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J Thorac Cardiovasc Surg 1996;112:1331-1339
© 1996 Mosby, Inc.
GENERAL THORACIC SURGERY |
Supported in part by DOE grant DE-f603-91 ER61227 NIH grant R01192 and the Heart and Lung Surgery Foundation.
Received for publication March 11, 1996 Revisions requested May 29, 1996; revisions received July 11, 1996 Accepted for publication July 15, 1996. Address for reprints: Robert J. McKenna, Jr., MD, 1245 Wilshire Blvd., Suite 606, Los Angeles, CA 90017.
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 (pnot 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 FEV1for patients who had upper lobe emphysema. Especially compromised patients (age 
75, with preoperative room air Po2
50 mm Hg or FEV1500 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. (J THORACCARDIOVASCSURG1996;112:1331-9)
Lung volume reduction surgery (LVRS) for treatment of emphysema is being performed with lasers or staples as unilateral or bilateral procedures.
1-4 In a randomized, prospective study, we showed that unilateral thoracoscopic staple LVRS produced significantly greater reduction in supplemental oxygen requirements, greater steroid independence, improved quality of life, and objective pulmonary function tests than contact-tip neodynium:yttrium-aluminum-garnet laser treatments. 3
The free beam laser may be more effective than the contact-tip laser. Little 1 showed a greater improvement with the free beam than our results with the contact tip 3 (18% vs 13%). With the combination of staples and free beam laser treatment by means of unilateral thoracoscopy, Eugene 2 reported results similar to those in our study using staples alone. 3 There was no apparent benefit to the addition of the laser to the staple procedure. Cooper 4,5 reported much greater improvement with a bilateral staple procedure (82%) compared with these results with unilateral procedures. 1-3
On the basis of the results of previous studies, we adopted the bilateral thoracoscopic staple LVRS as our standard operation. We have accrued approximately equivalent numbers of patients in the bilateral treatment group as in our initial group of patients treated with unilateral thoracoscopic staple LVRS.
Although overall improvement after bilateral LVRS appears superior to results after unilateral reduction, some unilaterally treated patients have had excellent clinical results. In this study we analyze the results of consecutive patients who underwent unilateral or bilateral operations for the treatment of generalized emphysema to compare the overall efficacy of these two approaches, to attempt to identify patients who respond well to unilateral procedures, and to help clarify the role for each approach.
Patients and methods.
Between June 1994 and June 1995, 166 patients 67 ± 7 years old (mean ± SD) underwent unilateral (n = 87) or bilateral (n = 79) staple LVRS. Entry criteria for this series have been previously described. 3 Despite maximal medical management, all patients had marked symptoms, as measured by a dyspnea index and quality-of-life assessment. Chest roentgenograms showed hyperexpansion of the thorax, with flattening or inversion of the diaphragms.
To be accepted for the procedure, the pattern of emphysema seen on computed tomography (CT) had to be heterogeneous and graded as severe. 6 The CT scan pattern was classified as upper lobe if the emphysema was primarily in the upper lobes, lower lobe if concentrated in the lower lobes, and diffuse if there was a heterogeneous pattern of emphysema with discreet areas of severe emphysema in the upper and lower lobes. Radionuclide lung perfusion scans were also used to confirm the heterogeneous pattern of emphysema.
Contraindications to surgery included current cigarette smoking, age greater than 80 years, severe CO2 retention (Paco2 >55 mm Hg), severe heart disease, history of cancer within the last 5 years, ventilator dependency, presence of a lung mass, or prior thoracic operation. All patients who underwent LVRS for treatment of emphysema were included in this study unless they had previously undergone an operation for emphysema, if they underwent a laser operation as part of a previous study, or if a lung cancer was identified.
Baseline function.
Baseline characteristics of the two patient groups appear in Table I. All of the patients had severe fixed airflow limitation. The mean forced vital capacity was 2.07 L (54 ± 9% predicted [mean ± SD]) and the mean forced expiratory volume in 1 second (FEV1) was 0.67 (25.5% ± 7% of predicted). The average result for the preoperative 6-minute walk was 350 feet.
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1-antitrypsin deficiency. Assignment to the unilateral- or bilateral-procedure group was essentially sequential, with unilateral procedures being performed in the first half of the study group and bilateral procedures in the second half. After the bilateral phase of the study had started, 10 patients underwent unilateral operations. In eight patients, a heterogeneous pattern of emphysema was found on the operated side, but the contralateral side showed a homogenous pattern. Bilateral operations had been planned for two additional patients, but large air leaks developed while surgeons were operating on the first side. These patients had histories of prolonged steroid use, and operating on their very soft lungs led to massive air leaks. When all efforts to seal the leaks were unsuccessful, the procedures were terminated without LVRS on the contralateral side.
Pulmonary rehabilitation.
Pulmonary rehabilitation is an integral part of the treatment for all our patients who undergo LVRS. Many of the patients lived great distances from our medical center and did not have adequate rehabilitation programs at their local hospitals. Rehabilitation, therefore, was not routinely performed preoperatively. However, all patients began rehabilitation in the hospital after the operation. The rehabilitation program included education about proper breathing techniques, anxiety control, muscle stretching and strengthening exercises, and walking on stairs and treadmills. This was continued on an outpatient basis at Chapman Medical Center for 2 to 3 weeks after discharge from the hospital. Patients were strongly encouraged to join a local rehabilitation program after completion of the postoperative rehabilitation program at Chapman Medical Center.
Operative techniques.
All patients underwent unilateral or bilateral video-assisted thoracic surgery while under paralyzed (pipecuronium) general anesthesia (isoflurane) using a left-sided double-lumen tube (Mallincrodt Anesthesia, St. Louis, Mo.). All procedures were performed, with patients in the lateral decubitus position, by one surgical group (R. M., R. F.). The trocar and thoracoscope were placed through the tenth intercostal space in the posterior axillary line. Three additional 1 to 2 cm incisions were made for the endoscopic stapler and for standard, nonthoracoscopic instruments, such as a ring forceps. For bilateral procedures, patients were turned to the contralateral decubitus position for a separate skin preparation after completion of surgery on the initial side.
The preoperative lung CT scan and ventilation/perfusion scan were used to identify areas of severely emphysematous lung targeted for resection. Ring forceps manipulated the lung into a 60 mm endoscopic stapler (ELC 60, Ethicon, Cincinati, Ohio) with bovine pericardium 4,5 (Peristrips, Biovascular, Saint Paul, Minn.) or Instat (Johnson and Johnson, New Brunswick, N.J.) to buttress the staples. The staples were fired an average of 15 times for a bilateral operation. Typically, approximately one half of the upper lobe was resected. Specimen weights ranged from 30 to 114 gm (74 ± 35 gm). Pleurodesis was not performed in any patient. The chest was drained with two apically placed chest tubes after completion of the procedure. Our policy is to not use suction on the chest drainage system unless the patient's condition is clinically unstable. Heimlich valves are used for prolonged air leaks (>5 days) to facilitate earlier discharge from the hospital. 7 After extubation in the operating room, patients were routinely transferred to the intensive care unit for overnight observation.
Lung function studies.
All patients underwent arterial blood gases and lung function studies on room air that included static lung volumes measured by plethysmographic techniques, 8 timed spirometry, and single-breath diffusing capacity in accordance with American Thoracic Society recommendations, 9,10 and the values were compared with predictions. 11-13 All patients were considered to have fixed airflow limitation because the FEV1 after three inhalations of aerosolized albuterol (670 µg) improved <12% or <200 ml. 10 Maximum inspiratory and expiratory flow volume curves, thoracic gas volume, 8 and airway resistance 8 were measured in a plethysmograph (Models 2800 and 6200, Sensormedics Inc., Yorba Buena, Calif.) and compared with predicted values. 14 The reciprocal of airway resistance, 8 conductance, was divided by the thoracic gas volume at which it was measured to calculate specific conductance. Residual volume was calculated by subtracting vital capacity from total lung capacity. Complete plethysmographic lung function and elastic recoil studies were obtained before operation. Because follow-up information usually was obtained from the patients' local pulmonologists, only timed spirometry and arterial blood gas data were available after operation.
Objective outcome assessment end points.
Change in postbronchodilator FEV1 and the percent change in FEV1 were the primary continuous objective end points measured to assess response to surgery.
Relief from prednisone dependence and elimination of need for supplemental oxygen were assessed as noncontinuous variables. Physicians involved in the surgical procedure did not make any recommendations or decisions regarding prednisone or oxygen treatment for any of the patients. These decisions were made independently by the patients' primary physicians.
Dyspnea improvement was defined as G2 point decrease in the dyspnea index or final dyspnea score H2. Lifestyle was assessed by the Medical Outcome Survey Short Form–36 (MOS SF-36) item quality-of-life questionnaire. 15
Mortality assessment.
Operative mortality was defined as death occurring within 30 days of the procedure, before discharge from the acute care hospital, or in a rehabilitation facility if the patient was transferred there from the acute care hospital. One-year mortality was defined as death from any cause up to 1 year after surgery, and it included operative mortality. The clinical status of all patients was known.
Statistical methods.
Group descriptive statistics are expressed as the mean ± standard error of the mean unless otherwise specified. Differences between groups are compared with two-tailed paired Student's t tests, with p < 0.05 considered significant. Pearson's 
2 statistics were used to analyze clinical features in the unilateral or bilateral staple groups. 16
Clinical evaluation.
Before operation and 6 months after operation, the MOS 36-item quality-of-life questionnaires 15 and the Modified Medical Research Council (MMRC) dyspnea index 17 were scored to document lifestyle improvement and response to operative intervention. Patients were referred to their local pulmonologists for weaning pulmonary medicines and oxygen, as appropriate. We contacted the patients to determine their clinical status and their use of pulmonary medicines and oxygen.
Results
This study included 166 consecutive patients who underwent LVRS. Follow-up pulmonary function evaluations were available for 139 (87%) of 161 surviving patients. Despite repeated efforts to question the other patients, no follow-up pulmonary functions could be obtained, even for patients who were clinically doing well. One-year clinical follow-up and mortality data were available for all patients.
Mortality.
The three deaths (3.5% mortality) for the unilateral procedure resulted from respiratory failure (1 patient), contralateral tension pneumothorax (1), and a cardiac event (1). The two deaths (2.5% mortality) after the bilateral operation resulted from an acute abdomen (1) and respiratory failure (1). There was no statistically significant difference in the mortality for the two groups, and there were no additional deaths at 3 months of follow-up (Table II).
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Table III. The mean postoperative length of stay was 11.4 ± 1.1 days and 10.9 ± 1.1 days for the unilateral and bilateral treatment groups, respectively (p not significant).
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7 has essentially eliminated the need for reoperation for air leak. The use of the Heimlich valve began during the bilateral phase of the study. After a bilateral operation, 14 (18%) patients were discharged with Heimlich valves for an average of 6.5 days. The remaining patients had their chest tubes removed while in the hospital. Discharge was to a rehabilitation hospital for 18 (23%) of the bilateral-procedure patients and 17 (19%) of the unilateral-procedure patients. At the time of transfer, two of these patients' lungs were being ventilated, but they were subsequently weaned. The remaining patients were transferred to the rehabilitation facilities for social reasons (i.e., they came from long distances to our facility and were without family or friends for support) or because their conditioning was poor preoperatively.
Steroid dependency.
The use of oral steroids at 6 months after the operation was recorded. In the unilateral-procedure group, 28 (54%) of the 51 patients who were taking prednisone preoperatively no longer used prednisone. In the bilateral-procedure group, 30 (85%) of the 35 patients who were taking prednisone preoperatively no longer required prednisone (p = 0.02) (Table IV).
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Dyspnea scale.
After both types of procedures, some patients still had significant dyspnea. In the unilaterally treated group, 73% of the patients had grade 3 or 4 dyspnea preoperatively, and 44% of the patients had dyspnea postoperatively. Although 76% of bilateral-treatment patients had grade 3 or 4 dyspnea preoperatively, only 12% had dyspnea after operation (p < 0.001).
Pulmonary function: follow-up.
There was no difference in pulmonary function results at initial follow-up visits (average 80 ± 6 days) compared with subsequent 6-month follow-up at 163 ± 10 days (Table V). Results of unilateral and bilateral volume reduction procedures are summarized in 
Tables IV, V, and VI. The mean improvement in the FEV1 from baseline for the unilateral and bilateral operations were 31% and 57%, respectively. Patients with predominantly upper lobe disease had significantly greater improvement in pulmonary function after unilateral or bilateral reduction than patients with diffuse or lower lobe disease (p < 0.01). For unilateral procedures, upper lobe disease was associated with a 35% ± 5% improvement from baseline, lower lobe disease with a 26% ± 7% improvement, and diffuse disease with a 15.7% ± 7% improvement. For bilateral procedures, the improvement from baseline was 68% ± 8%, 47.1% ± 18%, and 36.8% ± 9% for upper, lower, and diffuse disease, respectively (Fig. 1).
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Patients responding well to unilateral surgery.
Although the overall response was significantly greater for patients undergoing bilateral LVRS, some patients responded well to unilateral procedures. Multivariate analysis was performed to identify factors that could predict an excellent response to a unilateral procedure. No such factors could be identified.
However, one subgroup of unilateral-procedure patients had the same postoperative result as bilateral-procedure patients with the same features. Patients younger than 75 years initially seen with predominantly upper lobe disease, hyperinflation (TLC >7.5 L), normal Pco2 (<46 mm Hg), and preserved diaphragmatic excursion on at least one side (G2.0 cm) had a mean increase in FEV1 of 340 ml (45% ± 15%). Equivalent patients undergoing bilateral procedures showed a mean increase in the FEV1 of 46.6% ± 9% (355 ml). This subgroup of patients also had a significantly greater response to unilateral volume reduction compared with the rest of the unilaterally treated patients who experienced a mean increase in FEV1 22% ± 5% of predicted increase in FEV1, 147 ml average increase (p < 0.02).
Relationship between tissue resected and response.
An average of 74 gm (±35.5 gm SD) of tissue was resected from patients. Unilateral procedures removed approximately one half as much tissue (46 ± 16 gm) as bilateral procedures (98 ± 28 gm; p < 0.0001). Improvement in lung function (change in FEV1) after the procedure correlated with the total amount of lung tissue resected, as seen in Fig. 2 (r = 0.547; p < 0.0001).
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Table VI). The primary cause of delayed mortality was respiratory failure that occurred when a unilateral operation failed to produce enough improvement. Clinical factors associated with this delayed mortality in the unilateral-procedure group were preoperative room air Po2 <50 mm Hg, age >75 years, and FEV1 <500 ml (p < 0.001). After a unilateral procedure, patients with a preoperative room air Po2 <50 mm Hg had a 30% 1-year mortality. Discussion
The goals for LVRS for treating emphysematous pulmonary disease are to improve objective pulmonary function, reduce or eliminate supplemental oxygen or steroid dependence, and significantly improve subjective dyspnea, with acceptible morbidity and mortality levels. Previous studies have shown that unilateral and bilateral procedures can achieve these goals for some patents. 1-4 These studies do not, however, provide adequate data to compare the morbidity, mortality, and clinical outcomes after unilateral or bilateral operations, to determine relative benefits, or to define the indications for each of these procedures. We analyzed the results of the 166 patients treated with unilateral or bilateral thoracoscopic LVRS at our institution to address these issues.
A bilateral procedure is expected to produce greater overall improvement than a unilateral procedure. In this study the bilateral procedure provided greater oxygen independence (68% vs 35%), prednisone independence (86% vs 56%), and greater improvement in the FEV1 than the unilateral procedure (p < 0.05). Grade 3 or 4 dyspnea still affected 44% of patients after a unilateral operation but affected only 12% after a bilateral operation (p < 0.001). Because some patients have symptoms even after a bilateral procedure, it appears to be the procedure of choice.
Is there any role for the unilateral procedure? One potential rationale for a unilateral procedure is that some patients may be too debilitated to tolerate a bilateral procedure, and a unilateral procedure may be safer and can be done to improve the patient sufficiently for operative intervention on the contralateral side. However, the results in this study argue against that approach. Even for severely compromised patients, the operative morbidity and mortality rates for unilateral and bilateral operations were the same, but the clinical outcome was much better for the bilateral procedure. Severe debility is therefore not an indication for performing a unilateral operation rather than a bilateral operation.
This study shows that the short-term and long-term results are better for severely debilitated patients with a bilateral operation than with a unilateral procedure. Although operative mortality is the same for these two operative approaches, 1-year follow-up data reveal a dramatically higher mortality for the unilateral procedure compared with the bilateral LVRS. This delayed mortality affected severely debilitated patients (i.e., preoperative room air Po2 H50 mm Hg, age G75 years, or FEV1 H500 ml) who did not improve enough with the unilateral procedure to sustain survival. There was no delayed mortality in this subgroup of patients after bilateral operations. These data also show that an extremely low FEV1 is not a contraindication to LVRS. The operative mortality was not increased for patients with an FEV1 <500 ml. This study suggests that a bilateral procedure is the procedure of choice for severely compromised patients.
What rationale remains for a unilateral procedure? LVRS for emphysema is a procedure that provides palliation for uncertain durations. It is unknown whether a longer period of palliation will be achieved if a patient initially undergoes a bilateral operation or a unilateral operation with plans to reserve the contralateral side for a time when the patient again has symptoms.
Laros 18 found that operation for giant bullae significantly improved all patients with severe dyspnea for 2 to 5 years, but that all patients eventually returned to their preoperative level of dyspnea. Patients with LVRS for generalized emphysema may have similar durations of clinical benefit as patients who undergo operations for giant bullae. Long-term follow-up is needed to determine how the duration of clinical improvement with an initial bilateral operation compares with results from an initial unilateral operation with a plan to save treating the contralateral side until the return of symptoms.
If the surgical plan is to perform sequential operations, it is necessary to be able to predict which patients will get enough improvement from a unilateral operation. Because our multivariate analysis failed to identify such patients, our current operative approach is a bilateral operation.
A unilateral procedure may be the procedure of choice for hyperinflated patients (TLC >7.5 L) with Paco2 <45 mm Hg and diaphragmatic excursion >2 cm. These patients had the same improvement in the FEV1 whether the procedure was unilateral or bilateral. If these findings are confirmed in other studies, this may represent a subgroup of patients for unilateral LVRS.
Our standard operation is a bilateral staple operation, although we do perform unilateral operations in selected patients. Even during the bilateral LVRS phase of this study, unilateral operations were performed for eight patients who had a heterogeneous emphysema on one side and a homogenous pattern on the nonoperated side. Two additional patients had large air leaks that developed during the operation on the first side when a bilateral operation had been planned. These patients had lungs that were very soft, and the patients had a history of prolonged use of steroids. When all efforts to seal the leaks were unsuccessful, the procedures were terminated without LVRS on the contralateral side. Unilateral operations are also indicated for patients with contraindications for an operation on the opposite side, such as prior thoracotomy, prior pleurodesis, or extensive pleural disease seen on roentgenograms.
Bilateral staple LVRS can be performed by a VATS procedure, as in the current study, or through a median sternotomy, as developed by Cooper. 4 The average improvement in the FEV1 is somewhat related to the degree of hyperinflation. Cooper's patients had an average TLC of 144%. We selected a subgroup of hyperinflated patients comparable to Cooper's patients. These 41 patients had an average improvement in the FEV1 of 410 ml (72%), compared with the 82% improvement for Cooper's patients. The results of these studies suggest that bilateral procedures can be performed by median sternotomy or bilateral thoracoscopy with approximately equivalent responses. The incision is not as important as the procedure (i.e., laser or staples, unilateral or bilateral) to be performed.
The optimal amount of lung to be resected is also unknown. In this series, up to 114 gm of tissue was resected from one lung. Our current practice is to resect at least one half of the upper lobe from each lung, with an average weight of 60 to 75 gm per side. A correlation was seen between the total weight of tissue resected (including staples and bovine pericardium) and response to LVRS (see Fig. 2). This figure does not identify a point of diminishing returns beyond which further resection is associated with a lesser increase in postoperative FEV1. Perhaps our resections should be even more extensive. Areas of severe emphysematous change can be resected very aggressively because the Heimlich valve fascilitates closure of prolonged air leaks and resolution of postoperative apical air spaces without the need for reoperation or pleural tents. 7
This study suggests that the standard operation for a patient with severe heterogeneous emphysema should be a bilateral staple LVRS that is performed by median stenotomy or video-assisted thoracic surgery. Unilateral operations are reserved for patients with unilateral heterogeneous emphysema, prior contralateral thoracic operations, pleural scarring or pleurodesis, or a large air leak that cannot be closed while operating on the first side during a planned bilateral operation.
Appendix: Discussion
Dr. Claude Deschamps (Rochester, Minn.)
Dr. McKenna and his group have demonstrated through a retrospective study that volume reduction can be achieved through the scope, whether it is done on one or two sides, with reasonable results in this challenging group of patients. Dr. McKenna, you advertise "two sides for the price of one," and you say that treatment of the upper lobe disease has a better prognosis than for the middle or lower lung. I think it is difficult to draw any other conclusion from your study.
Lung volume reduction surgery, as suggested by Joe Miller earlier this week, has really been a roller-coaster ride. For us mortals north of St. Louis, arguing the legitimacy of this procedure with our Medicare provider has been only one of the challenges. The quest for the ideal patient is never ending. The challenging postoperative care has been equalled by problems in rehabilitation, psychiatry, and cost-benefit issues. Although it has insufflated some badly needed fresh air in the lung mechanics' community, it sometimes gives the impression that the wheel is being reinvented, especially when you look at the French-European experience; those researchers have been through this before, although perhaps in a less selective way. In our effort to choose our patients better, we do lung mechanics in all our patients with an esophageal balloon, and what we found is that when the maximum flow is plotted against the transpulmonary pressure or elastic recoil, when we have a shift of the expected curve to the right, our patients did not do as well. We concluded that airway obstruction in those patients might result from causes other than emphysema alone. Those patients do not fare very well, and this understanding is now part of our selection process for lung volume reduction patients.
You correlated the amount of lung resected and the changes in FEV1 and found a correlation of 0.5, which would explain only about 30% of the relationship between the amount resected and the increase in FEV1. It seems that using the changes in total lung capacity or residual volume would have been a better physiologic predictor of postoperative results. Is there an upper limit in grams of tissue resected that you suggest to aim for, and has your technique of resection been consistent through that study period?
Have you identified preoperative factors associated with a poor result for patients who did survive but did not do as well or for patients who got worse?
You do not use rehabilitation before and only encourage it after the operation, but you say that it is part of the treatment and part of the indication for patients who do not respond to maximal treatment. The article does not give a sense of whether rehabilitation is responsible for any improvement in your patient population. In those circumstances why use it at all, especially if in some places of the country it is not reimbursed?
You have shown that thoracoscopy can achieve results comparable to sternotomy, especially for bilateral surgery. Considering that VATS is not cheaper and probably a longer procedure, why not use a sternotomy for everyone?
Dr. McKenna
Your first question was about how much lung tissue to resect. We have resected as much as 112 gm on one side and 114 gm on the other side; we have done very aggressive resections. I don't know the optimal amount to resect. As you mentioned, the increase in the FEV1 continues to climb with increasing amounts of resection. Generally, we aim to remove at least one half of the upper lobe on each side, and if these upper lobes are completely destroyed, we take out the entire upper lobes. For patients that have 1-antitrypsin deficiency, we perform bilateral lower lobectomies. The technique has been consistent through the entire period.
I think the most important preoperative factor is a heterogenous pattern of emphysema and that it is very strongly heterogeneous if there is a big difference between the degree of anatomic destruction of lung tissue in one area compared with the better area that is to be left behind. Pulmonary rehabilitation has been very extensively studied. There are plenty of randomized, prospective studies that show that pulmonary rehabilitation fails to improve pulmonary function and fails to even slow the decline in pulmonary function. I do not think there is any question that this operation, which dramatically improves pulmonary function, is much better treatment and should be covered by the Health Care Finance Administration (HCFA) and paid for by the third-party payers. I think that pulmonary rehabilitation does have some benefit for the patients in that it can get them in better shape preoperatively; it can cut down the need for some patients to be transferred to rehabilitation facilities postoperatively. Outpatient rehabilitation is much less expensive than inpatient rehabilitation. I believe that is an important benefit. It also is helpful in excluding patients who are not good candidates—those who cannot complete the rehabilitation or do not have the motivation to do the work that they need to do after the operation.
You asked why I do VATS. I did 12 median sternotomies, and I have done the rest of our 350-case experience with video-assisted surgery. I do not think that VATS is any more expensive than an open procedure. It routinely takes us 1 to 1.5 hours to get both sides done with two separate preparations and drapings. As you saw in the slide, we use a reusable trocar for the camera. We do not use any additional trocars; we do not use any disposable instruments. We use a stapler, which is also used for the open procedure. I find it technically easier to deal with adhesions that are located diffusely through the chest or especially posteriorly when I have a lateral approach rather than an anterior approach. Twenty-four percent of our patients have had at least one half of the pleural space obliterated by adhesions, and I find it technically easier to lyse those adhesions from the side than from the front.
Dr. Akio Wakabayashi (Irvine, Calif.)
A 17% mortality at 1 year after unilateral lung volume reduction is unbelievably high. In my own experience, 39 of 579 patients were dead 1 year after unilateral thoracoscopic treatment of emphysema. Of our 841 patients, only 23% required second-side operations, with a mean interval of 1 year. Last year, I operated on one patient who had had other side treated by laser bullectomy 6 years earlier, and this is the longest-living patient. I have 178 patients who had unilateral thoracoscopy laser pneumoplasty more than 3 years ago and are doing still well. This illustrates the long-lasting beneficial effect of unilateral surgery.
Regardless of the technique we use, the surgical treatment of emphysema is palliative in nature. This may be a philosophical question, but I still believe that the unilateral procedure is all we need to do for most patients, because they enjoy life after unilateral surgery.
Dr. McKenna
We have experience following patients with unilateral and bilateral operations. Although some patients are dramatically better after unilateral procedures, a much higher percentage of our patients dramatically improve after bilateral operations. Overall, when you look at the improvement in the dyspnea scale, patients who have bilateral procedures average much greater improvement on the dyspnea scale. Although some patients may improve and be happy with their results after unilateral procedures, with the bilateral procedure, a greater percentage of patients are improved, and the amount of improvement is greater. Our multivariate analysis failed to identify which patients improve enough with a unilateral procedure. We therefore recommend the bilateral procedure as the standard operation.
Footnotes
From the Lung Center, Chapman Medical Center, Orange, Calif.,a the Pulmonary Department,b Lakewood Regional Medical Center, Lakewood, Calif., and UCI Medical Center,c UCLA Pulmonary Division,d and UCLA Department of Thoracic Surgery,e Los Angeles, Calif. 
Read at the Seventy-sixth Annual Meeting of The American Association for Thoracic Surgery, San Diego, Calif., April 28–May 1, 1996.
References
This article has been cited by other articles:
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  B. F. Meyers, P. K. Sultan, T. J. Guthrie, S. S. Lefrak, G. E. Davis, G. A. Patterson, J. D. Cooper, and R. D. Yusen Outcomes after unilateral lung volume reduction. Ann. Thorac. Surg., July 1, 2008; 86(1): 204 - 212. [Abstract] [Full Text] [PDF]
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 M. M. DeCamp Jr., R. J. McKenna Jr., C. C. Deschamps, and M. J. Krasna Lung Volume Reduction Surgery: Technique, Operative Mortality, and Morbidity Proceedings of the ATS, May 1, 2008; 5(4): 442 - 446. [Abstract] [Full Text] [PDF]
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G. J. Criner, A. L. Sternberg, and for the National Emphysema Treatment Trial Researc A Clinician's Guide to the Use of Lung Volume Reduction Surgery Proceedings of the ATS, May 1, 2008; 5(4): 461 - 467. [Abstract] [Full Text] [PDF]
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 T. C. Mineo, E. Pompeo, D. Mineo, P. Rogliani, C. Leonardis, and I. Nofroni Results of unilateral lung volume reduction surgery in patients with distinct heterogeneity of emphysema between lungs J. Thorac. Cardiovasc. Surg., January 1, 2005; 129(1): 73 - 79. [Abstract] [Full Text] [PDF]
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A. Iwasaki, Y. Yoshinaga, and T. Shirakusa Successful Removal of Bovine Pericardium by Bronchoscope After Lung Volume Reduction Surgery Ann. Thorac. Surg., December 1, 2004; 78(6): 2156 - 2157. [Abstract] [Full Text] [PDF]
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 S. D. Nathan, L. B. Edwards, S. D. Barnett, S. Ahmad, and N. A. Burton Outcomes of COPD Lung Transplant Recipients After Lung Volume Reduction Surgery Chest, November 1, 2004; 126(5): 1569 - 1574. [Abstract] [Full Text] [PDF]
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M. Brenner, N. M. Hanna, R. Mina-Araghi, A. F. Gelb, R. J. McKenna Jr, and H. Colt Innovative Approaches to Lung Volume Reduction for Emphysema Chest, July 1, 2004; 126(1): 238 - 248. [Abstract] [Full Text] [PDF]
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Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery J. Thorac. Cardiovasc. Surg., May 1, 2004; 127(5): 1350 - 1360. [Abstract] [Full Text] [PDF]
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B. F. Meyers, R. D. Yusen, T. J. Guthrie, G. A. Patterson, S. S. Lefrak, G. E. Davis, and J. D. Cooper Results of lung volume reduction surgery in patients meeting a National Emphysema Treatment Trial high-risk criterion J. Thorac. Cardiovasc. Surg., March 1, 2004; 127(3): 829 - 835. [Abstract] [Full Text] [PDF]
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J. W. Klena, A. F. Saari, D. O. Peterson, C. Collins, and J. A. Johnson Combined video-assisted thoracoscopic lung volume reduction surgery and lobectomy in a high-risk patient Ann. Thorac. Surg., December 1, 2003; 76(6): 2079 - 2080. [Abstract] [Full Text] [PDF]
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 S.Y. Soon, G. Saidi, M.L.H. Ong, A. Syed, M. Codispoti, and W.S. Walker Sequential VATS lung volume reduction surgery: prolongation of benefits derived after the initial operation Eur. J. Cardiothorac. Surg., July 1, 2003; 24(1): 149 - 153. [Abstract] [Full Text] [PDF]
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A. M. Ciccone, B. F. Meyers, T. J. Guthrie, G. E. Davis, R. D. Yusen, S. S. Lefrak, G. A. Patterson, and J. D. Cooper Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema J. Thorac. Cardiovasc. Surg., March 1, 2003; 125(3): 513 - 525. [Abstract] [Full Text] [PDF]
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I.F. Oey, D.A. Waller, S. Bal, S.J. Singh, T.J. Spyt, and M.D.L. Morgan Lung volume reduction surgery - a comparison of the long term outcome of unilateral vs. bilateral approaches Eur. J. Cardiothorac. Surg., October 1, 2002; 22(4): 610 - 614. [Abstract] [Full Text] [PDF]
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O. Senbaklavaci, W. Wisser, C. Ozpeker, G. Marta, P. Jaksch, E. Wolner, and W. Klepetko Successful lung volume reduction surgery brings patients into better condition for later lung transplantation Eur. J. Cardiothorac. Surg., September 1, 2002; 22(3): 363 - 367. [Abstract] [Full Text] [PDF]
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K. E.A. Burns, R. J. Keenan, W. F. Grgurich, J. D. Manzetti, and M. A. Zenati Outcomes of lung volume reduction surgery followed by lung transplantation: a matched cohort study Ann. Thorac. Surg., May 1, 2002; 73(5): 1587 - 1593. [Abstract] [Full Text] [PDF]
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E. Marchand, P. De Leyn, G. Gayan-Ramirez, F. Palecek, E. Verbeken, and M. Decramer Effects of lung volume reduction surgery in hamsters with elastase-induced emphysema Eur. Respir. J., March 1, 2002; 19(3): 422 - 428. [Abstract] [Full Text] [PDF]
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T. Fujimoto, H. Teschler, L. Hillejan, G. Zaboura, and G. Stamatis Long-term results of lung volume reduction surgery Eur. J. Cardiothorac. Surg., March 1, 2002; 21(3): 483 - 488. [Abstract] [Full Text] [PDF]
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T. Geiser, B. Schwizer, T. Krueger, M. Gugger, V. I. Hof, M. Dusmet, J.-W. Fitting, and H.-B. Ris Outcome after unilateral lung volume reduction surgery in patients with severe emphysema Eur. J. Cardiothorac. Surg., October 1, 2001; 20(4): 674 - 678. [Abstract] [Full Text] [PDF]
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G. R. Stirling, W. J. Babidge, M. J. Peacock, J. A. Smith, K. S. Matar, G. I. Snell, D. J. Colville, and G. J. Maddern Lung volume reduction surgery in emphysema: a systematic review Ann. Thorac. Surg., August 1, 2001; 72(2): 641 - 648. [Abstract] [Full Text] [PDF]
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R. L. Berger, B. R. Celli, A. L. Meneghetti, P. H. Bagley, C. D. Wright, E. P. Ingenito, A. Gray, and G. L. Snider Limitations of randomized clinical trials for evaluating emerging operations: the case of lung volume reduction surgery Ann. Thorac. Surg., August 1, 2001; 72(2): 649 - 657. [Abstract] [Full Text] [PDF]
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G. W. Herget, M. Kassa, U. N. Riede, Y. Lu, L. Brethner, and J. Hasse Experimental use of an albumin-glutaraldehyde tissue adhesive for sealing pulmonary parenchyma and bronchial anastomoses Eur. J. Cardiothorac. Surg., January 1, 2001; 19(1): 4 - 9. [Abstract] [Full Text] [PDF]
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K. S. Naunheim, S. R. Hazelrigg, L. R. Kaiser, R. J. Keenan, J. E. Bavaria, R. J. Landreneau, J. Osterloh, and C. A. Keller Risk analysis for thoracoscopic lung volume reduction: a multi-institutional experience Eur. J. Cardiothorac. Surg., June 1, 2000; 17(6): 673 - 679. [Abstract] [Full Text] [PDF]
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