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O.C.-Pioneered Surgery Gives Science Pause, Patients Relief

TIMES STAFF WRITER

David Greenstein had reached the point that he didn’t care if he died on the operating table.

Emphysema, the cruel wages of a 40-year, two-pack-a-day smoking habit, made him feel as though he were drowning--very slowly. Tethered to an oxygen tank and wheelchair-bound, the 62-year-old West Palm Beach, Fla., resident couldn’t perform life’s most basic tasks. His wife had to shower him, shampoo his hair and rub him dry because he lacked the stamina. Even talking tired the former auctioneer.

So when Greenstein’s doctor told him about physicians in California doing high-tech operations to ease breathing for patients like him, he was sold. And, true to his hopes, he says, the 90-minute procedure involving a laser, a video monitor and a cluster of small incisions on the side of his chest made him a new man.

“I think they were gods,” Greenstein said of his doctors at Chapman General Hospital in Orange, where more of these procedures have been done than anyplace else in the country and 300 people are on a waiting list. “I was wheeled in and I walked out.” Now he bathes himself, goes for short walks, plays nine holes of golf and is hoping to get rid of that albatross oxygen tank altogether.

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But the tales of Greenstein and people like him are not, as even doctors who do the procedure point out, the stuff of good science. Science, they say, demands carefully designed studies of short- and long-term outcomes; it involves painstaking calculations and comparisons. It requires publication in journals rigorously reviewed by peers.

And this is the crux of the debate over laser bullectomy.

The procedure uses lasers to shrink the bullae, or swollen bubbles, on the surface of the diseased lung that otherwise gradually lead to suffocation in thousands of emphysema patients each year. Some doctors say so little is known about the procedure’s risks and benefits that it is hasty and perhaps unethical to try it on large numbers of patients, many of them weak and desperate for any shred of hope.

In the face of exploding consumer demand, they say, it would be easy to make false promises and fuel false expectations.

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The bottom line, say doctors who do the laser bullectomy, is that it works well most of the time, when patients are carefully selected. Clinical trials have started in a handful of places in the country, including at Chapman. Surgeons say what they know from anecdotes and personal experience will be proven in good time.

“If my results were not good, I couldn’t do 900 cases,” said Dr. Akio Wakabayashi, an Irvine Medical Center surgeon who takes credit for pioneering the procedure in 1989 while at UCI Medical Center in Orange. Wakabayashi, who recently moved from Chapman, said 90% of his patients show improved quality of life.

No one doing the procedure touts the bullectomy as a cure or says that it is for everyone. Some patients are not sick enough; others’ lungs are too far gone. Some have asthma and bronchitis that would not be helped by surgery.

There are risks of air leaks from punctures in the lungs and of pneumonia. Mortality is estimated by surgeons at Chapman to be from 5% to 10%.

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Still, thoracic surgeon Dr. Robert McKenna Jr., who took Wakabayashi’s place at Chapman, believes the surgery could improve thousands of lives. “I don’t know numbers (but) the implications for this, I think, are enormous,” he said. “It’s possible there could be a huge boom in this type of surgery.” Laser bullectomy could be “to the 1990s what cardiac bypass surgery was to the ‘70s,” McKenna said. “There’s a lot of interest in this. We just need to study it a little bit better to know the indications and contraindications.”

At stake in the debate are the lives and the health of some of the country’s most miserable individuals, people whose days and nights are spent struggling for air. They have end-stage cases of bullous emphysema in which bullae form in the lungs as a result of destruction of their tiny air sacs. The lungs become so swollen and breathing so inefficient that patients gradually suffocate.

It is a horrible way to go. “Unless you have it, you don’t understand,” Greenstein said.

More than 16,000 people die of emphysema each year, according to the National Center for Health Statistics. Most have some form of bullous emphysema.

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Most of these people are elderly, longtime smokers whose condition is not much relieved by standard medications, including steroids and inhalers. Unless they have one giant bullae--as in a minority of cases--they also are not good candidates for conventional open-chest surgery.

Laser bullectomies, an outgrowth of advances in laser technology and so-called “keyhole” surgeries in the 1980s, involve inserting a laser through small incisions in the patient’s side. “Bullectomy” actually is a misnomer, because the surgery does not actually excise the bullae. Surgeons move the laser tip over the bullae so that they heat up and visibly contract, ultimately reducing the swelling of the lung overall.

The operation is done on one lung at a time with a thoracoscope, a tube with optical lenses that allow the surgeon to peer inside the body via a video screen without opening up the patient’s chest.

Many lung specialists and thoracic surgeons remain cautious, if not skeptical about the procedure.

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The Tustin-based California Thoracic Society, which has fielded numerous inquiries from interested patients, in October issued a public advisory that the laser treatment for diffuse bullous emphysema was “investigational” only and had not been proved to be of overall benefit.

The society said its opinion would stand until “objective data on patient improvement have been demonstrated in appropriately designed experimental trials.”

Surgery carries risks and complications, and the laser bullectomy, despite its less traumatizing keyhole approach, is no exception, doctors said.

“The fact remains that you are operating on people with significant lung disease. There are risks associated with anesthesia (and) they may have coexisting heart disease,” said Dr. Paul Selecky, chairman of the society’s clinical practice assembly.

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At least one researcher involved in the clinical trials has strong reservations.

“I don’t know with any certainty how helpful this procedure is in most patients with emphysema,” said Dr. Matt Brenner, a UCI lung and critical care specialist who helped design a study protocol at Chapman that compares laser bullectomies to another experimental approach of removing diseased lung tissue, using surgical staples.

It is clear, at least, that patients who have giant bullae can be helped by the laser bullectomy procedure, Brenner said, particularly if the bullae are causing crowding of the remaining lung. But few patients fit that description. Other subgroups of emphysema patients may benefit as well, but they have not been identified, he said.

“My own feeling is it needs to be studied, it needs to be followed,” Brenner said.

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Others point out that the laser bullectomy is not the only hope on the horizon: Dr. Joel Cooper of Washington University in St. Louis opens patients’ chests and uses the staple technique to cut out diseased portions of the lungs.

Chapman is comparing a variation on Cooper’s procedure with laser bullectomies. The difference between Cooper’s approach and Chapman’s is that Chapman surgeons use keyhole surgery and operate on one lung at a time, while Cooper does a large incision and can operate on both lungs.

McKenna said that in some cases, depending on what is best for the patient, both the staple and laser bullectomy techniques may be used in a single surgery. Wakabayashi and doctors at Western Medical Center-Anaheim often are using a combined approach as well.

“I think we’re trying to combine all of the modern techniques we have available,” said Dr. John Eugene, who has done 40 procedures in the series at Western Medical. “Eighty-five percent (of patients) say they feel better.”

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Eugene said he is working with doctors at the University of Nevada to assemble data.

“I think this is an operation we can do. . . . I have data to show in the short term it works. The problem is, we don’t know what the results are in the long term.”

Meanwhile, hundreds of debilitated emphysema patients from all over the country are flocking to Orange County in search of answers to their prayers. Other centers are seeing demand rise as well.

“We’re trying to be selective,” said Dr. Alex G. Little, chairman of surgery for the University of Nevada School of Medicine. “We’re discouraging patients from seeing this as a major success with no risk. In fact, I think one of the problems with the whole process is that these patients are desperate for help.

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“They’ll say to you, ‘I’ll do anything.’ I say, ‘That’s not very encouraging to me.’ I want you to know the risks.” He tells them that 80% of patients are improved, about half of them dramatically.

With this kind of consumer demand, there is money to be made. Medicare covers most of the surgeries, doctors and marketing specialists say.

The price tag varies. But Chapman officials tell patients that, assuming they are in the hospital 10 days, the bill will come to about $45,000.

A pair of former Chapman officials have created a corporation, U.S. Lung Centers Inc., in Yorba Linda that now has marketing contracts with Western Medical Center-Anaheim and the University of Nevada Medical Center, and is about to close negotiations with a medical center in Houston.

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It’s not just a money-making venture, said Vice President Linda Simons, former marketing director at Chapman and a former nurse, who has hooked up with former Chapman executive John Kramer.

“We’re helping people with a terminal disease,” Simons said. “I’ve seen what has happened to these patients. My concern is getting the word out there to get them some type of quality of life.”

“Sure we’re making money, but I’m sure we’re not going to be millionaires,” she said.

Simons said most patient referrals come from doctors, but that the corporation does a limited amount of newspaper advertising.

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About a year ago, the firm ran a newspaper ad that read “Emphysema--Now There’s a Cure,” which drew protests from the California Thoracic Society. Simons said that wording was immediately dropped.

Cure or not, for some patients who have had the procedure, it’s as close as they’ve been to magic.

“It’s just been a miracle,” said Ethel Hone, 64, of Mesquite, Nev., who had her surgery at Chapman about three months ago. “I couldn’t believe it. . . . I haven’t had to wear my oxygen to bed. The only time I wear it is when I’m riding my bike. I keep trying to pinch myself, it’s just so wonderful.”

Last week, the wife and daughter of one 76-year-old patient waited nervously in Chapman’s lounge. The patient, Clinton L. Hooten of Clermont, Fla., a 40-year smoker who quit nine years ago, had just been wheeled into the recovery room.

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Hooten used to be what his wife, Sue, called “the life of the party,” an avid golfer, traveler and bridge player. But lately “he just didn’t have the energy to do a lot of things.”

“His doctor was not enthusiastic about his coming,” she said. “Most doctors feel like it’s a risky thing.”

But to Hooten, who apparently came through the surgery well, the risk was worth it.

“Right before we got the call he’d been accepted, he told my mother and aunt he didn’t want to go on living,” his daughter, Suzanne Walker, said. “It was too terrible a quality of life.”

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