title: Repeated lung volume reduction surgery is successful in selected patients.
abstract: OBJECTIVE
  Lung volume reduction surgery (LVRS) improves dyspnoea, quality of life and may even prolong survival in carefully selected patients with end-stage emphysema. The benefit may be sustained for several years and vanishes with the natural progression of the disease. Data on repeated surgical treatment of emphysema are scarce. The aim of this study was to evaluate the safety, effects and outcomes of repeated LVRS (Re-LVRS) in patients no longer benefiting from their initial LVRS.
  
  
  METHODS
  Between June 2002 and December 2013, 22 patients (9 females) with advanced emphysema underwent Re-LVRS at a median of 60 months (25-196) after their initial LVRS. While initial LVRS was performed thoracoscopically as a bilateral procedure, Re-LVRS was performed unilaterally by a video-assisted thoracoscopic technique in 19 patients and, due to adhesions, by thoracotomy in 3 patients. Pulmonary function test (PFT) was performed at 3 and 12 months postoperatively.
  
  
  RESULTS
  Lung function at Re-LVRS was similar to that prior to the first LVRS. The 90-day mortality rate was 0%. The first patient died 15 months postoperatively. The median hospitalization time after Re-LVRS was significantly longer compared with the initial LVRS [14 days, interquartile range (IQR): 11-19, vs 9 days, IQR: 8-14; P = 0.017]. The most frequent complication was prolonged air leak with a median drainage time of 11 days (IQR: 6-13); reoperations due to persistent air leak were necessary in 7 patients (32%). Five patients (23%) had no complications. Lung function and Medical Research Council (MRC) score improved significantly for up to 12 months after Re-LVRS, with results similar to those after initial bilateral LVRS. The average increase in the forced expiratory volume in 1 s (FEV1) was 25% (a 7% increase over the predicted value or 0.18 l) at 3 months, and the mean reduction in hyperinflation, assessed by relative decrease in RV/TLC (residual volume/total lung capacity), was 12% at 3 months (a decrease of 8% in absolute ratios). The mean MRC breathlessness score decreased significantly after 3 months (from 3.7 to 2.2).
  
  
  CONCLUSIONS
  Re-LVRS can be performed successfully in carefully selected patients as a palliative treatment. It may be performed as a bridge to transplantation or in patients with newly diagnosed intrapulmonary nodules or during elective cardiac surgery. Morbidity is acceptable and outcomes may be satisfactory with significantly improved lung function and reduced dyspnoea for at least 12 months postoperatively.
authors.affiliation: Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland.
authors.forename: Arthur
authors.initials: A
authors.lastname: Kostron
authors.affiliation: Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland.
authors.forename: Michaela
authors.initials: M
authors.lastname: Horn-Tutic
authors.affiliation: Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland.
authors.forename: Daniel
authors.initials: D
authors.lastname: Franzen
authors.affiliation: Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland.
authors.forename: Peter
authors.initials: P
authors.lastname: Kestenholz
authors.affiliation: Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland.
authors.forename: Didier
authors.initials: D
authors.lastname: Schneiter
authors.affiliation: Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Opitz
authors.affiliation: Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland.
authors.forename: Malcolm
authors.initials: M
authors.lastname: Kohler
authors.affiliation: Department of Thoracic Surgery and Division of Pulmonology, University Hospital, Zurich, Switzerland walter.weder@usz.ch.
authors.forename: Walter
authors.initials: W
authors.lastname: Weder
mesh_terms: D000368:Aged; D005260:Female; D005541:Forced Expiratory Volume / Q000502:physiology; D006801:Humans; D008168:Lung / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009929:Organ Size; D011013:Pneumonectomy / Q000379:methods*; D011656:Pulmonary Emphysema / Q000601:surgery*; D012086:Reoperation; D012189:Retrospective Studies
keywords: End-stage pulmonary emphysema; Lung volume reduction; Lung volume reduction surgery; Reoperation