title: Awake thoracoscopic bullaplasty.
abstract: OBJECTIVE
  Staple excision of emphysematous bullae through general anesthesia is the standard surgical treatment of bullous emphysema. We have developed a new surgical technique entailing thoracoscopic bullaplasty performed in fully awake patients through sole epidural anesthesia.
  
  
  METHODS
  This prospective nonrandomized trial included 35 patients undergoing awake thoracoscopic bullaplasty between 2002 and 2009. Preoperative work-up included computed tomography with algorithm for quantitative measurement of the bulla volume. Outcome measures included patient's satisfaction with the anesthesia, scored into four grades (1=unsatisfactory; 4=excellent); ratio of arterial oxygen tension to fraction of inspired oxygen (PaO(2)/FiO(2)), and postoperative assessment of standard clinical measures at 6, 12, and 36 months.
  
  
  RESULTS
  There were 29 men and six women with a median age of 60 years. Median volume of the bulla was 688 ml. Awake bullaplasty was successfully completed in 34 patients. Perioperatively, PaO(2)/FiAO(2) decreased significantly (analysis of variance (ANOVA), P<0.0001) though remaining satisfactory (>300 mmHg), whereas PaCO(2) increased intraoperatively (ANOVA, P<0.0001) but returned to baseline values 1h after surgery (P=0.20). There was no mortality; four patients had air leaks longer than 7 days. Mean hospital stay was 4.9 ± 2.2 days. Comparisons between pre- to 6-month changes in outcome measures showed improvements (P<0.0001) in forced expiratory volume in 1s (FEV(1)) (+0.37 l), residual volume (-1.16 l), dyspnea index (-2), and standard 6-min walk test (SMWT) (+71 m). These improvements lasted for up to 36 months and in no patient did operated bullae recur.
  
  
  CONCLUSIONS
  Our study suggests that awake thoracoscopic bullaplasty was well tolerated and easily performed in the majority of the patients, and significant clinical improvements lasted for up to 36 months.
authors.affiliation: Department of Thoracic Surgery & Emphysema Center, Policlinico Tor Vergata University, Rome, Italy. pompeo@med.uniroma2.it
authors.forename: Eugenio
authors.initials: E
authors.lastname: Pompeo
authors.forename: Federico
authors.initials: F
authors.lastname: Tacconi
authors.forename: Luca
authors.initials: L
authors.lastname: Frasca
authors.forename: Tommaso C
authors.initials: TC
authors.lastname: Mineo
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000767:Anesthesia, Epidural / Q000379:methods; D001768:Blister / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery; D002245:Carbon Dioxide / Q000097:blood; D005260:Female; D005541:Forced Expiratory Volume / Q000502:physiology; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D010100:Oxygen / Q000097:blood; D010313:Partial Pressure; D011446:Prospective Studies; D011656:Pulmonary Emphysema / Q000000981:diagnostic imaging / Q000503:physiopathology / Q000601:surgery*; D011859:Radiography; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D002245:Carbon Dioxide; D010100:Oxygen