Lung-volume reduction surgery for severe emphysema: appraisal of its current status.

PURPOSE OF REVIEW: Chronic obstructive pulmonary disease (COPD) is the fourth leading cause of death in the United States, as well as a major cause of disability. In its end stages, its inexorable progression results in profound suffering for those afflicted. Medical therapy has proven largely ineffective in improving dyspnea and functional status, and does not alter pulmonary function. Over the past decade, lung-volume reduction surgery (LVRS) has been proposed as a palliative treatment for certain subgroups of COPD patients with emphysema, but initial enthusiasm over its application had been confounded by uncertainty about the potential cost and morbidities associated with LVRS, as well as durability of its beneficial effects. Longer-term follow-up data of initial uncontrolled trials along with several landmark controlled trials have recently been published, offering insight as to the "proper" place of LVRS in the treatment of these unfortunate patients. This review will summarize and offer perspective on these recent findings, as well as offer thoughts on recent refinements in preoperative imaging assessment, and pioneering efforts in less invasive bronchoscopic lung-volume reduction that should further aid the clinician in defining who should benefit from this treatment approach.

RECENT FINDINGS: Lung-volume reduction surgery can result in demonstrable benefit in selected subgroups of COPD patients with upper-lobe disease and poor exercise capacity before surgery with improvements in six-minute walk distances, forced expiratory volume in the first second (FEV1), dyspnea scores and quality-of-life scores, and decreases in residual volume (RV) as well as the need for supplemental oxygen. Patients with FEV1 less than 20% of predicted and either homogeneous emphysema or diffusing capacities (DLCO) less than 20% of predicted do not benefit from LVRS and have unacceptable peri-operative mortalities. Costs to society are high, with a cost of $98,000 per quality-adjusted-life year gained over a 2-year period if only those with upper-lobe disease are offered the procedure.

SUMMARY: Lung-volume reduction surgery can improve both objective and subjective measures of lung performance in properly selected COPD patients. Durable effects of up to 5 years have now been demonstrated. As costs (both fiscal and emotional) of such an approach are high, refinement in patient selection remains a current goal in the surgical approach to COPD.