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Everaerts S, Vandervelde CM, Shah P, Slebos DJ, Ceulemans LJ. Surgical and bronchoscopic pulmonary function-improving procedures in lung emphysema. Eur Respir Rev 2023; 32:230004. [PMID: 38123230 PMCID: PMC10731473 DOI: 10.1183/16000617.0004-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/17/2023] [Indexed: 12/23/2023] Open
Abstract
COPD is a highly prevalent, chronic and irreversible obstructive airway disease without curative treatment. Standard therapeutic strategies, both non-pharmacological and pharmacological, have only limited effects on lung function parameters of patients with severe disease. Despite optimal pharmacological treatment, many patients with severe COPD still have a high burden of dyspnoea and a poor quality of life. If these patients have severe lung emphysema, with hyperinflation as the driver of symptoms and exercise intolerance, lung volume reduction may be an effective treatment with a significant impact on lung function, exercise capacity and quality of life. Currently, different lung volume reduction approaches, both surgical and bronchoscopic, have shown encouraging results and have been implemented in COPD treatment recommendations. Nevertheless, choosing the optimal lung volume reduction strategy for an individual patient remains challenging. Moreover, there is still room for improving durability of effect and safety in all available procedures. Ongoing and innovative research is essential to push this field forwards. This review provides an overview of results and limitations of the current lung volume reduction options for patients with severe lung emphysema and hyperinflation.
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Affiliation(s)
- Stephanie Everaerts
- Department of Pulmonary Diseases, University Hospitals Leuven, Leuven, Belgium
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
| | - Christelle M. Vandervelde
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Pallav Shah
- Department of Pulmonology, Royal Brompton Hospital, London, UK
- National Heart and Lung Institute, Imperial College, London, UK
- Department of Pulmonology, Chelsea and Westminster Hospital, London, UK
| | - Dirk-Jan Slebos
- Department of Pulmonary Diseases, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Both authors contributed equally
| | - Laurens J. Ceulemans
- Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism, KU Leuven, Leuven, Belgium
- Department of Thoracic Surgery, University Hospitals Leuven, Leuven, Belgium
- Both authors contributed equally
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Caviezel C, Rodriguez M, Sirotkin P, Held U, Opitz I, Schneiter D. Relevance of pleural adhesions for short- and long-term outcomes after lung volume reduction surgery. JTCVS OPEN 2023; 16:996-1003. [PMID: 38204661 PMCID: PMC10774947 DOI: 10.1016/j.xjon.2023.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/14/2023] [Accepted: 06/20/2023] [Indexed: 01/12/2024]
Abstract
Objective Pleural adhesions (PLAs) have been shown to be a possible risk factor for air leak after lung volume reduction surgery (LVRS), but the relevance of PLA for lung function outcome remains unclear. We analyzed our LVRS cohort for the influence of PLA on short-term (ie, prolonged air leak) and long-term outcomes. Methods Retrospective observational cohort study with 187 consecutive patients who underwent LVRS from January 2016 to December 2019. PLA were defined as relevant if they were distributed extensively at the dorsal pleura; were present in at least at 2 areas, including the dorsal pleura; or present extensively at the mediastinal pleura. In patients with bilateral emphysema, bilateral LVRS was performed preferentially. The objectives were to quantify the association of PLA and rate of prolonged air leak (chest tube >7 days), and the association of PLA with postoperative exacerbations and with forced expiratory volume in 1 second 3 months postoperatively. The associations were quantified with odds ratios for binary outcomes, and with between-group differences for continuous outcomes. To account for missing observations, 100-fold multiple imputation was used. Results PLAs were found in 46 of 187 patients (24.6%). There was a 32.6% rate of prolonged air leak (n = 61), mean chest tube time was 7.84 days. A total of 94 (50.3%) LVRSs were unilateral and 93 were bilateral. There was evidence for an association between PLA and the rate of prolonged air leak (odds ratio, 2.83; 95% CI, 1.36 to 5.89; P = .006). There was no evidence for an association between PLA and postoperative exacerbations (odds ratio, 1.11; 95% CI, 0.5 to 2.45; P = .79). There was no evidence for an association between PLA and forced expiratory volume in 1 second (estimate -1.52; 95% CI -5.67 to 2.63; P = .47). Both unilateral and bilateral LVRS showed significant postoperative improvements in forced expiratory volume in 1 second by 27% (8.43 units; 95% CI, 3.66-13.12; P = .0006) and by 28% (7.87 units; 95% CI, 4.68-11.06; P < .0001) and a reduction in residual volume of 15% (-33.9 units; 95% CI, -56.37 to -11.42; P = .003) and 15% (-34.9 units; 95% CI, -52.57 to -17.22; P = .0001), respectively. Conclusions Patients should be aware of potential prolongation of hospitalization due to PLA. However, there might be no relevant influence of PLA on lung function outcomes.
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Affiliation(s)
- Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Medea Rodriguez
- Department of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Pavel Sirotkin
- Epidemiology, Biostatistics, and Prevention Institute, University of Zürich, Zürich, Switzerland
| | - Ulrike Held
- Epidemiology, Biostatistics, and Prevention Institute, University of Zürich, Zürich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital Zürich, Zürich, Switzerland
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Caviezel C, Steinack C, Schneiter D, Gaisl T, Schmitt-Opitz I. [Surgical or bronchoscopic lung volume reduction for emphysema therapy]. Zentralbl Chir 2023; 148:S51-S70. [PMID: 37604145 DOI: 10.1055/a-1990-4810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023]
Abstract
More than 20 years ago, surgical lung volume reduction (LVRS) was already established in patients with advanced emphysema as a palliative therapy option that reduces respiratory distress and improves lung function and quality of life. In addition, bronchoscopic procedures (BLVR) aimed at volume reduction have existed for just over 10 years. The advantages and disadvantages of LVRS and BLVR are discussed in this article.
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Caviezel C, Guglielmetti LC, Ladan M, Hansen HJ, Perch M, Schneiter D, Weder W, Opitz I, Franzen D. Lung volume reduction surgery as salvage procedure after previous use of endobronchial valves. Interact Cardiovasc Thorac Surg 2021; 32:263-269. [PMID: 33280038 DOI: 10.1093/icvts/ivaa261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 09/25/2020] [Accepted: 10/04/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES Lung volume reduction (LVR) is an efficient and approved treatment for selected emphysema patients. There is some evidence that repeated LVR surgery (LVRS) might be beneficial, but there are no current data on LVRS after unsuccessful bronchoscopic LVR (BLVR) with endobronchial valves (EBVs). We hypothesize good outcome of LVRS after BLVR with valves. METHODS In this study, we retrospectively investigated all patients who underwent LVRS between 2015 and 2019 at 2 centres after previous unsuccessful EBV treatment. They were further divided into subgroups with patients who never achieved the intended improvement after BLVR (primary failure) and patients whose benefit was fading over time due to the natural development of emphysema (secondary failure). Patients with severe air leak after BLVR and immediate concomitant LVRS and fistula closure thereafter were analysed separately. RESULTS A total of 38 patients were included. Of these, 19 patients had primary failure, 15 secondary failure and 4 were treated as an emergency due to severe air leak. At 3 months after LVRS, forced expiratory volume in 1 s had improved significantly by 12.5% (P = 0.011) and there was no 90-day mortality. Considering subgroups, patients with primary failure after BLVR seem to profit more than those with secondary failure. Patients with severe air leak after BLVR did not profit from fistula closure with concomitant LVRS. CONCLUSIONS LVRS after previous BLVR with EBVs can provide significant clinical improvement with low morbidity, although results might not be as good as after primary LVRS.
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Affiliation(s)
- Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | | | - Mateja Ladan
- Department of Cardiothoracic Surgery, Rigshospitalet, Copenhagen, Denmark
| | | | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation, Rigshospitalet, Copenhagen, Denmark
| | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Daniel Franzen
- Department of Pulmonary Medicine, University Hospital Zurich, Zurich, Switzerland
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Weder W, Ceulemans LJ, Opitz I, Schneiter D, Caviezel C. Lung Volume Reduction Surgery in Patients with Homogeneous Emphysema. Thorac Surg Clin 2021; 31:203-209. [PMID: 33926673 DOI: 10.1016/j.thorsurg.2021.02.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Randomized controlled trials have demonstrated that lung volume reduction surgery (LVRS) improves exercise capacity, lung function, and quality of life in patients with heterogenous emphysema on computed tomographic and perfusion scan. However, most patients have a nonheterogenous type of destruction. These patients, summarized under "homogeneous emphysema," may also benefit from LVRS as long they are severely hyperinflated, and adequate function is remaining with a diffusing capacity of the lungs for carbon monoxide greater than 20% and no pulmonary hypertension. Surgical mortality is low when patients are well selected.
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Affiliation(s)
- Walter Weder
- Thoracic Surgery, Thoraxchirurgie Bethanien, Toblerstrasse 61, 8044 Zürich, Switzerland.
| | - Laurens J Ceulemans
- Department of Thoracic Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| | - Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
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Lenga P, Ruwwe-Glösenkamp C, Grah C, Pfannschmidt J, Rückert J, Eggeling S, Gläser S, Schmidt B, Schneider P, Kurz S, Leschber G, Gebhardt A, Becke B, Schega O, Borchardt J, Hübner RH. Endoscopic lung volume reduction with endobronchial valves in very low D LCO patients: results from the German Registry - Lungenemphysemregister e.V. ERJ Open Res 2021; 7:00449-2020. [PMID: 33532454 PMCID: PMC7836438 DOI: 10.1183/23120541.00449-2020] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 09/23/2020] [Indexed: 11/29/2022] Open
Abstract
Background Endoscopic lung volume reduction (ELVR) with valves has been suggested to be the key strategy for patients with severe emphysema and concomitant low diffusing capacity of the lung for carbon monoxide (DLCO). However, robust evidence is still missing. We therefore aim to compare clinical outcomes in relation to DLCO for patients treated with ELVR. Methods We assessed DLCO at baseline and 3 months follow-up and compared pre- and postprocedural pulmonary function test, quality of life, exercise capacity and adverse events. This is a retrospective subanalysis of prospectively collected data from the German Lung Emphysema Registry. Results In total, 121 patients treated with ELVR were analysed. Thirty-four patients with a DLCO ≤20% and 87 patients with a DLCO >20% showed similar baseline characteristics. After ELVR, there was a decrease of residual volume (both p<0.001 to baseline) in both groups, and both demonstrated better quality of life (p<0.01 to baseline). Forced expiratory volume in 1 s (FEV1) improved significantly only in patients with a DLCO >20% (p<0.001 to baseline). Exercise capacity remained almost unchanged in both groups (p=0.3). The most frequent complication for both groups was a pneumothorax (DLCO ≤20%: 17.6% versus DLCO >20%: 16.1%; p=0.728). However, there were no significant differences in other adverse events between both groups. Conclusions ELVR improves lung function as well as quality of life in patients with DLCO >20% and DLCO ≤20%. Adverse events did not differ between groups. Therefore, ELVR should be considered as a treatment option, even in patients with a very low DLCO. Endoscopic lung volume reduction with endobronchial valves can be safely performed in patients with a very low diffusing capacity of the lung (DLCO). Clinical effectiveness is comparable to patients with higher DLCO.https://bit.ly/3cOgDK1
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Affiliation(s)
- Pavlina Lenga
- Dept of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,These authors contributed equally
| | - Christoph Ruwwe-Glösenkamp
- Dept of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany.,These authors contributed equally
| | - Christian Grah
- Dept of Internal Medicine and Respiratory Medicine, Clinic Havelhöhe Berlin, Berlin, Germany
| | - Joachim Pfannschmidt
- Dept of Thoracic Surgery, Heckeshorn Lung Clinic, Helios Klinikum Emil von Behring, Berlin, Germany
| | - Jens Rückert
- Dept of Surgery, Competence Center of Thoracic Surgery, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Eggeling
- Dept of Thoracic Surgery, Vivantes Netzwerk für Gesundheit, Klinikum Neukölln, Berlin, Germany
| | - Sven Gläser
- Dept of Pulmonary Medicine and Infectious Diseases, Vivantes-Klinikum Neukölln, Berlin, Germany
| | - Bernd Schmidt
- Dept of Respiratory Medicine, DRK Kliniken Berlin Mitte, Berlin, Germany
| | - Paul Schneider
- Dept of Thoracic Surgery, DRK Kliniken Berlin Mitte, Berlin, Germany
| | - Sylke Kurz
- Dept of Respiratory Medicine, ELK Berlin Chest Hospital, Berlin, Germany
| | - Gunda Leschber
- Dept of Thoracic Surgery, ELK Berlin Chest Hospital, Berlin, Germany
| | - Andreas Gebhardt
- Dept of Internal Medicine and Respiratory Medicine, Helios Hospital Emil von Behring, Berlin, Germany
| | - Birgit Becke
- Dept of Respiratory Medicine, Johanniter-Krankenhaus, Treuenbrietzen, Germany
| | - Olaf Schega
- Dept of Thoracic Surgery, Johanniter-Krankenhaus, Treuenbrietzen, Germany
| | - Jakob Borchardt
- Dept of Pulmonary Medicine and Infectious Diseases, Vivantes-Klinikum Friedrichshain, Berlin, Germany
| | - Ralf-Harto Hübner
- Dept of Infectious Diseases and Respiratory Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Kösek V, Thiel B, Nikolova K, Al-Masri E, Begher C, Frank C, Redwan B. Lung volume reduction surgery: from National Emphysema Treatment Trial to non-intubated awake video-assisted thoracoscopic surgery. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1468. [PMID: 33313213 PMCID: PMC7723631 DOI: 10.21037/atm-20-6430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a major public health problem. Loss of elastic recoil, hyperinflation and obstruction of the expiratory airflow lead to an increased breathing work, which results in dyspnea during minimal physical activity of the patients. Reduction of the lung volume in these patients leads to improvement of dyspnea, physical activity and quality of life in these patients. Beside endoscopic lung volume reduction (ELVR), lung volume reduction surgery (LVRS) represents an important and valuable treatment option for patients with advanced lung emphysema. Since the National Emphysema Treatment Trial (NETT), thoracic surgery experienced a remarkable evolution of the surgical techniques enabling safe surgery and quick recovery in this critically ill patient cohort. A paradigm shift from open surgical approaches to most minimally invasive techniques accompanied by improvement of anesthesiologic management of these patients was evident. Moreover, indications for LVRS, which were originally described in the NETT, were extended to apply for further groups of patients with advanced lung emphysema, enabling significant clinical improvement in well-selected patients with a low perioperative morbidity and mortality. The current review will give an overview of the historical approaches for LVRS, highlight the indications for LVRS and discuss the development of the surgical approaches.
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Affiliation(s)
- Volkan Kösek
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Burkhard Thiel
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Katina Nikolova
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Eyad Al-Masri
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Christian Begher
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Christina Frank
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
| | - Bassam Redwan
- Department of Thoracic Surgery, Klinikum Westfalen, Klinik am Park, Lünen, Germany
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8
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van Dijk M, Klooster K, Ten Hacken NHT, Sciurba F, Kerstjens HAM, Slebos DJ. The effects of lung volume reduction treatment on diffusing capacity and gas exchange. Eur Respir Rev 2020; 29:29/158/190171. [PMID: 33115787 DOI: 10.1183/16000617.0171-2019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 05/19/2020] [Indexed: 11/05/2022] Open
Abstract
Lung volume reduction (LVR) treatment in patients with severe emphysema has been shown to have a positive effect on hyperinflation, expiratory flow, exercise capacity and quality of life. However, the effects on diffusing capacity of the lungs and gas exchange are less clear. In this review, the possible mechanisms by which LVR treatment can affect diffusing capacity of the lung for carbon monoxide (D LCO) and arterial gas parameters are discussed, the use of D LCO in LVR treatment is evaluated and other diagnostic techniques reflecting diffusing capacity and regional ventilation (V')/perfusion (Q') mismatch are considered.A systematic review of the literature was performed for studies reporting on D LCO and arterial blood gas parameters before and after LVR surgery or endoscopic LVR with endobronchial valves (EBV). D LCO after these LVR treatments improved (40 studies, n=1855) and the mean absolute change from baseline in % predicted D LCO was +5.7% (range -4.6% to +29%), with no real change in blood gas parameters. Improvement in V' inhomogeneity and V'/Q' mismatch are plausible explanations for the improvement in D LCO after LVR treatment.
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Affiliation(s)
- Marlies van Dijk
- University of Groningen, Dept of Pulmonary Diseases, University Medical Center Groningen, Research Institute for Asthma and COPD Groningen, Groningen, The Netherlands
| | - Karin Klooster
- University of Groningen, Dept of Pulmonary Diseases, University Medical Center Groningen, Research Institute for Asthma and COPD Groningen, Groningen, The Netherlands
| | - Nick H T Ten Hacken
- University of Groningen, Dept of Pulmonary Diseases, University Medical Center Groningen, Research Institute for Asthma and COPD Groningen, Groningen, The Netherlands
| | - Frank Sciurba
- Division of Pulmonary and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Huib A M Kerstjens
- University of Groningen, Dept of Pulmonary Diseases, University Medical Center Groningen, Research Institute for Asthma and COPD Groningen, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- University of Groningen, Dept of Pulmonary Diseases, University Medical Center Groningen, Research Institute for Asthma and COPD Groningen, Groningen, The Netherlands
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Eichhorn ME, Gompelmann D, Hoffmann H, Dreher S, Hornemann K, Haag J, Kontogianni K, Heussel CP, Winter H, Herth FJF, Eberhardt R. Consolidating Lung Volume Reduction Surgery After Endoscopic Lung Volume Reduction Failure. Ann Thorac Surg 2020; 111:1858-1865. [PMID: 32991839 DOI: 10.1016/j.athoracsur.2020.06.148] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 05/09/2020] [Accepted: 06/29/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Bronchoscopic valve placement constitutes an effective endoscopic lung volume reduction (ELVR) therapy in patients with severe emphysema and low collateral ventilation. After the most destroyed lobe is occluded with valves, significant target lobe volume reduction leads to improvements in lung function, exercise capacity, and quality of life. The effects are not consistent in some patients, leading to long-term therapy failure. We hypothesized that surgical lung volume reduction (LVRS) would reestablish ELVR short-term clinical improvements after ELVR long-term failure. METHODS This retrospective single-center analysis included all patients who underwent consolidating LVRS by lobectomy after long-term failure of valve therapy between 2010 and 2015. Changes in forced expiratory volume in 1 second, residual volume, 6-minute walking distance, and Modified Medical Research Council dyspnea score 90 days after ELVR and LVRS were analyzed, and the outcomes of both procedures were compared. RESULTS LVRS was performed in 20 patients after ELVR failure. A lower lobectomy was performed in 90%. The 30-day mortality of the cohort was 0% and 90-day mortality was 5% (1 of 20). The remaining 19 patients showed a significant increase in forced expiratory volume in 1 second (+27.5% ± 19.4%) and a reduction in residual volume (-21.0% ± 17.4%) and total lung capacity (-11.1% ± 11.1%). This resulted in significant improvements in exercise tolerance (6-minute walking distance: +56 ± 60 m) and relief of dyspnea (ΔModified Medical Research Council: -1.8 ± 1.4 points.). CONCLUSIONS Consolidating LVRS by lobectomy after failure of a previously successful ELVR is feasible and results in significant symptom relief and improvement of lung function.
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Affiliation(s)
- Martin E Eichhorn
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL).
| | - Daniela Gompelmann
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Hans Hoffmann
- Division of Thoracic Surgery, Technical University of Munich, Munich, Germany
| | - Sascha Dreher
- Department of Thoracic Surgery, Klinik Schillerhöhe, Robert-Bosch-Hospital, Stuttgart, Germany
| | - Katrin Hornemann
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Johannes Haag
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Konstantina Kontogianni
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Claus P Heussel
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Diagnostic and Interventional Radiology with Nuclear Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Department of Diagnostic and Interventional Radiology, Heidelberg University, Heidelberg, Germany
| | - Hauke Winter
- Department of Thoracic Surgery, Thoraxklinik, Heidelberg University, Heidelberg, Germany; Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL)
| | - Felix J F Herth
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany
| | - Ralf Eberhardt
- Translational Lung Research Center (TLRC), Heidelberg, Germany, member of German Center for Lung Research (DZL); Department of Pneumology and Critical Care Medicine, Thoraxklinik, Heidelberg University, Heidelberg, Germany
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10
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Caviezel C, Froehlich T, Schneiter D, Muehlematter U, Frauenfelder T, Guglielmetti LC, Opitz I, Weder W. Identification of target zones for lung volume reduction surgery using three-dimensional computed tomography rendering. ERJ Open Res 2020; 6:00305-2020. [PMID: 32963992 PMCID: PMC7487346 DOI: 10.1183/23120541.00305-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 06/04/2020] [Indexed: 11/05/2022] Open
Abstract
Background The key issues for performing lung volume reduction surgery (LVRS) is the identification of the target zones. Recently introduced three-dimensional computed tomography rendering methods are used to identify the morphological distribution and its severity of lung emphysema by densitometry. We demonstrate a new software for emphysema imaging and show the pre- and post-operative results in patients undergoing LVRS planned based on this new technology. Methods A real-time three-dimensional image analysis software system was used pre- and 3 months post-operatively in five patients with heterogeneous emphysema and a single patient with homogeneous morphology scheduled for LVRS. Focus was on low attenuation areas with <950 HU, distribution on both lungs and the value of the three-dimensional images for planning surgery. Functional outcome was assessed by pulmonary function tests after 3 months. Results Five patients underwent bilateral LVRS and one patient had unilateral LVRS. All patients showed a median increase in forced expiratory volume in 1 s of 70% (range 30–120%), compared with baseline values. Hyperinflation (expressed as residual volume/total lung capacity ratio) was reduced by 30% (range 5–32%). In the patients with heterogeneous emphysema, the pre- and post-operative computed tomography scans and the densitometries showed a decrease in low attenuation areas by 23% (right side) and by 17% (left side), respectively. Conclusion We demonstrate three-dimensional computed tomography-rendered images for planning personalised remodelling of hyperinflated lungs using LVRS. This user-friendly software has the potential to assist surgeons and interventional pulmonologists to select patients and to visualise target areas in LVRS procedures. New, user-friendly software with 3D CT-rendered images can be used for planning personalised remodelling of hyperinflated lungs using LVRShttps://bit.ly/3fbICn2
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Affiliation(s)
- Claudio Caviezel
- Dept of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Tamara Froehlich
- Dept of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Didier Schneiter
- Dept of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Urs Muehlematter
- Institute for Interventional and Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute for Interventional and Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland
| | | | - Isabelle Opitz
- Dept of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Walter Weder
- Dept of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
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11
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van Dijk M, Hartman JE, Klooster K, Ten Hacken NHT, Kerstjens HAM, Slebos DJ. Endobronchial Valve Treatment in Emphysema Patients with a Very Low DLCO. Respiration 2020; 99:163-170. [PMID: 31962325 DOI: 10.1159/000505428] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/11/2019] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND For selected patients with severe emphysema, bronchoscopic lung volume reduction with endobronchial valves (EBV) is recognized as an additional treatment option. In most trials investigating EBV treatment, patients with a very low diffusing capacity (DLCO) were excluded from participation. OBJECTIVES Our goal was to investigate whether EBV treatment in patients with emphysema with a very low DLCO is safe and effective. METHODS This was a single-center retrospective analysis including patients with emphysema and a DLCO ≤20%pred who underwent EBV treatment. Follow-up was performed 6 months post-treatment. Outcome parameters were compared to a historical matched control group (DLCO >20%pred, matched for sex, age, forced expiratory volume in 1 s [FEV1], and residual volume [RV]). RESULTS Twenty patients (80% female, 64 ± 6 years, FEV1 26 ± 6%pred, RV 233 ± 45%pred, DLCO 18 ± 1.6%pred) underwent EBV treatment. At 6 months follow-up, we found a statistically significant improvement in FEV1 (0.08 ± 0.12 L), RV (-0.45 ± 0.95 L), 6-min walking distance (38 ± 65 m), and St. George's Respiratory Questionnaire (-12 ± 13 points). With the exception of FEV1, all exceeded the minimal clinically important difference. The most common serious adverse event was a pneumothorax requiring intervention (15%). There were no significant differences in outcome compared to the DLCO >20%pred control group. CONCLUSIONS In this single-center retrospective analysis, we showed statistically significant and clinically relevant improvements in lung function, exercise capacity, and quality of life up to 6 months after EBV treatment in emphysema patients with a DLCO ≤20% (14-20%) of predicted with no increased risk of serious adverse events.
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Affiliation(s)
- Marlies van Dijk
- University of Groningen, Department of Pulmonary Diseases, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands,
| | - Jorine E Hartman
- University of Groningen, Department of Pulmonary Diseases, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Karin Klooster
- University of Groningen, Department of Pulmonary Diseases, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Nick H T Ten Hacken
- University of Groningen, Department of Pulmonary Diseases, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Huib A M Kerstjens
- University of Groningen, Department of Pulmonary Diseases, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
| | - Dirk-Jan Slebos
- University of Groningen, Department of Pulmonary Diseases, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD, Groningen, The Netherlands
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12
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Weaver H, Greening NJ, Rathinam S. Lung volume reduction surgery in patients with low diffusion capacity. J Thorac Dis 2019; 11:S234-S236. [PMID: 30997185 DOI: 10.21037/jtd.2019.01.91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Helen Weaver
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Neil J Greening
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
| | - Sridhar Rathinam
- Department of Thoracic Surgery, Glenfield Hospital, Leicester, UK
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13
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Surgical and endoscopic interventions that reduce lung volume for emphysema: a systemic review and meta-analysis. THE LANCET RESPIRATORY MEDICINE 2019; 7:313-324. [PMID: 30744937 DOI: 10.1016/s2213-2600(18)30431-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 09/27/2018] [Accepted: 10/08/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Severe emphysema is a debilitating condition with few treatment options. Lung volume reduction procedures in the treatment of severe emphysema have shown excellent results in selected patients but their exact role remains unclear with studies reporting a wide variation in outcomes. We therefore aimed to evaluate the effects of volume reduction. METHODS We did a systematic review and meta-analysis. We searched MEDLINE on Sept 29, 2016, for trials of lung volume reduction in patients with emphysema, and we did an updated search on Embase and PubMed on June 18, 2018. We only included randomised controlled studies published in English evaluating the intervention with either sham or standard of care. Inclusion was limited to trials of techniques in which there was sustainable volume reduction. Primary outcomes were residual volume, FEV1, St George's Respiratory Questionnaire (SGRQ), and 6-min walk distance (6MWT). Secondary outcomes were severe adverse events (including mortality), short-term mortality, and overall mortality. We extracted summary level data from the trial publications and where necessary we obtained unpublished data. A random-effects model with the I2 statistic was used to determine heterogeneity and trial weight in each analysis. The study is registered with the PROSPERO database, number CRD42016045705. FINDINGS We identified 4747 references in the search, and included 20 randomised controlled trials of lung volume reduction involving 2794 participants with emphysema. Following lung volume reduction from any of the interventions in pooled analyses (ie, surgery, endobronchial valve, endobronchial coil, or sclerosing agents), the mean differences compared with the control were reduction in residual volume of 0·58 L (95% CI -0·80 to -0·37), increase in FEV1 of 15·87% (95% CI 12·27 to 19·47), improvement in 6MWT of 43·28 m (31·36 to 55·21), and reduction in the SGRQ of 9·39 points (-10·92 to -7·86). The odds ratio for a severe adverse event, which included mortality, was 6·21 (95% CI 4·02 to 9·58) following intervention. Regression analysis showed improvements relative to the degree of volume reduction: FEV1 (r2=0·86; p<0·0001), 6MWT (r2=0·77; p<0·0001), and SGRQ (r2=0·70; p<0·0001). Most studies were at high risk of bias for lack of blinding, and heterogeneity was high for some outcomes when pooled across all interventions, but was generally lower in the subgroups by intervention type. INTERPRETATION Despite limitations of high risk of bias and heterogeneity for some analyses, our results provide support that lung volume reduction in patients with severe emphysema on maximal medical treatment has clinically meaningful benefits. These benefits should be considered alongside potential adverse events. FUNDING None.
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14
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Caviezel C, Schneiter D, Opitz I, Weder W. Lung volume reduction surgery beyond the NETT selection criteria. J Thorac Dis 2018; 10:S2748-S2753. [PMID: 30210828 DOI: 10.21037/jtd.2018.08.93] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Lung volume reduction surgery (LVRS) for symptomatic patients with advanced emphysema was proven to be successful in a large randomized multi-center trial (NETT) and in several smaller randomized single center trials. This evidence primarily concerns patients with heterogeneous, upper-lobe predominant emphysema and low exercise tolerance within certain selection criteria regarding lung function values. As the most important effect of LVRS is generated by reducing the hyperinflation, even patients with homogeneous emphysema morphology profit from the procedure. Simultaneously, by removing distended and functionless areas in heterogeneous emphysema, also patients with seriously impaired diffusion capacity, moderate pulmonary arterial hypertension, a history of previous LVRS and alpha-1-antitrypsin-deficiency (AATD) can be considered as candidates for (re-)-LVRS. This article summarizes indications for LVRS in these various subtypes of emphysema patients.
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Affiliation(s)
- Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zurich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich, Switzerland
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15
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Opitz I, Ulrich S. Pulmonary hypertension in chronic obstructive pulmonary disease and emphysema patients: prevalence, therapeutic options and pulmonary circulatory effects of lung volume reduction surgery. J Thorac Dis 2018; 10:S2763-S2774. [PMID: 30210830 PMCID: PMC6129805 DOI: 10.21037/jtd.2018.07.63] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 07/12/2018] [Indexed: 11/06/2022]
Abstract
The exact prevalence of pulmonary hypertension (PH) and cor pulmonale (CP) in chronic obstructive pulmonary disease (COPD) is unknown, and varies considerably from 20-91%. Usually, mean pulmonary artery pressure (mPAP) does not exceed 30 mmHg, and PH is not severe. However, PH and CP are important predictors of mortality in COPD and contribute to disability in this disease. Many factors contribute to the development of PH in chronic lung disease, including reduction of the pulmonary vascular cross-sectional area due to parenchymal loss and accompanying hypoxia, effects of abnormal pulmonary mechanics due to hyperinflation, but also vascular remodeling processes. So far, PH associated with chronic lung disease cannot be treated medically. Therefore, it is indicated to treat the underlying pulmonary disease. Patients with severe PH should be referred to centers experienced in the management of PH and enrollment in clinical trials should be considered. Lung volume reduction surgery (LVRS) theoretically further increases pulmonary vascular resistance (PVR) by reducing the vascular bed when resecting lung tissue, however, this might be compensated by better pulmonary mechanics through reduction of hyperinflation, which will be discussed in the present article.
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Affiliation(s)
- Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Silvia Ulrich
- Department of Respiratory Diseases, University Hospital Zurich, Zurich, Switzerland
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