Bilateral Bronchoscopic Lung Volume Reduction After Surgical Fissure Completion

Although bilateral lung volume reduction surgery has been shown to be safe and effective in carefully selected patients with upper lobe-predominant emphysema and hyperinflation, bronchoscopic lung volume reduction via placement of endobronchial valves is conventionally performed only unilaterally. Furthermore, it is not offered to patients with interlobar collateral ventilation because of the lack of clinical efficacy. We describe two novel management approaches including (1) bilateral bronchoscopic lung volume reduction, and (2) a combined thoracic surgical and interventional pulmonary procedure involving surgical fissure completion followed by endobronchial valve placement, which culminated in safe and effective lung volume reduction of both lungs along with an excellent patient outcome. Although bilateral lung volume reduction surgery has been shown to be safe and effective in carefully selected patients with upper lobe-predominant emphysema and hyperinflation, bronchoscopic lung volume reduction via placement of endobronchial valves is conventionally performed only unilaterally. Furthermore, it is not offered to patients with interlobar collateral ventilation because of the lack of clinical efficacy. We describe two novel management approaches including (1) bilateral bronchoscopic lung volume reduction, and (2) a combined thoracic surgical and interventional pulmonary procedure involving surgical fissure completion followed by endobronchial valve placement, which culminated in safe and effective lung volume reduction of both lungs along with an excellent patient outcome. Bilateral lung volume reduction surgery (LVRS) has been shown to improve physiologic and clinical outcomes, including survival, among carefully selected patients with upper lobe-predominant emphysema and hyperinflation.1Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1656) Google Scholar Unilateral bronchoscopic lung volume reduction (BLVR) using endobronchial valves (EBVs) has been shown to improve physiologic and clinical outcomes in both heterogeneous and homogeneous emphysema.2Criner G.J. Sue R. Wright S. et al.A multicenter RCT of Zephyr(R) endobronchial valve treatment in heterogeneous emphysema (LIBERATE).Am J Respir Crit Care Med. 2018; 198: 1151-1164Crossref PubMed Scopus (160) Google Scholar, 3Criner G.J. Delage A. Voelker K. et al.Improving lung function in severe heterogenous emphysema with the spiration valve system (EMPROVE): a multicenter, open-label randomized controlled clinical trial.Am J Respir Crit Care Med. 2019; 200: 1354-1362Crossref PubMed Scopus (62) Google Scholar, 4Valipour A. Slebos D.J. Herth F. et al.Endobronchial valve therapy in patients with homogeneous emphysema. results from the IMPACT study.Am J Respir Crit Care Med. 2016; 194: 1073-1082Crossref PubMed Scopus (203) Google Scholar However, few clinical data are available on the safety and efficacy of bilateral BLVR. Additionally, BLVR requires complete fissures for success. We hypothesized that in patients with residual hyperinflation, contralateral BLVR may enhance clinical outcomes. Second, we hypothesized that in cases of incomplete lobar fissures, surgical fissure completion could enable successful BLVR. A 68-year-old woman with severe emphysema and hyperinflation was evaluated for exertional dyspnea despite optimal medical therapy including pulmonary rehabilitation. Testing revealed severe obstruction, hyperinflation, and low diffusing capacity (Dlco) (e-Table 1). Imaging (Fig 1) showed homogeneous emphysema along with largely complete (between 80% and 95%) major fissures and a largely incomplete (< 80%) minor fissure. Single-photon emission CT scan showed that each upper lobe accounted for approximately 10% of total perfusion. After a multidisciplinary assessment and detailed discussions, she elected to undergo BLVR. Bronchoscopic balloon occlusion assessment showed collateral ventilation across right-sided fissures but not the left fissure. Two EBVs were placed in the left upper lobe (Fig 2A). At 2 months, imaging showed complete lobar collapse, spirometry and Dlco were improved, and hyperinflation had decreased (e-Table 1). However, her exertional dyspnea still interfered with instrumental activities of daily living. Based on persistent hyperinflation, we offered contralateral lung volume reduction (LVR), either bronchoscopic or surgical. She favored BLVR because of the prospects of reversibility were it to make her symptoms worse for any reason. Given her known right-sided collateral ventilation, we planned to perform thoracoscopic surgical division followed by BLVR in one setting under general anesthesia. After re-confirmation of collateral ventilation, her right major fissure was thoracoscopically identified. Dissection was performed over the pulmonary artery and continued over the anterior hilum. The fissure was completely divided with surgical staplers (Video 1). Total operative time was 130 min, and estimated blood loss was 10 mL. Subsequent assessment confirmed the absence of collateral ventilation. One EBV each was used to occlude the right upper lobe and the right middle lobe (Fig 2B). The procedure was well tolerated, her postoperative course was unremarkable, and she was discharged on postoperative day 3. At 2 months, she reported marked improvement in dyspnea and functional status, walking for over 30 min on a treadmill and safely making a trip to Europe. Imaging illustrated successful LVR in all three treated lobes (Fig 3). Testing revealed further improvements in spirometry and Dlco along with nearly resolved hyperinflation (e-Table 1). We report a two-step, bilateral BLVR approach to manage residual hyperinflation after successful unilateral BLVR and a collaborative thoracic surgical and interventional pulmonary approach involving thoracoscopic division of an incomplete fissure to enable EBV placement. The putative mechanisms behind clinical improvement after BLVR include improving expiratory airflow and improving the mechanical advantage of inspiratory muscles, including the hemi-diaphragm.5Fessler H.E. Scharf S.M. Ingenito E.P. McKenna Jr., R.J. Sharafkhaneh A. Physiologic basis for improved pulmonary function after lung volume reduction.Proc Am Thorac Soc. 2008; 5: 416-420Crossref PubMed Scopus (59) Google Scholar Such benefits may be largely limited to the treated side, strengthening the case for a bilateral approach similar to that used in LVRS.1Fishman A. Martinez F. Naunheim K. et al.A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.N Engl J Med. 2003; 348: 2059-2073Crossref PubMed Scopus (1656) Google Scholar We observed much more marked volume reduction after the second procedure (e-Table 1); could compensatory hyperinflation of the contralateral lung have partially offset the benefits of unilateral BLVR earlier6Bilancia R. Oey I. Perikleous P. Tenconi S. Waller D. P63 salvage lung volume reduction surgery after failure or complications of endobronchial treatment with one-way valves for severe emphysema.Thorax. 2016; 71: A119Crossref Google Scholar? To our knowledge, ours is the first case describing bilateral BLVR since the 2018 approval of BLVR in the United States. Previously, Italian colleagues have described contralateral BLVR for patients who did not experience sustained LVR after the initial procedure (28% of total).7Fiorelli A. D’Andrilli A. Anile M. et al.Sequential bilateral bronchoscopic lung volume reduction with one-way valves for heterogeneous emphysema.Ann Thorac Surg. 2016; 102: 287-294Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar However, we have demonstrated that—in patients with both residual hyperinflation and residual clinical need and at experienced centers using a multidisciplinary approach—additional clinical benefit could be achieved by treating the contralateral lung even after successful unilateral BLVR. The second novel aspect of our management was the surgical completion of an incomplete lobar fissure, which enabled EBV placement. This approach was previously deemed safe and feasible in an animal study.8Majid A. Kheir F. Alape D. et al.Combined thoracoscopic surgical stapling and endobronchial valve placement for lung volume reduction with incomplete lobar fissures: an experimental pilot animal study.J Bronchol Interventional Pulmonol. 2020; 27: 128-134Crossref PubMed Scopus (3) Google Scholar Frequently, BLVR may be preferable to LVRS because of fewer postoperative complications, minimal pain, fewer adhesions complicating future lung transplantation, and potential reversibility should the intervention not lead to clinical improvement. In conclusion, patients with severe emphysema and hyperinflation who otherwise meet criteria for BLVR should be considered for surgical correction of incomplete lobar fissures. Second, patients who have clinically significant residual hyperinflation despite successful unilateral BLVR should be considered for bilateral BLVR. Future studies should aim to help optimize patient selection for a bilateral approach. Financial/nonfinancial disclosures: None declared. Other contributions: CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: The e-Table and Videos are available under “Supplementary Data.” eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkMGM1YTc5ZDA4ODczMTRhZWY1NzM5YTk5ZGM3MGQ2MCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjczMTUzNTM3fQ.VNi-ZWkjxaLhNOrr7WyZ5Kq_uF44e227wUIXUJWxbrkqyrmRKlSB_OAYeb1OCnrabLst7q1dnpEt6bxrUuyVqHpt6wJYUpgfxNDrPsUrroLoO1wCmecRSjuezpcvQJQOPOkP8ya2JS9wg7DecuC3Cgo3_tF6AHIndbld1HBAzrvudxW0p5_vEgy1mdnrYJEpEuUy-j9sxq7qB2zN1oFfMg2NIJVBxpkOUfsq-cE68uqA9seE7O7Motlt4Vn8pca2mL6dt4hUhGkVIvEUyhUsq5HoglUZAqG_V-tkHujltaM4MEgFJL0kaECYbKDAbVy_onIly2cwSrBM04Y0hj4xcw Download .mp4 (41.95 MB) Help with .mp4 files Video 1Thoracoscopic completion of the right major fissure. Download .docx (.01 MB) Help with docx files e-Online Data