Comparison of changes in hemodynamics between unilateral and bilateral lung volume reduction for pulmonary emphysema.

This study was aimed to compare changes in hemodynamics between unilateral (UL) or simultaneous bilateral (BL) lung volume reduction surgery (LVRS) for chronic obstructive lung disease. Sixteen patients underwent LVRS by stapler resection with neodymium: yttrium-alminum-garnet (Nd: YAG) laser ablation; five underwent BL-LVRS (four by median sternotomy and one by thoracoscopy) and 11 underwent UL-LVRS by thoracoscopy. Four patients had multiple bullae within pulmonary emphysema. At preoperation and 6, 12, 24, and 48 hours postoperatively, hemodynamics and right ventricular performance were evaluated. UL- and BL-LVRS reduced afterload of the right and left ventricle postoperatively. Although the pulmonary arterial resistance increased after surgery, the total pulmonary resistance decreased (p=0.001) in association with the reduced systemic vascular resistance (p=0.001). These reductions improved cardiopulmonary circulation, resulting in increased stroke volume and cardiac output (p=0.003). The right ventricular ejection fraction showed minimal change 48 hours postoperation. Two patients died of pneumonia caused by persistent air leakage. In conclusion, both the UL- and BL-LVRS showed similar effectiveness in terms of improvement in the systemic and cardiopulmonary circulation after LVRS, if there were no postoperative complications. We concluded that we had to reduce and repair the persistent air leakage after LVRS.     

Survival after unilateral versus bilateral lung volume reduction surgery for emphysema

OBJECTIVE: Bilateral staple lung volume reduction surgery (LVRS) immediately improves pulmonary function and dyspnea symptoms in patients with advanced heterogeneous emphysema to a greater degree than do unilateral procedures. However, the long-term outcome after these surgical procedures needs to be critically evaluated. We compare 2-year survival of patients who underwent unilateral versus bilateral video-assisted LVRS in a large cohort treated by a single surgical group. METHODS: The cases of all 260 patients who underwent video-assisted thoracoscopic stapled LVRS from April 1994 to March 1996 were analyzed to compare results after unilateral versus bilateral procedures. Overall survival was calculated by Kaplan-Meier methods; Cox proportional hazard methods were used to adjust for patient heterogeneity and baseline differences between groups. RESULTS: Overall survival at 2 years was 86.4% (95% CI 80. 9%-91.8%) after bilateral LVRS versus 72.6% (95% CI 64.2%-81.2%) after unilateral LVRS (P =.001 for overall survival comparison). Improved survival after bilateral LVRS was seen among high- and low-risk subgroups as well. Average follow-up time was 28.5 months (range, 6 days to 46.6 months) for the bilateral LVRS group and 29.3 months (range, 6 days to 45.0 months) for the unilateral LVRS patients. CONCLUSIONS: Comparison of unilateral versus bilateral thoracoscopic LVRS procedures for the treatment of emphysema reveals that bilateral LVRS by video-assisted thoracoscopy resulted in better overall survival at 2-year follow-up than did unilateral LVRS. This survival study, together with other studies demonstrating improved lung function after bilateral LVRS, suggests that bilateral surgery appears to be the procedure of choice for patients undergoing LVRS for most eligible patients with severe heterogeneous emphysema.     

A case of thoracoscopic bilateral lung volume reduction surgery in a supine position.

We present a case of thoracoscopic bilateral lung volume reduction surgery performed with the patient in a supine position. By rotating the operative table, bilateral apical resection could be performed without difficulty. The duration of the operation was 160 minutes and the patient's forced expiratory volume in 1 second improved from 0.81 l to 2.49 l.     

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。     

胸腔镜肺减容术围手术期处理

目的总结40例电视胸腔镜肺减容术(lung volum e reduction surgery,LVRS)围手术期处理经验。方法1999年7月~2005年12月,我院对40例重症慢性阻塞性肺部疾病行电视胸腔镜肺减容术(23例附加胸壁小切口),术中均采用内镜切割缝合器切除一侧肺容积的20%~30%。结果双肺减容术13例(单纯胸腔镜手术7例,辅助小切口6例),单肺减容术27例(单纯胸腔镜手术10例,辅助小切口17例)。本组无手术死亡。40例术后住院9~41 d,平均18 d。术后呼吸困难症状明显缓解,呼吸指数均上升1~2级。术前与术后1个月肺功能比较:第1秒用力呼气量(forced exp iratory volum ein 1 second,FEV1)占预计值百分比(48.3±4.9)%vs(68.5±5.6)%(t=17.169,P=0.000);残气量(residual volum e,RV)占预计值百分比(270.0±23.6)%vs(188.0±19.8)%(t=16.835,P=0.000);肺总量(total lung capac ity,TLC)占预计值百分比(123.0±9.8)%vs(102.0±8.7)%(t=10.135,P=0.000)。10例术后肺漏气,5例肺部感染,3例支气管哮喘,患者经对症治疗后均痊愈。37例随访3~77个月,平均46个月,3例术后6、10、20个月死于肺癌,2例术后3个月和8个月死于食管癌,1例术后6个月死于脑血管病,余31例全部存活。结论术中熟练掌握胸腔镜手术技巧,围手术期积极预防和处理并发症,是保证手术成功和患者早日康复的关键。     

胸腔镜肺减容手术临床观察

目的探讨慢性阻塞性肺疾病（COPD）患者应用胸腔镜行肺减容手术的方法及疗效。方法2004年10月至2007年6月,对23例重度COPD行胸腔镜肺减容手术。均为CT诊断非均质性COPD合并肺大疱患者,术前第一秒用力呼气量（FEV1）占预计值百分比（55．6±4．9）％,残气量占肺总量比值（RV／TLC）（49．4±8．3）％。采用内镜切割缝合器（Endo—GIA）切除单侧肺容积20％～30％。结果手术时间（38．0±4．3）min,术中出血少于100ml。术后复张性肺水肿3例,肺部感染4例,没有持续漏气,最长漏气达12d。胸液量150～400ml,胸管置留时间（6．3±2．1）d,术后住院时间（13．8±5．3）d。术后6个月FEV1％（61．8±4．0）％,RV／TLC（36．6±4．8）％,与术前比较P〈0．001,未见气胸复发。结论对非均质性COPD并肺大疱患者应用胸腔镜肺大疱切除术能较好改善患者症状,并发症少,疗效满意。     

Risk analysis for thoracoscopic lung volume reduction: a multi-institutional experience

Objective: Most reports of thoracoscopic lung volume reduction (TLVR) are relatively small and early experiences from a single institution, factors which limit both the statistical validity and the applicability to the population at large. In order to address these shortcomings we undertook an analysis of the TLVR experience at five separate institutions to assess operative morbidity and identify predictors of mortality. Methods: Questionnaires were sent to four groups of surgical investigators at five institutions actively performing TLVR. Data was requested regarding preoperative, operative and postoperative parameters. Twenty-five potential predictors of mortality were analyzed and seven proved to be at least marginally significant (P<0.10). These parameters were entered into a stepwise logistic regression analysis to identify independent predictors. Results: The 682 patients (415 males, 267 females, mean age 64.0 years) underwent unilateral (410) or bilateral (272) TLVRs. Overall, operative mortality was 6% with half of the deaths resulting from respiratory causes. The remaining patients were discharged to home (88%), a rehabilitation facility (4%) or a ventilator facility (2%). There were 25 perioperative factors chosen representing clinically important indices such as spirometry, oxygenation, functional status, clinical and demographic variables. Univariate analysis identified seven variables as predictors of mortality (P<0.10) and these were entered into a stepwise logistic regression analysis. Only age, 6-min walk, gender (male 8%, female 3% mortality) and the procedure performed (unilateral 4.6%, bilateral 8%) were independent predictors while preoperative steroid therapy, preoperative oxygen administration, and time since smoking cessation dropped out of the model. The specific institution, learning curve (early vs. late experience), type of lung disease, spirometric indices and predicted maximum VO₂ were not significant predictors. Conclusion: This experience suggests that unilateral and bilateral lung volume reduction procedure can be performed with acceptable morbidity and mortality. Although age, gender, exercise capacity and the procedure performed are all independent predictors of mortality, the risk of operative death did not appear excessive in this fragile patient subset.     

Correlation of unilateral thoracoscopic lung volume reduction with improvement in lung function and exercise performance in patients with severe pulmonary emphysema

1 ), forced vital capacity, static compliance, and maximal oxygen uptake. The functional residual capacity as measured by the gas dilution method (FRC_gas), was unchanged; however, it was found to be decreased significantly when measured by body plethysmograph (FRC_box). Positive correlations existed between the reduction in FRC_box and the increase in FEV₁ (r = 0.586, P = 0.0042) and maximal oxygen uptake (r = 0.550, P = 0.018). Pulmonary ventilation and exercise ability in patients with pulmonary emphysema were improved in a volume-dependent manner by thoracoscopic lung volume reduction. These findings indicate that patients with a preoperative trapped gas volume level exceeding 1 l would be ideal candidates for thoracoscopic lung volume reduction. (Received for publication on Mar. 4, 1998; accepted on Jan. 7, 1999)     

Early results of endoscopic lung volume reduction for emphysema

BACKGROUND: We determined the feasibility, safety, and short-term efficacy of bronchoscopic placement of a one-way endobronchial valve in selected bronchopulmonary segments as an alternative to surgical lung volume reduction. METHODS: A total of 21 patients with incapacitating emphysema who underwent this procedure were studied. All patients had placement of the endobronchial valves into the most emphysematous lung segments. We recorded any major complications or deaths attributed to the procedure and analyzed (1) improvements in the spirometric and functional parameters and quality of life and (2) the radiologic changes compared with the baseline data at 30 and 90 days. RESULTS: A total of 20 patients had complete follow-up data. There was no mortality in the group studied. The forced expiratory volume at 1 second, forced expiratory volume at 1 second (percentage of predicted), forced vital capacity, and forced vital capacity (percentage of predicted) all improved significantly at 90 days (0.73 +/- 0.26 L vs 0.92 +/- 0.34 L [P =.009]; 33.3% +/- 11.9% vs 42.2% +/- 15.0% [P =.006]; 1.94 +/- 0.62 L vs 2.25 +/- 0.61 L [P =.015]; and 63.3% +/- 17.6% vs 73.9% +/- 17.1% [P =.012], respectively). The 6-minute walking distance improved at 30 and 90 days (251.6 +/- 100.2 m vs 306.3 +/- 112.3 m and 322.3 +/- 129.7 m; P =.012 and P =.003). The results of the 36-Item Short-Form Health Survey and the St George Respiratory Questionnaire showed significant improvements at 90 days. The Medical Research Council dyspnea grade also improved significantly at 30 and at 90 days (P =.006 and P =.003, respectively). CONCLUSIONS: Endobronchial valve placement is a safe procedure, with significant short-term improvements in functional status, quality of life, and relief of dyspnea in selected patients with emphysema. A larger study with long-term follow-up is therefore warranted.     

Anaesthesia and postoperative pain management for bilateral lung volume reduction surgery.

Bilateral lung volume reduction surgery was introduced into Australia in 1995 for treatment of selected patients with emphysema. We present our experience of the anaesthetic management of our first 55 cases and describe factors associated with outcome. There were four postoperative deaths (7%). Mean (SD) total operation time was 231 (72) minutes. Median intensive care unit (ICU) stay was 26 hours. There was a significant improvement in postoperative lung function (FEV1, VC, 6-minute walk test, all P < 0.001). Eight patients (15%) required reintubation for respiratory failure; three of these patients subsequently died. With multivariate analysis, total operation time was the only significant predictor of length of ICU stay R2 = 0.25, P = 0.001), which itself was the only significant predictor of hospital stay duration (R2 = 0.36, P < 0.001).     

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.     

Long-term results of lung volume reduction surgery.

OBJECTIVE: Lung volume reduction surgery (LVRS) is effective in the short and intermediate term for the improvement of pulmonary function and subjective symptoms in selected patients with advanced emphysema. The purpose of this study was to examine the long-term functional results of LVRS and to investigate which subgroups would benefit in terms of long-term survival. METHODS: All records of the patients who underwent LVRS between 1994 and, 1998 at our hospital were reviewed. RESULTS: Eighty-eight consecutive patients underwent LVRS during the period. There were 62 men and 26 women with an average age of 56.1 years (range 34-72 years). Eleven patients with alpha1-antitrypsin deficiency were included. The perioperative mortality rate (<90 days) was 2.3% (n=2). Total lung capacity (7.5+/-0.3 l) and residual volume (4.8+/-0.3 l) at 3 years remained lower than baseline (9.2+/-0.2 l, 6.5+/-0.2 l, each) (P<0.001). The mean forced expiratory volume in 1 s (FEV(1)) at 3 years (0.86+/-0.08 l) was higher than baseline (0.78+/-0.02 l), but the difference did not reach statistical significance. The FEV(1) of the patients with alpha1-antitrypsin deficiency and of those with respiratory bronchiolitis returned to baseline at one year after LVRS and showed further deterioration. Overall survival rate at 5 years was 71.0% with the mean length of follow-up of 54.2 months. The survival difference was statistically significant between patients with preoperative FEV(1) >or=28.5% and those with FEV(1)<28.5% (P=0.0152). CONCLUSIONS: The improvement of total lung capacity and residual volume persisted long after the operation. Patients with alpha1-antitrypsin deficiency and those with bronchiolitis showed early deterioration of the lung function. Patients with higher preoperative FEV(1) had a survival benefit. The favorable long-term survival might justify LVRS for the treatment of selected patients with severe emphysema.     

Postoperative pain management following bilateral lung volume reduction surgery for severe emphysema

This study was conducted to audit the clinical management of a continuous local anaesthetic infusion delivered by a fluoroscopically placed thoracic epidural catheter in conjunction with supplemental intravenous opioid patient controlled analgesia for postoperative pain control following bilateral lung volume reduction surgery for severe emphysema. This retrospective case series involved a random sample of 43 patients from a possible 65 patients. The mean dose of epidural bupivacaine 0.15% was 6.7 ml/h (SD 1.5), while the mean daily dose of morphine or hydromorphone was 22.5 mg/day (SD 17.9) and 4.3 mg/day (SD 3.1), respectively. Inadequate analgesia was reported by 19 (44%) patients during the first two postoperative days, but was successfully treated by individual titration of these medications. The incidence of atrial fibrillation (n = 6), premature epidural catheter dislodgement (n=6) or respiratory failure (n=3) appeared to be greater among patients who had inadequate analgesia at some stage. One patient developed excessive sedation; otherwise, there were no major complications. The use of an epidural bupivacaine infusion in conjunction with intravenous opioid patient controlled analgesia proved to be a safe and effective pain medication regimen when accompanied by individual titration of these agents in response to acute exacerbations of postoperative pain.     

Combined video-assisted thoracoscopic lung volume reduction surgery and lobectomy in a high-risk patient

Nonsmall cell lung cancer often occurs in patients with severe emphysema. Lobectomy in these patients is often contraindicated due to extensive parenchymal destruction and subsequent pulmonary insufficiency. Video-assisted thoracoscopic lobectomy has been described as a less morbid procedure in high-risk patients. Lung volume reduction surgery has been shown to improve pulmonary function in selected patients with emphysema. We describe the successful combination of lobectomy and lung volume reduction surgery (LVRS) with a video-assisted thoracoscopic (VATS) approach in a high-risk patient with Stage I nonsmall cell lung cancer.     

单侧、双侧肺减容术后肺气肿兔动脉血气与肺通气功能的变化

目的 比较单侧、双侧肺减容术后肺气肿家兔动脉血气与肺通气功能的变化.方法 60只家兔随机分为正常对照(A组)、肺气肿(B组)、单侧假手术(C组)、单侧肺减容术(D组)、双侧假手术(E组)和双侧肺减容术(F组).除A组外,其余均采用吸烟加气管内滴注木瓜蛋白酶的方法制作成肺气肿模型.术后8周进行动脉血气分析和肺功能检查.结果 与B组比较,D组pH、氧分压(PaO2)和氧饱和度(SaO2)显著升高(P＜0.05),PaCO2显著降低(P＜0.05);F组pH、PaO2和SaO2显著升高(P ＜0.01),PaCO2显著降低(P＜0.01).与D组比较,F组pH、PaO2和SaO2显著升高(P＜0.05),PaCO2 显著降低(P＜0.05).与B组比较,C组和E组肺功能无显著性差异(P＞0.05);D组0.5s用力呼气容积( FEV0.5)和FEV0.5/FVC(用力肺活量)显著升高(P＜0.05),功能残气量(FRC )/TLC(肺总容积)、动态顺应性(Cld)和呼气相气道阻力(Re)显著降低(P＜0.05);F组FEV0.5和FEV0.5/FVC显著升高(P＜0.01),FRC/TLC、Cld和Re显著降低(P＜0.01).与D组比较,F组FEV0.5和FEV0.5/FVC显著升高(P＜0.05),FRC/TLC 、Cld和Re显著降低(P＜0.05).观察期内双侧肺减容术组兔死亡2只,其余各组兔均存活.结论 双侧肺减容术较单侧肺减容术更能改善动脉血气和肺通气功能.     

Outcome of bilateral lung volume reduction in patients with emphysema potentially eligible for lung transplantation.

OBJECTIVE: Between January 1993 and May 1998, we performed 200 consecutive bilateral lung volume reduction operations. After initial assessment, 99 of these patients were eligible for lung volume reduction and potentially eligible for immediate or eventual lung transplantation on the basis of age and absence of contraindications. All chose to proceed with lung volume reduction surgery. The outcomes of these 99 patients are reviewed to assess the consequences of proceeding with lung volume reduction surgery on patients potentially eligible for lung transplantation. METHODS: A retrospective study was performed with the use of a prospectively assembled computer database. RESULTS: The 61 men and 38 women were 55 +/- 7 years old at evaluation for lung volume reduction. Mean values for first second expired volume, total lung capacity, and residual volume were 24% +/- 8%, 141% +/- 19%, and 294% +/- 54% predicted. There were 4 operative deaths and 17 late deaths. Two-year and 5-year survival after evaluation for lung volume reduction are 92% and 75%. The 32 patients who have been listed for transplantation after lung volume reduction include 15 who have undergone transplantation, 14 who remain on the list, and 3 who have been removed from the list. All 15 transplant recipients survived transplantation and 3 have subsequently died of rejection or late infection. The 12 living recipients have a median post-transplantation follow-up of 1.7 years. The age at transplantation was 58 +/- 5 years with transplantation occurring 3.8 +/- 1.1 years after lung volume reduction. Sixteen of 99 patients underwent lower lobe volume reduction with an increased rate of listing (63%, P =.008) and transplantation (38%, P =.003) compared with patients undergoing upper lobe volume reduction. Patients listed for transplantation were younger, more impaired, and experienced less benefit from lung volume reduction than patients not yet listed for transplantation. CONCLUSIONS: The preliminary use of lung volume reduction in patients potentially suitable for transplantation does not appear to jeopardize the chances for subsequent successful transplantation.     

电视胸腔镜辅助小切口行双侧肺减容术治疗重度肺气肿

目的:评价电视胸腔镜辅助小切口行双侧肺减容术治疗重度肺气肿的疗效,并总结围术期的处理经验。方法:回顾分析2006年以来为18例重度肺气肿患者实施肺减容术的临床资料,对比分析手术前后肺功能指标和动脉血氧分压的变化。结果:本组无手术死亡病例,2例合并急性呼吸衰竭。术后随访半年,平均第1秒用力呼气量增加39.2%,用力肺活量增加20.1%,残气量下降26.5%,肺总量下降23.1%,动脉血氧分压平均上升15.1%,与术前相比差异有统计学意义(P<0.05)。结论:电视胸腔镜辅助小切口行双侧肺减容术是经济有效的治疗方法,能明显改善重度肺气肿患者的临床症状和生理状况,增加活动能力。