Lung volume reduction surgery for severe emphysema

What is it

Emphysema is a chronic lung condition in which the air sacs of the lungs are destroyed. When this happens, lungs lose some of their elasticity and are unable to empty completely. Emphysema can be caused by smoking or, in rare cases, it can be inherited. The earliest symptom of emphysema may be minor discomfort with breathing during exertion.

 Lung volume reduction surgery treats emphysema  innovatively by removing 20 to 30 percent of the lung tissue most damaged by emphysema. It appears that, by removing some portion of the diseased lung tissue, the elastic recoil of the remaining tissue is improved, resulting in increased expiratory airflow, and the respiratory muscles are allowed to operate at closer to their optimal force-generating length, resulting in increased inspiratory force. All these can make patient easier breathing. LVRS  is not a cure but, for some selected patients, the procedure provides an alternative to a lung transplant. It also is appropriate for patients who are not eligible for lung transplantation. The goal is to set the clock back two to five years. Patient who is to be considered a candidate for the surgery must have severe emphysema and meet strict requirements .

• Emphysema, on optimal management

• FEV1 15-40% predicted

• RV > 150% predicted

• CT and V /Q scans show macroscopic target zones of particularly damaged lung suitable

• for resection

• Able to comply with rehabilitation programme

• Unable/unwilling to exercise perioperatively, i.e. NYHA class IV, ventilator dependent

• Age > 70 years

• Previous thoracotomy/extensive pleural disease/pleurodesis

• Intrinsic airway disease requiring prednisolone > 15 mg/day

• Bronchiectasis

• PCO2 > 55 mmHg, pO2 < 45 mmHg on air

• Distance < 150 m in 6-min walk test

• Pulmonary artery pressure > 50 mmHg (assessed on echodoppler)

• DLCO < 30% predicted

• Cigarette smoking in last 3 months

• Other major organ dysfunction, i.e.significant coronary disease, CCF, cachexia, obesity etc.

Explanation: LVRS, lung volume reduction surgery; FEV1 forced expiratory volume in 1 s; RV, residual volume; CT,computed tomography; V/Q, nuclear isotopic ventilation/perfusion scan; NYHA, New York Heart Association; DLCO, gas transfer factor; CCF, congestive cardiac failure.

Our experience

Operative Techniques: 

Surgery is performed with a double-lumen endotracheal tube. The patient is placed in the full lateral decubitus position. 

The first incision is made in the 7th intercostal space in the midaxillary line.This incision is for thoracoscope to affords adequate visualization of the chest cavity. Additional incisions are made in the 4th intercostal space, anterior axillary, and in the 5th intercostal space in the posterior axillary line under thoracoscopic visualization. These incisions optimize insertion of instruments for lung manipulation and stapling. All pleural adhesions are lysed after that. 

The preoperative HDCT scan identify target tissue for resection. Ring forceps manipulate this tissue into an endoseopic stapler(45 mm Endo-GIA). It is important for the stapler to approach the lung tissue precisely to avoid tearing to lessen air leakage. After the target tissue is removed completely, the inferior pulmonary ligament is routinely divided to facilitate postoperative re-expansion of lung to occupy residual cavity. Then the anesthesiologist inflates lung to check air leakage. If there is a massive leakage, it should be closed with sutures or additional staples, and collagen is used to apply the cut edge. Thoracoscopy confirms apical-anterior and posterior placement of two straight chest tubes separately.

Outcome:

We pioneered Video-Assisted Thoracoscopic Stapled LVRS for emphysema at taizhou hospital. And more than 50 patients have undergone this kind of surgery here since 2002. The degree of dyspnea , FEV1 and performance in the 6-minute walk test were improved obviously post operations while RV and TLC decreased.