Review article S W I S S M E D W K LY 2 0 0 2 ; 1 3 2 : 5 5 7 – 5 6 1 · w w w . s m w . c h 557
Peer reviewed article
News on lung volume reduction surgery
Erich W. Russi, Walter Weder
Pulmonary Division and Division of Thoracic Surgery, Universitätsspital Zürich, Switzerland
Lung volume reduction surgery (LVRS) is an than 2% in appropriately selected patients, and
established therapeutic option for patients with current results suggest that the five-year survival
advanced pulmonary emphysema after all conser- in COPD patients may even be improved by this
vative measures, including comprehensive pul- palliative surgical intervention. In patients under
monary rehabilitation, have been exhausted. LVRS 60 LVRS may serve as a bridging procedure to lung
improves pulmonary function, shortness of breath, transplantation. Bronchoscopic creation of extra-
exercise capacity and hence quality of life in some anatomic bronchopulmonary passages – endo-
80% of cases for up to four years. Even patients scopic LVRS – is a novel approach now under in-
with homogeneous types of pulmonary emphy- vestigation.
sema improve if those with extremely low FEV1
and/or very low diffusion capacity are excluded. At Key words: pulmonary emphysema; lung volume
experienced centres perioperative mortality is less reduction surgery
Several prospective case series [1–3] and, more The degree of improvement is variable and may
recently, a few randomised, controlled prospective depend on different factors, including aetiology
trials [4–8] have demonstrated that lung volume and morphological types of emphysema, preoper-
reduction surgery (LVRS) improves dyspnoea, ative lung function, and amount of resected em-
lung function, exercise tolerance and quality of life physematous lung tissue.
 in patients with severe forms of emphysema.
Selection of patients
The selection of patients is based on sound a forced expiratory volume in one second (FEV1)
pathophysiological concepts and contraindica- of no more than 20% of the predicted value and
tions which are known to increase the periopera- either homogeneous distribution of emphysema
tive complication rate and mortality (table 1). Syn- on computed tomography or a carbon monoxide
opsis of all available data is important in this diffusing capacity of no more than 20 % of the
process. There is strong evidence that the two predicted value, 30-day mortality after surgery
major symptoms, i.e. limited exercise capacity and was 16% (95% confidence interval: 8.2–26.7%),
shortness of breath during exercise, are mainly a as compared to nil mortality among 70 patients
consequence of pulmonary hyperinflation, a hall- treated medically (p <0.001). Perioperative mor-
mark of severe pulmonary emphysema. Hence tality is considerably lower (<5%) in centres with
considerably increased thoracic gas volume re- experience in selecting and operating on suitable
mains the most important prerequisite for suc- patients . In our 150 patients 30-day mortality
cessful surgical volume reduction. It is not sur- was 2% .
prising that LVRS may have a high perioperative Certain authors have stressed that patients
complication rate if performed in patients whose with distinct regional differences in tissue destruc-
lung function, particularly gas exchange, is se- tion (i.e. with markedly heterogeneous emphy-
Supported by verely impaired due to an almost entirely de- sema) on computed tomography (CT), perfusion
Grants: Swiss Na-
stroyed lung, i.e. in those with so-called “vanish- scintigram or both, profit most from LVRS be-
3200–063709.00 ing” lung. This is unequivocally demonstrated by cause non-functional areas identified by imaging
and Zurich Lung an interim analysis of the National Emphysema techniques are ideal targets for resection . We
Treatment Trial (NETT) . In 69 patients with have corroborated this concept in previous analy-
News on lung volume reduction surgery 558
Table 1 Indications
Patient selection Severe emphysema hyperinflation: TLC >125% pred.
RV/TLC: ≥ 0.65
severe airflow obstruction: FEV1 <35% pred.
Impaired exercise performance 12 walking distance: <600 m
VO2 max: <12 ml/kg/min
Contraindications (absolute & relative)
Vanishing lung diffusing capacity <20% pred.
HRCT: almost no lung tissue left
Lung function FEV1 <20% pred.
Pulmonary hypertension PAPmean ≥ 35 mm Hg
Hypercapnia PaCO2 >55 mm Hg
Extrapulmonary factors coronary artery disease
malignancy with life expectancy <2 y
ses but, more importantly, we have been able to whether coronary angiography is required preop-
demonstrate that even patients with a uniform pat- eratively must be made on an individual basis. In
tern of emphysematous destruction (i.e. a homo- this patient population no sensitive and specific
geneous type) show significant and clinically rele- method is applicable to noninvasive detection
vant improvement after the operation . Thus a of relevant coronary ischaemia. In patients with
homogeneous type of emphysema is not a con- coronary artery stenoses, percutaneous transluminal
traindication for LVRS provided FEV1 and diffu- angioplasty may be performed preoperatively or
sion capacity are not below 20% of the predicted coronary artery bypass grafting in the same surgi-
values and if aspects of vanishing lung are absent cal session.
from CT scan. Twenty-three of our LVRS patient population
Hypercapnia per se is not a contraindication for have alpha-1-antitrypsin deficiency. All except two
LVRS provided a reasonable amount of functional were also heavy smokers. The natural history and
lung tissue is left (no vanishing lung) and the me- morphology of these patients’ lung disease is dif-
chanical impairment is marked. Only a minority ferent from pure smoker’s emphysema. We con-
of patients with advanced emphysema have more firm other investigators’ experience that in this pa-
than mild pulmonary hypertension . It is there- tient population the degree and mean duration of
fore unnecessary to perform routine echocardiog- functional improvement after LVRS is less than in
raphy or eventually right heart catheterisation in patients with smokers’ emphysema [16, 17]. How-
the preoperative evaluation. Approximately 15% ever, we observed that individual patients experi-
of LVRS candidates have relevant ischaemic heart enced several years’ benefit from the surgical in-
disease despite the fact that symptoms of myocar- tervention. Hence we do not consider alpha-1-
dial ischaemia are lacking . This is due to their antitrypsin deficiency per se as an absolute con-
low level of exercise capacity. Hence the decision traindication for LVRS .
Effects of LVRS
The beneficial effects of LVRS are sum- by LVRS. 15% of our patients had hypoxaemia to
marised in table 2. The improvements in pul- a degree fulfilling the criteria for long-term oxy-
monary mechanics have a marked impact on qual- gen therapy. After LVRS mean paO2 improved
ity of life in these patients, who are severely im- slightly for up to one year due to a transient in-
paired in their daily activities despite optimal med- crease in alveolar ventilation as indicated by a
ical treatment including pulmonary rehabilitation. lower paCO2. However, improvement of gas ex-
Almost all COPD patients with severe pul- change is not predictable in the individual patient.
monary emphysema have a history of heavy smok- This is important to know when counselling the
ing. Some of them suffer from symptoms of patient, who expects long-term oxygen therapy to
chronic bronchitis and particularly from recurrent be no longer necessary after LVRS.
exacerbations. These problems are not improved
S W I S S M E D W K LY 2 0 0 2 ; 1 3 2 : 5 5 7 – 5 6 1 · w w w . s m w . c h 559
Table 2 Shortness of breath (MRC): (1–2)
Changes after LVRS Breathing pattern:
in patients with
severe emphysema. Cough and sputum production:
Frequency of exacerbations:
Health-related quality of life:
peak exercise (Watts): (15)
timed walking distance (m): (90)
FEV1 (% pred): (13 )
IVC (% pred): (18)
Abbreviations: : improved; : unchanged; diminished: ; average changes at three months after LVRS
are given in their respective units; MRC: Medical Research Council dyspnoea scale (0–4; from no shortness
of breath to dyspnoea on minimal exercise; FEV1: forced expiratory volume in one second; IVC: inspiratory
vital capacity; RV: residual volume; TLC: total lung capacity; DLCO: carbon monoxide diffusing capacity;
PaO2: partial pressure of arterial oxygen; PaCO2: partial pressure for carbon dioxide.
LVRS for other obstructive lung diseases
According to theoretical considerations  cessfully performed LVRS in a 14-year-old boy
LVRS should improve lung function irrespective with disabling airflow obstruction and hyperinfla-
of the type of disease causing hyperinflation. The tion secondary to postinfectious bronchiolitis un-
functional gain achieved by LVRS is greatest if the responsive to medical therapy . Within days of
mismatch between the size of the lungs and of the LVRS major improvements in symptoms and lung
chest wall is most pronounced, i.e. hyperinflation of function had occurred and still persist after two
the lung is considerable, and if the amount of resected and a half years. To our knowledge this is the first
lung volume is substantial. Hence patients with se- successful LVRS in a patient with obstructive lung
vere chronic and irreversible pulmonary hyperin- disease not accompanied by pulmonary emphy-
flation of aetiology other than pulmonary emphy- sema.
sema may profit from LVRS as well. We have suc-
Several groups have reported beneficial long- ing maximum value within 6 months postopera-
term results after LVRS [1, 21]. 25 of our 150 pa- tively, the decline in FEV1 was most rapid in the
tients have now reached four years post LVRS. In first year and slowed down in the succeeding years
analysing their functional results one must con- according to an exponential decay. We conclude
sider a distinct positive bias due to deaths and pa- that the long-term functional results of LVRS may
tients lost to follow-up. Nevertheless, four years be more favourable than could be expected from
after LVRS the mean dyspnoea score is still better linear extrapolations of short-term observations.
then preoperatively and improvement of various Five-year survival in patients with emphysema
functional parameters also persists. To appreciate of severity comparable to our population ranges
these results one must consider the natural history around 50%. There are no controlled long-term
of COPD, i.e. emphysema, which is not influenced prospective trials comparing the survival of med-
by any medical intervention besides smoking ces- ically treated patients with that in patients who un-
sation and is attended by a constant decline in lung derwent LVRS. Mean survival in our patients at
function. We recently analysed the evolution pat- five years is approximately 70%, which is compa-
tern of lung function, i.e. the time course of FEV1 rable to observations by the group of Cooper et al.
for up to four years after LVRS . After reach- .
News on lung volume reduction surgery 560
LVRS has the potential to defer lung trans- in patients under 60 can be delayed for several
plantation and is therefore used in several centres years.
as a procedure whereby the time of transplantation
Endobronchial (bronchoscopic) approaches to deflation
of emphysematous lungs
The potentially favourable effect of LVRS on suggested creating passageways through the chest
respiratory mechanics is unquestionable. How- wall allowing trapped gas to exit from emphyse-
ever, since only relatively few patients are good matous lung areas by bypassing the small ob-
candidates for this procedure and the benefit to be structed airways. This concept was modified by
expected is often not in balance with the potential Joel Cooper and colleagues, who proposed that the
morbidity, various groups are currently investigat- creation of direct stented passages from the large
ing an endobronchial approach to deflation of em- airways into the emphysematous pulmonary
physematous lungs by bronchoscopy. parenchyma would improve expiratory flow and
Collateral ventilation, defined as the ability of respiratory mechanics (figure 1). Lausberg and
gas to travel through non-bronchial pathways colleagues  demonstrated in an ex vivo study in
from one part of the lung to another, is extensively emphysematous human lungs that FEV1 doubled
present in emphysema. However, due to the expi- when several stented passages were created. We
ratory collapse of the small airways air is trapped are currently investigating this concept in emphy-
and contributes markedly to pulmonary hyperin- sema patients who are not ideal candidates for
flation, which is believed to be the most important LVRS.
cause of dyspnoea. P. Macklen  has therefore Another group has proposed that the inser-
tion of small one-way valves (Heimlich valves) in
segmental bronchi would result in deflation of dis-
tal lung parenchyma. However, preliminary work
stent is placed over
has demonstrated no effect of this kind, probably
a guide wire and because the resistance of the valves is higher than
positioned in a newly that through pathways for collateral ventilation. A
created passage be-
tween a subsegmen- different concept is being investigated by another
tal bronchus and group who propose that bronchial lavage of em-
tissue under flexible
physematous lung tissue with antisurfactant and
bronchoscopic consequent sealing of the corresponding airway
control. creates a collapse of this area. However, thus far no
data have been forthcoming.
Prof. Dr. Erich W. Russi
University Hospital of Zurich
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