Lung volume reduction surgery (LVRS) patient selection guidelines are based on the National Emphysema Treatment Trial. Because of increased mortality and poor improvement in functional outcomes, patients with non–upper lobe emphysema and low baseline exercise capacity are determined as poor candidates for LVRS. In well-selected patients with heterogeneous emphysema, LVRS has a durable long-term outcome at up to 5-years of follow-up. Five-year survival rates in patients range between 63% and 78%. LVRS seems a durable alternative for end-stage heterogeneous emphysema in patients not eligible for lung transplantation. Future studies will help identify eligible patients with homogeneous emphysema for LVRS.
Key points
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Five-year survival rates post–lung volume reduction surgery (LVRS) for emphysema range between 63% and 78%.
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In well-selected patients with heterogeneous emphysema, there is a significant improvement in lung function at 5-years post-LVRS.
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There are durable improvements in disease-specific quality of life at 5 years post-LVRS.
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Select patients with homogenous emphysema may benefit from LVRS provided proper care is taken in resection of damaged tissue and careful patient selection.
Introduction
Chronic obstructive pulmonary disease (COPD), characterized by a spectrum of chronic bronchitis and emphysema, is one of the most debilitating lung conditions and is the fourth leading cause of death in the United States. Current treatment guidelines for COPD are focused on pulmonary rehabilitation and medical management with bronchodilators and inhaled corticosteroids, which have only been shown to decrease symptoms without prolonging patient survival. , Supplemental oxygen and smoking cessation are the only interventions shown to provide a survival benefit. , The high prevalence and mortality associated with COPD, along with limited treatment options, have spurred research into lung volume reduction surgery (LVRS) as a new treatment modality for advanced COPD.
LVRS was first described by Otto Brantigan in 1959. He enrolled 57 patients with obstructive pulmonary emphysema over a period of 8 years. The procedure involved thoracotomy followed by unilateral removal of 20% to 30% of the diseased peripheral lung tissue in patients with emphysema. If the patient still was symptomatic, then the second side was operated on. Results of the study showed that 75% of the patients had symptomatic improvement but the early mortality rate was 16%. The procedure was not widely accepted largely due to difficulties in quantitating improvement and the early mortality rate of 16%. In 1983, Gaensler and colleagues suggested that local resection should not be undertaken in patients with bullous emphysema.
Proper patient selection criteria were needed for performing lung volume reduction to improve the functional status and quality of life (QOL). Success was reported and published in the early 1990s using thoracoscopic laser techniques. It was at times difficult to replicate these results and the LVRS techniques evolved to stapled resection of the hyperinflated diseased lung. In 1995, Cooper and colleagues reported on LVRS and had performed the procedure in 20 patients without giant bullous emphysema but with very heterogeneous disease. The results showed promising improvement in lung function and QOL. Following this success, a larger study involving 150 patients with long-term follow-up was conducted. All patients had severe dyspnea, increased lung capacity, hyperinflation, and heterogeneous disease. Bilateral LVRS was performed using a sternotomy with removal of 20% to 30% of the lung volume in each lung using a linear stapler and bovine pericardial strips for suture line buttressing. Most of the damaged tissue was removed from the upper lobe whereas 18 patients had lower lobe destruction warranting removal of damaged tissue. The results showed a significant increase in percentage predicted value of forced expiratory volume in 1 second (FEV 1 ), a decrease in percentage predicted values of total lung capacity (TLC) and residual volume (RV), improved QOL with decreased oxygen, and corticosteroid use up to 2 years postsurgery. Following these studies, multiple studies were published that showed promising results with LVRS.
The current LVRS patient selection guidelines are based on the National Emphysema Treatment Trial (NETT), a prospective clinical trial of 1218 subjects randomized to LVRS or medical treatment with a follow-up between 6 months and 4.5 years. The study enrolled patients with heterogenous and homogenous emphysema and predominantly upper lobe emphysema and non–upper lobe emphysema (including predominantly affecting the lower lobes, diffuse, or predominantly affecting the superior segments of the lower lobes). All enrolled subjects underwent 6 weeks to 10 weeks of pulmonary rehabilitation prior to randomization. The study concluded that patients with both predominantly upper lobe emphysema and low baseline exercise capacity had a survival advantage. Because of the increased mortality and poor improvement in functional outcomes, patients with non–upper lobe emphysema and low baseline exercise capacity were determined as poor candidates for LVRS. Several studies with similar inclusion criteria have shown that LVRS is effective during the short-term follow-up when well selected; however, few studies have looked at long-term outcomes post-LVRS in patients with end-stage emphysema. This review looks at studies that followed-up patients for at least 24 months from the time of surgery.
Heterogenous emphysema
The NETT trial recommended LVRS for patients with predominantly upper lobe emphysema with low exercise capacity. At 24 months’ follow-up, the risk of death in patients with emphysema with predominantly upper lobe emphysema with low exercise capacity undergoing LVRS was 0.47 and there was an improvement in maximum workload (W) by more than 10-W, with improvement in St. George’s Respiratory Questionnaire Scores. At 5 years, the risk of death was 0.67 with improvement of St. George’s Respiratory Questionnaire Scores. The improvement in workload, however, was durable only up to 3 years. Long-term follow-up of NETT patients showed the mortality rates in LVRS patients was significantly lower (0.11 deaths per person-year) compared with the medical group (0.13 deaths per person-year), in spite of increased early mortality in the LVRS group. At 5-year follow-up, there was a sustained improvement in lung function indicators, including FEV 1 (+1.4%), forced vital capacity (FVC) (+3.44%), and RV (−19.49%) of the predicted values. There was an overall 0.89-W improvement in maximum workload, −4.12 improvement in shortness of breath score, and 0.088 improvement in quality of well-being scores. Based on the results from NETT study, LVRS was found to have a long-term durable effect on patients with emphysema with improvement in both functional and physiologic outcomes.
The authors followed 66 patients with predominantly upper lobe emphysema (ventilation-perfusion ratio [V/Q] ≤15%) for up to 5 years. Mean age was 66 years old, and 64% of the patients had a smoking history of 60 or more pack-years. All patients underwent 20 supervised pulmonary rehabilitation sessions prior to LVRS. Baseline mean values were FEV 1 , 25% of predicted value; FVC, 66% of predicted value; RV, 215% of predicted value; and diffusing capacity of the lungs for carbon monoxide (DLCO), 38% of predicted value. The 6-minute walk distance (6MWD) was 1194 ft at baseline. Arterial oxygen and carbon dioxide were 42 mm Hg and 69 mm Hg, respectively ( Table 1 ). At 5-year follow-up, there remained a significant improvement in FEV 1 (22%) , FVC (22%), and RV (−12%) compared with baseline ( Table 2 ). Improvement in DLCO was durable at 3 years whereas arterial pressure of oxygen and carbon dioxide was durable only up to 1 year follow-up (see Table 2 ). Based on the 36-item Short Form Health Survey (SF-36) QOL questionnaire, physical functioning, energy, and emotional well-being improved significantly compared with baseline and was durable up to 3 years post-LVRS. The limitation due to physical health, however, was significantly less compared with baseline values at 5-years post-LVRS ( Table 3 ). Survival rates at 1 year, 2 years, 3 years, 4 years, and 5 years were 92.4%, 90.7%, 85.4%, 79%, and 69%, respectively ( Fig. 1 ). The numbers of deaths at 1 year, 3 years, and 5 years post-LVRS in this group were 5 patients, 4 patients, and 7 patients. At the end of 5 years, 23 patients were lost to follow-up; however, there was no difference in baseline demographic and functional outcomes between those who did and did not complete 5-years of follow-up.
| Characteristics | Upper Lobe Perfusion Less than or Equal to 15% (n = 66) | Upper Lobe Perfusion Greater than 15% (n = 69) |
|---|---|---|
| Age, years, mean (SD) | 66.4 (±7.6) | 66.6 (±7.6) |
| BMI, kg/m 2 , mean (SD) | 24.9 (±4.4) | 25.2 (±4.6) |
| Gender (female) | 34 (52%) | 25 (36%) |
| Race/ethnicity | ||
| Non-Hispanic white | 64 (98%) | 66 (96%) |
| Non-Hispanic black | 1 (2%) | 3 (4%) |
| Smoking history | ||
| 10–19 pack-years | 0 (0%) | 1 (1%) |
| 20–29 pack-years | 1 (2%) | 6 (9%) |
| 30–39 pack-years | 10 (15%) | 6 (9%) |
| 40–49 pack-years | 8 (12%) | 7 (10%) |
| 50–59 pack-years | 5 (8%) | 8 (12%) |
| 60+ pack-years | 42 (64%) | 39 (58%) |
| FVC, % predicted value | 66 (53–75) | 67 (52–84) |
| FEV 1, % predicted value | 25 (22–30.5) | 24.5 (21–32.3) |
| RV, % predicted value | 215 (192–267) | 216 (190–240.5) |
| DLCO, % predicted value | 38 (28–45) | 37.5 (31.3–46.8) |
| 6MWD (ft) | 1194 (1030–1400) | 1200 (1038–1350) |
| Pa co 2 (mm Hg) | 42 (38–63) | 41 (35.8–44.7) |
| Pa o 2 (mm Hg) | 69 (63–74) | 68 (61–71.2) |
| Outcomes | Upper Lobe Perfusion Less than or Equal to 15%, median (interquartile range) | ||
|---|---|---|---|
| Year 1 (n = 43) | Year 3 (n = 27) | Year 5 (n = 15) | |
| FVC, % predicted value | 41.4 (23.5–62.1) c | 28.6 (20.0–45.2) c | 21.2 (−4.2–36.1) a |
| FEV 1 , % predicted value | 54.2 (26.3–72.7) c | 22.7 (12.0–51.5) c | 22.2 (−10.0–37.5) a |
| RV, % predicted value | −27.8 (−42.5 to −18.3) c | −21.9 (−30.3 to −13.6) c | −12.1 (−23.8 to −2.6) a |
| DLCO, % predicted value | 16.2 (0.0–28.2) c | 12.3 (−5.8–25.6) a | 8.7 (−13.3–26.2) |
| 6MWD (ft) | 9.3 (2.2–20.0) c | 1.4 (−5.4–16.1) | −0.6 (−29.2–9.1) |
| Pa co 2 (mm Hg) | −5.3 (−16.7–2.6) a | 2.2 (−6.3–7.0) | 2.3 (−10.7–9.8) |
| Pa o 2 (mm Hg) | 7.7 (0.0–20.9) b | 1.4 (−11.3–25.2) | 2.9 (−1.8–10.8) |
| Outcomes | Upper Lobe Perfusion greater than15% | ||
|---|---|---|---|
| Year 1 (n = 31) | Year 3 (n = 22) | Year 5 (n = 12) | |
| FVC, % predicted value | 27.7 (11.1–71.4) c | 21.0 (2.9 45.2) b | 30.8 (12.8–74.2) a |
| FEV 1 , % predicted value | 23.8 (6.2–56.0) c | 23.7 (−5.1–34.2) a | 37.5 (6.6–61.4) a |
| RV, % predicted value | −16.8 (−32.6 to −6.93) c | −14.6 (−21.9–3.5) | −1.6 (−20.5–2.6) |
| DLCO, % predicted value | 7.3 (−2.4–17.8) a | −4.3 (−17.2–20.0) | −2.1 (−13.9–20.3) |
| 6MWD (ft) | 2.8 (−4.9–16.3) | −12.2 (−28.1–9.1) | −2.0 (−16.5–7.3) |
| Pa co 2 (mm Hg) | −4.5 (−9.8–7.5) | 5.0 (−3.3–9.8) | 5.6 (−12.5–20.5) |
| Pa o 2 (mm Hg) | 0.0 (−2.9–14.5) | 1.5 (−5.9–14.7) | 1.3 (−10.6–27.3) |
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