Chest
Volume 123, Issue 4, April 2003, Pages 1026-1037
Journal home page for Chest

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

https://doi.org/10.1378/chest.123.4.1026Get rights and content

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 Ā± SD, 3.7 Ā± 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.

Section snippets

Design

A prospective cohort study design was used to assess the initial 200 patients undergoing bilateral LVRS since the inception of our program. Operative dates ranged from 1993 through 1998. The study follow-up ended in 2000. Given the variable duration of follow-up based on operation dates, we chose to analyze and report the results for three discrete postoperative follow-up time points: closest to 6 months after surgery, closest to 3 years after surgery, and closest to 5 years after surgery. The

Patient Selection

Study patients were accrued through review of approximately 3,000 sets of patient records obtained through mailed correspondence (from 1992 to 1997). Based on an audit of the records, approximately two thirds of the patients were not invited for an on-site evaluation predominantly because of insufficient heterogeneity of emphysema or insufficient impairment. Of the 517 patients evaluated on-site during the study recruitment, 206 patients (40%) were accepted for bilateral LVRS, 41 patients (8%)

Discussion

Patients with severe emphysema seek relief of dyspnea, improved functioning, and better quality of life from LVRS. Studies of LVRS limited to short-term follow-up have demonstrated improvements in physiologic measurements following surgery.5678910111213141516171819202122 A smaller number of short-term studies evaluating dyspnea and patient-perceived PF have also demonstrated improvements in these parameters after LVRS, but most studies have emphasized the assessment of physiologic parameters.

ACKNOWLEDGMENT

The results of our LVRS program depend on the assistance of a team of professionals. We thank the cardiothoracic anesthesia staff; the nursing services of the cardiothoracic operating room, the postoperative recovery area, and thoracic surgical units; the physical therapy (chest physiotherapy) and respiratory therapy departments; Dottie Biggar, RN, and the staff of the pulmonary rehabilitation program; Ms. Mary Vogel for assistance with patient follow-up; Mary Pohl, RN, Tracey Guthrie, RN, and

References (50)

  • ML Moy et al.

    Health-related quality of life improves following pulmonary rehabilitation and lung volume reduction surgery

    Chest

    (1999)
  • D Harpole et al.

    Prognostic models of thirty-day mortality and morbidity after major pulmonary resection

    Thorac Cardiovasc Surg

    (1999)
  • BF Meyers et al.

    Outcome of Medicare patients with chronic emphysema selected for, but denied lung volume reduction operation

    Ann Thorac Surg

    (1998)
  • BF Meyers et al.

    Improved long-term survival seen after lung volume reduction surgery compared to continued medical therapy for emphysema [letter]

    Ann Thorac Surg

    (2001)
  • National Center for Health Statistics

    National vital statistics report (vol 50, no 16)

    (2002)
  • American Thoracic Society

    Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease

    Am J Respir Crit Care Med

    (1995)
  • A McSweeny et al.

    Life quality of patients with chronic obstructive pulmonary disease

    Arch Intern Med

    (1982)
  • O Brantigan et al.

    Surgical treatment of pulmonary emphysema

    Am Surg

    (1957)
  • F Martinez et al.

    Lung-volume reduction improves dyspnea, dynamic hyperinflation, and respiratory muscle function

    Am J Respir Crit Care Med

    (1997)
  • RJ McKenna et al.

    A randomized, prospective trial of stapled lung reduction vs laser bullectomy for diffuse emphysema

    Thorac Cardiovasc Surg

    (1996)
  • FC Sciurba et al.

    Improvement in pulmonary function and elastic recoil after lung-reduction surgery for diffuse emphysema

    N Engl J Med

    (1996)
  • G Criner et al.

    Effect of lung volume reduction surgery on diaphragm strength

    Am J Respir Crit Care Med

    (1998)
  • G Criner et al.

    Prospective randomized trial comparing bilateral lung volume reduction surgery to pulmonary rehabilitation in severe chronic obstructive pulmonary disease

    Chest

    (1999)
  • D Geddes et al.

    Effect of lung-volume-reduction surgery in patients with severe emphysema

    N Engl J Med

    (2000)
  • A Gelb et al.

    Mechanism of short term improvement in lung function after emphysema resection

    Am J Respir Crit Care Med

    (1996)
  • Cited by (89)

    • Lung Volume Reduction Surgery

      2021, Cohen's Comprehensive Thoracic Anesthesia
    • Endoscopic Treatment of Chronic Obstructive Pulmonary Disease

      2021, Cohen's Comprehensive Thoracic Anesthesia
    • Critical appraisal on the impact of preoperative rehabilitation and outcomes after major abdominal and cardiothoracic surgery: A systematic review and meta-analysis

      2020, Surgery (United States)
      Citation Excerpt :

      There were only 5 multi-center studies. Studies were heterogeneous with respect to several factors: race, sex, and type of study (randomized versus nonrandomized) (Table I).19ā€“76 Variation in these factors was broadly reflective of known differences that exist between Asian and Western populations.

    • Management of Patients with End-Stage Chronic Obstructive Pulmonary Disease

      2011, Primary Care - Clinics in Office Practice
      Citation Excerpt :

      Results from the National Emphysema Treatment Trial, a randomized, multicenter trial comparing LVRS with medical treatment, showed improved exercise capacity, quality of life, and reduced mortality in patients with both predominantly upper-lobe emphysema and low baseline exercise capacity.62 Most of the benefit was maintained for at least 2 years and as long as 5 years after LVRS.63 Although LVRS may be helpful for some patients, many patients with end-stage COPD have specific risk factors (low FEV1, homogeneous emphysema, or very low carbon monoxide diffusing capacity) for increased risk of death following surgery.64

    View all citing articles on Scopus

    Supported, in part, by the National Heart, Lung, and Blood Institute of the National Institutes of Health, grant number 5 K23 HL04236-02 (Dr. Yusen).

    Dr. Cooper receives a royalty from Biovascular, Inc., for his development of the Peristrip staple-line reinforcement.

    Dr. Yusen is a consultant for Spiration, Inc.

    View full text