NO-CUT THORACOSCOPIC LUNG PLICATION - A NEW TECHNIQUE FOR LUNG-VOLUMEREDUCTION SURGERY

Background: Lung volume reduction surgery (LVRS) using a linear cuttin g stapler or laser ablation via median sternotomy or thoracoscopy is a current therapy for symptomatic emphysema. The primary causes of morb idity and mortality (as high as 20%) are existing comorbidities and pr olonged air leaks secondary to visceral pleural division. We report a novel technique using minimally invasive techniques designed to achiev e volume reduction while preserving the visceral pleura. A novel lung grasper and a knifeless stapler are used to permanently plicate lung t issue without cutting visceral pleura. Study Design: This prospective analysis involves a consecutive series of patients who had LVRS using this method. Between May 1995 and September 1996, 32 patients underwen t 50 unilateral, staged bilateral, or bilateral thoracoscopic lung pli cation procedures. The indications for LVRS were standard; they includ ed severe limiting dyspnea (forced expiratory volume in one second [FE V1] = 0.68 +/- 0.05), hyperinflated lungs with flattened diaphragms on chest x-ray, and diffuse emphysema seen on chest computed tomography scan. Ventilation and perfusion scanning was used to identify potentia l ventilation and perfusion mismatch target areas of lung for plicatio n. Results: The right lung was plicated first in 25 of 32 patients (78 %), and upper lobe plications predominated (77%), A mean of 9.3 +/- 0. 8 staple firing were used for each unilateral plication procedure. The re were no perioperative deaths. Two patients (4%) required axillary t horacotomies to repair air leaks. Mean chest tube duration was 6.3 +/- 0.5 days. Median hospital stay was 7 days (range 3-15). An Intensive Care Unit stay was required following 8 procedures (17%). Post-operati ve morbidity occurred in 18 (39%) of 46 procedures, including 5 cases of atrial fibrillation and 4 persistent (> 7 days) air leaks. A minimu m 2 month followup was available for 22 patients (32 of 46 procedures) , demonstrating a clear chest x-ray with significant improvement in ip silateral diaphragmatic contour. Twelve patients had unilateral reduct ion, and 10 patients had bilateral reduction in either a staged (n = 7 ) or sequential at one operation (n = 3) fashion. Twenty-five (78%) of 32 procedures were associated with improved pulmonary function, with a mean increase in FEV1, in patients in this subgroup of procedures, o f 43 +/- 7% for each ipsilateral plication at a mean followup of 3.8 /- 0.5 months. For the entire group of 32 procedures, the mean improve ment in measured FEV1 was 29 +/- 7%. Supplemental oxygen requirement w as significantly reduced in 9 of 16 patients following plication. Conc lusion: These data suggest that minimally invasive surgical techniques coupled with a no-cut lung plication can achieve significant lung vol ume reduction with favorable postoperative morbidity and mortality. Lu ng plication appears to hold promise as an alternative technique of LV RS. (C) 1997 by the American College of Surgeons.