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

This Article Abstract Full Text (PDF) 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): Hiroshi Inoue Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Iwasaki, M. Articles by Inoue, H. Search for Related Content PubMed PubMed Citation Articles by Iwasaki, M. Articles by Inoue, H.

Ann Thorac Surg 1999;67:815-817
© 1999 The Society of Thoracic Surgeons

---

Original Articles

Application of the fold plication method for unilateral lung volume reduction in pulmonary emphysema

^a Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa, Japan
^b Department of Anesthesiology, Tokai University School of Medicine, Isehara, Kanagawa, Japan
^c Department of Internal Medicine, Tokai University School of Medicine, Isehara, Kanagawa, Japan

Accepted for publication August 17, 1998.

Address reprint requests to Dr Iwasaki, Department of Surgery, Tokai University School of Medicine, Isehara, Kanagawa 259-1193 Japan

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Unilateral lung volume reduction procedures are used to treat pulmonary emphysema. The most significant technical problem with this operation is an air leak from the pulmonary stump. Bovine pericardium has been used to prevent air leaks but is associated with interstitial pneumonia and a high cost.

Methods. The fold plication method was devised to prevent postoperative air leaks to avoid interstitial pneumonia, and to decrease cost. This technique was applied in 20 consecutive patients with emphysema who underwent a unilateral lung volume reduction operation via a thoracoscopic two windows approach.

Results. The operative time was approximately 1 hour. There was minimal postoperative bleeding, no persistent air leaks, and no evidence of pneumonia. Pulmonary function improved in all patients.

Conclusions. The unilateral fold plication method is an economical and safe alternative to bovine pericardial patching after lung volume reduction operation to prevent stump air leaks.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
Brantigan and associates [1] first reported the surgical treatment of diffuse pulmonary emphysema in 1957. That study remained in obscurity because of the high surgical mortality rate. Surgical treatment of pulmonary emphysema was again spotlighted in 1991 by Wakabayashi [2], who used the carbon dioxide laser, and in 1995 by Cooper and associates [3], who performed lung volume reduction operations (LVRO) via median sternotomy. A significant degree of improvement in pulmonary function was reported.

The ideal surgical approach to pulmonary emphysema is currently a subject of much debate. Many authors have reported methods to treat pulmonary air leaks, but no standard has been established. Because the aim of the surgical treatment of emphysema is improvement of pulmonary function, attempts have been made to minimize the invasiveness of the procedure [4]. The most significant postoperative complication is a pulmonary air leak.

Overcoming or avoiding an air leak leads to early rehabilitation. Initially, bovine pericardium was used to prevent pulmonary leaks. However, some patients developed interstitial pneumonia at the pulmonary resection lines, resulting in subsequent loss of pulmonary function. We developed a surgical technique to prevent air leaks after LVRO that did not use bovine pericardium but involved fold plication.

A thoracoscopic two windows method [5] was used because it was less invasive than a median sternotomy. Swanson and associates [6] reported good results of the thoracoscopic plication method for LVRO. There are some differences between their plication method and our fold plication method.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

 
Twenty consecutive patients with pulmonary emphysema had unilateral LVRO by the fold plication method between April 1996 and March 1998. To be included in the study, patients met the following conditions: emphysema classified as Hugh-Jones 3 or worse despite medical treatment, strict compliance with prohibition of smoking for 3 months preoperatively, marked hyperinflation on chest radiography, and nonhomogeneous emphysema. The patients were all men between 43 and 75 years old (mean, 64.2 years).

The operative time, blood loss, period of continuous postoperative air leakage, length of hospital stay, and change in pulmonary function were assessed in each patient. The operation was performed thoracoscopically using the two windows method on one lung during unilateral pulmonary ventilation with the patient in the lateral position. A scalpelless END-S-GIA 60-4.8 automatic suture device (United States Surgical Corporation, Norwalk, CT) was used for fold plication. The target zone was determined on the basis of pulmonary ventilation-perfusion scintigraphy and findings on computed tomography. Fold plication was performed by first exerting traction on the apex of the target zone. END-S-GIAs were positioned on the right and left so that there was no gap between the tips of the instruments. The staplers were then fired (Fig 1). The peripheral side was folded so that the staple line became the apex of the fold. After folding again, an END-S-GIA was fired at the more central target zone, including the folded margin (Fig 2).

View larger version (94K): [in this window] [in a new window]   Fig 1. Photograph showing where the automatic stapling devices created a fold in the apex of the lung.

View larger version (87K): [in this window] [in a new window]   Fig 2. Appearance of the lung after the first suture line was folded and the second suture line was created.

	Results

Top Abstract Introduction Material and methods Results Comment References

Complications occurred in only 1 patient who had sudden pneumothorax and subcutaneous emphysema on postoperative day 7. Reoperation revealed a ruptured pulmonary cyst in the lower lobe, unrelated to the operative site.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
Because thoracoscopic operations are much less invasive than standard thoracotomy, they have been enthusiastically adopted for diagnosis and treatment of pneumothorax, peripheral lung tumors, and mediastinal tumors [5, 7]. Pulmonary emphysema is considered a good indication for thoracoscopic operation because it is important to minimize damage to the thorax in these patients [2, 4, 5, 6]. Thoracoscopic operation is also superior to standard thoracotomy for thorough examination of the entire thoracic cavity. We have used the two windows method for LVRO in patients with pulmonary emphysema, and we always use original silicon thoracic access (Thoraco-Holder; Fuji Systems Corporation, Tokyo, Japan) to minimize damage to the thorax.

The fold plication method was devised for LVRO as an alternative to bovine pericardial patching after partial resection of the lung. Bovine pericardium was first used by Cooper and colleagues [3]. Initially we performed partial resection of the lung followed by bovine pericardial patching. However, in two of our patients intractable interstitial pneumonia developed at the location of the bovine pericardial patches 3 months postoperatively. By coincidence, in both patients a portion of the partial resection line was covered by bovine pericardium and a portion was not. High-resolution computed tomography revealed that the interstitial pneumonia occurred only along the partial resection lines covered by bovine pericardium. This complication occurred even though the pericardium was washed thoroughly to prevent the preservation fluid from causing a tissue reaction. In these patients, the initial improvements in pulmonary function were eventually lost as a result of the interstitial pneumonia. For this reason and because they are expensive, we no longer use bovine pericardial patches.

It was necessary to devise a method to perform LVRO at sites of pulmonary emphysema that are technically difficult to reach via median sternotomy. The fold plication method makes LVRO possible at virtually any target zone. Furthermore, fold plication is more economical than other methods with respect to equipment and prosthetic material costs, shorter hospital stays, and shorter rehabilitation periods. Lung volume reduction operations using the fold plication method is a simple technique that can be performed by any thoracoscopic surgeon. Moreover, we have shown the safety of fold plication in experimental models of lung transplantation in beagles since 1993. In those studies, the surfaces of the transplanted lungs that were subjected to fold plication became smooth and integrated with the adjacent tissue when the plicated lung was absorbed about 3 months later. The fold plication method, which prevents air leaks by mechanically sealing the peripheral lung from the central lung, is safe, effective, and economical. Because it is minimally invasive, it should become the method of choice for LVRO in patients with pulmonary emphysema.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Brantigan O.C., Mueller E.A., Kress M.B. A surgical approach to pulmonary emphysema. Am Surg 1957;23:789-804.[Medline]
2. Wakabayashi A. Thoracoscopic laser pneumoplasty in the treatment of diffuse bullous emphysema. Ann Thorac Surg 1995;60:936-942.[Abstract/Free Full Text]
3. Cooper J.D., Trulock E.P., Triantafillou A.N., et al. Bilateral pneumectomy for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106-119.[Abstract/Free Full Text]
4. Naunheim K.S., Keller C.A., Krucylak, et al. Unilateral video-assisted thoracic surgical lung reduction. Ann Thorac Surg 1996;61:1092-1098.[Abstract/Free Full Text]
5. Iwasaki M., Nishiumi N., Inoue H., et al. Thoracoscopic surgery for lung cancer using the two small skin incisional method. J Cardiovasc Surg 1996;37:79-81.[Medline]
6. Swanson S.J., Mentzer S.J., DeCamp M.M., Jr, et al. No-cut thoracoscopic lung plication: a new technique for lung volume reduction surgery. J Am Coll Surg 1997;185:25-32.[Medline]
7. Iwasaki M., Kaga K., Nishiumi N., et al. Experience with the two-windows method for mediastinal lymph node dissection in lung cancer. Ann Thorac Surg 1998;65:800-802.[Abstract/Free Full Text]

This article has been cited by other articles:

				K. Adluri and J. M. Parmar Use the bulla for pneumostasis Interactive CardioVascular and Thoracic Surgery, March 1, 2004; 3(1): 19 - 20. [Abstract] [Full Text] [PDF]

				R. A. Maxfield New and Emerging Minimally Invasive Techniques for Lung Volume Reduction Chest, February 1, 2004; 125(2): 777 - 783. [Abstract] [Full Text] [PDF]

				S. Provencher and J. Deslauriers Late complication of bovine pericardium patches used for lung volume reduction surgery Eur. J. Cardiothorac. Surg., June 1, 2003; 23(6): 1059 - 1061. [Abstract] [Full Text] [PDF]

				I. Oey and D. A. Waller Metalloptysis: a late complication of lung volume reduction surgery Ann. Thorac. Surg., May 1, 2001; 71(5): 1694 - 1695. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) 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): Hiroshi Inoue Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Iwasaki, M. Articles by Inoue, H. Search for Related Content PubMed PubMed Citation Articles by Iwasaki, M. Articles by Inoue, H.