Objective : Lung volume reduction surgery (LVRS) has recently been propagated as a new surgical
treatment modality and an alternative to lung transplantation in carefully selected patients with severe emphysema. The purpose of this study was to review the initial experience with LVRS at our hospital.
Methods : Between May 1997 and September 1998, eighteen patients (11 males and 7 females) with
a mean (± SD) age of 57 ± 8 years (range 41 - 74 years) have been treated with LVRS with a median follow-up of 7 months (1-16 m). The cause of emphysema was smoking-related (n=17) or 1 antitrypsine deficiency (n=l). Patient selection was based on symptoms of dyspnea at rest and signs of severe hyperinflation (RV > 250% and TLC > 130%) with airflow obstruction (FEV1 < 30%) on pulmonary function tests. Patients with hypercapnia (PaCO2 > 50 mm Hg) and pulmonary hypertension (mean PAP> 30 mm Hg) were excluded.
All patients underwent a unilateral thoracoscopic approach. The side of operation (14 R - 4 L) was chosen on the basis of findings on CT and ventilation-perfusion scanning. The operative technique used was stapled plication (n=l) or stapled excision (n=17). Stapling lines were not buttressed in any patient.
Results : One female patient developed a contralateral tension pneumothorax with cardiac arrest
shortly after the start of the procedure. This was successfully treated and the procedure was continued. She received a tracheostomy for prolonged artificial ventilation. All other patients were extubated in the first hour following the operation. One patient had to be reintubated on arrival in the ICU. One patient suffered a postoperative stroke. Fifteen patients (83%) had a prolonged (>7 days) air leak. Chest drain was removed after a mean of 14 ± 9 days. The mean hospital stay was 20 ± 12 days. There has been no mortality.
When compared to the preoperative values, a significant improvement was noted at three months following the operation in FEV1 (from 0.80 ± 0.28 L to 1.06 ± 0.46 L; p < 0.05), in VC (from 2.62 ± 0.89 L to 3.18 ± 1.03 L; p < 0.01), in TLC (from 8.44 ± 1.91 L to 8.20 ± 1.50 L; p < 0.01), in RV (from 5.76 ± 2.01 L to 4.89 ± 1.50 L; p < 0.001), and in six-minute walking distance (from 286 ± 103 m to 393 ± 66 m; p < 0.05). The improvement in blood gases was not significant (from 66.4 ± 12.5 mm Hg to 70.1 ± 9.8 mm Hg for PaO2 and from 40.9 ± 6.9 to 39.4 ± 4.8 mm Hg for PaCO2). Quality of life assessed by the Nottingham Health Profile was significantly improved. Three patients (17%) experienced no subjective improvement in their dyspnea. One of these patients underwent a double lung transplantation 8 months after LVRS. One patient suffered a late sudden death at home (>6m).
Conclusions : Unilateral thoracoscopic LVRS is a safe and effective surgical palliation for patients with severe emphysema. The value of this approach on long-term functional results has to be
further awaited.