Analysis of Recent Literature on Lung Volume Reduction Surgery

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Key points

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    LVRS may enact clinical benefit through improvements in chest wall asynchrony, increased maximum inspiratory pressure, and reduction in inflammatory mediators.

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    Recent data demonstrate that LVRS may be performed safely with 6-month mortality of 0% to 1.5% and durable functional improvements.

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    Initial investigation suggests LVRS may benefit an expanded patient population, including carefully selected patients with homogenous emphysema and low DLCO.

Introduction: the National Emphysema Treatment Trial

Initial publication of the National Emphysema Treatment Trial (NETT) results in 2003 offered significant level I evidence in support of surgical therapy for the management of patients with severe emphysema.1,2 This landmark prospective multicenter trial randomized a total of 1218 patients to either lung volume reduction surgery (LVRS) or medical management, marking a notable departure from the small, heterogeneous, single-center case series that comprised most of the existing data.3, 4, 5 At

Physiologic implications of lung volume reduction surgery

Lung volume reduction has proven effective in promoting enhanced exercise capacity, lung function, and quality of life for select patients with emphysema.1,12 Although surgery was the first available means of volume reduction, less invasive strategies including endobronchial valves, coils, and sclerosing agents are under investigation.13, 14, 15 Regardless of the technical execution, reducing lung volume is thought to combat the primary physiologic derangements of emphysema: airflow

Examining surgical safety and durability

Despite the NETT results demonstrating significant postoperative benefits and survival advantage for select patient populations, controversy persists regarding use of LVRS. Much of the debate stems from concern for unacceptably high surgical morbidity and mortality. Indeed, the 2003 NETT publication reported a sobering 90-day mortality of 5.5% for non-high-risk surgical patients compared with 1.5% following medical management.1 This trepidation undoubtedly contributed to a marked decline in

Beyond the National Emphysema Treatment Trial: extending surgical candidacy

The NETT clearly demonstrated that patients with heterogeneous upper-lobe-predominant disease and low exercise capacity responded best to LVRS1; these findings have been reinforced by subsequent investigation.36 However, better understanding of disease physiology and the impact of surgery on respiratory mechanics have led investigators to push the boundaries of surgical candidacy.44 Recent studies have explored outcomes of LVRS in patients with alternative disease morphology and pathology and

Summary

Since publication of the initial findings of the NETT in 2003, great strides have been made in the understanding and provision of surgical treatment of patients with moderate and severe emphysema. Greater sophistication of surgical technique and deeper insight into the physiologic implications of lung volume reduction have paved the way for improved outcomes and innovative therapeutic alternatives. These findings have important implications for surgeons, researchers, and patients.

For

Clinics Care Point

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    In appropriately selected patients, bilateral LVRS provides durable physiologic, functional and quality-of-life benefits which exceed those achieved with best medical therapy.

Disclosure

Dr D.P. McCarthy receives research support from Ethicon Inc and Intuitive Surgical. Dr L.J. Taylor and Dr M.M. DeCamp do not have any commercial or financial conflicts of interest.

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References (59)

  • J.K. Stoller et al.

    Lung volume reduction surgery in patients with emphysema and alpha-1 antitrypsin deficiency

    Ann Thorac Surg

    (2007)
  • S. Thuppal et al.

    Pulmonary hypertension: a contraindication for lung volume reduction surgery?

    Ann Thorac Surg

    (2020)
  • L. Backhus et al.

    Outcomes in lung transplantation after previous lung volume reduction surgery in a contemporary cohort

    J Thorac Cardiovasc Surg

    (2014)
  • D.C. Chambers et al.

    The registry of the International Society for Heart and Lung Transplantation: thirty-fourth adult lung and heart-lung transplantation report-2017; focus theme: allograft ischemic time

    J Heart Lung Transplant

    (2017)
  • A. Fishman et al.

    A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema

    N Engl J Med

    (2003)
  • J. Concato et al.

    Randomized, controlled trials, observational studies, and the hierarchy of research designs

    N Engl J Med

    (2000)
  • J.D. Cooper et al.

    Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema

    J Thorac Cardiovasc Surg

    (1996)
  • T.M. Daniel et al.

    Lung volume reduction surgery. Case selection, operative technique, and clinical results

    Ann Surg

    (1996)

  • Patients at high risk of death after lung-volume–reduction surgery

    N Engl J Med

    (2001)
  • K.S. Naunheim et al.

    Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group

    Ann Thorac Surg

    (2006)
  • G.J. Criner et al.

    The National Emphysema Treatment Trial (NETT) part II: lessons learned about lung volume reduction surgery

    Am J Respir Crit Care Med

    (2011)
  • S.D. Ramsey et al.

    Cost-effectiveness of lung volume reduction surgery

    Proc Am Thorac Soc

    (2008)
  • G.J. Criner et al.

    A multicenter randomized controlled trial of zephyr endobronchial valve treatment in heterogeneous emphysema (LIBERATE)

    Am J Respir Crit Care Med

    (2018)
  • G.J. Criner et al.

    Improving lung function in severe heterogenous emphysema with the spiration valve system (EMPROVE). a multicenter, open-label randomized controlled clinical trial

    Am J Respir Crit Care Med

    (2019)
  • F.C. Sciurba et al.

    Effect of Endobronchial Coils vs usual care on exercise tolerance in patients with severe emphysema: the RENEW randomized clinical trial

    JAMA

    (2016)
  • A.F. Gelb et al.

    Physiologic diagnosis of subclinical emphysema

    Am Rev Respir Dis

    (1973)
  • R.M. Rogers et al.

    Effect of removal of bullae on airway conductance and conductance volume ratios

    J Clin Invest

    (1968)
  • H.E. Fessler et al.

    Physiologic basis for improved pulmonary function after lung volume reduction

    Proc Am Thorac Soc

    (2008)
  • J.J. Gilmartin et al.

    Abnormalities of chest wall motion in patients with chronic airflow obstruction

    Thorax

    (1984)

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