A new technique of thoracoscopic laser ablation of pulmonary bullae suitable for patients with multiple bullae and diffuse emphysema was developed and assessed in 22 patients. 20 of 22 patients survived. Pre-operative and postoperative functional evaluation is available for the 11 patients followed up for more than a month; at 1 to 3 months postoperatively there were increases in FVC (mean 2.0 litres pre-operatively to 2.7 litres postoperatively, p less than 0.001), in FEV1 (0.74 to 1.06 litres, p = 0.01), and in maximum exercise treadmill times (5.4 min to 8.0 min, p less than 0.01). Postoperative air leaks lasted a mean of 13 days and usually resolved spontaneously. Other complications were bleeding (1 patient) and unilateral acute lung injury (1 patient). These results suggest that selected patients with diffuse emphysema and pulmonary bullae may benefit from thoracoscopic carbon dioxide laser ablation

Barker, SJ

Berns, MW

Brenner, M

Della Bella, L

Kayaleh, RA

Rice, SJ

Tadir, Y

Wakabayashi, A

Wilson, AF

DellaBella, L

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UC IrvineUC Irvine Previously Published WorksTitleThoracoscopic carbon dioxide laser treatment of bullous emphysemaPermalinkhttps://escholarship.org/uc/item/0s37d7v2JournalThe Lancet, 337(8746)ISSN0140-6736AuthorsWakabayashi, ABrenner, MKayaleh, RAet al.Publication Date1991-04-01DOI10.1016/0140-6736(91)90206-5Copyright InformationThis work is made available under the terms of a Creative Commons Attribution License, availalbe at https://creativecommons.org/licenses/by/4.0/ Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of California881their infants. J Clin Endocrinol Metab 1986; 63: 1307-12.in angiotensin-sensitive prmigravidae. Lancet 1986; i: 1-3.SHORT REPORTSThoracoscopic carbon dioxidelaser treatment of bullousemphysemaA new technique of thoracoscopic laser ablation ofpulmonary bullae suitable for patients with multiplebullae and diffuse emphysema was developed andassessed in 22 patients. 20 of 22 patients survived.Pre-operative and postoperative functionalevaluation is available for the 11 patients followedup for more than a month; at 1 to 3 monthspostoperatively there were increases in FVC (mean2&middot;0 litres pre-operatively to 2&middot;7 litres postoperatively,p<0&middot;001), in FEV1 (0&middot;74 to 1&middot;06 litres, p=0&middot;01),and in maximum exercise treadmill times (5&middot;4 min to8&middot;0 min, p<0&middot;01). Postoperative air leaks lasteda mean of 13 days and usually resolvedspontaneously. Other complications were bleeding(1 patient) and unilateral acute lung injury(1 patient). These early results suggest that selectedpatients with diffuse emphysema and pulmonarybullae may benefit from thoracoscopic carbondioxide laser ablation.Bullous lung disease develops to a variable extent inpatients with chronic obstructive lung disease and otheracquired or congenital disorders.1 In general, patients withisolated giant unilateral or bilateral bullae and crowding ofadjacent vasculature, but not the larger group of patientswith diffuse bullous emphysema, have shown improvementin lung function after surgical resection.24 Duringinvestigation of CO2 laser for treatment of spontaneouspneumothorax we observed shrinkage of subpleural bullaeexposed to the laser. We thus developed a thoracoscopicmethod to ablate pulmonary bullae with a low-energy CO2laser and describe here the first 22 patients treated with it.Criteria for inclusion were: (1) respiratory symptoms sufficientto cause major impairment of activity and lifestyle, and(2) radiographic or computed tomographic (CT) evidence ofbullous lung disease, preferably with crowding of adjacent lungtissue.Pre-operative functional evaluation consisted of routine physicalexamination and laboratory investigations and, for all but 4 patients,pre-bronchodilator and post-bronchodilator pulmonary functiontesting and maximum exercise treadmill testing according to amodified low-level protocol specifically designed for pulmonaryimpaired patients.882Fig 1-Pulmonary and treadmill test results in patients withbullous emphysema before and 1-3 months afterthoracoscopic laser bullous ablation.Difference between mean pre-operativeand mean postoperative valuesfor:FEV, 0 32 (SEM 011, 95% C! 0 07 to O 57)FVC 0 70 (SEM 015. 95% CI 0 36 to 1 04)TLC -1 66 (SEM 052, 95% Ci -28to -05)DLCO 03 (SEM 07, 95% Ct-12 to 18)Treadmill time 2 60 (SEM 0 73, 95% CI 0-98 to 4 22)Thoracoscopic procedures were done under general anaesthesiawith patients intubated with a double-lumen endotracheal tube andplaced in a lateral position. 11 mm trocars were inserted throughtwo small incisions, one in the anterior and one in the posterioraxillary line at the fifth intercostal space for the passage of the rigidthoracoscopes and operating instruments. The lung was collapsed.Defocused CO2 laser beams were applied to the external surface ofthe bullae. Thick intraparenchymal--bullae were opened and thelaser beams were applied to the internal surface of the bullae. Aftercomplete contraction of all visible bullae, the lung was re-expandedand a chest tube was placed in the anterior chest. At the end of theprocedure, the wounds were closed in routine fashion.Postoperatively patients were maintained on a mechanicalventilator until adequate oxygenation and ventilation could beachieved with spontaneous breathing. The chest tubes were left inplace until there were no more air leaks. Pulmonary function testing,chest radiographs, and treadmill testing were repeated at 1 to 3, 6,and 12 months.The procedure was done twenty-four times in 22 patients(20 men, 2 women) over an 18-month period. 2 patientsFig 2-Follow-up of patients for 6 months or morepostoperatively.underwent bilateral procedures 3 and 4 months apart. 1patient died 14 days after surgery of myocardial infarction,and 1 patient on the 10th postoperative day of contralateralpneumonia. Thus, the surgical mortality rate wasapproximately 10%. Both patients had been extremenlydebilitated by severe emphysema before surgery.Persistent air leak occurred to some degree in all patients.It lasted 1 day to 5 weeks (mean 13 days). 1 patient requiredrepeat laser thoracoscopy to seal air leaks 48 hpostoperatively, after which air stopped leaking within 24 h.3 patients required thoracotomies-1 to control air leaks, Ito remove a flaccid bullous wall that had wrapped aroundthe chest tubes, and 1 to control bleeding. These 3 patientssubsequently did very well.In the immediate postoperative period all patients showedworsening of interstitial and alveolar infiltrates on chestX-ray films and increased requirements for supplementaryoxygen, but the lung injury responded to conventionalsupportive treatment, although radiographic abnormalitiespersisted for several weeks in some patients.Patients enrolled in this study had very advancedemphysema with severe pulmonary dysfunction. Meanpre-operative forced expiratory volume in 1 second (FEVJwas 0-84 litres (SEM 0-02) (26% predicted values, n = 22 [ascalculated by Morris criteria]). All patients reportedimprovement in symptoms such as shortness of breath onexertion. Postoperative pulmonary function tests were donein 11 patients. FEV1 and FVC increased significantly, TLCdecreased, DLCO was unchanged (fig 1). Maximumexercise treadmill capacity increased significantly (fig 1).Continued pulmonary function improvement is being seenmore than 3 months postoperatively in some patients (fig 2).Chest radiographs showed complete disappearance of bullaein 20 chests and reappearance in 2.Surgical bullectomy, used for over 30 years for treatmentof bullous lung disease,1-4,6 carries a high complication rateand is generally limited to the rare group of patients withsingle or a few giant bullae occupying at least half thehemithorax and compressing normal adjacent lung tissue.’When there is severe underlying emphysema!’7 surgicalmortality rates (up to 20%) are high and long-term resultsare poor.3,6,7 In patients with severe bullous lung disease,surgical mortality rates for intracavitary drainage andpleurodesis procedures8-lO are similar to those of surgicalbullectomy. The advantages of thoracoscopic laser ablationinclude the safety of the procedure for adjacent lungparenchyma and its suitability for patients with severeunderlying lung disease. Since most of our patients (19/21)had severe diffuse bullous emphysema and did not satisfy883standard criteria for conventional surgical bullectomy, theoverall operative mortality rate of 10% seems acceptable.It is uncertain whether the acute lung injury found in allpatients immediately after the laser operation representsreperfusion injury, re-expansion interstitial pulmonaryoedema, or laser thermal injury. Physiologically, increasedshunting and hypoxaemia seem to peak at approximately24-72 h and to subside gradually in most patients, but insome they persisted to variable degrees for over 4 weeks.Significant objective improvement occurred in all 11 inwhom follow-up measurements were made. Patients withlarge multiple bullae showed more striking improvementthan those with small-to-medium bullae. All but 1 patientshowed significant improvement in treadmill performanceafter the laser treatment. In contrast to most reports onsurgical resection/ patients with less than half of theirhemithoraces replaced by bullae also improved after laserablation of the lesion.In patients followed up 6 months or more theimprovement has persisted. Whether it is only temporary, asreported after surgical resection3,6,7 remains to bedetermined by long-term follow-up studies.ADDENDUMLaser ablation has been done in 4 more patients. Therehave been no further perioperative deaths, but 2 patientshave died during follow-up-1 at 15 months from a strokeunrelated to respiratory disease and 1 at 4 months from acontralateral pneumonia.We thank Ms Nadia Kayaleh, Ms Lelaini Letua, and Ms Ann Shepard forcoordinating various aspects of this study; and Dr Steven J. Packer and theCommunity Hospital of Monterey Peninsula for their help with follow-uppulmonary function and treadmill evaluations.This paper was presented in part at the Western Surgical Association, Nov1989, and the Pacific Coast Surgical Association, Feb, 1990.REFERENCES1. Gaensler EA, Jederlinic PJ, FitzGerald MX. Patient work-up forbullectomy. J Thorac Imaging 1986; 1: 75-93.2. Brantigan OE, Mueller E, Kress MD. A surgical approach to bullousemphysema. Am Rev Resp Dis 1959; 80: 194-204.3. Gunstensen J, McCormack RJ. The surgical management of bullousemphysema. J Thorac Cardiovasc Surg 1973; 65: 920-25.4. O’Brien CJ, Hughes CF, Gianoutsos P. Surgical treatment of bullousemphysema. Aust NZ J Surg 1986; 56: 241-15.5. Wakabayashi A, Brenner M, Wilson AF, Tadir Y, Berns M.Thoracoscopic treatment of spontaneous pneumothorax using carbondioxide laser. Ann Thorac Surg 1990; 50: 786-90.6. Laros CD, Gelissen HJ, Bergstein PG, et al. Bullectomy for giant bullousemphysema. J Thorac Cardiovac Surg 1986; 91: 63-70.7. FitzGerald MX, Keelan PJ, Cugell DW, et al. Long-term results ofsurgery for bullous emphysema. J Thorac Cardiovasc Surg 1974; 68:566-87.8. Head JR, Avery AA. Intracavitary suction (Monaldi) in the treatment ofemphysematous bullae and blebs. J Thorac Cardiovasc Surg 1948; 40:443-60.9. MacArthur AM, Fountain SW. Intracavitary suction and drainage in thetreatment of emphysematous bullae. Thorax 1977; 32: 668-72.10. Venn GE, Williams PR, Goldstraw P. Intracavitary drainage for bullousemphysematous lung disease: experience with the Bromptontechnique. Thorax 1988; 43: 998-1002.ADDRESSES Departments of Surgery, Pulmonary and CriticalCare Medicine, Anesthesia, and Radiology, University ofCalifornia Irvine Medical Center, Orange, California, andBeckman Laser Institute, Irvine, California, USA(A Wakabayashi, MD, M. Brenner, MD, R. A. Kayaleh, MD, M W. Berns,PhD, S. J Barker, MD, S J. Rice, MD, Y. Tadir, MD, L. DellaBella, RN, A. F.Wilson, MD) Correspondence to Dr M Brenner, Pulmonary and CriticalCare Medicine Division, University of California Irvine Medical Center,101 City Drive South, Orange, California 92668, USA.Biotype as determinant of naturalimmunising effect of choleraTo test the hypothesis that clinical Vibrio cholerae O1infections protect against recurrent cholera, treatedcholera episodes in a rural Bangladesh population of188 153 people who were followed between 1985and 1988 were analysed. Of the 2214 people withinitial episodes of cholera, 7 had a second episode.The incidence of cholera was 61% lower in subjectswho had had an earlier episode than in those withoutsuch an episode. Whereas initial episodes of classicalcholera were associated with complete protectionagainst subsequent cholera, initial episodes of El Torcholera were associated with negligible protection.The development of live oral vaccines against cholera issupported by the notion that natural Vibrao cholerae 01infections are immunising and may protect against recurrentinfections.1 However, estimates of this natural protection havebeen conflicting, ranging from nil to over 90%. Systematicprospective surveillance for cholera during a recent field trial ofkilled oral cholera vaccines in rural Bangladesh offered theopportunity to evaluate the protective association betweennaturally occurring clinical cholera and the risk of recurrence.s-7As described in detail elsewhere,5-7 a large-scale field trial of oralcholera vaccines, in which children aged 2-15 years and adult womenwere randomly assigned to three doses of B subunit-killed whole cellvaccine (BS-WC), killed whole cell-only vaccine (WC), or anEscherichia coli K12 strain placebo (K12), was started in Matlab,Bangladesh, in January, 1985. Dosing was undertaken betweenJanuary and May, 1985, and all members of the Matlab population(whether or not they took part in the trial) were kept under continuoussurveillance for treated diarrhoeal episodes and for vital events.8 Weconsidered the base population of all 188 153 residents who werepresent on Jan 1,1985, and analysed data from surveillance up to June30, 1988. Individuals in the base population were regarded as"oontrols" until they had a treated episode of cholera, defined asbefore.5-7 An initial treated episode of cholera in a control subject wasregarded both as an outcome episode for that subject and as anexposure episode that transferred the subject to the "exposed" group.First recurrences of treated cholera were regarded as outcome episodesfor the exposed group. Each episode was dated according to the date ofonset of symptoms. Follow-up of the exposed and control groups wascensored by outcome episodes, death, outmigration, and the end of thestudy interval. The protective association between initial and recurrentepisodes of cholera was expressed as the incidence density ratio (IDR),which compared rates of cholera in the exposed group with those in thecontrol groUp.9 The proportionate reduction of the incidence ofcholera associated with previous episodes was calculated as(1 - IDR) x 100%.10 p values for IDRs were estimated withappropriate chi-square tests; 95% confidence intervals (CI) for IDRswere estimated with test-based methods.9 Adjustments for covariateswere done with Mantel-Haenszel methods.9During the 42-month surveillance, 2214 initial episodes ofcholera were recorded: 1065 (48%) classical Ogawa, 127 (6%)classical Inaba, 844 (38%) El Tor Ogawa, 170 (8%) El TorInaba, and 8 (04%) mixed classical and El Tor Ogawainfections. Seven recurrent episodes of cholera were detected,

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Thoracoscopic carbon dioxide laser treatment of bullous emphysema

Thoracoscopic carbon dioxide laser treatment of bullous emphysema.

Thoracoscopic carbon dioxide laser treatment of bullous emphysema.

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