Inger Oey

Metalloptysis: a late complication of lung volume reduction surgery

We describe three cases where patients expectorated titanium staples many months after lung volume reduction surgery (LVRS). The possible mechanisms and technical implications of this rare complication are discussed.

Lung volume reduction surgery – a comparison of the long term outcome of unilateral vs. bilateral approaches

OBJECTIVE Bilateral lung volume reduction surgery (LVRS) is thought to be preferable to unilateral surgery due to greater initial benefit but the subsequent rate of decline may also be greater. We compared the long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs. METHODS Prospective data were collected on a consecutive series of 65 patients undergoing LVRS who were all suitable for bilateral surgery. Twenty-six patients: age 59 (8) years underwent bilateral LVRS by video-assisted thoracoscopy (VAT) or sternotomy and 39 patients: age 60 (6) years underwent unilateral VAT. The perioperative effects of LVRS on spirometry were prospectively recorded at 3, 6, 12 and 24 months. RESULTS The unilateral group had similar preoperative lung volumes to the bilateral patients: forced expiratory volume in 1s (FEV(1)) 26 vs. 30% predicted, RV 275 vs. 246% predicted and total lung capacity (TLC) 148 vs. 142% predicted. Unilateral LVRS was associated with significantly lower weight of lung resected: 80 (31) vs. 118 (46) g; hospital stay: 16 (10) days vs. 28 (22) days. Thirty-day mortality was 3% in the unilateral and 8% in the bilateral group (P=0.34). Postoperative ventilation occurred in 5% in the unilateral and in 42% in the bilateral group (P=0.0002). The decline of FEV(1) during the first postoperative year was significant in the bilateral group (-313 ml/y, P=0.04) but not significant in the unilateral group (-50 ml/y, P=0.18). SF 36 scores in all eight domains were similar in both groups preoperatively and at any postoperative interval. CONCLUSION We have found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit.

En-bloc chest wall and lung resection for non-small cell lung cancer. Predictors of 60-day non-cancer related mortality.

OBJECTIVE Predictors for early mortality after isolated pulmonary resection have been identified and clear guidelines regarding fitness for surgery have been produced. However, the additional risk of en-bloc chest wall resection has not been extensively studied. AIM We analyzed our total experience of combined chest wall and lung resection for non-small-cell lung cancer (NSCLC) to identify additional risk factors for early non-tumour related mortality. PATIENTS AND METHODS A retrospective review of 41 consecutive patients, with median age of 69 (range 37-84) years, operated by a single surgeon over a 4-year period. Univariate analysis was performed to assess the relationship of selected preoperative and operative variables on mortality within 2 months from surgery. RESULTS Low preoperative body mass index, age over 75 years, and preoperative FEV(1) of less than 70% of predicted were associated with a significantly increased 60-day mortality. In those patients with any of these risk factors 60-day mortality was 47% (8 of 17). In those with none of the above there was no mortality (of 24 patients) (P=0.0004). DISCUSSION En-bloc pulmonary and chest wall resection for NSCLC should be avoided in the elderly, those with limited respiratory reserve or significant weight loss. These factors render the patient highly susceptible to chest complications leading to increased mortality.

The role of the emphysema multidisciplinary team in a successful lung volume reduction surgery programme

OBJECTIVES Lung volume reduction surgery (LVRS) for advanced emphysema is well established, with strong evidence from the National Emphysema Treatment Trial. However, there is still reluctance to offer the procedure, and many have looked for alternative, unproven treatments. The multidisciplinary approach has been well established in treatment of lung cancer and, more recently, in coronary artery surgery. We reviewed our practice to validate the role of our multidisciplinary team approach in our LVRS programme. METHODS Our multidisciplinary approach employs respiratory physicians, radiologists and surgeons involved in case selection, who meet on a regular basis. Cases are selected on the basis of clinical presentation, imaging (radionuclide lung perfusion and computerized tomography) and respiratory physiology. Retrospective analysis of prospectively collected data on 633 patients referred for lung volume reduction surgery between July 1995 and July 2013. RESULTS Six hundred and thirty-three patients (422 male) were referred for LVRS, of whom 253 [178 male; median age 61 years (range 37-79 years)] underwent 292 LVRS procedures.There were 268 video-assisted thoracoscopic surgical procedures, of which 13 were one-stage bilateral procedures and 37 required a staged second side. Overall median hospital stay was 13 (4-197) days, during which 11 patients died. Prolonged hospital stay was associated with increasing age and with duration of air leak, which in turn was associated with diffusion capacity and forced expiratory volume in 1 s. CONCLUSIONS The outcomes of a successful LVRS programme are not only dependent on good surgical technique and post-operative care. Case selection and work-up by a dedicated multidisciplinary approach for emphysema patients plays an invaluable and integral part in an LVRS programme.

Post-pneumonectomy video-assisted thoracoscopic bullectomy using extra-corporeal membrane oxygenation.

We describe a case of a patient who, 14 years after a pneumonectomy, required surgery for a life-threatening air-leak following accidental intubation of an emphysematous bulla in his remaining lung. To facilitate treatment by video-assisted thoracoscopic surgery, veno-venous extra-corporeal membrane oxygenation was employed.

The long-term health status improvements seen after lung volume reduction surgery

OBJECTIVES To correlate the long-term changes in respiratory physiology, body mass index (BMI) and health status after lung volume reduction surgery (LVRS). PATIENTS/METHODS From 1995 to 2002 77 patients; 48 male: 29 female, median age 59 (41-72) years, have undergone LVRS (simultaneous bilateral in 27; staged bilateral in 3; unilateral in 47). FEV(1), total lung capacity (TLC), residual volume (RV) and RV/TLC ratio were measured preoperatively and at 3 months, 6 months, 1 year, 2 years, 3 years and 4 years post surgery. At the same time interval health status was assessed by Euroquol and Short Form 36 (SF 36) questionnaires. Seventeen patients have died within 4 years of their operation (30 day mortality 5%). RESULTS The changes in FEV(1) are only significantly improved for 1 year post LVRS, while the improvements in TLC and RV remain significant up to 3 years postoperatively. The improvements in BMI also persist for 3 years. The best scores in Euroquol and SF 36 are obtained 6 months after LVRS but are only significantly improved up to 1 year. CONCLUSION The physiological effects of volume LVRS are lasting but initial improvements in health status decline more rapidly.

Postoperative pain detracts from early health status improvement seen after video-assisted thoracoscopic lung volume reduction surgery.

OBJECTIVES To assess the impact of lung volume reduction surgery (LVRS) on postoperative pain. METHODS Fifty-two patients, 34 male/18 female, median age 59 (46-70) years, underwent unilateral video-assisted thoracoscopic (VAT) LVRS. FEV(1), TLC, RV and RV/TLC ratio were assessed preoperatively and at 3, 6, 12 and 24 months post surgery. At the same time interval health status was assessed by Euroquol and SF 36 questionnaires. RESULTS Significant improvements in health status, as assessed by SF 36, persisted from 3 months to 1 year. However, in the pain domain there was a worsening of the mean score from 74 preoperatively to 64 at 3 months, 68 at 6 months, 73 at 12 months and 65 at 24 months. The improvements in Euroquol score were not statistically significant. However, they became significant for at least 2 years postoperatively, when those patients who had a worsening pain score postoperatively were excluded. While the percentage of patients with a worsening of pain scores measured with SF 36 remained between 40 and 45% even 2 years after LVRS, when using Euroquol this percentage did decrease from 30% at 3 months to 14% at 2 years. There was no significant correlation between the change of scores and length of operation, hospital stay or air leak. It was also not statistically significant whether these patients had an extra procedure (redo thoracotomy or insertion of extra drain postoperatively). There were some significant correlations between changes in hyperinflation and changes in pain scores but this was not consistent for Euroquol and SF 36. CONCLUSION Postoperative pain detracts from global improvement in health status after LVRS even after unilateral VATS. There may be an influence of alterations in chest mechanics after surgery on the development of pain.

Individualised risk in patients undergoing lung volume reduction surgery (LVRS): The Glenfield BFG Score

Lung volume reduction surgery (LVRS) has been shown to be beneficial in patients with chronic obstructive pulmonary disease, but there is low uptake, partly due to perceived concerns of high operative mortality. We aimed to develop an individualised risk score following LVRS. This was a cohort study of patients undergoing LVRS. Factors independently predicting 90-day mortality and a risk prediction score were identified. Reliability of the score was tested using area under the receiver operating characteristic curve (AUROC). 237 LVRS procedures were performed. The multivariate analysis factors associated independently with death were: body mass index (BMI)<18.5 kg·m−2 (OR 2.83, p=0.059), forced expiratory volume in 1 s (FEV1)<0.71 L (OR 5.47, p=0.011) and transfer factor of the lung for carbon monoxide (TLCO) <20% (OR 5.56, p=0.031). A risk score was calculated and total score assigned. AUROC for the risk score was 0.80 and a better predictor than individual components (p<0.01). The score was stratified into three risk groups. Of the total patients, 46% were classified as low risk. Similar improvements in lung function and health status were seen in all groups. The score was introduced and tested in a further 71 patients. AUROC for 90-day mortality in this cohort was 0.84. It is possible to provide an individualised predictive risk score for LVRS, which may aid decision making for both clinicians and patients. An individualised risk score for lung volume reduction surgery may aid decision making around surgery http://ow.ly/4lxm30b3n05

Staged lung volume reduction surgery--rationale and experience.

The current convention is for bilateral one-stage lung volume reduction surgery. Unilateral surgery results in a symptomatic improvement in most patients. A staged approach to the second lung may reduce the risk of surgery and lead to a slower decline in physiologic improvement. The timing of the second operation can be influenced by the patient and the surgeon. The surgeon may be anxious to avoid the patient becoming inoperable because of excessive physiological decline or the patient succumbing to the inherent mortal risk of emphysema. The patient may be the best arbiter. The operation should be intended to improve his or her subjective assessment of health status; therefore, this parameter ultimately should determine the surgical schedule.

S26 Individualising the Mortality Risk For Lung Volume Reduction Surgery

Background Despite the positive results of the NETT trial in favour of lung volume reduction surgery (LVRS) uptake of the technique has been limited largely due to an exaggerated fear of the associated mortality risk. We have analysed our 18 year experience of LVRS to provide a more sophisticated personalised risk profile based on individual patient data. Methods Since 1994 we have performed 250 lung volume reduction procedures on 220 patients: 153M:97F, age 61 (39–74) years. The initially approach was through median sternotomy (20 patients), with the subsequent 230 procedures performed by video-assisted thoracoscopic surgery (VATS), 3 of which required conversion to open thoracotomy. All patients underwent standard physiological and anatomical selection techniques with 51 (20%) falling outside recognised safety limits (FEV1 or DLCO <20% predicted). All patients were offered surgery after discussion in our LVRS MDT panel and counselled on risk on their basis of their physiological status. We analysed data collected prospectively using logistic regression to identify the factors predicting early postoperative mortality. Results Open surgery significantly increased the risk of 30 day mortality 22% vs VATS 3.6% (p=0.005). Bilateral vs unilateral VATS had no influence. At 30 days mortality was associated with low BMI, DLCO and KCO At 90 days, mortality was also associated with FEV1 and RV:TLC DLCO was the only significant independent predictor of 30 day (OR 0.88, CI 0.80–0.97) and 90 day (OR 0.92, CI 0.88–0.98) mortality after VATS (table 1). The causes of death after 30 days in the VATS group were mainly due to pneumonia (5 cases) with cardiac complications (2); tension pneumothorax (1) and fatal pulmonary haemorrhage (1) in the remainder. Conclusion LVRS is primarily a procedure to improve health status so accurately informed consent is imperative. Careful consideration of preoperative physiological characteristics and operative technique allows estimation of an individualised mortality risk for LVRS which may be lower than the commonly perceived overall figure. Abstract S26 Table 1 DLCO (%pred) 30 day mortality VATS 90 day mortality VATS <20%pred (n=19) 16% 32% 20–40%pred (n=102) 5% 11% 40–60%pred (n=76) 0% 0% >60%pred (n=16) 0% 6%