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The operation is called thoracoscopic lung volume reduction surgery. This procedure is being compared with medical therapy to determine which alternative provides greater relief from the severe shortness of breath experienced by patients with end-stage emphysema.
"While the reported early results of lung reduction surgery are quite encouraging, a formal medical trial is required before this type of surgery can be considered the standard of care," said Keith S. Naunheim, M.D., professor and chief of cardiothoracic surgery at the School of Medicine. "If surgery proves to be superior when compared directly to standard medical therapy, then this operation can be made available to all of the appropriate candidates."
Medical therapy is designed to support patients with oxygen, exercise programs and bronchodilators to help their breathing. As an alternative treatment, surgery is designed to remove the most diseased portions of lungs and thus shrink the size of the lungs. This "volume reduction" allows the chest wall and diaphragm to return to their normal positions, helping them to function more efficiently. The goal is to relieve shortness of breath and increase lung function for the emphysema patient.
The operation generally is performed by one of two approaches. The "sternotomy" approach entails a large incision down the center of the chest and sawing the breast bone in half. Through this incision, the surgeon can operate on both lungs.
The alternative approach, called "thoracoscopy," is used by Saint Louis University physicians. With this procedure, three one-half-inch incisions are made on either side of the chest. Through these small slits, a video telescope and instruments are placed so that the operation can be performed inside the chest with videoscopic guidance. The thoracoscopic approach is performed on both sides at one time. The use of thoracoscopy allows the same procedure to be done through smaller incisions. This proves less painful, easier to tolerate and shortens recovery time for the patient.
Emphysema usually is caused by a prolonged history of cigarette smoking, although the disease sometimes is genetic in origin. In emphysema, the tiny air sacs of the lungs become inflamed, and the walls of the sacs break down and form tiny bubbles or bullae. These areas are less efficient in exchanging oxygen and carbon dioxide for the body, and, thus, patients get easily fatigued and may have to rely on supplemental oxygen to survive. The bullae in the lungs themselves gradually enlarge and put outward pressure on the rib cage and downward pressure on the diaphragm. The enlargement prevents the normal flow of air in and out of the lungs. The trapped air gives patients the appearance of having an enlarged, or "barrel," chest. The current National Emphysema Treatment Trial is sponsored by the Health Care Finance Administration and is open to all Medicare-eligible patients. All costs for patient evaluation and treatment are covered under the Medicare reimbursement rules, whether patients are eventually accepted into the trial or not. For more information, call the study's clinical coordinator, Joan Osterloh, at 577-8341.
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