Interact CardioVasc Thorac Surg 2008;7:1011-1014. doi:10.1510/icvts.2008.181255
© 2008 European Association of Cardio-Thoracic Surgery
Institutional report - Thoracic general |
Changes in ventilatory capacity, exercise capacity, and pulmonary blood flow after lobectomy in patients with lung cancer – which lobectomy has the most loss in exercise capacity?
Keiji Kushibe*,
Takeshi Kawaguchi,
Michitaka Kimura,
Makoto Takahama,
Takashi Tojo and
Shigeki Taniguchi
Department of Thoracic and Cardiovascular Surgery, Nara Medical University School of Medicine, Kashihara, Nara, Japan, 634-8522
Received 4 April 2008;
received in revised form 28 May 2008;
accepted 21 July 2008
 Presented at the 16th European Conference on General Thoracic Surgery, Bologna, Italy, June 8–11, 2008.
Corresponding author. Tel.: +81-744-22-3051; fax: +81-744-24-8040.
E-mail address: mdkeiji{at}m3.kcn.ne.jp (K. Kushibe).
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Abstract
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The aim of this study was to compare the changes in ventilatory capacity, exercise capacity, and pulmonary blood flow (PBF) in the operated lung after lobectomy according to the lobe resected. Thirty-one patients underwent right upper lobectomy (RUL), 26 left upper lobectomy (LUL), 24 right lower lobectomy (RLL), and 25 left lower lobectomy (LLL). Pulmonary function tests, exercise capacity tests, and perfusion lung scans were performed preoperatively and six months to one year after lobectomy. RUL was associated with significantly less loss in forced vital capacity (FVC) than RLL or LLL (P<0.05). LUL was associated with the greatest loss in maximum oxygen consumption  (P<0.05). LUL was associated with significantly greater loss in PBF in the operated lung than RUL (P<0.05). LUL had a significantly higher negative value in percentage change in  – percentage change in FVC, and percentage change in PBF – percentage change in FVC than RLL or LLL (P<0.05). LUL was not associated with the greatest loss in ventilatory capacity or PBF, although it was associated with the greatest loss in . Each lobectomy has its own peculiarity in magnitude of loss in , PBF or FVC.
Key Words: Lobectomy; Ventilatory capacity; Exercise capacity; Pulmonary blood flow
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1. Introduction
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Change in exercise capacity after major lung resection is an important measure of postoperative quality of life. Several authors have reported on changes in ventilatory capacity and exercise capacity after major lung resections, including lobectomy [1–4]. However, no previous studies have evaluated the changes in ventilatory capacity or exercise capacity after lung resection according to the resected lobe.
Maximum oxygen consumption , exercise capacity is a function of blood flow and oxygen extraction by the tissue and can be influenced by a number of factors affecting the cardiovascular, respiratory, and musculoskeletal systems [5]. As there is a loss in both ventilatory capacity and pulmonary blood flow (PBF) after lung resection [6], change in exercise capacity after lobectomy seems to have a relationship with change in ventilatory capacity and PBF in the operated lung. However, no previous studies have reported on change in PBF in the operated lung after lobectomy.
The aim of this study was to compare the changes in ventilatory capacity, exercise capacity, and PBF in the operated lung after lung lobectomy according to the lobe resected, and to clarify which lobectomy is associated with the greatest loss in exercise capacity.
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2. Materials and methods
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We retrospectively reviewed 172 patients who underwent lobectomy for non-small cell lung cancer at Nara Medical University Hospital from January 2004 to August 2006. One hundred and sixty-two consecutive patients underwent preoperative evaluation which consisted of pulmonary function tests, exercise tests, and lung perfusion scans. One patient could not perform preoperative exercise test for severe limiting musculoskeletal disorders, and nine patients did not undergo preoperative exercise tests or lung perfusion scans because informed consent for the tests could not be obtained. All patients underwent posterolateral thoracotomy sparing serratus anterior muscle. The inferior pulmonary ligament was not divided. Of these 162 patients, 153 were re-evaluated six months to one year after lobectomy. Nine patients could not be re-evaluated for the following reasons: two died within 30 days after surgery because of postoperative complications; three had progressive metastatic disease and could not take exercise tests; and four could not be contacted six months to one year after surgery. Exclusion criteria were right middle lobectomy (n=5), failure to quit smoking postoperatively (n=1), receipt of adjuvant chemotherapy or radiotherapy (n=14), or severe pulmonary complications (n=3). We also excluded patients with preoperative segmental or lobar atelectasis (n=7), or a tumor more than 4 cm in diameter (n=16) because lack of function of the resected lung tissue was not necessarily due to emphysemas. We also excluded one patient who had markedly impaired pulmonary function after lobectomy, with weaker function than expected, due to severe narrowing of the orifice of left lower lobe bronchus on bronchoscopy. Finally, 106 patients were enrolled in this study.
Pulmonary function tests and exercise tests were performed on the same day before surgery and six months to one year after surgery. The mean time interval between lobectomy and postoperative evaluation of pulmonary function and exercise tests was 7.9±1.9 months. Exercise capacity was determined by an incremental exercise test on a cycle ergometer with breath-by-breath analysis of gas exchange (MMC 4400tc; Sensormedics Corporation; Anaheim, CA, USA). The exercise protocol consisted of a 10–15-W ramped increase work every minute until the patient could not continue because of severe dyspnea or leg discomfort. The patient's heart rate, ECG, and oxygen saturation were monitored during the exercise study. Continuous measurements of minute ventilation  , oxygen consumption  , and carbon dioxide production  were averaged every 15 s. Maximum oxygen consumption and maximum minute ventilation  were defined as the highest  and  , respectively, achieved during the exercise test. No specific postoperative rehabilitation program was provided.
Lung perfusion scans were performed by intravenous injection of 150 mBq 99mTc-labeled macroaggregates of albumin. Perfusion scan views were obtained in the sitting position in four projections (anterior, posterior, left posterior oblique and right posterior oblique) with 5x105 counts per image each on a one-head gamma camera (Diacam; Siemens, Erlangen, Germany). Quantification was performed using the system-integrated region-ratio program in anterior and posterior projections for right-left lung quantification (geometric mean). The radioactivity in the operated side of the lung was expressed as a percentage of the operated side to the total lung activity. Change in PBF was assessed by loss in radioactivity in the operated side of the lung obtained from lung perfusion scans. The ratio of radioactivity in the operated lung before lobectomy – loss in radioactivity caused by lobectomy to radioactivity in the non-operated lung before lobectomy is equal to that of radioactivity in the operated lung after lobectomy to radioactivity in non-operated lung after lobectomy, i.e.:
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A; percentage of radioactivity in the operated lung before lobectomy
B; percentage of radioactivity in the operated lung after lobectomy
C; percentage loss in radioactivity in the operated lung caused by lobectomy
We calculated the percentage loss in radioactivity in the operated lung (C) by using the formula (#) as stated above, i.e.:
The mean time interval between lobectomy and postoperative lung perfusion scan was 8.0±1.8 months. All descriptive statistics were expressed as mean±S.D. for continuous variables. A probability value of <0.05 was accepted as statistically significant. Statistical analysis was performed using the statistical software Statview 5.0 (SAS Inc., Cary, NC, USA).
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3. Results
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Thirty-one patients underwent right upper lobectomy (RUL), 26 left upper lobectomy (LUL), 24 right lower lobectomy (RLL), and 25 left lower lobectomy (LLL). Patient characteristics are shown in Table 1.
Table 2 shows percentage change in pulmonary function, exercise capacity, and PBF in the operated lung after lobectomy. With regard to the change in pulmonary function, the RUL group had significantly less loss in forced vital capacity (FVC) than the RLL or LLL group (P<0.05). With regard to the change in exercise capacity, LUL was associated with the greatest loss in (P<0.05). In addition, the LUL group had significantly more loss in workload than the RUL or RLL groups (P<0.05). LUL was associated with significantly greater loss in PBF in the operated lung than RUL (P<0.05).
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Table 2 Percent change in pulmonary function, exercise capacity, and pulmonary blood flow in the operated lung after lobectomy
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We compared the differences between the percentage changes in (% ), FVC (%FVC), and PBF (%PBF) in the operated lung according to resected lung lobe (Table 3). In % – %FVC, the LUL group had a significantly higher negative value than the RLL or LLL groups (P<0.05). In % – %PBF, there was no significant difference between the four groups. In %PBF – %FVC, the LUL group had a significantly higher negative value than the RLL or LLL group (P<0.05).
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Table 3 Differences between percent change in , percent change in FVC, and percent change in pulmonary blood flow in the operated lung
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4. Discussion
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Several authors have reported on changes in exercise capacity after lobectomy or pneumonectomy [1–4]. The functional loss in after lobectomy and pneumonectomy has been reported to vary from 0% to 13% and from 20% to 28%, respectively [1–4]. The functional loss in workload after lobectomy and pneumonectomy has been reported to vary from 0% to 12% and from 15% to 42%, respectively [1–4]. However, no previous studies have evaluated changes in exercise capacity after lung resection according to the lobe resected. We found that LUL was associated with the greatest loss in (P<0.05) and with significantly greater loss in workload than RUL or RLL (P<0.05).
, exercise capacity is a function of blood flow and oxygen extraction by the tissue and can be influenced by a number of factors affecting the cardiovascular, respiratory, and musculoskeletal systems [5]. As lung resection is associated with losses in both ventilatory capacity and PBF [6], change in exercise capacity after lobectomy seems to have a relationship with change in ventilatory capacity and PBF. Furthermore, we evaluated the changes in ventilatory capacity and PBF in the operated lung after lung resection according to the lobe resected. However, LUL was not associated with the greatest loss in ventilatory capacity or PBF, although it was associated with the greatest loss in . Change in exercise capacity does not have a strong relationship with change in ventilatory capacity or PBF in the operated lung after lobectomy. Pelletier et al. found that change in pulmonary function was a poor predictor of change in exercise capacity after lung resection [1]. Larsen et al. also showed that there was only a weak correlation between changes in spirometric variables and changes in exercise variables [3].
We evaluated the differences between %, %FVC, and %PBF according to the lobe resected. LUL was associated with significantly higher negative values in both % – %FVC and %PBF – %FVC than RLL or LLL. LUL was associated with a greater magnitude of loss in or PBF in the operated lung than of loss in FVC compared with RLL or LLL. In other words, each lobectomy had its own peculiarity in magnitude of loss in , PBF in the operated lung or FVC.
Bobbio et al. showed that ventilatory capacity in patients with chronic obstructive pulmonary disease (COPD) after lobectomy was not significantly altered, whereas the was not significantly reduced [7]. Recent studies show that selected patients with COPD have improvement in ventilatory capacity and exercise capacity after lobectomy [8, 9]. Improvement in exercise capacity after lobectomy for those patients would be due to improvement in ventiratory capacity and ventilation-perfusion matching. In this study, there was no significant difference in the rate of COPD patients among the sites of lobectomy. So, it was not due to the difference in the rate of COPD patients for LUL to be associated with a greater magnitude of loss in .
Why would LUL be associated with a greater magnitude of loss in or PBF in the operated lung than in FVC compared with RLL or LLL? A narrowing of the orifice of lower or middle lobe bronchus has sometimes been identified after upper lobectomy [10]. After LUL, we encountered one patient with strongly impaired pulmonary function, which was greater than expected, due to severe narrowing of the orifice of left lower lobe bronchus. Although we excluded this patient in this study, such anatomic feature with which LUL might be associated to some extent influence the magnitude of loss in or PBF in the operated lung.
Barker demonstrated that all patients undergoing upper lobectomy had anterior and apical residual air spaces to some extent [11]. As the left upper lobe has a greater volume of lung parenchyma compared with the right upper lobe, LUL would have a greater volume of residual air space. Furthermore, upper lobectomy would increase the risk of air leak due to poor visceral-parietal pleural apposition [12, 13]. These features of LUL might also influence the magnitude of loss in or PBF in the operated lung.
Diffusing capacity of the lung for carbon monoxide (DLco) is sensitive to detect emphysema and a reduced pulmonary capillary bed. Ferguson et al. showed that DLco was a strong predictor of mortality [14]. Wang et al. have reported that the increase in DLco during exercise was the most conservative testing parameter in estimating functional loss [15]. Unfortunately, we measured DLco in a few patients, and could not compare the changes in FVC, DLco, , and PBF.
In conclusion, this small, retrospective study suggests LUL was associated with the greatest loss in exercise capacity after surgery, and that each lobectomy had its own peculiarity in magnitude of loss in , PBF in the operated lung, or FVC. A large prospective study could confirm these findings, and knowledge of this functional change in exercise capacity according to the resected lobe is useful for preoperative counseling.
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Abstract
1. Introduction
