Original Articles
Morphologic Grading of the Emphysematous Lung and Its Relation to Improvement After Lung Volume Reduction Surgery

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Abstract

Background. The morphologic criteria for lung volume reduction surgery, such as severity and heterogeneity of disease, differ widely between patients, and this makes any comparison of functional results between centers difficult. Here we present a morphologic scoring system and describe its possible relation to functional results after lung volume reduction operations.

Methods. Between September 1994 and December 1996, 47 consecutive patients underwent bilateral lung volume reduction operations. The morphology of emphysema was quantified with standard chest roentgenograms and computed tomographic imaging, which were used to define the following four variables: degree of hyperinflation (grade 0 to 4), degree of impairment in diaphragmatic mechanics, degree of heterogeneity (grade 0 to 4), and severity of parenchymal destruction (range, 0 to 48).

Results. All four variables showed good reproducibility. Degree of heterogeneity had a significant influence on functional improvement in terms of forced expiratory volume in 1 second (p = 0.0413, r2 = 0.11). Severity of parenchymal destruction was significantly associated with 30-day mortality: patients who died after operation (n = 4) had a severity of parenchymal destruction of 28.4 ± 2.1 compared with 21.3 ± 1.0 for those who survived (n = 43) (p = 0.003).

Conclusions. This morphologic scoring system is easy to use, is reproducible, and allows quantification of the morphology of emphysema, thereby allowing definition of different patient subgroups. Such an exact morphologic quantification may help in the comparison of functional results between centers. Furthermore, the risk factors for certain morphologic subgroups, such as patients with a homogeneous distribution pattern, may be clarified in the future.

Section snippets

Design

The study comprised 47 consecutive patients (27 men and 20 women with a mean age of 55.9 ± 1.4 years; range, 38 to 75 years) who underwent bilateral LVRS between September 1994 and December 1996. The first 15 patients underwent operation through a median sternotomy, and the remaining 32 patients, by a videoendoscopic approach. In 5 patients, conversion from a videoendoscopic approach to a thoracotomy was necessary because of multiple adhesions. The operative procedure was performed as described

Morphologic Assessment

The DHI, DIDM, DHG, and SPD data are summarized in Table 1, Table 2. The DHI showed good interobserver agreement (weighted kappa = 0.687, 0.712, and 0.752 for the three readers). A similar agreement was observed for the DHG (weighted kappa = 0.682, 0.539, and 0.785, respectively). The interobserver differences for the SPD were also small. Of the differences in the scores between the readers, 97.9% were within the ±3 interval.

The distribution types were as follows: homogeneous, 15 patients

Comment

Lung volume reduction surgery has been introduced to treat patients with diffuse nonbullous emphysema 7, 8. Several reports 1, 9, 10, 11, 12, 13have demonstrated its beneficial effects on lung function and on chest wall mechanics as well. However, the reported range of improvement in lung function variables, especially FEV1, varies widely. In part, this is due to the application of different surgical techniques (eg, unilateral versus bilateral reduction) and, in part, to different patient

Acknowledgements

We acknowledge the contributions of Marlene Thiem, RTA, and Sylvia Kiss, RTA, for their extra efforts computing the regions of interest in the CT scans.

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Copyright © 1998 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.