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Ann Thorac Surg 1998;66:582-584
© 1998 The Society of Thoracic Surgeons

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How to Do It

Muscle-sparing anterior thoracotomy for one-stage bilateral lung volume reduction operation

^a Unit of Thoracic Surgery, Department of Surgery, University Hospital of Geneva, Geneva, Switzerland
^b Division of Anesthesiology, University Hospital of Geneva, Geneva, Switzerland

Accepted for publication March 26, 1998.

Address reprint requests to Dr Spiliopoulos, Unit of Thoracic Surgery, Department of Surgery, University Hospital of Geneva, 1211 Geneva 14, Switzerland

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Bilateral lung volume reduction produces significant clinical and physiologic improvement in selected patients with end-stage emphysema. Current surgical approaches consist of median sternotomy and video-assisted thoracoscopy. This report describes an alternate technique of single-stage, bilateral lung volume reduction using muscle-sparing anterior thoracotomy in 18 patients with severe lung emphysema.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Since 1994, lung volume reduction (LVR) has been used as an effective procedure to relieve dyspnea and to increase exercise tolerance in patients with end-stage emphysema [1]. A debate still exists as to the best method of removal of emphysematous lung portions. Median sternotomy allows easy access to both lungs with no direct injury of the respiratory muscles, whereas video-assisted thoracoscopic surgery is a minimally invasive technique with reduced surgical trauma [2–4]. Although thoracotomy is commonly performed for unilateral procedures, such a surgical approach generally has not been reported for one-stage bilateral LVR because concerns have been raised about postoperative respiratory dysfunction. To avoid the disadvantages related to large thoracic incisions, we have used a muscle-sparing anterior minithoracotomy and have examined early morbidity and pulmonary function after bilateral LVR.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patient demographics
Between January 1996 and August 1997, 18 consecutive patients with severe respiratory insufficiency resulting from nonbullous emphysema underwent one-stage bilateral LVR through a muscle-sparing anterior thoracotomy. All these patients were highly symptomatic and were selected according to standard eligibility criteria (residual volume greater than 250% of predicted, forced expiratory volume in 1 second less than 35% of predicted, and less than 20 mg of prednisolone per day) [1–4]. According to chest computed tomographic scanning, radiographs, and ventilation/perfusion studies, emphysema predominated in the upper part of the lung in 14 patients and in the lower part in 4 patients. The diagnosis of ₁-antitrypsin deficiency was established in 4 patients (3 with lower lung emphysema).

Anesthesia and operative technique
A thoracic epidural catheter was used for continuous intraoperative and postoperative analgesia; after induction of anesthesia, a double-lumen endotracheal tube was inserted for selective lung ventilation. Patients were positioned supine with both arms extended over the head and with a triangular blanket rolled under the scapula. The skin was prepared from the upper sternum to the xiphoid appendix and laterally to the posterior axillary line. Resection was started on the most severely damaged lung, with the table rotated 30 degrees toward the opposite side. Access to the fifth intercostal space was prepared by a short incision (5 to 7 cm) from below the nipple toward the anterior axillary line (Fig 1). The latissimus dorsi and pectoralis major muscles were left intact, whereas the serratus anterior muscle was split anteriorly along the direction of its fibers. The intercostal muscle was separated from the upper border of the fifth rib with the use of the electrocautery. After unilateral lung deflation and pleural incision, splitting of the intercostal muscle was extended anteriorly and posteriorly (up to 10 cm). The ribs were spread with a retractor (Finochietto retractor; width, 30 mm; blade depth, 40 or 60 mm) to allow access to all sites of the lung. Noncollapsed areas were easily visualized and corresponded to the most destroyed lung parts documented preoperatively.

View larger version (125K): [in this window] [in a new window]   Fig 1. With the patient in a supine position (both arms extended over the head as for sequential bilateral lung graft), a short skin incision (5 to 7 cm) is marked on each side.

After completion of the first side, the same procedure was then performed on the contralateral side. The patient was extubated at the end of the operation to avoid barotrauma and exacerbation of air leaks secondary to positive-pressure ventilation.

Postoperative medical management primarily involved the restricted use of intravenous fluid (0.8 to 1.2 mL · kg^-1 · h^-1), chest tube drainage, physiotherapy, early mobilization and nutrition, and psychological reassurance. Continuous epidural analgesia with bupivacaine 0.125% and fentanyl (3 µg/mL) was used for the first 48 hours followed by epidural morphine (2 to 4 mg/12 h) until the 5th to 8th postoperative day. An antiinflammatory medication was also given in each case (ketorolac, 20 to 30 mg/8 h).

Assessment
Spirometric volumes and dyspnea score (from 1 = no dyspnea to 5 = respiratory distress at rest) were determined before the operation and 3 months postoperatively. Time to extubation, chest drainage, and lengths of intermediate care unit and hospital stays also were recorded.

Statistical analysis
Paired Student’s t test was used to compare values before and after operation. All values were expressed as the mean ± standard deviation or median and range.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Muscle-sparing anterior minithoracotomy was used to remove part of the upper lobes in 11 patients, lower lobes in 4 patients, or both in 3 patients. The mean duration of the operation was 108 minutes (range, 75 to 150 minutes) and mean time to extubation was 23 minutes (range, 14 to 55 minutes). In the early recovery period, the epidural analgesic regimen provided satisfactory pain relief and blood exchange remained in an acceptable range (arterial carbon dioxide tension 6.5 kPa and arterial oxygen tension 9 kPa with supplemental inhaled oxygen). No patients had to be reintubated after the operation.

The median overall duration of chest tube drainage was 11 days (range 5 to 42 days). There was no difference between those patients with (n = 7) or without (n = 11) talc poudrage (10 versus 12.6 days; not significant). Prolonged air leak (>7 days) occurred in 6 patients, and 2 of them required surgical reexploration for restapling. Other complications consisted of recurrent bronchospasms (n = 2), sepsis of unknown origin (n = 1), and deep venous thrombosis (n = 1). There was no perioperative death. After a short stay in the intermediate care unit (median, 5 days), patients were discharged from the hospital after a median stay of 21 days (range, 8 to 37 days) including the reinitiation of the pulmonary rehabilitation program. Results at 3-month follow-up demonstrated significant improvement in forced expiratory volume in 1 second (from 0.75 ± 0.24 L to 1.15 ± 0.47 L) and reduction in dyspnea (from 4.1 to 2.5 on a 5-point scale).

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
In the present series, we elected to perform bilateral LVR through a muscle-sparing minithoracotomy in patients with end-stage emphysema. All the patients were extubated shortly after the operation (<60 minutes) and lung gas exchange remained adequate postoperatively. Importantly, we found that the benefits in terms of improved lung function and relief of dyspnea were similar to those reported by other authors using different surgical approaches. Hence, selection of patients with appropriate inclusion criteria and successful removal of the most diseased lung parts largely determine the clinical and functional improvement after LVR, regardless of the surgical approach for lung resection, ie, median sternotomy, video-assisted thoracic surgery, or minithoracotomy [1–4].

With the patients lying supine, both sides were sequentially operated on; a 30-degree lateral table tilt favored blood perfusion in the dependent-ventilated lung and allowed easy access contralaterally if emergent reexploration was required. Previously, muscle-sparing anteroaxillary thoracotomy has been associated with excellent surgical exposure, less postoperative pain, and less impairment in lung function, compared with standard posterolateral thoracotomy [5]. We used a small anterior incision that preserved several thoracic muscles (latissimus dorsi, pectoralis major, and the largest part of the serratus anterior). Compared with sternotomy, the surgical chest trauma was limited to the fifth intercostal space (instead of involving five to six dermatomas) and incisional pain could be easily obtunded with epidural analgesics without causing further impairment in respiratory function.

With regard to postoperative air leaks, talc poudrage appeared to be useless and could even potentially compromise later thoracic operations. The prolonged drainage duration and reexploration rate were similar to those in earlier reports of patients undergoing LVR through other approaches [2, 6] and likely can be attributed to the learning curve of our surgical team.

Median sternotomy, thoracotomy, and upper abdominal incisions all have been associated with a loss of functional residual capacity that has been attributed to several mechanisms: (1) development of atelectasis due to intraoperative lung retraction and reflex inhibition of diaphragmatic activity [7], (2) lung edema as a result of fluid overload and pressure-induced failure of the alveolar-capillary membrane [8], and (3) chest pain or muscle fatigability resulting in diminished inspiratory efforts [9]. According to our limited experience, muscle-sparing anterior thoracotomy offered excellent exposure to both the upper and lower lobes and thus contributed to reduce the operating time and to minimize the lung trauma. Adequate control of pain with an epidural infusion of analgesics allowed immediate weaning from the ventilator and facilitated early chest physiotherapy using abdominal breathing pattern and deep voluntary inspirations. Furthermore, restricted administration of intravenous fluids attenuated interstitial lung edema and also could be implicated in the maintenance of satisfactory lung oxygenation indices postoperatively.

In summary, we demonstrated that bilateral muscle-sparing anteroaxillary thoracotomies can be safely and efficiently performed for LVR with minimal morbidity. Operating conditions were excellent, postoperative recovery was facilitated by alleviating pain with epidural analgesics, and significant clinical and functional improvements were observed later.

	References

Top Abstract Introduction Patients and methods Results Comment References

 

1. Cooper J.D., Patterson G.A., Sundaresan R.S., et al. Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg 1996;112:1319-1330.[Abstract/Free Full Text]
2. Bingisser R., Zollinger A., Hauser M., Bloch K.E., Russi E.W., Weder W. Bilateral volume reduction surgery for diffuse pulmonary emphysema by video-assisted thoracoscopy. J Thorac Cardiovasc Surg 1996;112:875-882.[Abstract/Free Full Text]
3. Vigneswaran W.T., Podblielski F.J. Single-stage bilateral, video-assisted thoracoscopic lung reduction operation. Ann Thorac Surg 1997;63:1807-1809.[Abstract/Free Full Text]
4. Wisser W., Tschnernko E., Senbaklavaci O., et al. Functional improvement after volume reduction: sternotomy versus videoendoscopic approach. Ann Thorac Surg 1997;63:822-828.[Abstract/Free Full Text]
5. Nomori H., Horio H., Fuyuno G., Kobayashi R. Non–serratus-sparing antero-axillary thoracotomy with disconnection of anterior rib cartilage: improvement in postoperative lung function and pain in comparison to posterolateral thoracotomy. Chest 1997;111:572-576.[Abstract/Free Full Text]
6. Cooper J.D., Trulock E.P., Triantafillou A.N., et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106-119.[Abstract/Free Full Text]
7. Maeda H., Nakahara K., Ohno K., Kido T., Ikeda M., Kawashima Y. Diaphragm function after pulmonary resection. Am Rev Respir Dis 1988;137:678-681.[Medline]
8. Kolobow T., Moretti M., Fumagalli R., et al. Severe impairment in lung function induced by high peak airway pressure during mechanical ventilation. Am Rev Respir Dis 1987;135:312-315.[Medline]
9. Estenne M., Yernault J.-C., De Smet J.-M., de Troyer A. Phrenic and diaphragm function after coronary artery bypass grafting. Thorax 1985;40:293-299.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. Brenner, N. M. Hanna, R. Mina-Araghi, A. F. Gelb, R. J. McKenna Jr, and H. Colt Innovative Approaches to Lung Volume Reduction for Emphysema Chest, July 1, 2004; 126(1): 238 - 248. [Abstract] [Full Text] [PDF]

				J. Hamacher, E. W. Russi, and W. Weder Lung Volume Reduction Surgery : A Survey on the European Experience Chest, June 1, 2000; 117(6): 1560 - 1567. [Abstract] [Full Text] [PDF]

				J. A. Smith Bilateral anterior thoracotomies for lung volume reduction. Ann. Thorac. Surg., April 1, 1999; 67(4): 1217 - 1218. [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Marc de Perrot Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by de Perrot, M. Articles by Spiliopoulos, A. Search for Related Content PubMed PubMed Citation Articles by de Perrot, M. Articles by Spiliopoulos, A.