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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/].

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
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%
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
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. No difference between groups; individual values not reported
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)
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
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%
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
Brenner M, McKenna RJ, Jr., Gelb AF, Fischel RJ, Wilson AF. 1998 USA	May 1994 - July 1996 157 Unilateral LVRS - 46 VATS Laser - 111 VATS Staple 219 Bilateral LVRS - 21 VATS laser and staple - 184 VATS Staple - 14 Sternotomy and staple	Nonrandomised prospective, Level III	Improvement in FEV1 (%)	Bilateral Surgery: - 56± 4% (VATS + Staple) - 22±10% (VATS + Laser + Staple) - 41± 13% (Median Sternotomy + Staple) Unilateral Surgery - 15±9% (VATS + Laser) - 21± 3% (VATS + Staple) Bilateral Surgery: - 14.1% (VATS + Staple) - 35.7% (VATS + Laser + Staple) - 2.7% (Median Sternotomy + Staple) Unilateral Surgery - 17.3% (VATS + Laser) - 27.9% (VATS + Staple)
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
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%
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

Comment(s)

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.

Clinical 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

1. Clark SJ, Zoumot Z, Bamsey O, Polkey MI, Dusmet M, Lim E et al. Surgical approaches for lung volume reduction in emphysema. Clinical Medicine, Journal of the Royal College of Physicians of London 2014;14:122-27
2. Oey IF, Morgan MD, Spyt TJ, Waller DA. Staged bilateral lung volume reduction surgery - the benefits of a patient-led strategy. Eur J Cardiothorac Surg 2010;37:846-52.
3. 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 Eur J Cardiothorac Surg 2003;24:149-53; discussion 53
4. 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 Eur J Cardiothorac Surg 2002;22:610-4
5. 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. The Annals of thoracic surgery 2000;69:1670-4.
6. 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 The Annals of thoracic surgery 1999;68:2026-2
7. 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. J Thorac Cardiovasc Surg 1999;118:1101-9
8. Brenner M, McKenna RJ, Jr., Gelb AF, Fischel RJ, Wilson AF. Rate of FEV1 change following lung volume reduction surgery. Chest 1998;113:652-9.
9. 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. Chest 1998;113:890-5.
10. Argenziano M, Thomashow B, Jellen PA, Rose EA, Steinglass KM, Ginsburg ME et al. Functional comparison of unilateral versus bilateral lung volume reduction surgery. Annals of Thoracic Surgery 1997;64:321-27.
11. McKenna RJ, Jr., Brenner M, Fischel RJ, Gelb AF. Should lung volume reduction for emphysema be unilateral or bilateral? J Thorac Cardiovasc Surg 1996;112:1331-8; discussion 38-9.