Bilateral Apical vs Nonapical Stapling Resection During Lung Volume Reduction Surgery

¹ From the Division of Pulmonary and Critical Care Medicine, and Cardiothoracic Surgery, Temple University School of Medicine, Philadelphia, PA.

John M. Travaline, MD, FCCP, Pulmonary and Critical Care, Temple University School of Medicine, 3401 North Broad Street, Philadelphia, PA 19140

Study Objectives: To determine whether biapical stapling resection alone or resection of diseased, nonapical areas of emphysematous lung provides comparable physiologic outcomes or alters morbidity and mortality after lung volume reduction surgery (LVRS).

Design: Consecutive case-series analysis.

Setting: Urban university hospital.

Patients: Forty-seven patients ([mean ± SD] aged 58 ± 8 years; 18 men) with severe emphysema (FEV₁, 0.7 ± 0.2 L; total lung capacity [TLC], 139 ± 23% predicted).

Interventions: Thirty-two patients underwent biapical LVRS, 27 by median sternotomy (MS) and 5 by video-assisted thoracoscopic surgery (VATS), and 15 underwent nonapical resection, 9 by MS and 6 by VATS. Patients were assessed for postoperative complications (respiratory tract infections, air leak duration, and death), length of stay, and physiologic parameters, which included a 6-min walk distance, spirometry, lung volume, gas exchange, diaphragm strength, and quality-of-life measures.

Measurements and Results: Patients were studied at baseline and at 3 months postoperatively. At the preoperative baseline, both groups had similar ages (57 vs 60 years; p = 0.2), 6-min walk distance (294 vs 263 m; p = 0.3), FEV₁ (28% vs 29% predicted; p = 0.6), degree of hyperinflation (TLC, 138% vs 141% predicted; p = 0.8), gas exchange (PaO₂/fraction of inspired oxygen, 344 vs 313, p = 0.1; PaCO₂ 46 vs 48 mm Hg, p = 0.4), and diaphragm strength (maximal transdiaphragmatic pressure sniff, 54 vs 46 cm H₂O, p = 0.4). Resected tissue weight was similar in both groups (94 vs 93 g, p = 0.9). There were no differences in the mean percentage of change from baseline for these physiologic parameters or for quality-of-life measures between the two groups. The 6-min walk distances increased by 20% and 33%, FEV₁ increased by 37% and 38%, the degrees of hyperinflation (residual volume/TLC) decreased by 16% and 15%, and the quality-of-life scores improved by 51% and 41%, respectively, in the groups that underwent biapical and nonapical resections at 3 months post-LVRS. The length of stay in the hospital for LVRS (18 vs 23 days; p = 0.4) and the duration of air leak (10 vs 15 days; p = 0.4) were also similar. Complications between the two groups (biapical vs nonapical) were similar (respiratory tract infection, 47% vs 60%, p = 0.2; reintubation, 34% vs 33%, p = 0.2; reoperation, 9% vs 20%, p = 0.4; and death, 9% vs 7%, p = 0.2).

Conclusions: LVRS, by biapical or nonapical resection, produces similar improvements in lung function, exercise, diaphragm strength, and quality of life, with comparable morbidity and mortality.

Key Words: COPD • emphysema • lung volume reduction surgery • reduction pneumoplasty

Submitted on February 5, 1998
Accepted on May 20, 1998

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