Chronic obstructive pulmonary disease surgery

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2], Priyamvada Singh, MBBS [3], Seyedmahdi Pahlavani, M.D. [4]

## Overview

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Patients with emphysema may have big bullae ranging from 1-4 cm and may occupy third of lung space. These bullae can cause compromise to ventilation and perfusion. Bullectomy is the surgical removal of these bullae. It is commonly done in patients with FEV1 < 50% of predicted and who are symptomatic. Bullectomy helps in re-expansion of the lung tissue. Lung reduction surgery may be an option for patients with severe symptoms that are not responding to maximal medical therapy.

## Surgery

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### Bullaectomy

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* The giant bullae (1-4 cm, giant bullae may occupy 1/3rd of lung tissue) seen in patients of emphysema can compress the surrounding lung tissues and cause compromised ventilation and blood flow to unaffected lung.
* Bullectomy is the process of removing these bullae and can help these patients as it causes expansion of the compressed lung
* Patients who are symptomatic and have an FEV1 of less than 50% of the predicted value have a better outcome after bullectomy.
* Postoperative bronchopleural air leak is the major complication.

### Lung volume reduction surgery

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* The ICSI 2011 COPD guidelines state that lung reduction surgery may be an option for patients with severe symptoms that are not responding to maximal medical therapy.

* Surgeons generally resect 20-30% of each lung from the upper zones in lung volume reduction surgery (LVRS).

* The surgery can be considered in heterogeneous (upper lobe) disease, low exercise capacity despite optimal medical therapy and cardiopulmonary rehabilitation. It should be avoided in (high risk group). Patients with an FEV1 of less than 20% of predicted and either homogenous disease or DLCO (diffusing capacity of lung for carbon monoxide) of less than 20% of predicted)

* Several studies have demonstrated significant benefit in spirometry, exercise tolerance, dyspnea, health-related quality of life, and mortality in selected group of patients.

* Complications[1][2]
* Mortality ranges somewhere between 0-18%
* Pneumonia
* Prolonged air leaks
* Indications:[3][4][5]
* Age <75 years
* Ex-smoker (>6 months)
* Clinical picture consistent with emphysema
* Dyspnea despite maximal medical therapy and pulmonary rehabilitation
* FEV1 after bronchodilator <45 percent predicted
* Hyperinflation (TLC >100 percent predicted, RV >150 percent)
* Post rehabilitation 6-minute walk distance >140 meters
* Low post rehabilitation maximal achieved cycle ergometry watts
* Chest radiograph - hyperinflation
* HRCT confirming severe emphysema, ideally with upper lobe predominance
* Contraindications:[3][4][5][6]
* Age ≥75 years
* Current smoking
* Surgical constraints (eg, previous thoracic procedure, pleurodesis, chest wall deformity)
* Pulmonary hypertension (PA systolic >45 mmHg, PA mean >35 mmHg)
* Clinically significant bronchiectasis
* Clinically significant coronary heart disease
* Heart failure with an ejection fraction <45 percent
* Uncontrolled hypertension
* Obesity
* FEV1 ≤20 percent predicted with either DLCO ≤20 percent predicted or homogeneous emphysema
* PaO2 ≤45 mmHg on room air
* PaCO2 ≥60 mmHg
* Homogeneous emphysema with FEV1 ≤20 percent predicted
* Significant pleural or interstitial changes on HRCT
* Non-upper lobe predominant emphysema and high post rehabilitation maximal achieved cycle ergometry watts

### Lung Transplantation

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* Lung transplantation is still not very popular around the world. It is undertaken mostly at tertiary centers.
* It is primarily done for improvement of symptoms and quality of life. Large scale trials are still needed to show its effect on survival.
* COPD patients are the largest single category of patients who undergo lung transplantation.
* Mean survival after lung transplantation is 5 years.
* The survival at 1 year is 80-90%.
* Criteria to consider in patient selection-
* Symptoms
* Co-morbid conditions
* BODE index >5, projected survival without transplantation
* Most centers have an age limit of 65 years.

## References

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1. ↑ Naunheim KS, Wood DE, Krasna MJ, DeCamp MM, Ginsburg ME, McKenna RJ, Criner GJ, Hoffman EA, Sternberg AL, Deschamps C (2006). "Predictors of operative mortality and cardiopulmonary morbidity in the National Emphysema Treatment Trial". J. Thorac. Cardiovasc. Surg. 131 (1): 43–53. doi:10.1016/j.jtcvs.2005.09.006. PMID 16399293.
2. ↑ Decker MR, Leverson GE, Jaoude WA, Maloney JD (2014). "Lung volume reduction surgery since the National Emphysema Treatment Trial: study of Society of Thoracic Surgeons Database". J. Thorac. Cardiovasc. Surg. 148 (6): 2651–8.e1. doi:10.1016/j.jtcvs.2014.02.005. PMC 4130795. PMID 24631312.
3. ↑ 3.0 3.1 Fishman A, Martinez F, Naunheim K, Piantadosi S, Wise R, Ries A, Weinmann G, Wood DE (2003). "A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema". N. Engl. J. Med. 348 (21): 2059–73. doi:10.1056/NEJMoa030287. PMID 12759479.
4. ↑ 4.0 4.1 Hamacher J, Büchi S, Georgescu CL, Stammberger U, Thurnheer R, Bloch KE, Weder W, Russi EW (2002). "Improved quality of life after lung volume reduction surgery". Eur. Respir. J. 19 (1): 54–60. PMID 11843327.
5. ↑ 5.0 5.1 Fessler HE, Scharf SM, Ingenito EP, McKenna RJ, Sharafkhaneh A (2008). "Physiologic basis for improved pulmonary function after lung volume reduction". Proc Am Thorac Soc. 5 (4): 416–20. doi:10.1513/pats.200708-117ET. PMC 2645312. PMID 18453348.
6. ↑ Ingenito EP, Evans RB, Loring SH, Kaczka DW, Rodenhouse JD, Body SC, Sugarbaker DJ, Mentzer SJ, DeCamp MM, Reilly JJ (1998). "Relation between preoperative inspiratory lung resistance and the outcome of lung-volume-reduction surgery for emphysema". N. Engl. J. Med. 338 (17): 1181–5. doi:10.1056/NEJM199804233381703. PMID 9554858.

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