Emphysema Surgery

In this section, we will talk about a surgical treatment that created great excitement when it was first introduced to the world, but did not receive the attention it deserved in the following years.

76 LUNG TRANSPLANT
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216 SCIENTIFIC PUBLICATION

The general acceptance is to regulate the drug and supportive treatment of these cases and reduce the risk factors. Of course, this is a correct treatment and must be done in the best possible way. However, I think that surgical intervention, which significantly increases the quality of life and exercise capacity in suitable patients, should be added to the treatment methods and at least offered as an option to the patients. It must be admitted that, despite the success achieved with surgical intervention, the fact that the procedure has not reached sufficient numbers is a matter of discussion that is broad enough to go beyond the limits of this page. There are many medical and non-medical reasons for this.

A similar process occurred in our country. Unfortunately, the desired success was not achieved with the surgeries performed with great enthusiasm. Because only a small group of patients diagnosed with COPD, which is defined as a large disease group and includes millions of people, can benefit from this procedure. Selecting the appropriate patients among this large group and planning the procedure at the right time and in the right way are the main factors of success. Apart from this, it is not possible to manage such a complex process.

In this section, some information about lung volume reduction surgery has been compiled. The beginning of this process in the world and personal experiences were mentioned, and efforts were made to understand the subject more clearly. Since surgical intervention is closely related to the complex working principles of the respiratory system, these mechanisms have been tried to be explained as simply as possible. However, there may be many points worth discussing from various perspectives, and these discussions will mostly serve to deepen our thoughts on the subject.

How Did Emphysema Surgery Begin?

The beginning story of emphysema surgery, later known as lung volume reduction surgery, which I heard from J Cooper, who performed the first successful lung transplant in the world, is as follows: One day, Cooper performs a transplant on a patient with emphysema whose respiratory functions are extremely limited. During the recipient surgery, the lungs are disabled one by one and the surgical procedure is progressed. While the team has finished preparing the recipient, the team that performed the donor surgery has not yet reached the hospital. While waiting during this period, they make the following observation: Despite very low functions (the patient's FEV1 is 15%), when one lung is disabled, the patient's oxygenation does not deteriorate and there is no need for additional support systems. Cooper's conclusion from this observation is that the patient then still has lung tissue to provide adequate oxygenation, but this tissue is not functioning as it should. Then, if we can make this tissue function, we may eliminate the patient's need for transplantation.

Following this observation, he looks at the history of thoracic surgery. Reviews surgical techniques used for emphysema over nearly a century. Indeed, in the last century, surgeons have used a variety of surprising techniques to treat emphysema. One of these is a technique that a surgeon named Brantigan published the results of in 1957 (A Surgical Approach to Pulmonary Emphysema, Brantigan OC et al.). The basis of this technique is to cut out the air trapped areas in emphysema and create the opportunity for healthy lung tissue to re-function. Brantigan performed such surgeries in those years, but this procedure was abandoned in later years due to high mortality rates.

Cooper bu tekniği temel olarak değiştirmeden ancak daha iyi hasta seçip, çok daha iyi hazırlık yaparak ve elbette anestezi uygulamalarında artan deneyimi kullanarak başarılı bir şekilde uygulamış ve tekniği yeniden ve tüm dünyada popüler hale getirmiştir. Tekniğin yeni bir anlayışla uygulanmasının sonuçları 1995 yılında Cooper tarafından yayınlanmıştır (Bilateral Peumectomy (Volume Reduction) for Chronic Obstructive Pulmonary Disease, Cooper J ve ark.). Bu sonuçlar ardından teknik önce ABD'de ve sonra dünyanın pek çok yerinde uygulanmaya başlamıştır. Girişimin adı bu yazıda biraz karmaşa yaratıyor olsa da sonraki dönemde akciğer hacim küçültücü cerrahi yaygın olarak kullanılmaya başlanmıştır.

The thoracic surgery team at Royal Brompton Hospital, where I worked in those years, planned a study to start these surgeries and invited Cooper to London. The legendary team consisting of Cooper, Goldstraw and Pastorino, who are considered giants in thoracic surgery, performed the first surgery in England in 1996. This was an unforgettable moment for me and 2-3 young surgeons like me, who had the opportunity to watch this surgery right next to the surgeons and witnessed their conversations.

In the following years, a multi-center study was initiated in the USA to both determine medical limits and regulate relations with insurance companies: NETT (National Emphysema Treatment Trial). With this study, which was conducted with the participation of 18 centers and 17 centers after a preparation period of approximately 2 years, it was determined for which patients emphysema surgery is more suitable. In addition, in the study planned at Brompton Hospital and the results of which were published in 2000, some selection criteria were revised and it was shown that the surgical group significantly benefited from the procedure.

By the time I joined the Brompton team as Specilist Registrar in 2000, emphysema surgery had become a part of the routine. Moreover, the procedure, which was performed by opening the chest cage in the middle, was now performed thoracoscopically. There has been a technical development that has significantly increased this success. These surgeries were planned at an average rate of 2 cases per month, and the results were seen in the following months. During this period, while I was learning the surgical technique of surgeries, I was copying the respiratory function tests of all patients in order to better understand the issue of patient selection, which is perhaps the most important step.

After returning home, I heard that this surgery was performed in the institution where I worked and in other centers, and I saw some of it. Apart from the surgeries I performed under supervision in London, the beginning of my personal experience was the thoracoscopic volume reduction surgery I performed in 2001. I think this case is the first case performed thoracoscopically in our country. This case was followed for 5 years after the procedure, and the respiratory parameters observed during the follow-up were published in 2011 (5 years after bilateral volume reduction surgery: Case report. Eryiğit H, Kutlu CA).

Although we could not reach the numbers we wanted in the following years, we compiled our clinical experience as a congress presentation in 2012. However, this presentation was not prepared for publication and was not printed. The point we have reached in the process has advanced enough to select patients close to the lower limit of the functions required to perform this surgery (Management of bilateral pneumothoraces after talc pleurodesis and unilateral volume reduction surgery. Akın O, Taşçı E, Olgaç G, Kutlu CA).

Despite many successful surgical series in the following years, studies with low success rates began to be published in medical journals, depending on the team, patient selection and experience level. The trend in the world has caused these surgeries to be performed less frequently, as in our country. We need to accept that a wide variety of factors, not just medical outcomes, play a role in this process. Additionally, this procedure was attempted to be performed through some bronchoscopic procedures rather than surgery. The desired successes in this regard have not been achieved over the years. In recent years, long-term successful results of surgical intervention have begun to be discussed again, publications have appeared on this subject, and as a result, emphysema surgery has begun to come to the agenda again.

Basic Logic of Lung Volume Reduction Surgery

To understand lung volume reduction surgery (LLC) performed in patients with emphysema, it is necessary to take a quick look at the definitions of COPD, chronic bronchitis (CrB) and emphysema (A). During our student years, this disease was not called COPD, but rather CrB and A, and the differences and discrimination criteria of these two clinical conditions were explained at length. In the following years, it began to be said that these definitions should no longer be used and that it would be more accurate to mention the clinical picture under the title of COPD, which was defined to include both conditions. KrB and A occur together in almost all patients. Each patient is a little KrB and a little A, like a slowly changing color band with black at one end and white at the other. According to this view, an evaluation under two separate subheadings is unnecessary. As a matter of fact, WHO has made an appropriate definition for this situation: long-term airway obstruction that disrupts normal breathing and is not completely reversible. According to this definition, the recommendations, support and medical treatments to be given to a patient diagnosed with COPD are almost the same. In this case, there is no problem in accepting the disease as a single disease and arranging treatment.

I personally have an objection to this situation: This definition is extremely useful for non-physicians or physicians practicing in different specialties and will not cause any problems in using it. However, while COPD is a disease that a branch of expertise deals with most, treats and investigates cause-effect relationships, it is not appropriate to evaluate the whole picture with such a wholesale approach. We all look at the various features of the car we drive and form an opinion about our car. But in order to have an opinion about a car, an auto racer wants to learn a thousand and one features that we have not even heard of and form an opinion accordingly.

If we call this disease COPD, we cannot find a single patient suitable for volume reduction surgery. However, the patient group that will benefit from this surgery is A patients. Attempting such a procedure in CrB patients will lead to irreversibly distressing consequences. Since the most important stage of the procedure is to determine which patient can benefit from this procedure, different clinical conditions between patients are of great importance. For example, just as we think of intermediate colors in a color band with black at one end and white at the other, I mean selecting the right patient from a group of patients with KrB at one end and A at the other end and many transitions in between. If we follow the WHO definition and say there is no black or white here, in fact they are all blue, how can we make this choice?

Patients who are candidates for AHKC should receive a diagnosis of A. This procedure can be performed in cases where KrB does not contribute to the clinical picture at all, perhaps very little. For this reason, a small portion of an already large COPD group is a candidate for this procedure. In fact, the mechanism of airway obstruction occurring in CrB and A patients is completely different from each other. Differences in mechanisms also significantly differentiate the symptoms of the disease and its effects on other systems.

In CrB patients, the airways are narrowed due to bronchial secretions and changes in the layer lining the bronchi. These patients cough and produce sputum. The problem is in the transportation of air to the lung tissue with each breath taken. Controlling all factors that cause this narrowing in the airways forms the basis of treatment in this group.

In the mechanism in A, the problem is not in the airlines. More precisely, the problem in the airlines exists to the extent that KrB is included in the picture. The main problem is that a balloon in a box cannot expand any further. Think of a sponge with elasticity like a balloon inside an elastic box. In patient A, the pores of this sponge have enlarged like a sea sponge, air is trapped inside, and the volume of the sponge has increased. In order for us to breathe, the elastic box (rib cage) must expand further and air must fill the solid pores of the sponge. But the expansion has reached such a point that the elastic box cannot expand any further. Since it cannot expand, it cannot create an airflow into the sponge (lung). Take a deep breath, try to breathe in and out by keeping your breath inside. This is how A patients live. This mechanical problem cannot be overcome by opening the airways further. Unless we can create this expansion, we cannot create airflow into the sponge, that is, the lung.

At this point, the technique applied by Brantigan provides great benefit for the patient. When these air-trapped lung areas are excised, the total lung volume decreases. The decrease in the volume of the lung also causes the chest cage in which it is located to shrink. Shrinkage reduces the distance between the ribs, but mostly allows the diaphragms to take their normal shape. As a result, when the flexibility of the rib cage increases, it becomes possible to create the airflow necessary for breathing. Shortly after the procedure, the rib cage begins to move with each breath.

Before Surgery
Immediately After Surgery
2 Weeks After Surgery

The images above show a typical patient A's pre-procedure chest x-ray, then how the lungs have shrunk after volume reduction surgery, and the chest x-ray after the rib cage has resumed normal function. With the procedure, a significant decrease in the volume of the lung was achieved. This is a condition that will form the basis for the success of the surgery.

Who Can Perform Lung Volume Reduction Surgery?

As we have seen in history, this procedure has been brought to the agenda again and started to be applied in patients who are candidates for lung transplantation. The increasing popularity of the procedure is mainly due to the fact that cases requiring lung transplantation due to CAOH-A can be treated in this way. Here, the patient is not only treated with an easier and simpler procedure compared to transplantation, but also the opportunity to use the lung to be used in another patient who has no other chance is created. From this perspective, all lung transplant centers should have patients who perform this procedure.

It should also be noted that A is a progressive disease. It will continue to progress after this process. After a successful intervention, the maximum benefit is achieved in the first year of surgery and patients return to their performance roughly 5 years ago. In the following years, they begin to decline from this peak and return to their current situation within 5-7 years. At this point, if there is no other obstacle, they may be candidates for lung transplantation. For this reason, the surgical intervention should be performed in a way that does not cause technical difficulties in the transplantation process in the future.

Respiratory capacities in the 5-year follow-up of the first case

The table above shows the respiratory capacities of the first case we performed, before and in the 1st and 5th years after the procedure. FEV1, which measures airflow and is an important value for this procedure, was measured at 17% when the patient was decided to have the procedure, and this value increased up to 25% during the preparation period. It peaked at 45% in the first year of the procedure, but at the end of 5 years the patient returned to baseline values. This is the typical curve observed after lung volume reduction surgery.

It should not be forgotten that this procedure is performed on people who can somehow continue their lives, even with shortness of breath. For this reason, increasing success to the highest level and making every effort to achieve this are among the main points. While every person who is medically involved in the process is expected to make this effort, of course, the candidate for the intervention will also be given important responsibilities and will be asked to make the necessary effort. This will be valid in the pre-transaction and post-transaction periods.

Every person willing to undergo this procedure must not have smoked in the last 6 months. This is confirmed by laboratory examination when necessary. It is accepted that the person who cannot achieve this does not have sufficient motivation for the success desired from this process. It is possible to carry out the necessary research and evaluations if this condition is met.

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