Lung Resection Improves the Quality of Life of
Patients With Symptomatic Bronchiectasis
Camilla Carlini Vallilo, MS, Ricardo Mingarini Terra, MD, PhD,
Andr
e Luis Pereira de Albuquerque, MD, PhD, Milena Mako Suesada, MD, PhD,
Alessandro Wasum Mariani, MD, PhD, Jo~ ao Marcos Salge, MD, PhD,
Priscilla Berenice da Costa, RN, and Paulo Manuel Pego-Fernandes, MD, PhD
Thoracic Surgery Division and Pulmonology Division, Heart Institute (INCOR) Hospital das Clnicas da Faculdade de Medicina da
Universidade de S~
ao Paulo, S~
ao Paulo, Brazil.
Background. Bronchiectasis is a signicant cause of
morbidity. Surgical resection is a treatment option,
but its main outcomes regarding quality of life
(QOL) and physiologic consequences have not been
addressed previously, to our knowledge. We aimed
to evaluate the effect of surgical procedures on QOL,
exercise capacity, and lung function in patients
with bronchiectasis in whom medical treatment was
unsuccessful.
Methods. Patients with noncystic brosis in whom
medical treatment was unsuccessful and who were can-
didates for lung resection were enrolled in a prospective
study. The main measurements before lung resection and
9 months afterward were QOL according to the Short
Form 36 Health Survey and World Health Organization
Quality of Life Questionnnaires, lung function test re-
sults, and the results of maximal cardiopulmonary exer-
cise testing on a cycle ergometer.
Results. Of 61 patients who were evaluated, 53 (50.9%
male, age 41.3 12.9 years) underwent surgical resection
B ronchiectasis is a heterogeneous disease with per-
manent abnormal dilation of central and medium-
sized bronchi as a result of a vicious circle of impaired
clearance of mucus and microorganisms, transmural
infection, and inammation [1]. It is a chronic condition
and represents a signicant cause of morbidity [2].
Patients with bronchiectasis report worse quality of
life (QOL) than do persons in the general population,
particularly those with poor lung function, frequent ex-
acerbations, bronchorrhea, chronic infection, and symp-
toms of depression and anxiety [36]. Most of them can be
treated medically, but patients in whom medical treat-
ment is unsuccessful may be eligible for surgical man-
agement to remove damaged areas of lung parenchyma
that antibiotics penetrate poorly, changing the pattern of
repeated infections and leading to relief from cough and
Accepted for publication April 4, 2014.
Presented at the Fiftieth Annual Meeting of The Society of Thoracic
Surgeons, Orlando, FL, Jan 2529, 2014.
Address correspondence to Dr Terra, Av. Dr. Eneas de Carvalho Aguiar,
44, Sala 9 ZIP 05403-000, S~
ao Paulo, Brazil; e-mail: rmterra@uol.com.br.
2014 by The Society of Thoracic Surgeons
Published by Elsevier Inc
(83% lobectomies), and 44 completed the 9-month follow-
up. At baseline, they had low QOL scores, mild obstruc-
tion, and diminished exercise capacity. After resection, 2
patients died and adverse events occurred in 24.5%. QOL
scores improved remarkably at the 9-month measure-
ments, achieving values considered normal for the gen-
eral population in most dimensions. Functionally,
resection caused mild reduction of lung volume; never-
theless, exercise capacity was not decreased. In fact, 52%
of the patients improved their exercise performance.
Multiple linear regression analysis showed that low QOL
before resection was an important predictor of QOL
improvement after resection (p [ 0.0001).
Conclusions. Lung resection promotes a signicant
improvement in the QOL of patients with noncystic
brosis bronchiectasis without compromising their exer-
cise capacity.
(Ann Thorac Surg 2014;-:--)
2014 by The Society of Thoracic Surgeons
sputum production. Operative intervention may also
benet patients with associated cavitary lung disease or
recurrent hemoptysis [7]. Thus, the main purposes of the
surgical treatment are to restore QOL and to prevent such
adverse events as infections and bleeding.
Most studies of the role of surgical procedures in
bronchiectasis focus on describing the surgical technique
and its adverse events; other outcomes, especially with
regard to QOL and the functional consequences of lung
resection (pulmonary function and exercise capacity), are
poorly addressed [810]. Therefore, this study aimed to
evaluate the impact of lung resection on QOL in patients
with symptomatic noncystic brosis bronchiectasis that
had not responded to medical treatment. The secondary
outcomes were to evaluate the impact of lung resection
on pulmonary and exercise capacity and to nd pre-
dictors of QOL improvement.
Dr Terra discloses a nancial relationship with Johnson
& Johnson.
0003-4975/$36.00
http://dx.doi.org/10.1016/j.athoracsur.2014.04.049
2 VALLILO ET AL
QUALITY OF LIFE AFTER LUNG RESECTION
Material and Methods
This was a prospective study conducted between 2010
and 2013 in a tertiary teaching hospital in Brazil. The
ethics committee (#3490/10/079) approved this study
(Clinicaltrials.gov: NCT01268475).
Study Population
Consecutive patients with symptomatic bronchiectasis in
whom medical treatment had been unsuccessful were
included. The diagnosis of bronchiectasis was based on
high-resolution computed tomographic (HRCT) scanning
with cylindrical Bronchiectasis, varicose and cystic bron-
chiectasis, even when associated with healed tuberculosis
cavities. We considered that medical treatment had failed
when, after 1 year of adequate medication, patients still
had frequent infectious exacerbations, chronic cough, or
purulent sputum interfering signicantly with their daily
activities. Hemoptysis and fungus ball were also consid-
ered to represent failure. Cystic brosis, active tubercu-
losis, immunodeciencies, and lung cancer were already
eliminated by a respiratory physician. We excluded in-
dividuals with comorbidities or lung function and cardio-
pulmonary capacity that precluded the planned resection
based on the American Thoracic Society / American Col-
lege of Chest Physicians statement on cardiopulmonary
exercise testing [11], musculoskeletal impairment inter-
fering with exercise performance, inability to understand
QOL questionnaires, bleeding diathesis; active infection,
or age above 80 years or below 18 years.
Outcomes
The main outcome was QOL improvement after resec-
tion. We assessed QOL before lung resection and 9
months afterward using Short Form 36 Health Survey
Questionnnaire (SF36v2) [12] and World Health Organi-
zation Quality of Life (WHOQOL) [13], both general
questionnaires validated for the Portuguese language.
Previously trained personnel applied all questionnaires.
The secondary outcomes were the impact of the
resection on pulmonary and exercise capacity and the
identication of predictors of QOL improvement. De-
mographic data, American Society of Anesthesiologist
score, and Charlson Comorbidity Index were collected for
later analysis. The same variables were analyzed as pre-
dictors of surgical adverse events. We dened as surgical
adverse events those that prolonged hospitalization or
required new procedures.
Intervention
At baseline, the study participants lled out QOL ques-
tionnaires and performed lung function tests (LFT) and
cardiopulmonary exercise tests (CPET). When referred to
our clinic, all patients already had undergone HRCT and
bronchoscopy with bronchoalveolar lavage, new exami-
nations were ordered only when necessary.
Pulmonary function tests (PFT) were performed in the
1085 ELITE system D (Medical Graphics Corporation St.
Paul, MO), and CPET was performed with the Cardio2
System (Medical Graphics Corporation) with the patient
Ann Thorac Surg
2014;-:--
on a cycle ergometer (CPE 2000, Medical Graphics Cor-
poration). All measurements were obtained on the basis
of recommended standards [11, 1416]. CPET was per-
formed with incremental load after a warm-up period
of 2 minutes, and the load was increased every minute
from 5 to 20 W//min (determined by the investigator
according to value physical tness reported by the pa-
tient) until the patient was exhausted. The predicted
values for PFT and CPET were derived from the Brazilian
population [17, 18].
Thoracic surgeons and pulmonologists decided
together to send patients to resection, considering the
extent of the resection and its risk based on LFT and
CPET. High-risk patients [11] were excluded, and all
others underwent lung resection. A double-lumen
endotracheal tube was used, and pulmonary resection
was achieved through a lateral thoracotomy. The surgical
procedure was aimed at primary resection of the affected
area, as assessed by HRCT. In case of multiple lesions, the
resected region showed the most exuberant change, ma-
jor bleeding, or the presence of fungal ball. The bronchial
stump was closed with 4.0 polydioxanone (PDS II, Ethicon
Cornelia, GA) suture and protected with a parietal pleural
ap. After the operation, we collected information con-
cerning the surgical procedure, admission time, post-
operative adverse events, and readmissions. Nine months
after the operation, the patients lled out QOL ques-
tionnaires and underwent repeated LFT and CPET. The
patients were regularly seen at our outpatient clinic, and
any event during follow-up was recorded.
Data Analysis
The results of the QOL, LFT, and CPET before and after
lung resection were compared using Students t test or
Wilcoxon rank sum test. Multiple linear and logistic
regression analyses were performed to identify the vari-
ables independently related to the improvement of
physical domain of QOL (SF36v2 and WHOQOL) and to
the presence of postoperative adverse events. A p value
<0.05 was considered signicant, and SPSS v21.0 software
was used.
Results
Participants
Sixty-one patients were enrolled in the study. The main
symptoms at presentation were shortness of breath on
moderate and minimum exertion (65.6%), hemoptysis
(57.4%), thoracic pain (50.8%), abundant purulent sputum
(44.3%), cough (40.9%) and clubbing (13%).
Figure 1 depicts the owchart throughout the study. Six
patients showed maximum oxygen uptake (Vo2max)
below 10 mL/kg $ min at CPET and were excluded. One
patient experienced supraventricular tachycardia during
the CPET and was referred to the cardiology department,
and 1 patient refused to undergo operation. Fifty-three
patients underwent the operation, but 9 did not have
the 9-month evaluation, 6 did not attend their second 9-
month evaluation, and 1 experienced bleeding in the
Ann Thorac Surg VALLILO ET AL 3
2014;-:-- QUALITY OF LIFE AFTER LUNG RESECTION

(mean peak VO2) was also reduced, with 64% showing

VO2 lower than normal. The reason for exercise limitation
was likely a combination of dyspnea and leg fatigue with
similar Borg scale results for both components. There was
a substantial ventilatory and cardiac reserve without
considerable gas exchange impairment.
Most QOL scores were reduced in the preoperative
evaluation. Figure 2 shows that the time 0 scores were
below those of the general population 50th percentile
according to SF36v2. This fact was also true for WHOQOL
(Fig 3).

Fig 1. Flow of patients throughout our study.
contralateral lung and had to undergo another operation.
Two patients died. One had a failed extubation on the rst
postoperative day and had to be reintubated; then, after
13 days of unsuccessful weaning from mechanical venti-
lation, he underwent a tracheostomy, and on the 24th
postoperative day he experienced multiple organ failure
and died. The other patient died 3 months after operation
as a result of the downstream consequences of a bron-
chial stump stula diagnosed 2 months after a right
pneumonectomy (active M. abscessus in the surgical
specimen). Table 1 shows the demographic data of the
patients who underwent lung resection.
Functionally, they had mild obstruction at spirometry
and mild reduction in carbon monoxide diffusion capac-
ity (DLCO) (Table 2). All patients stopped the exercise
when they became exhausted, achieving a respiratory
exchange ratio above 1.10. The exercise performance
Surgical Procedures
Table 3 summarizes the surgical outcomes in the 53 pa-
tients who underwent pulmonary resection. Apart from
the two fatalities previously described, 13 patients (24.5%)
had at least one postoperative adverse event within 90
days. Eight had adverse events that required only clinical
treatment: prolonged air leak (>7 days) in 2 patients,
pulmonary thromboembolism in 2, and acute renal fail-
ure, sepsis, empyema (treated with antibiotics), and
atelectasis (that resolved spontaneously) in 1 patient each.
Adverse events that needed intervention were atelectasis
requiring bronchoscopy (1 patient), pleural empyema on
the 9th postoperative day (1 patient who underwent
video-assisted thoracic surgery decortication), high-
volume alveolar stula (1 patient) and 2 bronchial
stump stulas, which were resolved with the use of a
serratus muscle ap. The stepwise backward logistic
regression analysis showed that only male gender was an
independent predictor of postoperative adverse events
(odds ratio 5.185; condence interval 1.08524.791, p
0.039).

Outcomes
Table 1. Demographics of the 53 Patients Who Underwent All patients with hemoptysis at presentation remained
Pulmonary Resection asymptomatic after intervention. Symptoms at the 9th
Age, y 41.3  12.9 month were shortness of breath on great effort (26.4%),
Sex (M/F), % 50.9/49.1 sporadic dry cough (11.3%), and sporadic pain in the
Cause Tuberculosis 60.4% surgical wound (18.9%). Sputum production was present
Othera 39.6% in only 1.9% of patients, whereas before operation it was
Bilateral disease 14 (26.4%)
present in 44.3%. We observed a signicant improvement
in all SF36v2 dimensions (Fig 2). The physical and mental
Charlson Comorbidity Index 1.5 IQ 0.82.7
components also improved (p < 0.001 for both compo-
ASA 2.0 IQ 23
nents); it is interesting that after operation patients began
Smoking 37.7%
to show values similar to those of the general population
Body mass index, kg/m2 23.2  4.3
(Fig 2). In the WHOQOL, we observed signicant
Affected segments 5.36 IQ 37
improvement in the overall health, physical, and psy-
Sputum culture (n 48) None 56.2% chologic dimensions (Fig 3).
Aspergillus 27.1% We built multiple linear regression models to evaluate
Pseudomonas species 8.3% the inuence of several variables in the difference be-
Nontuberculous 6.3% tween QOL measurement at the 9th month and at base-
mycobacteria
line. Only low QOL before the operation surgery was
Streptococcus 2.1% found to be a predictor of improvement after resection
a
Other - Recurrent respiratory infections (30.2%), chronic obstructive (p 0.0001 in all models).
pulmonary disease (3.8%), foreign body aspiration (3.8%) and bronchial Twelve patients had fungus ball as shown by HRCT;
tree malformation (1.9%). most were men with a history of tuberculosis. There was
Values expressed as mean ( standard deviation) or median (interquartile no difference between groups regarding length of inten-
range, 2575). sive care unit stay and hospital stay, readmission rate,
ASA American Society of Anesthesiologists. adverse events, reoperation rate, fatalities, and LFT and
4 VALLILO ET AL Ann Thorac Surg
QUALITY OF LIFE AFTER LUNG RESECTION 2014;-:--

Table 2. Baseline Lung Volumes, Exercise Capacity, and Quality of Life of 53 Patients Who Underwent Lung Resection
LFT (n 53) FVC (L) 3.14  0.9
(% predicted) 78.1  18.7
FEV1 (L) 2.24  0.8
(% predicted) 68.5  21.3
FEV1/FVC 0.71  0.1
DLCO (mL/min $ mm Hg) (n 44) 22.89  8.5
DLCO % predicted (n 44) 90.8  29.0
CPET (n 53) RER 1.22  0.1
Workload (Watts) 102.6  38.6
(% predicted) 78.8  23.8
Vo2max (mL/kg $ min) 20.7  7.0
(% predicted) 67.7  17.1
HRmax (beats/min) 151.6  20.5
(% predicted) 85.3  10.2
VE (L/min) 51.9  18.2
VE/MVV (n 43) 0.60  0.13
VE/VCO2 34.1  4.8
SpO2% 94.1  4.1
Borg (110) Dyspnea 4.61 (IQ 27)
Lower limbs 4.49 (IQ 38)
SF36v2 (n 53) Physical functioning 55.6  31.6
Role physical 37.0  42.2
Bodily pain 64.1  31.5
General health 48.7  23.2
Vitality 58.1  21.7
Social functioning 65.6  28.3
Role emotional 64.4  44.0
Mental health 61.4  21.6
WHOQOL (n 53) Quality of life 3.4  0.8
General health 2.9  1.0
Physical health 5.5  17.9
Psychologic 67.1  16.1
Social relations 69.2  18.8
Environmental 60.4  13.7

Numbers expressed as mean  standard deviation and interquartile range 2575.

DLCO carbon monoxide diffusion capacity; FEV1 forced expiratory volume in 1 second; FVC forced vital capacity; HRmax maximum
heart rate, modied Borg scale; MVV maximum voluntary ventilation; RER respiratory exchange ratio; SpO2 pulse oximetry; VE
minute ventilation; Vo2max maximum oxygen uptake.

CPET before or after operation. Although in some do-
mains the patients experienced lower QOL before and
after operation, we noticed an improvement in all of them
at the 9th month but without statistical signicance.
Table 4 summarizes the results at baseline and at the
9th month in the 44 patients who completed the follow-
up. After lung resection, the patients had mildly lower
values at spirometry but as a result of lower lung vol-
umes, inasmuch as the forced expiratory volume at 1
second (FEV1) and forced vital capacity remained con-
stant. DLCO was not changed, suggesting that predomi-
nantly nonfunctioning lung areas were resected. Exercise
performance generally did not change, but approximately
52% of the patients improved their VO2 and workload.
Sensorial discomforts (Borg scale) were not increased. All
individuals persisted with a large cardiac and ventilatory
reserve without gas exchange impairment. The
hyperventilation during exercise and the tidal volume
achieved after operation was maintained.
Comment
This study showed that lung resection signicantly
improved the QOL of patients with symptomatic bron-
chiectasis, and this was particularly relevant in the func-
tional and physical QOL domains. We also observed a
slight decrease in lung volumes after operation; never-
theless, this fact did not interfere with exercise capacity,
which remained unchanged in the 9th postoperative
month when compared with baseline. In our sample, we
could not identify predictors of improvement other than
low preoperative QOL.
Our patients had signicant impairment of LFT and
CPET at baseline, but most importantly, they had a severe
Ann Thorac Surg VALLILO ET AL 5
2014;-:-- QUALITY OF LIFE AFTER LUNG RESECTION

Table 3. Surgical Outcomes

Underwent
Operation resection (n 53)

Pneumonectomy Right 3 (5.7%)

Left 6 (11.3%)
Upper lobectomy Right 13 (24.5%)
Left 10 (18.9%)
Right middle lobectomy 5 (9.4%)
Lower lobectomy Right 6 (11.3%)
Left 10(18.9%)
Resected segments 4.5, IQ 35
Remaining segments 1, IQ 02
Complete operation 37 (69.8%)
Fig 2. Short Form 36 Health Survey Questionnnaire results at Incomplete operation 16 (30.2%)
baseline and at 9-month evaluation using norm-based scores (NBS) ICU stay (days) Median 2, IQ 04
for 1998 United States general population. (SF36 scales are scored Hospital stay (days) Median 7, IQ 712
using norm-based methods having a mean score of 50 with a standard Rehospitalization in 60 days 3 (5.7%)
deviation of 10). *p < 0.05. (BP bodily pain; GH general health;
Emergency department 7 (13.2%)
SF social functioning; MCS mental component score [VT SF evaluation in 60 days
RE MH]; MH mental health; PCS physical component score
Adverse events 13 (24.5%)
[PF RP BP GH]; PF physical functioning; RE role
emotional; RP role physical; VT vitality.) Reoperation 4 (7.5%)

ICU intensive care unit.

QOL impairment as measured by two validated ques-
tionnaires. Previous studies had already demonstrated
decreased QOL in patients with noncystic brosis bron-
chiectasis. Olveira and colleagues [5] showed, in patients
with bronchiectasis, a positive correlation between the
number of exacerbations and a poorer QOL on Saint
Georges Respiratory Questionnaire. Interestingly, QOL
was not associated with lung function and disease extent.
Moreno and colleagues [19] found a signicant correlation
between anxiety scores and the amount of expectorated
sputum and type of bacteria, especially Pseudomonas aer-
uginosa. Dyspnea, FEV1, and daily sputum were indepen-
dent determinants of QOL in patients with stable cystic
bronchiectasis in another large series [20].
Despite the relevance of QOL in bronchiectasis, we
found no studies evaluating such an outcome before and
after lung resection; most studies addressed only control
of symptoms or lung function behavior [21]. By contrast,
several studies evaluated QOL after lung resection in
lung cancer. Balduyck and colleagues [22] and Brunelli
and colleagues [23] applied European Organisation for
Research and Treatment of Cancer Quality of Life
Questionnaire-C30 LC13 and SF36v2 questionnaires,
respectively, in patients with lung cancer who underwent
pulmonary resection, and they observed low baseline
QOL scores. In both studies, the authors observed an
early decline in QOL, which returned to baseline after 3
months. In our series, we observed a remarkable
improvement of QOL after the operation at 9 months.
Such a fact underlines a basic difference between lung
resection in lung cancer and in bronchiectasis. In the rst

Fig 3. World Health Organization Quality of

Life Questionnnaire results at baseline and at
9-month evaluation. *Statistically signicant
improvement. (ENVIR environmental;
GEN general health; PHYS physical
health; PSYC psychologic; SOC social
relations; QOL quality of life.)
6 VALLILO ET AL Ann Thorac Surg
QUALITY OF LIFE AFTER LUNG RESECTION 2014;-:--

Table 4. Baseline and Ninth Month Complete Pulmonary Function and Cardiopulmonary Exercise Test Results (44 Patients
Completed Follow-Up)
0 month 9th month p

LFT (n 44) FVC (L) 3.15  0.9 2.85 0.8 <0.05

(% predicted) 79.3  17.9 71.4 17.7 <0.05
FEV1 (L) 2.21  0.8 1.98  0.8 <0.05
(% predicted) 68.5  21.4 61.1  21.1 <0.05
FEV1/FVC 0.7  0.1 0.7  0.2 0.400
DLCO (mL/min $ mm Hg) (n 37) 23.2  7.6 21.7  8.2 0.092
DLCO % predicted 92.1  24.6 86.3  27.1 0.340
CPET (n 44) Vo2max (mL/kg $ min) 20.9  7.4 20.2  8.1 0.452
(% predicted) 69.9  17.6 67.7  17.7 0.269
VE (L/min) 52.1  19.4 49.6  17.6 0.510
VE/MVV 0.6  0.1 0.7  0.2 0.001
VTmax (L) 1.32  0.4 1.25  0.4 0.476
VE/VCO2 34.2  4.8 35.7  9.9 0.37
HRmax (beats/min) 151.9  20.4 148.1  17.7 0.172
(% predicted) 85.5  10.3 83.4  9.1 0.175
RER 1.21  0.13 1.22  0.2 0.833
Workload (W) 103.2  38.9 100  33.6 0.195
SpO2% 93.7  4.3 94.1  4.2 0.690
Borg dyspnea 4.3 (IQ 17) 4.8 (IQ 37) 0.377
Borg lower limbs 4.3 (IQ 17) 4.9 (IQ 27) 0.231

Numbers expressed as mean and standard deviation, p value and IQ 2575.

Borg modied Borg scale; CPET cardiopulmonary exercise test; DLCO carbon monoxide diffusion capacity; FEV1 forced expiratory
volume at 1 second; FVC forced vital capacity; HRmax maximum heart rate; LFT lung function test; MVV maximum voluntary
ventilation; RER respiratory exchange ratio; SpO2 pulse oximetry; TV total volume; VE minute ventilation; Vo2max
maximum oxygen uptake.

situation, in addition to the cancer tissue, a large amount
of normal lung is resected. In the second situation,
diseased lung harboring inammatory and infectious
processes is removed. It is reasonable that QOL would
worsen or stay the same in lung cancer and that it would
improve in bronchiectasis. The removal of a source of
persistent infection and inammation might have had a
systemic impact, increasing patients vitality and well-
being. The downstream consequences of this improve-
ment in patients general condition could be the resolu-
tion of symptoms such as shortness of breath, which was
observed at baseline in 65% of our patients. Patients who
underwent pneumonectomy and incomplete resection
beneted from resection in terms of QOL. In fact,
improvement of QOL was quite homogeneous in our
population. Seven patients did not show improvement,
but these patients already had high baseline QOL scores.
Only 4 patients experienced worse QOL after the proce-
dure (1 had pulmonary embolism, which could have
justied the worsening of QOL).
Although QOL improved substantially after surgical
intervention, lung function was not a predictor of that. In
fact, patients had a decline of approximately 10% of
baseline volumes. Even though this drop was statistically
signicant, this was just 300 mL for forced vital capacity
and 200 mL for FEV1 and apparently did not lead to
clinical deterioration. Similarly to studies addressing
surgical resection in lung cancer, improvement in health
status of our patients did not correlate with exercise and
lung function response [24]. Interestingly, when all in-
dividuals were taken into account, mean exercise capacity
was the same after lung resection; nevertheless, individ-
ually, 52% of them improved their oxygen consumption.
Neither the behavior of ventilatory system nor gas ex-
changes changed after intervention. We can infer that the
lung area resected had not contributed to ventilatory
response during exercise before the intervention. Thus,
patients were able to maintain their exercise performance
(some of them even improved), with no impairment to
the response of the ventilatory system during maximal
testing.
The 30-day mortality rate was 1.8%, and the rate of
adverse events was 24.5%. These are slightly higher than
in other series, where we nd 30-day mortality rates
ranging from 0% to 1.1% and rates of adverse events
ranging from 12% to 22.4% [2528]. The large proportion
(60.4%) of tuberculosis, a well-known risk factor for
adverse events, might explain this fact [27]. In addition,
many patients were colonized with Pseudomonas species
and Aspergillus species, another important predictor of
adverse events [28].
Proportionally, the prole of adverse events in our
study was quite similar to those in previous reports but for
the high incidence of bronchial stump stula (5.7%),
Ann Thorac Surg
2014;-:--
which was experienced by 2 patients within a month and 1
patient after 2 months. All 3 patients had a particularly
risky bronchial closure, and the stump was covered with a
pleural ap. We were aware of the risks beforehand;
maybe a pedicled muscle ap (either intercostal or ser-
ratus) should have been used in the rst place.
Despite the encouraging results of our study, some
limitations should be recognized. First, our study had no
control group, and we cannot rule out the possibility that
the signicant improvement in QOL after the operation
resulted from the placebo effect of the procedure.
Nevertheless, the large differences between QOL scores
before and after the operation and the consistency of the
results in two QOL instruments support our conclusions.
Finally, although the number of patients was adequate to
address our main objective, it was too small to identify
predictors of adverse events and QOL improvement.
In conclusion, our results demonstrated that patients
with symptomatic noncystic brosis bronchiectasis ex-
perience a signicant improvement in their QOL after
resection of compromised areas in the lung. Moreover,
despite a slight decrease in lung volumes, a patients
exercise capacity remains unchanged after operation. Our
study highlights the role of surgical treatment of patients
with symptomatic bronchiectasis that is refractory to
clinical treatment or who experience such severe adverse
events as hemoptysis.
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DISCUSSION
DR MARCELO DASILVA (Chicago, IL): Great presentation,
Ricardo. Did you have a chance to look at the readmission rate
for the 9 months that you followed up those patients after the
operation? The quality of life is there, there is not a lot of change
in physiology in your patients, but those patients keep coming
VALLILO ET AL 7
QUALITY OF LIFE AFTER LUNG RESECTION
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back in for intravenous antibiotics, washouts and so forth,
reintubation, contralateral contamination of the lung. Did you
have a chance to look at that readmission rate, not surgical
readmission but medical readmission of those patients during
the 9 months?
8 VALLILO ET AL
QUALITY OF LIFE AFTER LUNG RESECTION
DR TERRA: Thank you so much for the question. Those results
that I showed that 5% of the patients were readmittedit was for
both medical and surgical reasons. That was the number that we
found in this cohort of patients.
DR DASILVA: So the readmission rate for treatment of pneu-
monias and so forth wasnt changed after the operation? Thats
my question.
DR TERRA: We didnt know exactly the number of exacerba-
tions they had before. These patients were sent to us after 1 year
of treatment in the pulmonology department, and these
numbers were not really reliable, and so we didnt do that
analysis. Anyway, none of our patients was readmitted because
of pneumonia. Thats the answer I can give you.
DR JOHN MITCHELL (Aurora, CO): I have two quick ques-
tions. This was a nice study. First, did the extent of the resection
inuence your resultsfor example, pneumonectomy versus
right middle lobectomy? Second, some of the medical regi-
mensthe antibiotic therapyassociated with some of these
diagnoses are pretty onerous. How did this inuence your
results?
DR TERRA: The rst question, comparing pneumonectomy
with lobectomy, we looked at these data, and actually the results
were pretty much the same. We didnt nd any difference in
regard to both quality of life and exercise and lung function
capacity. That was a little bit surprising for us, but the sample
size is small. Maybe those differences werent captured in our
sample. The second question?
DR MITCHELL: The inuence of the medical regimens on the
quality of life outcomes.
Ann Thorac Surg
2014;-:--
DR TERRA: You mean before?
DR MITCHELL: And after as well. What was the timing of the
medical treatment in relation to the data collection times?
DR TERRA: Well, these patients were treated for a year before
operation. Some of them actually werent treated for a year
because they had adverse events along the way, like hemop-
tysis, and so they were sent to us before. This is in more detail
in the report. Because of time restrictions, we dont have the
time to show every single piece of data. These patients were
treated for 1 year with medical therapy, like corticosteroids,
physical therapy, and then sent to us if they were still symp-
tomatic or having frequent exacerbations; and those who had
some sort of adverse events, like hemoptysis and so on, they
were sent to us earlier.
DR JOHN P. MAURICE (Newport Beach, CA): Congratulations
on 9 months of showing all of your patients who got thoracot-
omies in this study who felt they had the same quality of life as
the regular population. I wonder if you could give a little more
detail on how you do your thoracotomies, and also if you have
looked at a subset of patients who maybe got a thoracoscopic
procedure instead.
DR TERRA: That is a very good question. Most patients undergo
a muscle-sparing thoracotomy. Some of themthose who had
lung cavities and the pleura was thoroughly obliterated may
have had a larger thoracotomy. We looked at that, and there was
no difference regarding quality of life and lung function. They
could undergo thoracoscopy, but in our hospital we have some
restrictions for using staplers and so on, and so we decided that
we should spare the staplers for lung cancer patients, and that
was an administrative decision.