An Alternative Technique in the Management of Bullous Emphysema: Thoracoscopic Endoloop Ligation of Bullae

doi:10.1378/chest.111.2.489

Chest

Volume 111, Issue 2, February 1997, Pages 489-493

https://doi.org/10.1378/chest.111.2.489 Get rights and content

Study objective

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 FEV₁ (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.

Section snippets

Patient Population

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,

Results

Because of skepticism about the safety of surgical intervention, in all 79 patients, only one lung was treated. No bilateral operations were performed simultaneously or sequentially. In most patients, the bullae occupied most of the upper lobes and varying amounts of the middle and lower lobes. Ablation of the bullae consisted of at least two to three precise ligations of each bulla cyst with preservation of normal lung parenchymal tissue as much as possible. In some instances, small bullae

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

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Cited by (25)

Lung volume reduction surgery for emphysema and bullous pulmonary emphysema
2012, Revue de Pneumologie Clinique
Améliorer la symptomatologie respiratoire des patients emphysémateux par la chirurgie est un concept qui a évolué au cours du temps. Initialement réservée aux bulles géantes, cette chirurgie a ensuite été appliquée aux patients porteurs d’un emphysème diffus microbulleux. Le concept physiopathologique sur lequel repose ces interventions est le même dans les deux cas : améliorer les performances respiratoires en réduisant l’hyperpression intrapleurale induite par le poumon ou les bulles distendus. Le bénéfice fonctionnel et l’augmentation de la survie après une réduction volumique pulmonaire chirurgicale (RVPC) dans l’emphysème diffus sévère, ont été validés par l’étude National Emphysema Treatment Trial (NETT) et les études ultérieures permettant également d’identifier des facteurs pronostiques. La qualité des données recueillies, à la fois cliniques, morphologiques et fonctionnelles, a conduit à l’élaboration de recommandations désormais largement utilisées en pratique courante. La chirurgie des bulles géantes, sur poumon peu ou moyennement emphysémateux, est d’une approche souvent plus simple qui nécessite cependant là aussi une prise en charge spécialisée pour optimiser ses résultats.
The improvement of respiratory symptoms for emphysematous patients by surgery is a concept that has evolved over time. Initially used for giant bullae, this surgery was then applied to patients with diffuse microbullous emphysema. The physiological and pathological concepts underlying these surgical procedures are the same in both cases: improve respiratory performance by reducing the high intrapleural pressure. The functional benefit of lung volume reduction surgery (LVRS) in the severe diffuse emphysema has been validated by the National Emphysema Treatment Trial (NETT) and the later studies which allowed to identify prognostic factors. The quality of the clinical, morphological and functional data made it possible to develop recommendations now widely used in current practice. Surgery for giant bullae occurring on little or moderately emphysematous lung is often a simpler approach but also requires specialised support to optimize its results.
Giant bullous lung disease: Evaluation, selection, techniques, and outcomes
2003, Chest Surgery Clinics of North America
Thoracoscopic Ipsilateral Approach to Contralateral Bullous Lesion in Patients with Bilateral Spontaneous Pneumothorax
2003, Annals of Thoracic Surgery
Citation Excerpt :
However, incisional pain, poor cosmetic outcome, and possible respiratory impairment occasionally cause trouble. With the rapid expansion of and improvements in thoracoscopy, VATS has been used not only to diagnose chest lesions but also to treat various thoracic diseases [3, 6]. We began performing VATS bleb excision and pleural abrasion for primary spontaneous pneumothorax in 1991.
Video-assisted thoracic surgery (VATS) has gained a prominent role in routine thoracic surgical practice. This study describes a novel ipsilateral approach to a contralateral bullous lesion using VATS to achieve simultaneous bilateral bleb excision and pleurodesis.
From 2001 to 2003, 6 patients underwent our ipsilateral approach with VATS for bilateral pneumothorax. The clinical features, surgical indications, and patient outcomes were reviewed.
All the patients were men between 18 and 35 years old (mean age, 25.8 years). The ipsilateral-approach VATS procedure for bilateral pneumothorax was performed successfully in 4 patients. Two patients were switched to a one-stage sequential bilateral VATS procedure. The bullous lesions were at the apex or confined to the upper lobe in 5 patients; multiple lobes were involved in 1 patient. The bullae were resected with an Endo-GIA stapler or ligated with a homemade endoloop. The mean duration of operation was 54.8 minutes. The mean time of chest tube removal was 4.7 days after insertion, and the mean postoperative stay was 5.7 days. There was no recurrence of pneumothorax during the follow-up period.
The thoracoscopic ipsilateral approach is technically feasible for treating patients with bilateral pneumothorax.
Intraoperative techniques to prevent air leaks
2002, Chest Surgery Clinics of North America
Justifying video-assisted thoracic surgery for spontaneous hemopneumothorax
2002, Chest
Citation Excerpt :
With the rapidly expanding and improving of thoracoscopy, VATS was employed not only to diagnose the chest lesions but was also used in the treatment of various thoracic diseases.13,14,15 Our experience7,15,16 led us to believe that the minimal-access approach to treat SHP is a good alternative. The benefits of VATS have encouraged us to employ for this potentially life-threatening disease.
Video-assisted thoracic surgery (VATS) has gained a prominent role in routine thoracic surgery practice. This study discusses the clinical aspects and utility of VATS in spontaneous hemopneumothorax (SHP).
Of 363 spontaneous pneumothorax (SP) cases, 24 patients presented with SHP (6.6%). The clinical features, surgical indications, emergency VATS technique, and patient outcomes are discussed.
All 24 patients were male (mean age, 25.3 years). Eleven patients were in hypovolemic shock, and their hemoglobin levels ranged from 6.7 to 12.7 g/dL; therefore, they received fluid resuscitation and blood transfusion. The amount of blood drained through the chest tube varied from 200 to 3,500 mL. Emergency VATS revealed that 5 cases were simple hemothoraces and 19 cases were associated with pneumothorax. The cause of bleeding was identified by thoracoscopy, as from an aberrant vessel (n = 11), torn parietal pleura (n = 4), ruptured vascularized bullae (n = 2), and lung parenchyma (n = 1). Six patients had no evidence of an obvious bleeding site. Bullous lesions were at the apex of the upper lobe in 14 patients, and multiple lobar involvement was seen in 2 patients. All the bullae were resected with endoscopic stapler in eight patients and ligated with a homemade endoloop in eight patients. The mean operation time was 42 min. The mean chest tube removal time was 3.5 days after insertion, and mean postoperative stay was 4.5 days. There is no recurrence of SHP or SP during the follow-up period.
SHP complicated by severe bleeding presents a potentially grave emergency. VATS may be considered as feasible treatment for patients with SHP.
Therapeutic thoracoscopy
1998, Clinics in Chest Medicine
The history of therapeutic thoracoscopy parallels that of diagnostic interventions. Indeed, our ability to treat patients with pleural and pulmonary diseases through small incisions using a rigid telescope attached to a video camera is only limited by our imaginations, access to newer technology, and the need to justify the use of new techniques after comparing their safety and efficacy with time-proven therapies.
Today, therapeutic thoracoscopy encompasses procedures performed by medical and surgical thoracoscopists alike. Many procedures are direct extensions from those used during open chest surgical procedures and readily fall under the umbrella of video-assisted thoracic surgery (VATS). Improved instrumentation, however, has also allowed the experienced and expert nonsurgeon thoracoscopist to expand the spectrum of therapeutic alternatives already available. In this article, turf issues or medical/surgical boundaries are ignored in an attempt to present simply, from the thoracoscopist's perspective, a basic description of the instrumentation, techniques, indications, and complications of therapeutic thoracoscopy as it is performed in the operating room today.
The first therapeutic thoracoscopy was actually performed by Jacobaeus,²³ who, in 1921 described a technique of cauterization of pleural pulmonary adhesions during collapse therapy for tuberculosis. Thoracoscopic pleurodesis was performed between 1920 and 1950 in Europe and the United States for recurrent malignant pleural effusions and pneumothorax.⁶⁰ In the 1940s thoracoscopy was used to evacuate traumatic hemothoraces and detect bleeding. Parietal pleural and intercostal blood vessels could be repaired through small incisions rather than subjecting patients to open thoracotomy.⁴ Between 1965 and 1990, however, thoracoscopy was virtually ignored in the United States. Additional advances of therapeutic thoracoscopic techniques were made only in Europe, where thoracoscopy continued to be performed by a small number of pleural disease specialists.
Since 1990, thoracoscopy has exploded worldwide. Thoracoscopists were encouraged by the results of therapeutic laparoscopy, advanced videotechnology, and improved endoscopic instrumentation. Initially, instruments designed for laparoscopy were used for chest procedures, but quickly, specially designed instruments and new thoracoscopic strategies were developed. In 1991, the councils of the American Association for Thoracic Surgery and the Society of Thoracic Surgeons appointed a joint committee to develop standards and guidelines pertaining to therapeutic thoracoscopy.⁵³ A few months later, thoracoscopic interventions were a major topic at the First International Congress of Thoracic Endoscopy held in Paris, France.

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Chest

Minimally Invasive TechniquesAn Alternative Technique in the Management of Bullous Emphysema: Thoracoscopic Endoloop Ligation of Bullae

Study objective

Patients:

Results

Conclusion

Section snippets

Patient Population

Results

Discussion

J Thorac Cardiovasc Surg

Lancet

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Chest

Chest

J Thorac Cardiovasc Surg

Clin Chest Med

Minimally Invasive Techniques
An Alternative Technique in the Management of Bullous Emphysema: Thoracoscopic Endoloop Ligation of Bullae