Functional improvement after volume reduction: sternotomy versus videoendoscopic approach

Current Controversies in Surgical Therapy for Emphysema

Interest in surgical therapy for emphysema has grown phenomenally since the reintroduction of lung volume reduction surgery (LVRS). Although early results have shown promise, important controversies have also emerged. Some of the central issues include refining patient selection criteria, identifying optimal measure ments of improvement after LVRS, achieving a more complete understanding of the functional consequences after LVRS, and, most importantly, identifying the effect of LVRS, an admittedly palliative procedure, on disease progression and mortality in emphysema. Secondary issues surrounding LVRS include its role in combination with other procedures and its potentially large eco nomic impact. The National Emphysema Treatment Trial, a joint effort between the National Heart, Lung, and Blood Institute and the Health Care Financing Administration, is designed to address and clarify these and other questions about LVRS.

Early outcomes after bilateral thoracoscopy versus median sternotomy for lung volume reduction

OBJECTIVE

: A National Emphysema Treatment Trial subanalysis, although finally describing outcomes as "comparable," suggested that bilateral lung volume reduction surgery (LVRS) by video-assisted thoracoscopic surgery (VATS) may be slightly less morbid than by median sternotomy (MS). We report a single surgeon experience using both the MS and VATS approaches to provide additional information on this issue in a setting of uniform patient selection and perioperative management. Our hypothesis was that a VATS approach would provide equivalent or less morbidity than MS despite being applied to a group of patients subjectively selected to be higher risk than those undergoing MS.

METHODS

: Consecutive patients over a 9-year period underwent LVRS by one surgeon by either MS or VATS in a nonrandomized fashion. Thoracoscopy was selected over MS primarily when the surgeon estimated a greater overall risk profile and thus a greater chance of morbidity/mortality in a particular patient.

RESULTS

: There were 15 patients in the VATS group and 35 in the MS group. In terms of measures of risk profile, there were no differences between the groups that met statistical significance, but several values trended toward higher risk within the VATS group (eg, age, 63 VATS vs. 59 MS, P = 0.08; moderate pulmonary hypertension, 38% VATS vs. 14% MS, P = 0.11; and residual volume, 241% VATS vs. 226% MS, P = 0.32). With regard to outcomes, operative time was significantly longer in the VATS group (VATS = 155 minutes vs. MS=129 minutes, P = 0.01). All other outcomes, including the incidence of major complications (13.3% VATS vs. 17.1% MS, P = 0.39), were similar between the groups. There was a single death within 90 days (1.9% of entire series; 2.9% of MS group).

CONCLUSIONS

: In this series, although patients undergoing LVRS by VATS tended to have a higher risk profile, their outcomes were no worse than in those undergoing LVRS by MS. This suggests that the VATS approach to bilateral LVRS may incur slightly less morbidity and thus may be the best option in the most compromised patients who is nonetheless felt will benefit from LVRS.

Sternotomy or bilateral thoracoscopy: pain and postoperative complications after lung-volume reduction surgery

OBJECTIVES

Video-assisted thoracoscopic surgery (VATS) and median sternotomy (MS) are two approaches in lung-volume reduction surgery (LVRS). This study focused on the two surgical approaches with regard to postoperative pain.

METHODS

In this prospective, non-randomized study, pain was measured preoperatively and postoperatively using the visual analog scale (VAS) and the brief pain inventory (BPI). Incentive spirometry (IS) assessed restriction of the thoracic cage due to pain. Factors associated with treatment complications, medication usage, hospital stay, operating times, and chest-tube duration differences were examined between groups.

RESULTS

Of 85 patients undergoing LVRS, 23 patients underwent reduction via MS and 62 patients via bilateral VATS. VAS scores revealed no difference in postoperative pain except for VAS scores on days 6 (PM) and 7 (PM). BPI scores yielded higher scores in the VATS group on postoperative day (POD) 1 in the reactive dimension, but no other overall differences. MS patients receiving tramadol consumed a higher mean amount than VATS patients on POD 5 and POD 6. IS change from baseline to postoperative were similar between groups, and increased pain correlated with decreased IS scores on POD 1. Chest-tube duration, complications, and pain medication were similar between groups.

CONCLUSIONS

Bilateral VATS and MS offer similar outcomes with regard to postoperative pain and complications. These results suggest that the choice of LVRS operative approach should be dependent on disease presentation, surgeon expertise, and patient preference, not based upon differences in perceived postoperative pain between MS and bilateral VATS.

The National Emphysema Treatment Trial (NETT) Part II: Lessons learned about lung volume reduction surgery

Substantial information regarding the role of lung volume reduction surgery (LVRS) in severe emphysema emanates from the National Emphysema Treatment Trial (NETT). The NETT was not a crossover trial and therefore was able to examine the effects of optimal medical management and LVRS on short- and long-term survival,as well as lung function, exercise performance, and quality of life.The NETT generated multiple insights into the preoperative, perioperative,and postoperative management of patients undergoing thoracotomy; described pain control techniques that were safe and effective; and emphasized the need to address nonpulmonary issues to optimize surgical outcomes. After the NETT, newer investigation has focused on bronchoscopic endobronchial interventions and other techniques less invasive than LVRS to achieve lung reduction.In this review, we summarize what we currently know about the role of LVRS in the treatment of severe emphysema as a result of insights gained from the NETT and provide a brief review of the newer techniques of lung volume reduction.

Lung transplantation and lung volume reduction surgery

Since the publication of the last edition of the Handbook of Physiology, lung transplantation has become widely available, via specialized centers, for a variety of end-stage lung diseases. Lung volume reduction surgery, a procedure for emphysema first conceptualized in the 1950s, electrified the pulmonary medicine community when it was rediscovered in the 1990s. In parallel with their technical and clinical refinement, extensive investigation has explored the unique physiology of these procedures. In the case of lung transplantation, relevant issues include the discrepant mechanical function of the donor lungs and recipient thorax, the effects of surgical denervation, acute and chronic rejection, respiratory, chest wall, and limb muscle function, and response to exercise. For lung volume reduction surgery, there have been new insights into the counterintuitive observation that lung function in severe emphysema can be improved by resecting the most diseased portions of the lungs. For both procedures, insights from physiology have fed back to clinicians to refine patient selection and to scientists to design clinical trials. This section will first provide an overview of the clinical aspects of these procedures, including patient selection, surgical techniques, complications, and outcomes. It then reviews the extensive data on lung and muscle function following transplantation and its complications. Finally, it reviews the insights from the last 15 years on the mechanisms whereby removal of lung from an emphysema patient can improve the function of the lung left behind.

Alternatives to lung transplantation: lung volume reduction for COPD

Emphysema is disabling and progressive and hallmarked by decreased exercise tolerance and impaired quality of life. Surgical interventions that reduce lung volume have been the focus of multiple interventions for decades; however, until recently, limited evidence has documented their effectiveness. Lung volume reduction surgery (LVRS) underwent rigorous study in the National Emphysema Treatment Trial (NETT), which demonstrated its short-term and long-term effectiveness, associated morbidity and mortality, and the essential factors that predict LVRS success or failure. This article summarizes the major results of the NETT and briefly reviews newer bronchoscopic lung volume reduction techniques that show promise as alternative treatments for select patients with COPD undergoing consideration for lung transplantation.

The National Emphysema Treatment Trial: summary and update

Surgery for severe emphysema involves a cohort of patients who are already at risk for increased perioperative morbidity and mortality. Through the careful screening and selection process, improved intraoperative techniques and rigorous attention to postoperative care, the NETT managed to yield acceptable improvements in survival and functional outcomes in this fragile patient cohort and these benefits were sustained over the long-term. Identification of the characteristics associated with a higher risk of death has provided tangible patient selection criteria for the ongoing application of LVRS. Because the NETT was such a large-scale study, the protocols that were developed had to be standardized across several centers. This produced reliable and reproducible standards for evaluation and treatment that can be applied to the surgical treatment of emphysema. When considering these criteria, although individualized patient selection is important, only patients with upper-lobe predominant disease on chest CT and possibly those with non-upper-lobe predominant disease who also have low baseline exercise capacity are appropriate candidates for LVRS. Expectedly, questions remain regarding the exact mechanism whereby the benefits derived from LVRS are obtained. Additionally, the benefit of LVRS in patients with heterogeneous but non-upper-lobe predominant disease remains to be further elucidated. In spite of the limitations of the study, the NETT, through a tremendous coordinated effort, provided valuable outcomes data, answered the pressing questions regarding lung volume reduc-tion surgery that existed at the time, and provided valuable insight into other facets of emphysema physiology and management through direct observation. Based on the NETT findings, in November 2003, CMS published criteria for expanded coverage for LVRS to include non-high-risk patients who demonstrated either upper-lobe predominant emphysema, or non-upper-lobe predominant emphysema and low baseline exercise capacity and who met the screening guidelines.29 This study not only provided data regarding the clinical efficacy of LRVS, but it was instrumental in determining health policy guidelines for the surgical management of emphysema.

A clinician's guide to the use of lung volume reduction surgery

The primary purpose of the National Emphysema Treatment Trial (NETT) was to evaluate the clinical efficacy of lung volume reduction surgery (LVRS) compared with medical therapy as a treatment for advanced emphysema. Transitioning the results of a complex multicenter long-term clinical trial into routine clinical practice is challenging, particularly when the therapy examined is controversial, as was the case in NETT. Aspects of the "clinical art" used by the study investigators to select and treat patients are not always transparent to practitioners reading study publications. At the last NETT Steering Committee meeting, a roundtable discussion was held with investigators, coordinators, Steering Committee leadership, and Data Coordinating Center staff regarding the clinical aspects of patient evaluation and selection and performance of LVRS in advanced emphysema. The questions posed to the meeting participants were ones that are commonly asked by patients and their treating physicians who are considering LVRS and included the following: Why recommend LVRS to a patient? When should LVRS be recommended to a patient? What types of patients are candidates for LVRS? What are the important barriers to performing LVRS? What are the major messages delivered by NETT? It is hoped that answers from NETT investigators to some of these commonly encountered questions will provide clarity and guidance to clinicians faced with the responsibility of considering and discussing LVRS with their patients. NETT investigators were also queried regarding the future directions of research in emphysema and the role that NETT played in shaping that future. The following article is a summary of the highlights of these discussions.

Lung volume reduction surgery: technique, operative mortality, and morbidity

The objective of lung volume reduction surgery (LVRS) is the safe, effective, and durable palliation of dyspnea in appropriately selected patients with moderate to severe emphysema. Appropriate patient selection and preoperative preparation are prerequisites for successful LVRS. An effective LVRS program requires participation by and communication between experts from pulmonary medicine, thoracic surgery, thoracic anesthesiology, critical care medicine, rehabilitation medicine, respiratory therapy, chest radiology, and nursing. The critical analysis of perioperative outcomes has influenced details of the conduct of the procedure and has established a bilateral, stapled approach as the standard of care for LVRS. The National Emphysema Treatment Trial (NETT) remains the world's largest multi-center, randomized trial comparing LVRS to maximal medical therapy. NETT purposely enrolled a broad spectrum of anatomic patterns of emphysema. This, along with the prospective, audited collection of extensive demographic, physiologic, radiographic, surgical and quality-of-life data, has positioned NETT as the most robust repository of evidence to guide the refinement of patient selection criteria for LVRS, to assist surgeons in providing optimal intraoperative and postoperative care, and to establish benchmarks for survival, complication rates, return to independent living, and durability of response. This article reviews the evolution of current LVRS practice with a particular emphasis on technical aspects of the operation, including the predictors and consequences of its most common complications.

Changes in arterial oxygenation and self-reported oxygen use after lung volume reduction surgery

RATIONALE

Lung volume reduction surgery (LVRS) is inconsistently reported to improve arterial oxygenation in patients with chronic obstructive pulmonary disease.

OBJECTIVES

We studied the effects of surgery on oxygenation in a large cohort and identified predictors of postoperative oxygenation improvement.

METHODS

We evaluated oxygenation in 1,078 subjects with chronic obstructive pulmonary disease enrolled in the National Emphysema Treatment Trial after LVRS compared with medical control subjects, including arterial blood gases, use of supplemental oxygen during treadmill walking, and self-reported use of oxygen during rest, exertion, and sleep.

MEASUREMENTS AND MAIN RESULTS

Pa(O(2)) breathing room air was equal in medical and surgical subjects at baseline (64.8 vs. 65.0 mm Hg, P = not significant), but lower in medical subjects at 6 months (63.6 vs. 70.0 mm Hg, P < 0.001), 12 months (63.9 vs. 68.7 mm Hg, P < 0.001), and 24 months (62.4 vs. 68.0 mm Hg, P < 0.001). Fewer medical subjects required oxygen for treadmill walking at baseline compared with surgical subjects (46 vs. 53%, P = 0.02). However, more medical subjects required oxygen for this activity at 6 months (49 vs. 33%, P < 0.001), 12 months (50 vs. 36%, P < 0.001), and 24 months (52 vs. 42%, P = 0.02). Self-reported oxygen use was greater in medical than in surgical subjects at 6, 12, and 24 months. Multivariate modeling of preoperative characteristics showed baseline oxygenation status was the best predictor of postoperative oxygenation.

CONCLUSIONS

LVRS increases Pa(O(2)), and decreases treadmill and self-reported use of oxygen for up to 24 months post-procedure. Clinical trial registered with www.clinicaltrials.gov (NCT 00000606).

Cytokine response is lower after lung volume reduction through bilateral thoracoscopy versus sternotomy

BACKGROUND

Lung volume reduction surgery performed through bilateral video-assisted thoracoscopy (BVATS) was associated in the National Emphysema Treatment Trial with a statistically significant reduction in intensive care unit days, failure to wean, hospital stay, and cost, and earlier recovery compared with median sternotomy. Studies comparing other minimally invasive techniques with "open" procedures, including pulmonary lobectomy, have demonstrated reduced serum proinflammatory mediators postoperatively. We measured these levels after lung volume reduction surgery through BVATS and sternotomy.

METHODS

Serum cytokine levels were measured by radioimmunoassay in 9 consecutive, steroid-free patients undergoing sternotomy and lung volume reduction surgery and 6 undergoing BVATS and lung volume reduction surgery. The groups were not statistically different with respect to age, partial pressure of arterial carbon dioxide, percent forced expiratory volume in 1 second, percent residual volume, percent total lung capacity, diffusion capacity of the lung for carbon monoxide, 6-minute walk, or apical perfusion fraction. Proinflammatory interleukin 6 and interleukin 8 and antiinflammatory interleukin 10 were evaluated preoperatively and postoperatively on days 1, 4, and 5. Clinical data were prospectively collected.

RESULTS

There were no major postoperative complications or deaths. Interleukin 6 levels were lower in the BVATS than the sternotomy group (p = 0.016 by repeated measures analysis of variance). Interleukin 8 levels were lower in the BVATS group at most postoperative time points, but there were no significant differences in interleukin 8 or interleukin 10 levels between the sternotomy and BVATS groups at any individual time point or by analysis of variance.

CONCLUSIONS

Use of a BVATS approach to lung volume reduction surgery is associated with reduced postoperative release of proinflammatory cytokines compared with a sternotomy approach. This may account for the reduction in recovery time and some measures of postoperative morbidity seen with the BVATS approach.

Patient and surgical factors influencing air leak after lung volume reduction surgery: lessons learned from the National Emphysema Treatment Trial

BACKGROUND

Although staple line buttressing is advocated to reduce air leak after lung volume reduction surgery (LVRS), its effectiveness is unknown. We sought to identify risk factors for air leak and its duration and to estimate its medical consequences for selecting optimal perioperative technique(s), such as buttressing technique, to preempt or treat post-LVRS air leak.

METHODS

Detailed air leak data were available for 552 of 580 patients receiving bilateral stapled LVRS in the National Emphysema Treatment Trial. Risk factors for prevalence and duration of air leak were identified by logistic and hazard function analyses. Medical consequences were estimated in propensity-matched pairs with and without air leak.

RESULTS

Within 30 days of LVRS, 90% of patients developed air leak (median duration = 7 days). Its occurrence was more common and duration prolonged in patients with lower diffusing capacity (p = 0.06), upper lobe disease (p = 0.04), and important pleural adhesions (p = 0.007). Duration was also protracted in Caucasians (p < 0.0001), patients using inhaled steroids (p = 0.004), and those with lower 1-second forced expiratory volume (p = 0.0003). Surgical approach, buttressing, stapler brand, and intraoperative adjunctive procedures were not associated with fewer or less prolonged air leaks (p >/= 0.2). Postoperative complications occurred more often in matched patients experiencing air leak (57% vs 30%, p = 0.0004), and postoperative stay was longer (11.8 +/- 6.5 days vs 7.6 +/- 4.4 days, p = 0.0005).

CONCLUSIONS

Air leak accompanies LVRS in 90% of patients, is often prolonged, and is associated with a more complicated and protracted hospital course. Its occurrence and duration are associated with characteristics of patients and their disease, not with a specific surgical technique.

Innovative approaches to lung volume reduction for emphysema

The 10 years of resurgent interest in lung volume reduction surgery (LVRS) and recent National Emphysema Treatment Trial findings for emphysema have stimulated a range of innovative alternative ideas aimed at improving outcomes and reducing complications associated with current LVRS techniques. Concepts being actively investigated at this time include surgical resection with compression/banding devices, endobronchial blockers, sealants, obstructing devices and valves, and bronchial bypass methods. These novel approaches are reaching the stage of clinical trials at this time. Theory, design issues, methods, potential advantages and limitations, and available results are presented. Extensive research in the near future will help to determine the potential clinical applicability of these new approaches to the treatment of emphysema symptoms.

[Lung volume reduction surgery for emphysema: a unilateral or bilateral approach?]

INTRODUCTION

Lung Volume reduction surgery (LVRS) is a recognized therapeutic option for patients presenting with severe and disabling pulmonary emphysema. Case selection is based upon clinical, morphological and functional criteria.

STATE OF THE ART

LVRS has shown promising results, with improvements in exercise capacity, pulmonary function and quality of life, in selected patients with severe and disabling emphysema. A variety of surgical techniques have been described. The procedure may be unilateral or bilateral, through a sternotomy or by a video-assisted thoracoscopic (VATS) technique. The controversial aspects of the surgical technique will be analysed and discussed in the following review.

PERSPECTIVES

A bilateral approach clearly offers a better functional improvement when compared to a unilateral procedure, however, the postoperative functional decline appears greater and more rapid after a bilateral procedure. A unilateral approach, with often less postoperative morbidity, allows the option to perform a future contra-lateral procedure in the event of further clinical or functional deterioration.

CONCLUSIONS

In selected cases LVRS is an effective treatment for severe pulmonary emphysema. Different surgical techniques have been described. Nowadays VATS is considered to be the technique of choice, with the option to carry out a future unilateral or bilateral procedure.

Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery

BACKGROUND

The National Emphysema Treatment Trial, a randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema, included randomized and nonrandomized comparisons of the median sternotomy and video-assisted thoracoscopic approaches for lung volume reduction surgery.

METHODS

Lung volume reduction surgery was performed by median sternotomy only at 8 centers and video-assisted thoracoscopy only at 3 centers; 6 centers randomized the approach to lung volume reduction surgery. Mortality, morbidity, functional status, and costs were assessed.

RESULTS

In the nonrandomized comparison, 359 patients received lung volume reduction surgery by median sternotomy, and 152 patients received lung volume reduction surgery by video-assisted thoracoscopy. The 90-day mortality was 5.9% for median sternotomy and 4.6% for video-assisted thoracoscopy (P =.67). Overall mortality was 0.08 deaths per person-year for median sternotomy and 0.10 deaths per person-year for video-assisted thoracoscopy (video-assisted thoracoscopy-median sternotomy risk ratio, 1.18; P =.42). Complication rates were low and not statistically different for the 2 approaches. The median hospital length of stay was longer for median sternotomy than for video-assisted thoracoscopy (10 vs 9 days; P =.01). By 30 days after surgery, 70.5% of median sternotomy patients and 80.9% of video-assisted thoracoscopy patients were living independently (P =.02). Functional outcomes were similar for median sternotomy and video-assisted thoracoscopy at 12 and 24 months. Costs for the operation and the associated hospital stay and costs in the 6 months after surgery were both less for video-assisted thoracoscopy than for median sternotomy (P <.01 in both cases). Similar results were noted for the randomized comparison.

CONCLUSIONS

Morbidity and mortality were comparable after lung volume reduction surgery by video-assisted thoracoscopy or median sternotomy, as were functional results. The video-assisted thoracoscopic approach to lung volume reduction surgery allowed earlier recovery at a lower cost than median sternotomy.

Complications after lung volume reduction surgery

LVRS has greater morbidity than most general thoracic surgical procedures. Proper care of patients after LVRS is a labor-intensive activity, but it is worthwhile because LVRS can be performed with acceptable risk. Patient selection, postoperative care, and an understanding of the potential complications are the keys to successful LVRS.

Results of lung volume reduction surgery for emphysema

LVRS provides an exciting opportunity for palliation of symptoms and improvement in quality of life for patients who have severe end-stage emphysema. Because no medical therapy has been able to improve pulmonary function or reverse the inexorable decline of breathless patients who have emphysema, this opportunity to improve lung function and quality of life is one of the most innovative additions to thoracic surgery since the first successful lung transplant procedure 20 years ago. Although initial short-term, case-controlled surgeries were criticized because of incomplete and short follow-up care, substantial long-term data now exist to support the use of LVRS for select patients who have severe emphysema. Patients who have upper lobe predominant disease or low exercise capacity are more likely to have a benefit in exercise capacity and quality of life after LVRS. Selected patients who have upper lobe emphysema and poor exercise capacity are also more likely to have improved survival after LVRS. The individual contributions by the large number of investigators pioneering LVRS development, along with the collective contributions of the NETT investigators, have propelled the knowledge surrounding LVRS far beyond that of any similar new technology or procedure in its adolescence.

Technical issues and controversies in lung volume reduction surgery

The goal of lung volume reduction surgery (LVRS) is to safely palliate dyspnea in patients suffering from emphysema. Successful LVRS demands attention to the details of patient selection, preoperative preparation, intraoperative anesthetic and surgical technique and multidisciplinary postoperative care. Expertise in and effective communication between pulmonary medicine, thoracic surgery, thoracic anesthesia, pain management services, critical care medicine, respiratory therapy and rehabilitation medicine are vital components to any LVRS program. In experienced centers, bilateral approaches yield nearly twice the physiologic benefit to unilateral LVRS without adversely affecting operative morbidity or mortality. Current practice favors stapled resection over laser ablation to achieve volume reduction. Controversy persists regarding open versus video-assisted operations. The cost-effective need for and choice of materials to buttress staple-lines to reduce the incidence of postoperative air leak have yet to be defined. Ongoing multi-center, randomized, controlled trials should define the utility and durability of LVRS for appropriately selected patients and resolve some of the residual technical controversies. Therapeutic innovations may further reduce the invasiveness of lung volume reduction strategies and allow a more tailored approach to palliate patients with moderate to severe emphysema.

Outcomes of lung volume reduction surgery followed by lung transplantation: a matched cohort study

BACKGROUND

Lung volume reduction surgery (LVRS) has been demonstrated to provide symptomatic relief and to improve lung function in patients with end-stage emphysema. The goal of this study was to assess the additional morbidity associated with lung transplantation after LVRS for end-stage emphysema with regard to immediate postoperative outcomes, longitudinal spirometry, and survival rates compared to an age-, gender-, procedure-matched, and transplant time-matched cohort that had lung transplantation alone.

METHODS

We compared the postoperative and long-term outcomes of a sequential procedure cohort to a matched cohort to assess the possible added post-transplant morbidity.

RESULTS

Fifteen patients who underwent sequential LVRS (including 11 unilateral LVRS, 4 bilateral LVRS) and lung transplantation (ipsilateral in 7 and contralateral in 8) on average 28.1 +/- 17.2 months (median, 27.4 months; range, 3.7 to 61.7 months) later were assessed. No significant differences were noted in pretransplant demographics, post-transplant variables, longitudinal spirometric indices, or survival. A trend toward a lower pretransplant arterial carbon dioxide tension was apparent in the sequential procedure cohort. Group analysis revealed a significant increase in the number of patients requiring transfusion and in the total number of units transfused in patients undergoing ispsilateral transplantation after LVRS; a significant increase in the length of intensive care unit stay; and a trend toward an increase in the duration of hospital stay in patients undergoing lung transplantation within 18 months of LVRS.

CONCLUSIONS

In appropriate candidates, LVRS bridged the time to transplantation by an average of 28.1 +/- 17.2 months (median, 27.4 months; range, 3.7 to 61.7 months) without significantly increasing post-transplant morbidity or mortality. Furthermore, bilateral LVRS bridged the time to transplantation to a greater extent than unilateral LVRS (34.9 +/- 29.8 months; median, 32.1 months versus 25.4 +/- 16.3 months; median, 22.3 months; p = 0.23).

Anesthesia considerations for lung volume reduction surgery

Patient selection is of crucial importance for outcome after lung volume reduction surgery. The anesthesiologist should be involved actively in patient selection, because he or she is in charge of the treatment during the critical perioperative period. Patient history and status and results from chest radiographs, high-resolution CT scans, and catheterization of the right heart should be taken carefully into account in the patient selection process. Promising new results involving functional parameters may predict outcome objectively after lung volume reduction surgery in the future. Careful selection and preoperative preparation of patients also are important to avoid complications and keep the success rate high. The anesthesiologist's understanding of the principles involved is important for the successful conduct of lung volume reduction surgery. It is unclear if lung volume reduction surgery is superior to conventional therapy in the long run because the decline in lung function is progressive after the procedure. A multicenter trial comparing patients undergoing lung volume reduction surgery with patients with emphysema who are treated conventionally hopefully will clarify this important question in the future.

Lung volume reduction surgery for emphysema

Over the past decades, extensive literature has been published regarding surgical therapies for advanced COPD. Lung-volume reduction surgery would be an option for a significantly larger number of patients than classic bullectomy or lung transplantation. Unfortunately, the initial enthusiasm has been tempered by major questions regarding the optimal surgical approach, safety, firm selection criteria, and confirmation of long-term benefits. In fact, the long-term follow-up reported in patients undergoing classical bullectomy should serve to caution against unbridled enthusiasm for the indiscriminate application of LVRS. Those with the worst long-term outcome despite favourable short-term improvements after bullectomy have consistently been those with the lowest pulmonary function and significant emphysema in the remaining lung who appear remarkably similar to those being evaluated for LVRS. With this in mind, the National Heart, Lung and Blood Institute partnered with the Health Care Finance Administration to establish a multicenter, prospective, randomized study of intensive medical management, including pulmonary rehabilitation versus the same plus bilateral (by MS or VATS), known as the National Emphysema Treatment Trial. The primary objectives are to determine whether LVRS improves survival and exercise capacity. The secondary objectives will examine effects on pulmonary function and HRQL, compare surgical techniques, examine selection criteria for optimal response, identify criteria to determine those who are at prohibitive surgical risk, and examine long-term cost effectiveness. It is hoped that data collected from this novel, multicenter collaboration will place the role of LVRS in a clearer perspective for the physician caring for patients with advanced emphysema.

Lung volume reduction surgery: a survey on the European experience

STUDY OBJECTIVE

To evaluate the activity and evolution in the field of lung volume reduction surgery (LVRS) performed at surgical centers in Europe.

BACKGROUND

LVRS is a novel surgical therapy with the potential to improve lung function, exercise performance, and quality of life in selected patients suffering from severe pulmonary emphysema.

METHODS

Questionnaire addressed to 75 European thoracic surgical centers presumed to perform LVRS, and review of the literature.

RESULTS

Of 45 responding centers, 42 centers in 17 countries covering a population of 423 million reported performing LVRS. Until the end of 1998, 1,120 patients were reported to have undergone LVRS, corresponding to 2.6 patients/million inhabitants. Thirty-one of 40 centers (78%) perform the operation bilaterally. Most centers (83%) evaluate their activity prospectively. The average perioperative mortality rate of 4.1% is moderate. The most commonly utilized technique is video-assisted thoracoscopy, which is most frequently performed bilaterally. Two thirds of the centers treat patients with alpha(1)-antitrypsin deficiency, and half of the centers will consider patients with homogenous morphology of emphysema on CT scan for LVRS. Half of the centers also perform lung transplantation. The five largest centers have operated on 49% of all LVRS patients assessed by this survey.

CONCLUSIONS

LVRS is performed at few thoracic surgical centers throughout Europe, with a large variation in the operative activity between different regions. Half of the centers also perform lung transplantation. Between 1995 and 1997, the number of LVRS procedures performed per year nearly tripled but has reached a plateau since then. As five centers perform nearly half the total number of operations, an optimal exchange of knowledge with smaller centers seems important.

Is long-term functional outcome after lung volume reduction surgery predictable?

OBJECTIVE

The aim of this retrospective study was to analyze which preoperative parameters might predict a persistent improvement in forced expiratory volume in 1 s (FeV1) 1 year after surgery.

METHODS

Seventy consecutive lung volume reduction surgery (LVRS) patients (age, 56.5+/-1.2 years) with a follow-up period of at least 1 year were analyzed (from September 1994 to September 1997). The patients were described by lung function tests, blood gas analysis, ventilatory mechanics (intrinsic positive endexpiratory pressure (PEEP)) and morphometric data (degree of heterogeneity, DHG; degree of hyperinflation, DHI; severity of parenchymal destruction, SPD) preoperatively. Based on the postoperative course of FeV1 (percentual increase compared with preoperative values, % increase), patients were divided into four groups: group A, (n=21) no improvement (FeV1</=20% increase); group B, (n=10) FeV1>/=20% increase, which declined to preoperative values after 1 year; group C, (n=18) FeV1, 20-40% increase, sustaining at 1 year; group D, (n=21) FeV1>/=40% increase, sustaining at 1 year. The statistics comprised of analysis of variance (ANOVA) and chi-square testing, with values presented as means+/-SEM.

RESULTS

No differences were found for lung function parameters (FeV1: 27.7+/-2.7, 26.0+/-2.5, 23. 9+/-2.2 and 23.9+/-1.9% predicted, in groups A, B, C and D, respectively). Arterial blood gas levels preoperatively revealed significant differences between the groups; the arterial pO(2) was 66.2+/-1.2 mmHg in groups A+B compared with 61.8+/-1.5 mmHg in groups C+D (P=0.030). The arterial pCO(2) was 39.2+/-1.1 mmHg in groups A+B compared with 43.3+/-1.5 mmHg in groups C+D (P=0.038). The morphometric data had a strong trend towards higher heterogeneity in groups C and D. Marked DHI was found in 59 and 81% of patients in groups A+B versus C+D, respectively (P=0.121). Marked DHG was present in 22 and 54% of patients in groups A+B versus C+D, respectively (P=0.010).

CONCLUSION

Preoperative arterial pO(2) and pCO(2), and the DHG are predictors for long-term benefit after LVRS with regard to the FeV1, 1 year postoperatively.

Lung transplantation following lung volume reduction surgery

OBJECTIVE

Lung volume reduction surgery (LVRS) has been proposed as a possible alternative treatment to lung transplantation (LTX) for selected patients with end-stage emphysema. But whether LVRS is a temporary or permanent alternative to LTX is still under investigation. The aim of this study was to analyze the course of patients undergoing LVRS followed by subsequent LTX.

METHODS

Fifteen patients (10 male, 5 female, mean age 53.3 +/- 1.7 years) out of 102 patients, who underwent LVRS between September 1994 and August 1998, underwent LTX 19.6 +/- 3.1 months after LVRS (range 1.7 to 37.6 months) between June 1996 and October 1998. In 9 patients bilateral LVRS was performed, in 6 patients unilateral LVRS. Subsequent LTX was performed bilaterally in 10 patients and unilaterally in 5 patients (1 of these on the contralateral side) to the previous LVRS. The course of lung function and clinical outcome were analyzed in these 15 patients.

RESULTS

Mean forced expiratory volume in 1 second (FEV(1)) in the 15 patients prior to LVRS was 18.3 +/- 1.2% of predicted (%p) and increased to 27.0 +/- 2.9 %p (best value within the first 6 months postLVRS) (p = 0.043). In 8 of these patients (non-responders) (53%) LVRS failed to improve FEV(1), whereas in the other 7 patients (responders) (47%) a significant improvement was detected (FEV(1) 18.1 +/- 1.8 %p and 31.9 +/- 3.7 %p, pre- and post-LVRS, respectively, p = 0.003), but declined after 6 to 36 months. At the time of listing for LTX the mean FEV(1) was 18.0 +/- 1.9 %p (no difference between the 2 groups). LTX was performed 15.5 +/- 3.6 months (non-responders) and 25.7 +/- 4.6 months (responders) after LVRS. FEV(1) improved to 81.0 +/- 5.6 %p after LTX (p < 0.001 compared to pre-LTX). The mortality after LVRS was 0%. The 3-month mortality after LTX was 20% (1 patient with primary organ failure, 1 patient with ongoing rejection, 1 patient with sepsis). All 3 patients belonged to the group of nonresponders. Two patients died 5. 5 and 8.5 months after LTX (13.3%) due to fungal infection (Aspergillus spp.) and MRSA sepsis, respectively (1 non-responder, 1 responder).

CONCLUSIONS

Successful LVRS delays the need for LTX and offers better conditions for LTX. However, patients without functional improvement after LVRS have a high perioperative risk at subsequent LTX.

Rationale and design of the national emphysema treatment trial. A prospective randomized trial of lung volume reduction surgery. The national emphysema treatment trial research group

The National Emphysema Treatment Trial is a multicenter, randomized clinical trial of medical therapy vs medical therapy plus lung volume reduction surgery (LVRS) for the treatment of patients with severe bilateral emphysema. LVRS will be accomplished by bilateral stapled excision via median sternotomy or video-assisted thoracoscopic surgery. Every patient will complete 6 to 10 weeks of pulmonary rehabilitation prior to randomization and will participate in a maintenance program of pulmonary rehabilitation after randomization. The primary outcome to be assessed by the trial is survival. Additional outcomes to be assessed are maximum exercise capacity, pulmonary function, oxygen requirement, distance walked in 6 min, quality of life, respiratory symptoms, and health-care utilization and costs. In addition, selected clinics will evaluate lung mechanics and respiratory muscle function, partial and maximal flow-volume curves, gas exchange during maximal exercise, and right heart function. The trial is targeted to enroll patients with severe emphysema who have no significant comorbid conditions; each patient will be randomized to one of the two treatment groups. The study duration is 4.5 years with a close-out period of 6 months.

Rationale and design of The National Emphysema Treatment Trial: a prospective randomized trial of lung volume reduction surgery. The National Emphysema Treatment Trial Research Group

The National Emphysema Treatment Trial is a multicenter, randomized clinical trial of medical therapy vs medical therapy plus lung volume reduction surgery (LVRS) for the treatment of patients with severe bilateral emphysema. LVRS will be accomplished by bilateral stapled excision via median sternotomy or video-assisted thoracoscopic surgery. Every patient will complete 6 to 10 weeks of pulmonary rehabilitation prior to randomization and will participate in a maintenance program of pulmonary rehabilitation after randomization. The primary outcome to be assessed by the trial is survival. Additional outcomes to be assessed are maximum exercise capacity, pulmonary function, oxygen requirement, distance walked in 6 min, quality of life, respiratory symptoms, and health-care utilization and costs. In addition, selected clinics will evaluate lung mechanics and respiratory muscle function, partial and maximal flow-volume curves, gas exchange during maximal exercise, and right heart function. The trial is targeted to enroll patients with severe emphysema who have no significant comorbid conditions; each patient will be randomized to one of the two treatment groups. The study duration is 4.5 years with a close-out period of 6 months.

Surgical strategy for lung volume reduction surgery

Lung volume reduction surgery (LVRS) has been a popular procedure since the early 1990s. It appears that there has developed a consensus in the literature that the ideal patient is one with evidence of marked hyperinflation and heterogenous disease. In this patient profile, LVRS has produced excellent results with respect to lung function and improved exercise tolerance. General areas of controversy are discussed which include the role of lasers; unilateral versus bilateral procedures; the role of a staged unilateral procedure; and which surgical route is best for patients. The existing literature is reviewed on these issues.

Comparison of staged thoracoscopy and median sternotomy for lung volume reduction

BACKGROUND

Lung volume reduction operations have proved beneficial for emphysematous patients, but questions remain about the role of a unilateral procedure.

METHODS

Fifty patients were prospectively enrolled in a lung volume reduction surgery program for emphysema with staged unilateral video-assisted thoracoscopic procedures (VATS group). These patients were compared with 29 patients having bilateral lung volume reduction procedures by median sternotomy.

RESULTS

The VATS group was slightly older and had shorter 6-minute walk distances, but otherwise the two groups were similar. Hospital stays were shorter for each unilateral VATS procedure, but the total of the two hospital stays was longer than the stay for the sternotomy group (21.1 versus 14.8 days). Complications were comparable, there were no in-hospital deaths, and there was significant difference in the 1-year mortality rate (VATS, 6% versus sternotomy, 13.8%; p = 0.137). Functional test results were comparable between the groups with improvements in percent predicted forced expiratory volume in 1 second (VATS, 41%, and sternotomy, 40%), 6-minute walk distances (VATS, 48%, and sternotomy, 26%), dyspnea scores, and acid base measurements.

CONCLUSIONS

Staged lung volume reduction operations do not appear to offer any measurable advantages over a single hospitalization and bilateral lung volume reduction procedures.

Chronic hypercapnia should not exclude patients from lung volume reduction surgery

OBJECTIVE

Chronic hypercapnia is still considered to increase the risk for perioperative mortality and therefore to be a contraindication for lung volume reduction surgery (LVRS). The aim of this study was to analyse the influences of hypercapnia upon postoperative outcome.

METHODS

The functional improvement (preop vs. 3 months postop) and clinical outcome was studied in 22 patients with chronic hypercapnia (preoperative arterial pCO2 > or = 45 mmHg) who underwent LVRS between 9/94 and 2/97 and were compared to all other patients (n = 58) without hypercapnia. Data are expressed as the mean +/- SEM.

RESULTS

The 30-day mortality was 9.1% (2/22) in patients with chronic hypercapnia (HC) and 5.2% (3/58) in patients with normal arterial pCO2 levels (control) (P = n.s). The stay on the ICU (3.5 +/- 0.8 vs. 2.1 +/- 0.3 days) and duration of chest drainage (7.3 +/- 1.2 vs. 7.2 +/- 0.8 days) was similar between both groups (HC vs. control) (P = n.s). The preoperative lung function (% of predicted) and blood gas (mmHg) parameters were significantly worse in HC patients compared to control patients. In both groups significant functional improvements were observed: FeV1 in the control group increased by 37% within the first 3 months (29.1 +/- 1.7% of predicted vs. 39.9 +/- 3.1% of predicted, P = 0.0198). In the HC group, FeV1 increased by 73% which was even higher than in the controls (19.5 +/- 1.5% of predicted vs. 33.7 +/- 4.7% of predicted, P = 0.0385). All patients of both groups who died perioperatively had a significantly higher severity of parenchymal destruction than those who survived (P = 0.0277 and 0.0380, respectively).

CONCLUSIONS

Patients with chronic hypercapnia alone, had no significantly higher mortality and morbidity, and therefore should not be excluded from LVRS. However, the presence of additional risk factors, such as homogeneity of disease, high degree of parenchymal destruction or pulmonary hypertension should be considered as contraindications for the procedure.

Outcome of Medicare patients with emphysema selected for, but denied, a lung volume reduction operation

BACKGROUND

Lung volume reduction operation shows promise in relieving symptoms and improving function in highly selected patients with emphysema. Withdrawal of Medicare funding for patients selected for operation by standard criteria created a matched control group with which to compare lung volume reduction recipients.

METHODS

A retrospective study was done comparing 22 volume reduction candidates denied operation with 65 contemporaneous and comparable volume reduction recipients. Baseline physiologic characteristics were compared and longitudinal measures of pulmonary function were followed up for 24 months.

RESULTS

Patients denied operation were similar to volume reduction recipients in all baseline measurements. Patients denied operation experienced a progressive worsening of their function, whereas volume reduction patients experienced sustained improvements. Absolute survival to date is 82% for the surgical group and 64% for the medical group.

CONCLUSIONS

The improvement seen in volume reduction patients cannot be attributed to the effects of patient selection or preoperative and postoperative rehabilitation.

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

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

Unilateral thoracoscopic reduction pneumoplasty for asymmetric emphysema

OBJECTIVE

We prospectively analyzed the surgical and functional results of unilateral thoracoscopic reduction pneumoplasty which we performed by choice in patients with asymmetric emphysema.

METHODS

Between October 1995 and June 1997, 119 emphysematous patients were examined and 34 were operated upon. Among these, 14 selected patients with asymmetric distribution of emphysema in the lungs underwent unilateral reduction pneumoplasty (ten right, and four left). There were 13 males and one female, with a mean age of 62 years. Eligibility criteria included bullous and non-bullous end-stage emphysema with severe limitation to daily activity.

RESULTS

No patient required conversion to thoracotomy. Mean operative time ranged between 70 and 240 min with a mean of 103 min. There was no postoperative mortality but five patients developed one or more complications: five prolonged air leaks (>7 days); two pulmonary infections; one empyema. No patient required postoperative mechanical ventilation. Median hospital stay was 8 days. At the 3-month follow-up the mean FEV1 increased from 0.8 l to 1.2 l (P < 0.001). Mean FVC increased from 2.6 l to 2.9 l (P < 0.001). The Medical Research Council dyspnea score decreased from a mean of 3.2 to 1.8 (P < 0.001).

CONCLUSIONS

Asymmetric distribution is a frequent finding in patients with severe emphysema. Unilateral thoracoscopic reduction pneumoplasty may represent an ideal approach in this selected group of patients.

Lung volume reduction surgery for emphysema: out on a limb without a NETT

Lung volume reduction surgery (LVRS) has recently been rediscovered and offers the potential of improving the quality of life of patients with advanced emphysema. In this article, we discuss the historical and contemporary versions of LVRS. Although initial enthusiasm has been substantial, existing data seem insufficient to demonstrate the safety and efficacy of the procedure in comparison with conventional medical therapy. Fundamental questions remain regarding the long-term effects of an operation versus medical therapy, the optimal selection criteria, the best measures of efficacy, the mechanisms of improvement, the cost-effectiveness of the procedure, and the optimal surgical technique. Until such questions are answered, advising patients about the best management their emphysema will be difficult. The National Emphysema Treatment Trial will address many of these issues and should be embraced by both health-care providers and patients.

Morphologic grading of the emphysematous lung and its relation to improvement after lung volume reduction surgery

BACKGROUND

The morphologic criteria for lung volume reduction surgery, such as severity and heterogeneity of disease, differ widely between patients, and this makes any comparison of functional results between centers difficult. Here we present a morphologic scoring system and describe its possible relation to functional results after lung volume reduction operations.

METHODS

Between September 1994 and December 1996, 47 consecutive patients underwent bilateral lung volume reduction operations. The morphology of emphysema was quantified with standard chest roentgenograms and computed tomographic imaging, which were used to define the following four variables: degree of hyperinflation (grade 0 to 4), degree of impairment in diaphragmatic mechanics, degree of heterogeneity (grade 0 to 4), and severity of parenchymal destruction (range, 0 to 48).

RESULTS

All four variables showed good reproducibility. Degree of heterogeneity had a significant influence on functional improvement in terms of forced expiratory volume in 1 second (p = 0.0413, r2 = 0.11). Severity of parenchymal destruction was significantly associated with 30-day mortality: patients who died after operation (n = 4) had a severity of parenchymal destruction of 28.4 +/- 2.1 compared with 21.3 +/- 1.0 for those who survived (n = 43) (p = 0.003).

CONCLUSIONS

This morphologic scoring system is easy to use, is reproducible, and allows quantification of the morphology of emphysema, thereby allowing definition of different patient subgroups. Such an exact morphologic quantification may help in the comparison of functional results between centers. Furthermore, the risk factors for certain morphologic subgroups, such as patients with a homogeneous distribution pattern, may be clarified in the future.