Objective predictors of response for staple versus laser emphysematous lung reduction.

Abstract

Recently described surgical approaches to the treatment of emphysema, including buttressed stapled volume reduction and laser coagulation, are associated with variable clinical outcomes. We examined objective preoperative factors as predictors of response to treatment in patients enrolled in a randomized trial of staple versus laser volume-reduction surgery in order to help define patient selection criteria for these procedures. Seventy-two patients with severe symptomatic emphysema without bullae were entered into the protocol (39 staple, 33 laser). Preoperative objective variables (pulmonary function tests, smoking history, demographics, and graded chest computed tomographic [eT] scans) were evaluated as predictors of response to treatment (defined as a change in FEV1) at 3-to 6-mo follow-up, using linear and multivariate regression analysis. Follow-up pulmonary function was obtained on 90% of the 68 patients surviving at 6 mo. Overall improvement was significant only for staple-treated patients, and improved outcome correlated with greater smoking history and younger age for stapletreated patients. When physiologic variables were analyzed, greater smoking history, lower Dl..co, and younger age predicted improved outcome for laser-treated patients. Preoperative FEV1 and gasexchange variables did not predict outcome in staple-treated patients. When CTscan grading was included in multivariate regression analysis, hyperinflation (increased thoracic gas volume) was the primary predictor of response for laser-treated patients. These findings suggest that younger patients with evidence of advanced emphysematous lung disease and hyperinflation are optimal candidates for lung-volume-reduction surgery, particularly by staple-reduction techniques. Additional studies with long-term follow-up, bilateral procedures, and assessment of other outcome measures must be performed to further define operative criteria for lung-volume-reduction surgery for emphysema. Brenner M, McKenna R, Jr., Gelb A, Osann K, Schein MJ, Panzera J, Wong H, Bems MW, Wilson AF. ObJedlve preclldon of response for staple venus laser emphysematous lung redudlon.

Treatment of chronic respiratory failure: lung volume reduction surgery versus rehabilitation

“…Indeed, although several factors were shown to be significantly related to response, the models, in general, only explain a relatively limited fraction of the variance such that they do not allow proper prediction of the response in an individual patient. Indeed, BRENNER et al [93] analysed the variables related to response in a study comparing buttressed stapled resections with laser coagulation. Buttressed stapled resections were clearly more effective than laser coagulation.…”

“…They are summarised in table 4. For the clinical criteria, age w75-80 yrs is usually associated with poor outcome [64,93], although this has been debated in other studies [95]. Severe comorbidity is usually considered to be an exclusion criterion.…”

“…The surgical approach has varied and has included: median sternotomy, standard thoracotomy, and unilateral or bilateral video-assisted thoracoscopic surgery. Some authors also promote laser ablation, but comparative trials have shown this technique to be inferior [93,118]. In general, bilateral procedures produce better effects than unilateral ones [60].…”

Emphysema lung lobe volume reduction: effects on the ipsilateral and contralateral lobes

“…LVRS has been shown to benefit some patients with advanced emphysema [2][3][4][5][6][7], but studies have shown a wide range of individual outcomes [2,5,6,[8][9][10][11][12][13]. More recently, bronchoscopic lung volume reduction (BLVR) procedures have been investigated that aim to induce significant volume reduction in the most diseased lobe(s) [7,14].…”

Physiological basis of improvement after lung volume reduction surgery for severe emphysema: where are we?

“…This should not obscure the fact that up to 20% of the patients do not experience an improvement either subjectively or in the pulmonary function tests [4, 39, 41, 42, 45±48, 51, 52, 54, 57, 61, 62] and that mortality is not negligible [4,39,40,43,47,49,50,52,54,58,99], reaching 10% in some series [49]. The determinants of outcome have not yet received much attention.…”