Search

Objectives: Lung volume reduction surgery (LVRS) is an established therapeutic option for advanced emphysema. To improve patients' safety and reduce complications, an enhanced recovery protocol (ERP) was implemented. This study aims to describe and evaluate the short-term outcome of this ERP., Methods: This retrospective single-centre study included all consecutive LVRS patients (1 January 2017 until 15 September 2020). An ERP for LVRS was implemented and stepwise optimised from 1 August 2019, it consisted of changes in pre-, peri- and postoperative care pathways. Patients were compared before and after implementation of ERP. Primary outcome was incidence of postoperative complications (Clavien-Dindo), and secondary outcomes included chest tube duration, incidence of prolonged air leak (PAL), length of stay (LOS) and 90-day mortality. Lung function and exercise capacity were evaluated at 3 and 6 months post-LVRS., Results: Seventy-six LVRS patients were included (pre-ERP: n=41, ERP: n=35). The ERP cohort presented with lower incidence of postoperative complications (42% vs 83%, P=0.0002), shorter chest tube duration (4 vs 12 days, P<0.0001) with a lower incidence of PAL (21% vs 61%, P=0.0005) and shorter LOS (6 vs 14 days, P<0.0001). No in-hospital mortality occurred in the ERP cohort versus 4 pre-ERP. Postoperative forced expiratory volume in 1 s was higher in the ERP cohort compared to pre-ERP at 3 months (1.35 vs 1.02 l) and at 6 months (1.31 vs 1.01 l)., Conclusions: Implementation of ERP as part of a comprehensive reconceptualisation towards LVRS, demonstrated fewer postoperative complications, including PAL, resulting in reduced LOS. Improved short-term functional outcomes were observed at 3 and 6 months., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Randomized controlled trials have demonstrated that lung volume reduction surgery (LVRS) improves exercise capacity, lung function, and quality of life in patients with heterogenous emphysema on computed tomographic and perfusion scan. However, most patients have a nonheterogenous type of destruction. These patients, summarized under "homogeneous emphysema," may also benefit from LVRS as long they are severely hyperinflated, and adequate function is remaining with a diffusing capacity of the lungs for carbon monoxide greater than 20% and no pulmonary hypertension. Surgical mortality is low when patients are well selected., Competing Interests: Disclosure W. Weder: Astra Zeneca: Advisory Board & Speaker, Covidien (Medtronic): Teaching Grant & Speaker., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objectives: Lung volume reduction (LVR) is an efficient and approved treatment for selected emphysema patients. There is some evidence that repeated LVR surgery (LVRS) might be beneficial, but there are no current data on LVRS after unsuccessful bronchoscopic LVR (BLVR) with endobronchial valves (EBVs). We hypothesize good outcome of LVRS after BLVR with valves., Methods: In this study, we retrospectively investigated all patients who underwent LVRS between 2015 and 2019 at 2 centres after previous unsuccessful EBV treatment. They were further divided into subgroups with patients who never achieved the intended improvement after BLVR (primary failure) and patients whose benefit was fading over time due to the natural development of emphysema (secondary failure). Patients with severe air leak after BLVR and immediate concomitant LVRS and fistula closure thereafter were analysed separately., Results: A total of 38 patients were included. Of these, 19 patients had primary failure, 15 secondary failure and 4 were treated as an emergency due to severe air leak. At 3 months after LVRS, forced expiratory volume in 1 s had improved significantly by 12.5% (P = 0.011) and there was no 90-day mortality. Considering subgroups, patients with primary failure after BLVR seem to profit more than those with secondary failure. Patients with severe air leak after BLVR did not profit from fistula closure with concomitant LVRS., Conclusions: LVRS after previous BLVR with EBVs can provide significant clinical improvement with low morbidity, although results might not be as good as after primary LVRS., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Severe emphysema is a debilitating condition with few treatment options. Lung volume reduction procedures in the treatment of severe emphysema have shown excellent results in selected patients but their exact role remains unclear with studies reporting a wide variation in outcomes. We therefore aimed to evaluate the effects of volume reduction., Methods: We did a systematic review and meta-analysis. We searched MEDLINE on Sept 29, 2016, for trials of lung volume reduction in patients with emphysema, and we did an updated search on Embase and PubMed on June 18, 2018. We only included randomised controlled studies published in English evaluating the intervention with either sham or standard of care. Inclusion was limited to trials of techniques in which there was sustainable volume reduction. Primary outcomes were residual volume, FEV 1 , St George's Respiratory Questionnaire (SGRQ), and 6-min walk distance (6MWT). Secondary outcomes were severe adverse events (including mortality), short-term mortality, and overall mortality. We extracted summary level data from the trial publications and where necessary we obtained unpublished data. A random-effects model with the I 2 statistic was used to determine heterogeneity and trial weight in each analysis. The study is registered with the PROSPERO database, number CRD42016045705., Findings: We identified 4747 references in the search, and included 20 randomised controlled trials of lung volume reduction involving 2794 participants with emphysema. Following lung volume reduction from any of the interventions in pooled analyses (ie, surgery, endobronchial valve, endobronchial coil, or sclerosing agents), the mean differences compared with the control were reduction in residual volume of 0·58 L (95% CI -0·80 to -0·37), increase in FEV 1 of 15·87% (95% CI 12·27 to 19·47), improvement in 6MWT of 43·28 m (31·36 to 55·21), and reduction in the SGRQ of 9·39 points (-10·92 to -7·86). The odds ratio for a severe adverse event, which included mortality, was 6·21 (95% CI 4·02 to 9·58) following intervention. Regression analysis showed improvements relative to the degree of volume reduction: FEV 1 (r 2 =0·86; p<0·0001), 6MWT (r 2 =0·77; p<0·0001), and SGRQ (r 2 =0·70; p<0·0001). Most studies were at high risk of bias for lack of blinding, and heterogeneity was high for some outcomes when pooled across all interventions, but was generally lower in the subgroups by intervention type., Interpretation: Despite limitations of high risk of bias and heterogeneity for some analyses, our results provide support that lung volume reduction in patients with severe emphysema on maximal medical treatment has clinically meaningful benefits. These benefits should be considered alongside potential adverse events., Funding: None., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Objectives: We hypothesize a significant correlation between parameters of preoperative dynamic magnetic resonance imaging (MRI) and postoperative outcomes measured by pulmonary function tests., Methods: Dynamic MRI of the lungs was prospectively performed during 2 breath cycles 1 day before and 3 months after surgery, herein termed as pre- and post-lung-volume reduction surgery (LVRS) MRI. Quantitative measurements were performed on sagittal planes for the left lung and right lung: lung height, anteroposterior diameter, hemidiaphragm height and area as well as perimeter. Additionally, dynamic changes in hemidiaphragmatic area and height were measured. Parameters were normalized by patients' height. Pulmonary function test pre-LVRS and post-LVRS was performed. The cut-off value for treatment benefit was defined as a 30% increase in forced expiratory volume in 1 s., Results: Thirty-nine consecutive patients (15 women, median age 61 years) were included. On expiration, the mean lung area on both sides (Pright = 0.001 and Pleft = 0.016) and anteroposterior diameter of the right lung (Pright = 0.003) improved post-LVRS. Dynamic measurements showed differences pre- and post-LVRS on the right lung but not on the left lung (Pright < 0.001 and Pleft = 0.090). There were no significant changes in lung height for both sides, in hemidiaphragmatic height on the right as well as diaphragmatic area pre- and post-LVRS (P > 0.05). Except for hemidiaphragmatic height on the left lung (P = 0.039), no significant differences were found on inspiration. Considering the 30% cut-off for treatment benefit, the receiver operating curves analysis indicated a height-normalized expiratory lung area ≥35 793 mm2 as the most sensitive preoperative outcome predictor (sensitivity = 86%; specificity = 61%)., Conclusions: Preoperative dynamic MRI can be used as an additional outcome predictor for patient selection in LVRS. A height-normalized total lung area in expiration ≥35 793 mm2 correlates with a 30% increase in forced expiratory volume in 1 s., Clinical Trial Registration Number: SNCTP000000480., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: Pulmonary hypertension (PH) is considered a contraindication for lung volume reduction surgery (LVRS). Because, it has been reported that endobronchial lung volume reduction may have a beneficial effect without increased mortality in patients with emphysema and PH, we evaluated its effect on PH in patients undergoing LVRS., Methods: From January 2014 until June 2016, 119 LVRSs were performed at Zurich University Hospital. PH was a contraindication for patients with homogeneous emphysema but was acceptable for those with heterogeneous emphysema. Thirty patients underwent echocardiography before and after LVRS, 10 of whom had preoperative systolic pulmonary artery pressures >35 mmHg and 20 of whom had normal systolic pulmonary artery pressure. The effect of LVRS on pulmonary artery pressure, lung function and survival was analysed., Results: Ninety-day mortality for all 30 patients was 0, and the postoperative course did not differ significantly between the 2 groups. In patients with PH, the median systolic pulmonary artery pressure decreased from 41 mmHg [interquartile range (IQR) 39-47] to 37 mmHg (IQR 36-38, P = 0.04). These patients had an improvement of forced expiratory volume in 1 s from the median 27% predicted (IQR 23-34) to 33% (IQR 28-40, P = 0.007) 3 months postoperatively., Conclusions: If further confirmed in other cohorts, mild to moderate PH may no longer be considered a contraindication for LVRS in patients with heterogeneous emphysema.

Background: Lung volume reduction surgery (LVRS) has been proven to be a successful procedure and can be performed with low mortality when defined selection criteria are met. We hypothesized good outcome and low mortality after LVRS for selected patients with severe hyperinflation and nonhomogeneous morphology even when diffusion capacity of the lung for carbon monoxide (Dlco) is less than 20%., Methods: The study included all patients scheduled for LVRS between March 2005 and May 2014 with a preoperative Dlco of less than 20%. Postoperative 90-day mortality was the primary end point. Secondary end points were postoperative lung function and surgical morbidity at 3, 6, and 12 months., Results: Included were 33 patients with a median forced expiratory volume in 1 second of 23% (interquartile range, 19% to 28%), a median diffusion capacity of 15% (interquartile range, 13% to 18%), and a median hyperinflation of 76% (residual volume-to-total lung capacity ratio of 70% to 76%). Mean follow-up was 44.8 months (range, 10 to 141 months). Heterogeneous emphysema was present in 26 patients, and 7 showed intermediately heterogeneous morphology. Sixteen procedures were bilateral, and 31 were performed by video-assisted thoracoscopic surgery. The 90-day mortality was 0%. Median forced expiratory volume in 1 second percentage predicted at 3 months increased from 23% to 29% (p < 0.001). Median Dlco increased from 15% to 24% (p < 0.001), and median hyperinflation decreased from 76% to 63% (p < 0.001). A prolonged air leak exceeding 7 days occurred in 16 patients (48.5%), and 6 required reoperation for fistula closure. The 7 patients with intermediately heterogeneous emphysema showed a median increase in forced expiratory volume in 1 second from 20% preoperatively to 28% postoperatively (p = 0.028)., Conclusions: Selected patients with severely impaired Dlco of less than 20% can cautiously be considered as potential candidates if hyperinflation is severe and the lungs show areas with advanced destruction as targets for resection., (Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Lung volume reduction surgery (LVRS) offers improvement in lung function, quality of life and even survival in well selected patients with severe emphysema. Patients with all types of emphysema morphology can profit from LVRS when certain selection criteria are present. Hyperinflation plays a key role in qualifying for the procedure. Candidate selection should be performed at high volume centers with a multidisciplinary emphysema board. Qualified thoracic surgeons together with pulmonologists and radiologists identify the suitable patient considering emphysema morphology with its target areas for resection, lung function parameters and cardiac comorbidities. This review outlines candidate selection, technique and results of LVRS to inform referring physicians how to screen und inform their patients., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Lung volume reduction surgery improves exercise tolerance, lung function, and quality of life for selected patients with emphysema. Lung volume reduction surgery is well established for patients in a highly elective setting. It is, however, contraindicated in cases of acute cardiorespiratory failure. We present the case of a patient with severe emphysema who had acute respiratory failure and decompensated cor pulmonale requiring life-saving venovenoarterial extracorporeal life support after admission to the emergency unit. He underwent lung volume reduction surgery with intent to wean from extracorporeal life support. He had complete functional recovery after 4 months., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

In a number of large case series in the mid-1990s, lung volume reduction surgery (LVRS) was shown to reduce dyspnoea and improve pulmonary function and quality of life in patients with advanced pulmonary emphysema. The large randomised National Emphysema Treatment Trial (NETT) confirmed this in the early 2000s and also demonstrated that selected patients live longer after surgery. Patient selection is crucial to the success of the procedure and should be performed at a specialised experienced centre with a multidisciplinary team approach on emphysema treatment. The upper-lobe predominant heterogeneous type of emphysema is the best indication, but there are other types of emphysema morphology that are also eligible for surgery, if ideally chosen. Nowadays there is also growing evidence for positive effects after different types of bronchoscopic lung volume reduction (BLVR) with increasing quality. These methods add to the range of multimodal emphysema treatment., (Georg Thieme Verlag KG Stuttgart · New York.)

Objective: The purpose of this study was to evaluate the influence of sinogram-affirmed iterative reconstruction (SAFIRE) on quantification of lung volume and pulmonary emphysema in low-dose chest computed tomography compared with filtered back projection (FBP)., Methods: Enhanced or nonenhanced low-dose chest computed tomography was performed in 20 patients with chronic obstructive pulmonary disease (group A) and in 20 patients without lung disease (group B). Data sets were reconstructed with FBP and SAFIRE strength levels 3 to 5. Two readers semiautomatically evaluated lung volumes and automatically quantified pulmonary emphysema, and another assessed image quality. Radiation dose parameters were recorded., Results: Lung volume between FBP and SAFIRE 3 to 5 was not significantly different among both groups (all P > 0.05). When compared with those of FBP, total emphysema volume was significantly lower among reconstructions with SAFIRE 4 and 5 (mean difference, 0.56 and 0.79 L; all P < 0.001). There was no nondiagnostic image quality., Conclusions: Sinogram-affirmed iterative reconstruction does not alter lung volume measurements, although quantification of lung emphysema is affected at higher strength levels.

Objectives: Lung volume reduction surgery (LVRS) improves dyspnoea, quality of life and may even prolong survival in carefully selected patients with end-stage emphysema. The benefit may be sustained for several years and vanishes with the natural progression of the disease. Data on repeated surgical treatment of emphysema are scarce. The aim of this study was to evaluate the safety, effects and outcomes of repeated LVRS (Re-LVRS) in patients no longer benefiting from their initial LVRS., Methods: Between June 2002 and December 2013, 22 patients (9 females) with advanced emphysema underwent Re-LVRS at a median of 60 months (25-196) after their initial LVRS. While initial LVRS was performed thoracoscopically as a bilateral procedure, Re-LVRS was performed unilaterally by a video-assisted thoracoscopic technique in 19 patients and, due to adhesions, by thoracotomy in 3 patients. Pulmonary function test (PFT) was performed at 3 and 12 months postoperatively., Results: Lung function at Re-LVRS was similar to that prior to the first LVRS. The 90-day mortality rate was 0%. The first patient died 15 months postoperatively. The median hospitalization time after Re-LVRS was significantly longer compared with the initial LVRS [14 days, interquartile range (IQR): 11-19, vs 9 days, IQR: 8-14; P = 0.017]. The most frequent complication was prolonged air leak with a median drainage time of 11 days (IQR: 6-13); reoperations due to persistent air leak were necessary in 7 patients (32%). Five patients (23%) had no complications. Lung function and Medical Research Council (MRC) score improved significantly for up to 12 months after Re-LVRS, with results similar to those after initial bilateral LVRS. The average increase in the forced expiratory volume in 1 s (FEV1) was 25% (a 7% increase over the predicted value or 0.18 l) at 3 months, and the mean reduction in hyperinflation, assessed by relative decrease in RV/TLC (residual volume/total lung capacity), was 12% at 3 months (a decrease of 8% in absolute ratios). The mean MRC breathlessness score decreased significantly after 3 months (from 3.7 to 2.2)., Conclusions: Re-LVRS can be performed successfully in carefully selected patients as a palliative treatment. It may be performed as a bridge to transplantation or in patients with newly diagnosed intrapulmonary nodules or during elective cardiac surgery. Morbidity is acceptable and outcomes may be satisfactory with significantly improved lung function and reduced dyspnoea for at least 12 months postoperatively., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Patients with a homogeneous type of emphysema have been excluded a priori from LVRS in many centers because of the fear of removing parenchyma, which potentially contributes to gas exchange, and because the observation that heterogeneity of emphysema is a predictor of functional improvement. It is obvious that resection of functionless tissue, such as in heterogeneous emphysema with bullae, can be advised to the patient with a relative low risk. However, as the main positive effect of LVRS is its improvement on respiratory mechanics, it is not surprising that well-selected patients with homogeneous emphysema also benefit from surgery. Their selection has to be done cautiously. It is crucial to exclude patients with a very low functional reserve, such as with diffusing capacity below 20% predicted or with pulmonary hypertension, and with extreme parenchymal loss (vanished lungs) on CT from LVRS. Additionally, cofactors which may potentially interfere with a smooth postoperative course, such as previous recurrent infections, extensive scarring of the lungs, or previous surgery, have to be taken into consideration. When respecting these caveats, LVRS in patients with complete homogeneous emphysema provides a comparable symptomatic and almost the same functional improvement as in patients with heterogeneous emphysema. Although the perioperative mortality is low, patients with homogeneous emphysema have a slightly reduced long-term survival without lung transplantation compared with patients with heterogeneous emphysema. Based on our own experience, we conclude that LVRS can be recommended to selected symptomatic patients with advanced homogenous emphysema associated with severe hyperinflation, if diffusing capacity is not below 20% of predicted values and if the CT scan does not show aspects of vanished lungs.

Background: The purpose of this study was to evaluate whether favorable short-term results achieved by lung volume reduction surgery in selected patients with homogeneous emphysema would persist for longer periods. Their symptoms, lung function, and survival for several years were analyzed in comparison to patients with heterogeneous emphysema., Methods: Two hundred fifty consecutive patients (105 women), mean (+/- standard deviation) age 64 +/- 8.4 years, with advanced emphysema underwent bilateral thoracoscopic lung volume reduction surgery. Forced expiratory volume in 1 second was 28% +/- 8% of predicted, 6-minute walking distance was 245 +/- 118 m, and Medical Research Council dyspnea score was 3.5 +/- 0.7. In 138 patients (55%) computed tomography revealed homogeneous emphysema (including 82 intermediate type) distribution and in 112 patients (45%) heterogeneous emphysema. Baseline characteristics were otherwise similar in the two groups that were prospectively observed for several years., Results: Thirty-day mortality was 2.4%. Both groups revealed significant improvements 3 months after lung volume reduction surgery: in homogeneous emphysema, predicted forced expiratory volume in 1 second was 38% +/- 14% (35% improvement), 6-minute walk distance was 324 +/- 87 m, and dyspnea score was 1.8 +/- 0.9 (p < 0.05 all outcomes). Corresponding results in heterogeneous emphysema were 44% +/- 15% (61% improvement), 382 +/- 95 m, and 1.3 +/- 0.9 points (p < 0.05 versus baseline; not significant versus homogeneous). Median time until predicted forced expiratory volume in 1 second and 6-minute walk distance had returned to baseline was 36 months in both groups. One-year survival was similar in both groups. At 5 years, median survival without lung transplantation was 64% in the homogeneous and 73% in the heterogeneous group (Cox proportional hazard, 0.81; 95% confidence interval, 0.66 to 0.98; p = 0.03)., Conclusions: In selected patients with homogeneous pulmonary emphysema, lung volume reduction surgery can be successfully performed with low perioperative mortality. Significant improvements in dyspnea, lung function, and exercise capacity are maintained for several years.

Objective: Prolonged air leak is reported in up to 50% of patients after lung volume reduction surgery. The effect of an autologous fibrin sealant on the intensity and duration of air leak and on the time to chest drain removal after lung volume reduction surgery was investigated in a randomized prospective clinical trial., Methods: Twenty-five patients underwent bilateral thoracoscopic lung volume reduction surgery. In each patient, an autologous fibrin sealant was applied along the staple lines on one side, whereas no additional measure was taken on the other side. Randomization of treatment was performed at the end of the resection on the first side. Air leak was assessed semiquantitatively by use of a severity score (0 = no leak; 4 = continuous severe leak) by two investigators blinded to the treatment., Result: Mean value of the total severity scores for the first 48 hours postoperative was significantly lower in the treated group (4.7 +/- 7.7) than in the control group (16.0 +/- 10.1) (P < .001), independently of the length of the resection. Prolonged air leak and mean duration of drainage were also significantly reduced after application of the sealant (4.5% and 2.8 +/- 1.9 days versus 31.8% and 5.9 +/- 2.9 days) (P = .03 and P < .001)., Conclusions: Autologous fibrin sealant for reinforcement of the staple lines after lung volume reduction surgery significantly reduces prolonged air leak and duration of chest tube drainage.

To explore if change in the extent of emphysema correlated with change in lung function, the effect of resection of emphysematous tissue was studied by computed tomography (CT) densitometry. In addition, the current authors studied how surgery-induced change in emphysema related to lung density in control subjects. In total, 30 patients (14 females; mean+/-sd age 59+/-10 yrs) with severe emphysema before and 3 months after lung volume reduction surgery (LVRS), 48 patients with moderate emphysema and 76 control subjects were investigated. Lung density (15th percentile point) of both lungs and heterogeneity of lung density between 12 isovolumetric partitions in each lung were calculated from chest CT images. The 15th percentile point and its heterogeneity could distinguish controls from subjects with moderate emphysema with a sensitivity and specificity of >95%. LVRS significantly increased lung density by 5.0+/-10.9 g.L(-1) (n=30). Improvement in the diffusing capacity of the lung for carbon monoxide and in residual volume significantly correlated with an increase in lung density (n=20 and 28, respectively). Change in forced expiratory volume in one second did not correlate with change in lung density. In conclusion, lung density 15th percentile point is a valuable surrogate marker for detection of both the extent of and reduction in emphysema.

Background: In this study, we prospectively analyzed the functional outcome and the survival after lung-volume reduction surgery (LVRS) in patients with end-stage emphysema who were initially potential candidates for lung transplantation (LTX), and investigated the impact of LVRS on posttransplant course in patients who underwent LTX after LVRS., Methods: Of the 216 patients who underwent LVRS between 1994 and 2005, 58 were potential candidates for LTX at the time of LVRS (age 65 years or younger, forced expiratory volume in 1 second 25% of predicted or less; LVRS/LTX group). Lung-volume reduction surgery was performed by means of video-assisted, bilateral stapled resection of target areas. During the same period, 31 patients underwent primary LTX for end-stage emphysema (LTX group). Spirometry, plethysmography, carbon monoxide diffusing capacity, 6-minute walking distance, and dyspnea score were assessed preoperatively and at predetermined times after operation. Survival analysis was performed by use of the Kaplan-Meier method., Results: All the functional variables significantly improved after LVRS and peaked within the first year. Subjective improvement was observed for up to 5 years after LVRS, and 53% (31 of 58) of the patients were still alive and had not undergone transplantation after a median follow-up of 44 months. Fourteen percent (8 of 58) of the patients underwent secondary LTX because of progressive worsening of the respiratory function after a median bridging time between LVRS and LTX of 33 months. Postoperative recovery after transplantation and median survival time were comparable between the 8 patients of the LVRS/LTX group and the 31 patients of the LTX group (96.5 months versus 118.5 months, p = 0.9)., Conclusions: Lung-volume reduction surgery can significantly improve symptoms and lung function in selected patients who are initially potential candidates for LTX. Lung-volume reduction surgery can allow the postponement of LTX for up to 4 to 5 years and does not impair the chances for a subsequent successful LTX.

Objectives: One-lung ventilation (OLV) during thoracoscopic surgery is associated with a significant decline in arterial PO(2) in patients with severe pulmonary emphysema and patients with preserved lung function. The authors hypothesized that patterns of arterial PO(2) changes are different in these 2 patient groups., Design: Prospective nonrandomized study., Setting: University hospital., Participants: Twenty-five patients undergoing thoracoscopic interventions: 16 with severe pulmonary emphysema and 9 patients without emphysema., Interventions: Continuous arterial blood gas measurement (PaO(2), PaCO(2), pHa) during OLV of the left lung in left lateral position using the Paratrend 7 blood gas monitoring system (PT7; Pfizer Hospital Products Group, High Wycombe, UK)., Main Results: The decrease of PaO(2) was delayed in patients with severe emphysema. Steady state (defined as DeltaPaO(2) <7.5 mmHg/min) was reached after 18 +/- 4 minutes compared with 11 +/- 3 minutes (mean +/- standard deviation) in patients with normal lung function (p = 0.0002). PaO(2) values at steady state were comparable (p = 0.49); the pattern of changes in PaO(2) for the first 15 minutes of left-sided OLV was significantly different between the groups (p = 0.0004). The difference of predicted versus measured PaO(2) at steady state was -48 +/- 160 mmHg for patients with emphysema and -51 +/- 60 mmHg for patients with normal lung function (p = 0.019)., Conclusion: During OLV, oxygenation is better preserved for a longer period of time in patients with severe pulmonary emphysema as compared with patients with normal lung function. In contrast to patients without emphysema, prediction of oxygenation during OLV for the individual patient with emphysema is unreliable because of large interindividual differences.

Background: Lung volume reduction surgery (LVRS) improves symptoms and lung function in selected patients with severe emphysema., Objectives: We investigated whether models based on physiologic and radiologic predictors discriminated patients with a favorable from those with a poor spirometric response to LVRS., Methods: Data of a derivation cohort of 70 patients who had previously undergone LVRS served to develop two types of prediction models, lookup functions and logistic regression equations. Presence or absence of improvement in forced expiratory volume in 1 s (FEV1) > or =300 ml and forced vital capacity (FVC) > or =500 ml represented dichotomous outcomes. The residual volume/total lung capacity ratio, CT-radiological emphysema heterogeneity scores and diffusing capacity, a marker of emphysema severity, were the predictors. Models were used to predict spirometric outcomes for a validation cohort of 60 emphysema patients referred for LVRS. Furthermore, the surgeon preoperatively estimated outcomes based on all available clinical data but blinded to model predictions. Spirometric changes within 6 months following surgery were compared to predictions., Results: Median FEV1 in the validation cohort increased from 0.69 to 1.00 liters (+41%), and FVC from 2.07 to 2.78 liters (+29%; p < 0.05 for changes). Lookup functions and logistic regression equations identified patients experiencing major increases in FEV1 > or =300 ml and FVC > or =500 ml with an accuracy quantified by areas under the receiver-operating characteristic curves of 0.72 to 0.76 (all areas >0.5, p < 0.05). Predictions by the surgeon had an accuracy of 0.71 to 0.78 (p = NS vs. models)., Conclusions: The accuracy of models based on three predictors was fair and similar to assessment by an experienced surgeon based on all available clinical information. Prediction models may contribute to the consistent assessment of LVRS candidates.

Background: The favorable effects of lung volume reduction surgery for selected patients with smoker's emphysema has been demonstrated. However, outcome data for patients with alpha(1)-antitrypsin deficiency emphysema are scarce., Methods: We prospectively studied pulmonary function, dyspnea, and 6-minute walking distance in 21 patients with severe alpha(1)-antitrypsin deficiency emphysema (PiZZ 18, PiZO 1, PiSZ 2, 10 female patients, median age 56 years, range 38-74 years) for as long as 5 years after thoracoscopic lung volume reduction surgery., Results: Lung volume reduction surgery improved the mean dyspnea score, from 3.7 +/- 0.1 preoperatively to 1.4 +/- 0.2 at 3 months; the score remained improved for as long as 3.5 years. Mean vital capacity (% predicted) improved from 79% +/- 4.4% to 98% +/- 4.8% at 3 months, and the ratio of residual volume to total lung capacity decreased from 0.67 to 0.51. These improvements lasted for as long as 2 years. The mean airflow obstruction (forced expiratory volume in 1 second % predicted) improved from 27% +/- 1.9% to 38% +/- 3.3% at 3 months and remained statistically improved for 1 year. Four patients showed long-term improvement in lung function for as long as 3.5 years. These patients had markedly heterogeneous emphysema and showed no radiologic signs of airway inflammation., Conclusions: Lung volume reduction surgery in patients with advanced emphysema from alpha(1)-antitrypsin deficiency results in a significant improvement in dyspnea and lung function for as long as 3.5 years in some cases. It appears that magnitude and duration of these effects are inferior and shorter than those in patients with pure smoker's emphysema. Patients with heterogeneous disease and no or minor inflammatory airway disease may benefit most.

Patient selection for lung volume reduction surgery (LVRS) relies on sound physiologic concepts and experience from large case series. LVRS should be considered in severely symptomatic emphysema with marked airflow obstruction and hyperinflation despite optimal medical management, and in the absence of major comorbidities associated with excessive perioperative risks. Qualitative estimation of functional benefit from LVRS in suitable candidates has been based on functional criteria (e.g., high inspiratory conductance, high residual volume/total lung capacity ratio), on heterogeneity of emphysema assessed by computed tomography (CT) or perfusion scans, and on severity of emphysema assessed by CT or impaired diffusing capacity. Selection strategies relying on such criteria have provided favorable functional results at a low mortality, but further validation of potential outcome predictors in prospective trials is needed., (Copyright 2002, Elsevier Science (USA). All rights reserved.)

Objective: Surgical lung volume reduction improves lung function and dyspnea in advanced emphysema to a variable degree. Because long-term results with this procedure are scant, we prospectively investigated lung function over several years after lung volume reduction surgery with regard to emphysema morphology., Methods: Bilateral video-assisted thoracoscopic lung volume reduction surgery was performed in severely symptomatic patients with marked hyperinflation caused by advanced nonbullous emphysema. Emphysema heterogeneity was visually graded on chest computed tomography. Symptoms and lung function were assessed before the operation and 3, 6, and then every 6 months after the operation., Results: A total of 115 patients with a median forced expiratory volume in 1 second of 0.73 L (27% of predicted value) underwent lung volume reduction surgery. Follow-up extended over a median of 37 months. Median forced expiratory volume in 1 second significantly increased within 6 months after the operation by 37% in homogeneous (n = 27), by 38% in intermediately heterogeneous (n = 37), and by 63% in markedly heterogeneous emphysema (n = 51, P <.05 vs. other morphologies). Maximal forced expiratory volume in 1 second was reached within 6 months after lung volume reduction surgery and decreased in the first postoperative year by 0.16 L per year in homogeneous, by 0.19 L per year in intermediately heterogenous, and by 0.32 L per year in markedly heterogeneous emphysema (P <.01 vs. other morphologies). The decline in forced expiratory volume in 1 second over subsequent years decelerated according to an exponential decay and was similar for all morphologic types (median annual decrease of 0.09 L [9%])., Conclusions: Lung volume reduction surgery improves lung function in severe homogeneous and, to an even greater extent, heterogeneous emphysema. Forced expiratory volume in 1 second peaks within 6 months postoperatively. The subsequent decline is most rapid in the first year and slows down in succeeding years according to an exponential decay. Therefore, long-term functional results of lung volume reduction surgery may be more favorable than expected from linear extrapolations of short-term observations.

Lung volume reduction surgery (LVRS) improves dyspnoea, pulmonary function, and physical performance in patients with severe pulmonary emphysema. This study investigated the impact of LVRS on health-related quality of life (HRQL) over a 2-yr period following surgery. Thirty-nine consecutive patients were prospectively assessed before LVRS, and followed over 24 months postoperatively. The assessments included pulmonary function, dyspnoea (Medical Research Council (MRC) dyspnoea score), 6-min walking distance (6MWD) and HRQL using the Short Form 36-item questionnaire (SF-36). Several domains of SF-36 improved considerably over 2 yrs after surgery: Physical Functioning: 39 +/- 4 (mean +/- SEM) versus 16 +/- 2 (p<0.01); Vitality: 51 +/- 3 versus 32 +/- 3 (p<0.01); Social Functioning: 72 +/- 4 versus 51 +/- 5 (p<0.01). Also, improvements in pulmonary function (forced expiratory volume in one second (FEV1): 27 +/- 1% predicted, residual volume (RV)/total lung capacity (TLC): 0.65 +/- 0.01), 6 MWD (274 +/- 16 m) and dyspnoea (MRC: 3.9 +/- 01) were sustained for up to 2 yrs after LVRS (FEV1 36 +/- 2% pred, RV/TLC: 0.58 +/- 0.02; 6 MWD: 342 +/- 19 m; MRC: 2.0 +/- 0.2; p<0.05). In patients with severe emphysema, lung volume reduction surgery had positive effects on health-related quality of life and pulmonary function over 2 yrs.

Part of the functional benefit provided by lung volume reduction surgery (LVRS) may be related to improvement in respiratory muscle function resulting from changes in diaphragm dimension and configuration. To study these changes, we obtained 3D reconstructions of the muscle using spiral computed tomography in 11 patients with severe emphysema before and 3 mo after surgery, and in 11 normal subjects matched for sex, age, height, and weight. Bilateral LVRS was performed by thoracoscopy in eight patients and by sternotomy in three patients. Acquisitions were made in the supine posture at relaxed FRC, midinspiratory capacity, and TLC. On average, LVRS produced a 51 +/- 11% increase in FEV(1) and a 30 +/- 4% decrease in FRC. The total surface area of the diaphragm (A(di)) and of the zone of apposition (A(ap)) at FRC increased by 17 +/- 4% and 43 +/- 8%, respectively, but the surface area of the dome did not change. Compared with the values recorded in the normal subjects, postoperative values of A(di) and A(ap) at FRC were reduced by 11% (p < 0.05) and 24% (p < 0.005), respectively. The curvature of the dome increased at TLC in the left sagittal plane, but was otherwise unaffected by the procedure. We conclude that LVRS substantially increases A(di) and A(ap), but does not significantly improve diaphragm configuration at FRC.

Background: The intention of buttressing the staple line in lung volume reduction surgery is to reduce air leaks and to shorten the hospital stay. A randomized three-center study was carried out to test this hypothesis., Methods: Sixty-five patients with a mean age of 59.2 +/- 1.2 years underwent bilateral lung volume reduction surgery by video-assisted thoracoscopy using endoscopic staplers (ET 45B; Ethicon Endo-Surgery, Cincinnati, OH) either without or with bovine pericardium for buttressing (Peri-Strips Dry; Bio-Vascular, Inc, Saint Paul, MN). There were no differences between the control and treatment groups in lung function, degree of dyspnea, and arterial blood gases before and 3 months after LVRS., Results: Seven patients (3 in the treatment group) needed a reoperation because of persistent air leak. The median duration of air leaks was shorter in the treatment group (0.0 day [range, 0 to 28 days versus 4 days [range, 0 to 27 days); p < 0.001), confirmed by a shorter median drainage time in this group (5 days [range, 1 to 35 days] versus 7.5 days [range, 2 to 29 days); p = 0.045). Hospital stay was comparable between the two groups (9.5 days [range, 6 to 44 days] versus 12.0 days [range, 5 to 46 days]; p = 0.14)., Conclusions: Buttressing the staple line significantly shortens the duration of air leaks and the drainage time. As hospital stay did not differ significantly between the two groups, cost-effectiveness may depend on the local situation.

Study Objective: To evaluate the activity and evolution in the field of lung volume reduction surgery (LVRS) performed at surgical centers in Europe., Background: LVRS is a novel surgical therapy with the potential to improve lung function, exercise performance, and quality of life in selected patients suffering from severe pulmonary emphysema., Methods: Questionnaire addressed to 75 European thoracic surgical centers presumed to perform LVRS, and review of the literature., Results: Of 45 responding centers, 42 centers in 17 countries covering a population of 423 million reported performing LVRS. Until the end of 1998, 1,120 patients were reported to have undergone LVRS, corresponding to 2.6 patients/million inhabitants. Thirty-one of 40 centers (78%) perform the operation bilaterally. Most centers (83%) evaluate their activity prospectively. The average perioperative mortality rate of 4.1% is moderate. The most commonly utilized technique is video-assisted thoracoscopy, which is most frequently performed bilaterally. Two thirds of the centers treat patients with alpha(1)-antitrypsin deficiency, and half of the centers will consider patients with homogenous morphology of emphysema on CT scan for LVRS. Half of the centers also perform lung transplantation. The five largest centers have operated on 49% of all LVRS patients assessed by this survey., Conclusions: LVRS is performed at few thoracic surgical centers throughout Europe, with a large variation in the operative activity between different regions. Half of the centers also perform lung transplantation. Between 1995 and 1997, the number of LVRS procedures performed per year nearly tripled but has reached a plateau since then. As five centers perform nearly half the total number of operations, an optimal exchange of knowledge with smaller centers seems important.

Lung volume reduction surgery is a palliative procedure that improves dyspnea and pulmonary function in selected patients with advanced emphysema. Postoperative benefit is sustained for an individual period and depends on the emphysema morphology, the surgical technique, and other not yet well-defined factors. The question whether lung volume reduction surgery can be performed a second time on the same thoracic cavity is often raised but experience in this regard is lacking. We describe a patient who has undergone a successful redo operation 2 years after the initial lung volume reduction surgery.

Background: Lung volume reduction surgery (LVRS) improves dyspnea, pulmonary function, and quality of life in selected patients with severe emphysema. We investigated the role of emphysema morphology in 37 patients as an outcome predictor for up to 2 years after operation., Methods: Patients selected for bilateral thoracoscopic LVRS were divided, according to a simplified emphysema morphology classification, into three groups (homogeneous, moderately heterogeneous, and markedly heterogeneous) based on a preoperative chest computed tomogram. Pulmonary function, walking distance, and dyspnea were assessed., Results: Functional improvement after LVRS was best in markedly heterogeneous emphysema with an increase from preoperative forced expiratory volume in 1 second of 31% +/- 2% (mean +/- standard error of the mean) to 52% +/- 4% of predicted postoperatively. It was significantly higher than in homogeneous emphysema (from 26% +/- 1% to 38% +/- 2% predicted) and in intermediately heterogeneous emphysema (from 29% +/- 2% to 44% +/- 45% predicted). At 24 months postoperatively, forced expiratory volume in 1 second and dyspnea score continued to be significantly better than preoperative levels in all three morphologic groups. The survival rate was highest in patients with markedly heterogeneous emphysema., Conclusions: Functional and subjective improvements were maintained after LVRS for at least 24 months in patients with heterogeneous or homogeneous emphysema type.

Lung volume reduction surgery (LVRS) in patients with advanced pulmonary emphysema aims to alleviate symptoms and enhance quality of life by improving respiratory mechanics. The theoretical concepts of the operation predict the greatest functional benefit in patients with marked hyperinflation, and with airflow obstruction due to loss of elastic recoil. Consistent observations in several centres, have confirmed these expectations. To achieve maximal reduction in lung volume at the least cost of functional tissue, resection is targeted to the lung zones with the most severe destruction by emphysema, leaving zones with relatively well-preserved tissue intact. Heterogeneity in emphysema distribution as assessed by visual scoring of the chest computed tomography scan according to a simple grading system has been shown to correlate with LVRS outcome variables. Therefore, evaluation of lung volume reduction surgery candidates has to include the functional and morphological characteristics of the emphysema as well as a general assessment of perioperative risk. However, the knowledge of potential predictive factors of lung volume reduction surgery outcome is so far based on retrospective analysis of highly selected patients. Therefore, many questions in respect of the selection of ideal candidates for this procedure remain unanswered at the present time.

Lung volume reduction surgery is a novel operative concept, which may be applied in certain patients, who are severely handicapped by advanced pulmonary emphysema and suffer from dyspnea at minimal exercise despite optimal medical therapy. The most destroyed lung parts are resected by video-assisted thoracoscopy. This type of surgery has a surprisingly low morbidity and mortality at specialized centers. It improves symptoms by ameliorating lung function and exercise tolerance. Maximal functional improvement is observed and lung function starts to decline slowly within one to two years thereafter.

Over the last 15 years lung transplantation developed from an experimental technique to a valid therapy for patients with end-stage pulmonary emphysema. The main reason for this progress are better defined selection criteria, improved operative technique and organ preservation, optimized peri- and postoperative management, and a more precise immunosuppressive and anti-infective therapy. Indications, technique, treatment and results of lung transplantation in emphysema patients are discussed.

Lung perfusion scintigraphy is employed to evaluate patients with severe emphysema who are candidates for lung volume reduction surgery (LVRS). Our purpose was to investigate the role of scintigraphy in relation to chest computed tomography (CT) and lung function in this setting. Six observers blinded to clinical data retrospectively scored preoperative scintigrams of 70 patients undergoing bilateral video-assisted LVRS according to the distribution of lung perfusion as homogeneous, intermediately heterogeneous, or markedly heterogeneous. Heterogeneity of emphysema distribution was also assessed by chest CT. Dyspnea and pulmonary function were measured preoperatively and 3 mo postoperatively. In 42 patients with markedly heterogeneous, in 18 with intermediately heterogeneous, and in 10 with homogeneous perfusion, mean (+/- SE) FEV1 increased by 57 +/- 8% (p < 0.0001), 38 +/- 9% (p < 0.001), and 23 +/- 9% (p = NS) (p = NS for intergroup comparisons). In a multiple regression analysis, functional improvement after LVRS was more closely correlated with preoperative hyperinflation and the degree of emphysema heterogeneity estimated by chest CT than with the degree of perfusion heterogeneity assessed by scintigraphy. In 16 of 22 patients with homogeneous emphysema distribution in the chest CT scintigraphy revealed intermediately or markedly heterogeneous perfusion. We conclude that lung perfusion scintigraphy has a limited role in prediction of outcome, but it may help to identify target areas for resection in LVRS candidates with homogeneous CT morphology.

Objective: The presence of pulmonary hypertension in severe pulmonary emphysema has been considered a relative contraindication to lung volume reduction surgery (LVRS). There was concern that resection of lung tissue might further increase pulmonary artery pressure. To address this point, the prevalence of pulmonary hypertension in candidates for LVRS was investigated. The changes in pulmonary artery pressures after bilateral videoassisted thoracoscopic resection was studied in patients with homo- and heterogeneously destroyed emphysematous lungs., Design: The pulmonary arterial pressures by right heart catheterization were prospectively assessed, before and 6 months after LVRS in 21 consecutive patients (15 males, six females, mean (+/- S.E.) age: 62 +/- 1.9, range 42-74 years). All were former smokers and three had ZZ-AT1 deficiency. The inclusion criteria were: (a) severe bronchial obstruction (FEV1 < 35% predicted); (b) pulmonary hyperinflation (RV/TLC > 0.60); and (c) absence of hypercapnia (PaCO2 < 50 mmHg)., Results: The FEV1 had increased from 28 +/- 2% to 35 +/- 3% of the predicted value (P < 0.05) 6 months after surgery. The RV/TLC had declined from 0.65 +/- 0.02 to 0.55 +/- 0.02; PaO2 increased (66 +/- 1 versus 71 +/- 2 mmHg, P = 0.04), PaCO2 (38 +/- 2 versus 36 +/- 1 mmHg, P = 0.26) did not change. The pulmonary artery mean pressure (PAPmean) remained unchanged (18 +/- 1 versus 19 +/- 1 mmHg, P = 0.26). In six patients PAPmean was > or = 20 mmHg (up to 24 mmHg) preoperatively. After 6 months, six patients had a PAPmean > or = 20 mmHg (up to 31 mmHg)., Conclusions: In patients with severe emphysema who are candidates for LVRS (but have only mild to moderate hypoxemia and a PaCO2 < 50 mmHg) we found no relevant pulmonary hypertension and pulmonary artery pressure did not change significantly after surgery. Therefore, routine right heart catheterization is not mandatory for preoperative evaluation.

We investigated functional results, complications and survival of patients undergoing bilateral video-assisted thoracoscopic (VAT) lung volume reduction surgery (VRS) for severe, diffuse pulmonary emphysema [FEV1 28 +/- 0.8 (% pred.), RV/TLC 0.65 +/- 0.01, 12' walking distance 499 +/- 21 (m)]. From January 1994 to March 1998, 106 of 286 candidates were operated, 85 patients (mean age 64, range 38-78 years, 30 females) fulfilled the study criteria and were included in the prospective study. Hyperinflation decreased to an RV/TLC ratio of 0.51 +/- 0.01 after 3 months and 0.55 +/- 0.02 after 24 months, FEV1 increased to 43 +/- 1.6 (% pred.) after 3 months and 35 +/- 2.3 (% pred.) after 24 months, and the 12' walking distance was 687 +/- 29 (m) 3 months postoperative and 626 +/- 44 (m) after 24 months.

Background: Lung volume reduction surgery is known to alleviate dyspnea and to improve pulmonary function, performance in daily activity, and quality of life in selected patients with severe pulmonary emphysema. We investigated the role of radiologically assessed emphysema morphology on functional outcome after a lung volume reduction operation., Methods: The preoperative chest computed tomograms in 50 consecutive patients who had undergone surgical lung volume reduction were retrospectively reviewed by 6 physicians blinded to the clinical outcome. Emphysema morphology was determined according to a simplified classification (ie, homogeneous, moderately heterogeneous, and markedly heterogeneous; lobe predominance). We studied the impact of these morphologic aspects on functional outcome at 3 months., Results: We found a fair interobserver agreement applying our classification system. Functional improvement after surgical lung volume reduction was best in markedly heterogeneous emphysema with an increase in forced expiratory volume in 1 second of 81% +/- 17% (mean +/- standard error, n = 17) compared with 44% +/- 10% (n = 16) for intermediately heterogeneous emphysema. But also in patients with homogeneous emphysema clinical relevant improvement of function could be observed (increase in forced expiratory volume in 1 second = 34% +/- 6%; n = 17)., Conclusions: The morphologic type of emphysema, assessed by a simplified surgically oriented classification, is an important predictor of surgical outcome. Lung volume reduction surgery may also improve dyspnea and lung function in homogeneous emphysema.

Surgical lung volume reduction may improve pulmonary function and dyspnea in advanced pulmonary emphysema. To investigate mechanisms of these beneficial effects we studied breathing patterns before and after surgery. Nineteen patients with diffuse pulmonary emphysema (FEV1 < 35% of predicted, total lung capacity > 130% predicted) were studied within 1 mo before, and 1.5 to 7 mo after thoracoscopic volume reduction. Changes of rib cage and abdominal volumes were monitored with calibrated respiratory inductive plethysmography for 20 to 60 min during natural breathing at rest. Pulmonary function and dyspnea were also assessed. Postoperative tidal volumes, respiratory cycle times, and minute ventilation were not significantly different from preoperative values. The contribution of abdominal volume changes to tidal volumes increased from a mean +/- SD of 43 +/- 17% preoperatively to 58 +/- 14% postoperatively (p = 0.03). The fraction of inspiratory time with abdominal paradoxical motion decreased from 12.3 +/- 8.3% preoperatively to 5.1 +/- 5.1% postoperatively (p = 0.02). The phase shift between rib cage and abdominal motion was reduced postoperatively. Hyperinflation, airway obstruction, and subjective ratings of dyspnea were significantly improved. The better synchronization of rib cage-abdominal motion and the greater contribution of abdominal volume changes to tidal volumes are consistent with a reduction of inspiratory loading and a greater force-generating capacity of the diaphragm after surgery.

Objectives: Most patients with severe pulmonary emphysema referred for lung volume reduction surgery (LVRS) have a long-standing history of cigarette smoking. Coronary artery disease (CAD) predisposes to perioperative cardiac complications. Since symptoms and signs of myocardial ischemia are often absent in patients with severe ventilatory impairment even during exercise, we investigated the prevalence of CAD in candidates for LVRS by angiography., Design: We prospectively studied the prevalence of CAD by angiography and assessed the CAD risk factor profile in 41 candidates for LVRS (26 men, 15 women; mean age, 66+/-6.8 years; range, 52 to 76 years), who had no current symptoms or a history of myocardial ischemia., Results: In six patients (15%), asymptomatic but significant coronary lesions (> 70% stenosis) were detected. In five patients, these findings altered the clinical management. Patients with CAD had significant higher cholesterol levels, tended to have smoked more, and had more often additional vascular risk factors., Conclusions: We found a high prevalence of angiographically significant but clinically silent CAD in this particular population of heavy smokers with advanced emphysema.

Objective: In a prospective study, we investigated the functional results, complications and survival of bilateral video-assisted thoracoscopic (VAT) lung volume reduction (LVR) in a selected group of patients with severe, nonbullous pulmonary emphysema. From January 1994 to September 1996, 42 of 143 candidates (13 female, 29 male, 42-78 years) were operated. They were short of breath on minimal exertion due to severe airflow obstruction and hyperinflation (FEV1 < 30%) pred., TLC > 130% pred., RV > 200% pred.)., Methods: LVR was performed bilaterally by VAT using endoscopic staplers without buttressing the staple lines. Pulmonary function test (PFT), MRC dyspnea score and 12 min walking distance were assessed preoperatively, at 3, 6 and 12 months. In addition lung function was measured at hospital discharge., Results: The patients reported a marked relief of dyspnea, which persisted at all follow-up visits (P<0.001). FEV1 increased from 0.80 +/- 0.24 (L) to 1.14 +/- 0.41 (L) postoperatively, a 43% gain (P < 0.001). A relevant increase of FEV1 persisted for at least 1 year. The residual volume to total lung capacity ratio decreased from 0.64 to 0.56 at hospital discharge. The mean 12 min walking distance increased from 500 +/- 195 (m) to 770 +/- 222 (m) after 1 year (P < 0.001). The mean hospital stay was 13 +/- 5.5 days (median 12.0), drainage time was 9 +/- 4.3 (median 8.0) days. There was no 30 day mortality. Three patients died between 2 and 15 months postoperatively by non surgery related reasons. One patient underwent lung transplantation 5 months after surgical lung volume reduction., Conclusions: In a selected group of patients with severe, nonbullous pulmonary emphysema, bilateral LVR by VAT results in instantaneous postoperative improvement in pulmonary function and dyspnea. These favorable effects, including an amelioriation in exercise performance, lasted for at least 1 year.

Arterial blood gases were studied prospectively using continuous intraarterial blood gas monitoring during thoracoscopic volume reduction surgery (VRS) in 24 patients with advanced diffuse pulmonary emphysema. Additionally, the early postoperative course (48 h) of arterial blood gases was studied retrospectively. Twenty-six operations were performed using a combination of thoracic epidural and general anesthesia with left-sided double-lumen intubation for one-lung ventilation (OLV). Arterial blood gases were determined awake, during two-lung ventilation prior to surgery, during OLV (extreme values), and after tracheal extubation. Additionally, the extremes during the whole procedure were determined: avoiding excessive peak inspiratory pressures (26.4 +/- 7.0 cm H2O), minimum PaO2 was 77 +/- 39 mm Hg (mean +/- SD), maximum PaCO2 65 +/- 14 mm Hg (P < 0.0001 versus preoperative values), and minimum pHa 7.22 +/- 0.08 (P < 0.0001). One tension pneumothorax occurred during OLV. Immediate postoperative extubation was performed in 25 of 26 cases, reintubation was necessary in two cases. One patient with coronary artery disease died 36 h after surgery. Hypercapnia (maximum PaCO2 49 +/- 8 mm Hg, minimum pHa 7.37 +/- 0.04, P < 0.01) was still observed 48 h after surgery. These results demonstrate that adequate oxygenation can be preserved during OLV for VRS, but CO2 elimination is impaired. However, intraoperative hypercapnia and immediate postoperative tracheal extubation are well tolerated.

In a prospective study, we investigated the functional results, complications, and survival of patients who underwent bilateral video-assisted thoracoscopic (VAT) lung volume reduction surgery (VRS) for severe, diffuse pulmonary emphysema (FEV1 0.77 +/- 0.03 [1], RV/TLC 0.65, 12' walking distance 482 +/- 26 [m]). From January 94 to March 97, 67 of 179 candidates underwent the operation, and 58 patients (mean age 64 +/- 1.1, range 42-78 years; 17 women) fulfilled the study criteria. There was no 30-day mortality; hyperinflation decreased to an RV/TLC ratio of 0.52 +/- 0.01 after 3 months; FEV1 increased to 1.2 +/- 0.08 [1]; and the 12' walking distance was 687 +/- 29 [m].

Lung volume reduction surgery (LVRS) is performed to alleviate dyspnoea of selected patients with severe pulmonary emphysema and to improve their pulmonary function, performance in daily activity and quality of life. By resection of destroyed lung areas the achievable improvements in function may consist of: 1) a reduction in hyperinflation resulting in amelioration of diaphragm and chest wall mechanics; 2) an increase of elastic recoil pressure, thereby augmenting expiratory flow rates; and 3) possibly an improvement in gas exchange. Meticulous selection of suitable patients, refinements in operative techniques, anaesthesiological and postoperative management has lowered perioperative mortality to less than 5% in groups who are experienced with this type of procedure. The best functional results are achieved by bilateral resection, which can either be performed by median sternotomy or by video-assisted thoracoscopy (VAT). The average increase in forced expiratory volume in one second (FEV1), obtained by bilateral resection in patients already receiving optimal medical therapy ranges 32-93%, and the reduction in hyperinflation, assessed by a decrease in total lung capacity ranges 15-20%. These favourable improvements have been reported to last in most of the patients for at least one year.

Unlabelled: We prospectively studied the surgical aspects, functional results, and complications of video-assisted bilateral thoracoscopic volume reduction surgery in patients with severe diffuse pulmonary emphysema., Methods: Fifteen men and five women with a mean age of 64 years (range 42 to 78 years) whose daily activity was substantially impaired by severe airflow obstruction and hyperinflation underwent thoracoscopic volume reduction surgery. The prospective preoperative assessment and postoperative assessment at 3 months included (1) pulmonary function studies, (2) grading of dyspnea, and (3) exercise performance; pulmonary function tests were also performed immediately before discharge from the hospital., Results: There was no perioperative mortality. All patients left the hospital after a median stay of 15 days (6 to 27 days). Only seven patients had a prolonged chest tube drainage time (>7 days). At 3 months the mean (+/- standard deviation) forced expiratory volume in 1 second had improved by 42% (+/-3.8%), from 0.80 L (+/-0.23) to 1.09 L (+/-0.28) (p < 0.001); residual volume had decreased from 5.8 L (+/-1.5) to 4.4 L (+/-1.0) (p < 0.001). Shortly before discharge the forced expiratory volume in 1 second was already 1.10 L (+/-0.26). The median 12-minute walking distance increased from 495 m (35 to 790 m) to 688 m (175 to 1035 m) (p < 0.001) and the mean maximal oxygen consumption from 10 ml/kg per minute (+/-2.5) to 13 ml/kg per minute (+/-2.3) (p < 0.0005). The patients reported a substantial relief of dyspnea with a mean decrease in the Medical Research Council score from 3.4 to 1.8.

Resection of large bullae to decompress adjacent lung tissue with the goal of improving pulmonary function has been an accepted surgical approach for many years. However, the indication for lung volume reduction is not bullous disease but diffuse emphysema and the surgical approach is based on an entirely different concept. The resection of the most affected parts of the emphysematous parenchyma aims at a reduction of the over expansion of the chest with the goal of improving respiratory mechanics. This concept was introduced by Brantigan in 1959, but has failed to gain widespread acceptance until recently. Based on the extensive experience in lung transplantation for patients with end stage emphysema J. D. Cooper reevaluated the idea successfully. He reported remarkable improvements in FEV1 and a reduction in hyperinflation after performing bilateral lung volume reduction through a median sternotomy. During the last 2 years we performed bilateral lung volume reduction in more than 30 patients with diffuse emphysema using video assisted thoracoscopy (VAT) and studied the results prospectively. In the first 20 patients preoperative mean forced expiratory volume in 1 second (FEV1) was 765 ml/sec and improved by a mean of 42% (0-100%) three months postoperatively. This gain in FEV1 was already observed at the end of hospitalisation approximately two weeks after surgery. The 12 minute walking distance improved over 40%. In our highly selected study population we had no perioperative mortality. Lung volume reduction is a palliative treatment of severe pulmonary emphysema. Currently no data is available on the duration of the improvement. In this selected group of patients dyspnea is reduced and pulmonary mechanics are improved, with a resulting increase in quality of life.