there was purported to be significant subjective functional improvement, these efforts were not widely appreciated or adopted due to a lack of published data [6] or small patient numbers [7].
Recently, Cooper and colleagues [8] resurrected the technique espoused by Brantigan and colleagues with some significant changes. Their approach involves a sternotomy, which allows for bilateral simultaneous lung reduction through an incision less painful than a thoracotomy. The early results for this approach appear quite encouraging, and it is now being performed across the country. In an attempt to achieve similar improvement with lesser morbidity, we decided to undertake lung reduction using the video-assisted thoracic surgical (VATS) approach unilaterally. This study details the results of our initial experience.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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60 mm Hg) Once accepted as candidates, patients were enrolled in a monitored pulmonary rehabilitation program with emphasis on improving their conditioning, upper body strength, and exercise tolerance. For those patients receiving steroids, the referring pulmonologist was encouraged to wean the patient from steroid medication as much as possible. Those patients who appeared cachectic or had indicators of poor nutrition in their serum chemistry were given nutritional supplementation.
Once the patient was thought to have reached his or her maximal level in rehabilitation, the patient was scheduled for final preoperative testing, which included full pulmonary function tests with plethysmography, room air blood gas, 6-minute walk, and exercise stress test. Patients were then scheduled electively for operation.
Operative management included placement of an arterial line, peripheral intravenous line, central venous access, and urinary catheter. The first 25 patients also had a pulmonary artery catheter with oximetric capability placed for routine monitoring purposes. Thereafter, such catheters were used selectively. End-tidal volume capnography and pulse oximetry were constantly monitored. The choice of which side to operate on hinged on the differential ventilation/perfusion scan and chest computed tomography. The intention was to operate on the ``worse'' side first while supporting the patient's ventilation using the ``better'' lung. The worse side was identified by evaluating the relative perfusion of the right and left lung using a 55:45 (right:left) ratio as normal. Once the side was selected, the site for lung excision was targeted by identifying the least perfused area as determined by multiple views of the lung perfusion scan. This usually coincided with the site of xenon isotope gas retention during the ventilation scan washout phase and with the maximal structural changes as depicted on the computed tomographic scan.
General anesthesia was induced with sodium pentothal and maintained with isoflurane inhalation. A left-sided double-lumen tube was placed and its position confirmed bronchoscopically. Hemodynamic monitoring included an arterial line in all patients and a pulmonary artery thermodilution catheter in the first 25 patients. Thereafter, the pulmonary artery catheter was used infrequently at the discretion of the anesthesiologist. The patient was then placed in the lateral decubitus position, and prepared and draped as if for thoracotomy. In general, three trocar port sites were fashioned, each approximately 2 cm. These were located in the fifth or sixth intercostal space in the anterior and midaxillary line, and in the sixth or seventh intercostal space in the posterior axillary line. In rare patients, an incision was lengthened to 3 to 4 cm to allow simultaneous placement of two instruments through the same incision. Carbon dioxide insufflation at 10 mm Hg pressure was routinely used to aid in lung collapse, and was well tolerated by most patients. In those few patients in whom hypotension resulted from insufflation it was discontinued. The procedures were performed using a 0-degree 10-mm rigid thoracoscope with a one-chip camera. The ``target'' area of lung was identified, lifted with a sponge forceps, and excised using an endoscopic stapling device (Endo GIA 60 or EZ45 Endostapler; Ethicon Endosurgery, Inc, Cincinnati, OH). Bovine pericardium (Periguard; Biovascular, St. Paul, MN) was not routinely used to buttress the staple line. Early in the experience, multiple wedges or strips of lung were excised individually. This technique has evolved throughout the experience, and presently the goal is to excise a single strip of lung comprising approximately 20% to 25% of the volume of the lung. The average weight of lung tissue removed was 59 ± 15 g (range, 29 to 111 g). For patients with upper lobe disease, we try to excise a ``hockey stick'' shaped portion of lung so that the remaining lung will conform to and fill the apical portion of the selected hemithorax. For patients with diseases in the bases we resect portions of the basilar segments of the lower lobes, the inferior portion of the lingula or middle lobe, or both, allowing the diaphragm to rise and conform to the underside of the remaining lung (Fig 1
). The resected lung is usually removed through the anterior trocar site, as the intercostal space is largest in that area. Saline solution is then introduced into the chest until the staple line is immersed and the lung is slowly expanded, and the staple line is tested at 10, 15 and 20 cm H2O of continuous positive pressure. When air leaks are identified, they are stapled with or without bovine pericardium buttress. Sites of air leaks not amenable to direct stapling (ie, deep in the fissure) are treated with either an endoscopically fashioned pleural flap or fibrin glue instillation, or both. Two 28F or 32F chest tubes are then placed in the anterior and posterior aspects of the apex of the hemithorax. For patients undergoing basilar resection, an additional right-angled chest tube was also left along the diaphragm. These tubes are connected to a chest drainage system at -10 cm H2O suction. If no air leak or only a small to moderate leak was noted, this was converted to waterseal in the recovery room. The time of operation varied from 65 to 200 minutes.
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Statistical analysis consisted of a paired Student's t test for continuous variables. A p value less than 0.05 was considered significant.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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1-antitrypsin deficiency in 5 patients (10%). At the time of evaluation, 17 patients (34%) were on daily oral steroid regimens, and 37 patients (74%) required oxygen supplementation (27 patients continuously, 10 during exercise and at night). Prior thoracic operations included thoracotomy in 2 patients (drainage in 1, lobectomy in 1) for the treatment of tuberculosis. Three patients were on the recipient list awaiting lung transplantation.
Preoperative Profile
The preoperative profile for all 50 patients is depicted in Table 1. Patients accepted into the study were extremely compromised, with an average FEV1 of 26% of predicted and an average room air resting arterial oxygen tension of 64 mm Hg (90% saturation) in 48 patients. Two patients could not tolerate having their oxygen removed for blood gas determination.
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. There were two operative deaths (4%). One 69-year-old woman underwent an uneventful lung reduction and was extubated and conversing with her family 6 hours after the operation when she complained of chest pain and became hypotensive. Despite aggressive resuscitation she died within 1 hour. Postmortem examination revealed an acute myocardial infarction and significant unsuspected coronary disease, which was not manifest in the electrocardiographic tracings during her pulmonary stress test. The second patient was a 65-year-old man in whom a large air leak was present postoperatively. The lung remaining after the reduction procedure did not expand to fill his thorax. Despite a second attempt at controlling air leaks via an axillary thoracotomy, the leak persisted and pneumonia developed, which necessitated mechanical ventilation. After resolution of the pneumonia and performance of a tracheostomy, the family requested transfer back to a chronic ventilator facility for weaning from mechanical ventilation. He was transferred to such a facility 8 weeks after his initial procedure, and died in that facility.
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Posthospitalization Events
Of the 48 hospital survivors, 5 (10%) required a second admission for late complication. In 2 patients (4%) pneumococcal pneumonia developed at 1 and 3 months after discharge. In the latter patient, the pneumonia developed in the nonreduced lung and progressed despite antibiotic therapy, and the patient died 4 months after lung reduction. Thus the 60- and 90-day mortalities are 4%, identical to the figure for operative mortality. The second patient with pneumonia was treated with intravenous antibiotics and discharged. The remaining 3 late morbidity patients (6%) were readmitted for spontaneous pneumothorax on the operative side within 3 months of follow-up. In all 3 patients tube thoracostomy was required, and pneumonia also developed in 2 of these patients during their readmission.
Seven patients (15%) have subsequently undergone additional thoracic surgical procedures. Five patients who enjoyed significant subjective and objective postoperative improvement have returned and undergone VATS lung reduction on the contralateral lung (mean interval, 3.5 months) with no operative mortality. One of these 5 patients had been on the transplant list at the time of his original procedure and was 57 years old after his second lung reduction. Despite significant objective and subjective improvement, he still required 1 L of oxygen per minute (down from 4 L/min). Because he was near the cutoff for age for lung transplantation, it was decided he should proceed with transplantation, and this occurred 13 months after his original operation. A second patient was also bridged to transplantation, which occurred 3 months after his lung reduction.
Three-Month Follow-up
Twenty-five hospital survivors have been followed up for at least 3 months since operation. Preoperatively, 21 of 25 (84%) required oxygen continuously or with exertion. Currently, 10 of these 21 patients (48%) are not receiving oxygen, 3 (14%) have decreased their rate to 1 L/min, and 7 (33%) continue to receive O2 unchanged from their preoperative rate. The last patient was successfully bridged to transplantation and does not receive oxygen.
Sixteen patients have returned for follow-up testing at 3 months, and an additional 9 patients have not yet reached 3 months of follow-up but have had spirometric data obtained between 1 and 3 months after their procedure. Results of pulmonary function testing, blood gas determination, and functional tests are shown in Table 3. At 3 months there have been significant improvements in expiratory flow, vital capacity, resting oxygen tension, and functional capacity as determined by a 6-minute walk.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Excellent results with low morbidity have been reported for bilateral simultaneous lung reduction via the sternotomy approach [8]. Unfortunately, these are quite fragile patients and a bilateral open approach can be a significant surgical insult to such patients. Not all programs have been able to reproduce this low operative mortality [12]. It was our intention to undertake this procedure using a unilateral VATS approach in hopes that this minimally invasive approach might decrease perioperative morbidity.
Cooper and associates [8] also considered this approach, but decided against it for several reasons. First, they thought it important to be able to palpate and examine all areas of the lung before selecting areas for resection. Although we visualize all areas of the lung using the VATS approach, we do not believe that palpation or visual inspection plays a significant role in the selection of areas for resection. Our choice of target zones is directed primarily by the perfusion scan, which is obtained in multiple views (anterior, posterior, lateral, and oblique). We resect those areas of lung that are least well perfused, on the assumption that nonperfused lung is nonfunctional lung and therefore expendable. Thus, intraoperative inspection plays little role in our site selection. A second rationale for the open approach is the ability to more easily detect and secure sites of air leak. Indeed, the VATS approach does have a learning curve and it can be somewhat more difficult to accomplish these tasks thoracoscopically, but it can be achieved with experience. Cooper and associates [8] noted a 55% incidence of prolonged (>7 days) air leak in their original report, but early in that experience began using bovine pericardium to minimize this problem. However, a recent report by other investigators also notes a prolonged air leak in more than 50% of patients when using the bilateral open approach [12]. Our prolonged air leak incidence of 30% compares favorably with these reports; however, it must be remembered that whereas we operated unilaterally, the sternotomy procedure treats both lungs simultaneously, which results in a doubling of the risk potential for air leak. Thus, although it is inappropriate to directly compare these two approaches, it seems reasonable to conclude that prolonged air leaks are still a problem regardless of the approach. The question of whether or not bovine pericardium can really decrease the incidence and frequency of air leaks must await the results of a prospective, randomized trial currently underway.
Other complications occur frequently. Our 16% rate of reoperation appears similar to the 18% [12] and 20% [8] reported by others, whereas our 6% incidence of pneumonia (defined as pulmonary infiltrate with either fever, elevated white blood cell count, or purulent sputum production) is lower than others. Thus, we believe that the unilateral VATS approach has a relatively low morbidity that is equal and in some cases superior to that reported for the open bilateral approach. Our operative mortality (4%) also appears acceptable despite an older, more fragile patient population with inferior functional status as measured by the 6-minute walk.
The other major issue to be dealt with is efficacy of the unilateral procedure. It has been suggested that a bilateral approach should be undertaken to ensure maximal improvement with a single operation [8]. The hypothesis is that operating on both sides will allow the chest cage to come back more toward its normal configuration, whereas a unilateral reduction will lead to persistent expansion of the nonoperated side, which will prevent chest wall remodeling. Indeed, our initial plan was to perform sequential unilateral VATS procedures 3 to 6 months apart with the intent of reducing both lungs. However, it became apparent that a second procedure would not be needed (or agreed to) by some individuals who noted marked improvement after a unilateral operation. Figure 2 depicts the chest roentgenographic appearance in 1 of our 1-antitrypsin patients before and after unilateral lung reduction. Significant remodeling with an elevated diaphragm and decreased anteroposterior chest diameter can be appreciated. Simultaneous bilateral VATS lung reduction procedures can certainly be undertaken, and are currently being performed [13]; however, it appears that in some patients bilateral procedures may not be required or indicated.
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Although comparing numbers and values is quite easy to do, it can be difficult to identify who has truly improved. If the FEV1 increases significantly in a patient but there is no improvement in dyspnea or functional capacity, can this be called a success? Conversely, if oxygen requirements and quality of life indicators significantly improve but FEV1 and functional capacity do not change, can this really be labeled a failure? Because of the multitude of measurable parameters and the lack of reliability of any single parameter to indicate benefit, we have used a scoring system to determine whether a procedure is successful. Two parameters each dealing with spirometry, gas transfer, and functional capacity are assessed (Table 4). The two parameters within each of the three groups were selected so as to be as independent as possible from one another. A single point is assigned for each criterion met, and a sum of 3 points is necessary for an operation to be considered successful. This means that significant improvement must be obtained in at least two of the three areas (spirometry, oxygenation, functional status) for determination of a successful outcome. Conversely, not all three areas are required to demonstrate improvement to avoid the label of ``failure.'' When the system was applied to 15 of the 16 patients 3 months postoperatively (1 of the 16 had been bridged to transplantation), 11 (73%) were judged to be successful procedures. If meaningful comparisons are to be made both within and between programs, this or some similar scoring system will have to be used to allow systematic and reproducible comparisons.
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We believe it is important to emphasize that it is the procedure performed (lung resection) and not the operative approach that is critical to the success of the operation. The concept of partial lung resection or volume reduction first espoused by Brantigan and colleagues and recently popularized by Cooper and colleagues has been validated by these results, and those of other investigators. It is our belief that sternotomy, thoracoscopy, and perhaps even muscle-sparing thoracotomy will all prove useful in the future for specific patient subsets. Eventually it is likely that the clinical profile of the patient rather than the operative experience of the surgeon will determine which procedure is most appropriate for that individual. However, ongoing studies must be performed in a careful, prospective fashion so that meaningful and valid information can be obtained and clinical guidelines fashioned.
Due to the lack of patient numbers and short follow-up, the duration of benefit and the effect on long-term survival cannot yet be determined. What is certain is that lung volume reduction, whether performed via an open or a thoracoscopic approach, provides significant subjective and objective improvement in the short term. Improvements in spirometry, oxygenation, dyspnea, and functional capacity can be documented. There is no doubt that a significant quality of life improvement does occur.
Many questions remain to be answered. Will 1-antitrypsin deficiency patients benefit from lung reduction in a fashion similar to those with emphysema secondary to smoking? Is there an age limit for these procedures? What will be the duration of the benefit obtained, and will survival be prolonged? Which approach (open versus VATS) will prove advantageous for which patient subset? Will the operation prove to be cost-effective by decreasing the incidence of hospitalization? It is hoped that future investigations will answer these questions and confirm the promise of these techniques for emphysema patients.
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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J. D. Cooper, G. A. Patterson, R. S. Sundaresan, E. P. Trulock, R. D. Yusen, M. S. Pohl, and S. S. Lefrak RESULTS OF 150 CONSECUTIVE BILATERAL LUNG VOLUME REDUCTION PROCEDURES IN PATIENTS WITH SEVERE EMPHYSEMA J. Thorac. Cardiovasc. Surg., November 1, 1996; 112(5): 1319 - 1330. [Abstract] [Full Text]
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K. S. Naunheim and M. K. Ferguson The Current Status of Lung Volume Reduction Operations for Emphysema Ann. Thorac. Surg., August 1, 1996; 62(2): 601 - 612. [Abstract] [Full Text]
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