Gaissert H A, Trulock E P, Cooper J D, Sundaresan R S, Patterson G A
Department of Surgery, Washington University School of Medicine, St. Louis, Mo, USA.
J Thorac Cardiovasc Surg. 1996 Feb;111(2):296-306; discussion 306-7. doi: 10.1016/s0022-5223(96)70438-5.
Bilateral lung volume reduction is designed to improve pulmonary function in selected patients with severe emphysema by improving diaphragmatic and chest wall mechanics. Early results of lung volume reduction suggest significant improvement to selected patients with chronic obstructive pulmonary disease, some of whom might otherwise be considered for lung transplantation. The purpose of this review was to compare intermediate results of volume reduction with single and bilateral lung transplantation.
Functional performance and survival after volume reduction were compared with single and bilateral sequential lung transplantation. After evaluation, patients were enrolled in a supervised intensive preoperative and postoperative program of pulmonary rehabilitation. Functional assessment, including pulmonary function tests, room air arterial blood gas analysis, and 6-minute walk distance, was obtained before the operation and 3, 6, and 12 months after the operation.
Thirty-three patients underwent volume reduction (mean age 57 years), 39 patients single lung transplantation (55 years), and 27 patients bilateral lung transplantation (49 years). Early mortality was 0, 1 of 39, and 2 of 25 and mortality at 12 months was 1 of 33, 4 of 39, and 4 of 25 in the volume reduction, single, and bilateral lung transplantation groups, respectively. At 6 months, mean forced expiratory volume in 1 second was improved by 79% (volume reduction), by 231% (single lung transplantation), and by 498% (bilateral lung transplantation) over preoperative values. Exercise endurance as measured by 6-minute walk distance increased by 28% (volume reduction), by 47% (single lung transplantation), and by 79% (bilateral lung transplantation) from baseline. At 6 months, all patients having single or bilateral lung transplantation and 26 of 33 patients having volume replacement were free of supplemental oxygen.
Although single and bilateral lung transplantation result in superior lung function, volume reduction achieves satisfactory improvement of disabling symptoms early after operation while avoiding immunosuppression and transplant-specific complications. Our experience suggests that (1) volume reduction is a suitable alternative in selected patients eligible for transplantation; (2) volume reduction provides an earlier option for treatment in patients who may require transplantation at some future date; (3) volume reduction is the only surgical treatment available to the many patients who are not current or future transplant candidates. Conversely, in patients not suitable for volume reduction, transplantation remains the only choice for surgical therapy.
双侧肺减容术旨在通过改善膈肌和胸壁力学，改善部分重度肺气肿患者的肺功能。肺减容术的早期结果显示，部分慢性阻塞性肺疾病患者的病情有显著改善，其中一些患者原本可能会被考虑进行肺移植。本综述的目的是比较肺减容术与单肺移植和双肺移植的中期结果。
将肺减容术后的功能表现和生存率与单肺移植和双肺序贯移植进行比较。评估后，患者参加了一个有监督的术前和术后强化肺康复计划。在手术前以及手术后3、6和12个月进行功能评估，包括肺功能测试、室内空气动脉血气分析和6分钟步行距离测试。
33例患者接受了肺减容术（平均年龄57岁），39例患者接受了单肺移植（55岁），27例患者接受了双肺移植（49岁）。肺减容术组、单肺移植组和双肺移植组的早期死亡率分别为0、39例中的1例和25例中的2例，12个月时的死亡率分别为33例中的1例、39例中的4例和25例中的4例。在6个月时，与术前值相比，1秒用力呼气量平均提高了79%（肺减容术）、231%（单肺移植）和498%（双肺移植）。以6分钟步行距离衡量的运动耐力从基线分别提高了28%（肺减容术）、47%（单肺移植）和79%（双肺移植）。在6个月时，所有接受单肺或双肺移植的患者以及33例接受肺减容术的患者中的26例无需吸氧。
虽然单肺移植和双肺移植能带来更好的肺功能，但肺减容术在术后早期能令人满意地改善致残症状，同时避免免疫抑制和移植相关并发症。我们的经验表明：（1）肺减容术是部分适合移植患者的合适替代方案；（2）肺减容术为一些未来可能需要移植的患者提供了更早的治疗选择；（3）肺减容术是许多目前或未来不适合移植的患者唯一可用的手术治疗方法。相反，对于不适合肺减容术的患者，移植仍然是手术治疗的唯一选择。
