HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

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): Wilfried Wisser Ernst Wolner Walter Klepetko Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wisser, W. Articles by Klepetko, W. Search for Related Content PubMed PubMed Citation Articles by Wisser, W. Articles by Klepetko, W. Related Collections Related Article

Ann Thorac Surg 1997;63:822-827
© 1997 The Society of Thoracic Surgeons

---

Original Article: General Thoracic

Functional Improvement After Volume Reduction: Sternotomy Versus Videoendoscopic Approach

Departments of Cardiothoracic Surgery, Anesthesiology, and Radiology, University of Vienna, and Pulmonary Department, Lainz Hospital, Vienna, Austria

Accepted for publication October 28, 1996.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Background. Volume reduction has been proved to increase ventilatory mechanics in diffuse, nonbullous lung emphysema. However, the best approach is still controversial.

Methods. We retrospectively compared the perioperative data of and functional results in 15 patients having sternotomy (group I) with those of 15 patients having a videoendoscopic approach (group II).

Results. The 30-day mortality was 2 patients in group I and 1 patient in group II. Mean duration of chest tube drainage was 8.7 ± 1.8 days and 8.0 ± 1.9 days and mean hospital stay, 12.3 ± 1.9 and 12.5 ± 2.1 days in groups I and II, respectively. Work of breathing decreased from 1.89 ± 0.33 J/L and 1.76 ± 0.22 J/L preoperatively to 0.75 ± 0.06 J/L and 0.8 ± 0.06 J/L (p < 0.01 and p < 0.05, respectively) after 3 months; and intrinsic positive end-expiratory pressure decreased from 7.15 ± 1.31 cm H₂O and 6.24 ± 1.33 cm H₂O to preoperatively 0.79 ± 0.46 cm H₂O and 1.13 ± 0.44 cm H₂O (p < 0.005 and p < 0.01, respectively) after 3 months in groups I and II, respectively. Forced expiratory volume in 1 second increased from preoperative values of 21.6% ± 2.9% and 25.3% ± 2.4% of predicted to 34.5% ± 5.0% and 40.9% ± 7.5% of predicted after 3 months (p < 0.05 in both groups) in groups I and II, respectively.

Conclusions. Both surgical approaches resulted in similar substantial improvement in lung function and physical fitness. The incidence of air leakage, the duration of chest tube drainage, and the hospital stay were the same for both procedures.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
See also page 827a.

A number of surgical approaches to end-stage emphysema have been used in the past [1–3]. However, only one procedure, surgical resection of bullous emphysema, has gained widespread acceptance and become well accepted during the 1980s and 1990s [4–8]. It was convincingly demonstrated that resection of bullous lung tissue resulted in improved lung function by expansion of preoperatively compressed lung tissue [5, 9, 10].

Diffuse emphysema, on the other hand, was thought to be a clear contraindication for the surgical approach. Since 1959 when Brantigan and colleagues [11] advocated the principle of a surgical approach to diffuse pulmonary emphysema and since the new emphasis on this approach in the early 1990s [12], a substantial functional improvement has clearly been shown [12–17]. By resecting the most useless and functionless areas of severely distended lungs in patients with chronic obstructive pulmonary disease, a dome-shaped diaphragm is recreated, resulting in subsequent improvement in respiratory function. Some groups use a median sternotomy and others, a videoendoscopic approach, but the best method is still not decided [18].

We retrospectively compared the results in two groups of patients: those having the operation through a median sternotomy and those having the operation through a videoendoscopic approach. The impact of both operative techniques on respiratory function was analyzed.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Patient Demographics
Between September 1994 and May 1995, 30 patients with severe pulmonary emphysema and distention of the thorax underwent volume reduction. Inclusion criteria were residual volume greater than 250% of predicted, total lung capacity greater than 120% of predicted, forced expiratory volume in 1 second less than 35% of predicted, and less than 20 mg of prednisolone per day. Patients with bullae were excluded from this study. All patients had major functional impairment despite maximum medical therapy and rehabilitation (Table 1). Patients were encouraged to participate in a rehabilitation program for at least 1 month, but this was not a requirement for inclusion in the program. All patients were highly symptomatic, and the disease had a major impact on their quality of life. Informed consent was obtained from all patients.

Operative Procedure
In the first 15 patients (group I), both pleural cavities were opened through a median sternotomy, and the side with the most severely damaged parenchyma was approached first. Under single-lung ventilation of the contralateral lung, multiple extraanatomical wedge resections of the most destroyed areas, according to the preoperative evaluation and the intraoperative aspect, were performed. Resections were accomplished with linear stapling devices (Auto Suture GIA 60 and 80 linear stapling devices; US Surgical Corporation, Vienna, Austria) buttressed with bovine pericardium (Biovascular bovine pericardial patch; Ameco GmbH, Vienna, Austria) [19]. In the subsequent 15 patients (group II), resections were carried out through a videoendoscopic approach using videoscopic linear staplers (EZ45 B endo linear stapler; Ethicon, Johnson & Johnson, Vienna, Austria) without buttressing material. The side with the most overinflated lung areas, as depicted in the preoperative computed tomographic scan, was done first. Immediately after the first side was completed, the procedure was done on the contralateral side. The goal was to achieve a well-shaped lung surface to avoid major air spaces in the thoracic cavity. Chest tubes were put on 10 cm H₂O suction routinely.

Assessment
Respiratory function was assessed before operation and 1 month, 3 months, and 6 months postoperatively. The assessment included standard lung function testing by body plethysmography, arterial blood gas values, spiroergometry, measurement of dyspnea [20], catheterization of the right heart, quantitative nuclear lung perfusion/ventilation scan, and posteroanterior and lateral chest roentgenograms on inspiration and expiration. On the chest spiral computed tomographic scan, the amount of hyperinflation was shown. All areas with density values between -950 and -1024 Hounsfield units were defined as the most damaged and hyperinflated lung regions and therefore were the target areas for resection [21, 22]. If coronary artery disease was suspected, left heart catheterization was performed.

In addition, ventilatory mechanics were assessed by means of a BICORE CP-100 monitor [23, 24]. Monitoring was performed before operation, daily during the first postoperative week, and 1 month, 3 months, and 6 months after operation. Work of breathing, dynamic compliance, and intrinsic PEEP (iPEEP) were measured with this device.

The impact of each operative procedure on postoperative outcome was studied. A comparison between the two groups in terms of procedure-related problems such as prolonged air leakage, lengths of intensive care unit (ICU) and hospital stays, and functional outcome was performed.

Statistical Analysis
Statistical analysis was performed with paired Student's t test to compare values before and after operation. All values are expressed as the mean ± the standard error of the mean.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
In group I, all patients except 1 were extubated in the operating room. The exception was a highly cachectic woman who, despite 6 weeks' training, had a performance of 0 W preoperatively on the bicycle ergometer. She was weaned from the ventilator through a tracheotomy within 3 weeks postoperatively. In group II, time to extubation was 8.9 ± 2.7 hours after operation. Mean stay in the ICU was 6.5 ± 1.6 days and 3.3 ± 1.2 days and mean hospital stay was 12.3 ± 1.9 days and 12.5 ± 2.1 days in groups I and II, respectively (p = not significant).

The 30-day mortality rate in group I was 13% (2 patients). Both patients died within the first postoperative week. After an initially uneventful period, 1 patient had development of severe pulmonary edema 24 hours after the operation and eventually died of multiorgan failure. The other patient aspirated and subsequently died of pneumonia. In group II, 1 patient (7%) died of hepatic failure of unknown origin on the 21st postoperative day.

Two patients (13.3%) in group II required conversion from a videoendoscopic procedure to a unilateral thoracotomy because of multiple lung adhesions.

Air Leakage
Mean duration of chest tube drainage was 8.7 ± 1.8 days in group I and 8.0 ± 1.9 days in group II (p = not significant). Repeat drainage was necessary in 6.7% of group I patients and no group II patients. Marked subcutaneous emphysema developed in 33.3% of the patients in group 2 versus none in group I.

Lung Function Tests
On spirometry, a significant decrease in residual volume was observed within the first month. The forced expiratory volume in 1 second increased steadily to a maximum 3 months postoperatively (Fig 1). Data are presented in Table 2.

View larger version (15K): [in this window] [in a new window]   Fig 1. . Forced expiratory volume in 1 second before and after operation. ( sterno = sternotomy; video = videoendoscopy.)

View larger version (14K): [in this window] [in a new window]   Fig 2. . Intrinsic positive end-expiratory pressure before and 3 months after operation. Abbreviations are the same as in Figure 1.

View larger version (14K): [in this window] [in a new window]   Fig 3. . Work of breathing before and 3 months after operation. Abbreviations are the same as in Figure 1.

All patients had severely impaired exercise endurance preoperatively. On the bicycle ergometer, the mean performance was 25.7 ± 3.7 W in group I and 32.8 ± 3.4 W in group II. One month after operation, bicycle performance was improved to 29.3 ± 2.0 W in group I and 37.5 ± 7.5 W in group II.

All but 1 patient (91.7%) came off oxygen in group I, and 8 of the 10 oxygen-dependent patients (80%) in group II did not need supplemental oxygen postoperatively (p = not significant). No patient in either group now requires oxygen for the entire day.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Volume reduction is becoming an increasingly established surgical procedure for patients with chronic obstructive pulmonary disease and severe distention of the chest. The benefit to patients in terms of improved lung function testing and fitness and relief from dyspnea has been shown [12–15, 25]. However, many questions remain unanswered. One of the most essential is the choice of surgical approach. The impact of the endoscopic versus the open approach on functional improvement and procedure-related complications is unclear. The same is true for a unilateral versus a bilateral reduction procedure. Various groups have reported their experience with a single approach (Table 3). Whereas Cooper and associates [12, 16, 17] and Miller and colleagues [26] discussed their experience with bilateral resections through a sternotomy, McKenna [13], Keenan [14] and their co-workers presented their results with a unilateral endoscopic approach. Several other groups [27–29] have tried different techniques but presented their data in a summarized way. As expected, the functional benefit after a bilateral volume reduction procedure seems to be twice that seen after a unilateral resection.

A significant difference was found in time to extubation. All group I patients but 1 were extubated in the operating room, but patients in group II were extubated in the ICU 8.9 hours after operation. The difference in extubation time cannot be attributed to technique but rather to our changed policy. Like most other groups, when we started our program, we thought extubation immediately after operation in the operating room was mandatory. However, we realized that even patients with severe chronic obstructive pulmonary disease can be safely weaned from the respirator. In an effort to reduce time in the operating room, we began to extubate all patients having operation through a videoendoscopic approach in the ICU under safe conditions without the pressure of time. Moreover, in our hospital, the ICU and the operating rooms are located on different floors, and transporting a patient to the ICU can take 30 minutes.

Despite the differences in extubation time, the mean stay in the ICU was shorter for group II patients. The time to discharge from the hospital was equal in both groups. The duration of chest tube drainage was similar in both groups, but 1 patient in group I required repeat drainage. In retrospect, the chest tubes were removed too early in this patient, our fourth. Even though we altered our perioperative management, no change in the incidence or the severity of air leakage was noted. We had actually expected that the longer ventilation time in group II might result in the development of air leaks. In fact, we could detect no difference between groups in this perioperative complication.

This finding is even more remarkable because of the difference in operative technique. Stapler lines in group I were buttressed with bovine pericardium, whereas the endoscopic stapler was used without additional reinforcement in group II. We have observed intraoperatively that tiny air leaks are most likely to occur beside, but rarely through, the stapler line. The resection leads to increased tension on the visceral pleura surrounding the stapler line. Because the lung tissue in these patients is very weak and flimsy, the pleura can tear easily, especially when large portions of the lung are resected. Two other groups [12, 13] reported a duration of chest tube drainage of more than 7 days in at least half of their patients. This is comparable to or longer than the time in our patients, but the authors used buttressed stapler lines. On the basis of these observations, we question whether the use of expensive buttressing material can still be justified.

The holes in the parietal pleura after endoscopy are usually not tightly closed or leak proof. Therefore, air in the intrapleural space can easily pass into the subcutaneous space, and this resulted in the high incidence of subcutaneous emphysema in our patients. We now try to close the incision as accurately and tightly as possible. In contrast, the possibility of subcutaneous emphysema after a sternotomy is virtually nil.

Pathophysiologically, chronic obstructive pulmonary disease leads to decreased compliance, dynamic hyperinflation, and subsequently elevated work of breathing. One of the main issues has been that volume reduction restores circumferential traction on small airways, thus diminishing air trapping [11]. We prospectively measured iPEEP and work of breathing before and after operation to examine this hypothesis. We found that the preoperatively elevated iPEEP rapidly decreased by 77% with a sternotomy and 73% with the videoendoscopic approach immediately after operation. This marked improvement can be attributed to the removal of destroyed and hyperinflated areas of the lung, thus leading to decompression of the airways. A similar decrease for both approaches was noted for work of breathing. The functional improvement in terms of lung function was similar in both groups at 3 months and thereafter. In patients who underwent endoscopic resection, forced expiratory volume in 1 second increased substantially within the first month, whereas after sternotomy, the maximal improvement was observed after 3 months (see Fig 1). One must be careful not to overemphasize this fact, but the result could be due to differences in procedure. Although all patients received maximal analgesia through an epidural catheter, the more invasive sternotomy may have an impact on late postoperative recovery because it causes more pain than videoendoscopy. This is probably reflected by the difference in forced expiratory volume in 1 second and vital capacity after 1 month between the two groups. However, functional improvement is equal for both surgical approaches 3 months postoperatively and thereafter.

In conclusion, our results demonstrate that volume reduction significantly reduces iPEEP and work of breathing initially after the operation, followed by a substantial improvement in lung function and physical fitness, regardless of the surgical approach. The incidence of air leakage, the duration of chest tube drainage, and the length of hospital stay are similar for both procedures. However, videoendoscopic volume reduction seems to be less invasive and henceforth is our approach of choice.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
We are indebted to Conny Fürstauer, CRN, Roswitha Herics, CRN, and Karin Scherhaufer, CRN, for assistance in coordinating the project and to Marlene Thiem, RTA, and Sylvia Kiss, RTA, for their extra efforts in computing the regions of interest of the computed tomographic scans.

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Wisser, Department of Cardiothoracic Surgery, University of Vienna, Währinger Gürtel 18-20, A-1090 Vienna, Austria.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment Acknowledgments References

 

1. Alexander HL, Kountz WB. Symptomatic relief of emphysema by an abdominal belt. Am J Med Sci 1934;187:687–92.
2. Carter MG, Gaensler EA, Kyllonen A. Pneumoperitoneum in the treatment of pulmonary emphysema. N Engl J Med 1950;243:549–58.
3. Freund WA. Zur operativen Behandlung gewisser Lungenkrankheiten, insbesondere des auf starrer Thoraxdilatation beruhenden alveolären Emphysems (mit einem Operationsfalle). Z Exp Pathol Ther 1906;3:479–98.
4. Deslauriers J. Surgical treatment of bullous emphysema. Ann Thorac Surg 1993;56:196–7.[Medline]
5. Connolly JE, Wilson A. The current status of surgery for bullous emphysema. J Thorac Cardiovasc Surg 1989;97:351–61.
6. Brenner M, Kayaleh RA, Milne EN, et al. Thoracoscopic laser ablation of pulmonary bullae. J Thorac Cardiovasc Surg 1994;107:883–90.[Abstract/Free Full Text]
7. Vishnevsky AA, Nickoladze GD. One-stage operation for bilateral bullous lung disease. J Thorac Cardiovasc Surg 1990;99:30–4.[Abstract]
8. Gaensler EA, Gaensler EHL. Surgical treatment of bullous emphysema. In: Baue AE, Geha AS, Hammond GL, Laks H, Naunheim KS, eds. Glenn's thoracic and cardiovascular surgery. Norwalk, CT: Appleton & Lange, 1991:193–217.
9. Potgieter PD, Benatar SR, Hewitson RP, Ferguson AD. Surgical treatment of bullous lung disease. Thorax 1981;36:885–90.[Abstract/Free Full Text]
10. Boushy SF, Billig DM, Kohen R. Changes in pulmonary function after bullectomy. Am J Med 1969;47:916–23.[Medline]
11. Brantigan OC, Mueller E, Kress MB. A surgical approach to pulmonary emphysema. Am Rev Respir Dis 1959;80:194–202.[Medline]
12. 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]
13. McKenna 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;111:317–22.[Abstract/Free Full Text]
14. Keenan RJ, Landreneau RJ, Sciurba FC, et al. Unilateral thoracoscopic surgical approach for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:308–16.[Abstract/Free Full Text]
15. Sciurba FC, Rogers RM, Keenan RJ, et al. Improvement in pulmonary function and elastic recoil after lung-reduction surgery for diffuse emphysema. N Engl J Med 1996;334:1095–9.[Abstract/Free Full Text]
16. Cooper JD, Patterson GA. Lung volume reduction surgery for severe emphysema. Semin Thorac Cardiovasc Surg 1996;8:52–60.[Medline]
17. Cooper JD, Patterson GA. Lung volume reduction surgery for severe emphysema. Chest Surg Clin North Am 1995;5:815–31.[Medline]
18. Naunheim KS, Ferguson MK. The current status of lung volume reduction operations for emphysema. Ann Thorac Surg 1996;62:601–12.[Abstract/Free Full Text]
19. Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038–9.[Abstract]
20. Mahler DA, Wells K. Evaluation of clinical methods for rating dyspnea. Chest 1988;93:580–6.[Abstract/Free Full Text]
21. Gevenois PA, DeVuyst P, Sy M, et al. Pulmonary emphysema: quantitative CT during expiration. Radiology 1996;199:825–9.[Abstract/Free Full Text]
22. Müller NL, Thurlbeck WM. Thin-section CT, emphysema, air trapping, and airway obstruction. Radiology 1996;199:621–2.[Free Full Text]
23. Branson RD. Volume monitoring accuracy of four ventilators and the BICORE CP-100 monitor. Respir Care 1991;36:135–9.
24. Petros AJ, Lamond CT, Benett D. The Bicore pulmonary monitor. A device to assess the work of breathing while weaning from mechanical ventilation. Anaesthesia 1993;48:985–8.[Medline]
25. Gaissert HA, Trulock EP, Cooper JD, Sundaresan RS, Patterson GA. Comparison of early functional results after volume reduction or lung transplantation for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1996;111:296–307.[Abstract/Free Full Text]
26. Miller DL, Dowling RD, McConnell JW, Skolnick JL. Effects of lung volume reduction surgery on lung and chest wall mechanics. Ann Thorac Surg (in press).
27. Eugene J, Dajee A, Kayaleh R, Gogia HS, Dos Santos C, Gazzaniga AB. Reduction pneumonoplasty for patients with a forced expiratory volume in 1 second of 500 milliliters or less. Ann Thorac Surg 1997;63:186–92.[Abstract/Free Full Text]
28. Argenziano M, Moazami N, Thomashow B, et al. Extended indications for lung volume reduction surgery in advanced emphysema. Ann Thorac Surg 1996;62:1588–97.[Abstract/Free Full Text]
29. Zenati M, Keenan RJ, Sciurba FC, Manzetti JD, Landreneau RJ, Griffith BP. Role of lung reduction in lung transplant candidates with pulmonary emphysema. Ann Thorac Surg 1996;62:994–9.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. L. Snyder, C. H. Goss, B. Neradilek, N. L. Polissar, Z. Mosenifar, R. A. Wise, A. P. Fishman, J. O. Benditt, and for the National Emphysema Treatment Trial Researc Changes in Arterial Oxygenation and Self-Reported Oxygen Use after Lung Volume Reduction Surgery Am. J. Respir. Crit. Care Med., August 15, 2008; 178(4): 339 - 345. [Abstract] [Full Text] [PDF]

				M. M. DeCamp Jr., R. J. McKenna Jr., C. C. Deschamps, and M. J. Krasna Lung Volume Reduction Surgery: Technique, Operative Mortality, and Morbidity Proceedings of the ATS, May 1, 2008; 5(4): 442 - 446. [Abstract] [Full Text] [PDF]

				G. J. Criner, A. L. Sternberg, and for the National Emphysema Treatment Trial Researc A Clinician's Guide to the Use of Lung Volume Reduction Surgery Proceedings of the ATS, May 1, 2008; 5(4): 461 - 467. [Abstract] [Full Text] [PDF]

				M. E. Friscia, J. Zhu, J. W. Kolff, Z. Chen, L. R. Kaiser, C. S. Deutschman, and J. B. Shrager Cytokine Response is Lower After Lung Volume Reduction Through Bilateral Thoracoscopy Versus Sternotomy Ann. Thorac. Surg., January 1, 2007; 83(1): 252 - 256. [Abstract] [Full Text] [PDF]

				M. M. DeCamp, E. H. Blackstone, K. S. Naunheim, M. J. Krasna, D. E. Wood, Y. M. Meli, R. J. McKenna Jr, and for the NETT Research Group Patient and Surgical Factors Influencing Air Leak After Lung Volume Reduction Surgery: Lessons Learned From the National Emphysema Treatment Trial Ann. Thorac. Surg., July 1, 2006; 82(1): 197 - 207. [Abstract] [Full Text] [PDF]

				M. Brenner, N. M. Hanna, R. Mina-Araghi, A. F. Gelb, R. J. McKenna Jr, and H. Colt Innovative Approaches to Lung Volume Reduction for Emphysema Chest, July 1, 2004; 126(1): 238 - 248. [Abstract] [Full Text] [PDF]

				Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery J. Thorac. Cardiovasc. Surg., May 1, 2004; 127(5): 1350 - 1360. [Abstract] [Full Text] [PDF]

				E.W. Russi, K.E. Bloch, and W. Weder Lung volume reduction surgery: what can we learn from the National Emphysema Treatment Trial? Eur. Respir. J., October 1, 2003; 22(4): 571 - 573. [Full Text] [PDF]

				O. Senbaklavaci, W. Wisser, C. Ozpeker, G. Marta, P. Jaksch, E. Wolner, and W. Klepetko Successful lung volume reduction surgery brings patients into better condition for later lung transplantation Eur. J. Cardiothorac. Surg., September 1, 2002; 22(3): 363 - 367. [Abstract] [Full Text] [PDF]

				K. E.A. Burns, R. J. Keenan, W. F. Grgurich, J. D. Manzetti, and M. A. Zenati Outcomes of lung volume reduction surgery followed by lung transplantation: a matched cohort study Ann. Thorac. Surg., May 1, 2002; 73(5): 1587 - 1593. [Abstract] [Full Text] [PDF]

				J. Hamacher, S. Buchi, C.L. Georgescu, U. Stammberger, R. Thurnheer, K.E. Bloch, W. Weder, and E.W. Russi Improved quality of life after lung volume reduction surgery Eur. Respir. J., January 1, 2002; 19(1): 54 - 60. [Abstract] [Full Text] [PDF]

				W. Wisser, O. Senbaklavaci, C. Ozpeker, M. Ploner, T. Wanke, E. Tschernko, E. Wolner, and W. Klepetko Is long-term functional outcome after lung volume reduction surgery predictable? Eur. J. Cardiothorac. Surg., June 1, 2000; 17(6): 666 - 672. [Abstract] [Full Text] [PDF]

				J. Hamacher, E. W. Russi, and W. Weder Lung Volume Reduction Surgery : A Survey on the European Experience Chest, June 1, 2000; 117(6): 1560 - 1567. [Abstract] [Full Text] [PDF]

				M. A. de Castro Current Controversies in Surgical Therapy for Emphysema Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2000; 4(1): 26 - 30. [Abstract] [PDF]

				T. N. E. T. T. R. Group Rationale and Design of the National Emphysema Treatment Trial : A Prospective Randomized Trial of Lung Volume Reduction Surgery Chest, December 1, 1999; 116(6): 1750 - 1761. [Abstract] [Full Text] [PDF]

				RATIONALE AND DESIGN OF THE NATIONAL EMPHYSEMA TREATMENT TRIAL (NETT): A PROSPECTIVE RANDOMIZED TRIAL OF LUNG VOLUME REDUCTION SURGERY J. Thorac. Cardiovasc. Surg., September 1, 1999; 118(3): 518 - 528. [Full Text] [PDF]

				S. R Hazelrigg, T. M Boley, A. Grasch, and T. Shawgo Surgical strategy for lung volume reduction surgery Eur. J. Cardiothorac. Surg., September 1, 1999; 16(suppl_1): S57 - S60. [Abstract] [Full Text] [PDF]

				W. Wisser, W. Klepetko, O. Senbaklavaci, T. Wanke, E. Gruber, E. Tschernko, and E. Wolner Chronic hypercapnia should not exclude patients from lung volume reduction surgery Eur. J. Cardiothorac. Surg., August 1, 1999; 14(2): 107 - 112. [Abstract] [Full Text] [PDF]

				T. C. Mineo, E. Pompeo, G. Simonetti, A. F. Sabato, F. Turani, P. Rogliani, F. De Padova, and I. Nofroni Unilateral thoracoscopic reduction pneumoplasty for asymmetric emphysema Eur. J. Cardiothorac. Surg., July 1, 1999; 14(1): 33 - 39. [Abstract] [Full Text] [PDF]

				S. R. Hazelrigg, T. M. Boley, M. J. Magee, C. H. Lawyer, and J. Q. Henkle Comparison of staged thoracoscopy and median sternotomy for lung volume reduction Ann. Thorac. Surg., October 1, 1998; 66(4): 1134 - 1139. [Abstract] [Full Text] [PDF]

				M. de Perrot, M. Licker, and A. Spiliopoulos Muscle-sparing anterior thoracotomy for one-stage bilateral lung volume reduction operation Ann. Thorac. Surg., August 1, 1998; 66(2): 582 - 584. [Abstract] [Full Text] [PDF]

				W. Wisser, W. Klepetko, M. Kontrus, A. Bankier, O. Senbaklavaci, A. Kaider, T. Wanke, E. Tschernko, and E. Wolner Morphologic Grading of the Emphysematous Lung and Its Relation to Improvement After Lung Volume Reduction Surgery Ann. Thorac. Surg., March 1, 1998; 65(3): 793 - 799. [Abstract] [Full Text] [PDF]

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): Wilfried Wisser Ernst Wolner Walter Klepetko Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Wisser, W. Articles by Klepetko, W. Search for Related Content PubMed PubMed Citation Articles by Wisser, W. Articles by Klepetko, W. Related Collections Related Article