LUNG VOLUME REDUCTION SURGERY
The goal of lung volume reduction surgery (LVRS) is to safely palliate dyspnea in patients with emphysema. Successful LVRS demands attention to the details of patient selection, preoperative preparation, intraoperative anesthetic and surgical technique, and multidisciplinary postoperative care. Expertise and effective communication among pulmonary medicine, thoracic surgery, thoracic anesthesia, pain management services, critical care medicine, respiratory therapy, and rehabilitation medicine departments are vital components to any LVRS program. In experienced centers, bilateral approaches yield nearly twice the physiologic benefit to unilateral LVRS without adversely affecting operative morbidity or mortality. Current practice favors stapled bilateral resection over plication or laser ablation to achieve lung volume reduction.
Bilateral LVRS is most commonly performed by median
sternotomy or bilateral video-assisted thoracoscopic surgery (VATS). Via either
approach, LVRS involves the resection of approximately two-thirds of the
hyperinflated upper lobe using a series of intersecting staple lines. When
performed through a sternotomy, the resection progresses from an anteromedial
orientation and is completed posteriorly and laterally near the tip of the
superior segment of the lower lobe. During VATS LVRS, the resection begins
laterally and ends medially abutting the mediastinum. A buttressing material
derived from either bovine pericardium or expanded polytetrafluoroethylene is
commonly used to reinforce the staple lines and decrease the incidence of
prolonged air leak after the procedure.
The National Emphysema Treatment Trial (NETT) was a
multicenter, randomized, controlled trial that compared LVRS with maximal
medical therapy in patients with severe emphysema. NETT enrolled patients with
a variety of emphysema morphologies and has better defined who benefits and who
does not benefit from LVRS. Patients with an extremely low forced expiratory
volume in 1 second (FEV1) with either a diffuse pattern of emphysema
or a DLCO (diffusing capacity for carbon monoxide) less than 20%
predicted have excessive mortality after LVRS, as do patients with non–upper
lobe emphysema and preserved exercise capacity. Conversely, patients not in
these high-risk groups who undergo LVRS have a mortality risk not different
from continued medical therapy but do have a greater chance for improvement in
exercise capacity and in most cases a greater chance for sustained improvement
in health-related quality of life. Moreover, those patients with upper
lobe–predominant emphysema and low baseline exercise capacity enjoy a survival
advantage after LVRS compared with patients who continue with only medical
therapy. This is the only intervention for emphysema since the availability of
portable supplemental oxygen to show a survival benefit.
Examination of NETT results with regards to approach to LVRS demonstrates an operative time for median sternotomy that was 20 minutes shorter then VATS but no difference in terms of air leak, days on the ventilator, or operative mortality. Patients undergoing bilateral VATS LVRS spent fewer days in the intensive care unit and on average 1 to 2 fewer days in the hospital. At 90 days after surgery, more VATS patients were at home and independent of additional nursing care. The functional outcomes of LVRS in terms of exercise capacity, FEV1, 6-minute walk distance, and respiratory-specific quality of life were not different between the VATS and median sternotomy group. Total health care expenditure for both the hospitalization as well as 6 months of care after LVRS favored the VATS approach. On average, VATS patients expended $10,000 less than patients undergoing LVRS via a median sternotomy. Based on these experiences, it appears that LVRS is safe, reproducible, and effective by either median sternotomy or VATS. The complication rate is low and similar for both surgical approaches. Additionally, functional outcomes and durability between 3 and 5 years of follow-up are also similar between the two approaches. It does appear however, based on the only randomized data available, that VATS provides earlier recovery at a l wer cost than median sternotomy for bilateral LVRS.
