Ömer Senbaklavaci

Morphologic Grading of the Emphysematous Lung and Its Relation to Improvement After Lung Volume Reduction Surgery

BACKGROUND The morphologic criteria for lung volume reduction surgery, such as severity and heterogeneity of disease, differ widely between patients, and this makes any comparison of functional results between centers difficult. Here we present a morphologic scoring system and describe its possible relation to functional results after lung volume reduction operations. METHODS Between September 1994 and December 1996, 47 consecutive patients underwent bilateral lung volume reduction operations. The morphology of emphysema was quantified with standard chest roentgenograms and computed tomographic imaging, which were used to define the following four variables: degree of hyperinflation (grade 0 to 4), degree of impairment in diaphragmatic mechanics, degree of heterogeneity (grade 0 to 4), and severity of parenchymal destruction (range, 0 to 48). RESULTS All four variables showed good reproducibility. Degree of heterogeneity had a significant influence on functional improvement in terms of forced expiratory volume in 1 second (p = 0.0413, r2 = 0.11). Severity of parenchymal destruction was significantly associated with 30-day mortality: patients who died after operation (n = 4) had a severity of parenchymal destruction of 28.4 +/- 2.1 compared with 21.3 +/- 1.0 for those who survived (n = 43) (p = 0.003). CONCLUSIONS This morphologic scoring system is easy to use, is reproducible, and allows quantification of the morphology of emphysema, thereby allowing definition of different patient subgroups. Such an exact morphologic quantification may help in the comparison of functional results between centers. Furthermore, the risk factors for certain morphologic subgroups, such as patients with a homogeneous distribution pattern, may be clarified in the future.

Functional Improvement After Volume Reduction: Sternotomy Versus Videoendoscopic Approach

BACKGROUND Volume reduction has been proved to increase ventilatory mechanics in diffuse, nonbullous lung emphysema. However, the best approach is still controversial. METHODS We retrospectively compared the perioperative data of and functional results in 15 patients having sternotomy (group I) with those of 15 patients having a videoendoscopic approach (group II). RESULTS The 30-day mortality was 2 patients in group I and 1 patient in group II. Mean duration of chest tube drainage was 8.7 +/- 1.8 days and 8.0 +/- 1.9 days and mean hospital stay, 12.3 +/- 1.9 and 12.5 +/- 2.1 days in groups I and II, respectively. Work of breathing decreased from 1.89 +/- 0.33 J/L and 1.76 +/- 0.22 J/L preoperatively to 0.75 +/- 0.06 J/L and 0.8 +/- 0.06 J/L (p < 0.01 and p < 0.05, respectively) after 3 months; and intrinsic positive end-expiratory pressure decreased from 7.15 +/- 1.31 cm H2O and 6.24 +/- 1.33 cm H2O to preoperatively 0.79 +/- 0.46 cm H2O and 1.13 +/- 0.44 cm H2O (p < 0.005 and p < 0.01, respectively) after 3 months in groups I and II, respectively. Forced expiratory volume in 1 second increased from preoperative values of 21.6% +/- 2.9% and 25.3% +/- 2.4% of predicted to 34.5% +/- 5.0% and 40.9% +/- 7.5% of predicted after 3 months (p < 0.05 in both groups) in groups I and II, respectively. CONCLUSIONS Both surgical approaches resulted in similar substantial improvement in lung function and physical fitness. The incidence of air leakage, the duration of chest tube drainage, and the hospital stay were the same for both procedures.

Chronic hypercapnia should not exclude patients from lung volume reduction surgery

OBJECTIVE Chronic hypercapnia is still considered to increase the risk for perioperative mortality and therefore to be a contraindication for lung volume reduction surgery (LVRS). The aim of this study was to analyse the influences of hypercapnia upon postoperative outcome. METHODS The functional improvement (preop vs. 3 months postop) and clinical outcome was studied in 22 patients with chronic hypercapnia (preoperative arterial pCO2 > or = 45 mmHg) who underwent LVRS between 9/94 and 2/97 and were compared to all other patients (n = 58) without hypercapnia. Data are expressed as the mean +/- SEM. RESULTS The 30-day mortality was 9.1% (2/22) in patients with chronic hypercapnia (HC) and 5.2% (3/58) in patients with normal arterial pCO2 levels (control) (P = n.s). The stay on the ICU (3.5 +/- 0.8 vs. 2.1 +/- 0.3 days) and duration of chest drainage (7.3 +/- 1.2 vs. 7.2 +/- 0.8 days) was similar between both groups (HC vs. control) (P = n.s). The preoperative lung function (% of predicted) and blood gas (mmHg) parameters were significantly worse in HC patients compared to control patients. In both groups significant functional improvements were observed: FeV1 in the control group increased by 37% within the first 3 months (29.1 +/- 1.7% of predicted vs. 39.9 +/- 3.1% of predicted, P = 0.0198). In the HC group, FeV1 increased by 73% which was even higher than in the controls (19.5 +/- 1.5% of predicted vs. 33.7 +/- 4.7% of predicted, P = 0.0385). All patients of both groups who died perioperatively had a significantly higher severity of parenchymal destruction than those who survived (P = 0.0277 and 0.0380, respectively). CONCLUSIONS Patients with chronic hypercapnia alone, had no significantly higher mortality and morbidity, and therefore should not be excluded from LVRS. However, the presence of additional risk factors, such as homogeneity of disease, high degree of parenchymal destruction or pulmonary hypertension should be considered as contraindications for the procedure.

Successful lung volume reduction surgery brings patients into better condition for later lung transplantation.

OBJECTIVES Lung volume reduction surgery (LVRS) is accepted as a potential alternative therapy to lung transplantation (LTX) for selected patients. However, the possible impact of LVRS on a subsequent LTX has not been clearly elucidated so far. We therefore analyzed the course of 27 patients who underwent LVRS followed by LTX in our institution. METHODS Twenty-seven patients (11 male, 16 female, mean age 51.9+/-2.2 years) out of 119 patients who underwent LVRS between 1994 and 1999 underwent LTX 29.7+/-3.2 months (range 2-57 months) after LVRS. Based on the postoperative course of FeV1 after LVRS (best value within the first 6 months postoperatively compared with the preoperative value) patients were divided into two groups: Group A (n=11) without any improvement (FeV1 <20% increase), and Group B (n=16) with FeV1 increase > or = 20% after successful LVRS which declined to preoperative values after 8-42 months. Subsequent LTX was performed 22.9+/-5.6 months after LVRS in Group A and 34.3+/-4.9 months after LVRS in Group B (P<0.05). Patients were analyzed according to the course of their functional improvement and of their body mass index (BMI) after LVRS and to survival after LTX, respectively. Values are given as the mean+/-SEM and significance was calculated by the chi(2)-test whereas continuous values were estimated by Students t-test. RESULTS Patients in Group A without improvement in FeV1 after LVRS had no increase in BMI as well and this resulted in a high perioperative mortality of 27.3% after LTX. On the contrary, patients in Group B, who had a clear increase of FeV1 after LVRS, experienced a significant increase of BMI of 23.2+/-4.5% as well (P<0.05). This improvement in BMI remained stable despite a later deterioration of FeV1 prior to LTX. After LTX, these patients had a significantly lower perioperative mortality of 6.3% as compared to Group A (P=0.03). CONCLUSIONS Successful LVRS delays the need for transplantation, improves nutritional status and brings patients into a better pretransplant condition, which results in decreased perioperative mortality at LTX. Patients after failed LVRS, however, should be considered as poor candidates for later transplantation.

Is long-term functional outcome after lung volume reduction surgery predictable?

OBJECTIVE The aim of this retrospective study was to analyze which preoperative parameters might predict a persistent improvement in forced expiratory volume in 1 s (FeV1) 1 year after surgery. METHODS Seventy consecutive lung volume reduction surgery (LVRS) patients (age, 56.5+/-1.2 years) with a follow-up period of at least 1 year were analyzed (from September 1994 to September 1997). The patients were described by lung function tests, blood gas analysis, ventilatory mechanics (intrinsic positive endexpiratory pressure (PEEP)) and morphometric data (degree of heterogeneity, DHG; degree of hyperinflation, DHI; severity of parenchymal destruction, SPD) preoperatively. Based on the postoperative course of FeV1 (percentual increase compared with preoperative values, % increase), patients were divided into four groups: group A, (n=21) no improvement (FeV1</=20% increase); group B, (n=10) FeV1>/=20% increase, which declined to preoperative values after 1 year; group C, (n=18) FeV1, 20-40% increase, sustaining at 1 year; group D, (n=21) FeV1>/=40% increase, sustaining at 1 year. The statistics comprised of analysis of variance (ANOVA) and chi-square testing, with values presented as means+/-SEM. RESULTS No differences were found for lung function parameters (FeV1: 27.7+/-2.7, 26.0+/-2.5, 23. 9+/-2.2 and 23.9+/-1.9% predicted, in groups A, B, C and D, respectively). Arterial blood gas levels preoperatively revealed significant differences between the groups; the arterial pO(2) was 66.2+/-1.2 mmHg in groups A+B compared with 61.8+/-1.5 mmHg in groups C+D (P=0.030). The arterial pCO(2) was 39.2+/-1.1 mmHg in groups A+B compared with 43.3+/-1.5 mmHg in groups C+D (P=0.038). The morphometric data had a strong trend towards higher heterogeneity in groups C and D. Marked DHI was found in 59 and 81% of patients in groups A+B versus C+D, respectively (P=0.121). Marked DHG was present in 22 and 54% of patients in groups A+B versus C+D, respectively (P=0.010). CONCLUSION Preoperative arterial pO(2) and pCO(2), and the DHG are predictors for long-term benefit after LVRS with regard to the FeV1, 1 year postoperatively.

Incidence and outcome of major non-pulmonary surgical procedures in lung transplant recipients

OBJECTIVE Pulmonary transplant recipients are at high risk from various conditions requiring surgical intervention. As little is known about their exact incidence and course, we examined such procedures in detail. METHODS AND PATIENTS We have retrospectively analyzed major nonpulmonary surgical procedures performed in 124 consecutive patients who received an isolated lung transplant at the University of Vienna between 1989 and December 1995. Twenty-two patients underwent a total of 28 major interventions (22/124 = 17.7%), resulting in an incidence of one procedure every 5.8 patient years of follow-up. The mean interval between transplantation and intervention was 17.9 months (range 3 days to 62 months) with six interventions being carried out during the first month after transplantation. Fourteen emergency operations were performed, the remaining 14 procedures were carried out electively. Overall, 15 abdominal procedures, four thoracic, four orthopedic, two gynecological, one neurosurgical, one urological and one plastic surgery were performed. RESULTS There was no intraoperative death. Perioperatively, five surgery related deaths were observed (5/28, related mortality 17.9%) with multiple organ failure as the cause of death in all cases. All of these deaths followed emergency operations (5/14 = 35.7%) and all were observed in patients with septic abdominal complications. In contrast, even very extensive procedures were performed electively without related mortality (0/14, P = 0.02). During the first month after transplantation, major surgery was associated with a 50% (3/6) mortality, for late interventions mortality was 9.1% (2/22; P = 0.047). CONCLUSIONS Pulmonary transplant recipients showed a high incidence of conditions requiring surgical intervention. As expected, septic complications, especially during the immediate post transplant period, carried a very poor prognosis. However, it was reassuring to observe that even extensive surgical procedures could be performed safely without associated mortality in the elective setting.

Lung transplantation following lung volume reduction surgery

OBJECTIVE Lung volume reduction surgery (LVRS) has been proposed as a possible alternative treatment to lung transplantation (LTX) for selected patients with end-stage emphysema. But whether LVRS is a temporary or permanent alternative to LTX is still under investigation. The aim of this study was to analyze the course of patients undergoing LVRS followed by subsequent LTX. METHODS Fifteen patients (10 male, 5 female, mean age 53.3 +/- 1.7 years) out of 102 patients, who underwent LVRS between September 1994 and August 1998, underwent LTX 19.6 +/- 3.1 months after LVRS (range 1.7 to 37.6 months) between June 1996 and October 1998. In 9 patients bilateral LVRS was performed, in 6 patients unilateral LVRS. Subsequent LTX was performed bilaterally in 10 patients and unilaterally in 5 patients (1 of these on the contralateral side) to the previous LVRS. The course of lung function and clinical outcome were analyzed in these 15 patients. RESULTS Mean forced expiratory volume in 1 second (FEV(1)) in the 15 patients prior to LVRS was 18.3 +/- 1.2% of predicted (%p) and increased to 27.0 +/- 2.9 %p (best value within the first 6 months postLVRS) (p = 0.043). In 8 of these patients (non-responders) (53%) LVRS failed to improve FEV(1), whereas in the other 7 patients (responders) (47%) a significant improvement was detected (FEV(1) 18.1 +/- 1.8 %p and 31.9 +/- 3.7 %p, pre- and post-LVRS, respectively, p = 0.003), but declined after 6 to 36 months. At the time of listing for LTX the mean FEV(1) was 18.0 +/- 1.9 %p (no difference between the 2 groups). LTX was performed 15.5 +/- 3.6 months (non-responders) and 25.7 +/- 4.6 months (responders) after LVRS. FEV(1) improved to 81.0 +/- 5.6 %p after LTX (p < 0.001 compared to pre-LTX). The mortality after LVRS was 0%. The 3-month mortality after LTX was 20% (1 patient with primary organ failure, 1 patient with ongoing rejection, 1 patient with sepsis). All 3 patients belonged to the group of nonresponders. Two patients died 5. 5 and 8.5 months after LTX (13.3%) due to fungal infection (Aspergillus spp.) and MRSA sepsis, respectively (1 non-responder, 1 responder). CONCLUSIONS Successful LVRS delays the need for LTX and offers better conditions for LTX. However, patients without functional improvement after LVRS have a high perioperative risk at subsequent LTX.

Single versus bilateral lung transplantation

Following the initial success with heart/lung transplantation in Stanford (8), the first successful single lung transplant was accomplished by the Toronto team in 1983 (9). In recent years phenomenal progress has been made in the application of lung transplantation for patients with end-stage pulmonary disease. Experiences of individual groups have challenged old dogmas and led to new approaches in all facets of lung transplantation. However, it still remains in debate which form of lung transplantation represents the optimal treatment for the specific indications. Despite the clinical acceptance of both, single and double lung transplantation, their role and potential has still to be determined. This refers to the clarification of the ideal indications, to the functional benefit, as well as to the long-term outcome that can be reached with each technique. In this chapter, the various aspects of single and double lung transplantation are discussed.

Lung volume reduction surgery in patients with emphysema@@@Lungenvolumsreduzierende Operation bei Patienten mit Emphysem

SummaryBackground: Lung Volume Reduction Surgery (LVRS) is a new surgical approach in patients with severe, non-bullous lung emphysema. Although it was first described byBrantigan in 1957,Cooper reintroduced the technique 1995 into surgical practice. Selection of patients for LVRS is based on history, clinical investigation, chest X-ray, lung function testing with blood gas analysis, measurement of ventilatory mechanics and CT-scan. Selection criteria are severe emphysema (FeV1<35 % predicted, RV>250 % predicted, TLC>130 % predicted), dyspnea despite optimized medical therapy, radiological signs of hyperinflation, heterogeneity of disease and impaired ventilatory mechanics. Once a patient is accepted for the procedure he should enter a rehabilitation program to optimize his overall condition and exercise endurance. Selection of patients for LVRS is based on history, clinical investigation, chest X-ray, lung function testing with blood gas analysis, measurement of ventilatory mechanics and CT-scan. Selection criteria are severe emphysema (FeV1<35 % predicted, RV \s>250% predicted, TLC\s>130 % predicted), dyspnea despite optimized medical therapy, radiological signs of hyperinflation, heterogeneity of disease and impaired ventilatory mechanics. Once a patient is accepted for the procedure he should enter a rehabilitation program to optimize his overall condition and exercise endurance. Methods: Excision of peripheral lung segments is performed with stapling devices. Usually it is achieved to resect about 30 % of lung tissue. With removal of the most diseased parts of the lung, LVRS intends to reduce residual and total lung volume, to bring the diaphragm back to a normal position and to restore transdiaphragmatic pressure generation. Recent studies have demonstrated improvements in pulmonary function. ventilatory mechanics, exercise tolerance and quality of life in selected patients following LVRS. However some questions regarding overall benefit, optimal patient selection, operative techniques and duration of response still remain undefined. Results: In our own experience, between September 1994 and May 1998 LVRS was performed through median sternotomy (n=15), videoendoscopically (n=49), by thoracotomy (n=18) or combined, videoendoscopically on one side, thoracotomy on the other (n=9) in 91 patients (age 33–80 years; mean 56.4 years). Perioperative mortality was 5.5 % (5 patients). Mean FeV1 significantly increased by 28.6 % from 25.5±1.2 % preoperatively to 32.8±1.9 % after the first 6 months postoperatively (p<0.05). Mean RV was reduced from 320.3±7.9 %, preoperatively to 248.4±7.5 % 6 months post-operatively and mean TLC from 140.2±2.4 % to 126.1±2.11 % (p<0.05). Intrinsic PEEP decreased significantly from 5.1±0.4 cm H2O preoperatively to 2.3±0.3 cm H2O postoperatively (p<0.05). Conclusions: These results suggest LVRS as an excellent therapeutic option for selected patients with severe emphysema and additional signs of severe hyperinflation. LVRS offers the possibility of significant postoperative functional improvement and marked increase in quality of life.ZusammenfassungGrundlagen: Die Lungenvolumenreduktion (LVRS) ist ein neues chirurgisches Verfahren bei Patienten mit schwerem, nichtbullösem Lungenemphysem. Obwohl LVRS erstmals 1957 vonBrantigan beschrieben wurde, führteCooper 1995 die Technik wieder in die chirurgische Praxis ein. Die Patientenselektion für LVRS basiert auf Anamnese, klinischer Untersuchung, Thoraxröntgen, Lungenfunktion mit Blutgasanalyse. Vermessung der Atemmechanik und CT-Untersuchung. Die Selektionskriterien sind schweres Emphysem (FeV1<35 % des Sollwertes, RV > 250 % des Sollwertes. TLC > 130 % des Sollwertes), Dyspnoe trotz optimaler medikamentöser Therapie, radiologische Zeichen der Überblähung sowie Heterogenität der Erkrankung und eingeschränkte Atemmechanik. Wird ein Patient für das Verfahren ausgewählt, soll er ein Rehabilitationsprogramm absolvieren, um seinen Allgemeinzustand und seine körperliche Belastbarkeit zu optimieren. Methodik: Die Resektion von peripheren Lungensegmenten wird mit Klammernahtapparaten durchgeführt. Eine Verringerung von zirka 30 % des Lungengewebes wird angestrebt. Durch die Resektion der am meisten destruierten Areale verringert sich das Residual- und Gesamtlungenvolumen, das Zwerchfell erhält wieder seine funktionell bessere Wölbung, so daß eine Verbesserung des transdiaphragmentalen Druckaufbaues möglich wird. Studien zeigten bei selektionierten Patienten eine Verbesserung der Lungenfunktion, der Atemmechanik, der Leistungsfähigkeit und der Lebensqualität nach LVRS. Jedoch sind noch einige Fragen hinsichtlich der optimalen Patientenselektion, der Operationstechnik und des Langzeiterfolges offen. Ergebnisse: An unserer Abteilung wurde die LVRS zwischen September 1994 und Mai 1999 über mediane Sternotomie (n=49), über Thorakotomie (n=18) oder kombiniert über Thorakotomie auf einer Seite und Videoendoskopisch auf der anderen Seite (n=9) bei insgesamt 91 Patienten (Alter 33 bis 80 Jahre, mittleres Alter 56,4 Jahre) durchgeführt. Die perioperative Mortalität betrug 5,5 % (5 Patienten). Die mittlere FeV1 erhöhte sich signifikant um 28,6 % von 25,5±1,2 % des Sollwertes präoperativ auf 32,8±1,9 % des Sollwertes innerhalb der ersten 6 Monate postoperativ (p<0,05). Das mittlere RV sank von 320,3 ±7,91 % des Sollwertes präoperativ auf 248,4±7,5 % des Sollwertes 6 Monate postoperativ und die mittlere TLC von 140,2 ± 2,4 % des Sollwertes auf 126,1±2,1 (p<0,05). Der intrinsische PEEP sank signifikant von 5,1±0,4 cm H2O präoperativ auf 2,3 ±0,3 cm H2O postoperativ (p < 0,5). Schlußfolgerungen: Diese Ergebnisse deuten darauf hin, daß LVRS eine ausgezeichnete therapeutische Option bei selektionierten Patienten mit schwerem Emphysem und zusätzlichem Zeichen einer schweren Überblähung ist. LVRS bietet die Möglichkeit einer signifikanten postoperativen funktionellen Verbesserung und einer deutlichen Steigerung der Lebensqualität.

Lung Volume Reduction Surgery in Patients with Emphysema

SummaryBackground: Lung Volume Reduction Surgery (LVRS) is a new surgical approach in patients with severe, non-bullous lung emphysema. Although it was first described byBrantigan in 1957,Cooper reintroduced the technique 1995 into surgical practice. Selection of patients for LVRS is based on history, clinical investigation, chest X-ray, lung function testing with blood gas analysis, measurement of ventilatory mechanics and CT-scan. Selection criteria are severe emphysema (FeV1<35 % predicted, RV>250 % predicted, TLC>130 % predicted), dyspnea despite optimized medical therapy, radiological signs of hyperinflation, heterogeneity of disease and impaired ventilatory mechanics. Once a patient is accepted for the procedure he should enter a rehabilitation program to optimize his overall condition and exercise endurance. Selection of patients for LVRS is based on history, clinical investigation, chest X-ray, lung function testing with blood gas analysis, measurement of ventilatory mechanics and CT-scan. Selection criteria are severe emphysema (FeV1<35 % predicted, RV \s>250% predicted, TLC\s>130 % predicted), dyspnea despite optimized medical therapy, radiological signs of hyperinflation, heterogeneity of disease and impaired ventilatory mechanics. Once a patient is accepted for the procedure he should enter a rehabilitation program to optimize his overall condition and exercise endurance. Methods: Excision of peripheral lung segments is performed with stapling devices. Usually it is achieved to resect about 30 % of lung tissue. With removal of the most diseased parts of the lung, LVRS intends to reduce residual and total lung volume, to bring the diaphragm back to a normal position and to restore transdiaphragmatic pressure generation. Recent studies have demonstrated improvements in pulmonary function. ventilatory mechanics, exercise tolerance and quality of life in selected patients following LVRS. However some questions regarding overall benefit, optimal patient selection, operative techniques and duration of response still remain undefined. Results: In our own experience, between September 1994 and May 1998 LVRS was performed through median sternotomy (n=15), videoendoscopically (n=49), by thoracotomy (n=18) or combined, videoendoscopically on one side, thoracotomy on the other (n=9) in 91 patients (age 33–80 years; mean 56.4 years). Perioperative mortality was 5.5 % (5 patients). Mean FeV1 significantly increased by 28.6 % from 25.5±1.2 % preoperatively to 32.8±1.9 % after the first 6 months postoperatively (p<0.05). Mean RV was reduced from 320.3±7.9 %, preoperatively to 248.4±7.5 % 6 months post-operatively and mean TLC from 140.2±2.4 % to 126.1±2.11 % (p<0.05). Intrinsic PEEP decreased significantly from 5.1±0.4 cm H2O preoperatively to 2.3±0.3 cm H2O postoperatively (p<0.05). Conclusions: These results suggest LVRS as an excellent therapeutic option for selected patients with severe emphysema and additional signs of severe hyperinflation. LVRS offers the possibility of significant postoperative functional improvement and marked increase in quality of life.ZusammenfassungGrundlagen: Die Lungenvolumenreduktion (LVRS) ist ein neues chirurgisches Verfahren bei Patienten mit schwerem, nichtbullösem Lungenemphysem. Obwohl LVRS erstmals 1957 vonBrantigan beschrieben wurde, führteCooper 1995 die Technik wieder in die chirurgische Praxis ein. Die Patientenselektion für LVRS basiert auf Anamnese, klinischer Untersuchung, Thoraxröntgen, Lungenfunktion mit Blutgasanalyse. Vermessung der Atemmechanik und CT-Untersuchung. Die Selektionskriterien sind schweres Emphysem (FeV1<35 % des Sollwertes, RV > 250 % des Sollwertes. TLC > 130 % des Sollwertes), Dyspnoe trotz optimaler medikamentöser Therapie, radiologische Zeichen der Überblähung sowie Heterogenität der Erkrankung und eingeschränkte Atemmechanik. Wird ein Patient für das Verfahren ausgewählt, soll er ein Rehabilitationsprogramm absolvieren, um seinen Allgemeinzustand und seine körperliche Belastbarkeit zu optimieren. Methodik: Die Resektion von peripheren Lungensegmenten wird mit Klammernahtapparaten durchgeführt. Eine Verringerung von zirka 30 % des Lungengewebes wird angestrebt. Durch die Resektion der am meisten destruierten Areale verringert sich das Residual- und Gesamtlungenvolumen, das Zwerchfell erhält wieder seine funktionell bessere Wölbung, so daß eine Verbesserung des transdiaphragmentalen Druckaufbaues möglich wird. Studien zeigten bei selektionierten Patienten eine Verbesserung der Lungenfunktion, der Atemmechanik, der Leistungsfähigkeit und der Lebensqualität nach LVRS. Jedoch sind noch einige Fragen hinsichtlich der optimalen Patientenselektion, der Operationstechnik und des Langzeiterfolges offen. Ergebnisse: An unserer Abteilung wurde die LVRS zwischen September 1994 und Mai 1999 über mediane Sternotomie (n=49), über Thorakotomie (n=18) oder kombiniert über Thorakotomie auf einer Seite und Videoendoskopisch auf der anderen Seite (n=9) bei insgesamt 91 Patienten (Alter 33 bis 80 Jahre, mittleres Alter 56,4 Jahre) durchgeführt. Die perioperative Mortalität betrug 5,5 % (5 Patienten). Die mittlere FeV1 erhöhte sich signifikant um 28,6 % von 25,5±1,2 % des Sollwertes präoperativ auf 32,8±1,9 % des Sollwertes innerhalb der ersten 6 Monate postoperativ (p<0,05). Das mittlere RV sank von 320,3 ±7,91 % des Sollwertes präoperativ auf 248,4±7,5 % des Sollwertes 6 Monate postoperativ und die mittlere TLC von 140,2 ± 2,4 % des Sollwertes auf 126,1±2,1 (p<0,05). Der intrinsische PEEP sank signifikant von 5,1±0,4 cm H2O präoperativ auf 2,3 ±0,3 cm H2O postoperativ (p < 0,5). Schlußfolgerungen: Diese Ergebnisse deuten darauf hin, daß LVRS eine ausgezeichnete therapeutische Option bei selektionierten Patienten mit schwerem Emphysem und zusätzlichem Zeichen einer schweren Überblähung ist. LVRS bietet die Möglichkeit einer signifikanten postoperativen funktionellen Verbesserung und einer deutlichen Steigerung der Lebensqualität.