Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Leicester, LE3 9QP, UK.
Eur J Cardiothorac Surg. 2010 Apr;37(4):846-52. doi: 10.1016/j.ejcts.2009.10.025. Epub 2009 Dec 1.
Lung volume reduction surgery (LVRS) is conventionally a one-staged bilateral operation. We hypothesised that a more conservative staged bilateral approach determined by the patient not the surgeon would reduce operative risk and prolong the overall benefit.
In a population of 114 consecutive patients who were identified as suitable for bilateral LVRS an initial cohort of 26 patients (15 male; 11 female, median age: 58 years) underwent one-staged bilateral surgery: 18 by median sternotomy and eight by video-assisted thoracoscopic surgery (VATS) (group OB). A subsequent cohort of 88 patients had unilateral VATS LVRS with the contralateral operation not scheduled until the patient requested this. Longitudinal follow-up included analysis of lung function, health status (SF 36) and survival.
At a median follow-up of 2.8 (range: 0-9.9) years, staged bilateral LVRS was performed in 16 patients (10 male; 6 female, median age: 59 years) (group SB) at a median interval of 3.9 (range: 0.7-5.9) years after the first operation. Unilateral LVRS has been performed in 73 patients (43 male; 30 female, median age: 60 years) (group U). There were significant improvements in forced expiratory volume in 1s (FEV1) for 6 months in groups OB and U; in group SB there was a second improvement at 4 years (p<0.05). There were significant reductions in residual volume (RV) and total lung capacity (TLC) in groups OB and U for 2 years; in group SB there was a further significant reduction lasting up to 6 years in TLC (p<0.05) and RV (p<0.01). There were significant improvements in health status lasting up to 1 year in groups OB and U. However, in group SB these improvements lasted for 4 years in the domain of physical functioning and 6 years in the domains of social functioning and energy/vitality. There was no significant difference (p=0.07) in 30-day mortality among groups OB (7.7%), SB (13%) and U (4.1%). Similarly, there was no difference between groups OB and SB/U in 3-year survival (81% vs 77%) or 5-year survival (54% vs 66%).
A staged bilateral approach to LVRS dictated by patients' perception of their condition appears to lead to a more prolonged overall benefit than one-staged LVRS without compromising survival.
肺减容术（LVRS）通常是一种分两阶段的双侧手术。我们假设，根据患者而非外科医生决定的更为保守的分阶段双侧方法将降低手术风险并延长整体获益。
在 114 例连续适合双侧 LVRS 的患者中，我们选择了一组初始队列的 26 例患者（15 例男性；11 例女性，中位年龄：58 岁）接受了一次性双侧手术：18 例经正中胸骨切开术，8 例经电视辅助胸腔镜手术（VATS）（OB 组）。随后的 88 例患者接受了单侧 VATS LVRS，直到患者要求进行对侧手术才安排对侧手术。纵向随访包括肺功能、健康状况（SF 36）和生存情况的分析。
在中位随访 2.8 年（范围：0-9.9 年）时，16 例患者（10 例男性；6 例女性，中位年龄：59 岁）（SB 组）接受了分期双侧 LVRS，在首次手术后中位间隔 3.9 年（范围：0.7-5.9 年）。73 例患者（43 例男性；30 例女性，中位年龄：60 岁）（U 组）接受了单侧 LVRS。OB 和 U 组在 6 个月时用力呼气量（FEV1）有显著改善；SB 组在 4 年时有第二次改善（p<0.05）。OB 和 U 组在 2 年内残气量（RV）和肺总量（TLC）有显著降低；SB 组在 6 年内 TLC（p<0.05）和 RV（p<0.01）有进一步显著降低。OB 和 U 组的健康状况有长达 1 年的显著改善。然而，在 SB 组中，在身体机能领域的改善持续了 4 年，在社会功能和能量/活力领域的改善持续了 6 年。OB（7.7%）、SB（13%）和 U（4.1%）三组之间 30 天死亡率无显著差异（p=0.07）。同样，OB 和 SB/U 组在 3 年生存率（81% vs 77%）或 5 年生存率（54% vs 66%）方面也无差异。
根据患者对其病情的认知，采用分期双侧方法进行 LVRS 似乎比一次性双侧 LVRS 更能延长整体获益，而不会影响生存。
