Functional Surgery of Bullous Emphysema

Abstract

Multiple large and small emphysematous bullae were resected in 27 patients with chronic obstructive lung disease (COLD). Twenty-two patients were operated on one side, and 5 patients underwent bilateral consecutive operations. Twenty-five patients were male, 2 female, and they were between 22 and 67 years old (mean 49.5 years). All patients had a follow-up examination between 3 and 48 months postoperatively. As operative techniques, resection by means of a clamp, plication of cysts according to Nissen, resection with homologous dura plasty (7 patients) and pericardial plasty (7 patients) were used. In 19 patients preoperative and postoperative pulmonary function was compared. Functional improvement occurred in 17 patients - including all of the 5 bilateral procedures. Postoperative improvement was more pronounced with decreasing preoperative pulmonary function, measured as VC, RV, IGV and Raw. Partial pulmonary insufficiency could be improved in 9 patients and global pulmonary insufficiency was improved in 5. In 16 cases physical work capacity was increased. The hemodynamics of the pulmonary circulation were improved in all patients with increased preoperative pulmonary artery pressure (latent pulmonary hypertension in 7 patients, overt pulmonary hypertension in 5). FEV1 was least influenced by surgery, especially in patients more than 50 years old. The long-term prognosis, thus has to be judged cautiously. One patient died postoperatively (mortality 4%). The technique of dura and pericardial plasty, aiming at functional adaptation, is described. Sutures inverting or folding pulmonary tissue are avoided. The aspect of at least temporary (up to 3 years) functional improvement leads us to advocate the use of extended criteria of operability.

Effect of Lung Volume Reduction Surgery on Gas Exchange and Pulmonary Hemodynamics at Rest and during Exercise

“…In one study (1) even an improvement of pulmonary hemodynamics after the procedure was reported. In contrast, in the case of reduction pneumoplasty for giant bullous emphysema, the basis of lung volume reduction surgery (LVRS) is to withdraw functionless yet nonbullous lung tissue in order to improve the lung's mechanical properties by increasing its elastic recoil (2)(3)(4) and to increase diaphragmatic motion, thus lowering the work of breathing (5)(6)(7)(8).…”

Awake thoracoscopic bullaplasty

“…Among the different surgical techniques that have been employed to treat emphysematous bullae, bullectomy with resection or plication of the bullae carried out through thoracotomy [4][5][6] or even median sternotomy for one-stage bilateral treatment [7] has been frequently employed to eliminate these space-occupying lesions.…”

Chirurgische oder bronchoskopische Lungenvolumenreduktion zur Emphysemtherapie

“…In Fällen von einzelnen Riesenbullae, voluminösen, einen ganzen Lappen einnehmenden Bullae oder mehreren, die Lappen zerstörenden, paraseptal aufgereihten Bullae scheint auch eher ein chirurgisches Vorgehen indiziert [23]. Gerade bei Patienten mit einem sekundären Spontanpneumothoraxmeist erstversorgt mit einer Thoraxdrainagewird häufig eine Talkumpleurodese empfohlen [24].…”

“…Im Falle einer erfolgreichen kontralateralen BLVR können die Ventile in situ gelassen werden, um eine er-neute plötzliche Zunahme der Überblähung nach der Entfernung zu vermeiden. Bei entsprechender Zielzone auf der Gegenseite und Erfüllung der Voraussetzungen für eine BLVR können die Patienten auch von einer erneuten BLVR der Gegenseite profitieren, wie auch Fallbeispiel 5 zeigt [23,27].…”