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Ann Thorac Surg 1997;63:186-192
© 1997 The Society of Thoracic Surgeons

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Original Articles: General Thoracic

Reduction Pneumonoplasty for Patients With a Forced Expiratory Volume in 1 Second of 500 Milliliters or Less

Departments of Surgery and Medicine and The U.S. Lung Center, Western Medical Center, Anaheim, and Departments of Surgery and Pulmonary Medicine, University of California, Irvine, California

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Addendum. References

 
Background. Patients with severely impaired pulmonary function are considered at high risk for emphysema operations. We prospectively evaluated 44 patients with a forced expiratory volume in 1 second of 0.5 L or less undergoing reduction pneumonoplasty for dyspnea uncontrolled by medical management (confirmed by Borg and modified Medical Research Council dyspnea scales).

Methods. There were 28 men and 16 women (mean age, 66 years) with a mean preoperative forced expiratory volume in 1 second of 0.41 L (range, 0.23 L to 0.50 L). Preoperative therapy consisted of bronchodilators (100% of patients), oxygen (80%), and steroids (72%). Hypercarbia was seen in 80% of patients, and 66% had pulmonary hypertension. Unilateral reduction pneumonoplasty by a video-assisted thoracic surgical approach was performed in 34 patients, 6 patients underwent bilateral reduction pneumonoplasty by a video-assisted thoracic surgical approach, and 4 patients underwent bilateral reduction pneumonoplasty by median sternotomy. Discrete emphysematous regions were resected using staplers with buttressing, and regions of homogeneous emphysema were plicated with KTP or neodymium:yttrium-aluminum garnet laser radiation.

Results. There was one death within 30 days, two additional deaths within 60 days, and five additional deaths within 1 year. Hospital stay averaged 12 days. Intensive care unit stay averaged 4 days. Subjective improvement was noted by 89%. Borg and modified dyspnea scores improved from 7.6 to 4.5 (p < 0.01) and from 3.9 to 2.35 (p < 0.01), respectively. Forced expiratory volume in 1 second was 0.62 L at 1 year, a 51% improvement (p < 0.001). Forced vital capacity was 1.32 L preoperatively and 2.05 L at 1 year (a 56% improvement) (p < 0.001).

Conclusions. This experience documents that patients with severely impaired lung function can successfully undergo operation for emphysema. To obtain these results one must tailor the operative approach to the patient's disease.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Addendum. References

 
See also page 190.

The surgical treatment of emphysema produces a reduction in lung size by anatomic or functional removal of the most diseased areas. This allows the more normal and previously compressed remaining lung to reexpand. The normal elastic recoil properties of the reexpanded lung lead to improved intrapleural negative pressures and less bronchial collapse. In addition, reduction in lung size improves chest wall dynamics [1–4]. Inclusion criteria are lifestyle-limiting dyspnea, reduced pulmonary function (typically a forced expiratory volume in 1 second [FEV₁] 20% to 40% of predicted and residual volume greater than 250% of predicted), hyperexpansion, and diffuse bullous emphysema. Exclusion criteria include advanced age, hypercarbia, irreversible pulmonary hypertension, prior operation, thoracic deformities, significant comorbidity, poor patient compliance, and severely impaired pulmonary function. Our interest in emphysema surgery led us to evaluate one of the most high risk groups for operation, those with markedly impaired pulmonary function. A protocol was developed to enable us to safely operate on these patients. This report presents an approach to the surgical treatment of emphysema in patients with an FEV₁ of 500 mL or less.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Addendum. References

 
From January 1994 through June 1995, we prospectively studied 44 patients with an FEV₁ of 500 mL or less undergoing reduction pneumonoplasty at Western Medical Center, Anaheim, CA. This represents 29% of the emphysema patients we treated surgically during this time. There were 28 men and 16 women, aged 49 to 82 years (mean, 66 years). All patients were incapacitated by their dyspnea and were unable to work or to care for themselves, with 1 patient bedridden and 5 patients wheelchair-bound. Their symptoms were rated by the Borg category scale and the modified Medical Research Council dyspnea scale. All patients were receiving oral and aerosol bronchodilators; 80% of patients received continuous oxygen therapy, and the remaining 20% required intermittent oxygen therapy. Three patients had a permanent tracheostomy. Seventy-two percent of the patients required prednisone. Hypercarbia (carbon dioxide tension > 45 mm Hg) was identified in 80% of these patients (carbon dioxide tension range, 36 mm Hg to 80 mm Hg; mean, 53 mm Hg). Pulmonary hypertension (pulmonary artery systolic pressure > 40 mm Hg) was present in 66% of patients, and 1 patient had antiprotease deficiency. Preoperative pulmonary rehabilitation was not used in this series. Database entries for all patients included complete pulmonary function test results including spirometry, plethysmography, diffusion capacity, and arterial blood gases. Chest roentgenograms, posteroanterior and lateral, typically showed hyperinflation, and high-resolution computed axial tomography was performed in all patients to define the anatomy of their emphysema. Quantitative ventilation-perfusion lung scanning was used to identify the functioning areas of the lung and ventilation-perfusion mismatches.

Using the information obtained from the high-resolution computed tomographic scan and the ventilation-perfusion scan, we identified target areas of emphysema for resection or laser plication. If the patients had anatomic evidence of emphysema bilaterally with equal perfusion bilaterally, we performed a bilateral procedure. If there was no anatomic evidence of emphysema on one side or unequal perfusion between the lungs, we would choose to operate only on one lung. The side chosen was the side with the lowest percent of perfusion.

Pulmonary artery (Swan-Ganz) catheters were used in all patients and were inserted the night before the operation. Operations were performed using a double-lumen tube, pulmonary artery (Swan-Ganz) catheter, and arterial line monitoring with continuous in-line blood gas measurements. Patients were positioned supine for bilateral pneumonoplasty via median sternotomy or in the lateral decubitus position for unilateral pneumonoplasty. When a bilateral procedure was performed by the thoracic approach, patients were positioned in a lateral decubitus position, then repositioned to the opposite lateral decubitus position once the first operation was completed. If there was a problem identified with the first operation such as a large air leak, we elected not to proceed with the second side but delayed the second operation to a later date. Intraoperatively, decisions were made on the basis of the anatomic findings and the location of the disease.

Free beam KTP (532 nm) laser radiation (Laserscope, Inc) and/or free beam neodymium:yttrium-aluminum garnet (Nd:YAG) (1,064 nm) laser radiation (Laserscope, Inc) were directed at homogeneous emphysematous areas to plicate and contract these regions of the lung. Laser radiation was also used at the mediastinal and hilar areas of the lung because these areas are not readily accessible for resection. KTP laser radiation was delivered from 6 W to 10 W continuous wave power, and Nd:YAG laser radiation was delivered from 20 W to 30 W continuous wave power. When heterogeneous emphysematous areas of the lung were encountered or when large nonfunctioning areas of the lung required resection, this was performed using both endoscopic staplers and standard gastrointestinal staplers. Most staple lines were buttressed using bovine pericardium (Biovascular, Inc). The goal of the operation was to achieve a 20% to 30% reduction in the size of the lung.

Postoperatively, patients were extubated within 24 hours. Chest tubes were maintained at 10 cm H₂O of negative pressure if there was an air leak, or underwater seal if there was no air leak. Patients were begun on physical therapy and activity on the first postoperative day. Patients whose lung position remained stable on routine chest roentgenograms were discharged with Heimlich valves. Postoperative pulmonary rehabilitation was undertaken by 40 patients. After discharge, patients were followed up by telephone and letter and postoperative examinations (when they lived locally) every 3 months. Pulmonary function tests were performed at 1 month, 3 months, 6 months, and 1-year intervals postoperatively. If a patient was poorly compliant, we visited the patient's home with a portable spirometer.

Operative mortality was reported as death within 30 days of operation or during the initial hospitalization. Prolonged postoperative air leaks were reported as air leaks persisting greater than 7 days. Data are reported as mean ± standard error of the mean. Statistical comparison was performed between preoperative and postoperative findings using the t test and ² test.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Addendum. References

 
There were 4 bilateral operations performed by median sternotomy, 6 bilateral operations performed by video-assisted thoracic surgery (VATS), and 34 unilateral procedures performed by VATS (including 2 planned bilateral procedures that were aborted). All median sternotomy procedures included the use of laser radiation to treat homogeneous emphysema and resection for areas of heterogeneous emphysema or large bullae. Among the thoracic procedures, nine were performed by VATS and laser radiation alone. The remainder of the operations consisted of laser radiation and surgical resection performed by VATS. Of the 44 patients, 32 were extubated in the operating room and another 11 patients were extubated with 24 hours. Only 1 patient remained on prolonged ventilation postoperatively. Intensive care unit stay averaged 4 days and total hospitalization averaged 12 days.

One patient died 15 days postoperatively of sepsis secondary to a spontaneous colon perforation. This was considered an operative death. Perforated diverticulitis occurred in 2 patients postoperatively; they had multiple hospital readmissions and ultimately died of sepsis 40 days and 50 days postoperatively. A fourth patient had an acute myocardial infarction 46 days postoperatively and died. A fifth patient died at 90 days of a ruptured abdominal aortic aneurysm.

An additional three deaths occurred within the next 9 months because of pneumonia (2 patients) and pulmonary embolism (1 patient). An additional 4 patients died of respiratory failure during the second year; 32 patients are still being followed up. Prolonged postoperative air leaks occurred in 36% of patients. Gastrointestinal complications were seen in 18% of cases, and these included ileus (2 cases), pseudomembranous enterocolitis, lower gastrointestinal bleeding, and gangrenous cholecystitis in addition to the colon perforation and diverticulitis (2 cases) already mentioned.

There were 38 patients still alive at 6-month follow-up, and 89% (34/38) of patients reported subjective improvement in dyspnea. Borg scores improved from 7.6 to 4.65 (p < 0.01). Modified Medical Research Council dyspnea scale improved from 3.9 to 2.35 (p < 0.01). The mean postoperative oxygen tension was 60 ± 2 mm Hg, a significant improvement (p < 0.01) from the preoperative mean oxygen tension of 49 ± 2 mm Hg, and supplemental oxygen was required by 45% (17/38) of the patients compared with 80% preoperatively (p < 0.01). The mean postoperative carbon dioxide tension was 46 ± 1 mm Hg (p < 0.01 compared with the mean preoperative value of 53 ± 2 mm Hg), and 30% (10/38) of the patients had hypercarbia. Prednisone was necessary in 42% (16/38) of the patients compared with 72% steroid use before the operation (p < 0.01). The average reduction in lung size was 25% as determined by comparing the preoperative and postoperative chest films of all patients [5].

A comparison of preoperative and postoperative pulmonary function tests is shown in Table 1. The FEV₁ improved from 0.41 L (15% of predicted) preoperatively to 0.57 L (21% of predicted) at 1 month, 0.63 L (23% of predicted) at 3 months, 0.62 L at 6 months, and 0.62 L (23% of predicted) at 1 year. This represents a 51% improvement in FEV₁ (p < 0.001). Similarly, forced vital capacity improved from 1.32 L (36% of predicted) preoperatively to 2.04 L 1 year postoperatively, a 55% improvement (p < 0.001). Residual volume decreased by 30% (p < 0.01), and total lung capacity decreased by 23% (p < 0.01) within the first year of follow-up. The pulmonary function tests of the 6-month survivors were also evaluated according to the type of operation performed. Unilateral reduction pneumonoplasty (resection plus laser) showed a 45% improvement in FEV₁ (0.42 L preoperatively and 0.61 L postoperatively). Bilateral reduction pneumonoplasty (resection plus laser) showed an 82% improvement in FEV₁ (0.38 L preoperatively and 0.69 L postoperatively). The operations that were performed by laser radiation alone (one bilateral, eight unilateral) resulted in a 40% improvement in FEV₁ (0.42 L preoperatively and 0.58 L postoperatively).

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Addendum. References

The operative techniques used have all been previously described [1–4]. Wakabayashi [1] used thoracoscopy and a contact Nd:YAG laser probe to plicate diffuse emphysema and thoracoscopic resection to treat bullae. Little and associates [2] used free-beam Nd:YAG laser radiation via thoracoscopy to plicate diffuse bullous emphysema. Our group [3] used a VATS approach with both Nd:YAG and KTP laser plication of homogeneous emphysema and surgical resection of bullae. Cooper and colleagues [4] performed bilateral stapled resections via median sternotomy to treat heterogeneous emphysema. These techniques all have the common goal of lung reduction to improve compliance, improve airway patency, and allow improved diaphragmatic and chest wall motion.

In approaching the very high risk patient, we attempted to individualize the operation for each patient, drawing from all of the surgical techniques currently available. The preoperative workup was used to determine the surgical approach for each patient. If the high-resolution computed tomographic scan showed emphysema bilaterally and there was no prior history of thoracic operation, a bilateral approach was considered. If the high-resolution computed tomographic scan showed predominance of emphysema in one lung or evidence of severe scarring in a hemithorax, then a unilateral operation was considered. If the ventilation-perfusion scan showed equal perfusion between the lungs, a bilateral procedure was considered, but a perfusion difference of greater than 10% was an indication for a unilateral procedure. For example, we would consider a patient for a bilateral operation if the perfusion was measured at 55% for one lung and 45% for the other, but would favor a unilateral operation once the ventilation-perfusion scan showed 56% perfusion to one lung. Usually the normal split in lung perfusion is 55% for the right lung and 45% for the left lung. In the high-risk emphysema patient, however, respiratory physiology is not normal, and we used the nuclear scan to estimate the pulmonary function available during one-lung ventilation and chose 10% as our limit. If a bilateral operation was planned, the next decision was median sternotomy versus bilateral VATS approaches. Predominance of bilateral upper lobe emphysema as well as normal thoracic configuration favored median sternotomy. Contraindications included prior sternotomy, tracheostomy, severe kyphosis, high-dose steroid use, and predominant location of emphysema in the lower lobes.

Intraoperatively, decisions regarding extent of resection and laser plication were made on the basis of anatomic findings and the response of emphysematous lungs to laser radiation. If firm adhesions were encountered or if an extensive resection was planned, we would convert from thoracoscopy to video-assisted thoracotomy. If there was a good response to laser radiation with obvious contracture and shrinking of lung parenchyma, we would use laser radiation alone and not add resection to the operation. Resections were performed using staplers to remove strips of lung along the edges of each lobe.

Laser radiation was used after resections to scarify the visceral pleura and to plicate areas not accessible to staplers such as the hilar region of the lung. Lung tissue normal in color usually responded well to KTP laser radiation, and anthracotic lung tissue responded to Nd:YAG laser radiation. Laser radiation can be used diagnostically as well as therapeutically in emphysema patients. Functioning areas of the lung have normal blood vessel architecture, and blood flow provides cooling for the tissues, which obviates the thermal effects of phototherapy. Emphysematous areas of the lung, however, have a paucity of blood vessels. These regions are exquisitely sensitive to the thermal effects of laser radiation and respond by contracting and shrinking to cause plication of the entire emphysematous section of the lung.

Little and associates [2] used free-beam Nd:YAG laser radiation to treat emphysema via VATS. With a unilateral approach they reported an 18% improvement in FEV₁, subjective improvement in 80% of patients, and an operative mortality of 5.5%. Severely impaired pulmonary function is one of their exclusion criteria for operation. Wakabayashi [1] has reported using contact probe Nd:YAG laser radiation and bullous resection to treat emphysema via unilateral VATS. He reports an improvement in FEV₁ of 62% in patients with less than 14% of predicted and an improvement in FEV₁ of 28% in patients with more than 15% of predicted. Our prior work [11] with contact laser techniques has shown perforation, tearing, and disruption of tissue at the contact surface. This explains why some groups have obtained unsatisfactory results using a contact laser technique and why we, therefore, recommended free-beam laser radiation. Wakabayashi has a great deal of experience with his technique, and it appears that he may have found a way to overcome the deficiencies of the contact laser probe. We still believe, however, that the free-beam technique holds several advantages over contact laser use in terms of ease of use, directional stability, and improved laser–tissue interaction. Cooper and colleagues [4] do not use phototherapy in the treatment of diffuse bullous emphysema. They report an improvement in FEV₁ of 82% using bilateral resectional techniques alone. The basis for their study is the work of Brantigan and associates [12], who theorized that most of the diffuse bullous changes occurred in a subpleural location and that these emphysematous areas could be eliminated by multiple small wedge resections performed along the pleural surface. If this diffuse emphysema is indeed found at the periphery of the lung, then it should be easier to treat this diffuse disease with laser radiation than with localized resection. That is why we have chosen to use laser radiation and reserve resection for areas of heterogeneous emphysema and large bullae.

The present series shows that we can operate on patients with an FEV₁ of 500 mL or less, but does this necessarily mean that we should operate on them? Several patients died within a few months after the operation, and although most of these deaths were due to nonpulmonary causes, this early mortality rate shows that this is a group of patients at high risk for other fatal illnesses. Several other patients died within the first year, giving a 1-year survival thus far of 36/44 (82%), with not all of the patients yet followed up at 1 year. Wakabayashi [1] similarly showed that there was a high early mortality rate in the patients who had severely impaired pulmonary function. The patients who survived had a greatly improved quality of life, but there has to be a better way to select the patients so that we can improve on the 1-year survival. Our patients are currently evaluated preoperatively by gastroenterologists as well as pulmonologists, cardiologists, and surgeons in an attempt to avoid gastrointestinal complications. We have also begun to use preoperative pulmonary rehabilitation in our high-risk patients, as recommended by Cooper and colleagues [4], even though our bed-ridden patients and wheelchair-bound patients have had good long-term results in this series. The data presented herein show that a very high risk group of patients can undergo emphysema operation if the operative approach is carefully tailored to the patient. With continued refinement in our program, it is possible that the surgical treatment of these severely impaired patients may become routine.

	Addendum.

Top Footnotes Abstract Introduction Patients and Methods Results Comment Addendum. References

 
Since the submission of this article, all patients have been followed up for at least 1 year. The 1-year survival is 82%, and the 2-year survival is 73%. Figure 1 shows the the survival curve for the patient population.

View larger version (11K): [in this window] [in a new window]   Fig 1. . Survival of patients with a forced expiratory volume in 1 second of 500 milliliters or less undergoing reduction pneumoplasty.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Addendum. References

 
Presented at the Thirty-second Annual Meeting of The Society of Thracic Surgeons, Orlands, FL., Jan 29–31, 1996.

Address reprint requests to Dr Eugene, 1107 S Anaheim Blvd, Anaheim, CA 92805.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Addendum. References

 

1. Wakabayashi A. Thoracoscopic laser pneumoplasty in the treatment of diffuse bullous emphysema. Ann Thorac Surg 1995;60:936–42.[Abstract/Free Full Text]
2. Little AG, Swain JA, Nino JJ, Prabhu RD, Schlacter MD, Barcia TC. Reduction pneumonoplasty for emphysema-early results. Ann Surg 1995;222:365–75.[Medline]
3. Eugene J, Ott RA, Gogia HS, Dos Santos C, Zeit R, Kayaleh RA. Video-thoracic surgery for treatment of end-stage bullous emphysema and chronic obstructive pulmonary disease. Am Surg 1995;61:934–6.[Medline]
4. Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106–19.[Abstract/Free Full Text]
5. Harris TR, Pratt PC, Kilburn KH. Total lung capacity measured by roentgenograms. Am J Med 1971;50:106–19.
6. Gass GD, Olsen GN. Preoperative pulmonary function testing to predict postoperative morbidity and mortality. Chest 1986;89:127–35.[Free Full Text]
7. Hallfeldt KKJ, Siebeck M, Thetter O, Schweiberer L. The effect of thoracic surgery on pulmonary function. Am J Crit Care 1995;4:352–4.
8. Miller JI. Physiologic evaluation of pulmonary function in the candidate for lung resection. J Thorac Cardiovasc Surg 1993;105:347–52.[Abstract]
9. Burrows B, Earle RH. Course and prognosis of chronic obstructive lung disease. N Engl J Med 1969;280:397–404.
10. Diener CV, Burrows B. Further observations on the course and prognosis of chronic obstructive lung disease. Am Rev Respir Dis 1975;111:719–24.[Medline]
11. Baribeau Y, Eugene J, Firestein SL, Hammer-Wilson M, Berns MW. Comparison of contact and free-beam laser endarterectomy. J Surg Res 1990;48:127–33.[Medline]
12. Brantigan GE, Muellar E, Krest MD. A surgical approach to bullous emphysema. Am Rev Respir Dis 1959;79:194–206.

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): John Eugene Alan B. Gazzaniga Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Eugene, J. Articles by Gazzaniga, A. B. Search for Related Content PubMed PubMed Citation Articles by Eugene, J. Articles by Gazzaniga, A. B. Related Collections Related Article