What Is Lung Volume Reduction Surgery?
Lung Volume Reduction Surgery (LVRS) is a surgical procedure performed to remove diseased, emphysematous lung tissue.
Emphysema is a chronic ongoing disease, a progressive condition affecting over 2 million Americans most commonly caused by smoking. The disease damages the lungs and makes breathing difficult.
Generally it is a breakdown in the walls of the air sacs of the lung causing them to become abnormally enlarged. These abnormally enlarged air sacs function poorly for oxygenation.
In addition, they cause the small airways which carry the air to and from the air sacs to collapse during breathing; especially exhalation. These abnormally enlarged air sacs fill easily with air during inspiration but they lose their ability to empty the lung through the small airways during exhalation. This resembles airways obstruction which is why some use the term chronic obstructive pulmonary disease to describe emphysema. The problem of easy filling and poor emptying of the lung leads to progressive hyperexpansion of the lungs resulting in inefficient breathing mechanics. This in addition to the poor oxygenating capability of emphysema lungs makes it more and more difficult to breathe.
Lung Volume Reduction Surgery has been shown to help improve breathing ability, lung capacity and overall quality of life in selected patients as approximately 20-35% of the poorly functioning space occupying lung tissue from each lung is removed. By reducing the lung size, the remaining lung and surrounding muscles (intercostals and diaphragm) are able to work more efficiently. This makes breathing easier and helps patients achieve greater quality of life.
To optimize exercise capacity and improve early postoperative recovery, patients must participate in a 6 to 10 week pulmonary rehabilitation program prior to surgery.
The goal of LVRS is to remove up to 30 percent of each lung, making the lungs smaller and allowing them to function better.
The operation requires general anesthesia and can be performed by either a STERNOTOMY or with a minimally invasive technique called THORACOSCOPY. Your surgeon will carefully evaluate you to determine the safest surgical approach to treat your medical condition.
STERNOTOMY involves A traditional open-surgery approach that uses an incision to divide the breast bone to resect or remove large mediastinal masses or tumors. A sternotomy allows access to the entire chest cavity including the heart, great vessels and lungs, and may be necessary for larger tumors and masses. Both lungs (a bilateral approach) are reduced at the same time in this procedure.
A minimally-invasive technique, the Thoracoscopy requires 3 to 5 small incisions made on both sides of the chest, between the ribs.
A videoscope is inserted through one of the incisions to allow the surgeon to see your lungs. THORACOSCOPY can be used to operate on either one (unilateral) or both lungs (bilateral) and allows your surgeon to assess and resect any part of the lungs.
A stapler and grasper are inserted in the other incisions and are used to remove the most damaged areas of the lung.
The stapler is used to reseal the remaining lung.
Am I A Candidate For Lung Volume Reduction Surgery?
It is very important that this operation is only offered to people who are likely to benefit from the procedure with the lowest risk of complications.
A good candidate for LVRS is someone who has stopped smoking for at least 4 months and has disabling emphysema despite complete compliance with optimum medical therapy.
The patient must be able to participate in a pulmonary rehabilitation program prior to and after surgery.
Any other medical conditions that the candidate may have must be well controlled and must not present unacceptable risks for complications from the procedure.
Most importantly, the patient must have a pattern of emphysema that is amenable to surgical management. This means that there are space occupying, poorly functioning areas of the lung which can be removed to improve lung function. Imaging studies including chest x-ray, CAT scan, and lung perfusion studies are done to determine this.
Lung Volume Reduction Surgery may be an appropriate treatment for select patients who meet established criteria specifically:
Group 1: Patients with predominantly upper lobe emphysema and low exercise capacity. These patients have improved survival and functional outcomes after LVRS compared to medical therapy.
Group 2: Patients with predominantly upper lobe emphysema and high exercise capacity. These patients have improved functional outcomes after LVRS but no difference in survival compared to medical therapy.
Group 3: Patients with non-upper lobe emphysema and low exercise capacity. These patients have improved survival after LVRS but no difference in survival compared to medical therapy.
Patients who fall into Group 1 are the best candidates for LVRS. Your thoracic surgeon and pulmonologist will discuss your treatment options to determine the best treatment for you.
The following groups of patients are not candidates for LVRS:
The effectiveness of Lung Volume Reduction Surgery depends on the location or extent of the diseased tissue, as well as the patient’s exercise tolerance and ability to tolerate surgery. While effective for some patients, there are risks involved with lung reduction surgery, including:
Advantages Of Lung Volume Reduction Surgery
Lung Volume Reduction Surgery is beneficial for patients with predominant upper lobe disease and low exercise capacity, as compared with other medical treatment. Lung Volume Reduction Surgery is a procedure used for some patients with severe emphysema, a common type of chronic obstructive pulmonary disease (COPD), disabling dyspnea (shortness of breath, difficulty breathing) and evidence of severe air trapping.
There are significant risks associated with LVRS because of the poor baseline lung function. The major risks associated with this procedure are:
Prolonged air leakage is the most common complication after LVRS. Approximately 40% of patients will have this problem. Some patients will actually go home with a chest drain in place for a few days to help manage this.
ARE THERE ALTERNATIVES TO SURGERY FOR LUNG VOLUME REDUCTION?
Approaches that use endobronchial valves to achieve lung volume reduction without the need for incisions are currently being investigated. These valves are placed into the inside of the lung via abronchoscopy. During a bronchoscopy, a long, thin tube called a bronchoscope is passed through the nose or mouth and down the airway as far as necessary. A small camera conveys the images to a television monitor.
PREPARATION FOR SURGERY
Before traveling to Cyprus, as part of your surgery preparation we require detailed medical information in the form of a medical questionnaire, ECG, Pulmonary tests and blood work. In some cases an Angiogram is required.
Although not all the tests may be required for each patient, they usually include:
All of this information will allow the doctors that we work with to determine your eligibility for the procedure. Your surgeon will give you specific instructions about any dietary changes or activity restrictions you should follow before surgery.
Tell your surgeon what medications you are taking, especially aspirin or an anticoagulant ("blood thinner"). Your surgeon will tell you if you should stop taking them. Also bring a complete list of your current medications (including over-the-counter drugs, vitamins and herbal supplements), allergies, your medical records and any health insurance information.
If you smoke, stop immediately to improve your blood flow and breathing.
If you develop a cold, fever or sore throat within a few days of your surgery, or have other questions or concerns, contact our offices immediately.
Ten days prior to your arrival in Cyprus, you will receive all the necessary pre operative instructions, to prepare yourself both physically and mentally for your chosen procedure.
Upon arriving in Cyprus, as part of the pre-surgery tests done at our partner hospitals you will again receive chest X-rays, blood tests, an electrocardiogram and any other pre operative tests your surgeon feels necessary.
Your surgeon and anesthetist will also go through you medical and surgical issues with you. During this visit, your surgeon will discuss your procedure and answer any questions.
Getting Your House Ready For Surgery
It is also important to get your house ready for after you come home from the hospital. At first it will be harder for you to move around, so arrange your furniture and household items ahead of time to make it easier for you during your rehabilitation.
Preparation for the hospital
Here are a few things to keep in mind as you pack and prepare for the hospital and recuperation:
Getting dressed in the morning helps you feel better, so be sure to bring some comfortable clothing to the hospital:
Day Before Surgery
Your surgical nurse will provide you with these instructions the night before surgery:
Morning Of Surgery
On the day of your surgery, your designated SALUS Patient Concierge along with a nurse may talk with you and your loved ones. They shall tell you what to expect. You will most likely feel a little nervous before surgery, so the SALUS team and the hospital staff will do all they can to answer your questions and help you relax.
Make sure all your medicines in their original containers with you to the hospital.
You will meet with the anesthesiologist who will talk to you about general anesthesia. This is a controlled sleep while the surgery is being done so you will not feel any pain or remember the surgery.
You should leave jewelry, watches, money and other valuables with the person who accompanies you or with our staff member who will place them in our safe.
Proceed with your routine morning care:
You will have an IV or intravenous line put in to give you fluid and medicine during your surgery.
When it is time for you to go to surgery, your family/ companion will be asked to wait in the waiting area. Your doctor will talk to your family/ companion there after your surgery is done.
RECOVERY AFTER SURGERY
After surgery, the patient is moved to the Intensive Care Unit where family members can visit the periodically.
Immediately after the procedure patients are awakened from the general anesthetic and allowed to breathe on their own.
Pain medicine is given through an epidural catheter to help control postoperative discomfort.
Drainage tubes are left in the chest to drain any excess air or fluid from the chest after surgery. These are removed once the air and fluid leakage stops.
Physical therapy is reinstituted early during the recovery phase during the hospitalization.
Patients usually stay in our partner hospitals for about one week or ten days as necessary, after surgery. This time does give our surgeon adequate time to monitor post operative recovery. During this time, some tests will be done to assess and monitor the patient’s condition.
Hospital Discharge and Home Instructions
Your diet is slowly increased from ice chips to liquids to solid foods as your intestines start functioning.
Before leaving the hospital, our surgeon and staff will help you adjust to recovery in every way possible. You will receive specific instructions and precautions from your surgeon and nursing staff and they will show you safe techniques of simple activities like getting in and out of bed, bathing, going to the bathroom, managing steps at home and getting in and out of a car.
You will be able to leave the hospital when you are:
LIFE AFTER SURGERY
These guidelines give you an overview of what you may expect as part of your care after you leave the hospital. Be sure to follow your doctor’s discharge instructions if they are different from what is listed here.
Pulmonary rehabilitation usually begins within the first 4 to 6 weeks after surgery, and is a very important part of your recovery.
Many of these side effects usually disappear in four to six weeks, but a full recovery may take a few months or more. The patient is usually enrolled in a physician-supervised program of cardiac and pulmonary rehabilitation. This program teaches stress management techniques and other important lessons (e.g., about diet and exercise) and helps people rebuild their strength and confidence.
Patients are often advised to eat less fat and cholesterol and to walk or do other physical activity to help regain strength.
Doctors also often recommend following a home routine of increasing activity- doing light housework, going out, visiting friends, climbing stairs. The goal is to return to a normal, active lifestyle.
Most people with sedentary office jobs can return to work in four to six weeks. Those with physically demanding jobs will have to wait longer. In some cases they may have to find other employment.
Lifting and Reaching
If your surgery required an incision on your sternum (breastbone), it will take about 6-8 weeks for your sternum to heal. During this time, you may do light household chores, such as laundry, shopping, cooking, light gardening, dusting, and washing dishes when you feel up to it.
Do not lift, push or pull objects heavier than 5 pounds until your doctor says it is okay to do so.
Try not to stand in one place for longer than 15 minutes. Do not sit for more than an hour; take a break for a few minutes and walk around or move your legs.
You may do light, quick activities where your arms are above your shoulders, such as brushing your hair. But do not do any activities where your arms are above shoulder level for a long time, such as washing a window or dusting a high shelf. Do not do any activity that causes pain or pulling across your chest.
To get the most out of your day, plan to do the most important activities first. Don't try to do everything at once, and schedule unfinished activities for another day. Make sure that you get plenty of rest in between activities.
Climbing Stairs and Steps
Unless restricted by your doctor, it's okay for you to climb stairs and steps. Because you may be off-balanced after surgery, be careful and hold the handrail when walking up and down stairs. If you need to, stop and rest before you finish walking up or down a full flight. Try not to use the stairs immediately after surgery, and try to plan your activities so that you use the stairs only when necessary.
Fatigue is probably the number one patient complaint following surgery. Fatigue results from an extended lack of sleep while in the hospital, energy used by your body to heal its wounds, and energy used to fight off pain. To combat fatigue, listen to what your body is telling you. Space your activities to allow for rest periods. Take plenty of naps, walk regularly, eat well, and use your pain medication as needed. It's important that you rest and get a good night's sleep. Even if it's early in the night, if you feel tired, go to bed.
Driving and Riding in a Car
You should not drive for 3-4 weeks from the date of your surgery or while you are still taking narcotic pain pills. During this time your reaction time may be dulled, and if an incision was made on your sternum, your breastbone will still be healing. You may be a passenger in a car at any time. Make sure to wear your seat belt. You may cushion your incision with a soft towel or pillow.
Returning to Work
Returning to work depends upon the type of work you do and your energy level. It usually takes 4-6 weeks before most patients feel they have returned to their full energy level. The decision to return to work should be made jointly between you and your surgeon. You may want to consider working half days at first.
Delay vacations or extended trips away from home for approximately 2-3 weeks, or until after the first post operative visit with your surgeon. Avoid air travel for two weeks from the date of your discharge. This restriction is designed to prevent you from being too far away from your surgeon should a problem arise.
Your surgeon will advise you accordingly.
Proper exercise will help your healing and recovery, as well as increase your stamina, maintain your ideal weight by burning calories, and lower stress in your everyday life.
Tips for exercising:
Along with exercise, eating healthy will speed up your recovery and healing. If your appetite is poor, try to eat smaller but more frequent meals.
Depending on your condition, your doctor or dietician may put you on a special diet. For example, patients with heart failure must follow a 2,000 mg low-sodium diet. Diabetic patients must follow a low-sugar, low-fat diet.
Tips to healthy eating:
Poor Appetite and Nausea
Many patients lose weight in the postoperative period. They complain of lack of appetite and mild nausea. Certain medications such as pain pills may cause nausea. Try eating small frequent amounts of food, and take medications on a full stomach unless otherwise directed. If you continue to experience nausea or lack of appetite, call your primary physician.
Constipation is due to inactivity, limited fluid intake and lack of dietary fiber. It is aggravated by medications such as pain pills and iron. Eating plenty of fiber and fresh fruits, drinking 6-8 glasses of water daily and using your prescribed stool softener (Colace) as instructed can usually relieve constipation. If this does not work, Milk of Magnesia or Dulcolax may be helpful. Avoid Milk of Magnesia if you have kidney problems.
Your total calories may be changed to increase, decrease, or maintain your weight as necessary. Being overweight increases the work of the heart. Your drug therapy may cause you to be hungry, you may eat more, and you may then gain weight. It is, therefore, very important that you pay attention to the total amount of food you take in. In addition to adding to the work of your heart, being overweight is associated with high levels of Triglycerides (fats) in the blood stream. Having a lot of fats in your blood increases the possibility of having the blood vessels of your heart become thickened. This will be described in more detail in the section on cholesterol and fats that follows.
Cholesterol and Saturated Fat Restriction
Cholesterol is a necessary fatty substance found in the body and many animal foods. Fats are concentrated sources of energy which occur in three forms: polyunsaturated, monounsaturated, and saturated. People who have large amounts of cholesterol and saturated fats in their blood are at increased risk of having thickening of their blood vessels throughout their bodies. This is because saturated fats and cholesterol in your blood will gather along the walls of your blood vessels causing them to narrow. If this narrowing becomes severe in the blood vessels of your heart, the blood supply to your heart will not get enough oxygen, and the cells of your heart will die. This is called "Coronary Artery Disease."
In addition to your diet, your medications may also increase the level of fats in your blood. Thus, in order to prevent coronary artery disease, your overall fat intake must be restricted after surgery. Generally, your overall fat intake should not be more than 30% of your total calories each day. Increasing the proportion of monounsaturated and polyunsaturated fat in your diet and decreasing your total saturated fat intake to less than 10% of your total fat intake will actually help to lower cholesterol and saturated fat levels in your blood. The aim of this diet is to keep the levels of fats in your blood within normal limits.