Do criteria for volume reduction and transplantation overlap?
Patients with COPD who met the criteria for lung transplantation have received LVR surgery . Post-hoc analysis suggested that improvements following volume reduction were equivalent to improvements seen among LVR surgery patients who were not eligible for transplants (Fig. 14.2). At 6 months, FEV1 increased by 59% in the 'transplant-eligible' group, compared to a 79% increase in the overall LVR surgery group. The 6-min walk test increased by 33% in 'transplant-eligible' subjects. This figure was intermediate between 28% for the overall group of LVR surgery patients and 47% for those who had received single-lung transplantations. The actual walking distance was 449 m for 'transplant-eligible' LVR surgery patients and 461 m post-SLT. Thus, although the LVR patients had a smaller improvement in their FEV1 (0.55-0.87 L after LVR vs. 0.48-1.59 L after SLT), the improvements in functional exercise capacity were similar with the two procedures, without the risks or complications of SLT such as rejection and immunosuppression.
What are the future directions?
The value of surgery for giant bullae is well established and without question. Short-term randomized trials have demonstrated that LVR surgery is effective in improving pulmonary mechanics, decreasing dyspnoea, increasing exercise tolerance and improving quality of life. Longer-term studies will quantify the duration of benefit, appropriate selection criteria and best techniques. Animal models of emphysema  enable us to evaluate several potential endo-bronchial techniques that might improve pulmonary mechanics and health-related quality of life for patients with emphysema. This is likely to become an area of very active research. Transplantation will continue to be an option for a minority of patients with end-stage emphysema. More widespread use of transplantation will depend on significant improvements in immunosuppres-sion as well as an expansion of the donor pool. Until that time, the balance for clinicians and patients remains the risk of early death or major complications, against the improvements in functional exercise capacity and health-related quality of life.
1 Cooper JD. The history of surgical procedures for emphysema. Ann Thorac Surg 1997; 63: 312-19.
2 Potgieter PD, Benatar SR, Hewitson RP, Ferguson AD. Surgical treatment of bullous lung disease. Thorax 1981; 36: 885-90.
3 Laros CD, Gelissen HJ, Bergstein PG et al. Bullectomy for giant bullae in emphysema. J Thorac Cardiovasc Surg 1986; 91: 63-70.
4 Petro W, Hubner C, Greschuchna D, Maasen W, Konietzko N. Bullectomy. Thorac Cardiovasc Surg 1983; 31: 342-5.
5 Maurer JR. Surgical approaches to endstage disease: lung transplantation and volume reduction. Clin Chest Med 1997; 18: 173-414.
6 Shrager JB, Kaiser LR, Edelman JD. Lung volume reduction surgery. Curr Prob Surg 2000; 37: 253-317.
7 Brenner M, McKenna RJ, Gelb AF etal. Dyspnea response following bilateral thoracoscopic staple lung volume reduction surgery. Chest 1997; 112: 916-23.
8 Cooper JD, Patterson GA, Sundaresan RS etal. Results of 150 consecutive lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg 1996; 112: 1319-30.
9 Keenan RJ, Landreneau RJ, Sciurba FC etal. Unilateral thoracoscopic surgical approach for diffuse emphysema. J Thorac Cardiovasc Surg 1996; 111: 308-16.
10 Leyenson V, Furukawa S, Kuzma AM
et al. Correlation of changes in quality of life after lung volume reduction surgery with changes in lung function, exercise, and gas exchange. Chest 2000; 118: 728-35.
11 Lowdermilk GA, Keenan RJ, Landreneau RJ etal. Comparison of clinical results for unilateral and bilateral thoracoscopic lung volume reduction. Ann Thorac Surg 2000; 69: 1670-4.
12 Moy ML, Ingenito EP, Mentzer SJ, Evans RB, Reilly J Jr. Health-related quality of life improves following pulmonary rehabilitation and lung volume reduction surgery. Chest 1999; 115: 383-9.
13 Geddes D, Davies M, Koyama H etal. Effect of lung volume reduction surgery in patients with severe emphysema. N Engl J Med 2000; 343: 239-45.
14 Criner GJ, Cordova FC, Furukawa S etal. Prospective randomized trial comparing bilateral lung volume reduction surgery to pulmonary rehabilitation in severe chronic obstructive pulmonary disease. Am J Respir Crit Care Med 1999; 160: 2018-27.
15 Pompeo E, Marino M, Nofroni I, Matteucci G, Mineo TC. Reduction pneumoplasty versus respiratory rehabilitation in severe emphysema: a randomized study. Ann Thorac Surg 2000; 70: 948-54.
16 National Emphysema Treatment Trial Research Group. Patients at high risk of death after lung volume reduction surgery. N Engl J Med 2001; 345: 1075-83.
17 Meyers BF, Yusen RD, Lefrak SS etal. Outcome of Medicare patients with emphysema selected for, but denied, a lung volume reduction operation. Ann Thorac Surg 1998; 66: 331-6.
18 Brenner M, McKenna RJ, Chen JC etal. Survival following bilateral staple lung volume reduction surgery for emphysema. Chest 1999; 115: 390-6.
19 Gelb AF, McKenna RJ, Brenner M et al. Contribution of lung and chest wall mechanics following emphysema resection. Chest 1996; 110: 11-17.
20 Tschernko EM, Wisser W, Hofer S etal. The influence of lung volume reduction surgery on ventilatory mechanics in patients suffering from severe chronic obstructive pulmonary disease. Anesth Analg 1996; 83: 996-1001.
21 Cooper JD, Trulock EP, Triantafillou AN etal. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995; 109: 106-19.
22 McKenna RJ, Brenner M, Fischel RJ, Gelb AF. Should lung volume reduction for emphysema be unilateral or bilateral? J
Thorac Cardiovasc Surg 1996; 112: 1331-9.
23 Kotloff RM, Tino G, Palevsky HI etal. Comparison of short-term functional outcomes following unilateral and bilateral lung volume reduction surgery. Chest 1998; 113: 890-5.
24 Wisser W , Tschernko E, Klepetko W etal. Functional improvement after volume reduction: sternotomy versus videoendoscopic approach. Ann Thorac Surg 1997; 63: 822-8.
25 Kotloff RM, Tino G, Bavaria JE etal. Bilateral lung volume reduction surgery for advanced emphysema. Chest 1996; 110: 1399-406.
26 Roberts JR, Bavaria JE, Wahl P et al. Comparison of open and thoracoscopic bilateral volume reduction surgery: complications analysis. Ann Thorac Surg 1998; 66: 1759-65.
27 Thurnheer R, Engel H, Weder W etal. Role of lung perfusion scintigraphy in relation to chest computed tomography and pulmonary function in the evaluation of candidates for lung volume reduction surgery. Am J Respir Crit Care Med 1999; 159: 301-10.
28 McKenna RJ, Brenner M, Fischel RJ etal. Patient selection criteria for lung volume reduction surgery. J Thorac Cardiovasc Surg 1997; 114: 957-67.
29 Ingenito EP, Evans RB, Loring SH etal. Relation between preoperative inspiratory lung resistance and the outcome of lungvolume reduction surgery for emphysema. N Engl J Med 1998; 338: 1181-5.
30 Hosenpud JD, Bennett LE, Keck BM, Edwards EB, Novick RJ. Effect of diagnosis on survival benefit of lung transplantation for end-stage lung disease. Lancet 1998; 351: 24-7.
31 Sundaresan RS, Shiraishi Y, Trulock EP etal. Single or bilateral transplantation for emphysema. J Thorac Cardiovasc Surg 1996; 112: 1485-95.
32 Bando K, Paradis IL, Keenan RJ etal. Comparison of outcomes after single and bilateral lung transplantation for obstructive lung disease. J Heart Lung Transplant 1995; 14: 692-8.
33 Bavaria JE, Kotloff R, Palevsky H etal. Bilateral versus single lung transplantation for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1997; 113: 520-8.
34 Orens JB, Becker FS, Lynch JP et al. Cardiopulmonary exercise testing following allogeneic lung transplantation for different underlying disease states. Chest 1995; 107: 144-9.
35 Sundaresan S, Semenkovich J, Ochoa L etal. Successful outcome of lung transplantation is not compromised by the use of marginal donor lungs. J Thorac Cardiovasc Surg 1995; 109: 1075-80.
36 Smith CM. Patient selection, evaluation, and preoperative management for lung transplant candidates. Clin Chest Med 1997; 18: 183-98.
37 Gaissert HA, Trulock EP, Cooper JD, Sundaresan RS, Patterson GA. Comparison of early functional results after volume reduction or lung transplantation for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1996; 111: 296-307.
38 Shrager JB, Kim DK, Hashmi YJ etal. Lung volume reduction surgery restores the normal diaphragmatic length-tension relationship in emphysematous rats. J Thorac Cardiovasc Surg 2001; 121: 217-24.
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