Thomas K. Varghese Jr.
Introduction
Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality, affecting 13 million adults in the United States, with over 134,000 deaths annually making it the third leading cause of death. Emphysema, a form of COPD defined by abnormal and permanent enlargement of the airspaces distal to the terminal bronchioles associated with destruction of the alveolar wall, limits airflow and decreases functional area for gas exchange. Lung volume reduction surgery (LVRS) or reduction pneumoplasty aims to reduce nonfunctional lung volume by wedge excision of emphysematous tissue. By reducing the volume of hyperinflated lung, underlying compressed lung is allowed to expand, thus establishing improved respiratory function. Typically the amount of tissue removed is 20% to 35% of each lung during the procedure, targeting the most diseased portions.
There are two approaches to LVRS—via median sternotomy (transsternal approach) and video-assisted thoracoscopic surgery or VATS. Although surgeons may prefer one approach to the other, to date there has not been any demonstrated benefit with respect to mortality with either of the approaches as compared to the other. LVRS using the VATS approach typically takes longer secondary time needed to reposition the patient. To date, both approaches have offered equivalent results in pulmonary function improvement. Surgeon expertise and patient preference often have the heaviest influences for use of one technique over the other.
INDICATIONS
Indications for LVRS in the modern era are derived from the results of the National Emphysema Treatment Trial (NETT). The largest randomized clinical trial (RCT) dealing with LVRS, the goals of NETT were to identify the effects of treatment as well as the optimal candidates for intervention. NETT involved 17 centers and enrolled 1,218 patients with end-stage emphysema. The first publication from the study occurred after noting a specific high-risk subset of patients—those with FEV1 <20% with homogenous disease or a diffusing capacity or transfer factor of the lung for carbon monoxide (DLCO) <20%—at the 6-month follow-up had high mortality with surgery, with minimal improvement. After this high-risk group was excluded, the major findings were derived from the remaining 1,078 patients. Mid-term and long-term results demonstrated clinically significant improvements in spirometry, lung volumes, diffusing parameters, oxygenation, quality of life, dyspnea, exercise capacity, and long-term survival. Two key predictive factors were identified in NETT: Distribution of emphysema and the level of baseline exercise capacity. Bilateral LVRS provides clinically significant improvements in quality of life for patients with heterogenous upper lobe predominant emphysema, with additional survival benefit in the low exercise capacity subset of these patients.
The Centers for Medicare & Medicaid Services (CMS) has based its reimbursement policies wholly on the results of NETT and thus will pay for bilateral LVRS in patients with advanced upper lobe predominant emphysema that meet NETT criteria. They will not pay for the procedure in those with lower lobe disease, alpha-1 antitrypsin deficiency, homogenous disease, extremely advanced disease (both FEV1 <20% and DLCO <20% predicted) and those with a contraindication for bilateral procedures (asymmetric unilateral disease or those with bilateral disease and a history of thoracotomy). CMS recommends that procedures be performed at facilities that fulfill one of the following criteria:
Certified by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) under the LVRS disease-specific care certification program
Or approved as Medicare lung or heart-lung transplantation hospitals
In addition, Medicare-covered LVRS approaches are limited to bilateral resections. The procedure is reimbursed if all of their criteria are met (Table 6.1) in the setting of severe upper lobe predominant emphysema (on CT scan), or severe nonupper lobe emphysema with low exercise capacity. Patients with low exercise capacity are those with maximal exercise capacity at or below 25 W for women and 40 W for men after completion of the preoperative therapeutic program in preparation for LVRS. Exercise capacity is measured by incremental, maximal, symptom-limited exercise with a cycle ergometer utilizing 5 or 10 watts/minute ramp on 30% oxygen after 3 minutes of unloaded pedaling.
TABLE 6.1 Indications for LVRS (CMS Criteria for Coverage)
CONTRAINDICATIONS
LVRS is not indicated in any of the following circumstances:
Patient characteristics carry a high risk for perioperative morbidity and/or mortality.
Disease is unsuitable for LVRS (i.e., homogenous disease).
Patient is unable to complete the preoperative and postoperative pulmonary diagnostic and therapeutic program required for surgery.
FEV1 ≤20% predicted + homogenous distribution of emphysema on CT scan, or DLCO ≤20% predicted (high-risk group identified in NETT).
Severe, nonupper lobe emphysema with high exercise capacity. High exercise capacity is defined as maximal workload at the completion of the preoperative diagnostic and therapeutic program that is above 25 W for women and 40 W for men.
PREOPERATIVE PLANNING
The surgery must be preceded and followed by a program of diagnostic and therapeutic services consistent with those outlined in NETT. These programs are designed to optimize patient’s health before surgery and improve the chance for successful recovery. Elements of the preoperative program include:
Six- to ten-week series of at least 16, and not more than 20, preoperative sessions each lasting a minimum of 2 hours. The focus of the rehabilitation program is to optimize exercise capacity, achieve physical fitness to affect early postoperative mobilization and provide a baseline of optimized preoperative exercise capacity or comparison with postoperative exercise capacity.
Components of the pulmonary rehabilitation program include:
Comprehensive evaluation of medical, psychosocial, and nutritional needs
Setting of goals for education and exercise training
Exercise training (lower extremity, flexibility, strengthening, and upper extremity)
Education about emphysema and medical treatments
Psychosocial counseling
Nutritional counseling
The program should be arranged, monitored, and performed under the coordination of the facility where the surgery will take place.
Common elements of preoperative pulmonary rehabilitation programs include controlled breathing and cough techniques, instructions in incentive spirometry exercises, and peripheral muscle exercise training consisting of aerobic work. Bronchodilator therapy may be used without steroids.
SURGERY
Those who advocate for median sternotomy cite the shorter operative times (as repositioning during the case is not needed) and avoiding injury to chest wall muscles and intercostal nerves both from the operative approach and from chest tubes brought out below the costal arch.
Working IV lines, an arterial line, and a thoracic epidural are often placed at the beginning of the procedure. A working thoracic epidural is used to ensure adequate pain control thus allowing for adequate pulmonary toilet in the immediate postoperative period.
After induction of general anesthesia, the patient is first intubated with a single-lumen endotracheal tube to allow for bronchoscopy. Flexible bronchoscopy is used to suction secretions and obtain a specimen for STAT gram stain and cultures. In addition to pulmonary toilet, bronchoscopy allows for assessment of airway anatomy and to rule out any endoluminal abnormalities. The single-lumen endotracheal tube is then exchanged for a left-sided double-lumen endotracheal tube, with bronchoscopic confirmation of its position.
Figure 6.1 Positioning of patient for Transsternal LVRS.
Positioning
The patient is positioned with arms tucked, a shoulder roll to gently extend the neck, and pressure points appropriately padded (Fig. 6.1). The neck, chest and upper abdomen are prepped and draped in standard surgical fashion.
Technique
Sternotomy and Right LVRS
A midline incision is made from the sternal notch to the xiphisternum (Fig. 6.2). Adequate clearance of pleura away from the retrosternal area is performed by sweeping from the suprasternal and subxiphoid areas. A rolled sponge can help with the same. Ventilation to both lungs is briefly suspended just before division of the sternum with the sternal saw. Ventilation is restarted. The right mediastinal pleura is sharply incised taking care to avoid injury to the phrenic nerve located at the apex of the chest. The right lung is visualized while still ventilating to assess the degree of damage caused by emphysema to the various portions of the lung, as well as the location of the fissures. Single-lung ventilation is initiated to allow for decompression of the right lung. Care is taken to avoid hyperinflating the left lung, and airway pressures are maintained at 15 to 20 cm H2O pressure.
Figure 6.2 Median sternotomy.
Figure 6.3 Right upper lobe LVRS. Resection is begun just above the hilum and extended straight back to an area just above the fissure. Care is taken to avoid crossing the fissure and compromising the superior segment of the right lower lobe.
Upper lobe predominant disease is the most common indication for LVRS. Hence the right middle and lower lobes are usually well-deflated soon after initiation of single-lung ventilation. The inferior pulmonary ligament is located and taken down to the level of the inferior pulmonary vein. Adhesions are taken down with a combination of sharp and electrocautery dissection under direct vision. For upper lobe disease, removal of around 75% of the right upper lung is typical. Ring forceps are introduced to help in mobilizing the lung. Precompression of the lungs at the area of planned resection line with the aid of ring forceps can help with application of the stapler. Selective use of cautery can be done to puncture hyperinflated areas of lung to be removed. Traditional GIA linear staplers were used in early series. Endoscopic staplers allow for increased maneuverability and now come in specialized forms for use with thick tissues such as the Endo GIA Tri-Staple and Echelon Endopath staplers. Buttress reinforcement of the staple line can be done, such as use of bovine pericardium. Staple lengths encompassing 4.8-mm thickness are used for lung resection. (Black load [4 to 4.5 to 5 mm] for the Endo GIA Tri-Staple and Green load [4.8 mm] for Echelon Endopath staplers). Multiple firings of the stapler are performed, typically straight across the upper lobe beginning medially above the hilum and ending just above the upper extent of the oblique fissure (Fig. 6.3). Stapling across the fissure is avoided to avoid compromising the ability of remaining middle and lower lobes to fully re-expand. If the apex of the lung is densely adherent to the chest wall, it is often easier to divide the lung first and then lyse the adhesions. After resection has been completed, the specimen is removed and submitted to pathology. Warm saline is used to fill the chest, and the remaining lung reinflated to search for any air leaks. Irrigation fluid is removed. Some have advocated for the use of biologic sealants over the staple lines, but this should not be an attempt to make up for poor surgical technique or technical failure. Two chest tubes are placed into the pleural space, anteriorly and posteriorly and brought out near the midline via subcostal incisions. Chest tubes are secured to the chest wall and connected to Pleur-Evacs.
Left LVRS
The procedure is now repeated on the left side. The mediastinal pleura is sharply incised, taking care to visualize and avoid injury to the phrenic nerve. Taking down the inferior pulmonary ligament on the left side can be tricky due to the position of the heart, and this step may need to be skipped if it is too difficult to perform. For upper lobe predominant disease, the lingula is left intact. The upper 2/3 of the left upper lobe is removed with multiple applications of the stapler as before. The line of excision is parallel to the oblique fissure separating the upper and lower lobes (Fig. 6.4). Care is taken to avoid crossing the fissure into the superior segment of the lower lobe, as this will compromise its ability to re-expand at the completion of the procedure. The specimen is removed, the lung is reinflated and inspected for air leaks, and two chest tubes are placed into the left pleural space similar to what was done on the contralateral side.
Figure 6.4 Left upper lobe LVRS. The lingula is spared, and the upper 2/3 of the left upper lobe is resected with the line of excision parallel to the oblique fissure. Care is taken to avoid crossing the fissure.
The mediastinal pleura is closed on both sides, leaving a small window open inferiorly to allow for drainage of any mediastinal fluid. A separate mediastinal drain is not needed if this is done, as any mediastinal fluid collection should drain into the pleural space.
Sternal Closure
As most patients are on steroids before surgery, bone quality of the sternum is a concern. Figure-of-eight stainless steel wires are the norm during closure to minimize the occurrence of wound dehiscence. In especially brittle bone, consideration is given to use 2.4-mm thickness titanium plates for additional support.
After completion of bilateral LVRS, the patient is returned to the supine position. A chest x-ray can be performed prior to extubation, or shortly after arrival to the recovery room. If postop chest x-ray demonstrates full re-expansion, the chest tubes can be put on water seal.
POSTOPERATIVE MANAGEMENT
Principles of standard thoracic postoperative management are followed including:
Early ambulation.
Transition from epidural analgesia to oral pain medications in 48 to 72 hours that provide adequate analgesia.
Pulmonary toilet measures (which had begun preoperatively) such as deep breathing, coughing, use of incentive spirometry, and handling of secretions.
Nebulized bronchodilator therapy is initiated in the early postoperative period to minimize airway reactivity and transitioned to inhalers as needed.
Nutritional assessment and intervention is important, as it aids in healing.
Systemic steroids may be needed in the perioperative period.
Unlike other thoracic surgical procedures, early water seal is the norm and can be started with expansion of the lung even in the presence of an air leak. Chest tubes are removed once air leaks resolve and output has minimized, in the standard fashion. Those with persistent air leaks in the postoperative period may be transitioned to Heimlich valve as long as the lung remains expanded on water seal, output is minimal, and the patient is able to care for the drain in the postdischarge setting.
COMPLICATIONS
LVRS is a procedure performed on a patient population with significant comorbidities. Avoiding complications is the best path toward functional recovery. Patient selection is key for the same.
In NETT, the operative mortality was 6%, major pulmonary morbidity was 30%, and major cardiovascular morbidity was 20%. The most common complications were reintubation (22%), arrhythmias (19%), pneumonia (18%), mechanical ventilation for more than 2 days (13%), and persistent air leak for 30 days (12%). Myocardial infarction, deep venous thrombosis (DVT), pulmonary embolism (PE), and wound infection occurred less frequently.
Most patients have an initial air leak that seal, but prolonged air leaks can be a source of significant morbidity. Gentle handling of tissues, use of buttressed or specially designed staplers for lung tissue and avoiding crossing of staple lines can help minimize postoperative air leaks. Suction is selectively used for those patients with large symptomatic air leaks. Pleurodesis and reoperations are rarely done but may be needed in situations where one needs to revise the staple line or excise the source of the leak.
Pneumonia is avoided by aggressive pulmonary toilet measures, early ambulation, and management of secretions. Sputum collected by bronchoscopy can be used to tailor antibiotic therapy if infiltrates develop in the postoperative period. Pleural effusions may require additional drainage tubes. Development of empyema will require surgical intervention, as well as any development of mediastinitis.
Mucus plugging and respiratory complications can occur in the LVRS population. Patients with copious sputum production should be carefully screened during the preoperative evaluation period. If after induction of general anesthesia, bronchoscopy demonstrates purulent sputum or copious secretions, it is better to cancel the procedure and reassess after appropriate antibiotic therapy and evaluation.
There have been reports of association of LVRS and gastrointestinal complications such as ileus, intestinal ischemia, and perforation. Bowel function should be carefully monitored in the early postoperative period.
RESULTS
NETT mid-term and long-term results of demonstrated clinically significant improvements in spirometry (FEV1, FVC), lung volumes, diffusing parameters (DLCO, PCO2), oxygenation (PO2, O2 utilization), quality of life (SF-36, Quality of Well-being survey), dyspnea (St. George’s Respiratory Quotient), exercise capacity (6-minute walk, treadmill exercise test), and long-term survival. Several institutional case series have reported remarkably consistent results irrespective of surgical approach. This is likely secondary to rigid criteria used for patient selection, methodical preoperative preparation, and vigilance in the postoperative period. Most series report a postoperative length of stay ranging from 8 to 14 days, with air leaks being the most common reason for prolonged length of stay. Reported benefits have included gains in exercise tolerance, freedom from oxygen use, freedom from steroid use, and improvement in subjective quality of life scores.
Relief of dyspnea has been examined in nonrandomized series and in the NETT as a secondary endpoint. Ciconne et al. reported in a series of 250 patients from Washington University that 79% of patients at 1 year, and 40% of patients at 5 years had improved dyspnea scores over baseline. In a follow-up of the NETT, quality of life scores for those with upper lobe predominant disease and preoperative low exercise tolerance lasted through 5 years of follow-up.
Both LVRS and transplantation can be considered in end-stage emphysema. In a retrospective series comparing LVRS, single-lung transplantation, and double-lung transplantation findings included the following:
FEV1 improved by 79% at 6 months and 82% at 12 months for LVRS patients, 231% and 212% for single-lung ventilation patients, and 498% and 518% for double-lung ventilation patients.
Six-minute walk test distance at 6 months improved 28% for LVRS, 47% for single-lung transplants, and 79% for double-lung transplant recipients.
LVRS patients and transplant patients needed oxygen therapy before surgery. While all the transplant patients did not require supplemental oxygen after surgery, 5.5% of LVRS patients needed supplemental oxygen during exercise after surgery while none needed it at rest.
Thus, though LVRS can be beneficial, it is a palliative procedure whereas lung transplantation can result in superior lung function. Limitations of the study were its retrospective nature, and baseline differences in age between the groups.
CONCLUSIONS
LVRS is a surgical technique that involves selective reduction of lung volume by excision of tissue in areas where the emphysematous changes are pronounced. The choice between transsternal and VATS approaches is most commonly a result of surgeon expertise and patient preference.
The amount of tissue resected is 20% to 35% of each lung, which for upper lobe predominant disease is 75% of the right upper lobe, and 2/3 of the left upper lobe.
LVRS can lead to modest improvement in spirometry, lung volumes, diffusing parameters, oxygenation, quality of life, dyspnea, exercise capacity, and long-term survival. Key to success is strict patient selection criteria, optimizing patients preoperatively, and aggressive postoperative management to minimize the occurrence of complications.
Complications postoperatively include persistent air leak, reintubation, prolonged mechanical ventilation, pneumonia, wound infection, arrhythmias, and less commonly myocardial infarction, DVT, PE, and death.
Majority of patients are extubated in the operating room. Effective management of pain, pulmonary toilet, early ambulation, and management of secretions are key steps in minimizing complications.
Recommended References and Readings
Brantigan OC, Mueller E. Surgical treatment of pulmonary emphysema. Am Surg. 1957;23:789–804.
Centers for Medicare & Medicaid Services (CMS). National Coverage Determination (NCD) for Lung Volume Reduction Surgery (Reduction Pneumoplasty) [240.1]. http://cms.hhs.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId= 119&ncdver=3&bc=AgAAQAAAAAAAAA%3D%3D&. Accessed on April 20, 2014.
Cetinag IB, Boley TM, Magee MJ, et al. Postoperative gastrointestinal complications after lung volume reduction operations. Ann Thorac Surg. 1999;68:1029–1033.
Centers for Disease Control and Prevention (CDC). Chronic Obstructive Pulmonary Disease (COPD). http://www.cdc.gov/copd/ Accessed on April 20, 2014.
Ciccone AM, Meyers BM, Guthrie TJ, et al. Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema. J Thorac Cardiovasc Surg. 2003;125:513–525.
Joint Commission Lung Volume Reduction Surgery (LVRS) Certification. http://cms.hhs.gov/medicare-coverage-database/details/ncd-details.aspx?NCDId=119&ncdver=3&bc=AgAAQAAAAAAAAA%3D%3D&. Accessed on April 20, 2014.
McKenna RJ Jr, Brenner M, Fischel RJ, et al. Patient selection criteria for lung volume reduction surgery. J Thorac Cardiovasc Surg. 1997;114:957–964.
Fishman A, Martinez F, Naunheim K, et al.; National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med.2003;348:2059–2073.
National Emphysema Treatment Trial Research Group. Patients at high risk of death after lung-volume-reduction surgery. N Engl J Med. 2001;345:1075–1083.
Naunheim KS, Wood DE, Mohsenifar Z, et al.; National Emphysema Treatment Trial Research Group. Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group. Ann Thorac Surg. 2006;82:431–443.
Naunheim KS. Chapter 20: For whom is lung volume reduction surgery effective? In: Ferguson M, ed. Difficult Decisions in Thoracic Surgery. 2nd ed. New York, NY: Springer; 2011:179–186.