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.     

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。     

电视胸腔镜肺减容术治疗27例重度肺气肿的疗效分析

目的探讨电视胸腔镜（VATS）下行肺减容术（LVRS）治疗重度肺气肿的临床疗效。方法回顾性分析27例重度肺气肿患者在电视胸腔镜下行LVRS的资料,其中双侧12例,单侧15例,切除每侧肺容积的20%～40%,比较手术前后的肺功能、血气分析等指标变化。结果 15例行VATS下单侧LVRS,4例同期行VATS下双侧LVRS,8例半年内分期行VATS下双侧LVRS,无死亡病例。术前与术后的各项指标比较,肺功能、血气分析及6min步行距离,差异有统计学意义。结论 VATS下LVRS治疗重度肺气肿可以取得良好疗效,双侧LVRS是更好的治疗手段。     

肺移植治疗终末期肺气肿19例报告

目的 探讨肺移植治疗终末期肺气肿的手术适应证、术式的选择及术后疗效.方法 报告肺移植治疗终末期肺气肿19例,患者术前CT检查均以弥漫性肺气肿为主,均经2～3年不同程度的吸氧治疗,其中依赖呼吸机的有5例.手术方式分别为:单肺移植6例;单肺移植加对侧肺减容术7例;双肺移植6例.结合这19例患者的肺移植效果进行分析和总结.结果 单肺移植的受者中,术后第1天内有2例受者胸腔引流量超过2000 ml,再次剖胸探查止血.19例受者术后机械通气时间为3～22 d,平均呼吸机脱机时间为7 d.术后1个月内死亡5例,死亡原因分别为:原发性移植物功能丧失1例、支气管吻合口漏1例、重症急性排斥反应(4A级)1例及重症细菌和霉菌感染2例.6例双肺移植的受者术后早期均康复出院.19例患者术后1、2、3年存活率分别为73.7%、63.2%和52.6%.结论 肺移植是治疗终末期肺气肿最有效的方法;单肺移植口丁作为终末期肺气肿的常用术式,单肺移植结合对侧肺减容术可以更好的利用供肺,同时又解除了术后对侧自体肺的并发症;对年龄较轻及有双肺感染的终末期肺气肿患者,应首选双肺移植,双肺移植较单肺移植术后并发症更少.     

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.     

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.     

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.


     

Lung volume reduction surgery combined with cardiac interventions.

OBJECTIVE: Postoperative course and functional outcome were evaluated in patients who underwent lung volume reduction surgery (LVRS) or in combination with valve replacement (VR), percutaneous transluminal coronary angioplasty (PTCA), placement of a stent, or coronary artery bypass grafting (CABG). METHODS: Patients with severe bronchial obstruction and hyperinflation due to pulmonary emphysema were evaluated for lung volume reduction surgery. Cardiac disorders were screened by history and physical examination and assessed by coronary angiography. Nine patients were accepted for LVRS in combination with an intervention for coronary artery disease (CAD). In addition, three patients with valve disease and severe emphysema were accepted for valve replacement (two aortic-, one mitral valve) only in combination with LVRS. Functional results over the first 6 months were analysed. RESULTS: Pulmonary function testing demonstrates a significant improvement in postoperative FEV1 in patients who underwent LVRS combined with an intervention for CAD. This was reflected in reduction of overinflation (residual volume/total lung capacity (RV/TLC)), and improvement in the 12-min walking distance and dyspnea. Median hospital stay was 15 days (10-33). One patient in the CAD group died due to pulmonary edema on day 2 postoperatively. One of the three patients who underwent valve replacement and LVRS died on day 14 postoperatively following intestinal infarction. Both survivors improved in pulmonary function, dyspnea score and exercise capacity. Complications in all 12 patients included pneumothorax (n = 2), hematothorax (n = 1) and urosepsis (n = 1). CONCLUSION: Functional improvement after LVRS in patients with CAD is equal to patients without CAD. Mortality in patients who underwent LVRS after PTCA or CABG was comparable to patients without CAD. LVRS enables valve replacement in selected patients with severe emphysema otherwise inoperable.     

Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema

OBJECTIVE: Numerous reports have confirmed the early benefits of lung volume reduction surgery for selected patients with emphysema. This report documents the long-term survival and functional results after lung volume reduction surgery. METHODS: Between January 1993 and June 2000, a total of 250 consecutive patients underwent bilateral lung volume reduction surgery through median sternotomy at our institution. All patients had disabling dyspnea, thoracic hyperinflation, and a heterogeneous pattern of emphysema with suitable target areas for resection. Preoperative pulmonary rehabilitation was required and post-rehabilitation data were used as the baseline for data analysis. Follow-up ranged from 1.8 to 9.1 years (median 4.4 years). RESULTS: Prolonged air leaks (>7 days) were the most common complication (45.2%, n = 113). Reexploration rates for air leak and bleeding were 3.2% (n = 8) and 1.2% (n = 3), respectively. Eighteen patients (7.2%) required reintubation and mechanical ventilation. The in-hospital mortality in this series was 4.8% (n = 12). The median length of hospitalization was 9 days (range 4-168 days). Kaplan-Meier survivals after lung volume reduction surgery were 93.6%, 84.4%, and 67.7% at 1, 3, and 5 years, respectively. Eighteen patients (7.2%) have subsequently undergone lung transplantation after a median interval of 4.3 years (range 2.1-6.4 years). Spirometric values, lung volumes, and gas exchange parameters improved after surgery. The forced expiratory volume in 1 second and the residual volume showed statistically significant improvements between preoperative values and each time point of follow-up. Health-related quality of life showed significant postoperative improvement and with time correlated well with the improvement in forced expiratory volume in 1 second. CONCLUSIONS: Lung volume reduction surgery produces significant functional improvement for selected patients with emphysema. For most of these patients, benefits appear to last at least 5 years.     

Sequential VATS lung volume reduction surgery: prolongation of benefits derived after the initial operation.

OBJECTIVE: Sequential lung volume reduction (LVR) is thought to provide additional and prolonged benefit compared with unilateral LVR. We tested this hypothesis by reviewing physiological, subjective and survival outcome data on patients who underwent sequential or unilateral LVR. METHODS: LVR was performed as a unilateral video-assisted thoracoscopic surgery (VATS) procedure, with bilateral reduction being undertaken in a staged manner. Pulmonary function data were collected prospectively. A telephone survey of patients and general practitioners was used to determine quality of life and survival. RESULTS: Fifty patients underwent LVR. Twenty-one patients had staged reduction of the contra-lateral lung at a median interval of 9 months. Pre-operatively, patients undergoing sequential LVR were not significantly different from patients undergoing unilateral LVR: forced expiratory volume in 1 s (FEV1) 23% predicted vs. 27% predicted, KCO 40% vs. 45%, total lung capacity (TLC) 124% vs. 121%, residual volume (RV) 217% vs. 214%, health score 34.5 vs. 30.8. After single-side LVR, both groups demonstrated equivalent and significant improvement in spirometric and subjective health scores: FEV1 +15% predicted (P<0.01), TLC -5% (P=0.03), health score +80% (P<0.01). Patients undergoing sequential reduction demonstrated no further significant improvements using either an intragroup comparison with their pre-second operation values or an intergroup comparison with the unilateral LVR patients. However, sequential LVR appeared to prolong the benefits experienced after the initial surgery by 1 year. Overall, 12 patients (24%) died during follow-up with no survival difference between the two groups (P=0.65). CONCLUSION: Sequential LVR is a safe strategy. Undertaking LVR to the second side does not further improve spirometric or subjective performance but does prolong the benefits achieved with the initial reduction.     

Gain and subsequent loss of lung function after lung volume reduction surgery in cases of severe emphysema with different morphologic patterns

OBJECTIVE: Surgical lung volume reduction improves lung function and dyspnea in advanced emphysema to a variable degree. Because long-term results with this procedure are scant, we prospectively investigated lung function over several years after lung volume reduction surgery with regard to emphysema morphology. METHODS: Bilateral video-assisted thoracoscopic lung volume reduction surgery was performed in severely symptomatic patients with marked hyperinflation caused by advanced nonbullous emphysema. Emphysema heterogeneity was visually graded on chest computed tomography. Symptoms and lung function were assessed before the operation and 3, 6, and then every 6 months after the operation. RESULTS: A total of 115 patients with a median forced expiratory volume in 1 second of 0.73 L (27% of predicted value) underwent lung volume reduction surgery. Follow-up extended over a median of 37 months. Median forced expiratory volume in 1 second significantly increased within 6 months after the operation by 37% in homogeneous (n = 27), by 38% in intermediately heterogeneous (n = 37), and by 63% in markedly heterogeneous emphysema (n = 51, P <.05 vs. other morphologies). Maximal forced expiratory volume in 1 second was reached within 6 months after lung volume reduction surgery and decreased in the first postoperative year by 0.16 L per year in homogeneous, by 0.19 L per year in intermediately heterogenous, and by 0.32 L per year in markedly heterogeneous emphysema (P <.01 vs. other morphologies). The decline in forced expiratory volume in 1 second over subsequent years decelerated according to an exponential decay and was similar for all morphologic types (median annual decrease of 0.09 L [9%]). CONCLUSIONS: Lung volume reduction surgery improves lung function in severe homogeneous and, to an even greater extent, heterogeneous emphysema. Forced expiratory volume in 1 second peaks within 6 months postoperatively. The subsequent decline is most rapid in the first year and slows down in succeeding years according to an exponential decay. Therefore, long-term functional results of lung volume reduction surgery may be more favorable than expected from linear extrapolations of short-term observations.     

Factors related to postoperative mortality in lung transplantation for emphysema

BACKGROUND: Chronic obstructive pulmonary disease is the primary indication for lung transplantation worldwide. In this study, we analyzed the early outcomes of patients with emphysema undergoing bilateral lung transplantation at our center. METHODS: This retrospective analysis included 79 consecutive bilateral lung transplantation performed due to emphysema (8 with alpha-1 antitrypsin [AAT] deficiency) between 1993 and 2005. We analyzed variety of demographic, clinical, respiratory function, and surgical variables. Early mortality was defined as death occurring in the first month after lung transplantation. Statistical analysis included Student t test and Fisher exact test. RESULTS: Seventy-nine patients with emphysema, 74 men and 5 women, with a mean FEV1 of 21.1%+/-6.3%, underwent bilateral lung transplantation. Fourteen patients (17.7%) died in the first month after surgery. Compared with survivors, patients who died in the first month, had longer ischemic times (365+/-60 vs 295+/-55 minutes; P=.01), needed more cardiopulmonary bypass (69.2% vs 6.2%; P<.0001), and had a greater incidence of hemothorax (46.2% vs 10.9%; P=.007). Patients with ischemic time longer than 6 hours had a greater 1-month mortality rate (38.5%) than those with shorter ischemic times (12.9%; P=.03). No preoperative variable was related to 1-month mortality after bilateral lung transplantation. CONCLUSIONS: In our experience, 1-month mortality after bilateral lung transplantation in emphysema was higher among patients with more than 6 hours of ischemic time, those undergoing cardiopulmonary bypass, and those developing posttransplantation hemothorax.     

Relation of lung function, maximal inspiratory pressure, dyspnoea, and quality of life with exercise capacity in patients with chronic obstructive pulmonary disease.

BACKGROUND--Several studies have shown that both objective and subjective measurements are related to exercise capacity in patients with chronic obstructive pulmonary disease (COPD). In this study the relative contribution of lung function, maximal inspiratory pressure, dyspnoea, and quality of life to the performance in a walking distance test and a bicycle ergometer test was investigated. METHODS--Static lung volumes, forced expiratory volume in one second (FEV1), inspiratory slow vital capacity (IVC), transfer factor for carbon monoxide (TLCO) divided by the alveolar volume (TLCO/VA), static compliance (Cst), and maximal inspiratory peak pressure (PImaxPOES) were measured in 40 patients with COPD with severe airways obstruction (mean FEV1 44% predicted, mean FEV1/IVC 37% predicted). Quality of life was assessed by the Chronic Respiratory Questionnaire (CRQ) and dyspnoea by the Borg category scale. Exercise capacity was measured by both a six minute walking distance (test) and a maximal work load of the bicycle ergometer test (Wmax). RESULTS--Spirometric values and maximal inspiratory pressure were modestly correlated with both the six minute walking test and Wmax, r values ranging from 0.50 to 0.58. The TLCO was strongly correlated with the six minute walking test (r = 0.62) and with Wmax (r = 0.78). Quality of life showed no correlation with exercise capacity, while there was a correlation between dyspnoea and the six minute walking test (r = -0.41). Backward linear regression analysis selected TLCO and PImaxPOES as the most significant determinants for exercise performance. They explained 54% and 69% of the variance in the six minute walking test and Wmax, respectively. CONCLUSIONS--The results show that exercise capacity in patients with COPD with severe airways obstruction is more strongly related to inspiratory muscle strength and lung function than to dyspnoea and quality of life. The significant correlation between dyspnoea and the six minute walking test suggests that subjective variables are more strongly related to walking tests than to bicycle ergometer tests.     

Long-term results after lung volume reduction surgery in patients with alpha1-antitrypsin deficiency

BACKGROUND: The favorable effects of lung volume reduction surgery for selected patients with smoker's emphysema has been demonstrated. However, outcome data for patients with alpha(1)-antitrypsin deficiency emphysema are scarce. METHODS: We prospectively studied pulmonary function, dyspnea, and 6-minute walking distance in 21 patients with severe alpha(1)-antitrypsin deficiency emphysema (PiZZ 18, PiZO 1, PiSZ 2, 10 female patients, median age 56 years, range 38-74 years) for as long as 5 years after thoracoscopic lung volume reduction surgery. RESULTS: Lung volume reduction surgery improved the mean dyspnea score, from 3.7 +/- 0.1 preoperatively to 1.4 +/- 0.2 at 3 months; the score remained improved for as long as 3.5 years. Mean vital capacity (% predicted) improved from 79% +/- 4.4% to 98% +/- 4.8% at 3 months, and the ratio of residual volume to total lung capacity decreased from 0.67 to 0.51. These improvements lasted for as long as 2 years. The mean airflow obstruction (forced expiratory volume in 1 second % predicted) improved from 27% +/- 1.9% to 38% +/- 3.3% at 3 months and remained statistically improved for 1 year. Four patients showed long-term improvement in lung function for as long as 3.5 years. These patients had markedly heterogeneous emphysema and showed no radiologic signs of airway inflammation. CONCLUSIONS: Lung volume reduction surgery in patients with advanced emphysema from alpha(1)-antitrypsin deficiency results in a significant improvement in dyspnea and lung function for as long as 3.5 years in some cases. It appears that magnitude and duration of these effects are inferior and shorter than those in patients with pure smoker's emphysema. Patients with heterogeneous disease and no or minor inflammatory airway disease may benefit most.     

Thoracoscopic lung volume reduction surgery for pulmonary emphysema patients with severe hypercapnia

OBJECTIVES: We assessed whether hypercapnia patients with an extremely high level of PaCO2 > or = 60 mmHg were suitable candidates for lung volume reduction in the treatment of severe pulmonary emphysema. METHODS: Of 65 patients undergoing lung volume reduction surgery between May 1993 and August 1997, 6 (9.23%) who had a preoperative rest room air blood gas level of PaCO2 > or = 60 mmHg were selected for study. All patients underwent video-assisted thoracoscopic surgery. Of the 6 with severe hypercapnia, 5 underwent the unilateral procedure and 1 the bilateral procedure. RESULTS: All severe hypercapnia patients showed significant clinical improvement. When assessed at 3 to 6 months after lung volume reduction surgery, significant improvements were seen in mean forced expiratory volume in 1 second (preop: 0.44 +/- 0.04 L; postop: 0.74 +/- 0.20 L; p < 0.01), for a magnitude improvement of 69.8%, and in trapped gas volume (preop: 3.28 +/- 1.11 L; postop: 1.61 +/- 1.02 L; p < 0.05). Arterial blood gas analysis showed significant improvement in PaO2 from 51.1 +/- 6.68 mmHg to 69.8 +/- 7.87 mmHg (p < 0.001) with a decrease in PaCO2 from 70.4 +/- 9.41 mmHg to 46.9 +/- 3.44 mmHg (p < 0.01). Postoperative follow-up averaged 55 months (43-69 months). All but 1 patient remain alive and well. CONCLUSION: Patients with severe pulmonary emphysema accompanied by hypercapnia can gain relief and a better quality of life through volume reduction surgery and should not be excluded from surgical treatment simply based on this condition. Selection should involve a comprehensive view of the patient's condition that includes criteria such as the results of radiographic diagnosis and detailed pulmonary function tests.     

Lung cancer resection combined with lung volume reduction in patients with severe emphysema

OBJECTIVE: Certain patients with resectable lung cancer and severe respiratory limitation due to emphysema may have a suitable operative risk by combining cancer resection with lung volume reduction surgery. The purpose of this study is to review our experience with such patients. METHODS: A review was conducted on 21 patients with lung cancer in the setting of severe emphysema who underwent an operation designed to provide complete cancer resection and volume reduction effect. RESULTS: In the 21 patients, the mean preoperative forced expiratory volume in 1 second was 0.7 +/- 0.2 L (29% predicted), residual volume was 5.5 +/- 1.0 L (271%), and diffusing capacity for carbon monoxide was 8.0 +/- 2.2 mL/min/mm Hg (34% predicted). In 9 patients, the cancer was located in a severely emphysematous lobe and the lung volume reduction surgery component of the procedure was accomplished with lobectomy alone. In the remaining 12 patients, the cancer resection lobectomy (n = 9) and wedge resection (n = 3) were supplemented with lung volume reduction surgery. Final pathologic staging was stage I in 16 patients, stage II in 2 patients, and stage III in 2 patients. One patient was found to have stage IV disease due to multifocal tumors in separate lobes. There were no hospital deaths. Postoperative complications included prolonged air leak in 11 patients, atrial fibrillation in 6 patients, and reintubation for ventilatory assistance in 2 patients. All patients showed improved lung function postoperatively. Survival was 100% and 62.7% at 1 and 5 years, respectively. CONCLUSIONS: Patients with severe emphysema and resectable lung cancer who have a favorable anatomy for lung volume reduction surgery may undergo a combined cancer resection and lung volume reduction surgery with an acceptable risk and good long-term survival.     

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.     

肺气肿胸腔镜减容术

目的探讨肺气肿的外科处理方法。方法对５例重度肺气肿的患者进行胸腔镜双肺减容术的外科治疗。患者均为男性,平均年龄６４．３岁。３例行部分肺切除术,１例行肺折叠术,１例行部分肺切除术加折叠术。术中计算机气道内监测ＣＯ２变化和顺应性改变,发现气道阻力明显下降和肺顺应性增高,术后无需呼吸机维持通气。结果经３、６和１０个月随防,患者肺功能均有逐步好转。ＦＥＶ１从０．３８～０．５３恢复至０．８３～１．４,ＦＶＣ从１．１５～２．３９回复至２．２２～３．０。胸片提示膈肌部分弧度从平面恢复弧形。活动能力从平卧和只行走１０米到术后可以步行至２００米以上。结论表明严重肺气肿的患者经肺容积减少术后各方面指标改善,活动能力好转,恢复生活自理     

Endoscopic lung volume reduction coils for patients with severe emphysema—a single-centre retrospective analysis

 Open in a separate windowOBJECTIVESPatients with chronic obstructive pulmonary disease and lung emphysema may benefit from surgical or endoscopic lung volume reduction (ELVR). Previously reported outcomes of nitinol coil-based ELVR techniques have been ambiguous. The analysis was done to analyse outcomes of ELVR with nitinol coils in patients with severe pulmonary emphysema.METHODSFrom September 2013 to November 2014, our centre performed a total of 41 coil implantations on 29 patients with severe emphysema. Coils were bronchoscopically placed during general anaesthesia. Twelve out of 29 patients received staged contralateral treatments up to 112 days later to avoid bilateral pneumothorax. Lung function and 6-min walking distance were assessed 1 week prior, 1 week after as well as 6–12 months after the procedure. Patients were followed up to 48 months after ELVR and overall mortality was compared to a historic cohort.RESULTSWhile coil-based ELVR led to significant short-term improvement of vital capacity (VC, +0.14 ± 0.39 l, P = 0.032) and hyperinflation (Δ residual volume/total lung capacity −2.32% ± 6.24%, P = 0.022), no significant changes were observed in 6-min walking distance or forced expiratory volume in 1 s. Benefits were short-lived, with only 15.4% and 14.3% of patients showing sustained improvements in forced expiratory volume in 1 s or residual volume after 6 months. Adverse events included haemoptysis (40%) and pneumothorax (3.4%), major complications occurred in 6.9% of cases. Overall survival without lung transplant was 63.8% after 48 months following ELVR, differing insignificantly from what BODE indices of patients would have predicted as median 4-year survival (57%) at the time of ELVR treatment.CONCLUSIONSELVR with coils can achieve small and short-lived benefits in lung function at the cost of major complications in a highly morbid cohort. Treatment failed to improve 4-year overall survival. ELVR coils are not worthwhile the risk for most patients with severe emphysema.     

Two years' outcome of lung volume reduction surgery in different morphologic emphysema types

BACKGROUND: Lung volume reduction surgery (LVRS) improves dyspnea, pulmonary function, and quality of life in selected patients with severe emphysema. We investigated the role of emphysema morphology in 37 patients as an outcome predictor for up to 2 years after operation. METHODS: Patients selected for bilateral thoracoscopic LVRS were divided, according to a simplified emphysema morphology classification, into three groups (homogeneous, moderately heterogeneous, and markedly heterogeneous) based on a preoperative chest computed tomogram. Pulmonary function, walking distance, and dyspnea were assessed. RESULTS: Functional improvement after LVRS was best in markedly heterogeneous emphysema with an increase from preoperative forced expiratory volume in 1 second of 31% +/- 2% (mean +/- standard error of the mean) to 52% +/- 4% of predicted postoperatively. It was significantly higher than in homogeneous emphysema (from 26% +/- 1% to 38% +/- 2% predicted) and in intermediately heterogeneous emphysema (from 29% +/- 2% to 44% +/- 45% predicted). At 24 months postoperatively, forced expiratory volume in 1 second and dyspnea score continued to be significantly better than preoperative levels in all three morphologic groups. The survival rate was highest in patients with markedly heterogeneous emphysema. CONCLUSIONS: Functional and subjective improvements were maintained after LVRS for at least 24 months in patients with heterogeneous or homogeneous emphysema type.