Evidence-based medicine: lung volume reduction surgery (LVRS).
Lung volume reduction surgery (LVRS) was developed as a means of surgical treatment for severe pulmonary emphysema. To date, various studies have been designed to explain the mechanisms involved in pathophysiological changes after treatment, to define criteria for patient selection, to identify the surgical technique of choice and to propose appropriate follow-up care. Preliminary results of follow-up studies (up to five years) have already been published, indicating improved pulmonary function and quality of life after surgical treatment. However, the alarming results from the National Emphysema Treatment Trial (NETT) Research Group indicated a considerable risk for death in patients with homogenous emphysema and low forced expiratory volume in one second (FEV1) undergoing LVRS. This brief review summarizes the results of currently published studies to supply evidence for selection criteria in order to better define the subset of patients for which LVRS offers an effective and safe means of palliation from the symptoms of advanced COPD. Due to acceptable morbidity and mortality rates, stapler device wedge excision and closure has become the standard procedure for removing non-functioning, hyperinflated lung areas in heterogeneously affected organs. LVRS is carried out in two ways - using video-assisted thoracoscopic surgery (VATS) as well as thoracotomy/sternotomy-and performed in unilateral and bilateral procedures. In contrast, most clinics have found laser resection of emphysematous parenchyma to be unsuccessful. In some patients, LVRS was carried out as an alternative to lung transplantation, whereas in others, it served as a bridge-to-transplant procedure. LVRS has proven effective in the reduction of dyspnea, especially in patients with recovery options in both the circulatory and pulmonary system. In responders, recovery from labored breathing and O(2) dependency and increased physical capacity are usually accompanied by improved spirometric data. These results are mainly explained by a more regular breathing pattern and an increase in the maximum volume of ventilation in the affected lung. In most cases, functional improvement is maximized during the first six months postoperatively and decreases steadily thereafter indicating the need for a systematic postoperative patient care after surgical treatment. After indicating at-risk patients who should not be considered for LVRS, long-term results from the multicenter NETT research group will hopefully help clarify the impact of this treatment on survival of patients further.
Koebe
H G
HG
Schwerpunkt Thoraxchirurgie, Klinikum Kassel, Germany.
Kugler
C
C
Dienemann
H
H
D019317:Evidence-Based Medicine; D006801:Humans; D011013:Pneumonectomy / Q000379:methods; D011656:Pulmonary Emphysema / Q000601:surgery*; D020775:Thoracic Surgery, Video-Assisted; D013908:Thoracotomy; D016896:Treatment Outcome