Thoracoscopic Volume Reduction of the Native Lung after Single Lung Transplantation for Emphysema

FEDERICO VENUTA, TIZIANO DE GIACOMO, ERINO A. RENDINA, GIORGIO DELLA ROCCA, ISAC FLAISHMAN, ENRICO GUARINO, and COSTANTE RICCI

Department of Thoracic Surgery, University of Rome "La Sapienza," Rome, Italy

	INTRODUCTION

TOP INTRODUCTION DISCUSSION REFERENCES

In recent years, emphysema has become the most frequent indication to single lung transplantation (SLT); nonetheless, up to a decade ago, ventilation-perfusion imbalance and hyperinflation of the native lung were considered a serious deterrent in this setting. These concerns have been progressively eliminated by subsequent clinical successes; however, early and late hyperinflation of the native emphysematous lung is occasionally still reported. In particular, late hyperinflation of the native lung may be related to the decreased compliance of the graft (obliterative bronchiolitis, infection, rejection) or to progression of chronic obstructive pulmonary disease in the native lung itself. We report a case of late hyperinflation of the native lung occurring 3 yr after SLT for emphysema and successfully treated by unilateral video-assisted thoracoscopic lung volume reduction.

	CASE REPORT

A 44-yr-old woman with panlobular emphysema was referred to our department for lung transplantation. She had progressively developed severe respiratory failure with a FEV₁ of 0.36 L (12% of the predicted value). Blood gases without oxygen support showed a Pa_O2 of 39 mm Hg and a Pa_CO2 of 45 mm Hg. The patient required continuous oxygen therapy (3 L/min) to reach a stable 95% pulse saturation at rest. A right SLT was performed, and after an uneventful postoperative course the patient resumed her daily activities, with a Pa_O2 and Pa_CO2 at rest of 90 and 35 mm Hg, respectively (room air). However, after 3 yr, dyspnea and exercise intolerance progressively recurred. Pa_O2 and Pa_CO2 at rest were 86 and 39 mm Hg (room air), but the FEV₁ dropped back to 0.53 L (18% of the predicted). The chest radiograph showed marked hyperinflation of the native left lung, with mediastinal displacement, graft compression, and depression of the left hemidiaphragm (Figure 1). Transbronchial lung biopsies and bronchoalveolar lavage in the transplanted lung proved negative; an obliterative bronchiolitis syndrome (OBS) was suspected, but empiric augmentation of the immunosuppressive regimen did not allow any functional or clinical improvement. Supplemental oxygen was administered during exercise and 2 mo later it was required also at rest (2 L/min). A video- assisted thoracoscopic volume reduction of the native lung was planned. Single photon emission computed tomography (SPECT) showed areas of markedly reduced perfusion of the left lung corresponding to the posterior and apical segments of the upper lobe and the apical segment of the lower lobe. The procedure was performed under general anesthesia with one-lung ventilation; three trocars were inserted, and pneumectomy was accomplished by means of endoscopic linear staplers (EndoGIA 45; Ethicon, Somerville, NJ), resecting all the unperfused areas according to preoperative workup, without any reinforcement of the stapler line. Unassisted ventilation was resumed at completion of the procedure. A constant low-volume air leak required 34 d of pleural drainage (during the last week, it was managed with a Heimelich valve in the outpatient clinic). Oxygen support was discontinued 48 h after the procedure, and recovery was otherwise uneventful. The postoperative radiographs showed a reduced inflation of the native lung, a normal diaphragmatic contour, and no mediastinal shift (Figure 2). Immediate symptomatic improvement was reported by the patient after the procedure, and the FEV₁ is now superior to that recorded 1 yr after transplantation. After 8 mo the pulmonary function tests show stable values (Table 1).

View larger version (184K): [in this window] [in a new window]   Figure 1.   Preoperative chest X-ray showing hyperinflation of the native right lung with mediastinal and diaphragmatic displacement.

View larger version (151K): [in this window] [in a new window]   Figure 2.   Postoperative chest X-ray showing a reduction of the volume of the native lung and remodeling of the chest cavity.

	DISCUSSION

TOP INTRODUCTION DISCUSSION REFERENCES

SLT has long been considered contraindicated in patients with end-stage emphysema as ventilation-perfusion imbalance due to the high compliance and relatively increased pulmonary vascular resistances of the native lung was initially reported. However, experimental and clinical successes in this field have appeared in the literature in the last decade (1, 2). Temporary hyperinflation in the early postoperative period has been occasionally reported (3) but it is usually transitory and specific decompressive maneuvers are rarely required; separate ventilation and early extubation are the keys to reduce the incidence of this complication. Only exceptionally, bullectomy or pulmonary resections may be indicated to equilibrate the respiratory and hemodynamic parameters.

Late progressive deterioration of the pulmonary function and its possible relationship with hyperinflation of the native lung requires different considerations (8). Infectious complications should be excluded, and the possible development of obliterative bronchiolitis should be ruled out. In the absence of histologic confirmation, the diagnosis of OBS should be presumed. If augmented immunosuppression does not result in clear functional improvement and marked hyperinflation of the native lung is evident, the latter could play a major role in the development of dyspnea. However, preoperative workup may not allow a precise assessment of the amount of dysfunction related to progressive compression of the graft by the native lung and the possible coexistence of OBS. If marked functional improvement follows unilateral volume reduction, the diagnosis of OBS may be left out.

When hyperinflation is related to the presence of large bullae, bullectomy is well established to relieve compression. More recently, attention has been focused on the potential benefits of surgical resection of diffusely emphysematous lung parenchyma to reduce dyspnea and improve exercise tolerance (11). Other cases of unilateral volume reduction surgery (lobectomy, bullectomy, stapled resection) of the native lung after SLT for emphysema have been reported (8) but the procedure was performed via lateral thoracotomy. Video-assisted thoracic surgery has been increasingly used for a number of pulmonary surgical procedures, and its advantages are well known. In particular, unilateral thoracoscopic stapled lung reduction has been reported (12, 13) and its results are satisfactory. In our case, lung reduction was guided only by preoperative SPECT scan since inflation and deflation maneuvers and digital palpation of the parenchyma are difficult at thoracoscopy. The volume of the lung was reduced by approximately 25% (corresponding to 50 g of lung tissue), tailoring the resection to avoid postoperative space problems. The outcome was positive, both in terms of radiographic and functional improvement. Pulmonary function tests are stable 8 mo after the surgical procedure. Functional progression in the ability to exercise was confirmed by the significant improvement in the 6-min walk test.

In conclusion, unilateral thoracoscopic stapled reduction of the native lung for late hyperinflation after SLT for emphysema could allow a satisfactory restoration of functional and mechanical parameters in selected patients.

	Footnotes

Correspondence and requests for reprints should be addressed to Federico Venuta, M.D., Cattedra di Chirurgia Toracica, Policlinico Umberto I, Universitá di Roma "La Sapienza," Vialle del Policlinico, 00161 Rome, Italy.

(Received in original form September 12, 1996 and in revised form June 5, 1997).

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