Histopathologic Diagnosis Made in Lung Tissue Resected From Patients With Severe Emphysema Undergoing Lung Volume Reduction Surgery

doi:10.1378/chest.111.4.941

Chest

Volume 111, Issue 4, April 1997, Pages 941-947

https://doi.org/10.1378/chest.111.4.941 Get rights and content

Study objectives

This study reports histopathologic findings in a group of emphysema patients who underwent thoracoscopic lung volume reduction surgery (75) or sternotomy (five) with the purpose to induce functional improvement and relief of dyspnea. Immediate outcome and complications were correlated to histologic patterns.

Design

Histopathologic material obtained in lung volume reduction surgery in 80 consecutive patients was analyzed. Thirty patients who had other histopathologic diagnoses in addition to emphysema were grouped and compared with 50 patients found to have emphysema exclusively. Postoperative outcome and preoperative lung function variables were compared.

Measurements and results

All patients had severe obstructive lung disease and significant air trapping preoperatively documented by pulmonary function testing. All had severe exertional dyspnea. All had chest radiographs, CT, and nuclear medicine lung scans consistent only with emphysema. All portions of resected lung tissue were weighed, lung volume was estimated, and routine histopathologic studies were made. Thirty patients (37.5%) had unsuspected findings such as interstitial fibrosis, noncaseating granulomatosis, chronic inflammation, and unsuspected neoplasia (three carcinomas, one carcinoid). Retrospective review of imaging studies in these patients failed to show infiltrative processes. The average lung weight resected in this group was significantly heavier (65±18 g) compared with the other group (56±13 g), although both had the same estimated lung volume. Average number of days requiring chest tubes and length of hospitalization was also significantly higher (12.8±19 vs 6.4±5 days with chest tubes and 17.4±22 vs 8.5±6 days of hospitalization, respectively). None of the preoperative pulmonary function tests variables were different between the two groups. Serious postoperative complications were more frequent in these patients compared with those who showed only emphysema.

Conclusions

A significant portion of patients diagnosed as having severe emphysema will have other unsuspected histologic findings. When subjected to lung volume reduction surgery, this subgroup will have more serious complications and longer periods of air leaks, requiring longer hospitalization time. Retrospective review of imaging studies and preoperative pulmonary function tests used to select patients for lung volume reduction failed to identify this subgroup.

Section snippets

Patient Selection

All patients selected had a well-established clinical diagnosis of end-stage emphysema. All were receiving maximal medical therapy that included bronchodilator therapy, antibiotics, and corticosteroids when indicated, and most of the patients were receiving oxygen therapy. All patients subjected to surgery had participated in pulmonary rehabilitation for at least 6 weeks. This clinical research protocol was approved by the institutional review board for human studies at St. Louis University.

RESULTS

The main characteristics of the patients studied are listed in Table 1. The mean age was 62 years; nine subjects had α₁-antitrypsin deficiency-related emphysema. All patients had severe dyspnea preoperatively. The average baseline focal score was 3.26±1.7 and consistent with severe dyspnea during functional activities and while performing efforts and tasks common to daily life. Their PFT results showed severe obstructive lung disease with a mean FEV₁ <25% of normal, and with severe air trapping

DISCUSSION

Our results show that 37.5% of patients selected for lung volume reduction surgery with well-established diagnoses of emphysema by PFTs and imaging studies had other histologic findings in addition to emphysema. These findings were clinically relevant. Patients in this subgroup required longer time to seal postoperative airleaks, and remained hospitalized for a significantly longer time, showing tendency to develop serious complications more frequently than those found to have only emphysema.

CONCLUSION

Over one third of patients diagnosed as having severe emphysema undergoing lung volume reduction surgery were found to have unsuspected histologic findings in resected lung tissues. These findings were present despite preoperative screening, including chest radiographs and CT scans of the chest not showing infiltrative processes, and PFTs showing severe emphysema. In some instances, these findings had significant clinical relevance. Those patients showing histologic findings in addition to

ACKNOWLEDGMENTS

The authors would like to thank Gregg Ruppel, Med RRT, and Allan Hibbett, RRT, Pulmonary Function Laboratory, St. Louis University for assistance and collaboration in the evaluation of pulmonary function of the study group; and to Kelly Flynn for assistance in the preparation of this manuscript.

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Chest

Clinical Investigations: COPDHistopathologic Diagnosis Made in Lung Tissue Resected From Patients With Severe Emphysema Undergoing Lung Volume Reduction Surgery

Study objectives

Design

Measurements and results

Conclusions

Section snippets

Patient Selection

RESULTS

DISCUSSION

CONCLUSION

ACKNOWLEDGMENTS

Chest

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

Chest

Lung volume reduction surgery for severe emphysema

Semin Thorac Cardiovasc Surg

Clinical Investigations: COPD
Histopathologic Diagnosis Made in Lung Tissue Resected From Patients With Severe Emphysema Undergoing Lung Volume Reduction Surgery