VOLUME REDUCTION SURGERY

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VOLUME REDUCTION SURGERY
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Emphysema

• Emphysema is a chronic lung disease characterized
  by large bullae in the lung tissue
• Bullae develop as a result of smoking, air
  pollution, work environment, or lung infections
• The structure/function of the lung is altered
  causing them to lose their elasticity
• Over time, the muscles and ribs surrounding the
  lungs are stretched to accommodate the expanding
  lungsthe diaphragm flattens and loses its
  effectiveness
• Dyspnea develops and increases over time as the
  overdistension worsens and the effort required
  for each individual breath increases

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How LVRS works

• Removing large space-occupying bullae in patients
  with COPD may significantly reduce the symptoms
  of dyspnea and improve the persons exercise
  tolerance
• Its indicated in patients with incapacitating
  dyspnea who have compression of normal lung
  tissue by these large bullae

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History

• In the 1950s, Dr. Otto Brantigan performed LVRS
  thinking that overdistension decreases the
  circumferential pull on airways
• He thought decreasing the lung volume would
  restore the outward pull on the airways so they
  would stay more patent
• He performed multiple operations and had clinical
  improvement, but the procedure didnt become well
  accepted due to a fairly high mortality rate
  (16)
• His work was discovered about 15 years ago by
  Dr. Cooper

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Patient Selection Criteria

• FEV 1 lt35 predicted
• lt70 years old
• Willingness to accept 5 mortality rate
• Unacceptable dyspnea with optimal medical therapy
• Acceptable nutritional status
• Prednisone dependence lt10 mg/daily

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Exclusion Criteria

• Significant bronchitis/asthma
• Kyphosis
• Prior thoracotomy/pleurodesis
• Pulmonary artery hypertension
• PaCO2 gt60 mm Hg
• Significant co-morbidity (eg-CAD)
• Ongoing tobacco use

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Techniques

• Surgery takes 4 hours
• Thoracotomy/Median Sternotomy
• Use thoracic epidural anesthetic
• Patient intubated with a double lumen ETT
• One lung is non-ventilated, the other is
  ventilated
• Worst lung is done first
• The healthy part of the non-ventilated lung will
  deflate by absoprtion atelectasis the bullae
  remain inflated due to poor blood flow to them
• Distended sections are cut out
• The ends are stapled together with bovine
  pericardium to hold them together and reduce air
  leaks
• The lung is re-inflated to check that enough
  volume was reduced (try for 30)
• Deflate the other lung and do the same procedure
  to it
• 2 chest tubes are placed in each side
• Patient is extubated at the end of the procedure

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Techniques

• Laser
• Unilateral lung ventilation is donethe lung not
  being worked on is ventilated
• The lung being operated on is connected to CPAP
  at 1-5 cm H2O
• A contact laser probe is moved over the bullae,
  kind-of like ironing a shirt
• The lung is then manually inflated to make sure
  you got it all

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Techniques

• Thoracoscopic laser bullectomy (Dr. Wakabayashis
  technique)
• General anesthesia is used with unilateral
  ventilationthe lung not being worked on is
  ventilated
• A unilateral thoracoscopy is done
• Small bullae are ironed out with a laser
• Large bullae are opened and resected
• Its a combination of the previous 2 procedures

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Results

• Few deathsmortality is 4-10
• Some air leaks
• Increased FEV1 (by as much as 82)
• Most patients extubated within a day
• No significant effect on PaO2 or PaCO2
• Decreased RV/TLC (means less overdistension)
• Decreased dyspnea
• Increased quality of life
• Reduction of steroid dependence
• Wean totally off oxygen or reduced need for O2