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Ann Thorac Surg 1996;61:1464-1468
© 1996 The Society of Thoracic Surgeons
Division of General Thoracic Surgery, Section of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. From August 1, 1994, to August 1, 1995, 53 patients underwent lung volume reduction at Emory University for generalized emphysema. There were 17 women and 36 men ranging in age from 55 to 75 years. The length of stay ranged from 10 to 59 days. At the time of presentation, 47 patients were receiving oxygen and 35 were receiving steroids. Forty-six patients were operated on using a median sternotomy and 7 through a unilateral thoracotomy. All patients underwent preoperative and postoperative pulmonary rehabilitation.
Results. There was one early death and four late deaths. Lessons learned from this group of patients are presented.
Conclusions. Lung volume reduction surgery remains a sea of relatively uncharted waters, with the future direction yet to be determined.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Lung volume reduction surgery was originally proposed by Otto Brantigan in 1958 [1]. Although their initial results were encouraging, the operative mortality was significant and enthusiasm for this operation waned. Cooper and colleagues [2] reintroduced the concept of lung volume reduction surgery in April 1994 and published their results in 1995 [2]. They demonstrated that with improved anesthetic technique, pain control, pulmonary rehabilitation, and improvement in surgical instrumentation, lung volume reduction operations could be performed with low mortality and expected good physiologic results [2]. This report details our initial 1-year experience with 6-month follow-up and the lessons learned regarding lung volume reduction surgery.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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From July 26, 1994, to August 1, 1995, 53 patients underwent lung volume reduction operations at affiliated hospitals of Emory University for advanced generalized emphysema. There were 17 women and 36 men ranging in age from 55 to 75 years, with a mean of 67 years. The length of stay varied from 10 to 59 days, with 15 patients requiring hospitalization greater than 15 days and 38 patients being discharged before or at 15 days. At the time of presentation, 47 patients were receiving oxygen and 35 were receiving steroids. All patients were evaluated by a detailed selection process and underwent 6 weeks of pulmonary rehabilitation before operation. Forty-six patients were operated on through a median sternotomy and 7 through a unilateral thoracotomy.
Criteria for inclusion in the program included the following: advanced generalized emphysema, no bullae greater than 5 cm, failure of maximum medical therapy, age less than 75 years, spirometry and arterial blood gases with a forced expiratory volume in 1 second (FEV1) less than 30% of predicted; a carbon dioxide tension less than or equal to 50 mm Hg, an oxygen tension greater than 40 mm Hg on room air, no significant coronary artery disease, no major psychiatric problems, no life-threatening illnesses, the ability to perform pulmonary rehabilitation, the abstinence from all tobacco for a minimum of 6 months, prednisone dosages less than 15 mg/day, and the absence of generalized osteoporosis. Patients were excluded if any of the following were present: predominant bullous emphysema, present smoking, too good physiologic state, significant coronary artery disease (blockage of >70% luminal diameter of a coronary artery not amenable to angioplasty), pulmonary hypertension with a mean pressure greater than 35 mm Hg or systolic pressure greater than 45 mm Hg, the inability to participate in pulmonary rehabilitation, prednisone dosage greater than 15 mg/day, use of multiple psychiatric drugs, significant bronchitis or asthma, or previous pulmonary operation or sclerosis.
All patients underwent a standard workup, which included a complete history and physical, spirometry with arterial blood gases, a 6-minute walk test, a high-resolution computed tomographic scan of the chest, split ventilation and perfusion lung scan with total and lobar counts, inspiratory and expiratory chest roentgenography, pulmonary rehabilitation consultation with targeted goals, dobutamine stress echocardiography, and right heart catheterization. Left heart catheterization was performed if indicated on the dobutamine stress echocardiogram.
Radiographic criteria included a routine chest roentgenogram hyperinflation with flattened diaphragms, the presence of generalized emphysema, and no significant bullous component. On computed tomographic scan, heterogeneous generalized emphysema was looked for with no bullae greater than 5 cm. On perfusion lung scan, targeted areas of heterogenicity of disease with nonfunctioning lung were those best suited for resection. In certain cases, nonheterogenicity was accepted when all other criteria were appropriate.
All patients underwent preoperative pulmonary rehabilitation and were entered into exercise programs similar to those instituted at St. Louis [3]. The patients underwent three types of exercises: exercise arm ergometry, stationary bicycle, and an exercise treadmill. Ergometry strengthened the upper extremities, whereas the stationary bike and treadmill improved overall endurance and lower extremity strength. Exercise programs were established throughout the state of Georgia and in the surrounding southern states. Patients were initially seen at Emory University Medical Center and then referred to their home areas for the performance of the pulmonary rehabilitation. They were then seen again at Emory, with operation subsequently performed. The exercise program was divided into two parts: that during the first 6 months and that during the last 6 months. During the first 6 months, it became apparent that patients were exercising and going through rehabilitation without having met specific target goals. It became our opinion that the patients must be able to perform 30 minutes consecutively on the bicycle and treadmill to achieve a physiologic good result. Therefore, beginning in March 1995, no patient was accepted for operation who could not perform 30 consecutive minutes on the bicycle at 1.5 miles per hour and 30 minutes consecutively on the treadmill at 1.0 mile per hour. The patients were allowed to use oxygen up to 6 to 8 L to achieve these goals if needed.
Postoperative pulmonary rehabilitation was used to improve exercise capacity and chest wall mechanics. As soon as possible, arm ergometry was started in the intensive care unit, and a stationary bicycle was placed in the patient's room on the third postoperative day. Walking exercises were instituted on day 4, and rehabilitation was continued until the time of discharge. Postoperatively, all patients were instructed to maintain rehabilitation requirements under supervision for a minimum of 2 months and encouraged to exercise for the rest of their life.
Operative technique consisted of a median sternotomy in 46 patients and a unilateral thoracotomy in 7 patients, with epidural anesthesia used in all. It was the goal, at the time of operation, to resect 20% to 30% of each lung, which generally corresponded to 50 to 75 g of tissue per side. All stapling was done using bovine pericardium.
Postoperatively, 51 of 53 patients were able to be extubated immediately. Follow-up was planned at 1-, 3-, and 6-month intervals to consist of pulmonary spirometry with arterial blood gases, a 6-minute walk test, a posteroanterior and lateral chest roentgenogram, and evaluation of dyspnea index.
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Results |
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Complications are as listed in Table 1
. The most common complication was a prolonged air leak, which was present in 21 patients for greater than 7 days and present greater than 14 days in 14 patients. If a patient is down to a single chest tube on each side with full lung expansion and otherwise doing well medically, the patient would be discharged between days 12 and 14 with a Heimlich valve and be followed up in the outpatient clinic. Reintubation was required in 9 patients, and significant arrhythmias developed in 11 patients. Significant gastrointestinal problems developed in 8 patients, with 2 patients requiring abdominal exploration because of massive colonic distention, each being treated with a colostomy and feeding jejunostomy. Pneumonia developed in 9 patients, with other significant infections in 5. Neurologic events occurred in 3 patients, and a tracheostomy was required in 7 patients.
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Six-month follow-up was available in 40 of the patients and 1-year follow-up in 4 patients. Follow-up data consisted of patient visits at 1-, 3-, and 6-month intervals postoperatively with posteroanterior and lateral inspiratory and expiratory chest roentgenograms, evaluation of spirometric data, arterial blood gases, a 6-minute walk test, and functional dyspnea evaluation. Evaluation of 40 of these patients at 6 months revealed the following data, as outlined in Table 2. The average preoperative FEV1 was 0.56 L. The average 6-month spirometric value was 1.1 L. The FEV1/forced vital capacity went from 24% preoperatively to 52% at the 6-month follow-up visit. Maximum voluntary ventilation went from an average preoperatively of 18% to 40%. Arterial blood gases did not show any significant major change, although there was a slight increase in oxygen tension from 62 to 70 mm Hg and a slight decrease in carbon dioxide tension from 43 to 40 mm Hg. Six-minute walk tests increased significantly from an average of 785 ft preoperatively to 1,600 ft postoperatively. Forty-seven patients were receiving oxygen preoperatively and at 6 months, only 7 patients continued to receive oxygen, 6 of these with exercise. There was no oxygen requirement greater than 2 L/min. Thirty-five patients were receiving steroids preoperatively, and at follow-up only 15 of the original 35 were still receiving steroids. Significant symptomatic improvement based on dyspnea index and historical evaluation was present in 36 of the 40 patients. No significant change was noted in 3, and 1 patient felt that he might be worse. Incidental lung nodules suspicious for cancer were discovered on high-resolution computed tomographic scans in 3 patients and were resected at the time of operation.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Selection Process
The lessons learned in the selection process consist of the following general and specific recommendations. First, the physician involved in the selection process must be extremely strict and selective in choosing patients for lung volume reduction operation. The following would be our recommendation. In regard to age, it should be the rare patient greater than 70 years of age who should be selected for this operation. The majority of all of our complications developed in those patients greater than 70 years of age. Initially, we would operate up to the age of 75 years, but in the last 3 months, we have used the age of 70 years as a cutoff criteria as it became evident that from a standpoint of morbidity and mortality, the most significant complications are in those patients greater than 70 years of age. Second, for patients who are hypercapnic with a carbon dioxide tension greater than 50 mm Hg, we will no longer operate. In our group of 4 hypercapnic patients, all 4 had major complications, which resulted in death in 2. We believe that a carbon dioxide tension greater than 50 mm Hg is a contraindication to lung volume reduction operation. Third, in regard to spirometry, if a patient cannot meet a goal of an FEV1 of at least 0.5 L after pulmonary rehabilitation or if the patient's maximum voluntary ventilation is less than 15% of predicted or diffusion capacity is less than 10% of predicted, we would advise against operation in this group of patients. These patients would be better suited for transplantation or maintained in rehabilitation as the complication rate increases significantly when the FEV1 is less than 0.5 L, the maximum voluntary ventilation is less than 15% of predicted, or the diffusion capacity is less than 10%. The ideal patient would have an FEV1 greater than 0.5 L but less than or equal to 1 L, a maximum voluntary ventilation of 20% to 30% of predicted, and a diffusion capacity greater than 20% of predicted.
Other criteria thought to be important in the selection process consist of the following. If the patient is significantly obese, we would advise against operation as the excess weight prevents the patient from performing early postoperative pulmonary rehabilitation. We have operated on 4 patients whom we considered to be obese, and only 1 of these did well in the postoperative period. In addition, in patients receiving prednisone greater than 15 mg/day, we would advise holding operation until their dosage could be tapered down to less than 10 mg/day. If a patient is receiving significant preoperative tranquilizers for whatever reason, we would advise against operation as the incidence of panic attacks in the postoperative period approaches 35% to 40%, and such attacks are associated with a marked increase in complications. A history of panic attacks should alert the physician to either denying operation or have a preoperative psychiatric consultation. We have found a history of panic attacks in the preoperative period to be the most significant contributing factor to postoperative complications and a poor outcome. If the patient has a significant history of panic attacks that are not controllable with a lorazepam dose of less than 0.5 mg twice daily, then we would not operate. If a patient does not have adequate home support at the time of discharge from the hospital, this tends to be a negative factor. Eighty percent of the patients had targeted lung areas as identified on preoperative computed tomographic scan and perfusion lung scan and confirmed at the time of operation with gas trapping. Twenty percent of the group had homogenicity of lung volume averaging on perfusion scanning or with a split not greater than 10% between the upper and the lower lobes. In all of these patients with the exception of 1, the physiologic result at 6 months was the same as those that had specific targeted areas. A careful functional analysis will need to be made in this subset of patients to determine if the functional results at 6 months and 1 year are equal in the nontargeted group compared with the targeted group.
Pulmonary Rehabilitation
The second major category of lessons learned is in the field of pulmonary rehabilitation. The basic lesson learned is if the patient cannot meet the targeted rehabilitation goals of 30 consecutive minutes on the stationary bicycle and 30 consecutive minutes on the treadmill, then we would not operate. Pulmonary rehabilitation is undoubtedly the most important component in the entire program of lung volume reduction surgery. In our initial 6-month experience, rehabilitation programs were set up and the patients were allowed to undergo pulmonary rehabilitation outside the Atlanta area. They then returned after undergoing rehabilitation and underwent operation. Of the initial 21 patients who were treated in this manner, 16 did quite well but 5 had major difficulties, and all five deaths occurred in this group. At this time, we made a repeat visit to St. Louis with further discussion with Dr Cooper, and it was our own impression that strict criteria of 30 consecutive minutes on the bicycle and treadmill were required to achieve a successful physiologic end result. Accordingly, in March 1995, no patient was accepted for operation who could not meet the criteria as stated above. Since that time, 31 patients have undergone operation with no major complications and there were no deaths in this group. This seems to be an important clinical concept, and if the patient cannot achieve the targeted rehabilitation goals, we would advise against operating on those particular patients.
Operative Technique
The third major component is the operative technique for lung volume reduction. Lessons learned that are considered to be important and that have evolved since the initiation of the technique are as follows: As originally stated by Cooper and colleagues [2], 20% to 30% of the volume of each lung should be resected per side. It is recognized that in general, this will correspond to 50 to 75 g of lung tissue per side. As pointed out by Cooper, in personal discussions, as inverted U-shaped incision encompassing the entire upper lobe appears to be the best method of attacking targeted upper lobe disease. A standard U on the lower lobes is done when approaching predominantly lower lobe disease. The procedure is now done under a single collapse of the lung without reinflating the lung as it is thought that this leads to increased alveolar capillary damage. No suction is placed on the chest at the completion of the procedure, and all patients are extubated in the operating room or in the recovery room immediately after the operation. A right-angled chest tube is used any time an operative procedure is done on the lower lobes. In the future, a question will need to be raised whether a unilateral approach is a viable alternative to median sternotomy. Seven patients in our series had a unilateral approach: 3 because of severe pectus excavatum, 2 because of severity of the underlying disease process and concern that the patient could not tolerate a bilateral operation, and 2 because of previous operative procedures on the other side. All 7 patients in whom a unilateral approach was performed have done well. From this, we would consider a unilateral approach when there are underlying skeletal deformities such as pectus excavatum, a history of previous thoracic operation, or previous pleural sclerosis.
Postoperative Care
Lessons learned in postoperative care in the initial 1-year experience are the following: In the first 24 hours after the operation, pain control should be optimized to its maximum extent using fentanyl, bupivacaine, and ketorolac tromethamine. On the second postoperative day, bupivacaine, and ketorolac tromethamine can likewise be used along with small doses of hydromorphone hydrochloride. Beginning on the third postoperative day and subsequently thereafter, pain control is optimized in all patients with bupivacaine and ketorolac tromethamine without the addition of any other narcotic agent. This tends to minimize postoperative bowel problems seen in this particular group of patients.
Specific to the lung volume reduction group of patients have been the problems of panic attacks, bowel complications, pulmonary infiltrates, and pulmonary hypertension. In terms of panic attacks as a postoperative complication, their potential for occurring needs to be recognized preoperatively and dealt with at that time. They need to be controlled quickly, and the patient and nursing staff need to be educated in how to control these. Any panic attack that goes on for a prolonged time can result in reintubation and ultimately in major complications.
The second major group of complications seen in these patients, which we were not previously aware of, are the bowel problems with marked distention of the colon, particularly the right colon. Thoracic surgeons have been familiar with the slight ileus that can occur in patients with epidural anesthesia after routine lung resection. However, the magnitude of potential problems seen in this group of patients is greater. From this standpoint, we think the following are important: First, the treating physician should be aware of the patient's potential development of postoperative bowel complications. Second, pain control should be with bupivacaine and ketorolac tromethamine without the addition of narcotics unless absolutely required. Abdominal films are to be done routinely on days 3, 4, and 5, and if there is any indication of the development of a significant ileus, then it should be treated appropriately. Third, pulmonary infiltrates can be seen at any phase during the postoperative period. We routinely do sputum cultures on days 2, 3, and 4 and adjust antibiotics accordingly. If the patient has a totally negative sputum postoperatively, which is our goal, then he or she is given a simple cephalosporin. If there is a gram-positive sputum culture on day 2, 3, or 4, then the treatment is changed to vancomycin and ceftazidime. If there is a gram-negative culture the patient is given vancomycin and imipenem-cilastatin sodium.
Postoperative Pulmonary Rehabilitation
Postoperative rehabilitation begins in the intensive care unit the day after the operation. The patient should be started on upper body ergometry on day 1 after operation. On day 2, the patient should be on the bicycle, and by day 4, the patient should be on the bicycle plus walking. At the time of discharge, the patient is instructed that rehabilitation will be a process for the remainder of his or her life.
Follow-up
The fourth major component of the program is in lessons learned in follow-up after lung volume reduction operation. All patients should be restudied at 1, 3, and 6 months postoperatively and preferably also at 1 year. In addition, we hope that all institutions participating in this type of surgery will participate in the lung volume reduction databank being maintained in St. Louis. Observations learned, at this time, consist of the following: at 1 month postoperatively, there is very little physiologic change, although there is some subjective improvement. The patients are just starting to get over the effects of the operation per se. At 3 months, 90% of the expected physiologic improvement results are achieved on pulmonary function studies and 6-minute walk. At 6 months, we believe that 100% of the physiologic results have been obtained as seen from spirometric values, dyspnea index, and 6-minute walk. Our results so far show that at 12 months, the results are as good as those obtained at 6 months in the initial group of patients.
Conclusion
In conclusion, the following statements are presented as an overall summary: (1) The learning curve is steep. (2) The individual surgeon must learn when to say no. (3) Be selective, be strict, and be cautious. (4) A team approach is required. (5) Use good judgment. (6) Do not over-sell the operation or expected results. (7) The physiologic results at 2 years will ultimately determine the outcome of this operation and if it should be continued. (8) At 18 months, the results indicate potentially significant physiologic and subjective benefit in carefully selected patients. (9) Lung volume reduction programs should not be undertaken at this time by nontertiary centers or nonacademic centers as the risks are significant and chances of success slim. Lung volume reduction surgery remains a sea of relatively uncharted waters, with the future direction yet to be determined.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Miller, Emory University School of Medicine, 25 Prescott St, NE, Suite 3417, Atlanta, GA 30308.
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C. A. KELLER, G. RUPPEL, A. HIBBETT, J. OSTERLOH, and K. S. NAUNHEIM Thoracoscopic Lung Volume Reduction Surgery Reduces Dyspnea and Improves Exercise Capacity in Patients with Emphysema Am. J. Respir. Crit. Care Med., July 1, 1997; 156(1): 60 - 67. [Abstract] [Full Text]
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G. Massard, M. Oswald, R. Kessler, J.-G. Hentz, J. Lonsdorfer, and J.-M. Wihlm Operation for emphysema. Ann. Thorac. Surg., March 1, 1997; 63(3): 912 - 913. [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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