Abstract
OBJECTIVES
Lung volume reduction (LVR) is an efficient and approved treatment for selected emphysema patients. There is some evidence that repeated LVR surgery (LVRS) might be beneficial, but there are no current data on LVRS after unsuccessful bronchoscopic LVR (BLVR) with endobronchial valves (EBVs). We hypothesize good outcome of LVRS after BLVR with valves.
METHODS
In this study, we retrospectively investigated all patients who underwent LVRS between 2015 and 2019 at 2 centres after previous unsuccessful EBV treatment. They were further divided into subgroups with patients who never achieved the intended improvement after BLVR (primary failure) and patients whose benefit was fading over time due to the natural development of emphysema (secondary failure). Patients with severe air leak after BLVR and immediate concomitant LVRS and fistula closure thereafter were analysed separately.
RESULTS
A total of 38 patients were included. Of these, 19 patients had primary failure, 15 secondary failure and 4 were treated as an emergency due to severe air leak. At 3 months after LVRS, forced expiratory volume in 1 s had improved significantly by 12.5% (P = 0.011) and there was no 90-day mortality. Considering subgroups, patients with primary failure after BLVR seem to profit more than those with secondary failure. Patients with severe air leak after BLVR did not profit from fistula closure with concomitant LVRS.
CONCLUSIONS
LVRS after previous BLVR with EBVs can provide significant clinical improvement with low morbidity, although results might not be as good as after primary LVRS.
Keywords: LVRS, BLVR, Lung volume reduction surgery, Endobronchial valves, Emphysema
Lung volume reduction (LVR) has been established as a beneficial and safe procedure in patients with pulmonary emphysema and hyperinflation.
INTRODUCTION
Lung volume reduction (LVR) has been established as a beneficial and safe procedure in patients with pulmonary emphysema and hyperinflation. LVR surgery (LVRS) and bronchoscopic LVR (BLVR) with endobronchial valves (EBVs), coils or bronchial thermal vapour ablation are available [1–3]. All methods have been demonstrated to improve lung function, exercise capacity and quality of life in patients with both heterogeneous and homogeneous emphysema [4–7]. LVRS and BLVR with EBVs have been shown to prolong survival in highly selected patients [7, 8]. For the selection of patients and the optimal LVR procedure, it is recommendable to establish multidisciplinary conferences [9, 10].
However, chronic obstructive pulmonary disease is a progressive disease and neither LVR procedure is able to stop the natural course with an annual lung function decline and recurring hyperinflation [11]. Therefore, initially successful LVR treatment effects may diminish over months or years [4, 12, 13]. Repeated LVRS (Re-LVRS) shows promising results in highly selected patients, who are slowly deteriorating after initially successful LVRS [14, 15]. Once a patient who already had LVR with EBVs is referred, LVRS might be offered.
To the best of our knowledge, there are so far no reports on LVRS after BLVR.
In this retrospective study from 2 European centres, we aimed to investigate LVRS after previous BLVR with EBVs with focus on mortality, morbidity and outcome.
PATIENTS AND METHODS
Ethical approval
This study was performed under both institutional boards’ ethical approval.
All patients with previous BVLR with EBVs, who underwent LVRS at 1 of the 2 study centres (Department of Thoracic Surgery, University Hospital Zurich, Switzerland, and Department of Cardiothoracic Surgery, University Hospital Rigshospitalet, Copenhagen, Denmark) between December 2015 and December 2019, were included. Previous BLVR had been performed at the institutions or elsewhere. Re-LVR were considered, when previous LVR was assessed to be unsuccessful (primary failure) according to the multidisciplinary emphysema board or initial benefit had faded over time (secondary failure). In- and exclusion criteria for LVRS were described previously [16, 17] and were similar in both study centres.
As many patients were referred from other centres, indications for EBV were not always according to our own policy and our usual emphysema board protocol. However, institutional guidelines from both study centres generally read as follows.
Primary scheduled for LVRS:
bilateral, upper-lobe predominant emphysema,
bulleous or paraseptal emphysema and
concomitant nodule.
Primary scheduled for BLVR with valves:
heterogeneous emphysema markedly involving 1 whole lobe without collateral ventilation and
bilateral homogeneous emphysema without collateral ventilation.
Absent collateral ventilation must be proven by a interlobar fissure integrity score of >85% (measured by StratX®, Pulmonx, USA) and a negative Chartis® measurement.
All patients—for whom both LVRS and BLVR are possible—are fully offered and explained all alternatives. However, many patients already have their own firm preference.
After LVRS, patients after previous BLVR were retrospectively allocated to 2 groups:
Primary EBV non-responder (primary failure): no clinical improvement from beginning to 3 months after BLVR despite bronchoscopic revision attempt in case of absent target atelectasis (i.e. for valve replacement).
Secondary EBV non-responder (secondary failure): loss of benefit after initial subjective and objective improvement following BLVR (with and without target lobar atelectasis). The time interval between BLVR and the time of ‘secondary failure’ was only driven by the patient’s decision to announce subjective loss of the initial benefit.
Patients with high-flow fistula after BLVR who thereafter received surgery for combined fistula closure and LVRS (during the same hospitalization) were analysed separately.
Decisions to remove EBVs prior to LVRS depended on the presence of target atelectasis (absent target lobe atelectasis triggered indication to remove EBVs, whereas left in place in case of evidence of atelectasis).
Surgery and perioperative phase
Preoperatively, all potential LVRS patients were functionally assessed with spirometry and bodyplethysmography. For cardiac evaluation, a transthoracic echocardiogram was performed for screening for pulmonary hypertension. If systolic pulmonary arterial pressure exceeds 35 mmHg, patients are further assessed with right heart catheterization. If mean pulmonary pressure exceeds 35 mmHg, they are usually excluded from LVRS.
LVRS target zones were selected using CT scans, perfusion scans, densitometries and intraoperative emphysema appearance. The area with most destruction in heterogeneous emphysema was approached in cases without persisting atelectasis and without functional valves in situ. In patients with persistent atelecatasis and therefore valves left in situ, a target zone on the contralateral side was searched imperatively.
LVRS was performed by video-assisted thoracoscopic surgery (VATS) or exceptionally by anterolateral thoracotomy in case of severe pleural adhesions. Pulmonary resection was performed with standard staplers and 1–2 chest tubes were placed applying suction with 2–5 cmH2O. All patients were extubated in the OR and transferred to intensive care or intermediate care units.
Follow-up and outcome measures
Follow-up of pulmonary function fests (PFTs) was scheduled at 3 months postoperatively.
Primary outcome measures were improvement of forced expiratory volume in 1 s (FEV1) and residual volume (RV). Secondary end-points included length of hospital stay (LOS), chest tube time, postoperative complications and 90-day mortality.
Statistical analysis
Descriptive statistics were used to summarize patients’ characteristics. Normality was assessed using the Shapiro–Wilk test. Normally distributed continuous variables were reported as mean and standard deviation and compared using two-sample independent t-tests. Non-normally distributed continuous variables were reported as median and range, and for comparisons between 2 groups, the Mann–Whitney U-test was used. Paired continuous variables were compared using paired-samples t-test. Categorical variables were summarized as frequencies (%) and compared using Pearson’s chi-squared test or Fisher’s exact test where applicable.
RESULTS
Thirty-eight patients were included (Fig. 1). Four patients had persistent pneumothorax with high-flow fistula even after the removal of EBVs. Nineteen patients were primary EBV non-responders despite previous bronchoscopic revision (group 1), and 15 patients had secondary failure (Group 2). Both groups were further divided into subgroups dependent on the presence of target atelectasis. Five patients were primary EBV non-responders despite the presence of a target atelectasis compared to 14 patients without atelectasis. In Group 2, 3 patients had loss of effect despite a persistent atelectasis after initially successful EBV treatment, and 12 patients with both loss of effect and atelectasis. EBVs were removed prior to LVRS in all patients without evidence of atelectasis. In those with persistent atelectasis (n = 8), EBVs were removed in 3 patients attributed to Group 1. In patients with secondary failure and persistent atelectasis (n = 3), EBVs were not removed and LVRS was performed contralateral.
Figure 1:
Flow chart of patients undergoing lung volume reduction surgery after previous bronchoscopic lung volume reduction using endobronchial valves (n = 38). BLVR: bronchoscopic lung volume reduction; LVRS: lung volume reduction surgery.
LVRS outcome in patients with primary or secondary failure after previous EBVs (n = 34)
Nineteen patients were female (55.9%). Thirty patients had a VATS procedure (88.24%), while 4 patients had VATS converted to a thoracotomy due to adhesions. The median LOS was 8 days [interquartile range (IQR) 6–13]. The median chest tube time was 5 days (IQR 3–11). Ten patients (29.4 %) had prolonged air leak longer than 7 days, and 1 patient had revision surgery for fistula closure (2.9%). One patient had a pneumothorax after chest tube removal and needed a new chest drain. No other relevant postoperative complications occurred. Ninety-day mortality after LVRS was zero.
Pre- and postoperative values of PFTs are displayed in Table 1. The median time interval between BLVR and LVRS was 10 months (IQR 6–14.25).
Table 1:
Pulmonary function tests pre- and post-lung volume reduction surgery in patients with primary and secondary endobronchial valve failure (n = 34)
| Mean (± SD) | Pre-LVRS | 3 months post-LVRS | P-value |
|---|---|---|---|
| FEV1 (ml) |
640 (± 210) (n = 32) |
720 (± 141.1) | 0.011 |
| FEV1 (% predicted) |
23 (± 3.6) (n = 34) |
29.7 (± 6.4) | 0.010 |
| TLC (ml) |
7661.4 (± 1853.3) (n = 26) |
7599.6 (± 1782.8) | 0.22 |
| TLC (% predicted) |
137.4 (± 23.8) (n = 27) |
130 (± 18.0) | 0.12 |
| RV (ml) |
6070 (± 1725.3) (n = 27) |
5180 (± 720.2) | 0.014 |
| RV (% predicted) |
272 (± 80.6) (n = 29) |
0.70 (± 0.17) | 0.002 |
| DLCO (% predicted) |
25 (± 5) (n = 34) |
23.3 (± 5.8) | 0.043 |
DLCO: diffusion capacity; FEV1: forced expiratory volume in 1 s; RV: residual volume; SD: standard deviation; TLC: total lung capacity.
LVRS outcome comparing patients operated for primary failure (n = 19) versus secondary failure (n = 15)
There was no significant difference of LOS (9 vs 7 days), chest tube time (6 vs 4 days) and proportion of patients with prolonged air leak (43% vs 20%) between Groups 1 and 2. However, improvement of PFT values between pre- and post-LVRS was more pronounced in Group 1 (Table 2). The median time interval between BLVR and LVRS in patients with primary failure (9 months, IQR 5–13) did not differ significantly from patients with secondary failure (median 12 months, IQR 7–16, P = 0.286).
Table 2:
Pulmonary function tests in patients with primary failure (n = 19) and in patients with secondary failure (n = 15)
| Mean (± SD) | Primary failure (n = 19) |
Secondary failure (n = 15) |
||||
|---|---|---|---|---|---|---|
| Pre-LVRS | 3 months post-LVRS | P-value | Pre-LVRS | 3 months post-LVRS | P-value | |
| FEV1 (ml) |
752.9 (± 303.9) (n = 17) |
871.9 (± 306.8) (n = 16) |
0.003 |
689.3 (± 220) (n = 15) |
733.9 (± 182) (n = 13) |
0.63 |
| FEV1 (% predicted) |
26 (± 8.4) (n = 19) |
31.3 (± 9.1) (n = 17) |
0.002 |
26.9 (± 11.6) (n = 15) |
28.9 (± 9.6) (n = 13) |
0.77 |
| TLC (ml) |
8464.6 (± 1917.6) (n = 14) |
8334.3 (± 1879.6) (n = 14) |
0.39 |
6859.2 (± 1443.1) (n = 13) |
6742.5 (± 1248.9) (n = 12) |
0.21 |
| TLC (% predicted) |
143.8 (± 25.1) (n = 13) |
136.7 (± 20.5) (n = 14) |
0.39 |
131.0 (± 21.4) (n = 13) |
122.3 (± 10.7) (n = 12) |
0.21 |
| RV, ml | 5144 (± 2437) (n = 14) |
4244.9 (± 2365.1) (n = 14) |
0.035 |
4812.3 (± 1263) (n = 13) |
4413.3 (± 1274.9) (n = 12) |
0.020 |
| RV (% predicted) |
259.1 (± 57) (n = 13) |
227.2 (± 54.5) (n = 14) |
0.20 |
231.3 (± 43) (n = 13) |
207.8 (± 42.8) (n = 12) |
0.021 |
| RV/TLC |
0.70 (± 0.04) (n = 16) |
0.63 (± 0.06) (n = 15) |
0.044 |
0.69 (± 0.06) (n = 13) |
0.64 (± 0.07) (n = 12) |
0.062 |
| DLCO (% predicted) |
31.22 (±12.12) (n = 19) |
36.2 (± 11.6) (n = 16) |
0.15 |
32.76 (± 12.31) (n = 15) |
32.4 (± 11.5) (n = 11) |
0.22 |
DLCO: diffusion capacity; FEV1: forced expiratory volume in 1 s; RV: residual volume; SD: standard deviation; TLC: total lung capacity.
LVRS outcome in patients treated with EBVs but without achieving a lobar atelectasis
Concerning patients with absent atelectasis, there were no significant differences in LOS, chest tube time and proportion of prolonged air leak between the 14 patients with primary failure compared to the 12 patients in Group 2. Again, improvement of PFT values was distinctly better in the primary failure group (Table 3). The median time interval between BLVR and LVRS in patients with primary failure (9 months, IQR 4.75–13.5) did not differ significantly from patients with secondary failure (11.5 months, IQR 6.25–15.75, P = 0.494).
Table 3:
Pulmonary function tests in patients with primary failure and no atelectasis (n = 14) and in patients with secondary failure and never or loss of atelectasis (n = 12)
| Mean (± SD) | Primary failure, no atelectasis (n = 14) |
Secondary failure, never or loss of atelectasis (n = 12) |
||||
|---|---|---|---|---|---|---|
| Pre-LVRS | 3 months post-LVRS | P-value | Pre-LVRS | 3 months post-LVRS | P-value | |
| FEV1 (ml) |
723.8 (± 291.6) (n = 13) |
827.7 (± 274.6) (n = 13) |
0.045 |
631.7 (± 180.2) (n = 12) |
678 (± 149.7) (n = 10) |
0.60 |
| FEV1 (%) |
26.1 (± 9.2) (n = 14) |
30.4 (± 9.7) (n = 13) |
0.029 |
25.6 (± 11.1) (n = 12) |
28 (± 9.3) (n = 10) |
0.74 |
| TLC (ml) |
8943.6 (± 1644.6) (n = 12) |
8785.5 (± 1674.1) (n = 11) |
0.42 |
6706.0 (± 1599.9) (n = 10) |
6694.0 (± 1299.2) (n = 10) |
0.37 |
| TLC (%) |
149.3 (± 23.3) (n = 11) |
143.1 (± 17.9) (n = 11) |
0.44 |
134.1 (± 23.0) (n = 10) |
123.3 (± 11.4) (n = 10) |
0.28 |
| RV (ml) |
5327.2 (± 2598.2) (n = 12) |
4364.4 (± 2653) (n = 11) |
0.030 |
4825 (± 1427.7) (n = 10) |
4471 (± 1354.4) (n = 10) |
0.084 |
| RV (%) |
271.3 (± 53) (n = 11) |
241.3 (± 50.7) (n = 11) |
0.20 |
236.5 (± 48.1) (n = 10) |
212.1 (± 45.5) (n = 10) |
0.08 |
| RV/TLC |
70.3 (± 4.2) (n = 12) |
65.1 (± 6.5) (n = 11) |
0.15 |
70.4 (± 6) (n = 10) |
65.7 (± 7.8) (n = 10) |
0.18 |
| DLCO |
30.6 (± 11.2) (n = 14) |
37 (± 12.4) (n = 13) |
0.013 |
29.4 (± 10.2) (n = 12) |
30.6 (± 11) (n = 9) |
0.18 |
DLCO: diffusion capacity; FEV1: forced expiratory volume in 1 s; RV: residual volume; SD: standard deviation; TLC: total lung capacity.
LVRS outcome in patients with (persistent) lobar atelectasis after EBVs (primary or secondary failure, n = 8)
There were 8 patients with (persistent) atelectasis. Of these, EBVs were removed prior to LVRS in 3 patients, but in 5 patients, EBVs were left in situ and LVRS was performed at the contralateral side. In all 8 patients, there were no anaesthesiological or perioperative complications. The median LOS was 6 days (IQR 4–14 days), and a median chest tube time was 3 days (IQR 2–12 days). Three had a prolonged air leak (37.5%). At 3 months postoperatively, there was only a significant improvement of RV and RV/total lung capacity, but not in FEV1 (Table 4). In patients who had EBVs removed before LVRS (n = 3), the median LOS was 15 days (range 6–20) and the median chest tube time was 12 days (range 1–17). Two patients had a prolonged air leak. FEV1 improved from median 840 ml (540–1370) to 1140 ml (730–1550). Preoperative median RV was 3790 ml (value only known for n = 1 patient), and postoperative median RV was 3795 ml (range 2900–4690 ml).
Table 4:
Pulmonary function tests in patients with (persistent) atelectasis after bronchoscopic lung volume reduction (primary or secondary failure, n = 8)
| Mean (± SD) | Pre-LVRS | 3 months post-LVRS | P-value |
|---|---|---|---|
| FEV1 (ml) |
878.6 (± 300.1) (n = 7) |
990 (± 306) (n = 6) |
0.071 |
| FEV1 (%) |
28 (± 9.9) (n = 8) |
33.1 (± 8.8) (n = 7) |
0.12 |
| TLC (ml) |
6567.5 (± 1119.5) (n = 5) |
6330 (± 1282.5) (n = 5) |
0.24 |
| TLC (%) |
117.6 (± 9.2) (n = 5) |
114.7 (± 7.2) (n = 5) |
0.26 |
| RV (ml) |
4480 (± 622.7) (n = 5) |
3934 (± 850.7) (n = 5) |
0.013 |
| RV (%) |
205.3 (± 16.2) (n = 5) |
179.9 (± 28.8) (n = 5) |
0.007 |
| RV/TLC |
67.6 (± 5) (n = 7) |
58.4 (± 3) (n = 6) |
0.004 |
| DLCO |
37.9 (± 15.3) (n = 8) |
35.8 (± 9.8) (n = 5) |
0.54 |
DLCO: diffusion capacity; FEV1: forced expiratory volume in 1 s; RV: residual volume; SD: standard deviation; TLC: total lung capacity.
In patients who did not have EBVs removed and received contralateral LVRS (n = 5), the median LOS was 5 days (range 2–11) and the median chest tube time was 3 days (range 2–10). One patient had a prolonged air leak FEV1 improved from median 785 ml (range 640–1190) to 880 ml (range 780–1120). RV decreased from median 4475 ml (range 4210–5450) to 3830 (3360–4890).
The median time interval between BLVR and LVRS was 11 months (IQR 8.25–14).
Outcome of patients with high-flow fistula (n = 4)
Four patients with immediate pneumothorax after BLVR with EBVs developed a high-flow fistula. EBVs were removed during the same hospitalization (after a median of 11 days after BLVR, IQR 4.5–15.3), followed by VATS. All patients had a fistula at the non-target lobe, which was closed surgically. At the same time, LVRS was performed at the target lobe. The median postoperative LOS was 10.5 days (range 7–45). The median chest tube time was 19 days (range 2–43) with 1 patient having a postoperative chest tube time of 43 days and a second patient of 30 days. One 63-year-old female patient died because of suicide during in-patient rehabilitation 2 weeks after LVRS. One 58-year-old male patient reported no benefit at 3 months postoperatively. Complete pre- and postoperative PFTs were only available in 2 patients. The mean FEV1 increased from 550 ml (± 210 ml) to 700 ml (± 141 ml) and RV increased from 5470 ml (± 720 ml) to 6070 ml (± 1725 ml). Diffusion capacity decreased from 25% (± 5%) predicted to 21% (± 5.8%) predicted.
DISCUSSION
This retrospective study aimed at investigating the postoperative outcome of patients who underwent LVRS after previous BLVR who despite initial success deteriorated or who were unsuccessful immediately after EBV treatment.
LVRS in this sequence is not ideal and has to be considered as salvage therapy. Key issues of a successful LVRS include many aspects, but selecting the right volume and the right target area for resection in balance with physiologic parameters is of paramount importance. After EBVs, a lobar atelectasis may be present and valves may be still in place causing disturbance of bronchial secret clearance. Both leads to compromises in LVRS treatment. Despite this, the presented data show that the procedure can be offered in some patients without 90-day mortality and a significant improvement in lung function. This information is important for interdisciplinary emphysema boards counselling patients. Patients must know that LVRS after EBV might still be possible but is not equally effective than performed at first choice. The concept of LVRS and EBV is distinctly different despite the common goal of reducing the hyperinflation of emphysematous lungs.
EBVs have been shown to be an effective and safe LVR procedure in several randomized controlled trials [6, 18–20]. Improvement of FEV1 by 17–29.3% from baseline can be expected [5, 6, 18, 19, 21]. Considering FEV1, there is a responder rate ranging between 47% at 3 months and 59% at 6 months [6, 18]. There are several reasons for an unsuccessful EBV treatment, which can be classified as primary failure or as fading effect over time (secondary failure). While insufficient data are available on reasons for primary failure, there are several reported reasons for the loss of efficacy over time. According to 1-year follow-up data from the STELVIO trial, permanent removal of EBVs was required in 17% of the patients [22]. Reasons included recurrent pneumothorax, torsion of bronchus, pneumonia and granulation tissue. Besides other factors, the latter is maybe leading to paravalvular leakage and subsequent loss of atelectasis.
In both our study centres, patients who failed to develop an atelectasis or showed a loss of atelectasis after EBVs usually received revision bronchoscopy at 1–3 months after initial BLVR. Those who still had no profit despite EBV replacement were discussed at the multidisciplinary emphysema board. Performing LVRS in some of these, there was a significant improvement of PFT values at 3 months, which was more distinct in patients with primary failure after EBV treatment. Furthermore, there is a tendency that patients, undergoing unplanned LVRS due to high-flow fistula after EBV treatment, might have a poor outcome.
Compared to primary LVRS with a reported improvement of FEV1 between 41% and 73% [23–26], efficiency of LVRS in patients with previous EBV therapy seems inferior. However, our study was not designed to answer this specific question, and comparison to historical LVRS cohorts is not without challenges. At least, postoperative morbidity and mortality seem comparable to primary LVRS.
Usually, target lobe atelectasis after EBVs is a good indicator for a favourable outcome with improvements of dyspnoea, quality of life (QoL), 6-minute walking distance (6-MWD) and PFT values [27]. However, in this study, we found 8 patients with unsuccessful EBV treatment in spite of an existing target lobe atelectasis. Reasons for these rare cases are not completely understood. Certainly, indications for EBVs (in particular hyperinflation) must be reviewed. The question arises, if EBVs should be removed or left in situ prior to LVRS in these cases. Interestingly, all patients with persistent atelectasis but loss of clinical benefit from EBVs improved after LVRS in FEV1 and RV. According to our experience, these patients can be safely treated with contralateral LVRS, leaving EBVs in situ. Conceptually, this corresponds to results from previous studies concerning Re-LVRS, and as such, the fading benefit after EBVs reflects the natural course of pulmonary emphysema [11, 14, 28]. The questions remain open, if valves should be removed prior to LVRS. A total lobar atelectasis is a relevant intervention into the physiology of a patient with advanced emphysema. Lobectomy performed during LVRS should be reserved only to the rare cases of a total lobar destruction. In all our cases, better preserved lung parenchyma was left in place. If valves would be removed and the totally atelectatic lung would re-expand including the functioning lung parenchyma, a more balanced remodelling by LVRS would be possible [29].
However, in patients with absent atelectasis, improvement was only significant in those with primary failure. This is surprising, since patients with secondary failure had experienced a temporary benefit after EBV treatment and thus, the principle of LVR was proven to succeed in these patients. Maybe in patients with secondary failure, the natural course of emphysema already was too advanced and prevented any LVR procedure to be beneficial again. According to our experience from these retrospective and heterogeneous data, EBV removal and subsequent LVRS are the promising options in patients with primary failure after previous EBV therapy.
Time interval between BLVR and LVRS did not differ significantly between patients with primary failure and those with secondary failure. Only in patients with primary failure, the decision for a further intervention usually was already made 3 months after BLVR. In patients with secondary failure, this decision was dependent on patient’s subjective loss of benefit. Altogether, including planning time for LVRS and several other patient factors, this finding might be coincidental.
Pneumothorax occurs in ∼15–30% of patients after BLVR with EBVs, which is usually treated with a chest tube drainage [5, 18, 30]. In ∼70% of cases, these patients have a prolonged air leak continuing longer than 7 days [30]. In our study, there were 4 patients with persistent high-flow fistula despite previous EBV removal, as recommended [2]. In these patients, fistula closure by VATS followed by LVRS at the former EBV target lobe was performed. The outcome was poor. Although firm conclusions are not possible based on our small experience, combined fistula closure and LVRS might not be recommendable. Probably, a staged procedure is preferable.
Limitations
There are some limitations to this study, essentially due to its retrospective nature and the relatively small and heterogeneous group of patients. Quality of EBV therapy was not assessed, and the definition of failure was not quantitative and, thus, only assessed by patient’s statements. In addition, outcome of LVRS after EBV was only described by morbidity, mortality and PFTs, missing, i.e. 6-MWD or quality of life. Maximum benefit after LVRS is usually reached after 3–6 months, whereas our data only consist of 3-month follow-up.
The small patient’s number in this study might be sufficient to point out the favourable outcome of LVRS after previous EBVs, while the conclusions drawn from the subgroup analyses might be interpreted with some caution.
CONCLUSION
LVRS after previous BLVR with EBVs shows low morbidity and no mortality and significant clinical improvement can be expected, although results might not be as good as after primary LVRS.
ABBREVIATIONS
- BLVR
Bronchoscopic lung volume reduction
- EBVs
Endobronchial valves
- FEV1
Forced expiratory volume in first second
- IQR
Interquartile range
- LOS
Length of hospital stay
- LVR
Lung volume reduction
- LVRS
Lung volume reduction surgery
- PFTs
Pulmonary function fests
- Re-LVRS
Repeated lung volume reduction surgery
- RV
Residual volume
Conflict of interest: Daniel Franzen has received speaking honoraries and consultancy fees from Pulmonx SA. Walter Wedel has received honoraries from Medtronic for teaching and proctoring. Henrik Jessen Hansen participates in advisory boards for Medtronic, BD/Bard and Medela. Mateja Ladan has received a research grant from PulmonX SA. All other authors declare no conflict of interest.
Author contributions
Claudio Caviezel: Conceptualization; Data curation; Formal analysis; Investigation; Methodology; Project administration; Resources; Supervision; Validation; Visualization; Writing—original draft; Writing—review and editing. Laura-Chiara Guglielmetti: Data curation; Formal analysis; Investigation; Methodology; Validation; Writing—original draft; Writing—review and editing. Mateja Ladan: Data curation; Formal analysis; Investigation; Methodology; Validation; Writing—original draft; Writing—review and editing. Henrik Jessen Hansen: Data curation; Formal analysis; Methodology; Validation; Visualization; Writing—review and editing. Michael Perch: Formal analysis; Methodology; Validation; Writing—review and editing. Didier Schneiter: Data curation; Investigation; Resources; Writing—original draft; Writing—review and editing. Walter Weder: Investigation; Supervision; Validation; Writing—original draft; Writing—review & editing. Isabelle Opitz: Conceptualization; Data curation; Investigation; Methodology; Project administration; Resources; Supervision; Validation; Visualization; Writing—original draft; Writing—review and editing. Daniel Franzen: Conceptualization; Formal analysis; Investigation; Methodology; Project administration; Resources; Supervision; Validation; Visualization; Writing—original draft; Writing—review and editing.
Reviewer information
Interactive CardioVascular and Thoracic Surgery thanks Clemens Aigner and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.
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