Lung volume reduction surgery--a comparison of the long term outcome of unilateral vs. bilateral approaches.

OBJECTIVE: Bilateral lung volume reduction surgery (LVRS) is thought to be preferable to unilateral surgery due to greater initial benefit but the subsequent rate of decline may also be greater. We compared the long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs. METHODS: Prospective data were collected on a consecutive series of 65 patients undergoing LVRS who were all suitable for bilateral surgery. Twenty-six patients: age 59 (8) years underwent bilateral LVRS by video-assisted thoracoscopy (VAT) or sternotomy and 39 patients: age 60 (6) years underwent unilateral VAT. The perioperative effects of LVRS on spirometry were prospectively recorded at 3, 6, 12 and 24 months. RESULTS: The unilateral group had similar preoperative lung volumes to the bilateral patients: forced expiratory volume in 1s (FEV(1)) 26 vs. 30% predicted, RV 275 vs. 246% predicted and total lung capacity (TLC) 148 vs. 142% predicted. Unilateral LVRS was associated with significantly lower weight of lung resected: 80 (31) vs. 118 (46) g; hospital stay: 16 (10) days vs. 28 (22) days. Thirty-day mortality was 3% in the unilateral and 8% in the bilateral group (P=0.34). Postoperative ventilation occurred in 5% in the unilateral and in 42% in the bilateral group (P=0.0002). The decline of FEV(1) during the first postoperative year was significant in the bilateral group (-313 ml/y, P=0.04) but not significant in the unilateral group (-50 ml/y, P=0.18). SF 36 scores in all eight domains were similar in both groups preoperatively and at any postoperative interval. CONCLUSION: We have found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit.     

Long-term outcome of staged versus one-stage bilateral thoracoscopic reduction pneumoplasty.

OBJECTIVE: In a prospective non-randomized study, we tested the hypothesis that unilateral reduction pneumoplasty followed by completion of bilateral treatment at the reappearance of symptoms might result in more sustained improvements and better survival than one-stage bilateral treatment. METHOD: Fifty-nine patients undergoing bilateral thoracoscopic reduction pneumoplasty as a one-stage (n=33) or staged (n=26) procedure were evaluated on. The main indication for staged reduction pneumoplasty was symptom deterioration after unilateral treatment for asymmetric emphysema. Complete clinical assessment was carried out preoperatively and every 6 months postoperatively. RESULTS: The mean length of follow-up was 34+/-15 months. Interval time between operations in the staged group averaged 15.2 months. There was no inter-group difference in baseline data. Peak improvements in forced expiratory volume in 1 s (FEV(1)), forced vital capacity (FVC) and residual volume (RV) was significantly greater following one-stage bilateral reduction pneumoplasty. In particular, Delta FEV(1) was 0.33+/-0.2 l in the staged group and 0.43+/-0.2 l in the one-stage group (P=0.007). At 48 months, FEV(1), RV and 6-min-walking-test (6MWT) were still significantly improved only in the staged group. Four-year survival was 70% in the staged group and 81% in the one-stage group (Cox-Mantel test, P=not significant). CONCLUSION: Durable physiological improvements and satisfactory survival were achieved in this study for up to 4 years following either staged or one-stage bilateral reduction pneumoplasty using thoracoscopic technique. However, while peak improvements in FEV(1), FVC and RV were significantly greater following one-stage bilateral reduction, long-term improvements in FVC and 6MWT were more stable following a staged procedure. We speculate that sequential unilateral reduction pneumoplasty may reduce the mechanical stress in the lung leading to less steep postoperative deterioration of respiratory function.     

Single-Stage Bilateral, Video-Assisted Thoracoscopic Lung Volume Reduction Operation

Lung volume reduction (LVR) produces significant clinical and objective improvement in selected patients with diffuse emphysema. Unilateral and bilateral approaches have been successfully employed. A median sternotomy approach is the standard for bilateral LVR, whereas video-assisted thoracoscopy has been used to perform unilateral LVR. Encouraging video-assisted thoracoscopic results with sequential, staged, bilateral LVR have been shown. This report describes an alternate technique of single-stage, bilateral LVR for end-stage emphysema.     

肺减容术治疗晚期肺气肿

目的 总结肺减容术治疗晚期肺气肿的临床经验。方法 回顾性分析22例晚期肺气肿行肺减容术患者的临床资料。结果 患者术前1s用力呼吸量（FEV1）为24．5％、残气量（RV）为196．5％、总肺活量（TLC）为130．5％,术后FEV1为27．8％、RV为148．8％,TLC为112．5％。术前16例患者经常吸氧,术后5例活动后需吸氧。术前16例完成6min行走试验,平均行走198m,术后所有患者均完成行走试验,平均行走256m。术前呼吸困难14例3级,8例4级;术后5例2级,13例3级,4例4级。结论 靶区明确的非均质型尤其泡性肺气肿是肺减容术最佳适应证,经严格选择均质型肺气肿病例亦可手术。手术适应证及禁忌证值得进一步探讨;胸腔镜辅助腋下小切口单侧肺减容术安全、可靠、有效;机械缝切器和牛心包加垫可减少漏气。     

Quality of life after tailored combined surgery for stage I non-small-cell lung cancer and severe emphysema

BACKGROUND: We analyzed the early and long-term quality of life changes occurring in 16 patients undergoing tailored combined surgery for stage I non-small-cell lung cancer (NSCLC) and severe emphysema. METHODS: Mean age was 65 +/- 5 years. All patients had severe emphysema with severely impaired respiratory function and quality of life. Tumor resection was performed with sole lung volume reduction (LVR) in 5 patients, separate wedge resection in 3 patients, segmentectomy in 2 patients, and lobectomy in 6 patients. A bilateral LVR was performed in 5 patients. Quality of life was assessed at baseline and every 6 months postoperatively by the Short-form 36 (SF-36) item questionnaire. RESULTS: Mean follow-up was 44 +/- 21 months. All tumors were pathologic stage I. There was no hospital mortality nor major morbidity. Significant improvements occurred for up to 36 months in the general health (p = 0.02) domain and for up to 24 months in physical functioning (p = 0.02), role physical (p = 0.005), and general health (p = 0.01) SF-36 domains. Associated improvements regarded dyspnea index (-1.3 +/- 0.6) forced expiratory volume in one second (+0.28 +/- 0.2L), residual volume (-1.18 +/- 0.5L) and 6-minute-walking test distance (+86 +/- 67 m). Actuarial 5-year survival was similar to that of patients with no cancer undergoing LVRS during the same period (68% vs 82%, p = not significant). CONCLUSIONS: Our study suggests that selected patients with stage I NSCLC and severe emphysema may significantly benefit from tailored combined surgery in terms of long-term quality of life and survival.     

Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema

BACKGROUND: Guidelines on patient selection for lung cancer resection identify a predicted postoperative forced expiratory volume in 1 second (ppoFEV(1)) of <40% as a predictor of high risk. Experience with lung volume reduction surgery suggests that ppoFEV(1) may be underestimated in those with concomitant emphysema. METHODS: Anatomical lobectomy was performed in 29 patients with a resectable lung cancer within a poorly perfused, hyperinflated emphysematous lobe identified by radionuclide perfusion scintigraphy and computed tomographic scanning. Perioperative changes in spirometric parameters at 3 months were compared in 14 patients (group A) of mean age 69 years (range 48-78) with ppoFEV(1) <40% (mean (SD) 31.4 (7)%) and 15 patients (group B) with ppoFEV(1) >40% (mean (SD) 47 (5)%). The correlation between predicted and actual postoperative FEV(1) was also assessed. RESULTS: In group B there was a significant perioperative reduction in FEV(1) (p=0.01) but in group A FEV(1) did not change significantly after lobectomy (p=0.87); mean difference in perioperative change between groups A and B 331 ml (95% CI 150 to 510). Despite the difference in ppoFEV(1) between the groups, there was no difference in actual FEV(1) at 3 months. In-hospital mortality was 14% in group A and zero in group B, but at a median follow up of 12 (range 6-40) months there was no difference in survival between the groups. CONCLUSIONS: Selection for lung cancer resection in patients with emphysema using standard calculations of ppoFEV(1) may be misleading. The effect of lobar volume reduction allows for an extension of the selection criteria.     

Thoracoscopic bilateral lung volume reduction for diffuse pulmonary emphysema

Objective: In a prospective study, we investigated the functional results, complications and survival of bilateral video-assisted thoracoscopic (VAT) lung volume reduction (LVR) in a selected group of patients with severe, nonbullous pulmonary emphysema. From January 1994 to September 1996, 42 of 143 candidates (13 female, 29 male, 42–78 years) were operated. They were short of breath on minimal exertion due to severe airflow obstruction and hyperinflation (FEV1<30% pred., TLC>130% pred., RV>200% pred.). Methods: LVR was performed bilaterally by VAT using endoscopic staplers without buttressing the staple lines. Pulmonary function test (PFT), MRC dyspnea score and 12 min walking distance were assessed preoperatively, at 3, 6 and 12 months. In addition lung function was measured at hospital discharge. Results: The patients reported a marked relief of dyspnea, which persisted at all follow-up visits (P<0.001). FEV1 increased from 0.80±0.24 (L) to 1.14±0.41 (L) postoperatively, a 43% gain (P<0.001). A relevant increase of FEV1 persisted for at least 1 year. The residual volume to total lung capacity ratio decreased from 0.64 to 0.56 at hospital discharge. The mean 12 min walking distance increased from 500±195 (m) to 770±222 (m) after 1 year (P<0.001). The mean hospital stay was 13±5.5 days (median 12.0), drainage time was 9±4.3 (median 8.0) days. There was no 30 day mortality. Three patients died between 2 and 15 months postoperatively by non surgery related reasons. One patient underwent lung transplantation 5 months after surgical lung volume reduction. Conclusions: In a selected group of patients with severe, nonbullous pulmonary emphysema, bilateral LVR by VAT results in instantaneous postoperative improvement in pulmonary function and dyspnea. These favorable effects, including an amelioriation in exercise performance, lasted for at least 1 year.     

Surgical and functional results after surgical lung volume reduction in 94 patients with severe emphysema

Lung volume reduction (LVR) is a new surgical approach designed to relieve shortness of breath and improve exercise tolerance in patients with severe lung emphysema. The aim of this study was to analyse surgical results and changes in the lung function, gas exchange, exercise tolerance and degree of dyspnoea until two years after LVR. From June 1994 to September 1997 ninety-four patients (31 women and 63 men, mean age 64 [35-79] years) with severe emphysema (12 with alpha 1-Pi-deficiency) underwent unilateral (n = 24) or bilateral (n = 70) LVR. 92 from 94 patients were extubated immediately after surgery. 30 days mortality was 2.2% (2/94), 90 days 3.3% (3/94) respectively. Most common postoperative complications were pneumonia (n = 15, 16%) and air leakage longer than 7 days (n = 22, 23.4%). One month after surgery there was a significant increase in forced expiratory vital capacity after one second (FEV1 59%) and significant decrease in total lung capacity (TLC 19%) and residual volume (RV 28%). Also significant changes were observed in paO2, paCO2, 6-minute walking distance, dyspnoea score and respiratory muscle function. Two years after LVR lung function tests in patients with smokers emphysema showed the benefit to be maintained (high responders). Patients with alpha 1-Pi-deficiency showed 6 to 12 months after surgery a remarkable deterioration of functional data (low responders). In selected patients with severe emphysema surgical LVR shows significant improved pulmonary function, gas exchange, dyspnoea and walking distance. The results are better after bilateral operation. Patients selection, rehabilitation program and interdisciplinary care resulted in a low operative morbidity and mortality.     

Thoracoscopic lung volume reduction surgery for emphysema. Evaluation using ventilation-perfusion scintigraphy.

Thoracoscopic lung volume reduction surgery was conducted in 28 consecutive patients (bilateral 21, unilateral 7). The bilateral procedure was conducted simultaneously in 16 and as a planned staged approach in 5, using stapler resection with Nd:YAG laser ablation. Perfusion and ventilation scintigraphy were used to evaluate status before and after surgery. One operative death (3.6%) due to pneumonia occurred after a simultaneous bilateral procedure. Three to 6 months after surgery, the forced expiratory volume in 1 second (FEV1.0) had improved an average of 44% after the bilateral procedure and 17% after unilateral. Improved ventilation and perfusion distribution in the lower lung field correlated significantly with improved dyspnea scale (p < 0.01). Mean transit time was shortened significantly in each lung field (p < 0.01). Improved mean transit time correlated significantly with improved FEV1.0 and maximum oxygen consumption (VO2max) (p < 0.05). In conclusion, we found that bilateral thoracoscopic lung volume reduction surgery produces short-term functional outcomes superior to those of the unilateral procedure, and should be considered the procedure of choice for most patients. Ventilation and perfusion scintigraphy are useful both in determining target areas for resection and in evaluating lung volume reduction surgery effects.     

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).     

进胸取膈神经移位术后肺功能的变化

目的　研究进胸取膈神经移位术后患者肺功能的变化。方法　对 5例进胸取膈神经移位患者术前及术后 (8～ 14个月 )肺功能的变化进行比较。结果　 5例在术后均未出现供氧不足症状。 3例出现膈肌抬高 ;术后肺活量 (VC)、肺活量预计值百分数 (VC % )分别比术前减少 17.3 %和 3 2 .3 % ,两者差异有显著性意义 (tvc=3 .49、tvc% =4.17,P <0 .0 5 )。其它项目如残气量 (RV)、肺总量 (TLC)、残气量 /肺总量比值 (RV/TLC)、用力肺活量 (FVC)、1s用力呼气量 (FEV1)、1s用力呼气量 /用力肺活量比值(FEV1/FVC)、5 0 %肺活量的最大呼气流量预计值百分数 (FEF 5 0 % )的变化 ,和术前相比均无明显差异。结论　进胸取膈神经移位术后成人的肺容量有部分丧失 ,但其丧失程度在机体可耐受范围内 ,不会导致呼吸功能障碍     

Maximal exercise capacity and peripheral skeletal muscle function following lung transplantation.

BACKGROUND: There have been many suggestions that diminished exercise capacity in patients that have undergone lung transplantation is due, in part, to peripheral muscle dysfunction, brought on by either detraining or immunosuppressive therapy. There is limited data quantifying skeletal muscle function in this population, especially in those more than 18 months post-procedure. The present study sought to quantitate skeletal muscle function and cardiopulmonary responses to graded exercise in 19 lung transplant recipients, 15 of which were mostly more than 18 months post-procedure. METHODS: Ten single- (SLT) and 9 double-lung transplantation (DLT) underwent anthropometric measures and performed expiratory spirometry, whole body plethysmography to assess lung volumes, static maximal mouth pressures to assess respiratory muscle strength, progressive exercise testing on a cycle ergometer (with cardiac output measurements being performed every second workload) and isokinetic cycling to assess peripheral muscle power and work capacity. RESULTS: The DLT group was younger than the SLT group (23.0 [21.0-32.0] vs 47.5 [43.0-55.0] median [interquartile range], p < .05) with no differences in height, weight, or BMI. Despite the DLT group having significantly better spirometric values (FEV1: 86% vs 56.5% median) and less airtrapping (RV/TLC: 30% vs 53.5%), both groups were equally limited in exercise capacity (Wmax)(38.0 percent predicted [30.0-65.0] vs 37.5 percent predicted [30.0-44.0], SLT vs DLT), leg power (76.1 percent predicted [53.8-81.4] vs 69.0 percent predicted [58.3-76.0]) and leg work capacity (63.3 percent predicted [34.7-66.8] vs 38.4 percent predicted [27.5-57.3]). This lack of difference in performance persisted when the analysis was limited to those more than 18 months post-procedure. Respiratory muscle strength was also not different for the two groups, and was within normal limits. Wmax was best correlated with leg work capacity (r = .84), but also with leg power, RV/TLC, FEV1 (r = .49, -.52, .58). When normalized for age, height, and sex, percent predicted Wmax only correlated with percent predicted leg work capacity (r = .58). Cardiac output was appropriate for the work performed. CONCLUSIONS: We conclude that peripheral skeletal muscle work capacity is reduced following lung transplantation and mostly responsible for the limitation of exercise performance. While the causes of muscular dysfunction have yet to be clarified, the preservation of respiratory muscle strength with the concomitant reduction in leg power and work capacity suggests that most of the muscular dysfunction post-transplantation is attributable to detraining.     

Changes in ventilatory mechanics and diaphragmatic function after lung volume reduction surgery in patients with COPD

BACKGROUND: Lung volume reduction (LVR) has recently been used to treat severe emphysema. About 25% of the volume of each lung is removed with this method. Little is known about the mechanism of functional improvement so a study was undertaken to investigate the changes in ventilatory mechanics and diaphragmatic function in eight patients after LVR. METHODS: Measurements of work of breathing (WOB), intrinsic positive end expiratory pressure (PEEPi), dynamic compliance (Cdyn), and arterial carbon dioxide tension (PaCO2) were performed on the day before surgery and daily for seven days after surgery, as well as one, three, and six months after surgery. All measurements were performed on spontaneously breathing patients, simultaneously assessing oesophageal pressure via an oesophageal balloon catheter and air flow via a tightly adjusted mask. Diaphragmatic function was evaluated by measuring oesophageal and transdiaphragmatic pressure (Pdi) preoperatively and at one, three, and six months postoperatively. RESULTS: Mean forced expiratory volume in one second (FEV1) was 23 (3.6)% predicted, and all patients were oxygen dependent before the-operation. One day after LVR the mean decrease in WOB was 0.93 (95% confidence interval (CI) 0.46 to 1.40) joule/l, the mean decrease in PEEPi was 0.61 (95% CI 0.35 to 0.87) kPa, and the mean increase in Cdyn was 182.5 (95% CI 80.0 to 284.2) ml/kPa. Similar changes were found seven days and six months after surgery. PaCO2 was higher on the day after the operation but was significantly reduced six months later. Pdi was increased three and six months after surgery. CONCLUSIONS: Ventilatory mechanics improved immediately after LVR, probably by decompression of lung tissue and relief of thoracic distension. An improvement in diaphragmatic function three and six months postoperatively also contributes to improved respiratory function after LVR.


     

Reduction pneumonoplasty for emphysema. Early results.

OBJECTIVE: The authors determined the role of Nd:YAG laser reduction pneumonoplasty for selected patients with diffuse emphysema. SUMMARY BACKGROUND DATA: The study is based on the concepts introduced 30 years ago by Brantigan regarding the value of lung reduction surgery in patients with emphysema. The authors used minimally invasive techniques with the hopes of providing appropriate clinical results with the least surgical morbidity. METHODS: Fifty-five patients with advanced symptomatic emphysema were treated with unilateral Nd:YAG laser reduction pneumonoplasty to achieve lung volume reduction. RESULTS: Patients experienced significant improvement in exercise capacity and relief of breathlessness. This correlated with improvement in objective measures of pulmonary function and with reduction in lung volume by radiographic and spirometric measures. Significant associated hospital morbidity and a 5.5% mortality were associated. CONCLUSIONS: These encouraging results with treatment of only one lung will be built on with both sequential lung and simultaneous, bilateral lung treatment protocols.     

单双侧肺减容术后早期肺功能及肺血流动力学的变化

目的探讨单、双侧肺减容（LVRS）术后早期肺功能及肺血流动力学的不同变化。方法86例重度慢性阻塞性肺气肿患者（COPD）行LVRS手术,单侧61例、双侧25例,术前、术后3、6个月分别测量肺功能[第1秒用力呼气量（FEV1）、残气量（RV）、肺总量（TLC）]、动脉血气[动脉血氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）]、心脏超声多普勒检查[心输出量（CO）、心脏指数（CI）、射血分数（EF）并计算肺动脉压（PAP）],并对其结果进行比较分析。结果80例患者痊愈出院,6例死亡;单侧LVRS术后3、6个月的FEV,较术前有明显提高（P〈0．05）,双侧LVRS术后各项指标改善较单侧更好（P=0．015）,RV、TLC较术前有明显降低（P〈0．05）;术后PaO2比术前提高（P〈0．05）,PaCO2较术前显著减低（P〈0．05）;肺血流动力学（CO、CI、EF、PAP）无明显变化（P〉0．05）。结论单、双侧LVRS治疗重度COPD患者是安全有效的,术后早期均可明显改善患者的肺功能,但双侧手术效果优于单侧;单、双侧LVRS对肺血流动力学无明显负影响,术前术后无明显改变。     

Is there a role for therapeutic lobectomy for emphysema?

OBJECTIVE: The feasibility of performing a standard lobectomy in patients with non-small cell lung cancer (NSCLC) and severe heterogeneous emphysema whose respiratory reserve is outside standard operability guidelines has been described [Edwards JG, Duthie DJR, Waller DA. Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema. Thorax 2001;56:791-5; Korst RJ, Ginsberg RJ, Ailawadi M, Bains MS, Downey RJ, Rusch V, Stover D. Lobectomy improves ventilatory function in selected patients with severe COPD. Ann Thorac Surg 1998;66:898-902; Carretta A, Zannini P, Puglisi A, Chiesa G, Vanzulli A, Bianchi A, Fumagalli A, Bianco S. Improvement in pulmonary function after lobectomy for non-small cell lung cancer in emphysematous patients. Eur J Cardiothorac Surg 1999;15(5):602-7]. Postoperative lung function was better than predicted, attributable to the therapeutic benefit of deflation of the hemithorax. Our aim was to determine whether the physiological benefits of this approach were superior to conventional non-anatomical lung volume reduction surgery (LVRS) in similar patients. METHODS: A retrospective review of a single surgeon's experience identified 34 consecutive patients who underwent upper lobectomy for completely resected stage I-II NSCLC, and who had severe heterogeneous emphysema of apical distribution with a predicted postoperative FEV1 of less than 40%. Their perioperative characteristics, postoperative spirometry and survival of these cases were compared to 46 similar patients who underwent unilateral upper lobe LVRS during the same period. RESULTS: Data expressed as median (range). LVRS patients were significantly younger (59 years [39-70] vs 67 years [48-79] p<0.001), with more severe airflow obstruction (FEV(1) %pred 24 [12-60] vs 44 [17-54] p<0.001) and more heterogenous disease ('Q' score 4 [0.5-11.5] vs 7 [1-13] p=0.001) than the lobectomy group. No significant difference was found in median survival (88 vs 53 months, p=0.06). Lobectomy patients had a shorter air leak duration (5 days [2-36] vs 9 days [1-40], p=0.02) and hospital stay (8 days [3-63] vs 13 days [6-90] p=0.01). A significant correlation was found between pre-operative Q score and percentage improvement in FEV1 (r=-0.33, p=0.02). CONCLUSIONS: Lobectomy for lung cancer in patients in severe heterogenous chronic obstructive pulmonary disease is associated with similar improvement in airflow obstruction as conventional LVRS, but is associated with a shorter postoperative course. Lobectomy may therefore offer a therapeutic alternative to conventional LVRS in a selected population.     

Long-term survival after thoracoscopic lung volume reduction: a multiinstitutional review

Background. It has been suggested that bilateral thoracoscopic lung volume reduction (BTLVR) yields significantly better long-term survival than unilateral thoracoscopic lung volume reduction (UTLVR).

Methods. All perioperative data were collected at the time of the procedure. Follow-up data were obtained during office visits or by telephone.

Results. A total of 673 patients underwent thoracoscopic LVR: 343 had either simultaneous or staged BTLVR and 330, UTLVR. As of July 1998, follow-up was available on 667 (99%) of the 673 patients with a mean follow-up of 24.3 months. The patients in the BTLVR group were significantly younger (62.6 ± 8.0 years versus 65.4 ± 8.1 years; p < 0.0001), had a higher preoperative arterial oxygen tension (69.7 ± 12 mm Hg versus 65.3 ± 11 mm Hg; p < 0.0001), and had a superior preoperative 6-minute walk performance (279.9 ± 93.6 m [933 ± 312 feet] versus 244.5 ± 101.4 m [815 ± 338 feet] p < 0.0001). There was no difference in the operative mortality rate between the two groups (UTLVR, 5.1%, and BTLVR, 7%). Actuarial survival rates for the UTLVR group at 1 year, 2 years, and 3 years were 86%, 75%, and 69%, respectively versus 90%, 81%, and 74%, respectively, for the BTLVR group (p = not significant).

Conclusions. Contrary to previous reports, survival after BTLVR was not superior to that after UTLVR even though the former group appeared to have a lower risk preoperatively because of younger age, higher arterial oxygen tension, more advantageous anatomy, and better functional status. Despite thoracoscopic LVR, the actuarial mortality rate approached 30% at 3 years, and this calls into question whether this procedure offers any survival advantage to patients with end-stage emphysema.     

Bronchiolitis obliterans syndrome in single lung transplant recipients--patients with emphysema versus patients with idiopathic pulmonary fibrosis.

Bronchiolitis obliterans syndrome (BOS) after lung transplantation is a disease of small airways that is currently graded according to a decline in forced expiratory volume in 1 second (FEV(1)) even in single lung transplant recipients in whom native diseased lung may influence lung physiology. The aim of this study was to evaluate the comparative changes in lung function and survival following the onset of BOS in patients with emphysema and patients with idiopathic pulmonary fibrosis (IPF) who have undergone single lung transplantation. We analyzed data from 31 single lung transplant recipients with emphysema and 25 with IPF who were at risk of BOS. There was no difference in the incidence of BOS between the 2 groups (10 patients with emphysema and 6 patients with IPF), but after the onset of BOS the patients with emphysema had a significantly greater median survival (18 months vs 8 months) despite a poorer mean FEV(1) (1.26 liter, 45% predicted vs 2.11 liter, 67% predicted) compared with the IPF group (p < 0.05) and this difference in lung function persisted at death (0.8 liter, 30% predicted vs 1.65 liter, 51% predicted) (p < 0.05). In summary the native lung physiology appears to influence lung function and therefore survival, and this may indicate that the classification of BOS should include disease-specific characteristics.     

Pulmonary lobectomy for lung cancer: a prospective study to compare patients with forced expiratory volume in 1 s more or less than 80% of predicted.

OBJECTIVE: To compare post-operative course, lung function and survival of lung cancer patients with a forced expiratory volume in 1 s (FEV1) more or less than 80% of predicted submitted to lobectomy. METHODS: The data of patients undergoing lobectomy for non small cell carcinoma at the Thoracic Surgery Unit of the Ospedale Maggiore Policlinico of Milan, Italy, were prospectively collected. Inclusion criteria were a radical resectable tumor with size less than 2.5 cm, negative mediastinal nodes, capability to complete pulmonary function tests, Exclusion criteria were FEV1 <40% of predicted, pre- or post-operative chemo or radiotherapy, lobe to be resected receiving more than 30% of the perfusion, incapacity to quit smoking. RESULTS: Eighty-eight patients entered the study and were divided into two groups according to their FEV1%: 45 patients were included in control group (mean FEV1: 92.2%) and 42 in chronic obstructive pulmonary disease group (mean FEV1: 64.2%). Post-operative complications, operative mortality and actuarial survival were the same in the 2 groups. Six months after lobectomy, the mean changes in FEV1 were -14.9% for first group and -3.2% for second group (P<0.001). CONCLUSION: Lobectomy for cancer can be performed successfully also in selected patients with chronic obstructive pulmonary disease. Post-operative course and survival of these patients is not different from that of patients with normal FEV1, on the contrary, patients with low FEV1 may lose less pulmonary function or even mend it.     

Examination of post operative split lung function using quantitative xenon 133 (133Xe) inhalation scan]

133Xe inhalation scan and ordinary lung function testing were performed three times in 34 patients undergoing pulmonary resection: before surgery, and one and six months postoperatively. Forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1.0) were used as spirometric parameters. From the 133Xe inhalation scan, a split lung capacity (right to left, upper, middle and lower) and T1/2 (time required for half of the inhalation of 133Xe gas to be expired) were calculated by computer and used as indices of split lung capacity and ventilation, respectively. Results obtained from this study are as follows. 1) The predicted postoperative lung functions were calculated using preoperative spirometric respiratory function and 133Xe inhalation data according to the formula reported by Ali and associates. At sixth postoperative month, both predicted FVC (r = 0.895, p < 0.001) and FEV1.0 (r = 0.897, p < 0.001) correlated highly with those actually observed. These results appear to be very useful for preoperative evaluation of operative indications and the choice of surgical methods. 2) The ratios of observed to predicted lung capacity in the post operative state were examined by splitting the right and left lung and the means +/- S.D. (%) were as follows. One month after surgery, operated side; 80.5 +/- 9.7%, opposite side; 119.2 +/- 11.7%. Six months after surgery, operated side; 111.0 +/- 5.6%, opposite side; 96.7 +/- 16.4%. The post operative T1/2 values on the operated sides were about 2.4 times the preoperative values at one month after surgery but had recovered to the preoperative values by the six postoperative month.(ABSTRACT TRUNCATED AT 250 WORDS)