thoracic surgery emphysema lung

1. Surgery of Emphysema
Tummarat Ruangpratyakul, MD.

2. Emphysema
COPD
Enlargement of airways distal to the terminal bronchiole
in association with destruction of the normal
architecture.
"Bullae" Diameter >=2 cm
"Bullous" not identify any size
Cigarette smoking, alpha1-protease inhibitor deficiency

3. Pathophysiology
Permanent and irreversible loss of alveolar septi, loss of
the elastic tissue.
Increased tendency to premature collapse of smaller
airways during expiration.
Lack of elastic recoil in adjoining airways leads to
occlusion and atelectasis.
Upper lobe is more common.

4. Clinical Features
Dyspnea or difficulty breathing
Cough with/without productive of sputum
Wheezing
Bronchitis, hyperreactive airways
Decrease in exercise tolerance
Cyanosis

5. Diagnosis
CXR: hyperexpanded chest, flattened diaphragms,
widened ICS and horizontal rib, seen bullae.
PFT: decrease FEV1, FEV1/FVC, increase LV, TLC,
FRC, RV.

7. Surgical Procedure
Bullectomy
Lung transplantation
Lung Volume Reduction Surgery

8. Selection patient for surgery
Remain symptomatic despite optimal medical therapy.
Smoking cessation least 6 month.
Pulmonary rehabilitation program 6-12 weeks.

9. Bullectomy
Substantial air-filled bulla with symptom(dyspnea, pain,
pneumothorax, bleeding, infection)
Single bulla encompressing more than one half the
volume of pleural cavity.
Parenchyma air leaks are most common postop
complication

10. Techniques (open)
Anterolateral 5-6 ICS
Open bulla longitudinally and explored
Excised strands of fibrous septa
Long Allis forceps applied from inside, grasp pleural at
reflection of relatively normal parenchyma with cyst cavity
Visceral pleura(cyst wall) folded over saw surface
Linear stapler applied along base of bullae

12. Techniques (VATS)
Full posterolateral thoracotomy
3 trocars; 1st thoracoscopic trocar inserted 2 FB below
tip of scapular, 12mm port inserted halfway between
post border of scapular and spine
Seen bullae and bases are well demarcated, Deflated
and excised using Endo-GIA stapples

13. Lung transplantation
Adv: complete improvement of dz and nonfn lung
Disadv: lack of donors, lifelong immunosuppression
Bilate or unilateral are controversial
Bilate: younger with alpha1-antitrypsin deficiency

16. Techniques (patient)
Bilate anterior thoracotomies 4-5 ICS
IMA was ligated and divided bilaterally
Sternum divided tansverely at 4 ICS, chest is clamshelled open
PA, PV dissected beyond primary bifurcation to preserve length of
main trunks
Artery , venous and bronchus resection
Bronchus transected between cart. rings and post bundle of
Lymphatic and bronchial artery

17. Techniques (donor)
Bronchus divided two rings proximal to upper lobe orifice.
Minimal resection
PA and Lt. atrium cuff freed from any pericardial attachments
Kept cold with iced saline and slush
Bronchus, artery, and atrium
Running stitch peribronchial tissue and lymphatic graft 4-0 PDS
Cart. ring interrupted figure of 8, 4-0 PDS

18. Techniques (donor)
Pulmonary a. clamped centrally with Satinsky clamp,
anatomosis created with running 5-0 Prolene suture
Satinsky clamp centally atrium, anatomosis performed
with 4-0 Prolene suture

21. Lung Volume Reduction Sx
Concept "extensive of bullectomy, destroyed and
functionless lung is resected"
Early and late mortality rate lower than transplantation
Gains 20-30% FEV1 in unilateral, 40-80% in bilateral
NETT 7.9% 90-day surgical mortality
High risk of death after sx: very low FEV1, homogenous
emphysema, very low DLco

23. Techniques
Median sternotomy for bilateral LVR
One lung ventilation
Avoid injury to phrenic nerve
Excised with linear stapler butressed with strips of
bovine pericardium
2 drains: post-dome of diaphram, ant-apex of chest
near mediastinum

25. Combination of Lung
transplantation and LVR
LVR as a bridge to
transplantation
Avoid transplantation
Delayed transplantation
for several years

26. Brochoscopic
Endoscopic placement of
one-way valve
Airway bypass

27. Summary
Bullectomy: functionless, space-occupying bullae that
compresses normal adjacent lung
LVR: hyperinflation, heterogenous distribution of dz,
FEV1>20, normal Pco2
Transplantation: diffuse disease, lower FEV1,
hypercapnia, PHT, alpha1-antitrypsin deficiency