Thoracic Surgery Division

Lung Volume Reduction Surgery (LVRS)

Background Information on LVRS | What to Expect Before, During and After Surgery | Patient Evaluation, Testing, etc.

Background Information on LVRS

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This approach to treating emphysema was first used 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 long-term benefits and high-risk mortality. Due to recent medical developments, physicians have begun using LVRS in the 1990s to help 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 lungs so that the remaining tissue and surrounding muscles are able to work more efficiently, making breathing easier.

Between 1994 and 1997, over seven hundred patients were evaluated at the University of Maryland’s Emphysema and Treatment program with over 120 procedures performed.

In 1997, the University of Maryland was awarded a National Institutes of Health (NIH) grant to become one of the 17 centers of excellence in the National Emphysema Treatment Trial (NETT). This national clinical trial was designed to determine what is the best treatment for people with severe emphysema: medical management alone, which typically involves medication and rehabilitation or medical management plus Lung Volume Reduction Surgery (LVRS), in which damaged portions of each lung are removed. At the University of Maryland Medical Center, patients are evaluated for two different approaches: open sternotomy or bilateral thoracoscopy (VATS).

The results of the NETT Study indicate that, on average, patients who undergo LVRS with medical therapy are more likely to function better after two years and do not face an increased risk of death compared to those who receive medical therapy only. Specific subgroups have been identified in the assessment of risk and functional benefits from LVRS.

Lung Volume Reduction Surgery

The National Emphysema Treatment Trial (NETT) study results have identified four sub-groups of patients who had different risks and benefits from LVRS. Specifically:

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 the NETT criteria as the patient who would not benefit from LVRS but is more likely to be harmed, as outlined in Group 4 above. 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.

Emphysema

Emphysema is a disease of the lung, which is caused by chronic irritation of the lung tissue. The most common cause of Emphysema is smoking. Chronic irritation of the lungs causes the lung sacks (aveoli) to break down and form large “bullae” or “air sacks”. These air sacks trap air in your lungs. These air sacks are not used efficiently in gas exchange during normal breathing. The air sacks also compress the underlying lung and stretch the overlying muscles used in breathing. This compression and the decreased ability to use the normal mechanism of breathing may be the reason emphysema patients are short of breath.

In Lung Volume Reduction Surgery, surgeons remove about 30 percent of the damaged lungs. By reducing the lung size, the remaining lung and surrounding muscles (intercostals and diaphragm) are able to work more efficiently and make breathing easier. The patient will need to go under general anesthesia for this operation.

Risks

There are many risks involved with lung reduction surgery. Lung reduction surgery has a higher risk than heart surgery. This is because the candidates have poor lung function and are generally older.
The death rate of this surgery is about 6 to 10 percent nationwide. This is one of the highest risk procedures performed electively.

Complications

Air leakage-- this is the most common complication. 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 the air leakage and prevent the collapse of the lung tissue. Over 50% of patients have some degree of air leak.
Pneumonia (19%) or infection (1-5%) is common in emphysema patients, especially when they have a history of recurrent bouts.
Stroke (less than 1%)
Bleeding (2-5%)
Heart attack (1%)
Death which results from a worsening of one of the above complications causing a combination of problems which ultimately lead to death (6-10%)

Surgical Techniques

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 close the incisions. This technique can be used to operate on either one or both lungs and allows assesment and resection of any part of the lungs.

Sternotomy (bilateral)

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 thoracocopy is not appropriate. This approach is usually used only for upper lobe disease.

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 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.

Chest Tubes

Chest tubes are used for drainage and to monitor air leaking. These are placed at the time of surgery. The chest tube is hooked up to a container and water chamber. The chest tube will remain in until the drainage stops and there is no air leaking. Occasionally, chest tubes are left in after discharge from the hospital and are removed in a subsequent office visit.

Pain Control

Operations create pain. We make every effort to minimize your discomfort through IV medications and epidural catheters. An epidural catheter is a very small tube placed in your back at the time of surgery. Pain medication is infused through the catheter that will bathe the spinal cord and prevent pain. You will feel discomfort from the chest tube, but the pain will be managed through the catheter. You will be asked frequently about your pain. Please be honest about your pain. It is very important for the pain to be under control because taking deep breaths and moving are essential for quick recovery.

Pulmonary Rehabilitation

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.

Deep Breathing & Coughing & Incentive Spirometry

It is very important to cough and deep breathe 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.

The Hospital Experience

Patients should expect to stay approximately 5 to 10 days on the Cardio-Thoracic 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

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 every day!

Visiting Hours

Cardio-Thoracic 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. – 7:00 p.m. and 8:00 p.m. – 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 6^th 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. – 8:30 p.m. Please note that these hours are at the discretion of the nursing staff.

Patient Updates

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
Or call into the patient’s room directly.

This page was last updated on: May 20, 2008.

For more information or to schedule a consultation in our clinic, please contact us at 410-328-6366 or fax 410-328-0693.