Eur J Cardiothorac Surg 1999;16:S57-S60
© 1999 Elsevier Science NL
Surgical strategy for lung volume reduction surgery
Stephen R Hazelrigg*,
Theresa M Boley,
Anthony Grasch,
Tilitha Shawgo
Southern Illinois University, School of Medicine, Cardiothoracic Surgery, 701 North First Street, P.O. Box 19638, Springfield IL 62794-9638, USA
* Corresponding author. Tel.: +1-217-782-8875; fax: +1-217-524-1793 (Email: shazelrigg{at}siumed.edu).
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Abstract
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Lung volume reduction surgery (LVRS) has been a popular procedure since the early 1990s. It appears that there has developed a consensus in the literature that the ideal patient is one with evidence of marked hyperinflation and heterogenous disease. In this patient profile, LVRS has produced excellent results with respect to lung function and improved exercise tolerance. General areas of controversy are discussed which include the role of lasers; unilateral versus bilateral procedures; the role of a staged unilateral procedure; and which surgical route is best for patients. The existing literature is reviewed on these issues.
Key Words: Lung volume reduction surgery • Emphysema • Thoracoscopy • Video-assisted thoracic surgery • Hyperinflated lung
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1. Introduction
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Lung volume reduction surgery (LVRS) has had a fairly well chronicled history, whose final chapter has yet to be authored. Multiple procedures have been reported and advocated since the turn of the century for the treatment of emphysema and the diversity of procedures has included methods to restrict the chest volume (i.e. phrenic nerve injury) as well as ways to allow the chest to expand further (i.e. costal cartilage resection). Brantigan in 1959 reported a procedure that bears some similarity to the present day surgery and included wedge excisions of lung via thoracotomy [1]. For a variety of reasons, including a modest perioperative mortality (18%) and a lack of sophisticated documentation of success, this procedure did not gain general support.
The idea of an operation for emphysema resurfaced in the late 1980s using various lasers as well as the argon beam coagulator (ABC) [2,3]. This procedure should be distinguished from the accepted surgery for giant bullae. Using lasers, the generalized emphysematous lung was contracted with reported success. Although this procedure was met with reluctance in the surgical community, it was embraced by the patient population.
Reports subsequently were published that did document some modest improvements with these surgeries, but the next wave of enthusiasm arose with the presentation of a bilateral stapled resection by Cooper et al. that produced phenomenal results clearly unachievable by any other means [4]. The resultant exponential rise in the performance of this pneumectomy or LVRS continued without many critical questions answered. Since that time, we have struggled to determine the appropriate patient characteristics that will lead to a successful outcome. The selection criteria has progressed to a fairly precise patient profile that includes some physiologic parameters as well as evidence of hyperinflation characteristics.
Numerous questions about the surgical technique have arisen. Some of the questions have included laser versus stapled resection, unilateral versus bilateral LVRS, the role of stapled unilateral LVRS and finally the best surgical route (i.e. sternotomy versus thoracoscopy (VATS)). Most of these questions have at least partial answers and will serve as the body of this manuscript.
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2. Clinical controversies in LVRS
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2.1 Role of the laser
The revival of LVRS, as we now call it, originated with reports of laser procedures. Wakabayashi et al. published several reports, first with the CO2 laser and later with the Nd:YAG laser that suggested benefit for emphysematous patients [2,5]. Others reported using free beam neodymium: yttrium-aluminum garnet (Nd:YAG), as well as the potassium titanyl phosphate (KTP) laser and the ABC. The mechanism for all was to 'shrink' the lung and hence produce favorable changes in intrathoracic pressures and diaphragm position. The laser reports are summarized in Table 1. We became interested in this procedure early on and did a prospective randomized study using the Nd:YAG laser with a contact tip [6]. All patients were studied preoperatively and again at 3 months after the unilateral thoracoscopic procedure. Modest improvements were seen in forced expiratory volume in one second (FEV1) (18%) and 6-min walk distances, but not as good as others had reported and nowhere close to the improvements reported by Cooper et al., even correcting for a unilateral versus a bilateral procedure [4]. Our enthusiasm for the laser LVRS waned as we analyzed those results. There have been advocates of the laser LVRS and some have argued that using a free beam mode results in better outcomes.
There have been a few direct comparisons of laser to stapled LVRS, although none have been prospective or randomized. McKenna et al. reported significantly better results with stapled LVRS over the laser method [7].
With few exceptions, the results have favored stapled LVRS over the laser method. Whether there may be a role for the laser if used in combination with stapled resection is unclear, but possible. Occasionally, there are target regions in areas that are not good for stapled resection where the Nd:YAG laser may be beneficial, however these instances are rare.
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3. Unilateral versus bilateral
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The original thoughts with regard to this surgery was that these patients were sick and fragile and hence the early surgical procedures were unilateral and thoracoscopic. This approach evolved when reports of good success with relatively low mortality and morbidity rates were reported while doing bilateral procedures. Clearly, the improvement in breathing parameters should be better with a bilateral procedures and if the costs in terms of deaths and complications were similar to unilateral surgical procedures there should be little role for a unilateral approach.
Direct comparisons of unilateral versus bilateral procedures exist, however, again no prospective or randomized studies have been reported. McKenna demonstrated better results with bilateral procedures and even suggested better 1-year mortality figures for this group. Complication rates were similar and he recommended bilateral procedures. The lower 1-year mortality rate was reasoned to be due to the better physiologic results from the bilateral procedure [8].
Our own results have confirmed better results in FEV1 with a bilateral procedure. The improvement in physiologic parameters has not proved to make a great difference. Hospital stays are shorter and air leaks less after a unilateral procedure, but otherwise the complications are similar.
A recent report by Naunheim et al., on 673 patients having LVRS, did demonstrate some support for unilateral procedures [9]. The unilateral group had significantly less pneumonia (15% versus 7.8% P<0.01), and arrhythmias (8.9% versus 3.6%, P<0.005) with similar intermediate term survival (median 24 months). His actuarial 1-, 2- and 3-year survival in the unilateral group was 86%, 75% and 69%, respectively as compared to 90%, 81%, and 74% in the bilateral group. He concludes that the unilateral LVRS may yet have a role.
The upshot of the present results suggest an advantage for the bilateral procedure. The bilateral pulmonary function improvements are superior and the cost in terms of serious complications or death do not appear to be increased.
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4. Staged unilateral versus bilateral
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The next question was whether there was a role for a staged procedure, especially in the patients felt to be at a high risk due to their poor physiologic condition. Reports have suggested that overall morbidity and mortality have been comparable between a bilateral and unilateral LVRS. Given this information, it would seem hard to argue for a unilateral approach even if staged. We looked at this issue and compared 50 patients who were prospectively enrolled in a study that performed staged unilateral LVRS separated by 3 months [10]. This group was compared to 29 patients undergoing a bilateral procedure by sternotomy during this same time period. These groups were comparable with the exception of the stapled LVRS patients being slightly older (67.5 versus 63 years, P=0.006) and able to walk shorter distances in their 6-min walk (229.5 versus 283.5 m, P=0.04). Results demonstrated that ultimate pulmonary function and arterial blood gas changes were comparable in the two groups (staged unilateral versus median sternotomy) with FEV1 improvements of 41% and 40%, respectively. Six-minute walk distances improved by a greater degree in the staged group (47% versus 26%), likely due to their lower starting points. There were no significant differences in the two groups with respect to major complications. Adding the two hospitalizations for the staged group resulted in more total days when staged (17.8 versus 11.9 days, P=0.006). There were no in-hospital deaths in this study, however, 1-year mortalities were 6% (3/50) in the staged group and 13.8% (4/29) in the sternotomy group (P=0.137). This was not a statistically significant difference, but may serve as an area for further study.
The data would not presently support a staged unilateral LVRS over a simple bilateral procedure. Further studies may find a high risk group for which the staged approach may be best, but this remains to be seen. A recent report on 673 patients having LVRS by Naunheim et al. did demonstrate more pneumonias in those undergoing a bilateral procedure (14.7% versus 7.8%, P<0.01) and more arrhythmias (8.9% versus 3.6%, P<0.005) [9]. He also demonstrated equivalent 3-year actuarial survival and this may revive enthusiasm for the unilateral or staged unilateral approach.
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5. Best surgical approach?
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5.1 Bilateral VATS versus median sternotomy
There are now multiple studies that demonstrate equivalent results with respect to improvements in pulmonary function between these two surgical routes [11–13]. Kotloff et al. demonstrated a lower in hospital mortality in the VATS group (2.5% versus 13.8%, P=0.05) over sternotomy [12]. This study included 120 patients and otherwise results were similar. They concluded that VATS was associated with a significantly lower incidence of respiratory failure. Several other studies comparing these techniques, however, have found comparable mortalities. Our data on 50 bilateral VATS LVRS versus 29 sternotomies demonstrated a 1-year mortality due to respiratory failure of 2% in the VATS group versus 10.3% in those having sternotomy [10].
The present feeling is that these two surgical approaches are equivalent and the surgical route chosen is largely dependent upon surgeon preference. We have favored thoracoscopy (VATS) for patients on high dose steroids at risk for wound problems as well as for patients with inferior and posterior lung nodules than would be resected at the same time. The suggestion of fewer respiratory complications with VATS may provide weak support for this approach in the ‘sickest' of these patients.
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6. Summary
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The preponderance of evidence seems to clearly support LVRS for the hyperinflated patient especially with heterogenous disease. It can be expected to produce improvements in pulmonary function and exercise parameters. Its impact upon survival is unclear. A recent publication from Meyers et al., however, provided some interesting information [14]. They reported on the follow-up of 22 patients who had been accepted for LVRS but did not receive the operation because of a loss of funding by Medicare for the procedure. These patients were compared to 65 matched patients who did receive the operation. Follow-up data was collected at 2 years and demonstrated huge differences, favoring those having LVRS in FEV1 and O2 requirements. After LVRS (at 24 months), the FEV1 was increased 50% from baseline, while those not receiving the operation had a decrease of 16%. They also showed an 83% actuarial survival rate after LVRS and only 64% in those denied the operation. This was not a statistically significant difference. This data represents a small sample size, but may offer a glimpse into the impact of LVRS.
Our present recommendation is LVRS for patients with FEV1<35% predicted, residual volume >200% predicted, DLCO >30% predicted with 6-min walk distances greater than 500 '. We perform a simultaneous bilateral stapled resection and do not feel that the route (VATS versus sternotomy) is of great importance in most cases. We look forward to further studies to help refine these recommendations, but are convinced LVRS will continue to play a role in these patients in the future.
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Footnotes
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Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong, November 20–21, 1998.
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References
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- Brantigan OC, Mueller E, Kress MB. A surgical approach to pulmonary emphysema. Am Rev Respir Dis 1959;80:194-206.[Medline]
- Wakabayashi A, Brenner M, Kayaleh R, et al. Thoracoscopic carbon dioxide laser treatment of bullous emphysema. Lancet 1991;337:881-883.[Medline]
- Lewis RJ, Caccavale RJ, Sisler G. VATS-argon beam coagulator treatment of diffuse end-stage bilateral bullous disease of the lung. Ann Thorac Surg 1993;55:1394-1399.[Abstract]
- Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106-119.[Abstract/Free Full Text]
- Wakabayashi A. Thoracoscopic laser pneumoplasty in the treatment of diffuse bullous emphysema. Ann Thorac Surg 1995;60:936-942.[Abstract/Free Full Text]
- Hazelrigg S, Boley T, Henkle J, Lawyer C, Johnstone D, Naunheim K, Keller C, Keenan R, Landreneau R, Sciurba F, Feins R, Levy P, Magee M. Thoracoscopic laser bullectomy: a prospective study with three-month results. J Thorac Cardiovasc Surg 1996;112:319-327.[Abstract/Free Full Text]
- McKenna Jr RJ, Brenner M, Gelb AF, et al. A randomized, prospective trial of stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:317-322.[Abstract/Free Full Text]
- McKenna Jr RJ, Brenner M, Fischel RJ, Gelb AF. Should lung volume reduction for emphysema be unilateral or bilateral?. J Thorac Cardiovasc Surg 1996;112:1331-1339.[Abstract/Free Full Text]
- Naunheim KS, Kaiser LR, Bavaria JE, Hazelrigg SR, Magee MJ, Landreneau RJ, Keenan RJ, Osterloh J, Keller CA. Long-term survival following thoracoscopic lung volume reduction: a multi-institutional review. Ann Thorac Surg 1999.
- Hazelrigg SR, Boley TM, Magee MJ, Lawyer CH, Henkle JQ. Comparison of staged thoracoscopy and median sternotomy for lung volume reduction. Ann Thorac Surg (in press) 1998;66:1134-1139.[Abstract/Free Full Text]
- Wisser W, Tschernko E, Senbaklavaci Ö, Kontrus M, Wanke T, Wolner E, Klepetko W. Functional improvement after volume reduction: sternotomy versus videoendoscopic approach. Ann Thorac Surg 1997;63:822-828.[Abstract/Free Full Text]
- Kotloff RM, Tino G, Bavaria JE, Palevsky HI, Hansen-Flaschen J, Wahl PM, Kaiser LR. Bilateral lung volume reduction surgery for advanced emphysema. Chest 1996;110:1399-1406.[Abstract/Free Full Text]
- Bingisser R, Zollinger A, Hauser M, Bloch KE, Russi EW, Weder W. Bilateral volume reduction surgery for diffuse pulmonary emphysema by video-assisted thoracoscopy. J Thorac Cardiovasc Surg 1996;112:875-882.[Abstract/Free Full Text]
- Meyers BF, Yusen RD, Lefrak SS, Patterson GA, Pohl MS, Richardson VJ, Cooper JD. Outcome of medicare patients with emphysema selected for, but denied, a lung volume reduction operation. Ann Thorac Surg 1998;66:331-336.[Abstract/Free Full Text]
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Abstract
1. Introduction
