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

5 Jan

An Alternative Technique in the Management of Bullous Emphysema (Introduction)Study objectives: With the improvements in video-assisted thoracoscopic surgery, more older patients and patients with respiratory impairments are undergoing bulla ablation using new and costly technology. We evaluated the cost-effective technique of thoracoscopic endoloop ligation of bullae in patients with bullous emphysema.

Patients: From March 1992 through January 1996, 79 advanced age (mean age, 64 years) and oxygen dependency patients underwent thoracoscopic procedure using endoloop ligation for treatment of bullous emphysema. Clinical data were collected from chart review. Only patients with radiographically confirmed diagnosis of bullous emphysema were included in this evaluation. Thoracoscopic endoloop ligation of bulla was carried out under general anesthesia with double-lumen endotracheal tube and single-lung ventilation.

Results: Sixty-five patients (82%) exhibited subjective improvement in their symptom status at 3-month follow-up (from grade 2 or 3 to grade 1 or 2) according to the Modified Medical Research Council dyspnea scale. The mean duration of chest drainage was 6 days (range, 4 to 16 days). Average hospital stay was 9.5 days (range, 5 to 26 days). There was no postoperative death. A comparison of preoperative and postoperative functional evaluation was available in only 16 patients who showed an increase in FEVX (from 0.85 to 1.02 L) and a decline in residual volume after operation. Complications include persistent airleak over 10 days in seven patients (8.9%), wound infection in three patients, and localized empyema in two patients. There was no recurrence after a mean follow-up of 21 months.

Conclusion: These encouraging results have shown that thoracoscopic endoloop ligation of bulla has proved to be a safe, reliable, and cost-effective technique for bullous emphysema. With careful preoperative evaluation and meticulous postoperative care, many patients could be rehabilitated by endoloop litigation of the bullae.

Bullous emphysema is usually seen in patients with advanced age (>45 years) who frequently exhibit alterations in ventilation, gas exchange, and lung compliance with decreased respiratory function. Overdistention of airspaces and increased radi-olucency are easily seen on chest radiograph. When bullae become large, they frequently compress relatively normal functioning lung tissue which results in respiratory impairment. Many physicians and surgeons have been unwilling to advise surgical intervention for this group of patients. This is mainly because the improvement in pulmonary function test results following surgery has not been great in emphysematous patients, especially those with diffuse bullous emphysema. In addition, most of the patients were severely functionally impaired and usually did not tolerate surgical procedures well.

In view of the fact that video-assisted thoraco-scopic surgery recently has been considered minimally invasive and has been shown in functionally impaired patients to have faster recuperation and clinical improvement, an increased number of these patients have been considering surgery. Several minimally invasive surgical techniques using stapler or laser have been shown to be effective in achieving lung volume reduction in patients with bullous or diffuse emphysema. However, these are not inexpensive. Because of cost containment, we used selfmade endoloops to decompress the bullae since the establishment of the use of videothoracoscopic surgery in our hospital. This report demonstrated the efficacy of using thoracoscopic endoloop ligation to achieve cost-effective “volume reduction” procedures in patients with bullous emphysema.