P&S Journal: Winter 1996, Vol.16, No.1
Lung Reduction Surgery
Some emphysema patients are able to breathe easier thanks to Dr. Mark Ginsburg, assistant clinical professor of surgery and associate director of general thoracic surgery. For the estimated 1.93 million Americans afflicted with emphysema, the simple function of breathing becomes increasingly difficult until each breath is a laborious chore. As the disease progresses, patients can no longer engage in even minor physical activities, and they eventually become dependent on supplemental oxygen.
Currently, the only treatment physicians can offer emphysema patients is palliative: bronchodilators, steroids, and oxygen. Some younger patients (under age 65) may be candidates for lung transplants.
In 1994, Dr. Ginsburg became one of a few surgeons in the country to use a new surgical technique to remove damaged portions of emphysema patients' lungs, thus improving lung function and quality of life for many patients. The technique was first introduced in the 1950s by Dr. Otto Brantigan, a surgeon at the University of Maryland, but the mortality rate was unacceptably high. It was resurrected in 1993 by Dr. Joel D. Cooper at Washington University School of Medicine in St. Louis with modern diagnostic and surgical refinements. Dr. Ginsburg has made advancements in the technique and plans to expand its use to higher risk patients.
Emphysema, which develops primarily as a result of smoking, causes the walls between the lung's air sacs to break down. As the air sacs become unnaturally enlarged, elasticity of the lung tissue is lost, which prevents the lungs from expanding and contracting normally. As emphysema progresses, lungs gradually enlarge, crowding the chest cavity and flattening the diaphragm.
The surgery excises 20 percent to 40 percent of the patient's lung volume, resulting in improved ventilation. By reducing the volume of hyperinflated lung and removing portions with poor circulation, patients experience increased exercise tolerance and decreased dyspnea, and many are able to discontinue use of oxygen.
John C. Giattino, one of Dr. Ginsburg's patients, swears by the operation. Diagnosed with emphysema 13 years ago, 70-year-old Mr. Giattino slowed down to the point where he gasped for air after a short walk. When he realized he was reading 15 books a month because he didn't have the energy to do anything else, Mr. Giattino was ready to try something radical. Told that he had three to 18 months to live and that oxygen therapy would be permanent, he overcame his fear of surgery and allowed Dr. Ginsburg to perform lung reduction surgery in March 1995.
When Dr. Ginsburg checked on his patient immediately following surgery, he found Mr. Giattino sitting in a chair singing "My Funny Valentine" to his wife. "I was so happy to be able to breathe, I walked around the hospital singing to everyone," says Mr. Giattino. He still reads books, but now he is able to drive a car, shower by himself, walk, and-his favorite activity of all-sing!
Dr. Ginsburg reports a success rate of 85 percent to 90 percent-defined as survival and improvement in quality of life-in the 55 patients who have had lung reduction surgery at CPMC. It's too early to tell whether the procedure will prolong life over the long term, but many of these patients have been able to stop oxygen therapy and steroids.
One of the modifications Dr. Ginsburg has made to the surgical procedure is the incision. Based on a cardiac surgery incision developed in the 1950s, the technique involves cutting across the front of the chest, across the rib cage. "This bilateral thoracosternotomy provides excellent access to the chest and less morbidity and allows the procedure to be performed in patients with osteoporosis for whom a sternotomy is risky," says Dr. Ginsburg. Patients with a history of smoking are highly susceptible to developing osteoporosis.
Dr. Ginsburg emphasizes that this surgery is a team effort among several disciplines, including pulmonary medicine, thoracic surgery, anesthesia, physical and respiratory therapy, critical care medicine, nursing, and radiology.
The surgery does not cure emphysema. However, if early success is predictive of long-term benefit, the surgery may prolong patients' lives and may become an alternative to lung transplantation or a bridge to transplantation. Patients like Mr. Giattino are just grateful for a renewed sense of vitality.