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Ann Thorac Surg 1998;66:1134-1139
© 1998 The Society of Thoracic Surgeons
a Division of Thoracic and Cardiovascular Surgery, Southern Illinois University School of Medicine, Springfield, Illinois USA
b Division of Pulmonary Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
Address reprint requests to Dr Hazelrigg, Department of Surgery, SIU School of Medicine, PO Box 19230, Springfield, IL 62794-1312
e-mail: (shazelrigg{at}siumed.edu)
Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.
Abstract
Background. Lung volume reduction operations have proved beneficial for emphysematous patients, but questions remain about the role of a unilateral procedure.
Methods. Fifty patients were prospectively enrolled in a lung volume reduction surgery program for emphysema with staged unilateral video-assisted thoracoscopic procedures (VATS group). These patients were compared with 29 patients having bilateral lung volume reduction procedures by median sternotomy.
Results. The VATS group was slightly older and had shorter 6-minute walk distances, but otherwise the two groups were similar. Hospital stays were shorter for each unilateral VATS procedure, but the total of the two hospital stays was longer than the stay for the sternotomy group (21.1 versus 14.8 days). Complications were comparable, there were no in-hospital deaths, and there was significant difference in the 1-year mortality rate (VATS, 6% versus sternotomy, 13.8%; p = 0.137). Functional test results were comparable between the groups with improvements in percent predicted forced expiratory volume in 1 second (VATS, 41%, and sternotomy, 40%), 6-minute walk distances (VATS, 48%, and sternotomy, 26%), dyspnea scores, and acid base measurements.
Conclusions. Staged lung volume reduction operations do not appear to offer any measurable advantages over a single hospitalization and bilateral lung volume reduction procedures.
Although many questions remain unanswered regarding lung volume reduction surgery (LVRS) for emphysema, the preponderance of evidence has supported its use in properly selected patients [1–14]. Almost uniformly there have been substantial improvements in forced expiratory volumes, reductions in static lung volumes (ie, total lung capacity and residual volume), and improvements in dyspnea scores and measures of endurance (6-minute walk test). Comparative studies [10, 15] have favored a stapled LVRS to a laser operation alone. The earliest reports of LVRS concerned unilateral procedures because it was believed that these patients were fragile and that a unilateral approach especially by thoracoscopy would be best tolerated. As experience increased, however, we began to see bilateral procedures by either video-assisted thoracoscopic techniques (VATS) or sternotomy. Data suggested lower long-term mortality for bilateral procedures because of better results from LVRS on both lungs [11].
With reports of superior improvements with bilateral procedures, there appeared to be a limited role for unilateral LVRS. The questions that remained were whether there was a role for a staged unilateral LVRS and whether this approach would result in fewer complications and be preferable to doing both lungs at the same operation.
To evaluate the potential merits of a staged unilateral LVRS, we operated on 50 patients and planned for them to return in 3 months for LVRS on the opposite side. This group was compared with a group of patients having bilateral LVRS by median sternotomy.
Material and methods
Fifty patients were prospectively enrolled in an LVRS program between April 1995 and October 1996 with the plan of staged unilateral thoracoscopic volume reduction procedures (VATS group). The second operation was carried out approximately 3 months after the first. This group was compared with 29 patients having LVRS through a median sternotomy (both lungs operated on) between July 1995 and August 1996.
Selection into the two surgical approaches was nonrandomized and based largely on patient choice, location of dominant bullous disease, and presence of nodules to be resected. There was some preference for VATS for resection of posteriorly located nodules or dominant localized bullous disease. No patient was selected for a surgical approach on the basis of his or her overall health status. There was no significant difference in patient accrual to each surgical approach over the time of the study.
Data were collected on in-hospital lengths of stay and morbidity and mortality. All patients had complete preoperative evaluations including pulmonary function tests, blood gas analysis, cardiac workup, 6-minute walk tests, and quality of life questionnaires (medical outcomes study short form [MOS-36]). These studies were repeated prior to the second operation and again at 6 months postoperatively.
Operative technique
Unilateral VATS LVRS was performed as previously described. All procedures were done with the patient under general anesthesia with a double-lumen endotracheal tube. Typically, three access ports were required with the patient in the full lateral position. Areas to be resected were identified by preoperative information gained by computed tomographic scans and differential ventilation perfusion scans as well as by visual findings intraoperatively. The areas with the most disease were resected with the goal of a 20% to 30% volume reduction. All staple lines were buttressed with bovine pericardial strips (Bio-Vascular, Minneapolis, MN).
Median sternotomy was performed in a standard fashion, and LVRS was performed sequentially with one-lung ventilation. The most diseased lung was identified by preoperative testing and was operated on first. Again, all staple lines were buttressed with bovine pericardial strips.
Hospital management
Chest tubes were removed 24 hours after the last sign of air leak. Suction was used only when major pneumothoraces were present, and the lowest possible amount of suction was used to achieve expansion. Heimlich valves were placed for prolonged air leaks in patients who could be managed on waterseal drainage. A stay in the intensive care unit (ICU) initially was routine, but this evolved into a more selective use of the ICU over time.
Statistical methods
Descriptive statistics are presented with means and standard deviations. Student’s t test was used to compare results of LVRS by staged thoracoscopy versus median sternotomy for continuous variables. The paired t test was used to compare changes in continuous variables between the first and second operation. The 
2 or Fisher’s exact test was used to examine discrete variables. A p value of 0.05 or less was considered significant.
Results
All 50 patients had completion of the contralateral VATS volume reduction procedure within a 3- to 4-month interval after the first operation. The preoperative characteristics of this group were comparable with those of the sternotomy group except for age, residual volume, and 6-minute walk distance. The VATS group was older (67.5 versus 63.0 years; p 
0.05) and had a shorter 6-minute walk distances (765 versus 945 ft; p 0.05) (Table 1). Residual volumes were significantly higher in absolute volume, but when corrected by percent predicted, they were not significantly different between the two groups.
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0.05). However, when both hospital admissions for the staged procedure were combined, the total duration of chest tube use was significantly longer than for the median sternotomy group (17.8 days versus 11.9 days; p = 0.006). The findings were similar for total hospital stay: each VATS procedure resulted in a shorter stay (p = 0.02), but when they were combined, the total was considerably greater than the stay for the sternotomy group (21.1 days versus 14.8 days; p = 0.005). The ICU stay was comparable for each procedure, but in reality, this measurement probably is biased by changes in routine practice standards during the course of this study. Early in the study, an ICU stay was routine, but as the study progressed, several patients were not managed in the ICU.
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There were no in-hospital deaths, and the 1-year mortality rate was 6% (3/50) in the staged VATS group and 13.8% (4/29) in the sternotomy group. This difference was not significant (p = 0.137). In the VATS group, the causes of death were pulmonary embolus (n = 1), prostate cancer (n = 1), and respiratory failure (n = 1), and in the sternotomy group, the causes were respiratory failure (n = 3) and gastrointestinal bleeding (n = 1).
Postoperative results of pulmonary function tests, arterial blood gas studies, and 6-minute distances are shown in Table 4. The final results after the staged procedure were statistically comparable to the results after sternotomy in all instances (p 
0.05). The pulmonary function test results seemed to change proportionally with each staged unilateral procedure; eg, the forced expiratory volume in 1 second (FEV1) improved by a mean of 0.14 L after the first side and 0.13 L after the second. The physiologic changes measured by the 6-minute walk distance improved more with the first operation (251.5 ft) than the second (112.0 ft). This was also true of the quality-of-life analysis. Only 42% of patients considered their health status to be good in the staged VATS group preoperatively; this increased to 69% after the first unilateral procedure, with 2% rating their health as excellent, and there was little further change in the quality-of-life questionnaire scores after the second procedure. In the sternotomy group, health status improved from a 55% good or better rating to 66% after LVRS.
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The changes in oxygen and steroid use in the two groups were similar. Oxygen was required by 62% of the staged VATS patients and 59% of the sternotomy group. After bilateral LVRS, the percentages fell to 54% and 50%, respectively. Steroid use fell from 32% to 14% in the staged group and from 34% to 14% in the sternotomy group.
Comment
The first lung volume reduction procedure, described by Brantigan and associates [16], was performed unilaterally through a thoracotomy. Similarly, in many reports of LVRS in the early 1990s, a unilateral approach with VATS was also used. The assumption was that because of the fragility of this patient population, a smaller incision and an operation on only one lung would be better tolerated. This presumption was questioned by Cooper and co-workers [2] and others who performed LVRS by sternotomy and demonstrated better improvement in lung function studies by operating simultaneously on both lungs with comparable early morbidity and mortality. Subsequently, data on bilateral VATS LVRS that demonstrated similar results to those achieved by sternotomy were available [8, 11, 17]. McKenna and associates [11] reported a higher 1-year mortality for patients having only unilateral LVRS. This increased long-term mortality was reasoned to be due to the smaller improvement in pulmonary function achieved with a unilateral approach.
Given this information, the consensus supported a bilateral procedure by either VATS or sternotomy. Prospective studies supported this conclusion, and the role of a unilateral procedure was limited to the rare patient with unilateral disease or reason to avoid entrance into one chest cavity. Kotloff and colleagues [8] compared bilateral VATS LVRS with LVRS by median sternotomy and found similar functional results (ie, 
FEV1:VATS, 41.2%, versus sternotomy, 41.4%) but suggested a significant advantage for the VATS group with respect to the in-hospital mortality rate (VATS, 2.5%, versus sternotomy, 13.8%; p = 0.05).
Our study attempted to determine whether there is any advantage to staging a unilateral VATS LVRS versus a one-time bilateral procedure. Our two groups were comparable, although the staged group was older and probably a bit less physiologically fit as evidenced by a lower 6-minute walk distance. The enrollment was not randomized between a staged VATS approach and sternotomy and hence may suffer from some selection bias. There was no attempt to direct sicker patients to either group. The staged approach resulted in a shorter chest tube requirement and hospital stay for each procedure, but when the two hospitalizations were combined, the overall stay was significantly longer than for the group having LVRS by sternotomy (hospital stay, 21.1 days versus 14.8 days; p = 0.005). All patients were discharged home with no need of alternative health care facilities.
Clearly in terms of results as measured by FEV1 the two approaches resulted in almost identical outcomes. The single hospitalization for bilateral LVRS seems to result in fewer total hospital days and hence to be a more cost-effective approach. The suggestion by Kotloff and coworkers [8] of lower in-hospital mortality with the bilateral VATS approach over median sternotomy was not seen with our staged approach. However, our in-hospital mortality rate was 0%, and one 1-year mortality rate did favor the staged VATS group (6% versus 13.8%). The 1-year mortality rate related to respiratory failure was 2% (1/50) for the staged group and 10.3% (3/29) for the sternotomy group. Because the total number of patients in the sternotomy group was only 29, any conclusion drawn with respect to mortality is probably premature.
The improvement in 6-minute walk distances was greater in the VATS group than for the sternotomy group (108.9 m versus 74.1 m). This difference is probably explained by the lower starting distance in this group and the absence of standardized preoperative rehabilitation requirements. It has been noted that marked improvements in 6-minute walk distances can occur with rehabilitation alone, and without standardization of rehabilitation preoperatively, there is no way to compare these results. The precise importance of preoperative rehabilitation is still debated. We think its importance is inversely related to the starting physiologic condition of the patient. We now require a formal 6-week rehabilitation program for patients having initial 6-minute walk distances of less than 225 m, but we do not require it for those walking further.
Improvements in arterial blood gas results at rest were noted, with increased oxygen and decreased carbon dioxide saturation. In spite of improvements in oxygenation, many patients were still requiring oxygen with exercise, and we agree with prior studies [18] suggesting that the improvement in perceived dyspnea should be substantiated by exercise testing before the complete withdrawal of supplemental oxygen.
It was interesting that whereas the pulmonary function (ie, FEV1) increased proportionately with each procedure, the improvement in dyspnea, like that in the 6-minute walk distance, improved more after the first procedure than the second. This can also be explained by entrance into a formal rehabilitation program and medical intervention that resulted in a great deal of early improvement.
We were not able to identify a specific group of patients (eg, age >65 years, FEV1 < 20% predicted) who benefited from a staged approach. Thus, given similar complication rates and outcomes, we have to favor a simultaneous bilateral approach in all patients with bilateral disease.
In conclusion, comparison of 50 patients having staged unilateral LVRS with 29 patients undergoing a simultaneous bilateral procedure revealed similar improvements. The FEV1 increased by approximately 40% in both groups. Although each unilateral approach had a shorter duration of chest tube requirement and hospital stay, the combination of two hospitalizations was longer than in the bilateral group. Morbidity and mortality were similar in the two groups.
Although there may exist a high-risk group in whom staged LVRS would be better tolerated, we could not identify such a group. Nor were we able to discern a distinct advantage for staging the procedure, and hence we recommend a simultaneous bilateral procedure for all patients with bilateral disease undergoing LVRS. The 1-year mortality was lower in the staged LVRS group, and this may warrant further study.
References
This article has been cited by other articles:
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  M. M. DeCamp Jr., R. J. McKenna Jr., C. C. Deschamps, and M. J. Krasna Lung Volume Reduction Surgery: Technique, Operative Mortality, and Morbidity Proceedings of the ATS, May 1, 2008; 5(4): 442 - 446. [Abstract] [Full Text] [PDF]
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 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]
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C. A. Keller Lasers, Staples, Bovine Pericardium, Talc, Glue and... Suction Cylinders?: Tools of the Trade To Avoid Air Leaks in Lung Volume Reduction Surgery Chest, February 1, 2004; 125(2): 361 - 363. [Full Text] [PDF]
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 I.F. Oey, D.A. Waller, S. Bal, S.J. Singh, T.J. Spyt, and M.D.L. Morgan Lung volume reduction surgery - a comparison of the long term outcome of unilateral vs. bilateral approaches Eur. J. Cardiothorac. Surg., October 1, 2002; 22(4): 610 - 614. [Abstract] [Full Text] [PDF]
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E. Pompeo and T. C. Mineo Long-term outcome of staged versus one-stage bilateral thoracoscopic reduction pneumoplasty Eur. J. Cardiothorac. Surg., April 1, 2002; 21(4): 627 - 633. [Abstract] [Full Text] [PDF]
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T. Geiser, B. Schwizer, T. Krueger, M. Gugger, V. I. Hof, M. Dusmet, J.-W. Fitting, and H.-B. Ris Outcome after unilateral lung volume reduction surgery in patients with severe emphysema Eur. J. Cardiothorac. Surg., October 1, 2001; 20(4): 674 - 678. [Abstract] [Full Text] [PDF]
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K. S. Naunheim, S. R. Hazelrigg, L. R. Kaiser, R. J. Keenan, J. E. Bavaria, R. J. Landreneau, J. Osterloh, and C. A. Keller Risk analysis for thoracoscopic lung volume reduction: a multi-institutional experience Eur. J. Cardiothorac. Surg., June 1, 2000; 17(6): 673 - 679. [Abstract] [Full Text] [PDF]
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S. R Hazelrigg, T. M Boley, A. Grasch, and T. Shawgo Surgical strategy for lung volume reduction surgery Eur. J. Cardiothorac. Surg., September 1, 1999; 16(suppl_1): S57 - S60. [Abstract] [Full Text] [PDF]
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