Lung volume reduction surgery (LVRS) is a promising new treatment for certain patients with moderate to severe emphysema. The purpose of the surgery is to remove parts of the lung that do not work, allowing the remaining lung tissue to work more effectively. LVRS is the first treatment to demonstrate actual improvement in lung function, quality of life, exercise tolerance and survival for selected patients with emphysema.
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Comparison of LVRS to Nonsurgical Treatments
Cedars-Sinai Medical Center was one of 17 centers in the United States to participate in the National Emphysema Treatment Trial (NETT). Completed in 2002, the study showed that patients with upper lobe emphysema had better pulmonary function and exercise tolerance after LVRS than after medical (nonsurgical) treatment. For patients with upper lobe emphysema and poor exercise tolerance, the survival rate was better after LVRS than after medical treatment.
Candidates for LVRS
The most important selection factor for LVRS candidates is the presence of a heterogeneous pattern of emphysema. In other words, parts of the patient's lung are not functional, and other parts of the lung function better. Because this heterogeneous pattern is found in only 20 percent of patients with emphysema, a minority of patients are candidates for the procedure.
LVRS patients are usually oxygen dependent, severely restricted in activities, and experience considerable difficulty with dressing, showering and walking short distances, even after undergoing pulmonary rehabilitation. Patients are typically younger than 75 years of age, but selected older patients may be candidates for LVRS. The procedure is generally not recommended for:
- Severely incapacitated patients (e.g., ventilator dependent or wheelchair dependent) with severe hypercarbia (increased carbon dioxide in the blood)
- Patients who use four liters of nasal oxygen
- Patients with severe anxiety or depression that may decrease participation in a required preoperative exercise regimen
The standard evaluation for potential LVRS candidates includes:
- Medical history and physical
- Chest X-ray
- High resolution chest CT scan
- Arterial blood gases test
- Plethysmography (measures and records changes in lung function)
- Lung perfusion scan (nuclear medicine test that determines how well different parts of the lung function)
- Six-minute walk to measure exercise tolerance
Prior to LVRS surgery, qualified patients must undergo a pulmonary rehabilitation program that includes an aggressive exercise regimen to optimize physical condition, reduce operative risk and decrease the need for inpatient pulmonary rehabilitation following the operation. Candidates for LVRS must be motivated to complete the program and must be able to control the anxiety caused by shortness of breath during exercise.
How LVRS Is Performed
Bilateral staple LVRS is the standard operative procedure for patients who receive the surgery at Cedars-Sinai. With this technique, the surgeon uses staples to cut out diseased lung tissue from healthy lung tissue. "Bilateral" means the surgery is performed on both lungs instead of only one.
Cedars-Sinai surgeons pioneered the use of video-assisted thoracoscopy (VATS), a minimally invasive surgical technique, to perform LVRS. VATS offers surgical access to all areas of the chest, including the lower lobes, through one-half-inch incisions under the arms. A miniature video camera is inserted into the chest to guide the surgeon, usually eliminating the need for open chest surgery and allowing for less scarring, reduced pain and quicker recovery.
The procedure is performed under general anesthesia. An epidural catheter (tube to deliver pain medication) is inserted in the patient's back for postoperative pain management. The amount of lung removed is determined by the areas of severe destruction seen on the preoperative CT scan and the lung perfusion scan. For upper lobe emphysema, approximately 50 percent of each upper lobe is removed, and an even larger amount is removed for lower lobe emphysema.
The patient's breathing tube is removed in the operating room, and the patient is transferred to the intensive care unit. Less than five percent of patients require the breathing tube to be replaced to assist breathing after the operation. To reduce the risk of pneumonia, patients are encouraged to be out of bed on the day of the procedure. The epidural catheter and Foley catheter (a tube in the bladder to drain urine) remain in place for three postoperative days. The average length of hospital stay is seven to 10 days.
LVRS Outcomes, Mortality and Complications
Approximately 80 percent of all LVRS patients improve while 15 percent fail to improve. For patients with an upper lobe distribution of emphysema, bilateral staple LVRS offers a 68 percent chance of oxygen independence, an 85 percent chance of prednisone independence and a 60 to 70 percent improvement in pulmonary function. The length of time that patients benefit following LVRS is currently still being studied. For some patients the benefit lasts only six to 12 months. The typical length of benefit is two to three years, although some patients have experienced improvement for five to six years.
Five to ten percent of patients receiving bilateral staple LVRS die as a result of the surgery. An air leak lasting at least seven days has occurred in 35 to 50 percent of patients. Other complications found in less than five percent of patients include pneumonia, arrhythmia (irregular heartbeat), heart attack and internal bleeding.
Combined LVRS and Lung Cancer Operations
LVRS allows the removal of lung cancer in some patients who are otherwise not candidates for LVRS due to poor pulmonary function. If the cancer and emphysema are in the same part of the lung, a formal anatomic lobectomy (removal of a lung lobe) and lymph node removal can be performed. If the lung cancer is in the better part of the lung, a wedge resection and LVRS can be performed.
LVRS and Lung Transplantation
LVRS can achieve patient improvement while avoiding complications specific to lung transplantation. In some cases, LVRS can provide relief for transplant patients until a donor lung becomes available. LVRS may be the only surgical option for some individuals (such as those too old for transplantation), while transplantation may remain the only surgical option for others (those without a pattern of emphysema suitable for LVRS).