Combined Thoracoscopic Surgical Stapling and Endobronchial Valve Placement For Lung Volume Reduction With Incomplete Lobar Fissures

Abstract

Background: In patients with severe emphysema and complete fissures, bronchoscopic lung volume reduction with valves reduces target lobe volume providing improvement in respiratory symptoms, lung function, quality of life, and exercise capacity. It is estimated that up to 88% of patients with emphysema have at least 1 incomplete interlobar fissure. The aim of this study was to evaluate the feasibility of creating a complete fissure with stapling via minimally invasive video-assisted thoracoscopic surgery (VATS) followed by bronchoscopic valve placement to induce lobar collapse in a swine model. Methods: Chest computed tomography (CT) scans were performed on 2 swine and at least 1 target incomplete fissure was identified. Both swine underwent VATS to complete the target fissure using a surgical stapler, followed by bronchoscopic placement of the Spiration endobronchial valves. A chest CT scan was performed immediately postprocedure. Follow-up bronchoscopy and CT scans were performed 2 weeks after the initial procedure prior to sacrifice. Results: Successful fissure completion was accomplished using VATS and confirmed at postmortem explanted lung gross examination. Flexible bronchoscopy 2 weeks following valve placement showed proper positioning of the valves. Effectiveness of combined procedures was confirmed by a chest CT scan that showed complete atelectasis of the target lobe at 2-week follow-up. There was no perioperative or postoperative morbidity or mortality. Conclusion: Combined minimally invasive VATS fissure stapling with bronchoscopic valve placement to induce lobar atelectasis appears safe and feasible in the swine model. Future research in humans using a combined procedure is needed to confirm safety and clinical efficacy.

Thoracoscopic Surgical Stapling as Salvage Therapy for Failed Endobronchial Valve Treatment in Patients With Incomplete Lobar Fissures

“…In the future, we believe a combined approach VATS and EBVs may help expand the number of patients who could benefit from BLVR with EBVs by increasing the number of patients with complete or near-complete interlobar fissures as recently shown in a proof-of-concept animal study done by our group9 and as a salvage therapy for those patients who did not respond to BLVR with EBVs either because of pleural adhesions or incomplete fissures.…”

Determinants of Lung Fissure Completeness

“…Currently, several studies are already ongoing that investigate the possibility of closing fissure gaps to prevent collateral ventilation by applying a polymer sealant (NCT04256408 and NCT04559464) (25). In addition, in swine, an experiment was successful to eliminate collateral ventilation by surgical stapling incomplete fissures (26).…”

Complementary Applications of Video-assisted Thoracic Surgery and Endobronchial Valves

“…For example, for emphysema patients with collateral ventilation who are not candidates or who failed to respond to treatment, completion of the interlobar fissure via VATS may enable effective BLVR therapy as recently shown in an animal model. 8 Through coordinated efforts between interventional pulmonologists and thoracic surgeons, the various interfaces between VATS procedures and BLVR not accounted for in existing guidelines and evidence will continue to evolve. Dear Editor, we appreciate the comments on our recent publication, "Flexible bedside bronchoscopy using closed sheath system devised from ultrasound probe cover for use in SARS-CoV-2 patients.…”

“…In the future, we believe a combined approach of VATS and EBV may help expand the use of BLVR. For example, for emphysema patients with collateral ventilation who are not candidates or who failed to respond to treatment, completion of the interlobar fissure via VATS may enable effective BLVR therapy as recently shown in an animal model 8…”