Salvage surgery after failed endobronchial valve lung volume reduction: A stepwise approach

Area of Science:

• Pulmonology
• Thoracic Surgery
• Interventional Bronchoscopy

Background:

• Endoscopic lung volume reduction with endobronchial valves (LVRV) is effective for severe emphysema patients with minimal collateral ventilation (CV).
• Treatment failure occurs in approximately 10% of patients, potentially due to factors beyond CV assessment, such as pleural or parenchymal constraints.
• Limitations in the Chartis® evaluation may also contribute to suboptimal outcomes.

Purpose of the Study:

• To describe a stepwise surgical salvage strategy for patients with severe emphysema who did not achieve target lobe volume reduction (TLVR) after LVRV with endobronchial valves.
• To evaluate the efficacy of a sequential robot-assisted thoracoscopic approach in a patient with persistent lack of TLVR.

Main Methods:

• A patient with severe emphysema received endobronchial valves in the right upper lobe (RUL) but showed no TLVR after two bronchoscopic revisions.
• A sequential robot-assisted thoracoscopic surgery was performed, including complete adhesiolysis, intraoperative reventilation testing, and surgical fissure interruption.
• Lung volume reduction and functional parameters were assessed post-intervention.

Main Results:

• The surgical salvage strategy resulted in partial atelectasis of the RUL.
• At 3 months post-intervention, target lobe volume reduction (TLVR) reached 50.6%, indicating partial success.
• Clinically meaningful functional improvement was observed despite not fully achieving the initial volume reduction target.

Conclusions:

• A stepwise surgical salvage strategy combining adhesiolysis, reventilation testing, and fissure interruption can be a viable option for patients failing LVRV.
• This approach offers a potential therapeutic solution for refractory cases of severe emphysema after endobronchial valve treatment.
• Further investigation is warranted to establish the role of this sequential strategy in managing challenging LVRV outcomes.