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Chest

Volume 128, Issue 4, October 2005, Pages 2043-2050
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Clinical Investigations
Elective Surgery for Giant Bullous Emphysema: A 5-Year Clinical and Functional Follow-up

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Background

So far, very few studies in the literature have reported data on the long-term follow-up of patients who have undergone surgery for giant bullous emphysema (GBE), and much still needs to be known on the late fate of these patients.

Aims

To evaluate patients who have undergone elective surgery due to GBE, early and late mortality following surgery, the early and late reappearance of bullae, and the early and late modifications of clinical and functional data.

Subjects and methods

Forty-one consecutive patients (36 men; mean [± SD] age, 48.4 ± 14.8 years) who underwent elective surgery for GBE were enrolled in a prospective study, and were studied both before and after undergoing bullectomy for a 5-year-follow-up period. Analyses were performed on the whole population and on two subgroups of patients who were divided on the basis of the absence of underlying diffuse emphysema (group A; n = 23) or the presence of underlying diffuse emphysema (group B; n = 18).

Results

The early mortality rate was 7.3% (within the first year), and the late mortality rate was 4.9% (overall mortality rate at 5 years, 12.2%; mortality rate in group B, 27.8%). Bullae did not reappear and residual bullae did not become enlarged in any patients at the site of the bullectomy. During the follow-up, the dyspnea score was reduced significantly soon after bullectomy and up to the fourth year of follow-up; intrathoracic gas volume also was reduced significantly (average, 0.7 L). The same was true for the FEV1 percent predicted and the FEV1/vital capacity ratio, which kept increasing until the second year; then, from the third year of follow-up these values were reduced, yet remained above the prebullectomy values until the fifth year of follow-up. When considered separately, the patients in group B appeared to be the most impaired, clinically and functionally (eg, FEV1 showed a similar significant increase up to the second year in both groups after surgery, while a different mean annual decrease was appreciable from the second to the fifth year of follow-up: group A, 25 mL/year; group B, 83 mL/year. Furthermore, patients in group B were the only ones who contributed to the mortality rate, on the whole showing a behavior similar to that of patients who had undergone lung volume reduction surgery.

Conclusions

In patients with GBE who were enrolled in the study prospectively and were investigated yearly during a 5-year-follow-up period, elective surgery appears to have been fairly safe, and allowed clinical and functional improvement for at least 5 years. Better results may be expected in patients without underlying diffuse emphysema.

Section snippets

Materials and Methods

Among all consecutive patients who underwent surgery for bullous emphysema between January 1985 and December 1999 at the Cardiac and Thoracic Department of the University of Pisa (Italy), the study included all of those who underwent elective surgery for the removal of giant bullae.

The study inclusion criteria were as follows: (1) the presence of giant bullae occupying over one third of a hemithorax; (2) signs of compression over the mediastinum (ie, mediastinal shift and/or herniation) or

Clinical Functional Evaluation

Patients were interviewed about their medical history, both recent and more distant, according to a predefined form; particular attention was paid to the presence of dyspnea, which was graded on the basis of a modified British Medical Research Council (mBMRC) score.14 The diagnosis of GBE was made by chest radiography and CT lung scan, which most of the time was performed after suspicion had been raised on the basis of history, clinical assessment, and pulmonary function test (PFT) results.

Follow-up

Patients were followed up for 5 years after undergoing surgery, with six control checkups scheduled within 3 to 6 months after surgery and, subsequently, at 1, 2, 3, 4, and 5 years after undergoing surgery. Each appointment was scheduled in advance, and one of the pneumologists in charge of the protocol guaranteed that the follow-up procedure was correctly performed. During such checkups, the same examinations that had been performed before surgery were repeated. During the 5-year follow-up

Statistical Analysis

To compare unpaired and paired data, unpaired and paired t tests or Wilcoxon tests were used for quantitative variables, while the Fisher Exact Test and the McNemar test were used for qualitative variables. The time trend in quantitative variables was analyzed by analysis of variance with repeated measures, and multiple comparisons were performed by the Dunnet test, with the prebullectomy value used as the reference value. Comparison between groups A and B was performed by analysis of variance

Results

Of the 245 consecutive patients who were referred to our department for treatment of bullous emphysema, 193 (79%) met the criteria for surgery and underwent the intervention. Among them, 41 patients (21%) also met both inclusion and exclusion criteria for the present study, and were, therefore, set as the object of our study.

All 41 patients (36 men; mean [± SD] age, 48.4 ± 14.8 years; age range, 15 to 77 years) underwent the removal of giant bullae (standard thoracotomy, 27 patients;

Mortality Rate

During hospitalization, there were no deceases, and all patients were able to perform the first clinical and functional assessment 3 to 6 months after undergoing surgery. Between the first and the second scheduled checkup (1 year after surgery), three patients (7.3%) died because of acute respiratory failure due to pulmonary infection; all three patients were in group B. Two patients (4.9%) died 2 years after undergoing surgery because of acute cardiovascular disease, and another patient died 3

Reappearance of Bullae

Chest radiography and CT lung scan performed on patients during the follow-up period showed no new bullae at the site of bullectomy or any residual small bullae with significant enlargement; consequently, no patient required further bullectomy.

Clinical and Functional Data

By analyzing the data of the 41 predefined forms submitted to patients on study enrollment, we observed dyspnea in 36 of 41 patients (88%), with a mean dyspnea score of 2.2 ± 0.6. The overall mean dyspnea score of the 41 patients was 1.9 ± 0.9 (Table 1). Such a value showed a significant inverse correlation with FEV1 (in liters; r= −0.31; p = 0.050), FEV1 (percent predicted; r = −0.35; p = 0.027), and FEV1/VC ratio (r= −0.31; p = 0.045) and a direct correlation with residual volume (r = 0.32; p

Clinical and Functional Data by Extension of Emphysema

Dyspnea was found in 20 of 23 patients (87.0%) in group A and in 16 of 18 patients (88.9%) in group B, with no statistical difference in mean dyspnea score between the two groups (Table 1).

Patients in group B showed lower values of FEV1/VC ratio, FEV1 (in liters), and FEV1 percent predicted (difference not significant), higher values of functional residual capacity (FRC) [p = 0.018] and FRC percent predicted (difference not significant), similar values of TGV (difference not significant), and

Discussion

The first result of this study, with no patient lost through follow-up, concerns the absence of early postoperative mortality and the presence of acceptable overall early and late mortality rates. As a further result, no new bullae appeared on the site of the bullectomy and no residual small bullae became enlarged during the follow-up period. Such results demonstrate that elective surgery, independently of the type of surgical approach chosen, is safe in both the short term and the long term.

References (37)

  • BrennerM et al.

    Rate of FEV1 change following lung volume reduction surgery

    Chest

    (1998)
  • GelbAF et al.

    Lung function 4 years after lung volume reduction surgery for emphysema

    Chest

    (1999)
  • YusenRD et al.

    A prospective evaluation of lung volume reduction surgery in 200 consecutive patients

    Chest

    (2003)
  • PotgieterPD et al.

    Surgical treatment of bullous lung disease

    Thorax

    (1998)
  • Hugh-JonesP et al.

    The etiology and management of disabling emphysema

    Am Rev Respir Dis

    (1978)
  • MenconiGF et al.

    Treatment by VATS of giant bullous emphysema: results

    Eur J Cardiothorac Surg

    (1998)
  • PearsonMG et al.

    Surgical treatment of emphysematous bullae: late outcome

    Thorax

    (1983)
  • HughesJA et al.

    Long-term changes in lung function after surgical treatment of bullous emphysema in smokers and ex-smokers

    Thorax

    (1984)

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