title: Staged bilateral lung volume reduction surgery - the benefits of a patient-led strategy.
abstract: OBJECTIVE
  Lung volume reduction surgery (LVRS) is conventionally a one-staged bilateral operation. We hypothesised that a more conservative staged bilateral approach determined by the patient not the surgeon would reduce operative risk and prolong the overall benefit.
  
  
  METHODS
  In a population of 114 consecutive patients who were identified as suitable for bilateral LVRS an initial cohort of 26 patients (15 male; 11 female, median age: 58 years) underwent one-staged bilateral surgery: 18 by median sternotomy and eight by video-assisted thoracoscopic surgery (VATS) (group OB). A subsequent cohort of 88 patients had unilateral VATS LVRS with the contralateral operation not scheduled until the patient requested this. Longitudinal follow-up included analysis of lung function, health status (SF 36) and survival.
  
  
  RESULTS
  At a median follow-up of 2.8 (range: 0-9.9) years, staged bilateral LVRS was performed in 16 patients (10 male; 6 female, median age: 59 years) (group SB) at a median interval of 3.9 (range: 0.7-5.9) years after the first operation. Unilateral LVRS has been performed in 73 patients (43 male; 30 female, median age: 60 years) (group U). There were significant improvements in forced expiratory volume in 1s (FEV1) for 6 months in groups OB and U; in group SB there was a second improvement at 4 years (p<0.05). There were significant reductions in residual volume (RV) and total lung capacity (TLC) in groups OB and U for 2 years; in group SB there was a further significant reduction lasting up to 6 years in TLC (p<0.05) and RV (p<0.01). There were significant improvements in health status lasting up to 1 year in groups OB and U. However, in group SB these improvements lasted for 4 years in the domain of physical functioning and 6 years in the domains of social functioning and energy/vitality. There was no significant difference (p=0.07) in 30-day mortality among groups OB (7.7%), SB (13%) and U (4.1%). Similarly, there was no difference between groups OB and SB/U in 3-year survival (81% vs 77%) or 5-year survival (54% vs 66%).
  
  
  CONCLUSIONS
  A staged bilateral approach to LVRS dictated by patients' perception of their condition appears to lead to a more prolonged overall benefit than one-staged LVRS without compromising survival.
authors: Department of Respiratory Medicine and Thoracic Surgery, Glenfield Hospital, Leicester, LE3 9QP, UK. ingeroey@hotmail.com
authors: Inger F
authors: IF
authors: Oey
authors: Michael D L
authors: MD
authors: Morgan
authors: Tom J
authors: TJ
authors: Spyt
authors: David A
authors: DA
authors: Waller
mesh_terms: D000328:Adult; D000368:Aged; D004812:Epidemiologic Methods; D005260:Female; D005541:Forced Expiratory Volume; D006801:Humans; D008297:Male; D008875:Middle Aged; D018802:Patient-Centered Care / Q000379:methods; D011013:Pneumonectomy / Q000379:methods; D011656:Pulmonary Emphysema / Q000503:physiopathology / Q000601:surgery*; D012115:Residual Volume; D020775:Thoracic Surgery, Video-Assisted / Q000379:methods; D014109:Total Lung Capacity; D016896:Treatment Outcome