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Lund A, Soldath P, Nodin E, Hansen HJ, Perch M, Jensen K, Hornbech K, Kalhauge A, Mortensen J, Petersen RH. Predictors of reoperation after lung volume reduction surgery. Surg Endosc 2024; 38:679-687. [PMID: 38017156 PMCID: PMC10830766 DOI: 10.1007/s00464-023-10559-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/22/2023] [Indexed: 11/30/2023]
Abstract
OBJECTIVES Lung volume reduction surgery (LVRS) has proven an effective treatment for emphysema, by decreasing hyperinflation and improving lung function, activity level and reducing dyspnoea. However, postoperative air leak is an important complication, often leading to reoperation. Our aim was to analyse reoperations after LVRS and identify potential predictors. METHODS Consecutive single-centre unilateral VATS LVRS performed from 2017 to 2022 were included. Typically, 3-5 minor resections were made using vascular magazines without buttressing. Data were obtained from an institutional database and analysed. Multivariable logistic regression was used to identify predictors of reoperation. Number and location of injuries were registered. RESULTS In total, 191 patients were included, 25 were reoperated (13%). In 21 patients, the indication for reoperation was substantial air leak, 3 patients bleeding and 1 patient empyema. Length of stay (LOS) was 21 (11-33) vs. 5 days (3-11), respectively. Only 3 injuries were in the stapler line, 13 within < 2cm and 15 injuries were in another site. Multivariable logistic regression analysis showed that decreasing DLCO increased risk of reoperation, OR 1.1 (1.03, 1.18, P = 0.005). Resections in only one lobe, compared to resections in multiple lobes, were also a risk factor OR 3.10 (1.17, 9.32, P = 0.03). Patients undergoing reoperation had significantly increased 30-day mortality, OR 5.52 (1.03, 26.69, P = 0.02). CONCLUSIONS Our incidence of reoperation after LVRS was 13% leading to prolonged LOS and increased 30-day mortality. Low DLCO and resections in a single lobe were significant predictors of reoperation. The air leak was usually not localized in the stapler line.
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Affiliation(s)
- Alberte Lund
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
| | - Patrick Soldath
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Erika Nodin
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Henrik Jessen Hansen
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Michael Perch
- Department of Cardiology, Section for Lung Transplantation and Respiratory Medicine, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristine Jensen
- Department of Cardiology, Section for Lung Transplantation and Respiratory Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Kåre Hornbech
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Anna Kalhauge
- Department of Diagnostic Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Jann Mortensen
- Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - René Horsleben Petersen
- Department of Cardiothoracic surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Thuppal S, Lanzotti N, Vost B, Crabtree T, Markwell S, Seadler B, Rizvi N, Sawyer J, McCullough K, Hazelrigg SR. Life Expectancy and Rate of Decline After Lung Volume Reduction Surgery. Thorac Surg Clin 2021; 31:177-188. [PMID: 33926671 DOI: 10.1016/j.thorsurg.2021.01.001] [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: 11/24/2022]
Abstract
Lung volume reduction surgery (LVRS) patient selection guidelines are based on the National Emphysema Treatment Trial. Because of increased mortality and poor improvement in functional outcomes, patients with non-upper lobe emphysema and low baseline exercise capacity are determined as poor candidates for LVRS. In well-selected patients with heterogeneous emphysema, LVRS has a durable long-term outcome at up to 5-years of follow-up. Five-year survival rates in patients range between 63% and 78%. LVRS seems a durable alternative for end-stage heterogeneous emphysema in patients not eligible for lung transplantation. Future studies will help identify eligible patients with homogeneous emphysema for LVRS.
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Affiliation(s)
- Sowmyanarayanan Thuppal
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA; Center for Clinical Research, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA
| | - Nicholas Lanzotti
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA
| | - Bradley Vost
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA
| | - Traves Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA
| | - Stephen Markwell
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA
| | - Benjamin Seadler
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA
| | - Nisha Rizvi
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA; Center for Clinical Research, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA
| | - Justin Sawyer
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA
| | - Kyle McCullough
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA
| | - Stephen R Hazelrigg
- Division of Cardiothoracic Surgery, Department of Surgery, SIU School of Medicine, 701 North 1st Street, Springfield, IL 62794-9679, USA.
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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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Abstract
Lung transplantation (LT) is proved to be effective in patients with end-stage lung disease who are failing optimal therapy. Chronic obstructive pulmonary disease (emphysema) is the most common indication for adult lung transplantation. As most patients with emphysema (EMP) can survive long term, it could be difficult to decide which patient should be listed for LT. LT is a complex surgery. Therefore, it is extremely important to choose a recipient in whom expected survival is at less equal or comparable to the survival without surgery. This paper reviews patient selection, bridging strategies until lung transplantation, surgical approach and choice of the procedure, and functional outcome in emphysema recipients.
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Affiliation(s)
- Ilhan Inci
- Department of Thoracic Surgery, University Hospital, Raemistrasse, Zurich, Switzerland
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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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Caviezel C, von Rotz J, Schneiter D, Inci I, Hillinger S, Opitz I, Weder W. Improved postoperative lung function after sublobar resection of non-small-cell lung cancer combined with lung volume reduction surgery in patients with advanced emphysema. J Thorac Dis 2018; 10:S2704-S2710. [PMID: 30210822 DOI: 10.21037/jtd.2018.06.79] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Radiotherapy is recommended as primary local therapy for inoperable patients with non-small cell lung cancer (NSCLC). We hypothesized that selected patients with advanced emphysema could be candidates for surgery and improved functional outcome might result in addition to low mortality and morbidity and successful cancer control when sublobar resection in a lung volume reduction surgery (LVRS) concept is applied. Methods All patients with NSCLC and severe emphysema who underwent cancer resection in a LVRS concept between 2003 and 2015 were included for analysis. Postoperative 90-day mortality, complications, survival and lung function with forced expiratory volume in one second pre-operatively and three months postoperatively served as endpoints. Results Fourteen patients were included. Three procedures were bilateral and eleven unilateral, eight have been performed with thoracoscopy and six with conversion to an open procedure due to adhesions. In ten patients, tumor resection was atypical and in four patients an anatomic segmentectomy was performed. All patients had lung volume reduction. Prolonged air leak occurred in three patients. Perioperative 90-mortality was zero. Median pre-operative forced expiratory volume in one second was 32.5% and increased to 37% (P=0.002) 3 months following surgery. Three and 5-year survival rates were 50% and 35%, respectively. Conclusions Sublobar resection of NSCLC combined with LVRS in patients with severely impaired lung function due to emphysema can be performed with low mortality and morbidity making it an alternative treatment modality to radiotherapy. This approach allows cancer resection in marginal patients and improves emphysema symptoms simultaneously.
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Affiliation(s)
- Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zurich, Switzerland
| | - Julia von Rotz
- Department of Thoracic Surgery, University Hospital Zurich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital Zurich, Switzerland
| | - Ilhan Inci
- Department of Thoracic Surgery, University Hospital Zurich, Switzerland
| | - Sven Hillinger
- 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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Martini K, Caviezel C, Schneiter D, Milanese G, Opitz I, Weder W, Frauenfelder T. Dynamic magnetic resonance imaging as an outcome predictor for lung-volume reduction surgery in patients with severe emphysema†. Eur J Cardiothorac Surg 2018; 55:446-454. [DOI: 10.1093/ejcts/ezy277] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/29/2018] [Accepted: 07/08/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Katharina Martini
- Institute for Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Claudio Caviezel
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Didier Schneiter
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Gianluca Milanese
- Institute for Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Walter Weder
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Frauenfelder
- Institute for Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
- Faculty of Medicine, University of Zurich, Zurich, Switzerland
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Caviezel C, Schaffter N, Schneiter D, Franzen D, Inci I, Opitz I, Weder W. Outcome After Lung Volume Reduction Surgery in Patients With Severely Impaired Diffusion Capacity. Ann Thorac Surg 2018; 105:379-385. [DOI: 10.1016/j.athoracsur.2017.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 08/09/2017] [Accepted: 09/11/2017] [Indexed: 10/18/2022]
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van Agteren JEM, Hnin K, Grosser D, Carson KV, Smith BJ. Bronchoscopic lung volume reduction procedures for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2017; 2:CD012158. [PMID: 28230230 PMCID: PMC6464526 DOI: 10.1002/14651858.cd012158.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND In the recent years, a variety of bronchoscopic lung volume reduction (BLVR) procedures have emerged that may provide a treatment option to participants suffering from moderate to severe chronic obstructive pulmonary disease (COPD). OBJECTIVES To assess the effects of BLVR on the short- and long-term health outcomes in participants with moderate to severe COPD and determine the effectiveness and cost-effectiveness of each individual technique. SEARCH METHODS Studies were identified from the Cochrane Airways Group Specialised Register (CAGR) and by handsearching of respiratory journals and meeting abstracts. All searches are current until 07 December 2016. SELECTION CRITERIA We included randomized controlled trials (RCTs). We included studies reported as full text, those published as abstract only and unpublished data, if available. DATA COLLECTION AND ANALYSIS Two independent review authors assessed studies for inclusion and extracted data. Where possible, data from more than one study were combined in a meta-analysis using RevMan 5 software. MAIN RESULTS AeriSealOne RCT of 95 participants found that AeriSeal compared to control led to a significant median improvement in forced expiratory volume in one second (FEV1) (18.9%, interquartile range (IQR) -0.7% to 41.9% versus 1.3%, IQR -8.2% to 12.9%), and higher quality of life, as measured by the St Georges Respiratory Questionnaire (SGRQ) (-12 units, IQR -22 units to -5 units, versus -3 units, IQR -5 units to 1 units), P = 0.043 and P = 0.0072 respectively. Although there was no significant difference in mortality (Odds Ratio (OR) 2.90, 95% CI 0.14 to 62.15), adverse events were more common for participants treated with AeriSeal (OR 3.71, 95% CI 1.34 to 10.24). The quality of evidence found in this prematurely terminated study was rated low to moderate. Airway bypass stentsTreatment with airway bypass stents compared to control did not lead to significant between-group changes in FEV1 (0.95%, 95% CI -0.16% to 2.06%) or SGRQ scores (-2.00 units, 95% CI -5.58 units to 1.58 units), as found by one study comprising 315 participants. There was no significant difference in mortality (OR 0.76, 95% CI 0.21 to 2.77), nor were there significant differences in adverse events (OR 1.33, 95% CI 0.65 to 2.73) between the two groups. The quality of evidence was rated moderate to high. Endobronchial coilsThree studies comprising 461 participants showed that treatment with endobronchial coils compared to control led to a significant between-group mean difference in FEV1 (10.88%, 95% CI 5.20% to 16.55%) and SGRQ (-9.14 units, 95% CI -11.59 units to -6.70 units). There were no significant differences in mortality (OR 1.49, 95% CI 0.67 to 3.29), but adverse events were significantly more common for participants treated with coils (OR 2.14, 95% CI 1.41 to 3.23). The quality of evidence ranged from low to high. Endobronchial valvesFive studies comprising 703 participants found that endobronchial valves versus control led to significant improvements in FEV1 (standardized mean difference (SMD) 0.48, 95% CI 0.32 to 0.64) and scores on the SGRQ (-7.29 units, 95% CI -11.12 units to -3.45 units). There were no significant differences in mortality between the two groups (OR 1.07, 95% CI 0.47 to 2.43) but adverse events were more common in the endobronchial valve group (OR 5.85, 95% CI 2.16 to 15.84). Participant selection plays an important role as absence of collateral ventilation was associated with superior clinically significant improvements in health outcomes. The quality of evidence ranged from low to high. Intrabronchial valvesIn the comparison of partial bilateral placement of intrabronchial valves to control, one trial favoured control in FEV1 (-2.11% versus 0.04%, P = 0.001) and one trial found no difference between the groups (0.9 L versus 0.87 L, P = 0.065). There were no significant differences in SGRQ scores (MD 2.64 units, 95% CI -0.28 units to 5.56 units) or mortality rates (OR 4.95, 95% CI 0.85 to 28.94), but adverse events were more frequent (OR 3.41, 95% CI 1.48 to 7.84) in participants treated with intrabronchial valves. The lack of functional benefits may be explained by the procedural strategy used, as another study (22 participants) compared unilateral versus partial bilateral placement, finding significant improvements in FEV1 and SGRQ when using the unilateral approach. The quality of evidence ranged between moderate to high. Vapour ablationOne study of 69 participants found significant mean between-group differences in FEV1 (14.70%, 95% CI 7.98% to 21.42%) and SGRQ (-9.70 units, 95% CI -15.62 units to -3.78 units), favouring vapour ablation over control. There was no significant between-group difference in mortality (OR 2.82, 95% CI 0.13 to 61.06), but vapour ablation led to significantly more adverse events (OR 3.86, 95% CI 1.00 to 14.97). The quality of evidence ranged from low to moderate. AUTHORS' CONCLUSIONS Results for selected BLVR procedures indicate they can provide significant and clinically meaningful short-term (up to one year) improvements in health outcomes, but this was at the expense of increased adverse events. The currently available evidence is not sufficient to assess the effect of BLVR procedures on mortality. These findings are limited by the lack of long-term follow-up data, limited availability of cost-effectiveness data, significant heterogeneity in results, presence of skew and high CIs, and the open-label character of a number of the studies.
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Affiliation(s)
| | - Khin Hnin
- Flinders UniversityAdelaideAustralia
| | | | | | - Brian J Smith
- The University of AdelaideSchool of MedicineAdelaideAustralia
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Tzafos S, Collaud S, Wilhelm M, Wieser S, Weder W, Inci I. Lung Volume Reduction Surgery on Extracorporeal Life Support. Ann Thorac Surg 2017; 103:e115-e117. [DOI: 10.1016/j.athoracsur.2016.07.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 06/09/2016] [Accepted: 07/25/2016] [Indexed: 11/28/2022]
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Abstract
BACKGROUND Lung volume reduction surgery (LVRS) performed to treat patients with severe diffuse emphysema was reintroduced in the nineties. Lung volume reduction surgery aims to resect damaged emphysematous lung tissue, thereby increasing elastic properties of the lung. This treatment is hypothesised to improve long-term daily functioning and quality of life, although it may be costly and may be associated with risks of morbidity and mortality. Ten years have passed since the last version of this review was prepared, prompting us to perform an update. OBJECTIVES The objective of this review was to gather all available evidence from randomised controlled trials comparing the effectiveness of lung volume reduction surgery (LVRS) versus non-surgical standard therapy in improving health outcomes for patients with severe diffuse emphysema. Secondary objectives included determining which subgroup of patients benefit from LVRS and for which patients LVRS is contraindicated, to establish the postoperative complications of LVRS and its morbidity and mortality, to determine which surgical approaches for LVRS are most effective and to calculate the cost-effectiveness of LVRS. SEARCH METHODS We identified RCTs by using the Cochrane Airways Group Chronic Obstructive Pulmonary Disease (COPD) register, in addition to the online clinical trials registers. Searches are current to April 2016. SELECTION CRITERIA We included RCTs that studied the safety and efficacy of LVRS in participants with diffuse emphysema. We excluded studies that investigated giant or bullous emphysema. DATA COLLECTION AND ANALYSIS Two independent review authors assessed trials for inclusion and extracted data. When possible, we combined data from more than one study in a meta-analysis using RevMan 5 software. MAIN RESULTS We identified two new studies (89 participants) in this updated review. A total of 11 studies (1760 participants) met the entry criteria of the review, one of which accounted for 68% of recruited participants. The quality of evidence ranged from low to moderate owing to an unclear risk of bias across many studies, lack of blinding and low participant numbers for some outcomes. Eight of the studies compared LVRS versus standard medical care, one compared two closure techniques (stapling vs laser ablation), one looked at the effect of buttressing the staple line on the effectiveness of LVRS and one compared traditional 'resectional' LVRS with a non-resectional surgical approach. Participants completed a mandatory course of pulmonary rehabilitation/physical training before the procedure commenced. Short-term mortality was higher for LVRS (odds ratio (OR) 6.16, 95% confidence interval (CI) 3.22 to 11.79; 1489 participants; five studies; moderate-quality evidence) than for control, but long-term mortality favoured LVRS (OR 0.76, 95% CI 0.61 to 0.95; 1280 participants; two studies; moderate-quality evidence). Participants identified post hoc as being at high risk of death from surgery were those with particularly impaired lung function, poor diffusing capacity and/or homogenous emphysema. Participants with upper lobe-predominant emphysema and low baseline exercise capacity showed the most favourable outcomes related to mortality, as investigators reported no significant differences in early mortality between participants treated with LVRS and those in the control group (OR 0.87, 95% CI 0.23 to 3.29; 290 participants; one study), as well as significantly lower mortality at the end of follow-up for LVRS compared with control (OR 0.45, 95% CI 0.26 to 0.78; 290 participants; one study). Trials in this review furthermore provided evidence of low to moderate quality showing that improvements in lung function parameters other than forced expiratory volume in one second (FEV1), quality of life and exercise capacity were more likely with LVRS than with usual follow-up. Adverse events were more common with LVRS than with control, specifically the occurrence of (persistent) air leaks, pulmonary morbidity (e.g. pneumonia) and cardiovascular morbidity. Although LVRS leads to an increase in quality-adjusted life-years (QALYs), the procedure is relatively costly overall. AUTHORS' CONCLUSIONS Lung volume reduction surgery, an effective treatment for selected patients with severe emphysema, may lead to better health status and lung function outcomes, specifically for patients who have upper lobe-predominant emphysema with low exercise capacity, but the procedure is associated with risks of early mortality and adverse events.
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Affiliation(s)
| | | | - Leong Ung Tiong
- The Queen Elizabeth HospitalDepartment of SurgeryAdelaideAustralia
| | - Brian J Smith
- The University of AdelaideSchool of MedicineAdelaideAustralia
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Iftikhar IH, McGuire FR, Musani AI. Predictors of efficacy for endobronchial valves in bronchoscopic lung volume reduction: A meta-analysis. Chron Respir Dis 2014; 11:237-45. [PMID: 25147348 DOI: 10.1177/1479972314546766] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Over the last several years, numerous trials have been carried out to check the efficacy of one-way valves in the management of advanced emphysema. While the design of the valves has not altered much, by selectively studying these valves in a select group of participants, such as those with and without intact fissures (FI+ and FI-), and by using different procedural techniques, our understanding of the valves has evolved. In this meta-analysis, we sought to study the effect of these factors on the efficacy of one-way valves. From PubMed and Embase, we included only those studies that provided separate data on fissure integrity or collateral ventilation. Our study outcomes included the mean change in forced expiratory volume in first second (FEV1), 6-minute walk distance (6MWD) and the St George's Respiratory Questionnaire (SGRQ). In the FI+ subgroup of participants, the pooled standardized mean difference in FEV1, 6MWD, and SGRQ were 0.50 (95% confidence interval (CI): 0.34 to 0.67), p ≤ 0.001, 0.29 (95% CI: 0.13 to 0.45), p ≤ 0.001 and -6.02 (95% CI: -12.12 to 0.06), p = 0.05, respectively. In comparison, these results were superior to the FI- subgroup of participants. A separate analysis of the FI+ subgroup based on lobar occlusion versus nonlobar occlusion favored the former for superior efficacy. The preliminary findings of our meta-analysis confirm that one-way valves perform better in a select group of patients who show intact fissures on lung imaging pretreatment and in those who achieve lobar occlusion.
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Affiliation(s)
- Imran H Iftikhar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of South Carolina, Columbia, SC, USA
| | - Franklin R McGuire
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of South Carolina, Columbia, SC, USA
| | - Ali I Musani
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, National Jewish Health, Denver, CO, USA
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Bronchoscopic interventions in the management of chronic obstructive pulmonary disease. Curr Opin Pulm Med 2013; 19:145-51. [PMID: 23313960 DOI: 10.1097/mcp.0b013e32835cfd59] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW In the past few years, there have been exciting developments in bronchoscopic efforts at attaining lung volume reduction (LVR), given real and perceived risks of surgical LVR. The purpose of this review is to discuss these techniques, with special emphasis on what we have learnt in the past 1-2 years. RECENT FINDINGS Bronchoscopic techniques can be broadly classified as one-way valves, which allow air to exit but not enter, thus reducing air trapping; airway bypass stents, which create an extra-anatomical pathway for air to exit; biologic and polymeric substances, which seal the emphysematous lung, eventually collapsing it; bronchial thermal vapor ablation, which causes thermal damage and thus achieves LVR; and endobronchial elastic coils, which mechanically cause LVR. The specific role of these is being defined by recent publications. The central role of collateral ventilation in choosing amongst these procedures is now established, as it has become clear that in the presence of collateral ventilation, valves provide only modest benefit, if any at all. Thus it is of interest that the other modalities which are independent of collateral ventilation are being studied further. SUMMARY Though the preliminary results are quite encouraging, further trials need to be done before these procedures can be adopted in daily practice.
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Koenigkam-Santos M, Paula WDD, Gompelmann D, Kauczor HU, Heussel CP, Puderbach M. Endobronchial valves in severe emphysematous patients: CT evaluation of lung fissures completeness, treatment radiological response and quantitative emphysema analysis. Radiol Bras 2013. [DOI: 10.1590/s0100-39842013000100008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE: To evaluate lung fissures completeness, post-treatment radiological response and quantitative CT analysis (QCTA) in a population of severe emphysematous patients submitted to endobronchial valves (EBV) implantation. MATERIALS AND METHODS: Multi-detectors CT exams of 29 patients were studied, using thin-section low dose protocol without contrast. Two radiologists retrospectively reviewed all images in consensus; fissures completeness was estimated in 5% increments and post-EBV radiological response (target lobe atelectasis/volume loss) was evaluated. QCTA was performed in pre and post-treatment scans using a fully automated software. RESULTS: CT response was present in 16/29 patients. In the negative CT response group, all 13 patients presented incomplete fissures, and mean oblique fissures completeness was 72.8%, against 88.3% in the other group. QCTA most significant results showed a reduced post-treatment total lung volume (LV) (mean 542 ml), reduced EBV-submitted LV (700 ml) and reduced emphysema volume (331.4 ml) in the positive response group, which also showed improved functional tests. CONCLUSION: EBV benefit is most likely in patients who have complete interlobar fissures and develop lobar atelectasis. In patients with no radiological response we observed a higher prevalence of incomplete fissures and a greater degree of incompleteness. The fully automated QCTA detected the post-treatment alterations, especially in the treated lung analysis.
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Koenigkam-Santos M, Puderbach M, Gompelmann D, Eberhardt R, Herth F, Kauczor HU, Heussel CP. Incomplete fissures in severe emphysematous patients evaluated with MDCT: Incidence and interobserver agreement among radiologists and pneumologists. Eur J Radiol 2012; 81:4161-6. [DOI: 10.1016/j.ejrad.2012.06.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2012] [Revised: 06/11/2012] [Accepted: 06/12/2012] [Indexed: 10/28/2022]
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Berger RL, Decamp MM, Criner GJ, Celli BR. Lung volume reduction therapies for advanced emphysema: an update. Chest 2010; 138:407-17. [PMID: 20682529 DOI: 10.1378/chest.09-1822] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Observational and randomized studies provide convincing evidence that lung volume reduction surgery (LVRS) improves symptoms, lung function, exercise tolerance, and life span in well-defined subsets of patients with emphysema. Yet, in the face of an estimated 3 million patients with emphysema in the United States, < 15 LVRS operations are performed monthly under the aegis of Medicare, in part because of misleading reporting in lay and medical publications suggesting that the operation is associated with prohibitive risks and offers minimal benefits. Thus, a treatment with proven potential for palliating and prolonging life may be underutilized. In an attempt to lower risks and cost, several bronchoscopic strategies (bronchoscopic emphysema treatment [BET]) to reduce lung volume have been introduced. The following three methods have been tested in some depth: (1) unidirectional valves that allow exit but bar entry of gas to collapse targeted hyperinflated portions of the lung and reduce overall volume; (2) biologic lung volume reduction (BioLVR) that involves intrabronchial administration of a biocompatible complex to collapse, inflame, scar, and shrink the targeted emphysematous lung; and (3) airway bypass tract (ABT) or creation of stented nonanatomic pathways between hyperinflated pulmonary parenchyma and bronchial tree to decompress and reduce the volume of oversized lung. The results of pilot and randomized pivotal clinical trials suggest that the bronchoscopic strategies are associated with lower mortality and morbidity but are also less efficient than LVRS. Most bronchoscopic approaches improve quality-of-life measures without supportive physiologic or exercise tolerance benefits. Although there is promise of limited therapeutic influence, the available information is not sufficient to recommend use of bronchoscopic strategies for treating emphysema.
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Affiliation(s)
- Robert L Berger
- Division of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Deaconess, Boston, MA 02215, USA.
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