Should lung volume reduction for emphysema be unilateral or bilateral?

Abstract

Both unilateral and bilateral lung volume reduction procedures are being advocated for treatment of severe, generalized emphysema. We analyzed the results of 166 consecutive patients who underwent unilateral (n = 87) or bilateral (n = 79) thoracoscopic stapled lung volume reductions to help define the role for these procedures. There was no statistically significant difference in the operative mortality (3.5% vs 2.5%), mean length of stay (11.4 +/- 1 vs 10.9 +/- 1 days), or morbidity for the unilateral and bilateral groups, respectively (p not significant for all variables). Oxygen dependence was eliminated in 18 (36%) of 50 patients who had unilateral procedures and 30 (68%) of 44 of those who had bilateral procedures (p < 0.01). Prednisone was eliminated for 38 (54%) of 51 unilateral-procedure patients, compared with 30 (85%) of 35 bilateral-procedure patients (p = 0.02). Overall, bilateral procedures produced a mean improvement in the forced expiratory volume in 1 second (FEV1) of 57%, compared with 31% for unilateral reduction procedures (p < 0.01). Our bilateral staple procedure produced a 72.8% mean increase in the FEV1 for patients who had upper lobe emphysema. Especially compromised patients (age > or = 75, with preoperative room air Po2 < or = 50 mm Hg or FEV1 < or = 500 ml) had the same morbidity and operative mortality with unilateral or bilateral procedures, but they had a higher 1-year mortality (17% vs 5%), primarily because of respiratory failure after the unilateral operation (p < .001). Although unilateral staple lung volume reduction may produce an excellent result in a given patient, the bilateral procedure appears to be the procedure of choice, because it provides better overall results at no increased morbidity or mortality compared with the unilateral procedure. The results of bilateral staple lung volume reduction by thoracoscopy appear to be comparable to those of median sternotomy.

Effects of lung volume reduction surgery in hamsters with elastase-induced emphysema

“…The mean RV/TLC ratio in Sham was 26%. This compares to values of y65% in patients selected for LVRS in a large series in the literature [13,14]. It could be argued that the low RV/TLC ratio in the present study is caused by the definition of RV and TLC in hamsters.…”

Lung volume reduction surgery: an overview

“…Spirometry, lung volumes and quality of life appeared to be superior for bilateral compared to unilateral LVRS, although there was no significant difference in mortality between the two methods 21 . Serna 22 and colleagues found that survival at two years was better for bilateral than unilateral VATS LVRS. A recent study published by Pompeo 23 and colleagues analyzed 97 patients with upperlobe prevailing emphysema by unilateral LVRS, and showed 82% of 5-year related survival.…”

“…The current technique is just a resection from the front, straight toward the back, removing almost all the upper lobe on the right. On the left, the portion of the upper lobe is removed almost completely, thus just the lingula is left intact 1,21,22 . Although this transverse resection is now preferred over oblique resection and it seems that there is no significant difference between both methods.…”

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

“…By way of contrast, O'DONNELL et al [53] did not find any improvement in V 'O 2 ,max in a heterogeneous group of patients, despite postoperative rehabilitation. Dyspnoea, evaluated by variable means, has also been shown to decrease after LVRS [39±43, 45,47,48,50,51,53,54,56,57,60,69].…”

“…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.…”