LVRS

LVRS (Lung Volume Reduction Surgery)

What is LVRS?

This is a relatively new procedure. It is based on the observation that emphysema causes the lung to expand and compress good lung tissue. If the diseased lung tissue is removed, it will result in more room in the chest cavity for the good lung tissue to expand and carry on gas exchange. In 1957 Brantigan and Mueller removed 20-30% of lung volume. They did not have a lot of success with the procedure because they did not have modern anesthetics nor did they have the staples that are used today. In 1994, Dr. Joel Cooper rediscovered the procedure and has had good results so far.

What do they do?

In lung volume reduction surgery 20-30% of the diseased portions of the lungs are removed so that there is more space for the good lung tissue to expand and carry on gas exchange as well as more room for the diaphragm to take on its normal shape and function. The surgery can be performed with staples, lasers, or both. The staples are reinforced with the membrane of a cow’s heart to prevent air leaks. This works much like adding bias tape to cloth to prevent tearing while sewing. Open and closed procedures are used removing tissue from one or both lungs.

What are the results?

Lung volume reduction surgery is done to improve the quality of life of patients with emphysema. It is not a cure. Current results based on a three month evaluation of 17 patients show 79% of the patients reporting an improved quality of life, and 89% of patients who were previously reliant on supplemental oxygen are reduced to using oxygen with exercise. With pulmonary function test, 49% improved in FEV1 (forced expiratory volume in one second) and 23% improved in FVC (forced vital capacity). Because most of the positive results obtained were from small scale, poorly controlled studies of small patient populations, most scientists would agree that more studies need doing in order to prove that this surgery is effective. Currently, two federal government agencies, the Health Care Financing Administration and the National Institute of Health are sponsoring a study that will enroll over 3000 patients at 18 different study centers including more than 21 hospitals to search for the answer. Specifically, the study wishes to address how much improvement each patient will have, how soon the improvement will occur, and how long the improvement will last. What we do know is that most patients are seeing improvements. What we need to find out is whether or not those improvements are a direct result of lung volume reduction surgery.

What are the complications of surgery?

This surgery is different than other surgeries in that it should not be considered a single procedure. There is an extensive pre and post-operative rehabilitation program which needs to be followed for maximal effect.

The main complication of lung volume reduction surgery is an air leak. Normally there is a vacuum between the ribs and the lungs which helps to make the lungs expand and fill with air when the chest wall expands. If an air leak allows air in the potential space between the ribs and lungs then the vacuum effect is gone and the lung sags like a flat tire. This makes it very difficult to inflate the lungs and perform gas exchange.

Some general surgery complications include: fever, wound infections, wound hematomas, postoperative fatigue, and tachycardia.

Other complications include: pneumonia, atelectasis, aspiratoin, pulmonary edema, fat embolism, ARDS, conversion of the procedure to a thoracotomy, large bowel ischemia, myocardial infarction, cardiac arrhythmias, ileus, perforated peptic ulcer, delayed pheumothorax, renal failure, cerebrovascular accident, empyema, tracheostomy, hypertension, delerium tremens, depression, thyroid disorders, adrenal insufficiency, and hypercoagulable states. These should be discussed with your doctor.

Who is eligible?

About 20% of emphysema patients are eligible for this procedure. Good candidates for surgery experience breathlessness, have a diaphragm that does not move much on chest x-rays taken during inhalation and exhalation, have pulmonary function tests which show severe obstruction and enlarged lungs, and have normal function of the right side of the heart. It is also important for patients to have strong family support due to the extensive rehabilitation programs.

Some factors which exclude patients for this procedure include hypertension of the pulmonary artery, malnutrition, very overweight individuals, high carbon dioxide retention, decreased diffusion capacity of the lungs, high doses of steroid therapy, and advanced age. (1)

Bulla (12cm) before it was removed from the lung (A1AD patient) during LVRS.

Healthy lung tissue in this photo is purple.
The diseased lung tissue is pink due to advanced emphysema (A1AD patient).

Recovery of the bulla sack from the lung (A1AD patient) during LVRS

Muscle was used as a "patch" and sutured over an air leak that occurred post LVRS (A1AD patient).

Thoracic Incisions of an 37 y/o female with A1AD also known as Hereditary Emphysema.
LVRS was performed on both the left and right lung to remove damage

X-ray of 37 y/o female with A1AD after an LVRS,
in which the lower left lung was removed due to severe lung disease, emphysema.

References:
1. Pamphlet information compiled by Afi Eframian, Martin Janout, Nate Nelson, and Kelle Sauer. Creighton University Medical Center December 14, 1998.
2. Photos A, B, C & D courtesy of Froedtert Memorial Medical College; thoracic surgeon George B. Haasler

Disclaimer
This site is not a substitute for genuine medical advice. The information provided by this site is for the education and support of people diagnosed with A1Ad and others wishing to know more about this condition. It is intended that this site will enable you to ask your own doctors the right questions about your condition.