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Early Outcomes After Bilateral Thoracoscopy Versus Median Sternotomy for Lung Volume Reduction

Puc, Matthew M. MD*†; Sonnad, Seema S. PhD*; Shrager, Joseph B. MD*‡

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March-April 2010 - Volume 5 - Issue 2 - p 97-102
doi: 10.1097/IMI.0b013e3181d9277d
Original Article

Objective: A National Emphysema Treatment Trial subanalysis, although finally describing outcomes as “comparable,” suggested that bilateral lung volume reduction surgery (LVRS) by video-assisted thoracoscopic surgery (VATS) may be slightly less morbid than by median sternotomy (MS). We report a single surgeon experience using both the MS and VATS approaches to provide additional information on this issue in a setting of uniform patient selection and perioperative management. Our hypothesis was that a VATS approach would provide equivalent or less morbidity than MS despite being applied to a group of patients subjectively selected to be higher risk than those undergoing MS.

Methods: Consecutive patients over a 9-year period underwent LVRS by one surgeon by either MS or VATS in a nonrandomized fashion. Thoracoscopy was selected over MS primarily when the surgeon estimated a greater overall risk profile and thus a greater chance of morbidity/mortality in a particular patient.

Results: There were 15 patients in the VATS group and 35 in the MS group. In terms of measures of risk profile, there were no differences between the groups that met statistical significance, but several values trended toward higher risk within the VATS group (eg, age, 63 VATS vs. 59 MS, P = 0.08; moderate pulmonary hypertension, 38% VATS vs. 14% MS, P = 0.11; and residual volume, 241% VATS vs. 226% MS, P = 0.32). With regard to outcomes, operative time was significantly longer in the VATS group (VATS = 155 minutes vs. MS=129 minutes, P = 0.01). All other outcomes, including the incidence of major complications (13.3% VATS vs. 17.1% MS, P = 0.39), were similar between the groups. There was a single death within 90 days (1.9% of entire series; 2.9% of MS group).

Conclusions: In this series, although patients undergoing LVRS by VATS tended to have a higher risk profile, their outcomes were no worse than in those undergoing LVRS by MS. This suggests that the VATS approach to bilateral LVRS may incur slightly less morbidity and thus may be the best option in the most compromised patients who is nonetheless felt will benefit from LVRS.

From the *Division of Thoracic Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA USA; †Division of Thoracic Surgery, Department of Surgery, St. Luke's Health Network, Bethlehem, PA USA; and ‡Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA USA.

Accepted for publication February 12, 2010.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, Boston, MA USA, June 11–14, 2008.

Address correspondence and reprint requests to Matthew Puc, MD, St. Luke's Health Network, 701 Ostrum Street, Suite 603, Bethlehem, PA 18015 USA. E-mail: pucm@slhn.org.

© 2010 Lippincott Williams & Wilkins, Inc.