Staged unilateral lung volume reduction surgery: from mini-invasive to minimalist treatment strategies

Abstract

Lung volume reduction surgery (LVRS) entailing unilateral or bilateral non-anatomical resection of severely damaged emphysematous tissue carried out by thoracoscopic or open surgical approaches, under general anesthesia with single-lung ventilation, has resulted in significant and long-lasting clinical and functional benefit. Unfortunately, the morbidity rates reported by simultaneous bilateral resectional LVRS has led to raise criticism regarding its cost-effectiveness and has stimulated in recent years the development of less invasive bronchoscopic and surgical non-resectional methods of treatment that are preferentially performed in a staged unilateral fashion. We had previously proposed an innovative LVRS modality, which did not entail any resection of lung tissue and was electively carried out according to a staged unilateral strategy by a multiport thoracoscopic access, through thoracic epidural anesthesia in conscious, spontaneously ventilating patients (awake LVRS). The awake LVRS resulted in significant clinical benefit paralleling that achieved by the resectional method with lower morbidity rates and shorter hospital stay. Moreover, the awake LVRS proved also suitable to be employed in stringently selected patients to perform redo procedures following previous successful bilateral LVRS. More recently, in order to minimize the global surgery- and anesthesia-related traumas, we have modified our original non-resectional method by adopting a single thoracoscopic access as well as an anesthesia protocol entailing use of a simple intercostal block with target control sedation, to realize an ultra-minimally invasive or minimalist LVRS. Hence, a deeper investigation of the pros and cons of staged unilateral LVRS strategies as well as of the novel surgical non-resectional and redo LVRS is warranted in order to verify, the optimal strategies of treatment, which will prove to reduce the typical LVRS-related morbidity while assuring the most durable benefit in patients with advanced emphysema.

Keywords: Lung volume reduction surgery (LVRS); chronic obstructive pulmonary disease (COPD); emphysema; nonintubated anesthesia; thoracoscopy; video-assisted thoracic surgery (VATS).

Figure 1

Operative details and radiological outcome of a right-sided minimalist LVRS procedure. (A) Operative view of the minimalist LVRS method showing the single-access approach including adoption of a laryngeal mask (a) and of a silk suture crossing the wound-covering port to fix the camera in upward position and facilitating surgical maneuvering (b); (B) a large plication is being accomplished by peripheral no-knife stapling starting in the middle of the lung upper lobe; preoperative (C) versus postoperative (D) computed tomography scan of the chest demonstrate that following minimalist LVRS, a significant reduction of the right lung volume is achieved with any loss of tissue. LVRS, lung volume reduction surgery.

Figure 2

Typical HRCT findings of a patient undergoing staged unilateral minimalist LVRS. (A) Preoperative HRCT findings with upper lobe predominant severe non-bullous emphysema; (B) postoperative HRCT axial image after right minimalist LVRS; (C) postoperative radiological findings following left minimalist LVRS performed 15 months later. HRCT, high-resolution computed tomography; LVRS, lung volume reduction surgery.