Results
None of the patients included in our study had perioperative death. Surgery lasted for 126.36±14.40 min, post-surgery mechanical ventilation lasted for 9.68±1.49 h, post-surgery thoracic drainage tube lasted for 9.09±1.31 days, and hospitalization lasted for 15.73±2.75 days. Among the cases, 5 cases had lung air leakage for 10.40±2.97 days, 7 cases had pulmonary infection, and 5 cases had atelectasis. All patients were cured and there was no other complications such as heart and lung failure or thrombosis. One case was relatively typical, and was diagnosed as COPE with giant bullae (also known as vanishing lung syndrome). After unilateral LVRS surgery, parameters of lung function of the patients were improved significantly compared with those prior to surgery (Fig. 1).
The pulmonary function, arterial blood gas analysis and activity of the daily living of the patients before surgery were compared three months after unilateral LVRS and three months after bilateral surgery. Comparative results showed that the proportion of FEV1 in predicting value [FEV1 (%)], arterial PO2 and 6MWD were increased compared with these parameters before surgery while arterial pCO2 was reduced compared with that before surgery; there was no significant difference in the pulmonary function and blood gas analysis of the patients between unilateral and bilateral LVRS (p>0.05) (Table I).
Moreover, the SF-36 included items such as physical functioning (PF), role-physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role-emotional (RE) and mental health (MH) and were used to evaluate preliminarily the quality of life. Fig. 2 shows the scores for the SF-36 scale. Compared with pre-surgery, short-term life quality of patients after LVRS surgery was greatly improved and patients could take care of themselves. Comparison of bilateral and unilateral LVRS surgery was not statistically significant in terms of lung function and quality of life(p>0.05).
Discussion
Physical and psychology effects of thoracic surgery on patients are relatively slight and small. Patients gain physiologic functions very soon after thoracic surgery (4). The indications for single-port thoracoscope have been gradually extended (5). Gonzalez-Rivas et al reported on the single-port thoracoscope bronchus and pulmonary artery double sleeve pulmonary lobectomy (6). The mechanism of LVRS involves the excision of 20–40% of the overventilated lung tissues to increase their elasticity, adjustment of the ventilation/blood flow ratio, reduction of the pulmonary heterogeneity to alleviate the respiratory pump failure, and improvement of alveolar gas exchange. Additionally, the improvement of pulmonary function and quality of life of the patients after LVRS could last for 3–4 years (7). For COPE dominated by the superior lobe, we recommend LVRS (8). It was reported that the lung function and quality of life of COPE patients was significantly improved 6 months after simultaneous bilateral thoracoscopic LVRS (9). This may be because ventilation efficiency was greatly improved after LVRS surgery (10).
The incision of single-port thoracoscope was between the fifth and sixth rib between the anterior axillary line and the midaxillary line. An endoscopic cut stapler of 5 mm was selected, with 30̊ angle and rotatable head (11). After one-lung ventilation, due to obstructive airway obstruction, patients in this group sometimes had insufficient lung collapse and extensive pleural adhesion, thus greatly limiting the vision and operation. To avoid the residue of pulmonary bulla tissues and protect the normal lung tissues, the incision had to be performed several times, thus resulting in extended surgical time and a waste of medical resources. The single direction incison procedure by Liu and the preoperative CT reconstruction may be utilized to precisely locate the target lung tissues (12), thus it was a favorable method to overcome such a limit and save medical resources. Major complications of LVRS included pulmonary atelectasis, pulmonary infection and persistent pulmonary leakage. Overlap of the incisal margins and interlocking suture by 4–0 prolene thread, combined with biogel significantly reduced post-surgery air leakage (13). The chest was closed after 10 min of lung filling. Conventionally, 2 chest tubes were inserted individually, with the ends of the tube placed into the top and bottom of the thoracic cavity. Special care was given to avoid that the tube did not touch the heart so as to prevent arrhythmia such as atrial fibrillation after surgery. The patient were provided with nutrition, assistance in coughing and expectorating and off-bed activity and were regularly monitored by chest X-ray to clarify the degree of pulmonary re-expansion. It has been reported that OK-432 effectively reduces the recurrence of pneumothorax and the adverse effects were relatively minimal (14). We used OK-432 to perform thoracic cavity perfusion on patients after pneumothorax and pulmonary trachea operation to promote pleural adhesion and have received quite favorable curative effects.
The major causes of post-surgery pulmonary infection in patients with chronic obstructive pulmonary disease is increased sputum secretion and obstructed discharge, most of which are complicated by tracheal colonization bacteria. The airway passage needs to be healthy before surgery and thus sensitive antibiotics should be selected before and after surgery (15). Furthermore, the lung function of patients with chronic obstructive lung disease is relatively poor, thus assistant sputum excretion and rehabilitation therapy after surgery was required (16). In the present study, patients were treated with conventional small dose hormone aerosol inhalation to control airway inflammation.
By contrast, patients in our study received partial resection of the pulmonary lobe, including pulmonary bullae so as to preserve the reserve function of their lung. Beckers et al reported that, compared with pulmonary lobe partial resection, lobectomy could better improve the curative effects on the lung function of patients with severe emphysema (17). A meta-analysis by Iftikhar et al indicated that bronchoscopic lung volume reduction (BLVR) was a simple replacement therapy of emphysema (18). Chen et al confirmed the curative effects of lung transplantation and LVRS on treating end-stage emphysema, indicating that compared with LVRS, lung transplantation could better improve lung function of patients, blood gas analysis and quality of life after surgery. Therefore, it was suggested that if conditions permitted, lung transplantation be considered the first choice of surgical treatment for patients with end-stage emphysema (19). However, Trotter and Hopkins demonstrated the role of lung volume reduction and lung transplantation for treating emphysema. Since there were few lung donors available, endobronchial valve therapy, bronchial vapor ablation and LVRS should be considered (20). Shah and Herth reported that endobronchial valve therapy could significantly improve the lung function and activity endurance of patients with emphysema (21).
In conclusion, staged bilateral single-port thoracoscopic LVRS is safe and effective for treating patients with COPE combined with pulmonary bullae. Since the sample number of our study was relatively small, its short-term curative effect still requires a multi-center, large scale study and its long-term curative effect requires closer follow-up.