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Ann Thorac Surg 1997;64:321-326
© 1997 The Society of Thoracic Surgeons
Divisions of Cardiothoracic Surgery and Pulmonary Medicine, Columbia-Presbyterian Medical Center, New York, New York
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. Over 20 months, we performed LVRS in 92 patients selected on the basis of severe hyperinflation with air trapping, diaphragmatic dysfunction, and disease heterogeneity. Twenty-eight patients underwent unilateral LVRS on the basis of asymmetric disease distribution, prior thoracic operation, or concomitant tumor resection.
Results. Unilateral LVRS resulted in comparable improvements in exercise capacity and dyspnea as the bilateral procedure, with a similar perioperative mortality and actuarial survival to 24 months. Improvements in spirometric indices of pulmonary function, however, were less in patients undergoing unilateral than bilateral LVRS.
Conclusions. In properly selected patients, unilateral LVRS provides functional and subjective benefits of comparable magnitude to those associated with a bilateral operation. Unilateral LVRS is therefore an option in the therapy of end-stage emphysema in patients with asymmetric disease distribution, a prior thoracic operation, or contraindications to sternotomy, and may have a role as a bridge to transplantation in selected cases.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Lung volume reduction surgery (LVRS), originally conceived in the 1950s by Brantigan and associates [1] and Delarue and colleagues [2] and recently resurrected by Cooper and coworkers [3], has emerged as a tenable option in the treatment of end-stage emphysema. Early to medium-term results obtained since 1994 suggest that in properly selected patients, LVRS can provide significant improvements in respiratory function and dyspnea with low perioperative morbidity and mortality [3–5]. Presently, indications for LVRS include disabling dyspnea associated with hyperinflation, diaphragmatic dysfunction, and heterogeneous disease distribution [6]. Factors variously associated with the success of this procedure have included the presence of resectable "target" areas of disease, thoracic decompression, and maximal tissue removal [4]. For these reasons, patients with bilateral apical disease are currently regarded as ideal candidates for this operation, and bilateral LVRS is considered the procedure of choice.
Notwithstanding the theoretical appeal of resection of bilaterally symmetric disease, a number of patients with end-stage emphysema referred for evaluation do not qualify as "ideal" candidates. Many are not eligible for bilateral LVRS on the basis of a prior thoracic operation, and others are found to possess significant asymmetry in the distribution of emphysema, such that a bilateral procedure appears unnecessary. For these reasons, we have performed a number of unilateral LVRS procedures over a 2-year period, and herein report our results, comparing unilateral with bilateral LVRS.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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A total of 92 patients underwent LVRS for end-stage emphysema over a 20-month period. Informed consent was obtained in all cases. Mean age was 64 years, with a range of 45 to 80 years. Fifty-four patients (59%) were female, 64 (69%) dependent on continuous supplemental oxygen, and 51 (55%) on regular doses of oral prednisone. Twenty-seven patients (29%) had a daily steroid requirement greater than or equal to 10 mg of prednisone, and 33 patients (35%) had arterial carbon dioxide tension greater than 45 mm Hg. During initial evaluation, 17 patients were found to have intrathoracic neoplasms. Of these, 11 met criteria for LVRS and underwent operation with simultaneous nonanatomic wedge resection (8 cases), lobectomy (2 cases), or thymectomy (1 case).
Preoperative Assessment
RADIOGRAPHIC.
Evaluation included inspiratory and expiratory posteroanterior and lateral chest radiographs as well as inspiratory and expiratory chest computed tomographic scans. Quantitative ventilation-perfusion scans with xenon washout studies were obtained in all patients, and left heart catheterization was performed in patients with suspected coronary artery disease.
PHYSIOLOGIC.
Assessment included standard pulmonary spirometry, including measurement of forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), total lung capacity, residual volume, and maximal voluntary ventilation, as well as lung volume determination by helium dilution and body plethysmography. Arterial blood gas analysis, quantitative nuclear ventilation-perfusion scan with xenon washout, cardiopulmonary stress testing, and 6-minute walk test were also performed.
DEGREE OF DYSPNEA.
Patients were asked to subjectively classify their degree of dyspnea according to the modified Medical Research Council dyspnea index [8]. This screening tool grades the degree of dyspnea on a scale ranging from 0 to 5. Grade 0 represents no functional impairment, and grade 5 represents dyspnea at rest:
Follow-up
Postoperatively, spirometry, 6-minute walk test, and dyspnea grading were performed at 3, 6, and 12 months. Additionally, lung volume measurements by helium dilution and body plethysmography were repeated at 6 and 12 months after the operation. Of 92 patients undergoing LVRS, 66 have follow-up for greater than 3 months. For purposes of analysis, the most recent available data (from the 3- or 6-month evaluation) were used to calculate postoperative data.
Statistical Analysis
Data were analyzed using SAS system software (SAS Institute, Inc, Cary, NC). Kaplan-Meier product limit estimates were used to graphically display survival after operation, providing actuarial estimates and 95% confidence intervals. The paired Student's t test was used for analyzing the relationship between preoperative and postoperative data. The Wilcoxon rank-sum test, the nonparametric analogue of the two-sample t test, was used to compare differences in percent change in FEV1 and FVC and absolute change in 6-minute walk (feet) and dyspnea index (Medical Research Council units) between groups. All p values are reported without corrections for multiple comparisons, and p less than 0.05 is considered significant.
Operative Approach
Twenty-eight patients (30%) underwent unilateral LVRS either through an open thoracotomy (27 patients) or thoracoscopically (1 patient). Sixty-eight patients (70%) had bilateral procedures, via either median sternotomy (16 patients), bilateral thoracotomy (2 patients), or bilateral thoracosternotomy (46 patients) (Table 1
). The choice of the unilateral versus bilateral approach was made on the basis of a number of criteria (Table 2). In 12 patients, unilateral LVRS was chosen because of asymmetric distribution of perfusion (one lung with less than 30% of total perfusion as per ventilation/perfusion scan) or parenchymal disease (qualitative evaluation of computed tomographic scan). In 10 others, bilateral LVRS was prohibited by a prior thoracic operation including lung transplantation (with graft failure), lung resection, pleurodesis, and coronary artery bypass grafting with harvesting of the left internal mammary artery. In 5 patients, unilateral LVRS was performed as part of a pulmonary tumor resection. Finally, 1 patient with severe osteoporosis and malnutrition was deemed at high risk for sternal wound dehiscence, and underwent unilateral LVRS.
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After placement of a thoracic epidural catheter, the patient is placed in the supine position and intubated with a double-lumen endotracheal tube. The patient is placed in the supine position for bilateral procedures and in the lateral decubitus position for unilateral procedures. The chest is opened by thoracotomy, median sternotomy, or bilateral thoracosternotomy, and the lung on the operating side is deflated. Lung volume reduction is performed using GIA stapling devices (United States Surgical Corporation, Norwalk, CT; Ethicon, Inc, Cincinnati, OH) lined with bovine pericardial strips (Bio-Vascular, Inc, St. Paul, MN) to minimize air leakage. Extent of resection is guided by preoperative radiographic and physiologic studies. After staple lines are meticulously checked for major leaks and the lungs are carefully reexpanded, bilateral apical thoracostomy tubes are placed and left to water-seal drainage. If significant air leaks or space problems are anticipated, apical pleural tents are created. The chest is closed, the patient is extubated in the operating room or shortly after arrival to the intensive care unit, and epidural bupivicaine analgesia is carried out for the first few days.
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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). Preoperative pulmonary function in the patients undergoing LVRS was severely impaired, and the average 6-minute walk distance and dyspnea index corresponded to profound disability and diminished quality of life (Table 4). Patients undergoing bilateral and unilateral procedures exhibited similar degrees of objective and subjective impairment as assessed by these indices.
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). Patients undergoing unilateral LVRS experienced a mean improvement of 28% in FEV1 and 29% in FVC, whereas those undergoing bilateral LVRS had greater average improvements in these spirometric measures, with improvements of 70% and 48%, respectively (Table 6). Nonetheless, unilateral LVRS was comparable with bilateral LVRS with respect to improvements in 6-minute walk distance (315 versus 289 ft) and dyspnea index (2.6 versus 2.3 units).
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). Although severity of dyspnea improved to a similar degree after unilateral and bilateral LVRS, 6-minute walk distance improved to a greater extent after bilateral lung reduction, and spirometric indices improved only after bilateral procedures, with no appreciable change in FEV1 or FVC after unilateral procedures.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Our results in patients undergoing unilateral LVRS are encouraging. Unilateral LVRS effected smaller increases in spirometric indices of pulmonary function than bilateral LVRS but achieved equivalent functional results, with comparable improvements in both 6-minute walk distance and degree of dyspnea. Of interest was the subpopulation of severely hypercapneic patients, in whom objective improvement after unilateral LVRS was less apparent. Perioperative mortality and actuarial survival to 24 months were similarly comparable in patients undergoing unilateral and bilateral procedures. Finally, perioperative morbidity, as assessed by rates of specific postoperative complications, was lower in the unilateral group, a likely consequence of the lesser negative impact of unilateral operation.
Although the majority of patients undergoing LVRS currently meet selection criteria developed to identify the "ideal" patient with bilateral apical disease and relative sparing of the remaining lung, a substantial proportion of patients presenting for LVRS evaluation do not possess these characteristics. In these patients, targeted resection of predominantly unilateral disease may be preferable to bilateral volume reduction, because equivalent functional improvement may be expected with lesser morbidity. Because the longevity of the functional improvement afforded by LVRS has not yet been determined, unilateral operation with the option of subsequent "rescue" contralateral volume reduction might serve to prolong the palliative benefits of this therapy. The success of this "staged LVRS" strategy, however, would depend on the demonstration that the functional benefits of unilateral LVRS were of similar longevity to those of bilateral LVRS. Although it is reasonable to predict that this might not be the case, because lesser improvements in spirometric indices might result in earlier recurrence of functional disability, properly designed randomized clinical trials will be required to definitively answer this question.
Although the potential applicability of staged unilateral LVRS is controversial, the implications of our present findings are much clearer for patients with contraindications to a bilateral operation. A number of absolute and relative contraindications to LVRS have been proposed, and although many of these remain as subjects of considerable controversy, it is generally agreed that patients with a prior thoracic operation are not candidates for LVRS on the previously operated side, due to technical difficulties resulting in a prohibitively high rate of bronchopleural fistulization [7]. Likewise, although few patients with severe osteoporosis and poor nutritional status have undergone LVRS in reported series, these high-risk candidates may be at prohibitive risk of sternal wound complications. In these patients, unilateral LVRS has much to offer. As evidenced in our series, a significant proportion of patients presented after unilateral lung transplantation with progressive respiratory failure due to graft dysfunction. As the population of lung transplant recipients grows, this indication for unilateral LVRS will likely become more common.
A number of authors have demonstrated the feasibility of thoracoscopic LVRS [9–11], and although bilateral procedures have been shown to achieve superior clinical results [12, 13], these have been hampered by the requirement for prolonged operative time. If unilateral thoracoscopic LVRS can effect significant functional improvements, this low-morbidity technique may become more widely used.
Finally, Zenati and colleagues [14] have reported a case of unilateral thoracoscopic LVRS used as a bridge to lung transplantation. The concept of applying LVRS as a palliative measure before transplantation is intriguing, especially in the face of ever-increasing transplantation waiting times [15]. In this setting, unilateral LVRS is theoretically superior to bilateral LVRS, because the contralateral side is left unviolated, facilitating subsequent transplantation. Furthermore, because the long-term results of LVRS are still uncertain, preservation of one pleural space might allow lung transplantation after the benefits of LVRS have waned.
In summary, our experience demonstrates that in properly selected patients with end-stage emphysema, unilateral LVRS can provide significant functional and symptomatic benefits. Implications of these findings include the wider application of this technique to patients with contraindications to a bilateral operation, asymmetric disease distribution, and failing lung transplants, as well as to those on transplantation waiting lists. The role of staged, sequential, unilateral LVRS in an attempt to prolong the temporal benefits of surgical therapy is unclear, and requires formal study in the form of a randomized clinical trial. In any event, the eventual application of this approach to an increasing number of patients is certain to ensue.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Gorenstein, Columbia-Presbyterian Medical Center, 161 Fort Washington Ave, Rm 310, New York, NY 10032.
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