Lung Volume Reduction Surgery - An Overview

Introduction

Lung volume reduction surgery is carried out in patients with terminal-stage chronic obstructive pulmonary disease. This surgery focuses on improving the quality of life for the patients suffering.

What Is Lung Volume Reduction Surgery (LVRS)?

Lung volume reduction surgery is a procedure that can be done in patients with chronic obstructive pulmonary disease or severe emphysema. The technique was first described in the 1950s, but the main rise in considering the procedure as a treatment option was seen in the 1990s only after good management of the complications was sought. In 2003, a landmark study in the evolution of this surgical procedure was done by a center known as the National Emphysema Treatment Trial (NETT). The study was based on the effectiveness of the procedure on the life quality and survival rate of patients as compared to normal medical therapy.

When Is Lung Volume Reduction Surgery (LVRS) Considered?

The anatomy and physiology of the affected lung play the prime role in considering lung volume reduction surgery in the individual. With the high rate of COPD-related deaths worldwide, patients with emphysema due to the disease have a poor quality of life. Emphysema leads to small airway disease and reduced elastic recoil that creates lung hyperinflation due to air trapping. Some lung function tests that indicate the obstruction process is an increase in Functional Residual Capacity (FRC) and a decrease in Inspiratory Capacity. Earlier, the technique was focused on altering the chest wall or diaphragm, but the latest technology includes transplantation, bullectomy, and LVRS.

What Are the Indications For Lung Volume Reduction Surgery (LVRS)?

In 2003, a randomized trial was carried out by NETT across 17 institutions with nearly 1000 patients to check the effect of medical therapy in comparison to medical therapy along with Lung Volume Reduction Surgery (LVRS). The indications are

• Body mass index (BMI) which is lower than 32 kg/m2.

• The forced expiratory volume in one second should be less than 45 %.

• The arterial pressure of CO2 (carbon dioxide) should be less than 60 mmHg.

• The arterial pressure of oxygen should be greater than 44 mmHg.

• No smoking for at least four months before initial screening.

What Are the Contraindications For Lung Volume Reduction Surgery (LVRS)?

The contraindications of lung volume reduction surgery are -

1. Impaired Pulmonary Function - Patients must have a certain lung function level to tolerate surgery. If the lung function is compromised, the risks may outweigh the potential benefits.

2. Significant Comorbidities - The presence of severe heart disease, liver disease, or other serious health conditions may increasesurgical risk.

3. Active Smoking - Smoking is a major risk factor for emphysema. However active smoking at the time of surgery increases the likelihood of complications and hinders postoperative recovery.

4. Cancer of Lung Infection - Current or recurring cancer as well as the active infection lungs are the contraindications for the procedure.

5. Inability To Complete Rehabilitation - The success of LVRS is often contingent on postoperative rehabilitation. Patients unable to participate in rehabilitation may not derive the full benefits of surgery.

What Are the Techniques of LVRS?

The techniques used for LVRS are typically surgeries -

• Median Sternotomy - This is a surgical procedure that involves making an incision along the midline of the sternum to access the thoracic cavity. This approach provides a direct and comprehensive view of the heart and other structures within the chest. The sternum is typically divided allowing surgeons access to perform the LVRS.

• Video Assisted Thoracic Surgery (VATS) - This technique is minimally invasive where several small incisions are made in the chest wall. A thoracoscope (a thin-walled tube with a camera) and specific instruments are put through the incisions, allowing the surgeons to view and operate on the lungs.

• Bullectomy - In some cases, especially when large air sacs called bullae are present, surgeons may perform bullectomy( removal of one or more large bullae) as a part of LVRS to improve lung function.

A special surgical instrument called an eternal saw is used for median sternotomy. An endotracheal tube, arterial line insertion, and post-operative as well as preoperative considerations should be checked ahead of time. Some surgeons have preferred buttressing material and stapler methods of suture to prevent air leaks but there has been no particular evidence to suggest postoperative air leaks.

What Are the Complications of LVRS?

Some possible complications of LVRS that require immediate and potential attention are -

• Infections including pneumonia.

• Air leaks from the lungs into the chest cavity.

• Excessive bleeding might happen in some cases.

• Cardiac complications such as arrhythmias or heart attacks.

• Blood clots or pulmonary embolism.

What Are the Advantages of Lung Volume Reduction Surgery?

Though not everyone suffering from COPD is a candidate for this surgery a successful surgery has the following advantages -

• It leads to improved lung function.

• Increase tolerance to physical activity and exercise.

• Enhanced quality of life.

• There is considerable relief to symptoms.

• This leads to a decrease in dependence on medication.

• Provides an alternative to lung transplant.

What Is the Prognosis of LVRS?

The prognosis of the procedure varies depending on the patient's overall health, severity of lung disease and how well they respond to surgery.The procedure is considered as the last resort in advanced cases hence the prognosis differs from person to person and the age.

Conclusion

In conclusion, lung volume reduction surgery is a valuable intervention for selected individuals with severe emphysema. While offering potential advantages such as improved lung function and enhanced quality of life, it is crucial to know the associated risks and complications. The decision to undergo LVRS should be based on careful patient selection. As the ongoing research refines techniques and patient criteria, LVRS continues to contribute to the management of severe emphysema, providing customized approaches to improve respiratory well-being.