Lung Volume Reduction Surgery
Lung volume reduction surgery (LVRS) was first used to treat emphysema in the 1950s after being described by Dr. Otto Brantigan at the University of Maryland. It was not widely practiced because of the uncertainty surrounding its long-term benefits and high-risk mortality. Thanks to medical developments, physicians began using LVRS in the 1990s to help treat people with severely disabling emphysema.
The Division of Thoracic Surgery at the University of Maryland is a leader in making this treatment option more widely available to patients. LVRS involves removing about 20 to 30 percent of the damaged lung so that the remaining tissue and surrounding muscles are able to work more efficiently, making breathing easier.
Candidates for Surgery
The National Emphysema Treatment Trial (NETT) study results identified four sub-groups of patients who had different risks and benefits from LVRS. Those groups include:
- Group 1: Mostly upper-lobe emphysema and low exercise capacity. These patients were more likely to live longer and were more likely to function better after LVRS than after medical treatment.
- Group 2: Mostly upper-lobe emphysema and high exercise capacity. These patients are more likely to function better after LVRS than after medical treatment, but there was no difference between the LVRS and Medical participants in survival.
- Group 3: Mostly non upper-lobe emphysema and low exercise capacity. These patients had similar survival and function after LVRS as after medical treatment.
- Group 4: Mostly non upper-lobe emphysema and high exercise capacity. These patients had worse survival after LVRS than after medical treatment; both LVRS and medical participants had similar low chance of functioning better.
A high-risk patient has been defined by NETT criteria as a patient who would not benefit from LVRS but is more likely to be harmed, as outlined in Group 4. Specifically, the high-risk patient is one who has a forced expiratory volume in the first second (FEV1) that is 20% or less of their predicted value and either homogenous distribution of emphysema on CT Scan or low carbon monoxide diffusing capacity (DlCO) that is 20% or less of their predicted value. These specific criteria can be determined after the testing process has been completed. Finally, a patient with a certain underlying medical disease, condition or multiple surgical risk factors may also not be a surgical candidate for LVRS.
LVRS candidates who fall into Groups 1, 2 or 3 are the best candidates for LVRS. All LVRS candidates are encouraged to discuss their individual characteristics with their primary care provider or pulmonologist to determine if they are likely to benefit from LVRS.
- There are numerous risks involved with lung reduction surgery. Lung reduction surgery has a higher risk than heart surgery, because the candidates have poor lung function and are generally older in age.
- The death rate for this surgery is approximately 6 to 10 percent nationwide. This is one of the highest risk elective procedures performed.
Thoracoscopy (Unilateral or Bilateral)
Thoracoscopy is a minimally invasive technique. Three small (approximately 1-inch) incisions are made in each side, between your ribs. A video-scope is placed through one of the incisions. This scope allows the surgeon to see your lungs. A stapler and grasper are inserted in the other incisions. These are used to cut away the most damaged areas of the lung. The stapler will reseal the remaining lung. Sutures that will eventually dissolve are used to close the incisions. This technique can be used to operate on either one or both lungs and allows assessment and resection of any part of the lungs.
An incision is made through the breastbone to expose both lungs. Both lungs are reduced at the same sitting in this procedure, one after the other. The chest bone is wired together and the skin is closed. This is the most invasive technique, used when thoracoscopy is not appropriate. This approach is usually used for upper lobe disease only.
Thoracotomy (Unilateral or One-Sided)
For the thoracotomy technique, an incision is made between your ribs. The incision is approximately 5 to 12 inches long. Your ribs are separated, not broken, and your lungs are seen. Only one lung is reduced with this procedure. Your muscle and skin are closed by sutures. Thoracotomy is often used when the surgeon is unable to see the lung clearly through the thoracoscope or when dense adhesions (scar tissue) is found.
- Air leakage -- This is the most common complication with over 50% of patients reporting some degree of air leakage. Air leakage occurs when air leaks from the lung tissue, coming from the suture line, into the chest cavity. If the air volume becomes too great, the pressure could collapse the lung tissue. One or more chest tubes are placed during surgery to monitor air leakage and prevent the collapse of the lung tissue.
- Pneumonia (19%) or infection (1-5%) is common in emphysema patients, especially when they have a history of these conditions.
- Stroke (less than 1%)
- Bleeding (2-5%)
- Heart attack (1%)
- Death that results from a worsening of one of the above complications (6-10%)
The Hospital Experience
Patients should expect to stay approximately 5 to 10 days on the Cardiothoracic Surgical Care Units. Most patients stay in the Intensive Care Unit (ICU) for at least two days. Expect to be up in the chair and walking within hours of surgery.
Pulmonary rehabilitation will start on your first post-operative day. These exercises and training are very important for your recovery. The more you exercise and move, the quicker and less painful your recovery will be. Your motivation to recover strongly affects this part of your treatment. You may not feel up to exercising, but you must. Listen to the nurses and therapists; they will be important keys in your recovery. You will be walking in the halls, on the treadmill or on the bicycle everyday!
- Cardiothoracic Intensive Care Unit (CTICU): Patients will stay in the CTICU post-operatively. While in the CTICU, patients will not require any items from home. Visiting hours are from 11:00 a.m. to 7:00 p.m. and 8:00 p.m. to 9:00 p.m. Please note that these hours are at the discretion of the nursing staff.
- 6 Gudelsky Building (6G): Once a patient is ready to be moved from the CTICU, they will be transferred to a room on the sixth floor of the Gudelsky Building. At this time, patients may keep their own personal items with them. Visiting hours are from 11:00 a.m. to 8:30 p.m. Please note that these hours are at the discretion of the nursing staff.
While a patient is in the CTICU or on 6G, the designated family spokesperson may check on their status by calling one of the following numbers:
- CTICU: 410-328-5382
- 6G: 410-328-5380
The family spokesperson may also call the patient's room directly.
During the pre-operative process, the patient has undergone extensive pulmonary rehabilitation. This process will need to be continued up until the time of surgery, as well as during the post-operative period, which includes the initial days after surgery.
It is very important to cough and breathe deeply after surgery. Your lungs need to be fully expanded to prevent infection and collapse. Deep breathing, coughing and incentive spirometry are the most effective means of achieving this goal. Please practice coughing and deep breathing before you come in for surgery.
- Deep Breathing: Fill your lungs up slowly over a count of five (5), hold for a count of five (5) and then exhale slowly over a count of five (5). REPEAT 10 TIMES per hour while you are awake.
- Coughing: Take three (3) slow breaths, filling your lungs up as much as possible. Initiate your cough on the second breath's exhale cycle. Make sure you hold your incision (splint) during your cough. REPEAT 10 TIMES per hour while you are awake.
- Incentive Spriometer: This device will be given to you the day of surgery. Hold the spirometer securely in two hands. Place your mouth on the mouthpiece and exhale around the mouthpiece, make a tight seal on the mouthpiece and inhale slowly to the count of five (5); watch the disc move upward. Hold for a count of five (5) and loosen the seal around the mouthpiece and exhale. REPEAT 10 TIMES per hour while you are awake.
To make an appointment with the University of Maryland Division of Thoracic Surgery, please call 410-328-6366.