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 is to present the surgical technique and the results with LVRS in our hospital.
Methods : Between May 1997 and March 2000, forty three patients (28 males and 15 females) with a mean (± SD) age of 57 ± 8 years (range 37 - 74 years) have been treated with LVRS. The cause of emphysema was smoking-related (n=38) or a1 antitrypsine deficiency (n=5). Patient selection was based on symptoms of dyspnea at rest (PaO2 = 67 ± 11 mm Hg), limited exercise tolerance (six-minute walking distance = 293 ± 115 meters), and signs of severe hyperinflation (RV = 264 ± 65% and TLC = 138 ± 13%) and airflow obstruction (FEV1 = 27.4 ± 7.3%) on pulmonary function tests. Patients with hypercapnia (PaCO2 = 40.1 ± 6.0 mm Hg) and pulmonary hypertension (mean PAP > 30 mm Hg) were excluded. All patients underwent a unilateral approach by thoracoscopy (n=38) or thoracotomy (n=5). The side of operation (36 R - 7 L) was chosen on the basis of findings on CT and V/Q scanning. The operative technique used was stapled plication (n=1), stapled excision (n=39), or lobectomy (n=3). Stapling lines were not buttressed in any patient. The technique of thoracoscopic stapled excision will be demonstrated on video.
Results : One female patient developped a contralateral tension pneumothorax with temporary cardiac arrest shortly after the start of the procedure. In three patients thoracoscopy was converted to thoracotomy (adhesions: n=2, hemorrhage: n=1). One patient was re-explored for bleeding. Two patients received a tracheostomy for prolonged artificial ventilation. One patient suffered a postoperative stroke. Thirty six patients (84%) had a prolonged (>7 days) airleak. One patient developped an empyema. The last chest drain was removed after a mean of 17 ± 11 days. The mean hospital stay was 21 ± 13 days. There has been one in-hospital death from pneumonia 5 weeks after the procedure (2.3%). One patient could not be weaned from the ventilator and underwent successful bilateral lung transplantation 5 weeks later. Two more patients have been transplanted with a double lung at 6 months and 8 months after the initial procedure, respectively and one more patient is currently on waiting list for a double lung transplant. Two patients have died at home 6 months and 24 months after the procedure, respectively. Actuarial survival was 95% at one year and 92% at two years. When compared to preoperative values, a significant improvement was noted in FEV1 and in six-minute walking distance at one year after the operation (n=28).
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.