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1 VATSArgon Beam Coagulator Treatment of Diffuse End-Stage Bilateral Bullous Disease of the Lung Ralph J. Lewis, MD, Robert J. Caccavale, MD, and Glenn E. Sisler, MD Department of Surgery, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, and Combined Thoracic Surgical Service, St. Peter s Medical Center and Robert Wood Johnson University Hospital, New Brunswick, New Jersey Diffuse bullous disease of the lungs remains an unrelentless, debilitating, terminal disease. Intensive medical therapy can give transient relief of symptoms. Thoracotomy and resection has not always been successful and can be associated with an increased mortality and morbidity. Eight patients with end-stage bullous disease, unresponsive to medical therapy and not considered to be candidates for a thoracotomy, underwent unilateral video-assisted thoracic surgical ablation of bullae using the Argon Beam Coagulator. Six men and 2 women ranging in age from 28 to 71 years reported a decrease in dyspnea. Three patients restudied had an increase in forced expiratory volume in 1 second of 34%. Postoper- atively, 7 patients had an air leak, pneumonia developed in 2 patients, and 3 patients had massive subcutaneous emphysema after parietal pleurectomy. Hospitalization averaged 13.6 days. All patients made a complete recovery, and each was subjectively improved. Steroid use decreased, oxygen requirements decreased, dyspneic episodes decreased, infections decreased, and endurance increased. In 3 patients with a limited follow-up evaluated postoperatively, video-assisted thoracic surgery and the Argon Beam Coagulator seemed to be beneficial for treating advanced, generalized bullous disease. (Ann Thorac Surg 2993;55:1394-9) iffuse emphysematous bullous disease of the lung D associated with chronic obstructive pulmonary disease is an unrelentless, intractable, debilitating process [l]. Expanding large bullae compress functioning alveoli and cause distention of the thorax leading to dyspnea. Despite costly, prolonged, complex medical therapy, the condition of many of these patients continues to deteriorate. In some patients, traditional surgical intervention for the resection of bullae can alleviate symptoms for various periods [24]. Morbidity and mortality, however, can be high because of the adverse effects of the thoracotomy incision on respiratory mechanics and the need to resect normal lung tissue adjacent to the bullae [5, 61. Debilitated, pulmonary compromised, and elderly patients with advanced compressive bullous disease or diffuse honeycombed changes have not responded satisfactorily to the currently available comprehensive medical or surgical treatments. Because of the absence of a uniform and reliable protocol for the surgical treatment of bullous disease, video-assisted thoracic surgery (VATS) and the Argon Beam Coagulator (ABC)(Birtcher Medical Systems, Irvine, CA) were used to try to diminish symptomatic progressive dyspnea in patients with deteriorating, refractory bullous disease unresponsive to medical therapy. Material and Methods Six men and 2 women ranging in age from 28 to 71 years underwent bullous ablation using the ABC. Each of these Presented at the Twenty-ninth Annual Meeting of The Society of Thoracic Surgeons, San Antonio, TX, Jan 25-27, Address reprint requests to Dr Lewis, 185 Livingston Ave, New Brunswick, NJ patients had dyspnea at rest and was capable of only very limited physical activity. Seven patients were receiving steroids preoperatively, and 6 patients had been receiving oxygen. Two patients had combined argon ablation and stapler resection of bullae, 2 had a complete parietal pleurectomy, and 1 patient had a partial parietal pleurectomy with the addition of doxycline hyclate (Vibramycin; Roerig, New York, NY) for sclerosis. Operating room times averaged 70 minutes, ranging from 14 to 150 minutes. In 3 patients, lysis of extensive adhesions between the visceral and parietal pleura accounted for the prolonged operating times. Four patients were discharged home with a chest tube and flutter valve because of persistent air leaks. Four other patients had their chest tubes removed before discharge anywhere from 5 to 18 days postoperatively, with an average period of days. Altogether, 7 patients had air leaks postoperatively. In 3 of the patients sent home with a chest tube and flutter valve, pneumonia developed and the patients had to be readmitted for treatment. Each of these patients recovered uneventfully. In 3 patients, who underwent parietal pleurectomy in an attempt to prevent prolonged postoperative air leaks, massive upper torso subcutaneous emphysema developed. One other patient was readmitted 14 days postoperatively with a spontaneous pneumothorax on the operated side requiring chest tube insertion. All of these patients recovered completely. There was no mortality. Presently, 3 patients have had preoperative and postoperative pulmonary function tests. Forced expiratory volume in 1 second, vital capacity, and volume reduction studies such as total lung capacity and residual volume by The Society of Thoracic Surgeons

2 Ann Thorac Surg 1993; LEWIS ET AL 1395 Table 1. Preoperative and Postoperative Results of the 8 Patients Variable Preop Postop Steroids 7 1 Oxygen 6 3 FEV, (L) a All 8 patients (mean) patients (mean) L (34% increase) Dyspnea 8 6 markedly improved, 2 slightly improved a Five patients refused pulmonary function tests. FEV, = forced expiratory volume in 1 second. seem to correlate best with improvement [7]. Postoperatively, there has been a reduction in steroid usage and oxygen requirements in all 8 patients, and there was a 34% increase in the forced expiratory volume in 1 second of the 3 patients restudied. Dyspnea was markedly improved in 6 patients and slightly improved in 2 (Table 1). Five patients, whose condition was subjectively improved, refused any postoperative studies. Technique Bullous ablation was accomplished using the technique of VATS and single-lung anesthesia [8]. Each patient was placed in the lateral thoracotomy position after insertion of a double-lumen tube. Usually, two or three incisions averaging 2 cm in length were required. The scope was inserted through an incision in the sixth or seventh intercostal space in the midaxillary line. One other incision was made in the third or fourth intercostal space for the ABC pencil or TL 30, ELC 60 stapler (Ethicon, Cincinnati, OH). Any adhesions were divided using endoscopic scissors, cautery, and the ABC. Lungs usually deflated very slowly because of air trapping in the bullae and frequently required gentle compression from sponge sticks to expedite collapse. Normal alveoli and functioning bullae deflated first. Nonfunctioning bullae that remained distended were partially reduced in size using the ABC set at 80 W and passed in a slow, methodical manner over their surface (Fig 1). A perpendicular direction of the beam or dwelling for too long a time in any single area could possibly cause deeper cauterization and eventual necrosis resulting in postoperative air leaks. Next, the lung was allowed to partially expand revealing the more elastic and functional bullae. Some of these bullae were then ablated using the ABC. If a bulla arose from a narrow stalk, it was resected using a stapler (Fig 2). Because, in this group of patients, eventual transplantation was not a consideration, a parietal pleurectomy was performed in 3 patients in an attempt to prevent or at least diminish postoperative air leaks. Chemical sclerosis was also used in 1 patient. One or two chest tubes were inserted, and the small wounds were carefully closed in layers. Fig 1. Argon Beam Coagulator pencil firing at distended bulla. Comment This group of patients in progressively deteriorating condition, who no longer responded to complex, comprehensive medical treatment, did not appear to be suitable candidates for a thoracotomy and resection. Their thin, overly distended chest walls composed of atrophic muscles and osteoporotic ribs were capable of only very limited ventilatory motion. In some patients, the inspiratory-expiratory cycle was barely perceptible. A formal thoracotomy, which would incise these weakened muscles and spread, dislocate, or fracture the very fragile ribs, seemed too great a burden for them to endure. It appeared, however, that some symptomatic relief might be obtained from bullous reduction, which would decrease intrathoracic volume. This could be accomplished using the small, atraumatic incisions of VATS and the ABC for superficial cauterization with partial ablation of selected Fig 2. ELC 60 stapler dividing bulla at the base.

3 1396 LEWIS ET AL VATS-ABC BULLOUS ABLATlON Ann Thorac Surg 1 Y93;55: bullae. Adjoining compressed alveoli could now expand and function, whereas a traditional surgical resection would have compromised some of this vital tissue. Surprisingly, each of these patients tolerated general anesthesia and one-lung ventilation without difficulty. Obviously, this is essential for the performance of this technique. Oxygen saturations remained acceptable even when a single lung with giant bullous disease was being ventilated. Some theories maintain that bullous ablation with reexpansion of collapsed viable lung accounts for the improvement in postoperative respiration [9]. Obviously, during one-lung anesthesia, at the time of operation, compressed pulmonary tissue in the ventilated thorax cannot expand; nevertheless, oxygen saturations still remain normal. This could be related to increased chest wall excursion resulting from muscle paralysis and positivepressure ventilation. Most likely, in patients with bullous disease, there is sufficient underlying, normally functioning lung tissue to maintain adequate respiration if it can be properly ventilated. Because of distorted respiratory mechanics due to persistent overexpansion, the chest wall is confined to a limited range of excursion. The requirements for increased expansion during inspiration and adequate passive recoil during expiration are adversely affected by the stiff, distended chest wall. Decreased intrathoracic volume resulting from bullous ablation, and the reexpansion of compressed lung, probably account for postoperative improvement. Respiratory muscles return to a more efficient configuration, discomfort from stretched chest wall receptors is reduced, and the elastic work of breathing is decreased [lo]. Even a very small increment of change resulting from recruitment of a small number of alveoli can result in an extraordinary subjective improvement in respiration for these patients. Because currently available tests such as roentgenography and pulmonary function studies are very gross measurements of respiration, they do not always correlate with the subjective benefits described by the patient. Although dyspnea is improved, increased physical capacity cannot always be demonstrated. This could be due to a ventilationlperfusion imbalance. Because of air trapping, these lungs do not collapse completely. In fact, in some patients thick-walled fibrotic bullae will deflate only imperceptibly when the ABC is passed over them. Subsequent controlled minimal reexpansion of the lung exhibits more elastic functional bullae, which can be ablated satisfactorily. One must refrain from aggressively cauterizing all bullae because the underlying scant amount of normally functioning lung tissue may not completely fill the thoracic cavity. Because no scientific measurements are currently available to determine the optimal amount of bullous ablation needed to lessen dyspnea, surgical judgment alone is relied upon to accomplish the desired goal of symptomatic improvement while avoiding any residual dead space. Despite the low ABC settings and extreme care in cauterizing the bullae, 7 patients had air leaks postoperatively. Three patients had no air leak initially, but leaks developed in them between 3 and 4 days postoperatively. Possibly delayed necrosis of the thin-walled bullae was Fig 3. Massive subcutaneous emphysema developing after parietal pleurectomy. responsible for these air leaks. Because of this occurrence, chest tubes now remain in the thoracic cavity for 5 or 6 days postoperatively even if there is no evidence of any air leak. Even the smallest loss of tidal volume in this very fragile group of patients can compromise ventilation. When air leaks did occur, negative-pressure chest tube drainage had to be terminated because of intolerable dyspnea. Despite incomplete expansion of the lung, water seal drainage had to suffice. Air leaks usually persisted for prolonged periods as healing was probably retarded because of steroid usage. Attempts to discharge these weak, compromised patients with a chest tube connected to a flutter valve were unsuccessful. Three of the 4 patients discharged in this manner had development of pneumonia and had to be readmitted. Because of this experience, these patients now remain hospitalized and are supported for the duration of the air leak. Hoping to eliminate or to seal air leaks more rapidly postoperatively, and to avoid prolonged hospitalizations, we performed total parietal pleurectomies in 2 patients [ll]. Massive upper torso subcutaneous emphysema developed and lasted 6 to 8 days (Fig 3). Even in these patients, negative-pressure chest drainage could not be used because tidal volume was compromised, causing severe dyspnea. In a third patient, hoping to avoid massive subcutaneous emphysema, we performed a partial parietal pleurectomy. Subcutaneous emphysema still occurred, although it was more mild. Currently, talc insufflation is being used instead of parietal pleurectomy. All patients reported that they felt much improved postoperatively and experienced less dyspnea. Two patients even claimed to be improved after being extubated in the recovery room. Postoperative chest roentgenograms usually revealed decreased volume on the ablated side (Fig 4). Forced expiratory volume in 1 second values

4 Ann Thorac Surg 1993;55: LEWIS ET AL 1397 A B Fig 4. (A) Preoperative chest roentgenogram. (B) Volume reduction of right thorax after ablation of bullae. were improved an average of 34% in the 3 patients restudied postoperatively, and each patient felt the procedure was very beneficial. Seven patients no longer require any supplemental steroid therapy, and 5 patients do not need oxygen. One patient had ablation of the opposite lung because of increasing dyspnea and had an excellent result after this second procedure. Two other patients, who remain improved, have requested ablation of the opposite lung hoping to gain even more ventilatory capacity. All patients in this series were carefully evaluated and prepared for this surgical intervention by a pulmonary team consisting of thoracic surgeons, pulmonologists, respiratory therapists, and physiotherapists. These patients are very fragile, severely compromised, and extremely anxious for any type of assistance that could relieve them of the intolerable symptoms of dyspnea. When first seen, many were constantly struggling for air and seemed to be in a perpetual state of impending asphyxiation. From our experience, it became very apparent that these patients would not survive any major surgical complications. Because very little time is wasted on entering or exiting the chest, minimally invasive VATS allows just about all of the operating time to be devoted to performing the essential parts of the procedure. Debilitating trauma to the chest wall from the thoracotomy incision, which increases restriction of respiration, can be avoided. Giant bullous disease of the lung is really a generalized process with transitional areas ranging from large bullae to diffuse emphysema. Resection or ablation of only a few of these bullae could not possibly result in a permanent cure. In fact, the results of surgical therapy in these patients must be considered similar to those of medical treatment in that this therapy primarily relieves symptoms. In the past, a thoracotomy incision was deemed unacceptable when only transient relief of symptoms could be expected. Since the inception of minimally invasive VATS, temporary, symptomatic improvement from surgical therapy is now more acceptable. Probably, giant bullous disease should be placed in the same category as other incurable but treatable medical problems, ie, heart disease, diabetes mellitus, and renal failure. A combined approach using VATS and medical therapy could provide the most lasting benefits. Currently, the best measurement of improvement seems to be the subjective response of the patient. Pulmonologists support VATS and the ABC because, after this treatment, patients recover from acute dyspneic episodes more quickly, have fewer infections, require decreased doses of steroids, use oxygen less frequently, and manifest greater physical endurance. The ability to detect and to objectively demonstrate only incremental improvement must await the development of more sensitive tests. Although this is a small series without a prolonged follow-up period, nevertheless, each of these patients had end-stage disease that was no longer responding to medical therapy. Each patient had severe shortness of breath and very limited physical activity, and all required supplemental oxygen, steroids, or both. One patient had a permanent tracheostomy. This was not an ideal patient population in which to initiate any new technique, but all patients enthusiastically accepted this procedure even though we could not promise them that there would be any improvement. Because the base of each bulla, in general, was not ligated to eliminate the ingress or egress of air, one can only speculate on the permanence of the procedure [12]. Probably with time, the bullae will once again distend, returning patients to their preoperative respiratory state. Because of the diffuse nature of this

5 1398 LEWIS ET AL Ann Thorac Surg 1993;55: disease, in some cases, progressive symptomatic deterioration could be anticipated from distention of other new developing bullae. The contralateral side may require ablation in some patients, whereas in others repeat ablation of the ipsilateral side will be needed. The minimal chest wall injury resulting from VATS makes this approach feasible. We hope that, in the future, VATS using the ABC will give even better results as the technique is refined, a less terminal patient population is selected, and a more scientific method for determining adequate bullous ablation is developed. Because these deteriorating patients had no other options, we were delighted that this technique was able to provide improvement for all of them. Much more experience is necessary, however, before we can determine the true merits of this procedure for bullous disease. References 1. Ribet ME. Cystic and bullous disease. Ann Thorac Surg 1992;53: Vejlsted H, Halkier EE. Surgical improvement of patients with pulmonary insufficiency due to localized bullous em physema or giant cysts. Thorac Cardiovasc Surg 1985;33: Laros CD, Gelissen HJ, Bergstein PGM, et al. Bullectomy for giant bullae in emphysema. J Thorac Cardiovasc Surg 1986; 91:6%70. Connolly JE, Wilson A. The current status of surgery for bullous emphysema. J Thorac Cardiovasc Surg 1989;97: Gaensler EA, Cugell DW, Knudson RJ, et al. Surgical management of emphysema. Clin Chest Med 1983; Klingman RR, Angelillo VA, DeMeester TR. Cystic and bullous lung disease. Ann Thorac Surg 1991;52: Nickoladze GD. Functional results of surgery for bullous emphysema. Chest 1992;101: Lewis RJ, Caccavale RJ, Sisler GE, Mackenzie JW. One hundred consecutive patients undergoing video-assisted thoracic surgery. Ann Thorac Surg 1992;54: Wade 111 JF, Mortonson R, Irvin CG. Physiologic evaluation of bullous emphysema. Chest 1991; Morgan MDL, Dennison DM, Strickland B. Value of computed tomography for selecting patients with bullous lung disease for surgery. Thorax 1986;41: Vishnevsky AA, Nickoladze GD. One stage operation for bilateral bullous lung disease. J Thorac Cardiovasc Surg 1990;99:3M. Wex P, Ebner H, Dragojevic D. Functional surgery of bullous emphysema. J Thorac Cardiovasc Surg 1983;31: DISCUSSION DR STEVE SCHWARTZ (San Jose, CA): Doctor Lewis, I really appreciate you presenting this because this presents quite a difficult problem to many of us in practice. I have three questions for you. First, how do we go about selecting which patients to approach or to offer the possibility of using this technique? Second, you describe the use of pleurectomy. Have you considered using talc instillation at the time of the thoracoscopy? Third, if you do happen to rupture a bleb, do you make any attempt to control the potential bronchopleural fistula, and if so, how do you do that? DR HANI SHENNIB (Montreal, Que, Canada): Perhaps I may represent some of the lung transplanters around here. I enjoyed your presentation very much, Dr Lewis. I find it provocative and, indeed, if this technique works it may well be sort of an alternative to lung transplantation. My concern, however, is that if we do not perform a careful study of this group of patients before treatment and follow them up long-term, what we may have is a patient who would have excessive scarring and extensive pleural adhesions that may actually preclude future transplantation. So my question to you is, would you at this point recommend this procedure for any patient with end-stage lung disease? Would you restrict it to those patients who would otherwise not be considered for transplantation, and if so, how would you propose to study them to determine whether this procedure works or not? DR CECIL C. VAUGHN (Phoenix, AZ): I congratulate Dr Lewis on tackling an extremely difficult group of patients. I have treated 7 patients with advanced bilateral bullous disease using a similar technique, using the yttrium-aluminum garnet laser for the ablation. I have been very concerned about the air leak that occurred with this, both in a contact and noncontact mode, and have made more liberal use of the stapling device for the very large sessile bullae, not necessarily pedunculated. In 1 of those patients operated on about 4 months ago, a tension pneumothorax recently developed on the operated side requiring an emergency chest tube insertion. I plan to attempt to obtain pleural symphysis with the use of talc in this patient. Also, the use of glue with cryoprecipitate and thrombin over some of these areas might be of help. What are your plans to try to prevent the occurrence of pneumothorax? DR PAUL A. THOMAS, JR (Chicago, IL): I congratulate you for your dedication to this very difficult clinical problem and for what you have shown us today as a useful alternative. 1 rise more as a historian than otherwise to remind everybody here that Dr Otto Brannigan for many, many years dedicated a lot of his energy and expertise to the problem of the patient that you describe. He described surgical restoration of the part of the lung that has some normal function to its maximum ability to support the patient. Also, I would like to point out to this group that pleurectomy is something that is not new. We wrote about that in the 1950s. I think that you have something, though, to offer thesc patients now that may be a distinct advantage if you can properly select them. That is the difficulty, properly selecting the patient who might achieve some benefit. In those patients in whom we tried tailoring the lung by open surgical means, it has been very difficult to objectively show that their pulmonary function is improved. However, the patients universally will say symptomatically they fee1 better, they can do more, and they appreciate what has been done for them. Once again I congratulate you for approaching this problem in a new and innovative way DR LEWIS: Well, as I mentioned at the beginning, these were fairly terminal patients. They had bilateral, generalized bullous disease. The impression you can get from the video is that there was not much normal lung tissue available. Initially, in the first few patients we were thinking of possible future lung transplan-

6 Ann Thorac Surg 1993;55: LEWIS ET AL 1399 tation, so we did not do a pleurectomy. It soon became apparent that these very advanced and elderly patients would not be suitable candidates for transplantation. It was believed that pleurectomy might decrease air leaks. After subcutaneous emphysema developed in the patients in whom we did the pleurectomy, it then occurred to us that maybe talc is a better way to go. 1 think we would use talc in this particularly advanced group of patients in the future. As far as selecting the patients for VATS, that was very easy. There was nothing else to offer them. They were receiving very high dosages of steroids, they were taking oxygen, 1 patient had a permanent tracheostomy, most of them were home bound, and they could barely walk across the floor. 1 might say 1 of these patients now walks a half mile every day; other patients have been seen at the mall shopping. So there have been improvements. Some of the improvements, however, were more subtle. Patients were not getting acute episodes of dyspnea anymore. They were getting fewer pulmonary infections. In fact, our pulmonologists have indicated to us that the patients have been much easier to treat since the ablation was done. All patients were worked up very carefully preoperatively. The average forced expiratory volume in 1 second was somewhere around So none of them had much reserve. As far as controlling air leaks, glue, talc, and pleurectomy are all being evaluated. We had 1 patient who did come back about 3 weeks after operation with a pneumothorax. We inserted a tube and attached a Heimlich valve. He eventually did very well. We have not had any further problems.