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General Thoracic Surgery > Surgery for Emphysema > Flashcards

Surgery for Emphysema Flashcards

1
Q

Pathophysiology of emphysema

A

Degredation of elastin-collagen matrix in airway, resulting in loss of elastic recoil that limits airflow and respiratory mechanics.

Ultimately results in irreversable destruction and permanent enlargement of distal airspaces and lung parenchyma

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2
Q

Goals of surgical intervention for emphysema

A

Palliation of symptoms

Improvement in survival

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3
Q

Diagnostic criteria for emphysema

A
  • Decreased FEV1:FVC ratio
  • Absolute decrease in FEV1
  • Hyperinflation of lungs
  • Flattening of diaphragm
  • Increased WOB
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4
Q

Preoperative evalution and planning essential for LVRS

A
  • Cardiopulmonary clearance
  • Rigerous pulmonary rehab program
    • Weaning of steriods
    • Optimization of bronchodilators
    • Nicotine abstinence
    • Physical re-conditioning
  • CT scan (chest)
    • Characterize distribution and extent of disease
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5
Q

Indications for LVRS

A
  • Decreased FEV1 (<= 40% predicted)
  • Increased TLC (>=100% predicted)
  • Significantly increased RV (>= 150% predicted)
  • No hypoxia or hypercarbia
  • Acceptable cardiac risk
  • Compiance with rigerous pulmonary rehabiliation (preop and postop)
  • Nicotine abstinence >= 6mo prior to LVRS
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6
Q

SIgnificant (Absolute) Contraindications for LVRS

A
  • Bronchiectasis
  • Hypercarbia (PCO2 > 60 mmHg on RA)
  • Pulmonary HTN
  • Prior lobectomy on ipsilateral side
  • Interstitial lung disease
  • Ventilator dependence
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7
Q

Relative Contraindications for LVRS

A
  • Chronic bronchitis
  • Asthma
  • Use of >= 20 mg Prednisone daily
  • Oxygen dependence
  • Active nicotine (smoking) use
  • Morbid obesity
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8
Q

Historical surgical techniques for emphysema

A
  • Techniques designed to enlarge thoracic cavity
    • costochondrectomy
    • transverse sternotomies
    • paravertebral thoracoplasties
  • Diaphragmatic plication
  • Pleurectomy
    • incrase collateral circulation to lung parenchyma
  • Bullectomy
  • Pneumonectomy
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9
Q

Contemporary definition (goal) of LVRS

A

Resection of non-anatomic, poorly perfused lung tissue by median sternotomy, thoracotomy, or VATS

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10
Q

Surgical principles of LVRS

A
  • Inspect/palpate entire lung
  • Observe and preserve ares of fastest desaturation and determine tissue for resection
  • Mobilize entire lung - divide inferior pulmonary ligament
  • Resect target area with reinforced stapler
    • Use Gortex or bovine pericardium to reinforce stapler
  • Avoid over resection to minimize space problems and air leaks
  • Use synthetic glues/sealent, pleural tents, or pleurodesis to reduce air leaks
  • Chest tube placement to water seal immediately
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11
Q

Perioperative managment principles following LVRS

A
  • Aggressive pulmonary toilet
  • Medical optimization
  • Physical therapy
  • Use of inhaled bronchodilators
  • Avoid steroids
  • Aggressive bronchoscopy strategy for pulmonary hygiene
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12
Q

Expected results after LVRS

A
  • Improvement:
    • FEV1
    • Respiratory muscle function
    • Expercise capacity
    • Dyspnea
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13
Q

Common postoperative complicatons following LVRS

A
  • Prolonged air leak
  • Respiratory failure
  • MI
  • PNA
  • Stroke
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14
Q

Perioperative mortaltiy after LVRS

A

5-15%

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15
Q

T/F:

Studies have demonstrated superior outcomes following VATS vs. open (median sternotomy, thoracotomy) LVRS?

A

False:

no differences in functional outcomes

however, VATS patients are able to return to independent living sooner

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16
Q

Results of National Emphysema Treatment Trial (NETT)

A

Patients with upper lobe predominant disease demonstrated decreased symptoms and improved exercise capacity tolerance with LVRS compared to medical therapy.

Patients with homogenous distribution of disease found to have decreased survival after LVRS compared to medical therapy.

NETT: RCT (17 centers, 1,218 patients, 7 year study period, Mean f/u 2 years)

17
Q

Surgical alternatives for emphysema

A
  • Investigational devices used as means of bypassing diseased areas of lung:
    • One-way endobronchial valves
      • VENT trial
        • Endobronchial valves may improve lung function, exercise tolerance, and symptoms
          • More frequenct COPD exacerbations, PNA, hemoptysis
    • Drug eluting stents

General Thoracic Surgery (36 decks)

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