Awake nonresectional lung volume reduction surgery

Abstract

Objective: To assess the feasibility, safety, and early results of awake lung volume reduction surgery (LVRS) performed under thoracic epidural anesthesia by a new nonresectional technique.

Summary background data: So far, resectional LVRS under general anesthesia and one-lung ventilation is the more frequently used technique, but procedure-related morbidity has been considerable.

Methods: The study cohort included 12 patients undergoing unilateral awake LVRS. Evaluated parameters included technical feasibility and anesthesia satisfaction scored into 4 grades (from 1 = poor to 4 = excellent), global operating room time, and arterial carbon dioxide tension (PaCO2). In addition, 6-month changes in outcome measures, including forced expiratory volume in 1 second (FEV1), residual volume (RV), 6-minute walking test (SMWT), and dyspnea index were recorded. Perioperative and 6-month results were comparable with those of a control group undergoing unilateral resectional LVRS.

Results: Technical feasibility was excellent to satisfactory in 11 patients. One patient required conversion to one-lung ventilation. Differences between the awake and control group included global operating room time (90 +/- 17 minutes versus 145 +/- 19 minutes, P < 0.00001); PaCO2 24 hours after surgery (45 +/- 6 mm Hg versus 49 +/- 6 mm Hg, P = 0.02); and hospital stay (7.8 +/- 5 days versus 11.7 +/- 4 days, P = 0.02). Significant (P < 0.002) improvements occurred at 6 months in FEV1 (0.31 +/- 0.17 L), RV (-1.41 +/- 0.7 L), SMWT (73 +/- 25 m), and dyspnea index (-1.3 +/- 0.5) and were comparable with those of the control group.

Conclusions: In this study, awake nonresectional LVRS proved feasible and safe. This new modality was associated with a faster recovery and satisfactory 6-month outcome, which did not differ from that of resectional LVRS.

FIGURE 1. Edges of the most emphysematous regions are grasped by 2 ring forceps while lung tissue is introflexed by a cotton swab (A); endoscopic “no knife” stapler is applied at the periphery of the plicated area (B); at the completion of the procedure, 3 staples are fired so that the upper lobe lung volume is reduced by about 50% (C).

FIGURE 2. Schematic sagittal drawing illustrating the conceptual difference between resectional LVRS (left) and introflexing lung plication (right). In resectional LVRS, the overall lung volume (A-A¹) is reduced (b) through resection of the most emphysematous lung region (a). The resulting suture line is continuous and placed deep into the lung lobe, thus involving subsegmental bronchi and vessels. Reexpansion forces (central arrow) are exerted directly on the suture line. In introflexing lung plication, equivalent loss of lung volume is achieved without resection of lung tissue; the staple suture line is interrupted and peripheral so that vessels and bronchi are less likely to be involved; furthermore, lung reexpansion forces are not directly applied on the suture due to the “inlay” buttress of the plicated visceral pleura (B-B¹) itself.

FIGURE 3. Preoperative (A, B) and postoperative (C, D) radiologic study of a patient undergoing awake nonresectional LVRS. Postoperative chest roentgenogram (C, D) and high resolution computed tomography (D) show the meaningful reduction of the left lung volume and the absence of suture line within the lung tissue due to the peripheral suturing achieved through introflexing lung plication.