(L V R S)
Presenter- Dr.Jyotindra Singh
NIZAMS INSTITUTE ,HYDERABAD
Lung volume reduction surgery (LVRS), or reduction pneumoplasty
(also referred to as lung shaving or lung contouring), is performed on
patients with severe emphysema in order to allow the remaining
compressed lung to expand and thus improve respiratory function.
In advanced stages of emphysema there is a sequence of events
that start with hyperinflation, followed by a reduction in
diaphragmatic mobility, an increase in resting pleural pressures that
intensifies expiratory muscle recruitment and reduces elastic recoil of
The medical treatment of this condition includes bronchodilators,
costicosteroids, oxygen and the management of exacerbations and
infections but it does not impact on survival
The current options for the surgical treatment are surgical ablation
of bulous disease (bullectomy), lung volume reduction surgery (LVRS)
and lung transplantation.
Dr. Brantigan in 1957 was the first person to
present the concept of LVRS.
His concept, based on
“Under normal circumstances, the elasticity
of expanded lung is transmitted to the small
airways which held opened by
circumferential elastic pull”
“Resection of the most useless area and
Down sizing the lung would help to restore
the outward pull
on the small airway”
Several decades later – Delarue and Dahan - unilateral
thoracotomy approach - pulmonary haemodynamics.
1991 – Wakabayashi-unilateral parenchymal laser ablation
by thoracoscopic approach.
In 1995, Cooper and Associate a modification of
Brantigan’s volume reduction operation,in which lung tissue
was resected from both lungs via median sternotomy.
In 2001, Cooper and associate report 6 cases of endobronchial
bypass procedure by creating extra-anatomic broncho-pulmonary
passage and placing a stent. His concern? How long the stent stay
This was followed by randomized studies that demonstrated
functional benefits and acceptable mortality in patients with low
exercise capacity and upper lobe predominant heterogeneous disease
(Ciccone, Meyers et al. 2003).
NETT RESEARCH GROUP
Carried between January 1998 and July 2002
17hospitals, data coordinating center JHSPH
Patients randomized to medical or surgery treatment
Secondary end points included quality of life, pulmonary function,
6-min walk distance
N Engl J Med 2001
What is Emphysema?
enlargement of the acini
Destruction of alveolar
walls without obvious
Specifically, two things combined:
Two kinds of emphysema
1-2% of cases
Inherited lack of alpha-1
antitrypsin, a protective
protein (inhibits neutrophil
Also caused by inability to
inhibit proteolytic enzymes
in the lungs
From inhaled toxins (e.g.,
20% of smokers at risk
Age 30…a robust young man
Age 51…riding into the sunset
Bullous Emphesyma CENTRIACINAR EMPHYSEMA
“Bullae are large dilated airspaces that
bulge out from beneath the pleura.”
Respiratory bronchioles in proximal portion of
acinus are lost
Alveoli distal to terminal bronchiole intact
Occurs in smokers with chronic bronchitis
Usually in upper lobes
1. VENTILATION/PERFUSION MISMATCH
Patients with end-stage emphysema have distended airspaces; these
may be inadequately ventilated.
These distended airspaces may continue to expand and compress
adjacent, well-perfused alveoli, which then become similarly
Resection of such damaged lung would remove some component of
the ventilation/perfusion mismatch and potentially allow reexpansion
of adjacent alveoli
The combination of the loss of the
driving force of elastic recoil and the
reduced tethering effect leads to
closure of terminal bronchioles earlier
in the expiratory cycle than what
would normally occur.
Over time, these forces result in
increased airway resistance and
hyperinflation of the lung.
LVR entails resection of hyperinflated
and nonfunctional lung
Loss of elastic recol
Expansion of rib cage
and flattening the
work of breathing
CHEST WALL & DIAPHRAGM
Chest Wall and Diaphraghm
Excision of nonfunctional hyperinflated lung
will lead to a smaller overall lung volume.
This provides the opportunity for the chest wall to
shrink down to a less hyperexpanded position and the
diaphragm to resume its more dome-like appearance.
Theoretically this return of the chest wall and diaphragm
to their more normal shape and position will restore some
of the functional capacity and muscular strength, leading
to greater volumes of air movement throughout
the respiratory cycle
Chest radiographs obtained at TLC and FRC in one patient before (Pre-op) and
at 6 months and 12 months after LVRS. Top six views: anteroposterior views.
HAEMODYNAMICS LVR would theoretically decrease the
size of the lung within the chest cavity
and, by decreasing airway resistance,
would lead to a lowering of the
intrathoracic pressure throughout the
It might therefore improve venous
return, decrease pulmonary vascular
resistance, and thus improve right heart
output and overall cardiac index.
This was in part the pathophysiologic
mechanism for improvement promoted
by DeLarue13 and Dahan
Decrease size of lung within
lowering of intrathoracic
Improve venous return,decrease
Improve right heart output
PRE OPERATIVE ASSESMENT
CHEST X RAY
Quantitative V/Q scan
Lung-volume measurement/ PFT
Maximal exercise testing-6-minute walk test
CHEST X RAY
INFLATED lungs is noted
with flattend and low
A horizontal pattern of ribs
A long thin heart shadow
Decreased markings of
lung peripheral vessels
. (A) Preoperative plain chest radiographs reveal marked emphysematous
changes with bullae over the apical zones of both lungs that were more
predominant on the right.
(B) A follow-up chest radiograph 3 months after surgery shows a less flattened
diaphragm and apparent lung marking over the right upper lung zone.
Document the presence of emphysema
Rule out the presence of infiltrative processes/ occult lung
Presence of solitary nodule undetected on X- RAY
HRCT – whether Emphysema is homogenous or heterogenous
Upper lobe predominant or lower lobe predominant
Three major types of emphysema distribution were defined: markedly heterogeneous (upper panel),
intermediately heterogeneous (middle panel), and homogeneous (lower panel).
HRCT shows diffuse emphysematous changes over both lungs, with bulla formation that predominates over
both upper lung zones, indicating vanishing tissue in the upper lungs.
(D) HRCT taken three months after surgery shows an apparent disappearance of bullae with more
pronounced vasculature in the right lung but with little change to the left lung.
Ventillation & Perfusion
significant lack of
perfusion in the upper
Persistent retention of
gas in same region
disease with severe
involvement in upper
Lung perfusion single positron emission computed tomography scan showing underperfused areas
(darkened zones) in the right lower lobe lateral basal segment and in the anterior segment of the left upper
PULMONARY FUNCTION TEST
Optimal candidates are those with severe obstructive
disease (forced expiratory volume in one second [FEV1]
<40% predicted) without a significant restrictive component
or reversible bronchoconstriction.
Plethysmography must demonstrate significantly increased
total lung capacity (TLC) >120% predicted as well as
elevated residual volume (RV) >150% predicted.
Initial testing also includes determination of resting arterial
blood gases (PO2 and PCO2). The diffusing capacity (DLCO)
is also measured and, proves to be an important parameter
that can occasionally contraindicate surgical intervention.
Ideally, patients who are candidates for LVR have a PO2
>60, a PCO2 <55 mm Hg, and a DLCO >20% predicted.
The BODE score
Four factors predict increased risk of death:
BODY MASS INDEX
The degree of airflow obstruction (FEV1)
Exercise tolerance (6 MW distance)
Patients with higher BODE score - are at higher risk of death
BODE index has a stronger ability to discriminate the probability of
survival among patients than FEV1
The BODE score predicts hospitalization better than FEV1
Computation of the BODE score
Variable Points on BODE Index
0 1 2 3
> 65 50-64 36-49 <35
6MW distance m >350 250-349 150-249 < 149
0-1 2 3 4
BMI > 21 < 21
CARDIO VASCULAR WORK UP
Doppler echocardiography is routinely used to rule out significant
cardiomyopathy and valvular heart disease.
Early in the clinical experience, Doppler echocardiography was
utilized to try to identify those patients with pulmonary hypertension,
because such patients were felt to have an elevated risk of mortality.
However, Fisher and coworkers documented relatively mediocre
sensitivity (60%) and specificity (74%) when echocardiography was
utilized in this fashion.
Patients in whom pulmonary hypertension is suspected on the basis
of signs, symptoms or radiographic findings should therefore undergo
right heart catheterization to determine whether pulmonary pressures
NOT ALL PATIENTS BENEFIT FROM
Severe emphysema not reversible by
Poor exercise performance.
The National Emphysema Treatment Trial (NETT) was a prospective, randomized,
multicenter trial which compared the results of LVRS to medical therapy which
showed that there were 3 groups of patients that tend to benefit from LVRS
Group 1: Patients with predominantly upper lobe emphysema and low exercise
capacity. These patients have improved survival and functional outcomes after
LVRS compared to medical therapy.
Group 2: Patients with predominantly upper lobe emphysema and high exercise
capacity. These patients have improved functional outcomes after LVRS but no
difference in survival compared to medical therapy.
Group 3: Patients with non-upper lobe emphysema and low exercise capacity.
These patients have improved survival after LVRS but no difference in survival
compared to medical therapy.
History and physical examination;
BMI ≤31.1 kg/m2 (men) or ≤32.3 kg/m2 (women) at randomization; stable on ≤20 mg
prednisone (or equivalent) daily
Radiographic HRCT scan evidence of bilateral emphysema
Pulmonary function (pre-rehabilitation) FEV1≤45% predicted (≥15% predicted if ≥70 years);
TLC ≥100% predicted; RV ≥150% predicted
Arterial blood gas (pre-rehabilitation) PCO2 ≤60 mm Hg (Denver: PCO2≤55 mm
Hg) PO2 ≥45 mm Hg (Denver: PO2 ≥30 mm Hg) on room air
Cardiac assessment Approval for surgery before randomization by cardiologist if any of
the following are present: unstable angina; LVEF cannot be estimated from the echocardiogram; LVEF
≤45%; dobutamine-radionuclide cardiac scan indicates coronary artery disease or ventricular dysfunction;
arrhythmia (≥5 PVCs per minute; cardiac rhythm, other than sinus; PACs at rest)
INCLUSION CRITERIA Surgical assessment Approval for surgery by pulmonary physician, thoracic
surgeon, and anesthesiologist after rehabilitation and before randomization
Exercise Post-rehabilitation 6-minute walk ≥140 meters; able to complete 3
minutes of unloaded pedaling in exercise tolerance test (before and after
Consent Signed consent forms for screening, rehabilitation, and randomization
Smoking Plasma cotinine ≤13.7 ng/mL (or arterial carboxyhemoglobin ≤2.5% if
using nicotine products); nonsmoking for 4 months before initial interview and
Rehabiliation -Must complete pre-randomization assessments, rehabilitation
program, and all post-rehabilitation and randomization assessments
Previous operation Lung transplantation; LVRS; median sternotomy or lobectomy
Cardiovascular Arrhythmia that might pose a risk during exercise or training; resting bradycardia (<50
beats/min); frequent multifocal PVCs; complex ventricular arrhythmia; sustained SVT; history of exercise-
related syncope; MI within 6 months and LVEF <45%; congestive heart failure within 6 months and LVEF
<45%; uncontrolled hypertension (systolic >200 mm Hg, diastolic >110 mg Hg)
Pulmonary History of recurrent infections with clinically significant sputum production; pleural or interstitial
disease that precludes surgery; clinically significant bronchiectasis; pulmonary nodule necessitating
surgery; giant bulla (greater than one third the volume of the lung); pulmonary hypertension; peak systolic
PPA ≥45 mm Hg (≥50 mm Hg in Denver) or mean PPA ≥35 mm Hg (≥38 mm Hg in Denver); (right heart
catheterization is required to rule out pulmonary hypertension if peak systolic PPA on echocardiogram ≥
45 mm Hg); requirement for ≥ 6 L oxygen to keep saturation 90% or greater with exercise
Radiographic CT evidence for diffuse emphysema judged unsuitable for LVRS
General Unplanned weight loss of <10% usual weight in 90 days before enrollment; evidence of systemic
disease or neoplasia expected to compromise survival during 5-year period; 6-minute walk distance ≤140
meters after rehabilitation; any disease or condition that interferes with completion of initial or follow-up
assessments; unwillingness or inability to complete screening or baseline data collection procedures
Lung Volume Reduction Surgery
Parameter Favourable Unfavourable
Clinical Age <75 yrs Age > 75–80 yrs
Clinical picture consistent with emphysema
Co-morbid illness which would increase surgical
Not actively smoking (>3–6 months) Clinically significant coronary artery disease
Severe dyspnea despite maximal medical treatment
including pulmonary rehabilitation
Pulmonary hypertension (PA systolic >45, PA mean
Requiring <20 mg prednisone•day-1
Severe obesity or cachexia
Previous thoracic procedure
Chest wall deformity
Physiological FEV1 after bronchodilator <45% pred FEV1 <20% pred and D L,CO <20% pred
Hyperinflation Decreased inspiratory conductance
TLC >100% pred
Pa,O2 > 6 kPa (45 mmHg)
Pa,CO2 < 8 kPa (60 mmHg)
Post-rehabilitation 6-min walk >140 m
Low post-rehabilitation maximal achieved cycle ergometry
High-resolution computed tomography confirming severe
emphysema, ideally with upper lobe predominance Homogeneous emphysema and FEV1 <20% pred
Non-upper lobe predominant emphysema and high
post-rehabilitation cycle ergometry maximal
Most programs insist on a 6- to 8-week course of pulmonary
rehabilitation prior to LVR in order to optimize the patient's physical
condition and thus avoid any unnecessary morbidity or mortality from
the operation itself.
Rehabilitation comprises a number of elements, including nutritional
counseling, psychosocial counseling, and skill training with regard to
breathing strategies and management of anxiety.
The exercise component includes maneuvers to improve both strength
and flexibility as well as to maximize lower- and upper-body aerobic
capacity. This entails upper-body weight training as well as treadmill
work with supplemental oxygen as necessary.
LVRS performed by means of bilateral VATS
or median sternotomy (buttressed or non
buttressed with bovine peri cardium).
Resection is directed to the target areas
identified by means of analysis of the CT
scan and perfusion scan as the lung and
the lung zones with the most pronounced
emphysematous alteration and greatest
reduction in perfusion.
LVRS by Median Sternotomy
The procedure involves bilateral LVRS in one operation, aiming to reduce the total
lung volumeby 30% and to reshape each lung to best adapt to its hemithorax.
The decision in favour of bilateral operation was predicated on the view that it would
maximise the improvement in chest wall mechanics by allowing the sternum to return
to a more normal position.
This avoids the problem of further hyperinflation of theremaining lung from disabling
the operated lung if a unilateral procedure were used.
General anaesthesia is used with a left sided double- lumen tube to allow selective
ventilation of each lung.
An epidural catheter is inserted before operation to allow epidural anaesthesia and
reduce the need for analgesics, which may cause respiratory depression in the
LVRS by Median Sternotomy
Median sternotomy is carried out to carefully preserve the pleural membranes so that mobilisation of the apical
pleurae can be achieved to provide apical pleural tents after resection, so that the lung apices will be covered by
pleura, the space above the pleura will fill with fluid and intrapleural air spaces will be avoided.
The most severely affected side is operated on first.
Ventilation to that lung is ceased and the pleural cavity is opened.
Absorption collapse occurs in the more normal lung parts
The worstaffected areas remain inflated. These observations are considered with the information from the CT and
ventilation-perfusion scans, to decide on the most strategic areas for resection.
Resection of each lung is limited to 30% and the stapled resection line is shaped to tailor the lung to best fit the
Linear staplers with the staple blades lined by reinforcing strips of bovine pericardium have proved to be a most
effective way to secure an airless staple line.
Air leaks are meticulously dealt with, the opposite lung is then reduced and both pleural cavities are drained with
low-pressure suction. Immediate
LVRS by Bilateral Thoraco-Sternotomy – the “Clam-Shell”
Whilst the median sternotomy approach has many advantages, particularly its avoidance of damage to the
lateral chest wall, exposure of the posterior surface of the lung, and in particular, the lower lobes is difficult.
The clam-shell incision is an inviting alternative that overcomes some of these problems
Video Assisted Thoracoscopic Surgery
The widespread current use of video-assisted
thoracoscopy (VATS), owes much to the
pioneering work of Wakabayashi and co-workers5,
who used a VATS approach to ablate
emphysematous bullae using carbon dioxide laser.
The use of laser techniques in non-bullous
emphysema has been shown to be less effective
than stapling in a prospective trial by McKenna
and colleagues16. They compare 33 patients in
whom Neodymium:YAG laser was used, with 39
patients in whom staplers were used.
Both groups were exposed to unilateral operation
with low mortality, but the frequency of functional
improvement was greater in the stapled group at
32.9% compared with 13.4% in the laser group
Performed in OT under general anesthesia
Patient intubated and FB is advanced through ET
Target segmental bronchus is visualised and a guidewire is inserted
into the operating channel of bronchoscope to reach the desired
Leaving the guidewire in place, the bronchoscope is withdrawn and the
delivery catheter is passed on the guidewire.
After the removal of the latter the valve is delivered.
Between three and five valves
Postoperative hospital stay ~ 2 day
Unilateral Versus Bilateral Approach
Early during the modern evolution of LVR surgery, there was a controversy regarding whether to perform the
procedure unilaterally or bilaterally.
Cooper8 and other investigators performing median sternotomy routinely performed simultaneous bilateral
procedures. Those performing a thoracoscopic LVR surgery initially performed unilateral procedures. This
rapidly evolved to a simultaneous bilateral thoracoscopic procedure, but—not surprisingly—it was clear from
early results that the morbidity of a bilateral thoracoscopic procedure exceeded that of a unilateral procedure.
Thus the question arose as to whether LVR should be done unilaterally, bilaterally in a sequential fashion, or in a
simultaneous bilateral procedure.
Studies by McKenna and Argenziano suggested that a bilateral LVR surgery yielded significantly greater
improvements in spirometric indices than did unilateral procedures. Interestingly, the former author noted no
increased morbidity for the
Because of the improved spirometric and quality-of-life results following bilateral LVR, the bilateral approach has
become the routine for most surgeons undertaking this intervention.
Unilateral approach- These include patients in whom one pleural cavity or the other will be obliterated by dense
adhesions, such as those with a history of prior unilateral thoracotomy, empyema, or pleurodesis. The unilateral
approach should also be entertained in those whose emphysema is asymmetric and primarily unilateral. For
such patients, unilateral LVR can still provide significant benefit
Who benefits from LVRS Maximum
Many reports support the claim that
improvement following LVRS is better
in patients whose target areas are in
the upper lobes than in patients with
A high ratio of emphysema in the
upper lobe to the lower lobe on CT or
perfusion scan predicted short-term
functional improvements well
Recently, it has been shown that
LVRS yields a survival advantage for
patients with both predominantly
upper-lobe emphysema and low
baseline exercise capacity, whereas it
does not afford patients with non–
upper-lobe emphysema and high
exercise capacity the benefit.
Does lung functions improve after LVRS?
Source: JTCS 2002: 123:845
Konrad et al have reported
115 patients underwent LVRS.
Symptoms and lung functions
were assessedbefore the
operation and 3, 6 and every 6
months after the operation.
CONCLUDE FEV1.0 peaks within
6 months postoperative then
decline in the fist year and
slows down in succeeding
years to baseline.
PATIENTS AT HIGH RISK
OF DEATH AFTER LVRS
A total of 1033 patients had been randomized by
69 Patients had FEVI < 20% of their predicted value and
homogenous distribution of emphysema on CT scan or their
DLCO < 20% of predicted value.
The 30-days mortality rate after surgery was 16% as compared
with the rate of 0% among 70 medically treated patients (P <
Concluded: Very low DLCO
Very low FEV1.0
Homogenous distribution of emphysema are
at high risk of death after LVRS.
Source: NEJM 345: 1075 – 1083 Oct. 2001
DEVELOPMENT OF PULMONARY
Weg. et al reported that development of
pulmonary hypertension may occur after
9 Patients were involved in a prospective
study with an average age of 64 years
After LVRS (PA) systolic pressure rose to
47.69 ± 12.4 mmHg but the changes in PAP
did not correlate with the changes in
Source: AM.J. Respir. Crit Care, 1999
17 clinical centers
Randomized 1,218 patients to medical therapy or medical therapy plus
FEV1 15% to 45%
RV > 150%
No significant cardiac disease or pulmonary HTN
No other pulmonary diseases present
Bilateral emphysema amenable to LVRS
Upper lobe predominant
NETT Research Group Chest, 1999
Durability of LVRS
Naunheim et al, Ann Thorac Surg 2006
UL/Low Exercise UL/high Exercise
Exercise performance all patients
10 watt improvement
Months LVRS Medical Rx p value
6 28% 4% <0.001
12 22% 5% <0.001
24 15% 3% <0.001
NETT Research Group NEJM, 2003
Who should not get surgery?
NETT Research Group NEJM, 2001
Video Assisted Thorascopy (VATS)
vs Median Sternotomy (MS)
8 centers used MS
3 used VATS
6 randomized to either
Total patients: 359 MS vs 152 VATS
Randomized patients: 77 MS vs 71 VATS
McKenna et al, J Thorac Cardiovasc Surg, 2004
VATS vs MS
30 day mortality
2.8% MS vs 2.0% VATS (p = 0.76)
90 day mortality
5.9% MS vs 4.6% (p = 0.67)
No mortality difference for randomized patients
Intra-operative hypoxemia more common in VATS
(0.8% vs 5.3%)
No difference in days with air leak
Median hospital LOS of 10 d in MS vs 9 in VATS
Randomized patients: 15d for MS vs 9d for VATS
(p<0.001) McKenna et al, J Thorac Cardiovasc Surg, 2004
Most important lessons from NETT?
Interventions to improve survival
Oxygenation and oxygen requirements
Favorable alters breathing patterns
TAKE HOME MESSAGE
There are no long term data as yet.
LVRS improved the life of many patients.
We are still on a learning curve in predicting
outcome after LVRS.