Awake Nonresectional Lung Volume Reduction Surgery

Abstract

Objective: To assess the feasibility, safety, and early results of awake lung volume reduction surgery (LVRS) performed under thoracic epidural anesthesia by a new nonresectional technique. Summary Background Data: So far, resectional LVRS under general anesthesia and one-lung ventilation is the more frequently used technique, but procedure-related morbidity has been considerable. Methods: The study cohort included 12 patients undergoing unilateral awake LVRS. Evaluated parameters included technical feasibility and anesthesia satisfaction scored into 4 grades (from 1 ϭ poor to 4 ϭ excellent), global operating room time, and arterial carbon dioxide tension (PaCO 2 ). In addition, 6-month changes in outcome measures, including forced expiratory volume in 1 second (FEV1), residual volume (RV), 6-minute walking test (SMWT), and dyspnea index were recorded. Perioperative and 6-month results were comparable with those of a control group undergoing unilateral resectional LVRS. Results: Technical feasibility was excellent to satisfactory in 11 patients. One patient required conversion to one-lung ventilation. Differences between the awake and control group included global operating room time (90 Ϯ 17 minutes versus 145 Ϯ 19 minutes, P Ͻ 0.00001); PaCO 2 24 hours after surgery (45 Ϯ 6 mm Hg versus 49 Ϯ 6 mm Hg, P ϭ 0.02); and hospital stay (7.8 Ϯ 5 days versus 11.7 Ϯ 4 days, P ϭ 0.02). Significant (P Ͻ 0.002) improvements occurred at 6 months in FEV1 (0.31 Ϯ 0.17 L), RV (Ϫ1.41 Ϯ 0.7 L), SMWT (73 Ϯ 25 m), and dyspnea index (Ϫ1.3 Ϯ 0.5) and were comparable with those of the control group. Conclusions: In this study, awake nonresectional LVRS proved feasible and safe. This new modality was associated with a faster recovery and satisfactory 6-month outcome, which did not differ from that of resectional LVRS. (Ann Surg 2006;243: 131-136)

Lung Volume Reduction Reoperations

“…Procedures were completion lobectomy in 7 patients, nonanatomic resection of the most hyperinflated lung regions in 5 patients under general anesthesia, and awake lung plication under thoracic epidural anesthesia in 5 patients [8]. All patients gave written informed consent for the procedure, and the Tor Vergata Ethical Committee approved the study.…”

“…On the basis of our previous experience with awake lung volume reduction operations under epidural anes- thesia [8], we have recently decided to use the same approach to perform LVRR in an attempt to minimize morbidity by avoiding adverse effects related to general anesthesia. Our main concern in this regard was initially related to the presence of pleural adhesions resulting from the previous procedure, particularly when bovine pericardium buttress had been used.…”

Two-Year Improvement in Multidimensional Body Mass Index, Airflow Obstruction, Dyspnea, and Exercise Capacity Index After Nonresectional Lung Volume Reduction Surgery in Awake Patients

“…Anesthesia and surgical technique have been already described in detail [16]. Briefly, thoracic epidural anesthesia was initiated to achieve somatosensory and motor block at the T1 to T8 level while preserving diaphragmatic respiration.…”

“…After an initial pilot study to assess feasibility and early results [16], we have now analyzed the comprehensive 2-year outcome of nonresectional LVRS in awake patients, including the multidimensional body mass index, airflow obstruction, dyspnea, and exercise capacity (BODE) index, which has proved a useful predictor of survival [17] in patients with chronic obstructive pulmonary disease (COPD) and has recently shown to improve significantly after LVRS [18].…”

Late-Onset Occult Pneumothorax After Lung Volume-Reduction Surgery

“…We therefore now prefer videoassisted thoracoscopic surgery management with the goal of sealing pulmonary tears and reducing the risks of triggering further complications. In addition, having further experience with awake procedures for resection of pulmonary nodules [9] and LVRS [10], we are prone to adopt this option even in this setting, with the aim of reducing surgical risks in these delicate patients. Previous studies have focused on the advantages of this approach to managing air leak problems [11,12].…”