Thomas Waddell and Roger Goldstein

Introduction

Surgeons encounter patients with chronic obstructive pulmonary disease (COPD) in a variety of contexts. For example, some patients develop mass lesions that require surgery to advance their diagnosis or management. In others, a spontaneous pneumothorax demands prompt surgical assistance. These are standard surgical roles with which every thoracic surgeon and pulmonary specialist is familiar. In contrast, surgical contributions to the management of end-stage emphysema have a long and fascinating history [1]. A number of once exciting procedures fell into disfavour for lack of evidence of their efficacy among an extremely high-risk group of patients. Such procedures include costochondrectomy, phrenic nerve crush, pneumoperi-toneum and resection of the carotid body. Other procedures, based on sounder physiological principles, have enjoyed more success. In this chapter, we will comment on the role of surgery in the management of COPD, with particular emphasis on approaches that remove or replace emphysema-tous tissue. These include bullectomy, lung volume reduction and lung transplantation.

Why bullectomy?

Bullectomy for resection of compressive giant bullae is clearly beneficial, provided patients are selected carefully. Criteria for consideration of surgery include the presence of a localized giant bulla, defined as occupying more than one-third of the hemithorax, in the presence of compression of the surrounding, relatively 'normal' lung. Whereas there has never been a randomized controlled trial of bullectomy, early surgical case series reported favourable experience with minimal mortality and functional improvement [2]. Laros et al. reported long-term results in 27 patients followed for 10 years after surgical resection [3]. They noted improvements in forced expiratory volume in 1 s (FEV1) when the bulla communicated with the bronchial tree. Resection of a closed bulla resulted in a larger increase in forced vital capacity (FVC). Older patients with more advanced lung disease had significant palliation, with a mean survival time of 7years. There were no recurrent bullae. The techniques and indications for surgery for this relatively rare opportunity do not require extensive discussion. Bullectomy is usually performed through a thoracotomy, for a unilateral procedure, although recently video-assisted thoracic surgery (VATS) has been used. The operation is often simplified if several bullae are on one pedicle. Selection criteria vary from one-third to two-thirds of the hemithoracic volume, provided that there is significant dyspnoea and compression of the remaining lung. The boundary between a giant bulla and heterogeneous diffuse emphysema can occasionally be difficult, but is increasingly becoming only a semantic discrimination. Chronic bronchitis and hypercapnia remain important risk factors [4].

What are the options for patients with generalized emphysema?

Several overviews regarding the surgical management of COPD have recently been published [5,6]. For patients with more generalized emphysema, resection of lung parenchyma improves elastic recoil and chest wall mechanics. Advances in preoperative diagnostic imaging, thoracic anaesthesia, surgical technique and critical care have led to great interest in this area. As with resection of large bullae, lung volume reduction has specific indications and is not appropriate for most patients with COPD. Transplantation of one or both lungs provides the best restoration of pulmonary function. Unlike bullectomy or volume reduction, transplantation is independent of the anatomic subtypes of emphysema. However, transplantation has its own indications, limitations and exclusion criteria that must be taken into account to identify those most likely to benefit from this procedure.

What is the role of lung volume reduction surgery?

The role of lung volume reduction (LVR) in the management of end-stage emphysema remains controversial. In carefully selected patients, surgery has been associated with statistically significant improvements in lung volumes, expiratory flow rates, exercise capacity and work of breathing [7-11]. It has also been shown to improve subjective measures of dyspnoea and health-related quality of life (HRQL) beyond that which could be achieved by pulmonary rehabilitation alone [12]. In a randomized controlled trial of LVR surgery among subjects with stable, severe COPD, surgery did not influence survival compared with the control group. It is therefore considered primarily for its potential benefit on quality of life. The duration of these improvements

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