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ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery 52 (2017) 982–988
doi:10.1093/ejcts/ezx242 Advance Access publication 31 July 2017
Cite this article as: Perikleous P, Sharkey A, Oey I, Bilancia R, Tenconi S, Rathinam S et al. Long-term survival and symptomatic relief in lower lobe
lung volume reduction surgery. Eur J Cardiothorac Surg 2017;52:982–8.
Long-term survival and symptomatic relief in lower lobe
lung volume reduction surgery†
Periklis Perikleous, Annabel Sharkey, Inger Oey, Rocco Bilancia, Sara Tenconi,
Sridhar Rathinam and David A. Waller*
Department of Thoracic Surgery, Glenfield Hospital, University Hospitals of Leicester, Leicester, UK
* Corresponding author. Department of Thoracic Surgery, Glenfield Hospital, University Hospitals of Leicester, Groby Road, Leicester LE3 9QP, UK.
Tel: +44-116-2563959; e-mail: waller.david13@googlemail.com (D.A. Waller).
Received 29 November 2016; received in revised form 12 March 2017; accepted 30 March 2017
Abstract
OBJECTIVES: Lung volume reduction surgery (LVRS) has been demonstrated to provide symptomatic relief and improve lung function in
patients with end-stage emphysema. The National Emphysema Treatment Trial specifically noted functional benefits in patients with predominantly upper lobe emphysema and demonstrated improvement in quality-of-life parameters, in patients with non-upper lobe emphysema and a low-baseline exercise capacity. We aimed to investigate whether physiological and health status benefits correlated with
lower lobe LVRS.
METHODS: A retrospective analysis was performed from our prospectively collected patient database. A total of 36 patients with severe,
non-upper lobe predominant emphysema underwent lower lobe LVRS in our institution, over a 20-year period. The assessments consisted
of measurements of body mass index, pulmonary function tests and health-related quality of life using the Short Form 36-item
questionnaires.
RESULTS: Forced expiratory volume in 1 s was seen to improve 3 months [coefficient of time = 1.55 (0.88, 2.21); P < 0.0001] after the procedure, maintained until the first 6 months [0.48 (0.12, 0.85); P = 0.010], decline over the second half of the first year and gradually return
to preoperative levels after 2 years, while residual volume to total lung capacity (%) ratio was seen to follow a similar pattern with significant decrease from baseline after 3 months [coefficient of time = -1.76 (-2.75, -0.76); P = 0.001] and 6 months [-1.05 (-1.51, -0.59);
P < 0.0001]. Quality-of-life improvements were mainly noted in physical components.
CONCLUSIONS: Contrary to a widely held misconception following the National Emphysema Treatment Trial that lower lobe lung volume
reduction does not offer significant benefits to patients with non-upper lobe predominant emphysema, we feel justified in offering lower
lobe LVRS in these patients when they meet the same selection criteria as upper lobe LVRS.
Keywords: Lung volume reduction surgery • Emphysema • Lower lobe • LVRS • Thoracic surgery • NETT
INTRODUCTION
The National Emphysema Treatment Trial (NETT) showed that
lung volume reduction surgery (LVRS) provides symptomatic relief and improved lung function in patients with end-stage emphysema. More specifically, it demonstrated that LVRS offers an
overall increase in the chance of improved exercise capacity but
does not confer a survival advantage over medical therapy, except for patients with both predominantly upper lobe emphysema and low-baseline exercise capacity. Patients previously
reported to be at high risk and patients with non-upper lobe emphysema and high-baseline exercise capacity were regarded as
†Presented at the 24th Annual Meeting of the European Conference on
General Thoracic Surgery, Naples, Italy, 29 May–1 June 2016.
poor surgical candidates because of increased mortality and negligible functional gain [1].
Because maximal benefits were found in patients with predominantly upper lobe emphysema and low-baseline exercise
capacity, whereas the non-upper predominant group sustained
increased mortality and trifle results, many pulmonologists, as
well as thoracic surgeons, falsely presumed that lower lobe LVRS
was not indicated for all patients. The goal of our study was to
challenge this misconception.
The NETT remains to this time the largest and most complete
collection of patient demographics, clinical, physiological and
radiographic data ever compiled in severe emphysema.
However, great progress has been made in the constantly evolving field of LVRS since the outcomes of the NETT were published
in 2003. Subsequent reports highlighted the importance of examining the overall pathogenesis of emphysema and its response to
C The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
V
P. Perikleous et al. / European Journal of Cardio-Thoracic Surgery
METHODS
Data collection
A retrospective analysis was performed from a prospectively
populated patient database, operative logbooks and patients’
medical records.
The assessments consisted of measurements of body mass
index, pulmonary function tests (PFTs) and health-related quality
of life using the Short Form 36-item questionnaires (SF-36), over
3-, 6-, 12- and 24-month time intervals.
Patient population
We identified 40 lower lobe LVRS procedures performed on 36
individual patients [22 male (61.11%)] with severe, non-upper
lobe predominant emphysema, from a grand total of 382 LVRS
procedures performed in our institution over a 20-year period
(1996–2016). Four patients had undergone staged bilateral lower
lobe procedures, and we only considered their first procedure in
our analysis.
Alpha1-antitrypsin deficiency (a1-AD) was diagnosed in 14
(38.89%) patients. Only 1 patient (who was confirmed to be a1-antitrypsin deficient) of the 36 patients had not previously smoked.
All patients underwent physical examination, basic spirometry,
plethysmography, arterial blood gas analysis, chest radiography,
computed tomography and quantitative radionuclide perfusion
scintigraphy.
For 33 patients (91.67%), unilateral LVRS was performed via
video-assisted thoracoscopic surgery (VATS), guided by target
areas on the quantitative perfusion scan. For 2 (5.56%) patients,
median sternotomy and bilateral lower lobe reduction were performed (1996 and 1998). For 1 patient (2.78%), VATS had to be
converted to open thoracotomy to allow lung mobilization because of extensive adhesions.
All operations were performed by 1 of 3 surgeons (D.A.W., S.R.
and T.J.S.) in the same hospital. All preoperative investigations,
operative procedures and postoperative follow-up were paid for
by the National Health Service.
Patient selection criteria
Patients in our institution are offered LVRS following discussion
at a dedicated multidisciplinary team (MDT) meeting consisting
of a team of thoracic surgeons, pulmonologists and radiologists.
Patients with emphysema are considered for LVRS if they are
symptomatic with breathlessness, despite optimized medical management, including pulmonary rehabilitation. Our inclusion criteria
comprises patients with evidence of obstructive disease [forced
expiratory volume in 1 s (FEV1) <40% predicted] and hyperinflation
[residual volume to total lung capacity ratio >55%]. Also, for patients to be offered surgical management, a carbon monoxide diffusing capacity >20% is required (a carbon monoxide diffusing
capacity of <20% is not considered an absolute contraindication,
patients can be considered for LVRS if FEV1 > 20% predicted; written informed consent is obtained for high-risk patients), as well as
clear target areas on both high-resolution computed tomography
and perfusion scintigraphy. Our exclusion criteria consist of pulmonary hypertension (mean pulmonary arterial pressure
>40 mmHg) and hypercapnia with partial pressure of carbon dioxide >7 kPa. Patients who are excluded continue to receive medical
management or are referred for lung transplant as appropriate.
We have summarized our MDT approach in a retrospective
analysis of prospectively collected data on 633 patients referred
for LVRS between July 1995 and July 2013 [9]. Of those, 382 did
not proceed to surgery for a variety of reasons including absence
of target areas for resection on a quantitative perfusion scan, patients were deemed to be ‘too good’ (either by the MDT because
their pulmonary function did not show severe enough airway obstruction and/or hyperinflation or because the patients felt they
were too good to consider surgery at this stage), respiratory failure
(hypercapnia and/or pulmonary hypertension), previous thoracic
surgery or other associated respiratory conditions (frequent exacerbations, bronchiectasis or lung fibrosis). Sixteen patients
whom the MDT did not consider to be suitable for an intervention
during the time they were first discussed were rediscussed on follow-up meetings and offered surgery when deemed appropriate.
Before surgery, patients are required to quit smoking for a
period of at least 6 months and are encouraged to attend a pulmonary rehabilitation programme following which they would
be expected to successfully complete a shuttle walk test at 150 m
or more. We do not routinely perform shuttle walk tests during
our postoperative follow-ups due to limited resources. Patients
who are reassessed for staged bilateral procedures undertake a
shuttle walk test as part of their preoperative workup.
Prior to surgery, but after rehabilitation, patients were asked to
complete SF-36 health status questionnaires. The SF-36 is a generic
health status questionnaire, in which 36 questions cover 8 health
domains: physical functioning, social functioning, role limitations
due to physical problems, role limitations due to emotional problems, mental health, energy/vitality, pain and general health status.
For each domain, scores are transformed to range from 0 (worst
possible health status) to 100 (best possible health status) [10].
Surgical approach
At the start of our LVRS programme, operations were performed
bilaterally via median sternotomy or VATS. Throughout the years,
THORACIC
medical therapy, identified specific risk factors that can attribute
to increased mortality, and underlined the potential negative
consequences of malnutrition and oxygen desaturation [2].
Updated data proved LVRS to be long-term more cost–effective,
compared with medical therapy, and emphasized on alternative
approaches for LVRS that are less invasive and could be offered
as an alternative treatment to patients unfit for surgical intervention [3].
A valuable lesson that was learned from NETT is that LVRS can
be a safe and an effective disease-modifying therapy for a large
group of carefully selected patients suffering from severe emphysema [4]. Computed tomographic measurements [5] and perfusion scintigraphy [6] can provide significant information towards
selection of patients that would be expected to benefit the most
out of LVRS, with regard to anatomical disease distribution. Even
though the benefits for patients with non-upper lobe predominant emphysema are more modest and short lived, compared
with the ones with upper lobe predominant disease [6], there is
still a statistically significant improvement in their functional
measurements as well as their quality of life, which can further be
extended by a staged bilateral approach to LVRS, dictated by patients’ perception of their condition [7, 8].
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P. Perikleous et al. / European Journal of Cardio-Thoracic Surgery
984
our surgical techniques have been revised and optimized to improve postoperative respiratory mechanics, minimize complication rates and reduce hospital stay. Currently, all LVRS
procedures performed in our centre are executed via a unilateral
VATS approach with 2–3 ports and all our patients are offered
epidural analgesia prior to anaesthetic induction to aid with
mobilization and expectoration of secretions postoperatively.
The epidural infusion contains fentanyl 5 mcg ml with bupivacaine 0.1% in 250 ml 0.9% saline. Patients are discharged home
on oral analgesia as appropriate.
Patients included in this study at earliest stages had stapled resection of functionless areas of lung using buttresses (Peri Strips,
Synovis Life Technologies Inc., St Paul, MN, USA; Gore Seamguard,
WL Gore and Associates Inc., Flagstaff, AZ, USA; Peristrips Dry,
Veritas, Synovis Life Technologies Inc.; or BiodesignV Staple Line
Reinforcement, Cook Medical, Bloomington, IN, USA). Most recently, we have adopted another technique to provide better aerostasis to prevent and reduce the occurrence and duration of
postoperative air leaks, in which TissuePatchTM (Tissuemed Surgical
Technologies, UK), a synthetic, self-adhesive film with a multilayer
structure is applied at the staple lines for reinforcement [11].
BioGlueV Surgical Adhesive (CryoLife Inc., Kennesaw, GA, USA) has
also been used according to individual surgeon preference.
Lung volume is reduced via non-anatomical stapled resection
of the emphysematous and poorly perfused areas of the lobes, as
previously identified by imaging. The number of firings used to
complete the operation and the weight of the resected tissue are
documented in the patient’s operative notes. Most patients had
approximately 40% resected (50–80 g) from their lower lobes.
Lower lobe LVRS can be technically more challenging compared
with the upper lobes, as there are no clear anatomical marks to
follow while attempting to remodel the lung. In some patients,
lung tissue from other areas of the lung had been resected (bullectomy), guided by intraoperative appearances of the lung.
At the end of the procedure, 1 or 2 drains are positioned to
the chest cavity and remain connected to Rocket under water
seal bottles (Rocket Medical, UK) or Thopaz digital drainage system (Medela, Switzerland). Following their operation, patients are
extubated in theatres and transferred to a high-dependency unit.
Suction -2 kPa on Thopaz digital drainage system or -5 kPa
wall suction for Rocket under water seal bottles is applied only if
there is significant lung collapse on the postoperative chest films.
Significant surgical emphysema is further managed by insertion
of a subcutaneous drain [12].
R
R
Postoperative follow-up
Patients with prolonged air leaks can be discharged home with
their drains connected to Heimlich valve bags (Portex Ltd, Hythe,
UK) and are regularly reviewed in clinics, until the air leak resolves and then the drain is removed.
All patients are routinely reviewed in outpatient clinics at 3, 6,
12 months and then yearly after their surgery. At each visit, patients undergo detailed spirometry and plethysmography. They
also complete SF-36 health status questionnaires.
Statistical analysis
Categorical data are represented as number (percentage), while
numerical variables are represented as mean (95% confidence
interval). Generalized linear models were used to estimate the
effect of time on the various variables considering that repeated
measures were made. For each model, the baseline value and
time were included as covariates, and the coefficient of time with
its 95% confidence intervals was reported as effect of time on
each of the variables. Several models were generated, e.g. from 0
to 3 months and 0 to 6 months. To correct for multiple comparison, a pragmatic decision was made to set the significance level
at 0.01 for each model.
Survival data were analysed using the Kaplan–Meier method.
Statistical analyses were performed with the use of IBM SPSS
Statistics for Windows (version 23.0, IBM Corp. Released 2016;
IBM Corp., Armonk, NY, USA).
RESULTS
Thirty-six patients [22 male (61.11%)] with a mean age of 59 years
underwent a total of 40 procedures (4 second stage) between
1996 and 2016. For the patients with staged procedures, only the
first intervention was considered for data analysis. Of the 36 patients, a1-AD was confirmed in 14 (38.89%) patients.
Baseline mean values are presented in Table 1.
Median follow-up was 9.5 years.
There were significant changes in FEV1 from baseline to
3 months and from baseline to 6 months. The results suggest that
between 0 and 3 months, for every unit increase in time on the
average, the FEV1 increased by 1.55% and the corresponding result for 0–6 months was 0.48% for a unit increase in time
(Table 2, Fig. 1).
There were also significant changes in the residual volume to
total lung capacity ratio from baseline to 3 months and from
baseline to 6 months. The results suggest that between 0 and
3 months, for every unit increase in time on the average, the residual volume to total lung capacity ratio decreased by 1.76 and
the corresponding result for 0–6 months was 1.05 for a unit increase in time (Table 2, Fig. 2).
No statistically significant changes were observed in measurements of body mass index or the a1-AD group.
Quality-of-life improvements were mainly noted in physical components. There was sustained improvement in physical function and
brief improvement in general health perceptions and role limitations
Table 1:
Baseline characteristics
Variables
n
Mean (95% CI)
FEV1 (%)
RV/TLC (%)
FVC (%)
DLCO (%)
BMI (kg/m2)
Physical functioning
Bodily pain
Physical role functioning
General health perceptions
Vitality
Social role functioning
Emotional role functioning
Mental health
34
33
34
34
30
26
26
26
26
26
26
26
26
27.9 (24.8 to 30.9)
68.0 (64.7 to 71.2)
62.7 (55.9 to 69.5)
40.2 (35.6 to 44.8)
22.8 (21.6 to 23.8)
20.1 (13.3 to 26.8)
70.9 (60.9 to 81.0)
15.4 (5.1 to 25.7)
26.5 (20.9 to 32.0)
30.2 (22.6 to 37.8)
42.3 (31.8 to 52.8)
57.7 (38.4 to 76.9)
63.8 (56.4 to 71.3)
FEV: forced expiratory volume in 1 s; RV: residual volume; TLC: total
lung capacity; FVC: forced vital capacity; DLCO: carbon monoxide diffusing capacity; BMI: body mass index; CI: confidence interval.
P. Perikleous et al. / European Journal of Cardio-Thoracic Surgery
985
Table 2: Results overview: change in parameters over time (using time as covariate in model)
Variables
Period (months)
FEV1
Physical component
Mental component
Short Form-36 quality-of-life questionnaire
RV/TLC
Physical functioning
Bodily pain
Physical role functioning
General health perceptions
Vitality
Social role functioning
Emotional role functioning
Mental health
0–3
0–6
0–12
0–24
1.55 (0.88 to 2.21)
0.0001
-1.76 (-2.75 to -0.76)
0.001
4.98 (2.52 to 7.44)
<0.0001
-8.87 (-9.51 to -4.22)
<0.0001
6.69 (2.03 to 11.35)
0.005
3.19 (0.86 to 5.53)
0.007
5.73 (3.56 to 7.90)
<0.0001
6.05 (1.52 to 10.58)
0.009
0.53 (-6.27 to 7.33)
0.88
0.99 (-1.78 to 3.77)
0.48
0.48 (0.12 to 0.85)
0.010
-1.05 (-1.51 to -0.59)
< 0.0001
1.55 (0.10 to 3.01)
0.036
-2.67 (-4.32 to -1.01)
0.002
1.38 (-1.35 to 4.12)
0.32
0.72 (-0.62 to 2.07)
0.29
1.93 (0.53 to 3.33)
0.007
2.15 (-0.44 to 4.73)
0.10
-1.09 (-5.15 to 2.97)
0.60
1.24 (-0.23 to 2.71)
0.097
0.05 (-0.16 to 0.25)
0.66
-0.31 (-0.56 to -0.06)
0.013
0.89 (0.29 to 1.57)
0.010
-0.92 (-4.32 to -1.01)
0.002
0.003 (-1.30 to 1.30)
0.99
0.19 (-0.62 to 1.00)
0.64
0.36 (-0.35 to 1.07)
0.33
0.96 (-0.22 to 2.14)
0.11
-0.15 (-2.08 to 1.78)
0.88
0.49 (-0.20 to 1.18)
0.16
-0.06 (-0.17 to 0.05)
0.30
-0.04 (-0.18 to 0.09)
0.54
Coeff. time (95% CI)
P-value
Coeff. time (95% CI)
P-value
Coeff. time (95% CI)
P-value
Coeff. time (95% CI)
P-value
Coefficient time (95% CI)
P-value
Coeff. time (95% CI)
P-value
Coeff. time (95% CI)
P-value
Coeff. time (95% CI)
P-value
Coeff. time (95% CI)
P-value
Coeff. time (95% CI)
P-value
THORACIC
FEV1: forced expiratory volume in 1 s; RV: residual volume; TLC: total lung capacity; Coeff. time: coefficient of time; CI: confidence interval.
Figure 1: FEV1 improved significantly over a period of 6 months and returned
to preoperative levels 2 years postoperatively. FEV1: forced expiratory volume
in 1 s.
Figure 2: RV/TLC decreased significantly over a period of 6 months and returned to preoperative levels 2 years postoperatively. RV: residual volume; TLC:
total lung capacity.
due to physical health. Pain was, as expected, worse following the
operation and that was sustained for 1 year after the operation
(Table 2, Fig. 3).
No changes have been evidenced in mental health or role
limitations due to emotional problems. Social functioning despite
a brief improvement remained practically unchanged while vitality remained improved for a period of 6 months, before returning
to preoperative levels at the end of the first year (Table 2, Fig. 4).
Overall, median survival was calculated at 5 years (60 months),
while 2 patients died within the first 90 days following their operation (mortality: 90 days, 5.6%; 1 year, 8.3%; 2 years, 11.4%;
5 years, 52.9%) (Fig. 5). Of these 2 patients, 1 patient who underwent LVRS via a median sternotomy in 1996, was transferred to
intensive care immediately after the procedure and remained
there until the time of death 5 days later. The other patient had
undergone LVRS via a unilateral VATS procedure in 2007 and
was discharged home with a drain in situ due to prolonged air
leak. While at home, the patient suffered a cardiac arrest and
died 20 days after the procedure while an inpatient at the local
hospital.
Overall mortality in our series of all LVRS patients is estimated
to be 4.2% at 30 days, 8.9% at 90 days and 12% at 1 year. On
multivariate analysis, we have found that factors associated independently with death are body mass index of <18.5 kg/m2, FEV1
of <0.71 l and carbon monoxide diffusing capacity of <20%.
There was no association between site of lung resection and
mortality. For our preoperative assessment, we have implemented a perioperative risk score, ‘The Glenfield BFG score’, according to which we inform patients at higher risk for surgery
during their consultation in clinics [13].
DISCUSSION
Lung hyperinflation impairs chest wall and respiratory muscle mechanics, increases breathlessness, decreases exercise performance and
increases mortality, while it may also have important negative consequences to cardiac performance [2]. LVRS better matches the size
of the lungs to the size of the thorax containing them, thus restoring
forced expiratory volumes and the mechanical advantage of the
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P. Perikleous et al. / European Journal of Cardio-Thoracic Surgery
Figure 3: Physical component: sustained improvement in physical functioning with brief improvement in general health perception and physical role. Worse pain
following the operation which was sustained.
Figure 4: Mental component: improvement in vitality was sustained for 6 months following the procedure but returned to baseline levels after the end of the first
year. Social role function improved only briefly, and no changes were observed in mental health and role emotional components.
inspiratory muscles. In patients with heterogeneous emphysema,
LVRS may also allow space occupied by air cysts to be reclaimed by
more normal lung [14]. In patients with a good target area (functionless lung) and evident hyperinflation with preserved diffusion capacity, we would expect to see a benefit regardless of which part of
lung is resected, as the remodelling of the lung alone should improve the mechanics of breathing and lower the burden that the
diseased lung puts on the right ventricular function.
The purpose of our study was to emphasize that patients with
lower lobe predominant emphysema should not be excluded
Figure 5: Kaplan–Meier survival estimate.
from consideration of LVRS based on the results of the NETT.
Even though the success of the trial is undisputed when it comes
to identifying groups of patients that would have the most benefit or be at unnecessary risk from a volume reduction operation,
for patients with lower lobe predominant disease there is, undeniably, a grey area. These patients should be appropriately
referred by their physicians to dedicated MDT meetings where
their cases will be individually assessed.
The way NETT was designed does not allow safe conclusions
to be drawn for the management of lower lobe emphysema. For
the purposes of analysis, the distribution of emphysema was
radiologically classified as predominantly affecting the upper
lobes, predominantly affecting the lower lobes, diffuse or predominantly affecting the superior segments of the lower lobes,
and all 3 latter categories were grouped together as predominantly non-upper lobe emphysema. A ratio of perfusion in the
upper lung regions to that in the lower regions was quantified
based on radionuclide scans; the results, however, were not interpreted in a uniform way but separately at each centre [15]. A post
hoc analysis of the trial, which was performed to determine
whether lung perfusion could predict response to LVRS in patients who had complete scintigraphy results at baseline, showed
that in patients with non-upper lobe predominant emphysema,
measurement of upper zone perfusion did not provide any prognostic information [6].
In our department, only 10% of patients who underwent LVRS
had non-upper lobe surgery. Comparing patients who have
undergone upper lobe to lower lobe LVRS has been outside of the
scope of our study. We do not believe that a direct comparison
between upper and lower lobe LVRS patients will result to safe
conclusions as to who should have surgery and who should not.
The NETT and subsequent studies have shown that there are other
disorders that contribute to emphysema [16], among them a1-AD,
which has been found to affect primarily the lower lobes [17].
Apart from the NETT, not many studies have addressed lower
lobe LVRS. In our study, 39% of patients had a1-AD, and there was
no statistically significant difference between them and the nona1-AD-deficient group. It has been suggested that physiological
changes observed in patients with a1-AD having undergone lower
lobe LVRS could be attributed to increased lung elastic recoil [18].
A study by Tutic et al. [19] showed that LVRS in patients with
advanced emphysema related to a1-AD resulted in a significant
improvement in dyspnoea and lung function as long as 3.5 years;
however, the magnitude and duration of these effects are inferior
and shorter than those in patients with pure smoker’s emphysema.
Further study of individuals who had long-term benefits showed a
987
clear heterogeneity of the destruction of the lung with wellpreserved lung beside a largely destroyed lung as well as minimal
signs of chronic inflammatory airway disease. Stoller et al. [20]
highlighted trends of lower magnitude and duration of FEV1 rise
after surgery in a1-AD versus a1-antitrypsin-replete subjects and
higher mortality in deficient individuals, suggesting caution in recommending LVRS in a1-AD. Several other studies noted benefits
from LVRS regardless of different morphologic types. Hamacher
et al. [21] showed maintained functional and subjective improvements for at least 24 months after LVRS in patients with heterogeneous or homogeneous emphysema types .
With the advancement of alternative approaches for lung volume reduction [22, 23], data show that patients with lower lobe
disease could have comparable benefits without the need to
undergo surgery [24], which can be technically challenging, as resection typically requires shaving of the ‘bottom of the pyramid’.
In a minority of cases, where most of the lower lobe is nonfunctional, a lower lobectomy may be considered; however, the
same result could potentially be achieved by an endobronchial
approach. The relative risks and benefits of LVRS and bronchoscopic lung volume reduction are yet to be prospectively compared, but there is no current evidence to consider one modality
and not the other. Specific algorithms consider bronchoscopic
lung volume reduction to be the treatment of choice for lower
lobe predominant emphysema; however, LVRS should not be
ruled out in this context [25]. It should also be noted that for
endobronchial volume reduction to be successful, patients will
need to have intact fissures; LVRS currently remains the intervention of choice for those with collateral ventilation.
We believe that LVRS for patients with non-upper lobe disease
is justified in a carefully selected population, who fulfil the same
remaining criteria as the ones with upper lobe disease. It can result in reduced morbidity with evident physiological benefits. The
advancement of minimally invasive procedures as well as the
concept of staged bilateral procedures will act accumulatively in
offering symptomatic relief and improvement to quality of life of
these patients, by ‘resetting the time’ in the natural progression of
their disease. Unfortunately, there may not be sufficient patients
with lower lobe predominant emphysema who meet the
required selection criteria for a prospective randomized comparison, either with medical therapy or with endobronchial methods.
Limitations
The limitations of this study are its non-randomized, retrospective nature, the heterogeneity of its population and of the surgical
procedures performed, the effect of the learning curve, the relatively small number of patients with lower lobe LVRS and the
non-appearance of a control group to compare the natural
course of best medical treatment.
CONCLUSIONS
Contrary to widely held misconception following the NETT that
lower lobe lung volume reduction does not offer significant
benefits to patients with non-upper lobe predominant emphysema, we feel justified in offering LVRS in patients meeting standard selection criteria with non-upper lobe predominant disease.
Our results suggest that lower lobe LVRS results in evident
physiological and functional improvements.
THORACIC
P. Perikleous et al. / European Journal of Cardio-Thoracic Surgery
988
P. Perikleous et al. / European Journal of Cardio-Thoracic Surgery
Patients should be considered on an individual case-by-case
basis for lower lobe LVRS, especially if they have heterogeneous
disease with a clear target area and are significantly hyperinflated. The principle is to remove as much non-functioning lung
as possible to restore chest wall mechanics.
[13]
[14]
ACKNOWLEDGEMENTS
The initial few cases were performed by Tomasz J. Spyt who has
retired from National Health Service practice.
[15]
[16]
Funding
[17]
This research received no specific grant; all preoperative investigations, operative procedures and postoperative follow-up were
paid for by the National Health Service.
[18]
[19]
[20]
Conflict of interest: none declared.
[21]
REFERENCES
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[3] Criner GJ, Cordova F, Sternberg AL, Martinez FJ. The National
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APPENDIX. CONFERENCE DISCUSSION
Dr I. Polyakov (Krasnodar, Russian Federation): It is interesting for me, because the
author used this technique to remove the affected zone in the lower lobe. For
me it is not clear why I should remove the targeted zone in the upper lobe if it is
not affected by disease.
Dr Perikleous: I am not sure I understand the question. It had to do with the
lower lobes entirely.
Dr Polyakov: Yes, just remove the targeted zone in the lower lobe, but nobody can force me to remove the upper lobe if it is not affected by disease.
Dr Perikleous: Yes, of course.
Dr Polyakov: But in general, do you prefer removing the targeted zone from
the upper lobe or the lower lobe in your practice?
Dr Perikleous: We are talking about patients with non-upper lobe predominant disease. So the upper lobe is in better condition and that is why we go for
the lower lobes.
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