Is bilateral lung volume reduction better than unilateral lung volume reduction in end-stage emphysema?
Date First Published:
July 21, 2022
Last Updated:
October 12, 2022
Report by:
Kudzayi Kutywayo, Registrar- Cardiothoracic Surgery (Glenfield Hospital, University Hospital of Leicester NHS Trust)
Search checked by:
Nathan Tyson, Glenfield Hospital, University Hospital of Leicester NHS Trust
Three-Part Question:
In [patients with end-stage emphysema] is [unilateral or bilateral lung volume reduction surgery superior] for [improving symptoms and quality of life]?
Clinical Scenario:
A 62-year-old gentleman attends thoracic outpatients with end-stage emphysema for consideration for lung volume reduction surgery. Imaging has identified heterogenous emphysematous areas in both upper lobes with minimal perfusion, and the patient is keen to discuss surgical options. You wonder what surgical approach would be most beneficial to the patient, bilateral or unilateral LVRS. You decide to undertake a review to investigate post-operative improvement following each procedure
Search Strategy:
Medline and Embase Databases, January 1946 to December 2021:
[exp LVRS/ OR lung volume reduction.mp OR LVRS.mp] AND [exp surgery/ OR exp VATS/ OR thoracotomy.mp OR sternotomy.mp OR pneumoplasty.mp OR thoracoscop*.mp] AND [unilateral.mp OR bilateral.mp OR staged OR single?stage.mp] AND [exp emphysema/].
[exp LVRS/ OR lung volume reduction.mp OR LVRS.mp] AND [exp surgery/ OR exp VATS/ OR thoracotomy.mp OR sternotomy.mp OR pneumoplasty.mp OR thoracoscop*.mp] AND [unilateral.mp OR bilateral.mp OR staged OR single?stage.mp] AND [exp emphysema/].
Outcome:
481 papers were found using the reported search. From these, 11 papers were identified that provided the best evidence to answer the question. These are presented in table 1.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Surgical approaches for lung volume reduction in emphysema. Clark SJ, Zoumot Z, Bamsey O, Polkey MI, Dusmet M, Lim E et al. 2014 United Kingdom | January 2000 – September 2012 104 patients undergoing LVRS 81 Unilateral 23 Bilateral |
Nonrandomised retrospective, Level III |
Mortality (%) | 30-Day: 0% vs 17.4% 90-Day: 0% vs 21.7% | Surgical approach not stated |
| Length of Stay (Days) | 13.8±11.0 vs 21.4±24.1 | ||||
| Pulmonary Complications | 11.4% vs 39.1% | ||||
| Cardiac Complications | 6.3% vs 13.0% | ||||
| Discharge with Chest Drain | 16.5% vs 31.6% | ||||
| Reoperation for Airleak | 0% vs 5.2% | ||||
| Staged bilateral lung volume reduction surgery - the benefits of a patient-led strategy. Oey IF, Morgan MD, Spyt TJ, Waller DA. 2010 United Kingdom | 15 year period (Dates not Specified) 73 Unilateral LVRS 16 Bilateral two-stage LVRS 26 Bilateral single-stage LVRS |
Non-randomised comparison. Level III |
30-Day Mortality | 7.7% vs 13% vs 4.1%; P=0.07 | |
| Long Term Survival | 3-Year: 81% vs 72%; P=0.2 5-Year: 54% vs 56%; P=0.6 | ||||
| Increase in FEV1 | Significant for first 6 months only in OB and U Significant for 12 months in staged group | ||||
| Sequential VATS lung volume reduction surgery: prolongation of benefits derived after the initial operation Soon SY, Saidi G, Ong ML, Syed A, Codispoti M, Walker WS 2003 United Kingdom | 1994 – 2001 29 Unilateral VATS 21 Bilateral Sequential VATS |
Nonrandomised prospective, Level III |
Overall Survival | No difference between groups; P=0.65 | |
| Change in FEV1 | No difference between groups; individual values not reported | ||||
| Change in TLC | No difference between groups; individual values not reported | ||||
| Change in Health Score | 2.tNo difference between groups; individual values not reported | ||||
| Lung volume reduction surgery--a comparison of the long term outcome of unilateral vs. bilateral approaches Oey IF, Waller DA, Bal S, Singh SJ, Spyt TJ, Morgan MD 2002 United Kingdom | 5 Year Duration (Dates not specified) 39 Unilateral VATS (U) 26 Bilateral; open or VATS (B) |
Nonrandomised retrospective, Level III |
30-Day Mortality | 3% vs 8%; P=0.34 | |
| ITU Stay (Days) | 2±13 vs 7±9; P=0.04 | ||||
| Post-Operative Stay | 16±10 vs 28±22; P=0.004 | ||||
| Change in FEV1 (% Predicted) | 12 Months: 31±113 vs 35 ± 13 24 Months: 34±15 vs 31±13 | ||||
| Change in Health Status (SF36 Score) | Significant improvement in both groups at 12 months (Values not stated) | ||||
| Comparison of clinical results for unilateral and bilateral thoracoscopic lung volume reduction. Lowdermilk GA, Keenan RJ, Landreneau RJ, Hazelrigg SR, Bavaria JE, Kaiser LR et al. 2000 USA | February 1993 – July 1998 Multicentre. 344 Bilateral VATS 338 Unilateral VATS |
Retrospective multicentre study Level III |
Operative Mortality | 7% vs5.1%; P>0.05 | |
| Improvement in Predicted FVC (%) | 9.6±30.1% vs 21.3±35%; p=0.0003 | ||||
| Improvement in Predicted FEV1 (%) | 20±39.3% vs 33.5±42.2%; p=0.0006 | ||||
| Improvement in Residual Volume (%) | 10.3±35% vs 22.3±20.1%; P=0.0001 | ||||
| Improvement in SMWD (feet) | 26.2±66.1 vs 31±59.6; P>0.05 | ||||
| Improvement in VO2 (mL/min/Kg) | 2.9±24.6 vs 2.8 ±28.7; P>0.05 | ||||
| Patient-Reported Improved QOL | 79% vs 88%; P=0.03 | ||||
| Improvement in Breathing Symptoms | 61.5 vs 71%; P=0.03 | ||||
| Long-term survival after thoracoscopic lung volume reduction: a multiinstitutional review Naunheim KS, Kaiser LR, Bavaria JE, Hazelrigg SR, Magee MJ, Landreneau RJ et al. 1999 USA | February 1993 – July 1998 72 staged procedures. 330 Unilateral VATS 343 Bilateral VATS |
Level II | Air leak | 60% vs 68%; P<0.05 | |
| Post-Operative Pneumonia | 7.8% vs 14%; P<0.01 | ||||
| Post-Operative Arrythmia | 3.6% vs 8.9%; P=0.005 | ||||
| Prolonged Ventilator Dependence | 4.1% vs 6.2%; P>0.05 | ||||
| Operative Mortality | 5.2% vs 7.0%; P>0.05 | ||||
| Respiratory Mortality | 2.1% vs 3.5%; P>0.05 | ||||
| Length of Hospital Stay | 15.3±17.3 vs 20.6±22.2 days; P<0.05 | ||||
| 3-Year Survival | 69% vs 74% | ||||
| Survival after unilateral versus bilateral lung volume reduction surgery for emphysema. Serna DL, Brenner M, Osann KE, McKenna RJ, Jr., Chen JC, Fischel RJ et al. 1999 USA | April 1994 – March 1996 106 Unilateral VATS LVRS 154 Bilateral VATS LRVS Subgroup analysis of age >70, post-operative FEV1 |
Historical comparison Level IIb |
2-Year Survival | 72.6% vs 86.4%; P=0.001 | |
| Follow Up Period | 29.3 Months vs 28.5 Months | ||||
| Death from Respiratory Failure | 29% vs 10% | ||||
| Mean Improvement in FEV1 (2 year) | 77ml vs 274ml | ||||
| Mean Improvement in FVC (2 Year) | 301ml vs 711 ml | ||||
| Rate of FEV1 change following lung volume reduction surgery. Brenner M, McKenna RJ, Jr., Gelb AF, Fischel RJ, Wilson AF. 1998 USA | May 1994 - July 1996 157 Unilateral LVRS -t46 VATS Laser -t111 VATS Staple 219 Bilateral LVRS -t21 VATS laser and staple -t184 VATS Staple -t14 Sternotomy and staple |
Nonrandomised prospective, Level III |
Improvement in FEV1 (%) | Bilateral Surgery: -t56± 4% (VATS + Staple) -t22±10% (VATS + Laser + Staple) -t41± 13% (Median Sternotomy + Staple) Unilateral Surgery -t15±9% (VATS + Laser) -t21± 3% (VATS + Staple) Bilateral Surgery: -t14.1% (VATS + Staple) -t35.7% (VATS + Laser + Staple) -t2.7% (Median Sternotomy + Staple) Unilateral Surgery -t17.3% (VATS + Laser) -t27.9% (VATS + Staple) | |
| Comparison of short-term functional outcomes following unilateral and bilateral lung volume reduction surgery. Kotloff RM, Tino G, Palevsky HI, Hansen-Flaschen J, Wahl PM, Kaiser LR et al. 1998 USA | 151 patients: 32 unilateral, 119 bilateral. | Nonrandomised prospective Level III |
30-Day Mortality | 0 vs 5%; P<0.05 | |
| Change in FEV1 (L) | 0.16 vs 0.25; P<0.001 | ||||
| Change in FVC (L) | 0.34 vs 0.42; P<0.001 | ||||
| Change in RV (L) | -0.9 vs -1.38; P<0.001 | ||||
| Change in SMWD (feet) | 147 vs 195; p<0.001 | ||||
| Functional comparison of unilateral versus bilateral lung volume reduction surgery. Argenziano M, Thomashow B, Jellen PA, Rose EA, Steinglass KM, Ginsburg ME et al. 1997 USA | 20 Months Duration (Period of study not specified) 92 patients undergoing LRVS for end-stage emphysema 28 unilateral LVRS 68 bilateral LVRS Follow up at 3, 6 and 12 months; range 1-25 months. |
Nonrandomised prospective, Level III |
Mean Improvement in FEV1 | 28±28% vs 70±79% | |
| Mean Improvement in FVC | 29±338% vs 48±63% | ||||
| Mean Improvement in SMWD (Feet) | 315±270 vs 289±320 | ||||
| Mean Improvement in Dyspnoea Index | -2.6±1.4 vs -2.3±1.4 | ||||
| Persistent (>7 days) air leak | 46% vs 53% | ||||
| Reintubation | 4% vs 8% | ||||
| Pneumonia | 0% vs 9% | ||||
| Reoperation | 0% vs 2% | ||||
| Should lung volume reduction for emphysema be unilateral or bilateral? McKenna RJ, Jr., Brenner M, Fischel RJ, Gelb AF. 1996 USA | June 1994 – June 1996 87 Unilateral stapled VATS 79 Bilateral stapled VATS |
Level III | Persistent (>7 Days) Air Leak | 53% vs 47% | Follow-up pulmonary function available for 87% of patients |
| Bleeding | 0% vs 1% | ||||
| Reoperation | 5% vs 5% | ||||
| Pneumonia | 4% vs 3% | ||||
| Reduction in Steroid Dependency | 54% vs 85% P=0.02 | ||||
| Reduction in Oxygen Dependency | 36% vs 68%; P<0.01 | ||||
| Post-operative Dyspnoea (Grade 3-4) | 44% vs 12%; P<0.001 |
Author Commentary:
There is some evidence to show that concurrent bilateral LVRS results in superior post-operative PFTs. Patients in this group deteriorate faster in the first post-operative year with most studies demonstrating a greater morbidity and mortality risk in the peri-operative period when compared with staged-bilateral and unilateral procedures.
Although not significantly improving PFTs more-so than unilateral or one-stage bilateral procedures, staged bilateral procedures provide more stable long-term improvements in PFTs. It also allows for the second stage to be performed at the patient’s discretion when they feel their function has deteriorated again, with some patients not requiring a second procedure. Furthermore, the staged-bilateral approach may avoid the need for median sternotomy. This has clear benefits on length of hospital admission, and where feasible, staged-bilateral LRVS via a thoracoscopic approach should be offered to suitable patients.
Although not significantly improving PFTs more-so than unilateral or one-stage bilateral procedures, staged bilateral procedures provide more stable long-term improvements in PFTs. It also allows for the second stage to be performed at the patient’s discretion when they feel their function has deteriorated again, with some patients not requiring a second procedure. Furthermore, the staged-bilateral approach may avoid the need for median sternotomy. This has clear benefits on length of hospital admission, and where feasible, staged-bilateral LRVS via a thoracoscopic approach should be offered to suitable patients.
Bottom Line:
Although not significantly improving PFTs more-so than unilateral or one-stage bilateral procedures, staged bilateral procedures provide more stable long-term improvements in PFTs.
References:
- Clark SJ, Zoumot Z, Bamsey O, Polkey MI, Dusmet M, Lim E et al. . Surgical approaches for lung volume reduction in emphysema.
- Oey IF, Morgan MD, Spyt TJ, Waller DA. . Staged bilateral lung volume reduction surgery - the benefits of a patient-led strategy.
- Soon SY, Saidi G, Ong ML, Syed A, Codispoti M, Walker WS. Sequential VATS lung volume reduction surgery: prolongation of benefits derived after the initial operation
- Oey IF, Waller DA, Bal S, Singh SJ, Spyt TJ, Morgan MD. Lung volume reduction surgery--a comparison of the long term outcome of unilateral vs. bilateral approaches
- Lowdermilk GA, Keenan RJ, Landreneau RJ, Hazelrigg SR, Bavaria JE, Kaiser LR et al. . Comparison of clinical results for unilateral and bilateral thoracoscopic lung volume reduction.
- Naunheim KS, Kaiser LR, Bavaria JE, Hazelrigg SR, Magee MJ, Landreneau RJ et al. . Long-term survival after thoracoscopic lung volume reduction: a multiinstitutional review
- Serna DL, Brenner M, Osann KE, McKenna RJ, Jr., Chen JC, Fischel RJ et al. . Survival after unilateral versus bilateral lung volume reduction surgery for emphysema.
- Brenner M, McKenna RJ, Jr., Gelb AF, Fischel RJ, Wilson AF. . Rate of FEV1 change following lung volume reduction surgery.
- Kotloff RM, Tino G, Palevsky HI, Hansen-Flaschen J, Wahl PM, Kaiser LR et al. . Comparison of short-term functional outcomes following unilateral and bilateral lung volume reduction surgery.
- Argenziano M, Thomashow B, Jellen PA, Rose EA, Steinglass KM, Ginsburg ME et al. . Functional comparison of unilateral versus bilateral lung volume reduction surgery.
- McKenna RJ, Jr., Brenner M, Fischel RJ, Gelb AF. . Should lung volume reduction for emphysema be unilateral or bilateral?