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Pompeo E, Rogliani P, Palombi L, Orlandi A, Cristino B, Dauri M. The complex care of severe emphysema: role of awake lung volume reduction surgery. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:108. [PMID: 26046049 DOI: 10.3978/j.issn.2305-5839.2015.04.17] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/16/2015] [Indexed: 11/14/2022]
Abstract
The resectional lung volume reduction surgery (LVRS) procedure entailing nonanatomic resection of destroyed lung regions through general anesthesia with single-lung ventilation has shown to offer significant and long-lasting improvements in respiratory function, exercise capacity, quality of life and survival, particularly in patients with upper-lobe predominant emphysema and low exercise capacity. However mortality and morbidity rates as high as 5% and 59%, respectively, have led to a progressive underuse and have stimulated investigation towards less invasive surgical and bronchoscopic nonresectional methods that could assure equivalent clinical results with less morbidity. We have developed an original nonresectional LVRS method, which entails plication of the most severely emphysematous target areas performed in awake patients through thoracic epidural anesthesia (TEA). Clinical results of this ultra-minimally invasive procedure have been highly encouraging and in a uni-center randomized study, intermediate-term outcomes paralleled those of resectional LVRS with shorter hospital stay and fewer side-effects. In this review article we analyze indications, technical details and results of awake LVRS taking into consideration the available data from the literature.
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Affiliation(s)
- Eugenio Pompeo
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Paola Rogliani
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Leonardo Palombi
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Augusto Orlandi
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Benedetto Cristino
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
| | - Mario Dauri
- Departments of 1 Thoracic Surgery, 2 Pulmonology, 3 Epidemiology and Public Health, 4 Anatomic Pathology, 5 Anesthesia and Intensive Care, Policlinico Tor Vergata University, Rome, Italy
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Berger RL, Wood KA, Cabral HJ, Goodnight-White S, Ingenito EP, Gray A, Miller J, Springmeyer SC. Lung Volume Reduction Surgery. ACTA ACUST UNITED AC 2005; 4:201-9. [PMID: 15987235 DOI: 10.2165/00151829-200504030-00004] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND Observational studies have suggested that lung volume reduction surgery (LVRS) is superior to optimal medical therapy for selected subsets of patients with advanced emphysema. Randomized clinical trials (RCTs) with the exception of the National Emphysema Treatment Trial (NETT), failed to enroll a sufficient number of patients to provide clinicians and patients with convincing outcome data on the usefulness of LVRS. It was postulated that a meta-analysis of these RCTs (3-12 months' follow up) may provide more compelling information on the value of LVRS in patients with emphysema. METHODS A comprehensive search of the MEDLINE database between January 1994 and January 2004 for RCTs on LVRS was performed. RESULTS From a total of eight RCTs on record, six studies (306 patients) with 3- to 12-month follow up were deemed suitable for meta-analysis. Key baseline features of these RCT populations included heterogeneous emphysema, comparable inclusion/exclusion criteria and, in retrospect, low walking capacity as measured by the 6-minute walk distance (6MWD). This profile closely resembles NETT's 'predominantly upper lobe--low exercise tolerance emphysema' cohort. The LVRS arm of the meta-analysis population showed better results than the medical cohort in terms of pulmonary function (FEV(1) p < 0.0001, FVC p < 0.0001, residual volume p < 0.0001, total lung capacity p = 0.004), gas exchange (arterial partial pressure of oxygen p < 0.0001) and exercise capacity (6MWD p = 0.0002). Although information on quality-of-life measures was not sufficiently uniform to qualify for meta-analysis, a survey of available data revealed better results in the surgical than in the medical arms of each RCT. Mortality 6-12 months after random assignment to treatment was similar in the two study arms, suggesting that the operative mortality from LVRS was offset, within months, by deaths in the medical arm. CONCLUSIONS This meta-analysis showed that a selected subset of patients with advanced, heterogeneous emphysema and low exercise tolerance (6MWD) experienced better outcomes from LVRS than from medical therapy.
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Affiliation(s)
- Robert L Berger
- Department of Surgery, Harvard Medical School, Boston, Massachusetts 02445, USA.
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Pezzetta E, Vallet C, El-Lamaa Z, Haller C, Ris HB. [Lung volume reduction surgery for emphysema: a unilateral or bilateral approach?]. Rev Mal Respir 2004; 21:567-71. [PMID: 15292849 DOI: 10.1016/s0761-8425(04)71361-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- E Pezzetta
- Service de Chirurgie Thoracique et Vasculaire, CHUV, Lausanne, Suisse.
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Toloza EM, Harpole DH. Intraoperative techniques to prevent air leaks. CHEST SURGERY CLINICS OF NORTH AMERICA 2002; 12:489-505. [PMID: 12469483 DOI: 10.1016/s1052-3359(02)00020-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Persistent air leaks prolong chest tube duration and hospital stay after lung surgery. Air leaks also may lead to life-threatening empyemas. Preventing postoperative air leaks and BPFs is the best treatment for air-leak complications. Meticulous closure of parenchymal, pleural, and bronchial defects is the mainstay of air-leak control. The reinforcement of parenchymal suture and staple lines, pleural apposition, and well-vascularized tissue-flap coverage of bronchial suture and staple lines further reduce the incidence of prolonged air leaks and BPFs.
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Affiliation(s)
- Eric M Toloza
- Department of Surgery, Division of Thoracic Surgery, Duke University Medical Center, Box 3048, Durham, NC 27710, USA.
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Roviaro G, Varoli F, Francese M, Caminiti R, Vergani C, Maciocco M. Thoracoscopy and transplantation: a new attractive tool. Transplantation 2002; 73:1013-8. [PMID: 11965025 DOI: 10.1097/00007890-200204150-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Transplanted patients on immunosuppressive treatment have an increased risk of infections or neoplasms. Transplantation candidates with infection or a suspected malignancy are excluded from transplantation. In patients already transplanted, thoracoscopy can resolve complications or treat the pulmonary pathology without compromising the precarious existing reactive equilibrium. These patients require an approach that is as least traumatic as possible. METHODS From September 1991 to December 2000, of 2068 videothoracoscopic procedures carried out at our hospital, 2 were in patients who had undergone transplantation and 3 in candidates for kidney, liver, and bone marrow transplantation. Starting from our personal experience in videothoracoscopy as a diagnostic and therapeutic approach, the possibilities of the method in the field of transplantation are reported by a review of the literature carried out by consulting the reference systems of the most important data banks. CONCLUSIONS In our experience, videothoracoscopy had a major impact on the management of candidates for transplant, because it allowed us to rule out or treat conditions that would have determined exclusion from a transplant program. In transplanted patients, videothoracoscopy allows a correct diagnosis and treatment with minimal trauma.
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Affiliation(s)
- Giancarlo Roviaro
- Department of General Surgery, San Giuseppe Hospital, F.b.F-A.Fa.R., University of Milan, Italy.
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Pompeo E, Marino M, Nofroni I, Matteucci G, Mineo TC. Reduction pneumoplasty versus respiratory rehabilitation in severe emphysema: a randomized study. Pulmonary Emphysema Research Group. Ann Thorac Surg 2000; 70:948-53; discussion 954. [PMID: 11016339 DOI: 10.1016/s0003-4975(00)01646-5] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND The purpose of the study was to determine in a prospective randomized trial the independent short-term physiologic impact of reduction pneumoplasty (RP) on respiratory rehabilitation (RR). METHODS Sixty patients eligible for RP were randomly selected by computer to receive either RP (n = 30) or comprehensive RR (n = 30). Pulmonary function tests, analysis of blood gas levels, measurement of respiratory muscle strength (maximal inspiratory and expiratory pressures), 6-minute walk test (6MWT), and incremental treadmill test (ITT), were performed at baseline and at 3 and 6 months. RESULTS Two treatment-related deaths occurred after RP and one after RR. At 6 months dyspnea index, maximal inspiratory pressure, 6MWT, ITT, and PaO2 were significantly improved in both groups whereas forced expiratory volume in 1 second and residual volume were significantly improved only in the surgical arm. In addition at 6 months, dyspnea index, 6MWT, maximal ITT, and PaO2 improved significantly more after RP than after RR. CONCLUSIONS In our study short-term improvements in dyspnea index, oxygenation, inspiratory muscle strength, and exercise capacity occurred after either RP and RR. However dyspnea index, PaO2, and exercise capacity improved more after RP than after RR whereas pulmonary function improved only after RP.
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Affiliation(s)
- E Pompeo
- Division of Thoracic Surgery, Tor Vergata University, Rome, Italy.
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Pompeo E, Sergiacomi G, Nofroni I, Roscetti W, Simonetti G, Mineo TC. Morphologic grading of emphysema is useful in the selection of candidates for unilateral or bilateral reduction pneumoplasty. Eur J Cardiothorac Surg 2000; 17:680-6. [PMID: 10856859 DOI: 10.1016/s1010-7940(00)00441-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
OBJECTIVE Radiologic morphology of emphysema proves useful in the selection of candidates for bilateral reduction pneumoplasty. We developed a simple morphologic grading system capable of identifying subsets of patients who had maximal functional improvement after unilateral or bilateral operation. METHODS Fifty-two patients who underwent unilateral (n=34) or bilateral (n=18) reduction pneumoplasty were evaluated. Emphysema morphology was visually scored by digital roentgenograms and high-resolution computed tomography. In each lung, severity of emphysema (ES), heterogeneity (DHT) and hyperinflation (DHF) degrees, were assessed. Asymmetric ratio of emphysema (ARE) between the lungs was expressed as: higher ES/lower ES scores. Morphometric data were correlated with absolute preoperative-postoperative FEV(1) change (DeltaFEV(1)). RESULTS No difference was found between the unilateral and the bilateral group for ES and DHT. DHF was greater in the bilateral group (3.1 vs. 2.7, P=0.02) whereas ARE was greater in the unilateral group (1.29 vs. 1. 05, P=0.0001). Stepwise logistic regression extracted as best predictors of maximal DeltaFEV(1), ARE (odds ratio=238, Wald test P=0.04) in the unilateral group, and DHT (odds ratio=24, P=0.03) in the bilateral group. Unilateral group DeltaFEV(1) was greater in patients with ARE>/=1.3 (0.44 vs. 0.24 l, P=0.02). Bilateral group DeltaFEV(1) was greater in patients with DHT>1 (0.50 vs. 0.31 l, P=0. 03). No difference was found when comparing DeltaFEV(1) resulting from unilateral RP and ARE>/=1.3, and bilateral RP (0.44 vs. 0.41 l, not significant). CONCLUSIONS This morphologic grading system identified subsets of patients who had maximal functional benefit from unilateral or bilateral reduction pneumoplasty and might be useful in the preoperative screening of candidates for either approach.
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Affiliation(s)
- E Pompeo
- Department of Thoracic Surgery, Tor Vergata University, P. le Umanesimo 10, 00144, Rome, Italy.
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Hamacher J, Russi EW, Weder W. Lung volume reduction surgery: a survey on the European experience. Chest 2000; 117:1560-7. [PMID: 10858383 DOI: 10.1378/chest.117.6.1560] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- J Hamacher
- Department of Surgery, University Hospital, Zürich, Switzerland
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Galbis J, Zulueta J, Iribarren JM, Torre W. [Bilateral lung reduction by video-assisted thoracoscopy in a patient with non-bullous pulmonary emphysema and laryngeal neoplasia]. Arch Bronconeumol 2000; 36:162-4. [PMID: 10782268 DOI: 10.1016/s0300-2896(15)30202-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Lung reduction has been show to be a promising treatment for the final phases of non-bullous pulmonary emphysema. The role of video-assisted thoracoscopy (VAT) in this disease has not yet been established. We report a case of bilateral non-bullous pulmonary emphysema in which transplantation was ruled out because of laryngeal neoplasm treated three months earlier. Using VAT, we performed bilateral lung reduction in the apical zones with good therapeutic results. We find that in patients reduction by VAT, although not a curative treatment, leads to immediate postoperative improvement in lung function and dyspnea, and does not exclude the possibility of later performing lung transplantation.
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Affiliation(s)
- J Galbis
- Servicio de Cirugía Torácica, Facultad de Medicina, Universidad de Navarra
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