THERE鈥橲 no better advert for an anti-smoking campaign than a patient with advanced emphysema. With up to 90 per cent of their lung tissue destroyed, such people are often too fragile to survive the traditional operations that might otherwise help them. But all that may be changing with the advent of less invasive surgical techniques that employ lasers and tiny video cameras, as well as the usual scalpel.
The intention behind the procedures remains the same: to remove dead tissue and reshape what lung remains so that it can function more normally. 鈥淚 don鈥檛 want to send out any messages of false hope, but no one鈥檚 calling this experimental any longer,鈥� says Alex Little, a thoracic surgeon at the University of Nevada. 鈥淲e鈥檙e looking for long-term results.鈥�
People who develop emphysema eventually find each breath a struggle. As the disease dismantles lung tissue, it leaves behind scarred sacs of air called bullae. The body struggles on with what tissue remains, but the bullae take up more and more room inside the patient鈥檚 chest. 鈥淭he lungs get so overinflated that you can鈥檛 take a breath,鈥� explains John Eugene, a thoracic and cardiovascular surgeon in Los Angeles, California. 鈥淎nd when you do, you can鈥檛 get it out.鈥�
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Eugene customises his approach to each case. First he combines data from X-rays, CT scans and other imaging methods with breathing tests to characterise the type and extent of damage. Large pockets of bullae generally mean opening the chest, cutting out the dead tissue, and perhaps stapling the edges of healthy lung back together. 鈥淏ut if the emphysema is diffuse, bullae are mixed in with healthy tissue, and we may use the laser,鈥� he says. 鈥淚f we can combine it with thoroscopy, that鈥檚 the least invasive and patients are getting up the next day.鈥�
In this procedure, called lung-reduction pneumenoplasty or LRP, the surgeon makes three small openings in the patient鈥檚 chest and inserts a miniature videocamera and a low-energy laser. He manoeuvres the instruments to the diseased regions of the lungs, where a television monitor pictures bullae as grey, membranous 鈥渂listers鈥� of air. Then the surgeon turns on the laser to burn them away.
鈥淭he theory has always been that functioning lung is not affected by radiation because it has normal blood flow, which cools it off and prevents damage,鈥� says Eugene, who has used the new technique in about 40 operations since early 1994. 鈥淒iseased lung, which has lost blood vessels, will respond by contracting and plicating, somewhat like a pleated skirt. It鈥檚 a thermal reaction.鈥�
LRP reduces the lung by about 25 per cent, which eases the overstretched chest wall and allows the diaphragm to return to its normal position.
鈥淢ore than 85 per cent of these patients can breathe better, can exercise lightly, and say that they would go through the operation again,鈥� says Little. 鈥淚nstead of the 25 per cent who die within the first year [of reaching this stage], we鈥檙e seeing 90 per cent survival in the year after surgery.鈥�
People with advanced emphysema, most of whom are elderly, usually have only a 20 per cent chance of surviving five years, according to Eugene. His earliest patients are still breathing better by the time they reach the two-year mark.
