Lung volume-reduction surgery (LVRS) is one of the most interesting and controversial areas in thoracic surgery. The purpose of the operation is to palliate dyspnea and improve functional status and quality of life for a highly select group of patients with emphysema. It is estimated that 12 million people in the United States have chronic obstructive pulmonary disease (COPD).1 Nearly 2 million of these people develop severe dyspnea with a reduction in their quality of life, and emphysema accounts for more than 90,000 deaths annually.2,3 Most patients with COPD are managed with medical therapy consisting of smoking cessation, pulmonary rehabilitation, bronchodilator therapy, and oxygen. Unfortunately, there is no medical therapy capable of improving pulmonary function or reversing the inexorable decline of breathless patients with emphysema.
The goal of LVRS is to lessen the severity of some of the distressing symptoms and limitations imposed by end-stage emphysema. The controversy has focused on the procedure, interpretation of the results, and the manner in which new surgical procedures should be introduced, scientifically evaluated, and funded by health care providers. Ideal candidates for LVRS have marked hyperinflation and significant regions of severe destruction juxtaposed with other more healthy areas of lung parenchyma. The areas to be removed, frequently referred to as target areas, are usually located in the upper lobes and have little, if any, perfusion. Excision of these areas improves both respiratory mechanics and function of the remaining lung. Clinically, the anticipated benefits are a reduction in dyspnea and improved exercise tolerance. A subset of highly selected patients may experience a survival benefit as well.
The debilitating symptoms of pulmonary emphysema have attracted the interest of surgeons for decades. Many innovative and creative operations have been devised to treat the dyspnea caused by this disease. Costochondrectomy, phrenic crush, pneumoperitoneum, pleural abrasion, lung denervation, and thoracoplasty all have been proposed as surgical treatments for the hyperexpanded and poorly perfused emphysematous lung.4 As Laforet cogently explained, “The alleged benefits of these maneuvers were frequently lost on patients whose worsening dyspnea left them with little energy to debate with their surgeons.”5
LVRS was proposed by Brantigan in conjunction with lung denervation.5 Among 33 patients having the operation, there were 6 operative deaths (18% mortality) and no objective data to support the claim that patients who survived were helped subjectively. LVRS was discarded after this initial experience revealed the operation to be too risky. Over the subsequent four decades, different groups attempted variations on Brantigan's procedure with limited success. Observations about the physiologic behavior of emphysema patients during and after lung transplantation led to the reconsideration of volume reduction by Cooper and colleagues.6 Similar to Brantigan's procedure, Cooper's group removed approximately 30% of the patient's lung volume by performing peripheral resection of the most emphysematous portions. However, the new approach used linear cutting/stapling devices and was performed as a bilateral procedure via median sternotomy. The procedure was ...