Seventy-nine patients with the clinical impression of bullous emphysema were treated for breathlessness and dyspnea on exertion, which severely interfered with their daily life quality despite aggressive respiratory care and medical therapy. The patients consisted of 67 men and 12 women with a mean age of 63 years (range, 48 to 101 years). Most of the patients had a history of smoking, but most had quit several years ago. All patients had significant limitation of their daily life activities, grade 2 or 3 according to the Modified Medical Research Council (MMRC) dyspnea scale (Table 1). Fifty-eight (73.4%) of these patients were using oxygen either continuously or intermittently. All patients were using nebulizer bronchodilator treatment and 41 patients (52%) were taking oral prednisolone at the time of surgery. All patients had typical chest radiographic manifestations of bullous emphysematous change, flattened diaphragm, and increased posterior-anterior chest wall diameter.
Operative and anesthesia consents were signed with particular emphasis to the patients and families that although others’ surgical experiences showed a clinical benefit, the surgical risks for both morbidity and mortality were still high in this group of patients.
Thoracoscopic endoloop ligation of bullae was carried out under general anesthesia with one-lung ventilation. The arterial line and pulse oximeter were used routinely. Surgical procedures were carried out using a 10-mm, 0° rigid thoracoscope, a video camera, dual monitor screen, and conventional thoracic surgical instruments. Adhesions were commonly encountered and freed by a sharp dissection technique using electrocautery. The bullae were also freed in this manner from the adjacent tissue. In general, bullae were found at the sites of adhesions. Sometimes the interlobar fissure was divided to expose the hidden bullae. After the superficial bulla was freed from the adhesions, it was stabbed to collapse using the tip of the electrocautery (Fig 1, A). The shrunken bulla (Fig 1, B) was twisted to its base until normal lung parenchyma was reached (Fig 1, C), at which point the endoloop was applied and the preformed loop was cinched down using a knot advancer (Fig 1, D). Frequently, two to three endoloops of No. 1 polydiaxonone suture (Ethicon; UK) were applied to each bulla cyst to ensure the tightness of the bulla. After ligation of all bullae, the lung was manually inflated, and if no bullae bulged out and the consistency of the underlying lung parenchyma appeared normal, the ligation was considered adequate. If a significant number of bullae bulged out, these were ligated again. The endoscopic stapler was not used in these patients for fear of air leak and, perhaps, mainly because of cost containment. After ligation, talcum powder (3 to 5 g) was routinely insufflated to enhance postoperative pleurodesis. After completion of the procedures, a chest tube (32F) was inserted with all the wounds closed and the patient was sent to the ICU for further management. At ICU, the patients were supported by a ventilator until they met the standard weaning profile. If air leaks persisted with residual pneumothorax on chest radiograph, they were usually managed by continuous low-pressure suction (15 cm H20) on the tube. If an air leak was massive or a patient suffered from extensive and progressive subcutaneous emphysema, a second chest tube was inserted through one of the incision wounds and connected to a low-pressure suction system. Chest tubes were removed when air leaks terminated completely and showed a fully expanded lung on follow-up chest radiograph. If air leaks persist, the chest tube may be removed from the patient after a trial clamping of the tube, which usually demonstrates that adhesions of the pleura to the chest wall will keep the lung expanded after removal of the tube. For the rare patient with a continued air leak over 14 days, the tube was shortened and managed as open drainage. The patients were discharged from the hospital when their general condition was stable, but those patients who were oxygen dependent or had carbon dioxide retention (PaC02>60 mm Hg) were usually transferred back to the pulmonologist for further medical care and chest physiotherapy.
Statistics and Analysis
Data are expressed as mean ± SEM. Student’s t tests were used to examine changes in spirometry measurements. Results were considered significant for p<0.05.
Table 1—MMRC Dyspnea Scale
|0||Not troubled with breathlessness except with strenuous exercise|
|1||Troubled by shortness of breath when hurrying on the level or walking up a slight hill|
|2||Walks slower than people of the same age on the level because of breathlessness or has to stop for breath when walking at own pace on the level|
|3||Stops for breath after walking about 100 yards or after a few minutes on the level|
|4||Too breathless to leave the house or breathless when dressing or undressing|
FIGURE 1. A: bulla was stabbed to collapse using electrocautery. B: the shrunken bulla seen on thoracoscopy. C: shrunken bulla twisted to its base until normal lung parenchyma reached. D: endoloop was applied and the preformed loop was tightened using knot advancer.