title: A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema.
abstract: BACKGROUND
  Lung-volume-reduction surgery has been proposed as a palliative treatment for severe emphysema. Effects on mortality, the magnitude and durability of benefits, and criteria for the selection of patients have not been established.
  
  
  METHODS
  A total of 1218 patients with severe emphysema underwent pulmonary rehabilitation and were randomly assigned to undergo lung-volume-reduction surgery or to receive continued medical treatment.
  
  
  RESULTS
  Overall mortality was 0.11 death per person-year in both treatment groups (risk ratio for death in the surgery group, 1.01; P=0.90). After 24 months, exercise capacity had improved by more than 10 W in 15 percent of the patients in the surgery group, as compared with 3 percent of patients in the medical-therapy group (P<0.001). With the exclusion of a subgroup of 140 patients at high risk for death from surgery according to an interim analysis, overall mortality in the surgery group was 0.09 death per person-year, as compared with 0.10 death per person-year in the medical-therapy group (risk ratio, 0.89; P=0.31); exercise capacity after 24 months had improved by more than 10 W in 16 percent of patients in the surgery group, as compared with 3 percent of patients in the medical-therapy group (P<0.001). Among patients with predominantly upper-lobe emphysema and low exercise capacity, mortality was lower in the surgery group than in the medical-therapy group (risk ratio for death, 0.47; P=0.005). Among patients with non-upper-lobe emphysema and high exercise capacity, mortality was higher in the surgery group than in the medical-therapy group (risk ratio, 2.06; P=0.02).
  
  
  CONCLUSIONS
  Overall, lung-volume-reduction surgery increases the chance of improved exercise capacity but does not confer a survival advantage over medical therapy. It does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low base-line exercise capacity. Patients previously reported to be at high risk and those with non-upper-lobe emphysema and high base-line exercise capacity are poor candidates for lung-volume-reduction surgery, because of increased mortality and negligible functional gain.
authors.affiliation: University of Pennsylvania, Philadelphia, USA.
authors.forename: Alfred
authors.initials: A
authors.lastname: Fishman
authors.forename: Fernando
authors.initials: F
authors.lastname: Martinez
authors.forename: Keith
authors.initials: K
authors.lastname: Naunheim
authors.forename: Steven
authors.initials: S
authors.lastname: Piantadosi
authors.forename: Robert
authors.initials: R
authors.lastname: Wise
authors.forename: Andrew
authors.initials: A
authors.lastname: Ries
authors.forename: Gail
authors.initials: G
authors.lastname: Weinmann
authors.forename: Douglas E
authors.initials: DE
authors.lastname: Wood
mesh_terms: D000368:Aged; D017079:Exercise Tolerance; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011013:Pneumonectomy; D011336:Probability; D011656:Pulmonary Emphysema / Q000188:drug therapy / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D012307:Risk Factors; D016896:Treatment Outcome