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1 INTRODUCTION TO THE THESIS QUESTION Chronic obstructive pulmonary disease (COPD) is a global health problem, and it is estimated that by 2020, COPD will be ranked 5th in terms of disease burden and 3rd in mortality [1] Emphysema is one of the main physiological disorders of COPD Emphysema causes shortness of breath due to limited air flow, pulmonary relaxation and reduced alveolar surface area The treatment of chronic obstructive pulmonary disease is still primarily internal medical With the development of science and technology and anesthesia resuscitation in lung volume reduction treatment in patients with COPD with severe emphysema has good results The principle of lung volume reduction treatment is to decrease the mismatch between the chest and the lung volume, increase the elasticity of the lungs and reduce airway resistance Therefore, this treatment method helps patients improve air flow, corresponding activity between the respiratory muscles and the remaining lung parenchyma leading to improve symptoms, reduce the number of flares and improve the patient life quality with COPD [2] At present, there are two main groups of lung volume reduction treatment: lung volume reduction surgery and lung volume reduction through bronchoscopy Lung volume reduction surgery for patients with COPD with severe emphysema has been successfully implemented since the late twentieth century The results of the studies in lung volume reduction surgery have proved effective for COPD with severe emphysema with low rates of complications and technical complications [3], [4] Lung volume reduction surgery is to remove the major pulmonary emphysema in symptomatic treatment for patients with COPD This surgery removes at least 20-30% of the volume of one or two lungs (in some cases, a whole lobus pulmonis or one lung is removed), which is usually the top of the lung and it is carried out with the thoracic opening along the middle sternum or lateral thoracic or total laparoscopic surgery [5] Research objectives: In Vietnam, lung volume reduction surgery in patients with COPD with severe emphysema has been successfully implemented at the Thoracic Department, 103 Military Hospital in Vietnam Military Medical University since 2014 However, research and application of this method have not yet been systematically conducted Stemming from the above practice, we conduct research on the subject: "Application of laparoscopic surgery in lung volume reduction to treat COPD" with two following objectives: - Comment on some clinical and subclinical characteristics of COPD with severe emphysema which is cured by laparoscopic surgery to reduce lung volume - Assess the results of treatment of chronic obstructive pulmonary disease with severe emphysema by laparoscopic surgery to reduce lung volume New contributions of the thesis From the results of the clinical, subclinical characteristics study and the effectiveness of lung volume reduction surgery for patients with COPD, who have severe emphysema, we have the new following contributions: 2.1 Comment on some clinical and subclinical characteristics in patients with COPD with severe emphysema who have indicated laparoscopic surgery to reduce lung volume - All 31 study patients were male, with an average age of 66,16 ± 5,62 years The average disease duration of all patients was 6,65 ± 3,88 years Majority of the patients have had the disease for less than 10 years (96,77%) - All patients in the study had history of smoking, with prolonged smoking time (average of 30,29 ± 8,62 years) and average-cigarette packet-of-year index of 30,94 ± 12,32 packets per year - Body mass index (BMI) average is 20,46 ± 3,03 kg / m²; - The number of outbreaks in a year is 3,13 ± 0,72 times 3 - The average mMRC score is 2,35 ± 0,98 points - Average CAT score is 19,00 ± 6,06 points, there are 83,87% of patients with CAT ≥ 10 - Average 6-minute walking distance is 293,90 ± 70,79 meters - Computerized tomography of the chest: + Severe emphysema in the right lower lung lobe reaches high proportion (83,87%), emphysema entire lobes reaches 74,19%, only patient (3,23%) has a sludge balloon with emphysema in whole lobes and emphysema by the wall + The average emphysema score is 2,67 ± 0,83 points - Respiratory function: + The average value of VC, FVC and FEV1 are respectively 87,90 ± 21,91% predicted; 85.77 ± 20.00% predicted and 52.00 ± 18.71% predicted + The average value of RV, TLC and Raw are respectively 213,84± 76,16% predicted; 140.61±21.03% predicted and 8,49±5,39 cmH2O/liter/ second - Arterial blood gases: + There were 48,39% of patients with decreased PaO and 22,58% of patients with increased PaCO2 in arterial blood + There were patients (19,35%) with respiratory failure 2.2 Results of treatment of chronic obstructive pulmonary disease by lung volume reduction surgery - Out of the 31 patients who were treated by lung volume reduction surgery, there were 23 patients (74,19%) received supportive laparoscopic surgery Only patients (25,81%) had complete laparoscopic surgery - Average surgery time is 92,74 ± 23,69 minutes - Average weight of lung reduced is 31,09 ± 6,35 grams - The average time for drainage of pleural cavity is 4,87 ± 4,27 days - There were no deaths to months after surgery 4 - Clinical changes at month, months and months after surgery: CAT scores, mMRC and average 6-minute walking distance of the surgical group are improved better than that before surgery - Changing computerized tomography: emphysema scores tend to decrease after surgery at the track time - Change in respiratory function: + VC, FVC and FEV1 increased statistically at the time of month, months and months after surgery compared to before surgery + Average values of RV, TLC and Raw decreased after surgery The layout of the thesis The thesis consists of 149 pages, in addition to the question, conclusions and recommendations, the thesis includes parts: chapter 1- Document overview: 36 pages, chapter 2- Objects and research methods: 23 pages, chapters 3- Research results: 29 pages, chapter 4- Discussion: 26 pages The thesis has 45 tables, pictures, 12 charts The thesis uses 121 references 5 CHAPTER 1: DOCUMENT OVERVIEW 1.1 Clinical characteristics of COPD The main symptom is shortness of breath, persistent shortness of breath Coughing chronic phlegm, increasing At first often sputum less, mucous sputum During an outbreak, the number of sputum increases, changing both color and properties Wheezing and a feeling of suffocation are often nonspecific and change over time [18], [19] - Respiratory symptoms: + Breathing frequency increases, then exhales for a long time, contracting the secondary respiratory muscle such as concave withdrawal on the breast, the intercostal space and the puncture on the lash + Stretched chest, barrel shape, wide cavity space Pulmonary echoes, vibration reduction and alveolar murmur reduction [18] - Cardiovascular symptoms: + Symptoms of chronic heart failure and right heart failure such as hepatomegaly, lower extremities edema, floating neck veins + Chronic heart failure, heart failure may be up to 30% 1.2 Subclinical characteristics of COPD 1.2.1 X-ray image of the lung - Image of blood vessel transformation: Sparse peripheral pulmonary artery, decreased blood vessel size, and a rapid decrease in the smoothness of blood vessels - Pictures of lung relaxation: + The diaphragm arch is lowered, the ribs space widens, the morning space is wide + In case of severe emphysema, the diaphragm dome can be reversed, the heart is in the shape of water droplets and suspended on the diaphragm dome Cardiac/thoracic index 1cm [22] 6 1.2.2 Computerized tomography of emphysema - Emphysema of the center of small lobes: small spots or lights of a small size, clearly defined and reduced in intensity Emphysema spaces located in the center of the lobules, around the central artery of the secondary lobes, are not directly in contact with the visceral pleura or bronchial components and blood vessels of the lobes, subsegment and often predominate in the high areas on both sides of the lung - Emphysema of the entire lobes: Large air chambers with no clear limits and loss of central lobes of the arteries The image of the "black lung" is uniform, diffuse, homogeneous, the blood vessels are sparse and often focus on the lower lobes on either side or the whole lung Lesions are often heterogeneous - Emphysema adjacent to the wall: The emphysema is located at the periphery, there is a limited localization in the pleura or in contact with the interstitial tissue around the blood vessels bronchus, the thin edge corresponds to the inter-lobar septum - Air bubbles: are the emphysema with clear boundaries, diameter ≥ cm, thin wall 45mmHg on echocardiography + Arterial blood gases: PCO2> 60mmHg at room condition + Daily use> 20mg prednisolon + Patients at high risk group when having lung volume reduction surgery according to NETT standards, if there is at least one of the following criterias: ≥ 75 years old FEV1 ≤ 20% of the theoretical value DLCO ≤ 20% of theoretical value 10 Emphysema diffuses uniformly in both lungs on high resolution chest computerized tomography + Thick pleural adhesion associated with previous chest opening + Thick adhesion pleural associated pleural diseases which exist before + Patients in high-risk group when opening the chest Surgical methods to reduce lung volume - Surgery by opening along the middle of the breastbone - Endoscope surgery on both sides through the front chest incision - Endoscope surgery through lateral chest incision 11 CHAPTER 2: SUBJECTS AND METHODS OF RESEARCH 2.1 Research subjects Including 31 patients diagnosed with COPD with severe emphysema who were treated at the Department of Thoracic Surgery, Military Hospital 103 from 2013 to 2018 Patients were assigned laparoscopic surgery to reduce lung volume, monitoring and evaluation after surgery following a uniform procedure Diagnosis and identification of COPD according to GOLD standards (2013) [1]: The diagnosis of COPD has severe emphysema as standard: + Shortness of breath on exertion, often and gradually + The body is thin, the chest is tight, knocking, vibration is reduced, whispering alveoli sharply decreases + Standard lung X - ray: Pulmonary picture brightened, sparse pulmonary vascular network, flat diaphragm arch and teardropshaped heart + Computerized tomography of the thoracic region: the area of the lung parenchyma increased in intensity below the threshold - 950 HU Indications for surgery to reduce lung volume according to NETT (2011) [55]: - Patients with stable COPD - The patient has quit smoking for more than months - BMI