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Surgery has been proven to be beneficial for selected patients with severe emphysema. Compared with medical management, lung volume reduction surgery (LVRS) significantly improves pulmonary function, exercise tolerance, quality of life, and even survival for selected patients.
This article will describe the technique for LVRS by VATS.
Indications for LVRS
The indications for LVRS are the same, whether the procedure is performed with VATS or a median sternotomy. Candidates have severe emphysema and are symptomatic despite maximal medical management. Maximal medical management includes medicines, inhalers, steroids, oxygen, and pulmonary rehabilitation. These patients have difficulties with simple activities of daily living, such as taking a shower, doing household chores, bending, and carrying anything. They can walk only short distances. If oxygen saturations regularly drop below 90%, randomized trials have shown that oxygen therapy prolongs survival. Pulmonary function tests for candidates include the following: forced expiratory volume 1 < 45% predicted, mean total lung capacity = 140% predicted, and mean residual volume = 250% predicted. Rehabilitation does improve quality of life, lead to better exercise tolerance, and reduce hospitalizations, but it does not impact survival, does not improve pulmonary function, and really provides only minor benefit. Therefore, there is a need for either better medical treatment or an operation to improve the plight of the patient with severe emphysema.
The most important selection factor for LVRS is the presence of a heterogeneous pattern of emphysema. Only about 20% of patients with severe emphysema have a heterogeneous pattern of emphysema. The basic concept behind LVRS is resection of nonfunctional areas of lung to allow the better areas work more effectively. Patients usually have severe destruction of the parenchyma in the upper lobes bilaterally. Patients with severe destruction in the lower lobes (related both to smoking and to alpha-1 antitrypsin deficiency) are potentially candidates. There is little evidence that LVRS benefits patients with a homogeneous pattern of emphysema.
Position of the Patient
Although a few surgeons place the patient supine for VATS LVRS, most surgeons perform the procedure with the patient in the lateral decubitus position. This means two separate preps, but this allows the best exposure for the procedure. Repeated episodes of bronchitis and pneumonia may lead to pleural adhesions. If these adhesions are located posteriorly, lysis of those adhesions is performed better and more safely from a lateral approach.
VATS LVRS is usually a bilateral staple procedure that is performed under general anesthesia utilizing selective lung ventilation. As soon as the patient is placed in the lateral decubitus position, one-lung ventilation is instituted because the poor elastic recoil of emphysematous lung causes it to decompress very slowly. Target areas for resection often remain expanded, whereas the better areas become atelectatic. Bronchoscopy with suctioning through the double lumen endotracheal tube helps to collapse the lung for LVRS.
LVRS: Sternotomy or VATS?
Most surgeons perform LVRS by a median sternotomy because they are more comfortable with that approach. The NETT, a randomized prospective trial comparing medical management with and without LVRS, showed that LVRS provided better pulmonary function, exercise tolerance, quality of life, and survival for properly selected patients. A substudy of the NETT compared LVRS by VATS versus median sternotomy. The two approaches showed comparable morbidity, mortality (4% for VATS and 4.6% for median sternotomy, P = 1.0), and functional improvement. The length of stay (median, nine for MS and eight for VATS, P = 0.001), costs of hospital care and also all medical care for 6 months following LVRS, and return to independent activities favor the VATS approach.
LVRS has been shown to provide benefit over medical management whether it is performed with a median sternotomy or VATS. Although the functional benefits are the same for the two approaches, the VATS approach does offer some advantages that are statistically significant.
The National Emphysema Treatment Trial Research Group
Effects of lung volume reduction surgery versus medical therapy: results from the National Emphysema Treatment Trial.