Advances in thoracic surgery : emphysema and simultaneous bronchial carcinoma.

Abstract

Indiscriminate use of LVRS should be avoided, and appropriate patient selection by rigorous assessment is mandatory [10, 11]. LVRS should be considered a palliative procedure to be offered only to a minority of patients with severe emphysema [11]. Assessment for LVRS is based on (a) general, (b) functional and (c) imaging features. These criteria, currently applied in most institutions, are summarized in table 1. Clinical criteria include age, which is arbitrarily cut off at 75 years, smoking cessation and absence of general or local contraindications for surgery. Functional criteria play an essential role in patient selection. Relevant results in this respect recently emerged from a preliminary report of the National Emphysema Treatment Trial: a significantly impaired outcome with high postoperative mortality and little functional benefit in survivors has been observed in patients with DLCO <20% in combination with FEV1 <20% predicted [12]. Morphological criteria, mainly established by high resolution CT scan and ventilationperfusion lung scintigram (fig. 1), are useful tools in determining a heterogeneous pattern of emphysema and identifying target areas of non-functional lung parenchyma for resection [13, 14]. Imaging features are considered important predictors of postoperative functional outcome [10, 11, 15]. In heterogeneous emphysema with upper lobe predominance LVRS has a better and longer-lasting effect than in homogeneous emphysema [15]. This was recently emphasised in a retrospective analysis by Kotloff et al., who deLung volume reduction surgery (LVRS), first described by Brantigan in 1957, has recently been reintroduced and refined as a treatment option in the management of severe disabling pulmonary emphysema [1, 2]. This surgical approach to emphysematous lung disease allows resection of the most impaired and non-functional lung tissue, with improvement of respiration mechanics and enhancement of the lung’s elastic recoil and compliance [3, 4]. The method has shown promising short-term results with substantial improvement of dyspnoea, exercise tolerance, quality of life and pulmonary function in carefully selected patients; this has been observed in some recent controlled trials comparing LVRS with medical treatment [5–9]. However, despite widespread use of the procedure and the rapid progress of the technique, some aspects are still controversial or incompletely elucidated. The aim of this article is to summarise some of the recent data about patient selection criteria and surgical technique, with particular emphasis on the role of LVRS in lung cancer surgery and on the unilateral VATS approach.