ICVTS Click here to goto Smart Canula website
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Interact CardioVasc Thorac Surg 2009;8:529-533. doi:10.1510/icvts.2008.196303
© 2009 European Association of Cardio-Thoracic Surgery
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Takashi Tojo
Shigeki Taniguchi
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kushibe, K.
Right arrow Articles by Taniguchi, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kushibe, K.
Right arrow Articles by Taniguchi, S.

Institutional report - Thoracic non-oncologic

Influence of the site of lobectomy and chronic obstructive pulmonary disease on pulmonary function: a follow-up analysis

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, 634-8522, Japan

Received 10 October 2008; received in revised form 5 January 2009; accepted 21 January 2009

*Corresponding author. Tel.: +81-744-22-3051; fax: +81-744-24-8040.

E-mail address: mdkeiji{at}m3.kcn.ne.jp (K. Kushibe).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Comments
 References
 
The aim of this retrospective study was to evaluate the influence of the site of lobectomy and the presence of chronic obstructive pulmonary disease (COPD) on pulmonary function at different postoperative periods. The patients were divided into groups of COPD and non-COPD patients, and the differences between observed and predicted postoperative values of pulmonary function at different evaluation times according to the resected lobe were assessed. The observed postoperative percentage change in FEV1 (opo%{Delta}FEV1) – predicted postoperative percentage change in FEV1 (ppo%{Delta}FEV1) one month and six months after right upper lobectomy or left upper lobectomy in COPD patients was of significantly higher positive value than in non-COPD patients. In non-COPD patients, opo%{Delta}FEV1 – ppo%{Delta}FEV1 one month and six months after surgery was of significantly higher negative value in those who had right upper lobectomy than in those who had right lower lobectomy or left lower lobectomy (P<0.05). COPD may strongly influence pulmonary function at early- and late-terms after upper lobectomy. In non-COPD patients, the site of lobectomy may strongly influence pulmonary function at early- and late-terms after surgery.

Key Words: Chronic obstructive pulmonary disease; Lobectomy; Predicted postoperative pulmonary function; Observed postoperative pulmonary function; Postoperative period


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Comments
 References
 
Pulmonary function after major lung resection plays an important role in postoperative quality of life [1, 2]. Previous studies showed that predicted values of pulmonary function after major lung resection correlate well with those observed several months after surgery [1–5]. Meanwhile, several studies have shown discordance between observed and predicted values of pulmonary function at the early-term after lobectomy [6–8].

Furthermore, a recent study showed that the postsurgical observed values in patients who had lower lobectomy and chronic obstructive pulmonary disease (COPD) are better preserved than predicted [9–12]. The site of lobectomy [12, 13] and presence of COPD [9–12] are considered to influence postoperative pulmonary function. However, little information can be found concerning the influence of the site of lobectomy and the presence of COPD on pulmonary function at different times after lobectomy.

The aim of this study was to investigate the influence of the site of lobectomy and presence of COPD on pulmonary function at different postoperative periods. We divided our patients into COPD and non-COPD groups and retrospectively investigated pulmonary function one month and six months after lung resection according to the lobe resected. In addition, we evaluated the differences between the observed and predicted postoperative values of pulmonary function.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Comments
 References
 
We retrospectively reviewed the medical records of 258 patients who underwent lobectomy for non-small cell lung cancer at Nara Medical University Hospital from January 2004 to June 2007. Exclusion criteria were right middle lobectomy (n=12), failure to quit smoking postoperatively (n=1), receipt of adjuvant chemotherapy or radiotherapy (n=34), and postoperative severe pulmonary complications (n=4). The total number of eligible patients was 207.

Pulmonary function tests were performed before surgery and one month and six months after surgery. Postoperative pulmonary function data were not available in 21 patients for the following reasons; four died within 30 days after surgery, four had progressive metastatic disease, and 13 were unable to be contacted one month or six months after surgery.

The final analysis included 186 patients. The patients were divided into a COPD group (n=53) and a non-COPD group (n=133) according to the Global Initiative on Obstructive Lung Disease guidelines (Table 1). Predicted postoperative forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were calculated based on the number of functioning/unobstructed segments to be resected during surgery, in keeping with the British Thoracic Society recommendation [14]. The number of functioning/unobstructed segments was estimated by means of computed tomographic scan and bronchoscopy. We compared the differences between observed and predicted postoperative values of pulmonary function at different evaluation times in the COPD and non-COPD groups. As a rule, we don't need the IRB approval for the retrospective study at our institution. However, patients were fully informed about the nature of this study and all gave their informed consent for participation.


View this table:
[in this window]
[in a new window]

  		Table 1 Definition of COPD

 
All descriptive statistics were expressed as the mean±S.D. for continuous variables. A probability value of P<0.05 was accepted as statistically significant. Statistical analysis was performed using the statistical software, Statview 5.0 (SAS Inc, Cary, NC, USA). Univariate comparison was made between the groups by means of the Student's t-test (numerical variables) and the {chi}2-test (categorical variables). The Scheffé's F procedure (ANOVA test) was applied as a correction for multiple comparisons.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Comments
 References
 
There were 31 upper lobectomies (right upper lobectomy [RUL], n=16; left upper lobectomy [LUL], n=15), 22 lower lobectomies (right lower lobectomy [RLL], n=11; left lower lobectomy [LLL], n=11) in the COPD patients, and 70 upper lobectomies (RUL, n=35; LUL, n=35), 63 lower lobectomies (RLL, n=34; LLL n=29) in the non-COPD patients. The characteristics of the COPD and non-COPD patients are shown in Table 2.


View this table:
[in this window]
[in a new window]

  		Table 2 Characteristics of the COPD and non-COPD patients

 
Table 3 shows the percentage change in pulmonary function prior to surgery and after surgery at different evaluation times in the COPD and non-COPD patient groups. In both the COPD and non-COPD patients, all four lobectomy groups had a significant increase in the percentage change in pulmonary function six months after surgery compared with one month postoperatively (P<0.05).


View this table:
[in this window]
[in a new window]

  		Table 3 Percentage change in preoperative and postoperative pulmonary function at early and late evaluation times

 
We compared the differences between observed and predicted postoperative values of pulmonary function at different evaluation times in the COPD and non-COPD patients (Table 4). The observed postoperative percentage change in FVC (opo%{Delta}FVC) – predicted postoperative percentage in FVC (ppo%{Delta}FVC) one month after RUL or LUL was of a significantly higher positive value in the COPD patients than in non-COPD patients (P<0.05). The observed postoperative percentage change in FEV1 (opo%{Delta}FEV1) – predicted postoperative percentage in FEV1 (ppo%{Delta}FEV1) one month and six months after RUL or LUL was of a significantly higher positive value in COPD patients than in non-COPD patients (P<0.05).


View this table:
[in this window]
[in a new window]

  		Table 4 Comparison of differences between the observed and predicted postoperative pulmonary function at early and late evaluation times

 
When the site of lobectomy was compared in non-COPD patients, the opo%{Delta}FVC – ppo%{Delta}FVC one month after surgery in the RUL group was of a significantly higher negative value than in patients who had LUL, RLL, or LLL (P<0.05). In the non-COPD patients, the opo%{Delta}FEV1 – ppo%{Delta}FEV1 one month and six months after surgery was of a significantly higher negative value in patients who had RUL than in those who had RLL or LLL (P<0.05).


   4. Comments
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Comments
References
 
A number of studies have demonstrated a good correlation between predicted and observed values of pulmonary function after major lung resection [1–5]. However, most of these studies assessed pulmonary function 3–6 months after surgery and several studies have shown discordance between the observed and predicted values of pulmonary function at early-term after lobectomy [6–8]. We found that all four lobectomy groups in both COPD and non-COPD patients had a significant increase in percentage change in pulmonary function six months after surgery compared with one month after surgery. A new formula is needed to predict postoperative pulmonary function at early-term after lobectomy.

Several studies have recently reported that lobectomy in select patients with lung cancer and severe COPD was favored by no change or an improvement in postoperative pulmonary function [9–12], but little information can be found concerning the influence of COPD on pulmonary function at different times after lobectomy. Most studies assessed pulmonary function several months after lobectomy. With regard to pulmonary function at early-term after lobectomy in COPD patients, Sekine et al. showed that FEV1 one month after surgery was better preserved than predicted [12]. Brunelli et al. showed that COPD patients had a lower percentage loss of FEV1 than non-COPD patients one month after lobectomy [13]. We found that COPD patients had a significantly higher positive value for the opo%{Delta}FEV1 – ppo%{Delta}FEV1 one month and six months after RUL or LUL than the non-COPD patients. These results indicate that COPD could strongly influence FEV1 at both the early and late terms after upper lobectomy. Recent studies reported that lung volume reduction surgery (LVRS) offered a greater chance for improvement in pulmonary function in patients with predominately upper lobe emphysema compared with predominately non-upper lobe emphysema [15]. We suggested that the resection of emphysematous lung tissue in the upper lobectomy would provide the same favorable effect as LVRS in predominately upper lobe emphysema. This may explain why COPD may strongly influence FEV1 after upper lobectomy.

Concerning the influence of the site of lobectomy on postoperative pulmonary function, Sekine et al. reported that the observed values of FEV1 one month after surgery in patients who had a lower lobectomy are better preserved than predicted [12]. Brunelli et al. reported that, in patients having a lower lobectomy, maximum oxygen consumption at early-term after surgery tends to be better than predicted [13]. In the non-COPD patients, we found that the opo%{Delta}FEV1 – ppo%{Delta}FEV1 one month and six months after surgery in the RUL group had a significantly higher negative value than for those who had RLL or LLL. These results suggest that the site of lobectomy in the non-COPD patients may influence FEV1 strongly at both early and late terms after surgery. Sekine et al. suggested that a narrowing of the orifice of the lower or middle lobe bronchus has sometimes been identified after upper lobectomy. This anatomic feature associated with upper lobectomy might make a difference in the postoperative pulmonary function compared with a lower lobectomy [12]. We speculated that, in COPD patients, upper lobectomy would have greater volume reduction effect than lower lobectomy, and would have little influence on the decrease in postoperative pulmonary function due to the anatomic feature. In contrast, in non-COPD patients, right upper lobectomy would have a strong influence on the decrease in postoperative pulmonary function due to the anatomic feature.

The opo%{Delta}FVC – ppo%{Delta}FVC one month after RUL or LUL was of a significantly higher positive value in COPD patients than in non-COPD patients. In addition, we found that opo%{Delta}FVC – ppo%{Delta}FVC one month after surgery in the non-COPD patients who had RUL was of a significantly higher negative value than in those who had LUL, RLL, or LLL. We demonstrated that COPD could strongly influence FVC at early-term after upper lobectomy, and that the site of lobectomy in the non-COPD patient could influence FVC at early-term after surgery.

One question is why the site of lobectomy would influence FVC in non-COPD patients only at early-term after surgery? We suggest that the stenotic change in the residual bronchus after an upper lobectomy may slightly improve at late-term, and that the FVC would respond better to the improvement than FEV1. Additionally, why would COPD influence FVC only at early-term after upper lobectomy when this was not observed at late-term? Upper lobectomy would have greater volume reduction effect than lower lobectomy in COPD patients, and would have little influence on the decrease in postoperative pulmonary function due to the anatomic feature. In COPD patients, the observed FVC after upper lobectomy might be slightly better preserved than predicted. Moreover, because FVC would respond better to the improvement in the stenotic change after upper lobectomy in the non-COPD patients, FVC would not decrease due to the anatomic feature. This might explain why COPD may influence FVC only at early-term after upper lobectomy.

In this study, we demonstrated that COPD could strongly influence pulmonary function at both early- and late-terms after upper lobectomy, and that the site of lobectomy in non-COPD patients may strongly influence pulmonary function at both early- and late-terms after surgery. Although a large prospective study will be needed to confirm these findings, our results may be useful for improving the accuracy of predictions of postoperative pulmonary function and for preoperative counseling.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Comments
 References
 

  1. Ali KM, Mountain CF, Ewer MS, Johnson D, Haynie TP. Predicting loss of pulmonary function after pulmonary resection for bronchogenic carcinoma. Chest 1980;77:337–342.[CrossRef][Medline]
  2. Bolliger CT, Guckel C, Engel H, Stohr S, Wyser CP, Schoetzau A, Habicht J, Solèr M, Taum M, Perruchoud AP. Prediction of functional reserves after lung resection: comparison between quantitative computed tomography, scintigraphy, and anatomy. Respiration 2002;69:482–489.[CrossRef][Medline]
  3. Bria WF, Kanarek DJ, Kazemi H. Prediction of postoperative pulmonary function following thoracic operations. J Thorac Cardiovasc Surg 1983;86:186–192.[Abstract]
  4. Nakahara K, Monden Y, Ohno K, Miyoshi S, Maeda H. A method for predicting postoperative lung function and its relation to postoperative complications in patients with lung cancer. Ann Thorac Surg 1985;39:260–265.[Abstract]
  5. Zeiher BG, Gross TJ, Kern JA, Lanza LA, Peterson MW. Prediction postoperative pulmonary function in patients undergoing lung resection. Chest 1995;108:62–72.[CrossRef][Medline]
  6. Brunelli A, Sabbatini A, Xiumé F, Refai MA, Borri A, Salati M, Marasco RD, Fianchini A. A model to predict the decline of the forced expiratory volume in one second and the carbon monoxide lung capacity early after major lung resection. Interact CardioVasc Thorac Surg 2005;4:61–65.[Abstract/Free Full Text]
  7. Varela G, Brunelli A, Rocco G, Marasco R, Jiménez MF, Sciarra V, Aranda JL, Gatani T. Predicted versus observed FEV1 in the immediately postoperative period after pulmonary lobectomy. Eur J Cardiothoarc Surg 2006;30:644–648.[CrossRef]
  8. Brunelli A, Refai M, Salati M, Xiumé F, Babbatini A. Predicted versus observed FEV1 and DLco after major lung resection: a prospective evaluation at different postoperative periods. Ann Thorac Surg 2007;83:1134–1139.[Abstract/Free Full Text]
  9. Korst RJ, Ginsberg RJ, Ailawadi M, Bains MS, Burt ME, Downey RJ, Rusch VW, Stover D. Lobectomy improves ventilatory function in selected patients with severe COPD. Ann Thorac Surg 1998;66:898–902.[Abstract/Free Full Text]
  10. Edwards JG, Duthie DJR, Waller DA. Lobar volume reduction surgery: a method of increasing the lung cancer resection rate in patients with emphysema. Thorax 2001;56:791–795.[Abstract/Free Full Text]
  11. Subotic DR, Mandaric DV, Eminovic TM, Gajic MM, Mujovic NM, Atanasijadis ND, Dzeletovic PP, Andric LD, Bulajic BM, Dimitrijevic ID, Sobic D. Influence of chronic obstructive pulmonary disease on postoperative lung function and complications in patients undergoing operations for primary non-small cell lung cancer. J Thorac Cardiovasc Surg 2007;134:1292–1299.[Abstract/Free Full Text]
  12. Sekine Y, Iwata T, Chiyo M, Yasufuku K, Motohashi S, Yoshida S, Suzuki M, Iizawa T, Saitoh Y, Fujisawa T. Minimal alternation of pulmonary function after lobectomy in lung cancer patients with chronic obstructive pulmonary disease. Ann Thorac Surg 2003;76:356–362.[Abstract/Free Full Text]
  13. Brunelli A, Monteverde M, Borri A, Salati M, Refai MA, Fianchini A. Predicted versus observed maximum oxygen consumption early after lung resection. Ann Thorac Surg 2003;76:376–380.[Abstract/Free Full Text]
  14. British Thoracic Society, and the Society of Cardiothoracic Surgeons of Great Britain and Ireland Working Party. BTS guidelines: guidelines on the selection of patients with lung cancer for surgery. Thorax 2001;56:89–108.[Free Full Text]
  15. National Emphysema Treatment Trial Research Group. A randomized trial comparing lung volume reduction surgery with medical therapy for severe emphysema. N Engl J Med 2003;348:2059–2073.[Abstract/Free Full Text]




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Takashi Tojo
Shigeki Taniguchi
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kushibe, K.
Right arrow Articles by Taniguchi, S.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kushibe, K.
Right arrow Articles by Taniguchi, S.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS