Brenner M, McKenna R, Gelb A, Osann K, Schein M J, Panzera J, Wong H, Berns M W, Wilson A F
Department of Medicine, University of California Irvine Medical Center, Chapman General Hospital, Orange 92668, USA.
Am J Respir Crit Care Med. 1997 Apr;155(4):1295-301. doi: 10.1164/ajrccm.155.4.9105070.
Recently described surgical approaches to the treatment of emphysema, including buttressed stapled volume reduction and laser coagulation, are associated with variable clinical outcomes. We examined objective preoperative factors as predictors of response to treatment in patients enrolled in a randomized trial of staple versus laser volume-reduction surgery in order to help define patient selection criteria for these procedures. Seventy-two patients with severe symptomatic emphysema without bullae were entered into the protocol (39 staple, 33 laser). Preoperative objective variables (pulmonary function tests, smoking history, demographics, and graded chest computed tomographic [CT] scans) were evaluated as predictors of response to treatment (defined as a change in FEV1) at 3- to 6-mo follow-up, using linear and multivariate regression analysis. Follow-up pulmonary function was obtained on 90% of the 68 patients surviving at 6 mo. Overall improvement was significant only for staple-treated patients, and improved outcome correlated with greater smoking history and younger age for staple-treated patients. When physiologic variables were analyzed, greater smoking history, lower DL(CO), and younger age predicted improved outcome for laser-treated patients. Preoperative FEV1 and gas-exchange variables did not predict outcome in staple-treated patients. When CT scan grading was included in multivariate regression analysis, hyperinflation (increased thoracic gas volume) was the primary predictor of response for laser-treated patients. These findings suggest that younger patients with evidence of advanced emphysematous lung disease and hyperinflation are optimal candidates for lung-volume-reduction surgery, particularly by staple-reduction techniques. Additional studies with long-term follow-up, bilateral procedures, and assessment of other outcome measures must be performed to further define operative criteria for lung-volume-reduction surgery for emphysema.
最近描述的治疗肺气肿的手术方法，包括支撑吻合器减容术和激光凝固术，其临床疗效各不相同。我们在一项关于吻合器与激光减容手术的随机试验中，研究了术前客观因素作为患者治疗反应的预测指标，以帮助确定这些手术的患者选择标准。72例无肺大疱的重度症状性肺气肿患者纳入研究方案（39例行吻合器手术，33例行激光手术）。术前客观变量（肺功能测试、吸烟史、人口统计学资料以及胸部计算机断层扫描[CT]分级）通过线性和多变量回归分析，被评估为3至6个月随访时治疗反应（定义为第一秒用力呼气容积[FEV1]的变化）的预测指标。68例6个月存活患者中90%获得了随访肺功能。仅吻合器治疗的患者总体改善显著，且吻合器治疗患者的改善结果与更长的吸烟史和更年轻的年龄相关。分析生理变量时，更长的吸烟史、更低的一氧化碳弥散量（DL(CO)）以及更年轻的年龄预测激光治疗患者的改善结果。术前FEV1和气体交换变量不能预测吻合器治疗患者的结果。当CT扫描分级纳入多变量回归分析时，肺过度充气（胸腔气体容积增加）是激光治疗患者反应的主要预测指标。这些发现表明，有晚期肺气肿性肺疾病和肺过度充气证据的年轻患者是肺减容手术的最佳候选者，尤其是采用吻合器减容技术。必须进行更多的长期随访、双侧手术以及其他结局指标评估的研究，以进一步明确肺气肿肺减容手术的手术标准。
