Lung Volume Reduction Surgery

In 1997, the University of California, San Diego Medical Center was awarded a National Institutes of Health (NIH) grant to become one of the 17 centers of excellence in the National Emphysema Treatment Trial (NETT). This national clinical trial was designed to determine what is the best treatment for people with severe emphysema: medical management alone, which typically involves medication and rehabilitation or medical management plus Lung Volume Reduction Surgery (LVRS), in which damaged portions of each lung are removed.

The results of the NETT Study indicate that, on average, patients who undergo LVRS with medical therapy are more likely to function better after two years and do not face an increased risk of death compared to those who receive medical therapy only. Specific subgroups were identified in the assessment of risk and functional benefits from LVRS. Lung Volume Reduction Surgery

The National Emphysema Treatment Trial (NETT) study results have identified four sub-groups of patients who had different risks and benefits from LVRS.

Group 1: Mostly upper-lobe emphysema and low exercise capacity. These patients were more likely to live longer and were more likely to function better after LVRS than after medical treatment.

Group 2: Mostly upper-lobe emphysema and high exercise capacity. These patients are more likely to function better after LVRS than after medical treatment, but there was no difference between the LVRS and Medical participants in survival.

Group 3: Mostly non upper-lobe emphysema and low exercise capacity. These patients had similar survival and function after LVRS as after medical treatment.

Group 4: Mostly non upper-lobe emphysema and high exercise capacity. These patients had worse survival after LVRS than after medical treatment; both LVRS and medical participants had similar low chance of functioning better.

A high-risk patient has been defined by the NETT criteria as the patient who would not benefit from LVRS but is more likely to be harmed, as outlined in Group 4 above. Specifically, the high-risk patient is one who has a forced expiratory volume in the first second (FEV1) that is 20% or less of their predicted value and either homogenous distribution of emphysema on CT Scan or low carbon monoxide diffusing capacity (DlCO) that is 20% or less of their predicted value. These specific criteria can be determined after the testing process has been completed. Finally, a patient with a certain underlying medical disease, condition or multiple surgical risk factors may also not be a surgical candidate for LVRS. LVRS candidates who fall into Groups 1, 2 or 3 are the best candidates for LVRS. All LVRS candidates are encouraged to discuss their individual characteristics with their Primary Care Provider or Pulmonologist to determine if they are likely to benefit from LVRS.

Emphysema

Emphysema is a disease of the lung, which is caused by chronic irritation of the lung tissue. The most common cause of Emphysema is smoking. Chronic irritation of the lungs causes the lung sacks (aveoli) to break down and form large "bullae" or "air sacks". These air sacks trap air in your lungs. These air sacks are not used efficiently in gas exchange during normal breathing. The air sacks also compress the underlying lung and stretch the overlying muscles used in breathing. This compression and the decreased ability to use the normal mechanism of breathing may be the reason emphysema patients are short of breath.

In Lung Volume Reduction Surgery, surgeons remove about 30 percent of the damaged lungs. By reducing the lung size, the remaining lung and surrounding muscles (intercostals and diaphragm) are able to work more efficiently and make breathing easier. The patient will need to go under general anesthesia for this operation.

Risks

There are many risks involved with lung reduction surgery. Lung reduction surgery has a higher risk than heart surgery. This is because the candidates have poor lung function and are generally older.

The death rate of this surgery is about 6 to 10 percent nationwide. This is one of the highest risk procedures performed electively.

Complications

• Air leakage-- this is the most common complication. Air leakage occurs when air leaks from the lung tissue, coming from the suture line, into the chest cavity. If the air volume becomes too great, the pressure could collapse the lung tissue. One or more chest tubes are placed during surgery to monitor the air leakage and prevent the collapse of the lung tissue. Over 50% of patients have some degree of air leak.
• Pneumonia (19%) or infection (1-5%) is common in emphysema patients, especially when they have a history of recurrent bouts
• Stroke (less than 1%)
• Bleeding (2-5%)
• Heart attack (1%)
• Death which results from a worsening of one of the above complications causing a combination of problems which ultimately lead to death (6-10%)

Pulmonary Rehabilitation

During the pre-operative process, you will have undergone extensive pulmonary rehabilitation. This process will need to be continued up until the time of surgery.

Pulmonary Rehabilitation will start on your first post-operative day. These exercises and training are very important for your recovery. The more you exercise and move, the quicker and less painful your recovery will be. Your motivation to recover strongly affects this aspect of your treatment. You may not feel up to exercising, but it is an essential part of your recovery. Listen to the nurses and therapists; they will be important keys in your recovery. You will be walking in the halls, on the treadmill or on the bicycle every day.