An Alternative Technique in the Management of Bullous Emphysema (Discussion)

11 Jan
2014

An Alternative Technique in the Management of Bullous Emphysema (Discussion)Bullous emphysema is usually seen in heavy smokers older than 45 years of age who exhibit alterations in lung volume, ventilation, and pulmonary gas exchange. When bullae become large, they can compress relatively normal functioning lung tissue. Bullae are usually multiple and may involve bilateral lungs. By removal of the nonfunctioning bullous tissue, the compressed lung parenchyma can be well expanded which increases the patient’s ventilatory reserve and thereby results in successful surgical intervention.4 8_ 10 Because patients with bullous emphysema are generally considered intolerant to surgical procedure, it has become widely accepted that such surgical intervention is not safe and thus few patients have been willing to be operated on. Recently, video-assisted thoracoscopic surgery has proved minimally invasive and has been shown to benefit patients with functional impairment with faster recuperation and clinical improvement. Thus, in this group with bullous lung disease, the number of patients considering surgical intervention has increased. canadian neighbor pharmacy online

In our group of patients with bullous emphysema, the indication for operation was incapacitating dyspnea with unequivocal compression of relatively normal parenchymal lung tissue. From recent published data, the presence of bullous emphysema should not exclude patients from consideration for surgery. On the contrary, such patients are most in need of help and even a small increment in breathing capacity may greatly improve the quality of their lives. From our experience, good results have been seen in patients with multiple, well-demarcated bullae and with radiographic evidence of compression. Under these circumstances, we have accepted very poor-risk patients for minimally invasive volume reduction surgery using endoloop ligation. Clinical results have been gratifying even though improvement in terms of respiratory function often was insignificant. Only 24% of our patients had preoperative pulmonary spirometry data. Most of the patients with bullous emphysematous changes of the lung did not receive preoperative assessment of pulmonary function when the chest tube was inserted. In view of all the patients, 82% of the total patients showed clinical improvement and rehabilitation from grade 2 or 3 to grade 1 or 2 according to the MMRC dyspnea scale. Admittedly, they constitute a group with higher surgical risk. However, a minimally invasive surgical technique combined with the ligation of unventilated pulmonary tissue, the results are promising and the risks seem to be low.

There are several procedures developed for the relief of dyspnea in patients with bullous emphysema. These procedures include carbon dioxide laser to ablate peripheral bullae via video thoracoscopic approach reported by Wakabayashi et al. Cooper et al returned to the open approach using stapling devices and bovine pericardial strips to bolster and minimize air leaks through the staple line. Stapled wedge resection for pneumothorax through videoassisted thoracoscopy has also been reported to be promising. Undoubtedly, the advent of videoassisted thoracic surgery has renewed interest in the therapy of bullous emphysema. No group of patients has presented more difficult problems than those with bullous emphysema who were referred for surgical intervention. Previously, we have reported that thoracoscopic endoloop ligation has been an effective approach in patients with parenchymal blebs or bullae. Our attempts to ligate the bulla in patients with spontaneous pneumothorax appear promising. We chose to use endoloop ligation because it is convenient and commonly available in all hospitals. In addition, it is truly cost-effective. Having established the efficacy and safety of this technique as well as its convenience, we proceeded with the technique that became routine for patients with bullous lung diseases. The initial patient first referred for surgery was a former heavy cigarette smoker, bedridden and oxygen dependent, whose chest radiograph showed multiple bulla occupying the left hemithorax. Because of skepticism about the safety of surgical intervention in such a poor-risk patient, it was elected to ablate the bulla using a simple and minimally invasive endoloop ligation technique. A dramatic response was noted in the left hemithorax with expansion of the underlying lung. The chest tube was removed 5 days after the operation; afterward, the patient achieved exercise and daily life activity tolerance well. This improvement was maintained throughout our follow-up study.

On review of the data published in the English-language literature, most of the studies favored using endostapling devices or laser technique to resect the bullae. The use of these devices is expensive. Since the importance of reducing health-care costs is now of increasing concern, the endostapling device, as the most costly instrument, must be used cautiously. Our previous experience suggests that thoracoscopic endoloop ligation of blebs has been shown to be safe, simple, and cost-effective. The clinical results in this report also support the rationale for the use of endoloop ligation in treating patients with bullous emphysema to achieve lung volume reduction. Although many expensive surgical approaches have been proposed and evaluated for bullae ablation, including lung volume reduction, thoracoscopic endoloop ligation of visible bullae seems to be the only technique that is cost-effective and minimally invasive. The surgeon should try to reduce to a minimum the cost for patients who are most likely to benefit from minimally invasive surgery. Also, expenditure brought about by newly developed endoscopic instruments can be a “pressure” for poor patients which in turn would be reflected in their willingness for surgery. Although our follow-up has not been long enough to provide an accurate evaluation of the efficacy of the technique in patients with bullous emphysema, the early results are encouraging and provide us with the opportunity to observe the further results of the technique used in this group of patients.

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