ISKANDER AL GITHMI, M.D.

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ISKANDER AL GITHMI, M.D.
LUNG VOLUME REDUCTION SURGERY (L V R S)
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BACKGROUND
Dr. Brantigan in 1957 was the first person to
present the concept of LVRS. His concept, based
on Under normal circumstances, the elasticity
of expanded lung is transmitted to the small
airways which held opened by circumferential
elastic pull
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In emphysema this elasticity and circumferential
pull on the small airways are lost. He
proposed Resection of the most useless area
and Down sizing the lung would help to restore
the outward pull on the small airway
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In 1991, Wakabayashi and colleague reported
using the carbon dioxide laser to shrink
bullous areas of the lung via VATs. In 1995,
Cooper and Associate a modification of
Brantigans volume reduction operation, in which
lung tissue was resected from both lungs via
median sternotomy. He reported his initial 20
cases with no operative mortality and the
operation produced an 82 mean increase in
FEV1.0 and significant improvement in 6 min.
walking distance.
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In 2001, Cooper and associate report 6 cases of
endobronchial bypass procedure by creating
extra-anatomic broncho-pulmonary passage and
placing a stent. His concern? How long the
stent stay open.
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OVERVIEW
EMPHYSEMA is a condition of the
lung characterized by abnormal permanent
enlargement of airspace distal to the terminal
bronchiole, accompanied by destruction of their
wall in the absence of fibrosis.
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PATHO PHYSIOLOGY
Dyspnea
Loss of elastic recol
Increase resting volume
Increase work of breathing
Expansion of rib cage and flattening the
diaphragm
Inefficient respiratory muscle
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PATIENT SELECTION
NOT ALL PATIENTS BENEFIT FROM LVRS

• Indication

• Severe emphysema not reversible by
• medical treatment.
• Poor exercise performance.
• Marked hyperinflation.

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EXCLUSION CRITERIA

• Advanced age, above 70 years
• Paco2 more than 55 mmHg.
• Mean pulmonary artery pressure gt35mmHg
• Psychosocial unstable
• Severe active infection bronchiectasis, TB
• Malignancy with life expectancy less than
  2 years
• Significant coronary artery disease not candidate
  for revascularization.

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INCLUSION CRITERIA

• Age less than 75 years
• FEV1.0 less than 35 of predicted value
• TLC more than 125 of predicted value
• RV/TLC more than 0.6
• Vo2 max. less than 12 ml/kg/min
• Highly motivated and stably psychosocial patient.
• Radiological evidence of heterogenous
  distribution of emphysema.

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PATIENT EVALUATION

• Initial screening routine CXR PA and lateral.
• Standard pulmonary function tests.
• Extensive history and exam.

On this basis 70 of applicants are turned down,
due to a lack of distension or the presence of
homogenous severe destruction throughout the
lung.
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FINAL EVALUATION

• HRCT scan
• Quantitative V/Q scan
• Lung-volume measurement
• Dobutamine echo cardiogram
• 6-minute walk test (140 m)

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OUTCOME MEASURE
PRIMARY MEASURES According to NETT study group -
Survival - Maximum exercise capacity
SURVIVAL is chosen as primary measure because
- It is clinically significant - It can be
assessed early and quantified
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OUTCOME MEASURE
MAXIMUM EXERCISE IS CHOSEN BECAUSE - It is
easier to standardize - More reproducable than
6 min walk test - There is no study document a
consistent
relationship between
improvement in
functional status and changes in
pulmonary function.
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SECONDARY MEASURES

• Quality of life and specific symptoms dyspnea
• Pulmonary function and gas exchange
• Radiologic studies
• - CT scan to verify the presence of
• emphysema and to assess the severity
• of the disease.
• 6 Minute Walking Test
• - to assess the exercise performance

Source JTCS 1999, 118
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Does lung functions improve after LVRS?

• Konrad et al have reported 115 patients
• underwent LVRS.
• Symptoms and lung functions were assessed
• before the operation and 3, 6 and every 6
• months after the operation.
• CONCLUDE FEV1.0 peaks within 6 months post
• operative then decline in the fist year and
• slows down in succeeding years to baseline.

Source JTCS 2002 123845
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RELATION BETWEEN AGE AND CLINICAL OUTCOME
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RELATION BETWEEN RADIOLOGICAL PATTERN AND
CLINICAL OUTCOME
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SURGICAL INTERVENTION
LVRS performed by means of bilateral VATS or
median sternotomy (buttressed or non buttressed
with bovine peri cardium). Resection is
directed to the target areas identified by means
of analysis of the CT scan and perfusion scan as
the lung and the lung zones with the most
pronounced emphysematous alteration and greatest
reduction in perfusion.
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PATIENTS AT HIGH RISK OF DEATH AFTER LVRS
A total of 1033 patients had been randomized by
June 2001. 69 Patients had FEVI lt 20 of their
predicted value and homogenous distribution of
emphysema on CT scan or their DLCO lt 20 of
predicted value. The 30-days mortality rate
after surgery was 16 as compared with the rate
of 0 among 70 medically treated patients (P lt
0.001). Concluded Very low DLCO
Very low FEV1.0
Homogenous distribution of emphysema are
at high risk of death after LVRS.
Source NEJM 345 1075 1083 Oct. 2001
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ISSUES AFTER L V R S
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DEVELOPMENT OF PULMONARY HYPERTENSION
Weg. et al reported that development of
pulmonary hypertension may occur after LVRS. 9
Patients were involved in a prospective study
with an average age of 64 years After LVRS (PA)
systolic pressure rose to 47.69 12.4 mmHg but
the changes in PAP did not correlate with the
changes in symptoms.
Source AM.J. Respir. Crit Care, 1999
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TAKE HOME MESSAGE

• There are no long term data as yet.
• LVRS improved the life of many patients.
• We are still on a learning curve in predicting
• outcome after LVRS.

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THANK YOU!