A Prospective Evaluation of Lung Volume Reduction Surgery in 200 Consecutive Patients

Roger D. Yusen, MD, MPH, FCCP, Stephen S. Lefrak, MD, FCCP, David S. Gierada, MD, Gail E. Davis, RN, Bryan F. Meyers, MD, FCCP, G. Alexander Patterson, MD, FCCP, and Joel D. Cooper, MD, FCCP

Disclosures

CHEST. 2003;123(4) 

In This Article

Abstract and Introduction

Objectives: Though numerous studies have demonstrated the short-term efficacy of lung volume reduction surgery (LVRS) in select patients with emphysema, the longer-term follow-up studies are just being reported. The primary objectives of this study were to assess long-term health-related quality of life, satisfaction, physiologic status, and survival of patients following LVRS.
Design: We used a prospective cohort study design to assess the first 200 patients undergoing bilateral LVRS (from 1993 to 1998), with follow-up through the year 2000. Each patient served as his own control, initially receiving optimal medical management including exercise rehabilitation before undergoing surgery. Preoperative postrehabilitation data were used as the baseline for comparisons with postoperative data. The primary end points were the effects of LVRS on dyspnea (modified Medical Research Council dyspnea sale), general health-related quality of life (Medical Outcomes Study 36-Item Short-Form Health Survey [SF-36]), patient satisfaction, and survival. The secondary end points were the effects of LVRS on pulmonary function, exercise capacity, and supplemental oxygen requirements.
Setting: A tertiary care urban university-based referral center.
Patients: Eligibility requirements for LVRS included disabling dyspnea due to marked airflow obstruction, thoracic hyperinflation, and heterogeneously distributed emphysema that provided target areas for resection. Patients were assessed at 6 months, 3 years, and 5 years after surgery.
Interventions: Preoperative pulmonary rehabilitation and bilateral stapling LVRS.
Measurements and results: The 200 patients accrued 735 person-years (mean SD, 3.7 1.6 years; median, 4.0 years) of follow-up. Over the three follow-up periods, an average of > 90% of evaluable patients completed testing. Six months, 3 years, and 5 years after surgery, dyspnea scores were improved in 81%, 52%, and 40% of patients, respectively. Dyspnea scores were the same or improved in 96% (6 months), 82% (3 years), and 74% (5 years) of patients. Improvements in SF-36 physical functioning were demonstrated in 93% (6 months), 78% (3 years), and 69% (5 years) of patients. Good-to-excellent satisfaction with the outcomes was reported by 96% (6 months), 89% (3 years), and 77% (5 years) of patients. The FEV1 was improved in 92% (6 months), 72% (3 years), and 58% (5 years) of patients. Changes in dyspnea and general health-related quality-of-life scores, and patient satisfaction scores were all significantly correlated with changes in FEV1. Following surgery, the median length of hospital stay in survivors was 9 days. The 90-day postoperative mortality was 4.5%. Annual Kaplan-Meier survival through 5 years after surgery was 93%, 88%, 83%, 74%, and 63%, respectively. During follow-up, 15 patients underwent subsequent lung transplantation.
Conclusions: In stringently selected patients, LVRS resulted in substantial beneficial effects over and above those achieved with optimized medical therapy. The duration of improvement was at least 5 years in the majority of survivors.

COPD and other allied conditions are the fourth-leading cause of death in the United States.[1] Emphysema affects approximately 2 million Americans.[2] When advanced, emphysema causes severe dyspnea that markedly diminishes quality of life.[3] Despite medical therapy, the course of advanced disease is slowly but relentlessly progressive.

In the 1950s, Brantigan and Mueller[4] proposed that excision of the most hyperinflated and destroyed portions of the emphysematous lung might improve lung elastic recoil, reduce airflow limitation, and improve chest wall mechanics. However, the unilateral partial lung reduction, combined with radical hilar stripping, resulted in high mortality, limited clinical success, and general lack of acceptance. Based on the work of Brantigan and Mueller,[4] we developed and initiated a procedure for bilateral lung volume reduction surgery (LVRS) at Barnes-Jewish Hospital in 1993.

Published results of LVRS during the 1990s have been encouraging. The short-term efficacy of LVRS in selected patients has been demonstrated, and mechanisms of improvement have been described.[5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22] However, the value of LVRS has remained controversial due to varied patient selection, inconsistent utilization of preoperative rehabilitation, differences in surgical methods, incomplete follow-up data, varying degrees of benefit, and a lack of long-term results in published reports.[23,24] This report describes the long-term results of a prospective evaluation of the first 200 patients in our program undergoing bilateral LVRS.

Comments

3090D553-9492-4563-8681-AD288FA52ACE

processing....