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Ann Thorac Surg 1998;66:1759-1765
© 1998 The Society of Thoracic Surgeons

Original articles: general thoracic

Comparison of open and thoracoscopic bilateral volume reduction surgery: complications analysis

John R. Roberts, MDa, Joseph E. Bavaria, MDa, Peter Wahl, BAa, Angela Wurster, CRNPa, Joseph S. Friedberg, MDa, Larry R. Kaiser, MDa

a Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA

Address reprint requests to Dr Roberts, Department of Cardiac and Thoracic Surgery, 2986 The Vanderbilt Clinic, Nashville, TN 37232-5734
e-mail: (bob.roberts{at}mcmail.vanderbilt.edu)

Presented at the Forty-fourth Annual Meeting of the Southern Thoracic Surgical Association, Naples, FL, Nov 6–8, 1997.


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
Background. The effectiveness of lung volume reduction for the treatment of patients with emphysema is well established, but data about the surgical approach, the postoperative management, and complications are limited. We report a comparison of patients undergoing bilateral lung volume reduction (BLVRS) via median sternotomy and thoracoscopic techniques with emphasis on hospital course and complications.

Methods. All patients undergoing BLVRS at Hospital of University of Pennsylvania were analyzed for mortality and morbidity, using a combination of prospective data analysis and retrospective chart review.

Results. Patients undergoing BLVRS via median sternotomy were older than those undergoing video-assisted thoracoscopic surgery (VATS) procedures (63.9 ± 6.89 vs 59.3 ± 9.4 years, p = 0.005). Operating time was longer for the VATS procedure (147 versus 129 minutes, p = 0.006) while estimated blood less was greater for median sternotomy (209 versus 82 L, p = 0.0000017).

Significant differences were found in intensive care unit stay, days intubated, life-threatening complications, respiratory complications, requirement for tracheostomy, and death that favored VATS BLVRS. When only later cohorts of patients were compared, more life-threatening complications and deaths were found in patients undergoing BLVRS by median sternotomy. There were no differences between early and late median sternotomy BLVRS patients. Twenty-six percent of the lethal complications in median sternotomy BLVRS patients were bowel perforations, equally divided between duodenal ulcers and colons.

Conclusions. Managing patients after BLVRS remains complex. Bilateral video-assisted volume reduction offers equivalent functional outcome with potentially decreased morbidity and mortality. Gastrointestinal perforations can complicate the management of these patients.


   Introduction
Top
 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
When Cooper and coworkers [1] refined and reintroduced a technique for bilateral lung volume reduction surgery (BLVRS) originally described by Brantigan [2, 3], the treatment options for patients with emphysema changed dramatically. BLVRS often yields dramatic improvement in spirometry and exercise capability (as measured by 6-minute walk test [6MWT]) in selected patients with emphysema [1, 4, 5]. Postoperative evaluation of these patients reveals that 6MWT results and maximal oxygen consumption improve [4–7] and persist for 18 months after surgery [7, 8].

Despite long-term functional and spirometric follow-up reported in the literature, there has been minimal evaluation of the perioperative management. We evaluated our experience with BLVRS via two approaches, median sternotomy (MS) and video-assisted thoracoscopic surgery (VATS), with analysis of perioperative complications. A previous report from our institution [4] demonstrated that the two approaches yield equivalent functional results. Specifically, MS patients’ forced expiratory volume in 1 second (FEV1) improved 41.4% ± 37.3% while VATS patients’ FEV1 improved 41.2% ± 39.2%. Similarly, MS patients’ 6MWT improved from 999 to 1181 feet (20.2% ± 29.0%) while VATS patients’ 6MWT improved from 969 to 1244 feet (35.3% ± 35.8%). Neither of these differences was statistically significant. Our experience demonstrates significant gastrointestinal complications after this surgery that might be avoidable with attention to these problems.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patient population
Patients undergoing BLVRS at the University of Pennsylvania were eligible whether they had simultaneous MS, simultaneous VATS, or staged VATS procedures. These patients had severe airflow obstruction with FEV1 from 20% to 30% of predicted and residual volumes (RV) greater than 200% of predicted, as measured by body to plethysmography. All patients had large zones of poorly ventilated and perfused lung on quantitative perfusion lung scanning but did not have giant bullae.

Exclusion criteria included: (1) carbon dioxide partial pressure (pCO2) greater than 50 mm Hg, (2) pulmonary artery systolic pressure greater than 50 mm Hg, (3) recent (within 3 months) cigarette smoking, (4) body weight less than 80% or more than 120% of ideal body weight, (5) significant bronchospasm, (6) copious daily sputum production, and (7) poor functional status demonstrated by inability to walk 600 feet in a 6MWT after pulmonary rehabilitation. During the screening process, approximately 60% of patients were excluded from surgery.

After passing the initial screening, patients were enrolled in an outpatient pulmonary rehabilitation program for 6 weeks and the 6MWT repeated. Medical management was optimized and oral corticosteroids were weaned to the lowest dose possible. Patients requiring greater than 20 mg prednisone daily or its equivalent were excluded.

Surgical approach
The technique chosen represented each surgeon’s preference and was not based on patient characteristics. Similarly, referral to these surgeons was determined by patient and referring physician preference and was not affected by the patient’s characteristics. The technical aspects of both procedures were standard. At median sternotomy a double lumen endotracheal tube allowed sequential collapse of the lungs for resection using a linear stapling device buttressed with strips of bovine pericardium. Resection was directed toward diseased lung previously identified by ventilation-perfusion scanning. Apical pleural tents were used selectively and significant air leaks closed if possible. Two chest tubes were placed in both pleural spaces and the sternum closed in routine fashion with wire.

The thoracoscopic technique was performed with slight variation among the two surgeons. One surgeon (J.E.B.) typically used a small, vertical access thoracotomy (4 cm) to manipulate the lung while the thoracoscope was placed through a port in the anterior seventh intercostal space (the first chest tube site) and the stapling device through the same small access incision (a "two-port" VATS technique). The second surgeon (J.R.R.) placed the thoracoscope in the anterior seventh intercostal space. If the pleural space was free, the lung was removed through a second port in the second intercostal space after division through a third port in the anterior axillary line. Buttressing material was not used through the VATS approach.

Data from patients undergoing a staged procedure were added in order to compare the procedures. Thus, the length of stay, chest tube duration, epidural duration, and intensive care unit (ICU) duration for a staged VATS procedure would be the sum of the times from both hospitalizations. Similarly, the complications from both hospitalizations, if any, were included when analyzing complications from the staged VATS procedures.

Perioperative management
All patients were extubated in the operating room. Epidural catheters were placed preoperatively. A combination of epidural narcotics and local anesthetic was used. Rectal indomethacin or intravenous Toradol (Roche Laboratories, Nutley, NJ) were used to supplement pain control initially, but after several gastrointestinal complications, Indocin (Merck & Co., Westpoint, PA) was stopped entirely and Toradol used sparingly. After 4 days patients were converted to oral opioids or intravenous patient controlled narcotics.

Chest physiotherapy and inhaled bronchodilators were used on a routine schedule. Early ambulation was encouraged. Chest tubes were pulled within 24 hours after cessation of air leaks. Heimlich valves were used in patients with persistent air leaks to allow earlier discharge. Patients spent the first postoperative night in the recovery room and, if stable, were then transferred to the regular nursing unit. If reintubation was necessary early tracheostomy was employed. Intensive care management was otherwise routine.

Complications
Measured variables include incidence of reintubation, tracheostomy, Heimlich valve placement, bowel perforations, significant respiratory complications, and death. Further, complications were divided into three categories: life-threatening—causing cardiac arrest, sepsis, reintubation, transfer to the ICU or emergency surgery; major complications—resulting in prolonged hospital stay (such as elective surgery) but not requiring reintubation nor transfer to the ICU; and minor complications—requiring minimal intervention that did not prolong hospital stay (Table 1). In order to accurately analyze complications, we chose a broad definition of postoperative death to include not only those deaths that occurred in the hospital before discharge, but in outside hospitals (rehabilitation or ventilatory) after discharge.


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  		Table 1. Classification of Complications After Bilateral Lung Volume Reduction

 
Statistics
Data are expressed as means ± standard deviation. Unpaired Student’s t test was used to compare differences in continuous variables between the two techniques. Chi-square analysis was used to compare proportions of patients with a particular complication or outcome. A p value of less than 0.05 was considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
One hundred thirty-six patients underwent BLVRS. Eighty-six patients underwent simultaneous BLVRS via MS. Fifty patients underwent BLVRS via thoracoscopic techniques: 38 patients had bilateral procedures at the same sitting while 12 patients had two separate procedures. Table 2 details the demographics and preoperative pulmonary testing of the patients undergoing BLVRS. No differences in distribution of sex, pulmonary function, arterial blood gas results, nor 6MWT results were found. The patients undergoing MS were significantly older (63.9 ± 6.8 years versus 59.3 ± 9.4 years, p < 0.005).


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  		Table 2. Clinical Characteristics of Volume Reduction Patients

 
Hospital stay data, other than complications, are listed in Table 3. There were no significant differences in length of stay, chest tube duration, epidural duration, or Heimlich valve requirement. Operating times were significantly longer for the bilateral thoracoscopic technique (147 versus 129 minutes). Estimated blood loss was statistically greater for median sternotomy (82 versus 209 L) though of no clinical significance.


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  		Table 3. Hospital Data After Bilateral Lung Volume Reduction

 
When the complications in BLVRS patients were compared, MS patients suffered more major respiratory complications, were more likely to be reintubated, had longer ICU stays, and more frequently required tracheostomy (Tables 1 and 4). There were tendencies toward increased frequency of bowel perforation and reintubation that did not reach statistical significance.


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  		Table 4. Overall Complications After Bilateral Lung Volume Reduction

 
In order to eliminate learning curve bias that favored VATS BLVRS because many of the MS BLVRS patients were treated earlier in our experience, two cohorts from September 1993 to March 29, 1995 and from March 29, 1995 to March 1997 were compared. This date was chosen for two reasons: it gave roughly equal numbers of patients in each group (43 MS versus 49 VATS), and it marked the halfway point for the MS patients. Table 5 summarizes these data and reveals that length of ICU stay and incidence of respiratory complications remained greater with MS even in the later experience.


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  		Table 5. Complications After Bilateral Lung Volume Reduction—Comparison of Late Cohorts of MS and VATS

 
As noted in the Materials and Methods section, all complications were classified into one of three groups to compare the relative frequency of life-threatening, major, and minor complications. Tables 1 and 6 summarize the comparison between MS and VATS approaches as related to these complications and death, both for the overall groups and for the comparison of the late cohorts. Video-assisted thoracoscopic surgery patients suffered fewer life-threatening complications in both comparisons. Further, the overall comparisons revealed fewer deaths among VATS patients, though this difference did not persist in the comparison of the late cohorts. When the ages of the patients who died were compared with those of the group overall, there was a tendency but no statistical difference (deaths 66.6 ± 7.9 years versus survivors 62.2 ± 8.4 years, p = 0.054), suggesting that age is not an independent determinant.


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  		Table 6. Overall Incidence of Complications and Death After Bilateral Lung Volume Reduction

 
We were struck by the incidence of gastrointestinal complications in the patients undergoing BLVRS by MS. Five of 11 deaths in these patients were due to a perforated viscus (ulcer or colon). These complications developed in patients who were faring well, without significant respiratory issues (Table 4). This complication occurred exclusively in patients undergoing MS, was equally divided between the early and late cohorts (Table 7), and did not appear to relate to the use of non-steroidal antiinflammatory agents for pain control.


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  		Table 7. Comparison of Early and Late Cohorts Undergoing Bilateral Lung Volume Reduction (BLVRS) via Median Sternotomy (MS)

 
Table 7 summarizes the comparison between early and late cohorts of patients undergoing MS. There were no differences in any spirometric, blood gas, or functional parameter between the two groups. The later cohort was somewhat older (65.4 versus 62.4 years, p = 0.042) yet had shorter ICU stays, fewer days intubated, and shorter lengths of stay. Though these differences did not reach statistical significance due to wide standard deviations, they serve to illustrate the learning curve for the management of these patients.


   Comment
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Despite the benefits to some emphysema patients undergoing BLVRS, several questions remain. Among these are the ideal approach and the optimum postoperative management. Our analysis was designed to clarify these issues. Kotloff and coworkers had previously reported our experience with BLVRS when they compared 80 patients who underwent BLVRS via MS and 40 patients via VATS [4]. That analysis found no postoperative functional nor spirometric differences between the results of the two procedures. Further, the same group noted a greater mortality in patients undergoing MS BLVRS that was largely confined to patients older than 65 [4]. This report will focus on the postoperative complications of a somewhat larger group. The conclusions of this study are limited by two factors. First, it is not randomized, and thus is prone to selection bias. Second, the patients undergoing MS were older, and although functionally equivalent from pulmonary and cardiac standpoints, may have been frailer in terms of gastrointestinal or neurologic function.

Cooper and colleagues’ first series of 20 patients underwent BLVRS via MS with no significant morbidity nor mortality [1]. They subsequently reported on their first 100 patients, with a 90-day mortality rate of 3%, all from respiratory complications [9]. Since then, others have reported their experience with BLVRS via MS, with mortality rates (0–19.1%) generally greater than those reported by Cooper. Bousamra and coworkers operated on 45 patients with 5 deaths for a mortality rate of 11.1% [6]. Bagley and coworkers operated on 55 patients in a community hospital setting using mostly median sternotomy and occasional anterior thoracotomies because of previous tracheostomy [10]. They reported 3 deaths for a mortality rate of 5.45%. Szekely and associates reported 47 patients with a 19.1% mortality rate in a university hospital setting [11]. Date and associates had no mortality in 39 patients [12]. The weighted average mortality rate of all series combined was 6.83%.

We noted a 90-day mortality rate of 12.8% (11 patients) in our cohort of 86 patients undergoing BLVRS by MS. Four patients (36.4% of the deaths) died from gastric, duodenal, or colonic perforations in patients who were faring well from a respiratory standpoint (Table 1). Three patients (21.4%) died from pneumonia or other respiratory failure, and 1 patient each (9.1%) from empyema, mediastinitis, postoperative bleeding, and cardiac arrest. Gastrointestinal complications represented a significant fraction of the mortality in our patients. All of these patients were tolerating a regular diet prior to BLVRS with no history of peptic ulcer disease nor constipation. Further, narcotics were restricted to avoid respiratory depression and thus contributed little to constipation. These findings suggest: (1) routine gastrointestinal prophylaxis (antacids, H2 blockers, or proton-pump inhibitors) is warranted and (2) prevention of constipation should be of paramount importance. Though we considered nonsteroidal use, contributory analysis reveals that the incidence did not decrease after stopping non-steroidals.

McKenna and colleagues first reported on a comparison of unilateral and bilateral thoracoscopic volume reduction and found a mortality rate of 2.5% in 79 patients (2 deaths) [13]. One death resulted from an acute abdomen and the second from respiratory failure. Bissinger and colleagues described their experience with 20 patients and no mortality [14]. Brenner and coworkers studied dyspnea response in 139 patients and reported 6 deaths—3 due to respiratory complications and one each to PE, cardiopulmonary arrest, and acute abdominal event [15]. Finally, McKenna and colleagues’ comparison of stapled and laser volume reduction resulted in a single death (2.5%) in 39 patients due to a contralateral pneumothorax. The weighted average of mortality rate in these series was 2.5%.

We found a greater morbidity and mortality rate in patients undergoing BLVRS via MS compared with VATS. As noted above, the patients undergoing MS were older and may have been frailer, but the data are nonetheless compelling. Our data, combined with review of the literature, suggest that VATS may be better tolerated, although several of the reports on BLVRS by MS came from institutions with less general thoracic experience and might be expected to have higher mortality. Cooper and associates’ mortality rate with BLVRS by MS compares well with any by VATS.

It is unclear why MS might be less well tolerated than VATS. Median sternotomy, though somewhat painful, is not nearly so painful as a thoracotomy and is routinely managed after coronary bypass surgery without an epidural. However, Berrizbeitia and coworkers studied the effects of MS and coronary artery bypass surgery on postoperative pulmonary mechanics and found loss of pulmonary function persisting 8 weeks after surgery [16]. Their group of 10 patients undergoing coronary artery bypass grafting without harvest of an internal mammary artery lost 0.45 ± 0.27 L in their FEV1, approximately 16% of preoperative FEV1. These data argue that a median sternotomy adversely affects pulmonary function. The effect of thoracoscopic wounds on pulmonary function is not known.

There was 1 death in our series of 50 patients undergoing VATS BLVRS, from pneumonia and acute respiratory distress syndrome. There were no gastrointestinal complications compared with 5 deaths in MS group resulting from gastrointestinal complications (0% versus 5.81% mortality). This difference from the MS group is difficult to explain, as epidural catheters were used for the same duration. After removal of the epidural catheters, patients were placed on oral oxycodone and rectal indomethacin as needed, until the Indocin (Merck) was discontinued. Patients having undergone MS BLVRS might have required more oxycodone, causing constipation and colonic distention. The older MS patients might have been more prone to constipation.

The management of these patients will continue to be difficult and gastrointestinal complications appear to occur with significant frequency and are associated with high mortality. Future management will require vigilance about potential gastrointestinal complications, and decisions about appropriate patient selection for the procedure. These questions should be clarified by the National Emphysema Treatment Trial.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. 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]
  2. Brantigan O.C., Mueller E. Surgical treatment of pulmonary emphysema. Am Surg 1957;23:789-804.[Medline]
  3. Brantigan O.C., Mueller E., Kress M.B. A surgical approach to pulmonary emphysema. Am Rev Respir Dis 1959;80:194-202.[Medline]
  4. Kotloff R.M., Tino G., Bavaria J.E., et al. Bilateral lung volume reduction surgery for advanced emphysema: a comparison of median sternotomy and thoracoscopic approaches. Chest 1996;110:1399-1406.[Abstract/Free Full Text]
  5. Sciurba F.C., Rogers R.M., Keenan R.J., et al. Improvement in pulmonary function and elastic recoil after lung-reduction surgery for diffuse emphysema. N Engl J Med 1996;334:1095-1099.[Abstract/Free Full Text]
  6. Bousamra M., Haasler G.B., Lipchik R.J., et al. Functional and oximetric assessment of patients after lung reduction surgery. J Thorac Cardiovasc Surg 1997;113:675-682.[Abstract/Free Full Text]
  7. Cordova F., O’Brien G., Furukawa S., Kuzma A.M., Travaline J., Criner G.J. Stability of improvements in exercise performance and quality of life following bilateral lung volume reduction surgery in severe COPD. Chest 1997;112:907-915.[Abstract/Free Full Text]
  8. Gelb A.F., Brenner M., McKenna R.J., Zamel N., Rischel R., Epstein J.D. Lung function 12 months following emphysema resection. Chest 1996;110:1407-1415.[Abstract/Free Full Text]
  9. Cooper J.D., Patterson G.A. Lung volume reduction surgery for severe emphysema. Sem Thorac Cardiovasc Surg 1996;8:52-60.[Medline]
  10. Bagley P.H., Davis S.M., Oshea M., Coleman A.-M. Lung volume reduction surgery at a community hospital: Program development and outcomes. Chest 1997;111:1552-1559.[Abstract/Free Full Text]
  11. Szekely L.A., Oelberg D.A., Wright C., et al. Preoperative predictors of operative morbidity and mortality in COPD patients undergoing bilateral lung volume reduction surgery. Chest 1997;111:550-558.[Abstract/Free Full Text]
  12. Date H., Goto K., Souda R., et al. Bilateral lung volume reduction surgery via median sternotomy for severe pulmonary emphysema. Ann Thorac Surg 1998;65:939-942.[Abstract/Free Full Text]
  13. McKenna R.J., Brenner M., Fischel R.J., Gelb A.F. Should lung volume reduction for emphysema be unilateral or bilateral?. J Thorac Cardiovasc Surg 1996;112:1331-1339.[Abstract/Free Full Text]
  14. Bissinger 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]
  15. Brenner M., McKenna R.J., Gelb A.F., et al. Dyspnea response following bilateral thoracoscopic staple lung volume reduction surgery. Chest 1997;112:916-923.[Abstract/Free Full Text]
  16. Berrizbeitia L.D., Tessler S., Jacobowitz I.J., Kaplan P., Budzilowicz, Cunningham J.N. Effect of sternotomy and coronary bypass surgery on postoperative pulmonary mechanics: Comparison of internal mammary and saphenous vein bypass grafts. Chest 1989;96:873-876.[Abstract/Free Full Text]



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